2020 list of covered drugs/formulary - aetna · 15/10/2019 · a day, 7 days a week. the call is...

2020 List of Covered

Drugs/Formulary

AETNA BETTER HEALTH® OF OHIO a MyCare Ohio plan (Medicare-Medicaid Plan)

Aetna Better Health of Ohio, a MyCare Ohio plan (Medicare-Medicaid Plan)is a health plan that contracts with Medicare and Ohio Medicaid

to provide benefits of both programs to enrollees.

For more recent information or other questions, please contact us at 1‑855‑364‑0974 (TTY: 711), 24 hours a day, 7 days a week or visit

aetnabetterhealth.com/ohio

92.05.300.1-OH M Updated on 10/15/2019 H7172_20DRUG LST R FINAL ACCEPTED

http://aetnabetterhealth.com/ohio

If you have questions, please call Aetna Better Health of Ohio at 1-855-364-0974 (TTY: 711), 24 hours a day, 7 days a week. If you need to speak to your care manager, please call 1-855-364-0974 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more information, visit www.aetnabetterhealth.com/ohio. I

Aetna Better Health of Ohio | 2020 List of Covered Drugs (Formulary)

Introduction This document is called the List of Covered Drugs (also known as the Drug List). It tells you which prescription drugs and over-the-counter drugs and items are covered by Aetna Better Health of Ohio. The Drug List also tells you if there are any special rules or restrictions on any drugs covered by Aetna Better Health of Ohio. Key terms and their definitions appear in the last chapter of the Member Handbook .

Table of Contents A. Disclaimers ......................................................................................................................................................III

B. Frequently Asked Questions (FAQ)...............................................................................................................IV

B1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the “Drug List” for short.) ............................................................IV

B2. Does the Drug List ever change? .........................................................................................................IV

B3. What happens when there is a change to the Drug List?..................................................................V

B4. Are there any restrictions or limits on drug coverage or any required actions to take to get certain drugs? ...................................................................................................VI

B5. How will you know if the drug you want has limitations or if there are required actions to take to get the drug? ...........................................................................................................VI

B6. What happens if we change our rules about some drugs (for example, prior authorization (approval), quantity limits, and/or step therapy restrictions)? ................................VI

B7. How can you find a drug on the Drug List? ...................................................................................... VII

B8. What if the drug you want to take is not on the Drug List?............................................................ VII

B9. What if you are a new Aetna Better Health of Ohio member and can’t find your drug on the Drug List or have a problem getting your drug? ............................................... VII

B10. Can you ask for an exception to cover your drug?......................................................................... VIII

B11. How can you ask for an exception?.....................................................................................................IX

B12. How long does it take to get an exception? .......................................................................................IX

B13. What are generic drugs?.......................................................................................................................IX

B14. What are OTC drugs? ............................................................................................................................IX

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If you have questions, please call Aetna Better Health of Ohio at 1-855-364-0974 (TTY: 711), 24 hours a day, 7 days a week. If you need to speak to your care manager, please call 1-855-364-0974 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more information, visit www.aetnabetterhealth.com/ohio. II

B15. Does Aetna Better Health of Ohio cover non-drug OTC products? ................................................IX

B16. What is your copay? ..............................................................................................................................IX

B17. What are drug tiers?...............................................................................................................................X

C. List of Covered Drugs by Medical Condition...............................................................................................XI

D. Index of Covered Drugs............................................................................................................................. 172


If you have questions, please call Aetna Better Health of Ohio at 1-855-364-0974 (TTY: 711), 24 hours a day, 7 days a week. If you need to speak to your care manager, please call 1-855-364-0974 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more information, visit www.aetnabetterhealth.com/ohio. III

A. Disclaimers This is a list of drugs that members can get in Aetna Better Health of Ohio.

❖ Aetna Better Health of Ohio is a health plan that contracts with both Medicare and Ohio Medicaid to provide benefits of both programs to enrollees.

❖ ATTENTION: If you speak Spanish or Somali, language assistance services, free of charge, are available to you. Call 1‑855‑364‑0974 (TTY: 711), 24 hours a day, 7 days a week. The call is free.

ATENCIÓN: Si habla español o somalí, tiene a su disposición servicios de idiomas gratuitos. Llame al1‑855‑364‑0974 (TTY: 711) las 24 horas del día, los 7 días de la semana. Esta llamada es gratuita.

FIIRI: Haddii aad ku hadasho Isbaanish ama Soomaali, adeegyada lluqadda, oo bilaash ah, ayaa laguu heli karaa adiga. Wac 1‑855‑364‑0974 (TTY: 711), 24 saacadood maalintii, 7 maalmood todobaadkii. Wicitaanku waa bilaash.

❖ You can get this document for free in other formats, such as large print, braille, or audio. Call 1‑855‑364‑0974 (TTY: 711), 24 hours a day, 7 days a week. The call is free.

❖ If you wish to make or change a standing request to receive materials in a language other than English or in an alternate format, you can call Aetna Better Health of Ohio Member Services at 1‑855‑364‑0974 (TTY: 711), 24 hours a day, 7 days a week.


If you have questions, please call Aetna Better Health of Ohio at 1-855-364-0974 (TTY: 711), 24 hours a day, 7 days a week. If you need to speak to your care manager, please call 1-855-364-0974 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more information, visit www.aetnabetterhealth.com/ohio. IV

B. Frequently Asked Questions (FAQ) Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer.

B1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the “Drug List” for short.)

The drugs on the List of Covered Drugs that starts on page 1 are the drugs covered by Aetna Better Health of Ohio. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as “network pharmacies.”

• Aetna Better Health of Ohio will cover all medically necessary drugs on the Drug List if:

° your doctor or other prescriber says you need them to get better or stay healthy, and

° you fill the prescription at an Aetna Better Health of Ohio network pharmacy.

• Aetna Better Health of Ohio may have additional steps to access certain drugs (see question B4 below).

You can also see an up-to-date list of drugs that we cover on our website at www.aetnabetterhealth.com/ohio or call Member Services at 1‑855‑364‑0974 (TTY: 711), 24 hours a day, 7 days a week. The call is free.

B2. Does the Drug List ever change? Yes, and Aetna Better Health of Ohio must follow Medicare and Medicaid rules when making changes. We may add or remove drugs on the Drug List during this year.

We may also change our rules about drugs. For example, we could:

• Decide to require or not require prior approval for a drug. (Prior approval is permission from Aetna Better Health of Ohio before you can get a drug.)

• Add or change the amount of a drug you can get (called quantity limits).

• Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.)

For more information on these drug rules, see question B4.

If you are taking a drug that was covered at the beginning of the year, we will generally not remove or change coverage of that drug during the rest of the year unless:

• a new, cheaper drug comes on the market that works as well as a drug on the Drug List now, or

• we learn that a drug is not safe, or

• a drug is removed from the market.



If you have questions, please call Aetna Better Health of Ohio at 1-855-364-0974 (TTY: 711), 24 hours a day, 7 days a week. If you need to speak to your care manager, please call 1-855-364-0974 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more information, visit www.aetnabetterhealth.com/ohio. V

Questions B3 and B6 below have more information on what happens when the Drug List changes.

• You can always check Aetna Better Health of Ohio’s up to date Drug List online at www.aetnabetterhealth.com/ohio.

• You can also call Member Services to check the current Drug List at 1‑855‑364‑0974 (TTY: 711), 24 hours a day, 7 days a week.

B3. What happens when there is a change to the Drug List? Some changes to the Drug List will happen immediately. For example:

• A new generic drug becomes available. Sometimes, a new generic drug comes on the market that works as well as a brand name drug on the Drug List now. When that happens, we may remove the brand name drug and add the new generic drug, but your cost for the new drug will stay the same. When we add the new generic drug, we may also decide to keep the brand name drug on the list but change its coverage rules or limits.

° We may not tell you before we make this change, but we will send you information about the specific change we made once it happens.

° You or your provider can ask for an exception from these changes. We will send you a notice with the steps you can take to ask for an exception. Please see question B10 for more information on exceptions.

• A drug is taken off the market. If the Food and Drug Administration (FDA) says a drug you are taking is not safe or the drug’s manufacturer takes a drug off the market, we will take it off the Drug List. If you are taking the drug, we will let you know that.

• We will send you a letter telling you. We will also notify your doctor about this change, and will work with you to find another drug for your condition. Please contact your doctor if a drug you are taking is removed from the drug list.

We may make other changes that affect the drugs you take. We will tell you in advance about these other changes to the Drug List. These changes might happen if:

• The FDA provides new guidance or there are new clinical guidelines about a drug.

• We add a generic drug that is new to the market and

° Replace a brand name drug currently on the Drug List or

° Change the coverage rules or limits for the brand name drug.

• We add a generic drug that is not new to the market and

° Replace a brand name drug currently on the Drug List or

° Change the coverage rules or limits for the brand name drug.

When these changes happen, we will:

• Tell you at least 30 days before we make the change to the Drug List or

• Let you know and give you a 30-day supply of the drug in an outpatient setting and 31-day supply of the drug in a long-term care facility after you ask for a refill.



If you have questions, please call Aetna Better Health of Ohio at 1-855-364-0974 (TTY: 711), 24 hours a day, 7 days a week. If you need to speak to your care manager, please call 1-855-364-0974 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more information, visit www.aetnabetterhealth.com/ohio. VI

This will give you time to talk to your doctor or other prescriber. He or she can help you decide:

• If there is a similar drug on the Drug List you can take instead or

• Whether to ask for an exception from these changes. To learn more about exceptions, seequestion B10.

B4. Are there any restrictions or limits on drug coverage or any required actions to take to get certain drugs?

Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you or your doctor or other prescriber must do something before you can get the drug. For example:

• Prior approval (or prior authorization): For some drugs, you or your doctor or otherprescriber must get approval from Aetna Better Health of Ohio before you fill your prescription.Aetna Better Health of Ohio may not cover the drug if you do not get approval.

• Quantity limits: Sometimes Aetna Better Health of Ohio limits the amount of a drug youcan get.

• Step therapy: Sometimes Aetna Better Health of Ohio requires you to do step therapy. Thismeans you will have to try drugs in a certain order for your medical condition. You might haveto try one drug before we will cover another drug. If your doctor thinks the first drug doesn’twork for you, then we will cover the second.

You can find out if your drug has any additional requirements or limits by looking in the tables on page 1 - 171. You can also get more information by visiting our web site at www.aetnabetterhealth.com/ohio. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy.

You can ask for an exception from these limits. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Please see questions B10-B12 for more information about exceptions.

B5. How will you know if the drug you want has limitations or if there are required actions to take to get the drug?

The List of Covered Drugs on page 1 has a column labeled “Necessary actions, restrictions, or limits on use.”

B6. What happens if we change our rules about some drugs (for example, prior authorization (approval), quantity limits, and/or step therapy restrictions)?

In some cases, we will tell you in advance if we add or change prior approval, quantity limits, and/or step therapy restrictions on a drug. See question B3 for more information about this advance notice and situations where we may not be able to tell you in advance when our rules about drugs on the Drug List change.



If you have questions, please call Aetna Better Health of Ohio at 1-855-364-0974 (TTY: 711), 24 hours a day, 7 days a week. If you need to speak to your care manager, please call 1-855-364-0974 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more information, visit www.aetnabetterhealth.com/ohio. VII

B7. How can you find a drug on the Drug List? There are two ways to find a drug:

• You can search alphabetically (if you know how to spell the drug), or

• You can search by medical condition.

To search alphabetically, go to the Index of Covered Drugs section. You can find it on page 172. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information.

To search by medical condition, find the section labeled “List of drugs by medical condition” on page 1. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular. That is where you will find drugs that treat heart conditions.

B8. What if the drug you want to take is not on the Drug List? If you don’t see your drug on the Drug List, call Member Services at 1‑855‑364‑0974 (TTY: 711), 24 hours a day, 7 days a week and ask about it. If you learn that Aetna Better Health of Ohio will not cover the drug, you can do one of these things:

• Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or

• You can ask the health plan to make an exception to cover your drug. Please see questions B10-B12 for more information about exceptions.

B9. What if you are a new Aetna Better Health of Ohio member and can’t find your drug on the Drug List or have a problem getting your drug?

We can help. We may cover a temporary 30-day supply of your drug in an outpatient setting and 31-day supply of your drug in a long-term care facility during the first 90 days you are a member of Aetna Better Health of Ohio. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception.

If your prescription is written for fewer days, we will allow multiple refills to provide up to a maximum of 30-day supply of medication in an outpatient setting and 31-day supply of medication in a long-term care facility.

We will cover a 30-day supply of a drug in an outpatient setting and 31-day supply of a drug in a long-term care facility if:

• you are taking a drug that is not on our Drug List, or

• health plan rules do not let you get the amount ordered by your prescriber, or


If you have questions, please call Aetna Better Health of Ohio at 1-855-364-0974 (TTY: 711), 24 hours a day, 7 days a week. If you need to speak to your care manager, please call 1-855-364-0974 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more

VIII information, visit www.aetnabetterhealth.com/ohio.

• the drug requires prior approval by Aetna Better Health of Ohio, or

• you are taking a drug that is part of a step therapy restriction.

If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List or if you cannot easily get the drug you need, we can help. If you have been in the plan for more than 90 days, live in a long-term care facility, and need a supply right away:

• We will cover one 31-day supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new Aetna Better Health of Ohio member.

• This is in addition to the temporary supply during the first 90 days you are a member of Aetna Better Health of Ohio.

Current members with a change in level of care

• We will cover a one-time temporary 31-day supply if you move from a hospital or a long-term care facility to a home setting and:

° You need a drug that is not on our drug list, or

° Your ability to get the drug is limited

• We will cover a one-time temporary 31-day supply (see the note below for exceptions) if you move into or out of a long-term care setting and:

° You need a drug that is not on our drug list, or

° Your ability to get the drug is limited

Note: Oral brand name solid dosage forms such as tablets or capsules are limited to 14 day fills with exceptions as required by Medicare Part D rules. To ask for a temporary supply of a drug, call Member Services.

During the time when you are getting a temporary supply of a drug, you should talk to your provider to decide what to do when the temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. For example, you can ask the plan to cover a drug even though it is not on the Drug List. Or you can ask the plan to cover the drug without limits. If your provider says you have a good medical reason for an exception, he or she can help you ask for one.

B10. Can you ask for an exception to cover your drug? Yes. You can ask Aetna Better Health of Ohio to make an exception to cover a drug that is not on the Drug List.

You can also ask us to change the rules on your drug.

• For example, Aetna Better Health of Ohio may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more.

• Other examples: You can ask us to drop step therapy restrictions or prior approval requirements.


If you have questions, please call Aetna Better Health of Ohio at 1-855-364-0974 (TTY: 711), 24 hours a day, 7 days a week. If you need to speak to your care manager, please call 1-855-364-0974 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more information, visit www.aetnabetterhealth.com/ohio. IX

B11. How can you ask for an exception? To ask for an exception, call Member Services. A Member Services representative will work with you and your provider to help you ask for an exception. You can also read Chapter 9 of the Member Handbook to learn more about exceptions.

B12. How long does it take to get an exception? First, we must get a statement from your prescriber supporting your request for an exception. After we get the statement, we will give you a decision on your exception request within 72 hours.

If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of getting your prescriber’s supporting statement.

B13. What are generic drugs? Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don’t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA).

Aetna Better Health of Ohio covers both brand name drugs and generic drugs.

B14. What are OTC drugs? OTC stands for “over-the-counter”. Aetna Better Health of Ohio covers some OTC drugs when they are written as prescriptions by your provider.

You can read the Aetna Better Health of Ohio Drug List to see what OTC drugs are covered.

B15. Does Aetna Better Health of Ohio cover non‑drug OTC products? Aetna Better Health of Ohio covers some non-drug OTC products when they are written as prescriptions by your provider.

Examples of non-drug OTC products include alcohol swabs, or insect repellent. There is no cost sharing or copays.

You can read the Aetna Better Health of Ohio Drug List to see what non-drug OTC products are covered.

B16. What is your copay? As an Aetna Better Health of Ohio member, you have no copays for prescription and OTC drugs as long as you follow Aetna Better Health of Ohio’s rules.


If you have questions, please call Aetna Better Health of Ohio at 1-855-364-0974 (TTY: 711), 24 hours a day, 7 days a week. If you need to speak to your care manager, please call 1-855-364-0974 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more information, visit www.aetnabetterhealth.com/ohio. X

B17. What are drug tiers? Tiers are groups of drugs on our Drug List.

• Tier 1 drugs are Part D prescription brand name and generic drugs.

• Tier 2 drugs are Part D prescription brand name and generic drugs.

• Tier 3 drugs are Non-Part D prescription and over-the-counter drugs.

All tiers have no copay.


XI

C. List of Covered Drugs by Medical Condition The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular. That is where you will find drugs that treat heart conditions.

The following list of covered drugs gives you information about the drugs covered by Aetna Better Health of Ohio. If you have trouble finding your drug in the list, turn to the Index of Covered Drugs that begins on page 172. The index alphabetically lists all drugs covered by Aetna Better Health of Ohio.

The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., PRADAXA), and generic drugs are listed in lower-case italics (e.g., amoxicillin).

The information in the necessary actions, restrictions, or limits on use column tells you if Aetna Better Health of Ohio has any rules for covering your drug.

Here are the meanings of the codes used in the “Necessary actions, restrictions, or limits on use” column:

* = Non-Part D drugs or OTC items that are covered by Medicaid

PA = Prior Authorization QL = Quantity Limits ST = Step Therapy

NM = Not available at Mail-order

B/D = Covered under Medicare B or D LA = Limited Access

Note: The asterisk (*) next to a drug means the drug is not a “Part D drug.” The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage).

• In addition, if you are getting Extra Help to pay for your prescriptions, you will not get any Extra Help to pay for these drugs. For more information on Extra Help, please see the call-out box below.

Extra Help is a Medicare program that helps people with limited incomes and resources reduce Medicare Part D prescription drug costs, such as premiums, deductibles, and copays. Extra Help is also called the “Low-Income Subsidy,” or “LIS.”

• These drugs also have different rules for appeals. An appeal is a formal way of asking us to review a coverage decision and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or Medicaid.

• If you or your doctor disagrees with our decision, you can appeal. To ask for instructions on how to appeal, call Member Services at 1‑855‑364‑0974 (TTY: 711), 24 hours a day, 7 days a week. You can also read the Chapter 9 of the Member Handbook to learn how to appeal a decision.

If you have questions, please call Aetna Better Health of Ohio at 1-855-364-0974 (TTY: 711), 24 hours a day, 7 days a week. If you need to speak to your care manager, please call 1-855-364-0974 (TTY: 711), 24 hours a day, 7 days a week. These calls are free. For more information, visit www.aetnabetterhealth.com/ohio.


table A

Name of drug

What the drug will cost

you (tier

level)

Necessary actions, restrictions,

or limits on use ANALGESICS - DRUGS TO TREAT PAIN AND INFLAMMATION

GOUT - DRUGS TO TREAT GOUT allopurinol tab $0(1) colchicine w/ probenecid $0(1) COLCRYS $0(2) QL (120 tabs / 30 days) MITIGARE $0(2) QL (60 caps / 30 days) probenecid $0(1)

MISCELLANEOUS acephen $0(3) NM; * acetaminophen ELIX; LIQD; SOLN; SUPP; TABS; TBCR

$0(3) NM; *

acetaminophen childrens $0(3) NM; * acetaminophen extra stren $0(3) NM; * acetaminophen infants $0(3) NM; * adult aspirin regimen $0(3) NM; * arthritis pain relief TBCR $0(3) NM; * arthritis pain reliever $0(3) NM; * aspir-low $0(3) NM; * aspirin CHEW; TABS; TBEC $0(3) NM; * ASPIRIN SUPP $0(3) NM; * aspirin 81 $0(3) NM; * aspirin adult low dose $0(3) NM; * aspirin adult low strengt $0(3) NM; * aspirin childrens $0(3) NM; * aspirin ec low dose $0(3) NM; * aspirin enteric coated ad $0(3) NM; * aspirin low dose $0(3) NM; * aspirin low strength $0(3) NM; * bayer aspirin $0(3) NM; * bayer aspirin ec low dose $0(3) NM; * bayer low dose $0(3) NM; * betatemp childrens $0(3) NM; * chewable acetaminophen ch $0(3) NM; *

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid Formulary ID 00020351 v6 1

Name of drug


you (tier

level)


or limits on use childrens acetaminophen $0(3) NM; * childrens apap $0(3) NM; * childrens aspirin $0(3) NM; * childrens aspirin low str $0(3) NM; * childrens pain reliever $0(3) NM; * childrens silapap $0(3) NM; * childrens tactinal $0(3) NM; * ecotrin $0(3) NM; * ecotrin low strength $0(3) NM; * ecpirin $0(3) NM; * ed-apap $0(3) NM; * eq aspirin ec $0(3) NM; * feverall adults $0(3) NM; * feverall childrens $0(3) NM; * FEVERALL INFANTS $0(3) NM; * feverall junior strength $0(3) NM; * gnp 8 hour pain reliever $0(3) NM; * gnp acetaminophen $0(3) NM; * gnp adult aspirin low str $0(3) NM; * gnp arthritis pain relief $0(3) NM; * gnp aspirin $0(3) NM; * gnp aspirin low dose $0(3) NM; * gnp childrens easy-melts $0(3) NM; * gnp childrens pain relief $0(3) NM; * gnp infants pain relief $0(3) NM; * gnp infants pain/fever $0(3) NM; * gnp pain & fever children $0(3) NM; * gnp pain relief $0(3) NM; * gnp pain relief extra str $0(3) NM; * goodsense arthritis pain $0(3) NM; * goodsense aspirin $0(3) NM; * goodsense aspirin adult l $0(3) NM; * goodsense aspirin low dos $0(3) NM; * goodsense pain & fever ch $0(3) NM; *


Name of drug


you (tier

level)


or limits on use goodsense pain & fever in $0(3) NM; * goodsense pain relief $0(3) NM; * goodsense pain relief ext $0(3) NM; * healthy mama shake that a $0(3) NM; * hm acetaminophen children $0(3) NM; * hm arthritis pain relief $0(3) NM; * hm aspirin $0(3) NM; * hm aspirin ec $0(3) NM; * hm aspirin ec low dose $0(3) NM; * hm pain & fever childrens $0(3) NM; * hm pain & fever infants $0(3) NM; * hm pain relief extra stre $0(3) NM; * hm pain reliever $0(3) NM; * 8 hour arthritis pain rel $0(3) NM; * 8hr muscle aches & pain $0(3) NM; * kp aspirin $0(3) NM; * liquid pain relief $0(3) NM; * little remedies fever/pai $0(3) NM; * little remedies for fever $0(3) NM; * mapap $0(3) NM; * mapap acetaminophen extra $0(3) NM; * mapap arthritis pain $0(3) NM; * mapap childrens $0(3) NM; * medi-tabs extra strength $0(3) NM; * menstrual pain relief mul $0(3) NM; * non-aspirin $0(3) NM; * non-aspirin childrens $0(3) NM; * non-aspirin extra strengt $0(3) NM; * non-aspirin pain relief $0(3) NM; * non-aspirin pain relief e $0(3) NM; * nortemp $0(3) NM; * NORTEMP INFANTS $0(3) NM; * pain & fever $0(3) NM; * pain & fever childrens $0(3) NM; *


Name of drug


you (tier

level)


or limits on use pain & fever extra streng $0(3) NM; * pain & fever infants $0(3) NM; * pain relief extra strengt $0(3) NM; * pain reliever extra stren $0(3) NM; * pharbetol $0(3) NM; * pharbetol extra strength $0(3) NM; * px arthritis pain relief $0(3) NM; * px aspirin $0(3) NM; * px childrens pain relief $0(3) NM; * px pain relief extra stre $0(3) NM; * qc acetaminophen 8 hours $0(3) NM; * qc arthritis pain relief $0(3) NM; * qc aspirin $0(3) NM; * qc aspirin low dose $0(3) NM; * qc chewable aspirin low d $0(3) NM; * qc enteric aspirin $0(3) NM; * qc non-aspirin childrens $0(3) NM; * qc non-aspirin extra stre $0(3) NM; * qc non-aspirin jr strengt $0(3) NM; * qc pain relief $0(3) NM; * qc pain relief childrens $0(3) NM; * qc pain relief extra stre $0(3) NM; * qc pain relief infants $0(3) NM; * sb arthritis pain relief $0(3) NM; * sb aspirin $0(3) NM; * sb aspirin adult low stre $0(3) NM; * sb childrens aspirin $0(3) NM; * sb low dose asa ec $0(3) NM; * sb non-aspirin $0(3) NM; * sb non-aspirin extra stre $0(3) NM; * sb pain reliever children $0(3) NM; * sb pain reliever extra st $0(3) NM; * sm 8 hour pain relief $0(3) NM; * sm arthritis pain relief $0(3) NM; *


Name of drug


you (tier

level)


or limits on use sm arthritis pain relieve $0(3) NM; * sm aspirin $0(3) NM; * sm aspirin adult low stre $0(3) NM; * sm aspirin ec low strengt $0(3) NM; * sm aspirin enteric coated $0(3) NM; * sm aspirin low dose $0(3) NM; * sm childrens aspirin $0(3) NM; * sm pain & fever childrens $0(3) NM; * sm pain & fever infants $0(3) NM; * sm pain relief extra stre $0(3) NM; * sm pain reliever $0(3) NM; * sm pain reliever extra st $0(3) NM; * st joseph low dose aspiri $0(3) NM; * tactinal $0(3) NM; * tactinal extra strength $0(3) NM; * tension headache $0(3) NM; * tgt acetaminophen childre $0(3) NM; * tgt acetaminophen extra s $0(3) NM; * tgt arthritis pain relief $0(3) NM; * tgt aspirin $0(3) NM; * tgt aspirin low dose $0(3) NM; * tgt childrens acetaminoph $0(3) NM; * tgt childrens aspirin $0(3) NM; * tgt enteric-coated aspiri $0(3) NM; * v-r aspirin ec max str $0(3) NM; *

NSAIDS - DRUGS TO TREAT PAIN AND INFLAMMATION advil junior strength $0(3) NM; * all day pain relief $0(3) NM; * all day relief $0(3) NM; * celecoxib CAPS 50mg $0(1) QL (240 caps / 30 days) celecoxib CAPS 100mg $0(1) QL (120 caps / 30 days) celecoxib CAPS 200mg $0(1) QL (60 caps / 30 days) celecoxib CAPS 400mg $0(1) QL (30 caps / 30 days) childrens ibuprofen $0(3) NM; *


Name of drug


you (tier

level)


or limits on use diclofenac potassium $0(1) QL (120 tabs / 30 days) diclofenac sodium TB24; TBEC $0(1) diflunisal TABS $0(1) eq naproxen sodium $0(3) NM; * eql naproxen sodium $0(3) NM; * etodolac $0(1) etodolac er $0(1) flanax pain relief $0(3) NM; * flurbiprofen TABS $0(1) gnp all day pain relief $0(3) NM; * gnp childrens ibuprofen $0(3) NM; * gnp ibuprofen $0(3) NM; * gnp ibuprofen infants $0(3) NM; * gnp ibuprofen junior stre $0(3) NM; * gnp naproxen sodium $0(3) NM; * goodsense ibuprofen $0(3) NM; * goodsense ibuprofen child $0(3) NM; * goodsense ibuprofen infan $0(3) NM; * goodsense ibuprofen junio $0(3) NM; * goodsense naproxen sodium $0(3) NM; * hm ibuprofen $0(3) NM; * hm ibuprofen childrens $0(3) NM; * hm ibuprofen ib $0(3) NM; * hm ibuprofen infants $0(3) NM; * hm naproxen sodium $0(3) NM; * ibu tab 600mg $0(1) ibu tab 800mg $0(1) ibu-200 $0(3) NM; * ibuprofen CAPS $0(3) NM; * ibuprofen SUSP $0(1) ibuprofen TABS 200mg $0(3) NM; * ibuprofen TABS 400mg, 600mg, 800mg $0(1) ibuprofen childrens $0(3) NM; * ibuprofen infants $0(3) NM; *


Name of drug


you (tier

level)


or limits on use ibuprofen junior strength $0(3) NM; * infants ibuprofen $0(3) NM; * kls naproxen sodium $0(3) NM; * ks ibuprofen $0(3) NM; * medi-profen $0(3) NM; * mediproxen $0(3) NM; * meijer ibuprofen $0(3) NM; * meloxicam TABS $0(1) nabumetone TABS $0(1) naproxen TABS $0(1) naproxen dr $0(1) naproxen sodium CAPS $0(3) NM; * naproxen sodium TABS 220mg $0(3) NM; * naproxen sodium TABS 275mg, 550mg $0(1) piroxicam CAPS $0(1) provil $0(3) NM; * px all day relief $0(3) NM; * px childrens profen ib $0(3) NM; * px ibuprofen $0(3) NM; * px ibuprofen junior stren $0(3) NM; * px infants profen ib $0(3) NM; * qc ibuprofen $0(3) NM; * qc ibuprofen ib $0(3) NM; * qc ibuprofen infants $0(3) NM; * qc naproxen sodium $0(3) NM; * sb ibuprofen $0(3) NM; * sb infants ibuprofen $0(3) NM; * sb naproxen sodium $0(3) NM; * sm childrens ibuprofen $0(3) NM; * sm ibuprofen $0(3) NM; * sm ibuprofen ib $0(3) NM; * sm ibuprofen jr $0(3) NM; * sm infants ibuprofen $0(3) NM; * sm naproxen sodium $0(3) NM; *


Name of drug


you (tier

level)


or limits on use sulindac TABS $0(1) tgt childrens ibuprofen $0(3) NM; * tgt ibuprofen $0(3) NM; * tgt ibuprofen childrens $0(3) NM; * tgt ibuprofen junior stre $0(3) NM; * tgt naproxen sodium $0(3) NM; *

OPIOID ANALGESICS - DRUGS TO TREAT PAIN acetaminophen w/ codeine 300-15mg $0(1) QL (400 tabs / 30 days) acetaminophen w/ codeine 300-30mg $0(1) QL (360 tabs / 30 days) acetaminophen w/ codeine 300-60mg $0(1) QL (180 tabs / 30 days) acetaminophen w/ codeine soln $0(1) QL (2700 mL / 30 days) buprenorphine patch $0(1) QL (4 patches / 28 days), PA butorphanol tartrate SOLN 1mg/ml, 2mg/ml $0(2) nalbuphine hcl SOLN $0(2) tramadol hcl tab 50 mg $0(1) QL (240 tabs / 30 days) tramadol-acetaminophen $0(1) QL (240 tabs / 30 days)

OPIOID ANALGESICS, CII - DRUGS TO TREAT PAIN endocet 2.5-325mg $0(1) QL (360 tabs / 30 days) endocet 5-325mg $0(1) QL (360 tabs / 30 days) endocet 7.5-325mg $0(1) QL (240 tabs / 30 days) endocet 10-325mg $0(1) QL (180 tabs / 30 days) fentanyl citrate LPOP $0(2) QL (120 lozenges / 30 days), PA fentanyl patch 12 mcg/hr $0(1) QL (10 patches / 30 days), PA fentanyl patch 25 mcg/hr $0(1) QL (10 patches / 30 days), PA fentanyl patch 50 mcg/hr $0(1) QL (10 patches / 30 days), PA fentanyl patch 75 mcg/hr $0(1) QL (10 patches / 30 days), PA fentanyl patch 100 mcg/hr $0(1) QL (10 patches / 30 days), PA hydroco/apap tab 5-325mg $0(1) QL (240 tabs / 30 days) hydroco/apap tab 7.5-325 $0(1) QL (180 tabs / 30 days) hydroco/apap tab 10-325mg $0(1) QL (180 tabs / 30 days) hydrocodone-acetaminophen 7.5-325 mg/15ml $0(1) QL (2700 mL / 30 days) hydrocodone-ibuprofen tab 7.5-200 mg $0(1) QL (150 tabs / 30 days) hydromorphone hcl LIQD $0(1) QL (600 mL / 30 days)


Name of drug


you (tier

level)


or limits on use hydromorphone hcl SOLN 10mg/ml, 50mg/5ml, 500mg/50ml

$0(2) B/D

hydromorphone hcl TABS $0(1) QL (180 tabs / 30 days) HYSINGLA ER $0(2) QL (30 tabs / 30 days), PA lorcet hd tab 10-325mg $0(1) QL (180 tabs / 30 days) lorcet plus tab 7.5-325 $0(1) QL (180 tabs / 30 days) lorcet tab 5-325mg $0(1) QL (240 tabs / 30 days) methadone hcl SOLN 5mg/5ml, 10mg/5ml $0(1) QL (450 mL / 30 days), PA methadone hcl 5mg $0(1) QL (90 tabs / 30 days), PA methadone hcl 10mg $0(1) QL (90 tabs / 30 days), PA methadone hcl intensol $0(1) QL (90 mL / 30 days), PA morphine ext-rel tab $0(1) QL (90 tabs / 30 days), PA morphine sul inj 1mg/ml $0(2) B/D morphine sul inj 10mg/ml $0(2) B/D MORPHINE SULFATE SOLN 2mg/ml, 4mg/ml, 5mg/ml, 8mg/ml, 10mg/ml, 150mg/30ml

$0(2) B/D

morphine sulfate SOLN 4mg/ml, 8mg/ml, 10mg/ml

$0(2) B/D

morphine sulfate TABS $0(1) QL (180 tabs / 30 days) morphine sulfate oral soln 10mg/5ml $0(1) QL (900 mL / 30 days) morphine sulfate oral soln 20mg/5ml $0(1) QL (900 mL / 30 days) morphine sulfate oral soln 100mg/5ml $0(1) QL (180 mL / 30 days) NUCYNTA ER $0(2) QL (60 tabs / 30 days), PA oxycodone hcl CAPS $0(1) QL (180 caps / 30 days) oxycodone hcl CONC $0(1) QL (180 mL / 30 days) oxycodone hcl SOLN $0(1) QL (900 mL / 30 days) oxycodone hcl TABS $0(1) QL (180 tabs / 30 days) oxycodone w/ acetaminophen 2.5-325mg $0(1) QL (360 tabs / 30 days) oxycodone w/ acetaminophen 5-325mg $0(1) QL (360 tabs / 30 days) oxycodone w/ acetaminophen 7.5-325mg $0(1) QL (240 tabs / 30 days) oxycodone w/ acetaminophen 10-325mg $0(1) QL (180 tabs / 30 days) OXYCONTIN $0(2) QL (60 tabs / 30 days), PA

ANESTHETICS - DRUGS FOR NUMBING LOCAL ANESTHETICS

lidocaine hcl (local anesth.) $0(1) B/D


Name of drug


you (tier

level)


or limits on use lidocaine inj 0.5% $0(1) B/D lidocaine inj 1% $0(1) B/D lidocaine inj 1.5% preservative free (pf) $0(1) B/D

ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS ANTI-BACTERIALS - MISCELLANEOUS

amikacin sulfate SOLN $0(1) gentamicin in saline $0(1) gentamicin sulfate SOLN $0(1) neomycin sulfate TABS $0(1) paromomycin sulfate CAPS $0(1) streptomycin sulfate SOLR $0(2) SULFADIAZINE TABS $0(2) tobramycin NEBU $0(2) NM, PA tobramycin inj 1.2 gm/30ml $0(1) tobramycin inj 1.2gm $0(2) tobramycin inj 10mg/ml $0(1) tobramycin inj 80mg/2ml $0(1) tobramycin sulfate SOLN $0(1)

ANTI-INFECTIVES - MISCELLANEOUS albendazole TABS $0(2) ALINIA $0(2) atovaquone SUSP $0(2) aztreonam $0(1) CAYSTON $0(2) NM, LA, PA clindamycin cap 75mg $0(1) clindamycin cap 300mg $0(1) clindamycin hcl cap 150 mg $0(1) clindamycin phosphate in d5w $0(1) CLINDAMYCIN PHOSPHATE IN NACL $0(2) clindamycin phosphate inj $0(1) clindamycin soln 75mg/5ml $0(1) colistimethate sodium SOLR $0(1) cvs pinworm treatment $0(3) NM; * dapsone TABS $0(1)


Name of drug


you (tier

level)


or limits on use daptomycin $0(2) EMVERM $0(2) QL (12 tabs / 365 days) ertapenem sodium $0(1) imipenem-cilastatin $0(1) ivermectin TABS $0(1) linezolid in sodium chloride $0(2) linezolid inj $0(1) linezolid susp $0(2) linezolid tab 600mg $0(1) meropenem $0(1) methenamine hippurate $0(1) metronidazole TABS $0(1) metronidazole in nacl $0(1) NEBUPENT $0(2) B/D nitrofurantoin macrocrystal 50mg, 100mg $0(2) nitrofurantoin monohyd macro $0(2) PENTAM 300 $0(2) pentamidine isethionate $0(1) pinworm medicine $0(3) NM; * praziquantel TABS $0(1) reeses pinworm medicine SUSP $0(3) NM; * REESES PINWORM MEDICINE TABS $0(3) NM; * SIVEXTRO $0(2) sulfamethoxazole-trimethop ds $0(1) sulfamethoxazole-trimethoprim inj $0(1) sulfamethoxazole-trimethoprim susp $0(1) sulfamethoxazole-trimethoprim tab 400-80mg $0(1) SYNERCID $0(2) tigecycline $0(2) trimethoprim TABS $0(1) vancomycin hcl CAPS 125mg $0(1) QL (120 caps / 30 days) vancomycin hcl CAPS 250mg $0(2) QL (240 caps / 30 days) vancomycin hcl SOLR 1gm, 5gm, 10gm, 500mg, 750mg

$0(1)


Name of drug


you (tier

level)


or limits on use VANCOMYCIN IN NACL $0(2)

ANTIFUNGALS - DRUGS TO TREAT FUNGAL INFECTIONS ABELCET $0(2) B/D AMBISOME $0(2) B/D amphotericin b SOLR $0(1) B/D caspofungin acetate $0(2) fluconazole SUSR; TABS $0(1) fluconazole inj nacl 200 $0(1) fluconazole inj nacl 400 $0(1) flucytosine CAPS $0(2) griseofulvin microsize $0(1) griseofulvin ultramicrosize $0(1) itraconazole CAPS $0(1) PA ketoconazole TABS $0(1) PA MYCAMINE $0(2) NOXAFIL SUSP $0(2) QL (630 mL / 30 days) NOXAFIL TBEC $0(2) QL (93 tabs / 30 days) nystatin TABS $0(1) terbinafine hcl TABS $0(1) QL (90 tabs / year) voriconazole SOLR $0(2) PA voriconazole SUSR $0(2) PA voriconazole TABS 50mg $0(1) voriconazole TABS 200mg $0(2)

ANTIMALARIALS - DRUGS TO TREAT MALARIA atovaquone-proguanil hcl $0(1) chloroquine phosphate TABS $0(1) COARTEM $0(2) mefloquine hcl $0(1) primaquine phosphate 26.3mg $0(1) PRIMAQUINE PHOSPHATE 26.3mg $0(2) quinine sulfate CAPS $0(1) PA

ANTIRETROVIRAL AGENTS - DRUGS TO SUPPRESS HIV/AIDS INFECTION abacavir sulfate $0(1) APTIVUS $0(2)


Name of drug


you (tier

level)


or limits on use atazanavir sulfate $0(1) CRIXIVAN $0(2) didanosine $0(1) EDURANT $0(2) efavirenz CAPS 50mg $0(1) efavirenz CAPS 200mg $0(2) efavirenz TABS $0(2) EMTRIVA $0(2) fosamprenavir tab 700 mg $0(2) FUZEON $0(2) NM INTELENCE $0(2) INVIRASE $0(2) ISENTRESS $0(2) ISENTRESS HD $0(2) lamivudine $0(1) LEXIVA SUSP $0(2) nevirapine susp 50 mg/5ml $0(1) nevirapine tab 100mg er $0(1) nevirapine tab 200mg $0(1) nevirapine tab 400mg er $0(1) NORVIR PACK $0(2) NORVIR SOLN $0(2) PIFELTRO $0(2) PREZISTA SUSP $0(2) QL (400 mL / 30 days) PREZISTA TABS 75mg $0(2) QL (480 tabs / 30 days) PREZISTA TABS 150mg $0(2) QL (240 tabs / 30 days) PREZISTA TABS 600mg $0(2) QL (60 tabs / 30 days) PREZISTA TABS 800mg $0(2) QL (30 tabs / 30 days) RESCRIPTOR $0(2) REYATAZ PACK $0(2) ritonavir $0(1) SELZENTRY $0(2) stavudine $0(1) tenofovir disoproxil fumarate $0(1)


Name of drug


you (tier

level)


or limits on use TIVICAY $0(2) TROGARZO $0(2) NM, LA TYBOST $0(2) VIDEX EC 125mg $0(2) VIDEX PEDIATRIC $0(2) VIRACEPT $0(2) VIREAD POWD $0(2) VIREAD TABS 150mg, 200mg, 250mg $0(2) zidovudine cap 100mg $0(1) zidovudine syp 50mg/5ml $0(1) zidovudine tab 300mg $0(1)

ANTIRETROVIRAL COMBINATION AGENTS - DRUGS TO SUPPRESS HIV/AIDS INFECTION abacavir sulfate-lamivudine $0(1) abacavir sulfate-lamivudine-zidovudine $0(2) ATRIPLA $0(2) BIKTARVY $0(2) CIMDUO $0(2) COMPLERA $0(2) DELSTRIGO $0(2) DESCOVY $0(2) DOVATO $0(2) EVOTAZ $0(2) GENVOYA $0(2) JULUCA $0(2) KALETRA TAB 100-25MG $0(2) KALETRA TAB 200-50MG $0(2) lamivudine-zidovudine $0(1) lopinavir-ritonavir $0(1) ODEFSEY $0(2) PREZCOBIX $0(2) STRIBILD $0(2) SYMFI $0(2) SYMFI LO $0(2) SYMTUZA $0(2)


Name of drug


you (tier

level)


or limits on use TRIUMEQ $0(2) TRUVADA TAB 100-150 $0(2) QL (30 tabs / 30 days) TRUVADA TAB 133-200 $0(2) QL (30 tabs / 30 days) TRUVADA TAB 167-250 $0(2) QL (30 tabs / 30 days) TRUVADA TAB 200-300 $0(2) QL (30 tabs / 30 days)

ANTITUBERCULAR AGENTS - DRUGS TO TREAT TUBERCULOSIS cycloserine CAPS $0(2) ethambutol hcl TABS $0(1) isoniazid TABS $0(1) isoniazid syp 50mg/5ml $0(1) PASER D/R $0(2) PRIFTIN $0(2) pyrazinamide TABS $0(1) rifabutin $0(1) rifampin CAPS; SOLR $0(1) RIFATER $0(2) SIRTURO $0(2) LA, PA TRECATOR $0(2)

ANTIVIRALS - DRUGS TO TREAT VIRAL INFECTIONS acyclovir CAPS; SUSP; TABS $0(1) acyclovir sodium $0(1) B/D adefovir dipivoxil $0(2) BARACLUDE SOLN $0(2) entecavir $0(1) EPCLUSA $0(2) NM, PA EPIVIR HBV SOLN $0(2) famciclovir $0(1) ganciclovir sodium $0(1) B/D HARVONI $0(2) NM, PA lamivudine (hbv) $0(1) MAVYRET $0(2) NM, PA oseltamivir phosphate CAPS 30mg $0(1) QL (168 caps / year) oseltamivir phosphate CAPS 45mg, 75mg $0(1) QL (84 caps / year) oseltamivir phosphate SUSR $0(1) QL (1080 mL / year)


Name of drug


you (tier

level)


or limits on use PEGASYS $0(2) NM, PA PEGASYS PROCLICK $0(2) NM, PA REBETOL SOLN $0(2) NM RELENZA DISKHALER $0(2) QL (6 inhalers / year) ribasphere CAPS $0(1) NM ribasphere TABS 200mg $0(1) NM ribasphere TABS 600mg $0(2) NM ribavirin 200mg $0(1) NM rimantadine hydrochloride $0(1) valacyclovir hcl TABS $0(1) valganciclovir hcl $0(2) VEMLIDY $0(2) VOSEVI $0(2) NM, PA

CEPHALOSPORINS - DRUGS TO TREAT INFECTIONS cefaclor $0(1) CEFACLOR MONOHYDRATE ER $0(2) cefadroxil $0(1) CEFAZOLIN IN DEXTROSE 2GM/100ML-4% $0(2) cefazolin inj $0(1) cefazolin sodium SOLR 1gm, 20gm $0(1) CEFAZOLIN SODIUM 1 GM/50ML $0(2) cefdinir $0(1) cefepime hcl $0(1) cefixime SUSR $0(1) cefoxitin sodium $0(1) cefpodoxime proxetil $0(1) cefprozil $0(1) ceftazidime SOLR $0(1) CEFTAZIDIME/DEXTROSE $0(2) ceftriaxone sodium SOLR 1gm, 2gm, 10gm, 250mg, 500mg

$0(1)

cefuroxime axetil $0(1) cefuroxime sodium $0(1) cephalexin CAPS 250mg, 500mg $0(1)


Name of drug


you (tier

level)


or limits on use cephalexin SUSR $0(1) tazicef SOLR $0(1) TEFLARO $0(2)

ERYTHROMYCINS/MACROLIDES - DRUGS TO TREAT INFECTIONS azithromycin PACK; SOLR; SUSR; TABS $0(1) clarithromycin TABS $0(1) clarithromycin er $0(1) clarithromycin for susp $0(1) DIFICID $0(2) e.e.s 400 $0(1) ery-tab $0(1) ERYTHROCIN LACTOBIONATE $0(2) erythrocin stearate $0(1) erythromycin base $0(1) erythromycin cap 250mg ec $0(1) erythromycin ethylsuccinate TABS $0(1) erythromycin tab ec $0(1)

FLUOROQUINOLONES - DRUGS TO TREAT INFECTIONS ciprofloxacin SUSR $0(1) ciprofloxacin hcl tab $0(1) ciprofloxacin in d5w $0(1) levofloxacin TABS $0(1) levofloxacin in d5w $0(1) levofloxacin inj 25mg/ml $0(1) levofloxacin oral soln 25 mg/ml $0(1) moxifloxacin hcl TABS $0(1)

PENICILLINS - DRUGS TO TREAT INFECTIONS amoxicillin $0(1) amoxicillin & pot clavulanate 200-28.5 chw tabs $0(1) amoxicillin & pot clavulanate 200/5ml susr $0(1) amoxicillin & pot clavulanate 250-125 tabs $0(1) amoxicillin & pot clavulanate 250/5ml susr $0(1) amoxicillin & pot clavulanate 400-57 chw tabs $0(1) amoxicillin & pot clavulanate 400/5ml susr $0(1)


Name of drug


you (tier

level)


or limits on use amoxicillin & pot clavulanate 500-125 tabs $0(1) amoxicillin & pot clavulanate 600/5ml susr $0(1) amoxicillin & pot clavulanate 875-125 tabs $0(1) amoxicillin & pot clavulanate er 12hr 1000-62.5 tabs

$0(1)

ampicillin & sulbactam sodium $0(1) ampicillin cap 500mg $0(1) ampicillin inj $0(1) ampicillin sodium $0(1) BICILLIN L-A $0(2) dicloxacillin sodium $0(1) nafcillin sodium 1gm, 2gm $0(1) nafcillin sodium 10gm $0(2) NAFCILLIN SODIUM FOR INJ 10GM $0(2) oxacillin sodium 1gm, 2gm $0(1) oxacillin sodium 10gm $0(2) PENICILLIN G POT IN DEXTROSE 2MU $0(2) PENICILLIN G POT IN DEXTROSE 3MU $0(2) PENICILLIN G PROCAINE $0(2) penicillin g sodium $0(1) penicillin v potassium $0(1) penicilln gk inj 5mu $0(1) penicilln gk inj 20mu $0(1) pfizerpen-g inj 5mu $0(1) pfizerpen-g inj 20mu $0(1) piper/tazoba inj 2-0.25gm $0(1) piper/tazoba inj 3-0.375gm $0(1) piper/tazoba inj 4-0.5gm $0(1) piper/tazoba inj 12-1.5gm $0(1) piper/tazoba inj 36-4.5gm $0(1)

TETRACYCLINES - DRUGS TO TREAT INFECTIONS doxy 100 $0(1) doxycycline (monohydrate) CAPS 50mg, 100mg

$0(1)


Name of drug


you (tier

level)


or limits on use doxycycline (monohydrate) TABS 50mg, 75mg, 100mg

$0(1)

doxycycline hyclate CAPS $0(1) doxycycline hyclate SOLR $0(1) doxycycline hyclate TABS 20mg, 100mg $0(1) minocycline hcl CAPS $0(1) mondoxyne nl cap 100mg $0(1) morgidox cap 1x50mg $0(1) tetracycline hcl CAPS $0(1)

ANTINEOPLASTIC AGENTS - DRUGS TO TREAT CANCER ALKYLATING AGENTS

BENDEKA $0(2) B/D, NM cyclophosphamide CAPS $0(1) B/D cyclophosphamide SOLR $0(2) B/D EMCYT $0(2) GLEOSTINE $0(2) LEUKERAN $0(2)

ANTHRACYCLINES adriamycin SOLN $0(1) B/D doxorubicin hcl $0(1) B/D doxorubicin hcl liposomal $0(2) B/D epirubicin hcl $0(1) B/D

ANTIMETABOLITES adrucil inj $0(1) B/D ALIMTA $0(2) B/D azacitidine $0(2) B/D cytarabine 20mg/ml $0(1) B/D fluorouracil SOLN $0(1) B/D gemcitabine inj soln $0(1) B/D gemcitabine inj solr $0(1) B/D mercaptopurine TABS $0(1) methotrexate sodium inj soln $0(1) B/D methotrexate sodium inj solr $0(1) B/D PURIXAN $0(2) NM


Name of drug


you (tier

level)


or limits on use TABLOID $0(2)

ANTIMITOTIC, TAXOIDS ABRAXANE $0(2) B/D docetaxel CONC 20mg/ml, 80mg/4ml $0(2) B/D DOCETAXEL CONC 80mg/4ml, 160mg/8ml, 200mg/10ml

$0(2) B/D

docetaxel SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml

$0(2) B/D

DOCETAXEL SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml

$0(2) B/D

paclitaxel $0(1) B/D TAXOTERE 80mg/4ml $0(2) B/D

ANTIMITOTIC, VINCA ALKALOIDS vincristine sulfate $0(1) B/D vinorelbine tartrate $0(1) B/D

BIOLOGIC RESPONSE MODIFIERS AVASTIN $0(2) LA, PA BORTEZOMIB $0(2) PA DAURISMO $0(2) NM, LA, PA ERIVEDGE $0(2) NM, LA, PA FARYDAK $0(2) NM, LA, PA HERCEPTIN $0(2) PA HERCEPTIN HYLECTA $0(2) PA IBRANCE $0(2) QL (21 caps / 28 days), NM, LA,

PA IDHIFA $0(2) QL (30 tabs / 30 days), NM, LA,

PA KADCYLA $0(2) B/D KEYTRUDA $0(2) NM, PA KISQALI $0(2) NM, PA KISQALI FEMARA 200 DOSE $0(2) NM, PA KISQALI FEMARA 400 DOSE $0(2) NM, PA KISQALI FEMARA 600 DOSE $0(2) NM, PA LYNPARZA $0(2) NM, LA, PA NINLARO $0(2) NM, PA


Name of drug


you (tier

level)


or limits on use ODOMZO $0(2) NM, LA, PA RITUXAN $0(2) LA, PA RITUXAN HYCELA $0(2) NM, LA, PA RUBRACA $0(2) NM, LA, PA TALZENNA $0(2) NM, LA, PA TECENTRIQ $0(2) NM, LA, PA TIBSOVO $0(2) NM, LA, PA VELCADE $0(2) PA VENCLEXTA $0(2) NM, LA, PA VENCLEXTA STARTING PACK $0(2) NM, LA, PA VERZENIO $0(2) NM, LA, PA ZEJULA $0(2) NM, LA, PA ZOLINZA $0(2) NM, PA

HORMONAL ANTINEOPLASTIC AGENTS abiraterone acetate $0(2) NM, PA anastrozole TABS $0(1) bicalutamide $0(1) DEPO-PROVERA INJ 400/ML $0(2) B/D ERLEADA $0(2) NM, LA, PA exemestane $0(1) flutamide $0(1) fulvestrant $0(2) B/D letrozole TABS $0(1) leuprolide inj 1mg/0.2 $0(1) NM, PA LUPRON DEPOT (1-MONTH) 3.75mg $0(2) NM, PA LUPRON DEPOT INJ 11.25MG (3-MONTH) $0(2) NM, PA LYSODREN $0(2) megestrol ac sus 40mg/ml $0(2) megestrol ac tab 20mg $0(2) megestrol ac tab 40mg $0(2) megestrol sus 625mg/5ml $0(2) PA nilutamide $0(2) NUBEQA $0(2) NM, LA, PA SOLTAMOX $0(2)


Name of drug


you (tier

level)


or limits on use tamoxifen citrate TABS $0(1) toremifene citrate $0(2) TRELSTAR DEP INJ 3.75MG $0(2) NM, PA TRELSTAR LA INJ 11.25MG $0(2) NM, PA XTANDI $0(2) NM, LA, PA ZYTIGA 500mg $0(2) NM, LA, PA

IMMUNOMODULATORS POMALYST CAP 1MG $0(2) QL (21 caps / 21 days), NM, LA,

PA POMALYST CAP 2MG $0(2) QL (21 caps / 21 days), NM, LA,



PA REVLIMID $0(2) QL (28 caps / 28 days), NM, LA,

PA THALOMID 50mg, 100mg $0(2) QL (28 caps / 28 days), NM, PA THALOMID 150mg, 200mg $0(2) QL (56 caps / 28 days), NM, PA

KINASE INHIBITORS AFINITOR $0(2) QL (30 tabs / 30 days), NM, PA AFINITOR DISPERZ 2mg $0(2) QL (150 tabs / 30 days), NM, PA AFINITOR DISPERZ 3mg $0(2) QL (90 tabs / 30 days), NM, PA AFINITOR DISPERZ 5mg $0(2) QL (60 tabs / 30 days), NM, PA ALECENSA $0(2) NM, LA, PA ALUNBRIG $0(2) NM, LA, PA BALVERSA $0(2) NM, LA, PA BOSULIF $0(2) NM, PA BRAFTOVI $0(2) NM, LA, PA CABOMETYX $0(2) QL (30 tabs / 30 days), NM, LA,

PA CALQUENCE $0(2) NM, LA, PA CAPRELSA $0(2) NM, LA, PA COMETRIQ $0(2) NM, LA, PA COPIKTRA $0(2) NM, LA, PA COTELLIC $0(2) NM, LA, PA


Name of drug


you (tier

level)


or limits on use erlotinib hcl 25mg $0(2) QL (90 tabs / 30 days), NM, PA erlotinib hcl 100mg, 150mg $0(2) QL (30 tabs / 30 days), NM, PA GILOTRIF TAB 20MG $0(2) NM, LA, PA GILOTRIF TAB 30MG $0(2) NM, LA, PA GILOTRIF TAB 40MG $0(2) NM, LA, PA ICLUSIG $0(2) NM, LA, PA imatinib mesylate 100mg $0(2) QL (90 tabs / 30 days), NM, PA imatinib mesylate 400mg $0(2) QL (60 tabs / 30 days), NM, PA IMBRUVICA $0(2) NM, LA, PA INLYTA 1mg $0(2) QL (180 tabs / 30 days), NM, LA,

PA INLYTA 5mg $0(2) QL (120 tabs / 30 days), NM, LA,

PA INREBIC $0(2) NM, LA, PA IRESSA $0(2) NM, LA, PA JAKAFI $0(2) QL (60 tabs / 30 days), NM, LA,

PA LENVIMA 4 MG DAILY DOSE $0(2) NM, LA, PA LENVIMA 8 MG DAILY DOSE $0(2) NM, LA, PA LENVIMA 10 MG DAILY DOSE $0(2) NM, LA, PA LENVIMA 12MG DAILY DOSE $0(2) NM, LA, PA LENVIMA 14 MG DAILY DOSE $0(2) NM, LA, PA LENVIMA 18 MG DAILY DOSE $0(2) NM, LA, PA LENVIMA 20 MG DAILY DOSE $0(2) NM, LA, PA LENVIMA 24 MG DAILY DOSE $0(2) NM, LA, PA LORBRENA $0(2) NM, LA, PA MEKINIST $0(2) NM, LA, PA MEKTOVI $0(2) NM, LA, PA NERLYNX $0(2) NM, LA, PA NEXAVAR $0(2) NM, LA, PA PIQRAY 200MG DAILY DOSE $0(2) NM, PA PIQRAY 250MG DAILY DOSE $0(2) NM, PA PIQRAY 300MG DAILY DOSE $0(2) NM, PA RYDAPT $0(2) NM, PA SPRYCEL $0(2) NM, PA


Name of drug


you (tier

level)


or limits on use STIVARGA $0(2) NM, LA, PA SUTENT $0(2) QL (30 caps / 30 days), NM, PA TAFINLAR $0(2) NM, LA, PA TAGRISSO $0(2) QL (30 tabs / 30 days), NM, LA,

PA TASIGNA $0(2) NM, PA TURALIO $0(2) NM, LA, PA TYKERB $0(2) NM, LA, PA VITRAKVI $0(2) NM, LA, PA VIZIMPRO $0(2) NM, LA, PA VOTRIENT $0(2) NM, LA, PA XALKORI $0(2) NM, LA, PA XOSPATA $0(2) NM, LA, PA ZELBORAF $0(2) NM, LA, PA ZYDELIG $0(2) NM, LA, PA ZYKADIA $0(2) NM, LA, PA

MISCELLANEOUS bexarotene $0(2) NM, PA hydroxyurea CAPS $0(1) LONSURF $0(2) NM, PA MATULANE $0(2) LA SYLATRON $0(2) PA SYNRIBO $0(2) NM, PA tretinoin (chemotherapy) $0(2) XPOVIO 60 MG ONCE WEEKLY $0(2) NM, LA, PA XPOVIO 80 MG ONCE WEEKLY $0(2) NM, LA, PA XPOVIO 80 MG TWICE WEEKLY $0(2) NM, LA, PA XPOVIO 100 MG ONCE WEEKLY $0(2) NM, LA, PA

PLATINUM-BASED AGENTS carboplatin $0(1) B/D cisplatin SOLN $0(1) B/D oxaliplatin inj 50mg $0(2) B/D oxaliplatin inj 50mg/10ml $0(1) B/D oxaliplatin inj 100mg $0(2) B/D oxaliplatin inj 100mg/20ml $0(1) B/D


Name of drug


you (tier

level)


or limits on use PROTECTIVE AGENTS

leucovorin calcium SOLN 500mg/50ml $0(1) B/D leucovorin calcium SOLR $0(1) B/D leucovorin calcium TABS $0(1) MESNEX TABS $0(2)

TOPOISOMERASE INHIBITORS etoposide SOLN $0(1) B/D irinotecan hcl $0(1) B/D toposar $0(1) B/D

CARDIOVASCULAR - DRUGS TO TREAT HEART AND CIRCULATION CONDITIONS ACE INHIBITOR COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE

amlodipine--benazepril hcl cap 10-20 mg $0(1) amlodipine-benazepril hcl cap 2.5-10 mg $0(1) amlodipine-benazepril hcl cap 5-10 mg $0(1) amlodipine-benazepril hcl cap 5-20 mg $0(1) amlodipine-benazepril hcl cap 5-40 mg $0(1) amlodipine-benazepril hcl cap 10-40mg $0(1) benazepril & hydrochlorothiazide $0(1) captopril & hydrochlorothiazide $0(1) enalapril maleate & hydrochlorothiazide $0(1) fosinopril sodium & hydrochlorothiazide $0(1) lisinopril & hydrochlorothiazide $0(1) quinapril-hydrochlorothiazide $0(1)

ACE INHIBITORS - DRUGS TO TREAT HIGH BLOOD PRESSURE benazepril hcl TABS $0(1) captopril TABS $0(1) enalapril maleate TABS $0(1) fosinopril sodium $0(1) lisinopril TABS $0(1) moexipril hcl $0(1) perindopril erbumine $0(1) quinapril hcl $0(1) ramipril $0(1) trandolapril $0(1)


Name of drug


you (tier

level)


or limits on use ALDOSTERONE RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSURE

eplerenone $0(1) spironolactone TABS $0(1)

ALPHA BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE doxazosin mesylate TABS $0(1) prazosin hcl $0(1) terazosin hcl $0(1)

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE

amlodipine besylate-olmesartan medoxomil $0(1) amlodipine besylate-valsartan tab 5-160 mg $0(1) amlodipine besylate-valsartan tab 5-320 mg $0(1) amlodipine besylate-valsartan tab 10-160 mg $0(1) amlodipine besylate-valsartan tab 10-320 mg $0(1) amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg

$0(1)

amlodipine-valsartan-hydrochlorothiazide 5-160-25mg

$0(1)

amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg

$0(1)


$0(1)


$0(1)

candesartan cilexetil-hydrochlorothiazide $0(1) ENTRESTO $0(2) irbesartan-hydrochlorothiazide $0(1) losartan-hydrochlorothiazide $0(1) olmesartan medoxomil-amlodipine-hydrochlorothiazide

$0(1)

olmesartan medoxomil-hydrochlorothiazide $0(1) telmisartan-amlodipine $0(1) telmisartan-hydrochlorothiazide $0(1) valsartan-hydrochlorothiazide $0(1)


Name of drug


you (tier

level)


or limits on use ANGIOTENSIN II RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSURE

candesartan cilexetil $0(1) eprosartan mesylate $0(1) irbesartan $0(1) losartan potassium $0(1) olmesartan medoxomil TABS $0(1) telmisartan $0(1) valsartan $0(1)

ANTIARRHYTHMICS - DRUGS TO CONTROL HEART RHYTHM amiodarone hcl soln $0(1) amiodarone tab 100mg $0(1) amiodarone tab 200mg $0(1) amiodarone tab 400mg $0(1) disopyramide phosphate $0(2) dofetilide $0(1) flecainide acetate $0(1) MULTAQ $0(2) NORPACE CR $0(2) pacerone $0(1) propafenone hcl $0(1) propafenone hcl 12hr $0(1) quinidine sulfate $0(1) sorine $0(1) sotalol hcl $0(1) sotalol hcl (afib/afl) $0(1)

ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS - DRUGS TO TREAT HIGH CHOLESTEROL atorvastatin calcium TABS $0(1) lovastatin $0(1) pravastatin sodium $0(1) rosuvastatin calcium $0(1) QL (30 tabs / 30 days) simvastatin TABS 5mg, 10mg, 20mg, 40mg $0(1) simvastatin TABS 80mg $0(1) QL (30 tabs / 30 days)

ANTILIPEMICS, MISCELLANEOUS - DRUGS TO TREAT HIGH CHOLESTEROL cholestyramine $0(1)


Name of drug


you (tier

level)


or limits on use cholestyramine light pack $0(1) cholestyramine light powd $0(1) colesevelam hcl $0(1) colestipol hcl gran $0(1) colestipol hcl pack $0(1) colestipol hcl tabs $0(1) ezetimibe $0(1) ezetimibe-simvastatin $0(1) fenofibrate TABS 48mg, 54mg, 145mg, 160mg

$0(1)

fenofibrate micronized 67mg, 134mg, 200mg $0(1) gemfibrozil TABS $0(1) JUXTAPID $0(2) NM, LA, PA niacin (antihyperlipidemic) $0(1) niacin er (antihyperlipidemic) 500mg $0(1) QL (60 tabs / 30 days) niacin er (antihyperlipidemic) 750mg, 1000mg $0(1) niacor $0(1) PRALUENT $0(2) PA prevalite $0(1) VASCEPA $0(2)

BETA-BLOCKER/DIURETIC COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS

atenolol & chlorthalidone $0(1) bisoprolol & hydrochlorothiazide $0(1) metoprolol & hctz tab 50-25mg $0(1) metoprolol & hctz tab 100-25mg $0(1) metoprolol & hctz tab 100-50mg $0(1) propranolol & hydrochlorothiazide $0(1)

BETA-BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS acebutolol hcl CAPS $0(1) atenolol TABS $0(1) betaxolol hcl $0(1) bisoprolol fumarate $0(1) BYSTOLIC 2.5mg, 5mg, 10mg $0(2) QL (30 tabs / 30 days) BYSTOLIC 20mg $0(2) QL (60 tabs / 30 days)


Name of drug


you (tier

level)


or limits on use carvedilol $0(1) labetalol hcl TABS $0(1) metoprolol succinate $0(1) metoprolol tartrate SOCT $0(1) metoprolol tartrate SOLN $0(1) metoprolol tartrate TABS 25mg, 50mg, 100mg $0(1) nadolol TABS $0(1) pindolol $0(1) propranolol cap er $0(1) propranolol hcl TABS $0(1) propranolol oral sol $0(1) timolol maleate TABS $0(1)

CALCIUM CHANNEL BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS

amlodipine besylate TABS $0(1) cartia xt cap 120/24hr $0(1) cartia xt cap 180/24hr $0(1) cartia xt cap 240/24hr $0(1) cartia xt cap 300/24hr $0(1) dilt-xr cap $0(1) diltiazem cap 240mg cd $0(1) diltiazem cap 360mg cd $0(1) diltiazem cap er/12hr $0(1) diltiazem hcl TABS $0(1) diltiazem hcl coated beads CP24 $0(1) diltiazem hcl coated beads cap sr 24hr $0(1) diltiazem hcl extended release beads cap sr $0(1) diltiazem inj $0(1) felodipine $0(1) isradipine $0(1) nicardipine hcl CAPS $0(1) nifedipine TB24 $0(1) nifedipine er $0(1) nimodipine CAPS $0(2)


Name of drug


you (tier

level)


or limits on use NYMALIZE $0(2) taztia xt $0(1) verapamil cap er $0(1) verapamil hcl SOLN; TABS $0(1) verapamil hcl tab er $0(1)

DIGITALIS GLYCOSIDES - DRUGS TO TREAT HEART CONDITIONS digitek .25mg $0(1) PA; PA if 70 years and older digitek .125mg $0(1) QL (30 tabs / 30 days) digox 125mcg $0(1) QL (30 tabs / 30 days) digox 250mcg $0(1) PA; PA if 70 years and older digoxin TABS 125mcg $0(1) QL (30 tabs / 30 days) digoxin TABS 250mcg $0(1) PA; PA if 70 years and older digoxin inj $0(1) digoxin sol 50mcg/ml $0(1) PA; PA if 70 years and older

DIURETICS - DRUGS TO TREAT HEART CONDITIONS acetazolamide CP12; TABS $0(1) amiloride & hydrochlorothiazide $0(1) amiloride hcl TABS $0(1) bumetanide $0(1) chlorothiazide tabs $0(1) chlorthalidone $0(1) furosemide SOLN; TABS $0(1) furosemide inj $0(1) hydrochlorothiazide CAPS; TABS $0(1) indapamide $0(1) methazolamide TABS $0(1) metolazone $0(1) spironolactone & hydrochlorothiazide $0(1) torsemide tabs $0(1) triamterene & hydrochlorothiazide cap 37.5-25 mg

$0(1)

triamterene & hydrochlorothiazide tabs $0(1) MISCELLANEOUS

aliskiren fumarate $0(1)


Name of drug


you (tier

level)


or limits on use clonidine hcl TABS $0(1) clonidine hcl ptwk $0(1) CORLANOR $0(2) DEMSER $0(2) PA hydralazine hcl SOLN; TABS $0(1) midodrine hcl $0(1) minoxidil TABS $0(1) NORTHERA 100mg $0(2) QL (90 caps / 30 days), NM, LA,

PA NORTHERA 200mg, 300mg $0(2) QL (180 caps / 30 days), NM, LA,

PA ranolazine $0(1)

NITRATES - DRUGS TO TREAT HEART CONDITIONS isosorb mononitrate tab $0(1) isosorbide dinitrate $0(1) isosorbide dinitrate er $0(1) isosorbide mononitrate er $0(1) minitran $0(1) NITRO-BID $0(2) NITRO-DUR DIS 0.3MG/HR $0(2) NITRO-DUR DIS 0.8MG/HR $0(2) nitroglycerin SOLN .4mg/spray $0(1) nitroglycerin SUBL $0(1) nitroglycerin td patch $0(1)

PULMONARY ARTERIAL HYPERTENSION - DRUGS TO TREAT PULMONARY HYPERTENSION ADEMPAS $0(2) QL (90 tabs / 30 days), NM, LA,

PA ambrisentan $0(2) QL (30 tabs / 30 days), NM, LA,

PA bosentan 62.5mg $0(2) QL (120 tabs / 30 days), NM, LA,

PA bosentan 125mg $0(2) QL (60 tabs / 30 days), NM, LA,

PA OPSUMIT $0(2) QL (30 tabs / 30 days), NM, LA,

PA


Name of drug


you (tier

level)


or limits on use sildenafil citrate tab 20 mg (pulmonary hypertension)

$0(1) QL (90 tabs / 30 days), NM, PA

treprostinil $0(2) NM, LA, PA VENTAVIS $0(2) NM, PA

CENTRAL NERVOUS SYSTEM - DRUGS TO TREAT NERVOUS SYSTEM DISORDERS ANTIANXIETY - DRUGS TO TREAT ANXIETY

alprazolam tab 0.5mg $0(1) QL (150 tabs / 30 days) alprazolam tab 0.25mg $0(1) QL (150 tabs / 30 days) alprazolam tab 1mg $0(1) QL (150 tabs / 30 days) alprazolam tab 2mg $0(1) QL (150 tabs / 30 days) buspirone hcl TABS $0(1) fluvoxamine maleate TABS $0(1) lorazepam SOLN $0(1) lorazepam TABS $0(1) QL (150 tabs / 30 days) lorazepam intensol $0(1) QL (150 mL / 30 days)

ANTICONVULSANTS - DRUGS TO TREAT SEIZURES APTIOM $0(2) QL (60 tabs / 30 days) BANZEL SUS 40MG/ML $0(2) PA BANZEL TAB 200MG $0(2) PA BANZEL TAB 400MG $0(2) PA BRIVIACT INJ 50MG/5ML $0(2) PA BRIVIACT SOL 10MG/ML $0(2) PA BRIVIACT TAB 10MG $0(2) PA BRIVIACT TAB 25MG $0(2) PA BRIVIACT TAB 50MG $0(2) PA BRIVIACT TAB 75MG $0(2) PA BRIVIACT TAB 100MG $0(2) PA carbamazepine CHEW; CP12; SUSP; TABS; TB12

$0(1)

CELONTIN $0(2) clobazam $0(1) PA clonazepam TABS 2mg $0(1) QL (300 tabs / 30 days) clonazepam TABS .5mg, 1mg $0(1) QL (90 tabs / 30 days) clonazepam TBDP 2mg $0(1) QL (300 tabs / 30 days) clonazepam TBDP .125mg, .25mg, .5mg, 1mg $0(1) QL (90 tabs / 30 days)


Name of drug


you (tier

level)


or limits on use clorazepate dipotassium $0(1) QL (180 tabs / 30 days), PA; PA if

65 years and older DIASTAT ACUDIAL $0(2) DIASTAT PEDIATRIC $0(2) diazepam TABS $0(1) QL (120 tabs / 30 days), PA; PA if

65 years and older diazepam gel $0(1) diazepam inj $0(1) diazepam intensol $0(1) QL (240 mL / 30 days), PA; PA if

65 years and older diazepam oral soln 1 mg/ml $0(1) QL (1200 mL / 30 days), PA; PA if

65 years and older DILANTIN CAP 30MG $0(2) DILANTIN CAP 100MG $0(2) DILANTIN CHEW TAB 50MG $0(2) DILANTIN-125 SUSP $0(2) divalproex sodium CSDR; TB24; TBEC $0(1) EPIDIOLEX $0(2) QL (600 mL / 30 days), NM, LA,

PA epitol $0(1) ethosuximide CAPS; SOLN $0(1) felbamate SUSP $0(2) felbamate TABS $0(1) FYCOMPA SUSP $0(2) QL (720 mL / 30 days), PA FYCOMPA TABS 2mg, 4mg, 6mg $0(2) QL (60 tabs / 30 days), PA FYCOMPA TABS 8mg, 10mg, 12mg $0(2) QL (30 tabs / 30 days), PA gabapentin CAPS 100mg $0(1) QL (1080 caps / 30 days) gabapentin CAPS 300mg $0(1) QL (360 caps / 30 days) gabapentin CAPS 400mg $0(1) QL (270 caps / 30 days) gabapentin SOLN $0(1) QL (2160 mL / 30 days) gabapentin TABS 600mg $0(1) QL (180 tabs / 30 days) gabapentin TABS 800mg $0(1) QL (120 tabs / 30 days) lamotrigine CHEW; TABS; TB24 $0(1) levetiracetam SOLN; TABS; TB24 $0(1) levetiracetam in sodium chloride $0(1)


Name of drug


you (tier

level)


or limits on use levetiracetam oral soln 100 mg/ml $0(1) oxcarbazepine $0(1) PEGANONE $0(2) phenobarbital ELIX; TABS $0(2) PA; PA if 70 years and older PHENOBARBITAL SODIUM SOLN 65mg/ml $0(2) PA; PA if 70 years and older phenobarbital sodium SOLN 130mg/ml $0(2) PA; PA if 70 years and older PHENYTEK $0(2) phenytoin CHEW; SUSP $0(1) phenytoin sodium extended $0(1) phenytoin sodium inj 50mg/ml $0(1) pregabalin CAPS 25mg, 50mg, 75mg, 100mg, 150mg

$0(1) QL (120 caps / 30 days), PA

pregabalin CAPS 200mg $0(1) QL (90 caps / 30 days), PA pregabalin CAPS 225mg, 300mg $0(1) QL (60 caps / 30 days), PA pregabalin SOLN $0(1) QL (900 mL / 30 days), PA primidone TABS $0(1) roweepra $0(1) roweepra xr $0(1) SPRITAM $0(2) subvenite tab $0(1) SYMPAZAN $0(2) PA tiagabine hcl $0(1) topiramate CPSP; TABS $0(1) valproate sodium SOLN $0(1) valproic acid CAPS $0(1) vigabatrin powd pack 500mg $0(2) QL (180 packets / 30 days), NM,

LA, PA vigabatrin tab 500mg $0(2) QL (180 tabs / 30 days), NM, LA,

PA vigadrone $0(2) QL (180 packets / 30 days), NM,

LA, PA VIMPAT 50mg $0(2) QL (120 tabs / 30 days) VIMPAT 100mg, 150mg, 200mg $0(2) QL (60 tabs / 30 days) VIMPAT INJ 200MG/20ML $0(2) VIMPAT SOL 10MG/ML $0(2) QL (1200 mL / 30 days)


Name of drug


you (tier

level)


or limits on use zonisamide CAPS $0(1)

ANTIDEMENTIA - DRUGS TO TREAT DEMENTIA AND MEMORY LOSS donepezil hydrochloride TABS 5mg $0(1) QL (30 tabs / 30 days) donepezil hydrochloride TABS 10mg $0(1) donepezil hydrochloride TBDP 5mg $0(1) QL (30 tabs / 30 days) donepezil hydrochloride TBDP 10mg $0(1) galantamine hydrobromide SOLN $0(1) galantamine hydrobromide TABS $0(1) QL (60 tabs / 30 days) galantamine hydrobromide er $0(1) QL (30 caps / 30 days) memantine hcl cp24 $0(1) PA; PA if < 30 yrs memantine soln $0(1) PA; PA if < 30 yrs memantine tabs $0(1) PA; PA if < 30 yrs memantine titration pak $0(2) PA; PA if < 30 yrs NAMZARIC $0(2) rivastigmine tartrate 1.5mg, 3mg $0(1) QL (90 caps / 30 days) rivastigmine tartrate 4.5mg, 6mg $0(1) QL (60 caps / 30 days) rivastigmine td patch 24hr 4.6 mg/24hr $0(1) QL (30 patches / 30 days) rivastigmine td patch 24hr 9.5 mg/24hr $0(1) QL (30 patches / 30 days) rivastigmine td patch 24hr 13.3 mg/24hr $0(1) QL (30 patches / 30 days)

ANTIDEPRESSANTS - DRUGS TO TREAT DEPRESSION amitriptyline hcl TABS $0(2) amoxapine tab 25mg $0(2) amoxapine tab 50mg $0(2) amoxapine tab 100mg $0(2) amoxapine tab 150mg $0(2) bupropion hcl TABS $0(1) bupropion hcl TB12 $0(1) bupropion hcl TB24 150mg, 300mg $0(1) citalopram hydrobromide $0(1) clomipramine hcl CAPS $0(2) PA desipramine hcl TABS $0(2) desvenlafaxine succinate $0(1) QL (30 tabs / 30 days), PA doxepin hcl CAPS; CONC $0(2) duloxetine hcl CPEP 20mg, 30mg, 60mg $0(1) QL (60 caps / 30 days)


Name of drug


you (tier

level)


or limits on use EMSAM $0(2) QL (30 patches / 30 days), PA escitalopram oxalate $0(1) FETZIMA 20mg, 40mg $0(2) QL (60 caps / 30 days), PA FETZIMA 80mg, 120mg $0(2) QL (30 caps / 30 days), PA FETZIMA TITRATION PACK $0(2) PA fluoxetine cap 10mg $0(1) fluoxetine cap 20mg $0(1) fluoxetine cap 40mg $0(1) fluoxetine hcl SOLN $0(1) imipramine hcl TABS $0(2) maprotiline hcl $0(1) MARPLAN TAB 10MG $0(2) QL (180 tabs / 30 days) mirtazapine TABS; TBDP $0(1) nefazodone hcl $0(1) nortriptyline hcl CAPS; SOLN $0(2) paroxetine hcl tabs $0(2) PAXIL SUSP $0(2) QL (900 mL / 30 days) phenelzine sulfate TABS $0(1) protriptyline hcl $0(2) sertraline hcl CONC; TABS $0(1) tranylcypromine sulfate $0(1) trazodone hcl TABS 50mg, 100mg, 150mg $0(1) trimipramine maleate CAPS 25mg $0(2) QL (240 caps / 30 days) trimipramine maleate CAPS 50mg $0(2) QL (120 caps / 30 days) trimipramine maleate CAPS 100mg $0(2) QL (60 caps / 30 days) TRINTELLIX 5mg $0(2) QL (120 tabs / 30 days), PA TRINTELLIX 10mg $0(2) QL (60 tabs / 30 days), PA TRINTELLIX 20mg $0(2) QL (30 tabs / 30 days), PA venlafaxine hcl CP24; TABS $0(1) VIIBRYD STARTER PACK $0(2) PA VIIBRYD TAB $0(2) QL (30 tabs / 30 days), PA

ANTIPARKINSONIAN AGENTS - DRUGS TO TREAT PARKINSONS DISEASE amantadine hcl CAPS $0(1) QL (120 caps / 30 days) amantadine hcl SYRP; TABS $0(1)


Name of drug


you (tier

level)


or limits on use APOKYN $0(2) QL (20 cartridges / 30 days),

NM, LA, PA benztropine mesylate inj $0(1) benztropine mesylate tab 0.5mg $0(2) PA; PA if 70 years and older benztropine mesylate tab 1mg $0(2) PA; PA if 70 years and older benztropine mesylate tab 2mg $0(2) PA; PA if 70 years and older bromocriptine mesylate CAPS; TABS $0(1) carbidopa-levodopa $0(1) carbidopa/levodopa/entacapone $0(1) entacapone $0(1) NEUPRO $0(2) pramipexole tab 0.5mg $0(1) pramipexole tab 0.25mg $0(1) pramipexole tab 0.75mg $0(1) pramipexole tab 0.125mg $0(1) pramipexole tab 1.5mg $0(1) pramipexole tab 1mg $0(1) rasagiline mesylate TABS $0(1) ropinirole tab 0.5mg $0(1) ropinirole tab 0.25mg $0(1) ropinirole tab 1mg $0(1) ropinirole tab 2mg $0(1) ropinirole tab 3mg $0(1) ropinirole tab 4mg $0(1) ropinirole tab 5mg $0(1) selegiline hcl CAPS; TABS $0(1) trihexyphenidyl hcl $0(2) PA; PA if 70 years and older

ANTIPSYCHOTICS - DRUGS TO TREAT PSYCHOSES ABILIFY MAINTENA $0(2) QL (1 injection / 28 days) aripiprazole odt $0(2) QL (60 tabs / 30 days) aripiprazole oral solution 1 mg/ml $0(2) QL (900 mL / 30 days) aripiprazole tab $0(1) QL (30 tabs / 30 days) ARISTADA 441mg/1.6ml, 662mg/2.4ml, 882mg/3.2ml

$0(2) QL (1 injection / 28 days)

ARISTADA 1064mg/3.9ml $0(2) QL (1 injection / 56 days)


Name of drug


you (tier

level)


or limits on use ARISTADA INITIO $0(2) chlorpromazine hcl TABS $0(1) CHLORPROMAZINE INJ $0(2) clozapine odt 12.5mg, 25mg $0(1) PA clozapine odt 100mg $0(1) QL (270 tabs / 30 days), PA clozapine odt 150mg $0(1) QL (180 tabs / 30 days), PA clozapine odt 200mg $0(1) QL (135 tabs / 30 days), PA clozapine tab 25mg $0(1) clozapine tab 50mg $0(1) clozapine tab 100mg $0(1) QL (270 tabs / 30 days) clozapine tab 200mg $0(1) QL (135 tabs / 30 days) FANAPT $0(2) QL (60 tabs / 30 days), PA FANAPT TITRATION PACK $0(2) PA fluphenazine decanoate SOLN $0(1) fluphenazine hcl $0(1) GEODON SOLR $0(2) QL (6 mL / 3 days) haloperidol TABS $0(1) haloperidol conc 2mg/ml $0(1) haloperidol decanoate SOLN $0(1) haloperidol lactate inj 5mg/ml $0(1) INVEGA SUST INJ 39 MG/0.25 ML $0(2) QL (1 injection / 28 days) INVEGA SUST INJ 78 MG/0.5 ML $0(2) QL (1 injection / 28 days) INVEGA SUST INJ 117 MG/0.75 ML $0(2) QL (1 injection / 28 days) INVEGA SUST INJ 156MG/ML $0(2) QL (1 injection / 28 days) INVEGA SUST INJ 234 MG/1.5 ML $0(2) QL (1 injection / 28 days) INVEGA TRINZA $0(2) QL (1 injection / 90 days) LATUDA 20mg, 40mg, 60mg, 120mg $0(2) QL (30 tabs / 30 days) LATUDA 80mg $0(2) QL (60 tabs / 30 days) loxapine succinate $0(1) molindone hcl $0(1) NUPLAZID CAPS $0(2) QL (30 caps / 30 days), NM, LA,

PA NUPLAZID TABS 10MG $0(2) QL (30 tabs / 30 days), NM, LA,

PA olanzapine SOLR $0(1) QL (3 vials / 1 day)


Name of drug


you (tier

level)


or limits on use olanzapine TABS 2.5mg, 5mg, 10mg $0(1) QL (60 tabs / 30 days) olanzapine TABS 7.5mg, 15mg, 20mg $0(1) QL (30 tabs / 30 days) olanzapine TBDP 5mg, 15mg, 20mg $0(1) QL (30 tabs / 30 days) olanzapine TBDP 10mg $0(1) QL (60 tabs / 30 days) paliperidone 1.5mg, 3mg, 9mg $0(1) QL (30 tabs / 30 days) paliperidone 6mg $0(1) QL (60 tabs / 30 days) perphenazine TABS $0(1) PERSERIS $0(2) QL (1 injection / 30 days) pimozide $0(1) quetiapine fumarate TABS $0(1) quetiapine fumarate TB24 50mg, 300mg, 400mg

$0(1) QL (60 tabs / 30 days), PA

quetiapine fumarate TB24 150mg, 200mg $0(1) QL (30 tabs / 30 days), PA REXULTI 3mg, 4mg $0(2) QL (30 tabs / 30 days) REXULTI .25mg, .5mg, 1mg, 2mg $0(2) QL (60 tabs / 30 days) RISPERDAL INJ 12.5MG $0(2) QL (2 injections / 28 days) RISPERDAL INJ 25MG $0(2) QL (2 injections / 28 days) RISPERDAL INJ 37.5MG $0(2) QL (2 injections / 28 days) RISPERDAL INJ 50MG $0(2) QL (2 injections / 28 days) risperidone SOLN $0(1) QL (240 mL / 30 days) risperidone TABS $0(1) risperidone TBDP 1mg, 2mg, 3mg, 4mg $0(1) QL (60 tabs / 30 days) risperidone TBDP .25mg, .5mg $0(1) QL (90 tabs / 30 days) SAPHRIS $0(2) QL (60 tabs / 30 days) thioridazine hcl TABS $0(1) thiothixene $0(1) trifluoperazine hcl $0(1) VERSACLOZ $0(2) QL (600 mL / 30 days), PA VRAYLAR 1.5mg $0(2) QL (60 caps / 30 days), PA VRAYLAR 3mg, 4.5mg, 6mg $0(2) QL (30 caps / 30 days), PA VRAYLAR THERAPY PACK $0(2) PA ziprasidone hcl $0(1) QL (60 caps / 30 days) ZYPREXA RELPREVV 300mg $0(2) QL (2 vials / 28 days), PA ZYPREXA RELPREVV 405mg $0(2) QL (1 vial / 28 days), PA


Name of drug


you (tier

level)


or limits on use ZYPREXA RELPREVV INJ 210MG $0(2) QL (2 vials / 28 days), PA

ATTENTION DEFICIT HYPERACTIVITY DISORDER - DRUGS TO TREAT ADHD amphetamine-dextroamphetamine cap sr 24hr 5 mg

$0(1) QL (90 caps / 30 days)

amphetamine-dextroamphetamine cap sr 24hr 10 mg

$0(1) QL (90 caps / 30 days)


$0(1) QL (30 caps / 30 days)


$0(1) QL (30 caps / 30 days)


$0(1) QL (30 caps / 30 days)


$0(1) QL (30 caps / 30 days)

amphetamine-dextroamphetamine tab 5 mg $0(1) QL (120 tabs / 30 days) amphetamine-dextroamphetamine tab 7.5 mg $0(1) QL (120 tabs / 30 days) amphetamine-dextroamphetamine tab 10 mg $0(1) QL (120 tabs / 30 days) amphetamine-dextroamphetamine tab 12.5 mg $0(1) QL (120 tabs / 30 days) amphetamine-dextroamphetamine tab 15 mg $0(1) QL (90 tabs / 30 days) amphetamine-dextroamphetamine tab 20 mg $0(1) QL (90 tabs / 30 days) amphetamine-dextroamphetamine tab 30 mg $0(1) QL (60 tabs / 30 days) atomoxetine hcl 10mg, 18mg, 25mg $0(1) QL (120 caps / 30 days) atomoxetine hcl 40mg $0(1) QL (60 caps / 30 days) atomoxetine hcl 60mg, 80mg, 100mg $0(1) QL (30 caps / 30 days) dexmethylphenidate hcl TABS 2.5mg, 5mg $0(1) QL (120 tabs / 30 days) dexmethylphenidate hcl TABS 10mg $0(1) QL (60 tabs / 30 days) guanfacine er (adhd) $0(2) PA; PA if 70 years and older metadate er tab 20mg $0(1) QL (90 tabs / 30 days) methylphenidate hcl TABS 5mg, 10mg $0(1) QL (180 tabs / 30 days) methylphenidate hcl TABS 20mg $0(1) QL (90 tabs / 30 days) methylphenidate hcl oral soln 5mg/5ml $0(1) QL (1800 mL / 30 days) methylphenidate hcl oral soln 10mg/5ml $0(1) QL (900 mL / 30 days) methylphenidate hcl tbcr 10 mg $0(1) QL (90 tabs / 30 days) methylphenidate hcl tbcr 20mg $0(1) QL (90 tabs / 30 days)


Name of drug


you (tier

level)


or limits on use HYPNOTICS - DRUGS TO TREAT INSOMNIA

eszopiclone $0(2) QL (30 tabs / 30 days), PA; PA applies if 70 years and older

after a 90 day supply in a calendar year

HETLIOZ $0(2) NM, LA, PA SILENOR $0(2) QL (30 tabs / 30 days) temazepam 7.5mg $0(1) QL (30 caps / 30 days), PA; PA

applies if 65 years and older after a 90 day supply in a

calendar year temazepam 15mg $0(1) QL (60 caps / 30 days), PA; PA


calendar year zaleplon $0(2) QL (60 caps / 30 days), PA; PA


calendar year zolpidem tartrate TABS $0(2) QL (30 tabs / 30 days), PA; PA


calendar year MIGRAINE - DRUGS TO TREAT SEVERE HEADACHES

AIMOVIG $0(2) QL (1 pen / 30 days), PA dihydroergotamine mesylate inj 1 mg/ml $0(2) dihydroergotamine mesylate nasal spr 4 mg/ml $0(2) QL (8 mL / 30 days), PA eletriptan hydrobromide $0(1) QL (12 tabs / 30 days) EMGALITY SOAJ $0(2) QL (2 pens / 30 days), PA EMGALITY SOSY 120mg/ml $0(2) QL (2 syringes / 30 days), PA ergotamine w/ caffeine TABS $0(1) naratriptan hcl $0(1) QL (12 tabs / 30 days) rizatriptan benzoate $0(1) QL (18 tabs / 30 days) rizatriptan benzoate odt $0(1) QL (18 tabs / 30 days) sumatriptan SOLN 5mg/act $0(1) QL (24 inhalers / 30 days) sumatriptan SOLN 20mg/act $0(1) QL (12 inhalers / 30 days) sumatriptan inj 4mg/0.5ml $0(1) QL (18 injections / 30 days)


Name of drug


you (tier

level)


or limits on use sumatriptan inj 6mg/0.5ml $0(1) QL (12 injections / 30 days) sumatriptan succinate TABS $0(1) QL (12 tabs / 30 days) zolmitriptan TABS $0(1) QL (12 tabs / 30 days) zolmitriptan odt $0(1) QL (12 tabs / 30 days)

MISCELLANEOUS AUSTEDO 6mg $0(2) QL (60 tabs / 30 days), NM, LA,

PA AUSTEDO 9mg, 12mg $0(2) QL (120 tabs / 30 days), NM, LA,

PA lithium carbonate CAPS; TABS $0(1) lithium carbonate er $0(1) LITHIUM SOLN 8MEQ/5ML $0(2) LYRICA CR $0(2) QL (60 tabs / 30 days), PA NUEDEXTA $0(2) QL (60 caps / 30 days), PA pyridostigmine tab 60mg $0(1) riluzole $0(1) tetrabenazine 12.5mg $0(2) QL (240 tabs / 30 days), NM, PA tetrabenazine 25mg $0(2) QL (120 tabs / 30 days), NM, PA

MULTIPLE SCLEROSIS AGENTS - DRUGS TO TREAT MULTIPLE SCLEROSIS BETASERON $0(2) QL (14 syringes / 28 days), NM,

PA dalfampridine $0(2) NM, PA GILENYA CAP 0.5MG $0(2) QL (28 caps / 28 days), NM, PA glatiramer acetate 20mg/ml $0(2) QL (30 syringes / 30 days), NM,

PA glatiramer acetate 40mg/ml $0(2) QL (12 syringes / 28 days), NM,

PA glatopa 20mg/ml $0(2) QL (30 syringes / 30 days), NM,

PA glatopa 40mg/ml $0(2) QL (12 syringes / 28 days), NM,

PA MUSCULOSKELETAL THERAPY AGENTS - DRUGS TO TREAT MUSCLE SPASMS

baclofen TABS 10mg, 20mg $0(1) carisoprodol TABS 350mg $0(2) QL (120 tabs / 30 days), PA; PA if

70 years and older cyclobenzaprine hcl TABS 5mg, 10mg $0(2) PA; PA if 70 years and older


Name of drug


you (tier

level)


or limits on use dantrolene sodium CAPS $0(1) methocarbamol TABS $0(2) PA; PA if 70 years and older tizanidine hcl TABS $0(1)

NARCOLEPSY/CATAPLEXY - DRUGS FOR SLEEP DISORDERS armodafinil 50mg $0(1) QL (90 tabs / 30 days), PA armodafinil 150mg, 200mg, 250mg $0(1) QL (30 tabs / 30 days), PA XYREM $0(2) QL (540 mL / 30 days), NM, LA,

PA PSYCHOTHERAPEUTIC-MISC

acamprosate calcium $0(1) acetaminophen pm extra st $0(3) NM; * buprenorphine hcl SUBL $0(1) QL (90 tabs / 30 days), PA buprenorphine hcl-naloxone hcl dihydrate 2-0.5mg

$0(1) QL (90 films / 30 days)

buprenorphine hcl-naloxone hcl dihydrate 4-1mg

$0(1) QL (90 films / 30 days)


$0(1) QL (90 films / 30 days)


$0(1) QL (60 films / 30 days)

buprenorphine hcl-naloxone hcl sl $0(1) QL (90 tabs / 30 days) bupropion hcl (smoking deterrent) $0(1) CHANTIX $0(2) PA CHANTIX CONTINUING MONTH $0(2) PA CHANTIX STARTER PACK $0(2) PA cvs nicotine polacrilex $0(3) NM; * diphenhydramine-acetaminophen (sleep) $0(3) NM; * disulfiram TABS $0(1) gnp headache pm $0(3) NM; * gnp nicotine gum $0(3) NM; * gnp nicotine mini lozenge $0(3) NM; * gnp nicotine polacrilex $0(3) NM; * gnp nicotine polacrilex m $0(3) NM; * gnp nicotine transdermal $0(3) NM; * gnp pain relief pm extra $0(3) NM; *


Name of drug


you (tier

level)


or limits on use goodsense headache pm $0(3) NM; * goodsense nicotine gum $0(3) NM; * goodsense nicotine polacr $0(3) NM; * goodsense pain relief pm $0(3) NM; * headache pm $0(3) NM; * headache relief pm $0(3) NM; * healthy mama eazzze the p $0(3) NM; * hm acetaminophen pm extra $0(3) NM; * hm nicotine polacrilex $0(3) NM; * hm nicotine transdermal s $0(3) NM; * hm pain reliever pm extra $0(3) NM; * mapap pm $0(3) NM; * naloxone inj 0.4mg/ml $0(1) naloxone inj 1mg/ml $0(1) naltrexone hcl TABS $0(1) NARCAN $0(2) nicorelief $0(3) NM; * nicotine $0(3) NM; * nicotine polacrilex GUM; LOZG $0(3) NM; * NICOTINE TRANSDERMAL SYST KIT $0(3) NM; * nicotine transdermal syst PT24 $0(3) NM; * NICOTROL INHALER $0(2) NICOTROL NS $0(2) night time pain medicine $0(3) NM; * pain relief pm extra stre $0(3) NM; * pain reliever pm $0(3) NM; * pain reliever pm extra st $0(3) NM; * px pain relief pm extra s $0(3) NM; * px stop smoking aid $0(3) NM; * sb non-aspirin nighttime $0(3) NM; * sm nicotine $0(3) NM; * sm nicotine polacrilex $0(3) NM; * sm nicotine transdermal s $0(3) NM; * sm pain reliever pm extra $0(3) NM; *


Name of drug


you (tier

level)


or limits on use tgt nicotine gum $0(3) NM; * tgt nicotine polacrilex $0(3) NM; * tgt nicotine step one $0(3) NM; * tgt nicotine step three $0(3) NM; * tgt nicotine step two $0(3) NM; * thrive $0(3) NM; * VIVITROL $0(2)

ENDOCRINE AND METABOLIC - DRUGS TO TREAT DIABETES AND REGULATE HORMONES ANDROGENS - DRUGS TO REGULATE MALE HORMONES

ANADROL-50 $0(2) PA ANDRODERM $0(2) QL (30 patches / 30 days), PA oxandrolone TABS $0(1) PA testosterone GEL 1%, 25mg/2.5gm, 50mg/5gm

$0(1) QL (300 grams / 30 days), PA

testosterone cypionate SOLN 100mg/ml, 200mg/ml

$0(1) PA

testosterone enanthate SOLN $0(1) PA ANTIDIABETICS, INJECTABLE - DRUGS TO TREAT DIABETES

BASAGLAR KWIKPEN $0(2) BD ALCOHOL SWABS $0(2) BD ULTRAFINE INSULIN SYRINGE $0(2) BD ULTRAFINE/NANO PEN NEEDLES $0(2) BYDUREON BCISE $0(2) QL (4 pens / 28 days) BYDUREON PEN $0(2) QL (4 pens / 28 days) BYETTA $0(2) QL (1 pen / 30 days) FIASP $0(2) FIASP FLEXTOUCH $0(2) GAUZE PADS 2” X 2” $0(2) HUMULIN R INJ U-500 $0(2) B/D HUMULIN R U-500 KWIKPEN $0(2) INSULIN PEN NEEDLE $0(2) INSULIN SAFETY NEEDLES $0(2) INSULIN SYRINGE $0(2) LEVEMIR $0(2) LEVEMIR FLEXTOUCH $0(2)


Name of drug


you (tier

level)


or limits on use NOVOLIN 70/30 $0(2) (brand RELION not covered) NOVOLIN 70/30 FLEXPEN $0(2) (brand RELION not covered) NOVOLIN N $0(2) (brand RELION not covered) NOVOLIN R $0(2) (brand RELION not covered) NOVOLOG $0(2) NOVOLOG 70/30 FLEXPEN $0(2) NOVOLOG FLEXPEN $0(2) NOVOLOG MIX 70/30 $0(2) NOVOLOG PENFILL $0(2) OZEMPIC INJ 0.25 OR 0.5MG/DOSE $0(2) QL (1 pen / 28 days) OZEMPIC INJ 1MG/DOSE $0(2) QL (2 pens / 28 days) SOLIQUA 100/33 $0(2) QL (10 pens / 30 days) TRESIBA FLEXTOUCH $0(2) TRESIBA INJ $0(2) TRULICITY $0(2) QL (4 pens / 28 days) VICTOZA $0(2) QL (3 pens / 30 days) XULTOPHY 100/3.6 $0(2) QL (5 pens / 30 days)

ANTIDIABETICS, ORAL - DRUGS TO TREAT DIABETES acarbose TABS $0(1) FARXIGA $0(2) QL (30 tabs / 30 days) glimepiride 1mg, 2mg $0(2) QL (90 tabs / 30 days) glimepiride 4mg $0(2) QL (60 tabs / 30 days) glip/metform tab 2.5-250mg $0(1) QL (240 tabs / 30 days) glip/metform tab 2.5-500mg $0(1) QL (120 tabs / 30 days) glip/metform tab 5-500mg $0(1) QL (120 tabs / 30 days) glipizide TABS 5mg $0(1) QL (240 tabs / 30 days) glipizide TABS 10mg $0(1) QL (120 tabs / 30 days) glipizide TB24 2.5mg, 5mg $0(1) QL (90 tabs / 30 days) glipizide TB24 10mg $0(1) QL (60 tabs / 30 days) glipizide xl 2.5mg, 5mg $0(1) QL (90 tabs / 30 days) glipizide xl 10mg $0(1) QL (60 tabs / 30 days) glyburide TABS 1.25mg $0(2) QL (480 tabs / 30 days), PA; PA if

70 years and older glyburide TABS 2.5mg $0(2) QL (240 tabs / 30 days), PA; PA if

70 years and older


Name of drug


you (tier

level)


or limits on use glyburide TABS 5mg $0(2) QL (120 tabs / 30 days), PA; PA if

70 years and older glyburide micronized 1.5mg $0(2) QL (240 tabs / 30 days), PA; PA if

70 years and older glyburide micronized 3mg $0(2) QL (120 tabs / 30 days), PA; PA if

70 years and older glyburide micronized 6mg $0(2) QL (60 tabs / 30 days), PA; PA if

70 years and older glyburide-metformin tab 1.25-250 mg $0(2) QL (240 tabs / 30 days), PA; PA if

70 years and older glyburide-metformin tab 2.5-500 mg $0(2) QL (120 tabs / 30 days), PA; PA if

70 years and older glyburide-metformin tab 5-500mg $0(2) QL (120 tabs / 30 days), PA; PA if

70 years and older JANUMET $0(2) QL (60 tabs / 30 days) JANUMET XR TAB 50-500MG $0(2) QL (60 tabs / 30 days) JANUMET XR TAB 50-1000 $0(2) QL (60 tabs / 30 days) JANUMET XR TAB 100-1000 $0(2) QL (30 tabs / 30 days) JANUVIA $0(2) QL (30 tabs / 30 days) JARDIANCE 10mg $0(2) QL (60 tabs / 30 days) JARDIANCE 25mg $0(2) QL (30 tabs / 30 days) JENTADUETO $0(2) QL (60 tabs / 30 days) JENTADUETO TAB XR 2.5-1000 MG $0(2) QL (60 tabs / 30 days) JENTADUETO TAB XR 5-1000 MG $0(2) QL (30 tabs / 30 days) metformin er 500mg $0(1) QL (120 tabs / 30 days); (generic

of GLUCOPHAGE XR) metformin er 750mg $0(1) QL (60 tabs / 30 days); (generic

of GLUCOPHAGE XR) metformin hcl TABS 500mg $0(1) QL (150 tabs / 30 days) metformin hcl TABS 850mg $0(1) QL (90 tabs / 30 days) metformin hcl TABS 1000mg $0(1) QL (75 tabs / 30 days) nateglinide $0(1) QL (90 tabs / 30 days) pioglitazone hcl $0(1) QL (30 tabs / 30 days) repaglinide 2mg $0(1) QL (240 tabs / 30 days) repaglinide .5mg, 1mg $0(1) QL (120 tabs / 30 days) SYNJARDY TAB 5-500MG $0(2) QL (120 tabs / 30 days)


Name of drug


you (tier

level)


or limits on use SYNJARDY TAB 5-1000MG $0(2) QL (60 tabs / 30 days) SYNJARDY TAB 12.5-500MG $0(2) QL (60 tabs / 30 days) SYNJARDY TAB 12.5-1000MG $0(2) QL (60 tabs / 30 days) SYNJARDY XR TAB 5-1000MG $0(2) QL (60 tabs / 30 days) SYNJARDY XR TAB 10-1000MG $0(2) QL (60 tabs / 30 days) SYNJARDY XR TAB 12.5-1000MG $0(2) QL (60 tabs / 30 days) SYNJARDY XR TAB 25-1000MG $0(2) QL (30 tabs / 30 days) TRADJENTA $0(2) QL (30 tabs / 30 days) XIGDUO XR TAB 2.5-1000MG $0(2) QL (60 tabs / 30 days) XIGDUO XR TAB 5-500MG $0(2) QL (60 tabs / 30 days) XIGDUO XR TAB 5-1000MG $0(2) QL (60 tabs / 30 days) XIGDUO XR TAB 10-500MG $0(2) QL (30 tabs / 30 days) XIGDUO XR TAB 10-1000MG $0(2) QL (30 tabs / 30 days)

BISPHOSPHONATES - DRUGS TO TREAT BONE LOSS alendronate sodium $0(1) ibandronate sodium tabs $0(1) B/D PAMIDRONATE DISODIUM 6mg/ml $0(2) B/D pamidronate disodium 30mg/10ml, 90mg/10ml

$0(1) B/D

pamidronate inj 30mg $0(1) B/D pamidronate inj 90mg $0(1) B/D risedronate sodium TABS 5mg, 35mg, 150mg $0(1) risedronate sodium TBEC $0(1) zoledronic acid inj 5mg/100ml $0(1) B/D, NM zoledronic inj 4mg/5ml $0(1) B/D, NM

CHELATING AGENTS CHEMET $0(2) DEPEN TITRATABS $0(2) JADENU $0(2) NM, LA, PA JADENU SPRINKLE $0(2) NM, LA, PA kionex sus 15gm/60ml $0(1) sodium polystyrene sulfonate powder $0(1) sodium polystyrene sulfonate susp $0(1) sps susp 15gm/60ml $0(1)


Name of drug


you (tier

level)


or limits on use trientine hcl $0(2) PA

CONTRACEPTIVES - DRUGS FOR BIRTH CONTROL aftera $0(3) NM; * altavera tab $0(1) alyacen 1/35 $0(1) amethia $0(1) amethia lo $0(1) apri $0(1) aranelle $0(1) ashlyna $0(1) aubra $0(1) aviane $0(1) balziva $0(1) bekyree $0(1) blisovi 24 fe $0(1) blisovi fe 1.5/30 $0(1) briellyn $0(1) camila $0(1) camrese lo $0(1) caziant pak $0(1) cryselle-28 $0(1) cyclafem 1/35 $0(1) cyclafem 7/7/7 $0(1) cyred tab $0(1) dasetta 1/35 $0(1) dasetta 7/7/7 $0(1) deblitane $0(1) delyla $0(1) desogestrel & ethinyl estradiol $0(1) desogestrel-ethinyl estradiol (biphasic) $0(1) drospirenone-ethinyl estradiol $0(1) drospirenone-ethinyl estradiol-levomefolate calcium

$0(1)

DUREX REALFEEL NON-LATEX $0(3) NM; *


Name of drug


you (tier

level)


or limits on use econtra ez $0(3) NM; * econtra one-step $0(3) NM; * ELLA $0(2) emoquette $0(1) enpresse-28 $0(1) enskyce $0(1) errin $0(1) estarylla tab 0.25-35 $0(1) ethynodiol diacet & eth estrad $0(1) ethynodiol tab 1-50 $0(1) falmina $0(1) fayosim $0(1) FC2 FEMALE CONDOM $0(3) NM; * femynor $0(1) gianvi $0(1) hailey 24 fe $0(1) heather $0(1) incassia $0(1) introvale $0(1) isibloom $0(1) jasmiel $0(1) jolessa tab 0.15-0.03 mg $0(1) jolivette $0(1) juleber $0(1) junel 1.5/30 $0(1) junel 1/20 $0(1) junel fe 1.5/30 $0(1) junel fe 1/20 $0(1) junel fe 24 $0(1) kaitlib fe $0(1) kariva $0(1) kelnor 1/35 $0(1) kelnor 1/50 $0(1) kurvelo $0(1)


Name of drug


you (tier

level)


or limits on use larin 1.5/30 $0(1) larin 1/20 $0(1) larin fe 1.5/30 $0(1) larin fe 1/20 $0(1) larissia tab $0(1) layolis fe $0(1) leena $0(1) lessina $0(1) levonest $0(1) levonor/ethi tab $0(1) levonorgestrel & eth estradiol $0(1) levonorgestrel (emergency oc) $0(3) NM; * levonorgestrel-ethinyl estradiol (91-day) $0(1) levora 0.15/30-28 $0(1) loryna $0(1) low-ogestrel $0(1) lutera $0(1) lyza $0(1) marlissa $0(1) medroxyprogesterone acetate (contraceptive) $0(1) melodetta 24 fe $0(1) mibelas 24 fe $0(1) microgestin 1.5/30 $0(1) microgestin 1/20 $0(1) microgestin fe 1.5/30 $0(1) microgestin fe 1/20 $0(1) mili $0(1) mono-linyah tab 0.25-35 $0(1) my choice $0(3) NM; * my way $0(3) NM; * necon 0.5/35-28 $0(1) new day $0(3) NM; * nikki $0(1) nora-be tab $0(1)


Name of drug


you (tier

level)


or limits on use nore/eth/fer chw 0.4mg-35 $0(1) noreth/ethin chw fe $0(1) norethin acet & estrad-fe $0(1) norethindrone (contraceptive) $0(1) norethindrone acet & eth estra $0(1) norgest/ethi tab 0.25/35 $0(1) norgestimate-ethinyl estradiol (triphasic) 0.18-25/0.215-25/0.25-25 mg-mcg

$0(1)

norgestimate-ethinyl estradiol (triphasic) 0.18-35/0.215-35/0.25-35 mg-mcg

$0(1)

norlyroc $0(1) nortrel 0.5/35 (28) $0(1) nortrel 1/35 $0(1) nortrel 7/7/7 $0(1) NUVARING $0(2) ocella tab 3-0.03mg $0(1) opcicon one-step $0(3) NM; * option 2 $0(3) NM; * orsythia $0(1) philith $0(1) pimtrea $0(1) pirmella 1/35 $0(1) portia-28 $0(1) PREMIUM CONDOMS LUBRICATE $0(3) NM; * previfem $0(1) react $0(3) NM; * reclipsen $0(1) rivelsa $0(1) setlakin tab $0(1) sharobel $0(1) sprintec 28 $0(1) sronyx $0(1) syeda $0(1) take action $0(3) NM; * tarina 24 fe $0(1)


Name of drug


you (tier

level)


or limits on use tarina fe 1/20 $0(1) tilia fe $0(1) tri-estarylla $0(1) tri-legest fe $0(1) tri-linyah $0(1) tri-lo marzia $0(1) tri-lo-estarylla $0(1) tri-lo-sprintec $0(1) tri-mili $0(1) tri-previfem $0(1) tri-sprintec $0(1) tri-vylibra $0(1) tri-vylibra lo $0(1) trivora-28 $0(1) TRUSTEX/RIA NON-LUBRICATE $0(3) NM; * tulana $0(1) tydemy $0(1) velivet $0(1) vienva $0(1) viorele $0(1) vyfemla $0(1) vylibra $0(1) wymzya fe $0(1) xulane $0(1) zarah $0(1) zovia 1/35e $0(1)

ENDOMETRIOSIS danazol CAPS $0(1) SYNAREL $0(2)

ENZYME REPLACEMENTS - DRUGS TO TREAT ENZYME DEFICIENCIES ALDURAZYME $0(2) NM, LA, PA CARBAGLU $0(2) NM, LA, PA CERDELGA $0(2) NM, PA CEREZYME $0(2) NM, LA, PA


Name of drug


you (tier

level)


or limits on use CYSTADANE $0(2) NM, LA CYSTAGON $0(2) NM, LA, PA FABRAZYME $0(2) NM, LA, PA KUVAN $0(2) NM, LA, PA levocarnitine (metabolic modifiers) $0(1) B/D LUMIZYME $0(2) NM, LA, PA miglustat $0(2) NM, PA NAGLAZYME $0(2) NM, LA, PA NITYR $0(2) NM, LA, PA ORFADIN $0(2) NM, LA, PA sodium phenylbutyrate $0(2) NM, PA

ESTROGENS - DRUGS TO REGULATE FEMALE HORMONES DELESTROGEN 10mg/ml $0(2) estradiol PTWK; TABS $0(2) estradiol vaginal cream $0(1) estradiol vaginal tab $0(1) estradiol valerate OIL $0(1) fyavolv $0(2) jinteli $0(2) norethindrone acetate-ethinyl estradiol $0(2) yuvafem vaginal tablet 10 mcg $0(1)

GLUCOCORTICOIDS - DRUGS TO TREAT INFLAMMATORY RESPONSE cortisone acetate TABS $0(1) DEXAMETHASONE CONC $0(2) dexamethasone ELIX; SOLN; TABS $0(1) dexamethasone sodium phosphate $0(1) fludrocortisone acetate TABS $0(1) hydrocortisone TABS $0(1) methylpr ss inj $0(1) B/D methylpred pak 4mg $0(1) methylpred tab 4mg $0(1) B/D methylpred tab 8mg $0(1) B/D methylpred tab 16mg $0(1) B/D methylpred tab 32mg $0(1) B/D


Name of drug


you (tier

level)


or limits on use methylprednisolone acetate $0(1) B/D pred sod pho sol 5mg/5ml $0(1) B/D prednisolone sodium phosphate SOLN 15mg/5ml

$0(1) B/D

prednisolone sol 15mg/5ml $0(1) B/D prednisolone sol 25mg/5ml $0(1) B/D PREDNISONE CON 5MG/ML $0(2) B/D prednisone pak 5mg $0(1) prednisone pak 10mg $0(1) prednisone sol 5mg/5ml $0(1) B/D prednisone tab 1mg $0(1) B/D prednisone tab 2.5mg $0(1) B/D prednisone tab 5mg $0(1) B/D prednisone tab 10mg $0(1) B/D prednisone tab 20mg $0(1) B/D prednisone tab 50mg $0(1) B/D SOLU-CORTEF $0(2)

GLUCOSE ELEVATING AGENTS - DRUGS TO TREAT LOW BLOOD SUGAR BD GLUCOSE $0(3) NM; * CVS GLUCOSE CHEW $0(3) NM; * cvs glucose GEL $0(3) NM; * CVS GLUCOSE BITS $0(3) NM; * cvs glucose liquid shot $0(3) NM; * cvs glucose shot $0(3) NM; * DEX4 $0(3) NM; * DEX4 FAST ACTING GLUCOSE CHEW; GEL $0(3) NM; * DEX4 POUCH PACK $0(3) NM; * DEX4 QUICK DISSOLVE GLUCO $0(3) NM; * dextrose (diabetic use) $0(3) NM; * GLUCAGEN HYPOKIT $0(2) GLUCAGON EMERGENCY KIT $0(2) gluco burst GEL $0(3) NM; * GLUCOSE CHEW; LIQD $0(3) NM; * GLUCOSE INSTANT ENERGY $0(3) NM; *


Name of drug


you (tier

level)


or limits on use GNP GLUCOSE $0(3) NM; * GNP QUICK DISSOLVE GLUCOS $0(3) NM; * GOODSENSE GLUCOSE $0(3) NM; * HM GLUCOSE $0(3) NM; * HY-VEE GLUCOSE $0(3) NM; * INSTA-GLUCOSE $0(3) NM; * KROGER GLUCOSE $0(3) NM; * LEADER GLUCOSE $0(3) NM; * LEADER QUICK DISSOLVE GLU $0(3) NM; * LONGS GLUCOSE $0(3) NM; * MEIJER GLUCOSE $0(3) NM; * PREFERRED PLUS GLUCOSE $0(3) NM; * PROGLYCEM SUS 50MG/ML $0(2) PX GLUCOSE $0(3) NM; * RA GLUCOSE CHEW $0(3) NM; * ra glucose GEL $0(3) NM; * RA TRUEPLUS GLUCOSE $0(3) NM; * RELION GLUCOSE CHEW $0(3) NM; * relion glucose GEL $0(3) NM; * relion glucose drink $0(3) NM; * SM GLUCOSE $0(3) NM; * SMART SENSE GLUCOSE $0(3) NM; * SMART SENSE GLUCOSE TABLE $0(3) NM; * TGT GLUCOSE $0(3) NM; * TRUEPLUS GLUCOSE GEL $0(3) NM; * UP & UP GLUCOSE $0(3) NM; * VALUE PLUS GLUCOSE CHEW $0(3) NM; * value plus glucose GEL $0(3) NM; * WALGREENS GLUCOSE $0(3) NM; *

MISCELLANEOUS cabergoline $0(1) calcitonin (salmon) $0(1) B/D cinacalcet hcl 30mg, 90mg $0(2) B/D, QL (120 tabs / 30 days), NM cinacalcet hcl 60mg $0(2) B/D, QL (60 tabs / 30 days), NM


Name of drug


you (tier

level)


or limits on use FORTEO $0(2) NM, PA GENOTROPIN $0(2) NM, PA GENOTROPIN MINIQUICK $0(2) NM, PA INCRELEX $0(2) NM, LA, PA KORLYM $0(2) NM, LA, PA LUPRON DEP-PED INJ 7.5MG $0(2) NM, PA LUPRON DEP-PED INJ 11.25MG (3-MONTH) $0(2) NM, PA LUPRON DEPOT-PED (1-MONTH $0(2) NM, PA LUPRON DEPOT-PED (3-MONTH $0(2) NM, PA NATPARA $0(2) NM, PA octreotide acetate 50mcg/ml, 100mcg/ml, 200mcg/ml

$0(1) NM, PA

octreotide acetate 500mcg/ml, 1000mcg/ml $0(2) NM, PA PROLIA $0(2) QL (1 injection / 180 days), NM raloxifene hcl $0(1) SIGNIFOR $0(2) NM, LA, PA SOMATULINE DEPOT $0(2) NM, PA SOMAVERT $0(2) NM, LA, PA TYMLOS $0(2) NM, PA XGEVA $0(2) NM, PA

PHOSPHATE BINDER AGENTS - DRUGS TO REGULATE CALCIUM AND PHOSPHORUS LEVELS AURYXIA $0(2) QL (360 tabs / 30 days), PA calcium acetate (phosphate binder) CAPS $0(1) QL (360 caps / 30 days) calcium acetate (phosphate binder) TABS $0(1) QL (360 tabs / 30 days) sevelamer carbonate PACK 2.4gm $0(2) QL (180 packets / 30 days) sevelamer carbonate PACK .8gm $0(2) QL (540 packets / 30 days) sevelamer carbonate TABS $0(1) QL (540 tabs / 30 days)

PROGESTINS - DRUGS TO REGULATE FEMALE HORMONES medroxyprogesterone acetate tab $0(1) norethindrone acetate TABS $0(1)

THYROID AGENTS - DRUGS TO REGULATE THYROID LEVELS levo-t $0(1) levothyroxine sodium TABS $0(1) levoxyl $0(1)


Name of drug


you (tier

level)


or limits on use liothyronine sodium TABS $0(1) methimazole TABS $0(1) propylthiouracil TABS $0(1) SYNTHROID $0(2) unithroid $0(1)

VASOPRESSINS - DRUGS TO REGULATE PITUITARY HORMONES desmopressin acetate spray $0(1) desmopressin acetate spray refrigerated $0(1) desmopressin acetate tabs $0(1) desmopressin inj 4mcg/ml $0(1) STIMATE $0(2) NM

GASTROINTESTINAL - DRUGS TO TREAT STOMACH AND INTESTINAL DISORDERS ANTACIDS

acid gone $0(3) NM; * almacone $0(3) NM; * almacone double strength $0(3) NM; * ALUMINUM HYDROXIDE $0(3) NM; * aluminum hydroxide gel $0(3) NM; * antacid CHEW 500mg $0(3) NM; * antacid SUSP $0(3) NM; * antacid advanced $0(3) NM; * antacid anti-gas maximum $0(3) NM; * antacid anti-gas regular $0(3) NM; * antacid calcium extra str $0(3) NM; * antacid calcium regular s $0(3) NM; * antacid extra strength $0(3) NM; * antacid fast acting $0(3) NM; * antacid fast relief $0(3) NM; * antacid flavor chews $0(3) NM; * antacid maximum $0(3) NM; * antacid maximum strength $0(3) NM; * antacid plus anti-gas fas $0(3) NM; * antacid plus anti-gas rel $0(3) NM; * antacid regular strength $0(3) NM; *


Name of drug


you (tier

level)


or limits on use ANTACID ULTRA STRENGTH $0(3) NM; * antacid/simethicone doubl $0(3) NM; * cal-gest antacid $0(3) NM; * calcium antacid $0(3) NM; * calcium antacid extra str $0(3) NM; * calcium antacid ultra max $0(3) NM; * calcium antacid ultra str $0(3) NM; * calcium carbonate CHEW 500mg $0(3) NM; * CALCIUM CARBONATE TABS 648mg, 650mg $0(3) NM; * calcium carbonate (antacid) CHEW $0(3) NM; * cvs antacid & anti-gas fa $0(3) NM; * cvs antacid kids $0(3) NM; * cvs antacid supreme $0(3) NM; * cvs antacid/anti-gas $0(3) NM; * cvs chewy not chalky flav $0(3) NM; * cvs heartburn relief $0(3) NM; * cvs smooth antacid extra $0(3) NM; * eq antacid extra strengthOMInterface $0(3) NM; * eq antacid ultra strengthOMInterface $0(3) NM; * eql antacid ultra strengtOMInterface $0(3) NM; * eql antacid/anti-gas $0(3) NM; * fast acting antacid plus $0(3) NM; * GAVISCON $0(3) NM; * GAVISCON EXTRA STRENGTH SUSP $0(3) NM; * GAVISCON EXTRA STRENGTH R $0(3) NM; * geri-lanta $0(3) NM; * geri-mox $0(3) NM; * gnp antacid $0(3) NM; * gnp antacid & anti-gas ma $0(3) NM; * gnp antacid & anti-gas/re $0(3) NM; * gnp antacid and anti-gas/ $0(3) NM; * gnp antacid anti-gas $0(3) NM; * gnp antacid anti-gas/maxi $0(3) NM; * gnp antacid extra strengt $0(3) NM; *


Name of drug


you (tier

level)


or limits on use gnp antacid ultra strengt $0(3) NM; * gnp antacid/regular stren $0(3) NM; * gnp foaming antacid $0(3) NM; * gnp magnesium $0(3) NM; * gnp masanti maximum stren $0(3) NM; * gnp masanti regular stren $0(3) NM; * healthy mama tame the fla $0(3) NM; * heartburn antacid extra s $0(3) NM; * hm advanced antacid maxim $0(3) NM; * hm antacid $0(3) NM; * hm antacid anti-gas extra $0(3) NM; * hm antacid/antigas $0(3) NM; * hm calcium antacid extra $0(3) NM; * hm calcium antacid smooth $0(3) NM; * hm calcium antacid ultra $0(3) NM; * hm magnesium $0(3) NM; * MAG-AL $0(3) NM; * mag-al plus $0(3) NM; * mag-al plus xs $0(3) NM; * MAGNESIUM CAPS 500mg $0(3) NM; * MAGNESIUM OXIDE CAPS $0(3) NM; * magnesium oxide TABS 250mg, 400mg $0(3) NM; * MAGNESIUM OXIDE HEAVY $0(3) NM; * MI-ACID CHEW $0(3) NM; * mi-acid SUSP $0(3) NM; * mi-acid maximum strength $0(3) NM; * milantex $0(3) NM; * milantex extra strength $0(3) NM; * mintox $0(3) NM; * mintox maximum strength $0(3) NM; * mintox plus $0(3) NM; * px antacid extra strength $0(3) NM; * px antacid maximum streng $0(3) NM; * px antacid regular streng $0(3) NM; *


Name of drug


you (tier

level)


or limits on use px calcium antacid regula $0(3) NM; * qc antacid $0(3) NM; * qc antacid extra strength $0(3) NM; * qc antacid/anti-gas $0(3) NM; * qc antacid/anti-gas maxim $0(3) NM; * qc heartburn antacid $0(3) NM; * ra antacid $0(3) NM; * rolaids $0(3) NM; * rulox $0(3) NM; * sb antacid $0(3) NM; * sb antacid anti-gas $0(3) NM; * sb antacid extra strength $0(3) NM; * sm antacid advanced $0(3) NM; * sm antacid advanced maxi $0(3) NM; * sm antacid anti-gas $0(3) NM; * sm antacid maximum streng $0(3) NM; * sm antacid/antigas $0(3) NM; * sm calcium antacid $0(3) NM; * sm calcium antacid extra $0(3) NM; * sm foaming antacid $0(3) NM; * SODIUM BICARBONATE POWD $0(3) NM; * sodium bicarbonate (antacid) $0(3) NM; * tgt antacid $0(3) NM; * tgt antacid anti-gas regu $0(3) NM; * tgt antacid extra strengt $0(3) NM; * TUMS CHEWY DELIGHTS $0(3) NM; * tums smoothies $0(3) NM; * URO MAG $0(3) NM; * URO-MAG $0(3) NM; *

ANTI-DIARRHEAL abatinex $0(3) NM; * ACIDOPHILUS WAFR $0(3) NM; * acidophilus extra strengt $0(3) NM; * acidophilus probiotic $0(3) NM; *


Name of drug


you (tier

level)


or limits on use acidophilus probiotic for $0(3) NM; * ACIDOPHILUS/BIFIDUS $0(3) NM; * ACIDOPHILUS/CITRUS PECTIN $0(3) NM; * align jr for kids $0(3) NM; * anti-diarrheal CAPS; TABS $0(3) NM; * bismatrol $0(3) NM; * bismatrol maximum strengt $0(3) NM; * bismuth subsalicylate CHEW $0(3) NM; * CULTURELLE BABY GROW THRI LIQD $0(3) NM; * cvs acidophilus probiotic $0(3) NM; * cvs anti-diarrheal $0(3) NM; * cvs bismuth $0(3) NM; * cvs bismuth maximum stren $0(3) NM; * cvs stomach relief $0(3) NM; * diamode $0(3) NM; * diarrhea $0(3) NM; * dofus $0(3) NM; * eq pink-bismuth $0(3) NM; * eq stomach reliefce. $0(3) NM; * eql digestive probiotic $0(3) NM; * eql probiotic acidophilusOMInterface $0(3) NM; * eql stomach reliefe. $0(3) NM; * eql stomach relief maximuOMInterface $0(3) NM; * FLORAJEN ACIDOPHILUS $0(3) NM; * floranex $0(3) NM; * freeze dried acidophilus $0(3) NM; * geri-pectate $0(3) NM; * gnp anti-diarrheal $0(3) NM; * gnp k-pec $0(3) NM; * gnp loperamide hcl $0(3) NM; * gnp pink bismuth $0(3) NM; * gnp stomach relief $0(3) NM; * gnp stomach relief maximu $0(3) NM; * goodsense stomach relief $0(3) NM; *


Name of drug


you (tier

level)


or limits on use hm acidophilus probiotic $0(3) NM; * hm anti-diarrheal $0(3) NM; * hm loperamide hcl $0(3) NM; * hm stomach relief $0(3) NM; * hm stomach relief maximum $0(3) NM; * intestinex $0(3) NM; * KALA $0(3) NM; * kao-tin SUSP $0(3) NM; * kaopectate $0(3) NM; * kaopectate extra strength $0(3) NM; * lactinex CHEW $0(3) NM; * lacto-key-100 $0(3) NM; * lacto-key-600 $0(3) NM; * lactobacillus $0(3) NM; * lactobacillus acidophilus-pectin $0(3) NM; * lactobacillus extra stren $0(3) NM; * loperamide hcl SUSP $0(3) NM; * medi-bismuth $0(3) NM; * MORE-DOPHILUS ACIDOPHILUS $0(3) NM; * peptic relief $0(3) NM; * pink bismuth $0(3) NM; * probiata $0(3) NM; * PROBIOTIC CAPS $0(3) NM; * probiotic acidophilus $0(3) NM; * probiotic acidophilus sup $0(3) NM; * probiotic gold extra stre $0(3) NM; * px stomach relief $0(3) NM; * px stomach relief maximum $0(3) NM; * qc anti-diarrheal $0(3) NM; * qc diarrhea relief $0(3) NM; * qc pink bismuth $0(3) NM; * ra acidophilus $0(3) NM; * ra digestive health $0(3) NM; * ra pink bismuth $0(3) NM; *


Name of drug


you (tier

level)


or limits on use ra stomach relief $0(3) NM; * ra stomach relief maximum $0(3) NM; * REPHRESH PRO-B $0(3) NM; * sb anti-diarrhea $0(3) NM; * sb bismuth $0(3) NM; * sm acidophilus $0(3) NM; * sm anti-diarrheal $0(3) NM; * sm loperamide hcl $0(3) NM; * sm stomach relief $0(3) NM; * sm stomach relief liquid $0(3) NM; * soothe CHEW; SUSP; TABS $0(3) NM; * stomach relief $0(3) NM; * stomach relief maximum st $0(3) NM; * tgt anti-diarrheal $0(3) NM; * tgt stomach relief $0(3) NM; *

ANTIEMETICS - DRUGS FOR NAUSEA AND VOMITING aprepitant $0(1) B/D aprepitant pak 80mg & 125mg $0(1) B/D compro $0(1) dramamine less drowsy $0(3) NM; * driminate $0(3) NM; * dronabinol $0(1) B/D, QL (60 caps / 30 days) EMEND SUSR $0(2) B/D gnp motion sickness relie $0(3) NM; * granisetron hcl SOLN $0(1) granisetron hcl TABS $0(1) B/D hm motion relief $0(3) NM; * hm motion sickness relief $0(3) NM; * meclizine hcl CHEW $0(3) NM; * meclizine hcl TABS 12.5mg, 25mg $0(2) meclizine hcl TABS 12.5mg, 25mg $0(3) NM; * metoclopramide hcl SOLN; TABS $0(1) metoclopramide hcl inj $0(1) motion sickness relief $0(3) NM; *


Name of drug


you (tier

level)


or limits on use motion-time $0(3) NM; * ondansetron hcl TABS $0(1) B/D ondansetron hcl inj $0(1) ondansetron hcl oral soln $0(1) B/D ondansetron odt $0(1) B/D prochlorperazine inj $0(1) prochlorperazine maleate TABS $0(1) prochlorperazine supp $0(1) promethazine hcl SYRP; TABS $0(2) PA; PA if 70 years and older promethazine hcl inj $0(2) PA; PA if 70 years and older sb motion sickness $0(3) NM; * scopolamine $0(2) QL (10 patches / 30 days), PA;

PA if 70 years and older sm motion sickness $0(3) NM; * sm motion sickness relief $0(3) NM; * travel sickness $0(3) NM; * travel-ease $0(3) NM; *

ANTISPASMODICS - DRUGS FOR STOMACH SPASMS dicyclomine hcl cap 10mg $0(2) dicyclomine hcl soln 10mg/5ml $0(2) dicyclomine hcl tab 20mg $0(2) glycopyrrolate tab 1mg $0(1) glycopyrrolate tab 2mg $0(1)

H2-RECEPTOR ANTAGONISTS - DRUGS FOR ULCERS AND STOMACH ACID acid controller maximum s $0(3) NM; * acid reducer TABS $0(3) NM; * acid reducer maximum stre $0(3) NM; * famotidine SUSR $0(1) famotidine TABS 10mg $0(3) NM; * famotidine TABS 20mg, 40mg $0(1) famotidine in nacl $0(1) famotidine inj $0(1) gnp acid control 150 maxi $0(3) NM; * gnp acid reducer $0(3) NM; * gnp acid reducer maximum $0(3) NM; *


Name of drug


you (tier

level)


or limits on use gnp heartburn relief $0(3) NM; * goodsense acid reducer $0(3) NM; * heartburn relief $0(3) NM; * heartburn relief 150 maxi $0(3) NM; * heartburn relief maximum $0(3) NM; * hm acid reducer $0(3) NM; * hm famotidine $0(3) NM; * px acid reducer $0(3) NM; * px acid reducer maximum s $0(3) NM; * qc acid controller $0(3) NM; * qc acid controller maximu $0(3) NM; * ranitidine 150 maximum st $0(3) NM; * ranitidine hcl TABS 75mg, 150mg $0(3) NM; * ranitidine hcl TABS 150mg, 300mg $0(1) ranitidine hcl inj $0(1) ranitidine syrup $0(1) sb acid reducer $0(3) NM; * sm acid reducer $0(3) NM; * sm acid reducer maximum s $0(3) NM; *

INFLAMMATORY BOWEL DISEASE balsalazide disodium $0(1) budesonide ec $0(1) colocort enema 100mg $0(1) hydrocortisone (enema) $0(1) mesalamine CPDR $0(1) mesalamine ENEM $0(1) mesalamine SUPP $0(2) mesalamine TBEC 1.2gm $0(1) mesalamine w/ cleanser $0(1) sulfasalazine TABS $0(1) sulfasalazine ec $0(1)

LAXATIVES bisac-evac $0(3) NM; * bisacodyl SUPP $0(3) NM; *


Name of drug


you (tier

level)


or limits on use bisacodyl ec $0(3) NM; * bisacodyl laxative $0(3) NM; * biscolax $0(3) NM; * calcium polycarbophil $0(3) NM; * castor oil stimulant laxa $0(3) NM; * chocolated laxative $0(3) NM; * clearlax $0(3) NM; * colace 2-in-1 $0(3) NM; * COLACE CLEAR $0(3) NM; * constulose $0(1) cvs castor oil $0(3) NM; * cvs chocolate laxative pi $0(3) NM; * cvs enema ready-to-use $0(3) NM; * cvs epsom salt $0(3) NM; * cvs fiber laxative $0(3) NM; * cvs laxative pills $0(3) NM; * cvs magnesium citrate SOLN $0(3) NM; * cvs mineral oil $0(3) NM; * cvs mineral oil enema $0(3) NM; * cvs natural daily fiber $0(3) NM; * CVS NATURAL FIBER SUPPLEM PACK $0(3) NM; * cvs senna $0(3) NM; * cvs senna-extra $0(3) NM; * cvs soluble fiber therapy $0(3) NM; * diocto $0(3) NM; * docu $0(3) NM; * docu soft $0(3) NM; * docusate calcium $0(3) NM; * docusate sodium CAPS; LIQD; TABS $0(3) NM; * docusil $0(3) NM; * DOCUSOL KIDS $0(3) NM; * DOCUSOL MINI $0(3) NM; * DOCUSOL PLUS MINI-ENEMA $0(3) NM; * docuzen $0(3) NM; *


Name of drug


you (tier

level)


or limits on use dok $0(3) NM; * dok plus $0(3) NM; * ducodyl $0(3) NM; * enema ready-to-use $0(3) NM; * ENEMEEZ MINI $0(3) NM; * ENEMEEZ PLUS $0(3) NM; * enulose $0(1) epsom salt GRAN $0(3) NM; * EPSOM SALT POWD $0(3) NM; * eq magnesium citrate $0(3) NM; * eq mineral oil $0(3) NM; * eq natural laxative $0(3) NM; * eq vegetable laxative $0(3) NM; * eql castor oil $0(3) NM; * EQL EPSOM SALT $0(3) NM; * eql fiber therapy $0(3) NM; * eql laxative eql laxative $0(3) NM; * eql laxative maximum stre $0(3) NM; * eql senna laxative $0(3) NM; * eql stool softener $0(3) NM; * EQUALACTIN $0(3) NM; * evac-u-gen TABS $0(3) NM; * fiber laxative $0(3) NM; * fiber therapy TABS $0(3) NM; * fiber-lax $0(3) NM; * FLEET BISACODYL $0(3) NM; * gavilax $0(3) NM; * gavilyte-c $0(1) gavilyte-g $0(1) gavilyte-n/flavor pack $0(1) generlac $0(1) gentle laxative $0(3) NM; * gentlelax $0(3) NM; * geri-kot $0(3) NM; *


Name of drug


you (tier

level)


or limits on use geri-mucil $0(3) NM; * glycolax $0(3) NM; * gnp bisa-lax $0(3) NM; * gnp castor oil $0(3) NM; * gnp clearlax $0(3) NM; * gnp enema $0(3) NM; * gnp epsom salt $0(3) NM; * gnp fiber therapy $0(3) NM; * gnp fiber-caps $0(3) NM; * gnp gentle laxative $0(3) NM; * gnp laxative $0(3) NM; * gnp laxative pills $0(3) NM; * gnp magnesium citrate $0(3) NM; * gnp milk of magnesia $0(3) NM; * gnp mineral oil enema $0(3) NM; * gnp mineral oil heavy $0(3) NM; * gnp natural fiber $0(3) NM; * gnp senna lax $0(3) NM; * gnp senna plus $0(3) NM; * gnp senna-lax $0(3) NM; * gnp stool softener $0(3) NM; * gnp stool softener extra $0(3) NM; * gnp stool softener/stimul $0(3) NM; * gnp womens gentle laxativ $0(3) NM; * gnp womens laxative $0(3) NM; * GOLYTELY $0(2) goodsense clearlax $0(3) NM; * goodsense magnesium citra $0(3) NM; * goodsense mineral oil lub $0(3) NM; * goodsense natural fiber $0(3) NM; * goodsense senna laxative $0(3) NM; * goodsense stimulant laxat $0(3) NM; * healthy mama move it alon $0(3) NM; * healthylax $0(3) NM; *


Name of drug


you (tier

level)


or limits on use hm clearlax $0(3) NM; * hm enema mineral oil $0(3) NM; * hm enema ready-to-use $0(3) NM; * hm enema saline laxative $0(3) NM; * hm epsom salt $0(3) NM; * hm fiber $0(3) NM; * hm laxative $0(3) NM; * hm magnesium citrate $0(3) NM; * hm milk of magnesia $0(3) NM; * hm mineral oil $0(3) NM; * hm senna $0(3) NM; * hm senna-s $0(3) NM; * hm stool softener $0(3) NM; * hm stool softener maximum $0(3) NM; * hm stool softener/stimula $0(3) NM; * HYDROCIL INSTANT PACK $0(3) NM; * kao-tin CAPS $0(3) NM; * kls fiber-tabs $0(3) NM; * kls natural psyllium fibe $0(3) NM; * KONSYL POWD $0(3) NM; * KONSYL DAILY FIBER PACK 28.3%, 100% $0(3) NM; * konsyl daily fiber POWD 28.3% $0(3) NM; * KONSYL DAILY FIBER POWD 100% $0(3) NM; * KONSYL-D $0(3) NM; * kp bisacodyl $0(3) NM; * kp senna $0(3) NM; * ks stool softener $0(3) NM; * lactulose SOLN $0(1) lactulose (encephalopathy) $0(1) laxa basic $0(3) NM; * laxacin $0(3) NM; * laxative $0(3) NM; * laxative pills maximum st $0(3) NM; * laxative pills regular st $0(3) NM; *


Name of drug


you (tier

level)


or limits on use magnesium citrate SOLN $0(3) NM; * medi-natural $0(3) NM; * medi-natural plus $0(3) NM; * METAMUCIL CAPS .36gm $0(3) NM; * METAMUCIL PACK $0(3) NM; * metamucil POWD 28.3% $0(3) NM; * METAMUCIL WAFR $0(3) NM; * METAMUCIL FIBER $0(3) NM; * METAMUCIL FREE & NATURAL $0(3) NM; * METAMUCIL MULTIHEALTH FIB $0(3) NM; * metamucil smooth texture $0(3) NM; * milk of magnesia $0(3) NM; * MILK OF MAGNESIA CONCENTR $0(3) NM; * mineral oil ENEM $0(3) NM; * MINERAL OIL OIL $0(3) NM; * mineral oil OIL 99.9% $0(3) NM; * MINERAL OIL HEAVY $0(3) NM; * natural fiber $0(3) NM; * natural fiber laxative $0(3) NM; * natural fiber therapy $0(3) NM; * natural senna laxative $0(3) NM; * NULYTELY/FLAVOR PACKS $0(2) PEDIA-LAX CHEW; LIQD $0(3) NM; * pediatric enema $0(3) NM; * peg 3350-kcl-sod bicarb-sod chloride-sod sulfate

$0(1)

peg 3350-potassium chloride-sod bicarbonate-sod chloride

$0(1)

peg 3350/electrolytes $0(1) PLENVU $0(2) polyethylene glycol 3350 PACK; POWD $0(3) NM; * px docusate sodium $0(3) NM; * px fiber $0(3) NM; * px laxative $0(3) NM; * px milk of magnesia $0(3) NM; *


Name of drug


you (tier

level)


or limits on use qc docusate calcium $0(3) NM; * qc enema $0(3) NM; * qc epsom salt $0(3) NM; * qc fiber laxative $0(3) NM; * qc gentle laxative $0(3) NM; * qc laxative $0(3) NM; * qc magnesium citrate $0(3) NM; * qc milk of magnesia $0(3) NM; * qc mineral oil heavy $0(3) NM; * qc natura-lax $0(3) NM; * qc natural vegetable $0(3) NM; * qc natural vegetable laxa $0(3) NM; * qc senna $0(3) NM; * qc senna-s $0(3) NM; * qc stool softener $0(3) NM; * qc stool softener plus la $0(3) NM; * qc stool softener plus st $0(3) NM; * ra epsom salt $0(3) NM; * RA EPSOM SALT $0(3) NM; * RA EPSOM SALT LAVENDER $0(3) NM; * ra laxative $0(3) NM; * ra mineral oil $0(3) NM; * ra multihealth fiber supp $0(3) NM; * reguloid CAPS $0(3) NM; * reguloid POWD 28.3%, 48.57%, 58.6% $0(3) NM; * sb bisacodyl laxative ec $0(3) NM; * sb docusate sodium $0(3) NM; * sb docusate sodium/senna $0(3) NM; * sb fib lax orange 33% $0(3) NM; * sb laxative $0(3) NM; * sb milk of magnesia $0(3) NM; * sb senna-lax $0(3) NM; * senexon $0(3) NM; * senexon-s $0(3) NM; *


Name of drug


you (tier

level)


or limits on use senna laxative $0(3) NM; * senna plus $0(3) NM; * senna-grx $0(3) NM; * senna-lax $0(3) NM; * senna-s $0(3) NM; * senna-tabs $0(3) NM; * senna-time $0(3) NM; * senna-time s $0(3) NM; * senno $0(3) NM; * sennosides $0(3) NM; * sennosides-docusate sodium $0(3) NM; * senokot extra strength $0(3) NM; * silace $0(3) NM; * sm castor oil $0(3) NM; * sm clearlax $0(3) NM; * sm enema $0(3) NM; * sm epsom salt $0(3) NM; * sm fiber $0(3) NM; * sm fiber laxative $0(3) NM; * SM FIBER POWDER 25% $0(3) NM; * sm gentle laxative $0(3) NM; * sm laxative $0(3) NM; * sm laxative maximum stren $0(3) NM; * sm magnesium citrate $0(3) NM; * sm milk of magnesia $0(3) NM; * sm mineral oil $0(3) NM; * sm natural laxative plus $0(3) NM; * sm senna laxative $0(3) NM; * sm senna-s $0(3) NM; * sm stool softener $0(3) NM; * sm stool softener plus la $0(3) NM; * sodium phosphates $0(3) NM; * soluble fiber $0(3) NM; * SORBITOL SOLN 70% $0(3) NM; *


Name of drug


you (tier

level)


or limits on use stimulant laxative $0(3) NM; * stool softener $0(3) NM; * stool softener extra stre $0(3) NM; * stool softener laxative $0(3) NM; * stool softener plus laxat $0(3) NM; * stool softener/laxative $0(3) NM; * SUPREP BOWEL PREP KIT $0(2) tgt fiber therapy $0(3) NM; * tgt gentle laxative $0(3) NM; * tgt laxative pills maximu $0(3) NM; * tgt natural laxative pill $0(3) NM; * tgt powderlax $0(3) NM; * tgt psyllium fiber $0(3) NM; * tgt saline laxative $0(3) NM; * tgt senna laxative $0(3) NM; * tgt stool softener $0(3) NM; * tgt stool softener & stim $0(3) NM; * tgt womens laxative $0(3) NM; * the magic bullet $0(3) NM; * trilyte $0(1) vegetable laxative+stool $0(3) NM; * wal-mucil $0(3) NM; * womans laxative $0(3) NM; *

MISCELLANEOUS alosetron hcl $0(2) PA AMITIZA CAP 8MCG $0(2) QL (180 caps / 30 days) AMITIZA CAP 24MCG $0(2) QL (60 caps / 30 days) BICARSIM FORTE $0(3) NM; * cromolyn sodium (mastocytosis) $0(2) cvs gas relief $0(3) NM; * cvs gas relief extra stre $0(3) NM; * cvs gas relief infants $0(3) NM; * cvs gas relief ultra stre $0(3) NM; * diphenoxylate w/ atropine $0(2)


Name of drug


you (tier

level)


or limits on use eq gas relief $0(3) NM; * eq infants gas relief $0(3) NM; * eql gas relief extra stre $0(3) NM; * eql gas relief ultra stre $0(3) NM; * eql infants gas relief $0(3) NM; * gas relief $0(3) NM; * gas relief extra strength $0(3) NM; * gas relief infants $0(3) NM; * gas relief ultra strength $0(3) NM; * gas-x extra strength CAPS $0(3) NM; * GAS-X EXTRA STRENGTH STRP $0(3) NM; * gas-x ultra strength $0(3) NM; * GATTEX $0(2) NM, LA, PA gnp anti-gas $0(3) NM; * gnp gas relief $0(3) NM; * gnp gas relief extra stre $0(3) NM; * gnp infants gas relief $0(3) NM; * goodsense gas relief extr $0(3) NM; * hm gas relief $0(3) NM; * hm gas relief infants $0(3) NM; * infants gas relief $0(3) NM; * infants simethicone $0(3) NM; * LINZESS $0(2) QL (30 caps / 30 days) little remedies for tummy SUSP $0(3) NM; * loperamide hcl CAPS $0(1) mi-acid gas relief $0(3) NM; * misoprostol TABS $0(1) MOVANTIK 12.5mg $0(2) QL (60 tabs / 30 days) MOVANTIK 25mg $0(2) QL (30 tabs / 30 days) PHAZYME MAXIMUM STRENGTH $0(3) NM; * px gas relief extra stren $0(3) NM; * px gas relief infants $0(3) NM; * px gas relief ultra stren $0(3) NM; * qc anti-gas ultra strengt $0(3) NM; *


Name of drug


you (tier

level)


or limits on use ra gas relief $0(3) NM; * ra gas relief extra stren $0(3) NM; * RELISTOR SOLN $0(2) PA simethicone CAPS; CHEW; SUSP $0(3) NM; * sm gas relief $0(3) NM; * sm gas relief antiflatuen $0(3) NM; * sm gas relief drops infan $0(3) NM; * sm gas relief extra stren $0(3) NM; * sucralfate TABS $0(1) tgt gas relief extra stre $0(3) NM; * tgt gas relief infants dr $0(3) NM; * ursodiol CAPS; TABS $0(1) v-r anti-gas maximum stre $0(3) NM; * XIFAXAN 550mg $0(2) PA

PANCREATIC ENZYMES CREON $0(2) ZENPEP $0(2)

PROTON PUMP INHIBITORS - DRUGS FOR ULCERS AND STOMACH ACID acid reducer CPDR $0(3) NM; * DEXILANT $0(2) QL (30 caps / 30 days) esomeprazole magnesium 20mg $0(3) NM; * esomeprazole magnesium 20mg, 40mg $0(1) QL (30 caps / 30 days), ST gnp esomeprazole magnesiu $0(3) NM; * gnp lansoprazole $0(3) NM; * GNP OMEPRAZOLE $0(3) NM; * goodsense lansoprazole $0(3) NM; * heartburn treatment 24 ho $0(3) NM; * hm esomeprazole magnesium $0(3) NM; * hm lansoprazole $0(3) NM; * HM OMEPRAZOLE $0(3) NM; * lansoprazole CPDR 15mg $0(3) NM; * lansoprazole CPDR 15mg, 30mg $0(1) QL (30 caps / 30 days) OMEPRAZOLE TBEC $0(3) NM; * omeprazole cap 10mg $0(1)


Name of drug


you (tier

level)


or limits on use omeprazole cap 20mg $0(1) omeprazole cap 40mg $0(1) omeprazole magnesium $0(3) NM; * pantoprazole sodium SOLR $0(1) pantoprazole sodium tbec $0(1) qc omeprazole magnesium $0(3) NM; * rabeprazole sodium $0(1) QL (30 tabs / 30 days) SB OMEPRAZOLE $0(3) NM; * sm esomeprazole magnesium $0(3) NM; * sm lansoprazole $0(3) NM; * SM OMEPRAZOLE $0(3) NM; *

GENITOURINARY - DRUGS TO TREAT GENITAL AND URINARY TRACT CONDITIONS BENIGN PROSTATIC HYPERPLASIA - DRUGS TO TREAT ENLARGED PROSTATE

alfuzosin hcl $0(1) QL (30 tabs / 30 days) dutasteride CAPS $0(1) QL (30 caps / 30 days) dutasteride-tamsulosin hcl $0(1) QL (30 caps / 30 days) finasteride TABS 5mg $0(1) tamsulosin hcl $0(1)

MISCELLANEOUS bethanechol chloride TABS $0(1) gnp urinary pain relief $0(3) NM; * potassium citrate (alkalinizer) er tabs $0(1) sb urinary pain relief ma $0(3) NM; * sm urinary pain relief $0(3) NM; * sm urinary pain relief ma $0(3) NM; * urinary pain relief $0(3) NM; * urinary pain relief maxim $0(3) NM; *

URINARY ANTISPASMODICS - DRUGS TO TREAT URINARY INCONTINENCE MYRBETRIQ $0(2) QL (30 tabs / 30 days) oxybutynin chloride SYRP $0(1) oxybutynin chloride TABS $0(1) oxybutynin chloride TB24 5mg $0(1) QL (30 tabs / 30 days) oxybutynin chloride TB24 10mg, 15mg $0(1) QL (60 tabs / 30 days) tolterodine tartrate cap er $0(1) QL (30 caps / 30 days), ST


Name of drug


you (tier

level)


or limits on use tolterodine tartrate tabs $0(1) ST TOVIAZ $0(2) QL (30 tabs / 30 days) trospium chloride TABS $0(1) QL (60 tabs / 30 days)

VAGINAL ANTI-INFECTIVES clindamycin phosphate vaginal $0(1) clotrimazole 3 $0(3) NM; * clotrimazole vaginal $0(3) NM; * 3 day vaginal $0(3) NM; * gnp clotrimazole 3 $0(3) NM; * gnp miconazole 3 $0(3) NM; * gnp miconazole 7 $0(3) NM; * metronidazole vaginal $0(1) miconazole 1 $0(3) NM; * miconazole 3 $0(3) NM; * miconazole 3 combination $0(3) NM; * miconazole 3 combo pack $0(3) NM; * miconazole 7 $0(3) NM; * miconazole nitrate vaginal CREA $0(3) NM; * miconazole nitrate vaginal KIT $0(3) NM; * miconazole nitrate vaginal SUPP 100mg $0(3) NM; * px miconazole 3-day combo $0(3) NM; * qc 3 day vaginal cream $0(3) NM; * qc miconazole 7 $0(3) NM; * sm 3-day vaginal $0(3) NM; * sm clotrimazole vaginal $0(3) NM; * sm miconazole 3 $0(3) NM; * sm miconazole 7 $0(3) NM; * terconazole vaginal $0(1) tgt miconazole 3 combinat $0(3) NM; * tgt miconazole 7 $0(3) NM; * vandazole $0(1)

HEMATOLOGIC - DRUGS TO TREAT BLOOD DISORDERS ANTICOAGULANTS - BLOOD THINNERS

COUMADIN $0(2)


Name of drug


you (tier

level)


or limits on use ELIQUIS 2.5mg $0(2) QL (60 tabs / 30 days) ELIQUIS 5mg $0(2) QL (74 tabs / 30 days) ELIQUIS STARTER PACK $0(2) QL (74 tabs / 30 days) enoxaparin sodium $0(1) fondaparinux sodium 2.5mg/0.5ml $0(1) fondaparinux sodium 5mg/0.4ml, 7.5mg/0.6ml, 10mg/0.8ml

$0(2)

heparin sod (porcine) in d5w $0(2) heparin sod inj 1000/ml $0(1) B/D heparin sod inj 5000/ml $0(1) B/D heparin sod inj 10000/ml $0(1) B/D heparin sod inj 20000/ml $0(1) B/D HEPARIN SODIUM/NACL 0.45% $0(2) jantoven $0(1) PRADAXA $0(2) QL (60 caps / 30 days) warfarin sodium $0(1) XARELTO 2.5mg $0(2) QL (60 tabs / 30 days) XARELTO 10mg, 15mg, 20mg $0(2) QL (30 tabs / 30 days) XARELTO STARTER PACK $0(2) QL (51 tabs / 30 days)

HEMATOPOIETIC GROWTH FACTORS PROCRIT $0(2) NM, PA ZARXIO $0(2) NM, PA

IRON bprotected pedia iron $0(3) NM; * CORVITE 150 $0(3) NM; * CORVITE FE $0(3) NM; * cvs iron $0(3) NM; * cvs slow release iron $0(3) NM; * eq slow-release iron $0(3) NM; * eql carbonyl iron $0(3) NM; * eql iron supplement thera $0(3) NM; * eql slow release iron $0(3) NM; * EZFE 200 $0(3) NM; * FERAHEME $0(3) NM; *


Name of drug


you (tier

level)


or limits on use ferate $0(3) NM; * fergon $0(3) NM; * FERIVA 21/7 $0(3) NM; * FERIVAFA $0(3) NM; * ferosul $0(3) NM; * ferrex 150 $0(3) NM; * ferric x-150 $0(3) NM; * ferrous gluconate TABS 27mg, 240mg, 324mg $0(3) NM; * FERROUS GLUCONATE TABS 324mg $0(3) NM; * ferrous sulfate ELIX $0(3) NM; * FERROUS SULFATE LIQD $0(3) NM; * FERROUS SULFATE POWD $0(3) NM; * ferrous sulfate SOLN $0(3) NM; * FERROUS SULFATE SYRP $0(3) NM; * ferrous sulfate TABS $0(3) NM; * FERROUS SULFATE TBEC 324mg $0(3) NM; * ferrous sulfate TBEC 325mg $0(3) NM; * ferrous sulfate iron $0(3) NM; * ferrousul $0(3) NM; * FUSION PLUS $0(3) NM; * gnp iron $0(3) NM; * gnp slow release iron $0(3) NM; * HEMOCYTE PLUS $0(3) NM; * hemocyte-f $0(3) NM; * hm iron $0(3) NM; * hm iron slow release $0(3) NM; * iferex 150 $0(3) NM; * INJECTAFER $0(3) NM; * INTEGRA F $0(3) NM; * INTEGRA PLUS $0(3) NM; * IRON TABS $0(3) NM; * iron 27 $0(3) NM; * IRON CHEWS PEDIATRIC $0(3) NM; * iron slow release 45mg $0(3) NM; *


Name of drug


you (tier

level)


or limits on use iron supplement childrens $0(3) NM; * IRON UP $0(3) NM; * IROSPAN 24/6 $0(3) NM; * kp ferrous gluconate $0(3) NM; * kp ferrous sulfate $0(3) NM; * myferon 150 $0(3) NM; * myferon 150 forte $0(3) NM; * NEPHRON FA $0(3) NM; * NOVAFERRUM 50 $0(3) NM; * NOVAFERRUM PEDIATRIC DROP $0(3) NM; * nu-iron 150 $0(3) NM; * PERFECT IRON $0(3) NM; * poly-iron 150 $0(3) NM; * poly-iron 150 forte $0(3) NM; * PROFE $0(3) NM; * PROFERRIN-FORTE $0(3) NM; * PROTECTIRON $0(3) NM; * px iron $0(3) NM; * qc ferrous sulfate $0(3) NM; * ra high potency iron $0(3) NM; * ra iron $0(3) NM; * ra slow release iron $0(3) NM; * slow fe $0(3) NM; * slow iron $0(3) NM; * slow release iron $0(3) NM; * slow-release iron $0(3) NM; * sm iron $0(3) NM; * sm iron slow release $0(3) NM; * sm slow release iron 142mg $0(3) NM; * SM SLOW RELEASE IRON 143mg $0(3) NM; * sodium ferric gluconate complex in sucrose $0(3) NM; * TARON FORTE $0(3) NM; * VENOFER $0(3) NM; * wee care $0(3) NM; *


Name of drug


you (tier

level)


or limits on use MISCELLANEOUS

anagrelide hcl $0(1) BERINERT $0(2) QL (24 boxes / 30 days), NM, LA,

PA cilostazol $0(1) DROXIA $0(2) ENDARI $0(2) NM, LA, PA HAEGARDA 2000unit $0(2) QL (30 vials / 30 days), NM, LA,

PA HAEGARDA 3000unit $0(2) QL (20 vials / 30 days), NM, LA,

PA icatibant acetate $0(2) QL (9 syringes / 30 days), NM,

PA pentoxifylline TBCR $0(1) PROMACTA PACK $0(2) QL (360 packets / 30 days), NM,

LA, PA PROMACTA TABS 12.5mg, 25mg $0(2) QL (30 tabs / 30 days), NM, LA,

PA PROMACTA TABS 50mg, 75mg $0(2) QL (60 tabs / 30 days), NM, LA,

PA tranexamic acid SOLN; TABS $0(1)

PLATELET AGGREGATION INHIBITORS aspirin-dipyridamole $0(1) BRILINTA $0(2) clopidogrel tab 75mg $0(1) prasugrel hcl $0(1)

IMMUNOLOGIC AGENTS - DRUGS TO TREAT DISORDERS OF THE IMMUNE SYSTEM DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) - DRUGS TO TREAT RHEUMATOID ARTHRITIS

HUMIRA 10mg/0.1ml, 20mg/0.2ml $0(2) QL (2 injections / 28 days), NM, PA

HUMIRA 40mg/0.4ml $0(2) QL (6 injections / 28 days), NM, PA

HUMIRA INJ 10MG/0.2ML $0(2) QL (2 syringes / 28 days), NM, PA

HUMIRA KIT 20MG/0.4ML $0(2) QL (2 syringes / 28 days), NM, PA


Name of drug


you (tier

level)


or limits on use HUMIRA KIT 40MG/0.8ML $0(2) QL (6 syringes / 28 days), NM,

PA HUMIRA PEDIATRIC CROHNS DISEASE $0(2) NM, PA HUMIRA PEN $0(2) QL (6 pens / 28 days), NM, PA HUMIRA PEN CD/UC/HS STARTER $0(2) NM, PA HUMIRA PEN INJ CD/UC/HS STARTER $0(2) NM, PA HUMIRA PEN INJ PS/UV STARTER $0(2) NM, PA HUMIRA PEN-PS/UV STARTER $0(2) NM, PA hydroxychloroquine sulfate $0(1) leflunomide TABS $0(1) QL (30 tabs / 30 days) methotrexate sodium tabs $0(1) REMICADE $0(2) NM, PA RENFLEXIS $0(2) NM, LA, PA STELARA SOLN 45mg/0.5ml $0(2) QL (1 vial / 28 days), NM, LA, PA STELARA SOSY $0(2) QL (1 syringe / 28 days), NM, PA XATMEP $0(2) B/D XELJANZ $0(2) QL (60 tabs / 30 days), NM, PA XELJANZ XR $0(2) QL (30 tabs / 30 days), NM, PA

IMMUNOGLOBULINS BIVIGAM $0(2) NM, PA GAMASTAN S/D $0(2) B/D, NM GAMMAGARD LIQUID $0(2) NM, PA GAMMAGARD S/D $0(2) NM, PA GAMMAKED $0(2) NM, PA GAMMAPLEX $0(2) NM, PA GAMMAPLEX 10GM/100ML $0(2) NM, PA GAMUNEX-C $0(2) NM, PA OCTAGAM $0(2) NM, PA PANZYGA $0(2) NM, PA PRIVIGEN $0(2) NM, PA

IMMUNOMODULATORS ACTIMMUNE $0(2) NM, LA, PA ARCALYST $0(2) NM, PA INTRON-A INJ 10MU $0(2) B/D INTRON-A INJ 18MU $0(2) B/D


Name of drug


you (tier

level)


or limits on use INTRON-A INJ 25MU $0(2) B/D INTRON-A INJ 50MU $0(2) B/D

IMMUNOSUPPRESSANTS azathioprine TABS $0(1) B/D BENLYSTA $0(2) NM, PA cyclosporine CAPS; SOLN $0(1) B/D cyclosporine modified (for microemulsion) $0(1) B/D gengraf $0(1) B/D mycophenolate mofetil CAPS; TABS $0(1) B/D mycophenolate mofetil SUSR $0(2) B/D mycophenolate sodium tbec $0(1) B/D NULOJIX $0(2) B/D PROGRAF PACK $0(2) B/D SANDIMMUNE SOLN 100mg/ml $0(2) B/D sirolimus SOLN $0(2) B/D sirolimus TABS 2mg $0(2) B/D sirolimus TABS .5mg, 1mg $0(1) B/D tacrolimus CAPS $0(1) B/D ZORTRESS TAB 0.5MG $0(2) B/D ZORTRESS TAB 0.25MG $0(2) B/D ZORTRESS TAB 0.75MG $0(2) B/D ZORTRESS TAB 1MG $0(2) B/D

VACCINES ACTHIB $0(2) ADACEL $0(2) BCG VACCINE $0(2) BEXSERO $0(2) BOOSTRIX $0(2) DAPTACEL $0(2) DIPHTHERIA/TETANUS TOXOID $0(2) B/D ENGERIX-B SUSP $0(2) B/D GARDASIL 9 $0(2) HAVRIX $0(2) HIBERIX $0(2)


Name of drug


you (tier

level)


or limits on use IMOVAX RABIES (H.D.C.V.) $0(2) B/D INFANRIX $0(2) IPOL INACTIVATED IPV $0(2) IXIARO $0(2) KINRIX $0(2) M-M-R II $0(2) MENACTRA $0(2) MENVEO $0(2) PEDIARIX $0(2) PEDVAX HIB $0(2) PENTACEL $0(2) PROQUAD $0(2) QUADRACEL $0(2) RABAVERT $0(2) B/D RECOMBIVAX HB $0(2) B/D ROTARIX $0(2) ROTATEQ $0(2) SHINGRIX $0(2) QL (2 vials per lifetime) TDVAX $0(2) B/D TENIVAC $0(2) B/D TRUMENBA $0(2) TWINRIX INJ $0(2) TYPHIM VI $0(2) VAQTA $0(2) VARIVAX $0(2) YF-VAX $0(2) ZOSTAVAX $0(2) QL (1 vial per lifetime)

NUTRITIONAL/SUPPLEMENTS - VITAMINS AND SUPPLEMENTS ELECTROLYTES

advantage care oral elect $0(3) NM; * CERALYTE 50 $0(3) NM; * CERALYTE 70 $0(3) NM; * CERALYTE 90 $0(3) NM; * CERASPORT $0(3) NM; *


Name of drug


you (tier

level)


or limits on use CERASPORT EX1 $0(3) NM; * cvs electrolyte solution $0(3) NM; * cvs pediatric electrolyte $0(3) NM; * DRIPDROP $0(3) NM; * ENFAMIL ENFALYTE $0(3) NM; * gnp pediatric electrolyte $0(3) NM; * h-e-b oral electrolyte so $0(3) NM; * hm pediatric electrolyte $0(3) NM; * klor-con 8 $0(1) klor-con 10 $0(1) klor-con m10 $0(1) klor-con m15 $0(1) klor-con m20 $0(1) klor-con pak 20meq $0(1) klor-con spr cap 8meq $0(1) klor-con spr cap 10meq $0(1) MAGNESIUM SULFATE SOLN 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml

$0(2)

magnesium sulfate SOLN 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml, 50%

$0(2)

MAGNESIUM SULFATE IN D5W $0(2) magnesium sulfate in dextrose $0(2) magnesium sulfate inj 50% $0(2) MEDI-LYTE $0(3) NM; * NORMALYTE $0(3) NM; * oral electrolytes $0(3) NM; * oralyte $0(3) NM; * oralyte freezer pops $0(3) NM; * pedia vance $0(3) NM; * PEDIALYTE PACK $0(3) NM; * PEDIATRIC ELECTROLYTE $0(3) NM; * pediatric electrolyte fre $0(3) NM; * pediatric electrolyte/zin $0(3) NM; *


Name of drug


you (tier

level)


or limits on use potassium chloride CPCR $0(1) potassium chloride PACK $0(1) potassium chloride SOLN 10%, 20% $0(1) potassium chloride TBCR $0(1) potassium chloride microencapsulated crystals er

$0(1)

ra pediatric electrolyte $0(3) NM; * rehydralyte $0(3) NM; * REPLACE SR $0(3) NM; * sb pediatric electrolyte $0(3) NM; * sm pediatric electrolyte $0(3) NM; * sodium chloride SOLN 2.5meq/ml $0(1) sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln

$0(1)

THERMOTABS $0(3) NM; * TPN ELECTROLYTES $0(2) B/D

IV NUTRITION AMINOSYN II INJ 10% $0(2) B/D AMINOSYN-PF 7% $0(2) B/D AMINOSYN-PF INJ 10% $0(2) B/D CLINIMIX 4.25%/DEXTROSE 5% $0(2) B/D CLINIMIX 5%/DEXTROSE 15% $0(2) B/D CLINIMIX 5%/DEXTROSE 20% $0(2) B/D CLINIMIX INJ 4.25/D10 $0(2) B/D CLINOLIPID $0(2) B/D FREAMINE HBC 6.9% $0(2) B/D FREAMINE III $0(2) B/D hepatamine $0(2) B/D INTRALIPID 30% $0(2) B/D INTRALIPID INJ 20% $0(2) B/D NEPHRAMINE $0(2) B/D NUTRILIPID INJ 20% $0(2) B/D PREMASOL SOL 10% $0(2) B/D PROCALAMINE $0(2) B/D PROSOL $0(2) B/D


Name of drug


you (tier

level)


or limits on use TRAVASOL $0(2) B/D TROPHAMINE INJ 10% $0(2) B/D

IV REPLACEMENT SOLUTIONS dextrose 2.5%/nacl 0.45% $0(1) dextrose 5% $0(1) DEXTROSE 5% /ELECTROLYTE $0(2) dextrose 5%/nacl 0.2% $0(1) DEXTROSE 5%/NACL 0.3% $0(2) dextrose 5%/nacl 0.9% $0(1) dextrose 5%/nacl 0.33% $0(1) dextrose 5%/nacl 0.45% $0(1) dextrose 5%/nacl 0.225% $0(1) dextrose 5%/potassium chl $0(1) dextrose 10% flex contain $0(1) DEXTROSE 10% W/ SODIUM CHLORIDE 0.2% $0(2) dextrose 10%/nacl 0.45% $0(1) dextrose 50% $0(1) dextrose in lactated ringers $0(1) dextrose inj 70% $0(1) IONOSOL-MB/DEXTROSE 5% $0(2) ISOLYTE P $0(2) ISOLYTE S $0(2) kcl0.15%/d5w/nacl0.2% $0(1) KCL 0.3%/D5W/NACL 0.9% $0(2) kcl 0.3%/d5w/nacl 0.45% $0(1) kcl 0.15%/d5w/nacl 0.9% $0(1) KCL 0.15%/D5W/NACL 0.225% $0(2) kcl 0.075%/d5w/nacl 0.45% $0(1) kcl/d5w inj 0.3% $0(1) kcl/d5w/nacl inj 0.22%/0.45% $0(1) kcl/d5w/nacl inj .15/.33% $0(1) kcl/d5w/nacl inj .15/.45% $0(1) kcl/nacl inj 0.3-0.9 $0(1) kcl/nacl inj 0.15%-0.9% $0(1)


Name of drug


you (tier

level)


or limits on use lactated ringer’s $0(1) NORMOSOL-M IN D5W $0(2) NORMOSOL-R $0(2) NORMOSOL-R IN D5W $0(2) PLASMA-LYTE A $0(2) PLASMA-LYTE-148 $0(2) pot chloride inj 2meq/ml $0(1) potassium chloride SOLN .4meq/ml, 2meq/ml, 10meq/100ml, 10meq/50ml, 20meq/100ml, 40meq/100ml

$0(1)

potassium chloride in nacl $0(1) sodium chloride SOLN 3%, 5% $0(1) sodium chloride 0.45% $0(1) sodium chloride inj 0.9% $0(1)

MINERALS cal-carb forte $0(3) NM; * CAL-CITRATE PLUS VITAMIN $0(3) NM; * CAL-LAC $0(3) NM; * CAL-MINT $0(3) NM; * CAL-QUICK $0(3) NM; * CALCI-CHEW $0(3) NM; * CALCI-MIX $0(3) NM; * calcitrate $0(3) NM; * CALCIUM TABS $0(3) NM; * calcium 500 + d $0(3) NM; * calcium 500 +d $0(3) NM; * calcium 500 +d3 $0(3) NM; * calcium 500+d $0(3) NM; * calcium 500+d3 $0(3) NM; * calcium 500+d high potenc $0(3) NM; * calcium 500/d $0(3) NM; * calcium 500/vitamin d $0(3) NM; * calcium 600 $0(3) NM; * calcium 600 + d $0(3) NM; * calcium 600 high potency $0(3) NM; *


Name of drug


you (tier

level)


or limits on use calcium 600 with vitamin $0(3) NM; * calcium 600+d $0(3) NM; * calcium 600+d3 $0(3) NM; * calcium 600+d3 plus miner $0(3) NM; * calcium 600+d high potenc $0(3) NM; * calcium 600+d plus minera $0(3) NM; * calcium 600-d $0(3) NM; * calcium 600/vitamin d $0(3) NM; * calcium 600/vitamin d3 $0(3) NM; * CALCIUM 1000 + D $0(3) NM; * calcium 1200 $0(3) NM; * CALCIUM CARBONATE CHEW 260mg $0(3) NM; * CALCIUM CARBONATE POWD $0(3) NM; * calcium carbonate TABS 500mg, 600mg, 1250mg

$0(3) NM; *

calcium carbonate (antacid) SUSP $0(3) NM; * CALCIUM CARBONATE EXTRA L $0(3) NM; * CALCIUM CARBONATE HEAVY $0(3) NM; * calcium carbonate-cholecalciferol $0(3) NM; * calcium carbonate-vitamin d $0(3) NM; * calcium carbonate-vitamin d w/ minerals $0(3) NM; * CALCIUM CITRATE GRAN $0(3) NM; * calcium citrate TABS 200mg $0(3) NM; * CALCIUM CITRATE TABS 250mg, 1040mg $0(3) NM; * calcium citrate + d $0(3) NM; * calcium citrate + d3 $0(3) NM; * calcium citrate + d3 max $0(3) NM; * calcium citrate + d3 maxi $0(3) NM; * calcium citrate +d $0(3) NM; * CALCIUM CITRATE W/D $0(3) NM; * calcium citrate+ d $0(3) NM; * calcium citrate+d $0(3) NM; * calcium citrate+d3 $0(3) NM; * calcium citrate+d3 petite $0(3) NM; *


Name of drug


you (tier

level)


or limits on use calcium citrate-vitamin d $0(3) NM; * CALCIUM CITRATE/VITAMIN D $0(3) NM; * calcium creamies $0(3) NM; * calcium extra d3 $0(3) NM; * calcium gummies $0(3) NM; * calcium high potency $0(3) NM; * calcium high potency + vi $0(3) NM; * CALCIUM LACTATE $0(3) NM; * CALCIUM PLUS D3 ABSORBABL $0(3) NM; * CALCIUM PLUS VITAMIN D $0(3) NM; * calcium plus vitamin d3 $0(3) NM; * calcium+d3 $0(3) NM; * CALCIUM/VITAMIN D $0(3) NM; * caltrate 600 $0(3) NM; * CALTRATE 600+D3 SOFT CHEW $0(3) NM; * CALTRATE MINIS PLUS MIN E $0(3) NM; * CHEWABLE CALCIUM $0(3) NM; * CITRACAL CALCIUM GUMMIES $0(3) NM; * CITRACAL+D3 $0(3) NM; * citrus calcium +d $0(3) NM; * cvs calcium TABS $0(3) NM; * cvs calcium 600 & vitamin $0(3) NM; * cvs calcium 600 + d plus $0(3) NM; * cvs calcium 600+d $0(3) NM; * cvs calcium carbonate $0(3) NM; * cvs calcium citrate + d $0(3) NM; * cvs calcium citrate +d3 m $0(3) NM; * CVS MAGNESIUM CHEW $0(3) NM; * cvs magnesium TABS 500mg $0(3) NM; * cvs oyster shell calcium $0(3) NM; * DISNEY CALCIUM + VITAMIN $0(3) NM; * eq calcium 500+d $0(3) NM; * eq calcium 600+d $0(3) NM; * eq calcium 600+d+minerals $0(3) NM; *


Name of drug


you (tier

level)


or limits on use eq calcium citrate+d $0(3) NM; * eql calcium 600mg/vitamin $0(3) NM; * eql calcium citrate w/vit $0(3) NM; * eql calcium citrate/ vita $0(3) NM; * EQL CALCIUM/VITAMIN D CAPS $0(3) NM; * eql calcium/vitamin d TABS $0(3) NM; * GALZIN $0(3) NM; * gnp calcium $0(3) NM; * gnp calcium 500 +d3 $0(3) NM; * gnp calcium 500/d $0(3) NM; * gnp calcium 600 +d3 $0(3) NM; * gnp calcium 600 +d3/miner $0(3) NM; * gnp calcium 600 +d/minera $0(3) NM; * gnp calcium 600/d $0(3) NM; * gnp calcium 1200 $0(3) NM; * gnp calcium citrate +d3 $0(3) NM; * gnp calcium citrate+d3 ma $0(3) NM; * gnp calcium citrate+d max $0(3) NM; * gnp calcium plus 600 +d $0(3) NM; * gnp calcuim/vitamin d/min $0(3) NM; * high potency calcium $0(3) NM; * hm calcium 600 & vitamin $0(3) NM; * hm calcium 600 + d plus m $0(3) NM; * hm calcium 600 + vitamin $0(3) NM; * hm calcium citrate + vita $0(3) NM; * hm calcium citrate+d3 pet $0(3) NM; * hm calcium/vitamin d $0(3) NM; * hm calcium/vitamin d/mine $0(3) NM; * kp calcium 600+d $0(3) NM; * kp calcium 600+d3 $0(3) NM; * kp calcium citrate+d $0(3) NM; * kp mag-oxide magnesium $0(3) NM; * LIQUID CALCIUM WITH D3 MA $0(3) NM; * liquid calcium/d3 $0(3) NM; *


Name of drug


you (tier

level)


or limits on use liquid calcium/vitamin d $0(3) NM; * MAG64 $0(3) NM; * mag-g $0(3) NM; * mag-oxide $0(3) NM; * MAG-SR PLUS CALCIUM $0(3) NM; * MAGDELAY 70mg $0(3) NM; * MAGNESIUM CAPS 400mg $0(3) NM; * MAGNESIUM CHLORIDE POWD $0(3) NM; * MAGNESIUM CHLORIDE/CALCIU $0(3) NM; * magnesium gluconate TABS 27.5mg, 500mg $0(3) NM; * MAGNESIUM GLUCONATE TABS 250mg, 500mg, 550mg

$0(3) NM; *

magnesium lactate $0(3) NM; * MAGNESIUM OXIDE 400 $0(3) NM; * magnesium oxide (mg supplement) $0(3) NM; * magnesium-oxide $0(3) NM; * magonate TABS $0(3) NM; * mgo $0(3) NM; * NU-MAG $0(3) NM; * orazinc CAPS $0(3) NM; * ORAZINC TABS $0(3) NM; * os-cal $0(3) NM; * os-cal calcium + d3 $0(3) NM; * os-cal extra d3 $0(3) NM; * OSTEO-PORETICAL $0(3) NM; * oysco 500 $0(3) NM; * oysco 500+d $0(3) NM; * oyst-cal-d 500 $0(3) NM; * oyster calcium/vitamin d $0(3) NM; * oyster shell $0(3) NM; * oyster shell calcium 250+ $0(3) NM; * oyster shell calcium 500 $0(3) NM; * oyster shell calcium 500+ $0(3) NM; * oyster shell calcium + d $0(3) NM; *


Name of drug


you (tier

level)


or limits on use oyster shell calcium + d3 $0(3) NM; * oyster shell calcium + vi $0(3) NM; * oyster shell calcium plus $0(3) NM; * oyster shell calcium+d $0(3) NM; * oyster shell calcium/d3 $0(3) NM; * OYSTER SHELL CALCIUM/VITA PACK $0(3) NM; * oystercal $0(3) NM; * oystercal-d $0(3) NM; * pa oyster shell calcium $0(3) NM; * phospha 250 neutral $0(3) NM; * potassium & sodium phosphates $0(3) NM; * pronutrients calcium+d3 $0(3) NM; * px calcium&d $0(3) NM; * qc calcium fast dissoluti $0(3) NM; * qc calcium/minerals/vitam $0(3) NM; * ra calcium 600 $0(3) NM; * ra calcium 600 plus vitam $0(3) NM; * ra calcium 600/vit d/mine $0(3) NM; * ra calcium citrate plus v $0(3) NM; * ra calcium citrate/vitami $0(3) NM; * RA CALCIUM HI-CAL/VITAMIN $0(3) NM; * ra calcium plus vitamin d $0(3) NM; * ra calcium/minerals/vitam $0(3) NM; * ra hi cal $0(3) NM; * ra hi-cal $0(3) NM; * ra hi-cal plus vitamin d $0(3) NM; * ra magnesium $0(3) NM; * ra oyster shell calcium $0(3) NM; * ra oyster shell calcium/v $0(3) NM; * RISACAL-D $0(3) NM; * sb calcium + d $0(3) NM; * sb oyster shell calcium $0(3) NM; * slow magnesium chloride/ $0(3) NM; * SLOW-MAG $0(3) NM; *


Name of drug


you (tier

level)


or limits on use sm calcium 500/vitamin d3 $0(3) NM; * sm calcium 600+d3 $0(3) NM; * sm calcium 600/vitamin d $0(3) NM; * sm calcium /vitamin d $0(3) NM; * sm calcium citrate w/vita $0(3) NM; * sm calcium citrate+ w/vit $0(3) NM; * sm calcium citrate/vitami $0(3) NM; * sm calcium/vitamin d $0(3) NM; * sm calcium/vitamin d3 $0(3) NM; * sm magnesium $0(3) NM; * sm oyster shell calcium/v $0(3) NM; * super calcium $0(3) NM; * super calcium 600 + d3 $0(3) NM; * super calcium 600+d3 400 $0(3) NM; * super calcium 600+d 400 $0(3) NM; * tgt calcium + vitamin d3 $0(3) NM; * UPCAL D $0(3) NM; * ZINC 15 $0(3) NM; * ZINC SULFATE CAPS 50mg $0(3) NM; * zinc sulfate CAPS 220mg $0(3) NM; * ZINC SULFATE POWD $0(3) NM; * zinc sulfate TABS 220mg $0(3) NM; * ZINC SULFATE GRANULAR $0(3) NM; * ZINC SULFATE MONOHYDRATE $0(3) NM; * zinc-220 $0(3) NM; *

MISCELLANEOUS ALPHA LIPOIC ACID CAPS $0(3) NM; * ALPHA-LIPOIC ACID CAPS $0(3) NM; * alpha-lipoic acid (thioctic acid) $0(3) NM; * arginine CAPS $0(3) NM; * ARGININE PACK $0(3) NM; * ARGININE TABS 500mg $0(3) NM; * arginine TABS 1000mg $0(3) NM; * ARGININE2000 $0(3) NM; *


Name of drug


you (tier

level)


or limits on use CHEW Q $0(3) NM; * co q10 maximum strength $0(3) NM; * CO-ENZYME Q10/VITAMIN E $0(3) NM; * COENZYME Q10 CHEW; LIQD; TABS $0(3) NM; * coenzyme q10 (ubidecarenone) $0(3) NM; * coq10 maximum strength $0(3) NM; * COQ-10 TR $0(3) NM; * COROMEGA OMEGA 3 KIDS $0(3) NM; * COROMEGA OMEGA 3 SQUEEZE $0(3) NM; * cvs coenzyme q-10 $0(3) NM; * cvs coq-10 $0(3) NM; * cvs fish oil $0(3) NM; * cvs natural fish oil $0(3) NM; * cvs omega-3 gummy fish/dh $0(3) NM; * CYTO-Q $0(3) NM; * CYTO-Q MAX $0(3) NM; * CYTO-Q T/F $0(3) NM; * ENDUR-THINE $0(3) NM; * eql coq10 $0(3) NM; * eql fish oil $0(3) NM; * eql omega 3 fish oil $0(3) NM; * eql omega-3 fish oil $0(3) NM; * FISH OIL CHEW $0(3) NM; * fish oil adult gummies $0(3) NM; * fish oil burp-less $0(3) NM; * fish oil concentrate $0(3) NM; * fish oil double strength $0(3) NM; * fish oil extra strength $0(3) NM; * fish oil maximum strength $0(3) NM; * fish oil omega-3 $0(3) NM; * fish oil pearls $0(3) NM; * FISH OIL PEARLS $0(3) NM; * FISH OIL TRIPLE STRENGTH $0(3) NM; * FISH OIL ULTRA $0(3) NM; *


Name of drug


you (tier

level)


or limits on use fish oil/super potent/no $0(3) NM; * glutamine POWD $0(3) NM; * glutimmune $0(3) NM; * gnp co q10 $0(3) NM; * gnp coenzyme q-10 $0(3) NM; * gnp fish oil CAPS $0(3) NM; * gnp fish oil CPDR $0(3) NM; * GNP FISH OIL CPDR $0(3) NM; * gnp fish oil maximum stre $0(3) NM; * h2q CAPS $0(3) NM; * healthy kids gummies omeg $0(3) NM; * hm coq10 $0(3) NM; * hm fish oil CAPS $0(3) NM; * HM FISH OIL CAPS $0(3) NM; * hm fish oil CPDR $0(3) NM; * kp fish oil $0(3) NM; * kp omega-3 fish oil $0(3) NM; * L-ARGININE POWD $0(3) NM; * l-arginine maximum streng $0(3) NM; * l-arginine-500 $0(3) NM; * L-GLUTAMINE POWD $0(3) NM; * L-GLUTATHIONE $0(3) NM; * L-ISOLEUCINE $0(3) NM; * LIPOIC ACID CAPS $0(3) NM; * LIQ-10 $0(3) NM; * maximum epa $0(3) NM; * melatonin CHEW $0(3) NM; * NEOQ10 $0(3) NM; * norwegian salmon oil $0(3) NM; * odorless coated fish oil/ $0(3) NM; * omega 3 500 $0(3) NM; * omega essentials basic $0(3) NM; * omega iii epa+dha $0(3) NM; * OMEGA-3 $0(3) NM; *


Name of drug


you (tier

level)


or limits on use OMEGA-3 2100 $0(3) NM; * omega-3 fatty acids $0(3) NM; * OMEGA-3 FISH OIL EXTRA ST $0(3) NM; * OMEGA-3 IQ $0(3) NM; * omera $0(3) NM; * ovega-3 $0(3) NM; * pa coenzyme q-10 $0(3) NM; * pa fish oil $0(3) NM; * PRENATAL OMEGA BABY $0(3) NM; * PRO NUTRIENTS OMEGA 3 $0(3) NM; * pure l-arginine hcl $0(3) NM; * PURE L-CITRULLINE CAPS $0(3) NM; * px fish oil $0(3) NM; * Q-GEL $0(3) NM; * q-gel forte $0(3) NM; * q-gel mega $0(3) NM; * q-gel ultra $0(3) NM; * q-sorb $0(3) NM; * q-sorb co q-10 $0(3) NM; * ra coenzyme q-10 $0(3) NM; * ra fish oil CAPS $0(3) NM; * ra fish oil CPDR $0(3) NM; * RA FISH OIL CPDR $0(3) NM; * ra l-arginine $0(3) NM; * RA TRIPLE STRENGTH FISH O $0(3) NM; * SALMON OIL-1000 $0(3) NM; * sam-e.p.a. $0(3) NM; * sb omega-3 fish oil $0(3) NM; * sea-omega $0(3) NM; * sea-omega 30 $0(3) NM; * sm co q-10 $0(3) NM; * sm coenzyme q-10 $0(3) NM; * sm coq-10 $0(3) NM; * sm fish oil $0(3) NM; *


Name of drug


you (tier

level)


or limits on use SM FISH OIL $0(3) NM; * sm omega-3 fish oil $0(3) NM; * super dha gems $0(3) NM; * super omega-3 $0(3) NM; * SUPER TWIN EPA/DHA $0(3) NM; * the very finest fish oil $0(3) NM; * theragran-m fish oil conc $0(3) NM; * theromega $0(3) NM; * ultra omega-3 $0(3) NM; * ULTRA OMEGA-3 FISH OIL BU $0(3) NM; * vitajoy gummies $0(3) NM; * yl coenzyme q10 $0(3) NM; *

VITAMINS a thru z advanced $0(3) NM; * a thru z high potency $0(3) NM; * a thru z select $0(3) NM; * a thru z select 50+ advan $0(3) NM; * a thru z select 50+ mens $0(3) NM; * a thru z select advanced $0(3) NM; * a thru z select ultimate $0(3) NM; * a thru z ultimate mens $0(3) NM; * A-25 $0(3) NM; * abaneu-sl $0(3) NM; * abc plus $0(3) NM; * abc plus senior adults 50 $0(3) NM; * ABDEK CAPS $0(3) NM; * abdek CHEW $0(3) NM; * abdek pediatric $0(3) NM; * ACEROLA C 500 $0(3) NM; * acerola c-500 $0(3) NM; * actical $0(3) NM; * 50+ adult eye health $0(3) NM; * ADULT ONE DAILY GUMMIES $0(3) NM; * advanced multi ea $0(3) NM; *


Name of drug


you (tier

level)


or limits on use advanced stress formula/z $0(3) NM; * airborne CHEW; TBEF $0(3) NM; * AIRBORNE LOZG $0(3) NM; * airborne gummies $0(3) NM; * ALIVE ONCE DAILY WOMENS 5 $0(3) NM; * ALIVE PRENATAL MULTI-VITA $0(3) NM; * ALIVE WOMENS ENERGY $0(3) NM; * ALIVE WOMENS GUMMY VITAMI $0(3) NM; * allbee plus vitamin c $0(3) NM; * alph-e $0(3) NM; * alph-e-mixed $0(3) NM; * alph-e-mixed 1000 $0(3) NM; * animal chews $0(3) NM; * animal shapes $0(3) NM; * ANIMAL SHAPES/IRON $0(3) NM; * anti-oxidant $0(3) NM; * antioxidant $0(3) NM; * antioxidant formula TABS $0(3) NM; * antioxidant vitamins $0(3) NM; * APETIGEN-PLUS TABS $0(3) NM; * AQUA-E $0(3) NM; * AQUADEKS CHEW $0(3) NM; * aquadeks LIQD $0(3) NM; * aqueous vitamin d infants $0(3) NM; * aqueous vitamin e $0(3) NM; * asco-tabs-1000 $0(3) NM; * ASCOR $0(3) NM; * ascorbic acid CHEW; CPCR; LIQD; TABS; TBCR $0(3) NM; * ASCORBIC ACID POWD $0(3) NM; * b6 natural $0(3) NM; * b complex w/ c $0(3) NM; * B-12 CAPS $0(3) NM; * B-12 LOZG 1000mcg $0(3) NM; * B-12 TABS $0(3) NM; *

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

100 Formulary ID 00020351 v6

Name of drug


you (tier

level)


or limits on use B-12 DOTS $0(3) NM; * B-12 DUAL SPECTRUM $0(3) NM; * B-12 METHYLCOBALAMIN $0(3) NM; * b-12 microlozenge $0(3) NM; * B-12 SUPER STRENGTH $0(3) NM; * b-12 tr $0(3) NM; * b-complex balanced $0(3) NM; * b-complex w/ c & calcium $0(3) NM; * b-complex w/ c & folic acid $0(3) NM; * B-COMPLEX/FOLIC ACID/VITA $0(3) NM; * B-NATAL $0(3) NM; * baby super daily d3 $0(3) NM; * baby vitamin d3 drops $0(3) NM; * balanced b complex tr $0(3) NM; * bec/zinc $0(3) NM; * berocca $0(3) NM; * better b complex $0(3) NM; * BIO-35 GLUTEN-FREE $0(3) NM; * BIO-D-MULSION $0(3) NM; * BIO-D-MULSION FORTE $0(3) NM; * BIOCAL $0(3) NM; * BIOSUPP $0(3) NM; * BIOTECT PLUS $0(3) NM; * BIOTIN CAPS 1mg $0(3) NM; * biotin CAPS 5mg, 10mg, 2500mcg, 5000mcg $0(3) NM; * BIOTIN POWD $0(3) NM; * biotin TABS 5mg, 300mcg, 1000mcg $0(3) NM; * biotin 5000 $0(3) NM; * biotin plus/calcium/vit d $0(3) NM; * biotin/maximum strength $0(3) NM; * BIOVOL $0(3) NM; * body/hair/skin/nails $0(3) NM; * bprotected multi-vite $0(3) NM; * bprotected pedia d-vite $0(3) NM; *


Name of drug


you (tier

level)


or limits on use bprotected pedia poly-vit $0(3) NM; * bprotected pedia tri-vite $0(3) NM; * BRAINSTRONG PRENATAL $0(3) NM; * c 250 $0(3) NM; * c 500 $0(3) NM; * c 500/rose hips $0(3) NM; * c 1000 $0(3) NM; * c-250 $0(3) NM; * c-500 $0(3) NM; * c-500 prolonged release $0(3) NM; * c-500/rose hips $0(3) NM; * c-1000 $0(3) NM; * c-1000 prolonged release $0(3) NM; * c-1000/rose hips $0(3) NM; * C-BUFF $0(3) NM; * c-chewable $0(3) NM; * CAL-CITRATE $0(3) NM; * calcidol $0(3) NM; * calciferol $0(3) NM; * calcitriol CAPS $0(1) B/D calcitriol inj $0(1) B/D calcitriol oral soln 1 mcg/ml $0(1) B/D carravite $0(3) NM; * centamin $0(3) NM; * centavite $0(3) NM; * centavite a-z complete mu $0(3) NM; * centravites $0(3) NM; * centravites 50 plus $0(3) NM; * CENTRAVITES 50 PLUS $0(3) NM; * CENTRAVITES ADULTS $0(3) NM; * CENTRUM CHEW $0(3) NM; * CENTRUM CARDIO $0(3) NM; * CENTRUM FLAVOR BURST ADUL $0(3) NM; * CENTRUM FLAVOR BURST KIDS $0(3) NM; *



Name of drug


you (tier

level)


or limits on use centrum kids $0(3) NM; * centrum kids complete $0(3) NM; * CENTRUM MULTIGUMMIES ADUL $0(3) NM; * CENTRUM SILVER $0(3) NM; * CENTRUM SILVER ULTRA MENS $0(3) NM; * CENTRUM SILVER ULTRA WOME $0(3) NM; * CENTRUM SPECIALIST HEART $0(3) NM; * CENTRUM SPECIALIST PRENAT $0(3) NM; * CENTRUM SPECIALIST VISION $0(3) NM; * CENTRUM ULTRA WOMENS $0(3) NM; * century $0(3) NM; * century mature $0(3) NM; * cerovite advanced formula $0(3) NM; * cerovite jr $0(3) NM; * cerovite senior $0(3) NM; * certa plus $0(3) NM; * certa-vite $0(3) NM; * certagen $0(3) NM; * CERTAVITE SENIOR/ANTIOXID $0(3) NM; * certavite/antioxidants $0(3) NM; * CHEW-12 $0(3) NM; * chewable vite childrens $0(3) NM; * chewable vite with iron/c $0(3) NM; * childrens animal shapes c $0(3) NM; * childrens chewable multiv $0(3) NM; * childrens chewable vitami $0(3) NM; * childrens gummies $0(3) NM; * childrens multivitamin $0(3) NM; * CHLORELLA $0(3) NM; * chlorocaps $0(3) NM; * cholecalciferol CAPS; CHEW; LIQD; TABS $0(3) NM; * CLASSIC PRENATAL $0(3) NM; * companion $0(3) NM; * compete $0(3) NM; *


Name of drug


you (tier

level)


or limits on use complete $0(3) NM; * complete multivitamin/mul $0(3) NM; * complete senior $0(3) NM; * CONCEPTIONXR MOTILITY SUP $0(3) NM; * CORVITE $0(3) NM; * corvite free $0(3) NM; * cvs airshield $0(3) NM; * CVS AIRSHIELD IMMUNITY SU $0(3) NM; * cvs b1 $0(3) NM; * cvs b6 $0(3) NM; * cvs b12 $0(3) NM; * cvs b complex plus c $0(3) NM; * cvs b-1 $0(3) NM; * cvs b-12 LIQD; TABS $0(3) NM; * cvs biotin $0(3) NM; * cvs biotin high potency $0(3) NM; * cvs chewable childrens vi $0(3) NM; * cvs childrens chewable co $0(3) NM; * cvs d3 $0(3) NM; * cvs daily gummies $0(3) NM; * cvs daily multiple for me $0(3) NM; * cvs daily multiple for wo $0(3) NM; * CVS DIABETES HEALTH SUPPO $0(3) NM; * cvs e $0(3) NM; * cvs eye health & lutein $0(3) NM; * cvs folic acid $0(3) NM; * cvs gummy dinos $0(3) NM; * cvs gummy dinos childrens $0(3) NM; * cvs gummy multivitamin ki $0(3) NM; * cvs mens daily gummies $0(3) NM; * cvs one daily essential $0(3) NM; * CVS ONE DAILY MENS 50+ AD $0(3) NM; * CVS PRENATAL $0(3) NM; * CVS PRENATAL MULTI+DHA $0(3) NM; *



Name of drug


you (tier

level)


or limits on use CVS SPECTRAVITE ADULT 50+ $0(3) NM; * cvs spectravite advanced $0(3) NM; * cvs spectravite senior $0(3) NM; * cvs spectravite ultra hea $0(3) NM; * CVS SPECTRAVITE ULTRA MEN $0(3) NM; * cvs spectravite ultra wom $0(3) NM; * CVS SPECTRAVITE ULTRA WOM $0(3) NM; * cvs stress formula/zinc $0(3) NM; * cvs super b complex/c $0(3) NM; * cvs vitamin b12 $0(3) NM; * cvs vitamin b12 tr $0(3) NM; * cvs vitamin b-12 $0(3) NM; * cvs vitamin b-12 tr $0(3) NM; * cvs vitamin c $0(3) NM; * cvs vitamin c/rose hips $0(3) NM; * cvs vitamin d3 $0(3) NM; * cvs vitamin d3 drops/infa $0(3) NM; * cvs vitamin d childrens g $0(3) NM; * cvs vitamin e CAPS $0(3) NM; * cvs womens active daily $0(3) NM; * cvs womens daily gummies $0(3) NM; * cyanocobalamin LIQD $0(3) NM; * cyanocobalamin LOZG $0(3) NM; * cyanocobalamin SOLN 1000mcg/ml $0(3) NM; * cyanocobalamin SUBL $0(3) NM; * cyanocobalamin TABS $0(3) NM; * cyanocobalamin TBCR $0(3) NM; * cyanocobalamin TBDP $0(3) NM; * d3 adult $0(3) NM; * D3 DOTS $0(3) NM; * d3 high potency $0(3) NM; * d3 kids $0(3) NM; * d3 maximum strength $0(3) NM; * d3 super strength $0(3) NM; *


Name of drug


you (tier

level)


or limits on use d3 vitamin $0(3) NM; * d3-50 $0(3) NM; * d3-1000 $0(3) NM; * d2000 ultra strength $0(3) NM; * d 400 CHEW; TABS $0(3) NM; * d 1000 $0(3) NM; * d 2000 $0(3) NM; * d 5000 $0(3) NM; * d 10000 $0(3) NM; * d-3-5 $0(3) NM; * d-400 $0(3) NM; * d-1000 extra strength $0(3) NM; * d-2000 maximum strength $0(3) NM; * d-5000 $0(3) NM; * daily combo multi vitamin $0(3) NM; * daily multi $0(3) NM; * daily multiple vitamin $0(3) NM; * daily multiple vitamin/ir $0(3) NM; * daily multiple vitamins $0(3) NM; * daily multiple vitamins w $0(3) NM; * daily multivitamin $0(3) NM; * daily value multivitamin $0(3) NM; * daily vitamin $0(3) NM; * daily vitamin formula+ir $0(3) NM; * daily vitamin formula+iro $0(3) NM; * daily vitamin formula+min $0(3) NM; * daily vitamins $0(3) NM; * daily vite $0(3) NM; * daily vite multivitamin/i $0(3) NM; * daily-vite $0(3) NM; * daily-vite/iron/beta-caro $0(3) NM; * DDROPS 1000ut/0.028ml, 2000ut/0.028ml $0(3) NM; * decara 10000unit, 50000unit $0(3) NM; * DECARA 25000unit $0(3) NM; *



Name of drug


you (tier

level)


or limits on use DECUBI-VITE $0(3) NM; * DEKAS BARIATRIC $0(3) NM; * DEKAS ESSENTIAL $0(3) NM; * DEKAS PLUS $0(3) NM; * delta d3 $0(3) NM; * diabetes health formula $0(3) NM; * DIABETES HEALTH PACK $0(3) NM; * dialyvite 800 TABS $0(3) NM; * DIALYVITE 800 WAFR $0(3) NM; * DIALYVITE 800/IRON $0(3) NM; * dialyvite 800/ultra d $0(3) NM; * dialyvite vitamin d3 max $0(3) NM; * dialyvite vitamin d 5000 $0(3) NM; * dino-life $0(3) NM; * dino-life w extra c $0(3) NM; * DINO-LIFE W/IRON & ZINC $0(3) NM; * disney cars gummies $0(3) NM; * disney princess gummies $0(3) NM; * DOSOQUIN $0(3) NM; * dry eye formula $0(3) NM; * e200 $0(3) NM; * e400 mixed $0(3) NM; * e1000 $0(3) NM; * e 1000 $0(3) NM; * e-200 $0(3) NM; * e-400 $0(3) NM; * e-400-clear $0(3) NM; * e-400-mixed $0(3) NM; * e-max-1000 $0(3) NM; * e-oil 100unt/0.25ml $0(3) NM; * e-pherol $0(3) NM; * eldertonic $0(3) NM; * ELFOLATE PLUS $0(3) NM; * EMERGEN-C BLUE $0(3) NM; *


Name of drug


you (tier

level)


or limits on use EMERGEN-C HEART HEALTH $0(3) NM; * EMERGEN-C IMMUNE PLUS $0(3) NM; * EMERGEN-C KIDZ $0(3) NM; * EMERGEN-C MSM LITE $0(3) NM; * EMERGEN-C PINK $0(3) NM; * EMERGEN-C SUPER FRUIT $0(3) NM; * EMERGEN-C VITAMIN C $0(3) NM; * EMERGEN-C VITAMIN D & CAL $0(3) NM; * endur-acin $0(3) NM; * endur-c/rose hips $0(3) NM; * ENDUR-VM $0(3) NM; * ENDUR-VM WITH IRON $0(3) NM; * ENFAMIL EXPECTA $0(3) NM; * ENLYTE $0(3) NM; * enviro-stress $0(3) NM; * eq complete chewable mult $0(3) NM; * eq complete multivitamin $0(3) NM; * EQ COMPLETE MULTIVITAMIN $0(3) NM; * eq multivitamin gummies c $0(3) NM; * EQ ONE DAILY MENS HEALTH $0(3) NM; * eq one daily womens healt $0(3) NM; * EQ ONE DAILY WOMENS HEALT $0(3) NM; * eq one daily womens pro-a $0(3) NM; * eql b-6 $0(3) NM; * eql century $0(3) NM; * eql century mature $0(3) NM; * EQL CENTURY MATURE ADULTS $0(3) NM; * EQL CENTURY MENS $0(3) NM; * eql childrens multivitami $0(3) NM; * eql one daily mens 50+ ad $0(3) NM; * eql one daily mens health $0(3) NM; * eql one daily womens 50+ $0(3) NM; * eql stress b-complex/vita $0(3) NM; * eql super b complex/vitam $0(3) NM; *



Name of drug


you (tier

level)


or limits on use eql vision formula $0(3) NM; * eql vitamin b-12 $0(3) NM; * eql vitamin b-12 tr $0(3) NM; * eql vitamin c $0(3) NM; * eql vitamin c/rose hips $0(3) NM; * eql vitamin d3 $0(3) NM; * eql vitamin e $0(3) NM; * ergocalciferol CAPS; SOLN $0(3) NM; * ESCAVITE $0(3) NM; * essentia $0(3) NM; * essential balance $0(3) NM; * ester-e $0(3) NM; * eyeprotect $0(3) NM; * fa-8 $0(3) NM; * flintstones complete $0(3) NM; * flintstones gummies plus $0(3) NM; * flintstones plus calcium $0(3) NM; * flintstones plus extra c $0(3) NM; * flintstones plus iron $0(3) NM; * flintstones/my first $0(3) NM; * FLORIVA PLUS $0(3) NM; * folbee $0(3) NM; * folbee plus $0(3) NM; * folbee plus cz $0(3) NM; * folbic $0(3) NM; * FOLIC ACID CAPS 5mg, 20mg $0(3) NM; * folic acid CAPS 800mcg $0(3) NM; * FOLIC ACID POWD $0(3) NM; * folic acid SOLN $0(3) NM; * folic acid TABS $0(3) NM; * folplex 2.2 $0(3) NM; * FOLTANX $0(3) NM; * formula e 400 $0(3) NM; * FREEDAVITE $0(3) NM; *


Name of drug


you (tier

level)


or limits on use fruit c 500 $0(3) NM; * fruit c-100 $0(3) NM; * fruity c $0(3) NM; * fruity chewables multivit $0(3) NM; * fruity chews $0(3) NM; * fruity chews/iron $0(3) NM; * FULL SPECTRUM B/VITAMIN C $0(3) NM; * geriaton $0(3) NM; * gerivite complete $0(3) NM; * glucoten $0(3) NM; * GLYCO-TECH $0(3) NM; * gnp animal shapes $0(3) NM; * gnp animal shapes plus ex $0(3) NM; * gnp animal shapes plus ir $0(3) NM; * gnp b-12 $0(3) NM; * gnp b-complex plus vitami $0(3) NM; * gnp biotin $0(3) NM; * gnp century $0(3) NM; * gnp century adults 50+ se $0(3) NM; * gnp century cardio health $0(3) NM; * gnp century mature $0(3) NM; * gnp century ultimate mens $0(3) NM; * gnp century ultimate wome $0(3) NM; * gnp childrens chewables w $0(3) NM; * gnp childrens chewables/e $0(3) NM; * gnp childrens chewables/i $0(3) NM; * GNP CHILDRENS COMPLETE CH $0(3) NM; * gnp diabetic support form $0(3) NM; * gnp essential one daily $0(3) NM; * gnp folic acid $0(3) NM; * gnp hair/skin/nails $0(3) NM; * gnp healthy eyes $0(3) NM; * gnp healthy eyes supervis $0(3) NM; * gnp little ones childrens $0(3) NM; *



Name of drug


you (tier

level)


or limits on use gnp maximum one daily $0(3) NM; * gnp mega multi for men $0(3) NM; * gnp mega multi for women $0(3) NM; * gnp niacin $0(3) NM; * gnp niacin tr $0(3) NM; * gnp one daily maximum $0(3) NM; * gnp one daily mens 50+ ad $0(3) NM; * gnp one daily mens health $0(3) NM; * gnp one daily plus iron $0(3) NM; * gnp one daily womens 50+ $0(3) NM; * gnp one daily womens heal $0(3) NM; * gnp one daily womens meta $0(3) NM; * gnp opti-vitamins $0(3) NM; * GNP PRENATAL $0(3) NM; * gnp therapeutic-m $0(3) NM; * gnp vitamin b-1 $0(3) NM; * gnp vitamin b-6 $0(3) NM; * gnp vitamin b-12 $0(3) NM; * gnp vitamin b-12 prolonge $0(3) NM; * gnp vitamin b-12 tr $0(3) NM; * gnp vitamin c $0(3) NM; * gnp vitamin c drops $0(3) NM; * gnp vitamin c pr $0(3) NM; * gnp vitamin c tr $0(3) NM; * gnp vitamin c w/rose hips $0(3) NM; * gnp vitamin c/rose hips $0(3) NM; * gnp vitamin d $0(3) NM; * gnp vitamin d3 extra stre $0(3) NM; * gnp vitamin d maximum str $0(3) NM; * gnp vitamin d super stren $0(3) NM; * gnp vitamin d-400 $0(3) NM; * gnp vitamin e $0(3) NM; * gnp vitamin e water dispe $0(3) NM; * gnp womens one daily $0(3) NM; *


Name of drug


you (tier

level)


or limits on use gnp zoochews gummies $0(3) NM; * GOODSENSE PRENATAL VITAMI $0(3) NM; * gummi bear multivitamin/m $0(3) NM; * hair formula extra streng $0(3) NM; * HAIR SKIN & NAILS ADVANCE $0(3) NM; * hair/skin/nails CAPS $0(3) NM; * HAIR/SKIN/NAILS CAPS $0(3) NM; * hair/skin/nails TABS $0(3) NM; * hair/skin/nails/biotin $0(3) NM; * halls defense vitamin c d $0(3) NM; * healthy eyes $0(3) NM; * healthy eyes/lutein $0(3) NM; * healthy hair skin & nails $0(3) NM; * HEALTHY KIDS GUMMIES $0(3) NM; * healthy kids vitamin d3 $0(3) NM; * hm animal shapes $0(3) NM; * hm antioxidant vitamins $0(3) NM; * hm biotin CAPS $0(3) NM; * hm complete $0(3) NM; * HM COMPLETE $0(3) NM; * hm complete 50+ $0(3) NM; * HM COMPLETE 50+ MENS ULTI $0(3) NM; * HM COMPLETE 50+ WOMENS UL $0(3) NM; * HM COMPLETE MEN $0(3) NM; * hm complete women $0(3) NM; * hm folic acid $0(3) NM; * HM HAIR/SKIN/NAILS $0(3) NM; * hm mens 50+ advanced one $0(3) NM; * hm niacin $0(3) NM; * hm niacin tr $0(3) NM; * HM ONE DAILY MENS $0(3) NM; * HM ONE DAILY WOMENS $0(3) NM; * hm one daily/iron $0(3) NM; * HM PRENATAL $0(3) NM; *



Name of drug


you (tier

level)


or limits on use hm super vitamin b comple $0(3) NM; * hm vitamin b6 $0(3) NM; * hm vitamin b12 $0(3) NM; * hm vitamin b12 tr $0(3) NM; * hm vitamin b12 ultra stre $0(3) NM; * hm vitamin b complex/vita $0(3) NM; * hm vitamin c $0(3) NM; * hm vitamin c tr $0(3) NM; * hm vitamin c/rose hips $0(3) NM; * hm vitamin d $0(3) NM; * hm vitamin d3 2000unit $0(3) NM; * HM VITAMIN D3 4000unit $0(3) NM; * hm vitamin e $0(3) NM; * hm womens 50+ advanced on $0(3) NM; * HONEY BEARS $0(3) NM; * HONEY BEARS W/IRON AND ZI $0(3) NM; * HYALEX $0(3) NM; * hydroxocobalamin acetate $0(3) NM; * i-vite $0(3) NM; * i-vite protect $0(3) NM; * icaps $0(3) NM; * ICAPS AREDS FORMULA $0(3) NM; * icaps lutein & omega-3 $0(3) NM; * icaps mv $0(3) NM; * ICAPS PLUS $0(3) NM; * IMMUNE SUPPORT $0(3) NM; * INFUVITE ADULT $0(3) NM; * INFUVITE PEDIATRIC $0(3) NM; * just d $0(3) NM; * k 100 $0(3) NM; * K-PAX IMMUNE SUPPORT FORM $0(3) NM; * kids first vitamin d3 gum $0(3) NM; * kp adults 50+ daily formu $0(3) NM; * kp adults daily formula $0(3) NM; *


Name of drug


you (tier

level)


or limits on use kp b complex/c $0(3) NM; * kp folic acid $0(3) NM; * kp mens 50+ daily formula $0(3) NM; * kp mens daily formula $0(3) NM; * KP MENS DAILY PACK $0(3) NM; * kp niacin $0(3) NM; * KP PRENATAL MULTIVITAMINS $0(3) NM; * kp vision formula $0(3) NM; * kp vision formula w/lutei $0(3) NM; * kp vitamin b-6 $0(3) NM; * kp vitamin b-12 $0(3) NM; * kp vitamin d $0(3) NM; * kp vitamin d3 $0(3) NM; * kp vitamin e $0(3) NM; * kp womens 50+ daily formu $0(3) NM; * kp womens daily formula $0(3) NM; * KP WOMENS DAILY PACK $0(3) NM; * KPN PRENATAL $0(3) NM; * L-METHYL-B6-B12 $0(3) NM; * L-METHYL-MC $0(3) NM; * land before time multivit $0(3) NM; * LIFE PACK MENS $0(3) NM; * LIFE PACK WOMENS $0(3) NM; * liqui-e $0(3) NM; * little animals plus iron $0(3) NM; * lysiplex plus $0(3) NM; * M-NATAL PLUS $0(2) M.V.I. ADULT $0(3) NM; * M.V.I. PEDIATRIC $0(3) NM; * macular health formula $0(3) NM; * MACULAR VITAMIN BENEFIT $0(3) NM; * macuvite $0(3) NM; * macuvite eye care $0(3) NM; * macuvite/lutein $0(3) NM; *



Name of drug


you (tier

level)


or limits on use MAXIMIN PACK $0(3) NM; * maximum blue label $0(3) NM; * maximum d3 $0(3) NM; * maximum daily green $0(3) NM; * maximum green label $0(3) NM; * maximum red label $0(3) NM; * mediplex plus $0(3) NM; * MEGA MULTI FOR MEN $0(3) NM; * MEGA MULTIVITAMIN FOR MEN $0(3) NM; * MEGA MULTIVITAMIN FOR WOM $0(3) NM; * mega vm-80 $0(3) NM; * mega-marathon 100 tr $0(3) NM; * MEGAVITE FRUITS & VEGGIES $0(3) NM; * MEGAVITE GOLDEN YEARS 55+ $0(3) NM; * meijer advanced formula $0(3) NM; * meijer advanced formula f $0(3) NM; * meijer c $0(3) NM; * MENS 50+ ADVANCED $0(3) NM; * mens daily formula/lycope $0(3) NM; * MENS MULTI VITAMIN & MINE $0(3) NM; * MENS PACK $0(3) NM; * meribin $0(3) NM; * METAFOLBIC $0(3) NM; * MH MACULAR HEALTH $0(3) NM; * MIL-A-MULSION $0(3) NM; * milltrium senior $0(3) NM; * MTERYTI $0(3) NM; * MTERYTI FOLIC 5 $0(3) NM; * multi + omega-3 adult gum $0(3) NM; * multi adult gummies $0(3) NM; * multi complete/iron $0(3) NM; * multi for her $0(3) NM; * multi for her 50+ $0(3) NM; * MULTI FOR HIM PACK $0(3) NM; *


Name of drug


you (tier

level)


or limits on use multi for him TABS $0(3) NM; * multi for him 50+ $0(3) NM; * MULTI PRENATAL $0(3) NM; * MULTI VITAMIN $0(3) NM; * multi vitamin daily $0(3) NM; * multi vitamin mens $0(3) NM; * MULTI VITAMIN/D-3 $0(3) NM; * multi-day $0(3) NM; * multi-day plus iron $0(3) NM; * multi-day plus minerals $0(3) NM; * multi-day vitamins $0(3) NM; * multi-delyn $0(3) NM; * MULTI-DELYN/IRON $0(3) NM; * multi-vit/iron/fluoride $0(3) NM; * multi-vitamin $0(3) NM; * multi-vitamin daily $0(3) NM; * multi-vitamin gummies $0(3) NM; * MULTI-VITAMIN MONOCAPS $0(3) NM; * multi-vitamin/minerals $0(3) NM; * multi-vitamin/multi-miner $0(3) NM; * multi-vitamins $0(3) NM; * multi-vitamins/iron $0(3) NM; * multilex $0(3) NM; * multilex-t&m $0(3) NM; * multimineral plus $0(3) NM; * multiple vitamin $0(3) NM; * multiple vitamin/minerals $0(3) NM; * multiple vitamins essenti $0(3) NM; * multiple vitamins w/ iron $0(3) NM; * multiple vitamins w/ minerals $0(3) NM; * multiple vitamins/womens $0(3) NM; * multivitamin $0(3) NM; * multivitamin & mineral $0(3) NM; * MULTIVITAMIN ADULT $0(3) NM; *



Name of drug


you (tier

level)


or limits on use MULTIVITAMIN ADULT EXTRA $0(3) NM; * multivitamin adults $0(3) NM; * MULTIVITAMIN ADULTS $0(3) NM; * multivitamin adults 50+ $0(3) NM; * multivitamin childrens $0(3) NM; * MULTIVITAMIN DROPS/IRON I $0(3) NM; * multivitamin gummies adul $0(3) NM; * multivitamin gummies chil $0(3) NM; * MULTIVITAMIN GUMMIES CHIL $0(3) NM; * multivitamin gummies mens $0(3) NM; * multivitamin gummies wome $0(3) NM; * MULTIVITAMIN INFANT & TOD $0(3) NM; * multivitamin men 50+ $0(3) NM; * multivitamin mens $0(3) NM; * MULTIVITAMIN PLUS IRON CH $0(3) NM; * multivitamin with fluorid SOLN $0(3) NM; * multivitamin women $0(3) NM; * multivitamin women 50+ $0(3) NM; * multivitamin womens $0(3) NM; * MULTIVITAMIN+ $0(3) NM; * multivitamin/extra vitami $0(3) NM; * multivitamin/fluoride CHEW $0(3) NM; * multivitamins $0(3) NM; * MVW COMPLETE FORMULATION CAPS $0(3) NM; * mvw complete formulation CHEW $0(3) NM; * MVW COMPLETE FORMULATION CHEW $0(3) NM; * MVW COMPLETE FORMULATION SOLN $0(3) NM; * my-vitalife $0(3) NM; * myamulti $0(3) NM; * mynephrocaps $0(3) NM; * mynephron $0(3) NM; * nail-ex $0(3) NM; * NANOVM 1-3 YEARS $0(3) NM; * NANOVM 4-8 YEARS $0(3) NM; *


Name of drug


you (tier

level)


or limits on use NANOVM 9-18 YEARS $0(3) NM; * NANOVM T/F $0(3) NM; * NASCOBAL $0(3) NM; * natural c/rose hips $0(3) NM; * natural vitamin d-3 $0(3) NM; * natural vitamin e CAPS $0(3) NM; * NATURAL VITAMIN E TABS $0(3) NM; * NEPHPLEX RX $0(3) NM; * NEPHRONEX $0(3) NM; * neuro-k-50 $0(3) NM; * niacin CPCR; TABS; TBCR $0(3) NM; * NIACIN POWD $0(3) NM; * NIACIN TR $0(3) NM; * niacin-50 $0(3) NM; * NO IRON MULTIPLE VITAMIN/ $0(3) NM; * NUFOLA $0(3) NM; * nutr-e-sol $0(3) NM; * NUTRICAP $0(3) NM; * NUTRIVIT $0(3) NM; * ocutabs $0(3) NM; * ocutabs vision formula $0(3) NM; * ocutabs/lutein $0(3) NM; * OCUVITE ADULT 50+ $0(3) NM; * OCUVITE ADULT FORMULA $0(3) NM; * ocuvite extra $0(3) NM; * ocuvite eye + multi $0(3) NM; * ocuvite eye health gummie $0(3) NM; * OCUVITE LUTEIN $0(3) NM; * ocuvite/lutein $0(3) NM; * OMNICAP $0(3) NM; * once daily $0(3) NM; * once daily/iron $0(3) NM; * ONCOVITE $0(3) NM; * one daily $0(3) NM; *



Name of drug


you (tier

level)


or limits on use one daily adults 50+ $0(3) NM; * one daily complete $0(3) NM; * one daily for men 50+ adv $0(3) NM; * one daily for men/lycopen $0(3) NM; * one daily for women $0(3) NM; * one daily for women 50+a $0(3) NM; * one daily healthy weight $0(3) NM; * one daily maximum $0(3) NM; * one daily mens $0(3) NM; * one daily mens 50+ multiv $0(3) NM; * one daily mens health/lyc $0(3) NM; * one daily multivitamin ad $0(3) NM; * one daily multivitamin/ir $0(3) NM; * one daily plus iron $0(3) NM; * one daily plus minerals $0(3) NM; * one daily womens 50 plus $0(3) NM; * one daily womens 50+ $0(3) NM; * one daily/iron/calcium $0(3) NM; * one daily/minerals $0(3) NM; * ONE-A-DAY ADULT VITACRAVE $0(3) NM; * ONE-A-DAY ENERGY $0(3) NM; * ONE-A-DAY FOR HER VITACRA $0(3) NM; * ONE-A-DAY FOR HIM/VITACRA $0(3) NM; * ONE-A-DAY MENOPAUSE FORMU $0(3) NM; * ONE-A-DAY MENS 50+ ADVANT $0(3) NM; * ONE-A-DAY MENS HEALTH FOR $0(3) NM; * ONE-A-DAY MENS VITACRAVES $0(3) NM; * ONE-A-DAY PROACTIVE 65+ $0(3) NM; * one-a-day teen advantage $0(3) NM; * ONE-A-DAY TEEN ADVANTAGE $0(3) NM; * ONE-A-DAY VITACRAVES $0(3) NM; * ONE-A-DAY VITACRAVES ADUL $0(3) NM; * ONE-A-DAY VITACRAVES GUMM $0(3) NM; * ONE-A-DAY VITACRAVES SOUR $0(3) NM; *


Name of drug


you (tier

level)


or limits on use ONE-A-DAY VITACRAVES WOME $0(3) NM; * ONE-A-DAY WOMENS VITACRAV $0(3) NM; * one-daily multi vitamins $0(3) NM; * ONE-DAILY MULTI-VITAMIN $0(3) NM; * ONE-DAILY MULTI-VITAMIN/M $0(3) NM; * one-daily/iron $0(3) NM; * optic-vites $0(3) NM; * OPTIMAL D3 M $0(3) NM; * optimal-d $0(3) NM; * optimal-d pack $0(3) NM; * optimum pms $0(3) NM; * OPTISOURCE POST BARIATRIC $0(3) NM; * OPURITY/BYPASS OPTIMIZED $0(3) NM; * orthovite $0(3) NM; * pa biotin $0(3) NM; * PA MENS 50 PLUS VITAPAK $0(3) NM; * PA MENS VITAPAK $0(3) NM; * pa vitamin d-3 $0(3) NM; * pa vitamin d-3 gummy $0(3) NM; * pa vitamin e $0(3) NM; * PA WOMENS 50 PLUS VITAPAK $0(3) NM; * PA WOMENS VITAPAK $0(3) NM; * paricalcitol CAPS $0(1) B/D PARVLEX $0(3) NM; * pediatric multiple vitamins w/ iron $0(3) NM; * pediavit $0(3) NM; * PHLEXY-VITS $0(3) NM; * PHYTOMULTI $0(3) NM; * phytonadione SOLN; TABS $0(3) NM; * PNV FOLIC ACID + IRON MUL $0(2) poly vitamin $0(3) NM; * polyvitamin $0(3) NM; * polyvitamin/iron $0(3) NM; * PRENATAL $0(2)



Name of drug


you (tier

level)


or limits on use PRENATAL $0(3) NM; * PRENATAL LOW IRON $0(3) NM; * PRENATAL MULTI + DHA $0(3) NM; * PRENATAL MULTIVITAMIN + D $0(3) NM; * PRENATAL MULTIVITAMIN PLU CAPS $0(3) NM; * PRENATAL ONE DAILY $0(3) NM; * PRENATAL PLUS $0(2) PRENATAL PLUS LOW IRON $0(2) PRENATAL TABLETS $0(3) NM; * PRENATAL VITAMIN $0(3) NM; * PRENATAL VITAMIN & MINERA $0(3) NM; * PRENATAL VITAMIN/IRON $0(3) NM; * PRENATAL VITAMINS $0(3) NM; * PRESERVISION AREDS $0(3) NM; * PRESERVISION AREDS 2 CAPS $0(3) NM; * PRESERVISION/LUTEIN $0(3) NM; * prevent $0(3) NM; * PRO-CAL TABS $0(3) NM; * PROCERV HP $0(3) NM; * PRORENAL+D $0(3) NM; * PRORENAL+D/OMEGA-3 $0(3) NM; * prosight $0(3) NM; * prosight w/lutein $0(3) NM; * PROTECT CARDIO AF $0(3) NM; * PROTECT PLUS NF $0(3) NM; * PROTECT PLUS SO $0(3) NM; * PROTEGRA $0(3) NM; * pure c 500 $0(3) NM; * pureway-c $0(3) NM; * px advanced formula multi $0(3) NM; * px b complex/vitamin c $0(3) NM; * px childrens vitamin $0(3) NM; * px complete senior multiv $0(3) NM; * px folic acid $0(3) NM; *


Name of drug


you (tier

level)


or limits on use px mens multivitamins $0(3) NM; * px niacin $0(3) NM; * px vitamin c $0(3) NM; * px vitamin e $0(3) NM; * pyridoxine hcl SOLN; TABS $0(3) NM; * qc childrens chewable com $0(3) NM; * qc childrens chewable vit $0(3) NM; * qc daily multivitamins/ir $0(3) NM; * qc maximum daily multivit $0(3) NM; * qc mens daily multivitami $0(3) NM; * qc multi-vite $0(3) NM; * qc multi-vite 50 & over $0(3) NM; * QC PRENATAL $0(3) NM; * qc therin-m $0(3) NM; * qc womens daily multivita $0(3) NM; * QUIN B STRONG $0(3) NM; * QUINTABS $0(3) NM; * quintabs-m $0(3) NM; * QUINTABS-M $0(3) NM; * ra b-complex/vitamin c tr $0(3) NM; * ra biotin $0(3) NM; * ra central-vite $0(3) NM; * RA CENTRAL-VITE $0(3) NM; * ra central-vite energy $0(3) NM; * ra central-vite select $0(3) NM; * ra central-vite select ma $0(3) NM; * ra central-vite senior $0(3) NM; * RA CENTRAL-VITE UNDER 50 $0(3) NM; * ra central-vite womens ma $0(3) NM; * ra central-vite/antioxida $0(3) NM; * RA ESSENCE-C $0(3) NM; * ra folic acid $0(3) NM; * ra gummy vitamins & miner $0(3) NM; * ra hair/skin/nails $0(3) NM; *



Name of drug


you (tier

level)


or limits on use ra mature womens dietary $0(3) NM; * ra natural vitamin e $0(3) NM; * ra niacin $0(3) NM; * ra no flush niacin 500 $0(3) NM; * ra one daily energy formu $0(3) NM; * ra one daily essential $0(3) NM; * ra one daily gummy vites $0(3) NM; * ra one daily maximum $0(3) NM; * ra one daily mens 50+ wit $0(3) NM; * ra one daily mens/vitamin $0(3) NM; * ra one daily multi-vitami $0(3) NM; * ra one daily womens/vitam $0(3) NM; * ra stress formula advance $0(3) NM; * ra stress formula energy $0(3) NM; * ra therapeutic m plus bet $0(3) NM; * ra vision vite plus zinc $0(3) NM; * ra vitamin b12 $0(3) NM; * ra vitamin b-6 $0(3) NM; * RA VITAMIN B-12 LIQD $0(3) NM; * ra vitamin b-12 TABS $0(3) NM; * ra vitamin b-12 tr $0(3) NM; * ra vitamin c CHEW $0(3) NM; * ra vitamin c TABS $0(3) NM; * ra vitamin c tr $0(3) NM; * ra vitamin c/acerola $0(3) NM; * ra vitamin c/rose hips $0(3) NM; * ra vitamin d-3 $0(3) NM; * ra vitamin e CAPS $0(3) NM; * ra vitamin e blend $0(3) NM; * ra whole source complete $0(3) NM; * ra whole source dietary $0(3) NM; * ra whole source dietary f $0(3) NM; * ra whole source dietary m $0(3) NM; * rabano yodado $0(3) NM; *


Name of drug


you (tier

level)


or limits on use RAYALDEE $0(2) rena-vite $0(3) NM; * rena-vite rx $0(3) NM; * renal caps $0(3) NM; * renal multivitamin formul $0(3) NM; * renal vitamin $0(3) NM; * renal-vite $0(3) NM; * renaplex $0(3) NM; * RENAPLEX-D $0(3) NM; * reno caps $0(3) NM; * REPLACE $0(3) NM; * REPLESTA $0(3) NM; * REPLESTA CHILDRENS $0(3) NM; * REPLESTA NX $0(3) NM; * RIGHT STEP PRENATAL $0(3) NM; * savision TABS $0(3) NM; * sb vitamin c $0(3) NM; * sclerex $0(3) NM; * SCOOBY-DOO ONE A DAY $0(3) NM; * senior tabs $0(3) NM; * sentry $0(3) NM; * SENTRY $0(3) NM; * sentry adults under 50 $0(3) NM; * sentry senior $0(3) NM; * SENTRY SENIOR $0(3) NM; * slo-niacin 250mg $0(3) NM; * sm animal shapes complete $0(3) NM; * sm animal shapes kids fir $0(3) NM; * sm antioxidant vitamins $0(3) NM; * sm b super vitamin comple $0(3) NM; * SM B-COMPLEX/VITAMIN C $0(3) NM; * sm chewable c $0(3) NM; * sm chewable vitamin c $0(3) NM; * sm complete $0(3) NM; *



Name of drug


you (tier

level)


or limits on use sm complete 50+ $0(3) NM; * sm complete 50+ ultimate $0(3) NM; * sm complete advanced form $0(3) NM; * sm complete senior formul $0(3) NM; * sm folic acid $0(3) NM; * sm hair/skin/nails $0(3) NM; * sm multiple vitamins esse $0(3) NM; * sm multiple vitamins/iron $0(3) NM; * sm niacin cr $0(3) NM; * SM ONE DAILY MENS $0(3) NM; * SM ONE DAILY WOMENS $0(3) NM; * sm opti-vitamins $0(3) NM; * SM PRENATAL VITAMINS $0(3) NM; * sm super b complex-vitami $0(3) NM; * sm vit c/rose hips $0(3) NM; * sm vitamin b6 $0(3) NM; * sm vitamin b12 $0(3) NM; * sm vitamin b12 tr $0(3) NM; * sm vitamin b-6 $0(3) NM; * sm vitamin b-12 $0(3) NM; * sm vitamin c $0(3) NM; * sm vitamin c tr $0(3) NM; * sm vitamin c/rose hips $0(3) NM; * sm vitamin d $0(3) NM; * sm vitamin d3 $0(3) NM; * SM VITAMIN D3 MAXIMUM STR $0(3) NM; * sm vitamin e $0(3) NM; * sm vitamin e blended $0(3) NM; * SOLO $0(3) NM; * stress b-complex/vitamin $0(3) NM; * stress b/zinc $0(3) NM; * stress formula $0(3) NM; * stress formula w/iron $0(3) NM; * stress formula/iron $0(3) NM; *


Name of drug


you (tier

level)


or limits on use stress formula/zinc $0(3) NM; * stresstabs advanced $0(3) NM; * stresstabs energy $0(3) NM; * sunvite advanced $0(3) NM; * SUPER ANTIOXIDANT $0(3) NM; * super antioxidant/a/c/e/s $0(3) NM; * super aytinal 50 plus $0(3) NM; * super aytinal for active $0(3) NM; * super b with c $0(3) NM; * super b-complex/folic aci $0(3) NM; * super b-complex/vitamin c $0(3) NM; * super biotin $0(3) NM; * SUPER DAILY D3 $0(3) NM; * super multiple $0(3) NM; * super nu-thera LIQD; TABS $0(3) NM; * SUPER NU-THERA POWD $0(3) NM; * super thera vite m $0(3) NM; * super vikaps $0(3) NM; * super vita-mins $0(3) NM; * SUPERIORSOURCE K1 $0(3) NM; * superplex-t $0(3) NM; * tab-a-vite $0(3) NM; * tab-a-vite w/beta caroten $0(3) NM; * tab-a-vite/iron $0(3) NM; * thera $0(3) NM; * THERA $0(3) NM; * THERA M PLUS $0(3) NM; * thera vital m $0(3) NM; * thera-d 2000 $0(3) NM; * THERA-D 4000 $0(3) NM; * thera-d rapid repletion $0(3) NM; * thera-m $0(3) NM; * THERA-M $0(3) NM; * thera-tabs $0(3) NM; *



Name of drug


you (tier

level)


or limits on use THERA-TABS M $0(3) NM; * therabasic-m $0(3) NM; * THERAGRAN-M $0(3) NM; * THERAGRAN-M ADVANCED $0(3) NM; * THERAGRAN-M ADVANCED 50 P $0(3) NM; * THERAGRAN-M PREMIER $0(3) NM; * THERAGRAN-M PREMIER 50 PL $0(3) NM; * THERANATAL PLUS $0(3) NM; * therapeutic $0(3) NM; * therapeutic formula/hemat $0(3) NM; * therapeutic m $0(3) NM; * therapeutic multi vitamin $0(3) NM; * therapeutic-m $0(3) NM; * therapeutic-m/lutein $0(3) NM; * theratrum complete $0(3) NM; * theratrum complete 50 plu $0(3) NM; * theravim -m $0(3) NM; * therems $0(3) NM; * THEREMS-H $0(3) NM; * THEREMS-M $0(3) NM; * THIAMINE HCL POWD $0(3) NM; * thiamine hcl SOLN; TABS $0(3) NM; * THRIVITE 19 $0(3) NM; * total b/c $0(3) NM; * total formula $0(3) NM; * total formula 2 $0(3) NM; * total formula 3 $0(3) NM; * totalday multiple $0(3) NM; * TRI-VITAMIN INFANT & TODD $0(3) NM; * TRICARE $0(2) tropical liquid nutrition $0(3) NM; * trueplus diabetic multivi $0(3) NM; * ultra choice multivitamin $0(3) NM; * ultra freeda $0(3) NM; *


Name of drug


you (tier

level)


or limits on use ultra freeda/iron $0(3) NM; * ULTRA MEGA $0(3) NM; * ULTRA MEGA GOLD $0(3) NM; * ULTRA MEGA TWO $0(3) NM; * ULTRA MENS PACK $0(3) NM; * ultrachoice advanced form $0(3) NM; * UNICOMPLEX-M $0(3) NM; * UPSPRING BABY VITAMIN D $0(3) NM; * UPSPRINGBABY MULTIVITAMIN $0(3) NM; * v-c forte $0(3) NM; * vic-forte $0(3) NM; * virt-caps $0(3) NM; * vision formula 2 $0(3) NM; * vision formula eye health $0(3) NM; * vision formula/lutein $0(3) NM; * vision vitamins $0(3) NM; * vita hair $0(3) NM; * vita-bee/c $0(3) NM; * VITA-C $0(3) NM; * VITA-RESPA $0(3) NM; * vitabasic complete $0(3) NM; * vitabasic senior $0(3) NM; * VITABEX PLUS $0(3) NM; * vitachew multiple vitamin $0(3) NM; * vitajoy daily d gummies $0(3) NM; * VITAL-D RX $0(3) NM; * vitalee $0(3) NM; * VITALETS CHILDRENS $0(3) NM; * VITAMAX $0(3) NM; * VITAMENT $0(3) NM; * VITAMIN & MINERAL SUPPLEM $0(3) NM; * VITAMIN B12 $0(3) NM; * vitamin b12 tr $0(3) NM; * VITAMIN B 12 250mcg $0(3) NM; *



Name of drug


you (tier

level)


or limits on use vitamin b complex-c $0(3) NM; * VITAMIN B-1 500mg $0(3) NM; * VITAMIN B-12 LIQD $0(3) NM; * VITAMIN B-12 LOZG 50mcg $0(3) NM; * vitamin b-12 tr 1000mcg, 2000mcg $0(3) NM; * VITAMIN C PACK $0(3) NM; * VITAMIN C POWD $0(3) NM; * VITAMIN C TABS 100mg $0(3) NM; * vitamin c drops $0(3) NM; * vitamin c plus wild rose $0(3) NM; * vitamin c/rose hips tr $0(3) NM; * VITAMIN D2 $0(3) NM; * VITAMIN D3 LIQD 1000unit/spray, 1200unit/15ml

$0(3) NM; *

VITAMIN D3 TABS 3000unit, 10000unit $0(3) NM; * VITAMIN D3 TBDP $0(3) NM; * vitamin d3 adult gummies $0(3) NM; * VITAMIN D3 COMPLETE $0(3) NM; * vitamin d3 gummies adult $0(3) NM; * VITAMIN D3 IMMUNE HEALTH $0(3) NM; * vitamin d3 maximum streng $0(3) NM; * vitamin d3 super strength $0(3) NM; * vitamin d3 ultra strength $0(3) NM; * vitamin d high potency $0(3) NM; * vitamin d infant $0(3) NM; * vitamin d-400 $0(3) NM; * vitamin d-1000 maximum st $0(3) NM; * vitamin e CAPS $0(3) NM; * VITAMIN E CHEW $0(3) NM; * vitamin e OIL $0(3) NM; * vitamin e SOLN $0(3) NM; * VITAMIN E TABS 100unit, 200unit $0(3) NM; * vitamin e TABS 400unit $0(3) NM; * vitamin e blend $0(3) NM; *


Name of drug


you (tier

level)


or limits on use vitamin e complex natural $0(3) NM; * vitamin e high potency $0(3) NM; * vitamin e-200 $0(3) NM; * vitamin e-400 $0(3) NM; * vitamin e/d-alpha natural $0(3) NM; * VITASANA $0(3) NM; * vitatrum CHEW $0(3) NM; * VITATRUM TABS $0(3) NM; * vitatrum complete $0(3) NM; * VITRUM 50+ SENIOR MULTI $0(3) NM; * vitrum senior $0(3) NM; * vol-care rx $0(3) NM; * VOL-NATE $0(3) NM; * VOL-TAB RX $0(3) NM; * vp-vite rx $0(3) NM; * womens 50+ advanced $0(3) NM; * WOMENS BIOMULTIPLE $0(3) NM; * womens daily formula $0(3) NM; * womens daily formula/foli $0(3) NM; * womens multi $0(3) NM; * womens one daily $0(3) NM; * WOMENS PACK $0(3) NM; * YELETS TEENAGE FORMULA $0(3) NM; * yl folic acid $0(3) NM; * yl vitamin b-6 $0(3) NM; * yl vitamin c $0(3) NM; * yl vitamin c/rose hips $0(3) NM; * yl vitamin e $0(3) NM; * YOUR LIFE MULTI ADULT GUM $0(3) NM; * ZINC LOZG $0(3) NM; * zoo friends $0(3) NM; * ZOO FRIENDS COMPLETE $0(3) NM; * zoo friends gummies $0(3) NM; * zoo friends plus extra c $0(3) NM; *



Name of drug


you (tier

level)


or limits on use zoo friends plus iron $0(3) NM; * zoo friends/extra c $0(3) NM; *

OPHTHALMIC - DRUGS TO TREAT EYE CONDITIONS ANTI-INFECTIVE/ANTI-INFLAMMATORY - DRUGS TO TREAT INFECTIONS AND INFLAMMATION

bacitracin-poly-neomycin-hc $0(1) BLEPHAMIDE OINT $0(2) neomycin-polymy-dexameth $0(1) neomycin-polymyxin-hc (ophth) $0(1) sulfacetamide sod-prednisolone $0(1) TOBRADEX OINT $0(2) TOBRADEX ST $0(2) tobramycin-dexamethasone $0(1) ZYLET $0(2)

ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS AZASITE $0(2) bacitracin (ophthalmic) $0(1) bacitracin-polymyxin b (ophth) $0(1) BESIVANCE $0(2) CILOXAN OINT $0(2) ciprofloxacin hcl (ophth) $0(1) erythromycin (ophth) $0(1) gatifloxacin (ophth) $0(1) gentak $0(1) gentamicin sulfate soln (ophth) $0(1) MOXEZA $0(2) moxifloxacin hcl (ophth) $0(1) NATACYN $0(2) neomycin-bacitracin zn-polymyxin $0(1) neomycin-polymyxin-gramicidin $0(1) ofloxacin (ophth) $0(1) polymyxin b-trimethoprim $0(1) sulfacetamide sodium (ophth) $0(1) tobramycin (ophth) $0(1) trifluridine $0(1)


Name of drug


you (tier

level)


or limits on use ZIRGAN $0(2)

ANTI-INFLAMMATORIES - DRUGS TO TREAT INFLAMMATION ALREX $0(2) bromfenac sodium (ophth) $0(1) BROMSITE $0(2) dexamethasone sodium phosphate (ophth) $0(1) diclofenac sodium (ophth) $0(1) DUREZOL $0(2) fluorometholone $0(1) flurbiprofen sodium $0(1) ILEVRO $0(2) ketorolac tromethamine (ophth) $0(1) LOTEMAX GEL; OINT $0(2) loteprednol etabonate $0(1) prednisolone acetate (ophth) $0(1) PREDNISOLONE SODIUM PHOSPHATE (OPHTH)

$0(2)

PROLENSA $0(2) ANTIALLERGICS - DRUGS TO TREAT ALLERGIES

alaway $0(3) NM; * alaway childrens allergy $0(3) NM; * azelastine drop 0.05% $0(1) BEPREVE $0(2) cromolyn sodium (ophth) $0(1) eye itch relief $0(3) NM; * hm eye itch relief $0(3) NM; * ketotifen fumarate (ophth) $0(3) NM; * kp ketotifen fumarate $0(3) NM; * LASTACAFT $0(2) olopatadine hcl 0.2% $0(1) PAZEO $0(2) sm eye itch relief $0(3) NM; *

ANTIGLAUCOMA - DRUGS TO TREAT GLAUCOMA ALPHAGAN P SOL 0.1% $0(2)



Name of drug


you (tier

level)


or limits on use AZOPT $0(2) betaxolol hcl (ophth) $0(1) BETOPTIC-S $0(2) brimonidine sol 0.2% $0(1) brimonidine sol 0.15% $0(1) carteolol hcl (ophth) $0(1) COMBIGAN $0(2) dorzolamide hcl $0(1) dorzolamide hcl-timolol maleate $0(1) latanoprost SOLN $0(1) levobunolol hcl $0(1) LUMIGAN $0(2) PHOSPHOLINE IODIDE $0(2) pilocarpine hcl SOLN $0(1) RHOPRESSA $0(2) SIMBRINZA $0(2) timolol maleate (ophth) soln $0(1) timolol maleate gel $0(1) timolol maleate ophth soln 0.5% (once-daily) $0(1) TRAVATAN Z $0(2)

MISCELLANEOUS akwa tears $0(3) NM; * altachlore $0(3) NM; * artificial tears $0(3) NM; * ATROPINE SULFATE SOLN 1% $0(2) cvs lubricant eye drops $0(3) NM; * cvs sodium chloride $0(3) NM; * CYSTARAN $0(2) NM, LA, PA eq restore plus lubricant $0(3) NM; * eq restore tears $0(3) NM; * for sty relief $0(3) NM; * FRESHKOTE $0(3) NM; * FRESHKOTE PF $0(3) NM; * GENTEAL SEVERE $0(3) NM; *


Name of drug


you (tier

level)


or limits on use genteal tears liquid drop $0(3) NM; * genteal tears night-time $0(3) NM; * gnp artificial tears $0(3) NM; * gnp eye drops .5% $0(3) NM; * gnp lubricant eye drops $0(3) NM; * gnp lubricant pm $0(3) NM; * gnp lubricating plus eye $0(3) NM; * gnp ultra lubricant eye d $0(3) NM; * goodsense artificial tear $0(3) NM; * goodsense lubricating plu $0(3) NM; * hm artificial tears $0(3) NM; * hm dry eye relief $0(3) NM; * hm lubricating plus $0(3) NM; * hm lubricating tears $0(3) NM; * ISOPTO TEARS $0(3) NM; * liquitears $0(3) NM; * lubricant eye drops .5% $0(3) NM; * lubricating eye drops $0(3) NM; * lubricating plus eye drop $0(3) NM; * MURO 128 SOLN 2% $0(3) NM; * polyvinyl alcohol SOLN $0(3) NM; * proparacaine hcl SOLN $0(1) puralube $0(3) NM; * pure & gentle lubricant $0(3) NM; * px artificial tears $0(3) NM; * ra lubricant eye drops .5% $0(3) NM; * ra ophthalmic solution $0(3) NM; * REFRESH $0(3) NM; * refresh celluvisc $0(3) NM; * refresh lacri-lube $0(3) NM; * REFRESH LIQUIGEL $0(3) NM; * REFRESH OPTIVE GEL $0(3) NM; * REFRESH OPTIVE ADVANCED $0(3) NM; * REFRESH OPTIVE ADVANCED S $0(3) NM; *



Name of drug


you (tier

level)


or limits on use REFRESH OPTIVE MEGA-3 $0(3) NM; * REFRESH OPTIVE PRESERVATI $0(3) NM; * refresh p.m. $0(3) NM; * RESTASIS $0(2) QL (60 single use vials / 30 days) RESTASIS MULTIDOSE $0(2) QL (1 bottle / 30 days) RETAINE HPMC $0(3) NM; * retaine pm $0(3) NM; * sm artificial tears $0(3) NM; * sm dry eye relief $0(3) NM; * sm lubricant eye drops $0(3) NM; * sm lubricating plus $0(3) NM; * sm lubricating tears $0(3) NM; * sochlor $0(3) NM; * sodium chloride hypertonic $0(3) NM; * soothe xp/xtra protection $0(3) NM; * STERILE LUBRICANT DROPS $0(3) NM; * stye $0(3) NM; * SYSTANE GEL $0(3) NM; * systane nighttime $0(3) NM; * SYSTANE OVERNIGHT THERAPY $0(3) NM; * tears again $0(3) NM; * tgt lubricant eye drops $0(3) NM; * tgt lubricant eye nightti $0(3) NM; * th eye drop advanced reli $0(3) NM; * THERATEARS SOLN $0(3) NM; * ultra fresh $0(3) NM; * ultra fresh pm $0(3) NM; *

RESPIRATORY - DRUGS TO TREAT BREATHING DISORDERS ANTICHOLINERGIC/BETA AGONIST COMBINATIONS - DRUGS TO TREAT COPD

ANORO ELLIPTA $0(2) QL (60 blisters / 30 days) BEVESPI AEROSPHERE $0(2) QL (1 inhaler / 30 days) COMBIVENT RESPIMAT $0(2) QL (2 inhalers / 30 days) ipratropium-albuterol nebu $0(1) B/D TRELEGY ELLIPTA $0(2) QL (60 blisters / 30 days)


Name of drug


you (tier

level)


or limits on use ANTICHOLINERGICS - DRUGS TO TREAT COPD

ATROVENT HFA $0(2) QL (2 inhalers / 30 days) INCRUSE ELLIPTA $0(2) QL (30 blisters / 30 days) ipratropium bromide SOLN $0(1) B/D ipratropium bromide (nasal) $0(1)

ANTIHISTAMINES - DRUGS TO TREAT ALLERGIES ALA-HIST IR $0(3) NM; * aler-cap $0(3) NM; * all day allergy TABS $0(3) NM; * all day allergy childrens $0(3) NM; * all-day allergy childrens $0(3) NM; * aller-chlor $0(3) NM; * aller-ease $0(3) NM; * allergy $0(3) NM; * allergy 24-hr $0(3) NM; * allergy childrens $0(3) NM; * allergy non-drowsy $0(3) NM; * allergy relief CAPS 25mg $0(3) NM; * allergy relief TABS $0(3) NM; * allergy relief TBDP $0(3) NM; * allergy relief 24hr $0(3) NM; * allergy relief child $0(3) NM; * allergy relief childrens LIQD; SOLN $0(3) NM; * allergy relief/indoor/out $0(3) NM; * allergy tablets $0(3) NM; * allergy-time $0(3) NM; * azelastine spr 0.1% $0(1) azelastine spr 0.15% $0(1) banophen CAPS; LIQD; TABS $0(3) NM; * cetirizine hcl $0(3) NM; * cetirizine hcl allergy ch $0(3) NM; * cetirizine hcl childrens $0(3) NM; * cetirizine hcl hives reli $0(3) NM; * cetirizine hydrochloride $0(3) NM; *



Name of drug


you (tier

level)


or limits on use cetirizine syrup $0(1) childrens allergy $0(3) NM; * childrens loratadine $0(3) NM; * chlorhist $0(3) NM; * chlorphen sr $0(3) NM; * chlorpheniramine maleate TABS; TBCR $0(3) NM; * complete allergy medicine $0(3) NM; * cyproheptadine hcl SYRP; TABS $0(2) PA; PA if 70 years and older dayhist allergy 12 hour r $0(3) NM; * diphen TABS $0(3) NM; * diphenhist $0(3) NM; * diphenhydramine hcl CAPS $0(3) NM; * diphenhydramine hcl LIQD $0(3) NM; * diphenhydramine hcl TABS 25mg $0(3) NM; * diphenhydramine hcl inj 50mg/ml $0(1) dye-free allergy relief c $0(3) NM; * ed chlorped jr $0(3) NM; * eql all day allergy $0(3) NM; * fexofenadine hcl TABS $0(3) NM; * geri-dryl $0(3) NM; * geri-dryl allergy relief $0(3) NM; * gnp all day allergy $0(3) NM; * gnp all day allergy child $0(3) NM; * gnp allergy $0(3) NM; * gnp allergy antihistamine $0(3) NM; * gnp allergy relief $0(3) NM; * gnp allergy relief for ki $0(3) NM; * gnp childrens allergy $0(3) NM; * gnp dayhist allergy $0(3) NM; * gnp loratadine $0(3) NM; * gnp loratadine childrens $0(3) NM; * goodsense all day allergy $0(3) NM; * goodsense aller-ease $0(3) NM; * goodsense allergy relief $0(3) NM; *


Name of drug


you (tier

level)


or limits on use HISTEX $0(3) NM; * HISTEX PD $0(3) NM; * HISTEX PDX $0(3) NM; * hm all day allergy $0(3) NM; * hm all day allergy childr $0(3) NM; * hm allergy $0(3) NM; * hm allergy relief $0(3) NM; * hm allergy relief childre $0(3) NM; * hm allgery multi symptom $0(3) NM; * hm cetirizine hcl childre $0(3) NM; * hm cetirizine hydrochlori $0(3) NM; * hm fexofenadine hydrochlo $0(3) NM; * hm loratadine $0(3) NM; * hm loratadine childrens $0(3) NM; * 24hr allergy relief $0(3) NM; * hydroxyzine hcl SYRP; TABS $0(2) PA; PA if 70 years and older hydroxyzine hcl inj $0(2) PA; PA if 70 years and older hydroxyzine pamoate CAPS 25mg, 50mg $0(2) PA; PA if 70 years and older kls aller-tec $0(3) NM; * kls allerclear $0(3) NM; * kp loratadine $0(3) NM; * levocetirizine dihydrochloride SOLN $0(1) levocetirizine dihydrochloride TABS 5mg $0(1) levocetirizine dihydrochloride TABS 5mg $0(3) NM; * loradamed $0(3) NM; * loratadine CAPS; CHEW; TABS $0(3) NM; * loratadine childrens $0(3) NM; * m-hist pd $0(3) NM; * medi-phedryl $0(3) NM; * mucinex allergy $0(3) NM; * PEDIAVENT $0(3) NM; * pharbechlor $0(3) NM; * pharbedryl $0(3) NM; * px allergy $0(3) NM; *



Name of drug


you (tier

level)


or limits on use px allergy relief $0(3) NM; * px childrens allergy $0(3) NM; * qc all day allergy $0(3) NM; * qc allergy relief $0(3) NM; * qc childrens allergy $0(3) NM; * qc chlor-pheniramine $0(3) NM; * qc complete allergy medic $0(3) NM; * qc fexofenadine hydrochlo $0(3) NM; * qc loratadine allergy rel $0(3) NM; * sb allergy $0(3) NM; * sb allergy medicine $0(3) NM; * sb chlorpheniramine $0(3) NM; * sb loratadine $0(3) NM; * sb loratadine allergy rel $0(3) NM; * siladryl allergy $0(3) NM; * sm all day allergy $0(3) NM; * sm all day allergy childr $0(3) NM; * sm allergy 4 hour $0(3) NM; * sm allergy relief $0(3) NM; * sm allergy relief childre $0(3) NM; * sm childrens loratadine $0(3) NM; * sm fexofenadine hcl $0(3) NM; * sm fexofenadine hydrochlo $0(3) NM; * sm loratadine $0(3) NM; * sm loratadine allergy rel $0(3) NM; * tgt all day allergy relie $0(3) NM; * tgt allergy relief $0(3) NM; * tgt allergy relief childr $0(3) NM; * tgt loratadine childrens $0(3) NM; * total allergy $0(3) NM; * triprolidine hcl LIQD $0(3) NM; * wal-dryl allergy $0(3) NM; *

BETA AGONISTS - DRUGS TO TREAT ASTHMA AND COPD albuterol sulfate AERS 108mcg/act $0(1) QL (2 inhalers / 30 days);

(generic of Proair HFA)


Name of drug


you (tier

level)


or limits on use albuterol sulfate AERS 108mcg/act $0(1) QL (2 inhalers / 30 days);

(generic of Ventolin HFA) albuterol sulfate NEBU $0(1) B/D albuterol sulfate SYRP $0(1) albuterol sulfate TABS $0(1) albuterol sulfate TB12 $0(1) levalbuterol hcl NEBU $0(1) B/D levalbuterol hcl soln nebu conc 1.25 mg/0.5ml $0(1) B/D levalbuterol tartrate hfa $0(1) QL (2 inhalers / 30 days) SEREVENT DISKUS $0(2) QL (60 inhalations / 30 days) terbutaline sulfate TABS $0(1) VENTOLIN HFA $0(2) QL (2 inhalers / 30 days)

COUGH AND COLD aceta-gesic $0(3) NM; * acetaminophen congestion $0(3) NM; * ALA-HIST PE $0(3) NM; * ALAHIST CF $0(3) NM; * ALAHIST DM $0(3) NM; * all day allergy d $0(3) NM; * all day allergy d-12 $0(3) NM; * all day allergy-d $0(3) NM; * all-nite cold & flu night $0(3) NM; * allergy d-12 $0(3) NM; * allergy multi-symptom $0(3) NM; * allergy relief d $0(3) NM; * allergy relief d-24 $0(3) NM; * allergy relief-d $0(3) NM; * allergy relief/nasal deco $0(3) NM; * ambi 10peh/400gfn $0(3) NM; * ambi 10peh/400gfn/20dm $0(3) NM; * ambi 40pse/400gfn $0(3) NM; * aprodine $0(3) NM; * AQUANAZ $0(3) NM; * ATUSS DA $0(3) NM; * BENZEDREX INHALER $0(3) NM; *



Name of drug


you (tier

level)


or limits on use benzonatate $0(3) NM; * BROHIST D $0(3) NM; * bromfed dm $0(3) NM; * BRONKAID $0(3) NM; * BROTAPP DM $0(3) NM; * CAPCOF $0(3) NM; * CAPMIST DM $0(3) NM; * CAPRON DM $0(3) NM; * CAPRON DMT $0(3) NM; * cetirizine-pseudoephedrine $0(3) NM; * cheratussin ac $0(3) NM; * childrens cold & allergy $0(3) NM; * childrens mucus relief co $0(3) NM; * childrens mucus relief ex $0(3) NM; * childrens pain relief plu $0(3) NM; * childrens silfedrine $0(3) NM; * CHLO HIST $0(3) NM; * CHLO TUSS $0(3) NM; * cold & allergy childrens $0(3) NM; * cold & cough childrens $0(3) NM; * cold head congestion dayt $0(3) NM; * cold head congestion seve $0(3) NM; * cold relief/non-drowsy/da $0(3) NM; * cold/allergy childrens $0(3) NM; * cold/cough childrens $0(3) NM; * CONEX COLD/ALLERGY $0(3) NM; * cough & chest congestion $0(3) NM; * cough & cold $0(3) NM; * cough & cold hbp $0(3) NM; * cough dm $0(3) NM; * cough dm childrens $0(3) NM; * cough syrup $0(3) NM; * coughtab $0(3) NM; * cromolyn sodium (nasal) $0(3) NM; *


Name of drug


you (tier

level)


or limits on use cvs cough dm $0(3) NM; * DAYCLEAR ALLERGY RELIEF $0(3) NM; * daytime cold & flu relief $0(3) NM; * daytime multi-symptom col $0(3) NM; * daytime severe cold & flu $0(3) NM; * DECONEX DMX $0(3) NM; * DECONEX IR $0(3) NM; * decongestant 12hour maxim $0(3) NM; * delsym cough + chest cong $0(3) NM; * delsym cough + cold dayti $0(3) NM; * delsym cough + cold night $0(3) NM; * dextromethorphan polistirex $0(3) NM; * dextromethorphan-guaifenesin $0(3) NM; * diabetic siltussin das-na $0(3) NM; * diabetic siltussin-dm $0(3) NM; * diabetic siltussin-dm max $0(3) NM; * diabetic tussin $0(3) NM; * diabetic tussin dm $0(3) NM; * diabetic tussin maximum s $0(3) NM; * dimaphen childrens $0(3) NM; * dimaphen dm cold & cough $0(3) NM; * DURAFLU $0(3) NM; * DURAVENT DM $0(3) NM; * ed a-hist TABS $0(3) NM; * ed a-hist dm LIQD $0(3) NM; * ED A-HIST DM TABS $0(3) NM; * ed a-hist pse $0(3) NM; * ED BRON GP $0(3) NM; * ED CHLORPED D $0(3) NM; * endacof-dm $0(3) NM; * eq cough dm $0(3) NM; * eql allergy/congestion re $0(3) NM; * fexofenadine-pseudoephedrine $0(3) NM; * flu hbp $0(3) NM; *



Name of drug


you (tier

level)


or limits on use flu/severe cold & cough d $0(3) NM; * gnp 12 hour nasal spray $0(3) NM; * gnp all day allergy-d $0(3) NM; * gnp allergy & congestion $0(3) NM; * gnp allergy plus severe s $0(3) NM; * gnp allergy plus sinus he $0(3) NM; * gnp cold & allergy childr $0(3) NM; * gnp cold & allergy maximu $0(3) NM; * gnp cold & cough children $0(3) NM; * gnp cold head congestion $0(3) NM; * gnp cold relief head cong $0(3) NM; * gnp cold relief multi-sym $0(3) NM; * gnp cough dm er $0(3) NM; * gnp cough relief $0(3) NM; * gnp day time cold/flu $0(3) NM; * gnp day time cold/flu rel $0(3) NM; * gnp flu & severe cold & c $0(3) NM; * gnp loratadine-d 12hr $0(3) NM; * gnp mucus dm maximum stre $0(3) NM; * gnp mucus relief $0(3) NM; * gnp mucus relief children $0(3) NM; * gnp mucus relief cold & s $0(3) NM; * gnp mucus relief cold flu $0(3) NM; * gnp mucus relief cough ch $0(3) NM; * gnp mucus relief dm $0(3) NM; * gnp mucus relief pe $0(3) NM; * gnp nasal decongestant $0(3) NM; * gnp nasal decongestant pe $0(3) NM; * gnp nasal decongestant/ma $0(3) NM; * gnp nasal spray $0(3) NM; * gnp nasal spray extra moi $0(3) NM; * gnp nasal spray fast acti $0(3) NM; * gnp night time cold & flu $0(3) NM; * gnp night time cough $0(3) NM; *


Name of drug


you (tier

level)


or limits on use gnp no drip nasal spray $0(3) NM; * gnp nose drops extra stre $0(3) NM; * gnp pseudoephedrine hcl 1 $0(3) NM; * gnp pseudoephedrine hcl e $0(3) NM; * gnp sinus & cold-d $0(3) NM; * gnp sinus relief congesti $0(3) NM; * gnp sinus relief pressure $0(3) NM; * gnp sinus relief severe c $0(3) NM; * gnp suphedrin $0(3) NM; * gnp tab tussin $0(3) NM; * gnp tab tussin dm $0(3) NM; * gnp tussin cf cough & col $0(3) NM; * gnp tussin cough long act $0(3) NM; * gnp tussin dm $0(3) NM; * gnp tussin dm cough $0(3) NM; * gnp tussin dm max $0(3) NM; * gnp tussin mucus & chest $0(3) NM; * goodsense cough dm $0(3) NM; * goodsense cough dm childr $0(3) NM; * goodsense day time cold & $0(3) NM; * goodsense daytime cold & $0(3) NM; * goodsense mucus relief ch $0(3) NM; * goodsense nighttime cold $0(3) NM; * goodsense tussin cf $0(3) NM; * guaiatussin ac $0(3) NM; * guaifenesin LIQD; SOLN; TABS; TB12 $0(3) NM; * guaifenesin ac $0(3) NM; * guaifenesin-codeine $0(3) NM; * HISTEX-AC $0(3) NM; * HISTEX-DM $0(3) NM; * HISTEX-PE $0(3) NM; * hm allergy complete-d $0(3) NM; * hm allergy relief & nasal $0(3) NM; * hm chest congestion relie $0(3) NM; *



Name of drug


you (tier

level)


or limits on use hm cold & allergy childre $0(3) NM; * hm cold & cough childrens $0(3) NM; * hm cold & sinus relief $0(3) NM; * hm cough dm $0(3) NM; * hm day time $0(3) NM; * hm mucus er $0(3) NM; * hm mucus relief d $0(3) NM; * hm nasal decongestant $0(3) NM; * hm nasal decongestant 12 $0(3) NM; * hm nasal decongestant pe $0(3) NM; * hm nasal spray $0(3) NM; * hm night time cold & flu $0(3) NM; * hm night time multi sympt $0(3) NM; * hm night time multi-sympt $0(3) NM; * hm nose drops extra stren $0(3) NM; * hm severe cold & flu $0(3) NM; * hm severe cold/cough/flu $0(3) NM; * hm sinus & cold-d $0(3) NM; * hm sinus nasal spray $0(3) NM; * hm tussin adult $0(3) NM; * hm tussin adult cough & c $0(3) NM; * hm tussin adult multi-sym $0(3) NM; * hm tussin cough/chest con $0(3) NM; * 12 hour decongestant $0(3) NM; * 12 hour nasal decongestan $0(3) NM; * 12 hour nasal spray $0(3) NM; * hydrocodone polistirex-chlorpheniramine polistirex

$0(3) NM; *

hydrocodone w/ homatropine $0(3) NM; * hydromet $0(3) NM; * kidkare cough/cold $0(3) NM; * kls aller-tec d $0(3) NM; * kls allerclear d-24hr $0(3) NM; * kp pseudoephedrine hcl $0(3) NM; *


Name of drug


you (tier

level)


or limits on use LODRANE D $0(3) NM; * LOHIST-D $0(3) NM; * LOHIST-DM $0(3) NM; * loratadine-d 12hr $0(3) NM; * loratadine-d 24hr $0(3) NM; * LORTUSS DM $0(3) NM; * LORTUSS EX $0(3) NM; * LORTUSS LQ $0(3) NM; * M-CLEAR WC $0(3) NM; * M-END DMX $0(3) NM; * M-END PE $0(3) NM; * mapap cold formula multi- $0(3) NM; * mapap sinus maximum stren $0(3) NM; * MAR-COF BP $0(3) NM; * MAXI-TUSS CD $0(3) NM; * MAXI-TUSS DM $0(3) NM; * MAXICHLOR PEH DM $0(3) NM; * MAXIFED $0(3) NM; * medi-tussin dm $0(3) NM; * meijer nasal decongestant $0(3) NM; * mucinex chest congestion $0(3) NM; * mucinex cough childrens $0(3) NM; * MUCINEX COUGH FOR KIDS $0(3) NM; * MUCINEX D MAXIMUM STRENGT $0(3) NM; * mucinex fast-max cold & s $0(3) NM; * mucinex fast-max cold flu TABS $0(3) NM; * MUCINEX FAST-MAX COLD/FLU CAPS $0(3) NM; * mucinex fast-max congesti $0(3) NM; * mucinex fast-max day time $0(3) NM; * MUCINEX FAST-MAX DAY TIME $0(3) NM; * MUCINEX FAST-MAX DAY/NIGH $0(3) NM; * MUCINEX FAST-MAX DAY/NITE $0(3) NM; * mucinex fast-max dm max $0(3) NM; * mucinex fast-max night ti $0(3) NM; *



Name of drug


you (tier

level)


or limits on use mucinex fast-max severe c CAPS $0(3) NM; * mucinex fast-max severe c TABS $0(3) NM; * MUCINEX FAST-MAX SEVERE C TABS $0(3) NM; * MUCINEX FOR KIDS $0(3) NM; * mucinex multi-symptom col LIQD $0(3) NM; * MUCINEX MULTI-SYMPTOM COL MISC $0(3) NM; * MUCINEX SINUS-MAX DAY/NIG CPPK $0(3) NM; * mucinex sinus-max day/nig MISC $0(3) NM; * mucinex sinus-max full fo $0(3) NM; * mucinex sinus-max night t $0(3) NM; * mucinex sinus-max pressur $0(3) NM; * MUCINEX SINUS-MAX SEVERE CAPS $0(3) NM; * mucinex sinus-max severe LIQD; TABS $0(3) NM; * MUCINEX STUFFY NOSE & COL $0(3) NM; * mucosa $0(3) NM; * mucosa dm $0(3) NM; * mucus d $0(3) NM; * mucus relief $0(3) NM; * mucus relief chest conges $0(3) NM; * mucus relief childrens $0(3) NM; * mucus relief cold & sinus $0(3) NM; * mucus relief cold flu & s $0(3) NM; * mucus relief cough childr $0(3) NM; * mucus relief dm $0(3) NM; * mucus relief dm cough $0(3) NM; * mucus relief dm maximum s $0(3) NM; * mucus relief pe sinus con $0(3) NM; * mucus relief severe cold $0(3) NM; * mucus-dm maximum strength $0(3) NM; * mucusrelief sinus $0(3) NM; * multi symptom flu & sever $0(3) NM; * NASAL DECONGESTANT LIQD; SYRP $0(3) NM; * nasal decongestant TABS $0(3) NM; * nasal decongestant maximu $0(3) NM; *


Name of drug


you (tier

level)


or limits on use nasal decongestant pe $0(3) NM; * nasal decongestant pe max $0(3) NM; * nasal decongestant spray $0(3) NM; * nasal four $0(3) NM; * nasal relief $0(3) NM; * nasal spray 12 hour $0(3) NM; * nasal spray extra moistur $0(3) NM; * NASOPEN PE $0(3) NM; * night time multi-symptom $0(3) NM; * nighttime cold/flu relief $0(3) NM; * nighttime cold/flu/maximu $0(3) NM; * nighttime cough $0(3) NM; * nighttime severe cold & f $0(3) NM; * nighttime sinus congestio $0(3) NM; * NINJACOF $0(3) NM; * NINJACOF-A $0(3) NM; * NINJACOF-D $0(3) NM; * NINJACOF-XG $0(3) NM; * nite time multi-symptom c $0(3) NM; * NIVANEX DMX $0(3) NM; * no drip nasal spray $0(3) NM; * nohist-dm $0(3) NM; * nohist-lq $0(3) NM; * NOREL AD $0(3) NM; * pedia relief cough/cold $0(3) NM; * pediatric cough/cold $0(3) NM; * PHENYLEPHRINE HCL/PYRILAM $0(3) NM; * phenylephrine w/ dm-gg $0(3) NM; * POLY HIST FORTE $0(3) NM; * POLY-HIST DM $0(3) NM; * POLY-HIST PD $0(3) NM; * POLY-TUSSIN AC $0(3) NM; * POLY-VENT DM $0(3) NM; * POLY-VENT IR $0(3) NM; *



Name of drug


you (tier

level)


or limits on use POLYTUSSIN DM $0(3) NM; * PRIMATENE MIST $0(3) NM; * PRO-RED AC $0(3) NM; * promethazine w/codeine $0(3) NM; * promethazine-dm $0(3) NM; * promethazine-phenylephrine-codeine $0(3) NM; * pseudoephed-bromphen-dm $0(3) NM; * pseudoephed-cpm w/ hydrocod $0(3) NM; * pseudoephedrine hcl TABS; TB12 $0(3) NM; * pseudoephedrine-guaifenesin $0(3) NM; * pulmosal $0(3) NM; * px allergy relief d $0(3) NM; * px nasal decongestant $0(3) NM; * qc allergy relief multi-s $0(3) NM; * qc allergy/sinus headache $0(3) NM; * qc cough/sore throat nigh $0(3) NM; * qc ibuprofen cold/sinus $0(3) NM; * qc loratadine-d $0(3) NM; * qc medifin 400 $0(3) NM; * qc medifin dm $0(3) NM; * qc sinus pain relief $0(3) NM; * qc suphedrine maximum str $0(3) NM; * qc tussin cf $0(3) NM; * qc tussin dm cough & ches $0(3) NM; * qc tussin mucus + chest c $0(3) NM; * ra cough dm $0(3) NM; * RESCON $0(3) NM; * RESCON DM $0(3) NM; * RESPAIRE-30 $0(3) NM; * robafen $0(3) NM; * robafen ac $0(3) NM; * robafen cf multi-symptom $0(3) NM; * robafen cough $0(3) NM; * robafen dm $0(3) NM; *


Name of drug


you (tier

level)


or limits on use robafen dm cough $0(3) NM; * robafen dm cough clear $0(3) NM; * robafen dm cough/chest co $0(3) NM; * robafen mucus/chest conge $0(3) NM; * RONDEC-D $0(3) NM; * RU-HIST D $0(3) NM; * RYDEX $0(3) NM; * RYMED $0(3) NM; * rynex dm $0(3) NM; * rynex pe $0(3) NM; * rynex pse $0(3) NM; * sb 12hr nasal spray $0(3) NM; * sb allerfed cold & allerg $0(3) NM; * sb allergy & cold pe $0(3) NM; * sb allergy relief/nasal d $0(3) NM; * sb cold & cough hbp $0(3) NM; * sb cold & flu severe $0(3) NM; * sb cold multi-symptom sev $0(3) NM; * sb cough control $0(3) NM; * sb cough control dm $0(3) NM; * sb cough control dm max $0(3) NM; * sb coughtab $0(3) NM; * sb mucus relief dm $0(3) NM; * sb mucus relief pe $0(3) NM; * sb severe cold pe $0(3) NM; * sb sinus & allergy maximu $0(3) NM; * sb sinus congestion & pai $0(3) NM; * sb tab tussin dm $0(3) NM; * silphen dm cough $0(3) NM; * siltussin das $0(3) NM; * siltussin dm das $0(3) NM; * siltussin sa $0(3) NM; * siltussin-dm $0(3) NM; * sinus and headache daytim $0(3) NM; *



Name of drug


you (tier

level)


or limits on use sinus congestion & pain d $0(3) NM; * sinus congestion & pain s $0(3) NM; * sinus nasal spray $0(3) NM; * sinus pressure/pain/adult $0(3) NM; * sinus relief extra streng $0(3) NM; * sm 12 hour sinus deconges $0(3) NM; * sm all day allergy-d $0(3) NM; * sm chest congestion relie $0(3) NM; * sm cold & allergy childre $0(3) NM; * sm cold & allergy pe $0(3) NM; * sm cold & cough dm childr $0(3) NM; * sm cold & flu severe $0(3) NM; * sm day time cold & flu re $0(3) NM; * sm day time pe cold & flu $0(3) NM; * sm lorata-dine d $0(3) NM; * sm loratadine d 12hr $0(3) NM; * sm mucus relief cough chi $0(3) NM; * sm nasal decongestant max $0(3) NM; * sm nasal decongestant pe $0(3) NM; * sm nasal spray $0(3) NM; * sm nasal spray 12 hour $0(3) NM; * sm nasal spray moisturizi $0(3) NM; * sm nasal spray sinus $0(3) NM; * sm night time liquid caps $0(3) NM; * sm nite time cold & flu $0(3) NM; * sm nose drops nasal decon $0(3) NM; * sm sinus & cold-d $0(3) NM; * sm tussin cf $0(3) NM; * sm tussin dm $0(3) NM; * sm tussin dm cough/chest $0(3) NM; * sm tussin mucus + chest c $0(3) NM; * sodium chloride (inhalant) $0(3) NM; * soothing - 12 hour nasal $0(3) NM; * STAHIST $0(3) NM; *


Name of drug


you (tier

level)


or limits on use STAHIST AD $0(3) NM; * sudafed 12 hour $0(3) NM; * sudogest $0(3) NM; * sudogest 12 hour $0(3) NM; * sudogest pe $0(3) NM; * sudogest sinus & allergy $0(3) NM; * tgt allergy & congestion $0(3) NM; * tgt allergy+ congestion r $0(3) NM; * tgt sinus 12 hour $0(3) NM; * theraflu expressmax sever $0(3) NM; * THERAFLU FLU & SORE THROA $0(3) NM; * triacting nightime cold& $0(3) NM; * TRIAMINIC COLD & ALLERGY $0(3) NM; * TRIAMINIC COLD & COUGH DA $0(3) NM; * triaminic fever & cold mu $0(3) NM; * TRIAMINIC NIGHT TIME COLD $0(3) NM; * trymine cg $0(3) NM; * TUSNEL $0(3) NM; * TUSNEL C $0(3) NM; * tusnel diabetic $0(3) NM; * TUSNEL PEDIATRIC $0(3) NM; * TUSNEL-DM PEDIATRIC $0(3) NM; * TUSSICAPS $0(3) NM; * tussin cf $0(3) NM; * tussin cf cough & cold $0(3) NM; * tussin cf max multi-sympt $0(3) NM; * tussin cf severe multi-sy $0(3) NM; * tussin cough $0(3) NM; * tussin dm $0(3) NM; * tussin dm cough + chest c $0(3) NM; * tussin dm max $0(3) NM; * tussin dm max adult $0(3) NM; * tussin mucus & chest cong $0(3) NM; * tussin mucus + chest cong $0(3) NM; *



Name of drug


you (tier

level)


or limits on use tussin multi-symptom cold $0(3) NM; * v-r pedia relief $0(3) NM; * VANACOF $0(3) NM; * VANACOF AC $0(3) NM; * VANACOF-8 $0(3) NM; * VANATAB AC $0(3) NM; * VANATAB DM $0(3) NM; * virtussin a/c $0(3) NM; * 4-way fast acting $0(3) NM; * Z-TUSS AC $0(3) NM; *

LEUKOTRIENE MODULATORS montelukast sodium CHEW; PACK; TABS $0(1) zafirlukast $0(1)

MAST CELL STABILIZERS - DRUGS TO TREAT ALLERGIES cromolyn sodium nebu $0(1) B/D

MISCELLANEOUS acetylcysteine SOLN 10%, 20% $0(1) B/D afrin saline nasal mist $0(3) NM; * altamist $0(3) NM; * ARALAST NP $0(2) NM, LA, PA ayr $0(3) NM; * AYR NASAL DROPS $0(3) NM; * AYR NASAL MIST ALLERGY & $0(3) NM; * ayr saline nasal $0(3) NM; * ayr saline nasal no-drip $0(3) NM; * baby ayr saline $0(3) NM; * CVS NASAL MIST .9% $0(3) NM; * cvs saline nasal spray $0(3) NM; * cvs saline nose spray $0(3) NM; * DALIRESP $0(2) deep sea nasal spray $0(3) NM; * epinephrine (anaphylaxis) .15mg/0.3ml, .3mg/0.3ml

$0(1) (generic of EpiPen)

epinephrine (anaphylaxis) .15mg/0.15ml, .3mg/0.3ml

$0(1) (generic of Adrenaclick)


Name of drug


you (tier

level)


or limits on use eq saline nasal spray $0(3) NM; * eql saline nasal spray $0(3) NM; * ESBRIET $0(2) NM, PA gnp nasal moisturizing $0(3) NM; * hm saline nasal spray $0(3) NM; * KALYDECO $0(2) NM, PA little noses saline $0(3) NM; * little noses stuffy nose $0(3) NM; * LITTLE REMEDIES BABY STER $0(3) NM; * meijer saline nasal spray $0(3) NM; * NASADROPS SALINE ON THE G $0(3) NM; * nasal moist $0(3) NM; * nasal moisturizing spray $0(3) NM; * nasogel $0(3) NM; * NUCALA $0(2) NM, LA, PA ocean for kids $0(3) NM; * OFEV $0(2) NM, PA ORKAMBI $0(2) NM, PA PROLASTIN-C $0(2) NM, LA, PA PULMOZYME $0(2) NM, PA px saline nasal spray $0(3) NM; * ra saline nasal spray $0(3) NM; * RA STERILE SALINE NASAL M $0(3) NM; * RHINARIS $0(3) NM; * saline GEL $0(3) NM; * saline SOLN .65% $0(3) NM; * saline mist $0(3) NM; * sb saline nose $0(3) NM; * SIMPLY SALINE $0(3) NM; * SINUS WASH SALT $0(3) NM; * sm nasal spray saline $0(3) NM; * SYMDEKO $0(2) NM, LA, PA SYMJEPI $0(2) tgt nasal spray $0(3) NM; *



Name of drug


you (tier

level)


or limits on use tgt saline nasal spray $0(3) NM; * THEO-24 $0(2) theophylline $0(1) theophylline tab er 12hr 300 mg $0(1) theophylline tab er 12hr 450 mg $0(1) theophylline tab sr 24hr $0(1) XOLAIR $0(2) NM, LA, PA ZEMAIRA $0(2) NM, LA, PA

NASAL STEROIDS - DRUGS TO TREAT ALLERGIES allergy relief SUSP $0(3) NM; * budesonide (nasal) $0(3) NM; * flunisolide (nasal) $0(1) QL (3 bottles / 30 days) fluticasone propionate (nasal) 50mcg/act $0(1) QL (1 bottle / 30 days) fluticasone propionate (nasal) 50mcg/act $0(3) NM; * gnp 24 hour nasal allerg $0(3) NM; * gnp budesonide nasal spra $0(3) NM; * gnp fluticasone propionat $0(3) NM; * goodsense nasal allergy s $0(3) NM; * hm allergy relief nasal s $0(3) NM; * nasal allergy 24 hour mul $0(3) NM; * qc fluticasone propionate $0(3) NM; * sm allergy relief nasal s $0(3) NM; * triamcinolone acetonide (nasal) $0(3) NM; *

STEROID INHALANTS - DRUGS TO TREAT ASTHMA ARNUITY ELLIPTA $0(2) QL (30 inhalations / 30 days) budesonide (inhalation) .25mg/2ml, .5mg/2ml $0(1) B/D FLOVENT DISKUS 50mcg/blist, 100mcg/blist $0(2) QL (120 inhalations / 30 days) FLOVENT DISKUS 250mcg/blist $0(2) QL (240 inhalations / 30 days) FLOVENT HFA $0(2) QL (2 inhalers / 30 days) PULMICORT FLEXHALER $0(2) QL (2 inhalers / 30 days)

STEROID/BETA-AGONIST COMBINATIONS - DRUGS TO TREAT ASTHMA AND COPD ADVAIR DISKUS $0(2) QL (60 inhalations / 30 days) ADVAIR HFA $0(2) QL (1 inhaler / 30 days) BREO ELLIPTA $0(2) QL (60 blisters / 30 days)


Name of drug


you (tier

level)


or limits on use SYMBICORT $0(2) QL (1 inhaler / 30 days)

TOPICAL - DRUGS TO TREAT EAR AND SKIN CONDITIONS DERMATOLOGY, ACNE

acne medication 5 GEL $0(3) NM; * ACNE MEDICATION 5 LOTN $0(3) NM; * acne medication 10 GEL $0(3) NM; * ACNE MEDICATION 10 LOTN $0(3) NM; * acne treatment cleansing $0(3) NM; * acne-clear $0(3) NM; * ACNEFREE SEVERE 24 HOUR C $0(3) NM; * amnesteem $0(1) PA avita $0(1) QL (45 grams / 30 days), PA benzepro FOAM 5.3% $0(3) NM; * benzepro short contact $0(3) NM; * benzoyl peroxide FOAM $0(3) NM; * BENZOYL PEROXIDE GEL 2.5% $0(3) NM; * benzoyl peroxide GEL 5%, 10% $0(3) NM; * benzoyl peroxide cleanser LIQD 6% $0(3) NM; * BENZOYL PEROXIDE CLEANSER LIQD 6% $0(3) NM; * BENZOYL PEROXIDE CLEANSER LOTN $0(3) NM; * benzoyl peroxide wash $0(3) NM; * benzoyl peroxide-erythromycin $0(1) bp gel $0(3) NM; * bp wash 2.5%, 5%, 10% $0(3) NM; * BPO $0(3) NM; * bpo foaming cloths $0(3) NM; * claravis $0(1) PA clindamycin phosphate (topical) GEL $0(1) QL (75 grams / 30 days) clindamycin phosphate (topical) LOTN $0(1) clindamycin phosphate (topical) SOLN $0(1) QL (60 mL / 30 days) ery pad 2% $0(1) erythromycin (acne aid) $0(1) isotretinoin CAPS $0(1) PA kp benzoyl peroxide $0(3) NM; *



Name of drug


you (tier

level)


or limits on use kp benzoyl peroxide wash $0(3) NM; * myorisan $0(1) PA panoxyl wash $0(3) NM; * sulfacetamide sodium (acne) $0(1) tretinoin CREA $0(1) QL (45 grams / 30 days), PA tretinoin GEL .01%, .025% $0(1) QL (45 grams / 30 days), PA zenatane $0(1) PA

DERMATOLOGY, ANTIBIOTICS bacitracin (topical) $0(3) NM; * bacitracin zinc OINT $0(3) NM; * blis-to-sol LIQD $0(3) NM; * curad triple antibiotic $0(3) NM; * double antibiotic $0(3) NM; * gentamicin sulfate (topical) $0(1) gnp bacitracin zinc $0(3) NM; * gnp triple antibiotic $0(3) NM; * gnp triple antibiotic plu $0(3) NM; * hm bacitracin $0(3) NM; * hm double antibiotic $0(3) NM; * hm triple antibiotic $0(3) NM; * hm triple antibiotic plus $0(3) NM; * kp bacitracin zinc $0(3) NM; * kp double antibiotic $0(3) NM; * medi-first triple antibio $0(3) NM; * mupirocin OINT $0(1) QL (220 grams / 30 days) px triple ointment $0(3) NM; * qc bacitracin $0(3) NM; * sb triple antibiotic $0(3) NM; * silver sulfadiazine CREA $0(1) sm antibiotic $0(3) NM; * sm antibiotic plus pain r $0(3) NM; * sm double antibiotic $0(3) NM; * sm triple antibiotic $0(3) NM; * sm triple antibiotic orig $0(3) NM; *


Name of drug


you (tier

level)


or limits on use sm triple antibiotic plus $0(3) NM; * ssd $0(1) SULFAMYLON CREA $0(2) tgt first aid antibiotic $0(3) NM; * tri-biozene $0(3) NM; * triple antibiotic $0(3) NM; * triple antibiotic first a $0(3) NM; * triple antibiotic plus $0(3) NM; *

DERMATOLOGY, ANTIFUNGALS ALEVAZOL $0(3) NM; * anti-fungal $0(3) NM; * anti-fungal powder $0(3) NM; * anti-itch CREA $0(3) NM; * anti-itch maximum strengt SOLN $0(3) NM; * antifungal $0(3) NM; * antifungal powder $0(3) NM; * athletes foot af cream $0(3) NM; * athletes foot powder spra $0(3) NM; * athletes foot spray $0(3) NM; * AZOLEN TINCTURE $0(3) NM; * banophen CREA $0(3) NM; * baza antifungal $0(3) NM; * benzoin compound $0(3) NM; * BENZOIN TINCTURE $0(3) NM; * BENZOIN TINCTURE PLAIN $0(3) NM; * carrington antifungal $0(3) NM; * castellani paint $0(3) NM; * ciclopirox CREA $0(1) QL (90 grams / 30 days) ciclopirox SUSP $0(1) QL (60 mL / 30 days) clotrimazole (topical) CREA 1% $0(1) clotrimazole (topical) CREA 1% $0(3) NM; * clotrimazole (topical) SOLN 1% $0(1) QL (30 mL / 30 days) clotrimazole (topical) SOLN 1% $0(3) NM; * clotrimazole anti-fungal $0(3) NM; *



Name of drug


you (tier

level)


or limits on use clotrimazole antifungal $0(3) NM; * clotrimazole grx $0(3) NM; * clotrimazole w/ betamethasone CREA $0(1) critic-aid clear af $0(3) NM; * cvs jock itch $0(3) NM; * dermafungal $0(3) NM; * desenex shake powder $0(3) NM; * diphenhydramine-zinc acetate $0(3) NM; * FUNGOID TINCTURE $0(3) NM; * fungoid-d $0(3) NM; * gnp anti-itch CREA $0(3) NM; * gnp athletes foot $0(3) NM; * gnp itch relief extra str $0(3) NM; * gnp miconazole nitrate $0(3) NM; * gnp miconazorb af $0(3) NM; * gnp terbinafine hydrochlo $0(3) NM; * gnp tolnaftate $0(3) NM; * itch relief extra strengt $0(3) NM; * jock itch spray $0(3) NM; * ketoconazole cream $0(1) QL (60 grams / 30 days) kp clotrimazole $0(3) NM; * kp miconazole nitrate $0(3) NM; * kp tolnaftate $0(3) NM; * miconazole antifungal $0(3) NM; * miconazole nitrate (topical) $0(3) NM; * micro guard $0(3) NM; * nyamyc $0(1) QL (60 grams / 30 days) nystatin (topical) $0(1) nystatin pow 100000 $0(1) QL (60 grams / 30 days) nystop $0(1) QL (60 grams / 30 days) podactin powder $0(3) NM; * px athletic foot $0(3) NM; * qc anti-itch extra streng $0(3) NM; * qc tolnaftate $0(3) NM; *


Name of drug


you (tier

level)


or limits on use remedy antifungal $0(3) NM; * remedy antifungal clear/p $0(3) NM; * remedy phytoplex antifung $0(3) NM; * sb anti-fungal $0(3) NM; * sm allergy maximum streng $0(3) NM; * sm anti-itch extra streng $0(3) NM; * sm antifungal clotrimazol $0(3) NM; * sm antifungal miconazole $0(3) NM; * sm antifungal tolnaftate $0(3) NM; * sm athletes foot $0(3) NM; * SM BENZOIN TINCTURE $0(3) NM; * soothe & cool inzo antifu $0(3) NM; * terbinafine hcl (topical) $0(3) NM; * tgt antifungal $0(3) NM; * tgt antifungal spray powd $0(3) NM; * tgt clotrimazole $0(3) NM; * tgt itch relief extra str $0(3) NM; * tolnaftate $0(3) NM; * triple paste af $0(3) NM; * zeasorb-af $0(3) NM; *

DERMATOLOGY, ANTIPSORIATICS acitretin $0(1) PA calcipotriene CREA; OINT $0(1) QL (120 grams / 30 days), PA calcipotriene SOLN $0(1) QL (120 mL / 30 days), PA calcitrene $0(1) QL (120 grams / 30 days), PA tazarotene CREA $0(1) QL (60 grams / 30 days), PA TAZORAC CREA .05% $0(2) QL (60 grams / 30 days), PA

DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo $0(1) selenium sulfide LOTN $0(1)

DERMATOLOGY, CORTICOSTEROIDS ala-cort $0(1) alclometasone dipropionate $0(1) anti-itch maximum strengt CREA $0(3) NM; *



Name of drug


you (tier

level)


or limits on use aquanil hc $0(3) NM; * betamethasone dipropionate (topical) $0(1) betamethasone dipropionate augmented $0(1) betamethasone valerate CREA; LOTN; OINT $0(1) curad hydrocortisone $0(3) NM; * cvs anti-itch maximum str $0(3) NM; * cvs cortisone maximum str CREA $0(3) NM; * dermarest eczema $0(3) NM; * ENSTILAR $0(2) QL (120 grams / 30 days), PA eql anti-itch maximum str $0(3) NM; * fluocinolone acetonide CREA; OIL; OINT $0(1) fluocinolone acetonide SOLN $0(1) QL (90 mL / 30 days) fluocinolone acetonide oil body $0(1) fluocinonide CREA .05% $0(1) QL (120 grams / 30 days) fluocinonide GEL $0(1) QL (60 grams / 30 days) fluocinonide OINT $0(1) QL (60 grams / 30 days) fluocinonide SOLN $0(1) QL (60 mL / 30 days) fluocinonide emulsified base $0(1) QL (120 grams / 30 days) fluticasone propionate CREA; OINT $0(1) gnp hydrocortisone $0(3) NM; * gnp hydrocortisone maximu $0(3) NM; * gnp hydrocortisone plus $0(3) NM; * gnp hydrocortisone/aloe $0(3) NM; * halobetasol propionate CREA; OINT $0(1) QL (50 grams / 30 days) hm hydrocortisone plus $0(3) NM; * hm hydrocortisone/aloe ma $0(3) NM; * hydrocortisone (topical) $0(3) NM; * hydrocortisone (topical) cream 1% $0(1) hydrocortisone (topical) cream 2.5% $0(1) hydrocortisone (topical) lotion 2.5% $0(1) hydrocortisone (topical) oint 2.5% $0(1) hydrocortisone butyrate cream 0.1% $0(1) QL (45 grams / 30 days) hydrocortisone butyrate oint 0.1% $0(1) QL (45 grams / 30 days) hydrocortisone maximum st $0(3) NM; *


Name of drug


you (tier

level)


or limits on use hydrocortisone-aloe vera $0(3) NM; * kp hydrocortisone $0(3) NM; * kp hydrocortisone maximum $0(3) NM; * kp hydrocortisone/aloe $0(3) NM; * mometasone furoate CREA; OINT; SOLN $0(1) noble formula hc $0(3) NM; * preparation h CREA $0(3) NM; * px hydrocream $0(3) NM; * sb hydrocortisone $0(3) NM; * sb hydrocortisone maximum $0(3) NM; * sb hydrocortisone plus $0(3) NM; * scalpicin maximum strengt $0(3) NM; * sm hydrocortisone $0(3) NM; * sm hydrocortisone maximum $0(3) NM; * sm hydrocortisone plus $0(3) NM; * sm hydrocortisone/aloe ma $0(3) NM; * TEXACORT SOLN 2.5% $0(2) triamcinolone acetonide (topical) CREA .1% $0(1) QL (454 grams / 30 days) triamcinolone acetonide (topical) CREA .025%, .5%

$0(1)

triamcinolone acetonide (topical) LOTN $0(1) triamcinolone acetonide (topical) OINT $0(1)

DERMATOLOGY, LOCAL ANESTHETICS glydo $0(1) QL (30 mL / 30 days), PA lidocaine PTCH $0(1) QL (3 patches / 1 day), PA lidocaine hcl GEL $0(1) QL (30 mL / 30 days), PA lidocaine hcl SOLN 4% $0(1) QL (50 mL / 30 days), PA lidocaine oint 5% $0(1) QL (50 grams / 30 days), PA lidocaine-prilocaine $0(1) QL (30 grams / 30 days), PA

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE ABSORBASE $0(3) NM; * ALBOLENE $0(3) NM; * ALOE VESTA PROTECTIVE $0(3) NM; * americerin $0(3) NM; *



Name of drug


you (tier

level)


or limits on use AMERIDERM PERISHIELD $0(3) NM; * ameriphor $0(3) NM; * amlactin $0(3) NM; * ammonium lactate CREA; LOTN $0(1) anti-dandruff shampoo $0(3) NM; * aplicare povidone-iodine $0(3) NM; * aplicare povidone/iodine SOLN $0(3) NM; * AQUA GLYCOLIC FACE CREAM $0(3) NM; * AQUAPHILIC $0(3) NM; * AQUAPHOR $0(3) NM; * AQUAPHOR ADVANCED THERAPY $0(3) NM; * ARTHRITIS PAIN RELIEVING $0(3) NM; * BASLE $0(3) NM; * baza protect $0(3) NM; * BETA CARE CREA $0(3) NM; * BETA XMA $0(3) NM; * BETADINE 5% $0(3) NM; * BULL FROG MOSQUITO COAST $0(3) NM; * CALAZIME SKIN PROTECTANT/ $0(3) NM; * capsaicin CREA $0(3) NM; * CARRINGTON MOISTURE BARRI $0(3) NM; * CERAVE CREA; LOTN $0(3) NM; * CERAVE PM $0(3) NM; * CETAPHIL DAILY ADVANCE UL $0(3) NM; * CETAPHIL MOISTURIZING $0(3) NM; * CETAPHIL THERAPEUTIC HAND $0(3) NM; * clorox nasal antiseptic s $0(3) NM; * COCONUT OIL BEAUTY $0(3) NM; * COLEMAN 100 MAX INSECT RE $0(3) NM; * COLEMAN BOTANICALS INSECT $0(3) NM; * COLEMAN INSECT REPELLENT/ $0(3) NM; * COLEMAN SKINSMART INSECT $0(3) NM; * corn and callus remover $0(3) NM; * CRITIC-AID CLEAR MOISTURE $0(3) NM; *


Name of drug


you (tier

level)


or limits on use CRITIC-AID THICK MOISTURE $0(3) NM; * CUTTER $0(3) NM; * CUTTER ALL FAMILY $0(3) NM; * CUTTER ALL FAMILY MOSQUIT $0(3) NM; * CUTTER BACKWOODS $0(3) NM; * CUTTER BACKWOODS DRY $0(3) NM; * CUTTER DRY $0(3) NM; * CUTTER LEMON EUCALYPTUS $0(3) NM; * CUTTER NATURAL $0(3) NM; * CUTTER SKINSATIONS $0(3) NM; * CUTTER SPORT $0(3) NM; * cvs advanced healing oint $0(3) NM; * CVS INSECT REPELLENT $0(3) NM; * cvs moisturizing cream $0(3) NM; * cvs moisturizing extra dr $0(3) NM; * CVS TOTAL HOME INSECT REP $0(3) NM; * DAILY CONDITIONING TREATM $0(3) NM; * DERMABASE OIL IN WATER $0(3) NM; * dermacerin $0(3) NM; * dermafix OINT $0(3) NM; * dermamed $0(3) NM; * dermaphor $0(3) NM; * dermavantage $0(3) NM; * DHS ZINC $0(3) NM; * DIABETIDERM CREA $0(3) NM; * DIABETIDERM FOOT REJUVENA $0(3) NM; * diclofenac sodium (topical) 1% gel $0(1) QL (1000 grams / 30 days), PA DML FORTE $0(3) NM; * DROXY CREAM $0(3) NM; * dry skin treatment $0(3) NM; * e-ointment $0(3) NM; * EAGLE WATCH MOSQUITO ELIM $0(3) NM; * EMOLLIA-CREME $0(3) NM; * EUCERIN INTENSIVE REPAIR CREA $0(3) NM; *



Name of drug


you (tier

level)


or limits on use EUCERIN PLUS CREA $0(3) NM; * flanders buttocks $0(3) NM; * fluorouracil (topical) CREA 5% $0(1) QL (40 grams / 30 days) fluorouracil (topical) SOLN $0(1) QL (10 mL / 30 days) GENTLE $0(3) NM; * geri-hydrolac 12 $0(3) NM; * gnp aloe vera/lidocaine $0(3) QL (227 gm / 30 days), NM; * gnp capsaicin CREA $0(3) NM; * GNP CAPSAICIN LIQD $0(3) NM; * gnp lidocaine pain relief $0(3) QL (30 patches / 30 days), NM; * gnp povidone-iodine $0(3) NM; * gnp scalp relief $0(3) NM; * gnp wart remover $0(3) NM; * GOLD BOND ULTIMATE HEALIN CREA; OINT $0(3) NM; * goodsense hemorrhoidal oi $0(3) NM; * hm povidone-iodine $0(3) NM; * HYDRASYN25 $0(3) NM; * HYDRO-LAN $0(3) NM; * HYDROCERIN CREA $0(3) NM; * hydrocerin LOTN $0(3) NM; * hydrocerin plus $0(3) NM; * hydrolatum $0(3) NM; * hydrophor $0(3) NM; * imiquimod CREA 5% $0(1) QL (24 packets / 30 days) KERADAN $0(3) NM; * kerodex-51 dry/oily $0(3) NM; * kerodex-71 wet $0(3) NM; * lac-hydrin five $0(3) NM; * lactic acid (ammonium lactate) $0(3) NM; * LACTINOL HX $0(3) NM; * LANAPHILIC $0(3) NM; * LANOLOR $0(3) NM; * LEADER FINGER CREAM $0(3) NM; * LEMON-GLYCERIN SWABSTICKS $0(3) NM; *


Name of drug


you (tier

level)


or limits on use lidocaine CREA 4% $0(3) QL (133 gm / 30 days), NM; * major-prep hemorrhoidal $0(3) NM; * MAXI DEET $0(3) NM; * MEDELA TENDER CARE LANOLI $0(3) NM; * medi pads $0(3) NM; * medicated callus removers $0(3) NM; * medicated corn removers $0(3) NM; * metronidazole (topical) CREA; LOTN $0(1) metronidazole gel 0.75% $0(1) minerin $0(3) NM; * moisturel therapeutic $0(3) NM; * moisturizing cream $0(3) NM; * MOISTURIZING CREAM $0(3) NM; * NATRAPEL $0(3) NM; * NATRAPEL 12-HOUR TICK & I $0(3) NM; * NEUTROGENA HAND $0(3) NM; * NIVEA CREA $0(3) NM; * NIVEA SOFT $0(3) NM; * noble formula LIQD $0(3) NM; * NUTRADERM CREA $0(3) NM; * OFF ACTIVE $0(3) NM; * OFF DEEP WOODS $0(3) NM; * OFF DEEP WOODS DRY $0(3) NM; * OFF DEEP WOODS SPORTSMEN $0(3) NM; * OFF DEEP WOODS TOWELETTES $0(3) NM; * OFF FAMILYCARE CLEAN FEEL $0(3) NM; * OFF FAMILYCARE SMOOTH & D $0(3) NM; * OFF FAMILYCARE TROPICAL F $0(3) NM; * OFF FAMILYCARE UNSCENTED $0(3) NM; * OFF SMOOTH & DRY $0(3) NM; * OINTMENT BASE $0(3) NM; * pain relieving maximum st $0(3) QL (133 gm / 30 days), NM; * PANRETIN $0(2) QL (60 grams / 30 days) PEN-KERA $0(3) NM; *



Name of drug


you (tier

level)


or limits on use PENTRAVAN $0(3) NM; * PENTRAVAN PLUS $0(3) NM; * periguard $0(3) NM; * PETROLATUM OINT $0(3) NM; * PICATO .05% $0(2) QL (2 tubes / 30 days) PICATO .015% $0(2) QL (3 tubes / 30 days) podofilox SOLN $0(1) povidone-iodine OINT $0(3) NM; * povidone-iodine SOLN $0(3) NM; * povidone-iodine SWAB 10% $0(3) NM; * PRETTY FEET & HANDS $0(3) NM; * procto-med hc $0(1) procto-pak $0(1) proctosol hc cre 2.5% $0(1) proctozone-hc $0(1) PROSHIELD PLUS SKIN PROTE $0(3) NM; * qc povidone iodine $0(3) NM; * RA ADVANCED HEALING OINT $0(3) NM; * RA GENTLE SKIN CREAM $0(3) NM; * ra hydrating healing $0(3) NM; * ra moisturizing therapy $0(3) NM; * ra renewal moisturizing $0(3) NM; * RECTIV $0(2) QL (30 grams / 30 days) REMEDY CLEAR-AID $0(3) NM; * REMEDY DIMETHICONE MOISTU $0(3) NM; * REMEDY NUTRASHIELD $0(3) NM; * REMEDY SKIN REPAIR $0(3) NM; * REPEL 100 $0(3) NM; * REPEL FAMILY $0(3) NM; * REPEL FAMILY DRY $0(3) NM; * REPEL HUNTERS FORMULA $0(3) NM; * REPEL LEMON EUCALYPTUS IN $0(3) NM; * REPEL MOSQUITO WIPES $0(3) NM; * REPEL SPORTSMEN $0(3) NM; *


Name of drug


you (tier

level)


or limits on use REPEL SPORTSMEN DRY $0(3) NM; * REPEL SPORTSMEN MAX $0(3) NM; * REPEL TICK DEFENSE $0(3) NM; * RISABAL-PH $0(3) NM; * rosadan $0(1) sal-plant $0(3) NM; * salactic film $0(3) NM; * saratoga $0(3) NM; * SAWYER INSECT REPELLENT $0(3) NM; * SAWYER INSECT REPELLENT C $0(3) NM; * SAWYER PREMIUM INSECT REP $0(3) NM; * sb povidone-iodine $0(3) NM; * sebex $0(3) NM; * SENSI-CARE MOISTURIZING $0(3) NM; * sm povidone-iodine $0(3) NM; * SOOTHE & COOL FREE MEDSEP $0(3) NM; * SOOTHE & COOL FREE MOISTU $0(3) NM; * SOOTHE & COOL PROTECT MOI $0(3) NM; * SOOTHE & COOL SKIN CREAM $0(3) NM; * SORBIDON HYDRATE $0(3) NM; * SORBOLENE $0(3) NM; * sore throat $0(3) NM; * STUDIO 35 MOISTURIZING SK $0(3) NM; * tacrolimus (topical) $0(1) QL (100 grams / 30 days) TARGRETIN GEL $0(2) QL (60 grams / 30 days), NM, PA thera-derm $0(3) NM; * THERAPEUTIC MOISTURIZING $0(3) NM; * ULTRATHON INSECT REPELLEN $0(3) NM; * VALCHLOR $0(2) QL (60 grams / 30 days), NM, LA,

PA VANICREAM CREA $0(3) NM; * VELVACHOL $0(3) NM; * wart remover maximum stre $0(3) NM; * ZIKS ARTHRITIS PAIN RELIE $0(3) NM; * zostrix high potency $0(3) NM; *



Name of drug


you (tier

level)


or limits on use zostrix high potency foot $0(3) NM; * ZOSTRIX NATURAL PAIN RELI $0(3) NM; *

DERMATOLOGY, SCABICIDES AND PEDICULIDES bedding spray lice treat $0(3) NM; * cvs lice killing $0(3) NM; * cvs lice solution kit $0(3) NM; * eq complete lice treatmen $0(3) NM; * eq lice killing maximum s $0(3) NM; * eql lice killing maximum $0(3) NM; * gnp lice bedding $0(3) NM; * gnp lice solution kit $0(3) NM; * gnp lice treatment $0(3) NM; * hm lice killing maximum s $0(3) NM; * hm lice treatment $0(3) NM; * lice killing maximum stre $0(3) NM; * lice killing shampoo $0(3) NM; * lice treatment $0(3) NM; * licide $0(3) NM; * malathion $0(1) permethrin cre 5% $0(1) ra lice maximum strength $0(3) NM; * ra lice solution kit $0(3) NM; * RID ESSENTIAL LICE ELIMIN $0(3) NM; * rid lice killing shampoo $0(3) NM; * sb lice killing maximum s $0(3) NM; * sb lice treatment $0(3) NM; * sm bedding lice treatment $0(3) NM; * sm lice killing $0(3) NM; * sm lice killing maximum s $0(3) NM; * sm lice solution kit $0(3) NM; * sm lice treatment $0(3) NM; * stop lice complete lice t $0(3) NM; * stop lice maximum strengt $0(3) NM; * VANALICE $0(3) NM; *


Name of drug


you (tier

level)


or limits on use DERMATOLOGY, WOUND CARE AGENTS

acetic acid .25% $0(1) REGRANEX $0(2) QL (30 grams / 30 days), PA SANTYL $0(2) sodium chlor sol 0.9% irr $0(1) water for irrigation, sterile $0(1)

MOUTH/THROAT/DENTAL AGENTS cevimeline hcl $0(1) chlorhexidine gluconate (mouth-throat) $0(1) clotrimazole LOZG $0(1) lidocaine hcl (mouth-throat) $0(1) nystatin (mouth-throat) $0(1) paroex sol 0.12% $0(1) periogard $0(1) PHOS FLUR $0(3) NM; * PHOS-FLUR ORTHO DEFENSE $0(3) NM; * pilocarpine hcl (oral) $0(1) triamcinolone acetonide (mouth) $0(1)

OTIC - DRUGS TO TREAT CONDITIONS OF THE EAR acetic acid (otic) $0(1) CIPRODEX $0(2) ear drops $0(3) NM; * ear drops earwax removal $0(3) NM; * ear wax removal drops $0(3) NM; * ear wax removal kit $0(3) NM; * earwax removal kit $0(3) NM; * flac $0(1) fluocinolone acetonide (otic) $0(1) gnp ear drops $0(3) NM; * gnp ear systems $0(3) NM; * hm earwax removal aid $0(3) NM; * hm earwax removal kit $0(3) NM; * murine ear $0(3) NM; * murine for ear wax remova $0(3) NM; *



Name of drug


you (tier

level)


or limits on use neomycin-polymyxin-hc (otic) $0(1) ofloxacin (otic) $0(1) sm ear drops $0(3) NM; *


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D. Index of Covered DrugsDrug Name Page #1

12 hour decongestant 14512 hour nasal decongestan 14512 hour nasal spray 145

2

24hr allergy relief 138

3

3 day vaginal 78

4

4-way fast acting 153

5

50+ adult eye health 99

8

8 hour arthritis pain rel 38hr muscle aches & pain 3

A

A-25 99abacavir sulfate 12abacavir sulfate-lamivudine 14abacavir sulfate-lamivudine-zidovudine 14abaneu-sl 99abatinex 61abc plus 99abc plus senior adults 50 99abdek 99ABDEK 99abdek pediatric 99ABELCET 12ABILIFY MAINTENA 37abiraterone acetate 21ABRAXANE 20ABSORBASE 162acamprosate calcium 43acarbose 46acebutolol hcl 28acephen 1acerola c-500 99ACEROLA C 500 99aceta-gesic 140

Drug Name Page #acetaminophen 1acetaminophen childrens 1acetaminophen congestion 140acetaminophen extra stren 1acetaminophen infants 1acetaminophen pm extra st 43acetaminophen w/ codeine 300-15mg 8acetaminophen w/ codeine 300-30mg 8acetaminophen w/ codeine 300-60mg 8acetaminophen w/ codeine soln 8acetazolamide 30acetic acid 170acetic acid (otic) 170acetylcysteine 153acid controller maximum s 65acid gone 58ACIDOPHILUS 61ACIDOPHILUS/BIFIDUS 62ACIDOPHILUS/CITRUS PECTIN 62acidophilus extra strengt 61acidophilus probiotic 61acidophilus probiotic for 62acid reducer 65, 76acid reducer maximum stre 65acitretin 160acne-clear 156ACNEFREE SEVERE 24 HOUR C 156acne medication 5 156ACNE MEDICATION 5 156acne medication 10 156ACNE MEDICATION 10 156acne treatment cleansing 156ACTHIB 84actical 99ACTIMMUNE 83acyclovir 15acyclovir sodium 15ADACEL 84adefovir dipivoxil 15ADEMPAS 31adriamycin 19adrucil inj 19adult aspirin regimen 1ADULT ONE DAILY GUMMIES 99ADVAIR DISKUS 155ADVAIR HFA 155

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Drug Name Page #advanced multi ea 99advanced stress formula/z 100advantage care oral elect 85advil junior strength 5AFINITOR 22AFINITOR DISPERZ 22afrin saline nasal mist 153aftera 49AIMOVIG 41airborne 100AIRBORNE 100airborne gummies 100akwa tears 133ala-cort 160ALAHIST CF 140ALAHIST DM 140ALA-HIST IR 136ALA-HIST PE 140alaway 132alaway childrens allergy 132albendazole 10ALBOLENE 162albuterol sulfate 139, 140alclometasone dipropionate 160ALDURAZYME 53ALECENSA 22alendronate sodium 48aler-cap 136ALEVAZOL 158alfuzosin hcl 77align jr for kids 62ALIMTA 19ALINIA 10aliskiren fumarate 30ALIVE ONCE DAILY WOMENS 5 100ALIVE PRENATAL MULTI-VITA 100ALIVE WOMENS ENERGY 100ALIVE WOMENS GUMMY VITAMI 100allbee plus vitamin c 100all day allergy 136all day allergy childrens 136all-day allergy childrens 136all day allergy d 140all day allergy-d 140all day allergy d-12 140all day pain relief 5all day relief 5

Drug Name Page #aller-chlor 136aller-ease 136allergy 136allergy 24-hr 136allergy childrens 136allergy d-12 140allergy multi-symptom 140allergy non-drowsy 136allergy relief 136, 155allergy relief 24hr 136allergy relief child 136allergy relief childrens 136allergy relief d 140allergy relief-d 140allergy relief d-24 140allergy relief/indoor/out 136allergy relief/nasal deco 140allergy tablets 136allergy-time 136all-nite cold & flu night 140allopurinol tab 1almacone 58almacone double strength 58ALOE VESTA PROTECTIVE 162alosetron hcl 74ALPHAGAN P SOL 0.1% 132ALPHA LIPOIC ACID 95ALPHA-LIPOIC ACID 95alpha-lipoic acid (thioctic acid) 95alph-e 100alph-e-mixed 100alph-e-mixed 1000 100alprazolam tab 0.5mg 32alprazolam tab 0.25mg 32alprazolam tab 1mg 32alprazolam tab 2mg 32ALREX 132altachlore 133altamist 153altavera tab 49ALUMINUM HYDROXIDE 58aluminum hydroxide gel 58ALUNBRIG 22alyacen 1/35 49amantadine hcl 36ambi 10peh/400gfn 140ambi 10peh/400gfn/20dm 140

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Drug Name Page #ambi 40pse/400gfn 140AMBISOME 12ambrisentan 31americerin 162AMERIDERM PERISHIELD 163ameriphor 163amethia 49amethia lo 49amikacin sulfate 10amiloride hcl 30amiloride & hydrochlorothiazide 30AMINOSYN II INJ 10% 87AMINOSYN-PF 7% 87AMINOSYN-PF INJ 10% 87amiodarone hcl soln 27amiodarone tab 100mg 27amiodarone tab 200mg 27amiodarone tab 400mg 27AMITIZA CAP 8MCG 74AMITIZA CAP 24MCG 74amitriptyline hcl 35amlactin 163amlodipine-benazepril hcl cap 2.5-10 mg 25amlodipine-benazepril hcl cap 5-10 mg 25amlodipine-benazepril hcl cap 5-20 mg 25amlodipine-benazepril hcl cap 5-40 mg 25amlodipine--benazepril hcl cap 10-20 mg 25amlodipine-benazepril hcl cap 10-40mg 25amlodipine besylate 29amlodipine besylate-olmesartan medoxomil 26amlodipine besylate-valsartan tab 5-160 mg 26amlodipine besylate-valsartan tab 5-320 mg 26amlodipine besylate-valsartan tab 10-160 mg 26amlodipine besylate-valsartan tab 10-320 mg 26amlodipine-valsartan-hydrochlorothiazide 5-160-

12.5mg 26amlodipine-valsartan-hydrochlorothiazide 5-160-

25mg 26amlodipine-valsartan-hydrochlorothiazide 10-

160-12.5mg 26amlodipine-valsartan-hydrochlorothiazide 10-

160-25mg 26amlodipine-valsartan-hydrochlorothiazide 10-

320-25mg 26ammonium lactate 163amnesteem 156amoxapine tab 25mg 35

Drug Name Page #amoxapine tab 50mg 35amoxapine tab 100mg 35amoxapine tab 150mg 35amoxicillin 17amoxicillin & pot clavulanate 200/5ml susr 17amoxicillin & pot clavulanate 200-28.5 chw tabs . 17amoxicillin & pot clavulanate 250/5ml susr 17amoxicillin & pot clavulanate 250-125 tabs 17amoxicillin & pot clavulanate 400/5ml susr 17amoxicillin & pot clavulanate 400-57 chw tabs 17amoxicillin & pot clavulanate 500-125 tabs 18amoxicillin & pot clavulanate 600/5ml susr 18amoxicillin & pot clavulanate 875-125 tabs 18amoxicillin & pot clavulanate er 12hr 1000-62.5

tabs 18amphetamine-dextroamphetamine cap sr 24hr

5 mg 40amphetamine-dextroamphetamine cap sr 24hr





30 mg 40amphetamine-dextroamphetamine tab 5 mg 40amphetamine-dextroamphetamine tab 7.5 mg 40amphetamine-dextroamphetamine tab 10 mg 40amphetamine-dextroamphetamine tab 12.5 mg 40amphetamine-dextroamphetamine tab 15 mg 40amphetamine-dextroamphetamine tab 20 mg 40amphetamine-dextroamphetamine tab 30 mg 40amphotericin b 12ampicillin cap 500mg 18ampicillin inj 18ampicillin sodium 18ampicillin & sulbactam sodium 18ANADROL-50 45anagrelide hcl 82anastrozole 21ANDRODERM 45animal chews 100animal shapes 100ANIMAL SHAPES/IRON 100ANORO ELLIPTA 135

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Drug Name Page #antacid 58antacid advanced 58antacid anti-gas maximum 58antacid anti-gas regular 58antacid calcium extra str 58antacid calcium regular s 58antacid extra strength 58antacid fast acting 58antacid fast relief 58antacid flavor chews 58antacid maximum 58antacid maximum strength 58antacid plus anti-gas fas 58antacid plus anti-gas rel 58antacid regular strength 58antacid/simethicone doubl 59ANTACID ULTRA STRENGTH 59anti-dandruff shampoo 163anti-diarrheal 62anti-fungal 158antifungal 158anti-fungal powder 158antifungal powder 158anti-gas/and gnp antacid 59anti-itch 158anti-itch maximum strengt 158, 160anti-oxidant 100antioxidant 100antioxidant formula 100antioxidant vitamins 100APETIGEN-PLUS 100aplicare povidone-iodine 163aplicare povidone/iodine 163APOKYN 37aprepitant 64aprepitant pak 80mg & 125mg 64apri 49aprodine 140APTIOM 32APTIVUS 12aquadeks 100AQUADEKS 100AQUA-E 100AQUA GLYCOLIC FACE CREAM 163AQUANAZ 140aquanil hc 161AQUAPHILIC 163

Drug Name Page #AQUAPHOR 163AQUAPHOR ADVANCED THERAPY 163aqueous vitamin d infants 100aqueous vitamin e 100ARALAST NP 153aranelle 49ARCALYST 83arginine 95ARGININE 95ARGININE2000 95aripiprazole odt 37aripiprazole oral solution 1 mg/ml 37aripiprazole tab 37ARISTADA 37ARISTADA INITIO 38armodafinil 43ARNUITY ELLIPTA 155arthritis pain relief 1arthritis pain reliever 1ARTHRITIS PAIN RELIEVING 163artificial tears 133ASCOR 100ascorbic acid 100ASCORBIC ACID 100asco-tabs-1000 100ashlyna 49aspirin 1ASPIRIN 1aspirin 81 1aspirin adult low dose 1aspirin adult low strengt 1aspirin childrens 1aspirin-dipyridamole 82aspirin ec low dose 1aspirin enteric coated ad 1aspirin low dose 1aspirin low strength 1aspir-low 1atazanavir sulfate 13atenolol 28atenolol & chlorthalidone 28athletes foot af cream 158athletes foot powder spra 158athletes foot spray 158a thru z advanced 99a thru z high potency 99a thru z select 99

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Drug Name Page #a thru z select 50+ advan 99a thru z select 50+ mens 99a thru z select advanced 99a thru z select ultimate 99a thru z ultimate mens 99atomoxetine hcl 40atorvastatin calcium 27atovaquone 10atovaquone-proguanil hcl 12ATRIPLA 14ATROPINE SULFATE 133ATROVENT HFA 136ATUSS DA 140aubra 49AURYXIA 57AUSTEDO 42AVASTIN 20aviane 49avita 156ayr 153AYR NASAL DROPS 153AYR NASAL MIST ALLERGY & 153ayr saline nasal 153ayr saline nasal no-drip 153azacitidine 19AZASITE 131azathioprine 84azelastine drop 0.05% 132azelastine spr 0.1% 136azelastine spr 0.15% 136azithromycin 17AZOLEN TINCTURE 158AZOPT 133aztreonam 10

B

b6 natural 100B-12 100B-12 DOTS 101B-12 DUAL SPECTRUM 101B-12 METHYLCOBALAMIN 101b-12 microlozenge 101B-12 SUPER STRENGTH 101b-12 tr 101baby ayr saline 153baby super daily d3 101baby vitamin d3 drops 101

Drug Name Page #bacitracin (ophthalmic) 131bacitracin-polymyxin b (ophth) 131bacitracin-poly-neomycin-hc 131bacitracin (topical) 157bacitracin zinc 157baclofen 42balanced b complex tr 101balsalazide disodium 66BALVERSA 22balziva 49banophen 136, 158BANZEL SUS 40MG/ML 32BANZEL TAB 200MG 32BANZEL TAB 400MG 32BARACLUDE 15BASAGLAR KWIKPEN 45BASLE 163bayer aspirin 1bayer aspirin ec low dose 1bayer low dose 1baza antifungal 158baza protect 163BCG VACCINE 84b-complex balanced 101B-COMPLEX/FOLIC ACID/VITA 101b complex w/ c 100b-complex w/ c & calcium 101b-complex w/ c & folic acid 101BD ALCOHOL SWABS 45BD GLUCOSE 55BD ULTRAFINE INSULIN SYRINGE 45BD ULTRAFINE/NANO PEN NEEDLES 45bec/zinc 101bedding spray lice treat 169bekyree 49benazepril hcl 25benazepril & hydrochlorothiazide 25BENDEKA 19BENLYSTA 84BENZEDREX INHALER 140benzepro 156benzepro short contact 156benzoin compound 158BENZOIN TINCTURE 158BENZOIN TINCTURE PLAIN 158benzonatate 141benzoyl peroxide 156

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Drug Name Page #BENZOYL PEROXIDE 156benzoyl peroxide cleanser 156BENZOYL PEROXIDE CLEANSER 156benzoyl peroxide-erythromycin 156benzoyl peroxide wash 156benztropine mesylate inj 37benztropine mesylate tab 0.5mg 37benztropine mesylate tab 1mg 37benztropine mesylate tab 2mg 37BEPREVE 132BERINERT 82berocca 101BESIVANCE 131BETA CARE 163BETADINE 163betamethasone dipropionate augmented 161betamethasone dipropionate (topical) 161betamethasone valerate 161BETASERON 42betatemp childrens 1BETA XMA 163betaxolol hcl 28betaxolol hcl (ophth) 133bethanechol chloride 77BETOPTIC-S 133better b complex 101BEVESPI AEROSPHERE 135bexarotene 24BEXSERO 84bicalutamide 21BICARSIM FORTE 74BICILLIN L-A 18BIKTARVY 14BIO-35 GLUTEN-FREE 101BIOCAL 101BIO-D-MULSION 101BIO-D-MULSION FORTE 101BIOSUPP 101BIOTECT PLUS 101biotin 101BIOTIN 101biotin 5000 101biotin/maximum strength 101biotin plus/calcium/vit d 101BIOVOL 101bisac-evac 66bisacodyl 66

Drug Name Page #bisacodyl ec 67bisacodyl laxative 67biscolax 67bismatrol 62bismatrol maximum strengt 62bismuth subsalicylate 62bisoprolol fumarate 28bisoprolol & hydrochlorothiazide 28BIVIGAM 83BLEPHAMIDE 131blisovi 24 fe 49blisovi fe 1.5/30 49blis-to-sol 157B-NATAL 101body/hair/skin/nails 101BOOSTRIX 84BORTEZOMIB 20bosentan 31BOSULIF 22bp gel 156BPO 156bpo foaming cloths 156bprotected multi-vite 101bprotected pedia d-vite 101bprotected pedia iron 79bprotected pedia poly-vit 102bprotected pedia tri-vite 102bp wash 156BRAFTOVI 22BRAINSTRONG PRENATAL 102BREO ELLIPTA 155briellyn 49BRILINTA 82brimonidine sol 0.2% 133brimonidine sol 0.15% 133BRIVIACT INJ 50MG/5ML 32BRIVIACT SOL 10MG/ML 32BRIVIACT TAB 10MG 32BRIVIACT TAB 25MG 32BRIVIACT TAB 50MG 32BRIVIACT TAB 75MG 32BRIVIACT TAB 100MG 32BROHIST D 141bromfed dm 141bromfenac sodium (ophth) 132bromocriptine mesylate 37BROMSITE 132

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Drug Name Page #BRONKAID 141BROTAPP DM 141budesonide ec 66budesonide (inhalation) 155budesonide (nasal) 155BULL FROG MOSQUITO COAST 163bumetanide 30buprenorphine hcl 43buprenorphine hcl-naloxone hcl dihydrate

2-0.5mg 43buprenorphine hcl-naloxone hcl dihydrate 4-1mg 43buprenorphine hcl-naloxone hcl dihydrate 8-2mg 43buprenorphine hcl-naloxone hcl dihydrate 12-

3mg 43buprenorphine hcl-naloxone hcl sl 43buprenorphine patch 8bupropion hcl 35bupropion hcl (smoking deterrent) 43buspirone hcl 32butorphanol tartrate 8BYDUREON BCISE 45BYDUREON PEN 45BYETTA 45BYSTOLIC 28

C

c 250 102c-250 102c 500 102c-500 102c-500 prolonged release 102c 500/rose hips 102c-500/rose hips 102c 1000 102c-1000 102c-1000 prolonged release 102c-1000/rose hips 102cabergoline 56CABOMETYX 22CALAZIME SKIN PROTECTANT/ 163cal-carb forte 89CALCI-CHEW 89calcidol 102calciferol 102CALCI-MIX 89calcipotriene 160calcitonin (salmon) 56

Drug Name Page #calcitrate 89CAL-CITRATE 102CAL-CITRATE PLUS VITAMIN 89calcitrene 160calcitriol 102calcitriol inj 102calcitriol oral soln 1 mcg/ml 102CALCIUM 89calcium 500 + d 89calcium 500 +d 89calcium 500/d 89calcium 500+d 89calcium 500 +d3 89calcium 500+d3 89calcium 500+d high potenc 89calcium 500/vitamin d 89calcium 600 89calcium 600 + d 89calcium 600-d 90calcium 600+d 90calcium 600+d3 90calcium 600+d3 plus miner 90calcium 600+d high potenc 90calcium 600+d plus minera 90calcium 600 high potency 89calcium 600/vitamin d 90calcium 600/vitamin d3 90calcium 600 with vitamin 90CALCIUM 1000 + D 90calcium 1200 90calcium acetate (phosphate binder) 57calcium antacid 59calcium antacid extra str 59calcium antacid ultra max 59calcium antacid ultra str 59calcium carbonate 59, 90CALCIUM CARBONATE 59, 90calcium carbonate (antacid) 59, 90calcium carbonate-cholecalciferol 90CALCIUM CARBONATE EXTRA L 90CALCIUM CARBONATE HEAVY 90calcium carbonate-vitamin d 90calcium carbonate-vitamin d w/ minerals 90calcium citrate 90CALCIUM CITRATE 90calcium citrate + d 90calcium citrate +d 90

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Drug Name Page #calcium citrate+ d 90calcium citrate+d 90calcium citrate + d3 90calcium citrate+d3 90calcium citrate + d3 max 90calcium citrate + d3 maxi 90calcium citrate+d3 petite 90calcium citrate-vitamin d 91CALCIUM CITRATE/VITAMIN D 91CALCIUM CITRATE W/D 90calcium creamies 91calcium+d3 91calcium extra d3 91calcium gummies 91calcium high potency 91calcium high potency + vi 91CALCIUM LACTATE 91CALCIUM PLUS D3 ABSORBABL 91CALCIUM PLUS VITAMIN D 91calcium plus vitamin d3 91calcium polycarbophil 67CALCIUM/VITAMIN D 91cal-gest antacid 59CAL-LAC 89callus remover

and corn 163CAL-MINT 89CALQUENCE 22CAL-QUICK 89caltrate 600 91CALTRATE 600+D3 SOFT CHEW 91CALTRATE MINIS PLUS MIN E 91camila 49camrese lo 49candesartan cilexetil 27candesartan cilexetil-hydrochlorothiazide 26CAPCOF 141CAPMIST DM 141CAPRELSA 22CAPRON DM 141CAPRON DMT 141capsaicin 163captopril 25captopril & hydrochlorothiazide 25CARBAGLU 53carbamazepine 32carbidopa-levodopa 37

Drug Name Page #carbidopa/levodopa/entacapone 37carboplatin 24carisoprodol 42carravite 102carrington antifungal 158CARRINGTON MOISTURE BARRI 163carteolol hcl (ophth) 133cartia xt cap 120/24hr 29cartia xt cap 180/24hr 29cartia xt cap 240/24hr 29cartia xt cap 300/24hr 29carvedilol 29caspofungin acetate 12castellani paint 158castor oil stimulant laxa 67CAYSTON 10caziant pak 49C-BUFF 102c-chewable 102cefaclor 16CEFACLOR MONOHYDRATE ER 16cefadroxil 16CEFAZOLIN IN DEXTROSE 2GM/100ML-4% 16cefazolin inj 16cefazolin sodium 16CEFAZOLIN SODIUM 1 GM/50ML 16cefdinir 16cefepime hcl 16cefixime 16cefoxitin sodium 16cefpodoxime proxetil 16cefprozil 16ceftazidime 16CEFTAZIDIME/DEXTROSE 16ceftriaxone sodium 16cefuroxime axetil 16cefuroxime sodium 16celecoxib 5CELONTIN 32centamin 102centavite 102centavite a-z complete mu 102centravites 102centravites 50 plus 102CENTRAVITES 50 PLUS 102CENTRAVITES ADULTS 102CENTRUM 102

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Drug Name Page #CENTRUM CARDIO 102CENTRUM FLAVOR BURST ADUL 102CENTRUM FLAVOR BURST KIDS 102centrum kids 103centrum kids complete 103CENTRUM MULTIGUMMIES ADUL 103CENTRUM SILVER 103CENTRUM SILVER ULTRA MENS 103CENTRUM SILVER ULTRA WOME 103CENTRUM SPECIALIST HEART 103CENTRUM SPECIALIST PRENAT 103CENTRUM SPECIALIST VISION 103CENTRUM ULTRA WOMENS 103century 103century mature 103cephalexin 16, 17CERALYTE 50 85CERALYTE 70 85CERALYTE 90 85CERASPORT 85CERASPORT EX1 86CERAVE 163CERAVE PM 163CERDELGA 53CEREZYME 53cerovite advanced formula 103cerovite jr 103cerovite senior 103certagen 103certa plus 103certa-vite 103certavite/antioxidants 103CERTAVITE SENIOR/ANTIOXID 103CETAPHIL DAILY ADVANCE UL 163CETAPHIL MOISTURIZING 163CETAPHIL THERAPEUTIC HAND 163cetirizine hcl 136cetirizine hcl allergy ch 136cetirizine hcl childrens 136cetirizine hcl hives reli 136cetirizine hydrochloride 136cetirizine-pseudoephedrine 141cetirizine syrup 137cevimeline hcl 170CHANTIX 43CHANTIX CONTINUING MONTH 43CHANTIX STARTER PACK 43

Drug Name Page #CHEMET 48cheratussin ac 141CHEW-12 103chewable acetaminophen ch 1CHEWABLE CALCIUM 91chewable vite childrens 103chewable vite with iron/c 103CHEW Q 96childrens acetaminophen 2childrens allergy 137childrens animal shapes c 103childrens apap 2childrens aspirin 2childrens aspirin low str 2childrens chewable multiv 103childrens chewable vitami 103childrens cold & allergy 141childrens gummies 103childrens ibuprofen 5childrens loratadine 137childrens mucus relief co 141childrens mucus relief ex 141childrens multivitamin 103childrens pain relief plu 141childrens pain reliever 2childrens silapap 2childrens silfedrine 141childrens tactinal 2CHLO HIST 141CHLORELLA 103chlorhexidine gluconate (mouth-throat) 170chlorhist 137chlorocaps 103chloroquine phosphate 12chlorothiazide tabs 30chlorpheniramine maleate 137chlorphen sr 137chlorpromazine hcl 38CHLORPROMAZINE INJ 38chlorthalidone 30CHLO TUSS 141chocolated laxative 67cholecalciferol 103cholestyramine 27cholestyramine light pack 28cholestyramine light powd 28ciclopirox 158

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Drug Name Page #cilostazol 82CILOXAN 131CIMDUO 14cinacalcet hcl 56CIPRODEX 170ciprofloxacin 17ciprofloxacin hcl (ophth) 131ciprofloxacin hcl tab 17ciprofloxacin in d5w 17cisplatin 24citalopram hydrobromide 35CITRACAL CALCIUM GUMMIES 91CITRACAL+D3 91citrus calcium +d 91claravis 156clarithromycin 17clarithromycin er 17clarithromycin for susp 17CLASSIC PRENATAL 103clearlax 67clindamycin cap 75mg 10clindamycin cap 300mg 10clindamycin hcl cap 150 mg 10clindamycin phosphate in d5w 10clindamycin phosphate inj 10CLINDAMYCIN PHOSPHATE IN NACL 10clindamycin phosphate (topical) 156clindamycin phosphate vaginal 78clindamycin soln 75mg/5ml 10CLINIMIX 4.25%/DEXTROSE 5% 87CLINIMIX 5%/DEXTROSE 15% 87CLINIMIX 5%/DEXTROSE 20% 87CLINIMIX INJ 4.25/D10 87CLINOLIPID 87clobazam 32clomipramine hcl 35clonazepam 32clonidine hcl 31clonidine hcl ptwk 31clopidogrel tab 75mg 82clorazepate dipotassium 33clorox nasal antiseptic s 163clotrimazole 170clotrimazole 3 78clotrimazole anti-fungal 158clotrimazole antifungal 159clotrimazole grx 159

Drug Name Page #clotrimazole (topical) 158clotrimazole vaginal 78clotrimazole w/ betamethasone 159clozapine odt 38clozapine tab 25mg 38clozapine tab 50mg 38clozapine tab 100mg 38clozapine tab 200mg 38COARTEM 12COCONUT OIL BEAUTY 163COENZYME Q10 96coenzyme q10 (ubidecarenone) 96CO-ENZYME Q10/VITAMIN E 96colace 2-in-1 67COLACE CLEAR 67colchicine w/ probenecid 1COLCRYS 1cold & allergy childrens 141cold/allergy childrens 141cold & cough childrens 141cold/cough childrens 141cold head congestion dayt 141cold head congestion seve 141cold relief/non-drowsy/da 141COLEMAN 100 MAX INSECT RE 163COLEMAN BOTANICALS INSECT 163COLEMAN INSECT REPELLENT/ 163COLEMAN SKINSMART INSECT 163colesevelam hcl 28colestipol hcl gran 28colestipol hcl pack 28colestipol hcl tabs 28colistimethate sodium 10colocort enema 100mg 66COMBIGAN 133COMBIVENT RESPIMAT 135COMETRIQ 22companion 103compete 103COMPLERA 14complete 104complete allergy medicine 137complete multivitamin/mul 104complete senior 104compro 64CONCEPTIONXR MOTILITY SUP 104CONEX COLD/ALLERGY 141

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Drug Name Page #constulose 67COPIKTRA 22co q10 maximum strength 96coq10 maximum strength 96COQ-10 TR 96CORLANOR 31corn

and callus remover 163COROMEGA OMEGA 3 KIDS 96COROMEGA OMEGA 3 SQUEEZE 96cortisone acetate 54CORVITE 104CORVITE 150 79CORVITE FE 79corvite free 104COTELLIC 22cough & chest congestion 141cough & cold 141cough & cold hbp 141cough dm 141cough dm childrens 141cough syrup 141coughtab 141COUMADIN 78CREON 76critic-aid clear af 159CRITIC-AID CLEAR MOISTURE 163CRITIC-AID THICK MOISTURE 164CRIXIVAN 13cromolyn sodium (mastocytosis) 74cromolyn sodium (nasal) 141cromolyn sodium nebu 153cromolyn sodium (ophth) 132cryselle-28 49CULTURELLE BABY GROW THRI 62curad hydrocortisone 161curad triple antibiotic 157CUTTER 164CUTTER ALL FAMILY 164CUTTER ALL FAMILY MOSQUIT 164CUTTER BACKWOODS 164CUTTER BACKWOODS DRY 164CUTTER DRY 164CUTTER LEMON EUCALYPTUS 164CUTTER NATURAL 164CUTTER SKINSATIONS 164CUTTER SPORT 164

Drug Name Page #cvs acidophilus probiotic 62cvs advanced healing oint 164cvs airshield 104CVS AIRSHIELD IMMUNITY SU 104cvs antacid/anti-gas 59cvs antacid & anti-gas fa 59cvs antacid kids 59cvs antacid supreme 59cvs anti-diarrheal 62cvs anti-itch maximum str 161cvs b-1 104cvs b1 104cvs b6 104cvs b-12 104cvs b12 104cvs b complex plus c 104cvs biotin 104cvs biotin high potency 104cvs bismuth 62cvs bismuth maximum stren 62cvs calcium 91cvs calcium 600+d 91cvs calcium 600 + d plus 91cvs calcium 600 & vitamin 91cvs calcium carbonate 91cvs calcium citrate + d 91cvs calcium citrate +d3 m 91cvs castor oil 67cvs chewable childrens vi 104cvs chewy not chalky flav 59cvs childrens chewable co 104cvs chocolate laxative pi 67cvs coenzyme q-10 96cvs coq-10 96cvs cortisone maximum str 161cvs cough dm 142cvs d3 104cvs daily gummies 104cvs daily multiple for me 104cvs daily multiple for wo 104CVS DIABETES HEALTH SUPPO 104cvs e 104cvs electrolyte solution 86cvs enema ready-to-use 67cvs epsom salt 67cvs eye health & lutein 104cvs fiber laxative 67

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...............................................Drug Name Page #cvs fish oil 96cvs folic acid 104cvs gas relief 74cvs gas relief extra stre 74cvs gas relief infants 74cvs gas relief ultra stre 74cvs glucose 55CVS GLUCOSE 55CVS GLUCOSE BITS 55cvs glucose liquid shot 55cvs glucose shot 55cvs gummy dinos 104cvs gummy dinos childrens 104cvs gummy multivitamin ki 104cvs heartburn relief 59CVS INSECT REPELLENT 164cvs iron 79cvs jock itch 159cvs laxative pills 67cvs lice killing 169cvs lice solution kit 169cvs lubricant eye drops 133cvs magnesium 91CVS MAGNESIUM 91cvs magnesium citrate 67cvs mens daily gummies 104cvs mineral oil 67cvs mineral oil enema 67cvs moisturizing cream 164cvs moisturizing extra dr 164CVS NASAL MIST 153cvs natural daily fiber 67CVS NATURAL FIBER SUPPLEM 67cvs natural fish oil 96cvs nicotine polacrilex 43cvs omega-3 gummy fish/dh 96cvs one daily essential 104CVS ONE DAILY MENS 50+ AD 104cvs oyster shell calcium 91cvs pediatric electrolyte 86cvs pinworm treatment 10CVS PRENATAL 104CVS PRENATAL MULTI+DHA 104cvs saline nasal spray 153cvs saline nose spray 153cvs senna 67cvs senna-extra 67

Drug Name Page #cvs slow release iron 79cvs smooth antacid extra 59cvs sodium chloride 133cvs soluble fiber therapy 67CVS SPECTRAVITE ADULT 50+ 105cvs spectravite advanced 105cvs spectravite senior 105cvs spectravite ultra hea 105CVS SPECTRAVITE ULTRA MEN 105cvs spectravite ultra wom 105CVS SPECTRAVITE ULTRA WOM 105cvs stomach relief 62cvs stress formula/zinc 105cvs super b complex/c 105CVS TOTAL HOME INSECT REP 164cvs vitamin b-12 105cvs vitamin b12 105cvs vitamin b-12 tr 105cvs vitamin b12 tr 105cvs vitamin c 105cvs vitamin c/rose hips 105cvs vitamin d3 105cvs vitamin d3 drops/infa 105cvs vitamin d childrens g 105cvs vitamin e 105cvs womens active daily 105cvs womens daily gummies 105cyanocobalamin 105cyclafem 1/35 49cyclafem 7/7/7 49cyclobenzaprine hcl 42cyclophosphamide 19cycloserine 15cyclosporine 84cyclosporine modified (for microemulsion) 84cyproheptadine hcl 137cyred tab 49CYSTADANE 54CYSTAGON 54CYSTARAN 133cytarabine 19CYTO-Q 96CYTO-Q MAX 96CYTO-Q T/F 96

D

d-3-5 106

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Drug Name Page #d3-50 106d3-1000 106d3 adult 105D3 DOTS 105d3 high potency 105d3 kids 105d3 maximum strength 105d3 super strength 105d3 vitamin 106d 400 106d-400 106d 1000 106d-1000 extra strength 106d 2000 106d-2000 maximum strength 106d2000 ultra strength 106d 5000 106d-5000 106d 10000 106daily combo multi vitamin 106DAILY CONDITIONING TREATM 164daily multi 106daily multiple vitamin 106daily multiple vitamin/ir 106daily multiple vitamins 106daily multiple vitamins w 106daily multivitamin 106daily value multivitamin 106daily vitamin 106daily vitamin formula+ir 106daily vitamin formula+iro 106daily vitamin formula+min 106daily vitamins 106daily vite 106daily-vite 106daily-vite/iron/beta-caro 106daily vite multivitamin/i 106dalfampridine 42DALIRESP 153danazol 53dantrolene sodium 43dapsone 10DAPTACEL 84daptomycin 11dasetta 1/35 49dasetta 7/7/7 49DAURISMO 20

Drug Name Page #DAYCLEAR ALLERGY RELIEF 142dayhist allergy 12 hour r 137daytime cold & flu relief 142daytime multi-symptom col 142daytime severe cold & flu 142DDROPS 106deblitane 49decara 106DECARA 106DECONEX DMX 142DECONEX IR 142decongestant 12hour maxim 142DECUBI-VITE 107deep sea nasal spray 153DEKAS BARIATRIC 107DEKAS ESSENTIAL 107DEKAS PLUS 107DELESTROGEN 54DELSTRIGO 14delsym cough + chest cong 142delsym cough + cold dayti 142delsym cough + cold night 142delta d3 107delyla 49DEMSER 31DEPEN TITRATABS 48DEPO-PROVERA INJ 400/ML 21DERMABASE OIL IN WATER 164dermacerin 164dermafix 164dermafungal 159dermamed 164dermaphor 164dermarest eczema 161dermavantage 164DESCOVY 14desenex shake powder 159desipramine hcl 35desmopressin acetate spray 58desmopressin acetate spray refrigerated 58desmopressin acetate tabs 58desmopressin inj 4mcg/ml 58desogestrel & ethinyl estradiol 49desogestrel-ethinyl estradiol (biphasic) 49desvenlafaxine succinate 35DEX4 55DEX4 FAST ACTING GLUCOSE 55

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Drug Name Page #DEX4 POUCH PACK 55DEX4 QUICK DISSOLVE GLUCO 55dexamethasone 54DEXAMETHASONE 54dexamethasone sodium phosphate 54dexamethasone sodium phosphate (ophth) 132DEXILANT 76dexmethylphenidate hcl 40dextromethorphan-guaifenesin 142dextromethorphan polistirex 142dextrose 2.5%/nacl 0.45% 88dextrose 5% 88DEXTROSE 5% /ELECTROLYTE 88dextrose 5%/nacl 0.2% 88DEXTROSE 5%/NACL 0.3% 88dextrose 5%/nacl 0.9% 88dextrose 5%/nacl 0.33% 88dextrose 5%/nacl 0.45% 88dextrose 5%/nacl 0.225% 88dextrose 5%/potassium chl 88dextrose 10% flex contain 88dextrose 10%/nacl 0.45% 88DEXTROSE 10% W/ SODIUM CHLORIDE 0.2% 88dextrose 50% 88dextrose (diabetic use) 55dextrose inj 70% 88dextrose in lactated ringers 88DHS ZINC 164diabetes health formula 107DIABETES HEALTH PACK 107diabetic siltussin das-na 142diabetic siltussin-dm 142diabetic siltussin-dm max 142diabetic tussin 142diabetic tussin dm 142diabetic tussin maximum s 142DIABETIDERM 164DIABETIDERM FOOT REJUVENA 164dialyvite 800 107DIALYVITE 800 107DIALYVITE 800/IRON 107dialyvite 800/ultra d 107dialyvite vitamin d3 max 107dialyvite vitamin d 5000 107diamode 62diarrhea 62DIASTAT ACUDIAL 33

Drug Name Page #DIASTAT PEDIATRIC 33diazepam 33diazepam gel 33diazepam inj 33diazepam intensol 33diazepam oral soln 1 mg/ml 33diclofenac potassium 6diclofenac sodium 6diclofenac sodium (ophth) 132diclofenac sodium (topical) 1% gel 164dicloxacillin sodium 18dicyclomine hcl cap 10mg 65dicyclomine hcl soln 10mg/5ml 65dicyclomine hcl tab 20mg 65didanosine 13DIFICID 17diflunisal 6digitek 30digox 30digoxin 30digoxin inj 30digoxin sol 50mcg/ml 30dihydroergotamine mesylate inj 1 mg/ml 41dihydroergotamine mesylate nasal spr 4 mg/ml .. 41DILANTIN-125 SUSP 33DILANTIN CAP 30MG 33DILANTIN CAP 100MG 33DILANTIN CHEW TAB 50MG 33diltiazem cap 240mg cd 29diltiazem cap 360mg cd 29diltiazem cap er/12hr 29diltiazem hcl 29diltiazem hcl coated beads 29diltiazem hcl coated beads cap sr 24hr 29diltiazem hcl extended release beads cap sr 29diltiazem inj 29dilt-xr cap 29dimaphen childrens 142dimaphen dm cold & cough 142dino-life 107dino-life w extra c 107DINO-LIFE W/IRON & ZINC 107diocto 67diphen 137diphenhist 137diphenhydramine-acetaminophen (sleep) 43diphenhydramine hcl 137

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Drug Name Page #diphenhydramine hcl inj 50mg/ml 137diphenhydramine-zinc acetate 159diphenoxylate w/ atropine 74DIPHTHERIA/TETANUS TOXOID 84DISNEY CALCIUM + VITAMIN 91disney cars gummies 107disney princess gummies 107disopyramide phosphate 27disulfiram 43divalproex sodium 33DML FORTE 164docetaxel 20DOCETAXEL 20docu 67docusate calcium 67docusate sodium 67docusil 67docu soft 67DOCUSOL KIDS 67DOCUSOL MINI 67DOCUSOL PLUS MINI-ENEMA 67docuzen 67dofetilide 27dofus 62dok 68dok plus 68donepezil hydrochloride 35dorzolamide hcl 133dorzolamide hcl-timolol maleate 133DOSOQUIN 107double antibiotic 157DOVATO 14doxazosin mesylate 26doxepin hcl 35doxorubicin hcl 19doxorubicin hcl liposomal 19doxy 100 18doxycycline hyclate 19doxycycline (monohydrate) 18, 19dramamine less drowsy 64driminate 64DRIPDROP 86dronabinol 64drospirenone-ethinyl estradiol 49drospirenone-ethinyl estradiol-levomefolate

calcium 49DROXIA 82

Drug Name Page #DROXY CREAM 164dry eye formula 107dry skin treatment 164ducodyl 68duloxetine hcl 35DURAFLU 142DURAVENT DM 142DUREX REALFEEL NON-LATEX 49DUREZOL 132dutasteride 77dutasteride-tamsulosin hcl 77dye-free allergy relief c 137

E

e-200 107e200 107e-400 107e-400-clear 107e-400-mixed 107e400 mixed 107e 1000 107e1000 107EAGLE WATCH MOSQUITO ELIM 164ear drops 170ear drops earwax removal 170ear wax removal drops 170ear wax removal kit 170earwax removal kit 170econtra ez 50econtra one-step 50ecotrin 2ecotrin low strength 2ecpirin 2ed a-hist 142ed a-hist dm 142ED A-HIST DM 142ed a-hist pse 142ed-apap 2ED BRON GP 142ED CHLORPED D 142ed chlorped jr 137EDURANT 13e.e.s 400 17efavirenz 13eldertonic 107eletriptan hydrobromide 41ELFOLATE PLUS 107

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Drug Name Page #ELIQUIS 79ELIQUIS STARTER PACK 79ELLA 50e-max-1000 107EMCYT 19EMEND 64EMERGEN-C BLUE 107EMERGEN-C HEART HEALTH 108EMERGEN-C IMMUNE PLUS 108EMERGEN-C KIDZ 108EMERGEN-C MSM LITE 108EMERGEN-C PINK 108EMERGEN-C SUPER FRUIT 108EMERGEN-C VITAMIN C 108EMERGEN-C VITAMIN D & CAL 108EMGALITY 41EMOLLIA-CREME 164emoquette 50EMSAM 36EMTRIVA 13EMVERM 11enalapril maleate 25enalapril maleate & hydrochlorothiazide 25endacof-dm 142ENDARI 82endocet 2.5-325mg 8endocet 5-325mg 8endocet 7.5-325mg 8endocet 10-325mg 8endur-acin 108endur-c/rose hips 108ENDUR-THINE 96ENDUR-VM 108ENDUR-VM WITH IRON 108enema ready-to-use 68ENEMEEZ MINI 68ENEMEEZ PLUS 68ENFAMIL ENFALYTE 86ENFAMIL EXPECTA 108ENGERIX-B 84ENLYTE 108enoxaparin sodium 79enpresse-28 50enskyce 50ENSTILAR 161entacapone 37entecavir 15

Drug Name Page #ENTRESTO 26enulose 68enviro-stress 108e-oil 107e-ointment 164EPCLUSA 15e-pherol 107EPIDIOLEX 33epinephrine (anaphylaxis) 153epirubicin hcl 19epitol 33EPIVIR HBV 15eplerenone 26eprosartan mesylate 27epsom salt 68EPSOM SALT 68eq antacid extra strength 59eq antacid ultra strength 59eq aspirin ec 2eq calcium 500+d 91eq calcium 600+d 91eq calcium 600+d+minerals 91eq calcium citrate+d 92eq complete chewable mult 108eq complete lice treatmen 169eq complete multivitamin 108EQ COMPLETE MULTIVITAMIN 108eq cough dm 142eq gas relief 75eq infants gas relief 75eql all day allergy 137eql allergy/congestion re 142eql antacid/anti-gas 59eql antacid ultra strengt 59eql anti-itch maximum str 161eql b-6 108eql calcium 600mg/vitamin 92eql calcium citrate/ vita 92eql calcium citrate w/vit 92eql calcium/vitamin d 92EQL CALCIUM/VITAMIN D 92eql carbonyl iron 79eql castor oil 68eql century 108eql century mature 108EQL CENTURY MATURE ADULTS 108EQL CENTURY MENS 108

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Drug Name Page #eql childrens multivitami 108eql coq10 96eql digestive probiotic 62EQL EPSOM SALT 68eql fiber therapy 68eql fish oil 96eql gas relief extra stre 75eql gas relief ultra stre 75eq lice killing maximum s 169eql infants gas relief 75eql iron supplement thera 79eql laxative eql laxative 68eql laxative maximum stre 68eql lice killing maximum 169eql naproxen sodium 6eql omega 3 fish oil 96eql omega-3 fish oil 96eql one daily mens 50+ ad 108eql one daily mens health 108eql one daily womens 50+ 108eql probiotic acidophilus 62eql saline nasal spray 154eql senna laxative 68eql slow release iron 79eql stomach relief 62eql stomach relief maximu 62eql stool softener 68eql stress b-complex/vita 108eql super b complex/vitam 108eql vision formula 109eql vitamin b-12 109eql vitamin b-12 tr 109eql vitamin c 109eql vitamin c/rose hips 109eql vitamin d3 109eql vitamin e 109eq magnesium citrate 68eq mineral oil 68eq multivitamin gummies c 108eq naproxen sodium 6eq natural laxative 68EQ ONE DAILY MENS HEALTH 108eq one daily womens healt 108EQ ONE DAILY WOMENS HEALT 108eq one daily womens pro-a 108eq pink-bismuth 62eq restore plus lubricant 133

Drug Name Page #eq restore tears 133eq saline nasal spray 154eq slow-release iron 79eq stomach relief 62EQUALACTIN 68eq vegetable laxative 68ergocalciferol 109ergotamine w/ caffeine 41ERIVEDGE 20ERLEADA 21erlotinib hcl 23errin 50ertapenem sodium 11ery pad 2% 156ery-tab 17ERYTHROCIN LACTOBIONATE 17erythrocin stearate 17erythromycin (acne aid) 156erythromycin base 17erythromycin cap 250mg ec 17erythromycin ethylsuccinate 17erythromycin (ophth) 131erythromycin tab ec 17ESBRIET 154ESCAVITE 109escitalopram oxalate 36esomeprazole magnesium 76essentia 109essential balance 109estarylla tab 0.25-35 50ester-e 109estradiol 54estradiol vaginal cream 54estradiol vaginal tab 54estradiol valerate 54eszopiclone 41ethambutol hcl 15ethosuximide 33ethynodiol diacet & eth estrad 50ethynodiol tab 1-50 50etodolac 6etodolac er 6etoposide 25EUCERIN INTENSIVE REPAIR 164EUCERIN PLUS 165evac-u-gen 68EVOTAZ 14

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Drug Name Page #exemestane 21eye itch relief 132eyeprotect 109ezetimibe 28ezetimibe-simvastatin 28EZFE 200 79

F

fa-8 109FABRAZYME 54falmina 50famciclovir 15famotidine 65famotidine inj 65famotidine in nacl 65FANAPT 38FANAPT TITRATION PACK 38FARXIGA 46FARYDAK 20fast acting antacid plus 59fayosim 50FC2 FEMALE CONDOM 50felbamate 33felodipine 29femynor 50fenofibrate 28fenofibrate micronized 28fentanyl citrate 8fentanyl patch 12 mcg/hr 8fentanyl patch 25 mcg/hr 8fentanyl patch 50 mcg/hr 8fentanyl patch 75 mcg/hr 8fentanyl patch 100 mcg/hr 8FERAHEME 79ferate 80fergon 80FERIVA 21/7 80FERIVAFA 80ferosul 80ferrex 150 80ferric x-150 80ferrous gluconate 80FERROUS GLUCONATE 80ferrous sulfate 80FERROUS SULFATE 80ferrous sulfate iron 80ferrousul 80

Drug Name Page #FETZIMA 36FETZIMA TITRATION PACK 36feverall adults 2feverall childrens 2FEVERALL INFANTS 2feverall junior strength 2fexofenadine hcl 137fexofenadine-pseudoephedrine 142FIASP 45FIASP FLEXTOUCH 45fiber-lax 68fiber laxative 68fiber therapy 68finasteride 77FISH OIL 96fish oil adult gummies 96fish oil burp-less 96fish oil concentrate 96fish oil double strength 96fish oil extra strength 96fish oil maximum strength 96fish oil omega-3 96fish oil pearls 96FISH OIL PEARLS 96fish oil/super potent/no 97FISH OIL TRIPLE STRENGTH 96FISH OIL ULTRA 96flac 170flanax pain relief 6flanders buttocks 165flecainide acetate 27FLEET BISACODYL 68flintstones complete 109flintstones gummies plus 109flintstones/my first 109flintstones plus calcium 109flintstones plus extra c 109flintstones plus iron 109FLORAJEN ACIDOPHILUS 62floranex 62FLORIVA PLUS 109FLOVENT DISKUS 155FLOVENT HFA 155fluconazole 12fluconazole inj nacl 200 12fluconazole inj nacl 400 12flucytosine 12

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Drug Name Page #fludrocortisone acetate 54flu hbp 142flunisolide (nasal) 155fluocinolone acetonide 161fluocinolone acetonide oil body 161fluocinolone acetonide (otic) 170fluocinonide 161fluocinonide emulsified base 161fluorometholone 132fluorouracil 19fluorouracil (topical) 165fluoxetine cap 10mg 36fluoxetine cap 20mg 36fluoxetine cap 40mg 36fluoxetine hcl 36fluphenazine decanoate 38fluphenazine hcl 38flurbiprofen 6flurbiprofen sodium 132flu/severe cold & cough d 143flutamide 21fluticasone propionate 161fluticasone propionate (nasal) 155fluvoxamine maleate 32folbee 109folbee plus 109folbee plus cz 109folbic 109folic acid 109FOLIC ACID 109folplex 2.2 109FOLTANX 109fondaparinux sodium 79formula e 400 109for sty relief 133FORTEO 57fosamprenavir tab 700 mg 13fosinopril sodium 25fosinopril sodium & hydrochlorothiazide 25FREAMINE HBC 6.9% 87FREAMINE III 87FREEDAVITE 109freeze dried acidophilus 62FRESHKOTE 133FRESHKOTE PF 133fruit c-100 110fruit c 500 110

Drug Name Page #fruity c 110fruity chewables multivit 110fruity chews 110fruity chews/iron 110FULL SPECTRUM B/VITAMIN C 110fulvestrant 21fungoid-d 159FUNGOID TINCTURE 159furosemide 30furosemide inj 30FUSION PLUS 80FUZEON 13fyavolv 54FYCOMPA 33

G

gabapentin 33galantamine hydrobromide 35galantamine hydrobromide er 35GALZIN 92GAMASTAN S/D 83GAMMAGARD LIQUID 83GAMMAGARD S/D 83GAMMAKED 83GAMMAPLEX 83GAMMAPLEX 10GM/100ML 83GAMUNEX-C 83ganciclovir sodium 15GARDASIL 9 84gas relief 75gas relief extra strength 75gas relief infants 75gas relief ultra strength 75gas-x extra strength 75GAS-X EXTRA STRENGTH 75gas-x ultra strength 75gatifloxacin (ophth) 131GATTEX 75GAUZE PADS 2 45gavilax 68gavilyte-c 68gavilyte-g 68gavilyte-n/flavor pack 68GAVISCON 59GAVISCON EXTRA STRENGTH 59GAVISCON EXTRA STRENGTH R 59gemcitabine inj soln 19

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Drug Name Page #gemcitabine inj solr 19gemfibrozil 28generlac 68gengraf 84GENOTROPIN 57GENOTROPIN MINIQUICK 57gentak 131gentamicin in saline 10gentamicin sulfate 10gentamicin sulfate soln (ophth) 131gentamicin sulfate (topical) 157GENTEAL SEVERE 133genteal tears liquid drop 134genteal tears night-time 134GENTLE 165gentlelax 68gentle laxative 68GENVOYA 14GEODON 38geriaton 110geri-dryl 137geri-dryl allergy relief 137geri-hydrolac 12 165geri-kot 68geri-lanta 59geri-mox 59geri-mucil 69geri-pectate 62gerivite complete 110gianvi 50GILENYA CAP 0.5MG 42GILOTRIF TAB 20MG 23GILOTRIF TAB 30MG 23GILOTRIF TAB 40MG 23glatiramer acetate 20mg/ml 42glatiramer acetate 40mg/ml 42glatopa 42GLEOSTINE 19glimepiride 46glipizide 46glipizide xl 46glip/metform tab 2.5-250mg 46glip/metform tab 2.5-500mg 46glip/metform tab 5-500mg 46GLUCAGEN HYPOKIT 55GLUCAGON EMERGENCY KIT 55gluco burst 55

Drug Name Page #GLUCOSE 55GLUCOSE INSTANT ENERGY 55glucoten 110glutamine 97glutimmune 97glyburide 46, 47glyburide-metformin tab 1.25-250 mg 47glyburide-metformin tab 2.5-500 mg 47glyburide-metformin tab 5-500mg 47glyburide micronized 47glycolax 69glycopyrrolate tab 1mg 65glycopyrrolate tab 2mg 65GLYCO-TECH 110glydo 162gnp 8 hour pain reliever 2gnp 12 hour nasal spray 143gnp 24 hour nasal allerg 155gnp acetaminophen 2gnp acid control 150 maxi 65gnp acid reducer 65gnp acid reducer maximum 65gnp adult aspirin low str 2gnp all day allergy 137gnp all day allergy child 137gnp all day allergy-d 143gnp all day pain relief 6gnp allergy 137gnp allergy antihistamine 137gnp allergy & congestion 143gnp allergy plus severe s 143gnp allergy plus sinus he 143gnp allergy relief 137gnp allergy relief for ki 137gnp aloe vera/lidocaine 165gnp animal shapes 110gnp animal shapes plus ex 110gnp animal shapes plus ir 110gnp antacid 59

and anti-gas/ 59gnp antacid anti-gas 59gnp antacid & anti-gas ma 59gnp antacid anti-gas/maxi 59gnp antacid & anti-gas/re 59gnp antacid extra strengt 59gnp antacid/regular stren 60gnp antacid ultra strengt 60

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Drug Name Page #gnp anti-diarrheal 62gnp anti-gas 75gnp anti-itch 159gnp arthritis pain relief 2gnp artificial tears 134gnp aspirin 2gnp aspirin low dose 2gnp athletes foot 159gnp b-12 110gnp bacitracin zinc 157gnp b-complex plus vitami 110gnp biotin 110gnp bisa-lax 69gnp budesonide nasal spra 155gnp calcium 92gnp calcium 500/d 92gnp calcium 500 +d3 92gnp calcium 600/d 92gnp calcium 600 +d3 92gnp calcium 600 +d3/miner 92gnp calcium 600 +d/minera 92gnp calcium 1200 92gnp calcium citrate +d3 92gnp calcium citrate+d3 ma 92gnp calcium citrate+d max 92gnp calcium plus 600 +d 92gnp calcuim/vitamin d/min 92gnp capsaicin 165GNP CAPSAICIN 165gnp castor oil 69gnp century 110gnp century adults 50+ se 110gnp century cardio health 110gnp century mature 110gnp century ultimate mens 110gnp century ultimate wome 110gnp childrens allergy 137gnp childrens chewables/e 110gnp childrens chewables/i 110gnp childrens chewables w 110GNP CHILDRENS COMPLETE CH 110gnp childrens easy-melts 2gnp childrens ibuprofen 6gnp childrens pain relief 2gnp clearlax 69gnp clotrimazole 3 78gnp coenzyme q-10 97

Drug Name Page #gnp cold & allergy childr 143gnp cold & allergy maximu 143gnp cold & cough children 143gnp cold head congestion 143gnp cold relief head cong 143gnp cold relief multi-sym 143gnp co q10 97gnp cough dm er 143gnp cough relief 143gnp dayhist allergy 137gnp day time cold/flu 143gnp day time cold/flu rel 143gnp diabetic support form 110gnp ear drops 170gnp ear systems 170gnp enema 69gnp epsom salt 69gnp esomeprazole magnesiu 76gnp essential one daily 110gnp eye drops 134gnp fiber-caps 69gnp fiber therapy 69gnp fish oil 97GNP FISH OIL 97gnp fish oil maximum stre 97gnp flu & severe cold & c 143gnp fluticasone propionat 155gnp foaming antacid 60gnp folic acid 110gnp gas relief 75gnp gas relief extra stre 75gnp gentle laxative 69GNP GLUCOSE 56gnp hair/skin/nails 110gnp headache pm 43gnp healthy eyes 110gnp healthy eyes supervis 110gnp heartburn relief 66gnp hydrocortisone 161gnp hydrocortisone/aloe 161gnp hydrocortisone maximu 161gnp hydrocortisone plus 161gnp ibuprofen 6gnp ibuprofen infants 6gnp ibuprofen junior stre 6gnp infants gas relief 75gnp infants pain/fever 2

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Drug Name Page #gnp infants pain relief 2gnp iron 80gnp itch relief extra str 159gnp k-pec 62gnp lansoprazole 76gnp laxative 69gnp laxative pills 69gnp lice bedding 169gnp lice solution kit 169gnp lice treatment 169gnp lidocaine pain relief 165gnp little ones childrens 110gnp loperamide hcl 62gnp loratadine 137gnp loratadine childrens 137gnp loratadine-d 12hr 143gnp lubricant eye drops 134gnp lubricant pm 134gnp lubricating plus eye 134gnp magnesium 60gnp magnesium citrate 69gnp masanti maximum stren 60gnp masanti regular stren 60gnp maximum one daily 111gnp mega multi for men 111gnp mega multi for women 111gnp miconazole 3 78gnp miconazole 7 78gnp miconazole nitrate 159gnp miconazorb af 159gnp milk of magnesia 69gnp mineral oil enema 69gnp mineral oil heavy 69gnp motion sickness relie 64gnp mucus dm maximum stre 143gnp mucus relief 143gnp mucus relief children 143gnp mucus relief cold flu 143gnp mucus relief cold & s 143gnp mucus relief cough ch 143gnp mucus relief dm 143gnp mucus relief pe 143gnp naproxen sodium 6gnp nasal decongestant 143gnp nasal decongestant/ma 143gnp nasal decongestant pe 143gnp nasal moisturizing 154

Drug Name Page #gnp nasal spray 143gnp nasal spray extra moi 143gnp nasal spray fast acti 143gnp natural fiber 69gnp niacin 111gnp niacin tr 111gnp nicotine gum 43gnp nicotine mini lozenge 43gnp nicotine polacrilex 43gnp nicotine polacrilex m 43gnp nicotine transdermal 43gnp night time cold & flu 143gnp night time cough 143gnp no drip nasal spray 144gnp nose drops extra stre 144GNP OMEPRAZOLE 76gnp one daily maximum 111gnp one daily mens 50+ ad 111gnp one daily mens health 111gnp one daily plus iron 111gnp one daily womens 50+ 111gnp one daily womens heal 111gnp one daily womens meta 111gnp opti-vitamins 111gnp pain & fever children 2gnp pain relief 2gnp pain relief extra str 2gnp pain relief pm extra 43gnp pediatric electrolyte 86gnp pink bismuth 62gnp povidone-iodine 165GNP PRENATAL 111gnp pseudoephedrine hcl 1 144gnp pseudoephedrine hcl e 144GNP QUICK DISSOLVE GLUCOS 56gnp scalp relief 165gnp senna lax 69gnp senna-lax 69gnp senna plus 69gnp sinus & cold-d 144gnp sinus relief congesti 144gnp sinus relief pressure 144gnp sinus relief severe c 144gnp slow release iron 80gnp stomach relief 62gnp stomach relief maximu 62gnp stool softener 69

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Drug Name Page #gnp stool softener extra 69gnp stool softener/stimul 69gnp suphedrin 144gnp tab tussin 144gnp tab tussin dm 144gnp terbinafine hydrochlo 159gnp therapeutic-m 111gnp tolnaftate 159gnp triple antibiotic 157gnp triple antibiotic plu 157gnp tussin cf cough & col 144gnp tussin cough long act 144gnp tussin dm 144gnp tussin dm cough 144gnp tussin dm max 144gnp tussin mucus & chest 144gnp ultra lubricant eye d 134gnp urinary pain relief 77gnp vitamin b-1 111gnp vitamin b-6 111gnp vitamin b-12 111gnp vitamin b-12 prolonge 111gnp vitamin b-12 tr 111gnp vitamin c 111gnp vitamin c drops 111gnp vitamin c pr 111gnp vitamin c/rose hips 111gnp vitamin c tr 111gnp vitamin c w/rose hips 111gnp vitamin d 111gnp vitamin d3 extra stre 111gnp vitamin d-400 111gnp vitamin d maximum str 111gnp vitamin d super stren 111gnp vitamin e 111gnp vitamin e water dispe 111gnp wart remover 165gnp womens gentle laxativ 69gnp womens laxative 69gnp womens one daily 111gnp zoochews gummies 112GOLD BOND ULTIMATE HEALIN 165GOLYTELY 69goodsense acid reducer 66goodsense all day allergy 137goodsense aller-ease 137goodsense allergy relief 137

Drug Name Page #goodsense arthritis pain 2goodsense artificial tear 134goodsense aspirin 2goodsense aspirin adult l 2goodsense aspirin low dos 2goodsense clearlax 69goodsense cough dm 144goodsense cough dm childr 144goodsense day time cold & 144goodsense daytime cold & 144goodsense gas relief extr 75GOODSENSE GLUCOSE 56goodsense headache pm 44goodsense hemorrhoidal oi 165goodsense ibuprofen 6goodsense ibuprofen child 6goodsense ibuprofen infan 6goodsense ibuprofen junio 6goodsense lansoprazole 76goodsense lubricating plu 134goodsense magnesium citra 69goodsense mineral oil lub 69goodsense mucus relief ch 144goodsense naproxen sodium 6goodsense nasal allergy s 155goodsense natural fiber 69goodsense nicotine gum 44goodsense nicotine polacr 44goodsense nighttime cold 144goodsense pain & fever ch 2goodsense pain & fever in 3goodsense pain relief 3goodsense pain relief ext 3goodsense pain relief pm 44GOODSENSE PRENATAL VITAMI 112goodsense senna laxative 69goodsense stimulant laxat 69goodsense stomach relief 62goodsense tussin cf 144granisetron hcl 64griseofulvin microsize 12griseofulvin ultramicrosize 12guaiatussin ac 144guaifenesin 144guaifenesin ac 144guaifenesin-codeine 144guanfacine er (adhd) 40

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Drug Name Page #gummi bear multivitamin/m 112

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h2q 97HAEGARDA 82hailey 24 fe 50hair formula extra streng 112hair/skin/nails 112HAIR/SKIN/NAILS 112HAIR SKIN & NAILS ADVANCE 112hair/skin/nails/biotin 112halls defense vitamin c d 112halobetasol propionate 161haloperidol 38haloperidol conc 2mg/ml 38haloperidol decanoate 38haloperidol lactate inj 5mg/ml 38HARVONI 15HAVRIX 84headache daytim

and sinus 150headache pm 44headache relief pm 44healthy eyes 112healthy eyes/lutein 112healthy hair skin & nails 112HEALTHY KIDS GUMMIES 112healthy kids gummies omeg 97healthy kids vitamin d3 112healthylax 69healthy mama eazzze the p 44healthy mama move it alon 69healthy mama shake that a 3healthy mama tame the fla 60heartburn antacid extra s 60heartburn relief 66heartburn relief 150 maxi 66heartburn relief maximum 66heartburn treatment 24 ho 76heather 50h-e-b oral electrolyte so 86hemocyte-f 80HEMOCYTE PLUS 80heparin sod inj 1000/ml 79heparin sod inj 5000/ml 79heparin sod inj 10000/ml 79heparin sod inj 20000/ml 79

Drug Name Page #HEPARIN SODIUM/NACL 0.45% 79heparin sod (porcine) in d5w 79hepatamine 87HERCEPTIN 20HERCEPTIN HYLECTA 20HETLIOZ 41HIBERIX 84high potency calcium 92HISTEX 138HISTEX-AC 144HISTEX-DM 144HISTEX PD 138HISTEX PDX 138HISTEX-PE 144hm acetaminophen children 3hm acetaminophen pm extra 44hm acidophilus probiotic 63hm acid reducer 66hm advanced antacid maxim 60hm all day allergy 138hm all day allergy childr 138hm allergy 138hm allergy complete-d 144hm allergy relief 138hm allergy relief childre 138hm allergy relief & nasal 144hm allergy relief nasal s 155hm allgery multi symptom 138hm animal shapes 112hm antacid 60hm antacid/antigas 60hm antacid anti-gas extra 60hm anti-diarrheal 63hm antioxidant vitamins 112hm arthritis pain relief 3hm artificial tears 134hm aspirin 3hm aspirin ec 3hm aspirin ec low dose 3hm bacitracin 157hm biotin 112hm calcium 600 + d plus m 92hm calcium 600 & vitamin 92hm calcium 600 + vitamin 92hm calcium antacid extra 60hm calcium antacid smooth 60hm calcium antacid ultra 60

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Drug Name Page #hm calcium citrate+d3 pet 92hm calcium citrate + vita 92hm calcium/vitamin d 92hm calcium/vitamin d/mine 92hm cetirizine hcl childre 138hm cetirizine hydrochlori 138hm chest congestion relie 144hm clearlax 70hm cold & allergy childre 145hm cold & cough childrens 145hm cold & sinus relief 145hm complete 112HM COMPLETE 112hm complete 50+ 112HM COMPLETE 50+ MENS ULTI 112HM COMPLETE 50+ WOMENS UL 112HM COMPLETE MEN 112hm complete women 112hm coq10 97hm cough dm 145hm day time 145hm double antibiotic 157hm dry eye relief 134hm earwax removal aid 170hm earwax removal kit 170hm enema mineral oil 70hm enema ready-to-use 70hm enema saline laxative 70hm epsom salt 70hm esomeprazole magnesium 76hm eye itch relief 132hm famotidine 66hm fexofenadine hydrochlo 138hm fiber 70hm fish oil 97HM FISH OIL 97hm folic acid 112hm gas relief 75hm gas relief infants 75HM GLUCOSE 56HM HAIR/SKIN/NAILS 112hm hydrocortisone/aloe ma 161hm hydrocortisone plus 161hm ibuprofen 6hm ibuprofen childrens 6hm ibuprofen ib 6hm ibuprofen infants 6

Drug Name Page #hm iron 80hm iron slow release 80hm lansoprazole 76hm laxative 70hm lice killing maximum s 169hm lice treatment 169hm loperamide hcl 63hm loratadine 138hm loratadine childrens 138hm lubricating plus 134hm lubricating tears 134hm magnesium 60hm magnesium citrate 70hm mens 50+ advanced one 112hm milk of magnesia 70hm mineral oil 70hm motion relief 64hm motion sickness relief 64hm mucus er 145hm mucus relief d 145hm naproxen sodium 6hm nasal decongestant 145hm nasal decongestant 12 145hm nasal decongestant pe 145hm nasal spray 145hm niacin 112hm niacin tr 112hm nicotine polacrilex 44hm nicotine transdermal s 44hm night time cold & flu 145hm night time multi sympt 145hm night time multi-sympt 145hm nose drops extra stren 145HM OMEPRAZOLE 76hm one daily/iron 112HM ONE DAILY MENS 112HM ONE DAILY WOMENS 112hm pain & fever childrens 3hm pain & fever infants 3hm pain relief extra stre 3hm pain reliever 3hm pain reliever pm extra 44hm pediatric electrolyte 86hm povidone-iodine 165HM PRENATAL 112hm saline nasal spray 154hm senna 70

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Drug Name Page #hm senna-s 70hm severe cold/cough/flu 145hm severe cold & flu 145hm sinus & cold-d 145hm sinus nasal spray 145hm stomach relief 63hm stomach relief maximum 63hm stool softener 70hm stool softener maximum 70hm stool softener/stimula 70hm super vitamin b comple 113hm triple antibiotic 157hm triple antibiotic plus 157hm tussin adult 145hm tussin adult cough & c 145hm tussin adult multi-sym 145hm tussin cough/chest con 145hm vitamin b6 113hm vitamin b12 113hm vitamin b12 tr 113hm vitamin b12 ultra stre 113hm vitamin b complex/vita 113hm vitamin c 113hm vitamin c/rose hips 113hm vitamin c tr 113hm vitamin d 113hm vitamin d3 113HM VITAMIN D3 113hm vitamin e 113hm womens 50+ advanced on 113HONEY BEARS 113HONEY BEARS W/IRON AND ZI 113HUMIRA 82HUMIRA INJ 10MG/0.2ML 82HUMIRA KIT 20MG/0.4ML 82HUMIRA KIT 40MG/0.8ML 83HUMIRA PEDIATRIC CROHNS DISEASE 83HUMIRA PEN 83HUMIRA PEN CD/UC/HS STARTER 83HUMIRA PEN INJ CD/UC/HS STARTER 83HUMIRA PEN INJ PS/UV STARTER 83HUMIRA PEN-PS/UV STARTER 83HUMULIN R INJ U-500 45HUMULIN R U-500 KWIKPEN 45HYALEX 113hydralazine hcl 31HYDRASYN25 165

Drug Name Page #hydrocerin 165HYDROCERIN 165hydrocerin plus 165hydrochlorothiazide 30HYDROCIL INSTANT 70hydroco/apap tab 5-325mg 8hydroco/apap tab 7.5-325 8hydroco/apap tab 10-325mg 8hydrocodone-acetaminophen 7.5-325 mg/15ml 8hydrocodone-ibuprofen tab 7.5-200 mg 8hydrocodone polistirex-chlorpheniramine

polistirex 145hydrocodone w/ homatropine 145hydrocortisone 54hydrocortisone-aloe vera 162hydrocortisone butyrate cream 0.1% 161hydrocortisone butyrate oint 0.1% 161hydrocortisone (enema) 66hydrocortisone maximum st 161hydrocortisone (topical) 161hydrocortisone (topical) cream 1% 161hydrocortisone (topical) cream 2.5% 161hydrocortisone (topical) lotion 2.5% 161hydrocortisone (topical) oint 2.5% 161HYDRO-LAN 165hydrolatum 165hydromet 145hydromorphone hcl 8, 9hydrophor 165hydroxocobalamin acetate 113hydroxychloroquine sulfate 83hydroxyurea 24hydroxyzine hcl 138hydroxyzine hcl inj 138hydroxyzine pamoate 138HYSINGLA ER 9HY-VEE GLUCOSE 56

I

ibandronate sodium tabs 48IBRANCE 20ibu-200 6ibuprofen 6ibuprofen childrens 6ibuprofen infants 6ibuprofen junior strength 7ibu tab 600mg 6

198

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Drug Name Page #ibu tab 800mg 6icaps 113ICAPS AREDS FORMULA 113icaps lutein & omega-3 113icaps mv 113ICAPS PLUS 113icatibant acetate 82ICLUSIG 23IDHIFA 20iferex 150 80ILEVRO 132imatinib mesylate 23IMBRUVICA 23imipenem-cilastatin 11imipramine hcl 36imiquimod 165IMMUNE SUPPORT 113IMOVAX RABIES (H.D.C.V.) 85incassia 50INCRELEX 57INCRUSE ELLIPTA 136indapamide 30INFANRIX 85infants gas relief 75infants ibuprofen 7infants simethicone 75INFUVITE ADULT 113INFUVITE PEDIATRIC 113INJECTAFER 80INLYTA 23INREBIC 23INSTA-GLUCOSE 56INSULIN PEN NEEDLE 45INSULIN SAFETY NEEDLES 45INSULIN SYRINGE 45INTEGRA F 80INTEGRA PLUS 80INTELENCE 13intestinex 63INTRALIPID 30% 87INTRALIPID INJ 20% 87INTRON-A INJ 10MU 83INTRON-A INJ 18MU 83INTRON-A INJ 25MU 84INTRON-A INJ 50MU 84introvale 50INVEGA SUST INJ 39 MG/0.25 ML 38

Drug Name Page #INVEGA SUST INJ 78 MG/0.5 ML 38INVEGA SUST INJ 117 MG/0.75 ML 38INVEGA SUST INJ 156MG/ML 38INVEGA SUST INJ 234 MG/1.5 ML 38INVEGA TRINZA 38INVIRASE 13IONOSOL-MB/DEXTROSE 5% 88IPOL INACTIVATED IPV 85ipratropium-albuterol nebu 135ipratropium bromide 136ipratropium bromide (nasal) 136irbesartan 27irbesartan-hydrochlorothiazide 26IRESSA 23irinotecan hcl 25IRON 80iron 27 80IRON CHEWS PEDIATRIC 80iron slow release 80iron supplement childrens 81IRON UP 81IROSPAN 24/6 81ISENTRESS 13ISENTRESS HD 13isibloom 50ISOLYTE P 88ISOLYTE S 88isoniazid 15isoniazid syp 50mg/5ml 15ISOPTO TEARS 134isosorbide dinitrate 31isosorbide dinitrate er 31isosorbide mononitrate er 31isosorb mononitrate tab 31isotretinoin 156isradipine 29itch relief extra strengt 159itraconazole 12ivermectin 11i-vite 113i-vite protect 113IXIARO 85

J

JADENU 48JADENU SPRINKLE 48JAKAFI 23

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Drug Name Page #jantoven 79JANUMET 47JANUMET XR TAB 50-500MG 47JANUMET XR TAB 50-1000 47JANUMET XR TAB 100-1000 47JANUVIA 47JARDIANCE 47jasmiel 50JENTADUETO 47JENTADUETO TAB XR 2.5-1000 MG 47JENTADUETO TAB XR 5-1000 MG 47jinteli 54jock itch spray 159jolessa tab 0.15-0.03 mg 50jolivette 50juleber 50JULUCA 14junel 1.5/30 50junel 1/20 50junel fe 1.5/30 50junel fe 1/20 50junel fe 24 50just d 113JUXTAPID 28

K

k 100 113KADCYLA 20kaitlib fe 50KALA 63KALETRA TAB 100-25MG 14KALETRA TAB 200-50MG 14KALYDECO 154kaopectate 63kaopectate extra strength 63kao-tin 63, 70kariva 50KCL 0.3%/D5W/NACL 0.9% 88kcl 0.3%/d5w/nacl 0.45% 88kcl0.15%/d5w/nacl0.2% 88kcl 0.15%/d5w/nacl 0.9% 88KCL 0.15%/D5W/NACL 0.225% 88kcl 0.075%/d5w/nacl 0.45% 88kcl/d5w inj 0.3% 88kcl/d5w/nacl inj 0.22%/0.45% 88kcl/d5w/nacl inj .15/.33% 88kcl/d5w/nacl inj .15/.45% 88

Drug Name Page #kcl/nacl inj 0.3-0.9 88kcl/nacl inj 0.15%-0.9% 88kelnor 1/35 50kelnor 1/50 50KERADAN 165kerodex-51 dry/oily 165kerodex-71 wet 165ketoconazole 12ketoconazole cream 159ketoconazole shampoo 160ketorolac tromethamine (ophth) 132ketotifen fumarate (ophth) 132KEYTRUDA 20kidkare cough/cold 145kids first vitamin d3 gum 113KINRIX 85kionex sus 15gm/60ml 48KISQALI 20KISQALI FEMARA 200 DOSE 20KISQALI FEMARA 400 DOSE 20KISQALI FEMARA 600 DOSE 20klor-con 8 86klor-con 10 86klor-con m10 86klor-con m15 86klor-con m20 86klor-con pak 20meq 86klor-con spr cap 8meq 86klor-con spr cap 10meq 86kls allerclear 138kls allerclear d-24hr 145kls aller-tec 138kls aller-tec d 145kls fiber-tabs 70kls naproxen sodium 7kls natural psyllium fibe 70KONSYL 70KONSYL-D 70konsyl daily fiber 70KONSYL DAILY FIBER 70KORLYM 57kp adults 50+ daily formu 113kp adults daily formula 113kp aspirin 3K-PAX IMMUNE SUPPORT FORM 113kp bacitracin zinc 157kp b complex/c 114

200

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Drug Name Page #kp benzoyl peroxide 156kp benzoyl peroxide wash 157kp bisacodyl 70kp calcium 600+d 92kp calcium 600+d3 92kp calcium citrate+d 92kp clotrimazole 159kp double antibiotic 157kp ferrous gluconate 81kp ferrous sulfate 81kp fish oil 97kp folic acid 114kp hydrocortisone 162kp hydrocortisone/aloe 162kp hydrocortisone maximum 162kp ketotifen fumarate 132kp loratadine 138kp mag-oxide magnesium 92kp mens 50+ daily formula 114kp mens daily formula 114KP MENS DAILY PACK 114kp miconazole nitrate 159kp niacin 114KPN PRENATAL 114kp omega-3 fish oil 97KP PRENATAL MULTIVITAMINS 114kp pseudoephedrine hcl 145kp senna 70kp tolnaftate 159kp vision formula 114kp vision formula w/lutei 114kp vitamin b-6 114kp vitamin b-12 114kp vitamin d 114kp vitamin d3 114kp vitamin e 114kp womens 50+ daily formu 114kp womens daily formula 114KP WOMENS DAILY PACK 114KROGER GLUCOSE 56ks ibuprofen 7ks stool softener 70kurvelo 50KUVAN 54

L

labetalol hcl 29

Drug Name Page #lac-hydrin five 165lactated ringer’s 89lactic acid (ammonium lactate) 165lactinex 63LACTINOL HX 165lactobacillus 63lactobacillus acidophilus-pectin 63lactobacillus extra stren 63lacto-key-100 63lacto-key-600 63lactulose 70lactulose (encephalopathy) 70lamivudine 13lamivudine (hbv) 15lamivudine-zidovudine 14lamotrigine 33LANAPHILIC 165land before time multivit 114LANOLOR 165lansoprazole 76L-ARGININE 97l-arginine-500 97l-arginine maximum streng 97larin 1.5/30 51larin 1/20 51larin fe 1.5/30 51larin fe 1/20 51larissia tab 51LASTACAFT 132latanoprost 133LATUDA 38laxa basic 70laxacin 70laxative 70laxative pills maximum st 70laxative pills regular st 70layolis fe 51LEADER FINGER CREAM 165LEADER GLUCOSE 56LEADER QUICK DISSOLVE GLU 56leena 51leflunomide 83LEMON-GLYCERIN SWABSTICKS 165LENVIMA 4 MG DAILY DOSE 23LENVIMA 8 MG DAILY DOSE 23LENVIMA 10 MG DAILY DOSE 23LENVIMA 12MG DAILY DOSE 23

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Drug Name Page #LENVIMA 14 MG DAILY DOSE 23LENVIMA 18 MG DAILY DOSE 23LENVIMA 20 MG DAILY DOSE 23LENVIMA 24 MG DAILY DOSE 23lessina 51letrozole 21leucovorin calcium 25LEUKERAN 19leuprolide inj 1mg/0.2 21levalbuterol hcl 140levalbuterol hcl soln nebu conc 1.25 mg/0.5ml 140levalbuterol tartrate hfa 140LEVEMIR 45LEVEMIR FLEXTOUCH 45levetiracetam 33levetiracetam in sodium chloride 33levetiracetam oral soln 100 mg/ml 34levobunolol hcl 133levocarnitine (metabolic modifiers) 54levocetirizine dihydrochloride 138levofloxacin 17levofloxacin in d5w 17levofloxacin inj 25mg/ml 17levofloxacin oral soln 25 mg/ml 17levonest 51levonor/ethi tab 51levonorgestrel (emergency oc) 51levonorgestrel & eth estradiol 51levonorgestrel-ethinyl estradiol (91-day) 51levora 0.15/30-28 51levo-t 57levothyroxine sodium 57levoxyl 57LEXIVA 13L-GLUTAMINE 97L-GLUTATHIONE 97lice killing maximum stre 169lice killing shampoo 169lice treatment 169licide 169lidocaine 162, 166lidocaine hcl 162lidocaine hcl (local anesth.) 9lidocaine hcl (mouth-throat) 170lidocaine inj 0.5% 10lidocaine inj 1% 10lidocaine inj 1.5% preservative free (pf) 10

Drug Name Page #lidocaine oint 5% 162lidocaine-prilocaine 162LIFE PACK MENS 114LIFE PACK WOMENS 114linezolid inj 11linezolid in sodium chloride 11linezolid susp 11linezolid tab 600mg 11LINZESS 75liothyronine sodium 58LIPOIC ACID 97LIQ-10 97liquid calcium/d3 92liquid calcium/vitamin d 93LIQUID CALCIUM WITH D3 MA 92liquid pain relief 3liqui-e 114liquitears 134lisinopril 25lisinopril & hydrochlorothiazide 25L-ISOLEUCINE 97lithium carbonate 42lithium carbonate er 42LITHIUM SOLN 8MEQ/5ML 42little animals plus iron 114little noses saline 154little noses stuffy nose 154LITTLE REMEDIES BABY STER 154little remedies fever/pai 3little remedies for fever 3little remedies for tummy 75L-METHYL-B6-B12 114L-METHYL-MC 114LODRANE D 146LOHIST-D 146LOHIST-DM 146LONGS GLUCOSE 56LONSURF 24loperamide hcl 63, 75lopinavir-ritonavir 14loradamed 138loratadine 138loratadine childrens 138loratadine-d 12hr 146loratadine-d 24hr 146lorazepam 32lorazepam intensol 32

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Drug Name Page #LORBRENA 23lorcet hd tab 10-325mg 9lorcet plus tab 7.5-325 9lorcet tab 5-325mg 9LORTUSS DM 146LORTUSS EX 146LORTUSS LQ 146loryna 51losartan-hydrochlorothiazide 26losartan potassium 27LOTEMAX 132loteprednol etabonate 132lovastatin 27low-ogestrel 51loxapine succinate 38lubricant eye drops 134lubricating eye drops 134lubricating plus eye drop 134LUMIGAN 133LUMIZYME 54LUPRON DEPOT (1-MONTH) 21LUPRON DEPOT INJ 11.25MG (3-MONTH) 21LUPRON DEPOT-PED (1-MONTH 57LUPRON DEPOT-PED (3-MONTH 57LUPRON DEP-PED INJ 7.5MG 57LUPRON DEP-PED INJ 11.25MG (3-MONTH) 57lutera 51LYNPARZA 20LYRICA CR 42lysiplex plus 114LYSODREN 21lyza 51

M

macular health formula 114MACULAR VITAMIN BENEFIT 114macuvite 114macuvite eye care 114macuvite/lutein 114MAG64 93MAG-AL 60mag-al plus 60mag-al plus xs 60MAGDELAY 93mag-g 93MAGNESIUM 60, 93MAGNESIUM CHLORIDE 93

Drug Name Page #MAGNESIUM CHLORIDE/CALCIU 93magnesium citrate 71magnesium gluconate 93MAGNESIUM GLUCONATE 93magnesium lactate 93magnesium oxide 60magnesium-oxide 93MAGNESIUM OXIDE 60MAGNESIUM OXIDE 400 93MAGNESIUM OXIDE HEAVY 60magnesium oxide (mg supplement) 93magnesium sulfate 86MAGNESIUM SULFATE 86MAGNESIUM SULFATE IN D5W 86magnesium sulfate in dextrose 86magnesium sulfate inj 50% 86magonate 93mag-oxide 93MAG-SR PLUS CALCIUM 93major-prep hemorrhoidal 166malathion 169mapap 3mapap acetaminophen extra 3mapap arthritis pain 3mapap childrens 3mapap cold formula multi- 146mapap pm 44mapap sinus maximum stren 146maprotiline hcl 36MAR-COF BP 146marlissa 51MARPLAN TAB 10MG 36MATULANE 24MAVYRET 15MAXICHLOR PEH DM 146MAXI DEET 166MAXIFED 146MAXIMIN PACK 115maximum blue label 115maximum d3 115maximum daily green 115maximum epa 97maximum green label 115maximum red label 115MAXI-TUSS CD 146MAXI-TUSS DM 146M-CLEAR WC 146

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Drug Name Page #meclizine hcl 64MEDELA TENDER CARE LANOLI 166medi-bismuth 63medicated callus removers 166medicated corn removers 166medi-first triple antibio 157MEDI-LYTE 86medi-natural 71medi-natural plus 71medi pads 166medi-phedryl 138mediplex plus 115medi-profen 7mediproxen 7medi-tabs extra strength 3medi-tussin dm 146medroxyprogesterone acetate (contraceptive) 51medroxyprogesterone acetate tab 57mefloquine hcl 12mega-marathon 100 tr 115MEGA MULTI FOR MEN 115MEGA MULTIVITAMIN FOR MEN 115MEGA MULTIVITAMIN FOR WOM 115MEGAVITE FRUITS & VEGGIES 115MEGAVITE GOLDEN YEARS 55+ 115mega vm-80 115megestrol ac sus 40mg/ml 21megestrol ac tab 20mg 21megestrol ac tab 40mg 21megestrol sus 625mg/5ml 21meijer advanced formula 115meijer advanced formula f 115meijer c 115MEIJER GLUCOSE 56meijer ibuprofen 7meijer nasal decongestant 146meijer saline nasal spray 154MEKINIST 23MEKTOVI 23melatonin 97melodetta 24 fe 51meloxicam 7memantine hcl cp24 35memantine soln 35memantine tabs 35memantine titration pak 35MENACTRA 85

Drug Name Page #M-END DMX 146M-END PE 146MENS 50+ ADVANCED 115mens daily formula/lycope 115MENS MULTI VITAMIN & MINE 115MENS PACK 115menstrual pain relief mul 3MENVEO 85mercaptopurine 19meribin 115meropenem 11mesalamine 66mesalamine w/ cleanser 66MESNEX 25metadate er tab 20mg 40METAFOLBIC 115metamucil 71METAMUCIL 71METAMUCIL FIBER 71METAMUCIL FREE & NATURAL 71METAMUCIL MULTIHEALTH FIB 71metamucil smooth texture 71metformin er 47metformin hcl 47methadone hcl 9methadone hcl 5mg 9methadone hcl 10mg 9methadone hcl intensol 9methazolamide 30methenamine hippurate 11methimazole 58methocarbamol 43methotrexate sodium inj soln 19methotrexate sodium inj solr 19methotrexate sodium tabs 83methylphenidate hcl 40methylphenidate hcl oral soln 40methylphenidate hcl tbcr 10 mg 40methylphenidate hcl tbcr 20mg 40methylprednisolone acetate 55methylpred pak 4mg 54methylpred tab 4mg 54methylpred tab 8mg 54methylpred tab 16mg 54methylpred tab 32mg 54methylpr ss inj 54metoclopramide hcl 64

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Drug Name Page #metoclopramide hcl inj 64metolazone 30metoprolol & hctz tab 50-25mg 28metoprolol & hctz tab 100-25mg 28metoprolol & hctz tab 100-50mg 28metoprolol succinate 29metoprolol tartrate 29metronidazole 11metronidazole gel 0.75% 166metronidazole in nacl 11metronidazole (topical) 166metronidazole vaginal 78mgo 93m-hist pd 138MH MACULAR HEALTH 115mi-acid 60MI-ACID 60mi-acid gas relief 75mi-acid maximum strength 60mibelas 24 fe 51miconazole 1 78miconazole 3 78miconazole 3 combination 78miconazole 3 combo pack 78miconazole 7 78miconazole antifungal 159miconazole nitrate (topical) 159miconazole nitrate vaginal 78microgestin 1.5/30 51microgestin 1/20 51microgestin fe 1.5/30 51microgestin fe 1/20 51micro guard 159midodrine hcl 31miglustat 54MIL-A-MULSION 115milantex 60milantex extra strength 60mili 51milk of magnesia 71MILK OF MAGNESIA CONCENTR 71milltrium senior 115mineral oil 71MINERAL OIL 71MINERAL OIL HEAVY 71minerin 166minitran 31

Drug Name Page #minocycline hcl 19minoxidil 31mintox 60mintox maximum strength 60mintox plus 60mirtazapine 36misoprostol 75MITIGARE 1M-M-R II 85M-NATAL PLUS 114moexipril hcl 25moisturel therapeutic 166moisturizing cream 166MOISTURIZING CREAM 166molindone hcl 38mometasone furoate 162mondoxyne nl cap 100mg 19mono-linyah tab 0.25-35 51montelukast sodium 153MORE-DOPHILUS ACIDOPHILUS 63morgidox cap 1x50mg 19morphine ext-rel tab 9morphine sulfate 9MORPHINE SULFATE 9morphine sulfate oral soln 10mg/5ml 9morphine sulfate oral soln 20mg/5ml 9morphine sulfate oral soln 100mg/5ml 9morphine sul inj 1mg/ml 9morphine sul inj 10mg/ml 9motion sickness relief 64motion-time 65MOVANTIK 75MOXEZA 131moxifloxacin hcl 17moxifloxacin hcl (ophth) 131MTERYTI 115MTERYTI FOLIC 5 115mucinex allergy 138mucinex chest congestion 146mucinex cough childrens 146MUCINEX COUGH FOR KIDS 146MUCINEX D MAXIMUM STRENGT 146mucinex fast-max cold flu 146MUCINEX FAST-MAX COLD/FLU 146mucinex fast-max cold & s 146mucinex fast-max congesti 146MUCINEX FAST-MAX DAY/NIGH 146

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Drug Name Page #MUCINEX FAST-MAX DAY/NITE 146mucinex fast-max day time 146MUCINEX FAST-MAX DAY TIME 146mucinex fast-max dm max 146mucinex fast-max night ti 146mucinex fast-max severe c 147MUCINEX FAST-MAX SEVERE C 147MUCINEX FOR KIDS 147mucinex multi-symptom col 147MUCINEX MULTI-SYMPTOM COL 147mucinex sinus-max day/nig 147MUCINEX SINUS-MAX DAY/NIG 147mucinex sinus-max full fo 147mucinex sinus-max night t 147mucinex sinus-max pressur 147mucinex sinus-max severe 147MUCINEX SINUS-MAX SEVERE 147MUCINEX STUFFY NOSE & COL 147mucosa 147mucosa dm 147mucus d 147mucus-dm maximum strength 147mucus relief 147mucus relief chest conges 147mucus relief childrens 147mucus relief cold flu & s 147mucus relief cold & sinus 147mucus relief cough childr 147mucus relief dm 147mucus relief dm cough 147mucus relief dm maximum s 147mucus relief pe sinus con 147mucus relief severe cold 147mucusrelief sinus 147MULTAQ 27multi adult gummies 115multi complete/iron 115multi-day 116multi-day plus iron 116multi-day plus minerals 116multi-day vitamins 116multi-delyn 116MULTI-DELYN/IRON 116multi for her 115multi for her 50+ 115multi for him 116MULTI FOR HIM 115

Drug Name Page #multi for him 50+ 116multilex 116multilex-t&m 116multimineral plus 116multi + omega-3 adult gum 115multiple vitamin 116multiple vitamin/minerals 116multiple vitamins essenti 116multiple vitamins w/ iron 116multiple vitamins w/ minerals 116multiple vitamins/womens 116MULTI PRENATAL 116multi symptom flu & sever 147multi-vitamin 116multivitamin 116MULTI VITAMIN 116MULTIVITAMIN+ 117MULTIVITAMIN ADULT 116MULTIVITAMIN ADULT EXTRA 117multivitamin adults 117MULTIVITAMIN ADULTS 117multivitamin adults 50+ 117multivitamin childrens 117MULTI VITAMIN/D-3 116multi vitamin daily 116multi-vitamin daily 116MULTIVITAMIN DROPS/IRON I 117multivitamin/extra vitami 117multivitamin/fluoride 117multi-vitamin gummies 116multivitamin gummies adul 117multivitamin gummies chil 117MULTIVITAMIN GUMMIES CHIL 117multivitamin gummies mens 117multivitamin gummies wome 117MULTIVITAMIN INFANT & TOD 117multivitamin men 50+ 117multi vitamin mens 116multivitamin mens 117multivitamin & mineral 116multi-vitamin/minerals 116MULTI-VITAMIN MONOCAPS 116multi-vitamin/multi-miner 116MULTIVITAMIN PLUS IRON CH 117multi-vitamins 116multivitamins 117multi-vitamins/iron 116

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Drug Name Page #multivitamin with fluorid 117multivitamin women 117multivitamin women 50+ 117multivitamin womens 117multi-vit/iron/fluoride 116mupirocin 157murine ear 170murine for ear wax remova 170MURO 128 134M.V.I. ADULT 114M.V.I. PEDIATRIC 114mvw complete formulation 117MVW COMPLETE FORMULATION 117myamulti 117MYCAMINE 12my choice 51mycophenolate mofetil 84mycophenolate sodium tbec 84myferon 150 81myferon 150 forte 81mynephrocaps 117mynephron 117myorisan 157MYRBETRIQ 77my-vitalife 117my way 51

N

nabumetone 7nadolol 29nafcillin sodium 18NAFCILLIN SODIUM FOR INJ 10GM 18NAGLAZYME 54nail-ex 117nalbuphine hcl 8naloxone inj 0.4mg/ml 44naloxone inj 1mg/ml 44naltrexone hcl 44NAMZARIC 35NANOVM 1-3 YEARS 117NANOVM 4-8 YEARS 117NANOVM 9-18 YEARS 118NANOVM T/F 118naproxen 7naproxen dr 7naproxen sodium 7naratriptan hcl 41

Drug Name Page #NARCAN 44NASADROPS SALINE ON THE G 154nasal allergy 24 hour mul 155nasal decongestant 147NASAL DECONGESTANT 147nasal decongestant maximu 147nasal decongestant pe 148nasal decongestant pe max 148nasal decongestant spray 148nasal four 148nasal moist 154nasal moisturizing spray 154nasal relief 148nasal spray 12 hour 148nasal spray extra moistur 148NASCOBAL 118nasogel 154NASOPEN PE 148NATACYN 131nateglinide 47NATPARA 57NATRAPEL 166NATRAPEL 12-HOUR TICK & I 166natural c/rose hips 118natural fiber 71natural fiber laxative 71natural fiber therapy 71natural senna laxative 71natural vitamin d-3 118natural vitamin e 118NATURAL VITAMIN E 118NEBUPENT 11necon 0.5/35-28 51nefazodone hcl 36neomycin-bacitracin zn-polymyxin 131neomycin-polymy-dexameth 131neomycin-polymyxin-gramicidin 131neomycin-polymyxin-hc (ophth) 131neomycin-polymyxin-hc (otic) 171neomycin sulfate 10NEOQ10 97NEPHPLEX RX 118NEPHRAMINE 87NEPHRONEX 118NEPHRON FA 81NERLYNX 23NEUPRO 37

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Drug Name Page #neuro-k-50 118NEUTROGENA HAND 166nevirapine susp 50 mg/5ml 13nevirapine tab 100mg er 13nevirapine tab 200mg 13nevirapine tab 400mg er 13new day 51NEXAVAR 23niacin 118NIACIN 118niacin-50 118niacin (antihyperlipidemic) 28niacin er (antihyperlipidemic) 28NIACIN TR 118niacor 28nicardipine hcl 29nicorelief 44nicotine 44nicotine polacrilex 44nicotine transdermal syst 44NICOTINE TRANSDERMAL SYST 44NICOTROL INHALER 44NICOTROL NS 44nifedipine 29nifedipine er 29nighttime cold/flu/maximu 148nighttime cold/flu relief 148nighttime cough 148night time multi-symptom 148night time pain medicine 44nighttime severe cold & f 148nighttime sinus congestio 148nikki 51nilutamide 21nimodipine 29NINJACOF 148NINJACOF-A 148NINJACOF-D 148NINJACOF-XG 148NINLARO 20nite time multi-symptom c 148NITRO-BID 31NITRO-DUR DIS 0.3MG/HR 31NITRO-DUR DIS 0.8MG/HR 31nitrofurantoin macrocrystal 11nitrofurantoin monohyd macro 11nitroglycerin 31

Drug Name Page #nitroglycerin td patch 31NITYR 54NIVANEX DMX 148NIVEA 166NIVEA SOFT 166noble formula 166noble formula hc 162no drip nasal spray 148nohist-dm 148nohist-lq 148NO IRON MULTIPLE VITAMIN/ 118non-aspirin 3non-aspirin childrens 3non-aspirin extra strengt 3non-aspirin pain relief 3non-aspirin pain relief e 3nora-be tab 51nore/eth/fer chw 0.4mg-35 52NOREL AD 148noreth/ethin chw fe 52norethin acet & estrad-fe 52norethindrone acetate 57norethindrone acetate-ethinyl estradiol 54norethindrone acet & eth estra 52norethindrone (contraceptive) 52norgest/ethi tab 0.25/35 52norgestimate-ethinyl estradiol (triphasic) 0.18-

25/0.215-25/0.25-25 mg-mcg 52norgestimate-ethinyl estradiol (triphasic) 0.18-

35/0.215-35/0.25-35 mg-mcg 52norlyroc 52NORMALYTE 86NORMOSOL-M IN D5W 89NORMOSOL-R 89NORMOSOL-R IN D5W 89NORPACE CR 27nortemp 3NORTEMP INFANTS 3NORTHERA 31nortrel 0.5/35 (28) 52nortrel 1/35 52nortrel 7/7/7 52nortriptyline hcl 36NORVIR PACK 13NORVIR SOLN 13norwegian salmon oil 97NOVAFERRUM 50 81

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Drug Name Page #NOVAFERRUM PEDIATRIC DROP 81NOVOLIN 70/30 46NOVOLIN 70/30 FLEXPEN 46NOVOLIN N 46NOVOLIN R 46NOVOLOG 46NOVOLOG 70/30 FLEXPEN 46NOVOLOG FLEXPEN 46NOVOLOG MIX 70/30 46NOVOLOG PENFILL 46NOXAFIL 12NUBEQA 21NUCALA 154NUCYNTA ER 9NUEDEXTA 42NUFOLA 118nu-iron 150 81NULOJIX 84NULYTELY/FLAVOR PACKS 71NU-MAG 93NUPLAZID CAPS 38NUPLAZID TABS 10MG 38NUTRADERM 166nutr-e-sol 118NUTRICAP 118NUTRILIPID INJ 20% 87NUTRIVIT 118NUVARING 52nyamyc 159NYMALIZE 30nystatin 12nystatin (mouth-throat) 170nystatin pow 100000 159nystatin (topical) 159nystop 159

O

ocean for kids 154ocella tab 3-0.03mg 52OCTAGAM 83octreotide acetate 57ocutabs 118ocutabs/lutein 118ocutabs vision formula 118OCUVITE ADULT 50+ 118OCUVITE ADULT FORMULA 118ocuvite extra 118

Drug Name Page #ocuvite eye health gummie 118ocuvite eye + multi 118ocuvite/lutein 118OCUVITE LUTEIN 118ODEFSEY 14ODOMZO 21odorless coated fish oil/ 97OFEV 154OFF ACTIVE 166OFF DEEP WOODS 166OFF DEEP WOODS DRY 166OFF DEEP WOODS SPORTSMEN 166OFF DEEP WOODS TOWELETTES 166OFF FAMILYCARE CLEAN FEEL 166OFF FAMILYCARE SMOOTH & D 166OFF FAMILYCARE TROPICAL F 166OFF FAMILYCARE UNSCENTED 166OFF SMOOTH & DRY 166ofloxacin (ophth) 131ofloxacin (otic) 171OINTMENT BASE 166olanzapine 38, 39olmesartan medoxomil 27olmesartan medoxomil-amlodipine-

hydrochlorothiazide 26olmesartan medoxomil-hydrochlorothiazide 26olopatadine hcl 0.2% 132OMEGA-3 97omega 3 500 97OMEGA-3 2100 98omega-3 fatty acids 98OMEGA-3 FISH OIL EXTRA ST 98OMEGA-3 IQ 98omega essentials basic 97omega iii epa+dha 97OMEPRAZOLE 76omeprazole cap 10mg 76omeprazole cap 20mg 77omeprazole cap 40mg 77omeprazole magnesium 77omera 98OMNICAP 118once daily 118once daily/iron 118ONCOVITE 118ondansetron hcl 65ondansetron hcl inj 65

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Drug Name Page #ondansetron hcl oral soln 65ondansetron odt 65ONE-A-DAY ADULT VITACRAVE 119ONE-A-DAY ENERGY 119ONE-A-DAY FOR HER VITACRA 119ONE-A-DAY FOR HIM/VITACRA 119ONE-A-DAY MENOPAUSE FORMU 119ONE-A-DAY MENS 50+ ADVANT 119ONE-A-DAY MENS HEALTH FOR 119ONE-A-DAY MENS VITACRAVES 119ONE-A-DAY PROACTIVE 65+ 119one-a-day teen advantage 119ONE-A-DAY TEEN ADVANTAGE 119ONE-A-DAY VITACRAVES 119ONE-A-DAY VITACRAVES ADUL 119ONE-A-DAY VITACRAVES GUMM 119ONE-A-DAY VITACRAVES SOUR 119ONE-A-DAY VITACRAVES WOME 120ONE-A-DAY WOMENS VITACRAV 120one daily 118one daily adults 50+ 119one daily complete 119one daily for men 50+ adv 119one daily for men/lycopen 119one daily for women 119one daily for women 50+a 119one daily healthy weight 119one-daily/iron 120one daily/iron/calcium 119one daily maximum 119one daily mens 119one daily mens 50+ multiv 119one daily mens health/lyc 119one daily/minerals 119ONE-DAILY MULTI-VITAMIN 120one daily multivitamin ad 119one daily multivitamin/ir 119ONE-DAILY MULTI-VITAMIN/M 120one-daily multi vitamins 120one daily plus iron 119one daily plus minerals 119one daily womens 50+ 119one daily womens 50 plus 119opcicon one-step 52OPSUMIT 31optic-vites 120optimal-d 120

Drug Name Page #OPTIMAL D3 M 120optimal-d pack 120optimum pms 120option 2 52OPTISOURCE POST BARIATRIC 120OPURITY/BYPASS OPTIMIZED 120oral electrolytes 86oralyte 86oralyte freezer pops 86orazinc 93ORAZINC 93ORFADIN 54ORKAMBI 154orsythia 52orthovite 120os-cal 93os-cal calcium + d3 93os-cal extra d3 93oseltamivir phosphate 15OSTEO-PORETICAL 93ovega-3 98oxacillin sodium 18oxaliplatin inj 50mg 24oxaliplatin inj 50mg/10ml 24oxaliplatin inj 100mg 24oxaliplatin inj 100mg/20ml 24oxandrolone 45oxcarbazepine 34oxybutynin chloride 77oxycodone hcl 9oxycodone w/ acetaminophen 2.5-325mg 9oxycodone w/ acetaminophen 5-325mg 9oxycodone w/ acetaminophen 7.5-325mg 9oxycodone w/ acetaminophen 10-325mg 9OXYCONTIN 9oysco 500 93oysco 500+d 93oyst-cal-d 500 93oystercal 94oyster calcium/vitamin d 93oystercal-d 94oyster shell 93oyster shell calcium 250+ 93oyster shell calcium 500 93oyster shell calcium 500+ 93oyster shell calcium + d 93oyster shell calcium+d 94

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Drug Name Page #oyster shell calcium + d3 94oyster shell calcium/d3 94oyster shell calcium plus 94oyster shell calcium + vi 94OYSTER SHELL CALCIUM/VITA 94OZEMPIC INJ 0.25 OR 0.5MG/DOSE 46OZEMPIC INJ 1MG/DOSE 46

P

pa biotin 120pacerone 27paclitaxel 20pa coenzyme q-10 98pa fish oil 98pain & fever 3pain & fever childrens 3pain & fever extra streng 4pain & fever infants 4pain relief extra strengt 4pain relief pm extra stre 44pain reliever extra stren 4pain reliever pm 44pain reliever pm extra st 44pain relieving maximum st 166paliperidone 39PA MENS 50 PLUS VITAPAK 120PA MENS VITAPAK 120pamidronate disodium 48PAMIDRONATE DISODIUM 48pamidronate inj 30mg 48pamidronate inj 90mg 48panoxyl wash 157PANRETIN 166pantoprazole sodium 77pantoprazole sodium tbec 77PANZYGA 83pa oyster shell calcium 94paricalcitol 120paroex sol 0.12% 170paromomycin sulfate 10paroxetine hcl tabs 36PARVLEX 120PASER D/R 15pa vitamin d-3 120pa vitamin d-3 gummy 120pa vitamin e 120PA WOMENS 50 PLUS VITAPAK 120

Drug Name Page #PA WOMENS VITAPAK 120PAXIL 36PAZEO 132PEDIA-LAX 71PEDIALYTE 86pedia relief cough/cold 148PEDIARIX 85pediatric cough/cold 148PEDIATRIC ELECTROLYTE 86pediatric electrolyte fre 86pediatric electrolyte/zin 86pediatric enema 71pediatric multiple vitamins w/ iron 120pedia vance 86PEDIAVENT 138pediavit 120PEDVAX HIB 85peg 3350/electrolytes 71peg 3350-kcl-sod bicarb-sod chloride-sod sulfate. 71peg 3350-potassium chloride-sod bicarbonate-

sod chloride 71PEGANONE 34PEGASYS 16PEGASYS PROCLICK 16PENICILLIN G POT IN DEXTROSE 2MU 18PENICILLIN G POT IN DEXTROSE 3MU 18PENICILLIN G PROCAINE 18penicillin g sodium 18penicillin v potassium 18penicilln gk inj 5mu 18penicilln gk inj 20mu 18PEN-KERA 166PENTACEL 85PENTAM 300 11pentamidine isethionate 11pentoxifylline 82PENTRAVAN 167PENTRAVAN PLUS 167peptic relief 63PERFECT IRON 81periguard 167perindopril erbumine 25periogard 170permethrin cre 5% 169perphenazine 39PERSERIS 39PETROLATUM 167

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Drug Name Page #pfizerpen-g inj 5mu 18pfizerpen-g inj 20mu 18pharbechlor 138pharbedryl 138pharbetol 4pharbetol extra strength 4PHAZYME MAXIMUM STRENGTH 75phenelzine sulfate 36phenobarbital 34phenobarbital sodium 34PHENOBARBITAL SODIUM 34PHENYLEPHRINE HCL/PYRILAM 148phenylephrine w/ dm-gg 148PHENYTEK 34phenytoin 34phenytoin sodium extended 34phenytoin sodium inj 50mg/ml 34philith 52PHLEXY-VITS 120PHOS FLUR 170PHOS-FLUR ORTHO DEFENSE 170phospha 250 neutral 94PHOSPHOLINE IODIDE 133PHYTOMULTI 120phytonadione 120PICATO 167PIFELTRO 13pilocarpine hcl 133pilocarpine hcl (oral) 170pimozide 39pimtrea 52pindolol 29pink bismuth 63pinworm medicine 11pioglitazone hcl 47piper/tazoba inj 2-0.25gm 18piper/tazoba inj 3-0.375gm 18piper/tazoba inj 4-0.5gm 18piper/tazoba inj 12-1.5gm 18piper/tazoba inj 36-4.5gm 18PIQRAY 200MG DAILY DOSE 23PIQRAY 250MG DAILY DOSE 23PIQRAY 300MG DAILY DOSE 23pirmella 1/35 52piroxicam 7PLASMA-LYTE-148 89PLASMA-LYTE A 89

Drug Name Page #PLENVU 71PNV FOLIC ACID + IRON MUL 120podactin powder 159podofilox 167polyethylene glycol 3350 71POLY-HIST DM 148POLY HIST FORTE 148POLY-HIST PD 148poly-iron 150 81poly-iron 150 forte 81polymyxin b-trimethoprim 131POLY-TUSSIN AC 148POLYTUSSIN DM 149POLY-VENT DM 148POLY-VENT IR 148polyvinyl alcohol 134poly vitamin 120polyvitamin 120polyvitamin/iron 120POMALYST CAP 1MG 22POMALYST CAP 2MG 22POMALYST CAP 3MG 22POMALYST CAP 4MG 22portia-28 52potassium chloride 87, 89potassium chloride in nacl 89potassium chloride microencapsulated crystals

er 87potassium citrate (alkalinizer) er tabs 77potassium & sodium phosphates 94pot chloride inj 2meq/ml 89povidone-iodine 167PRADAXA 79PRALUENT 28pramipexole tab 0.5mg 37pramipexole tab 0.25mg 37pramipexole tab 0.75mg 37pramipexole tab 0.125mg 37pramipexole tab 1.5mg 37pramipexole tab 1mg 37prasugrel hcl 82pravastatin sodium 27praziquantel 11prazosin hcl 26prednisolone acetate (ophth) 132prednisolone sodium phosphate 55

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Drug Name Page #PREDNISOLONE SODIUM PHOSPHATE

(OPHTH) 132prednisolone sol 15mg/5ml 55prednisolone sol 25mg/5ml 55PREDNISONE CON 5MG/ML 55prednisone pak 5mg 55prednisone pak 10mg 55prednisone sol 5mg/5ml 55prednisone tab 1mg 55prednisone tab 2.5mg 55prednisone tab 5mg 55prednisone tab 10mg 55prednisone tab 20mg 55prednisone tab 50mg 55pred sod pho sol 5mg/5ml 55PREFERRED PLUS GLUCOSE 56pregabalin 34PREMASOL SOL 10% 87PREMIUM CONDOMS LUBRICATE 52PRENATAL 120, 121PRENATAL LOW IRON 121PRENATAL MULTI + DHA 121PRENATAL MULTIVITAMIN + D 121PRENATAL MULTIVITAMIN PLU 121PRENATAL OMEGA BABY 98PRENATAL ONE DAILY 121PRENATAL PLUS 121PRENATAL PLUS LOW IRON 121PRENATAL TABLETS 121PRENATAL VITAMIN 121PRENATAL VITAMIN/IRON 121PRENATAL VITAMIN & MINERA 121PRENATAL VITAMINS 121preparation h 162PRESERVISION AREDS 121PRESERVISION AREDS 2 121PRESERVISION/LUTEIN 121PRETTY FEET & HANDS 167prevalite 28prevent 121previfem 52PREZCOBIX 14PREZISTA 13PRIFTIN 15primaquine phosphate 12PRIMAQUINE PHOSPHATE 12PRIMATENE MIST 149

Drug Name Page #primidone 34PRIVIGEN 83probenecid 1probiata 63PROBIOTIC 63probiotic acidophilus 63probiotic acidophilus sup 63probiotic gold extra stre 63PRO-CAL 121PROCALAMINE 87PROCERV HP 121prochlorperazine inj 65prochlorperazine maleate 65prochlorperazine supp 65PROCRIT 79procto-med hc 167procto-pak 167proctosol hc cre 2.5% 167proctozone-hc 167PROFE 81PROFERRIN-FORTE 81PROGLYCEM SUS 50MG/ML 56PROGRAF 84PROLASTIN-C 154PROLENSA 132PROLIA 57PROMACTA 82promethazine-dm 149promethazine hcl 65promethazine hcl inj 65promethazine-phenylephrine-codeine 149promethazine w/codeine 149pronutrients calcium+d3 94PRO NUTRIENTS OMEGA 3 98propafenone hcl 27propafenone hcl 12hr 27proparacaine hcl 134propranolol cap er 29propranolol hcl 29propranolol & hydrochlorothiazide 28propranolol oral sol 29propylthiouracil 58PROQUAD 85PRO-RED AC 149PRORENAL+D 121PRORENAL+D/OMEGA-3 121PROSHIELD PLUS SKIN PROTE 167

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Drug Name Page #prosight 121prosight w/lutein 121PROSOL 87PROTECT CARDIO AF 121PROTECTIRON 81PROTECT PLUS NF 121PROTECT PLUS SO 121PROTEGRA 121protriptyline hcl 36provil 7pseudoephed-bromphen-dm 149pseudoephed-cpm w/ hydrocod 149pseudoephedrine-guaifenesin 149pseudoephedrine hcl 149PULMICORT FLEXHALER 155pulmosal 149PULMOZYME 154puralube 134pure c 500 121pure & gentle lubricant 134pure l-arginine hcl 98PURE L-CITRULLINE 98pureway-c 121PURIXAN 19px acid reducer 66px acid reducer maximum s 66px advanced formula multi 121px all day relief 7px allergy 138px allergy relief 139px allergy relief d 149px antacid extra strength 60px antacid maximum streng 60px antacid regular streng 60px arthritis pain relief 4px artificial tears 134px aspirin 4px athletic foot 159px b complex/vitamin c 121px calcium antacid regula 61px calcium&d 94px childrens allergy 139px childrens pain relief 4px childrens profen ib 7px childrens vitamin 121px complete senior multiv 121px docusate sodium 71

Drug Name Page #px fiber 71px fish oil 98px folic acid 121px gas relief extra stren 75px gas relief infants 75px gas relief ultra stren 75PX GLUCOSE 56px hydrocream 162px ibuprofen 7px ibuprofen junior stren 7px infants profen ib 7px iron 81px laxative 71px mens multivitamins 122px miconazole 3-day combo 78px milk of magnesia 71px nasal decongestant 149px niacin 122px pain relief extra stre 4px pain relief pm extra s 44px saline nasal spray 154px stomach relief 63px stomach relief maximum 63px stop smoking aid 44px triple ointment 157px vitamin c 122px vitamin e 122pyrazinamide 15pyridostigmine tab 60mg 42pyridoxine hcl 122

Q

qc 3 day vaginal cream 78qc acetaminophen 8 hours 4qc acid controller 66qc acid controller maximu 66qc all day allergy 139qc allergy relief 139qc allergy relief multi-s 149qc allergy/sinus headache 149qc antacid 61qc antacid/anti-gas 61qc antacid/anti-gas maxim 61qc antacid extra strength 61qc anti-diarrheal 63qc anti-gas ultra strengt 75qc anti-itch extra streng 159

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Drug Name Page #qc arthritis pain relief 4qc aspirin 4qc aspirin low dose 4qc bacitracin 157qc calcium fast dissoluti 94qc calcium/minerals/vitam 94qc chewable aspirin low d 4qc childrens allergy 139qc childrens chewable com 122qc childrens chewable vit 122qc chlor-pheniramine 139qc complete allergy medic 139qc cough/sore throat nigh 149qc daily multivitamins/ir 122qc diarrhea relief 63qc docusate calcium 72qc enema 72qc enteric aspirin 4qc epsom salt 72qc ferrous sulfate 81qc fexofenadine hydrochlo 139qc fiber laxative 72qc fluticasone propionate 155qc gentle laxative 72qc heartburn antacid 61qc ibuprofen 7qc ibuprofen cold/sinus 149qc ibuprofen ib 7qc ibuprofen infants 7qc laxative 72qc loratadine allergy rel 139qc loratadine-d 149qc magnesium citrate 72qc maximum daily multivit 122qc medifin 400 149qc medifin dm 149qc mens daily multivitami 122qc miconazole 7 78qc milk of magnesia 72qc mineral oil heavy 72qc multi-vite 122qc multi-vite 50 & over 122qc naproxen sodium 7qc natura-lax 72qc natural vegetable 72qc natural vegetable laxa 72qc non-aspirin childrens 4

Drug Name Page #qc non-aspirin extra stre 4qc non-aspirin jr strengt 4qc omeprazole magnesium 77qc pain relief 4qc pain relief childrens 4qc pain relief extra stre 4qc pain relief infants 4qc pink bismuth 63qc povidone iodine 167QC PRENATAL 122qc senna 72qc senna-s 72qc sinus pain relief 149qc stool softener 72qc stool softener plus la 72qc stool softener plus st 72qc suphedrine maximum str 149qc therin-m 122qc tolnaftate 159qc tussin cf 149qc tussin dm cough & ches 149qc tussin mucus + chest c 149qc womens daily multivita 122Q-GEL 98q-gel forte 98q-gel mega 98q-gel ultra 98q-sorb 98q-sorb co q-10 98QUADRACEL 85quetiapine fumarate 39quinapril hcl 25quinapril-hydrochlorothiazide 25QUIN B STRONG 122quinidine sulfate 27quinine sulfate 12QUINTABS 122quintabs-m 122QUINTABS-M 122

R

ra acidophilus 63RA ADVANCED HEALING 167ra antacid 61rabano yodado 123RABAVERT 85ra b-complex/vitamin c tr 122

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Drug Name Page #rabeprazole sodium 77ra biotin 122ra calcium 600 94ra calcium 600 plus vitam 94ra calcium 600/vit d/mine 94ra calcium citrate plus v 94ra calcium citrate/vitami 94RA CALCIUM HI-CAL/VITAMIN 94ra calcium/minerals/vitam 94ra calcium plus vitamin d 94ra central-vite 122RA CENTRAL-VITE 122ra central-vite/antioxida 122ra central-vite energy 122ra central-vite select 122ra central-vite select ma 122ra central-vite senior 122RA CENTRAL-VITE UNDER 50 122ra central-vite womens ma 122ra coenzyme q-10 98ra cough dm 149ra digestive health 63ra epsom salt 72RA EPSOM SALT 72RA EPSOM SALT LAVENDER 72RA ESSENCE-C 122ra fish oil 98RA FISH OIL 98ra folic acid 122ra gas relief 76ra gas relief extra stren 76RA GENTLE SKIN CREAM 167ra glucose 56RA GLUCOSE 56ra gummy vitamins & miner 122ra hair/skin/nails 122ra hi cal 94ra hi-cal 94ra hi-cal plus vitamin d 94ra high potency iron 81ra hydrating healing 167ra iron 81ra l-arginine 98ra laxative 72ra lice maximum strength 169ra lice solution kit 169raloxifene hcl 57

Drug Name Page #ra lubricant eye drops 134ra magnesium 94ra mature womens dietary 123ra mineral oil 72ramipril 25ra moisturizing therapy 167ra multihealth fiber supp 72ra natural vitamin e 123ra niacin 123ranitidine 150 maximum st 66ranitidine hcl 66ranitidine hcl inj 66ranitidine syrup 66ra no flush niacin 500 123ranolazine 31ra one daily energy formu 123ra one daily essential 123ra one daily gummy vites 123ra one daily maximum 123ra one daily mens 50+ wit 123ra one daily mens/vitamin 123ra one daily multi-vitami 123ra one daily womens/vitam 123ra ophthalmic solution 134ra oyster shell calcium 94ra oyster shell calcium/v 94ra pediatric electrolyte 87ra pink bismuth 63ra renewal moisturizing 167rasagiline mesylate 37ra saline nasal spray 154ra slow release iron 81RA STERILE SALINE NASAL M 154ra stomach relief 64ra stomach relief maximum 64ra stress formula advance 123ra stress formula energy 123ra therapeutic m plus bet 123RA TRIPLE STRENGTH FISH O 98RA TRUEPLUS GLUCOSE 56ra vision vite plus zinc 123ra vitamin b-6 123ra vitamin b-12 123ra vitamin b12 123RA VITAMIN B-12 123ra vitamin b-12 tr 123ra vitamin c 123

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Drug Name Page #ra vitamin c/acerola 123ra vitamin c/rose hips 123ra vitamin c tr 123ra vitamin d-3 123ra vitamin e 123ra vitamin e blend 123ra whole source complete 123ra whole source dietary 123ra whole source dietary f 123ra whole source dietary m 123RAYALDEE 124react 52REBETOL SOLN 16reclipsen 52RECOMBIVAX HB 85RECTIV 167reeses pinworm medicine 11REESES PINWORM MEDICINE 11REFRESH 134refresh celluvisc 134refresh lacri-lube 134REFRESH LIQUIGEL 134REFRESH OPTIVE 134REFRESH OPTIVE ADVANCED 134REFRESH OPTIVE ADVANCED S 134REFRESH OPTIVE MEGA-3 135REFRESH OPTIVE PRESERVATI 135refresh p.m. 135REGRANEX 170reguloid 72rehydralyte 87RELENZA DISKHALER 16relion glucose 56RELION GLUCOSE 56relion glucose drink 56RELISTOR 76remedy antifungal 160remedy antifungal clear/p 160REMEDY CLEAR-AID 167REMEDY DIMETHICONE MOISTU 167REMEDY NUTRASHIELD 167remedy phytoplex antifung 160REMEDY SKIN REPAIR 167REMICADE 83renal caps 124renal multivitamin formul 124renal vitamin 124

Drug Name Page #renal-vite 124renaplex 124RENAPLEX-D 124rena-vite 124rena-vite rx 124RENFLEXIS 83reno caps 124repaglinide 47REPEL 100 167REPEL FAMILY 167REPEL FAMILY DRY 167REPEL HUNTERS FORMULA 167REPEL LEMON EUCALYPTUS IN 167REPEL MOSQUITO WIPES 167REPEL SPORTSMEN 167REPEL SPORTSMEN DRY 168REPEL SPORTSMEN MAX 168REPEL TICK DEFENSE 168REPHRESH PRO-B 64REPLACE 124REPLACE SR 87REPLESTA 124REPLESTA CHILDRENS 124REPLESTA NX 124RESCON 149RESCON DM 149RESCRIPTOR 13RESPAIRE-30 149RESTASIS 135RESTASIS MULTIDOSE 135RETAINE HPMC 135retaine pm 135REVLIMID 22REXULTI 39REYATAZ 13RHINARIS 154RHOPRESSA 133ribasphere 16ribavirin 200mg 16RID ESSENTIAL LICE ELIMIN 169rid lice killing shampoo 169rifabutin 15rifampin 15RIFATER 15RIGHT STEP PRENATAL 124riluzole 42rimantadine hydrochloride 16

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Drug Name Page #RISABAL-PH 168RISACAL-D 94risedronate sodium 48RISPERDAL INJ 12.5MG 39RISPERDAL INJ 25MG 39RISPERDAL INJ 37.5MG 39RISPERDAL INJ 50MG 39risperidone 39ritonavir 13RITUXAN 21RITUXAN HYCELA 21rivastigmine tartrate 35rivastigmine td patch 24hr 4.6 mg/24hr 35rivastigmine td patch 24hr 9.5 mg/24hr 35rivastigmine td patch 24hr 13.3 mg/24hr 35rivelsa 52rizatriptan benzoate 41rizatriptan benzoate odt 41robafen 149robafen ac 149robafen cf multi-symptom 149robafen cough 149robafen dm 149robafen dm cough 150robafen dm cough/chest co 150robafen dm cough clear 150robafen mucus/chest conge 150rolaids 61RONDEC-D 150ropinirole tab 0.5mg 37ropinirole tab 0.25mg 37ropinirole tab 1mg 37ropinirole tab 2mg 37ropinirole tab 3mg 37ropinirole tab 4mg 37ropinirole tab 5mg 37rosadan 168rosuvastatin calcium 27ROTARIX 85ROTATEQ 85roweepra 34roweepra xr 34RUBRACA 21RU-HIST D 150rulox 61RYDAPT 23RYDEX 150

Drug Name Page #RYMED 150rynex dm 150rynex pe 150rynex pse 150

S

salactic film 168saline 154saline mist 154SALMON OIL-1000 98sal-plant 168sam-e.p.a. 98SANDIMMUNE 84SANTYL 170SAPHRIS 39saratoga 168savision 124SAWYER INSECT REPELLENT 168SAWYER INSECT REPELLENT C 168SAWYER PREMIUM INSECT REP 168sb 12hr nasal spray 150sb acid reducer 66sb allerfed cold & allerg 150sb allergy 139sb allergy & cold pe 150sb allergy medicine 139sb allergy relief/nasal d 150sb antacid 61sb antacid anti-gas 61sb antacid extra strength 61sb anti-diarrhea 64sb anti-fungal 160sb arthritis pain relief 4sb aspirin 4sb aspirin adult low stre 4sb bisacodyl laxative ec 72sb bismuth 64sb calcium + d 94sb childrens aspirin 4sb chlorpheniramine 139sb cold & cough hbp 150sb cold & flu severe 150sb cold multi-symptom sev 150sb cough control 150sb cough control dm 150sb cough control dm max 150sb coughtab 150

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Drug Name Page #sb docusate sodium 72sb docusate sodium/senna 72sb fib lax orange 72sb hydrocortisone 162sb hydrocortisone maximum 162sb hydrocortisone plus 162sb ibuprofen 7sb infants ibuprofen 7sb laxative 72sb lice killing maximum s 169sb lice treatment 169sb loratadine 139sb loratadine allergy rel 139sb low dose asa ec 4sb milk of magnesia 72sb motion sickness 65sb mucus relief dm 150sb mucus relief pe 150sb naproxen sodium 7sb non-aspirin 4sb non-aspirin extra stre 4sb non-aspirin nighttime 44sb omega-3 fish oil 98SB OMEPRAZOLE 77sb oyster shell calcium 94sb pain reliever children 4sb pain reliever extra st 4sb pediatric electrolyte 87sb povidone-iodine 168sb saline nose 154sb senna-lax 72sb severe cold pe 150sb sinus & allergy maximu 150sb sinus congestion & pai 150sb tab tussin dm 150sb triple antibiotic 157sb urinary pain relief ma 77sb vitamin c 124scalpicin maximum strengt 162sclerex 124SCOOBY-DOO ONE A DAY 124scopolamine 65sea-omega 98sea-omega 30 98sebex 168selegiline hcl 37selenium sulfide 160

Drug Name Page #SELZENTRY 13senexon 72senexon-s 72senior tabs 124senna-grx 73senna-lax 73senna laxative 73senna plus 73senna-s 73senna-tabs 73senna-time 73senna-time s 73senno 73sennosides 73sennosides-docusate sodium 73senokot extra strength 73SENSI-CARE MOISTURIZING 168sentry 124SENTRY 124sentry adults under 50 124sentry senior 124SENTRY SENIOR 124SEREVENT DISKUS 140sertraline hcl 36setlakin tab 52sevelamer carbonate 57sharobel 52SHINGRIX 85SIGNIFOR 57silace 73siladryl allergy 139sildenafil citrate tab 20 mg (pulmonary

hypertension) 32SILENOR 41silphen dm cough 150siltussin das 150siltussin-dm 150siltussin dm das 150siltussin sa 150silver sulfadiazine 157SIMBRINZA 133simethicone 76SIMPLY SALINE 154simvastatin 27sinus

and headache daytim 150sinus congestion & pain d 151

219

Drug Name Page #sinus congestion & pain s 151sinus nasal spray 151sinus pressure/pain/adult 151sinus relief extra streng 151SINUS WASH SALT 154sirolimus 84SIRTURO 15SIVEXTRO 11slo-niacin 124slow fe 81slow iron 81SLOW-MAG 94slow magnesium chloride/ 94slow release iron 81slow-release iron 81sm 3-day vaginal 78sm 8 hour pain relief 4sm 12 hour sinus deconges 151sm acidophilus 64sm acid reducer 66sm acid reducer maximum s 66sm all day allergy 139sm all day allergy childr 139sm all day allergy-d 151sm allergy 4 hour 139sm allergy maximum streng 160sm allergy relief 139sm allergy relief childre 139sm allergy relief nasal s 155sm animal shapes complete 124sm animal shapes kids fir 124sm antacid advanced 61sm antacid advanced maxi 61sm antacid anti-gas 61sm antacid/antigas 61sm antacid maximum streng 61sm antibiotic 157sm antibiotic plus pain r 157sm anti-diarrheal 64sm antifungal clotrimazol 160sm antifungal miconazole 160sm antifungal tolnaftate 160sm anti-itch extra streng 160sm antioxidant vitamins 124sm arthritis pain relief 4sm arthritis pain relieve 5sm artificial tears 135

Drug Name Page #SMART SENSE GLUCOSE 56SMART SENSE GLUCOSE TABLE 56sm aspirin 5sm aspirin adult low stre 5sm aspirin ec low strengt 5sm aspirin enteric coated 5sm aspirin low dose 5sm athletes foot 160SM B-COMPLEX/VITAMIN C 124sm bedding lice treatment 169SM BENZOIN TINCTURE 160sm b super vitamin comple 124sm calcium 500/vitamin d3 95sm calcium 600+d3 95sm calcium 600/vitamin d 95sm calcium antacid 61sm calcium antacid extra 61sm calcium citrate/vitami 95sm calcium citrate+ w/vit 95sm calcium citrate w/vita 95sm calcium /vitamin d 95sm calcium/vitamin d 95sm calcium/vitamin d3 95sm castor oil 73sm chest congestion relie 151sm chewable c 124sm chewable vitamin c 124sm childrens aspirin 5sm childrens ibuprofen 7sm childrens loratadine 139sm clearlax 73sm clotrimazole vaginal 78sm coenzyme q-10 98sm cold & allergy childre 151sm cold & allergy pe 151sm cold & cough dm childr 151sm cold & flu severe 151sm complete 124sm complete 50+ 125sm complete 50+ ultimate 125sm complete advanced form 125sm complete senior formul 125sm co q-10 98sm coq-10 98sm day time cold & flu re 151sm day time pe cold & flu 151sm double antibiotic 157

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220

Drug Name Page #sm dry eye relief 135sm ear drops 171sm enema 73sm epsom salt 73sm esomeprazole magnesium 77sm eye itch relief 132sm fexofenadine hcl 139sm fexofenadine hydrochlo 139sm fiber 73sm fiber laxative 73SM FIBER POWDER 73sm fish oil 98SM FISH OIL 99sm foaming antacid 61sm folic acid 125sm gas relief 76sm gas relief antiflatuen 76sm gas relief drops infan 76sm gas relief extra stren 76sm gentle laxative 73SM GLUCOSE 56sm hair/skin/nails 125sm hydrocortisone 162sm hydrocortisone/aloe ma 162sm hydrocortisone maximum 162sm hydrocortisone plus 162sm ibuprofen 7sm ibuprofen ib 7sm ibuprofen jr 7sm infants ibuprofen 7sm iron 81sm iron slow release 81sm lansoprazole 77sm laxative 73sm laxative maximum stren 73sm lice killing 169sm lice killing maximum s 169sm lice solution kit 169sm lice treatment 169sm loperamide hcl 64sm loratadine 139sm loratadine allergy rel 139sm lorata-dine d 151sm loratadine d 12hr 151sm lubricant eye drops 135sm lubricating plus 135sm lubricating tears 135

Drug Name Page #sm magnesium 95sm magnesium citrate 73sm miconazole 3 78sm miconazole 7 78sm milk of magnesia 73sm mineral oil 73sm motion sickness 65sm motion sickness relief 65sm mucus relief cough chi 151sm multiple vitamins esse 125sm multiple vitamins/iron 125sm naproxen sodium 7sm nasal decongestant max 151sm nasal decongestant pe 151sm nasal spray 151sm nasal spray 12 hour 151sm nasal spray moisturizi 151sm nasal spray saline 154sm nasal spray sinus 151sm natural laxative plus 73sm niacin cr 125sm nicotine 44sm nicotine polacrilex 44sm nicotine transdermal s 44sm night time liquid caps 151sm nite time cold & flu 151sm nose drops nasal decon 151sm omega-3 fish oil 99SM OMEPRAZOLE 77SM ONE DAILY MENS 125SM ONE DAILY WOMENS 125sm opti-vitamins 125sm oyster shell calcium/v 95sm pain & fever childrens 5sm pain & fever infants 5sm pain relief extra stre 5sm pain reliever 5sm pain reliever extra st 5sm pain reliever pm extra 44sm pediatric electrolyte 87sm povidone-iodine 168SM PRENATAL VITAMINS 125sm senna laxative 73sm senna-s 73sm sinus & cold-d 151sm slow release iron 81SM SLOW RELEASE IRON 81

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221

Drug Name Page #sm stomach relief 64sm stomach relief liquid 64sm stool softener 73sm stool softener plus la 73sm super b complex-vitami 125sm triple antibiotic 157sm triple antibiotic orig 157sm triple antibiotic plus 158sm tussin cf 151sm tussin dm 151sm tussin dm cough/chest 151sm tussin mucus + chest c 151sm urinary pain relief 77sm urinary pain relief ma 77sm vitamin b-6 125sm vitamin b6 125sm vitamin b-12 125sm vitamin b12 125sm vitamin b12 tr 125sm vitamin c 125sm vitamin c/rose hips 125sm vitamin c tr 125sm vitamin d 125sm vitamin d3 125SM VITAMIN D3 MAXIMUM STR 125sm vitamin e 125sm vitamin e blended 125sm vit c/rose hips 125sochlor 135SODIUM BICARBONATE 61sodium bicarbonate (antacid) 61sodium chloride 87, 89sodium chloride 0.45% 89sodium chloride hypertonic 135sodium chloride (inhalant) 151sodium chloride inj 0.9% 89sodium chlor sol 0.9% irr 170sodium ferric gluconate complex in sucrose 81sodium fluoride chew\; tab\; 1.1 (0.5 f) mg/ml

soln 87sodium phenylbutyrate 54sodium phosphates 73sodium polystyrene sulfonate powder 48sodium polystyrene sulfonate susp 48SOLIQUA 100/33 46SOLO 125SOLTAMOX 21

Drug Name Page #soluble fiber 73SOLU-CORTEF 55SOMATULINE DEPOT 57SOMAVERT 57soothe 64SOOTHE & COOL FREE MEDSEP 168SOOTHE & COOL FREE MOISTU 168soothe & cool inzo antifu 160SOOTHE & COOL PROTECT MOI 168SOOTHE & COOL SKIN CREAM 168soothe xp/xtra protection 135soothing - 12 hour nasal 151SORBIDON HYDRATE 168SORBITOL 73SORBOLENE 168sore throat 168sorine 27sotalol hcl 27sotalol hcl (afib/afl) 27spironolactone 26spironolactone & hydrochlorothiazide 30sprintec 28 52SPRITAM 34SPRYCEL 23sps susp 15gm/60ml 48sronyx 52ssd 158STAHIST 151STAHIST AD 152stavudine 13STELARA 83STERILE LUBRICANT DROPS 135STIMATE 58stimulant laxative 74STIVARGA 24st joseph low dose aspiri 5stomach relief 64stomach relief maximum st 64stool softener 74stool softener extra stre 74stool softener laxative 74stool softener/laxative 74stool softener plus laxat 74stop lice complete lice t 169stop lice maximum strengt 169streptomycin sulfate 10stress b-complex/vitamin 125

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222

Drug Name Page #stress b/zinc 125stress formula 125stress formula/iron 125stress formula w/iron 125stress formula/zinc 126stresstabs advanced 126stresstabs energy 126STRIBILD 14STUDIO 35 MOISTURIZING SK 168stye 135subvenite tab 34sucralfate 76sudafed 12 hour 152sudogest 152sudogest 12 hour 152sudogest pe 152sudogest sinus & allergy 152sulfacetamide sodium (acne) 157sulfacetamide sodium (ophth) 131sulfacetamide sod-prednisolone 131SULFADIAZINE 10sulfamethoxazole-trimethop ds 11sulfamethoxazole-trimethoprim inj 11sulfamethoxazole-trimethoprim susp 11sulfamethoxazole-trimethoprim tab 400-80mg 11SULFAMYLON 158sulfasalazine 66sulfasalazine ec 66sulindac 8sumatriptan 41sumatriptan inj 4mg/0.5ml 41sumatriptan inj 6mg/0.5ml 42sumatriptan succinate 42sunvite advanced 126SUPER ANTIOXIDANT 126super antioxidant/a/c/e/s 126super aytinal 50 plus 126super aytinal for active 126super b-complex/folic aci 126super b-complex/vitamin c 126super biotin 126super b with c 126super calcium 95super calcium 600 + d3 95super calcium 600+d3 400 95super calcium 600+d 400 95SUPER DAILY D3 126

Drug Name Page #super dha gems 99SUPERIORSOURCE K1 126super multiple 126super nu-thera 126SUPER NU-THERA 126super omega-3 99superplex-t 126super thera vite m 126SUPER TWIN EPA/DHA 99super vikaps 126super vita-mins 126SUPREP BOWEL PREP KIT 74SUTENT 24syeda 52SYLATRON 24SYMBICORT 156SYMDEKO 154SYMFI 14SYMFI LO 14SYMJEPI 154SYMPAZAN 34SYMTUZA 14SYNAREL 53SYNERCID 11SYNJARDY TAB 5-500MG 47SYNJARDY TAB 5-1000MG 48SYNJARDY TAB 12.5-500MG 48SYNJARDY TAB 12.5-1000MG 48SYNJARDY XR TAB 5-1000MG 48SYNJARDY XR TAB 10-1000MG 48SYNJARDY XR TAB 12.5-1000MG 48SYNJARDY XR TAB 25-1000MG 48SYNRIBO 24SYNTHROID 58SYSTANE GEL 135systane nighttime 135SYSTANE OVERNIGHT THERAPY 135

T

tab-a-vite 126tab-a-vite/iron 126tab-a-vite w/beta caroten 126TABLOID 20tacrolimus 84tacrolimus (topical) 168tactinal 5tactinal extra strength 5

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223

Drug Name Page #TAFINLAR 24TAGRISSO 24take action 52TALZENNA 21tamoxifen citrate 22tamsulosin hcl 77TARGRETIN 168tarina 24 fe 52tarina fe 1/20 53TARON FORTE 81TASIGNA 24TAXOTERE 20tazarotene 160tazicef 17TAZORAC 160taztia xt 30TDVAX 85tears again 135TECENTRIQ 21TEFLARO 17telmisartan 27telmisartan-amlodipine 26telmisartan-hydrochlorothiazide 26temazepam 41TENIVAC 85tenofovir disoproxil fumarate 13tension headache 5terazosin hcl 26terbinafine hcl 12terbinafine hcl (topical) 160terbutaline sulfate 140terconazole vaginal 78testosterone 45testosterone cypionate 45testosterone enanthate 45tetrabenazine 42tetracycline hcl 19TEXACORT SOLN 2.5% 162tgt acetaminophen childre 5tgt acetaminophen extra s 5tgt all day allergy relie 139tgt allergy & congestion 152tgt allergy+ congestion r 152tgt allergy relief 139tgt allergy relief childr 139tgt antacid 61tgt antacid anti-gas regu 61

Drug Name Page #tgt antacid extra strengt 61tgt anti-diarrheal 64tgt antifungal 160tgt antifungal spray powd 160tgt arthritis pain relief 5tgt aspirin 5tgt aspirin low dose 5tgt calcium + vitamin d3 95tgt childrens acetaminoph 5tgt childrens aspirin 5tgt childrens ibuprofen 8tgt clotrimazole 160tgt enteric-coated aspiri 5tgt fiber therapy 74tgt first aid antibiotic 158tgt gas relief extra stre 76tgt gas relief infants dr 76tgt gentle laxative 74TGT GLUCOSE 56tgt ibuprofen 8tgt ibuprofen childrens 8tgt ibuprofen junior stre 8tgt itch relief extra str 160tgt laxative pills maximu 74tgt loratadine childrens 139tgt lubricant eye drops 135tgt lubricant eye nightti 135tgt miconazole 3 combinat 78tgt miconazole 7 78tgt naproxen sodium 8tgt nasal spray 154tgt natural laxative pill 74tgt nicotine gum 45tgt nicotine polacrilex 45tgt nicotine step one 45tgt nicotine step three 45tgt nicotine step two 45tgt powderlax 74tgt psyllium fiber 74tgt saline laxative 74tgt saline nasal spray 155tgt senna laxative 74tgt sinus 12 hour 152tgt stomach relief 64tgt stool softener 74tgt stool softener & stim 74tgt womens laxative 74

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224

Drug Name Page #THALOMID 22the magic bullet 74THEO-24 155theophylline 155theophylline tab er 12hr 300 mg 155theophylline tab er 12hr 450 mg 155theophylline tab sr 24hr 155thera 126THERA 126therabasic-m 127thera-d 2000 126THERA-D 4000 126thera-derm 168thera-d rapid repletion 126theraflu expressmax sever 152THERAFLU FLU & SORE THROA 152THERAGRAN-M 127THERAGRAN-M ADVANCED 127THERAGRAN-M ADVANCED 50 P 127theragran-m fish oil conc 99THERAGRAN-M PREMIER 127THERAGRAN-M PREMIER 50 PL 127thera-m 126THERA-M 126THERA M PLUS 126THERANATAL PLUS 127therapeutic 127therapeutic formula/hemat 127therapeutic m 127therapeutic-m 127therapeutic-m/lutein 127THERAPEUTIC MOISTURIZING 168therapeutic multi vitamin 127thera-tabs 126THERA-TABS M 127THERATEARS 135theratrum complete 127theratrum complete 50 plu 127theravim -m 127thera vital m 126therems 127THEREMS-H 127THEREMS-M 127THERMOTABS 87theromega 99the very finest fish oil 99th eye drop advanced reli 135

Drug Name Page #thiamine hcl 127THIAMINE HCL 127thioridazine hcl 39thiothixene 39thrive 45THRIVITE 19 127tiagabine hcl 34TIBSOVO 21tigecycline 11tilia fe 53timolol maleate 29timolol maleate gel 133timolol maleate (ophth) soln 133timolol maleate ophth soln 0.5% (once-daily) 133TIVICAY 14tizanidine hcl 43TOBRADEX 131TOBRADEX ST 131tobramycin 10tobramycin-dexamethasone 131tobramycin inj 1.2gm 10tobramycin inj 1.2 gm/30ml 10tobramycin inj 10mg/ml 10tobramycin inj 80mg/2ml 10tobramycin (ophth) 131tobramycin sulfate 10tolnaftate 160tolterodine tartrate cap er 77tolterodine tartrate tabs 78topiramate 34toposar 25toremifene citrate 22torsemide tabs 30total allergy 139total b/c 127totalday multiple 127total formula 127total formula 2 127total formula 3 127TOVIAZ 78TPN ELECTROLYTES 87TRADJENTA 48tramadol-acetaminophen 8tramadol hcl tab 50 mg 8trandolapril 25tranexamic acid 82tranylcypromine sulfate 36

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225

Drug Name Page #TRAVASOL 88TRAVATAN Z 133travel-ease 65travel sickness 65trazodone hcl 36TRECATOR 15TRELEGY ELLIPTA 135TRELSTAR DEP INJ 3.75MG 22TRELSTAR LA INJ 11.25MG 22treprostinil 32TRESIBA FLEXTOUCH 46TRESIBA INJ 46tretinoin 157tretinoin (chemotherapy) 24triacting nightime cold& 152triamcinolone acetonide (mouth) 170triamcinolone acetonide (nasal) 155triamcinolone acetonide (topical) 162TRIAMINIC COLD & ALLERGY 152TRIAMINIC COLD & COUGH DA 152triaminic fever & cold mu 152TRIAMINIC NIGHT TIME COLD 152triamterene & hydrochlorothiazide cap 37.5-

25 mg 30triamterene & hydrochlorothiazide tabs 30tri-biozene 158TRICARE 127trientine hcl 49tri-estarylla 53trifluoperazine hcl 39trifluridine 131trihexyphenidyl hcl 37tri-legest fe 53tri-linyah 53tri-lo-estarylla 53tri-lo marzia 53tri-lo-sprintec 53trilyte 74trimethoprim 11tri-mili 53trimipramine maleate 36TRINTELLIX 36triple antibiotic 158triple antibiotic first a 158triple antibiotic plus 158triple paste af 160tri-previfem 53

Drug Name Page #triprolidine hcl 139tri-sprintec 53TRIUMEQ 15TRI-VITAMIN INFANT & TODD 127trivora-28 53tri-vylibra 53tri-vylibra lo 53TROGARZO 14TROPHAMINE INJ 10% 88tropical liquid nutrition 127trospium chloride 78trueplus diabetic multivi 127TRUEPLUS GLUCOSE GEL 56TRULICITY 46TRUMENBA 85TRUSTEX/RIA NON-LUBRICATE 53TRUVADA TAB 100-150 15TRUVADA TAB 133-200 15TRUVADA TAB 167-250 15TRUVADA TAB 200-300 15trymine cg 152tulana 53TUMS CHEWY DELIGHTS 61tums smoothies 61TURALIO 24TUSNEL 152TUSNEL C 152tusnel diabetic 152TUSNEL-DM PEDIATRIC 152TUSNEL PEDIATRIC 152TUSSICAPS 152tussin cf 152tussin cf cough & cold 152tussin cf max multi-sympt 152tussin cf severe multi-sy 152tussin cough 152tussin dm 152tussin dm cough + chest c 152tussin dm max 152tussin dm max adult 152tussin mucus & chest cong 152tussin mucus + chest cong 152tussin multi-symptom cold 153TWINRIX INJ 85TYBOST 14tydemy 53TYKERB 24

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226

Drug Name Page #TYMLOS 57TYPHIM VI 85

U

ultrachoice advanced form 128ultra choice multivitamin 127ultra freeda 127ultra freeda/iron 128ultra fresh 135ultra fresh pm 135ULTRA MEGA 128ULTRA MEGA GOLD 128ULTRA MEGA TWO 128ULTRA MENS PACK 128ultra omega-3 99ULTRA OMEGA-3 FISH OIL BU 99ULTRATHON INSECT REPELLEN 168UNICOMPLEX-M 128unithroid 58UPCAL D 95UPSPRINGBABY MULTIVITAMIN 128UPSPRING BABY VITAMIN D 128UP & UP GLUCOSE 56urinary pain relief 77urinary pain relief maxim 77URO MAG 61URO-MAG 61ursodiol 76

V

valacyclovir hcl 16VALCHLOR 168valganciclovir hcl 16valproate sodium 34valproic acid 34valsartan 27valsartan-hydrochlorothiazide 26value plus glucose 56VALUE PLUS GLUCOSE 56VANACOF 153VANACOF-8 153VANACOF AC 153VANALICE 169VANATAB AC 153VANATAB DM 153vancomycin hcl 11VANCOMYCIN IN NACL 12

Drug Name Page #vandazole 78VANICREAM 168VAQTA 85VARIVAX 85VASCEPA 28v-c forte 128vegetable laxative+stool 74VELCADE 21velivet 53VELVACHOL 168VEMLIDY 16VENCLEXTA 21VENCLEXTA STARTING PACK 21venlafaxine hcl 36VENOFER 81VENTAVIS 32VENTOLIN HFA 140verapamil cap er 30verapamil hcl 30verapamil hcl tab er 30VERSACLOZ 39VERZENIO 21vic-forte 128VICTOZA 46VIDEX EC 14VIDEX PEDIATRIC 14vienva 53vigabatrin powd pack 500mg 34vigabatrin tab 500mg 34vigadrone 34VIIBRYD STARTER PACK 36VIIBRYD TAB 36VIMPAT 34VIMPAT INJ 200MG/20ML 34VIMPAT SOL 10MG/ML 34vincristine sulfate 20vinorelbine tartrate 20viorele 53VIRACEPT 14VIREAD 14virt-caps 128virtussin a/c 153vision formula 2 128vision formula eye health 128vision formula/lutein 128vision vitamins 128vitabasic complete 128

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Drug Name Page #vitabasic senior 128vita-bee/c 128VITABEX PLUS 128VITA-C 128vitachew multiple vitamin 128vita hair 128vitajoy daily d gummies 128vitajoy gummies 99VITAL-D RX 128vitalee 128VITALETS CHILDRENS 128VITAMAX 128VITAMENT 128VITAMIN B-1 129VITAMIN B 12 128VITAMIN B-12 129VITAMIN B12 128vitamin b-12 tr 129vitamin b12 tr 128vitamin b complex-c 129VITAMIN C 129vitamin c drops 129vitamin c plus wild rose 129vitamin c/rose hips tr 129VITAMIN D2 129VITAMIN D3 129vitamin d3 adult gummies 129VITAMIN D3 COMPLETE 129vitamin d3 gummies adult 129VITAMIN D3 IMMUNE HEALTH 129vitamin d3 maximum streng 129vitamin d3 super strength 129vitamin d3 ultra strength 129vitamin d-400 129vitamin d-1000 maximum st 129vitamin d high potency 129vitamin d infant 129vitamin e 129VITAMIN E 129vitamin e-200 130vitamin e-400 130vitamin e blend 129vitamin e complex natural 130vitamin e/d-alpha natural 130vitamin e high potency 130VITAMIN & MINERAL SUPPLEM 128VITA-RESPA 128

Drug Name Page #VITASANA 130vitatrum 130VITATRUM 130vitatrum complete 130VITRAKVI 24VITRUM 50+ SENIOR MULTI 130vitrum senior 130VIVITROL 45VIZIMPRO 24vol-care rx 130VOL-NATE 130VOL-TAB RX 130voriconazole 12VOSEVI 16VOTRIENT 24vp-vite rx 130v-r anti-gas maximum stre 76v-r aspirin ec max str 5VRAYLAR 39VRAYLAR THERAPY PACK 39v-r pedia relief 153vyfemla 53vylibra 53

W

wal-dryl allergy 139WALGREENS GLUCOSE 56wal-mucil 74warfarin sodium 79wart remover maximum stre 168water for irrigation, sterile 170wee care 81womans laxative 74womens 50+ advanced 130WOMENS BIOMULTIPLE 130womens daily formula 130womens daily formula/foli 130womens multi 130womens one daily 130WOMENS PACK 130wymzya fe 53

X

XALKORI 24XARELTO 79XARELTO STARTER PACK 79XATMEP 83

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Aetna, Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Aetna, Inc. does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Aetna, Inc.: • Provides free aids and services to people with disabilities to communicate

effectively with us, such as:o Qualified sign language interpreterso Written information in other formats (large print, audio, accessible

electronic formats, other formats)

• Provides free language services to people whose primary language is not English,such as:

o Qualified interpreterso Information written in other languages

If you need these services, contact Aetna Medicaid Civil Rights Coordinator

If you believe that Aetna, Inc. has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Aetna Medicaid Civil Rights Coordinator, 4500 East Cotton Center Boulevard, Phoenix, AZ 85040, 1-‐888-‐234-‐7358, TTY 711, 860-‐900-‐7667 (fax), [email protected]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Aetna Medicaid Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-‐800-‐368-‐1019, 800-‐537-‐7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

aetnabetterhealth.com/ohio OH-18-12-01

Nondiscrimination Notice

228

Drug Name Page #XELJANZ 83XELJANZ XR 83XGEVA 57XIFAXAN 76XIGDUO XR TAB 2.5-1000MG 48XIGDUO XR TAB 5-500MG 48XIGDUO XR TAB 5-1000MG 48XIGDUO XR TAB 10-500MG 48XIGDUO XR TAB 10-1000MG 48XOLAIR 155XOSPATA 24XPOVIO 60 MG ONCE WEEKLY 24XPOVIO 80 MG ONCE WEEKLY 24XPOVIO 80 MG TWICE WEEKLY 24XPOVIO 100 MG ONCE WEEKLY 24XTANDI 22xulane 53XULTOPHY 100/3.6 46XYREM 43

Y

YELETS TEENAGE FORMULA 130YF-VAX 85yl coenzyme q10 99yl folic acid 130yl vitamin b-6 130yl vitamin c 130yl vitamin c/rose hips 130yl vitamin e 130YOUR LIFE MULTI ADULT GUM 130yuvafem vaginal tablet 10 mcg 54

Z

zafirlukast 153zaleplon 41zarah 53ZARXIO 79zeasorb-af 160ZEJULA 21ZELBORAF 24ZEMAIRA 155zenatane 157ZENPEP 76zidovudine cap 100mg 14zidovudine syp 50mg/5ml 14zidovudine tab 300mg 14ZIKS ARTHRITIS PAIN RELIE 168

Drug Name Page #ZINC 130ZINC 15 95zinc-220 95zinc sulfate 95ZINC SULFATE 95ZINC SULFATE GRANULAR 95ZINC SULFATE MONOHYDRATE 95ziprasidone hcl 39ZIRGAN 132zoledronic acid inj 5mg/100ml 48zoledronic inj 4mg/5ml 48ZOLINZA 21zolmitriptan 42zolmitriptan odt 42zolpidem tartrate 41zonisamide 35zoo friends 130ZOO FRIENDS COMPLETE 130zoo friends/extra c 131zoo friends gummies 130zoo friends plus extra c 130zoo friends plus iron 131ZORTRESS TAB 0.5MG 84ZORTRESS TAB 0.25MG 84ZORTRESS TAB 0.75MG 84ZORTRESS TAB 1MG 84ZOSTAVAX 85zostrix high potency 168zostrix high potency foot 169ZOSTRIX NATURAL PAIN RELI 169zovia 1/35e 53Z-TUSS AC 153ZYDELIG 24ZYKADIA 24ZYLET 131ZYPREXA RELPREVV 39ZYPREXA RELPREVV INJ 210MG 40ZYTIGA 22

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Nondiscrimination Notice

Aetna, Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Aetna, Inc. does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Aetna, Inc.:• Provides free aids and services to people with disabilities to communicate

effectively with us, such as:o Qualified sign language interpreterso Written information in other formats (large print, audio, accessible

electronic formats, other formats)

• Provides free language services to people whose primary language is not English,such as:

o Qualified interpreterso Information written in other languages

If you need these services, contact Aetna Medicaid Civil Rights Coordinator

If you believe that Aetna, Inc. has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Aetna Medicaid Civil Rights Coordinator, 4500 East Cotton Center Boulevard, Phoenix, AZ85040, 1-888-234-7358, TTY 711, 860-900-7667 (fax), [email protected]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Aetna Medicaid Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services200 Independence Avenue, SWRoom 509F, HHH BuildingWashington, D.C. 202011-800-368-1019, 800-537-7697 (TDD)Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.


mailto:[email protected]

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

http://www.hhs.gov/ocr/office/file/index.html


Multi-Language Interpreter Services

English: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-800-385-4104 (TTY: 711).

Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-385-4104 (TTY: 711).

Chinese: 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-385-4104 (TTY: 711)。

German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-385-4104 (TTY: 711

Pennsylvania Dutch: Geb Acht: Wann du Deitsch Pennsilfaanisch Deitsch schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call 1-800-385-4104 (TTY: 711).

Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-385-4104 (телетайп: 711).

French: ATTENTION: Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 1-800-385-4104 (ATS: 711).

Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-385-4104 (TTY: 711).

Cushite (Oromo): XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-800-385-4104 (TTY: 711).

Korean: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-385-4104 (TTY: 711) 번으로 전화해 주십시오.

Italian: ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-385-4104 (TTY: 711).

Japanese: 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-800-385-4104 (TTY: 711) まで、お電話にてご連絡ください。

Dutch: AANDACHT: Als u nederlands spreekt, kunt u gratis gebruikmaken van de taalkundige diensten. Bel 1-800-385-4104 (TTY: 711).

Ukrainian: УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 1-800-385-4104 (телетайп: 711).

Romanian: ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la 1-800-385-4104 (TTY: 711).

Somali: FEEJIGNAAN: Haddii af-Soomaali aad ku hadasho, adeegyada gargaarka luqadda, oo bilaash ah, ayaad heli kartaa. Wac 1-800-385-4104 (Kuwa Maqalka ku Adag 711).



Helpful information

Aetna Better Health of Ohio7400 W. Campus Rd.New Albany, OH 43054-8725

Member Services1-855-364-0974 (TTY: 711)

For more recent information or other questions, please contact us at 1-855-364-0974 (TTY: 711), 24 hours a day, 7 days a week or visit www.aetnabetterhealth.com/ohio

©2019 Aetna Inc. 92.05.300.1-OH M (10/19)Updated on 10/15/2019


2020 list of covered drugs/formulary - aetna · 15/10/2019 · a day, 7 days a week. the call is...

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