Arizona Complete Health-Complete Care Plan Lista completa ......La lista completa de medicamentos de Arizona Complete Health-Complete Care Plan incluye medicamentos que han sido revisados

Arizona Complete Health-Complete Care Plan Lista completa de medicamentos preferentes: La lista completa de medicamentos de Arizona Complete Health-Complete Care Plan incluye medicamentos que han sido revisados y aprobados por un comité de médicos y farmacéuticos. No es una lista completa de todos los medicamentos cubiertos. Si necesita un medicamento que no figura en la lista, llame a los servicios para afiliados de Arizona Complete Health-Complete Care Plan y pregunte si está cubierto. Si el medicamento no está cubierto, su médico puede solicitar autorización previa para cubrir el medicamento.

La lista de medicamentos se actualiza con frecuencia y puede cambiar. Puede ver la lista de medicamentos más reciente en www.azcompletehealth.com/providers/pharmacy.html

https://www.azcompletehealth.com/providers/pharmacy.html

Programa de farmacia Arizona Complete Health-Complete Care Plan proporciona farmacoterapia adecuada, de alta calidad y rentable a todos los afiliados de Arizona Complete Health-Complete Care Plan. Arizona Complete Health-Complete Care Plan cubre medicamentos recetados y ciertos medicamentos de venta libre (OTC) cuando son indicados por un médico. Algunos medicamentos requieren autorización previa (PA) o tienen límites para la edad, dosis y cantidades máximas.

Los medicamentos genéricos tienen el mismo principio activo que sus equivalentes con nombre de marca y deben usarse como primera línea de tratamiento. Esto se aplica a menos que se indique concretamente que se prefiere una marca. Si no hay un medicamento genérico disponible, puede haber más de un medicamento de nombre de marca que se pueda usar en su tratamiento. La Lista de medicamentos preferentes (PDL) completa de Arizona Complete Health-Complete Care se revisa con frecuencia por nuestro Comité de Farmacia y Tratamientos (P&T) de Arizona Complete Health. Esto ayuda a promover el uso apropiado y rentable de los medicamentos.

Límites de dosis Puede obtener hasta un suministro máximo de treinta (30) días por cada nueva receta médica o reabastecimiento de la mayoría de medicamentos. Puede obtener hasta un suministro de noventa (90) días si:

• El medicamento está prescrito para una enfermedad crónica • Usted va a estar fuera del área de servicio durante un largo periodo de tiempo

• La receta está limitada al periodo de tiempo • El medicamento está prescrito para anticoncepción

Debe haber transcurrido un total del 85 % del suministro de 30 días antes de que se pueda reabastecer la receta médica para la mayoría de los medicamentos.

Autorización previa y otros límites Algunos medicamentos que figuran en la PDL completa de Arizona Complete Health-Complete Care Plan pueden requerir autorización previa (PA). Su médico o farmacéutico solicitará una PA para usted. La información deberá ser presentada por el practicante o farmacéutico en el formulario de autorización previa de medicamentos. Puede encontrar este documento en el sitio web de Arizona Complete Health-Complete Care Plan en https://www.azcompletehealth.com/providers/pharmacy.html. Pueden enviar la PA por fax al 1-855-554-5233 o su proveedor médico puede enviar una solicitud de PA electrónicamente a https://www.covermymeds.com/epa/envolverx/

No todos los medicamentos oncológicos están enumerados abajo. Todos los agentes

https://www.azcompletehealth.com/providers/pharmacy.html

https://www.covermymeds.com/main/prior-authorization-forms/envolverx/

oncológicos (antineoplásicos) no reembolsables por las autoridades federales están disponibles mediante autorización previa.

Arizona Complete Health-Complete Care Plan cubrirá el/los medicamento(s) si:

1. Existe un motivo médico que requiera el/los medicamento(s) específico(s) 2. Dependiendo del medicamento, otros medicamentos en la PDL no han funcionado

Si la solicitud es aprobada, Arizona Complete Health-Complete Care Plan informa al médico por fax. Si la información clínica provista no cumple con los criterios de cobertura para el medicamento solicitado, Arizona Complete Health-Complete Care Plan realizará lo siguiente:

• Revisará la solicitud y les informará a usted y su médico sobre nuestra decisión • Le informará sobre medicamentos alternativos, si estuviesen disponibles • Proporcionará información sobre lo que puede hacer para apelar nuestra decisión si no está de acuerdo con ella.

Abreviación Significado Cómo funciona

AL Límite de edad Algunos medicamentos solo están cubiertos para ciertas edades.

F Formulario Estos medicamentos están cubiertos por Arizona Complete Health-Complete Care Plan.

MP Producto de mantenimiento

Estos medicamentos se utilizan para el tratamiento de afecciones o enfermedades a largo plazo.

NF Fuera del formulario

Estos medicamentos requieren autorización para estar cubiertos por Arizona Complete Health-Complete Care Plan.

PA Autorización previa

Su médico debe solicitar la aprobación de Arizona Complete Health-Complete Care Plan antes de cubrir algunos medicamentos.

QL Límite de cantidad

Algunos medicamentos solo están cubiertos para una cantidad determinada.

SP Producto especial

Se utilizan para el tratamiento de afecciones complejas o raras como hepatitis C o artritis reumatoide.

ST Terapia escalonada

En algunos casos, primero debe probar ciertos medicamentos antes de que Arizona Complete Health-Complete Care Plan cubra otro medicamento para su afección médica.

Por ejemplo, si el Medicamento A y el Medicamento B tratan su afección médica, el plan puede no cubrir el Medicamento B a menos que pruebe primero el Medicamento A.

Solicitudes por necesidad médica Si necesita un medicamento para tratar una afección que no figura en la PDL, su médico puede presentar una solicitud de necesidad médica (MN) para el medicamento.

Política de suministro de emergencia Las leyes estatales y federales exigen que una farmacia dispense un suministro de hasta 4 días a cualquier afiliado que espera una determinación de PA. El propósito es evitar la interrupción del tratamiento o retrasos en el inicio del tratamiento. Las farmacias de la red están autorizadas a proporcionar un suministro de hasta 4 días de medicamentos tradicionales (no especiales). Solicite a su farmacia que llame al Servicio de asistencia a farmacias al 1-888-624-1131 para obtener ayuda para reabastecer el suministro de emergencia de 4 días.

Exclusiones La lista de medicamentos de Arizona Complete Health-Complete Care Plan no incluye ciertos medicamentos. Los siguientes tipos de medicamentos están excluidos de la cobertura. Tampoco están disponibles como suministro de emergencia de 4 días.

• Los medicamentos que se consideran experimentales o de investigación (los afiliados que estén inscritos pueden participar en servicios experimentales; no obstante, AHCCCS no reembolsará dicho servicio experimental de acuerdo con la normativa A.A.C. R9-22-203)

• Medicamentos de estudios de eficacia e implementación de medicamentos (DESI) • Prótesis, aparatos y dispositivos • Medicamentos recetados para esterilidad • Medicamentos recetados para disfunción eréctil o sexual • Medicamentos recetados únicamente con fines estéticos o para el crecimiento del cabello

• Vitaminas y minerales orales o medicamentos de venta libre, con la excepción de los que figuran en la PDL o si un afiliado tiene déficit de una vitamina que no figure en la PDL

• Suplementos nutricionales • Marihuana médica • Los medicamentos elegibles para la cobertura de Medicare Part D (para afiliados elegibles de Medicare); los copagos y costos compartidos para medicamentos de salud mental están cubiertos para los afiliados de SMI que también sean elegibles para Medicare.

Productos recién aprobados Arizona Complete Health-Complete Care Plan revisa los nuevos medicamentos para determinar su seguridad y efectividad antes de agregarlos a la PDL. Durante este

período, el acceso a estos medicamentos se considerará mediante el proceso de revisión de PA.

Cómo reabastecer una receta médica

Puede reabastecer su receta médica en una farmacia de la red de Arizona Complete Health-Complete Care Plan. Para encontrar una farmacia dentro de la red, visite el sitio web de Arizona Complete Health-Complete Care Plan https://providersearch.azcompletehealth.com. También puede llamar a los servicios para afiliados para obtener ayuda para encontrar una farmacia de la red cerca suyo. Cuando seleccione una farmacia, traiga con usted su tarjeta de identificación de Arizona Complete Health-Complete Care Plan. La farmacia necesitará la información que figura en la tarjeta para reabastecer su receta médica.

Para obtener más información sobre sus beneficios de farmacia, consulte su Guía para afiliados o llame a los servicios para afiliados al 888-788-4408 (TTY/TDY 711).

https://findaprovider.azcompletehealth.com/location

Drug Name DrugTier

Requirements/Limits

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS - Drugs to TreatADHD, Sleep and Eating Disorders

Amphetamines ADDERALL TABS (amphetamine-dextroamphetamine)

F QL(2 ea daily);AL(At least 6yrs old)

ADDERALL XR CP24 2.5 MG-2.5 MG-2.5 MG-2.5 MG, 7.5 MG-7.5 MG-7.5 MG-7.5 MG, 1.25 MG-1.25 MG-1.25 MG-1.25 MG, 3.75 MG-3.75 MG-3.75 MG-3.75 MG, 6.25 MG-6.25 MG-6.25 MG-6.25 MG (amphetamine-dextroamphetamine)

F

QL(1 ea daily);AL(At least 6yrs old)

ADDERALL XR CP24 5 MG-5 MG-5 MG-5 MG (amphetamine-dextroamphetamine)

F


amphetamine-dextroamphetamine tabs 5mg-5 mg-5 mg-5 mg, 2.5mg-2.5 mg-2.5 mg-2.5 mg,7.5 mg-7.5 mg-7.5 mg-7.5mg, 1.25 mg-1.25 mg-1.25mg-1.25 mg, 3.75 mg-3.75mg-3.75 mg-3.75 mg,1.875 mg-1.875 mg-1.875mg-1.875 mg, 3.125 mg-3.125 mg-3.125 mg-3.125 mg

F


dextroamphetamine sulfatetabs 5 mg, 10 mg F


VYVANSE CAPS F QL(1 ea daily);AL(At least 6yrs old)

VYVANSE CHEW F QL(1 ea daily);AL(At least 6yrs old)

Attention-Deficit/Hyperactivity Disorder (ADHD)

atomoxetine hcl caps F QL(1 ea daily);AL(At least 6yrs old)

Drug Name DrugTier

Requirements/Limits

clonidine hcl (adhd) tb12 F QL(4 ea daily);AL(At least 6yrs old)

guanfacine hcl (adhd) tb24 F QL(1 ea daily);AL(At least 6yrs old)

INTUNIV TB24 (guanfacine hcl (adhd)) NF


STRATTERA CAPS (atomoxetine hcl) NF


Stimulants - Misc.

APTENSIO XR CP24 F QL(1 ea daily);AL(At least 6yrs old)

CONCERTA TBCR (methylphenidate hcl) F


DAYTRANA PTCH F QL(1 ea daily);AL(At least 6yrs old)

dexmethylphenidate hcltabs 5 mg, 10 mg, 2.5 mg F


FOCALIN TABS (dexmethylphenidate hcl) NF


FOCALIN XR CP24 (dexmethylphenidate hcl) F


METHYLIN SOLN (methylphenidate hcl) F

QL(10 mldaily); AL(Atleast 6 yrs old)

methylphenidate hcl cp24or 10 mg, 20 mg, 30 mg, 40mg, 60 mg


methylphenidate hcl cpcr or10 mg, 20 mg, 30 mg, 40mg, 50 mg, 60 mg


methylphenidate hcl tabs or5 mg, 10 mg, 20 mg F


RITALIN LA CP24 10 MG (methylphenidate hcl) F


Arizona Complete Health - Complete Care Plan Actualizada 10/2020

1

Drug Name DrugTier

Requirements/Limits

RITALIN LA CP24 20 MG, 30 MG, 40 MG (methylphenidate hcl)

NF QL(2 ea daily);AL(At least 6yrs old)

RITALIN TABS (methylphenidate hcl) NF


AMINOGLYCOSIDES - Drugs to Treat BacterialInfections

Aminoglycosides AMIKACIN SULFATE POWD XX F

amikacin sulfate soln ij 1gm/4ml, 500 mg/2ml F

BETHKIS NEBU (tobramycin) NF SP

gentamicin in saline soln F

gentamicin sulfate soln ij10 mg/ml, 40 mg/ml F

KITABIS PAK NEBU (tobramycin) F SP

neomycin sulfate tabs or F

paromomycin sulfate caps or F

STREPTOMYCIN SULFATE POWD XX F

streptomycin sulfate solr im F

TOBI NEBU (tobramycin) F SP

tobramycin nebu in 300mg/4ml, 300 mg/5ml F SP

TOBRAMYCIN SULFATE POWD XX F

tobramycin sulfate soln ij10 mg/ml, 40 mg/ml, 80mg/2ml, 1.2 gm/30ml

F

tobramycin sulfate solr ij1.2 gm F

ZEMDRI SOLN F

ANALGESICS - ANTI-INFLAMMATORY - Drugsto Treat Pain, Swelling, Muscle and JointConditions

Anti-TNF-alpha - Monoclonal Antibodies

Drug Name DrugTier

Requirements/Limits

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK PSKT

F PA; SP

HUMIRA PEN PNKT F PA; SP

HUMIRA PEN-CD/UC/HSSTARTER PNKT F PA; SP

HUMIRA PEN-PS/UVSTARTER PNKT F PA; SP

HUMIRA PSKT F PA; SP

Antirheumatic - Enzyme Inhibitors

XELJANZ TABS F PA; SP

Nonsteroidal Anti-inflammatory Agents (NSAIDs) ADVIL CAPS (ibuprofen) NF

ADVIL MIGRAINE CAPS (ibuprofen) NF

ADVIL TABS (ibuprofen) NF

ALEVE ARTHRITIS TABS (naproxen sodium) NF

ALEVE CAPS (naproxen sodium) NF

ALEVE TABS (naproxen sodium) NF

ANAPROX DS TABS (naproxen sodium) NF

ARTHROTEC 50 TBEC (diclofenac w/ misoprostol) NF

ARTHROTEC 75 TBEC (diclofenac w/ misoprostol) NF

CELEBREX CAPS (celecoxib) NF QL(2 ea daily)

celecoxib caps or 50 mg,100 mg, 200 mg, 400 mg F QL(2 ea daily)

CHILDRENS ADVIL SUSP (ibuprofen) NF RX/OTC

CHILDRENS MOTRIN SUSP (ibuprofen) NF RX/OTC

DAYPRO TABS (oxaprozin) NF

diclofenac potassium tabs50 mg F


2

Drug Name DrugTier

Requirements/Limits

diclofenac sodium tb24 or 100 mg F

diclofenac sodium tbec or 25 mg, 50 mg, 75 mg F

diclofenac w/ misoprostoltbec F

EC-NAPROSYN TBEC (naproxen) NF

etodolac caps 200 mg, 300 mg F

etodolac tabs 400 mg, 500 mg F

FELDENE CAPS (piroxicam) NF

fenoprofen calcium caps or400 mg F

fenoprofen calcium tabs or600 mg F

FLURBIPROFEN TABS OR 50 MG F

flurbiprofen tabs or 50 mg,100 mg F

ibuprofen caps or 200 mg F

ibuprofen chew or 100 mg F

ibuprofen susp or 100mg/5ml F RX/OTC

ibuprofen susp or 40mg/ml, 50 mg/1.25ml F

ibuprofen tabs or 200 mg,400 mg, 600 mg, 800 mg F

INDOCIN SUPP F

INDOCIN SUSP F

indomethacin caps or 25mg, 50 mg F

indomethacin cpcr or 75 mg F

INFANTS ADVIL SUSP (ibuprofen) NF

ketoprofen caps or 50 mg,75 mg F

ketoprofen cp24 or 200 mg F

Drug Name DrugTier

Requirements/Limits

ketorolac tromethamine tabs or 10 mg F QL(20 ea per

30 days retail)

LODINE TABS (etodolac) NF

meclofenamate sodium caps or 50 mg, 100 mg F

mefenamic acid caps or250 mg F

meloxicam tabs or 15 mg,7.5 mg F

MOBIC TABS (meloxicam) NF

MOTRIN CHILDRENS CHEW (ibuprofen) NF

MOTRIN INFANTS DROPS SUSP (ibuprofen) NF

nabumetone tabs or 500 mg, 750 mg F

NALFON CAPS 400 MG F

NALFON TABS 600 MG (fenoprofen calcium) NF

NAPROSYN SUSP (naproxen) NF

NAPROSYN TABS (naproxen) NF

naproxen sodium caps or220 mg F

naproxen sodium tabs or220 mg, 275 mg, 550 mg F

naproxen susp or 125mg/5ml F

naproxen tabs or 250 mg,375 mg, 500 mg F

naproxen tbec or 375 mg,500 mg F

oxaprozin tabs 600 mg F

piroxicam caps or 10 mg,20 mg F

sulindac tabs or 150 mg,200 mg F

tolmetin sodium caps F

tolmetin sodium tabs F


3

Drug Name DrugTier

Requirements/Limits

Phosphodiesterase 4 (PDE4) Inhibitors

OTEZLA TABS F PA; SP

OTEZLA TBPK F PA; SP

Pyrimidine Synthesis Inhibitors ARAVA TABS (leflunomide) NF

leflunomide tabs or 10 mg,20 mg F

Soluble Tumor Necrosis Factor Receptor Agents

ENBREL MINI SOCT F PA; SP

ENBREL SOLR F PA; SP

ENBREL SOSY F PA; SP

ENBREL SURECLICK SOAJ F PA; SP

ANALGESICS - NonNarcotic - Drugs to TreatPain, Muscle and Joint Conditions

Analgesic Combinations butalbital-acetaminophen-caffeine tabs 325 mg-40mg-50 mg

F QL(4 ea daily)

butalbital-aspirin-caffeinecaps 325 mg-40 mg-50 mg F QL(6 ea daily)

BUTALBITAL/ASPIRIN/CAFFEINE TABS 325 MG-40 MG-50 MG

F QL(6 ea daily)

ESGIC TABS (butalbital-acetaminophen-caffeine) NF QL(4 ea daily)

FIORINAL CAPS (butalbital-aspirin-caffeine) NF QL(6 ea daily)

Analgesics Other acetaminophen caps or500 mg F

acetaminophen chew or 80 mg F

acetaminophen elix or 160mg/5ml, 80 mg/2.5ml F

acetaminophen liqd or 160mg/5ml F

Drug Name DrugTier

Requirements/Limits

acetaminophen soln or 160mg/5ml, 650 mg/20.3ml,325 mg/10.15ml

F

acetaminophen supp re120 mg, 650 mg F

acetaminophen susp or160 mg/5ml, 80 mg/2.5ml,650 mg/20.3ml

F

acetaminophen tabs or 325mg, 500 mg F

FEVERALL JUNIOR STRENGTH SUPP F

TYLENOL CHILDRENS SUSP (acetaminophen) NF

TYLENOL EXTRA STRENGTH TABS (acetaminophen)

NF

TYLENOL INFANTS PAIN+FEVER SUSP (acetaminophen)

NF

TYLENOL INFANTS SUSP (acetaminophen) NF

TYLENOL TABS (acetaminophen) NF

Salicylates aspirin buffered (cal carb-mag carb-mag oxide) tabs F

aspirin chew or 81 mg F

ASPIRIN SUPP RE 300 MG, 600 MG F

aspirin tabs or 325 mg F

aspirin tbec or 81 mg, 324mg, 325 mg, 500 mg F

BUFFERIN TABS (aspirinbuffered (cal carb-magcarb-mag oxide))

NF

diflunisal tabs F

ECOTRIN MAXIMUM STRENGTH TBEC (aspirin)

NF

ECOTRIN REGULAR STRENGTH TBEC (aspirin)

NF


4

Drug Name DrugTier

Requirements/Limits

salsalate tabs or 500 mg,750 mg F

ANALGESICS - OPIOID - Drugs to Treat Pain,Muscle and Joint Conditions

Opioid Agonists DILAUDID LIQD OR 1 MG/ML (hydromorphone hcl)

NF QL(16 ml daily)

DILAUDID TABS OR 2 MG, 4 MG, 8 MG (hydromorphone hcl)

NF QL(6 ea daily)

DURAGESIC PT72 (fentanyl) NF PA

EMBEDA CPCR F PA

fentanyl pt72 12 mcg/hr, 25mcg/hr, 50 mcg/hr, 75mcg/hr, 100 mcg/hr

F PA

hydromorphone hcl liqd or1 mg/ml F QL(16 ml daily)

HYDROMORPHONE HCL SUPP RE 3 MG F

12 permonth;QL(0.4ea daily,12 eaper fill retail)

hydromorphone hcl tabs or2 mg, 4 mg, 8 mg F QL(6 ea daily)

meperidine hcl tabs or 50mg, 100 mg F

morphine sulfate soln or 10mg/5ml, 20 mg/5ml F

500 permonth;QL(16.67 ml daily)

morphine sulfate soln or 20mg/ml, 100 mg/5ml F

morphine sulfate supp re 5mg, 10 mg, 20 mg, 30 mg F QL(6 ea daily)

morphine sulfate tabs or 15mg, 30 mg F QL(6 ea daily)

morphine sulfate tbcr or 15mg, 30 mg, 60 mg, 100 mg,200 mg

F PA

MS CONTIN TBCR (morphine sulfate) NF PA

oxycodone hcl caps or 5 mg F QL(6 ea daily)

oxycodone hcl conc or 100mg/5ml F QL(6 ml daily)

Drug Name DrugTier

Requirements/Limits

oxycodone hcl soln or 5mg/5ml F QL(6 ml daily)

oxycodone hcl tabs or 5mg, 10 mg, 15 mg, 20 mg,30 mg

F QL(6 ea daily)

ROXICODONE TABS (oxycodone hcl) NF QL(6 ea daily)

tramadol hcl tabs or 50 mg F QL(6 ea daily)

tramadol hcl tb24 or 100 mg, 200 mg, 300 mg F PA

ULTRAM TABS (tramadol hcl) NF QL(6 ea daily)

XTAMPZA ER C12A F PA

Opioid Combinations acetaminophen w/ codeinesoln 12 mg/5ml-120mg/5ml

F QL(16 ml daily)

acetaminophen w/ codeinetabs 15 mg-300 mg, 30 mg-300 mg, 300 mg-60 mg

F QL(6 ea daily)

butalbital-acetaminophen-caffeine w/ codeine caps F QL(6 ea daily)

butalbital-aspirin-caffeinew/cod caps 30 mg-325 mg-40 mg-50 mg

F QL(6 ea daily)

FIORICET/CODEINECAPS (butalbital-acetaminophen-caffeine w/codeine)

NF

QL(6 ea daily)

FIORINAL/CODEINE #3CAPS (butalbital-aspirin-caffeine w/cod)

NF QL(6 ea daily)

hydrocodone-acetaminophen soln 108mg/5ml-2.5 mg/5ml, 217mg/10ml-5 mg/10ml, 325mg/15ml-7.5 mg/15ml

F

QL(16 ml daily)

hydrocodone-acetaminophen tabs 300mg-5 mg, 325 mg-5 mg, 10mg-300 mg, 10 mg-325mg, 2.5 mg-325 mg, 300mg-7.5 mg, 325 mg-7.5 mg

F

QL(6 ea daily)

hydrocodone-ibuprofentabs F QL(6 ea daily)


5

Drug Name DrugTier

Requirements/Limits

NORCO TABS (hydrocodone-acetaminophen)

NF QL(6 ea daily)

oxycodone w/acetaminophen tabs F QL(6 ea daily)

oxycodone-aspirin tabs F QL(6 ea daily)

OXYCODONE/ACETAMINOPHEN TABS 300 MG-5 MG, 10 MG-300 MG

F QL(6 ea daily)

PERCOCET TABS (oxycodone w/acetaminophen)

NF QL(6 ea daily)

PRIMLEV TABS 300 MG-5 MG, 10 MG-300 MG F QL(6 ea daily)

PROLATE TABS 300 MG-5 MG, 10 MG-300 MG F QL(6 ea daily)

ROXICET SOLN F 200 permonth;QL(6.67ml daily)

tramadol-acetaminophentabs 325 mg-37.5 mg F QL(3 ea daily)

TYLENOL/CODEINE #3TABS (acetaminophen w/codeine)

NF QL(6 ea daily)

TYLENOL/CODEINE #4TABS (acetaminophen w/codeine)

NF QL(6 ea daily)

ULTRACET TABS (tramadol-acetaminophen) NF QL(3 ea daily)

Opioid Partial Agonists

Drug Name DrugTier

Requirements/Limits

buprenorphine hcl subl sl 2 mg F

PA Req'dunless member is pregnant ornursing.Prescriber must note ICD-10 diagnosis codeon prescription.O09.91; O09.92; O09.93-Supervision ofhigh risk pregnancy, postpartumnursingmothers. First digit Letter, 2nddigit zeroQL(12ea daily)

buprenorphine hcl subl sl 8 mg F

PA Req'dunless member is pregnant ornursing.Prescriber must note ICD-10 diagnosis codeon prescription.O09.91; O09.92; O09.93-Supervision ofhigh risk pregnancy, postpartumnursingmothers. First digit Letter, 2nddigit zeroQL(3ea daily)

buprenorphine hcl-naloxone hcl dihydrate subl0.5 mg-2 mg

F QL(12 ea daily)

buprenorphine hcl-naloxone hcl dihydrate subl2 mg-8 mg

F QL(3 ea daily)

BUTRANS PTWK (buprenorphine) F PA

SUBLOCADE SOSY F PA; SP


6

Drug Name DrugTier

Requirements/Limits

SUBOXONE FILM 0.5 MG-2 MG (buprenorphine hcl-naloxone hcl dihydrate)

F QL(12 eadaily); AL(Atleast 6 yrs old)

SUBOXONE FILM 1 MG-4 MG (buprenorphine hcl-naloxone hcl dihydrate)






ANDROGENS-ANABOLIC - Drugs to Regulate Hormones

Androgens

ANDRODERM PT24 F PA

ANDROGEL GEL 25 MG/2.5GM, 40.5MG/2.5GM, 20.25MG/1.25GM (testosterone)

NF

PA

ANDROGEL PUMP GEL (testosterone) NF PA

danazol caps or 50 mg,100 mg, 200 mg F

DEPO-TESTOSTERONE SOLN (testosterone cypionate)

NF PA

testosterone cypionate solnim 100 mg/ml, 200 mg/ml F PA

testosterone enanthate soln im 200 mg/ml F PA

testosterone gel td 1.62 %,25 mg/2.5gm, 40.5mg/2.5gm, 20.25mg/1.25gm

F

PA

testosterone soln td 30 mg/act F PA

ANORECTAL AND RELATED PRODUCTS -Rectal Drugs to Treat Pain, Swelling and Itching

Intrarectal Steroids CORTENEMA ENEM (hydrocortisone(intrarectal))

NF

CORTIFOAM FOAM F

Drug Name DrugTier

Requirements/Limits

hydrocortisone (intrarectal)enem 100 mg/60ml F

Rectal Combinations ANALPRAM HC CREA (hydrocortisone acetate w/pramoxine)

NF

ANALPRAM HC SINGLES CREA (hydrocortisoneacetate w/ pramoxine)

NF

ANALPRAM-HC CREA 1 %-1 % (hydrocortisoneacetate w/ pramoxine)

NF

hydrocortisone acetate w/pramoxine crea F

PROCORT CREA F

Rectal Steroids ANUSOL-HC CREA (hydrocortisone (rectal)) NF

hydrocortisone (rectal) crea F

PROCTOCORT CREA EX 1 % (hydrocortisone(rectal))

NF

ANTACIDS

Antacid Combinations alum & mag hydrox-simethicone liqd 20mg/5ml-200 mg/5ml-200mg/5ml, 40 mg/5ml-400mg/5ml-400 mg/5ml

F

alum & mag hydrox-simethicone susp 0.2 %-40mg/10ml-400 mg/10ml-400mg/10ml, 20 mg/5ml-200mg/5ml-200 mg/5ml, 40mg/5ml-400 mg/5ml-400mg/5ml, 120 mg/30ml-1200mg/30ml-1200 mg/30ml,240 mg/30ml-2400mg/30ml-2400 mg/30ml, 20mg/5ml-20 mg/5ml-200mg/5ml-200 mg/5ml-200mg/5ml-200 mg/5ml, 40mg/5ml-40 mg/5ml-400mg/5ml-400 mg/5ml-400mg/5ml-400 mg/5ml,

F


7

Drug Name DrugTier

Requirements/Limits

HYVEE ADVANCED ANTACID MAXIMUM STRENGTH SUSP (alum & mag hydrox-simethicone)

NF

Antacids - Aluminum Salts ALUMINUM HYDROXIDE SUSP OR F

Antacids - Calcium Salts

ANTACID CHEW F

ANTACID SOFT CHEWS CHEW F

calcium carbonate (antacid) chew 400 mg,420 mg, 500 mg, 750 mg,1000 mg

F

CALCIUM CARBONATE TABS OR 648 MG F

CVS ANTACID SOFT CHEWS ULTRA STRENGTH CHEW

F

MAALOX CHEW F

TUMS CHEW (calcium carbonate (antacid)) NF

TUMS CHEWY BITES CHEW (calcium carbonate (antacid))

NF

TUMS CHEWY DELIGHTS CHEW F

TUMS E-X 750 CHEW (calcium carbonate (antacid))

NF

TUMS EXTRA STRENGTH 750 CHEW (calcium carbonate (antacid))

NF

TUMS KIDS CHEW (calcium carbonate (antacid))

NF

TUMS LASTING EFFECTS CHEW (calcium carbonate (antacid))

NF

TUMS SMOOTHIES CHEW (calcium carbonate (antacid))

NF

Drug Name DrugTier

Requirements/Limits

TUMS ULTRA 1000 CHEW (calcium carbonate (antacid))

NF

Antacids - Magnesium Salts magnesium oxide tabs 400 mg F

ANTHELMINTICS - Drugs to Treat Worm Infections

Anthelmintics albendazole tabs or 200 mg F PA

ALBENZA TABS (albendazole) NF PA

BILTRICIDE TABS (praziquantel) NF

ivermectin tabs or 3 mg F PA

praziquantel tabs or 600 mg F

pyrantel pamoate susp or F

REESES PINWORM MEDICINE TABS F

STROMECTOL TABS (ivermectin) NF PA

ANTI-INFECTIVE AGENTS - MISC. - Drugs to Treat Bacterial Infections

Anti-infective Agents - Misc. AEMCOLO TBEC F

bacitracin solr im F

FIRST-METRONIDAZOLE 100 SUSR F

FIRST-METRONIDAZOLE 50 SUSR F

FLAGYL CAPS (metronidazole) NF

FLAGYL TABS (metronidazole) NF

IMPAVIDO CAPS F

METRONIDAZOLE BENZOATE/SYRSPENDSF PH4 SUSR

F


8

Drug Name DrugTier

Requirements/Limits

metronidazole caps or 375 mg F

metronidazole in nacl soln F

METRONIDAZOLE SOLN IV 0.74 %-500 MG/100ML(metronidazole in nacl)

NF

METRONIDAZOLE SOLN IV 5 MG/ML F

metronidazole tabs or 250 mg, 500 mg F

NEBUPENT SOLR (pentamidine isethionate) NF

PENTAM 300 SOLR (pentamidine isethionate) NF

pentamidine isethionatesolr 300 mg F

PRIMSOL SOLN F

TINDAMAX TABS (tinidazole) NF

tinidazole tabs or 250 mg,500 mg F

TRIMETHOPRIM POWD XX F

trimethoprim tabs or F

TRIMPEX SOLN F

vancomycin hcl solr F

XIFAXAN TABS F

Anti-infective Misc. - Combinations BACTRIM DS TABS (sulfamethoxazole-trimethoprim)

NF

BACTRIM TABS (sulfamethoxazole-trimethoprim)

NF

sulfamethoxazole-trimethoprim soln F

sulfamethoxazole-trimethoprim susp F

sulfamethoxazole-trimethoprim tabs F

Drug Name DrugTier

Requirements/Limits

Antiprotozoal Agents

ALINIA SUSR F

ALINIA TABS F

atovaquone susp or 750mg/5ml F

MEPRON SUSP (atovaquone) NF

Carbapenems

doripenem solr F

imipenem-cilastatin solr F

meropenem solr F

MEROPENEM/SODIUMCHLORIDE SOLR F

MERREM SOLR (meropenem) NF

PRIMAXIN IV SOLR (imipenem-cilastatin) NF

RECARBRIO SOLR F

VABOMERE SOLR F

Chloramphenicols chloramphenicol sodiumsuccinate solr F

Cyclic Lipopeptides CUBICIN RF SOLR (daptomycin) NF

CUBICIN SOLR (daptomycin) NF

DAPTOMYCIN SOLR 350 MG (daptomycin) NF

daptomycin solr 350 mg,500 mg F

Glycopeptides FIRST-VANCOMYCIN 25 SOLN F

FIRST-VANCOMYCIN 50 SOLN F

FIRVANQ SOLR F


9

Drug Name DrugTier

Requirements/Limits

VANCOCIN CAPS (vancomycin hcl) NF

VANCOCIN HCL CAPS (vancomycin hcl) NF

VANCOMYCIN HCL + SYRSPENDSF PH4 SUSP F

vancomycin hcl caps F

vancomycin hcl solr F

VANCOMYCIN HYDROCHLORIDE SOLN 1000 MG/10ML, 1500MG/15ML, 2000 MG/20ML,500 MG/100ML, 750MG/7.5ML, 1000MG/200ML, 1500MG/300ML, 1250MG/12.5ML, 1750MG/17.5ML

F

VANCOMYCIN HYDROCHLORIDE SOLR 1.5 GM, 1.25 GM

F

VANCOMYCIN HYDROCHLORIDE/DEXTROSE SOLN

F

VANCOMYCIN SOLN F

Leprostatics dapsone tabs or 25 mg,100 mg F

Lincosamides CLEOCIN CAPS OR 75 MG, 150 MG, 300 MG (clindamycin hcl)

NF

CLEOCIN IN D5W SOLN (clindamycin phosphate ind5w)

NF

CLEOCIN PEDIATRIC GRANULES SOLR (clindamycin palmitatehydrochloride)

NF

CLEOCIN PHOSPHATE SOLN IJ 9 GM/60ML, 300MG/2ML, 600 MG/4ML,900 MG/6ML (clindamycin phosphate)

NF

Drug Name DrugTier

Requirements/Limits

CLEOCIN PHOSPHATE SOLN IV 300 MG/2ML, 600MG/4ML, 900 MG/6ML

F

CLEOCIN PHOSPHATE SOLN IV 300 MG/50ML-5%, 5 %-600 MG/50ML(clindamycin phosphate ind5w)

NF

CLIN SINGLE USE KIT KIT F

clindamycin hcl caps or 75mg, 150 mg, 300 mg F

clindamycin palmitatehydrochloride solr 75mg/5ml

F

clindamycin phosphate ind5w soln F

clindamycin phosphate solnij 9 gm/60ml, 300 mg/2ml,600 mg/4ml, 900 mg/6ml,9000 mg/60ml

F

clindamycin phosphate solniv 300 mg/2ml, 600 mg/4ml,900 mg/6ml

F

CLINDAMYCIN/SODIUMCHLORIDE SOLN F

LINCOCIN SOLN (lincomycin hcl) NF

lincomycin hcl soln ij 300mg/ml F

Monobactams AZACTAM SOLR (aztreonam) NF

AZACTAMIN ISO-OSMOTIC DEXTROSE SOLN

F

aztreonam solr F

Oxazolidinones linezolid in sodium chloride soln F

linezolid soln F

linezolid susr F

linezolid tabs F


10

Drug Name DrugTier

Requirements/Limits

SIVEXTRO SOLR F

SIVEXTRO TABS F

ZYVOX SOLN IV 200 MG/100ML F

ZYVOX SOLN IV 600 MG/300ML (linezolid) NF

ZYVOX SUSR OR 100 MG/5ML (linezolid) NF

ZYVOX TABS OR 600 MG (linezolid) NF

Pleuromutilins

XENLETA SOLN F

Polymyxins colistimethate sodium solr ij150 mg F

COLY-MYCIN M SOLR (colistimethate sodium) NF

POLYMYXIN B SULFATE POWD XX 100 MU, F

polymyxin b sulfate solr ij500000 unit F

Streptogramins

SYNERCID SOLR F

ANTIANGINAL AGENTS - Drugs to Treat Chest Pain

Antianginals-Other RANEXA TB12 (ranolazine) NF PA

ranolazine tb12 F PA

Nitrates

DILATRATE SR CPCR F

ISORDIL TITRADOSE TABS 5 MG (isosorbide dinitrate)

NF MP

isosorbide dinitrate tabs 5 mg, 10 mg, 20 mg, 30 mg F MP

isosorbide dinitrate tbcr 40 mg F MP

Drug Name DrugTier

Requirements/Limits

isosorbide mononitrate tabs F MP

isosorbide mononitrate tb24 F MP

NITRO-BID OINT F

NITRO-DUR PT24 0.1 MG/HR, 0.2 MG/HR, 0.4MG/HR, 0.6 MG/HR(nitroglycerin)

NF

MP

NITRO-DUR PT24 0.3 MG/HR, 0.8 MG/HR F

nitroglycerin cpcr or 9 mg,2.5 mg, 6.5 mg F MP

nitroglycerin pt24 td 0.1mg/hr, 0.2 mg/hr, 0.4mg/hr, 0.6 mg/hr

F MP

nitroglycerin subl sl 0.3 mg,0.4 mg, 0.6 mg F MP

NITROSTAT SUBL (nitroglycerin) NF MP

ANTIANXIETY AGENTS - Drugs to Treat Anxiety

Antianxiety Agents - Misc.

buspirone hcl tabs or 30 mg F


buspirone hcl tabs or 5 mg,10 mg, 15 mg, 7.5 mg F


hydroxyzine hcl syrp or 10mg/5ml F QL(10 ml daily)

hydroxyzine hcl tabs or 10mg, 25 mg, 50 mg F QL(8 ea daily)

hydroxyzine pamoate capsor 25 mg, 50 mg, 100 mg F QL(4 ea daily)

VISTARIL CAPS (hydroxyzine pamoate) NF QL(4 ea daily)

Benzodiazepines

ALPRAZOLAM INTENSOL CONC F

Limit 1 anxiolytic per30 days;QL(60ml per 15 daysretail); AL(Atleast 6 yrs old)


11

Drug Name DrugTier

Requirements/Limits

alprazolam tabs or 0.25mg, 0.5 mg, 1 mg F

Limit 1 anxiolytic per30 days;QL(4ea daily); AL(Atleast 6 yrs old)

alprazolam tabs or 2 mg F


alprazolam tb24 or 0.5 mg,1 mg, 2 mg, 3 mg F


alprazolam tbdp or 0.25mg, 0.5 mg, 1 mg F


alprazolam tbdp or 2 mg F


ATIVAN TABS OR 0.5 MG, 1 MG (lorazepam) NF


ATIVAN TABS OR 2 MG (lorazepam) NF


chlordiazepoxide hcl caps F QL(2 ea daily);AL(At least 6yrs old)

clorazepate dipotassiumtabs 15 mg F


clorazepate dipotassiumtabs 7.5 mg, 3.75 mg F


diazepam conc or 5 mg/ml F QL(2 ml daily)

diazepam soln or 5 mg/5ml F QL(10 ml daily)

diazepam tabs or 2 mg, 5mg, 10 mg F


Drug Name DrugTier

Requirements/Limits

lorazepam conc or 2 mg/ml F QL(2 ml daily);AL(At least 6yrs old)

lorazepam tabs or 0.5 mg,1 mg F


lorazepam tabs or 2 mg F


oxazepam caps F QL(2 ea daily);AL(At least 6yrs old)

TRANXENE T TABS (clorazepate dipotassium) NF


VALIUM TABS (diazepam) NF QL(4 ea daily);AL(At least 6yrs old)

XANAX TABS 0.25 MG, 0.5 MG, 1 MG (alprazolam) NF


XANAX TABS 2 MG (alprazolam) NF


XANAX XR TB24 (alprazolam) NF


ANTIARRHYTHMICS - Drugs to treat abnormal heart rhythms

Antiarrhythmics Type I-A disopyramide phosphate caps F

NORPACE CAPS (disopyramide phosphate) NF

NORPACE CR CP12 F

quinidine gluconate tbcr or324 mg F


12

Drug Name DrugTier

Requirements/Limits

quinidine sulfate tabs or200 mg, 300 mg F

Antiarrhythmics Type I-B mexiletine hcl caps 150mg, 200 mg, 250 mg F

Antiarrhythmics Type I-C

flecainide acetate tabs F

propafenone hcl cp12 F

propafenone hcl tabs F

RYTHMOL SR CP12 (propafenone hcl) NF

Antiarrhythmics Type III amiodarone hcl tabs or 100 mg, 200 mg F

CORDARONE TABS (amiodarone hcl) NF

dofetilide caps F PA

MULTAQ TABS F PA

TIKOSYN CAPS (dofetilide) NF PA

ANTIASTHMATIC AND BRONCHODILATOR AGENTS - Drugs to Treat Lung Conditions

Anti-Inflammatory Agents

cromolyn sodium nebu in F

CROMOLYN SODIUM NEBU IN F

CROMOLYN SODIUM POWD XX F

Bronchodilators - Anticholinergics

ATROVENT HFA AERS F

INCRUSE ELLIPTA AEPB F

IPRATROPIUM BROMIDE MONOHYDRATE POWD F

IPRATROPIUM BROMIDE POWD XX F

ipratropium bromide soln in F

Drug Name DrugTier

Requirements/Limits

LONHALA MAGNAIR REFILL KIT SOLN F

LONHALA MAGNAIR STARTER KIT SOLN F

SEEBRI NEOHALER CAPS F

SPIRIVA HANDIHALER CAPS F QL(1 ea daily)

SPIRIVA RESPIMAT AERS F

TUDORZA PRESSAIR AEPB F

YUPELRI SOLN F

Leukotriene Modulators ACCOLATE TABS (zafirlukast) NF

montelukast sodium chew or 4 mg, 5 mg F QL(1 ea daily)

montelukast sodium packor 4 mg F

QL(1 ea daily);AL(Up to 3 yrsold )

montelukast sodium tabs or 10 mg F QL(1 ea daily)

SINGULAIR CHEW 4 MG, 5 MG (montelukast sodium) NF QL(1 ea daily)

SINGULAIR PACK 4 MG (montelukast sodium) NF

QL(1 ea daily);AL(Up to 3 yrsold )

SINGULAIR TABS 10 MG (montelukast sodium) NF QL(1 ea daily)

zafirlukast tabs F

Selective Phosphodiesterase 4 (PDE4) Inhibitors

DALIRESP TABS F

Steroid Inhalants

ALVESCO AERS F

ARMONAIR RESPICLICK 113 AEPB F




13

Drug Name DrugTier

Requirements/Limits

ARNUITY ELLIPTA AEPB F

ASMANEX HFA AERO F

ASMANEX TWISTHALER 120 METERED DOSES AEPB

F


F


F


F


F

budesonide (inhalation) susp F AL(Up to 4 yrs

old )

FLOVENT DISKUS AEPB F

FLOVENT HFA AERO F

FLUNISOLIDE ANHYDROUS POWD F

PULMICORT FLEXHALER AEPB F

PULMICORT SUSP (budesonide (inhalation)) NF AL(Up to 4 yrs

old ) Sympathomimetics

ADVAIR HFA AERO F

AIRDUO RESPICLICK 113/14 AEPB (fluticasone-salmeterol)

NF


NF


NF

albuterol sulfate aers in 108 mcg/act F

6 rtl pack lmtamt,90 rtl packlmt day(s),

Drug Name DrugTier

Requirements/Limits

ALBUTEROL SULFATE NEBU IN 0.5 % F

albuterol sulfate nebu in 0.63 mg/3ml, 0.083 %, 0.5%, 1.25 mg/3ml, 2.5mg/0.5ml

F

ALBUTEROL SULFATE POWD XX F

albuterol sulfate syrp or 2mg/5ml F

albuterol sulfate tb12 or 4 mg, 8 mg F

ANORO ELLIPTA AEPB F

ARCAPTA NEOHALER CAPS F

BEVESPI AEROSPHERE AERO F

BREO ELLIPTA AEPB F

BROVANA NEBU F

budesonide-formoterol fumarate dihydrate aero F

COMBIVENT RESPIMAT AERS F

1 rtl pack lmtamt,30 rtl packlmt day(s),

DUAKLIR PRESSAIR AEPB F

DULERA AERO F

EPHEDRINE HCL POWD F

EPHEDRINE SULFATE POWD XX F

fluticasone-salmeterol aepb F

ipratropium-albuterol soln F

isoproterenol hcl soln ij 0.2mg/ml F

ISUPREL SOLN (isoproterenol hcl) NF

levalbuterol tartrate aero F

METAPROTERENOL SULFATE POWD XX F


14

Drug Name DrugTier

Requirements/Limits

metaproterenol sulfate syrpor 10 mg/5ml F

metaproterenol sulfate tabsor 10 mg, 20 mg F

PERFOROMIST NEBU F

PROAIR DIGIHALER AEPB F

PROAIR HFA AERS F 6 rtl pack lmtamt,90 rtl packlmt day(s),

PROAIR RESPICLICK AEPB F

racepinephrine hcl nebu in2.25 % F

S2 NEBU (racepinephrine hcl) NF

SEREVENT DISKUS AEPB F

STIOLTO RESPIMAT AERS F

STRIVERDI RESPIMAT AERS F

SYMBICORT AERO (budesonide-formoterol fumarate dihydrate)

F

TERBUTALINE SULFATE POWD XX F

terbutaline sulfate soln ij 1mg/ml F

terbutaline sulfate tabs or 5 mg, 2.5 mg F

TRELEGY ELLIPTA AEPB F

UTIBRON NEOHALER CAPS F

XOPENEX HFA AERO (levalbuterol tartrate) F

Xanthines AMINOPHYLLINE ANHYDROUS POWD F

AMINOPHYLLINE POWD XX F

aminophylline soln iv F

Drug Name DrugTier

Requirements/Limits

ELIXOPHYLLIN ELIX F

THEO-24 CP24 F

THEOPHYLLINE ETHYLENEDIAMINE EP POWD

F

theophylline soln F

theophylline tb12 F

theophylline tb24 F

THEOPHYLLINE/D5WSOLN F

ANTICOAGULANTS - Blood Thinners

Coumarin Anticoagulants COUMADIN TABS (warfarin sodium) NF

warfarin sodium tabs F

Direct Factor Xa Inhibitors ELIQUIS STARTER PACK TABS F QL(74 ea per

30 days retail)

ELIQUIS TABS 2.5 MG F QL(2 ea daily)

ELIQUIS TABS 5 MG F QL(74 ea per30 days retail)

XARELTO STARTER PACK TBPK F

51 per monthQL(1.7 eadaily)

XARELTO TABS F QL(2 ea daily)

Heparins And Heparinoid-Like Agents

enoxaparin sodium soln ij300 mg/3ml F

QL(180 ml per30 days retail);SP

enoxaparin sodium soln sc100 mg/ml, 150 mg/ml F


enoxaparin sodium soln sc30 mg/0.3ml F





15

Drug Name DrugTier

Requirements/Limits



enoxaparin sodium soln sc80 mg/0.8ml, 120 mg/0.8ml F


heparin (porcine) in sodiumchloride soln F

HEPARIN LOCK FLUSH SOLN (heparin sodium(porcine) lock flush)

NF

heparin sod (porcine) ind5w soln F

heparin sodium (porcine)lock flush soln F

heparin sodium (porcine)soln F

HEPARIN SODIUM/D5WSOLN F

HEPARIN SODIUM/D5WSOLN NF

HEPARIN SODIUM/DEXTROSESOLN 25000 UNIT/250ML-5 %, 25000 UNIT/500ML-5%

F

HEPARIN SODIUM/NACL0.45% SOLN 0.45 %-12500 UNIT/250ML

F

HEPARIN SODIUM/SODIUMCHLORIDE 0.9% SOLN

NF

HEPARIN SODIUM/SODIUMCHLORIDE SOLN 0.9 %-1000 UNIT/500ML, 0.9 %-2000 UNIT/L

F

LOVENOX SOLN IJ 300 MG/3ML (enoxaparin sodium)

NF QL(180 ml per30 days retail);SP

LOVENOX SOLN SC 100 MG/ML, 150 MG/ML(enoxaparin sodium)


LOVENOX SOLN SC 30 MG/0.3ML (enoxaparin sodium)


Drug Name DrugTier

Requirements/Limits





LOVENOX SOLN SC 80 MG/0.8ML, 120 MG/0.8ML(enoxaparin sodium)


Thrombin Inhibitors

PRADAXA CAPS F QL(2 ea daily)

ANTICONVULSANTS - Drugs to Treat Seizures

Anticonvulsants - Benzodiazepines

clobazam susp F PA

clobazam tabs F PA

clonazepam tabs or 0.5mg, 1 mg F


clonazepam tabs or 2 mg F QL(2 ea daily);AL(At least 6yrs old)

clonazepam tbdp or 0.125mg, 0.25 mg, 0.5 mg, 1 mg F


clonazepam tbdp or 2 mg F QL(2 ea daily);AL(At least 6yrs old)

DIASTAT ACUDIAL GEL (diazepam(anticonvulsant))

F QL(2 ea per 30days retail)

DIASTAT PEDIATRIC GEL (diazepam(anticonvulsant))


diazepam (anticonvulsant)gel F QL(2 ea per 30

days retail)

KLONOPIN TABS 0.5 MG, 1 MG (clonazepam) NF


KLONOPIN TABS 2 MG (clonazepam) NF


ONFI SUSP (clobazam) NF PA


16

Drug Name DrugTier

Requirements/Limits

ONFI TABS (clobazam) NF PA

Anticonvulsants - Misc. BANZEL SUSP F PA; SP

BANZEL TABS F PA; SP

carbamazepine chew or100 mg F

carbamazepine cp12 or100 mg, 200 mg, 300 mg F

carbamazepine susp or100 mg/5ml F

carbamazepine tabs or 200 mg F

carbamazepine tb12 or 100mg, 200 mg, 400 mg F

CARBATROL CP12 (carbamazepine) NF

gabapentin caps or 100mg, 300 mg, 400 mg F

gabapentin soln or 250mg/5ml, 300 mg/6ml F

gabapentin tabs or 600 mg,800 mg F

KEPPRA SOLN OR 100 MG/ML (levetiracetam) NF

KEPPRA TABS OR 250 MG, 500 MG, 750 MG, 1000 MG (levetiracetam)

NF

KEPPRA XR TB24 (levetiracetam) NF

LAMICTAL CHEWABLE DISPERSIBLE CHEW (lamotrigine)

NF

LAMICTAL ODT TBDP 25 MG, 50 MG, 100 MG, 200 MG (lamotrigine)

NF

LAMICTAL TABS (lamotrigine) NF

LAMICTAL XR TB24 200 MG, 250 MG, 300 MG (lamotrigine)

NF QL(2 ea daily)

LAMICTAL XR TB24 25 MG, 50 MG, 100 MG (lamotrigine)

NF QL(3 ea daily)

Drug Name DrugTier

Requirements/Limits

lamotrigine chew or 5 mg,25 mg F

lamotrigine tabs or 25 mg,100 mg, 150 mg, 200 mg F

lamotrigine tb24 or 200 mg,250 mg, 300 mg F QL(2 ea daily)

lamotrigine tb24 or 25 mg,50 mg, 100 mg F QL(3 ea daily)

lamotrigine tbdp or 25 mg,50 mg, 100 mg, 200 mg F

levetiracetam soln or 100 mg/ml, 500 mg/5ml F

levetiracetam tabs or 250 mg, 500 mg, 750 mg, 1000 mg

F

levetiracetam tb24 or 500 mg, 750 mg F

LYRICA CAPS (pregabalin) NF PA

LYRICA SOLN (pregabalin) NF PA

MYSOLINE TABS (primidone) NF

NEURONTIN CAPS (gabapentin) NF

NEURONTIN SOLN (gabapentin) NF

NEURONTIN TABS (gabapentin) NF

oxcarbazepine susp F

oxcarbazepine tabs F

pregabalin caps or 25 mg,50 mg, 75 mg, 100 mg, 150mg, 200 mg, 225 mg, 300 mg

F

PA

pregabalin soln or 20mg/ml F PA

primidone tabs or 50 mg,250 mg F

TEGRETOL SUSP (carbamazepine) NF

TEGRETOL TABS (carbamazepine) NF

TEGRETOL-XR TB12 (carbamazepine) NF


17

Drug Name DrugTier

Requirements/Limits

TOPAMAX SPRINKLE CPSP (topiramate) NF

TOPAMAX TABS (topiramate) NF

topiramate cpsp or 15 mg,25 mg F

topiramate tabs or 25 mg,50 mg, 100 mg, 200 mg F

TRILEPTAL SUSP (oxcarbazepine) NF

TRILEPTAL TABS (oxcarbazepine) NF

VIMPAT SOLN OR 10 MG/ML F PA

VIMPAT TABS OR 50 MG, 100 MG, 150 MG, 200 MG F PA

ZONEGRAN CAPS (zonisamide) NF

zonisamide caps or 25 mg,50 mg, 100 mg F

Carbamates felbamate susp 600mg/5ml F

felbamate tabs 400 mg F QL(9 ea daily)

felbamate tabs 600 mg F QL(6 ea daily)

FELBATOL SUSP 600 MG/5ML (felbamate) NF

FELBATOL TABS 400 MG (felbamate) NF QL(9 ea daily)

FELBATOL TABS 600 MG (felbamate) NF QL(6 ea daily)

GABA Modulators GABITRIL TABS (tiagabine hcl) NF PA

tiagabine hcl tabs F PA

Hydantoins DILANTIN CAPS 100 MG (phenytoin sodiumextended)

NF

DILANTIN CAPS 30 MG F

DILANTIN INFATABS CHEW (phenytoin) NF

Drug Name DrugTier

Requirements/Limits

DILANTIN-125 SUSP (phenytoin) NF

PHENYTEK CAPS (phenytoin sodiumextended)

NF

phenytoin chew or 50 mg F

phenytoin sodium extended caps F

phenytoin susp or 100mg/4ml, 125 mg/5ml F

Succinimides ethosuximide caps or 250 mg F

ethosuximide soln or 250 mg/5ml F

ZARONTIN CAPS (ethosuximide) NF

ZARONTIN SOLN (ethosuximide) NF

Valproic Acid DEPAKENE CAPS (valproic acid) NF

DEPAKENE SOLN (valproate sodium) NF

DEPAKOTE ER TB24 (divalproex sodium) NF

DEPAKOTE SPRINKLES CSDR (divalproex sodium) NF

DEPAKOTE TBEC 125 MG, 250 MG (divalproex sodium)

NF QL(16 ea daily)

DEPAKOTE TBEC 500 MG (divalproex sodium) NF QL(8 ea daily)

divalproex sodium csdr or125 mg F

divalproex sodium tb24 or250 mg, 500 mg F

divalproex sodium tbec or125 mg, 250 mg F QL(16 ea daily)

divalproex sodium tbec or500 mg F QL(8 ea daily)

valproate sodium soln or250 mg/5ml F


18

Drug Name DrugTier

Requirements/Limits

valproic acid caps or 250 mg F

ANTIDEPRESSANTS - Drugs to Treat Depression

Alpha-2 Receptor Antagonists (Tetracyclics)

mirtazapine tabs or 15 mg,30 mg, 45 mg F


mirtazapine tabs or 7.5 mg F QL(1 ea daily)

mirtazapine tbdp or 15 mg,30 mg, 45 mg F


REMERON SOLTAB TBDP (mirtazapine) NF


REMERON TABS (mirtazapine) NF


Antidepressants - Misc.

bupropion hcl tabs or 75mg, 100 mg F


bupropion hcl tb12 or 100mg, 150 mg, 200 mg F


bupropion hcl tb24 or 150mg, 300 mg F


maprotiline hcl tabs F AL(At least 6yrs old)

WELLBUTRIN SR TB12 (bupropion hcl) NF


WELLBUTRIN XL TB24 (bupropion hcl) NF


N-Methyl-D-aspartic acid (NMDA) Receptor SPRAVATO 56MG DOSE SOPK F PA; SP

SPRAVATO 84MG DOSE SOPK F PA; SP

Selective Serotonin Reuptake Inhibitors (SSRIs)

CELEXA TABS 10 MG (citalopram hydrobromide) NF


Drug Name DrugTier

Requirements/Limits

CELEXA TABS 20 MG, 40 MG (citalopramhydrobromide)


citalopram hydrobromidesoln 10 mg/5ml F

QL(20 mldaily); AL(Atleast 6 yrs old -Up to 12 yrsold)

citalopram hydrobromidetabs 10 mg F


citalopram hydrobromidetabs 20 mg, 40 mg F


escitalopram oxalate tabs10 mg F

45 permonth;QL(1.5ea daily); AL(Atleast 6 yrs old)

escitalopram oxalate tabs20 mg F


escitalopram oxalate tabs 5 mg F


fluoxetine hcl caps or 10mg, 40 mg F


fluoxetine hcl caps or 20 mg F


fluoxetine hcl soln or 20 mg/5ml F


FLUOXETINE HYDROCHLORIDE TABS (fluoxetine hcl)

NF QL(1 ea daily)

fluvoxamine maleate tabs 100 mg F







19

Drug Name DrugTier

Requirements/Limits

LEXAPRO TABS 10 MG (escitalopram oxalate) NF






paroxetine hcl tabs 10 mg,20 mg, 30 mg F


paroxetine hcl tabs 40 mg F


PAXIL TABS 10 MG, 20 MG, 30 MG (paroxetine hcl)


PAXIL TABS 40 MG (paroxetine hcl) NF


PROZAC CAPS 10 MG, 40 MG (fluoxetine hcl) NF


PROZAC CAPS 20 MG (fluoxetine hcl) NF


sertraline hcl conc or 20 mg/ml F


sertraline hcl tabs or 100 mg F


sertraline hcl tabs or 25 mg F QL(3 ea daily);AL(At least 6yrs old)

sertraline hcl tabs or 50 mg F QL(4 ea daily);AL(At least 6yrs old)

Drug Name DrugTier

Requirements/Limits

ZOLOFT CONC 20 MG/ML(sertraline hcl) NF


ZOLOFT TABS 100 MG (sertraline hcl) NF






Serotonin Modulators

trazodone hcl tabs or 100 mg F








Serotonin-Norepinephrine Reuptake Inhibitors

CYMBALTA CPEP 20 MG, 30 MG (duloxetine hcl) NF


CYMBALTA CPEP 60 MG (duloxetine hcl) NF


duloxetine hcl cpep or 20mg, 30 mg F


duloxetine hcl cpep or 60 mg F


EFFEXOR XR CP24 150 MG (venlafaxine hcl) NF


EFFEXOR XR CP24 75 MG, 37.5 MG (venlafaxine hcl)



20

Drug Name DrugTier

Requirements/Limits

venlafaxine hcl cp24 150 mg F


venlafaxine hcl cp24 75mg, 37.5 mg F


venlafaxine hcl tabs 25 mg F QL(4 ea daily);AL(At least 6yrs old)

venlafaxine hcl tabs 50 mg,100 mg, 37.5 mg F


venlafaxine hcl tabs 75 mg F QL(5 ea daily);AL(At least 6yrs old)

Tricyclic Agents amitriptyline hcl tabs or 10mg, 25 mg, 50 mg, 75 mg,100 mg, 150 mg

F AL(At least 6yrs old)

amoxapine tabs F AL(At least 6yrs old)

ANAFRANIL CAPS (clomipramine hcl) NF AL(At least 6

yrs old) clomipramine hcl caps or25 mg, 50 mg, 75 mg F AL(At least 6

yrs old) desipramine hcl tabs or 10mg, 25 mg, 50 mg, 75 mg,100 mg, 150 mg


doxepin hcl caps or 10 mg,25 mg, 50 mg, 75 mg, 100mg, 150 mg


doxepin hcl conc or 10mg/ml F

QL(6 ml daily);AL(At least 6yrs old)

imipramine hcl tabs or 10mg, 25 mg, 50 mg F AL(At least 6

yrs old)

imipramine pamoate caps F AL(At least 6yrs old)

NORPRAMIN TABS (desipramine hcl) NF AL(At least 6

yrs old) nortriptyline hcl caps or 10mg, 25 mg, 50 mg, 75 mg F AL(At least 6

yrs old) nortriptyline hcl soln or 10mg/5ml F AL(At least 6

yrs old) PAMELOR CAPS (nortriptyline hcl) NF AL(At least 6

yrs old)

Drug Name DrugTier

Requirements/Limits

protriptyline hcl tabs F AL(At least 6yrs old)

SURMONTIL CAPS (trimipramine maleate) NF AL(At least 6

yrs old) TOFRANIL TABS (imipramine hcl) NF AL(At least 6

yrs old) trimipramine maleate capsor 25 mg, 50 mg, 100 mg F AL(At least 6

yrs old) ANTIDIABETICS - Drugs to Regulate Blood Sugar Alpha-Glucosidase Inhibitors

acarbose tabs F MP

PRECOSE TABS (acarbose) NF MP

Antidiabetic - Amylin Analogs

SYMLINPEN 120 SOPN F PA

SYMLINPEN 60 SOPN F PA

Antidiabetic Combinations ACTOPLUS MET TABS (pioglitazone hcl-metforminhcl)

NF MP

ACTOPLUS MET XR TB24 F

glyburide-metformin tabs F MP

GLYXAMBI TABS F PA

JANUMET TABS F PA

JANUMET XR TB24 F PA

JENTADUETO TABS F PA

KOMBIGLYZE XR TB24 F PA

pioglitazone hcl-metforminhcl tabs F MP

Biguanides GLUCOPHAGE TABS (metformin hcl) NF MP

GLUCOPHAGE XR TB24 (metformin hcl) NF MP


21

Drug Name DrugTier

Requirements/Limits

metformin hcl tabs or 500 mg, 850 mg, 1000 mg F MP

metformin hcl tb24 or 500 mg, 750 mg F MP

Diabetic Other CVS GLUCOSE BITS CHEW F

CVS GLUCOSE CHEW 4 GM F

CVS SOFT GLUCOSE CHEW F

DEX4 FAST ACTING GLUCOSEGO-POUCH GEL

F

DEX4 QUICK DISSOLVE GLUCOSE CHEW F

dextrose (diabetic use) gel40 %, 15 gm/38gm F MP

GLUCAGON EMERGENCY KIT KIT F

1 permonth;QL(0.034 ea daily)

GLUCOSE CHEW 4 GM F

GLUCOSE GEL 15 GM/33GM F

GNP GLUCOSE CHEW 4 GM F

GNP QUICK DISSOLVE GLUCOSE CHEW F

INSTA-GLUCOSE GEL F

LEADER QUICK DISSOLVE GLUCOSE CHEW

F

SM GLUCOSE CHEW 4 GM F

WALGREENS GLUCOSE CHEW 4 GM F

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors

JANUVIA TABS F PA

ONGLYZA TABS F PA

TRADJENTA TABS F PA

Incretin Mimetic Agents (GLP-1 Receptor

Drug Name DrugTier

Requirements/Limits

BYDUREON PEN PEN F PA

BYDUREON SRER F PA

BYETTA SOPN F PA

VICTOZA SOPN F PA

Insulin Sensitizing Agents ACTOS TABS (pioglitazone hcl) NF MP

pioglitazone hcl tabs F MP

Insulin

HUMALOG KWIKPEN SOPN 100 UNIT/ML F

Limit 1.0 ml perday;QL(1 mldaily)

HUMALOG MIX 50/50KWIKPEN SUPN F


HUMALOG MIX 50/50SUSP F


HUMALOG MIX 75/25KWIKPEN SUPN F


HUMALOG MIX 75/25SUSP F


HUMALOG SOLN 100 UNIT/ML F


HUMULIN 70/30 SUSP 30UNIT/ML-70 UNIT/ML F


HUMULIN N SUSP 100 UNIT/ML F


HUMULIN R SOLN F Limit 1.0 ml perday;QL(1 mldaily)

HUMULIN R U-500 (CONCENTRATED) SOLN F PA

HUMULIN R U-500 KWIKPEN SOPN F PA


22

Drug Name DrugTier

Requirements/Limits

LANTUS SOLN 100 UNIT/ML F


LANTUS SOLOSTAR SOPN 100 UNIT/ML F


LEVEMIR FLEXTOUCH SOPN F


LEVEMIR SOLN F Limit 1.0 ml perday;QL(1 mldaily)

NOVOLIN N SUSP 100 UNIT/ML F


NOVOLIN R SOLN F Limit 1.0 ml perday;QL(1 mldaily)

NOVOLOG FLEXPEN SOPN 100 UNIT/ML F


NOVOLOG MIX 70/30PREFILLED FLEXPEN SUPN

F Limit 1.0 ml perday;QL(1 mldaily)

NOVOLOG MIX 70/30SUSP F


NOVOLOG PENFILL SOCT 100 UNIT/ML F


NOVOLOG SOLN 100 UNIT/ML F


SEMGLEE SOLN 100 UNIT/ML F


Meglitinide Analogues

nateglinide tabs F MP

PRANDIN TABS (repaglinide) NF MP

repaglinide tabs F MP

STARLIX TABS (nateglinide) NF MP

Sodium-Glucose Co-Transporter 2 (SGLT2)

Drug Name DrugTier

Requirements/Limits

FARXIGA TABS F PA

INVOKANA TABS F PA

JARDIANCE TABS F PA

Sulfonylureas AMARYL TABS (glimepiride) NF MP

glimepiride tabs F MP

glipizide tabs or 5 mg, 10 mg F MP

glipizide tb24 or 5 mg, 10mg, 2.5 mg F MP

GLUCOTROL TABS (glipizide) NF MP

GLUCOTROL XL TB24 (glipizide) NF MP

glyburide micronized tabs F MP

glyburide tabs or 5 mg, 2.5mg, 1.25 mg F MP

GLYNASE TABS (glyburide micronized) NF MP

tolazamide tabs F MP

tolbutamide tabs F

ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugs to Treat Diarrhea

Antidiarrheal/Probiotic Agents - Misc. bismuth subsalicylate chewor 262 mg F

bismuth subsalicylate suspor 262 mg/15ml, 525mg/15ml, 525 mg/30ml,527 mg/30ml, 1050mg/30ml

F

bismuth subsalicylate tabsor 262 mg F

FORTIFY OPTIMA PROBIOTIC CPDR F

FORTIFY PROBIOTIC WOMENSEXTRA STRENGTH CPDR

F


23

Drug Name DrugTier

Requirements/Limits

MVW COMPLETE PROBIOTIC FORMULATION CPDR

F

NEXABIOTIC CPDR F

PEPTO BISMOL TABS (bismuth subsalicylate) NF

PEPTO-BISMOL CHEW (bismuth subsalicylate) NF

PEPTO-BISMOL MAX STRENGTH SUSP (bismuth subsalicylate)

NF

PEPTO-BISMOL SUSP (bismuth subsalicylate) NF

PEPTO-BISMOL TO-GO CHEW (bismuth subsalicylate)

NF

Antiperistaltic Agents diphenoxylate w/ atropineliqd F

diphenoxylate w/ atropinetabs F

IMODIUM A-D CAPS 2 MG (loperamide hcl) NF RX/OTC

IMODIUM A-D LIQD 1 MG/7.5ML (loperamide hcl) NF

IMODIUM A-D TABS 2 MG (loperamide hcl) NF

LOMOTIL TABS (diphenoxylate w/ atropine) NF

loperamide hcl caps or 2 mg F RX/OTC

loperamide hcl liqd or 1mg/5ml, 1 mg/7.5ml F

loperamide hcl susp or 1mg/7.5ml F

loperamide hcl tabs or 2 mg F

ANTIDOTES AND SPECIFIC ANTAGONISTS

Opioid Antagonists naloxone hcl soct ij 0.4mg/ml F

naloxone hcl soln ij 0.4mg/ml, 4 mg/10ml F

Drug Name DrugTier

Requirements/Limits

naloxone hcl sosy ij 2mg/2ml F

naltrexone hcl tabs or F

NARCAN LIQD F

VIVITROL SUSR F SP

ANTIEMETICS - Drugs to Treat Nausea andVomiting

5-HT3 Receptor Antagonists

ANZEMET TABS F PA

granisetron hcl tabs or 1 mg F PA

ondansetron hcl soln or 4 mg/5ml F

ondansetron hcl tabs or 4 mg, 8 mg F QL(3 ea daily)

ondansetron tbdp F QL(1 ea daily)

ZOFRAN ODT TBDP (ondansetron) NF QL(1 ea daily)

ZOFRAN SOLN 4 MG/5ML(ondansetron hcl) NF

ZOFRAN TABS 4 MG, 8 MG (ondansetron hcl) NF QL(3 ea daily)

Antiemetics - Anticholinergic dimenhydrinate tabs or 50 mg F

DRAMAMINE CHEW 50 MG F

DRAMAMINE TABS (dimenhydrinate) NF

meclizine hcl chew or 25 mg F

meclizine hcl tabs or 25 mg, 12.5 mg F RX/OTC

TIGAN CAPS OR 300 MG (trimethobenzamide hcl) NF

trimethobenzamide hcl caps or 300 mg F

Substance P/Neurokinin 1 (NK1) Receptor aprepitant caps 40 mg, 80 mg, F QL(6 ea per 21

days retail)


24

Drug Name DrugTier

Requirements/Limits

EMEND CAPS OR 40 MG, 80 MG (aprepitant) NF QL(6 ea per 21

days retail) EMEND TRIPACK CAPS (aprepitant) NF QL(6 ea per 21

days retail)

ANTIFUNGALS - Drugs to Treat Fungal Infections

Antifungals

griseofulvin microsize susp F

griseofulvin microsize tabs F

nystatin tabs or 500000unit F

terbinafine hcl tabs or F QL(90 ea per365 days retail)

Imidazole-Related Antifungals DIFLUCAN SUSR 10 MG/ML, 40 MG/ML(fluconazole)

NF QL(20 ml daily)

DIFLUCAN TABS 50 MG, 100 MG, 150 MG, 200 MG (fluconazole)

NF QL(2 ea daily)

fluconazole susr or 10 mg/ml, 40 mg/ml F QL(20 ml daily)

fluconazole tabs or 50 mg,100 mg, 150 mg, 200 mg F QL(2 ea daily)

ANTIHISTAMINES - Drugs to Treat Allergies

Antihistamines - Alkylamines

ALA-HIST IR TABS F

BROMPHENIRAMINE MALEATE POWD F

BROMPHENIRAMINE SOLN F

brompheniramine tannatechew F

CHLOR-TRIMETON ALLERGY TBCR (chlorpheniramine maleate)

NF

CHLOR-TRIMETON SYRP (chlorpheniramine maleate) NF

CHLOR-TRIMETON TABS (chlorpheniramine maleate) NF

CHLORPHENIRAMINE MALEATE POWD XX F

Drug Name DrugTier

Requirements/Limits

chlorpheniramine maleatesyrp or 2 mg/5ml F

chlorpheniramine maleatetabs or 4 mg F

chlorpheniramine maleatetbcr or 12 mg F

dexchlorpheniraminemaleate soln or F

ED CHLORPED LIQD F

HISTEX CHEW F

HISTEX PD LIQD (triprolidine hcl) NF

HISTEX PDX LIQD F

HISTEX SYRP F

PEDIAVENT CHEW F

PEDIAVENT SYRP F

triprolidine hcl liqd or 0.313mg/ml, 0.625 mg/ml, 0.938mg/ml

F

triprolidine hcl syrp or 2.5mg/5ml F

VANACLEAR PD LIQD (triprolidine hcl) NF

VANAHIST PD LIQD (triprolidine hcl) NF

Antihistamines - Ethanolamines

ALER-DRYL TABS F

BENADRYL ALLERGY CAPS (diphenhydramine hcl)

NF

BENADRYL ALLERGY CHILDRENS CHEW (diphenhydramine hcl)

NF

BENADRYL ALLERGY CHILDRENS LIQD (diphenhydramine hcl)

NF

BENADRYL ALLERGY TABS (diphenhydramine hcl)

NF


25

Drug Name DrugTier

Requirements/Limits

carbinoxamine maleate soln 4 mg/5ml F

carbinoxamine maleate tabs 4 mg F

CARBINOXAMINE MALEATE TABS 6 MG F

CLEMASTINE FUMARATE POWD XX F

clemastine fumarate tabs or 1.34 mg, 2.68 mg F

DICOPANOL FUSEPAQ SUSR F

DICOPANOL RAPIDPAQ SUSR F

diphenhydramine hcl capsor 25 mg, 50 mg F

diphenhydramine hcl chewor 12.5 mg F

diphenhydramine hcl elix or12.5 mg/5ml F RX/OTC

diphenhydramine hcl liqd or25 mg/10ml, 50 mg/20ml,6.25 mg/ml, 12.5 mg/5ml

F

DIPHENHYDRAMINE HCL POWD XX F

diphenhydramine hcl soln ij50 mg/ml F

diphenhydramine hcl tabsor 25 mg F

diphenhydramine hcl tbdpor 12.5 mg F

DOXYLAMINE SUCCINATE POWD F RX/OTC

KARBINAL ER SUER F

RYVENT TABS F

VANAMINE PD LIQD (diphenhydramine hcl) NF

Antihistamines - Ethylenediamines PYRILAMINE MALEATE CRYS F

PYRILAMINE MALEATE POWD F

TRIPELENNAMINE HCL POWD F

Drug Name DrugTier

Requirements/Limits

Antihistamines - Non-Sedating ALLEGRA ALLERGY CHILDRENS SUSP 30 MG/5ML (fexofenadine hcl)

NF QL(5 ml daily)

ALLEGRA ALLERGY CHILDRENS TBDP 30 MG F QL(1 ea daily)

ALLEGRA ALLERGY TABS (fexofenadine hcl) NF QL(1 ea daily)

cetirizine hcl caps 10 mg F QL(1 ea daily)

cetirizine hcl chew 5 mg, 10 mg F QL(1 ea daily)

cetirizine hcl soln 1 mg/ml,5 mg/5ml F QL(5 ml daily);

RX/OTC cetirizine hcl syrp 1 mg/ml,5 mg/5ml F QL(5 ml daily);

RX/OTC cetirizine hcl tabs 5 mg, 10 mg F QL(1 ea daily)

CLARINEX SYRP 0.5 MG/ML F

CLARINEX TABS 5 MG (desloratadine) NF

CLARITIN ALLERGY CHILDRENS SYRP (loratadine)

NF QL(5 ml daily)

CLARITIN CAPS 10 MG (loratadine) NF QL(1 ea daily)

CLARITIN CHEW 5 MG (loratadine) NF QL(1 ea daily)

CLARITIN CHILDRENS CHEW (loratadine) NF QL(1 ea daily)

CLARITIN REDITABS TBDP 10 MG (loratadine) NF QL(1 ea daily)

CLARITIN REDITABS TBDP 5 MG F QL(1 ea daily)

CLARITIN SYRP 5 MG/5ML (loratadine) NF QL(5 ml daily)

CLARITIN TABS 10 MG (loratadine) NF QL(1 ea daily)

desloratadine tabs F

desloratadine tbdp F

fexofenadine hcl susp or 30mg/5ml F QL(5 ml daily)


26

Drug Name DrugTier

Requirements/Limits

fexofenadine hcl tabs or 60 mg, 180 mg F QL(1 ea daily)

levocetirizine dihydrochloride soln or 2.5mg/5ml

F RX/OTC

levocetirizine dihydrochloride tabs or 5 mg

F RX/OTC

loratadine caps or 10 mg F QL(1 ea daily)

loratadine chew or 5 mg F QL(1 ea daily)

loratadine soln or 5 mg/5ml F QL(5 ml daily)

loratadine syrp or 5 mg/5ml F QL(5 ml daily)

loratadine tabs or 10 mg F QL(1 ea daily)

loratadine tbdp or 10 mg F QL(1 ea daily)

QUZYTTIR SOLN F QL(5 ml daily)

XYZAL ALLERGY 24HR CHILDRENS SOLN (levocetirizine dihydrochloride)

NF

RX/OTC

XYZAL ALLERGY 24HR TABS (levocetirizine dihydrochloride)

NF RX/OTC

ZYRTEC ALLERGY CAPS (cetirizine hcl) NF QL(1 ea daily)

ZYRTEC ALLERGY CHILDRENS TBDP F QL(1 ea daily)

ZYRTEC ALLERGY TABS (cetirizine hcl) NF QL(1 ea daily)

ZYRTEC ALLERGY TBDP F QL(1 ea daily)

ZYRTEC CHILDRENS ALLERGY SOLN (cetirizine hcl)

NF QL(5 ml daily);RX/OTC

Antihistamines - Phenothiazines PHENERGAN SOLN (promethazine hcl) NF

promethazine hcl soln ij 25mg/ml, 50 mg/ml F

promethazine hcl soln or6.25 mg/5ml F

Drug Name DrugTier

Requirements/Limits

promethazine hcl supp re25 mg, 50 mg, 12.5 mg F

promethazine hcl syrp or6.25 mg/5ml F

promethazine hcl tabs or25 mg, 50 mg, 12.5 mg F

Antihistamines - Piperazines

AHIST TABS F

Antihistamines - Piperidines cyproheptadine hcl syrp or2 mg/5ml F

cyproheptadine hcl tabs or4 mg F

ANTIHYPERLIPIDEMICS - Drugs to Treat HighCholesterol Bile Acid Sequestrants

cholestyramine light pack F MP

cholestyramine light powd F MP

cholestyramine pack or 4 gm F MP

cholestyramine powd or 4gm/dose F MP

COLESTID FLAVORED GRAN (colestipol hcl) NF MP

COLESTID FLAVORED PACK (colestipol hcl) NF MP

COLESTID GRAN (colestipol hcl) NF MP

COLESTID PACK (colestipol hcl) NF MP

COLESTID TABS (colestipol hcl) NF MP

colestipol hcl gran F MP

colestipol hcl pack F MP

colestipol hcl tabs F MP

QUESTRAN LIGHT POWD (cholestyramine light) NF MP

QUESTRAN PACK (cholestyramine) NF MP


27

Drug Name DrugTier

Requirements/Limits

QUESTRAN POWD (cholestyramine) NF MP

Fibric Acid Derivatives fenofibrate micronized caps67 mg, 134 mg, 200 mg F MP

FENOFIBRATE TABS OR 160 MG F MP

fenofibrate tabs or 48 mg,54 mg, 145 mg, 160 mg F MP

FENOFIBRIC ACID TABS 105 MG F

fenofibric acid tabs 35 mg,105 mg F

FIBRICOR TABS 35 MG, 105 MG F

FIBRICOR TABS 35 MG, 105 MG (fenofibric acid) NF

gemfibrozil tabs or 600 mg F MP

LOPID TABS (gemfibrozil) NF MP

TRICOR TABS (fenofibrate) NF MP

TRIGLIDE TABS F MP

HMG CoA Reductase Inhibitors atorvastatin calcium tabs or 10 mg, 20 mg, 40 mg, 80 mg

F QL(1 ea daily);MP

LIPITOR TABS (atorvastatin calcium) NF QL(1 ea daily);

MP

lovastatin tabs F MP

PRAVACHOL TABS (pravastatin sodium) NF MP

pravastatin sodium tabs F MP

simvastatin tabs or 5 mg,10 mg, 20 mg, 40 mg, 80 mg

F MP

ZOCOR TABS (simvastatin) NF MP

Intestinal Cholesterol Absorption Inhibitors

ezetimibe tabs 10 mg F PA

Drug Name DrugTier

Requirements/Limits

ZETIA TABS (ezetimibe) NF PA

ANTIHYPERTENSIVES - Drugs to Treat HighBlood Pressure

ACE Inhibitors ACCUPRIL TABS (quinapril hcl) NF MP

ALTACE CAPS (ramipril) NF MP

benazepril hcl tabs or 5 mg,10 mg, 20 mg, 40 mg F MP

captopril tabs or 25 mg, 50mg, 100 mg, 12.5 mg F MP

enalapril maleate tabs or 5mg, 10 mg, 20 mg, 2.5 mg F MP

EPANED SOLN F

fosinopril sodium tabs F MP

lisinopril tabs or 5 mg, 10mg, 20 mg, 30 mg, 40 mg,2.5 mg

F MP

LOTENSIN TABS (benazepril hcl) NF MP

moexipril hcl tabs F MP

perindopril erbumine tabs F MP

PRINIVIL TABS (lisinopril) NF MP

quinapril hcl tabs F MP

ramipril caps F MP

trandolapril tabs F MP

VASOTEC TABS (enalapril maleate) NF MP

ZESTRIL TABS (lisinopril) NF MP

Angiotensin II Receptor Antagonists AVAPRO TABS (irbesartan) NF MP

COZAAR TABS (losartan potassium) NF MP

DIOVAN TABS (valsartan) NF MP


28

Drug Name DrugTier

Requirements/Limits

irbesartan tabs F MP

losartan potassium tabs or25 mg, 50 mg, 100 mg F MP

valsartan tabs F MP

Antiadrenergic Antihypertensives CARDURA TABS (doxazosin mesylate) NF MP

CATAPRES TABS (clonidine hcl) NF MP

CATAPRES-TTS-1 PTWK (clonidine) NF

QL(0.15 eadaily); AL(Atleast 6 yrs old);MP





clonidine hcl tabs or 0.1 mg, 0.2 mg, 0.3 mg F MP

clonidine ptwk F


doxazosin mesylate tabs or1 mg, 2 mg, 4 mg, 8 mg F MP

guanfacine hcl tabs F MP

methyldopa tabs F MP

MINIPRESS CAPS (prazosin hcl) NF MP

prazosin hcl caps F MP

terazosin hcl caps F MP

Antihypertensive Combinations ACCURETIC TABS (quinapril-hydrochlorothiazide)

NF MP

amlodipine besylate-benazepril hcl caps F MP

Drug Name DrugTier

Requirements/Limits

atenolol & chlorthalidone tabs F MP

AVALIDE TABS (irbesartan-hydrochlorothiazide)

NF MP

benazepril &hydrochlorothiazide tabs F MP

bisoprolol &hydrochlorothiazide tabs F MP

captopril &hydrochlorothiazide tabs F MP

DIOVAN HCT TABS (valsartan-hydrochlorothiazide)

NF MP

enalapril maleate &hydrochlorothiazide tabs F MP

fosinopril sodium &hydrochlorothiazide tabs F MP

HYZAAR TABS (losartan potassium &hydrochlorothiazide)

NF MP

irbesartan-hydrochlorothiazide tabs F MP

lisinopril &hydrochlorothiazide tabs F MP

LOPRESSOR HCT TABS (metoprolol &hydrochlorothiazide)

NF MP

losartan potassium &hydrochlorothiazide tabs F MP

LOTENSIN HCT TABS (benazepril &hydrochlorothiazide)

NF MP

LOTREL CAPS (amlodipine besylate-benazepril hcl)

NF MP

metoprolol &hydrochlorothiazide tabs F MP

moexipril-hydrochlorothiazide tabs F MP

propranolol &hydrochlorothiazide tabs F MP

quinapril-hydrochlorothiazide tabs F MP

TENORETIC 100 TABS (atenolol & chlorthalidone) NF MP


29

Drug Name DrugTier

Requirements/Limits

TENORETIC 50 TABS (atenolol & chlorthalidone) NF MP

valsartan-hydrochlorothiazide tabs F MP

VASERETIC TABS (enalapril maleate &hydrochlorothiazide)

NF MP

ZESTORETIC TABS (lisinopril &hydrochlorothiazide)

NF MP

ZIAC TABS (bisoprolol &hydrochlorothiazide) NF MP

Direct Renin Inhibitors TEKTURNA TABS (aliskiren fumarate) NF

Selective Aldosterone Receptor Antagonists

eplerenone tabs F PA

INSPRA TABS (eplerenone) NF PA

Vasodilators hydralazine hcl tabs or 10mg, 25 mg, 50 mg, 100 mg F MP

minoxidil tabs or 10 mg, 2.5 mg F MP

ANTIMALARIALS - Drugs to Treat Malaria(Parasitic Infections) Antimalarial Combinations atovaquone-proguanil hcltabs F

COARTEM TABS F

MALARONE TABS (atovaquone-proguanil hcl) NF

PYRIMETHAMINE/LEUCOVORIN CAPS F

Antimalarials

ARAKODA TABS F

CHLOROQUINE PHOSPHATE POWD XX F

chloroquine phosphatetabs or 250 mg, 500 mg F

QL(30 ea per90 daysretail,30 ea per90 days mail)

Drug Name DrugTier

Requirements/Limits

hydroxychloroquine sulfatetabs or 200 mg F


KRINTAFEL TABS F

mefloquine hcl tabs F

PLAQUENIL TABS (hydroxychloroquinesulfate)

NF


PRIMAQUINE PHOSPHATE TABS (primaquine phosphate)

NF

primaquine phosphate tabs26.3 mg F

QUALAQUIN CAPS (quinine sulfate) NF

QUINACRINE DIHYDROCHLORIDE POWD

F

QUINACRINE HCL POWD F

quinine sulfate caps or F

QUININE SULFATE DIHYDRATE POWD F

QUININE SULFATE POWD XX F

ANTIMYASTHENIC/CHOLINERGIC AGENTS

Antimyasthenic/Cholinergic Agents MESTINON SOLN (pyridostigmine bromide) NF

MESTINON TABS (pyridostigmine bromide) NF

MESTINON TIMESPAN TBCR (pyridostigminebromide)

NF

pyridostigmine bromidesoln or 60 mg/5ml F

pyridostigmine bromidetabs or 60 mg F

pyridostigmine bromide tbcror 180 mg F


30

Drug Name DrugTier

Requirements/Limits

ANTIMYCOBACTERIAL AGENTS - Drugs toTreat Tuberculosis (Bacterial Infections) Antimycobacterial Agents ethambutol hcl tabs or 100 mg, 400 mg F

isoniazid syrp or 50 mg/5ml F

ISONIAZID TABS OR 100 MG F

isoniazid tabs or 100 mg,300 mg F

MYAMBUTOL TABS (ethambutol hcl) NF

pyrazinamide tabs or F

RIFADIN CAPS OR 150 MG, 300 MG (rifampin) NF

rifampin caps or 150 mg,300 mg F

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - Drugs to Treat Cancer Antimetabolites

mercaptopurine tabs or F

methotrexate sodium tabs or 2.5 mg F

Antineoplastic - Antibodies

RITUXAN SOLN F PA; SP

Antineoplastic - Hormonal and Related Agents

anastrozole tabs or 1 mg F PA

ARIMIDEX TABS (anastrozole) NF PA

ELIGARD KIT F PA; SP

FARESTON TABS (toremifene citrate) NF PA

FASLODEX SOLN (fulvestrant) NF

FEMARA TABS (letrozole) NF

flutamide caps F

Drug Name DrugTier

Requirements/Limits

letrozole tabs or 2.5 mg F

leuprolide acetate kit ij F PA; SP

LUPRON DEPOT (1-MONTH) KIT F PA; SP




megestrol acetate susp or40 mg/ml, 400 mg/10ml F

megestrol acetate tabs or20 mg, 40 mg F

tamoxifen citrate tabs or 10 mg, 20 mg F

toremifene citrate tabs 60 mg F PA

Antineoplastic Enzyme Inhibitors

AFINITOR DISPERZ TBSO F PA; SP

AFINITOR TABS 10 MG F PA; SP

AFINITOR TABS 5 MG, 2.5 MG, 7.5 MG (everolimus) NF PA; SP

ALECENSA CAPS F PA; SP

BELEODAQ SOLR F PA; SP

CAPRELSA TABS F PA; SP

COTELLIC TABS F PA; SP

erlotinib hcl tabs F PA; SP

everolimus tabs F PA; SP

GLEEVEC TABS (imatinib mesylate) NF PA; SP

ICLUSIG TABS 15 MG, 45 MG F PA; SP

imatinib mesylate tabs F PA; SP

IMBRUVICA CAPS F PA; SP


31

Drug Name DrugTier

Requirements/Limits

IMBRUVICA TABS F PA; SP

INLYTA TABS F PA; SP

IRESSA TABS F PA; SP

JAKAFI TABS F PA; SP

NEXAVAR TABS F PA; SP

NINLARO CAPS F PA; SP

SPRYCEL TABS F PA; SP

SUTENT CAPS F PA; SP

TARCEVA TABS (erlotinib hcl) NF PA; SP

TASIGNA CAPS F PA; SP

TYKERB TABS F PA; SP

VOTRIENT TABS F PA; SP

XALKORI CAPS F PA; SP

ZOLINZA CAPS F PA; SP

Antineoplastics Misc. ACTIMMUNE SOLN F PA; SP

ALFERON N SOLN F PA; SP

bexarotene caps 75 mg F PA; SP

HYDREA CAPS (hydroxyurea) NF

hydroxyurea caps or 500 mg F

INTRON A SOLN F PA; SP

INTRON A SOLR F PA; SP

MATULANE CAPS F SP

SYLATRON KIT F PA; SP

TARGRETIN CAPS (bexarotene) NF PA; SP

Drug Name DrugTier

Requirements/Limits

tretinoin (chemotherapy) caps F SP

Chemotherapy Rescue/Antidote Agents leucovorin calcium tabs or 5 mg, 10 mg, 15 mg, 25 mg F PA

Mitotic Inhibitors

etoposide caps or F PA; SP

ANTIPARKINSON AND RELATED THERAPY AGENTS - Drugs to Treat Parkinson's Disease

Antiparkinson Anticholinergics benztropine mesylate tabsor 0.5 mg, 1 mg, 2 mg F

trihexyphenidyl hcl soln F

trihexyphenidyl hcl tabs F

Antiparkinson COMT Inhibitors COMTAN TABS (entacapone) NF

entacapone tabs 200 mg F

Antiparkinson Dopaminergics amantadine hcl caps or 100 mg F

amantadine hcl syrp or 50mg/5ml F

amantadine hcl tabs or 100 mg F

bromocriptine mesylatecaps or 5 mg F

bromocriptine mesylatetabs or 2.5 mg F

carbidopa-levodopa tabs F

carbidopa-levodopa tbcr F

carbidopa-levodopa tbdp F

MIRAPEX TABS (pramipexoledihydrochloride)

NF

PARLODEL CAPS (bromocriptine mesylate) NF


32

Drug Name DrugTier

Requirements/Limits

PARLODEL TABS (bromocriptine mesylate) NF

pramipexoledihydrochloride tabs 0.125mg, 0.25 mg, 0.75 mg, 0.5mg, 1 mg, 1.5 mg

F

REQUIP TABS (ropinirole hydrochloride) NF

ropinirole hydrochloridetabs 0.25 mg, 0.5 mg, 1mg, 2 mg, 3 mg, 4 mg, 5 mg

F

SINEMET CR TBCR (carbidopa-levodopa) NF

SINEMET TABS (carbidopa-levodopa) NF

STALEVO 100 TABS (carbidopa-levodopa-entacapone)

NF PA


NF PA


NF PA


NF PA


NF PA


NF PA

ANTIPSYCHOTICS/ANTIMANIC AGENTS -Drugs to Treat Mood Disorders

Antimanic Agents lithium carbonate caps or150 mg, 300 mg, 600 mg F AL(At least 6

yrs old) lithium carbonate tabs or 300 mg F AL(At least 6

yrs old) lithium carbonate tbcr or 300 mg, 450 mg F AL(At least 6

yrs old)

LITHIUM SOLN F AL(At least 6yrs old)

Drug Name DrugTier

Requirements/Limits

LITHOBID TBCR (lithium carbonate) NF AL(At least 6

yrs old) Antipsychotics - Misc. GEODON CAPS OR 20 MG, 40 MG, 60 MG (ziprasidone hcl)


GEODON CAPS OR 80 MG (ziprasidone hcl) NF


LATUDA TABS F QL(1 ea daily);AL(At least 6yrs old)

ziprasidone hcl caps 20mg, 40 mg, 60 mg F


ziprasidone hcl caps 80 mg F QL(2 ea daily);AL(At least 6yrs old)

Benzisoxazoles

INVEGA SUSTENNA SUSY F

1 rtl pack lmtamt,28 rtl packlmt day(s),;AL(At least 18yrs old); SP

INVEGA TRINZA SUSY F

Try InvegaSustenna first; Limit 1 per 3months;1 rtl pack lmtamt,90 rtl packlmt day(s),;AL(At least 18yrs old); SP

RISPERDAL CONSTA SRER F

Limit 2 per 4weeks 2 rtl MAX fill,28 rtl day(s) supply,;AL(At least 18yrs old); SP

RISPERDAL SOLN 1 MG/ML (risperidone) NF

QL(8 mldaily,240 mlper 30 daysretail); AL(Atleast 6 yrs old)

RISPERDAL TABS 0.25 MG, 0.5 MG (risperidone) NF



33

Drug Name DrugTier

Requirements/Limits

RISPERDAL TABS 1 MG, 2 MG (risperidone) NF


RISPERDAL TABS 3 MG, 4 MG (risperidone) NF


risperidone soln 1 mg/ml F

QL(8 mldaily,240 mlper 30 daysretail); AL(Atleast 6 yrs old)

risperidone tabs 0.25 mg,0.5 mg F


risperidone tabs 1 mg, 2 mg F


risperidone tabs 3 mg, 4 mg F


risperidone tbdp 0.25 mg,0.5 mg F


risperidone tbdp 1 mg, 2 mg F


risperidone tbdp 3 mg, 4 mg F


Butyrophenones HALDOL DECANOATE 100 SOLN (haloperidol decanoate)

NF AL(At least 18yrs old); SP

HALDOL DECANOATE 50 SOLN (haloperidoldecanoate)

NF AL(At least 18yrs old); SP

HALDOL SOLN (haloperidol lactate) NF AL(At least 6

yrs old); SP haloperidol decanoate solnim 50 mg/ml, 100 mg/ml F AL(At least 18

yrs old); SP haloperidol lactate conc or2 mg/ml F AL(At least 6

yrs old) haloperidol lactate soln ij 5mg/ml F AL(At least 6

yrs old); SP haloperidol tabs or 0.5 mg,1 mg, 2 mg, 5 mg, 10 mg,20 mg


Drug Name DrugTier

Requirements/Limits

Dibenzapines

CLOZAPINE ODT TBDP F QL(5 ea daily);AL(At least 18yrs old)

clozapine tabs F QL(5 ea daily);AL(At least 18yrs old)

clozapine tbdp F QL(5 ea daily);AL(At least 18yrs old)

CLOZARIL TABS (clozapine) NF


FAZACLO TBDP 150 MG (clozapine) F


FAZACLO TBDP 25 MG, 100 MG, 12.5 MG (clozapine)


loxapine succinate caps F AL(At least 6yrs old)

olanzapine tabs or 15 mg,20 mg, 2.5 mg, 7.5 mg F


olanzapine tabs or 5 mg,10 mg F


olanzapine tbdp or 15 mg,20 mg F


olanzapine tbdp or 5 mg,10 mg F


quetiapine fumarate tabs25 mg, 50 mg, 100 mg, 200 mg


quetiapine fumarate tabs300 mg, 400 mg F


SEROQUEL TABS 25 MG, 50 MG, 100 MG, 200 MG (quetiapine fumarate)


SEROQUEL TABS 300 MG, 400 MG (quetiapine fumarate)



34

Drug Name DrugTier

Requirements/Limits

ZYPREXA TABS OR 15 MG, 20 MG, 2.5 MG, 7.5 MG (olanzapine)


ZYPREXA TABS OR 5 MG, 10 MG (olanzapine) NF


ZYPREXA ZYDIS TBDP 15 MG, 20 MG (olanzapine) NF


ZYPREXA ZYDIS TBDP 5 MG, 10 MG (olanzapine) NF


Phenothiazines chlorpromazine hcl tabs or10 mg, 25 mg, 50 mg, 100mg, 200 mg


fluphenazine decanoatesoln ij F AL(At least 18

yrs old); SP fluphenazine hcl conc or 5mg/ml F AL(At least 6

yrs old) fluphenazine hcl elix or 2.5mg/5ml F AL(At least 6

yrs old) fluphenazine hcl tabs or 1mg, 5 mg, 10 mg, 2.5 mg F AL(At least 6

yrs old) perphenazine tabs or 2 mg,4 mg, 8 mg, 16 mg F AL(At least 6

yrs old) prochlorperazine maleatetabs or 5 mg, 10 mg F AL(At least 6

yrs old)

prochlorperazine supp F AL(At least 6yrs old)

thioridazine hcl tabs or 10 mg, 25 mg, 50 mg, 100 mg F AL(At least 6

yrs old)

trifluoperazine hcl tabs F AL(At least 6yrs old)

Quinolinone Derivatives

ABILIFY MAINTENA PRSY F


ABILIFY MAINTENA SRER F


Drug Name DrugTier

Requirements/Limits

ABILIFY TABS (aripiprazole) NF


aripiprazole tabs F QL(1 ea daily);AL(At least 6yrs old)

ARISTADA INITIO PRSY F

Limit 2 doses per 365 Days;2rtl MAX fill,365 rtl day(s)supply,; AL(Atleast 18 yrsold); SP

ARISTADA PRSY 1064 MG/3.9ML F

Limit 1 per 8weeks;1 rtl pack lmtamt,56 rtl packlmt day(s),;AL(At least 18yrs old); SP

ARISTADA PRSY 441 MG/1.6ML, 662 MG/2.4ML,882 MG/3.2ML

F


Thioxanthenes

thiothixene caps F AL(At least 6yrs old)

ANTISEPTICS & DISINFECTANTS

Antiseptics & Disinfectants HYDROGEN PEROXIDE SOLN EX 3 % F

hydrogen peroxide soln ex3 % F

ANTIVIRALS - Drugs to Treat Viral Infections

Antiretrovirals

abacavir sulfate soln F

abacavir sulfate tabs F

abacavir sulfate-lamivudine tabs 300 mg-600 mg F

abacavir sulfate-lamivudine-zidovudine tabs 150 mg-300 mg-300 mg

F


35

Drug Name DrugTier

Requirements/Limits

APTIVUS CAPS F

APTIVUS SOLN F

atazanavir sulfate caps F

ATRIPLA TABS F

BIKTARVY TABS F QL(1 ea daily)

COMBIVIR TABS (lamivudine-zidovudine) NF

COMPLERA TABS F

CRIXIVAN CAPS F

DESCOVY TABS F

didanosine cpdr 200 mg,400 mg F

EDURANT TABS F

efavirenz caps F

efavirenz tabs F

emtricitabine caps F

EMTRIVA CAPS 200 MG (emtricitabine) NF

EMTRIVA SOLN 10 MG/ML F

EPIVIR SOLN (lamivudine) NF

EPIVIR TABS (lamivudine) NF

EPZICOM TABS (abacavir sulfate-lamivudine) NF

EVOTAZ TABS F

fosamprenavir calcium tabs F

FUZEON SOLR F 1 rtl pack lmtamt,30 rtl packlmt day(s),; SP

GENVOYA TABS F

INTELENCE TABS F

Drug Name DrugTier

Requirements/Limits

INVIRASE CAPS F

INVIRASE TABS F

ISENTRESS CHEW F

ISENTRESS PACK F

ISENTRESS TABS F

KALETRA SOLN 100 MG/5ML-400 MG/5ML(lopinavir-ritonavir)

NF

KALETRA TABS 100 MG-25 MG, 200 MG-50 MG F

lamivudine soln F

lamivudine tabs F

lamivudine-zidovudine tabs 150 mg-300 mg F

LEXIVA SUSP 50 MG/ML F

LEXIVA TABS 700 MG (fosamprenavir calcium) NF

lopinavir-ritonavir soln F

nevirapine susp 50 mg/5ml F

nevirapine tabs 200 mg F

nevirapine tb24 400 mg F

NORVIR CAPS 100 MG F

NORVIR SOLN 80 MG/ML F

NORVIR TABS 100 MG (ritonavir) NF

ODEFSEY TABS F

PIFELTRO TABS F

PREZCOBIX TABS F

PREZISTA SUSP 100 MG/ML F

PREZISTA TABS 75 MG, 600 MG, 800 MG F


36

Drug Name DrugTier

Requirements/Limits

RESCRIPTOR TABS F

RETROVIR CAPS (zidovudine) NF

RETROVIR SYRP (zidovudine) NF

REYATAZ CAPS 150 MG, 200 MG, 300 MG (atazanavir sulfate)

NF

REYATAZ PACK 50 MG F

ritonavir tabs F

SELZENTRY SOLN F

SELZENTRY TABS F

stavudine caps F

STRIBILD TABS F

SUSTIVA CAPS (efavirenz) NF

SUSTIVA TABS (efavirenz) NF

tenofovir disoproxilfumarate tabs F

TIVICAY TABS 50 MG F

TRIUMEQ TABS F

TRIZIVIR TABS (abacavir sulfate-lamivudine-zidovudine)

NF

TRUVADA TABS F

TYBOST TABS F QL(1 ea daily)

VIDEX EC CPDR 125 MG F

VIDEX EC CPDR 200 MG, 250 MG, 400 MG (didanosine)

NF

VIDEXPEDIATRIC SOLR 4 GM F

VIRACEPT TABS F

VIRAMUNE SUSP (nevirapine) NF

Drug Name DrugTier

Requirements/Limits

VIRAMUNE TABS (nevirapine) NF

VIRAMUNE XR TB24 (nevirapine) NF

VIREAD POWD 40 MG/GM F

VIREAD TABS 300 MG (tenofovir disoproxilfumarate)

NF

ZERIT CAPS 15 MG, 20 MG, 30 MG, 40 MG (stavudine)

NF

ZERIT SOLR 1 MG/ML F

ZIAGEN SOLN (abacavir sulfate) NF

ZIAGEN TABS (abacavir sulfate) NF

zidovudine caps F

zidovudine syrp F

zidovudine tabs F

CMV Agents

cidofovir soln F

CYTOVENE SOLR (ganciclovir sodium) NF

FOSCAVIR SOLN F

ganciclovir sodium solr 500 mg F

VALCYTE SOLR (valganciclovir hcl) NF

VALCYTE TABS (valganciclovir hcl) NF

valganciclovir hcl solr F

valganciclovir hcl tabs F

Hepatitis Agents adefovir dipivoxil tabs 10 mg F PA

BARACLUDE SOLN 0.05 MG/ML F PA


37

Drug Name DrugTier

Requirements/Limits

BARACLUDE TABS 0.5 MG, 1 MG (entecavir) NF PA

entecavir tabs F PA

EPIVIR HBV SOLN 5 MG/ML F

EPIVIR HBV TABS 100 MG (lamivudine (hbv)) NF

HEPSERA TABS (adefovir dipivoxil) NF PA

lamivudine (hbv) tabs F

MAVYRET TABS F PA; SP

MODERIBA 1200 DOSE PACK TBPK F PA; SP

PEGASYS PROCLICK SOLN F PA; SP

PEGASYS SOLN F PA; SP

PEGINTRON KIT F PA; SP

REBETOL CAPS 200 MG (ribavirin (hepatitis c)) NF PA; SP

REBETOL SOLN 40 MG/ML F PA; SP

RIBASPHERE RIBAPAK TBPK F PA; SP

RIBASPHERE TABS F PA; SP

ribavirin (hepatitis c) caps F PA; SP

ribavirin (hepatitis c) tabs F PA; SP

SOFOSBUVIR/VELPATASVIR TABS F PA; SP

VEMLIDY TABS F PA; SP

Herpes Agents

acyclovir caps or 200 mg F

acyclovir sodium soln F

acyclovir susp or 200mg/5ml F

acyclovir tabs or 400 mg,800 mg F

Drug Name DrugTier

Requirements/Limits

famciclovir tabs or 125 mg,250 mg, 500 mg F

SITAVIG TABS F

valacyclovir hcl tabs or 1gm, 500 mg, 1000 mg F

VALTREX TABS (valacyclovir hcl) NF

ZOVIRAX CAPS OR 200 MG (acyclovir) NF

ZOVIRAX SUSP OR 200 MG/5ML (acyclovir) NF

ZOVIRAX TABS OR 400 MG, 800 MG (acyclovir) NF

Influenza Agents FLUMADINE TABS (rimantadine hydrochloride) NF

oseltamivir phosphate capsor 30 mg, 45 mg, 75 mg F QL(2 ea daily)

oseltamivir phosphate susror 6 mg/ml F QL(25 ml daily)

RAPIVAB SOLN F

RELENZA DISKHALER AEPB F

rimantadine hydrochloridetabs 100 mg F

TAMIFLU CAPS 30 MG, 45 MG, 75 MG (oseltamivir phosphate)

F QL(2 ea daily)

TAMIFLU SUSR 6 MG/ML(oseltamivir phosphate) F QL(25 ml daily)

XOFLUZA TBPK F

Respiratory Syncytial Virus (RSV) Agents

ribavirin solr in 6 gm F

VIRAZOLE SOLR (ribavirin) NF

BETA BLOCKERS - Drugs to Treat High BloodPressure

Alpha-Beta Blockers

carvedilol tabs F MP

COREG TABS (carvedilol) NF MP


38

Drug Name DrugTier

Requirements/Limits

labetalol hcl tabs or 100 mg, 200 mg, 300 mg F MP

Beta Blockers Cardio-Selective atenolol tabs or 25 mg, 50mg, 100 mg F MP

bisoprolol fumarate tabs F MP

LOPRESSOR TABS (metoprolol tartrate) NF MP

metoprolol succinate tb24 F MP

metoprolol tartrate tabs or25 mg, 50 mg, 75 mg, 100mg, 37.5 mg

F MP

TENORMIN TABS (atenolol) NF MP

TOPROL XL TB24 (metoprolol succinate) NF MP

Beta Blockers Non-Selective BETAPACE AF TABS (sotalol hcl (afib/afl)) NF MP

BETAPACE TABS (sotalol hcl) NF MP

INDERAL LA CP24 (propranolol hcl) NF MP

propranolol hcl cp24 or 60mg, 80 mg, 120 mg, 160 mg

F MP

propranolol hcl soln or 20mg/5ml F

propranolol hcl soln or 40mg/5ml F MP

propranolol hcl tabs or 10mg, 20 mg, 40 mg, 60 mg,80 mg

F MP

sotalol hcl (afib/afl) tabs F MP

sotalol hcl tabs F MP

CALCIUM CHANNEL BLOCKERS - Drugs toTreat High Blood Pressure

Calcium Channel Blockers ADALAT CC TB24 (nifedipine) NF QL(2 ea daily);

MP amlodipine besylate tabs or5 mg, 10 mg, 2.5 mg F QL(1 ea daily);

MP

Drug Name DrugTier

Requirements/Limits

CALAN SR TBCR (verapamil hcl) NF MP

CALAN TABS (verapamil hcl) NF MP

CARDIZEM CD CP24 (diltiazem hcl coated beads)

NF QL(1 ea daily);MP

CARDIZEM TABS (diltiazem hcl) NF MP

diltiazem hcl coated beads cp24 120 mg, 180 mg, 240mg, 300 mg, 360 mg

F QL(1 ea daily);MP

diltiazem hcl cp12 or 120 mg F MP

diltiazem hcl cp12 or 60mg, 90 mg F QL(2 ea daily);

MP diltiazem hcl cp24 or 120 mg F QL(2 ea daily);

MP diltiazem hcl cp24 or 180mg, 240 mg F QL(1 ea daily);

MP diltiazem hcl extended release beads cp24 F QL(1 ea daily);

MP diltiazem hcl tabs or 30 mg,60 mg, 90 mg, 120 mg F MP

felodipine tb24 F MP

nifedipine caps or 10 mg,20 mg F MP

nifedipine tb24 or 30 mg,60 mg, 90 mg F QL(2 ea daily)

nifedipine tb24 or 30 mg,60 mg, 90 mg F QL(2 ea daily);

MP NORVASC TABS (amlodipine besylate) NF QL(1 ea daily);

MP PROCARDIA CAPS (nifedipine) NF MP

PROCARDIA XL TB24 (nifedipine) NF QL(2 ea daily)

TIAZAC CP24 (diltiazem hcl extended release beads)

NF QL(1 ea daily);MP

verapamil hcl cp24 or 100mg, 200 mg, 300 mg F MP

verapamil hcl cp24 or 100mg, 200 mg, 300 mg F QL(1 ea daily);

MP


39

Drug Name DrugTier

Requirements/Limits

verapamil hcl cp24 or 120mg, 180 mg, 240 mg F QL(1 ea daily)

verapamil hcl cp24 or 360 mg F

verapamil hcl tabs or 40mg, 80 mg, 120 mg F MP

verapamil hcl tbcr or 120mg, 180 mg, 240 mg F MP

VERELAN CP24 120 MG, 180 MG, 240 MG (verapamil hcl)

NF QL(1 ea daily)

VERELAN CP24 360 MG (verapamil hcl) F

VERELAN PM CP24 (verapamil hcl) F MP

CARDIOTONICS - Drugs to Treat Heart Failureand Abnormal Heart Rhythm

Cardiac Glycosides

digoxin soln or 0.05 mg/ml F MP

digoxin tabs or 0.125 mg,125 mcg F MP

digoxin tabs or 0.25 mg,250 mcg F

LANOXIN TABS OR 125 MCG (digoxin) NF MP

LANOXIN TABS OR 250 MCG (digoxin) NF

LANOXIN TABS OR 62.5 MCG F

CARDIOVASCULAR AGENTS - MISC. - Drugs toTreat Heart and Circulation Conditions

Pulmonary Hypertension - Endothelin Receptor LETAIRIS TABS (ambrisentan) F PA; SP

TRACLEER TABS 125 MG, 62.5 MG (bosentan) F PA; SP

TRACLEER TBSO 32 MG F PA; SP

Pulmonary Hypertension - Phosphodiesterase ADCIRCA TABS 20 MG (tadalafil (pulmonaryhypertension))

F PA; SP

Drug Name DrugTier

Requirements/Limits

REVATIO SUSR 10 MG/ML (sildenafil citrate (pulmonary hypertension))

F AL(Up to 11 yrsold ); SP

REVATIO TABS 20 MG (sildenafil citrate (pulmonary hypertension))

NF PA; SP

sildenafil citrate (pulmonaryhypertension) tabs 20 mg F PA; SP

CEPHALOSPORINS - Drugs to Treat BacterialInfections

Cephalosporin Combinations

AVYCAZ SOLR F

ZERBAXA SOLR F

Cephalosporins - 1st Generation

cefadroxil caps F

cefadroxil susr F

cefadroxil tabs F

CEFAZOLIN SODIUM SOLN IV 1 GM/50ML-4 % F

cefazolin sodium solr ij 1gm, 10 gm, 20 gm, 500 mg F

CEFAZOLIN SODIUM SOLR IJ 100 GM, 300 GM F

cefazolin sodium solr iv 1 gm F

CEFAZOLIN SODIUM SOSY IV 1 GM/10ML, 2GM/20ML, 3 GM/20ML

F

CEFAZOLIN SODIUM/DEXTROSESOLN

F

CEFAZOLIN SODIUM/DEXTROSESOLR

F

CEFAZOLIN SODIUM/SODIUMCHLORIDE SOLN

F

CEFAZOLIN SODIUM/SODIUMCHLORIDE SOSY

F

CEFAZOLIN SOLN F


40

Drug Name DrugTier

Requirements/Limits

CEFAZOLIN/SODIUMCHLORIDE SOLN F

cephalexin caps F

cephalexin susr F

cephalexin tabs F

KEFLEX CAPS (cephalexin) NF

Cephalosporins - 2nd Generation

cefaclor caps F

CEFACLOR ER TB12 F

cefaclor susr F

CEFOTAN SOLR (cefotetan disodium) NF

cefotetan disodium solr F

CEFOTETAN/DEXTROSESOLR F

cefoxitin sodium solr ij 10 gm F

cefoxitin sodium solr iv 1 gm, 2 gm F

CEFOXITIN SODIUM SOLR IV 1 GM-4 %, 2 GM-2.2 %

F

cefprozil susr F

cefprozil tabs F

cefuroxime axetil tabs F

cefuroxime sodium solr F

Cephalosporins - 3rd Generation

cefdinir caps F

cefdinir susr F

cefditoren pivoxil tabs F

cefixime caps 400 mg F

Drug Name DrugTier

Requirements/Limits

cefixime susr 100 mg/5ml F 50ml permonth;QL(1.67ml daily)

cefixime susr 200 mg/5ml F QL(10 ml daily)

cefotaxime sodium solr F

cefpodoxime proxetil susr F

cefpodoxime proxetil tabs F

ceftazidime solr ij 1 gm, 2gm, 6 gm F

ceftazidime solr iv 1 gm, 2 gm F

CEFTAZIDIME/DEXTROSE SOLR F

CEFTRI-IM KIT F

ceftriaxone sodium in dextrose soln F

ceftriaxone sodium solr ij 1gm, 2 gm, 250 mg, 500 mg F

CEFTRIAXONE SODIUM SOLR IJ 100 GM F

ceftriaxone sodium solr iv 1 gm, 2 gm, 10 gm F

CEFTRIAXONE/DEXTROSE SOLR F

CEFTRISOL PLUS KIT F

CLAFORAN SOLR (cefotaxime sodium) NF

FORTAZ SOLR IJ 1 GM (ceftazidime) NF

FORTAZ SOLR IV 2 GM F

SUPRAX CAPS 400 MG (cefixime) NF

SUPRAX CHEW 100 MG, 200 MG F

SUPRAX SUSR 100 MG/5ML (cefixime) NF

50ml permonth;QL(1.67ml daily)

SUPRAX SUSR 200 MG/5ML (cefixime) NF QL(10 ml daily)


41

Drug Name DrugTier

Requirements/Limits

SUPRAX SUSR 500 MG/5ML F

TAZICEF SOLN F

Cephalosporins - 4th Generation

cefepime hcl solr F

CEFEPIME SOLN F

CEFEPIME/DEXTROSESOLR F

MAXIPIME SOLR IJ 1 GM, 2 GM (cefepime hcl) NF

MAXIPIME SOLR IV 1 GM, 2 GM F

Cephalosporins - 5th Generation

TEFLARO SOLR F

Cephalosporins - Siderophores

FETROJA SOLR F

CONTRACEPTIVES - Drugs to PreventPregnancy

Combination Contraceptives - Oral desogestrel & ethinylestradiol tabs F

desogestrel-ethinylestradiol (biphasic) tabs F

desogestrel-ethinylestradiol (triphasic) tabs F

drospirenone-ethinylestradiol tabs F

ESTROSTEP FE TABS (norethindrone acetate-ethinyl estradiol-fe)

NF

ethynodiol diacet & ethestrad tabs F

levonorgestrel & ethestradiol tabs F

levonorgestrel-eth estradiol(triphasic) tabs F

levonorgestrel-ethinylestradiol (91-day) tabs F

levonorgestrel-ethinylestradiol (continuous) tabs F

Drug Name DrugTier

Requirements/Limits

LOESTRIN 1.5/30-21TABS (norethindrone acet & eth estra)

NF

LOESTRIN 1/20-21 TABS(norethindrone acet & eth estra)

NF

LOESTRIN FE 1.5/30TABS (norethin acet & estrad-fe)

NF

LOESTRIN FE 1/20 TABS(norethin acet & estrad-fe) NF QL(1 ea daily)

LOSEASONIQUE TABS (levonorgestrel-ethinylestradiol (91-day))

NF

MIRCETTE TABS (desogestrel-ethinylestradiol (biphasic))

NF

norethin acet & estrad-fe tabs 1 mg-20 mcg-75 mg F QL(1 ea daily)

norethin acet & estrad-fe tabs 1.5 mg-30 mcg-75 mg F

norethindrone & eth estradiol tabs F

norethindrone acet & eth estra tabs F

norethindrone acetate-ethinyl estradiol-fe tabs 1mg-75 mg

F

norethindrone-eth estradiol (triphasic) tabs F

norgestimate-ethinylestradiol (triphasic) tabs F

norgestimate-ethinylestradiol tabs 0.25 mg-35 mcg

F

norgestrel & ethinylestradiol tabs 0.3 mg-30 mcg

F

norgestrel & ethinylestradiol tabs 0.5 mg-50 mcg

3

ORTHO TRI-CYCLEN LO TABS (norgestimate-ethinylestradiol (triphasic))

NF

ORTHO TRI-CYCLEN TABS (norgestimate-ethinylestradiol (triphasic))

NF


42

Drug Name DrugTier

Requirements/Limits

ORTHO-CYCLEN TABS (norgestimate-ethinylestradiol)

NF

ORTHO-NOVUM 1/35TABS (norethindrone & eth estradiol)

NF

ORTHO-NOVUM 7/7/7TABS (norethindrone-eth estradiol (triphasic))

NF

SEASONIQUE TABS (levonorgestrel-ethinylestradiol (91-day))

NF

TRI-NORINYL 28 TABS (norethindrone-eth estradiol (triphasic))

NF

YASMIN 28 TABS (drospirenone-ethinylestradiol)

NF

YAZ TABS (drospirenone-ethinyl estradiol) NF

Combination Contraceptives - Vaginal etonogestrel-ethinylestradiol ring 0.015mg/24hr-0.12 mg/24hr

F

NUVARING RING (etonogestrel-ethinylestradiol)

NF

Emergency Contraceptives levonorgestrel (emergencyoc) tabs 1.5 mg F

PLAN B ONE-STEP TABS (levonorgestrel (emergency oc))

NF

Progestin Contraceptives - Injectable DEPO-PROVERA CONTRACEPTIVE SUSP (medroxyprogesteroneacetate (contraceptive))

NF

DEPO-PROVERA CONTRACEPTIVE SUSY (medroxyprogesteroneacetate (contraceptive))

NF

DEPO-SUBQ PROVERA 104 SUSY F

Drug Name DrugTier

Requirements/Limits

medroxyprogesteroneacetate (contraceptive) susp

F

medroxyprogesteroneacetate (contraceptive) susy

F

Progestin Contraceptives - Oral norethindrone (contraceptive) tabs 0.35 mg

F

ORTHO MICRONOR TABS (norethindrone (contraceptive))

NF

CORTICOSTEROIDS - Steroid Hormone Drugs toTreat Systemic Swelling Conditions

Glucocorticosteroids

budesonide cpep or 3 mg F QL(3 ea daily)

CORTEF TABS (hydrocortisone) NF

DEPO-MEDROL SUSP 40 MG/ML(methylprednisolone acetate)

NF

DEXAMETHASONE 13-DAY DOSE PACK TBPK F

dexamethasone elix or 0.5 mg/5ml F

DEXAMETHASONE INTENSOL CONC F

dexamethasone soln or 0.5 mg/5ml F

dexamethasone tabs or 0.75 mg, 0.5 mg, 1 mg, 2mg, 4 mg, 6 mg, 1.5 mg

F

dexamethasone tbpk or 1.5 mg F

ENTOCORT EC CPEP (budesonide) NF QL(3 ea daily)

hydrocortisone tabs or 5mg, 10 mg, 20 mg F

KENALOG-10 SUSP F PA

KENALOG-40 SUSP (triamcinolone acetonide) NF


43

Drug Name DrugTier

Requirements/Limits

MEDROL DOSEPAK TBPK (methylprednisolone) NF

MEDROL TABS 2 MG F

MEDROL TABS 4 MG, 8 MG, 16 MG, 32 MG (methylprednisolone)

NF

methylprednisolone sodsucc solr F PA

methylprednisolone tabs or4 mg, 8 mg, 16 mg, 32 mg F

methylprednisolone tbpk or4 mg F

MILLIPRED TABS 5 MG F

ORAPRED ODT TBDP (prednisolone sodiumphosphate)

NF

PEDIAPRED SOLN (prednisolone sodiumphosphate)

NF

prednisolone sodiumphosphate soln or 5mg/5ml, 15 mg/5ml

F

prednisolone sodiumphosphate tbdp or 10 mg,15 mg, 30 mg

F

prednisolone soln or F

PREDNISONE INTENSOL CONC F

prednisone soln or 5mg/5ml F

prednisone tabs or 1 mg, 5mg, 10 mg, 20 mg, 50 mg,2.5 mg

F

prednisone tbpk or 5 mg,10 mg F

SOLU-CORTEF SOLR F PA

SOLU-MEDROL SOLR 2 GM F PA

SOLU-MEDROL SOLR 40 MG, 125 MG, 500 MG, 1000 MG (methylprednisolone sod succ)

NF

PA

Drug Name DrugTier

Requirements/Limits

TRIAMCINOLONE ACETONIDE PF SUSP F PA

TRIAMCINOLONE ACETONIDE SUSP IJ 50 MG/ML

F PA

Mineralocorticoids fludrocortisone acetate tabs or 0.1 mg F

COUGH/COLD/ALLERGY - Drugs to TreatCough, Cold and Allergy Symptoms

Antitussives

benzonatate caps F

BUCKLEYS COUGH LIQD F

CREO-TERPIN SYRP F

DELSYM COUGH CHILDRENS SUER (dextromethorphanpolistirex)

NF

DELSYM SUER (dextromethorphanpolistirex)

NF

dextromethorphan hbr capsor 15 mg F

dextromethorphan hbr liqdor 15 mg/5ml, 15 mg/15ml,7.5 mg/5ml

F

DEXTROMETHORPHAN HBR MONOHYDRATE CRYS

F

DEXTROMETHORPHAN HBR MONOHYDRATE POWD

F

DEXTROMETHORPHAN HBR POWD XX F

dextromethorphan hbr syrpor 10 mg/5ml, 15 mg/5ml F

dextromethorphanpolistirex lqcr 30 mg/5ml F

dextromethorphanpolistirex suer 30 mg/5ml F

ELIXSURE COUGH GEL F

HOLD LOZG NF


44

Drug Name DrugTier

Requirements/Limits

hydrocodone w/homatropine syrp 1.5mg/5ml-5 mg/5ml

F

QL(240 ml per12 days retail);AL(At least 18yrs old)

hydrocodone w/homatropine tabs 1.5 mg-5 mg


LITTLE COLDS COUGH FORMULA LIQD F

ROBITUSSIN CHILDRENS COUGH LONG-ACTING SYRP

F

ROBITUSSIN LINGERING COLDLONG-ACTING COUGHGELS CAPS (dextromethorphan hbr)

NF

SCOT-TUSSIN DIABETES LIQD F

TESSALON PERLES CAPS (benzonatate) NF

TRIAMINIC LONG ACTING COUGH LIQD 7.5 MG/5ML(dextromethorphan hbr)

NF

TRIAMINIC LONG ACTING COUGH STRP 7.5 MG F

VICKS DAYQUIL COUGH LIQD (dextromethorphan hbr)

NF

WAL-TUSSIN COUGH RELIEF CHILDRENS CHEW

F

Cough/Cold/Allergy Combinations

acetaminophen w/ dm susp F

ACTICON SOLN F

ACTICON TABS F

ACTIDOGESIC TABS F

ACTIDOGESIC-DF TABS F

ACTIDOM DMX LIQD F QL(16 ml daily)

ACTINEL DM LIQD F QL(16 ml daily)

ACTINEL LIQD F

Drug Name DrugTier

Requirements/Limits

ACTINEL PEDIATRIC LIQD F

ADVIL ALLERGY & CONGESTION TABS F

ADVIL ALLERGY SINUS TABS F

ADVIL COLD & SINUS CAPS 200 MG-30 MG F

ADVIL COLD & SINUS TABS (pseudoephedrine-ibuprofen)

NF

ADVIL MULTI-SYMPTOM COLD& FLU TABS F

ADVIL SINUS CONGESTION &PAIN TABS (phenylephrine-ibuprofen)

NF

ALA-HIST PE TABS (dexbrompheniramine-phenylephrine)

NF

ALAHIST CF TABS F

ALAHIST DM LIQD F

ALEVE-D SINUS & COLD TB12 (pseudoephedrine-naproxen sodium)

NF

ALEVE-D SINUS & HEADACHE TB12 (pseudoephedrine-naproxen sodium)

NF

ALKA-SELTZER PLUS COLD &COUGH CAPS F

ALKA-SELTZER PLUS COLD &COUGH FORMULA CAPS

F

ALKA-SELTZER PLUS COLD TBEF (chlorpheniramine-phenylephrine-asa)

NF

ALKA-SELTZER PLUS SEVERECOLD & FLU NIGHT PACK

F

ALKA-SELTZER PLUS SINUS FORMULA TBEF F


45

Drug Name DrugTier

Requirements/Limits

ALLEGRA-D 12 HOUR ALLERGY & CONGESTION TB12 (fexofenadine-pseudoephedrine)

NF

QL(2 ea daily)

ALLEGRA-D 24 HOUR ALLERGY & CONGESTION TB24 (fexofenadine-pseudoephedrine)

NF

QL(1 ea daily)

AP-HIST DM LIQD F

AQUANAZ TABS F

ATUSS DA LIQD F

BALAMINE DM SYRP F

BENADRYL ALLERGY PLUS CONGESTION CHILDRENS SOLN (diphenhydramine-phenylephrine)

NF

BIOBRON SF SYRP F QL(16 ml daily)

BIODESP DM SYRP F QL(16 ml daily)

BIONATUSS DXP LIQD F

BIONEL LIQD F

BIONEL PEDIATRIC LIQD F

BIOSPEC DMX LIQD F

BROHIST D TABS F

brompheniramine &phenyleph elix F

brompheniramine &phenyleph liqd F

brompheniramine &pseudoeph elix F QL(8 ml daily)

brompheniramine &pseudoeph liqd F QL(8 ml daily)

BRONKAID TABS F

BRONKIDS LIQD F

Drug Name DrugTier

Requirements/Limits

BRONTUSS DX LIQD F QL(16 ml daily)

BROTAPP DM LIQD F

CAPCOF SYRP F

CAPMIST DM TABS F

CAPRON DM LIQD F

CAPRON DMT TABS F

CARBAPHEN 12 LIQD F

CARBAPHEN 12 PED SUSP F

CARBAPHEN CH SUSP F

CARBAPHEN PED CH SUSP F

cetirizine-pseudoephedrinetb12 F QL(2 ea daily)

CHERACOL PLUS LIQD (dextromethorphan-guaifenesin)

NF QL(16 ml daily)

CHERACOL-D COUGH LIQD (dextromethorphan-guaifenesin)

NF QL(16 ml daily)

CHLO HIST SOLN F

CHLO TUSS LIQD F

CHLOPHED LIQD F

chlorpheniramine &phenylephrine liqd F

chlorpheniramine &phenylephrine tabs F

chlorpheniramine &pseudoeph tabs F

chlorpheniramine-acetaminophen tabs F

chlorpheniramine-dm liqd F

chlorpheniramine-dm tabs F


46

Drug Name DrugTier

Requirements/Limits

chlorpheniramine-phenylephrine-acetaminophen misc

F

chlorpheniramine-phenylephrine-acetaminophen tabs

F

chlorpheniramine-phenylephrine-asa tbef 2mg-325 mg-7.8 mg

F

CLARINEX-D 12 HOUR TB12 F

CLARITIN-D 12 HOUR TB12 (loratadine & pseudoephedrine)

NF QL(2 ea daily)

CLARITIN-D 24 HOUR TB24 (loratadine & pseudoephedrine)

NF QL(1 ea daily)

CLEAR COUGH PM MULTI-SYMPTOM LIQD (dextromethorphan-doxylamine-acetaminophen)

NF

CODAR AR LIQD F

CODITUSSIN AC LIQD F

CODITUSSIN DAC LIQD F

COLD & COUGH DAYTIME/NIGHTIMECHILDRENS MISC 2.5 MG/5ML-5 MG/5ML-6.25MG/5ML

F

COLD & FLU RELIEF NIGHTTIME D LIQD F

COMTREX COLD & COUGH DAY/NIGHTMAXIMUM STRENGTH MISC (phenylephrine-chlorpheniramine-dm w/ apap)

NF

COMTREX COLD & COUGH MAXIMUM STRENGTH TABS (dextromethorphan-phenylephrine-acetaminophen)

NF

Drug Name DrugTier

Requirements/Limits

COMTREX COLD & COUGH NIGHTTIME MAXIMUM STRENGTH TABS (phenylephrine-chlorpheniramine-dm w/ apap)

NF

COMTREX DEEP CHEST COLD MULTI-SYMPTOM TABS

F

CONEX COLD/ALLERGYSOLN F

CONEX COLD/ALLERGYTABS F

CONTAC COLD/FLU DAY& NIGHT MISC F

CONTAC COLD/FLUDAY/NIGHT TABS F

CONTAC COLD/FLUMAXIMUM STRENGTH TABS

F

CORICIDIN HBP COLD & FLU TABS (chlorpheniramine-acetaminophen)

NF

CORICIDIN HBP COUGH & COLD TABS (chlorpheniramine-dm)

NF

CORICIDIN HBP DAY & NIGHTMULTI-SYMPTOM COLD MISC

F

CORICIDIN HBP FLU TABS (dextromethorphan-acetaminophen-chlorpheniramine)

NF

CVS COUGH/CHESTCONGESTION DM CHILDRENS SOPK

F

CVS NON-DRYING SINUS PE TABS F

CVS SINUS RELIEF DAYTIME/NIGHTTIMEMISC

F

CVS TUSSIN DM DAY/NIGHT PACK LQPK F


47

Drug Name DrugTier

Requirements/Limits

DAY TIME MULTI-SYMPTOM COLD/FLURELIEF CAPS (dextromethorphan-phenylephrine-acetaminophen)

NF

DAYTIME COLD MEDICINE LIQD F

DECONEX DMX TABS (phenylephrine w/ dm-gg) NF

DECONEX IR TABS F

DELSYM CHILDRENS DAY NIGHT MISC F

DELSYM DAY NIGHT MISC F

DELTUSS DP LIQD F

DESGEN DM SYRP 100 MG/5ML-15 MG/5ML-5MG/5ML

F QL(16 ml daily)

DESGEN DM TABS 10 MG-200 MG-30 MG F

dexbrompheniramine-phenylephrine tabs 10 mg-2 mg

F

dextromethorphan-acetaminophen-chlorpheniramine susp

F

dextromethorphan-acetaminophen-chlorpheniramine tabs

F

dextromethorphan-doxylamine-acetaminophen caps

F

dextromethorphan-doxylamine-acetaminophenliqd

F

dextromethorphan-guaifenesin caps 10 mg-200 mg

F

dextromethorphan-guaifenesin liqd 10 mg/5ml-100 mg/5ml, 10 mg/5ml-200 mg/5ml, 20 mg/10ml-200 mg/10ml, 20 mg/10ml-400 mg/10ml, 15 mg/7.5ml-150 mg/7.5ml

F

QL(16 ml daily)

Drug Name DrugTier

Requirements/Limits

dextromethorphan-guaifenesin liqd 100mg/5ml-5 mg/5ml, 20mg/5ml-300 mg/5ml, 200mg/5ml-30 mg/5ml, 20mg/20ml-400 mg/20ml, 20mg/5ml-20 mg/5ml-300mg/5ml-300 mg/5ml, 200mg/5ml-200 mg/5ml-30mg/5ml-30 mg/5ml

F

dextromethorphan-guaifenesin syrp 10mg/5ml-100 mg/5ml, 10mg/5ml-10 mg/5ml-100mg/5ml-100 mg/5ml

F

dextromethorphan-guaifenesin tabs 20 mg-400 mg, 20 mg-20 mg-400mg-400 mg

F

QL(2 ea daily)

dextromethorphan-guaifenesin tb12 1200 mg-60 mg

F

dextromethorphan-guaifenesin tb12 30 mg-600 mg

F QL(2 ea daily)

dextromethorphan-phenylephrine-acetaminophen caps

F

dextromethorphan-phenylephrine-acetaminophen liqd

F

dextromethorphan-phenylephrine-acetaminophen pack

F

dextromethorphan-phenylephrine-acetaminophen tabs

F

DIABETIC TUSSIN COLD & FLU LIQD F

DIABETIC TUSSIN COLD/FLU CAPS F

DIABETIC TUSSIN NIGHT TIME COLD/FLU RELIEFLIQD

F

DIMETAPP COLD & ALLERGY ELIX (brompheniramine &phenyleph)

NF


48

Drug Name DrugTier

Requirements/Limits

DIMETAPP DM COLD & COUGH LIQD (phenylephrine-brompheniramine-dm)

NF

DIMETAPP LONG ACTING COUGH PLUS COLD SYRP

F

DIMETAPP MULTI-SYMPTOM COLD & FLU LIQD

F

DIMETAPP MULTI-SYMPTOM COLD RELIEF CHILDRENS LIQD (phenylephrine-brompheniramine-dm)

NF

diphenhydramine-acetaminophen tabs F

diphenhydramine-phenylephrine liqd F

diphenhydramine-phenylephrine soln F

diphenhydramine-phenylephrine tabs F

diphenhydramine-phenylephrine-acetaminophen liqd

F

diphenhydramine-phenylephrine-acetaminophen pack

F

diphenhydramine-phenylephrine-acetaminophen tabs

F

DOCTOR MANZANILLA PE SYRUP ANTIHISTAMINE/DECONGESTANT LIQD 10 MG/5ML-2.5 MG/5ML

F

DOLOGEN TABS F

DOLOGESIC LIQD F

DOLOGESIC TABS F

DOLOGESIC-DF TABS F

DOMETUSS-DA/CHILDREN LIQD F

Drug Name DrugTier

Requirements/Limits

DOMETUSS-DMX LIQD F QL(16 ml daily)

DOMETUSS-NR TABS F

DOUBLE-TUSSIN DM LIQD (dextromethorphan-guaifenesin)

NF

doxylamine-dm liqd F

doxylamine-dm lqpk F

doxylamine-phenylephrinetabs 10 mg-7.5 mg F

doxylamine-phenylephrine-acetaminophen misc F

DRIXORAL COLD/ALLERGY TB12 F

DRIXORAL COUGH & SORE THROAT CAPS F

DURAFLU TABS F

DURAVENT DM TABS F

DURAVENT PE TABS F

ED A-HIST DM TABS F

ED A-HIST LIQD (chlorpheniramine &phenylephrine)

NF

ED BRON GP LIQD F

ED CHLORPED D LIQD F

ENTEX T TABS (pseudoephedrine-guaifenesin)

NF

ephedrine-guaifenesin tabs F

EQ ALLERGY/SINUSHEADACHE TABS F

EQ SINUS RELIEF MAXIMUM STRENGTH TABS

F

EXACTUSS LIQD (phenylephrine w/ dm-gg) NF QL(16 ml

daily); RX/OTC

EXACTUSS TR TABS F RX/OTC


49

Drug Name DrugTier

Requirements/Limits

EXAPHEN CH TABS F

EXAPHEN TABS F

EXAPHEX TR TABS F RX/OTC

FATHER JOHNS MEDICINE PLUS SOLN F

fexofenadine-pseudoephedrine tb12 120mg-60 mg

F QL(2 ea daily)

fexofenadine-pseudoephedrine tb24 180mg-240 mg

F QL(1 ea daily)

G-DOLOGEN TABS F

G-P-TUSS DXP LIQD F

G-TUSICOF LIQD F QL(16 ml daily)

G-ZYNCOF SYRP F

GCON IR TABS F

GILPHEX TR TABS F RX/OTC

GILTUSS ALLERGY & SINUS TABS F

GILTUSS COUGH & COLD LIQD 10 MG/5ML-29MG/5ML-390 MG/5ML

F QL(16 ml daily)

GILTUSS COUGH & COLD TABS 10 MG-28 MG-388 MG

F RX/OTC

GILTUSS COUGH ALLERGY & SINUS TABS F

GILTUSS LIQD (phenylephrine w/ dm-gg) NF QL(16 ml

daily); RX/OTC GILTUSS SINUS & CONGESTION TABS F RX/OTC

GILTUSS TR TABS F RX/OTC

GLEN PE LIQD F

GLENMAX PEB DM LIQD F

GLENMAX PEB LIQD F

Drug Name DrugTier

Requirements/Limits

GLENTUSS LIQD 15 MG/5ML-30 MG/5ML-6.25MG/5ML

F

GNP COLD RELIEF PLUS TBEF F

guaifenesin-codeine liqd 10mg/5ml-100 mg/5ml F


guaifenesin-codeine liqd225 mg/5ml-7.5 mg/5ml F

guaifenesin-codeine soln10 mg/5ml-100 mg/5ml F


guaifenesin-codeine syrp10 mg/5ml-100 mg/5ml F


HERBIOMED DEEP COLD AND FLU NIGHTTIME LIQD

F

HERBIOMED FAST ACTING BODY ACHES & SINUS LIQD

F

HISTEX-AC SYRP F

HISTEX-DM SYRP F

HISTEX-PE SYRP NF

HYDROCODONE BITARTRATE/GUAIFENESIN SOLN

F

hydrocodone polistirex-chlorpheniramine polistirex suer

F

LITTLE REMEDIES FOR COLDSMULTI SYMPTOM LIQD

F

LODRANE D CAPS F

LOHIST-D LIQD F QL(16 ml daily)

LOHIST-DM SYRP F QL(16 ml daily)


50

Drug Name DrugTier

Requirements/Limits

loratadine & pseudoephedrine tb12 120mg-5 mg

F QL(2 ea daily)

loratadine & pseudoephedrine tb24 10mg-240 mg, 10 mg-10 mg-240 mg-240 mg

F

QL(1 ea daily)

LORTUSS DM LIQD NF

LORTUSS EX LIQD F

LORTUSS LQ LIQD F

M-CLEAR WC SOLN F

M-END DMX LIQD F

M-END PE LIQD F

MAR-COF BP LIQD F

MAR-COF CG EXPECTORANT LIQD (guaifenesin-codeine)

NF

MAXI-TUSS CD LIQD F

MAXI-TUSS DM LIQD F

MAXI-TUSS PE ELIX F

MAXI-TUSS PE JR LIQD F

MAXI-TUSS PE MAX LIQD F

MAXICHLOR PEH DM TABS F

MAXIFED TABS F

MUCINEX CHILDRENS COLD COUGH & SORE THROAT LIQD (phenylephrine-dm-gg w/ apap)

NF

MUCINEX CHILDRENS MULTI-SYMPTOM COLD & FEVER LIQD (phenylephrine-dm-gg w/ apap)

NF

Drug Name DrugTier

Requirements/Limits

MUCINEX CHILDRENS MULTI-SYMPTOM COLD LIQD (phenylephrine w/ dm-gg)

NF

QL(16 ml daily)

MUCINEX CONGESTION & COUGH CHILDRENS LIQD (phenylephrine w/ dm-gg)

NF

QL(16 ml daily)

MUCINEX COUGH & CONGESTION CHILDRENS LIQD (phenylephrine w/ dm-gg)

NF

QL(16 ml daily)

MUCINEX COUGH FOR KIDS PACK F

MUCINEX D MAXIMUM STRENGTH TB12 (pseudoephedrine-guaifenesin)

NF

MUCINEX D TB12 (pseudoephedrine-guaifenesin)

NF

MUCINEX DM MAXIMUM STRENGTH TB12 (dextromethorphan-guaifenesin)

NF

MUCINEX DM TB12 (dextromethorphan-guaifenesin)

NF QL(2 ea daily)

MUCINEX FAST-MAX COLD & SINUS LIQD (phenylephrine-acetaminophen-guaifenesin)

NF

MUCINEX FAST-MAX COLD FLU& SORE THROAT CLEAR & COOL LIQD (phenylephrine-dm-gg w/ apap)

NF

MUCINEX FAST-MAX COLD FLU& SORE THROAT LIQD (phenylephrine-dm-gg w/ apap)

NF

MUCINEX FAST-MAX COLD/FLU LIQD(phenylephrine-dm-gg w/ apap)

NF


51

Drug Name DrugTier

Requirements/Limits

MUCINEX FAST-MAX COLD/FLU/SORETHROAT CAPS (phenylephrine-dm-gg w/ apap)

NF

MUCINEX FAST-MAX DAY TIME/NIGHT TIME MISC F

MUCINEX FAST-MAX DAY TIME/NIGHT TIME MISC(phenylephrine-diphenhydramine-dm-guaifenesin-apap)

NF

MUCINEX FAST-MAX DAY/NIGHT CPPK(phenylephrine-doxylamine-dm-guaifenesin-apap)

NF

MUCINEX FAST-MAX DAY/NIGHT MAXIMUMSTRENGTH MISC

F

MUCINEX FAST-MAX DAY/NITE M/S MISC F

MUCINEX FAST-MAX SEVERE COLD LIQD (phenylephrine-dm-gg w/ apap)

NF

MUCINEX FAST-MAX SEVERE CONGESTION & COUGH CLEAR & COOL LIQD (phenylephrine w/ dm-gg)

NF

QL(16 ml daily)

MUCINEX FAST-MAX SEVERE CONGESTION & COUGH LIQD 100 MG/5ML-2.5 MG/5ML-5MG/5ML, 10 MG/20ML-20MG/20ML-400 MG/20ML(phenylephrine w/ dm-gg)

NF

QL(16 ml daily)

MUCINEX FAST-MAX SEVERE CONGESTION & COUGH TABS 10 MG-200 MG-5 MG

F

MUCINEX MULTI-SYMPTOM COLD DAY/NIGHT PACK MISC

F

MUCINEX SINUS-MAX DAY TIME/NIGHT TIMEMISC

F

Drug Name DrugTier

Requirements/Limits

MUCINEX SINUS-MAX DAY/NIGHT CPPK 10 MG-200 MG-325 MG-5 MG-6.25 MG (phenylephrine-doxylamine-dm-guaifenesin-apap)

NF

MUCINEX SINUS-MAX DAY/NIGHT MISC 12.5MG-200 MG-325 MG-5 MG

F

MUCINEX SINUS-MAX SEVERECONGESTION RELIEF CAPS (phenylephrine-dm-gg w/ apap)

NF

MUCINEX STUFFY NOSE & COLD CHILDRENS LIQD (phenylephrine-guaifenesin)

NF

MULTI-SYMPTOM COLD DAYTIME/NIGHTTIMECHILDRENS MISC

F

NASOPEN PE LIQD F

NEOTUSS PLUS LIQD F

NEOTUSS-D LIQD F QL(16 ml daily)

NEXAFED SINUS PRESSURE +PAIN TABS F

NINJACOF LIQD F

NINJACOF-A LIQD F

NINJACOF-XG LIQD F

NITE-TIME COLD/FLURELIEF LIQD F

NIVANEX DMX TABS F

NOREL AD TABS F

NOREL CS LIQD F

PANATUSS PED DROPS LIQD F

PANATUSS PED LIQD F

PECGEN DMX LIQD F


52

Drug Name DrugTier

Requirements/Limits

PEDIACARE COUGH & RUNNY NOSE LIQD F

PEDIATRIC COUGH/COLD LIQD F

PERCOGESIC TABS F

PHENAGIL CH TABS F

PHENAGIL TABS F

PHENYLEPHRINE HCL/PYRILAMINEMALEATE TABS

F

phenylephrine w/acetaminophen caps F

phenylephrine w/acetaminophen tabs F

phenylephrine w/ dm-ggliqd 10 mg/15ml-18mg/15ml-200 mg/15ml

F

phenylephrine w/ dm-ggliqd 100 mg/ml-2.5 mg/ml-5mg/ml, 10 mg/5ml-100mg/5ml-5 mg/5ml, 10mg/5ml-200 mg/5ml-5mg/5ml, 2.5 mg/5ml-5mg/5ml-75 mg/5ml, 10mg/5ml-15 mg/5ml-350mg/5ml, 100 mg/5ml-2.5mg/5ml-5 mg/5ml, 10mg/10ml-20 mg/10ml-200mg/10ml, 10 mg/20ml-20mg/20ml-400 mg/20ml, 10mg/5ml-10 mg/5ml-100mg/5ml-100 mg/5ml-5mg/5ml-5 mg/5ml

F

QL(16 ml daily)

phenylephrine w/ dm-ggliqd 2.5 mg/ml-5 mg/ml-50mg/ml, 2.5 mg/ml-7.5mg/ml-88 mg/ml, 10mg/5ml-15 mg/5ml-300mg/5ml, 10 mg/5ml-28mg/5ml-388 mg/5ml, 150mg/2.5ml-5 mg/2.5ml-7.5mg/2.5ml

F

QL(16 mldaily); RX/OTC

phenylephrine w/ dm-ggsyrp 10 mg/5ml-100mg/5ml-5 mg/5ml

F QL(16 ml daily)

Drug Name DrugTier

Requirements/Limits

phenylephrine w/ dm-ggtabs 10 mg-20 mg-400 mg,10 mg-17.5 mg-385 mg

F

phenylephrine-acetaminophen-guaifenesinliqd

F

phenylephrine-acetaminophen-guaifenesintabs

F

phenylephrine-brompheniramine-dm elix 1mg/5ml-2.5 mg/5ml-5mg/5ml

F

QL(16 ml daily)

phenylephrine-brompheniramine-dm liqd 1mg/5ml-2.5 mg/5ml-5mg/5ml, 10 mg/5ml-20mg/5ml-4 mg/5ml, 1mg/5ml-1 mg/5ml-2.5mg/5ml-2.5 mg/5ml-5mg/5ml-5 mg/5ml

F

phenylephrine-chlorphen-dm liqd F

phenylephrine-chlorpheniramine w/ dm-gg& apap tbpk 10 mg-2 mg-200 mg-325 mg-5 mg

F

phenylephrine-chlorpheniramine-dm w/apap liqd

F

phenylephrine-chlorpheniramine-dm w/apap misc

F

phenylephrine-chlorpheniramine-dm w/ apap susp

F

phenylephrine-chlorpheniramine-dm w/apap tabs

F

phenylephrine-diphenhydramine-dm w/apap misc

F

phenylephrine-diphenhydramine-dm-guaifenesin-apap misc

F

phenylephrine-diphenhydramine-dm-guaifenesin-apap tbpk

F


53

Drug Name DrugTier

Requirements/Limits

phenylephrine-diphenhydramine-gg w/apap misc

F

phenylephrine-dm liqd F

phenylephrine-dm soln F

phenylephrine-dm-gg w/ apap caps F

phenylephrine-dm-gg w/apap liqd F

phenylephrine-dm-gg w/apap tabs F

phenylephrine-doxylamine-dextromethorphan-acetaminophen caps

F

phenylephrine-doxylamine-dextromethorphan-acetaminophen liqd

F

phenylephrine-doxylamine-dextromethorphan-acetaminophen misc

F

phenylephrine-doxylamine-dm-guaifenesin-apap cppk F

phenylephrine-doxylamine-dm-guaifenesin-apap lqpk F

phenylephrine-guaifenesinliqd F

phenylephrine-guaifenesintabs F

phenylephrine-ibuprofentabs 10 mg-200 mg F

phenylephrine-triprolidine-dextromethorphan syrp F

POLY HIST FORTE TABS (doxylamine-phenylephrine)

NF

POLY-HIST DM LIQD F

POLY-HIST PD LIQD F

POLY-TUSSIN AC LIQD F

POLY-VENT DM TABS F

POLY-VENT IR TABS F

Drug Name DrugTier

Requirements/Limits

POLYTUSSIN DM SYRP F

PRIMATENE ASTHMA TABS (ephedrine-guaifenesin)

NF

PRO-RED AC SYRP F

promethazine &phenylephrine soln F QL(16 ml daily)

promethazine &phenylephrine syrp F QL(16 ml daily)

promethazine w/codeinesoln F


promethazine w/codeine syrp F


promethazine-dm soln F QL(16 ml daily)

promethazine-dm syrp F QL(16 ml daily)

promethazine-phenylephrine-codeine syrp F

PROMETHAZINE/PHENYLEPHRINE SYRP F QL(16 ml daily)

pseudoephed-bromphen-dm syrp F

pseudoephed-cpm w/hydrocod soln F

pseudoephedrine w/codeine-gg soln F


pseudoephedrine w/ dm-ggliqd F

pseudoephedrine-acetaminophen tabs F

pseudoephedrine-chlorphen-dm liqd F

pseudoephedrine-dexchlorpheniramine-chlophedianol liqd

F

pseudoephedrine-dexchlorpheniramine-dextromethorphan liqd

F


54

Drug Name DrugTier

Requirements/Limits

pseudoephedrine-guaifenesin syrp F

pseudoephedrine-guaifenesin tabs F

pseudoephedrine-guaifenesin tb12 F

pseudoephedrine-ibuprofentabs 200 mg-30 mg F

pseudoephedrine-naproxensodium tb12 120 mg-220 mg

F

PX DAYTIME MULTI-SYMPTOM CAPS F

PX NITETIME MULTI-SYMPTOM CAPS F

QC MEDIFIN PE TABS (phenylephrine-guaifenesin)

NF

QC TRIACTING DAYTIME CHILDRENS SYRP F

RA ACETAMINOPHEN FLU SEVERE COLD TABS F

RA SINUS RELIEF DAYTIME/NIGHTTIMEMISC

F

REFENESEN CHEST CONGESTION & PAIN RELIEF PE TABS

F

REFENESEN CHEST CONGESTION & PAIN RELIEF TABS

F

RESCON TABS F

RESPAIRE-30 CAPS F

ROBITUSSIN CHILDRENS COUGH & COLD CF LIQD F QL(16 ml daily)

ROBITUSSIN CHILDRENS COUGH/COLD LONG-ACTING LIQD

F

ROBITUSSIN COUGH & COLD DAY/NIGHT PACKMISC

F

ROBITUSSIN NIGHTTIME COUGH DM LIQD (doxylamine-dm)

NF

Drug Name DrugTier

Requirements/Limits

ROBITUSSIN NIGHTTIME COUGH LONG-ACTING DM CHILDRENS LIQD

F

ROBITUSSIN PEAK COLD COUGH+ CHEST CONGESTION DM MAX STRENGTH LIQD (dextromethorphan-guaifenesin)

NF

QL(16 ml daily)

ROBITUSSIN PEAK COLD DAY/NIGHT PACK DMMISC

F

ROBITUSSIN PEAK COLD DAY/NIGHT PACKMAXIMUM STRENGTH MISC

F

ROBITUSSIN PEAK COLD DM SYRP (dextromethorphan-guaifenesin)

NF

ROBITUSSIN PEAK COLD MULTI-SYMPTOM COLD LIQD (phenylephrine w/ dm-gg)

NF

QL(16 ml daily)

ROBITUSSIN TO GO COUGH &COLD CF LIQD (phenylephrine w/ dm-gg)

NF QL(16 ml daily)

RONDEC-D LIQD F

RU-HIST D TABS F

RYCONTUSS LIQD (phenylephrine-chlorphen-dm)

NF

RYDEX G TABS F

RYDEX LIQD F

RYMED TABS F

SB NIGHTTIME SINUS MULTI-SYMPTOM CAPS F

SCOT-TUSSIN DM LIQD F

SCOT-TUSSIN SENIOR LIQD F

SEMPREX-D CAPS F


55

Drug Name DrugTier

Requirements/Limits

SINADRIN PE COMPLETE SINUS RELIEF TABS F

SM COUGH & SORE THROAT DAYTIME PAIN RELIEVER LIQD

F

SORBUTUSS NR LIQD F

STAHIST AD LIQD F

STAHIST AD TABS F

STAHIST LIQD F

SUDAFED PE SINUS CONGESTION DAYTIME/NIGHTTIMETABS

F

SUPRESS A PEDIATRIC DROPS LIQD F

SUPRESS DM PEDIATRIC LIQD F

SUPRESS-PE PEDIATRIC LIQD F

THERACOF PLUS COUGH AND COLD RELIEVER LIQD

F

THERAFLU COLD & COUGH PACK F

THERAFLU FLU & SORE THROAT PACK F

THERAFLU POWERPODS DAYTIME SEVERE COLD MISC

F

THERAFLU POWERPODS NIGHTTIME SEVERE COLD MISC

F

THERAFLU SEVERE COLD & COUGH DAYTIME/NIGHTTIMEMISC (phenylephrine-diphenhydramine-dm w/ apap)

NF

THERAFLU SEVERE COLD & COUGH NIGHTTIME PACK (diphenhydramine-phenylephrine-acetaminophen)

NF

Drug Name DrugTier

Requirements/Limits

THERAFLU SEVERE COLD DAYTIME TABS F

THERAFLU SEVERE COLD MULTI SYMPTOM NIGHTTIME PACK

F

THERAFLU SEVERE COLD MULTI SYMPTOM PACK (dextromethorphan-phenylephrine-acetaminophen)

NF

THERAFLU SEVERE COLD NIGHTTIME TABS (phenylephrine-chlorpheniramine-dm w/ apap)

NF

TRIAMINIC CHEST/NASALCONGESTION LIQD

F

TRIAMINIC COLD & ALLERGY SYRP F

TRIAMINIC COLD & COUGH DAY TIME CHILDRENS SYRP

F

TRIAMINIC COLD & COUGH DAY/NIGHTCHILDRENS MISC

NF

TRIAMINIC COUGH & RUNNY NOSE CHILDRENS CHEW

F

TRIAMINIC COUGH & SORE THROAT CHEW F

TRIAMINIC FLU COUGH & FEVER SYRP F

TRIAMINIC FLU/COUGH/FEVER LIQD F

TRIAMINIC NIGHT TIME COLD & COUGH SYRP F

triprolidine &pseudoephedrine tabs F

TRISPEC DMX LIQD F

TRISPEC DMX PEDIATRIC LIQD F

TUSICOF LIQD F QL(16 ml daily)


56

Drug Name DrugTier

Requirements/Limits

TUSNEL C SYRP F


TUSNEL DM LIQD F QL(16 ml daily)

TUSNEL LIQD F

TUSNEL PEDIATRIC LIQD F

TUSNEL TABS F

TUSNEL-DM PEDIATRIC LIQD F

TUSSI-PRES PEDIATRIC LIQD (phenylephrine w/ dm-gg)

NF QL(16 ml daily)

TUSSICAPS CP12 F

TUSSIONEX PENNKINETIC EXTENDED RELEASE SUER (hydrocodonepolistirex-chlorpheniraminepolistirex)

NF

TUSSLIN LIQD F QL(16 mldaily); RX/OTC

TUSSLIN PEDIATRIC LIQD F QL(16 ml

daily); RX/OTC

TUXARIN ER TB12 F

TUZISTRA XR SUER F

TYLENOL CHILDRENS COLD/FLU SUSP(phenylephrine-chlorpheniramine-dm w/ apap)

NF

TYLENOL CHILDRENS PLUS MULTI-SYMPTOM COLD SUSP (phenylephrine-chlorpheniramine-dm w/ apap)

NF

TYLENOL COLD & FLU SEVERE TABS (phenylephrine-dm-gg w/ apap)

NF

Drug Name DrugTier

Requirements/Limits

TYLENOL COLD & HEAD SEVERE CONGESTION TABS (phenylephrine-acetaminophen-guaifenesin)

NF

TYLENOL COLD + FLU + COUGH FOR ADULTS/NIGHT LIQD(phenylephrine-doxylamine-dextromethorphan-acetaminophen)

NF

TYLENOL COLD MAX LIQD (dextromethorphan-phenylephrine-acetaminophen)

NF

TYLENOL COLD MULTI-SYMPTOM NIGHTTIME LIQD (phenylephrine-doxylamine-dextromethorphan-acetaminophen)

NF

TYLENOL COLD MULTI-SYMPTOM SEVERE DAYTIME LIQD (phenylephrine-dm-gg w/ apap)

NF

TYLENOL COLD PLUS FLU SEVERE FOR ADULTS DAY/NIGHTTBPK (phenylephrine-chlorpheniramine w/ dm-gg& apap)

NF

TYLENOL COLD/COUGH/RUNNYNOSE CHILDRENS SUSP (dextromethorphan-acetaminophen-chlorpheniramine)

NF

TYLENOL COLD/COUGH/SORETHROAT CHILDRENS SUSP (acetaminophen w/ dm)

NF

TYLENOL SINUS SEVERE TABS (phenylephrine-acetaminophen-guaifenesin)

NF


57

Drug Name DrugTier

Requirements/Limits

TYLENOL WARMING COUGH & SEVER CONGESTION DAYTIME LIQD (phenylephrine-dm-gg w/ apap)

NF

VANACOF AC LIQD F

VANACOF DM LIQD (phenylephrine w/ dm-gg) NF

VANACOF LIQD F

VANACOF-8 LIQD F

VANATAB AC TABS F

VANATAB DM TABS F

VICKS DAYQUIL MUCUS CONTROL DM LIQD F

VICKS DAYQUIL/NYQUILCOUGH LQPK (doxylamine-dm)

NF

VICKS DAYQUIL/NYQUILSEVERE LQPK (phenylephrine-doxylamine-dm-guaifenesin-apap)

NF

VICKS NYQUIL CHILDRENS COLD/COUGH LIQD

F

VICKS NYQUIL COLD & FLU LIQD (dextromethorphan-doxylamine-acetaminophen)

NF

VICKS NYQUIL COLD & FLU NIGHTTIME RELIEF LIQD 15 MG/15ML-325MG/15ML-6.25 MG/15ML(dextromethorphan-doxylamine-acetaminophen)

NF

VICKS NYQUIL COLD & FLU NIGHTTIME RELIEF LIQD 30 MG/30ML-4MG/30ML-650 MG/30ML

F

VICKS NYQUIL COUGH LIQD (doxylamine-dm) NF

Drug Name DrugTier

Requirements/Limits

VICKS NYQUIL HBP COLD & FLU LIQD (dextromethorphan-doxylamine-acetaminophen)

NF

VICKS NYQUIL SEVERE COLD& FLU MAX STRENGTH TABS

F

VICKS SINEX DAYQUIL/NYQUILDAYTIME/NIGHTTIMESINUS RELIEF MISC (doxylamine-phenylephrine-acetaminophen)

NF

VICKS SINEX DAYTIME/NIGHTTIME/CONGESTION/PRESSURE & PAIN MISC (doxylamine-phenylephrine-acetaminophen)

NF

WAL-FLU COLD & SORE THROAT PACK F

WAL-FLU SEVERE COLD DAYTIME PACK F

WAL-FLU SEVERE COLD NIGHT TIME PACK F

Y-TUSS LIQD F

Z-TUSS AC LIQD F

ZYNCOF SYRP F

ZYRTEC-D ALLERGY/CONGESTIONTB12 (cetirizine-pseudoephedrine)

NF

QL(2 ea daily)

Expectorants BROMHEXINE HCL POWD F

guaifenesin liqd or 100mg/5ml, 200 mg/5ml, 200mg/10ml, 400 mg/20ml

F QL(16 ml daily)

GUAIFENESIN POWD XX F


58

Drug Name DrugTier

Requirements/Limits

guaifenesin soln or 100mg/5ml, 200 mg/10ml, 300mg/15ml

F QL(16 ml daily)

guaifenesin syrp or 100mg/5ml, 200 mg/10ml F QL(16 ml daily)

guaifenesin tabs or 200mg, 400 mg F

guaifenesin tb12 or 600mg, 1200 mg F

HERBAL EXPEC LIQD F QL(16 ml daily)

MUCINEX FOR KIDS PACK F

MUCINEX MAXIMUM STRENGTH TB12 (guaifenesin)

NF

MUCINEX TB12 (guaifenesin) NF

SSKI SOLN F

TERPIN HYDRATE MONOHYDRATE POWD F

TERPIN HYDRATE POWD F

Misc. Respiratory Inhalants HYPER-SAL NEBU (sodium chloride (inhalant)) NF

HYPERSAL NEBU 7 % (sodium chloride (inhalant)) NF

sodium chloride (inhalant)nebu 0.9 %, 3 %, 7 % F

Mucolytics ACETYLCYSTEINE POWD XX F

acetylcysteine soln in 10%, 20 % F

N-ACETYL-L-CYSTEINE POWD F

DERMATOLOGICALS - Drugs to Treat SkinConditions

Acne Products

ABSORICA CAPS F PA

ACNE MEDICATION 10 LOTN F

Drug Name DrugTier

Requirements/Limits

ACNE MEDICATION 5 LOTN F

BENZAC AC WASH LIQD (benzoyl peroxide) NF RX/OTC

BENZEFOAM FOAM (benzoyl peroxide) NF RX/OTC

BENZEFOAM ULTRA FOAM (benzoyl peroxide) NF

benzoyl peroxide bar ex 10% F

BENZOYL PEROXIDE CLEANSER LIQD F

benzoyl peroxide crea ex10 %, 2.5 % F

benzoyl peroxide foam ex5.3 % F RX/OTC

benzoyl peroxide foam ex9.8 % F

benzoyl peroxide gel ex 5%, 10 %, 2.5 % F

benzoyl peroxide liqd ex 4%, 7 %, 10 % F

benzoyl peroxide liqd ex 5%, 2.5 % F RX/OTC

CLEOCIN-T GEL (clindamycin phosphate(topical))

NF

CLEOCIN-T LOTN (clindamycin phosphate(topical))

NF

CLEOCIN-T SOLN (clindamycin phosphate(topical))

NF

CLINDAGEL GEL 1 % (clindamycin phosphate(topical))

F

clindamycin phosphate(topical) gel 1 % F

clindamycin phosphate(topical) lotn 1 % F

clindamycin phosphate(topical) soln 1 % F

ERYGEL GEL (erythromycin (acne aid)) NF

erythromycin (acne aid) gel2 % F


59

Drug Name DrugTier

Requirements/Limits

erythromycin (acne aid)pads 2 % F

erythromycin (acne aid)soln 2 % F

isotretinoin caps or 10 mg,20 mg, 30 mg, 40 mg F PA

KLARON LOTN (sulfacetamide sodium (acne))

NF

NEUTROGENA ON-THE-SPOT ACNE TREATMENT CREA (benzoyl peroxide)

NF

OC8 GEL F

PANOXYL LIQD (benzoyl peroxide) NF RX/OTC

PANOXYL-4 CREAMY WASH LIQD (benzoyl peroxide)

NF

RETIN-A CREA (tretinoin) NF AL(Up to 26 yrsold )

RETIN-A GEL (tretinoin) NF AL(Up to 26 yrsold )

RETIN-A MICRO GEL (tretinoin microsphere) NF AL(Up to 26 yrs

old ) RETIN-A MICRO PUMP GEL 0.04 %, 0.1 % (tretinoin microsphere)

NF AL(Up to 26 yrsold )

RETIN-A MICRO PUMP GEL 0.08 % F AL(Up to 26 yrs

old )

RIAX FOAM F

sulfacetamide sodium (acne) lotn 10 % F

tretinoin crea ex 0.025 %,0.05 %, 0.1 % F AL(Up to 26 yrs

old ) tretinoin gel ex 0.025 %,0.01 % F AL(Up to 26 yrs

old )

tretinoin microsphere gel F AL(Up to 26 yrsold )

ZACLIR CLEANSING LOTN F

Anti-inflammatory Agents - Topical

diclofenac sodium (topical)gel 1 % F

QL(200 gm per30 days retail);RX/OTC

Drug Name DrugTier

Requirements/Limits

FLECTOR PTCH (diclofenac epolamine) NF

VOLTAREN GEL (diclofenac sodium (topical))

NF QL(200 gm per30 days retail);RX/OTC

Antibiotics - Topical BACIGUENT OINT EX (bacitracin (topical)) NF

bacitracin (topical) oint 500unit/gm F

bacitracin zinc oint ex 500 unit/gm F

bacitracin-polymyxin b oint F

BACTROBAN CREA (mupirocin calcium(topical))

NF QL(1 gm daily)

CENTANY OINT 2 % F

gentamicin sulfate (topical)crea 0.1 % F

gentamicin sulfate (topical)oint 0.1 % F

mupirocin calcium (topical)crea 2 % F QL(1 gm daily)

mupirocin oint ex 2 % F

neomycin-bacitracin-polymyxin oint F

neomycin-bacitracin-polymyxin-pramoxine oint F

NEOSPORIN ORIGINAL OINT (neomycin-bacitracin-polymyxin)

NF

POLYSPORIN OINT (bacitracin-polymyxin b) NF

Antifungals - Topical butenafine hcl crea 1 % F RX/OTC

ciclopirox olamine crea ex0.77 % F

ciclopirox olamine susp ex0.77 % F

ciclopirox soln 8 % F


60

Drug Name DrugTier

Requirements/Limits

clotrimazole (topical) crea 1% F RX/OTC

clotrimazole (topical) soln 1% F RX/OTC

clotrimazole w/betamethasone crea 0.05 %-1 %

F

EXELDERM CREA (sulconazole nitrate) NF

ketoconazole (topical) crea2 % F

ketoconazole (topical)sham 2 % F

LAMISIL AT CREA (terbinafine hcl (topical)) NF

LAMISIL AT JOCK ITCH CREA (terbinafine hcl (topical))

NF

LOPROX CREA (ciclopirox olamine) NF

LOPROX SUSP (ciclopirox olamine) NF

LOTRIMIN AF CREA (clotrimazole (topical)) NF RX/OTC

LOTRIMIN AF JOCK ITCH CREA (clotrimazole (topical))

NF RX/OTC

LOTRIMIN ANTIFUNGAL AERO (miconazole nitrate (topical))

NF

LOTRIMIN ULTRA CREA (butenafine hcl) NF RX/OTC

LOTRISONE CREA (clotrimazole w/betamethasone)

NF

LUZU CREA (luliconazole) NF

MICATIN CREA (miconazole nitrate (topical))

NF

miconazole nitrate (topical) aero F

miconazole nitrate (topical) crea F

miconazole nitrate (topical)powd F

Drug Name DrugTier

Requirements/Limits

MICONAZOLE NITRATE POWD F

NIZORAL SHAM (ketoconazole (topical)) NF

nystatin (topical) crea F

nystatin (topical) oint F

nystatin (topical) powd F

PENLAC NAIL LACQUER SOLN (ciclopirox) NF

terbinafine hcl (topical) crea1 % F

TINACTIN AERO (tolnaftate) NF

TINACTIN AERP (tolnaftate) NF

TINACTIN CREA (tolnaftate) NF

TINACTIN DEODORANT AERP (tolnaftate) NF

TINACTIN JOCK ITCH AERP (tolnaftate) NF

tolnaftate aero ex 1 % F

tolnaftate aerp ex 1 % F

tolnaftate crea ex 1 % F

tolnaftate liqd ex 1 % F

tolnaftate soln ex 1 % F

XOLEGEL GEL 2 % F

Antihistamines-Topical diphenhydramine hcl(topical) gel F

diphenhydramine hcl(topical) soln F

ITCH RELIEF CREA F

Antineoplastic or Premalignant Lesion Agents -CARAC CREA (fluorouracil (topical)) NF


61

Drug Name DrugTier

Requirements/Limits

EFUDEX CREA (fluorouracil (topical)) NF

fluorouracil (topical) crea 5% F

Antipsoriatics VECTICAL OINT (calcitriol (topical)) NF

Antiseborrheic Products OVACE PLUS WASH LIQD (sulfacetamide sodium) NF

OVACE WASH LIQD (sulfacetamide sodium) NF

selenium sulfide lotn ex 1 %, 2.5 % F

selenium sulfide sham ex 1 % F

SELSUN BLUE DAILY LOTN (selenium sulfide) NF

SELSUN BLUE LOTN (selenium sulfide) NF

SELSUN BLUE MEDICATED LOTN (selenium sulfide)

NF

SELSUN BLUE MOISTURIZING LOTN (selenium sulfide)

NF

sulfacetamide sodium liqdex 10 % F

Antivirals - Topical

ABREVA CREA (docosanol) NF

Limit 2 permonth;QL(0.067 gm daily)

acyclovir topical oint 5 % F QL(0.5 gmdaily)

docosanol crea ex 10 % F Limit 2 permonth;QL(0.067 gm daily)

ZOVIRAX OINT EX 5 % (acyclovir topical) NF QL(0.5 gm

daily) Burn Products SILVADENE CREA (silver sulfadiazine) NF

silver sulfadiazine crea ex 1 % F

Corticosteroids - Topical

Drug Name DrugTier

Requirements/Limits

betamethasone dipropionate (topical) lotn0.05 %

F

betamethasone dipropionate augmentedcrea 0.05 %

F

betamethasone valerate crea ex 0.1 % F

betamethasone valerate lotn ex 0.1 % F

betamethasone valerate oint ex 0.1 % F

clobetasol propionate creaex 0.05 % F QL(3.34 gm

daily) clobetasol propionateemollient base crea F QL(3.34 gm

daily) clobetasol propionate gelex 0.05 % F QL(118 gm per

fill retail) clobetasol propionate ointex 0.05 % F QL(3.34 gm

daily) clobetasol propionate solnex 0.05 % F QL(3.34 ml

daily) CLODERM CREA (clocortolone pivalate) NF

DERMA-SMOOTHE/FSBODY OIL 0.01 % (fluocinolone acetonide)

F 1 rtl pack lmtamt,30 rtl packlmt day(s),

DERMA-SMOOTHE/FSSCALP OIL 0.01 % (fluocinolone acetonide)

F 1 rtl pack lmtamt,30 rtl packlmt day(s),

DIPROLENE AF CREA (betamethasone dipropionate augmented)

NF

ELOCON CREA (mometasone furoate) NF

ELOCON OINT (mometasone furoate) NF

fluocinonide crea ex 0.05 % F QL(2 gm daily)

fluocinonide oint ex 0.05 % F QL(60 gm perfill retail)

fluocinonide soln ex 0.05 % F

fluticasone propionate creaex 0.05 % F

fluticasone propionate ointex 0.005 % F


62

Drug Name DrugTier

Requirements/Limits

halobetasol propionatecrea 0.05 % F QL(2 gm daily)

halobetasol propionate oint0.05 % F QL(2 gm daily)

hydrocortisone (topical)crea 0.5 %, 2.5 % F

hydrocortisone (topical)crea 1 % F RX/OTC

hydrocortisone (topical) gel1 % F

hydrocortisone (topical)lotn 1 %, 2.5 % F

hydrocortisone (topical)oint 0.5 %, 2.5 % F

hydrocortisone (topical)oint 1 % F RX/OTC

hydrocortisone acetate(topical) crea 1 % F

hydrocortisone-aloe veracrea 1 % F

mometasone furoate crea ex 0.1 % F

mometasone furoate oint ex 0.1 % F

mometasone furoate soln ex 0.1 % F

MONISTAT SOOTHING CARE ITCH RELIEF CREA (hydrocortisone (topical))

NF RX/OTC

TACLONEX SUSP (calcipotriene-betamethasone dipropionate)

NF

TEMOVATE CREA (clobetasol propionate) NF QL(3.34 gm

daily) TEMOVATE OINT (clobetasol propionate) NF QL(3.34 gm

daily) triamcinolone acetonide (topical) crea 0.025 %, 0.1%, 0.5 %

F

triamcinolone acetonide (topical) lotn 0.025 %, 0.1%

F

triamcinolone acetonide (topical) oint 0.025 %, 0.05%, 0.1 %, 0.5 %

F

Drug Name DrugTier

Requirements/Limits

ULTRAVATE CREA (halobetasol propionate) NF QL(2 gm daily)

ULTRAVATE OINT (halobetasol propionate) NF QL(2 gm daily)

Emollient/Keratolytic Agents ATRAC-TAIN CREA 10 % (urea) NF

REA-LO CREA F

URE-K CREA F

urea crea ex 10 %, 20 %,50 % F

urea crea ex 40 % F RX/OTC

urea lotn ex 40 % F

Emollients LAC-HYDRIN CREA (lactic acid (ammonium lactate)) NF RX/OTC

LAC-HYDRIN TWELVE LOTN (lactic acid (ammonium lactate))

NF RX/OTC

lactic acid (ammoniumlactate) crea 12 % F RX/OTC

lactic acid (ammoniumlactate) lotn 10 % F

lactic acid (ammoniumlactate) lotn 12 % F RX/OTC

NOBLE MYSTIQUE EMU-LAC CREA F

Immunomodulating Agents - Topical ALDARA CREA (imiquimod) NF

imiquimod crea ex 5 % F

Keratolytic/Antimitotic Agents AMBI EVEN & CLEAR EXFOLIATING WASH LIQD

F

AMBI EVEN & CLEAR FOAMINGCLEANSER LIQD

F

BETASAL SHAM F


63

Drug Name DrugTier

Requirements/Limits

CLEAN & CLEAR ACNE TRIPLECLEAR BUBBLE FOAM CLEANSER FOAM

F

CLEAN & CLEAR ADVANTAGE OIL ABSORBING CLEANSER CREA

F

CLEAN & CLEAR BLACKHEAD ERASER SCRUB CREA

F

CLEAN & CLEAR DEEP CLEANING ASTRINGENT SENSITIVE SKIN LIQD

F

CLEARASIL DAILY CLEAN GENTLE PREVENTION LIQD

F

CLN ACNE CLEANSER LIQD F

COMPOUND W LIQD (salicylic acid) NF

COMPOUND W MAXIMUM STRENGTH GEL (salicylic acid)

NF

CORN & CALLUS REMOVER SOLN F

CVS PSORIASIS MEDICATED SHAMPOO PLUS CONDITIONER SHAM

F

CVS THERAPEUTIC DANDRUFFMAXIMUM STRENGTH SHAM

F

DENOREX EXTRA STRENGTH 2-IN-1 SHAM F

DERMAREST PSORIASIS GEL F

DERMAREST PSORIASIS MEDICATED SHAMPOO PLUS CONDITIONER SHAM

F

FREEZONE LIQD F

GOLD BOND PSORIASIS RELIEF MULTI-SYMPTOM CREA

F

KERALYT GEL 3 % F

Drug Name DrugTier

Requirements/Limits

KERALYT GEL 6 % (salicylic acid) NF

MG217 PSORIASIS MULTI-SYMPTOM CREA 3 %

F

MOSCO CALLUS/CORNREMOVER SOLN F

NEUTROGENA T/SALSHAM F

P & S SHAM F

podofilox soln ex 0.5 % F

SALEX SHAM (salicylic acid) NF

salicylic acid crea ex 2 %, 6% F

salicylic acid foam ex 6 % F PA

salicylic acid gel ex 2 %, 6%, 17 % F

salicylic acid liqd ex 2 %, 3%, 17 % F

salicylic acid lotn ex 0.5 %,6 % F

salicylic acid sham ex 6 % F

salicylic acid soln ex 17 %,26 % F

SALVAX FOAM (salicylic acid) NF PA

SELSUN BLUE DEEP CLEANSING SHAM F

SELSUN BLUE NATURALS DRYSCALP SHAM

F

THERAPEUTIC DANDRUFF SHAM F

THERAPEUTIC T+PLUS MAXIMUM STRENGTH SHAM

F

Local Anesthetics - Topical

lidocaine hcl crea ex 4 % F

Max 2 tubes per 30days;QL(266gm per 30 daysretail)


64

Drug Name DrugTier

Requirements/Limits

lidocaine hcl crea ex 4 % F

Max 3 tubes per 30days;QL(230gm per 30 daysretail)

lidocaine hcl gel ex 2 % F QL(60 ml per30 days retail);RX/OTC

lidocaine hcl gel ex 2 % F

lidocaine hcl prsy ex 2 % F

lidocaine hcl soln ex 4 % F

lidocaine oint ex 5 % F PA; QL(50 gmper fill retail)

lidocaine ptch ex 5 % F PA; QL(3 eadaily)

lidocaine-prilocaine crea2.5 %-2.5 % F QL(30 gm per

30 days retail) LIDODERM PTCH (lidocaine) NF PA; QL(3 ea

daily)

LMX 4 CREA (lidocaine) NF

XOLIDO CREA F

Misc. Topical CALAMINE LOTN EX F

DESITIN RAPID RELIEF CREA F

DRYSOL SOLN 20 % F

GNP CALAMINE LOTN F

HM CALAMINE LOTN F

JOHNSONS NO MORE RASH CREA F

MEIJER CALAMINE LOTN F

PX CALAMINE LOTN F

QC CALAMINE LOTN F

RA CALAMINE LOTN 6.971 %-6.971 % F

Drug Name DrugTier

Requirements/Limits

SM CALAMINE LOTN F

zinc oxide (topical) crea 13% F

zinc oxide (topical) oint 20%, 40 % F

Rosacea Agents METROCREAM CREA (metronidazole (topical)) NF

METROLOTION LOTN (metronidazole (topical)) NF

metronidazole (topical)crea 0.75 % F

metronidazole (topical) gel0.75 % F

metronidazole (topical) lotn0.75 % F

Scabicides & Pediculicides

crotamiton lotn ex 10 % F PA

ELIMITE CREA (permethrin) NF

EURAX CREA 10 % F PA

EURAX LOTN (crotamiton) NF PA

LICEMD GEL F

lindane sham F

LYCELLE GEL F

NATROBA SUSP (spinosad) F PA

nit remover gel F

NIX CREME RINSE LIQD (permethrin) NF

permethrin crea ex 5 % F

permethrin liqd ex 1 % F

permethrin lotn ex 1 % F

pyrethrins-piperonylbutoxide sham 0.3 %-0.33 %-4 %, 0.33 %-4 %

F


65

Drug Name DrugTier

Requirements/Limits

pyrethrins-piperonylbutoxide-permethrin-nitremover kit 0.33 %-0.5 %-4 %

F

RA LICE SOLUTION KIT KIT F

RID COMPLETE LICE ELIMINATION KIT (pyrethrins-piperonylbutoxide-permethrin-nit remover)

NF

SCHOOLTIME SHAMPOO SHAM F

SKLICE LOTN F PA

spinosad susp F PA

DIAGNOSTIC PRODUCTS

Diagnostic Tests

ALBUSTIX STRP F

CHEMSTRIP MICRAL STRP F

CHEMSTRIP-K STRP F

KETONE STRP F

KETONE TEST STRIPS STRP F

KETOSTIX STRP F

RELION KETONE STRP F

RELION KETONE TEST STRIPS STRP F

TRUE METRIX BLOOD GLUCOSETEST STRIPS STRP

F

INSULIN USERS LIMITED TO 150 PER 30 DAYS, NON-INSULIN USERS LIMITED TO 100 PER 90 DAYS;RX/OTC

Drug Name DrugTier

Requirements/Limits

TRUETRACK TEST STRP F

INSULIN USERS LIMITED TO 150 PER 30 DAYS, NON-INSULIN USERS LIMITED TO 100 PER 90 DAYS;RX/OTC

DIGESTIVE AIDS - Drugs to Treat Low DigestiveEnzymes

Digestive Enzymes

CREON CPEP F 500 permonth;QL(16.67 ea daily)

SUCRAID SOLN F PA; SP

ZENPEP CPEP 10000 UNIT-14000 UNIT-3000 UNIT, 10000 UNIT-32000 UNIT-42000 UNIT, 20000 UNIT-63000 UNIT-84000 UNIT, 126000 UNIT-168000 UNIT-40000 UNIT

F

500 permonth;;QL(16.67 ea daily)

ZENPEP CPEP 17000 UNIT-24000 UNIT-5000 UNIT, 15000 UNIT-47000 UNIT-63000 UNIT, 105000 UNIT-25000 UNIT-79000 UNIT

F

500 permonth;QL(16.67 ea daily)

DIURETICS - Drugs to Treat Heart, CirculationConditions and Blood Pressure

Carbonic Anhydrase Inhibitors acetazolamide cp12 or 500 mg F MP

acetazolamide tabs or 125 mg, 250 mg F MP

methazolamide tabs or 25 mg, 50 mg F MP

Diuretic Combinations ALDACTAZIDE TABS 25 MG-25 MG (spironolactone& hydrochlorothiazide)

NF MP

ALDACTAZIDE TABS 50 MG-50 MG F


66

Drug Name DrugTier

Requirements/Limits

amiloride & hydrochlorothiazide tabs F MP

DYAZIDE CAPS (triamterene & hydrochlorothiazide)

NF MP

MAXZIDE TABS (triamterene & hydrochlorothiazide)

NF MP

MAXZIDE-25 TABS (triamterene & hydrochlorothiazide)

NF MP

spironolactone &hydrochlorothiazide tabs F MP

triamterene & hydrochlorothiazide caps F MP

triamterene & hydrochlorothiazide tabs F MP

Loop Diuretics bumetanide tabs or 0.5 mg,1 mg, 2 mg F MP

BUMEX TABS (bumetanide) NF MP

DEMADEX TABS (torsemide) NF MP

furosemide soln or 8 mg/ml, 10 mg/ml F MP

furosemide tabs or 20 mg,40 mg, 80 mg F MP

LASIX TABS (furosemide) NF MP

torsemide tabs F MP

Potassium Sparing Diuretics ALDACTONE TABS (spironolactone) NF MP

amiloride hcl tabs or 5 mg F MP

DYRENIUM CAPS (triamterene) NF MP

spironolactone tabs or 25mg, 50 mg, 100 mg F MP

triamterene caps or 50 mg,100 mg F MP

Thiazides and Thiazide-Like Diuretics

chlorothiazide tabs F MP

Drug Name DrugTier

Requirements/Limits

chlorthalidone tabs F MP

DIURIL SUSP F

hydrochlorothiazide caps or12.5 mg F MP

hydrochlorothiazide tabs or25 mg, 50 mg F MP

indapamide tabs F MP

methyclothiazide tabs F

metolazone tabs F MP

MICROZIDE CAPS (hydrochlorothiazide) NF MP

ENDOCRINE AND METABOLIC AGENTS -MISC. - Drugs to Treat Bone Disease andRegulate Hormones

Bone Density Regulators

alendronate sodium soln F

alendronate sodium tabs F

BONIVA TABS (ibandronate sodium) NF QL(1 ea per 30

days retail)

calcitonin (salmon) soln F

FORTEO SOPN F PA; SP

FOSAMAX TABS (alendronate sodium) NF

ibandronate sodium tabs 150 mg F QL(1 ea per 30

days retail)

PROLIA SOSY F PA; SP

Growth Hormones GENOTROPIN MINIQUICK SOLR F PA; SP

GENOTROPIN SOLR F PA; SP

NORDITROPIN FLEXPRO SOLN F PA; SP

Hormone Receptor Modulators EVISTA TABS (raloxifene hcl) NF


67

Drug Name DrugTier

Requirements/Limits

raloxifene hcl tabs 60 mg F

Insulin-Like Growth Factors (Somatomedins) INCRELEX SOLN F PA; SP

LHRH/GnRH Agonist Analog Pituitary

FENSOLVI KIT F PA; SP

Metabolic Modifiers calcitriol caps or 0.25 mcg,0.5 mcg F

calcitriol soln or 1 mcg/ml F

CARNITOR SF SOLN (levocarnitine (metabolicmodifiers))

NF

CARNITOR SOLN OR 1 GM/10ML (levocarnitine (metabolic modifiers))

NF

cinacalcet hcl tabs F PA; SP

ELAPRASE SOLN F PA; SP

levocarnitine (metabolicmodifiers) soln 1 gm/10ml F

paricalcitol caps 1 mcg F

ROCALTROL CAPS (calcitriol) NF

ROCALTROL SOLN (calcitriol) NF

SENSIPAR TABS (cinacalcet hcl) NF PA; SP

ZEMPLAR CAPS 1 MCG (paricalcitol) NF

Posterior Pituitary Hormones

DDAVP SOLN NA 0.01 % F

DDAVP SOLN NA 0.01 % (desmopressin acetate spray)

NF

DDAVP TABS OR 0.1 MG, 0.2 MG (desmopressin acetate)

NF PA

desmopressin acetatespray refrigerated soln F

Drug Name DrugTier

Requirements/Limits

desmopressin acetatespray soln 0.01 % F

desmopressin acetate tabsor 0.1 mg, 0.2 mg F PA

STIMATE SOLN F SP

ESTROGENS - Hormone Replacement/ModifyingDrugs

Estrogen Combinations

CLIMARA PRO PTWK F

PREMPRO TABS F QL(1 ea daily)

Estrogens

ALORA PTTW F

CLIMARA PTWK (estradiol) NF

ESTRACE TABS (estradiol) NF

estradiol pttw td 0.0375mg/24hr, 0.025 mg/24hr,0.075 mg/24hr, 0.05mg/24hr, 0.1 mg/24hr

F

estradiol ptwk td 0.025mg/24hr, 0.075 mg/24hr,0.05 mg/24hr, 0.06mg/24hr, 0.1 mg/24hr, 37.5mcg/24hr

F

estradiol tabs or 0.5 mg, 1mg, 2 mg F

MENEST TABS F

MENOSTAR PTWK F

MINIVELLE PTTW (estradiol) NF

PREMARIN TABS OR 0.625 MG, 0.45 MG, 0.3 MG, 0.9 MG, 1.25 MG

F

VIVELLE-DOT PTTW (estradiol) NF

FLUOROQUINOLONES - Drugs to Treat BacterialInfections

Fluoroquinolones


68

Drug Name DrugTier

Requirements/Limits

AVELOX SOLN NF

AVELOX TABS (moxifloxacin hcl) NF

BAXDELA SOLR F

BAXDELA TABS F

CIPRO I.V.-IN D5W SOLN (ciprofloxacin in d5w) NF

CIPRO SUSR 5 GM/100ML, 500 MG/5ML F

CIPRO TABS 250 MG, 500 MG (ciprofloxacin hcl) NF

ciprofloxacin hcl tabs or100 mg, 250 mg, 500 mg,750 mg

F

ciprofloxacin in d5w soln F

ciprofloxacin susr or F

ciprofloxacin-ciprofloxacinhcl tb24 F

LEVAQUIN TABS (levofloxacin) NF

levofloxacin in d5w soln F

levofloxacin soln F

levofloxacin tabs F

MOXIFLOXACIN HYDROCHLORIDE/SODIUM HYDROCHLORIDE SOLN 0.8 %-400 MG/250ML

F

moxifloxacin hcl tabs or F

MOXIFLOXACIN HYDROCHLORIDE SOLN IV 400 MG/250ML

F

ofloxacin tabs F

GASTROINTESTINAL AGENTS - MISC. -Miscellaneous Gastrointestinal Drugs

Antiflatulents

Drug Name DrugTier

Requirements/Limits

GAS-X CHEW (simethicone) NF

GAS-X EXTRA STRENGTH CHEW 125 MG (simethicone)

NF

MYLICON INFANTS GAS RELIEF DYE FREE SUSP (simethicone)

NF

MYLICON INFANTS GAS RELIEF SUSP (simethicone)

NF

PHAZYME CAPS (simethicone) NF

PHAZYME ULTRA STRENGTH CAPS (simethicone)

NF

simethicone caps or 125mg, 180 mg F

simethicone chew or 80 mg, 125 mg F

simethicone susp or 20mg/0.3ml, 40 mg/0.6ml F

Gallstone Solubilizing Agents

ACTIGALL CAPS (ursodiol) NF

URSO 250 TABS (ursodiol) NF

URSO FORTE TABS (ursodiol) NF

ursodiol caps or 300 mg F

ursodiol tabs or 250 mg,500 mg F

Gastrointestinal Chloride Channel Activators

AMITIZA CAPS F PA

Gastrointestinal Stimulants metoclopramide hcl soln or5 mg/5ml, 10 mg/10ml F

metoclopramide hcl tabs or5 mg, 10 mg F

metoclopramide hcl tbdp or5 mg F

METOCLOPRAMIDE ODT TBDP F


69

Drug Name DrugTier

Requirements/Limits

REGLAN TABS (metoclopramide hcl) NF

Inflammatory Bowel Agents ASACOL HD TBEC (mesalamine) NF QL(9 ea daily)

AZULFIDINE EN-TABS TBEC (sulfasalazine) NF QL(8 ea daily)

AZULFIDINE TABS (sulfasalazine) NF QL(8 ea daily)

balsalazide disodium caps750 mg F QL(9 ea daily)

COLAZAL CAPS (balsalazide disodium) NF QL(9 ea daily)

DIPENTUM CAPS F QL(4 ea daily)

mesalamine enem re 4 gm F QL(60 ml daily)

mesalamine tbec or 800 mg F QL(9 ea daily)

PENTASA CPCR F QL(9 ea daily)

RENFLEXIS SOLR F PA; SP

SFROWASA ENEM F QL(60 ml daily)

sulfasalazine tabs or 500 mg F QL(8 ea daily)

sulfasalazine tbec or 500 mg F QL(8 ea daily)

Intestinal Acidifiers lactulose (encephalopathy)soln F

Irritable Bowel Syndrome (IBS) Agents

LINZESS CAPS F PA

Phosphate Binder Agents calcium acetate (phosphatebinder) caps 667 mg F

calcium acetate (phosphatebinder) tabs 667 mg F RX/OTC

RENVELA TABS (sevelamer carbonate) NF

sevelamer carbonate tabs 800 mg F

Drug Name DrugTier

Requirements/Limits

GENITOURINARY AGENTS - MISCELLANEOUS - Miscellaneous Drugs to Treat ReproductiveOrgans and Urinary System

Alkalinizers potassium citrate(alkalinizer) tbcr F

potassium citrate-citric acidsoln 1100 mg/5ml-334mg/5ml, 1100 mg/5ml-1100mg/5ml-334 mg/5ml-334mg/5ml

F

RX/OTC

sodium citrate & citric acid soln F RX/OTC

UROCIT-K 10 TBCR (potassium citrate(alkalinizer))

NF


NF


NF

Interstitial Cystitis Agents

ELMIRON CAPS 100 MG F PA

Prostatic Hypertrophy Agents

alfuzosin hcl tb24 10 mg F

AVODART CAPS (dutasteride) NF

dutasteride caps or 0.5 mg F

finasteride tabs or 5 mg F

FLOMAX CAPS (tamsulosin hcl) NF

PROSCAR TABS (finasteride) NF

RAPAFLO CAPS 4 MG (silodosin) NF

tamsulosin hcl caps 0.4 mg F

UROXATRAL TB24 (alfuzosin hcl) NF

Urinary Analgesics


70

Drug Name DrugTier

Requirements/Limits

phenazopyridine hcl tabs or100 mg, 200 mg F

PYRIDIUM TABS (phenazopyridine hcl) NF

GOUT AGENTS - Drugs to Treat Gout

Gout Agents allopurinol tabs or 100 mg,300 mg F

colchicine tabs or 0.6 mg F

COLCRYS TABS (colchicine) NF

febuxostat tabs F PA

ULORIC TABS (febuxostat) NF PA

ZYLOPRIM TABS (allopurinol) NF

Uricosurics

probenecid tabs F

HEMATOLOGICAL AGENTS - MISC. - Drugs toTreat Blood Disorders

Hematorheologic Agents

pentoxifylline tbcr or F

Platelet Aggregation Inhibitors

BRILINTA TABS F PA

cilostazol tabs F

clopidogrel bisulfate tabs or75 mg, 300 mg F

dipyridamole tabs or 25mg, 50 mg, 75 mg F

PLAVIX TABS (clopidogrel bisulfate) NF

HEMATOPOIETIC AGENTS - Drugs to TreatBlood Disorders

Agents for Gaucher Disease

CERDELGA CAPS F PA; SP

CEREZYME SOLR F PA; SP

Drug Name DrugTier

Requirements/Limits

ELELYSO SOLR F PA; SP

miglustat caps 100 mg F PA; SP

VPRIV SOLR F PA; SP

Cobalamins

B-12 TABS F

cyanocobalamin soln ij1000 mcg/ml F

cyanocobalamin tabs or 50mcg, 100 mcg, 250 mcg,500 mcg, 1000 mcg, 2000 mcg

F

Folic Acid/Folates

folic acid tabs 1 mg F RX/OTC

folic acid tabs 400 mcg,800 mcg F

Hematopoietic Growth Factors

FULPHILA SOSY F PA; SP

NEUPOGEN SOLN F PA; SP

NEUPOGEN SOSY F PA; SP

NPLATE SOLR F PA; SP

PROMACTA TABS F PA; SP

RETACRIT SOLN 2000 UNIT/ML, 3000 UNIT/ML,4000 UNIT/ML, 10000UNIT/ML, 40000 UNIT/ML

F

PA; SP

UDENYCA SOSY F PA; SP

Iron

FEMIRON TABS F

FER-IN-SOL SOLN (ferrous sulfate) NF

FERRETTS TABS F

FERRIMIN 150 TABS F


71

Drug Name DrugTier

Requirements/Limits

FERROUS FUMARATE TABS OR 29 MG F

ferrous fumarate tabs or 324 mg F

ferrous gluconate tabs or27 mg, 240 mg, 324 mg F

FERROUS GLUCONATE TABS OR 324 MG F

FERROUS SULFATE LIQD 220 MG/5ML F

ferrous sulfate soln 15 mg/ml F

ferrous sulfate tabs 27 mg,65 mg, 325 mg F

ferrous sulfate tbec 325 mg F

HEMOCYTE TABS (ferrous fumarate) NF

HEMOSTATICS - Drugs to Stop Bleeding/TreatBlood Disorders

Hemostatics - Systemic AMICAR SOLN (aminocaproic acid) NF SP

AMICAR TABS (aminocaproic acid) NF SP

aminocaproic acid soln or0.25 gm/ml F SP

aminocaproic acid tabs or500 mg F SP

HYPNOTICS/SEDATIVES/SLEEP DISORDERAGENTS

Antihistamine Hypnotics diphenhydramine hcl(sleep) caps 25 mg F QL(2 ea daily)

diphenhydramine hcl(sleep) caps 50 mg F QL(1 ea daily)

diphenhydramine hcl(sleep) liqd 50 mg/30ml F QL(30 ml daily)

diphenhydramine hcl(sleep) tabs 25 mg F QL(2 ea daily)

diphenhydramine hcl(sleep) tabs 50 mg F QL(1 ea daily)

diphenhydramine hcl(sleep) tbdp 25 mg F QL(2 ea daily)

Drug Name DrugTier

Requirements/Limits

doxylamine succinate(sleep) tabs 25 mg F

NYTOL MAXIMUM STRENGTH TABS (diphenhydramine hcl(sleep))

NF

QL(1 ea daily)

UNISOM SLEEPGELS CAPS (diphenhydraminehcl (sleep))

NF QL(1 ea daily)

UNISOM SLEEPMELTS TBDP (diphenhydraminehcl (sleep))

NF QL(2 ea daily)

UNISOM SLEEPTABS TABS (doxylaminesuccinate (sleep))

NF

WAL-SLEEP Z LIQUID SHOTS LIQD F QL(50 ml daily)

ZZZQUIL CAPS 25 MG (diphenhydramine hcl(sleep))

NF QL(2 ea daily)

ZZZQUIL LIQD 50 MG/30ML(diphenhydramine hcl(sleep))

NF

QL(30 ml daily)

Barbiturate Hypnotics phenobarbital elix or 20mg/5ml F

phenobarbital soln or 20mg/5ml F

phenobarbital tabs or 15mg, 30 mg, 60 mg, 100 mg,16.2 mg, 32.4 mg, 64.8 mg,97.2 mg

F

Non-Barbiturate Hypnotics

AMBIEN TABS 10 MG (zolpidem tartrate) NF


AMBIEN TABS 5 MG (zolpidem tartrate) NF


eszopiclone tabs F QL(1 ea daily);AL(At least 6yrs old)

LUNESTA TABS (eszopiclone) NF



72

Drug Name DrugTier

Requirements/Limits

RESTORIL CAPS 15 MG, 30 MG (temazepam) NF


temazepam caps 15 mg,30 mg F


zolpidem tartrate tabs or 10 mg F


zolpidem tartrate tabs or 5 mg F


Selective Melatonin Receptor Agonists

ROZEREM TABS 8 MG (ramelteon) F

ST; Must tryTemazepamand Zolpidemfirst;QL(1 eadaily); AL(Atleast 6 yrs old)

LAXATIVES - Bowel Treatment Drugs

Bulk Laxatives

EVAC POWD (psyllium) NF

KONSYL DAILY FIBER POWD 100 % (psyllium) NF

KONSYL ORIGINAL FORMULADAILY FIBER POWD (psyllium)

NF

METAMUCIL CAPS 0.52 GM (psyllium) NF

METAMUCIL ORIGINAL TEXTURE POWD (psyllium)

NF

METAMUCIL POWD 48.57 % (psyllium) NF

psyllium caps 0.52 gm, 520 mg F

psyllium powd 30 %, 33 %,68 %, 100 %, 28.3 %, 30.9%, 58.6 %, 48.57 %,

F

Laxative Combinations COLYTE-FLAVOR PACKS SOLR (peg 3350-kcl-sodbicarb-sod chloride-sod sulfate)

NF

Drug Name DrugTier

Requirements/Limits

GOLYTELY SOLR 2.97 GM-22.74 GM-236 GM-5.86 GM-6.74 GM (peg3350-kcl-sod bicarb-sod chloride-sod sulfate)

NF

NULYTELY SOLR (peg3350-potassium chloride-sod bicarbonate-sod chloride)

NF

NULYTELY/FLAVORPACKS SOLR (peg 3350-potassium chloride-sodbicarbonate-sod chloride)

NF

peg 3350-kcl-sod bicarb-sod chloride-sod sulfate solr

F

peg 3350-potassiumchloride-sod bicarbonate-sod chloride solr 1.48 gm-11.2 gm-420 gm-5.72 gm

F

sennosides-docusate sodium tabs F

SENOKOT S TABS (sennosides-docusate sodium)

NF

Laxatives - Miscellaneous lactulose soln 10 gm/15ml,20 gm/30ml F

MIRALAX MIX-IN PAX PACK (polyethylene glycol 3350)

NF RX/OTC

MIRALAX PACK (polyethylene glycol 3350) NF RX/OTC

MIRALAX POWD (polyethylene glycol 3350) NF RX/OTC

polyethylene glycol 3350pack or 17 gm F RX/OTC

polyethylene glycol 3350powd or 17 gm/scoop, F RX/OTC

Saline Laxatives FLEET ENEMA ENEM (sodium phosphates) NF

FLEET ENEMA SIX PACK ENEM (sodium phosphates)

NF

FLEET PEDIATRIC ENEM (sodium phosphates) NF


73

Drug Name DrugTier

Requirements/Limits

magnesium citrate soln or1.745 gm/30ml, F

magnesium hydroxide suspor 7.75 %, 400 mg/5ml,1200 mg/15ml, 2400mg/10ml, 2400 mg/30ml,

F

sodium phosphates enem F

Stimulant Laxatives

bisacodyl supp re 10 mg F

bisacodyl tbec or 5 mg F

DULCOLAX SUPP (bisacodyl) NF

DULCOLAX TBEC (bisacodyl) NF

EX-LAX MAXIMUM STRENGTH TABS (sennosides)

NF

EX-LAX TABS (sennosides) NF

sennosides liqd 8.8 mg/5ml F

sennosides syrp 8.8mg/5ml F

sennosides tabs 15 mg, 25mg, 8.6 mg, 17.2 mg F

SENOKOT TABS (sennosides) NF

Surfactant Laxatives COLACE CAPS (docusate sodium) NF

COLACE CLEAR CAPS (docusate sodium) NF

docusate calcium caps F

docusate sodium caps or50 mg, 100 mg, 250 mg F

LOCAL ANESTHETICS-Parenteral - Drugs forNumbing

Local Anesthetics - Amides lidocaine hcl (local anesth.)soln ij 0.5 %, 1 %, 2 %, 4 % F PA

Drug Name DrugTier

Requirements/Limits

LIDOCAINE HYDROCHLORIDE SOLN IJ 1 %, 2 %

F PA

XYLOCAINE SOLN (lidocaine hcl (localanesth.))

NF PA

XYLOCAINE-MPF SOLN 0.5 %, 1 %, 2 % (lidocaine hcl (local anesth.))

NF PA

MACROLIDES - Drugs to Treat BacterialInfections

Azithromycin

azithromycin pack or 1 gm F

azithromycin solr iv 500 mg F

azithromycin susr or 100mg/5ml, 200 mg/5ml F

azithromycin tabs or 250mg, 500 mg, 600 mg F

ZITHROMAX PACK OR 1 GM (azithromycin) F

ZITHROMAX SOLR IV 500 MG (azithromycin) NF

ZITHROMAX SUSR OR 100 MG/5ML, 200 MG/5ML(azithromycin)

NF

ZITHROMAX TABS OR 250 MG, 500 MG, 600 MG (azithromycin)

NF

ZITHROMAX TRI-PAK TABS (azithromycin) NF

ZITHROMAX Z-PAK TABS (azithromycin) NF

Clarithromycin clarithromycin susr or 125mg/5ml, 250 mg/5ml F

clarithromycin tabs or 250mg, 500 mg F

clarithromycin tb24 or 500 mg F

Erythromycins E.E.S. GRANULES SUSR (erythromycinethylsuccinate)

NF


74

Drug Name DrugTier

Requirements/Limits

ERYPED 200 SUSR (erythromycinethylsuccinate)

NF

ERYPED 400 SUSR (erythromycinethylsuccinate)

NF

ERYTHROCIN LACTOBIONATE SOLR F

erythromycin base cpep F

erythromycin base tabs F

erythromycin base tbec F

ERYTHROMYCIN ETHYLSUCCINATE POWD XX

F

erythromycinethylsuccinate susr or 200mg/5ml, 400 mg/5ml

F

erythromycinethylsuccinate tabs or 400 mg

F

ERYTHROMYCIN POWD F

erythromycin stearate tabs F

Fidaxomicin

DIFICID TABS F

MEDICAL DEVICES AND SUPPLIES

Contraceptives OMNIFLEX DIAPHRAGM DPRH F

Diabetic Supplies TRUE METRIX CONTROL SOLUTION LEVEL 1 SOLN

F 1/ 90days;QL(0.012ea daily)

TRUE METRIX CONTROL SOLUTION LEVEL 2 SOLN


TRUE METRIX CONTROL SOLUTION LEVEL 3 SOLN


Drug Name DrugTier

Requirements/Limits

TRUECONTROL GLUCOSE CONTROL LEVEL 0 LIQD


TRUECONTROL GLUCOSE CONTROL LEVEL 1 LIQD


Parenteral Therapy Supplies 1ML TB SYRINGE/25G X5/8"/LUER SLIP TIP MISC F RX/OTC

1ML TB SYRINGE/27G X1/2"/LUER SLIP TIP MISC F RX/OTC

1ML TUBERCULIN SYRINGE DETACHABLE NEEDLE SLIP TIP 25GX5/8" MISC

F

RX/OTC

1ML VANISHPOINT TUBERCULIN SYRINGE 25GX5/8" MISC

F RX/OTC

1ML VANISHPOINT TUBERCULIN SYRINGE 27GX1/2" MISC

F RX/OTC

2-3ML SYRINGE/LUERLOCK TIP MISC F RX/OTC

2-3ML SYRINGE/LUERSLIP TIP MISC F RX/OTC

3ML LUER LOCK SAFETY SYRINGES 3ML/22G X 11/2" MISC

F RX/OTC

3ML LUER LOCK SAFETY SYRINGES MISC F RX/OTC

3ML LUER LOCK SAFETY SYRINGES/3ML/21G X 11/2" MISC

F RX/OTC

3ML LUER LOCK SAFETY SYRINGES/3ML/22G X 1"MISC

F


F RX/OTC


F RX/OTC

3ML LUER LOCK SAFETY SYRINGES/3ML/25G X5/8" MISC

F RX/OTC

3ML LUER-LOK SYRINGE 22GX 1-1/2" MISC F RX/OTC


75

Drug Name DrugTier

Requirements/Limits

3ML LUER-LOK SYRINGE21G X 1-1/2"MISC

F RX/OTC

3ML LUER-LOK SYRINGE22G X 1" MISC F

3ML LUER-LOK SYRINGE25G X 5/8" MISC F RX/OTC

3ML LUER-LOK TIP SYRINGE25G X 1-1/2"MISC

F

3ML SYRINGE/18G X 1-1/2"/LUER LOCK TIPMISC

F

3ML SYRINGE/20G X1"/LUER LOCK TIP MISC F RX/OTC

3ML SYRINGE/20G X1"/LUER SLIP TIP MISC F RX/OTC

3ML SYRINGE/21G X 1-1/2"/LUER LOCK TIPMISC

F RX/OTC

3ML SYRINGE/22G 1-1/2"/LUER LOCK TIPMISC

F RX/OTC

3ML SYRINGE/22G X1"/LUER LOCK TIP MISC F

3ML SYRINGE/25G X1"/LUER LOCK TIP MISC F RX/OTC

3ML SYRINGE/INTERLINKSYRINGE CANNULA MISC

F RX/OTC

3ML SYRINGE/INTERLINKVIAL ACCESS CANNULA MISC

F RX/OTC

3ML SYRINGE/LUERLOCK TIP MISC F RX/OTC

3ML SYRINGE/LUERLOCK TIP23GX1" MISC F RX/OTC

3ML SYRINGE/LUERLOCK TIP25G X 1-1/2"MISC

F

3ML SYRINGE/LUER SLIPTIP23GX1" MISC F RX/OTC

3ML SYRINGE/NEEDLEREGULAR WALL LUER-LOK 25GX5/8" SUB-QMISC

F

RX/OTC

Drug Name DrugTier

Requirements/Limits

ALLERGY SYRINGE/1ML/27G X 1/2"MISC

F RX/OTC

AXILLARY BLOCK NEEDLE BLOCK BEVEL 25GX1" MISC

F RX/OTC

BD 1ML TUBERCULIN SYRINGE/SAFETYGLIDETB NEEDLE 27GX1/2"MISC

F

RX/OTC

BD 1ML TUBERCULIN SYRINGEDETACHABLE NEEDLE SLIP TIP 27GX1/2" MISC

F

RX/OTC

BD 1ML TUBERCULIN SYRINGESLIP-TIP MISC F RX/OTC

BD 3ML LUER-LOCK SYRINGE18G X 1 1/2"MISC

F

BD 3ML LUER-LOK SYRINGE 18G X 1 1/2"MISC

F

BD 3ML LUER-LOK SYRINGE/20G X 1" MISC F RX/OTC

BD 3ML LUER-LOK SYRINGE/21G X 1-1/2"MISC

F RX/OTC


BD 3ML LUER-LOK SYRINGE/23G X 1-1/2"MISC

F


BD 3ML SYRINGE LUER-LOK TIP MISC F RX/OTC

BD 3ML SYRINGE SLIP TIP MISC F RX/OTC

BD 3ML SYRINGE/SAFETYGLIDESHIELDING IM NEEDLE 22GX1-1/2" MISC

F

RX/OTC

BD 3ML SYRINGE/SAFETYGLIDESHIELDING IM NEEDLE 23GX1" MISC

F

RX/OTC


76

Drug Name DrugTier

Requirements/Limits

BD 3ML SYRINGE/SAFETYGLIDESHIELDING NEEDLE 25GX5/8" MISC

F

RX/OTC

BD ALLERGY/SYRINGE/NEEDLE/1ML/28G X 1/2" MISC

F RX/OTC

BD BLUNT FILL NEEDLE MISC F RX/OTC

BD DISPOSABLE NEEDLE REGULAR BEVEL 25GX1" MISC

F RX/OTC

BD DISPOSABLE NEEDLE REGULAR BEVEL THIN WALL 18G X 1" MISC

F RX/OTC

BD ECLIPSE 18G X 1-1/2"MISC F RX/OTC

BD ECLIPSE NEEDLE 25G X 1.5" MISC F RX/OTC

BD ECLIPSE NEEDLE 25GX1" MISC F RX/OTC

BD ECLIPSE NEEDLE 27G X 1/2" MISC F RX/OTC

BD ECLIPSE NEEDLE/22G X 1-1/2"MISC

F RX/OTC

BD ECLIPSE NEEDLE/25G X5/8" MISC F RX/OTC

BD ECLIPSE NEEDLE/27G X 1/2" MISC F RX/OTC

BD ECLIPSE SYRINGE LUER-LOK/3ML/22G X 1"MISC

F

BD ECLIPSE SYRINGE LUER-LOK/3ML/25G X 1"MISC

F RX/OTC

BD ECLIPSE SYRINGE/3ML/23G X 1"MISC

F RX/OTC

BD ECLIPSE SYRINGE/3ML/25GX5/8"MISC

F RX/OTC

BD ECLIPSE SYRINGE/LUER-LOK/3ML/22G X 1-1/2"MISC

F

RX/OTC

Drug Name DrugTier

Requirements/Limits

BD HYPODERMIC NEEDLE REGULAR BEVEL 18G X 1-1/2" MISC

F RX/OTC

BD HYPODERMIC NEEDLE REGULAR BEVEL 22GX1-1/2" MISC

F RX/OTC

BD HYPODERMIC NEEDLE REGULAR BEVEL 25GX1" MISC

F RX/OTC

BD HYPODERMIC NEEDLE REGULAR BEVEL 25GX5/8" MISC

F RX/OTC

BD HYPODERMIC NEEDLE REGULAR BEVEL THIN WALL 18G X 1-1/2" MISC

F

RX/OTC

BD HYPODERMIC NEEDLE SHORT BEVEL 18G X 1-1/2" MISC

F RX/OTC

BD HYPODERMIC NEEDLE SHORT BEVEL 22GX1-1/2" MISC

F RX/OTC

BD HYPODERMIC NEEDLES 18GX1" MISC F RX/OTC

BD HYPODERMIC NEEDLES 18GX1.5" MISC F RX/OTC

BD HYPODERMIC NEEDLES 19GX1" MISC F RX/OTC



BD INTEGRA 3ML SYRINGE W/RETRACTINGNEEDLE/21G X 1-1/2"MISC

F

RX/OTC

BD INTEGRA 3ML SYRINGE W/RETRACTINGNEEDLE/25G X 1" MISC

F

RX/OTC

BD INTEGRA NEEDLE/25G X5/8" MISC F RX/OTC

BD INTEGRA SYRINGE/3ML/22G X 1.5"MISC

F RX/OTC


77

Drug Name DrugTier

Requirements/Limits

BD INTEGRA SYRINGE/3ML/23G X 1"MISC

F RX/OTC

BD INTEGRA SYRINGE/3ML/25G X 5/8MISC

F RX/OTC

BD NEEDLE/18G 1-1/2"MISC F RX/OTC

BD NEEDLE/19G X 1"MISC F RX/OTC

BD NEEDLE/22G X 1-1/2"MISC F RX/OTC

BD NEEDLE/25G X 5/8"MISC F RX/OTC

BD NEEDLE/27G X 1/2"MISC F RX/OTC

BD PLASTIPAK SYRINGES ALLERGY 28GX1/2 MISC

F RX/OTC

BD SAFETYGLIDE 27G X 5/8"NEEDLE MISC F

BD SAFETYGLIDE ALLERGY SYRINGE/1ML/27GX1/2"MISC

F

RX/OTC

BD SAFETYGLIDE HYPODERMICNEEDLE 18G X 1-1/2" MISC

F RX/OTC

BD SAFETYGLIDE HYPODERMICNEEDLE 25GX5/8" MISC

F RX/OTC

BD SAFETYGLIDE INJECTIONNEEDLE 22GX1-1/2" MISC

F RX/OTC

BD SAFETYGLIDE INJECTIONNEEDLE 25GX1" MISC

F RX/OTC

BD SAFETYGLIDE SYRINGE 3ML/25GX1"MISC

F RX/OTC

BD SYRINGE LUER-LOK/1ML MISC F RX/OTC

BD SYRINGE SLIP TIP 1ML MISC F RX/OTC

Drug Name DrugTier

Requirements/Limits

DIALYSIS SAFETY SYRINGES/LOW DEADSPACE 3ML/22GX1-1/2"MISC

F

RX/OTC

EASY GLIDE LUER LOCK 1MLSYRINGE MISC F RX/OTC

EASY TOUCH ALLERGY TRAY SAFETY SYRINGE/1ML/27G X 1/2"MISC

F

RX/OTC

EASY TOUCH FLIPLOCK NEEDLES 18GX1" MISC F RX/OTC

EASY TOUCH FLIPLOCK NEEDLES 18GX1-1/2"MISC

F RX/OTC



F RX/OTC



F RX/OTC

EASY TOUCH FLIPLOCK NEEDLES 25GX5/8" MISC F RX/OTC

EASY TOUCH FLIPLOCK NEEDLES 27GX1/2" MISC F RX/OTC

EASY TOUCH FLIPLOCK SAFETTY SYRINGES 3ML/18GX1-1/2" MISC

F

EASY TOUCH FLIPLOCK SAFETY SYRINGE 3ML/22GX1" MISC

F

EASY TOUCH FLIPLOCK SAFETY SYRINGE 3ML/22GX1-1/2" MISC

F RX/OTC


F RX/OTC

EASY TOUCH FLIPLOCK SAFETY SYRINGE 3ML/23GX1-1/2" MISC

F


F RX/OTC


78

Drug Name DrugTier

Requirements/Limits

EASY TOUCH FLIPLOCK SAFETY SYRINGE 3ML/25GX5/8" MISC

F RX/OTC

EASY TOUCH FLIPLOCK SAFETY SYRINGES 3ML/20GX1" MISC

F RX/OTC

EASY TOUCH FLIPLOCK SAFETY SYRINGES 3ML/21GX1-1/2" MISC

F RX/OTC

EASY TOUCH HYPODERMIC NEEDLES 18GX1" MISC

F RX/OTC

EASY TOUCH HYPODERMIC NEEDLES 18GX1-1/2" MISC

F RX/OTC


F RX/OTC


F RX/OTC


F RX/OTC


F RX/OTC

EASY TOUCH HYPODERMIC NEEDLES 25GX5/8" MISC

F RX/OTC

EASY TOUCH HYPODERMIC NEEDLES 27GX1/2" MISC

F RX/OTC

EASY TOUCH SAFETY SYRINGE/3ML/20G X 1"MISC

F RX/OTC


F

EASY TOUCH SAFETY SYRINGE/3ML/22G X 1-1/2" MISC

F RX/OTC


F RX/OTC


F RX/OTC

Drug Name DrugTier

Requirements/Limits

EASY TOUCH SAFETY SYRINGE/3ML/25G X 5/8"MISC

F RX/OTC

EASY TOUCH SHEATHLOCK SAFETY SYRINGE 3ML/21GX1-1/2"MISC

F

RX/OTC

EASY TOUCH SHEATHLOCK SAFETY SYRINGE 3ML/22GX1"MISC

F

EASY TOUCH SHEATHLOCK SAFETY SYRINGE 3ML/22GX1-1/2"MISC

F

RX/OTC


F

RX/OTC


F

RX/OTC

EASY TOUCH SHEATHLOCK SAFETY SYRINGE 3ML/25GX5/8"MISC

F

RX/OTC

EASY TOUCH TUBERCULIN FLIPLOCK SAFETY SYRINGE 1ML/27GX1/2" MISC

F

RX/OTC

EASY TOUCH TUBERCULIN FLIPLOCK SAFETY SYRINGE 1ML/28GX1/2" MISC

F

RX/OTC

EASY TOUCH TUBERCULIN SHEATHLOCK SAFETY SYRINGE 1ML/25GX5/8"MISC

F

RX/OTC


F

RX/OTC


79

Drug Name DrugTier

Requirements/Limits


F

RX/OTC

EASYPOINT NEEDLE 25G X 1" MISC F RX/OTC

EASYPOINT NEEDLE 25G X 5/8" MISC F RX/OTC

EASYPOINT NEEDLE 25GX1-1/2" MISC F RX/OTC

EASYPOINT NEEDLE/18GX 1" MISC F RX/OTC

EASYPOINT NEEDLE/18GX 1-1/2" MISC F RX/OTC

EASYPOINT NEEDLE/22GX 1-1/2" MISC F RX/OTC

HUBER NEEDLE/RIGHTANGLE19G X 1" MISC F RX/OTC

HUBER NEEDLE/RIGHTANGLE22G X 1-1/2" MISC F RX/OTC

HUBER NEEDLE/STRAIGHT22GX1-1/2" MISC

F RX/OTC

HYPODERMIC NEEDLE 18G X 1" MISC F RX/OTC

HYPODERMIC NEEDLE 18G X 1-1/2" MISC F RX/OTC

HYPODERMIC NEEDLE 19G X 1" MISC F RX/OTC

HYPODERMIC NEEDLE 22GX1-1/2" MISC F RX/OTC

HYPODERMIC NEEDLE 25GX1" MISC F RX/OTC

HYPODERMIC NEEDLE 25GX1-1/2" MISC F RX/OTC

HYPODERMIC NEEDLE 25GX5/8" MISC F RX/OTC

HYPODERMIC NEEDLE 27GX1/2" MISC F RX/OTC

HYPODERMIC NEEDLES 18GX1" MISC F RX/OTC

HYPODERMIC NEEDLES 18GX1-1/2" MISC F RX/OTC

HYPODERMIC NEEDLES 19GX1" MISC F RX/OTC

Drug Name DrugTier

Requirements/Limits



HYPODERMIC NEEDLES 25GX5/8" MISC F RX/OTC

HYPODERMIC NEEDLES 27GX1/2" MISC F RX/OTC

MAGELLAN TUBERCULIN SAFETY SYRINGE/1ML/27G X 1/2"MISC

F

RX/OTC

MAGELLAN TUBERCULIN SAFETY SYRINGE/1ML/28G X 1/2"MISC

F

RX/OTC

MONOJECT 1ML LUER LOCK TUBERCULIN SYRINGE/TIP CAP MISC

F RX/OTC

MONOJECT 3ML SYRINGE/STANDARDHYPODERMIC NEEDLE/21GX1-1/2" MISC

F

RX/OTC

MONOJECT BLUNTIP SYRINGE/3ML/CANNULA/IV ACCESS MISC

F RX/OTC

MONOJECT HYPO/ALUMHUB/18G X 1-1/2" MISC F RX/OTC

MONOJECT HYPO/ALUMHUB/LUER LOCK/INTMBEVEL/27G X 1/2" MISC

F RX/OTC

MONOJECT HYPO/ALUMHUB/LUER LOCK/REGBEVEL/18G X 1" MISC

F RX/OTC

MONOJECT HYPO/ALUMHUB/LUER LOCK/REGBEVEL/22G X 1-1/2" MISC

F RX/OTC

MONOJECT HYPO/ALUMHUB/LUER LOCK/REGBEVEL/25G X 5/8" MISC

F RX/OTC

MONOJECT HYPO/ALUMHUB/LUER LOCK/SHORTBEVEL/18G X 1" MISC

F RX/OTC

MONOJECT HYPO/ALUMHUB/LUER LOCK/SHORTBEVEL/18G X 1-1/2" MISC

F RX/OTC


80

Drug Name DrugTier

Requirements/Limits

MONOJECT HYPO/ALUMHUB/LUER LOCK/SPECBEVEL/19G TW X 1" MISC

F RX/OTC

MONOJECT HYPO/POLYPROPYLENEHUB/18G X 1" MISC

F RX/OTC

MONOJECT HYPO/POLYPROPYLENEHUB/18G X 1-1/2" MISC

F RX/OTC

MONOJECT HYPO/POLYPROPYLENEHUB/LL/BEVEL/25G X 1-1/2" MISC

F

RX/OTC

MONOJECT HYPO/POLYPROPYLENEHUB/LL/INTM BEVEL/25GX 5/8" MISC

F

RX/OTC

MONOJECT HYPO/POLYPROPYLENEHUB/LL/REG BEVEL/19GTW X 1" MISC

F

RX/OTC

MONOJECT HYPO/POLYPROPYLENEHUB/LL/REG BEVEL/25GX 1" MISC

F

RX/OTC

MONOJECT HYPO/POLYPROPYLENEHUB/LL/SHORTBEVEL/18G X 1" MISC

F

RX/OTC

MONOJECT HYPO/POLYPROPYLENEHUB/LL/SHORTBEVEL/18G X 1-1/2" MISC

F

RX/OTC

MONOJECT HYPO/POLYPROPYLENEHUB/LL/SHORTBEVEL/19G TW X 1" MISC

F

RX/OTC

MONOJECT HYPO/POLYPROPYLENEHUB/LL/SHORTBEVEL/22G X 1-1/2" MISC

F

RX/OTC

MONOJECT HYPO/POLYPROPYLENEHUB/REG BEVEL/27G X1/2" MISC

F

RX/OTC

MONOJECT HYPODERMIC NEEDL3 18G X 1" MISC

F RX/OTC

Drug Name DrugTier

Requirements/Limits

MONOJECT MAGELLAN SAFETYNEEDLE 18GX1" MISC

F RX/OTC

MONOJECT MAGELLAN SAFETYNEEDLE 18GX1-1/2" MISC

F RX/OTC


F RX/OTC

MONOJECT MAGELLAN SAFETYNEEDLE 22GX1-1/2" MISC

F RX/OTC


F RX/OTC

MONOJECT MAGELLAN SAFETYNEEDLE 25GX5/8" MISC

F RX/OTC

MONOJECT MAGELLAN SYRINGE/SAFETYNEEDLE/3ML/20G X 1"MISC

F

RX/OTC

MONOJECT MAGELLAN SYRINGE/SAFETYNEEDLE/3ML/21G X 1-1/2"MISC

F

RX/OTC


F

MONOJECT MAGELLAN SYRINGE/SAFETYNEEDLE/3ML/22G X 1-1/2"MISC

F

RX/OTC


F

RX/OTC


F

RX/OTC

MONOJECT MAGELLAN SYRINGE/SAFETYNEEDLE/3ML/25G X 5/8"MISC

F

RX/OTC


81

Drug Name DrugTier

Requirements/Limits

MONOJECT PHARMACY TRAY/LUER LOCK/3MLMISC

F RX/OTC

MONOJECT PHARMACY TRAY/REG LUER/1MLMISC

F RX/OTC

MONOJECT STANDARD HYPODERMIC NEEDLE/POLYPROPYLEN/22G X1-1/2" MISC

F

RX/OTC

MONOJECT STANDARD HYPODERMIC NEEDLE/POLYPROPYLENE HUB/18GX1" MISC

F

RX/OTC

MONOJECT STANDARD HYPODERMIC NEEDLE/POLYPROPYLENE HUB/19GX1" MISC

F

RX/OTC

MONOJECT STANDARD HYPODERMIC NEEDLE/POLYPROPYLENE/18GX1-1/2" MISC

F

RX/OTC


F

RX/OTC

MONOJECT STANDARD HYPODERMIC NEEDLE/POLYPROPYLENE/25GX1" MISC

F

RX/OTC


F

RX/OTC

MONOJECT STANDARD HYPODERMIC NEEDLE/POLYPROPYLENE/25GX5/8" MISC

F

RX/OTC

MONOJECT STANDARD HYPODERMIC NEEDLE/POLYPROPYLENE/27GX1/2" MISC

F

RX/OTC

MONOJECT SYRINGE PHARMACY TRAY/1MLLUER LOCK MISC

F RX/OTC

MONOJECT SYRINGE/LUERLOCK/3ML MISC

F RX/OTC

Drug Name DrugTier

Requirements/Limits

MONOJECT SYRINGE/LUERLOCK/3ML/20G X 1" MISC

F RX/OTC


F

MONOJECT SYRINGE/LUERLOCK/3ML/22G X 1-1/2"MISC

F

RX/OTC


F RX/OTC


F RX/OTC

MONOJECT SYRINGE/LUERLOCK/3ML/25G X 5/8"MISC

F

RX/OTC

MONOJECT SYRINGE/LUER-LOCKTIP/3ML MISC

F RX/OTC

MONOJECT SYRINGE/LUER-LOCK/3ML/21G X 1-1/2"MISC

F

RX/OTC

MONOJECT SYRINGE/REG LUER/3MLMISC

F RX/OTC

MONOJECT SYRINGE/REGULARTIP/3ML MISC

F RX/OTC

MONOJECT SYRINGE/STANDARDHYPODERMIC NEEDLE/3ML/20GX1"MISC

F

RX/OTC


F

MONOJECT SYRINGE/STANDARDHYPODERMIC NEEDLE/3ML/22GX1-1/2"MISC

F

RX/OTC


82

Drug Name DrugTier

Requirements/Limits


F

RX/OTC


F

RX/OTC

MONOJECT SYRINGE/STANDARDHYPODERMIC NEEDLE/3ML/25GX5/8"MISC

F

RX/OTC

MONOJECT TB SYRINGE-NDL 1ML 27GX1/2" MISC F RX/OTC

MONOJECT TUBERCULIN SAFETY SYRINGE/1ML/25G X 5/8"MISC

F

RX/OTC

MONOJECT TUBERCULIN SAFETY SYRINGE/1ML/28G X 1/2"MISC

F

RX/OTC

MONOJECT TUBERCULIN SYRINGE SOFTPACK 1ML REGULAR LUER TIP MISC

F

RX/OTC

MONOJECT TUBERCULIN SYRINGE/1ML/25GX5/8"MISC

F RX/OTC

MONOJECT TUBERCULIN SYRINGE/1ML/28G X 1/2"MISC

F RX/OTC

MONOJECT TUBERCULIN SYRINGE/DETACHNEEDLE/1ML/25G X 5/8"MISC

F

RX/OTC

MONOJECT TUBERCULIN SYRINGE/DETACHNEEDLE/1ML/27G X 1/2"MISC

F

RX/OTC

MONOJECT TUBERCULIN SYRINGE/PERMNEEDLE/1ML/28G X 1/2"MISC

F

RX/OTC

Drug Name DrugTier

Requirements/Limits

MONOJECT TUBERCULIN SYRINGE/WITHOUTNEEDLE/REG LUER/1MLMISC

F

RX/OTC

MULTI-DRAW NEEDLE 22GX1-1/2" MISC F RX/OTC

NOKOR ADMIX NEEDLE THIN WALL NON-CORING 18G X 1-1/2" MISC

F RX/OTC

NOKOR VENTED NEEDLE THINWALL NON-CORING 18G X 1" MISC

F RX/OTC

NOKOR VENTED NEEDLE THINWALL NON-CORING 18GX1-1/2" MISC

F RX/OTC

NORM-JECT TUBERKULIN 1MLLUER SLIP MISC

F RX/OTC

PATIENT SAFE SYRINGE 3ML MISC F RX/OTC

POLY HUB NEEDLE/18GX 1" MISC F RX/OTC

POLY HUB NEEDLE/18GX 1-1-1/2" MISC F RX/OTC

POLY HUB NEEDLE/22GX 1-1/2" MISC F RX/OTC

POLY HUB NEEDLE/25GX 1" MISC F RX/OTC

POLY HUB NEEDLE/25GX 1-1/2" MISC F RX/OTC

POLY HUB NEEDLE/25GX 5/8" MISC F RX/OTC

POLY HUB NEEDLE/27GX 1/2" MISC F RX/OTC

REGIONAL BLOCK NEEDLE SAFETY BEAD BLOCK BEVEL 22GX1-1/2" MISC

F

RX/OTC

RETROBULBAR NEEDLE 25G TWX 1-1/2" MISC F RX/OTC

SAFESNAP ALLERGY SYRINGE/1ML/27G X 1/2"MISC

F RX/OTC

SAFESNAP SYRINGE/3ML MISC F RX/OTC


83

Drug Name DrugTier

Requirements/Limits

SAFESNAP SYRINGE/NEEDLE/3ML/20G X 1" MISC

F RX/OTC

SAFESNAP SYRINGE/NEEDLE/3ML/21G X 1-1/2" MISC

F RX/OTC


F


F RX/OTC


F RX/OTC


F


F RX/OTC

SAFESNAP SYRINGE/NEEDLE/3ML/25G X 5/8" MISC

F RX/OTC

SAFESNAP TUBERCULIN SYRINGE/1ML/25G X 5/8"MISC

F RX/OTC

SAFESNAP TUBERCULIN SYRINGE/1ML/27G X 1/2"MISC

F RX/OTC

SAFETY SYRINGES/NEEDLE3ML/20GX1" MISC

F RX/OTC

SAFETY SYRINGES/NEEDLE3ML/21GX1-1/2" MISC

F RX/OTC


F

SAFETY SYRINGES/NEEDLE3ML/22GX1-1/2" MISC

F RX/OTC


F RX/OTC

SAFETY SYRINGES/NEEDLE3ML/25GX5/8" MISC

F RX/OTC

Drug Name DrugTier

Requirements/Limits

SAFETY-LOK SAFETY SYRINGE/1ML/25G X 5/8"MISC

F RX/OTC

SAFETY-LOK SYRINGE 3ML LUER-LOK MISC F RX/OTC

SAFETY-LOK SYRINGE/NEEDLE3MLLUER-LOK 21GX1-1/2"MISC

F

RX/OTC

SAFETY-LOK SYRINGE/NEEDLE3MLLUER-LOK 22GX1" MISC

F

SAFETY-LOK SYRINGE/NEEDLE3MLLUER-LOK 22GX1-1/2"MISC

F

RX/OTC

SAFETY-LOK SYRINGE/NEEDLE3MLLUER-LOK 23GX1" MISC

F RX/OTC

SAFETY-LOK SYRINGE/NEEDLE3MLLUER-LOK 25GX5/8"MISC

F

RX/OTC

SAFETY-LOK TB SYRINGE PERM NEEDLE 1ML 27GX1/2" MISC

F RX/OTC

SECURESAFE SAFETY HYPODERMIC NEEDLE/18G X 1" MISC

F RX/OTC

SECURESAFE SAFETY HYPODERMIC NEEDLE/18G X 1-1/2"MISC

F

RX/OTC

SECURESAFE SAFETY HYPODERMIC NEEDLE/19G X 1" MISC

F RX/OTC


F

RX/OTC


F

RX/OTC

SECURESAFE SAFETY HYPODERMIC NEEDLE/25G X 5/8" MISC

F RX/OTC


84

Drug Name DrugTier

Requirements/Limits

SECURESAFE SAFETY HYPODERMIC NEEDLE/27G X 1/2" MISC

F RX/OTC

SECURESAFE SYRINGE/NEEDLE/3ML/20G X 1" MISC

F RX/OTC

SECURESAFE SYRINGE/NEEDLE/3ML/21G X 1-1/2" MISC

F RX/OTC


F

SECURESAFE SYRINGE/NEEDLE/3ML/22G X 1-1/2" MISC

F RX/OTC


F RX/OTC

SECURESAFE SYRINGE/NEEDLE/3ML/25G X 5/8" MISC

F RX/OTC

SECURESAFE TUBERCULIN INSULIN SYRINGE/1ML/25G X 5/8"MISC

F

RX/OTC

SECURESAFE TUBERCULIN INSULIN SYRINGE/1ML/27G X 1/2"MISC

F

RX/OTC

STIMEX INSULATED NEEDLE TEFLON-COATED BLOCK BEVEL 22GX1-1/2" MISC

F

RX/OTC

SYRINGE/BLUNTPLASTIC CANNULA MISC F RX/OTC

SYRINGE/LUERLOCK/3ML MISC F RX/OTC

SYRINGE/LUERLOCK/3ML/20G X 1" MISC F RX/OTC

SYRINGE/LUERLOCK/3ML/21G X 1-1/2"MISC

F RX/OTC

SYRINGE/LUERLOCK/3ML/21GX1-1/2"MISC

F RX/OTC

SYRINGE/LUERLOCK/3ML/22G X 1" MISC F

Drug Name DrugTier

Requirements/Limits


F RX/OTC

SYRINGE/LUERLOCK/3ML/22GX1" MISC F

SYRINGE/LUERLOCK/3ML/22GX1-1/2"MISC

F RX/OTC



F

SYRINGE/LUERLOCK/3ML/23GX1" MISC F RX/OTC



F

SYRINGE/LUERLOCK/3ML/25G X 5/8"MISC

F RX/OTC

SYRINGE/LUERLOCK/3ML/25GX1" MISC F RX/OTC

SYRINGE/LUERLOCK/3ML/25GX5/8" MISC F RX/OTC

SYRINGE/LUER SLIP/1MLMISC F RX/OTC

SYRINGE/LUER SLIP/3MLMISC F RX/OTC

SYRINGES/LUERLOCK/1ML/20GX1" MISC F RX/OTC

SYRINGES/LUERLOCK/WITHOUTNEEDLE/3ML MISC

F RX/OTC

SYRINGES/LUERSLIP/WITHOUTNEEDLE/1ML MISC

F RX/OTC

ULTICARE SYRINGE/LOWDEADSPACE/3ML/22GX1-1/2" MISC

F RX/OTC

ULTICARE TUBERCULIN SAFETY SYRINGE/1ML/25G X 5/8"MISC

F

RX/OTC


85

Drug Name DrugTier

Requirements/Limits

VANISHPOINT SAFETY SYRINGE/3ML/20GX1"MISC

F RX/OTC

VANISHPOINT SAFETY SYRINGE/3ML/21GX1-1/2"MISC

F RX/OTC


F


F RX/OTC


F RX/OTC


F


F RX/OTC


F

VANISHPOINT SAFETY SYRINGE/3ML/25GX5/8"MISC

F RX/OTC

VANISHPOINT SYRINGE/3ML/20G X 1"MISC

F RX/OTC

VANISHPOINT SYRINGE/3ML/21G X 1-1/2" MISC

F RX/OTC


F


F RX/OTC


F RX/OTC


F


F RX/OTC

Drug Name DrugTier

Requirements/Limits


F

VANISHPOINT SYRINGE/3ML/25G X 5/8"MISC

F RX/OTC

VANISHPOINT TUBERCULIN SYRINGE 1ML/25G X 5/8" MISC

F RX/OTC

VANISHPOINT TUBERCULIN SYRINGE 1ML/27GX1/2" MISC

F RX/OTC

Respiratory Therapy Supplies AERIVA PORTABLE CONCENTRATOR NEBULIZER ALL IN ONE MISC

F

RX/OTC

AEROECLIPSE II BREATH ACTUATED NEBULIZER DISPOSABLE MISC

F RX/OTC

AERONEB GO COMPLETE SYSTEM MISC

F RX/OTC

AERONEB GO CONVENIENCE UNIT MISC

F RX/OTC

AERONEB GO NEBULIZER HANDSET MISC

F RX/OTC

AERONEB GO NEBULIZER HANDSET/CONNECTORCABLE MISC

F

RX/OTC

AIRIAL COMPACT COMPRESSORNEBULIZE R SYSTEM MISC

F RX/OTC

AIRIAL COMPACT MINI NEBULIZER MISC F RX/OTC

AIRIAL COMPARTMENT COMPRESSOR PEDIATRIC NEBULIZER MISC

F

RX/OTC

AIRIAL PEDIATRIC NEBULIZER/BUILDINGBLOCK MISC

F RX/OTC

AIRIAL PEDIATRIC NEBULIZER/DUCK MISC F RX/OTC


86

Drug Name DrugTier

Requirements/Limits

AIRIAL PEDIATRIC NEBULIZER/FIRE ENGINEMISC

F RX/OTC

AIRIAL PEDIATRIC NEBULIZER/PANDA MISC F RX/OTC

AIRIAL PEDIATRIC NEBULIZER/PENELOPEPANDA MISC

F RX/OTC

AIRIAL PEDIATRIC NEBULIZER/PENGUINMISC

F RX/OTC

AIRIAL VOYAGER PORTABLE NEBULIZER MISC

F RX/OTC

AIRS DISPOSABLE NEBULIZER MISC F RX/OTC

ALL-IN-ONE NEBULIZER SYSTEM MISC F RX/OTC

AURA PORTANEB MISC F RX/OTC

BENTLEY THE BEAR MISC F RX/OTC

CAPTAIN EAGLE MISC F RX/OTC

CLEVER CHOICE NEBULIZER MISC F RX/OTC

CLEVER CHOICE WHISPER AIRE AEROSOL DELIVERY SYSTEM MISC

F

RX/OTC

CLEVER CHOICE WHISPER AIRE PEDIATRIC AEROSOL DELIVERY SYSTEM MISC

F

RX/OTC

CLEVER CHOICE WHISPER AIRE PEDIATRIC COMPRESSOR NEBULIZER MISC

F

RX/OTC

COMP A-I-R COMPRESSOR NEBULIZER MISC

F RX/OTC

COMP AIR COMPRESSOR NEBULIZER MISC

F RX/OTC

Drug Name DrugTier

Requirements/Limits

COMP AIR ELITE COMPACT COMPRESSOR/NEBULIZER MISC

F

RX/OTC

COMPAIR COMPRESSOR NEBULIZER MISC F RX/OTC

COMPAIR XL COMPRESSOR NEBULIZER SYSTEM MISC

F

RX/OTC

COMPAIR XLT COMPRESSOR NEBULIZER SYSTEM MISC

F

RX/OTC

COMPMIST COMPRESSOR NEBULIZER MISC

F RX/OTC

COMPRESSOR NEBULIZER MISC F RX/OTC

COMPRESSOR/NEBULIZER MISC F RX/OTC

EASY AIR COMPRESSOR NEBULIZER MISC F RX/OTC

EASY NEB MISC F RX/OTC

EFLOW SCF ELECTRONIC NEBULIZER SYSTEM MISC

F

RX/OTC

EFLOW SCF NEBULIZER HANDSET MISC F RX/OTC

ELITE COMPRESSOR NEBULIZER MISC F RX/OTC

ELITE NEBULIZER SYSTEM MISC F RX/OTC

FLYP NEBULIZER MISC F RX/OTC

HOMENEB WITH SIDESTREAM/DISPOSABLE MISC

F RX/OTC

HOMENEB WITH SIDESTREAM/REUSABLE& DISPOSABLE MISC

F RX/OTC

INNOSPIRE DELUXE COMPRESSOR NEBULIZER SYSTEM MISC

F

RX/OTC


87

Drug Name DrugTier

Requirements/Limits

INNOSPIRE ELEGANCE COMPRESSOR NEBULIZER SYSTEM MISC

F

RX/OTC

INNOSPIRE ESSENCE COMPRESSOR NEBULIZER SYSTEM MISC

F

RX/OTC

INNOSPIRE GO PORTABLE MESH NEBULIZER MISC

F RX/OTC

INNOSPIRE MINI PORTABLE COMPRESSOR NEBULIZER MISC

F

RX/OTC

INNOSPIRE MINI PORTABLE COMPRESSOR NEBULIZER/BATTERYMISC

F

RX/OTC

INSPIRATION COMPRESSOR NEBULIZER SYSTEM MISC

F

RX/OTC

INSPIRATION ELITE COMPRESSOR NEBULIZER SYSTEM MISC

F

RX/OTC

LUMINEB II PISTON NEBULIZER MISC F RX/OTC

MABIS COMPXP COMPRESSOR NEBULIZER MISC

F RX/OTC

MABIS COSMOCOMP NEBULIZER MISC F RX/OTC

MARGO MOO COMPRESSOR NEBULIZER MISC

F RX/OTC

MICRO AIR NEBULIZER MISC F RX/OTC

MICRO PLUS HIGH EFFICIENCY NEBULIZER/REUSABLEMISC

F

RX/OTC

MICROAIR VIBRATING MESH NEBULIZER MISC F RX/OTC

Drug Name DrugTier

Requirements/Limits

MICROELITE COMPRESSOR NEBULIZER SYSTEM MISC

F

RX/OTC

MICROELITE COMPRESSOR NEBULIZER SYSTEM WITH BATTERY MISC

F

RX/OTC

MICRONEB MISC F RX/OTC

MINI COMPRESSOR MISC F RX/OTC

MINI PLUS REUSABLE HIGH EFFICIENCY NEBULIZER MISC

F RX/OTC

MINIBREEZE ULTRASONIC NEBULIZER MISC

F RX/OTC

MINIELITE COMPRESSOR NEBULIZER SYSTEM MISC

F

RX/OTC

MINIELITE COMPRESSOR NEBULIZER SYSTEM WITH BATTERY MISC

F

RX/OTC

MISTERNEB COMPRESSOR NEBULIZER SYSTEM MISC

F

RX/OTC

MY MDI PORTABLE NEBULISER PROCEDURE PACK MISC

F RX/OTC

NEB-RITE4 MISC F RX/OTC

NEBULIZER MISC F RX/OTC

NEBULIZER PED FROG MISC F RX/OTC

NEBULIZER PED FROG SYS W/DISP&REUSE NEBKIT MISC

F RX/OTC

NEBULIZER SYSTEM ALL-IN-ONE MISC F RX/OTC

OPTIONHOME COMPRESSOR NEBULIZER SYSTEM MISC

F

RX/OTC


88

Drug Name DrugTier

Requirements/Limits

PARI ALTERA NEBULIZER SYSTEM MISC

F RX/OTC

PARI BABY DEVI F RX/OTC

PARI BABY SIZE 1/PARILCPLUS DEVI F RX/OTC

PARI ERAPID NEBULIZER SYSTEM MISC F RX/OTC

PARI LC D NEBULIZER MISC F RX/OTC

PARI LC PLUS MISC F RX/OTC

PARI LC PLUS NEBULIZER MISC F RX/OTC

PARI LC PLUS NEBULIZER SET/PEDIATRIC MASKMISC

F

RX/OTC

PARI LC PLUS NEBULIZER VIOS PRO/REUSABLE MISC

F RX/OTC

PARI LC SPRINT NEBULIZERSET MISC F RX/OTC

PARI LC STAR MISC F RX/OTC

PARI LC STAR NEBULIZER MISC F RX/OTC

PARI PRONEB ULTRA II MISC F RX/OTC

PARI SINUS PULSATING AEROSOL SYSTEM MISC F RX/OTC

PARI TREK S COMPACT COMPRESSOR W/ 12VDC ADAPTOR DEVI

F RX/OTC

PARI VIOS PRO LC PLUS AEROSOL DELIVERY SYSTEM MISC

F RX/OTC

PARI VIOS PRO LC SPRINT AEROSOL DELIVERY SYSTEM MISC

F RX/OTC

PHILLIPS WILLIS THE WHALENEBULIZER MISC F RX/OTC

PORTABLE COMPRESSOR NEBULIZER MISC

F RX/OTC

Drug Name DrugTier

Requirements/Limits

PROCARE COMPRESSOR NEBULIZER MISC

F RX/OTC

PRODIGY MINI-MIST PORTABLE NEBULIZER MISC

F RX/OTC

PRODIGY MINI-MIST PORTABLE NEBULIZER SPANISH MISC

F RX/OTC

PRONEB ULTRA II DELUXE/LC SPRINT DEVI F RX/OTC

PRONEB ULTRA II DELUXE/LC STAR MISC F RX/OTC

PRONEB ULTRA II DELUXE/LCD DEVI F RX/OTC

PRONEB ULTRA II PEDIATRIC DEVI F RX/OTC

PRONEB ULTRA II WITH LC PLUS DEVI F RX/OTC

PRONEB ULTRA II/LCSPRINT MISC F RX/OTC

PRONEB ULTRA II/LCSPRINT PEDIATRIC MISC F RX/OTC

PURE AIR MINI NEBULIZER MISC F RX/OTC

SIDESTREAM NEBULIZER/DISPOSABLEMISC

F RX/OTC

SIDESTREAM NEBULIZER/REUSABLEMISC

F RX/OTC

SIDESTREAM PLUS REUSABLEHIGH EFFICIENCY NEBULIZER MISC

F

RX/OTC

SOOTHE NEB MESH NEBULIZER MISC F RX/OTC

SOOTHENEB COMPRESSOR NEBULIZER MISC

F RX/OTC

SPARKY THE DOG MISC F RX/OTC

VERSA-NEB COMPRESSOR/NEBULIZER SYSTEM MISC

F RX/OTC

VIOS AEROSOL DELIVERY SYSTEM MISC F RX/OTC


89

Drug Name DrugTier

Requirements/Limits

VIOS LC PLUS AEROSOL DELIVERY SYSTEM DELUXE MISC

F RX/OTC

VIOS LC PLUS AEROSOL DELIVERY SYSTEM MISC F RX/OTC

VIOS LC PLUS AEROSOL DELIVERY SYSTEM PEDIATRIC MISC

F RX/OTC

VIOS LC SPRINT AEROSOL DELIVERY SYSTEM MISC

F RX/OTC

VIOS LC SPRINT AEROSOL DELIVERY SYSTEM PEDIATRIC MISC

F

RX/OTC

VIOS LC SPRINT DELUXE AEROSOL DELIVERY SYSTEM MISC

F RX/OTC

MIGRAINE PRODUCTS - Drugs to Treat MigraineHeadaches

Calcitonin Gene-Related Peptide (CGRP) AJOVY SOAJ F PA; SP

AJOVY SOSY F PA; SP

EMGALITY SOAJ F PA; SP

EMGALITY SOSY F PA; SP

Migraine Combinations

CAFERGOT TABS (ergotamine w/ caffeine) NF

10 permonth;QL(0.34ea daily)

ergotamine w/ caffeinesupp re 100 mg-2 mg F 12 per month

ergotamine w/ caffeine tabsor 1 mg-100 mg F


Serotonin Agonists

AMERGE TABS (naratriptan hcl) NF

9 permonth;;QL(0.3ea daily)

IMITREX SOLN NA 5 MG/ACT, 20 MG/ACT(sumatriptan)

F Limit 6 permonth;QL(0.2ea daily)

Drug Name DrugTier

Requirements/Limits

IMITREX SOLN SC 6 MG/0.5ML (sumatriptan succinate)

NF

2 doses (1ml) permonth;QL(0.034 ml daily)

IMITREX STATDOSE REFILL SOCT (sumatriptan succinate)

NF


IMITREX STATDOSE SYSTEM SOAJ (sumatriptan succinate)

NF

Max 1 device per 90 days;Use refill cartridges;QL(1ml per 90 daysretail)

IMITREX TABS OR 25 MG, 50 MG, 100 MG (sumatriptan succinate)

NF 9 permonth;QL(0.3ea daily)

MAXALT TABS (rizatriptan benzoate) NF


MAXALT-MLT TBDP (rizatriptan benzoate) NF


naratriptan hcl tabs F 9 permonth;;QL(0.3ea daily)

rizatriptan benzoate tabs F 9 per monthQL(0.3 eadaily)

rizatriptan benzoate tbdp F 9 per monthQL(0.3 eadaily)

sumatriptan succinate soajsc 4 mg/0.5ml, 6 mg/0.5ml F

Max 1 device per 90 days;Use refill cartridges;QL(1ml per 90 daysretail)

sumatriptan succinate soctsc 4 mg/0.5ml, 6 mg/0.5ml F


sumatriptan succinate solnsc 6 mg/0.5ml F



90

Drug Name DrugTier

Requirements/Limits

sumatriptan succinate tabsor 25 mg, 50 mg, 100 mg F


zolmitriptan tabs or 5 mg,2.5 mg F


zolmitriptan tbdp or 2.5 mg F 9 permonth;;QL(0.3ea daily)

zolmitriptan tbdp or 5 mg F

9 permonth;;QL(0.3ea daily,9 eaper 30 daysretail)

ZOMIG SOLN NA 5 MG, 2.5 MG F


ZOMIG TABS OR 5 MG, 2.5 MG (zolmitriptan) NF


ZOMIG ZMT TBDP 2.5 MG (zolmitriptan) NF


ZOMIG ZMT TBDP 5 MG (zolmitriptan) NF

9 permonth;;QL(0.3ea daily,9 eaper 30 daysretail)

MINERALS & ELECTROLYTES

Calcium

CAL-CITRATE CAPS F

CAL-LAC CAPS F

CAL-MINT CHEW F

CALCI-CHEW CHEW F

CALCIUM ACETATE TABS OR F

CALCIUM CAPS 250 MG F

CALCIUM CARBONATE CHEW OR 260 MG, 500 MG

F

Drug Name DrugTier

Requirements/Limits

calcium carbonate tabs or 500 mg, 600 mg, 600 mg,1250 mg, 1500 mg

F

calcium carbonate-vitamin d caps F

calcium carbonate-vitamin d chew F

calcium carbonate-vitamin d tabs F

CALCIUM CHEW 500 MG F

CALCIUM CITRATE TABS OR 200 MG, 250 MG, 1040 MG

F

calcium citrate tabs or 200 mg, 950 mg F

calcium citrate-vitamin d tabs 200 unit-250 mg F

CALCIUM GLUCONATE TABS OR 50 MG, 500 MG F

CALCIUM LACTATE TABS 100 MG, 750 MG F

CALCIUM PLUS VITAMIN D CAPS F

CALCIUM TABS 200 UNIT-600 MG F

calcium tabs 500 mg, 600 mg F

CHELATED CALCIUM TABS F

oyster shell tabs F

RA CALCIUM HI-CAL/VITAMIND TABS 125UNIT-500 MG

F

Electrolyte Mixtures CERALYTE 70 SOLN 20 MEQ/L-30 MEQ/L-60MEQ/L-70 MEQ/L

F

CERASPORT EX1 SOLN F

CERASPORT SOLN 18 MEQ/L-20 MEQ/L-4MEQ/L-6 MEQ/L

F

ENFAMIL ENFALYTE SOLN F


91

Drug Name DrugTier

Requirements/Limits

EQUALYTE SOLN (oral electrolytes) NF

HYDRALYTE FREEZER POPS SOLN F

HYDRALYTE SOLN 210 MG/250ML-270MG/250ML, 16 GM/L-20MEQ/L-45 MEQ/L-45MEQ/L-90 MEQ/L

F

KINDERLYTE PREMAX SOLN 3.1 MG/360ML-320MG/360ML-620MG/360ML-630MG/360ML, 3.1MG/360ML-330MG/360ML-620MG/360ML-630 MG/360ML

F

KINDERLYTE SOLN 3.1 MG/360ML-300MG/360ML-445MG/360ML-560MG/360ML, 3.1MG/360ML-300MG/360ML-460MG/360ML-570 MG/360ML

F

oral electrolytes soln F

PEDIALYTE ADVANCED CARE SOLN (oral electrolytes)

NF

PEDIALYTE FREEZER POPS SOLN (oral electrolytes)

NF

PEDIALYTE SINGLES SOLN (oral electrolytes) NF

Drug Name DrugTier

Requirements/Limits

PEDIALYTE SOLN 0.5 MG/59ML-1.2 MEQ/59ML-1.5 GM/59ML-2.1MEQ/59ML-2.7MEQ/59ML, 20 GM/L-20MEQ/L-35 MEQ/L-45MEQ/L-5 GM/L, 10.6MEQ/237ML-4.7MEQ/237ML-8.3MEQ/237ML, 20 MEQ/L-25GM/L-30 MEQ/L-35MEQ/L-45 MEQ/L, 20MEQ/L-25 GM/L-35MEQ/L-45 MEQ/L-7.8MG/L (oral electrolytes)

NF

Fluoride sodium fluoride chew or 0.25 mg, 0.5 mg, 1 mg, 2.2 mg

F

sodium fluoride soln or 0.5 mg/ml F

sodium fluoride tabs or 0.5 mg, 1 mg F

Magnesium MAG-200 TABS (magnesium oxide (mgsupplement))

NF

MAGNESIUM CAPS 400 MG F

magnesium oxide (mgsupplement) caps F

magnesium oxide (mgsupplement) tabs F

MAGNESIUM OXIDE CAPS 400 MG F

MAGOX 400 TABS (magnesium oxide (mgsupplement))

NF

Mineral Combinations

BONE ESSENTIALS CAPS F

CAL-MAG-K CHELA MAX CAPS F

CALCIUM & VITAMIN D3 BONEHEALTH LIQD F

COLAMINE TABS F


92

Drug Name DrugTier

Requirements/Limits

CVS CALCIUM CHEWABLES 600PLUS CHEW

F

MULTI-MINERALS TABS F

multiple minerals tabs F

NF FORMULAS CALCIUM MAGNESIUM LIQD F

NUTRA-SUPPORT BONE CAPS F

Phosphate K-PHOS NEUTRAL TABS (pot phosphate monobasicw/ sod phosphate dibasic &monobasic)

NF

pot phosphate monobasicw/ sod phosphate dibasic &monobasic tabs 130 mg-155 mg-852 mg

F

Potassium CHELATED POTASSIUM TABS F

K-TAB TBCR 10 MEQ, 20 MEQ (potassium chloride) NF

K-TAB TBCR 8 MEQ (potassium chloride) F

potassium chloride cpcr or8 meq, 10 meq F

POTASSIUM CHLORIDE GRAN XX F RX/OTC

potassium chloridemicroencapsulated crystalser tbcr

F

potassium chloride pack or20 meq F

potassium chloride soln or10 %, 20 % F

potassium chloride tbcr or8 meq, 10 meq, 20 meq F

potassium tabs 75 mg, 99 mg F

POTASSIUM TABS 99 MG F

Sodium

Drug Name DrugTier

Requirements/Limits

SODIUM CHLORIDE SOLN IJ 0.9 % F

sodium chloride soln ij 0.9% F

sodium chloride soln iv 0.9 % F

MISCELLANEOUS THERAPEUTIC CLASSES

Chelating Agents CUPRIMINE CAPS (penicillamine) NF

penicillamine caps or 250 mg F

Immunomodulators

REVLIMID CAPS F PA; SP

THALOMID CAPS F PA; SP

Immunosuppressive Agents

ASTAGRAF XL CP24 F

azathioprine tabs or 50 mg F

CELLCEPT CAPS (mycophenolate mofetil) NF

CELLCEPT SUSR (mycophenolate mofetil) NF

CELLCEPT TABS (mycophenolate mofetil) NF

cyclosporine caps or 25mg, 100 mg F

cyclosporine modified (formicroemulsion) caps F

cyclosporine modified (formicroemulsion) soln F

everolimus (immunosuppressant) tabs F PA

IMURAN TABS (azathioprine) NF

mycophenolate mofetil caps F

mycophenolate mofetil susr F

mycophenolate mofetil tabs F


93

Drug Name DrugTier

Requirements/Limits

NEORAL CAPS (cyclosporine modified (formicroemulsion))

NF

NEORAL SOLN (cyclosporine modified (formicroemulsion))

NF

PROGRAF CAPS (tacrolimus) NF

RAPAMUNE SOLN 1 MG/ML (sirolimus) NF

RAPAMUNE TABS 0.5 MG, 1 MG, 2 MG (sirolimus)

NF QL(1 ea daily)

SANDIMMUNE CAPS 25 MG, 100 MG (cyclosporine) NF

SANDIMMUNE SOLN 100 MG/ML F

sirolimus soln or 1 mg/ml F

sirolimus tabs or 0.5 mg, 1mg, 2 mg F QL(1 ea daily)

tacrolimus caps or 0.5 mg,1 mg, 5 mg F

ZORTRESS TABS 0.25 MG, 0.75 MG, 0.5 MG (everolimus (immunosuppressant))

NF

PA

ZORTRESS TABS 1 MG F PA

Potassium Removing Agents sodium polystyrenesulfonate powd or F

sodium polystyrenesulfonate susp or 15gm/60ml

F

MOUTH/THROAT/DENTAL AGENTS

Anesthetics Topical Oral lidocaine hcl (mouth-throat)soln 2 % F QL(100 ml per

30 days retail) Anti-infectives - Throat clotrimazole troc mt F

nystatin (mouth-throat) susp F

Antiseptics - Mouth/Throat

Drug Name DrugTier

Requirements/Limits

chlorhexidine gluconate(mouth-throat) soln 0.12 % F

PERIDEX SOLN (chlorhexidine gluconate(mouth-throat))

NF

Steroids - Mouth/Throat/Dental triamcinolone acetonide (mouth) pste F

Throat Products - Misc. AQUORAL SOLN F RX/OTC

BIOTENE DRY MOUTH MOISTURIZING SPRAY SOLN

F RX/OTC

CAPHOSOL SOLN F RX/OTC

CVS DRY MOUTH SPRAY SOLN F RX/OTC

EQL DRY MOUTH ORAL RINSE SOLN F RX/OTC

MOI-STIR SOLN F RX/OTC

MOUTH KOTE REMINT SOLN F RX/OTC

MOUTH KOTE SOLN F RX/OTC

NUMOISYN LIQD F RX/OTC

ORAL RELIEF SPRAY FOR DRYMOUTH & DISCOMFORT SOLN

F RX/OTC

RA DRY MOUTH SOLN F RX/OTC

XEROSTOMIA RELIEF SPRAY SOLN F RX/OTC

MULTIVITAMINS

B-Complex w/ Folic Acid b-complex w/ c & folic acid caps F RX/OTC

Multiple Vitamins w/ Minerals

ONEVITE TABS F

THRIVITE 19 TABS F


94

Drug Name DrugTier

Requirements/Limits

UDAMIN SP TABS F

Ped MV w/ Iron BPROTECTED PEDIA POLY-VITE/IRON SOLN F

PC PEDIATRIC POLY-VITAMIN DROPS/IRONSOLN

F

pediatric multiple vitaminsw/ iron soln F

POLY-VITA/IRON SOLN F

Pediatric Multiple Vitamins pediatric multiple vitamin w/c soln F

POLY-VI-SOL SOLN F

Prenatal Vitamins CLASSIC PRENATAL TABS F

CO-NATAL FA TABS F RX/OTC

COMPLETENATE CHEW F

CVS PRENATAL TABS F

EQL PRENATAL FORMULA TABS F

GNP DAILY PRENATAL MISC F

GNP PRENATAL TABS F

GOODSENSE PRENATAL VITAMINS TABS F

HM ONE DAILY PRENATAL COMBO MISC F

HM PRENATAL TABS F

KP PRENATAL MULTIVITAMINS TABS F

KPN PRENATAL TABS F

M-NATAL PLUS TABS F RX/OTC

M-VIT TABS F RX/OTC

Drug Name DrugTier

Requirements/Limits

MULTI PRENATAL TABS F

MYNATAL ADVANCE TABS F

MYNATAL CAPS F

MYNATAL PLUS TABS F

MYNATAL ULTRACAPLET TABS F

MYNATAL-Z TABS F

MYNATE 90 PLUS TBCR F

NATALVIT TABS F

NEONATAL COMPLETE TABS F RX/OTC

NEONATAL PLUS TABS F RX/OTC

NEONATAL VITAMIN TABS F

NIVA-PLUS TABS F RX/OTC

O-CAL FA TABS F RX/OTC

O-CAL PRENATAL TABS F

ONE VITE WOMENS PRENATALVITAMIN PLUS TABS

F RX/OTC

ONE VITE WOMENS PRENATALVITAMIN TABS F

ONE-A-DAY WOMENS PRENATAL MISC F

PERRY PRENATAL CAPS F

PNV FOLIC ACID + IRON MULTIVITAMIN TABS F RX/OTC

PNV PRENATAL PLUS MULTIVITAMIN TABS F RX/OTC

PNV TABS 29-1 TABS F

PRE-NATAL FORMULA TABS F RX/OTC

PRENATABS FA TABS F RX/OTC


95

Drug Name DrugTier

Requirements/Limits

PRENATAL 19 CHEW 1 MG-100 MG-1000 UNIT-12 MCG-15 MG-20 MG-20 MG-200 MG-29 MG-3 MG-3 MG-30 UNIT-400 UNIT-7 MG

F

PRENATAL 19 TABS 1 MG-100 MG-1000 UNIT-12 MCG-15 MG-20 MG-20 MG-200 MG-25 MG-29 MG-3 MG-3 MG-30 UNIT-400 UNIT-7 MG

F

RX/OTC

PRENATAL AND IRON TABS F RX/OTC

PRENATAL FORTE TABS F RX/OTC

PRENATAL LOW IRON TABS F

PRENATAL MULTIVITAMIN TABS F

PRENATAL ONE DAILY TABS F

PRENATAL PLUS IRON TABS F

PRENATAL TABS 0.8 MG-1.5 MG-1.7 MG-100 MG-11 UNIT-18 MG-2.6 MG-25 MG-263 MG-27 MG-4 MCG-400 UNIT-4000 UNIT, 0.8 MG-1.7 MG-1.8 MG-120 MG-2.6 MG-20 MG-200 MG-25 MG-28 MG-30 UNIT-400 UNIT-4000 UNIT-8 MCG, 1.7 MG-1.8 MG-120 MG-2.6 MG-20 MG-200 MG-25 MG-28 MG-30 UNIT-400 UNIT-4000 UNIT-8 MCG-800 MCG, 1.7 MG-1.84 MG-100 MG-11 UNIT-160 MG-18 MG-2.6 MG-200 MG-25 MG-27 MG-4 MCG-400 UNIT-4000 UNIT-800 MCG

F

PRENATAL TABS 0.8 MG-1.7 MG-1.84 MG-100 MG-11 UNIT-18 MG-2.6 MG-200 MG-25 MG-27 MG-4 MCG-400 UNIT-4000 UNIT

F

RX/OTC

Drug Name DrugTier

Requirements/Limits

PRENATAL TABS 1 MG-1.84 MG-10 MG-12 MCG-120 MG-2 MG-20 MG-200 MG-22 MG-25 MG-27 MG-3 MG-400 UNIT-4000 UNIT

F

RX/OTC

prenatal vit w/ docusate-fefumarate-folic acid tabs F RX/OTC

prenatal vit w/ docusate-iron carbonyl-folic acid tabs F

prenatal vit w/ ferrousfumarate-folic acid chew F

prenatal vit w/ ferrousfumarate-folic acid tabs F

prenatal vit w/ ironcarbonyl-folic acid tabs F

PRENATAL VITAMIN & MINERAL TABS F

PRENATAL VITAMIN TABS F

PRENATAL VITAMIN/IRON TABS F

PRENATAL VITAMINS PLUS LOW IRON TABS F RX/OTC

PRENATAL VITAMINS TABS F

PRENATAL-U CAPS 0.8 MG-1 MG-1.3 MG-10 MG-10 MG-106.5 MG-15 MCG-200 MG-30 MG-5 MG-6 MG

F

PRENATRIX TABS F RX/OTC

PRENATVITE RX TABS F RX/OTC

PREPLUS TABS F RX/OTC

PRETAB TABS F RX/OTC

PX PRENATAL MULTIVITAMINS TABS F

QC PRENATAL TABS F

RA ONE DAILY MISC F

RA PRENATAL FORMULA/FOLICACIDTABS

F


96

Drug Name DrugTier

Requirements/Limits

RA PRENATAL TABS F

RIGHT STEP PRENATAL TABS F

SE-NATAL 19 CHEW 1 MG-100 MG-1000 UNIT-12 MCG-15 MG-20 MG-20 MG-200 MG-29 MG-3 MG-3 MG-30 UNIT-400 UNIT-7 MG

F

SE-NATAL 19 TABS 1 MG-100 MG-1000 UNIT-12 MCG-15 MG-20 MG-20 MG-200 MG-25 MG-29 MG-3 MG-3 MG-30 UNIT-400 UNIT-7 MG

F

RX/OTC

SM ONE DAILY PRENATAL MISC F

SM PRENATAL VITAMINS TABS F

THERANATAL CORE NUTRITION TABS F RX/OTC

THRIVITE RX TABS F

TRICARE TABS F RX/OTC

TRINATAL RX 1 TABS F

VIL-RX TABS F

VINATE M TABS F

VINATE ONE TABS F

VITAFOL-OB TABS F

VITATHELY/GINGERTABS F RX/OTC

VOL-NATE TABS F

VOL-PLUS TABS F RX/OTC

VOL-TAB RX TABS F

MUSCULOSKELETAL THERAPY AGENTS -Drugs to Treat Spasms

Central Muscle Relaxants

Drug Name DrugTier

Requirements/Limits

baclofen tabs or 10 mg, 20 mg F

cyclobenzaprine hcl tabs or5 mg, 10 mg F

methocarbamol tabs or 500 mg, 750 mg F

ROBAXIN TABS OR 500 MG (methocarbamol) NF

ROBAXIN-750 TABS (methocarbamol) NF

tizanidine hcl tabs or 2 mg,4 mg F

ZANAFLEX TABS 4 MG (tizanidine hcl) NF

Direct Muscle Relaxants DANTRIUM CAPS 25 MG (dantrolene sodium) NF

dantrolene sodium caps or25 mg, 100 mg F

NASAL AGENTS - SYSTEMIC AND TOPICAL -Drugs to treat the Nose or Sinus

Nasal Agent Combinations

AFRIN MENTHOL SOLN F

azelastine hcl-fluticasone propionate susp 137mcg/act-50 mcg/act

F

DYMISTA SUSP (azelastine hcl-fluticasone propionate)

NF

TICALAST KIT F

Nasal Agents - Misc. 4-WAY SALINE SOLN F

ALKALOL SOLN F

ALZAIR ALLERGY BLOCKER NASAL SPRAY POWD

F

AYR NASAL DROPS SOLN F

AYR NASAL MIST ALLERGY &SINUS HYPERTONIC SALINE SOLN

F


97

Drug Name DrugTier

Requirements/Limits

AYR SALINE NASAL GEL SWAB F

AYR SALINE NASAL NETI RINSE KIT PACK F

AYR SALINE NASAL RINSE KIT PACK F

AYR SALINE NASAL RINSE KIT REFILL PACK F

CVS NASAL MIST AERS F

ENTSOL NASAL SPRAY SOLN F

GELONASAL SOLN F

LITTLE NOSES MOISTURIZINGNASAL GEL GEL

F

LITTLE NOSES STERILE SALINE NASAL MIST AERS

F

LITTLE REMEDIES BABY STERILE SALINE MIST FOR NOSES AERS

F

LITTLE REMEDIES FOR NOSES SOLN F

NASADOCK PLUS PACK F

NASADROPS SALINE ON THE GO SOLN F

NASAFLO NETI POT NASAL WASH SYSTEM PACK

F

NASAFLO PORCELAIN NASAL RINSE PACK F

NASAL CLEANSE RINSE MIX PACK F

NASAL MOIST GEL GEL F

NASALCARE FOR KIDS PACK F

NASALCARE FOR KIDS STARTER KIT PACK F

NASALCARE NASALCLEANSE KIT PACK

F

NASALCARE PACK F

Drug Name DrugTier

Requirements/Limits

NASAMIST ALL-IN-ONE AERS F

NASAMIST HYPERTONIC AERS F

NASAMIST ISOTONIC AERS F

NOSE BETTER GEL F

NOSE BETTER NATURAL MIST SOLN F

NOSE BETTER SOLN F

OCEAN COMPLETE SINUS RINSE AERS F

OCEAN NASAL MOISTURIZER GEL F

OCEAN NASAL SPRAY SOLN (saline) NF

OCEAN ULTRA SALINE NASALMIST SOLN F

PONARIS SOLN F

PRETZ IRRIGATION SOLN F

PRETZ NATURAL MOISTURIZING NASAL SPRAY/YERBASANTA/SEA SALT SOLN

F

PRETZ SOLN NA F

RA SINUS WASH NASAL RELIEF REFILL PACK F

RA SINUS WASH NETI POT PACK F

RA STERILE SALINE NASAL MIST SOLN F

RHINARIS SOLN F

RHINASE GEL F

RHINASE SOLN F

saline gel na F

saline soln na 0.002 %-0.65 %, 0.65 % F


98

Drug Name DrugTier

Requirements/Limits

SALTAIRE SOLN F

SIMPLY SALINE AERS F

SINUCLEANSE NETI POT KIT (sodium chloride-sodium bicarbonate)

NF

SINUCLEANSE REFILL PACK (sodium chloride-sodium bicarbonate)

NF

SINUCLEANSE SQUEEZE KIT (sodium chloride-sodium bicarbonate)

NF

SINUFLO READYRINSE KIT F

SINUGATOR NASAL WASH PACK F

SINUS RINSE BOTTLE KIT PACK F

SINUS RINSE KIT PACK F

SINUS RINSE KIT PEDIATRIC PACK F

SINUS RINSE PACK F

SINUS RINSE PEDIATRIC STARTER KIT PACK F

SINUS RINSE REFILL PACK F

SINUS RINSE REFILL PEDIATRIC PACK F

SINUS WASH SALT CRYS F

sodium chloride-sodium bicarbonate kit F

sodium chloride-sodium bicarbonate pack F

TICASPRAY THPK 0.9 %-50 MCG/ACT F

XLEAR SINUS CARE SPRAY SOLN F

XLEAR SINUS CARE SPRAY/KIDS SOLN F

Nasal Anesthetics COCAINE HYDROCHLORIDE SOLN F

Drug Name DrugTier

Requirements/Limits

GOPRELTO SOLN F

NUMBRINO SOLN F

Nasal Anti-infectives BACTROBAN NASAL OINT F

Nasal Antiallergy azelastine hcl soln na 0.15 %, 0.1 %, 137 mcg/spray F

cromolyn sodium (nasal)aers 5.2 mg/act F

NASALCROM AERS (cromolyn sodium (nasal)) NF

olopatadine hcl (nasal) soln0.6 % F

PATANASE SOLN (olopatadine hcl (nasal)) NF

Nasal Anticholinergics ipratropium bromide (nasal)soln F

Nasal Steroids

BECONASE AQ SUSP F

budesonide (nasal) susp F

FLONASE ALLERGY RELIEF CHILDRENS SUSP (fluticasone propionate (nasal))

NF

RX/OTC

FLONASE ALLERGY RELIEF SUSP (fluticasone propionate (nasal))

NF RX/OTC

FLONASE SENSIMIST SUSP F

flunisolide (nasal) soln F

fluticasone propionate(nasal) susp F RX/OTC

mometasone furoate (nasal) susp F

NASACORT ALLERGY 24HR AERO (triamcinolone acetonide (nasal))

NF RX/OTC

NASACORT ALLERGY 24HR AERO 55 MCG/ACT F RX/OTC


99

Drug Name DrugTier

Requirements/Limits

NASACORT ALLERGY 24HR CHILDRENS AERO (triamcinolone acetonide (nasal))

NF

RX/OTC

NASONEX SUSP (mometasone furoate (nasal))

NF

OMNARIS SUSP F

PROPEL IMPL F

PROPEL MINI IMPL F

QNASL AERS F

QNASL CHILDRENS AERS F

SINUVA IMPL F

triamcinolone acetonide (nasal) aero 55 mcg/act F RX/OTC

XHANCE EXHU F

ZETONNA AERS F

Sympathomimetic Decongestants ADRENALIN SOLN NA 0.1 % (epinephrine hcl (nasal)) NF

AFRIN 12 HOUR SOLN (oxymetazoline hcl) NF

AFRIN ALL NIGHT NODRIP SOLN (oxymetazoline hcl)

NF

AFRIN CHILDRENS SOLN F

AFRIN NASAL SPRAY SOLN (oxymetazoline hcl) NF

AFRIN NODRIP EXTRA MOISTURIZING SOLN (oxymetazoline hcl)

NF

AFRIN NODRIP ORIGINAL SOLN (oxymetazoline hcl) NF

AFRIN NODRIP SEVERE CONGESTION SOLN (oxymetazoline hcl)

NF

AFRIN NODRIP SINUS SOLN (oxymetazoline hcl) NF

Drug Name DrugTier

Requirements/Limits

AFRIN PUMP MIST SOLN (oxymetazoline hcl) NF

AFRIN SINUS SOLN (oxymetazoline hcl) NF

AFRIN SOLN (oxymetazoline hcl) NF

BENZEDREX INHALER INHA F

CVS NASAL DECONGESTANT CAPS F

DRISTAN SPRAY SOLN (oxymetazoline hcl) NF

DURATION 12 HOUR SOLN (oxymetazoline hcl) NF

DURATION SPRAY SOLN (oxymetazoline hcl) NF

epinephrine hcl (nasal) soln0.1 % F

LITTLE COLDS DECONGESTANTFORMU LA LIQD

F

LITTLE NOSES DECONGESTANTNOSE DROPS SOLN

F

NASAL DECONGESTANT LIQD F

NASAL DECONGESTANT SYRP F

NEO-SYNEPHRINE COLD+ALLERGY EXTRA STRENGTH SOLN (phenylephrine hcl)

NF

NEO-SYNEPHRINE COLD+ALLERGY MILD STRENGTH SOLN

F

NEO-SYNEPHRINE COLD+ALLERGY REGULAR STRENGTH SOLN

F

oxymetazoline hcl soln na0.05 % F

phenylephrine hcl (oral)tabs F

PHENYLEPHRINE HCL CRYS XX F

PHENYLEPHRINE HCL POWD XX F RX/OTC


100

Drug Name DrugTier

Requirements/Limits

phenylephrine hcl soln na F

PHENYLEPHRINE HYDROCHLORIDE POWD XX

F RX/OTC

PHENYLPROPANOLAMIN E HYDROCHLORIDE USP POWD

F

PSEUDOEPHEDRINE HCL CRYS XX F

pseudoephedrine hcl liqdor 15 mg/5ml F

PSEUDOEPHEDRINE HCL POWD XX F

pseudoephedrine hcl tabaor 30 mg F

pseudoephedrine hcl tabsor 30 mg, 60 mg F

pseudoephedrine hcl tb12or 120 mg F

SUDAFED CHILDRENS LIQD (pseudoephedrine hcl)

NF

SUDAFED CONGESTION TABS (pseudoephedrine hcl)

NF

SUDAFED PE CHILDRENS NASAL DECONGESTANT SOLN

F

SUDAFED PE SINUS CONGESTION TABS (phenylephrine hcl (oral))

NF

SUDAFED SINUS CONGESTION TABS (pseudoephedrine hcl)

NF

SUDAFED SINUS CONGESTION24 HOUR TB24

F

VICKS SINEX 12 HOUR DECONGESTANT SOLN (oxymetazoline hcl)

NF

VICKS SINEX MOISTURIZING SOLN (oxymetazoline hcl)

NF

VICKS SINEX SEVERE NASALDECONGESTANT SOLN (oxymetazoline hcl)

NF

Drug Name DrugTier

Requirements/Limits

VICKS SINEX SEVERE SOLN (oxymetazoline hcl) NF

NEUROMUSCULAR AGENTS - Drugs toRelax/Paralyze Muscles

ALS Agents

RILUTEK TABS (riluzole) NF

riluzole tabs 50 mg F

NUTRIENTS

Misc. Nutritional Substances

FISH OIL CAPS F

FISH OIL CHEW F

FISH OIL PEARLS CAPS F

FISH OIL TRIPLE STRENGTH CAPS F

FISH OIL ULTRA CAPS F

HM FISH OIL CAPS F

OMEGA POWER CAPS F

OMEGA-3 2100 CAPS F

OMEGA-3 CAPS F

OMEGA-3 EPA FISH OIL CAPS F

omega-3 fatty acids caps F

omega-3 fatty acids chew F

OMEGA-3 FISH OIL EXTRA STRENGTH CAPS F

RA FISH OIL EXTRA STRENGTH CAPS F

RA TRIPLE STRENGTH FISH OIL CAPS F

SALMON CAPS F

SALMON OIL CAPS F


101

Drug Name DrugTier

Requirements/Limits

SALMON OIL-1000 CAPS F

SM FISH OIL CAPS F

SUPER TWIN EPA/DHACAPS F

ULTRA OMEGA 3 CAPS F

ULTRA OMEGA-3 FISH OIL BURP-LESS CAPS F

OPHTHALMIC AGENTS - Drugs to Treat the Eye

Artificial Tears and Lubricants

artificial tear ointment oint F

artificial tear solution soln F

ARTIFICIAL TEARS SOLN F

carboxymethylcellulosesodium (ophth) gel 1 % F

carboxymethylcellulosesodium (ophth) soln 0.25%, 0.5 %

F

GENTEAL MILD SOLN F

GENTEAL MILD TO MODERATE SOLN (hypromellose (ophth))

NF

GENTEAL SEVERE GEL F

GENTEAL SEVERE TEARS GEL F

GONIOVISC SOLN F

hypromellose (ophth) soln F

ISOPTO TEARS SOLN F

polyethylene glycol-propylene glycol (ophth)soln 0.3 %-0.4 %

F

polyvinyl alcohol soln op1.4 % F

REFRESH LIQUIGEL GEL (carboxymethylcellulosesodium (ophth))

NF

Drug Name DrugTier

Requirements/Limits

REFRESH TEARS SOLN (carboxymethylcellulosesodium (ophth))

NF

SYSTANE OVERNIGHT THERAPY LUBRICANT EYE GEL

F

SYSTANE SOLN (polyethylene glycol-propylene glycol (ophth))

NF

SYSTANE ULTRA HOME & AWAY PACK SOLN (polyethylene glycol-propylene glycol (ophth))

NF

SYSTANE ULTRA SOLN (polyethylene glycol-propylene glycol (ophth))

NF

THERATEARS SOLN 0.25 % (carboxymethylcellulosesodium (ophth))

NF

Beta-blockers - Ophthalmic BETAGAN SOLN (levobunolol hcl) NF

betaxolol hcl (ophth) soln F

BETIMOL SOLN F

BETOPTIC-S SUSP F

carteolol hcl (ophth) soln F

COSOPT SOLN (dorzolamide hcl-timolol maleate)

NF

dorzolamide hcl-timolol maleate soln 0.5 %-2 %, 20mg/ml-5 mg/ml, 22.3mg/ml-6.8 mg/ml

F

ISTALOL SOLN (timolol maleate (ophth)) NF

levobunolol hcl soln 0.5 % F

metipranolol soln F

timolol maleate (ophth) solg F

timolol maleate (ophth) soln F


102

Drug Name DrugTier

Requirements/Limits

TIMOPTIC OCUDOSE SOLN F

TIMOPTIC SOLN (timolol maleate (ophth)) NF

TIMOPTIC-XE SOLG (timolol maleate (ophth)) F

Cycloplegic Mydriatics ATROPINE SULFATE OINT OP 1 % F

ATROPINE SULFATE SOLN OP 1 % F

CYCLOGYL SOLN 1 %, 2 % (cyclopentolate hcl) NF

cyclopentolate hcl soln op1 %, 2 % F

homatropine hbr soln F

ISOPTO ATROPINE SOLN 1 % F

MYDRIACYL SOLN (tropicamide) NF

phenylephrine hcl(mydriatic) soln 10 % F

phenylephrine hcl(mydriatic) soln 2.5 % F QL(16 ml daily)

tropicamide soln op 0.5 %,1 % F

Miotics ISOPTO CARPINE SOLN (pilocarpine hcl) NF

pilocarpine hcl soln op 1 %,2 %, 4 % F

Ophthalmic Adrenergic Agents apraclonidine hcl soln 0.5% F

brimonidine tartrate soln op0.2 % F

IOPIDINE SOLN 0.5 % (apraclonidine hcl) NF

Ophthalmic Anti-infectives bacitracin (ophthalmic) oint500 unit/gm F QL(4 gm per 7

days retail) bacitracin-polymyxin b(ophth) oint F

Drug Name DrugTier

Requirements/Limits

BLEPH-10 SOLN (sulfacetamide sodium (ophth))

NF

CILOXAN OINT 0.3 % F

CILOXAN SOLN (ciprofloxacin hcl (ophth)) NF

ciprofloxacin hcl (ophth)soln 0.3 % F

erythromycin (ophth) oint F

gentamicin sulfate (ophth)oint F

gentamicin sulfate (ophth)soln F

levofloxacin (ophth) soln F

moxifloxacin hcl (ophth)soln 0.5 % F

NATACYN SUSP F

neomycin-bacitracin zn-polymyxin oint F

neomycin-polymyxin-gramicidin soln 0.025mg/ml-1.75 mg/ml-10000unit/ml

F

NEOSPORIN SOLN (neomycin-polymyxin-gramicidin)

NF

OCUFLOX SOLN (ofloxacin (ophth)) NF

ofloxacin (ophth) soln 0.3% F

polymyxin b-trimethoprimsoln 0.1 %-10000 unit/ml F

POLYTRIM SOLN (polymyxin b-trimethoprim) NF

sulfacetamide sodium (ophth) oint 10 % F

sulfacetamide sodium (ophth) soln 10 % F

tobramycin (ophth) soln 0.3% F

TOBREX OINT 0.3 % F 1 rtl pack lmtamt,7 rtl packlmt day(s),


103

Drug Name DrugTier

Requirements/Limits

TOBREX SOLN (tobramycin (ophth)) NF

trifluridine soln op 1 % F

VIGAMOX SOLN (moxifloxacin hcl (ophth)) NF

VIROPTIC SOLN (trifluridine) NF

Ophthalmic Decongestants naphazoline w/pheniramine soln F

NAPHCON-A SOLN (naphazoline w/pheniramine)

NF

OPCON-A SOLN (naphazoline w/pheniramine)

NF

Ophthalmic Immunomodulators

RESTASIS EMUL F PA

Ophthalmic Local Anesthetics

tetracaine hcl (ophth) soln F

Ophthalmic Steroids bacitracin-poly-neomycin-hc oint F

BLEPHAMIDE S.O.P. OINT F

BLEPHAMIDE SUSP F

dexamethasone sodium phosphate (ophth) soln F

fluorometholone (ophth) susp F

FML FORTE SUSP F

FML LIQUIFILM SUSP (fluorometholone (ophth)) NF

FML OINT F

MAXIDEX SUSP F

MAXITROL OINT (neomycin-polymy-dexameth)

NF

Drug Name DrugTier

Requirements/Limits

MAXITROL SUSP (neomycin-polymy-dexameth)

NF

neomycin-polymy-dexameth oint F

neomycin-polymy-dexameth susp F

neomycin-polymyxin-hc(ophth) susp F

OMNIPRED SUSP (prednisolone acetate(ophth))

NF

PRED FORTE SUSP (prednisolone acetate(ophth))

F

PRED FORTE SUSP (prednisolone acetate(ophth))

NF

PRED MILD SUSP F

PRED-G S.O.P. OINT F

PRED-G SUSP F

prednisolone acetate(ophth) susp F

PREDNISOLONE ACETATE P-F SUSP F

PREDNISOLONE SODIUM PHOSPHATE SOLN OP 1 %

F

sulfacetamide sod-prednisolone soln F

TOBRADEX OINT F QL(4 gm per 7days retail)

TOBRADEX ST SUSP F

TOBRADEX SUSP (tobramycin-dexamethasone)

NF

tobramycin-dexamethasone susp F

Ophthalmics - Misc. ACULAR LS SOLN (ketorolac tromethamine (ophth))

NF


104

Drug Name DrugTier

Requirements/Limits

ACULAR SOLN (ketorolac tromethamine (ophth)) NF

azelastine hcl (ophth) soln F

AZOPT SUSP F PA

cromolyn sodium (ophth)soln F

diclofenac sodium (ophth)soln F

dorzolamide hcl soln 2 % F

DORZOLAMIDE HCL SOLN 2 % F

flurbiprofen sodium soln F

ketorolac tromethamine (ophth) soln F

ketotifen fumarate (ophth)soln 0.025 % F

TRUSOPT SOLN (dorzolamide hcl) NF

ZADITOR SOLN (ketotifen fumarate (ophth)) NF

Prostaglandins - Ophthalmic latanoprost soln op 0.005% F QL(2.5 ml per

fill retail) TRAVATAN Z SOLN (travoprost) NF PA

travoprost soln 0.004 % F PA

XALATAN SOLN (latanoprost) NF QL(2.5 ml per

fill retail)

ZIOPTAN SOLN F PA

OTIC AGENTS - Drugs to Treat the Ear

Otic Agents - Miscellaneous

acetic acid (otic) soln F

carbamide peroxide (otic)soln 6.5 % F

DEBROX SOLN (carbamide peroxide (otic)) NF

Otic Anti-infectives

Drug Name DrugTier

Requirements/Limits

ciprofloxacin hcl (otic) soln F

Otic Combinations CIPRODEX SUSP 0.1 %-0.3 % (ciprofloxacin-dexamethasone)

F

neomycin-polymyxin-hc(otic) soln F

neomycin-polymyxin-hc(otic) susp F

Otic Steroids hydrocortisone w/aceticacid soln F

OXYTOCICS - Drugs to Prevent/Control UterineBleeding

Oxytocics methylergonovine maleatetabs or 0.2 mg F

PASSIVE IMMUNIZING AND TREATMENT AGENTS - Antibody Drugs to Treat Low ImmuneSystem

Immune Serums

BIVIGAM SOLN F PA; SP

FLEBOGAMMA DIF SOLN F PA; SP

GAMASTAN INJ F PA; SP

GAMMAGARD LIQUID SOLN F PA; SP

GAMMAGARD S/D IGALESS THAN 1MCG/MLSOLR

F PA; SP

GAMUNEX-C SOLN F PA; SP

HIZENTRA SOLN F PA; SP

Monoclonal Antibodies

SYNAGIS SOLN F PA; SP

PENICILLINS - Drugs to Treat Bacterial Infections

Aminopenicillins

amoxicillin caps F


105

Drug Name DrugTier

Requirements/Limits

amoxicillin chew F

amoxicillin susr F

amoxicillin tabs F

AMOXICILLIN TRIHYDRATE POWD F

ampicillin caps F

ampicillin sodium solr F

MOXATAG TB24 F

Natural Penicillins

BICILLIN L-A SUSP F

PENICILLIN G POTASSIUM IN ISO-OSMOTIC DEXTROSE SOLN

F

penicillin g potassium solr F

PENICILLIN G PROCAINE SUSP F

penicillin g sodium solr F

penicillin v potassium solr F

penicillin v potassium tabs F

Penicillin Combinations amoxicillin & potclavulanate chew F

amoxicillin & potclavulanate susr F

amoxicillin & potclavulanate tabs F

amoxicillin & potclavulanate tb12 F

ampicillin & sulbactamsodium solr F

AUGMENTIN ES-600 SUSR (amoxicillin & potclavulanate)

NF

AUGMENTIN SUSR 125 MG/5ML-31.25 MG/5ML F

Drug Name DrugTier

Requirements/Limits

AUGMENTIN SUSR 250 MG/5ML-62.5 MG/5ML(amoxicillin & potclavulanate)

NF

AUGMENTIN TABS 125 MG-500 MG, 125 MG-875 MG (amoxicillin & potclavulanate)

NF

AUGMENTIN XR TB12 (amoxicillin & potclavulanate)

NF

BICILLIN C-R SUSP F

piperacillin sodium-tazobactam sodium solr F

UNASYN BULK PACK SOLR (ampicillin &sulbactam sodium)

NF

UNASYN SOLR (ampicillin& sulbactam sodium) NF

ZOSYN SOLN 0.375 GM/50ML-3 GM/50ML-5 %,0.5 GM/100ML-4GM/100ML-5 %, 0.25GM/50ML-2 GM/50ML-5 %

F

ZOSYN SOLR 0.375 GM-3 GM, 0.25 GM-2 GM, 0.5 GM-4 GM, 36 GM-4.5 GM (piperacillin sodium-tazobactam sodium)

NF

Penicillinase-Resistant Penicillins

dicloxacillin sodium caps F

nafcillin sodium solr F

NAFCILLIN SOLN F

OXACILLIN SODIUM SOLN IV 1 GM/50ML-1.5GM/50ML, 2 GM/50ML-300MG/50ML

F

oxacillin sodium solr ij 1gm, 2 gm F

oxacillin sodium solr iv 10 gm F

PROGESTINS - Hormone Replacement/ModifyingDrugs


106

Drug Name DrugTier

Requirements/Limits

Progestins AYGESTIN TABS (norethindrone acetate) NF

MAKENA OIL IM 250 MG/ML F PA; SP

MAKENA SOAJ SC 275 MG/1.1ML F PA; SP

medroxyprogesteroneacetate tabs or 5 mg, 10mg, 2.5 mg

F

norethindrone acetate tabs or 5 mg F

progesterone micronizedcaps or 100 mg, 200 mg F QL(2 ea daily)

PROMETRIUM CAPS (progesterone micronized) NF QL(2 ea daily)

PROVERA TABS (medroxyprogesterone acetate)

NF

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. - Drugs to Treat Mental andEmotional Conditions

Agents for Chemical Dependency

acamprosate calcium tbec F

ANTABUSE TABS (disulfiram) NF

disulfiram tabs or 250 mg,500 mg F

Antidementia Agents ARICEPT TABS (donepezil hydrochloride) NF PA

donepezil hydrochloridetabs F PA

donepezil hydrochloridetbdp F PA

EXELON PT24 (rivastigmine) NF PA

galantamine hydrobromidecp24 F PA

galantamine hydrobromidesoln F PA

galantamine hydrobromidetabs F PA

Drug Name DrugTier

Requirements/Limits

memantine hcl soln 2 mg/ml, 10 mg/5ml F PA

memantine hcl tabs 10 mg F QL(6 ea daily)

memantine hcl tabs 5 mg F PA; QL(6 eadaily)

NAMENDA TABS 10 MG (memantine hcl) NF QL(6 ea daily)

NAMENDA TABS 5 MG (memantine hcl) NF PA; QL(6 ea

daily) RAZADYNE ER CP24 (galantaminehydrobromide)

NF PA

RAZADYNE TABS (galantaminehydrobromide)

NF PA

rivastigmine pt24 F PA

rivastigmine tartrate caps F PA

Multiple Sclerosis Agents

AVONEX KIT F PA; SP

AVONEX PEN AJKT F PA; SP

AVONEX PSKT F PA; SP

BETASERON KIT F PA; SP

COPAXONE SOSY 20 MG/ML (glatiramer acetate) F PA; SP

COPAXONE SOSY 40 MG/ML (glatiramer acetate) NF SP

EXTAVIA KIT F PA; SP

GILENYA CAPS F PA; SP

glatiramer acetate sosy 40mg/ml F PA; SP

REBIF REBIDOSE SOAJ F PA; SP

REBIF REBIDOSE TITRATIONPACK SOAJ F PA; SP

REBIF SOSY F PA; SP

REBIF TITRATION PACK SOSY F PA; SP


107

Drug Name DrugTier

Requirements/Limits

Postherpetic Neuralgia (PHN)/Neuropathic Pain

GRALISE TABS F PA

Psychotherapeutic and Neurological Agents -

ORAP TABS (pimozide) NF AL(At least 6yrs old)

pimozide tabs F AL(At least 6yrs old)

Restless Leg Syndrome (RLS) Agents

HORIZANT TBCR F PA

Smoking Deterrents

bupropion hcl (smokingdeterrent) tb12 150 mg F

QL(2 eadaily)84 rtlMAX day(s)supply,180 rtllmt day(s),

CHANTIX CONTINUING MONTHPAK TABS F


CHANTIX STARTING MONTH PAK TABS F


CHANTIX TABS F


NICODERM CQ PT24 (nicotine) NF


NICORETTE GUM 2 MG, 4 MG (nicotine polacrilex) NF


NICORETTE LOZG 2 MG, 4 MG (nicotine polacrilex) NF


Drug Name DrugTier

Requirements/Limits

NICORETTE MINI LOZG (nicotine polacrilex) NF


NICORETTE STARTER KIT GUM (nicotine polacrilex)

NF


nicotine polacrilex gum mt2 mg, 4 mg F


nicotine polacrilex lozg mt 2mg, 4 mg F


nicotine pt24 F


NICOTINE TRANSDERMAL SYSTEM KIT

F


NICOTROL INHALER INHA F

QL(16.8 eadaily)84 rtlMAX day(s)supply,180 rtllmt day(s),

NICOTROL NS SOLN F

QL(4 mldaily)84 rtlMAX day(s)supply,180 rtllmt day(s),

ZYBAN TB12 (bupropionhcl (smoking deterrent)) NF


RESPIRATORY AGENTS - MISC. - Drugs toTreat Lung Conditions

Alpha-Proteinase Inhibitor (Human)


108

Drug Name DrugTier

Requirements/Limits

ARALAST NP SOLR F PA; SP

GLASSIA SOLN F PA; SP

PROLASTIN-C SOLR F PA; SP

ZEMAIRA SOLR F PA; SP

Cystic Fibrosis Agents

PULMOZYME SOLN F PA; SP

SULFONAMIDES - Drugs to Treat BacterialInfections

Sulfonamides

SULFADIAZINE POWD F

SULFADIAZINE SODIUM POWD F

SULFADIAZINE TABS F

SULFAMETHOXAZOLE MICRO POWD F

SULFAMETHOXAZOLE POWD F

SULFAPYRIDINE POWD F

SULFATHIAZOLE POWD F

SULFISOXIZOLE CRYS F

TETRACYCLINES - Drugs to Treat BacterialInfections

Aminomethylcyclines

NUZYRA SOLR F

NUZYRA TABS F

Fluorocyclines

XERAVA SOLR F

Glycylcyclines TIGECYCLINE SOLR 50 MG F

tigecycline solr 50 mg F

Drug Name DrugTier

Requirements/Limits

TYGACIL SOLR (tigecycline) NF

Tetracycline Combinations

AVIDOXY DK KIT F

BENZODOX 30 KIT THPK F

BENZODOX 60 KIT THPK F

Tetracyclines

demeclocycline hcl tabs F

DORYX TBEC F

doxycycline (monohydrate) caps F

doxycycline (monohydrate) susr F

doxycycline (monohydrate)tabs F

doxycycline hyclate caps or50 mg, 100 mg F

DOXYCYCLINE HYCLATE DR TBEC F

DOXYCYCLINE HYCLATE POWD XX F

doxycycline hyclate solr iv100 mg F

doxycycline hyclate tabs or20 mg, 100 mg F

DOXYCYCLINE HYCLATE TBEC OR 80 MG F

MINOCIN CAPS OR 50 MG (minocycline hcl) NF

MINOCIN SOLR IV 100 MG F

minocycline hcl caps or 50mg, 75 mg, 100 mg F

MINOCYCLINE HCL POWD XX F

minocycline hcl tabs or 50mg, 75 mg, 100 mg F

minocycline hcl tb24 or 45mg, 55 mg, 65 mg, 80 mg,90 mg, 105 mg, 115 mg,135 mg

F


109

Drug Name DrugTier

Requirements/Limits

MINOCYCLINE HYDROCHLORIDEER CP24

F

MINOLIRA TB24 F

MORGIDOX 1X100MG KIT F

MORGIDOX 1X50MG KIT KIT F

MORGIDOX 2X100MG KIT F

NUTRIDOX KIT F

OXYTETRACYCLINE HCL POWD F

SEYSARA TABS F

SOLODYN TB24 (minocycline hcl) NF

tetracycline hcl caps or 250mg, 500 mg F

VIBRAMYCIN CAPS 100 MG (doxycycline hyclate) NF

VIBRAMYCIN SUSR 25 MG/5ML (doxycycline(monohydrate))

NF

VIBRAMYCIN SYRP 50 MG/5ML F

XIMINO CP24 45 MG, 90 MG, 135 MG F

THYROID AGENTS - Drugs to Regulate ThyroidHormones

Antithyroid Agents methimazole tabs or 5 mg,10 mg F

propylthiouracil tabs or F

TAPAZOLE TABS (methimazole) NF

Thyroid Hormones ARMOUR THYROID TABS 15 MG, 30 MG, 60 MG, 90 MG, 120 MG (thyroid)

NF

ARMOUR THYROID TABS 180 MG, 240 MG F

Drug Name DrugTier

Requirements/Limits

CYTOMEL TABS (liothyronine sodium) NF

levothyroxine sodium tabsor 25 mcg, 50 mcg, 75mcg, 88 mcg, 100 mcg,112 mcg, 125 mcg, 137mcg, 150 mcg, 175 mcg,200 mcg, 300 mcg

F

liothyronine sodium tabs or5 mcg, 25 mcg, 50 mcg F

NATURE-THROID NT-2.5 TABS F

NATURE-THROID TABS F

SYNTHROID TABS (levothyroxine sodium) NF

thyroid tabs or 15 mg, 30mg, 60 mg, 90 mg, 120 mg F

WESTHROID TABS F

WP THYROID TABS F

TOXOIDS

Toxoid Combinations

ADACEL SUSP F

Limit 1 dose per 10 years;1rtl MAX fill,999 rtl day(s)supply,; AL(Atleast 19 yrsold)

BOOSTRIX SUSP F


DAPTACEL SUSP F



110

Drug Name DrugTier

Requirements/Limits

TDVAX SUSP F


TENIVAC INJ F


TETANUS/DIPHTHERIATOXOIDS-ADSORBED ADULT SUSP

F


ULCER DRUGS - Drugs to Treat Bowel, Intestineand Stomach Conditions

Antispasmodics ANASPAZ TBDP (hyoscyamine sulfate) NF QL(4 ea daily)

CUVPOSA SOLN F

dicyclomine hcl caps or 10 mg F

dicyclomine hcl soln or 10mg/5ml F

dicyclomine hcl tabs or 20 mg F

glycopyrrolate tabs or 1mg, 2 mg F

hyoscyamine sulfate elix or0.125 mg/5ml F

hyoscyamine sulfate solnor 0.125 mg/ml F QL(8 ml daily)

hyoscyamine sulfate subl sl0.125 mg F QL(4 ea daily)

hyoscyamine sulfate tabsor 0.125 mg F QL(4 ea daily)

hyoscyamine sulfate tb12or 0.375 mg F QL(2 ea daily)

Drug Name DrugTier

Requirements/Limits

hyoscyamine sulfate tbdpor 0.125 mg F QL(4 ea daily)

LEVBID TB12 (hyoscyamine sulfate) NF QL(2 ea daily)

LEVSIN TABS OR 0.125 MG (hyoscyamine sulfate) NF QL(4 ea daily)

LEVSIN/SL SUBL(hyoscyamine sulfate) NF QL(4 ea daily)

methscopolamine bromidetabs or 5 mg, 2.5 mg F

propantheline bromide tabsor 15 mg F

ROBINUL FORTE TABS (glycopyrrolate) NF

ROBINUL TABS (glycopyrrolate) NF

SYMAX DUOTAB TBCR F

H-2 Antagonists DEPRIZINE FUSEPAQ SUSR F

famotidine susr or 40 mg/5ml F

famotidine tabs or 10 mg,40 mg F

famotidine tabs or 20 mg F RX/OTC

PEPCID AC MAXIMUM STRENGTH TABS (famotidine)

NF RX/OTC

PEPCID AC TABS (famotidine) NF

PEPCID SUSR 40 MG/5ML(famotidine) NF

PEPCID TABS 20 MG (famotidine) NF RX/OTC

PEPCID TABS 40 MG (famotidine) NF

ranitidine hcl caps or 150mg, 300 mg F

ranitidine hcl syrp or 15mg/ml, 75 mg/5ml, 150mg/10ml

F

ranitidine hcl tabs or 150 mg F RX/OTC


111

Drug Name DrugTier

Requirements/Limits

ranitidine hcl tabs or 75 mg, 300 mg F

ZANTAC 150 MAXIMUM STRENGTH TABS (ranitidine hcl)

NF RX/OTC

ZANTAC 75 TABS (ranitidine hcl) NF

ZANTAC TABS OR 300 MG (ranitidine hcl) NF

Misc. Anti-Ulcer CARAFATE TABS 1 GM (sucralfate) NF

sucralfate tabs or 1 gm F

Proton Pump Inhibitors

lansoprazole cpdr or 15 mg F RX/OTC

lansoprazole cpdr or 30 mg F

omeprazole cpdr or 10 mg,40 mg F

omeprazole cpdr or 20 mg F RX/OTC

omeprazole magnesiumcpdr 20 mg, 20.6 mg F

omeprazole tbec or 20 mg F

pantoprazole sodium packor 40 mg F

pantoprazole sodium tbecor 20 mg, 40 mg F

PREVACID 24HR CPDR (lansoprazole) NF RX/OTC

PREVACID CPDR 15 MG (lansoprazole) NF RX/OTC

PREVACID CPDR 30 MG (lansoprazole) NF

PROTONIX PACK OR 40 MG (pantoprazole sodium) NF

PROTONIX TBEC OR 20 MG, 40 MG (pantoprazole sodium)

NF

Ulcer Drugs - Prostaglandins CYTOTEC TABS (misoprostol) NF

Drug Name DrugTier

Requirements/Limits

misoprostol tabs or 100mcg, 200 mcg F

URINARY ANTI-INFECTIVES - Drugs to TreatBladder/Kidney Infections

Urinary Anti-infectives FURADANTIN SUSP (nitrofurantoin) NF

MACROBID CAPS (nitrofurantoin monohyd macro)

NF

MACRODANTIN CAPS (nitrofurantoin macrocrystal)

NF

nitrofurantoin macrocrystalcaps or 25 mg, 50 mg, 100 mg

F

nitrofurantoin monohydmacro caps 100 mg F

nitrofurantoin susp or 25mg/5ml F

URINARY ANTISPASMODICS - Drugs to TreatMiscellaneous Bladder Spasms

Urinary Antispasmodic - Antimuscarinics

DETROL LA CP24 (tolterodine tartrate) NF

ST; Tryoxybutynin or tolterodine IR first

DETROL TABS (tolterodine tartrate) NF ST

DITROPAN XL TB24 (oxybutynin chloride) NF QL(1 ea daily)

oxybutynin chloride syrp or5 mg/5ml F

oxybutynin chloride tabs or5 mg F

oxybutynin chloride tb24 or5 mg, 10 mg, 15 mg F QL(1 ea daily)

tolterodine tartrate cp24 2mg, 4 mg F

ST; Tryoxybutynin or tolterodine IR first

tolterodine tartrate tabs 1 mg, 2 mg F ST

trospium chloride tabs 20 mg F


112

Drug Name DrugTier

Requirements/Limits

Urinary Antispasmodics - Cholinergic Agonists bethanechol chloride tabs or 5 mg, 10 mg, 25 mg, 50 mg

F

URECHOLINE TABS (bethanechol chloride) NF

VACCINES

Bacterial Vaccines

BEXSERO SUSY F

Limit 2 doses per lifetime;2 rtlMAX fill,999 rtl day(s) supply,;AL(At least 19yrs old)

MENACTRA INJ F

Limit 1 dose per lifetime;1 rtlMAX fill,999 rtl day(s) supply,;AL(At least 19yrs old)

MENQUADFI INJ F


MENVEO SOLR F


PNEUMOVAX 23 INJ F


PNEUMOVAX 23/1 DOSEINJ F


Drug Name DrugTier

Requirements/Limits

PREVNAR 13 SUSP F


TRUMENBA SUSY F


Viral Vaccines

AFLURIA 2018-2019 SUSP F

Limit 1 dose perseason;QL(0.5ml per fillretail); AL(Atleast 3 yrs old)

AFLURIA PF 2018-2019 SUSY F


AFLURIA QUADRIVALENT 2018-2019 SUSP F


AFLURIA QUADRIVALENT 2018-2019 SUSY F







113

Drug Name DrugTier

Requirements/Limits





ENGERIX-B INJ F


ENGERIX-B SUSP F


FLUAD 2018-2019 SUSY F






FLUAD QUADRIVALENT INFLUENZA VACCINE FOR ADULTS PRSY

F


Drug Name DrugTier

Requirements/Limits

FLUARIX QUADRIVALENT 2018-2019 SUSY F






FLUBLOK QUADRIVALENT 2018-2019 SOSY

F



F



F


FLUCELVAX QUADRIVALENT 2018-2019 SUSP

F


FLUCELVAX QUADRIVALENT 2018-2019 SUSY

F



114

Drug Name DrugTier

Requirements/Limits


F



F



F



F


FLULAVAL QUADRIVALENT 2018-2019 SUSP

F


FLULAVAL QUADRIVALENT 2018-2019 SUSY

F


FLULAVAL QUADRIVALENT 2019-2020 SUSP

F



F


Drug Name DrugTier

Requirements/Limits


F


FLUZONE HIGH-DOSE PF 2020-2021 SUSY F

Limit 1 dose per season age65 and up;QL(0.7 mlper fill retail);AL(At least 65yrs old)

FLUZONE QUADRIVALENT 2018-2019 SUSP

F


FLUZONE QUADRIVALENT 2018-2019 SUSY

F



F



F



F



F



115

Drug Name DrugTier

Requirements/Limits

GARDASIL 9 SUSP F


GARDASIL 9 SUSY F


HAVRIX SUSP F


HEPLISAV-B SOLN F


HEPLISAV-B SOSY F


M-M-R II SOLR F


RECOMBIVAX HB SUSP F


SHINGRIX SUSR F

Limit 2 doses perlifetime;QL(1ea per fillretail); AL(Atleast 50 yrsold)

Drug Name DrugTier

Requirements/Limits

TWINRIX SUSP F


TWINRIX SUSY F


VAQTA SUSP F


VARIVAX INJ F


VAGINAL AND RELATED PRODUCTS

Vaginal Anti-infectives

AVC CREA F

CLEOCIN CREA VA 2 % (clindamycin phosphatevaginal)

NF

CLEOCIN SUPP VA 100 MG F

clindamycin phosphatevaginal crea F

clotrimazole vaginal crea F

GYNE-LOTRIMIN 3 CREA (clotrimazole vaginal) NF

GYNE-LOTRIMIN CREA (clotrimazole vaginal) NF

METROGEL-VAGINAL GEL (metronidazole vaginal)

NF

metronidazole vaginal gel0.75 % F


116

Drug Name DrugTier

Requirements/Limits

miconazole nitrate vaginal crea F

miconazole nitrate vaginalkit F

miconazole nitrate vaginal supp F

MONISTAT 1 COMBO PACK KIT (miconazole nitrate vaginal)

NF

MONISTAT 1 DAY OR NIGHT COMBO PACK KIT (miconazole nitrate vaginal)

NF

MONISTAT 3 COMBINATION PACK KIT (miconazole nitrate vaginal)

NF

MONISTAT 3 CREA (miconazole nitrate vaginal) NF

MONISTAT 7 COMBINATION PACK KIT F

MONISTAT 7 SIMPLY CURE CREA (miconazole nitrate vaginal)

NF

terconazole vaginal crea0.4 %, 0.8 % F

Vaginal Estrogens ESTRACE CREA (estradiol vaginal) NF

estradiol vaginal crea 0.1mg/gm F

estradiol vaginal tabs 10 mcg F QL(58 ea per

168 days retail)

ESTRING RING F

FEMRING RING 0.1 MG/24HR F PA

PREMARIN CREA VA 0.625 MG/GM F PA

VAGIFEM TABS (estradiol vaginal) NF QL(58 ea per

168 days retail) VASOPRESSORS - Drugs to Treat Heart andCirculation Conditions

Anaphylaxis Therapy Agents epinephrine (anaphylaxis)soaj 0.15 mg/0.3ml F QL(0.067 ea

daily)

Drug Name DrugTier

Requirements/Limits

epinephrine (anaphylaxis)soaj 0.15 mg/0.3ml, 0.3mg/0.3ml


Vasopressors

midodrine hcl tabs F QL(3 ea daily)

VITAMINS

Oil Soluble Vitamins

BABY DDROPS LIQD F

cholecalciferol caps or 25mcg, 50 mcg, 1.25 mg, 125mcg, 250 mcg, 400 unit,1000 unit, 2000 unit, 4000unit, 5000 unit, 10000 unit,50000 unit

F

cholecalciferol liqd or 400unit/ml F

cholecalciferol tabs or 25 mcg, 50 mcg, 400 unit,1000 unit, 2000 unit, 5000unit, 50000 unit

F

D-VI-SOL LIQD (cholecalciferol) NF

DECARA CAPS F

DRISDOL CAPS (ergocalciferol) NF

ergocalciferol caps F

KEY-E CHEW OR F AL(At least 6yrs old)

MAXIMUM D3 CAPS F

MEPHYTON TABS (phytonadione) NF

NATURAL VITAMIN E TABS F

OPTIMAL D3 M CAPS F

phytonadione tabs or 5 mg F

THERA-D 4000 TABS F

VITAMIN D2 TABS F


117

Drug Name DrugTier

Requirements/Limits

VITAMIN D3 TABS OR 3000 UNIT, 10000 UNIT F

vitamin e caps or 45 mg,100 unit, 200 unit, 400 unit,600 unit, 1000 unit

F

VITAMIN E CHEW OR 400 UNIT F AL(At least 6

yrs old) VITAMIN E TABS OR 100 UNIT, 200 UNIT F

vitamin e tabs or 400 unit F

Water Soluble Vitamins

B-1 TABS F

niacin cpcr F

niacin tabs F

niacin tbcr F

niacinamide tabs F

niacinamide tbcr F

pyridoxine hcl tabs F

SLO-NIACIN TBCR (niacin) NF

thiamine hcl tabs F


118

Index 1ML TB SYRINGE/25G X5/8"/LUER SLIP TIP 75 1ML TB SYRINGE/27G X1/2"/LUER SLIP TIP 75 1ML TUBERCULIN SYRINGE DETACHABLE NEEDLE SLIP TIP 25GX5/8" 75 1ML VANISHPOINT TUBERCULIN SYRINGE 25GX5/8" 75 1ML VANISHPOINT TUBERCULIN SYRINGE 27GX1/2" 75 2-3ML SYRINGE/LUER LOCKTIP 75 2-3ML SYRINGE/LUER SLIP TIP

75 3ML LUER LOCK SAFETY SYRINGES 75 3ML LUER LOCK SAFETY SYRINGES 3ML/22G X 1 1/2"

75 3ML LUER LOCK SAFETY SYRINGES/3ML/21G X 1 1/2"

75 3ML LUER LOCK SAFETY SYRINGES/3ML/22G X 1" 75 3ML LUER LOCK SAFETY SYRINGES/3ML/23G X 1" 75 3ML LUER LOCK SAFETY SYRINGES/3ML/25G X 1" 75 3ML LUER LOCK SAFETY SYRINGES/3ML/25G X 5/8" 75 3ML LUER-LOK SYRINGE 22GX 1-1/2" 75 3ML LUER-LOK SYRINGE21G X 1-1/2" 76 3ML LUER-LOK SYRINGE22G X 1" 76 3ML LUER-LOK SYRINGE25G X 5/8" 76 3ML LUER-LOK TIP SYRINGE25G X 1-1/2" 76 3ML SYRINGE/18G X 1-1/2"/LUER LOCK TIP 76 3ML SYRINGE/20G X 1"/LUERLOCK TIP 76 3ML SYRINGE/20G X 1"/LUERSLIP TIP 76 3ML SYRINGE/21G X 1-1/2"/LUER LOCK TIP 76 3ML SYRINGE/22G 1-1/2"/LUERLOCK TIP 76 3ML SYRINGE/22G X 1"/LUERLOCK TIP 76 3ML SYRINGE/25G X 1"/LUERLOCK TIP 76 3ML SYRINGE/INTERLINKSYRINGE CANNULA 76

3ML SYRINGE/INTERLINKVIAL ACCESS CANNULA 76 3ML SYRINGE/LUER LOCKTIP 76 3ML SYRINGE/LUER LOCKTIP23GX1" 76 3ML SYRINGE/LUER LOCKTIP25G X 1-1/2" 76 3ML SYRINGE/LUER SLIPTIP23GX1" 76 3ML SYRINGE/NEEDLEREGULAR WALL LUER-LOK 25GX5/8" SUB-Q 76 4-WAY SALINE 97 abacavir sulfate 35 abacavir sulfate-lamivudine 35 abacavir sulfate-lamivudine-zidovudine 35 ABILIFY 35 ABILIFY MAINTENA 35 ABREVA 62 ABSORICA 59 acamprosate calcium 107 acarbose 21 ACCOLATE 13 ACCUPRIL 28 ACCURETIC 29 acetaminophen 4 acetaminophen w/ codeine 5 acetaminophen w/ dm 45 acetazolamide 66 acetic acid (otic) 105 ACETYLCYSTEINE 59 acetylcysteine 59 ACNE MEDICATION 10 59 ACNE MEDICATION 5 59 ACTICON 45 ACTIDOGESIC 45 ACTIDOGESIC-DF 45 ACTIDOM DMX 45 ACTIGALL 69 ACTIMMUNE 32 ACTINEL 45 ACTINEL DM 45 ACTINEL PEDIATRIC 45 ACTOPLUS MET 21 ACTOPLUS MET XR 21 ACTOS 22 ACULAR 105

ACULAR LS 104 acyclovir 38 acyclovir sodium 38 acyclovir topical 62 ADACEL 110 ADALAT CC 39 ADCIRCA 40 ADDERALL 1 ADDERALL XR 1 adefovir dipivoxil 37 ADRENALIN 100 ADVAIR HFA 14 ADVIL 2 ADVIL ALLERGY & CONGESTION 45 ADVIL ALLERGY SINUS 45 ADVIL COLD & SINUS 45 ADVIL MIGRAINE 2 ADVIL MULTI-SYMPTOM COLD& FLU 45 ADVIL SINUS CONGESTION &PAIN 45 AEMCOLO 8 AERIVA PORTABLE CONCENTRATOR NEBULIZER ALL IN ONE 86 AEROECLIPSE II BREATH ACTUATED NEBULIZER DISPOSABLE 86 AERONEB GO COMPLETE SYSTEM 86 AERONEB GO CONVENIENCE UNIT 86 AERONEB GO NEBULIZER HANDSET 86 AERONEB GO NEBULIZER HANDSET/CONNECTORCABLE 86 AFINITOR 31 AFINITOR DISPERZ 31 AFLURIA 2018-2019 113 AFLURIA PF 2018-2019 113 AFLURIA QUADRIVALENT 2018-2019 113 AFLURIA QUADRIVALENT 2019-2020 113 AFLURIA QUADRIVALENT 2020-2021 114 AFRIN 100 AFRIN 12 HOUR 100 AFRIN ALL NIGHT NODRIP 100

Index 1

AFRIN CHILDRENS 100 ALBUTEROL SULFATE 14 amantadine hcl 32 AFRIN MENTHOL 97 albuterol sulfate 14 AMARYL 23 AFRIN NASAL SPRAY 100 ALDACTAZIDE 66 AMBI EVEN & CLEAR AFRIN NODRIP EXTRA MOISTURIZING 100 AFRIN NODRIP ORIGINAL 100 AFRIN NODRIP SEVERE CONGESTION 100

ALDACTONE ALDARA ALECENSA alendronate sodium

67 63 31 67

EXFOLIATING WASH AMBI EVEN & CLEAR FOAMINGCLEANSER AMBIEN AMERGE

63

63 72 90

AFRIN NODRIP SINUS 100 ALER-DRYL 25 AMICAR 72 AFRIN PUMP MIST 100 ALEVE 2 AMIKACIN SULFATE 2 AFRIN SINUS 100 ALEVE ARTHRITIS 2 amikacin sulfate 2 AHIST 27 ALEVE-D SINUS & COLD 45 amiloride & AIRDUO RESPICLICK 113/14 14 AIRDUO RESPICLICK 232/14 14 AIRDUO RESPICLICK 55/1414 AIRIAL COMPACT COMPRESSORNEBULIZER SYSTEM 86 AIRIAL COMPACT MINI NEBULIZER 86 AIRIAL COMPARTMENT COMPRESSOR PEDIATRIC NEBULIZER 86 AIRIAL PEDIATRIC NEBULIZER/BUILDINGBLOCK 86 AIRIAL PEDIATRIC NEBULIZER/DUCK 86 AIRIAL PEDIATRIC NEBULIZER/FIRE ENGINE 87 AIRIAL PEDIATRIC NEBULIZER/PANDA 87 AIRIAL PEDIATRIC NEBULIZER/PENELOPEPANDA 87 AIRIAL PEDIATRIC NEBULIZER/PENGUIN 87 AIRIAL VOYAGER PORTABLE

ALEVE-D SINUS & HEADACHE 45 ALFERON N 32 alfuzosin hcl 70 ALINIA 9 ALKA-SELTZER PLUS COLD 45 ALKA-SELTZER PLUS COLD &COUGH 45 ALKA-SELTZER PLUS COLD &COUGH FORMULA 45 ALKA-SELTZER PLUS SEVERECOLD & FLU NIGHT 45 ALKA-SELTZER PLUS SINUS FORMULA 45 ALKALOL 97 ALL-IN-ONE NEBULIZER SYSTEM 87 ALLEGRA ALLERGY 26 ALLEGRA ALLERGY CHILDRENS 26 ALLEGRA-D 12 HOUR ALLERGY & CONGESTION 46 ALLEGRA-D 24 HOUR ALLERGY &

hydrochlorothiazide 67 amiloride hcl 67 aminocaproic acid 72 AMINOPHYLLINE 15 aminophylline 15 AMINOPHYLLINE ANHYDROUS 15 amiodarone hcl 13 AMITIZA 69 amitriptyline hcl 21 amlodipine besylate 39 amlodipine besylate-benazeprilhcl 29 amoxapine 21 amoxicillin 105 amoxicillin & potclavulanate 106 AMOXICILLIN TRIHYDRATE 106 amphetamine-dextroamphetamine 1 ampicillin 106 ampicillin & sulbactamsodium 106 ampicillin sodium 106

NEBULIZER 87 CONGESTION 46 ANAFRANIL 21 AIRS DISPOSABLE NEBULIZER AJOVY ALA-HIST IR ALA-HIST PE ALAHIST CF ALAHIST DM albendazole ALBENZA ALBUSTIX albuterol sulfate ALBUTEROL SULFATE albuterol sulfate

87 90 25 45 45 45

8 8

66 14 14 14

ALLERGY SYRINGE/1ML/27GX 1/2" 76 allopurinol 71 ALORA 68 alprazolam 12 ALPRAZOLAM INTENSOL11 ALTACE 28 alum & mag hydrox-simethicone 7 ALUMINUM HYDROXIDE 8 ALVESCO 13 ALZAIR ALLERGY BLOCKER NASAL SPRAY 97

ANALPRAM HC ANALPRAM HC SINGLES ANALPRAM-HC ANAPROX DS ANASPAZ anastrozole ANDRODERM ANDROGEL ANDROGEL PUMP ANORO ELLIPTA ANTABUSE ANTACID

7 7 7 2

111 31

7 7 7

14 107

8

Index 2

ANTACID SOFT CHEWS 8 atazanavir sulfate 36 AZOPT 105 ANUSOL-HC 7 atenolol 39 aztreonam 10 ANZEMET 24 atenolol & chlorthalidone 29 AZULFIDINE 70 AP-HIST DM 46 ATIVAN 12 AZULFIDINE EN-TABS 70 apraclonidine hcl 103 atomoxetine hcl 1 B-1 118 aprepitant 24 atorvastatin calcium 28 B-12 71 APTENSIO XR 1 atovaquone 9 b-complex w/ c & folic acid 94 APTIVUS 36 atovaquone-proguanil hcl 30 BABY DDROPS 117 AQUANAZ 46 ATRAC-TAIN 63 BACIGUENT 60 AQUORAL 94 ATRIPLA 36 bacitracin 8 ARAKODA 30 ATROPINE SULFATE 103 bacitracin (ophthalmic) 103 ARALAST NP 109 ATROVENT HFA 13 bacitracin (topical) 60 ARAVA 4 ATUSS DA 46 bacitracin zinc 60 ARCAPTA NEOHALER 14 AUGMENTIN 106 bacitracin-poly-neomycin-hc

104 ARICEPT 107 AUGMENTIN ES-600 106 bacitracin-polymyxin b 60 ARIMIDEX 31 AUGMENTIN XR 106 bacitracin-polymyxin b

aripiprazole 35 AURA PORTANEB 87 (ophth) 103 ARISTADA 35 AVALIDE 29 baclofen 97 ARISTADA INITIO 35 AVAPRO 28 BACTRIM 9 ARMONAIR RESPICLICK AVC 116 BACTRIM DS 9 113 13 AVELOX 69 BACTROBAN 60 ARMONAIR RESPICLICK 232 13 AVIDOXY DK 109 BACTROBAN NASAL 99 ARMONAIR RESPICLICK AVODART 70 BALAMINE DM 46 55 13 AVONEX 107 balsalazide disodium 70 ARMOUR THYROID 110 AVONEX PEN 107 BANZEL 17 ARNUITY ELLIPTA 14 AVYCAZ 40 BARACLUDE 37,38 ARTHROTEC 50 2 AXILLARY BLOCK NEEDLE BAXDELA 69 ARTHROTEC 75 2 BLOCK BEVEL 25GX1" 76 BD 1ML TUBERCULIN artificial tear ointment 102 AYGESTIN 107 SYRINGE/SAFETYGLIDE TBartificial tear solution 102 AYR NASAL DROPS 97 NEEDLE 27GX1/2" 76

AYR NASAL MIST ALLERGY BD 1ML TUBERCULIN ARTIFICIAL TEARS 102 &SINUS HYPERTONIC SYRINGEDETACHABLE ASACOL HD 70 SALINE 97 NEEDLE SLIP TIP 27GX1/2"76

ASMANEX HFA 14 BD 1ML TUBERCULIN AYR SALINE NASAL GEL 98 ASMANEX TWISTHALER 120 SYRINGESLIP-TIP 76 AYR SALINE NASAL NETI METERED DOSES 14 BD 3ML LUER-LOCK RINSE KIT 98 ASMANEX TWISTHALER 14 SYRINGE18G X 1 1/2" 76 AYR SALINE NASAL RINSE METERED DOSES 14 BD 3ML LUER-LOK SYRINGE KIT 98 ASMANEX TWISTHALER 30 18G X 1 1/2" 76 AYR SALINE NASAL RINSE METERED DOSES 14 BD 3ML LUER-LOK KIT REFILL 98 ASMANEX TWISTHALER 60 SYRINGE/20G X 1" 76 AZACTAM 10 METERED DOSES 14 BD 3ML LUER-LOK

AZACTAMIN ISO-OSMOTIC ASMANEX TWISTHALER 7 SYRINGE/21G X 1-1/2" 76 DEXTROSE 10 METERED DOSES 14 BD 3ML LUER-LOK

aspirin 4 azathioprine 93 SYRINGE/23G X 1" 76 azelastine hcl 99 BD 3ML LUER-LOK ASPIRIN 4 SYRINGE/23G X 1-1/2" 76 azelastine hcl (ophth) 105 aspirin 4 BD 3ML LUER-LOK azelastine hcl-fluticasone aspirin buffered (cal carb-mag SYRINGE/25G X 1" 76 propionate 97 carb-mag oxide) 4 BD 3ML SYRINGE LUER-LOK azithromycin 74 ASTAGRAF XL 93 TIP 76

Index 3

BD 3ML SYRINGE SLIP TIP 76 BD HYPODERMIC NEEDLE BD SYRINGE LUER-BD 3ML REGULAR BEVEL THIN WALL LOK/1ML 78 SYRINGE/SAFETYGLIDE 18G X 1-1/2" 77 BD SYRINGE SLIP TIP 1ML 78

BD HYPODERMIC NEEDLE SHIELDING IM NEEDLE 22GX1- BECONASE AQ 99 SHORT BEVEL 18G X 1-1/2" 76 BELEODAQ 31 BD 3ML 1/2" 77 BD HYPODERMIC NEEDLE BENADRYL ALLERGY 25 SYRINGE/SAFETYGLIDESHORT BEVEL 22GX1- BENADRYL ALLERGY SHIELDING IM NEEDLE 1/2" 77 CHILDRENS 25 23GX1" 76 BD HYPODERMIC NEEDLES BENADRYL ALLERGY PLUS BD 3ML

SYRINGE/SAFETYGLIDE 18GX1" 77 CONGESTION CHILDRENS 46 BD HYPODERMIC NEEDLES benazepril &SHIELDING NEEDLE 18GX1.5" 77 hydrochlorothiazide 29 25GX5/8" 77

BD BD HYPODERMIC NEEDLES benazepril hcl 28 19GX1" 77 ALLERGY/SYRINGE/NEEDLE/1 BENTLEY THE BEAR 87 BD HYPODERMIC NEEDLES ML/28G X 1/2" 77 BENZAC AC WASH 59 22GX1.5" 77 BD BLUNT FILL NEEDLE 77 BD HYPODERMIC NEEDLES BENZEDREX INHALER 100 BD DISPOSABLE NEEDLE 25GX1.5" 77 BENZEFOAM 59 REGULAR BEVEL 25GX1" 77 BD INTEGRA 3ML SYRINGE

BD DISPOSABLE NEEDLE BENZEFOAM ULTRA 59 W/RETRACTING NEEDLE/21GREGULAR BEVEL THIN WALL X 1-1/2" 77 BENZODOX 30 KIT 109 18G X 1" 77 BD INTEGRA 3ML SYRINGE BENZODOX 60 KIT 109 BD ECLIPSE 18G X 1-1/2" 77 W/RETRACTING NEEDLE/25G benzonatate 44 BD ECLIPSE NEEDLE 25G X X 1" 77 1.5" 77 BD INTEGRA NEEDLE/25G benzoyl peroxide 59 BD ECLIPSE NEEDLE X5/8" 77 BENZOYL PEROXIDE 25GX1" 77 BD INTEGRA CLEANSER 59 BD ECLIPSE NEEDLE 27G X SYRINGE/3ML/22G X 1.5" 77 benztropine mesylate 32 1/2" 77 BD INTEGRA BETAGAN 102 BD ECLIPSE NEEDLE/22G X 1- SYRINGE/3ML/23G X 1" 78 betamethasone dipropionate1/2" 77 BD INTEGRA (topical) 62 BD ECLIPSE NEEDLE/25G SYRINGE/3ML/25G X 5/8 78 betamethasone dipropionateX5/8" 77 BD NEEDLE/18G 1-1/2" 78 augmented 62 BD ECLIPSE NEEDLE/27G X BD NEEDLE/19G X 1" 78 betamethasone valerate 62 1/2" 77 BD ECLIPSE SYRINGE LUER- BD NEEDLE/22G X 1-1/2" 78 BETAPACE 39 LOK/3ML/22G X 1" 77 BD NEEDLE/25G X 5/8" 78 BETAPACE AF 39 BD ECLIPSE SYRINGE LUER- BD NEEDLE/27G X 1/2" 78 BETASAL 63 LOK/3ML/25G X 1" 77 BD PLASTIPAK SYRINGES BD ECLIPSE BETASERON 107 ALLERGY 28GX1/2 78 SYRINGE/3ML/23G X 1" 77 betaxolol hcl (ophth) 102 BD SAFETYGLIDE 27G X BD ECLIPSE 5/8"NEEDLE 78 bethanechol chloride 113 SYRINGE/3ML/25GX5/8" 77 BD SAFETYGLIDE ALLERGY BETHKIS 2 BD ECLIPSE SYRINGE/LUER- SYRINGE/1ML/27GX1/2" 78 LOK/3ML/22G X 1-1/2" 77 BETIMOL 102 BD SAFETYGLIDE BD HYPODERMIC NEEDLE BETOPTIC-S 102 HYPODERMICNEEDLE 18G X REGULAR BEVEL 18G X 1- 1-1/2" 78 BEVESPI AEROSPHERE 14 1/2" 77 BD SAFETYGLIDE BD HYPODERMIC NEEDLE bexarotene 32

HYPODERMICNEEDLE REGULAR BEVEL 22GX1- BEXSERO 113 25GX5/8" 78 1/2" 77 BD SAFETYGLIDE BICILLIN C-R 106 BD HYPODERMIC NEEDLE INJECTIONNEEDLE 22GX1- BICILLIN L-A 106 REGULAR BEVEL 25GX1" 77 1/2" 78 BD HYPODERMIC NEEDLE BIKTARVY 36 BD SAFETYGLIDE REGULAR BEVEL BILTRICIDE 8 INJECTIONNEEDLE 25GX5/8" 77 25GX1" 78 BIOBRON SF 46 BD SAFETYGLIDE SYRINGE BIODESP DM 46 3ML/25GX1" 78

Index 4

BIONATUSS DXP 46 buprenorphine hcl-naloxone hcl CAPCOF 46 dihydrate 6 BIONEL 46 CAPHOSOL 94 bupropion hcl 19 BIONEL PEDIATRIC 46 CAPMIST DM 46 bupropion hcl (smoking

BIOSPEC DMX 46 CAPRELSA 31 deterrent) 108 BIOTENE DRY MOUTH buspirone hcl 11 CAPRON DM 46 MOISTURIZING SPRAY 94 butalbital-acetaminophen- CAPRON DMT 46 bisacodyl 74 caffeine 4 CAPTAIN EAGLE 87 bismuth subsalicylate 23 butalbital-acetaminophen- captopril 28 bisoprolol & caffeine w/ codeine 5

captopril &hydrochlorothiazide 29 butalbital-aspirin-caffeine 4 hydrochlorothiazide 29 bisoprolol fumarate 39 butalbital-aspirin-caffeine CARAC 61 w/cod 5 BIVIGAM 105 BUTALBITAL/ASPIRIN/CAFFEI CARAFATE 112 BLEPH-10 103 NE 4 carbamazepine 17 BLEPHAMIDE 104 butenafine hcl 60 carbamide peroxide (otic) 105 BLEPHAMIDE S.O.P. 104 BUTRANS 6 CARBAPHEN 12 46 BONE ESSENTIALS 92 BYDUREON 22 CARBAPHEN 12 PED 46 BONIVA 67 BYDUREON PEN 22 CARBAPHEN CH 46 BOOSTRIX 110 BYETTA 22 CARBAPHEN PED CH 46 BPROTECTED PEDIA POLY- CAFERGOT 90 CARBATROL 17 VITE/IRON 95 CAL-CITRATE 91 BREO ELLIPTA 14 carbidopa-levodopa 32

CAL-LAC 91 BRILINTA 71 carbinoxamine maleate 26 CAL-MAG-K CHELA MAX 92 CARBINOXAMINE brimonidine tartrate 103 CAL-MINT 91 MALEATE 26 BROHIST D 46 carboxymethylcellulose sodiumCALAMINE 65 BROMHEXINE HCL 58 (ophth) 102 CALAN 39 bromocriptine mesylate 32 CARDIZEM 39 CALAN SR 39 BROMPHENIRAMINE 25 CARDIZEM CD 39

brompheniramine & CALCI-CHEW 91 CARDURA 29 phenyleph 46 calcitonin (salmon) 67 CARNITOR 68 brompheniramine & calcitriol 68 CARNITOR SF 68 pseudoeph 46 CALCIUM 91 BROMPHENIRAMINE carteolol hcl (ophth) 102 MALEATE 25 calcium 91 carvedilol 38 brompheniramine tannate 25 CALCIUM & VITAMIN D3 CATAPRES 29 BONEHEALTH 92 BRONKAID 46 CATAPRES-TTS-1 29 CALCIUM ACETATE 91 BRONKIDS 46 calcium acetate (phosphate CATAPRES-TTS-2 29 BRONTUSS DX 46 binder) 70 CATAPRES-TTS-3 29 BROTAPP DM 46 CALCIUM CARBONATE 8,91 cefaclor 41 BROVANA 14 calcium carbonate 91 CEFACLOR ER 41 BUCKLEYS COUGH 44 calcium carbonate (antacid) 8 cefadroxil 40 budesonide 43 calcium carbonate-vitamin CEFAZOLIN 40 d 91 budesonide (inhalation) 14 CEFAZOLIN SODIUM 40 CALCIUM CITRATE 91 budesonide (nasal) 99 cefazolin sodium 40 calcium citrate 91 budesonide-formoterol fumarate CEFAZOLIN SODIUM 40 dihydrate 14 calcium citrate-vitamin d 91

cefazolin sodium 40 BUFFERIN 4 CALCIUM GLUCONATE 91 CEFAZOLIN SODIUM 40 bumetanide 67 CALCIUM LACTATE 91 CEFAZOLIN BUMEX 67 CALCIUM PLUS VITAMIN SODIUM/DEXTROSE 40 D 91 buprenorphine hcl 6

Index 5

CEFAZOLIN SODIUM/SODIUMCHLORIDE 40 CEFAZOLIN/SODIUMCHLORIDE 41 cefdinir 41 cefditoren pivoxil 41 CEFEPIME 42 cefepime hcl 42 CEFEPIME/DEXTROSE 42 cefixime 41 CEFOTAN 41 cefotaxime sodium 41 cefotetan disodium 41 CEFOTETAN/DEXTROSE 41 cefoxitin sodium 41 CEFOXITIN SODIUM 41 cefpodoxime proxetil 41 cefprozil 41 ceftazidime 41 CEFTAZIDIME/DEXTROSE 41 CEFTRI-IM 41 ceftriaxone sodium 41 CEFTRIAXONE SODIUM 41 ceftriaxone sodium 41 ceftriaxone sodium in dextrose 41 CEFTRIAXONE/DEXTROSE

41 CEFTRISOL PLUS 41 cefuroxime axetil 41 cefuroxime sodium 41 CELEBREX 2 celecoxib 2 CELEXA 19 CELLCEPT 93 CENTANY 60 cephalexin 41 CERALYTE 70 91 CERASPORT 91 CERASPORT EX1 91 CERDELGA 71 CEREZYME 71 cetirizine hcl 26 cetirizine-pseudoephedrine 46 CHANTIX 108 CHANTIX CONTINUING MONTHPAK 108 CHANTIX STARTING MONTH PAK 108

CHELATED CALCIUM 91 CHELATED POTASSIUM 93 CHEMSTRIP MICRAL 66 CHEMSTRIP-K 66 CHERACOL PLUS 46 CHERACOL-D COUGH 46 CHILDRENS ADVIL 2 CHILDRENS MOTRIN 2 CHLO HIST 46 CHLO TUSS 46 CHLOPHED 46 CHLOR-TRIMETON 25 CHLOR-TRIMETON ALLERGY 25 chloramphenicol sodiumsuccinate 9 chlordiazepoxide hcl 12 chlorhexidine gluconate(mouth-throat) 94 CHLOROQUINE PHOSPHATE 30 chloroquine phosphate 30 chlorothiazide 67 chlorpheniramine &phenylephrine 46 chlorpheniramine &pseudoeph 46 CHLORPHENIRAMINE MALEATE 25 chlorpheniramine maleate 25 chlorpheniramine-acetaminophen 46 chlorpheniramine-dm 46 chlorpheniramine-phenylephrine-acetaminophen

47 chlorpheniramine-phenylephrine-asa 47 chlorpromazine hcl 35 chlorthalidone 67 cholecalciferol 117 cholestyramine 27 cholestyramine light 27 ciclopirox 60 ciclopirox olamine 60 cidofovir 37 cilostazol 71 CILOXAN 103 cinacalcet hcl 68 CIPRO 69 CIPRO I.V.-IN D5W 69

CIPRODEX 105 ciprofloxacin 69 ciprofloxacin hcl 69 ciprofloxacin hcl (ophth) 103 ciprofloxacin hcl (otic) 105 ciprofloxacin in d5w 69 ciprofloxacin-ciprofloxacinhcl 69 citalopram hydrobromide 19 CLAFORAN 41 CLARINEX 26 CLARINEX-D 12 HOUR 47 clarithromycin 74 CLARITIN 26 CLARITIN ALLERGY CHILDRENS 26 CLARITIN CHILDRENS 26 CLARITIN REDITABS 26 CLARITIN-D 12 HOUR 47 CLARITIN-D 24 HOUR 47 CLASSIC PRENATAL 95 CLEAN & CLEAR ACNE TRIPLECLEAR BUBBLE FOAM CLEANSER 64 CLEAN & CLEAR ADVANTAGE OIL ABSORBING CLEANSER 64 CLEAN & CLEAR BLACKHEAD ERASER SCRUB 64 CLEAN & CLEAR DEEP CLEANING ASTRINGENT SENSITIVE SKIN 64 CLEAR COUGH PM MULTI-SYMPTOM 47 CLEARASIL DAILY CLEAN GENTLE PREVENTION 64 CLEMASTINE FUMARATE 26 clemastine fumarate 26 CLEOCIN 10,116 CLEOCIN IN D5W 10 CLEOCIN PEDIATRIC GRANULES 10 CLEOCIN PHOSPHATE 10 CLEOCIN-T 59 CLEVER CHOICE NEBULIZER 87 CLEVER CHOICE WHISPER AIRE AEROSOL DELIVERY SYSTEM 87 CLEVER CHOICE WHISPER AIRE PEDIATRIC AEROSOL DELIVERY SYSTEM 87

Index 6

CLEVER CHOICE WHISPER AIRE PEDIATRIC COMPRESSOR NEBULIZER 87 CLIMARA 68 CLIMARA PRO 68 CLIN SINGLE USE KIT 10 CLINDAGEL 59 clindamycin hcl 10 clindamycin palmitatehydrochloride 10 clindamycin phosphate 10 clindamycin phosphate(topical) 59 clindamycin phosphate ind5w 10 clindamycin phosphatevaginal 116 CLINDAMYCIN/SODIUMCHLORIDE 10 CLN ACNE CLEANSER 64 clobazam 16 clobetasol propionate 62 clobetasol propionate emollientbase 62 CLODERM 62 clomipramine hcl 21

COLAMINE 92 COLAZAL 70 colchicine 71 COLCRYS 71 COLD & COUGH DAYTIME/NIGHTIMECHILDRENS 47 COLD & FLU RELIEF NIGHTTIME D 47 COLESTID 27 COLESTID FLAVORED 27 colestipol hcl 27 colistimethate sodium 11 COLY-MYCIN M 11 COLYTE-FLAVOR PACKS73 COMBIVENT RESPIMAT 14 COMBIVIR 36 COMP A-I-R COMPRESSOR NEBULIZER 87 COMP AIR COMPRESSOR NEBULIZER 87 COMP AIR ELITE COMPACT COMPRESSOR/NEBULIZER

87 COMPAIR COMPRESSOR NEBULIZER 87 COMPAIR XL COMPRESSOR

CONEX COLD/ALLERGY 47 CONTAC COLD/FLU DAY &NIGHT 47 CONTAC COLD/FLUDAY/NIGHT 47 CONTAC COLD/FLU MAXIMUMSTRENGTH 47 COPAXONE 107 CORDARONE 13 COREG 38 CORICIDIN HBP COLD & FLU 47 CORICIDIN HBP COUGH & COLD 47 CORICIDIN HBP DAY & NIGHTMULTI-SYMPTOM COLD 47 CORICIDIN HBP FLU 47 CORN & CALLUS REMOVER 64 CORTEF 43 CORTENEMA 7 CORTIFOAM 7 COSOPT 102 COTELLIC 31 COUMADIN 15 COZAAR 28

clonazepam clonidine clonidine hcl clonidine hcl (adhd) clopidogrel bisulfate clorazepate dipotassium clotrimazole clotrimazole (topical) clotrimazole vaginal clotrimazole w/betamethasone clozapine CLOZAPINE ODT CLOZARIL CO-NATAL FA COARTEM COCAINE HYDROCHLORIDE CODAR AR CODITUSSIN AC CODITUSSIN DAC COLACE COLACE CLEAR

16 29 29

1 71 12 94 61

116

61 34 34 34 95 30

99 47 47 47 74 74

NEBULIZER SYSTEM 87 COMPAIR XLT COMPRESSOR NEBULIZER SYSTEM 87 COMPLERA 36 COMPLETENATE 95 COMPMIST COMPRESSOR NEBULIZER 87 COMPOUND W 64 COMPOUND W MAXIMUM STRENGTH 64 COMPRESSOR NEBULIZER 87 COMPRESSOR/NEBULIZER

87 COMTAN 32 COMTREX COLD & COUGH DAY/NIGHT MAXIMUMSTRENGTH 47 COMTREX COLD & COUGH MAXIMUM STRENGTH 47 COMTREX COLD & COUGH NIGHTTIME MAXIMUM STRENGTH 47 COMTREX DEEP CHEST COLD MULTI-SYMPTOM 47 CONCERTA 1

CREO-TERPIN 44 CREON 66 CRIXIVAN 36 cromolyn sodium 13 CROMOLYN SODIUM 13 cromolyn sodium (nasal) 99 cromolyn sodium (ophth) 105 crotamiton 65 CUBICIN 9 CUBICIN RF 9 CUPRIMINE 93 CUVPOSA 111 CVS ANTACID SOFT CHEWS ULTRA STRENGTH 8 CVS CALCIUM CHEWABLES 600PLUS 93 CVS COUGH/CHESTCONGESTION DM CHILDRENS 47 CVS DRY MOUTH SPRAY 94 CVS GLUCOSE 22 CVS GLUCOSE BITS 22 CVS NASAL DECONGESTANT 100

Index 7

CVS NASAL MIST 98 DELSYM COUGH DEXAMETHASONE CHILDRENS 44 INTENSOL 43 CVS NON-DRYING SINUS DELSYM DAY NIGHT dexamethasone sodium PE 47 48

phosphate (ophth) 104 CVS PRENATAL 95 DELTUSS DP 48 dexbrompheniramine-CVS PSORIASIS MEDICATED DEMADEX 67 phenylephrine 48 SHAMPOO PLUS demeclocycline hcl 109 dexchlorpheniramineCONDITIONER 64 DENOREX EXTRA maleate 25 CVS SINUS RELIEF STRENGTH 2-IN-1 64 dexmethylphenidate hcl 1 DAYTIME/NIGHTTIME 47 DEPAKENE 18 dextroamphetamine sulfate 1 CVS SOFT GLUCOSE 22 CVS THERAPEUTIC DEPAKOTE 18 dextromethorphan hbr 44 DANDRUFFMAXIMUM DEPAKOTE ER 18 DEXTROMETHORPHAN STRENGTH 64 HBR 44 DEPAKOTE SPRINKLES 18 CVS TUSSIN DM DAY/NIGHT dextromethorphan hbr 44 DEPO-MEDROL 43 PACK 47 DEXTROMETHORPHAN HBR DEPO-PROVERA cyanocobalamin 71 MONOHYDRATE 44 CONTRACEPTIVE 43 cyclobenzaprine hcl 97 DEPO-SUBQ PROVERA dextromethorphan polistirex 44 CYCLOGYL 103 104 43 dextromethorphan-

acetaminophen-chlorpheniraminecyclopentolate hcl 103 DEPO-TESTOSTERONE 7 cyclosporine 93 DEPRIZINE FUSEPAQ 111 48

dextromethorphan-doxylamine-cyclosporine modified (for DERMA-SMOOTHE/FS acetaminophen 48 microemulsion) 93 BODY 62 dextromethorphan-guaifenesin

DERMA-SMOOTHE/FSCYMBALTA 20 48 SCALP 62 dextromethorphan-cyproheptadine hcl 27 DERMAREST PSORIASIS 64 phenylephrine-acetaminophenCYTOMEL 110 DERMAREST PSORIASIS 48

CYTOTEC 112 MEDICATED SHAMPOO PLUS dextrose (diabetic use) 22 CONDITIONER 64 CYTOVENE 37 DIABETIC TUSSIN COLD & DESCOVY FLU D-VI-SOL 117 36 48 DESGEN DM 48 DIABETIC TUSSIN DALIRESP 13 COLD/FLU 48 desipramine hcl 21 danazol 7 DIABETIC TUSSIN NIGHT TIME DESITIN RAPID RELIEF 65 DANTRIUM 97 COLD/FLU RELIEF 48 desloratadine 26 DIALYSIS SAFETY dantrolene sodium 97 SYRINGES/LOW DEAD SPACEdesmopressin acetate 68 dapsone 10 3ML/22GX1-1/2" 78 desmopressin acetate DAPTACEL 110 DIASTAT ACUDIAL 16 spray 68

DAPTOMYCIN 9 desmopressin acetate spray DIASTAT PEDIATRIC 16 daptomycin 9 refrigerated 68 12 diazepam DAY TIME MULTI-SYMPTOM desogestrel & ethinyl diazepam (anticonvulsant) 16 COLD/FLU RELIEF 48 estradiol 42

desogestrel-ethinyl estradiol diclofenac potassium 2 DAYPRO 2 (biphasic) 42 diclofenac sodium 3 DAYTIME COLD MEDICINE 48 desogestrel-ethinyl estradiol diclofenac sodium (ophth) 105 DAYTRANA 1 (triphasic) 42 diclofenac sodium (topical) 60 DDAVP 68 DETROL 112 diclofenac w/ misoprostol 3 DEBROX 105 DETROL LA 112 dicloxacillin sodium 106 DEX4 FAST ACTING DECARA 117

GLUCOSEGO-POUCH 22 DICOPANOL FUSEPAQ 26 DECONEX DMX 48 DEX4 QUICK DISSOLVE DICOPANOL RAPIDPAQ 26 DECONEX IR 48 GLUCOSE 22 dicyclomine hcl 111 DELSYM 44 dexamethasone 43 didanosine 36 DELSYM CHILDRENS DAY DEXAMETHASONE 13-DAY

NIGHT 48 DOSE PACK 43 DIFICID 75 DIFLUCAN 25

Index 8

diflunisal 4 docusate sodium 74 DURAFLU 49 digoxin 40 dofetilide 13 DURAGESIC 5 DILANTIN 18 DOLOGEN 49 DURATION 12 HOUR 100 DILANTIN INFATABS 18 DOLOGESIC 49 DURATION SPRAY 100 DILANTIN-125 18 DOLOGESIC-DF 49 DURAVENT DM 49 DILATRATE SR 11 DILAUDID 5 diltiazem hcl 39 diltiazem hcl coated beads 39 diltiazem hcl extended release beads 39 dimenhydrinate 24 DIMETAPP COLD & ALLERGY 48 DIMETAPP DM COLD & COUGH 49 DIMETAPP LONG ACTING COUGH PLUS COLD 49 DIMETAPP MULTI-SYMPTOM COLD & FLU 49 DIMETAPP MULTI-SYMPTOM COLD RELIEF CHILDRENS 49 DIOVAN 28 DIOVAN HCT 29

DOMETUSS-DA/CHILDREN49

DOMETUSS-DMX 49 DOMETUSS-NR 49 donepezil hydrochloride 107 doripenem 9 DORYX 109 dorzolamide hcl 105 DORZOLAMIDE HCL 105 dorzolamide hcl-timolol maleate 102 DOUBLE-TUSSIN DM 49 doxazosin mesylate 29 doxepin hcl 21 doxycycline(monohydrate) 109 doxycycline hyclate 109 DOXYCYCLINE

DURAVENT PE 49 dutasteride 70 DYAZIDE 67 DYMISTA 97 DYRENIUM 67 E.E.S. GRANULES 74 EASY AIR COMPRESSOR NEBULIZER 87 EASY GLIDE LUER LOCK 1MLSYRINGE 78 EASY NEB 87 EASY TOUCH ALLERGY TRAY SAFETY SYRINGE/1ML/27G X1/2" 78 EASY TOUCH FLIPLOCK NEEDLES 18GX1" 78 EASY TOUCH FLIPLOCK NEEDLES 18GX1-1/2" 78 EASY TOUCH FLIPLOCK

DIPENTUM 70 HYCLATE 109 NEEDLES 19GX1" 78 diphenhydramine hcl 26 DIPHENHYDRAMINE HCL 26 diphenhydramine hcl 26 diphenhydramine hcl (sleep) 72 diphenhydramine hcl(topical) 61 diphenhydramine-acetaminophen

49 diphenhydramine-phenylephrine

49 diphenhydramine-phenylephrine-acetaminophen 49 diphenoxylate w/ atropine 24 DIPROLENE AF 62 dipyridamole 71 disopyramide phosphate 12 disulfiram 107 DITROPAN XL 112 DIURIL 67 divalproex sodium 18 docosanol 62 DOCTOR MANZANILLA PE SYRUP ANTIHISTAMINE/DECONGESTANT 49

doxycycline hyclate 109 DOXYCYCLINE HYCLATE 109 DOXYCYCLINE HYCLATE DR 109 DOXYLAMINE SUCCINATE 26 doxylamine succinate(sleep) 72 doxylamine-dm 49 doxylamine-phenylephrine 49 doxylamine-phenylephrine-acetaminophen 49 DRAMAMINE 24 DRISDOL 117 DRISTAN SPRAY 100 DRIXORAL COLD/ALLERGY 49 DRIXORAL COUGH & SORE THROAT 49 drospirenone-ethinylestradiol 42 DRYSOL 65 DUAKLIR PRESSAIR 14 DULCOLAX 74 DULERA 14

EASY TOUCH FLIPLOCK NEEDLES 22GX1-1/2" 78 EASY TOUCH FLIPLOCK NEEDLES 25GX1" 78 EASY TOUCH FLIPLOCK NEEDLES 25GX1-1/2" 78 EASY TOUCH FLIPLOCK NEEDLES 25GX5/8" 78 EASY TOUCH FLIPLOCK NEEDLES 27GX1/2" 78 EASY TOUCH FLIPLOCK SAFETTY SYRINGES 3ML/18GX1-1/2" 78 EASY TOUCH FLIPLOCK SAFETY SYRINGE 3ML/22GX1" 78 EASY TOUCH FLIPLOCK SAFETY SYRINGE 3ML/22GX1-1/2" 78 EASY TOUCH FLIPLOCK SAFETY SYRINGE 3ML/23GX1" 78 EASY TOUCH FLIPLOCK SAFETY SYRINGE 3ML/23GX1-1/2" 78 EASY TOUCH FLIPLOCK SAFETY SYRINGE 3ML/25GX1" 78 EASY TOUCH FLIPLOCK

docusate calcium 74 duloxetine hcl 20 SAFETY SYRINGE 3ML/25GX5/8"

Index 9

79

EASY TOUCH FLIPLOCK EASY TOUCH TUBERCULIN EMBEDA 5 SAFETY SYRINGES 3ML/20GX1" EASY TOUCH FLIPLOCK

79 SHEATHLOCK SAFETY SYRINGE 1ML/25GX5/8" 79 EASY TOUCH TUBERCULIN

EMEND EMEND TRIPACK

25 25

SAFETY SYRINGES SHEATHLOCK SAFETY EMGALITY 90 3ML/21GX1-1/2" 79 EASY TOUCH HYPODERMIC NEEDLES 18GX1" 79 EASY TOUCH HYPODERMIC NEEDLES 18GX1-1/2" 79 EASY TOUCH HYPODERMIC NEEDLES 19GX1" 79

SYRINGE 1ML/27GX1/2" 79 EASY TOUCH TUBERCULIN SHEATHLOCK SAFETY SYRINGE 1ML/28GX1/2" 80 EASYPOINT NEEDLE 25G X 1" 80 EASYPOINT NEEDLE 25G X

emtricitabine EMTRIVA enalapril maleate enalapril maleate &hydrochlorothiazide ENBREL

36 36 28

29 4

EASY TOUCH HYPODERMIC NEEDLES 22GX1-1/2" 79 EASY TOUCH HYPODERMIC NEEDLES 25GX1" 79 EASY TOUCH HYPODERMIC NEEDLES 25GX1-1/2" 79 EASY TOUCH HYPODERMIC NEEDLES 25GX5/8" 79 EASY TOUCH HYPODERMIC NEEDLES 27GX1/2" 79 EASY TOUCH SAFETY SYRINGE/3ML/20G X 1" 79 EASY TOUCH SAFETY SYRINGE/3ML/22G X 1" 79 EASY TOUCH SAFETY SYRINGE/3ML/22G X 1-1/2" 79 EASY TOUCH SAFETY

5/8" 80 EASYPOINT NEEDLE 25GX1-1/2" 80 EASYPOINT NEEDLE/18G X1" 80 EASYPOINT NEEDLE/18G X1-1/2" 80 EASYPOINT NEEDLE/22G X1-1/2" 80 EC-NAPROSYN 3 ECOTRIN MAXIMUM STRENGTH 4 ECOTRIN REGULAR STRENGTH 4 ED A-HIST 49 ED A-HIST DM 49

ENBREL MINI 4 ENBREL SURECLICK 4 ENFAMIL ENFALYTE 91 ENGERIX-B 114 enoxaparin sodium 15,16 entacapone 32 entecavir 38 ENTEX T 49 ENTOCORT EC 43 ENTSOL NASAL SPRAY 98 EPANED 28 EPHEDRINE HCL 14 EPHEDRINE SULFATE 14

SYRINGE/3ML/23G X 1" EASY TOUCH SAFETY SYRINGE/3ML/25G X 1" EASY TOUCH SAFETY

79

79

ED BRON GP ED CHLORPED ED CHLORPED D

49 25 49

ephedrine-guaifenesin epinephrine (anaphylaxis) epinephrine hcl (nasal)

49 117 100

SYRINGE/3ML/25G X 5/8" 79 EASY TOUCH SHEATHLOCK SAFETY SYRINGE 3ML/21GX1-1/2" 79 EASY TOUCH SHEATHLOCK SAFETY SYRINGE 3ML/22GX1" 79 EASY TOUCH SHEATHLOCK SAFETY SYRINGE 3ML/22GX1-1/2" 79 EASY TOUCH SHEATHLOCK SAFETY SYRINGE 3ML/23GX1" 79 EASY TOUCH SHEATHLOCK SAFETY SYRINGE 3ML/25GX1" 79 EASY TOUCH SHEATHLOCK SAFETY SYRINGE 3ML/25GX5/8" 79 EASY TOUCH TUBERCULIN FLIPLOCK SAFETY SYRINGE 1ML/27GX1/2" 79 EASY TOUCH TUBERCULIN

EDURANT 36 efavirenz 36 EFFEXOR XR 20 EFLOW SCF ELECTRONIC NEBULIZER SYSTEM 87 EFLOW SCF NEBULIZER HANDSET 87 EFUDEX 62 ELAPRASE 68 ELELYSO 71 ELIGARD 31 ELIMITE 65 ELIQUIS 15 ELIQUIS STARTER PACK 15 ELITE COMPRESSOR NEBULIZER 87 ELITE NEBULIZER SYSTEM 87 ELIXOPHYLLIN 15 ELIXSURE COUGH 44

EPIVIR 36 EPIVIR HBV 38 eplerenone 30 EPZICOM 36 EQ ALLERGY/SINUSHEADACHE 49 EQ SINUS RELIEF MAXIMUM STRENGTH 49 EQL DRY MOUTH ORAL RINSE 94 EQL PRENATAL FORMULA 95 EQUALYTE 92 ergocalciferol 117 ergotamine w/ caffeine 90 erlotinib hcl 31 ERYGEL 59 ERYPED 200 75 ERYPED 400 75 ERYTHROCIN LACTOBIONATE 75

FLIPLOCK SAFETY SYRINGE 1ML/28GX1/2" 79

ELMIRON ELOCON

70 62

ERYTHROMYCIN erythromycin (acne aid)

75 59

Index 10

erythromycin (ophth) 103 febuxostat 71 FLAGYL 8 erythromycin base 75 felbamate 18 FLEBOGAMMA DIF 105 ERYTHROMYCIN FELBATOL 18 flecainide acetate 13 ETHYLSUCCINATE 75 FELDENE 3 FLECTOR 60 erythromycin ethylsuccinate 75 felodipine 39 FLEET ENEMA 73 erythromycin stearate 75 FEMARA 31 FLEET ENEMA SIX PACK 73 escitalopram oxalate 19 FEMIRON 71 FLEET PEDIATRIC 73 ESGIC 4 FEMRING 117 FLOMAX 70 ESTRACE 68 FENOFIBRATE 28 FLONASE ALLERGY estradiol 68 RELIEF 99 fenofibrate 28 estradiol vaginal 117 FLONASE ALLERGY RELIEF

fenofibrate micronized 28 CHILDRENS 99 ESTRING 117 FENOFIBRIC ACID 28 FLONASE SENSIMIST 99 ESTROSTEP FE 42 fenofibric acid 28 FLOVENT DISKUS 14 eszopiclone 72 fenoprofen calcium 3 FLOVENT HFA 14 ethambutol hcl 31 FENSOLVI 68 FLUAD 2018-2019 114 ethosuximide 18 fentanyl 5 FLUAD 2019-2020 114 ethynodiol diacet & ethestrad 42 FER-IN-SOL 71 FLUAD 2020-2021 114 etodolac 3 FERRETTS 71 FLUAD QUADRIVALENT

INFLUENZA VACCINE FOR etonogestrel-ethinyl estradiol43 FERRIMIN 150 71 ADULTS 114 etoposide 32 FERROUS FUMARATE 72 FLUARIX QUADRIVALENT

EURAX 65 ferrous fumarate 72 2018-2019 114 EVAC 73 ferrous gluconate 72 FLUARIX QUADRIVALENT

2019-2020 114 everolimus 31 FERROUS GLUCONATE 72 FLUARIX QUADRIVALENT everolimus FERROUS SULFATE 72 2020-2021 114 (immunosuppressant) 93 ferrous sulfate 72 FLUBLOK QUADRIVALENT EVISTA 67 2018-2019 114 FETROJA 42 EVOTAZ 36 FLUBLOK QUADRIVALENT FEVERALL JUNIOR 2019-2020 114 EX-LAX 74 STRENGTH 4 FLUBLOK QUADRIVALENT EX-LAX MAXIMUM fexofenadine hcl 26,27 2020-2021 114 STRENGTH 74 fexofenadine-pseudoephedrine FLUCELVAX QUADRIVALENT EXACTUSS 49 50 2018-2019 114 EXACTUSS TR 49 FIBRICOR 28 FLUCELVAX QUADRIVALENT EXAPHEN 50 finasteride 70 2019-2020 115

FLUCELVAX QUADRIVALENT EXAPHEN CH 50 FIORICET/CODEINE 5 2020-2021 115 EXAPHEX TR 50 FIORINAL 4 fluconazole 25 EXELDERM 61 FIORINAL/CODEINE #3 5 fludrocortisone acetate 44

FIRST-METRONIDAZOLE EXELON 107 FLULAVAL QUADRIVALENT 100 8 EXTAVIA 107 2018-2019 115 FIRST-METRONIDAZOLE FLULAVAL QUADRIVALENT ezetimibe 28 50 8 2019-2020 115 famciclovir 38 FIRST-VANCOMYCIN 25 9 FLULAVAL QUADRIVALENT famotidine 111 FIRST-VANCOMYCIN 50 9 2020-2021 115 FARESTON 31 FIRVANQ 9 FLUMADINE 38 FARXIGA 23 FISH OIL 101 flunisolide (nasal) 99

FLUNISOLIDE FASLODEX 31 FISH OIL PEARLS 101 ANHYDROUS 14 FATHER JOHNS MEDICINE FISH OIL TRIPLE fluocinonide 62 PLUS 50 STRENGTH 101

FAZACLO 34 FISH OIL ULTRA 101 fluorometholone (ophth) 104

Index 11

fluorouracil (topical) 62 G-TUSICOF 50 GLENMAX PEB 50 fluoxetine hcl 19 G-ZYNCOF 50 GLENMAX PEB DM 50 FLUOXETINE HYDROCHLORIDE fluphenazine decanoate fluphenazine hcl

19 35 35

gabapentin GABITRIL galantaminehydrobromide

17 18

107

GLENTUSS 50 glimepiride 23 glipizide 23 GLUCAGON EMERGENCY

FLURBIPROFEN 3 GAMASTAN 105 KIT 22 flurbiprofen 3 GAMMAGARD LIQUID 105 GLUCOPHAGE 21 flurbiprofen sodium 105 GAMMAGARD S/D IGA LESS GLUCOPHAGE XR 21

THAN 1MCG/ML 105 flutamide 31 GLUCOSE 22 GAMUNEX-C 105 fluticasone propionate 62 GLUCOTROL 23 ganciclovir sodium 37 fluticasone propionate GLUCOTROL XL 23

(nasal) 99 GARDASIL 9 116 glyburide 23 fluticasone-salmeterol 14 GAS-X 69 glyburide micronized 23 fluvoxamine maleate 19 GAS-X EXTRA

glyburide-metformin 21 STRENGTH 69 FLUZONE HIGH-DOSE PF 2020-GCON IR 50 glycopyrrolate 111 2021 115

FLUZONE QUADRIVALENT GELONASAL 98 GLYNASE 23 2018-2019 115 gemfibrozil 28 GLYXAMBI 21 FLUZONE QUADRIVALENT

GENOTROPIN 67 GNP CALAMINE 65 2019-2020 115 FLUZONE QUADRIVALENT GENOTROPIN GNP COLD RELIEF PLUS 50 2020-2021 115 MINIQUICK 67 GNP DAILY PRENATAL 95 FLYP NEBULIZER 87 gentamicin in saline 2 GNP GLUCOSE 22 FML 104 gentamicin sulfate 2 GNP PRENATAL 95 gentamicin sulfateFML FORTE 104 GNP QUICK DISSOLVE (ophth) 103 FML LIQUIFILM 104 GLUCOSE 22 gentamicin sulfate (topical) 60 GOLD BOND PSORIASIS FOCALIN 1 GENTEAL MILD 102 RELIEF MULTI-SYMPTOM 64 FOCALIN XR 1 GENTEAL MILD TO GOLYTELY 73 folic acid 71 MODERATE 102 GONIOVISC 102 FORTAZ 41 GENTEAL SEVERE 102 GOODSENSE PRENATAL FORTEO 67 GENTEAL SEVERE VITAMINS 95

TEARS 102 FORTIFY OPTIMA GOPRELTO 99 PROBIOTIC 23 GENVOYA 36 GRALISE 108 FORTIFY PROBIOTIC GEODON 33 granisetron hcl 24 WOMENSEXTRA GILENYA 107 STRENGTH 23 griseofulvin microsize 25

GILPHEX TR 50 FOSAMAX 67 guaifenesin 58 GILTUSS 50 fosamprenavir calcium 36 GUAIFENESIN 58 GILTUSS ALLERGY & FOSCAVIR 37 guaifenesin 59 SINUS 50

fosinopril sodium 28 GILTUSS COUGH & guaifenesin-codeine 50 fosinopril sodium & COLD 50 guanfacine hcl 29 hydrochlorothiazide 29 GILTUSS COUGH ALLERGY & guanfacine hcl (adhd) 1 FREEZONE 64 SINUS 50

GYNE-LOTRIMIN 116 GILTUSS SINUS & FULPHILA 71 CONGESTION 50 GYNE-LOTRIMIN 3 116 FURADANTIN 112 GILTUSS TR 50 HALDOL 34 furosemide 67 GLASSIA 109 HALDOL DECANOATE 100 34 FUZEON 36 glatiramer acetate 107 HALDOL DECANOATE 50 34 G-DOLOGEN 50 GLEEVEC 31 halobetasol propionate 63 G-P-TUSS DXP 50 GLEN PE 50 haloperidol 34

Index 12

haloperidol decanoate 34 HUBER NEEDLE/STRAIGHT hydrogen peroxide 35 22GX1-1/2" 80 haloperidol lactate 34 hydromorphone hcl 5 HUMALOG 22 HAVRIX 116 HYDROMORPHONE HCL 5 HUMALOG KWIKPEN 22 HEMOCYTE 72 hydromorphone hcl 5 HUMALOG MIX 50/50 heparin (porcine) in sodium 22 hydroxychloroquine sulfate 30 HUMALOG MIX 50/50chloride 16 hydroxyurea 32 KWIKPEN 22 HEPARIN LOCK FLUSH 16 HUMALOG MIX 75/25 22 hydroxyzine hcl 11

heparin sod (porcine) in d5w 16 HUMALOG MIX 75/25 hydroxyzine pamoate 11 heparin sodium (porcine) 16 KWIKPEN 22 hyoscyamine sulfate 111 heparin sodium (porcine) lock HUMIRA 2 HYPER-SAL 59 flush 16 HUMIRA PEDIATRIC CROHNS HEPARIN SODIUM/D5W 16 HYPERSAL 59 DISEASE STARTER PACK 2 HEPARIN HYPODERMIC NEEDLE 18G X HUMIRA PEN 2 SODIUM/DEXTROSE 16 1" 80 HUMIRA PEN-CD/UC/HSHEPARIN SODIUM/NACL HYPODERMIC NEEDLE 18G X STARTER 2 0.45% 16 1-1/2" 80 HUMIRA PEN-PS/UVHEPARIN SODIUM/SODIUM HYPODERMIC NEEDLE 19G X STARTER 2 CHLORIDE 16 1" 80 HEPARIN SODIUM/SODIUM HUMULIN 70/30 22 HYPODERMIC NEEDLE 22GX1-CHLORIDE 0.9% 16 HUMULIN N 22 1/2" 80

HYPODERMIC NEEDLE HEPLISAV-B 116 HUMULIN R 22 25GX1" 80 HEPSERA 38 HUMULIN R U-500 HYPODERMIC NEEDLE 25GX1-(CONCENTRATED) 22 HERBAL EXPEC 59 1/2" 80 HUMULIN R U-500 HERBIOMED DEEP COLD AND HYPODERMIC NEEDLE KWIKPEN 22 FLU NIGHTTIME 50 25GX5/8" 80 hydralazine hcl 30 HERBIOMED FAST ACTING HYPODERMIC NEEDLE

BODY ACHES & SINUS 50 HYDRALYTE 92 27GX1/2" 80 HISTEX 25 HYDRALYTE FREEZER HYPODERMIC NEEDLES

POPS 92 18GX1" 80 HISTEX PD 25 HYDREA 32 HYPODERMIC NEEDLES

HISTEX PDX 25 18GX1-1/2" 80 hydrochlorothiazide 67 HISTEX-AC 50 HYPODERMIC NEEDLES HYDROCODONE 19GX1" 80 HISTEX-DM 50 BITARTRATE/GUAIFENESIN HYPODERMIC NEEDLES HISTEX-PE 50 50 22GX1-1/2" 80 hydrocodone polistirex-HIZENTRA 105 HYPODERMIC NEEDLES chlorpheniramine polistirex 50 25GX1-1/2" 80 HM CALAMINE 65 hydrocodone w/ HYPODERMIC NEEDLES HM FISH OIL 101 homatropine 45 25GX5/8" 80 HM ONE DAILY PRENATAL hydrocodone- HYPODERMIC NEEDLES COMBO 95 acetaminophen 5 27GX1/2" 80 HM PRENATAL 95 hydrocodone-ibuprofen 5 hypromellose (ophth) 102 HOLD 44 hydrocortisone 43 HYVEE ADVANCED ANTACID homatropine hbr 103 hydrocortisone (intrarectal) 7 MAXIMUM STRENGTH 8 HOMENEB WITH hydrocortisone (rectal) 7 HYZAAR 29 SIDESTREAM/DISPOSABLE hydrocortisone (topical) 63 ibandronate sodium 67

87 hydrocortisone acetate ibuprofen 3 HOMENEB WITH (topical) 63 SIDESTREAM/REUSABLE & ICLUSIG 31 hydrocortisone acetate w/DISPOSABLE 87 imatinib mesylate 31 pramoxine 7 HORIZANT 108 hydrocortisone w/acetic IMBRUVICA 31

HUBER NEEDLE/RIGHT acid 105 imipenem-cilastatin 9 ANGLE19G X 1" 80 hydrocortisone-aloe vera 63 imipramine hcl 21 HUBER NEEDLE/RIGHTANGLE22G X 1-1/2" 80 HYDROGEN PEROXIDE 35 imipramine pamoate 21

Index 13

imiquimod 63 IPRATROPIUM BROMIDE KETOSTIX 66 MONOHYDRATE 13 IMITREX 90 ketotifen fumarate (ophth) 105 ipratropium-albuterol 14 IMITREX STATDOSE KEY-E 117

REFILL 90 irbesartan 29 KINDERLYTE 92 IMITREX STATDOSE irbesartan-hydrochlorothiazideKINDERLYTE PREMAX 92 SYSTEM 90 29

IMODIUM A-D 24 IRESSA 32 KITABIS PAK 2 IMPAVIDO 8 ISENTRESS 36 KLARON 60 IMURAN 93 isoniazid 31 KLONOPIN 16 INCRELEX 68 ISONIAZID 31 KOMBIGLYZE XR 21 INCRUSE ELLIPTA 13 isoniazid 31 KONSYL DAILY FIBER 73 indapamide INDERAL LA

67 39

isoproterenol hcl ISOPTO ATROPINE

14 103

KONSYL ORIGINAL FORMULADAILY FIBER KP PRENATAL

73

INDOCIN 3 ISOPTO CARPINE 103 MULTIVITAMINS 95 indomethacin 3 ISOPTO TEARS 102 KPN PRENATAL 95 INFANTS ADVIL 3 ISORDIL TITRADOSE 11 KRINTAFEL 30 INLYTA 32 isosorbide dinitrate 11 labetalol hcl 39 INNOSPIRE DELUXE isosorbide mononitrate 11 LAC-HYDRIN 63 COMPRESSOR NEBULIZER SYSTEM 87 INNOSPIRE ELEGANCE COMPRESSOR NEBULIZER SYSTEM 88 INNOSPIRE ESSENCE COMPRESSOR NEBULIZER SYSTEM 88 INNOSPIRE GO PORTABLE MESH NEBULIZER 88 INNOSPIRE MINI PORTABLE COMPRESSOR

isotretinoin ISTALOL ISUPREL ITCH RELIEF ivermectin JAKAFI JANUMET JANUMET XR JANUVIA

60 102

14 61

8 32 21 21 22

LAC-HYDRIN TWELVE lactic acid (ammoniumlactate) lactulose lactulose (encephalopathy) LAMICTAL LAMICTAL CHEWABLE DISPERSIBLE LAMICTAL ODT LAMICTAL XR

63

63 73 70 17

17 17 17

NEBULIZER 88 JARDIANCE 23 LAMISIL AT 61 INNOSPIRE MINI PORTABLE COMPRESSOR NEBULIZER/BATTERY 88 INSPIRATION COMPRESSOR NEBULIZER SYSTEM 88 INSPIRATION ELITE COMPRESSOR NEBULIZER SYSTEM 88 INSPRA 30 INSTA-GLUCOSE 22 INTELENCE 36 INTRON A 32 INTUNIV 1 INVEGA SUSTENNA 33 INVEGA TRINZA 33 INVIRASE 36 INVOKANA 23 IOPIDINE 103 IPRATROPIUM BROMIDE 13 ipratropium bromide 13 ipratropium bromide (nasal) 99

JENTADUETO JOHNSONS NO MORE RASH K-PHOS NEUTRAL K-TAB KALETRA KARBINAL ER KEFLEX KENALOG-10 KENALOG-40 KEPPRA KEPPRA XR KERALYT ketoconazole (topical) KETONE KETONE TEST STRIPS ketoprofen ketorolac tromethamine ketorolac tromethamine (ophth)

21

65 93 93 36 26 41 43 43 17 17 64 61 66 66

3 3

105

LAMISIL AT JOCK ITCH 61 lamivudine 36 lamivudine (hbv) 38 lamivudine-zidovudine 36 lamotrigine 17 LANOXIN 40 lansoprazole 112 LANTUS 23 LANTUS SOLOSTAR 23 LASIX 67 latanoprost 105 LATUDA 33 LEADER QUICK DISSOLVE GLUCOSE 22 leflunomide 4 LETAIRIS 40 letrozole 31 leucovorin calcium 32 leuprolide acetate 31

Index 14

levalbuterol tartrate 14 LITHOBID 33 LOTENSIN 28 LEVAQUIN 69 LITTLE COLDS COUGH LOTENSIN HCT 29

FORMULA 45 LEVBID 111 LOTREL 29 LITTLE COLDS LEVEMIR 23 LOTRIMIN AF 61 DECONGESTANTFORMULA LEVEMIR FLEXTOUCH 23 100 LOTRIMIN AF JOCK ITCH 61

LITTLE NOSES levetiracetam 17 LOTRIMIN ANTIFUNGAL 61 DECONGESTANTNOSE levobunolol hcl 102 LOTRIMIN ULTRA 61 DROPS 100 levocarnitine (metabolic LITTLE NOSES LOTRISONE 61

modifiers) 68 MOISTURIZINGNASAL lovastatin 28 levocetirizine dihydrochloride27 GEL 98 LOVENOX 16 levofloxacin 69 LITTLE NOSES STERILE loxapine succinate 34 SALINE NASAL MIST 98 levofloxacin (ophth) 103 LUMINEB II PISTON LITTLE REMEDIES BABY levofloxacin in d5w 69 NEBULIZER 88 STERILE SALINE MIST FOR levonorgestrel & eth NOSES 98 LUNESTA 72 estradiol 42 LITTLE REMEDIES FOR LUPRON DEPOT (1-levonorgestrel (emergency COLDSMULTI SYMPTOM 50 MONTH) 31 oc) 43 LITTLE REMEDIES FOR LUPRON DEPOT (3-levonorgestrel-eth estradiol NOSES 98 MONTH) 31 (triphasic) 42 LMX 4 65 LUPRON DEPOT (4-levonorgestrel-ethinyl estradiol MONTH) 31 LODINE 3 (91-day) 42 LUPRON DEPOT (6-levonorgestrel-ethinyl estradiol LODRANE D 50 MONTH) 31 (continuous) 42 LOESTRIN 1.5/30-21 42 LUZU 61 levothyroxine sodium 110 LOESTRIN 1/20-21 42 LYCELLE 65 LEVSIN 111 LOESTRIN FE 1.5/30 42 LYRICA 17 LEVSIN/SL 111 LOESTRIN FE 1/20 42 M-CLEAR WC 51 LEXAPRO 20 LOHIST-D 50 M-END DMX 51 LEXIVA 36 LOHIST-DM 50 M-END PE 51 LICEMD 65 LOMOTIL 24 M-M-R II 116 lidocaine 65 LONHALA MAGNAIR REFILL M-NATAL PLUS 95 lidocaine hcl 64,65 KIT 13 M-VIT 95 LONHALA MAGNAIR lidocaine hcl (local anesth.) 74 STARTER KIT 13 MAALOX 8 lidocaine hcl (mouth-throat) 94 loperamide hcl 24 MABIS COMPXP LIDOCAINE COMPRESSOR LOPID 28 HYDROCHLORIDE 74 NEBULIZER 88 lidocaine-prilocaine 65 lopinavir-ritonavir 36 MABIS COSMOCOMP LIDODERM 65 LOPRESSOR 39 NEBULIZER 88 LINCOCIN 10 LOPRESSOR HCT 29 MACROBID 112

lincomycin hcl 10 LOPROX 61 MACRODANTIN 112

lindane 65 loratadine 27 MAG-200 92 loratadine & MAGELLAN TUBERCULIN linezolid 10 pseudoephedrine 51 SAFETY SYRINGE/1ML/27G Xlinezolid in sodium chloride 10 lorazepam 12 1/2" 80

LINZESS 70 MAGELLAN TUBERCULIN LORTUSS DM 51 liothyronine sodium 110 SAFETY SYRINGE/1ML/28G X

LORTUSS EX 51 1/2" 80 LIPITOR 28 LORTUSS LQ 51 MAGNESIUM 92 lisinopril 28 losartan potassium 29 magnesium citrate 74 lisinopril & losartan potassium &hydrochlorothiazide 29 magnesium hydroxide 74 hydrochlorothiazide 29 LITHIUM 33 magnesium oxide 8 LOSEASONIQUE 42

lithium carbonate 33 MAGNESIUM OXIDE 92

Index 15

magnesium oxide (mgsupplement) MAGOX 400 MAKENA MALARONE maprotiline hcl

92 92

107 30 19

MEPHYTON MEPRON mercaptopurine meropenem MEROPENEM/SODIUMCHLORIDE

117 9

31 9

9

metronidazole in nacl 9 metronidazole vaginal 116 mexiletine hcl 13 MG217 PSORIASIS MULTI-SYMPTOM 64 MICATIN 61

MAR-COF BP 51 MERREM 9 MICONAZOLE NITRATE 61 MAR-COF CG EXPECTORANT 51 MARGO MOO COMPRESSOR NEBULIZER 88 MATULANE 32 MAVYRET 38 MAXALT 90 MAXALT-MLT 90 MAXI-TUSS CD 51 MAXI-TUSS DM 51

mesalamine MESTINON MESTINON TIMESPAN METAMUCIL METAMUCIL ORIGINAL TEXTURE METAPROTERENOL SULFATE metaproterenol sulfate metformin hcl

70 30 30 73

73

14 15 22

miconazole nitrate (topical) 61 miconazole nitrate vaginal 117 MICRO AIR NEBULIZER 88 MICRO PLUS HIGH EFFICIENCY NEBULIZER/REUSABLE 88 MICROAIR VIBRATING MESH NEBULIZER 88 MICROELITE COMPRESSOR NEBULIZER SYSTEM 88 MICROELITE COMPRESSOR

MAXI-TUSS PE 51 methazolamide 66 NEBULIZER SYSTEM WITH MAXI-TUSS PE JR 51 methimazole 110 BATTERY 88

MAXI-TUSS PE MAX 51 methocarbamol 97 MICRONEB 88

MAXICHLOR PEH DM 51 methotrexate sodium 31 MICROZIDE 67

MAXIDEX MAXIFED MAXIMUM D3 MAXIPIME MAXITROL MAXZIDE

104 51

117 42

104 67

methscopolaminebromide methyclothiazide methyldopa methylergonovinemaleate METHYLIN

111 67 29

105 1

midodrine hcl 117 miglustat 71 MILLIPRED 44 MINI COMPRESSOR 88 MINI PLUS REUSABLE HIGH EFFICIENCY NEBULIZER 88 MINIBREEZE ULTRASONIC

MAXZIDE-25 meclizine hcl meclofenamate sodium MEDROL MEDROL DOSEPAK medroxyprogesterone acetate

67 24

3 44 44

107

methylphenidate hcl 1 methylprednisolone 44 methylprednisolone sod succ 44 metipranolol 102 metoclopramide hcl 69 METOCLOPRAMIDE ODT 69

NEBULIZER 88 MINIELITE COMPRESSOR NEBULIZER SYSTEM 88 MINIELITE COMPRESSOR NEBULIZER SYSTEM WITH BATTERY 88 MINIPRESS 29 MINIVELLE 68

medroxyprogesterone acetate(contraceptive) 43 mefenamic acid 3 mefloquine hcl 30 megestrol acetate 31 MEIJER CALAMINE 65

metolazone metoprolol &hydrochlorothiazide metoprolol succinate metoprolol tartrate METROCREAM

67

29 39 39 65

MINOCIN minocycline hcl MINOCYCLINE HCL minocycline hcl MINOCYCLINE HYDROCHLORIDEER

109 109 109 109

110 meloxicam 3 METROGEL-VAGINAL 116 MINOLIRA 110 memantine hcl 107 METROLOTION 65 minoxidil 30 MENACTRA 113 metronidazole 9 MIRALAX 73 MENEST 68 METRONIDAZOLE 9 MIRALAX MIX-IN PAX 73 MENOSTAR 68 metronidazole 9 MIRAPEX 32 MENQUADFI MENVEO meperidine hcl

113 113

5

metronidazole (topical) 65 METRONIDAZOLE BENZOATE/SYRSPEND SFPH4 8

MIRCETTE mirtazapine misoprostol

42 19

112

Index 16

MISTERNEB COMPRESSOR MONOJECT MONOJECT MAGELLAN NEBULIZER SYSTEM 88 HYPO/POLYPROPYLENE SYRINGE/SAFETYMOBIC 3 HUB/18G X 1" 81 NEEDLE/3ML/20G X 1" 81

MONOJECT MONOJECT MAGELLAN MODERIBA 1200 DOSE PACK 38 HYPO/POLYPROPYLENE SYRINGE/SAFETY

HUB/18G X 1-1/2" 81 NEEDLE/3ML/21G X 1-1/2" 81 moexipril hcl 28 MONOJECT MONOJECT MAGELLAN moexipril-hydrochlorothiazide HYPO/POLYPROPYLENE SYRINGE/SAFETY29 HUB/LL/BEVEL/25G X 1- NEEDLE/3ML/22G X 1" 81 MOI-STIR 94 1/2" 81 MONOJECT MAGELLAN mometasone furoate 63 MONOJECT SYRINGE/SAFETYmometasone furoate (nasal) 99 HYPO/POLYPROPYLENE NEEDLE/3ML/22G X 1-1/2" 81 MONISTAT 1 COMBO HUB/LL/INTM BEVEL/25G X MONOJECT MAGELLAN

5/8" 81 SYRINGE/SAFETYPACK 117 MONISTAT 1 DAY OR NIGHT MONOJECT NEEDLE/3ML/23G X 1" 81

HYPO/POLYPROPYLENE MONOJECT MAGELLAN COMBO PACK 117 HUB/LL/REG BEVEL/19G TW SYRINGE/SAFETYMONISTAT 3 117 X 1" 81 NEEDLE/3ML/25G X 1" 81 MONISTAT 3 COMBINATION MONOJECT MONOJECT MAGELLAN PACK 117 HYPO/POLYPROPYLENE SYRINGE/SAFETYMONISTAT 7 COMBINATION HUB/LL/REG BEVEL/25G X NEEDLE/3ML/25G X 5/8" 81 PACK 117 1" 81 MONOJECT PHARMACY MONISTAT 7 SIMPLY MONOJECT TRAY/LUER LOCK/3ML 82 CURE 117 HYPO/POLYPROPYLENE MONOJECT PHARMACY MONISTAT SOOTHING CARE HUB/LL/SHORT BEVEL/18G X TRAY/REG LUER/1ML 82 ITCH RELIEF 63 1" 81 MONOJECT STANDARD MONOJECT 1ML LUER LOCK MONOJECT HYPODERMIC TUBERCULIN SYRINGE/TIP HYPO/POLYPROPYLENE NEEDLE/POLYPROPYLEN/22GCAP 80 HUB/LL/SHORT BEVEL/18G X X1-1/2" 82 MONOJECT 3ML 1-1/2" 81 MONOJECT STANDARD SYRINGE/STANDARD MONOJECT HYPODERMIC HYPODERMIC NEEDLE/21GX1- HYPO/POLYPROPYLENE NEEDLE/POLYPROPYLENE1/2" 80 HUB/LL/SHORT BEVEL/19G HUB/18GX1" 82 MONOJECT BLUNTIP TW X 1" 81 MONOJECT STANDARD SYRINGE/3ML/CANNULA/IV MONOJECT HYPODERMIC ACCESS 80 HYPO/POLYPROPYLENE NEEDLE/POLYPROPYLENEMONOJECT HYPO/ALUMHUB/LL/SHORT BEVEL/22G X HUB/19GX1" 82 HUB/18G X 1-1/2" 80 MONOJECT STANDARD MONOJECT HYPO/ALUM 1-1/2" 81 MONOJECT HYPODERMIC HUB/LUER LOCK/INTMHYPO/POLYPROPYLENE NEEDLE/POLYPROPYLENE/18BEVEL/27G X 1/2" 80

MONOJECT HYPO/ALUM HUB/REG BEVEL/27G X GX1-1/2" 82 1/2" 81 MONOJECT STANDARD HUB/LUER LOCK/REGMONOJECT HYPODERMIC HYPODERMIC BEVEL/18G X 1" 80

MONOJECT HYPO/ALUM NEEDL3 18G X 1" 81 NEEDLE/POLYPROPYLENE/22MONOJECT MAGELLAN GX1-1/2" 82 HUB/LUER LOCK/REGSAFETYNEEDLE 18GX1" 81 MONOJECT STANDARD BEVEL/22G X 1-1/2" 80 MONOJECT MAGELLAN HYPODERMIC MONOJECT HYPO/ALUMSAFETYNEEDLE 18GX1- NEEDLE/POLYPROPYLENE/25HUB/LUER LOCK/REG1/2" 81 GX1" 82 BEVEL/25G X 5/8" 80 MONOJECT MAGELLAN MONOJECT STANDARD MONOJECT HYPO/ALUMSAFETYNEEDLE 19GX1" 81 HYPODERMIC HUB/LUER LOCK/SHORT MONOJECT MAGELLAN NEEDLE/POLYPROPYLENE/25BEVEL/18G X 1" 80 SAFETYNEEDLE 22GX1- GX1-1/2" 82 MONOJECT HYPO/ALUM1/2" 81 MONOJECT STANDARD HUB/LUER LOCK/SHORT MONOJECT MAGELLAN HYPODERMIC BEVEL/18G X 1-1/2" 80 SAFETYNEEDLE 25GX1" 81 NEEDLE/POLYPROPYLENE/25MONOJECT HYPO/ALUM MONOJECT MAGELLAN HUB/LUER LOCK/SPEC GX5/8" 82 SAFETYNEEDLE BEVEL/19G TW X 1" 81 25GX5/8" 81

Index 17

MONOJECT STANDARD HYPODERMIC NEEDLE/POLYPROPYLENE/27GX1/2" 82 MONOJECT SYRINGE PHARMACY TRAY/1ML LUERLOCK 82 MONOJECT SYRINGE/LUERLOCK/3ML 82 MONOJECT SYRINGE/LUERLOCK/3ML/20G X 1" 82 MONOJECT SYRINGE/LUERLOCK/3ML/22G X 1" 82 MONOJECT SYRINGE/LUERLOCK/3ML/22G X 1-1/2" 82 MONOJECT SYRINGE/LUERLOCK/3ML/23G X 1" 82 MONOJECT SYRINGE/LUERLOCK/3ML/25G X 1" 82 MONOJECT SYRINGE/LUERLOCK/3ML/25G X 5/8" 82 MONOJECT SYRINGE/LUER-LOCK TIP/3ML 82 MONOJECT SYRINGE/LUER-LOCK/3ML/21G X 1-1/2" 82 MONOJECT SYRINGE/REGLUER/3ML 82 MONOJECT SYRINGE/REGULARTIP/3ML

82 MONOJECT SYRINGE/STANDARDHYPODERMIC NEEDLE/3ML/20GX1"82 MONOJECT SYRINGE/STANDARDHYPODERMIC NEEDLE/3ML/22GX1"82 MONOJECT SYRINGE/STANDARDHYPODERMIC NEEDLE/3ML/22GX1-1/2"

82 MONOJECT SYRINGE/STANDARDHYPODERMIC NEEDLE/3ML/23GX1"83 MONOJECT SYRINGE/STANDARDHYPODERMIC NEEDLE/3ML/25GX1"83 MONOJECT SYRINGE/STANDARDHYPODERMIC NEEDLE/3ML/25GX5/8"

83 MONOJECT TB SYRINGE-NDL 1ML 27GX1/2" 83 MONOJECT TUBERCULIN SAFETY SYRINGE/1ML/25G X5/8" 83 MONOJECT TUBERCULIN SAFETY SYRINGE/1ML/28G X1/2" 83

MONOJECT TUBERCULIN SYRINGE SOFTPACK 1ML REGULAR LUER TIP 83 MONOJECT TUBERCULIN SYRINGE/1ML/25GX5/8" 83 MONOJECT TUBERCULIN SYRINGE/1ML/28G X 1/2" 83 MONOJECT TUBERCULIN SYRINGE/DETACHNEEDLE/1ML/25G X 5/8" 83 MONOJECT TUBERCULIN SYRINGE/DETACHNEEDLE/1ML/27G X 1/2" 83 MONOJECT TUBERCULIN SYRINGE/PERMNEEDLE/1ML/28G X 1/2" 83 MONOJECT TUBERCULIN SYRINGE/WITHOUTNEEDLE/REG LUER/1ML 83 montelukast sodium 13 MORGIDOX 1X100MG 110 MORGIDOX 1X50MG KIT 110 MORGIDOX 2X100MG 110 morphine sulfate 5 MOSCO CALLUS/CORNREMOVER 64 MOTRIN CHILDRENS 3 MOTRIN INFANTS DROPS 3 MOUTH KOTE 94 MOUTH KOTE REMINT 94 MOXATAG 106 MOXIFLOXACIN HYDROCHLORIDE/SODIUMHYDROCHLORIDE 69 moxifloxacin hcl 69 moxifloxacin hcl (ophth) 103 MOXIFLOXACIN HYDROCHLORIDE 69 MS CONTIN 5 MUCINEX 59 MUCINEX CHILDRENS COLD COUGH & SORE THROAT 51 MUCINEX CHILDRENS MULTI-SYMPTOM COLD 51 MUCINEX CHILDRENS MULTI-SYMPTOM COLD & FEVER 51 MUCINEX CONGESTION & COUGH CHILDRENS 51 MUCINEX COUGH & CONGESTION CHILDRENS 51

MUCINEX COUGH FOR KIDS 51 MUCINEX D 51 MUCINEX D MAXIMUM STRENGTH 51 MUCINEX DM 51 MUCINEX DM MAXIMUM STRENGTH 51 MUCINEX FAST-MAX COLD & SINUS 51 MUCINEX FAST-MAX COLD FLU& SORE THROAT 51 MUCINEX FAST-MAX COLD FLU& SORE THROAT CLEAR & COOL 51 MUCINEX FAST-MAX COLD/FLU 51 MUCINEX FAST-MAX COLD/FLU/SORE THROAT 52 MUCINEX FAST-MAX DAY TIME/NIGHT TIME 52 MUCINEX FAST-MAX DAY/NIGHT 52 MUCINEX FAST-MAX DAY/NIGHT MAXIMUMSTRENGTH 52 MUCINEX FAST-MAX DAY/NITEM/S 52 MUCINEX FAST-MAX SEVERE COLD 52 MUCINEX FAST-MAX SEVERE CONGESTION & COUGH 52 MUCINEX FAST-MAX SEVERE CONGESTION & COUGH CLEAR & COOL 52 MUCINEX FOR KIDS 59 MUCINEX MAXIMUM STRENGTH 59 MUCINEX MULTI-SYMPTOM COLD DAY/NIGHT PACK 52 MUCINEX SINUS-MAX DAY TIME/NIGHT TIME 52 MUCINEX SINUS-MAX DAY/NIGHT 52 MUCINEX SINUS-MAX SEVERECONGESTION RELIEF 52 MUCINEX STUFFY NOSE & COLD CHILDRENS 52 MULTAQ 13 MULTI PRENATAL 95 MULTI-DRAW NEEDLE 22GX1-1/2" 83 MULTI-MINERALS 93 MULTI-SYMPTOM COLD DAYTIME/NIGHTTIMECHILDRENS 52

Index 18

multiple minerals 93 NASAL neomycin-polymyxin-hcDECONGESTANT 100 (otic) 105 mupirocin 60 NASAL MOIST GEL 98 NEONATAL COMPLETE 95 mupirocin calcium (topical) 60 NASALCARE 98 NEONATAL PLUS 95 MVW COMPLETE PROBIOTIC

FORMULATION 24 NASALCARE FOR KIDS 98 NEONATAL VITAMIN 95 MY MDI PORTABLE NASALCARE FOR KIDS NEORAL 94 NEBULISER PROCEDURE STARTER KIT 98 NEOSPORIN 103 PACK 88 NASALCARE

NEOSPORIN ORIGINAL 60 MYAMBUTOL 31 NASALCLEANSE KIT 98 NASALCROM 99 NEOTUSS PLUS 52 mycophenolate mofetil 93 NASAMIST ALL-IN-ONE 98 NEOTUSS-D 52 MYDRIACYL 103

MYLICON INFANTS GAS NASAMIST HYPERTONIC 98 NEUPOGEN 71 RELIEF 69 NASAMIST ISOTONIC 98 NEURONTIN 17 MYLICON INFANTS GAS NEUTROGENA ON-THE-SPOT NASONEX 100 RELIEF DYE FREE 69 ACNE TREATMENT 60 NASOPEN PE 52 MYNATAL 95 NEUTROGENA T/SAL 64

NATACYN 103 MYNATAL ADVANCE 95 nevirapine 36 NATALVIT 95 MYNATAL PLUS 95 NEXABIOTIC 24 nateglinide 23 MYNATAL ULTRACAPLET 95 NEXAFED SINUS PRESSURE NATROBA 65 +PAIN 52 MYNATAL-Z 95 NATURAL VITAMIN E 117 NEXAVAR 32 MYNATE 90 PLUS 95 NATURE-THROID 110 NF FORMULAS CALCIUM MYSOLINE 17 MAGNESIUM 93 NATURE-THROID NT-N-ACETYL-L-CYSTEINE 59 2.5 110 niacin 118

nabumetone 3 NEB-RITE4 88 niacinamide 118 NAFCILLIN 106 NEBULIZER 88 NICODERM CQ 108 nafcillin sodium 106 NEBULIZER PED FROG 88 NICORETTE 108 NALFON 3 NEBULIZER PED FROG SYS NICORETTE MINI 108 naloxone hcl 24 W/DISP&REUSE NEB KIT 88 NICORETTE STARTER

NEBULIZER SYSTEM ALL-IN-naltrexone hcl 24 KIT 108 ONE 88 nicotine 108 NAMENDA 107 NEBUPENT 9

naphazoline w/ nicotine polacrilex 108 NEO-SYNEPHRINE pheniramine 104 NICOTINE TRANSDERMAL COLD+ALLERGY EXTRA NAPHCON-A 104 SYSTEM 108 STRENGTH 100 NICOTROL INHALER 108 NAPROSYN 3 NEO-SYNEPHRINE

COLD+ALLERGY MILD NICOTROL NS 108 naproxen 3 naproxen sodium 3 STRENGTH 100 nifedipine 39

NEO-SYNEPHRINE NINJACOF 52 naratriptan hcl 90 COLD+ALLERGY REGULAR NINJACOF-A 52 NARCAN 24 STRENGTH 100

NASACORT ALLERGY neomycin sulfate 2 NINJACOF-XG 52 24HR 99 neomycin-bacitracin zn- NINLARO 32 NASACORT ALLERGY 24HR polymyxin 103 nit remover 65 CHILDRENS 100 neomycin-bacitracin-polymyxin NITE-TIME COLD/FLUNASADOCK PLUS 98 60 RELIEF 52 NASADROPS SALINE ON THE neomycin-bacitracin-polymyxin- NITRO-BID 11 GO 98 pramoxine 60 NASAFLO NETI POT NASAL neomycin-polymy- NITRO-DUR 11

dexameth 104 WASH SYSTEM 98 nitrofurantoin 112 NASAFLO PORCELAIN NASAL neomycin-polymyxin-gramicidin nitrofurantoin macrocrystal 112 RINSE 98 103 nitrofurantoin monohyd NASAL CLEANSE RINSE neomycin-polymyxin-hc

macro 112 MIX 98 (ophth) 104 nitroglycerin 11

Index 19

NITROSTAT 11 NIVA-PLUS 95 NIVANEX DMX 52 NIX CREME RINSE 65 NIZORAL 61 NOBLE MYSTIQUE EMU-LAC 63 NOKOR ADMIX NEEDLE THIN

NOVOLOG MIX 70/30PREFILLED FLEXPEN NOVOLOG PENFILL NPLATE NULYTELY NULYTELY/FLAVORPACKS NUMBRINO

23 23 71 73

73 99

ONE VITE WOMENS PRENATALVITAMIN PLUS 95 ONE-A-DAY WOMENS PRENATAL 95 ONEVITE 94 ONFI 16 ONGLYZA 22 OPCON-A 104

WALL NON-CORING 18G X 1- NUMOISYN 94 OPTIMAL D3 M 117 1/2" 83 NOKOR VENTED NEEDLE THINWALL NON-CORING 18G X 1" 83 NOKOR VENTED NEEDLE THINWALL NON-CORING 18GX1-1/2" 83 NORCO 6 NORDITROPIN FLEXPRO 67 NOREL AD 52 NOREL CS 52 norethin acet & estrad-fe 42 norethindrone & eth estradiol42 norethindrone (contraceptive) 43 norethindrone acet & eth estra 42

NUTRA-SUPPORT BONE 93 NUTRIDOX 110 NUVARING 43 NUZYRA 109 nystatin 25 nystatin (mouth-throat) 94 nystatin (topical) 61 NYTOL MAXIMUM STRENGTH 72 O-CAL FA 95 O-CAL PRENATAL 95 OC8 60 OCEAN COMPLETE SINUS RINSE 98 OCEAN NASAL MOISTURIZER 98

OPTIONHOME COMPRESSOR NEBULIZER SYSTEM 88 oral electrolytes 92 ORAL RELIEF SPRAY FOR DRYMOUTH & DISCOMFORT 94 ORAP 108 ORAPRED ODT 44 ORTHO MICRONOR 43 ORTHO TRI-CYCLEN 42 ORTHO TRI-CYCLEN LO 42 ORTHO-CYCLEN 43 ORTHO-NOVUM 1/35 43 ORTHO-NOVUM 7/7/7 43 oseltamivir phosphate 38 OTEZLA 4

norethindrone acetate 107 norethindrone acetate-ethinylestradiol-fe 42 norethindrone-eth estradiol (triphasic) 42 norgestimate-ethinylestradiol 42 norgestimate-ethinyl estradiol(triphasic) 42 norgestrel & ethinyl estradiol 42 NORM-JECT TUBERKULIN 1MLLUER SLIP 83 NORPACE 12 NORPACE CR 12 NORPRAMIN 21 nortriptyline hcl 21 NORVASC 39 NORVIR 36 NOSE BETTER 98 NOSE BETTER NATURAL MIST 98 NOVOLIN N 23 NOVOLIN R 23 NOVOLOG 23 NOVOLOG FLEXPEN 23 NOVOLOG MIX 70/30 23

OCEAN NASAL SPRAY 98 OCEAN ULTRA SALINE NASALMIST 98 OCUFLOX 103 ODEFSEY 36 ofloxacin 69 ofloxacin (ophth) 103 olanzapine 34 olopatadine hcl (nasal) 99 OMEGA POWER 101 OMEGA-3 101 OMEGA-3 2100 101 OMEGA-3 EPA FISH OIL 101 omega-3 fatty acids 101 OMEGA-3 FISH OIL EXTRA STRENGTH 101 omeprazole 112 omeprazole magnesium 112 OMNARIS 100 OMNIFLEX DIAPHRAGM 75 OMNIPRED 104 ondansetron 24 ondansetron hcl 24 ONE VITE WOMENS PRENATALVITAMIN 95

OVACE PLUS WASH 62 OVACE WASH 62 OXACILLIN SODIUM 106 oxacillin sodium 106 oxaprozin 3 oxazepam 12 oxcarbazepine 17 oxybutynin chloride 112 oxycodone hcl 5 oxycodone w/ acetaminophen 6 oxycodone-aspirin 6 OXYCODONE/ACETAMINOPHEN 6 oxymetazoline hcl 100 OXYTETRACYCLINE HCL 110 oyster shell 91 P & S 64 PAMELOR 21 PANATUSS PED 52 PANATUSS PED DROPS 52 PANOXYL 60 PANOXYL-4 CREAMY WASH 60 pantoprazole sodium 112

Index 20

PARI ALTERA NEBULIZER SYSTEM 89 PARI BABY 89 PARI BABY SIZE 1/PARILCPLUS 89 PARI ERAPID NEBULIZER SYSTEM 89 PARI LC D NEBULIZER 89 PARI LC PLUS 89 PARI LC PLUS NEBULIZER 89

pediatric multiple vitamins w/iron 95 PEDIAVENT 25 peg 3350-kcl-sod bicarb-sodchloride-sod sulfate 73 peg 3350-potassium chloride-sod bicarbonate-sod chloride 73 PEGASYS 38 PEGASYS PROCLICK 38

PHENYLEPHRINE HCL 100 phenylephrine hcl 101 phenylephrine hcl(mydriatic) 103 phenylephrine hcl (oral) 100 PHENYLEPHRINE HCL/PYRILAMINEMALEATE 53 PHENYLEPHRINE HYDROCHLORIDE 101

PARI LC PLUS NEBULIZER SET/PEDIATRIC MASK 89 PARI LC PLUS NEBULIZER VIOS PRO/REUSABLE PARI LC SPRINT

89

NEBULIZERSET 89 PARI LC STAR 89 PARI LC STAR NEBULIZER 89 PARI PRONEB ULTRA II 89 PARI SINUS PULSATING AEROSOL SYSTEM 89 PARI TREK S COMPACT COMPRESSOR W/ 12V DCADAPTOR 89 PARI VIOS PRO LC PLUS AEROSOL DELIVERY SYSTEM 89 PARI VIOS PRO LC SPRINT AEROSOL DELIVERY SYSTEM 89 paricalcitol 68 PARLODEL 32 paromomycin sulfate 2 paroxetine hcl 20 PATANASE 99 PATIENT SAFE SYRINGE 3ML 83 PAXIL 20 PC PEDIATRIC POLY-VITAMIN DROPS/IRON 95 PECGEN DMX 52 PEDIACARE COUGH & RUNNY NOSE 53 PEDIALYTE 92 PEDIALYTE ADVANCED CARE 92 PEDIALYTE FREEZER POPS 92 PEDIALYTE SINGLES 92 PEDIAPRED 44 PEDIATRIC COUGH/COLD 53 pediatric multiple vitamin w/ c 95

PEGINTRON 38 penicillamine 93 penicillin g potassium 106 PENICILLIN G POTASSIUM IN ISO-OSMOTIC DEXTROSE 106 PENICILLIN G PROCAINE 106 penicillin g sodium 106 penicillin v potassium 106 PENLAC NAIL LACQUER 61 PENTAM 300 9 pentamidine isethionate 9 PENTASA 70 pentoxifylline 71 PEPCID 111 PEPCID AC 111 PEPCID AC MAXIMUM STRENGTH 111 PEPTO BISMOL 24 PEPTO-BISMOL 24 PEPTO-BISMOL MAX STRENGTH 24 PEPTO-BISMOL TO-GO 24 PERCOCET 6 PERCOGESIC 53 PERFOROMIST 15 PERIDEX 94 perindopril erbumine 28 permethrin 65 perphenazine 35 PERRY PRENATAL 95 PHAZYME 69 PHAZYME ULTRA STRENGTH 69 PHENAGIL 53 PHENAGIL CH 53 phenazopyridine hcl 71 PHENERGAN 27 phenobarbital 72

phenylephrine w/acetaminophen 53 phenylephrine w/ dm-gg 53 phenylephrine-acetaminophen-guaifenesin 53 phenylephrine-brompheniramine-dm 53 phenylephrine-chlorphen-dm

53 phenylephrine-chlorpheniraminew/ dm-gg & apap 53 phenylephrine-chlorpheniramine-dm w/ apap 53 phenylephrine-diphenhydramine-dm w/ apap 53 phenylephrine-diphenhydramine-dm-guaifenesin-apap 53 phenylephrine-diphenhydramine-gg w/ apap 54 phenylephrine-dm 54 phenylephrine-dm-gg w/ apap 54 phenylephrine-doxylamine-dextromethorphan-acetaminophen 54 phenylephrine-doxylamine-dm-guaifenesin-apap 54 phenylephrine-guaifenesin 54 phenylephrine-ibuprofen 54 phenylephrine-triprolidine-dextromethorphan 54 PHENYLPROPANOLAMINE HYDROCHLORIDE USP 101 PHENYTEK 18 phenytoin 18 phenytoin sodium extended 18 PHILLIPS WILLIS THE WHALENEBULIZER 89 phytonadione 117 PIFELTRO 36 pilocarpine hcl 103 pimozide 108 pioglitazone hcl 22 pioglitazone hcl-metforminhcl 21

Index 21

piperacillin sodium-tazobactam potassium 93 prenatal vit w/ docusate-fesodium 106 fumarate-folic acid 96 POTASSIUM 93 piroxicam 3 prenatal vit w/ docusate-iron

potassium chloride 93 carbonyl-folic acid 96 PLAN B ONE-STEP 43 POTASSIUM CHLORIDE 93 prenatal vit w/ ferrous fumarate-PLAQUENIL 30 folic acid 96 potassium chloride 93 PLAVIX 71 prenatal vit w/ iron carbonyl-folicpotassium chloride acid 96 PNEUMOVAX 23 113 microencapsulated crystals PRENATAL VITAMIN 96 PNEUMOVAX 23/1 DOSE 113 er 93

PRENATAL VITAMIN & PNV FOLIC ACID + IRON potassium citrateMULTIVITAMIN 95 (alkalinizer) 70 MINERAL 96 PNV PRENATAL PLUS potassium citrate-citric acid70 PRENATAL VITAMIN/IRON 96 MULTIVITAMIN 95 PRADAXA 16 PRENATAL VITAMINS 96 PNV TABS 29-1 95 pramipexole PRENATAL VITAMINS PLUS podofilox 64 dihydrochloride 33 LOW IRON 96

PRANDIN 23 PRENATAL-U 96 POLY HIST FORTE 54 POLY HUB NEEDLE/18G X PRAVACHOL 28 PRENATRIX 96 1" 83 pravastatin sodium 28 PRENATVITE RX 96 POLY HUB NEEDLE/18G X 1-1- praziquantel 8 PREPLUS 96 1/2" 83 POLY HUB NEEDLE/22G X 1- prazosin hcl 29 PRETAB 96 1/2" 83 PRE-NATAL FORMULA 95 PRETZ 98 POLY HUB NEEDLE/25G X PRECOSE 21 PRETZ IRRIGATION 98 1" 83 PRETZ NATURAL POLY HUB NEEDLE/25G X 1- PRED FORTE 104 MOISTURIZING NASAL 1/2" 83 PRED MILD 104 SPRAY/YERBA SANTA/SEAPOLY HUB NEEDLE/25G X PRED-G 104 SALT 98 5/8" 83 PRED-G S.O.P. 104 PREVACID 112 POLY HUB NEEDLE/27G X1/2" 83 prednisolone 44 PREVACID 24HR 112 POLY-HIST DM 54 prednisolone acetate PREVNAR 13 113

(ophth) 104 POLY-HIST PD 54 PREZCOBIX 36 PREDNISOLONE ACETATE P-POLY-TUSSIN AC 54 PREZISTA 36 F 104 POLY-VENT DM 54 prednisolone sodium PRIMAQUINE PHOSPHATE 30

phosphate 44 POLY-VENT IR 54 primaquine phosphate 30 PREDNISOLONE SODIUM POLY-VI-SOL 95 PRIMATENE ASTHMA 54 PHOSPHATE 104 POLY-VITA/IRON 95 prednisone 44 PRIMAXIN IV 9 polyethylene glycol 3350 73 PREDNISONE INTENSOL 44 primidone 17 polyethylene glycol-propylene pregabalin PRIMLEV 6 17 glycol (ophth) 102 PRIMSOL 9 PREMARIN 68,117 POLYMYXIN B SULFATE 11 PRINIVIL 28 PREMPRO 68 polymyxin b sulfate 11 PRO-RED AC 54 PRENATABS FA 95 polymyxin b-trimethoprim 103 PROAIR DIGIHALER 15 PRENATAL 96 POLYSPORIN 60 PROAIR HFA 15 PRENATAL 19 96 POLYTRIM 103 PROAIR RESPICLICK 15 PRENATAL AND IRON 96 POLYTUSSIN DM 54

PRENATAL FORTE 96 probenecid 71 polyvinyl alcohol 102 PROCARDIA 39 PRENATAL LOW IRON 96 PONARIS 98 PRENATAL PROCARDIA XL 39 PORTABLE COMPRESSOR MULTIVITAMIN 96 PROCARE COMPRESSOR NEBULIZER 89 PRENATAL ONE DAILY 96 NEBULIZER 89 pot phosphate monobasic w/ sodphosphate dibasic & PRENATAL PLUS IRON 96 prochlorperazine 35 monobasic 93 prochlorperazine maleate 35

Index 22

PROCORT 7 PROCTOCORT 7 PRODIGY MINI-MIST PORTABLE NEBULIZER 89 PRODIGY MINI-MIST PORTABLE NEBULIZER SPANISH 89 progesterone micronized 107 PROGRAF 94 PROLASTIN-C 109 PROLATE 6 PROLIA 67 PROMACTA 71 promethazine &phenylephrine 54 promethazine hcl 27 promethazine w/codeine 54 promethazine-dm 54 promethazine-phenylephrine-codeine 54 PROMETHAZINE/PHENYLEPHRINE 54 PROMETRIUM 107 PRONEB ULTRA II DELUXE/LCSPRINT 89 PRONEB ULTRA II DELUXE/LCSTAR 89 PRONEB ULTRA II

pseudoephed-cpm w/hydrocod 54 PSEUDOEPHEDRINE HCL 101 pseudoephedrine hcl 101 pseudoephedrine w/ codeine-gg 54 pseudoephedrine w/ dm-gg 54 pseudoephedrine-acetaminophen 54 pseudoephedrine-chlorphen-dm 54 pseudoephedrine-dexchlorpheniramine-chlophedianol 54 pseudoephedrine-dexchlorpheniramine-dextromethorphan 54 pseudoephedrine-guaifenesin

55 pseudoephedrine-ibuprofen 55 pseudoephedrine-naproxensodium 55 psyllium 73 PULMICORT 14 PULMICORT FLEXHALER14 PULMOZYME 109 PURE AIR MINI

QNASL 100 QNASL CHILDRENS 100 QUALAQUIN 30 QUESTRAN 27 QUESTRAN LIGHT 27 quetiapine fumarate 34 QUINACRINE DIHYDROCHLORIDE 30 QUINACRINE HCL 30 quinapril hcl 28 quinapril-hydrochlorothiazide

29 quinidine gluconate 12 quinidine sulfate 13 quinine sulfate 30 QUININE SULFATE 30 QUININE SULFATE DIHYDRATE 30 QUZYTTIR 27 RA ACETAMINOPHEN FLU SEVERE COLD 55 RA CALAMINE 65 RA CALCIUM HI-CAL/VITAMIND 91 RA DRY MOUTH 94 RA FISH OIL EXTRA STRENGTH 101

DELUXE/LCD 89 PRONEB ULTRA II PEDIATRIC 89 PRONEB ULTRA II WITH LC PLUS 89 PRONEB ULTRA II/LCSPRINT 89 PRONEB ULTRA II/LC SPRINTPEDIATRIC 89 propafenone hcl 13 propantheline bromide 111 PROPEL 100

NEBULIZER PX CALAMINE PX DAYTIME MULTI-SYMPTOM PX NITETIME MULTI-SYMPTOM PX PRENATAL MULTIVITAMINS pyrantel pamoate pyrazinamide pyrethrins-piperonylbutoxide

89 65

55

55

96 8

31

65

RA LICE SOLUTION KIT 66 RA ONE DAILY 96 RA PRENATAL 97 RA PRENATAL FORMULA/FOLICACID 96 RA SINUS RELIEF DAYTIME/NIGHTTIME 55 RA SINUS WASH NASAL RELIEF REFILL 98 RA SINUS WASH NETI POT98 RA STERILE SALINE NASAL MIST 98

PROPEL MINI propranolol &hydrochlorothiazide propranolol hcl

100

29 39

pyrethrins-piperonyl butoxide-permethrin-nit remover 66 PYRIDIUM 71 pyridostigmine bromide 30

RA TRIPLE STRENGTH FISH OIL 101 racepinephrine hcl 15 raloxifene hcl 68

propylthiouracil 110 pyridoxine hcl 118 ramipril 28 PROSCAR 70 PYRILAMINE MALEATE 26 RANEXA 11 PROTONIX 112 protriptyline hcl 21 PROVERA 107 PROZAC 20 pseudoephed-bromphen-dm 54

PYRIMETHAMINE/LEUCOVORIN 30 QC CALAMINE 65 QC MEDIFIN PE 55 QC PRENATAL 96 QC TRIACTING DAYTIME CHILDRENS 55

ranitidine hcl ranolazine RAPAFLO RAPAMUNE RAPIVAB RAZADYNE

111,112 11 70 94 38

107

Index 23

RAZADYNE ER 107 RHINASE 98 ROBITUSSIN PEAK COLD

REA-LO REBETOL

63 38

RIAX RIBASPHERE

60 38

DAY/NIGHT PACK MAXIMUMSTRENGTH 55 ROBITUSSIN PEAK COLD

REBIF 107 RIBASPHERE RIBAPAK 38 DM 55 ROBITUSSIN PEAK COLD REBIF REBIDOSE 107 ribavirin 38 MULTI-SYMPTOM COLD 55 REBIF REBIDOSE ribavirin (hepatitis c) 38 ROBITUSSIN TO GO COUGH TITRATIONPACK 107 RID COMPLETE LICE &COLD CF 55 REBIF TITRATION PACK 107 ELIMINATION 66 ROCALTROL 68

RECARBRIO 9 RIFADIN 31 RONDEC-D 55 RECOMBIVAX HB 116 rifampin 31 ropinirole hydrochloride 33 REESES PINWORM RIGHT STEP PRENATAL 97 ROXICET 6 MEDICINE 8 RILUTEK 101 REFENESEN CHEST ROXICODONE 5

riluzole 101 CONGESTION & PAIN ROZEREM 73 RELIEF 55 rimantadine hydrochloride 38 RU-HIST D 55 REFENESEN CHEST RISPERDAL 33,34 CONGESTION & PAIN RELIEF RYCONTUSS 55

RISPERDAL CONSTA 33 PE 55 RYDEX 55 risperidone 34 REFRESH LIQUIGEL 102 RYDEX G 55 RITALIN 2 REFRESH TEARS 102 RYMED 55

REGIONAL BLOCK NEEDLE RITALIN LA 1,2 RYTHMOL SR 13 SAFETY BEAD BLOCK BEVEL ritonavir 37 RYVENT 26 22GX1-1/2" 83 RITUXAN 31 REGLAN 70 S2 15

rivastigmine 107 SAFESNAP ALLERGY RELENZA DISKHALER 38 rivastigmine tartrate 107 SYRINGE/1ML/27G X 1/2" 83 RELION KETONE 66 rizatriptan benzoate 90 SAFESNAP SYRINGE/3ML 83 RELION KETONE TEST ROBAXIN 97 SAFESNAP STRIPS 66 SYRINGE/NEEDLE/3ML/20G XREMERON 19 ROBAXIN-750 97 1" 84 REMERON SOLTAB 19 ROBINUL 111 SAFESNAP RENFLEXIS 70 ROBINUL FORTE 111 SYRINGE/NEEDLE/3ML/21G X

ROBITUSSIN CHILDRENS 1-1/2" 84 RENVELA 70 COUGH & COLD CF 55 SAFESNAP repaglinide 23 ROBITUSSIN CHILDRENS SYRINGE/NEEDLE/3ML/22G XREQUIP 33 COUGH LONG-ACTING 45 1" 84

ROBITUSSIN CHILDRENS SAFESNAP RESCON 55 COUGH/COLD LONG- SYRINGE/NEEDLE/3ML/22G XRESCRIPTOR 37 ACTING 55 1-1/2" 84

RESPAIRE-30 55 ROBITUSSIN COUGH & COLD SAFESNAP RESTASIS 104 DAY/NIGHT PACK 55 SYRINGE/NEEDLE/3ML/23G X

ROBITUSSIN LINGERING 1" 84 RESTORIL 73 COLDLONG-ACTING SAFESNAP RETACRIT 71 COUGHGELS 45 SYRINGE/NEEDLE/3ML/23G XRETIN-A 60 ROBITUSSIN NIGHTTIME 1-1/2" 84 RETIN-A MICRO 60 COUGH DM 55 SAFESNAP

ROBITUSSIN NIGHTTIME SYRINGE/NEEDLE/3ML/25G XRETIN-A MICRO PUMP 60 COUGH LONG-ACTING DM 1" 84 RETROBULBAR NEEDLE 25G CHILDRENS 55 SAFESNAP TWX 1-1/2" 83 ROBITUSSIN PEAK COLD SYRINGE/NEEDLE/3ML/25G XRETROVIR 37 COUGH+ CHEST 5/8" 84 REVATIO 40 CONGESTION DM MAX SAFESNAP TUBERCULIN

STRENGTH 55 SYRINGE/1ML/25G X 5/8" 84 REVLIMID 93 ROBITUSSIN PEAK COLD SAFESNAP TUBERCULIN REYATAZ 37 DAY/NIGHT PACK DM 55 SYRINGE/1ML/27G X 1/2" 84

RHINARIS 98

Index 24

SAFETY SYRINGES/NEEDLE SECURESAFE SAFETY sennosides 74 3ML/20GX1" 84 HYPODERMIC NEEDLE/18G X sennosides-docusate SAFETY SYRINGES/NEEDLE 1-1/2" 84 sodium 73 3ML/21GX1-1/2" 84 SECURESAFE SAFETY SENOKOT 74 SAFETY SYRINGES/NEEDLE HYPODERMIC NEEDLE/19G X SENOKOT S 73 3ML/22GX1" 84 1" 84 SAFETY SYRINGES/NEEDLE SECURESAFE SAFETY SENSIPAR 68 3ML/22GX1-1/2" 84 HYPODERMIC NEEDLE/22G X SEREVENT DISKUS 15 SAFETY SYRINGES/NEEDLE 1-1/2" 84 SEROQUEL 34 3ML/23GX1" 84 SECURESAFE SAFETY SAFETY SYRINGES/NEEDLE HYPODERMIC NEEDLE/25G X sertraline hcl 20 3ML/25GX5/8" 84 1-1/2" 84 sevelamer carbonate 70 SAFETY-LOK SAFETY SECURESAFE SAFETY SEYSARA 110 SYRINGE/1ML/25G X 5/8" 84 HYPODERMIC NEEDLE/25G X SFROWASA 70 SAFETY-LOK SYRINGE 3ML 5/8" 84 LUER-LOK 84 SECURESAFE SAFETY SHINGRIX 116 SAFETY-LOK HYPODERMIC NEEDLE/27G X SIDESTREAM SYRINGE/NEEDLE3ML LUER- 1/2" 85 NEBULIZER/DISPOSABLE 89 LOK 21GX1-1/2" 84 SECURESAFE SIDESTREAM SAFETY-LOK SYRINGE/NEEDLE/3ML/20G X NEBULIZER/REUSABLE 89 SYRINGE/NEEDLE3ML LUER- 1" 85 SIDESTREAM PLUS LOK 22GX1" 84 SECURESAFE REUSABLEHIGH EFFICIENCY SAFETY-LOK SYRINGE/NEEDLE/3ML/21G X NEBULIZER 89 SYRINGE/NEEDLE3ML LUER- 1-1/2" 85 sildenafil citrate (pulmonaryLOK 22GX1-1/2" 84 SECURESAFE hypertension) 40 SAFETY-LOK SYRINGE/NEEDLE/3ML/22G X SILVADENE 62 SYRINGE/NEEDLE3ML LUER- 1" 85 silver sulfadiazine 62 LOK 23GX1" 84 SECURESAFE simethicone 69 SAFETY-LOK SYRINGE/NEEDLE/3ML/22G XSYRINGE/NEEDLE3ML LUER- 1-1/2" 85 SIMPLY SALINE 99 LOK 25GX5/8" 84 SECURESAFE simvastatin 28 SAFETY-LOK TB SYRINGE SYRINGE/NEEDLE/3ML/23G X SINADRIN PE COMPLETE PERM NEEDLE 1ML 1" 85 SINUS RELIEF 56 27GX1/2" 84 SECURESAFE SINEMET 33 SALEX 64 SYRINGE/NEEDLE/3ML/25G X

SINEMET CR 33 salicylic acid 64 5/8" 85 SECURESAFE TUBERCULIN SINGULAIR 13 saline 98 INSULIN SYRINGE/1ML/25G X SINUCLEANSE NETI POT 99 SALMON 101 5/8" 85 SINUCLEANSE REFILL 99 SALMON OIL 101 SECURESAFE TUBERCULIN INSULIN SYRINGE/1ML/27G X SINUCLEANSE SQUEEZE 99 SALMON OIL-1000 102 1/2" 85 SINUFLO READYRINSE 99 salsalate 5 SEEBRI NEOHALER 13 SINUGATOR NASAL WASH 99 SALTAIRE 99 selenium sulfide 62 SINUS RINSE 99 SALVAX 64 SELSUN BLUE 62 SINUS RINSE BOTTLE KIT 99 SANDIMMUNE 94 SELSUN BLUE DAILY 62 SINUS RINSE KIT 99 SB NIGHTTIME SINUS MULTI- SELSUN BLUE DEEP SINUS RINSE KIT SYMPTOM 55 CLEANSING 64 PEDIATRIC 99 SCHOOLTIME SHAMPOO 66 SELSUN BLUE SINUS RINSE PEDIATRIC SCOT-TUSSIN DIABETES 45 MEDICATED 62 STARTER KIT 99 SELSUN BLUE SCOT-TUSSIN DM 55 SINUS RINSE REFILL 99 MOISTURIZING 62 SCOT-TUSSIN SENIOR 55 SINUS RINSE REFILL SELSUN BLUE NATURALS PEDIATRIC 99 SE-NATAL 19 97 DRYSCALP 64 SINUS WASH SALT 99 SEASONIQUE 43 SELZENTRY 37

SINUVA 100 SECURESAFE SAFETY SEMGLEE 23 HYPODERMIC NEEDLE/18G X sirolimus 94 SEMPREX-D 55 1" 84

Index 25

SITAVIG 38 SIVEXTRO 11 SKLICE 66 SLO-NIACIN 118 SM CALAMINE 65 SM COUGH & SORE THROAT DAYTIME PAIN RELIEVER 56 SM FISH OIL 102 SM GLUCOSE 22 SM ONE DAILY PRENATAL 97 SM PRENATAL VITAMINS 97 SODIUM CHLORIDE 93 sodium chloride 93 sodium chloride (inhalant) 59 sodium chloride-sodium bicarbonate 99 sodium citrate & citric acid 70 sodium fluoride 92 sodium phosphates 74 sodium polystyrenesulfonate 94 SOFOSBUVIR/VELPATASVIR

38 SOLODYN 110 SOLU-CORTEF 44 SOLU-MEDROL 44 SOOTHE NEB MESH NEBULIZER 89 SOOTHENEB COMPRESSOR NEBULIZER 89 SORBUTUSS NR 56 sotalol hcl 39 sotalol hcl (afib/afl) 39 SPARKY THE DOG 89 spinosad 66 SPIRIVA HANDIHALER 13 SPIRIVA RESPIMAT 13 spironolactone 67 spironolactone &hydrochlorothiazide 67 SPRAVATO 56MG DOSE 19 SPRAVATO 84MG DOSE 19 SPRYCEL 32 SSKI 59 STAHIST 56 STAHIST AD 56 STALEVO 100 33 STALEVO 125 33 STALEVO 150 33

STALEVO 200 33 STALEVO 50 33 STALEVO 75 33 STARLIX 23 stavudine 37 STIMATE 68 STIMEX INSULATED NEEDLE TEFLON-COATED BLOCK BEVEL 22GX1-1/2" 85 STIOLTO RESPIMAT 15 STRATTERA 1 STREPTOMYCIN SULFATE 2 streptomycin sulfate 2 STRIBILD 37 STRIVERDI RESPIMAT 15 STROMECTOL 8 SUBLOCADE 6 SUBOXONE 7 SUCRAID 66 sucralfate 112 SUDAFED CHILDRENS 101 SUDAFED CONGESTION 101 SUDAFED PE CHILDRENS NASAL DECONGESTANT 101 SUDAFED PE SINUS CONGESTION 101 SUDAFED PE SINUS CONGESTION DAYTIME/NIGHTTIME 56 SUDAFED SINUS CONGESTION 101 SUDAFED SINUS CONGESTION24 HOUR 101 sulfacetamide sod-prednisolone 104 sulfacetamide sodium 62 sulfacetamide sodium (acne) 60 sulfacetamide sodium (ophth) 103 SULFADIAZINE 109 SULFADIAZINE SODIUM109 SULFAMETHOXAZOLE 109 SULFAMETHOXAZOLE MICRO 109 sulfamethoxazole-trimethoprim 9 SULFAPYRIDINE 109 sulfasalazine 70

SULFATHIAZOLE 109 SULFISOXIZOLE 109 sulindac 3 sumatriptan succinate 90,91 SUPER TWIN EPA/DHA 102 SUPRAX 41,42 SUPRESS A PEDIATRIC DROPS 56 SUPRESS DM PEDIATRIC 56 SUPRESS-PE PEDIATRIC 56 SURMONTIL 21 SUSTIVA 37 SUTENT 32 SYLATRON 32 SYMAX DUOTAB 111 SYMBICORT 15 SYMLINPEN 120 21 SYMLINPEN 60 21 SYNAGIS 105 SYNERCID 11 SYNTHROID 110 SYRINGE/BLUNT PLASTICCANNULA 85 SYRINGE/LUER LOCK/3ML 85 SYRINGE/LUER LOCK/3ML/20GX 1" 85 SYRINGE/LUER LOCK/3ML/21GX 1-1/2" 85 SYRINGE/LUERLOCK/3ML/21GX1-1/2" 85 SYRINGE/LUER LOCK/3ML/22GX 1" 85 SYRINGE/LUER LOCK/3ML/22GX 1-1/2" 85 SYRINGE/LUERLOCK/3ML/22GX1" 85 SYRINGE/LUERLOCK/3ML/22GX1-1/2" 85 SYRINGE/LUER LOCK/3ML/23GX 1" 85 SYRINGE/LUER LOCK/3ML/23GX 1-1/2" 85 SYRINGE/LUERLOCK/3ML/23GX1" 85 SYRINGE/LUER LOCK/3ML/25GX 1" 85 SYRINGE/LUER LOCK/3ML/25GX 1-1/2" 85 SYRINGE/LUER LOCK/3ML/25GX 5/8" 85 SYRINGE/LUERLOCK/3ML/25GX1" 85 SYRINGE/LUERLOCK/3ML/25GX5/8" 85

Index 26

SYRINGE/LUER SLIP/1ML 85 testosterone 7 TIAZAC 39 SYRINGE/LUER SLIP/3ML 85 SYRINGES/LUERLOCK/1ML/20GX1" 85 SYRINGES/LUERLOCK/WITHOUTNEEDLE/3ML 85 SYRINGES/LUERSLIP/WITHOUTNEEDLE/1ML 85 SYSTANE 102 SYSTANE OVERNIGHT THERAPY LUBRICANT EYE 102 SYSTANE ULTRA 102 SYSTANE ULTRA HOME & AWAY PACK 102 TACLONEX 63 tacrolimus 94

testosterone cypionate 7 testosterone enanthate 7 TETANUS/DIPHTHERIATOXOIDS-ADSORBED ADULT 111 tetracaine hcl (ophth) 104 tetracycline hcl 110 THALOMID 93 THEO-24 15 theophylline 15 THEOPHYLLINE ETHYLENEDIAMINE EP 15 THEOPHYLLINE/D5W 15 THERA-D 4000 117 THERACOF PLUS COUGH AND COLD RELIEVER 56 THERAFLU COLD &

TICALAST TICASPRAY TIGAN TIGECYCLINE tigecycline TIKOSYN timolol maleate (ophth) TIMOPTIC TIMOPTIC OCUDOSE TIMOPTIC-XE TINACTIN TINACTIN DEODORANT TINACTIN JOCK ITCH TINDAMAX tinidazole

97 99 24

109 109

13 102 103 103 103

61 61 61

9 9

TAMIFLU 38 COUGH 56 TIVICAY 37 tamoxifen citrate tamsulosin hcl TAPAZOLE

31 70

110

THERAFLU FLU & SORE THROAT 56 THERAFLU POWERPODS DAYTIME SEVERE COLD 56

tizanidine hcl TOBI TOBRADEX

97 2

104 TARCEVA TARGRETIN TASIGNA

32 32 32

THERAFLU POWERPODS NIGHTTIME SEVERE COLD 56 THERAFLU SEVERE COLD &

TOBRADEX ST tobramycin tobramycin (ophth)

104 2

103 TAZICEF 42 COUGH TOBRAMYCIN SULFATE 2 TDVAX 111 TEFLARO 42 TEGRETOL 17 TEGRETOL-XR 17 TEKTURNA 30 temazepam 73 TEMOVATE 63 TENIVAC 111 tenofovir disoproxil fumarate 37 TENORETIC 100 29 TENORETIC 50 30 TENORMIN 39 terazosin hcl 29 terbinafine hcl 25 terbinafine hcl (topical) 61 TERBUTALINE SULFATE 15 terbutaline sulfate 15 terconazole vaginal 117 TERPIN HYDRATE 59 TERPIN HYDRATE MONOHYDRATE 59 TESSALON PERLES 45

DAYTIME/NIGHTTIME 56 THERAFLU SEVERE COLD & COUGH NIGHTTIME 56 THERAFLU SEVERE COLD DAYTIME 56 THERAFLU SEVERE COLD MULTI SYMPTOM 56 THERAFLU SEVERE COLD MULTI SYMPTOM NIGHTTIME 56 THERAFLU SEVERE COLD NIGHTTIME 56 THERANATAL CORE NUTRITION 97 THERAPEUTIC DANDRUFF 64 THERAPEUTIC T+PLUS MAXIMUM STRENGTH 64 THERATEARS 102 thiamine hcl 118 thioridazine hcl 35 thiothixene 35 THRIVITE 19 94 THRIVITE RX 97 thyroid 110 tiagabine hcl 18

tobramycin sulfate 2 tobramycin-dexamethasone 104 TOBREX 103,104 TOFRANIL 21 tolazamide 23 tolbutamide 23 tolmetin sodium 3 tolnaftate 61 tolterodine tartrate 112 TOPAMAX 18 TOPAMAX SPRINKLE 18 topiramate 18 TOPROL XL 39 toremifene citrate 31 torsemide 67 TRACLEER 40 TRADJENTA 22 tramadol hcl 5 tramadol-acetaminophen 6 trandolapril 28 TRANXENE T 12

Index 27

TRAVATAN Z 105 travoprost 105 trazodone hcl 20 TRELEGY ELLIPTA 15 tretinoin 60 tretinoin (chemotherapy) 32 tretinoin microsphere 60 TRI-NORINYL 28 43 TRIAMCINOLONE ACETONIDE 44 triamcinolone acetonide (mouth) 94 triamcinolone acetonide (nasal) 100 triamcinolone acetonide (topical) 63 TRIAMCINOLONE ACETONIDE PF 44 TRIAMINIC CHEST/NASALCONGESTION 56 TRIAMINIC COLD & ALLERGY 56 TRIAMINIC COLD & COUGH DAY TIME CHILDRENS 56 TRIAMINIC COLD & COUGH DAY/NIGHT CHILDRENS 56 TRIAMINIC COUGH & RUNNY NOSE CHILDRENS 56 TRIAMINIC COUGH & SORE THROAT 56 TRIAMINIC FLU COUGH & FEVER 56 TRIAMINIC FLU/COUGH/FEVER 56 TRIAMINIC LONG ACTING COUGH 45 TRIAMINIC NIGHT TIME COLD & COUGH 56 triamterene 67 triamterene & hydrochlorothiazide 67 TRICARE 97 TRICOR 28 trifluoperazine hcl 35 trifluridine 104 TRIGLIDE 28 trihexyphenidyl hcl 32 TRILEPTAL 18 trimethobenzamide hcl 24 TRIMETHOPRIM 9 trimethoprim 9 trimipramine maleate 21 TRIMPEX 9

TRINATAL RX 1 97 TRIPELENNAMINE HCL 26 triprolidine &pseudoephedrine 56 triprolidine hcl 25 TRISPEC DMX 56 TRISPEC DMX PEDIATRIC 56 TRIUMEQ 37 TRIZIVIR 37 tropicamide 103 trospium chloride 112 TRUE METRIX BLOOD GLUCOSETEST STRIPS 66 TRUE METRIX CONTROL SOLUTION LEVEL 1 75 TRUE METRIX CONTROL SOLUTION LEVEL 2 75 TRUE METRIX CONTROL SOLUTION LEVEL 3 75 TRUECONTROL GLUCOSE CONTROL LEVEL 0 75 TRUECONTROL GLUCOSE CONTROL LEVEL 1 75 TRUETRACK TEST 66 TRUMENBA 113 TRUSOPT 105 TRUVADA 37 TUDORZA PRESSAIR 13 TUMS 8 TUMS CHEWY BITES 8 TUMS CHEWY DELIGHTS 8 TUMS E-X 750 8 TUMS EXTRA STRENGTH 750 8 TUMS KIDS 8 TUMS LASTING EFFECTS 8 TUMS SMOOTHIES 8 TUMS ULTRA 1000 8 TUSICOF 56 TUSNEL 57 TUSNEL C 57 TUSNEL DM 57 TUSNEL PEDIATRIC 57 TUSNEL-DM PEDIATRIC 57 TUSSI-PRES PEDIATRIC 57 TUSSICAPS 57 TUSSIONEX PENNKINETIC EXTENDED RELEASE 57 TUSSLIN 57

TUSSLIN PEDIATRIC 57 TUXARIN ER 57 TUZISTRA XR 57 TWINRIX 116 TYBOST 37 TYGACIL 109 TYKERB 32 TYLENOL 4 TYLENOL CHILDRENS 4 TYLENOL CHILDRENS COLD/FLU 57 TYLENOL CHILDRENS PLUS MULTI-SYMPTOM COLD 57 TYLENOL COLD & FLU SEVERE 57 TYLENOL COLD & HEAD SEVERE CONGESTION 57 TYLENOL COLD + FLU + COUGH FOR ADULTS/NIGHT 57 TYLENOL COLD MAX 57 TYLENOL COLD MULTI-SYMPTOM NIGHTTIME 57 TYLENOL COLD MULTI-SYMPTOM SEVERE DAYTIME 57 TYLENOL COLD PLUS FLU SEVERE FOR ADULTS DAY/NIGHT 57 TYLENOL COLD/COUGH/RUNNYNOSECHILDRENS 57 TYLENOL COLD/COUGH/SORETHROAT CHILDRENS 57 TYLENOL EXTRA STRENGTH 4 TYLENOL INFANTS 4 TYLENOL INFANTS PAIN+FEVER 4 TYLENOL SINUS SEVERE 57 TYLENOL WARMING COUGH & SEVER CONGESTION DAYTIME 58 TYLENOL/CODEINE #3 6 TYLENOL/CODEINE #4 6 UDAMIN SP 95 UDENYCA 71 ULORIC 71 ULTICARE SYRINGE/LOWDEADSPACE/3ML/22G X1-1/2" 85 ULTICARE TUBERCULIN SAFETY SYRINGE/1ML/25G X5/8" 85

Index 28

ULTRA OMEGA 3 102 VANCOMYCIN HCL + VASOTEC 28 ULTRA OMEGA-3 FISH OIL BURP-LESS 102 ULTRACET 6 ULTRAM 5 ULTRAVATE 63 UNASYN 106 UNASYN BULK PACK 106

SYRSPENDSF PH4 10 VANCOMYCIN HYDROCHLORIDE 10 VANCOMYCIN HYDROCHLORIDE/DEXTROSE 10 VANISHPOINT SAFETY SYRINGE/3ML/20GX1" 86 VANISHPOINT SAFETY

VECTICAL VEMLIDY venlafaxine hcl verapamil hcl VERELAN VERELAN PM VERSA-NEB

62 38 21

39,40 40 40

UNISOM SLEEPGELS UNISOM SLEEPMELTS

72 72

SYRINGE/3ML/21GX1-1/2"86

COMPRESSOR/NEBULIZERSYSTEM 89

UNISOM SLEEPTABS 72 URE-K 63 urea 63 URECHOLINE 113 UROCIT-K 10 70 UROCIT-K 15 70 UROCIT-K 5 70 UROXATRAL 70 URSO 250 69 URSO FORTE 69 ursodiol 69 UTIBRON NEOHALER 15 VABOMERE 9 VAGIFEM 117 valacyclovir hcl 38 VALCYTE 37 valganciclovir hcl 37 VALIUM 12 valproate sodium 18 valproic acid 19 valsartan 29 valsartan-hydrochlorothiazide

30 VALTREX 38 VANACLEAR PD 25 VANACOF 58

VANISHPOINT SAFETY SYRINGE/3ML/22GX1" 86 VANISHPOINT SAFETY SYRINGE/3ML/22GX1-1/2"

86 VANISHPOINT SAFETY SYRINGE/3ML/23GX1" 86 VANISHPOINT SAFETY SYRINGE/3ML/23GX1-1/2"

86 VANISHPOINT SAFETY SYRINGE/3ML/25GX1" 86 VANISHPOINT SAFETY SYRINGE/3ML/25GX1-1/2"

86 VANISHPOINT SAFETY SYRINGE/3ML/25GX5/8" 86 VANISHPOINT SYRINGE/3ML/20G X 1" 86 VANISHPOINT SYRINGE/3ML/21G X 1-1/2" 86 VANISHPOINT SYRINGE/3ML/22G X 1" 86 VANISHPOINT SYRINGE/3ML/22G X 1-1/2" 86 VANISHPOINT SYRINGE/3ML/23G X 1" 86 VANISHPOINT SYRINGE/3ML/23G X 1-1/2" 86 VANISHPOINT

VIBRAMYCIN 110 VICKS DAYQUIL COUGH 45 VICKS DAYQUIL MUCUS CONTROL DM 58 VICKS DAYQUIL/NYQUILCOUGH 58 VICKS DAYQUIL/NYQUILSEVERE 58 VICKS NYQUIL CHILDRENS COLD/COUGH 58 VICKS NYQUIL COLD & FLU 58 VICKS NYQUIL COLD & FLU NIGHTTIME RELIEF 58 VICKS NYQUIL COUGH 58 VICKS NYQUIL HBP COLD & FLU 58 VICKS NYQUIL SEVERE COLD& FLU MAX STRENGTH 58 VICKS SINEX 12 HOUR DECONGESTANT 101 VICKS SINEX DAYQUIL/NYQUILDAYTIME/NIGHTTIME SINUSRELIEF 58 VICKS SINEX DAYTIME/NIGHTTIME/CONGESTION/PRESSURE &PAIN 58 VICKS SINEX MOISTURIZING 101 VICKS SINEX SEVERE 101

VANACOF AC VANACOF DM VANACOF-8 VANAHIST PD VANAMINE PD VANATAB AC VANATAB DM VANCOCIN VANCOCIN HCL VANCOMYCIN vancomycin hcl

58 58 58 25 26 58 58 10 10 10

9

SYRINGE/3ML/25G X 1" 86 VANISHPOINT SYRINGE/3ML/25G X 1-1/2" 86 VANISHPOINT SYRINGE/3ML/25G X 5/8" 86 VANISHPOINT TUBERCULIN SYRINGE 1ML/25G X 5/8" 86 VANISHPOINT TUBERCULIN SYRINGE 1ML/27GX1/2" 86 VAQTA 116 VARIVAX 116 VASERETIC 30

VICKS SINEX SEVERE NASALDECONGESTANT 101 VICTOZA 22 VIDEX EC 37 VIDEXPEDIATRIC 37 VIGAMOX 104 VIL-RX 97 VIMPAT 18 VINATE M 97 VINATE ONE 97 VIOS AEROSOL DELIVERY SYSTEM 89

Index 29

VIOS LC PLUS AEROSOL WELLBUTRIN XL 19 ZENPEP 66 DELIVERY SYSTEM VIOS LC PLUS AEROSOL DELIVERY SYSTEM

90 WESTHROID WP THYROID

110 110

ZERBAXA ZERIT

40 37

DELUXE 90 XALATAN 105 ZESTORETIC 30 VIOS LC PLUS AEROSOL DELIVERY SYSTEM PEDIATRIC 90 VIOS LC SPRINT AEROSOL

XALKORI XANAX XANAX XR

32 12 12

ZESTRIL ZETIA ZETONNA

28 28

100 DELIVERY SYSTEM 90 XARELTO 15 ZIAC 30 VIOS LC SPRINT AEROSOL XARELTO STARTER ZIAGEN 37 DELIVERY SYSTEM PACK 15 zidovudine 37 PEDIATRIC 90 XELJANZ 2 VIOS LC SPRINT DELUXE zinc oxide (topical) 65

XENLETA 11 AEROSOL DELIVERY ZIOPTAN 105 SYSTEM 90 XERAVA 109 ziprasidone hcl 33 VIRACEPT 37 XEROSTOMIA RELIEF

ZITHROMAX 74 SPRAY 94 VIRAMUNE 37 XHANCE 100 ZITHROMAX TRI-PAK 74 VIRAMUNE XR 37 XIFAXAN 9 ZITHROMAX Z-PAK 74 VIRAZOLE 38 XIMINO 110 ZOCOR 28 VIREAD 37 XLEAR SINUS CARE ZOFRAN 24 VIROPTIC 104 SPRAY 99 ZOFRAN ODT 24 VISTARIL 11 XLEAR SINUS CARE ZOLINZA 32 VITAFOL-OB 97 SPRAY/KIDS 99 XOFLUZA 38 zolmitriptan 91 VITAMIN D2 117 ZOLOFT 20 XOLEGEL 61 VITAMIN D3 118 XOLIDO 65 zolpidem tartrate 73 vitamin e 118 ZOMIG 91 XOPENEX HFA 15 VITAMIN E 118 ZOMIG ZMT 91 XTAMPZA ER 5 vitamin e 118 ZONEGRAN 18 XYLOCAINE 74 VITATHELY/GINGER 97 zonisamide 18 XYLOCAINE-MPF 74 VIVELLE-DOT 68 ZORTRESS 94 XYZAL ALLERGY 24HR 27 VIVITROL 24 XYZAL ALLERGY 24HR ZOSYN 106 VOL-NATE 97 CHILDRENS 27 ZOVIRAX 38,62 VOL-PLUS 97 Y-TUSS 58 ZYBAN 108 VOL-TAB RX 97 YASMIN 28 43 ZYLOPRIM 71 VOLTAREN 60 YAZ 43 ZYNCOF 58 VOTRIENT 32 YUPELRI 13 ZYPREXA 35 VPRIV 71 Z-TUSS AC 58 ZYPREXA ZYDIS 35 VYVANSE 1 ZACLIR CLEANSING 60 ZYRTEC ALLERGY 27 WAL-FLU COLD & SORE ZADITOR 105 ZYRTEC ALLERGY THROAT 58

WAL-FLU SEVERE COLD zafirlukast 13 CHILDRENS 27 ZYRTEC CHILDRENS DAYTIME 58 ZANAFLEX 97 ALLERGY 27 WAL-FLU SEVERE COLD ZANTAC 112 ZYRTEC-D NIGHT TIME 58 ZANTAC 150 MAXIMUM ALLERGY/CONGESTION 58 WAL-SLEEP Z LIQUID STRENGTH 112 ZYVOX 11 SHOTS 72 ZANTAC 75 112 WAL-TUSSIN COUGH RELIEF ZZZQUIL 72

CHILDRENS 45 ZARONTIN 18 WALGREENS GLUCOSE 22 ZEMAIRA 109 warfarin sodium 15 ZEMDRI 2 WELLBUTRIN SR 19 ZEMPLAR 68

Index 30

Documents

Arizona Complete Health-Complete Care Plan Lista completa ......La lista completa de medicamentos de Arizona Complete Health-Complete Care Plan incluye medicamentos que han sido revisados