comprehensive preferred drug list - envolve …...- drugs prescribed for cosmetic purposes or hair...

Comprehensive PREFERRED DRUG LIST Coordinated Care

Pharmacy Program

Coordinated Care is committed to providing appropriate, high quality, and cost effective drug therapy to all Coordinated Care members. Coordinated Care works with providers and pharmacists to ensure that medications used to treat a variety of conditions and diseases are covered.

Coordinated Care covers prescription medications and certain over-the-counter (OTC) medications when ordered by a Washington Medicaid enrolled, Coordinated Care practitioner. The pharmacy program does not cover all medications. Some medications require prior authorization (PA) or have limitations on age, dosage, and maximum quantities.

Apple Health Core Connections

Coordinated Care has been selected as the statewide managed care health plan to run the Apple Health Foster Care program starting April 1, 2016. The Apple Health Core Connections program is a new managed care program.

Preferred Drug List

The Coordinated Care Preferred Drug List (PDL) is a list of covered drugs. The PDL is a list of drugs members can receive at retail pharmacies. The Coordinated Care PDL is continually evaluated by the Coordinated Care Pharmacy and Therapeutics (P&T) Committee to promote the appropriate and cost-effective use of medications. The P&T Committee is composed of the Coordinated Care Medical Director, Coordinated Care Pharmacy Program Director, and several Washington primary care physicians and specialists.

Pharmacy Benefit Manager

Coordinated Care works with Envolve Pharmacy Solutions to process all pharmacy claims for prescribed drugs. Envolve Pharmacy Solutions is Coordinated Care’s Pharmacy Benefit Manager (PBM). Some drugs on the Coordinated Care PDL require a PA and Envolve Pharmacy Solutions is responsible for administering the PA process.

Specialty Pharmacy Program

Certain medications are only covered when supplied by Coordinated Care’s specialty pharmacy provider. AcariaHealth is the preferred specialty pharmacy provider of Coordinated Care. All specialty drugs, such as biopharmaceuticals and injectables, require a PA to be approved for payment by Coordinated Care. Coordinated Care’s Medical Director and Pharmacy Director oversee the clinical review of these PA requests.

AcariaHealth provides the following services:

A dedicated, multilingual team available 24 hours a day, 7 days a week to meet the unique needs of each patient.

Disease-specific product education and training

Customized treatment programs and compliance monitoring

Prior authorization support

Timely delivery to the physician’s office or the patient’s home, as requested

Drug or disease state specific prior authorization forms will be available on Coordinated Care’s website.

Dispensing Limits

Drugs may be dispensed up to a maximum of a 34 day supply for each new prescription or refill. A total of 85% of the day supply must elapse before a prescription can be refilled.

Maintenance Drug Program

Members can obtain a 90 day supply (3 month supply) of maintenance drugs from participating pharmacies. Maintenance medications are used to treat long-term conditions or illnesses. Additional information about the Maintenance Drug Program, including a list of “Maintenance Medications” and participating pharmacies can be found at www.coordinatedcarehealth.com/for-providers/pharmacy-program/

Members may request their practitioner to transfer a current prescription or phone in a prescription directly to Coordinated Care’s mail order pharmacy, Homescripts. Homescripts may be reached at 1-800-785-4197. Members may also have their extended supply of maintenance medications filled at a Coordinated Care network pharmacy.

Appropriate Use and Safety Edits

The health and safety of the member is a priority of Coordinated Care. One of the ways we address member safety is through point-of-sale (POS) edits at the time a prescription is processed at the pharmacy. These edits are based on FDA recommendations and promote safe and effective medication utilization.

Additional information about the drugs that are part of the Appropriate Use and Safety Edits can be found in the Appropriate Use and Safety Edits document located on the Coordinated Care website at www.coordinatedcarehealth.com/for-providers/pharmacy-program/

Second Opinion Network (SON)

Washington’s Health Care Authority (HCA) implemented a drug initiative, called the Second Opinion Network (SON). The goal is to reduce therapeutic duplications of psychotropic drugs prescribed to children 17 years of age and younger. Coordinated Care has adopted the guidelines for age limitations and dosing limitations set forth by Washington’s HCA.

Members (17 years of age and younger) who are prescribed medications outside these guidelines for the “first time”, or prescribed prescriptions with “dose escalations”, will be referred by Coordinated Care to the HCA to initiate the process of the second opinion review. After the second opinion review has been completed by the HCA, Coordinated Care will receive a copy of the “SON” from the HCA. The “SON” will have recommendations explaining the approval or unable to approve determination of the psychotropic prescription request.

http://www.coordinatedcarehealth.com/for-providers/pharmacy-program/



Opioid Policy

Effective November 1, 2019, Apple Health will apply a safety limit to the total daily dose of opioids. The dose of different opioids is measured in units called morphine milligram equivalents (MME). An opioid prescription or combinations of opioid prescriptions that exceed a daily dose equal to 120 MME will require the prescriber to complete and sign an opioid attestation form. This safety limit helps ensure prescribers are following best practices.

Prior Authorizations

If a medication is not listed on the PDL, a Prior Authorization (PA) outlining the Medical Necessity for the drug is needed (please see Medical Necessity Requests information below). Furthermore, some medications listed on the Coordinated Care PDL may require a PA. The information should be submitted by the practitioner or pharmacist to Envolve Pharmacy Solutions on the Medication Prior Authorization Form. This form should be faxed to Envolve Pharmacy Solutions at 1-866-399-0929. This document is located on the Coordinated Care website at www.coordinatedcarehealth.com/for-providers/pharmacy-program/

In addition, Providers and Pharmacists can conduct a telephonic prior authorization via phone at 855-757-6565, from 5am – 5pm Pacific Time, Monday through Friday, for all non-specialty drugs. You can visit www.coordinatedcarehealth.com/for-providers/pharmacy-program/ for more details.

Coordinated Care will cover the medication if it is determined that:

1. There is a medical reason the member needs the specific medication.

2. Depending on the medication, other medications on the PDL have not worked.

All reviews are performed by a licensed clinical pharmacist using the criteria established by the Coordinated Care P&T Committee. Once approved, Envolve Pharmacy Solutions notifies the practitioner by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, Coordinated Care will notify the member and their practitioner of alternatives and provide information regarding the appeal process.

Step Therapy

Some medications listed on the Coordinated Care PDL may require specific medications to be used before the member can receive the step therapy medication. If Coordinated Care has a record that the required medication was tried first, the step therapy medications are automatically covered. If Coordinated Care does not have a record that the required medication was tried, the member and their practitioner may be required to provide additional information. If Coordinated Care does not grant a PA, then Coordinated Care will notify the member and their practitioner and provide information regarding the appeal process.

Quantity Limits

Coordinated Care may limit how much of a medication a member can get at one time. If the practitioner feels that the member has a medical reason for getting a larger amount, then the practitioner can submit a




PA. If Coordinated Care does not grant a PA, Coordinated Care will notify the member and their practitioner and provide information regarding the appeal process.

Age Limits

Some medications on the Coordinated Care PDL may have age limits. These are set for certain drugs based on FDA approved labeling and for safety concerns and quality standards of care. Age limits align with current FDA alerts for the appropriate use of pharmaceuticals.

Medical Necessity Requests

If a member requires a medication that does not appear on the PDL, then the member or member’s practitioner can make a medical necessity request for the medication. It is anticipated that such exceptions will be rare and that PDL medications will be appropriate to treat the vast majority of medical conditions. Coordinated Care requires:

-Documentation of failure of at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications) for the same diagnosis (e.g. migraine, neuropathic pain, etc.); or

- Documented intolerance or contraindication to at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications); or

- Documented clinical history or presentation where the patient is not a candidate for any of the PDL agents for the indication.

All reviews are performed by a licensed clinical pharmacist using the criteria established by the Coordinated Care P&T Committee. If the clinical information provided does not meet the coverage criteria for the requested medication, Coordinated Care will notify the member and their practitioner of alternatives and provide information regarding the appeal process.

30-day Emergency Supply Policy

Up to a 30 day supply of medication can be dispensed to any member awaiting a PA determination. The purpose is to avoid interruption of current therapy or delay in the initiation of therapy. All participating pharmacies are authorized to provide up to a 30 day supply of medication and will be reimbursed for the ingredient cost and dispensing fee of the 30 day supply of medication whether or not the PA request is ultimately approved or denied. The pharmacy must call the Envolve Pharmacy Solutions at 1-866-716-5099 for a prescription override for payment.

Exclusions

The following drug categories are not part of Coordinated Care’s PDL and are not covered by the 30 day emergency supply policy:

- Drugs that are not approved by the FDA

- A drug from a manufacturer without a federal rebate agreement

- Drugs prescribed for weight loss or gain

- Drugs prescribed for infertility, frigidity, or impotence

- Drugs prescribed for sexual or erectile dysfunction

- Drugs prescribed for cosmetic purposes or hair growth

- Nutritional supplements

- DESI, IRS, or LTE drugs

- OTC drugs which are not listed on the PDL

- Drugs and drug-related supplies for multiple patient use

- Drugs prescribed for an indication that is not evidence-based

- Drugs prescribed for a non-medically accepted indication or dosing level

Newly Approved Products

Coordinated Care reviews new drugs for safety and effectiveness before adding them to the PDL. During this period, access to these medications will be considered through the PA review process. If Coordinated Care does not approve a PA, Coordinated Care will notify the member and their practitioner and provide information regarding the appeal process.

Over-the-Counter Medications

Coordinated Care’s PDL covers a variety of Over-the-Counter (OTC) medications. A list of covered OTC medications can be found in the Over-the-Counter Medications section of this document. Please note that this is not an all-inclusive list of covered OTC medications. Over-the-Counter medications are covered when the member has a prescription from a licensed practitioner that meets all the legal requirements for a prescription.

Generic Drugs

In most cases, when generic drugs are available, the brand-name drug will not be covered without prior authorization from Coordinated Care. Generic drugs have the same active ingredient as brand-name drugs. If the member or their practitioner feels a brand-name drug is medically necessary, the practitioner can ask for a PA. Coordinated Care will cover the brand-name drug according to clinical guidelines if there is a medical reason the member needs a particular brand-name drug. If Coordinated Care does not grant a PA, Coordinated Care will notify the member and their practitioner and provide information regarding the appeal process.

The provision is waived for the following products due to their narrow therapeutic index (NTI) as recognized by current medical and pharmaceutical literature: Aminophylline, Amiodarone, Carbamazepine, Clozapine, Cyclosporine, Digoxin, Disopyramide, Ethosuximide, Flecainide, L-thyroxine, Lithium, Phenytoin, Procainamide, Propafenone, Theophylline, Valproate Sodium, Valproic Acid, and Warfarin.

Drug Efficacy Study and Implementation Drugs

Drug Efficacy Study and Implementation (DESI) products and known related drug products are defined as less than effective by the Food and Drug Administration because there is a lack of substantial evidence of effectiveness for all labeling indications and because a compelling justification for their medical need has not been established. DESI products are not covered by Coordinated Care.

Filling a Prescription

A member can have prescriptions filled at a Coordinated Care network pharmacy. If the member decides to have a prescription filled at a network pharmacy, they can locate a pharmacy near them by contacting a Coordinated Care Member Services Representative. At the pharmacy, the member will need to provide the pharmacist with the prescription and their Coordinated Care ID card.

Copayments

Washington Apple Health members will not have copayments for drugs filled at a networkpharmacy.

Contact Information

Coordinated Care Provider Services: 1-877-644-4613 Fax: 1-877-644-4602

Envolve Pharmacy Solutions Prior Authorizations: 1-866-716-5099 Fax: 1-866-399-0929

Envolve Pharmacy Solutions Help Desk: 1-877-250-6176

Tier Definition:

Drug Tier Tier Definition

1 Preferred Generic

2 Preferred Brand

F Formulary

NF Non-formulary

NP Non-preferred drug

CO Carve-out drug

MP Maintenance Medication

Legend Description

AL Age Limit Drug is limited to specific age.

MDD Max Daily Dose A limit on the number of times the drug can be taken per day.

MPL Max Package Limit A limit on the amount of drug covered per prescription.

MFL Max Fill Limit There is a limit on the number of times this drug can be refilled.

MDS Max Days’ Supply There is a limit on the amount of this drug that is covered.

PA Prior Authorization Prior Authorization required before prescription can be filled.

QL Quantity Limit

There is a limit on the amount of drug covered per prescription, or within a specific time frame.

Rx/OTC Rx/OTC Product has both Rx and OTC National Drug Codes.

ST Step Therapy

Requires trial and failure of one or more preferred products prior to coverage.

SP Specialty Drug

Specialty drugs are high-cost drugs used to treat complex or rare conditions and may be limited to a specific pharmacy.

Drug Name DrugTier

Requirements/Limits

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

Amphetamines

ADDERALL TABS 1.25 MG-1.25 MG-1.25 MG-1.25 MG (amphetamine-dextroamphetamine)

NF

Age 5-8:MDD=7; Age 9-11: MDD=9; Age 12-17:MDD=12; Age18+: MDD=2;AL(Atleast 5 yrs old);MP


NF

Age 5-8:MDD=4.67; Age 9-11:MDD=6: Age12-17: MDD=8; Age 18+:MDD=2;AL(Atleast 5 yrs old);MP


NF

Age 5-8:MDD=3.5; Age9-11: MDD=4.5; Age12-17: MDD=6; Age 18+:MDD=2;AL(Atleast 5 yrs old);MP


NF

Age 5-8:MDD=2.8; Age9-11: MDD=3.6: Age12-17: MDD=4.8; Age18+:MDD=2;AL (At least 5 yrsold); MP


NF

Age 5-8:MDD=2.34; Age 9-11:MDD=3; Age12-17: MDD=4; Age 18+:MDD=2;AL(Atleast 5 yrs old);MP

Drug Name DrugTier

Requirements/Limits

ADDERALL TABS 5 MG-5 MG-5 MG-5 MG (amphetamine-dextroamphetamine)

NF

Age 5-8: MDD= 1.75; Age 9-11: MDD =2.25; Age 12-17:MDD = 3; Age18+: MDD = 2;AL(At least 5yrs old); MP


NF

Age 5-8:MDD=1.167; Age 9-11:MDD=1.5; Age12-17: MDD=2; Age18+:MDD=2;AL (At least 5 yrsold); MP

ADDERALL XR CP24 1.25 MG-1.25 MG-1.25 MG-1.25 MG (amphetamine-dextroamphetamine)

NF



NF



NF

Age 5-8:MDD=2.34; Age 9-11:MDD=3; Age12-17: 4; Age18+: MDD=1;AL(Atleast 5 yrs old);MP

Coordinated Care of Washington Updated April 1, 2020

1

Drug Name DrugTier

Requirements/Limits

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

NF

Age 5-8:MDD=1.75; Age 9-11:MDD=2.25; Age 12-17:MDD=3; Age18+:MDD=1;AL (At least 5 yrsold); MP


NF

Age 5-8: MDD=1.4; Age 9-11:MDD=1.8; Age12-17: MDD 2.4; Age 18+:MDD=1;AL(Atleast 5 yrs old);MP


NF

Age 5-8:MDD=1.167; Age 9-11:MDD=1.5; Age12-17: MDD=2; Age18+:MDD=1;AL (At least 5 yrsold); MP Age 5-8:MDD=28; Age9-11: MDD=36:

ADZENYS ER SUER NP Age 12-17:MDD=48; Age18+: MDD=48;AL(Atleast 5 yrs old)

ADZENYS XR-ODT TBED 12.5 MG NP

Age 5-8:MDD=2.8; Age9-11: MDD=3.6: Age12-17: MDD=4.8; Age18+:MDD=4.8; AL(At least 5yrs old)

Drug Name DrugTier

Requirements/Limits Age 5-8:MDD=2.2; Age9-11:


MDD=2.9; Age12-17: MDD=3.8; Age18+: MDD=3.8;AL(Atleast 5 yrs old) Age 5-8:MDD=1.9; Age9-11:


MDD=2.4; Age12-17: MDD=3.2; Age18+: MDD=3.2;AL(Atleast 5 yrs old)


Age 5-8:MDD=11.3; Age 9-11:MDD=14.5; Age 12-17:MDD=19.4; Age 18+:MDD=19.4;AL(At least 5 yrsold)


Age 5-8:MDD=5.6; Age9-11: MDD=7.1; Age12-17: MDD=9.5; Age18+: MDD=9.5 AL(At least 5yrs old) Age 5-8:MDD=3.7; Age9-11:


MDD=4.8; Age12-17: MDD=6.4; Age18+: MDD=6.4;AL(Atleast 5 yrs old)


2

Drug Name DrugTier

Requirements/Limits Age 5-8:MDD=28; Age9-11: MDD=36:

AMPHETAMINE ER SUER NP Age 12-17:MDD=48; Age18+: MDD=48;AL(Atleast 5 yrs old) Age 5-8:MDD=3.5; Age9-11:

amphetamine sulfate tabs10 mg NP MDD=4.5; Age

12-17: MDD=6; Age 18+:MDD=6;AL(Atleast 5 yrs old) Age 5-8:MDD=7; Age 9-11: MDD=9;

amphetamine sulfate tabs5 mg NP Age 12-17:

MDD=12; Age18+: MDD=12;AL(Atleast 5 yrs old)

amphetamine-dextroamphetamine cp241.25 mg-1.25 mg-1.25 mg-1.25 mg

1



1


Drug Name DrugTier

Requirements/Limits


1

Age 5-8:MDD=2.34; Age 9-11:MDD=3; Age12-17: 4; Age18+: MDD=1;AL(Atleast 5 yrs old);MP

amphetamine-dextroamphetamine cp24 5mg-5 mg-5 mg-5 mg

1



1



1


amphetamine-dextroamphetamine tabs1.25 mg-1.25 mg-1.25 mg-1.25 mg

1



3

Drug Name DrugTier

Requirements/Limits

amphetamine-dextroamphetamine tabs1.875 mg-1.875 mg-1.875mg-1.875 mg

1

Age 5-8:MDD=4.67; Age 9-11:MDD=6: Age12-17: MDD=8; Age 18+:MDD=2;AL(Atleast 5 yrs old);MP


1


amphetamine-dextroamphetamine tabs3.125 mg-3.125 mg-3.125mg-3.125 mg

1

Age 5-8:MDD=2.8; Age9-11: MDD=3.6: Age12-17: MDD=4.8; Age18+:MDD=2;AL (At least 5 yrsold); MP


1

Age 5-8:MDD=2.34; Age 9-11:MDD=3; Age12-17: MDD=4; Age 18+:MDD=2;AL(Atleast 5 yrs old);MP Age 5-8: MDD= 1.75; Age 9-

amphetamine-dextroamphetamine tabs 5mg-5 mg-5 mg-5 mg

1

11: MDD =2.25; Age 12-17: MDD = 3; Age 18+: MDD= 2;AL(At least5 yrs old); MP

Drug Name DrugTier

Requirements/Limits


1


DESOXYN TABS (methamphetamine hcl) NP PA

DEXEDRINE CP24 10 MG (dextroamphetaminesulfate)

NF



NF

Age 5-8:MDD=2.33;Age9-11: MDD=3; Age12-17:MDD=4; Age18+:MDD=2;AL(At least 5yrs old); MP


NF


dextroamphetamine sulfatecp24 10 mg 1



4

Drug Name DrugTier

Requirements/Limits


Age 5-8:MDD=2.33;Age9-11: MDD=3; Age12-17:MDD=4; Age18+:MDD=2;AL(At least 5yrs old); MP


Age 5-8:MDD=7; Age 9-11: MDD=9; Age 12-17:MDD=12; Age18+: MDD=1;AL(Atleast 5 yrs old);MP PA; Age 5-8:MDD=35; Age9-11: MDD=45;

dextroamphetamine sulfatesoln 5 mg/5ml NP Age 12-17:

MDD=60; Age18+: MDD=60;AL(Atleast 5 yrs old) Age 5-8:MDD=3.5; Age9-11:

dextroamphetamine sulfatetabs 10 mg NP MDD=4.5; Age

12-17: MDD=6; Age 18+:MDD=3;AL(Atleast 5 yrs old)

dextroamphetamine sulfatetabs 5 mg NP

Age 5-8:MDD=7; Age 9-11: MDD=9; Age 12-17:MDD=12; Age18+: MDD=3 ;AL(At least 5yrs old) Age 5-8: MDD=14; Age 9-11:MDD=18; Age

DYANAVEL XR SUER NP 12-17: MDD=24; Age18+: MDD=24;AL(Atleast 5 yrs old)

Drug Name DrugTier

Requirements/Limits Age 5-8:MDD=3.5; Age9-11:

EVEKEO ODT TBDP 10 MG NP MDD=4.5; Age

12-17: MDD=6; Age 18+:MDD=6;AL(Atleast 5 yrs old) Age 5-8:MDD=2.33; Age 9-11:

EVEKEO ODT TBDP 15 MG NP MDD=3; Age

12-17: MDD=4; Age 18+:MDD=4;AL(Atleast 5 yrs old) Age 5-8:MDD=1.75; Age 9-11:

EVEKEO ODT TBDP 20 MG NP

MDD=2.25; Age 12-17:MDD=3; Age18+: MDD=3;AL(Atleast 5 yrs old) Age 5-8:MDD=7; Age 9-11: MDD=9;

EVEKEO ODT TBDP 5 MG NP Age 12-17:MDD=12; Age18+: MDD=12;AL(Atleast 5 yrs old) Age 5-8:MDD=3.5; Age9-11:

EVEKEO TABS 10 MG (amphetamine sulfate) NP MDD=4.5; Age

12-17: MDD=6; Age 18+:MDD=6;AL(Atleast 5 yrs old) Age 5-8:MDD=7; Age 9-11: MDD=9;

EVEKEO TABS 5 MG (amphetamine sulfate) NP Age 12-17:



5

Drug Name DrugTier

Requirements/Limits

methamphetamine hcl tabs NP PA

MYDAYIS CP24 12.5 MG-12.5 MG-12.5 MG-12.5 MG NP

Age 5-8:MDD=0.7; Age9-11: MDD=0.9; Age12-17: MDD=1.2; Age18+: MDD=1.2 AL(At least 5yrs old) Age 5-8:MDD=2.8; Age9-11:

MYDAYIS CP24 3.125 MDD=3.6: AgeMG-3.125 MG-3.125 MG- NP 12-17: 3.125 MG MDD=4.8; Age

18+:MDD=4.8; AL(At least 5yrs old)

MYDAYIS CP24 6.25 MG-6.25 MG-6.25 MG-6.25 MG NP

Age 5-8:MDD=1.4; Age9-11: MDD=1.8; Age12-17: MDD=2.4; Age18+:MDD=2.4 AL(At least 5yrs old) Age 5-8:MDD=0.9; Age9-11:

MYDAYIS CP24 9.375 MDD=1.2; AgeMG-9.375 MG-9.375 MG- NP 12-17: 9.375 MG MDD=1.6; Age

18+: MDD=1.6 AL(At least 5yrs old)

VYVANSE CAPS 10 MG 2

Age 5-8:MDD=6; Age 9-11: MDD=7.5; Age 12-17:MDD =10; Age18+: PA. MDD=1;AL(Atleast 5 yrs old -Up to 17 yrsold); MP

Drug Name DrugTier

Requirements/Limits


Age 5-8:MDD=3; Age 9-11: MDD=3.75; Age 12-17:MDD=5; Age18+: PA, MDD=1;AL(Atleast 5 yrs old -Up to 17 yrsold); MP


Age 5-8: MDD=2; Age 9-11:MDD=2.5; Age12-17: MDD=3.34; Age 18+: PA,MDD=1;AL(Atleast 5 yrs old -Up to 17 yrsold); MP


Age 5-8:MDD=1.5; Age9-11: MDD=1.875; Age 12-17:MDD=2.5; Age18+: PA, MDD=1;AL(Atleast 5 yrs old -Up to 17 yrsold); MP


Age 5-8:MDD=1.2; Age9-11: MDD=1.5; Age12-17: MDD=2; Age 18+: PA,MDD=1;AL(Atleast 5 yrs old -Up to 17 yrsold); MP


Age 5-8:MDD=1; Age 9-11: MDD=1.25; Age 12-17:MDD=1.67; Age 18+: PA,MDD=1;AL(Atleast 5 yrs old -Up to 17 yrsold); MP


6

Drug Name DrugTier

Requirements/Limits


Age 5-8:MDD=0.86; Age 9-11:MDD=1.07; Age 12-17:MDD= 1.43; Age 18+: PA,MDD=1;AL(Atleast 5 yrs old -Up to 17 yrsold); MP

VYVANSE CHEW 10 MG 2

Age 5-8:MDD=6; Age 9-11: MDD=7.5; Age 12-17:MDD= 10; Age18+:MDD=10 AL(At least 5yrs old); MP


Age 5-8:MDD=3; Age 9-11: MDD=3.8; Age 12-17:MDD=5; Age18+: MDD=5;AL(Atleast 5 yrs old);MP


Age 5-8: MDD=2; Age 9-11:MDD=2.5; Age12-17: MDD=3.34; Age 18+:MDD=3.34;AL(At least 5 yrsold); MP


Age 5-8:MDD=1.5; Age9-11: MDD=1.9; Age12-17: MDD=2.5; Age18+:MDD=2.5 AL(At least 5yrs old); MP

Drug Name DrugTier

Requirements/Limits


Age 5-8:MDD=1.2; Age9-11: MDD=1.5; Age12-17: MDD=2; Age 18+:MDD=2 AL(Atleast 5 yrs old);MP


Age 5-8:MDD=1; Age 9-11: MDD=1.25; Age 12-17:MDD=1.67; Age 18+:MDD=1.67 AL(At least 5yrs old); MP

ZENZEDI TABS 15 MG NP

Age 5-8:MDD=2.33; Age 9-11:MDD=3; Age12-17: MDD=4;AL(Atleast 5 yrs old -Up to 17 yrsold)

ZENZEDI TABS 2.5 MG NP

Age 5-8:MDD=14; Age9-11: MDD=18; Age 12-17:MDD=24 ;AL(At least 5yrs old - Up to17 yrs old)


Age 5-8:MDD=1.75; Age 9-11:MDD=2.25; Age 12-17:MDD=3;AL(Atleast 5 yrs old -Up to 17 yrsold)


7

Drug Name DrugTier

Requirements/Limits


Age 5-8:MDD=1.167; Age 9-11:MDD=1.5; Age12-17: MDD=2;AL(Atleast 5 yrs old -Up to 17 yrsold)

ZENZEDI TABS 7.5 MG NP

Age 5-8:MDD=4.67; Age 9-11:MDD=6; Age12-17: MDD=8;AL(Atleast 5 yrs old -Up to 17 yrsold)

Analeptics

caffeine citrate soln 1 QL(45 ml perfill retail)

Attention-Deficit/Hyperactivity Disorder (ADHD)

atomoxetine hcl caps 10 mg 1

Age 5-17:MDD=12;AL(Atleast 5 yrs old);MP


Age 5-17:MDD=1.2;AL(At least 5 yrsold); MP









Drug Name DrugTier

Requirements/Limits


Age 5-17:MDD=1.5;AL(Atleast 5 yrs old);MP

clonidine hcl (adhd) tb12 1

Age 4-5:MDD=2; Age 6-8: MDD=3; Age9-17: MDD=4;AL(Atleast 4 yrs old);MP

guanfacine hcl (adhd) tb241 mg 1



Age 4-5:MDD=1; Age 6-8: MDD= 1.5; Age 9-17:MDD=2;AL(Atleast 4 yrs old);MP


Age 4-5:MDD=0.667; Age 6-8:MDD=1; Age 9-17: MDD=1.334;AL (At least 4 yrsold); MP


Age 4-5:MDD=0.5; Age6-8: MDD=0.75; Age 9-17:MDD=1;AL(Atleast 4 yrs old);MP

INTUNIV TB24 1 MG (guanfacine hcl (adhd)) NF



8

Drug Name DrugTier

Requirements/Limits






Age 4-5:MDD=0.5; Age6-8: MDD=0.75; Age 9-17:MDD=1;AL(Atleast 4 yrs old);MP

KAPVAY TB12 (clonidine hcl (adhd)) NF


STRATTERA CAPS 10 MG (atomoxetine hcl) NF










Drug Name DrugTier

Requirements/Limits




Age 5-17:MDD=1.5;AL(Atleast 5 yrs old);MP

Stimulants - Misc.

ADHANSIA XR CP24 25 MG NP

PA; Age 5-8:MDD=2.8; Age9-11: MDD=3.6: Age12-17: MDD=4.8; Age18+:MDD=4.8; AL(At least 5yrs old)


PA; Age 5-8:MDD=2; Age 9-11: MDD=2.57; Age 12-17:MDD=3.43; Age 18+:MDD=3.43;AL(At least 5 yrsold)


PA; Age 5-8:MDD=1.56; Age 9-11:MDD=2; Age12-17: MDD=2.67; Age 18+:MDD=2.67;AL(At least 5 yrsold)


PA; Age 5-8:MDD=1.27; Age 9-11:MDD=1.64; Age 12-17:MDD=2.18; Age 18+:MDD=2.18;AL(At least 5 yrsold)


9

Drug Name DrugTier

Requirements/Limits


PA; Age 5-8:MDD=1; Age 9-11: MDD=1.29; Age 12-17:MDD=1.71; Age 18+:MDD=1.71;AL(At least 5 yrsold)


PA; Age 5-8:MDD=0.82; Age 9-11:MDD=1.06; Age 12-17:MDD=1.41; Age 18+:MDD=1.41;AL(At least 5 yrsold)

APTENSIO XR CP24 10 MG 2



Age 5-8:MDD=4.7; Age9-11: MDD=6; Age 12-17:MDD=8; Age18+: MDD=8 AL(At least 5yrs old); MP



Drug Name DrugTier

Requirements/Limits









armodafinil tabs 1 PA; AL(At least18 yrs old); MP

CONCERTA TBCR 18 MG (methylphenidate hcl) NF

Age 5-8:MDD=3.89; Age 9-11:MDD=5; Age12-17: MDD=6.67; Age 18+:MDD=1;AL(Atleast 5 yrs old);MP


10

Drug Name DrugTier

Requirements/Limits


Age 5-8:MDD=2.59; Age 9-11:MDD=3.33; Age 12-17:MDD=4.44; Age18+:MDD=1;AL (At least 5 yrsold); MP


Age 5-8:MDD=1.94; Age 9-11:MDD=2.5; Age12-17: MDD=3.33; MDD=2;AL(Atleast 5 yrs old);MP


Age 5-8: MDD=1.296; Age 9-11: MDD=1.67; Age 12-17:MDD=2.22; Age 18+:MDD=1;AL(Atleast 5 yrs old);MP

COTEMPLA XR-ODT TBED 17.3 MG NP

PA; Age 5-8:MDD= 4; Age9-11: MDD=5.2; Age12-17: MDD=6.9; Age18+: MDD=6.9;;AL(At least 5 yrsold)


PA; Age 5-8:MDD=2.7; Age9-11: MDD=3.5; Age12-17: MDD=4.6; Age18+: MDD=4.6;AL(At least 5 yrsold)

Drug Name DrugTier

Requirements/Limits PA; Age 5-8:MDD=8.1; Age9-11:


MDD=10.5; Age 12-17:MDD=14; Age18+: MDD=14;;AL(Atleast 5 yrs old) PA; Age 5-8:MDD=3.5; Age9-11:

DAYTRANA PTCH 10 MG/9HR NP MDD=4.5; Age

12-17: MDD=6; Age 18+:MDD=6;AL(Atleast 5 yrs old) PA; Age 5-8:MDD=2.3; Age9-11: MDD=3;

DAYTRANA PTCH 15 MG/9HR NP Age 12-17:

MDD=4; Age18+: MDD=4;;AL(Atleast 5 yrs old) PA; Age 5-8:MDD=1.8; Age9-11:


12-17: MDD=3; Age 18+:MDD=3;;AL(Atleast 5 yrs old) PA; Age 5-8:MDD=1.2; Age9-11:


12-17: MDD=2; Age 18+:MDD=2;;AL(Atleast 5 yrs old)

dexmethylphenidate hclcp24 10 mg 1



11

Drug Name DrugTier

Requirements/Limits










Age 5-8:MDD=1; Age 9-11: MDD=1.3; Age 12-17:MDD=1.7; Age18+: MDD=1.7 AL(At least 5yrs old); MP

Drug Name DrugTier

Requirements/Limits


Age 5-8:MDD=0.9; Age9-11: MDD=1.1; Age12-17: MDD=1.5; Age18+: MDD=1.5 AL(At least 5yrs old); MP Age 5-8:MDD=7; Age 9-11: MDD=9;

dexmethylphenidate hclcp24 5 mg 1 Age 12-17:


dexmethylphenidate hcltabs 10 mg 1


dexmethylphenidate hcltabs 2.5 mg 1

Age 5-8: MDD=14; Age 9-11:MDD=18; Age12-17: MDD=24; Age18+: MDD=2;AL(Atleast 5 yrs old);MP

dexmethylphenidate hcltabs 5 mg 1

Age 5-8:MDD=7; Age 9-11: MDD=9; Age 12-17:MDD=12; Age18+: PA, MDD=2;AL(Atleast 5 yrs old);MP


12

Drug Name DrugTier

Requirements/Limits

FOCALIN TABS 10 MG (dexmethylphenidate hcl) NF


FOCALIN TABS 2.5 MG (dexmethylphenidate hcl) NF


FOCALIN TABS 5 MG (dexmethylphenidate hcl) NF

Age 5-8:MDD=7; Age 9-11: MDD=9; Age 12-17:MDD=12; Age18+: PA, MDD=2;AL(Atleast 5 yrs old);MP

FOCALIN XR CP24 10 MG (dexmethylphenidate hcl) NF




Drug Name DrugTier

Requirements/Limits








Age 5-8:MDD=1; Age 9-11: MDD=1.3; Age 12-17:MDD=1.7; Age18+: MDD=1.7 AL(At least 5yrs old); MP


Age 5-8:MDD=0.9; Age9-11: MDD=1.1; Age12-17: MDD=1.5; Age18+: MDD=1.5 AL(At least 5yrs old); MP


13

Drug Name DrugTier

Requirements/Limits Age 5-8:MDD=7; Age 9-11: MDD=9;

FOCALIN XR CP24 5 MG (dexmethylphenidate hcl) NF Age 12-17:


JORNAY PM CP24 100 MG NP

PA; Age 5-8:MDD=0.7; Age9-11: MDD=0.9; Age12-17: MDD=1.2; Age18+: MDD=1.2 AL(At least 5yrs old) PA; Age 5-8:MDD=3.5; Age9-11:

JORNAY PM CP24 20 MG NP MDD=4.5; Age12-17: MDD=6; Age 18+:MDD=6;AL(Atleast 5 yrs old) PA; Age 5-8:MDD=1.75; Age 9-11:MDD=2.25;

JORNAY PM CP24 40 MG NP Age 12-17:MDD=3; Age18+: MDD=3;AL(Atleast 5 yrs old) PA; Age 5-8:MDD=1.17; Age 9-11:

JORNAY PM CP24 60 MG NP MDD=1.5; Age12-17: MDD=2; Age 18+:MDD=2;AL(Atleast 5 yrs old)

Drug Name DrugTier

Requirements/Limits PA; Age 5-8:MDD=0.875; Age 9-11:MDD=1.125;

JORNAY PM CP24 80 MG NP Age 12-17:MDD=1.5; Age18+: MDD=1.5;AL(Atleast 5 yrs old)

METHYLIN SOLN 10 MG/5ML (methylphenidatehcl)

2

Age 5-8:MDD=35; Age9-11: MDD=45; Age 12-17:MDD=60;AL(Atleast 5 yrs old);MP

METHYLIN SOLN 5 MG/5ML (methylphenidatehcl)

2

Age 5-8:MDD=70; Age9-11: MDD=90; Age 12-17:MDD=120;AL(At least 5 yrsold); MP

methylphenidate hcl chew10 mg 1


methylphenidate hcl chew2.5 mg 1

Age 5-8:MDD=28; Age9-11: MDD=36: Age 12-17:MDD=48; Age18+: MDD=48;AL(Atleast 5 yrs old);MP

methylphenidate hcl chew5 mg 1



14

Drug Name DrugTier

Requirements/Limits

methylphenidate hcl cp2410 mg 1





Age 5-8:MDD=2.3; Age9-11: MDD=3; Age 12-17:MDD=4; Age18+: MDD=4;;AL(Atleast 5 yrs old);MP


Age 5-8:MDD=1.8; Age9-11: MDD=2.3; Age12-17: MDD=3; Age 18+:MDD=3;;AL(Atleast 5 yrs old);MP



Drug Name DrugTier

Requirements/Limits

methylphenidate hcl cpcr10 mg 1





Age 5-8:MDD=2.33; Age 9-11:MDD=3; Age12-17: MDD= 4; Age 18+:MDD=1;;AL(Atleast 5 yrs old);MP






15

Drug Name DrugTier

Requirements/Limits



methylphenidate hcl soln10 mg/5ml 1


methylphenidate hcl soln 5mg/5ml 1

Age 5-8:MDD=70; Age9-11: MDD=90; Age 12-17:MDD=120;AL(At least 5 yrsold); MP

methylphenidate hcl tabs10 mg 1


methylphenidate hcl tabs20 mg 1


methylphenidate hcl tabs 5 mg 1


Drug Name DrugTier

Requirements/Limits

methylphenidate hcl tb2427 mg 1

Age 5-8:MDD=2.59; Age 9-11:MDD=3.33; Age 12-17:MDD=4.44; Age 18+:MDD=1;AL(Atleast 5 yrs old);MP


Age 5-8:MDD=1.94; Age 9-11:MDD=2.5; Age12-17: MDD=3.33; Age 18+:MDD=2;AL(Atleast 5 yrs old);MP



methylphenidate hcl tbcr 10 mg 1





16

Drug Name DrugTier

Requirements/Limits




Age 5-8:MDD=2.59; Age 9-11:MDD=3.33; Age 12-17:MDD=4.44; Age18+:MDD=1;AL (At least 5 yrsold); MP


Age 5-8:MDD=1.94; Age 9-11:MDD=2.5; Age12-17: MDD=3.33; MDD=2;AL(Atleast 5 yrs old);MP



METHYLPHENIDATE HYDROCHLORIDE ER TB24 18 MG

2


Drug Name DrugTier

Requirements/Limits

METHYLPHENIDATE HYDROCHLORIDE ER TBCR 72 MG

NP

Age 5-8: MDD=0.97; Age 9-11: MDD=1.25; Age 12-17:MDD=1.67; Age 18+:MDD=1.67;;AL(At least 5 yrsold)

modafinil tabs 1 PA; AL(At least18 yrs old); MP

NUVIGIL TABS (armodafinil) NF PA; AL(At least

18 yrs old); MP PROVIGIL TABS (modafinil) NF PA; AL(At least

18 yrs old); MP

QUILLICHEW ER CHER 20 MG 2






QUILLIVANT XR SUSR 2



17

Drug Name DrugTier

Requirements/Limits

RELEXXII TBCR NP

Age 5-8: MDD=0.97; Age 9-11: MDD=1.25; Age 12-17:MDD=1.67; Age 18+:MDD=1.67;;AL(At least 5 yrsold)

RITALIN LA CP24 10 MG (methylphenidate hcl) NF





Age 5-8:MDD=2.3; Age9-11: MDD=3; Age 12-17:MDD=4; Age18+: MDD=4;;AL(Atleast 5 yrs old);MP


Age 5-8:MDD=1.8; Age9-11: MDD=2.3; Age12-17: MDD=3; Age 18+:MDD=3;;AL(Atleast 5 yrs old);MP

Drug Name DrugTier

Requirements/Limits

RITALIN TABS 10 MG (methylphenidate hcl) NF






ALLERGENIC EXTRACTS/BIOLOGICALS MISC

Allergenic Extracts

GRASTEK SUBL 2 PA

ORALAIR ADULT SAMPLE KIT SUBL 2 PA

ORALAIR ADULT STARTER PACK SUBL 2 PA

ORALAIR CHILDREN/ADOLESCENTS SAMPLE KIT THPK

2 PA

ORALAIR CHILDREN/ADOLESCENTS STARTER PACK SUBL

2 PA

ORALAIR SUBL 2 PA

RAGWITEK SUBL 2 PA

Biologicals Misc

ADAGEN SOLN 2 PA


18

Drug Name DrugTier

Requirements/Limits

AMEBICIDES

Amebicides

SOLOSEC PACK 2

AMINOGLYCOSIDES - Drugs to Treat BacterialInfections

Aminoglycosides

amikacin sulfate soln 1

ARIKAYCE SUSP NP PA

BETHKIS NEBU 2 PA

gentamicin in saline soln 1

GENTAMICIN SULFATE PEDIATRIC SOLN 2

gentamicin sulfate soln 1

GENTAMICIN SULFATE/0.9% SODIUMCHLORIDE SOLN

2

ISOTONIC GENTAMICIN SOLN 2

KITABIS PAK NEBU 2 PA; SP

neomycin sulfate tabs 1

paromomycin sulfate caps 1

PAROMOMYCIN SULFATE CAPS 2

STREPTOMYCIN SULFATE SOLR 2

TOBI NEBU (tobramycin) NP PA; SP

TOBI PODHALER CAPS 2 PA; SP

tobramycin nebu NP PA

tobramycin nebu 1 PA; SP

tobramycin nebu NP PA; SP

TOBRAMYCIN NEBU NP PA; SP

Drug Name DrugTier

Requirements/Limits

TOBRAMYCIN SULFATE SOLN 10 MG/ML, 40MG/ML

2

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

1

tobramycin sulfate solr 1.2 gm 1

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

Anti-TNF-alpha - Monoclonal Antibodies HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK PSKT 40 MG/0.8ML

2

PA; SP

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK PSKT 80 MG/0.8ML,

2

PA

HUMIRA PEN PNKT 2 PA; SP

HUMIRA PEN-CD/UC/HSSTARTER PNKT 2 PA; SP

HUMIRA PEN-PS/UVSTARTER PNKT 2 PA; SP

HUMIRA PSKT 10 MG/0.1ML, 20 MG/0.2ML 2 PA

HUMIRA PSKT 10 MG/0.2ML, 20 MG/0.4ML,40 MG/0.4ML, 40MG/0.8ML

2

PA; SP

SIMPONI ARIA SOLN NP PA

SIMPONI SOAJ NP PA; SP

SIMPONI SOSY NP PA; SP

Antirheumatic - Enzyme Inhibitors

OLUMIANT TABS 1 MG NP PA

OLUMIANT TABS 2 MG NP PA; SP

RINVOQ TB24 NP PA

XELJANZ TABS 10 MG NP PA


19

Drug Name DrugTier

Requirements/Limits

XELJANZ TABS 5 MG NP PA; SP

XELJANZ XR TB24 11 MG NP PA; SP

XELJANZ XR TB24 22 MG NP PA

Antirheumatic Antimetabolites

METHOTREXATE TABS 2

OTREXUP SOAJ NP PA

RASUVO SOAJ 10 MG/0.2ML, 15 MG/0.3ML,20 MG/0.4ML, 25MG/0.5ML, 30 MG/0.6ML,7.5 MG/0.15ML, 12.5MG/0.25ML, 17.5MG/0.35ML, 22.5MG/0.45ML

2

PA

RASUVO SOAJ 20 MG/0.4ML NP PA

Gold Compounds

RIDAURA CAPS 2 MP

Interleukin-1 Blockers

ARCALYST SOLR NP PA; SP

Interleukin-1 Receptor Antagonist (IL-1Ra) KINERET SOSY NP PA; SP

Interleukin-1beta Blockers

ILARIS SOLN NP PA

Interleukin-6 Receptor Inhibitors

ACTEMRA ACTPEN SOAJ NP PA

ACTEMRA SOLN NP PA

ACTEMRA SOSY NP PA

KEVZARA SOAJ NP PA

KEVZARA SOSY NP PA

Nonsteroidal Anti-inflammatory Agents (NSAIDs) ADVIL TABS (ibuprofen) NF MP

Drug Name DrugTier

Requirements/Limits

ALEVE ARTHRITIS TABS (naproxen sodium) NF QL(2 ea daily);

MP ALEVE TABS (naproxensodium) NF QL(2 ea daily);

MP ANAPROX DS TABS (naproxen sodium) NF MP

CELEBREX CAPS (celecoxib) NF PA; MP

celecoxib caps 1 PA; MP

CHILDRENS ADVIL SUSP (ibuprofen) NF RX/OTC; MP

CHILDRENS MOTRIN SUSP (ibuprofen) NF RX/OTC; MP

DAYPRO TABS (oxaprozin) NF MP

diclofenac potassium tabs 1 MP

diclofenac sodium tb24 1 MP

diclofenac sodium tbec 1 MP

EC-NAPROSYN TBEC (naproxen) NF QL(2 ea daily);

MP EC-NAPROXEN TBEC (naproxen) NF QL(2 ea daily);

MP

etodolac caps 1 MP

etodolac tabs 1 MP

etodolac tb24 1 MP

FELDENE CAPS (piroxicam) NF MP

FENOPROFEN CALCIUM CAPS 200 MG, 400 MG 2 PA; MP

fenoprofen calcium tabs600 mg 1 PA; MP

FENORTHO CAPS 2 PA; MP

flurbiprofen tabs 1 MP

ibuprofen chew 100 mg 1

ibuprofen susp 100 mg/5ml 1 RX/OTC; MP

ibuprofen susp 40 mg/ml,50 mg/1.25ml 1 MP


20

Drug Name DrugTier

Requirements/Limits

ibuprofen tabs 200 mg, 400mg, 600 mg, 800 mg 1 MP

indomethacin caps 1 MP

indomethacin cpcr 1 MP

INFANTS ADVIL SUSP (ibuprofen) NF MP

KETOPROFEN CAPS OR 50 MG, 75 MG 2 MP

KETOPROFEN ER CP24 2 MP

ketorolac tromethamine tabs or 10 mg 1

QL(20 ea per30 days retail);AL(At least 17yrs old)

LODINE TABS (etodolac) NF MP

MECLOFENAMATE SODIUM CAPS 2 PA; MP

mefenamic acid caps 1 PA; MP

meloxicam tabs 1 MP

MOBIC TABS (meloxicam) NF MP

MOTRIN CHILDRENS CHEW (ibuprofen) NF

MOTRIN INFANTS DROPS SUSP (ibuprofen) NF MP

nabumetone tabs 1 MP

NALFON CAPS 400 MG 2 PA; MP

NALFON TABS 600 MG (fenoprofen calcium) NF PA; MP

NAPROSYN SUSP (naproxen) NF MP

NAPROSYN TABS (naproxen) NF MP

naproxen sodium tabs 220 mg 1 QL(2 ea daily);

MP naproxen sodium tabs 275mg, 550 mg 1 MP

naproxen susp 125 mg/5ml 1 MP

naproxen tabs 250 mg, 375mg, 500 mg 1 MP

Drug Name DrugTier

Requirements/Limits

naproxen tbec 375 mg, 500 mg 1 QL(2 ea daily);

MP

oxaprozin tabs 1 MP

piroxicam caps 1 MP

sulindac tabs 1 MP

TOLMETIN SODIUM CAPS 2 MP

TOLMETIN SODIUM TABS 2 MP

Phosphodiesterase 4 (PDE4) Inhibitors

OTEZLA TABS NP PA; SP

OTEZLA TBPK NP PA; SP

Pyrimidine Synthesis Inhibitors ARAVA TABS (leflunomide) NF QL(1 ea daily);

MP

leflunomide tabs 1 QL(1 ea daily);MP

Selective Costimulation Modulators ORENCIA CLICKJECT SOAJ NP PA; SP

ORENCIA SOLR IV 250 MG NP PA

ORENCIA SOSY SC 125 MG/ML NP PA; SP

ORENCIA SOSY SC 50 MG/0.4ML, 87.5 MG/0.7ML NP PA

Soluble Tumor Necrosis Factor Receptor Agents

ENBREL MINI SOCT NP PA

ENBREL SOLR 2 PA; SP

ENBREL SOSY 2 PA; SP

ENBREL SURECLICK SOAJ 2 PA; SP

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

Analgesic Combinations butalbital-acetaminophentabs 325 mg-50 mg 1


21

Drug Name DrugTier

Requirements/Limits

butalbital-acetaminophen-caffeine caps 1 QL(4 ea daily)

butalbital-acetaminophen-caffeine tabs 1 QL(4 ea daily)

butalbital-aspirin-caffeine caps 1 QL(4 ea daily)

BUTALBITAL/ASPIRIN/CAFFEINE TABS 2 QL(4 ea daily)

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

FIORINAL CAPS (butalbital-aspirin-caffeine) NF QL(4 ea daily)

TENCON TABS 2

Analgesics Other acetaminophen elix or 160mg/5ml, 80 mg/2.5ml 1

acetaminophen liqd or 160mg/5ml 1

acetaminophen soln or 100mg/ml 1 QL(1 ml daily)

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

1

acetaminophen supp re120 mg, 650 mg 1 QL(12 ea per

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

1

acetaminophen tabs or 325mg, 500 mg 1

FEVERALL JUNIOR STRENGTH SUPP 2 QL(12 ea per

fill retail) NORTEMP INFANTS SUSP 2

TYLENOL CHILDRENS SUSP (acetaminophen) NF

TYLENOL EXTRA STRENGTH TABS (acetaminophen)

NF

TYLENOL INFANTS PAIN+FEVER SUSP (acetaminophen)

NF

TYLENOL INFANTS SUSP (acetaminophen) NF

Drug Name DrugTier

Requirements/Limits

TYLENOL TABS (acetaminophen) NF

Salicylates

aspirin chew 1

aspirin tabs 1

aspirin tbec 1

choline & mag salicylateliqd 1

diflunisal tabs 1 MP

ECOTRIN REGULAR STRENGTH TBEC (aspirin)

NF

salsalate tabs 1 MP

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

Opioid Agonists

ABSTRAL SUBL NP PA

ACTIQ LPOP (fentanylcitrate) NP PA

ARYMO ER TBEA NP

CODEINE SULFATE TABS 15 MG, 60 MG 2 AL(At least 21

yrs old) CODEINE SULFATE TABS 30 MG (codeine sulfate) 2 AL(At least 21

yrs old) codeine sulfate tabs 30 mg,60 mg 1 AL(At least 21

yrs old)

CONZIP CP24 NP AL(At least 21yrs old)

DEMEROL TABS (meperidine hcl) NP

DILAUDID LIQD 1 MG/ML(hydromorphone hcl) NP

DILAUDID TABS 2 MG, 4 MG, 8 MG (hydromorphonehcl)

NF

DOLOPHINE TABS 10 MG (methadone hcl) NP PA; QL(4 ea

daily) DOLOPHINE TABS 5 MG (methadone hcl) NP PA; QL(8 ea

daily)


22

Drug Name DrugTier

Requirements/Limits

DSUVIA SUBL NP

DURAGESIC PT72 (fentanyl) NF

EMBEDA CPCR NP

EXALGO T24A (hydromorphone hcl) NP

fentanyl citrate lpop bu 200mcg, 400 mcg, 600 mcg,800 mcg, 1200 mcg, 1600 mcg

NP

PA

FENTANYL CITRATE SOCT IJ 100 MCG/2ML NP PA

FENTANYL CITRATE SOLN IJ 100 MCG/2ML,250 MCG/5ML (fentanylcitrate)

NP

PA

fentanyl citrate soln ij 100mcg/2ml, 250 mcg/5ml,1000 mcg/20ml, 2500mcg/50ml

NP

PA

FENTANYL CITRATE SOLN IJ 500 MCG/10ML NP PA

FENTANYL CITRATE TABS BU 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG

NP

PA

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

1

fentanyl pt72 37.5 mcg/hr,62.5 mcg/hr, 87.5 mcg/hr NP

FENTORA TABS NP PA

hydrocodone bitartratec12a NP

hydromorphone hcl liqd or1 mg/ml NP

HYDROMORPHONE HCL SUPP RE 3 MG 2

hydromorphone hcl t24a or8 mg, 12 mg, 16 mg, 32 mg NP

hydromorphone hcl tabs or2 mg, 4 mg, 8 mg 1

HYSINGLA ER T24A NP

Drug Name DrugTier

Requirements/Limits

IONSYS PTCH NP

KADIAN CP24 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 80 MG, 100 MG (morphine sulfate)

NP

KADIAN CP24 200 MG NP

LAZANDA SOLN NP PA

levorphanol tartrate tabs 2 mg NP

LEVORPHANOL TARTRATE TABS 3 MG NP

MEPERIDINE HCL SOLN 50 MG/5ML NP

MEPERIDINE HCL TABS 50 MG, 100 MG NP

meperidine hcl tabs 50 mg,100 mg NP

methadone hcl conc or 10 mg/ml NP PA

METHADONE HCL POWD XX NP PA

methadone hcl soln ij 10mg/ml NP PA

METHADONE HCL SOLN IJ 10 MG/ML (methadone hcl)

NP PA

methadone hcl soln or 5 mg/5ml, 10 mg/5ml NP PA

METHADONE HCL SOLN OR 5 MG/5ML, 10 MG/5ML(methadone hcl)

NP PA

methadone hcl tabs or 10 mg NP PA; QL(4 ea

daily) methadone hcl tabs or 5 mg NP PA; QL(8 ea

daily) methadone hcl tbso or 40 mg NP PA

METHADOSE CONC (methadone hcl) NP PA

METHADOSE SUGAR-FREE CONC (methadone hcl)

NP PA

MORPHABOND ER T12A NP


23

Drug Name DrugTier

Requirements/Limits

morphine sulfate cp24 or10 mg, 20 mg, 30 mg, 40mg, 50 mg, 60 mg, 80 mg,100 mg

NP

MORPHINE SULFATE ER CP24 NP

morphine sulfate soln or 20mg/ml, 10 mg/5ml, 20mg/5ml, 100 mg/5ml

NP

MORPHINE SULFATE SUPP RE 10 MG, 20 MG, 30 MG

2

MORPHINE SULFATE SUPP RE 5 MG 2 QL(24 ea per

fill retail) morphine sulfate tabs or 15mg, 30 mg 1

MORPHINE SULFATE TABS OR 15 MG, 30 MG (morphine sulfate)

2

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

1 QL(3 ea daily)

MS CONTIN TBCR (morphine sulfate) NF QL(3 ea daily)

NUCYNTA ER TB12 NP

NUCYNTA TABS NP

OPANA ER (CRUSH RESISTANT) T12A NP

OPANA TABS (oxymorphone hcl) NP

OXAYDO TABA NP

oxycodone hcl caps 5 mg NP

oxycodone hcl conc 100mg/5ml NP

OXYCODONE HCL ER T12A NP QL(2 ea daily)

oxycodone hcl soln 5mg/5ml 1

oxycodone hcl tabs 10 mg,20 mg 1 AL(At least 18

yrs old) oxycodone hcl tabs 5 mg,15 mg, 30 mg 1

Drug Name DrugTier

Requirements/Limits

OXYCODONE HYDROCHLORIDE ER T12A

NP QL(2 ea daily)

OXYCONTIN T12A NP QL(2 ea daily)

oxymorphone hcl tabs NP

OXYMORPHONE HYDROCHLORIDE ER TB12

2

OXYMORPHONE HYDROCHLORIDEER TB12

2

ROXICODONE TABS (oxycodone hcl) NF

ROXYBOND TABA NP

SUBSYS LIQD NP PA

TRAMADOL HCL ER CP24 NP AL(At least 21yrs old)

tramadol hcl tabs 50 mg 1 AL(At least 21yrs old)

tramadol hcl tb24 100 mg,200 mg, 300 mg NP AL(At least 21

yrs old) tramadol hcl tb24 100 mg,200 mg, 300 mg 1 AL(At least 21

yrs old) ULTRAM TABS (tramadol hcl) NF AL(At least 21

yrs old)

XTAMPZA ER C12A NP

ZOHYDRO ER C12A (hydrocodone bitartrate) NP

Opioid Combinations acetaminophen w/ codeinesoln 1 AL(At least 21

yrs old) acetaminophen w/ codeinetabs 1 AL(At least 21

yrs old) acetaminophen-caff-dihydrocod tabs NP

ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINEBITARTRATE TABS

NP

ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINECAPS

NP


24

Drug Name DrugTier

Requirements/Limits

APADAZ TABS NP

BENZHYDROCODONE/ACETAMINOPHEN TABS NP

butalbital-acetaminophen-caffeine w/ codeine caps 1 AL(At least 21

yrs old) butalbital-aspirin-caffeinew/cod caps 1 AL(At least 21

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

NF

AL(At least 21yrs old)

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

NF AL(At least 21yrs old)

HYDROCODONE BITARTRATE/ACETAMINOPHEN SOLN

NP

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

1

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

1

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

NP

hydrocodone-ibuprofentabs 200 mg-5 mg NP

hydrocodone-ibuprofentabs 200 mg-5 mg, 200mg-10 mg, 200 mg-7.5 mg

1

IBUDONE TABS (hydrocodone-ibuprofen) NF

LORTAB ELIX NP

NORCO TABS 10 MG-325 MG (hydrocodone-acetaminophen)

NF

Drug Name DrugTier

Requirements/Limits

NORCO TABS 5 MG-325 MG, 7.5 MG-325 MG (hydrocodone-acetaminophen)

NP

oxycodone w/acetaminophen tabs 2.5mg-300 mg

NP

oxycodone w/acetaminophen tabs 5 mg-325 mg, 10 mg-325 mg, 2.5mg-325 mg, 7.5 mg-325 mg

1

oxycodone-aspirin tabs 1

OXYCODONE/ACETAMINOPHEN SOLN NP

OXYCODONE/ASPIRINTABS 2

OXYCODONE/IBUPROFEN TABS NP

PERCOCET TABS (oxycodone w/acetaminophen)

NF

PRIMLEV TABS NP

PROLATE TABS NP

ROXICET SOLN NP

tramadol-acetaminophentabs 1 AL(At least 21

yrs old)

TREZIX CAPS NP

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


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


ULTRACET TABS (tramadol-acetaminophen) NF AL(At least 21

yrs old) Opioid Partial Agonists

BELBUCA FILM NP

BUNAVAIL FILM 2.1 MG-0.3 MG NP

PA; QL(8 eadaily); AL(Atleast 16 yrsold)


25

Drug Name DrugTier

Requirements/Limits

BUNAVAIL FILM 4.2 MG-0.7 MG NP


BUNAVAIL FILM 6.3 MG-1 MG NP

PA; QL(2.7 eadaily); AL(Atleast 16 yrsold)

BUPRENEX SOLN (buprenorphine hcl) NP

buprenorphine hcl soln ij0.3 mg/ml NP

buprenorphine hcl subl sl 2 mg NP PA; QL(16 ea

daily) buprenorphine hcl subl sl 8 mg NP PA; QL(4 ea

daily)

buprenorphine hcl-naloxone hcl dihydrate film12 mg-3 mg

NP

PA required if >32mgbuprenorphineper day;QL(2.7ea daily); AL(Atleast 16 yrsold)

buprenorphine hcl-naloxone hcl dihydrate film2 mg-0.5 mg

NP

PA required if >32mgbuprenorphineper day;QL(16ea daily); AL(Atleast 16 yrsold)


NP


buprenorphine hcl-naloxone hcl dihydrate film4 mg-1 mg, 8 mg-2 mg, 12mg-3 mg, 2 mg-0.5 mg

NP


NP


Drug Name DrugTier

Requirements/Limits

buprenorphine hcl-naloxone hcl dihydrate subl2 mg-0.5 mg

1


buprenorphine hcl-naloxone hcl dihydrate subl8 mg-2 mg

1


buprenorphine ptwk 5mcg/hr, 10 mcg/hr, 15mcg/hr, 20 mcg/hr

1

BUPRENORPHINE PTWK 7.5 MCG/HR 2

butorphanol tartrate soln NP

BUTRANS PTWK 5 MCG/HR, 10 MCG/HR, 15MCG/HR, 20 MCG/HR(buprenorphine)

NP

BUTRANS PTWK 7.5 MCG/HR NP

pentazocine w/ naloxonetabs NP

PROBUPHINE IMPLANT KIT IMPL NP PA

SUBLOCADE SOSY NP PA

SUBOXONE FILM 12 MG-3 MG (buprenorphine hcl-naloxone hcl dihydrate)

2

PA required if >32mgbuprenorphineper day;QL(2.7ea daily); AL(Atleast 16 yrsold)

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

2



26

Drug Name DrugTier

Requirements/Limits


2



2


ZUBSOLV SUBL 0.7 MG-0.18 MG NP PA; QL(32.6 ea

daily)

ZUBSOLV SUBL 1.4 MG-0.36 MG NP

PA; QL(16.3 eadaily); AL(Atleast 16 yrsold)

ZUBSOLV SUBL 11.4 MG-2.9 MG NP PA; QL(2 ea

daily) ZUBSOLV SUBL 2.9 MG-0.71 MG NP PA; QL(7.9 ea

daily)

ZUBSOLV SUBL 5.7 MG-1.4 MG NP


ZUBSOLV SUBL 8.6 MG-2.1 MG NP PA; QL(2.7 ea

daily) ANDROGENS-ANABOLIC - Drugs to RegulateHormones

Anabolic Steroids

ANADROL-50 TABS 2 PA

OXANDRIN TABS (oxandrolone) NF PA

oxandrolone tabs 1 PA

Androgens

ANDRODERM PT24 2 PA; QL(1 eadaily); MP

ANDROGEL GEL 25 MG/2.5GM (testosterone) NF PA; MP

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

NP PA

Drug Name DrugTier

Requirements/Limits

ANDROGEL GEL 50 MG/5GM (testosterone) NP PA; MP

ANDROGEL PUMP GEL (testosterone) NP PA

ANDROID CAPS NP PA

AVEED SOLN NP PA

danazol caps 1

DEPO-TESTOSTERONE SOLN 100 MG/ML(testosterone cypionate)

NF

DEPO-TESTOSTERONE SOLN 200 MG/ML(testosterone cypionate)

NF QL(4 ml per 30days retail)

FORTESTA GEL (testosterone) NP PA

JATENZO CAPS NP PA

METHITEST TABS NP PA

METHYLTESTOSTERONE CAPS NP PA

NATESTO GEL NP PA

STRIANT MISC NP PA

TESTIM GEL (testosterone) NP PA; MP

TESTOPEL PLLT NP PA

testosterone cypionate solnim 100 mg/ml 1

testosterone cypionate solnim 200 mg/ml 1 QL(4 ml per 30

days retail) testosterone enanthate soln im 1

TESTOSTERONE ENANTHATE SOLN IM 2

testosterone gel 1 % 1 PA

testosterone gel 1 %, 50mg/5gm, 25 mg/2.5gm 1 PA; MP

TESTOSTERONE GEL 1 %, 50 MG/5GM, 25MG/2.5GM

2 PA; MP


27

Drug Name DrugTier

Requirements/Limits

testosterone gel 1.62 %, 10mg/act, 40.5 mg/2.5gm,20.25 mg/1.25gm

NP PA

TESTOSTERONE PUMP GEL 2 PA

testosterone soln 30 mg/act NP PA

TESTRED CAPS NP PA

VOGELXO GEL NP PA; MP

VOGELXO PUMP GEL NP PA

XYOSTED SOAJ NP PA

ANORECTAL AGENTS - Rectal Drugs to TreatPain, Swelling and Itching

Intrarectal Steroids CORTENEMA ENEM (hydrocortisone(intrarectal))

NF QL(420 ml perfill retail)

CORTIFOAM FOAM NP PA

hydrocortisone (intrarectal) enem 1 QL(420 ml per

fill retail) UCERIS FOAM RE 2 MG/ACT NP PA

Rectal Combinations LIDOCAINE HCL-HYDROCORTISONE ACETATE WITH ALOE GEL

NP

PA

LIDOCAINE HCL/HYDROCORTISONEACETATE KIT

NP PA

lidocaine-hydrocortisoneacetate (rectal) crea 3 %-0.5 %

1

lidocaine-hydrocortisoneacetate (rectal) kit 2 %-2%, 3 %-1 %, 3 %-0.5 %, 3%-2.5 %

NP

PA

PROCORT CREA NP PA

PROCTOFOAM HC FOAM NP PA

Rectal Steroids

Drug Name DrugTier

Requirements/Limits

ANUSOL-HC CREA (hydrocortisone (rectal)) NF

hydrocortisone (rectal) crea 1

PROCTOCORT CREA (hydrocortisone (rectal)) NF

Vasodilating Agents

RECTIV OINT 2 PA

ANTACIDS

Antacid Combinations

MAG-AL LIQD 2

Antacids - Calcium Salts calcium carbonate (antacid)chew 500 mg, 750 mg 1

calcium carbonate (antacid)susp 1250 mg/5ml 1 QL(16.67 ml

daily) CALCIUM CARBONATE TABS 2

TUMS CHEW (calcium carbonate (antacid)) NF

TUMS CHEWY BITES CHEW (calcium carbonate (antacid))

NF

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

NF

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

NF

TUMS KIDS CHEW (calcium carbonate (antacid))

NF

TUMS LASTING EFFECTS CHEW (calcium carbonate (antacid))

NF

TUMS SMOOTHIES CHEW (calcium carbonate (antacid))

NF

ANTHELMINTICS - Drugs to Treat WormInfections

Anthelmintics

albendazole tabs NP PA; AL(At least18 yrs old)


28

Drug Name DrugTier

Requirements/Limits

albendazole tabs 1 AL(At least 18yrs old)

ALBENZA TABS (albendazole) NP PA; AL(At least

18 yrs old)

BENZNIDAZOLE TABS NP PA

BILTRICIDE TABS (praziquantel) NP PA

EGATEN TABS 2

EMVERM CHEW NP PA; QL(1 eaper 14 daysretail)

ivermectin tabs 1

praziquantel tabs NP PA

pyrantel pamoate susp 1

1 fill per 30days;QL(60 mlper fill retail,60ml per 30 daysretail)

REESES PINWORM MEDICINE TABS 2

STROMECTOL TABS (ivermectin) NF

ANTI-INFECTIVE AGENTS - MISC. - Drugs toTreat Bacterial Infections

Anti-infective Agents - Misc. bacitracin solr im 50000 unit 1 PA

FLAGYL CAPS 375 MG (metronidazole) NP PA

FLAGYL TABS 250 MG, 500 MG (metronidazole) NF

IMPAVIDO CAPS 2 PA

metronidazole caps 375 mg NP PA

metronidazole tabs 250 mg, 500 mg 1

NEBUPENT SOLR (pentamidine isethionate) 2 PA

PENTAM 300 SOLR (pentamidine isethionate) NF PA

Drug Name DrugTier

Requirements/Limits

pentamidine isethionatesolr 1 PA

TINDAMAX TABS (tinidazole) NF

tinidazole tabs 1

trimethoprim tabs 1

vancomycin hcl solr iv 1000 mg 1 QL(14 ea per

fill retail) vancomycin hcl solr iv 500 mg 1 QL(14 ea per

30 days retail)

XIFAXAN TABS 200 MG 2 PA

XIFAXAN TABS 550 MG 2 PA; MP

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

NF

BACTRIM TABS (sulfamethoxazole-trimethoprim)

NF

sulfamethoxazole-trimethoprim soln iv 80mg/5ml-400 mg/5ml

1 PA

sulfamethoxazole-trimethoprim susp or 40mg/5ml-200 mg/5ml

1

sulfamethoxazole-trimethoprim tabs or 80 mg-400 mg, 160 mg-800 mg

1

Antiprotozoal Agents

ALINIA SUSR 2 PA

ALINIA TABS 2 PA

atovaquone susp 1

MEPRON SUSP (atovaquone) NF

Carbapenems

ertapenem sodium solr 1 PA

INVANZ SOLR (ertapenemsodium) NF PA


29

Drug Name DrugTier

Requirements/Limits

Glycopeptides FIRST-VANCOMYCIN 25 SOLN 2

FIRVANQ SOLR 2

VANCOCIN CAPS (vancomycin hcl) NF QL(8 ea daily)

VANCOCIN HCL CAPS (vancomycin hcl) NF QL(4 ea daily)

vancomycin hcl caps or125 mg 1 QL(4 ea daily)

vancomycin hcl caps or250 mg 1 QL(8 ea daily)

vancomycin hcl solr iv 1gm, 1000 mg 1 QL(14 ea per

fill retail) vancomycin hcl solr iv 500 mg 1 QL(14 ea per

30 days retail) VANCOMYCIN HYDROCHLORIDE SOLR OR 250 MG/5ML

2

Leprostatics

dapsone tabs 1 MP

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

NF

CLEOCIN PEDIATRIC GRANULES SOLR (clindamycin palmitatehydrochloride)

NF

QL(100 ml perfill retail)

clindamycin hcl caps 1

clindamycin palmitatehydrochloride solr 1 QL(100 ml per

fill retail) Monobactams AZACTAMIN ISO-OSMOTIC DEXTROSE SOLN

2

CAYSTON SOLR 2 PA; SP

Oxazolidinones

linezolid susr 1

linezolid tabs 1

Drug Name DrugTier

Requirements/Limits

SIVEXTRO TABS NP QL(6 ea per fillretail)

ZYVOX SUSR (linezolid) NF

ZYVOX TABS (linezolid) NF

ANTIANGINAL AGENTS - Drugs to Treat ChestPain

Antianginals-Other RANEXA TB12 (ranolazine) NF PA; MP

ranolazine tb12 1 PA; MP

Nitrates

DILATRATE SR CPCR NP PA

GONITRO PACK NP

ISORDIL TITRADOSE TABS 40 MG (isosorbide dinitrate)

NF

ISORDIL TITRADOSE TABS 5 MG (isosorbide dinitrate)

NF MP

ISOSORBIDE DINITRATE ER TBCR 2 MP

isosorbide dinitrate tabs 40 mg 1

isosorbide dinitrate tabs 5 mg, 10 mg, 20 mg, 30 mg 1 MP

isosorbide mononitrate tabs 10 mg, 20 mg 1 QL(2 ea daily);

MP isosorbide mononitrate tb24 30 mg, 60 mg, 120 mg 1 QL(1 ea daily);

MP

NITRO-BID OINT 2 MP

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

NF

MP

NITRO-DUR PT24 0.3 MG/HR, 0.8 MG/HR NP PA

NITRO-TIME CPCR 2 MP

NITROGLYCERIN IN DEXTROSE 5% SOLN 2 PA


30

Drug Name DrugTier

Requirements/Limits

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

1 MP

NITROGLYCERIN SOLN IV 5 MG/ML NP

nitroglycerin soln tl 0.4mg/spray NP PA

nitroglycerin subl sl 0.3 mg,0.4 mg, 0.6 mg 1 MP

NITROLINGUAL PUMPSPRAY SOLN (nitroglycerin)

NP PA

NITROMIST AERS NP PA

NITROSTAT SUBL (nitroglycerin) NF MP

ANTIANXIETY AGENTS - Drugs to Treat Anxiety

Antianxiety Agents - Misc.

buspirone hcl tabs 1 QL(3 ea daily);MP

droperidol soln 1

HYDROXYZINE HCL SOLN IM 25 MG/ML 2

hydroxyzine hcl syrp or 10mg/5ml 1

hydroxyzine hcl tabs or 10mg, 25 mg, 50 mg 1 MP

HYDROXYZINE HYDROCHLORIDE SOLN 2

HYDROXYZINE PAMOATE CAPS 100 MG 2

hydroxyzine pamoate caps25 mg 1

hydroxyzine pamoate caps50 mg 1 MP

meprobamate tabs NP PA

VISTARIL CAPS 25 MG (hydroxyzine pamoate) NF

VISTARIL CAPS 50 MG (hydroxyzine pamoate) NF MP

Benzodiazepines ALPRAZOLAM INTENSOL CONC NP

Drug Name DrugTier

Requirements/Limits

alprazolam tabs 0.25 mg,0.5 mg, 1 mg, 2 mg 1 QL(4 ea daily)

alprazolam tb24 0.5 mg, 1mg, 2 mg, 3 mg NP PA

alprazolam tbdp 0.25 mg,0.5 mg, 1 mg, 2 mg NP

ATIVAN SOLN IJ 2 MG/ML, 4 MG/ML(lorazepam)

NF

ATIVAN TABS OR 0.5 MG, 2 MG (lorazepam) NF QL(3 ea daily)

ATIVAN TABS OR 1 MG (lorazepam) NF QL(4 ea daily)

chlordiazepoxide hcl caps 1 QL(4 ea daily)

clorazepate dipotassiumtabs 1 QL(3 ea daily)

diazepam conc or 5 mg/ml 1

DIAZEPAM SOLN IJ 5 MG/ML 2

diazepam soln ij 5 mg/ml 1

DIAZEPAM SOLN OR 5 MG/5ML 2 QL(500 ml per

fill retail) diazepam tabs or 2 mg, 5mg, 10 mg 1 QL(4 ea daily)

lorazepam conc or 2 mg/ml 1

lorazepam soln ij 2 mg/ml,4 mg/ml, 20 mg/10ml 1

lorazepam tabs or 0.5 mg,2 mg 1 QL(3 ea daily)

lorazepam tabs or 1 mg 1 QL(4 ea daily)

oxazepam caps 10 mg, 15mg, 30 mg NP QL(4 ea daily)

OXAZEPAM CAPS 10 MG, 15 MG, 30 MG NP QL(4 ea daily)

TRANXENE T TABS (clorazepate dipotassium) NF QL(3 ea daily)

VALIUM TABS (diazepam) NF QL(4 ea daily)

XANAX TABS (alprazolam) NF QL(4 ea daily)

XANAX XR TB24 (alprazolam) NP PA


31

Drug Name DrugTier

Requirements/Limits

ANTIARRHYTHMICS - Drugs to treat abnormalheart rhythms

Antiarrhythmics - Misc. ADENOCARD SOLN (adenosine) 2 PA

adenosine soln 3 mg/ml, 6mg/2ml, 12 mg/4ml 1 PA

Antiarrhythmics Type I-A disopyramide phosphate caps 1 MP

NORPACE CAPS (disopyramide phosphate) NF MP

NORPACE CR CP12 NP

procainamide hcl soln 1 PA

QUINIDINE GLUCONATE SOLN IJ 80 MG/ML 2 PA

quinidine gluconate tbcr or324 mg 1 MP

QUINIDINE SULFATE TABS NP

Antiarrhythmics Type I-B

lidocaine hcl (cardiac) sosy 1 PA

LIDOCAINE HCL SOLN IV 100 MG/5ML 2 PA

LIDOCAINE HCL SOSY IV 50 MG/5ML, 100 MG/5ML 2 PA

lidocaine in d5w soln 1 PA

MEXILETINE HCL CAPS 150 MG, 200 MG, 250 MG 2 MP

mexiletine hcl caps 200mg, 250 mg 1 MP

XYLOCAINE SOLN 2 PA

Antiarrhythmics Type I-C

flecainide acetate tabs 1 MP

propafenone hcl cp12 1 MP

propafenone hcl tabs 1 MP

RYTHMOL SR CP12 (propafenone hcl) NF MP

Drug Name DrugTier

Requirements/Limits

Antiarrhythmics Type III amiodarone hcl soln iv 50 mg/ml, 150 mg/3ml, 450mg/9ml, 900 mg/18ml

1 PA

amiodarone hcl tabs or 100 mg, 200 mg, 400 mg 1 MP

CORDARONE TABS (amiodarone hcl) NF MP

CORVERT SOLN (ibutilide fumarate) 2 PA

dofetilide caps 1 MP

ibutilide fumarate soln 1 PA

MULTAQ TABS NP

NEXTERONE SOLN 2 PA

TIKOSYN CAPS (dofetilide) NF MP

ANTIASTHMATIC AND BRONCHODILATOR AGENTS - Drugs to Treat Lung Conditions

Anti-Inflammatory Agents

CROMOLYN SODIUM NEBU 2

QL(240 ml per30 days retail);MP

cromolyn sodium nebu 1 QL(240 ml per30 days retail);MP

Antiasthmatic - Monoclonal Antibodies

CINQAIR SOLN 2 PA; MP

FASENRA PEN SOAJ NP PA

FASENRA SOSY 2 PA; MP

NUCALA SOAJ 100 MG/ML 2 PA

NUCALA SOLR 100 MG 2 PA; MP

NUCALA SOSY 100 MG/ML 2 PA

XOLAIR SOLR 2 PA

XOLAIR SOSY 2 PA


32

Drug Name DrugTier

Requirements/Limits

Bronchodilators - Anticholinergics

ATROVENT HFA AERS 2 MP

INCRUSE ELLIPTA AEPB NP ST; MP

ipratropium bromide soln 1 QL(375 ml per25 days retail);MP

LONHALA MAGNAIR REFILL KIT SOLN NP MP

LONHALA MAGNAIR STARTER KIT SOLN NP MP

SEEBRI NEOHALER CAPS NP MP

SPIRIVA HANDIHALER CAPS 2 MP

SPIRIVA RESPIMAT AERS NP PA; MP

TUDORZA PRESSAIR AEPB NP ST; MP

YUPELRI SOLN NP

Leukotriene Modulators ACCOLATE TABS (zafirlukast) NF MP

montelukast sodium chew 1 QL(1 ea daily);MP

montelukast sodium pack 1 QL(1 ea daily);MP

montelukast sodium tabs 1 QL(1 ea daily);MP

SINGULAIR CHEW (montelukast sodium) NF QL(1 ea daily);

MP SINGULAIR PACK (montelukast sodium) NF QL(1 ea daily);

MP SINGULAIR TABS (montelukast sodium) NF QL(1 ea daily);

MP

zafirlukast tabs 1 MP

zileuton tb12 NP PA; MP

ZYFLO CR TB12 (zileuton) NP PA; MP

ZYFLO TABS NP PA; MP

Selective Phosphodiesterase 4 (PDE4) Inhibitors

Drug Name DrugTier

Requirements/Limits

DALIRESP TABS 2 PA

Steroid Inhalants

ALVESCO AERS NP MP

ARMONAIR RESPICLICK 113 AEPB NP MP



ARNUITY ELLIPTA AEPB NP MP

ASMANEX HFA AERO 100 MCG/ACT, 200 MCG/ACT NP MP

ASMANEX TWISTHALER 120 METERED DOSES AEPB

NP MP


NP MP


NP MP


NP MP


NP MP

budesonide (inhalation) susp 1

QL(120 ml per30 days retail);AL(At least 1yrs old - Up to8 yrs old); MP

FLOVENT DISKUS AEPB 100 MCG/BLIST, 250MCG/BLIST

2 QL(2 ea daily);MP

FLOVENT DISKUS AEPB 50 MCG/BLIST 2

QL(60 ea per25 days retail);MP

FLOVENT HFA AERO 110 MCG/ACT, 220 MCG/ACT 2

QL(12 gm per25 days retail);MP

FLOVENT HFA AERO 44 MCG/ACT 2



33

Drug Name DrugTier

Requirements/Limits

PULMICORT FLEXHALER AEPB 2 QL(1 ea per 30

days retail); MP

PULMICORT SUSP (budesonide (inhalation)) NF

QL(120 ml per30 days retail);AL(At least 1yrs old - Up to8 yrs old); MP

QVAR AERS NP ST; MP

QVAR REDIHALER AERB NP MP

Sympathomimetics ADVAIR DISKUS AEPB (fluticasone-salmeterol) 2 QL(2 ea daily);

MP

ADVAIR HFA AERO 2 QL(0.4 gmdaily); MP

AIRDUO RESPICLICK 113/14 AEPB NP PA; MP



albuterol sulfate aers in 108 mcg/act 2 MP

ALBUTEROL SULFATE ER TB12 2 MP

ALBUTEROL SULFATE HFA AERS NP MP

albuterol sulfate nebu in 0.083 % 1


albuterol sulfate nebu in 0.5 %, 2.5 mg/0.5ml 1 QL(2 ml daily);

MP

albuterol sulfate nebu in 0.63 mg/3ml, 1.25 mg/3ml 1


albuterol sulfate syrp or 2mg/5ml 1 MP

albuterol sulfate tabs or 2 mg, 4 mg 1 MP

ANORO ELLIPTA AEPB NP MP

ARCAPTA NEOHALER CAPS NP MP

BEVESPI AEROSPHERE AERO NP MP

Drug Name DrugTier

Requirements/Limits

BREO ELLIPTA AEPB 25 MCG/INH-100 MCG/INH NP ST; AL(At least

18 yrs old); MP

BREO ELLIPTA AEPB 25 MCG/INH-200 MCG/INH NP

ST; QL(2 eadaily); AL(Atleast 18 yrsold); MP

BROVANA NEBU NP ST; MP

BUDESONIDE/FORMOTEROL FUMARATE DIHYDRATE AERO

2 MP

COMBIVENT RESPIMAT AERS 2 QL(4 gm per fill

retail); MP DUAKLIR PRESSAIR AEPB NP PA

DULERA AERO 5 MCG/ACT-100 MCG/ACT,5 MCG/ACT-200MCG/ACT

2

MP

epinephrine hcl soln 1mg/ml 1 PA

FLUTICASONE PROPIONATE/SALMETEROL AEPB

NP PA; MP

fluticasone-salmeterol aepb 1 QL(2 ea daily);MP

ipratropium-albuterol soln 1 QL(12 mldaily); MP

levalbuterol hcl nebu 0.31 mg/3ml, 0.63 mg/3ml, 1.25mg/3ml

NP MP

levalbuterol hcl nebu 1.25 mg/0.5ml NP ST; MP

LEVALBUTEROL TARTRATE HFA AERO NP MP

METAPROTERENOL SULFATE SYRP 10 MG/5ML

NP QL(30 mldaily); MP

METAPROTERENOL SULFATE TABS 10 MG, 20 MG

NP MP

PERFOROMIST NEBU NP MP

PROAIR DIGIHALER AEPB NP PA

PROAIR HFA AERS (albuterol sulfate) 2


34

Drug Name DrugTier

Requirements/Limits

PROAIR RESPICLICK AEPB NP MP

PROVENTIL HFA AERS 2 MP

racepinephrine hcl nebu NP

S2 NEBU (racepinephrinehcl) NP

SEREVENT DISKUS AEPB 2 QL(2 ea daily);

MP STIOLTO RESPIMAT AERS 2 MP

STRIVERDI RESPIMAT AERS NP MP

SYMBICORT AERO 2 MP

terbutaline sulfate soln ij 1mg/ml NP

terbutaline sulfate tabs or 5 mg, 2.5 mg NP MP

TRELEGY ELLIPTA AEPB NP MP

UTIBRON NEOHALER CAPS NP MP

VENTOLIN HFA AERS NP MP

XOPENEX CONCENTRATE NEBU (levalbuterol hcl)

NP ST; MP

XOPENEX HFA AERO NP MP

XOPENEX NEBU (levalbuterol hcl) NP MP

Xanthines

aminophylline soln 1 PA

ELIXOPHYLLIN ELIX NP MP

THEO-24 CP24 NP MP

THEOPHYLLINE ER TB12 300 MG 2 MP

THEOPHYLLINE ER TB12 450 MG 2

theophylline soln 80mg/15ml 1 QL(475 ml per

fill retail); MP

Drug Name DrugTier

Requirements/Limits

theophylline tb12 100 mg,300 mg 1 MP

theophylline tb12 200 mg,450 mg 1

theophylline tb24 400 mg,600 mg 1 MP

THEOPHYLLINE/D5WSOLN 2 PA

ANTICOAGULANTS - Blood Thinners

Coumarin Anticoagulants COUMADIN TABS (warfarin sodium) NF MP

warfarin sodium tabs 1 MP

Direct Factor Xa Inhibitors

BEVYXXA CAPS NP

ELIQUIS STARTER PACK TABS 2 QL(4 ea daily);

MP

ELIQUIS TABS 2 QL(4 ea daily);MP

SAVAYSA TABS NP

XARELTO STARTER PACK TBPK 2

XARELTO TABS 10 MG 2

QL(35 ea per180 daysretail); AL(Atleast 18 yrsold); MP

XARELTO TABS 15 MG 2 QL(2 ea daily);AL(At least 18yrs old); MP

XARELTO TABS 2.5 MG 2

XARELTO TABS 20 MG 2 QL(1 ea daily);AL(At least 18yrs old); MP

Heparins And Heparinoid-Like Agents ARIXTRA SOLN (fondaparinux sodium) NP PA; SP

enoxaparin sodium soln ij300 mg/3ml 1 QL(42 ml per 7

days retail)


35

Drug Name DrugTier

Requirements/Limits

enoxaparin sodium soln sc100 mg/ml, 150 mg/ml 1

QL(14 ml per 7days retail)3 rtlMAX fill,180 rtl day(s) supply,

enoxaparin sodium soln sc30 mg/0.3ml 1






enoxaparin sodium soln sc80 mg/0.8ml, 120 mg/0.8ml 1


fondaparinux sodium soln NP PA; SP

FRAGMIN SOLN NP SP

heparin (porcine) in sodiumchloride soln 1 PA

HEPARIN LOCK FLUSH SOLN NF PA

HEPARIN LOCK FLUSH SOLN 2 PA

heparin sodium (porcine)lock flush soln 1 PA

heparin sodium (porcine)soln 1 PA

HEPARIN SODIUM SOLN IJ 5000 UNIT/ML 2 PA

HEPARIN SODIUM SOSY IJ 5000 UNIT/0.5ML 2 PA

HEPARIN SODIUM/D5WSOLN 40 UNIT/ML-5 %,100 UNIT/ML-5 %, 5 %-12500 UNIT/250ML, 5 %-25000 UNIT/500ML

2

PA

HEPARIN SODIUM/D5WSOLN 5 %-12500 UNIT/250ML

NF PA

Drug Name DrugTier

Requirements/Limits

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

2

PA

HEPARIN SODIUM/NACL0.45% SOLN 2 PA

HEPARIN SODIUM/SODIUMCHLORIDE 0.9% SOLN

2 PA

HEPARIN SODIUM/SODIUMCHLORIDE SOLN 2000 UNIT/L-0.9 %, 1000UNIT/500ML-0.9 %, 25000UNIT/250ML-0.45 %,25000 UNIT/500ML-0.45 %

2

PA

LOVENOX SOLN IJ 300 MG/3ML (enoxaparinsodium)

NF QL(42 ml per 7days retail)

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

NF


LOVENOX SOLN SC 30 MG/0.3ML (enoxaparinsodium)

NF



NF



NF


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

NF


Thrombin Inhibitors

PRADAXA CAPS 2 MP

ANTICONVULSANTS - Drugs to Treat Seizures

AMPA Glutamate Receptor Antagonists

FYCOMPA SUSP 2 PA; MP


36

Drug Name DrugTier

Requirements/Limits

FYCOMPA TABS 2 PA; MP

Anticonvulsants - Benzodiazepines

clobazam susp 1

clobazam tabs 1

clonazepam tabs 0.5 mg, 1mg, 2 mg 1 QL(4 ea daily);

MP clonazepam tbdp 0.125mg, 0.25 mg, 0.5 mg, 1 mg,2 mg

NP PA

DIASTAT ACUDIAL GEL 2 QL(1 ea per fillretail)

DIASTAT PEDIATRIC GEL 2 QL(1 ea per fillretail)

DIAZEPAM RECTAL GEL GEL 2 QL(1 ea per fill

retail) KLONOPIN TABS (clonazepam) NF QL(4 ea daily);

MP

NAYZILAM SOLN NP

ONFI SUSP (clobazam) NF

ONFI TABS (clobazam) NF

SYMPAZAN FILM NP PA

VALTOCO LIQD NP

VALTOCO LQPK NP

Anticonvulsants - Misc. APTIOM TABS NP PA

BANZEL SUSP 40 MG/ML NP PA

BANZEL TABS 200 MG NP PA; SP

BANZEL TABS 400 MG NP PA

BRIVIACT SOLN IV 50 MG/5ML 2 PA

BRIVIACT SOLN OR 10 MG/ML NP PA

Drug Name DrugTier

Requirements/Limits

BRIVIACT TABS OR 10 MG, 25 MG, 50 MG, 75 MG, 100 MG

NP PA

carbamazepine chew 1 MP

carbamazepine cp12 1 MP

carbamazepine susp 1 MP

carbamazepine tabs 1 MP

carbamazepine tb12 1 MP

CARBATROL CP12 (carbamazepine) NF MP

DIACOMIT CAPS NP PA

DIACOMIT PACK NP PA

EPIDIOLEX SOLN NP PA

gabapentin caps 100 mg,400 mg 1 QL(4 ea daily);

MP

gabapentin caps 300 mg 1 MP

gabapentin soln 250mg/5ml, 300 mg/6ml 1 MP

gabapentin tabs 600 mg 1 MP

gabapentin tabs 800 mg 1 QL(4 ea daily);MP

KEPPRA SOLN IV 500 MG/5ML (levetiracetam) NF PA

KEPPRA SOLN OR 100 MG/ML (levetiracetam) NF QL(30 ml

daily); MP KEPPRA TABS OR 1000 MG (levetiracetam) NF MP

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

NF QL(4 ea daily);MP

KEPPRA XR TB24 (levetiracetam) NF MP

LAMICTAL CHEWABLE DISPERSIBLE CHEW (lamotrigine)

NP PA

LAMICTAL ODT KIT NP PA


37

Drug Name DrugTier

Requirements/Limits

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

NP PA

LAMICTAL STARTER/NOTTAKING CARBAMAZEPINE KIT (lamotrigine)

NP

PA

LAMICTAL STARTER/TAKINGCARBAMAZEPINE/NOTTAKING VALPROATE KIT (lamotrigine)

NP

PA

LAMICTAL STARTER/TAKINGVALPROATE KIT (lamotrigine)

NP

PA

LAMICTAL TABS (lamotrigine) NF MP

LAMICTAL XR KIT NP PA

LAMICTAL XR TB24 25 MG, 50 MG, 100 MG, 200 MG, 250 MG, 300 MG (lamotrigine)

NP

PA

lamotrigine chew 5 mg, 25 mg NP PA

lamotrigine kit 25 mg NP PA

lamotrigine tabs 25 mg,100 mg, 150 mg, 200 mg 1 MP

lamotrigine tb24 25 mg, 50mg, 100 mg, 200 mg, 250mg, 300 mg

NP PA

lamotrigine tbdp 25 mg, 50mg, 100 mg, 200 mg NP PA

levetiracetam in sodium chloride soln 1 PA

LEVETIRACETAM SOLN IV 500 MG/100ML-820MG/100ML, 1000MG/100ML-750MG/100ML, 1500MG/100ML-540 MG/100ML(levetiracetam in sodium chloride)

2

PA

levetiracetam soln iv 500 mg/5ml 1 PA

Drug Name DrugTier

Requirements/Limits

levetiracetam soln or 100 mg/ml, 500 mg/5ml 1 QL(30 ml

daily); MP levetiracetam tabs or 1000 mg 1 MP

levetiracetam tabs or 250 mg, 500 mg, 750 mg 1 QL(4 ea daily);

MP levetiracetam tb24 or 500 mg, 750 mg 1 MP

LYRICA CAPS 225 MG, 300 MG (pregabalin) NP QL(2 ea daily)

LYRICA CAPS 25 MG, 50 MG, 75 MG, 100 MG, 150 MG, 200 MG (pregabalin)

NP QL(3 ea daily)

LYRICA SOLN 20 MG/ML(pregabalin) NP QL(30 ml daily)

MYSOLINE TABS (primidone) NF MP

NEURONTIN CAPS 100 MG, 400 MG (gabapentin) NF QL(4 ea daily);

MP NEURONTIN CAPS 300 MG (gabapentin) NF MP

NEURONTIN SOLN 250 MG/5ML (gabapentin) NF MP

NEURONTIN TABS 600 MG (gabapentin) NF MP

NEURONTIN TABS 800 MG (gabapentin) NF QL(4 ea daily);

MP

oxcarbazepine susp 1 MP

oxcarbazepine tabs 1 MP

OXTELLAR XR TB24 NP PA

pregabalin caps 225 mg,300 mg 1 QL(2 ea daily)

pregabalin caps 25 mg, 50mg, 75 mg, 100 mg, 150mg, 200 mg

1 QL(3 ea daily)

pregabalin soln 20 mg/ml 1 QL(30 ml daily)

primidone tabs 1 MP

QUDEXY XR CS24 NP PA

SPRITAM TB3D NP PA


38

Drug Name DrugTier

Requirements/Limits

TEGRETOL SUSP (carbamazepine) NF MP

TEGRETOL TABS (carbamazepine) NF MP

TEGRETOL-XR TB12 (carbamazepine) NF MP

TOPAMAX SPRINKLE CPSP 15 MG (topiramate) NF QL(6 ea daily);

MP TOPAMAX SPRINKLE CPSP 25 MG (topiramate) NF QL(8 ea daily);

MP TOPAMAX TABS (topiramate) NF QL(3 ea daily);

MP

topiramate cpsp 15 mg 1 QL(6 ea daily);MP

topiramate cpsp 25 mg 1 QL(8 ea daily);MP

TOPIRAMATE ER CS24 NP PA

topiramate tabs 25 mg, 50mg, 100 mg, 200 mg 1 QL(3 ea daily);

MP TRILEPTAL SUSP (oxcarbazepine) NF MP

TRILEPTAL TABS (oxcarbazepine) NF MP

TROKENDI XR CP24 2 MP

VIMPAT SOLN IV 200 MG/20ML 2 PA

VIMPAT SOLN OR 10 MG/ML 2 MP

VIMPAT TABS OR 50 MG, 100 MG, 150 MG, 200 MG 2 MP

ZONEGRAN CAPS (zonisamide) NF MP

zonisamide caps 1 MP

Carbamates

felbamate susp 1 PA; MP

felbamate tabs 1 PA; MP

FELBATOL SUSP (felbamate) NF PA; MP

FELBATOL TABS (felbamate) NF PA; MP

GABA Modulators

Drug Name DrugTier

Requirements/Limits

GABITRIL TABS (tiagabinehcl) NF PA; MP

SABRIL PACK (vigabatrin) NF PA; SP; MP

SABRIL TABS (vigabatrin) NF PA; MP

tiagabine hcl tabs 1 PA; MP

vigabatrin pack 1 PA; SP; MP

vigabatrin tabs 1 PA; MP

Hydantoins CEREBYX SOLN (fosphenytoin sodium) 2 PA

DILANTIN CAPS 100 MG (phenytoin sodiumextended)

NF MP

DILANTIN CAPS 30 MG 2 MP

DILANTIN INFATABS CHEW (phenytoin) NF MP

DILANTIN-125 SUSP (phenytoin) NF MP

fosphenytoin sodium soln 1 PA

PEGANONE TABS NP

PHENYTEK CAPS (phenytoin sodiumextended)

NF MP

phenytoin chew 1 MP

phenytoin sodium extended caps 1 MP

phenytoin sodium soln 1 PA

phenytoin susp 1 MP

Succinimides

CELONTIN CAPS NP

ethosuximide caps 1

ethosuximide soln 1

ZARONTIN CAPS (ethosuximide) 2


39

Drug Name DrugTier

Requirements/Limits

ZARONTIN SOLN (ethosuximide) 2

Valproic Acid DEPACON SOLN (valproate sodium) NF

DEPAKENE CAPS (valproic acid) NF MP

DEPAKENE SOLN (valproate sodium) NF MP

DEPAKOTE ER TB24 (divalproex sodium) NF MP

DEPAKOTE SPRINKLES CSDR (divalproex sodium) NF MP

DEPAKOTE TBEC (divalproex sodium) NF MP

divalproex sodium csdr 1 MP

divalproex sodium tb24 1 MP

divalproex sodium tbec 1 MP

valproate sodium soln iv100 mg/ml, 500 mg/5ml 1

valproate sodium soln or250 mg/5ml 1 MP

valproic acid caps 1 MP

ANTIDEPRESSANTS - Drugs to TreatDepression

Alpha-2 Receptor Antagonists (Tetracyclics)

mirtazapine tabs 1 QL(1 ea daily);MP

mirtazapine tbdp 1 QL(1 ea daily);MP

REMERON SOLTAB TBDP (mirtazapine) NF QL(1 ea daily);

MP REMERON TABS (mirtazapine) NF QL(1 ea daily);

MP

Antidepressants - Misc. APLENZIN TB24 NP

bupropion hcl tabs 75 mg,100 mg 1 QL(3 ea daily);

MP bupropion hcl tb12 100 mg,150 mg, 200 mg 1 QL(2 ea daily);

MP

Drug Name DrugTier

Requirements/Limits

bupropion hcl tb24 150 mg,300 mg 1 QL(1 ea daily);

MP BUPROPION HYDROCHLORIDE ER (XL) TB24

2

FORFIVO XL TB24 NP PA

MAPROTILINE HCL TABS NP MP

WELLBUTRIN SR TB12 (bupropion hcl) NF QL(2 ea daily);

MP WELLBUTRIN XL TB24 (bupropion hcl) NF QL(1 ea daily);

MP

Monoamine Oxidase Inhibitors (MAOIs) EMSAM PT24 2 MP

MARPLAN TABS NP MP

NARDIL TABS (phenelzinesulfate) NP PA; MP

PARNATE TABS (tranylcypromine sulfate) NF MP

phenelzine sulfate tabs 1 MP

tranylcypromine sulfatetabs 1 MP

Selective Serotonin Reuptake Inhibitors (SSRIs)

CELEXA TABS 10 MG (citalopram hydrobromide) NF

Age 6-99:MDD=4 AL(Atleast 6 yrs old);MP





citalopram hydrobromidesoln 10 mg/5ml NP

PA; Age 6-99:MDD=20;AL(Atleast 6 yrs old);MP

citalopram hydrobromidetabs 10 mg 1

Age 6-99:MDD=4 AL(Atleast 6 yrs old);MP


40

Drug Name DrugTier

Requirements/Limits





escitalopram oxalate soln 5mg/5ml NP

escitalopram oxalate tabs 5mg, 10 mg, 20 mg 1 QL(1 ea daily);

MP

FLUOXETINE DR CPDR NP

fluoxetine hcl caps 10 mg,20 mg 1 QL(4 ea daily);

MP

fluoxetine hcl caps 40 mg 1 QL(2 ea daily);MP

fluoxetine hcl soln 20 mg/5ml 1

Age 2-3:MDD=10; Age4-17: MDD=15; Age 18+:MDD=20; MP

fluoxetine hcl tabs 10 mg NP QL(1 ea daily);MP

fluoxetine hcl tabs 20 mg,60 mg NP

FLUOXETINE HYDROCHLORIDE TABS (fluoxetine hcl)

NP

fluvoxamine maleate cp24100 mg, 150 mg NP

fluvoxamine maleate tabs 100 mg 1 QL(3 ea daily);

MP fluvoxamine maleate tabs 25 mg, 50 mg 1 QL(2 ea daily);

MP LEXAPRO TABS (escitalopram oxalate) NF QL(1 ea daily);

MP paroxetine hcl tabs 10 mg,20 mg, 30 mg, 40 mg 1 QL(2 ea daily);

MP paroxetine hcl tb24 25 mg,12.5 mg, 37.5 mg NP

PAXIL CR TB24 (paroxetine hcl) NP

PAXIL SUSP 10 MG/5ML NP QL(40 mldaily); MP

Drug Name DrugTier

Requirements/Limits

PAXIL TABS 10 MG, 20 MG, 30 MG, 40 MG (paroxetine hcl)


PEXEVA TABS NP

PROZAC CAPS 10 MG, 20 MG (fluoxetine hcl) NF QL(4 ea daily);

MP PROZAC CAPS 40 MG (fluoxetine hcl) NF QL(2 ea daily);

MP sertraline hcl conc 20 mg/ml NP QL(10 ml

daily); MP

sertraline hcl tabs 100 mg 1 QL(2 ea daily);MP

sertraline hcl tabs 25 mg,50 mg 1 QL(1.5 ea

daily); MP ZOLOFT CONC 20 MG/ML(sertraline hcl) NP QL(10 ml

daily); MP ZOLOFT TABS 100 MG (sertraline hcl) NF QL(2 ea daily);

MP ZOLOFT TABS 25 MG, 50 MG (sertraline hcl) NF QL(1.5 ea

daily); MP

Serotonin Modulators NEFAZODONE HCL TABS 100 MG, 150 MG NP MP

nefazodone hcl tabs 50 mg,250 mg NP MP

NEFAZODONE HYDROCHLORIDE TABS NP MP

trazodone hcl tabs 300 mg 1 QL(2 ea daily);MP

trazodone hcl tabs 50 mg,100 mg, 150 mg 1 MP

TRINTELLIX TABS NP QL(1 ea daily);AL(At least 18yrs old); MP

VIIBRYD STARTER PACK KIT NP

VIIBRYD TABS NP QL(1 ea daily);MP

Serotonin-Norepinephrine Reuptake Inhibitors

CYMBALTA CPEP 20 MG (duloxetine hcl) NF

Age 7-99: MDD= 3; AL(At least7 yrs old); MP


Age 7-99: MDD= 2;AL(At least7 yrs old); MP


41

Drug Name DrugTier

Requirements/Limits


Age 7-99: MDD= 1;AL(At least7 yrs old); MP

DESVENLAFAXINE ER TB24 50 MG, 100 MG NP

desvenlafaxine succinate tb24 100 mg NP QL(4 ea daily);

MP desvenlafaxine succinate tb24 25 mg, 50 mg NP QL(1 ea daily);

MP

DRIZALMA SPRINKLE CSDR 20 MG NP

PA; Age 7-99:MDD = 3;AL(Atleast 7 yrs old)




PA; Age 7-99:MDD = 1.5;AL(At least7 yrs old)



duloxetine hcl cpep 20 mg 1 Age 7-99: MDD= 3; AL(At least7 yrs old); MP

duloxetine hcl cpep 30 mg 1 Age 7-99: MDD= 2;AL(At least7 yrs old); MP

duloxetine hcl cpep 40 mg 1

Age 7-99: MDD= 1.5;AL(Atleast 7 yrs old);MP

duloxetine hcl cpep 60 mg 1 Age 7-99: MDD= 1;AL(At least7 yrs old); MP

EFFEXOR XR CP24 (venlafaxine hcl) NF QL(2 ea daily);

MP

FETZIMA CP24 NP

FETZIMA TITRATION PACK C4PK NP

KHEDEZLA TB24 NP

PRISTIQ TB24 100 MG (desvenlafaxine succinate) NP QL(4 ea daily);

MP

Drug Name DrugTier

Requirements/Limits

PRISTIQ TB24 25 MG, 50 MG (desvenlafaxine succinate)

NP QL(1 ea daily);MP

venlafaxine hcl cp24 75mg, 150 mg, 37.5 mg 1 QL(2 ea daily);

MP venlafaxine hcl tabs 25 mg,50 mg, 75 mg, 100 mg,37.5 mg

1 MP

venlafaxine hcl tb24 75 mg,150 mg, 225 mg, 37.5 mg NP QL(1 ea daily);

MP

Tricyclic Agents

amitriptyline hcl tabs 1 MP

AMOXAPINE TABS 2 MP

ANAFRANIL CAPS 25 MG (clomipramine hcl) NP PA

ANAFRANIL CAPS 50 MG, 75 MG (clomipramine hcl) NP PA; MP

clomipramine hcl caps 25 mg NP PA

clomipramine hcl caps 50mg, 75 mg NP PA; MP

desipramine hcl tabs 10mg, 50 mg, 75 mg, 100 mg,150 mg

1 MP

desipramine hcl tabs 25 mg 1 QL(2 ea daily)

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

1 MP

DOXEPIN HCL CAPS 150 MG 2 MP

doxepin hcl conc 10 mg/ml 1 MP

imipramine hcl tabs 1 MP

imipramine pamoate caps NP

NORPRAMIN TABS 10 MG (desipramine hcl) NF MP

NORPRAMIN TABS 25 MG (desipramine hcl) NF QL(2 ea daily)

nortriptyline hcl caps 10mg, 25 mg, 50 mg, 75 mg 1 MP

nortriptyline hcl soln 10mg/5ml NP QL(20 ml

daily); MP


42

Drug Name DrugTier

Requirements/Limits

NORTRIPTYLINE HCL SOLN 10 MG/5ML NP QL(20 ml

daily); MP PAMELOR CAPS (nortriptyline hcl) NF MP

protriptyline hcl tabs NP MP

SURMONTIL CAPS (trimipramine maleate) NP PA; MP

TOFRANIL TABS (imipramine hcl) NF MP

trimipramine maleate caps NP PA; MP

ANTIDIABETICS - Drugs to Regulate BloodSugar Alpha-Glucosidase Inhibitors

acarbose tabs 1 MP

GLYSET TABS (miglitol) NP PA

miglitol tabs NP PA

PRECOSE TABS (acarbose) NF MP

Antidiabetic - Amylin Analogs

SYMLINPEN 120 SOPN 2 PA

SYMLINPEN 60 SOPN 2 PA

Antidiabetic Combinations ACTOPLUS MET TABS (pioglitazone hcl-metforminhcl)

NP PA; QL(2 eadaily)

ACTOPLUS MET XR TB24 NP

alogliptin-pioglitazone tabs 2 PA; QL(1 eadaily); MP

ALOGLIPTIN/METFORMINHCL TABS NP QL(2 ea daily);

MP DUETACT TABS (pioglitazone hcl-glimepiride)

NP PA

glipizide-metformin hcl tabs 1 MP

GLUCOVANCE TABS (glyburide-metformin) NF MP

Drug Name DrugTier

Requirements/Limits

glyburide-metformin tabs 1 MP

GLYXAMBI TABS NP PA

INVOKAMET TABS 2 MP

INVOKAMET XR TB24 NP

JANUMET TABS 2 MP

JANUMET XR TB24 2 MP

JENTADUETO TABS 2 QL(2 ea daily);AL(At least 18yrs old); MP

JENTADUETO XR TB24 NP

KAZANO TABS NP QL(2 ea daily);MP

KOMBIGLYZE XR TB24 2.5 MG-1000 MG NP

QL(2 ea daily);AL(At least 18yrs old)

KOMBIGLYZE XR TB24 5 MG-500 MG, 5 MG-1000 MG

NP QL(1 ea daily);AL(At least 18yrs old)

OSENI TABS NP PA; MP

pioglitazone hcl-glimepiridetabs NP PA

pioglitazone hcl-metforminhcl tabs NP PA; QL(2 ea

daily)

QTERN TABS NP PA

REPAGLINIDE/METFORMIN HYDROCHLORIDE TABS

NP PA

SEGLUROMET TABS NP

SOLIQUA 100/33 SOPN NP PA

STEGLUJAN TABS NP PA

SYNJARDY TABS NP

SYNJARDY XR TB24 NP

XIGDUO XR TB24 2 MP


43

Drug Name DrugTier

Requirements/Limits

XULTOPHY 100/3.6 SOPN NP PA

Biguanides FORTAMET TB24 (metformin hcl) NP PA

GLUCOPHAGE TABS 1000 MG (metformin hcl) NF QL(2 ea daily);

MP GLUCOPHAGE TABS 500 MG (metformin hcl) NF QL(5 ea daily);

MP GLUCOPHAGE TABS 850 MG (metformin hcl) NF QL(3 ea daily);

MP GLUCOPHAGE XR TB24 500 MG (metformin hcl) NF QL(4 ea daily);

MP GLUCOPHAGE XR TB24 750 MG (metformin hcl) NF QL(2 ea daily);

MP GLUMETZA TB24 (metformin hcl) NP PA

metformin hcl tabs 1000 mg 1 QL(2 ea daily);

MP

metformin hcl tabs 500 mg 1 QL(5 ea daily);MP

metformin hcl tabs 850 mg 1 QL(3 ea daily);MP

metformin hcl tb24 500 mg 1 QL(4 ea daily);MP

metformin hcl tb24 500 mg,1000 mg NP PA

metformin hcl tb24 750 mg 1 QL(2 ea daily);MP

METFORMIN HYDROCHLORIDE SOLN NP PA

RIOMET SOLN NP PA

Diabetic Other

CVS GLUCOSE CHEW 2 QL(50 ea per30 days retail)

CVS SOFT GLUCOSE CHEW 2 QL(50 ea per

30 days retail) DEX4 QUICK DISSOLVE GLUCOSE CHEW 2 QL(50 ea per

30 days retail)

dextrose (diabetic use) gel 1

GLUCAGEN HYPOKIT SOLR 2

GLUCAGON EMERGENCY KIT KIT 2 QL(1 ea per fill

retail)

Drug Name DrugTier

Requirements/Limits

GLUCOSE CHEW 2 QL(50 ea per30 days retail)

GNP GLUCOSE CHEW 2 QL(50 ea per30 days retail)

GNP QUICK DISSOLVE GLUCOSE CHEW 2 QL(50 ea per

30 days retail) LEADER QUICK DISSOLVE GLUCOSE CHEW

2 QL(50 ea per30 days retail)

SM GLUCOSE CHEW 2 QL(50 ea per30 days retail)

WALGREENS GLUCOSE CHEW 2 QL(50 ea per

30 days retail) Dipeptidyl Peptidase-4 (DPP-4) Inhibitors

ALOGLIPTIN TABS NP QL(1 ea daily)

JANUVIA TABS 2 MP

NESINA TABS NP QL(1 ea daily)

ONGLYZA TABS 2.5 MG NP

ONGLYZA TABS 5 MG NP QL(1 ea daily)

TRADJENTA TABS 2 QL(1 ea daily);AL(At least 18yrs old); MP

Dopamine Receptor Agonists - Antidiabetic

CYCLOSET TABS NP PA

Incretin Mimetic Agents (GLP-1 Receptor ADLYXIN SOPN NP

ADLYXIN STARTER PACK PNKT NP

BYDUREON BCISE AUIJ 2

BYDUREON PEN PEN 2

QL(4 ea per 28days retail);AL(At least 18yrs old)

BYDUREON SRER 2



44

Drug Name DrugTier

Requirements/Limits

BYETTA SOPN 10 MCG/0.04ML 2

QL(2 ml per 30days retail);AL(At least 18yrs old)

BYETTA SOPN 5 MCG/0.02ML 2


OZEMPIC SOPN NP

RYBELSUS TABS NP

TANZEUM PEN NP

TRULICITY SOPN NP

VICTOZA SOPN 2 Limit 9ml permonth;QL(0.3ml daily)

Insulin Sensitizing Agents ACTOS TABS (pioglitazone hcl) NF QL(1 ea daily);

MP

AVANDIA TABS NP QL(1 ea daily)

pioglitazone hcl tabs 1 QL(1 ea daily);MP

Insulin

ADMELOG SOLN NP QL(40 ml per30 days retail);MP

ADMELOG SOLOSTAR SOPN NP QL(1 ml daily)

ADMELOG SOLOSTAR SOPN NP QL(1 ml daily);

MP

AFREZZA POWD NP PA

APIDRA SOLN NP ST; QL(40 mlper 30 daysretail)

APIDRA SOLOSTAR SOPN NP

ST; QL(30 mlper 30 daysretail)

BASAGLAR KWIKPEN SOPN NP

PA; QL(30 mlper 30 daysretail); MP

FIASP FLEXTOUCH SOPN NP QL(30 ml per

30 days retail)

Drug Name DrugTier

Requirements/Limits

FIASP PENFILL SOCT NP

FIASP SOLN NP QL(30 ml per30 days retail)

HUMALOG JUNIOR KWIKPEN SOPN 2 QL(1 ml daily)

HUMALOG KWIKPEN SOPN 100 UNIT/ML 2 QL(1 ml daily)

HUMALOG KWIKPEN SOPN 200 UNIT/ML 2


HUMALOG MIX 50/50KWIKPEN SUPN 2


HUMALOG MIX 50/50SUSP 2


HUMALOG MIX 75/25KWIKPEN SUPN 2


HUMALOG MIX 75/25SUSP 2


HUMALOG SOCT 2 QL(40 ml per30 days retail);MP

HUMALOG SOLN 2 QL(40 ml per30 days retail);MP

HUMULIN 70/30 KWIKPENSUPN 2


HUMULIN 70/30 SUSP 2 QL(40 ml per30 days retail);MP

HUMULIN N KWIKPEN SUPN 2


HUMULIN N SUSP 2 QL(40 ml per30 days retail);MP

HUMULIN R SOLN 2 QL(40 ml per30 days retail);MP

HUMULIN R U-500 (CONCENTRATED) SOLN 2 MP


45

Drug Name DrugTier

Requirements/Limits

HUMULIN R U-500 KWIKPEN SOPN 2 MP

INSULIN ASPART FLEXPEN SOPN 2


INSULIN ASPART PENFILL SOCT 2

QL(30 ml per30 daysretail,90 ml per90 days mail);MP

INSULIN ASPART PROTAMINE/INSULINASPART FLEXPEN SUPN

2 QL(30 ml per30 days retail);MP

INSULIN ASPART PROTAMINE/INSULINASPART SUSP


INSULIN ASPART SOLN 2 QL(30 ml per30 days retail);MP

INSULIN LISPRO KWIKPEN SOPN NP QL(1 ml daily);

MP

INSULIN LISPRO SOLN NP QL(40 ml per30 days retail);MP

LANTUS SOLN 2 MP

LANTUS SOLOSTAR SOPN 2


LANTUS SOLOSTAR SOPN 2 QL(30 ml per

30 days retail) LEVEMIR FLEXTOUCH SOPN 2 MP

LEVEMIR SOLN 2 MP

NOVOLIN 70/30 FLEXPENRELION SUPN NP QL(30 ml per

30 days retail)

NOVOLIN 70/30 FLEXPENRELION SUPN NP


NOVOLIN 70/30 FLEXPENSUPN NP


NOVOLIN 70/30 FLEXPENSUPN NP QL(30 ml per

30 days retail)

Drug Name DrugTier

Requirements/Limits

NOVOLIN 70/30 RELIONSUSP NP


NOVOLIN 70/30 SUSP NP QL(40 ml per30 days retail);MP

NOVOLIN N FLEXPEN RELION SUPN 2


NOVOLIN N FLEXPEN SUPN 2


NOVOLIN N RELION SUSP NP


NOVOLIN N SUSP NP QL(40 ml per30 days retail);MP

NOVOLIN R RELION SOLN NP


NOVOLIN R SOLN NP QL(40 ml per30 days retail);MP

NOVOLOG FLEXPEN SOPN 2


NOVOLOG MIX 70/30PREFILLED FLEXPEN SUPN


NOVOLOG MIX 70/30SUSP 2


NOVOLOG PENFILL SOCT 2

QL(30 ml per30 daysretail,90 ml per90 days mail);MP

NOVOLOG SOLN 2 QL(30 ml per30 days retail);MP

TOUJEO MAX SOLOSTAR SOPN NP

TOUJEO SOLOSTAR SOPN NP

TRESIBA FLEXTOUCH SOPN NP


46

Drug Name DrugTier

Requirements/Limits

TRESIBA SOLN NP

Meglitinide Analogues

nateglinide tabs 1 QL(3 ea daily);MP

PRANDIN TABS (repaglinide) NF MP

repaglinide tabs 1 MP

STARLIX TABS (nateglinide) NF QL(3 ea daily);

MP

Sodium-Glucose Co-Transporter 2 (SGLT2) FARXIGA TABS 2 MP

INVOKANA TABS 2 MP

JARDIANCE TABS 2 QL(1 ea daily);MP

STEGLATRO TABS NP

Sulfonylureas AMARYL TABS 1 MG, 2 MG (glimepiride) NF QL(1 ea daily);

MP AMARYL TABS 4 MG (glimepiride) NF QL(2 ea daily);

MP CHLORPROPAMIDE TABS NP

glimepiride tabs 1 mg, 2 mg 1 QL(1 ea daily);

MP

glimepiride tabs 4 mg 1 QL(2 ea daily);MP

glipizide tabs 1 MP

glipizide tb24 1 MP

GLUCOTROL TABS (glipizide) NF MP

GLUCOTROL XL TB24 (glipizide) NF MP

glyburide micronized tabs 1 MP

glyburide tabs 1 MP

GLYNASE TABS (glyburide micronized) NF MP

Drug Name DrugTier

Requirements/Limits

TOLAZAMIDE TABS NP

TOLBUTAMIDE TABS NP

ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugsto Treat Diarrhea

Antidiarrheal/Probiotic Agents - Misc. bismuth subsalicylate chew262 mg 1

PEPTO-BISMOL CHEW 262 MG (bismuth subsalicylate)

NF

PEPTO-BISMOL TO-GO CHEW (bismuth subsalicylate)

NF

Antiperistaltic Agents diphenoxylate w/ atropinetabs 1

DIPHENOXYLATE/ATROPINE LIQD 2

IMODIUM A-D TABS (loperamide hcl) NF QL(2 ea daily)

LOMOTIL TABS (diphenoxylate w/ atropine) NF

loperamide hcl liqd 1mg/5ml 1

loperamide hcl tabs 2 mg 1 QL(2 ea daily)

PAREGORIC TINC 2

ANTIDOTES AND SPECIFIC ANTAGONISTS

Antidotes - Chelating Agents

CHEMET CAPS 2

deferasirox tabs 1 SP; MP

deferasirox tbso 1 SP; MP

EXJADE TBSO (deferasirox) NF SP; MP

FERRIPROX SOLN 100 MG/ML NP PA; MP

FERRIPROX TABS 1000 MG NP PA


47

Drug Name DrugTier

Requirements/Limits

FERRIPROX TABS 500 MG NP PA; MP

JADENU SPRINKLE PACK 2

JADENU TABS 180 MG 2 SP; MP

JADENU TABS 90 MG, 360 MG (deferasirox) 2 SP; MP

Antidotes and Specific Antagonists

BAL IN OIL SOLN 2 PA

deferoxamine mesylate solr 1

DESFERAL SOLR (deferoxamine mesylate) NF

SM IPECAC SYRUP SYRP 2

VISTOGARD PACK 2

Opioid Antagonists NALOXONE HCL SOCT 0.4 MG/ML 2

naloxone hcl soln 0.4 mg/ml, 4 mg/10ml 1

naloxone hcl sosy 2mg/2ml 1

naltrexone hcl tabs 1 AL(At least 18yrs old)

NARCAN LIQD 2

VIVITROL SUSR 2 QL(1 ea per 28days retail)

ANTIEMETICS - Drugs to Treat Nausea andVomiting

5-HT3 Receptor Antagonists ALOXI SOLN (palonosetron hcl) NP PA

ANZEMET TABS NP

GRANISETRON HCL SOLN IV 0.1 MG/ML 2

granisetron hcl soln iv 1mg/ml, 4 mg/4ml 1

granisetron hcl tabs or 1 mg 1

Drug Name DrugTier

Requirements/Limits

ondansetron hcl soln ij 4mg/2ml, 40 mg/20ml 1

ondansetron hcl soln or 4 mg/5ml 1 QL(50 ml per

fill retail) ondansetron hcl tabs or 24 mg 1 QL(1 ea daily)

ONDANSETRON HCL TABS OR 24 MG 2 QL(1 ea daily)

ondansetron hcl tabs or 4 mg 1 QL(6 ea daily)

ondansetron hcl tabs or 8 mg 1 QL(3 ea daily)

ONDANSETRON HYDROCHLORIDE SOLN 2

ondansetron tbdp 1 QL(2 ea daily)

palonosetron hcl soln NP PA

palonosetron hcl sosy NP

PALONOSETRON HYDROCHLORIDE SOLN 0.25 MG/2ML

NP

PALONOSETRON HYDROCHLORIDE SOLN 0.25 MG/5ML

NP PA

SANCUSO PTCH NP

SUSTOL PRSY NP

ZOFRAN ODT TBDP (ondansetron) NF QL(2 ea daily)

ZOFRAN SOLN 4 MG/5ML(ondansetron hcl) NF QL(50 ml per

fill retail) ZOFRAN TABS 4 MG (ondansetron hcl) NF QL(6 ea daily)

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

ZUPLENZ FILM NP

Antiemetics - Anticholinergic

dimenhydrinate tabs 1 QL(24 ea perfill retail)

DRAMAMINE TABS (dimenhydrinate) NF QL(24 ea per

fill retail)

meclizine hcl chew 25 mg 1


48

Drug Name DrugTier

Requirements/Limits

meclizine hcl tabs 25 mg,12.5 mg 1 RX/OTC

TIGAN CAPS OR 300 MG (trimethobenzamide hcl) NF PA

TIGAN SOLN IM 100 MG/ML 2 PA

trimethobenzamide hcl caps 1 PA

Antiemetics - Miscellaneous AKYNZEO CAPS OR 300 MG-0.5 MG NP PA

BONJESTA TBCR NP PA

CESAMET CAPS 2 PA

DICLEGIS TBEC (doxylamine-pyridoxine) NF PA

doxylamine-pyridoxine tbec 1 PA

Substance P/Neurokinin 1 (NK1) Receptor aprepitant caps 1

CINVANTI EMUL NP PA

EMEND CAPS OR 40 MG, 80 MG, 125 MG (aprepitant)

NF

EMEND SOLR IV 150 MG NP PA

EMEND SOLR IV 150 MG (fosaprepitantdimeglumine)

NP PA

EMEND SUSR OR 125 MG NP PA

EMEND TRIPACK CAPS (aprepitant) NF

FOSAPREPITANT DIMEGLUMINE SOLR NP PA

fosaprepitant dimegluminesolr NP PA

VARUBI TABS NP

ANTIFUNGALS - Drugs to Treat Fungal Infections

Antifungal - Glucan Synthesis Inhibitors

Drug Name DrugTier

Requirements/Limits

CANCIDAS SOLR (caspofungin acetate) NF PA

caspofungin acetate solr 50mg, 70 mg 1 PA

CASPOFUNGIN ACETATE SOLR 50 MG, 70 MG 2 PA

ERAXIS SOLR 2 PA

MYCAMINE SOLR 2 PA

Antifungals

ABELCET SUSP 2 PA

AMBISOME SUSR 2 PA

AMPHOTERICIN B SOLR 2 PA

ANCOBON CAPS (flucytosine) NP PA

flucytosine caps NP PA

GRIS-PEG TABS (griseofulvin ultramicrosize) NF

griseofulvin microsize susp 1

griseofulvin microsize tabs 1

griseofulvin ultramicrosizetabs 1

LAMISIL TABS (terbinafine hcl) NF

QL(1 eadaily,90 ea per120 days retail)

nystatin tabs 1 QL(6 ea daily)

terbinafine hcl tabs 1 QL(1 eadaily,90 ea per120 days retail)

Imidazole-Related Antifungals CRESEMBA CAPS OR 186 MG NP PA

CRESEMBA SOLR IV 372 MG 2 PA

DIFLUCAN SUSR 10 MG/ML, 40 MG/ML(fluconazole)


DIFLUCAN TABS 100 MG (fluconazole) NF QL(1 ea daily)


49

Drug Name DrugTier

Requirements/Limits

DIFLUCAN TABS 150 MG (fluconazole) NF QL(2 ea per fill

retail) DIFLUCAN TABS 200 MG (fluconazole) NF QL(2 ea daily)

DIFLUCAN TABS 50 MG (fluconazole) NF QL(7 ea per fill

retail) fluconazole in dextrose soln 1 PA

FLUCONAZOLE IN NACL SOLN 100 MG/50ML-0.9 % 2 PA

fluconazole in nacl soln 200 mg/100ml-0.9 %, 400mg/200ml-0.9 %

1 PA

fluconazole susr 10 mg/ml,40 mg/ml 1 QL(70 ml per

fill retail)

fluconazole tabs 100 mg 1 QL(1 ea daily)

fluconazole tabs 150 mg 1 QL(2 ea per fillretail)

fluconazole tabs 200 mg 1 QL(2 ea daily)

fluconazole tabs 50 mg 1 QL(7 ea per fillretail)

itraconazole caps 100 mg NP PA; QL(1 eadaily)

itraconazole soln 10 mg/ml 1 PA

ketoconazole tabs NP PA

NOXAFIL SOLN IV 300 MG/16.7ML 2 PA

NOXAFIL SUSP OR 40 MG/ML NP PA; MP

NOXAFIL TBEC OR 100 MG (posaconazole) NP PA

ONMEL TABS NP

posaconazole tbec NP PA

SPORANOX CAPS 100 MG (itraconazole) NP PA; QL(1 ea

daily) SPORANOX PULSEPAK CAPS (itraconazole) NP PA; QL(1 ea

daily) SPORANOX SOLN 10 MG/ML (itraconazole) NF PA

TOLSURA CAPS NP PA; QL(1 eadaily)

Drug Name DrugTier

Requirements/Limits

VFEND IV SOLR (voriconazole) NF PA

VFEND SUSR (voriconazole) NP PA

VFEND TABS (voriconazole) NP PA

voriconazole solr iv 200 mg 1 PA

voriconazole susr or 40 mg/ml NP PA

voriconazole tabs or 50 mg,200 mg NP PA

ANTIHISTAMINES - Drugs to Treat Allergies

Antihistamines - Alkylamines CHLOR-TRIMETON TABS (chlorpheniramine maleate) NF QL(120 ea per

fill retail) chlorpheniramine maleatetabs 1 QL(120 ea per

fill retail) Antihistamines - Ethanolamines

ALER-DRYL TABS 2 QL(4 ea daily)

BENADRYL ALLERGY CAPS (diphenhydraminehcl)

NF QL(4 ea daily)

BENADRYL ALLERGY CHILDRENS LIQD (diphenhydramine hcl)


BENADRYL ALLERGY TABS (diphenhydraminehcl)

NF QL(4 ea daily)

carbinoxamine maleate soln 4 mg/5ml 1 PA

CARBINOXAMINE MALEATE SOLN 4 MG/5ML

2 PA

carbinoxamine maleate tabs 4 mg 1 PA

diphenhydramine hcl caps25 mg, 50 mg 1 QL(4 ea daily)

diphenhydramine hcl liqd25 mg/10ml, 50 mg/20ml,12.5 mg/5ml

1 QL(240 ml perfill retail)

diphenhydramine hcl tabs25 mg 1 QL(4 ea daily)


50

Drug Name DrugTier

Requirements/Limits

KARBINAL ER SUER 2 PA

Antihistamines - Non-Sedating ALLEGRA ALLERGY TABS 180 MG (fexofenadine hcl)

NF QL(1 ea daily)

ALLEGRA ALLERGY TABS 60 MG (fexofenadine hcl)

NF QL(2 ea daily)

cetirizine hcl caps 10 mg 1

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

cetirizine hcl soln 1 mg/ml,5 mg/5ml 1 RX/OTC

cetirizine hcl syrp 1 mg/ml,5 mg/5ml 1 RX/OTC

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

CLARITIN ALLERGY CHILDRENS SYRP (loratadine)


CLARITIN CAPS 10 MG (loratadine) NF

CLARITIN REDITABS TBDP (loratadine) NF

CLARITIN SYRP 5 MG/5ML (loratadine) NF QL(240 ml per

fill retail) CLARITIN TABS 10 MG (loratadine) NF

fexofenadine hcl tabs 180 mg 1 QL(1 ea daily)

fexofenadine hcl tabs 60 mg 1 QL(2 ea daily)

loratadine caps 10 mg 1

loratadine soln 5 mg/5ml 1 QL(240 ml perfill retail)

loratadine syrp 5 mg/5ml 1 QL(240 ml perfill retail)

loratadine tabs 10 mg 1

loratadine tbdp 10 mg 1

ZYRTEC ALLERGY CAPS (cetirizine hcl) NF

Drug Name DrugTier

Requirements/Limits

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

ZYRTEC CHILDRENS ALLERGY SOLN (cetirizine hcl)

NF RX/OTC

Antihistamines - Phenothiazines

promethazine hcl soln or6.25 mg/5ml 1

QL(240 ml perfill retail); AL(Atleast 2 yrs old)

promethazine hcl supp re25 mg, 50 mg, 12.5 mg 1

QL(12 ea perfill retail); AL(Atleast 2 yrs old)

promethazine hcl syrp or6.25 mg/5ml 1


promethazine hcl tabs or25 mg, 50 mg, 12.5 mg 1 AL(At least 2

yrs old)

PROMETHEGAN SUPP 2 QL(12 ea perfill retail); AL(Atleast 2 yrs old)

Antihistamines - Piperidines

cyproheptadine hcl syrp 1

cyproheptadine hcl tabs 1

ANTIHYPERLIPIDEMICS - Drugs to Treat HighCholesterol Antihyperlipidemics - Combinations

ezetimibe-simvastatin tabs NP PA

VYTORIN TABS (ezetimibe-simvastatin) NP PA

Antihyperlipidemics - Misc. KYNAMRO SOSY NP PA

LOVAZA CAPS (omega-3-acid ethyl esters) NP PA

omega-3-acid ethyl esters caps NP PA

VASCEPA CAPS NP PA

Bile Acid Sequestrants

cholestyramine light pack 1 MP

cholestyramine light powd 1 MP


51

Drug Name DrugTier

Requirements/Limits

cholestyramine pack 1 MP

cholestyramine powd 1 MP

colesevelam hcl pack NP PA

colesevelam hcl tabs NP PA

COLESTID FLAVORED GRAN (colestipol hcl) NP PA

COLESTID FLAVORED PACK (colestipol hcl) NP PA

COLESTID GRAN 5 GM (colestipol hcl) NP PA

COLESTID PACK 5 GM (colestipol hcl) NP PA

COLESTID TABS 1 GM (colestipol hcl) NF MP

colestipol hcl gran 5 gm NP PA

colestipol hcl pack 5 gm NP PA

colestipol hcl tabs 1 gm 1 MP

QUESTRAN LIGHT POWD (cholestyramine light) NF MP

QUESTRAN PACK (cholestyramine) NF MP

QUESTRAN POWD (cholestyramine) NF MP

WELCHOL PACK (colesevelam hcl) NP PA

WELCHOL TABS (colesevelam hcl) NP PA

Fibric Acid Derivatives

ANTARA CAPS NP PA

choline fenofibrate cpdr NP PA

FENOFIBRATE CAPS 50 MG, 150 MG NP PA

fenofibrate micronized caps134 mg, 200 mg NP PA; QL(1 ea

daily) fenofibrate micronized caps43 mg, 130 mg NP PA

fenofibrate micronized caps67 mg NP PA; QL(2 ea

daily)

Drug Name DrugTier

Requirements/Limits

fenofibrate tabs 160 mg 1 QL(1 ea daily)

fenofibrate tabs 160 mg 1 QL(1 ea daily);MP

fenofibrate tabs 40 mg, 48mg, 120 mg, 145 mg, 160 mg

1 MP

fenofibrate tabs 54 mg 1 QL(3 ea daily);MP

FENOFIBRIC ACID TABS NP PA

FENOGLIDE TABS (fenofibrate) NF MP

FIBRICOR TABS 35 MG, 105 MG NP PA

gemfibrozil tabs 1 QL(2 ea daily);MP

LIPOFEN CAPS NP PA

LOPID TABS (gemfibrozil) NF QL(2 ea daily);MP

TRICOR TABS (fenofibrate) NF MP

TRIGLIDE TABS NP PA; QL(1 eadaily); MP

TRILIPIX CPDR (choline fenofibrate) NP PA

HMG CoA Reductase Inhibitors

ALTOPREV TB24 NP

atorvastatin calcium tabs 1 QL(1 ea daily);MP

CRESTOR TABS 10 MG, 20 MG (rosuvastatin calcium)

NF MP

CRESTOR TABS 5 MG, 40 MG (rosuvastatin calcium) NF

EZALLOR SPRINKLE CPSP NP PA

fluvastatin sodium caps 20mg, 40 mg NP

fluvastatin sodium tb24 80 mg NP PA

LESCOL XL TB24 (fluvastatin sodium) NP PA


52

Drug Name DrugTier

Requirements/Limits

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

MP

LIVALO TABS NP

lovastatin tabs 10 mg, 20 mg 1 QL(1 ea daily);

MP

lovastatin tabs 40 mg 1 QL(2 ea daily);MP

PRAVACHOL TABS (pravastatin sodium) NF QL(1 ea daily);

MP

pravastatin sodium tabs 1 QL(1 ea daily);MP

rosuvastatin calcium tabs 10 mg, 20 mg 1 MP

rosuvastatin calcium tabs 5 mg, 40 mg 1

simvastatin tabs 5 mg, 10mg, 20 mg, 40 mg 1 QL(1 ea daily);

MP

simvastatin tabs 80 mg 1 MP

ZOCOR TABS 5 MG, 10 MG, 20 MG, 40 MG (simvastatin)


ZOCOR TABS 80 MG (simvastatin) NF MP

ZYPITAMAG TABS NP

Intestinal Cholesterol Absorption Inhibitors

ezetimibe tabs 1 MP

ZETIA TABS (ezetimibe) NF MP

Microsomal Triglyceride Transfer Protein (MTP) JUXTAPID CAPS 2 PA; MP

Nicotinic Acid Derivatives niacin (antihyperlipidemic)tbcr 1 MP

NIACIN TABS 500 MG 2 MP

NIACOR TABS 2 MP

NIASPAN TBCR (niacin (antihyperlipidemic)) NF MP

Proprotein Convertase Subtilisin/Kexin Type 9

Drug Name DrugTier

Requirements/Limits

PRALUENT SOAJ NP PA; SP

REPATHA PUSHTRONEX SYSTEM SOCT NP PA

REPATHA PUSHTRONEX SYSTEM SOCT 2 PA

REPATHA SOSY 2 PA

REPATHA SOSY NP PA

REPATHA SURECLICK SOAJ NP PA; SP

REPATHA SURECLICK SOAJ 2 PA; SP; MP

ANTIHYPERTENSIVES - Drugs to Treat HighBlood Pressure

ACE Inhibitors ACCUPRIL TABS (quinapril hcl) NP PA; QL(1 ea

daily)

ALTACE CAPS (ramipril) NF QL(2 ea daily);MP

benazepril hcl tabs 40 mg 1 QL(2 ea daily);MP

benazepril hcl tabs 5 mg,10 mg, 20 mg 1 QL(1 ea daily);

MP

captopril tabs 1 QL(3 ea daily);MP

enalapril maleate tabs 1 QL(2 ea daily);MP

enalaprilat inj 1

EPANED SOLN NP

fosinopril sodium tabs 1 QL(1 ea daily);MP

lisinopril tabs 2.5 mg 1 QL(1 ea daily);MP

lisinopril tabs 5 mg, 10 mg,20 mg, 30 mg, 40 mg 1 QL(2 ea daily);

MP LOTENSIN TABS 10 MG, 20 MG (benazepril hcl) NF QL(1 ea daily);

MP LOTENSIN TABS 40 MG (benazepril hcl) NF QL(2 ea daily);

MP

moexipril hcl tabs NP


53

Drug Name DrugTier

Requirements/Limits

perindopril erbumine tabs NP

PRINIVIL TABS (lisinopril) NF QL(2 ea daily);MP

QBRELIS SOLN NP

quinapril hcl tabs NP PA; QL(1 eadaily)

ramipril caps 1 QL(2 ea daily);MP

trandolapril tabs 1 mg, 2 mg NP QL(1 ea daily)

trandolapril tabs 4 mg NP QL(2 ea daily)

VASOTEC TABS (enalaprilmaleate) NF QL(2 ea daily);

MP ZESTRIL TABS 2.5 MG (lisinopril) NF QL(1 ea daily);

MP ZESTRIL TABS 5 MG, 10 MG, 20 MG, 30 MG, 40 MG (lisinopril)


Agents for Pheochromocytoma

DEMSER CAPS NP PA

DIBENZYLINE CAPS (phenoxybenzamine hcl) NF

phenoxybenzamine hcl caps 1

phentolamine mesylate solr 1

Angiotensin II Receptor Antagonists ATACAND TABS (candesartan cilexetil) NP PA

AVAPRO TABS (irbesartan) NF QL(1 ea daily);

MP BENICAR TABS (olmesartan medoxomil) NF MP

candesartan cilexetil tabs NP PA

COZAAR TABS (losartan potassium) NF QL(1 ea daily);

MP

DIOVAN TABS (valsartan) NF QL(1 ea daily);MP

EDARBI TABS NP

Drug Name DrugTier

Requirements/Limits

EPROSARTAN MESYLATE TABS NP

irbesartan tabs 1 QL(1 ea daily);MP

losartan potassium tabs 1 QL(1 ea daily);MP

MICARDIS TABS (telmisartan) NP PA; QL(1 ea

daily)

olmesartan medoxomil tabs 1 MP

telmisartan tabs NP PA; QL(1 eadaily)

valsartan tabs 1 QL(1 ea daily);MP

Antiadrenergic Antihypertensives CARDURA TABS (doxazosin mesylate) NF MP

CATAPRES TABS 0.1 MG (clonidine hcl) NF






CATAPRES-TTS-1 PTWK (clonidine) NF MP




54

Drug Name DrugTier

Requirements/Limits

clonidine hcl tabs 0.1 mg 1






clonidine ptwk 1 MP

doxazosin mesylate tabs 1 MP

guanfacine hcl tabs 1 mg 1

Age 4-5: MDD=2, Age 6-8:MDD=3; Age 9-17: MDD=4;AL(Atleast 4 yrs old);MP

guanfacine hcl tabs 2 mg 1


methyldopa tabs 1 MP

METHYLDOPATE HCL SOLN 2 PA

MINIPRESS CAPS (prazosin hcl) NF MP

prazosin hcl caps 1 MP

terazosin hcl caps 1 MP

Drug Name DrugTier

Requirements/Limits

Antihypertensive Combinations ACCURETIC TABS 10 MG-12.5 MG (quinapril-hydrochlorothiazide)


ACCURETIC TABS 20 MG-12.5 MG (quinapril-hydrochlorothiazide)


ACCURETIC TABS 20 MG-25 MG (quinapril-hydrochlorothiazide)


amlodipine besylate-benazepril hcl caps 1 PA; QL(1 ea

daily); MP amlodipine besylate-olmesartan medoxomil tabs NP PA

amlodipine besylate-valsartan tabs 1 PA; MP

amlodipine-valsartan-hydrochlorothiazide tabs NP PA

ATACAND HCT TABS (candesartan cilexetil-hydrochlorothiazide)

NP PA

atenolol & chlorthalidone tabs 1 QL(1 ea daily);

MP AVALIDE TABS (irbesartan-hydrochlorothiazide)


AZOR TABS (amlodipinebesylate-olmesartanmedoxomil)

NP PA

benazepril &hydrochlorothiazide tabs 1 QL(1 ea daily);

MP BENICAR HCT TABS (olmesartan medoxomil-hydrochlorothiazide)

NF MP

bisoprolol &hydrochlorothiazide tabs 1 QL(1 ea daily);

MP

BYVALSON TABS NP PA

candesartan cilexetil-hydrochlorothiazide tabs NP PA

CAPTOPRIL/HYDROCHLOROTHIAZIDE TABS NP QL(2 ea daily)

CORZIDE TABS 40 MG-5 MG NP

CORZIDE TABS 80 MG-5 MG NP


55

Drug Name DrugTier

Requirements/Limits

DIOVAN HCT TABS (valsartan-hydrochlorothiazide)


DUTOPROL TB24 NP QL(1 ea daily)

EDARBYCLOR TABS NP PA

enalapril maleate &hydrochlorothiazide tabs 1 QL(2 ea daily);

MP EXFORGE HCT TABS (amlodipine-valsartan-hydrochlorothiazide)

NP PA

EXFORGE TABS (amlodipine besylate-valsartan)

NF PA; MP

fosinopril sodium &hydrochlorothiazide tabs 1 QL(1 ea daily);

MP HYZAAR TABS (losartan potassium &hydrochlorothiazide)


irbesartan-hydrochlorothiazide tabs 1 QL(1 ea daily);

MP lisinopril &hydrochlorothiazide tabs 10mg-12.5 mg, 20 mg-12.5 mg

1

QL(2 ea daily);MP

lisinopril &hydrochlorothiazide tabs 20mg-25 mg

1 QL(1 ea daily);MP

LOPRESSOR HCT TABS (metoprolol &hydrochlorothiazide)


losartan potassium &hydrochlorothiazide tabs 1 QL(1 ea daily);

MP LOTENSIN HCT TABS (benazepril &hydrochlorothiazide)


LOTREL CAPS (amlodipine besylate-benazepril hcl)

NF PA; QL(1 eadaily); MP

METHYLDOPA/HYDROCHLOROTHIAZIDE TABS NP PA

metoprolol &hydrochlorothiazide tabs 1 QL(2 ea daily);

MP

Drug Name DrugTier

Requirements/Limits

METOPROLOL SUCCINATE ER/HYDROCHLOROTHIAZIDE TB24

NP

QL(1 ea daily)

METOPROLOL/HYDROCHLOROTHIAZIDE TABS 2 QL(2 ea daily);

MP MICARDIS HCT TABS (telmisartan-hydrochlorothiazide)


moexipril-hydrochlorothiazide tabs NP

NADOLOL/BENDROFLUMETHIAZIDE TABS NP

olmesartan medoxomil-amlodipine-hydrochlorothiazide tabs

NP PA

olmesartan medoxomil-hydrochlorothiazide tabs 1 MP

PRESTALIA TABS NP PA

PROPRANOLOL/HYDROCHLOROTHIAZIDE TABS 2 QL(2 ea daily);

MP quinapril-hydrochlorothiazide tabs 10mg-12.5 mg

1 QL(3 ea daily);MP

quinapril-hydrochlorothiazide tabs 20mg-12.5 mg

1 QL(4 ea daily);MP

quinapril-hydrochlorothiazide tabs 20mg-25 mg

1 QL(2 ea daily);MP

TARKA TBCR (trandolapril-verapamil hcl) NP PA

TEKTURNA HCT TABS NP PA

telmisartan-amlodipine tabs NP PA

telmisartan-hydrochlorothiazide tabs NP PA; QL(1 ea

daily) TENORETIC 100 TABS (atenolol & chlorthalidone) NF QL(1 ea daily);

MP TENORETIC 50 TABS (atenolol & chlorthalidone) NF QL(1 ea daily);

MP trandolapril-verapamil hcltbcr NP PA

TRANDOLAPRIL/VERAPAMIL HCL ER TBCR NP PA


56

Drug Name DrugTier

Requirements/Limits

TRIBENZOR TABS (olmesartan medoxomil-amlodipine-hydrochlorothiazide)

NP

PA

TWYNSTA TABS (telmisartan-amlodipine) NP PA

valsartan-hydrochlorothiazide tabs 1 QL(1 ea daily);

MP VASERETIC TABS (enalapril maleate &hydrochlorothiazide)


ZESTORETIC TABS 10 MG-12.5 MG, 20 MG-12.5 MG (lisinopril &hydrochlorothiazide)

NF

QL(2 ea daily);MP

ZESTORETIC TABS 20 MG-25 MG (lisinopril &hydrochlorothiazide)


ZIAC TABS (bisoprolol &hydrochlorothiazide) NF QL(1 ea daily);

MP

Antihypertensives - Misc. VECAMYL TABS NP PA

Direct Renin Inhibitors

aliskiren fumarate tabs NP PA

TEKTURNA TABS 150 MG, 300 MG NP PA

TEKTURNA TABS 150 MG, 300 MG (aliskiren fumarate)

NP PA

Selective Aldosterone Receptor Antagonists

eplerenone tabs 1 MP

INSPRA TABS (eplerenone) NF MP

Vasodilators

CORLOPAM SOLN 2 PA

hydralazine hcl soln ij 20mg/ml 1 PA

hydralazine hcl tabs or 10mg, 25 mg, 50 mg, 100 mg 1 MP

minoxidil tabs 1 MP

Drug Name DrugTier

Requirements/Limits

NIPRIDE RTU SOLN 2 PA

NITROPRESS SOLN (nitroprusside sodium) 2 PA

nitroprusside sodium soln 1 PA

ANTIMALARIALS - Drugs to Treat Malaria(Parasitic Infections) Antimalarial Combinations atovaquone-proguanil hcltabs 1

COARTEM TABS 2 QL(24 ea perfill retail)

MALARONE TABS (atovaquone-proguanil hcl) NF

Antimalarials CHLOROQUINE PHOSPHATE TABS 250 MG

2 QL(60 ea per30 days retail);MP

chloroquine phosphate tabs500 mg 1 QL(8 ea per 56

days retail); MP DARAPRIM TABS (pyrimethamine) NP PA

hydroxychloroquine sulfatetabs 1 MP

KRINTAFEL TABS NP PA

MEFLOQUINE HCL TABS 2 MP

PLAQUENIL TABS (hydroxychloroquinesulfate)

NF MP

primaquine phosphate tabs 1

PRIMAQUINE PHOSPHATE TABS (primaquine phosphate)

NF

pyrimethamine tabs NP PA

QUALAQUIN CAPS (quinine sulfate) NF

quinine sulfate caps 1

ANTIMYASTHENIC/CHOLINERGIC AGENTS

Antimyasthenic/Cholinergic Agents


57

Drug Name DrugTier

Requirements/Limits

BLOXIVERZ SOLN (neostigmine methylsulfate) NF PA

ENLON SOLN 2 PA

FIRDAPSE TABS NP PA

GUANIDINE HCL TABS NP

MESTINON SOLN 60 MG/5ML (pyridostigminebromide)

2 PA

MESTINON TABS 60 MG (pyridostigmine bromide) NP PA

MESTINON TIMESPAN TBCR (pyridostigminebromide)

NP PA

NEOSTIGMINE METHYLSULFATE SOLN 5 MG/10ML, 10 MG/10ML

2 PA

neostigmine methylsulfatesoln 5 mg/10ml, 10mg/10ml

1 PA

pyridostigmine bromidesoln 60 mg/5ml 1 PA

PYRIDOSTIGMINE BROMIDE TABS 30 MG 2

pyridostigmine bromidetabs 60 mg 1

pyridostigmine bromidetbcr 180 mg 1

REGONOL SOLN 2 PA

RUZURGI TABS NP PA

ANTIMYCOBACTERIAL AGENTS - Drugs toTreat Tuberculosis (Bacterial Infections) Anti TB Combinations

RIFAMATE CAPS NP PA

RIFATER TABS NP PA

Antimycobacterial Agents

cycloserine caps 1

ethambutol hcl tabs 1 MP

Drug Name DrugTier

Requirements/Limits

ISONIAZID SYRP 50 MG/5ML 2 MP

isoniazid tabs 100 mg, 300 mg 1 MP

MYAMBUTOL TABS (ethambutol hcl) NF MP

MYCOBUTIN CAPS (rifabutin) NF

PASER PACK NP

PRETOMANID TABS NP PA

PRIFTIN TABS 2

pyrazinamide tabs 1

rifabutin caps 1

RIFADIN CAPS (rifampin) NF

rifampin caps 1

SIRTURO TABS 2

TRECATOR TABS 2

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - Drugs to Treat Cancer Alkylating Agents ALKERAN TABS (melphalan) NF

cyclophosphamide caps 25mg, 50 mg 1

CYCLOPHOSPHAMIDE CAPS 25 MG, 50 MG (cyclophosphamide)

2

GLEOSTINE CAPS 2 PA

HEXALEN CAPS 2 PA

LEUKERAN TABS 2 PA

melphalan tabs 1

MYLERAN TABS 2 PA

TEMODAR CAPS (temozolomide) NF PA


58

Drug Name DrugTier

Requirements/Limits

temozolomide caps 1 PA

Antimetabolites

capecitabine tabs 1 PA; SP

mercaptopurine tabs 1

methotrexate sodium soln ij25 mg/ml, 1 gm/40ml, 50mg/2ml, 250 mg/10ml

1

METHOTREXATE SODIUM SOLN IJ 250 MG/10ML

2

methotrexate sodium solr ij1 gm 1

methotrexate sodium tabs or 2.5 mg 1

PURIXAN SUSP 2 PA

TABLOID TABS 2

TREXALL TABS 2

XATMEP SOLN 2

XELODA TABS (capecitabine) NF PA; SP

Antineoplastic - BCL-2 Inhibitors VENCLEXTA STARTING PACK TBPK 2 PA

VENCLEXTA TABS 2 PA

Antineoplastic - Cellular Immunotherapy

KYMRIAH SUSP CO

YESCARTA SUSP CO

Antineoplastic - Hedgehog Pathway Inhibitors

DAURISMO TABS 2 PA

ERIVEDGE CAPS 2 PA

ODOMZO CAPS 2 PA; SP

Antineoplastic - Hormonal and Related Agents

abiraterone acetate tabs 1 PA; SP

Drug Name DrugTier

Requirements/Limits

anastrozole tabs 1

ARIMIDEX TABS (anastrozole) NF

AROMASIN TABS (exemestane) NF SP

bicalutamide tabs 1

CASODEX TABS (bicalutamide) NF

ELIGARD KIT 22.5 MG 2 PA

ELIGARD KIT 30 MG 2 PA

ELIGARD KIT 45 MG 2 PA

ELIGARD KIT 7.5 MG 2 PA; SP

EMCYT CAPS 2 PA

ERLEADA TABS 2 PA

exemestane tabs 1 SP

FARESTON TABS (toremifene citrate) NP PA

FEMARA TABS (letrozole) NF

flutamide caps 1

HYDROXYPROGESTERO NE CAPROATE SOLN 1.25 GM/5ML

2

PA; Limit 5ml permonth;QL(0.167 ml daily)

letrozole tabs 1

leuprolide acetate kit 1 PA; SP

LUPRON DEPOT (1-MONTH) KIT 2 PA; SP

LUPRON DEPOT (3-MONTH) KIT 2 PA



LYSODREN TABS 2 PA


59

Drug Name DrugTier

Requirements/Limits

megestrol acetate susp 1

megestrol acetate tabs 1

NILANDRON TABS (nilutamide) NF PA

nilutamide tabs 1 PA

NUBEQA TABS 2 PA

SOLTAMOX SOLN NP PA

tamoxifen citrate tabs 1 MP

toremifene citrate tabs NP PA

TRELSTAR MIXJECT SUSR 2 PA

VANTAS KIT 2 PA

XTANDI CAPS 2 PA

YONSA TABS NP PA

ZOLADEX IMPL 2 PA

ZYTIGA TABS 250 MG (abiraterone acetate) NF PA; SP

ZYTIGA TABS 500 MG NP PA

Antineoplastic - Immunomodulators

POMALYST CAPS 2 PA; SP

Antineoplastic Combinations KISQALI FEMARA 200 DOSE TBPK 2 PA

KISQALI FEMARA 400 DOSE TBPK 2 PA

KISQALI FEMARA 600 DOSE TBPK 2 PA

LONSURF TABS 2 PA

Antineoplastic Enzyme Inhibitors

AFINITOR DISPERZ TBSO 2 PA; SP

AFINITOR TABS 10 MG 2 PA; SP

Drug Name DrugTier

Requirements/Limits

AFINITOR TABS 5 MG, 2.5 MG, 7.5 MG (everolimus) 2 PA; SP

ALECENSA CAPS 2 PA

ALUNBRIG TABS 2 PA

ALUNBRIG TBPK 2 PA

AYVAKIT TABS 2 PA

BOSULIF TABS 2 PA

BRAFTOVI CAPS 2 PA

CABOMETYX TABS 2 PA

CALQUENCE CAPS 2 PA

CAPRELSA TABS 2 PA

COMETRIQ KIT 2 PA

COPIKTRA CAPS 2 PA

COTELLIC TABS 2 PA

erlotinib hcl tabs 1 PA; SP

everolimus tabs 1 PA; SP

FARYDAK CAPS 2 PA

GILOTRIF TABS 2 PA

GLEEVEC TABS (imatinib mesylate) NF PA; SP

IBRANCE CAPS 75 MG, 100 MG, 125 MG 2 PA; SP

ICLUSIG TABS 2 PA; SP

IDHIFA TABS 2 PA

imatinib mesylate tabs 1 PA; SP

IMBRUVICA CAPS 2 PA

IMBRUVICA TABS 2 PA


60

Drug Name DrugTier

Requirements/Limits

INLYTA TABS 2 PA

INREBIC CAPS 2 PA

IRESSA TABS 2 PA

JAKAFI TABS 2 PA

KISQALI TBPK 2 PA; SP

LENVIMA 10 MG DAILY DOSE CPPK 2 PA

LENVIMA 12MG DAILY DOSE CPPK 2 PA







LORBRENA TABS 2 PA

LYNPARZA CAPS 2 PA

LYNPARZA TABS 2 PA

MEKINIST TABS 2 PA

MEKTOVI TABS 2 PA

NERLYNX TABS 2 PA

NEXAVAR TABS 2 PA; SP

NINLARO CAPS 2 PA

PIQRAY 200MG DAILY DOSE TBPK 2 PA



Drug Name DrugTier

Requirements/Limits

ROZLYTREK CAPS 2 PA

RUBRACA TABS 2 PA

RYDAPT CAPS 2 PA

SPRYCEL TABS 2 PA; SP

STIVARGA TABS 2 PA; SP

SUTENT CAPS 2 PA; SP

TAFINLAR CAPS 2 PA; SP

TAGRISSO TABS 2 PA

TALZENNA CAPS 2 PA

TARCEVA TABS (erlotinib hcl) NF PA; SP

TASIGNA CAPS 150 MG, 200 MG 2 PA; SP

TASIGNA CAPS 50 MG 2 PA

TIBSOVO TABS 2 PA

TURALIO CAPS 2 PA

TYKERB TABS 2 PA; SP

VERZENIO TABS 2 PA

VITRAKVI CAPS 2 PA

VITRAKVI SOLN 2 PA

VIZIMPRO TABS 2 PA

VOTRIENT TABS 2 PA

XALKORI CAPS 2 PA; SP

XOSPATA TABS 2 PA

ZEJULA CAPS 2 PA

ZELBORAF TABS 2 PA

ZOLINZA CAPS 2 PA; SP


61

Drug Name DrugTier

Requirements/Limits

ZYDELIG TABS 2 PA

ZYKADIA CAPS 2 PA

ZYKADIA TABS 2 PA

Antineoplastic Radiopharmaceuticals

LUTATHERA SOLN CO

Antineoplastics Misc. ACTIMMUNE SOLN 2 PA; SP

bexarotene caps 1 PA; SP

HYDREA CAPS (hydroxyurea) NF

hydroxyurea caps 1

INTRON A SOLN 2 PA; SP

INTRON A SOLR 2 PA; SP

MATULANE CAPS NP PA

TARGRETIN CAPS OR 75 MG (bexarotene) NF PA; SP

tretinoin (chemotherapy) caps 1 PA

Chemotherapy Rescue/Antidote Agents LEUCOVORIN CALCIUM TABS OR 10 MG, 15 MG NP PA

leucovorin calcium tabs or 5 mg, 25 mg 1

MESNEX TABS 2

Mitotic Inhibitors

ETOPOSIDE CAPS 2 PA

Topoisomerase I Inhibitors

HYCAMTIN CAPS 2 PA

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

Antiparkinson Adjuvants

carbidopa tabs 1 MP

Drug Name DrugTier

Requirements/Limits

LODOSYN TABS (carbidopa) NF MP

Antiparkinson Anticholinergics benztropine mesylate solnij 1 mg/ml 1

benztropine mesylate tabsor 0.5 mg, 1 mg, 2 mg 1 MP

COGENTIN SOLN (benztropine mesylate) NF

trihexyphenidyl hcl soln 0.4mg/ml 1


trihexyphenidyl hcl tabs 2mg, 5 mg 1 MP

Antiparkinson COMT Inhibitors COMTAN TABS (entacapone) NF MP

entacapone tabs 1 MP

TASMAR TABS (tolcapone) NF MP

tolcapone tabs 1 MP

Antiparkinson Dopaminergics amantadine hcl caps 100 mg 1 MP

amantadine hcl syrp 50mg/5ml 1 MP

amantadine hcl tabs 100 mg NP

APOKYN SOCT NP

bromocriptine mesylate caps NP PA

bromocriptine mesylatetabs NP PA

carbidopa-levodopa tabs10 mg-100 mg, 25 mg-100mg, 25 mg-250 mg

1 MP

carbidopa-levodopa tbcr 25mg-100 mg, 50 mg-200 mg 1 MP

carbidopa-levodopa tbdp10 mg-100 mg, 25 mg-100mg, 25 mg-250 mg

NP

CARBIDOPA/LEVODOPA/ENTACAPONE TABS NP


62

Drug Name DrugTier

Requirements/Limits

DUOPA SUSP NP

GOCOVRI CP24 NP PA

INBRIJA CAPS NP PA

MIRAPEX ER TB24 (pramipexoledihydrochloride)

NP PA

MIRAPEX TABS (pramipexoledihydrochloride)

NF QL(3 ea daily);AL(At least 18yrs old); MP

NEUPRO PT24 NP

OSMOLEX ER TB24 NP PA

PARLODEL CAPS (bromocriptine mesylate) NP PA

PARLODEL TABS (bromocriptine mesylate) NP PA

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

1

QL(3 ea daily);AL(At least 18yrs old); MP

pramipexoledihydrochloride tb24 0.375mg, 0.75 mg, 3 mg, 1.5 mg,4.5 mg, 2.25 mg, 3.75 mg

NP

PA

REQUIP TABS 0.25 MG, 3 MG, 4 MG (ropinirolehydrochloride)


REQUIP TABS 0.5 MG, 1 MG, 2 MG, 5 MG (ropinirole hydrochloride)


REQUIP XL TB24 (ropinirole hydrochloride) NP PA

ropinirole hydrochloridetabs 0.25 mg, 3 mg, 4 mg 1 QL(6 ea daily);

MP ropinirole hydrochloridetabs 0.5 mg, 1 mg, 2 mg, 5 mg

1 QL(3 ea daily);MP

ropinirole hydrochloridetb24 2 mg, 4 mg, 6 mg, 8mg, 12 mg

NP PA

RYTARY CPCR NP

SINEMET CR TBCR (carbidopa-levodopa) NF MP

Drug Name DrugTier

Requirements/Limits

SINEMET TABS (carbidopa-levodopa) NF MP

STALEVO 100 TABS NP

STALEVO 125 TABS NP

STALEVO 150 TABS NP

STALEVO 200 TABS NP

STALEVO 50 TABS NP

STALEVO 75 TABS NP

Antiparkinson Monoamine Oxidase Inhibitors AZILECT TABS (rasagilinemesylate) NP PA

ELDEPRYL CAPS (selegiline hcl) NF MP

rasagiline mesylate tabs NP PA

selegiline hcl caps 1 MP

SELEGILINE HCL TABS 2 MP

selegiline hcl tabs 1 MP

XADAGO TABS NP

ZELAPAR TBDP NP

ANTIPSYCHOTICS/ANTIMANIC AGENTS -Drugs to Treat Mood Disorders

Antimanic Agents lithium carbonate caps 150mg, 300 mg, 600 mg 1 MP

LITHIUM CARBONATE CAPS 150 MG, 600 MG (lithium carbonate)

2 MP

lithium carbonate tabs 300 mg 1 MP

lithium carbonate tbcr 300 mg, 450 mg 1 MP

LITHIUM SOLN 2 MP

LITHOBID TBCR (lithium carbonate) NF MP


63

Drug Name DrugTier

Requirements/Limits

Antipsychotics - Misc. EQUETRO CP12 2 PA

GEODON CAPS OR 20 MG (ziprasidone hcl) NF

Age 6-12:MDD=4; Age;;13-17:MDD=8;;AL(Atleast 6 yrs old);MP




Age 6-12:MDD=1.34; Age 13-17:MDD=2.67;AL(At least 6 yrsold); MP



GEODON SOLR IM 20 MG (ziprasidone mesylate) NF

AL(At least 18yrs old - Up to64 yrs old)

LATUDA TABS 120 MG 2

Age 6-12:MDD=0.34;Age13-17: MDD=0.67;AL(At least 6 yrsold); MP

LATUDA TABS 20 MG 2

Age 6-12:MDD=2;Age13-17: MDD=4;AL(Atleast 6 yrs old);MP

LATUDA TABS 40 MG 2

Age 6-12:MDD=1;Age13-17: MDD=2;AL(Atleast 6 yrs old);MP

Drug Name DrugTier

Requirements/Limits

LATUDA TABS 60 MG 2

Age 6-12:MDD=0.67;Age13-17: MDD=1.34;AL(At least 6 yrsold); MP

LATUDA TABS 80 MG 2

Age 6-12:MDD=0.5;Age13-17: MDD=1;AL(Atleast 6 yrs old);MP

NUPLAZID CAPS 34 MG 2 PA

NUPLAZID TABS 10 MG 2 PA

NUPLAZID TABS 17 MG 2 PA; MP

VRAYLAR CAPS 3 MG, 6 MG, 1.5 MG, 4.5 MG 2

PA; Minimum age 18yo;AL(Atleast 18 yrsold); MP

VRAYLAR CPPK 2

PA; Minimum age 18yo;AL(Atleast 18 yrsold)

ziprasidone hcl caps 20 mg 1









64

Drug Name DrugTier

Requirements/Limits

ziprasidone mesylate solr 1 AL(At least 18yrs old - Up to64 yrs old)

Benzisoxazoles

FANAPT TABS 2 AL(At least 18yrs old)

FANAPT TITRATION PACK TABS NP AL(At least 18

yrs old)

INVEGA SUSTENNA SUSY 2


INVEGA TB24 (paliperidone) NF AL(At least 18

yrs old)

INVEGA TRINZA SUSY 2 AL(At least 18yrs old - Up to64 yrs old); MP

paliperidone tb24 1 AL(At least 18yrs old)

PERSERIS PRSY NP AL(At least 18yrs old)

RISPERDAL CONSTA SRER 2

AL(At least 18yrs old - Up to64 yrs old); SP

RISPERDAL M-TAB TBDP 0.5 MG (risperidone) NF

Age 3-5:MDD=4; Age 6-12: MDD=8; Age 13- 17:MDD=12;AL(Atleast 3 yrs old);MP

RISPERDAL M-TAB TBDP 1 MG (risperidone) NF



Age 3-5:MDD=0.67; Age 6-12:MDD=1.34; Age 13-17:MDD=2;AL(Atleast 3 yrs old);MP

Drug Name DrugTier

Requirements/Limits


Age 3-5:MDD=0.5; Age6-12: MDD=1; Age 13-17:MDD=1.5;AL(Atleast 3 yrs old);MP

RISPERDAL SOLN 1 MG/ML (risperidone) NF


RISPERDAL TABS 0.25 MG (risperidone) NF

Age 3-5:MDD=8; Age;;6-12:MDD=16; Age;;13-17:MDD=24;;AL(Atleast 3 yrs old);MP

RISPERDAL TABS 0.5 MG (risperidone) NF

Age 3-5:MDD=4; Age;;6-12:MDD=8; Age13-;;17: MDD=12;;AL(Atleast 3 yrs old);MP

RISPERDAL TABS 1 MG (risperidone) NF





65

Drug Name DrugTier

Requirements/Limits




Age 3-5:MDD=0.5;;;Age6-12: MDD=1; Age;;13-17:MDD=1.5;;AL(At least 3 yrsold); MP

RISPERIDONE ODT TBDP 2

Age 3-5:MDD=8; Age 6-12: MDD=16; Age 13-17:MDD=24;AL(Atleast 3 yrs old);MP

risperidone soln 1 mg/ml 1


risperidone tabs 0.25 mg 1

Age 3-5:MDD=8; Age;;6-12:MDD=16; Age;;13-17:MDD=24;;AL(At least 3 yrsold); MP

risperidone tabs 0.5 mg 1

Age 3-5:MDD=4; Age;;6-12:MDD=8; Age13-;;17: MDD=12;;AL(At least 3 yrsold); MP

Drug Name DrugTier

Requirements/Limits

risperidone tabs 1 mg 1







Age 3-5:MDD=0.5;;;Age6-12: MDD=1; Age;;13-17:MDD=1.5;;AL(At least 3 yrsold); MP

risperidone tbdp 0.5 mg 1


risperidone tbdp 1 mg 1



66

Drug Name DrugTier

Requirements/Limits






Age 3-5:MDD=0.5; Age6-12: MDD=1; Age 13-17:MDD=1.5;AL(At least 3 yrsold); MP

Butyrophenones HALDOL DECANOATE 100 SOLN (haloperidoldecanoate)

NF

HALDOL DECANOATE 50 SOLN (haloperidoldecanoate)

NF

HALDOL SOLN (haloperidol lactate) NF

haloperidol decanoate soln 1

haloperidol lactate conc or2 mg/ml 1

Age 6-12:MDD=5; Age;;13-17:MDD=7.5;;AL(At least 6 yrsold); MP

haloperidol lactate soln ij 5mg/ml 1

haloperidol tabs 0.5 mg 1

Age 6-12:MDD=20;;;Age13-17: MDD=30;;AL(At least 6 yrsold); MP

Drug Name DrugTier

Requirements/Limits

haloperidol tabs 1 mg 1

Age 6-12:MDD=10;;;Age13-17: MDD=15;;AL(Atleast 6 yrs old);MP


Age 6-12:MDD=1; Age;;13-17:MDD=1.5;;AL(At least 6 yrsold); MP


Age 6-12;MDD=5;;Age13-17: MDD=7.5;;AL(At least 6 yrsold); MP


Age 6-12:MDD=0.5; Age;;13-17:MDD=0.75;;AL(At least 6 yrsold); MP



Dibenzapines

ADASUVE AEPB NP

CLOZAPINE ODT TBDP 12.5 MG NP

PA; Age 13 -17: MDD = 56;AL(At least13 yrs old)

CLOZAPINE ODT TBDP 150 MG NP

PA; Age 13 -17: MDD = 4.67;AL(Atleast 13 yrsold)

CLOZAPINE ODT TBDP 200 MG NP

PA; Age 13 -17: MDD = 3.5;AL(At least13 yrs old)


67

Drug Name DrugTier

Requirements/Limits

clozapine tabs 100 mg 1

Age 13-17:MDD 7;AL(Atleast 13 yrsold)


Age 13 - 17:MDD = 3.5;AL(At least13 yrs old)




Age 13-17:MDD 14 AL(Atleast 13 yrsold)

clozapine tbdp 100 mg NP


clozapine tbdp 25 mg NP


CLOZARIL TABS 100 MG (clozapine) NF


CLOZARIL TABS 200 MG (clozapine) 2

Age 13 - 17:MDD = 3.5;AL(At least13 yrs old)

CLOZARIL TABS 25 MG (clozapine) NF


CLOZARIL TABS 50 MG (clozapine) 2

Age 13-17:MDD 14 AL(Atleast 13 yrsold)

FAZACLO TBDP 100 MG (clozapine) NP


FAZACLO TBDP 12.5 MG NP


Drug Name DrugTier

Requirements/Limits

FAZACLO TBDP 150 MG NP

PA; Age 13 -17: MDD = 4.67;AL(Atleast 13 yrsold)

FAZACLO TBDP 200 MG NP

PA; Age 13 -17: MDD = 3.5;AL(At least13 yrs old)

FAZACLO TBDP 25 MG (clozapine) NP


loxapine succinate caps 1 QL(4 ea daily);MP

olanzapine solr im 10 mg 1 AL(At least 18yrs old - Up to64 yrs old)

olanzapine tabs or 10 mg 1

Age 6-12:MDD=1; Age13-17: MDD=2;AL(Atleast 6 yrs old);MP


Age 6-12;MDD=0.67; Age 13-17:MDD=1.34;AL(At least 6 yrsold); MP

olanzapine tabs or 2.5 mg 1



Age 6-12:MDD=0.5; Age13-17: MDD=1;AL(Atleast 6 yrs old);MP




68

Drug Name DrugTier

Requirements/Limits

olanzapine tabs or 7.5 mg 1


olanzapine tbdp or 10 mg 1








quetiapine fumarate tabs100 mg 1






Drug Name DrugTier

Requirements/Limits







quetiapine fumarate tb24150 mg 1











69

Drug Name DrugTier

Requirements/Limits

SAPHRIS SUBL 2

Minimum age18yo;AL(Atleast 18 yrsold); MP

SECUADO PT24 NP PA

SEROQUEL TABS 100 MG (quetiapine fumarate) NF











Age 6-12:MDD=8; Age;;13-17:MDD=16;;AL(At least 6 yrsold); MP

SEROQUEL XR TB24 150 MG (quetiapine fumarate) NF


Drug Name DrugTier

Requirements/Limits









VERSACLOZ SUSP 2


ZYPREXA RELPREVV SUSR 2

AL(At least 18yrs old - Up to64 yrs old); SP

ZYPREXA SOLR IM 10 MG (olanzapine) NF


ZYPREXA TABS OR 10 MG (olanzapine) NF



Age 6-12;MDD=0.67; Age 13-17:MDD=1.34;AL(At least 6 yrsold); MP


70

Drug Name DrugTier

Requirements/Limits

ZYPREXA TABS OR 2.5 MG (olanzapine) NF






ZYPREXA TABS OR 7.5 MG (olanzapine) NF


ZYPREXA ZYDIS TBDP 10 MG (olanzapine) NF








Dihydroindolones

Drug Name DrugTier

Requirements/Limits

MOLINDONE HYDROCHLORIDE TABS 10 MG

2 QL(4 ea daily);MP

MOLINDONE HYDROCHLORIDE TABS 5 MG, 25 MG

2

Phenothiazines CHLORPROMAZINE HCL SOLN IJ 25 MG/ML, 50MG/2ML

2

chlorpromazine hcl tabs or10 mg 1 QL(10 ea

daily); MP chlorpromazine hcl tabs or25 mg, 50 mg, 100 mg, 200 mg

1 QL(3 ea daily);MP

fluphenazine decanoatesoln 1

FLUPHENAZINE HCL CONC OR 5 MG/ML 2

FLUPHENAZINE HCL SOLN IJ 2.5 MG/ML 2

fluphenazine hcl tabs or 1mg, 5 mg, 10 mg, 2.5 mg 1 MP

FLUPHENAZINE HCL TABS OR 1 MG, 5 MG, 10 MG, 2.5 MG

2 MP

FLUPHENAZINE HYDROCHLORIDE ELIX 2

perphenazine tabs 16 mg 1

Age 6-12:MDD=0.75; Age 13-17:MDD=1.5;AL(Atleast 6 yrs old);MP






71

Drug Name DrugTier

Requirements/Limits



prochlorperazine maleatetabs 1 MP

prochlorperazine supp 1

thioridazine hcl tabs 1 QL(3 ea daily);MP

trifluoperazine hcl tabs 1 QL(3 ea daily);MP

Quinolinone Derivatives

ABILIFY MAINTENA PRSY 2

AL(At least 18yrs old - Up to64 yrs old); SP;MP

ABILIFY MAINTENA SRER 2


ABILIFY MYCITE TABS 10 MG NP

Age 3-5:MDD=0.5;Age6-12: MDD=2;Age13-17: MDD=3;AL(Atleast 3 yrs old)


Age 3-5:MDD=0.34 ;Age 6-12:MDD=1.34;Age13-17: MDD=2;AL(Atleast 3 yrs old)


Age 3-5:MDD=2.5;Age6-12: MDD=10;Age13-17: MDD=15 AL(Atleast 3 yrs old)

Drug Name DrugTier

Requirements/Limits Age 3-5:MDD=0.25;Age


6-12: MDD=1;Age13-17: MDD=1.5 AL(Atleast 3 yrs old) Age 3-5:MDD=0.167;Ag


e 6-12: MDD=0.67;Age13-17: MDD=1;AL(Atleast 3 yrs old)


Age 3-5:MDD=1;Age 6-12: MDD=4;Age13-17: MDD=6 AL(At least 3yrs old)

ABILIFY TABS 10 MG (aripiprazole) NF

Age 3-5:MDD=0.5;Age6-12: MDD=2;Age13-17: MDD=3;AL(Atleast 3 yrs old);MP Age 3-5:MDD=0.34


;Age 6-12:MDD=1.34;Age13-17: MDD=2.;AL(Atleast 3 yrs old)


Age 3-5:MDD=2.5;Age6-12: MDD=10;Age13-17: MDD=15;AL(Atleast 3 yrs old);MP


72

Drug Name DrugTier

Requirements/Limits


Age 3-5:MDD=0.25;Age6-12: MDD=1;Age13-17: MDD=1.5;AL(At least 3 yrsold); MP


Age 3-5:MDD=0.167;Age 6-12: MDD=0.67;Age13-17: MDD=1;AL(Atleast 3 yrs old);MP


Age 3-5:MDD=1;Age 6-12: MDD=4;Age13-17: MDD=6;AL(Atleast 3 yrs old);MP

aripiprazole soln 1 mg/ml 1


aripiprazole tabs 10 mg 1

Age 3-5:MDD=0.5;Age6-12: MDD=2;Age13-17: MDD=3;AL(Atleast 3 yrs old);MP Age 3-5:MDD=0.34 ;Age 6-12:

aripiprazole tabs 15 mg 1 MDD=1.34;Age13-17: MDD=2.;AL(Atleast 3 yrs old)

Drug Name DrugTier

Requirements/Limits




Age 3-5:MDD=0.25;Age6-12: MDD=1;Age13-17: MDD=1.5;AL(Atleast 3 yrs old);MP


Age 3-5:MDD=0.167;Age 6-12: MDD=0.67;Age13-17: MDD=1;AL(Atleast 3 yrs old);MP



aripiprazole tbdp 10 mg 1


aripiprazole tbdp 15 mg 1

Age 3-5:MDD=0.34;Age6-12: MDD=1.34;Age13-17: MDD=2;AL(Atleast 3 yrs old);MP


73

Drug Name DrugTier

Requirements/Limits

ARISTADA INITIO PRSY NP AL(At least 18yrs old - Up to64 yrs old)

ARISTADA PRSY 1064 MG/3.9ML 2


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

2 AL(At least 18yrs old - Up to64 yrs old); MP

REXULTI TABS 2

Minimum age18yo;AL(Atleast 18 yrsold); MP

Thioxanthenes

thiothixene caps 1 QL(3 ea daily);MP

ANTISEPTICS & DISINFECTANTS

Antiseptics & Disinfectants

FORMALDEHYDE SOLN 2 QL(90 ml perfill retail)

formaldehyde soln 1 QL(90 ml perfill retail)

ANTIVIRALS - Drugs to Treat Viral Infections

Antiretrovirals abacavir sulfate soln 20 mg/ml 1 QL(30 ml daily)

abacavir sulfate tabs 300 mg 1 QL(2 ea daily)

abacavir sulfate-lamivudine tabs 1 QL(1 ea daily)

abacavir sulfate-lamivudine-zidovudine tabs 1 QL(2 ea daily)

APTIVUS CAPS 250 MG 2 QL(4 ea daily)

APTIVUS SOLN 100 MG/ML 2 QL(10 ml daily)

atazanavir sulfate caps 1 QL(2 ea daily)

ATRIPLA TABS 2 QL(1 ea daily)

BIKTARVY TABS NP

CIMDUO TABS NP

Drug Name DrugTier

Requirements/Limits

COMBIVIR TABS (lamivudine-zidovudine) NF QL(2 ea daily)

COMPLERA TABS 2 QL(1 ea daily)

CRIXIVAN CAPS 200 MG 2 QL(9 ea daily)

CRIXIVAN CAPS 400 MG 2 QL(6 ea daily)

DELSTRIGO TABS NP

DESCOVY TABS 2 QL(1 ea daily)

didanosine cpdr 200 mg,250 mg 1 QL(1 ea daily)

DIDANOSINE CPDR 200 MG, 400 MG 2 QL(1 ea daily)

DOVATO TABS NP

EDURANT TABS 2 QL(1 ea daily)

efavirenz caps 200 mg 1 QL(1 ea daily)

efavirenz caps 50 mg 1 QL(2 ea daily)

efavirenz tabs 600 mg 1 QL(1 ea daily)

EMTRIVA CAPS 200 MG 2 QL(1 ea daily)

EMTRIVA SOLN 10 MG/ML 2 QL(24 ml daily)

EPIVIR SOLN 10 MG/ML(lamivudine) NF QL(30 ml daily)

EPIVIR TABS 150 MG (lamivudine) NF QL(2 ea daily)

EPIVIR TABS 300 MG (lamivudine) NF QL(1 ea daily)

EPZICOM TABS (abacavir sulfate-lamivudine) NF QL(1 ea daily)

EVOTAZ TABS 2 QL(1 ea daily)

fosamprenavir calcium tabs 1

FUZEON SOLR 2

GENVOYA TABS 2 QL(1 ea daily)

INTELENCE TABS 200 MG 2 QL(2 ea daily)


74

Drug Name DrugTier

Requirements/Limits

INTELENCE TABS 25 MG, 100 MG 2 QL(4 ea daily)

INVIRASE CAPS 200 MG 2 QL(10 ea daily)

INVIRASE TABS 500 MG 2 QL(4 ea daily)

ISENTRESS CHEW 100 MG 2 QL(6 ea daily)

ISENTRESS CHEW 25 MG 2 QL(12 ea daily)

ISENTRESS HD TABS 2

ISENTRESS PACK 100 MG 2 QL(2 ea daily)

ISENTRESS TABS 400 MG 2 QL(2 ea daily)

JULUCA TABS NP

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

NF

KALETRA TABS 100 MG-25 MG 2 QL(4 ea daily)

KALETRA TABS 200 MG-50 MG 2 QL(6 ea daily)

lamivudine soln 10 mg/ml 1 QL(30 ml daily)

lamivudine tabs 150 mg 1 QL(2 ea daily)

lamivudine tabs 300 mg 1 QL(1 ea daily)

lamivudine-zidovudine tabs 1 QL(2 ea daily)

LEXIVA SUSP 50 MG/ML 2 QL(56 ml daily)

LEXIVA TABS 700 MG (fosamprenavir calcium) NF

lopinavir-ritonavir soln 1

NEVIRAPINE ER TB24 2 QL(3 ea daily)

nevirapine susp 50 mg/5ml 1 QL(40 ml daily)

nevirapine tabs 200 mg 1

nevirapine tb24 100 mg 1 QL(3 ea daily)

Drug Name DrugTier

Requirements/Limits

nevirapine tb24 400 mg 1 QL(1 ea daily)

NORVIR CAPS 100 MG NP PA; QL(12 eadaily)

NORVIR PACK 100 MG NP PA

NORVIR SOLN 80 MG/ML NP PA; QL(15 mldaily)

NORVIR TABS 100 MG (ritonavir) NF QL(12 ea daily)

ODEFSEY TABS 2

PIFELTRO TABS NP

PREZCOBIX TABS 2 QL(1 ea daily)

PREZISTA SUSP 100 MG/ML 2 QL(12 ml daily)

PREZISTA TABS 150 MG 2 QL(3 ea daily)

PREZISTA TABS 75 MG, 600 MG 2 QL(2 ea daily)

PREZISTA TABS 800 MG 2 QL(1 ea daily)

RESCRIPTOR TABS 100 MG 2 QL(12 ea daily)

RESCRIPTOR TABS 200 MG 2 QL(6 ea daily)

RETROVIR CAPS 100 MG (zidovudine) NF QL(6 ea daily)

RETROVIR IV INFUSION SOLN 2

RETROVIR SYRP 50 MG/5ML (zidovudine) NF QL(60 ml daily)

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

NF QL(2 ea daily)

REYATAZ PACK 50 MG 2 QL(6 ea daily)

ritonavir tabs 1 QL(12 ea daily)

SELZENTRY SOLN 20 MG/ML 2

SELZENTRY TABS 150 MG 2 QL(2 ea daily)


75

Drug Name DrugTier

Requirements/Limits

SELZENTRY TABS 25 MG, 75 MG 2

QL 2 perday;SL(2 eadaily)

SELZENTRY TABS 300 MG 2 QL(4 ea daily)

stavudine caps 1 QL(2 ea daily)

STRIBILD TABS 2 QL(1 ea daily)

SUSTIVA CAPS 200 MG (efavirenz) NF QL(1 ea daily)

SUSTIVA CAPS 50 MG (efavirenz) NF QL(2 ea daily)

SUSTIVA TABS 600 MG (efavirenz) NF QL(1 ea daily)

SYMFI LO TABS NP

SYMFI TABS NP

SYMTUZA TABS NP PA

TEMIXYS TABS NP

tenofovir disoproxilfumarate tabs 1 QL(1 ea daily)

TIVICAY TABS 10 MG, 25 MG 2

TIVICAY TABS 50 MG 2 QL(2 ea daily)

TRIUMEQ TABS 2 QL(1 ea daily)

TRIZIVIR TABS (abacavir sulfate-lamivudine-zidovudine)

NF QL(2 ea daily)

TROGARZO SOLN 2 PA

TRUVADA TABS 2 QL(1 ea daily)

TYBOST TABS 2 QL(1 ea daily)

VIDEX EC CPDR 125 MG 2 QL(1 ea daily)

VIDEX EC CPDR 200 MG, 250 MG (didanosine) NF QL(1 ea daily)

VIDEX EC CPDR 400 MG (didanosine) NP QL(1 ea daily)

VIDEXPEDIATRIC SOLR 2 QL(20 ml daily)

Drug Name DrugTier

Requirements/Limits

VIRACEPT TABS 250 MG 2 QL(9 ea daily)

VIRACEPT TABS 625 MG 2 QL(4 ea daily)

VIRAMUNE SUSP 50 MG/5ML (nevirapine) 2 QL(40 ml daily)

VIRAMUNE TABS 200 MG (nevirapine) NF

VIRAMUNE XR TB24 100 MG (nevirapine) NF QL(3 ea daily)

VIRAMUNE XR TB24 400 MG (nevirapine) NF QL(1 ea daily)

VIREAD POWD 40 MG/GM 2 QL(240 gm per30 days retail)

VIREAD TABS 150 MG, 200 MG, 250 MG 2 QL(1 ea daily)

VIREAD TABS 300 MG (tenofovir disoproxilfumarate)

NF QL(1 ea daily)

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

NF QL(2 ea daily)

ZERIT SOLR 1 MG/ML 2 QL(80 ml daily)

ZIAGEN SOLN 20 MG/ML(abacavir sulfate) NF QL(30 ml daily)

ZIAGEN TABS 300 MG (abacavir sulfate) NF QL(2 ea daily)

zidovudine caps 100 mg 1 QL(6 ea daily)

zidovudine syrp 50 mg/5ml 1 QL(60 ml daily)

zidovudine tabs 300 mg 1 QL(2 ea daily)

CMV Agents

cidofovir soln 1 PA

CYTOVENE SOLR (ganciclovir sodium) NF PA

ganciclovir sodium solr 1 PA

GANCICLOVIR SOLN 500 MG/10ML NP PA

GANCICLOVIR SOLN 500 MG/250ML 2 PA

PREVYMIS SOLN 2 PA


76

Drug Name DrugTier

Requirements/Limits

PREVYMIS TABS 2 PA

VALCYTE SOLR 50 MG/ML (valganciclovir hcl) NF

VALCYTE TABS 450 MG (valganciclovir hcl) NF QL(2 ea daily)

valganciclovir hcl solr 50mg/ml 1

valganciclovir hcl tabs 450 mg 1 QL(2 ea daily)

Hepatitis Agents

adefovir dipivoxil tabs 1

BARACLUDE SOLN 0.05 MG/ML NP

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

DAKLINZA TABS CO

entecavir tabs 1 SP

EPCLUSA TABS CO

EPIVIR HBV SOLN 5 MG/ML 2

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

HARVONI TABS 200 MG-45 MG, 400 MG-90 MG CO

HEPSERA TABS (adefovir dipivoxil) NF

lamivudine (hbv) tabs 1

LEDIPASVIR/SOFOSBUVIR TABS CO

MAVYRET TABS CO

MODERIBA 1200 DOSE PACK TBPK CO

MODERIBA 800 DOSE PACK TBPK CO

OLYSIO CAPS CO

PEGASYS PROCLICK SOLN CO

PEGASYS SOLN CO

Drug Name DrugTier

Requirements/Limits

PEGINTRON KIT CO

REBETOL CAPS 200 MG (ribavirin (hepatitis c)) CO

REBETOL SOLN 40 MG/ML CO

RIBASPHERE RIBAPAK TBPK CO

RIBASPHERE TABS CO

ribavirin (hepatitis c) caps CO

ribavirin (hepatitis c) tabs CO

SOFOSBUVIR/VELPATASVIR TABS CO

SOVALDI TABS CO

TECHNIVIE TABS CO

VEMLIDY TABS NP PA; SP

VIEKIRA PAK TBPK CO

VIEKIRA XR TB24 CO

VOSEVI TABS CO

ZEPATIER TABS CO

Herpes Agents

acyclovir caps 200 mg 1 QL(50 ea per30 days retail)

acyclovir sodium soln 50mg/ml 1 PA

ACYCLOVIR SODIUM SOLR 500 MG 2 PA

acyclovir susp 200 mg/5ml 1 QL(400 ml per30 days retail)

acyclovir tabs 400 mg 1 QL(3 ea daily)

acyclovir tabs 800 mg 1 QL(50 ea per30 days retail)

famciclovir tabs 1

SITAVIG TABS NP PA


77

Drug Name DrugTier

Requirements/Limits

valacyclovir hcl tabs 1 gm,1000 mg 1 QL(21 ea per

21 days retail) valacyclovir hcl tabs 500 mg 1 QL(60 ea per

30 days retail) VALTREX TABS 1 GM (valacyclovir hcl) NF QL(21 ea per

21 days retail) VALTREX TABS 500 MG (valacyclovir hcl) NF QL(60 ea per

30 days retail) ZOVIRAX CAPS OR 200 MG (acyclovir) NF QL(50 ea per

30 days retail) ZOVIRAX SUSP OR 200 MG/5ML (acyclovir) NF QL(400 ml per

30 days retail) ZOVIRAX TABS OR 400 MG (acyclovir) NF QL(3 ea daily)

ZOVIRAX TABS OR 800 MG (acyclovir) NF QL(50 ea per

30 days retail) Influenza Agents

FLUMADINE TABS NP PA

oseltamivir phosphate caps 1

oseltamivir phosphate susr 1

RAPIVAB SOLN 2 PA

RELENZA DISKHALER AEPB NP

QL(20 ea perfill retail); AL(Atleast 5 yrs old)

RIMANTADINE HYDROCHLORIDE TABS 1

TAMIFLU CAPS (oseltamivir phosphate) NF

TAMIFLU SUSR (oseltamivir phosphate) NF

XOFLUZA TBPK NP

Respiratory Syncytial Virus (RSV) Agents

ribavirin solr 1 PA

VIRAZOLE SOLR (ribavirin) NF PA

BETA BLOCKERS - Drugs to Treat High BloodPressure

Alpha-Beta Blockers

carvedilol phosphate cp24 1 QL(1 ea daily);MP

Drug Name DrugTier

Requirements/Limits

carvedilol tabs 12.5 mg,6.25 mg, 3.125 mg 1 QL(3 ea daily);

MP

carvedilol tabs 25 mg 1 QL(4 ea daily);MP

COREG CR CP24 (carvedilol phosphate) NF QL(1 ea daily);

MP COREG TABS 12.5 MG, 6.25 MG, 3.125 MG (carvedilol)


COREG TABS 25 MG (carvedilol) NF QL(4 ea daily);

MP

labetalol hcl soln iv 5 mg/ml 1 PA

labetalol hcl tabs or 100 mg 1 QL(3 ea daily);MP



LABETALOL HYDROCHLORIDE SOLN 5 MG/ML

2 PA

Beta Blockers Cardio-Selective

acebutolol hcl caps 1 MP

atenolol tabs 1 QL(2 ea daily);MP

betaxolol hcl tabs 1 MP

bisoprolol fumarate tabs 1 QL(1 ea daily);MP

BREVIBLOC PREMIXED DOUBLESTRENGTH SOLN (esmolol hcl-sodium chloride)

NF

BREVIBLOC PREMIXED SOLN (esmolol hcl-sodium chloride)

NF

BREVIBLOC SOLN 100 MG/10ML (esmolol hcl) NF PA

BREVIBLOC SOLN 2000 MG/100ML-4.1 MG/ML,2500 MG/250ML-5.9MG/ML (esmolol hcl-sodium chloride)

NF

BYSTOLIC TABS NP


78

Drug Name DrugTier

Requirements/Limits

esmolol hcl soln 1 PA

esmolol hcl-sodium chloride soln 1

ESMOLOL HYDROCHLORIDE INWATER DOUBLE STRENGTH SOLN

2

PA

ESMOLOL HYDROCHLORIDE INWATER SOLN

2 PA

KAPSPARGO SPRINKLE CS24 NP PA

LOPRESSOR TABS 100 MG (metoprolol tartrate) NF QL(2 ea daily);

MP LOPRESSOR TABS 50 MG (metoprolol tartrate) NF QL(3 ea daily);

MP metoprolol succinate tb24200 mg 1 QL(2 ea daily);

MP metoprolol succinate tb2425 mg, 50 mg, 100 mg 1 QL(1 ea daily);

MP METOPROLOL TARTRATE SOCT IV 5 MG/5ML

2 PA

metoprolol tartrate soln iv 5mg/5ml 1 PA

metoprolol tartrate tabs or25 mg, 100 mg 1 QL(2 ea daily);

MP metoprolol tartrate tabs or50 mg 1 QL(3 ea daily);

MP metoprolol tartrate tabs or75 mg, 37.5 mg 1

TENORMIN TABS (atenolol) NF QL(2 ea daily);

MP TOPROL XL TB24 200 MG (metoprolol succinate) NF QL(2 ea daily);

MP TOPROL XL TB24 25 MG, 50 MG, 100 MG (metoprolol succinate)


Beta Blockers Non-Selective BETAPACE AF TABS (sotalol hcl (afib/afl)) NF QL(2 ea daily);

MP BETAPACE TABS (sotalol hcl) NF QL(2 ea daily);

MP

CORGARD TABS (nadolol) NF QL(2 ea daily);MP

Drug Name DrugTier

Requirements/Limits

HEMANGEOL SOLN NP

INDERAL LA CP24 (propranolol hcl) NF QL(2 ea daily);

MP INDERAL XL CP24 80 MG, 120 MG NP

INNOPRAN XL CP24 80 MG, 120 MG NP

nadolol tabs 1 QL(2 ea daily);MP

pindolol tabs NP

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

1 QL(2 ea daily);MP

propranolol hcl soln iv 1mg/ml 1 PA

PROPRANOLOL HCL SOLN OR 20 MG/5ML, 40MG/5ML

2 MP

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

1 MP

sotalol hcl (afib/afl) tabs 1 QL(2 ea daily);MP

sotalol hcl tabs 240 mg 1 MP

sotalol hcl tabs 80 mg, 120mg, 160 mg 1 QL(2 ea daily);

MP

SOTYLIZE SOLN 2 MP

TIMOLOL MALEATE TABS 10 MG, 20 MG NP

timolol maleate tabs 5 mg NP

CALCIUM CHANNEL BLOCKERS - Drugs toTreat High Blood Pressure

Calcium Channel Blocker Combinations

CONSENSI TABS NP PA

Calcium Channel Blockers ADALAT CC TB24 30 MG, 90 MG (nifedipine) NF QL(1 ea daily);

MP ADALAT CC TB24 60 MG (nifedipine) NF QL(2 ea daily);

MP


79

Drug Name DrugTier

Requirements/Limits

amlodipine besylate tabs 1 QL(1 ea daily);MP

CALAN SR TBCR (verapamil hcl) NF QL(2 ea daily);

MP CALAN TABS (verapamilhcl) NF QL(3 ea daily);

MP

CARDENE IV SOLN 2 PA

CARDIZEM CD CP24 120 MG, 180 MG, 300 MG (diltiazem hcl coated beads)

NP

PA; QL(1 eadaily); MP

CARDIZEM CD CP24 240 MG (diltiazem hcl coated beads)

NP PA; QL(2 eadaily); MP

CARDIZEM CD CP24 360 MG (diltiazem hcl coated beads)

NF MP

CARDIZEM LA TB24 120 MG NP PA

CARDIZEM LA TB24 180 MG, 240 MG, 300 MG, 360 MG, 420 MG (diltiazem hcl coated beads)

NP

PA

CARDIZEM TABS (diltiazem hcl) NF QL(3 ea daily);

MP

CLEVIPREX EMUL 2 PA

DILT-XR CP24 120 MG, 180 MG 2 QL(1 ea daily);

MP

DILT-XR CP24 240 MG 2 QL(2 ea daily);MP

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

1 QL(1 ea daily);MP

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

NP PA; QL(1 eadaily); MP

diltiazem hcl coated beads cp24 240 mg 1 QL(2 ea daily);

MP diltiazem hcl coated beads cp24 240 mg 1 QL(2 ea daily)

diltiazem hcl coated beads cp24 240 mg NP PA; QL(2 ea

daily); MP diltiazem hcl coated beads cp24 360 mg 1 MP

Drug Name DrugTier

Requirements/Limits

diltiazem hcl coated beads tb24 180 mg, 240 mg, 300mg, 360 mg, 420 mg

NP PA

diltiazem hcl cp12 or 60mg, 90 mg, 120 mg 1 QL(2 ea daily);

MP diltiazem hcl cp24 or 120mg, 180 mg 1 QL(1 ea daily);

MP diltiazem hcl cp24 or 240 mg 1 QL(2 ea daily);

MP diltiazem hcl extended release beads cp24 120mg, 180 mg, 240 mg, 300mg, 360 mg

NP


diltiazem hcl extended release beads cp24 120mg, 180 mg, 240 mg, 300mg, 360 mg, 420 mg

1

QL(1 ea daily);MP

diltiazem hcl extended release beads cp24 360 mg

1

diltiazem hcl soln iv 25 mg/5ml, 50 mg/10ml, 125mg/25ml

1 PA

DILTIAZEM HCL SOLR IV 100 MG 2 PA

diltiazem hcl tabs or 30 mg,60 mg, 90 mg, 120 mg 1 QL(3 ea daily);

MP

felodipine tb24 1 QL(1 ea daily);MP

isradipine caps NP

KATERZIA SUSP NP PA

nicardipine hcl caps or 20mg, 30 mg NP

nicardipine hcl soln iv 2.5mg/ml 1 PA

nifedipine caps 10 mg, 20 mg 1 QL(4 ea daily);

MP nifedipine tb24 30 mg, 90 mg 1 QL(1 ea daily);

MP

nifedipine tb24 60 mg 1 QL(2 ea daily);MP

nimodipine caps NP

NISOLDIPINE ER TB24 NP


80

Drug Name DrugTier

Requirements/Limits

nisoldipine tb24 NP PA

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

MP

NYMALIZE SOLN NP

PROCARDIA CAPS (nifedipine) NF QL(4 ea daily);

MP PROCARDIA XL TB24 30 MG, 90 MG (nifedipine) NF QL(1 ea daily);

MP PROCARDIA XL TB24 60 MG (nifedipine) NF QL(2 ea daily);

MP

SULAR TB24 (nisoldipine) NP PA

TIAZAC CP24 120 MG, 180 MG, 240 MG, 300 MG, 360 MG (diltiazem hcl extended release beads)

NP


TIAZAC CP24 420 MG (diltiazem hcl extended release beads)


verapamil hcl cp24 or 100mg, 200 mg NP QL(2 ea daily)

verapamil hcl cp24 or 120mg, 180 mg, 240 mg NP PA; QL(2 ea

daily) verapamil hcl cp24 or 300 mg NP QL(1 ea daily)

VERAPAMIL HCL ER CP24 100 MG NP PA; QL(2 ea

daily) VERAPAMIL HCL ER CP24 300 MG NP QL(1 ea daily)

verapamil hcl soln iv 2.5mg/ml 1 PA

VERAPAMIL HCL SR CP24 NP PA; QL(1 ea

daily) verapamil hcl tabs or 40mg, 80 mg, 120 mg 1 QL(3 ea daily);

MP verapamil hcl tbcr or 120mg, 180 mg, 240 mg 1 QL(2 ea daily);

MP VERAPAMIL HYDROCHLORIDE ER CP24


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


VERELAN CP24 360 MG NP PA; QL(1 eadaily)

Drug Name DrugTier

Requirements/Limits

VERELAN PM CP24 100 MG, 200 MG NP PA; QL(2 ea

daily) VERELAN PM CP24 300 MG NP PA; QL(1 ea

daily) CARDIOTONICS - Drugs to Treat Heart Failureand Abnormal Heart Rhythm

Cardiac Glycosides

digoxin soln ij 0.25 mg/ml 1

digoxin soln or 0.05 mg/ml 1 MP

DIGOXIN SOLN OR 0.05 MG/ML (digoxin) 2 MP

digoxin tabs or 0.125 mg,0.25 mg, 125 mcg, 250 mcg

1 MP

LANOXIN PEDIATRIC SOLN NP

LANOXIN SOLN IJ 0.25 MG/ML (digoxin) NF

LANOXIN TABS OR 125 MCG, 250 MCG (digoxin) NF MP

LANOXIN TABS OR 62.5 MCG, 187.5 MCG NP

Phosphodiesterase Inhibitors milrinone lactate in dextrose soln 1 PA

milrinone lactate soln 1 PA

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

Cardiovascular Agents Misc. - Combinations amlodipine besylate-atorvastatin calcium tabs NP PA

BIDIL TABS NP PA

CADUET TABS (amlodipine besylate-atorvastatin calcium)

NP PA

ENTRESTO TABS 2 PA; MP

Prostaglandin Vasodilators

ORENITRAM TBCR NP PA


81

Drug Name DrugTier

Requirements/Limits

TYVASO REFILL SOLN 2 PA; MP

TYVASO SOLN 2 PA; MP

TYVASO STARTER SOLN 2 PA; MP

VENTAVIS SOLN 2 PA; SP; MP

Pulmonary Hypertension - Endothelin Receptor ambrisentan tabs 1 PA; SP

bosentan tabs 1 PA; SP; MP

LETAIRIS TABS (ambrisentan) 2 PA; SP

OPSUMIT TABS NP PA; SP

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

TRACLEER TBSO 32 MG NP PA; MP

Pulmonary Hypertension - Phosphodiesterase ADCIRCA TABS (tadalafil (pulmonary hypertension)) 2 PA; SP; MP

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

NP PA; SP

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

NF PA; SP; MP

sildenafil citrate (pulmonaryhypertension) susr 10mg/ml

NP PA; SP

sildenafil citrate (pulmonaryhypertension) tabs 20 mg 1 PA; SP; MP

tadalafil (pulmonaryhypertension) tabs NP PA; SP; MP

Pulmonary Hypertension - Prostacyclin Receptor UPTRAVI TABS 2 PA

UPTRAVI TBPK 2 PA

Pulmonary Hypertension - Sol Guanylate Cyclase

ADEMPAS TABS 2 PA; MP

Sinus Node Inhibitors

Drug Name DrugTier

Requirements/Limits

CORLANOR SOLN 5 MG/5ML 2 PA

CORLANOR TABS 5 MG, 7.5 MG 2 PA; MP

CEPHALOSPORINS - Drugs to Treat BacterialInfections

Cephalosporins - 1st Generation

cefadroxil caps 1

cefadroxil susr 1

cefadroxil tabs 1

CEFAZOLIN SODIUM SOLN IV 1 GM/50ML-4 % 2 PA

cefazolin sodium solr ij 1gm, 10 gm, 500 mg 1 PA

CEFAZOLIN SODIUM SOLR IJ 20 GM 2 PA

CEFAZOLIN SODIUM SOLR IV 1 GM 2 PA

CEFAZOLIN SODIUM/DEXTROSESOLR 1 GM-4 %, 2 GM-3 %

2

PA

CEFAZOLIN SOLN NP PA

cephalexin caps 250 mg,500 mg, 750 mg 1

cephalexin susr 125mg/5ml, 250 mg/5ml 1

CEPHALEXIN TABS 250 MG, 500 MG 2

DAXBIA CAPS NP

KEFLEX CAPS (cephalexin) NF

Cephalosporins - 2nd Generation cefaclor caps 250 mg, 500 mg 1

CEFACLOR ER TB12 NP

CEFACLOR SUSR 125 MG/5ML, 250 MG/5ML,375 MG/5ML

2 AL(Up to 12 yrsold )


82

Drug Name DrugTier

Requirements/Limits

CEFOTAN SOLR (cefotetan disodium) 2 PA

cefotetan disodium solr 1 PA

CEFOTETAN SOLR 2 PA

CEFOTETAN/DEXTROSESOLR 2 PA

cefoxitin sodium solr ij 10 gm 1 PA

cefoxitin sodium solr iv 1 gm, 2 gm 1 PA

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

2 PA

cefprozil susr 125 mg/5ml 1 AL(Up to 12 yrsold )

cefprozil susr 250 mg/5ml 1

QL(100 ml perfill retail);AL(Up to 12 yrsold )

cefprozil tabs 250 mg, 500 mg 1 QL(20 ea per

fill retail)

CEFTIN SUSR NP


cefuroxime axetil tabs 1 QL(20 ea perfill retail)

cefuroxime sodium solr 1 PA

Cephalosporins - 3rd Generation

cefdinir caps 300 mg 1 QL(20 ea perfill retail)

cefdinir susr 125 mg/5ml,250 mg/5ml 1

cefixime caps 1

cefixime susr 1

cefotaxime sodium solr 1 gm, 2 gm, 500 mg 1 PA

CEFOTAXIME SODIUM SOLR 2 GM, 10 GM, 500 MG

2 PA

cefpodoxime proxetil susr 1

Drug Name DrugTier

Requirements/Limits

cefpodoxime proxetil tabs 1

ceftazidime solr 1 PA

CEFTAZIDIME/DEXTROSE SOLR 2 PA

CEFTRIAXONE IN ISO-OSMOTIC DEXTROSE SOLN

2 PA

ceftriaxone sodium solr ij 1gm, 250 mg, 500 mg 1 PA; QL(3 ea

per fill retail) ceftriaxone sodium solr ij 2 gm 1 PA

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

CEFTRIAXONE/DEXTROSE SOLR 2 PA

CLAFORAN SOLR (cefotaxime sodium) NF PA

SUPRAX CAPS 400 MG (cefixime) NF

SUPRAX CHEW 100 MG, 200 MG 2

SUPRAX SUSR 100 MG/5ML, 200 MG/5ML(cefixime)

NF

SUPRAX SUSR 500 MG/5ML NP

TAZICEF SOLN 2 PA

TAZICEF SOLR 2 PA

Cephalosporins - 4th Generation

cefepime hcl solr 1 PA

CEFEPIME SOLN 2 PA

CEFEPIME/DEXTROSESOLR 2 PA

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

MAXIPIME SOLR IV 1 GM, 2 GM 2 PA

CONTRACEPTIVES - Drugs to PreventPregnancy

Combination Contraceptives - Oral


83

Drug Name DrugTier

Requirements/Limits

BALCOLTRA TABS 2 MP

BEYAZ TABS (drospirenone-ethinylestradiol-levomefolate calcium)

2

MP

DESOGEN TABS (desogestrel & ethinylestradiol)

NF MP

desogestrel & ethinylestradiol tabs 1 MP

desogestrel-ethinylestradiol (biphasic) tabs 1 MP

desogestrel-ethinylestradiol (triphasic) tabs 1 MP

drospirenone-ethinylestradiol tabs 1 MP

drospirenone-ethinylestradiol-levomefolate calcium tabs

1 MP

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

2 MP

ethynodiol diacet & ethestrad tabs 1 MP

FALESSA KIT 2 MP

GENERESS FE CHEW (norethindrone & ethinylestradiol-fe)

2 MP

levonorgestrel & ethestradiol tabs 1 MP

levonorgestrel-eth estradiol(triphasic) tabs 1 MP

levonorgestrel-ethinylestradiol (91-day) tabs 1 MP

levonorgestrel-ethinylestradiol (continuous) tabs 1 MP

LO LOESTRIN FE TABS 2 MP

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

2 MP

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

2 MP

Drug Name DrugTier

Requirements/Limits

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

2 MP

LOESTRIN FE 1/20 TABS(norethin acet & estrad-fe) 2 MP

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

2 MP

MINASTRIN 24 FE CHEW 2 MP

MINASTRIN 24 FE CHEW (norethin acet & estrad-fe) 2 MP

MIRCETTE TABS (desogestrel-ethinylestradiol (biphasic))

2 MP

NATAZIA TABS 2 MP

norethin acet & estrad-fe chew 1 MP

norethin acet & estrad-fe tabs 1 MP

norethindrone & eth estradiol tabs 1 MP

norethindrone & ethinylestradiol-fe chew 1 MP

norethindrone acet & eth estra tabs 1 MP

norethindrone acetate-ethinyl estradiol-fe tabs 1 MP

norethindrone-eth estradiol (triphasic) tabs 1 MP

norgestimate-ethinylestradiol (triphasic) tabs 1 MP

norgestimate-ethinylestradiol tabs 1 MP

norgestrel & ethinylestradiol tabs 1 MP

OGESTREL TABS 2 MP

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

2 MP

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

2 MP


84

Drug Name DrugTier

Requirements/Limits

ORTHO-CYCLEN TABS (norgestimate-ethinylestradiol)

2 MP

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

2 MP

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

2 MP

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

2 MP

SAFYRAL TABS (drospirenone-ethinylestradiol-levomefolate calcium)

2

MP

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

2 MP

TAYTULLA CAPS 2 MP

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

2 MP

YASMIN 28 TABS (drospirenone-ethinylestradiol)

2 MP

YAZ TABS (drospirenone-ethinyl estradiol) 2 MP

Combination Contraceptives - Transdermal XULANE PTWK 2 MP

Combination Contraceptives - Vaginal ANNOVERA RING 2

etonogestrel-ethinylestradiol ring 1 MP

NUVARING RING (etonogestrel-ethinylestradiol)

2 MP

Copper Contraceptives - IUD PARAGARD INTRAUTERINE COPPER CONTRACEPTIVE T380A IUD

2

Emergency Contraceptives

Drug Name DrugTier

Requirements/Limits

ELLA TABS 2 MP

levonorgestrel (emergencyoc) tabs 1 MP

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

2 MP

Progestin Contraceptives - IUD

KYLEENA IUD 2 MP

LILETTA IUD 2 MP

MIRENA IUD 2 SP; MP

SKYLA IUD 2 MP

Progestin Contraceptives - Implants

NEXPLANON IMPL 2 MP

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

2

MP

DEPO-PROVERA CONTRACEPTIVE SUSY (medroxyprogesteroneacetate (contraceptive))

2

MP

DEPO-SUBQ PROVERA 104 SUSY 2 MP

medroxyprogesteroneacetate (contraceptive) susp

1 MP

medroxyprogesteroneacetate (contraceptive) susy

1 MP

Progestin Contraceptives - Oral norethindrone (contraceptive) tabs 1 MP

ORTHO MICRONOR TABS (norethindrone (contraceptive))

2 MP

SLYND TABS 2

CORTICOSTEROIDS - Steroid Hormone Drugs toTreat Systemic Swelling Conditions


85

Drug Name DrugTier

Requirements/Limits

Glucocorticosteroids BETAMETHASONE COMBO SUSP 2

betamethasone sod phosphate & acetate susp 1

BETAMETHASONE SODIUM PHOSPHATE/BETAMETHASONE ACETATE SUSP

2

budesonide cpep 1

budesonide tb24 1

CELESTONE-SOLUSPAN SUSP (betamethasone sod phosphate & acetate)

NF

CORTEF TABS (hydrocortisone) NF

CORTISONE ACETATE TABS 2

DEPO-MEDROL SUSP 20 MG/ML 2 PA

DEPO-MEDROL SUSP 40 MG/ML, 80 MG/ML(methylprednisolone acetate)

NF

DERMACINRX CINLONE-I CPI KIT 2

dexamethasone elix 0.5 mg/5ml 1

DEXAMETHASONE INTENSOL CONC 2

DEXAMETHASONE SODIUM PHOSPHATE SOLN IJ 10 MG/ML

2 PA

DEXAMETHASONE SODIUM PHOSPHATE SOLN IJ 10 MG/ML(dexamethasone sodium phosphate)

2

PA

dexamethasone sodium phosphate soln ij 10 mg/ml,100 mg/10ml

1 PA

dexamethasone sodium phosphate soln ij 4 mg/ml,20 mg/5ml, 120 mg/30ml

1 PA; QL(150 mlper 30 daysretail)

Drug Name DrugTier

Requirements/Limits

DEXAMETHASONE SODIUM PHOSPHATE SOSY IJ 10 MG/ML

2 PA

DEXAMETHASONE SOLN 0.5 MG/5ML 2 PA

dexamethasone tabs 0.75 mg, 0.5 mg, 4 mg, 6 mg,1.5 mg

1

DEXAMETHASONE TABS 1 MG, 2 MG 2

dexamethasone tbpk 1.5 mg NP PA

DXEVO 11-DAY TBPK NP PA

EMFLAZA SUSP NP PA

EMFLAZA TABS NP PA

ENTOCORT EC CPEP (budesonide) NF

hydrocortisone tabs 1

KENALOG-10 SUSP 2 PA

KENALOG-40 SUSP (triamcinolone acetonide) NF

KENALOG-80 SUSP 2 PA

MEDROL DOSEPAK TBPK (methylprednisolone) NF

MEDROL TABS 2 MG NP PA

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

NF

methylprednisolone acetatesusp 40 mg/ml, 80 mg/ml 1

METHYLPREDNISOLONE ACETATE SUSP 40 MG/ML, 80 MG/ML

2

methylprednisolone sodsucc solr 1

methylprednisolone tabs 1

methylprednisolone tbpk 1

MILLIPRED DP TBPK NP PA


86

Drug Name DrugTier

Requirements/Limits

MILLIPRED SOLN 10 MG/5ML (prednisolonesodium phosphate)

NF

MILLIPRED TABS 5 MG NP PA

ORAPRED ODT TBDP (prednisolone sodiumphosphate)

NF

PEDIAPRED SOLN (prednisolone sodiumphosphate)

NF

prednisolone sodiumphosphate soln or 15mg/5ml


prednisolone sodiumphosphate soln or 20mg/5ml


PREDNISOLONE SODIUM PHOSPHATE SOLN OR 25 MG/5ML

2

prednisolone sodiumphosphate soln or 5mg/5ml, 10 mg/5ml

1

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

1

PREDNISOLONE SOLN 2

prednisolone syrp 1

PREDNISONE INTENSOL CONC 2

PREDNISONE SOLN 5 MG/5ML 2

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

1

prednisone tbpk 5 mg, 10 mg 1

RAYOS TBEC NP PA

SOLU-CORTEF SOLR 100 MG 2

SOLU-CORTEF SOLR 250 MG, 500 MG, 1000 MG 2 PA

SOLU-MEDROL SOLR 2 GM NP PA

Drug Name DrugTier

Requirements/Limits

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

NF

TAPERDEX 12-DAY TBPK NP PA

TAPERDEX 7-DAY TBPK NP PA

TRIAMCINOLONE ACETONIDE SUSP 2

triamcinolone acetonide susp 1

UCERIS TB24 OR 9 MG (budesonide) NF

VERIPRED 20 SOLN (prednisolone sodiumphosphate)


ZILRETTA SRER 2 PA

Mineralocorticoids

fludrocortisone acetate tabs 1 MP

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

Antitussives

benzonatate caps 100 mg 1 AL(At least 10yrs old)

benzonatate caps 200 mg 1


dextromethorphan hbr liqd 1

hydrocodone w/homatropine syrp 1

TESSALON PERLES CAPS (benzonatate) NF AL(At least 10

yrs old) Cough/Cold/Allergy Combinations

BIO-DTUSS DMX LIQD 2

CLARITIN-D 12 HOUR TB12 (loratadine & pseudoephedrine)

NF QL(2 ea daily)


87

Drug Name DrugTier

Requirements/Limits

CLARITIN-D 24 HOUR TB24 (loratadine & pseudoephedrine)

NF QL(1 ea daily)

DECON-A ELIX 2

dextromethorphan-guaifenesin syrp 1 QL(240 ml per

fill retail) loratadine & pseudoephedrine tb12 5mg-120 mg

1 QL(2 ea daily)

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

1

QL(1 ea daily)

promethazine &phenylephrine soln 1


promethazine w/codeinesoln 1


promethazine w/codeine syrp 1


promethazine-dm syrp 1 QL(240 ml perfill retail)

promethazine-phenylephrine-codeine syrp

1 AL(At least 6yrs old)

PROMETHAZINE/DEXTROMETHORPHAN SOLN 2 QL(240 ml per

fill retail)

PROMETHAZINE/PHENYLEPHRINE SYRP 2


PROMETHAZINE/PHENYLEPHRINE/CODEINE SYRP 2 AL(At least 6

yrs old) pseudoephed-bromphen-dm syrp 1 QL(240 ml per

fill retail) ROBITUSSIN PEAK COLD DM SYRP (dextromethorphan-guaifenesin)

NF

QL(240 ml perfill retail)

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


Drug Name DrugTier

Requirements/Limits

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


guaifenesin syrp 100mg/5ml, 200 mg/10ml 1 QL(240 ml per

6 days retail) guaifenesin tabs 200 mg,400 mg 1

guaifenesin tb12 600 mg,1200 mg 1

MUCINEX MAXIMUM STRENGTH TB12 (guaifenesin)

NF

MUCINEX TB12 (guaifenesin) NF

Misc. Respiratory Inhalants sodium chloride (inhalant) aers 1 QL(240 ml per

fill retail) sodium chloride (inhalant)nebu 1

Mucolytics

acetylcysteine soln 1

DERMATOLOGICALS - Drugs to Treat SkinConditions

Acne Products

ABSORICA CAPS 10 MG, 20 MG, 40 MG NP


ABSORICA CAPS 25 MG, 30 MG, 35 MG NP PA

ABSORICA LD CAPS NP PA

ACANYA GEL (clindamycinphosphate-benzoylperoxide)

NF PA

adapalene crea 0.1 % 1 PA

adapalene gel 0.3 % 1 PA

ADAPALENE LOTN 0.1 % 2 PA

AZELEX CREA 2 PA

benzoyl peroxide liqd 1 RX/OTC


88

Drug Name DrugTier

Requirements/Limits

CLEOCIN-T GEL (clindamycin phosphate(topical))


CLEOCIN-T LOTN (clindamycin phosphate(topical))

NF

CLEOCIN-T SOLN (clindamycin phosphate(topical))

NF

clindamycin phosphate(topical) gel 1 QL(60 ml per

fill retail) clindamycin phosphate(topical) lotn 1

clindamycin phosphate(topical) soln 1

clindamycin phosphate-benzoyl peroxide gel 1.2%-2.5 %

1 PA

DIFFERIN CREA 0.1 % (adapalene) NF PA

DIFFERIN GEL 0.3 % (adapalene) NF PA

DIFFERIN LOTN 0.1 % 2 PA

ERYGEL GEL (erythromycin (acne aid)) NF

erythromycin (acne aid) gel 1

erythromycin (acne aid)soln 1

isotretinoin caps 10 mg, 20mg, 40 mg 1


isotretinoin caps 30 mg 1 PA

KLARON LOTN (sulfacetamide sodium (acne))


RETIN-A CREA (tretinoin) NF

QL(45 gm perfill retail);AL(Up to 35 yrsold )

RETIN-A GEL (tretinoin) NF


Drug Name DrugTier

Requirements/Limits

SODIUM SULFACETAMIDE/SULFUR LOTN

2 QL(60 gm perfill retail)

SODIUM SULFACETAMIDE/SULFUR SUSP

2

sulfacetamide sodium (acne) lotn 1 QL(120 ml per

fill retail)

tretinoin crea 1


tretinoin gel 1


Agents for External Genital and Perianal Warts

VEREGEN OINT NP PA

Analgesics - Topical ACTIVE-TRAMADOL KIT CREA 2 PA

Anti-inflammatory Agents - Topical diclofenac sodium (topical)gel 1 QL(6.68 gm

daily) VOLTAREN GEL (diclofenac sodium (topical))

NF QL(6.68 gmdaily)

Antibiotics - Topical ALTABAX OINT 2 PA

BACIGUENT OINT (bacitracin (topical)) NF

bacitracin (topical) oint 1

bacitracin zinc oint 1

bacitracin-polymyxin b oint 1

BACTROBAN CREA (mupirocin calcium(topical))

NP PA

CENTANY AT KIT NP PA

CENTANY OINT NP PA


89

Drug Name DrugTier

Requirements/Limits

CORTISPORIN CREA NP

CORTISPORIN OINT NP

gentamicin sulfate (topical) crea 1

gentamicin sulfate (topical)oint 1

mupirocin calcium (topical) crea NP PA

MUPIROCIN CREA NP PA

mupirocin oint 1

NEO-SYNALAR CREA NP

NEO-SYNALAR KIT KIT NP

POLYSPORIN OINT (bacitracin-polymyxin b) NF

Antifungals - Topical butenafine hcl crea NP RX/OTC

CICLODAN CREAM KIT KIT NP PA

CICLODAN SOLUTION KIT KIT NP PA

ciclopirox gel 0.77 % NP

ciclopirox olamine crea 1

ciclopirox olamine susp 1

ciclopirox sham 1 % 1

ciclopirox soln 8 % NP PA

CICLOPIROX TREATMENT KIT NP PA

clotrimazole (topical) crea 1 QL(45 gm perfill retail);RX/OTC

clotrimazole (topical) soln 1 QL(30 ml perfill retail);RX/OTC

clotrimazole w/betamethasone crea 1

Drug Name DrugTier

Requirements/Limits

clotrimazole w/betamethasone lotn 1

DERMACINRX THERAZOLE PAK THPK NP PA

econazole nitrate crea NP

ERTACZO CREA NP PA

EXELDERM CREA NP

EXELDERM SOLN NP

EXTINA FOAM (ketoconazole (topical)) NP PA

JUBLIA SOLN NP

PA; Limit 8ml permonth;QL(0.267 ml daily)

KERYDIN SOLN NP PA

ketoconazole (topical) crea 1

ketoconazole (topical) foam NP PA

ketoconazole (topical)sham 1 QL(120 ml per

fill retail) LOPROX CREA (ciclopiroxolamine) NF

LOPROX KIT NP PA

LOPROX KIT KIT NP PA

LOPROX SHAMPOO SHAM (ciclopirox) NF

LOPROX SUSP (ciclopiroxolamine) NF

LOTRIMIN AF CREA (clotrimazole (topical)) NF

QL(45 gm perfill retail);RX/OTC

LOTRIMIN AF JOCK ITCH CREA (clotrimazole (topical))

NF QL(45 gm perfill retail);RX/OTC

LOTRIMIN ULTRA CREA (butenafine hcl) NP RX/OTC

LOTRISONE CREA (clotrimazole w/betamethasone)

NF


90

Drug Name DrugTier

Requirements/Limits

LULICONAZOLE CREA NP PA

LUZU CREA NP PA

MENTAX CREA NP RX/OTC

MICATIN CREA (miconazole nitrate (topical))

NF

miconazole nitrate (topical) aerp 1 PA

miconazole nitrate (topical) crea 1

MICONAZOLE NITRATE/ZINCOXIDE/WHITEPETROLATUM OINT

NP

PA

naftifine hcl crea 1 % NP

naftifine hcl crea 2 % NP PA

naftifine hcl gel 1 % NP PA

NAFTIN CREA 2 % (naftifine hcl) NP PA

NAFTIN GEL 1 % NP PA

NAFTIN GEL 1 % (naftifine hcl) NP PA

NAFTIN GEL 2 % NP

NIZORAL SHAM (ketoconazole (topical)) NF QL(120 ml per

fill retail)

nystatin (topical) crea 1

nystatin (topical) oint 1

nystatin (topical) powd 1

nystatin-triamcinolone crea 1

nystatin-triamcinolone oint 1

oxiconazole nitrate crea NP PA

OXISTAT CREA (oxiconazole nitrate) NP PA

OXISTAT LOTN NP

Drug Name DrugTier

Requirements/Limits

PENLAC NAIL LACQUER SOLN (ciclopirox) NP PA

SULCONAZOLE NITRATE CREA NP

SULCONAZOLE NITRATE SOLN NP

TINACTIN CREA (tolnaftate) NF

tolnaftate crea 1

VUSION OINT NP PA

Antineoplastic or Premalignant Lesion Agents -AMELUZ GEL 2 PA

CARAC CREA NP PA; QL(30 gmper fill retail)

diclofenac sodium (actinickeratoses) gel 1 PA

EFUDEX CREA (fluorouracil (topical)) NF QL(40 gm per

fill retail)

fluorouracil (topical) crea 1 QL(40 gm perfill retail)

FLUOROURACIL CREA 0.5 % NP PA; QL(30 gm

per fill retail) FLUOROURACIL SOLN 2 %, 5 % 2 PA; QL(10 ml

per fill retail) LEVULAN KERASTICK SOLR 2 PA

PANRETIN GEL 2 PA

PICATO GEL 2 PA

TARGRETIN GEL EX 1 % 2 PA

TOLAK CREA 2 PA

VALCHLOR GEL 2 PA

Antipruritics - Topical DOXEPIN HYDROCHLORIDE CREA 2 PA

PRUDOXIN CREA 2 PA

ZONALON CREA 2 PA


91

Drug Name DrugTier

Requirements/Limits

Antipsoriatics

acitretin caps 1

calcipotriene crea 1 QL(60 gm perfill retail)

CALCIPOTRIENE FOAM NP PA

calcipotriene oint 1

calcipotriene soln 1 QL(60 ml perfill retail)

CALCITRIOL OINT EX 3 MCG/GM NP

COSENTYX SENSOREADY PEN SOAJ NP PA; SP

COSENTYX SOSY NP PA; SP

DOVONEX CREA (calcipotriene) NF QL(60 gm per

fill retail)

ILUMYA SOSY NP PA

methoxsalen rapid caps NP PA

OXSORALEN ULTRA CAPS (methoxsalen rapid) NP PA

SILIQ SOSY NP PA

SKYRIZI PSKT NP PA

SORIATANE CAPS (acitretin) NF

SORILUX FOAM NP PA

STELARA SOLN SC 45 MG/0.5ML NP PA

STELARA SOSY SC 90 MG/ML, 45 MG/0.5ML NP PA; SP

TALTZ SOAJ NP PA

TALTZ SOSY NP PA

tazarotene crea NP PA; AL(Up to21 yrs old )

TAZORAC CREA 0.05 % NP AL(Up to 21 yrsold )

TAZORAC CREA 0.1 % (tazarotene) NP PA; AL(Up to

21 yrs old )

Drug Name DrugTier

Requirements/Limits

TAZORAC GEL 0.05 %, 0.1 % NP AL(Up to 21 yrs

old )

TREMFYA SOPN NP PA

TREMFYA SOSY NP PA

VECTICAL OINT NP

Antiseborrheic Products OVACE PLUS WASH LIQD (sulfacetamide sodium) NF

OVACE WASH LIQD (sulfacetamide sodium) NF

selenium sulfide lotn 1 QL(120 ml perfill retail)

sulfacetamide sodium liqd ex 1

Antivirals - Topical acyclovir topical crea NP PA

acyclovir topical oint NP PA; QL(30 gmper 30 daysretail)

DENAVIR CREA NP PA

XERESE CREA NP PA

ZOVIRAX CREA EX 5 % (acyclovir topical) NP PA

ZOVIRAX OINT EX 5 % (acyclovir topical) NP

PA; QL(30 gmper 30 daysretail)

Burn Products

mafenide acetate pack 1 PA

SILVADENE CREA (silver sulfadiazine) NF

silver sulfadiazine crea 1

SULFAMYLON CREA 85 MG/GM 2 PA

SULFAMYLON PACK 5 % (mafenide acetate) NF PA

Corticosteroids - Topical alclometasone dipropionate crea 1 PA


92

Drug Name DrugTier

Requirements/Limits

alclometasone dipropionateoint 1 PA

AMCINONIDE CREA NP PA

AMCINONIDE LOTN NP PA

AMCINONIDE OINT NP PA

APEXICON E CREA NP PA

AUGMENTED BETAMETHASONE DIPROPIONATE GEL

NP PA

BESER KIT NP PA

betamethasone dipropionate (topical) crea NP PA

betamethasone dipropionate (topical) lotn 1

betamethasone dipropionate (topical) oint NP PA

betamethasone dipropionate augmented crea

NP PA

betamethasone dipropionate augmentedgel

NP PA

betamethasone dipropionate augmentedlotn

NP PA

betamethasone dipropionate augmentedoint

NP PA

betamethasone valerate crea 0.1 % 1

betamethasone valerate foam 0.12 % NP PA

betamethasone valerate lotn 0.1 % 1 QL(60 ml per

fill retail) betamethasone valerate oint 0.1 % 1

BRYHALI LOTN NP PA

calcipotriene-betamethasone dipropionate oint

1

Drug Name DrugTier

Requirements/Limits

CALCIPOTRIENE/BETAMETHASONE DIPROPIONATE SUSP

NP PA

CAPEX SHAM NP PA

clobetasol propionate crea 1

clobetasol propionateemollient base crea NP PA

clobetasol propionateemulsion foam NP PA

clobetasol propionate foam NP PA

clobetasol propionate gel 1

clobetasol propionate liqd NP PA

clobetasol propionate lotn NP PA

clobetasol propionate oint 1

clobetasol propionate sham NP PA

clobetasol propionate soln 1

CLOBEX LIQD (clobetasol propionate) NP PA

CLOBEX LOTN (clobetasol propionate) NP PA

CLOBEX SHAM (clobetasol propionate) NP PA

CLOCORTOLONE PIVALATE CREA NP PA

CLOCORTOLONE PIVALATE PUMP CREA NP PA

CLODAN KIT KIT NP PA

CLODERM CREA NP PA

CLODERM PUMP CREA NP PA

CORDRAN CREA 0.05 % (flurandrenolide) NP PA

CORDRAN LOTN 0.05 % (flurandrenolide) NP PA

CORDRAN OINT 0.05 % (flurandrenolide) NP PA


93

Drug Name DrugTier

Requirements/Limits

CORDRAN TAPE 4 MCG/SQCM NP PA

CUTIVATE LOTN (fluticasone propionate) NP PA

DERMA-SMOOTHE/FSBODY OIL (fluocinolone acetonide)

NP PA

DERMA-SMOOTHE/FSSCALP OIL (fluocinolone acetonide)

NP PA

DERMASORB HC KIT NP PA

DERMASORB TA KIT NP PA

desonide crea 1 PA

desonide lotn 1 PA

desonide oint 1 PA

DESOWEN CREA (desonide) NF PA

DESOWEN LOTN (desonide) NF PA

DESOXIMETASONE CREA 0.05 % NP PA

desoximetasone crea 0.05 %, 0.25 % NP PA

desoximetasone gel 0.05% NP PA

desoximetasone liqd 0.25% NP PA

desoximetasone oint 0.05 %, 0.25 % NP PA

DIFLORASONE DIACETATE CREA NP PA

diflorasone diacetate oint NP PA

DIPROLENE AF CREA (betamethasone dipropionate augmented)

NP PA

DIPROLENE OINT (betamethasone dipropionate augmented)

NP PA

DUOBRII LOTN NP PA

Drug Name DrugTier

Requirements/Limits

ELOCON CREA (mometasone furoate) NF

ELOCON OINT (mometasone furoate) NF

ENSTILAR FOAM NP PA

EPIFOAM FOAM 2

fluocinolone acetonide crea NP PA

fluocinolone acetonide oil NP PA

fluocinolone acetonide oint NP PA

fluocinolone acetonide soln NP PA

fluocinonide crea NP PA

fluocinonide emulsified base crea NP PA

fluocinonide gel NP PA

fluocinonide oint NP PA

fluocinonide soln NP PA

flurandrenolide crea NP PA

flurandrenolide lotn NP PA

flurandrenolide oint NP PA

fluticasone propionate crea0.05 % 1

fluticasone propionate lotn0.05 % NP PA

fluticasone propionate oint0.005 % 1

HALAC KIT NP PA

halcinonide crea NP PA

halobetasol propionate crea 1

HALOBETASOL PROPIONATE FOAM NP PA

halobetasol propionate oint 1


94

Drug Name DrugTier

Requirements/Limits

HALOG CREA (halcinonide) NP PA

HALOG OINT NP PA

hydrocortisone (topical)crea 0.5 %, 2.5 % 1

hydrocortisone (topical)crea 1 % 1 RX/OTC

hydrocortisone (topical)lotn 1 %, 2.5 % 1

hydrocortisone (topical)oint 0.5 %, 2.5 % 1

hydrocortisone (topical)oint 1 % 1 RX/OTC

hydrocortisone butyrate crea NP PA

hydrocortisone butyratehydrophilic lipo base crea NP PA

hydrocortisone butyratelotn NP PA

hydrocortisone butyrateoint NP PA

hydrocortisone butyratesoln NP PA

hydrocortisone valerate crea NP PA

hydrocortisone valerateoint NP PA

KENALOG AERS (triamcinolone acetonide (topical))

NP PA

LEXETTE FOAM NP PA

LOCOID CREA (hydrocortisone butyrate) NP PA

LOCOID LIPOCREAM CREA (hydrocortisonebutyrate hydrophilic lipobase)

NP

PA

LOCOID LOTN (hydrocortisone butyrate) NP PA

LOCOID OINT (hydrocortisone butyrate) NP PA

LOCOID SOLN (hydrocortisone butyrate) NP PA

Drug Name DrugTier

Requirements/Limits

LUXIQ FOAM (betamethasone valerate) NP PA

mometasone furoate crea 1

mometasone furoate oint 1

mometasone furoate soln 1

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

NF RX/OTC

OLUX FOAM (clobetasol propionate) NP PA

OLUX-E FOAM (clobetasol propionate emulsion) NP PA

PANDEL CREA NP PA

PREDNICARBATE CREA NP PA

PREDNICARBATE OINT NP PA

PSORCON CREA NP PA

SERNIVO EMUL NP PA

SYNALAR CREA (fluocinolone acetonide) NP PA

SYNALAR CREAM KIT KIT NP PA

SYNALAR OINT (fluocinolone acetonide) NP PA

SYNALAR OINTMENT KIT KIT NP PA

SYNALAR SOLN (fluocinolone acetonide) NP PA

SYNALAR TS KIT NP PA

TACLONEX OINT (calcipotriene-betamethasone dipropionate)

NF

TACLONEX SUSP NP PA

TEMOVATE CREA (clobetasol propionate) NF

TEMOVATE OINT (clobetasol propionate) NF


95

Drug Name DrugTier

Requirements/Limits

TOPICORT CREA (desoximetasone) NP PA

TOPICORT GEL (desoximetasone) NP PA

TOPICORT LIQD (desoximetasone) NP PA

TOPICORT OINT (desoximetasone) NP PA

TOVET KIT KIT NP PA

triamcinolone acetonide (topical) aers 0.147 mg/gm NP PA

triamcinolone acetonide (topical) crea 0.025 % 1 QL(454 gm per

fill retail) triamcinolone acetonide (topical) crea 0.1 % 1

triamcinolone acetonide (topical) crea 0.5 % 1 QL(15 gm per

fill retail) triamcinolone acetonide (topical) lotn 0.025 %, 0.1%


triamcinolone acetonide (topical) oint 0.025 %, 0.1%

1

triamcinolone acetonide (topical) oint 0.05 % NP PA

triamcinolone acetonide (topical) oint 0.5 % 1 QL(15 gm per

fill retail)

TRIANEX OINT NP PA

TRIDESILON CREA (desonide) NF PA

ULTRAVATE CREA (halobetasol propionate) NF

ULTRAVATE LOTN NP PA

ULTRAVATE OINT (halobetasol propionate) NF

VANOS CREA (fluocinonide) NP PA

Eczema Agents DUPIXENT SOSY 200 MG/1.14ML NP PA

DUPIXENT SOSY 300 MG/2ML NP PA; SP

Emollient/Keratolytic Agents

Drug Name DrugTier

Requirements/Limits

urea crea 1 QL(200 gm perfill retail);RX/OTC

urea lotn 1 QL(325 ml perfill retail)

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

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

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

NF RX/OTC

lactic acid (ammoniumlactate) crea 1 RX/OTC

lactic acid (ammoniumlactate) lotn 1 RX/OTC

PETROLATUM OINT 2

vitamins a & d (topical) oint 1

Enzymes - Topical SANTYL OINT NP PA

Immunomodulating Agents - Topical ALDARA CREA (imiquimod) NF QL(48 ea per

180 days retail)

imiquimod crea 1 QL(48 ea per180 days retail)

IMIQUIMOD PUMP CREA NP PA

ZYCLARA CREA NP PA

ZYCLARA PUMP CREA 2.5 %, 3.75 % NP PA

Immunosuppressive Agents - Topical

ELIDEL CREA (pimecrolimus) 2

PA; QL(30 gmper 30 daysretail)

pimecrolimus crea 1 PA; QL(30 gmper 30 daysretail)

PROTOPIC OINT (tacrolimus (topical)) NP PA

tacrolimus (topical) oint NP PA


96

Drug Name DrugTier

Requirements/Limits

Keratolytic/Antimitotic Agents KERALYT GEL (salicylicacid) NF QL(240 gm per

fill retail)

podofilox soln 1 QL(4 ml per fillretail)

salicylic acid gel 1 QL(240 gm perfill retail)

Local Anesthetics - Topical LIDOCAINE AND TETRACAINECREAM CREA

2 PA

lidocaine hcl crea ex 3 % 1 RX/OTC

lidocaine hcl gel ex 2 % 1 QL(30 ml perfill retail)

LIDOCAINE HCL JELLY GEL 1 QL(30 ml per

fill retail)

lidocaine hcl prsy ex 2 % 1 QL(30 ml perfill retail)

lidocaine-prilocaine crea 1

PLIAGLIS CREA 2 PA

SYNERA PTCH 2 PA

Misc. Topical DRYSOL SOLN 2

Phosphodiesterase 4 (PDE4) Inhibitors - Topical EUCRISA OINT NP PA

Rosacea Agents

azelaic acid gel 1

DOXYCYCLINE CPDR NP PA

FINACEA FOAM 2

FINACEA GEL (azelaic acid) 2

ivermectin (rosacea) crea NP PA

METROCREAM CREA (metronidazole (topical)) NF QL(45 gm per

fill retail) METROGEL GEL (metronidazole (topical)) NF

Drug Name DrugTier

Requirements/Limits

METROLOTION LOTN (metronidazole (topical)) NF

metronidazole (topical)crea 0.75 % 1 QL(45 gm per

fill retail) metronidazole (topical) gel0.75 % 1 QL(45 gm per

fill retail) metronidazole (topical) gel1 % 1

metronidazole (topical) lotn0.75 % 1

MIRVASO GEL NP PA

NORITATE CREA NP PA

ORACEA CPDR NP PA

RHOFADE CREA NP PA

ROSADAN KIT KIT NP PA

SOOLANTRA CREA (ivermectin (rosacea)) NP PA

Scabicides & Pediculicides

CROTAN LOTN 2

ELIMITE CREA (permethrin) NF

EURAX CREA 2 QL(60 gm perfill retail)

EURAX LOTN NF

LINDANE SHAM NP

malathion lotn NP

PA; QL(59 mlper fillretail,118 ml per 30 daysretail)

NATROBA SUSP NP

PA; QL(120 mlper fillretail,240 ml per 30 daysretail); AL(Atleast 1 yrs old)

NIX CREME RINSE LIQD (permethrin) NF


97

Drug Name DrugTier

Requirements/Limits

OVIDE LOTN (malathion) NP

PA; QL(59 mlper fillretail,118 ml per 30 daysretail)

permethrin crea 1

permethrin liqd 1

permethrin lotn 1

pyrethrins-piperonylbutoxide liqd 1

pyrethrins-piperonylbutoxide sham 1

RID LIQD (pyrethrins-piperonyl butoxide) NF

SKLICE LOTN 2

SPINOSAD SUSP NP

QL(120 ml perfill retail,240 ml per 30 daysretail); AL(Atleast 1 yrs old)

ULESFIA LOTN 2 PA

VANALICE GEL 2

Wound Care Products

REGRANEX GEL 2 PA

DIAGNOSTIC PRODUCTS

Diagnostic Tests

CHEMSTRIP-K STRP 1

KETONE STRP 1

KETONE TEST STRIPS STRP 1

KETOSTIX STRP 1

Drug Name DrugTier

Requirements/Limits

TRUE METRIX BLOOD GLUCOSETEST STRIPS STRP

1

INSULIN USERS LIMITED TO 150 PER 30 DAYS, NON-INSULIN USERS LIMITED TO 100 PER 90 DAYS;QL(5 eadaily); RX/OTC

TRUE METRIX SELF MONITORING BLOOD GLUCOSE STRIPS STRP

1


TRUETRACK BLOOD GLUCOSE TEST STRP 1


TRUETRACK TEST STRP 1


DIGESTIVE AIDS - Drugs to Treat Low DigestiveEnzymes

Digestive Enzymes

CREON CPEP 2 MP


98

Drug Name DrugTier

Requirements/Limits

PANCREAZE CPEP NP

PERTZYE CPEP NP

VIOKACE TABS NP

ZENPEP CPEP 2 MP

DIURETICS - Drugs to Treat Heart, CirculationConditions and Blood Pressure

Carbonic Anhydrase Inhibitors

acetazolamide cp12 1 MP

acetazolamide sodium solr 1 PA

acetazolamide tabs 1 MP

KEVEYIS TABS NP

methazolamide tabs 1 MP

NEPTAZANE TABS (methazolamide) NF MP

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

NF MP

ALDACTAZIDE TABS 50 MG-50 MG NP

amiloride & hydrochlorothiazide tabs 1 MP

DYAZIDE CAPS (triamterene & hydrochlorothiazide)


MAXZIDE TABS (triamterene & hydrochlorothiazide)


MAXZIDE-25 TABS (triamterene & hydrochlorothiazide)


spironolactone &hydrochlorothiazide tabs 1 MP

triamterene & hydrochlorothiazide caps 1 QL(1 ea daily);

MP triamterene & hydrochlorothiazide tabs 1 QL(1 ea daily);

MP

Drug Name DrugTier

Requirements/Limits

Loop Diuretics bumetanide soln ij 0.25mg/ml 1 PA

bumetanide tabs or 0.5 mg,1 mg, 2 mg 1 MP

BUMEX TABS (bumetanide) NF MP

DEMADEX TABS (torsemide) NF QL(1 ea daily);

MP EDECRIN TABS (ethacrynic acid) NF MP

ethacrynate sodium solr 1 PA

ethacrynic acid tabs 1 MP

furosemide soln ij 10 mg/ml 1 PA

furosemide soln or 10 mg/ml 1 MP

FUROSEMIDE SOLN OR 8 MG/ML 2 MP

furosemide tabs or 20 mg,40 mg, 80 mg 1 MP

LASIX TABS (furosemide) NF MP

SODIUM EDECRIN SOLR (ethacrynate sodium) NF PA

torsemide tabs 1 QL(1 ea daily);MP

Potassium Sparing Diuretics ALDACTONE TABS (spironolactone) NF MP

amiloride hcl tabs 1 QL(4 ea daily);MP

CAROSPIR SUSP NP

DYRENIUM CAPS (triamterene) NP

spironolactone tabs 1 MP

triamterene caps NP

Thiazides and Thiazide-Like Diuretics

chlorothiazide sodium solr 1 PA


99

Drug Name DrugTier

Requirements/Limits

CHLOROTHIAZIDE TABS 250 MG 2 QL(2 ea daily);

MP CHLOROTHIAZIDE TABS 500 MG 2 QL(4 ea daily);

MP

chlorothiazide tabs 500 mg 1 QL(4 ea daily);MP

chlorthalidone tabs 1 MP

DIURIL SUSP NP

hydrochlorothiazide caps 1 MP

hydrochlorothiazide tabs 1 MP

indapamide tabs 1 MP

METHYCLOTHIAZIDE TABS 2 MP

metolazone tabs 1 MP

MICROZIDE CAPS (hydrochlorothiazide) NF MP

SODIUM DIURIL SOLR (chlorothiazide sodium) NF PA

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

Bone Density Regulators ACTONEL TABS 30 MG (risedronate sodium) NP PA; QL(1 ea

daily) ACTONEL TABS 35 MG, 150 MG (risedronate sodium)

NP PA

ACTONEL TABS 5 MG (risedronate sodium) NP PA; QL(1 ea

daily); MP ALENDRONATE SODIUM SOLN 70 MG/75ML 2 QL(10.8 ml

daily); MP alendronate sodium tabs 35 mg, 70 mg 1 QL(0.15 ea

daily); MP alendronate sodium tabs 5 mg, 10 mg 1 QL(1 ea daily);

MP ALENDRONATE SODIUM TABS 5 MG, 40 MG 2 QL(1 ea daily);

MP

ATELVIA TBEC (risedronate sodium) NP

PA; QL(4 eaper 28 daysretail); MP

Drug Name DrugTier

Requirements/Limits

BINOSTO TBEF NP PA

BONIVA SOLN IV 3 MG/3ML (ibandronate sodium)

NP PA

BONIVA TABS OR 150 MG (ibandronate sodium) NF MP

calcitonin (salmon) soln 1

Limit 2 permonth;QL(7 mlper 30 daysretail); MP

ETIDRONATE DISODIUM TABS NP

FORTEO SOLN 2

PA; Limit 2 permonth;QL(0.14ml daily); SP;MP

FOSAMAX PLUS D TABS NP PA

FOSAMAX TABS (alendronate sodium) NF QL(0.15 ea

daily); MP ibandronate sodium soln iv 3 mg/3ml NP PA

ibandronate sodium tabs or 150 mg 1 MP

MIACALCIN SOLN 2 PA; QL(2 mlper 30 daysretail)

NATPARA CART NP PA

pamidronate disodium soln30 mg/10ml, 90 mg/10ml NP PA

PAMIDRONATE DISODIUM SOLN 6 MG/ML

NP PA

PAMIDRONATE DISODIUM SOLR 30 MG, 90 MG

NP PA

PROLIA SOSY 2 PA

RECLAST SOLN (zoledronic acid) NF PA

risedronate sodium tabs 30 mg NP PA; QL(1 ea

daily) risedronate sodium tabs 35 mg, 150 mg NP PA


100

Drug Name DrugTier

Requirements/Limits

risedronate sodium tabs 5 mg NP PA; QL(1 ea

daily); MP

risedronate sodium tbec 35 mg NP

PA; QL(4 eaper 28 daysretail); MP

TYMLOS SOPN NP PA

XGEVA SOLN 2 PA; SP

zoledronic acid conc 4 mg/5ml 1 PA

ZOLEDRONIC ACID SOLN 4 MG/100ML 2 PA

zoledronic acid soln 5 mg/100ml 1 PA

ZOMETA CONC 4 MG/5ML (zoledronic acid) NF PA

ZOMETA SOLN 4 MG/100ML NP PA

Corticotropin

ACTHAR GEL 2 PA

Fertility Regulators CHORIONIC GONADOTROPIN SOLR 2 PA

NOVAREL SOLR 2 PA

PREGNYL W/DILUENTBENZYLALCOHOL/NACLSOLR

2 PA

GnRH/LHRH Antagonists

ORILISSA TABS 150 MG 2 PA

ORILISSA TABS 200 MG 2 PA; SP

Growth Hormone Receptor Antagonists

SOMAVERT SOLR 2 PA; SP

Growth Hormone Releasing Hormones (GHRH) EGRIFTA SOLR 2 PA

EGRIFTA SV SOLR 2 PA

Growth Hormones GENOTROPIN MINIQUICK SOLR 2 PA; SP

Drug Name DrugTier

Requirements/Limits

GENOTROPIN SOLR 2 PA; SP

HUMATROPE COMBO PACK SOLR NP PA

HUMATROPE SOLR NP PA

NORDITROPIN FLEXPRO SOLN 2 PA; SP

NUTROPIN AQ NUSPIN 10 SOLN NP PA



OMNITROPE SOLN 5 MG/1.5ML, 10 MG/1.5ML NP PA; SP

OMNITROPE SOLR 5.8 MG NP PA

SAIZEN CLICK.EASY SOLR NP PA

SAIZEN SOLR NP PA

SAIZENPREP RECONSTITUTIONKIT SOLR

NP PA

SEROSTIM SOLR NP PA

ZOMACTON SOLR 10 MG NP PA

ZOMACTON SOLR 5 MG NP PA; SP

ZORBTIVE SOLR NP PA

Hormone Receptor Modulators EVISTA TABS (raloxifene hcl) NF QL(1 ea daily);

MP

OSPHENA TABS NP PA

raloxifene hcl tabs 1 QL(1 ea daily);MP

Insulin-Like Growth Factors (Somatomedins) INCRELEX SOLN 2 PA; SP

LHRH/GnRH Agonist Analog Pituitary

LUPANETA PACK KIT 2 PA


101

Drug Name DrugTier

Requirements/Limits

LUPRON DEPOT-PED (1-MONTH) KIT 2 PA

LUPRON DEPOT-PED (3-MONTH) KIT 2 PA

SUPPRELIN LA KIT 2 PA

SYNAREL SOLN 2 PA

TRIPTODUR SRER 2 PA

Metabolic Modifiers

BRINEURA KIT CO

BUPHENYL POWD (sodium phenylbutyrate) NF PA

BUPHENYL TABS (sodium phenylbutyrate) NF PA

calcitriol caps or 0.25 mcg,0.5 mcg 1

calcitriol soln or 1 mcg/ml 1

CARBAGLU TABS 2 PA

CARNITOR SF SOLN (levocarnitine (metabolicmodifiers))

NF QL(30 ml daily)

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

NF QL(30 ml daily)

CARNITOR TABS 330 MG (levocarnitine (metabolicmodifiers))

NF QL(3 ea daily);RX/OTC

cinacalcet hcl tabs 1 PA; SP

CRYSVITA SOLN CO

CYSTADANE POWD 2 PA

doxercalciferol caps NP PA

GALAFOLD CAPS 2 PA

KUVAN PACK 2 PA; SP

KUVAN TBSO 2 PA; SP

levocarnitine (metabolicmodifiers) soln 1 gm/10ml 1 QL(30 ml daily)

Drug Name DrugTier

Requirements/Limits

levocarnitine (metabolicmodifiers) tabs 330 mg 1 QL(3 ea daily);

RX/OTC

nitisinone caps 1 PA

NITYR TABS 2 PA

ORFADIN CAPS 2 MG, 5 MG, 10 MG (nitisinone) NF PA

ORFADIN CAPS 20 MG 2 PA

ORFADIN SUSP 4 MG/ML 2 PA

PALYNZIQ SOSY CO

paricalcitol caps NP PA

RAVICTI LIQD NP PA

RAYALDEE CPCR NP PA

REVCOVI SOLN CO

ROCALTROL CAPS (calcitriol) NF

ROCALTROL SOLN (calcitriol) NF

SENSIPAR TABS (cinacalcet hcl) NF PA; SP

sodium phenylbutyratepowd 1 PA

sodium phenylbutyrate tabs 1 PA

ZEMPLAR CAPS (paricalcitol) NP PA

Posterior Pituitary Hormones DDAVP SOLN IJ 4 MCG/ML (desmopressin acetate)

NF PA

DDAVP SOLN NA 0.01 % NP PA; QL(5 mlper fill retail)

DDAVP SOLN NA 0.01 % (desmopressin acetate spray)

NF QL(5 ml per fillretail)

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

NF QL(6 ea daily)


102

Drug Name DrugTier

Requirements/Limits

desmopressin acetate solnij 4 mcg/ml 1 PA

desmopressin acetatespray refrigerated soln 1 QL(5 ml per fill

retail) desmopressin acetatespray soln 1 QL(5 ml per fill

retail) desmopressin acetate tabsor 0.1 mg, 0.2 mg 1 QL(6 ea daily)

NOCDURNA SUBL NP PA

NOCTIVA EMUL NP PA

STIMATE SOLN NP PA

VASOSTRICT SOLN 2 PA

Prolactin Inhibitors

cabergoline tabs 1

Somatostatic Agents OCTREOTIDE ACETATE SOLN 200 MCG/ML, 1000MCG/ML (octreotide acetate)

NF

PA; SP

octreotide acetate soln 50 mcg/ml, 100 mcg/ml, 200mcg/ml, 500 mcg/ml, 1000mcg/ml, 1000 mcg/5ml

1

PA; SP

SANDOSTATIN LAR DEPOT KIT 2 PA; SP

SANDOSTATIN SOLN (octreotide acetate) NF PA; SP

SOMATULINE DEPOT SOLN 2 PA; SP

Vasopressin Receptor Antagonists JYNARQUE TABS 15 MG, 30 MG 2 PA; SP

JYNARQUE TBPK NP PA

SAMSCA TABS 2 PA; SP

ESTROGENS - Hormone Replacement/ModifyingDrugs

Estrogen Combinations

Drug Name DrugTier

Requirements/Limits

ACTIVELLA TABS (estradiol & norethindrone acetate)


ANGELIQ TABS 2

BIJUVA CAPS NP

CLIMARA PRO PTWK 2

COMBIPATCH PTTW 2 QL(8 ea per 28days retail); MP

DUAVEE TABS 2 PA

estradiol & norethindrone acetate tabs 1 QL(1 ea daily);

MP FEMHRT LOW DOSE TABS (norethindrone acetate-ethinyl estradiol)

NF

norethindrone acetate-ethinyl estradiol tabs 1

PREFEST TABS NP

PREMPHASE TABS 2 QL(1 ea daily);MP

PREMPRO TABS 2 QL(1 ea daily);MP

Estrogens ALORA PTTW 0.025 MG/24HR, 0.075MG/24HR, 0.05 MG/24HR

NP PA; QL(0.29 eadaily); MP

ALORA PTTW 0.1 MG/24HR NP PA; QL(1 ea

daily); MP CLIMARA PTWK (estradiol) NF QL(4 ea per 28

days retail); MP DELESTROGEN OIL 10 MG/ML NP PA

DELESTROGEN OIL 20 MG/ML, 40 MG/ML(estradiol valerate)

NF

DEPO-ESTRADIOL OIL 2

DIVIGEL GEL 0.25 MG/0.25GM, 0.75MG/0.75GM, 0.5MG/0.5GM, 1 MG/GM

NP

ELESTRIN GEL NP


103

Drug Name DrugTier

Requirements/Limits

ESTRACE TABS OR 0.5 MG, 1 MG, 2 MG (estradiol)

NF MP

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

1

QL(0.29 eadaily); MP

estradiol pttw td 0.1mg/24hr 1 QL(1 ea daily);

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

1

QL(4 ea per 28days retail); MP

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

estradiol valerate oil 1

ESTROPIPATE TABS 2 QL(1 ea daily);MP

EVAMIST SOLN NP

MENEST TABS 2 MP

MENOSTAR PTWK NP

MINIVELLE PTTW 0.025 MG/24HR, 0.075MG/24HR, 0.05 MG/24HR(estradiol)

NP

PA; QL(0.29 eadaily); MP

MINIVELLE PTTW 0.0375 MG/24HR (estradiol) NF QL(0.29 ea

daily); MP MINIVELLE PTTW 0.1 MG/24HR (estradiol) NP PA; QL(1 ea

daily); MP PREMARIN SOLR IJ 25 MG NP PA

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

2 QL(1 ea daily);MP

VIVELLE-DOT PTTW 0.025 MG/24HR, 0.075MG/24HR, 0.05 MG/24HR(estradiol)

NP

PA; QL(0.29 eadaily); MP

VIVELLE-DOT PTTW 0.0375 MG/24HR(estradiol)

NF QL(0.29 eadaily); MP

VIVELLE-DOT PTTW 0.1 MG/24HR (estradiol) NP PA; QL(1 ea

daily); MP

Drug Name DrugTier

Requirements/Limits

FLUOROQUINOLONES - Drugs to Treat BacterialInfections

Fluoroquinolones AVELOX TABS (moxifloxacin hcl) NP PA

BAXDELA TABS OR 450 MG NP PA

CIPRO SUSR 5 GM/100ML NP PA

CIPRO SUSR 500 MG/5ML 2

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

CIPROFLOXACIN ER TB24 NP PA

CIPROFLOXACIN HCL TABS 100 MG 2 QL(6 ea per fill

retail) ciprofloxacin hcl tabs 250mg, 500 mg, 750 mg 1

ciprofloxacin susr or 500mg/5ml 1

LEVAQUIN TABS (levofloxacin) NF

QL(1 eadaily,14 ea perfill retail)

levofloxacin soln 25 mg/ml NP

levofloxacin tabs 250 mg,500 mg, 750 mg 1

QL(1 eadaily,14 ea perfill retail)

moxifloxacin hcl tabs NP PA

OFLOXACIN TABS 300 MG NP QL(56 ea per

fill retail)

ofloxacin tabs 400 mg NP QL(56 ea perfill retail)

GASTROINTESTINAL AGENTS - MISC. -Miscellaneous Gastrointestinal Drugs

5-HT4 Receptor Agonists

MOTEGRITY TABS NP PA

Agents for Chronic Idiopathic Constipation (CIC)

TRULANCE TABS NP PA; QL(1 eadaily)

Antiflatulents


104

Drug Name DrugTier

Requirements/Limits

GAS-X CHEW (simethicone) NF

GAS-X EXTRA STRENGTH CHEW (simethicone)

NF

MYLICON INFANTS GAS RELIEF DYE FREE SUSP (simethicone)

NF

MYLICON INFANTS GAS RELIEF SUSP (simethicone)

NF

simethicone chew 1

simethicone susp 1

Bile Acid Synthesis Disorder Agents

CHOLBAM CAPS NP QL(5 ea daily);MP

Farnesoid X Receptor (FXR) Agonists

OCALIVA TABS NP

Gallstone Solubilizing Agents ACTIGALL CAPS (ursodiol) NF QL(3 ea daily);

MP

CHENODAL TABS NP

URSO 250 TABS (ursodiol) NF QL(7 ea daily);MP

URSO FORTE TABS (ursodiol) NF

ursodiol caps 300 mg 1 QL(3 ea daily);MP

ursodiol tabs 250 mg 1 QL(7 ea daily);MP

ursodiol tabs 500 mg 1

Gastrointestinal Chloride Channel Activators

AMITIZA CAPS 2 PA; MP

Gastrointestinal Stimulants

metoclopramide hcl soln 1

metoclopramide hcl tabs 1

REGLAN TABS (metoclopramide hcl) NF

Drug Name DrugTier

Requirements/Limits

Inflammatory Bowel Agents APRISO CP24 (mesalamine) 2 MP

ASACOL HD TBEC (mesalamine) NP QL(3 ea daily)

AZULFIDINE EN-TABS TBEC (sulfasalazine) NF MP

AZULFIDINE TABS (sulfasalazine) NF MP

balsalazide disodium caps 1 QL(9 ea daily)

CANASA SUPP (mesalamine) 2

CIMZIA KIT NP PA; SP

CIMZIA STARTER KIT KIT NP PA; SP

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

DELZICOL CPDR (mesalamine) NF QL(6 ea daily);

MP

DIPENTUM CAPS NP

ENTYVIO SOLR NP PA

GIAZO TABS NP

INFLECTRA SOLR NP PA

LIALDA TBEC (mesalamine) 2

mesalamine cp24 or 0.375 gm 1 MP

mesalamine cpdr or 400 mg 1 QL(6 ea daily);

MP

mesalamine enem re 4 gm 1 QL(60 ml daily)

mesalamine supp re 1000 mg 1

mesalamine tbec or 1.2 gm 1

mesalamine tbec or 800 mg NP QL(3 ea daily)

mesalamine w/ cleanser kit 1

PENTASA CPCR 2 QL(8 ea daily);MP


105

Drug Name DrugTier

Requirements/Limits

REMICADE SOLR NP PA

RENFLEXIS SOLR NP PA

ROWASA KIT (mesalamine w/ cleanser) NF

SFROWASA ENEM NP

STELARA SOLN IV 130 MG/26ML NP PA

sulfasalazine tabs 1 MP

sulfasalazine tbec 1 MP

Intestinal Acidifiers lactulose (encephalopathy)soln 1 MP

Irritable Bowel Syndrome (IBS) Agents

alosetron hcl tabs NP PA

LINZESS CAPS 2 PA

LOTRONEX TABS (alosetron hcl) NP PA

VIBERZI TABS NP PA

Peripheral Opioid Receptor Antagonists

ENTEREG CAPS NP PA

MOVANTIK TABS 2 PA

RELISTOR SOLN NP PA

RELISTOR TABS NP PA

SYMPROIC TABS NP PA

Phosphate Binder Agents

AURYXIA TABS NP PA

calcium acetate (phosphatebinder) caps 1 MP

calcium acetate (phosphatebinder) tabs 1 RX/OTC; MP

FOSRENOL CHEW 500 MG, 750 MG, 1000 MG (lanthanum carbonate)

2 PA; MP

Drug Name DrugTier

Requirements/Limits

FOSRENOL PACK 750 MG, 1000 MG NP PA

lanthanum carbonate chew NP PA; MP

PHOSLYRA SOLN 2 MP

RENAGEL TABS (sevelamer hcl) NF

RENVELA PACK (sevelamer carbonate) 2 PA; MP

RENVELA TABS (sevelamer carbonate) 2 PA; MP

sevelamer carbonate pack NP PA; MP

sevelamer carbonate tabs NP PA; MP

sevelamer hcl tabs 1

SEVELAMER HYDROCHLORIDE TABS 2 PA; MP

VELPHORO CHEW NP PA

Short Bowel Syndrome (SBS) Agents

GATTEX KIT 2 PA

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

Acidifiers

K-PHOS NO 2 TABS 2

Alkalinizers potassium citrate(alkalinizer) tbcr 1080 mg 1

potassium citrate(alkalinizer) tbcr 540 mg 1 QL(1.433 ea

daily) potassium citrate-citric acidpack 1

sodium citrate & citric acid soln 1

QL(500 ml per30 days retail);RX/OTC

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

NF


106

Drug Name DrugTier

Requirements/Limits

UROCIT-K 5 TBCR (potassium citrate(alkalinizer))

NF QL(1.433 eadaily)

Cystinosis Agents

CYSTAGON CAPS 2

PROCYSBI CPDR 25 MG, 75 MG NP

Genitourinary Irrigants sodium chloride (guirrigant) soln 1

Interstitial Cystitis Agents

ELMIRON CAPS 2 PA; QL(3 eadaily)

RIMSO-50 SOLN 2 PA

Prostatic Hypertrophy Agents

alfuzosin hcl tb24 1 MP

AVODART CAPS (dutasteride) NF MP

CARDURA XL TB24 NP

dutasteride caps 1 MP

dutasteride-tamsulosin hcl caps NP PA

finasteride tabs 1 QL(1 ea daily);MP

FLOMAX CAPS (tamsulosin hcl) NF QL(2 ea daily);

MP JALYN CAPS (dutasteride-tamsulosin hcl) NP PA

PROSCAR TABS (finasteride) NF QL(1 ea daily);

MP

RAPAFLO CAPS 4 MG NP MP

RAPAFLO CAPS 4 MG, 8 MG (silodosin) NP MP

silodosin caps NP MP

tamsulosin hcl caps 1 QL(2 ea daily);MP

UROXATRAL TB24 (alfuzosin hcl) NF MP

Drug Name DrugTier

Requirements/Limits

Urinary Analgesics

phenazopyridine hcl tabs 1

PYRIDIUM TABS (phenazopyridine hcl) NF

Urinary Stone Agents

LITHOSTAT TABS 2 PA

THIOLA EC TBEC 2 PA

THIOLA TABS 2 PA

GOUT AGENTS - Drugs to Treat Gout

Gout Agent Combinations colchicine w/ probenecidtabs 1 MP

DUZALLO TABS NP PA

Gout Agents

allopurinol sodium solr 1 PA

allopurinol tabs 1 MP

ALOPRIM SOLR (allopurinol sodium) 2 PA

COLCHICINE CAPS 2

COLCHICINE TABS NP PA; QL(6 eaper fill retail)

colchicine tabs NP PA; QL(6 eaper fill retail)

COLCRYS TABS NP PA; QL(6 eaper fill retail)

febuxostat tabs NP PA; MP

GLOPERBA SOLN NP PA

KRYSTEXXA SOLN NP PA

MITIGARE CAPS NP PA

ULORIC TABS (febuxostat) NP PA; MP

ZURAMPIC TABS NP PA


107

Drug Name DrugTier

Requirements/Limits

ZYLOPRIM TABS (allopurinol) NF MP

Uricosurics

probenecid tabs 1 MP

HEMATOLOGICAL AGENTS - MISC. - Drugs toTreat Blood Disorders

Antihemophilic Products

ADVATE SOLR CO

ADYNOVATE SOLR CO

AFSTYLA KIT CO

ALPHANATE/VONWILLEBRANDFACTOR COMPLEX/HUMAN SOLR

CO

ALPHANINE SD SOLR CO

ALPROLIX SOLR CO

BEBULIN SOLR CO

BENEFIX KIT CO

COAGADEX SOLR CO

CORIFACT KIT CO

ELOCTATE SOLR CO

ESPEROCT SOLR CO

FEIBA SOLR CO

FIBRYGA SOLR CO

HELIXATE FS KIT CO

HEMLIBRA SOLN CO

HEMOFIL M SOLR CO

HUMATE-P SOLR CO

IDELVION SOLR CO

Drug Name DrugTier

Requirements/Limits

IXINITY SOLR CO

JIVI SOLR CO

KOATE SOLR CO

KOATE-DVI SOLR CO

KOGENATE FS BIO-SET KIT CO

KOGENATE FS KIT CO

KOVALTRY SOLR CO

MONOCLATE-P KIT CO

MONONINE SOLR CO

NOVOEIGHT SOLR CO

NOVOSEVEN RT SOLR CO

NUWIQ KIT CO

NUWIQ SOLR CO

OBIZUR SOLR CO

PROFILNINE SD SOLR CO

PROFILNINE SOLR CO

REBINYN SOLR CO

RECOMBINATE SOLR CO

RIASTAP SOLR CO

RIXUBIS SOLR CO

TRETTEN SOLR CO

VONVENDI SOLR CO

WILATE KIT CO

XYNTHA KIT CO

XYNTHA SOLOFUSE KIT CO


108

Drug Name DrugTier

Requirements/Limits

Bradykinin B2 Receptor Antagonists FIRAZYR SOLN (icatibant acetate) NF PA; SP

icatibant acetate soln 1 PA; SP

Complement Inhibitors

BERINERT KIT NP PA

CINRYZE SOLR 2 PA

HAEGARDA SOLR 2 PA

RUCONEST SOLR 2 PA

SOLIRIS SOLN 2 PA

ULTOMIRIS SOLN 2 PA

Hemataologic - Tyrosine Kinase Inhibitors

TAVALISSE TABS 2 PA

Hematorheologic Agents

pentoxifylline tbcr 1 MP

Hemin

PANHEMATIN SOLR 2 PA

Human Protein C

CEPROTIN SOLR 2 PA

Plasma Kallikrein Inhibitors

KALBITOR SOLN 2 PA

TAKHZYRO SOLN NP PA

Platelet Aggregation Inhibitors AGGRENOX CP12 (aspirin-dipyridamole) NF MP

AGRYLIN CAPS (anagrelide hcl) NF MP

anagrelide hcl caps 1 MP

aspirin-dipyridamole cp12 1 MP

ASPIRIN/OMEPRAZOLEER TBEC NP PA

Drug Name DrugTier

Requirements/Limits

ASPIRIN/OMEPRAZOLETBEC NP PA

BRILINTA TABS 2 QL(2 ea daily);MP

cilostazol tabs 1 QL(2 ea daily);MP

clopidogrel bisulfate tabs300 mg 1

clopidogrel bisulfate tabs75 mg 1 QL(1 ea daily);

MP

dipyridamole tabs 1 MP

DURLAZA CP24 NP

EFFIENT TABS (prasugrelhcl) NP PA; QL(1 ea

daily)

KENGREAL SOLR NP

PLAVIX TABS 300 MG (clopidogrel bisulfate) NF

PLAVIX TABS 75 MG (clopidogrel bisulfate) NF QL(1 ea daily);

MP

prasugrel hcl tabs NP PA; QL(1 eadaily)

YOSPRALA TBEC 40 MG-81 MG, 40 MG-325 MG NP PA

ZONTIVITY TABS NP

Protamine PROTAMINE SULFATE SOLN 2 PA

Thrombolytic Enzymes

ACTIVASE SOLR 2 PA

CATHFLO ACTIVASE SOLR 2 PA

RETAVASE HALF-KIT KIT NP PA

RETAVASE KIT NP PA

TNKASE KIT 2 PA

HEMATOPOIETIC AGENTS - Drugs to TreatBlood Disorders

Agents for Gaucher Disease


109

Drug Name DrugTier

Requirements/Limits

CERDELGA CAPS NP PA; MP

CEREZYME SOLR NP PA

ELELYSO SOLR NP PA

miglustat caps 1 PA; MP

VPRIV SOLR NP PA

ZAVESCA CAPS (miglustat) 2 PA; MP

Agents for Sickle Cell Anemia

ADAKVEO SOLN NP PA

DROXIA CAPS 2 MP

ENDARI PACK NP PA

SIKLOS TABS 2

Cobalamins cyanocobalamin soln 1000mcg/ml 1

Folic Acid/Folates

folic acid tabs 1 RX/OTC; MP

Hematopoietic Growth Factors ARANESP ALBUMIN FREE SOLN 2 PA

ARANESP ALBUMIN FREE SOSY 2 PA

DOPTELET TABS 2 PA

EPOGEN SOLN 2 PA; SP

FULPHILA SOSY NP PA

GRANIX SOLN 2 PA

GRANIX SOSY 2 PA

LEUKINE SOLR NP PA

MIRCERA SOSY NP PA

Drug Name DrugTier

Requirements/Limits

MULPLETA TABS 2 PA

NEULASTA ONPRO KIT PSKT NP PA; SP

NEULASTA SOSY NP PA; SP

NEUPOGEN SOLN 2 PA; SP

NEUPOGEN SOSY 2 PA; SP

NIVESTYM SOLN NP PA

NIVESTYM SOSY NP PA

NPLATE SOLR 2 PA

PROCRIT SOLN 2000 UNIT/ML, 3000 UNIT/ML,4000 UNIT/ML, 10000UNIT/ML, 20000 UNIT/ML,40000 UNIT/ML

NP

PA; SP

PROMACTA PACK 12.5 MG 2 PA; SP

PROMACTA TABS 25 MG, 50 MG, 75 MG, 12.5 MG 2 PA; SP; MP

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

NP

PA

UDENYCA SOSY NP PA

ZARXIO SOSY NP PA

ZIEXTENZO SOSY NP PA

Hematopoietic Mixtures ferrous fumarate-fa-b complex-c-zn-mg-mn-cutabs

1 QL(1 ea daily)

Iron FER-IN-SOL SOLN (ferrous sulfate) NF QL(3.4 ml

daily)

ferrous gluconate tabs 1

FERROUS GLUCONATE TABS 2

ferrous sulfate elix 220 mg/5ml 1 QL(16 ml daily)


110

Drug Name DrugTier

Requirements/Limits

FERROUS SULFATE LIQD 220 MG/5ML 2

ferrous sulfate soln 15 mg/ml 1 QL(3.4 ml

daily) ferrous sulfate tabs 65 mg,325 mg 1 MP

FERROUS SULFATE TBEC 324 MG 2

ferrous sulfate tbec 325 mg 1 MP

HEMOSTATICS - Drugs to Stop Bleeding/TreatBlood Disorders

Hemostatics - Systemic AMICAR SOLN 0.25 GM/ML (aminocaproicacid)

NP

AMICAR TABS 1000 MG (aminocaproic acid) NF

AMICAR TABS 500 MG (aminocaproic acid) NF QL(24 ea per

fill retail) aminocaproic acid soln iv250 mg/ml 1 PA

aminocaproic acid soln or0.25 gm/ml 1

aminocaproic acid tabs or1000 mg 1

aminocaproic acid tabs or500 mg 1 QL(24 ea per

fill retail) CYKLOKAPRON SOLN (tranexamic acid) 2 PA

LYSTEDA TABS (tranexamic acid) NF


tranexamic acid soln iv 1000 mg/10ml 1 PA

tranexamic acid tabs or 650 mg 1


TRANEXAMIC ACID/SODIUM CHLORIDESOLN

2 PA

HYPNOTICS/SEDATIVES/SLEEP DISORDERAGENTS

Antihistamine Hypnotics

Drug Name DrugTier

Requirements/Limits

diphenhydramine hcl(sleep) caps 1 QL(4 ea daily)

ZZZQUIL CAPS (diphenhydramine hcl(sleep))

NF QL(4 ea daily)

Barbiturate Hypnotics

AMYTAL SODIUM SOLR 2 PA

BUTISOL SODIUM TABS NP PA

NEMBUTAL SODIUM SOLN (pentobarbitalsodium)

NF PA

pentobarbital sodium soln 1 PA

phenobarbital elix 1 MP

PHENOBARBITAL SODIUM SOLN 65 MG/ML(phenobarbital sodium)

NF

phenobarbital sodium soln65 mg/ml, 130 mg/ml 1

phenobarbital soln 1 MP

phenobarbital tabs 1 MP

SECONAL SODIUM CAPS NP PA

Hypnotics - Tricyclic Agents

doxepin hcl (sleep) tabs NP PA; AL(At least18 yrs old)

SILENOR TABS (doxepinhcl (sleep)) NP PA; AL(At least

18 yrs old) Non-Barbiturate Hypnotics AMBIEN CR TBCR (zolpidem tartrate) NF AL(At least 18

yrs old)

AMBIEN TABS (zolpidem tartrate) NF


EDLUAR SUBL NP PA; AL(At least18 yrs old)

estazolam tabs NP AL(At least 18yrs old)

eszopiclone tabs NP PA; AL(At least18 yrs old)


111

Drug Name DrugTier

Requirements/Limits

FLURAZEPAM HCL CAPS NP QL(1 ea daily);AL(At least 18yrs old)

HALCION TABS (triazolam) NF


INTERMEZZO SUBL (zolpidem tartrate) NF AL(At least 18

yrs old) LUNESTA TABS (eszopiclone) NP PA; AL(At least

18 yrs old) MIDAZOLAM HCL SOLN IJ 5 MG/5ML 2

midazolam hcl soln ij 5mg/ml, 2 mg/2ml, 5mg/5ml, 10 mg/2ml, 25mg/5ml, 10 mg/10ml, 50mg/10ml

1

midazolam hcl syrp or 2mg/ml NP

RESTORIL CAPS 15 MG, 30 MG (temazepam) NF


RESTORIL CAPS 7.5 MG, 22.5 MG (temazepam) NF AL(At least 18

yrs old)

SONATA CAPS (zaleplon) NP


temazepam caps 15 mg,30 mg 1


temazepam caps 7.5 mg,22.5 mg 1 AL(At least 18

yrs old)

triazolam tabs 1 QL(1 ea daily);AL(At least 18yrs old)

zaleplon caps NP


zolpidem tartrate subl sl 3.5mg, 1.75 mg 1 AL(At least 18

yrs old)

zolpidem tartrate tabs or 5mg, 10 mg 1


zolpidem tartrate tbcr or12.5 mg, 6.25 mg 1 AL(At least 18

yrs old)

Drug Name DrugTier

Requirements/Limits

ZOLPIMIST SOLN NP PA; AL(At least18 yrs old)

Orexin Receptor Antagonists

BELSOMRA TABS NP PA; AL(At least18 yrs old)

Selective Melatonin Receptor Agonists

HETLIOZ CAPS NP PA

ramelteon tabs 1 PA; AL(At least18 yrs old); MP

ROZEREM TABS (ramelteon) NF PA; AL(At least

18 yrs old); MP

LAXATIVES - Bowel Treatment Drugs

Bulk Laxatives KONSYL DAILY FIBER POWD 2

KONSYL POWD 2

METAMUCIL ORIGINAL TEXTURE POWD (psyllium)

NF

METAMUCIL POWD (psyllium) NF

psyllium powd 1

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

NF

GAVILYTE-C SOLR 2

GOLYTELY SOLR (peg3350-kcl-sod bicarb-sod chloride-sod sulfate)

NF

MOVIPREP SOLR 2 PA

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

NF

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

1


112

Drug Name DrugTier

Requirements/Limits

peg 3350-potassiumchloride-sod bicarbonate-sod chloride solr

1

PREPOPIK PACK 2 PA

SUPREP BOWEL PREP KIT SOLN 2 PA

Laxatives - Miscellaneous

glycerin (laxative) supp 1

GLYCERIN ADULT SUPP (glycerin (laxative)) NF

lactulose soln 1 MP

MIRALAX PACK (polyethylene glycol 3350) NF RX/OTC

MIRALAX POWD (polyethylene glycol 3350) NF QL(34 gm

daily); RX/OTC polyethylene glycol 3350pack 1 RX/OTC

polyethylene glycol 3350powd 1 QL(34 gm

daily); RX/OTC

Saline Laxatives FLEET ENEMA ENEM (sodium phosphates) NF

FLEET ENEMA SIX PACK ENEM (sodium phosphates)

NF

FLEET PEDIATRIC ENEM (sodium phosphates) NF

magnesium citrate soln 1

magnesium hydroxide susp 1 QL(990 ml per30 days retail)

OSMOPREP TABS 2 PA

sodium phosphates enem 1

Stimulant Laxatives

bisacodyl supp re 10 mg 1 QL(12 ea perfill retail)

bisacodyl tbec or 5 mg 1 QL(1 ea daily)

DULCOLAX SUPP RE 10 MG (bisacodyl) NF QL(12 ea per

fill retail)

Drug Name DrugTier

Requirements/Limits

DULCOLAX TBEC OR 5 MG (bisacodyl) NF QL(1 ea daily)

sennosides tabs 1

SENOKOT TABS (sennosides) NF

Surfactant Laxatives COLACE CAPS (docusate sodium) NF QL(3 ea daily)

docusate sodium caps or100 mg, 250 mg 1 QL(3 ea daily)

docusate sodium enem re 283 mg 1

docusate sodium tabs or 100 mg 1 QL(3 ea daily)

DOCUSOL PLUS MINI-ENEMA ENEM 2

ENEMEEZ PLUS ENEM 2

MACROLIDES - Drugs to Treat BacterialInfections

Azithromycin AZITHROMYCIN PACK 1 GM 2 PA; QL(20 ea

per fill retail) azithromycin susr 100mg/5ml 1 QL(30 ml per

fill retail) azithromycin susr 200mg/5ml 1 QL(60 ml per

fill retail)

azithromycin tabs 250 mg 1 QL(6 ea per fillretail)

azithromycin tabs 500 mg 1 QL(4 ea daily)

azithromycin tabs 600 mg 1 QL(8 ea per 28days retail)

ZITHROMAX PACK 1 GM NP PA; QL(20 eaper fill retail)

ZITHROMAX PACK 1 GM NP PA

ZITHROMAX SUSR 100 MG/5ML (azithromycin) NF QL(30 ml per

fill retail) ZITHROMAX SUSR 200 MG/5ML (azithromycin) NF QL(60 ml per

fill retail) ZITHROMAX TABS 250 MG (azithromycin) NF QL(6 ea per fill

retail) ZITHROMAX TABS 500 MG (azithromycin) NF QL(4 ea daily)


113

Drug Name DrugTier

Requirements/Limits

ZITHROMAX TABS 600 MG (azithromycin) NF QL(8 ea per 28

days retail) ZITHROMAX TRI-PAK TABS (azithromycin) NF QL(4 ea daily)

ZITHROMAX Z-PAK TABS (azithromycin) NF QL(6 ea per fill

retail) Clarithromycin CLARITHROMYCIN SUSR 125 MG/5ML 2

CLARITHROMYCIN SUSR 250 MG/5ML 2 QL(200 ml per

fill retail) clarithromycin tabs 250 mg,500 mg 1 QL(28 ea per

fill retail)

clarithromycin tb24 500 mg NP QL(14 ea perfill retail)

Erythromycins

E.E.S. 400 TABS NP PA

E.E.S. GRANULES SUSR (erythromycinethylsuccinate)

NF

ERYPED 200 SUSR (erythromycinethylsuccinate)

NF

ERYPED 400 SUSR (erythromycinethylsuccinate)

NF

ERYTHROCIN STEARATE TABS NP

erythromycin base cpep250 mg 1

erythromycin base tabs250 mg, 500 mg NP

erythromycin base tbec250 mg, 333 mg, 500 mg 1

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

1

ERYTHROMYCIN ETHYLSUCCINATE TABS 400 MG

2

PCE TBEC NP

Fidaxomicin

DIFICID TABS NP

Drug Name DrugTier

Requirements/Limits

MEDICAL DEVICES AND SUPPLIES

Bandages-Dressings-Tape ADHESIVE PADS/LARGE/3"X4" PADS 2

ADHESIVE PADS/MEDIUM/2"X3"PADS

2

ALLEVYN PLUS CAVITY PADS 2 RX/OTC

ALLEVYN THIN PADS 2 RX/OTC

AMD FOAM DRESSING 4"X4" PADS 2 RX/OTC

AMD FOAM DRESSING/TOPSHEET4"X4" PADS

2 RX/OTC

BAND-AID ALL-IN-ONE ADHESIVE GAUZE PAD/LARGE PADS

2

BAND-AID ALL-IN-ONE ADHESIVE GAUZE PAD/MEDIUM PADS

2

BAND-AID GAUZE PADS LARGE4" X 4" PADS 2 RX/OTC

BAND-AID GAUZE PADS MEDIUM 3" X 3" PADS 2

BAND-AID GAUZE PADS SMALL2" X 2" PADS 2 RX/OTC

BAND-AID HURT-FREE NON-STICK PADS LARGE 3" X 4" PADS

2

BAND-AID HURT-FREE NON-STICK PADS MEDIUM 2" X 3" PADS

2

BAND-AID MIRASORB GAUZE SPONGES LARGE 4" X 4" PADS

2 RX/OTC

BAND-AID QUILTVENT WATERPROOF PAD LARGE 2.875" X 4" PADS

2

BIATAIN ADHESIVE FOAM DRESSING 4"X4" PADS

2 RX/OTC

BIATAIN FOAM DRESSING 4"X4" PADS 2 RX/OTC


114

Drug Name DrugTier

Requirements/Limits

BIOGUARD GAUZE SPONGE 2"X2" 8 PLY PADS

2 RX/OTC

BIOGUARD GAUZE SPONGES 4"X4" 12 PLY PADS

2 RX/OTC

BORDERED GAUZE PADS 2 RX/OTC

CARRASMART FOAM PADS 2 RX/OTC

CARRASMART PADS 2 RX/OTC

COPA ISLAND BORDERED FOAM DRESSING 4"X4" PADS

2 RX/OTC

COPA PLUS HYDROPHILIC FOAM DRESSING 4"X4" PADS

2 RX/OTC

COVRSITE COVER DRESSING PADS 2 RX/OTC

COVRSITE PLUS COMPOSITE DRESSING PADS

2 RX/OTC

CRUAD GAUZE PADS 4" X 4" PADS 2 RX/OTC

CURAD NON-STICK PADS WITHADHESIVE TABS 3"X4" PADS

2

CURITY ALL PURPOSE SPONGES 2"X2" 4PLY PADS

2 RX/OTC

CURITY ALL PURPOSE SPONGES 2"X2" PADS 2 RX/OTC


2

CURITY ALL PURPOSE SPONGES 4 PLY PADS 2 RX/OTC


2 RX/OTC

CURITY ALL PURPOSE SPONGES 4"X4" 4PLY/SOFT POUCH PADS

2 RX/OTC

CURITY ALL PURPOSE SPONGES 4"X4" PADS 2 RX/OTC

Drug Name DrugTier

Requirements/Limits

CURITY AMD ANTIMICROBIALGAUZE SPONGES 2"X2" 8 PLY PADS

2

RX/OTC

CURITY AMD ANTIMICROBIALGAUZE SPONGES 4"X4" 12 PLY PADS

2

RX/OTC

CURITY COVER SPONGE 4"X4" PADS 2 RX/OTC

CURITY COVER SPONGES 3"X3" PADS 2

CURITY COVER SPONGES 4"X4" PADS 2 RX/OTC

CURITY DRESSING SPONGES 4"X4" 6 PLY PADS

2 RX/OTC

CURITY GAUZE PADS 2"X2" 12 PLY PADS 2 RX/OTC

CURITY GAUZE PADS 2"X2" PADS 2 RX/OTC

CURITY GAUZE PADS 3"X3" PADS 2

CURITY GAUZE PADS 4"X4" 12 PLY PADS 2 RX/OTC

CURITY GAUZE SPONGE 2"X2" 8 PLY PADS 2 RX/OTC

CURITY GAUZE SPONGE 2"X2"12 PLY PADS 2 RX/OTC

CURITY GAUZE SPONGE 3"X3" 12 PLY PADS 2




CURITY GAUZE SPONGE 4"X4"16 PLY PADS 2 RX/OTC

CURITY GAUZE SPONGES 4"X4" 12 PLY PADS

2 RX/OTC

CURITY GAUZE SPONGES 4"X4" 8 PLY PADS

2 RX/OTC

CURITY NON-ADHERENT STRIPS 3"X3" PADS 2


115

Drug Name DrugTier

Requirements/Limits

CURITY SPONGES/CELLULOSEFILLED/2"X2" PADS

2 RX/OTC

CURITY SPONGES/CELLULOSEFILLED/4"X4" PADS

2 RX/OTC

CVS ADHESIVE PAD 4"X4" PADS 2

CVS ADHESIVE PAD 6"X6" PADS 2

CVS ADHESIVE PADS 2.25"X3" PADS 2

CVS GAUZE PAD 3"X3" PADS 2

CVS GAUZE PADS 2"X2" 12-PLY PADS 2 RX/OTC

CVS GAUZE PADS 4"X4" 12-PLY PADS 2 RX/OTC

CVS GAUZE PADS STERILE 4"X4" 12-PLY PADS

2 RX/OTC

DERMACEA DRAIN SPONGES 4"X4" PADS 2 RX/OTC

DERMACEA GAUZE SPONGE 2"X2" 12 PLY PADS

2 RX/OTC


2 RX/OTC


2


2


2 RX/OTC


2 RX/OTC


2 RX/OTC

DERMACEA I.V. DRAIN SPONGES 2"X2" PADS 2 RX/OTC

Drug Name DrugTier

Requirements/Limits

DERMACEA I.V. DRAIN SPONGES 4"X4" PADS 2 RX/OTC

DERMACEA I.V. SPONGES 2"X2" PADS 2 RX/OTC

DERMACEA NON-WOVEN SPONGES 2"X2" 4 PLY PADS

2 RX/OTC


2


2 RX/OTC


2 RX/OTC

DERMACEA TYPE VII GAUZE 2"X2" 12 PLY PADS

2 RX/OTC

DERMACEA TYPE VII GAUZE 2"X2" 8 PLY PADS 2 RX/OTC


2

DERMACEA TYPE VII GAUZE 3"X3" 12PLY PADS

2


2 RX/OTC


2 RX/OTC

DERMACEA TYPE VII GAUZE 4"X4" 8 PLY PADS 2 RX/OTC

DERMACEA X-RAY SPONGES 4"X4" 16 PLY PADS

2 RX/OTC

DERMALEVIN ADHESIVE FOAMDRESSING 4"X4" PADS

2 RX/OTC

DRYMAX EXTRA PADS 2 RX/OTC

EQL GAUZE PADS 2"X2"/SMALL PADS 2 RX/OTC

EQL GAUZE PADS 4"X4"/LARGE PADS 2 RX/OTC


116

Drug Name DrugTier

Requirements/Limits

EQL GAUZE STERILE PADS 3"X3" PADS 2

EXCILON AMD ANTIMICROBIALDRAIN SPONGES 4"X4" 6 PLY PADS

2

RX/OTC

EXCILON AMD ANTIMICROBIALNON-WOVEN SPONGES 4"X4" 6 PLY PADS

2

RX/OTC

EXCILON DRAIN SPONGE 4"X4" PADS 2 RX/OTC

EXCILON DRAIN SPONGES 4"X4" 6 PLY PADS

2 RX/OTC

EXCILON I.V. SPONGES 2"X2" 6 PLY PADS 2 RX/OTC

GAUZE DRESSING 4"X4" PADS 2 RX/OTC

GAUZE PADS 2"X2" PADS 2 RX/OTC

GAUZE PADS 3"X3" PADS 2

GAUZE PADS 4"X4" 12 PLY PADS 2 RX/OTC

GAUZE PADS 4"X4" PADS 2 RX/OTC

GAUZE SPONGE TYPE VII MEDI-PAK 2"X2" 8PLY PADS

2 RX/OTC

GAUZE SPONGES 4"X4" 12 PLY PADS 2 RX/OTC

GNP ADHESIVE PADS 3" X 4" PADS 2

GNP STERILE PADS 3"X3" PADS 2

HM ADHESIVE PADS ANTIBACTERIAL/SHEERPADS

2

HM STERILE PADS 2"X2" PADS 2 RX/OTC

HM STERILE PADS PADS 2 RX/OTC

HYDROCELL ADHESIVE DRESSING 4"X4" PADS 2 RX/OTC

HYDROCELL DRESSING 4"X4" PADS 2 RX/OTC

Drug Name DrugTier

Requirements/Limits

J & J ADHESIVE LARGE PADS 2

J & J GAUZE 2"X2" 8 PLY PADS 2 RX/OTC



J & J GAUZE SPONGES 12-PLY 4" X 4" MISC 2 RX/OTC

J & J GAUZE SPONGES 16-PLY 4" X 4" MISC 2 RX/OTC

J & J GAUZE SPONGES 8-PLY4" X 4" MISC 2 RX/OTC

J & J NON-STICK PADS 100LARGE PADS 2

KENDALL HYDROPHILIC FOAMDRESSING 2"X2" PADS

2 RX/OTC


2


2 RX/OTC

KENDALL HYDROPHILIC FOAMPLUS DRESSING 2"X2" PADS

2 RX/OTC

KENDALL HYDROPHILIC FOAMPLUS DRESSING 3"X3" PADS

2

KERLIX SPONGES 4" X 4" 12 PLY PADS 2 RX/OTC

KERLIX SPONGES 4" X 4" 16 PLY PADS 2 RX/OTC

MIRASORB SPONGES 2" X 2" MISC 2 RX/OTC

MIRASORB SPONGES 4" X 4" MISC 2 RX/OTC

MOLESKIN FOAM PADDING PADS 2

NEXCARE ABSOLUTE WATERPROOF PAD PADS

2

NU GAUZE 4PLY 4"X4" PADS 2 RX/OTC


117

Drug Name DrugTier

Requirements/Limits

NU GAUZE GENERAL-USE SPONGES 4"X4" 4 PLY MISC

2 RX/OTC

OPTIFOAM PADS 2 RX/OTC

POLYMEM DRESSING/3"X 3" PADS 2

POLYMEM DRESSING/4"X 4" PADS 2 RX/OTC

POLYMEM FILM DOT PADS 2

POLYMEM NON-ADHESIVE PAD PADS 2 RX/OTC

QC ALL PURPOSE DRESSINGS4"X4" PADS 2 RX/OTC

QC BORDER ISLAND GAUZE PAD 2"X2" PADS 2 RX/OTC

QC STERILE PADS PADS 2 RX/OTC

QC STERILE PADS PADS 2

RA ALL PURPOSE DRESSINGS4"X4" PADS 2 RX/OTC

RA DRESSING SPONGES 4"X4" PADS 2 RX/OTC

RA FIRST AID NON-STICK PADS PADS 2

RA GAUZE SPONGES 4"X4" PADS 2 RX/OTC

RA SHEER ADHESIVE LARGE PADS 2

RA STERILE PADS 2"X2" PADS 2 RX/OTC

RA STERILE PADS 3"X3" PADS 2

RA STERILE PADS 4"X4" PADS 2 RX/OTC

RAY-TEC X-RAY DETECTABLESPONGES 4" X 4" 16 PLY MISC

2 RX/OTC

RESTORE CONTACT LAYER/NON-ADHERENT2"X2" PADS

2 RX/OTC

RESTORE FOAM DRESSING BORDERED 4"X4" PADS

2 RX/OTC

Drug Name DrugTier

Requirements/Limits

RESTORE FOAM DRESSING NON-BORDERED 4"X4" PADS

2 RX/OTC

RESTORE ODOR ABSORBING DRESSING 4"X4" PADS

2 RX/OTC

RESTORE TRIO ABSORBENT DRESSING 3"X3" PADS

2

SM ADHESIVE PADS 2"X3" PADS 2

SM ADHESIVE PADS 3"X4" PADS 2

SM GAUZE PADS 2"X2" PADS 2 RX/OTC

SM GAUZE PADS 3"X3" PADS 2

SM GAUZE PADS 4"X4" PADS 2 RX/OTC

SM STERILE PADS 2"X2" PADS 2 RX/OTC

SM STERILE PADS PADS 2 RX/OTC

SOF-SET ADHESIVE PATCH PADS 2

SOF-WICK 4"X4" PADS 2 RX/OTC

STERILE GAUZE PADS 2"X2" PADS 2 RX/OTC

STERILE GAUZE PADS 3"X3" PADS 2

STERILE PADS 2"X2" PADS 2 RX/OTC

STERILE PADS 3"X3" PADS 2

STERILE PADS 4"X4" PADS 2 RX/OTC

SURGICAL GAUZE SPONGE PADS 2 RX/OTC

TEGADERM FOAM DRESSING 2"X2" PADS 2 RX/OTC

TEGADERM FOAM DRESSING 4"X4" PADS 2 RX/OTC

THERAGAUZE PADS 2 RX/OTC

TOPPER DRESSING SPONGES 4"X4" MISC 2 RX/OTC


118

Drug Name DrugTier

Requirements/Limits

VERSIVA XC 3" X 3" FOAM DRESSING/HYDROFIBERTECHNOLOGY PADS

2

VERSIVA XC 4" X 4" FOAM DRESSING/HYDROFIBERTECHNOLOGY PADS

2

RX/OTC

Contraceptives AIMSCO LUBRICATED MISC 2

CAYA DPRH 2

CONDOMS MISC 2

DUREX EXTRA SENSITIVE DEVI 2

FANTASY LUBRICATED MISC 2

FANTASY LUBRICATED/SPERMICIDE MISC

2

KAMELEON LUBRICATED MISC 2

KIMONO COLORS DEVI 2

KIMONO LUBRICATED MISC 2

KIMONO MICRO THIN MISC 2

KIMONO MICRO THIN PLUS SPERMICIDE LUBRICATED MISC

2

KIMONO PLUS SPERMICIDE LUBRICATED MISC

2

KIMONO PLUS SPERMICIDE/LUBRICATED MISC

2

KIMONO PS LUBRICATED MISC 2

KIMONO PS PLUS SPERMICIDE/LUBRICATED MISC

2

KIMONO SENSATION LUBRICATED MISC 2

Drug Name DrugTier

Requirements/Limits

KIMONO SENSATION PLUS SPERMICIDE LUBRICATED MISC

2

KIMONO SPECIAL DEVI 2

LIFESTYLES ASSORTED COLORS MISC 2

LIFESTYLES EXTRA STRENGTH MISC 2

LIFESTYLES FORM FITTING MISC 2

LIFESTYLES LUBRICATED MISC 2

LIFESTYLES RIBBED MISC 2

LIFESTYLES SKYN ORIGINAL MISC 2

LIFESTYLES SPERMICIDALLYLUBRIC ATED MISC

2

LIFESTYLES STUDDED MISC 2

LIFESTYLES ULTRA SENSITIVE MISC 2

LIFESTYLES ULTRA SENSITIVE/SPERMICIDEMISC

2

LIFESTYLES VIBRA-RIBBED MISC 2

LIFESTYLES VIBRA-RIBBED/SPERMICIDEMISC

2

LIFESTYLES XTRA PLEASURE MISC 2

MAXX LUBRICATED MISC 2

MAXX PLUS SPERMICIDE LUBRICATED MISC 2

PREMIUM CONDOMS LUBRICATED MISC 2

REALITY LATEX CONDOMS/LUBRICATEDMISC

2

REALITY LATEX/ULTRATEXTURED DEVI 2

REALITY LATEX/ULTRATHIN DEVI 2


119

Drug Name DrugTier

Requirements/Limits

TRUSTEX COLOR CONDOMS + LUBE MISC 2

TRUSTEX LUBRICATED EXTRALARGE MISC 2

TRUSTEX LUBRICATED EXTRASTRENGTH MISC 2

TRUSTEX LUBRICATED MISC 2

TRUSTEX LUBRICATED/RIBBED/STUDDED MISC

2

TRUSTEX LUBRICATED/SPERMICIDE EXTRA LARGE MISC

2

TRUSTEX LUBRICATED/SPERMICIDE EXTRA STRENGTH MISC

2

TRUSTEX LUBRICATED/SPERMICIDE MISC

2

TRUSTEX NATURAL CONDOMS +LUBE/LUBRICATEDMISC

2

TRUSTEX NON-LUBRICATED MISC 2

TRUSTEX WITH NONOXYNOL-9/RIBBED/STUDDEDMISC

2

TRUSTEX/RIALUBRICATED MISC 2

TRUSTEX/RIALUBRICATED SPERMICIDE MISC

2

TRUSTEX/RIALUBRICATED/SPERMICIDE MISC

2

TRUSTEX/RIA NON-LUBRICATED MISC 2

Diabetic Supplies 1ST TIER UNILET COMFORTOUCH LANCETS 28G MISC

1 200 /month;QL(6.67ea daily)

Drug Name DrugTier

Requirements/Limits

1ST TIER UNILET COMFORTOUCH LANCETS 30G MISC


ADJUSTABLE LANCING DEVICE MISC 2 QL(1 ea per

180 days retail)

ADVANCED MOBILE LANCET 30G MISC 1

200 /month;QL(6.67ea daily)

ADVOCATE LANCING DEVICE MISC 2 QL(1 ea per

180 days retail) ADVOCATE RAPID-SAFE LANCING DEVICE MISC 2 QL(1 ea per

180 days retail)

AGAMATRIX ULTRA-THIN LANCETS 33G MISC 1


AIMSCO TWIST LANCETS 32G MISC 1


AIMSCO TWIST LANCETS 33G MISC 1


ALTERNATE SITE LANCING DEVICE MISC 2 QL(1 ea per

180 days retail) AQUA LANCE ADJUSTABLE LANCING DEVICE DEVI


AURORA LANCET SUPER THIN30G MISC 1


AURORA LANCET THIN 23G MISC 1


AUTO-LANCET MINI MISC 2 QL(1 ea per180 days retail)

AUTO-LANCET MISC 2 QL(1 ea per180 days retail)

AUTOLET IMPRESSION LANCING DEVICE MISC 2 QL(1 ea per

180 days retail) AUTOLET LANCING DEVICE MISC 2 QL(1 ea per

180 days retail)

AUTOLET MINI MISC 2 QL(1 ea per180 days retail)

AUTOLET PLUS MISC 2 QL(1 ea per180 days retail)

BD LANCET ULTRAFINE 30G MISC 1



120

Drug Name DrugTier

Requirements/Limits

CARDIOCOM LANCING DEVICE MISC 2 QL(1 ea per

180 days retail) CAREONE ADVANCED LANCINGDEVICE MISC 2 QL(1 ea per

180 days retail)

CAREONE LANCET THIN MISC 1


CAREONE LANCET ULTRA THIN MISC 1


CARESENS LANCETS MISC 1 QL(6.67 ea

daily) CARETOUCH LANCING DEVICEWITH EJECTOR MISC


CLEANLET LANCETS 28G MISC 1


COMFORT ASSURED LANCETS SUPER THIN 28G MISC


COMFORT LANCETS MISC 1


CVS LANCETS 21G MISC 1 200 /month;QL(6.67ea daily)

CVS LANCETS MICRO THIN 33G MISC 1


CVS LANCETS MICRO-THIN 33G MISC 1


CVS LANCETS ORIGINAL MISC 1


CVS LANCETS THIN 26G MISC 1


CVS LANCETS ULTRA THIN 30G MISC 1


CVS LANCETS ULTRA-THIN 30G MISC 1


CVS LANCING DEVICE MISC 2 QL(1 ea per

180 days retail)

Drug Name DrugTier

Requirements/Limits

CVS ULTRA THIN LANCETS MISC 1


DIATHRIVE LANCETS MISC 1


DIATHRIVE LANCETS ULTRA THIN 30G MISC 1


DIATHRIVE LANCING DEVICE MISC 2 QL(1 ea per

180 days retail)

DROPLET LANCETS ULTRA THIN 30G MISC 1


DROPLET LANCING DEVICE MISC 2 QL(1 ea per

180 days retail) DRUG MART ADJUSTABLE LANCING DEVICE MISC


DRUG MART LANCETS THIN MISC 1


DRUG MART UNILET LANCETSSUPER THIN 30G MISC


DRUG MART UNILET LANCETSULTRA THIN 28G MISC


DRUG MART UNILET MICRO THIN LANCETS 33G MISC


E-Z JECT LANCETS 21G MISC 1


E-Z JECT LANCETS COLOR MISC 1


E-Z JECT LANCETS MISC 1 200 /month;QL(6.67ea daily)

E-Z JECT LANCETS SUPER THIN 30G MISC 1


E-Z JECT LANCETS THIN 26G MISC 1



121

Drug Name DrugTier

Requirements/Limits

E-ZJECT LANCETS MICRO-THIN 33G MISC 1


EASY MINI EJECT LANCING DEVICE MISC 2 QL(1 ea per

180 days retail) EASY MINI LANCING DEVICE MISC 2 QL(1 ea per

180 days retail)

EASY TOUCH LANCETS 26G/PULL-TOP MISC 1




EASY TOUCH LANCETS 28G/TWIST MISC 1






EASY TOUCH LANCETS 32G/TWIST MISC 1


EASY TOUCH LANCING DEVICE/EJECTOR MISC 2 QL(1 ea per

180 days retail)

EASYTEST II LANCETS MISC 1


EASYTEST LANCETS MISC 1


EQL COLOR LANCETS 21G MISC 1


EQL COLOR LANCETS MICRO THIN 33G MISC 1


EQL SUPER THIN LANCETS 30G MISC 1


EQL THIN LANCETS 26G MISC 1


Drug Name DrugTier

Requirements/Limits

EZ SMART BLOOD GLUCOSE LANCETS MISC


EZ-LETS LANCETS 26G SUPER-SOFT MISC 1


EZ-LETS LANCETS 28G ULTRA-SOFT MISC 1


EZ-LETS LANCETS 30G MISC 1


FORA LANCETS MISC 1 200 /month;QL(6.67ea daily)

FORA LANCING DEVICE MISC 2 QL(1 ea per

180 days retail) FORA LANCING DEVICE/CLEARCAP MISC 2 QL(1 ea per

180 days retail) FREDS PHARMACY AUTOLET LANCING DEVICE MISC


FREDS PHARMACY UNILET LANCETS SUPER THIN 30G MISC


FREDS PHARMACY UNILET LANCETS ULTRA THIN 28G MISC


GENTEEL LANCING DEVICE/BUFF BLACKMISC


GENTEEL LANCING DEVICE/BUTTERFLYBLUE MISC


GENTEEL LANCING DEVICE/GLORIOUSGOLD MISC


GENTEEL LANCING DEVICE/PLAYFULPURPLE MISC


GENTEEL LANCING DEVICE/PRECIOUSPLATINUM MISC


GENTEEL LANCING DEVICE/PRINCESS PINKMISC



122

Drug Name DrugTier

Requirements/Limits

GENTEEL LANCING DEVICE/STATELY SILVERMISC


GENTEEL LANCING DEVICE/WILLOWY WHITEMISC


GENTLE-LET GP LANCETS MISC 1


GENTLE-LET LANCETS GENERAL PURPOSE STYLE/FINE POINT MISC


GENTLE-LET LANCETS GENERAL PURPOSE STYLE/MEDIUM POINTMISC

1


GENTLE-LET LANCETS SAFETY STYLE/FINEPOINT MISC


GENTLE-LET LANCETS SAFETY STYLE/MEDIUMPOINT MISC


GLOBAL LANCING DEVICE MISC 2 QL(1 ea per

180 days retail)

GNP LANCETS 21G MISC 1 200 /month;QL(6.67ea daily)

GNP LANCETS MICRO THIN 33G MISC 1


GNP LANCETS MISC 1 200 /month;QL(6.67ea daily)

GNP LANCETS SUPER THIN 30G MISC 1


GNP LANCETS THIN 26G MISC 1


GNP LANCETS THIN MISC 1


GNP MICRO THIN LANCETS 33G MISC 1


GNP SUPER THIN LANCETS/30G MISC 1


Drug Name DrugTier

Requirements/Limits

GOJJI LANCING DEVICE/CLEAR CAPMISC


GOJJI STERILE LANCETS 30G MISC 1 QL(6.67 ea

daily) GOODSENSE LANCETS MICRO-THIN 33G UNIVERSAL MISC


GOODSENSE LANCETS ULTRA-THIN 26G UNIVERSAL MISC


GOODSENSE LANCING DEVICE MISC 2 QL(1 ea per

180 days retail) H-E-B INCONTROL ADVANCEDLANCING DEVICE MISC


H-E-B INCONTROL LANCETS MICRO THIN 33G MISC


H-E-B INCONTROL LANCETS SUPER THIN 30G MISC


H-E-B INCONTROL LANCETS ULTRA THIN 28G MISC


HEALTH CARE LANCING DEVICE MISC 2 QL(1 ea per

180 days retail) HEALTHY ACCENTS AUTOLET IMPRESSION LANCING DEVICE MISC


HEALTHY ACCENTS UNILET LANCETS SUPER THIN 30G MISC


HY-VEE LANCETS MISC 1 200 /month;QL(6.67ea daily)

HY-VEE THIN LANCETS MISC 1


IN TOUCH LANCING DEVICE MISC 2 QL(1 ea per

180 days retail)

KINNEY LANCETS MISC 1 200 /month;QL(6.67ea daily)

KINNEY THIN LANCETS MISC 1



123

Drug Name DrugTier

Requirements/Limits

KROGER AUTOLET LANCING DEVICE MISC 2 QL(1 ea per

180 days retail) KROGER HEALTHPRO TWIST LANCETS/26GMISC


KROGER HEALTHPRO TWIST LANCETS/30GMISC


KROGER HEALTHPRO TWIST LANCETS/33GMISC


KROGER LANCETS 21G MISC 1


KROGER LANCETS MICRO THIN33G MISC 1


KROGER LANCETS MISC 1 200 /month;QL(6.67ea daily)

KROGER LANCETS SUPER THIN MISC 1


KROGER LANCETS THIN 26G MISC 1


KROGER LANCETS THIN MISC 1


KROGER LANCETS ULTRATHIN30G MISC 1


KROGER LANCING DEVICE MISC 2 QL(1 ea per

180 days retail) LANCET DEVICE ADJUSTABLE MISC 2 QL(1 ea per

180 days retail) LANCET DEVICE WITH EJECTOR MISC 2 QL(1 ea per

180 days retail)

LANCETS 26G TWIST TOP MISC 1


LANCETS 28G MISC 1 200 /month;QL(6.67ea daily)

LANCETS 30G MISC 1 200 /month;QL(6.67ea daily)

Drug Name DrugTier

Requirements/Limits

LANCETS MISC 1 200 /month;QL(6.67ea daily)

LANCETS SAFETY SEAL 21G MISC 1






LANCETS THIN MISC 1 200 /month;QL(6.67ea daily)

LANCETS ULTRA THIN MISC 1


LANCING DEVICE ADJUSTABLE MISC 2 QL(1 ea per

180 days retail)

LANCING DEVICE MISC 2 QL(1 ea per180 days retail)

LANZO MISC 2 QL(1 ea per180 days retail)

LEADER ADVANCED LANCING DEVICE MISC 2 QL(1 ea per

180 days retail) LIBERTY MINI LANCING DEVICE MISC 2 QL(1 ea per

180 days retail) LITE TOUCH LANCING PEN MISC 2 QL(1 ea per

180 days retail) LIVE BETTER ADVANCED LANCING DEVICE MISC 2 QL(1 ea per

180 days retail)

LIVE BETTER LANCET SUPERTHIN 30G MISC 1


LIVE BETTER LANCET ULTRATHIN 28G MISC 1


LONGS LANCETS STANDARD MISC 1


LONGS LANCETS THIN MISC 1


MEDISENSE THIN LANCETS MISC 1



124

Drug Name DrugTier

Requirements/Limits

MEIJER COLOR LANCETS UNIVERSAL 33G MISC


MEIJER LANCETS MISC 1 200 /month;QL(6.67ea daily)

MEIJER LANCETS THIN MISC 1


MEIJER LANCETS UNIVERSAL21G MISC 1






MEIJER SUPER THIN LANCETS MISC 1


MICROLET NEXT MISC 2 QL(1 ea per180 days retail)

MINI LANCING DEVICE MISC 2 QL(1 ea per

180 days retail) MM LANCING DEVICE MISC 2 QL(1 ea per

180 days retail)

MONOLET LANCETS MISC 1


MONOLET OPD LANCETS MISC 1


MULTI-LANCET DEVICE MISC 2 QL(1 ea per

180 days retail)

NOVA SUREFLEX LANCETS MISC 1


NOVA SUREFLEX LANCING DEVICE MISC 2 QL(1 ea per

180 days retail) ON CALL LANCING DEVICE MISC 2 QL(1 ea per

180 days retail) ON CALL PLUS LANCING DEVICE MISC 2 QL(1 ea per

180 days retail) ONETOUCH DELICA LANCING DEVICE MISC 2 QL(1 ea per

180 days retail)

Drug Name DrugTier

Requirements/Limits

ONETOUCH DELICA PLUS LANCING DEVICE MISC


PC LANCETS SUPER THIN 30G MISC 1


PERFECT LANCETS 30G MISC 1


PHARMACY COUNTER LANCETS MISC 1


PRECISION THIN LANCETS MISC 1


PRECISION THINS GP LANCET MISC 1


PRECISION ULTRA LANCET MISC 1


PREFERRED PLUS LANCETS COLORED 21G MISC


PREFERRED PLUS LANCETS SUPER THIN 30G MISC


PREFERRED PLUS LANCETS THIN 26G MISC 1


PRODIGY LANCING DEVICE MISC 2 QL(1 ea per

180 days retail)

PRODIGY TWIST TOP LANCETS MISC 1


PSS SELECT GP LANCETS MISC 1


PSS SELECT SAFETY LANCETS MISC 1


PX ADVANCED LANCING DEVICE MISC 2 QL(1 ea per

180 days retail) PX LANCET AUTO INJECTOR MISC 2 QL(1 ea per

180 days retail)


125

Drug Name DrugTier

Requirements/Limits

PX LANCETS ULTRA THIN MISC 1


QC ADVANCED LANCING DEVICE MISC 2 QL(1 ea per

180 days retail)

QC LANCETS SUPER THIN MISC 1


QC LANCETS ULTRA THIN MISC 1


QC UNILET LANCETS 28G/ULTRA THIN MISC 1


QC UNILET LANCETS 33G/MICRO THIN MISC 1


RA E-ZJECT COLOR LANCETSMICRO-THIN 33G MISC


RA E-ZJECT LANCETS 28G MISC 1


RA E-ZJECT LANCETS THIN 26G MISC 1


RA E-ZJECT LANCETS THIN 28G MISC 1


RA E-ZJECT LANCETS ULTRATHIN 30G MISC 1


RA LANCING DEVICE MISC 2 QL(1 ea per

180 days retail)

REALITY LANCETS MISC 1 200 /month;QL(6.67ea daily)

RELION 2-IN-1 LANCET DEVICES 30G MISC 2 QL(1 ea per

180 days retail) RELION 2-IN-1 LANCING DEVICE 25G MISC 2 QL(1 ea per

180 days retail) RELION 2-IN-1 LANCING DEVICE 30G MISC 2 QL(1 ea per

180 days retail)

RELION LANCETS MICRO-THIN33G MISC 1


Drug Name DrugTier

Requirements/Limits

RELION LANCETS STANDARD 21G MISC 1


RELION LANCETS THIN 26G MISC 1


RELION LANCETS ULTRA-THIN30G MISC 1


RELION LANCING DEVICE MISC 2 QL(1 ea per

180 days retail) RELION ULTRA THIN LANCETS/30G MISC 1 QL(6.67 ea

daily)

RELION ULTRA THIN LANCETS30G MISC 1


RELION ULTRA THIN PLUS LANCETS 32G MISC


RELION ULTRA THIN PLUS LANCETS 33G MISC


REXALL LANCETS ULTRA THIN MISC 1


RIGHTEST GD500 LANCING DEVICE MISC 2 QL(1 ea per

180 days retail)

RIGHTEST GL300 LANCETS MISC 1


SAFETY SEAL LANCETS 28G MISC 1


SAFETY SEAL LANCETS 30G MISC 1


SB LANCETS THIN MISC 1 200 /month;QL(6.67ea daily)

SB LANCETS ULTRA THIN MISC 1


SELECT-LITE LANCING DEVICE MISC 2 QL(1 ea per

180 days retail) SHOPKO AUTOLET LANCING DEVICE MISC 2 QL(1 ea per

180 days retail)


126

Drug Name DrugTier

Requirements/Limits

SHOPKO UNILET LANCETS SUPER THIN 30G MISC


SHOPKO UNILET LANCETS ULTRA THIN 28G MISC


SIMPLE DIAGNOSTICS LANCING DEVICE MISC 2 QL(1 ea per

180 days retail)

SM MICRO THIN LANCETS 33G MISC 1


SM TRUEDRAW LANCING DEVICE MISC 2 QL(1 ea per

180 days retail) SMART DIABETES VANTAGE LANCING DEVICE MISC


SMART SENSE COLOR LANCETS UNIVERSAL 33G MISC


SMART SENSE STANDARD LANCETS UNIVERSAL 21G MISC


SMART SENSE SUPER THIN LANCETS UNIVERSAL 30G MISC


SMART SENSE THIN LANCETSUNIVERSAL 26G MISC


SOLUS V2 LANCING DEVICE MISC 2 QL(1 ea per

180 days retail)

STERILANCE TL MISC 1 200 /month;QL(6.67ea daily)

SUPER THIN LANCETS MISC 1


SURE COMFORT LANCING PEN MISC 2 QL(1 ea per

180 days retail)

SURE-PEN MISC 2 QL(1 ea per180 days retail)

SURELITE LANCETS MISC 1


TECHLITE AST LANCETS MISC 1


Drug Name DrugTier

Requirements/Limits

TECHLITE LANCETS 30G MISC 1


TECHLITE LANCETS MISC 1


TGT LANCET MICRO THIN 33G MISC 1


TGT LANCET THIN 26G MISC 1


TGT LANCET ULTRA THIN 30G MISC 1


TGT LANCING DEVICE MISC 2 QL(1 ea per

180 days retail)

THINLETS GP LANCETS MISC 1


THINLETS LANCET MISC 1 200 /month;QL(6.67ea daily)

TODAYS HEALTH ADVANCED LANCING DEVICE MISC


TODAYS HEALTH SUPER THINLANCETS 30G MISC 1


TODAYS HEALTH ULTRA THINLANCETS 28G MISC 1


TRUE METRIX CONTROL SOLUTION LEVEL 1 SOLN

2 QL(1 ea per 90days retail)




2

TRUECONTROL GLUCOSE CONTROL LEVEL 0 LIQD


TRUECONTROL GLUCOSE CONTROL LEVEL 1 LIQD



127

Drug Name DrugTier

Requirements/Limits

TRUEDRAW LANCING DEVICE MISC 2 QL(1 ea per

180 days retail)

TRUEPLUS LANCETS 26G MISC 1




TRUEPLUS LANCETS 28G SUPER THIN MISC 1




TRUEPLUS LANCETS 30G ULTRA THIN MISC 1




ULTI-LANCE AUTOMATIC/CLEAR TIP MISC 2 QL(1 ea per

180 days retail)

ULTILET CLASSIC LANCETS MISC 1


UNILET COMFORTOUCH LANCET MISC 1


UNILET EXCELITE II MISC 1 200 /month;QL(6.67ea daily)

UNILET EXCELITE MISC 1 200 /month;QL(6.67ea daily)

UNILET G.P. LANCET MISC 1


UNILET G.P. SUPERLITE LANCET MISC 1


UNILET GP 28 ULTRA THIN MISC 1


UNILET LANCET MISC 1 200 /month;QL(6.67ea daily)

Drug Name DrugTier

Requirements/Limits

UNILET LANCETS MICRO-THIN33G MISC 1


UNILET LANCETS MICRO-THIN33G MISC 1 QL(6.67 ea

daily)

UNILET LANCETS SUPER-THIN30G MISC 1


UNILET LANCETS ULTRA-THIN 28G MISC 1


UNILET SUPERLITE LANCET MISC 1


UNIVERSAL 1 LANCETS THIN26G MISC 1


UNIVERSAL 1 LANCETS ULTRA THIN 30G MISC 1


UNIVERSAL 1 LANCETS/33G/MICRO-THIN MISC


VALUE PLUS LANCETS STANDARD 21G MISC 1


VALUE PLUS LANCETS SUPERTHIN 30G MISC 1


VALUE PLUS LANCETS THIN 26G MISC 1


VALUE PLUS LANCING DEVICE MISC 2 QL(1 ea per

180 days retail)

VALUMARK LANCET SUPER THIN 30G MISC 1


VALUMARK LANCET ULTRA THIN 28G MISC 1


VIDA MIA AUTOLET LANCINGDEVICE MISC 2 QL(1 ea per

180 days retail) VIDA MIA UNILET LANCETS SUPER THIN 30G MISC



128

Drug Name DrugTier

Requirements/Limits

VIDA MIA UNILET LANCETS ULTRA THIN 28G MISC


VIVAGUARD LANCING DEVICE MISC 2 QL(1 ea per

180 days retail)

W&F LANCETS 26G MISC 1 200 /month;QL(6.67ea daily)

W&F LANCETS COLORED 21G MISC 1


WALGREENS COMFORT ASSUREDLANCETS MICRO THIN/33G MISC


WALGREENS COMFORT ASSUREDLANCETS SUPER THIN/28G MISC


WALGREENS THIN LANCETS MISC 1


Misc. Devices ALCOHOL PREP PADS PADS 2 RX/OTC

ALCOHOL SWABS PADS 2 RX/OTC

ALCOHOL SWABSTICK PADS 2 RX/OTC

ALCOHOL WIPES PADS 2 RX/OTC

APLICARE ALCOHOL SWABSTICK PADS 2 RX/OTC

BD SWABS SINGLE USE BUTTERFLY PADS 2 RX/OTC

BD SWABS SINGLE USE PADS 2 RX/OTC

CURITY ALCOHOL PREPS/MEDIUM 2 PLYPADS

2 RX/OTC

CURITY ALCOHOL SWABS PADS 2 RX/OTC

CVS PREP PADS PADS 2 RX/OTC

EASY TOUCH ALCOHOL PREP PADS/MEDIUMPADS

2 RX/OTC

FIFTY50 ALCOHOL PREP PADS PADS 2 RX/OTC

Drug Name DrugTier

Requirements/Limits

GNP ALCOHOL SWABS PADS 2 RX/OTC

HM STERILE ALCOHOL PREP PADS PADS 2 RX/OTC

MEIJER ALCOHOL SWABS EXTRA-THICK PADS

2 RX/OTC

PRO COMFORT ALCOHOL PADS PADS 2 RX/OTC

QC ALCOHOL SWABS PADS 2 RX/OTC

RA ALCOHOL SWABS PADS 2 RX/OTC

REALITY SWABS PADS 2 RX/OTC

RELION ALCOHOL SWABS PADS 2 RX/OTC

SB ALCOHOL PREP PADS PADS 2 RX/OTC

SHOPKO ALCOHOL SWABS PADS 2 RX/OTC

SM ALCOHOL PREP PADS PADS 2 RX/OTC

TGT ALCOHOL SWABS PADS 2 RX/OTC

WEBCOL ALCOHOL PREP LARGE 1 PLY PADS

2 RX/OTC

WEBCOL ALCOHOL PREP LARGE 2 PLY PADS

2 RX/OTC

WEBCOL ALCOHOL PREP MEDIUM 2 PLY PADS

2 RX/OTC

Parenteral Therapy Supplies 1ST TIER UNIFINE PENTIPS/MINI/31GX5MMMISC

2 QL(5 ea daily);RX/OTC

1ST TIER UNIFINE PENTIPS29GX12MM MISC


1ST TIER UNIFINE PENTIPS31GX6MM MISC 2 QL(5 ea daily);

RX/OTC 1ST TIER UNIFINE PENTIPS31GX8MM MISC 2 QL(5 ea daily);

RX/OTC


129

Drug Name DrugTier

Requirements/Limits

1ST TIER UNIFINE PENTIPS32GX4MM MISC 2 QL(5 ea daily);

RX/OTC 1ST TIER UNIFINE PENTIPS32GX6MM MISC 2 QL(5 ea daily)

1ST TIER UNIFINE PENTIPS33GX4MM MISC 2 QL(5 ea daily)

1ST TIER UNIFINE PENTIPSPLUS 31GX8MM MISC





2 QL(5 ea daily)

1ST TIER UNIFINE PENTIPSPLUS/MINI/31GX5MM MISC


1ST TIER UNIFINE PENTIPSPLUS/ORIGINAL/29GX12MM MISC


1ST TIER UNIFINE PENTIPSPLUS/ULTRASHORT/31GX6MM MISC


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

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

3ML LUER LOCK SAFETY SYRINGES MISC 2 RX/OTC

3ML SYRINGE/INTERLINKSYRINGE CANNULA MISC

2 RX/OTC

3ML SYRINGE/INTERLINKVIAL ACCESS CANNULA MISC

2 RX/OTC

ABOUTTIME PEN NEEDLE 32GX 5/32" MISC 2 QL(5 ea daily);

RX/OTC ABOUTTIME PEN NEEDLES 30GX 5/16"MISC


ABOUTTIME PEN NEEDLES 31G X 3/16"MISC


ABOUTTIME PEN NEEDLES 31G X 5/16"MISC


Drug Name DrugTier

Requirements/Limits

ADVOCATE INSULIN PEN NEEDLES 29GX12.7MM MISC


ADVOCATE INSULIN PEN NEEDLES 31GX5MM MISC


ADVOCATE INSULIN PEN NEEDLES 31GX8MM MISC


ADVOCATE INSULIN PEN NEEDLES MISC 2 QL(5 ea daily)

ADVOCATE INSULIN SYRINGE/U-100/0.3ML/29GX1/2" MISC


ADVOCATE INSULIN SYRINGE/U-100/0.3ML/30GX5/16"MISC

2

QL(5 ea daily);RX/OTC


2

QL(5 ea daily)

ADVOCATE INSULIN SYRINGE/U-100/0.5ML/29GX1/2" MISC



2



2

QL(5 ea daily)

ADVOCATE INSULIN SYRINGE/U-100/1ML/29GX1/2" MISC





2 QL(5 ea daily)

ANTI-STICK INSULIN SYRINGE/U-100/0.5ML/28G X 1/2"MISC

2



130

Drug Name DrugTier

Requirements/Limits

ANTI-STICK INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC

2


ANTI-STICK INSULIN SYRINGE/U-100/1ML/29GX 1/2" MISC


ASSURE ID INSULIN SAFETYSYRINGE/U-100/0.5ML/29G X 1/2"MISC

2


ASSURE ID INSULIN SAFETYSYRINGE/U-100/1ML/29G X 1/2" MISC


ASSURE ID SAFETY PEN NEEDLES 30G X 5/16"MISC


ASSURE ID SAFETY PEN NEEDLES 31G X 3/16"MISC


AURORA PEN NEEDLES 29GX12MM MISC 2 QL(5 ea daily);

RX/OTC AURORA PEN NEEDLES 31G X6MM MISC 2 QL(5 ea daily);

RX/OTC AURORA PEN NEEDLES 31G X8MM MISC 2 QL(5 ea daily);

RX/OTC AURORA UNIFINE PENTIPS/32GX5/32" MISC 2 QL(5 ea daily);

RX/OTC AURORA UNIFINE PENTIPS/MINI/31GX3/16"MISC


B-D INSULIN SYRINGE ULTRAFINE II/0.3ML/31GX 5/16" MISC

2 QL(5 ea daily)

B-D INSULIN SYRINGE ULTRAFINE II/0.5ML/31GX 5/16" MISC

2 QL(5 ea daily)

B-D INSULIN SYRINGE ULTRAFINE II/1ML/31G X5/16" MISC

2 QL(5 ea daily)

B-D INSULIN SYRINGE ULTRAFINE/0.3ML/30G X1/2" MISC

2 QL(5 ea daily)

B-D INSULIN SYRINGE ULTRAFINE/0.5ML/30G X1/2" MISC

2 QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits

BD LO-DOSE INSULIN SYRINGE MICROFINE IV/0.5ML/28G X 1/2" MISC


BD 3ML SYRINGE LUER-LOK TIP MISC 2 RX/OTC

BD 3ML SYRINGE SLIP TIP MISC 2 RX/OTC

BD BLUNT FILL NEEDLE MISC 2 RX/OTC

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

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

2 RX/OTC

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

2

RX/OTC

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

2 RX/OTC

BD HYPODERMIC NEEDLES 18GX1.5" MISC 2 RX/OTC

BD INSULIN SYRINGE LUER-LOK/U-100/1MLMISC


BD INSULIN SYRINGE MICROFINE IV/U-100/0.5ML/28G X 1/2"MISC

2


BD INSULIN SYRINGE MICROFINE IV/U-100/1ML/27G X 5/8" MISC

2 QL(5 ea daily)

BD INSULIN SYRINGE MICROFINE IV/U-100/1ML/28G X 1/2" MISC


BD INSULIN SYRINGE MICROFINE/U-100/0.5ML/28G X 1/2"MISC

2


BD INSULIN SYRINGE MICROFINE/U-100/1ML/27G X 5/8" MISC

2 QL(5 ea daily)

BD INSULIN SYRINGE MICROFINE/U-100/1ML/28G X 1/2" MISC



131

Drug Name DrugTier

Requirements/Limits

BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X1/2" MISC


BD INSULIN SYRINGE SLIP TIP/U-100/1ML MISC 2 QL(5 ea daily);

RX/OTC BD INSULIN SYRINGE ULTRA-FINE/0.3ML/30G X12.7MM MISC

2 QL(5 ea daily)

BD INSULIN SYRINGE ULTRA-FINE/0.3ML/31G X8MM MISC

2 QL(5 ea daily)

BD INSULIN SYRINGE ULTRA-FINE/0.5ML/30G X12.7MM MISC

2 QL(5 ea daily)

BD INSULIN SYRINGE ULTRA-FINE/0.5ML/31G X8MM MISC

2 QL(5 ea daily)

BD INSULIN SYRINGE ULTRA-FINE/1/2UNIT/0.3ML/31G X 8MMMISC

2

QL(5 ea daily)

BD INSULIN SYRINGE ULTRA-FINE/1ML/30G X12.7MM MISC

2 QL(5 ea daily)

BD INSULIN SYRINGE ULTRA-FINE/1ML/31G X8MM MISC

2 QL(5 ea daily)

BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X1/2" MISC

2 QL(5 ea daily)

BD INSULIN SYRINGE ULTRAFINE/0.5ML/31G X5/16" MISC

2 QL(5 ea daily)

BD INSULIN SYRINGE ULTRAFINE/1ML/30G X1/2" MISC

2 QL(5 ea daily)

BD INSULIN SYRINGE ULTRAFINE/U-100/0.3ML/29G X 1/2"MISC

2


BD INSULIN SYRINGE ULTRAFINE/U-100/0.5ML/29G X 1/2"MISC

2


BD INSULIN SYRINGE ULTRAFINE/U-100/1ML/29G X 1/2" MISC


Drug Name DrugTier

Requirements/Limits

BD INSULIN SYRINGE/0.3ML/29G X12.7MM MISC


BD INSULIN SYRINGE/0.5ML/29G X12.7MM MISC


BD INSULIN SYRINGE/1ML/27G X12.7MM MISC


BD INSULIN SYRINGE/1ML/29G X12.7MM MISC


BD INSULIN SYRINGE/DETACHABLENEEDLE/U-100/1ML/25GX 1" MISC

2

QL(5 ea daily)

BD INSULIN SYRINGE/DETACHABLENEEDLE/U-100/1ML/25GX 5/8" MISC

2

QL(5 ea daily)

BD INSULIN SYRINGE/DETACHABLENEEDLE/U-100/1ML/26GX 1/2" MISC

2

QL(5 ea daily)

BD INSULIN SYRINGE/U-100/1ML/27G X 1/2" MISC 2 QL(5 ea daily);

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

BD PEN NEEDLE/MICRO/ULTRA-FINE/32G X 6MM MISC

2 QL(5 ea daily)

BD PEN NEEDLE/MINI/ULTRA-FINE/31G X 5MM MISC


BD PEN NEEDLE/NANO2ND GEN/32G X 5/32"MISC


BD PEN NEEDLE/NANO/ULTRA-FINE/32G X 4MM MISC


BD PEN NEEDLE/ORIGINAL/ULTRA-FINE/29G X 12.7MMMISC

2


BD PEN NEEDLE/SHORT/ULTRA-FINE/31G X 8MM MISC



132

Drug Name DrugTier

Requirements/Limits

BD SAFETY-GLIDE INSULIN SYRINGE/0.5ML/29G X1/2" MISC

2


BD SAFETY-LOK INSULIN SYRINGE/PERMNEEDLE/UF/1ML/29G X1/2" MISC

2


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

2 RX/OTC

BD SAFETYGLIDE INSULIN SYRINGE/0.3ML/29G X1/2" MISC

2


BD SAFETYGLIDE INSULIN SYRINGE/0.3ML/31G X5/16" MISC

2

QL(5 ea daily)

BD SAFETYGLIDE INSULIN SYSYRINGE/0.5ML/30G X5/16" MISC

2


CAREFINE PEN NEEDLE 32GX4MM MISC 2 QL(5 ea daily);

RX/OTC CAREFINE PEN NEEDLES 29GX1/2" MISC 2 QL(5 ea daily);

RX/OTC CAREFINE PEN NEEDLES 30GX5/16"MISC


CAREFINE PEN NEEDLES 31GX6MM MISC







2 QL(5 ea daily)

CAREONE INSULIN SYRINGES/0.3ML/30G X1/2" MISC

2 QL(5 ea daily)


2 QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits


2 QL(5 ea daily)


2 QL(5 ea daily)

CAREONE INSULIN SYRINGES/1ML/30G X1/2" MISC

2 QL(5 ea daily)

CAREONE INSULIN SYRINGES/1ML/31GX5/16" MISC

2 QL(5 ea daily)

CAREONE UNIFINE PENTIPS 29GX12MM MISC


CAREONE UNIFINE PENTIPS 31GX5MM MISC 2 QL(5 ea daily);

RX/OTC CAREONE UNIFINE PENTIPS 31GX6MM MISC 2 QL(5 ea daily);

RX/OTC CAREONE UNIFINE PENTIPS 31GX8MM MISC 2 QL(5 ea daily);

RX/OTC CAREONE UNIFINE PENTIPS PEN NEEDLES 32GX4MM MISC


CAREONE UNIFINE PENTIPS PLUS PEN NEEDLES 29GX12MM MISC

2



2



2



2



2


CARETOUCH PEN NEEDLES 31G X 6 MM MISC



133

Drug Name DrugTier

Requirements/Limits

CARETOUCH PEN NEEDLES 31GX 5MM MISC








CLEVER CHOICE COMFORT EZINSULIN PEN NEEDLES 31GX8MM MISC

2


CLEVER CHOICE COMFORT EZINSULIN PEN NEEDLES 33GX4MM MISC

2

QL(5 ea daily)

CLEVER CHOICE COMFORT EZINSULIN SYRINGE/0.3ML/29G X1/2" MISC

2



2

QL(5 ea daily)


2



2

QL(5 ea daily)


2



2



2

QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits


2



2

QL(5 ea daily)


2

QL(5 ea daily)

CLEVER CHOICE COMFORT EZINSULIN SYRINGE/1ML/28G X 1/2"MISC

2


CLEVER CHOICE COMFORT EZINSULIN SYRINGE/1ML/29G X 1/2"MISC

2


CLEVER CHOICE COMFORT EZINSULIN SYRINGE/1ML/30G X5/16" MISC

2


CLEVER CHOICE COMFORT EZINSULIN SYRINGE/U-100/1ML/31GX5/16" MISC

2

QL(5 ea daily)

CLEVER CHOICE COMFORT EZPEN NEEDLES 29GX12MM MISC

2



2



2



2



2



134

Drug Name DrugTier

Requirements/Limits


2



2

QL(5 ea daily)


2

QL(5 ea daily)


2

QL(5 ea daily)

CLICKFINE PEN NEEDLE 32GX5/32" MISC 2 QL(5 ea daily);

RX/OTC CLICKFINE PEN NEEDLE UNIVERSAL/31GX1/4"MISC


CLICKFINE PEN NEEDLE UNIVERSAL/31GX5/16"MISC


CLICKFINE PEN NEEDLES 31G X 1/4"MISC






CLICKFINE PEN NEEDLES 31G X 8MM MISC




CLICKFINE PEN NEEDLES/31GX1/4" MISC 2 QL(5 ea daily);

RX/OTC CLICKFINE UNIVERSAL PEN NEEDLES 31GX5/16"MISC


COMFORT ASSIST INSULIN SYRINGE 0.3ML/29G X 1/2" MISC


Drug Name DrugTier

Requirements/Limits

COMFORT ASSIST INSULIN SYRINGE/0.3ML/30G X5/16" MISC

2



2

QL(5 ea daily)


2



2



2

QL(5 ea daily)

COMFORT ASSIST INSULIN SYRINGE/1ML/29G X 1/2"MISC

2


COMFORT ASSIST INSULIN SYRINGE/1ML/30G X5/16" MISC

2


COMFORT ASSIST INSULIN SYRINGE/1ML/31G X5/16" MISC

2

QL(5 ea daily)

COMFORT EZ INSULIN SYRINGE/U-100/0.5ML/31G X 5/16"MISC

2

QL(5 ea daily)

COMFORT EZ INSULIN SYRINGE/U-100/1ML/31GX 5/16" MISC

2 QL(5 ea daily)

COMFORT EZ MICRO/32G X 4MM MISC 2 QL(5 ea daily);

RX/OTC COMFORT EZ SHORT/31G X 8MM MISC 2 QL(5 ea daily);

RX/OTC COMFORT EZ/31G X 5MMMISC 2 QL(5 ea daily);

RX/OTC COMFORT EZ/31G X 6MMMISC 2 QL(5 ea daily);

RX/OTC


135

Drug Name DrugTier

Requirements/Limits

DROPLET INSULIN SYRINGE 0.3ML/29G X1/2" MISC


DROPLET INSULIN SYRINGE 0.5ML/29G X1/2" MISC


DROPLET INSULIN SYRINGE 1ML/29G X 1/2"MISC


DROPLET INSULIN SYRINGE U-100/0.3/31GX 5/16" MISC

2 QL(5 ea daily)

DROPLET INSULIN SYRINGE U-100/0.3ML/30G X 1/2"MISC

2

QL(5 ea daily)


2



2

QL(5 ea daily)


2



2

QL(5 ea daily)

DROPLET INSULIN SYRINGE U-100/1ML/30GX 1/2" MISC

2 QL(5 ea daily)




2 QL(5 ea daily)

DROPLET INSULIN SYRINGE/U-100/0.3ML/31G X 5/16"MISC

2

QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits


2

QL(5 ea daily)


2

QL(5 ea daily)

DROPLET INSULIN SYRINGE/U-100/1ML/30GX 1/2" MISC

2 QL(5 ea daily)

DROPLET INSULIN SYRINGE/U-100/1ML/31GX 5/16" MISC

2 QL(5 ea daily)

DROPLET PEN NEEDLES 29GX12MM MISC 2 QL(5 ea daily);

RX/OTC DROPLET PEN NEEDLES 30G X 5/16" MISC 2 QL(5 ea daily);

RX/OTC DROPLET PEN NEEDLES 31GX5MM MISC 2 QL(5 ea daily);



RX/OTC DROPLET PEN NEEDLES 32G X 1/4" MISC 2 QL(5 ea daily)

DROPLET PEN NEEDLES 32G X 3/16" MISC 2 QL(5 ea daily);

RX/OTC DROPLET PEN NEEDLES 32G X 5/16" MISC 2 QL(5 ea daily)

DROPLET PEN NEEDLES 32G X 5/32" MISC 2 QL(5 ea daily);



RX/OTC DROPLET PEN NEEDLES 32GX6MM MISC 2 QL(5 ea daily)

DROPLET PEN NEEDLES 32GX8MM MISC 2 QL(5 ea daily)

DROPSAFE SAFETY PEN NEEDLES/31G X 5/16"MISC


DROPSAFE SAFTEY PEN NEEDLES/31G X 1/4"MISC



136

Drug Name DrugTier

Requirements/Limits

DRUG MART UNIFINE PENTIPS 31GX5MM MISC 2 QL(5 ea daily);

RX/OTC DRUG MART UNIFINE PENTIPS29G X 12MM MISC


DRUG MART UNIFINE PENTIPS31GX6MM MISC 2 QL(5 ea daily);

RX/OTC DRUG MART UNIFINE PENTIPS31GX8MM MISC 2 QL(5 ea daily);

RX/OTC DRUG MART UNIFINE PENTIPS32GX4MM MISC 2 QL(5 ea daily);

RX/OTC DRUG MART UNIFINE PENTIPSPLUS 32GX4MM MISC


EASY COMFORT INSULIN SYRINGE/0.5ML/30G X5/16" MISC


EASY COMFORT INSULIN SYRINGE/0.5ML/31G X5/16" MISC

2 QL(5 ea daily)

EASY COMFORT INSULIN SYRINGE/1ML/30G X5/16" MISC


EASY COMFORT INSULIN SYRINGE/1ML/31G X5/16" MISC

2 QL(5 ea daily)

EASY COMFORT INSULIN SYRINGE/U-100/0.5ML/30G X 1/2"MISC

2

QL(5 ea daily)

EASY COMFORT INSULIN SYRINGE/U-100/1ML/30GX 1/2" MISC

2 QL(5 ea daily)

EASY COMFORT PEN NEEDLES31GX1/4" MISC 2 QL(5 ea daily);

RX/OTC EASY COMFORT PEN NEEDLES31GX3/16"MISC


EASY COMFORT PEN NEEDLES31GX5/16"MISC


EASY COMFORT PEN NEEDLES32GX5/32"MISC


EASY COMFORT PEN NEEDLES33G X 4MM MISC

2 QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits

EASY GLIDE PEN NEEDLES 33G X 5/32"MISC

2 QL(5 ea daily)

EASY TOUCH 32GX5MM MISC 2 QL(5 ea daily);

RX/OTC EASY TOUCH 32GX6MM MISC 2 QL(5 ea daily)

EASY TOUCH FLIPLOCK NEEDLES 18GX1-1/2"MISC

2 RX/OTC

EASY TOUCH FLIPLOCK SAFETY INSULIN SYRINGE 1ML/29GX1/2"MISC

2



2

QL(5 ea daily)


2



2

QL(5 ea daily)

EASY TOUCH HYPODERMIC NEEDLES 18GX1-1/2" MISC

2 RX/OTC

EASY TOUCH INSULIN SYRINGE/0.3ML/30G X5/16" MISC



2 QL(5 ea daily)





EASY TOUCH INSULIN SYRINGE/1ML/30G X5/16" MISC


EASY TOUCH INSULIN SYRINGE/SAFETY/U-100/0.5ML/29G X 1/2"MISC

2



137

Drug Name DrugTier

Requirements/Limits

EASY TOUCH INSULIN SYRINGE/SAFETY/U-100/0.5ML/30G X 5/16"MISC

2


EASY TOUCH INSULIN SYRINGE/SAFETY/U-100/1ML/29G X 1/2" MISC


EASY TOUCH INSULIN SYRINGE/SAFETY/U-100/1ML/30G X 1/2" MISC

2 QL(5 ea daily)

EASY TOUCH INSULIN SYRINGE/U-100/0.3ML/30G X 1/2"MISC

2

QL(5 ea daily)


2

QL(5 ea daily)


2



2

QL(5 ea daily)


2

QL(5 ea daily)

EASY TOUCH INSULIN SYRINGE/U-100/1ML/27GX 1/2" MISC







2 QL(5 ea daily)


2 QL(5 ea daily)

EASY TOUCH PEN NEEDLE 30G X 5/16"MISC


Drug Name DrugTier

Requirements/Limits

EASY TOUCH PEN NEEDLES 29GX1/2" MISC 2 QL(5 ea daily);

RX/OTC EASY TOUCH PEN NEEDLES 31GX1/4" MISC 2 QL(5 ea daily);

RX/OTC EASY TOUCH PEN NEEDLES 31GX5/16"MISC


EASY TOUCH PEN NEEDLES 32GX1/4" MISC 2 QL(5 ea daily)

EASY TOUCH PEN NEEDLES 32GX3/16"MISC


EASY TOUCH PEN NEEDLES 32GX5/32"MISC


EASY TOUCH PEN NEEDLES/31G X 3/16"MISC


EASY TOUCH SAFETY PEN NEEDLES/30G X5/16" MISC


EASY TOUCH SHEATHLOCK SAFETY INSULIN SYRINGE 1ML/29GX1/2" MISC

2



2



2

QL(5 ea daily)

EASY TOUCH SHEATHLOCK SAFETY SYRINGE 1ML/30GX1/2"MISC

2

QL(5 ea daily)

ELITE-THIN INSULIN SYRINGE/0.3ML/31G X5/16" MISC

2 QL(5 ea daily)






138

Drug Name DrugTier

Requirements/Limits

ELITE-THIN INSULIN SYRINGE/1ML/30G X5/16" MISC


ELITE-THIN INSULIN SYRINGE/U-100/0.5ML/28G X 1/2"MISC

2


ELITE-THIN INSULIN SYRINGE/U-100/0.5ML/31G X 5/16"MISC

2

QL(5 ea daily)

ELITE-THIN INSULIN SYRINGE/U-100/1ML/28GX 1/2" MISC





2 QL(5 ea daily)

EQL INSULIN SYRINGE/0.3ML/29G X1/2" MISC





2 QL(5 ea daily)






2 QL(5 ea daily)

EQL INSULIN SYRINGE/1ML/29G X 1/2"MISC


EQL INSULIN SYRINGE/1ML/30G X5/16" MISC


EQL INSULIN SYRINGE/1ML/31G X5/16" MISC

2 QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits

EXCEL COMFORT POINT INSULIN PEN NEEDLES 31G X 4MM MISC

2 QL(5 ea daily)

EXEL COMFORT POINT INSULIN PEN NEEDLES 29G X 12MM MISC






EXEL COMFORT POINT INSULIN SYRINGE/0.3ML/29G X1/2" MISC

2



2



2



2



2


EXEL COMFORT POINT INSULIN SYRINGE/1ML/28G X 1/2"MISC

2


EXEL COMFORT POINT INSULIN SYRINGE/1ML/29G X 1/2"MISC

2


EXEL COMFORT POINT INSULIN SYRINGE/1ML/30G X5/16" MISC

2


FIFTY50 PEN NEEDLES 31G X3/16" (5MM) MISC 2 QL(5 ea daily);

RX/OTC FIFTY50 PEN NEEDLES 31G X5/16" (8MM) MISC 2 QL(5 ea daily);

RX/OTC


139

Drug Name DrugTier

Requirements/Limits

FIFTY50 PEN NEEDLES 31GX5MM MISC 2 QL(5 ea daily);

RX/OTC FIFTY50 PEN NEEDLES/31GX8MMMISC


FIFTY50 PEN NEEDLES/32GX4MMMISC


FIFTY50 PEN NEEDLES/32GX6MMMISC

2 QL(5 ea daily)

FIFTY50 SUPERIOR COMFORTINSULIN SYRINGE/0.3ML/31G X5/16" MISC

2

QL(5 ea daily)

FIFTY50 SUPERIOR COMFORTINSULIN SYRINGE/0.5ML/31G X5/16" MISC

2

QL(5 ea daily)

FIFTY50 SUPERIOR COMFORTINSULIN SYRINGE/1ML/31G X5/16" MISC

2

QL(5 ea daily)

FREDS PHARMACY UNIFINE PENTIPS PEN NEEDLES 32GX4MM MISC

2


FREDS PHARMACY UNIFINE PENTIPS PLUS 31GX5MM MISC


FREDS PHARMACY UNIFINE PENTIPS PLUS 31GX8MM MISC


FREESTYLE PRECISION INSULIN SYRINGE/U-100/0.5ML/30G X 5/16"MISC

2


FREESTYLE PRECISION INSULIN SYRINGE/U-100/0.5ML/31G X 5/16"MISC

2

QL(5 ea daily)

FREESTYLE PRECISION INSULIN SYRINGE/U-100/1ML/31G X 5/16"MISC

2

QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits

FREESTYLE PRECISION INSULIN SYRINGES/U-100/1ML/30G X 5/16"MISC

2


GLOBAL EASE INJECT PEN NEEDLES 29GX12MM MISC






GLOBAL EASE INJECT PEN NEEEDLES 31GX5MM MISC


GLOBAL EASY GLIDE INSULINSYRINGE/U-100/0.3ML/31G X 5/16"MISC

2

QL(5 ea daily)

GLOBAL EASY GLIDE PEN NEEDLES 32GX4MM MISC


GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC

2



2

QL(5 ea daily)


2



2

QL(5 ea daily)


2



2



140

Drug Name DrugTier

Requirements/Limits


2

QL(5 ea daily)


2



2

QL(5 ea daily)

GLOBAL INJECT EASE INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC





2 QL(5 ea daily)

GLOBAL INJECT EASE INSULIN SYRINGE/U-100/1ML/30G X 5/16"MISC

2


GLOBAL INJECT EASE INSULIN SYRINGE/U-100/1ML/31G X 5/16"MISC

2

QL(5 ea daily)

GLOBAL INSULIN SYRINGE/U-100/0.3ML/30G X 1/2"MISC

2

QL(5 ea daily)

GLOBAL INSULIN SYRINGES/U-100/0.3ML/30GX5/16"MISC

2


GLUCOPRO INSULIN SYRINGE/U-100/0.3ML/30G X 1/2"MISC

2

QL(5 ea daily)


2


Drug Name DrugTier

Requirements/Limits


2

QL(5 ea daily)


2

QL(5 ea daily)


2



2

QL(5 ea daily)

GLUCOPRO INSULIN SYRINGE/U-100/1ML/30GX 1/2" MISC

2 QL(5 ea daily)




2 QL(5 ea daily)

GNP CLICKFINE PEN NEEDLEUNIVERSAL/31GX5/16" MISC


GNP CLICKFINE UNIVERSAL PEN NEEDLES 31GX1/4" MISC


GNP CLICKFINE UNIVERSAL PEN NEEDLES 31GX5/16"MISC

2


GNP INSULIN SYRINGE/0.3ML/29G X1/2" MISC





2 QL(5 ea daily)




141

Drug Name DrugTier

Requirements/Limits






2 QL(5 ea daily)

GNP INSULIN SYRINGE/1ML/28G X 1/2"MISC


GNP INSULIN SYRINGE/1ML/29G X 1/2"MISC


GNP INSULIN SYRINGE/1ML/30G X5/16" MISC


GNP INSULIN SYRINGE/1ML/31G X5/16" MISC

2 QL(5 ea daily)

GNP ULTRA COMFORT INSULIN SYRINGE/0.3ML/29G X1/2" MISC

2


GNP ULTRA COMFORT INSULIN SYRINGE/0.3ML/30G X5/16" SHORT MISC

2



2

QL(5 ea daily)


2



2



2


Drug Name DrugTier

Requirements/Limits


2

QL(5 ea daily)

GNP ULTRA COMFORT INSULIN SYRINGE/1ML/28G X 1/2"MISC

2


GNP ULTRA COMFORT INSULIN SYRINGE/1ML/29G X 1/2"MISC

2


GNP ULTRA COMFORT INSULIN SYRINGE/1ML/30G X5/16" SHORT MISC

2


GNP ULTRA COMFORT INSULIN SYRINGE/1ML/31G X5/16" SHORT MISC

2

QL(5 ea daily)

GOODSENSE CLICKFINE SAFETY PEN NEEDLE/31G X 3/16"MISC

2


GOODSENSE PEN NEEDLE/PENFINECLASSIC/31G X 3/16"MISC

2



2


GOODSENSE PEN NEEDLE/PENFINECLASSIC/32G X 1/4" MISC

2 QL(5 ea daily)


2


H-E-B IN CONTROL PEN NEEDLES 31GX5MM MISC







142

Drug Name DrugTier

Requirements/Limits

H-E-B IN CONTROL PEN NEEDLES/NANO/32GX4MM MISC


H-E-B IN CONTROL UNIFINEPENTIPS PLUS 31GX5MM MISC


H-E-B IN CONTROL UNIFINEPENTIPS PLUS 32GX4MM MISC


H-E-B INCONTROL PEN NEEDLES 29GX12MM MISC


HEALTHWISE INSULIN SYRINGE/U-100/0.3ML/30G X 5/16"MISC

2



2

QL(5 ea daily)


2



2

QL(5 ea daily)

HEALTHWISE INSULIN SYRINGE/U-100/1ML/30GX 5/16" MISC


HEALTHWISE INSULIN SYRINGE/U-100/1ML/31GX 5/16" MISC

2 QL(5 ea daily)

HEALTHWISE MICRON PEN NEEDLES/32G X5/32" MISC


HEALTHWISE MINI PEN NEEDLES 31GX6MM MISC


HEALTHWISE PEN NEEDLES 29GX12MM MISC


HEALTHWISE SHORT PEN NEEDLES 31GX8MM MISC


Drug Name DrugTier

Requirements/Limits

HEALTHWISE SHORT PEN NEEDLES/31G X3/16" MISC


HEALTHWISE SHORT PEN NEEDLES/31G X5/16" MISC


HEALTHWISE UNIFINE PENTIPS PEN NEEDLES 32GX4MM MISC


HEALTHY ACCENTS UNIFINE PENTIPS PEN NEEDLES 29GX12MM MISC

2



2



2



2



2


HM ULTICARE INSULIN SYRINGE/1ML/30G X 1/2"MISC

2 QL(5 ea daily)

HM ULTICARE INSULIN SYRINGE/U-100/0.3ML/31G X 5/16"MISC

2

QL(5 ea daily)

HM ULTICARE SHORT PEN NEEDLES 31GX8MM MISC


HYPODERMIC NEEDLE 18G X 1-1/2" MISC 2 RX/OTC

HYPODERMIC NEEDLES 18GX1-1/2" MISC 2 RX/OTC

INSULIN SYRINGE/0.3ML/29G X 1"MISC

2 QL(5 ea daily)


143

Drug Name DrugTier

Requirements/Limits

INSULIN SYRINGE/0.3ML/29G X1/2" MISC





2 QL(5 ea daily)


2 QL(5 ea daily)




2 QL(5 ea daily)




2 QL(5 ea daily)

INSULIN SYRINGE/1ML/28G X 1/2"MISC


INSULIN SYRINGE/1ML/29G X 1/2"MISC


INSULIN SYRINGE/1ML/30G X5/16" MISC


INSULIN SYRINGE/NEEDLE0.3ML/30G X 5/16" MISC



2 QL(5 ea daily)






2 QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits

INSULIN SYRINGE/NEEDLE1ML/29G X 1/2" MISC





2 QL(5 ea daily)

INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC






INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC 2 QL(5 ea daily);

RX/OTC INSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC 2 QL(5 ea daily);

RX/OTC INSULIN SYRINGE/U-100/1ML/30G X 5/16"MISC


INSULIN SYRINGE/U-100/1ML/31G X 5/16"MISC

2 QL(5 ea daily)

INSULIN SYRINGES/0.5ML/27GX1/2" MISC

2 QL(5 ea daily)








2 QL(5 ea daily)


2 QL(5 ea daily)


144

Drug Name DrugTier

Requirements/Limits

INSULIN SYRINGES/1ML/27GX/1/2"MISC


INSULIN SYRINGES/1ML/27GX1/2"MISC







2 QL(5 ea daily)

INSULIN SYRINGES/1ML/31GX5/16" MISC

2 QL(5 ea daily)

INSUPEN 29G X 12MM MISC 2 QL(5 ea daily);

RX/OTC INSUPEN 31G X 5MM MISC 2 QL(5 ea daily);



RX/OTC

INSUPEN 33GX4MM MISC 2 QL(5 ea daily)

INSUPEN PEN NEEDLES 32G X4MM MISC 2 QL(5 ea daily);

RX/OTC INSUPEN SENSITIVE 32GX6MM MISC 2 QL(5 ea daily)

INSUPEN SENSITIVE 32GX8MM MISC 2 QL(5 ea daily)

INSUPEN ULTRAFIN 29GX12MM MISC 2 QL(5 ea daily);

RX/OTC INSUPEN ULTRAFIN 30GX8MM MISC 2 QL(5 ea daily);



RX/OTC KINRAY INSULIN SYRINGE PREFERRED PLUS/0.3ML/31G X 5/16"MISC

2

QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits

KINRAY INSULIN SYRINGE PREFERRED PLUS/0.5ML/31G X 5/16"MISC

2

QL(5 ea daily)

KINRAY INSULIN SYRINGE PREFERRED PLUS/1ML/31G X 5/16"MISC

2

QL(5 ea daily)

KINRAY INSULIN SYRINGE/0.5ML/29G X1/2" MISC


KMART VALU PLUS INSULIN SYRINGE/1ML/29G MISC


KMART VALU PLUS INSULIN SYRINGE/1ML/30G MISC


KROGER INSULIN SYRINGE/0.3ML/29G X1/2" MISC





2 QL(5 ea daily)






2 QL(5 ea daily)

KROGER INSULIN SYRINGE/1ML/29G X 1/2"MISC


KROGER INSULIN SYRINGE/1ML/30G X5/16" MISC


KROGER INSULIN SYRINGE/1ML/31G X5/16" MISC

2 QL(5 ea daily)

KROGER PEN NEEDLES 29G X12MM MISC 2 QL(5 ea daily);

RX/OTC KROGER PEN NEEDLES 31G X8MM MISC 2 QL(5 ea daily);

RX/OTC


145

Drug Name DrugTier

Requirements/Limits

KROGER PEN NEEDLES 31GX1/4" MISC 2 QL(5 ea daily);

RX/OTC KROGER PEN NEEDLES/31G X1/4"MISC


KROGER PEN NEEDLES/31G X3/16"MISC







2 QL(5 ea daily)

LEADER INSULIN SYRINGE/0.3ML/29G X1/2" MISC





2 QL(5 ea daily)








2 QL(5 ea daily)

LEADER INSULIN SYRINGE/1ML/28G X 1/2"MISC


LEADER INSULIN SYRINGE/1ML/29G X 1/2"MISC


LEADER INSULIN SYRINGE/1ML/30G X5/16" MISC


Drug Name DrugTier

Requirements/Limits

LEADER INSULIN SYRINGE/1ML/31G X5/16" MISC

2 QL(5 ea daily)

LEADER UNIFINE PENTIPS PLUS/MINI/31GX3/16"MISC

2


LEADER UNIFINE PENTIPS PLUS/SHORT/31GX5/16"MISC

2


LEADER UNIFINE PENTIPS/MINI/31GX3/16"MISC


LEADER UNIFINE PENTIPS/NANO/32GX5/32" MISC


LEADER UNIFINE PENTIPS/PLUS/32GX5/32"MISC


LITETOUCH INSULIN PEN NEEDLES/32G X4MM/MINI MISC


LITETOUCH INSULIN SYRINGE/0.3ML/29G X1/2" MISC





2 QL(5 ea daily)




2 QL(5 ea daily)

LITETOUCH INSULIN SYRINGE/1ML/30G X5/16" MISC


LITETOUCH INSULIN SYRINGE/U-100/0.3ML/30G X 5/16"MISC

2



146

Drug Name DrugTier

Requirements/Limits


2

QL(5 ea daily)


2



2



2



2

QL(5 ea daily)

LITETOUCH INSULIN SYRINGE/U-100/1ML/28GX 1/2" MISC







2 QL(5 ea daily)

LITETOUCH PEN NEEDLES 29GX12.7MM MISC


LITETOUCH PEN NEEDLES 31G X 6MM MISC


LITETOUCH PEN NEEDLES 31G X 6MM/ULTRA SHORTMISC

2


LITETOUCH PEN NEEDLES 31GX8MM SHORT MISC


LITETOUCH PEN NEEDLES/31G X 3/16"MISC


Drug Name DrugTier

Requirements/Limits

LITETOUCH PEN NEEDLES/31G X5MM/MINI MISC


LITETOUCH PEN NEEDLES/31G X8MM/SHORT MISC


LONGS INSULIN SYRINGE/0.5ML/31G X5/16" MISC

2 QL(5 ea daily)

MAGELLAN INSULIN SAFETY SYRINGE/U-100/0.3ML/29G X 1/2"MISC

2



2



2



2


MAGELLAN INSULIN SAFETY SYRINGE/U-100/1ML/29G X 1/2" MISC


MAGELLAN INSULIN SAFETY SYRINGE/U-100/1ML/30G X 5/16"MISC

2


MARATHON MEDICAL PENTIPS29GX12MM MISC


MARATHON MEDICAL PENTIPS31GX5MM MISC 2 QL(5 ea daily);

RX/OTC MARATHON MEDICAL PENTIPS31GX8MM MISC 2 QL(5 ea daily);

RX/OTC MARATHON MEDICAL PENTIPS32GX4MM MISC 2 QL(5 ea daily);

RX/OTC MAXI-COMFORT INSULIN SYRINGE/U-100/0.5ML/28GX1/2" MISC


MAXI-COMFORT INSULIN SYRINGE/U-100/1ML/28GX1/2" MISC



147

Drug Name DrugTier

Requirements/Limits

MAXICOMFORT II PEN NEEDLES/31G X 1/4"MISC


MAXICOMFORT INSULIN SYRINGES 27G X 1/2"MISC


MAXICOMFORT INSULIN SYRINGES 27G X 1/2"MISC

2 QL(5 ea daily)

MEDIC INSULIN SYRINGE/0.3ML/30G X5/16" MISC


MEDIC INSULIN SYRINGE/0.5ML/30G X5/16" MISC


MEDICINE SHOPPE PEN NEEDLES 29G X 12MM MISC






MEIJER PEN NEEDLES 29G X12MM MISC 2 QL(5 ea daily);

RX/OTC MEIJER PEN NEEDLES 31G X6MM MISC 2 QL(5 ea daily);

RX/OTC MEIJER PEN NEEDLES 31G X8MM MISC 2 QL(5 ea daily);

RX/OTC MICRODOT PEN NEEDLE/31G X 6 MMMISC


MICRODOT PEN NEEDLE/32G X 4 MMMISC


MICRODOT PEN NEEDLE/33G X 4 MMMISC

2 QL(5 ea daily)

MM INSULIN SYRINGE/U-100/0.3ML/30G X 5/16"MISC


MM INSULIN SYRINGE/U-100/0.3ML/31G X 5/16"MISC

2 QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits

MM INSULIN SYRINGE/U-100/1/2ML/30G X 5/16"MISC


MM INSULIN SYRINGE/U-100/1/2ML/31G X 5/16"MISC

2 QL(5 ea daily)

MM INSULIN SYRINGE/U-100/1ML/30G X 5/16"MISC


MM INSULIN SYRINGE/U-100/1ML/31G X 5/16"MISC

2 QL(5 ea daily)

MM PEN NEEDLES 31G X 1/4" MISC 2 QL(5 ea daily);

RX/OTC MM PEN NEEDLES 31G X 3/16" MISC 2 QL(5 ea daily);



RX/OTC MONOJECT BLUNTIP SYRINGE/3ML/CANNULA/IV ACCESS MISC

2 RX/OTC

MONOJECT HYPO/ALUMHUB/18G X 1-1/2" MISC 2 RX/OTC

MONOJECT HYPO/ALUMHUB/LUER LOCK/SHORTBEVEL/18G X 1-1/2" MISC

2 RX/OTC

MONOJECT HYPO/POLYPROPYLENEHUB/18G X 1-1/2" MISC

2 RX/OTC

MONOJECT HYPO/POLYPROPYLENEHUB/LL/SHORTBEVEL/18G X 1-1/2" MISC

2

RX/OTC

MONOJECT INSULIN SYRINGE/1ML MISC 2 QL(5 ea daily);

RX/OTC MONOJECT INSULIN SYRINGE/1ML/31G X5/16" MISC

2 QL(5 ea daily)

MONOJECT INSULIN SYRINGE/DETACHNEEDLE/1ML/25G X 5/8"MISC

2

QL(5 ea daily)


148

Drug Name DrugTier

Requirements/Limits

MONOJECT INSULIN SYRINGE/DETACHNEEDLE/1ML/27G X 1/2"MISC

2


MONOJECT INSULIN SYRINGE/PERMNEEDLE/1ML/28G X 1/2"MISC

2


MONOJECT INSULIN SYRINGE/PERMNEEDLE/U-100/0.5ML/28GX 1/2" MISC

2


MONOJECT INSULIN SYRINGE/SAFETY/PERMNEEDLE/0.3ML/29G X 1/2"MISC

2


MONOJECT INSULIN SYRINGE/SAFETY/PERMNEEDLE/0.3ML/29GX1/2"MISC

2


MONOJECT INSULIN SYRINGE/SAFETY/PERMNEEDLE/0.5ML/29G X 1/2"MISC

2


MONOJECT INSULIN SYRINGE/SAFETY/PERMNEEDLE/1ML/29G X 1/2"MISC

2


MONOJECT INSULIN SYRINGE/SOFTPACK/1ML/27G X 1/2" MISC


MONOJECT INSULIN SYRINGE/SOFTPACK/U-100/0.5ML/28G X 1/2"MISC

2


MONOJECT INSULIN SYRINGE/U-100/0.3ML/30G X 5/16"MISC

2


MONOJECT INSULIN SYRINGE/U-100/0.5ML/30G X 5/16"MISC

2


MONOJECT INSULIN SYRINGE/U-100/1ML/28GX 1/2" MISC


Drug Name DrugTier

Requirements/Limits

MONOJECT INSULIN SYRINGE/U-100/1ML/30GX 5/16" MISC


MONOJECT INSULIN SYRINGEREGULAR LUER TIP/SOFTPACK/1ML MISC


MONOJECT MAGELLAN SAFETYNEEDLE 18GX1-1/2" MISC

2 RX/OTC

MONOJECT PHARMACY TRAY/LUER LOCK/3MLMISC

2 RX/OTC

MONOJECT STANDARD HYPODERMIC NEEDLE/POLYPROPYLENE/18GX1-1/2" MISC

2

RX/OTC

MONOJECT SYRINGE/LUERLOCK/3ML MISC

2 RX/OTC

MONOJECT SYRINGE/LUER-LOCKTIP/3ML MISC

2 RX/OTC

MONOJECT SYRINGE/REG LUER/3MLMISC

2 RX/OTC

MONOJECT SYRINGE/REGULARTIP/3ML MISC

2 RX/OTC

MONOJECT ULTRA COMFORT INSULIN SYRINGE/0.3ML/29G X1/2" MISC

2



2



2

QL(5 ea daily)


2



2



149

Drug Name DrugTier

Requirements/Limits


2



2

QL(5 ea daily)

MONOJECT ULTRA COMFORT INSULIN SYRINGE/1ML/28G X 1/2"MISC

2


MONOJECT ULTRA COMFORT INSULIN SYRINGE/1ML/29G X 1/2"MISC

2


MS INSULIN SYRINGE/0.3ML/31G X5/16" MISC

2 QL(5 ea daily)

MS INSULIN SYRINGE/0.5ML/31G X5/16" MISC

2 QL(5 ea daily)

MS INSULIN SYRINGE/1ML/31G X5/16" MISC

2 QL(5 ea daily)

NOKOR ADMIX NEEDLE THIN WALL NON-CORING 18G X 1-1/2" MISC

2 RX/OTC

NOKOR VENTED NEEDLE THINWALL NON-CORING 18GX1-1/2" MISC

2 RX/OTC

NOVOFINE 32GX6MM MISC 2 QL(5 ea daily)

NOVOFINE AUTOCOVER 30GX8MM MISC 2 QL(5 ea daily);

RX/OTC NOVOFINE PLUS 32GX4MM MISC 2 QL(5 ea daily);

RX/OTC NOVOTWIST 32GX5MM MISC 2 QL(5 ea daily);

RX/OTC PATIENT SAFE SYRINGE 3ML MISC 2 RX/OTC

PC UNIFINE PENTIPS 29G X1/2" MISC 2 QL(5 ea daily);

RX/OTC PC UNIFINE PENTIPS 31G X5MM MINI MISC 2 QL(5 ea daily);

RX/OTC

Drug Name DrugTier

Requirements/Limits

PC UNIFINE PENTIPS 31G X6MM ULTRA SHORT MISC


PC UNIFINE PENTIPS 31G X8MM SHORT MISC 2 QL(5 ea daily);

RX/OTC PEN NEEDLES 29G X 12MM MISC 2 QL(5 ea daily);

RX/OTC PEN NEEDLES 29GX1/2"MISC 2 QL(5 ea daily);


RX/OTC PEN NEEDLES 30GX8MM MISC 2 QL(5 ea daily);

RX/OTC PEN NEEDLES 31G X 1/4"SHORT MISC 2 QL(5 ea daily);

RX/OTC PEN NEEDLES 31G X 3/16" MISC 2 QL(5 ea daily);





RX/OTC PEN NEEDLES 31GX6MM (1/4") MISC 2 QL(5 ea daily);

RX/OTC PEN NEEDLES 31GX8MM (5/16") MISC 2 QL(5 ea daily);

RX/OTC PEN NEEDLES 31GX8MM MISC 2 QL(5 ea daily);



RX/OTC PEN NEEDLES 32G X 6MM MISC 2 QL(5 ea daily)

PEN NEEDLES 32GX4MM MISC 2 QL(5 ea daily);

RX/OTC PEN NEEDLES 33G X 5/32" MISC 2 QL(5 ea daily)

PEN NEEDLES/29G X 1/2"MISC 2 QL(5 ea daily);

RX/OTC PEN NEEDLES/31G X 1/4"MISC 2 QL(5 ea daily);

RX/OTC


150

Drug Name DrugTier

Requirements/Limits

PEN NEEDLES/31G X3/16" MISC 2 QL(5 ea daily);

RX/OTC PEN NEEDLES/31G X5/16" MISC 2 QL(5 ea daily);

RX/OTC PEN NEEDLES/32G X5/32" MISC 2 QL(5 ea daily);

RX/OTC PENTIPS 29G X 12MM MISC 2 QL(5 ea daily);

RX/OTC PENTIPS 29GX12MM MISC 2 QL(5 ea daily);



RX/OTC

PENTIPS 31GX5MM MISC 2 QL(5 ea daily);RX/OTC



PENTIPS 32G X 4MM MISC 2 QL(5 ea daily);

RX/OTC


POLY HUB NEEDLE/18GX 1-1-1/2" MISC 2 RX/OTC

PRECISION SURE-DOSE INSULIN SYRINGE/0.3ML/30G X5/16" MISC

2



2



2



2

QL(5 ea daily)

PRECISION SURE-DOSE INSULIN SYRINGE/1ML/28G X 1/2"MISC

2


Drug Name DrugTier

Requirements/Limits

PRECISION SURE-DOSE PLUSINSULIN SYRINGE/0.3ML/29G X1/2" MISC

2


PRECISION SURE-DOSE PLUSINSULIN SYRINGE/1ML/29G X 1/2"MISC

2


PREFERRED PLUS INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC

2



2



2



2



2


PREFERRED PLUS INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC


PREFERRED PLUS INSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC


PREFERRED PLUS INSULIN SYRINGE/U-100/1ML/30G X 5/16"MISC

2


PREFERRED PLUS UNIFINE PENTIPS 29G X 12MM MISC


PREFERRED PLUS UNIFINE PENTIPS 31G X 6MM ULTRA SHORT MISC

2


PREFERRED PLUS UNIFINE PENTIPS 31G X 8MM SHORT MISC



151

Drug Name DrugTier

Requirements/Limits

PREFERRED PLUS UNIFINE PENTIPS 32GX4MM MISC


PREFERRED PLUS UNIFINE PENTIPS/MINI/31GX5MMMISC

2


PREVENT SAFETY PEN NEEDLES 31GX1/4" MISC 2 QL(5 ea daily);

RX/OTC PREVENT SAFETY PEN NEEDLES 31GX5/16"MISC


PRO COMFORT INSULIN SYRINGES/0.5ML/30G X1/2" MISC

2 QL(5 ea daily)




2 QL(5 ea daily)

PRO COMFORT INSULIN SYRINGES/1ML/30G X1/2" MISC

2 QL(5 ea daily)




2 QL(5 ea daily)

PRO COMFORT PEN NEEDLES/31G X 8MMMISC







2 QL(5 ea daily)

PRODIGY INSULIN SYRING/U-100/0.3ML/31GX 5/16" MISC

2 QL(5 ea daily)

PRODIGY INSULIN SYRINGE/1/2ML/31G X5/16" MISC

2 QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits

PRODIGY INSULIN SYRINGE/1ML/28G X 1/2"MISC


PURE COMFORT PEN NEEDLE 32G X6MM MISC 2 QL(5 ea daily)

PURE COMFORT PEN NEEDLE 32G X8MM MISC 2 QL(5 ea daily)

PURE COMFORT PEN NEEDLE/32G X 5MMMISC


PURE COMFORT PEN NEEDLE/32G X4MM MISC 2 QL(5 ea daily);

RX/OTC PX EXTRA SHORT PEN NEEDLES 31GX6MM MISC


PX INSULIN SYRINGE/U-100/0.5ML/30G X 1/2"MISC

2 QL(5 ea daily)

PX MINI PEN NEEDLES 31GX5MM MISC 2 QL(5 ea daily);

RX/OTC PX PEN NEEDLE 29GX12MM MISC 2 QL(5 ea daily);

RX/OTC PX PEN NEEDLE 31GX8MM MISC 2 QL(5 ea daily);

RX/OTC PX SHORTLENGTH PEN NEEDLES/31GX8MMMISC


QC PEN NEEDLES 29G X 12MM MISC 2 QL(5 ea daily);

RX/OTC QC PEN NEEDLES 31G X 6MM MISC 2 QL(5 ea daily);

RX/OTC QC PEN NEEDLES 31G X 8MM MISC 2 QL(5 ea daily);

RX/OTC QC UNIFINE PENTIPS 32GX4MM MISC 2 QL(5 ea daily);

RX/OTC RA INSULIN SYRINGE/0.5ML/29G X1/2" MISC


RA INSULIN SYRINGE/1ML/29G X 1/2"MISC


RA INSULIN SYRINGE/U-100/0.5ML/30G X 5/16"MISC


RA INSULIN SYRINGE/U-100/1 ML/30G X 5/16"MISC



152

Drug Name DrugTier

Requirements/Limits

RA PEN NEEDLES 31G X 5MM3/16" MISC 2 QL(5 ea daily);

RX/OTC RA PEN NEEDLES 31G X 8MM5/16" MISC 2 QL(5 ea daily);

RX/OTC REALITY INSULIN SYRINGE/U-100/0.5ML/28G X 1/2"MISC

2


REALITY INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC

2


REALITY INSULIN SYRINGE/U-100/1ML/28GX 1/2" MISC


REALITY INSULIN SYRINGE/U-100/1ML/29GX 1/2" MISC


RELION INSULIN SYRINGE/U-00/1ML/29GX 1/2" MISC


RELION INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC

2



2



2

QL(5 ea daily)


2



2



2

QL(5 ea daily)



Drug Name DrugTier

Requirements/Limits


2 QL(5 ea daily)

RELION MINI PEN NEEDLES 31GX6MM MISC


RELION PEN NEEDLES 29GX12MM MISC 2 QL(5 ea daily);

RX/OTC RELION PEN NEEDLES 31GX6MM MISC 2 QL(5 ea daily);


RX/OTC RELION PEN NEEDLES 32G X5/32" MISC 2 QL(5 ea daily);


RX/OTC RELION PEN NEEDLES/31G X1/4" MISC 2 QL(5 ea daily);

RX/OTC RELION SHORT PEN NEEDLES31GX8MM MISC 2 QL(5 ea daily);

RX/OTC SAFESNAP INSULIN SYRINGE/0.3ML/30G X5/16" MISC


SAFESNAP INSULIN SYRINGE/0.5ML/29G X1/2" MISC


SAFESNAP INSULIN SYRINGE/0.5ML/30G X5/16" MISC


SAFESNAP INSULIN SYRINGE/1ML/28G X 1/2"MISC


SAFESNAP INSULIN SYRINGE/1ML/29G X 1/2"MISC


SAFESNAP SYRINGE/3ML MISC 2 RX/OTC

SAFETY INSULIN SYRINGES 0.5ML/29GX1/2" MISC


SAFETY INSULIN SYRINGES 0.5ML/30GX5/16" MISC


SAFETY INSULIN SYRINGES 1ML/27GX1/2"MISC



153

Drug Name DrugTier

Requirements/Limits




2 QL(5 ea daily)

SAFETY-LOK SYRINGE 3ML LUER-LOK MISC 2 RX/OTC

SB INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC


SB INSULIN SYRINGE/U-100/0.5ML/30G X 5/16"MISC


SB INSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC 2 QL(5 ea daily);

RX/OTC SB INSULIN SYRINGE/U-100/1ML/30G X 5/16"MISC


SB INSULIN SYRINGE/U-100/1ML/31G X 5/16"MISC

2 QL(5 ea daily)

SECURESAFE SAFETY HYPODERMIC NEEDLE/18G X 1-1/2"MISC

2

RX/OTC

SECURESAFE SAFETY INSULIN SYRINGES/U-100/0.5ML/29GX1/2" MISC


SECURESAFE SAFETY INSULIN SYRINGES/U-100/1ML/29GX1/2" MISC


SHOPKO UNIFINE PENTIPS PEN NEEDLES/MICRO/32GX4MM MISC

2


SHOPKO UNIFINE PENTIPS PEN NEEDLES/MINI/31GX5MMMISC

2


SHOPKO UNIFINE PENTIPS PEN NEEDLES/ORIGINAL/29GX12MM MISC

2


SHOPKO UNIFINE PENTIPS PEN NEEDLES/SHORT/31GX8MM MISC

2


Drug Name DrugTier

Requirements/Limits

SHOPKO UNIFINE PENTIPS PLUS PEN NEEDLES/MICRO/REMOVR/32GX4MM MISC

2


SHOPKO UNIFINE PENTIPS PLUS PEN NEEDLES/MINI/REMOVER/31GX5MM MISC

2


SHOPKO UNIFINE PENTIPS PLUS PEN NEEDLES/REMOVER/29GX12MM MISC

2


SHOPKO UNIFINE PENTIPS PLUS PEN NEEDLES/SHORT/REMOVR/31GX8MM MISC

2


SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC

2



2

QL(5 ea daily)


2


SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/31G X 5/16MISC

2

QL(5 ea daily)


2

QL(5 ea daily)


2



2



2

QL(5 ea daily)


154

Drug Name DrugTier

Requirements/Limits


2


SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/31G X 5/16MISC

2

QL(5 ea daily)

SURE COMFORT INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC





2 QL(5 ea daily)

SURE COMFORT INSULIN SYRINGE/U-100/1ML/30G X 5/16"MISC

2


SURE COMFORT INSULIN SYRINGE/U-100/1ML/31G X 5/16"MISC

2

QL(5 ea daily)

SURE COMFORT PEN NEEDLES29GX1/2"12.7MM MISC


SURE COMFORT PEN NEEDLES30GX5/16"SHORT MISC


SURE COMFORT PEN NEEDLES31GX3/16"(5MM) MISC


SURE COMFORT PEN NEEDLES31GX5/16"(8MM) MISC


SURE COMFORT PEN NEEDLES32GX5/32"MISC


SURE COMFORT PEN NEEDLES32GX6MM MISC 2 QL(5 ea daily)

SURE-FINE PEN NEEDLES 29GX1/2"12.7MM MISC


SURE-FINE PEN NEEDLES 31GX3/16"5MM MISC


Drug Name DrugTier

Requirements/Limits

SURE-FINE PEN NEEDLES 31GX5/16" 8MMMISC


SURE-JECT INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC

2



2



2

QL(5 ea daily)


2



2



2



2

QL(5 ea daily)

SURE-JECT INSULIN SYRINGE/U-100/1ML/28GX 1/2" MISC







2 QL(5 ea daily)

SYRINGE/BLUNTPLASTIC CANNULA MISC 2 RX/OTC

SYRINGE/LUERLOCK/3ML MISC 2 RX/OTC


155

Drug Name DrugTier

Requirements/Limits

SYRINGE/LUER SLIP/3MLMISC 2 RX/OTC

SYRINGES/LUERLOCK/WITHOUTNEEDLE/3ML MISC

2 RX/OTC

TECHLITE INSULIN SYRINGEU-100/0.3ML/29G X 1/2"MISC

2



2

QL(5 ea daily)


2



2

QL(5 ea daily)


2



2

QL(5 ea daily)


2



2

QL(5 ea daily)

TECHLITE INSULIN SYRINGEU-100/1ML/29GX 1/2" MISC



2 QL(5 ea daily)



Drug Name DrugTier

Requirements/Limits


2 QL(5 ea daily)

TECHLITE PEN NEEDLES 29GX 12 MM MISC 2 QL(5 ea daily);

RX/OTC TECHLITE PEN NEEDLES 31GX 5MM MISC 2 QL(5 ea daily);

RX/OTC TECHLITE PEN NEEDLES/31GX 5MMMISC


TECHLITE PEN NEEDLES/31GX 6 MMMISC


TECHLITE PEN NEEDLES/31GX 8MMMISC





2 QL(5 ea daily)


2 QL(5 ea daily)

TODAYS HEALTH MINI PEN NEEDLES 31G X 1/4"MISC


TODAYS HEALTH ORIGINAL PEN NEEDLES 29G X 1/2" MISC


TODAYS HEALTH SHORT PEN NEEDLES 31G X 5/16" MISC


TOPCARE CLICKFINE UNIVERSAL PEN EEDLES 31GX1/4" MISC


TOPCARE CLICKFINE UNIVERSAL PEN EEDLES 31GX5/16" MISC


TOPCARE ULTRA COMFORT INSULIN SYRINGE/0.3ML/30G X5/16" MISC

2



2

QL(5 ea daily)


156

Drug Name DrugTier

Requirements/Limits


2



2

QL(5 ea daily)

TOPCARE ULTRA COMFORT INSULIN SYRINGE/1ML/30G X5/16" MISC

2


TOPCARE ULTRA COMFORT INSULIN SYRINGE/1ML/31G X5/16" MISC

2

QL(5 ea daily)

TOPCARE ULTRA COMFORT INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC

2


TOPCARE ULTRA COMFORT INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC

2


TOPCARE ULTRA COMFORT INSULIN SYRINGE/U-100/1ML/29GX 1/2" MISC

2


TRUE COMFORT INSULIN SYRINGE/0.5ML/31G X5/16" MISC

2 QL(5 ea daily)

TRUE COMFORT INSULIN SYRINGE/1ML/31G X5/16" MISC

2 QL(5 ea daily)

TRUE COMFORT PEN NEEDLES31G X 5MM MISC






TRUEPLUS 5-BEVEL PEN NEEDLES 29GX12.7MM MISC


Drug Name DrugTier

Requirements/Limits

TRUEPLUS 5-BEVEL PEN NEEDLES 31GX5MM MISC








TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC

2



2



2

QL(5 ea daily)


2



2



2



2

QL(5 ea daily)

TRUEPLUS INSULIN SYRINGE/U-100/1ML/28GX 1/2" MISC





157

Drug Name DrugTier

Requirements/Limits




2 QL(5 ea daily)

TRUEPLUS PEN NEEDLES 29GX12MM MISC










ULTICARE INSULIN SAFETY SYRINGE/0.5ML/29G X1/2" MISC

2


ULTICARE INSULIN SAFETY SYRINGE/1ML/29G X 1/2"MISC

2


ULTICARE INSULIN SYRINGE/0.3ML/29G X1/2" MISC



2 QL(5 ea daily)








2 QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits



ULTICARE INSULIN SYRINGE/1ML/28G X 1/2"MISC





2 QL(5 ea daily)

ULTICARE INSULIN SYRINGE/1ML/30G X5/16" MISC


ULTICARE INSULIN SYRINGE/SHORT/0.3ML/30G X 5/16" MISC



2 QL(5 ea daily)




2 QL(5 ea daily)

ULTICARE INSULIN SYRINGE/SHORT/1ML/30G X 5/16" MISC


ULTICARE INSULIN SYRINGE/SHORT/1ML/31G X 5/16" MISC

2 QL(5 ea daily)

ULTICARE INSULIN SYRINGE/U-100/0.3ML/30G X 1/2"MISC

2

QL(5 ea daily)


2

QL(5 ea daily)


2

QL(5 ea daily)


158

Drug Name DrugTier

Requirements/Limits


2

QL(5 ea daily)

ULTICARE INSULIN SYRINGE/U-100/1ML/30GX 1/2" MISC

2 QL(5 ea daily)

ULTICARE INSULIN SYRINGE/U-100/1ML/31GX 5/16" MISC

2 QL(5 ea daily)

ULTICARE INSULIN SYRINGEULTRAFINE U-100/0.3ML/31G X 5/16"MISC

2

QL(5 ea daily)

ULTICARE INSULIN SYRINGEULTRAFINE U-100/0.5ML/31G X 5/16"MISC

2

QL(5 ea daily)

ULTICARE INSULIN SYRINGEULTRAFINE U-100/1ML/31G X 5/16"MISC

2

QL(5 ea daily)

ULTICARE MICRO PEN NEEDLES 31G X 8MM MISC


ULTICARE MICRO PEN NEEDLES 32G X 4MM MISC


ULTICARE MICRO PEN NEEDLES/31G X 1/4"MISC




ULTICARE MICRO PEN NEEDLES/32G X 4MMMISC




ULTICARE MINI PEN NEEDLES 31GX6MM MISC


ULTICARE MINI PEN NEEDLES ULTI-FINE IV MISC


Drug Name DrugTier

Requirements/Limits

ULTICARE MINI PEN NEEDLES/31G X 6MMMISC


ULTICARE MINI PEN NEEDLES/32G X 1/4"MISC

2 QL(5 ea daily)

ULTICARE MINI PEN NEEDLES31GX6MM MISC 2 QL(5 ea daily);

RX/OTC ULTICARE ORIGINAL PEN NEEDLES ULTI-FINE MISC


ULTICARE PEN NEEDLES 31GX 5MM MISC 2 QL(5 ea daily);

RX/OTC ULTICARE PEN NEEDLES 31GX 5MM/MINI MISC 2 QL(5 ea daily);

RX/OTC ULTICARE PEN NEEDLES/29GX 12.7MMMISC


ULTICARE SHORT PEN NEEDLES 31GX8MM MISC


ULTICARE SHORT PEN NEEDLES ULTI-FINE IV MISC


ULTICARE SHORT PEN NEEDLES/31G X 8MMMISC


ULTIGUARD SAFEPACK/MICROPENNEEDLE/32G X5/32"/SHARPS CONTAMISC

2


ULTIGUARD SAFEPACK/MINI PENNEEDLE/31G X1/4"/SHARPS CONTAINMISC

2


ULTIGUARD SAFEPACK/MINI PENNEEDLE/31G X3/16"/SHARPS CONTAIMISC

2


ULTIGUARD SAFEPACK/MINI PENNEEDLE/32G X1/4"/SHARPS CONTAINMISC

2

QL(5 ea daily)


159

Drug Name DrugTier

Requirements/Limits

ULTIGUARD SAFEPACK/SHORTPENNEEDLE/31G X5/16"/SHARPS CONTAMISC

2


ULTILET INSULIN SYRINGE/0.3ML/30G X8MM MISC



2 QL(5 ea daily)



ULTILET INSULIN SYRINGE/1ML/30G X8MM MISC


ULTILET INSULIN SYRINGE/1ML/31G X8MM MISC

2 QL(5 ea daily)

ULTILET INSULIN SYRINGE/SHORT/0.3ML/30G X 12.7MM MISC

2 QL(5 ea daily)

ULTILET INSULIN SYRINGE/SHORT/0.3ML/30G X 5/16" MISC



2 QL(5 ea daily)




2 QL(5 ea daily)

ULTILET INSULIN SYRINGE/SHORT/1ML/30G X 5/16" MISC


ULTILET INSULIN SYRINGE/SHORT/1ML/31G X 5/16" MISC

2 QL(5 ea daily)

ULTILET INSULIN SYRINGE/U-100/0.5ML/30G X 1/2"MISC

2

QL(5 ea daily)

ULTILET INSULIN SYRINGE/U-100/1ML/30GX 1/2" MISC

2 QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits

ULTILET PEN NEEDLE 29GX12.7MM MISC 2 QL(5 ea daily);

RX/OTC ULTILET PEN NEEDLE 31GX5MM MISC 2 QL(5 ea daily);



RX/OTC ULTILET PEN NEEDLE 32GX4MM/SHORT MISC 2 QL(5 ea daily);

RX/OTC ULTILET SHORT PEN NEEDLES 31GX5/16"MISC


ULTILET SHORT PEN NEEDLES31GX3/16" MISC 2 QL(5 ea daily);

RX/OTC ULTRA COMFORT INSULIN SYRINGE/U-100/0.3ML/30G X 5/16"MISC

2


ULTRA THIN PEN NEEDLES 32G X 4MM MISC


ULTRA-COMFORT INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC

2



2



2

QL(5 ea daily)


2



2



2



160

Drug Name DrugTier

Requirements/Limits


2

QL(5 ea daily)

ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC


ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC


ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/30G X 5/16"MISC

2


ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/31G X 5/16"MISC

2

QL(5 ea daily)

ULTRA-THIN II INSULIN SYRINGE SHORT/U-100/0.3ML/30GX5/16"MISC

2



2

QL(5 ea daily)


2



2

QL(5 ea daily)

ULTRA-THIN II INSULIN SYRINGE SHORT/U-100/1ML/30GX5/16" MISC


ULTRA-THIN II INSULIN SYRINGE SHORT/U-100/1ML/31GX5/16" MISC

2 QL(5 ea daily)

ULTRA-THIN II INSULIN SYRINGE/U-100/0.5ML/29GX1/2" MISC


ULTRA-THIN II INSULIN SYRINGE/U-100/1ML/29GX1/2" MISC


Drug Name DrugTier

Requirements/Limits

ULTRA-THIN II MINI PEN NEEEDLES/31GX3/16"MISC


ULTRA-THIN II PEN NEEDLES 29GX1/2" MISC 2 QL(5 ea daily);

RX/OTC ULTRA-THIN II PEN NEEDLES/SHORT/31GX5/16" MISC


ULTRACARE INSULIN SYRINGE/U-100/0.3ML/30G X 5/16"MISC

2



2

QL(5 ea daily)


2

QL(5 ea daily)


2



2

QL(5 ea daily)

ULTRACARE INSULIN SYRINGE/U-100/1ML/30GX 1/2" MISC

2 QL(5 ea daily)




2 QL(5 ea daily)

ULTRACARE PEN NEEDLES/31G X 1/4"MISC







161

Drug Name DrugTier

Requirements/Limits


2 QL(5 ea daily)






2 QL(5 ea daily)

UNIFINE PENTIPS 29GX12MM MISC 2 QL(5 ea daily);

RX/OTC UNIFINE PENTIPS 31G X 3/16" MISC 2 QL(5 ea daily);

RX/OTC UNIFINE PENTIPS 31GX5MM MISC 2 QL(5 ea daily);




RX/OTC UNIFINE PENTIPS 32GX6MM MISC 2 QL(5 ea daily)

UNIFINE PENTIPS 33GX4MM MISC 2 QL(5 ea daily)

UNIFINE PENTIPS PLUS 29GX12MM MISC 2 QL(5 ea daily);

RX/OTC UNIFINE PENTIPS PLUS 31GX5MM MISC 2 QL(5 ea daily);




RX/OTC UNIFINE PENTIPS PLUS 33GX4MM MISC 2 QL(5 ea daily)

UNIFINE SAFECONTROL PEN NEEDLE/30G X 5/16"MISC


VALUE HEALTH INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC

2


Drug Name DrugTier

Requirements/Limits

VALUE HEALTH INSULIN SYRINGE/U-100/1ML/29GX 1/2" MISC


VALUMARK PEN NEEDLES 29GX12MM MISC


VALUMARK PEN NEEDLES 31GX 6MM MISC


VALUMARK PEN NEEDLES 31GX 8MM MISC


VANISHPOINT INSULIN SYRINGE/0.5ML/30G X1/2" MISC

2 QL(5 ea daily)

VANISHPOINT INSULIN SYRINGE/0.5ML/30G X5/16" MISC


VANISHPOINT INSULIN SYRINGE/1ML/29G X 1/2"MISC


VANISHPOINT INSULIN SYRINGE/1ML/30G X5/16" MISC


VIDA MIA UNIFINE PENTIPS32GX4MM MISC 2 QL(5 ea daily);

RX/OTC VIDA MIA UNIFINE PENTIPSMINI 31GX6MM MISC


VIDA MIA UNIFINE PENTIPSORIGINAL 29GX12MM MISC


VIDA MIA UNIPFINE PENTIPSSHORT 31GX8MM MISC


VP INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC


WEGMANS UNIFINE PENTIPS PLUS 32GX4MM MISC


WEGMANS UNIFINE PENTIPS PLUS/MINI/31GX5MMMISC

2



162

Drug Name DrugTier

Requirements/Limits

WEGMANS UNIFINE PENTIPS PLUS/SHORT/31GX8MMMISC

2


WEGMANS UNIFINE PENTIPS PLUS/ULTRASHORT/31GX6MM MISC


Respiratory Therapy Supplies

ACE AEROSOL CLOUD ENHANCER MISC 2

QL(1 ea per360 daysretail); RX/OTC

ACTIVITY POUCH MISC 2 QL(1 ea per360 daysretail); RX/OTC

ADULT AEROSOL MASK MISC 2


ADULT MASK LARGE MISC 2


ADULT MASK MISC 2 QL(1 ea per360 daysretail); RX/OTC

AEROCHAMBER MINI AEROSOLCHAMBER DEVI

2 QL(2 ea per360 daysretail); RX/OTC

AEROCHAMBER MV MISC 2


AEROCHAMBER PLUS FLOW VU MISC 2


AEROCHAMBER PLUS FLOW-VU MISC 2


AEROCHAMBER PLUS FLOW-VU/LARGE MASKMISC


AEROCHAMBER PLUS FLOW-VU/MASK MISC 2


AEROCHAMBER PLUS FLOW-VU/MEDIUM MASKMISC


AEROCHAMBER PLUS FLOW-VU/SMALL MASKMISC


Drug Name DrugTier

Requirements/Limits

AEROCHAMBER Z-STAT PLUS VALVED HOLDING CHAMBER W/FLOW VUMISC

2


AEROCHAMBER Z-STAT PLUS/FLOWSIGNAL MISC 2


AEROCHAMBER Z-STAT PLUS/LARGE MASK MISC 2


AEROCHAMBER Z-STAT PLUS/MEDIUM MASKMISC


AEROCHAMBER Z-STAT PLUS/SMALL MASK MISC 2


AEROCHAMBER/FLOWSIGNAL MISC 2


AEROTRACH PLUS MISC 2 QL(1 ea per360 daysretail); RX/OTC

AEROVENT PLUS HOLDING CHAMBER/COLLAPSIBLEDEVI

2


AIRS PEDIATRIC AEROSOL MASK MISC 2


ALL FLOW 1000 PULMONARY FUNCTION FILTER MISC


ARIAL CHAMBER DEVI 2 QL(2 ea per360 daysretail); RX/OTC

BREATHE EASE NEBULIZER MASK/CHILDMISC


BREATHE EASE NEBULIZER MASK/INFANT MISC


BREATHE EASE/LARGEMASK DEVI 2


BREATHE EASE/MEDIUMMASK DEVI 2



163

Drug Name DrugTier

Requirements/Limits

BREATHE EASE/SMALLMASK DEVI 2


BREATHERITE COLLAPSIBLEADULT SPACER W/MASK MISC


BREATHERITE COLLAPSIBLECHILD SPACER W/MASK MISC


BREATHERITE COLLAPSIBLEINFANT SPACER W/MASK MISC


BREATHERITE COLLAPSIBLESMALL CHILD SPACER W/MASKMISC

2


BREATHERITE COLLAPSIBLESPACER W/ NEONATE MASK MISC


BREATHERITE MISC 2 QL(2 ea per360 daysretail); RX/OTC

BREATHERITE RIGID SPACERW/MASK MISC 2


BREATHERITE W/LARGEMASK MISC 2


BREATHERITE W/MEDIUM MASK MISC 2


BREATHERITE W/SMALLMASK MISC 2


BUBBLES THE FISH II PEDIATRIC MASK/PVCMISC


CLEVER CHOICE ANTI-STATICVALVED HOLDING CHAMBER/ADULT LARGEDEVI

2


CLEVER CHOICE ANTI-STATICVALVED HOLDING CHAMBER/MEDIUM DEVI

2


Drug Name DrugTier

Requirements/Limits

CLEVER CHOICE ANTI-STATICVALVED HOLDING CHAMBER/SMALL DEVI

2


CO MONITOR REPLACEMENT TPIECES MISC


COMPACT SPACE CHAMBER/ANTI-STATICDEVI


COMPACT SPACE CHAMBER/ANTI-STATIC/LARGE MASKDEVI

2


COMPACT SPACE CHAMBER/ANTI-STATIC/MEDIUM MASKDEVI

2


COMPACT SPACE CHAMBER/ANTI-STATIC/SMALL MASKDEVI

2


EASIVENT MISC 2 QL(2 ea per360 daysretail); RX/OTC

EASIVENT/MASK-LARGEMISC 2


EASIVENT/MASK-MEDIUM MISC 2


EASIVENT/MASK-SMALLMISC 2


EBASE CONTROLLER KIT MISC 2


EFLOW SCF AEROSOL HEAD MISC 2


ELITE DC AUTO ADAPTER MISC 2


FILTER AIR PP MISC 2 QL(1 ea per360 daysretail); RX/OTC


164

Drug Name DrugTier

Requirements/Limits

FLEXICHAMBER DEVI 2 QL(2 ea per360 daysretail); RX/OTC

FLYP HYPERSONIQ CARTRIDGE MISC 2


FULL KIT NEBULIZER SET MISC 2


HEALTHY LIVING REPLACEMENT FILTERS MISC


HEALTHY LIVING REPLACEMENT KIT FOR NEBULIZER MISC


HEALTHY LIVING REPLACEMENT MASKS MISC


HUDSON RCI SEE-THRU AEROSOL MASK ELONGATED/ADULTMISC

2


INNOSPIRE REPLACEMENT FILTER MISC


INSPIRACHAMBER/ANTI-STATIC VALVED/MOUTHPIECEDEVI

2


INSPIRACHAMBER/LARGE DEVI 2


INSPIRACHAMBER/SOOTHERMASK/INSPIRAMASK/MEDIUM DEVI


INSPIRACHAMBER/SOOTHERMASK/INSPIRAMASK/SMALL DEVI


INSPIREASE DRUG DELIVERYSYSTEM MISC 2


INSPIREASE RESERVOIR BAGS MISC 2 QL(3 ea per

180 days retail)

LITEAIRE DEVI 2 QL(2 ea per360 daysretail); RX/OTC

Drug Name DrugTier

Requirements/Limits

LITETOUCH MASK LARGE MISC 2


LITETOUCH MASK MEDIUM MISC 2


LITETOUCH MASK SMALL MISC 2


MICROCHAMBER DEVI 2 QL(2 ea per360 daysretail); RX/OTC

MICROCHAMBER MISC 2 QL(2 ea per360 daysretail); RX/OTC

MICROELITE FILTER REPLACEMENTS MISC 2


MICROELITE RECHARGEABLE BATTERY MISC


MICROSPACER MISC 2 QL(2 ea per360 daysretail); RX/OTC

MINIELITE FILTER REPLACEMENTS MISC 2


MINIELITE RECHARGEABLE BATTERY MISC


NEBULIZER AIR TUBE/PLUGS MISC 2


NEBULIZER PEDIATRIC MASK MISC 2


NOSE CLIP MISC 2 QL(1 ea per360 daysretail); RX/OTC

OPTICHAMBER ADVANTAGE/LARGEMASK MISC


OPTICHAMBER ADVANTAGE/MEDIUMFACE MASK MISC


OPTICHAMBER ADVANTAGE/SMALLFACE MASK MISC



165

Drug Name DrugTier

Requirements/Limits

OPTICHAMBER DIAMOND MISC 2


OPTICHAMBER DIAMOND/LARGEFACEMASK DEVI


OPTICHAMBER DIAMOND/MEDIUM FACEMASK MISC


OPTICHAMBER DIAMOND/SMALLFACEMASK MISC


OPTICHAMBER FACE MASK/LARGE MISC 2


OPTICHAMBER FACE MASK/MEDIUM MISC 2


OPTICHAMBER FACE MASK/SMALL MISC 2


OPTIHALER MDI DRUG DELIVERY SYSTEM DEVI 2


OPTIHALER MISC 2 QL(2 ea per360 daysretail); RX/OTC

PARI ALTERA NEBULIZER HANDSET MISC


PARI BABY CONVERSION KITSIZE 1 MISC 2






PARI ERAPID NEBULIZER HANDSET MISC 2


PARI EXPIRATORY FILTER VALVE SET DEVI 2


PARI MASK SET MISC 2 QL(1 ea per360 daysretail); RX/OTC

Drug Name DrugTier

Requirements/Limits

PARI SOFT PLASTIC ADULT MASK MISC 2


PARI SOFT PLASTIC PEDIATRIC MASK MISC 2


PARI VORTEX ADULT MASK MISC 2


PEDIATRIC MOUTHPIECE/DISPOSABLE MISC


PFLEX MISC 2 QL(1 ea per360 daysretail); RX/OTC

PILLOW MASK/ADULTMISC 2


PILLOW MASK/CHILDMISC 2


PILLOW MASK/PEDIATRIC MISC 2


POCKET CHAMBER DEVI 2 QL(2 ea per360 daysretail); RX/OTC

POCKET SPACER DEVI 2 QL(2 ea per360 daysretail); RX/OTC

PRO COMFORT INHALER SPACER CHAMBER ADULT MISC


PRO COMFORT INHALER SPACER CHAMBER CHILD MISC


PROCARE SPACER CHAMBER W/ADULTMASK DEVI


PROCARE SPACER CHAMBER W/CHILDMASK DEVI


PRONEB ULTRA FILTER SET MISC 2


REPLACEMENT AIR FILTER MISC 2



166

Drug Name DrugTier

Requirements/Limits

REPLACEMENT FILTERS MISC 2


RITEFLO DEVI 2 QL(2 ea per360 daysretail); RX/OTC

SAMI THE SEAL REPLACEMENTFILTERS MISC


SIDESTREAM ADULT FACE MASK MISC 2


SIDESTREAM PEDIATRIC FACEMASK MISC 2


SIDESTREAM PEDIATRIC FACEMASK/SAMI THESEAL MISC


SIDESTREAM PEDIATRIC FACEMASK/TUCKER THETURTLE MISC


SIDESTREAM PLUS ADULT FACE MASK MISC 2


SILICONE MASK FOR BREATHERITE CHAMBER/ADULT MISC


SILICONE MASK FOR BREATHERITE CHAMBER/INFANT MISC


SILICONE MASK FOR BREATHERITE CHAMBER/PEDIATRICMISC

2


SILICONE MASK FOR BREATHRITE CHAMBER/ADULT MISC


SOOTHENEB NBL 100 CHILD MASK MISC 2


SOOTHENEB NBL 100 MEDICATION CUP MISC 2


SOOTHENEB NBL 100 MESH CAP MISC 2


Drug Name DrugTier

Requirements/Limits

SOOTHENEB NBL100 ADULT MASK MISC 2


THRESHOLD IMT MISC 2 QL(1 ea per360 daysretail); RX/OTC

TUBING/WING TIP MISC 2 QL(1 ea per360 daysretail); RX/OTC

VALVED HOLDING CHAMBER DEVI 2


VORTEX VALVED HOLDING CHAMBER DEVI


WATCHHALER DEVI 2 QL(2 ea per360 daysretail); RX/OTC

WINDMILL TRAINER MISC 2


MIGRAINE PRODUCTS - Drugs to Treat MigraineHeadaches

Migraine Combinations CAFERGOT TABS (ergotamine w/ caffeine) NP PA; AL(At least

18 yrs old)

ergotamine w/ caffeine tabs NP PA; AL(At least18 yrs old)

MIGERGOT SUPP 2

MIGRANOW THPK NP PA

sumatriptan-naproxensodium tabs NP PA

TREXIMET TABS 10 MG-60 MG NP PA

TREXIMET TABS 85 MG-500 MG (sumatriptan-naproxen sodium)

NP PA

Migraine Products - Monoclonal Antibodies AIMOVIG SOAJ 140 MG/ML NP PA

AIMOVIG SOAJ 70 MG/ML NP PA; SP

AJOVY SOSY NP PA


167

Drug Name DrugTier

Requirements/Limits

EMGALITY SOAJ 2 PA

EMGALITY SOSY 2 PA

UBRELVY TABS 50 MG NP PA

Migraine Products - NSAIDs

CAMBIA PACK 2 PA

Migraine Products D.H.E. 45 SOLN (dihydroergotaminemesylate)

NF PA; AL(At least18 yrs old)

dihydroergotaminemesylate soln ij 1 mg/ml 1 PA; AL(At least

18 yrs old) DIHYDROERGOTAMINE MESYLATE SOLN NA 4 MG/ML

2 PA; AL(At least18 yrs old)

ERGOMAR SUBL 2 PA

MIGRANAL SOLN 2 PA; AL(At least18 yrs old)

Serotonin Agonists

almotriptan malate tabs NP QL(6 ea per 30days retail)

AMERGE TABS (naratriptan hcl) NF


AXERT TABS (almotriptanmalate) NP QL(6 ea per 30

days retail)

eletriptan hydrobromidetabs NP

PA; QL(6 eaper 30 daysretail); AL(Atleast 18 yrsold)

FROVA TABS (frovatriptansuccinate) NP PA

frovatriptan succinate tabs NP PA

IMITREX SOLN NA 5 MG/ACT, 20 MG/ACT(sumatriptan)

NF


Drug Name DrugTier

Requirements/Limits

IMITREX SOLN SC 6 MG/0.5ML (sumatriptansuccinate)

NF


IMITREX STATDOSE REFILL SOCT 4 MG/0.5ML(sumatriptan succinate)

NF

IMITREX STATDOSE REFILL SOCT 6 MG/0.5ML(sumatriptan succinate)

NF


IMITREX STATDOSE SYSTEM SOAJ 4 MG/0.5ML (sumatriptansuccinate)

NF

IMITREX STATDOSE SYSTEM SOAJ 6 MG/0.5ML (sumatriptansuccinate)

NF


IMITREX TABS OR 25 MG, 50 MG, 100 MG (sumatriptan succinate)

NF


MAXALT TABS (rizatriptanbenzoate) NF


MAXALT-MLT TBDP (rizatriptan benzoate) NF

naratriptan hcl tabs 1


ONZETRA XSAIL EXHP NP PA

RELPAX TABS (eletriptanhydrobromide) NP


REYVOW TABS NP PA

rizatriptan benzoate tabs 5mg, 10 mg 1


rizatriptan benzoate tbdp 5mg, 10 mg 1


168

Drug Name DrugTier

Requirements/Limits

sumatriptan soln 1


sumatriptan succinate soajsc 4 mg/0.5ml 1

sumatriptan succinate soajsc 6 mg/0.5ml 1


sumatriptan succinate soctsc 4 mg/0.5ml 1

sumatriptan succinate soctsc 6 mg/0.5ml 1


sumatriptan succinate solnsc 6 mg/0.5ml 1


SUMATRIPTAN SUCCINATE SOSY SC 6 MG/0.5ML

NP


sumatriptan succinate tabsor 25 mg, 50 mg, 100 mg 1


TOSYMRA SOLN NP PA

ZEMBRACE SYMTOUCH SOAJ NP PA

zolmitriptan tabs NP


zolmitriptan tbdp NP


ZOMIG SOLN NA 2.5 MG NP

ZOMIG SOLN NA 5 MG NP AL(At least 12yrs old)

Drug Name DrugTier

Requirements/Limits

ZOMIG TABS OR 5 MG, 2.5 MG (zolmitriptan) NP


ZOMIG ZMT TBDP (zolmitriptan) NP


MINERALS & ELECTROLYTES

Calcium

CALCI-CHEW CHEW 2

CALCIUM CARBONATE CHEW 2

calcium carbonate-cholecalciferol tabs 1

calcium carbonate-vitamin d tabs 200 unit-500 mg,500 mg-200 unit, 500 mg-500 mg-200 unit-200 unit

1

calcium carbonate-vitamin d tabs 200 unit-600 mg,400 unit-600 mg, 600 mg-200 unit, 600 mg-400 unit

1

QL(2 ea daily)

CALCIUM CHEW 2

oyster shell tabs 1

PARVA-CAL TABS 2

RA OYSTER SHELL CALCIUM/VITAMIN DTABS

2

Electrolyte Mixtures

CERALYTE 70 SOLN 2

CERASPORT EX1 SOLN 2

CERASPORT SOLN 4 MEQ/L-18 MEQ/L-20MEQ/L-6 MEQ/L

2

ENFAMIL ENFALYTE SOLN 2

EQUALYTE SOLN (oral electrolytes) NF


169

Drug Name DrugTier

Requirements/Limits

HYDRALYTE FREEZER POPS SOLN 2

HYDRALYTE SOLN 270 MG/250ML-210MG/250ML, 45 MEQ/L-45MEQ/L-20 MEQ/L-90MEQ/L-16 GM/L

2

oral electrolytes soln 1

PEDIALYTE ADVANCED CARE SOLN (oral electrolytes)

NF

PEDIALYTE FREEZER POPS SOLN (oral electrolytes)

NF

PEDIALYTE SINGLES SOLN (oral electrolytes) NF

PEDIALYTE SOLN (oral electrolytes) NF

Fluoride

FLURA-DROPS SOLN 2 MP

sodium fluoride chew 1 MP

sodium fluoride soln 1 MP

Phosphate K-PHOS NEUTRAL TABS (pot phosphate monobasicw/ sod phosphate dibasic &monobasic)

NF

QL(8 ea daily);MP

pot phosphate monobasicw/ sod phosphate dibasic &monobasic tabs

1 QL(8 ea daily);MP

Potassium K-TAB TBCR 10 MEQ (potassium chloride) NF MP

K-TAB TBCR 8 MEQ 2 MP

KLOR-CON M15 TBCR 2 MP

potassium bicarbonate tbef 1 MP

potassium chloride cpcr or10 meq 1 MP

POTASSIUM CHLORIDE ER TBCR 2 MP

Drug Name DrugTier

Requirements/Limits

potassium chloridemicroencapsulated crystalser tbcr

1 MP

potassium chloride pack or20 meq 1 MP

potassium chloride soln or10 %, 20 % 1 MP

potassium chloride tbcr or 8meq, 10 meq 1 MP

MISCELLANEOUS THERAPEUTIC CLASSES

Chelating Agents CUPRIMINE CAPS (penicillamine) NF PA

D-PENAMINE TABS NP PA

DEPEN TITRATABS TABS (penicillamine) NF PA

penicillamine caps 1 PA

penicillamine tabs 1 PA

SYPRINE CAPS (trientine hcl) NF PA

trientine hcl caps 1 PA

Immunomodulators

REVLIMID CAPS 2 PA; SP

THALOMID CAPS 2 PA; SP; MP

Immunosuppressive Agents

ASTAGRAF XL CP24 NP PA

AZASAN TABS NP PA; QL(3 eadaily); MP

AZATHIOPRINE SOLR IJ 100 MG NP

azathioprine tabs or 50 mg 1 MP

CELLCEPT CAPS 250 MG (mycophenolate mofetil) NF QL(2 ea daily);

MP CELLCEPT SUSR 200 MG/ML (mycophenolatemofetil)

NF MP


170

Drug Name DrugTier

Requirements/Limits

CELLCEPT TABS 500 MG (mycophenolate mofetil) NF QL(4 ea daily);

MP

cyclosporine caps 1 QL(4 ea daily);MP

cyclosporine modified (formicroemulsion) caps 25mg, 100 mg

1 QL(4 ea daily);MP

cyclosporine modified (formicroemulsion) caps 50 mg NP PA; QL(4 ea

daily); MP cyclosporine modified (formicroemulsion) soln 100mg/ml

1 QL(8 ml daily);MP

ENVARSUS XR TB24 NP PA

everolimus (immunosuppressant) tabs NP

GAMIFANT SOLN CO

IMURAN TABS (azathioprine) NF MP

mycophenolate mofetilcaps 250 mg 1 QL(2 ea daily);

MP mycophenolate mofetil susr200 mg/ml 1 MP

mycophenolate mofetil tabs500 mg 1 QL(4 ea daily);

MP mycophenolate sodiumtbec 180 mg NP PA; QL(2 ea

daily); MP mycophenolate sodiumtbec 360 mg NP PA; QL(4 ea

daily); MP MYFORTIC TBEC 180 MG (mycophenolate sodium) NP PA; QL(2 ea

daily); MP MYFORTIC TBEC 360 MG (mycophenolate sodium) NP PA; QL(4 ea

daily); MP NEORAL CAPS 25 MG, 100 MG (cyclosporinemodified (formicroemulsion))

NF

QL(4 ea daily);MP

NEORAL SOLN 100 MG/ML (cyclosporinemodified (formicroemulsion))

NF

QL(8 ml daily);MP

PROGRAF CAPS OR 0.5 MG, 1 MG, 5 MG (tacrolimus)


PROGRAF PACK OR 0.2 MG, 1 MG NP PA

Drug Name DrugTier

Requirements/Limits

PROGRAF SOLN IV 5 MG/ML 2 PA

RAPAMUNE SOLN 1 MG/ML (sirolimus) NP PA; MP

RAPAMUNE TABS 0.5 MG, 1 MG, 2 MG (sirolimus)

NF MP

SANDIMMUNE CAPS 25 MG, 100 MG (cyclosporine) NF QL(4 ea daily);

MP SANDIMMUNE SOLN 100 MG/ML NP PA; QL(8 ml

daily); MP

sirolimus soln 1 mg/ml NP PA; MP

sirolimus tabs 0.5 mg, 1mg, 2 mg 1 MP

tacrolimus caps 1 QL(3 ea daily);MP

ZORTRESS TABS 0.25 MG, 0.75 MG, 0.5 MG (everolimus (immunosuppressant))

NP

ZORTRESS TABS 1 MG NP

Irrigation Solutions irrigation solutions,physiological soln 1 PA

ringer's irrigation soln 1 PA

Potassium Removing Agents

LOKELMA PACK NP PA

sodium polystyrenesulfonate powd or 1 QL(454 gm per

fill retail) sodium polystyrenesulfonate susp or 15gm/60ml

1

sodium polystyrenesulfonate susp re 30gm/120ml, 50 gm/200ml

1

VELTASSA PACK 2

MOUTH/THROAT/DENTAL AGENTS

Anesthetics Topical Oral lidocaine hcl (mouth-throat)soln 1 QL(100 ml per

fill retail)


171

Drug Name DrugTier

Requirements/Limits

Anti-infectives - Throat clotrimazole lozg 1

clotrimazole troc 1

nystatin (mouth-throat) susp 1 QL(120 ml per

fill retail) Antiseptics - Mouth/Throat chlorhexidine gluconate(mouth-throat) soln 1

PERIDEX SOLN (chlorhexidine gluconate(mouth-throat))

NF

Dental Products PREVIDENT 5000 DRY MOUTH GEL (sodium fluoride (dental))

NF MP

PREVIDENT 5000 PLUS CREA (sodium fluoride (dental))

NF MP

PREVIDENT FLUORIDE GEL (sodium fluoride (dental))

NF MP

PREVIDENT RINSE SOLN (sodium fluoride (dental)) NF MP

sodium fluoride (dental) crea 1 MP

sodium fluoride (dental) gel 1 MP

sodium fluoride (dental)soln 1 MP

stannous fluoride conc 1 RX/OTC; MP

Steroids - Mouth/Throat/Dental triamcinolone acetonide (mouth) pste 1 QL(5 gm per fill

retail) Throat Products - Misc.

AQUORAL SOLN 2 QL(900 ml perfill retail);RX/OTC

BIOTENE DRY MOUTH MOISTURIZING SPRAY SOLN

2 QL(900 ml perfill retail);RX/OTC

CAPHOSOL SOLN 2 QL(900 ml perfill retail);RX/OTC

Drug Name DrugTier

Requirements/Limits

cevimeline hcl caps 1 PA; MP

CVS DRY MOUTH SPRAY SOLN 2

QL(900 ml perfill retail);RX/OTC

EQL DRY MOUTH ORAL RINSE SOLN 2


EVOXAC CAPS (cevimeline hcl) NF PA; MP

MOI-STIR SOLN 2 QL(900 ml perfill retail);RX/OTC

MOUTH KOTE REMINT SOLN 2


MOUTH KOTE SOLN 2 QL(900 ml perfill retail);RX/OTC

NUMOISYN LIQD 2 QL(900 ml perfill retail);RX/OTC

ORAL RELIEF SPRAY FOR DRYMOUTH & DISCOMFORT SOLN

2 QL(900 ml perfill retail);RX/OTC

pilocarpine hcl (oral) tabs 1 QL(6 ea daily);MP

RA DRY MOUTH SOLN 2 QL(900 ml perfill retail);RX/OTC

SALAGEN TABS (pilocarpine hcl (oral)) NF QL(6 ea daily);

MP

XEROSTOMIA RELIEF SPRAY SOLN 2


MULTIVITAMINS

B-Complex w/ Folic Acid b-complex w/ c & folic acidcaps 1.5 mg-5 mg-20 mg-1.7 mg-6 mcg-1 mg-150mcg-10 mg-100 mg, 5 mg-1.7 mg-6 mcg-20 mg-1.5mg-1 mg-150 mcg-10 mg-100 mg

1



172

Drug Name DrugTier

Requirements/Limits

b-complex w/ c & folic acidtabs 1.5 mg-10 mg-20 mg-1.7 mg-6 mcg-1 mg-300mcg-10 mg-60 mg, 30mcg-1.5 mg-20 mg-1.7 mg-1 mg-1 mg-300 mcg-8 mg-200 mg, 10 mg-20 mg-1.7mg-6 mcg-1.5 mg-1 mg-300 mcg-10 mg-100 mg, 6mcg-1.5 mg-10 mg-20 mg-1.7 mg-1 mg-300 mcg-10mg-100 mg, 1.5 mg-1.7mg-10 mg-0.01 mcg-20mg-1 mg-300 mcg-10 mg-60 mg, 20 mg-1.7 mg-10mg-0.006 mg-1.5 mg-1 mg-0.3 mg-10 mg-100 mg, 6mcg-1.5 mg-10 mg-20 mg-1.7 mg-1000 mcg-300mcg-10 mg-100 mg, 6mcg-6 mcg-1.5 mg-1.5 mg-10 mg-10 mg-20 mg-20mg-1.7 mg-1.7 mg-1 mg-1mg-300 mcg-300 mcg-10mg-10 mg-100 mg-100 mg

1

RX/OTC

b-complex w/ c & folic acidtabs 1.5 mg-10 mg-20 mg-1.7 mg-6 mcg-800 mcg-300 mcg-10 mg-60 mg, 20mg-1.7 mg-10 mg-6 mcg-1.5 mg-800 mcg-300 mcg-10 mg-60 mg, 1.7 mg-10mg-0.006 mg-10 mg-20mg-1.5 mg-0.8 mg-0.3 mg-60 mg

1

FULL SPECTRUM B/VITAMIN C TABS 2

NEPHRO-VITE RX TABS (b-complex w/ c & folicacid)

NF RX/OTC

NEPHRO-VITE TABS (b-complex w/ c & folic acid) NF

NEPHROCAPS CAPS (b-complex w/ c & folic acid) NF QL(1 ea daily);

RX/OTC VITALINE BIOTIN FORTE TABS 2

WEST-VITE W/FOLICACID TABS 2

Multiple Vitamins w/ Minerals

Drug Name DrugTier

Requirements/Limits

ADULT ONE DAILY GUMMIES CHEW 2

ALIVE WOMENS 50+ CHEW 2

ALIVE WOMENS GUMMY VITAMINS CHEW 2

AQUADEKS CHEW 2

BACMIN TABS 1 RX/OTC

BARIATRIC FUSION CHEW 2

CELEBRATE MULTI-COMPLETE18 CHEW 2




CENTRUM CHEW 2

CENTRUM FLAVOR BURST ADULT CHEW 2

CENTRUM FLAVOR BURST CHEW 2

CENTRUM FLAVOR BURST KIDS CHEW 2

CENTRUM MULTIGUMMIES ADULTS CHEW

2

CENTRUM MULTIGUMMIES MEN CHEW

2

CENTRUM MULTIGUMMIES MULTI +OMEGA 3 CHEW

2

CENTRUM MULTIGUMMIES WOMEN CHEW

2

CENTRUM SILVER CHEW 2

CENTRUM VITAMINTS CHEW 2

CHOICEFUL MULTIVITAMIN CHEW 2


173

Drug Name DrugTier

Requirements/Limits

CULTURELLE PROBIOTICS + MULTIVITAMIN CHEW

2

CVS AIRSHIELD IMMUNITY SUPPORT CHEW

2

CVS SPECTRAVITE ADULT 50+ CHEW 4 MG-10 MCG-25 MCG-100 MCG-4.5 MG-10 MCG-5 MCG-125 MG-70 UNIT-100 MCG-25 MCG-200 MG-150 MCG-2 MG-15 MG-50 MG-2.2 MG-10 MG-4000 UNIT-250 MCG-12 MG-2.7 MG-25 MCG-400 UNIT-500 MCG-45 MCG-7 MG-75 MG

2

CVS SPECTRAVITE ADULT GUMMIES CHEW 2

DEKAS BARIATRIC CHEW 2

DEKAS PLUS CHEW 2

EMERGEN-C IMMUNE PLUS/VITAMIN D CHEW 2

EMERGEN-C VITAMIN C CHEW 2

EQ MULTIVITAMINS ADULT GUMMY CHEW 2

EQL ONE DAILY ADULT GUMMIES CHEW 2

IMMUNE SUPPORT CHEW 2

Drug Name DrugTier

Requirements/Limits

multiple vitamins w/minerals chew 15 unit-4.5 mg-0.5 mg-2.5 mg-50 mg,3.75 mcg-0.75 mg-7.5 unit-10 mg-2 mg-500 unit-250mg, 3.75 mcg-2 mg-7.5unit-10 mg-0.75 mg-11.25mg-500 unit-250 mg, 5mcg-1.667 mg-3.333 mg-0.033 mg-0.333 mg-20mcg-2.233 mg-250 mg, 5mcg-3.333 mg-0.033 mg-0.333 mg-66.666 unit-3.333unit-333.333 mg, 2.5 mg-20unit-40 mcg-5 mg-2000unit-4 mcg-400 unit-200mcg-75 mcg-1 mg-30 mg,50 mg-1.25 mg-15 unit-20mcg-1250 unit-4.5 mcg-400unit-200 mcg-75 mcg-1 mg-15 mg, 50 mg-1.25 mg-20mcg-1250 unit-4.5 mcg-400unit-200 mcg-15 unit-75mcg-1 mg-15 mg, 50 mg-15 unit-20 mcg-1.25 mg-1250 unit-4.5 mcg-400 unit-200 mcg-75 mcg-1 mg-15mg, 10 unit-20 mcg-1.25mg-10 mcg-15 mcg-1000unit-2.5 mcg-100 unit-37.5mcg-0.5 mg-15 mg, 15 unit-37.5 mcg-3.75 mg-5 mg-1250 unit-10 mg-3 mcg-500unit-200 mcg-75 mcg-1 mg-30 mg, 2.5 mg-20 unit-40mcg-5 mg-2000 unit-20mcg-30 mcg-5 mcg-200unit-200 mcg-75 mcg-1 mg-30 mg, 20 unit-40 mcg-2.5mg-5 mg-20 mcg-30 mcg-2000 unit-5 mcg-200 unit-200 mcg-75 mcg-1 mg-30mg, 40 mcg-2.5 mg-5 mg-20 mcg-30 mcg-2000 unit-5mcg-200 unit-200 mcg-20unit-75 mcg-1 mg-30 mg,55 mcg-75 mcg-2.5 mg-1250 unit-3 mg-7.5 mcg-500 unit-80 mcg-15 unit-37.5 mcg-2.5 mg-22.5 mg,5 mg-113.5 mg-1.9 mg-10unit-5 mg-25 mg-25 mg-

1


174

Drug Name DrugTier

Requirements/Limits

1250 unit-10 mg-3 mcg-1000 unit-200 mcg-0.9 mg,140 mg-7.5 unit-1 mg-2.5mg-2.5 mg-5 mg-30 mcg-20 mcg-1250 unit-3 mcg-400 unit-200 mcg-150 mcg-1 mg-30 mg, 55 mcg-15unit-75 mcg-2.5 mg-5 mg-20 mcg-30 mcg-2000 unit-7.5 mcg-200 unit-200 mcg-300 mcg-2.5 mg-37.5 mg,55 mcg-2.5 mg-15 unit-75mcg-5 mg-20 mcg-30 mcg-2000 unit-7.5 mcg-200 unit-200 mcg-300 mcg-2.5 mg-37.5 mg, 55 mcg-2.5 mg-15 unit-75 mcg-5 mg-2000unit-20 mcg-30 mcg-7.5mcg-200 unit-200 mcg-300mcg-2.5 mg-37.5 mg, 75mcg-18.75 mcg-60 mcg-7.5unit-5 mg-137.5 mcg-1.5mg-20 mcg-1250 unit-6mcg-400 unit-5 mg-200mcg-7.5 mcg-2 mg-15 mg,75 mcg-9.4 mcg-1.9 mg-60mcg-15 unit-19 mcg-1 mg-5 mg-3 mcg-20 mcg-1250unit-9 mcg-200 unit-10 mg-150 mcg-15 mcg-2 mg-15mg, 20 mcg-1 mg-50 mg-60 unit-150 mcg-20 mg-108 mg-2 mg-15 mg-40mg-1.5 mg-18 mg-10 mg-3500 unit-20 mg-10 unit-1.7 mg-6 mcg-400 unit-400mcg-45 mcg-2 mg-60 mg,4 mg-10 mcg-22.5 mcg-100 mcg-4.5 mg-10 mcg-5mcg-125 mg-70 unit-25mcg-100 mcg-2 mg-15 mg-50 mg-2.2 mg-200 mg-10mg-4000 unit-250 mcg-12mg-2.7 mg-25 mcg-400unit-500 mcg-45 mcg-7mg-75 mg, 1 mg-7.5 mg-1mg-60 mcg-1 mg-75 mg-75mcg-25 mcg-7.5 mg-25mg-35 mcg-15 mg-75 unit-6.25 mg-5 mg-22.5 mg-10mg-10 mg-10 mg-500 mcg-1.7 mg-5000 unit-500 mcg-

Drug Name DrugTier

Requirements/Limits

1500 unit-400 mcg-300mcg-2 mg-45 mg multiple vitamins w/minerals tabs 0.05 mg-50mcg-60 unit-20 mcg-3 mg-15 mg-50 mg-20 mg-10mg-100 mg-20 mg-25 mg-50 mcg-1 mg-0.15 mg-25mg-500 mg-400 unit, 50mcg-10 mg-60 mg-100unit-125 mg-33 mg-25 mg-5000 unit-50 mg-25 mg-25mg-200 unit-1 mg-300mcg-25 mg-500 mg, 50mcg-10 mg-80 mg-125 mg-200 unit-33 mg-25 mg-5000 unit-50 mg-25 mg-25mg-25 mg-1 mg-100 unit-300 mcg-500 mg, 30 unit-0.1 mg-5 mg-3 mg-22.5mg-50 mg-20 mg-27 mg-5000 unit-100 mg-20 mg-25 mg-50 mcg-0.8 mg-0.15mg-25 mg-500 mg, 200mcg-5 mg-50 mcg-66 mg-2.5 mg-50 unit-400 unit-20mg-50 mg-20 mg-5000unit-100 mg-20 mg-25 mg-50 mcg-1000 mcg-200mcg-25 mg-500 mg, 1 mg-150 mcg-125 unit-125 mcg-35 mg-35 mg-10 mg-25mg-125 mcg-35 mg-400mcg-35 mg-3.4 mg-5 mg-70 mcg-400 unit-1.25 mg-75 mcg-35 mg-500 mg,33.333 mcg-0.667 mg-1.667 mg-3.333 mg-26.667mg-5 mcg-66.667 unit-5mg-66.667 mg-1666.667unit-5 mg-16.667 mg-66.667 mg-133.333 mg-16.667 mcg-133.333 unit-16.667 mg-133.333 mg-16.667 mg-333.333 mcg-50mcg-16.667 mg-333.333mg-166.667 mg

1

RX/OTC

MULTIVITAMIN ADULT CHEW 2

MULTIVITAMIN ADULT EXTRAVITAMIN C CHEW 2


175

Drug Name DrugTier

Requirements/Limits

MVW COMPLETE FORMULATION CHEW 2

NICADAN TABS 1 RX/OTC

NICADAN ZX TABS 1 RX/OTC

NICAZEL FORTE TABS 1 RX/OTC

NICAZEL TABS 1 RX/OTC

NUTRICAP TABS 1 RX/OTC

ONE A DAY MENS VITACRAVES MULTI GUMMIES CHEW

2

ONE-A-DAY FOR HER VITACRAVES TEEN MULTI GUMMIES CHEW

2

ONE-A-DAY FOR HIM/VITACRAVES TEENMULTI GUMMIES CHEW

2

ONE-A-DAY MENS VITACRAVES GUMMIES CHEW

2

ONE-A-DAY VITACRAVES ADULT CHEW 2

ONE-A-DAY VITACRAVES CHEW 2

ONE-A-DAY VITACRAVES GUMMIES/IMMUNITYSUPPORT CHEW

2

ONE-A-DAY VITACRAVES SOURGUMMIES CHEW 2

ONE-A-DAY VITACRAVES WOMENS MULTI CHEW 2

ONE-A-DAY WOMENS 50+ HEALTHY ADVANTAGE TABS (multiple vitamins w/minerals)

NF

RX/OTC

ONE-A-DAY WOMENS VITACRAVES GUMMIES CHEW

2

OPTIMUM AIRVITES CHEW 2

OPTISOURCE POST BARIATRIC SURGERY CHEW

2

Drug Name DrugTier

Requirements/Limits

OPURITY/BYPASSOPTIMIZED CHEW 2

PRESERVISION AREDS 2 CHEW 2

REQ 49+ TABS 1 RX/OTC

SIDEROL TABS 1 RX/OTC

STROVITE FORTE TABS (multiple vitamins w/minerals)

1 RX/OTC

STROVITE ONE TABS 1 RX/OTC

SYSTANE ICAPS AREDS2 CHEW 1 MG-200 UNIT-12.5 MG-1 MG-5 MG-250 MG

2

VITAROCA PLUS TABS (multiple vitamins w/minerals)

1 RX/OTC

VP-ZEL TABS 1 RX/OTC

WAL-BORN VITAMIN C CHEW 2

WOMENS MULTI GUMMIES CHEW 2

YOUR LIFE MULTI ADULT GUMMIES CHEW 2

YOUR LIFE TEEN MULTIVITAMIN GUMMIES CHEW

2

Ped MV w/ Fluoride

FLORIVA PLUS SOLN 2


MULTIVITAMIN/FLUORIDE CHEW 2

QL(1 ea daily);AL(Up to 13 yrsold )


176

Drug Name DrugTier

Requirements/Limits

pediatric multivitamins w/flchew 0.25 mg-15 unit-1.2mg-2500 unit-4.5 mcg-400unit-1.05 mg-13.5 mg-1.05mg-0.3 mg-60 mg, 0.25mg-15 unit-400 unit-2500unit-1.2 mg-4.5 mcg-13.5mg-1.05 mg-0.3 mg-1.05mg-60 mg, 0.5 mg-15 unit-1.2 mg-2500 unit-4.5 mcg-400 unit-1.05 mg-13.5 mg-1.05 mg-0.3 mg-60 mg, 0.5mg-15 unit-400 unit-2500unit-1.2 mg-4.5 mcg-13.5mg-1.05 mg-0.3 mg-1.05mg-60 mg, 1 mg-15 unit-1.2 mg-2500 unit-4.5 mcg-400 unit-1.05 mg-13.5 mg-1.05 mg-0.3 mg-60 mg, 1mg-15 unit-400 unit-2500unit-1.2 mg-4.5 mcg-13.5mg-1.05 mg-0.3 mg-1.05mg-60 mg, 15 unit-1 mg-1.05 mg-13.5 mg-1.2 mg-2500 unit-4.5 mcg-400 unit-0.3 mg-1.05 mg-60 mg, 15unit-1 mg-2500 unit-13.5mg-1.2 mg-4.5 mcg-400unit-1.05 mg-0.3 mg-1.05mg-60 mg, 15 unit-0.5 mg-1.05 mg-13.5 mg-1.2 mg-2500 unit-4.5 mcg-400 unit-0.3 mg-1.05 mg-60 mg, 15unit-0.5 mg-2500 unit-13.5mg-1.2 mg-4.5 mcg-400unit-1.05 mg-0.3 mg-1.05mg-60 mg, 15 unit-0.25mg-1.05 mg-13.5 mg-1.2mg-2500 unit-4.5 mcg-400unit-0.3 mg-1.05 mg-60mg, 15 unit-0.25 mg-2500unit-13.5 mg-1.2 mg-4.5mcg-400 unit-1.05 mg-0.3mg-1.05 mg-60 mg

1


Drug Name DrugTier

Requirements/Limits

pediatric multivitamins w/flsoln 0.25 mg/ml-0.6 mg/ml-8 mg/ml-1500 unit/ml-2mcg/ml-400 unit/ml-0.5mg/ml-5 unit/ml-0.4 mg/ml-35 mg/ml, 0.25 mg/ml-5unit/ml-0.6 mg/ml-8 mg/ml-1500 unit/ml-2 mcg/ml-400unit/ml-0.5 mg/ml-0.4mg/ml-35 mg/ml, 0.25mg/ml-5 unit/ml-8 mg/ml-0.6 mg/ml-1500 unit/ml-2mcg/ml-400 unit/ml-0.5mg/ml-0.4 mg/ml-35 mg/ml,0.5 mg/ml-0.6 mg/ml-8mg/ml-1500 unit/ml-2mcg/ml-400 unit/ml-0.5mg/ml-5 unit/ml-0.4 mg/ml-35 mg/ml, 0.5 mg/ml-5unit/ml-0.6 mg/ml-8 mg/ml-1500 unit/ml-2 mcg/ml-400unit/ml-0.5 mg/ml-0.4mg/ml-35 mg/ml, 0.5mg/ml-5 unit/ml-8 mg/ml-0.6 mg/ml-1500 unit/ml-2mcg/ml-400 unit/ml-0.5mg/ml-0.4 mg/ml-35 mg/ml,5 unit/ml-0.5 mg/ml-0.6mg/ml-8 mg/ml-1500unit/ml-2 mcg/ml-400unit/ml-0.5 mg/ml-0.4mg/ml-35 mg/ml, 5 unit/ml-0.5 mg/ml-8 mg/ml-0.6mg/ml-1500 unit/ml-2mcg/ml-400 unit/ml-0.5mg/ml-0.4 mg/ml-35 mg/ml,5 unit/ml-0.25 mg/ml-0.6mg/ml-8 mg/ml-1500unit/ml-2 mcg/ml-400unit/ml-0.5 mg/ml-0.4mg/ml-35 mg/ml

1


pediatric vitamins acd w/fluoride soln 1



177

Drug Name DrugTier

Requirements/Limits

QUFLORA PEDIATRIC CHEW 108 MCG-1 MG-15 UNIT-1 MG-15 MG-1200 UNIT-5 MG-1.3 MG-4 MCG-400 UNIT-1.2 MG-100 MCG-1.5 MG-60 MG, 108 MCG-1 MG-15 UNIT-0.5 MG-15 MG-1200 UNIT-5 MG-1.3 MG-4 MCG-400 UNIT-1.2 MG-100 MCG-1.5 MG-60 MG, 108 MCG-1 MG-15 UNIT-0.25 MG-15 MG-1200 UNIT-5 MG-1.3 MG-4 MCG-400 UNIT-1.2 MG-100 MCG-1.5 MG-60 MG

2


QUFLORA PEDIATRIC SOLN 150 MCG/ML-1MG/ML-0.5 MG/ML-12MG/ML-1100 UNIT/ML-2MG/ML-1 MG/ML-3MCG/ML-400 UNIT/ML-1MG/ML-81 MCG/ML-12UNIT/ML-1 MG/ML-45MG/ML, 65 MCG/ML-1MG/ML-0.25 MG/ML-10MG/ML-1000 UNIT/ML-0.8MG/ML-0.6 MG/ML-2MCG/ML-400 UNIT/ML-0.5MG/ML-35 MCG/ML-5UNIT/ML-0.4 MG/ML-35MG/ML

2


Ped MV w/ Iron pediatric multiple vitaminsw/ iron soln 1 QL(60 ml per

fill retail) POLY-VI-SOL/IRON SOLN(pediatric multiple vitaminsw/ iron)


Ped Multi Vitamins w/Fl & FE

ped multivitamins w/fl &iron soln 1


TRI-VIT/FLUORIDE/IRONSOLN 2


Pediatric Vitamins

Drug Name DrugTier

Requirements/Limits

pediatric vitamins adc soln 1

TRI-VI-SOL SOLN (pediatric vitamins adc) NF

Prenatal Vitamins ATABEX PRENATAL CHEW 2

BRAINSTRONG PRENATAL MISC 2

CADEAU DHA CAPS 2

CALNA TABS 2

CENTRUM SPECIALIST PRENATAL MISC 2

CLASSIC PRENATAL TABS 2 QL(1 ea daily);

MP CLINICAL NUTRIENTS PRENATAL FORMULA TABS

2

CO-NATAL FA TABS 2 QL(1 ea daily);RX/OTC

COMPLETENATE CHEW 2 QL(1 ea daily)

CVS PRENATAL GUMMY/DHA/FOLIC ACIDCHEW

2

CVS PRENATAL MULTI+DHA CAPS 2

CVS PRENATAL TABS 2 QL(1 ea daily);MP

CVS WOMENS PRENATAL+DHA MISC 2

ENFAMIL EXPECTA MISC 2

EQL PRENATAL FORMULA TABS 2 QL(1 ea daily);

MP

EZFE FORTE CAPS 2

GNP DAILY PRENATAL MISC 2

GNP PRENATAL TABS 2 QL(1 ea daily);MP

GOODSENSE PRENATAL VITAMINS TABS 2 QL(1 ea daily);

MP HM ONE DAILY PRENATAL COMBO MISC 2


178

Drug Name DrugTier

Requirements/Limits

HM PRENATAL TABS 2 QL(1 ea daily);MP

INATAL GT TABS 2

KP PRENATAL MULTIVITAMINS TABS 2 QL(1 ea daily);

MP

KPN PRENATAL TABS 2 QL(1 ea daily)

M-NATAL PLUS TABS 2 RX/OTC; MP

M-VIT TABS 2 RX/OTC; MP

MULTI PRENATAL TABS 2 QL(1 ea daily);MP

MYNATAL ADVANCE TABS 2

MYNATAL CAPS 2 QL(1 ea daily)

MYNATAL PLUS TABS 2 QL(1 ea daily)

MYNATAL ULTRACAPLET TABS 2

MYNATAL-Z TABS 2 QL(1 ea daily)

MYNATE 90 PLUS TBCR 2 QL(1 ea daily)

NATALVIT TABS 2 QL(1 ea daily)

NEONATAL COMPLETE TABS 2 RX/OTC; MP

NEONATAL PLUS TABS 2 RX/OTC; MP

NEONATAL VITAMIN TABS 2 QL(1 ea daily);

MP

NESTABS ONE CAPS 2

NIVA-PLUS TABS 2 RX/OTC; MP

O-CAL FA TABS 2 RX/OTC; MP

O-CAL PRENATAL TABS 2 QL(1 ea daily)

OBTREX DHA MISC 2 RX/OTC

OBTREX TABS 2 RX/OTC

ONE A DAY WOMENS PRENATAL/DHA MISC 2

Drug Name DrugTier

Requirements/Limits

ONE A DAY WOMENS PRENATAL1 CAPS 2

ONE-A-DAY WOMENS PRENATAL MISC 2

PA PRENATAL FORMULA TABS 2

PERRY PRENATAL CAPS 2 QL(1 ea daily)

PNV FOLIC ACID + IRON MULTIVITAMIN TABS 2 RX/OTC; MP

PNV PRENATAL PLUS MULTIVITAMIN TABS 2 RX/OTC; MP

PNV TABS 29-1 TABS 2 QL(1 ea daily);MP

PRE-NATAL FORMULA TABS 2 QL(1 ea daily);

RX/OTC

PRENATABS FA TABS 2 QL(1 ea daily);RX/OTC

PRENATABS RX TABS 2 QL(1 ea daily);MP

PRENATAL 19 CHEW 2 QL(1 ea daily)

PRENATAL 19 TABS 2 QL(1 ea daily)

PRENATAL AND IRON TABS 2 QL(1 ea daily);

RX/OTC PRENATAL COMPLETE TABS 2

PRENATAL FORMULA A-FREE TABS 2

PRENATAL FORMULA CAPS 2

PRENATAL FORTE TABS 2 QL(1 ea daily);RX/OTC

PRENATAL LOW IRON TABS 2 QL(1 ea daily);

MP PRENATAL MULTI + DHA CAPS 2

PRENATAL MULTI +DHA CAPS 2

PRENATAL MULTIVITAMIN + DHA MISC

2

PRENATAL MULTIVITAMIN PLUS DHA CAPS

2


179

Drug Name DrugTier

Requirements/Limits

PRENATAL MULTIVITAMIN PLUS DHA MISC

2

PRENATAL MULTIVITAMIN TABS 2 QL(1 ea daily);

MP PRENATAL ONE DAILY TABS 2 QL(1 ea daily);

MP PRENATAL PLUS IRON TABS 2 QL(1 ea daily);

MP

PRENATAL PLUS TABS 2 RX/OTC; MP

PRENATAL TABS 11 QL(1 ea daily);UNIT-263 MG-25 MG-1.5 MP MG-27 MG-4000 UNIT-18 MG-1.7 MG-4 MCG-400 UNIT-0.8 MG-2.6 MG-100 MG, 30 UNIT-4000 UNIT-25 MG-1.8 MG-200 MG-28 MG-20 MG-1.7 MG-8 MCG-400 UNIT-0.8 MG-2.6 MG-120 MG, 30 UNIT-25 MG-1.8 MG-200 MG-28 MG-20 MG-1.7 MG-4000 UNIT-8 MCG-400 UNIT-800 MCG-2.6 MG-120 MG, 30 UNIT-4000 UNIT-25 MG-1.8 MG-200 MG-28 MG-20 MG-1.7 MG-8 2 MCG-400 UNIT-800 MCG-2.6 MG-120 MG, 4000 UNIT-30 UNIT-200 MG-25 MG-1.8 MG-28 MG-20 MG-1.7 MG-8 MCG-400 UNIT-800 MCG-2.6 MG-120 MG, 4000 UNIT-30 UNIT-25 MG-1.8 MG-200 MG-28 MG-20 MG-1.7 MG-8 MCG-400 UNIT-800 MCG-2.6 MG-120 MG, 160 MG-11 UNIT-200 MG-25 MG-1.84 MG-27 MG-4000 UNIT-18 MG-1.7 MG-4 MCG-400 UNIT-800 MCG-2.6 MG-100 MG PRENATAL TABS 22 MG-2 MG-25 MG-1.84 MG-200 MG-27 MG-4000 UNIT-20 MG-3 MG-12 MCG-400 UNIT-1 MG-10 MG-120 MG

2

RX/OTC; MP

Drug Name DrugTier

Requirements/Limits

PRENATAL TABS 3.75 UNIT-0.5 MG-50 MG-0.5 MG-25 MG-15 MG-3.75 MG-6.75 MG-2.5 MG-5 MG-0.75 MG-500 UNIT-2.5 MCG-0.5 MG-200 MCG-25 MCG-0.75 MG-100 UNIT

2

PRENATAL TABS 4000 UNIT-200 MG-11 UNIT-27 MG-25 MG-1.84 MG-18 MG-1.7 MG-4 MCG-400 UNIT-0.8 MG-2.6 MG-100 MG

2


PRENATAL VITAMIN & MINERAL TABS 2 QL(1 ea daily);

MP PRENATAL VITAMIN TABS 2 QL(1 ea daily);

MP PRENATAL VITAMIN/IRON TABS 2 QL(1 ea daily);

MP PRENATAL VITAMINS PLUS LOW IRON TABS 2 RX/OTC; MP

PRENATAL VITAMINS TABS 2 QL(1 ea daily);

MP

PRENATAL+DHA MISC 2

PRENATAL/OMEGA-3/FOLIC ACID/IRON CAPS 2

PRENATVITE RX TABS 2 QL(1 ea daily);RX/OTC

PREPLUS TABS 2 RX/OTC; MP

PRETAB TABS 2 QL(1 ea daily);RX/OTC

PX PRENATAL MULTIVITAMINS TABS 2 QL(1 ea daily);

MP

QC PRENATAL TABS 2 QL(1 ea daily);MP

RA ONE DAILY MISC 2

RA PRENATAL FORMULA/FOLICACIDTABS

2 QL(1 ea daily);MP

RA PRENATAL TABS 2 QL(1 ea daily);MP

RIGHT STEP PRENATAL TABS 2 QL(1 ea daily);

MP

SE-NATAL 19 CHEW 2 QL(1 ea daily)


180

Drug Name DrugTier

Requirements/Limits

SE-NATAL 19 TABS 2 QL(1 ea daily)

SIMILAC PRENATAL EARLY SHIELD MISC 2

SM ONE DAILY PRENATAL MISC 2

SM PRENATAL VITAMINS TABS 2 QL(1 ea daily);

MP

STUART ONE CAPS 2

THERANATAL COMPLETE MISC 2

THERANATAL CORE NUTRITION TABS 2 RX/OTC; MP

THERANATAL ONE CAPS 2

THRIVITE 19 TABS 2 QL(1 ea daily)

THRIVITE RX TABS 2 QL(1 ea daily);MP

TRICARE TABS 2 RX/OTC; MP

TRINATAL RX 1 TABS 2 QL(1 ea daily)

VIL-RX TABS 2 QL(1 ea daily);MP

VINATE M TABS 2 QL(1 ea daily)

VINATE ONE TABS 2 QL(1 ea daily)

VITAFOL-OB TABS 2 QL(1 ea daily)

VITATHELY/GINGERTABS 2 RX/OTC; MP

VOL-PLUS TABS 2 RX/OTC; MP

VOL-TAB RX TABS 2 QL(1 ea daily);MP

WEGMANS COMPLETE PRENATAL+DHA MISC 2

YOUR LIFE MULTI PRENATAL CAPS 2

MUSCULOSKELETAL THERAPY AGENTS -Drugs to Treat Spasms

Central Muscle Relaxants AMRIX CP24 (cyclobenzaprine hcl) NP PA

Drug Name DrugTier

Requirements/Limits

baclofen soln it 40 mg/20ml, 500 mcg/ml,20000 mcg/20ml

NP PA

baclofen tabs or 10 mg, 20 mg 1 MP

BACLOFEN TABS OR 5 MG NP PA

carisoprodol tabs NP PA

CHLORZOXAZONE TABS 250 MG NP

chlorzoxazone tabs 500 mg NP

cyclobenzaprine hcl cp2415 mg, 30 mg NP PA

cyclobenzaprine hcl tabs 5mg, 10 mg 1 QL(3 ea daily)

cyclobenzaprine hcl tabs7.5 mg 1

FEXMID TABS (cyclobenzaprine hcl) NF

GABLOFEN SOLN 10000 MCG/20ML, 20000MCG/20ML, 40000MCG/20ML

NP

PA

GABLOFEN SOLN 20000 MCG/20ML (baclofen) NP PA

GABLOFEN SOSY 50 MCG/ML, 10000MCG/20ML, 20000MCG/20ML, 40000MCG/20ML

NP

PA

LIORESAL INTRATHECAL SOLN 0.05 MG/ML, 10MG/5ML

NP PA

LIORESAL INTRATHECAL SOLN 10 MG/20ML, 40MG/20ML (baclofen)

NP PA

METAXALONE TABS 400 MG NP

metaxalone tabs 800 mg NP PA

methocarbamol soln ij 1000mg/10ml NP PA

methocarbamol tabs or 500 mg, 750 mg 1


181

Drug Name DrugTier

Requirements/Limits

orphenadrine citrate soln ij30 mg/ml, 60 mg/2ml NP PA

orphenadrine citrate tb12or 100 mg NP

ROBAXIN SOLN IJ 1000 MG/10ML (methocarbamol) NP PA

ROBAXIN TABS OR 500 MG (methocarbamol) NF

ROBAXIN-750 TABS (methocarbamol) NF

SKELAXIN TABS (metaxalone) NP PA

SOMA TABS (carisoprodol) NP PA

tizanidine hcl caps 2 mg, 4mg, 6 mg NP PA

tizanidine hcl tabs 2 mg 1 QL(18 eadaily); MP

tizanidine hcl tabs 4 mg 1 QL(9 ea daily);MP

ZANAFLEX CAPS 2 MG, 4 MG, 6 MG (tizanidine hcl) NP PA

ZANAFLEX TABS 4 MG (tizanidine hcl) NF QL(9 ea daily);

MP

Direct Muscle Relaxants DANTRIUM CAPS (dantrolene sodium) NP PA

DANTRIUM IV SOLR (dantrolene sodium) 2 PA

dantrolene sodium caps or100 mg NP

dantrolene sodium caps or25 mg, 50 mg NP PA

dantrolene sodium solr iv 20 mg 1 PA

RYANODEX SUSR 2 PA

Muscle Relaxant Combinations carisoprodol w/ aspirin &codeine tabs NP PA

carisoprodol w/ aspirin tabs NP PA

CARISOPRODOL/ASPIRIN TABS NP PA

CARISOPRODOL/ASPIRIN/CODEINE TABS NP PA

Drug Name DrugTier

Requirements/Limits

NORGESIC FORTE TABS NP PA

ORPHENADRINE CITRATE/ASPIRIN/CAFFEINE TABS

NP PA

ORPHENGESIC FORTE TABS NP PA

NASAL AGENTS - SYSTEMIC AND TOPICAL -Drugs to treat the Nose or Sinus

Nasal Agent Combinations azelastine hcl-fluticasone propionate susp NP

DYMISTA SUSP (azelastine hcl-fluticasone propionate)

NP

Nasal Agents - Misc. OCEAN NASAL SPRAY SOLN (saline) NF QL(50 ml per

fill retail)

saline soln 1 QL(50 ml perfill retail)

Nasal Anti-infectives BACTROBAN NASAL OINT NP PA

Nasal Antiallergy ASTEPRO SOLN (azelastine hcl) NF QL(1 ml daily)

azelastine hcl soln 1 QL(1 ml daily)

olopatadine hcl (nasal) soln NP PA

PATANASE SOLN (olopatadine hcl (nasal)) NP PA

Nasal Anticholinergics

ipratropium bromide (nasal)soln 0.03 % 1


ipratropium bromide (nasal)soln 0.06 % 1


Nasal Steroids

budesonide (nasal) susp 1

FLONASE ALLERGY RELIEF SUSP (fluticasone propionate (nasal))

NF RX/OTC


182

Drug Name DrugTier

Requirements/Limits

FLONASE SENSIMIST SUSP 2

FLUNISOLIDE SOLN 1 QL(25 ml perfill retail)

fluticasone propionate(nasal) susp 1

QL(16 gm per30 daysretail,48 gm per90 days mail);RX/OTC

NASACORT ALLERGY 24HR AERO (triamcinolone acetonide (nasal))

NF RX/OTC

OMNARIS SUSP 2 PA

triamcinolone acetonide (nasal) aero 1

QL(17 gm perfill retail); AL(Atleast 2 yrs old);RX/OTC

ZETONNA AERS 2 PA

Sympathomimetic Decongestants ADRENALIN SOLN NA 0.1 % 2

LITTLE COLDS DECONGESTANTFORMU LA LIQD

1

pseudoephedrine hcl tabs 1

SUDAFED CONGESTION TABS (pseudoephedrinehcl)

NF

SUDAFED SINUS CONGESTION TABS (pseudoephedrine hcl)

NF

NEUROMUSCULAR AGENTS - Drugs toRelax/Paralyze Muscles

ALS Agents

RADICAVA SOLN CO

RILUTEK TABS (riluzole) NF MP

riluzole tabs 1 MP

TIGLUTIK SUSP NP PA

Muscular Dystrophy Agents

Drug Name DrugTier

Requirements/Limits

EXONDYS 51 SOLN CO

Spinal Muscular Atrophy Agents (SMA) SPINRAZA SOLN CO

ZOLGENSMA 10.1-10.5 KG KIT CO





















183

Drug Name DrugTier

Requirements/Limits



OPHTHALMIC AGENTS - Drugs to Treat the Eye

Artificial Tears and Lubricants

artificial tear ointment oint 1 QL(4 gm per fillretail)

carboxymethylcellulosesodium (ophth) soln 0.5 % 1

GENTEAL MILD SOLN 2 PA

ISOPTO TEARS SOLN 2 PA

polyethylene glycol-propylene glycol (ophth)soln

1 QL(3 ml daily)

polyvinyl alcohol soln 1 QL(15 ml perfill retail)

REFRESH PLUS SOLN (carboxymethylcellulosesodium (ophth))

NF

SYSTANE SOLN (polyethylene glycol-propylene glycol (ophth))

NF QL(3 ml daily)

SYSTANE ULTRA HOME & AWAY PACK SOLN (polyethylene glycol-propylene glycol (ophth))

NF

QL(3 ml daily)

SYSTANE ULTRA SOLN (polyethylene glycol-propylene glycol (ophth))

NF QL(3 ml daily)

TEARS NATURALE PM OINT (white petrolatum-mineral oil)

NF

white petrolatum-mineral oiloint 1

Beta-blockers - Ophthalmic BETAGAN SOLN (levobunolol hcl) NF MP

betaxolol hcl (ophth) soln NP

BETOPTIC-S SUSP NP

CARTEOLOL HCL SOLN NP QL(0.5 mldaily)

Drug Name DrugTier

Requirements/Limits

COMBIGAN SOLN 2 MP

COSOPT PF SOLN (dorzolamide hcl-timolol maleate)

NF

COSOPT SOLN (dorzolamide hcl-timolol maleate)

NF QL(10 ml perfill retail); MP

dorzolamide hcl-timolol maleate soln 2 %-0.5 % 1

dorzolamide hcl-timolol maleate soln 2 %-0.5 %, 20mg/ml-5 mg/ml, 22.3mg/ml-6.8 mg/ml

1

QL(10 ml perfill retail); MP

DORZOLAMIDE HCL/TIMOLOL MALEATESOLN

2 QL(10 ml perfill retail); MP

ISTALOL SOLN (timolol maleate (ophth)) NF MP

levobunolol hcl soln 1 MP

LEVOBUNOLOL HCL SOLN 2 MP

METIPRANOLOL SOLN NP

timolol maleate (ophth) soln 1 MP

TIMOLOL MALEATE OPHTHALMIC GEL FORMING SOLG

2 MP

TIMOPTIC OCUDOSE SOLN 0.25 % NP QL(60 ea per

fill retail) TIMOPTIC OCUDOSE SOLN 0.5 % NP

TIMOPTIC SOLN (timolol maleate (ophth)) NF MP

TIMOPTIC-XE SOLG 2 MP

Cycloplegic Mydriatics ATROPINE SULFATE OINT OP 1 % 2 MP

ATROPINE SULFATE SOLN OP 1 % 2 MP

CYCLOGYL SOLN 0.5 % (cyclopentolate hcl) NF QL(15 ml per

fill retail); MP CYCLOGYL SOLN 1 %, 2 % (cyclopentolate hcl) NF MP


184

Drug Name DrugTier

Requirements/Limits

CYCLOMYDRIL SOLN 2 MP

cyclopentolate hcl soln 0.5% 1 QL(15 ml per

fill retail); MP cyclopentolate hcl soln 1%, 2 % 1 MP

ISOPTO ATROPINE SOLN 2 MP

MYDRIACYL SOLN (tropicamide) NF MP

phenylephrine hcl(mydriatic) soln 1 PA

tropicamide soln 0.5 % 1 QL(15 ml perfill retail); MP

tropicamide soln 1 % 1 MP

Miotics ISOPTO CARPINE SOLN (pilocarpine hcl) NP PA

MIOCHOL-E SOLR NP

MIOSTAT SOLN NP

PHOSPHOLINE IODIDE SOLR NP

pilocarpine hcl soln NP PA

Ophthalmic Adrenergic Agents

ALPHAGAN P SOLN 0.1 % 2 MP

ALPHAGAN P SOLN 0.15 % (brimonidine tartrate) 2 MP

apraclonidine hcl soln NP PA

brimonidine tartrate soln 0.15 % 1 MP

brimonidine tartrate soln 0.2 % 1 QL(15 ml per

fill retail); MP IOPIDINE SOLN 0.5 % (apraclonidine hcl) NP PA

IOPIDINE SOLN 1 % NP

SIMBRINZA SUSP 2 MP

Ophthalmic Anti-infectives

AZASITE SOLN NP

Drug Name DrugTier

Requirements/Limits

BACITRACIN OINT OP 500 UNIT/GM NP

bacitracin-polymyxin b(ophth) oint NP QL(4 gm per fill

retail)

BESIVANCE SUSP NP

BLEPH-10 SOLN (sulfacetamide sodium (ophth))


CILOXAN OINT NP QL(4 gm per fillretail)

CILOXAN SOLN (ciprofloxacin hcl (ophth)) NF

ciprofloxacin hcl (ophth)soln 1

erythromycin (ophth) oint 1 QL(4 gm per fillretail)

gatifloxacin (ophth) soln NP PA

GENTAK OINT NP QL(4 gm per fillretail)

gentamicin sulfate (ophth)soln 1

KLARITY-A SOLN NP

levofloxacin (ophth) soln NP

MOXEZA SOLN (moxifloxacin hcl (ophth)) NF

moxifloxacin hcl (ophth)soln 1 QL(3 ml per fill

retail) moxifloxacin hcl (ophth)soln 1

NATACYN SUSP 2

neomycin-bacitracin zn-polymyxin oint NP QL(4 gm per fill

retail) NEOMYCIN/POLYMYXIN/GRAMICIDIN SOLN NP

NEOSPORIN SOLN NP

OCUFLOX SOLN (ofloxacin (ophth)) NF

ofloxacin (ophth) soln 1

polymyxin b-trimethoprimsoln 1 QL(10 ml per

fill retail)


185

Drug Name DrugTier

Requirements/Limits

POLYTRIM SOLN (polymyxin b-trimethoprim) NF QL(10 ml per

fill retail) sulfacetamide sodium (ophth) soln 1 QL(15 ml per

fill retail) SULFACETAMIDE SODIUM OINT OP 2

tobramycin (ophth) soln 1 QL(5 ml per fillretail)

TOBREX OINT NP QL(4 gm per fillretail)

TOBREX SOLN (tobramycin (ophth)) NF QL(5 ml per fill

retail)

TRIFLURIDINE SOLN 2 QL(8 ml per fillretail)

VIGAMOX SOLN (moxifloxacin hcl (ophth)) 2 QL(3 ml per fill

retail)

VIROPTIC SOLN NP QL(8 ml per fillretail)

ZIRGAN GEL NP PA

ZYMAXID SOLN (gatifloxacin (ophth)) NP PA

Ophthalmic Decongestants naphazoline w/pheniramine soln 1 QL(0.5 ml

daily) NAPHCON-A SOLN (naphazoline w/pheniramine)

NF QL(0.5 mldaily)

Ophthalmic Gene Therapy

LUXTURNA SUSP CO

Ophthalmic Immunomodulators

CEQUA SOLN NP PA

RESTASIS EMUL 2 MP

RESTASIS MULTIDOSE EMUL 2 MP

Ophthalmic Integrin Antagonists

XIIDRA SOLN NP PA

Ophthalmic Kinase Inhibitors

RHOPRESSA SOLN NP

Drug Name DrugTier

Requirements/Limits

ROCKLATAN SOLN NP

Ophthalmic Local Anesthetics

AKTEN GEL NP

ALCAINE SOLN (proparacaine hcl) 2 PA

proparacaine hcl soln 1

tetracaine hcl (ophth) soln 1

Ophthalmic Nerve Growth Factors

OXERVATE SOLN 2 PA

Ophthalmic Steroids

ALREX SUSP NP

bacitracin-poly-neomycin-hc oint NP

BLEPHAMIDE S.O.P. OINT NP PA; QL(4 gm

per fill retail)

BLEPHAMIDE SUSP NP PA

DEXAMETHASONE SODIUM PHOSPHATE SOLN OP 0.1 %

2 QL(5 ml per fillretail)

DUREZOL EMUL 2

FLAREX SUSP NP

fluorometholone (ophth) susp 1

FML FORTE SUSP NP

FML LIQUIFILM SUSP (fluorometholone (ophth)) NF

FML OINT NP QL(4 gm per fillretail)

INVELTYS SUSP NP PA

LOTEMAX GEL NP

LOTEMAX OINT NP

LOTEMAX SM GEL NP


186

Drug Name DrugTier

Requirements/Limits

LOTEMAX SUSP (loteprednol etabonate) NP PA

loteprednol etabonate susp NP PA

MAXIDEX SUSP NP

MAXITROL OINT 10000 UNIT/GM-3.5 MG/GM-0.1% (neomycin-polymy-dexameth)

NF

QL(4 gm per fillretail)

MAXITROL SUSP 10000 UNIT/ML-3.5 MG/ML-0.1 %(neomycin-polymy-dexameth)

NF

QL(5 ml per fillretail)

neomycin-polymy-dexameth oint 10000 unit/gm-3.5 mg/gm-0.1 %

1 QL(4 gm per fillretail)

neomycin-polymy-dexameth susp 10000unit/ml-3.5 mg/ml-0.1 %

1 QL(5 ml per fillretail)

NEOMYCIN/POLYMYXIN/HYDROCORTISONE SUSP

NP QL(8 ml per fillretail)

OMNIPRED SUSP NP PA; QL(0.5 mldaily)

PRED FORTE SUSP NP PA; QL(0.5 mldaily)

PRED MILD SUSP NP QL(10 ml perfill retail)

PRED-G S.O.P. OINT NP

PRED-G SUSP NP

PREDNISOLONE ACETATE SUSP 2 QL(0.5 ml

daily) PREDNISOLONE SODIUM PHOSPHATE SOLN OP 1 %

NP

sulfacetamide sod-prednisolone soln 1

SULFACETAMIDE SODIUM/PREDNISOLONESODIUM PHOSPHATE SOLN

2

TOBRADEX OINT 2 QL(4 gm per fillretail)

TOBRADEX ST SUSP NP PA

Drug Name DrugTier

Requirements/Limits

TOBRADEX SUSP (tobramycin-dexamethasone)

NF

tobramycin-dexamethasone susp 1

ZYLET SUSP NP

Ophthalmics - Misc. ACULAR LS SOLN (ketorolac tromethamine (ophth))

NF QL(0.167 mldaily)

ACULAR SOLN (ketorolac tromethamine (ophth)) NF

ACUVAIL SOLN NP

ALOCRIL SOLN NP QL(5 ml per fillretail)

ALOMIDE SOLN NP QL(10 ml perfill retail)

azelastine hcl (ophth) soln NP QL(6 ml per fillretail)

AZOPT SUSP 2 MP

BEPREVE SOLN NP

bromfenac sodium (ophth)soln NP

BROMSITE SOLN NP

cromolyn sodium (ophth)soln 1

CYSTARAN SOLN 2 PA; MP

diclofenac sodium (ophth)soln 1

DORZOLAMIDE HCL SOLN 2 QL(10 ml per

fill retail); MP

dorzolamide hcl soln 1 QL(10 ml perfill retail); MP

ELESTAT SOLN (epinastine hcl (ophth)) NP PA

EMADINE SOLN NP

epinastine hcl (ophth) soln NP PA

flurbiprofen sodium soln 1 QL(3 ml per fillretail)


187

Drug Name DrugTier

Requirements/Limits

FLURBIPROFEN SODIUM SOLN 2 QL(3 ml per fill

retail)

ILEVRO SUSP 2

ketorolac tromethamine (ophth) soln 0.4 % 1 QL(0.167 ml

daily) ketorolac tromethamine (ophth) soln 0.5 % 1

ketotifen fumarate (ophth)soln 1 QL(10 ml per

fill retail)

LASTACAFT SOLN NP

NEVANAC SUSP NP

olopatadine hcl soln NP PA; RX/OTC

PATADAY SOLN (olopatadine hcl) NP PA; RX/OTC

PATANOL SOLN (olopatadine hcl) NP PA; RX/OTC

PAZEO SOLN NP

PROLENSA SOLN NP

TRUSOPT SOLN (dorzolamide hcl) NF QL(10 ml per

fill retail); MP ZADITOR SOLN (ketotifen fumarate (ophth)) NF QL(10 ml per

fill retail) Prostaglandins - Ophthalmic

bimatoprost soln NP

LATANOPROST SOLN 2 QL(3 ml per fillretail); MP

latanoprost soln 1 QL(3 ml per fillretail); MP

LUMIGAN SOLN NP

TRAVATAN Z SOLN (travoprost) NF MP

travoprost soln 1 MP

VYZULTA SOLN NP

XALATAN SOLN (latanoprost) NF QL(3 ml per fill

retail); MP

XELPROS EMUL NP PA

Drug Name DrugTier

Requirements/Limits

ZIOPTAN SOLN NP

OTIC AGENTS - Drugs to Treat the Ear

Otic Agents - Miscellaneous

acetic acid (otic) soln 1 QL(15 ml perfill retail)

carbamide peroxide (otic)soln 1 QL(15 ml per

fill retail) DEBROX SOLN (carbamide peroxide (otic)) NF QL(15 ml per

fill retail) Otic Anti-infectives

CETRAXAL SOLN NP

CIPROFLOXACIN SOLN OT 0.2 % NP

FLOXIN OTIC SOLN (ofloxacin (otic)) NF

ofloxacin (otic) soln 1

OTIPRIO SUSP NP

Otic Combinations

CIPRO HC SUSP 2

CIPRODEX SUSP 2 QL(8 ml per fillretail)

CIPROFLOXACIN/FLUOCINOLONE ACETONIDE PF SOLN

NP

COLY-MYCIN S SUSP NP

CORTISPORIN-TC SUSP NP

neomycin-polymyxin-hc(otic) soln 1 QL(10 ml per

fill retail) neomycin-polymyxin-hc(otic) susp 1 QL(10 ml per

fill retail)

OTOVEL SOLN NP

PRAMOTIC LIQD 2 QL(1 ml per 30days retail)

Otic Steroids DERMOTIC OIL (fluocinolone acetonide (otic))

NF


188

Drug Name DrugTier

Requirements/Limits

fluocinolone acetonide (otic) oil 1

hydrocortisone w/aceticacid soln 1 QL(10 ml per

fill retail) OXYTOCICS - Drugs to Prevent/Control UterineBleeding

Oxytocics methylergonovine maleatetabs 1

PASSIVE IMMUNIZING AND TREATMENT AGENTS - Antibody Drugs to Treat Low ImmuneSystem

Immune Serums

HYPERRHO S/D SOSY 2 AL(At least 18yrs old)

RHOGAM ULTRA-FILTERED PLUS SOSY 2 AL(At least 18

yrs old) Monoclonal Antibodies

SYNAGIS SOLN 2 PA

PENICILLINS - Drugs to Treat Bacterial Infections

Aminopenicillins amoxicillin caps 250 mg,500 mg 1

AMOXICILLIN CHEW 125 MG, 250 MG 2

amoxicillin susr 125 mg/5ml, 200 mg/5ml, 250mg/5ml, 400 mg/5ml

1

amoxicillin tabs 500 mg,875 mg 1

AMPICILLIN CAPS 2

ampicillin sodium solr ij 1gm, 2 gm, 250 mg, 500 mg 1

AMPICILLIN SODIUM SOLR IJ 125 MG 2

AMPICILLIN SODIUM SOLR IV 1 GM 2

ampicillin sodium solr iv 2gm, 10 gm 1

Natural Penicillins

BICILLIN L-A SUSP 2 PA

Drug Name DrugTier

Requirements/Limits

PENICILLIN G POTASSIUM IN ISO-OSMOTIC DEXTROSE SOLN

2

PA

penicillin g potassium solr 1 PA

PENICILLIN G PROCAINE SUSP 2 PA

PENICILLIN G SODIUM SOLR 2 PA

PENICILLIN V POTASSIUM SOLR 125 MG/5ML, 250 MG/5ML

2

penicillin v potassium tabs250 mg, 500 mg 1

PFIZERPEN SOLR (penicillin g potassium) NF PA

Penicillin Combinations amoxicillin & potclavulanate susr 400 mg/5ml-57 mg/5ml, 200mg/5ml-28.5 mg/5ml, 250mg/5ml-62.5 mg/5ml, 600mg/5ml-42.9 mg/5ml

1

amoxicillin & potclavulanate tabs 250 mg-125 mg

1 QL(30 ea perfill retail)

amoxicillin & potclavulanate tabs 500 mg-125 mg, 875 mg-125 mg

1 QL(20 ea perfill retail)

amoxicillin & potclavulanate tb12 1000 mg-62.5 mg


AMOXICILLIN/CLAVULANATE POTASSIUM CHEW 2 QL(20 ea per

fill retail) AMOXICILLIN/CLAVULANATE POTASSIUM ER TB12


ampicillin & sulbactamsodium solr 1 PA

AMPICILLIN-SULBACTAM SOLR 2 PA

AUGMENTIN ES-600 SUSR (amoxicillin & potclavulanate)

NF

AUGMENTIN SUSR 125 MG/5ML-31.25 MG/5ML NP PA


189

Drug Name DrugTier

Requirements/Limits

AUGMENTIN SUSR 250 MG/5ML-62.5 MG/5ML(amoxicillin & potclavulanate)

NF

AUGMENTIN TABS 500 MG-125 MG, 875 MG-125 MG (amoxicillin & potclavulanate)

NF

QL(20 ea perfill retail)

AUGMENTIN XR TB12 (amoxicillin & potclavulanate)

NP QL(40 ea per30 days retail)

BICILLIN C-R SUSP 2 PA

piperacillin sodium-tazobactam sodium solr 1 PA

UNASYN BULK PACK SOLR (ampicillin &sulbactam sodium)

NF PA

UNASYN SOLR (ampicillin& sulbactam sodium) NF PA

ZOSYN SOLN 0.375 GM/50ML-3 GM/50ML-5%, 0.5 GM/100ML-4GM/100ML-5 %, 0.25GM/50ML-2 GM/50ML-5 %

2

PA

ZOSYN SOLR 0.375 GM-3 GM, 0.25 GM-2 GM, 0.5 GM-4 GM, 4.5 GM-36 GM (piperacillin sodium-tazobactam sodium)

NF

PA

Penicillinase-Resistant Penicillins

dicloxacillin sodium caps 1

PHARMACEUTICAL ADJUVANTS

Semi Solid Vehicles

AQUABASE OINT 2

lanolin oint 1 RX/OTC

PROGESTINS - Hormone Replacement/ModifyingDrugs

Progestins AYGESTIN TABS (norethindrone acetate) NF MP

hydroxyprogesteronecaproate oil 250 mg/ml 1 PA

Drug Name DrugTier

Requirements/Limits

MAKENA OIL IM 250 MG/ML(hydroxyprogesterone caproate)

2

PA

MAKENA SOAJ SC 275 MG/1.1ML NP PA

medroxyprogesteroneacetate tabs 1 MP

MEGACE ES SUSP (megestrol acetate(appetite))

NF MP

megestrol acetate(appetite) susp 1 MP

norethindrone acetate tabs 1 MP

progesterone micronizedcaps 100 mg 1


progesterone micronizedcaps 200 mg 1


progesterone oil 1

PROMETRIUM CAPS 100 MG (progesteronemicronized)

NF QL(30 ea per30 days retail);MP

PROMETRIUM CAPS 200 MG (progesteronemicronized)

NF QL(20 ea per30 days retail);MP

PROVERA TABS (medroxyprogesterone acetate)

NF MP

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. - Drugs to Treat Mental andEmotional Conditions

Agents for Chemical Dependency

acamprosate calcium tbec 1 MP

ANTABUSE TABS (disulfiram) NF MP

disulfiram tabs 1 MP

LUCEMYRA TABS NP PA

Anti-Cataplectic Agents

XYREM SOLN NP PA


190

Drug Name DrugTier

Requirements/Limits

Antidementia Agents

ARICEPT TABS (donepezilhydrochloride) NF


donepezil hydrochloridetabs 1


EXELON PT24 (rivastigmine) NF

PA; QL(1 eadaily); AL(Atleast 18 yrsold); MP

galantamine hydrobromidecp24 8 mg, 16 mg, 24 mg 1


GALANTAMINE HYDROBROMIDE SOLN 4 MG/ML

2 QL(6 ml daily);AL(At least 18yrs old); MP

galantamine hydrobromidetabs 4 mg, 8 mg, 12 mg 1


memantine hcl soln 2 mg/ml, 10 mg/5ml 1

PA; QL(10 mldaily); AL(Atleast 18 yrsold); MP

memantine hcl tabs 1

PA; QL(49 eaper fill retail);AL(At least 18yrs old)

memantine hcl tabs 5 mg,10 mg 1


NAMENDA TABS (memantine hcl) NF


NAMENDA TITRATION PAK TABS (memantine hcl)

NF

PA; QL(49 eaper fill retail);AL(At least 18yrs old)

RAZADYNE ER CP24 (galantaminehydrobromide)


RAZADYNE TABS (galantaminehydrobromide)


Drug Name DrugTier

Requirements/Limits

rivastigmine pt24 1


rivastigmine tartrate caps 1


Combination Psychotherapeutics CHLORDIAZEPOXIDE/AMITRIPTYLINE TABS NP

olanzapine-fluoxetine hclcaps 12 mg-25 mg, 12 mg-50 mg

NP

PA; Age 6-12:MDD=0.84; Age 13-17:MDD=1.67;AL(At least 6 yrsold)

olanzapine-fluoxetine hclcaps 3 mg-25 mg NP

PA; Age 6-12:MDD=3.34; Age 13-17:MDD=6.67 ;AL(At least 6yrs old)

olanzapine-fluoxetine hclcaps 6 mg-25 mg, 6 mg-50 mg

NP


PERPHENAZINE/AMITRIPTYLINE TABS 10 MG-2 MG, 25 MG-2 MG

2

Age 6-12:MDD=6; Age13-17: MDD=12.;AL(Atleast 6 yrs old);MP

PERPHENAZINE/AMITRIPTYLINE TABS 10 MG-4 MG, 25 MG-4 MG, 50 MG-4 MG

2

Age 6-12:MDD=3; Age13-17: MDD=6.;AL(Atleast 6 yrs old);MP

SYMBYAX CAPS 12 MG-25 MG, 12 MG-50 MG (olanzapine-fluoxetine hcl)

NP



191

Drug Name DrugTier

Requirements/Limits

SYMBYAX CAPS 3 MG-25 MG (olanzapine-fluoxetinehcl)

NP

PA; Age 6-12:MDD=3.34; Age 13-17:MDD=6.67 ;AL(At least 6yrs old)

SYMBYAX CAPS 6 MG-25 MG, 6 MG-50 MG (olanzapine-fluoxetine hcl)

NP


Fibromyalgia Agents

SAVELLA TABS NP PA; QL(2 eadaily); MP

SAVELLA TITRATION PACK MISC NP

PA; QL(55 eaper 365 daysretail)

Movement Disorder Drug Therapy

AUSTEDO TABS NP PA

INGREZZA CAPS NP PA

INGREZZA CPPK NP PA

tetrabenazine tabs 1 PA; SP; MP

XENAZINE TABS (tetrabenazine) NF PA; SP; MP

Multiple Sclerosis Agents AMPYRA TB12 (dalfampridine) NP PA

AUBAGIO TABS NP

AVONEX KIT 2 SP

AVONEX PEN AJKT 2 SP

AVONEX PSKT 2 SP

BETASERON KIT 2

COPAXONE SOSY (glatiramer acetate) 2 SP

dalfampridine tb12 NP PA

GILENYA CAPS 0.25 MG NP

Drug Name DrugTier

Requirements/Limits

GILENYA CAPS 0.5 MG 2 SP

glatiramer acetate sosy NP SP

LEMTRADA SOLN NP

MAVENCLAD TBPK NP PA

MAYZENT STARTER PACK TBPK NP

MAYZENT TABS NP

OCREVUS SOLN NP PA; SP

PLEGRIDY SOPN NP ST

PLEGRIDY SOSY NP ST

PLEGRIDY STARTER PACK SOPN NP ST

PLEGRIDY STARTER PACK SOSY NP ST

REBIF REBIDOSE SOAJ 2

REBIF REBIDOSE TITRATIONPACK SOAJ 2

REBIF SOSY 2

REBIF TITRATION PACK SOSY 2

TECFIDERA CPDR 2 SP

TECFIDERA STARTER PACK MISC 2 SP

TYSABRI CONC NP

VUMERITY CPDR NP PA

ZINBRYTA SOSY NP

Postherpetic Neuralgia (PHN)/Neuropathic Pain

GABACAINE THPK NP PA

GRALISE STARTER MISC NP PA

GRALISE TABS NP PA


192

Drug Name DrugTier

Requirements/Limits

LYRICA CR TB24 NP PA

Premenstrual Dysphoric Disorder (PMDD) Agents

FLUOXETINE CAPS NP

fluoxetine hcl (pmdd) tabs NP

SARAFEM TABS (fluoxetine hcl (pmdd)) NP

Pseudobulbar Affect (PBA) Agents

NUEDEXTA CAPS NP PA; MP

Psychotherapeutic and Neurological Agents -ERGOLOID MESYLATES TABS 2 MP

ORAP TABS NF MP

PIMOZIDE TABS 2 MP

Restless Leg Syndrome (RLS) Agents

HORIZANT TBCR NP PA

Smoking Deterrents

bupropion hcl (smokingdeterrent) tb12 1


CHANTIX CONTINUING MONTHPAK TABS 2


CHANTIX STARTING MONTH PAK TABS 2

QL(53 ea per180 daysretail); AL(Atleast 18 yrsold)

CHANTIX TABS 2 QL(2 ea daily);AL(At least 18yrs old)

NICODERM CQ PT24 (nicotine) NF

QL(1 eadaily)180 rtlMAX day(s)supply,365 rtllmt day(s),

NICORETTE GUM 2 MG, 4 MG (nicotine polacrilex) NF


Drug Name DrugTier

Requirements/Limits

NICORETTE LOZG 2 MG, 4 MG (nicotine polacrilex) NF


NICORETTE MINI LOZG (nicotine polacrilex) NF


NICORETTE STARTER KIT GUM (nicotine polacrilex)

NF


nicotine polacrilex gum 2mg, 4 mg 1


nicotine polacrilex lozg 2mg, 4 mg 1


nicotine pt24 1


NICOTINE TRANSDERMAL SYSTEM KIT

NP

PA; 180 rtl MAX day(s)supply,365 rtllmt day(s),

NICOTROL INHALER INHA NP QL(504 ea per

30 days retail)

NICOTROL NS SOLN NP QL(120 ml per30 days retail)

ZYBAN TB12 (bupropionhcl (smoking deterrent)) NF


Vasomotor Symptom Agents BRISDELLE CAPS (paroxetine mesylate(vasomotor))

NP PA

paroxetine mesylate(vasomotor) caps NP PA


193

Drug Name DrugTier

Requirements/Limits

RESPIRATORY AGENTS - MISC. - Drugs toTreat Lung Conditions

Alpha-Proteinase Inhibitor (Human) ARALAST NP SOLR 2 PA

GLASSIA SOLN 2 PA

PROLASTIN-C SOLN 2 PA

PROLASTIN-C SOLR 2 PA

ZEMAIRA SOLR 2 PA

Cystic Fibrosis Agents

KALYDECO PACK 25 MG 2 PA

KALYDECO PACK 50 MG, 75 MG 2 PA; SP

KALYDECO TABS 150 MG 2 PA; SP

ORKAMBI PACK 100 MG-125 MG, 150 MG-188 MG 2 PA

ORKAMBI TABS 100 MG-125 MG, 200 MG-125 MG 2 PA; SP

PULMOZYME SOLN 2 PA; SP

SYMDEKO TBPK 2 PA

TRIKAFTA TBPK NP PA

Pulmonary Fibrosis Agents

ESBRIET CAPS 2 PA

ESBRIET TABS 2 PA

OFEV CAPS 2 PA

SULFONAMIDES - Drugs to Treat BacterialInfections

Sulfonamides

SULFADIAZINE TABS 2

TETRACYCLINES - Drugs to Treat BacterialInfections

Aminomethylcyclines

Drug Name DrugTier

Requirements/Limits

NUZYRA SOLR IV 100 MG 2 PA

NUZYRA TABS OR 150 MG NP

Fluorocyclines

XERAVA SOLR 2 PA

Glycylcyclines

tigecycline solr 1 PA

TIGECYCLINE SOLR 2 PA

TYGACIL SOLR (tigecycline) NF PA

Tetracyclines ACTICLATE TABS (doxycycline hyclate) NF

demeclocycline hcl tabs NP

DORYX MPC TBEC NP

DORYX TBEC (doxycyclinehyclate) NP PA

doxycycline (monohydrate)caps 50 mg, 100 mg 1

doxycycline (monohydrate)caps 75 mg, 150 mg NP

doxycycline (monohydrate)susr 25 mg/5ml NP PA

doxycycline (monohydrate)tabs 50 mg, 75 mg, 100mg, 150 mg

1

doxycycline hyclate caps or50 mg, 100 mg 1

doxycycline hyclate solr iv100 mg 1 PA

doxycycline hyclate tabs or20 mg, 75 mg, 100 mg, 150 mg

1

doxycycline hyclate tbec or50 mg, 200 mg NP PA

doxycycline hyclate tbec or75 mg, 100 mg, 150 mg NP

MINOCIN CAPS OR 100 MG (minocycline hcl) NF


194

Drug Name DrugTier

Requirements/Limits

MINOCIN CAPS OR 50 MG (minocycline hcl) 2

MINOCIN SOLR IV 100 MG 2 PA

minocycline hcl caps 50mg, 75 mg, 100 mg 1

minocycline hcl tabs 50mg, 75 mg, 100 mg NP

minocycline hcl tb24 45mg, 55 mg, 65 mg, 80 mg,90 mg, 105 mg, 115 mg,135 mg

NP

PA

MINOCYCLINE HYDROCHLORIDEER CP24

NP

MINOLIRA TB24 NP PA

MORGIDOX 1X100MG KIT NP

MORGIDOX 1X50MG KIT KIT NP

MORGIDOX 2X100MG KIT NP

SOLODYN TB24 (minocycline hcl) NP PA

tetracycline hcl caps 1

VIBRAMYCIN CAPS 100 MG (doxycycline hyclate) NF

VIBRAMYCIN SUSR 25 MG/5ML (doxycycline(monohydrate))

NP PA

VIBRAMYCIN SYRP 50 MG/5ML NP

XIMINO CP24 NP

THYROID AGENTS - Drugs to Regulate ThyroidHormones

Antithyroid Agents

methimazole tabs 1 MP

propylthiouracil tabs 1 MP

TAPAZOLE TABS (methimazole) NF MP

Thyroid Hormones

Drug Name DrugTier

Requirements/Limits

ARMOUR THYROID TABS 15 MG, 30 MG, 60 MG, 90 MG, 120 MG (thyroid)

2 MP

ARMOUR THYROID TABS 180 MG, 240 MG, 300 MG 2 MP

CYTOMEL TABS (liothyronine sodium) NF MP

LEVOTHYROXINE SODIUM SOLN IV 100 MCG/5ML, 200 MCG/5ML,500 MCG/5ML

NP

levothyroxine sodium tabsor 25 mcg, 50 mcg, 75mcg, 88 mcg, 100 mcg,112 mcg, 125 mcg, 137mcg, 150 mcg, 175 mcg,200 mcg, 300 mcg

1

MP

liothyronine sodium tabs 1 MP

NATURE-THROID TABS 2 MP

SYNTHROID TABS (levothyroxine sodium) NF MP

thyroid tabs 1 MP

THYROLAR-1 TABS NP MP

THYROLAR-1/2 TABS NP MP

THYROLAR-1/4 TABS NP MP



TIROSINT CAPS NP

TIROSINT-SOL SOLN NP

WESTHROID TABS 2 MP

WP THYROID TABS 2 MP

TOXOIDS

Toxoid Combinations


195

Drug Name DrugTier

Requirements/Limits

ADACEL SUSP 2

QL(1 ml per999 daysretail); AL(Atleast 18 yrsold)

BOOSTRIX SUSP 2


DIPHTHERIA/TETANUSTOXOIDS ADSORBED PEDIATRIC SUSP

2


INFANRIX SUSP 2


TDVAX SUSP 2


TENIVAC INJ 2


ULCER DRUGS - Drugs to Treat Bowel, Intestineand Stomach Conditions

Antispasmodics ANASPAZ TBDP (hyoscyamine sulfate) NP MP

BELLADONNA/OPIUMSUPP NP

BENTYL CAPS (dicyclomine hcl) NF

BENTYL SOLN (dicyclomine hcl) NF

chlordiazepoxide hcl-clidinium bromide caps NP PA

CUVPOSA SOLN NP

dicyclomine hcl caps or 10 mg 1

Drug Name DrugTier

Requirements/Limits

dicyclomine hcl soln im 10mg/ml 1

dicyclomine hcl soln or 10mg/5ml 1 QL(40 ml daily)

dicyclomine hcl tabs or 20 mg 1

GLYCATE TABS NP

glycopyrrolate soln ij 0.4mg/2ml, 0.2 mg/ml, 1mg/5ml, 4 mg/20ml

1

GLYCOPYRROLATE SOSY IJ 0.4 MG/2ML, 0.2MG/ML

NP

glycopyrrolate tabs or 1mg, 2 mg 1 QL(4 ea daily)

GLYCOPYRROLATE TABS OR 1.5 MG NP

GLYRX-PF SOLN NP

hyoscyamine sulfate elix or0.125 mg/5ml 1 MP

hyoscyamine sulfate elix or0.125 mg/5ml 1

hyoscyamine sulfate soln ij0.5 mg/ml NP PA

hyoscyamine sulfate solnor 0.125 mg/ml 1 MP

hyoscyamine sulfate subl sl0.125 mg 1 MP

hyoscyamine sulfate tabsor 0.125 mg 1 MP

hyoscyamine sulfate tb12or 0.375 mg 1 QL(4 ea daily);

MP hyoscyamine sulfate tbdpor 0.125 mg 1 MP

LEVBID TB12 (hyoscyamine sulfate) NF QL(4 ea daily);

MP LEVSIN SOLN IJ 0.5 MG/ML (hyoscyaminesulfate)

NP PA

LEVSIN TABS OR 0.125 MG (hyoscyamine sulfate) NP MP

LEVSIN/SL SUBL(hyoscyamine sulfate) NP MP


196

Drug Name DrugTier

Requirements/Limits

LIBRAX CAPS (chlordiazepoxide hcl-clidinium bromide)

NP PA

methscopolamine bromidetabs 5 mg, 2.5 mg 1

METHSCOPOLAMINE BROMIDE TABS 5 MG, 2.5 MG

2

PROPANTHELINE BROMIDE TABS 2

ROBINUL FORTE TABS (glycopyrrolate) NF QL(4 ea daily)

ROBINUL SOLN IJ 0.4 MG/2ML, 0.2 MG/ML, 1MG/5ML, 4 MG/20ML(glycopyrrolate)

NF

ROBINUL TABS OR 1 MG (glycopyrrolate) NF QL(4 ea daily)

SYMAX DUOTAB TBCR 2 MP

H-2 Antagonists

CIMETIDINE HCL SOLN 2 QL(27 mldaily); MP

cimetidine tabs 200 mg 1 RX/OTC

cimetidine tabs 300 mg,400 mg, 800 mg 1 MP

famotidine tabs 10 mg 1

famotidine tabs 20 mg 1 RX/OTC; MP

famotidine tabs 40 mg 1 MP

PEPCID AC MAXIMUM STRENGTH TABS (famotidine)

NF RX/OTC; MP

PEPCID AC TABS (famotidine) NF

PEPCID TABS 20 MG (famotidine) NF RX/OTC; MP

PEPCID TABS 40 MG (famotidine) NF MP

ranitidine hcl caps 150 mg 1 QL(2 ea daily);MP

ranitidine hcl caps 300 mg 1 QL(1 ea daily);MP

Drug Name DrugTier

Requirements/Limits

ranitidine hcl syrp 15mg/ml, 75 mg/5ml, 150mg/10ml

1 QL(20 mldaily); MP

ranitidine hcl tabs 150 mg 1 QL(2 ea daily);RX/OTC; MP

ranitidine hcl tabs 300 mg 1 QL(2 ea daily);MP

ranitidine hcl tabs 75 mg 1 QL(2 ea daily)

TAGAMET HB TABS (cimetidine) NF RX/OTC

ZANTAC 150 MAXIMUM STRENGTH TABS (ranitidine hcl)

NF QL(2 ea daily);RX/OTC; MP

ZANTAC 75 TABS (ranitidine hcl) NF QL(2 ea daily)

ZANTAC TABS (ranitidine hcl) NF QL(2 ea daily);

MP

Misc. Anti-Ulcer CARAFATE SUSP 1 GM/10ML (sucralfate) 2 MP

CARAFATE TABS 1 GM (sucralfate) NF QL(4 ea daily);

MP

sucralfate susp 1 gm/10ml 1 MP

sucralfate tabs 1 gm 1 QL(4 ea daily);MP

Proton Pump Inhibitors ACIPHEX TBEC (rabeprazole sodium) NF PA; MP

DEXILANT CPDR 2 ST; MP

FIRST-OMEPRAZOLE SUSP 2 QL(10 ml

daily); MP

lansoprazole cpdr 15 mg 1 QL(4 ea daily);RX/OTC; MP

NEXIUM 24HR CPDR (esomeprazolemagnesium)

2 QL(2 ea daily);RX/OTC; MP

OMEPRAZOLE + SYRSPEND SFALKA SUSP

2 QL(10 mldaily); MP

omeprazole cpdr 20 mg 1 QL(4 ea daily);RX/OTC; MP

omeprazole cpdr 40 mg 1 QL(2 ea daily);MP


197

Drug Name DrugTier

Requirements/Limits

omeprazole magnesiumcpdr 1

OMEPRAZOLE TBEC 20 MG 2 QL(1 ea daily)

omeprazole tbec 20 mg 1 QL(1 ea daily)

pantoprazole sodium tbec 1 QL(1 ea daily);MP

PREVACID 24HR CPDR (lansoprazole) NF QL(4 ea daily);

RX/OTC; MP PREVACID CPDR (lansoprazole) NF QL(4 ea daily);

RX/OTC; MP

PRILOSEC OTC TBEC 2 QL(1 ea daily)

PROTONIX TBEC (pantoprazole sodium) NF QL(1 ea daily);

MP

rabeprazole sodium tbec 1 PA; MP

Ulcer Drugs - Prostaglandins CYTOTEC TABS (misoprostol) NF MP

misoprostol tabs 1 MP

Ulcer Therapy Combinations amoxicillin-clarithromycinw/ lansoprazole misc NP PA

famotidine-calcium carbonate-magnesiumhydroxide chew

1

OMECLAMOX-PAK MISC NP PA

PEPCID COMPLETE CHEW (famotidine-calcium carbonate-magnesiumhydroxide)

NF

PREVPAC MISC (amoxicillin-clarithromycinw/ lansoprazole)

NP PA

PYLERA CAPS 2

URINARY ANTI-INFECTIVES - Drugs to TreatBladder/Kidney Infections

Urinary Anti-infective Combinations methenamine-hyosc-methylene blue-sod phos-phenyl sal tabs

1

Drug Name DrugTier

Requirements/Limits

Urinary Anti-infectives FURADANTIN SUSP (nitrofurantoin) NF

MACROBID CAPS (nitrofurantoin monohyd macro)

NF

MACRODANTIN CAPS (nitrofurantoin macrocrystal)

NF

methenamine mandelate tabs 1

MONUROL PACK 2 PA

nitrofurantoin macrocrystal caps 1

nitrofurantoin monohyd macro caps 1

nitrofurantoin susp 1

URINARY ANTISPASMODICS - Drugs to TreatMiscellaneous Bladder Spasms

Urinary Antispasmodic - Antimuscarinics darifenacin hydrobromidetb24 1 PA; MP

DETROL LA CP24 (tolterodine tartrate) NF QL(1 ea daily);

MP DETROL TABS (tolterodine tartrate) NF QL(2 ea daily);

MP DITROPAN XL TB24 (oxybutynin chloride) NF QL(2 ea daily);

MP ENABLEX TB24 (darifenacin hydrobromide) NF PA; MP

oxybutynin chloride syrp 5mg/5ml 1


oxybutynin chloride tabs 5 mg 1 QL(3 ea daily);

MP oxybutynin chloride tb24 5mg, 10 mg, 15 mg 1 QL(2 ea daily);

MP

solifenacin succinate tabs 1 PA; MP

tolterodine tartrate cp24 2mg, 4 mg 1 QL(1 ea daily);

MP tolterodine tartrate tabs 1 mg, 2 mg 1 QL(2 ea daily);

MP


198

Drug Name DrugTier

Requirements/Limits

TOVIAZ TB24 2 PA; MP

trospium chloride tabs 1 QL(2 ea daily);MP

VESICARE TABS (solifenacin succinate) NF PA; MP

Urinary Antispasmodics - Beta-3 Adrenergic

MYRBETRIQ TB24 2 PA; MP

Urinary Antispasmodics - Cholinergic Agonists

bethanechol chloride tabs 1 MP

URECHOLINE TABS (bethanechol chloride) NF MP

Urinary Antispasmodics - Direct Muscle Relaxants

flavoxate hcl tabs 1 MP

VACCINES

Bacterial Vaccines

ACTHIB SOLR 2


BEXSERO SUSY 2 AL(At least 18yrs old)

HIBERIX SOLR 2


MENACTRA INJ 2 AL(At least 18yrs old)

MENVEO SOLR 2 AL(At least 18yrs old)

PEDVAX HIB SUSP 2


PNEUMOVAX 23 INJ 2 AL(At least 18yrs old)

PNEUMOVAX 23/1 DOSEINJ 2 AL(At least 18

yrs old)

Drug Name DrugTier

Requirements/Limits

PREVNAR 13 SUSP 2 AL(At least 18yrs old)

TRUMENBA SUSY 2 AL(At least 18yrs old)

Viral Vaccines ENGERIX-B INJ IM 10 MCG/0.5ML 2 AL(At least 18

yrs old) ENGERIX-B INJ IM 20 MCG/ML 2 AL(At least 7

yrs old) ENGERIX-B SUSP IJ 20 MCG/ML, 10 MCG/0.5ML 2 AL(At least 18

yrs old)

GARDASIL 9 SUSP 2 AL(At least 18yrs old)

GARDASIL 9 SUSY 2 AL(At least 18yrs old)

HAVRIX SUSP 2 AL(At least 18yrs old)

M-M-R II SOLR 2 AL(At least 7yrs old)

RECOMBIVAX HB SUSP 2 AL(At least 18yrs old)

SHINGRIX SUSR 2

Limit 2 doses perlifetime;QL(2ea per 999days retail);AL(At least 50yrs old)

TWINRIX SUSP 2


TWINRIX SUSY 2 AL(At least 18yrs old)

VAQTA SUSP 2 AL(At least 18yrs old)

VARIVAX INJ 2 AL(At least 18yrs old)

ZOSTAVAX SUSR 2 AL(At least 50yrs old)

VAGINAL AND RELATED PRODUCTS

Miscellaneous Vaginal Products

INTRAROSA INST NP PA


199

Drug Name DrugTier

Requirements/Limits

Spermicides

ENCARE SUPP 2

nonoxynol-9 gel 1

OPTIONS CONCEPTROL VAGINAL CONTRACEPTIVE GEL (nonoxynol-9)

NF

OPTIONS GYNOL II VAGINALCONTRACEPTIV E GEL

2

SHUR-SEAL GEL 2

VCF VAGINAL CONTRACEPTIVE FILM FILM

2

Vaginal Anti-infectives

AVC CREA NP

CLEOCIN CREA VA 2 % (clindamycin phosphatevaginal)

NF QL(40 gm perfill retail)

CLEOCIN SUPP VA 100 MG 2

clindamycin phosphatevaginal crea 1 QL(40 gm per

fill retail)

CLINDESSE CREA NP PA

clotrimazole vaginal crea 1% 1 QL(45 gm per

fill retail) clotrimazole vaginal crea 2% 1

GYNAZOLE-1 CREA NP

GYNE-LOTRIMIN 3 CREA (clotrimazole vaginal) NF

GYNE-LOTRIMIN CREA (clotrimazole vaginal) NF QL(45 gm per

fill retail) METROGEL-VAGINAL GEL (metronidazole vaginal)


metronidazole vaginal gel 1 QL(70 gm perfill retail)

MICONAZOLE 3 SUPP 2 QL(3 ea per fillretail)

Drug Name DrugTier

Requirements/Limits

miconazole nitrate vaginalcrea 2 % 1 QL(45 gm per

fill retail) miconazole nitrate vaginalcrea 4 % 1 QL(45 gm per

30 days retail) MONISTAT 3 CREA (miconazole nitrate vaginal) NF QL(45 gm per

30 days retail) MONISTAT 7 SIMPLY CURE CREA (miconazole nitrate vaginal)


NUVESSA GEL NP PA

TERAZOL 7 CREA (terconazole vaginal) NF QL(45 gm per

fill retail)

TERCONAZOLE CREA 2 QL(20 gm perfill retail)

terconazole vaginal crea0.4 % 1 QL(45 gm per

fill retail) terconazole vaginal supp80 mg NP QL(3 ea per fill

retail) Vaginal Estrogens

ESTRACE CREA VA 0.1 MG/GM (estradiol vaginal) NF


estradiol vaginal crea 0.1mg/gm 1


estradiol vaginal tabs 10 mcg 1

ESTRING RING 2

FEMRING RING NP

IMVEXXY MAINTENANCE PACK INST NP PA

IMVEXXY STARTER PACK INST NP PA

PREMARIN CREA VA 0.625 MG/GM 2


VAGIFEM TABS (estradiol vaginal) NF

Vaginal Progestins

CRINONE GEL NP PA

VASOPRESSORS - Drugs to Treat Heart andCirculation Conditions


200

Drug Name DrugTier

Requirements/Limits

Anaphylaxis Therapy Agents ADRENALIN SOLN IJ 1 MG/ML 2

ADRENALIN SOLN IJ 1 MG/ML, 30 MG/30ML NP PA

AUVI-Q SOAJ 0.15 MG/0.15ML NP


epinephrine (anaphylaxis)soaj 0.15 mg/0.3ml, 0.3mg/0.3ml

NP PA; QL(2 eaper 25 daysretail)

epinephrine (anaphylaxis)soaj 0.15 mg/0.3ml, 0.3mg/0.3ml


EPINEPHRINE SOAJ 0.15 MG/0.15ML NP


EPIPEN 2-PAK SOAJ (epinephrine (anaphylaxis)) NP


EPIPEN-JR 2-PAK SOAJ (epinephrine (anaphylaxis)) NP


SYMJEPI SOSY NP PA; QL(2 eaper 25 daysretail)

Neurogenic Orthostatic Hypotension (NOH) -NORTHERA CAPS NP PA

Vasopressors AKOVAZ SOLN (ephedrinesulfate (pressors)) NF PA

dobutamine hcl soln 1 PA

dobutamine in d5w soln 1 PA

dopamine hcl soln 40mg/ml 1 PA

DOPAMINE HCL SOLN 80 MG/ML, 160 MG/ML 2 PA

dopamine in d5w soln 1 PA

ephedrine sulfate(pressors) soln 1 PA

EPHEDRINE SULFATE SOLN IJ 50 MG/ML 2 PA

Drug Name DrugTier

Requirements/Limits

EPHEDRINE SULFATE SOLN IV 50 MG/ML 2 PA

EPINEPHRINE HCL SOLN 1 MG/ML, 30 MG/30ML 2 PA

epinephrine soln 1 mg/ml 1 PA

epinephrine sosy 1mg/10ml 1 PA

LEVOPHED SOLN (norepinephrine bitartrate) 2 PA

midodrine hcl tabs 1

norepinephrine bitartratesoln 1 PA

phenylephrine hcl(pressors) soln 1 PA

PHENYLEPHRINE HYDROCHLORIDE SOLN IV 10 MG/ML(phenylephrine hcl(pressors))

2

PA

VAZCULEP SOLN (phenylephrine hcl(pressors))

2 PA

VITAMINS

Oil Soluble Vitamins cholecalciferol caps 25mcg, 1000 unit 1 QL(100 ea per

fill retail) cholecalciferol tabs 25 mcg, 1000 unit 1

DRISDOL CAPS (ergocalciferol) NF MP

ergocalciferol caps 1 MP

MEPHYTON TABS (phytonadione) NF

phytonadione tabs 1

Water Soluble Vitamins

niacin cpcr 500 mg 1

niacin tabs 500 mg 1

niacin tbcr 500 mg, 750 mg 1


201

Drug Name DrugTier

Requirements/Limits

NIACIN TR TBCR 2

pyridoxine hcl tabs 1

SLO-NIACIN TBCR (niacin) NF

thiamine hcl tabs 1 QL(100 ea per34 days retail)


202

Index 1ST TIER UNIFINE PENTIPS/MINI/31GX5MM 129 1ST TIER UNIFINE PENTIPS29GX12MM 129 1ST TIER UNIFINE PENTIPS31GX6MM 129 1ST TIER UNIFINE PENTIPS31GX8MM 129 1ST TIER UNIFINE PENTIPS32GX4MM 130 1ST TIER UNIFINE PENTIPS32GX6MM 130 1ST TIER UNIFINE PENTIPS33GX4MM 130 1ST TIER UNIFINE PENTIPSPLUS 31GX8MM 130 1ST TIER UNIFINE PENTIPSPLUS 32GX4MM 130 1ST TIER UNIFINE PENTIPSPLUS 33GX4MM 130 1ST TIER UNIFINE PENTIPSPLUS/MINI/31GX5MM

130 1ST TIER UNIFINE PENTIPSPLUS/ORIGINAL/29GX12MM 130 1ST TIER UNIFINE PENTIPSPLUS/ULTRASHORT/31GX6MM 130 1ST TIER UNILET COMFORTOUCH LANCETS 28G 120 1ST TIER UNILET COMFORTOUCH LANCETS 30G 120 2-3ML SYRINGE/LUER LOCKTIP 130 2-3ML SYRINGE/LUER SLIP TIP

130 3ML LUER LOCK SAFETY SYRINGES 130 3ML SYRINGE/INTERLINKSYRINGE CANNULA 130 3ML SYRINGE/INTERLINK VIALACCESS CANNULA 130 abacavir sulfate 74 abacavir sulfate-lamivudine 74 abacavir sulfate-lamivudine-zidovudine 74 ABELCET 49 ABILIFY 72,73 ABILIFY MAINTENA 72 ABILIFY MYCITE 72 abiraterone acetate 59 ABOUTTIME PEN NEEDLE 32GX 5/32" 130

ABOUTTIME PEN NEEDLES 30GX 5/16" 130 ABOUTTIME PEN NEEDLES 31G X 3/16" 130 ABOUTTIME PEN NEEDLES 31G X 5/16" 130 ABSORICA 88 ABSORICA LD 88 ABSTRAL 22 acamprosate calcium 190 ACANYA 88 acarbose 43 ACCOLATE 33 ACCUPRIL 53 ACCURETIC 55 ACE AEROSOL CLOUD ENHANCER 163 acebutolol hcl 78 acetaminophen 22 acetaminophen w/ codeine 24 acetaminophen-caff-dihydrocod

24 ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE 24 ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINEBITARTRATE 24 acetazolamide 99 acetazolamide sodium 99 acetic acid (otic) 188 acetylcysteine 88 ACIPHEX 197 acitretin 92 ACTEMRA 20 ACTEMRA ACTPEN 20 ACTHAR 101 ACTHIB 199 ACTICLATE 194 ACTIGALL 105 ACTIMMUNE 62 ACTIQ 22 ACTIVASE 109 ACTIVE-TRAMADOL KIT 89 ACTIVELLA 103 ACTIVITY POUCH 163 ACTONEL 100 ACTOPLUS MET 43 ACTOPLUS MET XR 43 ACTOS 45

ACULAR 187 ACULAR LS 187 ACUVAIL 187 acyclovir 77 acyclovir sodium 77 ACYCLOVIR SODIUM 77 acyclovir topical 92 ADACEL 196 ADAGEN 18 ADAKVEO 110 ADALAT CC 79 adapalene 88 ADAPALENE 88 ADASUVE 67 ADCIRCA 82 ADDERALL 1 ADDERALL XR 1,2 adefovir dipivoxil 77 ADEMPAS 82 ADENOCARD 32 adenosine 32 ADHANSIA XR 9,10 ADHESIVE PADS/LARGE/3"X4" 114 ADHESIVE PADS/MEDIUM/2"X3" 114 ADJUSTABLE LANCING DEVICE 120 ADLYXIN 44 ADLYXIN STARTER PACK 44 ADMELOG 45 ADMELOG SOLOSTAR 45 ADRENALIN 183,201 ADULT AEROSOL MASK 163 ADULT MASK 163 ADULT MASK LARGE 163 ADULT ONE DAILY GUMMIES 173 ADVAIR DISKUS 34 ADVAIR HFA 34 ADVANCED MOBILE LANCET 30G 120 ADVATE 108 ADVIL 20 ADVOCATE INSULIN PEN NEEDLES 130 ADVOCATE INSULIN PEN NEEDLES 29GX12.7MM 130 ADVOCATE INSULIN PEN NEEDLES 31GX5MM 130

Index 1

ADVOCATE INSULIN PEN AEROCHAMBER Z-STAT ALDARA 96 NEEDLES 31GX8MM 130 PLUS/MEDIUM MASK 163 ALECENSA 60ADVOCATE INSULIN AEROCHAMBER Z-STAT

ALENDRONATE SODIUM 100SYRINGE/U- PLUS/SMALL MASK 163 100/0.3ML/29GX1/2" 130 AEROCHAMBER/FLOWSIGNA alendronate sodium 100 ADVOCATE INSULIN L 163 ALENDRONATE SODIUM 100SYRINGE/U- AEROTRACH PLUS 163 ALER-DRYL 50100/0.3ML/30GX5/16" 130 AEROVENT PLUS HOLDINGADVOCATE INSULIN CHAMBER/COLLAPSIBLE ALEVE 20 SYRINGE/U- 163 ALEVE ARTHRITIS 20 100/0.3ML/31GX5/16" 130 AFINITOR 60 alfuzosin hcl 107ADVOCATE INSULIN AFINITOR DISPERZ 60 ALINIA 29SYRINGE/U-100/0.5ML/29GX1/2" 130 AFREZZA 45 aliskiren fumarate 57 ADVOCATE INSULIN AFSTYLA 108 ALIVE WOMENS 50+ 173 SYRINGE/U- AGAMATRIX ULTRA-THIN ALIVE WOMENS GUMMY100/0.5ML/30GX5/16" 130 LANCETS 33G 120 VITAMINS 173ADVOCATE INSULIN AGGRENOX 109 ALKERAN 58SYRINGE/U-

AGRYLIN 109 ALL FLOW 1000 PULMONARY100/0.5ML/31GX5/16" 130 FUNCTION FILTER 163ADVOCATE INSULIN AIMOVIG 167 ALLEGRA ALLERGY 51SYRINGE/U-100/1ML/29GX1/2" AIMSCO LUBRICATED 119

130 ALLEVYN PLUS CAVITY 114AIMSCO TWIST LANCETSADVOCATE INSULIN 32G 120 ALLEVYN THIN 114SYRINGE/U-100/1ML/30GX5/16" AIMSCO TWIST LANCETS allopurinol 107130 33G 120ADVOCATE INSULIN allopurinol sodium 107AIRDUO RESPICLICKSYRINGE/U-100/1ML/31GX5/16" almotriptan malate 168113/14 34

130 AIRDUO RESPICLICK ALOCRIL 187ADVOCATE LANCING 232/14 34 ALOGLIPTIN 44DEVICE 120 AIRDUO RESPICLICKADVOCATE RAPID-SAFE alogliptin-pioglitazone 4355/14 34LANCING DEVICE 120 AIRS PEDIATRIC AEROSOL ALOGLIPTIN/METFORMINADYNOVATE 108 HCL 43MASK 163 ADZENYS ER 2 AJOVY 167 ALOMIDE 187

ADZENYS XR-ODT 2 AKOVAZ 201 ALOPRIM 107 AEROCHAMBER MINI ALORA 103AKTEN 186 AEROSOLCHAMBER 163 alosetron hcl 106AKYNZEO 49AEROCHAMBER MV 163 ALOXI 48albendazole 28AEROCHAMBER PLUS FLOW ALPHAGAN P 185ALBENZA 29VU 163 ALPHANATE/VONAEROCHAMBER PLUS FLOW- albuterol sulfate 34 WILLEBRANDFACTORVU 163 ALBUTEROL SULFATEAEROCHAMBER PLUS FLOW- COMPLEX/HUMAN 108ER 34VU/LARGE MASK 163 ALBUTEROL SULFATE ALPHANINE SD 108 AEROCHAMBER PLUS FLOW- HFA 34 alprazolam 31 VU/MASK 163 ALCAINE 186 ALPRAZOLAM INTENSOL 31AEROCHAMBER PLUS FLOW- alclometasone ALPROLIX 108VU/MEDIUM MASK 163 dipropionate 92AEROCHAMBER PLUS FLOW- ALREX 186ALCOHOL PREP PADS 129VU/SMALL MASK 163 ALTABAX 89AEROCHAMBER Z-STAT PLUS ALCOHOL SWABS 129 ALTACE 53VALVED HOLDING CHAMBER ALCOHOL SWABSTICK 129 ALTERNATE SITE LANCINGW/FLOW VU 163 ALCOHOL WIPES 129 DEVICE 120AEROCHAMBER Z-STAT PLUS/FLOWSIGNAL 163 ALDACTAZIDE 99 ALTOPREV 52 AEROCHAMBER Z-STAT ALDACTONE 99 ALUNBRIG 60 PLUS/LARGE MASK 163

Index 2

ALVESCO 33 AMPHOTERICIN B 49 APRISO 105 amantadine hcl 62 AMPICILLIN 189 APTENSIO XR 10 AMARYL AMBIEN AMBIEN CR AMBISOME ambrisentan AMCINONIDE AMD FOAM DRESSING 4"X4" AMD FOAM

47 111 111

49 82 93

114

ampicillin & sulbactamsodium 189 ampicillin sodium 189 AMPICILLIN SODIUM 189 ampicillin sodium 189 AMPICILLIN-SULBACTAM

189 AMPYRA 192 AMRIX 181

APTIOM 37 APTIVUS 74 AQUA LANCE ADJUSTABLE LANCING DEVICE 120 AQUABASE 190 AQUADEKS 173 AQUORAL 172 ARALAST NP 194 ARANESP ALBUMIN

DRESSING/TOPSHEET4"X4" 114

AMYTAL SODIUM ANADROL-50

111 27

FREE ARAVA

110 21

AMELUZ 91 ANAFRANIL 42 ARCALYST 20 AMERGE AMICAR

168 111

anagrelide hcl ANAPROX DS

109 20

ARCAPTA NEOHALER ARIAL CHAMBER

34 163

amikacin sulfate 19 ANASPAZ 196 ARICEPT 191 amiloride & hydrochlorothiazide 99 amiloride hcl 99 aminocaproic acid 111 aminophylline 35 amiodarone hcl 32 AMITIZA 105 amitriptyline hcl 42 amlodipine besylate 80 amlodipine besylate-atorvastatincalcium 81 amlodipine besylate-benazeprilhcl 55 amlodipine besylate-olmesartanmedoxomil 55 amlodipine besylate-valsartan 55 amlodipine-valsartan-hydrochlorothiazide 55 AMOXAPINE 42 amoxicillin 189 AMOXICILLIN 189 amoxicillin 189 amoxicillin & potclavulanate 189 amoxicillin-clarithromycin w/lansoprazole 198 AMOXICILLIN/CLAVULANATEPOTASSIUM 189 AMOXICILLIN/CLAVULANATEPOTASSIUM ER 189 AMPHETAMINE ER 3

anastrozole 59 ANCOBON 49 ANDRODERM 27 ANDROGEL 27 ANDROGEL PUMP 27 ANDROID 27 ANGELIQ 103 ANNOVERA 85 ANORO ELLIPTA 34 ANTABUSE 190 ANTARA 52 ANTI-STICK INSULIN SYRINGE/U-100/0.5ML/28G X1/2" 130 ANTI-STICK INSULIN SYRINGE/U-100/0.5ML/29G X1/2" 131 ANTI-STICK INSULIN SYRINGE/U-100/1ML/29G X1/2" 131 ANUSOL-HC 28 ANZEMET 48 APADAZ 25 APEXICON E 93 APIDRA 45 APIDRA SOLOSTAR 45 APLENZIN 40 APLICARE ALCOHOL SWABSTICK 129 APOKYN 62

ARIKAYCE 19 ARIMIDEX 59 aripiprazole 73 ARISTADA 74 ARISTADA INITIO 74 ARIXTRA 35 armodafinil 10 ARMONAIR RESPICLICK 113 33 ARMONAIR RESPICLICK 232 33 ARMONAIR RESPICLICK 55 33 ARMOUR THYROID 195 ARNUITY ELLIPTA 33 AROMASIN 59 artificial tear ointment 184 ARYMO ER 22 ASACOL HD 105 ASMANEX HFA 33 ASMANEX TWISTHALER 120 METERED DOSES 33 ASMANEX TWISTHALER 14 METERED DOSES 33 ASMANEX TWISTHALER 30 METERED DOSES 33 ASMANEX TWISTHALER 60 METERED DOSES 33 ASMANEX TWISTHALER 7 METERED DOSES 33 aspirin 22

amphetamine sulfate amphetamine-dextroamphetamine

3

3,4

apraclonidine hcl aprepitant

185 49

aspirin-dipyridamole ASPIRIN/OMEPRAZOLE

109 109

Index 3

ASPIRIN/OMEPRAZOLEER 109 ASSURE ID INSULIN SAFETYSYRINGE/U-100/0.5ML/29G X 1/2" 131 ASSURE ID INSULIN SAFETYSYRINGE/U-100/1ML/29G X 1/2" 131 ASSURE ID SAFETY PEN NEEDLES 30G X 5/16" 131 ASSURE ID SAFETY PEN NEEDLES 31G X 3/16" 131 ASTAGRAF XL 170

AUTO-LANCET 120 AUTO-LANCET MINI 120 AUTOLET IMPRESSION LANCING DEVICE 120 AUTOLET LANCING DEVICE 120 AUTOLET MINI 120 AUTOLET PLUS 120 AUVI-Q 201 AVALIDE 55 AVANDIA 45

B-D INSULIN SYRINGE ULTRAFINE II/1ML/31G X5/16"B-D INSULIN SYRINGE ULTRAFINE/0.3ML/30G X1/2"B-D INSULIN SYRINGE ULTRAFINE/0.5ML/30G X1/2" BACIGUENT bacitracin BACITRACIN

131

131

131 89 29

185

ASTEPRO 182 AVAPRO 54 bacitracin (topical) 89

ATABEX PRENATAL ATACAND ATACAND HCT atazanavir sulfate ATELVIA atenolol

178 54 55 74

100 78

AVC AVEED AVELOX AVODART AVONEX AVONEX PEN

200 27

104 107 192 192

bacitracin zinc 89 bacitracin-poly-neomycin-hc

186 bacitracin-polymyxin b 89 bacitracin-polymyxin b(ophth) 185 baclofen 181

atenolol & chlorthalidone 55 AXERT 168 BACLOFEN 181

ATIVAN 31 AYGESTIN 190 BACMIN 173

atomoxetine hcl 8 atorvastatin calcium 52 atovaquone 29 atovaquone-proguanil hcl 57 ATRIPLA 74 ATROPINE SULFATE 184 ATROVENT HFA 33 AUBAGIO 192 AUGMENTED BETAMETHASONE DIPROPIONATE 93 AUGMENTIN 189,190 AUGMENTIN ES-600 189 AUGMENTIN XR 190 AURORA LANCET SUPER THIN30G 120 AURORA LANCET THIN 23G 120 AURORA PEN NEEDLES 29GX12MM 131 AURORA PEN NEEDLES 31G X6MM 131 AURORA PEN NEEDLES 31G X8MM 131 AURORA UNIFINE PENTIPS/32GX5/32" 131 AURORA UNIFINE PENTIPS/MINI/31GX3/16" 131 AURYXIA 106 AUSTEDO 192

AYVAKIT 60 AZACTAMIN ISO-OSMOTIC DEXTROSE 30 AZASAN 170 AZASITE 185 AZATHIOPRINE 170 azathioprine 170 azelaic acid 97 azelastine hcl 182 azelastine hcl (ophth) 187 azelastine hcl-fluticasone propionate 182 AZELEX 88 AZILECT 63 AZITHROMYCIN 113 azithromycin 113 AZOPT 187 AZOR 55 AZULFIDINE 105 AZULFIDINE EN-TABS 105 b-complex w/ c & folicacid 172,173 B-D INSULIN SYRINGE ULTRAFINE II/0.3ML/31G X5/16" 131 B-D INSULIN SYRINGE ULTRAFINE II/0.5ML/31G X5/16" 131

BACTRIM 29 BACTRIM DS 29 BACTROBAN 89 BACTROBAN NASAL 182 BAL IN OIL 48 BALCOLTRA 84 balsalazide disodium 105 BAND-AID ALL-IN-ONE ADHESIVE GAUZE PAD/LARGE 114 BAND-AID ALL-IN-ONE ADHESIVE GAUZE PAD/MEDIUM 114 BAND-AID GAUZE PADS LARGE4" X 4" 114 BAND-AID GAUZE PADS MEDIUM 3" X 3" 114 BAND-AID GAUZE PADS SMALL2" X 2" 114 BAND-AID HURT-FREE NON-STICK PADS LARGE 3" X 4" 114 BAND-AID HURT-FREE NON-STICK PADS MEDIUM 2" X 3" 114 BAND-AID MIRASORB GAUZE SPONGES LARGE 4" X 4" 114 BAND-AID QUILTVENT WATERPROOF PAD LARGE 2.875" X 4" 114 BANZEL 37 BARACLUDE 77

Index 4

BARIATRIC FUSION 173 BD INSULIN SYRINGE BD PEN NEEDLE/MINI/ULTRA-ULTRA-FINE/1/2 FINE/31G X 5MM 132BASAGLAR KWIKPEN 45 UNIT/0.3ML/31G X 8MM 132 BD PEN NEEDLE/NANO 2ND

BAXDELA 104 BD INSULIN SYRINGE GEN/32G X 5/32" 132 BD LO-DOSE INSULIN ULTRA-FINE/1ML/30G X BD PEN SYRINGE MICROFINE 12.7MM 132 NEEDLE/NANO/ULTRA-IV/0.5ML/28G X 1/2" 131 BD INSULIN SYRINGE FINE/32G X 4MM 132 BD 3ML SYRINGE LUER-LOK ULTRA-FINE/1ML/31G X BD PEN TIP 131 8MM 132 NEEDLE/ORIGINAL/ULTRA-BD 3ML SYRINGE SLIP BD INSULIN SYRINGE FINE/29G X 12.7MM 132 TIP 131 ULTRAFINE/0.5ML/30G X BD PEN BD BLUNT FILL NEEDLE 131 1/2" 132 NEEDLE/SHORT/ULTRA-BD ECLIPSE 18G X 1-1/2" 131 BD INSULIN SYRINGE FINE/31G X 8MM 132

ULTRAFINE/0.5ML/31G X BD SAFETY-GLIDE INSULINBD HYPODERMIC NEEDLE 5/16" 132 SYRINGE/0.5ML/29G XREGULAR BEVEL 18G X 1- BD INSULIN SYRINGE 1/2" 1331/2" 131 ULTRAFINE/1ML/30G X BD SAFETY-LOK INSULINBD HYPODERMIC NEEDLE 1/2" 132 SYRINGE/PERMREGULAR BEVEL THIN WALL BD INSULIN SYRINGE NEEDLE/UF/1ML/29G X18G X 1-1/2" 131 ULTRAFINE/U-100/0.3ML/29G 1/2" 133BD HYPODERMIC NEEDLE X 1/2" 132 BD SAFETYGLIDESHORT BEVEL 18G X 1- BD INSULIN SYRINGE HYPODERMICNEEDLE 18G X1/2" 131 ULTRAFINE/U-100/0.5ML/29G 1-1/2" 133BD HYPODERMIC NEEDLES X 1/2" 132 BD SAFETYGLIDE INSULIN18GX1.5" 131 BD INSULIN SYRINGE SYRINGE/0.3ML/29G XBD INSULIN SYRINGE LUER-ULTRAFINE/U-100/1ML/29G X 1/2" 133LOK/U-100/1ML 131 1/2" 132 BD SAFETYGLIDE INSULINBD INSULIN SYRINGE BD INSULIN SYRINGE/0.3ML/31G XMICROFINE IV/U-SYRINGE/0.3ML/29G X 5/16" 133100/0.5ML/28G X 1/2" 131 12.7MM 132 BD SAFETYGLIDE INSULINBD INSULIN SYRINGE BD INSULIN SYSYRINGE/0.5ML/30G XMICROFINE IV/U-100/1ML/27GSYRINGE/0.5ML/29G X 5/16" 133X 5/8" 131

BD INSULIN SYRINGE 12.7MM 132 BD SWABS SINGLE USE 129 BD INSULINMICROFINE IV/U-100/1ML/28G BD SWABS SINGLE USE

X 1/2" 131 SYRINGE/1ML/27G X BUTTERFLY 12912.7MM 132BD INSULIN SYRINGE BEBULIN 108BD INSULINMICROFINE/U-100/0.5ML/28G X BELBUCA 25SYRINGE/1ML/29G X1/2" 131 12.7MM 132 BELLADONNA/OPIUM 196BD INSULIN SYRINGE BD INSULINMICROFINE/U-100/1ML/27G X BELSOMRA 112 SYRINGE/DETACHABLE5/8" 131 BENADRYL ALLERGY 50

BD INSULIN SYRINGE NEEDLE/U-100/1ML/25G X BENADRYL ALLERGYMICROFINE/U-100/1ML/28G X 1" 132 CHILDRENS 50BD INSULIN1/2" 131 benazepril &BD INSULIN SYRINGE SYRINGE/DETACHABLE hydrochlorothiazide 55SAFETYGLIDE/1ML/29G X NEEDLE/U-100/1ML/25G X benazepril hcl 531/2" 132 5/8" 132

BD INSULIN BENEFIX 108BD INSULIN SYRINGE SLIP TIP/U-100/1ML 132 SYRINGE/DETACHABLE BENICAR 54 BD INSULIN SYRINGE ULTRA- NEEDLE/U-100/1ML/26G X BENICAR HCT 55FINE/0.3ML/30G X 12.7MM132 1/2" 132 BD INSULIN SYRINGE ULTRA- BD INSULIN SYRINGE/U- BENTYL 196 FINE/0.3ML/31G X 8MM 132 100/1ML/27G X 1/2" 132 BENZHYDROCODONE/ACETA

MINOPHENBD INSULIN SYRINGE ULTRA- BD LANCET ULTRAFINE 25 FINE/0.5ML/30G X 12.7MM132 30G 120 BENZNIDAZOLE 29 BD INSULIN SYRINGE ULTRA- BD NEEDLE/18G 1-1/2" 132 benzonatate 87 FINE/0.5ML/31G X 8MM 132 BD PEN benzoyl peroxide 88NEEDLE/MICRO/ULTRA- benztropine mesylate 62FINE/32G X 6MM 132

Index 5

BEPREVE 187 bismuth subsalicylate 47 BREVIBLOC PREMIXED DOUBLESTRENGTH 78BERINERT 109 bisoprolol &

hydrochlorothiazide 55 BRILINTA 109BESER 93 bisoprolol fumarate 78 brimonidine tartrate 185BESIVANCE 185 BLEPH-10 185 BRINEURA 102BETAGAN 184 BLEPHAMIDE 186 BRISDELLE 193BETAMETHASONE

COMBO 86 BLEPHAMIDE S.O.P. 186 BRIVIACT 37 betamethasone dipropionate BLOXIVERZ 58 bromfenac sodium (ophth) 187 (topical) 93 BONIVA 100 bromocriptine mesylate 62betamethasone dipropionate

BONJESTA 49 BROMSITE 187augmented 93 betamethasone sod phosphate & BOOSTRIX 196 BROVANA 34 acetate 86 BORDERED GAUZE 115 BRYHALI 93BETAMETHASONE SODIUM bosentan BUBBLES THE FISH IIPHOSPHATE/BETAMETHASON 82

PEDIATRIC MASK/PVC 164E ACETATE 86 BOSULIF 60 budesonide 86betamethasone valerate 93 BRAFTOVI 60 budesonide (inhalation) 33BETAPACE 79 BRAINSTRONG

PRENATAL 178 budesonide (nasal) 182BETAPACE AF 79 BREATHE EASE NEBULIZER BUDESONIDE/FORMOTEROLBETASERON 192 MASK/CHILD 163 FUMARATE DIHYDRATE 34 betaxolol hcl 78 BREATHE EASE NEBULIZER bumetanide 99

MASK/INFANT 163betaxolol hcl (ophth) 184 BUMEX 99BREATHE EASE/LARGEbethanechol chloride 199 BUNAVAIL 25,26MASK 163 BETHKIS 19 BREATHE EASE/MEDIUM BUPHENYL 102 BETOPTIC-S 184 MASK 163 BUPRENEX 26BREATHE EASE/SMALLBEVESPI AEROSPHERE 34 buprenorphine 26MASK 164BEVYXXA 35 BUPRENORPHINE 26BREATHERITE 164 bexarotene 62 BREATHERITE buprenorphine hcl 26 BEXSERO 199 COLLAPSIBLEADULT buprenorphine hcl-naloxone hcl

SPACER W/MASK 164 dihydrate 26BEYAZ 84 BREATHERITE bupropion hcl 40BIATAIN ADHESIVE FOAM COLLAPSIBLECHILD SPACER bupropion hcl (smokingDRESSING 4"X4" 114 BIATAIN FOAM DRESSING W/MASK 164 deterrent) 193

BREATHERITE4"X4" 114 BUPROPIONCOLLAPSIBLEINFANT HYDROCHLORIDE ER (XL) 40bicalutamide 59 SPACER W/MASK 164 buspirone hcl 31BICILLIN C-R 190 BREATHERITE butalbital-acetaminophen 21BICILLIN L-A 189 COLLAPSIBLESMALL CHILD SPACER W/MASK 164 butalbital-acetaminophen-BIDIL 81 BREATHERITE caffeine 22

BIJUVA 103 COLLAPSIBLESPACER W/ butalbital-acetaminophen-BIKTARVY 74 NEONATE MASK 164 caffeine w/ codeine 25

BREATHERITE RIGID butalbital-aspirin-caffeine 22BILTRICIDE 29 SPACERW/MASK 164 butalbital-aspirin-caffeinebimatoprost 188 BREATHERITE W/LARGE w/cod 25

BINOSTO 100 MASK 164 BUTALBITAL/ASPIRIN/CAFFEINBIO-DTUSS DMX 87 BREATHERITE W/MEDIUM E 22 BIOGUARD GAUZE SPONGE MASK 164 butenafine hcl 90 2"X2" 8 PLY 115 BREATHERITE W/SMALL BUTISOL SODIUM 111BIOGUARD GAUZE SPONGES MASK 164

butorphanol tartrate 264"X4" 12 PLY 115 BREO ELLIPTA 34 BIOTENE DRY MOUTH BREVIBLOC 78 BUTRANS 26 MOISTURIZING SPRAY 172 BYDUREON 44BREVIBLOC PREMIXED 78bisacodyl 113

Index 6

BYDUREON BCISE 44 CARBAGLU 102 CAREONE INSULIN SYRINGES/1ML/31GX5/16"BYDUREON PEN 44 carbamazepine 37

133BYETTA 45 carbamide peroxide (otic) 188 CAREONE LANCET THIN 121 BYSTOLIC 78 CARBATROL 37 CAREONE LANCET ULTRA BYVALSON 55 carbidopa 62 THIN 121

CAREONE UNIFINE PENTIPScabergoline 103 carbidopa-levodopa 62 29GX12MM 133CABOMETYX 60 CARBIDOPA/LEVODOPA/ENT CAREONE UNIFINE PENTIPSACAPONE 62CADEAU DHA 178 31GX5MM 133carbinoxamine maleate 50CADUET 81 CAREONE UNIFINE PENTIPS

CARBINOXAMINE 31GX6MM 133CAFERGOT 167 MALEATE 50 CAREONE UNIFINE PENTIPScaffeine citrate 8 carbinoxamine maleate 50 31GX8MM 133 CALAN 80 carboxymethylcellulose sodium CAREONE UNIFINE PENTIPS CALAN SR 80 (ophth) 184 PEN NEEDLES 32GX4MM 133

CARDENE IV 80 CAREONE UNIFINE PENTIPSCALCI-CHEW 169 PLUS PEN NEEDLESCARDIOCOM LANCINGcalcipotriene 92 29GX12MM 133DEVICE 121 CALCIPOTRIENE 92 CAREONE UNIFINE PENTIPSCARDIZEM 80 calcipotriene-betamethasone PLUS PEN NEEDLESCARDIZEM CD 80dipropionate 93 31GX5MM 133 CALCIPOTRIENE/BETAMETHA CARDIZEM LA 80 CAREONE UNIFINE PENTIPS

PLUS PEN NEEDLESSONE DIPROPIONATE 93 CARDURA 54 31GX6MM 133calcitonin (salmon) 100 CARDURA XL 107 CAREONE UNIFINE PENTIPSCALCITRIOL 92 CAREFINE PEN NEEDLE PLUS PEN NEEDLES32GX4MM 133calcitriol 102 31GX8MM 133CAREFINE PEN NEEDLES CAREONE UNIFINE PENTIPSCALCIUM 169 29GX1/2" 133 PLUS PEN NEEDLEScalcium acetate (phosphate CAREFINE PEN NEEDLES 32GX4MM 133binder) 106 30GX5/16" 133 CARESENS LANCETS 121CALCIUM CARBONATE 28 CAREFINE PEN NEEDLES CARETOUCH LANCINGcalcium carbonate (antacid) 28 31GX6MM 133 DEVICEWITH EJECTOR 121CAREFINE PEN NEEDLEScalcium carbonate- CARETOUCH PEN NEEDLES31GX8MM 133cholecalciferol 169 31G X 6 MM 133CAREFINE PEN NEEDLEScalcium carbonate-vitamin CARETOUCH PEN NEEDLES32GX5MM 133d 169 31GX 5MM 134CAREFINE PEN NEEDLESCALNA 178 CARETOUCH PEN NEEDLES32GX6MM 133

CALQUENCE 60 CAREONE ADVANCED 31GX 8MM 134 CARETOUCH PEN NEEDLESCAMBIA 168 LANCINGDEVICE 121 32GX 4MM 134CAREONE INSULINCANASA 105 CARETOUCH PEN NEEDLESSYRINGES/0.3ML/30G XCANCIDAS 49 32GX 5MM 1341/2" 133

candesartan cilexetil 54 CAREONE INSULIN carisoprodol 181 candesartan cilexetil- SYRINGES/0.3ML/31G X carisoprodol w/ aspirin 182 hydrochlorothiazide 55 5/16" 133 carisoprodol w/ aspirin &capecitabine 59 CAREONE INSULIN codeine 182

SYRINGES/0.5ML/30G X CARISOPRODOL/ASPIRINCAPEX 93 1/2" 133 182CAPHOSOL 172 CAREONE INSULIN CARISOPRODOL/ASPIRIN/CODCAPRELSA 60 SYRINGES/0.5ML/31G X EINE 182 captopril 53 5/16" 133 CARNITOR 102CAREONE INSULINCAPTOPRIL/HYDROCHLOROT CARNITOR SF 102SYRINGES/1ML/30G XHIAZIDE 55 1/2" 133 CAROSPIR 99CARAC 91 CARRASMART 115CARAFATE 197 CARRASMART FOAM 115

Index 7

CARTEOLOL HCL 184 cefuroxime sodium 83 CHANTIX CONTINUING

carvedilol carvedilol phosphate CASODEX

78 78 59

CELEBRATE MULTI-COMPLETE18 CELEBRATE MULTI-COMPLETE36

173

173

MONTHPAK 193 CHANTIX STARTING MONTH PAK 193 CHEMET 47

caspofungin acetate CASPOFUNGIN ACETATE CATAPRES

49 49 54

CELEBRATE MULTI-COMPLETE45 CELEBRATE MULTI-COMPLETE60

173

173

CHEMSTRIP-K CHENODAL CHILDRENS ADVIL

98 105

20 CATAPRES-TTS-1 54 CELEBREX 20 CHILDRENS MOTRIN 20 CATAPRES-TTS-2 54 celecoxib 20 CHLOR-TRIMETON 50 CATAPRES-TTS-3 CATHFLO ACTIVASE CAYA CAYSTON

54 109 119

30

CELESTONE-SOLUSPAN 86 CELEXA 40 CELLCEPT 170,171 CELONTIN 39

chlordiazepoxide hcl 31 chlordiazepoxide hcl-clidiniumbromide 196 CHLORDIAZEPOXIDE/AMITRIPTYLINE 191

cefaclor CEFACLOR CEFACLOR ER cefadroxil CEFAZOLIN CEFAZOLIN SODIUM cefazolin sodium

82 82 82 82 82 82 82

CENTANY 89 CENTANY AT 89 CENTRUM 173 CENTRUM FLAVOR BURST 173 CENTRUM FLAVOR BURST ADULT 173 CENTRUM FLAVOR BURST

chlorhexidine gluconate (mouth-throat) 172 CHLOROQUINE PHOSPHATE 57 chloroquine phosphate 57 CHLOROTHIAZIDE 100 chlorothiazide 100 chlorothiazide sodium 99

CEFAZOLIN SODIUM CEFAZOLIN SODIUM/DEXTROSE cefdinir CEFEPIME cefepime hcl CEFEPIME/DEXTROSE cefixime CEFOTAN cefotaxime sodium

82

82 83 83 83 83 83 83 83

KIDS 173 CENTRUM MULTIGUMMIES ADULTS 173 CENTRUM MULTIGUMMIES MEN 173 CENTRUM MULTIGUMMIES MULTI +OMEGA 3 173 CENTRUM MULTIGUMMIES WOMEN 173 CENTRUM SILVER 173 CENTRUM SPECIALIST PRENATAL 178

chlorpheniramine maleate 50 CHLORPROMAZINE HCL 71 chlorpromazine hcl 71 CHLORPROPAMIDE 47 chlorthalidone 100 CHLORZOXAZONE 181 chlorzoxazone 181 CHOICEFUL MULTIVITAMIN 173 CHOLBAM 105

CEFOTAXIME SODIUM 83 CENTRUM VITAMINTS 173 cholecalciferol 201 CEFOTETAN cefotetan disodium CEFOTETAN/DEXTROSE cefoxitin sodium

83 83 83 83

cephalexin CEPHALEXIN CEPROTIN CEQUA

82 82

109 186

cholestyramine cholestyramine light choline & mag salicylate choline fenofibrate

52 51 22 52

CEFOXITIN SODIUM 83 CERALYTE 70 169 CHORIONIC cefpodoxime proxetil cefprozil ceftazidime

83 83 83

CERASPORT CERASPORT EX1 CERDELGA

169 169 110

GONADOTROPIN 101 CICLODAN CREAM KIT 90 CICLODAN SOLUTION KIT 90

CEFTAZIDIME/DEXTROSE 83 CEFTIN 83

CEREBYX CEREZYME

39 110

ciclopirox ciclopirox olamine

90 90

CEFTRIAXONE IN ISO-OSMOTIC DEXTROSE 83 ceftriaxone sodium 83 CEFTRIAXONE/DEXTROSE

83 cefuroxime axetil 83

CESAMET cetirizine hcl CETRAXAL cevimeline hcl CHANTIX

49 51

188 172 193

CICLOPIROX TREATMENT 90 cidofovir 76 cilostazol 109 CILOXAN 185 CIMDUO 74 cimetidine 197

Index 8

CIMETIDINE HCL 197 CLEVER CHOICE COMFORT CLEVER CHOICE COMFORT

CIMZIA CIMZIA STARTER KIT cinacalcet hcl

105 105 102

EZINSULIN SYRINGE/0.3ML/29G X1/2" 134 CLEVER CHOICE COMFORT

EZPEN NEEDLES 31GX5MM 134 CLEVER CHOICE COMFORT EZPEN NEEDLES

CINQAIR CINRYZE CINVANTI

32 109

49

EZINSULIN SYRINGE/0.3ML/30G X1/2" 134 CLEVER CHOICE COMFORT

31GX6MM 134 CLEVER CHOICE COMFORT EZPEN NEEDLES 31GX8MM 134

CIPRO 104 EZINSULIN CLEVER CHOICE COMFORT CIPRO HC CIPRODEX

188 188

SYRINGE/0.3ML/30G X5/16" 134 CLEVER CHOICE COMFORT

EZPEN NEEDLES 32GX4MM 134 CLEVER CHOICE COMFORT

ciprofloxacin CIPROFLOXACIN CIPROFLOXACIN ER CIPROFLOXACIN HCL

104 188 104 104

EZINSULIN SYRINGE/0.3ML/31G X5/16" 134 CLEVER CHOICE COMFORT EZINSULIN

EZPEN NEEDLES 32GX5MM 135 CLEVER CHOICE COMFORT EZPEN NEEDLES 32GX6MM 135

ciprofloxacin hcl 104 ciprofloxacin hcl (ophth) 185 CIPROFLOXACIN/FLUOCINOLONE ACETONIDE PF 188 citalopram hydrobromide 40,41 CLAFORAN 83

SYRINGE/0.5ML/28G X1/2" 134 CLEVER CHOICE COMFORT EZINSULIN SYRINGE/0.5ML/29G X1/2" 134 CLEVER CHOICE COMFORT

CLEVER CHOICE COMFORT EZPEN NEEDLES 32GX8MM 135 CLEVER CHOICE COMFORT EZPEN NEEDLES 33GX4MM 135 CLEVIPREX 80

CLARITHROMYCIN 114 EZINSULIN CLICKFINE PEN NEEDLE clarithromycin 114 CLARITIN 51 CLARITIN ALLERGY CHILDRENS 51 CLARITIN REDITABS 51 CLARITIN-D 12 HOUR 87 CLARITIN-D 24 HOUR 88 CLASSIC PRENATAL 178 CLEANLET LANCETS 28G 121 CLEOCIN 30,200 CLEOCIN PEDIATRIC GRANULES 30 CLEOCIN-T 89 CLEVER CHOICE ANTI-STATICVALVED HOLDING CHAMBER/ADULT LARGE 164 CLEVER CHOICE ANTI-STATICVALVED HOLDING CHAMBER/MEDIUM 164 CLEVER CHOICE ANTI-STATICVALVED HOLDING CHAMBER/SMALL 164 CLEVER CHOICE COMFORT EZINSULIN PEN NEEDLES 31GX8MM 134 CLEVER CHOICE COMFORT EZINSULIN PEN NEEDLES 33GX4MM 134

SYRINGE/0.5ML/30G X1/2" 134 CLEVER CHOICE COMFORT EZINSULIN SYRINGE/0.5ML/30G X5/16" 134 CLEVER CHOICE COMFORT EZINSULIN SYRINGE/0.5ML/31G X5/16" 134 CLEVER CHOICE COMFORT EZINSULIN SYRINGE/1.0ML/30G X1/2" 134 CLEVER CHOICE COMFORT EZINSULIN SYRINGE/1ML/28G X1/2" 134 CLEVER CHOICE COMFORT EZINSULIN SYRINGE/1ML/29G X1/2" 134 CLEVER CHOICE COMFORT EZINSULIN SYRINGE/1ML/30G X5/16" 134 CLEVER CHOICE COMFORT EZINSULIN SYRINGE/U-100/1ML/31GX5/16" 134 CLEVER CHOICE COMFORT EZPEN NEEDLES 29GX12MM 134

32GX5/32" 135 CLICKFINE PEN NEEDLE UNIVERSAL/31GX1/4" 135 CLICKFINE PEN NEEDLE UNIVERSAL/31GX5/16" 135 CLICKFINE PEN NEEDLES 31G X 1/4" 135 CLICKFINE PEN NEEDLES 31G X 3/16" 135 CLICKFINE PEN NEEDLES 31G X 5/16" 135 CLICKFINE PEN NEEDLES 31G X 8MM 135 CLICKFINE PEN NEEDLES 32G X 5/32" 135 CLICKFINE PEN NEEDLES/31GX1/4" 135 CLICKFINE UNIVERSAL PEN NEEDLES 31GX5/16" 135 CLIMARA 103 CLIMARA PRO 103 clindamycin hcl 30 clindamycin palmitatehydrochloride 30 clindamycin phosphate(topical) 89 clindamycin phosphatevaginal 200 clindamycin phosphate-benzoylperoxide 89 CLINDESSE 200

Index 9

CLINICAL NUTRIENTS COLY-MYCIN S 188 COMPACT SPACE PRENATAL FORMULA 178 COLYTE-FLAVOR CHAMBER/ANTI-clobazam 37 PACKS 112 STATIC/LARGE MASK 164

COMPACT SPACEclobetasol propionate 93 COMBIGAN 184 CHAMBER/ANTI-clobetasol propionate emollient COMBIPATCH 103 STATIC/MEDIUM MASK 164base 93 COMBIVENT RESPIMAT 34 COMPACT SPACEclobetasol propionateCOMBIVIR 74 CHAMBER/ANTI-STATIC/SMALLemulsion 93 MASK 164CLOBEX 93 COMETRIQ 60 COMPLERA 74CLOCORTOLONE COMFORT ASSIST INSULIN

PIVALATE 93 SYRINGE 0.3ML/29G X COMPLETENATE 178 CLOCORTOLONE PIVALATE 1/2" 135 COMTAN 62 PUMP 93 COMFORT ASSIST INSULIN CONCERTA 10,11CLODAN KIT 93 SYRINGE/0.3ML/30G X CONDOMS 1195/16" 135CLODERM 93 COMFORT ASSIST INSULIN CONSENSI 79 CLODERM PUMP 93 SYRINGE/0.3ML/31G X CONZIP 22 clomipramine hcl 42 5/16" 135 COPA ISLAND BORDERED

COMFORT ASSIST INSULINclonazepam 37 FOAM DRESSING 4"X4" 115SYRINGE/0.5ML/29G X COPA PLUS HYDROPHILICclonidine 55 1/2" 135 FOAM DRESSING 4"X4" 115clonidine hcl 55 COMFORT ASSIST INSULIN COPAXONE 192

clonidine hcl (adhd) 8 SYRINGE/0.5ML/30G X COPIKTRA 605/16" 135clopidogrel bisulfate 109 COMFORT ASSIST INSULIN CORDARONE 32clorazepate dipotassium 31 SYRINGE/0.5ML/31G X CORDRAN 93,94clotrimazole 172 5/16" 135 COREG 78COMFORT ASSIST INSULINclotrimazole (topical) 90

SYRINGE/1ML/29G X COREG CR 78clotrimazole vaginal 200 1/2" 135 CORGARD 79clotrimazole w/ COMFORT ASSIST INSULIN CORIFACT 108betamethasone 90 SYRINGE/1ML/30G Xclozapine 68 5/16" 135 CORLANOR 82 CLOZAPINE ODT 67 COMFORT ASSIST INSULIN CORLOPAM 57

SYRINGE/1ML/31G X CORTEF 86CLOZARIL 68 5/16" 135CO MONITOR REPLACEMENT CORTENEMA 28COMFORT ASSUREDTPIECES 164 CORTIFOAM 28LANCETS SUPER THINCO-NATAL FA 178 28G 121 CORTISONE ACETATE 86 COAGADEX 108 COMFORT EZ INSULIN CORTISPORIN 90 COARTEM 57 SYRINGE/U-100/0.5ML/31G X CORTISPORIN-TC 1885/16" 135CODEINE SULFATE 22 COMFORT EZ INSULIN CORVERT 32 codeine sulfate 22 SYRINGE/U-100/1ML/31G X CORZIDE 55 COGENTIN 62 5/16" 135 COSENTYX 92COMFORT EZ MICRO/32G XCOLACE 113 COSENTYX SENSOREADY4MM 135COLAZAL 105 PEN 92COMFORT EZ SHORT/31G XCOLCHICINE 107 8MM 135 COSOPT 184 colchicine 107 COMFORT EZ/31G X COSOPT PF 184

5MM 135colchicine w/ probenecid 107 COTELLIC 60COMFORT EZ/31G X

COLCRYS 107 COTEMPLA XR-ODT 116MM 135 colesevelam hcl 52 COMFORT LANCETS 121 COUMADIN 35

COVRSITE COVERCOLESTID 52 COMPACT SPACE COLESTID FLAVORED 52 CHAMBER/ANTI-STATIC DRESSING 115

COVRSITE PLUS COMPOSITE colestipol hcl 52 164 DRESSING 115

Index 10

COZAAR 54 CURITY GAUZE PADS CVS LANCETS THIN 26G 121 3"X3" 115CREON 98 CVS LANCETS ULTRA THINCURITY GAUZE PADS 4"X4" 30G 121CRESEMBA 49 12 PLY 115 CVS LANCETS ULTRA-THIN

CRESTOR 52 CURITY GAUZE SPONGE 30G 1212"X2" 8 PLY 115CRINONE 200 CVS LANCING DEVICE 121CURITY GAUZE SPONGECRIXIVAN 74 CVS PRENATAL 1782"X2"12 PLY 115

CROMOLYN SODIUM 32 CURITY GAUZE SPONGE CVS PRENATAL cromolyn sodium 32 3"X3" 12 PLY 115 GUMMY/DHA/FOLIC ACID 178

CURITY GAUZE SPONGE CVS PRENATALcromolyn sodium (ophth) 187 4"X4" 12 PLY 115 MULTI+DHA 178 CROTAN 97 CURITY GAUZE SPONGE CVS PREP PADS 129 CRUAD GAUZE PADS 4" X 4"X4" 16 PLY 115 CVS SOFT GLUCOSE 444" 115 CURITY GAUZE SPONGE CVS SPECTRAVITE ADULTCRYSVITA 102 4"X4" 8 PLY 115 50+ 174CULTURELLE PROBIOTICS + CURITY GAUZE SPONGE CVS SPECTRAVITE ADULTMULTIVITAMIN 174 4"X4"16 PLY 115 GUMMIES 174CURITY GAUZE SPONGESCUPRIMINE 170 CVS ULTRA THIN4"X4" 12 PLY 115CURAD NON-STICK PADS LANCETS 121CURITY GAUZE SPONGESWITHADHESIVE TABS CVS WOMENS4"X4" 8 PLY 1153"X4" 115 PRENATAL+DHA 178CURITY NON-ADHERENTCURITY ALCOHOL cyanocobalamin 110STRIPS 3"X3" 115PREPS/MEDIUM 2 PLY 129 CURITY cyclobenzaprine hcl 181CURITY ALCOHOL SPONGES/CELLULOSEFILLE CYCLOGYL 184SWABS 129 D/2"X2" 116CURITY ALL PURPOSE CYCLOMYDRIL 185CURITYSPONGES 2"X2" 115 SPONGES/CELLULOSEFILLE cyclopentolate hcl 185CURITY ALL PURPOSE D/4"X4" 116 cyclophosphamide 58SPONGES 2"X2" 4PLY 115 CURITY ALL PURPOSE CUTIVATE 94 CYCLOPHOSPHAMIDE 58 SPONGES 3"X3" 4PLY 115 CUVPOSA 196 cycloserine 58 CURITY ALL PURPOSE CVS ADHESIVE PAD CYCLOSET 44SPONGES 4 PLY 115 4"X4" 116 cyclosporine 171CURITY ALL PURPOSE CVS ADHESIVE PAD SPONGES 4"X4" 115 6"X6" 116 cyclosporine modified (forCURITY ALL PURPOSE CVS ADHESIVE PADS microemulsion) 171 SPONGES 4"X4" 4PLY 115 2.25"X3" 116 CYKLOKAPRON 111 CURITY ALL PURPOSE CVS AIRSHIELD IMMUNITY CYMBALTA 41,42SPONGES 4"X4" 4PLY/SOFT SUPPORT 174 cyproheptadine hcl 51POUCH 115 CVS DRY MOUTH CURITY AMD SPRAY 172 CYSTADANE 102 ANTIMICROBIALGAUZE CVS GAUZE PAD 3"X3" 116 CYSTAGON 107 SPONGES 2"X2" 8 PLY 115 CVS GAUZE PADS 2"X2" 12- CYSTARAN 187CURITY AMD PLY 116 CYTOMEL 195ANTIMICROBIALGAUZE CVS GAUZE PADS 4"X4" 12-SPONGES 4"X4" 12 PLY 115 CYTOTEC 198PLY 116CURITY COVER SPONGE CVS GAUZE PADS STERILE CYTOVENE 76 4"X4" 115 4"X4" 12-PLY 116 D-PENAMINE 170CURITY COVER SPONGES CVS GLUCOSE 44 D.H.E. 45 1683"X3" 115

CVS LANCETS 21G 121CURITY COVER SPONGES DAKLINZA 77 4"X4" 115 CVS LANCETS MICRO THIN dalfampridine 192CURITY DRESSING SPONGES 33G 121

DALIRESP 334"X4" 6 PLY 115 CVS LANCETS MICRO-THIN CURITY GAUZE PADS 33G 121 danazol 27 2"X2" 115 CVS LANCETS DANTRIUM 182CURITY GAUZE PADS 2"X2" 12 ORIGINAL 121 DANTRIUM IV 182PLY 115

Index 11

dantrolene sodium 182 DERMACEA GAUZE SPONGE desogestrel-ethinyl estradiol4"X4" 12 PLY 116 (biphasic) 84dapsone 30 DERMACEA GAUZE SPONGE desogestrel-ethinyl estradiol

DARAPRIM 57 4"X4" 16 PLY 116 (triphasic) 84 darifenacin hydrobromide 198 DERMACEA GAUZE SPONGE desonide 94

4"X4" 8 PLY 116DAURISMO 59 DESOWEN 94DERMACEA I.V. DRAINDAXBIA 82 DESOXIMETASONE 94SPONGES 2"X2" 116 DAYPRO 20 DERMACEA I.V. DRAIN desoximetasone 94 DAYTRANA 11 SPONGES 4"X4" 116 DESOXYN 4DERMACEA I.V. SPONGESDDAVP 102 DESVENLAFAXINE ER 422"X2" 116DEBROX 188 DERMACEA NON-WOVEN desvenlafaxine succinate 42 DECON-A 88 SPONGES 2"X2" 4 PLY 116 DETROL 198

DERMACEA NON-WOVENdeferasirox 47 DETROL LA 198SPONGES 3"X3" 4 PLY 116deferoxamine mesylate 48 DEX4 QUICK DISSOLVEDERMACEA NON-WOVEN GLUCOSE 44DEKAS BARIATRIC 174 SPONGES 4"X4" 4 PLY 116 dexamethasone 86DERMACEA NON-WOVENDEKAS PLUS 174

SPONGES 4"X4" 6 PLY 116 DEXAMETHASONE 86DELESTROGEN 103 DERMACEA TYPE VII GAUZE dexamethasone 86DELSTRIGO 74 2"X2" 12 PLY 116 DEXAMETHASONE 86DELZICOL 105 DERMACEA TYPE VII GAUZE 2"X2" 8 PLY 116 dexamethasone 86DEMADEX 99 DERMACEA TYPE VII GAUZE DEXAMETHASONEdemeclocycline hcl 194 3"X3" 12 PLY 116 INTENSOL 86

DEMEROL 22 DERMACEA TYPE VII GAUZE DEXAMETHASONE SODIUM DEMSER 54 3"X3" 12PLY 116 PHOSPHATE 86

DERMACEA TYPE VII GAUZE dexamethasone sodiumDENAVIR 92 4"X4" 12 PLY 116 phosphate 86DEPACON 40 DERMACEA TYPE VII GAUZE DEXAMETHASONE SODIUM DEPAKENE 40 4"X4" 16 PLY 116 PHOSPHATE 186

DERMACEA TYPE VII GAUZEDEPAKOTE 40 DEXEDRINE 4 4"X4" 8 PLY 116DEPAKOTE ER 40 DEXILANT 197DERMACEA X-RAY

DEPAKOTE SPRINKLES 40 SPONGES 4"X4" 16 PLY 116 dexmethylphenidate hcl 11,12 DEPEN TITRATABS 170 DERMACINRX CINLONE-I dextroamphetamine sulfate 4,5

CPI 86DEPO-ESTRADIOL 103 dextromethorphan hbr 87DERMACINRX THERAZOLE dextromethorphan-guaifenesinDEPO-MEDROL 86 PAK 90 88DEPO-PROVERA DERMALEVIN ADHESIVE dextrose (diabetic use) 44CONTRACEPTIVE 85 FOAMDRESSING 4"X4" 116 DEPO-SUBQ PROVERA DERMASORB HC 94 DIACOMIT 37 104 85 DIASTAT ACUDIAL 37DERMASORB TA 94DEPO-TESTOSTERONE 27 DIASTAT PEDIATRIC 37DERMOTIC 188DERMA-SMOOTHE/FS DIATHRIVE LANCETS 121DESCOVY 74BODY 94 DIATHRIVE LANCETS ULTRADERMA-SMOOTHE/FS DESFERAL 48 THIN 30G 121SCALP 94 desipramine hcl 42 DIATHRIVE LANCINGDERMACEA DRAIN SPONGES desmopressin acetate 103 DEVICE 1214"X4" 116 DERMACEA GAUZE SPONGE desmopressin acetate diazepam 31 2"X2" 12 PLY 116 spray 103 DIAZEPAM 31 DERMACEA GAUZE SPONGE desmopressin acetate spray diazepam 312"X2" 8 PLY 116 refrigerated 103

DIAZEPAM RECTAL GEL 37DERMACEA GAUZE SPONGE DESOGEN 84 3"X3" 12 PLY 116 desogestrel & ethinyl DIBENZYLINE 54 DERMACEA GAUZE SPONGE estradiol 84 DICLEGIS 493"X3" 8 PLY 116

Index 12

diclofenac potassium 20 diclofenac sodium 20 diclofenac sodium (actinickeratoses) 91 diclofenac sodium (ophth) 187 diclofenac sodium (topical) 89 dicloxacillin sodium 190 dicyclomine hcl 196 didanosine 74 DIDANOSINE 74 DIFFERIN 89 DIFICID 114 DIFLORASONE DIACETATE 94 diflorasone diacetate 94 DIFLUCAN 49,50 diflunisal 22 digoxin 81 DIGOXIN 81 digoxin 81 dihydroergotaminemesylate 168 DIHYDROERGOTAMINE MESYLATE 168 DILANTIN 39 DILANTIN INFATABS 39 DILANTIN-125 39 DILATRATE SR 30 DILAUDID 22 DILT-XR 80 diltiazem hcl 80 DILTIAZEM HCL 80 diltiazem hcl 80 diltiazem hcl coated beads 80 diltiazem hcl extended release beads 80 dimenhydrinate 48 DIOVAN 54 DIOVAN HCT 56 DIPENTUM 105 diphenhydramine hcl 50 diphenhydramine hcl(sleep) 111 diphenoxylate w/ atropine 47 DIPHENOXYLATE/ATROPINE

47 DIPHTHERIA/TETANUSTOXOIDS ADSORBED PEDIATRIC 196 DIPROLENE 94

DIPROLENE AF 94 dipyridamole 109 disopyramide phosphate 32 disulfiram 190 DITROPAN XL 198 DIURIL 100 divalproex sodium 40 DIVIGEL 103 dobutamine hcl 201 dobutamine in d5w 201 docusate sodium 113 DOCUSOL PLUS MINI-ENEMA 113 dofetilide 32 DOLOPHINE 22 donepezil hydrochloride 191 dopamine hcl 201 DOPAMINE HCL 201 dopamine in d5w 201 DOPTELET 110 DORYX 194 DORYX MPC 194 DORZOLAMIDE HCL 187 dorzolamide hcl 187 dorzolamide hcl-timolol maleate 184 DORZOLAMIDE HCL/TIMOLOLMALEATE 184 DOVATO 74 DOVONEX 92 doxazosin mesylate 55 doxepin hcl 42 DOXEPIN HCL 42 doxepin hcl 42 doxepin hcl (sleep) 111 DOXEPIN HYDROCHLORIDE 91 doxercalciferol 102 DOXYCYCLINE 97 doxycycline(monohydrate) 194 doxycycline hyclate 194 doxylamine-pyridoxine 49 DRAMAMINE 48 DRISDOL 201 DRIZALMA SPRINKLE 42 droperidol 31

DROPLET INSULIN SYRINGE 0.3ML/29G X 1/2" 136 DROPLET INSULIN SYRINGE 0.5ML/29G X 1/2" 136 DROPLET INSULIN SYRINGE 1ML/29G X 1/2" 136 DROPLET INSULIN SYRINGE U-100/0.3/31G X 5/16" 136 DROPLET INSULIN SYRINGE U-100/0.3ML/30G X 1/2" 136 DROPLET INSULIN SYRINGE U-100/0.3ML/30G X 5/16" 136 DROPLET INSULIN SYRINGE U-100/0.5ML/30G X 1/2" 136 DROPLET INSULIN SYRINGE U-100/0.5ML/30G X 5/16" 136 DROPLET INSULIN SYRINGE U-100/0.5ML/31G X 5/16" 136 DROPLET INSULIN SYRINGE U-100/1ML/30G X 1/2" 136 DROPLET INSULIN SYRINGE U-100/1ML/30G X 5/16" 136 DROPLET INSULIN SYRINGE U-100/1ML/31G X 5/16" 136 DROPLET INSULIN SYRINGE/U-100/0.3ML/31G X5/16" 136 DROPLET INSULIN SYRINGE/U-100/0.5ML/30G X1/2" 136 DROPLET INSULIN SYRINGE/U-100/0.5ML/31G X5/16" 136 DROPLET INSULIN SYRINGE/U-100/1ML/30G X1/2" 136 DROPLET INSULIN SYRINGE/U-100/1ML/31G X5/16" 136 DROPLET LANCETS ULTRA THIN 30G 121 DROPLET LANCING DEVICE 121 DROPLET PEN NEEDLES 29GX12MM 136 DROPLET PEN NEEDLES 30G X 5/16" 136 DROPLET PEN NEEDLES 31GX5MM 136 DROPLET PEN NEEDLES 31GX6MM 136 DROPLET PEN NEEDLES 31GX8MM 136 DROPLET PEN NEEDLES 32G X 1/4" 136 DROPLET PEN NEEDLES 32G X 3/16" 136 DROPLET PEN NEEDLES 32G X 5/16" 136

Index 13

DROPLET PEN NEEDLES 32G DURAGESIC 23 EASY COMFORT PEN X 5/32" 136 DROPLET PEN NEEDLES 32GX4MM 136 DROPLET PEN NEEDLES 32GX5MM 136 DROPLET PEN NEEDLES

DUREX EXTRA SENSITIVE DUREZOL DURLAZA dutasteride

119 186 109 107

NEEDLES31GX3/16"EASY COMFORT PEN NEEDLES31GX5/16"EASY COMFORT PEN NEEDLES32GX5/32"EASY COMFORT PEN

137

137

137

32GX6MM 136 dutasteride-tamsulosin NEEDLES33G X 4MM 137 DROPLET PEN NEEDLES hcl 107 EASY GLIDE PEN NEEDLES 32GX8MM 136 DROPSAFE SAFETY PEN NEEDLES/31G X 5/16" 136 DROPSAFE SAFTEY PEN

DUTOPROL DUZALLO DXEVO 11-DAY

56 107

86

33G X 5/32" 137 EASY MINI EJECT LANCING DEVICE 122 EASY MINI LANCING

NEEDLES/31G X 1/4" 136 drospirenone-ethinylestradiol 84 drospirenone-ethinyl estradiol-levomefolate calcium 84 DROXIA 110 DRUG MART ADJUSTABLE LANCING DEVICE 121 DRUG MART LANCETS THIN 121 DRUG MART UNIFINE PENTIPS 31GX5MM 137 DRUG MART UNIFINE PENTIPS29G X 12MM 137 DRUG MART UNIFINE PENTIPS31GX6MM 137 DRUG MART UNIFINE PENTIPS31GX8MM 137 DRUG MART UNIFINE PENTIPS32GX4MM 137 DRUG MART UNIFINE PENTIPSPLUS 32GX4MM 137 DRUG MART UNILET LANCETSSUPER THIN 30G 121 DRUG MART UNILET LANCETSULTRA THIN 28G 121 DRUG MART UNILET MICRO THIN LANCETS 33G 121 DRYMAX EXTRA 116 DRYSOL 97 DSUVIA 23 DUAKLIR PRESSAIR 34 DUAVEE 103 DUETACT 43 DULCOLAX 113 DULERA 34 duloxetine hcl 42 DUOBRII 94 DUOPA 63 DUPIXENT 96

DYANAVEL XR 5 DYAZIDE 99 DYMISTA 182 DYRENIUM 99 E-Z JECT LANCETS 121 E-Z JECT LANCETS 21G121 E-Z JECT LANCETS COLOR 121 E-Z JECT LANCETS SUPER THIN 30G 121 E-Z JECT LANCETS THIN 26G 121 E-ZJECT LANCETS MICRO-THIN 33G 122 E.E.S. 400 114 E.E.S. GRANULES 114 EASIVENT 164 EASIVENT/MASK-LARGE

164 EASIVENT/MASK-MEDIUM

164 EASIVENT/MASK-SMALL

164 EASY COMFORT INSULIN SYRINGE/0.5ML/30G X5/16" 137 EASY COMFORT INSULIN SYRINGE/0.5ML/31G X5/16" 137 EASY COMFORT INSULIN SYRINGE/1ML/30G X5/16" 137 EASY COMFORT INSULIN SYRINGE/1ML/31G X5/16" 137 EASY COMFORT INSULIN SYRINGE/U-100/0.5ML/30G X1/2" 137 EASY COMFORT INSULIN SYRINGE/U-100/1ML/30G X1/2" 137 EASY COMFORT PEN NEEDLES31GX1/4" 137

DEVICE 122 EASY TOUCH 32GX5MM 137 EASY TOUCH 32GX6MM 137 EASY TOUCH ALCOHOL PREP PADS/MEDIUM 129 EASY TOUCH FLIPLOCK NEEDLES 18GX1-1/2" 137 EASY TOUCH FLIPLOCK SAFETY INSULIN SYRINGE 1ML/29GX1/2" 137 EASY TOUCH FLIPLOCK SAFETY INSULIN SYRINGE 1ML/30GX1/2" 137 EASY TOUCH FLIPLOCK SAFETY INSULIN SYRINGE 1ML/30GX5/16" 137 EASY TOUCH FLIPLOCK SAFETY INSULIN SYRINGE 1ML/31GX5/16" 137 EASY TOUCH HYPODERMIC NEEDLES 18GX1-1/2" 137 EASY TOUCH INSULIN SYRINGE/0.3ML/30G X5/16" 137 EASY TOUCH INSULIN SYRINGE/0.3ML/31G X5/16" 137 EASY TOUCH INSULIN SYRINGE/0.5ML/29G X1/2" 137 EASY TOUCH INSULIN SYRINGE/0.5ML/30G X5/16" 137 EASY TOUCH INSULIN SYRINGE/1ML/30G X5/16" 137 EASY TOUCH INSULIN SYRINGE/SAFETY/U-100/0.5ML/29G X 1/2" 137 EASY TOUCH INSULIN SYRINGE/SAFETY/U-100/0.5ML/30G X 5/16" 138 EASY TOUCH INSULIN SYRINGE/SAFETY/U-100/1ML/29G X 1/2" 138

Index 14

EASY TOUCH INSULIN EASY TOUCH PEN NEEDLES ELITE DC AUTO SYRINGE/SAFETY/U-100/1ML/30G X 1/2" 138 EASY TOUCH INSULIN SYRINGE/U-100/0.3ML/30G X1/2" 138 EASY TOUCH INSULIN SYRINGE/U-100/0.5ML/27G X1/2" 138 EASY TOUCH INSULIN SYRINGE/U-100/0.5ML/28G X1/2" 138 EASY TOUCH INSULIN SYRINGE/U-100/0.5ML/30G X1/2" 138 EASY TOUCH INSULIN SYRINGE/U-100/0.5ML/31G X5/16" 138 EASY TOUCH INSULIN SYRINGE/U-100/1ML/27G X1/2" 138 EASY TOUCH INSULIN SYRINGE/U-100/1ML/28G X1/2" 138 EASY TOUCH INSULIN SYRINGE/U-100/1ML/29G X1/2" 138 EASY TOUCH INSULIN SYRINGE/U-100/1ML/30G X1/2" 138 EASY TOUCH INSULIN SYRINGE/U-100/1ML/31G X5/16" 138 EASY TOUCH LANCETS 26G/PULL-TOP 122 EASY TOUCH LANCETS 28G/PULL-TOP 122 EASY TOUCH LANCETS 28G/TWIST 122 EASY TOUCH LANCETS 30G/PULL-TOP 122 EASY TOUCH LANCETS 32G/PULL-TOP 122 EASY TOUCH LANCETS 32G/TWIST 122 EASY TOUCH LANCING DEVICE/EJECTOR 122 EASY TOUCH PEN NEEDLE 30G X 5/16" 138 EASY TOUCH PEN NEEDLES 29GX1/2" 138 EASY TOUCH PEN NEEDLES 31GX1/4" 138 EASY TOUCH PEN NEEDLES 31GX5/16" 138 EASY TOUCH PEN NEEDLES 32GX1/4" 138 EASY TOUCH PEN NEEDLES 32GX3/16" 138

32GX5/32" 138 EASY TOUCH PEN NEEDLES/31G X 3/16" 138 EASY TOUCH SAFETY PEN NEEDLES/30G X 5/16" 138 EASY TOUCH SHEATHLOCK SAFETY INSULIN SYRINGE 1ML/29GX1/2" 138 EASY TOUCH SHEATHLOCK SAFETY INSULIN SYRINGE 1ML/30GX5/16" 138 EASY TOUCH SHEATHLOCK SAFETY INSULIN SYRINGE 1ML/31GX5/16" 138 EASY TOUCH SHEATHLOCK SAFETY SYRINGE 1ML/30GX1/2" 138 EASYTEST II LANCETS 122 EASYTEST LANCETS 122 EBASE CONTROLLER KIT 164 EC-NAPROSYN 20 EC-NAPROXEN 20 econazole nitrate 90 ECOTRIN REGULAR STRENGTH 22 EDARBI 54 EDARBYCLOR 56 EDECRIN 99 EDLUAR 111 EDURANT 74 efavirenz 74 EFFEXOR XR 42 EFFIENT 109 EFLOW SCF AEROSOL HEAD 164 EFUDEX 91 EGATEN 29 EGRIFTA 101 EGRIFTA SV 101 ELDEPRYL 63 ELELYSO 110 ELESTAT 187 ELESTRIN 103 eletriptan hydrobromide 168 ELIDEL 96 ELIGARD 59 ELIMITE 97 ELIQUIS 35 ELIQUIS STARTER PACK 35

ADAPTER 164 ELITE-THIN INSULIN SYRINGE/0.3ML/31G X5/16" 138 ELITE-THIN INSULIN SYRINGE/0.5ML/29G X1/2" 138 ELITE-THIN INSULIN SYRINGE/0.5ML/30G X5/16" 138 ELITE-THIN INSULIN SYRINGE/1ML/30G X5/16" 139 ELITE-THIN INSULIN SYRINGE/U-100/0.5ML/28G X1/2" 139 ELITE-THIN INSULIN SYRINGE/U-100/0.5ML/31G X5/16" 139 ELITE-THIN INSULIN SYRINGE/U-100/1ML/28G X1/2" 139 ELITE-THIN INSULIN SYRINGE/U-100/1ML/29G X1/2" 139 ELITE-THIN INSULIN SYRINGE/U-100/1ML/31G X5/16" 139 ELIXOPHYLLIN 35 ELLA 85 ELMIRON 107 ELOCON 94 ELOCTATE 108 EMADINE 187 EMBEDA 23 EMCYT 59 EMEND 49 EMEND TRIPACK 49 EMERGEN-C IMMUNE PLUS/VITAMIN D 174 EMERGEN-C VITAMIN C 174 EMFLAZA 86 EMGALITY 168 EMSAM 40 EMTRIVA 74 EMVERM 29 ENABLEX 198 enalapril maleate 53 enalapril maleate &hydrochlorothiazide 56 enalaprilat 53 ENBREL 21

Index 15

ENBREL MINI ENBREL SURECLICK ENCARE

21 21

200

EQL GAUZE PADS 4"X4"/LARGE 116 EQL GAUZE STERILE PADS 3"X3" 117

ERYTHROCIN STEARATE 114 erythromycin (acne aid) 89 erythromycin (ophth) 185

ENDARI 110 ENEMEEZ PLUS 113 ENFAMIL ENFALYTE 169 ENFAMIL EXPECTA 178 ENGERIX-B 199 ENLON 58 enoxaparin sodium 35,36 ENSTILAR 94 entacapone 62 entecavir 77 ENTEREG 106 ENTOCORT EC 86 ENTRESTO 81 ENTYVIO 105 ENVARSUS XR 171 EPANED 53 EPCLUSA 77 EPHEDRINE SULFATE 201 ephedrine sulfate(pressors) 201 EPIDIOLEX 37 EPIFOAM 94 epinastine hcl (ophth) 187 EPINEPHRINE 201 epinephrine 201 epinephrine (anaphylaxis) 201 epinephrine hcl 34 EPINEPHRINE HCL 201

EQL INSULIN SYRINGE/0.3ML/29G X1/2" 139 EQL INSULIN SYRINGE/0.3ML/30G X5/16" 139 EQL INSULIN SYRINGE/0.3ML/31G X5/16" 139 EQL INSULIN SYRINGE/0.5ML/29G X1/2" 139 EQL INSULIN SYRINGE/0.5ML/30G X5/16" 139 EQL INSULIN SYRINGE/0.5ML/31G X5/16" 139 EQL INSULIN SYRINGE/1ML/29G X1/2" 139 EQL INSULIN SYRINGE/1ML/30G X5/16" 139 EQL INSULIN SYRINGE/1ML/31G X5/16" 139 EQL ONE DAILY ADULT GUMMIES 174 EQL PRENATAL FORMULA 178 EQL SUPER THIN LANCETS 30G 122 EQL THIN LANCETS 26G 122

erythromycin base 114 erythromycinethylsuccinate 114 ERYTHROMYCIN ETHYLSUCCINATE 114 ESBRIET 194 escitalopram oxalate 41 ESGIC 22 esmolol hcl 79 esmolol hcl-sodium chloride 79 ESMOLOL HYDROCHLORIDE INWATER 79 ESMOLOL HYDROCHLORIDE INWATER DOUBLE STRENGTH 79 ESPEROCT 108 estazolam 111 ESTRACE 104,200 estradiol 104 estradiol & norethindrone acetate 103 estradiol vaginal 200 estradiol valerate 104 ESTRING 200 ESTROPIPATE 104 ESTROSTEP FE 84 eszopiclone 111 ethacrynate sodium 99 ethacrynic acid 99 ethambutol hcl 58

EPIPEN 2-PAK 201 EQUALYTE 169 ethosuximide 39 EPIPEN-JR 2-PAK 201 EPIVIR 74 EPIVIR HBV 77 eplerenone 57 EPOGEN 110 EPROSARTAN MESYLATE 54 EPZICOM 74 EQ MULTIVITAMINS ADULT GUMMY 174

EQUETRO ERAXIS ergocalciferol ERGOLOID MESYLATES ERGOMAR ergotamine w/ caffeine ERIVEDGE ERLEADA

64 49

201

193 168 167

59 59

ethynodiol diacet & ethestrad 84 ETIDRONATE DISODIUM 100 etodolac 20 etonogestrel-ethinyl estradiol85 ETOPOSIDE 62 EUCRISA 97 EURAX 97 EVAMIST 104

EQL COLOR LANCETS 21G 122 EQL COLOR LANCETS MICRO THIN 33G 122

erlotinib hcl ERTACZO ertapenem sodium

60 90 29

EVEKEO EVEKEO ODT everolimus

5 5

60 EQL DRY MOUTH ORAL RINSE EQL GAUZE PADS 2"X2"/SMALL

172

116

ERYGEL ERYPED 200 ERYPED 400

89 114 114

everolimus (immunosuppressant) EVISTA

171 101

Index 16

EVOTAZ 74 EXJADE 47 fentanyl 23 EVOXAC 172 EXONDYS 51 183 fentanyl citrate 23 EXALGO 23 EXTINA 90 FENTANYL CITRATE 23 EXCEL COMFORT POINT EZ SMART BLOOD GLUCOSE fentanyl citrate 23 INSULIN PEN NEEDLES 31G X LANCETS 122 FENTANYL CITRATE 234MM 139 EZ-LETS LANCETS 26G

FENTORA 23EXCILON AMD SUPER-SOFT 122 ANTIMICROBIALDRAIN EZ-LETS LANCETS 28G FER-IN-SOL 110 SPONGES 4"X4" 6 PLY 117 ULTRA-SOFT 122 FERRIPROX 47,48EXCILON AMD EZ-LETS LANCETS 30G 122 ferrous fumarate-fa-b complex-c-ANTIMICROBIALNON-WOVEN EZALLOR SPRINKLE 52 zn-mg-mn-cu 110SPONGES 4"X4" 6 PLY 117 ezetimibe 53 ferrous gluconate 110EXCILON DRAIN SPONGE 4"X4" 117 ezetimibe-simvastatin 51 FERROUS GLUCONATE 110 EXCILON DRAIN SPONGES EZFE FORTE 178 ferrous sulfate 110 4"X4" 6 PLY 117 FALESSA 84 FERROUS SULFATE 111EXCILON I.V. SPONGES 2"X2" 6

famciclovir 77 ferrous sulfate 111PLY 117 EXEL COMFORT POINT famotidine 197 FERROUS SULFATE 111 INSULIN PEN NEEDLES 29G X famotidine-calcium carbonate- ferrous sulfate 111 12MM 139 magnesium hydroxide 198 FETZIMA 42EXEL COMFORT POINT FANAPT 65 FETZIMA TITRATION PACK42INSULIN PEN NEEDLES 31G X FANAPT TITRATION6MM 139 FEVERALL JUNIORPACK 65EXEL COMFORT POINT STRENGTH 22FANTASY LUBRICATED 119INSULIN PEN NEEDLES 31G X FEXMID 181FANTASY8MM 139 fexofenadine hcl 51EXEL COMFORT POINT LUBRICATED/SPERMICIDE

119 FIASP 45INSULIN SYRINGE/0.3ML/29G X1/2" 139 FARESTON 59 FIASP FLEXTOUCH 45 EXEL COMFORT POINT FARXIGA 47 FIASP PENFILL 45 INSULIN SYRINGE/0.3ML/30G X FARYDAK 60 FIBRICOR 525/16" 139 FASENRA 32 FIBRYGA 108EXEL COMFORT POINT INSULIN SYRINGE/0.5ML/28G X FASENRA PEN 32 FIFTY50 ALCOHOL PREP 1/2" 139 FAZACLO 68 PADS 129

FIFTY50 PEN NEEDLES 31GEXEL COMFORT POINT febuxostat 107INSULIN SYRINGE/0.5ML/29G X X3/16" (5MM) 139 1/2" 139 FEIBA 108 FIFTY50 PEN NEEDLES 31G EXEL COMFORT POINT felbamate 39 X5/16" (8MM) 139 INSULIN SYRINGE/0.5ML/30G X FIFTY50 PEN NEEDLESFELBATOL 395/16" 139 31GX5MM 140

FELDENE 20 FIFTY50 PENEXEL COMFORT POINT INSULIN SYRINGE/1ML/28G X felodipine 80 NEEDLES/31GX8MM 140

FIFTY50 PEN1/2" 139 FEMARA 59 EXEL COMFORT POINT NEEDLES/32GX4MM 140

FEMHRT LOW DOSE 103 FIFTY50 PENINSULIN SYRINGE/1ML/29G XFEMRING 200 NEEDLES/32GX6MM 1401/2" 139 FIFTY50 SUPERIOREXEL COMFORT POINT FENOFIBRATE 52 COMFORTINSULININSULIN SYRINGE/1ML/30G X fenofibrate 52 SYRINGE/0.3ML/31G X5/16" 139 fenofibrate micronized 52 5/16" 140EXELDERM 90 FENOFIBRIC ACID 52 FIFTY50 SUPERIOR

EXELON 191 COMFORTINSULINFENOGLIDE 52exemestane 59 SYRINGE/0.5ML/31G XFENOPROFEN CALCIUM 20EXFORGE 56 5/16" 140 fenoprofen calcium 20EXFORGE HCT 56 FENORTHO 20

Index 17

FIFTY50 SUPERIOR COMFORTINSULIN SYRINGE/1ML/31G X5/16" FILTER AIR PP FINACEA finasteride FIORICET/CODEINE FIORINAL FIORINAL/CODEINE #3 FIRAZYR FIRDAPSE FIRST-OMEPRAZOLE

140 164

97 107

25 22 25

109 58

197

FLUOXETINE DR fluoxetine hcl fluoxetine hcl (pmdd) FLUOXETINE HYDROCHLORIDE fluphenazine decanoate FLUPHENAZINE HCL fluphenazine hcl FLUPHENAZINE HCL FLUPHENAZINE HYDROCHLORIDE FLURA-DROPS flurandrenolide

41 41

193

41 71 71 71 71

71 170

94

fosamprenavir calcium 74 FOSAPREPITANT DIMEGLUMINE 49 fosaprepitant dimeglumine 49 fosinopril sodium 53 fosinopril sodium &hydrochlorothiazide 56 fosphenytoin sodium 39 FOSRENOL 106 FRAGMIN 36 FREDS PHARMACY AUTOLET LANCING DEVICE 122 FREDS PHARMACY UNIFINE PENTIPS PEN NEEDLES

FIRST-VANCOMYCIN 25 30 FLURAZEPAM HCL 112 32GX4MM 140 FIRVANQ 30 FLAGYL 29 FLAREX 186 flavoxate hcl 199 flecainide acetate 32 FLEET ENEMA 113 FLEET ENEMA SIX PACK 113 FLEET PEDIATRIC 113 FLEXICHAMBER 165 FLOMAX 107 FLONASE ALLERGY RELIEF 182 FLONASE SENSIMIST 183 FLORIVA PLUS 176 FLOVENT DISKUS 33 FLOVENT HFA 33 FLOXIN OTIC 188 fluconazole 50 fluconazole in dextrose 50 FLUCONAZOLE IN NACL 50 fluconazole in nacl 50 flucytosine 49 fludrocortisone acetate 87 FLUMADINE 78 FLUNISOLIDE 183 fluocinolone acetonide 94 fluocinolone acetonide

flurbiprofen 20 flurbiprofen sodium 187 FLURBIPROFEN SODIUM 188 flutamide 59 fluticasone propionate 94 fluticasone propionate(nasal) 183 FLUTICASONE PROPIONATE/SALMETEROL

34 fluticasone-salmeterol 34 fluvastatin sodium 52 fluvoxamine maleate 41 FLYP HYPERSONIQ CARTRIDGE 165 FML 186 FML FORTE 186 FML LIQUIFILM 186 FOCALIN 13 FOCALIN XR 13,14 folic acid 110 fondaparinux sodium 36 FORA LANCETS 122 FORA LANCING DEVICE122 FORA LANCING DEVICE/CLEARCAP 122 FORFIVO XL 40 FORMALDEHYDE 74

FREDS PHARMACY UNIFINE PENTIPS PLUS 31GX5MM 140 FREDS PHARMACY UNIFINE PENTIPS PLUS 31GX8MM 140 FREDS PHARMACY UNILET LANCETS SUPER THIN 30G 122 FREDS PHARMACY UNILET LANCETS ULTRA THIN 28G 122 FREESTYLE PRECISION INSULIN SYRINGE/U-100/0.5ML/30G X 5/16" 140 FREESTYLE PRECISION INSULIN SYRINGE/U-100/0.5ML/31G X 5/16" 140 FREESTYLE PRECISION INSULIN SYRINGE/U-100/1ML/31G X 5/16" 140 FREESTYLE PRECISION INSULIN SYRINGES/U-100/1ML/30G X 5/16" 140 FROVA 168 frovatriptan succinate 168 FULL KIT NEBULIZER SET 165 FULL SPECTRUM B/VITAMINC 173 FULPHILA 110 FURADANTIN 198 furosemide 99 FUROSEMIDE 99

(otic) 189 fluocinonide 94 fluocinonide emulsified base 94 fluorometholone (ophth) 186 FLUOROURACIL 91 fluorouracil (topical) 91 FLUOXETINE 193

formaldehyde FORTAMET FORTEO FORTESTA FOSAMAX FOSAMAX PLUS D

74 44

100 27

100 100

furosemide FUZEON FYCOMPA GABACAINE gabapentin GABITRIL GABLOFEN

99 74 36

192 37 39

181

Index 18

GALAFOLD 102 GENTEEL LANCING GLOBAL INJECT EASE INSULIN

galantamine hydrobromide 191 GALANTAMINE HYDROBROMIDE 191 galantamine hydrobromide 191 GAMIFANT 171

DEVICE/PRECIOUSPLATINUM GENTEEL LANCING DEVICE/PRINCESSPINK GENTEEL LANCING

122

122

SYRINGE/U-100/0.3ML/30G X1/2" 140 GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.3ML/30G X5/16" 140 GLOBAL INJECT EASE INSULIN

GANCICLOVIR ganciclovir sodium GARDASIL 9 GAS-X GAS-X EXTRA

76 76

199 105

DEVICE/STATELYSILVER GENTEEL LANCING DEVICE/WILLOWYWHITE GENTLE-LET GP

123

123


STRENGTH gatifloxacin (ophth) GATTEX GAUZE DRESSING 4"X4" GAUZE PADS 2"X2"

105 185 106 117 117

LANCETS 123 GENTLE-LET LANCETS GENERAL PURPOSE STYLE/FINE POINT 123 GENTLE-LET LANCETS GENERAL PURPOSE


GAUZE PADS 3"X3" 117 GAUZE PADS 4"X4" 117 GAUZE PADS 4"X4" 12 PLY 117 GAUZE SPONGE TYPE VII MEDI-PAK 2"X2" 8PLY 117 GAUZE SPONGES 4"X4" 12 PLY 117 GAVILYTE-C 112 gemfibrozil 52 GENERESS FE 84 GENOTROPIN 101 GENOTROPIN MINIQUICK101 GENTAK 185 gentamicin in saline 19 gentamicin sulfate 19 gentamicin sulfate (ophth) 185 gentamicin sulfate (topical) 90 GENTAMICIN SULFATE PEDIATRIC 19 GENTAMICIN SULFATE/0.9%SODIUM CHLORIDE 19 GENTEAL MILD 184 GENTEEL LANCING DEVICE/BUFF BLACK 122 GENTEEL LANCING DEVICE/BUTTERFLYBLUE 122 GENTEEL LANCING DEVICE/GLORIOUSGOLD 122 GENTEEL LANCING DEVICE/PLAYFULPURPLE 122

STYLE/MEDIUM POINT 123 GENTLE-LET LANCETS SAFETY STYLE/FINEPOINT 123 GENTLE-LET LANCETS SAFETY STYLE/MEDIUMPOINT 123 GENVOYA 74 GEODON 64 GIAZO 105 GILENYA 192 GILOTRIF 60 GLASSIA 194 glatiramer acetate 192 GLEEVEC 60 GLEOSTINE 58 glimepiride 47 glipizide 47 glipizide-metformin hcl 43 GLOBAL EASE INJECT PEN NEEDLES 29GX12MM 140 GLOBAL EASE INJECT PEN NEEDLES 31GX8MM 140 GLOBAL EASE INJECT PEN NEEDLES 32GX4MM 140 GLOBAL EASE INJECT PEN NEEEDLES 31GX5MM 140 GLOBAL EASY GLIDE INSULINSYRINGE/U-100/0.3ML/31G X 5/16" 140 GLOBAL EASY GLIDE PEN NEEDLES 32GX4MM 140 GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.3ML/29G X 1/2" 140

SYRINGE/U-100/0.5ML/30G X5/16" 141 GLOBAL INJECT EASE INSULIN SYRINGE/U-100/0.5ML/31G X5/16" 141 GLOBAL INJECT EASE INSULIN SYRINGE/U-100/1ML/28G X1/2" 141 GLOBAL INJECT EASE INSULIN SYRINGE/U-100/1ML/29G X1/2" 141 GLOBAL INJECT EASE INSULIN SYRINGE/U-100/1ML/30G X1/2" 141 GLOBAL INJECT EASE INSULIN SYRINGE/U-100/1ML/30G X5/16" 141 GLOBAL INJECT EASE INSULIN SYRINGE/U-100/1ML/31G X5/16" 141 GLOBAL INSULIN SYRINGE/U-100/0.3ML/30G X 1/2" 141 GLOBAL INSULIN SYRINGES/U-100/0.3ML/30GX5/16" 141 GLOBAL LANCING DEVICE 123 GLOPERBA 107 GLUCAGEN HYPOKIT 44 GLUCAGON EMERGENCY KIT 44 GLUCOPHAGE 44 GLUCOPHAGE XR 44 GLUCOPRO INSULIN SYRINGE/U-100/0.3ML/30G X1/2" 141 GLUCOPRO INSULIN SYRINGE/U-100/0.3ML/30G X5/16" 141

Index 19

GLUCOPRO INSULIN GNP INSULIN GNP ULTRA COMFORT SYRINGE/U-100/0.3ML/31G X SYRINGE/0.3ML/29G X INSULIN SYRINGE/0.3ML/31G X5/16" 141 1/2" 141 5/16" SHORT 142 GLUCOPRO INSULIN GNP INSULIN GNP ULTRA COMFORT SYRINGE/U-100/0.5ML/30G X SYRINGE/0.3ML/30G X INSULIN SYRINGE/0.5ML/28G X1/2" 141 5/16" 141 1/2" 142 GLUCOPRO INSULIN GNP INSULIN GNP ULTRA COMFORT SYRINGE/U-100/0.5ML/30G X SYRINGE/0.3ML/31G X INSULIN SYRINGE/0.5ML/29G X5/16" 141 5/16" 141 1/2" 142 GLUCOPRO INSULIN GNP INSULIN GNP ULTRA COMFORT SYRINGE/U-100/0.5ML/31G X SYRINGE/0.5ML/28G X INSULIN SYRINGE/0.5ML/30G X5/16" 141 1/2" 141 5/16" SHORT 142 GLUCOPRO INSULIN GNP INSULIN GNP ULTRA COMFORT SYRINGE/U-100/1ML/30G X SYRINGE/0.5ML/29G X INSULIN SYRINGE/0.5ML/31G X1/2" 141 1/2" 142 5/16" SHORT 142 GLUCOPRO INSULIN GNP INSULIN GNP ULTRA COMFORT SYRINGE/U-100/1ML/30G X SYRINGE/0.5ML/30G X INSULIN SYRINGE/1ML/28G X5/16" 141 5/16" 142 1/2" 142 GLUCOPRO INSULIN GNP INSULIN GNP ULTRA COMFORT SYRINGE/U-100/1ML/31G X SYRINGE/0.5ML/31G X INSULIN SYRINGE/1ML/29G X5/16" 141 5/16" 142 1/2" 142 GLUCOSE 44 GNP INSULIN GNP ULTRA COMFORT

SYRINGE/1ML/28G X INSULIN SYRINGE/1ML/30G XGLUCOTROL 47 1/2" 142 5/16" SHORT 142GLUCOTROL XL 47 GNP INSULIN GNP ULTRA COMFORT GLUCOVANCE 43 SYRINGE/1ML/29G X INSULIN SYRINGE/1ML/31G XGLUMETZA 44 1/2" 142 5/16" SHORT 142

GNP INSULIN GOCOVRI 63glyburide 47 SYRINGE/1ML/30G X GOJJI LANCINGglyburide micronized 47 5/16" 142 DEVICE/CLEAR CAP 123 glyburide-metformin 43 GNP INSULIN GOJJI STERILE LANCETS

SYRINGE/1ML/31G X 30GGLYCATE 196 1235/16" 142glycerin (laxative) 113 GOLYTELY 112GNP LANCETS 123 GONITRO 30GLYCERIN ADULT 113 GNP LANCETS 21G 123 GOODSENSE CLICKFINEglycopyrrolate 196 GNP LANCETS MICRO THIN SAFETY PEN NEEDLE/31G XGLYCOPYRROLATE 196 12333G 3/16" 142

glycopyrrolate 196 GNP LANCETS SUPER THIN GOODSENSE LANCETS30G 123 MICRO-THIN 33GGLYCOPYRROLATE 196 GNP LANCETS THIN 123 UNIVERSAL 123GLYNASE 47 GNP LANCETS THIN GOODSENSE LANCETS

GLYRX-PF 196 26G 123 ULTRA-THIN 26G GLYSET 43 GNP MICRO THIN LANCETS UNIVERSAL 123

33G 123 GOODSENSE LANCINGGLYXAMBI 43 GNP PRENATAL 178 DEVICE 123GNP ADHESIVE PADS 3" X

4" 117 GNP QUICK DISSOLVE GOODSENSE PEN GLUCOSE 44 NEEDLE/PENFINEGNP ALCOHOL SWABS 129 GNP STERILE PADS CLASSIC/31G X 3/16" 142

GNP CLICKFINE PEN GOODSENSE PEN3"X3" 117NEEDLEUNIVERSAL/31GX5/16" GNP SUPER THIN NEEDLE/PENFINE141 LANCETS/30G 123 CLASSIC/31G X 5/16" 142

GNP CLICKFINE UNIVERSAL GNP ULTRA COMFORT GOODSENSE PENPEN NEEDLES 31GX1/4" 141 INSULIN SYRINGE/0.3ML/29G NEEDLE/PENFINEGNP CLICKFINE UNIVERSAL X 1/2" 142 CLASSIC/32G X 1/4" 142PEN NEEDLES 31GX5/16" 141 GNP ULTRA COMFORT GOODSENSE PEN GNP DAILY PRENATAL 178 NEEDLE/PENFINEINSULIN SYRINGE/0.3ML/30GGNP GLUCOSE 44 X 5/16" SHORT 142 CLASSIC/32G X 5/32" 142

Index 20

GOODSENSE PRENATAL HALOBETASOL HEALTHY ACCENTS UNIFINE VITAMINS 178 PROPIONATE 94 PENTIPS PEN NEEDLES GRALISE 192 HALOG 95 31GX8MM 143

HEALTHY ACCENTS UNIFINEGRALISE STARTER 192 haloperidol 67 PENTIPS PEN NEEDLESGRANISETRON HCL 48 haloperidol decanoate 67 32GX4MM 143 granisetron hcl 48 haloperidol lactate 67 HEALTHY ACCENTS UNILET

LANCETS SUPER THINGRANIX 110 HARVONI 77 30G 123GRASTEK 18 HAVRIX 199 HEALTHY LIVING

GRIS-PEG 49 HEALTH CARE LANCING REPLACEMENT FILTERS 165DEVICE 123griseofulvin microsize 49 HEALTHY LIVINGHEALTHWISE INSULIN REPLACEMENT KIT FORgriseofulvin ultramicrosize 49 SYRINGE/U-100/0.3ML/30G X NEBULIZER 165guaifenesin 88 5/16" 143 HEALTHY LIVINGHEALTHWISE INSULINguanfacine hcl 55 REPLACEMENT MASKS 165SYRINGE/U-100/0.3ML/31G Xguanfacine hcl (adhd) 8 HELIXATE FS 1085/16" 143 GUANIDINE HCL 58 HEALTHWISE INSULIN HEMANGEOL 79 GYNAZOLE-1 200 SYRINGE/U-100/0.5ML/30G X HEMLIBRA 108

5/16" 143GYNE-LOTRIMIN 200 HEMOFIL M 108HEALTHWISE INSULINGYNE-LOTRIMIN 3 200 heparin (porcine) in sodiumSYRINGE/U-100/0.5ML/31G X chloride 36H-E-B IN CONTROL PEN 5/16" 143 HEPARIN LOCK FLUSH 36NEEDLES 31GX5MM 142 HEALTHWISE INSULINH-E-B IN CONTROL PEN SYRINGE/U-100/1ML/30G X HEPARIN SODIUM 36 NEEDLES 31GX6MM 142 5/16" 143 heparin sodium (porcine) 36H-E-B IN CONTROL PEN HEALTHWISE INSULIN heparin sodium (porcine) lockNEEDLES 31GX8MM 142 SYRINGE/U-100/1ML/31G X flush 36H-E-B IN CONTROL PEN 5/16" 143 HEPARIN SODIUM/D5W 36NEEDLES/NANO/32GX4MM HEALTHWISE MICRON PEN HEPARIN143 NEEDLES/32G X 5/32" 143H-E-B IN CONTROL SODIUM/DEXTROSE 36HEALTHWISE MINI PENUNIFINEPENTIPS PLUS NEEDLES 31GX6MM 143 HEPARIN SODIUM/NACL

0.45% 3631GX5MM 143 HEALTHWISE PEN NEEDLESH-E-B IN CONTROL HEPARIN SODIUM/SODIUM29GX12MM 143 CHLORIDE 36UNIFINEPENTIPS PLUS HEALTHWISE SHORT PEN HEPARIN SODIUM/SODIUM32GX4MM 143 NEEDLES 31GX8MM 143 CHLORIDE 0.9% 36H-E-B INCONTROL HEALTHWISE SHORT PEN ADVANCEDLANCING NEEDLES/31G X 3/16" 143 HEPSERA 77 DEVICE 123 HEALTHWISE SHORT PEN HETLIOZ 112 H-E-B INCONTROL LANCETS NEEDLES/31G X 5/16" 143 HEXALEN 58MICRO THIN 33G 123 HEALTHWISE UNIFINE HIBERIX 199H-E-B INCONTROL LANCETS PENTIPS PEN NEEDLES SUPER THIN 30G 123 32GX4MM 143 HM ADHESIVE PADS H-E-B INCONTROL LANCETS HEALTHY ACCENTS ANTIBACTERIAL/SHEER 117 ULTRA THIN 28G 123 HM ONE DAILY PRENATALAUTOLET IMPRESSIONH-E-B INCONTROL PEN COMBO 178LANCING DEVICE 123NEEDLES 29GX12MM 143 HEALTHY ACCENTS UNIFINE HM PRENATAL 179 HAEGARDA 109 PENTIPS PEN NEEDLES HM STERILE ALCOHOL PREP HALAC 94 29GX12MM 143 PADS 129

HEALTHY ACCENTS UNIFINE HM STERILE PADS 117halcinonide 94 PENTIPS PEN NEEDLES HM STERILE PADS 2"X2" 117HALCION 112 31GX5MM 143 HM ULTICARE INSULINHALDOL 67 HEALTHY ACCENTS UNIFINE SYRINGE/1ML/30G X 1/2" 143PENTIPS PEN NEEDLESHALDOL DECANOATE 100 67 HM ULTICARE INSULIN31GX6MM 143HALDOL DECANOATE 50 67 SYRINGE/U-100/0.3ML/31G X5/16" 143halobetasol propionate 94

Index 21

HM ULTICARE SHORT PEN HYDROCODONE ILARIS 20 NEEDLES 31GX8MM 143 BITARTRATE/ACETAMINOPH ILEVRO 188HORIZANT 193 EN 25 ILUMYA 92HUDSON RCI SEE-THRU hydrocodone w/AEROSOL MASK homatropine 87 imatinib mesylate 60

hydrocodone-ELONGATED/ADULT 165 IMBRUVICA 60acetaminophen 25HUMALOG 45 imipramine hcl 42hydrocodone-ibuprofen 25HUMALOG JUNIOR imipramine pamoate 42

KWIKPEN 45 hydrocortisone 86 imiquimod 96HUMALOG KWIKPEN 45 hydrocortisone (intrarectal) 28 IMIQUIMOD PUMP 96HUMALOG MIX 50/50 45 hydrocortisone (rectal) 28 IMITREX 168HUMALOG MIX 50/50 hydrocortisone (topical) 95 IMITREX STATDOSEKWIKPEN 45 hydrocortisone butyrate 95 REFILL 168HUMALOG MIX 75/25 45 hydrocortisone butyrate IMITREX STATDOSEHUMALOG MIX 75/25 hydrophilic lipo base 95 SYSTEM 168KWIKPEN 45 hydrocortisone valerate 95 IMMUNE SUPPORT 174HUMATE-P 108 hydrocortisone w/acetic IMODIUM A-D 47HUMATROPE 101 acid 189 IMPAVIDO 29HUMATROPE COMBO hydromorphone hcl 23

PACK 101 IMURAN 171HYDROMORPHONE HCL 23HUMIRA 19 IMVEXXY MAINTENANCE

hydromorphone hcl 23 PACK 200HUMIRA PEDIATRIC CROHNS hydroxychloroquine sulfate 57 IMVEXXY STARTERDISEASE STARTER PACK 19 HYDROXYPROGESTERONE PACK 200HUMIRA PEN 19 CAPROATE 59 IN TOUCH LANCINGHUMIRA PEN-CD/UC/HS hydroxyprogesterone DEVICE 123STARTER 19 caproate 190 INATAL GT 179HUMIRA PEN-PS/UVhydroxyurea INBRIJASTARTER 19 62 63

HUMULIN 70/30 45 HYDROXYZINE HCL 31 INCRELEX 101 HUMULIN 70/30 KWIKPEN 45 hydroxyzine hcl 31 INCRUSE ELLIPTA 33

HYDROXYZINEHUMULIN N 45 indapamide 100HYDROCHLORIDE 31HUMULIN N KWIKPEN 45 INDERAL LA 79HYDROXYZINE

HUMULIN R 45 PAMOATE 31 INDERAL XL 79 HUMULIN R U-500 hydroxyzine pamoate 31 indomethacin 21 (CONCENTRATED) 45 hyoscyamine sulfate 196 INFANRIX 196HUMULIN R U-500

HYPERRHO S/D 189 INFANTS ADVIL 21KWIKPEN 46 HYPODERMIC NEEDLE 18G XHY-VEE LANCETS 123 INFLECTRA 105 1-1/2" 143HY-VEE THIN LANCETS 123 INGREZZA 192HYPODERMIC NEEDLES

HYCAMTIN 62 18GX1-1/2" 143 INLYTA 61 hydralazine hcl 57 HYSINGLA ER 23 INNOPRAN XL 79

INNOSPIRE REPLACEMENTHYDRALYTE 170 HYZAAR 56 FILTER 165HYDRALYTE FREEZER ibandronate sodium 100 INREBIC 61POPS 170 IBRANCE 60 INSPIRACHAMBER/ANTI-HYDREA 62 IBUDONE 25 STATICHYDROCELL ADHESIVE

ibuprofen 20,21 VALVED/MOUTHPIECE 165DRESSING 4"X4" 117 INSPIRACHAMBER/LARGEHYDROCELL DRESSING ibutilide fumarate 32 1654"X4" 117 icatibant acetate 109 INSPIRACHAMBER/SOOTHERhydrochlorothiazide 100 ICLUSIG 60 MASK/INSPIRAMASK/MEDIUM

hydrocodone bitartrate 23 165IDELVION 108 IDHIFA 60

Index 22

INSPIRACHAMBER/SOOTHER INSULIN SYRINGE/NEEDLE INSUPEN PEN NEEDLES 32G MASK/INSPIRAMASK/SMALL 1ML/31G X 5/16" 144 X4MM 145

165 INSULIN SYRINGE/U- INSUPEN SENSITIVE INSPIREASE DRUG 100/0.3ML/29G X 1/2" 144 32GX6MM 145 DELIVERYSYSTEM 165 INSULIN SYRINGE/U- INSUPEN SENSITIVE INSPIREASE RESERVOIR 100/0.5ML/28G X 1/2" 144 32GX8MM 145 BAGS 165 INSULIN SYRINGE/U- INSUPEN ULTRAFIN INSPRA 57 100/0.5ML/29G X 1/2" 144 29GX12MM 145

INSULIN SYRINGE/U- INSUPEN ULTRAFININSULIN ASPART 46 100/1ML/28G X 1/2" 144 30GX8MM 145INSULIN ASPART INSULIN SYRINGE/U- INSUPEN ULTRAFINFLEXPEN 46 100/1ML/29G X 1/2" 144 31GX6MM 145INSULIN ASPART PENFILL 46 INSULIN SYRINGE/U- INSUPEN ULTRAFIN INSULIN ASPART 100/1ML/30G X 5/16" 144 31GX8MM 145 PROTAMINE/INSULIN INSULIN SYRINGE/U- INTELENCE 74,75ASPART 46 100/1ML/31G X 5/16" 144 INTERMEZZO 112INSULIN ASPART INSULIN PROTAMINE/INSULIN ASPART SYRINGES/0.5ML/27GX1/2" INTRAROSA 199 FLEXPEN 46 144 INTRON A 62 INSULIN LISPRO 46 INSULIN INTUNIV 8,9

SYRINGES/0.5ML/28GX1/2"INSULIN LISPRO KWIKPEN 46 INVANZ 29 INSULIN SYRINGE/0.3ML/29G X INSULIN

144 INVEGA 651" 143 SYRINGES/0.5ML/29GX1/2" INVEGA SUSTENNA 65INSULIN SYRINGE/0.3ML/29G X 1441/2" 144 INVEGA TRINZA 65INSULININSULIN SYRINGE/0.3ML/30G X INVELTYS 186SYRINGES/0.5ML/30GX5/16"5/16" 144 144 INVIRASE 75INSULIN SYRINGE/0.3ML/31G X INSULIN5/16" 144 INVOKAMET 43

SYRINGES/0.5ML/31GXINSULIN SYRINGE/0.5ML/27G X INVOKAMET XR 435/16" 1441/2" 144 INVOKANA 47INSULININSULIN SYRINGE/0.5ML/28G X SYRINGES/0.5ML/31GX5/16" IONSYS 231/2" 144 INSULIN SYRINGE/0.5ML/30G X 144 IOPIDINE 185INSULIN1/2" 144 ipratropium bromide 33SYRINGES/1ML/27GX/1/2"INSULIN SYRINGE/0.5ML/30G X

145 ipratropium bromide (nasal)1825/16" 144 INSULIN SYRINGE/0.5ML/31G X INSULIN ipratropium-albuterol 34

SYRINGES/1ML/27GX1/2"5/16" 144 irbesartan 54 INSULIN SYRINGE/1ML/28G X 145 irbesartan-hydrochlorothiazideINSULIN1/2" 144 56INSULIN SYRINGE/1ML/29G X SYRINGES/1ML/28GX1/2" IRESSA 611/2" 144 145

INSULIN irrigation solutions,INSULIN SYRINGE/1ML/30G X5/16" 144 SYRINGES/1ML/29GX1/2" physiological 171

145 ISENTRESS 75INSULIN SYRINGE/NEEDLE0.3ML/30G X 5/16" 144 INSULIN ISENTRESS HD 75 INSULIN SYRINGE/NEEDLE SYRINGES/1ML/30GX1/2" ISONIAZID 580.3ML/31G X 5/16" 144 145

isoniazid 58INSULIN SYRINGE/NEEDLE INSULIN 0.5ML/29G X 1/2" 144 SYRINGES/1ML/31GX5/16" ISOPTO ATROPINE 185 INSULIN SYRINGE/NEEDLE 145 ISOPTO CARPINE 185 0.5ML/30G X 5/16" 144 INSUPEN 29G X 12MM 145 ISOPTO TEARS 184INSULIN SYRINGE/NEEDLE INSUPEN 31G X 5MM 145 ISORDIL TITRADOSE 300.5ML/31G X 5/16" 144 INSUPEN 31G X 8MM 145INSULIN SYRINGE/NEEDLE isosorbide dinitrate 30 1ML/29G X 1/2" 144 INSUPEN 32G X 4MM 145 ISOSORBIDE DINITRATE INSULIN SYRINGE/NEEDLE INSUPEN 33GX4MM 145 ER 30 1ML/30G X 5/16" 144

Index 23

isosorbide mononitrate 30 KARBINAL ER 51 KIMONO PLUS

ISOTONIC GENTAMICIN isotretinoin isradipine

19 89 80

KATERZIA KAZANO KEFLEX

80 43 82

SPERMICIDE/LUBRICATED119

KIMONO PS LUBRICATED119 KIMONO PS PLUS

ISTALOL itraconazole ivermectin ivermectin (rosacea) IXINITY

184 50 29 97

108

KENALOG 95 KENALOG-10 86 KENALOG-40 86 KENALOG-80 86 KENDALL HYDROPHILIC

SPERMICIDE/LUBRICATED119

KIMONO SENSATION LUBRICATED 119 KIMONO SENSATION PLUS SPERMICIDE

J & J ADHESIVE LARGE 117 J & J GAUZE 2"X2" 8 PLY 117 J & J GAUZE 4"X4" 12 PLY117 J & J GAUZE 4"X4" 8 PLY 117 J & J GAUZE SPONGES 12-PLY 4" X 4" 117 J & J GAUZE SPONGES 16-PLY 4" X 4" 117 J & J GAUZE SPONGES 8-PLY4" X 4" 117 J & J NON-STICK PADS 100LARGE 117 JADENU 48 JADENU SPRINKLE 48

FOAMDRESSING 2"X2" 117 KENDALL HYDROPHILIC FOAMDRESSING 3"X3" 117 KENDALL HYDROPHILIC FOAMDRESSING 4"X4" 117 KENDALL HYDROPHILIC FOAMPLUS DRESSING 2"X2" 117 KENDALL HYDROPHILIC FOAMPLUS DRESSING 3"X3" 117 KENGREAL 109 KEPPRA 37 KEPPRA XR 37 KERALYT 97

LUBRICATED 119 KIMONO SPECIAL 119 KINERET 20 KINNEY LANCETS 123 KINNEY THIN LANCETS 123 KINRAY INSULIN SYRINGE PREFERRED PLUS/0.3ML/31GX 5/16" 145 KINRAY INSULIN SYRINGE PREFERRED PLUS/0.5ML/31GX 5/16" 145 KINRAY INSULIN SYRINGE PREFERRED PLUS/1ML/31G X5/16" 145 KINRAY INSULIN

JAKAFI 61 JALYN 107 JANUMET 43 JANUMET XR 43 JANUVIA 44 JARDIANCE 47 JATENZO 27 JENTADUETO 43 JENTADUETO XR 43 JIVI 108 JORNAY PM 14 JUBLIA 90 JULUCA 75 JUXTAPID 53 JYNARQUE 103 K-PHOS NEUTRAL 170 K-PHOS NO 2 106 K-TAB 170 KADIAN 23 KALBITOR 109 KALETRA 75 KALYDECO 194 KAMELEON LUBRICATED 119 KAPSPARGO SPRINKLE 79 KAPVAY 9

KERLIX SPONGES 4" X 4" 12 PLY 117 KERLIX SPONGES 4" X 4" 16 PLY 117 KERYDIN 90 ketoconazole 50 ketoconazole (topical) 90 KETONE 98 KETONE TEST STRIPS 98 KETOPROFEN 21 KETOPROFEN ER 21 ketorolac tromethamine 21 ketorolac tromethamine (ophth) 188 KETOSTIX 98 ketotifen fumarate (ophth)188 KEVEYIS 99 KEVZARA 20 KHEDEZLA 42 KIMONO COLORS 119 KIMONO LUBRICATED 119 KIMONO MICRO THIN 119 KIMONO MICRO THIN PLUS SPERMICIDE LUBRICATED 119 KIMONO PLUS SPERMICIDE LUBRICATED 119

SYRINGE/0.5ML/29G X1/2" 145 KISQALI 61 KISQALI FEMARA 200 DOSE 60 KISQALI FEMARA 400 DOSE 60 KISQALI FEMARA 600 DOSE 60 KITABIS PAK 19 KLARITY-A 185 KLARON 89 KLONOPIN 37 KLOR-CON M15 170 KMART VALU PLUS INSULIN SYRINGE/1ML/29G 145 KMART VALU PLUS INSULIN SYRINGE/1ML/30G 145 KOATE 108 KOATE-DVI 108 KOGENATE FS 108 KOGENATE FS BIO-SET 108 KOMBIGLYZE XR 43 KONSYL 112 KONSYL DAILY FIBER 112 KOVALTRY 108 KP PRENATAL MULTIVITAMINS 179

Index 24

KPN PRENATAL 179 KRINTAFEL 57 KROGER AUTOLET LANCING DEVICE 124 KROGER HEALTHPRO TWIST LANCETS/26G 124 KROGER HEALTHPRO TWIST LANCETS/30G 124 KROGER HEALTHPRO TWIST LANCETS/33G 124 KROGER INSULIN

KROGER PEN NEEDLES/31GX3/16" 146 KROGER PEN NEEDLES/31GX5/16" 146 KROGER PEN NEEDLES/32GX5/32" 146 KROGER PEN NEEDLES/33GX5/32" 146 KRYSTEXXA 107 KUVAN 102 KYLEENA 85

LANCETS SAFETY SEAL 28G LANCETS THIN LANCETS ULTRA THIN LANCING DEVICE LANCING DEVICE ADJUSTABLE lanolin LANOXIN LANOXIN PEDIATRIC

124 124 124 124

124 190

81 81

SYRINGE/0.3ML/29G X1/2"KROGER INSULIN

145 KYMRIAH KYNAMRO

59 51

lansoprazole lanthanum carbonate

197 106

SYRINGE/0.3ML/30G X5/16"KROGER INSULIN SYRINGE/0.3ML/31G X5/16"KROGER INSULIN SYRINGE/0.5ML/29G X1/2"KROGER INSULIN SYRINGE/0.5ML/30G X5/16"KROGER INSULIN

145

145

145

145

labetalol hcl LABETALOL HYDROCHLORIDE LAC-HYDRIN LAC-HYDRIN TWELVE lactic acid (ammoniumlactate) lactulose lactulose (encephalopathy) LAMICTAL

78

78 96 96

96 113

106 38

LANTUS 46 LANTUS SOLOSTAR 46 LANZO 124 LASIX 99 LASTACAFT 188 LATANOPROST 188 latanoprost 188 LATUDA 64 LAZANDA 23 LEADER ADVANCED LANCING

SYRINGE/0.5ML/31G X5/16" 145 KROGER INSULIN SYRINGE/1ML/29G X 1/2" 145 KROGER INSULIN SYRINGE/1ML/30G X5/16" 145 KROGER INSULIN SYRINGE/1ML/31G X5/16" 145 KROGER LANCETS 124 KROGER LANCETS 21G 124 KROGER LANCETS MICRO THIN33G 124 KROGER LANCETS SUPER THIN 124 KROGER LANCETS THIN 124 KROGER LANCETS THIN 26G 124 KROGER LANCETS ULTRATHIN30G 124 KROGER LANCING DEVICE 124 KROGER PEN NEEDLES 29G X12MM 145 KROGER PEN NEEDLES 31G X8MM 145 KROGER PEN NEEDLES 31GX1/4" 146 KROGER PEN NEEDLES/31GX1/4" 146

LAMICTAL CHEWABLE DISPERSIBLE 37 LAMICTAL ODT 37,38 LAMICTAL STARTER/NOTTAKING CARBAMAZEPINE 38 LAMICTAL STARTER/TAKINGCARBAMAZEPINE/NOTTAKING VALPROATE 38 LAMICTAL STARTER/TAKINGVALPROATE 38 LAMICTAL XR 38 LAMISIL 49 lamivudine 75 lamivudine (hbv) 77 lamivudine-zidovudine 75 lamotrigine 38 LANCET DEVICE ADJUSTABLE 124 LANCET DEVICE WITH EJECTOR 124 LANCETS 124 LANCETS 26G TWIST TOP 124 LANCETS 28G 124 LANCETS 30G 124 LANCETS SAFETY SEAL 21G 124 LANCETS SAFETY SEAL 26G 124

DEVICE 124 LEADER INSULIN SYRINGE/0.3ML/29G X1/2" 146 LEADER INSULIN SYRINGE/0.3ML/30G X5/16" 146 LEADER INSULIN SYRINGE/0.3ML/31G X5/16" 146 LEADER INSULIN SYRINGE/0.5ML/28G X1/2" 146 LEADER INSULIN SYRINGE/0.5ML/29G X1/2" 146 LEADER INSULIN SYRINGE/0.5ML/30G X5/16" 146 LEADER INSULIN SYRINGE/0.5ML/31G X5/16" 146 LEADER INSULIN SYRINGE/1ML/28G X 1/2" 146 LEADER INSULIN SYRINGE/1ML/29G X 1/2" 146 LEADER INSULIN SYRINGE/1ML/30G X5/16" 146 LEADER INSULIN SYRINGE/1ML/31G X5/16" 146

Index 25

LEADER QUICK DISSOLVE GLUCOSE 44 LEADER UNIFINE PENTIPS PLUS/MINI/31GX3/16" 146 LEADER UNIFINE PENTIPS PLUS/SHORT/31GX5/16" 146 LEADER UNIFINE PENTIPS/MINI/31GX3/16" 146 LEADER UNIFINE PENTIPS/NANO/32GX5/32"

146 LEADER UNIFINE PENTIPS/PLUS/32GX5/32"

146 LEDIPASVIR/SOFOSBUVIR

77 leflunomide 21 LEMTRADA 192 LENVIMA 10 MG DAILY DOSE 61 LENVIMA 12MG DAILY DOSE 61 LENVIMA 14 MG DAILY DOSE 61 LENVIMA 18 MG DAILY DOSE 61 LENVIMA 20 MG DAILY DOSE 61 LENVIMA 24 MG DAILY DOSE 61 LENVIMA 4 MG DAILY DOSE 61 LENVIMA 8 MG DAILY DOSE 61 LESCOL XL 52 LETAIRIS 82 letrozole 59 LEUCOVORIN CALCIUM 62 leucovorin calcium 62 LEUKERAN 58 LEUKINE 110 leuprolide acetate 59 levalbuterol hcl 34 LEVALBUTEROL TARTRATE HFA 34 LEVAQUIN 104 LEVBID 196 LEVEMIR 46 LEVEMIR FLEXTOUCH 46 LEVETIRACETAM 38 levetiracetam 38 levetiracetam in sodium chloride 38 levobunolol hcl 184

LEVOBUNOLOL HCL 184 levocarnitine (metabolicmodifiers) 102 levofloxacin 104 levofloxacin (ophth) 185 levonorgestrel & ethestradiol 84 levonorgestrel (emergencyoc) 85 levonorgestrel-eth estradiol(triphasic) 84 levonorgestrel-ethinyl estradiol(91-day) 84 levonorgestrel-ethinyl estradiol(continuous) 84 LEVOPHED 201 levorphanol tartrate 23 LEVORPHANOL TARTRATE 23 LEVOTHYROXINE SODIUM 195 levothyroxine sodium 195 LEVSIN 196 LEVSIN/SL 196 LEVULAN KERASTICK 91 LEXAPRO 41 LEXETTE 95 LEXIVA 75 LIALDA 105 LIBERTY MINI LANCING DEVICE 124 LIBRAX 197 LIDOCAINE AND TETRACAINECREAM 97 LIDOCAINE HCL 32 lidocaine hcl 97 lidocaine hcl (cardiac) 32 lidocaine hcl (mouth-throat) 171 LIDOCAINE HCL JELLY 97 LIDOCAINE HCL-HYDROCORTISONE ACETATE WITH ALOE 28 LIDOCAINE HCL/HYDROCORTISONEACETATE 28 lidocaine in d5w 32 lidocaine-hydrocortisoneacetate (rectal) 28 lidocaine-prilocaine 97 LIFESTYLES ASSORTED COLORS 119 LIFESTYLES EXTRA STRENGTH 119

LIFESTYLES FORM FITTING 119 LIFESTYLES LUBRICATED 119 LIFESTYLES RIBBED 119 LIFESTYLES SKYN ORIGINAL 119 LIFESTYLES SPERMICIDALLYLUBRICATED

119 LIFESTYLES STUDDED 119 LIFESTYLES ULTRA SENSITIVE 119 LIFESTYLES ULTRA SENSITIVE/SPERMICIDE 119 LIFESTYLES VIBRA-RIBBED 119 LIFESTYLES VIBRA-RIBBED/SPERMICIDE 119 LIFESTYLES XTRA PLEASURE 119 LILETTA 85 LINDANE 97 linezolid 30 LINZESS 106 LIORESAL INTRATHECAL 181 liothyronine sodium 195 LIPITOR 53 LIPOFEN 52 lisinopril 53 lisinopril &hydrochlorothiazide 56 LITE TOUCH LANCING PEN 124 LITEAIRE 165 LITETOUCH INSULIN PEN NEEDLES/32G X4MM/MINI 146 LITETOUCH INSULIN SYRINGE/0.3ML/29G X1/2" 146 LITETOUCH INSULIN SYRINGE/0.3ML/30G X5/16" 146 LITETOUCH INSULIN SYRINGE/0.3ML/31G X5/16" 146 LITETOUCH INSULIN SYRINGE/0.5ML/30G X5/16" 146 LITETOUCH INSULIN SYRINGE/0.5ML/31G X5/16" 146 LITETOUCH INSULIN SYRINGE/1ML/30G X5/16" 146

Index 26

LITETOUCH INSULIN LITHOSTAT 107 LOTEMAX 186 SYRINGE/U-100/0.3ML/30G X5/16" 146 LITETOUCH INSULIN SYRINGE/U-100/0.3ML/31G X5/16" 147 LITETOUCH INSULIN SYRINGE/U-100/0.5ML/28G X1/2" 147 LITETOUCH INSULIN SYRINGE/U-100/0.5ML/29G X1/2" 147 LITETOUCH INSULIN

LITTLE COLDS DECONGESTANTFORMULA

183 LIVALO 53 LIVE BETTER ADVANCED LANCING DEVICE 124 LIVE BETTER LANCET SUPERTHIN 30G 124 LIVE BETTER LANCET ULTRATHIN 28G 124 LO LOESTRIN FE 84

LOTEMAX SM 186 LOTENSIN 53 LOTENSIN HCT 56 loteprednol etabonate 187 LOTREL 56 LOTRIMIN AF 90 LOTRIMIN AF JOCK ITCH 90 LOTRIMIN ULTRA 90 LOTRISONE 90

SYRINGE/U-100/0.5ML/30G X5/16" 147 LITETOUCH INSULIN SYRINGE/U-100/0.5ML/31G X5/16" 147 LITETOUCH INSULIN SYRINGE/U-100/1ML/28G X1/2" 147 LITETOUCH INSULIN

LOCOID LOCOID LIPOCREAM LODINE LODOSYN LOESTRIN 1.5/30-21 LOESTRIN 1/20-21 LOESTRIN FE 1.5/30

95 95 21 62 84 84 84

LOTRONEX lovastatin LOVAZA LOVENOX loxapine succinate LUCEMYRA LULICONAZOLE

106 53 51 36 68

190 91

SYRINGE/U-100/1ML/29G X1/2" 147 LITETOUCH INSULIN SYRINGE/U-100/1ML/30G X5/16" 147 LITETOUCH INSULIN SYRINGE/U-100/1ML/31G X5/16" 147 LITETOUCH MASK LARGE 165 LITETOUCH MASK MEDIUM 165 LITETOUCH MASK SMALL165 LITETOUCH PEN NEEDLES 29GX12.7MM 147 LITETOUCH PEN NEEDLES 31G X 6MM 147 LITETOUCH PEN NEEDLES 31G X 6MM/ULTRASHORT 147 LITETOUCH PEN NEEDLES 31GX8MM SHORT 147 LITETOUCH PEN NEEDLES/31G X 3/16" 147 LITETOUCH PEN NEEDLES/31G X5MM/MINI 147 LITETOUCH PEN NEEDLES/31G X8MM/SHORT 147 LITHIUM 63 lithium carbonate 63 LITHIUM CARBONATE 63 lithium carbonate 63 LITHOBID 63

LOESTRIN FE 1/20 84 LOKELMA 171 LOMOTIL 47 LONGS INSULIN SYRINGE/0.5ML/31G X5/16" 147 LONGS LANCETS STANDARD 124 LONGS LANCETS THIN 124 LONHALA MAGNAIR REFILL KIT 33 LONHALA MAGNAIR STARTER KIT 33 LONSURF 60 loperamide hcl 47 LOPID 52 lopinavir-ritonavir 75 LOPRESSOR 79 LOPRESSOR HCT 56 LOPROX 90 LOPROX KIT 90 LOPROX SHAMPOO 90 loratadine 51 loratadine & pseudoephedrine 88 lorazepam 31 LORBRENA 61 LORTAB 25 losartan potassium 54 losartan potassium &hydrochlorothiazide 56 LOSEASONIQUE 84

LUMIGAN LUNESTA LUPANETA PACK LUPRON DEPOT (1-MONTH)LUPRON DEPOT (3-MONTH)LUPRON DEPOT (4-MONTH)LUPRON DEPOT (6-MONTH)LUPRON DEPOT-PED (1-MONTH)LUPRON DEPOT-PED (3-MONTH) LUTATHERA LUXIQ LUXTURNA LUZU LYNPARZA LYRICA LYRICA CR LYSODREN LYSTEDA M-M-R II M-NATAL PLUS M-VIT MACROBID MACRODANTIN mafenide acetate MAG-AL

188 112 101

59

59

59

59

102

102 62 95

186 91 61 38

193 59

111 199 179 179 198 198

92 28

Index 27

MAGELLAN INSULIN SAFETY MAXZIDE 99 MEKTOVI 61 SYRINGE/U-100/0.3ML/29G X1/2" 147 MAGELLAN INSULIN SAFETY SYRINGE/U-100/0.3ML/30G X5/16" 147 MAGELLAN INSULIN SAFETY SYRINGE/U-100/0.5ML/29G X1/2" 147 MAGELLAN INSULIN SAFETY

MAXZIDE-25 MAYZENT MAYZENT STARTER PACK meclizine hcl MECLOFENAMATE SODIUM MEDIC INSULIN

99 192

192 48,49

21

meloxicam melphalan memantine hcl MENACTRA MENEST MENOSTAR MENTAX

21 58

191 199 104 104

91 SYRINGE/U-100/0.5ML/30G X5/16" 147 MAGELLAN INSULIN SAFETY

SYRINGE/0.3ML/30G X5/16"MEDIC INSULIN

148 MENVEO MEPERIDINE HCL

199 23

SYRINGE/U-100/1ML/29G X1/2" 147 MAGELLAN INSULIN SAFETY SYRINGE/U-100/1ML/30G X5/16" 147 magnesium citrate 113 magnesium hydroxide 113 MAKENA 190

SYRINGE/0.5ML/30G X5/16" 148 MEDICINE SHOPPE PEN NEEDLES 29G X 12MM 148 MEDICINE SHOPPE PEN NEEDLES 31G X 6MM 148 MEDICINE SHOPPE PEN NEEDLES 31G X 8MM 148 MEDISENSE THIN

meperidine hcl MEPHYTON meprobamate MEPRON mercaptopurine mesalamine mesalamine w/ cleanser

23 201

31 29 59

105 105

MALARONE 57 LANCETS 124 MESNEX 62 malathion 97 MEDROL 86 MESTINON 58 MAPROTILINE HCL 40 MEDROL DOSEPAK 86 MESTINON TIMESPAN 58 MARATHON MEDICAL PENTIPS29GX12MM MARATHON MEDICAL PENTIPS31GX5MM MARATHON MEDICAL

147

147

medroxyprogesterone acetate 190 medroxyprogesterone acetate(contraceptive) 85 mefenamic acid 21

METAMUCIL METAMUCIL ORIGINAL TEXTURE METAPROTERENOL SULFATE

112

112

34 PENTIPS31GX8MM MARATHON MEDICAL PENTIPS32GX4MM

147

147

MEFLOQUINE HCL MEGACE ES

57 190

METAXALONE metaxalone

181 181

MARPLAN 40 MATULANE 62 MAVENCLAD 192 MAVYRET 77 MAXALT 168 MAXALT-MLT 168 MAXI-COMFORT INSULIN SYRINGE/U-100/0.5ML/28GX1/2" 147 MAXI-COMFORT INSULIN SYRINGE/U-100/1ML/28GX1/2"

147 MAXICOMFORT II PEN NEEDLES/31G X 1/4" 148 MAXICOMFORT INSULIN SYRINGES 27G X 1/2" 148 MAXIDEX 187 MAXIPIME 83 MAXITROL 187 MAXX LUBRICATED 119 MAXX PLUS SPERMICIDE LUBRICATED 119

megestrol acetate 60 megestrol acetate(appetite) 190 MEIJER ALCOHOL SWABS EXTRA-THICK 129 MEIJER COLOR LANCETS UNIVERSAL 33G 125 MEIJER LANCETS 125 MEIJER LANCETS THIN 125 MEIJER LANCETS UNIVERSAL21G 125 MEIJER LANCETS UNIVERSAL30G 125 MEIJER LANCETS UNIVERSAL33G 125 MEIJER PEN NEEDLES 29G X12MM 148 MEIJER PEN NEEDLES 31G X6MM 148 MEIJER PEN NEEDLES 31G X8MM 148 MEIJER SUPER THIN LANCETS 125 MEKINIST 61

metformin hcl 44 METFORMIN HYDROCHLORIDE 44 methadone hcl 23 METHADONE HCL 23 methadone hcl 23 METHADONE HCL 23 methadone hcl 23 METHADOSE 23 METHADOSE SUGAR-FREE 23 methamphetamine hcl 6 methazolamide 99 methenamine mandelate 198 methenamine-hyosc-methyleneblue-sod phos-phenyl sal 198 methimazole 195 METHITEST 27 methocarbamol 181 METHOTREXATE 20 methotrexate sodium 59

Index 28

METHOTREXATE SODIUM 59 miconazole nitrate (topical)91 MIRAPEX 63 methotrexate sodium 59 miconazole nitrate MIRAPEX ER 63 methoxsalen rapid 92 vaginal 200 MIRASORB SPONGES 2" X

MICONAZOLE NITRATE/ZINC 2" 117methscopolamine bromide 197 OXIDE/WHITE MIRASORB SPONGES 4" XMETHSCOPOLAMINE PETROLATUM 91 4" 117BROMIDE 197 MICROCHAMBER 165 MIRCERA 110METHYCLOTHIAZIDE 100 MICRODOT PEN MIRCETTE 84methyldopa 55 NEEDLE/31G X 6 MM 148 MIRENA 85METHYLDOPA/HYDROCHLOR MICRODOT PEN OTHIAZIDE 56 NEEDLE/32G X 4 MM 148 mirtazapine 40

MICRODOT PENMETHYLDOPATE HCL 55 MIRVASO 97NEEDLE/33G X 4 MM 148methylergonovine maleate 189 misoprostol 198MICROELITE FILTER

METHYLIN 14 REPLACEMENTS 165 MITIGARE 107 methylphenidate hcl 15,16 MICROELITE MM INSULIN SYRINGE/U-METHYLPHENIDATE RECHARGEABLE 100/0.3ML/30G X 5/16" 148

BATTERY 165 MM INSULIN SYRINGE/U-HYDROCHLORIDE ER 17 MICROLET NEXT 125 100/0.3ML/31G X 5/16" 148methylprednisolone 86 MM INSULIN SYRINGE/U-

methylprednisolone acetate 86 MICROSPACER 165 100/1/2ML/30G X 5/16" 148 METHYLPREDNISOLONE MICROZIDE 100 MM INSULIN SYRINGE/U-ACETATE 86 MIDAZOLAM HCL 112 100/1/2ML/31G X 5/16" 148 methylprednisolone sod MM INSULIN SYRINGE/U-midazolam hcl 112 succ 86 100/1ML/30G X 5/16" 148midodrine hcl 201METHYLTESTOSTERONE 27 MM INSULIN SYRINGE/U-

MIGERGOT 167 100/1ML/31G X 5/16" 148METIPRANOLOL 184 miglitol 43 MM LANCING DEVICE 125metoclopramide hcl 105 miglustat 110 MM PEN NEEDLES 31G Xmetolazone 100 1/4" 148MIGRANAL 168metoprolol & MM PEN NEEDLES 31G X

hydrochlorothiazide 56 MIGRANOW 167 3/16" 148 metoprolol succinate 79 MILLIPRED 87 MM PEN NEEDLES 31G X METOPROLOL SUCCINATE 5/16" 148MILLIPRED DP 86ER/HYDROCHLOROTHIAZIDE MM PEN NEEDLES 32G Xmilrinone lactate 8156 5/32" 148

milrinone lactate inMETOPROLOL TARTRATE 79 MOBIC 21dextrose 81metoprolol tartrate 79 modafinil 17MINASTRIN 24 FE 84METOPROLOL/HYDROCHLOR MODERIBA 1200 DOSEMINI LANCING DEVICE 125OTHIAZIDE 56 PACK 77MINIELITE FILTER MODERIBA 800 DOSEMETROCREAM 97 REPLACEMENTS 165 PACK 77METROGEL 97 MINIELITE RECHARGEABLE moexipril hcl 53METROGEL-VAGINAL 200 BATTERY 165 moexipril-hydrochlorothiazide

METROLOTION 97 MINIPRESS 55 56 metronidazole 29 MINIVELLE 104 MOI-STIR 172 metronidazole (topical) 97 MINOCIN 194,195 MOLESKIN FOAM metronidazole vaginal 200 minocycline hcl 195 PADDING 117

MOLINDONEMINOCYCLINEMEXILETINE HCL 32 HYDROCHLORIDE 71HYDROCHLORIDEER 195mexiletine hcl 32 mometasone furoate 95MINOLIRA 195MIACALCIN 100 MONISTAT 3 200minoxidil 57MICARDIS 54 MONISTAT 7 SIMPLYMIOCHOL-E 185 CURE 200MICARDIS HCT 56 MIOSTAT 185 MONISTAT SOOTHING CAREMICATIN 91 MIRALAX 113 ITCH RELIEF 95MICONAZOLE 3 200 MONOCLATE-P 108

Index 29

MONOJECT BLUNTIP MONOJECT INSULIN MONOJECT ULTRA COMFORT SYRINGE/3ML/CANNULA/IV SYRINGE/U-100/1ML/30G X INSULIN SYRINGE/1ML/29G XACCESS 148 5/16" 149 1/2" 150 MONOJECT HYPO/ALUM MONOJECT INSULIN MONOLET LANCETS 125 HUB/18G X 1-1/2" 148 SYRINGEREGULAR LUER MONOLET OPD LANCETS125MONOJECT HYPO/ALUM TIP/SOFTPACK/1ML 149 MONONINE 108HUB/LUER LOCK/SHORT MONOJECT MAGELLAN BEVEL/18G X 1-1/2" 148 SAFETYNEEDLE 18GX1- montelukast sodium 33 MONOJECT 1/2" 149 MONUROL 198HYPO/POLYPROPYLENE MONOJECT PHARMACY MORGIDOX 1X100MG 195HUB/18G X 1-1/2" 148 TRAY/LUER LOCK/3ML 149 MONOJECT MONOJECT STANDARD MORGIDOX 1X50MG KIT 195 HYPO/POLYPROPYLENE HYPODERMIC MORGIDOX 2X100MG 195 HUB/LL/SHORT BEVEL/18G X NEEDLE/POLYPROPYLENE/1 MORPHABOND ER 231-1/2" 148 8GX1-1/2" 149 morphine sulfate 24MONOJECT INSULIN MONOJECT SYRINGE/LUERSYRINGE/1ML 148 LOCK/3ML 149 MORPHINE SULFATE 24 MONOJECT INSULIN MONOJECT SYRINGE/LUER- morphine sulfate 24 SYRINGE/1ML/31G X LOCK TIP/3ML 149 MORPHINE SULFATE 245/16" 148 MONOJECT SYRINGE/REGMONOJECT INSULIN LUER/3ML 149 morphine sulfate 24 SYRINGE/DETACH MONOJECT MORPHINE SULFATE ER 24 NEEDLE/1ML/25G X 5/8" 148 SYRINGE/REGULARTIP/3ML MOTEGRITY 104MONOJECT INSULIN 149 MOTRIN CHILDRENS 21SYRINGE/DETACH MONOJECT ULTRA NEEDLE/1ML/27G X 1/2" 149 COMFORT INSULIN MOTRIN INFANTS DROPS 21 MONOJECT INSULIN SYRINGE/0.3ML/29G X MOUTH KOTE 172 SYRINGE/PERM 1/2" 149 MOUTH KOTE REMINT 172NEEDLE/1ML/28G X 1/2" 149 MONOJECT ULTRA

MOVANTIK 106MONOJECT INSULIN COMFORT INSULIN SYRINGE/PERM NEEDLE/U- SYRINGE/0.3ML/30G X MOVIPREP 112 100/0.5ML/28G X 1/2" 149 5/16" 149 MOXEZA 185MONOJECT INSULIN MONOJECT ULTRA moxifloxacin hcl 104SYRINGE/SAFETY/PERM COMFORT INSULIN NEEDLE/0.3ML/29G X 1/2" 149 SYRINGE/0.3ML/31G X moxifloxacin hcl (ophth) 185 MONOJECT INSULIN 5/16" 149 MS CONTIN 24 SYRINGE/SAFETY/PERM MONOJECT ULTRA MS INSULIN NEEDLE/0.3ML/29GX1/2" 149 COMFORT INSULIN SYRINGE/0.3ML/31G XMONOJECT INSULIN SYRINGE/0.5ML/28G X 5/16" 150SYRINGE/SAFETY/PERM 1/2" 149 MS INSULIN NEEDLE/0.5ML/29G X 1/2" 149 MONOJECT ULTRA SYRINGE/0.5ML/31G XMONOJECT INSULIN COMFORT INSULIN 5/16" 150SYRINGE/SAFETY/PERM SYRINGE/0.5ML/29G X MS INSULIN SYRINGE/1ML/31GNEEDLE/1ML/29G X 1/2" 149 1/2" 149 X 5/16" 150MONOJECT INSULIN MONOJECT ULTRA MUCINEX 88SYRINGE/SOFTPACK/1ML/27G COMFORT INSULIN MUCINEX MAXIMUMX 1/2" 149 SYRINGE/0.5ML/30G X STRENGTH 88MONOJECT INSULIN 5/16" 150 MULPLETA 110SYRINGE/SOFTPACK/U- MONOJECT ULTRA 100/0.5ML/28G X 1/2" 149 COMFORT INSULIN MULTAQ 32 MONOJECT INSULIN SYRINGE/0.5ML/31G X MULTI PRENATAL 179 SYRINGE/U-100/0.3ML/30G X 5/16" 150 MULTI-LANCET DEVICE 1255/16" 149 MONOJECT ULTRA multiple vitamins w/MONOJECT INSULIN COMFORT INSULIN minerals 174,175SYRINGE/U-100/0.5ML/30G X SYRINGE/1ML/28G X MULTIVITAMIN ADULT 1755/16" 149 1/2" 150 MULTIVITAMIN ADULTMONOJECT INSULIN SYRINGE/U-100/1ML/28G X EXTRAVITAMIN C 175 1/2" 149

Index 30

MULTIVITAMIN/FLUORIDE176

MUPIROCIN 90 mupirocin 90 mupirocin calcium (topical) 90 MVW COMPLETE FORMULATION 176 MYAMBUTOL 58 MYCAMINE 49 MYCOBUTIN 58 mycophenolate mofetil 171 mycophenolate sodium 171 MYDAYIS 6 MYDRIACYL 185 MYFORTIC 171 MYLERAN 58 MYLICON INFANTS GAS RELIEF 105 MYLICON INFANTS GAS RELIEF DYE FREE 105 MYNATAL 179 MYNATAL ADVANCE 179 MYNATAL PLUS 179 MYNATAL ULTRACAPLET 179 MYNATAL-Z 179 MYNATE 90 PLUS 179 MYRBETRIQ 199 MYSOLINE 38 nabumetone 21 nadolol 79 NADOLOL/BENDROFLUMETHIAZIDE 56 naftifine hcl 91 NAFTIN 91 NALFON 21 NALOXONE HCL 48 naloxone hcl 48 naltrexone hcl 48 NAMENDA 191 NAMENDA TITRATION PAK 191 naphazoline w/pheniramine 186 NAPHCON-A 186 NAPROSYN 21 naproxen 21 naproxen sodium 21 naratriptan hcl 168 NARCAN 48

NARDIL 40 NASACORT ALLERGY 24HR 183 NATACYN 185 NATALVIT 179 NATAZIA 84 nateglinide 47 NATESTO 27 NATPARA 100 NATROBA 97 NATURE-THROID 195 NAYZILAM 37 NEBULIZER AIR TUBE/PLUGS 165 NEBULIZER PEDIATRIC MASK 165 NEBUPENT 29 NEFAZODONE HCL 41 nefazodone hcl 41 NEFAZODONE HYDROCHLORIDE 41 NEMBUTAL SODIUM 111 NEO-SYNALAR 90 NEO-SYNALAR KIT 90 neomycin sulfate 19 neomycin-bacitracin zn-polymyxin 185 neomycin-polymy-dexameth 187 neomycin-polymyxin-hc(otic) 188 NEOMYCIN/POLYMYXIN/GRAMICIDIN 185 NEOMYCIN/POLYMYXIN/HYDROCORTISONE 187 NEONATAL COMPLETE 179 NEONATAL PLUS 179 NEONATAL VITAMIN 179 NEORAL 171 NEOSPORIN 185 NEOSTIGMINE METHYLSULFATE 58 neostigmine methylsulfate 58 NEPHRO-VITE 173 NEPHRO-VITE RX 173 NEPHROCAPS 173 NEPTAZANE 99 NERLYNX 61 NESINA 44 NESTABS ONE 179

NEULASTA 110 NEULASTA ONPRO KIT 110 NEUPOGEN 110 NEUPRO 63 NEURONTIN 38 NEVANAC 188 nevirapine 75 NEVIRAPINE ER 75 NEXAVAR 61 NEXCARE ABSOLUTE WATERPROOF PAD 117 NEXIUM 24HR 197 NEXPLANON 85 NEXTERONE 32 NIACIN 53 niacin 201 niacin (antihyperlipidemic) 53 NIACIN TR 202 NIACOR 53 NIASPAN 53 NICADAN 176 NICADAN ZX 176 nicardipine hcl 80 NICAZEL 176 NICAZEL FORTE 176 NICODERM CQ 193 NICORETTE 193 NICORETTE MINI 193 NICORETTE STARTER KIT 193 nicotine 193 nicotine polacrilex 193 NICOTINE TRANSDERMAL SYSTEM 193 NICOTROL INHALER 193 NICOTROL NS 193 nifedipine 80 NILANDRON 60 nilutamide 60 nimodipine 80 NINLARO 61 NIPRIDE RTU 57 nisoldipine 81 NISOLDIPINE ER 80 nitisinone 102 NITRO-BID 30 NITRO-DUR 30

Index 31

NITRO-TIME 30 nitrofurantoin 198 nitrofurantoin macrocrystal 198 nitrofurantoin monohyd macro 198 nitroglycerin 31 NITROGLYCERIN 31 nitroglycerin 31 NITROGLYCERIN IN

norgestimate-ethinyl estradiol(triphasic) 84 norgestrel & ethinylestradiol 84 NORITATE 97 NORPACE 32 NORPACE CR 32 NORPRAMIN 42 NORTEMP INFANTS 22

NU GAUZE GENERAL-USE SPONGES 4"X4" 4 PLY 118 NUBEQA 60 NUCALA 32 NUCYNTA 24 NUCYNTA ER 24 NUEDEXTA 193 NULYTELY/FLAVORPACKS 112

DEXTROSE 5% 30 NORTHERA 201 NUMOISYN 172 NITROLINGUAL PUMPSPRAY 31 NITROMIST 31 NITROPRESS 57 nitroprusside sodium 57 NITROSTAT 31 NITYR 102 NIVA-PLUS 179 NIVESTYM 110 NIX CREME RINSE 97 NIZORAL 91 NOCDURNA 103 NOCTIVA 103 NOKOR ADMIX NEEDLE THIN WALL NON-CORING 18G X 1-

nortriptyline hcl 42 NORTRIPTYLINE HCL 43 NORVASC 81 NORVIR 75 NOSE CLIP 165 NOVA SUREFLEX LANCETS 125 NOVA SUREFLEX LANCING DEVICE 125 NOVAREL 101 NOVOEIGHT 108 NOVOFINE 32GX6MM 150 NOVOFINE AUTOCOVER 30GX8MM 150 NOVOFINE PLUS 32GX4MM 150

NUPLAZID 64 NUTRICAP 176 NUTROPIN AQ NUSPIN 10 101 NUTROPIN AQ NUSPIN 20 101 NUTROPIN AQ NUSPIN 5 101 NUVARING 85 NUVESSA 200 NUVIGIL 17 NUWIQ 108 NUZYRA 194 NYMALIZE 81 nystatin 49 nystatin (mouth-throat) 172

1/2" 150 NOKOR VENTED NEEDLE THINWALL NON-CORING 18GX1-1/2" 150 nonoxynol-9 200 NORCO 25 NORDITROPIN FLEXPRO 101

NOVOLIN 70/30 46 NOVOLIN 70/30FLEXPEN 46 NOVOLIN 70/30 FLEXPENRELION 46 NOVOLIN 70/30 RELION 46 NOVOLIN N 46

nystatin (topical) nystatin-triamcinolone O-CAL FA O-CAL PRENATAL OBIZUR OBTREX

91 91

179 179 108 179

norepinephrine bitartrate norethin acet & estrad-fe

201 84

NOVOLIN N FLEXPEN NOVOLIN N FLEXPEN

46 OBTREX DHA OCALIVA

179 105

norethindrone & eth estradiol84 norethindrone & ethinyl estradiol-fe 84 norethindrone (contraceptive) 85 norethindrone acet & eth estra 84

RELION NOVOLIN N RELION NOVOLIN R NOVOLIN R RELION NOVOLOG NOVOLOG FLEXPEN

46 46 46 46 46 46

OCEAN NASAL SPRAY OCREVUS OCTREOTIDE ACETATE octreotide acetate OCUFLOX ODEFSEY

182 192 103 103 185

75 norethindrone acetate 190 norethindrone acetate-ethinylestradiol 103 norethindrone acetate-ethinylestradiol-fe 84 norethindrone-eth estradiol (triphasic) 84 NORGESIC FORTE 182 norgestimate-ethinylestradiol 84

NOVOLOG MIX 70/30 46 NOVOLOG MIX 70/30PREFILLED FLEXPEN 46 NOVOLOG PENFILL 46 NOVOSEVEN RT 108 NOVOTWIST 32GX5MM 150 NOXAFIL 50 NPLATE 110 NU GAUZE 4PLY 4"X4" 117

ODOMZO OFEV OFLOXACIN ofloxacin ofloxacin (ophth) ofloxacin (otic) OGESTREL olanzapine

59 194 104 104 185 188

84 68,69

olanzapine-fluoxetine hcl 191

Index 32

olmesartan medoxomil 54 ONE-A-DAY VITACRAVES OPTIONS GYNOL II olmesartan medoxomil-amlodipine-hydrochlorothiazide

56 olmesartan medoxomil-hydrochlorothiazide 56 olopatadine hcl 188 olopatadine hcl (nasal) 182 OLUMIANT 19 OLUX 95 OLUX-E 95 OLYSIO 77

SOURGUMMIES 176 ONE-A-DAY VITACRAVES WOMENS MULTI 176 ONE-A-DAY WOMENS 50+ HEALTHY ADVANTAGE 176 ONE-A-DAY WOMENS PRENATAL 179 ONE-A-DAY WOMENS VITACRAVES GUMMIES 176 ONETOUCH DELICA LANCING DEVICE 125 ONETOUCH DELICA PLUS LANCING DEVICE 125

VAGINALCONTRACEPTIVE 200

OPTISOURCE POST BARIATRIC SURGERY 176 OPURITY/BYPASSOPTIMIZED 176 ORACEA 97 oral electrolytes 170 ORAL RELIEF SPRAY FOR DRYMOUTH & DISCOMFORT 172 ORALAIR 18

OMECLAMOX-PAK omega-3-acid ethyl esters omeprazole OMEPRAZOLE

198 51

197 198

ONFI ONGLYZA ONMEL ONZETRA XSAIL

37 44 50

168

ORALAIR ADULT SAMPLE KIT 18 ORALAIR ADULT STARTER PACK 18 ORALAIR

OMEPRAZOLE + SYRSPEND SFALKA 197 omeprazole magnesium 198 OMNARIS 183 OMNIPRED 187 OMNITROPE 101 ON CALL LANCING DEVICE 125 ON CALL PLUS LANCING DEVICE 125 ondansetron 48 ondansetron hcl 48

OPANA 24 OPANA ER (CRUSHRESISTANT) 24 OPSUMIT 82 OPTICHAMBER ADVANTAGE/LARGEMASK 165 OPTICHAMBER ADVANTAGE/MEDIUM FACEMASK 165 OPTICHAMBER ADVANTAGE/SMALL FACEMASK 165

CHILDREN/ADOLESCENTSSAMPLE KIT 18 ORALAIR CHILDREN/ADOLESCENTSSTARTER PACK 18 ORAP 193 ORAPRED ODT 87 ORENCIA 21 ORENCIA CLICKJECT 21 ORENITRAM 81 ORFADIN 102 ORILISSA 101

ONDANSETRON HCL 48 ondansetron hcl 48 ONDANSETRON HYDROCHLORIDE 48 ONE A DAY MENS VITACRAVES MULTI GUMMIES 176 ONE A DAY WOMENS PRENATAL/DHA 179 ONE A DAY WOMENS PRENATAL1 179 ONE-A-DAY FOR HER VITACRAVES TEEN MULTI GUMMIES 176 ONE-A-DAY FOR HIM/VITACRAVES TEEN MULTIGUMMIES 176 ONE-A-DAY MENS VITACRAVES GUMMIES 176 ONE-A-DAY VITACRAVES 176 ONE-A-DAY VITACRAVES ADULT 176 ONE-A-DAY VITACRAVES

OPTICHAMBER DIAMOND 166 OPTICHAMBER DIAMOND/LARGEFACEMASK 166 OPTICHAMBER DIAMOND/MEDIUM FACEMASK 166 OPTICHAMBER DIAMOND/SMALLFACEMASK 166 OPTICHAMBER FACE MASK/LARGE 166 OPTICHAMBER FACE MASK/MEDIUM 166 OPTICHAMBER FACE MASK/SMALL 166 OPTIFOAM 118 OPTIHALER 166 OPTIHALER MDI DRUG DELIVERY SYSTEM 166 OPTIMUM AIRVITES 176 OPTIONS CONCEPTROL

ORKAMBI 194 orphenadrine citrate 182 ORPHENADRINE CITRATE/ASPIRIN/CAFFEINE

182 ORPHENGESIC FORTE 182 ORTHO MICRONOR 85 ORTHO TRI-CYCLEN 84 ORTHO TRI-CYCLEN LO 84 ORTHO-CYCLEN 85 ORTHO-NOVUM 1/35 85 ORTHO-NOVUM 7/7/7 85 oseltamivir phosphate 78 OSENI 43 OSMOLEX ER 63 OSMOPREP 113 OSPHENA 101 OTEZLA 21 OTIPRIO 188

GUMMIES/IMMUNITYSUPPORT 176

VAGINAL CONTRACEPTIVE 200

OTOVEL OTREXUP

188 20

Index 33

OVACE PLUS WASH 92 pantoprazole sodium 198 ped multivitamins w/fl &iron 178OVACE WASH 92 PARAGARD INTRAUTERINE

COPPER CONTRACEPTIVE PEDIALYTE 170OVIDE 98 T380A 85 PEDIALYTE ADVANCEDOXANDRIN 27 PAREGORIC 47 CARE 170 oxandrolone 27 PEDIALYTE FREEZERPARI ALTERA NEBULIZER

POPS 170oxaprozin 21 HANDSET 166 PARI BABY CONVERSION PEDIALYTE SINGLES 170OXAYDO 24 KITSIZE 1 166 PEDIAPRED 87oxazepam 31 PARI BABY CONVERSION PEDIATRICOXAZEPAM 31 KITSIZE 2 166 MOUTHPIECE/DISPOSABLE

oxcarbazepine 38 PARI BABY CONVERSION 166 OXERVATE 186 KITSIZE 3 166 pediatric multiple vitamins w/

PARI ERAPID NEBULIZER iron 178oxiconazole nitrate 91 HANDSET 166 pediatric multivitamins w/fl 177OXISTAT 91 PARI EXPIRATORY FILTER pediatric vitamins acd w/VALVE SET 166OXSORALEN ULTRA 92 fluoride 177PARI MASK SET 166OXTELLAR XR 38 pediatric vitamins adc 178PARI SOFT PLASTIC ADULToxybutynin chloride 198 PEDVAX HIB 199MASK 166 oxycodone hcl 24 PARI SOFT PLASTIC peg 3350-kcl-sod bicarb-sod

chloride-sod sulfate 112OXYCODONE HCL ER 24 PEDIATRIC MASK 166 PARI VORTEX ADULT peg 3350-potassium chloride-sodOXYCODONE MASK 166 bicarbonate-sod chloride 113HYDROCHLORIDE ER 24

oxycodone w/ paricalcitol 102 PEGANONE 39 acetaminophen 25 PARLODEL 63 PEGASYS 77 oxycodone-aspirin 25 PARNATE 40 PEGASYS PROCLICK 77 OXYCODONE/ACETAMINOPHE paromomycin sulfate 19 PEGINTRON 77N 25 PAROMOMYCIN PEN NEEDLES 29G XOXYCODONE/ASPIRIN 25 SULFATE 19 12MM 150 OXYCODONE/IBUPROFEN 25 paroxetine hcl 41 PEN NEEDLES 29GX1/2" 150 OXYCONTIN 24 paroxetine mesylate PEN NEEDLES 30GX5/16" 150

(vasomotor) 193oxymorphone hcl 24 PEN NEEDLES 30GX8MM 150 OXYMORPHONE PARVA-CAL 169 PEN NEEDLES 31G X 1/4"HYDROCHLORIDE ER 24 PASER 58 SHORT 150 OXYMORPHONE PEN NEEDLES 31G XPATADAY 188HYDROCHLORIDEER 24 3/16" 150PATANASE 182oyster shell 169 PEN NEEDLES 31G X

PATANOL 188 5MM 150OZEMPIC 45 PATIENT SAFE SYRINGE PEN NEEDLES 31G XPA PRENATAL FORMULA 179 3ML 150 6MM 150 paliperidone 65 PAXIL 41 PEN NEEDLES 31G X palonosetron hcl 48 PAXIL CR 41 8MM 150 PALONOSETRON PEN NEEDLES 31GX5/16" 150PAZEO 188HYDROCHLORIDE 48 PEN NEEDLES 31GX6MMPC LANCETS SUPER THINPALYNZIQ 102 (1/4") 15030G 125 PEN NEEDLES 31GX8MM 150PAMELOR 43 PC UNIFINE PENTIPS 29G

PEN NEEDLES 31GX8MMpamidronate disodium 100 X1/2" 150 PC UNIFINE PENTIPS 31G (5/16") 150PAMIDRONATE PEN NEEDLES 32G XX5MM MINI 150DISODIUM 100 4MM 150PC UNIFINE PENTIPS 31GPANCREAZE 99 PEN NEEDLES 32G XX6MM ULTRA SHORT 150

PANDEL 95 5MM 150PC UNIFINE PENTIPS 31G PEN NEEDLES 32G XPANHEMATIN 109 X8MM SHORT 150 6MM 150PANRETIN 91 PCE 114 PEN NEEDLES 32GX4MM 150

Index 34

PEN NEEDLES 33G X perphenazine 71,72 piperacillin sodium-tazobactam5/32" 150 PERPHENAZINE/AMITRIPTYL sodium 190 PEN NEEDLES/29G X 1/2" 150 INE 191 PIQRAY 200MG DAILY

DOSE 61PEN NEEDLES/31G X 1/4" 150 PERRY PRENATAL 179 PIQRAY 250MG DAILYPEN NEEDLES/31G X PERSERIS 65 DOSE 613/16" 151 PERTZYE 99 PIQRAY 300MG DAILYPEN NEEDLES/31G X DOSE 61PETROLATUM 965/16" 151 piroxicam 21PEN NEEDLES/32G X PEXEVA 41 5/32" 151 PLAN B ONE-STEP 85PFIZERPEN 189 penicillamine 170 PLAQUENIL 57PFLEX 166 penicillin g potassium 189 PLAVIX 109PHARMACY COUNTER PENICILLIN G POTASSIUM IN LANCETS 125 PLEGRIDY 192 ISO-OSMOTIC phenazopyridine hcl 107 PLEGRIDY STARTERDEXTROSE 189 PACK 192phenelzine sulfate 40PENICILLIN G PROCAINE 189 PLIAGLIS 97phenobarbital 111PENICILLIN G SODIUM 189 PNEUMOVAX 23 199PHENOBARBITALPENICILLIN V SODIUM 111 PNEUMOVAX 23/1 DOSE 199POTASSIUM 189 phenobarbital sodium 111 PNV FOLIC ACID + IRONpenicillin v potassium 189 MULTIVITAMIN 179phenoxybenzamine hcl 54PENLAC NAIL LACQUER 91 PNV PRENATAL PLUSphentolamine mesylate 54PENTAM 300 29 MULTIVITAMIN 179

phenylephrine hcl PNV TABS 29-1 179pentamidine isethionate 29 (mydriatic) 185 POCKET CHAMBER 166PENTASA 105 phenylephrine hcl(pressors) 201 POCKET SPACER 166pentazocine w/ naloxone 26 PHENYLEPHRINE podofilox 97PENTIPS 29G X 12MM 151 HYDROCHLORIDE 201 POLY HUB NEEDLE/18G X 1-1-PENTIPS 29GX12MM 151 PHENYTEK 39 1/2" 151

PENTIPS 31G X 5MM 151 phenytoin 39 POLY-VI-SOL/IRON 178 PENTIPS 31G X 8MM 151 phenytoin sodium 39 polyethylene glycol 3350 113 PENTIPS 31GX5MM 151 phenytoin sodium polyethylene glycol-propylenePENTIPS 31GX6MM 151 extended 39 glycol (ophth) 184

PHOSLYRA 106 POLYMEM DRESSING/3" XPENTIPS 31GX8MM 151 3" 118PHOSPHOLINE IODIDE 185PENTIPS 32G X 4MM 151 POLYMEM DRESSING/4" Xphytonadione 201PENTIPS 32GX4MM 151 4" 118 PICATO 91pentobarbital sodium 111 POLYMEM FILM DOT 118

pentoxifylline 109 PIFELTRO 75 POLYMEM NON-ADHESIVE PILLOW MASK/ADULT 166 PAD 118PEPCID 197 polymyxin b-trimethoprim 185PILLOW MASK/CHILD 166PEPCID AC 197 PILLOW POLYSPORIN 90PEPCID AC MAXIMUM MASK/PEDIATRIC 166 POLYTRIM 186STRENGTH 197

PEPCID COMPLETE 198 pilocarpine hcl 185 polyvinyl alcohol 184 pilocarpine hcl (oral) 172PEPTO-BISMOL 47 POMALYST 60 pimecrolimus 96PEPTO-BISMOL TO-GO 47 posaconazole 50

PERCOCET 25 PIMOZIDE 193 pot phosphate monobasic w/ sodpindolol 79 phosphate dibasic &PERFECT LANCETS 30G 125 monobasic 170pioglitazone hcl 45PERFOROMIST 34 potassium bicarbonate 170pioglitazone hcl-PERIDEX 172 glimepiride 43 potassium chloride 170

perindopril erbumine 54 pioglitazone hcl-metformin POTASSIUM CHLORIDE permethrin 98 hcl 43 ER 170

Index 35

potassium chloride PREDNISOLONE PREGNYL W/DILUENTmicroencapsulated crystals ACETATE 187 BENZYLALCOHOL/NACL 101 er 170 prednisolone sodium PREMARIN 104,200potassium citrate phosphate 87 PREMIUM CONDOMS(alkalinizer) 106 PREDNISOLONE SODIUM LUBRICATED 119 potassium citrate-citric acid 106 PHOSPHATE 87 PREMPHASE 103prednisolone sodiumPRADAXA 36 PREMPRO 103phosphate 87PRALUENT 53 PREDNISOLONE SODIUM PRENATABS FA 179 pramipexole dihydrochloride 63 PHOSPHATE 187 PRENATABS RX 179 PRAMOTIC 188 PREDNISONE 87 PRENATAL 180 PRANDIN 47 prednisone 87 PRENATAL 19 179 prasugrel hcl 109 PREDNISONE INTENSOL 87 PRENATAL AND IRON 179PREFERRED PLUS INSULINPRAVACHOL 53 PRENATAL COMPLETE 179SYRINGE/U-100/0.3ML/29G Xpravastatin sodium 53 1/2" 151 PRENATAL FORMULA 179 praziquantel 29 PREFERRED PLUS INSULIN PRENATAL FORMULA A-prazosin hcl 55 SYRINGE/U-100/0.3ML/30G X FREE 179

5/16" 151 PRENATAL FORTE 179PRE-NATAL FORMULA 179 PREFERRED PLUS INSULINPRECISION SURE-DOSE PRENATAL LOW IRON 179SYRINGE/U-100/0.5ML/28G XINSULIN SYRINGE/0.3ML/30G X PRENATAL MULTI + DHA 1791/2" 1515/16" 151 PREFERRED PLUS INSULIN PRENATAL MULTI +DHA 179PRECISION SURE-DOSE SYRINGE/U-100/0.5ML/29G X PRENATALINSULIN SYRINGE/0.5ML/28G X 1/2" 151 MULTIVITAMIN 1801/2" 151 PREFERRED PLUS INSULIN PRENATAL MULTIVITAMIN +PRECISION SURE-DOSE SYRINGE/U-100/0.5ML/30G X DHA 179INSULIN SYRINGE/0.5ML/29G X 5/16" 151 PRENATAL MULTIVITAMIN1/2" 151 PREFERRED PLUS INSULIN PLUS DHA 179PRECISION SURE-DOSE SYRINGE/U-100/1ML/28G X PRENATAL ONE DAILY 180INSULIN SYRINGE/0.5ML/30G X 1/2" 1513/8" 151 PRENATAL PLUS 180PREFERRED PLUS INSULINPRECISION SURE-DOSE PRENATAL PLUS IRON 180SYRINGE/U-100/1ML/29G XINSULIN SYRINGE/1ML/28G X 1/2" 151 PRENATAL VITAMIN 1801/2" 151 PREFERRED PLUS INSULIN PRENATAL VITAMIN &PRECISION SURE-DOSE SYRINGE/U-100/1ML/30G X MINERAL 180PLUSINSULIN 5/16" 151 PRENATALSYRINGE/0.3ML/29G X PREFERRED PLUS LANCETS VITAMIN/IRON 1801/2" 151 COLORED 21G 125 PRENATAL VITAMINS 180PRECISION SURE-DOSE PREFERRED PLUS LANCETS PRENATAL VITAMINS PLUSPLUSINSULIN SUPER THIN 30G 125SYRINGE/1ML/29G X 1/2" 151 LOW IRON 180PREFERRED PLUS LANCETSPRECISION THIN PRENATAL+DHA 180THIN 26G 125LANCETS 125 PRENATAL/OMEGA-3/FOLICPREFERRED PLUS UNIFINEPRECISION THINS GP ACID/IRON 180PENTIPS 29G X 12MM 151LANCET 125 PREFERRED PLUS UNIFINE PRENATVITE RX 180 PRECISION ULTRA PENTIPS 31G X 6MM ULTRA PREPLUS 180LANCET 125 SHORT 151 PREPOPIK 113PRECOSE 43 PREFERRED PLUS UNIFINE PRESERVISION AREDS 2 176PRED FORTE 187 PENTIPS 31G X 8MM

SHORT 151 PRESTALIA 56PRED MILD 187 PREFERRED PLUS UNIFINE PRETAB 180PRED-G 187 PENTIPS 32GX4MM 152 PRETOMANID 58PRED-G S.O.P. 187 PREFERRED PLUS UNIFINE PREDNICARBATE 95 PENTIPS/MINI/31GX5MM PREVACID 198

152 PREVACID 24HR 198PREDNISOLONE 87 PREFEST 103 PREVENT SAFETY PENprednisolone 87 pregabalin 38 NEEDLES 31GX1/4" 152

Index 36

PREVENT SAFETY PEN PROAIR DIGIHALER 34 promethazine-phenylephrine-NEEDLES 31GX5/16" 152 codeine 88PROAIR HFA 34PREVIDENT 5000 DRY PROMETHAZINE/DEXTROMET

PROAIR RESPICLICK 35MOUTH 172 HORPHAN 88 PREVIDENT 5000 PLUS 172 probenecid 108 PROMETHAZINE/PHENYLEPHR

PROBUPHINE IMPLANT INE 88PREVIDENT FLUORIDE 172 KIT 26 PROMETHAZINE/PHENYLEPHR

PREVIDENT RINSE 172 INE/CODEINE 88procainamide hcl 32PREVNAR 13 199 PROMETHEGAN 51PROCARDIA 81PREVPAC 198 PROMETRIUM 190PROCARDIA XL 81PREVYMIS 76 PRONEB ULTRA FILTERPROCARE SPACER SET 166PREZCOBIX 75 CHAMBER W/ADULT propafenone hcl 32PREZISTA 75 MASK 166

PROCARE SPACER PROPANTHELINEPRIFTIN 58 CHAMBER W/CHILD BROMIDE 197 PRILOSEC OTC 198 MASK 166 proparacaine hcl 186 primaquine phosphate 57 prochlorperazine 72 propranolol hcl 79 PRIMAQUINE PHOSPHATE 57 prochlorperazine maleate 72 PROPRANOLOL HCL 79 primidone 38 PROCORT 28 propranolol hcl 79 PRIMLEV 25 PROCRIT 110 PROPRANOLOL/HYDROCHLOR

OTHIAZIDE 56PRINIVIL 54 PROCTOCORT 28 propylthiouracil 195PRISTIQ 42 PROCTOFOAM HC 28

PRO COMFORT ALCOHOL PROSCAR 107PROCYSBI 107PADS 129 PROTAMINE SULFATE 109PRODIGY INSULINPRO COMFORT INHALER SYRING/U-100/0.3ML/31G X PROTONIX 198SPACER CHAMBER 5/16" 152 PROTOPIC 96ADULT 166 PRODIGY INSULINPRO COMFORT INHALER protriptyline hcl 43SYRINGE/1/2ML/31G XSPACER CHAMBER PROVENTIL HFA 355/16" 152CHILD 166 PRODIGY INSULIN PROVERA 190PRO COMFORT INSULIN SYRINGE/1ML/28G XSYRINGES/0.5ML/30G X PROVIGIL 171/2" 1521/2" 152 PROZAC 41PRODIGY LANCINGPRO COMFORT INSULIN DEVICE 125 PRUDOXIN 91SYRINGES/0.5ML/30G X PRODIGY TWIST TOP pseudoephed-bromphen-dm 885/16" 152 LANCETS 125PRO COMFORT INSULIN pseudoephedrine hcl 183PROFILNINE 108SYRINGES/0.5ML/31G X PSORCON 95PROFILNINE SD 1085/16" 152 PSS SELECT GP

PRO COMFORT INSULIN progesterone 190 LANCETS 125SYRINGES/1ML/30G X progesterone micronized 190 PSS SELECT SAFETY1/2" 152 LANCETS 125PROGRAF 171PRO COMFORT INSULIN psyllium 112SYRINGES/1ML/30G X PROLASTIN-C 194

PULMICORT 345/16" 152 PROLATE 25PRO COMFORT INSULIN PULMICORT FLEXHALER 34PROLENSA 188SYRINGES/1ML/31G X PULMOZYME 194 5/16" 152 PROLIA 100 PURE COMFORT PEN NEEDLEPRO COMFORT PEN PROMACTA 110 32G X6MM 152NEEDLES/31G X 8MM 152 promethazine & PURE COMFORT PEN NEEDLEPRO COMFORT PEN phenylephrine 88 32G X8MM 152NEEDLES/32G X 4MM 152 promethazine hcl 51 PURE COMFORT PENPRO COMFORT PEN NEEDLE/32G X 5MM 152promethazine w/codeine 88NEEDLES/32G X 5MM 152 PURE COMFORT PENPRO COMFORT PEN promethazine-dm 88 NEEDLE/32G X4MM 152NEEDLES/32G X 6MM 152 PURIXAN 59

Index 37

PX ADVANCED LANCING DEVICE 125 PX EXTRA SHORT PEN NEEDLES 31GX6MM 152 PX INSULIN SYRINGE/U-100/0.5ML/30G X 1/2" 152 PX LANCET AUTO INJECTOR 125 PX LANCETS ULTRA THIN 126 PX MINI PEN NEEDLES 31GX5MM 152 PX PEN NEEDLE 29GX12MM 152 PX PEN NEEDLE

QC UNILET LANCETS 33G/MICRO THIN QTERN QUALAQUIN QUARTETTE QUDEXY XR QUESTRAN QUESTRAN LIGHT quetiapine fumarate QUFLORA PEDIATRIC QUILLICHEW ER QUILLIVANT XR

126 43 57 85 38 52 52 69

178 17 17

RA ONE DAILY RA OYSTER SHELL CALCIUM/VITAMIN DRA PEN NEEDLES 31G X 5MM3/16"RA PEN NEEDLES 31G X 8MM5/16" RA PRENATAL RA PRENATAL FORMULA/FOLICACIDRA SHEER ADHESIVE LARGE RA STERILE PADS 2"X2" RA STERILE PADS 3"X3"

180

169

153

153 180

180

118 118 118

31GX8MM 152 PX PRENATAL MULTIVITAMINS 180 PX SHORTLENGTH PEN NEEDLES/31GX8MM 152 PYLERA 198 pyrantel pamoate 29 pyrazinamide 58 pyrethrins-piperonyl butoxide98 PYRIDIUM 107 pyridostigmine bromide 58 PYRIDOSTIGMINE BROMIDE 58 pyridostigmine bromide 58 pyridoxine hcl 202 pyrimethamine 57 QBRELIS 54 QC ADVANCED LANCING DEVICE 126 QC ALCOHOL SWABS 129 QC ALL PURPOSE DRESSINGS4"X4" 118 QC BORDER ISLAND GAUZE PAD 2"X2" 118 QC LANCETS SUPER THIN 126 QC LANCETS ULTRA THIN 126 QC PEN NEEDLES 29G X 12MM 152 QC PEN NEEDLES 31G X 6MM 152 QC PEN NEEDLES 31G X 8MM 152 QC PRENATAL 180 QC STERILE PADS 118 QC UNIFINE PENTIPS 32GX4MM 152 QC UNILET LANCETS 28G/ULTRA THIN 126

quinapril hcl 54 quinapril-hydrochlorothiazide

56 QUINIDINE GLUCONATE 32 quinidine gluconate 32 QUINIDINE SULFATE 32 quinine sulfate 57 QVAR 34 QVAR REDIHALER 34 RA ALCOHOL SWABS 129 RA ALL PURPOSE DRESSINGS4"X4" 118 RA DRESSING SPONGES 4"X4" 118 RA DRY MOUTH 172 RA E-ZJECT COLOR LANCETSMICRO-THIN 33G 126 RA E-ZJECT LANCETS 28G 126 RA E-ZJECT LANCETS THIN 26G 126 RA E-ZJECT LANCETS THIN 28G 126 RA E-ZJECT LANCETS ULTRATHIN 30G 126 RA FIRST AID NON-STICK PADS 118 RA GAUZE SPONGES 4"X4" 118 RA INSULIN SYRINGE/0.5ML/29G X1/2" 152 RA INSULIN SYRINGE/1ML/29G X1/2" 152 RA INSULIN SYRINGE/U-100/0.5ML/30G X 5/16" 152 RA INSULIN SYRINGE/U-100/1 ML/30G X 5/16" 152 RA LANCING DEVICE 126

RA STERILE PADS 4"X4" 118 rabeprazole sodium 198 racepinephrine hcl 35 RADICAVA 183 RAGWITEK 18 raloxifene hcl 101 ramelteon 112 ramipril 54 RANEXA 30 ranitidine hcl 197 ranolazine 30 RAPAFLO 107 RAPAMUNE 171 RAPIVAB 78 rasagiline mesylate 63 RASUVO 20 RAVICTI 102 RAY-TEC X-RAY DETECTABLESPONGES 4" X 4" 16 PLY 118 RAYALDEE 102 RAYOS 87 RAZADYNE 191 RAZADYNE ER 191 REALITY INSULIN SYRINGE/U-100/0.5ML/28G X 1/2" 153 REALITY INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" 153 REALITY INSULIN SYRINGE/U-100/1ML/28G X 1/2" 153 REALITY INSULIN SYRINGE/U-100/1ML/29G X 1/2" 153 REALITY LANCETS 126 REALITY LATEX CONDOMS/LUBRICATED 119 REALITY LATEX/ULTRATEXTURED 119

Index 38

REALITY LATEX/ULTRATHIN 119 REALITY SWABS 129 REBETOL 77 REBIF 192 REBIF REBIDOSE 192 REBIF REBIDOSE TITRATIONPACK 192

RELION LANCETS ULTRA-THIN30G 126 RELION LANCING DEVICE 126 RELION MINI PEN NEEDLES 31GX6MM 153 RELION PEN NEEDLES 29GX12MM 153 RELION PEN NEEDLES

RESTORE CONTACT LAYER/NON-ADHERENT2"X2" 118 RESTORE FOAM DRESSING BORDERED 4"X4" 118 RESTORE FOAM DRESSING NON-BORDERED 4"X4" 118 RESTORE ODOR ABSORBING DRESSING 4"X4" 118

31GX6MM 153 RESTORE TRIO ABSORBENTREBIF TITRATION PACK 192 RELION PEN NEEDLES DRESSING 3"X3" 118REBINYN 108 31GX8MM 153 RESTORIL 112RECLAST 100 RELION PEN NEEDLES 32G RETACRIT 110RECOMBINATE 108 X5/32" 153

RETAVASE 109RELION PEN NEEDLESRECOMBIVAX HB 199 32GX4MM 153 RETAVASE HALF-KIT 109RECTIV 28 RELION PEN NEEDLES/31G RETIN-A 89REESES PINWORM X1/4" 153 RETROVIR 75MEDICINE 29 RELION SHORT PEN REFRESH PLUS 184 NEEDLES31GX8MM 153 RETROVIR IV INFUSION 75

RELION ULTRA THINREGLAN 105 REVATIO 82 LANCETS/30G 126REGONOL 58 REVCOVI 102RELION ULTRA THIN

REGRANEX 98 LANCETS30G 126 REVLIMID 170 RELENZA DISKHALER 78 RELION ULTRA THIN PLUS REXALL LANCETS ULTRA

LANCETS 32G 126 THIN 126RELEXXII 18 RELION ULTRA THIN PLUS REXULTI 74RELION 2-IN-1 LANCET LANCETS 33G 126 REYATAZ 75DEVICES 30G 126 RELISTOR 106RELION 2-IN-1 LANCING REYVOW 168RELPAX 168DEVICE 25G 126 RHOFADE 97RELION 2-IN-1 LANCING REMERON 40 RHOGAM ULTRA-FILTEREDDEVICE 30G 126 REMERON SOLTAB 40 PLUS 189RELION ALCOHOL REMICADE 106 RHOPRESSA 186SWABS 129

RELION INSULIN SYRINGE/U- RENAGEL 106 RIASTAP 108 00/1ML/29G X 1/2" 153 RENFLEXIS 106 RIBASPHERE 77 RELION INSULIN SYRINGE/U- RENVELA 106 RIBASPHERE RIBAPAK 77100/0.3ML/29G X 1/2" 153 RELION INSULIN SYRINGE/U- repaglinide 47 ribavirin 78 100/0.3ML/30G X 5/16" 153 REPAGLINIDE/METFORMIN ribavirin (hepatitis c) 77 RELION INSULIN SYRINGE/U- HYDROCHLORIDE 43 RID 98100/0.3ML/31G X 5/16" 153 REPATHA 53 RIDAURA 20RELION INSULIN SYRINGE/U- REPATHA PUSHTRONEX100/0.5ML/29G X 1/2" 153 SYSTEM 53 rifabutin 58 RELION INSULIN SYRINGE/U- RIFADIN 58REPATHA SURECLICK 53100/0.5ML/30G X 5/16" 153 REPLACEMENT AIR RIFAMATE 58RELION INSULIN SYRINGE/U-100/0.5ML/31G X 5/16" 153 FILTER 166 rifampin 58

REPLACEMENTRELION INSULIN SYRINGE/U- RIFATER 58FILTERS 167100/1ML/30G X 5/16" 153 RIGHT STEP PRENATAL 180REQ 49+ 176RELION INSULIN SYRINGE/U- RIGHTEST GD500 LANCING100/1ML/31G X 5/16" 153 REQUIP 63 DEVICE 126RELION LANCETS MICRO- REQUIP XL 63 RIGHTEST GL300THIN33G 126 RESCRIPTOR 75 LANCETS 126RELION LANCETS STANDARD 21G 126 RESTASIS 186 RILUTEK 183 RELION LANCETS THIN RESTASIS MULTIDOSE 186 riluzole 183 26G 126 RIMANTADINE

HYDROCHLORIDE 78

Index 39

RIMSO-50 107 ringer's irrigation 171 RINVOQ 19 RIOMET 44 risedronate sodium 100,101 RISPERDAL 65,66 RISPERDAL CONSTA 65 RISPERDAL M-TAB 65 risperidone 66 RISPERIDONE ODT 66 RITALIN 18 RITALIN LA 18 RITEFLO 167 ritonavir 75 rivastigmine 191 rivastigmine tartrate 191 RIXUBIS 108 rizatriptan benzoate 168 ROBAXIN 182 ROBAXIN-750 182 ROBINUL 197 ROBINUL FORTE 197 ROBITUSSIN PEAK COLD DM 88 ROCALTROL 102 ROCKLATAN 186 ropinirole hydrochloride 63 ROSADAN KIT 97 rosuvastatin calcium 53 ROWASA 106 ROXICET 25 ROXICODONE 24 ROXYBOND 24 ROZEREM 112 ROZLYTREK 61 RUBRACA 61 RUCONEST 109 RUZURGI 58 RYANODEX 182 RYBELSUS 45 RYDAPT 61 RYTARY 63 RYTHMOL SR 32 S2 35 SABRIL 39

SAFESNAP INSULIN SYRINGE/0.3ML/30G X5/16" 153 SAFESNAP INSULIN SYRINGE/0.5ML/29G X1/2" 153 SAFESNAP INSULIN SYRINGE/0.5ML/30G X5/16" 153 SAFESNAP INSULIN SYRINGE/1ML/28G X1/2" 153 SAFESNAP INSULIN SYRINGE/1ML/29G X1/2" 153 SAFESNAP SYRINGE/3ML 153 SAFETY INSULIN SYRINGES 0.5ML/29GX1/2" 153 SAFETY INSULIN SYRINGES 0.5ML/30GX5/16" 153 SAFETY INSULIN SYRINGES 1ML/27GX1/2" 153 SAFETY INSULIN SYRINGES 1ML/29GX1/2" 154 SAFETY INSULIN SYRINGES 1ML/30GX1/2" 154 SAFETY SEAL LANCETS 28G 126 SAFETY SEAL LANCETS 30G 126 SAFETY-LOK SYRINGE 3ML LUER-LOK 154 SAFYRAL 85 SAIZEN 101 SAIZEN CLICK.EASY 101 SAIZENPREP RECONSTITUTIONKIT 101 SALAGEN 172 salicylic acid 97 saline 182 salsalate 22 SAMI THE SEAL REPLACEMENTFILTERS 16 7 SAMSCA 103 SANCUSO 48 SANDIMMUNE 171 SANDOSTATIN 103 SANDOSTATIN LAR DEPOT 103 SANTYL 96 SAPHRIS 70 SARAFEM 193 SAVAYSA 35

SAVELLA 192 SAVELLA TITRATION PACK 192 SB ALCOHOL PREP PADS 129 SB INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" 154 SB INSULIN SYRINGE/U-100/0.5ML/30G X 5/16" 154 SB INSULIN SYRINGE/U-100/1ML/29G X 1/2" 154 SB INSULIN SYRINGE/U-100/1ML/30G X 5/16" 154 SB INSULIN SYRINGE/U-100/1ML/31G X 5/16" 154 SB LANCETS THIN 126 SB LANCETS ULTRA THIN 126 SE-NATAL 19 180 SEASONIQUE 85 SECONAL SODIUM 111 SECUADO 70 SECURESAFE SAFETY HYPODERMIC NEEDLE/18G X1-1/2" 154 SECURESAFE SAFETY INSULIN SYRINGES/U-100/0.5ML/29GX1/2" 154 SECURESAFE SAFETY INSULIN SYRINGES/U-100/1ML/29GX1/2" 154 SEEBRI NEOHALER 33 SEGLUROMET 43 SELECT-LITE LANCING DEVICE 126 selegiline hcl 63 SELEGILINE HCL 63 selenium sulfide 92 SELZENTRY 75,76 sennosides 113 SENOKOT 113 SENSIPAR 102 SEREVENT DISKUS 35 SERNIVO 95 SEROQUEL 70 SEROQUEL XR 70 SEROSTIM 101 sertraline hcl 41 sevelamer carbonate 106 sevelamer hcl 106 SEVELAMER HYDROCHLORIDE 106

Index 40

SFROWASA 106 SHINGRIX 199 SHOPKO ALCOHOL SWABS 129 SHOPKO AUTOLET LANCING DEVICE 126 SHOPKO UNIFINE PENTIPS PEN NEEDLES/MICRO/32GX4MM

154 SHOPKO UNIFINE PENTIPS PEN NEEDLES/MINI/31GX5MM

154 SHOPKO UNIFINE PENTIPS PEN NEEDLES/ORIGINAL/29GX12MM 154 SHOPKO UNIFINE PENTIPS PEN NEEDLES/SHORT/31GX8MM

154 SHOPKO UNIFINE PENTIPS PLUS PEN NEEDLES/MICRO/REMOVR/32GX4MM 154 SHOPKO UNIFINE PENTIPS PLUS PEN NEEDLES/MINI/REMOVER/31GX5MM 154

sildenafil citrate (pulmonaryhypertension) 82 SILENOR 111 SILICONE MASK FOR BREATHERITE CHAMBER/ADULT 167 SILICONE MASK FOR BREATHERITE CHAMBER/INFANT 167 SILICONE MASK FOR BREATHERITE CHAMBER/PEDIATRIC 167 SILICONE MASK FOR BREATHRITE CHAMBER/ADULT 167 SILIQ 92 silodosin 107 SILVADENE 92 silver sulfadiazine 92 SIMBRINZA 185 simethicone 105 SIMILAC PRENATAL EARLY SHIELD 181 SIMPLE DIAGNOSTICS LANCING DEVICE 127 SIMPONI 19 SIMPONI ARIA 19

SM IPECAC SYRUP 48 SM MICRO THIN LANCETS 33G 127 SM ONE DAILY PRENATAL 181 SM PRENATAL VITAMINS 181 SM STERILE PADS 118 SM STERILE PADS 2"X2" 118 SM TRUEDRAW LANCING DEVICE 127 SMART DIABETES VANTAGE LANCING DEVICE 127 SMART SENSE COLOR LANCETS UNIVERSAL 33G 127 SMART SENSE STANDARD LANCETS UNIVERSAL 21G 127 SMART SENSE SUPER THIN LANCETS UNIVERSAL 30G 127 SMART SENSE THIN LANCETSUNIVERSAL 26G 127 sodium chloride (guirrigant) 107 sodium chloride (inhalant) 88 sodium citrate & citric acid 106

SHOPKO UNIFINE PENTIPS simvastatin 53 SODIUM DIURIL 100 PLUS PEN NEEDLES/REMOVER/29GX12MM 154 SHOPKO UNIFINE PENTIPS PLUS PEN NEEDLES/SHORT/REMOVR/31GX8MM 154 SHOPKO UNILET LANCETS SUPER THIN 30G 127 SHOPKO UNILET LANCETS ULTRA THIN 28G 127 SHUR-SEAL 200 SIDEROL 176 SIDESTREAM ADULT FACE MASK 167 SIDESTREAM PEDIATRIC FACEMASK 167 SIDESTREAM PEDIATRIC FACEMASK/SAMI THESEAL 167

SINEMET SINEMET CR SINGULAIR sirolimus SIRTURO SITAVIG SIVEXTRO SKELAXIN SKLICE SKYLA SKYRIZI SLO-NIACIN SLYND SM ADHESIVE PADS 2"X3" SM ADHESIVE PADS 3"X4"

63 63 33

171 58 77 30

182 98 85 92

202 85

118

118

SODIUM EDECRIN 99 sodium fluoride 170 sodium fluoride (dental) 172 sodium phenylbutyrate 102 sodium phosphates 113 sodium polystyrenesulfonate 171 SODIUM SULFACETAMIDE/SULFUR

89 SOF-SET ADHESIVE PATCH 118 SOF-WICK 4"X4" 118 SOFOSBUVIR/VELPATASVIR

77 solifenacin succinate 198 SOLIQUA 100/33 43 SOLIRIS 109

SIDESTREAM PEDIATRIC FACEMASK/TUCKER THETURTLE 167 SIDESTREAM PLUS ADULT FACE MASK 167 SIKLOS 110

SM ALCOHOL PREP PADS 129 SM GAUZE PADS 2"X2" 118 SM GAUZE PADS 3"X3" 118 SM GAUZE PADS 4"X4" 118 SM GLUCOSE 44

SOLODYN SOLOSEC SOLTAMOX SOLU-CORTEF SOLU-MEDROL

195 19 60 87 87

Index 41

SOLUS V2 LANCING STERILE PADS 3"X3" 118 SUPPRELIN LA 102 DEVICE 127 SOMA 182 SOMATULINE DEPOT 103 SOMAVERT 101 SONATA 112 SOOLANTRA 97 SOOTHENEB NBL 100 CHILD MASK 167 SOOTHENEB NBL 100 MEDICATION CUP 167 SOOTHENEB NBL 100 MESH CAP 167 SOOTHENEB NBL100 ADULT MASK 167 SORIATANE 92

STERILE PADS 4"X4" STIMATE STIOLTO RESPIMAT STIVARGA STRATTERA STREPTOMYCIN SULFATE STRIANT STRIBILD STRIVERDI RESPIMAT STROMECTOL STROVITE FORTE STROVITE ONE

118 103

35 61

9

19 27 76 35 29

176 176

SUPRAX 83 SUPREP BOWEL PREP KIT 113 SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/29G X1/2" 154 SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/30G X1/2" 154 SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/30G X5/16" 154 SURE COMFORT INSULIN SYRINGE/U-100/0.3ML/31G X5/16 154 SURE COMFORT INSULIN

SORILUX sotalol hcl sotalol hcl (afib/afl) SOTYLIZE SOVALDI SPINOSAD SPINRAZA

92 79 79 79 77 98

183

STUART ONE SUBLOCADE SUBOXONE SUBSYS sucralfate SUDAFED CONGESTION SUDAFED SINUS

181 26

26,27 24

197

183

SYRINGE/U-100/0.3ML/31G X5/16" 154 SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/28G X1/2" 154 SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/29G X1/2" 154 SURE COMFORT INSULIN

SPIRIVA HANDIHALER SPIRIVA RESPIMAT spironolactone spironolactone &hydrochlorothiazide SPORANOX SPORANOX PULSEPAK SPRITAM SPRYCEL STALEVO 100

33 33 99

99 50 50 38 61 63

CONGESTION 183 SULAR 81 SULCONAZOLE NITRATE91 sulfacetamide sod-prednisolone 187 sulfacetamide sodium 92 SULFACETAMIDE SODIUM 186 sulfacetamide sodium (acne) 89 sulfacetamide sodium

SYRINGE/U-100/0.5ML/30G X1/2" 154 SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/30G X5/16" 155 SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/31G X5/16 155 SURE COMFORT INSULIN SYRINGE/U-100/1ML/28G X1/2" 155 SURE COMFORT INSULIN

STALEVO 125 63 STALEVO 150 63 STALEVO 200 63 STALEVO 50 63 STALEVO 75 63 stannous fluoride 172 STARLIX 47 stavudine 76 STEGLATRO 47 STEGLUJAN 43 STELARA 92,106 STERILANCE TL 127 STERILE GAUZE PADS 2"X2" 118 STERILE GAUZE PADS 3"X3" 118 STERILE PADS 2"X2" 118

(ophth) 186 SULFACETAMIDE SODIUM/PREDNISOLONESODIUM PHOSPHATE 187 SULFADIAZINE 194 sulfamethoxazole-trimethoprim

29 SULFAMYLON 92 sulfasalazine 106 sulindac 21 sumatriptan 169 sumatriptan succinate 169 SUMATRIPTAN SUCCINATE 169 sumatriptan succinate 169 sumatriptan-naproxensodium 167 SUPER THIN LANCETS 127

SYRINGE/U-100/1ML/29G X1/2" 155 SURE COMFORT INSULIN SYRINGE/U-100/1ML/30G X1/2" 155 SURE COMFORT INSULIN SYRINGE/U-100/1ML/30G X5/16" 155 SURE COMFORT INSULIN SYRINGE/U-100/1ML/31G X5/16" 155 SURE COMFORT LANCING PEN 127 SURE COMFORT PEN NEEDLES29GX1/2"12.7MM 155 SURE COMFORT PEN NEEDLES30GX5/16"SHORT 155

Index 42

SURE COMFORT PEN SYMAX DUOTAB 197 TALZENNA 61 NEEDLES31GX3/16" SYMBICORT 35 TAMIFLU 78(5MM) 155 SYMBYAX 191,192 tamoxifen citrate 60SURE COMFORT PEN NEEDLES31GX5/16" SYMDEKO 194 tamsulosin hcl 107 (8MM) 155 SYMFI 76 TANZEUM 45SURE COMFORT PEN SYMFI LO 76 TAPAZOLE 195NEEDLES32GX5/32" 155 SURE COMFORT PEN SYMJEPI 201 TAPERDEX 12-DAY 87 NEEDLES32GX6MM 155 SYMLINPEN 120 43 TAPERDEX 7-DAY 87 SURE-FINE PEN NEEDLES SYMLINPEN 60 43 TARCEVA 6129GX1/2" 12.7MM 155 SYMPAZAN 37 TARGRETIN 62,91SURE-FINE PEN NEEDLES 31GX3/16" 5MM 155 SYMPROIC 106 TARKA 56 SURE-FINE PEN NEEDLES SYMTUZA 76 TASIGNA 6131GX5/16" 8MM 155 SYNAGIS 189 TASMAR 62SURE-JECT INSULIN SYRINGE/U-100/0.3ML/29G X SYNALAR 95 TAVALISSE 109 1/2" 155 SYNALAR CREAM KIT 95 TAYTULLA 85 SURE-JECT INSULIN SYNALAR OINTMENT KIT95 tazarotene 92SYRINGE/U-100/0.3ML/30G X5/16" 155 SYNALAR TS 95 TAZICEF 83 SURE-JECT INSULIN SYNAREL 102 TAZORAC 92 SYRINGE/U-100/0.3ML/31G X SYNERA 97 TDVAX 196 5/16" 155 SYNJARDY 43 TEARS NATURALE PM 184SURE-JECT INSULIN SYRINGE/U-100/0.5ML/28G X SYNJARDY XR 43 TECFIDERA 192 1/2" 155 SYNTHROID 195 TECFIDERA STARTER SURE-JECT INSULIN PACK 192SYPRINE 170SYRINGE/U-100/0.5ML/29G X TECHLITE AST LANCETS 127SYRINGE/BLUNT PLASTIC1/2" 155 TECHLITE INSULIN SYRINGEU-CANNULA 155SURE-JECT INSULIN SYRINGE/LUER 100/0.3ML/29G X 1/2" 156 SYRINGE/U-100/0.5ML/30G X TECHLITE INSULIN SYRINGEU-LOCK/3ML 1555/16" 155 SYRINGE/LUER 100/0.3ML/30G X 1/2" 156 SURE-JECT INSULIN TECHLITE INSULIN SYRINGEU-SLIP/3ML 156SYRINGE/U-100/0.5ML/31G X SYRINGES/LUER 100/0.3ML/30G X 5/16" 156 5/16" 155 TECHLITE INSULIN SYRINGEU-LOCK/WITHOUTSURE-JECT INSULIN 100/0.3ML/31G X 5/16" 156NEEDLE/3ML 156SYRINGE/U-100/1ML/28G X TECHLITE INSULIN SYRINGEU-SYSTANE 1841/2" 155 100/0.5ML/29G X 1/2" 156SYSTANE ICAPSSURE-JECT INSULIN TECHLITE INSULIN SYRINGEU-AREDS2SYRINGE/U-100/1ML/29G X 176 100/0.5ML/30G X 1/2" 156 1/2" 155 SYSTANE ULTRA 184 TECHLITE INSULIN SYRINGEU-SURE-JECT INSULIN SYSTANE ULTRA HOME & 100/0.5ML/30G X 5/16" 156 SYRINGE/U-100/1ML/30G X AWAY PACK 184 TECHLITE INSULIN SYRINGEU-5/16" 155 TABLOID 59 100/0.5ML/31G X 5/16" 156 SURE-JECT INSULIN TECHLITE INSULIN SYRINGEU-TACLONEX 95SYRINGE/U-100/1ML/31G X 100/1ML/29G X 1/2" 156tacrolimus 1715/16" 155 TECHLITE INSULIN SYRINGEU-SURE-PEN 127 tacrolimus (topical) 96 100/1ML/30G X 1/2" 156

tadalafil (pulmonary TECHLITE INSULIN SYRINGEU-SURELITE LANCETS 127 hypertension) 82 100/1ML/30G X 5/16" 156SURGICAL GAUZE TECHLITE INSULIN SYRINGEU-TAFINLAR 61SPONGE 118 100/1ML/31G X 5/16" 156TAGAMET HB 197SURMONTIL 43 TECHLITE LANCETS 127TAGRISSO 61SUSTIVA 76 TECHLITE LANCETS 30G 127TAKHZYRO 109SUSTOL 48 TECHLITE PEN NEEDLES 29GX TALTZ 92SUTENT 61 12 MM 156

Index 43

TECHLITE PEN NEEDLES 31GX 5MM 156 TECHLITE PEN NEEDLES/31GX5MM 156 TECHLITE PEN NEEDLES/31GX6 MM 156 TECHLITE PEN NEEDLES/31GX8MM 156 TECHLITE PEN NEEDLES/32GX4MM 156 TECHLITE PEN NEEDLES/32GX6MM 156 TECHLITE PEN NEEDLES/32GX8MM 156 TECHNIVIE 77 TEGADERM FOAM DRESSING 2"X2" 118 TEGADERM FOAM DRESSING 4"X4" 118 TEGRETOL 39 TEGRETOL-XR 39 TEKTURNA 57 TEKTURNA HCT 56 telmisartan 54 telmisartan-amlodipine 56 telmisartan-hydrochlorothiazide

56 temazepam 112 TEMIXYS 76 TEMODAR 58 TEMOVATE 95 temozolomide 59 TENCON 22 TENIVAC 196 tenofovir disoproxil fumarate 76 TENORETIC 100 56

testosterone cypionate 27 testosterone enanthate 27 TESTOSTERONE ENANTHATE 27 TESTOSTERONE PUMP 28 TESTRED 28 tetrabenazine 192 tetracaine hcl (ophth) 186 tetracycline hcl 195 TGT ALCOHOL SWABS 129 TGT LANCET MICRO THIN 33G 127 TGT LANCET THIN 26G 127 TGT LANCET ULTRA THIN 30G 127 TGT LANCING DEVICE 127 THALOMID 170 THEO-24 35 theophylline 35 THEOPHYLLINE ER 35 THEOPHYLLINE/D5W 35 THERAGAUZE 118 THERANATAL COMPLETE 181 THERANATAL CORE NUTRITION 181 THERANATAL ONE 181 thiamine hcl 202 THINLETS GP LANCETS127 THINLETS LANCET 127 THIOLA 107 THIOLA EC 107 thioridazine hcl 72 thiothixene 74

TIGECYCLINE 194 TIGLUTIK 183 TIKOSYN 32 TIMOLOL MALEATE 79 timolol maleate 79 timolol maleate (ophth) 184 TIMOLOL MALEATE OPHTHALMIC GEL FORMING 184 TIMOPTIC 184 TIMOPTIC OCUDOSE 184 TIMOPTIC-XE 184 TINACTIN 91 TINDAMAX 29 tinidazole 29 TIROSINT 195 TIROSINT-SOL 195 TIVICAY 76 tizanidine hcl 182 TNKASE 109 TOBI 19 TOBI PODHALER 19 TOBRADEX 187 TOBRADEX ST 187 tobramycin 19 TOBRAMYCIN 19 tobramycin (ophth) 186 TOBRAMYCIN SULFATE 19 tobramycin sulfate 19 tobramycin-dexamethasone 187 TOBREX 186 TODAYS HEALTH ADVANCED

TENORETIC 50 TENORMIN TERAZOL 7 terazosin hcl terbinafine hcl terbutaline sulfate TERCONAZOLE terconazole vaginal TESSALON PERLES TESTIM TESTOPEL testosterone TESTOSTERONE testosterone

56 79

200 55 49 35

200 200

87 27 27 27 27 28

THRESHOLD IMT THRIVITE 19 THRIVITE RX thyroid THYROLAR-1 THYROLAR-1/2 THYROLAR-1/4 THYROLAR-2 THYROLAR-3 tiagabine hcl TIAZAC TIBSOVO TIGAN tigecycline

167 181 181 195 195 195 195 195 195

39 81 61 49

194

LANCING DEVICE 127 TODAYS HEALTH MINI PEN NEEDLES 31G X 1/4" 156 TODAYS HEALTH ORIGINAL PEN NEEDLES 29G X 1/2" 156 TODAYS HEALTH SHORT PEN NEEDLES 31G X 5/16" 156 TODAYS HEALTH SUPER THINLANCETS 30G 127 TODAYS HEALTH ULTRA THINLANCETS 28G 127 TOFRANIL 43 TOLAK 91 TOLAZAMIDE 47 TOLBUTAMIDE 47 tolcapone 62 TOLMETIN SODIUM 21

Index 44

tolnaftate 91 TRAMADOL HCL ER 24 TRIFLURIDINE 186 TOLSURA 50 tramadol-acetaminophen 25 TRIGLIDE 52 tolterodine tartrate 198 trandolapril 54 trihexyphenidyl hcl 62 TOPAMAX 39 TOPAMAX SPRINKLE 39 TOPCARE CLICKFINE UNIVERSAL PEN EEDLES 31GX1/4" 156 TOPCARE CLICKFINE

trandolapril-verapamil hcl 56 TRANDOLAPRIL/VERAPAMILHCL ER 56 tranexamic acid 111 TRANEXAMIC ACID/SODIUMCHLORIDE 111

TRIKAFTA TRILEPTAL TRILIPIX trimethobenzamide hcl trimethoprim

194 39 52 49 29

UNIVERSAL PEN EEDLES 31GX5/16" 156 TOPCARE ULTRA COMFORT INSULIN SYRINGE/0.3ML/30G X5/16" 156 TOPCARE ULTRA COMFORT INSULIN SYRINGE/0.3ML/31G X5/16" 156 TOPCARE ULTRA COMFORT

TRANXENE T tranylcypromine sulfate TRAVATAN Z travoprost trazodone hcl TRECATOR TRELEGY ELLIPTA

31 40

188 188

41 58 35

trimipramine maleate TRINATAL RX 1 TRINTELLIX TRIPTODUR TRIUMEQ TRIZIVIR TROGARZO

43 181

41 102

76 76 76

INSULIN SYRINGE/0.5ML/30G X5/16" 157 TOPCARE ULTRA COMFORT INSULIN SYRINGE/0.5ML/31G X5/16" 157 TOPCARE ULTRA COMFORT INSULIN SYRINGE/1ML/30G X5/16" 157 TOPCARE ULTRA COMFORT INSULIN SYRINGE/1ML/31G X5/16" 157 TOPCARE ULTRA COMFORT INSULIN SYRINGE/U-100/0.3ML/29G X 1/2" 157 TOPCARE ULTRA COMFORT INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" 157 TOPCARE ULTRA COMFORT INSULIN SYRINGE/U-100/1ML/29G X 1/2" 157 TOPICORT 96

TRELSTAR MIXJECT 60 TREMFYA 92 TRESIBA 47 TRESIBA FLEXTOUCH 46 tretinoin 89 tretinoin (chemotherapy) 62 TRETTEN 108 TREXALL 59 TREXIMET 167 TREZIX 25 TRI-NORINYL 28 85 TRI-VI-SOL 178 TRI-VIT/FLUORIDE/IRON

178 TRIAMCINOLONE ACETONIDE 87 triamcinolone acetonide 87 triamcinolone acetonide

TROKENDI XR 39 tropicamide 185 trospium chloride 199 TRUE COMFORT INSULIN SYRINGE/0.5ML/31G X5/16" 157 TRUE COMFORT INSULIN SYRINGE/1ML/31G X5/16" 157 TRUE COMFORT PEN NEEDLES31G X 5MM 157 TRUE COMFORT PEN NEEDLES31G X 6MM 157 TRUE COMFORT PEN NEEDLES32G X 4MM 157 TRUE METRIX BLOOD GLUCOSETEST STRIPS 98 TRUE METRIX CONTROL SOLUTION LEVEL 1 127 TRUE METRIX CONTROL SOLUTION LEVEL 2 127

topiramate 39 TOPIRAMATE ER 39 TOPPER DRESSING SPONGES 4"X4" 118 TOPROL XL 79 toremifene citrate 60 torsemide 99 TOSYMRA 169 TOUJEO MAX SOLOSTAR 46

(mouth)triamcinolone acetonide (nasal)triamcinolone acetonide (topical) triamterene triamterene & hydrochlorothiazide TRIANEX triazolam

172

183

96 99

99 96

112

TRUE METRIX CONTROL SOLUTION LEVEL 3 127 TRUE METRIX SELF MONITORING BLOOD GLUCOSE STRIPS 98 TRUECONTROL GLUCOSE CONTROL LEVEL 0 127 TRUECONTROL GLUCOSE CONTROL LEVEL 1 127 TRUEDRAW LANCING DEVICE 128

TOUJEO SOLOSTAR 46 TRIBENZOR 57 TRUEPLUS 5-BEVEL PEN TOVET KIT TOVIAZ TRACLEER

96 199

82

TRICARE TRICOR TRIDESILON

181 52 96

NEEDLES 29GX12.7MM 157 TRUEPLUS 5-BEVEL PEN NEEDLES 31GX5MM 157 TRUEPLUS 5-BEVEL PEN

TRADJENTA 44 trientine hcl 170 NEEDLES 31GX6MM 157 tramadol hcl 24 trifluoperazine hcl 72

Index 45

TRUEPLUS 5-BEVEL PEN TRUETRACK BLOOD TURALIO 61 NEEDLES 31GX8MM 157 GLUCOSE TEST 98 TWINRIX 199TRUEPLUS 5-BEVEL PEN TRUETRACK TEST 98 TWYNSTA 57NEEDLES 32GX4MM 157 TRULANCE 104TRUEPLUS INSULIN TYBOST 76

TRULICITY 45SYRINGE/U-100/0.3ML/29G X TYGACIL 1941/2" 157 TRUMENBA 199 TYKERB 61TRUEPLUS INSULIN TRUSOPT 188SYRINGE/U-100/0.3ML/30G X TYLENOL 22TRUSTEX COLOR CONDOMS5/16" 157 TYLENOL CHILDRENS 22+ LUBE 120TRUEPLUS INSULIN TYLENOL EXTRATRUSTEX LUBRICATED 120SYRINGE/U-100/0.3ML/31G X STRENGTH 22TRUSTEX LUBRICATED5/16" 157 TYLENOL INFANTS 22EXTRALARGE 120TRUEPLUS INSULIN TRUSTEX LUBRICATED TYLENOL INFANTSSYRINGE/U-100/0.5ML/28G X EXTRASTRENGTH 120 PAIN+FEVER 221/2" 157 TRUSTEX TYLENOL/CODEINE #3 25TRUEPLUS INSULIN LUBRICATED/RIBBED/STUDDSYRINGE/U-100/0.5ML/29G X TYLENOL/CODEINE #4 25

ED 1201/2" 157 TYMLOS 101TRUSTEXTRUEPLUS INSULIN LUBRICATED/SPERMICIDE TYSABRI 192SYRINGE/U-100/0.5ML/30G X120 TYVASO 825/16" 157 TRUSTEXTRUEPLUS INSULIN TYVASO REFILL 82LUBRICATED/SPERMICIDESYRINGE/U-100/0.5ML/31G X TYVASO STARTER 82EXTRA LARGE 1205/16" 157 TRUSTEX UBRELVY 168TRUEPLUS INSULIN LUBRICATED/SPERMICIDE UCERIS 28,87SYRINGE/U-100/1ML/28G X EXTRA STRENGTH 1201/2" 157 UDENYCA 110TRUSTEX NATURALTRUEPLUS INSULIN ULESFIA 98CONDOMSSYRINGE/U-100/1ML/29G X

1/2" 157 +LUBE/LUBRICATED 120 ULORIC 107 TRUEPLUS INSULIN TRUSTEX NON- ULTI-LANCE AUTOMATIC/

LUBRICATED 120 CLEAR TIP 128SYRINGE/U-100/1ML/30G X5/16" 158 TRUSTEX WITH ULTICARE INSULIN SAFETY TRUEPLUS INSULIN NONOXYNOL- SYRINGE/0.5ML/29G X

9/RIBBED/STUDDED 120SYRINGE/U-100/1ML/31G X 1/2" 158 5/16" 158 TRUSTEX/RIA ULTICARE INSULIN SAFETY TRUEPLUS LANCETS LUBRICATED 120 SYRINGE/1ML/29G X 1/2" 158

TRUSTEX/RIA LUBRICATED ULTICARE INSULIN26G 128 TRUEPLUS LANCETS SPERMICIDE 120 SYRINGE/0.3ML/29G X28G 128 TRUSTEX/RIA 1/2" 158

LUBRICATED/SPERMICIDETRUEPLUS LANCETS 28G ULTICARE INSULIN SUPER THIN 128 120 SYRINGE/0.3ML/30G XTRUEPLUS LANCETS TRUSTEX/RIA NON- 1/2" 158 30G 128 LUBRICATED 120 ULTICARE INSULIN TRUEPLUS LANCETS 30G TRUVADA 76 SYRINGE/0.3ML/30G XULTRA THIN 128 TUBING/WING TIP 167 5/16" 158 TRUEPLUS LANCETS ULTICARE INSULINTUDORZA PRESSAIR 3333G 128 SYRINGE/0.5ML/28G XTRUEPLUS PEN NEEDLES TUMS 28 1/2" 158 29GX12MM 158 TUMS CHEWY BITES 28 ULTICARE INSULIN TRUEPLUS PEN NEEDLES SYRINGE/0.5ML/29G XTUMS E-X 750 28 31GX5MM 158 1/2" 158TUMS EXTRA STRENGTHTRUEPLUS PEN NEEDLES ULTICARE INSULIN750 2831GX6MM 158 SYRINGE/0.5ML/30G XTUMS KIDS 28TRUEPLUS PEN NEEDLES 1/2" 158TUMS LASTING31GX8MM 158 ULTICARE INSULIN

EFFECTS 28TRUEPLUS PEN NEEDLES SYRINGE/0.5ML/30G X32GX4MM 158 TUMS SMOOTHIES 28 5/16" 158

Index 46

ULTICARE INSULIN ULTICARE MICRO PEN ULTILET INSULIN SYRINGE/1ML/28G X 1/2" 158 NEEDLES/31G X 1/4" 159 SYRINGE/0.5ML/30G XULTICARE INSULIN ULTICARE MICRO PEN 8MM 160 SYRINGE/1ML/29G X 1/2" 158 NEEDLES/31G X 5/16" 159 ULTILET INSULIN ULTICARE INSULIN ULTICARE MICRO PEN SYRINGE/1ML/30G X 8MM160 SYRINGE/1ML/30G X 1/2" 158 NEEDLES/32G X 4MM 159 ULTILET INSULIN ULTICARE INSULIN ULTICARE MICRO PEN SYRINGE/1ML/31G X 8MM160 SYRINGE/1ML/30G X NEEDLES/32G X 5/32" 159 ULTILET INSULIN 5/16" 158 ULTICARE MINI PEN SYRINGE/SHORT/0.3ML/30G XULTICARE INSULIN NEEDLES 31GX6MM 159 12.7MM 160 SYRINGE/SHORT/0.3ML/30G X ULTICARE MINI PEN ULTILET INSULIN 5/16" 158 NEEDLES ULTI-FINE IV 159 SYRINGE/SHORT/0.3ML/30G XULTICARE INSULIN ULTICARE MINI PEN 5/16" 160 SYRINGE/SHORT/0.3ML/31G X NEEDLES/31G X 6MM 159 ULTILET INSULIN 5/16" 158 ULTICARE MINI PEN SYRINGE/SHORT/0.3ML/31G XULTICARE INSULIN NEEDLES/32G X 1/4" 159 5/16" 160 SYRINGE/SHORT/0.5ML/30G X ULTICARE MINI PEN ULTILET INSULIN 5/16" 158 NEEDLES31GX6MM 159 SYRINGE/SHORT/0.5ML/30G XULTICARE INSULIN ULTICARE ORIGINAL PEN 5/16" 160 SYRINGE/SHORT/0.5ML/31G X NEEDLES ULTI-FINE 159 ULTILET INSULIN 5/16" 158 ULTICARE PEN NEEDLES SYRINGE/SHORT/0.5ML/31G XULTICARE INSULIN 31GX 5MM 159 5/16" 160 SYRINGE/SHORT/1ML/30G X ULTICARE PEN NEEDLES ULTILET INSULIN 5/16" 158 31GX 5MM/MINI 159 SYRINGE/SHORT/1ML/30G XULTICARE INSULIN ULTICARE PEN 5/16" 160 SYRINGE/SHORT/1ML/31G X NEEDLES/29GX 12.7MM 159 ULTILET INSULIN 5/16" 158 ULTICARE SHORT PEN SYRINGE/SHORT/1ML/31G XULTICARE INSULIN NEEDLES 31GX8MM 159 5/16" 160 SYRINGE/U-100/0.3ML/30G X ULTICARE SHORT PEN ULTILET INSULIN SYRINGE/U-1/2" 158 NEEDLES ULTI-FINE IV 159 100/0.5ML/30G X 1/2" 160 ULTICARE INSULIN ULTICARE SHORT PEN ULTILET INSULIN SYRINGE/U-SYRINGE/U-100/0.3ML/31G X NEEDLES/31G X 8MM 159 100/1ML/30G X 1/2" 160

ULTIGUARD5/16" 158 ULTILET PEN NEEDLE ULTICARE INSULIN SAFEPACK/MICROPEN 29GX12.7MM 160 SYRINGE/U-100/0.5ML/30G X NEEDLE/32G X 5/32"/SHARPS ULTILET PEN NEEDLE 1/2" 158 CONTA 159 31GX5MM 160 ULTICARE INSULIN ULTIGUARD SAFEPACK/MINI ULTILET PEN NEEDLE SYRINGE/U-100/0.5ML/31G X PEN NEEDLE/31G X 31GX8MM 160 5/16" 159 1/4"/SHARPS CONTAIN 159 ULTILET PEN NEEDLE ULTICARE INSULIN ULTIGUARD SAFEPACK/MINI 32GX4MM 160 SYRINGE/U-100/1ML/30G X PEN NEEDLE/31G X ULTILET PEN NEEDLE 1/2" 159 3/16"/SHARPS CONTAI 159 32GX4MM/SHORT 160 ULTICARE INSULIN ULTIGUARD SAFEPACK/MINI ULTILET SHORT PEN SYRINGE/U-100/1ML/31G X PEN NEEDLE/32G X NEEDLES 31GX5/16" 160 5/16" 159 1/4"/SHARPS CONTAIN 159 ULTILET SHORT PEN ULTICARE INSULIN ULTIGUARD NEEDLES31GX3/16" 160 SYRINGEULTRAFINE U- SAFEPACK/SHORTPEN ULTOMIRIS 109 100/0.3ML/31G X 5/16" 159 NEEDLE/31G X 5/16"/SHARPS ULTRA COMFORT INSULIN

CONTA 160ULTICARE INSULIN SYRINGE/U-100/0.3ML/30G XSYRINGEULTRAFINE U- ULTILET CLASSIC 5/16" 160 100/0.5ML/31G X 5/16" 159 LANCETS 128 ULTRA THIN PEN NEEDLESULTILET INSULINULTICARE INSULIN 32G X 4MM 160SYRINGE/0.3ML/30G XSYRINGEULTRAFINE U- ULTRA-COMFORT INSULIN

8MM 160100/1ML/31G X 5/16" 159 SYRINGE/U-100/0.3ML/29G XULTICARE MICRO PEN ULTILET INSULIN 1/2" 160 NEEDLES 31G X 8MM 159 SYRINGE/0.3ML/31G X ULTRA-COMFORT INSULIN ULTICARE MICRO PEN 8MM 160 SYRINGE/U-100/0.3ML/30G XNEEDLES 32G X 4MM 159 5/16" 160

Index 47

ULTRA-COMFORT INSULIN ULTRACARE INSULIN UNIFINE PENTIPS SYRINGE/U-100/0.3ML/31G X SYRINGE/U-100/0.3ML/30G X 33GX4MM 162 5/16" 160 5/16" 161 UNIFINE PENTIPS PLUS ULTRA-COMFORT INSULIN ULTRACARE INSULIN 29GX12MM 162 SYRINGE/U-100/0.5ML/28G X SYRINGE/U-100/0.3ML/31G X UNIFINE PENTIPS PLUS 1/2" 160 5/16" 161 31GX5MM 162 ULTRA-COMFORT INSULIN ULTRACARE INSULIN UNIFINE PENTIPS PLUS SYRINGE/U-100/0.5ML/29G X SYRINGE/U-100/0.5ML/30G X 31GX6MM 162 1/2" 160 1/2" 161 UNIFINE PENTIPS PLUS ULTRA-COMFORT INSULIN ULTRACARE INSULIN 31GX8MM 162 SYRINGE/U-100/0.5ML/30G X SYRINGE/U-100/0.5ML/30G X UNIFINE PENTIPS PLUS 5/16" 160 5/16" 161 32GX4MM 162 ULTRA-COMFORT INSULIN ULTRACARE INSULIN UNIFINE PENTIPS PLUS SYRINGE/U-100/0.5ML/31G X SYRINGE/U-100/0.5ML/31G X 33GX4MM 162 5/16" 161 5/16" 161 UNIFINE SAFECONTROL PEN ULTRA-COMFORT INSULIN ULTRACARE INSULIN NEEDLE/30G X 5/16" 162 SYRINGE/U-100/1ML/28G X SYRINGE/U-100/1ML/30G X UNILET COMFORTOUCH 1/2" 161 1/2" 161 LANCET 128 ULTRA-COMFORT INSULIN ULTRACARE INSULIN UNILET EXCELITE 128 SYRINGE/U-100/1ML/29G X SYRINGE/U-100/1ML/30G X UNILET EXCELITE II 128 1/2" 161 5/16" 161 UNILET G.P. LANCET 128ULTRA-COMFORT INSULIN ULTRACARE INSULIN UNILET G.P. SUPERLITESYRINGE/U-100/1ML/30G X SYRINGE/U-100/1ML/31G X LANCET 1285/16" 161 5/16" 161 UNILET GP 28 ULTRAULTRA-COMFORT INSULIN ULTRACARE PEN SYRINGE/U-100/1ML/31G X NEEDLES/31G X 1/4" 161 THIN 128 5/16" 161 ULTRACARE PEN UNILET LANCET 128 ULTRA-THIN II INSULIN NEEDLES/31G X 3/16" 161 UNILET LANCETS MICRO-SYRINGE SHORT/U- ULTRACARE PEN THIN33G 128 100/0.3ML/30GX5/16" 161 NEEDLES/31G X 5/16" 161 UNILET LANCETS SUPER-ULTRA-THIN II INSULIN ULTRACARE PEN THIN30G 128 SYRINGE SHORT/U- NEEDLES/32G X 1/14" 162 UNILET LANCETS ULTRA-THIN 100/0.3ML/31GX5/16" 161 ULTRACARE PEN 28G 128 ULTRA-THIN II INSULIN NEEDLES/32G X 3/16" 162 UNILET SUPERLITE SYRINGE SHORT/U- ULTRACARE PEN LANCET 128 100/0.5ML/30GX5/16" 161 NEEDLES/32G X 5/32" 162 UNIVERSAL 1 LANCETS ULTRA-THIN II INSULIN ULTRACARE PEN THIN26G 128 SYRINGE SHORT/U- NEEDLES/33G X 5/32" 162 UNIVERSAL 1 LANCETS ULTRA 100/0.5ML/31GX5/16" 161 ULTRACET 25 THIN 30G 128

UNIVERSAL 1ULTRA-THIN II INSULIN ULTRAM 24SYRINGE SHORT/U- LANCETS/33G/MICRO-THIN

ULTRAVATE 96100/1ML/30GX5/16" 161 128 ULTRA-THIN II INSULIN UNASYN 190 UPTRAVI 82 SYRINGE SHORT/U- UNASYN BULK PACK 190 urea 96 100/1ML/31GX5/16" 161 UNIFINE PENTIPS URECHOLINE 199ULTRA-THIN II INSULIN 29GX12MM 162 UROCIT-K 10 106SYRINGE/U- UNIFINE PENTIPS 31G X 100/0.5ML/29GX1/2" 161 3/16" 162 UROCIT-K 5 107 ULTRA-THIN II INSULIN UNIFINE PENTIPS UROXATRAL 107SYRINGE/U-100/1ML/29GX1/2" 31GX5MM 162 URSO 250 105161 UNIFINE PENTIPS ULTRA-THIN II MINI PEN 31GX6MM 162 URSO FORTE 105 NEEEDLES/31GX3/16" 161 UNIFINE PENTIPS ursodiol 105 ULTRA-THIN II PEN NEEDLES 31GX8MM 162 UTIBRON NEOHALER 3529GX1/2" 161 UNIFINE PENTIPS VAGIFEM 200ULTRA-THIN II PEN 32GX4MM 162 NEEDLES/SHORT/31GX5/16" UNIFINE PENTIPS valacyclovir hcl 78

161 32GX6MM 162 VALCHLOR 91

Index 48

VALCYTE 77 VAQTA 199 VIDA MIA UNIFINE PENTIPSORIGINALvalganciclovir hcl 77 VARIVAX 199 29GX12MM 162VALIUM 31 VARUBI 49 VIDA MIA UNILET LANCETS

valproate sodium 40 valproic acid 40 valsartan 54 valsartan-hydrochlorothiazide

57 VALTOCO 37

VASCEPA VASERETIC VASOSTRICT VASOTEC VAZCULEP VCF VAGINAL

51 57

103 54

201

SUPER THIN 30G 128 VIDA MIA UNILET LANCETS ULTRA THIN 28G 129 VIDA MIA UNIPFINE PENTIPSSHORT 31GX8MM 162 VIDEX EC 76

VALTREX 78 VALUE HEALTH INSULIN SYRINGE/U-100/0.5ML/29G X1/2" 162 VALUE HEALTH INSULIN SYRINGE/U-100/1ML/29G X1/2" 162 VALUE PLUS LANCETS STANDARD 21G 128 VALUE PLUS LANCETS SUPERTHIN 30G 128 VALUE PLUS LANCETS THIN 26G 128

CONTRACEPTIVE FILM 200 VECAMYL 57 VECTICAL 92 VELPHORO 106 VELTASSA 171 VEMLIDY 77 VENCLEXTA 59 VENCLEXTA STARTING PACK 59 venlafaxine hcl 42 VENTAVIS 82

VIDEXPEDIATRIC 76 VIEKIRA PAK 77 VIEKIRA XR 77 vigabatrin 39 VIGAMOX 186 VIIBRYD 41 VIIBRYD STARTER PACK 41 VIL-RX 181 VIMPAT 39 VINATE M 181

VALUE PLUS LANCING DEVICE 128 VALUMARK LANCET SUPER THIN 30G 128

VENTOLIN HFA verapamil hcl VERAPAMIL HCL ER

35 81 81

VINATE ONE VIOKACE VIRACEPT

181 99 76

VALUMARK LANCET ULTRA THIN 28G 128 VALUMARK PEN NEEDLES 29GX12MM 162 VALUMARK PEN NEEDLES

VERAPAMIL HCL SR VERAPAMIL HYDROCHLORIDE ER VEREGEN

81

81 89

VIRAMUNE VIRAMUNE XR VIRAZOLE VIREAD

76 76 78 76

31GX 6MM 162 VERELAN 81 VIROPTIC 186 VALUMARK PEN NEEDLES 31GX 8MM 162 VALVED HOLDING CHAMBER 167 VANALICE 98 VANCOCIN 30 VANCOCIN HCL 30

VERELAN PM 81 VERIPRED 20 87 VERSACLOZ 70 VERSIVA XC 3" X 3" FOAM DRESSING/HYDROFIBERTECHNOLOGY 119 VERSIVA XC 4" X 4" FOAM

VISTARIL VISTOGARD VITAFOL-OB VITALINE BIOTIN FORTE vitamins a & d (topical) VITAROCA PLUS

31 48

181 173

96 176

vancomycin hcl 29,30 VANCOMYCIN HYDROCHLORIDE 30 VANISHPOINT INSULIN SYRINGE/0.5ML/30G X1/2" 162 VANISHPOINT INSULIN

DRESSING/HYDROFIBERTECHNOLOGY 119 VERZENIO 61 VESICARE 199 VFEND 50 VFEND IV 50

VITATHELY/GINGER VITRAKVI VIVAGUARD LANCING DEVICE VIVELLE-DOT VIVITROL

181 61

129 104

48 SYRINGE/0.5ML/30G X5/16" 162 VANISHPOINT INSULIN SYRINGE/1ML/29G X 1/2" 162 VANISHPOINT INSULIN SYRINGE/1ML/30G X5/16" 162 VANOS 96 VANTAS 60

VIBERZI 106 VIBRAMYCIN 195 VICTOZA 45 VIDA MIA AUTOLET LANCINGDEVICE 128 VIDA MIA UNIFINE PENTIPS32GX4MM 162 VIDA MIA UNIFINE PENTIPSMINI 31GX6MM162

VIZIMPRO VOGELXO VOGELXO PUMP VOL-PLUS VOL-TAB RX VOLTAREN VONVENDI voriconazole

61 28 28

181 181

89 108

50

Index 49

VORTEX VALVED HOLDING WILATE 108 YOSPRALA 109 CHAMBER VOSEVI VOTRIENT VP INSULIN SYRINGE/U-100/0.3ML/29G X 1/2" VP-ZEL VPRIV VRAYLAR VUMERITY VUSION VYTORIN VYVANSE VYZULTA

167 77 61

162 176 110

64 192

91 51

6,7 188

WINDMILL TRAINER WOMENS MULTI GUMMIES WP THYROID XADAGO XALATAN XALKORI XANAX XANAX XR XARELTO XARELTO STARTER PACK XATMEP

167

176 195

63 188

61 31 31 35

35 59

YOUR LIFE MULTI ADULT GUMMIES 176 YOUR LIFE MULTI PRENATAL 181 YOUR LIFE TEEN MULTIVITAMIN GUMMIES 176 YUPELRI 33 ZADITOR 188 zafirlukast 33 zaleplon 112 ZANAFLEX 182 ZANTAC 197 ZANTAC 150 MAXIMUM STRENGTH 197

W&F LANCETS 26G 129 XELJANZ 19,20 ZANTAC 75 197 W&F LANCETS COLORED 21G 129 WAL-BORN VITAMIN C 176 WALGREENS COMFORT ASSUREDLANCETS MICRO

XELJANZ XR XELODA XELPROS XENAZINE

20 59

188 192

ZARONTIN ZARXIO ZAVESCA ZEJULA

39 110 110

61 THIN/33G 129 WALGREENS COMFORT ASSUREDLANCETS SUPER THIN/28G 129 WALGREENS GLUCOSE 44 WALGREENS THIN LANCETS 129 warfarin sodium 35 WATCHHALER 167 WEBCOL ALCOHOL PREP LARGE 1 PLY 129 WEBCOL ALCOHOL PREP LARGE 2 PLY 129 WEBCOL ALCOHOL PREP MEDIUM 2 PLY 129 WEGMANS COMPLETE

XERAVA XERESE XEROSTOMIA RELIEF SPRAY XGEVA XIFAXAN XIGDUO XR XIIDRA XIMINO XOFLUZA XOLAIR XOPENEX XOPENEX CONCENTRATE

194 92

172 101

29 43

186 195

78 32 35

35

ZELAPAR ZELBORAF ZEMAIRA ZEMBRACE SYMTOUCH ZEMPLAR ZENPEP ZENZEDI ZEPATIER ZERIT ZESTORETIC ZESTRIL ZETIA ZETONNA

63 61

194 169 102

99 7,8 77 76 57 54 53

183 PRENATAL+DHA 181 XOPENEX HFA 35 ZIAC 57 WEGMANS UNIFINE PENTIPS PLUS 32GX4MM 162 WEGMANS UNIFINE PENTIPS

XOSPATA XTAMPZA ER

61 24

ZIAGEN zidovudine

76 76

PLUS/MINI/31GX5MM 162 WEGMANS UNIFINE PENTIPS

XTANDI XULANE

60 85

ZIEXTENZO zileuton

110 33

PLUS/SHORT/31GX8MM 163 WEGMANS UNIFINE PENTIPS PLUS/ULTRASHORT/31GX6MM 163 WELCHOL 52

XULTOPHY 100/3.6 XYLOCAINE XYNTHA XYNTHA SOLOFUSE

44 32

108 108

ZILRETTA ZINBRYTA ZIOPTAN ziprasidone hcl

87 192 188

64 WELLBUTRIN SR 40 XYOSTED 28 ziprasidone mesylate 65 WELLBUTRIN XL 40 XYREM 190 ZIRGAN 186 WEST-VITE W/FOLICACID 173 WESTHROID 195 white petrolatum-mineral oil 184

YASMIN 28 YAZ YESCARTA YONSA

85 85 59 60

ZITHROMAX 113,114 ZITHROMAX TRI-PAK 114 ZITHROMAX Z-PAK 114 ZOCOR 53

Index 50

ZOFRAN 48 ZORBTIVE 101 ZOFRAN ODT 48 ZORTRESS 171 ZOHYDRO ER 24 ZOSTAVAX 199 ZOLADEX 60 ZOSYN 190 zoledronic acid 101 ZOVIRAX 78,92 ZOLEDRONIC ACID 101 ZUBSOLV 27 zoledronic acid 101 ZUPLENZ 48 ZOLGENSMA 10.1-10.5 ZURAMPIC 107 KG 183 ZYBAN 193ZOLGENSMA 10.6-11.0

ZYCLARA 96KG 183 ZOLGENSMA 11.1-11.5 ZYCLARA PUMP 96 KG 183 ZYDELIG 62ZOLGENSMA 11.6-12.0 ZYFLO 33KG 183 ZOLGENSMA 12.1-12.5 ZYFLO CR 33 KG 183 ZYKADIA 62 ZOLGENSMA 12.6-13.0 ZYLET 187KG 183

ZYLOPRIM 108ZOLGENSMA 13.1-13.5 KG 183 ZYMAXID 186

ZOLGENSMA 3.1-3.5 KG 183 ZYPREXA 70,71

ZOLGENSMA 5.1-5.5 KG 183 ZYRTEC CHILDRENS

ZOLGENSMA 2.6-3.0 KG 183 ZYPITAMAG 53

ZOLGENSMA 3.6-4.0 KG 183 ZYPREXA RELPREVV 70 ZOLGENSMA 4.1-4.5 KG 183 ZYPREXA ZYDIS 71 ZOLGENSMA 4.6-5.0 KG 183 ZYRTEC ALLERGY 51

ALLERGY 51ZOLGENSMA 5.6-6.0 KG 183 ZYTIGA 60ZOLGENSMA 6.1-6.5 KG 183 ZYVOX 30ZOLGENSMA 6.6-7.0 KG 183 ZZZQUIL 111ZOLGENSMA 7.1-7.5 KG 183

ZOLGENSMA 7.6-8.0 KG 183 ZOLGENSMA 8.1-8.5 KG 183 ZOLGENSMA 8.6-9.0 KG 183 ZOLGENSMA 9.1-9.5 KG 184 ZOLGENSMA 9.6-10.0 KG 184 ZOLINZA 61 zolmitriptan 169 ZOLOFT 41 zolpidem tartrate 112 ZOLPIMIST 112 ZOMACTON 101 ZOMETA 101 ZOMIG 169 ZOMIG ZMT 169 ZONALON 91 ZONEGRAN 39 zonisamide 39 ZONTIVITY 109

Index 51

comprehensive preferred drug list - envolve …...- drugs prescribed for cosmetic purposes or hair...

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