formulary - (list of covered drugs) - archcare
TRANSCRIPT
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
1
This formulary was updated on April 1, 2019. For more recent
information or other questions, please contact ArchCare Senior Life
(PACE) Member Services at 1-866-412-5435 or, for TTY users, 711, 24
hours a day, 7 days a week, or visit www.ArchCareSeniorLife.org.
2019 Formulary
(List of Covered Drugs)
H4393_2019 Formulary_C
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
2
ArchCare Senior Life (PACE)
2019 Formulary
List of Covered Drugs
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION
ABOUT THE DRUGS WE COVER IN THIS PLAN
Formulary ID 00019299, Version Number: 9
Note to existing members: This formulary has changed since last year. Please review this
document to make sure that it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us”, or “our,” it means Catholic Managed Long
Term Care, Inc. When it refers to “plan” or “our plan,” it means ArchCare Senior Life (PACE).
ArchCare Senior Life is a Program of All-inclusive Care for the Elderly (PACE). PACE is a
community-based healthcare program created for people 55 and over who require nursing-home-
level care, but prefer to receive it in their own familiar surroundings.
This document includes a list of the drugs (formulary) for our plan which is current as of April 1,
2019. For an updated formulary, please contact us. Our contact information, along with the date
we last updated the formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits,
formulary, and/or pharmacy network may change on January 1, 2019, and from time to time
during the year.
What is the ArchCare Senior Life (PACE) Formulary?
A formulary is a list of covered drugs selected by ArchCare Senior Life (PACE) in consultation
with a team of health care providers, which represents the prescription therapies believed to be a
necessary part of a quality treatment program. ArchCare Senior Life (PACE) will generally cover
the drugs listed in our formulary as long as the drug is medically necessary, the prescription is
filled at an ArchCare Senior Life (PACE) network pharmacy, and other plan rules are followed.
Can the Formulary (drug list) change?
Generally, if you are taking a drug on our 2019 formulary that was covered at the beginning of the
year, we will not discontinue or reduce coverage of the drug during the 2019 coverage year except
when a new, less expensive generic drug becomes available or when new adverse information
about the safety or effectiveness of a drug is released. Other types of formulary changes, such as
removing a drug from our formulary, will not affect members who are currently taking the drug. It
will remain available at the same cost-sharing for those members taking it for the remainder of the
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
3
coverage year. We feel it is important that you have continued access for the remainder of the
coverage year to the formulary drugs that were available when you chose our plan, except for
cases in which you can save additional money or we can ensure your safety.
If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step
therapy restrictions on a drug, we must notify affected members of the change at least 30 days
before the change becomes effective, or at the time the member requests a refill of the drug, at
which time the member will receive a 30-day supply of the drug. If the Food and Drug
Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes
the drug from the market, we will immediately remove the drug from our formulary and provide
notice to members who take the drug. The enclosed formulary is current as of April 1, 2019. To
get updated information about the drugs covered by ArchCare Senior Life (PACE), please contact
us. Our contact information appears on the front and back cover pages. Please visit our web site at
www.ArchCareSeniorLife.org or call Member Services at 1-866-412-5435, 24 hours a day, 7 days
a week. TTY/TDD users should call 711. We will notify you by mail in the event of mid-year non-
maintenance formulary changes.
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 10. The drugs in this formulary are grouped into categories
depending on the type of medical conditions that they are used to treat. For example, drugs
used to treat a heart condition are listed under the category, “Cardiovascular”. If you know
what your drug is used for, look for the category name in the list that begins below. Then look
under the category name for your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that
begins on page 697. The Index provides an alphabetical list of all of the drugs included in this
document. Both brand name drugs and generic drugs are listed in the Index. Look in the
Index and find your drug. Next to your drug, you will see the page number where you can find
coverage information. Turn to the page listed in the Index and find the name of your drug in
the first column of the list.
What are generic drugs?
ArchCare Senior Life (PACE) covers both brand name drugs and generic drugs. A generic
drug is approved by the FDA as having the same active ingredient as the brand name
drug. Generally, generic drugs cost less than brand name drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements
and limits may include:
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
4
Prior Authorization: ArchCare Senior Life (PACE) requires you or your physician to get
prior authorization for certain drugs. This means that you will need to get approval from
ArchCare Senior Life (PACE) before you fill your prescriptions. If you don’t get approval,
ArchCare Senior Life (PACE) may not cover the drug.
Quantity Limits: For certain drugs, ArchCare Senior Life (PACE) limits the amount of
the drug that ArchCare Senior Life (PACE) will cover. For example, ArchCare Senior Life
(PACE) provides 30 tablets per prescription for Vesicare. This may be in addition to a
standard one-month or three-month supply.
Step Therapy: In some cases, ArchCare Senior Life (PACE) requires you to first try
certain drugs to treat your medical condition before we will cover another drug for that
condition. For example, if Drug A and Drug B both treat your medical condition,
ArchCare Senior Life (PACE) may not cover Drug B unless you try Drug A first. If Drug
A does not work for you, ArchCare Senior Life (PACE) will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the
formulary that begins on page 10. You can also get more information about the restrictions
applied to specific covered drugs by visiting our Web site. We have posted online a document that
explains our prior authorization and step therapy restrictions. You may also ask us to send you a
copy. Our contact information, along with the date we last updated the formulary, appears on the
front and back cover pages.
You can ask ArchCare Senior Life (PACE) to make an exception to these restrictions or limits or
for a list of other, similar drugs that may treat your health condition. See the section, “How do I
request an exception to the ArchCare Senior Life (PACE)’s formulary?” on page 5 for information
about how to request an exception.
What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of covered drugs), you should first contact
Member Services and ask if your drug is covered.
If you learn that ArchCare Senior Life (PACE) does not cover your drug, you have two options:
You can ask Member Services for a list of similar drugs that are covered by ArchCare
Senior Life (PACE). When you receive the list, show it to your doctor and ask him or her
to prescribe a similar drug that is covered by ArchCare Senior Life (PACE).
You can ask ArchCare Senior Life (PACE) to make an exception and cover your drug. See
below for information about how to request an exception.
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
5
How do I request an exception to the ArchCare Senior Life (PACE)’s
Formulary?
You can ask ArchCare Senior Life (PACE) to make an exception to our coverage rules. There are
several types of exceptions that you can ask us to make.
You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will
be covered.
You can ask us to waive coverage restrictions or limits on your drug. For example, for
certain drugs, ArchCare Senior Life (PACE) limits the amount of the drug that we will
cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a
greater amount.
Generally, ArchCare Senior Life (PACE) will only approve your request for an exception if the
alternative drugs included on the plan’s formulary or additional utilization restrictions would not
be as effective in treating your condition and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary or utilization
restriction exception. When you request a formulary or utilization restriction exception you
should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting
statement. You can request an expedited (fast) exception if you or your doctor believe that your
health could be seriously harmed by waiting up to 72 hours for a decision. If your request to
expedite is granted, we must give you a decision no later than 24 hours after we get a supporting
statement from your doctor or other prescriber.
What do I do before I can talk to my doctor about changing my drugs or
requesting an exception?
As a new or continuing member in our plan you may be taking drugs that are not on our formulary.
Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For
example, you may need a prior authorization from us before you can fill your prescription. You
should talk to your doctor to decide if you should switch to an appropriate drug that we cover or
request a formulary exception so that we will cover the drug you take. While you talk to your
doctor to determine the right course of action for you, we may cover your drug in certain cases
during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited,
we will cover a temporary 30-day supply (unless you have a prescription written for fewer days)
when you go to a network pharmacy. After your first 30-day supply, we will not pay for these
drugs, even if you have been a member of the plan less than 90 days.
If you are a resident of a long-term care facility, we will allow you to refill your prescription until
we have provided you with a 31-day transition supply, consistent with dispensing increment,
(unless you have a prescription written for fewer days). If you need a drug that is not on our
formulary or if your ability to get your drugs is limited, but you are past the first 90 days of
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
6
membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a
prescription for fewer days) while you pursue a formulary exception.
If you experience a change in level of care, we will cover a transition supply of your drugs. A level
of care change occurs when you are discharged from a hospital or moved to or from a long-term
care facility. In these instances, we will provide an emergency supply of non-formulary
medication (including Part D medications that are on our formulary but require prior authorization
or step therapy under our utilization management rules). This emergency supply will be for one 31
day supply, or less if your prescription is written for fewer days. The emergency supply is to
ensure that you receive you medications while an exception has been requested.
For more information
For more detailed information about your ArchCare Senior Life (PACE) prescription drug
coverage, please review your plan materials.
If you have questions about ArchCare Senior Life (PACE), please contact us. Our contact
information, along with the date we last updated the formulary, appears on the front and back
cover pages.
If you have general questions about Medicare prescription drug coverage, please call Medicare at
1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-
877-486-2048. Or, visit http://www.medicare.gov.
ArchCare Senior Life (PACE)’s Formulary
The formulary below provides coverage information about the drugs covered by ArchCare Senior
Life (PACE). If you have trouble finding your drug in the list, turn to the Index that begins on
page 697.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g.,
COUMADIN) and generic drugs are listed in lower-case italics (e.g., warfarin).
The information in the Requirements/Limits column tells you if ArchCare Senior Life (PACE) has
any special requirements for coverage of your drug.
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
7
GUIDE TO ABBREVIATIONS
PA – Prior Authorization required. This means that you or your physician must get approval
from us before you fill your prescriptions for certain drugs. If you do not get approval, we
may not cover the drugs.
QL – Quantity limits apply. For certain drugs we limit the amount that the plan will cover.
B/D – The plan will determine whether this drug will be covered under Medicare Part B or Part D
based on the reason this drug has been prescribed by your doctor.
LA – Limited access. The drug is only available at a limited number of specialty pharmacies.
NM – Not available at our mail-order pharmacies. Not all drugs are available at mail-order, please
check with customer service if you have any questions.
ST – Step Therapy. This means that we may require you to first try certain drugs to treat your
medical condition before we will cover another drug for that condition.
ArchCare Senior Life is a Program of All-inclusive Care for the Elderly (PACE).
You can ask for this information for free in other formats, such as Braille, large print, data CD,
audio CD or qualified reader. Puede solicitar esta información de forma gratuita en otros formatos,
tales como Braille, letra grande, en CD, CD de audio o un lector cualificado.
The formulary, pharmacy network and provider network may change at any time. You will
receive notice when necessary.
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
8
Discrimination is Against the Law
ArchCare complies with applicable Federal civil rights laws and does not discriminate on
the basis of race, color, national origin, age, disability, or sex. ArchCare does not exclude people
or treat them differently because of race, color, national origin, age, disability, or sex.
ArchCare
Provides free aids and services to people with disabilities to communicate effectively with
us, such as:
o Qualified sign language interpreters
o Written information in other formats (large print, audio, accessible electronic
formats, other formats)
Provides free language services to people whose primary language is not English, such as:
o Qualified interpreters
o Information written in other languages
If you need these services, contact Jane Schauben @ (646) 289-7746, TTY 711
If you believe that ArchCare has failed to provide these services listed above or
discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you
can file a grievance with: Jane Schauben, (646) 289-7746, TTY 711, or email
[email protected]. You can file a grievance in person or by mail, fax, or email.
If you need help filing a grievance, Jane Schauben (646) 289-7746, TTY 711 is available to help
you.
You can also file a civil rights complaint with the U.S. Department of Health and Human
Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint
Portal, available at https://ocrportal.hhs.gov/ocr/cp/wizard_cp.jsf or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available on-line at http://www.hhs.gov/civil-rights/filing-a-
complaint/complaint-process/index.html
ATTENTION: If you speak English, language assistance services, free of charge, are available to
you. Call 1-855-380-2589 (TTY: 711).
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.
Llame al 1-855-380-2589 (TTY: 711).
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
9
注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電1-855-380-2589 (TTY:
711)。
CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số
1-855-380-2589 (TTY: 711).
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수
있습니다. 1-855-380-2589 (청각 장애인용 서비스: 711)으로 전화해 주십시오.
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong
sa wika nang walang bayad. Tumawag sa 1-855-380-2589 (TTY: 711).
ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги
перевода. Звоните 1-855-380-2589 (телетайп: 711).
2589-380-855-1ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم
(711:YTT)هاتف الصم والبكم رقم
ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele
1-855-380-2589 (TTY: 711).
ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés
gratuitement. Appelez le 1-855-380-2589 (ATS: 711).
UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń
pod numer 1-855-380-2589 (TTY: 711).
ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para
1-855-380-2589 (TTY: 711).
ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza
linguistica gratuiti. Chiamare il numero 1-855-380-2589 (TTY: 711).
ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche
Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-855-380-2589 (TTY: 711).
注意事項:日本語を話される場合、無料の言語支援をご利用いただけます。(1-855-380-2589 (TTY: 711).まで、お電話にてご連絡ください。
شما رای گان ب صورت رای ی ب ان یالت زب سھ ید، ت ن گو می ک ت ف سی گ ار ان ف ھ زب ر ب وجھ: اگ ت
ف یم دشاب .اب.(TTY: 711) 2589-380-855-1 سامت دیریگب.
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
10
ArchCare Senior Life (PACE) Formulary
Effective April 1, 2019
Drug Name Drug Tier Requirements/Limits
ANALGESICS
GOUT
allopurinol tab 1
colchicine w/ probenecid 1
COLCRYS 2 QL (120 tabs / 30 days)
MITIGARE 2 QL (60 caps / 30 days)
probenecid 1
ULORIC 2 ST
MISCELLANEOUS
acephen 120mg, 325mg, 650mg 3
acetaminophen LIQD 160mg/5ml 3
acetaminophen SOLN 325mg/10.15ml, 650mg/20.3ml
3
acetaminophen SUPP 120mg, 650mg 3
acetaminophen TABS 325mg 3
acetaminophen TBCR 650mg 3
acetaminophen extra stren TABS 500mg 3
arthritis pain relief TBCR 650mg 3
aspir-low 81mg 3
aspirin CHEW 81mg 3
ASPIRIN SUPP 300mg, 600mg 3
aspirin TABS 325mg 3
aspirin TBEC 81mg, 325mg 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
11
Drug Name Drug Tier Requirements/Limits
aspirin 81 3
aspirin adult low dose TBEC 81mg 3
aspirin low dose CHEW 81mg 3
aspirin low dose TBEC 81mg 3
aspirin low strength 81mg 3
childrens acetaminophen SUSP 160mg/5ml
3
childrens aspirin 81mg 3
childrens aspirin low str 3
childrens pain reliever TBDP 80mg 3
childrens silapap 160mg/5ml 3
ecpirin 3
feverall adults 3
feverall childrens 3
FEVERALL INFANTS 80mg 3
feverall junior strength 3
gnp adult aspirin low str CHEW 81mg 3
gnp arthritis pain relief 650mg 3
gnp aspirin TABS 325mg 3
gnp aspirin TBEC 325mg 3
gnp aspirin low dose 81mg 3
gnp pain & fever children 160mg/5ml 3
gnp pain relief TABS 325mg 3
gnp pain relief extra str TABS 500mg 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
12
Drug Name Drug Tier Requirements/Limits
goodsense arthritis pain 650mg 3
goodsense aspirin CHEW 81mg 3
goodsense aspirin TABS 325mg 3
goodsense pain & fever ch 160mg/5ml 3
goodsense pain & fever in 160mg/5ml 3
goodsense pain relief TBCR 650mg 3
goodsense pain relief ext 500mg 3
hm arthritis pain relief 650mg 3
hm aspirin CHEW 81mg 3
hm aspirin TABS 325mg 3
hm aspirin ec 325mg 3
hm aspirin ec low dose 81mg 3
hm pain & fever childrens 160mg/5ml 3
hm pain & fever infants 160mg/5ml 3
hm pain relief extra stre 500mg 3
hm pain reliever 325mg 3
8hr muscle aches & pain 650mg 3
mapap CAPS 500mg 3
mapap CHEW 80mg 3
mapap LIQD 160mg/5ml 3
mapap TABS 325mg, 500mg 3
mapap arthritis pain 650mg 3
mapap childrens SUSP 160mg/5ml 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
13
Drug Name Drug Tier Requirements/Limits
mapap childrens TBDP 3
mapap extra strength 3
pain & fever 3
pain & fever childrens CHEW 80mg 3
pain & fever childrens SOLN 3
pain & fever childrens SUSP 160mg/5ml 3
pain & fever childrens dy 160mg/5ml 3
pain & fever extra streng 3
pain & fever infants 160mg/5ml 3
pain relief extra strengt 500mg 3
pain reliever extra stren 500mg 3
pharbetol 325mg 3
pharbetol extra strength 500mg 3
qc acetaminophen 8 hours 650mg 3
qc arthritis pain relief 650mg 3
qc aspirin TABS 325mg 3
qc aspirin low dose 81mg 3
qc chewable aspirin low d 81mg 3
qc non-aspirin extra stre 500mg 3
qc pain relief childrens 160mg/5ml 3
qc pain relief infants 160mg/5ml 3
sb aspirin TABS 325mg 3
sb aspirin TBEC 81mg 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
14
Drug Name Drug Tier Requirements/Limits
sb aspirin adult low stre 81mg 3
sb low dose asa ec 3
sb non-aspirin TABS 3
sb non-aspirin extra stre 500mg 3
sb pain reliever extra st 500mg 3
sm 8 hour pain relief 650mg 3
sm arthritis pain relief 650mg 3
sm aspirin 325mg 3
sm aspirin adult low stre CHEW 81mg 3
sm aspirin adult low stre TBEC 81mg 3
sm aspirin low dose CHEW 81mg 3
sm childrens aspirin 81mg 3
sm pain & fever childrens 80mg/2.5ml,
160mg/5ml
3
sm pain reliever extra st CAPS 500mg 3
sm pain reliever extra st TABS 500mg 3
tactinal 325mg 3
tactinal extra strength 3
tri-buffered aspirin 3
NSAIDS
celecoxib CAPS 50mg 1 QL (240 caps / 30 days)
celecoxib CAPS 100mg 1 QL (120 caps / 30 days)
celecoxib CAPS 200mg 1 QL (60 caps / 30 days)
celecoxib CAPS 400mg 1 QL (30 caps / 30 days)
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
15
Drug Name Drug Tier Requirements/Limits
childrens ibuprofen 100mg/5ml 3
childs ibuprofen 3
diclofenac potassium 1 QL (120 tabs / 30 days)
diclofenac sodium TB24; TBEC 1
diflunisal 1
etodolac 1
etodolac er 1
flurbiprofen TABS 1
gnp childrens ibuprofen 100mg/5ml 3
gnp ibuprofen TABS 200mg 3
goodsense ibuprofen TABS 200mg 3
goodsense ibuprofen child 100mg/5ml 3
hm ibuprofen CAPS 200mg 3
hm ibuprofen TABS 200mg 3
hm ibuprofen childrens 100mg/5ml 3
hm ibuprofen ib 200mg 3
ibu tab 600mg 1
ibu tab 800mg 1
ibu-200 200mg 3
ibuprofen CAPS 200mg 3
ibuprofen SUSP 100mg/5ml 1
ibuprofen TABS 200mg 3
ibuprofen TABS 400mg, 600mg, 800mg 1
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
16
Drug Name Drug Tier Requirements/Limits
ibuprofen childrens 100mg/5ml 3
meloxicam TABS 1
nabumetone TABS 1
naproxen TABS 1
naproxen dr 1
naproxen sodium TABS 275mg, 550mg 1
piroxicam CAPS 1
provil 200mg 3
qc childrens ibuprofen 100mg/5ml 3
qc ibuprofen TABS 200mg 3
sb ibuprofen 200mg 3
sm childrens ibuprofen 100mg/5ml 3
sm ibuprofen TABS 200mg 3
sm ibuprofen ib TABS 200mg 3
sulindac TABS 1
OPIOID ANALGESICS
acetaminophen w/ codeine 300-15mg 1 QL (400 tabs / 30 days)
acetaminophen w/ codeine 300-30mg 1 QL (360 tabs / 30 days)
acetaminophen w/ codeine 300-60mg 1 QL (180 tabs / 30 days)
acetaminophen w/ codeine soln 1 QL (2700 mL / 30 days)
buprenorphine patch 1 QL (4 patches / 28 days), PA
butorphanol tartrate SOLN 1mg/ml, 2mg/ml
2
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
17
Drug Name Drug Tier Requirements/Limits
BUTRANS 2 QL (4 patches / 28 days), PA
nalbuphine hcl SOLN 2
tramadol hcl tab 50 mg 1 QL (240 tabs / 30 days)
tramadol-acetaminophen 1 QL (240 tabs / 30 days)
OPIOID ANALGESICS, CII
endocet 2.5-325mg 1 QL (360 tabs / 30 days)
endocet 5-325mg 1 QL (360 tabs / 30 days)
endocet 7.5-325mg 1 QL (240 tabs / 30 days)
endocet 10-325mg 1 QL (180 tabs / 30 days)
fentanyl citrate LPOP 2 QL (120 lozenges / 30 days), PA
fentanyl patch 12 mcg/hr 1 QL (10 patches / 30 days), PA
fentanyl patch 25 mcg/hr 1 QL (10 patches / 30 days), PA
fentanyl patch 50 mcg/hr 1 QL (10 patches / 30 days), PA
fentanyl patch 75 mcg/hr 1 QL (10 patches / 30
days), PA
fentanyl patch 100 mcg/hr 1 QL (10 patches / 30
days), PA
FENTORA 2 QL (120 tabs / 30 days),
PA
hydroco/apap tab 5-325mg 1 QL (240 tabs / 30 days)
hydroco/apap tab 7.5-325 1 QL (180 tabs / 30 days)
hydroco/apap tab 10-325mg 1 QL (180 tabs / 30 days)
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
18
Drug Name Drug Tier Requirements/Limits
hydrocodone-acetaminophen 7.5-325 mg/15ml
1 QL (2700 mL / 30 days)
hydrocodone-ibuprofen tab 7.5-200 mg 1 QL (150 tabs / 30 days)
hydromorphone hcl LIQD 1 QL (600 mL / 30 days)
hydromorphone hcl SOLN 10mg/ml,
50mg/5ml, 500mg/50ml
2 B/D
hydromorphone hcl TABS 1 QL (180 tabs / 30 days)
HYSINGLA ER 2 QL (30 tabs / 30 days),
PA
lorcet hd tab 10-325mg 1 QL (180 tabs / 30 days)
lorcet plus tab 7.5-325 1 QL (180 tabs / 30 days)
lorcet tab 5-325mg 1 QL (240 tabs / 30 days)
methadone hcl SOLN 5mg/5ml, 10mg/5ml 1 QL (450 mL / 30 days),
PA
methadone hcl 5mg 1 QL (90 tabs / 30 days),
PA
methadone hcl 10mg 1 QL (90 tabs / 30 days),
PA
methadone hcl intensol 1 QL (90 mL / 30 days),
PA
morphine ext-rel tab 15mg, 30mg, 60mg,
100mg
1 QL (90 tabs / 30 days),
PA
morphine ext-rel tab 200mg 1 QL (60 tabs / 30 days), PA
morphine sul inj 1mg/ml 2 B/D
MORPHINE SUL INJ 4MG/ML 2 B/D
morphine sul inj 10mg/ml 2 B/D
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
19
Drug Name Drug Tier Requirements/Limits
MORPHINE SULFATE SOLN 2mg/ml, 4mg/ml, 5mg/ml, 8mg/ml, 10mg/ml, 150mg/30ml
2 B/D
morphine sulfate SOLN 4mg/ml, 8mg/ml, 10mg/ml
2 B/D
morphine sulfate TABS 15mg 1 QL (180 tabs / 30 days)
morphine sulfate TABS 30mg 1 QL (90 tabs / 30 days)
morphine sulfate oral soln 10mg/5ml 1 QL (900 mL / 30 days)
morphine sulfate oral soln 20mg/5ml 1 QL (750 mL / 30 days)
morphine sulfate oral soln 100mg/5ml 1 QL (180 mL / 30 days)
NUCYNTA ER 50mg, 100mg, 200mg,
250mg
2 QL (60 tabs / 30 days),
PA
NUCYNTA ER 150mg 2 QL (90 tabs / 30 days),
PA
oxycodone hcl CAPS 1 QL (180 caps / 30 days)
oxycodone hcl CONC 1 QL (180 mL / 30 days)
oxycodone hcl SOLN 1 QL (900 mL / 30 days)
oxycodone hcl TABS 1 QL (180 tabs / 30 days)
oxycodone w/ acetaminophen 2.5-325mg 1 QL (360 tabs / 30 days)
oxycodone w/ acetaminophen 5-325mg 1 QL (360 tabs / 30 days)
oxycodone w/ acetaminophen 7.5-325mg 1 QL (240 tabs / 30 days)
oxycodone w/ acetaminophen 10-325mg 1 QL (180 tabs / 30 days)
OXYCONTIN 2 QL (60 tabs / 30 days),
PA
ANESTHETICS
LOCAL ANESTHETICS
lidocaine hcl (local anesth.) 1 B/D
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
20
Drug Name Drug Tier Requirements/Limits
lidocaine inj 0.5% 1 B/D
lidocaine inj 1% 1 B/D
lidocaine inj 1.5% preservative free (pf) 1 B/D
ANTI-INFECTIVES
ANTI-BACTERIALS - MISCELLANEOUS
amikacin sulfate SOLN 1
gentamicin in saline 1
gentamicin sulfate SOLN 1
neomycin sulfate TABS 1
paromomycin sulfate CAPS 1
streptomycin sulfate SOLR 2
SULFADIAZINE TABS 2
tobramycin NEBU 2 NM, PA
tobramycin inj 1.2 gm/30ml 1
tobramycin inj 1.2gm 2
tobramycin inj 10mg/ml 1
tobramycin inj 40mg/ml 1
tobramycin inj 80mg/2ml 1
ANTI-INFECTIVES - MISCELLANEOUS
albendazole TABS 2
ALBENZA 2
ALINIA 2
atovaquone SUSP 2
AZACTAM IN ISO-OSMOTIC DE 2
AZACTAM/DEX INJ 2
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
21
Drug Name Drug Tier Requirements/Limits
aztreonam 1
BILTRICIDE 2
CAYSTON 2 NM, LA, PA
clindamycin cap 75mg 1
clindamycin cap 300mg 1
clindamycin hcl cap 150 mg 1
clindamycin phosphate in d5w 1
CLINDAMYCIN PHOSPHATE IN NACL 2
clindamycin phosphate inj 1
clindamycin soln 75mg/5ml 1
colistimethate sodium SOLR 1
dapsone TABS 1
DAPTOMYCIN 350mg 2
daptomycin 500mg 2
EMVERM 2
ertapenem sodium 1
imipenem-cilastatin 1
INVANZ 2
ivermectin TABS 1
linezolid in sodium chloride 2
linezolid inj 1
linezolid susp 2
linezolid tab 600mg 2
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
22
Drug Name Drug Tier Requirements/Limits
meropenem 1
methenamine hippurate 1
metronidazole TABS 1
metronidazole in nacl 1
NEBUPENT 2 B/D
nitrofurantoin macrocrystal 50mg, 100mg 2 PA; PA applies if 70 years and older after a
90 day supply in a calendar year
nitrofurantoin monohyd macro 2 PA; PA applies if 70 years and older after a 90 day supply in a
calendar year
PENTAM 300 2
praziquantel TABS 1
SIVEXTRO 2
sulfamethoxazole-trimethop ds 1
sulfamethoxazole-trimethoprim inj 1
sulfamethoxazole-trimethoprim susp 1
sulfamethoxazole-trimethoprim tab 400-80mg
1
SYNERCID 2
tigecycline 2
trimethoprim TABS 1
vancomycin hcl CAPS 125mg 1
vancomycin hcl CAPS 250mg 2
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
23
Drug Name Drug Tier Requirements/Limits
vancomycin hcl SOLR 1gm, 5gm, 10gm, 500mg, 750mg
1
VANCOMYCIN IN NACL 2
ANTIFUNGALS
ABELCET 2 B/D
AMBISOME 2 B/D
amphotericin b SOLR 1 B/D
caspofungin acetate 2
fluconazole SUSR; TABS 1
fluconazole in dextrose 1
fluconazole inj nacl 200 1
fluconazole inj nacl 400 1
flucytosine CAPS 2
griseofulvin microsize 1
griseofulvin ultramicrosize 1
itraconazole CAPS 1 PA
ketoconazole TABS 1 PA
MYCAMINE 2
NOXAFIL SUSP 2 QL (630 mL / 30 days)
NOXAFIL TBEC 2 QL (93 tabs / 30 days)
nystatin TABS 1
terbinafine hcl TABS 1 QL (90 tabs / year)
voriconazole SOLR 1
voriconazole SUSR; TABS 2
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
24
Drug Name Drug Tier Requirements/Limits
ANTIMALARIALS
atovaquone-proguanil hcl 1
chloroquine phosphate TABS 1
COARTEM 2
mefloquine hcl 1
PRIMAQUINE PHOSPHATE 2
quinine sulfate CAPS 1 PA
ANTIRETROVIRAL AGENTS
abacavir sulfate 1 NM
APTIVUS 2 NM
atazanavir sulfate 2 NM
CRIXIVAN 2 NM
didanosine 1 NM
EDURANT 2 NM
efavirenz CAPS 50mg 1 NM
efavirenz CAPS 200mg 2 NM
efavirenz TABS 2 NM
EMTRIVA 2 NM
fosamprenavir tab 700 mg 2 NM
FUZEON 2 NM
INTELENCE 2 NM
INVIRASE 2 NM
ISENTRESS 2 NM
ISENTRESS HD 2 NM
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
25
Drug Name Drug Tier Requirements/Limits
lamivudine 1 NM
LEXIVA SUSP 2 NM
nevirapine susp 50 mg/5ml 1 NM
nevirapine tab 100mg er 1 NM
nevirapine tab 200mg 1 NM
nevirapine tab 400mg er 1 NM
NORVIR PACK 2 NM
NORVIR SOLN 2 NM
PIFELTRO 2 NM
PREZISTA SUSP 2 QL (400 mL / 30 days), NM
PREZISTA TABS 75mg 2 QL (480 tabs / 30 days), NM
PREZISTA TABS 150mg 2 QL (240 tabs / 30 days), NM
PREZISTA TABS 600mg 2 QL (60 tabs / 30 days), NM
PREZISTA TABS 800mg 2 QL (30 tabs / 30 days), NM
RESCRIPTOR 2 NM
REYATAZ PACK 2 NM
ritonavir 1 NM
SELZENTRY 2 NM
stavudine 1 NM
tenofovir disoproxil fumarate 2 NM
TIVICAY 2 NM
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
26
Drug Name Drug Tier Requirements/Limits
TROGARZO 2 NM, LA
TYBOST 2 NM
VIDEX EC 125mg 2 NM
VIDEX PEDIATRIC 2 NM
VIRACEPT 2 NM
VIRAMUNE SUSP 2 NM
VIREAD POWD 2 NM
VIREAD TABS 150mg, 200mg, 250mg 2 NM
zidovudine cap 100mg 1 NM
zidovudine syp 50mg/5ml 1 NM
zidovudine tab 300mg 1 NM
ANTIRETROVIRAL COMBINATION AGENTS
abacavir sulfate-lamivudine 1 NM
abacavir sulfate-lamivudine-zidovudine 2 NM
ATRIPLA 2 NM
BIKTARVY 2 NM
CIMDUO 2 NM
COMPLERA 2 NM
DELSTRIGO 2 NM
DESCOVY 2 NM
EVOTAZ 2 NM
GENVOYA 2 NM
JULUCA 2 NM
KALETRA TAB 100-25MG 2 NM
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
27
Drug Name Drug Tier Requirements/Limits
KALETRA TAB 200-50MG 2 NM
lamivudine-zidovudine 1 NM
lopinavir-ritonavir 1 NM
ODEFSEY 2 NM
PREZCOBIX 2 NM
STRIBILD 2 NM
SYMFI 2 NM
SYMFI LO 2 NM
SYMTUZA 2 NM
TRIUMEQ 2 NM
TRUVADA TAB 100-150 2 QL (60 tabs / 30 days), NM
TRUVADA TAB 133-200 2 QL (30 tabs / 30 days), NM
TRUVADA TAB 167-250 2 QL (30 tabs / 30 days),
NM
TRUVADA TAB 200-300 2 QL (30 tabs / 30 days),
NM
ANTITUBERCULAR AGENTS
cycloserine CAPS 2
ethambutol hcl TABS 1
isoniazid TABS 1
isoniazid syp 50mg/5ml 1
PASER D/R 2
PRIFTIN 2
pyrazinamide TABS 1
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
28
Drug Name Drug Tier Requirements/Limits
rifabutin 1
rifampin CAPS; SOLR 1
RIFATER 2
SIRTURO 2 LA, PA
TRECATOR 2
ANTIVIRALS
acyclovir CAPS; SUSP; TABS 1
acyclovir sodium 1 B/D
adefovir dipivoxil 2 NM
BARACLUDE SOLN 2 NM
entecavir 2 NM
EPCLUSA 2 NM, PA
EPIVIR HBV SOLN 2 NM
famciclovir 1
ganciclovir sodium 1 B/D
HARVONI 2 NM, PA
lamivudine (hbv) 1 NM
MAVYRET 2 NM, PA
oseltamivir phosphate CAPS 30mg 1 QL (168 caps / year)
oseltamivir phosphate CAPS 45mg, 75mg 1 QL (84 caps / year)
oseltamivir phosphate SUSR 1 QL (1080 mL / year)
PEGASYS 2 NM, PA
PEGASYS PROCLICK 2 NM, PA
REBETOL SOLN 2 NM
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
29
Drug Name Drug Tier Requirements/Limits
RELENZA DISKHALER 2 QL (6 inhalers / year)
ribasphere CAPS 1 NM
ribasphere TABS 200mg 1 NM
RIBASPHERE TABS 400mg 2 NM
ribasphere TABS 600mg 2 NM
ribavirin 200mg 1 NM
rimantadine hydrochloride 1
valacyclovir hcl TABS 1
valganciclovir hcl 2
VEMLIDY 2 NM
VOSEVI 2 NM, PA
ZEPATIER 2 NM, PA
CEPHALOSPORINS
cefaclor 1
CEFACLOR MONOHYDRATE ER 2
cefadroxil 1
CEFAZOLIN IN DEXTROSE 2GM/100ML-4% 2
cefazolin inj 1
cefazolin sodium SOLR 1gm, 20gm 1
CEFAZOLIN SODIUM 1 GM/50ML 2
cefdinir 1
cefepime hcl 1
cefixime 1
cefotaxime sodium 1
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
30
Drug Name Drug Tier Requirements/Limits
cefoxitin sodium 1
cefpodoxime proxetil 1
cefprozil 1
ceftazidime SOLR 1
CEFTAZIDIME/DEXTROSE 2
ceftriaxone sodium SOLR 1gm, 2gm, 10gm, 250mg, 500mg
1
cefuroxime axetil 1
cefuroxime sodium 1
cephalexin CAPS 250mg, 500mg 1
cephalexin SUSR 1
SUPRAX CAPS 2
SUPRAX CHEW 2
SUPRAX SUSR 500mg/5ml 2
tazicef SOLR 1
TEFLARO 2
ERYTHROMYCINS/MACROLIDES
azithromycin PACK; SOLR; SUSR; TABS 1
clarithromycin TABS 1
clarithromycin er 1
clarithromycin for susp 1
DIFICID 2
e.e.s 400 1
ery-tab 1
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
31
Drug Name Drug Tier Requirements/Limits
ERYTHROCIN LACTOBIONATE 2
erythrocin stearate 1
erythromycin base 1
erythromycin cap 250mg ec 1
erythromycin ethylsuccinate TABS 1
FLUOROQUINOLONES
ciprofloxacin SUSR 1
ciprofloxacin hcl tab 1
ciprofloxacin in d5w 1
levofloxacin TABS 1
levofloxacin in d5w 1
levofloxacin inj 25mg/ml 1
levofloxacin oral soln 25 mg/ml 1
moxifloxacin hcl TABS 1
PENICILLINS
amoxicillin 1
amoxicillin & pot clavulanate 1
ampicillin & sulbactam sodium 1
ampicillin cap 500mg 1
ampicillin inj 1
ampicillin sodium 1
BICILLIN L-A 2
dicloxacillin sodium 1
nafcillin sodium 1gm, 2gm 1
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
32
Drug Name Drug Tier Requirements/Limits
nafcillin sodium 10gm 2
NAFCILLIN SODIUM FOR INJ 10GM 2
oxacillin sodium 1gm, 2gm 1
oxacillin sodium 10gm 2
PENICILLIN G POT IN DEXTROSE 2MU 2
PENICILLIN G POT IN DEXTROSE 3MU 2
PENICILLIN G PROCAINE 2
penicillin g sodium 1
penicillin v potassium 1
penicilln gk inj 5mu 1
penicilln gk inj 20mu 1
pfizerpen-g inj 5mu 1
pfizerpen-g inj 20mu 1
piper/tazoba inj 2-0.25gm 1
piper/tazoba inj 3-0.375gm 1
piper/tazoba inj 4-0.5gm 1
PIPER/TAZOBA INJ 12-1.5GM 2
piper/tazoba inj 36-4.5gm 1
TETRACYCLINES
doxy 100 1
doxycycline (monohydrate) CAPS 50mg, 100mg
1
doxycycline (monohydrate) TABS 1
doxycycline hyclate CAPS 1
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
33
Drug Name Drug Tier Requirements/Limits
doxycycline hyclate SOLR 1
doxycycline hyclate TABS 20mg, 100mg 1
minocycline hcl CAPS 1
mondoxyne nl cap 100mg 1
morgidox cap 1x50mg 1
tetracycline hcl CAPS 1
ANTINEOPLASTIC AGENTS
ALKYLATING AGENTS
BENDEKA 2 B/D, NM
cyclophosphamide CAPS 1 B/D
cyclophosphamide SOLR 2 B/D
dacarbazine 100mg 1 B/D
EMCYT 2
GLEOSTINE 2
IFEX INJ 3GM 2 B/D
ifosfamide inj 1gm/20ml 1 B/D
IFOSFAMIDE INJ 3GM 2 B/D
ifosfamide inj 3gm/60ml 1 B/D
LEUKERAN 2
ANTHRACYCLINES
adriamycin 1 B/D
doxorubicin hcl 1 B/D
doxorubicin hcl liposomal 2 B/D
epirubicin hcl 1 B/D
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
34
Drug Name Drug Tier Requirements/Limits
ANTIBIOTICS
bleomycin sulfate 1 B/D
mitomycin SOLR 2 B/D
ANTIMETABOLITES
adrucil 1 B/D
ALIMTA 2 B/D
azacitidine 2 B/D, NM
cytarabine 20mg/ml 1 B/D
fluorouracil SOLN 1 B/D
gemcitabine inj soln 1 B/D
gemcitabine inj solr 1 B/D
mercaptopurine TABS 1
methotrexate sodium inj 1 B/D
PURIXAN 2 NM
TABLOID 2
ANTIMITOTIC, TAXOIDS
ABRAXANE 2 B/D
docetaxel CONC 20mg/ml, 80mg/4ml 2 B/D
DOCETAXEL CONC 80mg/4ml, 160mg/8ml, 200mg/10ml
2 B/D
docetaxel SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml
2 B/D
DOCETAXEL SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml
2 B/D
paclitaxel 1 B/D
TAXOTERE 80mg/4ml 2 B/D
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
35
Drug Name Drug Tier Requirements/Limits
ANTIMITOTIC, VINCA ALKALOIDS
vinblastine sulfate 1 B/D
vincasar pfs 1 B/D
vincristine sulfate 1 B/D
vinorelbine tartrate 1 B/D
BIOLOGIC RESPONSE MODIFIERS
AVASTIN 2 NM, LA, PA
BORTEZOMIB 2 NM, PA
DAURISMO 2 NM, LA, PA
ERIVEDGE 2 NM, LA, PA
FARYDAK 2 NM, LA, PA
HERCEPTIN 2 NM, PA
IBRANCE 2 NM, LA, PA
IDHIFA 2 NM, LA, PA
KADCYLA 2 B/D, NM
KEYTRUDA 2 NM, PA
KISQALI 2 NM, PA
KISQALI FEMARA 200 DOSE 2 NM, PA
KISQALI FEMARA 400 DOSE 2 NM, PA
KISQALI FEMARA 600 DOSE 2 NM, PA
LYNPARZA 2 NM, LA, PA
MYLOTARG 2 NM, LA, PA
NINLARO 2 NM, PA
ODOMZO 2 NM, LA, PA
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
36
Drug Name Drug Tier Requirements/Limits
RITUXAN 2 NM, LA, PA
RITUXAN HYCELA 2 NM, LA, PA
RUBRACA 2 NM, LA, PA
TALZENNA 2 NM, LA, PA
TECENTRIQ 1200mg/20ml 2 NM, LA, PA
TIBSOVO 2 NM, LA, PA
VELCADE 2 NM, PA
VENCLEXTA 2 NM, LA, PA
VENCLEXTA STARTING PACK 2 NM, LA, PA
VERZENIO 2 NM, LA, PA
ZEJULA 2 NM, LA, PA
ZOLINZA 2 NM, PA
HORMONAL ANTINEOPLASTIC AGENTS
abiraterone acetate 2 NM, PA
anastrozole TABS 1
bicalutamide 1
DEPO-PROVERA INJ 400/ML 2 B/D
ERLEADA 2 NM, LA, PA
exemestane 1
FARESTON 2
FASLODEX 2 B/D
flutamide 1
letrozole TABS 1
leuprolide inj 1mg/0.2 1 NM, PA
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
37
Drug Name Drug Tier Requirements/Limits
LUPRON DEPOT (1-MONTH) 3.75mg 2 NM, PA
LUPRON DEPOT INJ 11.25MG (3-MONTH) 2 NM, PA
LYSODREN 2
megestrol ac sus 40mg/ml 2
megestrol ac tab 20mg 2
megestrol ac tab 40mg 2
megestrol sus 625mg/5ml 2 PA
nilutamide 2
SOLTAMOX 2
tamoxifen citrate TABS 1
toremifene citrate 2
TRELSTAR DEP INJ 3.75MG 2 NM, PA
TRELSTAR LA INJ 11.25MG 2 NM, PA
XTANDI 2 NM, LA, PA
ZYTIGA 2 NM, LA, PA
IMMUNOMODULATORS
POMALYST CAP 1MG 2 NM, LA, PA
POMALYST CAP 2MG 2 NM, LA, PA
POMALYST CAP 3MG 2 NM, LA, PA
POMALYST CAP 4MG 2 NM, LA, PA
REVLIMID 2 QL (28 caps / 28 days), NM, LA, PA
THALOMID 50mg, 100mg 2 QL (30 caps / 30 days), NM, PA
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
38
Drug Name Drug Tier Requirements/Limits
THALOMID 150mg, 200mg 2 QL (60 caps / 30 days), NM, PA
KINASE INHIBITORS
AFINITOR 2 QL (30 tabs / 30 days),
NM, PA
AFINITOR DISPERZ 2mg 2 QL (150 tabs / 30 days),
NM, PA
AFINITOR DISPERZ 3mg 2 QL (90 tabs / 30 days),
NM, PA
AFINITOR DISPERZ 5mg 2 QL (60 tabs / 30 days),
NM, PA
ALECENSA 2 NM, LA, PA
ALUNBRIG 2 NM, LA, PA
BOSULIF 2 NM, PA
BRAFTOVI 2 NM, LA, PA
CABOMETYX 2 QL (30 tabs / 30 days),
NM, LA, PA
CALQUENCE 2 NM, LA, PA
CAPRELSA 2 NM, LA, PA
COMETRIQ 2 NM, LA, PA
COPIKTRA 2 NM, LA, PA
COTELLIC 2 NM, LA, PA
GILOTRIF TAB 20MG 2 NM, LA, PA
GILOTRIF TAB 30MG 2 NM, LA, PA
GILOTRIF TAB 40MG 2 NM, LA, PA
ICLUSIG 2 NM, LA, PA
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
39
Drug Name Drug Tier Requirements/Limits
imatinib mesylate 100mg 2 QL (90 tabs / 30 days), NM, PA
imatinib mesylate 400mg 2 QL (60 tabs / 30 days), NM, PA
IMBRUVICA 2 NM, LA, PA
INLYTA 1mg 2 QL (180 tabs / 30 days), NM, LA, PA
INLYTA 5mg 2 QL (120 tabs / 30 days), NM, LA, PA
IRESSA 2 NM, LA, PA
JAKAFI 2 QL (60 tabs / 30 days),
NM, LA, PA
LENVIMA 4 MG DAILY DOSE 2 NM, LA, PA
LENVIMA 8 MG DAILY DOSE 2 NM, LA, PA
LENVIMA 10 MG DAILY DOSE 2 NM, LA, PA
LENVIMA 12MG DAILY DOSE 2 NM, LA, PA
LENVIMA 14 MG DAILY DOSE 2 NM, LA, PA
LENVIMA 18 MG DAILY DOSE 2 NM, LA, PA
LENVIMA 20 MG DAILY DOSE 2 NM, LA, PA
LENVIMA 24 MG DAILY DOSE 2 NM, LA, PA
LORBRENA 2 NM, LA, PA
MEKINIST 2 NM, LA, PA
MEKTOVI 2 NM, LA, PA
NERLYNX 2 NM, LA, PA
NEXAVAR 2 NM, LA, PA
RYDAPT 2 NM, PA
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
40
Drug Name Drug Tier Requirements/Limits
SPRYCEL 2 NM, PA
STIVARGA 2 NM, LA, PA
SUTENT 2 NM, PA
TAFINLAR 2 NM, LA, PA
TAGRISSO 2 NM, LA, PA
TARCEVA 25mg 2 QL (90 tabs / 30 days), NM, LA, PA
TARCEVA 100mg, 150mg 2 QL (30 tabs / 30 days), NM, LA, PA
TASIGNA 2 NM, PA
TYKERB 2 NM, LA, PA
VITRAKVI 2 NM, LA, PA
VIZIMPRO 2 NM, LA, PA
VOTRIENT 2 NM, LA, PA
XALKORI 2 NM, LA, PA
XOSPATA 2 NM, LA, PA
ZELBORAF 2 NM, LA, PA
ZYDELIG 2 NM, LA, PA
ZYKADIA 2 NM, LA, PA
MISCELLANEOUS
bexarotene 2 NM, PA
hydroxyurea CAPS 1
LONSURF 2 NM, PA
MATULANE 2 LA
SYLATRON KIT 200MCG 2 NM, PA
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
41
Drug Name Drug Tier Requirements/Limits
SYLATRON KIT 300MCG 2 NM, PA
SYLATRON KIT 600MCG 2 NM, PA
SYNRIBO 2 NM, PA
tretinoin (chemotherapy) 2
PLATINUM-BASED AGENTS
carboplatin 1 B/D
cisplatin 1 B/D
oxaliplatin inj 50mg 2 B/D
oxaliplatin inj 50mg/10ml 1 B/D
oxaliplatin inj 100mg 2 B/D
oxaliplatin inj 100mg/20ml 1 B/D
PROTECTIVE AGENTS
dexrazoxane 500mg 2 B/D
leucovorin calcium SOLR 1 B/D
leucovorin calcium TABS 1
MESNEX TABS 2
TOPOISOMERASE INHIBITORS
etoposide SOLN 1 B/D
irinotecan hcl 1 B/D
toposar 1 B/D
topotecan hcl 2 B/D
TOPOTECAN INJ 4MG/4ML 2 B/D
CARDIOVASCULAR
ACE INHIBITOR COMBINATIONS
amlodipine--benazepril hcl cap 10-20 mg 1
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
42
Drug Name Drug Tier Requirements/Limits
amlodipine-benazepril hcl cap 2.5-10 mg 1
amlodipine-benazepril hcl cap 5-10 mg 1
amlodipine-benazepril hcl cap 5-20 mg 1
amlodipine-benazepril hcl cap 5-40 mg 1
amlodipine-benazepril hcl cap 10-40mg 1
benazepril & hydrochlorothiazide 1
captopril & hydrochlorothiazide 1
enalapril maleate & hydrochlorothiazide 1
fosinopril sodium & hydrochlorothiazide 1
lisinopril & hydrochlorothiazide 1
moexipril-hydrochlorothiazide 1
quinapril-hydrochlorothiazide 1
ACE INHIBITORS
benazepril hcl TABS 1
captopril TABS 1
enalapril maleate TABS 1
fosinopril sodium 1
lisinopril TABS 1
moexipril hcl 1
perindopril erbumine 1
quinapril hcl 1
ramipril 1
trandolapril 1
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
43
Drug Name Drug Tier Requirements/Limits
ALDOSTERONE RECEPTOR ANTAGONISTS
eplerenone 1
spironolactone TABS 1
ALPHA BLOCKERS
doxazosin mesylate TABS 1
prazosin hcl 1
terazosin hcl 1
ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS
amlodipine besylate-olmesartan medoxomil 1
amlodipine besylate-valsartan tab 5-160 mg
1
amlodipine besylate-valsartan tab 5-320 mg
1
amlodipine besylate-valsartan tab 10-160 mg
1
amlodipine besylate-valsartan tab 10-320 mg
1
amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg
1
amlodipine-valsartan-hydrochlorothiazide 5-160-25mg
1
amlodipine-valsartan-hydrochlorothiazide
10-160-12.5mg
1
amlodipine-valsartan-hydrochlorothiazide
10-160-25mg
1
amlodipine-valsartan-hydrochlorothiazide
10-320-25mg
1
candesartan cilexetil-hydrochlorothiazide 1
ENTRESTO 2
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
44
Drug Name Drug Tier Requirements/Limits
irbesartan-hydrochlorothiazide 1
losartan-hydrochlorothiazide 1
olmesartan medoxomil-amlodipine-hydrochlorothiazide
1
olmesartan medoxomil-hydrochlorothiazide 1
telmisartan-amlodipine 1
telmisartan-hydrochlorothiazide 1
valsartan-hydrochlorothiazide 1
ANGIOTENSIN II RECEPTOR ANTAGONISTS
candesartan cilexetil 1
eprosartan mesylate 1
irbesartan 1
losartan potassium 1
olmesartan medoxomil TABS 1
telmisartan 1
valsartan 1
ANTIARRHYTHMICS
amiodarone hcl soln 1
amiodarone tab 100mg 1
amiodarone tab 200mg 1
amiodarone tab 400mg 1
disopyramide phosphate 2
dofetilide 1 NM
flecainide acetate 1
mexiletine hcl 1
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
45
Drug Name Drug Tier Requirements/Limits
MULTAQ 2
NORPACE CR 2
pacerone 1
propafenone hcl 1
propafenone hcl 12hr 1
quinidine gluconate 1
quinidine sulfate 1
sorine 1
sotalol hcl 1
sotalol hcl (afib/afl) 1
ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS
atorvastatin calcium TABS 1
lovastatin 1
pravastatin sodium 1
rosuvastatin calcium 1 QL (30 tabs / 30 days)
simvastatin TABS 5mg, 10mg, 20mg, 40mg
1
simvastatin TABS 80mg 1 QL (30 tabs / 30 days)
ANTILIPEMICS, MISCELLANEOUS
cholestyramine 1
cholestyramine light 1
colesevelam hcl 1
colestipol hcl gran 1
colestipol hcl pack 1
colestipol hcl tabs 1
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
46
Drug Name Drug Tier Requirements/Limits
ezetimibe 1
ezetimibe-simvastatin 1
fenofibrate TABS 48mg, 54mg, 145mg, 160mg
1
fenofibrate micronized 67mg, 134mg,
200mg
1
gemfibrozil TABS 1
JUXTAPID 2 NM, LA, PA
KYNAMRO 2 PA
niacin er (antihyperlipidemic) 500mg 1 QL (90 tabs / 30 days)
niacin er (antihyperlipidemic) 750mg,
1000mg
1
niacor 1
PRALUENT 2 PA
prevalite 1
VASCEPA 2
WELCHOL PAK 2
BETA-BLOCKER/DIURETIC COMBINATIONS
atenolol & chlorthalidone 1
bisoprolol & hydrochlorothiazide 1
metoprolol & hctz tab 50-25mg 1
metoprolol & hctz tab 100-25mg 1
metoprolol & hctz tab 100-50mg 1
propranolol & hydrochlorothiazide 1
BETA-BLOCKERS
acebutolol hcl CAPS 1
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
47
Drug Name Drug Tier Requirements/Limits
atenolol TABS 1
betaxolol hcl 1
bisoprolol fumarate 1
BYSTOLIC 2.5mg, 5mg, 10mg 2 QL (30 tabs / 30 days)
BYSTOLIC 20mg 2 QL (60 tabs / 30 days)
carvedilol 1
labetalol hcl TABS 1
metoprolol succinate 1
metoprolol tartrate SOCT 1
metoprolol tartrate SOLN 1
metoprolol tartrate TABS 25mg, 50mg, 100mg
1
nadolol TABS 1
pindolol 1
propranolol cap er 1
propranolol hcl TABS 1
propranolol oral sol 1
timolol maleate TABS 1
CALCIUM CHANNEL BLOCKERS
amlodipine besylate TABS 1
cartia xt cap 120/24hr 1
cartia xt cap 180/24hr 1
cartia xt cap 240/24hr 1
cartia xt cap 300/24hr 1
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
48
Drug Name Drug Tier Requirements/Limits
dilt-xr cap 1
diltiazem cap 120mg cd 1
diltiazem cap 180mg cd 1
diltiazem cap 240mg cd 1
diltiazem cap 360mg cd 1
diltiazem cap er/12hr 1
diltiazem hcl TABS 1
diltiazem hcl cap sr 24hr 1
diltiazem hcl coated beads cap sr 24hr 1
diltiazem hcl extended release beads cap sr
1
diltiazem inj 1
felodipine 1
isradipine 1
nicardipine hcl CAPS 1
nifedipine TB24 1
nifedipine er 1
nimodipine CAPS 2
NYMALIZE 2
taztia xt 1
verapamil cap er 1
verapamil hcl SOLN; TABS 1
verapamil hcl tab er 1
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
49
Drug Name Drug Tier Requirements/Limits
DIGITALIS GLYCOSIDES
digitek .25mg 1 PA; PA if 70 years and
older
digitek .125mg 1 QL (30 tabs / 30 days)
digox 125mcg 1 QL (30 tabs / 30 days)
digox 250mcg 1 PA; PA if 70 years and older
digoxin TABS 125mcg 1 QL (30 tabs / 30 days)
digoxin TABS 250mcg 1 PA; PA if 70 years and older
digoxin inj 1
digoxin sol 50mcg/ml 1 PA; PA if 70 years and
older
DIRECT RENIN INHIBITORS/COMBINATIONS
TEKTURNA 2
TEKTURNA HCT 2
DIURETICS
acetazolamide CP12; TABS 1
amiloride & hydrochlorothiazide 1
amiloride hcl TABS 1
bumetanide 1
chlorothiazide tabs 1
chlorthalidone 1
furosemide SOLN; TABS 1
furosemide inj 1
hydrochlorothiazide CAPS; TABS 1
indapamide 1
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
50
Drug Name Drug Tier Requirements/Limits
methazolamide TABS 1
methyclothiazide 1
metolazone 1
spironolactone & hydrochlorothiazide 1
torsemide tabs 1
triamterene & hydrochlorothiazide cap 37.5-25 mg
1
triamterene & hydrochlorothiazide tabs 1
MISCELLANEOUS
clonidine hcl TABS 1
clonidine hcl ptwk 1
CORLANOR 2
DEMSER 2 PA
hydralazine hcl SOLN; TABS 1
midodrine hcl 1
minoxidil TABS 1
NORTHERA 2 NM, LA, PA
RANEXA 2
NITRATES
isosorb mononitrate tab 1
isosorbide dinitrate 1
isosorbide dinitrate er 1
isosorbide mononitrate er 1
minitran 1
NITRO-BID 2
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
51
Drug Name Drug Tier Requirements/Limits
NITRO-DUR DIS 0.3MG/HR 2
NITRO-DUR DIS 0.8MG/HR 2
nitroglycerin SOLN .4mg/spray 1
nitroglycerin SUBL 1
nitroglycerin td patch 1
PULMONARY ARTERIAL HYPERTENSION
ADEMPAS 2 QL (90 tabs / 30 days),
NM, LA, PA
LETAIRIS 2 QL (30 tabs / 30 days),
NM, LA, PA
OPSUMIT 2 QL (30 tabs / 30 days),
NM, LA, PA
REMODULIN 2 NM, LA, PA
sildenafil citrate tab 20 mg (pulmonary hypertension)
1 QL (90 tabs / 30 days), NM, PA
TRACLEER TABS 62.5mg 2 QL (120 tabs / 30 days), NM, LA, PA
TRACLEER TABS 125mg 2 QL (60 tabs / 30 days), NM, LA, PA
VENTAVIS 2 NM, PA
CENTRAL NERVOUS SYSTEM
ANTIANXIETY
alprazolam tab 0.5mg 1 QL (150 tabs / 30 days)
alprazolam tab 0.25mg 1 QL (150 tabs / 30 days)
alprazolam tab 1mg 1 QL (150 tabs / 30 days)
alprazolam tab 2mg 1 QL (150 tabs / 30 days)
buspirone hcl TABS 1
fluvoxamine maleate TABS 1
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
52
Drug Name Drug Tier Requirements/Limits
lorazepam SOLN 1
lorazepam TABS 1 QL (150 tabs / 30 days)
lorazepam intensol 1 QL (150 mL / 30 days)
ANTICONVULSANTS
APTIOM 200mg 2 QL (180 tabs / 30 days)
APTIOM 400mg 2 QL (90 tabs / 30 days)
APTIOM 600mg, 800mg 2 QL (60 tabs / 30 days)
BANZEL SUS 40MG/ML 2 PA
BANZEL TAB 200MG 2 PA
BANZEL TAB 400MG 2 PA
BRIVIACT INJ 50MG/5ML 2 PA
BRIVIACT SOL 10MG/ML 2 PA
BRIVIACT TAB 10MG 2 PA
BRIVIACT TAB 25MG 2 PA
BRIVIACT TAB 50MG 2 PA
BRIVIACT TAB 75MG 2 PA
BRIVIACT TAB 100MG 2 PA
carbamazepine CHEW; CP12; SUSP; TABS; TB12
1
CELONTIN 2
clobazam 1 PA
clonazepam TABS 2mg 1 QL (300 tabs / 30 days)
clonazepam TABS .5mg, 1mg 1 QL (90 tabs / 30 days)
clonazepam TBDP 2mg 1 QL (300 tabs / 30 days)
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
53
Drug Name Drug Tier Requirements/Limits
clonazepam TBDP .125mg, .25mg, .5mg, 1mg
1 QL (90 tabs / 30 days)
clorazepate dipotassium 1 QL (180 tabs / 30 days), PA; PA if 65 years and older
DIASTAT ACUDIAL 2
DIASTAT PEDIATRIC 2
diazepam TABS 1 QL (120 tabs / 30 days), PA; PA if 65 years and older
diazepam gel 1
diazepam inj 1
diazepam intensol 1 QL (240 mL / 30 days), PA; PA if 65 years and older
diazepam oral soln 1 mg/ml 1 QL (1200 mL / 30 days), PA; PA if 65 years and
older
DILANTIN CAP 30MG 2
DILANTIN CAP 100MG 2
DILANTIN CHEW TAB 50MG 2
DILANTIN-125 SUSP 2
divalproex sodium CSDR; TB24; TBEC 1
EPIDIOLEX 2 QL (600 mL / 30 days), NM, LA, PA
epitol 1
ethosuximide CAPS; SOLN 1
felbamate SUSP 2
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
54
Drug Name Drug Tier Requirements/Limits
felbamate TABS 1
FYCOMPA SUSP 2 QL (720 mL / 30 days), PA
FYCOMPA TABS 2mg, 4mg, 6mg 2 QL (60 tabs / 30 days), PA
FYCOMPA TABS 8mg, 10mg, 12mg 2 QL (30 tabs / 30 days), PA
gabapentin CAPS 100mg 1 QL (1080 caps / 30 days)
gabapentin CAPS 300mg 1 QL (360 caps / 30 days)
gabapentin CAPS 400mg 1 QL (270 caps / 30 days)
gabapentin SOLN 1 QL (2160 mL / 30 days)
gabapentin TABS 600mg 1 QL (180 tabs / 30 days)
gabapentin TABS 800mg 1 QL (120 tabs / 30 days)
lamotrigine CHEW; TABS; TB24 1
levetiracetam SOLN; TABS; TB24 1
levetiracetam in sodium chloride 1
levetiracetam oral soln 100 mg/ml 1
LYRICA CAPS 25mg, 50mg, 75mg,
100mg, 150mg
2 QL (120 caps / 30 days)
LYRICA CAPS 200mg 2 QL (90 caps / 30 days)
LYRICA CAPS 225mg, 300mg 2 QL (60 caps / 30 days)
LYRICA SOLN 2 QL (946 mL / 30 days)
ONFI 2 PA
oxcarbazepine 1
PEGANONE 2
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
55
Drug Name Drug Tier Requirements/Limits
phenobarbital ELIX; TABS 2 PA; PA if 70 years and older
PHENOBARBITAL SODIUM SOLN 65mg/ml 2 PA; PA if 70 years and older
phenobarbital sodium SOLN 130mg/ml 2 PA; PA if 70 years and older
PHENYTEK 2
phenytoin CHEW; SUSP 1
phenytoin sodium extended 1
phenytoin sodium inj 50mg/ml 1
primidone TABS 1
roweepra 1
roweepra xr 1
SABRIL TABS 2 QL (180 tabs / 30 days),
NM, LA, PA
SPRITAM 2
subvenite tab 1
SYMPAZAN 2 PA
tiagabine hcl 1
topiramate CPSP; TABS 1
valproate sodium SOLN 1
valproic acid CAPS 1
vigabatrin powd pack 500mg 2 QL (180 packets / 30
days), NM, LA, PA
vigabatrin tab 500mg 2 QL (180 tabs / 30 days),
NM, LA, PA
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
56
Drug Name Drug Tier Requirements/Limits
VIMPAT 50mg 2 QL (120 tabs / 30 days)
VIMPAT 100mg, 150mg, 200mg 2 QL (60 tabs / 30 days)
VIMPAT INJ 200MG/20ML 2
VIMPAT SOL 10MG/ML 2 QL (1200 mL / 30 days)
zonisamide CAPS 1
ANTIDEMENTIA
donepezil hydrochloride TABS 5mg 1 QL (30 tabs / 30 days)
donepezil hydrochloride TABS 10mg 1
donepezil hydrochloride TBDP 5mg 1 QL (30 tabs / 30 days)
donepezil hydrochloride TBDP 10mg 1
galantamine hydrobromide SOLN 1
galantamine hydrobromide TABS 1 QL (60 tabs / 30 days)
galantamine hydrobromide er 1 QL (30 caps / 30 days)
memantine hcl cp24 1 PA; PA if < 30 yrs
memantine soln 1 PA; PA if < 30 yrs
memantine tabs 1 PA; PA if < 30 yrs
memantine titration pak 2 PA; PA if < 30 yrs
NAMZARIC 2
rivastigmine tartrate 1.5mg, 3mg 1 QL (90 caps / 30 days)
rivastigmine tartrate 4.5mg, 6mg 1 QL (60 caps / 30 days)
rivastigmine td patch 24hr 4.6 mg/24hr 1 QL (30 patches / 30 days)
rivastigmine td patch 24hr 9.5 mg/24hr 1 QL (30 patches / 30 days)
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
57
Drug Name Drug Tier Requirements/Limits
rivastigmine td patch 24hr 13.3 mg/24hr 1 QL (30 patches / 30 days)
ANTIDEPRESSANTS
amitriptyline hcl TABS 2
amoxapine tab 25mg 2
amoxapine tab 50mg 2
amoxapine tab 100mg 2
amoxapine tab 150mg 2
bupropion hcl TABS 1
bupropion hcl TB12 1
bupropion hcl TB24 150mg, 300mg 1
citalopram hydrobromide 1
clomipramine hcl CAPS 2 PA
desipramine hcl TABS 2
desvenlafaxine succinate 1 QL (30 tabs / 30 days), PA
doxepin hcl CAPS; CONC 2
duloxetine hcl CPEP 20mg 1 QL (180 caps / 30 days)
duloxetine hcl CPEP 30mg 1 QL (120 caps / 30 days)
duloxetine hcl CPEP 60mg 1 QL (60 caps / 30 days)
EMSAM 2 QL (30 patches / 30 days), PA
escitalopram oxalate 1
FETZIMA 20mg 2 QL (180 caps / 30
days), PA
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
58
Drug Name Drug Tier Requirements/Limits
FETZIMA 40mg 2 QL (90 caps / 30 days), PA
FETZIMA 80mg, 120mg 2 QL (30 caps / 30 days), PA
FETZIMA TITRATION PACK 2 PA
fluoxetine cap 10mg 1
fluoxetine cap 20mg 1
fluoxetine cap 40mg 1
fluoxetine hcl SOLN 1
imipramine hcl TABS 2
maprotiline hcl 1
MARPLAN TAB 10MG 2 QL (180 tabs / 30 days)
mirtazapine TABS; TBDP 1
nefazodone hcl 1
nortriptyline hcl CAPS; SOLN 2
paroxetine hcl tabs 2
PAXIL SUSP 2 QL (900 mL / 30 days)
phenelzine sulfate TABS 1
protriptyline hcl 2
sertraline hcl CONC; TABS 1
tranylcypromine sulfate 1
trazodone hcl TABS 50mg, 100mg, 150mg 1
trimipramine maleate CAPS 25mg 2 QL (240 caps / 30 days)
trimipramine maleate CAPS 50mg 2 QL (120 caps / 30 days)
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
59
Drug Name Drug Tier Requirements/Limits
trimipramine maleate CAPS 100mg 2 QL (60 caps / 30 days)
TRINTELLIX 5mg 2 QL (120 tabs / 30 days)
TRINTELLIX 10mg 2 QL (60 tabs / 30 days)
TRINTELLIX 20mg 2 QL (30 tabs / 30 days)
venlafaxine hcl CP24; TABS 1
VIIBRYD STARTER PACK 2
VIIBRYD TAB 2 QL (30 tabs / 30 days)
ANTIPARKINSONIAN AGENTS
amantadine hcl CAPS 1 QL (120 caps / 30 days)
amantadine hcl SYRP; TABS 1
APOKYN 2 QL (20 cartridges / 30
days), NM, LA, PA
benztropine mesylate inj 1
benztropine mesylate tab 0.5mg 2 PA; PA if 70 years and older
benztropine mesylate tab 1mg 2 PA; PA if 70 years and older
benztropine mesylate tab 2mg 2 PA; PA if 70 years and older
bromocriptine mesylate CAPS; TABS 1
carbidopa-levodopa 1
carbidopa/levodopa/entacapone 1
entacapone 1
NEUPRO 2
pramipexole tab 0.5mg 1
pramipexole tab 0.25mg 1
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
60
Drug Name Drug Tier Requirements/Limits
pramipexole tab 0.75mg 1
pramipexole tab 0.125mg 1
pramipexole tab 1.5mg 1
pramipexole tab 1mg 1
rasagiline mesylate TABS 1
ropinirole tab 0.5mg 1
ropinirole tab 0.25mg 1
ropinirole tab 1mg 1
ropinirole tab 2mg 1
ropinirole tab 3mg 1
ropinirole tab 4mg 1
ropinirole tab 5mg 1
selegiline hcl CAPS; TABS 1
trihexyphenidyl hcl 2 PA; PA if 70 years and older
ANTIPSYCHOTICS
ABILIFY MAINTENA 2 QL (1 injection / 28
days)
aripiprazole odt 2 QL (60 tabs / 30 days)
aripiprazole oral solution 1 mg/ml 2 QL (900 mL / 30 days)
aripiprazole tab 1 QL (30 tabs / 30 days)
ARISTADA 441mg/1.6ml, 662mg/2.4ml,
882mg/3.2ml
2 QL (1 injection / 28
days)
ARISTADA 1064mg/3.9ml 2 QL (1 injection / 56
days)
ARISTADA INITIO 2
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
61
Drug Name Drug Tier Requirements/Limits
chlorpromazine hcl TABS 1
CHLORPROMAZINE INJ 2
clozapine odt 12.5mg, 25mg 1 PA
clozapine odt 100mg 1 QL (270 tabs / 30 days),
PA
clozapine odt 150mg 1 QL (180 tabs / 30 days),
PA
clozapine odt 200mg 2 QL (135 tabs / 30 days),
PA
clozapine tab 25mg 1
clozapine tab 50mg 1
clozapine tab 100mg 1 QL (270 tabs / 30 days)
clozapine tab 200mg 1 QL (135 tabs / 30 days)
FANAPT 2 QL (60 tabs / 30 days)
FANAPT TITRATION PACK 2
fluphenazine decanoate SOLN 1
fluphenazine hcl 1
GEODON SOLR 2 QL (6 mL / 3 days)
haloperidol TABS 1
haloperidol conc 2mg/ml 1
haloperidol decanoate SOLN 1
haloperidol lactate inj 5mg/ml 1
INVEGA SUST INJ 39 MG/0.25 ML 2 QL (1 injection / 28 days)
INVEGA SUST INJ 78 MG/0.5 ML 2 QL (1 injection / 28 days)
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
62
Drug Name Drug Tier Requirements/Limits
INVEGA SUST INJ 117 MG/0.75 ML 2 QL (1 injection / 28 days)
INVEGA SUST INJ 156MG/ML 2 QL (1 injection / 28 days)
INVEGA SUST INJ 234 MG/1.5 ML 2 QL (1 injection / 28 days)
INVEGA TRINZA 2 QL (1 injection / 90 days)
LATUDA 20mg, 60mg, 80mg 2 QL (60 tabs / 30 days)
LATUDA 40mg, 120mg 2 QL (30 tabs / 30 days)
loxapine succinate 1
molindone hcl 1
NUPLAZID CAPS 2 QL (30 caps / 30 days), NM, LA, PA
NUPLAZID TABS 10MG 2 QL (30 tabs / 30 days), NM, LA, PA
NUPLAZID TABS 17MG 2 QL (60 tabs / 30 days), NM, LA, PA
olanzapine SOLR 1 QL (3 vials / 1 day)
olanzapine TABS 2.5mg 1 QL (240 tabs / 30 days)
olanzapine TABS 5mg 1 QL (120 tabs / 30 days)
olanzapine TABS 7.5mg, 15mg, 20mg 1 QL (30 tabs / 30 days)
olanzapine TABS 10mg 1 QL (60 tabs / 30 days)
olanzapine TBDP 5mg, 15mg, 20mg 1 QL (30 tabs / 30 days)
olanzapine TBDP 10mg 1 QL (60 tabs / 30 days)
paliperidone 1.5mg, 3mg, 9mg 2 QL (30 tabs / 30 days)
paliperidone 6mg 2 QL (60 tabs / 30 days)
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
63
Drug Name Drug Tier Requirements/Limits
perphenazine TABS 1
pimozide 1
quetiapine fumarate TABS 1
quetiapine fumarate TB24 50mg, 300mg,
400mg
1 QL (60 tabs / 30 days)
quetiapine fumarate TB24 150mg, 200mg 1 QL (30 tabs / 30 days)
REXULTI 1mg 2 QL (90 tabs / 30 days)
REXULTI 2mg 2 QL (60 tabs / 30 days)
REXULTI 3mg, 4mg 2 QL (30 tabs / 30 days)
REXULTI .5mg 2 QL (180 tabs / 30 days)
REXULTI .25mg 2 QL (360 tabs / 30 days)
RISPERDAL INJ 12.5MG 2 QL (2 injections / 28 days)
RISPERDAL INJ 25MG 2 QL (2 injections / 28 days)
RISPERDAL INJ 37.5MG 2 QL (2 injections / 28 days)
RISPERDAL INJ 50MG 2 QL (2 injections / 28 days)
risperidone SOLN 1 QL (240 mL / 30 days)
risperidone TABS 1
risperidone TBDP .5mg 1 QL (90 tabs / 30 days)
risperidone TBDP .25mg, 1mg, 2mg, 3mg, 4mg
1 QL (60 tabs / 30 days)
SAPHRIS 2.5mg 2 QL (240 tabs / 30 days)
SAPHRIS 5mg 2 QL (120 tabs / 30 days)
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
64
Drug Name Drug Tier Requirements/Limits
SAPHRIS 10mg 2 QL (60 tabs / 30 days)
thioridazine hcl TABS 1
thiothixene 1
trifluoperazine hcl 1
VERSACLOZ 2 QL (600 mL / 30 days), PA
VRAYLAR 1.5mg 2 QL (60 caps / 30 days), PA
VRAYLAR 3mg, 4.5mg, 6mg 2 QL (30 caps / 30 days), PA
VRAYLAR THERAPY PACK 2 PA
ziprasidone hcl 1 QL (60 caps / 30 days)
ZYPREXA RELPREVV 300mg 2 QL (2 vials / 28 days),
PA
ZYPREXA RELPREVV 405mg 2 QL (1 vial / 28 days), PA
ZYPREXA RELPREVV INJ 210MG 2 QL (2 vials / 28 days),
PA
ATTENTION DEFICIT HYPERACTIVITY DISORDER
amphetamine-dextroamphetamine cap sr
24hr 5 mg
1 QL (90 caps / 30 days)
amphetamine-dextroamphetamine cap sr
24hr 10 mg
1 QL (90 caps / 30 days)
amphetamine-dextroamphetamine cap sr
24hr 15 mg
1 QL (30 caps / 30 days)
amphetamine-dextroamphetamine cap sr
24hr 20 mg
1 QL (30 caps / 30 days)
amphetamine-dextroamphetamine cap sr
24hr 25 mg
1 QL (30 caps / 30 days)
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
65
Drug Name Drug Tier Requirements/Limits
amphetamine-dextroamphetamine cap sr 24hr 30 mg
1 QL (30 caps / 30 days)
amphetamine-dextroamphetamine tab 5 mg
1 QL (360 tabs / 30 days)
amphetamine-dextroamphetamine tab 7.5 mg
1 QL (240 tabs / 30 days)
amphetamine-dextroamphetamine tab 10 mg
1 QL (180 tabs / 30 days)
amphetamine-dextroamphetamine tab 12.5 mg
1 QL (90 tabs / 30 days)
amphetamine-dextroamphetamine tab 15 mg
1 QL (120 tabs / 30 days)
amphetamine-dextroamphetamine tab 20 mg
1 QL (90 tabs / 30 days)
amphetamine-dextroamphetamine tab 30 mg
1 QL (60 tabs / 30 days)
atomoxetine hcl 10mg, 18mg, 25mg 1 QL (120 caps / 30 days)
atomoxetine hcl 40mg 1 QL (60 caps / 30 days)
atomoxetine hcl 60mg, 80mg, 100mg 1 QL (30 caps / 30 days)
dexmethylphenidate hcl TABS 2.5mg, 5mg 1 QL (120 tabs / 30 days)
dexmethylphenidate hcl TABS 10mg 1 QL (60 tabs / 30 days)
guanfacine er (adhd) 2 PA; PA if 70 years and
older
metadate er tab 20mg 1 QL (90 tabs / 30 days)
methylphenidate hcl TABS 5mg, 10mg 1 QL (180 tabs / 30 days)
methylphenidate hcl TABS 20mg 1 QL (90 tabs / 30 days)
methylphenidate hcl oral soln 5mg/5ml 1 QL (1800 mL / 30 days)
methylphenidate hcl oral soln 10mg/5ml 1 QL (900 mL / 30 days)
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
66
Drug Name Drug Tier Requirements/Limits
methylphenidate tab 10mg er 1 QL (90 tabs / 30 days)
methylphenidate tab 20mg er 1 QL (90 tabs / 30 days)
HYPNOTICS
eszopiclone 2 QL (30 tabs / 30 days), PA; PA applies if 70 years and older after a
90 day supply in a calendar year
HETLIOZ 2 NM, LA, PA
SILENOR 3mg 2 QL (60 tabs / 30 days)
SILENOR 6mg 2 QL (30 tabs / 30 days)
temazepam 7.5mg 1 QL (30 caps / 30 days), PA; PA applies if 65 years and older after a
90 day supply in a calendar year
temazepam 15mg 1 QL (60 caps / 30 days), PA; PA applies if 65
years and older after a 90 day supply in a
calendar year
zaleplon 2 QL (60 caps / 30 days),
PA; PA applies if 70 years and older after a 90 day supply in a
calendar year
zolpidem tartrate TABS 2 QL (30 tabs / 30 days),
PA; PA applies if 70 years and older after a
90 day supply in a calendar year
MIGRAINE
dihydroergotamine mesylate inj 1 mg/ml 2
dihydroergotamine mesylate nasal 2 QL (8 mL / 30 days)
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
67
Drug Name Drug Tier Requirements/Limits
eletriptan hydrobromide 1 QL (12 tabs / 30 days)
ergotamine w/ caffeine TABS 1
naratriptan hcl 1 QL (12 tabs / 30 days)
rizatriptan benzoate 1 QL (18 tabs / 30 days)
rizatriptan benzoate odt 1 QL (18 tabs / 30 days)
sumatriptan SOLN 5mg/act 1 QL (24 inhalers / 30 days)
sumatriptan SOLN 20mg/act 1 QL (12 inhalers / 30 days)
sumatriptan inj 4mg/0.5ml 1 QL (18 injections / 30 days)
sumatriptan inj 6mg/0.5ml 1 QL (12 injections / 30 days)
sumatriptan succinate TABS 1 QL (12 tabs / 30 days)
zolmitriptan TABS 1 QL (12 tabs / 30 days)
zolmitriptan odt 1 QL (12 tabs / 30 days)
MISCELLANEOUS
AUSTEDO 6mg 2 QL (60 tabs / 30 days),
NM, LA, PA
AUSTEDO 9mg, 12mg 2 QL (120 tabs / 30 days),
NM, LA, PA
lithium carbonate CAPS; TABS 1
lithium carbonate er 1
LITHIUM SOLN 8MEQ/5ML 2
LYRICA CR 82.5mg, 165mg 2 QL (90 tabs / 30 days),
PA
LYRICA CR 330mg 2 QL (60 tabs / 30 days),
PA
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
68
Drug Name Drug Tier Requirements/Limits
NUEDEXTA 2 QL (60 caps / 30 days), PA
pyridostigmine tab 60mg 1
riluzole 1
tetrabenazine 12.5mg 2 QL (240 tabs / 30 days),
NM, PA
tetrabenazine 25mg 2 QL (120 tabs / 30 days),
NM, PA
MULTIPLE SCLEROSIS AGENTS
AMPYRA 2 NM, LA, PA
BETASERON 2 QL (14 syringes / 28 days), NM, PA
dalfampridine 2 NM, PA
GILENYA CAP 0.5MG 2 QL (28 caps / 28 days),
NM, PA
glatiramer acetate 20mg/ml 2 QL (30 syringes / 30
days), NM, PA
glatiramer acetate 40mg/ml 2 QL (12 syringes / 28
days), NM, PA
glatopa 20mg/ml 2 QL (30 syringes / 30 days), NM, PA
glatopa 40mg/ml 2 QL (12 syringes / 28 days), NM, PA
MUSCULOSKELETAL THERAPY AGENTS
baclofen TABS 10mg, 20mg 1
carisoprodol TABS 350mg 2 QL (120 tabs / 30 days),
PA; PA if 70 years and older
cyclobenzaprine hcl TABS 5mg, 10mg 2 PA; PA if 70 years and older
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
69
Drug Name Drug Tier Requirements/Limits
dantrolene sodium CAPS 1
methocarbamol TABS 2 PA; PA if 70 years and older
tizanidine hcl TABS 1
NARCOLEPSY/CATAPLEXY
armodafinil 50mg 1 QL (90 tabs / 30 days), PA
armodafinil 150mg, 200mg, 250mg 1 QL (30 tabs / 30 days), PA
XYREM 2 QL (540 mL / 30 days), NM, LA, PA
PSYCHOTHERAPEUTIC-MISC
acamprosate calcium 1
buprenorphine hcl SUBL 1 QL (90 tabs / 30 days), PA
buprenorphine hcl-naloxone hcl sl 1 QL (90 tabs / 30 days)
bupropion hcl (smoking deterrent) 1
CHANTIX 2 PA
CHANTIX CONTINUING MONTH 2 PA
CHANTIX STARTER PACK 2 PA
disulfiram TABS 1
gnp nicotine mini lozenge 2mg 3
gnp nicotine polacrilex GUM 2mg, 4mg 3
gnp nicotine polacrilex LOZG 2mg 3
gnp nicotine polacrilex m 4mg 3
gnp nighttime sleep aid 25mg 3
goodsense nicotine gum 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
70
Drug Name Drug Tier Requirements/Limits
goodsense nicotine polacr 4mg 3
hm nicotine polacrilex GUM 2mg 3
hm nicotine polacrilex LOZG 2mg 3
hm nicotine transdermal s 7mg/24hr,
14mg/24hr, 21mg/24hr
3
naloxone inj 0.4mg/ml 1
naloxone inj 1mg/ml 1
naltrexone hcl TABS 1
NARCAN 2
nicorelief 2mg, 4mg 3
nicotine 7mg/24hr, 14mg/24hr, 21mg/24hr
3
nicotine polacrilex GUM 2mg, 4mg 3
nicotine polacrilex LOZG 2mg, 4mg 3
nicotine transdermal syst PT24 7mg/24hr,
14mg/24hr, 21mg/24hr
3
NICOTROL INHALER 2
NICOTROL NS 2
night time sleep aid 25mg 3
nighttime sleep aid TABS 25mg 3
sb sleep 3
sleep tabs 3
sm nicotine GUM 4mg 3
sm nicotine LOZG 2mg 3
sm nicotine polacrilex GUM 2mg, 4mg 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
71
Drug Name Drug Tier Requirements/Limits
sm nicotine polacrilex LOZG 4mg 3
sm nicotine transdermal s 7mg/24hr, 14mg/24hr, 21mg/24hr
3
sm sleep aid night time 25mg 3
SUBOXONE MIS 2-0.5MG 2 QL (90 films / 30 days)
SUBOXONE MIS 4-1MG 2 QL (90 films / 30 days)
SUBOXONE MIS 8-2MG 2 QL (90 films / 30 days)
SUBOXONE MIS 12-3MG 2 QL (60 films / 30 days)
VIVITROL 2
ENDOCRINE AND METABOLIC
ANDROGENS
ANADROL-50 2 PA
ANDRODERM 2 QL (30 patches / 30
days), PA
oxandrolone TABS 1 PA
testosterone GEL 1%, 25mg/2.5gm, 50mg/5gm
1 QL (300 grams / 30 days), PA
testosterone cypionate SOLN 100mg/ml, 200mg/ml
1 PA
testosterone enanthate SOLN 1 PA
ANTIDIABETICS, INJECTABLE
ALCOHOL SWABS 2
BASAGLAR KWIKPEN 2
BD ULTRAFINE INSULIN SYRINGE 2
BD ULTRAFINE/NANO PEN NEEDLES 2
BYDUREON BCISE 2 QL (4 pens / 28 days)
BYDUREON INJ 2 QL (4 vials / 28 days)
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
72
Drug Name Drug Tier Requirements/Limits
BYDUREON PEN 2 QL (4 pens / 28 days)
BYETTA 2 QL (1 pen / 30 days)
FIASP 2
FIASP FLEXTOUCH 2
GAUZE PADS 2" X 2" 2
HUMULIN R INJ U-500 2 B/D
HUMULIN R U-500 KWIKPEN 2
INSULIN PEN NEEDLE 2
INSULIN SAFETY NEEDLES 2
INSULIN SYRINGE 2
LEVEMIR 2
LEVEMIR FLEXTOUCH 2
NOVOLIN 70/30 2 (brand RELION not
covered)
NOVOLIN 70/30 FLEXPEN 2 (brand RELION not covered)
NOVOLIN N 2 (brand RELION not covered)
NOVOLIN R 2 (brand RELION not covered)
NOVOLOG 2
NOVOLOG 70/30 FLEXPEN 2
NOVOLOG FLEXPEN 2
NOVOLOG MIX 70/30 2
NOVOLOG PENFILL 2
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
73
Drug Name Drug Tier Requirements/Limits
OZEMPIC INJ 0.25 OR 0.5MG/DOSE 2 QL (1 pen / 28 days)
OZEMPIC INJ 1MG/DOSE 2 QL (2 pens / 28 days)
SOLIQUA 100/33 2 QL (10 pens / 30 days)
TRESIBA FLEXTOUCH 2
TRESIBA INJ 2
TRULICITY 2 QL (4 pens / 28 days)
VICTOZA 2 QL (3 pens / 30 days)
XULTOPHY 100/3.6 2 QL (5 pens / 30 days)
ANTIDIABETICS, ORAL
acarbose 1
FARXIGA 5mg 2 QL (60 tabs / 30 days)
FARXIGA 10mg 2 QL (30 tabs / 30 days)
glimepiride 1mg 1 QL (240 tabs / 30 days)
glimepiride 2mg 1 QL (120 tabs / 30 days)
glimepiride 4mg 1 QL (60 tabs / 30 days)
glip/metform tab 2.5-250mg 1 QL (240 tabs / 30 days)
glip/metform tab 2.5-500mg 1 QL (120 tabs / 30 days)
glip/metform tab 5-500mg 1 QL (120 tabs / 30 days)
glipizide TABS 5mg 1 QL (240 tabs / 30 days)
glipizide TABS 10mg 1 QL (120 tabs / 30 days)
glipizide TB24 2.5mg 1 QL (240 tabs / 30 days)
glipizide TB24 5mg 1 QL (120 tabs / 30 days)
glipizide TB24 10mg 1 QL (60 tabs / 30 days)
glipizide xl 2.5mg 1 QL (240 tabs / 30 days)
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
74
Drug Name Drug Tier Requirements/Limits
glipizide xl 5mg 1 QL (120 tabs / 30 days)
glipizide xl 10mg 1 QL (60 tabs / 30 days)
glyburide TABS 1.25mg 2 QL (480 tabs / 30 days), PA; PA if 70 years and
older
glyburide TABS 2.5mg 2 QL (240 tabs / 30 days), PA; PA if 70 years and older
glyburide TABS 5mg 2 QL (120 tabs / 30 days), PA; PA if 70 years and
older
glyburide micronized 1.5mg 2 QL (240 tabs / 30 days),
PA; PA if 70 years and older
glyburide micronized 3mg 2 QL (120 tabs / 30 days), PA; PA if 70 years and
older
glyburide micronized 6mg 2 QL (60 tabs / 30 days),
PA; PA if 70 years and older
glyburide-metformin tab 1.25-250 mg 2 QL (240 tabs / 30 days), PA; PA if 70 years and
older
glyburide-metformin tab 2.5-500 mg 2 QL (120 tabs / 30 days),
PA; PA if 70 years and older
glyburide-metformin tab 5-500mg 2 QL (120 tabs / 30 days), PA; PA if 70 years and
older
JANUMET 2 QL (60 tabs / 30 days)
JANUMET XR TAB 50-500MG 2 QL (60 tabs / 30 days)
JANUMET XR TAB 50-1000 2 QL (60 tabs / 30 days)
JANUMET XR TAB 100-1000 2 QL (30 tabs / 30 days)
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
75
Drug Name Drug Tier Requirements/Limits
JANUVIA 2 QL (30 tabs / 30 days)
JARDIANCE 10mg 2 QL (60 tabs / 30 days)
JARDIANCE 25mg 2 QL (30 tabs / 30 days)
JENTADUETO 2 QL (60 tabs / 30 days)
JENTADUETO TAB XR 2.5-1000 MG 2 QL (60 tabs / 30 days)
JENTADUETO TAB XR 5-1000 MG 2 QL (30 tabs / 30 days)
metformin er 500mg 1 QL (120 tabs / 30 days); (generic of
GLUCOPHAGE XR)
metformin er 750mg 1 QL (60 tabs / 30 days);
(generic of GLUCOPHAGE XR)
metformin hcl TABS 500mg 1 QL (150 tabs / 30 days)
metformin hcl TABS 850mg 1 QL (90 tabs / 30 days)
metformin hcl TABS 1000mg 1 QL (75 tabs / 30 days)
nateglinide 1 QL (90 tabs / 30 days)
pioglitazone hcl 1 QL (30 tabs / 30 days)
repaglinide 2mg 1 QL (240 tabs / 30 days)
repaglinide .5mg, 1mg 1 QL (120 tabs / 30 days)
SYNJARDY TAB 5-500MG 2 QL (120 tabs / 30 days)
SYNJARDY TAB 5-1000MG 2 QL (60 tabs / 30 days)
SYNJARDY TAB 12.5-500MG 2 QL (60 tabs / 30 days)
SYNJARDY TAB 12.5-1000MG 2 QL (60 tabs / 30 days)
SYNJARDY XR TAB 5-1000MG 2 QL (60 tabs / 30 days)
SYNJARDY XR TAB 10-1000MG 2 QL (60 tabs / 30 days)
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
76
Drug Name Drug Tier Requirements/Limits
SYNJARDY XR TAB 12.5-1000MG 2 QL (60 tabs / 30 days)
SYNJARDY XR TAB 25-1000MG 2 QL (30 tabs / 30 days)
TRADJENTA 2 QL (30 tabs / 30 days)
XIGDUO XR TAB 2.5-1000MG 2 QL (60 tabs / 30 days)
XIGDUO XR TAB 5-500MG 2 QL (60 tabs / 30 days)
XIGDUO XR TAB 5-1000MG 2 QL (60 tabs / 30 days)
XIGDUO XR TAB 10-500MG 2 QL (30 tabs / 30 days)
XIGDUO XR TAB 10-1000MG 2 QL (30 tabs / 30 days)
BISPHOSPHONATES
alendronate sodium 1
ibandronate sodium TABS 1 B/D
PAMIDRONATE DISODIUM 6mg/ml 2 B/D
pamidronate disodium 30mg/10ml, 90mg/10ml
1 B/D
pamidronate inj 30mg 1 B/D
pamidronate inj 90mg 1 B/D
risedronate sodium TABS 5mg, 35mg,
150mg
1
risedronate sodium TBEC 1
zoledronic acid inj 5mg/100ml 1 B/D, NM
zoledronic inj 4mg/5ml 1 B/D, NM
CALCIUM RECEPTOR AGONISTS
cinacalcet hcl 30mg, 90mg 2 B/D, QL (120 tabs / 30 days), NM
cinacalcet hcl 60mg 2 B/D, QL (60 tabs / 30 days), NM
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
77
Drug Name Drug Tier Requirements/Limits
SENSIPAR 30mg, 90mg 2 B/D, QL (120 tabs / 30 days), NM
SENSIPAR 60mg 2 B/D, QL (60 tabs / 30 days), NM
CHELATING AGENTS
CHEMET 2
DEPEN TITRATABS 2
JADENU 2 NM, LA, PA
JADENU SPRINKLE 2 NM, LA, PA
kionex sus 15gm/60ml 1
sodium polystyrene sulfonate powder 1
sodium polystyrene sulfonate susp 1
sps susp 15gm/60ml 1
trientine hcl 2 PA
ENDOMETRIOSIS
danazol CAPS 1
SYNAREL 2
ENZYME REPLACEMENTS
ADAGEN 2 NM, LA, PA
ALDURAZYME 2 NM, LA, PA
CARBAGLU 2 NM, LA, PA
CERDELGA 2 NM, PA
CEREZYME 2 NM, LA, PA
CYSTADANE 2 NM, LA
CYSTAGON 2 NM, LA, PA
FABRAZYME 2 NM, LA, PA
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
78
Drug Name Drug Tier Requirements/Limits
KUVAN 2 NM, LA, PA
levocarnitine (metabolic modifiers) 1 B/D
LUMIZYME 2 NM, LA, PA
miglustat 2 NM, PA
NAGLAZYME 2 NM, LA, PA
NITYR 2 NM, LA, PA
ORFADIN 2 NM, LA, PA
sodium phenylbutyrate 2 NM, PA
ESTROGENS
DELESTROGEN 10mg/ml 2
estradiol PTWK; TABS 2
estradiol vaginal cream 1
estradiol vaginal tab 1
estradiol valerate OIL 1
fyavolv 2
jinteli 2
norethindrone acetate-ethinyl estradiol 2
yuvafem vaginal tablet 10 mcg 1
GLUCOCORTICOIDS
cortisone acetate TABS 1
DEXAMETHASONE CONC 2
dexamethasone ELIX; SOLN; TABS 1
dexamethasone sodium phosphate 1
fludrocortisone acetate TABS 1
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
79
Drug Name Drug Tier Requirements/Limits
hydrocortisone TABS 1
methylpr ss inj 1 B/D
methylpred pak 4mg 1
methylpred tab 4mg 1 B/D
methylpred tab 8mg 1 B/D
methylpred tab 16mg 1 B/D
methylpred tab 32mg 1 B/D
methylprednisolone acetate 1 B/D
pred sod pho sol 5mg/5ml 1 B/D
prednisolone sodium phosphate SOLN 15mg/5ml
1 B/D
prednisolone sol 15mg/5ml 1 B/D
prednisolone sol 25mg/5ml 1 B/D
PREDNISONE CON 5MG/ML 2 B/D
prednisone pak 5mg 1
prednisone pak 10mg 1
prednisone sol 5mg/5ml 1 B/D
prednisone tab 1mg 1 B/D
prednisone tab 2.5mg 1 B/D
prednisone tab 5mg 1 B/D
prednisone tab 10mg 1 B/D
prednisone tab 20mg 1 B/D
prednisone tab 50mg 1 B/D
SOLU-CORTEF 2
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
80
Drug Name Drug Tier Requirements/Limits
GLUCOSE ELEVATING AGENTS
GLUCAGEN HYPOKIT 2
GLUCAGON EMERGENCY KIT 2
HM GLUCOSE 3
PROGLYCEM SUS 50MG/ML 2
SM GLUCOSE 3
MISCELLANEOUS
cabergoline 1
calcitonin (salmon) 1 B/D
FORTEO 2 NM, PA
GENOTROPIN 2 NM, PA
GENOTROPIN MINIQUICK 2 NM, PA
INCRELEX 2 NM, LA, PA
KORLYM 2 NM, LA, PA
LUPRON DEP-PED INJ 7.5MG 2 NM, PA
LUPRON DEP-PED INJ 11.25MG (3-MONTH) 2 NM, PA
LUPRON DEPOT-PED (1-MONTH 2 NM, PA
LUPRON DEPOT-PED (3-MONTH 2 NM, PA
NATPARA 2 NM, PA
octreotide acetate 50mcg/ml, 100mcg/ml, 200mcg/ml
1 NM, PA
octreotide acetate 500mcg/ml, 1000mcg/ml
2 NM, PA
PROLIA 2 QL (1 injection / 180 days), NM
raloxifene hcl 1
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
81
Drug Name Drug Tier Requirements/Limits
SIGNIFOR 2 NM, LA, PA
SOMATULINE DEPOT 2 NM, PA
SOMAVERT 2 NM, LA, PA
TYMLOS 2 NM, PA
XGEVA 2 NM, PA
PHOSPHATE BINDER AGENTS
AURYXIA 2 QL (360 tabs / 30 days),
PA
calcium acetate (phosphate binder) CAPS 1 QL (360 caps / 30 days)
calcium acetate (phosphate binder) TABS 667mg
1 QL (360 tabs / 30 days)
sevelamer carbonate PACK 2.4gm 2 QL (180 packets / 30 days)
sevelamer carbonate PACK .8gm 2 QL (540 packets / 30 days)
sevelamer carbonate TABS 1 QL (540 tabs / 30 days)
PROGESTINS
medroxyprogesterone acetate tab 1
norethindrone acetate TABS 1
THYROID AGENTS
levo-t 1
levothyroxine sodium TABS 1
levoxyl 1
liothyronine sodium TABS 1
methimazole TABS 1
propylthiouracil TABS 1
SYNTHROID 2
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
82
Drug Name Drug Tier Requirements/Limits
unithroid 1
VASOPRESSINS
desmopressin acetate spray 1
desmopressin acetate spray refrigerated 1
desmopressin acetate tabs 1
desmopressin inj 4mcg/ml 1
STIMATE 2 NM
GASTROINTESTINAL
ANTACIDS
acid gone 3
almacone 3
almacone double strength 3
ALUMINUM HYDROXIDE 320mg/5ml 3
antacid CHEW 500mg 3
antacid SUSP 3
antacid anti-gas maximum 3
antacid calcium extra str 750mg 3
antacid calcium regular s 500mg 3
antacid fast acting 3
antacid fast relief 3
antacid maximum strength 3
antacid plus anti-gas fas 3
antacid plus anti-gas rel 3
antacid regular strength 3
cal-gest antacid 500mg 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
83
Drug Name Drug Tier Requirements/Limits
calcium antacid 500mg 3
calcium antacid extra str 750mg 3
calcium antacid ultra max 1000mg 3
CALCIUM CARBONATE TABS 648mg 3
cvs heartburn relief CHEW 3
GAVISCON CHEW 3
GAVISCON EXTRA STRENGTH R 3
gnp antacid anti-gas 3
gnp antacid extra strengt 750mg 3
gnp masanti regular stren 3
heartburn antacid extra s 3
hm advanced antacid maxim 3
hm antacid 3
hm antacid anti-gas extra 3
hm antacid/antigas 3
hm calcium antacid 500mg 3
hm calcium antacid extra 750mg 3
hm calcium antacid smooth 750mg 3
mag-al plus 3
magnesium oxide TABS 400mg, 420mg 3
MI-ACID CHEW 3
mi-acid SUSP 3
mi-acid maximum strength 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
84
Drug Name Drug Tier Requirements/Limits
mintox 3
mintox plus 3
qc antacid CHEW 500mg 3
qc antacid SUSP 3
qc antacid/anti-gas 3
qc heartburn antacid 3
rulox 3
sb antacid 3
sb antacid extra strength 750mg 3
sm antacid advanced 3
sm antacid anti-gas 3
sm antacid maximum streng 3
sm antacid/antigas 3
sm calcium antacid 500mg 3
sm calcium antacid extra 750mg 3
sodium bicarbonate (antacid) 650mg 3
tums smoothies 750mg 3
ANTI-DIARRHEAL
anti-diarrheal TABS 2mg 3
bismatrol CHEW 262mg 3
bismatrol SUSP 262mg/15ml 3
gnp anti-diarrheal CAPS 2mg 3
gnp anti-diarrheal TABS 2mg 3
hm anti-diarrheal 2mg 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
85
Drug Name Drug Tier Requirements/Limits
loperamide hcl LIQD 1mg/5ml 3
peptic relief CHEW 262mg 3
peptic relief SUSP 3
qc anti-diarrheal 2mg 3
sb anti-diarrhea 3
sm anti-diarrheal TABS 2mg 3
sm stomach relief CHEW 262mg 3
sm stomach relief SUSP 262mg/15ml 3
stomach relief SUSP 262mg/15ml 3
ANTIEMETICS
aprepitant 1 B/D
aprepitant pak 80mg & 125mg 1 B/D
compro 1
driminate 3
dronabinol 1 B/D, QL (60 caps / 30
days)
EMEND SUSR 2 B/D
gnp motion sickness relie 50mg 3
granisetron hcl SOLN 1
granisetron hcl TABS 1 B/D
meclizine hcl TABS 12.5mg 3
meclizine hcl TABS 12.5mg, 25mg 2
metoclopramide hcl SOLN; TABS 1
metoclopramide hcl inj 1
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
86
Drug Name Drug Tier Requirements/Limits
motion-time 25mg 3
ondansetron hcl TABS 1 B/D
ondansetron hcl inj 1
ondansetron hcl oral soln 1 B/D
ondansetron odt 1 B/D
prochlorperazine inj 1
prochlorperazine maleate TABS 1
prochlorperazine supp 1
promethazine hcl SYRP; TABS 2 PA; PA if 70 years and
older
promethazine hcl inj 2 PA; PA if 70 years and older
sb motion sickness 3
scopolamine patch 2 QL (10 patches / 30 days), PA; PA if 70 years
and older
sm motion sickness relief 50mg 3
TRANSDERM-SCOP 2 QL (10 patches / 30 days), PA; PA if 70 years and older
travel sickness CHEW 25mg 3
travel sickness TABS 50mg 3
ANTISPASMODICS
dicyclomine hcl cap 10mg 2
dicyclomine hcl soln 10mg/5ml 2
dicyclomine hcl tab 20mg 2
glycopyrrolate tab 1mg 1
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
87
Drug Name Drug Tier Requirements/Limits
glycopyrrolate tab 2mg 1
H2-RECEPTOR ANTAGONISTS
acid reducer TABS 10mg 3
acid reducer maximum stre 20mg 3
famotidine SUSR 1
famotidine TABS 10mg 3
famotidine TABS 20mg, 40mg 1
famotidine in nacl 1
famotidine inj 1
gnp acid reducer 10mg 3
gnp acid reducer maximum 20mg 3
gnp heartburn relief 200mg 3
heartburn relief 10mg 3
hm acid reducer 75mg 3
hm famotidine 10mg 3
qc acid controller maximu 20mg 3
ranitidine hcl TABS 75mg, 150mg 3
ranitidine hcl TABS 150mg, 300mg 1
ranitidine hcl inj 1
ranitidine inj 1
ranitidine syrup 1
sb acid reducer 150mg 3
sm acid reducer 10mg, 75mg, 200mg 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
88
Drug Name Drug Tier Requirements/Limits
INFLAMMATORY BOWEL DISEASE
APRISO 2 QL (120 caps / 30 days)
balsalazide disodium 1
budesonide ec 2
CANASA 2
colocort enema 100mg 1
DELZICOL 2
hydrocortisone (enema) 1
mesalamine ENEM 1
mesalamine SUPP 1
mesalamine TBEC 800mg 1
mesalamine w/ cleanser 1
sulfasalazine TABS 1
sulfasalazine ec 1
LAXATIVES
bisac-evac SUPP 10mg 3
bisacodyl SUPP 10mg 3
bisacodyl ec 5mg 3
biscolax 3
calcium polycarbophil 625mg 3
clearlax POWD 3
constulose 1
cvs glycerin child 3
cvs laxative pills 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
89
Drug Name Drug Tier Requirements/Limits
docqlace 100mg 3
docu 50mg/5ml 3
docusate sodium CAPS 100mg 3
docusate sodium LIQD 50mg/5ml 3
docusil 3
DOCUSOL MINI 3
dok CAPS 100mg 3
dok TABS 100mg 3
ducodyl 3
ENEMEEZ MINI 3
ENEMEEZ PLUS 3
enulose 1
eq laxative maximum stren 25mg 3
eql laxative maximum stre 25mg 3
fiber laxative TABS 625mg 3
fiber-lax 625mg 3
FLEET BISACODYL 3
gavilax POWD 3
gavilyte-c 1
gavilyte-g 1
gavilyte-n/flavor pack 1
generlac 1
glycerin (laxative) 1gm 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
90
Drug Name Drug Tier Requirements/Limits
glycolax 3
gnp bisa-lax 5mg 3
gnp clearlax POWD 3
gnp fiber-caps 625mg 3
gnp laxative TBEC 5mg 3
gnp laxative pills 3
gnp milk of magnesia 1200mg/15ml 3
gnp senna plus 3
gnp senna-lax 8.6mg 3
gnp stool softener CAPS 100mg 3
gnp stool softener/stimul 3
GOLYTELY 2
healthylax 3
hm clearlax 3
hm enema ready-to-use 3
hm enema saline laxative 3
hm fiber POWD 58.6% 3
hm fiber TABS 500mg 3
hm laxative TBEC 5mg 3
hm milk of magnesia 1200mg/15ml 3
hm senna 8.6mg 3
hm stool softener CAPS 100mg 3
hm stool softener TABS 100mg 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
91
Drug Name Drug Tier Requirements/Limits
kao-tin CAPS 240mg 3
konsyl POWD 30.9% 3
KONSYL POWD 60.3%, 71.67% 3
KONSYL DAILY FIBER PACK 100% 3
KONSYL DAILY FIBER POWD 100% 3
konsyl fiber 3
KONSYL-D POWD 52.3% 3
lactulose SOLN 1
lactulose (encephalopathy) 1
laxative SUPP 10mg 3
laxative TABS 3
laxative pills maximum st 25mg 3
magnesium citrate SOLN 1.745gm/30ml 3
milk of magnesia 7.75%, 400mg/5ml, 1200mg/15ml
3
MOVIPREP 2
natural fiber therapy 28.3%, 48.57% 3
NULYTELY/FLAVOR PACKS 2
peg 3350-kcl-sod bicarb-sod chloride-sod
sulfate
1
peg 3350-potassium chloride-sod bicarbonate-sod chloride
1
peg 3350/electrolytes 1
polyethylene glycol 3350 PACK 3
polyethylene glycol 3350 POWD 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
92
Drug Name Drug Tier Requirements/Limits
qc enema 3
qc laxative 3
qc milk of magnesia 400mg/5ml 3
qc natura-lax 3
qc natural vegetable laxa 3
ra laxative TABS 3
reguloid POWD 28.3%, 48.57%, 58.6% 3
sb bisacodyl laxative ec 3
sb milk of magnesia 400mg/5ml 3
senexon TABS 3
senexon-s 3
senna plus 3
senna-lax 8.6mg 3
senna-tabs 8.6mg 3
senna-time 3
senna-time s 3
senno 3
sennosides SYRP 8.8mg/5ml 3
sennosides TABS 8.6mg 3
sennosides-docusate sodium 3
silace LIQD 150mg/15ml 3
silace SYRP 60mg/15ml 3
sm clearlax 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
93
Drug Name Drug Tier Requirements/Limits
sm fiber POWD 28.3%, 48.57% 3
sm fiber laxative 500mg 3
sm gentle laxative 5mg 3
sm natural laxative plus 3
sm senna laxative maximum 3
sm stool softener CAPS 100mg, 240mg, 250mg
3
sodium phosphates 3
soluble fiber 3
stimulant laxative 5mg 3
stool softener CAPS 100mg, 240mg 3
stool softener extra stre 250mg 3
SUPREP BOWEL PREP KIT 2
tgt laxative pills maximu 25mg 3
tgt natural laxative pill 3
trilyte 1
womans laxative 5mg 3
MISCELLANEOUS
alosetron hcl 2 PA
AMITIZA CAP 8MCG 2 QL (180 caps / 30 days)
AMITIZA CAP 24MCG 2 QL (60 caps / 30 days)
cromolyn sodium (mastocytosis) 2
diphenoxylate w/ atropine 2
gas relief extra strength CAPS 125mg 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
94
Drug Name Drug Tier Requirements/Limits
GATTEX 2 NM, LA, PA
LINZESS 2 QL (30 caps / 30 days)
loperamide hcl CAPS 2mg 1
misoprostol TABS 1
MOVANTIK 12.5mg 2 QL (60 tabs / 30 days)
MOVANTIK 25mg 2 QL (30 tabs / 30 days)
RELISTOR SOLN 2 PA
sm gas relief extra stren 125mg 3
sucralfate TABS 1
SYMPROIC 2
ursodiol CAPS; TABS 1
XIFAXAN 550mg 2 PA
PANCREATIC ENZYMES
CREON 2
ZENPEP 2
PROTON PUMP INHIBITORS
DEXILANT 2 QL (30 caps / 30 days)
esomeprazole magnesium 20mg, 40mg 1 QL (30 caps / 30 days)
esomeprazole sodium inj 1
gnp lansoprazole 15mg 3
GNP OMEPRAZOLE 20mg 3
goodsense lansoprazole 3
heartburn treatment 24 ho 15mg 3
hm lansoprazole 15mg 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
95
Drug Name Drug Tier Requirements/Limits
HM OMEPRAZOLE 20mg 3
lansoprazole CPDR 15mg 3
lansoprazole CPDR 15mg, 30mg 1 QL (30 caps / 30 days)
OMEPRAZOLE TBEC 20mg 3
omeprazole cap 10mg 1
omeprazole cap 20mg 1
omeprazole cap 40mg 1
pantoprazole sodium SOLR 1
pantoprazole sodium tbec 1
rabeprazole sodium 1 QL (30 tabs / 30 days)
sm lansoprazole 15mg 3
SM OMEPRAZOLE 20mg 3
GENITOURINARY
BENIGN PROSTATIC HYPERPLASIA
alfuzosin hcl 1 QL (30 tabs / 30 days)
dutasteride CAPS 1 QL (30 caps / 30 days)
dutasteride-tamsulosin hcl 1 QL (30 caps / 30 days)
finasteride TABS 5mg 1
tamsulosin hcl 1
MISCELLANEOUS
bethanechol chloride TABS 1
potassium citrate (alkalinizer) er tabs 1
URINARY ANTISPASMODICS
MYRBETRIQ 25mg 2 QL (60 tabs / 30 days)
MYRBETRIQ 50mg 2 QL (30 tabs / 30 days)
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
96
Drug Name Drug Tier Requirements/Limits
oxybutynin chloride SYRP 1
oxybutynin chloride TABS 1
oxybutynin chloride TB24 5mg 1 QL (30 tabs / 30 days)
oxybutynin chloride TB24 10mg, 15mg 1 QL (60 tabs / 30 days)
tolterodine tartrate cap er 1 QL (30 caps / 30 days), ST
tolterodine tartrate tabs 1 ST
TOVIAZ 2 QL (30 tabs / 30 days)
trospium chloride TABS 1 QL (60 tabs / 30 days)
VESICARE 2 QL (30 tabs / 30 days)
VAGINAL ANTI-INFECTIVES
clindamycin phosphate vaginal 1
clotrimazole vaginal CREA 1% 3
gnp miconazole 7 2% 3
metronidazole vaginal 1
miconazole 7 CREA 2% 3
miconazole 7 SUPP 100mg 3
miconazole nitrate vaginal CREA 2% 3
miconazole nitrate vaginal SUPP 100mg 3
sm miconazole 7 CREA 2% 3
sm miconazole 7 SUPP 100mg 3
terconazole vaginal 1
vandazole 1
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
97
Drug Name Drug Tier Requirements/Limits
HEMATOLOGIC
ANTICOAGULANTS
COUMADIN 2
ELIQUIS 2
ELIQUIS STARTER PACK 2
enoxaparin sodium 1
fondaparinux sodium 2.5mg/0.5ml 1
fondaparinux sodium 5mg/0.4ml, 7.5mg/0.6ml, 10mg/0.8ml
2
heparin sod (porcine) in d5w 2
heparin sod inj 1000/ml 1 B/D
heparin sod inj 5000/ml 1 B/D
heparin sod inj 10000/ml 1 B/D
heparin sod inj 20000/ml 1 B/D
HEPARIN SODIUM/NACL 0.45% 2
jantoven 1
PRADAXA 2
warfarin sodium 1
XARELTO 2
XARELTO STARTER PACK 2
HEMATOPOIETIC GROWTH FACTORS
GRANIX 2 NM, PA
NEUPOGEN 2 NM, PA
PROCRIT 2 NM, PA
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
98
Drug Name Drug Tier Requirements/Limits
IRON
ferosul ELIX 3
ferosul TABS 325mg 3
ferrous fumarate TABS 324mg 3
ferrous gluconate TABS 324mg 3
FERROUS GLUCONATE TABS 324mg 3
ferrous sulfate ELIX 220mg/5ml 3
FERROUS SULFATE LIQD 220mg/5ml 3
ferrous sulfate SOLN 15mg/ml 3
FERROUS SULFATE SYRP 3
ferrous sulfate TABS 325mg 3
FERROUS SULFATE TBEC 324mg 3
ferrous sulfate TBEC 325mg 3
ferrousul 3
iferex 150 150mg 3
INFED 50mg/ml 3
sodium ferric gluconate complex in sucrose 12.5mg/ml
3
VENOFER 20mg/ml 3
MISCELLANEOUS
anagrelide hcl 1
BERINERT 2 QL (24 boxes / 30 days), NM, LA, PA
cilostazol 1
DROXIA 2
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
99
Drug Name Drug Tier Requirements/Limits
ENDARI 2 NM, LA, PA
FIRAZYR 2 QL (9 syringes / 30 days), NM, PA
HAEGARDA 2000unit 2 QL (30 vials / 30 days), NM, LA, PA
HAEGARDA 3000unit 2 QL (20 vials / 30 days), NM, LA, PA
pentoxifylline TBCR 1
PROMACTA PACK 2 QL (360 packets / 30
days), NM, LA, PA
PROMACTA TABS 12.5mg 2 QL (360 tabs / 30 days),
NM, LA, PA
PROMACTA TABS 25mg 2 QL (180 tabs / 30 days),
NM, LA, PA
PROMACTA TABS 50mg 2 QL (90 tabs / 30 days),
NM, LA, PA
PROMACTA TABS 75mg 2 QL (60 tabs / 30 days),
NM, LA, PA
tranexamic acid SOLN; TABS 1
PLATELET AGGREGATION INHIBITORS
aspirin-dipyridamole 1
BRILINTA 2
clopidogrel tab 75mg 1
prasugrel hcl 1
ZONTIVITY 2
IMMUNOLOGIC AGENTS
DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS)
HUMIRA 10mg/0.1ml, 20mg/0.2ml 2 QL (2 injections / 28
days), NM, PA
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
100
Drug Name Drug Tier Requirements/Limits
HUMIRA 40mg/0.4ml 2 QL (6 injections / 28 days), NM, PA
HUMIRA INJ 10MG/0.2ML 2 QL (2 syringes / 28 days), NM, PA
HUMIRA KIT 20MG/0.4ML 2 QL (2 syringes / 28 days), NM, PA
HUMIRA KIT 40MG/0.8ML 2 QL (6 syringes / 28 days), NM, PA
HUMIRA PEDIATRIC CROHNS DISEASE 2 NM, PA
HUMIRA PEN 2 QL (6 pens / 28 days), NM, PA
HUMIRA PEN CD/UC/HS STARTER 2 NM, PA
HUMIRA PEN INJ CD/UC/HS STARTER 2 NM, PA
HUMIRA PEN INJ PS/UV STARTER 2 NM, PA
HUMIRA PEN-PS/UV STARTER 2 NM, PA
hydroxychloroquine sulfate 1
leflunomide TABS 1
methotrexate sodium tabs 1
REMICADE 2 NM, PA
XATMEP 2 B/D
XELJANZ 2 QL (60 tabs / 30 days),
NM, PA
XELJANZ XR 2 QL (30 tabs / 30 days),
NM, PA
IMMUNOGLOBULINS
BIVIGAM 2 NM, PA
CARIMUNE NANOFILTERED 2 NM, PA
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
101
Drug Name Drug Tier Requirements/Limits
FLEBOGAMMA DIF 2 NM, PA
GAMASTAN S/D 2 B/D, NM
GAMMAGARD LIQUID 2 NM, PA
GAMMAGARD S/D 2 NM, PA
GAMMAKED 2 NM, PA
GAMMAPLEX 2 NM, PA
GAMMAPLEX 10GM/100ML 2 NM, PA
GAMUNEX-C 2 NM, PA
OCTAGAM 2 NM, PA
PANZYGA 2 NM, PA
PRIVIGEN 2 NM, PA
IMMUNOMODULATORS
ACTIMMUNE 2 NM, LA, PA
ARCALYST 2 NM, PA
INTRON-A INJ 10MU 2 B/D, NM
INTRON-A INJ 18MU 2 B/D, NM
INTRON-A INJ 25MU 2 B/D, NM
INTRON-A INJ 50MU 2 B/D, NM
IMMUNOSUPPRESSANTS
azathioprine TABS 1 B/D
BENLYSTA 2 NM, PA
cyclosporine CAPS; SOLN 1 B/D, NM
cyclosporine modified (for microemulsion) 1 B/D, NM
gengraf 1 B/D, NM
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
102
Drug Name Drug Tier Requirements/Limits
mycophenolate mofetil CAPS; TABS 1 B/D, NM
mycophenolate mofetil SUSR 2 B/D, NM
mycophenolate sodium tbec 1 B/D, NM
NULOJIX 2 B/D, NM
RAPAMUNE SOLN 2 B/D, NM
SANDIMMUNE SOLN 100mg/ml 2 B/D, NM
sirolimus SOLN 2 B/D, NM
sirolimus TABS 2mg 2 B/D, NM
sirolimus TABS .5mg, 1mg 1 B/D, NM
tacrolimus CAPS 1 B/D, NM
ZORTRESS TAB 0.5MG 2 B/D, NM
ZORTRESS TAB 0.25MG 2 B/D, NM
ZORTRESS TAB 0.75MG 2 B/D, NM
ZORTRESS TAB 1MG 2 B/D, NM
VACCINES
ACTHIB 2
ADACEL 2
BCG VACCINE 2
BEXSERO 2
BOOSTRIX 2
DAPTACEL 2
DIPHTHERIA/TETANUS TOXOID 2 B/D
ENGERIX-B SUSP 2 B/D
GARDASIL 9 2
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
103
Drug Name Drug Tier Requirements/Limits
HAVRIX 2
HIBERIX 2
IMOVAX RABIES (H.D.C.V.) 2 B/D
INFANRIX 2
IPOL INACTIVATED IPV 2
IXIARO 2
KINRIX 2
M-M-R II 2
MENACTRA 2
MENVEO 2
PEDIARIX 2
PEDVAX HIB 2
PENTACEL 2
PROQUAD 2
QUADRACEL 2
RABAVERT 2 B/D
RECOMBIVAX HB 2 B/D
ROTARIX 2
ROTATEQ 2
SHINGRIX 2 QL (2 vials per lifetime)
TDVAX 2 B/D
TENIVAC 2 B/D
TRUMENBA 2
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
104
Drug Name Drug Tier Requirements/Limits
TWINRIX INJ 2
TYPHIM VI 2
VAQTA 2
VARIVAX 2
YF-VAX 2
ZOSTAVAX 2 QL (1 vial per lifetime)
MISCELLANEOUS
NON MED D
A1C NOW SELFCHECK 3
A + D PERSONAL CARE LOTIO 3
A + D PERSONAL CARE WIPES 3
a thru z advanced 3
a thru z advanced adult f 3
a thru z advantage 3
a thru z high potency 3
a thru z select 3
a thru z select 50+ advan 3
a thru z select 50+ mens 3
a thru z select advanced 3
a thru z select ultimate 3
a thru z ultimate mens 3
A+D FIRST AID 3
A-25 3
a-200 AERO 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
105
Drug Name Drug Tier Requirements/Limits
A-200 GEL; KIT 3
a-200 maximum strength 3
a-10000 3
a-caro-25 3
A-MANTLE 3
abanatuss ped 3
abanatuss ped drops 3
abatinex 3
ABATREX 3
ABATRON 3
abatron af 3
abatuss dmx 3
abc plus 3
abc plus senior 3
abc plus senior adults 50 3
ABDEK CAPS 3
abdek CHEW 3
abdek pediatric 3
ABREVA 10% 3
ABSORBASE 3
ACAI WEIGHT CONTROL 3
ACCU-CHEK 3 MIS METER 3
ACCU-CHEK ACTIVE 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
106
Drug Name Drug Tier Requirements/Limits
ACCU-CHEK ACTIVE STRIPS 3
ACCU-CHEK ADVANTAGE H TES 3
ACCU-CHEK ADVANTAGE METER 3
ACCU-CHEK ADVANTAGE TEST 3
ACCU-CHEK AVIVA DEVI; STRP 3
ACCU-CHEK AVIVA CONNECT 3
ACCU-CHEK AVIVA PLUS 3
ACCU-CHEK COMFORT CURVE T 3
ACCU-CHEK COMPACT PLUS 3
ACCU-CHEK COMPACT STRIPS 3
ACCU-CHEK COMPACT TEST DR 3
ACCU-CHEK EA MIS DIA METR 3
ACCU-CHEK EASY TEST STRIP 3
ACCU-CHEK GUIDE 3
ACCU-CHEK INSTANT CARE KI 3
ACCU-CHEK KIT III 3
ACCU-CHEK NANO SMARTVIEW 3
ACCU-CHEK SIMPLICITY 3
ACCU-CHEK SIMPLICITY TEST 3
ACCU-CHEK SMARTVIEW STRIP 3
ACCU-CHEK SOFT TOUCH LANC 3
ACCU-CHEK SOFTCLIX LANCET MISC 3
ACCU-CHEK VOICEMATE 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
107
Drug Name Drug Tier Requirements/Limits
ACCUTREND GLUCOSE 3
ACE AEROSOL CLOUD ENHANCE 3
acephen 120mg, 650mg 3
acerola c 3
ACEROLA C 500 3
acerola c-500 3
aceta-gesic 3
acetadryl 3
acetaminophen CAPS 3
acetaminophen CHEW 3
acetaminophen ELIX 3
acetaminophen LIQD 160mg/5ml,
500mg/5ml
3
acetaminophen SOLN 80mg/0.8ml,
100mg/ml, 160mg/5ml, 325mg/10.15ml, 650mg/20.3ml
3
acetaminophen SUPP 120mg, 650mg 3
acetaminophen SUSP 3
acetaminophen TABS 325mg, 500mg 3
acetaminophen TBCR 650mg 3
acetaminophen 8 hour 3
acetaminophen childrens 3
acetaminophen congestion 3
acetaminophen extra stren CAPS 3
acetaminophen extra stren LIQD 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
108
Drug Name Drug Tier Requirements/Limits
acetaminophen extra stren TABS 500mg 3
acetaminophen infants 3
acetaminophen junior stre 3
acetaminophen pm 3
acetaminophen pm extra st 3
acetaminophen rapid tabs 3
acetaminophen-pamabrom-pyrilamine 3
ACETYL SALICYLIC ACID 3
acetylcarnitine hcl (nutrient) 3
acid control maximum stre 3
acid controller 3
acid controller complete 3
acid controller maximum s 3
acid reducer CPDR 3
acid reducer TABS 10mg, 75mg, 150mg 3
acid reducer + antacid 3
acid reducer complete 3
acid reducer maximum stre 20mg, 150mg 3
acid relief 3
ACIDOPHILUS CAPS; WAFR 3
acidophilus extra strengt 3
ACIDOPHILUS HIGH-POTENCY 3
ACIDOPHILUS PEARLS 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
109
Drug Name Drug Tier Requirements/Limits
ACIDOPHILUS PLUS PECTIN 3
acidophilus probiotic CAPS 3
ACIDOPHILUS PROBIOTIC TABS 3
acidophilus probiotic TABS .5mg, 1mg,
10mg
3
ACIDOPHILUS PROBIOTIC BLE 3
ACIDOPHILUS PROBIOTIC COM 3
acidophilus probiotic for 3
ACIDOPHILUS SUPER PROBIOT 3
ACIDOPHILUS XTRA 3
ACIDOPHILUS/BIFIDUS 3
ACIDOPHILUS/CITRUS PECTIN 3
ACIDOPHILUS/GOAT MILK 3
acne foaming wash 3
acne maximum strength 3
ACNE MEDICATION 3
acne medication 5 GEL 5% 3
ACNE MEDICATION 5 LOTN 3
acne medication 10 GEL 10% 3
ACNE MEDICATION 10 LOTN 3
acne pimple medication ma 3
acne treatment cleansing 3
acne treatment gel 3
acne wash 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
110
Drug Name Drug Tier Requirements/Limits
acne-clear 3
ACNEFREE 24 HOUR ACNE CLE 3
ACNEFREE SEVERE 24 HOUR C 3
act anticavity fluoride r 3
act restoring fluoride ri 3
act total care 3
actical 3
ACTICOAT 7 2"X2" 3
ACTICOAT 7 4"X5" 3
ACTICOAT ABSORBENT ANTIMI 3
ACTICOAT ANTIMICROBIAL DR 3
ACTICOAT FLEX 3 BARRIER D 3
ACTICON 3
ACTIDOGESIC 3
ACTIDOM DMX 3
actidose-aqua 3
actidose/sorbitol 3
actifed cold & allergy 3
ACTIFED PLUS 3
ACTIFED PLUS TAB 3
ACTIFED TAB 2.5-60MG 3
ACTIFED TAB SINUS 3
ACTIFLOVIT EAR HEALTH 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
111
Drug Name Drug Tier Requirements/Limits
ACTINEL 3
ACTINEL PEDIATRIC 3
ACTIPROTECT UF 3
ACTISEP 3
ACTITROM 3
ACTITROM-D 3
ACTIVESSENTIALS 3
ACTIVITE EC 3
ACTIVITY POUCH 3
ACTIVNUTRIENTS 3
ACURA BLOOD GLUCOSE MONIT 3
ACURA BLOOD GLUCOSE TEST 3
ACURA PLUS BLOOD GLUCOSE 3
ACUWASH 3
adapalene GEL .1% 3
ADAPTER PED DISPOSABLE MO 3
ADAPTIC NON-ADHERING DRES 3
ADD-INS COMPLETE 3
addaprin 3
added strength headache r 3
ADDITIONS FOOD ENHANCER 3
ADHERES FLUFF UNDERPAD 3
ADHERES INCONTINENCE PAD 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
112
Drug Name Drug Tier Requirements/Limits
ADJUSTABLE LANCING DEVICE 3
ADK 3
ADRENAL C FORMULA 3
ADRENAL STRESS CALM 3
ADRENOID 3
ADULT AEROSOL MASK 3
adult aspirin ec low stre 3
ADULT ASPIRIN LOW STRENGT 3
adult aspirin regimen 3
ADULT DISPOSABLE MOUTHPIE 3
50+ adult eye health 3
adult gummy 3
ADULT MASK MISC 3
ADULT MASK LARGE 3
ADULT OMEGA PLUS DHA 3
ADULT ONE DAILY GUMMIES 3
ADVANCE INTUITION BLOOD G 3
ADVANCE INTUITION TEST ST 3
ADVANCE MICRO-DRAW METER 3
ADVANCE MICRO-DRAW TEST S 3
ADVANCED C PLUS 3
ADVANCED CALCIUM FORMULA 3
ADVANCED CALCIUM/VITAMIN 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
113
Drug Name Drug Tier Requirements/Limits
ADVANCED COLLAGEN 3
ADVANCED DIABETIC MULTIVI 3
ADVANCED E 3
advanced eye health 3
advanced healing ointment 3
advanced multi ea 3
ADVANCED PROBIOTIC 3
ADVANCED PROBIOTIC 10 3
advanced stress formula/z 3
advantage care oral elect 3
ADVIL 3
ADVIL ALLERGY & CONGESTIO 3
ADVIL ALLERGY SINUS 3
ADVIL COLD & SINUS 3
ADVIL CONGESTION RELIEF 3
advil junior strength 3
ADVIL MIGRAINE 3
ADVIL PM TABS 3
ADVIL SINUS CONGESTION & 3
ADVIL TAB 200MG 3
ADVOCATE BLOOD GLUCOSE MO 3
ADVOCATE LANCING DEVICE 3
ADVOCATE RAPID-SAFE LANCI 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
114
Drug Name Drug Tier Requirements/Limits
ADVOCATE REDI-CODE 3
ADVOCATE REDI-CODE+ BLOOD 3
ADVOCATE REDI-CODE+ TEST 3
ADVOCATE REDI-CODE+/ TALK 3
ADVOCATE REDI-CODE/TALKIN 3
ADVOCATE TEST STRIPS 3
ADVOCATE UNDERPADS 3
AEROTRACH PLUS 3
af allergy relief 3
AF CAPSICUM OLEORESIN 3
AFIRM 1X 3
AFIRM 2X 3
AFIRM 3X 3
AFRIN 3
AFRIN 12 HOUR 3
AFRIN ALL NIGHT NODRIP 3
AFRIN CHILDRENS 3
AFRIN EXTRA MOISTURIZING 3
AFRIN MENTHOL 3
AFRIN NASAL SPRAY 3
AFRIN NODRIP EXTRA MOISTU 3
AFRIN NODRIP ORIGINAL 3
AFRIN NODRIP SEVERE CONGE 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
115
Drug Name Drug Tier Requirements/Limits
AFRIN NODRIP SINUS 3
afrin saline nasal mist 3
AFRIN SINUS 3
AGAMATRIX AMP NO CODE ADV 3
AGAMATRIX AMP NO CODE TES 3
AGAMATRIX JAZZ TEST STRIP 3
AGAMATRIX JAZZ WIRELESS 2 3
AGAMATRIX KEYNOTE TEST ST 3
AGAMATRIX PRESTO 3
AGAMATRIX PRESTO PRO METE 3
AGAMATRIX PRESTO TEST STR 3
AHIST 3
AIR PERMEABLE UNDERPAD 23 3
AIR-DRI BREATHABLES FLUID 3
AIR-DRI BREATHABLES PLUS 3
airborne CHEW; TBEF 3
AIRBORNE LOZG 3
airborne gummies 3
airborne immune system 3
AIRS PEDIATRIC AEROSOL MA 3
AIRSHIELD 3
AIRZONE PEAK FLOW METER 3
akedamins 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
116
Drug Name Drug Tier Requirements/Limits
al12 3
ala seb 3
ala-cort 1% 3
ALA-HIST IR 3
ALA-HIST PE 3
ALAHIST CF 3
ALAHIST DM 3
alamag-plus 3
alavert 3
alavert allergy/sinus 3
alaway 3
alaway childrens allergy 3
ALBAFORT 3
albertson's headache form 3
albertson's night time co 3
albertsons bis-mate 3
albertsons magnesium citr 3
ALBOLENE 3
alcalak 3
ALDEX AN 3
ALDEX D 3
ALDEX GS 3
ALDEX GS DM 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
117
Drug Name Drug Tier Requirements/Limits
ALDEX-CT 3
aler-cap 3
ALER-DRYL 3
alertab 3
alertness aid 3
alertness aid maximum str 3
ALEVE 3
ALEVE ARTHRITIS 3
ALEVE COLD & SINUS 3
ALEVE SINUS & HEADACHE 3
ALEVE TAB 220MG 3
ALEVE-D SINUS & COLD 3
ALEVE-D SINUS & HEADACHE 3
ALGA 3
ALIGN CAPS 3
ALIGN EXTRA STRENGTH 3
ALIVE ENERGY 50+ 3
alive gummies for childre 3
ALIVE MENS ENERGY 3
alive multi-vitamin child 3
ALIVE ONCE DAILY WOMENS 5 3
ALIVE ONCE DAILY WOMENS U 3
ALIVE WOMENS 50+ 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
118
Drug Name Drug Tier Requirements/Limits
ALIVE WOMENS ENERGY 3
ALIVE WOMENS GUMMY VITAMI 3
ALKA-SELTZER 3
ALKA-SELTZER EXTRA STRENG 3
ALKA-SELTZER GOLD 3
ALKA-SELTZER HEARTBURN RE 3
ALKA-SELTZER HEARTBURN+GA 3
ALKA-SELTZER ORIGINAL 3
alka-seltzer plus allergy 3
ALKA-SELTZER PLUS COLD 3
ALKA-SELTZER PLUS COLD & 3
alka-seltzer plus day col 3
ALKA-SELTZER PLUS DAY/NIG 3
alka-seltzer plus mucus & 3
alka-seltzer plus night c CAPS 3
ALKA-SELTZER PLUS NIGHT C TBEF 3
alka-seltzer plus severe CAPS 3
ALKA-SELTZER PLUS SEVERE PACK; TBEF 3
ALKA-SELTZER PLUS SINUS F 3
ALKA-SELTZER PLUS-D SINUS 3
all day allergy TABS 10mg 3
all day allergy childrens SOLN 1mg/ml, 5mg/5ml
3
all day allergy d 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
119
Drug Name Drug Tier Requirements/Limits
all day allergy d-12 3
all day allergy-d 3
all day pain relief 3
all day pain relief sinus 3
all day relief 3
ALL FLOW 1000 PULMONARY F 3
all-day allergy childrens 5mg/5ml 3
all-nite cold & flu night 3
all-nite multi-symptom co 3
allbee plus vitamin c 3
ALLCLENZ 3
ALLEGRA ALLERGY 3
ALLEGRA ALLERGY CHILDRENS SUSP;
TABS
3
ALLEGRA-D 12 HOUR ALLERGY 3
ALLEGRA-D 24 HOUR ALLERGY 3
aller-chlor SYRP 3
aller-chlor TABS 4mg 3
aller-ease 3
aller-ease allergy 3
aller-ease childrens 3
aller-time 3
allerfrim 3
allergy CAPS 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
120
Drug Name Drug Tier Requirements/Limits
allergy CREA 3
allergy TABS 4mg, 10mg, 25mg 3
allergy TBCR 3
allergy TBDP 3
allergy 4 hour 3
allergy 24-hr 3
allergy 24hour indoor/out 3
allergy & congestion reli 3
allergy & sinus intense s 3
allergy childrens LIQD 3
allergy childrens SYRP 5mg/5ml 3
allergy d-12 3
allergy eye drops 3
allergy medication 3
allergy medication childr 3
allergy multi-symptom 3
ALLERGY MULTI-SYMPTOM DAY MISC 3
allergy multi-symptom day TABS 3
allergy multi-symptom nig 3
allergy nasal spray 24 ho 3
allergy non-drowsy 10mg 3
allergy relief CAPS 25mg 3
allergy relief GEL 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
121
Drug Name Drug Tier Requirements/Limits
allergy relief SUSP 3
allergy relief SYRP 3
allergy relief TABS 4mg, 10mg, 25mg, 60mg, 180mg
3
allergy relief TBDP 3
allergy relief 24hr 180mg 3
allergy relief child 3
allergy relief childrens CHEW 3
allergy relief childrens LIQD 12.5mg/5ml 3
allergy relief childrens SOLN 5mg/5ml 3
allergy relief childrens SYRP 3
allergy relief childrens TBDP 3
allergy relief d 3
allergy relief d-24 3
allergy relief for kids 3
allergy relief nighttime 3
allergy relief plus sinus 3
allergy relief-d 3
allergy relief/nasal deco 3
allergy sinus-d maximum s 3
allergy tablets 3
allergy-relief-d 3
allergy-time 4mg 3
allergy/congestion relief 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
122
Drug Name Drug Tier Requirements/Limits
allergy/sinus pain reliev 3
allerhist 3
allerhist-1 3
ALLERWELL ALLERGY FORMULA 3
ALLEVYN ADHESIVE 3
ALLEVYN AG ADHESIVE 3
ALLEVYN AG GENTLE BORDER 3
ALLEVYN AG NON-ADHESIVE 3
ALLEVYN AG SACRUM 3
ALLEVYN COMPRESSION 3
ALLEVYN GENTLE 3
ALLEVYN GENTLE BORDER 3
ALLEVYN GENTLE BORDER HEE 3
ALLEVYN GENTLE BORDER LIT 3
ALLEVYN GENTLE BORDER MUL 3
ALLEVYN GENTLE BORDER SAC 3
ALLEVYN HEEL 3
ALLEVYN LIFE 3
ALLEVYN LIFE HEEL 3
ALLEVYN LIFE SACRUM 3
ALLEVYN NON-ADHESIVE 3
ALLEVYN PLUS ADHESIVE 3
ALLEVYN PLUS CAVITY 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
123
Drug Name Drug Tier Requirements/Limits
ALLEVYN PLUS SACRUM 3
ALLEVYN SACRUM 3
ALLEVYN THIN 3
ALLEVYN TRACHEOSTOMY 3-1/ 3
ALLFEN 3
allfen dm 3
ALOE 10000 & PROBIOTICS 3
ALOE AFTERSUN LOTION 3
ALOE VESTA 2-N-1 PROTECTI 3
ALOE VESTA ANTIFUNGAL 3
ALOE VESTA BATHING CLOTHS 3
aloe vesta body was h/sha 3
aloe vesta body wash/sham 3
ALOE VESTA CLEAR ANTIFUNG 3
ALOE VESTA CLEAR BARRIER 3
ALOE VESTA DAILY MOISTURI 3
ALOE VESTA PROTECTIVE 3
ALOE VESTA SKIN CONDITION 3
ALOE VESTA SKIN PROTECTAN 3
ALOETOUCH PERSONAL CLEANS 3
alophen 3
alph-e 3
alph-e-mixed 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
124
Drug Name Drug Tier Requirements/Limits
alph-e-mixed 1000 3
alpha betic 3
ALPHA LIPOIC ACID CAPS 3
ALPHA-LIPOIC ACID CAPS 3
alpha-lipoic acid (thioctic acid) 3
alphasoft 3
altachlore 3
altalube 3
altamist 3
altarussin 3
altarussin dm 3
altarussin-pe 3
altaryl 3
altazine 3
ALTERNATE SITE LANCING DE 3
alum & mag hydrox-simethicone 3
aluminum & magnesium hydroxide 3
ALUMINUM CHLORIDE 3
ALUMINUM CHLORIDE HEXAHYD CRYS 3
ALUMINUM HYDROXIDE 320mg/5ml 3
aluminum hydroxide gel 3
aluminum hydroxide-mag carb 3
ALWAYS DISCREET PADS/LINE 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
125
Drug Name Drug Tier Requirements/Limits
ALWAYS DISCREET PADS/MODE 3
ALWAYS DISCREET UNDERWEAR 3
ALWAYS DISCREET/LONG LENG 3
ALWAYS DISCREET/MAXIMUM/L 3
ALWAYS DISCREET/MODERATE/ 3
ALWAYS DISCREET/ULTIMATE/ 3
ALWAYS FEMININE WIPES 3
ALWAYS MAXI MAXIMUM PROTE 3
ALWAYS PANTILINERS/THONG 3
ALWAYS ULTRA OVERNIGHT PA 3
ALWAYS ULTRA THIN PADS 3
ALWAYS WIPES-TO-GO 3
ambi 10peh/4cpm 3
ambi 10peh/400gfn 3
ambi 10peh/400gfn/20dm 3
ambi 12.5cpd/1dcpm/30pse 3
AMBI 12.5CPD/100GFN/30PSE 3
ambi 40pse/400gfn 3
ambi 60pse/4cpm 3
AMBI 60PSE/400GFN 3
AMBI 60PSE/400GFN/20DM 3
AMBI ESSENTIALS DAILY MOI 3
AMBI ESSENTIALS GENTLE CL 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
126
Drug Name Drug Tier Requirements/Limits
AMBI EVEN & CLEAR DAILY M 3
AMBI EVEN & CLEAR TARGETE 3
AMBI FADE NORMAL SKIN 3
AMBI FADE OILY SKIN 3
AMBI SOFT & EVEN CREAMY O 3
AMEDA TRIPLE ZERO LANOLIN 3
americerin 3
AMERIDERM PERISHIELD 3
AMERIGEL BARRIER 3
AMERIGEL CARE 3
ameriphor 3
ameristore 3
amina-21 3
amino acids 3
amino acids complex 3
amino action 3
aminofen 3
aminos 3
amlactin 3
AMLACTIN CERAPEUTIC 3
AMLACTIN ULTRA 3
amoryn mood booster 3
amplify relief mm 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
127
Drug Name Drug Tier Requirements/Limits
ANACIN 3
ANACIN MAX STRENGTH 3
ANACIN TAB 400-30MG 3
analgesic cream/aloe 3
analgesic creme rub/aloe 3
analgesic creme/aloe 3
anbesol cold sore therapy 3
anecream 3
anecream5 3
anefrin nasal spray 3
anefrin nasal spray extra 3
anefrin nasal spray sooth 3
anefrin nasal spray/no dr 3
animal chewable multi 3
animal chews 3
antacid CHEW 420mg, 500mg 3
ANTACID CHEW 1177mg 3
antacid SUSP 3
antacid + anti-gas liquid 3
antacid advanced 3
antacid anti-gas 3
antacid anti-gas fast act 3
antacid anti-gas maximum 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
128
Drug Name Drug Tier Requirements/Limits
antacid anti-gas regular 3
antacid calcium extra str 750mg 3
antacid calcium regular s 500mg 3
antacid double strength 3
antacid extra strength 3
antacid extra strength an 3
antacid fast acting 3
antacid fast relief 3
antacid flavor chews 3
antacid i 3
antacid iii 3
antacid liquid 3
antacid m 3
antacid maximum 3
antacid maximum strength 3
antacid multi-symptom 3
antacid plus anti-gas fas 3
antacid plus anti-gas rel 3
antacid regular strength 3
ANTACID SOFT CHEWS 3
ANTACID ULTRA STRENGTH 3
antacid ultra strength 1000mg 3
antacid w/simethicone 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
129
Drug Name Drug Tier Requirements/Limits
antacid/simethicone doubl 3
anti-allergy 3
ANTI-BACTERIAL HAND LOTIO 3
anti-dandruff shampoo 3
anti-diarrheal CAPS 3
anti-diarrheal LIQD 3
anti-diarrheal TABS 2mg 3
anti-diarrheal plus gas r 3
anti-fungal 3
anti-gas 3
anti-gas ultra strength 3
anti-hist allergy 3
anti-itch 3
anti-itch intensive heali 3
anti-itch maximum strengt CREA 1%, 2% 3
anti-itch maximum strengt SOLN 3
anti-nausea 3
anti-nausea/rekematol 3
anti-oxidant 3
anti-oxidant formula 3
antibiotic + pain relief 3
antibiotic plus pain reli 3
antifungal AERO 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
130
Drug Name Drug Tier Requirements/Limits
antifungal CREA 1%, 2% 3
antifungal foot 3
antifungal foot/sneaker s 3
antifungal powder 3
antifungal spray powder 3
antioxidant 3
antioxidant formula 3
ANTIOXIDANT FORMULA SG 3
antioxidant formula/miner 3
ANTIOXIDANT FORTE 3
antioxidant protection fo 3
antioxidant vitamins 3
antioxin 4000 3
antiseptic 3
antiseptic mouth rinse 3
antiseptic pain relief 3
antiseptic skin cleanser 3
anu-med 3
anusert hc-1 3
ANUSOL 3
AO-SEPT DISINFECTION/NEUT SOLN 3
AOSEPT 3
AP-HIST DM 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
131
Drug Name Drug Tier Requirements/Limits
AP-ZEL 3
APAP 500 3
apap extra strength 3
apapgesic 3
APATATE 3
APATATE FORTE 3
APETEX 3
APETIGEN 3
APETIGEN-PLUS 3
aphedrid 3
aphen 3
aplicare povidone-iodine 3
APLICARE POVIDONE/IODINE GEL 3
aplicare povidone/iodine SOLN 3
apra 3
aprodine 3
aqua care 3
AQUA GLYCOLIC FACE CREAM 3
AQUA GLYCOLIC FACIAL CLEA 3
AQUA GLYCOLIC HAND & BODY 3
AQUA GLYCOLIC HAND/BODY 3
AQUA GLYCOLIC SHAMPOO & B 3
AQUA GLYCOLIC TONER 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
132
Drug Name Drug Tier Requirements/Limits
AQUA LACTEN 3
AQUA LANCE ADJUSTABLE LAN 3
aqua lube 3
aqua lube plus 3
AQUA-E 3
AQUACEL EXTRA/HYDROFIBER 3
AQUACEL FOAM 3.2"X3.2" 3
AQUACEL FOAM 4"X4" 3
AQUACEL FOAM 5"X5" 3
AQUACEL FOAM 6"X6" 3
AQUACEL FOAM 6"X8" 3
AQUACEL FOAM 7"X7" 3
AQUACEL FOAM 8"X5.5" 3
AQUACEL FOAM 8"X7" 3
AQUADEKS CHEW 3
AQUADERM 3
AQUADERM TREATMENT/MOISTU 3
AQUAMED 3
AQUANAZ 3
aquanil hc 3
AQUANIL SKIN CLEANSER 3
AQUAPHILIC 3
AQUAPHILIC/CARBAMIDE 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
133
Drug Name Drug Tier Requirements/Limits
AQUAPHOR 3
AQUAPHOR ADVANCED THERAPY 3
AQUAPHOR LIP REPAIR 3
AQUASITE IMPREGNATED DRES 3
AQUASITE IMPREGNATED GAUZ 3
AQUASITE SHEET DRESSING 4 3
AQUASOL A PARENTERAL 3
AQUASOL E 3
aquavit-e 3
AQUEOUS SELENIUM 3
aqueous vitamin d infants 3
aqueous vitamin e 3
AQUIFY LONG-LASTING COMFO 3
AQUIFY MULTI-PURPOSE 3
AQUORAL 3
arctic relief pain reliev 3
arctic relief roll-on pai 3
ARGIMENT 3
ARGIMENT AT 3
arginine CAPS 3
ARGININE PACK 3
ARGININE TABS 500mg 3
arginine TABS 500mg, 1000mg 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
134
Drug Name Drug Tier Requirements/Limits
ARGININE2000 3
ARGITEIN 3
ARGLAES FILM 2-3/8" X 3-1 3
ARGLAES FILM 3" X 14" 3
ARGLAES FILM 4" X 4-3/4" 3
ARGLAES FILM 4-3/4" X 10" 3
ARGLAES ISLAND 2-3/8" X 3 3
ARGLAES ISLAND 4" X 4-3/4 3
ARGLAES ISLAND 4-3/4" X 1 3
ARIAL CHAMBER 3
ARKALIOX 3
aromatic inhalants 3
arthogenic plus 3
arthricream 3
arthricream rub 3
arthritis hot 3
arthritis pain 3
arthritis pain relief CREA 3
arthritis pain relief TBCR 650mg 3
arthritis pain reliever 3
ARTHRITIS PAIN RELIEVING 3
arthritis/aloe 3
ARTIFICIAL TEAR OPHTH SO 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
135
Drug Name Drug Tier Requirements/Limits
artificial tear solution 3
artificial tears OINT 3
ARTIFICIAL TEARS SOLN .4% 3
artificial tears SOLN .4%, 1.4% 3
ASC LOTIONIZED ANTIMICROB 3
ASCENSIA AUTODISC TEST ST 3
asco-tabs-1000 3
ASCOCID 3
ASCOCID-500-D 3
ASCOCID-1000 3
ASCOCID-ISO-PH 3
ascorbic acid CHEW 100mg, 250mg,
300mg, 500mg
3
ascorbic acid CPCR 3
ASCORBIC ACID GRAN 3
ascorbic acid LIQD 3
ASCORBIC ACID POWD 3
ascorbic acid SYRP 3
ascorbic acid TABS 100mg, 250mg,
500mg, 1000mg
3
ascorbic acid TBCR 3
ASCRIPTIN 3
ASCRIPTIN TAB 3
asper-flex 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
136
Drug Name Drug Tier Requirements/Limits
aspercreme w/lidocaine 3
ASPERCREME/ALOE 3
aspir-low 81mg 3
aspir-trin 3
aspirin CHEW 81mg 3
ASPIRIN POWD 3
ASPIRIN SUPP 120mg, 200mg 3
aspirin SUPP 300mg, 600mg 3
ASPIRIN TABS 81mg 3
aspirin TABS 325mg, 500mg 3
aspirin TBEC 81mg, 162mg, 325mg, 500mg, 650mg
3
ASPIRIN TBEC 650mg 3
aspirin 81 low dose 3
aspirin adult low dose CHEW 3
aspirin adult low dose TBEC 81mg 3
aspirin adult low strengt 3
aspirin buffered (al hydrox-mg hydrox-ca
carb)
3
aspirin buffered (cal carb-mag carb-mag
oxide)
3
aspirin child 3
aspirin childrens 3
aspirin ec lo-dose 3
aspirin ec low dose 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
137
Drug Name Drug Tier Requirements/Limits
aspirin effervescent 3
aspirin enteric coated ad 3
aspirin low dose CHEW 81mg 3
ASPIRIN LOW DOSE TABS 3
aspirin low dose TBEC 81mg 3
aspirin low strength 81mg 3
aspirin regimen low dose/ 3
aspirin-acetaminophen-caffeine 3
aspirin-caffeine 3
aspirtab 3
aspirtab maximum strength 3
aspridrox 3
ASSESS FULL RANGE PEAK FL 3
ASSESS LOW RANGE PEAK FLO 3
ASSESS PEAK FLOW METER FU 3
ASSESS PEAK FLOW METER LO 3
ASSURANCE BELTED SHIELD/M 3
ASSURANCE BELTED UNDERGAR 3
ASSURANCE BLADDER CONTROL 3
ASSURANCE BOXERS MENS/LAR 3
ASSURANCE BOXERS MENS/SMA 3
ASSURANCE FITTED BRIEF LA 3
ASSURANCE FITTED BRIEF ME 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
138
Drug Name Drug Tier Requirements/Limits
ASSURANCE FITTED BRIEF SM 3
ASSURANCE GUARDS FOR MEN 3
ASSURANCE GUARDS FOR MEN/ 3
ASSURANCE PREMIUM WASHCLO 3
ASSURANCE UNDERGARMENT 3
ASSURANCE UNDERPADS 3
ASSURANCE UNDERPADS/30"-3 3
ASSURANCE UNDERPADS/LARGE 3
ASSURANCE UNDERWEAR/MENS/ 3
ASSURANCE UNDERWEAR/WOMEN 3
ASSURE 3 TEST STRIPS 3
ASSURE 4 BLOOD GLUCOSE ME 3
ASSURE 4 TEST STRIPS 3
ASSURE II 3
ASSURE II CHECK STRIP 3
ASSURE II TEST STRIPS 3
ASSURE PLATINUM BLOOD GLU 3
ASSURE PLATINUM TEST STRI 3
ASSURE PRISM MULTI BLOOD 3
ASSURE PRISM MULTI TEST S 3
ASSURE PRO BLOOD GLUCOSE 3
ASSURE PRO TEST STRIPS 3
ASTHMA CHECK METER-ZONE S 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
139
Drug Name Drug Tier Requirements/Limits
ASTHMAMENTOR 3
asthmanefrin refill 3
asthmanefrin starter kit 3
ASTRING-O-SOL 3
astroglide 3
AT LAST TEST STRIPS 3
athletes foot 3
athletes foot af cream 3
athletes foot powder 3
athletes foot powder spra 3
athletes foot spray 3
ATRAC-TAIN 3
ATRAPRO DERMAL SPRAY 3
ATTENDS BARIATRIC BRIEF 1 3
ATTENDS BOOSTER PAD 3
ATTENDS BREATHABLE BRIEFS 3
ATTENDS BRIEFS 8 LARGE 3
ATTENDS BRIEFS 8 MEDIUM 3
ATTENDS BRIEFS 8 REGULAR 3
ATTENDS BRIEFS 8 X-LARGE 3
ATTENDS BRIEFS 9 LARGE 3
ATTENDS BRIEFS 9 MEDIUM 3
ATTENDS BRIEFS 9 REGULAR 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
140
Drug Name Drug Tier Requirements/Limits
ATTENDS BRIEFS 9 X-LARGE 3
ATTENDS BRIEFS 10 CLASSIC 3
ATTENDS BRIEFS 10 LARGE 3
ATTENDS BRIEFS 10 MEDIUM 3
ATTENDS BRIEFS 10 REGULAR 3
ATTENDS BRIEFS 10 SMALL 3
ATTENDS BRIEFS 10 X-LARGE 3
ATTENDS BRIEFS LARGE WAIS 3
ATTENDS BRIEFS MEDIUM 3
ATTENDS BRIEFS MEDIUM WAI 3
ATTENDS BRIEFS SMALL 3
ATTENDS CLASSIC UNDERPAD 3
ATTENDS GUARDS FOR MEN UN 3
ATTENDS INSERT PAD 3 3
ATTENDS INSERT PAD 4 3
ATTENDS LIGHT PADS EXTRA 3
ATTENDS LIGHT PADS REGULA 3
ATTENDS LIGHT PADS ULTRA 3
ATTENDS MESH PANTS BARIAT 3
ATTENDS MESH PANTS LARGE 3
ATTENDS MESH PANTS X-LARG 3
ATTENDS MESH PANTS XX-LAR 3
ATTENDS NIGHT PRESERVER 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
141
Drug Name Drug Tier Requirements/Limits
ATTENDS PULL-ON BRIEFS LA 3
ATTENDS PULL-ON BRIEFS ME 3
ATTENDS SHAPED PAD 4 3
ATTENDS SHAPED PAD 5 3
ATTENDS SHAPED PAD 6 3
ATTENDS SHAPED PAD 7 3
ATTENDS SHAPED PAD 8 3
ATTENDS SHAPED PAD 9 3
ATTENDS SHAPED PADS EXTEN 3
ATTENDS UNDERGARMENTS 6 B 3
ATTENDS UNDERPADS EXTRA A 3
ATTENDS UNDERPADS MODERAT 3
ATTENDS UNDERPADS REGULAR 3
ATTENDS UNDERWEAR 7 EXTRA 3
ATTENDS UNDERWEAR 7 SUPER 3
ATTENDS WASHCLOTH 3
ATTENDS WASHCLOTH X-LARGE 3
ATTENDS WASHCLOTHS 3
ATUSS DA 3
auraphene-b 3
auro eardrops 3
auro-dri 3
AUTO-LANCET 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
142
Drug Name Drug Tier Requirements/Limits
AUTO-LANCET MINI 3
AUTOLET IMPRESSION LANCIN 3
AUTOLET LANCING DEVICE 3
AUTOLET MINI 3
AUTOLET PLUS 3
AVEENO ACTIVE NATURALS DA 3
AVEENO ACTIVE NATURALS EC 3
AVEENO ACTIVE NATURALS PU 3
AVEENO ACTIVE NATURALS SK CREA;
OINT
3
AVEENO ADVANCED CARE MOIS 3
AVEENO ANTI-ITCH 3
AVEENO ANTI-ITCH CREAM 3
aveeno anti-itch maximum 3
AVEENO BABY CALMING COMFO LIQD 3
AVEENO BABY CLEANSING THE 3
AVEENO BABY ECZEMA THERAP 3
AVEENO BABY SOOTHING BATH 3
AVEENO BABY SOOTHING RELI CREA 3
AVEENO BATH MOISTURIZING 3
AVEENO CONTINUOUS RADIANC 3
AVEENO DAILY FIRMING 3
AVEENO DAILY MOISTURIZING LOTN 3
AVEENO INTENSE RELIEF HAN 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
143
Drug Name Drug Tier Requirements/Limits
AVEENO POSITIVELY AGELESS 3
AVEENO POSITIVELY NOURISH 3
AVEENO POSITIVELY RADIANT 3
AVEENO POSITIVELY SMOOTH LOTN 3
aveeno shower & bath oil 3
AVEENO SKIN BRIGHTENING D 3
AVEENO SKIN RELIEF SHOWER 3
AVEENO SMART ESSENTIALS D 3
AVEENO SMART ESSENTIALS N 3
AVEENO SOOTHING BATH TREA 3
AVEENO STRESS RELIEF MOIS 3
AVEENO ULTRA-CALMING 3
AVORIA CAL+D 3
awake maximum strength 3
AXID AR 3
AXSAIN 3
ayr 3
AYR NASAL DROPS 3
AYR NASAL MIST ALLERGY & 3
ayr saline nasal 3
AYR SALINE NASAL NETI RIN 3
ayr saline nasal no-drip 3
AYR SALINE NASAL RINSE KI 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
144
Drug Name Drug Tier Requirements/Limits
AZEC 3
azo dine 3
azo dine maximum strength 3
azo tabs 3
AZO TEST STRIPS 3
azo urinary pain relief 3
azo urinary pain relief e 3
azo urinary pain relief m 3
azo-standard 3
AZOLEN TINCTURE 3
b1 high potency 3
B1 NATURAL 3
b6 natural 3
b12 fast dissolve 3
B12 FOLATE 3
B12-ACTIVE 3
b50 complex tr 3
B & L SENSITIVE EYES PLUS 3
b complete 3
B COMPLEX + C TR 3
b complex formula #1 3
b complex maxi 3
b complex plus 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
145
Drug Name Drug Tier Requirements/Limits
b complex w/ c 3
b complex w/ iron 3
B COMPLEX/FOLIC ACID 3
B&L RENU DISINFECTING SOL 3
B&L RENU SALINE SOLUTION 3
B&L SENSITIVE EYES 3
B&L SENSITIVE EYES DAILY 3
B&L SENSITIVE EYES SALINE 3
B&L STERILE DAILY CLEANER 3
B-1 3
B-2-400 3
B-12 3
B-12 1000 3
B-12 + FOLIC ACID 3
B-12 DOTS 3
B-12 DUAL SPECTRUM 3
b-12 fast dissolve 3
B-12 METHYLCOBALAMIN 3
b-12 microlozenge 3
B-12 PLUS FOLIC ACID 3
B-12 QUICK DISSOLVE 3
B-12 SUPER STRENGTH 3
b-12 tr 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
146
Drug Name Drug Tier Requirements/Limits
b-12-sl 3
b-50 3
b-50 complex 3
b-50 tr 3
b-100 3
b-100 complex TABS 3
B-100 COMPLEX TABS 3
b-100 complex TBCR 3
b-100 complex tr 3
b-100 tr 3
b-caro-t 3
b-compleet-50 3
b-compleet-100 3
B-COMPLEX CAPS 3
b-complex 50 3
b-complex 50 tr 3
b-complex 100 tr 3
b-complex balanced 3
b-complex formula 1 3
b-complex high potency 3
b-complex high strength 1 3
b-complex vitamins CAPS 3
b-complex vitamins LIQD 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
147
Drug Name Drug Tier Requirements/Limits
b-complex vitamins TABS 3
b-complex w/ c & calcium 3
b-complex w/ c & folic acid 3
b-complex w/ c + mg zn 3
b-complex w/ folic acid 3
b-complex w/biotin & folic acid 3
B-COMPLEX/FOLIC ACID/VITA 3
B-COMPLEX/VITAMIN C/FOLIC 3
B-NATAL 3
b-plex 3
b-plex plus 3
b-redi/red hearts/red roo 3
b-stress 3
BABY ANBESOL 3
baby ayr saline 3
baby chest rub 3
baby darlings pediatric e 3
baby darlings soothing ba 3
BABY DDROPS 3
baby diaper rash cream 3
BABY ORAJEL 3
baby orarelief 3
baby super daily d3 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
148
Drug Name Drug Tier Requirements/Limits
baby teething 3
baby teething pain medici 3
baby vitamin 3
baby vitamin a & d 3
baby vitamin d3 drops 3
BACID 3
BACIGUENT 3
bacitracin (topical) 500u/gm, 500unit/gm 3
bacitracin zinc OINT 500unit/gm 3
bacitracin-polymyxin b 3
BACITRAYCIN PLUS 3
bacitraycin plus 500unit/gm 3
back & body extra strengt 3
BACK PAIN-OFF 3
backache relief extra str 3
BACMIN 3
BAG BALM 3
BALAMINE DM 3
balance b-50 3
balance b-100 3
balanced b complex 3
balanced b complex tr 3
balanced b-50 TABS 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
149
Drug Name Drug Tier Requirements/Limits
balanced b-50 TBCR 3
balanced b-50 complex 3
balanced b-100 TABS 3
balanced b-100 TBCR 3
balanced b-100 complex tr 3
BALMEX OIN 3
balmex skin protectant 3
BALNETAR LIQUIM 3
BANATROL PLUS 3
BAND-AID HYDRO SEAL BLIST PADS 3
BAND-AID HYDRO SEAL CORN 3
band-aid liquid bandage 3
BAND-AID MOLESKIN ADHESIV 3
banophen CAPS 25mg, 50mg 3
banophen CREA 3
banophen LIQD 12.5mg/5ml 3
banophen TABS 25mg 3
BARC 3
BARD DISPOZ-A-BAG LEG BAG 3
BARD DISPOZ-A-BAG/FLIP-FL 3
BARIATRIC FUSION 3
BARIATRIC MULTIVITAMINS/I 3
BARIDIUM 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
150
Drug Name Drug Tier Requirements/Limits
BASIC AM 3
BASIC PM 3
BASIS CLEANSER EXTRA DRY 3
BASIS CLEANSER NORMAL/DRY 3
BASIS CLEANSER SENSITIVE 3
BASIS FACIAL MOISTURIZER 3
BASIS OVERNIGHT 3
BASLE 3
bayer advanced aspirin ex 3
bayer advanced aspirin re 3
BAYER ASPIRIN PACK 3
bayer aspirin TABS 3
bayer aspirin ec low dose 3
bayer aspirin extra stren 3
bayer aspirin regimen 3
BAYER BACK & BODY 3
BAYER BACK & BODY PAIN EX 3
BAYER BREEZE 2 BLOOD GLUC 3
BAYER BREEZE 2 TEST DISC 3
bayer chewable low dose 3
BAYER CONTOUR BLOOD GLUCO 3
BAYER CONTOUR LINK 2.4 BL 3
BAYER CONTOUR LINK BLOOD 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
151
Drug Name Drug Tier Requirements/Limits
BAYER CONTOUR NEXT USB BL 3
BAYER CONTOUR USB BLOOD G 3
bayer low dose 3
BAYER MICROLET 2 LANCING 3
bayer migraine 3
BAYER PLUS 3
BAYER PM 3
BAYER WOMENS 3
baza antifungal 3
BAZA CLEANSE & PROTECT 3
baza clear 3
baza protect 3
BC FAST PAIN RELIEF 3
BC FAST PAIN RELIEF ARTHR 3
BD GLUCOSE 3
BD LANCET DEVICE 3
BD LATITUDE DIABETES MANA 3
BD LOGIC BLOOD GLUCOSE MO 3
bd posiflush 3
BD TEST STRIPS 3
BEAU RX 3
beauty lotion 3
bec/zinc 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
152
Drug Name Drug Tier Requirements/Limits
bedding spray lice treat 3
bedding spray lice treatm 3
bee zee 3
BEELITH 3
BELTED UNDERGARMENT 3
BELTED UNDERGARMENT XTRA 3
BELTED UNDERGARMENT/REGUL 3
BENADRYL 3
BENADRYL ALLERGY 3
BENADRYL ALLERGY & COLD 3
BENADRYL ALLERGY & SINUS 3
BENADRYL ALLERGY CHILDREN 3
BENADRYL ALLERGY/SINUS/HE 3
BENADRYL DYE-FREE ALLERGY 3
BENADRYL EXTRA STRENGTH CREA 3
benadryl extra strength LIQD 3
BENADRYL ITCH STOPPING CREA 3
benadryl itch stopping GEL 3
BENADRYL MAXIMUM STRENGTH 3
benadryl severe allergy & 3
BENADRYL-D ALLERGY & SINU 3
BENEFIBER 3
BENEFIBER FOR CHILDREN 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
153
Drug Name Drug Tier Requirements/Limits
benefiber on the go POWD 3
BENEFIBER PLUS CALCIUM CHEW 3
BENEPROTEIN 3
BENFOTIAMINE CAPS 3
benfotiamine multi-b neur 3
BENFOTIAMINE-V 3
BENGAY ARTHRITIS FORMULA 3
BENGAY GREASELESS 3
benoxyl 10 3
BENYLIN ADULT FORMULA 3
BENYLIN SYP MULTI 3
BENZAC AC WASH 3
BENZALKONIUM CHLORIDE CONC 3
BENZEDREX INHALER 3
BENZEFOAM 3
BENZEFOAM ULTRA 3
benzepro 3
benzepro short contact 3
benzoin 3
benzoin compound 3
BENZOIN COMPOUND TINCTURE 3
BENZOIN TINCTURE 3
BENZOIN TINCTURE PLAIN 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
154
Drug Name Drug Tier Requirements/Limits
benzonatate 100mg, 150mg, 200mg 3
benzoyl peroxide CREA 3
benzoyl peroxide FOAM 3
BENZOYL PEROXIDE GEL 2.5% 3
benzoyl peroxide GEL 5%, 10% 3
benzoyl peroxide LOTN 3
BENZOYL PEROXIDE CLEANSER 3%, 6%, 9%
3
benzoyl peroxide cleanser 6% 3
benzoyl peroxide wash 3
benzoyl peroxide wash acn 3
berocca 3
berri-freez pain relievin GEL 3.5% 3
berri-freez pain relievin LIQD 3
BETA CARE 3
beta care betatar gel 3
beta carotene CAPS 10000iu, 10000unit, 25000unit
3
BETA CAROTENE CAPS 10000unit 3
beta carotene provitamin 3
beta hc 3
beta med 3
BETA XMA 3
BETADINE 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
155
Drug Name Drug Tier Requirements/Limits
BETADINE SKIN CLEANSER 3
BETADINE SURGICAL SCRUB 3
BETADINE SWAB AID 3
BETADINE SWABSTICKS 3
BETASAL 3
betasept surgical scrub 3
betatemp childrens 3
better b complex 3
BG STAR BLOOD GLUCOSE TES 3
BICARSIM 3
BICARSIM FORTE 3
BICLORA 3
BICLORA-D 3
bidex 3
BIFERA 3
big 100 3
BILBERRY PLUS 3
bio t pres 3
bio t pres pediatric 3
bio t pres-b 3
BIO-35 GLUTEN-FREE 3
BIO-35 IRON FREE 3
bio-d-mulsion 400unt/0.03ml 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
156
Drug Name Drug Tier Requirements/Limits
BIO-D-MULSION 400unt/0.04ml 3
bio-d-mulsion forte 2000unt/0.03ml 3
BIO-D-MULSION FORTE 2000unt/0.04ml 3
bio-rytuss 3
BIOBRANE 5"X5" 3
BIOBRANE 5"X15" 3
BIOBRANE 10"X15" 3
BIOBRANE 15"X20" 3
BIOBRANE-L 5"X5" 3
BIOBRANE-L 5"X15" 3
BIOBRANE-L 10"X15" 3
BIOBRON SF 3
BIOCAL 3
biocel 3
biocotron 3
BIODESP DM 3
bioflavonoid products 3
BIOFLAVONOID-1000 3
bioflavonoids 3
bioflex 3
BIOFLONEX 3
BIOFREEZE AERO 3
biofreeze GEL; LIQD 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
157
Drug Name Drug Tier Requirements/Limits
biofreeze colorless 3
biofreeze roll-on 3
biofreeze roll-on colorle 3
biogtuss 3
BIOHM PROBIOTIC SUPPLEMEN CAPS 3
biolle gel tears 3
biolle tears 3
bion tears 3
BIONATUSS DXP 3
BIONEL 3
BIONEL PEDIATRIC 3
BIOSCANNER GLUCOSE TEST S 3
BIOSPEC DMX 3
BIOSUPP 3
BIOTALAN CLEAR 3
BIOTECT PLUS 3
BIOTENE DRY MOUTH GENTLE LIQD 3
BIOTENE DRY MOUTH MOISTUR 3
BIOTENE DRY MOUTH MOUTHWA 3
BIOTENE DRY MOUTH ORAL RI 3
BIOTENE MOISTURIZING MOUT 3
BIOTENE ORALBALANCE DRY M LIQD 3
BIOTENE PBF DRY MOUTH MOU 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
158
Drug Name Drug Tier Requirements/Limits
BIOTIN CAPS 1mg 3
biotin CAPS 5mg, 10mg, 2500mcg, 5000mcg
3
BIOTIN POWD 3
BIOTIN SUBL 3
biotin TABS 10mg, 300mcg, 800mcg,
1000mcg, 5000mcg, 10000mcg
3
BIOTIN TABS 800mcg, 7500mcg 3
BIOTIN TBDP 3
biotin 5000 3
BIOTIN FORTE 3mg 3
biotin forte 5mg 3
BIOTIN GUMMIES 3
biotin maximum 3
biotin maximum strength 3
BIOTIN PLUS KERATIN 3
biotin plus/calcium/vit d 3
BIOTIN-D 3
biotinex 3
BIOTRUE 3
BIOVOL 3
BIPHENOX 3
bisac-evac SUPP 10mg 3
bisac-evac TBEC 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
159
Drug Name Drug Tier Requirements/Limits
bisacodyl SUPP 10mg 3
bisacodyl TBEC 3
bisacodyl ec 5mg 3
bisacodyl laxative 3
bismatrol CHEW 262mg 3
bismatrol SUSP 262mg/15ml 3
bismatrol maximum strengt 3
bismuth 3
BISMUTH SUBGALLATE 3
bismuth subsalicylate CHEW; SUSP 3
bite-a-mins 3
bite-a-mins/iron 3
bl 3 day vaginal 3
bl 12 hour cold 3
bl adult aspirin low stre 3
bl allergy relief for kid 3
bl antacid 3
bl anti-diarrheal 3
bl anti-gas 3
bl anti-itch 3
bl aspirin 3
bl b-50 balanced 3
bl beta carotene 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
160
Drug Name Drug Tier Requirements/Limits
bl bisa-lax 3
bl calcium citrate+d 3
bl calcium/magnesium/zinc 3
bl chromium picolinate 3
bl cimetidine 3
bl epsom salt 3
bl essential one daily 3
bl fiber therapy 3
BL FINGER CREAM 3
BL FITTED BRIEFS EXTRA WI 3
bl glucosamine/chondroiti 3
BL GLUCOSE 3
BL HOT STEAM LIQUID 3
bl ibu-profen cold & sinu 3
bl infants pain reliever 3
bl l-lysine 3
bl laxative pills 3
bl lorata-dine d 3
bl loratadine allergy rel 3
bl lozenges 3
bl miconazole 3 3
bl mineral oil 3
BL MINERAL OIL LIGHT 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
161
Drug Name Drug Tier Requirements/Limits
bl niacin tr 3
bl no drip nasal spray 3
bl one daily plus iron 3
bl pain reliever extra st 3
bl pediatric electrolyte 3
bl permethrin 3
bl pink bismuth 3
BL PROTECTIVE UNDERWEAR 3
bl severe cold/flu maximu 3
bl sleep aid 3
bl stool softener 3
bl stool softener/stimula 3
bl stress formula+iron 3
BL TEST STRIPS 3
bl tolnaftate 3
bl triacting chest conges 3
bl triacting cold/allergy 3
BL UNDERPADS EXTRA LARGE 3
BL UNDERPADS REGULAR 3
BL UNDERPADS SUPER LARGE 3
bl vitamin a 3
bl vitamin b12 3
bl vitamin b complex 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
162
Drug Name Drug Tier Requirements/Limits
bl vitamin b-6 3
bl vitamin c 3
bl vitamin c w/rose hips 3
bl vitamin c/rose hips 3
bl vitamin e 3
bl womens menstrual relie 3
BL ZINC LOZENGE W/VIT C 3
BLACK DRAUGHT 3
BLADDER CONTROL PADS EXTR 3
BLADDER CONTROL PADS REGU 3
BLADDER CONTROL PADS ULTR 3
BLENDED SUSPENDING COMPOU 3
blis-to-sol LIQD 3
BLISTEX MEDICATED 3
BLOOD GLUCOSE MONITORING 3
BLOOD GLUCOSE SYSTEM PAK 3
BLOOD GLUCOSE TEST STRIPS 3
blue gel 3
BLUE-EMU SUPER STRENGTH 3
BODI LOTION 3
BODI PROTECT 3
BODI WHIRL OIL 3
body/hair/skin/nails 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
163
Drug Name Drug Tier Requirements/Limits
BONE DENSITY 3
BONE DENSITY BUILDER 3
BONE ESSENTIALS 3
BONE MEAL 3
bone meal w/ vitamin d 3
bonine 25mg 3
BONINE 25mg 3
boric acid GRAN 3
BORIC ACID GRAN 3
BORON 3
BOUDREAUXS BABY BUTT SMOO 3
BOUDREAUXS BUTT BATH BODY 3
BOUDREAUXS BUTT PASTE 3
boudreauxs butt paste max 3
bounty bears/c 3
BP 8 COUGH 3
BP CLEANSING LOTION 3
bp foam 3
bp foaming wash 3
bp gel 3
bp wash 2.5%, 5%, 5.25%, 10% 3
bpm-dm-phen 3
BPO CREAMY WASH COMPLETE 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
164
Drug Name Drug Tier Requirements/Limits
bpo-5 wash 3
bpo-10 wash 3
bprotected multi-vite 3
bprotected pedia d-vite 3
bprotected pedia iron 3
bprotected pedia poly-vit 3
bprotected pedia tri-vite 3
bprotected vitamin c/rose 3
BRAIN 3
BRAIN MIGHT/DHA & CO Q10 3
BREEZE 2 BLOOD GLUCOSE MO 3
BREWERS YEAST POWD 3
brewers yeast TABS 3
BRIEFS OVERNIGHT LARGE 3
BRIEFS OVERNIGHT MEDIUM 3
BROHIST D 3
bromfed dm 3
BROMI-LOTION 3
bromphenex dm 3
brompheniramine & phenylprop 3
bronchial asthma relief 3
bronchial mist 3
bronchial mist refill 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
165
Drug Name Drug Tier Requirements/Limits
broncho saline 3
broncotron 3
broncotron ped 3
broncotron ped drops 3
BRONCOTRON-D 3
BRONCOTRON-S 3
BRONKAID 3
BRONKIDS 3
BRONTUSS DX 3
brontuss sf 3
brontuss sf nr 3
brotapp 3
BROVEX PEB 3
BROVEX PEB DM 3
BROVEX PSB 3
BROVEX PSB DM 3
BTREX 3
BUBBLE GUM 3
BUBBLES THE FISH II PEDIA 3
buckleys chest congestion 3
BUCKLEYS COUGH 3
budesonide (nasal) 3
buffered aspirin 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
166
Drug Name Drug Tier Requirements/Limits
buffered c 3
buffered salt 3
BUFFERED VITAMIN C 3
BUFFERIN 3
BUFFERIN EXTRA STRENGTH 3
BUFFERIN LOW DOSE 3
BULL FROG MOSQUITO COAST 3
BUNION GUARD 3
BURIED TREASURE ACTIVE 55 3
butenafine hcl 3
c1000 tr/rose hips/biofla 3
c1500 tr/rose hips/biofla 3
c1500/rose hips/bioflavon 3
c 250 3
c 500 3
c 500/rose hips 3
c 1000 3
c 1000/bioflavonoids/rose 3
c & e 3
c complex 3
c-250 3
c-500 3
c-500 non-acid 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
167
Drug Name Drug Tier Requirements/Limits
c-500 prolonged release 3
c-500 sr 3
c-500/rose hips 3
c-500/rose hips sr 3
c-1000 3
c-1000 prolonged release 3
c-1000 sr 3
c-1000/rose hips 3
c-1000/rose hips sr 3
c-1500/rose hips sr 3
C-BUFF 3
c-caps tr 3
c-chewable 3
C-PLEX 3
c-time sr 3
CA-PLUS 3
caffeine 3
CAFFEINE ANHYDROUS 3
CAIRPAD BREATHABLE UNDERP 3
CAIRPAD FLUID CONTROL PAD 3
CAL MAG ZINC +D3 3
cal-carb forte 3
CAL-CITRATE 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
168
Drug Name Drug Tier Requirements/Limits
CAL-CITRATE PLUS VITAMIN 3
CAL-CO3Y 3
CAL-CYUM 3
CAL-DAY 1000 3
cal-gest antacid 500mg 3
CAL-GLU 3
CAL-LAC 3
cal-mag 3
cal-mag aspartate 3
CAL-MAG CHELA-MAX 3
CAL-MAG COMPLEX 3
CAL-MAG ZINC II 3
CAL-MAG ZINC III 3
CAL-MAG-K CHELA MAX 3
CAL-MAG-ZINC-D 3
CAL-MAG-ZINC-D3 3
CAL-MINT 3
CAL-QUICK 3
CAL/MAG 3
CALADRYL 3
calagesic 3
calahist 3
CALAMINE LOTN; POWD 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
169
Drug Name Drug Tier Requirements/Limits
CALAMINE LOT PHENOLAT 3
calamine medicated 3
calamine phenolated 3
CALAMINE PHENOLATED 3
CALAZIME SKIN PROTECTANT/ 3
calcarb 600 3
CALCET CREAMY BITES 3
CALCET PETITES 3
CALCI-CHEW 3
CALCI-MAX 3
CALCI-MIX 3
calcidol 3
calciferol 3
CALCIONATE 3
calcitrate 950mg 3
calcitrate plus d 3
CALCIUM CHEW 3
CALCIUM TABS 3
calcium TABS 500mg, 600mg 3
calcium 250+d 3
CALCIUM 500 3
calcium 500 + d 3
CALCIUM 500 + D3 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
170
Drug Name Drug Tier Requirements/Limits
calcium 500 +d 3
calcium 500 +d3 3
calcium 500+d 3
calcium 500+d3 3
calcium 500+d high potenc 3
calcium 500/d CHEW 3
calcium 500/d TABS 3
calcium 500/vitamin d 3
calcium 600 3
calcium 600 + d 3
calcium 600 + minerals 3
calcium 600 high potency 3
calcium 600 with vitamin 3
calcium 600+d 3
calcium 600+d3 3
calcium 600+d3 plus miner 3
calcium 600+d high potenc 3
calcium 600+d plus minera 3
calcium 600-d 3
CALCIUM 600/MAGNESIUM 300 3
calcium 600/vitamin d 3
calcium 600/vitamin d3 3
CALCIUM 1000 + D 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
171
Drug Name Drug Tier Requirements/Limits
calcium 1200 3
calcium 1200+d3 3
CALCIUM & VITAMIN D3 BONE 3
calcium + d 3
CALCIUM + D + K 3
CALCIUM ACETATE TABS 3
calcium acetate (phosphate binder) TABS 667mg
3
calcium antacid 500mg 3
calcium antacid extra str 750mg 3
calcium antacid ultra 3
calcium antacid ultra max 1000mg 3
calcium antacid ultra str 3
CALCIUM ASCORBATE POWD 3
calcium ascorbate TABS 3
CALCIUM CARBONATE CHEW 3
CALCIUM CARBONATE POWD 3
calcium carbonate TABS 500mg, 600mg,
1250mg, 1500mg
3
CALCIUM CARBONATE TABS 648mg,
650mg
3
calcium carbonate (antacid) CHEW 3
calcium carbonate (antacid) SUSP 1250mg/5ml
3
calcium carbonate (antacid) TABS 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
172
Drug Name Drug Tier Requirements/Limits
CALCIUM CARBONATE EXTRA L 3
CALCIUM CARBONATE HEAVY 3
CALCIUM CARBONATE LIGHT 3
calcium carbonate-cholecalciferol CAPS 3
calcium carbonate-cholecalciferol CHEW 3
calcium carbonate-cholecalciferol TABS 3
calcium carbonate-ergocalciferol 3
calcium carbonate-vitamin d CAPS 3
calcium carbonate-vitamin d TABS 3
calcium carbonate-vitamin d w/ minerals 3
CALCIUM CHEWS 3
CALCIUM CHLORIDE 3
calcium chloride (dihydrate) 3
CALCIUM CITRATE GRAN 3
calcium citrate TABS 200mg 3
CALCIUM CITRATE TABS 200mg, 250mg,
1040mg
3
calcium citrate + 3
calcium citrate + d 3
calcium citrate + d3 3
calcium citrate + d3 max 3
calcium citrate + d3 maxi 3
calcium citrate +d 3
calcium citrate chewy bit 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
173
Drug Name Drug Tier Requirements/Limits
CALCIUM CITRATE MALATE/VI 3
calcium citrate maximum/v 3
calcium citrate plus 3
calcium citrate plus/magn 3
CALCIUM CITRATE W/D 3
CALCIUM CITRATE W/VITAMIN 3
calcium citrate+ d 3
calcium citrate+d 3
calcium citrate+d3 3
calcium citrate+d3 petite 3
calcium citrate-vitamin d 3
calcium citrate/d3 3
CALCIUM CITRATE/MAGNESIUM 3
CALCIUM CITRATE/VITAMIN D 3
calcium creamies 3
calcium extra d3 3
calcium for women 3
calcium glubionate SYRP 3
CALCIUM GLUCONATE POWD 3
CALCIUM GLUCONATE TABS 50mg 3
calcium gluconate TABS 500mg, 650mg 3
CALCIUM GLUCONATE ANHYDRO 3
CALCIUM GLUCONATE MONOHYD 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
174
Drug Name Drug Tier Requirements/Limits
calcium gummies 3
calcium high potency 3
calcium high potency + vi 3
calcium lactate 0mg, 650mg 3
CALCIUM LACTATE 100mg, 648mg, 750mg
3
CALCIUM LACTATE PENTAHYDR 3
CALCIUM MAGNESIUM 750 3
CALCIUM PANTOTHENATE TABS 100mg, 200mg
3
calcium pantothenate TABS 500mg 3
CALCIUM PHOSPHATE DIBASIC 3
CALCIUM PHOSPHATE TRIBASI 3
CALCIUM PLUS D3 ABSORBABL 3
calcium plus soy 3
CALCIUM PLUS VITAMIN D 3
calcium plus vitamin d3 3
calcium polycarbophil 625mg 3
calcium soft chews 3
CALCIUM SOFT CHEWS 3
calcium stool softener 3
calcium w/ magnesium 3
calcium w/ vitamin d 3
CALCIUM W/D CAP 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
175
Drug Name Drug Tier Requirements/Limits
calcium+d3 3
calcium+d3 gradual releas 3
CALCIUM+MENAQ7 3
calcium-carb 600 3
calcium-carb 600 + d 3
CALCIUM-D-PANTOTHENATE 3
calcium-magnesium-zinc 3
CALCIUM/C/D 3
CALCIUM/D 3
CALCIUM/D3 ADULT GUMMIES 3
CALCIUM/MAGNESIUM 3
CALCIUM/MAGNESIUM/VITAMIN 3
CALCIUM/MAGNESIUM/ZINC 3
CALCIUM/MAGNESIUM/ZINC/VI 3
CALCIUM/VITAMIN D 3
CALCIUM/VITAMIN D3 GUMMIE 3
calcium/vitamin d3/adult 3
calcium/vitamin d/mineral 3
caldyphen 3
CALICYLIC 3
CALLUS CUSHIONS 3
callus removers 3
callus removers extra thi 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
176
Drug Name Drug Tier Requirements/Limits
CALMAG THINS 3
CALMOSEPTINE 3
CALNA 3
calphron 3
caltrate 600 3
caltrate 600+d 3
CALTRATE 600+D3 3
CALTRATE 600+D3 SOFT CHEW 3
CALTRATE 600+D PLUS MINER 3
CALTRATE GUMMY BITES 3
CALTRATE MINIS PLUS MIN E 3
calvite p&d 3
calypxo 3
CAM 3
cameo oil 3
CAMPHO-PHENIQUE LIQD 3
CAMPHOR CRYS 3
camphor & phenol 3
camphor-eucalyptus-menthol 3
CANDERMYL 3
cank-oxide 3
cankaid 3
CAPCOF 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
177
Drug Name Drug Tier Requirements/Limits
CAPHOSOL SOLN 3
CAPMIST DM 3
CAPRON DM 3
CAPRON DMT 3
CAPSAGEL 3
CAPSAGEL EXTRA STRENGTH 3
CAPSAGEL MAXIMUM STRENGTH 3
capsaicin CREA 3
CAPSAICIN POWD 3
capsaicin hot patch 3
capsaicin hp 3
CAPZASIN 3
CAPZASIN-HP 3
CAPZASIN-P 3
CARA-KLENZ 3
CARB INTERCEPT/PHASE 2 3
CARB-O-LAN 10 3
CARB-O-LAN 20 3
CARB-O-PHILIC/10 3
CARB-O-PHILIC/20 3
CARB-O-SAL 5 3
carbamide peroxide SOLN 3
carbamide peroxide (otic) 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
178
Drug Name Drug Tier Requirements/Limits
carbamoxide ear drops 3
CARBAPHEN CH 3
CARBAPHEN PED CH 3
CARBOFLEX ODOR CONTROL DR 3
CARBOLIC ACI LIQ 3
carboxymethylcellulose sodium (ophth) 3
cardec 3
cardec dm 3
CARDENZ 3
CARDIO TONE 3
CARDIOCOM LANCING DEVICE 3
CARDIOPRESS 3
CARDIOWHEY 3
careall aspirin 3
CAREFREE ACTI-FRESH BODY 3
CAREFREE ORIGINAL PANTILI 3
CAREFREE PANTY SHIELDS 3
CAREFREE PANTY SHIELDS/DE 3
CAREFREE PANTY SHIELDS/LO 3
CAREFREE PANTY SHIELDS/MA 3
CAREFREE PANTY SHIELDS/TE 3
CAREFREE PANTY SHIELDS/UN 3
CAREFREE ULTRA PROTECTION 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
179
Drug Name Drug Tier Requirements/Limits
CAREONE ADVANCED LANCING 3
CAREONE BLOOD GLUCOSE MON 3
CAREONE BLOOD GLUCOSE TES 3
CARESENS N BLOOD GLUCOSE 3
CARESENS N GLUCOSE MONITO 3
CARESENS N VOICE BLOOD GL 3
CARETOUCH BLOOD GLUCOSE M 3
CARETOUCH BLOOD GLUCOSE T 3
CARETOUCH LANCING DEVICE 3
CARMOL 10 3
CARMOL 20 3
caroguard 3
CAROZYME 3
carracolloid 4"x4" 3
carracolloid 6"x6" 3
CARRAGAUZE 2 X 2 3
CARRAGAUZE 4 X 4 3
carravite 3
carrington antifungal 2% 3
CARRINGTON MOISTURE BARRI 3
CARRINGTON SHA BOD WASH 3
carters little pills 3
castellani paint 1.5% 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
180
Drug Name Drug Tier Requirements/Limits
CASTIVA WARMING 3
CASTOR OIL 3
castor oil stimulant laxa 3
catrix correction 3
CAVERJECT 3 QL (6 vials / 25 days)
CAVERJECT IMPULSE 10mcg 3 QL (6 each / 25 days)
cavilon 3
CCP CAFFEINE FREE 3
celacyn 3
celebrate calcium citrate 3
CELEBRATE CALCIUM PLUS 50 3
CELEBRATE MULTI-COMPLETE 3
CELLULAR SECURITY 3
cemill 3
CEMILL PLUS 3
cemill sr 3
cemill/bioflavonoids 3
centamin 3
centavite 3
centavite a-z complete mu 3
centravites 3
centravites 50 plus 3
CENTRAVITES 50 PLUS 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
181
Drug Name Drug Tier Requirements/Limits
CENTRAVITES ADULTS 3
CENTRUM 3
CENTRUM ADULTS 3
CENTRUM CARDIO 3
CENTRUM FLAVOR BURST 3
CENTRUM FLAVOR BURST ADUL 3
CENTRUM FLAVOR BURST KIDS 3
centrum kids complete 3
CENTRUM MEN 3
CENTRUM MULTIGUMMIES ADUL 3
CENTRUM MULTIGUMMIES MEN 3
CENTRUM MULTIGUMMIES WOME 3
CENTRUM MULTIVITAMIN FLAV 3
CENTRUM PERFORMANCE 3
CENTRUM SILVER 3
CENTRUM SILVER 50+MEN 3
CENTRUM SILVER 50+WOMEN 3
CENTRUM SILVER ADULT 50+ 3
CENTRUM SILVER ULTRA MENS 3
CENTRUM SILVER ULTRA WOME 3
CENTRUM SPECIALIST ENERGY 3
CENTRUM SPECIALIST HEART 3
CENTRUM SPECIALIST IMMUNE 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
182
Drug Name Drug Tier Requirements/Limits
CENTRUM SPECIALIST PRENAT 3
CENTRUM SPECIALIST VISION 3
CENTRUM ULTRA MENS 3
CENTRUM ULTRA WOMENS 3
CENTRUM VITAMINTS 3
CENTRUM WOMEN 3
century 3
century mature 3
CEO-TWO 3
CEPACOL SORE THROAT 3
CEPACOL SORE THROAT & COU 3
CEPACOL SORE THROAT EXTRA 3
CEPASTAT 3
CERALYTE 50 3
CERALYTE 50 POTASSIUM FRE 3
CERALYTE 70 PACK 3
ceralyte 70 SOLN 3
CERALYTE 70 SOLN 3
CERALYTE 90 3
ceramax 3
CERASPORT 3
CERASPORT EX1 3
CERAVE 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
183
Drug Name Drug Tier Requirements/Limits
CERAVE AM SPF 30 3
cerave baby 3
CERAVE FOAMING FACIAL CLE 3
CERAVE HYDRATING CLEANSER 3
CERAVE PM 3
CERAVE RENEWING SA 3
CERAVE SA RENEWING 3
CEROVITE ADVANCED FORMULA LIQD 3
cerovite advanced formula TABS 3
cerovite jr 3
cerovite senior 3
certa plus 3
certa-vite 3
certagen 3
CERTAINTY ADJUSTABLE UNDE 3
CERTAINTY ADULT WASHCLOTH 3
CERTAINTY BELTED SHIELDS/ 3
CERTAINTY BOXERS FOR MEN/ 3
CERTAINTY CLEANSING WIPES 3
CERTAINTY FITTED BRIEFS/L 3
CERTAINTY FITTED BRIEFS/M 3
CERTAINTY FITTED BRIEFS/X 3
CERTAINTY GUARDS FOR MEN 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
184
Drug Name Drug Tier Requirements/Limits
CERTAINTY LINERS/WOMEN/RE 3
CERTAINTY OVERNIGHT UNDER 3
CERTAINTY PADS/REGULAR/MA 3
CERTAINTY PADS/REGULAR/UL 3
CERTAINTY PADS/WOMEN 3
CERTAINTY PADS/WOMEN/LONG 3
CERTAINTY PADS/WOMEN/MAXI 3
CERTAINTY PADS/WOMEN/OVER 3
CERTAINTY PADS/WOMEN/REGU 3
CERTAINTY PADS/WOMEN/ULTI 3
CERTAINTY PADS/WOMEN/ULTR 3
CERTAINTY PURSEREADY UND 3
CERTAINTY ULTRA THIN UNDE 3
CERTAINTY UNDERPADS MEN & 3
CERTAINTY UNDERPADS/EXTRA 3
CERTAINTY UNDERPADS/MEN & 3
CERTAINTY UNDERPADS/REGUL 3
CERTAINTY UNDERPADS/SUPER 3
CERTAINTY UNDERWEAR/LARGE 3
CERTAINTY UNDERWEAR/MEN/L 3
CERTAINTY UNDERWEAR/MEN/S 3
CERTAINTY UNDERWEAR/MENS/ 3
CERTAINTY UNDERWEAR/SMALL 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
185
Drug Name Drug Tier Requirements/Limits
CERTAINTY UNDERWEAR/UNISE 3
CERTAINTY UNDERWEAR/WOMEN 3
CERTAINTY UNDERWEAR/X-LAR 3
CERTAINTY UNDERWEAR/X-SMA 3
CERTAINTY UNDERWEAR/XLARG 3
certavite/antioxidants LIQD 3
CERTUSS-D 3
CESIUM 3
CESIUM 500 3
CESIUM 1000 3
CETAKLENZ 3
CETAPHIL 3
CETAPHIL DAILY ADVANCE UL 3
CETAPHIL DAILY FACIAL MOI 3
CETAPHIL DERMACONTROL FOA 3
CETAPHIL DERMACONTROL MOI 3
CETAPHIL GENTLE CLEANSER 3
CETAPHIL MOISTURIZING 3
CETAPHIL RESTORADERM 3
CETAPHIL THERAPEUTIC HAND 3
cetirizine hcl CHEW 5mg, 10mg 3
cetirizine hcl SOLN 3
cetirizine hcl SYRP 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
186
Drug Name Drug Tier Requirements/Limits
cetirizine hcl TABS 5mg, 10mg 3
cetirizine hcl allergy ch 5mg/5ml 3
cetirizine hcl childrens CHEW 3
cetirizine hcl childrens SOLN 1mg/ml,
5mg/5ml
3
cetirizine hcl hives reli 3
cetirizine hydrochloride 3
cetirizine-pseudoephedrine 3
CHAPSTICK OVERNIGHT 3
CHAPSTICK ULTRA MOISTURE 3
chapstick ultra renewal n 3
CHAPSTICK ULTRASMOOTH FOR 3
CHAPSTICK ULTRASMOOTH NOU 3
CHAPSTICK ULTRASMOOTH REJ 3
CHAPSTICK ULTRASMOOTH SOO 3
CHARCOAL POWD 3
CHARCOAL 6-16 MESH/TECHNI 3
CHARCOAL ACTIVATED POWD 3
CHEK-STIX COMBO PAK URINA 3
CHEK-STIX CONTROL 3
CHELATED CALCIUM 3
CHEMSTRIP 3
CHEMSTRIP 2 GP STRIPS 3
CHEMSTRIP 2 LN STRIPS 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
187
Drug Name Drug Tier Requirements/Limits
CHEMSTRIP 5 OB 3
CHEMSTRIP 7 3
CHEMSTRIP 9 STRIPS 3
CHEMSTRIP 10 MD 3
CHEMSTRIP -10 WITH SG 3
CHEMSTRIP BG STRIPS 3
CHEMSTRIP UGK 3
CHEMSTRIP-K 3
CHEMSTRIP-UG 3
CHERACOL PLUS 3
CHERACOL SORE THROAT 3
CHERACOL-D COUGH 3
cheratussin ac 3
cheratussin dac 3
CHERRY CONCENTRATE SYRP 3
cherry cough drops 3
CHERRY SYRUP 3
chest congestion & cough 3
chest congestion & sinus 3
chest congestion and sinu 3
chest congestion children 3
chest congestion daytime 3
chest congestion relief 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
188
Drug Name Drug Tier Requirements/Limits
chest congestion relief d 3
chest congestion relief e 3
chest congestion relief p 3
chest congestion/cough re 3
chest congestion/pain & s 3
CHEST CONGESTION/PAIN REL 3
chest rub hands-free medi 3
CHEW Q 3
CHEW-12 3
chew-c 3
chewable acetaminophen ch 3
chewable antacid 3
chewable calcium 3
CHEWABLE CALCIUM 500mg 3
CHEWABLE IRON 3
CHEWABLE VITAMIN E 3
chewable vitamins childre 3
chewable vite childrens 3
chewable vite with iron/c 3
child ibuprofen 3
childrens acetaminophen SUSP
160mg/5ml, 320mg/10ml, 325mg/10.15ml, 640mg/20ml,
650mg/20.3ml
3
childrens acetaminophen TBDP 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
189
Drug Name Drug Tier Requirements/Limits
CHILDRENS ADVIL 3
childrens advil cold 3
childrens allergy 12.5mg/5ml 3
childrens animal shapes c 3
childrens apap 3
childrens aspirin 81mg 3
childrens aspirin free 3
childrens chewable multi 3
childrens chewable multiv 3
childrens chewable vitami 3
childrens cold & allergy 3
childrens complete allerg 3
childrens cough 3
childrens gummies 3
childrens ibuprofen 100mg/5ml 3
childrens ibuprofen 100 3
childrens ibuprofen cold 3
childrens loratadine SYRP 5mg/5ml 3
childrens mapap rapid tab 3
childrens medi-profen 3
childrens medi-tabs 3
CHILDRENS MOTRIN 3
CHILDRENS MOTRIN COLD 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
190
Drug Name Drug Tier Requirements/Limits
CHILDRENS MOTRIN JUNIOR S 3
childrens mucus relief co 3
childrens mucus relief ex 100mg/5ml 3
childrens multivitamin 3
CHILDRENS MYLANTA UPSET S 3
childrens non-aspirin 3
childrens non-aspirin pai 3
childrens non-aspirin plu CHEW 3
CHILDRENS NON-ASPIRIN PLU SYRP 3
childrens pain relief plu 3
childrens pain reliever CHEW 3
childrens pain reliever SUSP 3
childrens pain reliever TBDP 80mg 3
childrens pepto 3
CHILDRENS PLUS COLD 3
childrens plus cold & all 3
childrens plus cough/runn 3
childrens plus flu 3
childrens plus multi-symp 3
CHILDRENS PROBIOTIC PEARL 3
childrens silapap 160mg/5ml 3
childrens soothe 3
childrens tactinal 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
191
Drug Name Drug Tier Requirements/Limits
childrens tylenol plus co LIQD 3
CHILDRENS TYLENOL PLUS CO SUSP 3
childs allergy cold/cough 3
childs pain reliever w/o 3
childs pain reliever with 3
CHLO HIST 3
CHLO TUSS 3
CHLO TUSS EX 3
CHLOPHED 3
CHLOR-TRIMETON 3
CHLOR-TRIMETON ALLERGY 3
chloraseptic LIQD 3
chloraseptic gargle 3
chloraseptic mouth pain 3
chloraseptic sore throat 3
chloraseptic warming sore LIQD 3
CHLORELLA 3
CHLORHEXIDINE GLUCONATE LIQD 2% 3
chlorhexidine gluconate LIQD 4% 3
CHLORHEXIDINE GLUCONATE C 3
chlorhist 3
chlorocaps 3
chlorphen 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
192
Drug Name Drug Tier Requirements/Limits
chlorphen sr 3
chlorphen-phenylprop w/apap 3
chlorpheniramine & phenylephrine 3
chlorpheniramine & phenylprop 3
chlorpheniramine & pseudoeph 3
chlorpheniramine maleate SYRP; TABS; TBCR
3
chlorpheniramine-phenylephrine-acetaminophen
3
chlorpheniramine-pseudoephedrine-acetaminophen
3
chocolated laxative 3
CHOICEFUL MULTIVITAMIN 3
CHOLASE CONTROL 3
cholecalciferol CAPS 400unit, 1000unit, 2000unit, 5000unit, 10000unit, 50000unit
3
cholecalciferol CHEW 3
cholecalciferol LIQD 400unit/ml, 5000unit/ml
3
cholecalciferol TABS 400unit, 1000unit, 2000unit, 5000unit, 50000unit
3
CHROMACAPS 3
CHROMEMATE 3
chromic chloride 3
chromium 100mcg, 200mcg, 1000mcg 3
CHROMIUM 400mcg 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
193
Drug Name Drug Tier Requirements/Limits
CHROMIUM ASPARTATE 3
chromium gtf 3
chromium picolinate CAPS 200mcg 3
CHROMIUM PICOLINATE CAPS 200mcg,
500mcg
3
CHROMIUM PICOLINATE TABS 3
chromium picolinate TABS 200mcg, 400mcg, 500mcg, 800mcg, 1000mcg
3
chromium picolinate mega 3
chromium picolinate ultra 3
CIALIS 3 QL (6 tabs / 25 days)
CIBA VISION CLEANER 3
CIBA VISION MIRAFLOW 3
CIBA VISION SALINE 3
cidaflex 3
cimetidine TABS 200mg 3
cimetidine 200 3
cimetidine acid reducer 3
CITRACAL + D3 MAXIMUM 3
CITRACAL CALCIUM GUMMIES 3
CITRACAL CALCIUM+D SLOW R 3
CITRACAL MAXIMUM 3
CITRACAL PETITES/VITAMIN 3
CITRACAL PLUS 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
194
Drug Name Drug Tier Requirements/Limits
CITRACAL PLUS BONE DENSIT 3
CITRACAL PLUS HEART HEALT 3
CITRACAL+D3 3
CITRACAL/VITAMIN D 3
citroma 3
CITRUCEL 3
CITRUCEL FIBER LAXATIVE 3
CITRULLINE 1000 3
citrus calcium +d 3
clarispray 3
CLARITIN 3
claritin allergy children 5mg/5ml 3
CLARITIN ALLERGY CHILDREN 5mg/5ml 3
CLARITIN CHILDRENS 3
claritin eye 3
CLARITIN REDITABS 3
CLARITIN-D 12 HOUR 3
CLARITIN-D 24 HOUR 3
CLASSIC PRENATAL 3
CLEAN & CLEAR ACNE TRIPLE FOAM 3
clean & clear acne triple LIQD 3
CLEAN & CLEAR ADVANTAGE 3 3
clean & clear advantage a GEL; LIQD 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
195
Drug Name Drug Tier Requirements/Limits
clean & clear advantage d 3
clean & clear advantage m 3
clean & clear continuous 3
CLEAN & CLEAR DAILY PORE 3
CLEAN & CLEAR DEEP ACTION CREA 3
clean & clear deep cleani 2% 3
CLEAN & CLEAR ESSENTIALS 3
CLEAN & CLEAR FOAMING FAC 3
CLEAN & CLEAR MORNING BUR 3
CLEAN & CLEAR NIGHT RELAX LIQD 3
clean & clear persa-gel e 3
clean & clear persa-gel m 3
CLEAN & CLEAR SOFT MOISTU 3
CLEAN START VAPORIZER TAB TBSO 3
CLEANSING CLOTHS FLUSHABL 3
CLEANSING CREAM 3
CLEANSING EYELID PADS 3
clear away 3
CLEAR AWAY ONE STEP WART 3
CLEAR AWAY PLANTAR SYSTEM 3
CLEAR AWAY WART REMOVER S 3
CLEAR CARE 3
CLEAR CARE PLUS W/HYDRAGL 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
196
Drug Name Drug Tier Requirements/Limits
CLEAR COUGH PM MULTI-SYMP 3
clear eyes all seasons ou 3
CLEAR EYES CONTACT LENS R 3
CLEAR EYES FOR DRY EYES 3
clear eyes natural tears 3
CLEAR EYES REDNESS RELIEF 3
CLEAR EYES TRIPLE ACTION 3
clear soluble fiber 3
clear-atadine d 3
clearasil daily clear hyd 3
clearasil daily clear van 3
CLEARCANAL EAR WAX REMOVA 3
clearlax PACK 3
clearlax POWD 3
clearplex v 3
clearplex x 3
clearskin 3
clemastine fumarate TABS 1.34mg 3
CLEVER CHEK AUTO CODE VOI 3
CLEVER CHEK AUTO-CODE BLO 3
CLEVER CHEK AUTO-CODE TES 3
CLEVER CHEK AUTO-CODE VOI 3
CLEVER CHEK BLOOD GLUCOSE 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
197
Drug Name Drug Tier Requirements/Limits
CLEVER CHEK TEST STRIPS 3
CLEVER CHOICE AUTO-CODE P 3
CLEVER CHOICE MICRO BLOOD 3
CLEVER CHOICE MICRO TEST 3
CLEVER CHOICE MINI BLOOD 3
CLEVER CHOICE NO CODING T 3
CLEVER CHOICE TALK BLOOD 3
CLEVER CHOICE TALK NO COD 3
CLINICAL NUTRIENTS 45-PLU 3
CLINICAL NUTRIENTS 50-PLU 3
CLINICAL NUTRIENTS ANTIOX 3
CLINICAL NUTRIENTS FOR FE 3
CLINICAL NUTRIENTS FOR MA 3
CLINICAL NUTRIENTS FOR ME 3
CLINICAL NUTRIENTS FOR WO 3
CLINISTIX 3
CLINITEST 3
CLINITEST REAGENT 3
CLN BODY WASH GENTLE NON- 3
CLN FACIAL CLEANSER MOIST 3
CLN FACIAL MOISTURIZER NO 3
CLN HAND & FOOT WASH DEEP 3
CLN HEALTHY SCALP SHAMPOO 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
198
Drug Name Drug Tier Requirements/Limits
CLN MOISTURE RICH GENTLE 3
CLN SPORT WASH HIGH PERFO 3
CLN SPORTWASH 3
CLOFERA 3
clorox nasal antiseptic s 3
CLORPACTIN WCS-90 3
CLOSERCARE 3
clotrimazole 3 3
clotrimazole (topical) CREA 1% 3
clotrimazole (topical) SOLN 1% 3
clotrimazole af 3
clotrimazole anti-fungal 1% 3
clotrimazole antifungal 1% 3
clotrimazole grx 3
clotrimazole vaginal CREA 1% 3
clotrimazole vaginal TABS 3
clotrimazole-7 3
CLOVERINE SALVE 3
CLUSINEX 3
CO MONITOR REPLACEMENT T 3
co q10 maximum strength 3
CO Q-10 3
co q-10 maximum strength 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
199
Drug Name Drug Tier Requirements/Limits
CO Q-10 PLUS 3
CO-ENZYME Q10/VITAMIN E 3
CO-ENZYME Q-10 3
coal tar extract 3
COATS ALOE 3
COATS ALOE CREME 3
COATS ALOE GELLY 3
COATS ALOE JUICE DRINK 3
COATS ALOE JUICE DRINK UN 3
COATS ALOE MOISTURIZING L 3
COATS ALOE VERA 3
COATS ALOE VERA JUICE DRI 3
COATS ALOE VERA MOISTURIZ 3
cobalamine combinations 3
COCOA BUTTER LOTN 3
COCOA BUTTER HAND & BODY 3
COCOA BUTTER PETROLEUM JE 3
cocoa butter skin cream 3
COCONUT OIL BEAUTY 3
cod liver oil CAPS 3
COD LIVER OIL OIL 3
COD LIVER OIL FOR KIDS 3
COD LIVER OIL PLUS VITAMI 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
200
Drug Name Drug Tier Requirements/Limits
cod liver oil w/vitamins 3
cod liver oil/low vitamin 3
cod liver oil/vitamins a 3
CODAR AR 3
CODAR D 3
codar gf 3
CODITUSS DM 3
CODITUSSIN AC 3
CODITUSSIN DAC 3
COENZYME Q10 CHEW; LIQD; TABS 3
coenzyme q10 (ubidecarenone) 3
COLACE 3
colace 2-in-1 3
COLACE CLEAR 3
COLAMINE 3
666 cold 3
cold & allergy 3
cold & allergy childrens 3
cold & cough childrens 3
cold & cough daytime 3
cold & cough daytime/nigh 3
cold & flu intense streng 3
cold & flu multi-symptom 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
201
Drug Name Drug Tier Requirements/Limits
cold & flu relief multi-s 3
COLD & FLU RELIEF NIGHTTI 3
cold & flu severe 3
cold & flu severe daytime 3
cold & sinus relief 3
cold control pe intense c 3
cold head congestion dayt 3
cold head congestion nigh 3
cold head congestion seve 3
cold medicine plus 3
cold multi-symptom 3
cold multi-symptom day/ni 3
cold multi-symptom daytim 3
cold multi-symptom nightt 3
cold multi-symptom severe 3
cold multi-symptom warmin 3
666 cold preparation 3
cold relief plus 3
cold relief w/o aspirin 3
cold relief/non-drowsy/da 3
cold sore products 3
cold symptoms relief maxi 3
COLD-EEZE 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
202
Drug Name Drug Tier Requirements/Limits
cold/allergy 3
cold/allergy childrens 3
cold/allergy pe 3
cold/allergy/sinus 3
cold/cough childrens 3
cold/cough dm childrens 3
cold/cough/sore throat ch 3
cold/flu relief 3
cold/flu relief day/night 3
cold/flu relief multi-sym 3
COLEMAN 100 MAX INSECT RE 3
COLLADERM 3
COLLAGEN ULTRA 3
colloidal oatmeal 3
collyrium eye wash 3
collyrium for fresh eyes 3
COMBISTIX 3
COMFEEL PLUS CLEAR DRESSI 3
COMFEEL PLUS CONTOUR DRES 3
COMFEEL PLUS DRESSING 3
COMFEEL PLUS TRIANGLE DRE 3
COMFEEL PLUS ULCER DRESSI 3
COMFEEL ULCER CARE DRESSI 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
203
Drug Name Drug Tier Requirements/Limits
comfort gel 3
comfort gel antacid anti- 3
comfort gel antacid& anti 3
comfort gel extra strengt 3
COMFORT INSOLES WOMENS 3
COMFORT SHIELD UNDERPADS/ 3
COMFORT-AID 1.5"X2.5" 3
COMMIT 3
companion 3
compete 3
complere 3
complete 3
complete allergy 3
complete allergy medicati 3
complete allergy medicine 3
complete allergy relief 3
COMPLETE AMINO ACID MIX 3
complete daily with lutei 3
complete energy 3
complete lice treatment k 3
COMPLETE MENOPAUSE SUPPOR 3
complete moisture 3
complete multi-vitamin gu 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
204
Drug Name Drug Tier Requirements/Limits
complete multivitamin/mul 3
complete pms support comp 3
complete ready-to-use ene 3
complete senior 3
COMPLETE SINUS RELIEF 3
complete womens 3
COMPLEX 15 3
complex b-50 prolonged re 3
complex b-100 3
COMPLEX ESSENTIAL MSD 3
COMPLEX JUNIOR MSD 3
COMPLEX MSUD 3
COMPLEX MSUD AMINO ACID B 3
COMPOUND W LIQD 3
compound w PADS 3
compound w for kids 3
COMPOUND W GEL 3
COMPOUND W MAXIMUM STRENG 3
compound w one step pads/ 3
compound w one step plant 3
COMPOUND W PAD 17% 3
compoz 3
COMPUTER EYE DROPS 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
205
Drug Name Drug Tier Requirements/Limits
comtrex a/s 3
comtrex a/s caplets 3
COMTREX COLD & COUGH DAY/ 3
COMTREX COLD & COUGH MAXI 3
COMTREX COLD & COUGH NIGH 3
COMTREX DEEP CHEST COLD M 3
comtrex flu therapy maxim 3
comtrex severe cold & sin 3
CONCEPTIONXR MOTILITY SUP 3
CONE MASK 3
CONEX COLD/ALLERGY 3
CONFIDENCE EXTRA CARE BRI 3
CONFIDENCE FITTED BRIEF L 3
CONFIDENCE FITTED BRIEF M 3
CONFIDENCE FITTED BRIEF P 3
CONFIDENCE FITTED BRIEF R 3
CONFIDENCE FITTED BRIEF X 3
CONFIDENCE PREMIUM CARE B 3
CONFIDENCE WINGFOLD BRIEF 3
CONGESTAC 3
CONGESTAC TAB 60-400MG 3
congestant 3
constant-clens 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
206
Drug Name Drug Tier Requirements/Limits
contac cold+flu maximum s 3
contac cold+flu night 3
CONTAC COLD/FLU DAY & NIG 3
CONTAC COLD/FLU DAY/NIGHT 3
CONTAC COLD/FLU MAXIMUM S 3
CONTOUR BRIEF LARGE 3
CONTOUR BRIEF MEDIUM 3
CONTOUR NEXT BLOOD GLUCOS 3
CONTOUR NEXT EZ BLOOD GLU 3
CONTOUR NEXT LINK BLOOD G 3
CONTOUR NEXT LINK WIRELES 3
contragesic 3
CONTREET FOAM 3
CONTREET FOAM CAVITY 3
CONTREET FOAM HEEL 3
CONTREET FOAM SACRAL 3
CONTREET HYDROCOLLOID 3
CONTROL AST 3
CONTROL BLOOD GLUCOSE MON 3
CONTROL PADS EXTRA ABSORB 3
CONTROL TEST STRIPS 3
CONVEEN NET PANTS 3
cool & heat balm extra st 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
207
Drug Name Drug Tier Requirements/Limits
cool & heat extra strengt 3
COOL BLOOD GLUCOSE MONITO 3
COOL BLOOD GLUCOSE TEST S 3
COOL BOTTOMS 3
cool n heat extra strengt 3
cool n heat muscle & join 3
cooling burn relief 3
COPASIL 3
cope 3
COPPER 3
COPPER CAPS 3
COPPER GLUCONATE TABS 3
COPPER SULFATE 3
COPPERMIN 3
coq10 maximum strength 3
COQ10/VITAMIN E 3
coq-10 3
COQ-10 TR 3
CORAL CALCIUM CAPS 3
coral calcium plus 3
CORAL CALCIUM PLUS 3
coral calcium-magnesium w/ vitamin d 3
corfen-dm 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
208
Drug Name Drug Tier Requirements/Limits
CORICIDIN D 3
coricidin d cold/flu/sinu 3
coricidin hbp chest conge 3
CORICIDIN HBP COLD & FLU 3
CORICIDIN HBP COUGH & COL 3
CORICIDIN HBP DAY & NIGHT 3
CORICIDIN HBP FLU 3
coricidin hbp nighttime m 3
CORICIDIN NIGHTTIME COLD/ 3
corn & callus remover 12.6% 3
CORN & CALLUS REMOVER 12.6% 3
corn and callus remover 3
CORN CUSHIONS 3
corn dextrin 3
CORN HUSKERS 3
CORN REMOVER ONE STEP 3
CORN REMOVER ULTRA THIN 3
CORN REMOVER WATERPROOF 3
corn removers 3
correct 3
correctol 3
correctol extra gentle 3
cortaid advanced 12 hour 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
209
Drug Name Drug Tier Requirements/Limits
cortaid intensive therapy 3
cortaid maximum strength 3
corticool 3
CORTIZONE-10 CREA 3
cortizone-10 GEL 3
CORTIZONE-10 OINT 3
cortizone-10 OINT 1% 3
cortizone-10 diabetics sk 3
cortizone-10 eczema 3
cortizone-10 hydratensive 3
cortizone-10 intensive he 3
cortizone-10 plus 3
CORTIZONE-10 PLUS 3
cortizone-10/aloe CREA 3
corvite free 3
cosamin ds 3
COTTONELLE FRESH CARE 3
COTTONELLE FRESH MOIST WI 3
COTTONELLE MOIST WIPES 3
COTTONELLE MOIST WIPES FO 3
cottontails baby chest ru 3
cottontails diaper rash 3
cottontails diaper rash c 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
210
Drug Name Drug Tier Requirements/Limits
cough & chest congestion 3
cough & cold 3
cough & cold hbp 3
cough & sore throat day t 3
cough & sore throat night 3
cough cold & sore throat 3
cough control dm 3
cough daytime/nighttime 3
cough dm 30mg/5ml 3
cough dm childrens 3
cough drops 5.8mg, 7.5mg, 8.4mg, 9.1mg 3
cough drops menthol 3
cough drops sugar free 5.8mg 3
cough relief 3
cough relief adult/long-l 3
cough syrup 100mg/5ml 3
COUGH SYRUP D 3
cough syrup m 3
coughtab 200mg 3
COUPON ONE TOUCH ULTRA MI 3
CPR MICROSHIELD 3
CR-GTF 3
CR-PLUS 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
211
Drug Name Drug Tier Requirements/Limits
CRAMP TABS 3
CRANBERRY CONCENTRATE 3
CRANBERRY CONCENTRATE/VIT 3
cranberry plus vitamin c 3
cranberry urinary comfort 3
cranberry-vitamin c 3
cranberry-vitamin c-vitamin e 3
cranberry/vitamin c tripl 3
CREO-TERPIN 3
CREOMULSION ADULT 3
CREOMULSION FOR CHILDREN 3
critic-aid clear af 3
CRITIC-AID CLEAR MOISTURE 3
CRITIC-AID THICK MOISTURE 3
CRM 3
CRO-MAN-ZIN 3
cromolyn sodium (nasal) 5.2mg/act 3
cruex prescription streng 3
crush vitamin c drops 3
CU-5 3
CU-25 3
CU-PLUS 3
CULTURELLE 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
212
Drug Name Drug Tier Requirements/Limits
CULTURELLE ADVANCED IMMUN 3
CULTURELLE DIGESTIVE HEAL 3
CULTURELLE GENTLE-GO FORM 3
CULTURELLE HEALTH & WELLN 3
CULTURELLE IMMUNITY SUPPO 3
CULTURELLE KIDS 3
CULTURELLE PRO-WELL 3
cupric chloride 3
CUPRIC SULFATE 3
curad hydrocortisone 3
curad triple antibiotic 3
curaler 3
CURE-ALL 3
CURITY BEDDING/UPHOLSTERY 3
CURITY BRIEF LINERS 3
CURITY CLEANERS 3
CURITY HEAVY DRAINAGE PAC 3
CURITY PANTLINERS 3
CURITY POVIDONE-IODINE PA 3
CURITY POVIDONE-IODINE SC 3
CURITY SALINE DRESSING 8" 3
CURITY SODIUM CHLORIDE DR 3
CURITY YOUTH PANTS/LARGE/ 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
213
Drug Name Drug Tier Requirements/Limits
CURITY YOUTH PANTS/SMALL/ 3
CUTTER 3
CUTTER ALL FAMILY 3
CUTTER ALL FAMILY MOSQUIT 3
CUTTER BACKWOODS DRY 25% 3
CUTTER DRY 3
CUTTER NATURAL LIQD 3
CUTTER SKINSATIONS AERO 3
CUTTER SKINSATIONS LIQD 7% 3
CUTTER SPORT 3
cvs 3-day vaginal cream 3
cvs 8 hour pain relief 3
cvs 8hr arthritis pain re 3
cvs 8hr muscle aches & pa 3
cvs 12 hour cold relief 3
cvs 12 hour nasal deconge 3
cvs acetaminophen 3
cvs acetaminophen extra s 3
cvs acid controller 3
cvs acid controller maxim 3
cvs acid reducer 3
cvs acid reducer maximum 3
cvs acidophilus 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
214
Drug Name Drug Tier Requirements/Limits
cvs acidophilus probiotic 3
cvs acne 3
cvs acne cleansing bar 3
cvs acne control cleanser 3
cvs acne foaming face was 3
cvs acne spot treatment 3
cvs acne treatment 3
cvs acne treatment/maximu 3
CVS ADJUSTABLE UNDERWEAR/ 3
CVS ADULT 50+ PROBIOTIC 3
CVS ADULT PROBIOTIC 3
cvs advanced 3-in-1 exfol 3
cvs advanced acne spot tr LIQD 3
CVS ADVANCED GLUCOSE METE 3
cvs advanced healing oint 3
cvs af spray powder 3
cvs airshield 3
CVS AIRSHIELD 3
CVS AIRSHIELD IMMUNITY SU 3
cvs all day pain relief 3
cvs allergy 3
cvs allergy & sinus d chi 3
cvs allergy childrens 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
215
Drug Name Drug Tier Requirements/Limits
cvs allergy eye drops 3
cvs allergy relief CAPS 25mg 3
cvs allergy relief LIQD 3
cvs allergy relief TABS 4mg, 10mg, 25mg,
60mg, 180mg
3
cvs allergy relief TBCR 3
cvs allergy relief TBDP 3
cvs allergy relief adult 3
cvs allergy relief childr 3
cvs allergy relief d 3
cvs allergy relief d alle 3
cvs allergy relief nightt 3
cvs allergy relief-d 3
cvs allergy relief-d12 3
cvs allergy-d 3
cvs antacid 3
cvs antacid & anti-gas fa 3
cvs antacid extra 3
cvs antacid extra strengt 3
cvs antacid kids 3
cvs antacid liquid fast r 3
cvs antacid maximum stren 3
cvs antacid plus antigas 3
cvs antacid supreme 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
216
Drug Name Drug Tier Requirements/Limits
cvs antacid ultra strengt 3
cvs antacid/anti-gas 3
cvs antacid/anti-gas liq 3
cvs antacid/anti-gas maxi 3
cvs antacid/simethicone 3
cvs anti-dandruff 3
cvs anti-diarrheal 3
cvs anti-fungal powder 3
cvs anti-itch 3
cvs anti-itch max-strengt 3
cvs anti-itch maximum str 3
cvs anti-itch sensitive s 3
cvs antibiotic 3
cvs antibiotic plus 3
cvs antifungal 3
cvs antihistamine eye dro 3
cvs antiseptic mouth rins 3
cvs antiseptic skin clean 3
cvs arthricream 3
cvs arthritis pain relief TBCR 3
cvs artificial tears 3
cvs aspirin 3
cvs aspirin adult low dos 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
217
Drug Name Drug Tier Requirements/Limits
cvs aspirin adult low str 3
cvs aspirin child 3
cvs aspirin ec 3
cvs aspirin low dose 3
cvs aspirin low strength 3
cvs astringent eye drops 3
cvs athletes foot 3
cvs athletes foot powder 3
cvs b1 3
cvs b6 3
cvs b12 3
cvs b complex plus c 3
cvs b-1 3
cvs b-6 3
cvs b-12 3
cvs baby teething oral pa 3
cvs bacitracin 3
cvs back & body extra str 3
cvs backache relief extra 3
cvs balanced b50 3
cvs balanced b100 3
cvs balanced b-50 3
cvs balanced b-100 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
218
Drug Name Drug Tier Requirements/Limits
cvs balanced b-150 3
cvs bedding spray lice tr 3
cvs beta carotene 3
cvs biotin 3
cvs biotin high potency 3
cvs bisacodyl 3
cvs bismuth 3
cvs bismuth maximum stren 3
CVS BLADDER CONTROL PAD U 3
CVS BLADDER CONTROL PADS 3
cvs body powder medicated 3
CVS BRIEFS LARGE 3
CVS BRIEFS MEDIUM 3
CVS BRIEFS OVERNIGHT MEDI 3
CVS BRIEFS X-LARGE 3
cvs budesonide nasal spra 3
cvs buffered aspirin 3
cvs c-lax laxative 3
cvs caffeine 3
cvs calamine plus 3
cvs calcium 3
cvs calcium 500+d 3
cvs calcium 600 & vitamin 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
219
Drug Name Drug Tier Requirements/Limits
cvs calcium 600 + d plus 3
cvs calcium 600 + d/miner 3
cvs calcium 600+d 3
cvs calcium + d3 3
cvs calcium + d3 slow rel 3
cvs calcium carbonate 3
CVS CALCIUM CHEWABLES 600 3
CVS CALCIUM CITRATE 3
cvs calcium citrate + d 3
cvs calcium citrate +d 3
cvs calcium citrate +d3 m 3
cvs calcium citrate+d/mag 3
CVS CALCIUM CITRATE+D/MAG 3
cvs calcium soft chews 3
cvs calcium/magnesium/zin 3
CVS CALLUS CUSHION 3
CVS CALLUS REMOVER 3
cvs calohist skin protect 3
CVS CAPSAICIN 3
cvs capsaicin hp 3
cvs castor oil 3
cvs cherry menthol drops 3
cvs chest congestion chil 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
220
Drug Name Drug Tier Requirements/Limits
cvs chest congestion expe 3
cvs chest congestion plus 3
cvs chest congestion reli 3
cvs chest rub medicated 3
cvs chewable childrens vi 3
cvs chewy not chalky flav 3
cvs childrens allergy 3
cvs childrens allergy rel 3
cvs childrens aspirin 3
cvs childrens chewable co 3
cvs childrens chewable mu 3
cvs childrens ibuprofen 3
cvs childrens multivitami 3
cvs childrens pain relief 3
cvs childrens triacting c 3
cvs childrens vitamin d f 3
cvs childs non-aspirin 3
cvs chocolate laxative pi 3
cvs chromium picolinate 3
cvs cimetidine 3
cvs citrate of magnesia 3
CVS CLEANSING EYELID WIPE 3
CVS CLEANSING SKIN 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
221
Drug Name Drug Tier Requirements/Limits
CVS CLEANSING WIPES 3
CVS CLEANSING WIPES SENSI 3
cvs clotrimazole 3
cvs clotrimazole maximum 3
cvs cod liver oil CAPS 3
CVS COD LIVER OIL OIL 3
cvs coenzyme q10 3
cvs coenzyme q-10 3
cvs cold & allergy childr 3
cvs cold & cough children 3
cvs cold & cough dm child 3
cvs cold & cough nighttim 3
cvs cold & hot pain relie 3
cvs cold & sinus multi-sy 3
cvs cold & sinus relief 3
cvs cold relief multi-sym 3
cvs cold/cough dm childre 3
cvs cold/flu & sore throa 3
CVS CONTACT LENS RELIEF R 3
cvs coq-10 3
CVS CORN & CALLUS REMOVER 3
CVS CORN CUSHION 3
cvs corn remover 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
222
Drug Name Drug Tier Requirements/Limits
cvs corn removers 3
cvs cortisone cooling rel 3
cvs cortisone intense hea 3
cvs cortisone long-lastin 3
cvs cortisone maximum str 3
cvs cough & chest congest 3
cvs cough & runny nose ch 3
cvs cough & severe cold n 3
cvs cough & sore throat c 3
cvs cough dm 3
cvs cough dm childrens 3
cvs cough drops sugar fre 5.8mg 3
cvs cough/chest congestio LIQD 3
CVS COUGH/CHEST CONGESTIO SOPK 3
cvs cranberry 3
cvs creamy acne face wash 3
cvs d3 3
cvs daily facial cleanser 3
cvs daily fiber 3
cvs daily gummies 3
cvs daily multiple 3
cvs daily multiple for me 3
cvs daily multiple for wo 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
223
Drug Name Drug Tier Requirements/Limits
cvs daily multiple plus i 3
CVS DAILY PROBIOTIC 3
CVS DAILY ULTRA MOISTURE 3
CVS DAY & NIGHT UNDERPADS 3
cvs daytime nighttime mul 3
cvs daytime/nighttime cou 3
cvs decongestant inhaler 3
CVS DIABETES HEALTH SUPPO 3
cvs diaper rash 3
CVS DIGESTIVE PROBIOTIC 3
cvs digestive probiotic 250mg 3
cvs disposable douche med 3
cvs dm maximum adult 3
cvs dry eye relief 3
CVS DRY MOUTH SPRAY 3
cvs dry skin care unscent 3
cvs dry skin therapy 3
cvs dry-eye relief nightt 3
cvs dual action complete 3
cvs dye-free allergy 3
cvs e 3
cvs e oil 3
cvs ear drops 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
224
Drug Name Drug Tier Requirements/Limits
CVS EAR WAX CLEANSING SYS 3
cvs ear wax removal kit 3
cvs earwax removal kit 3
cvs earwax removal system 3
cvs easy fiber 3
cvs easy fiber/calcium 3
cvs eczema anti-itch maxi 3
cvs eczema relief 3
cvs effervescent antacid 3
cvs electrolyte solution 3
cvs enema disposable 3
cvs enema ready-to-use 3
cvs enteric aspirin 3
cvs epsom salt 3
CVS EPSOM SALT 3
cvs esomeprazole magnesiu 3
cvs extra moisturizing 3
cvs eye allergy relief 3
cvs eye drops dual action 3
cvs eye drops original 3
cvs eye health & lutein 3
cvs eye health formula 3
cvs eye itch relief 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
225
Drug Name Drug Tier Requirements/Limits
cvs eye lubricant 3
cvs eye lubricant nightti 3
cvs eye wash 3
cvs fever reducing childr 3
cvs fiber 3
cvs fiber gummies 3
cvs fiber gummy bears chi 3
cvs fiber laxative 3
cvs first aid 3
cvs fish oil 3
CVS FITTED BRIEFS DAY/NIG 3
cvs flu & severe cold day 3
cvs flu & severe cold nig 3
cvs flu relief childrens 3
cvs fluticasone propriona 3
cvs foaming acne face was 3
cvs folic acid 3
cvs foot & sneaker powder 3
cvs gas relief 3
cvs gas relief drops extr 3
cvs gas relief extra stre 3
cvs gas relief infants 3
cvs gas relief ultra stre 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
226
Drug Name Drug Tier Requirements/Limits
CVS GEL HEEL CUSHION WOME 3
cvs gentle laxative 3
cvs gentle laxative women 3
cvs gentle skin cleanser 3
cvs glucosamine 3
CVS GLUCOSAMINE CHONDROIT TABS 3
cvs glucosamine/chondroit 3
CVS GLUCOSE CHEW 3
cvs glucose GEL 3
CVS GLUCOSE BITS 3
cvs glucose liquid shot 3
cvs glucose shot 3
cvs glycerin adult 3
CVS GUARD MALE BRIEF 3
cvs gummy dinos 3
cvs gummy dinos childrens 3
cvs gummy multivitamin ki 3
cvs gummy swirls 3
cvs hair skin & nails/an 3
CVS HAIR/SKIN/NAILS 3
cvs hand wash advanced an 3
CVS HDYROCORTISONE ACETAT 3
cvs headache relief 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
227
Drug Name Drug Tier Requirements/Limits
cvs headache relief added 3
cvs headache relief extra 3
cvs heartburn relief TABS 3
cvs heartburn relief extr 3
cvs hemorrhoidal 3
CVS HIGH POTENCY IRON/VIT 3
cvs honey lemon drops 3
cvs hot steam 3
cvs hydrating skin treatm 3
cvs hydrocortisone anti-i 3
cvs hydrocortisone maximu 3
cvs hydrogen peroxide 3
cvs ibuprofen 3
cvs ibuprofen childrens 3
cvs ibuprofen ib 3
cvs ibuprofen infants 3
cvs ibuprofen junior stre 3
cvs ibuprofen liquid fill 3
cvs ibuprofen pm 3
CVS IMMUNE SUPPORT VITAMI 3
cvs indoor/outdoor allerg 3
cvs infant decongestant d 3
cvs infants gas relief 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
228
Drug Name Drug Tier Requirements/Limits
cvs infants pain relief 3
cvs inner ear plus 3
cvs instant itch relief 3
cvs instant medicated fir 3
cvs iron 3
CVS ISOPROPYL ALCOHOL 70% 3
cvs isopropyl alcohol 91% 3
CVS ISOPROPYL RUBBING ALC 3
cvs itch relief CREA; GEL 3
cvs itch relief antifunga 3
cvs itch relief extra str 3
cvs itch relief maximum s 3
cvs jock itch 3
CVS KETONE CARE 3
CVS LANCING DEVICE 3
cvs lanolin 3
cvs lansoprazole 3
cvs laxative dietary supp 3
cvs lice killing 3
cvs lice solution kit 3
cvs lice treatment 3
cvs loperamide hcl 3
cvs loperamide hydrochlor 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
229
Drug Name Drug Tier Requirements/Limits
cvs loratadine 3
cvs loratadine-d 24 hour 3
cvs lubricant eye drops 3
cvs lubricant eye drops l 3
cvs lubricant eye drops p 3
cvs lubricant gel drops 3
CVS LUBRICANT GEL DROPS 1% 3
cvs lubricating eye drops 3
cvs lubricating jelly 3
cvs lysine 3
cvs magnesium TABS 3
cvs magnesium citrate 3
cvs medicated heat patch 3
cvs medicated spot 3
cvs medicated wipes 3
cvs melatonin CAPS 5mg 3
cvs melatonin LIQD 3
cvs melatonin TABS 3
cvs melatonin extra stren 3
cvs menopause support 3
CVS MENOPAUSE SUPPORT 3
cvs mens daily gummies 3
CVS MENS UNDERWEAR LARGE/ 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
230
Drug Name Drug Tier Requirements/Limits
CVS MENS UNDERWEAR SMALL/ 3
cvs menthol drops 3
cvs miconazole 1 combinat 3
cvs miconazole 3 3
cvs miconazole 3 combinat 3
cvs miconazole 7 3
cvs migraine relief 3
cvs milk of magnesia 3
cvs mineral oil 3
cvs mineral oil enema 3
cvs mini enema kids 3
cvs moisturizing cream 3
CVS MOISTURIZING CREAM 3
cvs moisturizing extra dr 3
cvs moisturizing lotion 3
CVS MOLESKIN PLUS 3
CVS MOOD SUPPORT PROBIOTI 3
cvs motion sickness 3
cvs motion sickness ii 3
cvs motion sickness relie 3
cvs mouthwash 3
cvs mucus d extended rele 3
cvs mucus extended releas 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
231
Drug Name Drug Tier Requirements/Limits
CVS MULTI-PURPOSE SOLUTIO 3
cvs multi-symptom cold ch 3
cvs multi-symptoms cold & 3
cvs multi-symptoms cold c 3
cvs muscle rub 3
cvs naproxen sodium 3
cvs nasal allergy spray 3
cvs nasal decongestant TABS 3
cvs nasal decongestant in 3
cvs nasal decongestant ma 3
cvs nasal decongestant pe 3
CVS NASAL MIST AERS 3
cvs nasal mist SOLN 3
cvs nasal spray 3
cvs nasal spray/no drip 3
cvs natural daily fiber 3
CVS NATURAL FIBER SUPPLEM PACK 3
cvs natural fiber supplem POWD 3
cvs natural fish oil 3
cvs natural tears 3
cvs nausea relief 3
cvs niacin flush free 3
cvs nicotine 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
232
Drug Name Drug Tier Requirements/Limits
cvs nicotine lozenge 3
cvs nicotine polacrilex 3
cvs nicotine polacrilex s 3
cvs nicotine transdermal 3
cvs nighttime cold/flu re 3
cvs nighttime cough 3
cvs nighttime multi-sympt 3
cvs nighttime sleep aid 3
cvs nighttime sleep aid m 3
cvs nighttime tussin dm 3
cvs non-aspirin 3
cvs non-aspirin childrens 3
cvs non-aspirin extra str 3
cvs non-aspirin headache 3
cvs non-aspirin jr 3
cvs non-aspirin pm 3
CVS NON-DRYING SINUS PE 3
cvs nose drops 3
cvs nts step 1 3
CVS ODOR ABSORBING INSOLE 3
CVS OMEPRAZOLE 3
cvs omeprazole magnesium 3
cvs omeprazole/sodium bic 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
233
Drug Name Drug Tier Requirements/Limits
cvs one daily essential 3
CVS ONE DAILY MENS 50+ AD 3
cvs one daily womens form 3
cvs oral cleansing 3
CVS OVERNIGHT PADS/WOMENS 3
CVS OVERNIGHT UNDERWEAR/U 3
cvs oyster shell calcium 3
cvs pain & fever children 3
cvs pain & fever infants 3
cvs pain relief 8 hour 3
cvs pain relief adult/rap 3
cvs pain relief childrens 3
cvs pain relief extra str 3
cvs pain relief pm extra 3
cvs pain relief regular s 3
cvs pediatric electrolyte 3
cvs permethrin 3
cvs peroxide sore mouth c 3
cvs personal lubricant & 3
cvs petroleum jelly 3
cvs pinworm treatment 3
cvs plantar wart remover 3
cvs poly bacitracin 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
234
Drug Name Drug Tier Requirements/Limits
cvs potassium gluconate 3
cvs povidone-iodine 3
CVS PREMIUM ADULT WASH CL 3
CVS PRENATAL 3
CVS PRENATAL GUMMY/DHA/FO 3
CVS PRENATAL MULTI+DHA 3
CVS PROBIOTIC CAPS 3
cvs probiotic CAPS 10bcell 3
cvs probiotic acidophilus 3
CVS PROBIOTIC MAXIMUM STR 3
CVS PROBIOTIC PEARLS EXTR 3
CVS PROCEDURAL MASK 3
cvs prostate health formu 3
CVS PROTECTIVE PADS MAXIM 3
CVS PROTECTIVE PADS ULTIM 3
CVS PROTECTIVE PADS/LONG/ 3
CVS PROTECTIVE UNDERWEAR 3
CVS PSORIASIS MEDICATED S 3
cvs pure glycerin 3
cvs purelax 3
cvs quick relief diaper r 3
cvs ranitidine 3
cvs ready-to-use enema 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
235
Drug Name Drug Tier Requirements/Limits
cvs ringworm 3
cvs rubbing alcohol 3
cvs saline nasal spray 3
cvs saline nose spray 3
CVS SALINE WOUND WASH 3
cvs scar gel 3
cvs selenium 3
CVS SENIOR PROBIOTIC 3
cvs senna 3
cvs senna plus 3
cvs senna-extra 3
cvs severe cold/flu 3
cvs severe congestion rel 3
cvs severe cough & cold n 3
cvs severe cough & conges 3
cvs severe sinus congesti 3
cvs sinus & allergy maxim 3
cvs sinus & cold-d 3
cvs sinus congestion & pa 3
cvs sinus headache decong 3
cvs sinus headache pe 3
cvs sinus pain & congesti 3
cvs sinus pe decongestant 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
236
Drug Name Drug Tier Requirements/Limits
cvs sinus pe pressure pai 3
cvs sinus relief daytime/ 3
cvs sinus relief pressure 3
cvs sinus wash saline ref 3
cvs skin treatment 3
cvs skin treatment body l 3
cvs sleep aid 3
cvs sleep aid maximum str 3
cvs sleep aid nighttime 3
cvs sleep aid nighttime/m 3
cvs sleep-aid nighttime 3
cvs slow release iron 3
cvs smooth antacid extra 3
cvs sodium chloride 3
cvs soft chews calcium 3
cvs soluble fiber therapy 3
cvs sore throat maximum s 3
cvs sore throat spray 3
cvs special care 3
cvs spectravite 3
CVS SPECTRAVITE ADULT 50+ 3
CVS SPECTRAVITE ADULT GUM 3
cvs spectravite advanced 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
237
Drug Name Drug Tier Requirements/Limits
cvs spectravite senior 3
cvs spectravite ultra hea 3
CVS SPECTRAVITE ULTRA MEN 3
cvs spectravite ultra wom 3
CVS SPECTRAVITE ULTRA WOM 3
cvs stomach relief 3
cvs stool softener 3
cvs stool softener plus s 3
cvs stress formula 3
cvs stress formula/zinc 3
CVS STRETCH FIT ADJUSTABL 3
cvs stuffy nose & cold ch 3
cvs super b complex/c 3
CVS SUPER CRANBERRY URINA 3
CVS SUPREME BRIEFS MEDIUM 3
CVS TENSION HEADACHE CAPS 3
cvs tension headache TABS 3
cvs therapeutic 3
CVS THERAPEUTIC DANDRUFF 3
CVS THERAPEUTIC MAXIMUM S 3
cvs therapeutic menthol 3
cvs tioconazole 1 3
cvs triple antibiotic 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
238
Drug Name Drug Tier Requirements/Limits
cvs triple antibiotic max 3
cvs triple antibiotic/pai 3
CVS TRIPLE MAGNESIUM COMP 3
cvs tussin adult chest co 3
cvs tussin cf 3
cvs tussin cough 3
cvs tussin cough/cold cf 3
cvs tussin dm 3
cvs tussin dm adult cough 3
CVS TUSSIN DM DAY/NIGHT P 3
cvs tussin dm maximum str 3
cvs tussin long-acting 3
cvs tussin maximum streng 3
cvs ultra sleep 3
CVS UNDERGARMENT X-ABSORB 3
CVS UNDERPADS 22"X35" 3
CVS UNDERPADS DAY & NIGHT 3
cvs urinary pain relief 3
cvs vision formula 3
cvs vitamin a 3
cvs vitamin a & d 3
cvs vitamin a&d ointment 3
cvs vitamin b12 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
239
Drug Name Drug Tier Requirements/Limits
cvs vitamin b12 tr 3
cvs vitamin b-1 3
cvs vitamin b-2 3
cvs vitamin b-6 3
cvs vitamin b-12 3
cvs vitamin b-12 tr 3
cvs vitamin c 3
cvs vitamin c/rose hips 3
cvs vitamin d 3
cvs vitamin d3 3
cvs vitamin d3 drops/infa 3
cvs vitamin d 5000 high-p 3
cvs vitamin d childrens g 3
cvs vitamin d infants 3
cvs vitamin e 3
cvs vitamin e moisturizin 3
cvs wart remover 3
cvs wart remover gel pen 3
cvs wart remover/maximum 3
CVS WHEY PROTEIN 3
cvs witch hazel 3
cvs womens active daily 3
cvs womens daily gummies 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
240
Drug Name Drug Tier Requirements/Limits
CVS WOMENS PRENATAL+DHA 3
CVS WOMENS PROTECTIVE PAD 3
CVS WOMENS UNDERWEAR LARG 3
CVS WOMENS UNDERWEAR SMAL 3
CVS WOMENS UNDERWEAR X-LA 3
CVS WOMENS UNDERWEAR X-SM 3
cvs wound wash advanced 3
cvs yogurt + fiber gummie 3
CVS YOGURT+CALCIUM GUMMIE 3
cvs zinc 3
cvs zinc oxide 3
CYANOCOBALAMIN CRYS 3
cyanocobalamin LIQD 3
cyanocobalamin LOZG 3
cyanocobalamin SOLN 1000mcg/ml 3
cyanocobalamin SUBL 3
cyanocobalamin TABS 50mcg, 100mcg,
250mcg, 500mcg, 1000mcg
3
cyanocobalamin TBCR 3
cyanocobalamin TBDP 3
CYSTINE 3
CYTO B2 3
CYTO B7 3
CYTO-Q 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
241
Drug Name Drug Tier Requirements/Limits
CYTO-Q MAX 3
CYTO-Q T/F 3
CYTOLLINE 3
D3 + K2 DOTS 3
d3 adult 3
d3 adult gummy 3
D3 DOTS 3
d3 high potency 3
d3 kids 3
d3 maximum strength 3
600+d3 plus minerals 3
d3 super strength 3
d3 vitamin 3
d3-50 3
d3-1000 3
D3/VITAMIN C/ZINC 3
d2000 ultra strength 3
d 400 3
d 1000 3
d 1000 plus 3
D 1000 PLUS ALOE 3
d 2000 3
d 5000 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
242
Drug Name Drug Tier Requirements/Limits
d 10000 3
d-3-5 3
d-400 3
d-1000 3
d-1000 extra strength 3
d-2000 maximum strength 3
d-5000 3
d-natural-5 3
D-VI-SOL 3
d-vita 3
D-XYLOSE 3
d.o.s. 3
DAFLONEX-XL 3
daily betic 3
daily cleaner 3
daily combo multi vitamin 3
DAILY CONDITIONING TREATM 3
daily face wash 3
DAILY HEART HEALTH SUPPOR 3
daily mens health formula 3
daily multi 3
daily multi 50+ 3
daily multiple vitamin 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
243
Drug Name Drug Tier Requirements/Limits
DAILY MULTIPLE VITAMIN PL 3
daily multiple vitamin/ir 3
daily multiple vitamins 3
daily multiple vitamins w 3
daily multiple vitamins/i 3
daily multiple vitamins/m 3
daily multivitamin 3
DAILY PAK MAXIMUM MULTIVI 3
DAILY PROBIOTIC 3
daily value multivitamin 3
daily vitamin 3
daily vitamin formula+ir 3
daily vitamin formula+iro 3
daily vitamin formula+min 3
daily vitamin plus 3
daily vitamins 3
daily vite 3
daily vite multivitamin/i 3
daily womens health formu 3
daily-vitamin 3
daily-vitamin maximum for 3
daily-vitamin/iron 3
daily-vite 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
244
Drug Name Drug Tier Requirements/Limits
daily-vite/iron/beta-caro 3
DAKINS SOLUTION FULL STRE 3
DAKRINA 3
DALLERGY 3
dandrex 3
dandruff shampoo LOTN 3
DARA 3
DARA SHA 3
5 DAY 3
day time cold/flu relief 3
day time cough 3
DAY TIME MULTI-SYMPTOM CO CAPS 3
day time multi-symptom co LIQD 3
day time/nite time cold & 3
day time/nite time cold/f 3
3 day vaginal 3
day-time cold/flu relief 3
day-time multi-symptom co 3
day-time pe 3
day-time pe cold/flu reli 3
day-time sinus 3
DAYCLEAR ALLERGY RELIEF 3
dayhist allergy 12 hour r 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
245
Drug Name Drug Tier Requirements/Limits
dayquil severe + vapocool 3
daytime cold & cough chil 3
daytime cold & flu relief 3
DAYTIME COLD MEDICINE 3
daytime cold/flu relief 3
daytime cough 3
daytime multi symptom col 3
daytime multi-symptom col 3
daytime pe multi-symptom 3
daytime severe cold & flu 3
daytime sinus 3
daytime/nighttime 3
daytime/nite time cold/fl 3
DDROPS 3
DDROPS BOOSTER 3
de-chlor dm 3
DEBROX 3
decara 10000unit, 50000unit 3
DECARA 25000unit 3
DECON-A 3
DECONEX DMX 3
DECONEX IR 3
decongestant 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
246
Drug Name Drug Tier Requirements/Limits
decongestant 12hour maxim 3
decongestant 60 3
decongestant nose drops 3
decongestant plus 3
decongestant vapor inhale 3
decongestant/antihistamin 3
decorel forte plus severe 3
DECUBAMINE 3
DECUBI-VITE 3
deep sea nasal spray 3
DEKAS BARIATRIC 3
del-aqua 3
DELSYM 3
delsym childrens night ti 3
delsym cough + chest cong 3
delsym cough + cold dayti 3
delsym cough + cold night 3
DELSYM COUGH CHILDRENS 3
delsym cough relief plus 3
delsym cough+soothing a c 3
delsym night time cough/c 3
delsym night time multi-s 3
delta d3 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
247
Drug Name Drug Tier Requirements/Limits
deltuss dmx 3
DELTUSS DP 3
DENOREX EXTRA STRENGTH 3
DENOREX EXTRA STRENGTH 2- 3
DENOREX THERAPEUTIC 2-IN- 3
DENOVO 3
DENTIVA 3
DEPEND ADJUSTABLE UNDERWE 3
DEPEND BOOST INSERT 3
DEPEND EASY FIT UNDERGARM 3
DEPEND FITTED BRIEFS MAXI 3
DEPEND GUARDS FOR MEN 3
DEPEND PANT EXTRA LARGE 3
DEPEND PANT LARGE 3
DEPEND PANT SMALL/MEDIUM 3
DEPEND PROTECTION BRIEFS 3
DEPEND PROTECTIVE UNDERWE 3
DEPEND REAL-FIT BRIEFS FO 3
DEPEND SHIELDS FOR MEN 3
DEPEND SILHOUETTE ACTIVE 3
DEPEND SILHOUETTE BRIEFS 3
DEPEND SILHOUETTE UNDERWE 3
DEPEND UNDERGARMENT X-ABS 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
248
Drug Name Drug Tier Requirements/Limits
DEPEND UNDERGARMENTS X-AB 3
DEPEND UNDERWEAR FOR MEN 3
DEPEND UNDERWEAR FOR WOM 3
DEPEND UNDERWEAR LARGE/EX 3
DEPEND UNDERWEAR SMALL/ME 3
DEQUASINE 3
DERMA-G MILD 3
DERMA-GEL 4" X 4" 3
DERMABASE OIL IN WATER 3
dermacerin 3
DERMACLOUD 3
dermadaily non-greasy 3
DERMADROX OINT 3
dermafix OINT 3
dermafungal 3
DERMAGAUZE DRESSING 3
DERMAGRAN 3
DERMAGRAN BC 3
DERMAGRAN HYDROPHILIC WOU 3
DERMAGRAN HYDROPHILIC-B 3
DERMAGRAN SKIN PROTECTANT 3
DERMAGRAN WOUND CLEANSER 3
DERMAIDE ALOE 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
249
Drug Name Drug Tier Requirements/Limits
DERMAL THERAPY EXTRA STRE 3
DERMAL THERAPY FACE CARE 3
DERMAL THERAPY FOOT MASSA 3
DERMAL THERAPY HAND ELBO 3
DERMAL THERAPY HEEL CARE 3
DERMAL WOUND CLEANSER 3
DERMALUBE DAILY MOISTURIZ 3
dermamed 3
dermaphor 3
DERMAREST 3
dermarest eczema 3
DERMAREST PSORIASIS 3
DERMAREST PSORIASIS MEDIC 3
DERMAREST ROSACEA 3
dermasarra anti-itch 3
dermatological products, misc. 3
dermavantage 3
DERMAVITE 3
DERMAZINC CREAM 3
dermazinc shampoo 3
DERMAZINC SPRAY 3
DERMEND MOISTURIZING BRUI 3
desenex 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
250
Drug Name Drug Tier Requirements/Limits
desenex jock itch spray p 3
desenex shake powder 3
desenex spray liquid 3
desgen dm LIQD 3
DESGEN DM SYRP; TABS 3
desgen pediatric 3
desitin CREA 3
DESITIN OINT 3
desitin rapid relief 3
DESOXYN 3
despec 3
despec dm 3
DESPEC DM 3
despec dm-g 3
despec eda 3
DESPEC-DM 3
despec-dm tabs 3
despec-tab 3
DESPEC-TAB 3
DESQUAM-X WASH 3
DEWEES CARMINATIVE WITHOU 3
DEX4 3
DEX4 FAST ACTING GLUCOSE CHEW 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
251
Drug Name Drug Tier Requirements/Limits
DEX4 FAST ACTING GLUCOSE GEL 15gm/33gm
3
dex4 fast acting glucose GEL 15gm/38gm 3
DEX4 FAST ACTING GLUCOSE LIQD 3
DEX4 GLUCOSE 3
DEX4 NATURALS 3
DEX4 POUCH PACK 3
DEX4 QUICK DISSOLVE GLUCO 3
DEX-TUSS 3
DEXATREX D NASAL 3
DEXATRIM MAX 3
DEXATRIM MAX COMPLEX 7 3
DEXATRIM MAX DAYTIME CONT 3
DEXATRIM NATURAL 3
DEXATRIM NATURAL EXTRA EN 3
dexbrompheniramine & pseudoephedrine 3
dextromethorphan hbr SYRP 3
dextromethorphan-guaifene 3
dextromethorphan-guaifenesin LIQD 3
dextromethorphan-guaifenesin SOLN 3
dextromethorphan-guaifenesin SYRP 3
dextromethorphan-guaifenesin TABS 3
dextromethorphan-guaifenesin TB12 3
dextrose (diabetic use) 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
252
Drug Name Drug Tier Requirements/Limits
DEXTROSTIX TES STRIPS 3
DHEA CREA 3
DHS 3
DHS COLOR SAFE SHAMPOO 3
DHS CONDITIONING RINSE 3
DHS SAL 3
DHS TAR 3
DHS TAR GEL 3
DHS ZINC 3
diab klenz 3
diabetes health formula 3
DIABETES HEALTH PACK 3
DIABETES SUPPORT PACK 3
diabeti-gest 3
diabetic siltussin-dm 3
diabetic siltussin-dm max 3
diabetic tussin 3
diabetic tussin allergy 3
DIABETIC TUSSIN COLD & FL 3
DIABETIC TUSSIN COLD/FLU 3
DIABETIC TUSSIN COUGH DRO 3
diabetic tussin dm 3
DIABETIC TUSSIN DM 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
253
Drug Name Drug Tier Requirements/Limits
DIABETIC TUSSIN EX LIQD 3
diabetic tussin ex SYRP 3
diabetic tussin for child 3
diabetic tussin maximum s 3
DIABETIC TUSSIN MAXIMUM S 3
diabetic tussin mucus rel 3
DIABETIC TUSSIN NIGHT TIM 3
diabetic tussin sore thro 3
DIABETIDERM 3
DIABETIDERM CLEANSING 3
DIABETIDERM FOOT REJUVENA 3
DIABETIDERM HAND & BODY 3
DIABETIDERM MASSAGE STIMU 3
DIABETISWEET POWD 3
DIABETISWEET BROWN SUGAR 3
DIABETITRIM 3
dialyvite 800 TABS 3
DIALYVITE 800 WAFR 3
DIALYVITE 800 PLUS D 3
DIALYVITE 800/IRON 3
dialyvite 800/ultra d 3
DIALYVITE 800/ZINC 3
DIALYVITE 800/ZINC 15 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
254
Drug Name Drug Tier Requirements/Limits
dialyvite vitamin d3 max 3
dialyvite vitamin d 5000 3
diamode 3
diaper rash 3
diarrhea 3
diarrhea relief 3
DIASCREEN 1B 3
DIASCREEN 1G 3
DIASCREEN 1K 3
DIASCREEN 2GK 3
DIASCREEN 2GP 3
DIASCREEN 3 3
DIASCREEN 4NL 3
DIASCREEN 4OBL 3
DIASCREEN 4PH 3
DIASCREEN 5 3
DIASCREEN 6 3
DIASCREEN 7 3
DIASCREEN 8 3
DIASCREEN 9 3
DIASCREEN 10 3
DIASCREEN LIQUID URINE CO 3
DIASTIX 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
255
Drug Name Drug Tier Requirements/Limits
DIATHRIVE BLOOD GLUCOSE M 3
DIATHRIVE BLOOD GLUCOSE T 3
DIATRUE PLUS BLOOD GLUCOS 3
dibucaine (rectal) 3
DICEL 3
DICEL CD 3
DICEL DM 3
dickinsons witch hazel 3
DIDGET 3
dietary fiber laxative 3
DIETERS DETOX 3
DIETERS SUPER TEA 3
DIETEX FORTE 3
DIFF-STAT 3
DIFFERIN GEL .1% 3
DIGESTIVE ADVANTAGE 3
DIGESTIVE ADVANTAGE LACTO 3
digestive health probioti 3
DIGNITY BRIEFMATES MENS A 3
DIGNITY BRIEFMATES SUPERG 3
DIGNITY BRIEFMATES ULTRA 3
DIGNITY DERMATEAM UNDERPA 3
DIGNITY DERMATEAM WIPES 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
256
Drug Name Drug Tier Requirements/Limits
DIGNITY DRY WIPES 3
DIGNITY DUCHESS PANTY EXT 3
DIGNITY DUCHESS PANTY LAR 3
DIGNITY DUCHESS PANTY MED 3
DIGNITY DUCHESS PANTY SMA 3
DIGNITY DUCHESS WOMENS PA 3
DIGNITY EXTRA-DUTY DOUBLE 3
DIGNITY LITES LONG PADS 3
DIGNITY LITES STACKABLES 3
DIGNITY LITES THINSERTS 3
DIGNITY MENS BOXER SHORTS 3
DIGNITY MINI PADS 3
DIGNITY NATURALS PADS 3
DIGNITY PANT REGULAR 20"- 3
DIGNITY PANT REGULAR 24-2 3
DIGNITY PANT REGULAR EXTR 3
DIGNITY PANT REGULAR LARG 3
DIGNITY PANT REGULAR MEDI 3
DIGNITY PANT REGULAR SMAL 3
DIGNITY PLUS ADULT DISPOS 3
DIGNITY PLUS BRIEFMATES E 3
DIGNITY PLUS BRIEFMATES S 3
DIGNITY PLUS DERMATEAM BR 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
257
Drug Name Drug Tier Requirements/Limits
DIGNITY PLUS OVERNIGHT FI 3
DIGNITY PLUS REGULAR W/DR 3
DIGNITY PLUS SHEET/LINEN 3
DIGNITY PLUS SUPER LINERS 3
DIGNITY PLUS W/DRI-GARD B 3
DIGNITY PLUS YOUTH DISPOS 3
DIGNITY PREVENT PLUS BOYS 3
DIGNITY PREVENT PLUS GIRL 3
DIGNITY PREVENT PLUS T-SH 3
DIGNITY PROTECTIVE UNDERW 3
DIGNITY REGULAR CLASSIC 2 3
DIGNITY REGULAR CLASSIC E 3
DIGNITY REGULAR CLASSIC L 3
DIGNITY REGULAR CLASSIC M 3
DIGNITY REGULAR CLASSIC S 3
DIGNITY REGULAR-DUTY PADS 3
DIGNITY SHEET/LINEN PROTE 3
DIGNITY SPARTAN LINERS 7" 3
DIGNITY SUPER NATURALS 3
DIGNITY ULTRA ADULT DISPO 3
DIGNITY ULTRA WOMENS GUAR 3
DIGNITY WINGFOLD 3
dimaphen childrens 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
258
Drug Name Drug Tier Requirements/Limits
dimaphen dm cold & cough 3
dimaphen dm cold/cough ch 3
dimenhydrinate TABS 3
DIMETAPP COLD & ALLERGY 3
DIMETAPP DM COLD & COUGH 3
DIMETAPP LONG ACTING COUG 3
dimetapp multi-symptom co 3
DIMETAPP MULTI-SYMPTOM CO 3
dimetapp nd 3
dimetapp nighttime cold & 3
dino-life 3
dino-life w extra c 3
DINO-LIFE W/IRON & ZINC 3
diocto 3
dioctyl 3
dioctyl s.s. 3
diotame 3
diphen 3
diphenhist CAPS 3
diphenhist TABS 25mg 3
diphenhydramine cough 3
diphenhydramine hcl CAPS 25mg, 50mg 3
diphenhydramine hcl CHEW 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
259
Drug Name Drug Tier Requirements/Limits
diphenhydramine hcl ELIX 3
diphenhydramine hcl LIQD 3
diphenhydramine hcl SYRP 3
diphenhydramine hcl TABS 3
diphenhydramine hcl (sleep) 3
diphenhydramine hcl (topical) 3
diphenhydramine-acetaminophen (sleep) 3
diphenhydramine-zinc acetate 3
DISNEY CALCIUM + VITAMIN 3
disney cars gummies 3
disney princess gummies 3
disophrol 3
DISPOSABLE BRIEF LARGE 3
DISPOSABLE BRIEF MEDIUM 3
DISPOSABLE BRIEF SMALL 3
DISPOSABLE BRIEF X-LARGE 3
DISPOSABLE LINERS/TAPE ST 3
DISPOSABLE MOUTHPIECE FUL 3
DISPOSABLE MOUTHPIECE LOW 3
DISPOSABLE MOUTHPIECE/LOW 3
DISPOSABLE MOUTHPIECE/UNI 3
DISPOSABLE PANTS 3
DISPOSABLE PAPER MOUTHPIE 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
260
Drug Name Drug Tier Requirements/Limits
DISPOSABLE POLYMER PANTS/ 3
DISPOSABLE UNDERPADS SUPE 3
DISPOSABLE UNDERPADS/17"X 3
DISPOSABLE UNDERPADS/22G/ 3
DISPOSABLE UNDERPADS/31G/ 3
DISPOSABLE UNDERPADS/45G/ 3
DISPOSABLE UNDERPADS/60G/ 3
DISPOSABLE UNDERPADS/90G/ 3
DISPOSABLE UNDERPADS/105G 3
DISPOSABLE UNDERPADS/EXTR 3
DISPOSABLE UNDERPADS/MEDI 3
DISPOSABLE UNDERPADS/SMAL 3
DL-PA-500 3
dm max maximum strength 3
DMAE 3
dml 3
DML FORTE 3
doans extra strength 3
dobells solution 3
doc-q-lax 3
docqlace 100mg 3
doctors choice blister ca 3
DOCTORS CHOICE BURNS/SCAL 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
261
Drug Name Drug Tier Requirements/Limits
doctors choice corn/callu 3
doctors choice multivitam 3
docu 50mg/5ml 3
docu soft 3
docuprene 3
docusate calcium 3
docusate sodium CAPS 50mg, 100mg, 250mg
3
docusate sodium LIQD 50mg/5ml, 100mg/10ml, 150mg/15ml
3
docusate sodium SYRP 3
docusate sodium TABS 3
DOCUSOL KIDS 3
DOCUSOL PLUS MINI-ENEMA 3
docuzen 3
dofus 3
dok CAPS 100mg, 250mg 3
dok TABS 100mg 3
dok plus 3
DOLOGEN 3
DOLOGESIC 3
DOLOGESIC-DF 3
DOLOMITE 3
DOME-PASTE BANDAGE 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
262
Drug Name Drug Tier Requirements/Limits
DOMETUSS-DA/CHILDREN 3
DOMETUSS-DMX 3
DOMETUSS-NR 3
DONATUSSIN 3
dormin 3
DOSOQUIN 3
double antibiotic 3
double antibiotic + pain 3
DOUBLE-TUSSIN DM 3
DOVER ELASTIC FOAM STRAP 3
DOVER ELASTIC FOAM TAPE/ 3
DOVER TWO-SIDED ADHESIVE 3
doxylamine succinate (sleep) 3
dr edwards olive laxative 3
dr gs clear nail 3
DR SCHOLLS CORN CUSHIONS/ 3
DR SCHOLLS CUSTOM FIT ORT 3
DR SMITHS ADULT BARRIER S 3
DR SMITHS DIAPER 3
DR SMITHS DIAPER RASH SPR 3
DR SMITHS RASH + SKIN AERO 3
DRAMAMINE 3
dramamine less drowsy 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
263
Drug Name Drug Tier Requirements/Limits
DRAWTEX ADVANCED WOUND CA PADS 3
DRI-SORB PLUS UNDERPAD 3
DRI-SORB UNDERPAD 3
DRIPDROP 3
DRIPDROP HYDRATION POWDER 3
DRIPDROP ORS 3
DRISDOL 3
dristan cold 3
DRISTAN SPRAY 3
DRIXORAL ALLERGY SINUS 3
DRIXORAL CGH CAP 30MG 3
DRIXORAL COLD/ALLERGY 3
DRIXORAL COLD/FLU 3
DRIXORAL COUGH & SORE THR 3
DROPLET LANCING DEVICE 3
DROXY CREAM 3
DRUG MART ADJUSTABLE LANC 3
DRUG MART GLUCOSE 3
drx choice gas relief 3
DRY COMFORT EXTRA BRIEF L 3
DRY COMFORT EXTRA BRIEF M 3
DRY COMFORT EXTRA BRIEF S 3
DRY COMFORT EXTRA BRIEF X 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
264
Drug Name Drug Tier Requirements/Limits
DRY COMFORT WASHCLOTHS 3
dry e-synthetic 3
dry eye formula 3
DRY MOUTH SPRAY 3
dry skin treatment 3
dry skin treatment advanc 3
DRYMAX AF 3
dss 3
dual action complete 3
DUDRESS ISLAND DRESSING 4 3
DUDRESS ISLAND DRESSING 6 3
DULCOLAX 3
dulcolax balance 3
DULCOLAX BOWEL PREP KIT 3
dulcolax milk of magnesia 3
dulcolax pink stool softe 3
dulcolax stool softener 3
duo fusion 3
DUO-CARE TEST STRIPS 3
DUOFER 3
duofilm 3
DURAFLU 3
DURASORB UNDERPAD 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
265
Drug Name Drug Tier Requirements/Limits
DURATION 12 HOUR 3
DURATION SPRAY 3
DURAVENT DM 3
DURAVENT PE 3
DWELLE 3
dye-free allergy relief c 3
DYNA-HEX 2% 3
dyna-hex 4% 3
dyna-hex 2 3
dyna-hex 4 3
DYNASTEP/MEN 3
DYNASTEP/WOMEN 3
dyspel 3
e200 3
e400 3
e400 mixed 3
e600 3
e1000 3
e 400 blended 3
e 1000 3
e-200 3
e-400 3
e-400-clear 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
266
Drug Name Drug Tier Requirements/Limits
e-400-mixed 3
e-400/selenium 3
e-1000 3
e-cream 3
e-max-1000 3
e-oil 3
e-ointment 3
e-pherol 3
e-r-o ear drops 3
e-r-o ear wax removal sys 3
EAGLE WATCH MOSQUITO ELIM 3
ear drops 3
ear drops earwax removal 3
ear dry 3
ear health formula 3
ear health plus 3
EAR WAX CLEANSING 3
EAR WAX CLEANSING KIT 3
ear wax removal aid 3
ear wax removal drops 3
ear wax removal kit 3
ear wax removal system SOLN 3
EAR-LOOP MASK SMALL 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
267
Drug Name Drug Tier Requirements/Limits
EARLOOP MASK 3
earwax removal 3
earwax removal kit 3
earwax treatment drops 3
EASICLEANSE BATH 3
EASY CHECK BLOOD GLUCOSE 3
EASY CHECK GLUCOSE TEST S 3
easy fiber 3
EASY MINI EJECT LANCING D 3
EASY MINI LANCING DEVICE 3
EASY PLUS BLOOD GLUCOSE M 3
EASY PLUS BLOOD GLUCOSE T 3
EASY PLUS II BLOOD GLUCOS 3
EASY STEP BLOOD GLUCOSE M 3
EASY STEP TEST STRIPS 3
EASY TALK BLOOD GLUCOSE M 3
EASY TALK BLOOD GLUCOSE T 3
EASY TEST 3
EASY TEST STRIPS ACCU-CHE 3
EASY TEST TES 3
EASY TOUCH GLUCOSE MONITO 3
EASY TOUCH GLUCOSE TEST S 3
EASY TOUCH HEALTHPRO GLUC 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
268
Drug Name Drug Tier Requirements/Limits
EASY TOUCH LANCING DEVICE 3
EASY TRAK BLOOD GLUCOSE M 3
EASY TRAK BLOOD GLUCOSE T 3
easy-c 3
easy-lax 3
easy-lax plus 3
easygel 3
EASYGLUCO STRP 3
EASYGLUCO PLUS 3
EASYGLUCO PLUS BLOOD GLUC 3
EASYMAX 15 TEST STRIPS 3
EASYMAX L BLOOD GLUCOSE S 3
EASYMAX N BLOOD GLUCOSE S 3
EASYMAX NG SELF-MONITORIN 3
EASYMAX TEST STRIPS 3
EASYMAX V2 SELF-MONITORIN 3
EASYMAX V BLOOD GLUCOSE S 3
EASYPLUS BLOOD GLUCOSE TE 3
EASYPLUS R13N SELF-MONITO 3
EASYPLUS V SELF-MONITORIN 3
EASYPRO BLOOD GLUCOSE MON 3
EASYPRO BLOOD GLUCOSE TES 3
EASYPRO PLUS 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
269
Drug Name Drug Tier Requirements/Limits
EBASE CONTROLLER KIT 3
ec-81 aspirin 3
ecee plus 3
eck hi-cal calcium 3
ecolovit 3
ECONOLINE PLUS UNDERPAD 3
ecotrin 3
ecotrin low strength 3
ECOTRIN MAXIMUM STRENGTH 3
ECOTRIN REGULAR STRENGTH 3
ED A-HIST LIQD 3
ed a-hist TABS 3
ed a-hist dm LIQD 3
ED A-HIST DM TABS 3
ed a-hist pse 3
ED BRON GP 3
ED CHLORPED 3
ED CHLORPED D 3
ed chlorped jr 3
ed-apap 3
ed-chlortan 3
EDEX 10mcg 3 QL (6 each / 25 days)
effervescent antacid/pain 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
270
Drug Name Drug Tier Requirements/Limits
effervescent cold relief 3
effervescent pain relief 3
EFLOW SCF AEROSOL HEAD 3
ELASTO-GEL 2"X3" 3
ELASTO-GEL 3" ROUND 3
ELASTO-GEL 4"X4" 3
ELASTO-GEL 5"X5" 3
ELASTO-GEL 6"X8" 3
ELASTO-GEL 8"X16" 3
ELASTO-GEL 12"X12" 3
ELASTO-GEL CAST/SPLINT 4" 3
ELASTO-GEL CAST/SPLINT 6" 3
ELASTO-GEL CAST/SPLINT 8" 3
ELASTO-GEL CAST/SPLINT 12 3
ELASTO-GEL FACE MASK 3
ELASTO-GEL PLUS 2"X3" 3
ELASTO-GEL PLUS 4"X4" 3
ELASTO-GEL PLUS 8"X8" 3
ELEMENT AUTOCODE SYSTEM 3
ELEMENT COMPACT BLOOD GLU 3
ELEMENT COMPACT TEST STRI 3
ELEMENT COMPACT V BLOOD G 3
ELEMENT PLUS BLOOD GLUCOS 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
271
Drug Name Drug Tier Requirements/Limits
ELEMENT TEST STRIPS 3
ELIPHOS 3
ELITE CA/MG 3
ELITE DC AUTO ADAPTER 3
ELITE IRON 3
elite magnesium 3
ELITE ZINC 3
ELIXSURE COUGH 3
ELIXSURE FEVER/PAIN 3
ELLIS TONIC 3
ELON BARRIER PROTECTANT 3
ELON MATRIX 5000 3
ELON MATRIX 5000 COMPLETE 3
ELON MATRIX COMPLETE 3
ELON MATRIX PLUS 3
elon nail conditioner 3
ELON R3 3
ELON SKIN REPAIR SYSTEM 3
ELTA CREA 3
elta LOTN 3
ELTA CLEANSE ODOR ELIMINA 3
ELTA DERMAL WOUND CLEANSE 3
elta lite 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
272
Drug Name Drug Tier Requirements/Limits
elta seal 3
EMBRACE BLOOD GLUCOSE MON 3
EMBRACE BLOOD GLUCOSE TES 3
EMBRACE EVO BLOOD GLUCOSE 3
EMBRACE PRO BLOOD GLUCOSE 3
EMBRACE TALK BLOOD GLUCOS 3
emecheck 3
EMERGEN-C BLUE 3
EMERGEN-C ELECTRO MIX 3
EMERGEN-C FIVE 3
EMERGEN-C HEART HEALTH 3
EMERGEN-C IMMUNE 3
EMERGEN-C IMMUNE PLUS 3
EMERGEN-C IMMUNE PLUS/VIT 3
EMERGEN-C IMMUNE+ WARMERS 3
EMERGEN-C JOINT HEALTH 3
EMERGEN-C KIDZ 3
EMERGEN-C MSM LITE 3
EMERGEN-C PINK 3
EMERGEN-C SUPER FRUIT 3
EMERGEN-C VITAMIN C 3
EMERGEN-C VITAMIN C LITE 3
EMERGEN-C VITAMIN D & CAL 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
273
Drug Name Drug Tier Requirements/Limits
EMETROL 3
EMETROL SOL LEMONMIN 3
EMOLLIA-CREME 3
EMOLLIA-LOTION 3
emollient 3
END FATIGUE DAILY ENERGY 3
endacof-c 3
ENDACON 3
endur-acin 3
endur-amide 3
endur-b 3
endur-c/rose hips 3
ENDUR-VM 3
ENDUR-VM WITH IRON 3
enema disposable 3
enema ready-to-use 3
ENERGY BOOSTER 3
ENFALYTE 3
ENFAMIL ENFALYTE 3
ENFAMIL EXPECTA 3
ENTEX LQ 3
ENTEX PAC 3
ENTEX T 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
274
Drug Name Drug Tier Requirements/Limits
ENTRE-B 3
ENTRE-COUGH 3
ENTRE-COUGH TANNATE 3
ENTRE-HIST PSE 3
ENTRUST PLUS BLADDER CONT 3
ENTRUST PLUS BRIEFS 3
ENTRUST PLUS BRIEFS LARGE 3
ENTRUST PLUS BRIEFS MEDIU 3
ENTRUST PLUS BRIEFS SMALL 3
ENTRUST PLUS DISPOSABLE P 3
ENTRUST PLUS DISPOSABLE U 3
ENTRUST PLUS FITTED BRIEF 3
ENTRUST PLUS PROTECTIVE U 3
ENTRUST PLUS SHIELD 3
ENTRUST PLUS SHIELDS 3
ENTRUST PLUS UNDERGARMENT 3
ENTRUST PLUS UNDERPAD 3
ENTRUST PLUS UNDERPADS EX 3
ENTSOL NASAL GEL 3
ENUCLENE 3
enviro-stress 3
ephedrine sulfate CAPS 25mg 3
EPHEDRINE SULFATE CAPS 25mg 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
275
Drug Name Drug Tier Requirements/Limits
ephrine nose drops 3
EPILYT 3
EPIMIDE 3
epinephrine (base) 3
epinephrine mist 3
EPIPRAM AER 1% 3
epsom salt GRAN 3
EPSOM SALT GRAN 3
EPSOM SALT POWD 3
eq 1% hydrocortisone 3
eq 8hr arthritis pain rel 3
eq acetaminophen 3
eq acetaminophen children 3
eq acetaminophen extra st 3
eq acetaminophen junior 3
eq acetaminophen pm 3
eq acid reducer 3
eq acid reducer complete 3
eq acid reducer maximum s 3
eq adult aspirin low stre 3
eq allergy 3
eq allergy & congestion r 3
eq allergy & sinus headac 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
276
Drug Name Drug Tier Requirements/Limits
eq allergy childrens 3
eq allergy relief 3
eq allergy relief childre 3
eq allergy relief d 24 ho 3
eq allergy relief multi-s 3
eq allergy-d 3
eq allergy/sinus headache 3
EQ ALLERGY/SINUS HEADACHE 3
eq antacid 3
eq antacid & anti-gas max 3
eq antacid & pain relief 3
eq antacid antigas multi- 3
eq antacid extra strength 3
eq antacid maximum streng 3
eq antacid ultra strength 3
eq antacid/anti-gas 3
eq anti-diarrheal 3
eq anti-itch extra streng 3
eq anti-itch maximum stre 3
eq anti-nausea 3
eq antibiotic + pain reli 3
eq antifungal 3
eq antihistabs 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
277
Drug Name Drug Tier Requirements/Limits
eq arthricream rub 3
eq arthritis pain 3
eq artificial tears 3
eq aspirin 3
eq aspirin adult low dose 3
eq aspirin ec 3
eq aspirin low dose 3
eq athletes foot 3
eq athletes foot powder s 3
eq baby chest rub 3
eq bacitracin zinc 3
EQ BLOOD GLUCOSE TEST STR 3
EQ BODY CURVE PADS REGULA 3
eq buffered aspirin 3
eq calcium 500+d 3
eq calcium 600+d 3
eq calcium 600+d+minerals 3
eq calcium citrate+d 3
eq calcium citrate+d3 3
eq calcium citrate+d3/pet 3
eq childrens aspirin 3
EQ CHILDRENS COLD 3
eq childrens loratadine 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
278
Drug Name Drug Tier Requirements/Limits
eq childrens pain relieve 3
eq childrens plus multi-s 3
eq chlortabs 3
eq cimetidine acid reduce 3
eq clearlax 3
eq cold & cough dm child 3
eq cold multi-symptom day 3
eq cold multi-symptom sev 3
eq cold plus 3
eq cold relief 3
EQ COLD RELIEF COMPLETE 3
eq cold/allergy childrens 3
eq cold/cough dm 3
eq cold/cough plus 3
eq complete chewable mult 3
eq complete lice treatmen 3
eq complete multivitamin 3
EQ COMPLETE MULTIVITAMIN 3
eq cough childrens 3
eq cough dm 3
eq cough drops sugar free 3
eq daily fiber 3
eq dayhist allergy 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
279
Drug Name Drug Tier Requirements/Limits
eq daytime cold & flu mul 3
eq daytime cold & flu rel 3
eq daytime cold/flu relie 3
eq daytime sinus 3
eq daytime/nighttime cold 3
eq daytime/nitetime cold 3
eq daytime/nitetime sinus 3
eq diaper rash 3
eq ear wax removal aid 3
eq effervescent cold reli 3
eq effervescent pain reli 3
eq enema 3
EQ EVERYDAY LINERS/LONG 3
eq eye allergy relief 3
eq eye drops 3
eq eye itch relief 3
eq fiber laxative 3
eq fiber powder 3
eq fiber supplement 3
eq fiber therapy 3
eq first aid antiseptic 3
eq flu & severe cold & co 3
eq flu relief 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
280
Drug Name Drug Tier Requirements/Limits
EQ FLU/SEVERE COLD/CONGES 3
eq gas relief 3
eq gas relief extra stren 3
eq gentle laxative 3
eq gentle lubricant 3
eq headache relief 3
eq heartburn relief 3
eq hemorrhoidal 3
eq hemorrhoidal maximum s 3
eq hemorrhoidal pads 3
eq hemorrhoidal supposito 3
eq hydrocortisone maximu 3
eq hydrocortisone plus 3
eq hydrogen peroxide 3
eq hydrogen peroxide clea 3
eq hygienic cleansing wip 3
eq ibuprofen 3
eq ibuprofen childrens 3
eq ibuprofen cold childre 3
eq ibuprofen cold/sinus 3
eq ibuprofen infants 3
eq ibuprofen junior stren 3
eq ibuprofen pm 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
281
Drug Name Drug Tier Requirements/Limits
eq infants gas relief 3
eq infants pain reliever 3
eq itchy eye drops 3
eq jock itch 3
eq lansoprazole 3
eq laxative 3
eq laxative maximum stren 25mg 3
eq lice killing maximum s 3
eq loperamide hcl 3
eq loratadine 3
eq lubricant eye drops hi 3
eq lubricant eye drops lo 3
eq lubricating & rewettin 3
eq lubricating eye drops 3
eq magnesium citrate 3
EQ MAXI LONG SUPER/FLEXI- 3
EQ MAXI OVERNIGHT EXTRA H 3
EQ MAXI OVERNIGHT/FLEXI-W 3
EQ MAXI REGULAR/FLEXI-WIN 3
EQ MAXI SUPER 3
eq medicated body powder 3
eq medicated chest rub 3
eq menstrual complete 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
282
Drug Name Drug Tier Requirements/Limits
eq miconazole 1 3
eq miconazole 3 combo pac 3
eq miconazole 7 3
eq miconazole 7 day treat 3
eq migraine relief 3
eq milk of magnesia 3
eq mineral oil 3
eq motion sickness 3
eq motion sickness relief 3
eq mucus er 3
eq mucus relief cold flu 3
eq mucus relief dm 3
eq mucus relief severe co 3
EQ MULTI-PURPOSE SOLUTION 3
eq multi-symptom cold & f 3
eq multi-symptom cold chi 3
eq multi-symptom cold flu 3
eq multivitamin gummies c 3
EQ MULTIVITAMINS ADULT GU 3
eq multivitamins children 3
eq naproxen sodium 3
eq nasal allergy spray 3
eq nasal decongestant pe 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
283
Drug Name Drug Tier Requirements/Limits
eq nasal spray 3
eq nasal spray fast actin 3
eq natural fiber laxative 3
eq natural laxative 3
eq natural vegetable laxa 3
eq nicotine 3
eq nicotine gum 3
eq nicotine gum refill 3
eq nicotine gum starter 3
eq nicotine lozenges 3
eq nicotine polacrilex 3
eq nicotine step 3 3
eq night time cold & coug 3
eq night time cough 3
eq nighttime sleep aid 3
eq nighttime sleep aid ma 3
eq nite time cold/flu rel 3
eq nitetime cold & flu mu 3
eq non-drying sinus 3
EQ OMEPRAZOLE 3
eq omeprazole magnesium 3
EQ ONE DAILY MENS 50+ 3
EQ ONE DAILY MENS HEALTH 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
284
Drug Name Drug Tier Requirements/Limits
EQ ONE DAILY WOMENS 50+ 3
eq one daily womens healt 3
EQ ONE DAILY WOMENS HEALT 3
eq one daily womens pro-a 3
EQ OPTIONS LINERS LONG/VE 3
EQ OPTIONS LINERS REGULAR 3
EQ OPTIONS PADS LONG/MAXI 3
EQ OPTIONS PADS LONG/MODE 3
EQ OPTIONS PADS LONG/ULTI 3
EQ OPTIONS PADS REGULAR/M 3
EQ OPTIONS ULTRA THINS PA 3
eq pain & fever childrens 3
eq pain & fever infants 3
eq pain relief adult/rapi 3
eq pain reliever 3
eq pain reliever extra st 3
eq pain reliever junior 3
EQ PANTILINERS/LONG 3
EQ PANTILINERS/REGULAR 3
EQ PANTILINERS/REGULAR/ME 3
EQ PERSONAL CLEANSING CLO 3
eq personal lubricant jel 3
eq petroleum jelly 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
285
Drug Name Drug Tier Requirements/Limits
eq pink-bismuth 3
eq povidone-iodine 3
eq probiotic digestive sy 3
EQ PROBIOTIC DIGESTIVE SY 3
eq ranitidine 3
eq restore plus lubricant 3
eq restore pm 3
eq restore tears 3
eq revive plus 3
eq revive plus lubricant 3
eq saline nasal spray 3
EQ SALINE SOLUTION/SENSIT 3
eq senna-s 3
eq severe allergy & sinus 3
eq sinus congestion & pai 3
eq sinus maximum strength 3
EQ SINUS RELIEF MAXIMUM S 3
eq sleep aid 3
eq sleep-aid nighttime 3
eq slow-release iron 3
eq sore throat spray 3
eq stay awake 3
eq stomach relief 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
286
Drug Name Drug Tier Requirements/Limits
eq stomach relief maximum 3
eq stool softener 3
eq stool softener/stimula 3
eq suphedrine 3
eq suphedrine pe 3
eq suphedrine pe sinus & 3
EQ THERAPEUTIC DRY SKIN 3
EQ THERAPEUTIC MOISTURIZI 3
EQ THIN LINER/REGULAR 3
eq tioconazole 1 3
eq tolnaftate 3
EQ TRIACTING COLD/ALLERGY 3
eq triacting cold/cough 3
eq triacting night time 3
eq triple antibiotic 3
eq tussin 3
eq tussin cf cough & cold 3
eq tussin cf multi-sympto 3
eq tussin dm cough/chest 3
eq tussin dm max cough an 3
EQ ULTRA THIN OVERNIGHT/ 3
EQ ULTRA THIN REGULAR/FLE 3
EQ ULTRA THIN SUPER LONG/ 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
287
Drug Name Drug Tier Requirements/Limits
eq urinary pain relief 3
eq vaporizing rub 3
eq vegetable laxative 3
eq vision formula 50+ 3
eq vitamins a & d 3
eq wart remover 3
eq womans laxative 3
eq womens laxative 3
EQL 2 IN 1 PROBIOTIC 3
EQL 4X PROBIOTIC 3
eql 12 hour cold 3
eql 12 hour decongestant 3
eql absolute moisture dry 3
eql acetaminophen 3
eql acetaminophen 8 hour 3
eql acetaminophen childre 3
eql acetaminophen extra s 3
eql acetaminophen infants 3
eql acetaminophen rapid t 3
eql acid reducer 3
eql acid reducer maximum 3
EQL ACIDOPHILUS EXTRA STR 3
eql acne scrub pink grape 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
288
Drug Name Drug Tier Requirements/Limits
eql adult aspirin low str 3
eql advanced healing oint 3
eql advanced recovery ski 3
EQL ADVANCED RECOVERY SKI 3
eql advanced skin therapy 3
eql air protector 3
eql all day allergy 3
eql all day allergy child 3
eql all day allergy-d 3
eql all day pain relief 3
eql all day relief 3
eql aller-ease 3
eql allergy 3
eql allergy childrens 3
eql allergy relief 3
eql allergy relief childr 3
eql allergy/congestion re 3
eql allergy/sinus headach 3
eql aloe after sun 3
eql antacid 3
eql antacid advanced maxi 3
eql antacid extra strengt 3
eql antacid maximum stren 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
289
Drug Name Drug Tier Requirements/Limits
eql antacid ultra strengt 3
eql antacid/anti-gas 3
eql antacid/pain relief 3
eql anti-diarrheal 3
eql anti-itch extra stren 3
eql anti-itch intensive h 3
eql anti-itch maximum str 3
eql anti-nausea 3
eql antibiotic + pain rel 3
eql anticavity fluoride r 3
eql antifungal 3
eql antiseptic mouthrinse 3
eql apricot scrub 3
eql arthritis pain relief 3
eql aspirin 3
eql aspirin ec 3
eql aspirin low dose 3
eql athletes foot 3
eql athletes foot spray 3
eql b complex 3
eql b complex 50 3
eql b complex 100 3
eql b-6 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
290
Drug Name Drug Tier Requirements/Limits
eql b-12 3
eql b-100 complex tr 3
eql baby basics diaper ra 3
eql bacitracin zinc 3
EQL BELTED UNDERGARMENTS/ 3
EQL BELTLESS UNDERGARMENT 3
eql beta carotene 3
eql biotin 3
EQL BLADDER CONTROL PADS/ 3
EQL BODY WASH/SENSITIVE S 3
EQL BODY WASH/SHEA BUTTER 3
eql buffered aspirin 3
eql calamine medicated 3
eql calcium 3
eql calcium 600mg/vitamin 3
eql calcium citrate w/vit 3
eql calcium citrate/ vita 3
eql calcium gummies 3
eql calcium soft chews 3
eql calcium/magnesium/zin 3
EQL CALCIUM/VITAMIN D CAPS 3
eql calcium/vitamin d TABS 3
eql calcium/vitamin d/min 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
291
Drug Name Drug Tier Requirements/Limits
eql callus remover pads/e 3
eql carbonyl iron 3
eql castor oil 3
eql century 3
eql century mature 3
EQL CENTURY MATURE ADULTS 3
eql century mature men 50 3
eql century mature women 3
EQL CENTURY MENS 3
EQL CENTURY WOMENS 3
eql childrens allergy 3
eql childrens aspirin 3
eql childrens c 3
EQL CHILDRENS CALCIUM GUM 3
eql childrens ibuprofen 3
eql childrens immunity c 3
eql childrens loratadine 3
eql childrens multivitami 3
EQL CHILDRENS MULTIVITAMI 3
eql childrens pain relief 3
eql childrens plus cold m 3
eql childrens vitamin d g 3
eql chromium picolinate p 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
292
Drug Name Drug Tier Requirements/Limits
eql cleaning & disinfecti 3
EQL CLEAR HAND SOAP REFIL 3
eql clearlax 3
eql cold & allergy 3
eql cold & allergy pe 3
eql cold & cough children 3
eql cold head congestion 3
eql cold multi-symptom da 3
eql cold multi-symptom se 3
eql cold/allergy children 3
eql congestion relief 3
eql cool heat extra stren 3
eql coq10 3
eql coq10 maximum strengt 3
eql cough & cold pe multi 3
eql cough & cold relief h 3
eql cough dm 3
eql cough drops 5.8mg, 7.5mg 3
EQL DAILY PROBIOTIC 3
eql dayhist allergy 3
eql daytime & nighttime c 3
eql daytime cold & flu re 3
eql daytime cold/flu reli 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
293
Drug Name Drug Tier Requirements/Limits
eql daytime multi-symptom 3
eql daytime severe cold & 3
eql digestive probiotic 3
EQL DRY MOUTH ORAL RINSE 3
eql dual action complete 3
eql ear drops 3
eql effervescent cold rel 3
eql effervescent plus col 3
EQL EPSOM SALT 3
eql ester-c 3
eql eye drops 3
eql eye drops ac 3
eql fiber laxative 3
eql fiber supplement 3
eql fiber therapy 3
eql first aid antibiotic 3
eql fish oil 3
EQL FITTED BRIEFS/EXTRA L 3
eql flu & severe cold & c 3
eql flu & severe cold mul 3
eql flu/severe cold/conge 3
eql fluticasone propionat 3
eql folic acid 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
294
Drug Name Drug Tier Requirements/Limits
eql gas gone extra streng 3
eql gas prevention 3
eql gas relief 3
eql gas relief extra stre 3
eql gas relief ultra stre 3
eql gentle laxative 3
eql gentle skin cleanser 3
eql glucosamine chondroit TABS 3
eql gummies childrens 3
eql gummy adult 3
eql headache formula 3
eql headache pm 3
eql headache relief extra 3
eql heartburn prevention 3
eql heartburn prevention/ 3
eql heartburn relief 3
eql heartburn relief maxi 3
eql hemorrhoidal 3
eql hemorrhoidal cooling 3
eql hemorrhoidal maximum 3
eql high power body wash 3
eql hydrating beauty 3
eql hydrogen peroxide 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
295
Drug Name Drug Tier Requirements/Limits
eql ibuprofen 3
eql ibuprofen cold & sinu 3
eql ibuprofen cold childr 3
eql ibuprofen cold/sinus 3
eql ibuprofen infants 3
eql ibuprofen junior stre 3
eql ibuprofen pm 3
EQL INFANTS DECONGESTANT/ 3
eql infants gas relief 3
EQL INVIGORATING MAKEUP R 3
eql iron supplement thera 3
eql isopropyl alcohol 3
eql isopropyl rubbing alc 3
eql jock itch 3
eql l-lysine 3
eql laxative 3
eql laxative eql laxative 3
eql laxative maximum stre 25mg 3
eql lice killing maximum 3
eql lice solution kit 3
eql lice treatment 3
eql lice treatment maximu 3
EQL LINERS LONG LENGTH/VE 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
296
Drug Name Drug Tier Requirements/Limits
EQL LIQUID HAND SOAP 3
EQL LIQUID HAND SOAP REFI 3
eql loperamide hcl 3
eql lubricating jelly 3
eql magnesium 3
eql magnesium citrate 3
EQL MAKEUP REMOVER TOWELE 3
EQL MAXI FLEXI-WINGS ULTR 3
EQL MAXI FLEXI-WINGS/LONG 3
EQL MAXI FLEXI-WINGS/OVER 3
EQL MAXI/FLEXI-WINGS/LONG 3
EQL MAXI/MODERATE 3
EQL MAXI/REGULAR 3
eql medicated chest rub 3
eql medicated dandruff 3
eql medicated wipes 3
eql melatonin/vitamin b-6 3
eql menstrual relief maxi 3
eql miconazole 1 3
eql miconazole 3 3
eql miconazole 7 3
eql migraine formula 3
eql milk of magnesia 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
297
Drug Name Drug Tier Requirements/Limits
EQL MOISTURIZING CREAM 3
eql motion sickness relie 3
eql mouthwash/gargle 3
eql mucus relief children 3
eql mucus relief maximum 3
eql mucus-dm 3
eql mucus-dm maximum stre 3
eql mucus-er 12 hour 3
eql mucus-er maximum stre 3
EQL MULTI-PURPOSE DISINFE 3
eql multi-purpose solutio 3
EQL MULTI-PURPOSE SOLUTIO 3
eql multi-symptom daytime 3
eql multi-symptom nightti 3
eql muscle rub pain relie 3
eql naproxen sodium 3
eql nasal decongestant 3
eql nasal decongestant ma 3
eql nasal decongestant pe 3
eql nasal four 3
eql nasal spray 12 hour 3
eql nasal spray 12 hour/n 3
eql nasal spray fast acti 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
298
Drug Name Drug Tier Requirements/Limits
eql nasal spray no drip 3
eql nasal spray no drip 1 3
eql natural fiber 28.3%, 30.9%, 58.6% 3
EQL NATURAL FIBER 92% 3
eql natural zinc 3
eql niacin 3
eql niacin flush free 3
eql nicotine 3
eql nicotine polacrilex 3
eql nicotine polacrilex r 3
eql nicotine polacrilex s 3
eql night time cough 3
eql nighttime cold & flu 3
eql nighttime cold multi- 3
eql nighttime cold/flu re 3
eql nighttime cough relie 3
eql nighttime severe cold 3
eql nighttime sleep aid 3
eql non-drying sinus 3
eql omega 3 fish oil 3
eql omega-3 fish oil 3
EQL OMEPRAZOLE 3
EQL ONE DAILY ADULT GUMMI 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
299
Drug Name Drug Tier Requirements/Limits
eql one daily energy 3
eql one daily essential 3
EQL ONE DAILY MENS 3
eql one daily mens 50+ ad 3
eql one daily mens health 3
eql one daily womens 3
eql one daily womens 50+ 3
EQL OVERNIGHT PROTECTIVE 3
eql oyster shell calcium/ 3
EQL PADS BLADDER PROTECTI 3
eql pain & fever children 3
eql pain & fever infants 3
eql pain relief 3
eql pain relief allergy m 3
eql pain relief chest con 3
eql pain relief extra str 3
eql pain relief plus cold 3
eql pain relief pm 3
eql pain relief pm extra 3
eql pain relief/cold 3
eql pain relief/sinus 3
EQL PANTILINERS LONG 3
eql pediatric electrolyte 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
300
Drug Name Drug Tier Requirements/Limits
EQL PERSONAL CONFIDENCE B 3
EQL PERSONAL CONFIDENCE E 3
EQL PERSONAL CONFIDENCE F 3
EQL PERSONAL CONFIDENCE G 3
EQL PERSONAL CONFIDENCE P 3
EQL PERSONAL CONFIDENCE U 3
EQL PRENATAL FORMULA 3
eql pressure & pain pe pl 3
eql probiotic acidophilus 3
EQL PROBIOTIC COLON SUPPO 3
EQL PURSEREADY UNDERWEAR 3
eql ready-to-use enema 3
eql redness relief 3
eql saline nasal spray 3
eql scalp relief maximum 3
eql scar gel 3
eql senna laxative 3
eql senna-s 3
eql severe allergy pain r 3
eql severe cold 3
eql severe cold pe multi- 3
eql severe cold/flu 3
eql sinus & allergy pe 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
301
Drug Name Drug Tier Requirements/Limits
eql sinus congestion & pa 3
eql sinus headache maximu 3
eql sinus headache pe max 3
eql sinus nasal spray 3
eql sinus relief 12 hour 3
EQL SKIN ASTRINGENT 3
eql sleep aid 3
eql sleep aid maximum str 3
eql sleep aid nighttime 3
EQL SLIP-ON UNDERGARMENTS 3
eql slow release iron 3
eql sore throat 3
eql sore throat & cough l 3
eql sore throat spray 3
eql sour gummies children 3
eql stay awake 3
eql stay awake maximum st 3
eql stomach relief 3
eql stomach relief maximu 3
eql stool softener 3
eql stool softener/stimul 3
eql stress b-complex/vita 3
eql super b complex/vitam 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
302
Drug Name Drug Tier Requirements/Limits
EQL SUPER ENERGY BOOSTER 3
EQL SUPER MAXI 3
EQL SUPER PLUS PROTECTIVE 3
eql therapeutic 3
EQL THIN LINERS REGULAR 3
eql tioconazole-1 3
eql triacting cold/allerg 3
eql triacting cold/cough 3
eql triacting cold/night 3
EQL TRUE2GO BLOOD GLUCOSE 3
EQL TRUETEST BLOOD GLUCOS 3
EQL TRUETRACK TEST 3
eql tussin cf cough/cold/ 3
eql tussin chest congesti 3
eql tussin cough & chest 3
eql tussin cough & cold c 3
eql tussin cough long-act 3
eql tussin cough/chest co 3
eql tussin cough/cold max 3
eql tussin dm cough/chest 3
eql tussin mucus+chest co 3
eql tussin ped cough/cold 3
EQL ULTRA MOISTURIZING DA 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
303
Drug Name Drug Tier Requirements/Limits
EQL ULTRA THIN PADS/LIGHT 3
EQL ULTRA THIN/FLEXI-WING 3
EQL UNDERWEAR FOR MEN/LAR 3
EQL UNDERWEAR FOR MEN/SMA 3
EQL UNDERWEAR FOR WOMEN/ 3
EQL UNDERWEAR FOR WOMEN/X 3
eql vapor inhaler nasal d 3
eql vision formula 3
eql vitamin b-12 3
eql vitamin b-12 tr 3
eql vitamin c 3
EQL VITAMIN C DROPS 3
eql vitamin c gummies 3
eql vitamin c/rose hips 3
eql vitamin d3 3
eql vitamin d3 gummies 3
eql vitamin d-3 3
EQL VITAMIN D-3 HIGH POTE 3
eql vitamin e 3
eql vitamin e ultra stren 3
eql witch hazel 3
eql womans laxative 3
eql zinc 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
304
Drug Name Drug Tier Requirements/Limits
eql zinc cold relief 3
EQUALACTIN 3
equalizer gas relief 3
EQUALYTE 3
EQUALYTE SOL RTH 3
ergocalciferol CAPS 50000unit 3
ergocalciferol SOLN 8000unit/ml 3
ESOCOR P 3
esomeprazole magnesium 20mg 3
essentia 3
ESSENTIAL AMINO ACID MIX 3
essential balance 3
essential magnesium 3
essential one daily multi 3
ester-c TABS 3
ESTER-C TABS 3
ester-c TBCR 3
ester-c/bioflavonoids 3
ester-e 3
ESTROFACTORS 3
EUCALYPTUS OIL 3
EUCERIN 3
EUCERIN ADVANCED CLEANSIN LIQD 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
305
Drug Name Drug Tier Requirements/Limits
EUCERIN BABY 3
EUCERIN CALMING DAILY MOI 3
EUCERIN DAILY PROTECTION/ 3
eucerin eczema relief 3
EUCERIN INTENSIVE REPAIR 3
EUCERIN ORIGINAL HEALING 3
EUCERIN PLUS 3
EUCERIN PLUS INTENSIVE RE 3
EUCERIN PROFESSIONAL REPA 3
EUCERIN SKIN CALMING BODY 3
EUCERIN SKIN CALMING DAIL 3
EUCERIN SMOOTHING REPAIR 3
EVAC 3
EVAC-U-GEN CHEW 3
evac-u-gen TABS 3
EVENCARE + BLOOD GLUCOSE 3
EVENCARE BLOOD GLUCOSE TE 3
EVENCARE G2 BLOOD GLUCOSE 3
EVENCARE G2 TEST STRIPS 3
EVENCARE G3 BLOOD GLUCOSE 3
EVENCARE G3 TEST STRIPS 3
EVENCARE MINI BLOOD GLUCO 3
EVERYDAY LONG PANTILINERS 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
306
Drug Name Drug Tier Requirements/Limits
EVOLUTION60 3
EVOLUTION AUTOCODE 3
EX-LAX 3
EX-LAX MAXIMUM STRENGTH 3
ex-lax ultra 3
EXACTECH R-S-G TEST STRIP 3
EXACTECH TEST STRIPS 3
EXACTUSS TR 3
EXAPHEN 3
EXAPHEN CH 3
EXAPHEX TR 3
EXCEDRIN EXTRA STRENGTH 3
EXCEDRIN MENSTRUAL COMPLE 3
EXCEDRIN MIGRAINE 3
EXCEDRIN PM 3
EXCEDRIN SINUS HEADACHE 3
EXCEDRIN TENSION HEADACHE 3
exefen-ir 3
exocaine medicated rub 3
EXPIRATORY MOUTHPIECE 3
extra strength acetaminop 3
extra strength bayer 3
extra strength bayer arth 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
307
Drug Name Drug Tier Requirements/Limits
extra strength pain relie 3
extraprin 3
extraprin extra strength 3
extress 3
EXTRESS-30 3
extress-super 3
extussive 3
EXU-DRY 3"X4" 3
EXU-DRY 4"X6" 3
EXU-DRY 6"X9" 3
EXU-DRY 9"X15" 3
EXU-DRY 15"X18" 3
EXU-DRY 15"X24" 3
EXU-DRY 20"X28" 3
EXU-DRY ARM 27"X31" 3
EXU-DRY ARM/SHOULDER TIES 3
EXU-DRY BURN JACKET 31"X3 3
EXU-DRY BURN JACKET CHILD 3
EXU-DRY BUTTOCKS 23"X53" 3
EXU-DRY ELBOW/KNEE/HEEL 1 3
EXU-DRY FACE 9"X14" 3
EXU-DRY INCISION 3"X9" 3
EXU-DRY NON-PERMEABLE PAD 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
308
Drug Name Drug Tier Requirements/Limits
EXU-DRY PADDED HAND 12"X1 3
EXU-DRY PADDED HAND CHILD 3
EXU-DRY PADDED NECK 6"X25 3
EXU-DRY PERMEABLE PAD 24" 3
EXU-DRY SCALP 3"X14" 3
EXU-DRY SLIT TUBE 2"X3" 3
exuviance blemish treatme 3
eye allergy relief 3
eye drops 3
eye drops allergy relief 3
eye drops ar 3
eye drops extra 3
eye drops relief 3
EYE HEALTH 3
eye irrigating solution 3
eye itch relief 3
eye lubricant 3
EYE STREAM 3
eye vitamins 3
eye vitamins & minerals 3
eye wash 3
eye wash sterile 3
EYE-SCRUB 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
309
Drug Name Drug Tier Requirements/Limits
eye-vites 3
EYEAID IRRIGATING SOLUTIO 3
eyeprotect 3
EYESCRUB 3
EZ SMART BLOOD GLUCOSE TE 3
EZ SMART DIABETES MONITOR 3
EZ SMART PLUS BLOOD GLUCO 3
EZ SMART PLUS DIABETES MO 3
EZ-SORB UNDERPAD 3
EZFE 200 3
EZFE FORTE 3
fa-8 3
FACE MASK EARLOOP-STYLE 3
FACE MASK RESPIRATOR N-10 3
FACE MASK RESPIRATOR R-95 3
famotidine TABS 10mg, 20mg 3
FAMOTIDINE TAB 10 MG 3
fast acting antacid anti- 3
fast acting antacid plus 3
FAST ACTING B12 3
fast dissolve antacid 3
fast freeze pro style the GEL 3
FAT BLOCKER PLUS 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
310
Drug Name Drug Tier Requirements/Limits
father johns medicine 3
FATHER JOHNS MEDICINE PLU 3
FATTIBASE 3
FE ASPARTATE 3
fe c 3
fe c tab 3
fe c tab plus 3
FE CAPS/STOOL SOFTENER 3
FE GLUCONATE 3
FE PLUS PROTEIN 3
fe tabs 3
FEBROL 3
feenamint 3
FEM-CAL CITRATE 3
FEMININE GUARDS/REGULAR 3
FEMININE GUARDS/SUPER 3
feminine moisturizer & lu 3
FEMININE PADS 3
FEMININE PADS EXTRA PLUS 3
FEMININE PADS REGULAR 3
FEMININE PADS SUPER 3
FEMININE WIPES/ALOE VERA/ 3
FEMIRON 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
311
Drug Name Drug Tier Requirements/Limits
fenesin dm ir 3
FENESIN DM IR 3
fenesin ir 3
fenesin pe ir 3
FEOSOL 45mg, 200mg 3
feosol 65mg 3
FEOSOL BIFERA 3
FEOSTAT 3
FEOSTAT CHW 100MG 3
FER-IN-SOL 3
fer-iron 3
FERAHEME 3
ferate 3
fergon 27mg 3
FERGON 240mg 3
ferosul TABS 325mg 3
FERRETTS 3
FERRETTS CHEWABLE IRON 3
FERRETTS IPS 3
FERREX 28 3
ferrex 150 3
ferrex 150 forte 3
FERREX 150 FORTE 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
312
Drug Name Drug Tier Requirements/Limits
FERREX 150 FORTE PLUS 3
FERREX 150 PLUS 3
FERRIC SUBSULFATE 3
ferric x-150 3
FERRIMIN 150 3
FERRLECIT 3
ferro-bob 3
FERRO-SEQUELS 3
ferrocite 3
ferrotabs 3
FERROUS FUMARATE TABS 29mg, 90mg 3
ferrous fumarate TABS 325mg 3
ferrous gluconate TABS 27mg, 240mg,
324mg, 325mg
3
FERROUS GLUCONATE TABS 225mg, 324mg
3
ferrous sulfate CAPS 3
ferrous sulfate CPCR 3
ferrous sulfate ELIX 220mg/5ml 3
FERROUS SULFATE GRAN 3
FERROUS SULFATE LIQD 220mg/5ml 3
FERROUS SULFATE POWD 3
ferrous sulfate SOLN 15mg/0.6ml, 15mg/ml, 75mg/0.6ml
3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
313
Drug Name Drug Tier Requirements/Limits
ferrous sulfate TABS 27mg, 28mg, 65mg, 324mg, 325mg
3
ferrous sulfate TBCR 45mg, 50mg, 142mg 3
FERROUS SULFATE TBCR 140mg 3
FERROUS SULFATE TBEC 324mg 3
ferrous sulfate TBEC 325mg 3
FERROUS SULFATE ANHYDROUS 3
ferrous sulfate iron 3
fever reducer childrens 3
FEVERALL INFANTS 80mg 3
fexofenadine hcl TABS 60mg, 180mg 3
fexofenadine hcl children 30mg/5ml 3
fexofenadine-pseudoephedrine 3
FIBER CHEW 3
fiber POWD 3
FIBER POWD 3
fiber adult gummies 3
FIBER CON TAB 625MG 3
fiber laxative CAPS 3
fiber laxative TABS 625mg 3
fiber select gummies 3
fiber therapy 3
fiber-caps 3
fiber-lax 625mg 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
314
Drug Name Drug Tier Requirements/Limits
fiberchoice weight manage 3
FIBERCON 3
fibergen 3
FIBRACOL COLLAGEN-ALGINAT PADS 3
FIFTY50 GLUCOSE METER 2.0 3
FIFTY50 GLUCOSE TEST STRI 3
FIFTY50 LANCING DEVICE 3
FILTER AIR PP 3
first aid antibiotic 3
first aid antiseptic spra 3
first aid plus lidocaine 3
FIRST QUALITY PERSONAL CL 3
FIRST QUALITY WASHCLOTHS 3
fish oil burp-less 3
fish oil concentrate 3
fish oil double strength 3
fish oil extra strength 3
fish oil maximum strength 3
fish oil pearls 3
FITNESS TABS FOR MEN AM/P 3
FITNESS TABS FOR WOMEN A 3
FITTED BRIEF W/ALOE/LARGE 3
FITTED BRIEFS LARGE 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
315
Drug Name Drug Tier Requirements/Limits
FITTED BRIEFS MAXIMUM LAR 3
FITTED BRIEFS MAXIMUM MED 3
FITTED BRIEFS MAXIMUM XL 3
FITTED BRIEFS MEDIUM 3
FITTED BRIEFS SMALL 3
flanax heartburn relief 3
flanax pain relief 3
flanax pain relief linime 3
flanders buttocks 3
FLAVOR PACKETS 3
FLAVOUR PAC 3
FLEET ENEMA 3
FLEET ENEMA SIX PACK 3
fleet laxative 3
FLEET LIQUID GLYCERIN SUP 3
FLEET MINERAL OIL 3
FLEET MO ENE 3
FLEET OIL 3
FLEET PEDIATRIC 3
flexgen 3
FLEXICHAMBER ADULT MASK/S 3
FLEXICHAMBER CHILD MASK/L 3
FLEXICHAMBER CHILD MASK/S 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
316
Drug Name Drug Tier Requirements/Limits
flintstones complete 3
FLINTSTONES GUMMIES 3
FLINTSTONES GUMMIES COMPL 3
flintstones gummies plus 3
FLINTSTONES GUMMIES PLUS 3
flintstones plus calcium 3
flintstones plus extra c 3
flintstones plus iron 3
FLINTSTONES SOUR GUMMIES 3
FLINTSTONES TODDLER/TASTI 3
flintstones/my first 3
flogen 3
FLONASE ALLERGY RELIEF 3
FLONASE ALLERGY RELIEF CH 3
FLONASE SENSIMIST 3
flora assist 3
FLORA VANCE 3
FLORA-Q 3
FLORA-Q 2 3
FLORAJEN3 3
FLORAJEN4KIDS 3
FLORAJEN ACIDOPHILUS 3
FLORAJEN BIFIDOBLEND 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
317
Drug Name Drug Tier Requirements/Limits
floranex 3
FLORASTOR 3
FLORASTOR KIDS 3
FLOWTUSS 3
FLU & SORE THROAT 3
flu & sore throat relief 3
flu bp maximum strength 3
flu hbp 3
flu relief therapy daytim 3
flu relief therapy nightt 3
flu/severe cold & cough d 3
fluoridex daily renewal 3
fluorigard 3
fluticasone propionate (nasal) 50mcg/act 3
FOAM DRESSING BORDERED 3
FOAM DRESSING CIRCULAR BO 3
FOAM DRESSING NON-BORDERE 3
foaming antacid extra str 3
foaming antacid maximum s 3
FOLGARD 3
FOLIC + B12 3
FOLIC ACID CAPS 5mg, 20mg 3
folic acid CAPS 800mcg 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
318
Drug Name Drug Tier Requirements/Limits
FOLIC ACID POWD 3
folic acid SOLN 5mg/ml 3
folic acid TABS 1mg, 400mcg, 800mcg 3
FOLIC ACID XTRA 3
FOLIC ACID/B-6/B-12 3
FOLINIC-PLUS 3
FOLITAB 500 3
foltabs 800 3
FOLTRATE 3
for sty relief 3
FORA BLOOD GLUCOSE TEST S 3
FORA D15G BLOOD GLUCOSE T 3
FORA D20 BLOOD GLUCOSE TE 3
FORA D40/G31 BLOOD GLUCOS 3
FORA G20 BLOOD GLUCOSE MO 3
FORA G20 BLOOD GLUCOSE TE 3
FORA G30/PREMIUM V10 BLOO 3
FORA G30A BLOOD GLUCOSE M 3
FORA GD20 BLOOD GLUCOSE M 3
FORA GD20 TEST STRIPS 3
FORA GD50 BLOOD GLUCOSE M 3
FORA GD50 BLOOD GLUCOSE T 3
FORA LANCING DEVICE 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
319
Drug Name Drug Tier Requirements/Limits
FORA LANCING DEVICE/CLEAR 3
FORA PREMIUM V10 BLE BLOO 3
FORA TEST N' GO VOICE BLO 3
FORA TN'G VOICE BLOOD GLU 3
FORA TN'G/TN'G VOICE BLOO 3
FORA V10 BLOOD GLUCOSE MO 3
FORA V10 BLOOD GLUCOSE TE 3
FORA V12 BLOOD GLUCOSE MO 3
FORA V12 BLOOD GLUCOSE TE 3
FORA V20 BLOOD GLUCOSE MO 3
FORA V20 BLOOD GLUCOSE TE 3
FORA V30A BLOOD GLUCOSE M 3
FORA V30A BLOOD GLUCOSE T 3
FORACARE GD40 3
FORACARE GD40 BLOOD GLUCO 3
FORACARE PREMIUM V10 BLOO 3
FORACARE PREMIUM V10 TEST 3
FORACARE TEST N GO BLOOD 3
FORACARE TEST N GO TEST S 3
FORMALDEHYDE 37% 3
FORMULA 405 A.H.A FACIAL 3
FORMULA 405 BODY SMOOTHIN 3
FORMULA 405 ENRICHED EYE 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
320
Drug Name Drug Tier Requirements/Limits
FORMULA 405 FACE CREAM 3
FORMULA 405 FACIAL & BODY 3
FORMULA 405 LIGHT TEXTURE 3
FORMULA 405 MOISTURIZING 3
formula d 3
formula e 400 3
formula em 3
FORTAVIT 3
FORTIFY DAILY PROBIOTIC 3
FORTISCARE BLOOD GLUCOSE 3
FORTISCARE SELF-MONITORIN 3
FOSFREE 3
fp allergy/congestion rel 3
fp bladder control pads r 3
fp calcium 500 3
FP CLOTRIMAZOLE 3 3
fp clotrimazole 3 2% 3
fp elixir 3
FP FOAMICON 3
fp glucosamine 3
fp glucosamine/chondroiti 3
FP GLUCOSE 3
fp honey tussin cough 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
321
Drug Name Drug Tier Requirements/Limits
fp hydrocortisone 3
fp incontinent brief/xlar 3
fp incontinent undergarme 3
fp loratadine allergy rel 3
fp multi-purpose solution 3
FP MULTI-PURPOSE SOLUTION 3
fp multi-symptom pms 3
FP MULTI-SYMPTOM PMS 3
fp nasal allergy 3
fp nicotine 3
fp oyster shell calcium/d 3
fp pediatric electrolyte 3
fp permethrin 3
fp povidone-iodine 3
fp protective underwear/l 3
fp protective underwear/s 3
fp triacting chest conges 3
fp triacting cold & aller 3
fp tusssin severe congest 3
fp vitamin c drops 3
fp zinc lozenges 3
FQ AIR PERMEABLE UNDERPAD 3
FQ BELTED UNDERGARMENT SU 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
322
Drug Name Drug Tier Requirements/Limits
FQ FRONTAL TAPE BRIEF X-L 3
FQ FULL MAT BRIEF ADULT S 3
FQ FULL MAT BRIEF ADULT X 3
FQ FULL MAT BRIEF YOUTH 3
FQ NU-FIT ADULT BRIEF X-L 3
FQ PANT LINER LARGE 3
FQ PANT LINER LARGE PLUS 3
FQ PANT LINER LARGE W/ LE 3
FQ PANT LINER MEDIUM 3
FQ PANT LINER SMALL ELAST 3
FQ PERFIT LIMITED MAT ADU 3
FQ PREMIUM UNDERPAD 3
FQ PREVAIL BELTED UNDERGA 3
FQ PREVAIL BLADDER CONTR 3
FQ PROTECTIVE UNDERWEAR L 3
FQ PROTECTIVE UNDERWEAR S 3
FQ PROTECTIVE UNDERWEAR X 3
FQ PROTECTIVE UNDERWEAR Y 3
FREDS PHARMACY AUTOLET LA 3
FREE & ACTIV PAD REGULAR 3
FREE & ACTIVE FEMALE PANT 3
FREE & ACTIVE MALE BRIEF 3
FREE & ACTIVE PADS 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
323
Drug Name Drug Tier Requirements/Limits
free & clear LIQD 3
FREE & CLEAR SHAM 3
FREE & CLEAR FOR SENSITIV 3
FREEDAVITE 3
FREESTYLE FREEDOM 3
FREESTYLE FREEDOM LITE 3
FREESTYLE INSULINX BLOOD 3
FREESTYLE LITE BLOOD GLUC 3
FREESTYLE LITE TEST STRIP 3
FREESTYLE PRECISION NEO B 3
FREESTYLE SIDEKICK II VAL 3
FREESTYLE TEST STRIPS 3
freeze dried acidophilus 3
FREEZE IT 3
freezone callus remover 3
FRESHKOTE 3
FRUIT C 200 3
fruit c 500 3
fruit c-100 3
FRUIT OF THE EARTH/ALOE V 3
fruity c 3
fruity chewables multivit 3
fruity chews 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
324
Drug Name Drug Tier Requirements/Limits
fruity chews/iron 3
FULL KIT NEBULIZER SET 3
FULL MAT BRIEF REGULAR 3
FULL SPECTRUM B/VITAMIN C 3
fungi guard 3
fungi-guard 3
fungicure intensive with 3
FUNGOID TINCTURE 3
fungoid-d 3
FUSION 3
FV BENZOIN TINCTURE 3
FV EPSOM SALT 3
FV GENTIAN VIOLET 3
FV HYDROGEN PEROXIDE 3
FV IODINE TINCTURE 3
FV IPECAC 3
FV ISOPROPYL ALCOHOL 3
FV ISOPROPYL ALCOHOL/WINT 3
fv laxative vegetable 3
fv suphedrine 3
FV WITCH HAZEL 3
g tussin ac 3
G-DOLOGEN 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
325
Drug Name Drug Tier Requirements/Limits
g-fen dm 3
g-fen ex 3
G-P-TUSS DXP 3
G-PREPROTEIN 3
g-supress dx pediatric 3
g-tron 3
g-tron ped 3
g-tron pediatric drops 3
G-TUSICOF 3
G-ZYNCOF 3
GALZIN 3
gas free extra strength 3
gas relief 3
gas relief extra strength CAPS 125mg 3
gas relief extra strength CHEW 3
gas relief infants 3
gas relief maximum streng 3
gas relief ultra strength 3
GAS-X 3
gas-x extra strength CAPS 3
GAS-X EXTRA STRENGTH CHEW; STRP 3
gas-x infant drops 3
GAS-X PREVENTION 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
326
Drug Name Drug Tier Requirements/Limits
gas-x ultra strength 3
gasaid 3
gavilax PACK 3
gavilax POWD 3
gavis-care 3
GAVISCON CHEW 3
GAVISCON SUSP 3
GAVISCON EXTRA STRENGTH 3
GAVISCON EXTRA STRENGTH R 3
GE100 BLOOD GLUCOSE MONIT 3
GE100 BLOOD GLUCOSE TEST 3
GE-150 3
gel callus removers 3
GEL CORN CUSHIONS 3
GEL HEEL CUSHIONS 3
GEL HEEL CUSHIONS MENS 3
GEL HEEL CUSHIONS WOMENS 3
GEL-KAM 3
gel-tin 3
GELUSIL 3
genac 3
genahist 3
genaphed 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
327
Drug Name Drug Tier Requirements/Limits
gencontuss 3
genicin 3
genpril 3
GENSTRIP 50 3
GENTEAL 3
GENTEAL MILD 3
GENTEAL MILD TO MODERATE 3
GENTEAL SEVERE .3% 3
genteal tears liquid drop 3
genteal tears mild 3
GENTEAL TEARS MODERATE PF 3
genteal tears night-time 3
GENTEEL LANCING DEVICE/BU 3
GENTEEL LANCING DEVICE/GL 3
GENTEEL LANCING DEVICE/PL 3
GENTEEL LANCING DEVICE/PR 3
GENTEEL LANCING DEVICE/ST 3
GENTEEL LANCING DEVICE/WI 3
GENTIAN VIOLET SOLN 3
GENTLE 3
GENTLE CLEANSING SKIN CRE 3
gentle iron 3
gentle laxative 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
328
Drug Name Drug Tier Requirements/Limits
gentle laxative for women 3
gentle laxative overnight 3
GENTLE RAIN EXTRA MILD 3
GENTLE RAIN SHAMPOO AND S 3
gentle skin cleanser LIQD 3
gentle skin cleanser LOTN 3
GENTLE SKIN CLEANSER LOTN 3
gentle stool softener 3
gentlelax 3
GENULTIMATE TEST STRIPS 3
geravim 3
GERAVINE 3
GERI PROTECT 3
geri-dryl 3
geri-dryl allergy relief 3
GERI-FREEDA SENIOR FORMUL 3
geri-hydrolac 5 3
geri-hydrolac 12 3
geri-kot 3
geri-lanta 3
geri-lanta supreme 3
geri-lub 3
geri-mox 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
329
Drug Name Drug Tier Requirements/Limits
geri-mucil 3
geri-pectate 3
GERI-SHAMPOO/SHEA BUTTER 3
GERI-SOFT 3
geri-tonic 3
geri-tussin 3
geri-tussin dm 3
GERI-WASH 3
GERIAIDE 3
geriaton 3
GERIATRIC VITAMIN 3
GERISILK BATH OIL 3
GERITOL COMPLETE 3
GERITOL TONIC 3
gerivite complete 3
GERM DEFENSE PM 3
gets-it corn and callus r 3
GHT BLOOD GLUCOSE MONITO 3
GHT TEST STRIPS 3
GILTUSS ALLERGY & SINUS 3
giltuss cough & chest con 3
giltuss cough & cold LIQD 3
GILTUSS COUGH & COLD LIQD 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
330
Drug Name Drug Tier Requirements/Limits
GILTUSS COUGH & COLD TABS 3
giltuss cough & cold chil 3
GILTUSS COUGH ALLERGY & S 3
GILTUSS SINUS & CONGESTIO 3
GLEN PE 3
GLENMAX PEB 3
GLENMAX PEB DM 3
glenmax peb dm forte 3
glentuss 3
GLOBAL LANCING DEVICE 3
gluco burst GEL 3
GLUCO COR 3
GLUCO PERFECT 3 BLOOD GLU 3
GLUCO PERFECT 3 TEST STRI 3
GLUCOCARD 01 BLOOD GLUCOS 3
GLUCOCARD 01 SENSOR PLUS 3
GLUCOCARD 01-MINI BLOOD G 3
GLUCOCARD EXPRESSION AUDI 3
GLUCOCARD EXPRESSION BLOO 3
GLUCOCARD SHINE 3
GLUCOCARD SHINE CONNEX BL 3
GLUCOCARD SHINE EXPRESS B 3
GLUCOCARD SHINE TEST STRI 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
331
Drug Name Drug Tier Requirements/Limits
GLUCOCARD SHINE XL 3
GLUCOCARD VITAL BLOOD GLU 3
GLUCOCARD VITAL TEST STRI 3
GLUCOCARD X-METER 3
GLUCOCARD X-SENSOR 3
GLUCOCOM BLOOD GLUCOSE MO 3
GLUCOCOM TEST STRIPS 3
GLUCOFILM TEST STRIPS 3
GLUCOLET 2 AUTOMATIC LANC 3
GLUCOMETER KIT 3
GLUCONAVII BLOOD GLUCOSE 3
glucosamine chondroitin c CAPS 3
glucosamine hydrochloride TABS 3
glucosamine maximum stren 3
glucosamine relief CAPS 3
glucosamine sulfate CAPS 500mg 3
glucosamine-chondroitin 3
glucosamine/chondroitin d 3
glucosamine/chondroitin p 3
GLUCOSE 3
GLUCOSE CHW 4GM 3
GLUCOSE INSTANT ENERGY 3
GLUCOSE METER TEST STRIPS 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
332
Drug Name Drug Tier Requirements/Limits
GLUCOSOURCE LANCET DEVICE 3
GLUCOSTIX 3
glucoten 3
GLUTAMENT 3
glutamine CAPS 500mg 3
GLUTAMINE CAPS 500mg 3
glutamine POWD 3
glutamine TABS 3
GLUTARADE AMINO ACID BLEN 3
GLUTARADE ESSENTIAL GA-1 3
GLUTARADE JUNIOR GA-1 3
glutimmune 3
glutose 15 3
glutose 45 3
gly-oxide 3
glycerin (laxative) 1gm, 1.2gm, 1.5gm,
2gm, 2.1gm, 80.7%
3
glycerin (topical) 3
glycerin adult 2gm 3
GLYCERIN ADULT 2gm 3
GLYCINE POWD 3
GLYCINE500 3
GLYCINE (L) 3
GLYCO-TECH 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
333
Drug Name Drug Tier Requirements/Limits
GLYCOLIC ACD SOL 70% TECH 3
glycolic acid SOLN 70% 3
GLYCOLIC ACID SOLN 70% 3
GLYCOLIC ACID 70% HIGH PU 3
GLYCOTROL 3
GLYCOTROL COMPLETE 3
GMATE BLOOD GLUCOSE TEST 3
GMATE LANCING DEVICE 3
GMATE SMART METER KIT 3
GMATE SMART STARTER KIT 3
GMATE VOICE BLOOD GLUCOSE 3
gnc potassium gluconate 9 3
GNP 4X PROBIOTIC 3
gnp 8 hour pain relief 3
gnp 8 hour pain reliever 3
gnp 12 hour nasal spray 3
gnp 24 hour nasal allerg 3
gnp acetaminophen 3
gnp acetaminophen extra s 3
gnp acid control 75 3
gnp acid control 150 maxi 3
gnp acid reducer 10mg, 75mg 3
gnp acid reducer maximum 20mg 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
334
Drug Name Drug Tier Requirements/Limits
GNP ACIDOPHILUS HIGH POTE 3
gnp acne treatment maximu 3
gnp adult aspirin low str CHEW 81mg 3
gnp adult aspirin low str TBEC 3
GNP ADVANCED RECOVERY 3
gnp all day allergy 10mg 3
gnp all day allergy child 1mg/ml, 5mg/5ml 3
gnp all day allergy-d 3
gnp all day pain relief 3
gnp allergy CAPS 25mg 3
gnp allergy TABS 3
gnp allergy & congestion 3
gnp allergy & sinus heada 3
gnp allergy antihistamine 3
gnp allergy multi-symptom 3
gnp allergy plus severe s 3
gnp allergy plus sinus he 3
gnp allergy relief CAPS 3
gnp allergy relief CHEW 3
gnp allergy relief TABS 25mg, 180mg 3
gnp allergy relief TBDP 3
gnp allergy relief for ki 3
gnp allergy relief multi- 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
335
Drug Name Drug Tier Requirements/Limits
gnp allergy-d 12 hour all 3
gnp animal shapes 3
gnp animal shapes plus ex 3
gnp animal shapes plus ir 3
gnp antacid 3
gnp antacid & anti-gas ma 3
gnp antacid & anti-gas/re 3
gnp antacid and anti-gas/ 3
gnp antacid anti-gas 3
gnp antacid anti-gas/maxi 3
gnp antacid extra strengt 750mg 3
gnp antacid maximum stren 3
gnp antacid ultra strengt 3
gnp antacid/regular stren 3
gnp anti-diarrheal CAPS 2mg 3
gnp anti-diarrheal LIQD 3
gnp anti-diarrheal TABS 2mg 3
gnp anti-gas 3
gnp anti-itch 3
gnp anti-nausea 3
gnp antibiotic plus pramo 3
gnp antiseptic skin clean 3
gnp arthricream 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
336
Drug Name Drug Tier Requirements/Limits
gnp arthritis pain relief 650mg 3
gnp artificial tears 3
gnp aspirin TABS 325mg, 500mg 3
gnp aspirin TBEC 81mg, 325mg 3
gnp aspirin low dose 81mg 3
gnp athlete's foot relief 3
gnp athletes foot 1% 3
gnp b-12 3
gnp b-50 balanced 3
gnp b-50 complex prolonge 3
gnp b-100 balanced tr 3
gnp b-100 complex prolong 3
gnp b-complex plus vitami 3
gnp bacitracin zinc 500unit/gm 3
GNP BATHING CLOTHS/RINSE- 3
gnp best fiber 3
gnp biotin 3
gnp bisa-lax 5mg 3
gnp brewers yeast 3
gnp budesonide nasal spra 3
gnp cal mag zinc +d3 3
GNP CALAMINE 3
GNP CALAMINE PHENOLATED 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
337
Drug Name Drug Tier Requirements/Limits
gnp calcium 3
gnp calcium 500 3
gnp calcium 500 +d3 3
gnp calcium 500/d 3
gnp calcium 600 + d 3
gnp calcium 600 + soy 3
gnp calcium 600 +d 3
gnp calcium 600 +d3 3
gnp calcium 600 +d3/miner 3
gnp calcium 600 +d/minera 3
gnp calcium 600 plus d/mi 3
gnp calcium 600/d 3
gnp calcium 1200 3
gnp calcium citrate +d3 3
gnp calcium citrate+d3 ma 3
gnp calcium citrate+d max 3
gnp calcium plus 600 +d 3
gnp calcium/magnesium/zin 3
gnp calcuim/vitamin d/min 3
gnp caldyphen 3
gnp capsaicin CREA 3
GNP CAPSAICIN LIQD 3
gnp castor oil 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
338
Drug Name Drug Tier Requirements/Limits
gnp century 3
gnp century adult formula 3
gnp century adults 50+ se 3
gnp century cardio health 3
GNP CENTURY ENERGY METABO 3
gnp century mature 3
gnp century mature formul 3
gnp century ultimate mens 3
gnp century ultimate wome 3
gnp chest rub 3
gnp childrens allergy 3
gnp childrens chewables w 3
gnp childrens chewables/e 3
gnp childrens chewables/i 3
GNP CHILDRENS COMPLETE CH 3
gnp childrens easy-melts 3
gnp childrens ibuprofen 100mg/5ml 3
gnp childrens ibuprofen c 3
gnp childrens pain relief 3
gnp childrens plus cough 3
gnp childrens plus multi- 3
gnp chromium picolinate 3
gnp cimetidine 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
339
Drug Name Drug Tier Requirements/Limits
gnp clearlax PACK 3
gnp clearlax POWD 3
gnp clotrimazole 3 3
gnp co q10 3
gnp cod liver oil 3
gnp coenzyme q-10 3
gnp cold & allergy childr 3
gnp cold & allergy maximu 3
gnp cold & allergy pe 3
gnp cold & cough children 3
gnp cold & hot therapy ba 3
gnp cold + flu severe 3
gnp cold + head congestio 3
gnp cold head congestion 3
gnp cold max day/night ad 3
gnp cold max daytime for 3
gnp cold multi-symptom da 3
gnp cold multi-symptom ni 3
gnp cold relief cold & fl 3
gnp cold relief head cong 3
gnp cold relief multi-sym 3
GNP COLD RELIEF PLUS 3
gnp cold severe congestio 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
340
Drug Name Drug Tier Requirements/Limits
gnp cough dm er 3
gnp cough drops 9.1mg 3
gnp cough drops sugar fre 3
gnp cough gels 3
gnp cough relief 3
gnp d 1000 3
gnp d 2000 3
GNP DAILY PRENATAL 3
gnp day time cold & flu 3
gnp day time cold/flu 3
gnp day time cold/flu rel 3
gnp day time d cold/flu 3
GNP DAY TIME MUCUS RELIEF 3
gnp day time sinus 3
gnp dayhist allergy 3
gnp diabetic support form 3
gnp diaper rash 3
gnp diaper rash creamy 3
gnp docusate calcium 3
gnp dry mouth mouthwash 3
gnp dual action complete 3
gnp ear drops 3
gnp ear systems 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
341
Drug Name Drug Tier Requirements/Limits
GNP EASY TOUCH GLUCOSE MO 3
GNP EASY TOUCH GLUCOSE TE 3
gnp effervescent antacid/ 3
gnp enema 3
gnp enema mineral oil lax 3
gnp epsom salt 3
gnp esomeprazole magnesiu 3
gnp essential one daily 3
gnp eye drops 3
gnp eye itch relief 3
gnp eye wash 3
gnp fiber therapy 3
gnp fiber-caps 625mg 3
GNP FINGER CREAM 3
gnp first aid antibiotic 3
gnp fish oil 3
gnp fish oil maximum stre 3
gnp flu & severe cold & c 3
GNP FLU & SORE THROAT 3
gnp flu relief therapy se 3
gnp flu/severe cold & c o 3
gnp flu/severe cold dayti 3
gnp fluticasone propionat 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
342
Drug Name Drug Tier Requirements/Limits
gnp foaming antacid 3
gnp folic acid 3
gnp gas relief 3
gnp gas relief extra stre 3
gnp gas relief maximum st 3
GNP GENTIAN VIOLET 3
gnp gentle laxative 3
gnp glucosamine/chondroit 3
GNP GLUCOSE 3
gnp glycerin 3
gnp glycerin adult 3
gnp glycerin child 3
gnp glycerin infant 3
gnp hair/skin/nails 3
gnp headache pm 3
gnp headache relief 3
gnp headache relief added 3
gnp headache relief extra 3
gnp healthy eyes 3
gnp healthy eyes supervis 3
gnp heartburn relief 200mg 3
gnp heartburn relief 200 3
gnp hemorrhoidal 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
343
Drug Name Drug Tier Requirements/Limits
gnp hemorrhoidal cooling 3
gnp histafed 3
gnp hydro-lotion 3
gnp hydrocortisone 3
gnp hydrocortisone maximu 1% 3
gnp hydrocortisone plus 3
gnp hydrocortisone/aloe 3
gnp hydrogen peroxide 3
gnp hygienic cleansing 3
gnp hygienic cleansing pa 3
gnp ibuprofen CAPS 3
gnp ibuprofen TABS 200mg 3
gnp ibuprofen cold/sinus 3
gnp ibuprofen infants 3
gnp ibuprofen junior stre 3
gnp ibuprofen pm 3
gnp immune support 3
gnp infants gas relief 3
gnp infants pain relief 3
gnp infants pain/fever 3
GNP IODIDES TINCTURE 3
GNP IODINE TINCTURE 3
gnp iron 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
344
Drug Name Drug Tier Requirements/Limits
GNP ISOPROPYL ALCOHOL 70% 3
gnp isopropyl alcohol 91% 3
gnp itch relief extra str 3
gnp itchy eye 3
gnp k-pec 3
gnp l-lysine 500mg 3
GNP LANCING SYSTEM DEVICE 3
gnp lansoprazole 15mg 3
gnp laxative SUPP 3
gnp laxative TBEC 5mg 3
gnp lice bedding 3
gnp lice egg remover 3
gnp lice solution kit 3
gnp lice treatment LIQD 1% 3
gnp lice treatment SHAM 3
gnp little ones childrens 3
gnp loperamide hcl 3
gnp loratadine SYRP 5mg/5ml 3
gnp loratadine TABS 10mg 3
gnp loratadine allergy re 3
gnp loratadine childrens 3
gnp loratadine-d 12hr 3
gnp loratadine-d 24 hour 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
345
Drug Name Drug Tier Requirements/Limits
gnp lubricant eye drops 3
gnp lubricant pm 3
gnp lubricating jelly 3
gnp lubricating plus eye .5% 3
gnp magnesium 3
gnp magnesium citrate 3
gnp masanti maximum stren 3
gnp masanti regular stren 3
gnp maximum one daily 3
gnp medicated first aid s 3
gnp medicated wipes 3
gnp mega multi for men 3
gnp mega multi for women 3
gnp melatonin 3
gnp melatonin maximum str 3
gnp miconazole 1 3
gnp miconazole 3 3
gnp miconazole 3 combinat 3
gnp miconazole 7 2% 3
gnp miconazole nitrate 3
gnp miconazorb af 3
gnp migraine formula 3
gnp migraine relief 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
346
Drug Name Drug Tier Requirements/Limits
gnp milk of magnesia 1200mg/15ml 3
gnp mineral oil enema 3
gnp mineral oil heavy 3
gnp motion sickness relie 25mg, 50mg 3
gnp mucus d 12 hr 3
gnp mucus dm maximum stre 3
gnp mucus er 3
gnp mucus relief 400mg 3
gnp mucus relief children 3
gnp mucus relief cold & s 3
gnp mucus relief cold flu 3
gnp mucus relief cough ch 3
gnp mucus relief dm 3
gnp mucus relief dm max 3
gnp mucus relief pe 3
gnp mucus relief severe c 3
gnp mucus-er 3
gnp multi-purpose 3
gnp multi-symptom cold da 3
gnp multi-symptom cold ni 3
gnp muscle rub 3
gnp naproxen sodium 3
gnp nasal decongestant 30mg 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
347
Drug Name Drug Tier Requirements/Limits
gnp nasal decongestant pe 3
gnp nasal decongestant/ma 3
gnp nasal moisturizing 3
gnp nasal spray 3
gnp nasal spray extra moi 3
gnp nasal spray fast acti 3
gnp natural fiber 3
gnp nausea relief 3
gnp niacin 3
gnp niacin flush free 3
gnp niacin tr 3
gnp nicotine gum 3
gnp nicotine mini lozenge 2mg 3
gnp nicotine polacrilex GUM 2mg, 4mg 3
gnp nicotine polacrilex LOZG 2mg, 4mg 3
gnp nicotine polacrilex m 4mg 3
gnp nicotine transdermal 3
gnp night time cold & flu 3
gnp night time cold/flu r 3
gnp night time cough 3
gnp night time sinus 3
gnp nighttime sleep aid 25mg 3
gnp no drip nasal spray 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
348
Drug Name Drug Tier Requirements/Limits
gnp norwegian cod liver o 3
gnp nose drops extra stre 3
GNP OMEPRAZOLE 20mg 3
gnp one daily maximum 3
gnp one daily mens 50+ ad 3
gnp one daily mens health 3
gnp one daily plus iron 3
gnp one daily womens 50+ 3
gnp one daily womens heal 3
gnp one daily womens meta 3
gnp opti-vitamins 3
gnp pain & fever children 160mg/5ml 3
gnp pain relief CHEW 3
gnp pain relief TABS 325mg 3
gnp pain relief extra str LIQD 3
gnp pain relief extra str TABS 500mg 3
gnp pain relief infants 3
gnp pain relief pm extra 3
gnp pain reliever extra s 3
gnp pediatric electrolyte 3
GNP PERSONAL CLEANSING WI 3
gnp petroleum jelly 3
gnp pink bismuth 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
349
Drug Name Drug Tier Requirements/Limits
gnp potassium 3
gnp povidone-iodine 3
gnp pre-menstrual relief 3
GNP PRENATAL 3
GNP PROBIOTIC COLON SUPPO 3
gnp pseudoephedrine hcl 1 3
gnp pseudoephedrine hcl e 3
GNP QUICK DISSOLVE GLUCOS 3
GNP SALINE WOUND WASH 3
gnp scalp relief 3
gnp senna 3
gnp senna lax 3
gnp senna plus 3
gnp senna-lax 8.6mg 3
gnp severe cold/flu maxim 3
gnp severe day time cold 3
gnp sinus & allergy pe 3
gnp sinus & cold-d 3
gnp sinus + headache day/ 3
gnp sinus congestion & pa 3
gnp sinus congestion/pain 3
gnp sinus relief congesti 3
gnp sinus relief pressure 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
350
Drug Name Drug Tier Requirements/Limits
gnp sinus relief severe c 3
gnp sinus severe daytime 3
gnp sinus wash refill 3
gnp sleep aid 3
gnp sleep time 3
gnp slow release iron 3
gnp soothing bath treatme 3
gnp sore throat 3
gnp sore throat spray 3
gnp stay awake 3
gnp stomach relief 3
gnp stomach relief maximu 3
gnp stool softener CAPS 100mg, 250mg 3
gnp stool softener LIQD 3
gnp stool softener SYRP 3
gnp stool softener extra 3
gnp stool softener/stimul 3
gnp stress formula+iron 3
gnp suphedrin 3
gnp tab tussin 3
gnp tab tussin dm 3
gnp terbinafine hydrochlo 1% 3
gnp therapeutic blue gel 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
351
Drug Name Drug Tier Requirements/Limits
gnp therapeutic-m 3
gnp tioconazole 1 3
gnp tolnaftate 3
gnp triacting cold/allerg 3
gnp triacting day time co 3
gnp triacting night time 3
gnp triple antibiotic 3
gnp triple antibiotic plu 3
GNP TRUETRACK SMART SYSTE 3
gnp tussin 3
gnp tussin cf cough & col 3
gnp tussin cf max multi-s 3
gnp tussin cough long act 3
gnp tussin dm 3
gnp tussin dm cough 3
gnp tussin dm max 3
gnp tussin dm max cough & 3
gnp tussin mucus & chest 100mg/5ml 3
gnp tussin night time 3
gnp ultra lubricant eye d 3
GNP UNDERWEAR SUPER PLUS 3
gnp urinary pain relief 3
gnp vitamin a 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
352
Drug Name Drug Tier Requirements/Limits
gnp vitamin a & d 3
gnp vitamin b1 3
gnp vitamin b12 3
gnp vitamin b complex 3
gnp vitamin b-1 3
gnp vitamin b-6 3
gnp vitamin b-12 3
gnp vitamin b-12 prolonge 3
gnp vitamin b-12 tr 3
gnp vitamin c 3
gnp vitamin c drops 3
gnp vitamin c pr 3
gnp vitamin c tr 3
gnp vitamin c w/rose hips 3
gnp vitamin c/rose hips 3
gnp vitamin d 3
gnp vitamin d3 extra stre 3
gnp vitamin d maximum str 3
gnp vitamin d super stren 3
gnp vitamin d-400 3
gnp vitamin e 3
gnp vitamin e water dispe 3
gnp wart remover 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
353
Drug Name Drug Tier Requirements/Limits
gnp white petrolatum 3
gnp witch hazel 3
gnp womens gentle laxativ 3
gnp womens laxative 3
gnp womens menstrual reli 3
gnp womens one daily 3
gnp zinc 3
gnp zinc chelated 3
GNP ZINC LOZENGE W/VIT C 3
gnp zinc oxide 3
gnp zoochews gummies 3
GOLD BOND 3
GOLD BOND EXTRA STRENGTH 3
GOLD BOND MEDICATED BODY 3
GOLD BOND ULTIMATE LOTN 3
GOLD BOND ULTIMATE DEEP M 3
GOLD BOND ULTIMATE DIABET 3
GOLD BOND ULTIMATE HEALIN 3
GOLD BOND ULTIMATE OVERNI 3
GOLD BOND ULTIMATE PROTEC 3
GOLD BOND ULTIMATE RESTOR 3
GOLD BOND ULTIMATE SHEER 3
GOLD BOND ULTIMATE SOFTEN 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
354
Drug Name Drug Tier Requirements/Limits
GOLD BOND ULTIMATE SOOTHI 3
golden age vitamin/minera 3
GONAK 3
goniosoft 3
GONIOSOL 3
goniotaire 3
GONIOVISC 2% 3
goniovisc 2.5% 3
goodsense acid reducer 3
goodsense all day allergy SOLN 3
goodsense all day allergy TABS 10mg 3
goodsense aller-ease 180mg 3
goodsense allergy relief 3
goodsense antacid & pain 3
goodsense arthritis pain 650mg 3
goodsense artificial tear 3
goodsense aspirin CHEW 81mg 3
goodsense aspirin TABS 325mg 3
goodsense aspirin TBEC 3
goodsense aspirin adult l 3
goodsense aspirin low dos 3
goodsense best fiber 3
goodsense bisacodyl ec 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
355
Drug Name Drug Tier Requirements/Limits
GOODSENSE CAPSAICIN ARTHR 3
goodsense clearlax 3
goodsense cold & flu seve 3
goodsense cold & head con 3
goodsense cold multi-symp 3
goodsense cough dm 3
goodsense cough dm childr 3
goodsense day time cold & 3
goodsense daytime 3
goodsense daytime cold & 3
goodsense ear wax removal 3
goodsense epsom salt 3
goodsense esomeprazole ma 3
goodsense eye drops 3
goodsense fiber 3
goodsense flu & severe co 3
goodsense gas relief extr 3
GOODSENSE GLUCOSE 3
goodsense headache pm 3
goodsense headache relief 3
goodsense hemorrhoidal 3
goodsense hemorrhoidal oi 3
goodsense hydrogen peroxi 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
356
Drug Name Drug Tier Requirements/Limits
goodsense ibuprofen CAPS 3
goodsense ibuprofen TABS 200mg 3
goodsense ibuprofen child 100mg/5ml 3
goodsense ibuprofen infan 3
goodsense ibuprofen junio 3
goodsense ibuprofen pm 3
goodsense iron 3
goodsense itchy eye 3
GOODSENSE LANCING DEVICE 3
goodsense laxative pills 3
goodsense lubricant eye d 3
goodsense magnesium citra 3
goodsense menstrual relie 3
goodsense miconazole 1 3
goodsense migraine formul 3
goodsense mineral oil lub 3
goodsense mouthwash minty 3
goodsense mucus relief 3
goodsense mucus relief ch 3
goodsense mucus relief dm 3
goodsense mucus relief se 3
goodsense mucus-d 3
GOODSENSE MULTI-PURPOSE S 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
357
Drug Name Drug Tier Requirements/Limits
goodsense muscle rub 3
goodsense naproxen sodium 3
goodsense nasal allergy s 3
goodsense nasoflow 3
goodsense natural fiber 3
goodsense nicotine 3
goodsense nicotine polacr 4mg 3
goodsense nighttime cold 3
goodsense nighttime sinus 3
goodsense pain & fever ch 160mg/5ml 3
goodsense pain & fever in 160mg/5ml 3
goodsense pain relief TABS 3
goodsense pain relief TBCR 650mg 3
goodsense pain relief ext 500mg 3
goodsense pain relief pm 3
goodsense petroleum jelly 3
GOODSENSE PREMIUM BLOOD G 3
GOODSENSE PRENATAL VITAMI 3
goodsense pressure + pain 3
goodsense psyllium fiber 3
goodsense senna laxative 3
goodsense severe sinus co 3
goodsense sinus congestio 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
358
Drug Name Drug Tier Requirements/Limits
goodsense sinus relief ma 3
goodsense sinus severe fo 3
goodsense sleep aid 3
goodsense sleeptime 3
goodsense sore throat spr 3
goodsense stimulant laxat 3
goodsense stomach relief 3
goodsense tussin cf 3
GOODYS BODY PAIN 3
GOODYS EXTRA STRENGTH 3
GORDO-POOL 3
gordomatic LOTN 3
GORDONS-VITE A 3
gordons-vite e 3
gormel 10 3
gormel creme 3
GOWEY TINCTURE 3
GRAPE SYRUP 3
GREEN SOURCE 3
grx analgesic balm 3
GRX ASC LOTIONIZED ANTIMI 3
grx dyne 3
GRX HEMORRHOIDAL 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
359
Drug Name Drug Tier Requirements/Limits
GRX HYDROGEL GAUZE 2X2 3
GRX HYDROGEL GAUZE 4X4 3
grx vitamin e CREA 3
GRX VITAMIN E LOTN 3
GRX WHITE PETROLATUM 3
gtf chromium 3
guaiasorb dm 3
guaiatussin ac 3
guaicon dms 3
guaifenesin LIQD 100mg/5ml 3
guaifenesin SOLN 100mg/5ml, 200mg/10ml, 300mg/15ml
3
guaifenesin SYRP 3
guaifenesin TABS 3
guaifenesin TB12 600mg 3
guaifenesin ac 3
guaifenesin dac 3
guaifenesin la 3
guaifenesin-codeine 3
GUARDS FOR MEN 3
guiatuss 3
guiatuss dm 3
gummi bear multivitamin/m 3
GYNE-LOTRIMIN 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
360
Drug Name Drug Tier Requirements/Limits
GYNE-LOTRIMIN 3 3
gyne-moistrin 3
h2q CAPS 3
h-e-b aspirin 3
H-E-B INCONTROL ADVANCED 3
h-e-b oral electrolyte so 3
h-r lubricating jelly 3
h-r lubricating jelly 2-x 3
h-r lubricating jelly one 3
HAIR FARE 3
hair formula extra streng 3
HAIR NOURISHING SUPPLEMEN 3
HAIR SKIN & NAILS ADVANCE 3
hair skin and nails formu 3
hair vitamins 3
HAIR-VITES 3
hair/skin/nails CAPS 3
HAIR/SKIN/NAILS CAPS 3
hair/skin/nails TABS 3
hair/skin/nails/biotin 3
halls cough drops 9.1mg 3
halls cough drops sugar f 5.8mg 3
halls defense vitamin c d 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
361
Drug Name Drug Tier Requirements/Limits
halls-plus maximum streng 3
HAMMER TOE GEL CUSHION 3
HANKSCRAFT VAOPRIZER INHA 3
HARD NAILS 3
HARMONIE UNDERPAD 3
HARMONIE UNDERPAD EXTRA P 3
HARMONIE UNDERPAD REGULAR 3
HARMONIE UNDERPAD SECURE 3
HARMONIE UNDERPAD ULTRA 3
head congestion cold reli 3
headache formula 3
headache formula added st 3
headache pain-reliever 3
headache pm 3
headache pm formula 3
headache relief 3
headache relief pm 3
headache relief/extra str 3
headrin ex strength pain 3
HEAL AID PLUS 3
HEALTH CARE LANCING DEVIC 3
HEALTHWISE LANCING PEN 3
HEALTHY ACCENTS AUTOLET I 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
362
Drug Name Drug Tier Requirements/Limits
healthy eyes 3
healthy eyes/lutein 3
healthy hair skin & nails 3
healthy heart TABS 3
HEALTHY HEART COMPLEX 3
healthy kids cod liver oi 3
HEALTHY KIDS GUMMIES 3
healthy kids overall hea 3
HEALTHY KIDS VITAMIN C/RO 3
healthy kids vitamin d3 3
HEALTHY LIVING REPLACEMEN 3
healthy mama eazzze the p 3
healthy mama move it alon 3
healthy mama shake that a 3
healthy mama tame the fla 3
HEART 3
HEART SAVIOR 3
heartburn antacid extra s 3
heartburn relief 75mg, 200mg 3
heartburn relief 24 hour 3
heartburn relief 150 maxi 3
heartburn relief maximum 3
heartburn treatment 24 ho 15mg, 20mg 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
363
Drug Name Drug Tier Requirements/Limits
HEEL LINERS 3
hem-prep 3
HEMA-COMBISTIX 3
HEMATEX 3
hematron 3
HEMATRON DROPS 3
HEMATRON-AF 3
hemax 3
HEMOCYTE 3
hemorrhoid 3
hemorrhoidal CREA 3
hemorrhoidal OINT 3
HEMORRHOIDAL OINT 3
hemorrhoidal PADS 3
hemorrhoidal SUPP 3
hemorrhoidal cooling 3
hemorrhoidal cooling gel 3
hemorrhoidal hygiene pads 3
hemorrhoidal maximum stre 3
hemorrhoidal relief 3
hemorrhoidal suppositorie 3
HEPAMENT 3
HERBAL EXPEC 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
364
Drug Name Drug Tier Requirements/Limits
herbiomed allergy cold & 3
HERBIOMED DEEP COLD AND F 3
HERBIOMED FAST ACTING BOD 3
herbiomed severe cold & f 3
HEXASORB DISPOSABLE UNDER 3
hi c-500 3
hi-kovite 2-part formula 3
hi-potency multi-vitamin/ 3
HIBICLENS 3
HIGH CAPACITY PADS 3
HIGH CAPACITY PADS/TAILS 3
high potency calcium 3
HIGH POTENCY IRON CAPS 3
high potency iron TABS 3
HIGH POTENCY PROBIOTIC 3
hist-pse 3
histafed 3
HISTAFLEX 3
HISTEX 3
HISTEX PD 3
HISTEX PDX 3
HISTEX-AC 3
HISTEX-DM 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
365
Drug Name Drug Tier Requirements/Limits
HISTEX-PE 3
HM 4X PROBIOTIC 3
hm acetaminophen children 3
hm acetaminophen pm extra 3
hm acid reducer 75mg, 150mg 3
hm acid reducer maximum s 3
HM ACIDOPHILUS 3
hm acidophilus probiotic 3
hm advanced antacid maxim 3
hm all day allergy 10mg 3
hm all day allergy childr 3
hm allergy 25mg 3
hm allergy & congestion 3
hm allergy childrens 12.5mg/5ml 3
hm allergy complete child 3
hm allergy complete-d 3
hm allergy relief CAPS 25mg 3
hm allergy relief TABS 4mg, 10mg, 25mg 3
hm allergy relief TBDP 3
hm allergy relief & nasal 3
hm allergy relief childre 3
hm allergy relief nasal s 3
hm allgery multi symptom 25mg 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
366
Drug Name Drug Tier Requirements/Limits
hm animal shapes 3
hm antacid anti-gas extra 3
hm antacid/antigas 3
hm anti-diarrheal 2mg 3
hm anti-nausea 3
hm antioxidant vitamins 3
hm antiseptic skin cleans 3
hm arthiritis creme 3
hm arthritis pain relief 650mg 3
hm artificial tears 3
hm aspirin CHEW 81mg 3
hm aspirin TABS 325mg 3
hm aspirin ec 325mg 3
hm aspirin ec low dose 81mg 3
hm bacitracin 500unit/gm 3
hm biotin 3
HM CALAMINE 3
hm calcium 600 & vitamin 3
hm calcium 600 + d plus m 3
hm calcium 600 + vitamin 3
hm calcium antacid 500mg 3
hm calcium antacid extra 750mg 3
hm calcium antacid smooth 750mg 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
367
Drug Name Drug Tier Requirements/Limits
hm calcium antacid ultra 3
hm calcium citrate + vita 3
hm calcium citrate+d3 pet 3
hm calcium magnesium & zi 3
hm calcium/vitamin d 3
hm calcium/vitamin d/mine 3
hm cetirizine hcl childre 5mg/5ml 3
hm cetirizine hydrochlori 3
hm chest congestion relie 400mg 3
hm chest rub 3
hm clear fiber 3
hm clearlax 3
hm cold & allergy childre 3
hm cold & cough childrens 3
hm cold & sinus relief 3
hm cold flu & sore throat 3
hm complete 3
HM COMPLETE 3
hm complete 50+ 3
HM COMPLETE 50+ MENS ULTI 3
HM COMPLETE 50+ WOMENS UL 3
hm complete dual action 3
hm complete women 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
368
Drug Name Drug Tier Requirements/Limits
hm coq10 3
hm cough dm 3
hm cough relief 3
hm day time 3
hm day time liquid caps 3
hm daytime cold & flu 3
hm double antibiotic 3
hm dry eye relief 3
hm e vitamin 3
hm earwax removal aid 3
hm earwax removal kit 3
hm enema 3
hm enema mineral oil 3
hm enema ready-to-use 3
hm enema saline laxative 3
HM ENTRUST PLUS BLADDER C 3
HM ENTRUST PLUS DISPOSABL 3
HM ENTRUST PLUS UNDERPAD 3
hm epsom salt 3
hm esomeprazole magnesium 3
HM ESTROPLUS 3
hm eye drops 3
hm eye drops redness reli 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
369
Drug Name Drug Tier Requirements/Limits
hm eye itch relief 3
HM EYELID WIPES 3
hm famotidine 10mg, 20mg 3
hm fexofenadine hcl 60mg, 180mg 3
hm fexofenadine hydrochlo 60mg, 180mg 3
hm fiber CAPS 3
hm fiber POWD 28.3%, 30.9%, 48.57%, 51.7%, 58.6%
3
hm fiber TABS 500mg 3
HM FIBER POWDER 3
hm fish oil 3
hm folic acid 3
hm gas relief 3
hm gas relief extra stren 3
hm gas relief infants 3
hm gas relief infants dro 3
HM GLUCOSE 3
hm glycerin 3
HM HAIR/SKIN/NAILS 3
hm hemorrhoidal 3
hm hydrocortisone plus 3
hm hydrocortisone/aloe ma 3
hm hydrogen peroxide 3
hm ibuprofen CAPS 200mg 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
370
Drug Name Drug Tier Requirements/Limits
hm ibuprofen CHEW 3
hm ibuprofen TABS 200mg 3
hm ibuprofen childrens 100mg/5ml 3
hm ibuprofen ib 200mg 3
hm ibuprofen infants 3
hm ibuprofen pm 3
HM IODIDES TINCTURE 3
HM IODINE TINCTURE 3
hm iron 3
hm iron slow release 3
hm isopropyl alcohol 3
HM ISOPROPYL RUBBING ALCO 70% 3
hm isopropyl rubbing alco 91% 3
HM ISOPRPYL RUBBING ALCOH 3
hm lansoprazole 15mg 3
hm laxative SUPP 3
hm laxative TBEC 5mg 3
hm lice killing maximum s 3
hm lice treatment LIQD 1% 3
hm lice treatment LOTN 3
hm loperamide hcl 3
hm loratadine 10mg 3
hm loratadine childrens 5mg/5ml 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
371
Drug Name Drug Tier Requirements/Limits
hm lubricating plus .5% 3
hm lubricating tears 3
hm magnesium 3
hm magnesium citrate 3
hm medicated cooling pads 3
hm mens 50+ advanced one 3
HM MENS UNDERWEAR MAXIMUM 3
hm migraine formula 3
hm migraine relief 3
hm milk of magnesia 1200mg/15ml 3
hm mineral oil 3
hm motion relief 3
hm motion sickness 3
hm motion sickness relief 3
hm mucus er 600mg, 1200mg 3
hm mucus relief d 3
hm mucus relief dm maximu 3
hm mucus relief fm cold & 3
hm mucus relief fm cold/f 3
hm mucus relief fm severe 3
hm mucus relief multi-sym 3
hm multi-purpose solution 3
hm multivitamin adult gum 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
372
Drug Name Drug Tier Requirements/Limits
hm muscle rub 3
hm naproxen sodium 3
hm nasal decongestant 30mg 3
hm nasal decongestant 12 3
hm nasal decongestant pe 3
hm nasal spray 3
hm niacin 3
hm niacin tr 3
hm nicotine polacrilex GUM 2mg, 4mg 3
hm nicotine polacrilex LOZG 2mg, 4mg 3
hm nicotine transdermal s 7mg/24hr, 14mg/24hr, 21mg/24hr
3
hm night time cold & flu 3
hm night time multi sympt 3
hm night time multi-sympt 3
hm nighttime sleep aid 3
hm nose drops extra stren 3
HM OMEPRAZOLE 20mg 3
hm one daily essential 3
HM ONE DAILY ESSENTIAL 3
HM ONE DAILY MENS 3
HM ONE DAILY PRENATAL COM 3
HM ONE DAILY WOMENS 3
hm one daily/iron 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
373
Drug Name Drug Tier Requirements/Limits
hm pain & fever childrens 160mg/5ml 3
hm pain & fever infants 160mg/5ml 3
hm pain relief 3
hm pain relief childrens 3
hm pain relief extra stre 500mg 3
hm pain reliever 325mg 3
hm pain reliever pm extra 3
hm pediatric electrolyte 3
hm petroleum jelly 3
hm potassium 3
hm povidone-iodine 3
HM PRENATAL 3
hm probiotic digestive he 3
hm rapid melts junior 3
hm saline nasal spray 3
hm selenium 3
hm senna 8.6mg 3
hm senna-s 3
hm severe cold & flu 3
hm severe cold cough & fl 3
hm severe cold/cough/flu 3
hm severe congestion & co 3
hm sinus & cold-d 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
374
Drug Name Drug Tier Requirements/Limits
hm sinus nasal spray 3
hm sleep aid 3
hm slow release iron 3
hm sore throat spray 3
hm stay awake 3
hm stomach relief 3
hm stomach relief maximum 3
hm stool softener CAPS 100mg 3
hm stool softener TABS 100mg 3
hm stool softener maximum 3
hm stool softener/laxativ 3
hm stool softener/stimula 3
hm super vitamin b12 3
hm super vitamin b comple 3
hm triple antibiotic 3
hm triple antibiotic plus 3
hm trueplus fiber 3
hm tussin adult 100mg/5ml 3
hm tussin adult cough & c 3
hm tussin adult multi-sym 3
hm tussin cough/chest con 3
HM UNDERPADS 23" X 36" 3
hm vita-mini multi comple 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
375
Drug Name Drug Tier Requirements/Limits
hm vitamin b1 3
hm vitamin b6 3
hm vitamin b12 3
hm vitamin b12 tr 3
hm vitamin b12 ultra stre 3
hm vitamin b50 complex 3
hm vitamin b100 complex 3
hm vitamin b complex/vita 3
hm vitamin c 3
hm vitamin c tr 3
hm vitamin c/rose hips 3
hm vitamin d 3
hm vitamin d3 2000unit 3
HM VITAMIN D3 4000unit 3
hm vitamin e 3
hm witch hazel 3
hm womens 50+ advanced on 3
hm z-sleep 3
hm zinc 3
HOLD 3
HOMOCYSTEINE FORMULA 3
HONEY BEARS 3
HONEY BEARS W/IRON AND ZI 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
376
Drug Name Drug Tier Requirements/Limits
hot steam 3
12 hour allergy-d 3
12 hour antihistamine/dec 3
8 hour arthritis pain rel 3
12 hour decongestant 3
12 hour nasal decongestan 3
12 hour nasal relief spra 3
12 hour nasal spray 3
8 hour pain relief 3
8 hour pain reliever 3
hpa lanolin 3
24hr allergy relief 3
8hr muscle aches & pain 650mg 3
HUDSON RCI SEE-THRU AEROS 3
HUGGIES DIAPER RASH CREAM 3
humist 3
HW EMBRACE PRO BLOOD GLUC 3
HW EMBRACE TALK BLOOD GLU 3
hy-vee all day relief 3
HY-VEE GLUCOSE 3
HYALEX 3
HYCOFENIX 3
HYCOLOID-GRX 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
377
Drug Name Drug Tier Requirements/Limits
HYDRALYTE PACK; SOLN 3
HYDRALYTE FREEZER POPS 3
HYDRASYN25 3
HYDRAZONE LOTION 3
hydrisalic 3
hydro skin maximum streng 3
HYDRO-LAN 3
HYDROCERIN CREA 3
hydrocerin LOTN 3
hydrocerin moisturizing e 3
hydrocerin plus 3
HYDROCIL INSTANT 3
HYDROCODONE BITARTRATE/GU 3
hydrocodone polistirex-chlorpheniramine polistirex
3
hydrocodone w/ homatropine 3
hydrocol 6"x8" 3
HYDROCOL II 3
HYDROCOL II SACRAL 3
HYDROCOL II THIN 3
hydrocortisone 1% in abso 3
hydrocortisone (topical) CREA .5%, 1% 3
hydrocortisone (topical) LOTN 1% 3
hydrocortisone (topical) OINT .5%, 1% 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
378
Drug Name Drug Tier Requirements/Limits
hydrocortisone (topical) SOLN 3
hydrocortisone acetate (topical) 3
hydrocortisone in absorba 3
hydrocortisone intensive 3
hydrocortisone maximum st 1% 3
hydrocortisone plus 3
hydrocortisone-aloe vera 3
HYDROCREAM BASE WATER IN 3
HYDROFERA BLUE 4"X4" 3
HYDROFERA BLUE FOAM DRESS 3
HYDROFERA BLUE HEAVY DRAI 3
HYDROFERA BLUE READY FOAM 3
hydrogen peroxide 3% 3
HYDROGEN PEROXIDE 3% 3
hydrolatum 3
hydromet 3
hydrophor 3
hydroskin CREA 1% 3
hydroxocobalamin acetate 1000mcg/ml 3
hylavite 3
HYPAFIX/5 CM X 10M/2" X 1 3
HYPER-SAL 3
HYPERSAL 7% 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
379
Drug Name Drug Tier Requirements/Limits
hypotears OINT 3
HYPOTEARS SOLN 3
hysept 3
HYVEE ADVANCED ANTACID MA 3
hyvee ibuprofen childrens 3
i-prin 3
i-vite 3
i-vite protect 3
I.L.X. B-12 3
I.S.P. HAND & BODY 3
IB FULL MAT BRIEF LARGE 3
IB FULL MAT BRIEF MEDIUM 3
IBG STAR BLOOD GLUCOSE MO 3
ibu-200 200mg 3
ibu-drops 3
ibu-drops infants 3
ibu-profen cold/sinus 3
ibuprofen CAPS 200mg 3
ibuprofen SUSP 100mg/5ml 3
ibuprofen TABS 200mg 3
ibuprofen 100 junior stre 3
ibuprofen childrens 100mg/5ml 3
ibuprofen cold & sinus 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
380
Drug Name Drug Tier Requirements/Limits
ibuprofen infants 3
ibuprofen junior strength 3
ibuprofen pm TABS 3
ibuprofen tab 200 mg 3
ibuprofen/pseudoephedrine 3
icaps 3
icaps areds 2 CAPS 3
ICAPS AREDS 2 CHEW 3
ICAPS AREDS FORMULA 3
icaps lutein & omega-3 3
ICAPS LUTEIN & ZEAXANTHIN 3
ICAPS LUTEIN/ZEAXANTHIN 3
ICAPS LUTEIN/ZEAXANTHIN F 3
icaps mv 3
ICAPS PLUS 3
ICAPS TAB 3
ICAR 3
ICAR PEDIATRIC 3
ICAR-C 3
icar-c plus 3
ice blue gel 3
ICHTHAMMOL 3
icy hot balm extra streng 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
381
Drug Name Drug Tier Requirements/Limits
icy hot extra strength CREA 3
ICY HOT NO-MESS VAPOR GEL 3
iferex 150 150mg 3
IGLUCOSE BLOOD GLUCOSE MO 3
IGLUCOSE BLOOD GLUCOSE TE 3
ILEX SKIN PROTECTANT 3
IMMUNE SUPPORT 3
IMMUNE SUPPORT VITAMIN C 3
immunicare 3
IMODIUM A-D 3
IMODIUM ADVANCED 3
IMODIUM MULTI-SYMPTOM REL 3
IN TOUCH 3
IN TOUCH BLOOD GLUCOSE TE 3
IN TOUCH LANCING DEVICE 3
INCONTINENCE BRIEF/LARGE 3
INCONTINENCE BRIEF/MEDIUM 3
INFANTS ADVIL 3
infants gas relief 3
infants ibuprofen 3
infants medi-tabs 3
infants pain & fever 3
infants pain relief 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
382
Drug Name Drug Tier Requirements/Limits
infants pain reliever 3
INFANTS SILAPAP 3
infants simethicone 3
INFED 50mg/ml 3
INFINITY BLOOD GLUCOSE MO 3
INFINITY BLOOD GLUCOSE TE 3
INFINITY VOICE 3
INFUVITE ADULT 3
INFUVITE PEDIATRIC 3
INJECTAFER 3
INNOSPIRE REPLACEMENT FIL 3
INSTA-GLUCOSE 3
INSTACLEAN 3
instacort 5 3
INSTACORT 10 3
instant pain relief 3
INTEGRA 3
intense cold/flu medicine 3
intense cough reliever 3
intense cough reliever do 3
intense cough reliever ex 3
intestinex 3
INTRINSI B12/FOLATE 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
383
Drug Name Drug Tier Requirements/Limits
INULOSE BLOOD SUGAR SUPPO 3
invisible acne maximum st 3
invisible acne treatment 3
IODEX 3
IODIDES TINCTURE 3
IODINE TINC 3
iodine (kelp) 3
IODINE TINCTURE 3
IODINE TINCTURE MILD 3
IODINE TINCTURE STRONG 3
IODINE TINCTURE STRONG DE 3
IONIL LIQD 3
ionil-t 3
iophen c-nr 3
iophen dm-nr 3
iophen-nr 3
IOSAT 3
ipecac 3
IPECAC 3
IRO-PLEX 3
IROFOL 3
iromin-g 3
IRON 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
384
Drug Name Drug Tier Requirements/Limits
IRON 21/7 3
iron 27 3
iron 100 plus 3
iron 100/c 3
IRON CHEWS PEDIATRIC 3
iron complex 3
IRON FORMULA 3
iron slow release 45mg, 143mg 3
iron supplement 3
iron supplement childrens 3
IRON UP 3
iron w/ vitamins 3
ISOLEUCINE 3
ISOLEUCINE 1000 3
isopropyl alcohol 70%, 91% 3
ISOPROPYL ALCOHOL 70%, 91% 3
isopropyl alcohol, rubbing 3
ISOPTO TEARS 3
ITCH RELIEF 3
itch relief extra strengt 3
ITCH-ENDER! 3
ITCH-X GEL 3
J & J BURN CREAM 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
385
Drug Name Drug Tier Requirements/Limits
J & J FIRST AID CREAM 3
J & J GERM FILTER MASK 3
J&J CREAM PROTECTANT 3
J-MAX 3
J-TAN D PD 3
J-TAN PD 3
JESSNERS 3
JOBST IT STAYS/ROLL-ON 3
jock itch 3
jock itch relief 3
jock itch spray 3
jock itch spray powder 3
JOHNSONS BABY CREA 3
JOHNSONS BABY INTENSE MOI 3
JOHNSONS BODY CARE 24 HOU 3
JOHNSONS BODY CARE BE RAD 3
JOHNSONS BODY CARE DEEP H 3
JOHNSONS BODY CARE FOREVE 3
JOHNSONS BODY CARE MELT A 3
johnsons diaper rash 3
JOHNSONS HEAD-TO-TOE EXTR 3
johnsons no more rash 3
jr strength non-aspirin 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
386
Drug Name Drug Tier Requirements/Limits
junior mapap 3
just d 3
just for kids 3
just tears eye drops 3
K2 PLUS D3 3
k 100 3
K-PAX IMMUNE SUPPORT FORM 3
k-pec 3
k-y intrigue 3
k-y intrigue heat 3
k-y jelly 3
k-y lubricant jelly sensi 3
k-y lubricating jelly 3
k-y tingling jelly 3
k-y ultragel 3
k-y warming jelly 3
k-y yours+mine couples 3
KALA 3
KALTOSTAT 3
KALTOSTAT FORTEX 3
KALTOSTAT WOUND DRESSING 3
kaminos 3
kao-tin CAPS 240mg 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
387
Drug Name Drug Tier Requirements/Limits
kao-tin SUSP 3
KAOLIN 3
KAOLIN COLLOIDAL 3
KAOLIN/PECTIN 3
kaopectate 3
kaopectate extra strength 3
kaopectate stool softener 240mg 3
KAOPECTATE STOOL SOFTENER 240mg 3
KAZ BACTERIOSTATIC TREATM 3
KAZ INHALANT 3
KAZ WATER TREATMENT 3
keep alert 3
KELARX 3
kelo-cote GEL 3
KENDALL ALGINATE HYDROCOL 3
KENDALL WASHCLOTHS 3
KENDALL WASHCLOTHS/NOVONE 3
KENDALL ZINC CALCIUM ALGI PADS 3
KERADAN 3
KERALYT 3% 3
KERAMATRIX REPLICINE 5CMX PADS 3
KERAMATRIX REPLICINE 10CM PADS 3
KERASAL FUNGAL NAIL RENEW 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
388
Drug Name Drug Tier Requirements/Limits
KERI ADVANCED MOISTURE TH 3
KERI BASIC ESSENTIALS 3
KERI LONG LASTING 3
KERI NOURISHING SHEA BUTT 3
KERI ORIGINAL 3
KERI OVERNIGHT 3
KERI RENEWAL MILK BODY 3
KERI RENEWAL SKIN FIRMING 3
KERI RENEWAL STRETCH MARK 3
KERI SENSITIVE SKIN 3
kericort 10 3
KERLIX SUPER SPONGE SALIN 3
kerodex-51 dry/oily 3
kerodex-71 wet 3
kerr insta-char 3
KETO-DIASTIX 3
KETOCARE 3
KETONE TEST STRIPS 3
KETOSTIX 3
ketotifen fumarate (ophth) 3
KEY-E CHEW 3
KIDNEY TABS 3
kids first vitamin d3 gum 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
389
Drug Name Drug Tier Requirements/Limits
kids gummy bear vitamins 3
kids vitamins 3
kids vitamins complete 3
kids vitamins plus extra 3
kids vitamins plus iron 3
KINERASE 3
kita la tos-dm 3
KLOUT 3
kls acetaminophen extra s 3
kls acid controller compl 3
kls acid controller maxim 3
kls acid reducer 3
kls acid reducer maximum 3
kls aller-fex 3
kls aller-flo 3
kls aller-tec 3
kls aller-tec childrens 3
kls aller-tec d 3
kls allerclear 3
kls allerclear d-12 hr 3
kls allerclear d-12hr 3
kls allerclear d-24hr 3
kls allerclear-d 24hr 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
390
Drug Name Drug Tier Requirements/Limits
kls allergy medicine 3
kls antacid 3
kls anti-diarrheal 3
kls arthritis pain 3
kls aspirin ec 3
kls aspirin low dose 3
kls cold & flu multi-symp 3
kls esomeprazole magnesiu 3
kls fiber-tabs 3
kls hydrocortisone plus 3
kls ibuprofen 3
kls ibuprofen ib 3
kls infants pain relief 3
kls lansoprazole 3
kls laxaclear 3
kls mucus relief chest 3
kls multi-symptom cold ch 3
kls naproxen sodium 3
kls nasal decongestant sp 3
kls natural psyllium fibe 3
kls nighttime cold multi- 3
kls non aspirin 3
kls non-aspirin pm 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
391
Drug Name Drug Tier Requirements/Limits
KLS OMEPRAZOLE 3
kls pain & fever infants 3
kls pain relief childrens 3
kls quit2 3
kls quit4 3
kls rapid release pain re 3
kls sleep aid 3
kls stool softener 3
kls suphedrine pe 3
kobee 3
KOKO PEAK PRO REPLACEMENT 3
konsyl CAPS 3
KONSYL PACK 3
konsyl POWD 30.9% 3
KONSYL POWD 60.3%, 71.67%, 100% 3
KONSYL DAILY FIBER PACK 28.3%, 100% 3
konsyl daily fiber POWD 28.3% 3
KONSYL DAILY FIBER POWD 60.3%, 100%
3
KONSYL ORIGINAL FORMULA D 3
KONSYL-D PACK 3
KONSYL-D POWD 52.3% 3
kosher care 3
KOSHER CARE ALLERGY RELIE 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
392
Drug Name Drug Tier Requirements/Limits
kosher care dm 3
KOTEX CURVED MAXI 3
KOTEX LIGHTDAYS EXTRA COV 3
KOTEX LIGHTDAYS PANTILINE 3
KOTEX MAXI 3
KOTEX MAXI LIGHTDAYS PANT 3
KOTEX MAXI OVERNITE 3
KOTEX MAXI OVERNITE WITH 3
KOTEX MAXI PADS 3
KOTEX MAXI WITH WINGS 3
KOTEX OVERNITE PAD 3
KOTEX SUPER MAXI/LONG 3
KOTEX SUPER MAXI/LONG WIT 3
KOTEX THIN MAXI 3
KOTEX ULTRA COMPACT MAXI 3
KOTEX ULTRA MAXI OVERNIGH 3
KOTEX ULTRA THIN LONG MAX 3
KOTEX ULTRA THIN MAXI 3
KOTEX ULTRA THIN MAXI WIT 3
KOTEX ULTRA THIN MAXI/LON 3
kp adults 50+ daily formu 3
kp adults daily formula 3
kp aspirin 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
393
Drug Name Drug Tier Requirements/Limits
kp b complex/c 3
kp bacitracin zinc 3
kp benzoyl peroxide 3
kp benzoyl peroxide wash 3
kp bisacodyl 3
kp calcium 600+d 3
kp calcium 600+d3 3
kp calcium citrate+d 3
kp calcium/magnesium/zinc 3
kp cetirizine hcl 3
kp clotrimazole 3
kp diphenhydramine hcl 3
kp double antibiotic 3
kp ferrous gluconate 3
kp ferrous sulfate 3
kp fexofenadine hcl 3
kp fish oil 3
kp fluticasone propionate 3
kp folic acid 3
KP GENTLE SKIN CLEANSER 3
kp glucosamine chondroiti 3
kp hydrocortisone 3
kp hydrocortisone maximum 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
394
Drug Name Drug Tier Requirements/Limits
kp hydrocortisone/aloe 3
kp ketotifen fumarate 3
kp loratadine 3
kp mag-oxide magnesium 3
kp melatonin 3
kp mens 50+ daily formula 3
kp mens daily formula 3
KP MENS DAILY PACK 3
kp miconazole nitrate 3
kp niacin 3
kp omega-3 fish oil 3
kp omeprazole magnesium 3
KP PRENATAL MULTIVITAMINS 3
kp pseudoephedrine hcl 3
kp senna 3
kp terbinafine hydrochlor 3
kp tolnaftate 3
kp vision formula 3
kp vision formula w/lutei 3
kp vitamin b-6 3
kp vitamin b-12 3
kp vitamin d 3
kp vitamin d3 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
395
Drug Name Drug Tier Requirements/Limits
kp vitamin e 3
kp womens 50+ daily formu 3
kp womens daily formula 3
KP WOMENS DAILY PACK 3
KPN PRENATAL 3
KROGER BLOOD GLUCOSE MONI 3
KROGER BLOOD GLUCOSE TEST 3
KROGER GLUCOSE CHEW 3
kroger glucose GEL 3
KROGER LANCING DEVICE 3
KROGER PREMIUM BLOOD GLUC 3
KROGER TEST STRIPS 3
ks ibuprofen 3
ks stool softener 3
L-ARGININE POWD 3
l-arginine double strengt 3
l-arginine maximum streng 3
l-arginine-500 3
L-CARNITINE LIQD 3
L-CARNITINE TABS 250mg 3
L-CARNITINE FUMARATE 3
L-CITRULLINE CAPS 3
L-ISOLEUCINE 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
396
Drug Name Drug Tier Requirements/Limits
L-LEUCINE 3
L-THREONINE TABS 3
L-TRYPTOPHAN CAPS; TABS 3
L-TYROSINE POWD 3
L-VALINE POWD 3
LABSTIX 3
LABSTIX TES 3
LAC-HYDRIN 3
lac-hydrin five 3
LAC-HYDRIN TWELVE 3
lactic acid (ammonium lactate) 3
LACTICARE 3
lactinex CHEW 3
LACTINEX PACK 3
LACTINOL HX 3
lacto-key-100 3
lacto-key-600 3
LACTO-PECTIN 3
lactobacillus 3
lactobacillus acidophilus-pectin 3
lactobacillus extra stren 3
LACTOSE MONOHYDRATE 3
LADY DIGNITY PLUS PANTIES 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
397
Drug Name Drug Tier Requirements/Limits
LADY DIGNITY WOMENS PANTY 3
LADY ESTHER 4 PURPOSE FAC 3
LAMBS WOOL 3
LAMISIL ADVANCED 3
lamisil af defense AERP 1% 3
lamisil af defense POWD 3
LAMISIL AT 3
LAMISIL AT ATHLETES FOOT 3
LAMISIL AT JOCK ITCH 3
LAMISIL AT SPRAY 3
lan-o-soothe 3
lanabiotic 3
LANAPHILIC 3
LANAPHILIC/UREA 3
LANCET DEVICE ADJUSTABLE 3
LANCET DEVICE WITH EJECTO 3
LANCING DEVICE 3
LANCING DEVICE ADJUSTABLE 3
LAND BEFORE TIME BRIEF/JU 3
land before time multivit 3
lanolin OINT 3
LANOLOR 3
lansinoh for breastfeedin 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
398
Drug Name Drug Tier Requirements/Limits
lansoprazole CPDR 15mg 3
LANTISEPTIC SKIN PROTECTA 3
LANTISEPTIC THERAPEUTIC 3
LANZO 3
larynex 3
laxa basic 3
laxacin 3
laxative SUPP 10mg 3
laxative TBEC 3
laxative feminine 3
laxative pills maximum st 25mg 3
laxative pills regular st 3
laxative with senna 3
lc-4 lidocaine 3
lc-5 lidocaine 3
LDR BLOOD GLUCOSE TRUETES 3
LEADER ADVANCED LANCING D 3
LEADER FINGER CREAM 3
LEADER GLUCOSE 3
LEADER QUICK DISSOLVE GLU 3
LECITHIN GRAN 3
lee saline nasal spray 3
LEG-GESIC 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
399
Drug Name Drug Tier Requirements/Limits
LEUCINE PACK 3
LEVITRA 3 QL (6 tabs / 25 days)
levocarnitine CAPS 3
lexinal 3
LIBERTY BLOOD GLUCOSE MET 3
LIBERTY BLOOD GLUCOSE MON 3
LIBERTY MINI LANCING DEVI 3
LIBERTY NEXT GENERATION B 3
LIBERTY TEST STRIPS 3
lice egg remover 3
lice killing maximum stre LIQD 3
lice killing maximum stre SHAM 3
lice killing shampoo 3
lice md 3
lice solution complete 3
lice solution kit 3
lice treatment 3
lice treatment creme rins 3
lice treatment maximum st 3
LICEMD 3
liceout 3
liceout combo pak/comb 3
licide 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
400
Drug Name Drug Tier Requirements/Limits
licide complete lice trea 3
licide maximum strength 3
LICIDE TREATMENT KIT 3
lidocaine CREA 4% 3
lidocaine (anorectal) 3
lidocaine-transparent dressing 3
lidocream 3
LIFE PACK MENS 3
LIFE PACK WOMENS 3
LIGHT SHIELD 3
LIGHT SHIELD DELUXE SLEEP 3
LIGHTDAYS LONG PANTYLINER 3
lip balm 3
LIP BALM BASE 3
lip balm/vitamin e/aloe OINT 3
LIP MEDEX 3
lip treatment 3
lip-guard 3
LIPIDSHIELD PLUS 3
lipmagik 3
lipo-flavonoid plus 3
lipo-key 3
lipocomplex 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
401
Drug Name Drug Tier Requirements/Limits
lipoflavonoid 3
lipoflavovit 3
lipogen sg 3
LIPOIC ACID CAPS 3
LIPOTRIAD 3
LIPOTRIAD VISION SUPPORT 3
LIPOTRIAD VISIONARY 3
LIQ-10 3
LIQSORB 3
liqua-gel 3
LIQUACEL 3
LIQUACEL PROTEIN FREEZE P 3
LIQUACEL PUMP + GO 3
liqui-e 3
liquibid 3
liquibid d-r 3
LIQUIBID PD-R 3
liquid bandage 3
LIQUID C 3
LIQUID C 500 3
LIQUID CALCIUM WITH D3 MA 3
liquid calcium/d3 3
LIQUID CALCIUM/MAGNESIUM 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
402
Drug Name Drug Tier Requirements/Limits
liquid calcium/vitamin d 3
LIQUID CALCIUM/VITAMINS A 3
liquid corn & callus remo 3
liquid pain relief 3
liquitears 1.4% 3
liquituss gg 3
LISTERINE 3
LISTERINE ANTISEPTIC 3
LISTERINE NATURALS ANTISE 3
LISTERINE POCKETMIST 3
LISTERINE ULTRACLEAN/EVER 3
LISTERINE ZERO 3
LITE TOUCH LANCING DEVICE 3
LITE TOUCH LANCING PEN 3
LITETOUCH MASK LARGE 3
LITETOUCH MASK MEDIUM 3
LITETOUCH MASK SMALL 3
little animals 3
little animals plus iron 3
little animals/iron 3
LITTLE COLDS COUGH FORMUL 3
LITTLE NOSES DECONGESTANT 3
LITTLE NOSES MOISTURIZING 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
403
Drug Name Drug Tier Requirements/Limits
little noses saline 3
little noses stuffy nose 3
little remedies fever/pai 3
LITTLE REMEDIES FOR COLDS LIQD 3
little remedies for fever 3
little remedies for tummy SUSP 3
little teethers oral pain GEL 3
little tummys gas relief 3
little tummys nausea reli 3
little tummys yummy fiber 3
LIVE BETTER ADVANCED LANC 3
LIVER 3
LIVER EXTRACT 3
LMX 4 3
LMX 4 PLUS 3
LMX 5 3
lobana bath oil 3
LOBANA BODY LOTION 3
LOBANA PERI-GARDE 3
LOBOB SOFT LENS CLEANER 3
LOCALNESIUM 3
LOCALNESIUM-C 3
LODRANE D 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
404
Drug Name Drug Tier Requirements/Limits
LOHIST-D 3
LOHIST-DM 3
lohist-peb 3
lohist-peb-dm 3
long acting nasal spray 3
long lasting antacid 3
long lasting nasal spray 3
LONGEVITY 3
LONGEVITY PLUS 3
LONGS GLUCOSE 3
loperamide a-d 3
loperamide hcl CAPS 2mg 3
loperamide hcl LIQD 1mg/5ml 3
loperamide hcl SUSP 3
loperamide hcl TABS 3
loradamed 3
loratadine CAPS 10mg 3
loratadine CHEW 3
loratadine SOLN 3
loratadine SYRP 3
loratadine TABS 10mg 3
loratadine & pseudoephedrine 3
loratadine allergy relief 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
405
Drug Name Drug Tier Requirements/Limits
loratadine childrens CHEW 3
loratadine childrens SOLN 5mg/5ml 3
loratadine childrens SYRP 5mg/5ml 3
loratadine hives relief 3
loratadine-d 12hr 3
loratadine-d 24hr 3
LORTUSS DM 3
LORTUSS EX 3
LORTUSS LQ 3
LOTRIMIN AF AERO; CREA 3
lotrimin af POWD 3
lotrimin af deodorant pow 3
LOTRIMIN AF FOR HER 3
LOTRIMIN AF JOCK ITCH 3
lotrimin af jock itch pow 3
lotrimin af powder 3
LOTRIMIN ULTRA 3
LOW DOSE ASA TAB 81MG 3
lubricant drops 3
lubricant eye 3
lubricant eye drops .5%, .6% 3
lubricant eye drops dry e 3
lubricant eye drops/dual- 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
406
Drug Name Drug Tier Requirements/Limits
lubricant eye fast acting 3
lubricant eye nighttime 3
lubricants 3
lubricating eye drops 3
lubricating jelly 3
lubricating plus eye drop 3
lubricating skin lotion 3
lubricating& rewetting dr 3
LUBRICATING/REWETTING DRO 3
LUBRIDERM 3
LUBRIDERM ADVANCED THERAP 3
LUBRIDERM DAILY MOISTURE 3
LUBRIDERM DAILY MOISTURE/ 3
LUBRIDERM INTENSE SKIN RE 3
LUBRIDERM MENS 3-IN-1 3
LUBRIDERM SERIOUSLY SENSI 3
LUBRIDERM SKIN NOURISHING 3
LUBRIDERM SOOTHING RELIEF 3
LUBRIDERM SPORT/MENS 3
lubrifresh p.m. 3
lubrisilk 3
lubriskin 3
LUBRISOFT 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
407
Drug Name Drug Tier Requirements/Limits
LUMITENE 3
LUNG 3
LUNG PERFORMANCE PEAK FLO 3
LUSAIR 3
LYCELLE 3
lycopene 10mg 3
LYMPH 3
lysine 3
LYSINE4000 3
lysiplex plus 3
m2 b125 3
M2 B-60 3
M2 CALCIUM 3
M2 CHROMIUM 3
m2 magnesium 3
M2 POTASSIUM 3
m2 zinc-50 3
M-CLEAR WC 3
m-end dm 3
M-END DMX 3
M-END MAX D 3
M-END PE 3
m-end wc 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
408
Drug Name Drug Tier Requirements/Limits
m-hist dm 3
m-hist pd 3
M.V.I. ADULT 3
M.V.I.-12 WITHOUT VITAMIN 3
MAALOX 3
maalox advanced 3
MAALOX ADVANCED MAXIMUM S CHEW 3
maalox advanced maximum s SUSP 3
maalox childrens 3
MAALOX MAX CHEW 3
maalox max SUSP 3
maalox multi symptom maxi 3
MAALOX QUICK DISSOLVE MAX 3
MAALOX QUICK DISSOLVE REG 3
maalox regular strength 3
MAALOX TC 3
macular health formula 3
MACULAR VITAMIN BENEFIT 3
macuvite 3
macuvite eye care 3
macuvite/lutein 3
MAG GLYCINATE 3
MAG-200 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
409
Drug Name Drug Tier Requirements/Limits
MAG-AL 3
mag-al plus xs 3
mag-caps 3
mag-g 3
mag-sr 3
MAG-SR PLUS CALCIUM 3
MAG-TAB SR 3
magbee 3
MAGDELAY 3
MAGINEX 3
magnacaps 3
MAGNEBIND 200 3
MAGNESIUM CAPS 3
MAGNESIUM TABS 30mg, 200mg 3
magnesium TABS 100mg, 200mg, 250mg, 400mg
3
magnesium aspartate-potassium aspartate 3
MAGNESIUM CARBONATE HEAVY 3
MAGNESIUM CARBONATE LIGHT 3
MAGNESIUM CARBONATE POWDE 3
MAGNESIUM CHLORIDE POWD 3
magnesium chloride TBCR 3
MAGNESIUM CHLORIDE/CALCIU 3
MAGNESIUM CITRATE CAPS 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
410
Drug Name Drug Tier Requirements/Limits
magnesium citrate SOLN 1.745gm/30ml 3
MAGNESIUM CITRATE TABS 100mg 3
magnesium dr 3
MAGNESIUM ELEMENTAL 3
magnesium gluconate TABS 27.5mg, 500mg, 550mg
3
MAGNESIUM GLUCONATE TABS 250mg, 500mg, 550mg
3
magnesium hydroxide SUSP 3
magnesium lactate 3
MAGNESIUM OXIDE CAPS 3
magnesium oxide TABS 250mg, 400mg,
420mg
3
magnesium oxide (mg supplement) CAPS 3
magnesium oxide (mg supplement) TABS 241.3mg, 250mg, 400mg, 500mg
3
MAGNESIUM OXIDE HEAVY 3
MAGNESIUM OXIDE LIGHT 3
MAGNESIUM SULFATE CAPS 3
MAGNESIUM SULFATE POWD 3
magnesium sulfate (laxative) 3
MAGNESIUM SULFATE HEPTAHY 3
magnesium-oxide 3
magnum-75 3
MAGONATE LIQD 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
411
Drug Name Drug Tier Requirements/Limits
magonate TABS 3
MAGOX 400 3
major-prep hemorrhoidal 3
maldroxal 3
MAMMARY 3
manganese chloride 3
MANHOOD ABSORBENT POUCH 3
MAOX 3
mapap CAPS 500mg 3
mapap CHEW 80mg 3
mapap LIQD 160mg/5ml 3
mapap TABS 325mg, 500mg 3
mapap acetaminophen extra 3
mapap arthritis pain 650mg 3
mapap childrens CHEW 3
mapap childrens SUSP 160mg/5ml 3
mapap cold formula multi- 3
mapap pm 3
mapap sinus maximum stren 3
mapo bath oil 3
MAR-COF BP 3
MAR-COF CG EXPECTORANT 3
mar-zinc 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
412
Drug Name Drug Tier Requirements/Limits
MASK PEDIATRIC SIZE 1" 3
MASK PEDIATRIC SIZE 3" 3
MASK VORTEX/BABY WHIRL DU 3
MASK VORTEX/CHILD/FROG 3
MASK VORTEX/SPINNER THE D 3
MASK VORTEX/TODDLER/LADY 3
masophen 3
max strength complete 3
MAXAM 3
maxapap maximum strength 3
maxapap regular strength 3
MAXFE LIQD 3
MAXFE DROPS 3
MAXI DEET 3
maxi life glucosamine/cho 3
MAXI PAD DEODORANT 3
MAXI PAD LONG ULTRA THIN 3
MAXI PAD OVERNIGHT 3
MAXI PAD OVERNIGHT THIN 3
MAXI PAD REGULAR 3
MAXI PAD SUPER 3
MAXI PAD SUPER LONG 3
MAXI PAD ULTRA THIN 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
413
Drug Name Drug Tier Requirements/Limits
MAXI PAD ULTRA THIN OVERN 3
MAXI WITH FLEXI-WINGS/LON 3
MAXI WITH FLEXI-WINGS/OVE 3
MAXI-MASK 3
MAXI-TUSS CD 3
MAXI-TUSS DM 3
MAXICARE BELTED UNDERGARM 3
MAXICHLOR PEH DM 3
MAXIFED 3
MAXIFED DM 3
MAXILIFE RICE TOCOTRIENOL 3
maxilube 3
MAXIMA BLOOD GLUCOSE MONI 3
MAXIMA BLOOD GLUCOSE TEST 3
MAXIMA METER KIT 3
MAXIMA STARTER KIT 3
MAXIMIN PACK 3
maximum blue label 3
maximum d3 3
maximum daily green 3
maximum green label 3
maximum red label 3
MAXIPHEN DM 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
414
Drug Name Drug Tier Requirements/Limits
MAXORB EXTRA AG+ 3
MCT OIL 3
ME-500 3
mecholyl 3
meclizine hcl CHEW 3
meclizine hcl TABS 12.5mg, 25mg 3
med-derm hydrocortisone 3
MEDELA TENDER CARE LANOLI 3
MEDERMA 3
MEDERMA AG BODY CLEANSER 3
MEDERMA AG FACE CREAM 3
MEDERMA AG FACIAL CLEANSE 3
MEDERMA AG FACIAL TONER 3
MEDERMA AG HAND & BODY LO 3
MEDERMA FOR KIDS 3
mederma pm 3
MEDERMA SPF 30 3
MEDERMA STRETCH MARKS THE 3
medi-bismuth 3
medi-brom 3
medi-first anti-fungal 3
medi-first triple antibio 3
medi-gen 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
415
Drug Name Drug Tier Requirements/Limits
medi-gesic 3
MEDI-GRAINE 3
medi-lax 3
medi-lice combing 3
medi-lice shampoo 3
MEDI-LYTE 3
medi-meclizine 3
medi-milk of magnesia 3
medi-mucil 3
medi-natural 3
medi-natural plus 3
MEDI-PAK PERFORMANCE PLUS 3
medi-phedrine 3
medi-phedryl 3
medi-profen 3
medi-profen cold/sinus 3
medi-seltzer 3
medi-sleep 3
medi-soothe 3
medi-tabs 3
medi-tabs childrens 3
MEDI-TABS EXTRA STRENGTH 3
medi-tabs extra strength 500mg 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
416
Drug Name Drug Tier Requirements/Limits
medi-tabs junor strength 3
medi-tabs pm extra streng 3
medi-tussin 3
MEDI-TUSSIN COUGH/COLD 3
medi-tussin dm 3
medi-tussin dm diabetic 3
medi-tussin dm double str 3
medi-tussin max strength 3
medi-tussin pe 3
medi-tussin severe conges 3
medicated anti-fungal 3
medicated body 3
medicated body lotion 3
medicated calamine 3
medicated callus removers 3
medicated chest rub 3
MEDICATED CHEST RUB 3
medicated cleansing pads 3
medicated corn removers 3
medicated douche 3
medicated feminine douche 3
medicated first aid spray 3
medicated rash 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
417
Drug Name Drug Tier Requirements/Limits
medicated wart removers 3
medicated wipes 3
medicated wipes pre-moist 3
medicidin-d 3
MEDICINE SHOPPE FINGER 3
MEDICINE SHOPPE GLUCOSE 3
medicone 3
MEDIHONEY CALCIUM ALGINAT 3
MEDIHONEY WOUND & BURN DR 3
MEDIHONEY WOUND/BURN DRES PADS 3
medikoff drops 5.8mg 3
mediplast PADS 3
mediplex plus 3
mediproxen 3
mediwash eye irrigant 3
medtycholl b complex 3
MEGA BIOTIN 3
mega coq10 3
mega coq-10 3
MEGA MULTI FOR MEN 3
MEGA MULTI FOR WOMEN 3
MEGA MULTI MEN 3
MEGA MULTI WOMEN 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
418
Drug Name Drug Tier Requirements/Limits
mega multiple w/chelated 3
MEGA MULTIVITAMIN 3
MEGA MULTIVITAMIN FOR MEN 3
MEGA MULTIVITAMIN FOR WOM 3
MEGA PROBIOTIC 3
mega stress 600/60 3
mega vm-80 3
MEGA ZINC-100 3
mega-chol 3
mega-marathon 100 tr 3
MEGACE ES 3
MEGAVITE FRUITS & VEGGIES 3
MEGAVITE GOLDEN YEARS 55+ 3
megestrol acetate (appetite) 3
meijer advanced formula 3
meijer advanced formula f 3
meijer allergy relief 3
meijer allergy relief-d 3
meijer allergy/congestion 3
meijer antacid anti-gas 3
meijer antacid maximum st 3
meijer anti-diarrheal 3
meijer antihistamine alle 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
419
Drug Name Drug Tier Requirements/Limits
meijer aspirin ec 3
meijer aspirin free 3
MEIJER BLOOD GLUCOSE MONI 3
MEIJER BLOOD GLUCOSE TEST 3
meijer c 3
MEIJER CALAMINE 3
meijer cough syrup dm 3
MEIJER ESSENTIAL BLOOD GL 3
meijer ferrous sulfate 3
MEIJER GLUCOSE 3
meijer hydrocortisone 3
meijer hydrogen peroxide 3
meijer ibuprofen 3
meijer jr strength aspiri 3
meijer loratadine 3
meijer migraine formula 3
meijer nasal decongestant 3
MEIJER PREMIUM BLOOD GLUC 3
meijer saline nasal spray 3
meijer triple antibiotic 3
MEIJER TRUE2GO BLOOD GLUC 3
MEIJER TRUERESULT BLOOD G 3
MEIJER TRUETEST BLOOD GLU 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
420
Drug Name Drug Tier Requirements/Limits
MEIJER TRUETRACK BLOOD GL 3
meijer zinc oxide 3
melatin 3
melatonin CAPS 5mg 3
MELATONIN LIQD 1mg/4ml, 2.5mg/10ml 3
melatonin LIQD 1mg/ml 3
MELATONIN SUBL 3mg 3
MELATONIN TABS 3
melatonin TABS 1mg, 3mg, 5mg, 300mcg 3
melatonin TBCR 10mg 3
melatonin TBDP 5mg 3
melatonin extra strength 3
melatonin maximum strengt TABS 3
MELATONIN TIMED RELEASE 3
melatonin tr 3
melatonin-pyridoxine 3
melatonin/vitamin b-6 ext 3
men-phor 3
MENOPAUSE RELIEF 3
menopause support 3
MENOPAUSE TRIO 3
MENS 50+ ADVANCED 3
MENS 50+ MULTI VITAMIN & 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
421
Drug Name Drug Tier Requirements/Limits
mens daily formula/lycope 3
mens hair formula ultra m 3
mens life pack 3
MENS MULTI VITAMIN & MINE 3
MENS PACK 3
menstrual complete 3
menstrual pain relief mul 3
menstrual pms 3
menstrual relief maximum 3
MENTAX 3
menthoderm 3
menthol cough drops 3
MEPHYTON 5mg 3
mesehist dm 3
mesehist wc 3
MESH PANTS LARGE 3
MESH PANTS MEDIUM 3
MESH PANTS X-LARGE 3
META APPETITE CONTROL 3
META BIOTIC/BIO-ACTIVE 12 3
METAMUCIL CAPS 3
metamucil POWD 28.3% 3
METAMUCIL POWD 48.57% 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
422
Drug Name Drug Tier Requirements/Limits
METAMUCIL WAFR 3
METAMUCIL FIBER 3
METAMUCIL MULTIHEALTH FIB PACK 3
metamucil multihealth fib POWD 58.6% 3
METAMUCIL MULTIHEALTH FIB POWD 63%
3
metamucil original textur 30.9% 3
METAMUCIL ORIGINAL TEXTUR 48.57% 3
METAMUCIL SMOOTH TEXTURE PACK 3
metamucil smooth texture POWD 3
methacholine/liver 3
methagual 3
methamphetamine hcl 3
METHIONINE PACK 3
METHIONINE 500 3
METHYL B-12 3
METHYLCELLULOSE POWD 3
methylcobalamin SUBL 3
MEXSANA 3
MG217 MEDICATED TAR SHAMP 3
mg217 psoriasis anti-itch 3
MG-PLUS PROTEIN 3
MG/TAURINE FORTE 3
mgo 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
423
Drug Name Drug Tier Requirements/Limits
MH MACULAR HEALTH 3
mi-acid gas relief 3
mi-acid maximum strength 3
MIADERM RADIATION RELIEF 3
micaderm 3
MICATIN 3
miconazole 1 3
miconazole 3 3
miconazole 3 combination 3
miconazole 3 combo pack 3
miconazole 7 CREA 2% 3
miconazole 7 SUPP 100mg 3
miconazole antifungal 3
miconazole nitrate (topical) AERP 3
miconazole nitrate (topical) CREA 2% 3
miconazole nitrate vaginal CREA 2% 3
miconazole nitrate vaginal KIT 3
miconazole nitrate vaginal SUPP 100mg 3
miconazorb af 3
micro guard 3
MICROCYN LIQD 3
MICRODOT BLOOD GLUCOSE MO 3
MICRODOT TEST STRIPS 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
424
Drug Name Drug Tier Requirements/Limits
MICROELITE FILTER REPLACE 3
MICROELITE RECHARGEABLE B 3
MICROKLENZ ANTISEPTIC WOU 3
MICROLET NEXT 3
MICROLIFE DIGITAL PEAK FL 3
micronefrin 3
midol 3
midol caffeine free 3
MIDOL COMPLETE 3
midol extended relief 3
MIDOL MAXIMUM STRENGTH ME 3
midol teen 3
migraine formula 3
migraine relief 3
MIGRELIEF 3
MIL ADREGEN 3
MIL-A-MULSION 3
MILADRENE FORTE 3
milantex 3
milantex extra strength 3
MILCO-B-FORTE 3
milk of magnesia 7.75%, 400mg/5ml, 1200mg/15ml, 2400mg/30ml
3
MILK OF MAGNESIA CONCENTR 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
425
Drug Name Drug Tier Requirements/Limits
millguard 3
milltrium advanced formul 3
milltrium cardio 3
milltrium senior 3
milltrium stamina plus 3
MILPAN 3
MILTAB #1 3
mineral freez 3
mineral ice 3
mineral oil ENEM 3
MINERAL OIL OIL 3
mineral oil OIL 99.9% 3
MINERAL OIL HEAVY 3
MINERAL OIL LIGHT 3
minerin 3
MINI LANCING DEVICE 3
MINI WRIGHT AFS LOW RANGE 3
MINI WRIGHT AFS PEAK FLOW 3
MINI WRIGHT PEAK FLOW MET 3
MINI WRIGHT STD PEAK FLOW 3
MINIELITE FILTER REPLACEM 3
MINIELITE RECHARGEABLE BA 3
miniprin low dose 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
426
Drug Name Drug Tier Requirements/Limits
mintox 3
mintox maximum strength 3
mintox plus 3
MINUS WEIGHT PLUS ENERGY 3
mirafiber 3
MIRALAX 3
MISSION PRENATAL 3
MISSION PRENATAL HP 3
mm anti-diarrheal 3
mm aspirin 3
MM BIOTIN/KERATIN 3
MM EASY TOUCH BLOOD GLUCO 3
MM EASY TOUCH GLUCOSE TES 3
MM LANCING DEVICE 3
mm loratadine-d 24 hour 3
mm melatonin tr 3
mm stool softener 3
MOBISYL 3
MODESS FEMININE NAPKINS 3
MODESS FEMININE NAPKINS H 3
MOI-STIR 3
moist skin 3
MOIST WIPES FLUSHABLE 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
427
Drug Name Drug Tier Requirements/Limits
MOISTURE BARRIER CREA 3
moisture barrier OINT 3
MOISTURE CREAM 3
MOISTURE EYES 3
MOISTURE GUARD 3
MOISTURE LOT 3
moisture lotion 3
moisture recovery 3
moisturel therapeutic 3
moisturizing cream 3
MOISTURIZING CREAM 3
moisturizing lotion 3
moisturizing lubricant ey 3
moisturizing sensitive sk 3
moisturizing vitamin e ha 3
MOLDED HEEL CUSHIONS/MEN 3
MOLDED HEEL CUSHIONS/WOME 3
MOLESKIN PLUS 3
MOLESKIN PLUS ROLL 3
MOLYBDENUM CAPS 3
MOMENTUM MUSCULAR BACKACH 3
mommys bliss gas relief d 3
MOMMYS BLISS MULTIVITAMIN 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
428
Drug Name Drug Tier Requirements/Limits
MOMMYS BLISS PROBIOTIC 3
MOMMYS BLISS VITAMIN D OR 3
MONISTAT 1 COMBO PACK 3
MONISTAT 1 DAY OR NIGHT C 3
monistat 1-day 3
MONISTAT 3 3
MONISTAT 3 COMBINATION PA 3
MONISTAT 7 COMBINATION PA 3
MONISTAT 7 CRE 2% 3
MONISTAT 7 SIMPLY CURE 3
monistat soothing care 3
MONISTAT SOOTHING CARE IT 3
MONOCAL 3
monoject pharma grade flu 3
monoject sodium chloride 3
MORE-DOPHILUS ACIDOPHILUS 3
mosco one step corn remov 3
MOTHERS FRIEND 3
motion sickness 3
motion sickness relief 3
motion sickness relief ii 3
motion-time 25mg 3
motrin cold & sinus 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
429
Drug Name Drug Tier Requirements/Limits
motrin ib 3
MOTRIN INFANTS 3
MOTRIN INFANTS DROPS 3
MOTRIN JUNIOR STRENGTH 3
motrin pm 3
MOUTHKOTE 3
MPS 3
MS QUICK DISSOLVE GLUCOSE 3
ms-aid 3
MSM SKIN LOTION 3
MTERYTI 3
MTERYTI FOLIC 5 3
MTX SUPPORT 3
mucaphed 3
MUCINEX 600mg 3
mucinex allergy 3
mucinex chest congestion 100mg/5ml 3
MUCINEX CHILDRENS COLD CO 3
MUCINEX CHILDRENS MULTI-S 3
MUCINEX COLD FOR KIDS 3
MUCINEX CONGESTION & COUG 3
mucinex cough childrens 3
mucinex cough for kids LIQD 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
430
Drug Name Drug Tier Requirements/Limits
MUCINEX COUGH FOR KIDS PACK 3
MUCINEX D 3
MUCINEX D MAXIMUM STRENGT 3
MUCINEX DM 3
MUCINEX DM MAXIMUM STRENG 3
MUCINEX FAST-MAX COLD & S LIQD 3
mucinex fast-max cold & s TABS 3
MUCINEX FAST-MAX COLD FLU LIQD 3
mucinex fast-max cold flu TABS 3
MUCINEX FAST-MAX COLD/FLU 3
mucinex fast-max congesti 3
mucinex fast-max day time 3
MUCINEX FAST-MAX DAY TIME 3
MUCINEX FAST-MAX DAY/NIGH 3
MUCINEX FAST-MAX DAY/NITE 3
mucinex fast-max dm max 3
mucinex fast-max night ti 3
mucinex fast-max severe c CAPS 3
MUCINEX FAST-MAX SEVERE C LIQD 3
MUCINEX FAST-MAX SEVERE C PACK 3
mucinex fast-max severe c TABS 3
MUCINEX FAST-MAX SEVERE C TABS 3
MUCINEX FOR KIDS 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
431
Drug Name Drug Tier Requirements/Limits
MUCINEX MAXIMUM STRENGTH 3
mucinex multi-symptom col LIQD 3
MUCINEX MULTI-SYMPTOM COL MISC 3
mucinex nasal spray full 3
mucinex nasal spray moist 3
MUCINEX SINUS-MAX DAY TIM 3
MUCINEX SINUS-MAX DAY/NIG CPPK 3
mucinex sinus-max day/nig MISC 3
mucinex sinus-max full fo 3
mucinex sinus-max moistur 3
mucinex sinus-max night t 3
mucinex sinus-max pressur 3
MUCINEX SINUS-MAX SEVERE CAPS 3
mucinex sinus-max severe LIQD; TABS 3
MUCINEX STUFFY NOSE & COL 3
mucosa 3
mucosa dm 3
mucus & cough relief chil 3
mucus congestion & cough 3
mucus d 3
mucus d maximum strength 3
mucus relief TABS 400mg 3
mucus relief TB12 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
432
Drug Name Drug Tier Requirements/Limits
mucus relief chest conges 3
mucus relief childrens 100mg/5ml 3
mucus relief cold & sinus 3
mucus relief cold flu & s 3
mucus relief cold/flu/sor 3
mucus relief cold/sinus m 3
mucus relief cough childr 3
mucus relief d 3
mucus relief dm TABS 3
mucus relief dm TB12 3
mucus relief dm cough 3
mucus relief dm max 3
mucus relief dm maximum s 3
mucus relief er 3
mucus relief er 12 hour m 3
mucus relief multi sympto 3
mucus relief pe 3
mucus relief pe sinus con 3
mucus relief plus 3
mucus relief severe cold 3
mucus relief severe conge 3
mucus relief severe sinus 3
mucus relief sinus pressu 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
433
Drug Name Drug Tier Requirements/Limits
mucus relief sinus severe 3
mucus+chest congestion/ad 3
mucus-d 3
mucus-dm 3
mucus-dm max 3
mucus-dm maximum strength 3
mucus-er 3
multi + omega-3 adult gum 3
multi adult gummies 3
multi antibiotic plus 3
multi complete 3
multi complete/iron 3
multi for her CAPS; TABS 3
MULTI FOR HER PACK 3
multi for her 50+ 3
multi for him CAPS; TABS 3
MULTI FOR HIM PACK 3
multi for him 50+ 3
MULTI MEGA MINERALS 3
MULTI PRENATAL 3
multi symptom flu & sever 3
MULTI VITAMIN 3
multi vitamin daily 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
434
Drug Name Drug Tier Requirements/Limits
multi vitamin mens 3
multi vitamin with iron 3
MULTI VITAMIN/D-3 3
MULTI-B COMPLEX 3
MULTI-BETIC DIABETES 3
multi-day 3
multi-day plus iron 3
multi-day plus minerals 3
multi-day vitamins 3
multi-day w/calcium and e 3
multi-day weight trim 3
multi-delyn 3
MULTI-DELYN/IRON 3
MULTI-GLAN 3
MULTI-LANCET DEVICE 3
multi-lean 3
MULTI-MINERALS 3
multi-purpose solutio n n 3
multi-purpose solution 3
MULTI-PURPOSE SOLUTION 3
multi-symptom allergy 3
multi-symptom cold childr 3
MULTI-SYMPTOM COLD DAYTIM 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
435
Drug Name Drug Tier Requirements/Limits
multi-symptom cold plus c 3
multi-symptom cold/cough 3
multi-vitamin 3
multi-vitamin daily 3
multi-vitamin gummies 3
multi-vitamin hp/minerals 3
MULTI-VITAMIN MONOCAPS 3
multi-vitamin/menopausal 3
multi-vitamin/minerals 3
multi-vitamin/multi-miner 3
multi-vitamins 3
multi-vitamins/iron 3
multilex 3
multilex-t&m 3
multimineral plus 3
multiple minerals 3
multiple minerals w/ vitamins 3
multiple vitamin 3
multiple vitamin/minerals 3
multiple vitamins essenti 3
multiple vitamins w/ calcium 3
multiple vitamins w/ iron 3
multiple vitamins w/ minerals PACK 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
436
Drug Name Drug Tier Requirements/Limits
multiple vitamins w/ minerals TABS 3
multiple vitamins w/ minerals TBCR 3
multiple vitamins/womens 3
MULTIPURPOSE CONTACT LENS 3
MULTISOURCE CALCIUM MAGNE 3
MULTISTIX 3
MULTISTIX 5 3
MULTISTIX 7 3
MULTISTIX 7 TES STRIPS 3
MULTISTIX 8 SG 3
MULTISTIX 9 3
MULTISTIX 9 SG 3
MULTISTIX 10 SG 3
MULTISTIX TES SG STRIP 3
multivital 3
multivital platinum silve 3
multivitamin 3
multivitamin & mineral 3
MULTIVITAMIN ADULT 3
MULTIVITAMIN ADULT EXTRA 3
multivitamin adults 3
MULTIVITAMIN ADULTS 3
multivitamin adults 50+ 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
437
Drug Name Drug Tier Requirements/Limits
multivitamin childrens 3
multivitamin gummies adul 3
multivitamin gummies chil 3
MULTIVITAMIN GUMMIES CHIL 3
multivitamin gummies mens 3
multivitamin gummies wome 3
multivitamin iron-free 3
MULTIVITAMIN MEN 3
multivitamin men 50+ 3
multivitamin mens 3
MULTIVITAMIN PLUS IRON CH 3
multivitamin women 3
multivitamin women 50+ 3
multivitamin womens 3
MULTIVITAMIN+ 3
multivitamin/extra vitami 3
multivitamins 3
multivitamins pediatric 3
MURI-LUBE 3
MURINE 3
murine ear 3
murine ear drops 3
murine for ear wax remova 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
438
Drug Name Drug Tier Requirements/Limits
murine for red eyes 3
murine plus 3
murine tears for dry eyes 3
MURINE TEARS PLUS 3
MURO 128 OINT 3
MURO 128 SOLN 5% 3
muscle rub 3
muscle rub ultra strength 3
MUSE 250mcg, 500mcg, 1000mcg 3 QL (6 sup / 25 days)
mv-one 3
MVW COMPLETE FORMULATION CAPS 3
mvw complete formulation CHEW 3
MVW COMPLETE FORMULATION CHEW 3
MVW COMPLETE FORMULATION SOLN 3
MX-SOL 3
MX-SOL BLEND 3
MX-SOL BLEND SF 3
MX-SOL SF 3
MX-SOL SUSPEND 3
my-vitalife 3
myamulti 3
MYCELEX-7 3
MYCITRACIN OIN 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
439
Drug Name Drug Tier Requirements/Limits
MYCITRACIN OIN PLUS 3
mycocide clinical ns anti 3
myferon 150 3
MYGLUCOHEALTH BLOOD GLUCO 3
MYKIDZ IRON 3
MYKIDZ IRON 10 3
MYLANTA 3
MYLANTA CHW 3
MYLANTA DOUBLE-STRENGTH 3
MYLANTA GAS 3
MYLANTA GAS CHW 80MG 3
MYLANTA GAS RELIEF MAXIMU 3
mylanta maximum strength 3
MYLANTA SUS 3
MYLANTA ULTRA 3
MYLICON 3
MYLICON INFANTS GAS RELIE 3
MYOFLEX 3
mytab gas 3
mytab gas max str 3
mytussin dm 3
4-N-1 3
na-zone 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
440
Drug Name Drug Tier Requirements/Limits
nac 600mg 3
nac 600 3
NAIL SCRUB 3
nail-ex 3
NANOVM 1-3 YEARS 3
NANOVM 4-8 YEARS 3
NANOVM 9-18 YEARS 3
NANOVM T/F 3
NAPHCON-A 3
naproxen sodium CAPS 3
naproxen sodium TABS 220mg 3
naramin 3
NASACORT ALLERGY 24HR 3
NASACORT ALLERGY 24HR CHI 3
NASADROPS SALINE ON THE G 3
nasal allergy 3
nasal allergy 24 hour 3
nasal allergy 24 hour mul 3
nasal antiseptic 3
NASAL DECONGESTANT LIQD 30mg/5ml 3
nasal decongestant SOLN 3
nasal decongestant TABS 10mg, 30mg 3
nasal decongestant maximu 30mg 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
441
Drug Name Drug Tier Requirements/Limits
nasal decongestant pe 10mg 3
nasal decongestant pe max 10mg 3
nasal decongestant spray .05% 3
nasal four 3
nasal moist 3
nasal moisturizing spray 3
nasal spray 12 hour .05% 3
nasal spray anti-drip 3
nasal spray extra moistur 3
nasal spray long acting 3
nasal spray maximum stren 3
nasal spray moisturizing 3
nasal spray no drip 3
nasal spray sinus 3
nasal spray x-moist 3
NASALCROM 3
nasogel 3
nasohist 3
NASOHIST DM 3
NASOPEN 3
NASOPEN PE 3
nat-rul antioxidants c+e 3
nat-rul b-50 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
442
Drug Name Drug Tier Requirements/Limits
nat-rul b-100 3
nat-rul b-125 3
NAT-RUL C-COMPLEX 3
NAT-RUL C-COMPLEX TR 3
nat-rul coenzyme q-10 3
nat-rul daily-vite + iron 3
nat-rul iron 3
nat-rul oyster calcium + 3
NAT-RUL PRENATAL VITAMINS 3
NAT-RUL THERAVITE-M/HIGH 3
nat-rul vitamin d 3
NATRAPEL 3
natrul colon care 3
natrul magnesium 3
NATRUL PROBIOTIC 3
NATRUL-100 3
NATRUL-CAL 3
NATRUL-CHEWS 3
NATRUL-MEGA-75 3
NATRUL-VITES 3
natural balance tears 3
natural blend e-400 3
natural c/rose hips 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
443
Drug Name Drug Tier Requirements/Limits
natural cod liver oil 3
natural cold sore 3
natural fiber 3
natural fiber laxative 3
natural fiber therapy 30% 3
natural herb 3
natural herb cough drops 3
natural mixed tocopherols CAPS 3
natural oatmeal bath trea 3
natural oyster shell calc 3
natural psyllium seed ind 3
natural senna laxative 3
natural vegetable 3
natural vegetable fiber 3
natural vegetable laxativ POWD 3
natural vitamin a 3
natural vitamin d-3 3
natural vitamin e CAPS 3
NATURAL VITAMIN E TABS 200unit 3
natural vitamin e TABS 400unit 3
NATURAL WHEY 3
naturalyte 3
natures tears .4% 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
444
Drug Name Drug Tier Requirements/Limits
NATURES WASH PLUS 3
nausatrol 3
nausea control 3
NEBULIZER AIR TUBE/PLUGS 3
NEBULIZER PEDIATRIC MASK 3
nebusal 3% 3
NEO-SYNEPHRINE 3
NEO-SYNEPHRINE 12 HOUR EX 3
NEO-SYNEPHRINE COLD & SIN 3
NEOMULTIVITE 3
neomycin-bacitracin-polymyxin 3
neomycin-bacitracin-polymyxin w/
lidocaine
3
NEONATAL VITAMIN 3
NEOQ10 3
neosporin + pain relief m 3
neosporin af jock itch 3
neosporin eczema essentia 1% 3
NEOSPORIN ECZEMA ESSENTIA 1% 3
NEOSPORIN LIP HEALTH OVER 3
NEOSPORIN ORIGINAL 3
neosporin pain/itch/scar 3
NEOSPORIN PLUS MAXIMUM ST 3
NEOSPORIN PLUS PAIN RELIE 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
445
Drug Name Drug Tier Requirements/Limits
neotuss 3
NEOTUSS-D 3
nephro vitamins 3
NEPHRO-VITE 3
NEPHRONEX LIQD 3
nervidox-6 nr 3
NERVO B-12 SL 3
NESSI SPACER/LARGE MASK 3
NESSI SPACER/MOUTHPIECE 3
NESSI SPACER/SMALL/MED MA 3
NESTLE FLAVOR 3
NESTLE FLAVOR EXTRA STREN 3
NESTLE FLAVOR FOR KIDS 3
NEURO VITE 3
neuro-k-50 3
NEURO-K-250 T.D. 3
neuro-k-250 vitamin b6 3
neuro-k-500 3
NEUTEK 2TEK TEST STRIPS 3
NEUTRAHIST 3
neutralin 3
NEUTRAPHOR 3
NEUTRAPHORUS REX 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
446
Drug Name Drug Tier Requirements/Limits
neutrogena body clear acn 3
NEUTROGENA BODY LIGHT SES 3
NEUTROGENA CLEAN REPLENIS 3
NEUTROGENA DEEP CLEAN FAC 3
NEUTROGENA FRESH FOAMING 3
NEUTROGENA HAND 3
NEUTROGENA HAND/NORWEGIAN 3
NEUTROGENA HEALTHY SKIN 3
NEUTROGENA HEALTHY SKIN F 3
NEUTROGENA MAKEUP REMOVER 3
NEUTROGENA MOISTURE SENSI 3
neutrogena oil-free acne 3
neutrogena rapid clear ac 3
NEUTROGENA SHAMPOO 3
NEUTROGENA T/GEL 3
NEUTROGENA T/GEL CONDITIO 3
neutrogena t/gel extra st 3
NEUTROGENA T/GEL STUBBORN 3
NEUTROGENA T/GEL THERAPEU 3
NEUTROGENA T/SAL 3
NEUTROGENA TRIPLE MOISTUR 3
NEW LIFE HAIR 3
new skin LIQD 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
447
Drug Name Drug Tier Requirements/Limits
new skin scar therapy 3
NEXAFED SINUS PRESSURE + 3
NEXCARE ALL PURPOSE MASK 3
NEXCARE EARLOOP MASK 3
nexcare liquid bandage 3
NEXCARE WOUND CLEANSER 3
NEXGEN TEST STRIPS 3
NEXIUM CPDR 20mg 3
NEXIUM 24HR CPDR 3
NEXIUM 24HR CLEAR MINIS 3
NF FORMULAS CALCIUM MAGNE 3
NF FORMULAS CHILDRENS CHE 3
nf formulas nac 3
nia-chrom 3
niacin CPCR 125mg, 250mg, 400mg, 500mg
3
NIACIN POWD 3
niacin TABS 50mg, 100mg, 250mg,
500mg
3
niacin TBCR 250mg, 500mg, 750mg 3
niacin flush free 500mg 3
niacin flush free formula 3
NIACIN FLUSH-FREE EXTRA S 3
NIACIN TR 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
448
Drug Name Drug Tier Requirements/Limits
niacin-50 3
NIACINAMIDE POWD 3
niacinamide TABS 100mg, 500mg 3
niacinamide TBCR 3
NICADAN 3
NICADAN ZX 3
NICAZEL 3
NICAZEL FORTE 3
NICODERM CQ 3
nicorelief 2mg 3
NICORETTE 3
NICORETTE MINI 3
NICORETTE STARTER KIT 3
NICOTINAMIDE 3
nicotine 7mg/24hr, 14mg/24hr, 21mg/24hr
3
nicotine mini lozenge 3
nicotine polacrilex GUM 2mg, 4mg 3
nicotine polacrilex LOZG 2mg, 4mg 3
nicotine step 1 3
nicotine step 2 3
nicotine step 3 3
NICOTINE TRANSDERMAL SYST KIT 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
449
Drug Name Drug Tier Requirements/Limits
nicotine transdermal syst PT24 7mg/24hr, 14mg/24hr, 21mg/24hr
3
night time cold & flu rel 3
night time cough & cold r 3
night time multi-symptom 3
night time pain medicine 3
night time sleep aid 25mg 3
night-time cold/flu relie 3
night-time cough 3
night-time multi-symptom 3
night-time sinus 3
nighttime cold & flu 3
nighttime cold flu & reli 3
nighttime cold medicine 3
nighttime cold/flu relief 3
nighttime cold/flu/maximu 3
nighttime cough 3
nighttime d cold & flu re 3
nighttime multi-symptom c 3
nighttime severe cold & f 3
nighttime sinus congestio 3
nighttime sinus/multi-sym 3
nighttime sleep 3
nighttime sleep aid CAPS 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
450
Drug Name Drug Tier Requirements/Limits
nighttime sleep aid TABS 25mg, 50mg 3
nighttime sleep-aid 3
NINJACOF 3
NINJACOF-A 3
NINJACOF-D 3
NINJACOF-XG 3
NISEKO HYDRATING FACIAL M 3
nite time cough 3
nite time multi-symptom c 3
nite-time cold/flu 3
nite-time cold/flu relief CAPS 3
NITE-TIME COLD/FLU RELIEF LIQD 3
nite-time cough 3
nite-time multi-symptom c 3
nitetime sleep-aid 3
NITRATEST PAPER 3
niva-hist dm 3
NIVANEX DMX 3
NIVEA 3
NIVEA EXTRA ENRICHED 3
NIVEA EXTRA ENRICHED LOTI 3
NIVEA GENTLE BODY EXFOLIA 3
NIVEA LIGHT 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
451
Drug Name Drug Tier Requirements/Limits
NIVEA MOISTURIZING CREA 3
NIVEA MOISTURIZING BODY W 3
NIVEA ORIGINAL 3
NIVEA ORIGINAL MOISTURE 3
NIVEA SOFT 3
NIVEA TOUCH OF SMOOTHNESS 3
NIVEA VISAGE 3
NIVEA VISAGE FOAMING FACI 3
NIVEA VISAGE GENTLE CLEAN 3
NIVEA VISAGE INNER BEAUTY 3
NIVEA VISAGE MOISTURIZING 3
NIX COMPLETE LICE TREATME 3
NIX CREME LIQ RINSE 1% 3
NIX CREME RINSE 3
NIZATIDINE TAB 75 MG 3
NIZORAL A-D 3
no doz maximum strength 3
no drip nasal spray .05% 3
no flush niacin CAPS 3
NO IRON MULTIPLE VITAMIN/ 3
noble formula LIQD 3
noble formula hc 3
noble formula s 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
452
Drug Name Drug Tier Requirements/Limits
noble formula shampoo 3
NOBLE MYSTIQUE BODY CLEAN 3
NOBLE MYSTIQUE EMU-LAC 3
nohist-dm 3
nohist-lq 3
non-aspirin 3
non-aspirin 8 hour 3
non-aspirin childrens 3
non-aspirin extra strengt CAPS; SOLN;
TABS
3
NON-ASPIRIN EXTRA STRENGT TBDP 3
non-aspirin infant 3
non-aspirin junior streng 3
non-aspirin pain relief 3
non-aspirin pain relief c 3
non-aspirin pain relief e 3
non-aspirin pm extra stre 3
non-aspirin severe conges 3
non-drying sinus 3
non-pseudo cold relief 3
non-pseudo sinus deconges 3
non-pseudo sinus pain/pre 3
NOREL AD 3
NOREL CS 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
453
Drug Name Drug Tier Requirements/Limits
NORMALYTE 3
NORMLSHIELD 3
nortemp 3
NORTEMP INFANTS 3
nortuss-de 3
norwegian cod liver oil CAPS 3
NORWEGIAN COD LIVER OIL OIL 3
norwich aspirin 3
NOSE CLIP 3
nose drops extra strength 3
NOVA MAX BLOOD GLUCOSE MO 3
NOVA MAX GLUCOSE TEST STR 3
NOVA SUREFLEX LANCING DEV 3
NOVAFERRUM 50 3
NOVAFERRUM 125 3
NOVAFERRUM PEDIATRIC DROP 3
novaferrum pediatric mult 3
nrs nasal relief 3
nu-copd 3
NU-FIT ADULT BRIEF LARGE 3
NU-FIT ADULT BRIEF MEDIUM 3
NU-GEL WOUND DRESSING/3-3 3
NU-GEL WOUND DRESSING/6" 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
454
Drug Name Drug Tier Requirements/Limits
nu-iron 150 3
nu-way nasal decongestant 3
NUMOISYN LIQD 3
NUPERCAINAL 3
NUPREP 5% POVIDONE-IODINE 3
nutr-e-sol 3
NUTRA-SUPPORT BONE 3
NUTRA/PRO CHOCOLATE 3
NUTRA/PRO STRAWBERRY 3
NUTRA/PRO VANILLA 3
NUTRADERM CREA; LOTN 3
NUTRADERM ADVANCED FORMUL 3
NUTRAMIX 3
nutraplus 3
NUTRASENTIALS 3
NUTRATEAR 3
NUTRICAP 3
NUTRICION PORVIDA 3
nutrifac zx 3
NUTRISOURCE FIBER PACK 3
nycair 3
nycoff 3
NYQUIL 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
455
Drug Name Drug Tier Requirements/Limits
nyquil severe + vapocool 3
nyquil severe cold/flu 3
nyt-time sleep caps 3
nytol 3
NYTOL MAXIMUM STRENGTH 3
OBREDON 3
occlusal-hp 3
ocean for kids 3
OCEAN NASAL MOISTURIZER 3
OCEAN NASAL SPRAY 3
oceanic selenium 3
OCULAR VITAMINS 3
OCUSOFT BABY EYELID & EYE 3
OCUSOFT DRY EYE KIT 3
ocusoft eye wash 3
OCUSOFT EYELID CLEANSING 3
OCUSOFT HAND SOAP 3
OCUSOFT HYPOCHLOR LIQD 3
ocusoft irrigating ii 3
OCUSOFT LID SCRUB 3
OCUSOFT LID SCRUB COMPLIA 3
OCUSOFT LID SCRUB FOAMING 3
OCUSOFT LID SCRUB ORIGINA 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
456
Drug Name Drug Tier Requirements/Limits
OCUSOFT LID SCRUB PLUS 3
ocutabs 3
ocutabs vision formula 3
ocutabs/lutein 3
OCUVITE ADULT 50+ 3
OCUVITE ADULT FORMULA 3
ocuvite extra 3
ocuvite eye + multi 3
ocuvite eye health formul 3
ocuvite eye health gummie 3
OCUVITE LUTEIN 3
ocuvite/lutein 3
odor control foot & sneak 3
odor eaters antifungal 3
ODOR EATERS ECONOMY 3
odor eaters foot & sneake 3
ODOR EATERS SUPER TUFF 3
ODOR EATERS ULTRA DURABLE 3
odorless coated fish oil/ 3
OFF ACTIVE 15% 3
OFF DEEP WOODS TOWELETTES 3
OFF FAMILYCARE SMOOTH & D 3
OFF FAMILYCARE TROPICAL F 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
457
Drug Name Drug Tier Requirements/Limits
OFF FAMILYCARE UNSCENTED 7% 3
OFF SMOOTH & DRY 15% 3
OFF-EZY WART REMOVER 3
OINTMENT BASE 3
OMEGA DHA 3
omega-3 fatty acids 3
omega-3 fish oil concentr 3
omeprazole TBEC 20mg 3
OMEPRAZOLE TBEC 20mg 3
omeprazole magnesium 3
omeprazole-sodium bicarbonate CAPS 3
OMNI GEL 3
OMNICAP 3
ON CALL EXPRESS BLOOD GLU 3
ON CALL LANCING DEVICE 3
ON CALL PLUS BLOOD GLUCOS 3
ON CALL PLUS LANCING DEVI 3
ON CALL VIVID BLOOD GLUCO 3
ON CALL VIVID PAL BLOOD G 3
once daily 3
once daily/iron 3
ONE A DAY WOMENS PRENATAL 3
one daily 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
458
Drug Name Drug Tier Requirements/Limits
one daily 50 plus 3
one daily adults 50+ 3
one daily complete 3
one daily complete for me 3
one daily essential 3
one daily for men 50+ adv 3
one daily for men/lycopen 3
one daily for women 3
one daily for women 50+a 3
one daily healthy weight 3
one daily maximum 3
one daily mens 3
one daily mens 50+ multiv 3
ONE DAILY MENS FORMULA W/ 3
one daily mens health/lyc 3
one daily multivitamin ad 3
one daily multivitamin me 3
one daily multivitamin wo 3
one daily multivitamin/ir 3
one daily plus iron 3
ONE DAILY PLUS IRON 3
one daily plus minerals 3
one daily womens 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
459
Drug Name Drug Tier Requirements/Limits
ONE DAILY WOMENS 3
one daily womens 50 plus 3
one daily womens 50+ 3
one daily/iron/calcium 3
one daily/minerals 3
ONE DROP BLOOD GLUCOSE MO 3
ONE DROP BLOOD GLUCOSE TE 3
ONE FLOW TESTER TUBE MOUT 3
one step callus remover 3
ONE TOUCH DELICA LANCING 3
ONE TOUCH ULTRA TEST STRI 3
ONE TOUCH VERIO 3
ONE TOUCH VERIO IQ BLOOD 3
ONE TOUCH VERIO TEST STRI 3
ONE-A-DAY ADULT VITACRAVE 3
ONE-A-DAY CHOLESTEROL PLU 3
ONE-A-DAY ENERGY 3
ONE-A-DAY ENERGY FORMULA 3
ONE-A-DAY ESSENTIAL 3
ONE-A-DAY FOR HER VITACRA 3
ONE-A-DAY FOR HIM/VITACRA 3
ONE-A-DAY MENOPAUSE FORMU 3
ONE-A-DAY MENS 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
460
Drug Name Drug Tier Requirements/Limits
ONE-A-DAY MENS 50+ ADVANT 3
ONE-A-DAY MENS HEALTH FOR 3
ONE-A-DAY MENS PRO EDGE 3
ONE-A-DAY MENS VITACRAVES 3
ONE-A-DAY PROACTIVE 65+ 3
ONE-A-DAY SCOOBY-DOO GUMM 3
one-a-day teen advantage 3
ONE-A-DAY TEEN ADVANTAGE 3
ONE-A-DAY VITACRAVES 3
ONE-A-DAY VITACRAVES ADUL 3
ONE-A-DAY VITACRAVES GUMM 3
ONE-A-DAY VITACRAVES SOUR 3
ONE-A-DAY VITACRAVES WOME 3
ONE-A-DAY WEIGHT SMART AD 3
ONE-A-DAY WOMENS 50+ ADVA 3
ONE-A-DAY WOMENS ACTIVE M 3
ONE-A-DAY WOMENS FORMULA 3
ONE-A-DAY WOMENS PETITES 3
ONE-A-DAY WOMENS PLUS HEA 3
ONE-A-DAY WOMENS PRENATAL 3
ONE-A-DAY WOMENS VITACRAV 3
ONE-A-DAY/JOLLY RANCHER 3
one-daily multi vitamins 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
461
Drug Name Drug Tier Requirements/Limits
one-daily/iron 3
ONE-STEP PREP POVIDONE-IO 3
one-step wart remover med 3
ONE-WAY VALVED EXPIRATORY 3
ONE-WAY VALVED INSPIRATOR 3
ONETOUCH BASIC/PROFILE/ON 3
ONETOUCH DELICA LANCING D 3
ONETOUCH ULTRA 2 3
ONETOUCH ULTRA BLUE 3
ONETOUCH ULTRA MINI 3
ONETOUCH ULTRA SYSTEM KIT 3
ONETOUCH ULTRALINK SYSTEM 3
ONETOUCH ULTRASMART 3
ONETOUCH VERIO 3
ONETOUCH VERIO FLEX BLOOD 3
ONETOUCH VERIO IQ BLOOD G 3
ONETOUCH VERIO SYNC BLOOD 3
ONETOUCH VERIO TEST STRIP 3
ONEVITE 3
ONSET FORTE 3
OPCON-A 3
OPERAND CHLORHEXIDINE GLU 3
operand povidone/iodine 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
462
Drug Name Drug Tier Requirements/Limits
ophthalmic irrigation solution 3
OPTI-CLEAN II CLEANER 3
opti-clear 3
OPTI-FREE DAILY CLEANER 3
OPTI-FREE EXPRESS MULTI-P 3
OPTI-FREE EXPRESS REWETTI 3
OPTI-FREE FOR DISINFECTIO 3
OPTI-FREE PUREMOIST MULTI 3
OPTI-FREE PUREMOIST REWET 3
OPTI-FREE REPLENISH 3
OPTI-FREE REPLENISH CONVE 3
OPTI-FREE REPLENISH REWET 3
OPTI-FREE SOL EXPRESS 3
opti-free supra clens 3
OPTI-ONE 3
OPTI-ONE REWETTING 3
OPTI-WOMAN 3
optic-vites 3
optic-vites with lutein 3
OPTICHAMBER FACE MASK/LAR 3
OPTICHAMBER FACE MASK/MED 3
OPTICHAMBER FACE MASK/SMA 3
optics eye wash 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
463
Drug Name Drug Tier Requirements/Limits
optics mini drops 3
OPTIMAL D3 M 3
optimal-d 3
optimal-d pack 3
OPTIMUM AIRVITES 3
optimum pms 3
OPTISOURCE POST BARIATRIC 3
OPTIUM BLOOD GLUCOSE MONI 3
OPTIUM TEST STRIPS 3
OPTIUMEZ TEST STRIPS 3
OPTIVITE P.M.T. 3
OPTUMRX BLOOD GLUCOSE MET 3
OPTUMRX BLOOD GLUCOSE MON 3
OPTUMRX BLOOD GLUCOSE TES 3
OPURITY 3
OPURITY B12/FOLIC ACID 3
OPURITY CALCIUM CITRATE P 3
opurity vitamin d 3
OPURITY/BAND OPTIMIZED 3
OPURITY/BYPASS OPTIMIZED 3
ora relief sore throat 3
ORA-BLEND 3
ORA-BLEND SF 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
464
Drug Name Drug Tier Requirements/Limits
ORA-PLUS 3
ORA-SWEET 3
ORA-SWEET SF 3
oral electrolyte solution 3
oral electrolytes 3
ORAL MIX FLAVORED SUSPEND 3
ORAL MIX SF 3
oral relief 3
ORAL RELIEF SPRAY FOR DRY 3
ORAL SUSPEND 3
ORAL SUSPENDING COMPOUND 3
ORAL SYRUP FLAVORED VEHIC 3
ORAL SYRUP SF 3
oralseptic 3
oralyte 3
oralyte freezer pops 3
ORASEP 3
orazinc CAPS 3
ORAZINC TABS 3
ORCHIC 3
organ-i nr 3
original formula stomach 3
ormir 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
465
Drug Name Drug Tier Requirements/Limits
ornithine 500mg 3
ORNITHINE 500mg 3
ortho-nesic 3
orthovite 3
os-cal 3
os-cal calcium + d3 3
OS-CAL ULTRA 3
oscal 500/200 d-3 3
osteo bi-flex regular str 3
OSTEO-PORETICAL 3
OSTEOPRIME PLUS/CALCIUM & 3
osteoprime ultra 3
OSTIGEN 3
otix 3
OVARY TABS 3
OVERNIGHT SLEEP GUARD UNI 3
OXIPOR VHC PSORIASIS LOTI 3
oxymetazoline hcl SOLN 3
OXYTROL 3
OXYTROL FOR WOMEN 3
oysco 500+d CHEW 3
oysco d 3
oyst-cal 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
466
Drug Name Drug Tier Requirements/Limits
oyst-cal d 3
oyst-cal-d 500 3
oyster calcium/d3 3
oyster calcium/vitamin d 3
oyster shell 500mg 3
OYSTER SHELL CALCIUM 3
oyster shell calcium 250+ 3
oyster shell calcium 500 3
oyster shell calcium 500+ 3
oyster shell calcium + d 3
oyster shell calcium + d3 3
oyster shell calcium + vi 3
oyster shell calcium plus 3
OYSTER SHELL CALCIUM PLUS 3
oyster shell calcium+d 3
oyster shell calcium/d 3
oyster shell calcium/d3 3
OYSTER SHELL CALCIUM/MAGN 3
OYSTER SHELL CALCIUM/VITA TABS 3
oyster-cal 250 + d 3
oyster-cal 500 3
oyster-cal 500 + d 3
oystercal 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
467
Drug Name Drug Tier Requirements/Limits
oystercal-d 3
P & S SHAM 3
P D NATAL VITAMINS/FOLIC 3
P-1000 3
p-a-c 3
pa b-complex with b-12 3
pa biotin 3
pa calcium 600/vitamin d 3
pa coenzyme q-10 3
pa glucosamine/chondroiti TABS 3
pa l-arginine 3
pa melatonin 3
PA MENS 50 PLUS VITAPAK 3
PA MENS VITAPAK 3
pa mucus relief 3
pa oyster shell calcium 3
PA PRENATAL FORMULA 3
PA PROBIOTIC COMPLEX 3
pa vitamin b-12 tr 3
pa vitamin d-3 3
pa vitamin d-3 gummy 3
pa vitamin e 3
PA WOMENS 50 PLUS VITAPAK 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
468
Drug Name Drug Tier Requirements/Limits
PA WOMENS VITAPAK 3
PABA 3
PACQUIN PLUS 3
PADSORBER BED PAN LINERS 3
pain & fever childrens CHEW 80mg, 160mg
3
pain & fever childrens SUSP 160mg/5ml 3
pain & fever childrens dy 160mg/5ml 3
pain & fever childrens/dy 3
pain & fever infants 160mg/5ml 3
pain & fever junior 3
pain relief SOLN 3
PAIN RELIEF TABS 3
pain relief TABS 325mg, 500mg 3
pain relief 8 hour 3
pain relief allergy sinus 3
pain relief childrens 3
pain relief cold pe/day 3
pain relief cold severe c 3
pain relief extra strengt 500mg 3
PAIN RELIEF FLU 3
pain relief pm extra stre 3
pain relief regular stren 3
pain relief sinus 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
469
Drug Name Drug Tier Requirements/Limits
pain relief sinus pe dayt 3
pain reliever 3
pain reliever extra stren 500mg 3
pain reliever infants 3
pain reliever junior 3
pain reliever plus 3
pain reliever pm 3
pain reliever pm extra st 3
pain reliever/fever reduc 3
pain relieving cream 3
pain relieving gel 3
PAIN-A-LAY 3
pain-off 3
PALOMAR E 3
pamix 3
pamprin all day maximum s 3
pamprin max 3
PAMPRIN MAX PAIN FORMULA 3
PAMPRIN MULTI-SYMPTOM 3
pan-c 500/bioflavonoids 3
PANATUSS DXP 3
PANATUSS DXP PEDIATRIC 3
panatuss ped 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
470
Drug Name Drug Tier Requirements/Limits
panatuss ped drops 3
PANDA MASK LARGE 3
PANDA MASK MEDIUM 3
PANDA MASK SMALL 3
panoxyl BAR 3
PANOXYL LIQD 3
panoxyl creamy wash 3
panoxyl foaming wash 3
panoxyl wash 3
PANOXYL-4 CREAMY WASH 3
PANOXYL-8 CREAMY WASH 3
PANTILINERS 3
PANTILINERS CONTOURED 3
PANTILINERS LONG 3
PANTILINERS REGULAR 3
PANTILINERS THONG 3
PANTILINERS TO GO 3
PANTILINERS UNSCENTED LON 3
PANTO-250 3
pantothenic acid 3
PANTY LINERS REGULAR 3
para-aminobenzoic acid (paba) 3
PARATHYROID 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
471
Drug Name Drug Tier Requirements/Limits
PARI ALTERA NEBULIZER HAN 3
PARI BABY CONVERSION KIT 3
PARI ERAPID NEBULIZER HAN 3
PARI EXPIRATORY FILTER VA 3
PARI MASK SET 3
PARI SOFT PLASTIC ADULT M 3
PARI SOFT PLASTIC PEDIATR 3
PARVA-CAL 3
PARVA-CAL 250 3
PARVLEX 3
pc pediatric electrolyte 3
pc-tar 3
PEAK AIR PEAK FLOW METER 3
PEAK FLOW METER 3
PEARLS IC 3
PECGEN DMX 3
pecgen pse 3
PECTIN 3
pedi-atric nightrest 3
pedia care multi-symptom 3
pedia relief cough/cold 3
pedia vance 3
PEDIA-LAX 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
472
Drug Name Drug Tier Requirements/Limits
pedia-lax fiber gummies 3
PEDIA-POP ORAL ELECTROLYT 3
pediacare children 3
pediacare childrens aller 3
pediacare childrens long- 3
pediacare childrens multi 3
pediacare childrens night 3
pediacare cough & congest 3
PEDIACARE COUGH & RUNNY N 3
PEDIACARE COUGH/COLD 3
pediacare fever reducer/p 3
pediacare gas relief drop 3
pediacare infants 3
pediacare infants gas rel 3
pediacare multi symptom c 3
pediacold 3
PEDIALYTE 3
PEDIALYTE ADVANCED CARE 3
PEDIALYTE FREEZER POPS 3
PEDIALYTE SINGLES 3
PEDIALYTE SOL BUBL GUM 3
PEDIALYTE SOL UNFLAVRD 3
PEDIATRIC AEROSOL MASK 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
473
Drug Name Drug Tier Requirements/Limits
PEDIATRIC DISPOSABLE MOUT 3
PEDIATRIC ELECTROLYTE 3
pediatric electrolyte fre 3
pediatric electrolyte/wit 3
pediatric electrolyte/zin 3
pediatric enema 3
pediatric formula cough a 3
PEDIATRIC MEDIUM MASK 3
PEDIATRIC MOUTHPIECE/DISP 3
pediatric multiple vitamin w/ minerals 3
pediatric multiple vitamins w/ iron 3
PEDIATRIC PANDA MASK 3
PEDIATRIC SMALL MASK 3
pediatric vitamins adc 3
PEDIAVENT 3
pediavit 3
PEG 3
pegylax 3
PELEVERUS 3
PELEVERUS CLEAR 3
PELEVERUS GOLD 3
PEN-KERA 3
PENTRAVAN 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
474
Drug Name Drug Tier Requirements/Limits
PENTRAVAN PLUS 3
pentrax gold 3
PEPCID 20mg 3
PEPCID AC 3
PEPCID AC EZ CHEWS MAXIMU 3
PEPCID AC MAXIMUM STRENGT 3
PEPCID COMPLETE 3
peptic relief CHEW 262mg 3
PEPTO BISMOL 3
PEPTO-BISMOL 3
PEPTO-BISMOL INSTACOOL 3
PEPTO-BISMOL MAX STRENGTH 3
PEPTO-BISMOL TO-GO 3
PER-FIT BRIEF LARGE 3
PER-FIT BRIEF MEDIUM 3
PER-FIT UNDERWEAR EXTRA L 3
PER-FIT UNDERWEAR LARGE 3
PER-FIT UNDERWEAR MEDIUM 3
PERCOGESIC 3
percogesic extra strength 3
perdiem overnight relief 3
PERFECT IRON 3
perform pain relieving ge 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
475
Drug Name Drug Tier Requirements/Limits
peri-colace 3
PERI-WASH 3
PERIDIN-C 3
PERIFLEX LQ PKU 3
periguard 3
periomed 3
perishield 3
permethrin 3
permethrin lice treatment 3
perox-a-mint 3
PEROXICLEAR CLEANING & DI 3
PEROXYL 3
peroxyl 1.5% 3
PERRY PRENATAL 3
PERSONAL BEST FULL RANGE 3
PERSONAL BEST LOW RANGE 3
PERSONAL CLEANSING WASHCL 3
personal lubricant jelly 3
personal lubricant warmin GEL 3
PETROLATUM 3
PETROLEUM JELLY LIP TREAT 3
PFLEX 3
PHACID 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
476
Drug Name Drug Tier Requirements/Limits
pharbechlor 3
pharbedryl 25mg, 50mg 3
pharbetol 325mg 3
pharbetol extra strength 500mg 3
pharbinex 3
pharbinex-dm 3
pharbinex-pe 3
PHARMACIST CHOICE AUTOCOD 3
PHARMACIST CHOICE MINI BL 3
PHARMACIST CHOICE NO CODI 3
pharmacists creme 3
pharmalox 3
PHAZYME CAPS 3
phazyme CHEW 3
PHAZYME MAXIMUM STRENGTH 3
PHAZYME ULTRA STRENGTH 3
PHENABID DM 3
PHENAGIL 3
PHENAGIL CH 3
phenaseptic 3
phenazo 95mg 3
phenazopyridine hcl TABS 95mg 3
PHENOL LIQD 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
477
Drug Name Drug Tier Requirements/Limits
PHENYLADE 3
PHENYLADE40 DRINK MIX 3
PHENYLADE AMINO ACID 3
PHENYLADE AMINO ACID BLEN 3
PHENYLADE MTE 3
PHENYLADE MTE AMINO ACID 3
PHENYLADE PHEBLOC 3
phenylalanine TABS 3
phenylephrine hcl SOLN .25%, .5% 3
phenylephrine hcl (oral) 3
PHENYLEPHRINE HCL/PYRILAM 3
phenylephrine w/ dm-gg 3
phenylephrine-brompheniramine-dm 3
phenylephrine-cocoa butter 3
phenylephrine-guaifenesin 3
phenylephrine-shark liver oil-glycerin-
petrolatum
3
PHENYLHISTINE DH 3
phenylhistine dh modified 3
phenylprop-cpm-dm w/apap 3
phenylpropanolamine w/ dm-gg 3
phenylpropanolamine-gg 3
PHILLIPS 3
PHILLIPS COLON HEALTH 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
478
Drug Name Drug Tier Requirements/Limits
phillips milk of magnesia SUSP 7.75%, 400mg/5ml
3
PHILLIPS MILK OF MAGNESIA SUSP 800mg/5ml
3
phillips stool softener 3
PHLEXY-10 CAPS 3
phlexy-10 TABS 3
PHLEXY-VITS 3
PHOS FLUR 3
PHOS-FLUR ORTHO DEFENSE 3
PHOS-NAK POWDER CONCENTRA 3
PHYTOMULTI 3
phytonadione SOLN 1mg/0.5ml 3
phytonadione TABS 3
PIC 200 3
PIKO 1 ELECTRONIC 3
PILLOW MASK/ADULT 3
PILLOW MASK/CHILD 3
PILLOW MASK/PEDIATRIC 3
PIN-X CHEW 3
pin-x SUSP 3
pink bismuth 3
pink bismuth maximum stre 3
pink bismuth regular stre 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
479
Drug Name Drug Tier Requirements/Limits
pinworm medicine 3
PITUITARY 3
plantar wart remover 3
PLO ULTRAMAX 3
PNV PRENATAL PLUS MULTIVI TABS 3
POCKET PEAK FLOW METER 3
POCKETCHEM EZ BLOOD GLUCO 3
POCKETPEAK PEAK FLOW METE 3
podactin 3
podactin powder 3
POISE HOURGLASS SHAPE PAD 3
POISE LINERS 3
POISE LINERS VERY LIGHT A 3
POISE MICROLINERS/LIGHTES 3
POISE PAD 3
POISE PADS MAXIMUM ABSORB 3
POISE PADS MODERATE ABSOR 3
POISE PADS ULTIMATE ABSOR 3
POISE THIN-SHAPE PADS 3
POISE THIN-SHAPE PADS/MAX 3
POISE THIN-SHAPE PADS/MOD 3
POISE ULTRA THINS 3
polar frost 4% 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
480
Drug Name Drug Tier Requirements/Limits
POLAR FROST 4% 3
poly bacitracin 3
POLY HIST FORTE 3
poly vitamin 3
POLY-HIST DM 3
POLY-HIST PD 3
poly-iron 150 3
POLY-TUSSIN 3
POLY-TUSSIN AC 3
POLY-TUSSIN D 3
POLY-VENT DM 3
POLY-VENT IR 3
POLY-VI-SOL 3
POLY-VI-SOL/IRON 3
poly-vita drops 3
poly-vita/iron drops 3
poly-vitamin drops 3
poly-vitamin/iron drops 3
POLYBASE 3
polyethylene glycol 3350 PACK 3
polyethylene glycol 3350 POWD 3
POLYETHYLENE GLYCOL BLEND 3
POLYMEM ALGINATE DRESSING 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
481
Drug Name Drug Tier Requirements/Limits
POLYMEM SILVER DRESSING/4 3
polysaccharide iron complex 3
polysporin OINT 3
POLYSPORIN OINT 3
POLYSPORIN POWD 3
POLYTUSSIN DM 3
polyvinyl alcohol SOLN 3
polyvinyl alcohol-povidone (ophth) 3
polyvitamin 3
polyvitamin/iron 3
POSTURE 3
POSTURE-D CALCIUM/MAGNESI 3
potassium 99mg 3
potassium & sodium phosphates 3
POTASSIUM CITRATE GRAN 3
POTASSIUM CITRATE MONOHYD 3
potassium gluconate 2meq, 550mg,
595mg
3
POTASSIUM GLUCONATE 550mg 3
POTASSIUM GLUCONATE ER 3
POTASSIUM IODIDE SOLN; TABS 3
poten b-150 tr 3
povidone-iodine OINT 3
povidone-iodine SOLN 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
482
Drug Name Drug Tier Requirements/Limits
POVIDONE-IODINE SWAB 7.5% 3
povidone-iodine SWAB 10% 3
POVIDONE-IODINE PREP PAD 3
POVIDONE-IODINE PREP PADS 3
povidone-iodine vaginal 3
pramegel 3
pramegel hcl 3
pramoxine hcl (rectal) 3
pramoxine-calamine 3
pramoxine-phenylephrine-glycerin-petrolatum
3
prasterone (dhea) 3
PRAX 3
PRE PROTEIN POWD 3
pre protein TABS 3
pre-moistened witch hazel 3
PRE-NATAL 3
PRE-NATAL FORMULA 3
PRECISION LINK 3
PRECISION LINK DIRECT 3
PRECISION PCX 3
PRECISION PCX PLUS TEST S 3
PRECISION POINT OF CARE T 3
PRECISION QID MONITOR 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
483
Drug Name Drug Tier Requirements/Limits
PRECISION QID TEST STRIPS 3
PRECISION SOF-TACT MONITO 3
PRECISION SOF-TACT TEST S 3
PRECISION XTRA DEVI; KIT 3
PRECISION XTRA BLOOD GLUC 3
PRECISION XTRA MONITOR 3
PREFERRED PLUS GLUCOSE 3
PRELL LIQUID SHA N/O 3
PREMIUM BLOOD GLUCOSE TES 3
PREMIUM PACKETS 3
premsyn pms 3
PRENATAL 3
PRENATAL + COMPLETE MULTI 3
PRENATAL AND IRON 3
PRENATAL COMPLETE 3
PRENATAL FORMULA 3
PRENATAL FORMULA A-FREE 3
PRENATAL FORTE 3
PRENATAL GUMMIES/DHA & FO 3
PRENATAL LOW IRON 3
PRENATAL MULTI + DHA 3
PRENATAL MULTI +DHA 3
prenatal multivit-min w/fe-fa 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
484
Drug Name Drug Tier Requirements/Limits
PRENATAL MULTIVITAMIN 3
PRENATAL MULTIVITAMIN + D 3
PRENATAL MULTIVITAMIN PLU 3
*prenatal multivitamins & 3
PRENATAL ONE DAILY 3
PRENATAL TABLETS 3
PRENATAL VITAMIN 3
PRENATAL VITAMIN & MINERA 3
PRENATAL VITAMIN/IRON 3
PRENATAL VITAMINS 3
PRENATAL+DHA 3
PREORBOTIC 3
PREPARATION H CREA; GEL; OINT 3
preparation h PADS; SUPP 3
preparation h for women 3
preparation h hydrocortis 3
preparation h totables 3
PREPARATION H TOTABLES BU 3
PREPARATION H TOTABLES PA 3
PREPROTEIN 3
PREPROTEIN 20 3
pres gen 3
pres gen pediatric 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
485
Drug Name Drug Tier Requirements/Limits
PRESCRIPTIVE FORMULAS OPT 3
PRESERVISION AREDS 3
PRESERVISION AREDS 2 3
PRESERVISION AREDS 2 + MU 3
PRESERVISION/LUTEIN 3
presgen b 3
pressure & pain maximum s 3
PRETTY FEET & HANDS 3
PRETZ 3
PRETZ IRRIGATION 3
PREVACID 24HR 3
PREVAIL ADJUSTABLE UNDERW 3
PREVAIL ADULT BRIEF LARGE 3
PREVAIL ADULT BRIEF MEDIU 3
PREVAIL ADULT WASHCLOTHS 3
PREVAIL ADULT WASHCLOTHS/ 3
PREVAIL AIR PLUS STRETCHA 3
PREVAIL AIR STRETCHABLE B 3
PREVAIL ALL NITES UNDERWE 3
PREVAIL BARIATRIC A 3
PREVAIL BARIATRIC B 3
PREVAIL BLADDER CONTROL M 3
PREVAIL BLADDER CONTROL U 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
486
Drug Name Drug Tier Requirements/Limits
PREVAIL BOXERS FOR MEN L- 3
PREVAIL BOXERS FOR MEN SM 3
PREVAIL BREEZERS 360 SIZE 3
PREVAIL BREEZERS LARGE 3
PREVAIL BREEZERS MEDIUM 3
PREVAIL BREEZERS REGULAR 3
PREVAIL BREEZERS XL 3
PREVAIL BRIEF YOUTH 3
PREVAIL BRIEF/SMALL 3
PREVAIL CLASSIC FIT FOR W 3
PREVAIL COLOR COLLECTION 3
PREVAIL COLOR COLLECTIONS 3
PREVAIL CURVE PADS ULTIMA 3
PREVAIL EXTENDED USE BRIE 3
PREVAIL EXTRA PADS 3
PREVAIL EXTRA PLUS PADS 3
PREVAIL FITS TO A T LARGE 3
PREVAIL FITS TO A T MEDIU 3
PREVAIL FLUFF UNDERPADS/2 3
PREVAIL FOR MEN UNDERWEAR 3
PREVAIL FOR WOMEN UNDERWE 3
PREVAIL FULL COVERAGE UND 3
PREVAIL GUARDS FOR MEN 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
487
Drug Name Drug Tier Requirements/Limits
PREVAIL IB FULL MAT BRIEF 3
PREVAIL IBF FULL MAT BRIE 3
PREVAIL MESH PANTS 2XL 3
PREVAIL PADS/MAXIMUM ABSO 3
PREVAIL PADS/MODERATE ABS 3
PREVAIL PADS/OVERNIGHT 3
PREVAIL PADS/ULTIMATE ABS 3
PREVAIL PANT LINER/SMALL 3
PREVAIL PANTILINER 3
PREVAIL PER-FIT 360 UNDER 3
PREVAIL PER-FIT MEN UNDER 3
PREVAIL PER-FIT WOMEN UND 3
PREVAIL PREMIUM BRIEF ADU 3
PREVAIL PREMIUM UNDERPAD 3
PREVAIL PREMIUM WASHCLOTH 3
PREVAIL SIMPLY STRETCHFIT 3
PREVAIL SMOOTH FIT UNDERW 3
PREVAIL STRETCHFIT/SIZE A 3
PREVAIL STRETCHFIT/SIZE B 3
PREVAIL SUPER PLUS UNDERW 3
PREVAIL ULTIMATE BLADDER 3
PREVAIL ULTRA THIN PADS/L 3
PREVAIL ULTRATHIN UNDERWE 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
488
Drug Name Drug Tier Requirements/Limits
PREVAIL UNDERPADS SUPER A 3
PREVAIL UNDERWEAR 2XL 3
PREVAIL WASHCLOTHS 3
PREVAIL WET WIPES 3
PREVAIL WOMENS PURSEREADY 3
PREVAIL XTREME FIT/PLUS/4 3
PREVAIL XTREME FIT/REGULA 3
prevent 3
PREVENT PLUS SUPERGUARD 3
PRILOSEC OTC 3
PRIMACOL BORDERED DRESSIN 3
PRIMACOL DRESSING 4"X4" 3
PRIMACOL DRESSING 6"X6" 3
PRIMACOL DRESSING 8"X8" 3
PRIMACOL SPECIALTY DRESSI 3
primadophilus 3
PRIMATENE ASTHMA 3
PRIMATENE MIST AERS 3
PRO COMFORT INHALER SPACE 3
pro hormone dhea antioxid 3
PRO NUTRIENTS PROBIOTIC 3
PRO VOICE V8 BLOOD GLUCOS 3
PRO VOICE V8/V9 BLOOD GLU 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
489
Drug Name Drug Tier Requirements/Limits
PRO VOICE V9 BLOOD GLUCOS 3
PRO-BIOTIC BLEND 3
PRO-CAL TABS 3
PRO-CHLO 3
PRO-CLEAR AC 3
pro-ex antifungal 3
PRO-FLORA IMMUNE 3
PRO-RED AC 3
pro-stat 3
pro-stat 64 3
pro-stat 101 3
pro-stat awc 3
pro-stat max 3
pro-stat profile 3
pro-stat rc 3
pro-stat renal care 3
pro-stat sugar free 3
pro-stat/fiber 3
probiata 3
PROBIOMAX DAILY DF 3
PROBIOMAX PLUS DF 3
PROBIOTIC CAPS 3
PROBIOTIC & ACIDOPHILUS F 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
490
Drug Name Drug Tier Requirements/Limits
PROBIOTIC + COLOSTRUM 3
PROBIOTIC + OMEGA-3 3
probiotic acidophilus 3
PROBIOTIC ACIDOPHILUS 3
PROBIOTIC ACIDOPHILUS BEA 3
probiotic acidophilus sup 3
PROBIOTIC ADVANCED ULTRA 3
probiotic chewable childr 3
PROBIOTIC COLON SUPPORT 3
PROBIOTIC COMPLEX/ACIDOPH 3
PROBIOTIC DAILY 3
PROBIOTIC DIGESTIVE SUPPO 3
PROBIOTIC FORMULA 3
probiotic gold extra stre 3
PROBIOTIC GOLD EXTRA STRE 3.33mg 3
PROBIOTIC MATURE ADULT 3
PROBIOTIC MULTI-ENZYME 3
probiotic packets childre 3
PROBIOTIC PEARLS 3
PROBIOTIC PEARLS ADVANTAG 3
PROBIOTIC-10 3
PROBIOTIC-10 ULTIMATE 3
PROCARE ADULT BRIEFS LARG 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
491
Drug Name Drug Tier Requirements/Limits
PROCARE ADULT BRIEFS MEDI 3
PROCARE ADULT BRIEFS X-LA 3
PROCARE ADULT WASHCLOTHS/ 3
PROCARE BARIATRIC BRIEFS 3
PROCARE BREATHABLE ADULT 3
PROCARE PLUS UNDERWEAR LA 3
PROCARE PLUS UNDERWEAR ME 3
PROCARE PLUS UNDERWEAR X- 3
PROCARE PROTECTIVE UNDERW 3
PROCARE UNDERPADS/21"X34" 3
PROCEL 3
PROCEL 100 3
PROCERV HP 3
procomycin 3
PROCTOFOAM 3
PRODIGEN 3
PRODIGY AUTOCODE BLOOD GL 3
PRODIGY LANCING DEVICE 3
PRODIGY NO CODING BLOOD G 3
PRODIGY POCKET BLOOD GLUC 3
PRODIGY VOICE BLOOD GLUCO 3
prodium 3
PROFE 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
492
Drug Name Drug Tier Requirements/Limits
PROFE FORTE 3
PROFERRIN ES 3
PROFERRIN-FORTE 3
PROGAINE SHA NORM/OIL 3
promethazine vc/codeine 3
promethazine w/codeine 3
promethazine-dm 3
promethazine-phenylephrine-codeine 3
PROMISE DAY LIGHT PAD 3
promolaxin 3
PRONTO 3
PRONTO COMPLETE LICE KILL 3
pronto plus - lice killin 3
pronutrients calcium+d3 3
pronutrients coq10 3
PRONUTRIENTS SUPER B-COMP 3
pronutrients vitamin d3 3
propa ph acne medication 3
PROPA PH PEEL-OFF ACNE MA 3
PRORENAL+D 3
PRORENAL+D/OMEGA-3 3
PROSHIELD PLUS SKIN PROTE 3
PROSHIELD PROTECTIVE HAND 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
493
Drug Name Drug Tier Requirements/Limits
prosight w/lutein 3
PROSOURCE PACK 3
PROSTATE TABS 3
PROSTEON 3
PROSYNMINIC 3
PROTECT CARDIO AF 3
PROTECT PLUS 3
PROTECT PLUS NF 3
PROTECT PLUS SO 3
PROTECTION PLUS CLASSIC U 3
PROTECTION PLUS DELUXE UN 3
PROTECTION PLUS UNDERWEAR 3
PROTECTIVE UNDERWEAR EXTR 3
PROTECTIVE UNDERWEAR LARG 3
PROTECTIVE UNDERWEAR MEDI 3
PROTECTIVE UNDERWEAR SMAL 3
PROTECTIVE UNDERWEAR SU P 3
PROTECTIVE UNDERWEAR SUPE 3
PROTECTIVE UNDERWEAR XL 3
PROTECTIVE UNDERWEAR XTRA 3
PROTEGRA 3
protein CHEW 3
PROTEIN POWD 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
494
Drug Name Drug Tier Requirements/Limits
PROTEIN'D CHEESE SAUCE 3
PROTEINEX LIQD 3
proteinex TABS 3
proteinex p100 3
proteinex-18 3
PROTEXIN 3
PROVELLA 3
PROVIDE UNDERPAD 3
PROVIDE UNDERPAD ULTRA 3
provil 200mg 3
PROVIT 3
PROXACOL 3
PROXEED 3
pseudoeph-cpm-dm w/apap 3
pseudoeph-diphenhyd-dm w/apap 3
pseudoephed-bromphen-dm 3
pseudoephed-cpm w/ hydrocod 3
pseudoephed-doxyl-dm w/apap 3
PSEUDOEPHEDRINE 3
PSEUDOEPHEDRINE HCL LIQD 3
pseudoephedrine hcl SYRP 3
pseudoephedrine hcl TABS 30mg, 60mg 3
pseudoephedrine hcl TB12 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
495
Drug Name Drug Tier Requirements/Limits
PSEUDOEPHEDRINE HCL TAB 3 3
pseudoephedrine w/ acetam 3
pseudoephedrine w/ apap-dm tab 30-325-15 mg
3
pseudoephedrine w/ apap-dm tab 30-500-
15 mg
3
pseudoephedrine w/ dm-gg 3
pseudoephedrine-acetaminophen 3
pseudoephedrine-acetaminophen-dextromethorphan
3
pseudoephedrine-chlorphen-dm 3
pseudoephedrine-dm 3
pseudoephedrine-dm-gg w/ apap 3
pseudoephedrine-guaifenesin 3
psoriasin LIQD 3
PSORIASIS MEDICATED SKIN 3
psudatabs 3
psyldex 3
psyllium 3
PTS PANELS GLUCOSE TEST 3
pulmosal 3
PURACYN PLUS DUO-CARE 3
puralube 3
pure & gentle enema 3
pure & gentle lubricant 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
496
Drug Name Drug Tier Requirements/Limits
pure c 500 3
PURE EYES 1 CLEANER/RINSE 3
PURE EYES 2 DISINFECTANT/ 3
pure l-arginine hcl 3
PURE L-CITRULLINE 3
pure l-tyrosine 3
pureway-c 3
purpose 3
PURPOSE GENTLE CLEANING W 3
PURPOSE MOISTURIZER 3
pvp prep 3
px acid reducer 3
px acid reducer maximum s 3
px advanced formula multi 3
PX ADVANCED LANCING DEVIC 3
px all day relief 3
px allergy 3
px allergy relief 3
px allergy relief d 3
px allergy sinus pe 3
px antacid extra strength 3
px antacid maximum streng 3
px antacid regular streng 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
497
Drug Name Drug Tier Requirements/Limits
px anti-diarrheal 3
px arthritis pain relief 3
px artificial tears 3
px aspirin 3
px athletic foot 3
px b complex/vitamin c 3
px b-50 3
PX CALAMINE 3
px calcium antacid regula 3
px calcium&d 3
px childrens allergy 3
px childrens pain relief 3
px childrens profen ib 3
px childrens vitamin 3
px cold relief multi-symp 3
px cold/flu relief day/ni 3
px complete senior multiv 3
px dayhist allergy 3
px daytime cold 3
px daytime cold/flu relie 3
PX DAYTIME MULTI-SYMPTOM 3
px daytime pe 3
px dibromm cold/allergy c 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
498
Drug Name Drug Tier Requirements/Limits
px dibromm dm cold/cough 3
px docusate sodium 3
px dual action 3
px effervescent 3
px enteric aspirin 3
px fiber 3
px folic acid 3
px gas relief extra stren 3
px gas relief infants 3
px gas relief ultra stren 3
px glucosamine-chondroiti 3
px glucosamine/chondroiti 3
PX GLUCOSE 3
px glycerin 3
px headache relief added 3
px hemorrhoidal 3
px hydrocream 3
px hydrogen peroxide 3
px ibuprofen 3
px ibuprofen cold & sinus 3
px ibuprofen junior stren 3
px infants profen ib 3
px iron 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
499
Drug Name Drug Tier Requirements/Limits
PX LANCET AUTO INJECTOR 3
px laxative 3
px medicated chestrub 3
px mens multivitamins 3
px miconazole 3-day combo 3
px migraine relief 3
px milk of magnesia 3
px nasal decongestant 3
px nasal decongestant pe 3
px nasal four 3
px nasal spray extra mois 3
px niacin 3
px nighttime cold 3
px nitetime cold/flu reli 3
px nitetime cough 3
PX NITETIME MULTI-SYMPTOM 3
px no drip nasal spray 3
PX OMEPRAZOLE 3
px original nasal spray 3
px pain relief extra stre 3
px pain relief pm extra s 3
px personal lubricant jel 3
PX PRENATAL MULTIVITAMINS 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
500
Drug Name Drug Tier Requirements/Limits
px ranitidine 3
px saline nasal spray 3
px severe cold 3
px sinus relief 3
px sore throat 3
px sterile eye drops 3
px stomach relief 3
px stomach relief maximum 3
px stop smoking aid 3
px triple ointment 3
px tussin 3
px tussin cf 3
px tussin dm 3
px tussin max 3
px vegetable laxative 3
px vitamin a 3
px vitamin c 3
px vitamin e 3
pyrantel pamoate SUSP 3
PYRETHINS/PIPERONYL BUTO 3
pyrethrins-piperonyl butoxide 3
pyri 500 3
PYRIDOXAL-5-PHOSPHATE MON 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
501
Drug Name Drug Tier Requirements/Limits
PYRIDOXINE HCL POWD 3
pyridoxine hcl TABS 25mg, 50mg, 100mg, 250mg, 500mg
3
pyridoxine hcl TBCR 3
pyril d 3
PYRIL DM 3
pyrilamine maleate-phenylephrine hcl tannate
3
pyrroxate 3
q-dryl 3
Q-GEL 3
q-gel forte 3
q-gel mega 3
q-gel ultra 3
q-pap 3
q-pap childrens 3
q-pap extra strength 3
q-pap infants 3
q-sorb 3
q-sorb co q-10 3
q-tapp 3
q-tapp dm 3
q-tussin 3
q-tussin dm 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
502
Drug Name Drug Tier Requirements/Limits
q-up 3
qc 3 day vaginal cream 3
qc acetaminophen 8 hours 650mg 3
qc acid controller 3
qc acid controller maximu 20mg 3
QC ADVANCED LANCING DEVIC 3
qc all day allergy 3
qc allergy relief 3
qc allergy relief childre 3
qc allergy relief multi-s 3
qc allergy/sinus headache 3
qc antacid CHEW 500mg 3
qc antacid SUSP 3
qc antacid extra strength 3
qc antacid/anti-gas 3
qc antacid/anti-gas maxim 3
qc anti-diarrheal 2mg 3
qc anti-gas ultra strengt 3
qc anti-itch extra streng 3
qc antiseptic pain relief 3
qc arthritis cream 3
qc arthritis pain relief 650mg 3
qc artificial tears 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
503
Drug Name Drug Tier Requirements/Limits
qc aspirin TABS 325mg 3
qc aspirin TBEC 3
qc aspirin low dose 81mg 3
qc athletes foot 3
qc azo 3
qc bacitracin 3
QC CALAMINE 3
qc calcium 600 +d3 3
qc calcium fast dissoluti 3
qc calcium/minerals/vitam 3
qc chewable aspirin low d 81mg 3
qc childrens allergy 3
qc childrens aspirin 3
qc childrens chewable com 3
qc childrens chewable vit 3
qc childrens ibuprofen 100mg/5ml 3
qc chlor-pheniramine 3
qc clotrimazole 3
QC COD LIVER OIL 3
qc cold head congestion n 3
qc cold head congestion s 3
qc cold multi-symptom nig 3
qc cold multi-symptom sev 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
504
Drug Name Drug Tier Requirements/Limits
qc cold relief 3
qc cold relief plus 3
qc cold relief plus multi 3
qc complete allergy medic 3
qc cough & cold hbp 3
qc cough relief 3
qc cough/sore throat nigh 3
qc daily multivitamins/ir 3
qc daytime cold & flu 3
qc daytime multi-symptom 3
qc diarrhea relief 3
qc dibromm childrens cold 3
qc docusate calcium 3
qc ear wax removal drops 3
qc effervescent antacid/p 3
qc enema 3
qc enteric aspirin 3
qc epsom salt 3
qc essentials 3
qc eye wash 3
qc ferrous sulfate 3
qc fexofenadine hydrochlo 3
qc fiber laxative 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
505
Drug Name Drug Tier Requirements/Limits
qc flu relief therapy sev 3
qc fluticasone propionate 3
qc gas relief 3
qc gas relief extra stren 3
qc gentle laxative 3
qc glycerin 3
qc headache relief 3
qc headache relief pm 3
qc heartburn antacid 3
qc hemorrhoidal 3
qc hemorrhoidal maximum f 3
qc hydrocortisone 3
qc hydrocortisone maximum 3
qc hydrogen peroxide 3
qc ibuprofen CAPS 3
qc ibuprofen TABS 200mg 3
qc ibuprofen cold/sinus 3
qc ibuprofen ib 3
qc ibuprofen infants 3
QC IODIDES TINCTURE 3
QC IODINE TINCTURE 3
qc isopropyl rubbing alco 3
qc loratadine allergy rel 10mg 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
506
Drug Name Drug Tier Requirements/Limits
qc loratadine-d 3
qc m-zole 3 combination p 3
qc magnesium citrate 3
qc maximum daily multivit 3
qc medicated pads pre-moi 3
qc medifin 400 400mg 3
qc medifin dm 3
qc medifin mucus relief c 3
QC MEDIFIN PE 3
qc mens daily multivitami 3
qc miconazole 7 3
qc milk of magnesia 400mg/5ml 3
qc mineral oil heavy 3
qc mucus relief 3
qc mucus relief er 12 hou 3
QC MULTI-PURPOSE 3
qc multi-vite 3
qc multi-vite 50 & over 3
qc multi-vite plus 3
qc naproxen sodium 3
qc nasal relief extra moi 3
qc nasal relief sinus 3
qc natura-lax 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
507
Drug Name Drug Tier Requirements/Limits
qc natural vegetable 3
qc nicotine polacrilex 3
qc nighttime cold/flu rel 3
qc nighttime cough 3
qc nighttime multi-sympto 3
qc no drip nasal relief 3
qc non-aspirin 8 hour 3
qc non-aspirin childrens 3
qc non-aspirin extra stre 500mg 3
qc non-aspirin jr strengt 3
qc non-aspirin pm 3
qc omeprazole magnesium 3
qc pain relief 3
qc pain relief childrens 160mg/5ml 3
qc pain relief extra stre 3
qc pain relief infants 160mg/5ml 3
qc pain reliever extra st 3
qc pink bismuth 3
qc pm pain relief 3
qc povidone iodine 3
QC PRENATAL 3
qc rest simply 3
qc saline nasal relief 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
508
Drug Name Drug Tier Requirements/Limits
qc senna 3
qc senna-s 3
qc severe allergy 3
qc severe cold & cough da 3
qc severe cold & cough ni 3
qc sinus congestion & pai 3
qc sinus pain relief 3
qc sleep aid maximum stre 3
qc sore throat 3
qc sore throat spray 3
qc stool softener 3
qc stool softener plus la 3
qc stool softener plus st 3
qc suphedrine 3
qc suphedrine cough/cold 3
qc suphedrine maximum str 3
qc suphedrine pe 3
qc therin-m 3
qc tolnaftate 1% 3
qc tussin cf 3
qc tussin dm cough & ches 3
qc tussin mucus + chest c 3
qc urinary pain relief 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
509
Drug Name Drug Tier Requirements/Limits
qc witch hazel 3
qc womens daily multivita 3
QH 3
qlearquil 3
qlearquil all day & all n 3
qlearquil daytime sinus & 3
qlearquil nighttime alle 3
qlearquil nighttime sinu 3
quenalin 3
QUENCH 3
QUERCETIN 3
QUICKABLES DRY WIPES 3
QUICKCARE 3
QUICKTEK 3
QUICKTEK TEST STRIPS 3
QUIN B STRONG 3
quin b strong b-25 3
QUINTABS 3
quintabs-m 3
QUINTABS-M 3
QUINTET AC BLOOD GLUCOSE 3
QUINTET BLOOD GLUCOSE MON 3
QUINTET BLOOD GLUCOSE TES 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
510
Drug Name Drug Tier Requirements/Limits
qunol coq10/ubiquinol/meg 3
ra 8 hour pain relief 3
ra 12 hour nasal spray 3
ra acetaminophen 3
ra acetaminophen children 3
ra acetaminophen er 3
ra acetaminophen extra st 3
RA ACETAMINOPHEN FLU SEVE 3
ra acetaminophen pm extra 3
ra acetaminophen rapid me 3
ra acid reducer 3
ra acid reducer maximum s 3
ra acid reducer plus anta 3
ra acidophilus 3
ra acne cleanser oil-free 3
ra acne treatment 3
ra acta-tabs pe 3
RA ADULT WIPES 3
ra advanced healing LOTN 3
RA ADVANCED HEALING OINT 3
ra advanced recovery skin 3
ra allergy 3
ra allergy cream 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
511
Drug Name Drug Tier Requirements/Limits
ra allergy medication 3
ra allergy medication chi 3
ra allergy multi-symptom 3
ra allergy plus sinus 3
ra allergy relief 3
ra allergy relief 24 hour 3
ra allergy relief childre 3
ra allergy relief-d 3
ra allergy/congestion rel 3
ra alpha-lipoic acid 3
ra anorectal 3
ra antacid 3
ra antacid extra strength 3
ra antacid pain relief 3
ra antacid ultra strength 3
ra antacid/anti-gas 3
ra antacid/antigas maximu 3
ra antacid/gas relief max 3
ra anti-diarrheal 3
ra anti-gas 3
ra anti-itch & skin prote 3
ra anti-itch extra streng 3
ra anti-itch maximum stre 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
512
Drug Name Drug Tier Requirements/Limits
ra anti-itch/maximum stre 3
ra anti-nausea 3
ra antibiotic plus 3
ra antibiotic/pain relief 3
ra anticavity fluoride ri 3
ra antifungal 3
ra antifungal foot care 3
ra antifungal spray 3
ra antihistamine eye drop 3
ra antiseptic 3
ra antiseptic mouth clean 3
ra antiseptic mouth rinse 3
ra antiseptic skin cleans 3
ra apricot scrub 3
ra arthritic pain rub 3
ra arthritis pain relief 3
ra artificial tears eye c 3
ra aspirin 3
ra aspirin adult low dose 3
ra aspirin adult low stre 3
ra aspirin childrens 3
ra aspirin ec 3
ra aspirin ec adult low s 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
513
Drug Name Drug Tier Requirements/Limits
ra athletes foot 3
ra athletes foot powder s 3
RA B-12 3
ra b-complex 3
ra b-complex with b-12 3
ra b-complex/vitamin c tr 3
ra baby care oral pain re 3
ra baby care vitamins a&d 3
ra bacitracin 3
ra bacitracin zinc first 3
ra back & body pain relie 3
ra backache relief 3
ra balanced b-50 3
ra balanced b-50 tr 3
ra balanced b-100 3
ra balanced b-100 tr 3
RA BELTED UNDERGARMENT EX 3
RA BELTED UNDERGARMENT RE 3
ra beta carotene 3
ra biotin 3
RA BLADDER CONTROL LINERS 3
RA BLADDER CONTROL PADS 3
RA BLADDER CONTROL PADS/W 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
514
Drug Name Drug Tier Requirements/Limits
RA BLOOD GLUCOSE MONITOR 3
ra body powder medicated 3
RA BOXERS/MEDIUM ABSORBAN 3
RA BRIEFS FOR MEN & WOMEN 3
ra budesonide nasal spray 3
RA BUNION CUSHION 3
RA CALAMINE LOTN 3
ra calcium 3
ra calcium 600 3
ra calcium 600 plus vitam 3
ra calcium 600/vit d/mine 3
ra calcium citrate plus v 3
ra calcium citrate/vitami 3
ra calcium hi-cal 3
RA CALCIUM HI-CAL/VITAMIN 3
ra calcium high potency 3
ra calcium plus vitamin d 3
ra calcium soft chews 3
RA CALCIUM/BORON 3
ra calcium/magnesium/zinc 3
ra calcium/minerals/vitam 3
RA CALLUS CUSHIONS 3
ra calming daily moisturi 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
515
Drug Name Drug Tier Requirements/Limits
ra capsicum hot patch 3
ra central-vite 3
RA CENTRAL-VITE 3
ra central-vite cardio 3
ra central-vite energy 3
ra central-vite mens matu 3
ra central-vite performan 3
ra central-vite select 3
ra central-vite select ma 3
ra central-vite senior 3
RA CENTRAL-VITE UNDER 50 3
ra central-vite womens ma 3
ra central-vite/antioxida 3
ra cetiri-d 3
ra cetirizine 3
ra cetirizine childrens 3
ra cetirizine hcl childre 3
ra chewable vitamins comp 3
ra childrens aspirin 3
ra childrens chewable vit 3
ra childrens cold & aller 3
ra childrens flu relief p 3
ra childrens non-aspirin 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
516
Drug Name Drug Tier Requirements/Limits
ra childrens plus cough/r 3
ra childrens plus multisy 3
ra chlorpheniramine malea 3
ra chromium picolinate 3
ra cleaning/disinfecting 3
ra clotrimazole 3
ra clotrimazole 3 3
ra clotrimazole 7 3
ra cod liver oil CAPS 3
RA COD LIVER OIL OIL 3
ra coenzyme q-10 3
ra col-rite 3
ra cold & allergy 3
ra cold & cough childrens 3
ra cold & cough dm 3
ra cold & flu 3
ra cold multi-symptom day 3
ra cold multi-symptom nig 3
ra cold multi-symptom sev 3
ra cold/cough sinus relie 3
ra cold/flu multi-symptom 3
ra cold/flu relief daytim 3
ra cold/flu relief nightt 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
517
Drug Name Drug Tier Requirements/Limits
ra cold/flu/sore throat m 3
ra cold/sinus max 3
ra complete allergy 3
ra cool heat 3
ra coral calcium 3
RA CORN CUSHIONS/SMALL 3
ra corn removers ultra th 3
ra cough dm 3
ra cough drops 5.8mg, 9.1mg 3
ra daily face wash/deep c 3
ra dandruff shampoo LOTN 3
ra day time cold/flu form 3
ra day/night maximum stre 3
RA DAYLOGIC HEALING DRY S 3
ra daytime cold & flu rel 3
RA DAYTIME COLD/FLU 3
ra daytime multi-symptom 3
ra daytime/nighttime/cold 3
ra decongestant inhaler 3
RA DELUXE UNDERPADS FOR M 3
ra derma 3
ra diaper rash 3
ra digestive health 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
518
Drug Name Drug Tier Requirements/Limits
ra diphedryl allergy 3
ra double antibiotic 3
ra draw out salve 3
RA DRY MOUTH 3
RA DRY MOUTH MOUTHWASH 3
ra dual action complete a 3
RA EAR CARE 3
ra ear drops 3
RA EAR WAX CLEANSING SYST 3
RA EAR-LOOP MASK 3
ra earwax removal kit 3
RA EFFERVESCENT FORMULA 3
ra enema 3
ra epsom salt 3
RA EPSOM SALT 3
RA EPSOM SALT LAVENDER 3
ra esomeprazole magnesium 3
RA ESSENCE-C 3
ra eye allergy relief 3
ra eye itch relief 3
ra fast relief laxative 3
ra fever reducer & pain r 3
ra fever reducer/pain rel 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
519
Drug Name Drug Tier Requirements/Limits
ra fiber 3
ra fiber laxative 3
ra fiber supplement 3
ra fiber therapy 3
ra fiber weight managemen 3
ra fiber-cap 3
ra fiber-tab 3
ra first aid anti-itch sp 3
RA FIRST AID IODINE 3
ra first aid saline wound 3
ra fish oil CPDR 3
ra flu maximum strength 3
ra folic acid 3
ra foot care antifungal 3
ra gas relief 3
ra gas relief extra stren 3
ra gas relief maximum str 3
ra gas relief ultra stren 3
ra gas relief/infants 3
ra gel hammer toe cushion 3
ra gentle skin cleanser 3
RA GENTLE SKIN CREAM 3
ra gentle skin lotion 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
520
Drug Name Drug Tier Requirements/Limits
RA GERM DEFENSE TBEF 3
ra glucosamine/chondroiti 3
RA GLUCOSE CHEW 3
ra glucose GEL 3
ra glycerin 3
ra glycerin adult 3
ra glycerin child 3
RA GUARDS 3
RA GUARDS FOR MEN MAXIMUM 3
ra gummy vitamins & miner 3
ra hair/skin/nails 3
ra head congestion cold d 3
ra head congestion cold r 3
ra headache formula 3
ra headache formula extra 3
ra hemorrhoid relief 3
ra hemorrhoid relief medi 3
ra hemorrhoidal 3
ra hemorrhoidal cooling 3
ra hi cal 3
ra hi-cal 3
ra hi-cal plus vitamin d 3
ra high potency iron 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
521
Drug Name Drug Tier Requirements/Limits
ra hydrating healing 3
ra hydrocortisone maximum 3
ra hydrocortisone plus 3
ra hydrocortisone plus 12 3
ra hydrogen peroxide 3
ra ibu-profen cold/sinus 3
ra ibuprofen 3
ra ibuprofen childrens 3
ra ibuprofen cold childre 3
ra ibuprofen infants 3
ra ibuprofen junior stren 3
ra ibuprofen pm 3
ra intimacy gels for him 3
ra iron 3
ra isopropyl alcohol 3
ra isopropyl rubbing alco 3
ra jock itch 3
ra jock itch maximum stre 3
ra k-pec 3
ra l-arginine 3
RA LAMBS WOOL 3
RA LANCING DEVICE 3
ra lansoprazole 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
522
Drug Name Drug Tier Requirements/Limits
ra laxative CHEW; PACK; POWD; TBEC 3
ra laxative & stool softe 3
ra laxative extra strengt 3
ra laxative maximum stren 3
ra lice bedding 3
ra lice egg remover 3
ra lice maximum strength 3
ra lice solution kit 3
RA LICE SOLUTION KIT 3
ra lice treatment 3
ra liquid antacid 3
ra loperamide hcl 3
ra lorata-d 3
ra loratadine 3
ra loratadine childrens 3
ra lubricant eye 3
ra lubricant eye drops 3
ra lubricating gel 3
ra magnesium 3
ra magnesium citrate 3
RA MAKEUP REMOVER EYELID 3
ra mature womens dietary 3
RA MAXI PADS LONG 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
523
Drug Name Drug Tier Requirements/Limits
RA MAXI PADS REGULAR 3
RA MAXI SUPER 3
ra medicated chest rub 3
ra medicated first aid sp 3
ra medicated wipes pre-mo 3
ra melatonin TABS 3mg, 5mg 3
ra menopause support 3
ra menstrual complete pai 3
ra menstrual pain relief 3
ra menstrual relief 3
ra menthol nasal inhaler 3
ra miconazole 3 combinati 3
ra miconazole 7 3
ra migraine relief 3
ra milk of magnesia 3
ra mineral oil 3
ra mini nicotine 3
ra moisturizing oatmeal 3
ra moisturizing therapy 3
ra motion sickness relief 3
ra mouthwash alcohol free 3
ra mouthwash/gargle 3
ra mucus relief 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
524
Drug Name Drug Tier Requirements/Limits
ra mucus relief chest 3
ra mucus relief d 3
ra mucus relief d maximum 3
ra mucus relief dm 3
ra mucus relief maximum s 3
ra mucus relief plus 3
ra mucus relief sinus 3
ra multi-purpose solution 3
ra multi-symptom cold rel 3
ra multihealth fiber supp 3
ra naproxen sodium 3
ra nasal allergy spray 3
ra nasal decongestant 3
ra nasal decongestant pe 3
ra nasal spray maximum st 3
ra nasal spray/moisturizi 3
ra nasal spray/regular 3
ra nasal spray/sinus 3
ra natural magnesium 3
ra natural vitamin e 3
ra niacin 3
ra nicotine 3
ra nicotine gum 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
525
Drug Name Drug Tier Requirements/Limits
ra nicotine polacrilex 3
ra nicotine transdermal s 3
ra night sleep aid 3
ra nighttime cold & flu r 3
ra nighttime cold/flu rel 3
ra nighttime cough relief 3
ra nighttime sleep aid 3
ra nite time cold/flu for 3
ra nite time cough 3
ra no flush niacin 500 3
ra nose drops extra stren 3
RA OMEPRAZOLE 3
ra omeprazole/sodium bica 3
RA ONE DAILY 3
ra one daily energy formu 3
ra one daily essential 3
ra one daily gummy vites 3
ra one daily maximum 3
ra one daily mens 50+ wit 3
ra one daily mens multi 3
ra one daily mens/vitamin 3
ra one daily multi-vitami 3
ra one daily womens/vitam 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
526
Drug Name Drug Tier Requirements/Limits
ra one-step corn remover 3
ra ophthalmic solution 3
RA OVERNIGHT PADS FOR WOM 3
ra oyster shell calcium 3
ra oyster shell calcium/v 3
RA OYSTER SHELL CALCIUM/V 3
ra p col-rite 3
RA PADS FOR WOMEN MAXIMUM 3
RA PADS FOR WOMEN MODERAT 3
RA PADS FOR WOMEN ULTIMAT 3
ra pain relief acetaminop 3
ra pain relief ibuprofen 3
ra pain reliever extra st 3
ra pain reliever pm 3
RA PANTILINERS 3
RA PANTILINERS LONG 3
RA PANTY LINERS 3
RA PANTY SHIELDS 3
ra pediatric electrolyte 3
ra personal lubricant jel 3
ra personal lubricant moi 3
ra personal lubricating j 3
ra petroleum jelly GEL 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
527
Drug Name Drug Tier Requirements/Limits
ra pink bismuth 3
ra potassium gluconate 3
ra potassium/magnesium as 3
ra povidone iodine 3
RA PREMIUMPLUS FITTED BRI 3
RA PRENATAL 3
RA PRENATAL FORMULA/FOLIC 3
RA PROBIOTIC COLON CARE 3
RA PROBIOTIC COMPLEX 3
ra probiotic digestive ca CAPS 3
RA PROBIOTIC DIGESTIVE CA TABS 3
RA PROBIOTIC DIGESTIVE SU 3
RA PROBIOTIC MAXIMUM STRE 3
RA PROTECTIVE UNDERWEAR E 3
RA PROTECTIVE UNDERWEAR O 3
RA PROTECTIVE UNDERWEAR S 3
RA RENEWAL ADVANCED HEALI 3
ra renewal cocoa butter 3
ra renewal dandruff shamp 3
RA RENEWAL DRY SKIN THERA 3
ra renewal eczema moistur 3
ra renewal medicated acne 3
ra renewal moisturizing 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
528
Drug Name Drug Tier Requirements/Limits
ra renewal shower & bath 3
ra renewal soothing bath 3
ra rewetting drops 3
ra saline enema 3
ra saline nasal spray 3
ra saline solution 3
RA SALINE WOUND WASH 3
ra scalp itch/dandruff re 3
ra scar gel 3
ra selenium 3
ra selenium natural 3
ra senna TABS 3
ra senna plus 3
ra sensitive anti-itch 3
ra severe allergy plus si 3
ra severe cold & cough da 3
ra severe cold/night time 3
ra severe cold/sinus reli 3
ra severe congestion nasa 3
ra severe congestion/cold 3
ra severe sinus congestio 3
RA SIESTA MASK 3
ra sinus congestion & pai 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
529
Drug Name Drug Tier Requirements/Limits
ra sinus pressure/congest 3
RA SINUS RELIEF DAYTIME/N 3
RA SKIN CLEANSING 3
ra sleep aid 3
ra sleep aid maximum stre 3
ra sleep-aid nighttime 3
ra slow release iron 3
ra smooth antacid extra s 3
ra soluble fiber 3
ra sore throat 3
ra stay awake extra stren 3
ra stay awake maximum str 3
ra sterile eye wash 3
RA STERILE SALINE NASAL M 3
ra stimulant laxative 3
ra stomach relief 3
ra stomach relief kids 3
ra stomach relief maximum 3
ra stool softener 3
ra stress formula advance 3
ra stress formula energy 3
ra super moleskin 3
ra suphedrine 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
530
Drug Name Drug Tier Requirements/Limits
ra suphedrine pe 3
ra suphedrine pe day and 3
ra suphedrine pe sinus he 3
RA SURECHOICE BLADDER CO 3
RA SURECHOICE BLADDER CON 3
RA SURECHOICE PADS/LIGHT 3
RA SURECHOICE PADS/MAXIMU 3
RA SURECHOICE PADS/MODERA 3
RA SURECHOICE PANTILINER 3
ra tension headache pain 3
ra therapeutic blue gel 3
ra therapeutic m plus bet 3
ra therapeutic shampoo 3
ra tioconazole 1 3
ra total moisture 3
ra tri-buffered aspirin 3
ra triple antibiotic 3
ra triple antibiotic plus 3
RA TRIPLE ANTIBIOTIC SPRA 3
RA TRUE2GO BLOOD GLUCOSE 3
RA TRUEPLUS GLUCOSE 3
RA TRUERESULT BLOOD GLUCO 3
RA TRUETEST STRIPS 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
531
Drug Name Drug Tier Requirements/Limits
ra tugaboos creamy petrol 3
ra tugaboos petroleum je 3
ra tussin 3
ra tussin cf 3
ra tussin chest congestio 3
ra tussin cough 3
ra tussin cough & cold mu 3
ra tussin cough adult 3
ra tussin cough dm sugar 3
ra tussin cough/chest con 3
ra tussin dm 3
ra tussin long acting cou 3
ra tussin maximum strengt 3
ra tussin nighttime cough 3
RA UNDERPADS FOR MEN & WO 3
RA UNDERPADS FOR MEN/WOME 3
RA UNDERPADS SUPER LARGE 3
RA UNDERWEAR FOR MEN & WO 3
RA UNDERWEAR FOR MEN MAXI 3
RA UNDERWEAR FOR MEN/WOME 3
RA UNDERWEAR FOR WOMEN MA 3
RA UNDERWEAR FOR WOMEN MO 3
ra urinary pain relief 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
532
Drug Name Drug Tier Requirements/Limits
ra urinary pain relief ma 3
ra urinary tract pain rel 3
ra vanishing acne treatme 3
ra vaporizing steam 3
ra vision vite plus zinc 3
ra vitamin a 3
ra vitamin a & d 3
ra vitamin b12 3
ra vitamin b-1 3
ra vitamin b-6 3
ra vitamin b-6 tr 3
RA VITAMIN B-12 LIQD 3
ra vitamin b-12 TABS 3
ra vitamin b-12 tr 3
ra vitamin c CHEW 250mg, 500mg 3
RA VITAMIN C CHEW 300mg 3
ra vitamin c TABS 3
RA VITAMIN C DROPS 53mg 3
ra vitamin c drops 60mg 3
ra vitamin c tr 3
ra vitamin c/acerola 3
ra vitamin c/rose hips 3
ra vitamin c/rose hips tr 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
533
Drug Name Drug Tier Requirements/Limits
ra vitamin d-3 3
ra vitamin e 3
ra vitamin e blend 3
ra vitamin e natural 3
ra vitamins a & d 3
ra warming jelly lubrican 3
ra wart remover 3
ra wart remover ma ximum 3
ra whole source complete 3
ra whole source dietary 3
ra whole source dietary f 3
ra whole source dietary m 3
ra whole source womens 3
RA WIPES FLUSHABLE/MOIST 3
ra witch hazel 3
ra womens laxative 3
ra zinc 3
ra zinc oxide 3
rabano yodado 3
radiacream 3
RADIADERM SYSTEM R2 3
RADIAGUARD ADVANCED 3
radiaklenz 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
534
Drug Name Drug Tier Requirements/Limits
RAGUS 3
ranitidine 150 maximum st 3
ranitidine acid reducer 3
ranitidine hcl TABS 75mg, 150mg 3
RAPID B-12 ENERGY 3
rapid burst adult 3
RE:IIMMUNE 3
REALITY INCONTINENT BRIEF 3
RECEDO 3
recofen "d" 3
recort plus 3
rectacaine 3
rectasmoothe 3
RECTICARE 3
rederm 3
redness reliever eye drop 3
reeses onetab congestion 3
reeses pinworm medicine SUSP 3
REESES PINWORM MEDICINE TABS 3
refenesen 3
refenesen 400 3
REFENESEN CHEST CONGESTIO 3
refenesen dm 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
535
Drug Name Drug Tier Requirements/Limits
refenesen pe 3
refenesen plus 3
REFRESH 3
REFRESH CLEANSER 3
REFRESH CONTACTS 3
REFRESH DRY EYE THERAPY 3
REFRESH LIQUIGEL 3
REFRESH OPTIVE 3
REFRESH OPTIVE ADVANCED 3
REFRESH OPTIVE ADVANCED S 3
REFRESH OPTIVE MEGA-3 3
refresh p.m. 3
REFRESH PLUS 3
REFRESH TEARS 3
refreshing aloe 3
refreshing facial cleanse 3
REFUAH PLUS BLOOD GLUCOSE 3
reguloid CAPS 3
reguloid POWD 48.57%, 68% 3
rehydralyte 3
REHYLA HAIR + BODY CLEANS 3
REHYLA WASH 3
relcof c 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
536
Drug Name Drug Tier Requirements/Limits
relcof dm 3
relcof ir 3
RELHIST BP 3
relhist dmx 3
relief drops 3
relief eye drops 3
RELION 2-IN-1 LANCING DEV 3
RELION BLOOD GLUCOSE TEST 3
RELION CONFIRM BLOOD GLUC 3
RELION CONFIRM/MICRO TEST 3
RELION GLUCOSE CHEW 3
relion glucose GEL 3
relion glucose drink 3
RELION KETONE 3
RELION KETONE TEST STRIPS 3
RELION LANCING DEVICE MISC 3
RELION MICRO BLOOD GLUCOS 3
RELION PREMIER BLOOD GLUC 3
RELION PREMIER BLU BLOOD 3
RELION PREMIER COMPACT BL 3
RELION PREMIER VOICE BLOO 3
RELION PRIME BLOOD GLUCOS 3
RELION ULTIMA BLOOD GLUCO 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
537
Drug Name Drug Tier Requirements/Limits
RELION ULTIMA TEST STRIPS 3
REMEDY 4-IN-1 BODY CLEANS 3
remedy antifungal 3
remedy antifungal clear/p 3
REMEDY ANTIMICROBIAL CLEA 3
REMEDY CALAZIME 3
REMEDY CLEANSING BODY LOT 3
REMEDY CLEAR-AID 3
REMEDY DIMETHICONE MOISTU 3
REMEDY FOAMING BODY CLEAN 3
REMEDY NUTRASHIELD 3
remedy phytoplex antifung 3
REMEDY SKIN REPAIR 3
REMOVE ADHESIVE REMOVER 3
rena-vite 3
rena-vite rx 3
renal 3
renal multivitamin formul 3
renal vitamin 3
renal-vite 3
RENAMENT 3
renaplex 3
RENAPLEX-D 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
538
Drug Name Drug Tier Requirements/Limits
RENEW ADVANCED LANCING DE 3
RENU MULTIPLUS 3
RENU MULTIPLUS LUBRICATIN 3
REPEL FAMILY 15% 3
REPEL MOSQUITO WIPES 3
REPEL SPORTSMEN 25% 3
REPHRESH PRO-B 3
REPLACE 3
REPLACE SR 3
REPLACEMENT AIR FILTER 3
REPLACEMENT FILTERS 3
REPLESTA 3
REPLESTA CHILDRENS 3
REPLESTA NX 3
REPLICARE 1-1/2"X2-1/2" 3
REPLICARE 4"X4" 3
REPLICARE 6"X6" 3
REPLICARE 8"X8" 3
REPLICARE THIN 2"X2.75" 3
REPLICARE THIN 3.5"X5.5" 3
REPLICARE THIN 6"X8" 3
REPLICARE ULTRA 4"X4" 3
REPLICARE ULTRA 6"X6" 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
539
Drug Name Drug Tier Requirements/Limits
REPLICARE ULTRA SACRUM 7" 3
REQ 49+ 3
RESCON 3
RESCON DM 3
RESCON-GG 3
RESINOL 3
RESOURCE BENEPROTEIN 3
RESPA C&C IR 3
RESPAIRE-30 3
rest simply 3
RESTA 3
RESTA LITE 3
RESTA WOUND CLEANSER 3
restfully sleep 3
restizan 3
RESTORA 3
RESTORE CX WOUND CARE DRE 3
restore dimethicreme 3
RESTORE DRESSING FOR PSOR 3
RESTORE EXTRA THIN DRESSI 3
RESTORE HYDROGEL GAUZE PA 3
RESTORE PLUS WOUND CARE D 3
RESTORE SILVER DRESSING 2 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
540
Drug Name Drug Tier Requirements/Limits
RESTORE SILVER DRESSING 4 3
RESTORE SILVER DRESSING 6 3
RESTORE WOUND CARE DRESSI 3
retaine cmc 3
RETAINE HPMC 3
RETAINE MGD 3
retaine pm 3
RETAINE VISION 3
REVEAL BLOOD GLUCOSE MONI 3
REVEAL BLOOD GLUCOSE TEST 3
revital freezer pops 3
revital jell cups 3
revital liquid squeezers 3
REVITALENS OCUTEC 3
revive tears 3
rewetting drops 3
REXALL BLOOD GLUCOSE MONI 3
REXALL BLOOD GLUCOSE TEST 3
REZIRA 3
rhinall 3
RHINARIS 3
RHINASE GEL 3
rhinocort allergy 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
541
Drug Name Drug Tier Requirements/Limits
RHINOCORT AQUA 3
ri-gel 3
ri-gel ii 3
RI-MAG 3
RI-MAG PLUS 3
ri-mox 3
ri-mox plus 3
ri-tussin 3
ri-tussin dm 3
RIBOFLAVIN CAPS 3
riboflavin TABS 25mg, 50mg, 100mg 3
RIBOFLAVIN TABS 400mg 3
RID 3
RID COMPLETE LICE ELIMINA 3
RID ESSENTIAL LICE ELIMIN 3
rid lice killing shampoo 3
RIGHT STEP PRENATAL 3
RIGHTEST GD500 LANCING DE 3
RIGHTEST GM100 BLOOD GLUC 3
RIGHTEST GM300 BLOOD GLUC 3
RIGHTEST GM550 BLOOD GLUC 3
RIGHTEST GS100 BLOOD GLUC 3
RIGHTEST GS300 BLOOD GLUC 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
542
Drug Name Drug Tier Requirements/Limits
RIGHTEST GS550 BLOOD GLUC 3
RIGHTSOURCE BLOOD GLUCOSE 3
riginic 3
RISA-BID PROBIOTIC 3
RISABAL-PH 3
RISACAL-D 3
RISAMINE 3
risanoid plus 3
RISAQUAD 3
RISAQUAD-2 3
ritifed 3
robafen ac 3
robafen cf cough & cold 3
robafen cough 3
robafen dm 3
robafen dm clear 3
robafen dm cough 3
robafen dm cough clear 3
robafen mucus/chest conge 3
robisen 3
robitussin 12 hour cough 3
ROBITUSSIN CHEST CONGESTI 3
ROBITUSSIN CHILDRENS COUG 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
543
Drug Name Drug Tier Requirements/Limits
robitussin cold+flu dayti 3
robitussin cold+flu night 3
ROBITUSSIN COUGH & ALLERG 3
robitussin cough & chest 3
ROBITUSSIN COUGH & CHEST 3
robitussin cough & cold c 3
ROBITUSSIN COUGH & COLD D 3
robitussin cough & cold l 3
robitussin cough+chest co CAPS 3
ROBITUSSIN COUGH+CHEST CO LIQD 3
ROBITUSSIN COUGH/COLD CF 3
ROBITUSSIN COUGH/CONGESTI 3
ROBITUSSIN COUGHGELS 3
ROBITUSSIN DM 3
robitussin head/chest con 3
ROBITUSSIN LINGERING COLD CAPS 3
robitussin lingering cold LIQD 3
robitussin maximum streng 3
robitussin mucus+chest co 3
robitussin night time cou 3
robitussin nightime cough 3
ROBITUSSIN NIGHTTIME COUG 3
robitussin peak cold coug 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
544
Drug Name Drug Tier Requirements/Limits
ROBITUSSIN PEAK COLD COUG 3
ROBITUSSIN PEAK COLD DAY/ 3
ROBITUSSIN PEAK COLD DM 3
robitussin peak cold mult 3
ROBITUSSIN PEAK COLD MULT 3
robitussin peak cold nasa 3
robitussin peak cold nigh 3
ROBITUSSIN PEDIATRIC COUG 3
robitussin severe day & n 3
robitussin severe multi-s 3
robitussin to go cough & 3
ROBITUSSIN TO GO COUGH & 3
ROC AGE DIMINISHING NIGHT 3
ROC DEEP WRINKLE SERUM 3
ROC INSTANT FACIAL SMOOTH 3
ROC MAX RESURFACING FACIA 3
ROC MULTI CORREXION 5 IN CREA 3
ROC MULTI CORREXION LIFT 3
ROC MULTI CORREXION NOURI 3
ROC RETINOL CORREXION 3
ROC RETINOL CORREXION HAN 3
ROC RETINOL CORREXION MAX 3
ROC RETINOL CORREXION NIG 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
545
Drug Name Drug Tier Requirements/Limits
ROC RETINOL CORREXION SEN 3
rolaids 3
ROLAIDS EXTRA STRENGTH 3
RONDEC-D 3
ROSE MILK 3
RTD WOUND CARE DRESSING 2 3
RTD WOUND CARE DRESSING 4 3
RU-HIST D 3
RU-HIST-D 3
rutin TABS 50mg 3
RUTIN TABS 50mg, 500mg 3
rutin-50 3
rx support heartburn/acid 3
RX SUPPORT HEARTBURN/ACID 3
RYCONTUSS 3
RYDEX 3
RYDEX G 3
RYMED 3
rynex dm 3
rynex pe 3
rynex pse 3
S2 3
s.s.s. tonic 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
546
Drug Name Drug Tier Requirements/Limits
saccharomyces boulardii 3
SAF-CLENS AF 3
safe tussin 30 3
safe tussin dm adult 3
safe tussin pm 3
SAFE WASH 3
sal-plant 3
SALAC FOAM 3
salac LIQD 3
salactic film 3
SALESE 3
SALICYLIC ACID POWD 3
salicylic acid SOLN 17% 3
saline GEL 3
SALINE SOLN .9% 3
saline SOLN .65% 3
saline flush zr/sterile f 3
saline mist 3
saline nasal mist 3
saline sensitive eyes 3
SALINE WOUND WASH 3
SALIVA SUBSTITUTE 3
SALJET 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
547
Drug Name Drug Tier Requirements/Limits
SALJET RINSE 3
SALONPAS-HOT 3
SAMI THE SEAL REPLACEMENT 3
sani-supp adult 3
sani-supp pediatric 3
SAPS HEALTH INCONTINENCE 3
saratoga 3
SARNA 3
sarna sensitive 3
sarna sensitive anti-itch 3
sarnol-hc 3
SAVISION CAPS 3
savision TABS 3
SAWYER INSECT REPELLENT 3
SAWYER INSECT REPELLENT C 3
SAWYER PREMIUM INSECT REP 3
sb acid controller 3
sb acid controller maximu 3
sb acid reducer 10mg, 150mg 3
sb acid reducer ranitidin 3
sb allerfed cold & allerg 3
sb allergy CAPS 25mg 3
sb allergy TABS 10mg 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
548
Drug Name Drug Tier Requirements/Limits
sb allergy & cold pe 3
sb allergy medicine LIQD 3
sb allergy medicine TABS 25mg 3
sb allergy multi-symptom 3
sb allergy relief 3
sb allergy relief/nasal d 3
sb allergy/sinus/headache 3
sb analgesic 3
sb analgesic creme rub 3
sb antacid anti-gas 3
sb antacid anti-gas doubl 3
sb antacid extra strength 750mg 3
sb antacid/antigas 3
sb anti-fungal 3
sb anti-gas 3
sb anti-itch maximum stre 3
sb anti-nausea 3
sb antihistamine 3
sb arthritis pain relief 3
sb aspirin TABS 325mg 3
sb aspirin TBEC 81mg 3
sb aspirin adult low stre 81mg 3
sb aspirin ec 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
549
Drug Name Drug Tier Requirements/Limits
sb bacitracin 3
sb backache extra strengt 3
sb bismuth 3
sb bismuth maximum streng 3
sb bronchial 3
sb calcium + d 3
sb cetirizine hcl childre 3
sb childrens aspirin 3
sb childrens ibuprofen 3
sb childrens non-aspirin 3
sb childrens plus cough/r 3
sb childrens plus multisy 3
sb chlorpheniramine 4mg 3
sb cimetidine 3
sb clotrimazole foot 3
sb cold & allergy childre 3
sb cold & cough dm childr 3
sb cold & cough hbp 3
sb cold & flu hbp 3
sb cold & flu severe 3
sb cold head congestion s 3
sb cold medicine 3
sb cold multi-symptom day 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
550
Drug Name Drug Tier Requirements/Limits
sb cold multi-symptom sev 3
sb cough control 3
sb cough control cf 3
sb cough control dm 3
sb cough control dm max 3
sb cough control pe 3
sb cough relief 3
sb coughtab 3
sb day time cold/flu reli 3
sb daytime 3
sb daytime sinus 3
sb docusate sodium 3
sb docusate sodium/senna 3
sb ear wax remover 3
sb effervescent pain reli 3
sb fib lax orange 3
sb fiber laxative 3
sb flu maximum strength h 3
sb flu relief therapy sev 3
sb flu relief therapy/flu 3
sb gas relief 3
sb gentle lax-women 3
sb gentle laxative womens 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
551
Drug Name Drug Tier Requirements/Limits
sb glycerin adult 3
sb glycerin pediatric 3
sb hemorrhoid OINT 3
sb hydrocortisone 3
sb hydrocortisone plus 1% 3
sb ibuprofen 200mg 3
sb infants ibuprofen 3
sb itch relief maximum st 3
sb laxative 3
sb lice killing maximum s 3
sb lice treatment 3
sb loratadine 3
sb loratadine allergy rel 3
sb lubricating jelly 3
sb magnesium citrate 3
sb milk of magnesia 400mg/5ml 3
sb mucus relief 3
sb mucus relief dm 3
sb mucus relief pe 3
sb multi-purpose 3
sb naproxen sodium 3
sb nasal spray no-drip 3
sb natural fiber laxative 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
552
Drug Name Drug Tier Requirements/Limits
sb night time cold/flu re 3
sb nighttime cough 3
sb nighttime sinus multi- 3
sb non-asa night time 3
sb non-aspirin CHEW 3
sb non-aspirin extra stre 500mg 3
sb non-aspirin jr strengt 3
sb non-aspirin nighttime 3
SB OMEPRAZOLE 3
sb oyster shell calcium 3
sb pain relief x-str 3
sb pain reliever children 3
sb pain reliever extra st 500mg 3
sb pain reliever pm 3
sb pediatric electrolyte 3
sb peptic relief 3
sb polyethylene glycol 3 3
sb povidone-iodine 3
sb pseudoephedrin sinus 3
sb pseudoephedrine hcl 3
sb pseudoephedrine plus 3
sb saline nose 3
sb saline sensitive 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
553
Drug Name Drug Tier Requirements/Limits
sb senna-lax 3
SB SEV/CONGEST 3
sb severe cold congestion 3
sb severe cold pe 3
sb sinus & allergy maximu 3
sb sinus congestion & pai 3
sb sinus relief 3
sb sore throat spray 3
sb stool softener 3
sb tab tussin dm 3
sb triple antibiotic 3
sb urinary pain relief 3
sb urinary pain relief ma 3
sb vitamin c 3
scalp relief 3
scalp relief maximum stre 3
scalpicin 3
scalpicin 2 in 1 3
scalpicin maximum strengt 3
scar gel 3
scar treatment products 3
scaraway GEL 3
SCARCIN 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
554
Drug Name Drug Tier Requirements/Limits
SCARCIN GEL 3
SCHOLLS CALLUS CUSHIONS 3
SCHOOLTIME SHAMPOO 3
sclerex 3
SCOOBY-DOO ONE A DAY 3
SCOPE 3
SCOT-TUSSIN 3
scot-tussin allergy relie 3
SCOT-TUSSIN DIABETES 3
SCOT-TUSSIN DIABETES CF 3
scot-tussin dm 3
SCOT-TUSSIN DM 3
scot-tussin expectorant 3
SCOT-TUSSIN SENIOR 3
SCOTT MOIST WIPES 3
SCYTERA 3
se aspartate 3
SE PLUS PROTEIN 3
SE-100 3
sea buddies daily multipl 3
sea soft nasal mist 3
SEA-CLENS LIQ WOUND 3
SEA-CLENS WOUND CLEANSER 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
555
Drug Name Drug Tier Requirements/Limits
sea-omega 30 3
SEASORB-AG 3
sebex 3
SEBULEX 3
secura antifungal 3
secura antifungal extra t 3
SECURA DIMETHICONE PROTEC 3
SECURA EXTRA PROTECTIVE 3
SECURA MOISTURIZING CLEAN 3
SECURA PERSONAL CLEANSER 3
secura protective 3
SECURA TOTAL BODY CLEANSE 3
SECURE BELTED UNDERGARMEN 3
SECURE BELTLESS UNDERGARM 3
SECURE FEMALE PANTS W/OUT 3
SECURE FEMALE PANTS W/TRI 3
SECURE FITTED BRIEFS EXTR 3
SECURE FITTED BRIEFS LARG 3
SECURE FITTED BRIEFS MEDI 3
SECURE FITTED BRIEFS SMAL 3
SECURE FITTED BRIEFS YOUT 3
SECURE GUARDS 3
SECURE GUARDS EXTRA LENGT 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
556
Drug Name Drug Tier Requirements/Limits
SECURE GUARDS SUPER 3
SECURE GUARDS SUPER PLUS 3
SECURE LINERS EXTRA LENGT 3
SECURE LINERS HIGH CAPACI 3
SECURE LINERS MAXI 10"X24 3
SECURE LINERS MEDIUM 7"X1 3
SECURE LINERS SMALL 4"X14 3
SECURE MALE PANTS EXTRA L 3
SECURE MALE PANTS LARGE/3 3
SECURE MALE PANTS MEDIUM/ 3
SECURE MALE PANTS SMALL/2 3
SECURE MATTRESS COVER 36" 3
SECURE MATTRESS COVER 39" 3
SECURE MATTRESS COVER 54" 3
SECURE MATTRESS COVER 60" 3
SECURE MATTRESS COVER 75" 3
SECURE MATTRESS COVER FLA 3
SECURE PADS REGULAR 3
SECURE PADS SUPER 3
SECURE PLUS BELTED UNDERG 3
SECURE UNDERGARMENT STRAP 3
SECURE UNDERPADS EXTRA LA 3
SECURE UNDERPADS LARGE 23 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
557
Drug Name Drug Tier Requirements/Limits
SECURE UNDERPADS SMALL 17 3
SECURELY YOURS OB PAD 3
SECURELY YOURS STRETCH BR 3
SELECT BELTED UNDERGARMEN 3
SELECT BOOSTER PADS 3
SELECT CONTOURED SHIELD L 3
SELECT DAYTIME LINERS 3
SELECT DAYTIME PLUS LINER 3
SELECT DISPOSABLE ABSORBE 3
SELECT DISPOSABLE BRIEFS 3
SELECT EXTRA PERSONAL CAR 3
SELECT KIDS DISPOSABLE BR 3
SELECT LIGHT PERSONAL CAR 3
SELECT MESH PANTS EXTRA L 3
SELECT MESH PANTS LARGE 3
SELECT MESH PANTS MEDIUM 3
SELECT MESH PANTS XX-LARG 3
SELECT NIGHTTIME LINERS 3
SELECT REGULAR PERSONAL C 3
SELECT SHIELD PAD 3
SELECT SLIM N' SOFT GUARD 3
SELECT SLIM N' SOFT ULTRA 3
SELECT SOFT N' BREATHABLE 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
558
Drug Name Drug Tier Requirements/Limits
SELECT ULTRA UNDERPADS LA 3
SELECT UNDERGARMENT STRAP 3
SELECT UNDERPADS EXTRA LA 3
SELECT UNDERPADS LARGE 3
SELECT-LITE LANCING DEVIC 3
selenicaps-200 3
SELENIMIN 3
selenimin-200 3
selenium CAPS 3
SELENIUM TABS 25mcg 3
selenium TABS 50mcg, 100mcg, 200mcg 3
SELENIUM TBCR 3
SELENIUM-E 3
selenomax 3
SELSUN BLUE 3
selsun blue 3-in-1 treatm 3
SELSUN BLUE DAILY 3
SELSUN BLUE DEEP CLEANSIN 3
SELSUN BLUE MEDICATED 3
SELSUN BLUE MOISTURIZING 3
SELSUN BLUE NATURALS 3
SELSUN BLUE NATURALS DRY 3
SELSUN BLUE SHA 1% 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
559
Drug Name Drug Tier Requirements/Limits
sen-o-tabs 3
senexon LIQD 3
senexon-s 3
senior tabs 3
senior tonic 3
SENIOR VITES 3
SENNA SYRP 3
senna TABS 3
senna lax 3
senna laxative 3
SENNA LEAVES 3
senna maximum strength 3
senna plus 3
SENNA PROMPT 3
senna s 3
senna smooth 3
senna-grx 3
senna-lax 8.6mg 3
senna-plus 3
senna-s 3
senna-tabs 8.6mg 3
sennacon 3
sennalax-s 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
560
Drug Name Drug Tier Requirements/Limits
sennalex 3
sennazon 3
sennosides SYRP 8.8mg/5ml 3
sennosides TABS 8.6mg, 187mg 3
sennosides-docusate sodium 3
SENOKOT 3
senokot extra strength 3
SENOKOT S 3
SENOKOT TO GO 3
SENOKOT XTRA 3
SENSI-CARE BODY CREAM 3
SENSI-CARE MOISTURIZING 3
SENSI-CARE PROTECTIVE BAR 3
SENSI-CARE SEPTI-SOFT CON 3
sentry 3
SENTRY 3
sentry adults under 50 3
sentry senior 3
SENTRY SENIOR 3
SENTRY SENIOR/LUTEIN 3
severe allergy 3
severe cold 3
severe cold & cough night 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
561
Drug Name Drug Tier Requirements/Limits
severe cold & flu 3
severe cold & flu daytime 3
severe cold & flu nightti 3
severe congestion 3
severe congestion & cough 3
severe congestion sinus r 3
severe sinus congestion & 3
SHIELD LARGE 7"X17" 3
SHIELD REGULAR 4-1/4"X14" 3
SHIELD-SECURE FULL FACE S 3
shopko allergy relief-d 3
shopko athletes foot 3
SHOPKO AUTOLET LANCING DE 3
shopko nasal decongestant 3
SHOWER TABLETS 3
SHUR-CLENS 3
SIDEROL 3
SIDESTREAM ADULT FACE MAS 3
SIDESTREAM PEDIATRIC FACE 3
SIDESTREAM PLUS ADULT FAC 3
SIESTA MASK 3
signacal 3
sigtab 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
562
Drug Name Drug Tier Requirements/Limits
silace LIQD 150mg/15ml 3
silace SYRP 60mg/15ml 3
SILICA GEL 3
SILICONE MASK FOR BREATHE 3
SILICONE MASK FOR BREATHR 3
SILPHEN COUGH 3
silphen dm cough 3
siltussin das 3
siltussin sa 100mg/5ml 3
SILVERMED LIQD 3
simeped 3
simethicone CAPS; CHEW; SUSP; TABS 3
SIMETHICONE LIQD 3
SIMILAC PRENATAL EARLY SH 3
SIMPLE DIAGNOSTICS LANCIN 3
SIMPLE SYP 3
SIMPLE SYRUP 3
SIMPLICITY ADULT BRIEFS 3 3
SIMPLICITY ADULT BRIEFS 4 3
SIMPLICITY ADULT FLAT FOL 3
SIMPLICITY ADULT POLY BRI 3
SIMPLICITY COTTON SNAP PA 3
SIMPLICITY FLUFF UNDERPAD 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
563
Drug Name Drug Tier Requirements/Limits
SIMPLICITY GARMENT LINER 3
SIMPLICITY INSERT PAD 6-1 3
SIMPLICITY INSERT PAD 12" 3
SIMPLICITY INSERT PAD 14" 3
SIMPLICITY PANT LINER/ADH 3
SIMPLICITY QUILTED ADULT 3
SIMPLICITY UNDERPADS 3
simply allergy 3
simply cough 3
SIMPLY SALINE 3
simply saline baby 3
simply sleep 3
simply stuffy 30mg 3
SIMPLY STUFFY 30mg 3
SINADRIN PE COMPLETE SINU 3
sinex severe+ vapocool ni 3
SINUCLEANSE REFILL 3
sinus 3
sinus & allergy 12 hour 3
sinus & allergy pe maximu 3
sinus & cold-d non-drowsy 3
sinus & congestion daytim 3
sinus and headache daytim 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
564
Drug Name Drug Tier Requirements/Limits
sinus congestion & pain d 3
sinus congestion & pain s 3
sinus congestion/pain day 3
sinus congestion/pain sev 3
sinus daytime/nighttime 3
sinus headache max streng 3
sinus headache pe maximum 3
sinus maximum relief 3
sinus maximum strength 3
sinus nasal spray 3
sinus nasal spray 12 hour 3
sinus pain reliever maxim 3
sinus pressure/pain/adult 3
sinus relief SOLN 3
sinus relief extra streng 3
sinus relief mist 3
sinus relief nasal spray .05% 3
sinus wash saline refills 3
SINUS WASH SALT 3
sinus/allergy maximum str 3
sinutab sinus maximum str 3
SIR DIGNITY MENS BRIEFS E 3
SIR DIGNITY MENS BRIEFS L 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
565
Drug Name Drug Tier Requirements/Limits
SIR DIGNITY MENS BRIEFS M 3
SIR DIGNITY MENS BRIEFS S 3
SIR DIGNITY MENS BRIEFS X 3
SIR DIGNITY PLUS BRIEFS E 3
SIR DIGNITY PLUS BRIEFS L 3
SIR DIGNITY PLUS BRIEFS M 3
SIR DIGNITY PLUS BRIEFS S 3
SIR DIGNITY PLUS BRIEFS X 3
skarjel 3
SKIN BEAUTY & WELLNESS 3
skin care lotion 3
2ND SKIN MOIST BURN PADS 3
2ND SKIN MOIST DRESSING K 3
2ND SKIN MOIST GEL PADS 1 3
2ND SKIN MOIST GEL PADS 3 3
SKIN PROTECTANT MOISTURE 3
skin protectants, misc. 3
SKIN REPAIR 3
SKINTEGRITY 2" X 2" 3
SKINTEGRITY 4" X 4" 3
SKINTEGRITY WOUND 3
sleep aid 3
sleep ii 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
566
Drug Name Drug Tier Requirements/Limits
sleep-aid maximum strengt 3
sleep-tabs 3
SLIMLINE ADJUSTABLE BRIEF 3
SLIMLINE CONTOURED LINERS 3
SLIMLINE DISPOSABLE BRIEF 3
SLIMLINE FITTED LINERS 3
SLIMLINE PEACH SHEET CARE 3
SLIP-ON UNDERGARMENTS 3
slo-niacin 250mg 3
SLO-NIACIN 500mg, 750mg 3
slow fe 142mg 3
SLOW FE 142mg, 160mg 3
slow iron 3
slow magnesium chloride/ 3
slow release iron 3
SLOW-MAG 3
slow-release iron 3
sm 3-day vaginal 3
SM 4X PROBIOTIC 3
sm 8 hour pain relief 650mg 3
sm 12 hour sinus deconges 3
sm 12-hour no drip 3
sm acid reducer 10mg, 75mg, 200mg 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
567
Drug Name Drug Tier Requirements/Limits
sm acid reducer maximum s 3
sm acidophilus 3
SM ACIDOPHILUS PEARLS 3
sm all day allergy 10mg 3
sm all day allergy childr 1mg/ml, 5mg/5ml 3
sm all day allergy-d 3
sm all day pain relief 3
sm allergy 4 hour 4mg 3
sm allergy maximum streng 3
sm allergy multi-symptom 3
sm allergy relief CAPS 25mg 3
sm allergy relief LIQD 12.5mg/5ml 3
sm allergy relief TABS 3
sm allergy relief TBDP 3
sm allergy relief childre 3
sm allergy relief nasal s 3
sm allergy/sinus headache 3
sm animal shapes complete 3
sm animal shapes kids fir 3
sm animal shapes/iron 3
sm antacid advanced 3
sm antacid advanced maxi 3
sm antacid anti-gas 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
568
Drug Name Drug Tier Requirements/Limits
sm antacid anti-gas extr 3
sm antacid extra strength 3
sm antacid maximum streng 3
sm antacid/antigas 3
sm anti-dandruff coal tar 3
sm anti-diarrheal CAPS 3
sm anti-diarrheal LIQD 3
sm anti-diarrheal TABS 2mg 3
sm anti-itch 3
sm anti-itch extra streng 3
sm anti-nausea 3
sm antibiotic 500unit/gm 3
sm antibiotic plus pain r 3
sm anticavity fluoride ri 3
sm antifungal clotrimazol 1% 3
sm antifungal miconazole 3
sm antifungal tolnaftate 1% 3
sm antioxidant vitamins 3
sm antiseptic mouth rinse 3
sm arthricream rub 3
sm arthritis pain relief 650mg 3
sm arthritis pain relieve 3
sm artificial tears 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
569
Drug Name Drug Tier Requirements/Limits
sm aspirin 325mg 3
sm aspirin adult low stre CHEW 81mg 3
sm aspirin adult low stre TBEC 81mg 3
sm aspirin ec low strengt 3
sm aspirin enteric coated 3
sm aspirin low dose CHEW 81mg 3
sm aspirin low dose TBEC 3
sm aspirin tri-buffered 3
sm athletes foot AERO 3
sm athletes foot AERP 3
sm athletes foot CREA 1% 3
sm b super vitamin comple 3
sm b-complex 3
SM B-COMPLEX/VITAMIN C 3
sm balanced b-50 3
sm ballanced b-100 3
sm bedding lice treatment 3
SM BENZOIN TINCTURE 3
sm biotin 3
SM BUNION CUSHIONS 3
SM CALAMINE 3
SM CALAMINE PHENOLATED 3
sm calcium 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
570
Drug Name Drug Tier Requirements/Limits
sm calcium 500/vitamin d3 3
sm calcium 600 3
sm calcium 600 + d plus m 3
sm calcium 600+d3 3
sm calcium 600/vitamin d 3
sm calcium /vitamin d 3
sm calcium antacid 500mg 3
sm calcium antacid extra 750mg 3
sm calcium antacid ultra 3
sm calcium citrate + d 3
sm calcium citrate w/vita 3
sm calcium citrate+ w/vit 3
sm calcium citrate/vitami 3
sm calcium plus/vitamin d 3
sm calcium soft chews 3
sm calcium/magnesium/zinc 3
sm calcium/vitamin d 3
sm calcium/vitamin d3 3
sm caldyphen 3
SM CALLUS CUSHIONS 3
sm castor oil 3
sm chest congestion relie 400mg 3
sm chewable c 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
571
Drug Name Drug Tier Requirements/Limits
sm chewable vitamin c 3
sm childrens aspirin 81mg 3
sm childrens ibuprofen 100mg/5ml 3
sm childrens loratadine 5mg/5ml 3
sm childrens non-aspirin 3
sm childrens pain relief 3
sm chromium picolinate 3
sm clearlax 3
sm clotrimazole vaginal 3
sm co q-10 3
sm cod liver oil 3
sm coenzyme q-10 3
sm cold & allergy childre 3
sm cold & allergy pe 3
sm cold & cough childrens 3
sm cold & cough dm childr 3
sm cold & flu severe 3
sm cold & hot therapy pa 3
sm cold & sinus relief 3
sm cold head congestion d 3
sm cold head congestion n 3
sm cold head congestion s 3
sm complete 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
572
Drug Name Drug Tier Requirements/Limits
sm complete 50+ 3
sm complete 50+ ultimate 3
sm complete advanced form 3
sm complete dual action 3
sm complete senior formul 3
sm coq-10 3
SM CORAL CALCIUM 3
SM CORN CUSHIONS 3
sm cough & cold multi-sym 3
sm cough & runny nose chi 3
SM COUGH & SORE THROAT DA 3
sm cough & sore throat ni 3
sm cough drops 5.8mg 3
sm cough relief 3
sm daily diet support 3
sm day time cold & flu re 3
sm day time liquid caps 3
sm day time pe cold & flu 3
sm daytime cold & cough c 3
sm daytime liquid caps 3
sm daytime liquid caps/no 3
SM DISPOSABLE UNDERPADS/M 3
sm docusate calcium 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
573
Drug Name Drug Tier Requirements/Limits
sm double antibiotic 3
sm dry eye relief 3
sm dry skin therapy 3
sm ear drops 3
sm effervescent pain reli 3
sm enema 3
SM ENTRUST PLUS BLADDER C 3
sm epsom salt 3
sm esomeprazole magnesium 3
sm eye drops 3
sm eye itch relief 3
sm eye wash 3
sm fexofenadine hcl 60mg, 180mg 3
sm fiber CAPS 3
sm fiber POWD 28.3%, 48.57%, 51.7%, 58.6%
3
sm fiber TABS 3
sm fiber laxative 500mg, 625mg 3
SM FIBER POWDER 25% 3
sm fish oil 3
sm flu relief therapy sev 3
sm flu/cold/cough medicin 3
sm foaming antacid 3
sm folic acid 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
574
Drug Name Drug Tier Requirements/Limits
sm gas relief 3
sm gas relief antiflatuen 3
sm gas relief drops infan 3
sm gas relief extra stren 125mg 3
sm gas relief infants dro 3
sm gentle laxative 5mg 3
sm glucosamine chondroiti 3
sm glucosamine hcl 3
SM GLUCOSE 4gm 3
SM GLUCOSE TEST STRIPS 3
sm glycerin 3
sm glycerin adult 3
sm glycerin laxative pedi 3
sm glycerin pediatric 3
sm hair/skin/nails 3
sm headache added strengt 3
sm headache pain reliever 3
sm headache relief pm 3
sm hemorrhoidal 3
sm hemorrhoidal cooling g 3
sm hydrocortisone CREA .5%, 1% 3
sm hydrocortisone OINT 3
sm hydrocortisone maximum 1% 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
575
Drug Name Drug Tier Requirements/Limits
sm hydrocortisone plus 3
sm hydrocortisone/aloe ma 3
sm hydrogen peroxide 3
sm ibuprofen CAPS 3
sm ibuprofen TABS 200mg 3
sm ibuprofen cold & sinus 3
sm ibuprofen cold childre 3
sm ibuprofen ib CHEW 3
sm ibuprofen ib TABS 200mg 3
sm ibuprofen jr 3
sm ibuprofen pm 3
SM INCONTINENT LINER DISP 3
sm infants ibuprofen 3
sm infants pain reliever 3
SM IODIDES TINCTURE 3
SM IODINE TINCTURE 3
SM IPECAC SYRUP 3
SM IRON 134mg 3
sm iron 325mg 3
sm iron slow release 3
SM ISOPROPYL ALCOHOL 70% 3
sm isopropyl alcohol 91% 3
SM ISOPROPYL ALCOHOL RUBB 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
576
Drug Name Drug Tier Requirements/Limits
sm l-lysine 3
SM LAMBS WOOL 3
sm lansoprazole 15mg 3
sm laxative 3
sm laxative maximum stren 3
sm lice killing 3
sm lice killing maximum s 3
sm lice solution kit 3
sm lice treatment 3
sm loperamide hcl 3
sm lorata-dine d 3
sm loratadine SYRP 5mg/5ml 3
sm loratadine TABS 10mg 3
sm loratadine TBDP 3
sm loratadine allergy rel 3
sm loratadine d 12hr 3
sm lubricant eye drops 3
sm lubricating jelly 3
sm lubricating plus 3
sm lubricating tears 3
sm magnesium 3
sm magnesium citrate 3
sm medicated body powder 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
577
Drug Name Drug Tier Requirements/Limits
sm medicated chest rub 3
sm medicated corn remover 3
sm medicated wipes 3
sm melatonin 3
sm miconazole 3 3
sm miconazole 7 CREA 2% 3
sm miconazole 7 SUPP 100mg 3
sm migraine relief 3
sm milk of magnesia 3
sm mineral oil 3
SM MOLESKIN PLUS PADDING 3
sm motion sickness 3
sm motion sickness relief 50mg 3
sm mouth rinse antiseptic 3
sm mucus er 3
sm mucus relief childrens 3
sm mucus relief cough chi 3
sm mucus relief d 3
sm multi-purpose 3
sm multiple vitamins esse 3
sm multiple vitamins/iron 3
sm muscle rub 3
sm naproxen sodium 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
578
Drug Name Drug Tier Requirements/Limits
sm nasal decongestant 3
sm nasal decongestant max 30mg 3
sm nasal decongestant pe 3
sm nasal spray .05%, 1% 3
sm nasal spray 12 hour .05% 3
sm nasal spray moisturizi 3
sm nasal spray pump mist 3
sm nasal spray saline 3
sm nasal spray sinus 3
sm natural laxative plus 3
sm niacin cr 3
sm nicotine GUM 4mg 3
sm nicotine LOZG 2mg 3
sm nicotine PT24 3
sm nicotine polacrilex GUM 2mg, 4mg 3
sm nicotine polacrilex LOZG 4mg 3
sm nicotine transdermal s 7mg/24hr,
14mg/24hr, 21mg/24hr
3
sm night time liquid caps 3
sm nighttime sleep aid 3
sm nite time cold & flu 3
sm nite time cold & flu r 3
sm nite time cold/flu rel 3
sm nite time cough 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
579
Drug Name Drug Tier Requirements/Limits
sm non aspirin allergy si 3
sm non-aspirin flu 3
sm nose drops nasal decon 3
sm oatmeal bath 3
sm omega-3 fish oil 3
SM OMEPRAZOLE 20mg 3
SM ONE DAILY ESSENTIAL 3
SM ONE DAILY MENS 3
SM ONE DAILY PRENATAL 3
SM ONE DAILY WOMENS 3
sm opti-vitamins 3
sm oral cleanser 3
sm oyster shell calcium/v 3
sm pain & fever childrens 80mg/2.5ml, 160mg/5ml
3
sm pain & fever infants 3
sm pain relief 3
sm pain relief extra stre 3
sm pain reliever 3
sm pain reliever 8 hour e 3
sm pain reliever children 3
sm pain reliever cold 3
sm pain reliever extra st CAPS 500mg 3
sm pain reliever extra st TABS 500mg 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
580
Drug Name Drug Tier Requirements/Limits
sm pain reliever extra st TBCR 3
sm pain reliever infants 3
sm pain reliever junior s 3
sm pain reliever pm extra 3
sm pain reliever sinus ma 3
sm pain reliever sinus pe 3
sm pedia relief for child 3
sm pediatric electrolyte 3
sm petroleum jelly 3
SM PETROLEUM JELLY 3
sm potassium 3
sm povidone-iodine 3
SM PRENATAL VITAMINS 3
sm probiotic 3
sm rapid melts junior 3
sm redness relief 3
sm saline solution 3
sm selenium 3
sm senna laxative 3
sm senna-s 3
sm severe congestion & co 3
sm sinus & allergy maximu 3
sm sinus & allergy pe max 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
581
Drug Name Drug Tier Requirements/Limits
sm sinus & cold-d 3
sm sinus maximum strength 3
sm sinus wash 3
sm skin cleanser gentle/s 3
SM SKIN CLEANSER GENTLE/S 3
sm sleep aid 3
sm sleep aid maximum stre 3
sm sleep aid night time 25mg 3
sm slow release iron 142mg 3
SM SLOW RELEASE IRON 143mg 3
sm smooth antacid extra s 3
sm sore throat lozenges 3
sm sore throat spray 3
sm sports pain relief rub 3
sm stay awake 3
sm stay awake maximum str 3
sm stomach relief CHEW 262mg 3
sm stomach relief SUSP 262mg/15ml, 527mg/30ml
3
sm stomach relief TABS 3
sm stomach relief liquid 3
sm stomach relief max st 3
sm stomach relief maximum 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
582
Drug Name Drug Tier Requirements/Limits
sm stool softener CAPS 100mg, 240mg, 250mg
3
sm stool softener TABS 3
sm stool softener plus la 3
sm super b complex-vitami 3
sm swimmers ear drops 3
sm tension headache 3
sm tioconazole-1 3
sm triacting cold & cough 3
SM TRIACTING ORANGE 3
sm triple antibiotic 3
sm triple antibiotic orig 3
sm triple antibiotic plus 3
SM TRUEDRAW LANCING DEVIC 3
sm tussin 3
sm tussin cf 3
sm tussin cough & cold ma 3
sm tussin dm 3
sm tussin dm cough/chest 3
sm tussin dm max cough/ch 3
sm tussin mucus + chest c 3
sm urinary pain relief 3
sm urinary pain relief ma 3
SM VAPORIZER CLEANING 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
583
Drug Name Drug Tier Requirements/Limits
SM VAPORIZER INHALANT 3
sm vit c/rose hips 3
sm vitamin b1 3
sm vitamin b6 3
sm vitamin b12 3
sm vitamin b12 tr 3
sm vitamin b100 complex 3
sm vitamin b-1 3
sm vitamin b-6 3
sm vitamin b-12 3
sm vitamin b-12 tr 3
sm vitamin c 3
sm vitamin c cr 3
sm vitamin c tr 3
sm vitamin c/rose hips 3
sm vitamin d 3
sm vitamin d3 3
SM VITAMIN D3 MAXIMUM STR 4000unit 3
sm vitamin d3 maximum str 5000unit 3
sm vitamin e 3
sm vitamin e blended 3
sm wart remover maximum s 3
sm witch hazel 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
584
Drug Name Drug Tier Requirements/Limits
sm womans laxative 3
sm z-sleep 3
sm zinc 3
SM ZINC PLUS 3
SMART DIABETES VANTAGE LA 3
SMART DIABETES XPRES BLOO 3
SMART SENSE GLUCOSE 3
SMART SENSE GLUCOSE TABLE 3
SMART SENSE PREMIUM BLOOD 3
SMART SENSE VALUE BLOOD G 3
SMARTEST BLOOD GLUCOSE TE 3
SMARTEST EJECT BLOOD GLUC 3
SMARTEST EJECT STARTER KI 3
SMARTEST PERSONA STARTER 3
SMARTEST PRONTO STARTER K 3
SMARTEST PROTEGE BLOOD GL 3
SMARTEST PROTEGE STARTER 3
smarty pants kids complet 3
smooth antacid extra stre 3
smooth lax 3
sochlor 3
SODIUM ACETATE ANHYDROUS POWD 3
SODIUM ASCORBATE POWD 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
585
Drug Name Drug Tier Requirements/Limits
SODIUM BICARBONATE POWD 3
sodium bicarbonate (antacid) 325mg, 650mg
3
SODIUM CHLORIDE GRAN 3
sodium chloride SOLN .9% 3
SODIUM CHLORIDE SOLN .9% 3
sodium chloride TABS 1gm 3
sodium chloride (inhalant) 3
sodium chloride flush 3
SODIUM CHLORIDE GRANULES 3
sodium chloride hypertonic OINT 5% 3
sodium chloride hypertonic SOLN 5% 3
sodium chloride-sodium bicarbonate 3
sodium ferric gluconate complex in sucrose
12.5mg/ml
3
sodium phosphates 3
sof-lax 3
soft lens products 3
softden 3
SOFTWEAR SALINE 3
SOLARCAINE 3
solfiber 3
SOLO 3
SOLOCARE 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
586
Drug Name Drug Tier Requirements/Limits
SOLOSITE CONFORMABLE WOUN 3
soluble fiber 3
SOLUS V2 AUDIBLE BLOOD GL 3
SOLUS V2 AUDIBLE TEST 3
SOLUS V2 LANCING DEVICE 3
SOLVIL 3
sominex 3
sominex maximum strength 3
soothe CHEW; SUSP; TABS 3
SOOTHE SOLN 3
SOOTHE & COOL FREE MEDSEP 3
SOOTHE & COOL FREE MOISTU 3
SOOTHE & COOL FREE SKIN P 3
soothe & cool inzo antifu 2% 3
SOOTHE & COOL INZO BARRIE 3
SOOTHE & COOL MOISTURE BA 3
SOOTHE & COOL MOISTURIZIN 3
SOOTHE & COOL PROTECT MOI 3
SOOTHE & COOL SHAMPOO AND 3
SOOTHE & COOL SKIN CREAM 3
soothe hydration 3
soothe maximum strength 3
soothe night time 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
587
Drug Name Drug Tier Requirements/Limits
soothe nighttime dry eye 3
soothe xp 3
soothe xp/xtra protection 3
SOOTHENEB NBL100 ADULT MA 3
SOOTHENEB NBL 100 CHILD M 3
SOOTHENEB NBL 100 MEDICAT 3
SOOTHENEB NBL 100 MESH CA 3
soothing - 12 hour nasal 3
soothing ointment 3
SORBACELL FOAM DRESSING 4 3
SORBACELL FOAM DRESSING S 3
SORBIDON HYDRATE 3
SORBITOL SOLN 70% 3
SORBOLENE 3
SORBSAN TOPICAL WOUND DRE 3
sorbugen nr 3
sorbulax 3
sorbutuss 3
SORBUTUSS NR 3
sore throat 3
sore throat & cough lozen 3
sore throat relief 3
sore throat spray 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
588
Drug Name Drug Tier Requirements/Limits
SOURCECF 3
SOURCECF PEDIATRIC 3
SP SCAR MANAGEMENT 3
span c 3
SPATONE PUR-ABSORB IRON 3
SPECIAL CARE CREAM 3
SPENCO GEL HEEL CUSHIONS 3
SPENCO RX HEEL CUSHIONS 3
spider-man complete multi 3
SPLEEN TABS 3
spongebob squarepants gum 3
sports pain relief rub 3
SPORTS RUB INTENSE STRENG 3
SPORTSCREME 3
sr anti-diarrheal 3
sr nicotine gum 3
ST IVES SWISS FORMULA 24 3
ST JOSEPH ADULT 3
ST JOSEPH ADULT ANALGESIC 3
st joseph aspirin 3
st joseph cough syrup 3
st joseph low dose aspiri 3
stablegi 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
589
Drug Name Drug Tier Requirements/Limits
STAFLEX 3
STAHIST 3
STAHIST AD 3
STANBACK ASPIRIN FREE 3
STANBACK HEADACHE POWDERS 3
stannous fluoride GEL 3
STAPHSCRUB 3
STATUSS GREEN 3
STAXYN 3
stay awake 3
stay awake maximum streng 3
STAYFREE MAXI REGULAR/WIN 3
STAYFREE MAXI/DEODORANT 3
STAYFREE MAXI/OVERNIGHT 3
STAYFREE MAXI/REGULAR 3
STAYFREE MAXI/SUPER 3
STAYFREE MAXI/SUPER LONG 3
STAYFREE MAXI/THIN/DEODOR 3
STAYFREE MAXI/THIN/UNSCEN 3
STAYFREE MINI-PADS 3
STAYFREE PANTY LINER/UNSC 3
STAYFREE SUPER MAXI 3
STAYFREE ULTRA THIN LONG 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
590
Drug Name Drug Tier Requirements/Limits
STAYFREE ULTRA THIN OVERN 3
STAYFREE ULTRA THIN REGUL 3
STAYFREE ULTRA THIN SUPER 3
STAYFREE ULTRA THIN/OVERN 3
STENDRA 3 QL (6 tabs / 25 days)
steri-strip compound benz 3
STERILE LUBRICANT DROPS 3
sterile preserved saline 3
STERILE SALINE SOLUTION 3
STERILID 3
sterilube 3
stimulant laxative 5mg 3
STOMACH 3
stomach relief CHEW 3
stomach relief SUSP 262mg/15ml, 525mg/15ml, 527mg/30ml
3
stomach relief maximum st 3
stomach relief plus 3
stool softener CAPS 100mg, 240mg 3
stool softener TABS 3
stool softener & stimulan 3
stool softener extra stre 250mg 3
stool softener laxative 3
stool softener laxative d 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
591
Drug Name Drug Tier Requirements/Limits
stool softener plus laxat 3
stool softener plus stimu 3
stool softener/laxative 3
stop lice 3
stop lice complete lice t 3
stop lice maximum strengt 3
stop lice step 2 egg/nit 3
stop lice step 3 3
STOPAIN LIQD 3
STRATASORB COMPOSITE ISLA 3
stress 500 b-complex 3
stress b complex/iron 3
stress b-complex/c/zinc 3
stress b-complex/vitamin 3
stress b/zinc 3
stress formula 3
stress formula+iron 3
stress formula/iron 3
STRESS FORMULA/IRON 3
stress formula/zinc 3
stress plus zinc 3
STRESS-600/ZINC 3
stresstabs 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
592
Drug Name Drug Tier Requirements/Limits
stresstabs advanced 3
stresstabs energy 3
strip ease adhesive remov 3
STROVITE FORTE TABS 3
STROVITE ONE 3
STUART ONE 3
STUDIO 35 EXTRA MOISTURIZ 3
STUDIO 35 MOISTURIZING SK 3
stye 3
STYGIENE STERILE EYELID C 3
SUDAFED 3
sudafed 12 hour 3
SUDAFED 24 HOUR 3
SUDAFED CHILDRENS 3
SUDAFED CONGESTION 3
SUDAFED NASAL DECONGESTAN 3
sudafed pe cold & cough c 3
SUDAFED PE COLD/COUGH MUL 3
SUDAFED PE CONGESTION 3
SUDAFED PE DAY & NIGHT 3
SUDAFED PE DAY & NIGHT CO 3
SUDAFED PE MAXIMUM STRENG 3
sudafed pe nighttime cold 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
593
Drug Name Drug Tier Requirements/Limits
sudafed pe non-drying sin 3
sudafed pe preesure+pain+ 3
sudafed pe pressure+pain+ 3
SUDAFED PE SEVERE COLD MU 3
sudafed pe sinus headache 3
sudafed pe sinus pressure 3
sudafed pe sinus/allergy 3
sudafed plus 3
sudafed pressure+pain 12 3
SUDAFED TAB 30MG 3
SUDAFED TAB 60MG 3
SUDAFED TRIPLE ACTION 3
sudanyl 3
sudogest 30mg, 60mg 3
sudogest 12 hour 3
sudogest pe 10mg 3
sudogest sinus & allergy 3
SUEDE HEEL GRIPS 3
SUMMERS EVE CLEANSING WAS 3
summers eve medicated 3
SUMMERS EVE NIGHT-TIME CL LIQD 3
SUNBEAM BACTERIASTAT 3
SUNBEAM HUMIDIFIER/VAPORI 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
594
Drug Name Drug Tier Requirements/Limits
SUNBEAM INCONTINENT UNDER 3
SUNBEAM VAPORIZER INHALAN 3
sunkist vitamin c 3
sunvite active adult 50+ 3
sunvite advanced 3
super 28 formula 3
super amino acids 3
SUPER ANTIOXIDANT 3
super antioxidant/a/c/e/s 3
super antioxidants protec 3
super aytinal 50 plus 3
super aytinal for active 3
super b complex maxi 3
super b complex/c 3
super b with c 3
super b-50 3
SUPER B-50 B-COMPLEX 3
SUPER B-50 COMPLEX CAPS 3
super b-50 complex TABS 3
super b-50 complex plus 3
super b-100 3
SUPER B-COMPLEX CAPS 3
super b-complex TABS 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
595
Drug Name Drug Tier Requirements/Limits
super b-complex/folic aci 3
super b-complex/iron/vita 3
super b-complex/vitamin c 3
super biotin 3
super c-500 3
SUPER C-500 COMPLEX 3
super c-1000 3
SUPER CAL-MAG-D 3
super cal/mag 3
super calcium 3
super calcium 600 + d3 3
super calcium 600+d3 400 3
super calcium 600+d 400 3
super cold tabs 3
SUPER D3 COMPLEX 3
SUPER DAILY D3 3
super dec b-100 3
SUPER E CREA 3
SUPER E DAY 3
SUPER E EYE 3
SUPER E HAND/BODY 3
SUPER E NIGHT 3
super moleskin 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
596
Drug Name Drug Tier Requirements/Limits
super multiple 3
super natrul-100 3
super nu-thera LIQD; TABS 3
SUPER NU-THERA POWD 3
SUPER PROBIOTIC 3
SUPER PROBIOTIC DIGESTIVE 3
super quints b-50 3
super strength sinadrin 3
super stress b-complex tr 3
super thera vite m 3
super vikaps 3
super vita-mins 3
SUPER-AMINO 1600 3
SUPERB NAILS 3
superior 35 3
SUPERIORSOURCE K1 3
supersoft 3
SUPERSORB UNDERPAD 3
suphedrine 3
SUPLEVIT 3
SUPPORT 3
SUPPOSIBASE 3
SUPREME TEST STRIPS 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
597
Drug Name Drug Tier Requirements/Limits
SUPRESS A PEDIATRIC DROPS 3
SUPRESS DM PEDIATRIC 3
supress-dx pediatric 3
SUPRESS-PE PEDIATRIC 3
sur-q-lax 3
SURE & NATURAL PANTYLINER 3
SURE & NATURAL THIN MAXI/ 3
SURE & NATURAL ULTRA THIN 3
SURE CARE BELTED UNDERGAR 3
SURE CARE BELTLESS UNDERG 3
SURE CARE FLUFF AND POLYM 3
SURE CARE FLUFF UNDERPAD 3
SURE CARE PLUS PROTECTIVE 3
SURE CARE PROTECTIVE UNDE 3
SURE CARE UNDERGARMENT 3
SURE COMFORT LANCING PEN 3
SURE EDGE BLOOD GLUCOSE M 3
SURE EDGE BLOOD GLUCOSE T 3
sure guard anti-oxidant p 3
sure guard multi vitamin/ 3
sure result sr relief 3
SURE-PEN 3
SURE-TEST EASYPLUS MINI B 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
598
Drug Name Drug Tier Requirements/Limits
SURE-TEST EASYPLUS MINI S 3
SURECHEK BLOOD GLUCOSE MO 3
SURECHEK BLOOD GLUCOSE TE 3
sureprin 81 3
SURESTEP PRO TEST STRIPS 3
SURETYS SHIELD REGULAR 3
surfak 3
surgel 3
surgilube 3
SUSPENDOL-S 3
sv melatonin TABS 3
sv vitamin b12 tr 3
sw acid reducer 150 maxim 3
sw allergy relief 3
sw allergy relief-d 3
sw clearlax 3
sw cold & sinus pain reli 3
sw nasal decongestant max 3
sw nicotine polacrilex 3
SW OMEPRAZOLE 3
sw suphedrine 12 hour nas 3
swabflush saline flush 3
SWEEN CREAM 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
599
Drug Name Drug Tier Requirements/Limits
SWEETENING SUSPENDING COM 3
SWIM EAR 3
swimmers ear drops 3
swimmers instant ear dry 3
SYMPT-X 3
SYMPT-X G.I. 3
SYNDION 3
SYNDION-SF 3
SYNERTROPIN 3
synovacin 3
SYRPALTA 83% 3
SYRSPEND SF LIQD 3
SYRUP NF 3
SYSTANE 3
SYSTANE BALANCE RESTORATI 3
SYSTANE COMPLETE 3
systane contacts soothing 3
SYSTANE GEL 3
SYSTANE LID WIPES 3
SYSTANE LIQUID GEL 3
systane nighttime 3
SYSTANE PRESERVATIVE FREE 3
SYSTANE ULTRA 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
600
Drug Name Drug Tier Requirements/Limits
SYSTANE ULTRA HOME & AWAY 3
SYSTANE ULTRA PRESERVATIV 3
T-VITES 3
ta-poff 3
tab-a-vite maximum 3
TAB-A-VITE WOMENS 3
tab-a-vite/iron 3
tabtussin 3
tabtussin 400 3
tabtussin dm 3
tactinal 325mg 3
TAGAMET HB 3
TANDEM 3
TANNIC ACID 3
TAVIST ALLERGY 3
tears again 3
tears again advanced eyel SOLN 3
TEARS AGAIN NIGHT & DAY 3
tears naturale 3
tears naturale forte 3
TEARS NATURALE FORTE 3
tears naturale ii 3
TEARS NATURALE PM 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
601
Drug Name Drug Tier Requirements/Limits
tears pure 3
TEGADERM AG MESH DRESSING 3
TEGADERM ALGINATE AG DRES 3
TEGADERM HIGH GELLING ALG PADS 3
TEGADERM HIGH INTEGRITY A PADS 3
TELCARE BLOOD GLUCOSE MON 3
TELCARE BLOOD GLUCOSE TES 3
temp tab 3
TENA BELTED BRIEFS 3
TENA CLASSIC BRIEFS/LARGE 3
TENA CLASSIC BRIEFS/MEDIU 3
TENA CLASSIC BRIEFS/X-LAR 3
TENA COMPLETE + CARE BRIE 3
TENA COMPLETE BRIEF EXTRA 3
TENA COMPLETE BRIEF LARGE 3
TENA COMPLETE BRIEF MEDIU 3
TENA DAY DRY COMFORT HEAV 3
TENA DAY DRY COMFORT LIGH 3
TENA DAY DRY COMFORT MODE 3
TENA DAY LIGHT PAD 3
TENA DAY PLUS PAD 3
TENA DAY REGULAR PAD 3
TENA DISCREET SUPER/LARGE 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
602
Drug Name Drug Tier Requirements/Limits
TENA DISCREET SUPER/MEDIU 3
TENA DISCREET ULTRA/LARGE 3
TENA DISCREET ULTRA/MEDIU 3
TENA DISCREET/LARGE 3
TENA DISCREET/MEDIUM 3
TENA DISCREET/SMALL 3
TENA DISCREET/XLARGE 3
TENA FLEX 8 SUPER 3
TENA FLEX 12 MAXI 3
TENA FLEX 12 PLUS 3
TENA FLEX 12 SUPER 3
TENA FLEX 16 MAXI 3
TENA FLEX 16 PLUS 3
TENA FLEX 16 SUPER 3
TENA FLEX 20 3
TENA FOR MEN 3
TENA INSTADRY PADS/HEAVY 3
TENA MEN HEAVY PROTECTION 3
TENA NIGHT DRY COMFORT 3
TENA NIGHT SUPER PAD 3
TENA OVERNIGHT UNDERWEAR 3
TENA PANTS SUPER/MEDIUM 3
TENA PANTS ULTRA/LARGE 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
603
Drug Name Drug Tier Requirements/Limits
TENA PANTS ULTRA/MEDIUM 3
TENA PANTS/SMALL 3
TENA PANTS/XL-XXL 3
TENA PANTS/YOUTH 3
TENA PROTECTIVE UNDERWEAR 3
TENA SERENITY ACTIVE PADS 3
TENA SERENITY ACTIVE PANT 3
TENA SERENITY ANYWHERE PA 3
TENA SERENITY BRIEFS/ULTI 3
TENA SERENITY INSTADRY/LO 3
TENA SERENITY MALE GUARDS 3
TENA SERENITY OVERNIGHT P 3
TENA SERENITY PADS/HEAVY 3
TENA SERENITY PADS/MODERA 3
TENA SERENITY PADS/ULTIMA 3
TENA SERENITY PANTILINERS 3
TENA SERENITY PROTECTIVE 3
TENA SERENITY STYLISH PAD 3
TENA SKIN-CARING BODY WAS 3
TENA SKIN-CARING WASH CRE 3
TENA SKIN-CARING WASHCLOT 3
TENA STRETCH BRIEF 2XL/PL 3
TENA STRETCH BRIEF 2XL/UL 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
604
Drug Name Drug Tier Requirements/Limits
TENA STRETCH ULTRA BRIEF/ 3
TENA SUPER BRIEF/LARGE 3
TENA WASH CREAM 3
TENA WOMEN HEAVY PROTECTI 3
TENA YOUTH BRIEF EXTRA SM 3
TENDERSORB UNDERPAD 3
tension headache 3
tension headache relief 3
teo-tus 3
tera-gel tar 3
terbinafine hcl (topical) 1% 3
TESSALON PERLES 3
tetra-formula nighttime s 3
tetrahydrozoline hcl (ophth) 3
tetterine 3
TG 10PEH/380GFN 3
tg 10peh/380gfn/15dm 3
TG 45PSE/400GFN 3
TG 45PSE/400GFN/15DM 3
tgq 7.5peh/4brm/15dm 3
tgt 12 hour nasal deconge 3
tgt acetaminophen childre 3
tgt acetaminophen extra s 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
605
Drug Name Drug Tier Requirements/Limits
tgt acetaminophen infants 3
tgt acetaminophen melts c 3
tgt acid controller compl 3
tgt acid reducer 3
tgt acid reducer complete 3
TGT ADVANCED LANCING DEVI 3
tgt all day allergy relie 3
tgt all day allergy-d 3
tgt allergy & congestion 3
tgt allergy medication ch 3
tgt allergy melts childre 3
tgt allergy relief 3
tgt allergy relief childr 3
tgt allergy+ congestion r 3
tgt allergy/congestion re 3
tgt analgesic rub 3
tgt antacid 3
tgt antacid anti-gas regu 3
tgt antacid extra strengt 3
tgt antacid ultra strengt 3
tgt anti-diarrheal 3
tgt anti-itch maximum str 3
tgt anti-itch plus oatmea 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
606
Drug Name Drug Tier Requirements/Limits
tgt anti-itch/aloe maximu 3
tgt anti-itch/aloe/vitami 3
tgt antibiotic 3
tgt antifungal 3
tgt antifungal spray 3
tgt antifungal spray powd 3
tgt arthritis pain relief 3
tgt aspirin 3
tgt aspirin low dose 3
tgt athletes foot 3
tgt bacitracin 3
TGT BLOOD GLUCOSE METER M 3
TGT BLOOD GLUCOSE MONITOR 3
TGT BLOOD GLUCOSE TEST ST 3
tgt calcium + vitamin d3 3
tgt calcium dietary suppl 3
tgt childrens acetaminoph 3
tgt childrens aspirin 3
tgt childrens ibuprofen 3
tgt clotrimazole 3
tgt cold & hot pain relie 3
tgt cold and cough relief 3
tgt cold and hot pain-rel 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
607
Drug Name Drug Tier Requirements/Limits
tgt cold head congestion 3
tgt cold relief multi-sym 3
tgt cold/cough childrens 3
tgt cold/flu relief day t 3
tgt cold/flu relief day/n 3
tgt cold/flu relief multi 3
tgt cold/flu relief night 3
tgt cough drops 9.1mg 3
tgt cough formula dm 3
tgt cough formula dm max 3
tgt cough suppressant/top 3
tgt cough/cold adult 3
tgt daily multivitamin wo 3
tgt enteric-coated aspiri 3
tgt eye allergy relief 3
tgt eye itch relief 3
tgt fiber laxative 3
tgt fiber therapy 3
tgt first aid antibiotic 3
tgt flu/severe cold/cough 3
tgt gas relief extra stre 3
tgt gas relief infants dr 3
tgt gentle laxative 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
608
Drug Name Drug Tier Requirements/Limits
TGT GLUCOSE 3
tgt hemorrhoidal cream 3
tgt hemorrhoidal cream ma 3
tgt hemorrhoidal supposit 3
tgt hydrogen peroxide 3
tgt ibuprofen 3
tgt ibuprofen childrens 3
tgt ibuprofen junior stre 3
tgt ibuprofen pm 3
tgt infants ibuprofen 3
tgt itch relief extra str 3
TGT LANCING DEVICE 3
tgt laxative pills maximu 25mg 3
tgt lice complete kit 1-2 3
tgt lice killing maximum 3
tgt loperamide hcl 3
tgt loratadine childrens 3
tgt lubricant eye drops/m 3
tgt lubricant eye nightti 3
tgt medicated hemorrhoida 3
tgt medicated wipe/witch 3
tgt menstrual relief maxi 3
tgt miconazole 1 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
609
Drug Name Drug Tier Requirements/Limits
tgt miconazole 3 combinat 3
tgt miconazole 7 3
tgt migraine relief 3
tgt mucus relief children 3
tgt mucus relief cough ch 3
tgt mucus/cough relief 3
tgt multi-symptom cold pl 3
tgt multivitamin/multimin 3
tgt naproxen sodium 3
tgt nasal decongestant 3
tgt nasal decongestant 12 3
tgt nasal decongestant pe 3
tgt nasal spray 3
tgt nicotine gum 3
tgt nicotine polacrilex 3
tgt nicotine step one 3
tgt nicotine step three 3
tgt nicotine step two 3
tgt nighttime sleep aid 3
TGT OMEPRAZOLE 3
tgt pain reliever added s 3
tgt pain reliever jr stre 3
tgt pain reliever pm extr 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
610
Drug Name Drug Tier Requirements/Limits
tgt pain-relief 3
tgt pain/fever acetaminop 3
tgt pe multi-symptom seve 3
tgt powderlax 3
tgt psyllium fiber 3
tgt saline laxative 3
tgt saline nasal spray 3
tgt senna 3
tgt senna laxative 3
tgt senna laxative/stool 3
tgt severe cold relief 3
tgt sinus 12 hour 3
tgt sinus congestion/pain 3
tgt sleep aid maximum str 3
tgt sore throat spray 3
tgt stomach relief 3
tgt stool softener 3
tgt stool softener & stim 3
tgt tioconazole 1 3
tgt tioconazole 1day 3
tgt tussin dm cough 3
tgt vitamin c drops 3
tgt wart remover 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
611
Drug Name Drug Tier Requirements/Limits
tgt womens laxative 3
th 12 hour decongestant 3
th acetaminophen extra st 3
th acetaminophen pm extra 3
TH ACIDOPHILUS PROBIOTIC 3
th allergy relief 3
th allergy relief + cold 3
th allergy relief + sinus 3
th antacid 3
th antacid extra strength 3
th antacid regular streng 3
th antacid ultra strength 3
th antacid/anti-gas 3
th antacid/anti-gas extra 3
th anti-diarrheal 3
th antibiotic + pain reli 3
th arthritis pain relief 3
th aspirin 3
th aspirin low dose 3
th b 100 complex 3
th b complex/iron/vitamin 3
th bacitracin 3
th calcium 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
612
Drug Name Drug Tier Requirements/Limits
th calcium 600 with vitam 3
th calcium 600/vitamin d 3
th calcium citrate/vitami 3
th calcium/magnesium/zinc 3
th calcium/vitamin d/mine 3
th cetirizine hcl 3
th chest congestion relie 3
th childrens allergy 3
th childrens chewable mul 3
th childrens mucus relief 3
th childrens pain relieve 3
th childrens plus cough & 3
th clotrimazole 3
th co q-10 3
th cod liver oil 3
th cold & allergy 3
th congestion 3
th cough suppressant 3
th cranberry/vitamin c/vi 3
th daily multiple vitamin 3
th day time cold/flu reli 3
th day time multi-symptom 3
th enteric aspirin 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
613
Drug Name Drug Tier Requirements/Limits
th epsom salt 3
th eye drop original 3
th eye drop tears 3
th famotidine 10 3
th fish oil extra strengt 3
th folic acid 3
th gas relief extra stren 3
th gentle laxative 3
th hydrocortisone 3
th hydrocortisone/aloe 3
th ibuprofen 3
th l-lysine 3
th loratadine 3
th loratadine-d 3
th magnesium 3
th magnesium citrate 3
th milk of magnesia 3
th motion relief 3
th naproxen 3
th nasal decongestant pe 3
th nasal relief 3
th nasal relief extra moi 3
th nasal relief sinus 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
614
Drug Name Drug Tier Requirements/Limits
th natural fiber 3
th nighttime cold/flu rel 3
th nighttime cough 3
th nite time multi-sympto 3
th oyster shell calcium/v 3
th pain reliever pm extra 3
th pediatric electrolyte/ 3
th pink bismuth formula r 3
th rest simply 3
th severe cold multi-symp 3
th sinus headache pe 3
th sleep aid 3
th sleep aid maximum stre 3
th slow release iron 3
th sore throat spray 3
th stay awake 3
th stool softener 3
th stool softener plus la 3
th triple antibiotic 3
th tussin 3
th tussin cf 3
th tussin dm 3
th tussin dm max 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
615
Drug Name Drug Tier Requirements/Limits
th urinary pain relief 3
th vitamin b1 3
th vitamin b12 3
th vitamin b12 er 3
th vitamin b 50/b-complex 3
th vitamin b-6 3
th vitamin b-12 3
th vitamin c 3
th vitamin c/rose hips/bi 3
th vitamin d3 3
th vitamin e 3
th vitamin e/d-alpha 3
th womans laxative 3
th zinc 3
the itch eraser 3
the magic bullet 3
the treatment formula 3 3
thera 3
thera vital m 3
thera vital-m 3
thera-d 2000 3
THERA-D 4000 3
thera-d rapid repletion 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
616
Drug Name Drug Tier Requirements/Limits
thera-d sport 3
thera-derm 3
thera-derm bath oil 3
thera-ear 3
thera-gesic 3
thera-gesic plus 3
thera-m 3
thera-mill 3
thera-mill m 3
thera-plus 3
thera-tabs 3
THERA-TABS M 3
therabasic-m 3
THERABETIC EYE HEALTH 3
THERABETIC MULTI-VITAMIN 3
THERABETIC SKIN CARE 3
THERABREATH ORAL RINSE/FR 3
THERACAL D2000 3
THERACAL D4000 3
THERACAL RAPID REPLETION 3
theracaps cough & cold re 3
THERACOF PLUS COUGH AND C 3
theracort 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
617
Drug Name Drug Tier Requirements/Limits
theradex "m" 3
theradex "m"/beta caroten 3
THERAFLU COLD & COUGH 3
THERAFLU COLD & SORE THRO 3
THERAFLU COLD/COUGH DAYTI 3
theraflu expressmax 3
theraflu expressmax sever 3
THERAFLU FLU & CHEST CONG 3
THERAFLU FLU & SORE THROA 3
THERAFLU MAX-D SEVERE COL 3
theraflu nighttime maximu 3
theraflu non drowsy formu 3
THERAFLU POWERPODS DAYTIM 3
THERAFLU POWERPODS NIGHTT 3
THERAFLU SEVERE COLD & CO MISC; PACK
3
theraflu severe cold & co TABS 3
THERAFLU SEVERE COLD DAYT 3
THERAFLU SEVERE COLD MULT 3
THERAFLU SEVERE COLD NIGH 3
THERAFLU SINUS & COLD 3
THERAFLU WARMING RELIEF C 3
theraflu warming relief f 3
theraflu warming relief m 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
618
Drug Name Drug Tier Requirements/Limits
theraflu warming relief s 3
THERAGRAN-M 3
THERAGRAN-M ADVANCED 3
THERAGRAN-M ADVANCED 50 P 3
theragran-m fish oil conc 3
THERAGRAN-M PREMIER 3
THERAGRAN-M PREMIER 50 PL 3
THERAMILL FORTE 3
theramill plus 3
THERANATAL COMPLETE 3
THERANATAL CORE NUTRITION 3
THERANATAL LACTATION COMP 3
THERANATAL LACTATION ONE 3
THERANATAL LACTATION SUPP 3
THERANATAL ONE 3
THERANATAL OVAVITE 3
therapeutic 3
therapeutic bath oil 3
therapeutic formula/hemat 3
therapeutic ice gel 3
THERAPEUTIC LIQUID 3
therapeutic m 3
therapeutic menthol 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
619
Drug Name Drug Tier Requirements/Limits
THERAPEUTIC MOISTURIZING 3
therapeutic shampoo 3
therapeutic t+plus 3
THERAPEUTIC T+PLUS MAXIMU 3
therapeutic-m 3
therapeutic-m/lutein 3
THERAPLEX HYDROLOTION 3
THERAPLEX T 3
theraplex z 3
THERASEAL HAND PROTECTION 3
THERATEARS 3
theratears allergy eye it 3
theratein lotion 3
theratrum complete 3
theratrum complete 50 plu 3
theravim -m 3
therems 3
THEREMS-H 3
THEREMS-M 3
THERMOTABS 3
THIAMINE 3
THIAMINE HCL POWD 3
thiamine hcl SOLN 100mg/ml 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
620
Drug Name Drug Tier Requirements/Limits
thiamine hcl TABS 50mg, 100mg, 250mg 3
THIAMINE HYDROCHLORIDE 3
thiamine mononitrate TABS 3
THRESHOLD IMT 3
thrive 3
thrive for life womens 3
throat discs 3
throat lozenges 3
THUM 3
THYMUS TABS 3
THYROSAFE 3
THYROSHIELD 3
TIGER BALM EXTRA STRENGTH 3
TIGER BALM RED EXTRA STRE 3
TIGER BALM REGULAR STRENG 3
TIGER BALM ULTRA STRENGTH 3
TIN-CO-BEN 3
TINACTIN 3
TINACTIN DEODORANT 3
TINACTIN JOCK ITCH 3
tinaspore 3
tineacide 3
tioconazole 1 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
621
Drug Name Drug Tier Requirements/Limits
tioconazole-1 3
tippy toes diaper rash 3
titralac 3
tl-hem 150 3
tl-hist dm 3
tn dickinsons witch hazel 3
TODAYS HEALTH ADVANCED LA 3
TOE-AID 3
tolnaftate AERO 3
tolnaftate AERP 3
tolnaftate CREA 1% 3
tolnaftate POWD 1% 3
tolnaftate SOLN 3
tolnaftate 1% antifungal 3
tolu-sed dm 3
TONSILINE 3
TOPICLEAR 3
TOPLINERS 3
total allergy 3
total allergy medicine 3
total b/c 3
total fiber 3
total formula 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
622
Drug Name Drug Tier Requirements/Limits
total formula 2 3
total formula 3 3
totalday multiple 3
trace minerals (ca-cu-fe-i-k-mg-mn-p-zn) 3
TRACER BG TES 3
TRANQUILITY ADULT LINER 3
TRANQUILITY AIR-PLUS BARI 3
TRANQUILITY ATN ALL-THROU 3
TRANQUILITY BARIATRIC STR 3
TRANQUILITY BELTED UNDERG 3
TRANQUILITY CLEANSING WIP 3
TRANQUILITY HEAVY DUTY UN 3
TRANQUILITY HI-RISE BARIA 3
TRANQUILITY HIGH CAPACITY 3
TRANQUILITY MINI TRIMSHIE 3
TRANQUILITY PREMIUM DAYTI 3
TRANQUILITY PREMIUM OVERN 3
TRANQUILITY PREMIUM PROTE 3
TRANQUILITY SLIMLINE BREA 3
TRANQUILITY SLIMLINE BRIE 3
TRANQUILITY SLIMLINE FITT 3
TRANQUILITY SLIMLINE PEAC 3
TRANQUILITY SMARTCORE DIS 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
623
Drug Name Drug Tier Requirements/Limits
TRANQUILITY SUPER PLUS LI 3
TRANQUILITY THINLINER 202 3
TRANQUILITY THINLINER 610 3
TRANQUILITY THINLINER 714 3
TRANQUILITY TOPLINER 3
TRANQUILITY TOPLINER BOOS 3
TRANQUILITY TOPLINER MINI 3
TRANQUILITY TRIMSHIELD JU 3
TRANQUILITY TRIMSHIELD RE 3
TRANQUILITY TRIMSHIELD SU 3
TRANQUILITY XL+ BARIATRI 3
trav-tabs 3
travel sickness CHEW 25mg 3
travel sickness TABS 50mg 3
travel-ease 3
TREXBROM 3
tri super flavons 3
tri-afed allergy/head col 3
tri-biozene 3
tri-buffered aspirin 3
tri-dex pe 3
TRI-VI-SOL 3
tri-vita 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
624
Drug Name Drug Tier Requirements/Limits
tri-vitamin 3
tri-vitamins 3
TRIACTIN CHEST CONGESTION 3
triacting cold/allergy 3
triacting day time cold/c 3
triacting night time cold 3
triacting nightime cold& 3
triamcinolone acetonide (nasal) 3
triaminic allerchews 3
TRIAMINIC CHEST & NASAL C 3
TRIAMINIC CHEST CONGESTIO 3
TRIAMINIC CHEST/NASAL CON 3
TRIAMINIC COLD & ALLERGY 3
TRIAMINIC COLD & COUGH DA 3
TRIAMINIC COLD & COUGH NI 3
TRIAMINIC COLD/COUGH DAYT 3
TRIAMINIC COLD/COUGH NIGH 3
TRIAMINIC COUGH & RUNNY N 3
TRIAMINIC COUGH & SORE TH CHEW; SYRP
3
triaminic cough & sore th LIQD 3
triaminic fever & cold mu 3
TRIAMINIC FEVER REDUCER P 3
TRIAMINIC FLU COUGH & FEV 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
625
Drug Name Drug Tier Requirements/Limits
TRIAMINIC FLU/COUGH/FEVER 3
TRIAMINIC LONG ACTING COU LIQD; STRP
3
triaminic long acting cou SYRP 3
TRIAMINIC MULTI-SYMPTOM F 3
TRIAMINIC NIGHT TIME COLD 3
TRIAMINIC-D 3
TRIAMINO 3
TRICODE AR 3
TRICODE GF 3
TRIFERIC 3
TRIGOFEN DM 3
TRIMO-SAN 3
TRIMSHIELD JUST FOR MEN 3
TRIMSHIELD PAD REGULAR 3
TRIMSHIELD PAD SUPER-PLUS 3
trip-pse 3
triple antibiotic 3
triple antibiotic first a 3
triple antibiotic plus 3
triple antibiotic plus ma 3
triple antibiotic with pa 3
TRIPLE CREAM 3
TRIPLE HELIX COLLAGEN 2"X 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
626
Drug Name Drug Tier Requirements/Limits
TRIPLE PASTE 3
triple paste af 3
TRIPLE PASTE SP 3
TRIPLE PROBIOTIC 3
triprolidine & pseudoephedrine 3
triprolidine hcl LIQD 3
TRIPROLIDINE-PSEUDOEPHEDR 3
triptone 3
TRISPEC DMX 3
TRISPEC DMX PEDIATRIC 3
trispec pse 3
TRISPEC PSE 3
trispec pse pediatric 3
TRISPEC PSE PEDIATRIC 3
TROCAL COUGH SUPPRESSANT 3
trolamine salicylate 3
TROMBONEX 3
trombonex-d 3
TRONOLANE CREA 3
tronolane SUPP 3
tropical liquid nutrition 3
TRUBIOTICS 3
TRUE2GO BLOOD GLUCOSE MON 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
627
Drug Name Drug Tier Requirements/Limits
TRUE FOCUS BLOOD GLUCOSE 3
TRUE FOCUS SELF MONITORIN 3
TRUE METRIX 3
TRUE METRIX AIR BLOOD GLU 3
TRUE METRIX AIR W/BLUETOO 3
TRUE METRIX BLOOD GLUCOSE 3
TRUE METRIX GO BLOOD GLUC 3
TRUE METRIX SELF MONITORI 3
TRUEDRAW LANCING DEVICE 3
trueplus diabetic multivi 3
TRUEPLUS GLUCOSE GEL 3
TRUERESULT BLOOD GLUCOSE 3
TRUETEST BLOOD GLUCOSE T 3
TRUETEST STRIPS 3
TRUETRACK BLOOD GLUCOSE M 3
TRUETRACK BLOOD GLUCOSE T 3
TRUETRACK SMART SYSTEM 3
TRUETRACK TEST 3
TRUNATURE DIGESTIVE PROBI 3
TRUZONE PEAK FLOW METER 3
trymine cg 3
TUBING/WING TIP 3
TUCKABLES FLUFF UNDERPAD 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
628
Drug Name Drug Tier Requirements/Limits
TUCKABLES UNDERPAD 3
TUCKS 3
TUCKS ANTI-ITCH 3
TUCKS HEMORRHOIDAL 3
tucks medicated 3
tucks medicated cooling 3
TUFFSORB UNDERPAD 3
TUMS 3
TUMS CALCIUM FOR LIFE BON 3
TUMS CHEWY BITES 3
TUMS CHEWY DELIGHTS 3
tums dual action 3
TUMS E-X 750 3
TUMS EXTRA STRENGTH 750 3
tums freshers 3
tums gas relief chewy bit 3
TUMS KIDS 3
TUMS LASTING EFFECTS 3
tums smoothies 750mg 3
TUMS SMOOTHIES 750mg 3
TUMS ULTRA 1000 3
TUSICOF LIQD 3
tusicof TABS 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
629
Drug Name Drug Tier Requirements/Limits
TUSNEL 3
TUSNEL C 3
tusnel diabetic 3
TUSNEL DM 3
tusnel dm pediatric 3
TUSNEL PEDIATRIC 3
TUSNEL-DM PEDIATRIC 3
tussafex ex 3
TUSSAFEX-A 3
tussi-pres 3
tussi-pres b 3
tussi-pres pe pediatric 3
TUSSI-PRES PEDIATRIC 3
TUSSICAPS 3
tussigon 3
tussin 3
tussin adult 3
tussin cf 3
tussin cf cough & cold 3
tussin cf cough & cold ad 3
tussin cf max multi-sympt 3
tussin cf severe multi-sy 3
tussin chest congestion 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
630
Drug Name Drug Tier Requirements/Limits
tussin cold/congestion 3
tussin cough 3
tussin cough dm 3
tussin cough dm sugar fre 3
tussin cough long-acting 3
tussin dm LIQD 3
tussin dm SYRP 3
tussin dm clear 3
tussin dm cough + chest c 3
tussin dm max 3
tussin dm max adult 3
tussin dm maximum strengt 3
tussin expectorant 3
tussin mucus & chest cong 3
tussin mucus + chest cong LIQD 3
tussin mucus + chest cong SYRP
100mg/5ml
3
tussin multi-symptom cold 3
tussin pe 3
tussin severe 3
tussin severe congestion 3
TUSSIONEX PENNKINETIC EXT 3
tusslin 3
tusslin pediatric 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
631
Drug Name Drug Tier Requirements/Limits
TYLENOL 3
TYLENOL 8 HOUR 3
TYLENOL 8 HOUR ARTHRITIS 3
TYLENOL ALLERGY MULTI-SYM MISC 3
tylenol allergy multi-sym TABS 3
TYLENOL ALLERGY MULTI-SYM TABS 3
TYLENOL ARTHRITIS PAIN 3
TYLENOL CHEST CONGESTION 3
TYLENOL CHILDRENS SUSP 3
TYLENOL CHILDRENS CHEWABL 3
TYLENOL CHILDRENS COLD PL 3
TYLENOL CHILDRENS PLUS CO 3
TYLENOL CHILDRENS PLUS FL 3
TYLENOL CHILDRENS PLUS MU 3
TYLENOL CHILDRENS/FLAVOR 3
TYLENOL COLD 3
TYLENOL COLD & FLU SEVERE 3
TYLENOL COLD & HEAD SEVER 3
tylenol cold head congest MISC 3
tylenol cold head congest TABS 3
TYLENOL COLD HEAD CONGEST TABS 3
TYLENOL COLD MAX LIQD 3
tylenol cold max TABS 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
632
Drug Name Drug Tier Requirements/Limits
TYLENOL COLD MULTI-SYMPTO LIQD 3
tylenol cold multi-sympto MISC 3
tylenol cold multi-sympto TABS 3
TYLENOL COLD MULTI-SYMPTO TABS 3
TYLENOL COLD PLUS FLU SEV 3
TYLENOL COLD RELIEF 3
TYLENOL COLD RELIEF NIGHT 3
TYLENOL COLD SEVERE CONGE 3
TYLENOL COLD/COUGH/RUNNY 3
TYLENOL COLD/COUGH/SORE T 3
tylenol cough & sore thro LIQD 3
TYLENOL COUGH & SORE THRO LIQD 3
TYLENOL COUGH & SORE THRO MISC 3
TYLENOL EXTRA STRENGTH 3
TYLENOL EXTRA STRENGTH CA 3
TYLENOL GO TABS EXTRA STR 3
TYLENOL INFANTS 3
TYLENOL INFANTS PAIN+FEVE 3
TYLENOL JR MELTAWAYS 3
TYLENOL PM EXTRA STRENGTH TABS 3
TYLENOL SEVERE ALLERGY 3
TYLENOL SINUS CONGESTION MISC 3
tylenol sinus congestion TABS 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
633
Drug Name Drug Tier Requirements/Limits
TYLENOL SINUS CONGESTION TABS 3
TYLENOL SINUS CONVENIENCE 3
TYLENOL SINUS SEVERE 3
TYLENOL SINUS SEVERE CONG 3
tylenol sinus+headache 3
TYLENOL SORE THROAT DAYTI 3
TYLENOL SORE THROAT NIGHT 3
TYLENOL TAB 325MG 3
TYLENOL TAB 500MG 3
TYLENOL WARMING COLD MULT 3
TYLENOL WARMING COUGH & S 3
tyler lipoic acid 3
tylophen 3
tyrosine CAPS; TABS 3
TYROSINE PACK 3
ubiquinol CAPS 3
ubqh 100mg 3
UDAMIN SP 3
UDDERLY SMOOTH 3
UDDERLY SMOOTH EXTRA CARE 3
ULTEC HYDROCOLLOID DRESSI 3
ULTI-LANCE AUTO-ADJUST DE 3
ULTI-LANCE AUTOMATIC/ CLE 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
634
Drug Name Drug Tier Requirements/Limits
ULTIMA INCONTINENCE PAD 3
ULTIMA TEST STRIPS 3
ULTIMA TUCKABLES UNDERPAD 3
ULTIMA UNDERPAD 3
ultimate fat burner 3
ultimate probiotic formul 3
ultra antioxidant formula 3
ultra b-100 complex 3
ULTRA BIOTIN 3
ultra choice multivitamin 3
ULTRA COQ10 3
ULTRA DERM BATH OIL 3
ULTRA DIET AID 3
ultra fine mist nasal spr 3
ultra freeda 3
ultra freeda/iron 3
ultra fresh 3
ultra fresh pm 3
ultra lubricant eye drops 3
ULTRA MAN 3
ULTRA MEGA 3
ULTRA MEGA GOLD 3
ULTRA MEGA TWO 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
635
Drug Name Drug Tier Requirements/Limits
ULTRA MENS PACK 3
ultra multi formula/iron 3
ultra thin corn removers 3
ULTRA THIN WITH FLEXI-WIN 3
ULTRA TRAK PRO BLOOD GLUC 3
ultra vita-time 3
ULTRA WOMAN 3
ULTRA WOMENS PACK 3
ultra-derm 3
ultra-klenz 3
ultra-mega 3
ULTRA-SOFT CLASSIC BRIEFS 3
ULTRA-SOFT PLUS BRIEFS LA 3
ULTRA-SOFT PLUS BRIEFS ME 3
ULTRA-SOFT PLUS BRIEFS RE 3
ULTRA-SOFT PLUS BRIEFS X- 3
ULTRA-SOFT PLUS BRIEFS XX 3
ultrachoice advanced form 3
ULTRAFLORA IMMUNE HEALTH 3
ULTRASWIM 3
ULTRASWIM ULTRA REPAIR 3
ULTRATRAK ACTIVE 3
ULTRATRAK PRO 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
636
Drug Name Drug Tier Requirements/Limits
ULTRATRAK PRO TEST STRIPS 3
ULTRATRAK ULTIMATE MONITO 3
ULTRATRAK ULTIMATE TEST S 3
UNDERGARMENT BELT FREE LA 3
UNDERGARMENT BELT FREE SM 3
UNDERGARMENT EXTRA ABSORB 3
UNDERGARMENT REGULAR ABSO 3
UNDERPAD 23"X36" 3
UNDERPADS 3
UNDERPADS EXTRA LARGE 3
UNDERPADS/LARGE 23"X26" 3
UNDERPADS/REGULAR 3
UNDERPADS/SUPER 3
UNICOMPLEX-M 3
UNISOL 4 3
UNISOM 3
UNISOM SLEEPGELS 3
UNISOM SLEEPMELTS 3
UNISOM SLEEPTABS 3
UNISTIK 2 EXTRA 3
UNISTRIP1 GENERIC 3
UNIVERSAL PH STRIPS 3
UNJURY 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
637
Drug Name Drug Tier Requirements/Limits
UP & UP GLUCOSE 3
UPCAL D 3
UPSPRING BABY VITAMIN D 3
UPSPRINGBABY MULTIVITAMIN 3
urea CREA 10%, 20% 3
urea LOTN 10% 3
urea 20 intensive hydrati 3
ureacin-10 3
ureacin-20 3
URIN-TEK 3
urinary pain relief 3
urinary pain relief maxim 3
uristat 3
URISTIX 3
URISTIX 4 3
URO MAG 3
URO-MAG 3
UROCARE ADHESIVE REMOVER 3
UROFOAM-1 SINGLE-SIDED AD 3
UROFOAM-2 DOUBLE-SIDED AD 3
urosex 3
UTERUS 3
v-c forte 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
638
Drug Name Drug Tier Requirements/Limits
v-r anti-gas maximum stre 3
v-r aspirin ec max str 3
v-r beta carotene 3
v-r bronchial mist 3
v-r bronchial mist refill 3
v-r childrens non-aspirin 3
v-r cod liver oil 3
v-r coenzyme q-10 3
V-R FATIGUE RELIEF COMPLE 3
v-r heartburn relief 3
v-r infant non-aspirin 3
v-r infants non-aspirin 3
V-R IPECAC 3
v-r nasal allergy symptom 3
v-r pedia relief 3
V-R SALINE SENSITIVE EYES 3
V-R SOY FORMULA 3
v-r throat lozenges 3
v-r tussin honey 3
v-r valu-tapp 3
v-r vitamin a 3
v-r vitamin c 3
VAGISIL SCENTSITIVE SCENT MISC 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
639
Drug Name Drug Tier Requirements/Limits
VAGISTAT-1 3
vagistat-3 3
valihist 3
VALINE PACK 3
VALINE 1000 3
VALUE BUY ADULT BRIEF X-L 3
VALUE BUY BRIEF LARGE 3
VALUE BUY BRIEF MEDIUM 3
VALUE PLUS GLUCOSE CHEW 3
value plus glucose GEL 3
VALUE PLUS LANCING DEVICE 3
VANACLEAR PD 3
VANACOF 3
VANACOF AC 3
VANACOF APE 3
VANACOF CD 3
VANACOF DM 3
VANACOF DX 3
VANACOF G 3
VANACOF GPE 3
VANACOF-8 3
VANADIUM CAPS 3
VANAHIST PD 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
640
Drug Name Drug Tier Requirements/Limits
VANAMINE PD 3
VANATAB AC 3
VANATAB DM 3
VANATAB DX 3
VANICREAM CREA 3
VANICREAM LITE 3
VANIPLY 1% 3
VANQUISH 3
vapor inhaler 3
VAPOR PATCH 3
vaporizing chest rub 3
vaporizing cream 3
vaporizing steam 3
VAPORX BALM 3
varisan vitality 3
vaseline 3
VASELINE PETROLATUM GAUZE 3
vaseline pure ultra white 3
VASOCLEAR A 3
VASOFLEX CAPS 3
vasoflex TABS 3
VASOFLEX D1 3
vasoflex forte 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
641
Drug Name Drug Tier Requirements/Limits
vasoflex hd 3
VASOHA 3
vazobid-pd 3
vazotab 3
VB7 MAX 3
VELVACHOL 3
VENALIV 3
VENOFER 20mg/ml 3
veracolate 3
VERAMYST 3
VERASENS BLOOD GLUCOSE MO 3
VERASENS BLOOD GLUCOSE TE 3
vertin-32 3
vh essentials medicated d 3
VH ESSENTIALS UTI RELIEF 3
VIACTIV 3
VIACTIV MULTI-VITAMIN 3
VIAGRA 25mg, 50mg, 100mg 3 QL (6 tabs / 25 days)
VIAGRA 50mg, 100mg 3 QL (6 ea / 25 days)
vic-forte 3
VICKS BABYRUB 3
VICKS CASERO 3
vicks dayquil cold & flu 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
642
Drug Name Drug Tier Requirements/Limits
VICKS DAYQUIL COUGH 3
VICKS DAYQUIL HBP COLD & 3
VICKS DAYQUIL MUCUS CONTR 3
vicks dayquil multi-sympt 3
VICKS DAYQUIL NATURE FUSI LIQD 3
vicks dayquil nature fusi TABS 3
vicks dayquil severe cold 3
VICKS DAYQUIL SINEX DAYTI 3
vicks dayquil/nyquil cold 3
VICKS DAYQUIL/NYQUIL COUG 3
VICKS DAYQUIL/NYQUIL SEVE 3
VICKS FORMULA 44 COUGH RE 3
VICKS FORMULA 44D COUGH/N 3
VICKS FORMULA 44E COUGH/C 3
VICKS FORMULA 44E PEDIATR 3
VICKS NYQUIL CHILDRENS CO 3
vicks nyquil cold & flu CAPS 3
VICKS NYQUIL COLD & FLU LIQD 3
vicks nyquil cold & flu n CAPS 3
VICKS NYQUIL COLD & FLU N LIQD 3
VICKS NYQUIL COUGH 3
vicks nyquil d cold & flu 3
VICKS NYQUIL HBP COLD & F 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
643
Drug Name Drug Tier Requirements/Limits
VICKS NYQUIL NATURE FUSIO 3
vicks nyquil severe cold LIQD 3
VICKS NYQUIL SEVERE COLD TABS 3
VICKS NYQUIL SINEX NIGHTT 3
VICKS SINEX 3
VICKS SINEX 12 HOUR DECON 3
VICKS SINEX DAYQUIL/NYQUI 3
vicks sinex daytime conge 3
VICKS SINEX DAYTIME/NIGHT 3
VICKS SINEX MOISTURIZING 3
vicks sinex nighttime con 3
VICKS SINEX SEVERE 3
VICKS SINEX SEVERE NASAL 3
VICKS VAPO STEAM 3
VICKS VAPODROPS 3
VICKS VAPOINHALER 3
VICKS VAPORUB 3
VICKS VAPORUB CHILDRENS 3
VICTORY AGM-4000 TEST STR 3
VICTORY BLOOD GLUCOSE MON 3
VIDA MIA AUTOLET LANCING 3
VIGILON PRIMARY WOUND DRE 3
vigor 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
644
Drug Name Drug Tier Requirements/Limits
virdec 3
virdec dm 3
virtussin a/c 3
virtussin dac 3
VISBIOME PROBIOTIC HIGH P 3
VISINE 3
VISINE FOR CONTACTS 3
VISINE PURE TEARS 3
VISINE TEARS 3
VISINE TIRED EYE RELIEF 3
visine-a 3
visine-ac 3
VISINE-LR 3
vision formula 2 3
vision formula eye health 3
vision formula/lutein 3
vision plus 3
vision vitamins 3
visivites 3
visivites/lutein 3
vita hair 3
vita s forte 3
vita-bee/c 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
645
Drug Name Drug Tier Requirements/Limits
VITA-BOB 3
VITA-C 3
VITA-CALCIUM 3
VITA-MAG 3
vita-min 3
vita-plus e 3
vita-plus g 3
VITA-PLUS H 3
vitabasic complete 3
vitabasic senior 3
VITABEX 3
VITABEX PLUS 3
vitacel 3
vitachew multiple vitamin 3
vitachew vitamin c citrus 3
vitajoy daily d gummies 3
vitalee 3
VITALETS 3
VITALETS CHILDRENS 3
VITALINE BIOTIN FORTE 3
VITALINE BIOTIN FORTE/ZIN 3
VITALINE BUFFERED ZINC-22 3
vitaline coq10 TABS 60mg 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
646
Drug Name Drug Tier Requirements/Limits
VITALINE COQ10 TABS 200mg 3
vitaline selenium 3
VITALINE TOTAL FORMULA 2 3
VITALINE TOTAL FORMULA 3 3
vitalize 3
vitalize/ginseng 3
VITAMAX 3
vitamax pediatric 3
vitamelts energy vitamin 3
VITAMELTS RELAX L-THEANIN 3
VITAMELTS VITAMIN C 3
VITAMELTS VITAMIN D 3
VITAMELTS ZINC FAST DISSO 3
VITAMENT 3
VITAMIN & MINERAL SUPPLEM 3
vitamin a CAPS 8000unit, 10000iu,
10000unit, 25000iu
3
VITAMIN A CAPS 25000unit 3
VITAMIN A TABS 8000unit 3
vitamin a TABS 10000unit 3
VITAMIN A 7500 UNIT FISH 3
VITAMIN A PALMITATE TABS 3
vitamin a-25000/d-400 3
VITAMIN A/BETA CAROTENE 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
647
Drug Name Drug Tier Requirements/Limits
VITAMIN B6 3
VITAMIN B12 3
vitamin b12 tr 3
VITAMIN B12/FOLIC ACID 3
vitamin b50 complex tr 3
VITAMIN B 12 3
vitamin b complex-c 3
VITAMIN B-1 3
VITAMIN B-12 3
vitamin b-12 tr 3
vitamin b-12 tr sunmark 3
VITAMIN C CAPS; CHEW; LIQD; POWD;
SOLR; SYRP; TABS
3
VITAMIN C & D3/ROSE HIPS 3
vitamin c & e combination 3
vitamin c adult gummies 3
vitamin c drops 3
VITAMIN C EFFERVESCENT BL 3
VITAMIN C GUMMIE 3
vitamin c gummies 3
vitamin c immune health 3
vitamin c plus 3
vitamin c plus wild rose 3
VITAMIN C+ZINC 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
648
Drug Name Drug Tier Requirements/Limits
vitamin c/bioflavonoids/w 3
VITAMIN C/ELECTROLYTES 3
vitamin c/rose hips tr 3
vitamin c/rose hips/acero 3
VITAMIN D 3
VITAMIN D2 3
VITAMIN D3 LIQD 1000unit/spray, 1200unit/15ml, 5000unit/0.5ml
3
VITAMIN D3 TABS 3
VITAMIN D3 TBDP 3
vitamin d3 adult gummies 3
VITAMIN D3 COMPLETE 3
vitamin d3 gummies adult 3
vitamin d3 high potency 3
vitamin d3 maximum streng 3
vitamin d3 super strength 3
vitamin d3 ultra potency 3
vitamin d3 ultra strength 3
VITAMIN D3/VITAMIN C 3
vitamin d high potency 3
vitamin d infant 3
vitamin d-400 3
vitamin d-1000 maximum st 3
vitamin e CAPS 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
649
Drug Name Drug Tier Requirements/Limits
VITAMIN E CHEW 3
vitamin e OIL 3
vitamin e SOLN 3
VITAMIN E TABS 100unit, 200unit 3
vitamin e TABS 400unit 3
vitamin e (topical) 3
vitamin e beauty oil 3
vitamin e blend 3
VITAMIN E COMPLETE HIGH G 3
vitamin e complex 3
vitamin e complex natural 3
vitamin e high potency 3
vitamin e natural 3
VITAMIN E SKIN CREAM 3
vitamin e skin oil 3
VITAMIN E WITH PANTHENOL 3
vitamin e-200 3
vitamin e-400 3
vitamin e/d-alpha natural 3
VITAMIN K 3
VITAMIN K2 CAPS; TABS 3
VITAMIN K2 & D3 3
vitamin mixture 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
650
Drug Name Drug Tier Requirements/Limits
vitamin supplement e-400 3
vitamin supplement e-1000 3
vitamins a & d 3
vitamins a & d (topical) 3
vitamins c & e 3
vitamins for hair 3
VITAMINS FOR THE HAIR 3
VITAMINS TO GO MAXIMUM 3
VITAMINS TO GO MEN 3
VITAMINS TO GO WOMEN 3
vitamins w/ lipotropics 3
VITAROCA PLUS 3
VITASANA 3
vitatrum CHEW 3
VITATRUM TABS 3
vitatrum complete 3
VITEC 3
viteyes areds advanced 3
viteyes areds formula 3
viteyes areds formula plu 3
viteyes complete 3
viteyes multivitamin ared 3
viteyes smokers advanced 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
651
Drug Name Drug Tier Requirements/Limits
viteyes smokers formula p 3
VITONIC 3
VITRON-C 3
VITRUM 50+ SENIOR MULTI 3
vitrum senior 3
VIVA DROPS 3
VIVARIN 3
VOCAL POINT BLOOD GLUCOSE 3
VP-ZEL 3
VSL#3 CAPS 3
wal-act 3
WAL-BORN 3
WAL-BORN VITAMIN C 3
wal-dram 3
wal-dram ii 3
wal-dryl 3
wal-dryl allergy 3
wal-dryl allergy children 3
wal-dryl allergy dye-free 3
wal-dryl allergy relief c 3
wal-dryl allergy/sinus he 3
wal-dryl anti-itch 3
wal-dryl pe allergy/sinu 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
652
Drug Name Drug Tier Requirements/Limits
wal-dryl severe allergy & 3
WAL-DRYL-D 3
wal-dryl-d allergy/sinus 3
wal-fex 3
wal-fex 24 hour allergy 3
wal-fex allergy 3
wal-fex allergy 12 hour 3
wal-fex childrens 3
wal-fex d 12 hour allergy 3
wal-fex d 24 hour allergy 3
wal-finate 3
wal-finate-d 3
WAL-FLU COLD & SORE THROA 3
wal-flu severe cold & cou 3
WAL-FLU SEVERE COLD DAYTI 3
WAL-FLU SEVERE COLD NIGHT 3
wal-flu warming comfort s 3
wal-four 3
wal-hist 3
wal-itin 3
wal-itin aller-melts 3
wal-itin allergy relief r 3
wal-itin childrens 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
653
Drug Name Drug Tier Requirements/Limits
wal-itin d 3
wal-itin d 24 hour 3
wal-mucil 3
wal-phed 3
wal-phed 12 hour 3
wal-phed d 3
wal-phed pe 3
wal-phed pe cold & cough 3
wal-phed pe daytime/night 3
wal-phed pe nighttime col 3
wal-phed pe pressure+pain 3
wal-phed pe severe cold 3
wal-phed pe sinus headach 3
wal-phed pe sinus/allergy 3
wal-phed pe triple relief 3
wal-phed sinus/allergy 3
wal-profen 3
wal-profen cold & sinus 3
wal-profen cold/sinus 3
wal-sleep z 3
wal-som 3
wal-som maximum strength 3
wal-sporin 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
654
Drug Name Drug Tier Requirements/Limits
wal-tap childrens 3
wal-tap cold & allergy 3
WAL-TAP COLD/ALLERGY 3
wal-tap dm cold & cough 3
wal-tap dm cold/cough 3
wal-tussin 3
wal-tussin cf 3
wal-tussin cf max 3
wal-tussin cf max multi-s 3
wal-tussin chest congesti 3
wal-tussin cold 3
wal-tussin cough 3
wal-tussin cough & chest 3
wal-tussin cough & cold 3
wal-tussin cough long act 3
WAL-TUSSIN COUGH RELIEF C 3
wal-tussin cough/chest co 3
wal-tussin cough/cold cf 3
wal-tussin dm 3
wal-tussin dm cough & che 3
WAL-TUSSIN PEDIATRIC COUG 3
wal-vert 3
wal-zan 75 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
655
Drug Name Drug Tier Requirements/Limits
wal-zan 150 maximum stren 3
wal-zyr SOLN; TABS 3
wal-zyr all day allergy c 3
wal-zyr childrens 3
wal-zyr d 3
WALGREENS GLUCOSE 3
WART OFF 3
wart remover 3
wart remover maximum stre GEL; LIQD 3
wart remover medicated 3
WAVESENSE AMP 3
WAVESENSE KEYNOTE 3
WAVESENSE KEYNOTE PRO MET 3
WAVESENSE PRESTO TEST STR 3
4-way fast acting 3
4-way menthol 3
wee care 3
WEGMANS COMPLETE PRENATAL 3
weight loss daily multi 3
WELLESSE VITAMIN D3 3
WELLNESS PROTEIN SHAKE 3
WFHC PH PAPER 3
wheat germ oil 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
656
Drug Name Drug Tier Requirements/Limits
WHEY PROTEIN 3
WHEY PROTEIN CONCENTRATE 3
WHIRL-SOL 3
white petrolatum GEL 3
WHITE PETROLATUM OINT 3
WHITE PETROLATUM GEL 3
WHOLE FOOD MULTIVITAMIN 3
WIBI 3
WINDMILL TRAINER 3
WINGS ADULT BRIEFS/MEDIUM 3
WINGS ADULT BRIEFS/XXL 3
WINGS ADULT QUILTED BRIEF 3
WINGS BARIATRIC ADULT BRI 3
WINGS BREATHABLE UNDERPAD 3
WINGS CHOICE PLUS ADULT B 3
WINGS CHOICE PLUS YOUTH B 3
WINGS CLASSIC ADULT BRIEF 3
WINGS CONTOURED INSERT PA 3
WINGS FLUFF AND POLYMER U 3
WINGS FLUFF UNDERPAD 17"X 3
WINGS FLUFF UNDERPAD 23"X 3
WINGS FLUFF UNDERPAD 30"X 3
WINGS HL ADULT BRIEFS/LAR 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
657
Drug Name Drug Tier Requirements/Limits
WINGS HL ADULT BRIEFS/MED 3
WINGS HL ADULT BRIEFS/SMA 3
WINGS HL ADULT BRIEFS/XL 3
WINGS HL ULTRA ADULT BRIE 3
WINGS QUILTED BREATHABLE 3
WINGS SUPREME ADULT BRIEF 3
WINGS UNDERPAD/POLYMER IM 3
WINGS WASHCLOTHS 3
WITCH HAZEL LIQD; SOLN 3
witch hazel (hamamelis virginiana) 3
womans laxative 5mg 3
womans stool softener 3
womens 50+ advanced 3
WOMENS 50+ MULTI VITAMIN 3
WOMENS BIOMULTIPLE 3
womens daily formula 3
womens daily formula/foli 3
womens laxative 3
womens life pack 3
WOMENS MENOPAUSE VITA PAK 3
womens menstrual relief 3
womens multi 3
WOMENS MULTI VITAMIN & MI 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
658
Drug Name Drug Tier Requirements/Limits
womens multivitamin 3
womens one daily 3
WOMENS PACK 3
womens tylenol 3
WOMENS VITA PAK 3
WOUND CLEANSER 3
wound cleansers 3
WOUND WASH 3
WOUND WASH SALINE 3
WOUNDGARD 2-1/2"X2-1/2" 3
WOUNDGARD 4"X4-1/4" 3
WOUNDGARD 4"X6" 3
4X PROBIOTIC 3
XERAC AC 3
XEROFLO DRESSING 1"X8" 3
XEROFLO DRESSING 2"X2" 3
XEROFLO DRESSING 5"X9" 3
XEROSTOMIA RELIEF SPRAY 3
xpect 3
XPHE MAXAMUM 3
xtra-care 3
YELETS TEENAGE FORMULA 3
yl balanced b-100 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
659
Drug Name Drug Tier Requirements/Limits
yl beta carotene 3
yl chromium picolinate 3
yl coenzyme q10 3
yl dhea 3
yl folic acid 3
yl natural vitamin a & d 3
yl vitamin b-6 3
yl vitamin c 3
yl vitamin c/rose hips 3
yl vitamin e 3
YODEFAN-NF CHEST CONGESTI 3
YODORA DEODORANT 3
YOUR LIFE MULTI ADULT GUM 3
your life multi mens 50+ 3
your life multi womens 50 3
YOUR LIFE TEEN MULTIVITAM 3
yummy-c 3
Z-BUM 3
Z-CLINZ 3
z-cof 12dm 3
Z-TUSS AC 3
Z-TUSS E 3
ZADITOR 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
660
Drug Name Drug Tier Requirements/Limits
ZANTAC TABS 3
ZANTAC 75 3
ZANTAC 150 MAXIMUM STRENG 3
ZE-PLUS 3
zeasorb-af 3
ZEGERID OTC 3
ZIKS ARTHRITIS PAIN RELIE 3
ZIMS CRACK CREME DAYTIME 3
ZINC CAPS 3
ZINC LOZG 10mg 3
zinc LOZG 23mg 3
zinc TABS 25mg, 50mg 3
ZINC TABS 25mg, 100mg 3
ZINC 15 3
ZINC & C LOZENGES 3
zinc acetate w/ sweetleaf (stevia) 3
ZINC ASPARTATE 3
ZINC CHELATED 3
ZINC CHLORIDE GRAN 3
zinc chloride SOLN 3
zinc cold relief 3
zinc gluconate LOZG; TABS 3
ZINC LOZENGES/VITAMIN C 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
661
Drug Name Drug Tier Requirements/Limits
ZINC MAGNESIUM ASPARTATE 3
ZINC METHIONATE 3
ZINC OXIDE PSTE 3
zinc oxide (topical) 20%, 40% 3
ZINC PICOLINATE TABS 3
ZINC SULFATE CAPS 50mg 3
zinc sulfate CAPS 220mg 3
ZINC SULFATE POWD 3
ZINC SULFATE TABS 140mg 3
zinc sulfate TABS 220mg 3
ZINC SULFATE HEPTAHYDRATE POWD 3
ZINC SULFATE MONOHYDRATE 3
ZINC W/A&C 3
zinc-220 3
zinc-vites 3
ZINC/VITAMIN C 3
ZN-50 3
ZN-PLUS 3
ZNLIN 3
zoden 3
ZODRYL AC 25 3
ZODRYL AC 30 3
ZODRYL AC 35 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
662
Drug Name Drug Tier Requirements/Limits
ZODRYL AC 40 3
ZODRYL DAC 25 3
ZODRYL DAC 30 3
ZODRYL DAC 35 3
ZODRYL DAC 40 3
ZODRYL DEC 25 3
ZODRYL DEC 30 3
ZODRYL DEC 35 3
ZODRYL DEC 40 3
zoo friends 3
ZOO FRIENDS COMPLETE 3
zoo friends gummies 3
zoo friends gummies plus 3
zoo friends multi gummies 3
zoo friends plus extra c 3
zoo friends plus iron 3
zoo friends/extra c 3
zostrix 3
ZOSTRIX CRE 0.025% 3
zostrix high potency 3
zostrix high potency foot 3
ZOSTRIX NATURAL PAIN RELI 3
ZOSTRIX-HP 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
663
Drug Name Drug Tier Requirements/Limits
ZUTRIPRO 3
ZYNCOF SYRP 3
zyncof TABS 3
ZYRTEC ALLERGY TABS 3
ZYRTEC CHILDRENS ALLERGY 3
ZYRTEC CHILDRENS HIVES RE 3
ZYRTEC HIVES RELIEF 3
zyrtec itchy eye 3
ZYRTEC-D ALLERGY/CONGESTI 3
ZZZQUIL 3
NUTRITIONAL/SUPPLEMENTS
ELECTROLYTES
klor-con 8 1
klor-con 10 1
klor-con m10 1
klor-con m15 2
klor-con m20 1
klor-con pak 20meq 1
klor-con spr cap 8meq 1
klor-con spr cap 10meq 1
MAGNESIUM SULFATE SOLN 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml,
40gm/1000ml
2
magnesium sulfate SOLN 2gm/50ml,
4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml, 50%
2
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
664
Drug Name Drug Tier Requirements/Limits
MAGNESIUM SULFATE IN D5W 2
magnesium sulfate in dextrose 2
magnesium sulfate inj 50% 2
potassium chloride CPCR 1
potassium chloride PACK 1
potassium chloride SOLN 10%, 20% 1
potassium chloride TBCR 1
potassium chloride microencapsulated
crystals er
1
potassium chloride tab cr 10 meq 1
sm pediatric electrolyte 3
sodium chloride SOLN 2.5meq/ml 1
sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln
1
tpn electrolytes 2 B/D
IV NUTRITION
AMINOSYN 2 B/D
AMINOSYN 7%/ELECTROLYTES 2 B/D
aminosyn 8.5%/electrolyte 2 B/D
aminosyn ii 8.5%/electrol 2 B/D
AMINOSYN II INJ 8.5% 2 B/D
AMINOSYN II INJ 10% 2 B/D
AMINOSYN M 2 B/D
AMINOSYN-HBC 2 B/D
AMINOSYN-PF 7% 2 B/D
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
665
Drug Name Drug Tier Requirements/Limits
AMINOSYN-PF INJ 10% 2 B/D
AMINOSYN-RF 2 B/D
CLINIMIX 4.25%/DEXTROSE 5% 2 B/D
CLINIMIX 4.25%/DEXTROSE 25% 2 B/D
CLINIMIX 5%/DEXTROSE 15% 2 B/D
CLINIMIX 5%/DEXTROSE 20% 2 B/D
CLINIMIX 5%/DEXTROSE 25% 2 B/D
CLINIMIX INJ 4.25/D10 2 B/D
FREAMINE HBC 6.9% 2 B/D
FREAMINE III 2 B/D
hepatamine 2 B/D
INTRALIPID 30% 2 B/D
intralipid inj 20% 2 B/D
NEPHRAMINE 2 B/D
nutrilipid inj 20% 2 B/D
premasol sol 6% 1 B/D
PREMASOL SOL 10% 2 B/D
PROCALAMINE 2 B/D
PROSOL 2 B/D
TRAVASOL 2 B/D
TROPHAMINE INJ 10% 2 B/D
IV REPLACEMENT SOLUTIONS
dextrose 2.5%/nacl 0.45% 1
dextrose 5% 1
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
666
Drug Name Drug Tier Requirements/Limits
DEXTROSE 5% /ELECTROLYTE 2
dextrose 5%/nacl 0.2% 1
DEXTROSE 5%/NACL 0.3% 2
dextrose 5%/nacl 0.9% 1
dextrose 5%/nacl 0.33% 1
dextrose 5%/nacl 0.45% 1
dextrose 5%/nacl 0.225% 1
dextrose 5%/potassium chl 1
dextrose 10% flex contain 1
DEXTROSE 10%/NACL 0.2% 2
dextrose 10%/nacl 0.45% 1
dextrose 50% 1
dextrose in lactated ringers 1
dextrose inj 70% 1
IONOSOL-MB/DEXTROSE 5% 2
ISOLYTE P 2
ISOLYTE S 2
kcl0.15%/d5w/nacl0.2% 1
KCL 0.3%/D5W/NACL 0.9% 2
kcl 0.3%/d5w/nacl 0.45% 1
kcl 0.15%/d5w/nacl 0.9% 1
KCL 0.15%/D5W/NACL 0.225% 2
kcl 0.075%/d5w/nacl 0.45% 1
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
667
Drug Name Drug Tier Requirements/Limits
kcl/d5w inj 0.3% 1
kcl/d5w/nacl inj 0.22%/0.45% 1
kcl/d5w/nacl inj .15/.33% 1
kcl/d5w/nacl inj .15/.45% 1
kcl/nacl inj 0.3-0.9 1
kcl/nacl inj 0.15%-0.9% 1
lactated ringer's 1
NORMOSOL-M IN D5W 2
NORMOSOL-R 2
NORMOSOL-R IN D5W 2
PLASMA-LYTE A 2
PLASMA-LYTE-148 2
pot chloride inj 2meq/ml 1
potassium chloride SOLN .4meq/ml, 2meq/ml, 10meq/100ml, 10meq/50ml,
20meq/100ml, 40meq/100ml
1
potassium chloride in nacl 1
sodium chloride SOLN 3%, 5% 1
sodium chloride 0.45% 1
sodium chloride inj 0.9% 1
MINERALS
calcitrate 950mg 3
calcium 500/d CHEW 3
calcium carbonate TABS 600mg, 1250mg 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
668
Drug Name Drug Tier Requirements/Limits
calcium carbonate (antacid) SUSP 1250mg/5ml
3
calcium carbonate-cholecalciferol CHEW 3
calcium carbonate-cholecalciferol TABS 3
calcium carbonate-vitamin d TABS 3
CALCIUM GLUCONATE TABS 500mg 3
MAG64 3
MAGNEBIND 300 3
magnesium TABS 250mg 3
magnesium oxide (mg supplement) TABS
241.3mg, 400mg, 500mg
3
NU-MAG 3
os-cal extra d3 3
oysco 500 3
oysco 500+d TABS 3
oyster shell 500mg 3
sm oyster shell calcium/v 3
sodium chloride TABS 1gm 3
VITAMINS
animal shapes 3
ANIMAL SHAPES/IRON 3
aquadeks LIQD 3
ascorbic acid CHEW 250mg, 500mg 3
ascorbic acid TABS 250mg, 500mg 3
b-complex vitamins CAPS 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
669
Drug Name Drug Tier Requirements/Limits
b-complex vitamins TABS 3
balanced b-50 TABS 3
balanced b-100 TABS 3
biotin CAPS 5000mcg 3
biotin TABS 5mg, 300mcg 3
biotin/maximum strength 3
calcitriol CAPS 1 B/D
calcitriol inj 1 B/D
calcitriol oral soln 1 mcg/ml 1 B/D
CERTAVITE SENIOR/ANTIOXID 3
certavite/antioxidants TABS 3
cholecalciferol CAPS 2000unit 3
cholecalciferol LIQD 400unit/ml 3
cholecalciferol TABS 1000unit, 2000unit 3
cyanocobalamin SOLN 1000mcg/ml 3
cyanocobalamin TABS 1000mcg 3
DEKAS ESSENTIAL 3
DEKAS PLUS 3
ELDERTONIC 3
ergocalciferol CAPS 50000unit 3
ergocalciferol SOLN 8000unit/ml 3
folic acid SOLN 5mg/ml 3
folic acid TABS 1mg, 400mcg 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
670
Drug Name Drug Tier Requirements/Limits
GNP PRENATAL 3
hydroxocobalamin acetate 1000mcg/ml 3
icaps mv 3
M-NATAL PLUS 2
MEPHYTON 5mg 3
meribin 3
multiple vitamins w/ minerals TABS 3
NASCOBAL 3
niacin CPCR 500mg 3
niacin TABS 500mg 3
niacin TBCR 500mg 3
niacinamide TABS 500mg 3
NIVA-PLUS 2
O-CAL FA 2
ocuvite/lutein 3
ONCOVITE 3
one daily 3
one daily mens 3
paricalcitol CAPS 1 B/D
phytonadione SOLN 1mg/0.5ml, 10mg/ml 3
PNV FOLIC ACID + IRON MUL 2
PNV PRENATAL PLUS 2
PNV PRENATAL TAB PLUS 2
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
671
Drug Name Drug Tier Requirements/Limits
POLY-VI-SOL/IRON 3
polyvitamin 3
PRENATAL 2
PRENATAL 3
PRENATAL PLUS 2
PRENATAL PLUS LOW IRON 2
PREPLUS 2
prosight 3
pyridoxine hcl SOLN 3
pyridoxine hcl TABS 50mg, 100mg 3
RAYALDEE 2
stress formula 3
stress formula w/iron 3
stress formula/zinc 3
superplex-t 3
tab-a-vite 3
tab-a-vite w/beta caroten 3
tab-a-vite/iron 3
THERA 3
THERA M PLUS 3
THERA-M 3
thiamine hcl SOLN 100mg/ml 3
thiamine hcl TABS 100mg 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
672
Drug Name Drug Tier Requirements/Limits
total b/c 3
TRI-VI-SOL 3
TRICARE 2
vita-bee/c 3
vitamin a CAPS 10000unit 3
VOL-PLUS 2
OPHTHALMIC
ANTI-INFECTIVE/ANTI-INFLAMMATORY
bacitracin-poly-neomycin-hc 1
BLEPHAMIDE OINT 2
neomycin-polymy-dexameth 1
neomycin-polymyxin-hc (ophth) 1
sulfacetamide sod-prednisolone 1
TOBRADEX OINT 2
TOBRADEX ST 2
tobramycin-dexamethasone 1
ZYLET 2
ANTI-INFECTIVES
AZASITE 2
bacitracin (ophthalmic) 1
bacitracin-polymyxin b (ophth) 1
BESIVANCE 2
CILOXAN OINT 2
ciprofloxacin hcl (ophth) 1
erythromycin (ophth) 1
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
673
Drug Name Drug Tier Requirements/Limits
gatifloxacin (ophth) 1
gentak 1
gentamicin sulfate soln (ophth) 1
MOXEZA 2
moxifloxacin hcl (ophth) 1
NATACYN 2
neomycin-bacitracin zn-polymyxin 1
neomycin-polymyxin-gramicidin 1
ofloxacin (ophth) 1
polymyxin b-trimethoprim 1
sulfacetamide sodium (ophth) 1
tobramycin (ophth) 1
trifluridine 1
ZIRGAN 2
ANTI-INFLAMMATORIES
ALREX 2
bromfenac sodium (ophth) 1
BROMSITE 2
dexamethasone sodium phosphate (ophth) 1
diclofenac sodium (ophth) 1
DUREZOL 2
fluorometholone 1
flurbiprofen sodium 1
ILEVRO 2
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
674
Drug Name Drug Tier Requirements/Limits
ketorolac tromethamine (ophth) 1
LOTEMAX 2
prednisolone acetate (ophth) 1
PREDNISOLONE SODIUM PHOSPHATE
(OPHTH)
2
PROLENSA 2
ANTIALLERGICS
azelastine drop 0.05% 1
BEPREVE 2
cromolyn sodium (ophth) 1
LASTACAFT 2
olopatadine hcl 0.2% 1
PAZEO 2
ANTIGLAUCOMA
ALPHAGAN P SOL 0.1% 2
AZOPT 2
betaxolol hcl (ophth) 1
BETOPTIC-S 2
brimonidine sol 0.2% 1
brimonidine sol 0.15% 1
carteolol hcl (ophth) 1
COMBIGAN 2
dorzolamide hcl 1
dorzolamide hcl-timolol maleate 1
latanoprost SOLN 1
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
675
Drug Name Drug Tier Requirements/Limits
levobunolol hcl 1
LUMIGAN 2
PHOSPHOLINE IODIDE 2
pilocarpine hcl SOLN 1
SIMBRINZA 2
timolol maleate (ophth) soln 1
timolol maleate gel 1
timolol maleate ophth soln 0.5% (once-
daily)
1
TRAVATAN Z 2
MISCELLANEOUS
akwa tears 3
artificial tears OINT 3
artificial tears SOLN 1.4% 3
CYSTARAN 2 NM, LA, PA
GENTEAL SEVERE .3% 3
genteal tears liquid drop 3
genteal tears mild 3
gnp lubricant pm 3
gnp lubricating plus eye .5% 3
goodsense lubricating plu 3
hm lubricating plus .5% 3
hm lubricating tears 3
liquitears 1.4% 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
676
Drug Name Drug Tier Requirements/Limits
lubricant eye drops 3
lubricant eye drops dry e 3
lubricating eye drops 3
lubrifresh p.m. 3
MURO 128 SOLN 2% 3
natures tears 3
proparacaine hcl SOLN 1
REFRESH 3
refresh celluvisc 3
refresh lacri-lube 3
REFRESH OPTIVE ADVANCED 3
REFRESH OPTIVE SENSITIVE 3
RESTASIS 2 QL (60 single use vials /
30 days)
RESTASIS MULTIDOSE 2 QL (1 bottle / 30 days)
sm lubricant eye drops 3
sodium chloride hypertonic OINT 5% 3
sodium chloride hypertonic SOLN 5% 3
SYSTANE OVERNIGHT THERAPY 3
tears naturale 3
ultra lubricant eye drops 3
RESPIRATORY
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS
ANORO ELLIPTA 2 QL (60 blisters / 30
days)
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
677
Drug Name Drug Tier Requirements/Limits
BEVESPI AEROSPHERE 2 QL (1 inhaler / 30 days)
COMBIVENT RESPIMAT 2 QL (2 inhalers / 30 days)
ipratropium-albuterol nebu 1 B/D
TRELEGY ELLIPTA 2 QL (60 blisters / 30
days)
ANTICHOLINERGICS
ATROVENT HFA 2 QL (2 inhalers / 30 days)
INCRUSE ELLIPTA 2 QL (30 blisters / 30 days)
ipratropium bromide SOLN 1 B/D
ipratropium bromide (nasal) 1
ANTIHISTAMINES
all day allergy TABS 10mg 3
all day allergy childrens CHEW 3
all day allergy childrens SOLN 5mg/5ml 3
all-day allergy childrens 5mg/5ml 3
aller-chlor TABS 4mg 3
allergy TABS 4mg, 10mg 3
allergy childrens SYRP 5mg/5ml 3
allergy non-drowsy 10mg 3
allergy relief CAPS 25mg 3
allergy relief TABS 10mg, 180mg 3
allergy relief childrens LIQD 12.5mg/5ml 3
allergy relief childrens SOLN 5mg/5ml 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
678
Drug Name Drug Tier Requirements/Limits
allergy-time 4mg 3
azelastine spr 0.1% 1
azelastine spr 0.15% 1
banophen CAPS 25mg, 50mg 3
banophen LIQD 12.5mg/5ml 3
banophen TABS 25mg 3
cetirizine hcl CHEW 10mg 3
cetirizine hcl TABS 5mg, 10mg 3
cetirizine hcl allergy ch 5mg/5ml 3
cetirizine hcl childrens SOLN 1mg/ml, 5mg/5ml
3
cetirizine syrup 1
childrens allergy 12.5mg/5ml 3
childrens loratadine SOLN 3
childrens loratadine SYRP 5mg/5ml 3
cyproheptadine hcl SYRP; TABS 2 PA; PA if 70 years and older
diphenhist LIQD 3
diphenhist TABS 25mg 3
diphenhydramine hcl CAPS 25mg, 50mg 3
diphenhydramine hcl inj 50mg/ml 1
fexofenadine hcl TABS 60mg, 180mg 3
fexofenadine hcl children 30mg/5ml 3
gnp all day allergy 10mg 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
679
Drug Name Drug Tier Requirements/Limits
gnp all day allergy child 5mg/5ml 3
gnp allergy CAPS 25mg 3
gnp allergy relief TABS 180mg 3
gnp loratadine SYRP 5mg/5ml 3
gnp loratadine TABS 10mg 3
goodsense all day allergy TABS 10mg 3
goodsense aller-ease 180mg 3
hm all day allergy 10mg 3
hm allergy 25mg 3
hm allergy childrens 12.5mg/5ml 3
hm allergy relief CAPS 25mg 3
hm allergy relief TABS 4mg 3
hm allgery multi symptom 25mg 3
hm cetirizine hcl childre 5mg/5ml 3
hm fexofenadine hcl 180mg 3
hm fexofenadine hydrochlo 180mg 3
hm loratadine 10mg 3
hm loratadine childrens 5mg/5ml 3
hydroxyzine hcl SYRP; TABS 2 PA; PA if 70 years and older
hydroxyzine hcl inj 2 PA; PA if 70 years and older
hydroxyzine pamoate CAPS 25mg, 50mg 2 PA; PA if 70 years and older
levocetirizine dihydrochloride 1
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
680
Drug Name Drug Tier Requirements/Limits
loratadine CAPS 10mg 3
loratadine TABS 10mg 3
loratadine childrens SOLN 5mg/5ml 3
loratadine childrens SYRP 5mg/5ml 3
pharbedryl 25mg 3
qc loratadine allergy rel 10mg 3
sb allergy CAPS 25mg 3
sb allergy TABS 10mg 3
sb allergy medicine TABS 25mg 3
sb chlorpheniramine 4mg 3
siladryl allergy 3
sm all day allergy 10mg 3
sm all day allergy childr 5mg/5ml 3
sm allergy 4 hour 4mg 3
sm allergy relief CAPS 25mg 3
sm allergy relief LIQD 12.5mg/5ml 3
sm childrens loratadine 5mg/5ml 3
sm fexofenadine hcl 180mg 3
sm loratadine SYRP 5mg/5ml 3
sm loratadine TABS 10mg 3
BETA AGONISTS
albuterol sulfate AERS 108mcg/act 1 QL (2 inhalers / 30 days); (generic of Proair
HFA)
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
681
Drug Name Drug Tier Requirements/Limits
albuterol sulfate AERS 108mcg/act 1 QL (2 inhalers / 30 days); (generic of Ventolin HFA)
albuterol sulfate NEBU 1 B/D
albuterol sulfate SYRP 1
albuterol sulfate TABS 1
albuterol sulfate TB12 1
levalbuterol hcl NEBU 1 B/D
levalbuterol hcl soln nebu conc 1.25
mg/0.5ml
1 B/D
levalbuterol tartrate hfa 1 QL (2 inhalers / 30
days)
SEREVENT DISKUS 2 QL (60 inhalations / 30
days)
terbutaline sulfate TABS 1
VENTOLIN HFA 2 QL (2 inhalers / 30 days)
COUGH AND COLD
all day allergy d-12 3
all day allergy-d 3
allergy & congestion reli 3
allergy relief d-24 3
allergy relief/nasal deco 3
aprodine 3
benzonatate 100mg, 200mg 3
BROTAPP DM 3
cetirizine-pseudoephedrine 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
682
Drug Name Drug Tier Requirements/Limits
childrens cold & allergy 3
childrens mucus relief co 3
childrens mucus relief ex 100mg/5ml 3
childrens silfedrine 3
cold/cough childrens 3
cough & cold 3
cough dm 30mg/5ml 3
cough syrup 100mg/5ml, 200mg/10ml 3
coughtab 200mg 3
cromolyn sodium (nasal) 5.2mg/act 3
dextromethorphan polistirex 3
dextromethorphan-guaifenesin SYRP 3
diabetic siltussin das-na 3
diabetic siltussin-dm 3
dimaphen childrens 3
dimaphen dm cold & cough 3
ed a-hist TABS 3
endacof-dm 3
extra action cough 3
gnp all day allergy-d 3
gnp cold & allergy childr 3
gnp cold & cough children 3
gnp loratadine-d 12hr 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
683
Drug Name Drug Tier Requirements/Limits
gnp mucus relief 400mg 3
gnp mucus relief dm 3
gnp mucus relief pe 3
gnp nasal decongestant 30mg 3
gnp tussin cf cough & col 3
gnp tussin dm 3
gnp tussin dm max 3
gnp tussin mucus & chest 100mg/5ml 3
guaifenesin LIQD 100mg/5ml 3
guaifenesin SOLN 100mg/5ml, 200mg/10ml, 300mg/15ml
3
guaifenesin TB12 1200mg 3
hm allergy complete-d 3
hm allergy relief & nasal 3
hm chest congestion relie 400mg 3
hm mucus er 600mg, 1200mg 3
hm nasal decongestant 30mg 3
hm tussin adult 100mg/5ml 3
hm tussin adult cough & c 3
kidkare cough/cold 3
loratadine-d 12hr 3
loratadine-d 24hr 3
MUCINEX 600mg 3
mucinex chest congestion 100mg/5ml 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
684
Drug Name Drug Tier Requirements/Limits
MUCINEX DM 3
MUCINEX DM MAXIMUM STRENG 3
mucinex fast-max dm max 3
mucus relief TABS 400mg 3
mucus relief childrens 100mg/5ml 3
mucus relief cough childr 3
mucus relief dm TABS 3
mucusrelief sinus 3
NASAL DECONGESTANT LIQD 30mg/5ml 3
NASAL DECONGESTANT SYRP 3
nasal decongestant TABS 30mg 3
nasal decongestant maximu 30mg 3
nasal decongestant pe 10mg 3
nasal decongestant pe max 10mg 3
nasal decongestant spray .05% 3
nasal relief 3
nasal spray 12 hour .05% 3
no drip nasal spray .05% 3
pedia relief cough/cold 3
pediatric cough/cold 3
pseudoephedrine hcl TABS 30mg 3
qc medifin 400 400mg 3
qc medifin dm 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
685
Drug Name Drug Tier Requirements/Limits
qc tussin cf 3
robafen 3
robafen cf multi-symptom 3
robafen dm 3
robafen dm cough clear 3
robafen dm cough/chest co 3
sb 12hr nasal spray 3
sb mucus relief dm 3
siltussin dm das 3
siltussin sa 100mg/5ml 3
siltussin-dm 3
sinus relief nasal spray .05% 3
sm all day allergy-d 3
sm chest congestion relie 400mg 3
sm cold & allergy childre 3
sm lorata-dine d 3
sm mucus relief cough chi 3
sm nasal decongestant max 30mg 3
sm nasal spray .05% 3
sm nasal spray 12 hour .05% 3
sm tussin cf 3
sm tussin dm 3
sm tussin dm cough/chest 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
686
Drug Name Drug Tier Requirements/Limits
sudogest 30mg 3
sudogest pe 10mg 3
sudogest sinus & allergy 3
tusnel diabetic 3
tussin cf 3
tussin cf cough & cold 3
tussin dm LIQD 3
tussin dm SYRP 3
tussin dm max 3
tussin dm max adult 3
tussin mucus + chest cong SYRP 100mg/5ml
3
LEUKOTRIENE MODULATORS
montelukast sodium CHEW; PACK; TABS 1
zafirlukast 1
MAST CELL STABILIZERS
cromolyn sodium nebu 1 B/D
MISCELLANEOUS
acetylcysteine SOLN 10%, 20% 1 B/D
ARALAST NP 2 NM, LA, PA
DALIRESP 2
epinephrine (anaphylaxis) .15mg/0.15ml,
.3mg/0.3ml
1 (generic of Adrenaclick)
ESBRIET 2 NM, PA
KALYDECO 2 NM, PA
OFEV 2 NM, PA
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
687
Drug Name Drug Tier Requirements/Limits
ORKAMBI 2 NM, PA
PROLASTIN-C 2 NM, LA, PA
PULMOZYME 2 NM, PA
SYMDEKO 2 NM, LA, PA
THEO-24 2
theophylline 1
XOLAIR 2 NM, LA, PA
ZEMAIRA 2 NM, LA, PA
NASAL STEROIDS
flunisolide (nasal) 1 QL (3 bottles / 30 days)
fluticasone propionate (nasal) 50mcg/act 1 QL (1 bottle / 30 days)
STEROID INHALANTS
ARNUITY ELLIPTA 2 QL (30 inhalations / 30
days)
budesonide (inhalation) .25mg/2ml,
.5mg/2ml
1 B/D
FLOVENT DISKUS 50mcg/blist,
100mcg/blist
2 QL (120 inhalations / 30
days)
FLOVENT DISKUS 250mcg/blist 2 QL (240 inhalations / 30
days)
FLOVENT HFA 2 QL (2 inhalers / 30
days)
PULMICORT FLEXHALER 2 QL (2 inhalers / 30
days)
STEROID/BETA-AGONIST COMBINATIONS
ADVAIR DISKUS 2 QL (60 inhalations / 30 days)
ADVAIR HFA 2 QL (1 inhaler / 30 days)
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
688
Drug Name Drug Tier Requirements/Limits
BREO ELLIPTA 2 QL (60 blisters / 30 days)
SYMBICORT 2 QL (1 inhaler / 30 days)
TOPICAL
DERMATOLOGY, ACNE
acne medication 5 GEL 5% 3
acne medication 10 GEL 10% 3
amnesteem 1 PA
avita 1 PA
benzoyl peroxide GEL 10% 3
benzoyl peroxide-erythromycin 1
claravis 1 PA
clindacin-p 1
clindamycin phosphate (topical) GEL; LOTN; SOLN; SWAB
1
ery pad 2% 1
erythromycin (acne aid) 1
isotretinoin CAPS 1 PA
myorisan 1 PA
sulfacetamide sodium (acne) 1
tretinoin CREA 1 PA
tretinoin GEL .01%, .025% 1 PA
zenatane 1 PA
DERMATOLOGY, ANTIBIOTICS
bacitracin (topical) 500unit/gm 3
bacitracin zinc OINT 500unit/gm 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
689
Drug Name Drug Tier Requirements/Limits
gentamicin sulfate (topical) 1
gnp bacitracin zinc 500unit/gm 3
hm bacitracin 500unit/gm 3
mupirocin OINT 1
silver sulfadiazine CREA 1
sm antibiotic 500unit/gm 3
ssd 1
SULFAMYLON CREA 2
triple antibiotic 3
DERMATOLOGY, ANTIFUNGALS
ALEVAZOL 3
anti-fungal powder 3
antifungal CREA 1%, 2% 3
carrington antifungal 2% 3
castellani paint 1.5% 3
ciclopirox CREA; GEL; SUSP 1
ciclopirox shampoo 1% 1
clotrimazole (topical) CREA 1% 1
clotrimazole (topical) CREA 1% 3
clotrimazole (topical) SOLN 1% 1
clotrimazole anti-fungal 1% 3
clotrimazole antifungal 1% 3
clotrimazole w/ betamethasone CREA 1
gnp athletes foot 1% 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
690
Drug Name Drug Tier Requirements/Limits
gnp terbinafine hydrochlo 1% 3
ketoconazole cream 1
lamisil af defense AERP 1% 3
miconazole nitrate (topical) CREA 2% 3
nyamyc 1
nystatin (topical) 1
nystatin pow 100000 1
nystop 1
qc tolnaftate 1% 3
sm antifungal clotrimazol 1% 3
sm antifungal tolnaftate 1% 3
sm athletes foot CREA 1% 3
soothe & cool inzo antifu 2% 3
terbinafine hcl (topical) 1% 3
tolnaftate CREA 1% 3
tolnaftate POWD 1% 3
DERMATOLOGY, ANTIPSORIATICS
acitretin 2 PA
calcipotriene CREA; OINT 1 QL (120 gm / 30 days),
PA
calcipotriene SOLN 1 QL (120 mL / 30 days),
PA
calcitrene 1 QL (120 gm / 30 days),
PA
tazarotene CREA 1 PA
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
691
Drug Name Drug Tier Requirements/Limits
TAZORAC CREA .05% 2 PA
DERMATOLOGY, ANTISEBORRHEICS
ketoconazole shampoo 1
selenium sulfide LOTN 1
DERMATOLOGY, CORTICOSTEROIDS
ala-cort 1%, 2.5% 1
alclometasone dipropionate 1
anti-itch maximum strengt CREA 1% 3
betamethasone dipropionate (topical) 1
betamethasone dipropionate augmented 1
betamethasone valerate CREA; LOTN; OINT
1
ENSTILAR 2 PA
fluocinolone acetonide CREA; OIL; OINT; SOLN
1
fluocinolone acetonide oil body 1
fluocinonide CREA .05% 1
fluocinonide GEL 1
fluocinonide SOLN 1
fluocinonide emulsified base 1
fluticasone propionate CREA; OINT 1
gnp hydrocortisone maximu 1% 3
gnp hydrocortisone/aloe 3
halobetasol propionate CREA; OINT 1
hm hydrocortisone plus 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
692
Drug Name Drug Tier Requirements/Limits
hm hydrocortisone/aloe ma 3
hydrocortisone (topical) CREA 1% 3
hydrocortisone (topical) CREA 1%, 2.5% 1
hydrocortisone (topical) LOTN 2.5% 1
hydrocortisone (topical) OINT 1% 3
hydrocortisone (topical) OINT 2.5% 1
hydrocortisone butyrate cream 0.1% 1
hydrocortisone butyrate oint 0.1% 1
hydrocortisone maximum st 1% 3
hydrocortisone valerate 1
hydrocortisone-aloe vera 3
hydroskin CREA 1% 3
hydroskin LOTN 3
mometasone furoate CREA; OINT; SOLN 1
sb hydrocortisone maximum 3
sb hydrocortisone plus 1% 3
sm hydrocortisone CREA 1% 3
sm hydrocortisone maximum 1% 3
TEXACORT SOLN 2.5% 2
triamcinolone acetonide (topical) CREA;
LOTN; OINT
1
DERMATOLOGY, LOCAL ANESTHETICS
glydo 1 QL (30 mL / 30 days), PA
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
693
Drug Name Drug Tier Requirements/Limits
lidocaine PTCH 1 QL (3 patches / 1 day), PA
lidocaine hcl GEL 1 QL (30 mL / 30 days), PA
lidocaine hcl SOLN 4% 1 QL (50 mL / 30 days), PA
lidocaine oint 5% 1 QL (50 grams / 30 days), PA
lidocaine-prilocaine 1 QL (30 grams / 30 days), PA
DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE
ABREVA 10% 3
ammonium lactate CREA; LOTN 1
COLEMAN BOTANICALS INSECT 3
COLEMAN INSECT REPELLENT/ 3
COLEMAN SKINSMART INSECT 3
CUTTER BACKWOODS 3
CUTTER BACKWOODS DRY 25% 3
CUTTER LEMON EUCALYPTUS 3
CUTTER NATURAL AERO 3
CUTTER SKINSATIONS LIQD 7% 3
CVS INSECT REPELLENT 3
CVS TOTAL HOME INSECT REP 3
diclofenac sodium (topical) 1% gel 1 PA
fluorouracil (topical) CREA 5% 1
fluorouracil (topical) SOLN 1
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
694
Drug Name Drug Tier Requirements/Limits
imiquimod CREA 5% 1
metronidazole (topical) CREA; LOTN 1
metronidazole gel 0.75% 1
NATRAPEL 12-HOUR TICK & I 3
OFF ACTIVE 15% 3
OFF DEEP WOODS 3
OFF DEEP WOODS DRY 3
OFF DEEP WOODS SPORTSMEN 3
OFF FAMILYCARE CLEAN FEEL 3
OFF FAMILYCARE UNSCENTED 7% 3
OFF SMOOTH & DRY 15% 3
PANRETIN 2
PICATO .05% 2 QL (2 tubes / 30 days)
PICATO .015% 2 QL (3 tubes / 30 days)
podofilox SOLN 1
procto-med hc 1
procto-pak 1
proctosol hc cre 2.5% 1
proctozone-hc 1
REPEL 100 3
REPEL FAMILY 15% 3
REPEL FAMILY DRY 3
REPEL HUNTERS FORMULA 3
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
695
Drug Name Drug Tier Requirements/Limits
REPEL LEMON EUCALYPTUS IN 3
REPEL SPORTSMEN 25% 3
REPEL SPORTSMEN DRY 3
REPEL SPORTSMEN MAX 3
REPEL TICK DEFENSE 3
rosadan 1
tacrolimus (topical) 1
TARGRETIN GEL 2 NM, PA
ULTRATHON INSECT REPELLEN 3
VALCHLOR 2 NM, LA, PA
zinc oxide (topical) 20% 3
DERMATOLOGY, SCABICIDES AND PEDICULIDES
gnp lice treatment LIQD 1% 3
gnp lice treatment SHAM 3
hm lice treatment LIQD 1% 3
lice killing maximum stre SHAM 3
malathion 1
permethrin cre 5% 1
sm lice killing maximum s 3
DERMATOLOGY, WOUND CARE AGENTS
acetic acid .25% 1
REGRANEX 2 PA
SANTYL 2
sodium chlor sol 0.9% irr 1
This document includes a list of drugs covered on our formulary as of April 1, 2019. You
can find information on what the symbols and abbreviations on this table mean by going to
page 7.
696
Drug Name Drug Tier Requirements/Limits
water for irrigation, sterile 1
MOUTH/THROAT/DENTAL AGENTS
cevimeline hcl 1
chlorhexidine gluconate (mouth-throat) 1
clotrimazole LOZG 1
lidocaine hcl (mouth-throat) 1
nystatin (mouth-throat) 1
paroex sol 0.12% 1
periogard 1
pilocarpine hcl (oral) 1
triamcinolone acetonide (mouth) 1
OTIC
acetic acid (otic) 1
CIPRODEX 2
flac 1
fluocinolone acetonide (otic) 1
neomycin-polymyxin-hc (otic) 1
ofloxacin (otic) 1
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 697
Index
*
*prenatal multivitamins & .................................. 484
1
12 hour allergy-d ................................................... 376
12 hour antihistamine/dec ................................. 376
12 hour decongestant .......................................... 376
12 hour nasal decongestan ................................ 376
12 hour nasal relief spra ..................................... 376
12 hour nasal spray .............................................. 376
2
24hr allergy relief .................................................. 376
2ND SKIN MOIST BURN PADS .......................... 565
2ND SKIN MOIST DRESSING K ........................ 565
2ND SKIN MOIST GEL PADS 1 .......................... 565
2ND SKIN MOIST GEL PADS 3 .......................... 565
3
3 day vaginal ........................................................... 244
4
4-N-1 .......................................................................... 439
4-way fast acting ................................................... 655
4-way menthol ........................................................ 655
4X PROBIOTIC ........................................................ 658
5
5 DAY.......................................................................... 244
50+ adult eye health ............................................ 112
6
600+d3 plus minerals .......................................... 241
666 cold ..................................................................... 200
666 cold preparation ............................................ 201
8
8 hour arthritis pain rel ....................................... 376
8 hour pain relief ................................................... 376
8 hour pain reliever .............................................. 376
8hr muscle aches & pain ............................... 12, 376
A
A + D PERSONAL CARE LOTIO ......................... 104
A + D PERSONAL CARE WIPES ........................ 104
a thru z advanced .................................................. 104
a thru z advanced adult f.................................... 104
a thru z advantage ................................................ 104
a thru z high potency ........................................... 104
a thru z select ......................................................... 104
a thru z select 50+ advan .................................. 104
a thru z select 50+ mens ................................... 104
a thru z select advanced ..................................... 104
a thru z select ultimate ....................................... 104
a thru z ultimate mens ........................................ 104
A+D FIRST AID ....................................................... 104
a-10000 ..................................................................... 105
A1C NOW SELFCHECK ......................................... 104
a-200 .......................................................................... 104
A-200 .......................................................................... 105
a-200 maximum strength .................................. 105
A-25 ............................................................................ 104
abacavir sulfate ........................................................ 24
abacavir sulfate-lamivudine ................................. 26
abacavir sulfate-lamivudine-zidovudine ......... 26
abanatuss ped ......................................................... 105
abanatuss ped drops ............................................ 105
abatinex ..................................................................... 105
ABATREX ................................................................... 105
ABATRON .................................................................. 105
abatron af ................................................................. 105
abatuss dmx ............................................................ 105
abc plus ..................................................................... 105
abc plus senior ........................................................ 105
abc plus senior adults 50 .................................... 105
abdek .......................................................................... 105
ABDEK ........................................................................ 105
abdek pediatric ....................................................... 105
ABELCET ...................................................................... 23
ABILIFY MAINTENA ................................................. 60
abiraterone acetate ................................................. 36
ABRAXANE .................................................................. 34
ABREVA .............................................................. 105, 693
ABSORBASE ............................................................. 105
ACAI WEIGHT CONTROL ..................................... 105
acamprosate calcium .............................................. 69
acarbose ...................................................................... 73
a-caro-25 .................................................................. 105
ACCU-CHEK 3 MIS METER .................................. 105
ACCU-CHEK ACTIVE.............................................. 105
ACCU-CHEK ACTIVE STRIPS ............................. 106
ACCU-CHEK ADVANTAGE H TES ...................... 106
ACCU-CHEK ADVANTAGE METER .................... 106
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 698
ACCU-CHEK ADVANTAGE TEST ........................ 106
ACCU-CHEK AVIVA ................................................ 106
ACCU-CHEK AVIVA CONNECT ........................... 106
ACCU-CHEK AVIVA PLUS .................................... 106
ACCU-CHEK COMFORT CURVE T ...................... 106
ACCU-CHEK COMPACT PLUS ............................. 106
ACCU-CHEK COMPACT STRIPS ......................... 106
ACCU-CHEK COMPACT TEST DR ...................... 106
ACCU-CHEK EA MIS DIA METR ......................... 106
ACCU-CHEK EASY TEST STRIP ......................... 106
ACCU-CHEK GUIDE ............................................... 106
ACCU-CHEK INSTANT CARE KI ........................ 106
ACCU-CHEK KIT III ............................................... 106
ACCU-CHEK NANO SMARTVIEW ...................... 106
ACCU-CHEK SIMPLICITY ..................................... 106
ACCU-CHEK SIMPLICITY TEST ......................... 106
ACCU-CHEK SMARTVIEW STRIP ...................... 106
ACCU-CHEK SOFT TOUCH LANC ...................... 106
ACCU-CHEK SOFTCLIX LANCET ....................... 106
ACCU-CHEK VOICEMATE .................................... 106
ACCUTREND GLUCOSE ........................................ 107
ACE AEROSOL CLOUD ENHANCE ..................... 107
acebutolol hcl ............................................................ 46
acephen ............................................................... 10, 107
acerola c .................................................................... 107
ACEROLA C 500 ...................................................... 107
acerola c-500 .......................................................... 107
acetadryl ................................................................... 107
aceta-gesic ............................................................... 107
acetaminophen ................................................. 10, 107
acetaminophen 8 hour ......................................... 107
acetaminophen childrens .................................... 107
acetaminophen congestion ................................ 107
acetaminophen extra stren .................. 10, 107, 108
acetaminophen infants ........................................ 108
acetaminophen junior stre ................................. 108
acetaminophen pm ............................................... 108
acetaminophen pm extra st ............................... 108
acetaminophen rapid tabs .................................. 108
acetaminophen w/ codeine 300-15mg ............ 16
acetaminophen w/ codeine 300-30mg ............ 16
acetaminophen w/ codeine 300-60mg ............ 16
acetaminophen w/ codeine soln ......................... 16
acetaminophen-pamabrom-pyrilamine ......... 108
acetazolamide ........................................................... 49
acetic acid ................................................................. 695
acetic acid (otic) ..................................................... 696
ACETYL SALICYLIC ACID .................................... 108
acetylcarnitine hcl (nutrient) ............................. 108
acetylcysteine ......................................................... 686
acid control maximum stre ................................ 108
acid controller ......................................................... 108
acid controller complete ...................................... 108
acid controller maximum s ................................. 108
acid gone ..................................................................... 82
acid reducer ....................................................... 87, 108
acid reducer + antacid ......................................... 108
acid reducer complete .......................................... 108
acid reducer maximum stre ......................... 87, 108
acid relief .................................................................. 108
ACIDOPHILUS.......................................................... 108
acidophilus extra strengt .................................... 108
ACIDOPHILUS HIGH-POTENCY ......................... 108
ACIDOPHILUS PEARLS ......................................... 108
ACIDOPHILUS PLUS PECTIN .............................. 109
acidophilus probiotic ............................................. 109
ACIDOPHILUS PROBIOTIC ................................. 109
ACIDOPHILUS PROBIOTIC BLE ......................... 109
ACIDOPHILUS PROBIOTIC COM ....................... 109
acidophilus probiotic for ...................................... 109
ACIDOPHILUS SUPER PROBIOT ....................... 109
ACIDOPHILUS XTRA ............................................. 109
ACIDOPHILUS/BIFIDUS ....................................... 109
ACIDOPHILUS/CITRUS PECTIN ........................ 109
ACIDOPHILUS/GOAT MILK ................................. 109
acitretin ..................................................................... 690
acne foaming wash ............................................... 109
acne maximum strength ..................................... 109
ACNE MEDICATION ............................................... 109
acne medication 10 ....................................... 109, 688
ACNE MEDICATION 10 ......................................... 109
acne medication 5 ......................................... 109, 688
ACNE MEDICATION 5 ........................................... 109
acne pimple medication ma ............................... 109
acne treatment cleansing ................................... 109
acne treatment gel ................................................ 109
acne wash ................................................................. 109
acne-clear ................................................................. 110
ACNEFREE 24 HOUR ACNE CLE ........................ 110
ACNEFREE SEVERE 24 HOUR C ........................ 110
act anticavity fluoride r ....................................... 110
act restoring fluoride ri ........................................ 110
act total care ........................................................... 110
ACTHIB ...................................................................... 102
actical ......................................................................... 110
ACTICOAT 7 2 ......................................................... 110
ACTICOAT 7 4 ......................................................... 110
ACTICOAT ABSORBENT ANTIMI ....................... 110
ACTICOAT ANTIMICROBIAL DR ........................ 110
ACTICOAT FLEX 3 BARRIER D .......................... 110
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 699
ACTICON ................................................................... 110
ACTIDOGESIC ......................................................... 110
ACTIDOM DMX ........................................................ 110
actidose/sorbitol ..................................................... 110
actidose-aqua .......................................................... 110
actifed cold & allergy ............................................ 110
ACTIFED PLUS ......................................................... 110
ACTIFED PLUS TAB ............................................... 110
ACTIFED TAB 2.5-60MG ...................................... 110
ACTIFED TAB SINUS ............................................. 110
ACTIFLOVIT EAR HEALTH ................................... 110
ACTIMMUNE ............................................................. 101
ACTINEL .................................................................... 111
ACTINEL PEDIATRIC ............................................. 111
ACTIPROTECT UF ................................................... 111
ACTISEP .................................................................... 111
ACTITROM ................................................................ 111
ACTITROM-D............................................................ 111
ACTIVESSENTIALS ................................................ 111
ACTIVITE EC ............................................................ 111
ACTIVITY POUCH ................................................... 111
ACTIVNUTRIENTS .................................................. 111
ACURA BLOOD GLUCOSE MONIT..................... 111
ACURA BLOOD GLUCOSE TEST ........................ 111
ACURA PLUS BLOOD GLUCOSE ........................ 111
ACUWASH ................................................................. 111
acyclovir ...................................................................... 28
acyclovir sodium ...................................................... 28
ADACEL ...................................................................... 102
ADAGEN ....................................................................... 77
adapalene ................................................................. 111
ADAPTER PED DISPOSABLE MO ....................... 111
ADAPTIC NON-ADHERING DRES ..................... 111
addaprin .................................................................... 111
added strength headache r ................................ 111
ADD-INS COMPLETE ............................................. 111
ADDITIONS FOOD ENHANCER .......................... 111
adefovir dipivoxil ...................................................... 28
ADEMPAS .................................................................... 51
ADHERES FLUFF UNDERPAD ............................. 111
ADHERES INCONTINENCE PAD ........................ 111
ADJUSTABLE LANCING DEVICE ....................... 112
ADK ............................................................................. 112
ADRENAL C FORMULA .......................................... 112
ADRENAL STRESS CALM ..................................... 112
ADRENOID ................................................................ 112
adriamycin .................................................................. 33
adrucil .......................................................................... 34
ADULT AEROSOL MASK ....................................... 112
adult aspirin ec low stre ...................................... 112
ADULT ASPIRIN LOW STRENGT ....................... 112
adult aspirin regimen ........................................... 112
ADULT DISPOSABLE MOUTHPIE ...................... 112
adult gummy ........................................................... 112
ADULT MASK ........................................................... 112
ADULT MASK LARGE ............................................. 112
ADULT OMEGA PLUS DHA .................................. 112
ADULT ONE DAILY GUMMIES ............................ 112
ADVAIR DISKUS ..................................................... 687
ADVAIR HFA ............................................................. 687
ADVANCE INTUITION BLOOD G ....................... 112
ADVANCE INTUITION TEST ST ......................... 112
ADVANCE MICRO-DRAW METER ...................... 112
ADVANCE MICRO-DRAW TEST S ..................... 112
ADVANCED C PLUS ............................................... 112
ADVANCED CALCIUM FORMULA ....................... 112
ADVANCED CALCIUM/VITAMIN ........................ 112
ADVANCED COLLAGEN ........................................ 113
ADVANCED DIABETIC MULTIVI ........................ 113
ADVANCED E ........................................................... 113
advanced eye health ............................................ 113
advanced healing ointment ................................ 113
advanced multi ea ................................................. 113
ADVANCED PROBIOTIC ....................................... 113
ADVANCED PROBIOTIC 10 ................................. 113
advanced stress formula/z ................................. 113
advantage care oral elect ................................... 113
ADVIL ......................................................................... 113
ADVIL ALLERGY & CONGESTIO ........................ 113
ADVIL ALLERGY SINUS ........................................ 113
ADVIL COLD & SINUS .......................................... 113
ADVIL CONGESTION RELIEF ............................. 113
advil junior strength ............................................. 113
ADVIL MIGRAINE ................................................... 113
ADVIL PM .................................................................. 113
ADVIL SINUS CONGESTION & .......................... 113
ADVIL TAB 200MG ................................................. 113
ADVOCATE BLOOD GLUCOSE MO ................... 113
ADVOCATE LANCING DEVICE ........................... 113
ADVOCATE RAPID-SAFE LANCI ........................ 113
ADVOCATE REDI-CODE ....................................... 114
ADVOCATE REDI-CODE/TALKIN ...................... 114
ADVOCATE REDI-CODE+ BLOOD .................... 114
ADVOCATE REDI-CODE+ TEST ........................ 114
ADVOCATE REDI-CODE+/ TALK ...................... 114
ADVOCATE TEST STRIPS .................................... 114
ADVOCATE UNDERPADS ..................................... 114
AEROTRACH PLUS ................................................. 114
af allergy relief ........................................................ 114
AF CAPSICUM OLEORESIN ................................. 114
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 700
AFINITOR .................................................................... 38
AFINITOR DISPERZ ................................................. 38
AFIRM 1X .................................................................. 114
AFIRM 2X .................................................................. 114
AFIRM 3X .................................................................. 114
AFRIN ......................................................................... 114
AFRIN 12 HOUR ...................................................... 114
AFRIN ALL NIGHT NODRIP ................................. 114
AFRIN CHILDRENS ................................................ 114
AFRIN EXTRA MOISTURIZING .......................... 114
AFRIN MENTHOL .................................................... 114
AFRIN NASAL SPRAY ............................................ 114
AFRIN NODRIP EXTRA MOISTU ........................ 114
AFRIN NODRIP ORIGINAL .................................. 114
AFRIN NODRIP SEVERE CONGE ....................... 114
AFRIN NODRIP SINUS.......................................... 115
afrin saline nasal mist .......................................... 115
AFRIN SINUS ........................................................... 115
AGAMATRIX AMP NO CODE ADV ..................... 115
AGAMATRIX AMP NO CODE TES ...................... 115
AGAMATRIX JAZZ TEST STRIP ......................... 115
AGAMATRIX JAZZ WIRELESS 2 ........................ 115
AGAMATRIX KEYNOTE TEST ST ....................... 115
AGAMATRIX PRESTO ............................................ 115
AGAMATRIX PRESTO PRO METE ...................... 115
AGAMATRIX PRESTO TEST STR ....................... 115
AHIST ......................................................................... 115
AIR PERMEABLE UNDERPAD 23 ....................... 115
airborne ..................................................................... 115
AIRBORNE ................................................................ 115
airborne gummies ................................................. 115
airborne immune system .................................... 115
AIR-DRI BREATHABLES FLUID ......................... 115
AIR-DRI BREATHABLES PLUS ........................... 115
AIRS PEDIATRIC AEROSOL MA ........................ 115
AIRSHIELD ............................................................... 115
AIRZONE PEAK FLOW METER............................ 115
akedamins ................................................................ 115
akwa tears ................................................................ 675
al12 ............................................................................. 116
ala seb........................................................................ 116
ala-cort .............................................................. 116, 691
ALAHIST CF .............................................................. 116
ALAHIST DM ............................................................ 116
ALA-HIST IR ............................................................. 116
ALA-HIST PE ............................................................ 116
alamag-plus ............................................................. 116
alavert ........................................................................ 116
alavert allergy/sinus ............................................. 116
alaway ........................................................................ 116
alaway childrens allergy ...................................... 116
ALBAFORT ................................................................. 116
albendazole ................................................................ 20
ALBENZA ..................................................................... 20
albertsons bis-mate .............................................. 116
albertson's headache form ................................. 116
albertsons magnesium citr ................................. 116
albertson's night time co .................................... 116
ALBOLENE ................................................................. 116
albuterol sulfate ............................................. 680, 681
alcalak ........................................................................ 116
alclometasone dipropionate ............................... 691
ALCOHOL SWABS .................................................... 71
ALDEX AN ................................................................. 116
ALDEX D .................................................................... 116
ALDEX GS ................................................................. 116
ALDEX GS DM.......................................................... 116
ALDEX-CT ................................................................. 117
ALDURAZYME ............................................................ 77
ALECENSA ................................................................... 38
alendronate sodium ................................................ 76
aler-cap ..................................................................... 117
ALER-DRYL ............................................................... 117
alertab ........................................................................ 117
alertness aid ............................................................ 117
alertness aid maximum str ................................ 117
ALEVAZOL ................................................................. 689
ALEVE ......................................................................... 117
ALEVE ARTHRITIS.................................................. 117
ALEVE COLD & SINUS .......................................... 117
ALEVE SINUS & HEADACHE ............................... 117
ALEVE TAB 220MG ................................................ 117
ALEVE-D SINUS & COLD ..................................... 117
ALEVE-D SINUS & HEADACHE .......................... 117
alfuzosin hcl ............................................................... 95
ALGA ........................................................................... 117
ALIGN ......................................................................... 117
ALIGN EXTRA STRENGTH ................................... 117
ALIMTA ......................................................................... 34
ALINIA .......................................................................... 20
ALIVE ENERGY 50+ ............................................... 117
alive gummies for childre ................................... 117
ALIVE MENS ENERGY ........................................... 117
alive multi-vitamin child ...................................... 117
ALIVE ONCE DAILY WOMENS 5 ........................ 117
ALIVE ONCE DAILY WOMENS U ....................... 117
ALIVE WOMENS 50+ ............................................ 117
ALIVE WOMENS ENERGY .................................... 118
ALIVE WOMENS GUMMY VITAMI ..................... 118
ALKA-SELTZER ........................................................ 118
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 701
ALKA-SELTZER EXTRA STRENG ....................... 118
ALKA-SELTZER GOLD ........................................... 118
ALKA-SELTZER HEARTBURN RE ....................... 118
ALKA-SELTZER HEARTBURN+GA .................... 118
ALKA-SELTZER ORIGINAL .................................. 118
alka-seltzer plus allergy ...................................... 118
ALKA-SELTZER PLUS COLD ............................... 118
ALKA-SELTZER PLUS COLD & ........................... 118
alka-seltzer plus day col ..................................... 118
ALKA-SELTZER PLUS DAY/NIG ......................... 118
alka-seltzer plus mucus & .................................. 118
alka-seltzer plus night c ...................................... 118
ALKA-SELTZER PLUS NIGHT C ......................... 118
alka-seltzer plus severe ...................................... 118
ALKA-SELTZER PLUS SEVERE ........................... 118
ALKA-SELTZER PLUS SINUS F .......................... 118
ALKA-SELTZER PLUS-D SINUS ......................... 118
all day allergy .................................................. 118, 677
all day allergy childrens .............................. 118, 677
all day allergy d ...................................................... 118
all day allergy d-12 ....................................... 119, 681
all day allergy-d ............................................. 119, 681
all day pain relief ................................................... 119
all day pain relief sinus ........................................ 119
all day relief ............................................................. 119
ALL FLOW 1000 PULMONARY F ........................ 119
allbee plus vitamin c ............................................. 119
ALLCLENZ ................................................................. 119
all-day allergy childrens .............................. 119, 677
ALLEGRA ALLERGY ................................................ 119
ALLEGRA ALLERGY CHILDRENS ....................... 119
ALLEGRA-D 12 HOUR ALLERGY ........................ 119
ALLEGRA-D 24 HOUR ALLERGY ........................ 119
aller-chlor ......................................................... 119, 677
aller-ease .................................................................. 119
aller-ease allergy ................................................... 119
aller-ease childrens ............................................... 119
allerfrim ..................................................................... 119
allergy ........................................................ 119, 120, 677
allergy & congestion reli ............................. 120, 681
allergy & sinus intense s ..................................... 120
allergy 24hour indoor/out .................................. 120
allergy 24-hr ............................................................ 120
allergy 4 hour .......................................................... 120
allergy childrens ............................................. 120, 677
allergy d-12.............................................................. 120
allergy eye drops ................................................... 120
allergy medication ................................................. 120
allergy medication childr ..................................... 120
allergy multi-symptom ........................................ 120
allergy multi-symptom day ................................ 120
ALLERGY MULTI-SYMPTOM DAY ....................... 120
allergy multi-symptom nig ................................. 120
allergy nasal spray 24 ho ................................... 120
allergy non-drowsy ....................................... 120, 677
allergy relief ............................................. 120, 121, 677
allergy relief 24hr .................................................. 121
allergy relief child .................................................. 121
allergy relief childrens .................................. 121, 677
allergy relief d ......................................................... 121
allergy relief d-24 .......................................... 121, 681
allergy relief for kids ............................................. 121
allergy relief nighttime ........................................ 121
allergy relief plus sinus ........................................ 121
allergy relief/nasal deco .............................. 121, 681
allergy relief-d ......................................................... 121
allergy sinus-d maximum s ................................ 121
allergy tablets ......................................................... 121
allergy/congestion relief ...................................... 121
allergy/sinus pain reliev ...................................... 122
allergy-relief-d ........................................................ 121
allergy-time ...................................................... 121, 678
allerhist ...................................................................... 122
allerhist-1.................................................................. 122
aller-time .................................................................. 119
ALLERWELL ALLERGY FORMULA ...................... 122
ALLEVYN ADHESIVE .............................................. 122
ALLEVYN AG ADHESIVE....................................... 122
ALLEVYN AG GENTLE BORDER ......................... 122
ALLEVYN AG NON-ADHESIVE ............................ 122
ALLEVYN AG SACRUM .......................................... 122
ALLEVYN COMPRESSION .................................... 122
ALLEVYN GENTLE ................................................... 122
ALLEVYN GENTLE BORDER ................................ 122
ALLEVYN GENTLE BORDER HEE ....................... 122
ALLEVYN GENTLE BORDER LIT ......................... 122
ALLEVYN GENTLE BORDER MUL ....................... 122
ALLEVYN GENTLE BORDER SAC ....................... 122
ALLEVYN HEEL ........................................................ 122
ALLEVYN LIFE .......................................................... 122
ALLEVYN LIFE HEEL .............................................. 122
ALLEVYN LIFE SACRUM ....................................... 122
ALLEVYN NON-ADHESIVE ................................... 122
ALLEVYN PLUS ADHESIVE .................................. 122
ALLEVYN PLUS CAVITY ........................................ 122
ALLEVYN PLUS SACRUM ...................................... 123
ALLEVYN SACRUM ................................................. 123
ALLEVYN THIN ........................................................ 123
ALLEVYN TRACHEOSTOMY 3-1/ ....................... 123
ALLFEN ....................................................................... 123
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 702
allfen dm ................................................................... 123
all-nite cold & flu night ........................................ 119
all-nite multi-symptom co .................................. 119
allopurinol tab ........................................................... 10
almacone ..................................................................... 82
almacone double strength .................................... 82
ALOE 10000 & PROBIOTICS .............................. 123
ALOE AFTERSUN LOTION.................................... 123
ALOE VESTA 2-N-1 PROTECTI .......................... 123
ALOE VESTA ANTIFUNGAL ................................. 123
ALOE VESTA BATHING CLOTHS ....................... 123
aloe vesta body was h/sha ................................ 123
aloe vesta body wash/sham .............................. 123
ALOE VESTA CLEAR ANTIFUNG ........................ 123
ALOE VESTA CLEAR BARRIER ........................... 123
ALOE VESTA DAILY MOISTURI ......................... 123
ALOE VESTA PROTECTIVE .................................. 123
ALOE VESTA SKIN CONDITION ........................ 123
ALOE VESTA SKIN PROTECTAN ........................ 123
ALOETOUCH PERSONAL CLEANS ..................... 123
alophen ...................................................................... 123
alosetron hcl .............................................................. 93
alpha betic ................................................................ 124
ALPHA LIPOIC ACID .............................................. 124
ALPHAGAN P SOL 0.1%....................................... 674
ALPHA-LIPOIC ACID ............................................. 124
alpha-lipoic acid (thioctic acid) ......................... 124
alphasoft ................................................................... 124
alph-e ......................................................................... 123
alph-e-mixed ........................................................... 123
alph-e-mixed 1000 ................................................ 124
alprazolam tab 0.25mg ......................................... 51
alprazolam tab 0.5mg ............................................ 51
alprazolam tab 1mg ................................................ 51
alprazolam tab 2mg ................................................ 51
ALREX ......................................................................... 673
altachlore .................................................................. 124
altalube ...................................................................... 124
altamist ...................................................................... 124
altarussin .................................................................. 124
altarussin dm ........................................................... 124
altarussin-pe ............................................................ 124
altaryl ......................................................................... 124
altazine ...................................................................... 124
ALTERNATE SITE LANCING DE ......................... 124
alum & mag hydrox-simethicone ..................... 124
aluminum & magnesium hydroxide ................ 124
ALUMINUM CHLORIDE ......................................... 124
ALUMINUM CHLORIDE HEXAHYD .................... 124
ALUMINUM HYDROXIDE ................................ 82, 124
aluminum hydroxide gel ..................................... 124
aluminum hydroxide-mag carb ........................ 124
ALUNBRIG ................................................................... 38
ALWAYS DISCREET PADS/LINE ........................ 124
ALWAYS DISCREET PADS/MODE ..................... 125
ALWAYS DISCREET UNDERWEAR .................... 125
ALWAYS DISCREET/LONG LENG ...................... 125
ALWAYS DISCREET/MAXIMUM/L ..................... 125
ALWAYS DISCREET/MODERATE/ ..................... 125
ALWAYS DISCREET/ULTIMATE/ ....................... 125
ALWAYS FEMININE WIPES ................................. 125
ALWAYS MAXI MAXIMUM PROTE ..................... 125
ALWAYS PANTILINERS/THONG ........................ 125
ALWAYS ULTRA OVERNIGHT PA ...................... 125
ALWAYS ULTRA THIN PADS ............................... 125
ALWAYS WIPES-TO-GO ....................................... 125
amantadine hcl ......................................................... 59
A-MANTLE ................................................................. 105
ambi 10peh/400gfn .............................................. 125
ambi 10peh/400gfn/20dm ................................. 125
ambi 10peh/4cpm ................................................. 125
AMBI 12.5CPD/100GFN/30PSE ........................ 125
ambi 12.5cpd/1dcpm/30pse.............................. 125
ambi 40pse/400gfn ............................................... 125
AMBI 60PSE/400GFN............................................ 125
AMBI 60PSE/400GFN/20DM .............................. 125
ambi 60pse/4cpm .................................................. 125
AMBI ESSENTIALS DAILY MOI .......................... 125
AMBI ESSENTIALS GENTLE CL ......................... 125
AMBI EVEN & CLEAR DAILY M .......................... 126
AMBI EVEN & CLEAR TARGETE ......................... 126
AMBI FADE NORMAL SKIN ................................. 126
AMBI FADE OILY SKIN ......................................... 126
AMBI SOFT & EVEN CREAMY O ........................ 126
AMBISOME .................................................................. 23
AMEDA TRIPLE ZERO LANOLIN ........................ 126
americerin ................................................................. 126
AMERIDERM PERISHIELD ................................... 126
AMERIGEL BARRIER .............................................. 126
AMERIGEL CARE ..................................................... 126
ameriphor ................................................................. 126
ameristore ................................................................ 126
amikacin sulfate ....................................................... 20
amiloride & hydrochlorothiazide ........................ 49
amiloride hcl .............................................................. 49
amina-21 ................................................................... 126
amino acids .............................................................. 126
amino acids complex ............................................ 126
amino action ............................................................ 126
aminofen ................................................................... 126
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 703
aminos ....................................................................... 126
AMINOSYN ................................................................ 664
AMINOSYN 7%/ELECTROLYTES ....................... 664
aminosyn 8.5%/electrolyte ................................ 664
aminosyn ii 8.5%/electrol .................................. 664
AMINOSYN II INJ 10% ........................................ 664
AMINOSYN II INJ 8.5% ....................................... 664
AMINOSYN M ........................................................... 664
AMINOSYN-HBC ..................................................... 664
AMINOSYN-PF 7% ................................................. 664
AMINOSYN-PF INJ 10% ....................................... 665
AMINOSYN-RF ......................................................... 665
amiodarone hcl soln ................................................ 44
amiodarone tab 100mg ......................................... 44
amiodarone tab 200mg ......................................... 44
amiodarone tab 400mg ......................................... 44
AMITIZA CAP 24MCG ............................................. 93
AMITIZA CAP 8MCG ................................................ 93
amitriptyline hcl ....................................................... 57
amlactin ..................................................................... 126
AMLACTIN CERAPEUTIC ...................................... 126
AMLACTIN ULTRA .................................................. 126
amlodipine besylate ................................................ 47
amlodipine besylate-olmesartan medoxomil 43
amlodipine besylate-valsartan tab 10-160 mg ................................................................................... 43
amlodipine besylate-valsartan tab 10-320 mg ................................................................................... 43
amlodipine besylate-valsartan tab 5-160 mg ................................................................................... 43
amlodipine besylate-valsartan tab 5-320 mg ................................................................................... 43
amlodipine--benazepril hcl cap 10-20 mg ..... 41
amlodipine-benazepril hcl cap 10-40mg ......... 42
amlodipine-benazepril hcl cap 2.5-10 mg ...... 42
amlodipine-benazepril hcl cap 5-10 mg .......... 42
amlodipine-benazepril hcl cap 5-20 mg .......... 42
amlodipine-benazepril hcl cap 5-40 mg .......... 42
amlodipine-valsartan-hydrochlorothiazide 10-
160-12.5mg .......................................................... 43
amlodipine-valsartan-hydrochlorothiazide 10-
160-25mg .............................................................. 43
amlodipine-valsartan-hydrochlorothiazide 10-
320-25mg .............................................................. 43
amlodipine-valsartan-hydrochlorothiazide 5-
160-12.5mg .......................................................... 43
amlodipine-valsartan-hydrochlorothiazide 5-
160-25mg .............................................................. 43
ammonium lactate ................................................ 693
amnesteem .............................................................. 688
amoryn mood booster .......................................... 126
amoxapine tab 100mg ........................................... 57
amoxapine tab 150mg ........................................... 57
amoxapine tab 25mg ............................................. 57
amoxapine tab 50mg ............................................. 57
amoxicillin ................................................................... 31
amoxicillin & pot clavulanate .............................. 31
amphetamine-dextroamphetamine cap sr
24hr 10 mg............................................................ 64
amphetamine-dextroamphetamine cap sr
24hr 15 mg............................................................ 64
amphetamine-dextroamphetamine cap sr
24hr 20 mg............................................................ 64
amphetamine-dextroamphetamine cap sr
24hr 25 mg............................................................ 64
amphetamine-dextroamphetamine cap sr
24hr 30 mg............................................................ 65
amphetamine-dextroamphetamine cap sr
24hr 5 mg .............................................................. 64
amphetamine-dextroamphetamine tab 10 mg ................................................................................... 65
amphetamine-dextroamphetamine tab 12.5
mg ............................................................................. 65
amphetamine-dextroamphetamine tab 15 mg ................................................................................... 65
amphetamine-dextroamphetamine tab 20 mg ................................................................................... 65
amphetamine-dextroamphetamine tab 30 mg ................................................................................... 65
amphetamine-dextroamphetamine tab 5 mg ................................................................................... 65
amphetamine-dextroamphetamine tab 7.5
mg ............................................................................. 65
amphotericin b .......................................................... 23
ampicillin & sulbactam sodium ........................... 31
ampicillin cap 500mg ............................................. 31
ampicillin inj ............................................................... 31
ampicillin sodium ..................................................... 31
amplify relief mm ................................................... 126
AMPYRA ....................................................................... 68
ANACIN ...................................................................... 127
ANACIN MAX STRENGTH .................................... 127
ANACIN TAB 400-30MG ...................................... 127
ANADROL-50 ............................................................. 71
anagrelide hcl ............................................................ 98
analgesic cream/aloe ........................................... 127
analgesic creme rub/aloe ................................... 127
analgesic creme/aloe ........................................... 127
anastrozole ................................................................. 36
anbesol cold sore therapy .................................. 127
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 704
ANDRODERM ............................................................. 71
anecream .................................................................. 127
anecream5................................................................ 127
anefrin nasal spray................................................ 127
anefrin nasal spray extra .................................... 127
anefrin nasal spray sooth ................................... 127
anefrin nasal spray/no dr ................................... 127
animal chewable multi ......................................... 127
animal chews ........................................................... 127
animal shapes ......................................................... 668
ANIMAL SHAPES/IRON ........................................ 668
ANORO ELLIPTA ..................................................... 676
antacid ................................................................. 82, 127
ANTACID ................................................................... 127
antacid + anti-gas liquid ..................................... 127
antacid advanced ................................................... 127
antacid anti-gas...................................................... 127
antacid anti-gas fast act ..................................... 127
antacid anti-gas maximum .......................... 82, 127
antacid anti-gas regular ...................................... 128
antacid calcium extra str .............................. 82, 128
antacid calcium regular s .............................. 82, 128
antacid double strength ...................................... 128
antacid extra strength ......................................... 128
antacid extra strength an ................................... 128
antacid fast acting ........................................... 82, 128
antacid fast relief ............................................. 82, 128
antacid flavor chews ............................................. 128
antacid i ..................................................................... 128
antacid iii................................................................... 128
antacid liquid ........................................................... 128
antacid m .................................................................. 128
antacid maximum .................................................. 128
antacid maximum strength .......................... 82, 128
antacid multi-symptom ....................................... 128
antacid plus anti-gas fas ............................... 82, 128
antacid plus anti-gas rel ............................... 82, 128
antacid regular strength ............................... 82, 128
ANTACID SOFT CHEWS ....................................... 128
antacid ultra strength .......................................... 128
ANTACID ULTRA STRENGTH .............................. 128
antacid w/simethicone ......................................... 128
antacid/simethicone doubl ................................. 129
anti-allergy ............................................................... 129
ANTI-BACTERIAL HAND LOTIO ........................ 129
antibiotic + pain relief.......................................... 129
antibiotic plus pain reli ........................................ 129
anti-dandruff shampoo ........................................ 129
anti-diarrheal ..................................................... 84, 129
anti-diarrheal plus gas r ...................................... 129
antifungal .................................................. 129, 130, 689
anti-fungal ................................................................ 129
antifungal foot ......................................................... 130
antifungal foot/sneaker s .................................... 130
antifungal powder .................................................. 130
anti-fungal powder ................................................ 689
antifungal spray powder ..................................... 130
anti-gas ..................................................................... 129
anti-gas ultra strength ......................................... 129
anti-gas/ and gnp antacid ................................................. 335
anti-hist allergy ...................................................... 129
anti-itch ..................................................................... 129
anti-itch intensive heali ....................................... 129
anti-itch maximum strengt ........................ 129, 691
anti-nausea .............................................................. 129
anti-nausea/rekematol ........................................ 129
antioxidant ............................................................... 130
anti-oxidant .............................................................. 129
antioxidant formula ............................................... 130
anti-oxidant formula ............................................. 129
ANTIOXIDANT FORMULA SG ............................. 130
antioxidant formula/miner ................................. 130
ANTIOXIDANT FORTE ........................................... 130
antioxidant protection fo ..................................... 130
antioxidant vitamins ............................................. 130
antioxin 4000 .......................................................... 130
antiseptic................................................................... 130
antiseptic mouth rinse ......................................... 130
antiseptic pain relief ............................................. 130
antiseptic skin cleanser ....................................... 130
anu-med .................................................................... 130
anusert hc-1 ............................................................ 130
ANUSOL ..................................................................... 130
AOSEPT ...................................................................... 130
AO-SEPT DISINFECTION/NEUT ........................ 130
APAP 500................................................................... 131
apap extra strength .............................................. 131
apapgesic .................................................................. 131
APATATE .................................................................... 131
APATATE FORTE ..................................................... 131
APETEX ...................................................................... 131
APETIGEN ................................................................. 131
APETIGEN-PLUS ..................................................... 131
aphedrid .................................................................... 131
aphen ......................................................................... 131
AP-HIST DM ............................................................. 130
aplicare povidone/iodine ..................................... 131
APLICARE POVIDONE/IODINE .......................... 131
aplicare povidone-iodine ..................................... 131
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 705
APOKYN ....................................................................... 59
apra ............................................................................. 131
aprepitant ................................................................... 85
aprepitant pak 80mg & 125mg .......................... 85
APRISO ........................................................................ 88
aprodine ............................................................ 131, 681
APTIOM ........................................................................ 52
APTIVUS ...................................................................... 24
AP-ZEL ....................................................................... 131
aqua care .................................................................. 131
AQUA GLYCOLIC FACE CREAM ......................... 131
AQUA GLYCOLIC FACIAL CLEA ......................... 131
AQUA GLYCOLIC HAND & BODY ...................... 131
AQUA GLYCOLIC HAND/BODY .......................... 131
AQUA GLYCOLIC SHAMPOO & B ...................... 131
AQUA GLYCOLIC TONER ..................................... 131
AQUA LACTEN ......................................................... 132
AQUA LANCE ADJUSTABLE LAN ....................... 132
aqua lube .................................................................. 132
aqua lube plus ......................................................... 132
AQUACEL EXTRA/HYDROFIBER ........................ 132
AQUACEL FOAM 3.2 .............................................. 132
AQUACEL FOAM 4 .................................................. 132
AQUACEL FOAM 5 .................................................. 132
AQUACEL FOAM 6 .................................................. 132
AQUACEL FOAM 7 .................................................. 132
AQUACEL FOAM 8 .................................................. 132
aquadeks ................................................................... 668
AQUADEKS ............................................................... 132
AQUADERM............................................................... 132
AQUADERM TREATMENT/MOISTU ................... 132
AQUA-E ...................................................................... 132
AQUAMED ................................................................. 132
AQUANAZ .................................................................. 132
aquanil hc ................................................................. 132
AQUANIL SKIN CLEANSER ................................. 132
AQUAPHILIC............................................................. 132
AQUAPHILIC/CARBAMIDE .................................. 132
AQUAPHOR ............................................................... 133
AQUAPHOR ADVANCED THERAPY ................... 133
AQUAPHOR LIP REPAIR ....................................... 133
AQUASITE IMPREGNATED DRES ...................... 133
AQUASITE IMPREGNATED GAUZ ..................... 133
AQUASITE SHEET DRESSING 4 ........................ 133
AQUASOL A PARENTERAL ................................... 133
AQUASOL E .............................................................. 133
aquavit-e ................................................................... 133
AQUEOUS SELENIUM ........................................... 133
aqueous vitamin d infants .................................. 133
aqueous vitamin e ................................................. 133
AQUIFY LONG-LASTING COMFO ...................... 133
AQUIFY MULTI-PURPOSE .................................... 133
AQUORAL .................................................................. 133
ARALAST NP ............................................................. 686
ARCALYST ................................................................. 101
arctic relief pain reliev ......................................... 133
arctic relief roll-on pai .......................................... 133
ARGIMENT ................................................................ 133
ARGIMENT AT .......................................................... 133
arginine ...................................................................... 133
ARGININE ................................................................. 133
ARGININE2000 ....................................................... 134
ARGITEIN .................................................................. 134
ARGLAES FILM 2-3/8 ............................................ 134
ARGLAES FILM 3 .................................................... 134
ARGLAES FILM 4 .................................................... 134
ARGLAES FILM 4-3/4 ............................................ 134
ARGLAES ISLAND 2-3/8 ...................................... 134
ARGLAES ISLAND 4 .............................................. 134
ARGLAES ISLAND 4-3/4 ...................................... 134
ARIAL CHAMBER .................................................... 134
aripiprazole odt ......................................................... 60
aripiprazole oral solution 1 mg/ml .................... 60
aripiprazole tab ......................................................... 60
ARISTADA ................................................................... 60
ARISTADA INITIO .................................................... 60
ARKALIOX ................................................................. 134
armodafinil ................................................................. 69
ARNUITY ELLIPTA .................................................. 687
aromatic inhalants ................................................. 134
arthogenic plus ....................................................... 134
arthricream .............................................................. 134
arthricream rub ...................................................... 134
arthritis hot .............................................................. 134
arthritis pain ............................................................ 134
arthritis pain relief ........................................... 10, 134
arthritis pain reliever ............................................ 134
ARTHRITIS PAIN RELIEVING ............................. 134
arthritis/aloe ............................................................ 134
ARTIFICIAL TEAR OPHTH SO ............................ 134
artificial tear solution ........................................... 135
artificial tears .................................................. 135, 675
ARTIFICIAL TEARS ................................................ 135
ASC LOTIONIZED ANTIMICROB ....................... 135
ASCENSIA AUTODISC TEST ST ........................ 135
ASCOCID ................................................................... 135
ASCOCID-1000 ....................................................... 135
ASCOCID-500-D ..................................................... 135
ASCOCID-ISO-PH .................................................. 135
ascorbic acid .................................................... 135, 668
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 706
ASCORBIC ACID ..................................................... 135
asco-tabs-1000 ....................................................... 135
ASCRIPTIN ................................................................ 135
ASCRIPTIN TAB ...................................................... 135
aspercreme w/lidocaine ...................................... 136
ASPERCREME/ALOE .............................................. 136
asper-flex .................................................................. 135
aspirin .................................................................. 10, 136
ASPIRIN ............................................................... 10, 136
aspirin 81 .................................................................... 11
aspirin 81 low dose ............................................... 136
aspirin adult low dose .................................... 11, 136
aspirin adult low strengt ..................................... 136
aspirin buffered (al hydrox-mg hydrox-ca
carb) ...................................................................... 136
aspirin buffered (cal carb-mag carb-mag
oxide) .................................................................... 136
aspirin child .............................................................. 136
aspirin childrens ..................................................... 136
aspirin ec lo-dose................................................... 136
aspirin ec low dose ................................................ 136
aspirin effervescent .............................................. 137
aspirin enteric coated ad .................................... 137
aspirin low dose................................................ 11, 137
ASPIRIN LOW DOSE ............................................. 137
aspirin low strength ........................................ 11, 137
aspirin regimen low dose/ .................................. 137
aspirin-acetaminophen-caffeine ....................... 137
aspirin-caffeine ....................................................... 137
aspirin-dipyridamole ............................................... 99
aspir-low ............................................................. 10, 136
aspirtab...................................................................... 137
aspirtab maximum strength .............................. 137
aspir-trin ................................................................... 136
aspridrox ................................................................... 137
ASSESS FULL RANGE PEAK FL.......................... 137
ASSESS LOW RANGE PEAK FLO ....................... 137
ASSESS PEAK FLOW METER FU ....................... 137
ASSESS PEAK FLOW METER LO ....................... 137
ASSURANCE BELTED SHIELD/M ...................... 137
ASSURANCE BELTED UNDERGAR .................... 137
ASSURANCE BLADDER CONTROL .................... 137
ASSURANCE BOXERS MENS/LAR ..................... 137
ASSURANCE BOXERS MENS/SMA ................... 137
ASSURANCE FITTED BRIEF LA ......................... 137
ASSURANCE FITTED BRIEF ME......................... 137
ASSURANCE FITTED BRIEF SM ........................ 138
ASSURANCE GUARDS FOR MEN....................... 138
ASSURANCE GUARDS FOR MEN/ ..................... 138
ASSURANCE PREMIUM WASHCLO ................... 138
ASSURANCE UNDERGARMENT.......................... 138
ASSURANCE UNDERPADS .................................. 138
ASSURANCE UNDERPADS/30 ............................ 138
ASSURANCE UNDERPADS/LARGE ................... 138
ASSURANCE UNDERWEAR/MENS/ .................. 138
ASSURANCE UNDERWEAR/WOMEN ................ 138
ASSURE 3 TEST STRIPS ...................................... 138
ASSURE 4 BLOOD GLUCOSE ME ...................... 138
ASSURE 4 TEST STRIPS ...................................... 138
ASSURE II ................................................................. 138
ASSURE II CHECK STRIP .................................... 138
ASSURE II TEST STRIPS ..................................... 138
ASSURE PLATINUM BLOOD GLU ...................... 138
ASSURE PLATINUM TEST STRI ......................... 138
ASSURE PRISM MULTI BLOOD.......................... 138
ASSURE PRISM MULTI TEST S .......................... 138
ASSURE PRO BLOOD GLUCOSE ....................... 138
ASSURE PRO TEST STRIPS ................................ 138
ASTHMA CHECK METER-ZONE S ..................... 138
ASTHMAMENTOR .................................................... 139
asthmanefrin refill ................................................. 139
asthmanefrin starter kit ...................................... 139
ASTRING-O-SOL ..................................................... 139
astroglide .................................................................. 139
AT LAST TEST STRIPS ......................................... 139
atazanavir sulfate .................................................... 24
atenolol ........................................................................ 47
atenolol & chlorthalidone ...................................... 46
athletes foot ............................................................. 139
athletes foot af cream .......................................... 139
athletes foot powder ............................................. 139
athletes foot powder spra ................................... 139
athletes foot spray ................................................ 139
atomoxetine hcl ........................................................ 65
atorvastatin calcium ............................................... 45
atovaquone ................................................................ 20
atovaquone-proguanil hcl ..................................... 24
ATRAC-TAIN ............................................................. 139
ATRAPRO DERMAL SPRAY .................................. 139
ATRIPLA ....................................................................... 26
ATROVENT HFA ....................................................... 677
ATTENDS BARIATRIC BRIEF 1 .......................... 139
ATTENDS BOOSTER PAD..................................... 139
ATTENDS BREATHABLE BRIEFS ....................... 139
ATTENDS BRIEFS 10 CLASSIC ......................... 140
ATTENDS BRIEFS 10 LARGE .............................. 140
ATTENDS BRIEFS 10 MEDIUM .......................... 140
ATTENDS BRIEFS 10 REGULAR ........................ 140
ATTENDS BRIEFS 10 SMALL .............................. 140
ATTENDS BRIEFS 10 X-LARGE ......................... 140
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 707
ATTENDS BRIEFS 8 LARGE ................................ 139
ATTENDS BRIEFS 8 MEDIUM ............................. 139
ATTENDS BRIEFS 8 REGULAR........................... 139
ATTENDS BRIEFS 8 X-LARGE ............................ 139
ATTENDS BRIEFS 9 LARGE ................................ 139
ATTENDS BRIEFS 9 MEDIUM ............................. 139
ATTENDS BRIEFS 9 REGULAR........................... 139
ATTENDS BRIEFS 9 X-LARGE ............................ 140
ATTENDS BRIEFS LARGE WAIS ........................ 140
ATTENDS BRIEFS MEDIUM ................................. 140
ATTENDS BRIEFS MEDIUM WAI ....................... 140
ATTENDS BRIEFS SMALL .................................... 140
ATTENDS CLASSIC UNDERPAD ........................ 140
ATTENDS GUARDS FOR MEN UN ..................... 140
ATTENDS INSERT PAD 3 ..................................... 140
ATTENDS INSERT PAD 4 ..................................... 140
ATTENDS LIGHT PADS EXTRA .......................... 140
ATTENDS LIGHT PADS REGULA ....................... 140
ATTENDS LIGHT PADS ULTRA .......................... 140
ATTENDS MESH PANTS BARIAT ....................... 140
ATTENDS MESH PANTS LARGE ......................... 140
ATTENDS MESH PANTS X-LARG ....................... 140
ATTENDS MESH PANTS XX-LAR ....................... 140
ATTENDS NIGHT PRESERVER ........................... 140
ATTENDS PULL-ON BRIEFS LA ......................... 141
ATTENDS PULL-ON BRIEFS ME......................... 141
ATTENDS SHAPED PAD 4 .................................... 141
ATTENDS SHAPED PAD 5 .................................... 141
ATTENDS SHAPED PAD 6 .................................... 141
ATTENDS SHAPED PAD 7 .................................... 141
ATTENDS SHAPED PAD 8 .................................... 141
ATTENDS SHAPED PAD 9 .................................... 141
ATTENDS SHAPED PADS EXTEN ...................... 141
ATTENDS UNDERGARMENTS 6 B ..................... 141
ATTENDS UNDERPADS EXTRA A ...................... 141
ATTENDS UNDERPADS MODERAT ................... 141
ATTENDS UNDERPADS REGULAR .................... 141
ATTENDS UNDERWEAR 7 EXTRA ..................... 141
ATTENDS UNDERWEAR 7 SUPER ..................... 141
ATTENDS WASHCLOTH ........................................ 141
ATTENDS WASHCLOTH X-LARGE .................... 141
ATTENDS WASHCLOTHS ..................................... 141
ATUSS DA ................................................................. 141
auraphene-b ............................................................ 141
auro eardrops .......................................................... 141
auro-dri ...................................................................... 141
AURYXIA ...................................................................... 81
AUSTEDO .................................................................... 67
AUTO-LANCET ......................................................... 141
AUTO-LANCET MINI .............................................. 142
AUTOLET IMPRESSION LANCIN ....................... 142
AUTOLET LANCING DEVICE ............................... 142
AUTOLET MINI ........................................................ 142
AUTOLET PLUS ........................................................ 142
AVASTIN ...................................................................... 35
AVEENO ACTIVE NATURALS DA ....................... 142
AVEENO ACTIVE NATURALS EC ....................... 142
AVEENO ACTIVE NATURALS PU ....................... 142
AVEENO ACTIVE NATURALS SK ....................... 142
AVEENO ADVANCED CARE MOIS ..................... 142
AVEENO ANTI-ITCH .............................................. 142
AVEENO ANTI-ITCH CREAM ............................... 142
aveeno anti-itch maximum ................................ 142
AVEENO BABY CALMING COMFO ..................... 142
AVEENO BABY CLEANSING THE ....................... 142
AVEENO BABY ECZEMA THERAP ...................... 142
AVEENO BABY SOOTHING BATH ..................... 142
AVEENO BABY SOOTHING RELI ....................... 142
AVEENO BATH MOISTURIZING ........................ 142
AVEENO CONTINUOUS RADIANC .................... 142
AVEENO DAILY FIRMING..................................... 142
AVEENO DAILY MOISTURIZING ....................... 142
AVEENO INTENSE RELIEF HAN ......................... 142
AVEENO POSITIVELY AGELESS ........................ 143
AVEENO POSITIVELY NOURISH ....................... 143
AVEENO POSITIVELY RADIANT ........................ 143
AVEENO POSITIVELY SMOOTH ......................... 143
aveeno shower & bath oil ................................... 143
AVEENO SKIN BRIGHTENING D ....................... 143
AVEENO SKIN RELIEF SHOWER ....................... 143
AVEENO SMART ESSENTIALS D ....................... 143
AVEENO SMART ESSENTIALS N ....................... 143
AVEENO SOOTHING BATH TREA ...................... 143
AVEENO STRESS RELIEF MOIS ........................ 143
AVEENO ULTRA-CALMING .................................. 143
avita ............................................................................ 688
AVORIA CAL+D ....................................................... 143
awake maximum strength.................................. 143
AXID AR ..................................................................... 143
AXSAIN ...................................................................... 143
ayr ............................................................................... 143
AYR NASAL DROPS ................................................ 143
AYR NASAL MIST ALLERGY & ............................ 143
ayr saline nasal ....................................................... 143
AYR SALINE NASAL NETI RIN ........................... 143
ayr saline nasal no-drip ....................................... 143
AYR SALINE NASAL RINSE KI ........................... 143
azacitidine ................................................................... 34
AZACTAM IN ISO-OSMOTIC DE ......................... 20
AZACTAM/DEX INJ .................................................. 20
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 708
AZASITE .................................................................... 672
azathioprine ............................................................. 101
AZEC ........................................................................... 144
azelastine drop 0.05% ......................................... 674
azelastine spr 0.1% .............................................. 678
azelastine spr 0.15% ........................................... 678
azithromycin .............................................................. 30
azo dine ..................................................................... 144
azo dine maximum strength.............................. 144
azo tabs ..................................................................... 144
AZO TEST STRIPS.................................................. 144
azo urinary pain relief .......................................... 144
azo urinary pain relief e ...................................... 144
azo urinary pain relief m ..................................... 144
AZOLEN TINCTURE ................................................ 144
AZOPT ........................................................................ 674
azo-standard ........................................................... 144
aztreonam .................................................................. 21
B
B & L SENSITIVE EYES PLUS ............................. 144
b complete ................................................................ 144
B COMPLEX + C TR ............................................... 144
b complex formula #1 ......................................... 144
b complex maxi ...................................................... 144
b complex plus ........................................................ 144
b complex w/ c ....................................................... 145
b complex w/ iron .................................................. 145
B COMPLEX/FOLIC ACID ..................................... 145
B&L RENU DISINFECTING SOL ......................... 145
B&L RENU SALINE SOLUTION ........................... 145
B&L SENSITIVE EYES ........................................... 145
B&L SENSITIVE EYES DAILY ............................. 145
B&L SENSITIVE EYES SALINE ........................... 145
B&L STERILE DAILY CLEANER .......................... 145
B-1 ............................................................................... 145
b1 high potency ...................................................... 144
B1 NATURAL ............................................................ 144
b-100 .......................................................................... 146
b-100 complex ........................................................ 146
B-100 COMPLEX ..................................................... 146
b-100 complex tr ................................................... 146
b-100 tr ..................................................................... 146
B-12 ............................................................................ 145
B-12 + FOLIC ACID .............................................. 145
B-12 1000 ................................................................. 145
B-12 DOTS ............................................................... 145
B-12 DUAL SPECTRUM ......................................... 145
b12 fast dissolve .................................................... 144
b-12 fast dissolve .................................................. 145
B12 FOLATE ............................................................. 144
B-12 METHYLCOBALAMIN ................................... 145
b-12 microlozenge ................................................. 145
B-12 PLUS FOLIC ACID ....................................... 145
B-12 QUICK DISSOLVE ....................................... 145
B-12 SUPER STRENGTH ...................................... 145
b-12 tr ........................................................................ 145
B12-ACTIVE ............................................................. 144
b-12-sl ....................................................................... 146
B-2-400 ..................................................................... 145
b-50 ............................................................................ 146
b-50 complex .......................................................... 146
b50 complex tr........................................................ 144
b-50 tr ........................................................................ 146
b6 natural ................................................................. 144
BABY ANBESOL ....................................................... 147
baby ayr saline ....................................................... 147
baby chest rub ........................................................ 147
baby darlings pediatric e..................................... 147
baby darlings soothing ba .................................. 147
BABY DDROPS ......................................................... 147
baby diaper rash cream ...................................... 147
BABY ORAJEL ........................................................... 147
baby orarelief .......................................................... 147
baby super daily d3 .............................................. 147
baby teething .......................................................... 148
baby teething pain medici .................................. 148
baby vitamin ............................................................ 148
baby vitamin a & d ................................................ 148
baby vitamin d3 drops ......................................... 148
BACID ......................................................................... 148
BACIGUENT .............................................................. 148
bacitracin (ophthalmic) ....................................... 672
bacitracin (topical) ........................................ 148, 688
bacitracin zinc ................................................. 148, 688
bacitracin-polymyxin b ........................................ 148
bacitracin-polymyxin b (ophth) ........................ 672
bacitracin-poly-neomycin-hc ............................. 672
bacitraycin plus....................................................... 148
BACITRAYCIN PLUS .............................................. 148
back & body extra strengt .................................. 148
BACK PAIN-OFF ...................................................... 148
backache relief extra str ..................................... 148
baclofen ....................................................................... 68
BACMIN...................................................................... 148
BAG BALM ................................................................. 148
BALAMINE DM ......................................................... 148
balance b-100 ......................................................... 148
balance b-50 ............................................................ 148
balanced b complex .............................................. 148
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 709
balanced b complex tr ......................................... 148
balanced b-100 ............................................... 149, 669
balanced b-100 complex tr ................................ 149
balanced b-50 ......................................... 148, 149, 669
balanced b-50 complex ....................................... 149
BALMEX OIN ............................................................ 149
balmex skin protectant ........................................ 149
BALNETAR LIQUIM ................................................ 149
balsalazide disodium .............................................. 88
BANATROL PLUS .................................................... 149
BAND-AID HYDRO SEAL BLIST......................... 149
BAND-AID HYDRO SEAL CORN ......................... 149
band-aid liquid bandage...................................... 149
BAND-AID MOLESKIN ADHESIV....................... 149
banophen .......................................................... 149, 678
BANZEL SUS 40MG/ML .......................................... 52
BANZEL TAB 200MG ............................................... 52
BANZEL TAB 400MG ............................................... 52
BARACLUDE ............................................................... 28
BARC ........................................................................... 149
BARD DISPOZ-A-BAG LEG BAG ....................... 149
BARD DISPOZ-A-BAG/FLIP-FL .......................... 149
BARIATRIC FUSION .............................................. 149
BARIATRIC MULTIVITAMINS/I .......................... 149
BARIDIUM ................................................................. 149
BASAGLAR KWIKPEN .............................................. 71
BASIC AM .................................................................. 150
BASIC PM .................................................................. 150
BASIS CLEANSER EXTRA DRY .......................... 150
BASIS CLEANSER NORMAL/DRY ...................... 150
BASIS CLEANSER SENSITIVE ........................... 150
BASIS FACIAL MOISTURIZER ........................... 150
BASIS OVERNIGHT ............................................... 150
BASLE ......................................................................... 150
bayer advanced aspirin ex ................................. 150
bayer advanced aspirin re .................................. 150
bayer aspirin ............................................................ 150
BAYER ASPIRIN ...................................................... 150
bayer aspirin ec low dose ................................... 150
bayer aspirin extra stren .................................... 150
bayer aspirin regimen .......................................... 150
BAYER BACK & BODY ........................................... 150
BAYER BACK & BODY PAIN EX ......................... 150
BAYER BREEZE 2 BLOOD GLUC ....................... 150
BAYER BREEZE 2 TEST DISC ............................ 150
bayer chewable low dose .................................... 150
BAYER CONTOUR BLOOD GLUCO .................... 150
BAYER CONTOUR LINK 2.4 BL .......................... 150
BAYER CONTOUR LINK BLOOD ........................ 150
BAYER CONTOUR NEXT USB BL ....................... 151
BAYER CONTOUR USB BLOOD G ..................... 151
bayer low dose ........................................................ 151
BAYER MICROLET 2 LANCING ........................... 151
bayer migraine ........................................................ 151
BAYER PLUS ............................................................. 151
BAYER PM ................................................................. 151
BAYER WOMENS ..................................................... 151
baza antifungal ....................................................... 151
BAZA CLEANSE & PROTECT ............................... 151
baza clear ................................................................. 151
baza protect ............................................................. 151
BC FAST PAIN RELIEF .......................................... 151
BC FAST PAIN RELIEF ARTHR ........................... 151
b-caro-t...................................................................... 146
BCG VACCINE .......................................................... 102
b-compleet-100 ...................................................... 146
b-compleet-50 ........................................................ 146
B-COMPLEX .............................................................. 146
b-complex 100 tr ................................................... 146
b-complex 50 .......................................................... 146
b-complex 50 tr ...................................................... 146
b-complex balanced .............................................. 146
b-complex formula 1 ............................................ 146
b-complex high potency ...................................... 146
b-complex high strength 1 ................................. 146
b-complex vitamins....................... 146, 147, 668, 669
b-complex w/ c & calcium .................................. 147
b-complex w/ c & folic acid ................................ 147
b-complex w/ c + mg zn ..................................... 147
b-complex w/ folic acid........................................ 147
b-complex w/biotin & folic acid ........................ 147
B-COMPLEX/FOLIC ACID/VITA ......................... 147
B-COMPLEX/VITAMIN C/FOLIC ......................... 147
BD GLUCOSE ........................................................... 151
BD LANCET DEVICE .............................................. 151
BD LATITUDE DIABETES MANA ........................ 151
BD LOGIC BLOOD GLUCOSE MO...................... 151
bd posiflush .............................................................. 151
BD TEST STRIPS .................................................... 151
BD ULTRAFINE INSULIN SYRINGE .................... 71
BD ULTRAFINE/NANO PEN NEEDLES ............... 71
BEAU RX .................................................................... 151
beauty lotion ............................................................ 151
bec/zinc ..................................................................... 151
bedding spray lice treat....................................... 152
bedding spray lice treatm ................................... 152
bee zee ...................................................................... 152
BEELITH ..................................................................... 152
BELTED UNDERGARMENT ................................... 152
BELTED UNDERGARMENT XTRA ....................... 152
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 710
BELTED UNDERGARMENT/REGUL.................... 152
BENADRYL ................................................................ 152
BENADRYL ALLERGY ............................................. 152
BENADRYL ALLERGY & COLD ............................ 152
BENADRYL ALLERGY & SINUS .......................... 152
BENADRYL ALLERGY CHILDREN ....................... 152
BENADRYL ALLERGY/SINUS/HE ....................... 152
BENADRYL DYE-FREE ALLERGY ........................ 152
benadryl extra strength ...................................... 152
BENADRYL EXTRA STRENGTH .......................... 152
benadryl itch stopping ......................................... 152
BENADRYL ITCH STOPPING ............................... 152
BENADRYL MAXIMUM STRENGTH .................... 152
benadryl severe allergy & ................................... 152
BENADRYL-D ALLERGY & SINU ........................ 152
benazepril & hydrochlorothiazide ...................... 42
benazepril hcl ............................................................ 42
BENDEKA .................................................................... 33
BENEFIBER ............................................................... 152
BENEFIBER FOR CHILDREN ............................... 152
benefiber on the go............................................... 153
BENEFIBER PLUS CALCIUM ................................ 153
BENEPROTEIN ......................................................... 153
BENFOTIAMINE ....................................................... 153
benfotiamine multi-b neur ................................. 153
BENFOTIAMINE-V .................................................. 153
BENGAY ARTHRITIS FORMULA ......................... 153
BENGAY GREASELESS ......................................... 153
BENLYSTA ................................................................. 101
benoxyl 10 ................................................................ 153
BENYLIN ADULT FORMULA ................................. 153
BENYLIN SYP MULTI ............................................. 153
BENZAC AC WASH ................................................. 153
BENZALKONIUM CHLORIDE ............................... 153
BENZEDREX INHALER .......................................... 153
BENZEFOAM ............................................................. 153
BENZEFOAM ULTRA .............................................. 153
benzepro ................................................................... 153
benzepro short contact ........................................ 153
benzoin ...................................................................... 153
benzoin compound ................................................ 153
BENZOIN COMPOUND TINCTURE .................... 153
BENZOIN TINCTURE ............................................. 153
BENZOIN TINCTURE PLAIN ................................ 153
benzonatate ..................................................... 154, 681
benzoyl peroxide ............................................ 154, 688
BENZOYL PEROXIDE ............................................. 154
benzoyl peroxide cleanser .................................. 154
BENZOYL PEROXIDE CLEANSER ...................... 154
benzoyl peroxide wash ........................................ 154
benzoyl peroxide wash acn ................................ 154
benzoyl peroxide-erythromycin ........................ 688
benztropine mesylate inj ...................................... 59
benztropine mesylate tab 0.5mg ....................... 59
benztropine mesylate tab 1mg ........................... 59
benztropine mesylate tab 2mg ........................... 59
BEPREVE .................................................................... 674
BERINERT ................................................................... 98
berocca ...................................................................... 154
berri-freez pain relievin ....................................... 154
BESIVANCE .............................................................. 672
BETA CARE ............................................................... 154
beta care betatar gel ............................................ 154
beta carotene .......................................................... 154
BETA CAROTENE .................................................... 154
beta carotene provitamin ................................... 154
beta hc ....................................................................... 154
beta med ................................................................... 154
BETA XMA ................................................................. 154
BETADINE ................................................................. 154
BETADINE SKIN CLEANSER ............................... 155
BETADINE SURGICAL SCRUB ............................ 155
BETADINE SWAB AID ........................................... 155
BETADINE SWABSTICKS ..................................... 155
betamethasone dipropionate (topical) .......... 691
betamethasone dipropionate augmented ..... 691
betamethasone valerate ..................................... 691
BETASAL .................................................................... 155
betasept surgical scrub ....................................... 155
BETASERON ............................................................... 68
betatemp childrens ............................................... 155
betaxolol hcl............................................................... 47
betaxolol hcl (ophth) ............................................ 674
bethanechol chloride .............................................. 95
BETOPTIC-S ............................................................. 674
better b complex .................................................... 155
BEVESPI AEROSPHERE ........................................ 677
bexarotene ................................................................. 40
BEXSERO ................................................................... 102
BG STAR BLOOD GLUCOSE TES ...................... 155
bicalutamide .............................................................. 36
BICARSIM ................................................................. 155
BICARSIM FORTE ................................................... 155
BICILLIN L-A .............................................................. 31
BICLORA .................................................................... 155
BICLORA-D ............................................................... 155
bidex ........................................................................... 155
BIFERA ....................................................................... 155
big 100 ....................................................................... 155
BIKTARVY.................................................................... 26
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 711
BILBERRY PLUS ...................................................... 155
BILTRICIDE ................................................................ 21
bio t pres ................................................................... 155
bio t pres pediatric ................................................ 155
bio t pres-b .............................................................. 155
BIO-35 GLUTEN-FREE .......................................... 155
BIO-35 IRON FREE ................................................ 155
BIOBRANE 10 .......................................................... 156
BIOBRANE 15 .......................................................... 156
BIOBRANE 5 ............................................................. 156
BIOBRANE-L 10 ...................................................... 156
BIOBRANE-L 5 ......................................................... 156
BIOBRON SF ............................................................ 156
BIOCAL ...................................................................... 156
biocel .......................................................................... 156
biocotron ................................................................... 156
BIODESP DM ............................................................ 156
bio-d-mulsion .......................................................... 155
BIO-D-MULSION ..................................................... 156
bio-d-mulsion forte ............................................... 156
BIO-D-MULSION FORTE ...................................... 156
bioflavonoid products ........................................... 156
BIOFLAVONOID-1000 .......................................... 156
bioflavonoids............................................................ 156
bioflex ........................................................................ 156
BIOFLONEX .............................................................. 156
biofreeze ................................................................... 156
BIOFREEZE ............................................................... 156
biofreeze colorless ................................................. 157
biofreeze roll-on ..................................................... 157
biofreeze roll-on colorle....................................... 157
biogtuss ..................................................................... 157
BIOHM PROBIOTIC SUPPLEMEN ...................... 157
biolle gel tears ........................................................ 157
biolle tears ................................................................ 157
bion tears .................................................................. 157
BIONATUSS DXP .................................................... 157
BIONEL ...................................................................... 157
BIONEL PEDIATRIC ............................................... 157
bio-rytuss .................................................................. 156
BIOSCANNER GLUCOSE TEST S ...................... 157
BIOSPEC DMX ......................................................... 157
BIOSUPP .................................................................... 157
BIOTALAN CLEAR ................................................... 157
BIOTECT PLUS ........................................................ 157
BIOTENE DRY MOUTH GENTLE ......................... 157
BIOTENE DRY MOUTH MOISTUR...................... 157
BIOTENE DRY MOUTH MOUTHWA ................... 157
BIOTENE DRY MOUTH ORAL RI ........................ 157
BIOTENE MOISTURIZING MOUT ...................... 157
BIOTENE ORALBALANCE DRY M ....................... 157
BIOTENE PBF DRY MOUTH MOU ...................... 157
biotin ................................................................... 158, 669
BIOTIN ....................................................................... 158
biotin 5000 ............................................................... 158
biotin forte ................................................................ 158
BIOTIN FORTE ......................................................... 158
BIOTIN GUMMIES .................................................. 158
biotin maximum ..................................................... 158
biotin maximum strength ................................... 158
BIOTIN PLUS KERATIN ........................................ 158
biotin plus/calcium/vit d...................................... 158
biotin/maximum strength ................................... 669
BIOTIN-D .................................................................. 158
biotinex ...................................................................... 158
BIOTRUE .................................................................... 158
BIOVOL ...................................................................... 158
BIPHENOX ................................................................. 158
bisac-evac ........................................................... 88, 158
bisacodyl ............................................................. 88, 159
bisacodyl ec ....................................................... 88, 159
bisacodyl laxative .................................................. 159
biscolax ........................................................................ 88
bismatrol ............................................................. 84, 159
bismatrol maximum strengt .............................. 159
bismuth ...................................................................... 159
BISMUTH SUBGALLATE ....................................... 159
bismuth subsalicylate ........................................... 159
bisoprolol & hydrochlorothiazide ........................ 46
bisoprolol fumarate ................................................. 47
bite-a-mins ............................................................... 159
bite-a-mins/iron ..................................................... 159
BIVIGAM .................................................................... 100
bl 12 hour cold ........................................................ 159
bl 3 day vaginal ...................................................... 159
bl adult aspirin low stre ....................................... 159
bl allergy relief for kid .......................................... 159
bl antacid .................................................................. 159
bl anti-diarrheal ...................................................... 159
bl anti-gas ................................................................ 159
bl anti-itch ................................................................ 159
bl aspirin ................................................................... 159
bl b-50 balanced .................................................... 159
bl beta carotene ..................................................... 159
bl bisa-lax ................................................................. 160
bl calcium citrate+d .............................................. 160
bl calcium/magnesium/zinc ............................... 160
bl chromium picolinate ........................................ 160
bl cimetidine ............................................................ 160
bl epsom salt ........................................................... 160
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 712
bl essential one daily ............................................ 160
bl fiber therapy ....................................................... 160
BL FINGER CREAM ................................................. 160
BL FITTED BRIEFS EXTRA WI ........................... 160
bl glucosamine/chondroiti .................................. 160
BL GLUCOSE ............................................................ 160
BL HOT STEAM LIQUID ........................................ 160
bl ibu-profen cold & sinu ..................................... 160
bl infants pain reliever ......................................... 160
bl laxative pills ........................................................ 160
bl l-lysine .................................................................. 160
bl loratadine allergy rel ....................................... 160
bl lorata-dine d ....................................................... 160
bl lozenges ............................................................... 160
bl miconazole 3....................................................... 160
bl mineral oil ............................................................ 160
BL MINERAL OIL LIGHT ....................................... 160
bl niacin tr ................................................................ 161
bl no drip nasal spray .......................................... 161
bl one daily plus iron ............................................ 161
bl pain reliever extra st ....................................... 161
bl pediatric electrolyte ......................................... 161
bl permethrin ........................................................... 161
bl pink bismuth ....................................................... 161
BL PROTECTIVE UNDERWEAR........................... 161
bl severe cold/flu maximu .................................. 161
bl sleep aid ............................................................... 161
bl stool softener ..................................................... 161
bl stool softener/stimula ..................................... 161
bl stress formula+iron ......................................... 161
BL TEST STRIPS ..................................................... 161
bl tolnaftate ............................................................. 161
bl triacting chest conges ..................................... 161
bl triacting cold/allergy ........................................ 161
BL UNDERPADS EXTRA LARGE ......................... 161
BL UNDERPADS REGULAR .................................. 161
BL UNDERPADS SUPER LARGE ......................... 161
bl vitamin a .............................................................. 161
bl vitamin b complex ............................................ 161
bl vitamin b12 ......................................................... 161
bl vitamin b-6 .......................................................... 162
bl vitamin c .............................................................. 162
bl vitamin c w/rose hips ...................................... 162
bl vitamin c/rose hips........................................... 162
bl vitamin e .............................................................. 162
bl womens menstrual relie ................................. 162
BL ZINC LOZENGE W/VIT C ............................... 162
BLACK DRAUGHT ................................................... 162
BLADDER CONTROL PADS EXTR ...................... 162
BLADDER CONTROL PADS REGU ..................... 162
BLADDER CONTROL PADS ULTR ...................... 162
BLENDED SUSPENDING COMPOU ................... 162
bleomycin sulfate ..................................................... 34
BLEPHAMIDE ............................................................ 672
BLISTEX MEDICATED ........................................... 162
blis-to-sol .................................................................. 162
BLOOD GLUCOSE MONITORING ...................... 162
BLOOD GLUCOSE SYSTEM PAK ........................ 162
BLOOD GLUCOSE TEST STRIPS ....................... 162
blue gel ...................................................................... 162
BLUE-EMU SUPER STRENGTH ........................... 162
B-NATAL .................................................................... 147
BODI LOTION .......................................................... 162
BODI PROTECT ....................................................... 162
BODI WHIRL OIL .................................................... 162
body/hair/skin/nails .............................................. 162
BONE DENSITY ....................................................... 163
BONE DENSITY BUILDER .................................... 163
BONE ESSENTIALS ................................................ 163
BONE MEAL .............................................................. 163
bone meal w/ vitamin d ...................................... 163
bonine ........................................................................ 163
BONINE ...................................................................... 163
BOOSTRIX ................................................................ 102
boric acid ................................................................... 163
BORIC ACID ............................................................. 163
BORON ....................................................................... 163
BORTEZOMIB ............................................................. 35
BOSULIF ...................................................................... 38
BOUDREAUXS BABY BUTT SMOO .................... 163
BOUDREAUXS BUTT BATH BODY ..................... 163
BOUDREAUXS BUTT PASTE................................ 163
boudreauxs butt paste max ............................... 163
bounty bears/c ........................................................ 163
BP 8 COUGH ............................................................ 163
BP CLEANSING LOTION ....................................... 163
bp foam ..................................................................... 163
bp foaming wash .................................................... 163
bp gel ......................................................................... 163
bp wash ..................................................................... 163
b-plex ......................................................................... 147
b-plex plus ................................................................ 147
bpm-dm-phen ......................................................... 163
BPO CREAMY WASH COMPLETE ....................... 163
bpo-10 wash ............................................................ 164
bpo-5 wash .............................................................. 164
bprotected multi-vite ............................................ 164
bprotected pedia d-vite ....................................... 164
bprotected pedia iron ........................................... 164
bprotected pedia poly-vit .................................... 164
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 713
bprotected pedia tri-vite ..................................... 164
bprotected vitamin c/rose .................................. 164
BRAFTOVI ................................................................... 38
BRAIN ......................................................................... 164
BRAIN MIGHT/DHA & CO Q10 .......................... 164
b-redi/red hearts/red roo ................................... 147
BREEZE 2 BLOOD GLUCOSE MO ...................... 164
BREO ELLIPTA ......................................................... 688
brewers yeast .......................................................... 164
BREWERS YEAST .................................................... 164
BRIEFS OVERNIGHT LARGE ............................... 164
BRIEFS OVERNIGHT MEDIUM ........................... 164
BRILINTA..................................................................... 99
brimonidine sol 0.15% ........................................ 674
brimonidine sol 0.2% ........................................... 674
BRIVIACT INJ 50MG/5ML ...................................... 52
BRIVIACT SOL 10MG/ML ....................................... 52
BRIVIACT TAB 100MG............................................ 52
BRIVIACT TAB 10MG .............................................. 52
BRIVIACT TAB 25MG .............................................. 52
BRIVIACT TAB 50MG .............................................. 52
BRIVIACT TAB 75MG .............................................. 52
BROHIST D ............................................................... 164
bromfed dm ............................................................. 164
bromfenac sodium (ophth) ................................ 673
BROMI-LOTION ....................................................... 164
bromocriptine mesylate......................................... 59
bromphenex dm ..................................................... 164
brompheniramine & phenylprop ...................... 164
BROMSITE ................................................................ 673
bronchial asthma relief ........................................ 164
bronchial mist ......................................................... 164
bronchial mist refill ............................................... 164
broncho saline ......................................................... 165
broncotron ................................................................ 165
broncotron ped ....................................................... 165
broncotron ped drops ........................................... 165
BRONCOTRON-D .................................................... 165
BRONCOTRON-S .................................................... 165
BRONKAID ................................................................ 165
BRONKIDS ................................................................ 165
BRONTUSS DX ........................................................ 165
brontuss sf................................................................ 165
brontuss sf nr .......................................................... 165
brotapp ...................................................................... 165
BROTAPP DM ........................................................... 681
BROVEX PEB ............................................................ 165
BROVEX PEB DM .................................................... 165
BROVEX PSB ............................................................ 165
BROVEX PSB DM .................................................... 165
b-stress ...................................................................... 147
BTREX ......................................................................... 165
BUBBLE GUM ........................................................... 165
BUBBLES THE FISH II PEDIA ............................ 165
buckleys chest congestion .................................. 165
BUCKLEYS COUGH ................................................ 165
budesonide (inhalation) ...................................... 687
budesonide (nasal)................................................ 165
budesonide ec ........................................................... 88
buffered aspirin ...................................................... 165
buffered c .................................................................. 166
buffered salt............................................................. 166
BUFFERED VITAMIN C .......................................... 166
BUFFERIN .................................................................. 166
BUFFERIN EXTRA STRENGTH ............................ 166
BUFFERIN LOW DOSE .......................................... 166
BULL FROG MOSQUITO COAST ........................ 166
bumetanide ................................................................ 49
BUNION GUARD ..................................................... 166
buprenorphine hcl .................................................... 69
buprenorphine hcl-naloxone hcl sl .................... 69
buprenorphine patch .............................................. 16
bupropion hcl ............................................................. 57
bupropion hcl (smoking deterrent) ................... 69
BURIED TREASURE ACTIVE 55 ......................... 166
buspirone hcl ............................................................. 51
butenafine hcl ......................................................... 166
butorphanol tartrate ............................................... 16
BUTRANS .................................................................... 17
BYDUREON BCISE ................................................... 71
BYDUREON INJ ......................................................... 71
BYDUREON PEN ........................................................ 72
BYETTA ........................................................................ 72
BYSTOLIC .................................................................... 47
C
c & e ............................................................................ 166
c 1000 ........................................................................ 166
c 1000/bioflavonoids/rose .................................. 166
c 250 ........................................................................... 166
c 500 ........................................................................... 166
c 500/rose hips ....................................................... 166
c complex .................................................................. 166
c-1000 ........................................................................ 167
c-1000 prolonged release ................................... 167
c-1000 sr ................................................................... 167
c1000 tr/rose hips/biofla .................................... 166
c-1000/rose hips .................................................... 167
c-1000/rose hips sr ............................................... 167
c1500 tr/rose hips/biofla .................................... 166
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 714
c-1500/rose hips sr ............................................... 167
c1500/rose hips/bioflavon .................................. 166
c-250 .......................................................................... 166
c-500 .......................................................................... 166
c-500 non-acid ........................................................ 166
c-500 prolonged release ..................................... 167
c-500 sr ..................................................................... 167
c-500/rose hips ...................................................... 167
c-500/rose hips sr ................................................. 167
cabergoline ................................................................. 80
CABOMETYX ............................................................... 38
caffeine ...................................................................... 167
CAFFEINE ANHYDROUS ....................................... 167
CAIRPAD BREATHABLE UNDERP ...................... 167
CAIRPAD FLUID CONTROL PAD ........................ 167
CAL MAG ZINC +D3 .............................................. 167
CAL/MAG ................................................................... 168
CALADRYL ................................................................. 168
calagesic .................................................................... 168
calahist....................................................................... 168
CALAMINE ................................................................. 168
CALAMINE LOT PHENOLAT ................................. 169
calamine medicated .............................................. 169
calamine phenolated ............................................ 169
CALAMINE PHENOLATED .................................... 169
CALAZIME SKIN PROTECTANT/ ........................ 169
calcarb 600............................................................... 169
cal-carb forte ........................................................... 167
CALCET CREAMY BITES ....................................... 169
CALCET PETITES .................................................... 169
CALCI-CHEW............................................................ 169
calcidol ....................................................................... 169
calciferol .................................................................... 169
CALCI-MAX ............................................................... 169
CALCI-MIX ................................................................ 169
CALCIONATE ............................................................ 169
calcipotriene............................................................. 690
calcitonin (salmon) .................................................. 80
calcitrate ........................................................... 169, 667
CAL-CITRATE ........................................................... 167
calcitrate plus d ...................................................... 169
CAL-CITRATE PLUS VITAMIN ............................ 168
calcitrene .................................................................. 690
calcitriol ..................................................................... 669
calcitriol inj ............................................................... 669
calcitriol oral soln 1 mcg/ml .............................. 669
calcium ....................................................................... 169
CALCIUM ................................................................... 169
CALCIUM & VITAMIN D3 BONE ........................ 171
calcium + d .............................................................. 171
CALCIUM + D + K ................................................. 171
CALCIUM 1000 + D ............................................... 170
calcium 1200 ........................................................... 171
calcium 1200+d3 ................................................... 171
calcium 250+d ........................................................ 169
CALCIUM 500 .......................................................... 169
calcium 500 + d ..................................................... 169
CALCIUM 500 + D3 ............................................... 169
calcium 500 +d ....................................................... 170
calcium 500 +d3 .................................................... 170
calcium 500/d ................................................. 170, 667
calcium 500/vitamin d ......................................... 170
calcium 500+d ........................................................ 170
calcium 500+d high potenc ............................... 170
calcium 500+d3 ..................................................... 170
calcium 600 .............................................................. 170
calcium 600 + d ..................................................... 170
calcium 600 + minerals ....................................... 170
calcium 600 high potency ................................... 170
calcium 600 with vitamin .................................... 170
CALCIUM 600/MAGNESIUM 300 ...................... 170
calcium 600/vitamin d ......................................... 170
calcium 600/vitamin d3 ....................................... 170
calcium 600+d ........................................................ 170
calcium 600+d high potenc ............................... 170
calcium 600+d plus minera ............................... 170
calcium 600+d3 ..................................................... 170
calcium 600+d3 plus miner ............................... 170
calcium 600-d ......................................................... 170
CALCIUM ACETATE ................................................ 171
calcium acetate (phosphate binder) ......... 81, 171
calcium antacid ................................................. 83, 171
calcium antacid extra str .............................. 83, 171
calcium antacid ultra ............................................ 171
calcium antacid ultra max ............................ 83, 171
calcium antacid ultra str ..................................... 171
calcium ascorbate .................................................. 171
CALCIUM ASCORBATE ......................................... 171
calcium carbonate ......................................... 171, 667
CALCIUM CARBONATE ................................... 83, 171
calcium carbonate (antacid) ...................... 171, 668
CALCIUM CARBONATE EXTRA L ....................... 172
CALCIUM CARBONATE HEAVY .......................... 172
CALCIUM CARBONATE LIGHT ........................... 172
calcium carbonate-cholecalciferol ........... 172, 668
calcium carbonate-ergocalciferol ..................... 172
calcium carbonate-vitamin d ..................... 172, 668
calcium carbonate-vitamin d w/ minerals .... 172
CALCIUM CHEWS ................................................... 172
CALCIUM CHLORIDE ............................................. 172
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 715
calcium chloride (dihydrate) .............................. 172
calcium citrate ........................................................ 172
CALCIUM CITRATE ................................................. 172
calcium citrate + .................................................... 172
calcium citrate + d ................................................ 172
calcium citrate + d3 ............................................. 172
calcium citrate + d3 max ................................... 172
calcium citrate + d3 maxi .................................. 172
calcium citrate +d ................................................. 172
calcium citrate chewy bit .................................... 172
CALCIUM CITRATE MALATE/VI ......................... 173
calcium citrate maximum/v ............................... 173
calcium citrate plus ............................................... 173
calcium citrate plus/magn .................................. 173
CALCIUM CITRATE W/D ...................................... 173
CALCIUM CITRATE W/VITAMIN ........................ 173
calcium citrate/d3 .................................................. 173
CALCIUM CITRATE/MAGNESIUM...................... 173
CALCIUM CITRATE/VITAMIN D ......................... 173
calcium citrate+ d ................................................. 173
calcium citrate+d ................................................... 173
calcium citrate+d3 ................................................ 173
calcium citrate+d3 petite ................................... 173
calcium citrate-vitamin d .................................... 173
calcium creamies ................................................... 173
calcium extra d3 .................................................... 173
calcium for women ................................................ 173
calcium glubionate ................................................ 173
calcium gluconate .................................................. 173
CALCIUM GLUCONATE ................................. 173, 668
CALCIUM GLUCONATE ANHYDRO .................... 173
CALCIUM GLUCONATE MONOHYD ................... 173
calcium gummies ................................................... 174
calcium high potency ........................................... 174
calcium high potency + vi .................................. 174
calcium lactate ........................................................ 174
CALCIUM LACTATE ................................................ 174
CALCIUM LACTATE PENTAHYDR ...................... 174
CALCIUM MAGNESIUM 750 ................................ 174
calcium pantothenate ........................................... 174
CALCIUM PANTOTHENATE .................................. 174
CALCIUM PHOSPHATE DIBASIC ....................... 174
CALCIUM PHOSPHATE TRIBASI ........................ 174
CALCIUM PLUS D3 ABSORBABL ....................... 174
calcium plus soy ..................................................... 174
CALCIUM PLUS VITAMIN D ................................ 174
calcium plus vitamin d3 ...................................... 174
calcium polycarbophil ..................................... 88, 174
calcium soft chews ................................................ 174
CALCIUM SOFT CHEWS ....................................... 174
calcium stool softener .......................................... 174
calcium w/ magnesium ........................................ 174
calcium w/ vitamin d ............................................ 174
CALCIUM W/D CAP ................................................ 174
CALCIUM/C/D .......................................................... 175
CALCIUM/D .............................................................. 175
CALCIUM/D3 ADULT GUMMIES ........................ 175
CALCIUM/MAGNESIUM ........................................ 175
CALCIUM/MAGNESIUM/VITAMIN ..................... 175
CALCIUM/MAGNESIUM/ZINC ............................ 175
CALCIUM/MAGNESIUM/ZINC/VI ...................... 175
CALCIUM/VITAMIN D ............................................ 175
calcium/vitamin d/mineral ................................. 175
CALCIUM/VITAMIN D3 GUMMIE ....................... 175
calcium/vitamin d3/adult .................................... 175
calcium+d3 .............................................................. 175
calcium+d3 gradual releas ................................. 175
CALCIUM+MENAQ7 ............................................... 175
calcium-carb 600 ................................................... 175
calcium-carb 600 + d ........................................... 175
CALCIUM-D-PANTOTHENATE ............................ 175
calcium-magnesium-zinc .................................... 175
CAL-CO3Y ................................................................. 168
CAL-CYUM ................................................................. 168
CAL-DAY 1000......................................................... 168
caldyphen ................................................................. 175
cal-gest antacid ................................................ 82, 168
CAL-GLU .................................................................... 168
CALICYLIC ................................................................ 175
CAL-LAC..................................................................... 168
CALLUS CUSHIONS ............................................... 175
callus r and gets-it corn ................................................. 329
callus remover and corn................................................................ 208
callus removers ...................................................... 175
callus removers extra thi .................................... 175
cal-mag ...................................................................... 168
cal-mag aspartate ................................................. 168
CAL-MAG CHELA-MAX .......................................... 168
CAL-MAG COMPLEX ............................................... 168
CALMAG THINS ....................................................... 176
CAL-MAG ZINC II ................................................... 168
CAL-MAG ZINC III ................................................. 168
CAL-MAG-K CHELA MAX ...................................... 168
CAL-MAG-ZINC-D .................................................. 168
CAL-MAG-ZINC-D3 ................................................ 168
CAL-MINT .................................................................. 168
CALMOSEPTINE ...................................................... 176
CALNA ........................................................................ 176
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 716
calphron..................................................................... 176
CALQUENCE ............................................................... 38
CAL-QUICK ............................................................... 168
caltrate 600 .............................................................. 176
caltrate 600+d ........................................................ 176
CALTRATE 600+D PLUS MINER ........................ 176
CALTRATE 600+D3 ............................................... 176
CALTRATE 600+D3 SOFT CHEW ...................... 176
CALTRATE GUMMY BITES ................................... 176
CALTRATE MINIS PLUS MIN E .......................... 176
calvite p&d................................................................ 176
calypxo ....................................................................... 176
CAM ............................................................................. 176
cameo oil ................................................................... 176
CAMPHO-PHENIQUE ............................................. 176
CAMPHOR .................................................................. 176
camphor & phenol ................................................. 176
camphor-eucalyptus-menthol ........................... 176
CANASA ....................................................................... 88
CANDERMYL ............................................................. 176
candesartan cilexetil ............................................... 44
candesartan cilexetil-hydrochlorothiazide ...... 43
cankaid ...................................................................... 176
cank-oxide ................................................................ 176
CAPCOF ...................................................................... 176
CAPHOSOL ................................................................ 177
CA-PLUS .................................................................... 167
CAPMIST DM ............................................................ 177
CAPRELSA ................................................................... 38
CAPRON DM ............................................................. 177
CAPRON DMT ........................................................... 177
CAPSAGEL ................................................................. 177
CAPSAGEL EXTRA STRENGTH ........................... 177
CAPSAGEL MAXIMUM STRENGTH .................... 177
capsaicin.................................................................... 177
CAPSAICIN ............................................................... 177
capsaicin hot patch ............................................... 177
capsaicin hp ............................................................. 177
captopril ...................................................................... 42
captopril & hydrochlorothiazide .......................... 42
CAPZASIN ................................................................. 177
CAPZASIN-HP .......................................................... 177
CAPZASIN-P ............................................................. 177
CARA-KLENZ ............................................................ 177
CARB INTERCEPT/PHASE 2 ................................ 177
CARBAGLU .................................................................. 77
carbamazepine.......................................................... 52
carbamide peroxide .............................................. 177
carbamide peroxide (otic) .................................. 177
carbamoxide ear drops ........................................ 178
CARBAPHEN CH ...................................................... 178
CARBAPHEN PED CH ............................................. 178
carbidopa/levodopa/entacapone ........................ 59
carbidopa-levodopa................................................. 59
CARBOFLEX ODOR CONTROL DR .................... 178
CARB-O-LAN 10 ...................................................... 177
CARB-O-LAN 20 ...................................................... 177
CARBOLIC ACI LIQ ................................................ 178
CARB-O-PHILIC/10 ............................................... 177
CARB-O-PHILIC/20 ............................................... 177
carboplatin .................................................................. 41
CARB-O-SAL 5 ........................................................ 177
carboxymethylcellulose sodium (ophth) ....... 178
cardec ......................................................................... 178
cardec dm ................................................................. 178
CARDENZ .................................................................. 178
CARDIO TONE ......................................................... 178
CARDIOCOM LANCING DEVICE ........................ 178
CARDIOPRESS......................................................... 178
CARDIOWHEY .......................................................... 178
careall aspirin .......................................................... 178
CAREFREE ACTI-FRESH BODY .......................... 178
CAREFREE ORIGINAL PANTILI .......................... 178
CAREFREE PANTY SHIELDS ............................... 178
CAREFREE PANTY SHIELDS/DE ........................ 178
CAREFREE PANTY SHIELDS/LO ........................ 178
CAREFREE PANTY SHIELDS/MA ....................... 178
CAREFREE PANTY SHIELDS/TE......................... 178
CAREFREE PANTY SHIELDS/UN ........................ 178
CAREFREE ULTRA PROTECTION ....................... 178
CAREONE ADVANCED LANCING ....................... 179
CAREONE BLOOD GLUCOSE MON ................... 179
CAREONE BLOOD GLUCOSE TES ..................... 179
CARESENS N BLOOD GLUCOSE ....................... 179
CARESENS N GLUCOSE MONITO ..................... 179
CARESENS N VOICE BLOOD GL ....................... 179
CARETOUCH BLOOD GLUCOSE M .................... 179
CARETOUCH BLOOD GLUCOSE T ..................... 179
CARETOUCH LANCING DEVICE ........................ 179
CARIMUNE NANOFILTERED ............................... 100
carisoprodol ............................................................... 68
CARMOL 10 .............................................................. 179
CARMOL 20 .............................................................. 179
caroguard .................................................................. 179
CAROZYME ............................................................... 179
carracolloid 4 ........................................................... 179
carracolloid 6 ........................................................... 179
CARRAGAUZE 2 X 2 .............................................. 179
CARRAGAUZE 4 X 4 .............................................. 179
carravite .................................................................... 179
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 717
carrington antifungal .................................... 179, 689
CARRINGTON MOISTURE BARRI...................... 179
CARRINGTON SHA BOD WASH ......................... 179
carteolol hcl (ophth) ............................................. 674
carters little pills .................................................... 179
cartia xt cap 120/24hr ........................................... 47
cartia xt cap 180/24hr ........................................... 47
cartia xt cap 240/24hr ........................................... 47
cartia xt cap 300/24hr ........................................... 47
carvedilol ..................................................................... 47
caspofungin acetate ................................................ 23
castellani paint ................................................ 179, 689
CASTIVA WARMING .............................................. 180
CASTOR OIL ............................................................. 180
castor oil stimulant laxa ...................................... 180
catrix correction ..................................................... 180
CAVERJECT ............................................................... 180
CAVERJECT IMPULSE............................................ 180
cavilon ........................................................................ 180
CAYSTON .................................................................... 21
C-BUFF ....................................................................... 167
c-caps tr .................................................................... 167
c-chewable ............................................................... 167
CCP CAFFEINE FREE ............................................. 180
cefaclor ........................................................................ 29
CEFACLOR MONOHYDRATE ER ........................... 29
cefadroxil .................................................................... 29
CEFAZOLIN IN DEXTROSE 2GM/100ML-4% .. 29
cefazolin inj ................................................................ 29
cefazolin sodium ...................................................... 29
CEFAZOLIN SODIUM 1 GM/50ML ...................... 29
cefdinir ......................................................................... 29
cefepime hcl ............................................................... 29
cefixime ....................................................................... 29
cefotaxime sodium .................................................. 29
cefoxitin sodium ....................................................... 30
cefpodoxime proxetil .............................................. 30
cefprozil ....................................................................... 30
ceftazidime ................................................................. 30
CEFTAZIDIME/DEXTROSE .................................... 30
ceftriaxone sodium .................................................. 30
cefuroxime axetil ..................................................... 30
cefuroxime sodium .................................................. 30
celacyn ....................................................................... 180
celebrate calcium citrate ..................................... 180
CELEBRATE CALCIUM PLUS 50 ......................... 180
CELEBRATE MULTI-COMPLETE ......................... 180
celecoxib ..................................................................... 14
CELLULAR SECURITY ............................................ 180
CELONTIN ................................................................... 52
cemill .......................................................................... 180
CEMILL PLUS ........................................................... 180
cemill sr ..................................................................... 180
cemill/bioflavonoids .............................................. 180
centamin ................................................................... 180
centavite ................................................................... 180
centavite a-z complete mu ................................ 180
centravites ................................................................ 180
centravites 50 plus ................................................ 180
CENTRAVITES 50 PLUS ....................................... 180
CENTRAVITES ADULTS ........................................ 181
CENTRUM .................................................................. 181
CENTRUM ADULTS ................................................. 181
CENTRUM CARDIO................................................. 181
CENTRUM FLAVOR BURST .................................. 181
CENTRUM FLAVOR BURST ADUL ...................... 181
CENTRUM FLAVOR BURST KIDS ...................... 181
centrum kids complete ........................................ 181
CENTRUM MEN ........................................................ 181
CENTRUM MULTIGUMMIES ADUL .................... 181
CENTRUM MULTIGUMMIES MEN ...................... 181
CENTRUM MULTIGUMMIES WOME .................. 181
CENTRUM MULTIVITAMIN FLAV ....................... 181
CENTRUM PERFORMANCE .................................. 181
CENTRUM SILVER .................................................. 181
CENTRUM SILVER 50+MEN................................ 181
CENTRUM SILVER 50+WOMEN ........................ 181
CENTRUM SILVER ADULT 50+ .......................... 181
CENTRUM SILVER ULTRA MENS ....................... 181
CENTRUM SILVER ULTRA WOME ..................... 181
CENTRUM SPECIALIST ENERGY ....................... 181
CENTRUM SPECIALIST HEART .......................... 181
CENTRUM SPECIALIST IMMUNE ....................... 181
CENTRUM SPECIALIST PRENAT ........................ 182
CENTRUM SPECIALIST VISION ......................... 182
CENTRUM ULTRA MENS ....................................... 182
CENTRUM ULTRA WOMENS ................................ 182
CENTRUM VITAMINTS .......................................... 182
CENTRUM WOMEN ................................................. 182
century ....................................................................... 182
century mature ....................................................... 182
CEO-TWO .................................................................. 182
CEPACOL SORE THROAT ..................................... 182
CEPACOL SORE THROAT & COU ...................... 182
CEPACOL SORE THROAT EXTRA ...................... 182
CEPASTAT ................................................................. 182
cephalexin................................................................... 30
CERALYTE 50 ........................................................... 182
CERALYTE 50 POTASSIUM FRE ......................... 182
ceralyte 70 ............................................................... 182
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 718
CERALYTE 70 ........................................................... 182
CERALYTE 90 ........................................................... 182
ceramax ..................................................................... 182
CERASPORT ............................................................. 182
CERASPORT EX1 .................................................... 182
CERAVE ...................................................................... 182
CERAVE AM SPF 30 ............................................... 183
cerave baby ............................................................. 183
CERAVE FOAMING FACIAL CLE ........................ 183
CERAVE HYDRATING CLEANSER ...................... 183
CERAVE PM ............................................................... 183
CERAVE RENEWING SA ....................................... 183
CERAVE SA RENEWING ....................................... 183
CERDELGA .................................................................. 77
CEREZYME .................................................................. 77
cerovite advanced formula ................................. 183
CEROVITE ADVANCED FORMULA..................... 183
cerovite jr ................................................................. 183
cerovite senior ........................................................ 183
certa plus .................................................................. 183
certagen .................................................................... 183
CERTAINTY ADJUSTABLE UNDE ....................... 183
CERTAINTY ADULT WASHCLOTH ..................... 183
CERTAINTY BELTED SHIELDS/ ......................... 183
CERTAINTY BOXERS FOR MEN/ ....................... 183
CERTAINTY CLEANSING WIPES ....................... 183
CERTAINTY FITTED BRIEFS/L ........................... 183
CERTAINTY FITTED BRIEFS/M .......................... 183
CERTAINTY FITTED BRIEFS/X........................... 183
CERTAINTY GUARDS FOR MEN......................... 183
CERTAINTY LINERS/WOMEN/RE ...................... 184
CERTAINTY OVERNIGHT UNDER ...................... 184
CERTAINTY PADS/REGULAR/MA ...................... 184
CERTAINTY PADS/REGULAR/UL ....................... 184
CERTAINTY PADS/WOMEN ................................. 184
CERTAINTY PADS/WOMEN/LONG .................... 184
CERTAINTY PADS/WOMEN/MAXI ..................... 184
CERTAINTY PADS/WOMEN/OVER .................... 184
CERTAINTY PADS/WOMEN/REGU .................... 184
CERTAINTY PADS/WOMEN/ULTI ...................... 184
CERTAINTY PADS/WOMEN/ULTR ..................... 184
CERTAINTY PURSEREADY UND ........................ 184
CERTAINTY ULTRA THIN UNDE ........................ 184
CERTAINTY UNDERPADS MEN & ...................... 184
CERTAINTY UNDERPADS/EXTRA...................... 184
CERTAINTY UNDERPADS/MEN & ...................... 184
CERTAINTY UNDERPADS/REGUL ..................... 184
CERTAINTY UNDERPADS/SUPER ..................... 184
CERTAINTY UNDERWEAR/LARGE .................... 184
CERTAINTY UNDERWEAR/MEN/L ..................... 184
CERTAINTY UNDERWEAR/MEN/S .................... 184
CERTAINTY UNDERWEAR/MENS/ .................... 184
CERTAINTY UNDERWEAR/SMALL .................... 184
CERTAINTY UNDERWEAR/UNISE ..................... 185
CERTAINTY UNDERWEAR/WOMEN .................. 185
CERTAINTY UNDERWEAR/X-LAR ..................... 185
CERTAINTY UNDERWEAR/XLARG .................... 185
CERTAINTY UNDERWEAR/X-SMA .................... 185
certa-vite .................................................................. 183
CERTAVITE SENIOR/ANTIOXID ........................ 669
certavite/antioxidants .................................. 185, 669
CERTUSS-D .............................................................. 185
CESIUM ...................................................................... 185
CESIUM 1000 .......................................................... 185
CESIUM 500 ............................................................. 185
CETAKLENZ .............................................................. 185
CETAPHIL .................................................................. 185
CETAPHIL DAILY ADVANCE UL ......................... 185
CETAPHIL DAILY FACIAL MOI ........................... 185
CETAPHIL DERMACONTROL FOA ..................... 185
CETAPHIL DERMACONTROL MOI ..................... 185
CETAPHIL GENTLE CLEANSER .......................... 185
CETAPHIL MOISTURIZING .................................. 185
CETAPHIL RESTORADERM .................................. 185
CETAPHIL THERAPEUTIC HAND ....................... 185
cetirizine hcl ............................................. 185, 186, 678
cetirizine hcl allergy ch ................................ 186, 678
cetirizine hcl childrens ................................. 186, 678
cetirizine hcl hives reli ......................................... 186
cetirizine hydrochloride ....................................... 186
cetirizine syrup ....................................................... 678
cetirizine-pseudoephedrine ........................ 186, 681
cevimeline hcl.......................................................... 696
CHANTIX ..................................................................... 69
CHANTIX CONTINUING MONTH ......................... 69
CHANTIX STARTER PACK ...................................... 69
CHAPSTICK OVERNIGHT ..................................... 186
CHAPSTICK ULTRA MOISTURE ......................... 186
chapstick ultra renewal n .................................... 186
CHAPSTICK ULTRASMOOTH FOR ..................... 186
CHAPSTICK ULTRASMOOTH NOU .................... 186
CHAPSTICK ULTRASMOOTH REJ ...................... 186
CHAPSTICK ULTRASMOOTH SOO .................... 186
CHARCOAL ................................................................ 186
CHARCOAL 6-16 MESH/TECHNI ....................... 186
CHARCOAL ACTIVATED ....................................... 186
CHEK-STIX COMBO PAK URINA ....................... 186
CHEK-STIX CONTROL ........................................... 186
CHELATED CALCIUM ............................................. 186
CHEMET ....................................................................... 77
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 719
CHEMSTRIP .............................................................. 186
CHEMSTRIP 10 MD ................................................ 187
CHEMSTRIP -10 WITH SG .................................. 187
CHEMSTRIP 2 GP STRIPS ................................... 186
CHEMSTRIP 2 LN STRIPS ................................... 186
CHEMSTRIP 5 OB ................................................... 187
CHEMSTRIP 7 .......................................................... 187
CHEMSTRIP 9 STRIPS .......................................... 187
CHEMSTRIP BG STRIPS ....................................... 187
CHEMSTRIP UGK .................................................... 187
CHEMSTRIP-K.......................................................... 187
CHEMSTRIP-UG ...................................................... 187
CHERACOL PLUS .................................................... 187
CHERACOL SORE THROAT ................................. 187
CHERACOL-D COUGH ........................................... 187
cheratussin ac ......................................................... 187
cheratussin dac....................................................... 187
CHERRY CONCENTRATE ...................................... 187
cherry cough drops ............................................... 187
CHERRY SYRUP ....................................................... 187
chest congestion and sinu ................................................................ 187
chest congestion & cough ................................... 187
chest congestion & sinus .................................... 187
chest congestion children ................................... 187
chest congestion daytime ................................... 187
chest congestion relief ......................................... 187
chest congestion relief d ..................................... 188
chest congestion relief e ..................................... 188
chest congestion relief p ..................................... 188
chest congestion/cough re ................................. 188
chest congestion/pain & s .................................. 188
CHEST CONGESTION/PAIN REL ....................... 188
chest rub hands-free medi ................................. 188
CHEW Q ..................................................................... 188
CHEW-12 ................................................................... 188
chewable acetaminophen ch ............................. 188
chewable antacid ................................................... 188
chewable calcium ................................................... 188
CHEWABLE CALCIUM ............................................ 188
CHEWABLE IRON ................................................... 188
CHEWABLE VITAMIN E......................................... 188
chewable vitamins childre .................................. 188
chewable vite childrens ....................................... 188
chewable vite with iron/c .................................... 188
chew-c ........................................................................ 188
child ibuprofen ........................................................ 188
childrens acetaminophen .............................. 11, 188
CHILDRENS ADVIL ................................................ 189
childrens advil cold ................................................ 189
childrens allergy ............................................. 189, 678
childrens animal shapes c .................................. 189
childrens apap ......................................................... 189
childrens aspirin ............................................... 11, 189
childrens aspirin free ............................................ 189
childrens aspirin low str ........................................ 11
childrens chewable multi .................................... 189
childrens chewable multiv .................................. 189
childrens chewable vitami .................................. 189
childrens cold & allergy ............................... 189, 682
childrens complete allerg .................................... 189
childrens cough ...................................................... 189
childrens gummies ................................................ 189
childrens ibuprofen.......................................... 15, 189
childrens ibuprofen 100 ....................................... 189
childrens ibuprofen cold ...................................... 189
childrens loratadine ...................................... 189, 678
childrens mapap rapid tab .................................. 189
childrens medi-profen .......................................... 189
childrens medi-tabs .............................................. 189
CHILDRENS MOTRIN ............................................ 189
CHILDRENS MOTRIN COLD ................................ 189
CHILDRENS MOTRIN JUNIOR S ........................ 190
childrens mucus relief co ............................ 190, 682
childrens mucus relief ex ............................ 190, 682
childrens multivitamin ......................................... 190
CHILDRENS MYLANTA UPSET S ....................... 190
childrens non-aspirin ............................................ 190
childrens non-aspirin pai ..................................... 190
childrens non-aspirin plu .................................... 190
CHILDRENS NON-ASPIRIN PLU ........................ 190
childrens pain relief plu ....................................... 190
childrens pain reliever .................................... 11, 190
childrens pepto ....................................................... 190
CHILDRENS PLUS COLD ...................................... 190
childrens plus cold & all ....................................... 190
childrens plus cough/runn .................................. 190
childrens plus flu .................................................... 190
childrens plus multi-symp .................................. 190
CHILDRENS PROBIOTIC PEARL ........................ 190
childrens silapap .............................................. 11, 190
childrens silfedrine ................................................ 682
childrens soothe ..................................................... 190
childrens tactinal .................................................... 190
childrens tylenol plus co ...................................... 191
CHILDRENS TYLENOL PLUS CO ........................ 191
childs allergy cold/cough .................................... 191
childs ibuprofen ........................................................ 15
childs pain reliever w/o ....................................... 191
childs pain reliever with ...................................... 191
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 720
CHLO HIST ............................................................... 191
CHLO TUSS .............................................................. 191
CHLO TUSS EX ........................................................ 191
CHLOPHED ................................................................ 191
chloraseptic .............................................................. 191
chloraseptic gargle ................................................ 191
chloraseptic mouth pain ...................................... 191
chloraseptic sore throat ...................................... 191
chloraseptic warming sore ................................. 191
CHLORELLA .............................................................. 191
chlorhexidine gluconate ...................................... 191
CHLORHEXIDINE GLUCONATE .......................... 191
chlorhexidine gluconate (mouth-throat) ....... 696
CHLORHEXIDINE GLUCONATE C ..................... 191
chlorhist ..................................................................... 191
chlorocaps ................................................................ 191
chloroquine phosphate .......................................... 24
chlorothiazide tabs .................................................. 49
chlorphen .................................................................. 191
chlorphen sr ............................................................. 192
chlorpheniramine & phenylephrine ................. 192
chlorpheniramine & phenylprop ....................... 192
chlorpheniramine & pseudoeph ........................ 192
chlorpheniramine maleate .................................. 192
chlorpheniramine-phenylephrine-
acetaminophen .................................................. 192
chlorpheniramine-pseudoephedrine-
acetaminophen .................................................. 192
chlorphen-phenylprop w/apap .......................... 192
chlorpromazine hcl .................................................. 61
CHLORPROMAZINE INJ .......................................... 61
chlorthalidone............................................................ 49
CHLOR-TRIMETON ................................................. 191
CHLOR-TRIMETON ALLERGY ............................. 191
chocolated laxative ............................................... 192
CHOICEFUL MULTIVITAMIN ............................... 192
CHOLASE CONTROL .............................................. 192
cholecalciferol .................................................. 192, 669
cholestyramine ......................................................... 45
cholestyramine light ............................................... 45
CHROMACAPS ......................................................... 192
CHROMEMATE ......................................................... 192
chromic chloride ..................................................... 192
chromium .................................................................. 192
CHROMIUM ............................................................... 192
CHROMIUM ASPARTATE ...................................... 193
chromium gtf ........................................................... 193
chromium picolinate ............................................. 193
CHROMIUM PICOLINATE ..................................... 193
chromium picolinate mega ................................. 193
chromium picolinate ultra ................................... 193
CIALIS ........................................................................ 193
CIBA VISION CLEANER ........................................ 193
CIBA VISION MIRAFLOW .................................... 193
CIBA VISION SALINE ........................................... 193
ciclopirox ................................................................... 689
ciclopirox shampoo 1% ....................................... 689
cidaflex....................................................................... 193
cilostazol ..................................................................... 98
CILOXAN.................................................................... 672
CIMDUO ....................................................................... 26
cimetidine ................................................................. 193
cimetidine 200 ........................................................ 193
cimetidine acid reducer ....................................... 193
cinacalcet hcl ............................................................. 76
CIPRODEX ................................................................. 696
ciprofloxacin ............................................................... 31
ciprofloxacin hcl (ophth) ..................................... 672
ciprofloxacin hcl tab ................................................ 31
ciprofloxacin in d5w ................................................ 31
cisplatin ....................................................................... 41
citalopram hydrobromide ..................................... 57
CITRACAL + D3 MAXIMUM ................................. 193
CITRACAL CALCIUM GUMMIES ......................... 193
CITRACAL CALCIUM+D SLOW R ...................... 193
CITRACAL MAXIMUM ............................................ 193
CITRACAL PETITES/VITAMIN ............................ 193
CITRACAL PLUS ...................................................... 193
CITRACAL PLUS BONE DENSIT ......................... 194
CITRACAL PLUS HEART HEALT ......................... 194
CITRACAL/VITAMIN D .......................................... 194
CITRACAL+D3 ......................................................... 194
citroma ....................................................................... 194
CITRUCEL .................................................................. 194
CITRUCEL FIBER LAXATIVE ............................... 194
CITRULLINE 1000 .................................................. 194
citrus calcium +d ................................................... 194
claravis ....................................................................... 688
clarispray .................................................................. 194
clarithromycin ........................................................... 30
clarithromycin er ...................................................... 30
clarithromycin for susp .......................................... 30
CLARITIN................................................................... 194
claritin allergy children ........................................ 194
CLARITIN ALLERGY CHILDREN ......................... 194
CLARITIN CHILDRENS ......................................... 194
claritin eye ................................................................ 194
CLARITIN REDITABS............................................. 194
CLARITIN-D 12 HOUR .......................................... 194
CLARITIN-D 24 HOUR .......................................... 194
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 721
CLASSIC PRENATAL .............................................. 194
clean & clear acne triple ...................................... 194
CLEAN & CLEAR ACNE TRIPLE .......................... 194
CLEAN & CLEAR ADVANTAGE 3 ........................ 194
clean & clear advantage a .................................. 194
clean & clear advantage d .................................. 195
clean & clear advantage m ................................ 195
clean & clear continuous ..................................... 195
CLEAN & CLEAR DAILY PORE ............................ 195
CLEAN & CLEAR DEEP ACTION ......................... 195
clean & clear deep cleani .................................... 195
CLEAN & CLEAR ESSENTIALS ........................... 195
CLEAN & CLEAR FOAMING FAC ........................ 195
CLEAN & CLEAR MORNING BUR ....................... 195
CLEAN & CLEAR NIGHT RELAX ......................... 195
clean & clear persa-gel e .................................... 195
clean & clear persa-gel m ................................... 195
CLEAN & CLEAR SOFT MOISTU ........................ 195
CLEAN START VAPORIZER TAB ........................ 195
CLEANSING CLOTHS FLUSHABL ...................... 195
CLEANSING CREAM ............................................... 195
CLEANSING EYELID PADS .................................. 195
clear away ................................................................ 195
CLEAR AWAY ONE STEP WART ......................... 195
CLEAR AWAY PLANTAR SYSTEM ...................... 195
CLEAR AWAY WART REMOVER S ..................... 195
CLEAR CARE ............................................................. 195
CLEAR CARE PLUS W/HYDRAGL ....................... 195
CLEAR COUGH PM MULTI-SYMP ....................... 196
clear eyes all seasons ou .................................... 196
CLEAR EYES CONTACT LENS R......................... 196
CLEAR EYES FOR DRY EYES .............................. 196
clear eyes natural tears....................................... 196
CLEAR EYES REDNESS RELIEF ......................... 196
CLEAR EYES TRIPLE ACTION ............................. 196
clear soluble fiber .................................................. 196
clearasil daily clear hyd ....................................... 196
clearasil daily clear van ....................................... 196
clear-atadine d ........................................................ 196
CLEARCANAL EAR WAX REMOVA ..................... 196
clearlax ................................................................ 88, 196
clearplex v ................................................................ 196
clearplex x ................................................................ 196
clearskin .................................................................... 196
clemastine fumarate ............................................. 196
CLEVER CHEK AUTO CODE VOI ....................... 196
CLEVER CHEK AUTO-CODE BLO....................... 196
CLEVER CHEK AUTO-CODE TES ....................... 196
CLEVER CHEK AUTO-CODE VOI ....................... 196
CLEVER CHEK BLOOD GLUCOSE ..................... 196
CLEVER CHEK TEST STRIPS .............................. 197
CLEVER CHOICE AUTO-CODE P ....................... 197
CLEVER CHOICE MICRO BLOOD ...................... 197
CLEVER CHOICE MICRO TEST .......................... 197
CLEVER CHOICE MINI BLOOD .......................... 197
CLEVER CHOICE NO CODING T ........................ 197
CLEVER CHOICE TALK BLOOD .......................... 197
CLEVER CHOICE TALK NO COD ........................ 197
clindacin-p ................................................................ 688
clindamycin cap 300mg ......................................... 21
clindamycin cap 75mg ........................................... 21
clindamycin hcl cap 150 mg ................................ 21
clindamycin phosphate (topical) ...................... 688
clindamycin phosphate in d5w ........................... 21
CLINDAMYCIN PHOSPHATE IN NACL ............... 21
clindamycin phosphate inj .................................... 21
clindamycin phosphate vaginal .......................... 96
clindamycin soln 75mg/5ml ................................. 21
CLINICAL NUTRIENTS 45-PLU .......................... 197
CLINICAL NUTRIENTS 50-PLU .......................... 197
CLINICAL NUTRIENTS ANTIOX ......................... 197
CLINICAL NUTRIENTS FOR FE .......................... 197
CLINICAL NUTRIENTS FOR MA ......................... 197
CLINICAL NUTRIENTS FOR ME ......................... 197
CLINICAL NUTRIENTS FOR WO ........................ 197
CLINIMIX 4.25%/DEXTROSE 25% .................. 665
CLINIMIX 4.25%/DEXTROSE 5% .................... 665
CLINIMIX 5%/DEXTROSE 15% ........................ 665
CLINIMIX 5%/DEXTROSE 20% ........................ 665
CLINIMIX 5%/DEXTROSE 25% ........................ 665
CLINIMIX INJ 4.25/D10....................................... 665
CLINISTIX ................................................................. 197
CLINITEST ................................................................ 197
CLINITEST REAGENT ............................................ 197
CLN BODY WASH GENTLE NON- ...................... 197
CLN FACIAL CLEANSER MOIST ......................... 197
CLN FACIAL MOISTURIZER NO......................... 197
CLN HAND & FOOT WASH DEEP ...................... 197
CLN HEALTHY SCALP SHAMPOO ...................... 197
CLN MOISTURE RICH GENTLE .......................... 198
CLN SPORT WASH HIGH PERFO ....................... 198
CLN SPORTWASH ................................................... 198
clobazam ..................................................................... 52
CLOFERA ................................................................... 198
clomipramine hcl ...................................................... 57
clonazepam .......................................................... 52, 53
clonidine hcl ............................................................... 50
clonidine hcl ptwk .................................................... 50
clopidogrel tab 75mg.............................................. 99
clorazepate dipotassium ....................................... 53
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 722
clorox nasal antiseptic s ...................................... 198
CLORPACTIN WCS-90 .......................................... 198
CLOSERCARE ........................................................... 198
clotrimazole .............................................................. 696
clotrimazole (topical) ................................... 198, 689
clotrimazole 3 .......................................................... 198
clotrimazole af ........................................................ 198
clotrimazole antifungal ................................ 198, 689
clotrimazole anti-fungal ...................................... 198
clotrimazole anti-fungal ...................................... 689
clotrimazole grx ...................................................... 198
clotrimazole vaginal ........................................ 96, 198
clotrimazole w/ betamethasone ....................... 689
clotrimazole-7 ......................................................... 198
CLOVERINE SALVE ................................................ 198
clozapine odt ............................................................. 61
clozapine tab 100mg .............................................. 61
clozapine tab 200mg .............................................. 61
clozapine tab 25mg ................................................. 61
clozapine tab 50mg ................................................. 61
CLUSINEX ................................................................. 198
CO MONITOR REPLACEMENT T ......................... 198
CO Q-10 .................................................................... 198
co q10 maximum strength ................................. 198
co q-10 maximum strength ............................... 198
CO Q-10 PLUS ......................................................... 199
coal tar extract ....................................................... 199
COARTEM .................................................................... 24
COATS ALOE ............................................................ 199
COATS ALOE CREME ............................................. 199
COATS ALOE GELLY .............................................. 199
COATS ALOE JUICE DRINK ................................ 199
COATS ALOE JUICE DRINK UN ......................... 199
COATS ALOE MOISTURIZING L ........................ 199
COATS ALOE VERA ................................................ 199
COATS ALOE VERA JUICE DRI .......................... 199
COATS ALOE VERA MOISTURIZ ....................... 199
cobalamine combinations ................................... 199
COCOA BUTTER ...................................................... 199
COCOA BUTTER HAND & BODY ........................ 199
COCOA BUTTER PETROLEUM JE ....................... 199
cocoa butter skin cream ...................................... 199
COCONUT OIL BEAUTY ........................................ 199
cod liver oil ............................................................... 199
COD LIVER OIL ....................................................... 199
COD LIVER OIL FOR KIDS .................................. 199
COD LIVER OIL PLUS VITAMI ........................... 199
cod liver oil w/vitamins ....................................... 200
cod liver oil/low vitamin ...................................... 200
cod liver oil/vitamins a ........................................ 200
CODAR AR ................................................................ 200
CODAR D ................................................................... 200
codar gf ..................................................................... 200
CODITUSS DM......................................................... 200
CODITUSSIN AC ..................................................... 200
CODITUSSIN DAC .................................................. 200
COENZYME Q10 ...................................................... 200
CO-ENZYME Q-10 .................................................. 199
coenzyme q10 (ubidecarenone) ....................... 200
CO-ENZYME Q10/VITAMIN E ............................. 199
COLACE ...................................................................... 200
colace 2-in-1 ............................................................ 200
COLACE CLEAR ....................................................... 200
COLAMINE ................................................................ 200
colchicine w/ probenecid ....................................... 10
COLCRYS ..................................................................... 10
cold & allergy ........................................................... 200
cold & allergy childrens ....................................... 200
cold & cough childrens ......................................... 200
cold & cough daytime ........................................... 200
cold & cough daytime/nigh ................................ 200
cold & flu intense streng ..................................... 200
cold & flu multi-symptom ................................... 200
cold & flu relief multi-s ........................................ 201
COLD & FLU RELIEF NIGHTTI............................ 201
cold & flu severe .................................................... 201
cold & flu severe daytime ................................... 201
cold & sinus relief .................................................. 201
cold control pe intense c ..................................... 201
cold head congestion dayt.................................. 201
cold head congestion nigh .................................. 201
cold head congestion seve ................................. 201
cold medicine plus ................................................. 201
cold multi-symptom .............................................. 201
cold multi-symptom day/ni ................................ 201
cold multi-symptom daytim ............................... 201
cold multi-symptom nightt ................................. 201
cold multi-symptom severe ............................... 201
cold multi-symptom warmin .............................. 201
cold relief plus ......................................................... 201
cold relief w/o aspirin ........................................... 201
cold relief/non-drowsy/da .................................. 201
cold sore products ................................................. 201
cold symptoms relief maxi ................................. 201
cold/allergy .............................................................. 202
cold/allergy childrens ........................................... 202
cold/allergy pe ........................................................ 202
cold/allergy/sinus .................................................. 202
cold/cough childrens ..................................... 202, 682
cold/cough dm childrens ..................................... 202
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 723
cold/cough/sore throat ch .................................. 202
cold/flu relief ........................................................... 202
cold/flu relief day/night ....................................... 202
cold/flu relief multi-sym ...................................... 202
COLD-EEZE .............................................................. 201
COLEMAN 100 MAX INSECT RE ........................ 202
COLEMAN BOTANICALS INSECT ...................... 693
COLEMAN INSECT REPELLENT/ ........................ 693
COLEMAN SKINSMART INSECT ........................ 693
colesevelam hcl ........................................................ 45
colestipol hcl gran.................................................... 45
colestipol hcl pack ................................................... 45
colestipol hcl tabs .................................................... 45
colistimethate sodium ............................................ 21
COLLADERM ............................................................. 202
COLLAGEN ULTRA .................................................. 202
colloidal oatmeal .................................................... 202
collyrium eye wash ............................................... 202
collyrium for fresh eyes ....................................... 202
colocort enema 100mg .......................................... 88
COMBIGAN ............................................................... 674
COMBISTIX .............................................................. 202
COMBIVENT RESPIMAT ....................................... 677
COMETRIQ .................................................................. 38
COMFEEL PLUS CLEAR DRESSI ........................ 202
COMFEEL PLUS CONTOUR DRES ..................... 202
COMFEEL PLUS DRESSING ................................ 202
COMFEEL PLUS TRIANGLE DRE ........................ 202
COMFEEL PLUS ULCER DRESSI ........................ 202
COMFEEL ULCER CARE DRESSI ....................... 202
comfort gel ............................................................... 203
comfort gel antacid anti- .................................... 203
comfort gel antacid& anti ................................... 203
comfort gel extra strengt .................................... 203
COMFORT INSOLES WOMENS ........................... 203
COMFORT SHIELD UNDERPADS/ ..................... 203
COMFORT-AID 1.5 ................................................. 203
COMMIT ..................................................................... 203
companion ................................................................ 203
compete ..................................................................... 203
COMPLERA .................................................................. 26
complere ................................................................... 203
complete ................................................................... 203
complete allergy ..................................................... 203
complete allergy medicati .................................. 203
complete allergy medicine ................................. 203
complete allergy relief ......................................... 203
COMPLETE AMINO ACID MIX ............................ 203
complete daily with lutei ..................................... 203
complete energy .................................................... 203
complete lice treatment k................................... 203
COMPLETE MENOPAUSE SUPPOR .................... 203
complete moisture ................................................. 203
complete multi-vitamin gu ................................. 203
complete multivitamin/mul ................................ 204
complete pms support comp ............................. 204
complete ready-to-use ene ................................ 204
complete senior ...................................................... 204
COMPLETE SINUS RELIEF ................................... 204
complete womens .................................................. 204
COMPLEX 15 ............................................................ 204
complex b-100 ........................................................ 204
complex b-50 prolonged re ................................ 204
COMPLEX ESSENTIAL MSD ................................ 204
COMPLEX JUNIOR MSD........................................ 204
COMPLEX MSUD ..................................................... 204
COMPLEX MSUD AMINO ACID B ...................... 204
compound w ............................................................ 204
COMPOUND W ......................................................... 204
compound w for kids ............................................ 204
COMPOUND W GEL................................................ 204
COMPOUND W MAXIMUM STRENG ................. 204
compound w one step pads/ ............................. 204
compound w one step plant .............................. 204
COMPOUND W PAD 17% .................................... 204
compoz ...................................................................... 204
compro ......................................................................... 85
COMPUTER EYE DROPS ....................................... 204
comtrex a/s .............................................................. 205
comtrex a/s caplets .............................................. 205
COMTREX COLD & COUGH DAY/...................... 205
COMTREX COLD & COUGH MAXI ..................... 205
COMTREX COLD & COUGH NIGH ..................... 205
COMTREX DEEP CHEST COLD M ...................... 205
comtrex flu therapy maxim ............................... 205
comtrex severe cold & sin .................................. 205
CONCEPTIONXR MOTILITY SUP ....................... 205
CONE MASK ............................................................. 205
CONEX COLD/ALLERGY ....................................... 205
CONFIDENCE EXTRA CARE BRI ........................ 205
CONFIDENCE FITTED BRIEF L .......................... 205
CONFIDENCE FITTED BRIEF M ......................... 205
CONFIDENCE FITTED BRIEF P .......................... 205
CONFIDENCE FITTED BRIEF R .......................... 205
CONFIDENCE FITTED BRIEF X .......................... 205
CONFIDENCE PREMIUM CARE B....................... 205
CONFIDENCE WINGFOLD BRIEF ...................... 205
CONGESTAC ............................................................. 205
CONGESTAC TAB 60-400MG ............................. 205
congestant ................................................................ 205
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 724
constant-clens ......................................................... 205
constulose ................................................................... 88
CONTAC COLD/FLU DAY & NIG ........................ 206
CONTAC COLD/FLU DAY/NIGHT ....................... 206
CONTAC COLD/FLU MAXIMUM S ...................... 206
contac cold+flu maximum s .............................. 206
contac cold+flu night ........................................... 206
CONTOUR BRIEF LARGE ...................................... 206
CONTOUR BRIEF MEDIUM .................................. 206
CONTOUR NEXT BLOOD GLUCOS .................... 206
CONTOUR NEXT EZ BLOOD GLU ...................... 206
CONTOUR NEXT LINK BLOOD G ...................... 206
CONTOUR NEXT LINK WIRELES ....................... 206
contragesic ............................................................... 206
CONTREET FOAM ................................................... 206
CONTREET FOAM CAVITY ................................... 206
CONTREET FOAM HEEL ........................................ 206
CONTREET FOAM SACRAL .................................. 206
CONTREET HYDROCOLLOID .............................. 206
CONTROL AST ......................................................... 206
CONTROL BLOOD GLUCOSE MON ................... 206
CONTROL PADS EXTRA ABSORB ..................... 206
CONTROL TEST STRIPS ....................................... 206
CONVEEN NET PANTS .......................................... 206
cool & heat balm extra st ................................... 206
cool & heat extra strengt .................................... 207
COOL BLOOD GLUCOSE MONITO .................... 207
COOL BLOOD GLUCOSE TEST S ...................... 207
COOL BOTTOMS ..................................................... 207
cool n heat extra strengt .................................... 207
cool n heat muscle & join ................................... 207
cooling burn relief .................................................. 207
COPASIL .................................................................... 207
cope ............................................................................ 207
COPIKTRA ................................................................... 38
COPPER ...................................................................... 207
COPPER CAPS .......................................................... 207
COPPER GLUCONATE ............................................ 207
COPPER SULFATE................................................... 207
COPPERMIN .............................................................. 207
coq-10 ........................................................................ 207
coq10 maximum strength .................................. 207
COQ-10 TR ............................................................... 207
COQ10/VITAMIN E ................................................ 207
CORAL CALCIUM .................................................... 207
coral calcium plus .................................................. 207
CORAL CALCIUM PLUS ......................................... 207
coral calcium-magnesium w/ vitamin d ........ 207
corfen-dm ................................................................. 207
CORICIDIN D ........................................................... 208
coricidin d cold/flu/sinu ....................................... 208
coricidin hbp chest conge ................................... 208
CORICIDIN HBP COLD & FLU ............................ 208
CORICIDIN HBP COUGH & COL ........................ 208
CORICIDIN HBP DAY & NIGHT ......................... 208
CORICIDIN HBP FLU ............................................. 208
coricidin hbp nighttime m ................................... 208
CORICIDIN NIGHTTIME COLD/ ........................ 208
CORLANOR ................................................................. 50
corn and callus remover ........................................... 208
corn & callus remover .......................................... 208
CORN & CALLUS REMOVER ................................ 208
CORN CUSHIONS ................................................... 208
corn dextrin .............................................................. 208
CORN HUSKERS ..................................................... 208
CORN REMOVER ONE STEP................................ 208
CORN REMOVER ULTRA THIN ........................... 208
CORN REMOVER WATERPROOF ........................ 208
corn removers ......................................................... 208
correct ........................................................................ 208
correctol .................................................................... 208
correctol extra gentle ........................................... 208
cortaid advanced 12 hour ................................... 208
cortaid intensive therapy .................................... 209
cortaid maximum strength ................................. 209
corticool ..................................................................... 209
cortisone acetate ..................................................... 78
cortizone-10 ............................................................. 209
CORTIZONE-10 ....................................................... 209
cortizone-10 diabetics sk .................................... 209
cortizone-10 eczema ............................................ 209
cortizone-10 hydratensive .................................. 209
cortizone-10 intensive he ................................... 209
cortizone-10 plus ................................................... 209
CORTIZONE-10 PLUS ........................................... 209
cortizone-10/aloe ................................................... 209
corvite free ............................................................... 209
cosamin ds ............................................................... 209
COTELLIC .................................................................... 38
COTTONELLE FRESH CARE ................................. 209
COTTONELLE FRESH MOIST WI ....................... 209
COTTONELLE MOIST WIPES .............................. 209
COTTONELLE MOIST WIPES FO ....................... 209
cottontails baby chest ru .................................... 209
cottontails diaper rash ......................................... 209
cottontails diaper rash c ...................................... 209
cough & chest congestion ................................... 210
cough & cold .................................................... 210, 682
cough & cold hbp ................................................... 210
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 725
cough & sore throat day t .................................. 210
cough & sore throat night .................................. 210
cough cold & sore throat..................................... 210
cough control dm ................................................... 210
cough daytime/nighttime ................................... 210
cough dm .......................................................... 210, 682
cough dm childrens ............................................... 210
cough drops ............................................................. 210
cough drops menthol ........................................... 210
cough drops sugar free ....................................... 210
cough relief .............................................................. 210
and tgt cold ......................................................... 606
cough relief adult/long-l ...................................... 210
cough syrup ..................................................... 210, 682
COUGH SYRUP D .................................................... 210
cough syrup m ........................................................ 210
coughtab ........................................................... 210, 682
COUMADIN ................................................................. 97
COUPON ONE TOUCH ULTRA MI ...................... 210
C-PLEX ....................................................................... 167
CPR MICROSHIELD................................................ 210
CRAMP TABS ............................................................ 211
CRANBERRY CONCENTRATE .............................. 211
CRANBERRY CONCENTRATE/VIT ..................... 211
cranberry plus vitamin c ..................................... 211
cranberry urinary comfort .................................. 211
cranberry/vitamin c tripl ..................................... 211
cranberry-vitamin c .............................................. 211
cranberry-vitamin c-vitamin e .......................... 211
CREOMULSION ADULT ......................................... 211
CREOMULSION FOR CHILDREN ........................ 211
CREON.......................................................................... 94
CREO-TERPIN .......................................................... 211
CR-GTF....................................................................... 210
critic-aid clear af .................................................... 211
CRITIC-AID CLEAR MOISTURE ......................... 211
CRITIC-AID THICK MOISTURE ......................... 211
CRIXIVAN .................................................................... 24
CRM ............................................................................. 211
CRO-MAN-ZIN ......................................................... 211
cromolyn sodium (mastocytosis) ....................... 93
cromolyn sodium (nasal) ............................ 211, 682
cromolyn sodium (ophth) ................................... 674
cromolyn sodium nebu ........................................ 686
CR-PLUS .................................................................... 210
cruex prescription streng .................................... 211
crush vitamin c drops ........................................... 211
c-time sr .................................................................... 167
CU-25 ......................................................................... 211
CU-5 ............................................................................ 211
CULTURELLE ............................................................ 211
CULTURELLE ADVANCED IMMUN ..................... 212
CULTURELLE DIGESTIVE HEAL ......................... 212
CULTURELLE GENTLE-GO FORM ...................... 212
CULTURELLE HEALTH & WELLN ........................ 212
CULTURELLE IMMUNITY SUPPO ....................... 212
CULTURELLE KIDS ................................................. 212
CULTURELLE PRO-WELL ...................................... 212
CU-PLUS .................................................................... 211
cupric chloride ......................................................... 212
CUPRIC SULFATE ................................................... 212
curad hydrocortisone ............................................ 212
curad triple antibiotic ........................................... 212
curaler ........................................................................ 212
CURE-ALL .................................................................. 212
CURITY BEDDING/UPHOLSTERY ...................... 212
CURITY BRIEF LINERS ......................................... 212
CURITY CLEANERS ................................................ 212
CURITY HEAVY DRAINAGE PAC ........................ 212
CURITY PANTLINERS ............................................ 212
CURITY POVIDONE-IODINE PA ........................ 212
CURITY POVIDONE-IODINE SC ........................ 212
CURITY SALINE DRESSING 8 ............................ 212
CURITY SODIUM CHLORIDE DR ....................... 212
CURITY YOUTH PANTS/LARGE/ ........................ 212
CURITY YOUTH PANTS/SMALL/ ........................ 213
CUTTER ...................................................................... 213
CUTTER ALL FAMILY ............................................. 213
CUTTER ALL FAMILY MOSQUIT ......................... 213
CUTTER BACKWOODS .......................................... 693
CUTTER BACKWOODS DRY ........................ 213, 693
CUTTER DRY ............................................................ 213
CUTTER LEMON EUCALYPTUS ........................... 693
CUTTER NATURAL .......................................... 213, 693
CUTTER SKINSATIONS ................................ 213, 693
CUTTER SPORT ....................................................... 213
cvs 12 hour cold relief ......................................... 213
cvs 12 hour nasal deconge ................................ 213
cvs 3-day vaginal cream ..................................... 213
cvs 8 hour pain relief ............................................ 213
cvs 8hr arthritis pain re ....................................... 213
cvs 8hr muscle aches & pa ................................ 213
cvs acetaminophen ............................................... 213
cvs acetaminophen extra s ................................ 213
cvs acid controller.................................................. 213
cvs acid controller maxim ................................... 213
cvs acid reducer ..................................................... 213
cvs acid reducer maximum ................................ 213
cvs acidophilus ........................................................ 213
cvs acidophilus probiotic ..................................... 214
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 726
cvs acne .................................................................... 214
cvs acne cleansing bar ......................................... 214
cvs acne control cleanser ................................... 214
cvs acne foaming face was ................................ 214
cvs acne spot treatment ..................................... 214
cvs acne treatment ............................................... 214
cvs acne treatment/maximu ............................. 214
CVS ADJUSTABLE UNDERWEAR/ ..................... 214
CVS ADULT 50+ PROBIOTIC ............................. 214
CVS ADULT PROBIOTIC ....................................... 214
cvs advanced 3-in-1 exfol .................................. 214
cvs advanced acne spot tr ................................. 214
CVS ADVANCED GLUCOSE METE ..................... 214
cvs advanced healing oint .................................. 214
cvs af spray powder .............................................. 214
cvs airshield ............................................................. 214
CVS AIRSHIELD ...................................................... 214
CVS AIRSHIELD IMMUNITY SU ......................... 214
cvs all day pain relief ........................................... 214
cvs allergy ................................................................ 214
cvs allergy & sinus d chi...................................... 214
cvs allergy childrens ............................................. 214
cvs allergy eye drops ........................................... 215
cvs allergy relief ..................................................... 215
cvs allergy relief adult .......................................... 215
cvs allergy relief childr ......................................... 215
cvs allergy relief d ................................................. 215
cvs allergy relief d alle ......................................... 215
cvs allergy relief nightt ........................................ 215
cvs allergy relief-d ................................................. 215
cvs allergy relief-d12 ............................................ 215
cvs allergy-d ............................................................ 215
cvs antacid ............................................................... 215
cvs antacid & anti-gas fa .................................... 215
cvs antacid extra .................................................... 215
cvs antacid extra strengt .................................... 215
cvs antacid kids ...................................................... 215
cvs antacid liquid fast r ....................................... 215
cvs antacid maximum stren .............................. 215
cvs antacid plus antigas ...................................... 215
cvs antacid supreme ............................................. 215
cvs antacid ultra strengt ..................................... 216
cvs antacid/anti-gas ............................................. 216
cvs antacid/anti-gas liq ....................................... 216
cvs antacid/anti-gas maxi .................................. 216
cvs antacid/simethicone ...................................... 216
cvs antibiotic ............................................................ 216
cvs antibiotic plus .................................................. 216
cvs anti-dandruff .................................................... 216
cvs anti-diarrheal ................................................... 216
cvs antifungal .......................................................... 216
cvs anti-fungal powder ........................................ 216
cvs antihistamine eye dro .................................. 216
cvs anti-itch ............................................................. 216
cvs anti-itch maximum str ................................. 216
cvs anti-itch max-strengt ................................... 216
cvs anti-itch sensitive s ....................................... 216
cvs antiseptic mouth rins .................................... 216
cvs antiseptic skin clean ..................................... 216
cvs arthricream....................................................... 216
cvs arthritis pain relief ......................................... 216
cvs artificial tears................................................... 216
cvs aspirin................................................................. 216
cvs aspirin adult low dos ..................................... 216
cvs aspirin adult low str ...................................... 217
cvs aspirin child ...................................................... 217
cvs aspirin ec ........................................................... 217
cvs aspirin low dose .............................................. 217
cvs aspirin low strength ...................................... 217
cvs astringent eye drops ..................................... 217
cvs athletes foot ..................................................... 217
cvs athletes foot powder ..................................... 217
cvs b complex plus c ............................................ 217
cvs b1 ......................................................................... 217
cvs b-1 ....................................................................... 217
cvs b12 ...................................................................... 217
cvs b-12..................................................................... 217
cvs b6 ......................................................................... 217
cvs b-6 ....................................................................... 217
cvs baby teething oral pa ................................... 217
cvs bacitracin........................................................... 217
cvs back & body extra str ................................... 217
cvs backache relief extra .................................... 217
cvs balanced b100 ................................................. 217
cvs balanced b-100 ............................................... 217
cvs balanced b-150 ............................................... 218
cvs balanced b50 ................................................... 217
cvs balanced b-50 ................................................. 217
cvs bedding spray lice tr ..................................... 218
cvs beta carotene .................................................. 218
cvs biotin ................................................................... 218
cvs biotin high potency ........................................ 218
cvs bisacodyl ........................................................... 218
cvs bismuth .............................................................. 218
cvs bismuth maximum stren ............................. 218
CVS BLADDER CONTROL PAD U ...................... 218
CVS BLADDER CONTROL PADS ........................ 218
cvs body powder medicated .............................. 218
CVS BRIEFS LARGE ............................................... 218
CVS BRIEFS MEDIUM ........................................... 218
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 727
CVS BRIEFS OVERNIGHT MEDI ........................ 218
CVS BRIEFS X-LARGE .......................................... 218
cvs budesonide nasal spra ................................. 218
cvs buffered aspirin .............................................. 218
cvs caffeine .............................................................. 218
cvs calamine plus................................................... 218
cvs calcium ............................................................... 218
cvs calcium + d3 .................................................... 219
cvs calcium + d3 slow rel ................................... 219
cvs calcium 500+d ................................................ 218
cvs calcium 600 & vitamin ................................. 218
cvs calcium 600 + d plus .................................... 219
cvs calcium 600 + d/miner ................................ 219
cvs calcium 600+d ................................................ 219
cvs calcium carbonate ......................................... 219
CVS CALCIUM CHEWABLES 600 ...................... 219
CVS CALCIUM CITRATE ....................................... 219
cvs calcium citrate + d ........................................ 219
cvs calcium citrate +d ......................................... 219
cvs calcium citrate +d3 m .................................. 219
cvs calcium citrate+d/mag ................................ 219
CVS CALCIUM CITRATE+D/MAG ...................... 219
cvs calcium soft chews ........................................ 219
cvs calcium/magnesium/zin .............................. 219
CVS CALLUS CUSHION ........................................ 219
CVS CALLUS REMOVER ....................................... 219
cvs calohist skin protect ...................................... 219
CVS CAPSAICIN ...................................................... 219
cvs capsaicin hp ..................................................... 219
cvs castor oil ............................................................ 219
cvs cherry menthol drops ................................... 219
cvs chest congestion chil .................................... 219
cvs chest congestion expe ................................. 220
cvs chest congestion plus ................................... 220
cvs chest congestion reli ..................................... 220
cvs chest rub medicated ..................................... 220
cvs chewable childrens vi ................................... 220
cvs chewy not chalky flav ................................... 220
cvs childrens allergy ............................................. 220
cvs childrens allergy rel ....................................... 220
cvs childrens aspirin ............................................. 220
cvs childrens chewable co .................................. 220
cvs childrens chewable mu ................................ 220
cvs childrens ibuprofen ........................................ 220
cvs childrens multivitami .................................... 220
cvs childrens pain relief ....................................... 220
cvs childrens triacting c ....................................... 220
cvs childrens vitamin d f ..................................... 220
cvs childs non-aspirin ........................................... 220
cvs chocolate laxative pi ..................................... 220
cvs chromium picolinate ..................................... 220
cvs cimetidine ......................................................... 220
cvs citrate of magnesia ....................................... 220
cvs c-lax laxative ................................................... 218
CVS CLEANSING EYELID WIPE ......................... 220
CVS CLEANSING SKIN ......................................... 220
CVS CLEANSING WIPES ...................................... 221
CVS CLEANSING WIPES SENSI ........................ 221
cvs clotrimazole ...................................................... 221
cvs clotrimazole maximum ................................ 221
cvs cod liver oil ....................................................... 221
CVS COD LIVER OIL.............................................. 221
cvs coenzyme q10 ................................................. 221
cvs coenzyme q-10 ............................................... 221
cvs cold & allergy childr ...................................... 221
cvs cold & cough children ................................... 221
cvs cold & cough dm child .................................. 221
cvs cold & cough nighttim .................................. 221
cvs cold & hot pain relie ...................................... 221
cvs cold & sinus multi-sy .................................... 221
cvs cold & sinus relief .......................................... 221
cvs cold relief multi-sym ..................................... 221
cvs cold/cough dm childre .................................. 221
cvs cold/flu & sore throa ..................................... 221
CVS CONTACT LENS RELIEF R .......................... 221
cvs coq-10 ................................................................ 221
CVS CORN & CALLUS REMOVER ...................... 221
CVS CORN CUSHION ............................................ 221
cvs corn remover ................................................... 221
cvs corn removers ................................................. 222
cvs cortisone cooling rel ...................................... 222
cvs cortisone intense hea ................................... 222
cvs cortisone long-lastin ..................................... 222
cvs cortisone maximum str ................................ 222
cvs cough & chest congest ................................. 222
cvs cough & runny nose ch ................................ 222
cvs cough & severe cold n .................................. 222
cvs cough & sore throat c ................................... 222
cvs cough dm .......................................................... 222
cvs cough dm childrens ....................................... 222
cvs cough drops sugar fre .................................. 222
cvs cough/chest congestio ................................. 222
CVS COUGH/CHEST CONGESTIO .................... 222
cvs cranberry ........................................................... 222
cvs creamy acne face wash ............................... 222
cvs d3 ......................................................................... 222
cvs daily facial cleanser ....................................... 222
cvs daily fiber .......................................................... 222
cvs daily gummies ................................................. 222
cvs daily multiple ................................................... 222
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 728
cvs daily multiple for me .................................... 222
cvs daily multiple for wo ..................................... 222
cvs daily multiple plus i ....................................... 223
CVS DAILY PROBIOTIC ........................................ 223
CVS DAILY ULTRA MOISTURE ........................... 223
CVS DAY & NIGHT UNDERPADS ....................... 223
cvs daytime nighttime mul ................................ 223
cvs daytime/nighttime cou................................. 223
cvs decongestant inhaler .................................... 223
CVS DIABETES HEALTH SUPPO ........................ 223
cvs diaper rash ....................................................... 223
cvs digestive probiotic ......................................... 223
CVS DIGESTIVE PROBIOTIC .............................. 223
cvs disposable douche med ............................... 223
cvs dm maximum adult ....................................... 223
cvs dry eye relief ................................................... 223
CVS DRY MOUTH SPRAY ..................................... 223
cvs dry skin care unscent ................................... 223
cvs dry skin therapy ............................................. 223
cvs dry-eye relief nightt ...................................... 223
cvs dual action complete .................................... 223
cvs dye-free allergy .............................................. 223
cvs e ........................................................................... 223
cvs e oil ..................................................................... 223
cvs ear drops ........................................................... 223
CVS EAR WAX CLEANSING SYS ....................... 224
cvs ear wax removal kit ...................................... 224
cvs earwax removal kit ....................................... 224
cvs earwax removal system .............................. 224
cvs easy fiber .......................................................... 224
cvs easy fiber/calcium ......................................... 224
cvs eczema anti-itch maxi .................................. 224
cvs eczema relief ................................................... 224
cvs effervescent antacid ..................................... 224
cvs electrolyte solution ........................................ 224
cvs enema disposable .......................................... 224
cvs enema ready-to-use ..................................... 224
cvs enteric aspirin ................................................. 224
cvs epsom salt ........................................................ 224
CVS EPSOM SALT................................................... 224
cvs esomeprazole magnesiu .............................. 224
cvs extra moisturizing .......................................... 224
cvs eye allergy relief............................................. 224
cvs eye drops dual action ................................... 224
cvs eye drops original .......................................... 224
cvs eye health & lutein ........................................ 224
cvs eye health formula ........................................ 224
cvs eye itch relief ................................................... 224
cvs eye lubricant .................................................... 225
cvs eye lubricant nightti ...................................... 225
cvs eye wash ........................................................... 225
cvs fever reducing childr ..................................... 225
cvs fiber ..................................................................... 225
cvs fiber gummies ................................................. 225
cvs fiber gummy bears chi ................................. 225
cvs fiber laxative .................................................... 225
cvs first aid ............................................................... 225
cvs fish oil ................................................................. 225
CVS FITTED BRIEFS DAY/NIG........................... 225
cvs flu & severe cold day .................................... 225
cvs flu & severe cold nig ..................................... 225
cvs flu relief childrens .......................................... 225
cvs fluticasone propriona .................................... 225
cvs foaming acne face was ................................ 225
cvs folic acid ............................................................ 225
cvs foot & sneaker powder ................................. 225
cvs gas relief............................................................ 225
cvs gas relief drops extr ...................................... 225
cvs gas relief extra stre ....................................... 225
cvs gas relief infants ............................................. 225
cvs gas relief ultra stre ........................................ 225
CVS GEL HEEL CUSHION WOME ...................... 226
cvs gentle laxative................................................. 226
cvs gentle laxative women ................................. 226
cvs gentle skin cleanser ...................................... 226
cvs glucosamine ..................................................... 226
CVS GLUCOSAMINE CHONDROIT .................... 226
cvs glucosamine/chondroit................................. 226
cvs glucose ............................................................... 226
CVS GLUCOSE ......................................................... 226
CVS GLUCOSE BITS .............................................. 226
cvs glucose liquid shot ......................................... 226
cvs glucose shot ..................................................... 226
cvs glycerin adult ................................................... 226
cvs glycerin child ...................................................... 88
CVS GUARD MALE BRIEF .................................... 226
cvs gummy dinos ................................................... 226
cvs gummy dinos childrens ................................ 226
cvs gummy multivitamin ki ................................ 226
cvs gummy swirls .................................................. 226
cvs hair skin & nails/an ....................................... 226
CVS HAIR/SKIN/NAILS ........................................ 226
cvs hand wash advanced an .............................. 226
CVS HDYROCORTISONE ACETAT ..................... 226
cvs headache relief ............................................... 226
cvs headache relief added .................................. 227
cvs headache relief extra .................................... 227
cvs heartburn relief ......................................... 83, 227
cvs heartburn relief extr ..................................... 227
cvs hemorrhoidal ................................................... 227
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 729
CVS HIGH POTENCY IRON/VIT ......................... 227
cvs honey lemon drops........................................ 227
cvs hot steam .......................................................... 227
cvs hydrating skin treatm................................... 227
cvs hydrocortisone anti-i .................................... 227
cvs hydrocortisone maximu ............................... 227
cvs hydrogen peroxide ........................................ 227
cvs ibuprofen ........................................................... 227
cvs ibuprofen childrens ........................................ 227
cvs ibuprofen ib ...................................................... 227
cvs ibuprofen infants ............................................ 227
cvs ibuprofen junior stre ..................................... 227
cvs ibuprofen liquid fill ......................................... 227
cvs ibuprofen pm ................................................... 227
CVS IMMUNE SUPPORT VITAMI ....................... 227
cvs indoor/outdoor allerg ................................... 227
cvs infant decongestant d .................................. 227
cvs infants gas relief ............................................. 227
cvs infants pain relief ........................................... 228
cvs inner ear plus .................................................. 228
CVS INSECT REPELLENT ..................................... 693
cvs instant itch relief ............................................ 228
cvs instant medicated fir .................................... 228
cvs iron ...................................................................... 228
cvs isopropyl alcohol ............................................ 228
CVS ISOPROPYL ALCOHOL ................................. 228
CVS ISOPROPYL RUBBING ALC ........................ 228
cvs itch relief ........................................................... 228
cvs itch relief antifunga ....................................... 228
cvs itch relief extra str ......................................... 228
cvs itch relief maximum s .................................. 228
cvs jock itch ............................................................. 228
CVS KETONE CARE ................................................ 228
CVS LANCING DEVICE ......................................... 228
cvs lanolin ................................................................. 228
cvs lansoprazole ..................................................... 228
cvs laxative dietary supp .................................... 228
cvs laxative pills ....................................................... 88
cvs lice killing .......................................................... 228
cvs lice solution kit ................................................ 228
cvs lice treatment .................................................. 228
cvs loperamide hcl................................................. 228
cvs loperamide hydrochlor ................................. 228
cvs loratadine .......................................................... 229
cvs loratadine-d 24 hour ..................................... 229
cvs lubricant eye drops ....................................... 229
cvs lubricant eye drops l ..................................... 229
cvs lubricant eye drops p .................................... 229
cvs lubricant gel drops ......................................... 229
CVS LUBRICANT GEL DROPS ............................ 229
cvs lubricating eye drops .................................... 229
cvs lubricating jelly ............................................... 229
cvs lysine .................................................................. 229
cvs magnesium ....................................................... 229
cvs magnesium citrate ......................................... 229
cvs medicated heat patch ................................... 229
cvs medicated spot ............................................... 229
cvs medicated wipes ............................................. 229
cvs melatonin .......................................................... 229
cvs melatonin extra stren ................................... 229
cvs menopause support ...................................... 229
CVS MENOPAUSE SUPPORT ............................... 229
cvs mens daily gummies ..................................... 229
CVS MENS UNDERWEAR LARGE/ ..................... 229
CVS MENS UNDERWEAR SMALL/ ..................... 230
cvs menthol drops ................................................. 230
cvs miconazole 1 combinat ................................ 230
cvs miconazole 3 .................................................... 230
cvs miconazole 3 combinat ................................ 230
cvs miconazole 7 .................................................... 230
cvs migraine relief ................................................. 230
cvs milk of magnesia ............................................ 230
cvs mineral oil ......................................................... 230
cvs mineral oil enema .......................................... 230
cvs mini enema kids ............................................. 230
cvs moisturizing cream ........................................ 230
CVS MOISTURIZING CREAM .............................. 230
cvs moisturizing extra dr .................................... 230
cvs moisturizing lotion ......................................... 230
CVS MOLESKIN PLUS ........................................... 230
CVS MOOD SUPPORT PROBIOTI ...................... 230
cvs motion sickness .............................................. 230
cvs motion sickness ii .......................................... 230
cvs motion sickness relie .................................... 230
cvs mouthwash ....................................................... 230
cvs mucus d extended rele ................................ 230
cvs mucus extended releas ................................ 230
CVS MULTI-PURPOSE SOLUTIO ....................... 231
cvs multi-symptom cold ch ................................ 231
cvs multi-symptoms cold & ................................ 231
cvs multi-symptoms cold c ................................ 231
cvs muscle rub ........................................................ 231
cvs naproxen sodium ........................................... 231
cvs nasal allergy spray ........................................ 231
cvs nasal decongestant ....................................... 231
cvs nasal decongestant in .................................. 231
cvs nasal decongestant ma ................................ 231
cvs nasal decongestant pe ................................. 231
cvs nasal mist ......................................................... 231
CVS NASAL MIST ................................................... 231
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 730
cvs nasal spray ....................................................... 231
cvs nasal spray/no drip ....................................... 231
cvs natural daily fiber .......................................... 231
cvs natural fiber supplem ................................... 231
CVS NATURAL FIBER SUPPLEM ........................ 231
cvs natural fish oil ................................................. 231
cvs natural tears .................................................... 231
cvs nausea relief .................................................... 231
cvs niacin flush free .............................................. 231
cvs nicotine .............................................................. 231
cvs nicotine lozenge.............................................. 232
cvs nicotine polacrilex .......................................... 232
cvs nicotine polacrilex s ...................................... 232
cvs nicotine transdermal ..................................... 232
cvs nighttime cold/flu re ..................................... 232
cvs nighttime cough ............................................. 232
cvs nighttime multi-sympt ................................. 232
cvs nighttime sleep aid ........................................ 232
cvs nighttime sleep aid m .................................. 232
cvs nighttime tussin dm ...................................... 232
cvs non-aspirin ....................................................... 232
cvs non-aspirin childrens .................................... 232
cvs non-aspirin extra str ..................................... 232
cvs non-aspirin headache ................................... 232
cvs non-aspirin jr ................................................... 232
cvs non-aspirin pm................................................ 232
CVS NON-DRYING SINUS PE ............................. 232
cvs nose drops ........................................................ 232
cvs nts step 1 .......................................................... 232
CVS ODOR ABSORBING INSOLE ...................... 232
CVS OMEPRAZOLE ................................................. 232
cvs omeprazole magnesium .............................. 232
cvs omeprazole/sodium bic ............................... 232
cvs one daily essential ......................................... 233
CVS ONE DAILY MENS 50+ AD ........................ 233
cvs one daily womens form ............................... 233
cvs oral cleansing .................................................. 233
CVS OVERNIGHT PADS/WOMENS ................... 233
CVS OVERNIGHT UNDERWEAR/U .................... 233
cvs oyster shell calcium ...................................... 233
cvs pain & fever children .................................... 233
cvs pain & fever infants ....................................... 233
cvs pain relief 8 hour............................................ 233
cvs pain relief adult/rap ...................................... 233
cvs pain relief childrens ....................................... 233
cvs pain relief extra str ....................................... 233
cvs pain relief pm extra ...................................... 233
cvs pain relief regular s ....................................... 233
cvs pediatric electrolyte ...................................... 233
cvs permethrin ........................................................ 233
cvs peroxide sore mouth c ................................. 233
cvs personal lubricant & ...................................... 233
cvs petroleum jelly ................................................ 233
cvs pinworm treatment ....................................... 233
cvs plantar wart remover ................................... 233
cvs poly bacitracin ................................................. 233
cvs potassium gluconate ..................................... 234
cvs povidone-iodine .............................................. 234
CVS PREMIUM ADULT WASH CL ...................... 234
CVS PRENATAL ....................................................... 234
CVS PRENATAL GUMMY/DHA/FO ..................... 234
CVS PRENATAL MULTI+DHA ............................. 234
cvs probiotic ............................................................. 234
CVS PROBIOTIC ..................................................... 234
cvs probiotic acidophilus ..................................... 234
CVS PROBIOTIC MAXIMUM STR ....................... 234
CVS PROBIOTIC PEARLS EXTR ......................... 234
CVS PROCEDURAL MASK .................................... 234
cvs prostate health formu .................................. 234
CVS PROTECTIVE PADS MAXIM ....................... 234
CVS PROTECTIVE PADS ULTIM......................... 234
CVS PROTECTIVE PADS/LONG/........................ 234
CVS PROTECTIVE UNDERWEAR ....................... 234
CVS PSORIASIS MEDICATED S ........................ 234
cvs pure glycerin .................................................... 234
cvs purelax ............................................................... 234
cvs quick relief diaper r ....................................... 234
cvs ranitidine ........................................................... 234
cvs ready-to-use enema ..................................... 234
cvs ringworm ........................................................... 235
cvs rubbing alcohol ............................................... 235
cvs saline nasal spray .......................................... 235
cvs saline nose spray ........................................... 235
CVS SALINE WOUND WASH .............................. 235
cvs scar gel .............................................................. 235
cvs selenium ............................................................ 235
CVS SENIOR PROBIOTIC .................................... 235
cvs senna .................................................................. 235
cvs senna plus ........................................................ 235
cvs senna-extra ...................................................... 235
cvs severe cold/flu ................................................ 235
cvs severe congestion rel ................................... 235
cvs severe cough & cold n .................................. 235
cvs severe cough & conges ................................ 235
cvs severe sinus congesti ................................... 235
cvs sinus & allergy maxim .................................. 235
cvs sinus & cold-d .................................................. 235
cvs sinus congestion & pa .................................. 235
cvs sinus headache decong ............................... 235
cvs sinus headache pe ......................................... 235
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 731
cvs sinus pain & congesti ................................... 235
cvs sinus pe decongestant ................................. 235
cvs sinus pe pressure pai ................................... 236
cvs sinus relief daytime/ ..................................... 236
cvs sinus relief pressure...................................... 236
cvs sinus wash saline ref .................................... 236
cvs skin treatment................................................. 236
cvs skin treatment body l ................................... 236
cvs sleep aid ............................................................ 236
cvs sleep aid maximum str ................................ 236
cvs sleep aid nighttime ........................................ 236
cvs sleep aid nighttime/m .................................. 236
cvs sleep-aid nighttime ....................................... 236
cvs slow release iron ............................................ 236
cvs smooth antacid extra ................................... 236
cvs sodium chloride .............................................. 236
cvs soft chews calcium ........................................ 236
cvs soluble fiber therapy ..................................... 236
cvs sore throat maximum s ............................... 236
cvs sore throat spray ........................................... 236
cvs special care ...................................................... 236
cvs spectravite ........................................................ 236
CVS SPECTRAVITE ADULT 50+ ........................ 236
CVS SPECTRAVITE ADULT GUM ....................... 236
cvs spectravite advanced ................................... 236
cvs spectravite senior .......................................... 237
cvs spectravite ultra hea..................................... 237
CVS SPECTRAVITE ULTRA MEN ........................ 237
cvs spectravite ultra wom .................................. 237
CVS SPECTRAVITE ULTRA WOM ...................... 237
cvs stomach relief.................................................. 237
cvs stool softener .................................................. 237
cvs stool softener plus s ..................................... 237
cvs stress formula ................................................. 237
cvs stress formula/zinc ........................................ 237
CVS STRETCH FIT ADJUSTABL ......................... 237
cvs stuffy nose & cold ch .................................... 237
cvs super b complex/c ......................................... 237
CVS SUPER CRANBERRY URINA ....................... 237
CVS SUPREME BRIEFS MEDIUM ....................... 237
cvs tension headache ........................................... 237
CVS TENSION HEADACHE .................................. 237
cvs therapeutic ....................................................... 237
CVS THERAPEUTIC DANDRUFF ......................... 237
CVS THERAPEUTIC MAXIMUM S ...................... 237
cvs therapeutic menthol...................................... 237
cvs tioconazole 1 ................................................... 237
CVS TOTAL HOME INSECT REP ........................ 693
cvs triple antibiotic ................................................ 237
cvs triple antibiotic max ...................................... 238
cvs triple antibiotic/pai ........................................ 238
CVS TRIPLE MAGNESIUM COMP ...................... 238
cvs tussin adult chest co ..................................... 238
cvs tussin cf ............................................................. 238
cvs tussin cough ..................................................... 238
cvs tussin cough/cold cf ...................................... 238
cvs tussin dm .......................................................... 238
cvs tussin dm adult cough.................................. 238
CVS TUSSIN DM DAY/NIGHT P ......................... 238
cvs tussin dm maximum str .............................. 238
cvs tussin long-acting .......................................... 238
cvs tussin maximum streng ............................... 238
cvs ultra sleep ......................................................... 238
CVS UNDERGARMENT X-ABSORB ................... 238
CVS UNDERPADS 22 ............................................. 238
CVS UNDERPADS DAY & NIGHT ....................... 238
cvs urinary pain relief .......................................... 238
cvs vision formula .................................................. 238
cvs vitamin a ........................................................... 238
cvs vitamin a & d ................................................... 238
cvs vitamin a&d ointment ................................... 238
cvs vitamin b-1 ....................................................... 239
cvs vitamin b12 ...................................................... 238
cvs vitamin b-12 .................................................... 239
cvs vitamin b12 tr ................................................. 239
cvs vitamin b-12 tr ................................................ 239
cvs vitamin b-2 ....................................................... 239
cvs vitamin b-6 ....................................................... 239
cvs vitamin c............................................................ 239
cvs vitamin c/rose hips ........................................ 239
cvs vitamin d ........................................................... 239
cvs vitamin d 5000 high-p ................................. 239
cvs vitamin d childrens g .................................... 239
cvs vitamin d infants ............................................ 239
cvs vitamin d3 ......................................................... 239
cvs vitamin d3 drops/infa ................................... 239
cvs vitamin e ........................................................... 239
cvs vitamin e moisturizin .................................... 239
cvs wart remover ................................................... 239
cvs wart remover gel pen ................................... 239
cvs wart remover/maximum ............................. 239
CVS WHEY PROTEIN ............................................. 239
cvs witch hazel........................................................ 239
cvs womens active daily ..................................... 239
cvs womens daily gummies ............................... 239
CVS WOMENS PRENATAL+DHA ....................... 240
CVS WOMENS PROTECTIVE PAD ..................... 240
CVS WOMENS UNDERWEAR LARG .................. 240
CVS WOMENS UNDERWEAR SMAL .................. 240
CVS WOMENS UNDERWEAR X-LA ................... 240
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 732
CVS WOMENS UNDERWEAR X-SM .................. 240
cvs wound wash advanced ................................. 240
cvs yogurt + fiber gummie ................................ 240
CVS YOGURT+CALCIUM GUMMIE ................... 240
cvs zinc ...................................................................... 240
cvs zinc oxide .......................................................... 240
cyanocobalamin .............................................. 240, 669
CYANOCOBALAMIN ............................................... 240
cyclobenzaprine hcl ................................................. 68
cyclophosphamide ................................................... 33
cycloserine .................................................................. 27
cyclosporine ............................................................. 101
cyclosporine modified (for microemulsion) .. 101
cyproheptadine hcl ................................................ 678
CYSTADANE ............................................................... 77
CYSTAGON ................................................................. 77
CYSTARAN ................................................................ 675
CYSTINE .................................................................... 240
cytarabine ................................................................... 34
CYTO B2 .................................................................... 240
CYTO B7 .................................................................... 240
CYTOLLINE ............................................................... 241
CYTO-Q ...................................................................... 240
CYTO-Q MAX ............................................................ 241
CYTO-Q T/F .............................................................. 241
D
d 1000 ........................................................................ 241
d 1000 plus .............................................................. 241
D 1000 PLUS ALOE ................................................ 241
d 10000 ..................................................................... 242
d 2000 ........................................................................ 241
d 400 .......................................................................... 241
d 5000 ........................................................................ 241
d.o.s. .......................................................................... 242
d-1000 ....................................................................... 242
d-1000 extra strength ......................................... 242
d-2000 maximum strength ................................ 242
d2000 ultra strength ............................................ 241
D3 + K2 DOTS ........................................................ 241
d3 adult ..................................................................... 241
d3 adult gummy ..................................................... 241
D3 DOTS ................................................................... 241
d3 high potency ...................................................... 241
d3 kids ....................................................................... 241
d3 maximum strength ......................................... 241
d3 super strength .................................................. 241
d3 vitamin ................................................................ 241
D3/VITAMIN C/ZINC ............................................. 241
d3-1000 ..................................................................... 241
d-3-5 ........................................................................... 242
d3-50 .......................................................................... 241
d-400 .......................................................................... 242
d-5000 ....................................................................... 242
dacarbazine ................................................................ 33
DAFLONEX-XL ......................................................... 242
daily betic ................................................................. 242
daily cleaner ............................................................ 242
daily combo multi vitamin .................................. 242
DAILY CONDITIONING TREATM ....................... 242
daily face wash ....................................................... 242
DAILY HEART HEALTH SUPPOR ........................ 242
daily mens health formula .................................. 242
daily multi ................................................................. 242
daily multi 50+ ....................................................... 242
daily multiple vitamin ........................................... 242
DAILY MULTIPLE VITAMIN PL ............................ 243
daily multiple vitamin/ir ...................................... 243
daily multiple vitamins ......................................... 243
daily multiple vitamins w .................................... 243
daily multiple vitamins/i ...................................... 243
daily multiple vitamins/m ................................... 243
daily multivitamin .................................................. 243
DAILY PAK MAXIMUM MULTIVI ......................... 243
DAILY PROBIOTIC .................................................. 243
daily value multivitamin ...................................... 243
daily vitamin ............................................................ 243
daily vitamin formula+ir ..................................... 243
daily vitamin formula+iro ................................... 243
daily vitamin formula+min ................................. 243
daily vitamin plus ................................................... 243
daily vitamins .......................................................... 243
daily vite .................................................................... 243
daily vite multivitamin/i ...................................... 243
daily womens health formu ............................... 243
daily-vitamin ............................................................ 243
daily-vitamin maximum for................................ 243
daily-vitamin/iron .................................................. 243
daily-vite ................................................................... 243
daily-vite/iron/beta-caro ..................................... 244
DAKINS SOLUTION FULL STRE ........................ 244
DAKRINA ................................................................... 244
dalfampridine ............................................................ 68
DALIRESP .................................................................. 686
DALLERGY ................................................................. 244
danazol ........................................................................ 77
dandrex ..................................................................... 244
dandruff shampoo ................................................. 244
dantrolene sodium................................................... 69
dapsone ....................................................................... 21
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 733
DAPTACEL ................................................................. 102
daptomycin ................................................................ 21
DAPTOMYCIN ............................................................. 21
DARA .......................................................................... 244
DARA SHA ................................................................. 244
DAURISMO ................................................................. 35
day time cold/flu relief ......................................... 244
day time cough ....................................................... 244
day time multi-symptom co .............................. 244
DAY TIME MULTI-SYMPTOM CO ....................... 244
day time/nite time cold & ................................... 244
day time/nite time cold/f .................................... 244
DAYCLEAR ALLERGY RELIEF .............................. 244
dayhist allergy 12 hour r .................................... 244
dayquil severe + vapocool ................................. 245
daytime cold & cough chil .................................. 245
daytime cold & flu relief ...................................... 245
DAYTIME COLD MEDICINE ................................. 245
daytime cold/flu relief .......................................... 245
day-time cold/flu relief ........................................ 244
daytime cough ........................................................ 245
daytime multi symptom col ............................... 245
day-time multi-symptom co .............................. 244
daytime multi-symptom col ............................... 245
day-time pe .............................................................. 244
day-time pe cold/flu reli ...................................... 244
daytime pe multi-symptom ............................... 245
daytime severe cold & flu ................................... 245
daytime sinus .......................................................... 245
day-time sinus ........................................................ 244
daytime/nighttime ................................................. 245
daytime/nite time cold/fl .................................... 245
DDROPS ..................................................................... 245
DDROPS BOOSTER ................................................ 245
DEBROX ..................................................................... 245
decara ........................................................................ 245
DECARA ..................................................................... 245
de-chlor dm.............................................................. 245
DECON-A ................................................................... 245
DECONEX DMX ....................................................... 245
DECONEX IR ............................................................ 245
decongestant ........................................................... 245
decongestant 12hour maxim ............................ 246
decongestant 60 .................................................... 246
decongestant nose drops .................................... 246
decongestant plus ................................................. 246
decongestant vapor inhale ................................. 246
decongestant/antihistamin ................................ 246
decorel forte plus severe .................................... 246
DECUBAMINE .......................................................... 246
DECUBI-VITE ........................................................... 246
deep sea nasal spray ............................................ 246
DEKAS BARIATRIC ................................................ 246
DEKAS ESSENTIAL ................................................ 669
DEKAS PLUS ............................................................ 669
del-aqua .................................................................... 246
DELESTROGEN .......................................................... 78
DELSTRIGO ................................................................ 26
DELSYM ..................................................................... 246
delsym childrens night ti ..................................... 246
delsym cough + chest cong ............................... 246
delsym cough + cold dayti ................................. 246
delsym cough + cold night ................................. 246
DELSYM COUGH CHILDRENS ............................ 246
delsym cough relief plus ..................................... 246
delsym cough+soothing a c ............................... 246
delsym night time cough/c ................................ 246
delsym night time multi-s .................................. 246
delta d3 ..................................................................... 246
deltuss dmx ............................................................. 247
DELTUSS DP ............................................................ 247
DELZICOL ................................................................... 88
DEMSER ....................................................................... 50
DENOREX EXTRA STRENGTH ............................ 247
DENOREX EXTRA STRENGTH 2-....................... 247
DENOREX THERAPEUTIC 2-IN- ........................ 247
DENOVO .................................................................... 247
DENTIVA .................................................................... 247
DEPEN TITRATABS .................................................. 77
DEPEND ADJUSTABLE UNDERWE .................... 247
DEPEND BOOST INSERT ..................................... 247
DEPEND EASY FIT UNDERGARM ...................... 247
DEPEND FITTED BRIEFS MAXI.......................... 247
DEPEND GUARDS FOR MEN ............................... 247
DEPEND PANT EXTRA LARGE ............................ 247
DEPEND PANT LARGE ........................................... 247
DEPEND PANT SMALL/MEDIUM ........................ 247
DEPEND PROTECTION BRIEFS.......................... 247
DEPEND PROTECTIVE UNDERWE .................... 247
DEPEND REAL-FIT BRIEFS FO ........................... 247
DEPEND SHIELDS FOR MEN .............................. 247
DEPEND SILHOUETTE ACTIVE .......................... 247
DEPEND SILHOUETTE BRIEFS .......................... 247
DEPEND SILHOUETTE UNDERWE .................... 247
DEPEND UNDERGARMENT X-ABS .................... 247
DEPEND UNDERGARMENTS X-AB .................... 248
DEPEND UNDERWEAR FOR MEN ...................... 248
DEPEND UNDERWEAR FOR WOM .................... 248
DEPEND UNDERWEAR LARGE/EX .................... 248
DEPEND UNDERWEAR SMALL/ME ................... 248
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 734
DEPO-PROVERA INJ 400/ML ................................ 36
DEQUASINE ............................................................. 248
DERMABASE OIL IN WATER .............................. 248
dermacerin ............................................................... 248
DERMACLOUD ......................................................... 248
dermadaily non-greasy ........................................ 248
DERMADROX ............................................................ 248
dermafix .................................................................... 248
dermafungal............................................................. 248
DERMA-G MILD ....................................................... 248
DERMAGAUZE DRESSING .................................. 248
DERMA-GEL 4 .......................................................... 248
DERMAGRAN ............................................................ 248
DERMAGRAN BC ..................................................... 248
DERMAGRAN HYDROPHILIC WOU ................... 248
DERMAGRAN HYDROPHILIC-B .......................... 248
DERMAGRAN SKIN PROTECTANT .................... 248
DERMAGRAN WOUND CLEANSER .................... 248
DERMAIDE ALOE .................................................... 248
DERMAL THERAPY EXTRA STRE ....................... 249
DERMAL THERAPY FACE CARE .......................... 249
DERMAL THERAPY FOOT MASSA ..................... 249
DERMAL THERAPY HAND ELBO ........................ 249
DERMAL THERAPY HEEL CARE .......................... 249
DERMAL WOUND CLEANSER ............................. 249
DERMALUBE DAILY MOISTURIZ ....................... 249
dermamed ................................................................ 249
dermaphor ................................................................ 249
DERMAREST ............................................................. 249
dermarest eczema ................................................. 249
DERMAREST PSORIASIS ..................................... 249
DERMAREST PSORIASIS MEDIC ...................... 249
DERMAREST ROSACEA ........................................ 249
dermasarra anti-itch ............................................. 249
dermatological products, misc. ....................... 249
dermavantage ......................................................... 249
DERMAVITE .............................................................. 249
DERMAZINC CREAM .............................................. 249
dermazinc shampoo .............................................. 249
DERMAZINC SPRAY ............................................... 249
DERMEND MOISTURIZING BRUI ...................... 249
DESCOVY .................................................................... 26
desenex ..................................................................... 249
desenex jock itch spray p ................................... 250
desenex shake powder ........................................ 250
desenex spray liquid ............................................. 250
desgen dm ................................................................ 250
DESGEN DM ............................................................. 250
desgen pediatric ..................................................... 250
desipramine hcl ........................................................ 57
desitin ......................................................................... 250
DESITIN ..................................................................... 250
desitin rapid relief .................................................. 250
desmopressin acetate spray ................................ 82
desmopressin acetate spray refrigerated ....... 82
desmopressin acetate tabs .................................. 82
desmopressin inj 4mcg/ml ................................... 82
DESOXYN .................................................................. 250
despec ........................................................................ 250
despec dm ................................................................ 250
DESPEC DM .............................................................. 250
despec dm-g ............................................................ 250
despec eda ............................................................... 250
DESPEC-DM .............................................................. 250
despec-dm tabs ...................................................... 250
despec-tab ................................................................ 250
DESPEC-TAB ............................................................ 250
DESQUAM-X WASH ............................................... 250
desvenlafaxine succinate ...................................... 57
DEWEES CARMINATIVE WITHOU .................... 250
DEX4 ........................................................................... 250
dex4 fast acting glucose ..................................... 251
DEX4 FAST ACTING GLUCOSE .................. 250, 251
DEX4 GLUCOSE ...................................................... 251
DEX4 NATURALS .................................................... 251
DEX4 POUCH PACK ............................................... 251
DEX4 QUICK DISSOLVE GLUCO ....................... 251
dexamethasone ........................................................ 78
DEXAMETHASONE ................................................... 78
dexamethasone sodium phosphate .................. 78
dexamethasone sodium phosphate (ophth) 673
DEXATREX D NASAL ............................................. 251
DEXATRIM MAX ...................................................... 251
DEXATRIM MAX COMPLEX 7 .............................. 251
DEXATRIM MAX DAYTIME CONT ...................... 251
DEXATRIM NATURAL ............................................ 251
DEXATRIM NATURAL EXTRA EN ....................... 251
dexbrompheniramine & pseudoephedrine ... 251
DEXILANT ................................................................... 94
dexmethylphenidate hcl ........................................ 65
dexrazoxane .............................................................. 41
dextromethorphan hbr......................................... 251
dextromethorphan polistirex ............................. 682
dextromethorphan-guaifene .............................. 251
dextromethorphan-guaifenesin ................ 251, 682
dextrose (diabetic use) ........................................ 251
dextrose 10% flex contain ................................. 666
DEXTROSE 10%/NACL 0.2%............................. 666
dextrose 10%/nacl 0.45% ................................. 666
dextrose 2.5%/nacl 0.45% ................................ 665
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 735
dextrose 5% ............................................................ 665
DEXTROSE 5% /ELECTROLYTE......................... 666
dextrose 5%/nacl 0.2% ...................................... 666
dextrose 5%/nacl 0.225% ................................. 666
DEXTROSE 5%/NACL 0.3% ............................... 666
dextrose 5%/nacl 0.33% .................................... 666
dextrose 5%/nacl 0.45% .................................... 666
dextrose 5%/nacl 0.9% ...................................... 666
dextrose 5%/potassium chl ............................... 666
dextrose 50% .......................................................... 666
dextrose in lactated ringers ............................... 666
dextrose inj 70% ................................................... 666
DEXTROSTIX TES STRIPS .................................. 252
DEX-TUSS ................................................................. 251
DHEA .......................................................................... 252
DHS ............................................................................. 252
DHS COLOR SAFE SHAMPOO ............................ 252
DHS CONDITIONING RINSE .............................. 252
DHS SAL .................................................................... 252
DHS TAR .................................................................... 252
DHS TAR GEL .......................................................... 252
DHS ZINC ................................................................. 252
diab klenz ................................................................. 252
diabetes health formula ...................................... 252
DIABETES HEALTH PACK .................................... 252
DIABETES SUPPORT PACK ................................. 252
diabetic siltussin das-na ...................................... 682
diabetic siltussin-dm ..................................... 252, 682
diabetic siltussin-dm max ................................... 252
diabetic tussin ......................................................... 252
diabetic tussin allergy .......................................... 252
DIABETIC TUSSIN COLD & FL ........................... 252
DIABETIC TUSSIN COLD/FLU ............................ 252
DIABETIC TUSSIN COUGH DRO ....................... 252
diabetic tussin dm ................................................. 252
DIABETIC TUSSIN DM.......................................... 252
diabetic tussin ex ................................................... 253
DIABETIC TUSSIN EX ........................................... 253
diabetic tussin for child ....................................... 253
diabetic tussin maximum s ................................ 253
DIABETIC TUSSIN MAXIMUM S ........................ 253
diabetic tussin mucus rel .................................... 253
DIABETIC TUSSIN NIGHT TIM .......................... 253
diabetic tussin sore thro ..................................... 253
DIABETIDERM ......................................................... 253
DIABETIDERM CLEANSING ................................ 253
DIABETIDERM FOOT REJUVENA ....................... 253
DIABETIDERM HAND & BODY ........................... 253
DIABETIDERM MASSAGE STIMU...................... 253
diabeti-gest .............................................................. 252
DIABETISWEET ....................................................... 253
DIABETISWEET BROWN SUGAR ...................... 253
DIABETITRIM ........................................................... 253
dialyvite 800 ............................................................ 253
DIALYVITE 800 ....................................................... 253
DIALYVITE 800 PLUS D ....................................... 253
DIALYVITE 800/IRON ........................................... 253
dialyvite 800/ultra d ............................................. 253
DIALYVITE 800/ZINC ........................................... 253
DIALYVITE 800/ZINC 15 ..................................... 253
dialyvite vitamin d 5000 ..................................... 254
dialyvite vitamin d3 max .................................... 254
diamode ..................................................................... 254
diaper rash ............................................................... 254
diarrhea ..................................................................... 254
diarrhea relief .......................................................... 254
DIASCREEN 10 ........................................................ 254
DIASCREEN 1B ....................................................... 254
DIASCREEN 1G ....................................................... 254
DIASCREEN 1K ....................................................... 254
DIASCREEN 2GK .................................................... 254
DIASCREEN 2GP ..................................................... 254
DIASCREEN 3 .......................................................... 254
DIASCREEN 4NL ..................................................... 254
DIASCREEN 4OBL .................................................. 254
DIASCREEN 4PH ..................................................... 254
DIASCREEN 5 .......................................................... 254
DIASCREEN 6 .......................................................... 254
DIASCREEN 7 .......................................................... 254
DIASCREEN 8 .......................................................... 254
DIASCREEN 9 .......................................................... 254
DIASCREEN LIQUID URINE CO......................... 254
DIASTAT ACUDIAL................................................... 53
DIASTAT PEDIATRIC ............................................... 53
DIASTIX ..................................................................... 254
DIATHRIVE BLOOD GLUCOSE M ...................... 255
DIATHRIVE BLOOD GLUCOSE T ....................... 255
DIATRUE PLUS BLOOD GLUCOS ...................... 255
diazepam ..................................................................... 53
diazepam gel ............................................................. 53
diazepam inj .............................................................. 53
diazepam intensol .................................................... 53
diazepam oral soln 1 mg/ml ................................ 53
dibucaine (rectal) ................................................... 255
DICEL ......................................................................... 255
DICEL CD .................................................................. 255
DICEL DM .................................................................. 255
dickinsons witch hazel ......................................... 255
diclofenac potassium .............................................. 15
diclofenac sodium .................................................... 15
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 736
diclofenac sodium (ophth).................................. 673
diclofenac sodium (topical) 1% gel ................ 693
dicloxacillin sodium ................................................. 31
dicyclomine hcl cap 10mg .................................... 86
dicyclomine hcl soln 10mg/5ml .......................... 86
dicyclomine hcl tab 20mg ..................................... 86
didanosine .................................................................. 24
DIDGET ...................................................................... 255
dietary fiber laxative ............................................ 255
DIETERS DETOX ..................................................... 255
DIETERS SUPER TEA ............................................ 255
DIETEX FORTE ........................................................ 255
DIFFERIN .................................................................. 255
DIFF-STAT ................................................................ 255
DIFICID ....................................................................... 30
diflunisal ...................................................................... 15
DIGESTIVE ADVANTAGE ..................................... 255
DIGESTIVE ADVANTAGE LACTO ...................... 255
digestive health probioti ..................................... 255
digitek .......................................................................... 49
DIGNITY BRIEFMATES MENS A ........................ 255
DIGNITY BRIEFMATES SUPERG ....................... 255
DIGNITY BRIEFMATES ULTRA ........................... 255
DIGNITY DERMATEAM UNDERPA ..................... 255
DIGNITY DERMATEAM WIPES ........................... 255
DIGNITY DRY WIPES ............................................ 256
DIGNITY DUCHESS PANTY EXT ........................ 256
DIGNITY DUCHESS PANTY LAR ........................ 256
DIGNITY DUCHESS PANTY MED ....................... 256
DIGNITY DUCHESS PANTY SMA ....................... 256
DIGNITY DUCHESS WOMENS PA ..................... 256
DIGNITY EXTRA-DUTY DOUBLE ....................... 256
DIGNITY LITES LONG PADS .............................. 256
DIGNITY LITES STACKABLES ............................ 256
DIGNITY LITES THINSERTS ............................... 256
DIGNITY MENS BOXER SHORTS ...................... 256
DIGNITY MINI PADS ............................................. 256
DIGNITY NATURALS PADS ................................. 256
DIGNITY PANT REGULAR 20 .............................. 256
DIGNITY PANT REGULAR 24-2 ......................... 256
DIGNITY PANT REGULAR EXTR ........................ 256
DIGNITY PANT REGULAR LARG ........................ 256
DIGNITY PANT REGULAR MEDI ........................ 256
DIGNITY PANT REGULAR SMAL ........................ 256
DIGNITY PLUS ADULT DISPOS ......................... 256
DIGNITY PLUS BRIEFMATES E .......................... 256
DIGNITY PLUS BRIEFMATES S .......................... 256
DIGNITY PLUS DERMATEAM BR ....................... 256
DIGNITY PLUS OVERNIGHT FI .......................... 257
DIGNITY PLUS REGULAR W/DR ....................... 257
DIGNITY PLUS SHEET/LINEN ............................ 257
DIGNITY PLUS SUPER LINERS .......................... 257
DIGNITY PLUS W/DRI-GARD B ......................... 257
DIGNITY PLUS YOUTH DISPOS ........................ 257
DIGNITY PREVENT PLUS BOYS ......................... 257
DIGNITY PREVENT PLUS GIRL .......................... 257
DIGNITY PREVENT PLUS T-SH .......................... 257
DIGNITY PROTECTIVE UNDERW ...................... 257
DIGNITY REGULAR CLASSIC 2 ......................... 257
DIGNITY REGULAR CLASSIC E ......................... 257
DIGNITY REGULAR CLASSIC L ......................... 257
DIGNITY REGULAR CLASSIC M ........................ 257
DIGNITY REGULAR CLASSIC S ......................... 257
DIGNITY REGULAR-DUTY PADS ....................... 257
DIGNITY SHEET/LINEN PROTE ......................... 257
DIGNITY SPARTAN LINERS 7 ............................ 257
DIGNITY SUPER NATURALS ............................... 257
DIGNITY ULTRA ADULT DISPO ......................... 257
DIGNITY ULTRA WOMENS GUAR ..................... 257
DIGNITY WINGFOLD ............................................. 257
digox ............................................................................. 49
digoxin ......................................................................... 49
digoxin inj ................................................................... 49
digoxin sol 50mcg/ml ............................................. 49
dihydroergotamine mesylate inj 1 mg/ml ...... 66
dihydroergotamine mesylate nasal ................... 66
DILANTIN CAP 100MG ........................................... 53
DILANTIN CAP 30MG .............................................. 53
DILANTIN CHEW TAB 50MG ................................ 53
DILANTIN-125 SUSP............................................... 53
diltiazem cap 120mg cd ........................................ 48
diltiazem cap 180mg cd ........................................ 48
diltiazem cap 240mg cd ........................................ 48
diltiazem cap 360mg cd ........................................ 48
diltiazem cap er/12hr ............................................. 48
diltiazem hcl ............................................................... 48
diltiazem hcl cap sr 24hr....................................... 48
diltiazem hcl coated beads cap sr 24hr ........... 48
diltiazem hcl extended release beads cap sr 48
diltiazem inj ............................................................... 48
dilt-xr cap ................................................................... 48
dimaphen childrens ....................................... 257, 682
dimaphen dm cold & cough ....................... 258, 682
dimaphen dm cold/cough ch ............................. 258
dimenhydrinate ...................................................... 258
DIMETAPP COLD & ALLERGY ............................. 258
DIMETAPP DM COLD & COUGH ........................ 258
DIMETAPP LONG ACTING COUG ...................... 258
dimetapp multi-symptom co ............................. 258
DIMETAPP MULTI-SYMPTOM CO ...................... 258
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 737
dimetapp nd ............................................................. 258
dimetapp nighttime cold & ................................. 258
dino-life ..................................................................... 258
dino-life w extra c .................................................. 258
DINO-LIFE W/IRON & ZINC ............................... 258
diocto .......................................................................... 258
dioctyl ......................................................................... 258
dioctyl s.s. ................................................................ 258
diotame...................................................................... 258
diphen ........................................................................ 258
diphenhist ......................................................... 258, 678
diphenhydramine cough ...................................... 258
diphenhydramine hcl ............................ 258, 259, 678
diphenhydramine hcl (sleep) ............................. 259
diphenhydramine hcl (topical) .......................... 259
diphenhydramine hcl inj 50mg/ml .................. 678
diphenhydramine-acetaminophen (sleep) ... 259
diphenhydramine-zinc acetate ......................... 259
diphenoxylate w/ atropine ................................... 93
DIPHTHERIA/TETANUS TOXOID ...................... 102
DISNEY CALCIUM + VITAMIN ........................... 259
disney cars gummies ............................................ 259
disney princess gummies ................................... 259
disophrol ................................................................... 259
disopyramide phosphate ....................................... 44
DISPOSABLE BRIEF LARGE ................................ 259
DISPOSABLE BRIEF MEDIUM ............................ 259
DISPOSABLE BRIEF SMALL ................................ 259
DISPOSABLE BRIEF X-LARGE ........................... 259
DISPOSABLE LINERS/TAPE ST ......................... 259
DISPOSABLE MOUTHPIECE FUL ....................... 259
DISPOSABLE MOUTHPIECE LOW ..................... 259
DISPOSABLE MOUTHPIECE/LOW ..................... 259
DISPOSABLE MOUTHPIECE/UNI ...................... 259
DISPOSABLE PANTS ............................................. 259
DISPOSABLE PAPER MOUTHPIE ....................... 259
DISPOSABLE POLYMER PANTS/ ....................... 260
DISPOSABLE UNDERPADS SUPE ..................... 260
DISPOSABLE UNDERPADS/105G ..................... 260
DISPOSABLE UNDERPADS/17........................... 260
DISPOSABLE UNDERPADS/22G/ ...................... 260
DISPOSABLE UNDERPADS/31G/ ...................... 260
DISPOSABLE UNDERPADS/45G/ ...................... 260
DISPOSABLE UNDERPADS/60G/ ...................... 260
DISPOSABLE UNDERPADS/90G/ ...................... 260
DISPOSABLE UNDERPADS/EXTR ..................... 260
DISPOSABLE UNDERPADS/MEDI ..................... 260
DISPOSABLE UNDERPADS/SMAL ..................... 260
disulfiram .................................................................... 69
divalproex sodium ................................................... 53
DL-PA-500 ................................................................ 260
dm max maximum strength .............................. 260
DMAE .......................................................................... 260
dml .............................................................................. 260
DML FORTE ............................................................... 260
d-natural-5 ............................................................... 242
doans extra strength ............................................ 260
dobells solution ....................................................... 260
docetaxel ..................................................................... 34
DOCETAXEL ................................................................ 34
docqlace .............................................................. 89, 260
doc-q-lax ................................................................... 260
doctors choice blister ca...................................... 260
DOCTORS CHOICE BURNS/SCAL ..................... 260
doctors choice corn/callu .................................... 261
doctors choice multivitam .................................. 261
docu ...................................................................... 89, 261
docu soft ................................................................... 261
docuprene ................................................................. 261
docusate calcium ................................................... 261
docusate sodium .............................................. 89, 261
docusil .......................................................................... 89
DOCUSOL KIDS ...................................................... 261
DOCUSOL MINI ......................................................... 89
DOCUSOL PLUS MINI-ENEMA ........................... 261
docuzen ..................................................................... 261
dofetilide ..................................................................... 44
dofus ........................................................................... 261
dok......................................................................... 89, 261
dok plus ..................................................................... 261
DOLOGEN .................................................................. 261
DOLOGESIC ............................................................. 261
DOLOGESIC-DF ...................................................... 261
DOLOMITE ................................................................ 261
DOME-PASTE BANDAGE ...................................... 261
DOMETUSS-DA/CHILDREN ................................. 262
DOMETUSS-DMX .................................................... 262
DOMETUSS-NR ....................................................... 262
DONATUSSIN .......................................................... 262
donepezil hydrochloride ........................................ 56
dormin ........................................................................ 262
dorzolamide hcl ...................................................... 674
dorzolamide hcl-timolol maleate ...................... 674
DOSOQUIN ............................................................... 262
double antibiotic ..................................................... 262
double antibiotic + pain ...................................... 262
DOUBLE-TUSSIN DM ............................................ 262
DOVER ELASTIC FOAM STRAP .......................... 262
DOVER ELASTIC FOAM TAPE/ ........................... 262
DOVER TWO-SIDED ADHESIVE ........................ 262
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 738
doxazosin mesylate ................................................ 43
doxepin hcl ................................................................. 57
doxorubicin hcl.......................................................... 33
doxorubicin hcl liposomal ..................................... 33
doxy 100 ..................................................................... 32
doxycycline (monohydrate) ................................. 32
doxycycline hyclate ........................................... 32, 33
doxylamine succinate (sleep) ........................... 262
dr edwards olive laxative .................................... 262
dr gs clear nail ........................................................ 262
DR SCHOLLS CORN CUSHIONS/ ...................... 262
DR SCHOLLS CUSTOM FIT ORT........................ 262
DR SMITHS ADULT BARRIER S ........................ 262
DR SMITHS DIAPER .............................................. 262
DR SMITHS DIAPER RASH SPR ........................ 262
DR SMITHS RASH + SKIN .................................. 262
DRAMAMINE ............................................................. 262
dramamine less drowsy ...................................... 262
DRAWTEX ADVANCED WOUND CA ................. 263
driminate ..................................................................... 85
DRIPDROP ................................................................ 263
DRIPDROP HYDRATION POWDER .................... 263
DRIPDROP ORS ...................................................... 263
DRISDOL ................................................................... 263
DRI-SORB PLUS UNDERPAD .............................. 263
DRI-SORB UNDERPAD ......................................... 263
dristan cold .............................................................. 263
DRISTAN SPRAY ..................................................... 263
DRIXORAL ALLERGY SINUS ............................... 263
DRIXORAL CGH CAP 30MG ................................ 263
DRIXORAL COLD/ALLERGY ................................ 263
DRIXORAL COLD/FLU ........................................... 263
DRIXORAL COUGH & SORE THR ...................... 263
dronabinol ................................................................... 85
DROPLET LANCING DEVICE ............................... 263
DROXIA ........................................................................ 98
DROXY CREAM ........................................................ 263
DRUG MART ADJUSTABLE LANC ...................... 263
DRUG MART GLUCOSE......................................... 263
drx choice gas relief.............................................. 263
DRY COMFORT EXTRA BRIEF L ......................... 263
DRY COMFORT EXTRA BRIEF M ........................ 263
DRY COMFORT EXTRA BRIEF S ........................ 263
DRY COMFORT EXTRA BRIEF X ........................ 263
DRY COMFORT WASHCLOTHS .......................... 264
dry e-synthetic........................................................ 264
dry eye formula ...................................................... 264
DRY MOUTH SPRAY ............................................... 264
dry skin treatment ................................................ 264
dry skin treatment advanc ................................. 264
DRYMAX AF .............................................................. 264
dss ............................................................................... 264
dual action complete ............................................ 264
ducodyl ........................................................................ 89
DUDRESS ISLAND DRESSING 4....................... 264
DUDRESS ISLAND DRESSING 6....................... 264
DULCOLAX ................................................................ 264
dulcolax balance ..................................................... 264
DULCOLAX BOWEL PREP KIT ............................ 264
dulcolax milk of magnesia .................................. 264
dulcolax pink stool softe ..................................... 264
dulcolax stool softener ......................................... 264
duloxetine hcl ............................................................ 57
duo fusion ................................................................. 264
DUO-CARE TEST STRIPS .................................... 264
DUOFER ..................................................................... 264
duofilm ....................................................................... 264
DURAFLU ................................................................... 264
DURASORB UNDERPAD ....................................... 264
DURATION 12 HOUR ............................................ 265
DURATION SPRAY .................................................. 265
DURAVENT DM ........................................................ 265
DURAVENT PE ......................................................... 265
DUREZOL .................................................................. 673
dutasteride ................................................................. 95
dutasteride-tamsulosin hcl ................................... 95
D-VI-SOL ................................................................... 242
d-vita .......................................................................... 242
DWELLE ..................................................................... 265
D-XYLOSE ................................................................. 242
dye-free allergy relief c ....................................... 265
dyna-hex ................................................................... 265
DYNA-HEX................................................................. 265
dyna-hex 2 ............................................................... 265
dyna-hex 4 ............................................................... 265
DYNASTEP/MEN ...................................................... 265
DYNASTEP/WOMEN ............................................... 265
dyspel ......................................................................... 265
E
e and multi-day w/calcium ................................ 434
e 1000 ........................................................................ 265
e 400 blended ......................................................... 265
e.e.s 400 ..................................................................... 30
e1000 ......................................................................... 265
e-1000 ....................................................................... 266
e200 ............................................................................ 265
e-200 .......................................................................... 265
e400 ............................................................................ 265
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 739
e-400 .......................................................................... 265
e400 mixed .............................................................. 265
e-400/selenium ...................................................... 266
e-400-clear............................................................... 265
e-400-mixed ............................................................ 266
e600 ............................................................................ 265
EAGLE WATCH MOSQUITO ELIM ..................... 266
ear drops ................................................................... 266
ear drops earwax removal ................................. 266
ear dry ....................................................................... 266
ear health formula ................................................. 266
ear health plus ........................................................ 266
EAR WAX CLEANSING .......................................... 266
EAR WAX CLEANSING KIT .................................. 266
ear wax removal aid ............................................. 266
ear wax removal drops ........................................ 266
ear wax removal kit .............................................. 266
ear wax removal system ..................................... 266
EARLOOP MASK ...................................................... 267
EAR-LOOP MASK SMALL...................................... 266
earwax removal ...................................................... 267
earwax removal kit ............................................... 267
earwax treatment drops ..................................... 267
EASICLEANSE BATH ............................................. 267
EASY CHECK BLOOD GLUCOSE ........................ 267
EASY CHECK GLUCOSE TEST S ........................ 267
easy fiber .................................................................. 267
EASY MINI EJECT LANCING D ........................... 267
EASY MINI LANCING DEVICE ............................ 267
EASY PLUS BLOOD GLUCOSE M ....................... 267
EASY PLUS BLOOD GLUCOSE T........................ 267
EASY PLUS II BLOOD GLUCOS ......................... 267
EASY STEP BLOOD GLUCOSE M ....................... 267
EASY STEP TEST STRIPS .................................... 267
EASY TALK BLOOD GLUCOSE M ....................... 267
EASY TALK BLOOD GLUCOSE T ........................ 267
EASY TEST ................................................................ 267
EASY TEST STRIPS ACCU-CHE ......................... 267
EASY TEST TES ....................................................... 267
EASY TOUCH GLUCOSE MONITO ..................... 267
EASY TOUCH GLUCOSE TEST S ....................... 267
EASY TOUCH HEALTHPRO GLUC ...................... 267
EASY TOUCH LANCING DEVICE ....................... 268
EASY TRAK BLOOD GLUCOSE M ...................... 268
EASY TRAK BLOOD GLUCOSE T ....................... 268
easy-c ......................................................................... 268
easygel ....................................................................... 268
EASYGLUCO ............................................................. 268
EASYGLUCO PLUS .................................................. 268
EASYGLUCO PLUS BLOOD GLUC ...................... 268
easy-lax ..................................................................... 268
easy-lax plus ........................................................... 268
EASYMAX 15 TEST STRIPS................................. 268
EASYMAX L BLOOD GLUCOSE S....................... 268
EASYMAX N BLOOD GLUCOSE S ...................... 268
EASYMAX NG SELF-MONITORIN ...................... 268
EASYMAX TEST STRIPS ....................................... 268
EASYMAX V BLOOD GLUCOSE S ...................... 268
EASYMAX V2 SELF-MONITORIN ....................... 268
EASYPLUS BLOOD GLUCOSE TE ...................... 268
EASYPLUS R13N SELF-MONITO ....................... 268
EASYPLUS V SELF-MONITORIN ........................ 268
EASYPRO BLOOD GLUCOSE MON .................... 268
EASYPRO BLOOD GLUCOSE TES ...................... 268
EASYPRO PLUS ....................................................... 268
EBASE CONTROLLER KIT .................................... 269
ec-81 aspirin ............................................................ 269
ecee plus ................................................................... 269
eck hi-cal calcium .................................................. 269
ecolovit ...................................................................... 269
ECONOLINE PLUS UNDERPAD........................... 269
ecotrin ........................................................................ 269
ecotrin low strength .............................................. 269
ECOTRIN MAXIMUM STRENGTH ....................... 269
ECOTRIN REGULAR STRENGTH ........................ 269
ecpirin .......................................................................... 11
e-cream ..................................................................... 266
ed a-hist ............................................................ 269, 682
ED A-HIST ................................................................ 269
ed a-hist dm ............................................................ 269
ED A-HIST DM ......................................................... 269
ed a-hist pse ............................................................ 269
ED BRON GP ............................................................ 269
ED CHLORPED ......................................................... 269
ED CHLORPED D .................................................... 269
ed chlorped jr .......................................................... 269
ed-apap ..................................................................... 269
ed-chlortan ............................................................... 269
EDEX ........................................................................... 269
EDURANT .................................................................... 24
efavirenz ..................................................................... 24
effervescent antacid/pain ................................... 269
effervescent cold relief ........................................ 270
effervescent pain relief ........................................ 270
EFLOW SCF AEROSOL HEAD ............................. 270
ELASTO-GEL 12 ...................................................... 270
ELASTO-GEL 2 ........................................................ 270
ELASTO-GEL 3 ........................................................ 270
ELASTO-GEL 4 ........................................................ 270
ELASTO-GEL 5 ........................................................ 270
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 740
ELASTO-GEL 6 ........................................................ 270
ELASTO-GEL 8 ........................................................ 270
ELASTO-GEL CAST/SPLINT 12 .......................... 270
ELASTO-GEL CAST/SPLINT 4 ............................ 270
ELASTO-GEL CAST/SPLINT 6 ............................ 270
ELASTO-GEL CAST/SPLINT 8 ............................ 270
ELASTO-GEL FACE MASK .................................... 270
ELASTO-GEL PLUS 2 ............................................. 270
ELASTO-GEL PLUS 4 ............................................. 270
ELASTO-GEL PLUS 8 ............................................. 270
ELDERTONIC ............................................................ 669
ELEMENT AUTOCODE SYSTEM.......................... 270
ELEMENT COMPACT BLOOD GLU ..................... 270
ELEMENT COMPACT TEST STRI ........................ 270
ELEMENT COMPACT V BLOOD G ...................... 270
ELEMENT PLUS BLOOD GLUCOS ...................... 270
ELEMENT TEST STRIPS ........................................ 271
eletriptan hydrobromide ....................................... 67
ELIPHOS .................................................................... 271
ELIQUIS ....................................................................... 97
ELIQUIS STARTER PACK ....................................... 97
ELITE CA/MG ........................................................... 271
ELITE DC AUTO ADAPTER................................... 271
ELITE IRON .............................................................. 271
elite magnesium ..................................................... 271
ELITE ZINC ............................................................... 271
ELIXSURE COUGH ................................................. 271
ELIXSURE FEVER/PAIN ........................................ 271
ELLIS TONIC ............................................................ 271
ELON BARRIER PROTECTANT ............................ 271
ELON MATRIX 5000 .............................................. 271
ELON MATRIX 5000 COMPLETE ........................ 271
ELON MATRIX COMPLETE ................................... 271
ELON MATRIX PLUS .............................................. 271
elon nail conditioner ............................................. 271
ELON R3 .................................................................... 271
ELON SKIN REPAIR SYSTEM .............................. 271
elta .............................................................................. 271
ELTA ............................................................................ 271
ELTA CLEANSE ODOR ELIMINA ........................ 271
ELTA DERMAL WOUND CLEANSE ..................... 271
elta lite ....................................................................... 271
elta seal ..................................................................... 272
e-max-1000 ............................................................. 266
EMBRACE BLOOD GLUCOSE MON ................... 272
EMBRACE BLOOD GLUCOSE TES ..................... 272
EMBRACE EVO BLOOD GLUCOSE .................... 272
EMBRACE PRO BLOOD GLUCOSE .................... 272
EMBRACE TALK BLOOD GLUCOS ..................... 272
EMCYT .......................................................................... 33
emecheck .................................................................. 272
EMEND ......................................................................... 85
EMERGEN-C BLUE .................................................. 272
EMERGEN-C ELECTRO MIX ................................. 272
EMERGEN-C FIVE ................................................... 272
EMERGEN-C HEART HEALTH ............................. 272
EMERGEN-C IMMUNE ........................................... 272
EMERGEN-C IMMUNE PLUS ................................ 272
EMERGEN-C IMMUNE PLUS/VIT ....................... 272
EMERGEN-C IMMUNE+ WARMERS .................. 272
EMERGEN-C JOINT HEALTH ............................... 272
EMERGEN-C KIDZ .................................................. 272
EMERGEN-C MSM LITE ........................................ 272
EMERGEN-C PINK .................................................. 272
EMERGEN-C SUPER FRUIT ................................. 272
EMERGEN-C VITAMIN C ...................................... 272
EMERGEN-C VITAMIN C LITE ............................ 272
EMERGEN-C VITAMIN D & CAL ......................... 272
EMETROL ................................................................... 273
EMETROL SOL LEMONMIN .................................. 273
EMOLLIA-CREME .................................................... 273
EMOLLIA-LOTION ................................................... 273
emollient ................................................................... 273
EMSAM ......................................................................... 57
EMTRIVA ...................................................................... 24
EMVERM....................................................................... 21
enalapril maleate ..................................................... 42
enalapril maleate & hydrochlorothiazide ........ 42
END FATIGUE DAILY ENERGY ........................... 273
endacof-c .................................................................. 273
endacof-dm .............................................................. 682
ENDACON .................................................................. 273
ENDARI ........................................................................ 99
endocet 10-325mg .................................................. 17
endocet 2.5-325mg ................................................ 17
endocet 5-325mg .................................................... 17
endocet 7.5-325mg ................................................ 17
endur-acin ................................................................ 273
endur-amide ............................................................ 273
endur-b ...................................................................... 273
endur-c/rose hips .................................................. 273
ENDUR-VM ................................................................ 273
ENDUR-VM WITH IRON ....................................... 273
enema disposable .................................................. 273
enema ready-to-use ............................................. 273
ENEMEEZ MINI .......................................................... 89
ENEMEEZ PLUS ......................................................... 89
ENERGY BOOSTER ................................................. 273
ENFALYTE .................................................................. 273
ENFAMIL ENFALYTE............................................... 273
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 741
ENFAMIL EXPECTA................................................. 273
ENGERIX-B ............................................................... 102
enoxaparin sodium .................................................. 97
ENSTILAR .................................................................. 691
entacapone ................................................................. 59
entecavir ..................................................................... 28
ENTEX LQ .................................................................. 273
ENTEX PAC ............................................................... 273
ENTEX T ..................................................................... 273
ENTRE-B .................................................................... 274
ENTRE-COUGH ........................................................ 274
ENTRE-COUGH TANNATE .................................... 274
ENTRE-HIST PSE .................................................... 274
ENTRESTO .................................................................. 43
ENTRUST PLUS BLADDER CONT ...................... 274
ENTRUST PLUS BRIEFS ....................................... 274
ENTRUST PLUS BRIEFS LARGE ......................... 274
ENTRUST PLUS BRIEFS MEDIU ........................ 274
ENTRUST PLUS BRIEFS SMALL ......................... 274
ENTRUST PLUS DISPOSABLE P ........................ 274
ENTRUST PLUS DISPOSABLE U ........................ 274
ENTRUST PLUS FITTED BRIEF .......................... 274
ENTRUST PLUS PROTECTIVE U ........................ 274
ENTRUST PLUS SHIELD ....................................... 274
ENTRUST PLUS SHIELDS .................................... 274
ENTRUST PLUS UNDERGARMENT .................... 274
ENTRUST PLUS UNDERPAD ................................ 274
ENTRUST PLUS UNDERPADS EX ...................... 274
ENTSOL NASAL GEL .............................................. 274
ENUCLENE ................................................................ 274
enulose ........................................................................ 89
enviro-stress ............................................................ 274
e-oil ............................................................................. 266
e-ointment ................................................................ 266
EPCLUSA ..................................................................... 28
ephedrine sulfate ................................................... 274
EPHEDRINE SULFATE ........................................... 274
e-pherol ..................................................................... 266
ephrine nose drops ............................................... 275
EPIDIOLEX .................................................................. 53
EPILYT ........................................................................ 275
EPIMIDE..................................................................... 275
epinephrine (anaphylaxis) .................................. 686
epinephrine (base) ................................................ 275
epinephrine mist .................................................... 275
EPIPRAM AER 1% .................................................. 275
epirubicin hcl ............................................................. 33
epitol ............................................................................. 53
EPIVIR HBV ................................................................ 28
eplerenone.................................................................. 43
eprosartan mesylate ............................................... 44
epsom salt ................................................................ 275
EPSOM SALT ............................................................ 275
eq 1% hydrocortisone .......................................... 275
eq 8hr arthritis pain rel ....................................... 275
eq acetaminophen ................................................. 275
eq acetaminophen children ................................ 275
eq acetaminophen extra st ................................ 275
eq acetaminophen junior .................................... 275
eq acetaminophen pm ......................................... 275
eq acid reducer ....................................................... 275
eq acid reducer complete ................................... 275
eq acid reducer maximum s .............................. 275
eq adult aspirin low stre...................................... 275
eq allergy .................................................................. 275
eq allergy & congestion r .................................... 275
eq allergy & sinus headac ................................... 275
eq allergy childrens ............................................... 276
eq allergy relief ....................................................... 276
eq allergy relief childre ........................................ 276
eq allergy relief d 24 ho ...................................... 276
eq allergy relief multi-s ....................................... 276
eq allergy/sinus headache .................................. 276
EQ ALLERGY/SINUS HEADACHE ...................... 276
eq allergy-d .............................................................. 276
eq antacid ................................................................. 276
eq antacid & anti-gas max ................................. 276
eq antacid & pain relief ....................................... 276
eq antacid antigas multi- .................................... 276
eq antacid extra strength ................................... 276
eq antacid maximum streng .............................. 276
eq antacid ultra strength .................................... 276
eq antacid/anti-gas ............................................... 276
eq antibiotic + pain reli ....................................... 276
eq anti-diarrheal .................................................... 276
eq antifungal ............................................................ 276
eq antihistabs .......................................................... 276
eq anti-itch extra streng ..................................... 276
eq anti-itch maximum stre................................. 276
eq anti-nausea ........................................................ 276
eq arthricream rub ................................................ 277
eq arthritis pain ...................................................... 277
eq artificial tears .................................................... 277
eq aspirin .................................................................. 277
eq aspirin adult low dose .................................... 277
eq aspirin ec ............................................................ 277
eq aspirin low dose ............................................... 277
eq athletes foot ...................................................... 277
eq athletes foot powder s ................................... 277
eq baby chest rub .................................................. 277
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 742
eq bacitracin zinc ................................................... 277
EQ BLOOD GLUCOSE TEST STR ....................... 277
EQ BODY CURVE PADS REGULA ...................... 277
eq buffered aspirin ................................................ 277
eq calcium 500+d .................................................. 277
eq calcium 600+d .................................................. 277
eq calcium 600+d+minerals ............................. 277
eq calcium citrate+d............................................. 277
eq calcium citrate+d3 .......................................... 277
eq calcium citrate+d3/pet .................................. 277
eq childrens aspirin ............................................... 277
EQ CHILDRENS COLD .......................................... 277
eq childrens loratadine ........................................ 277
eq childrens pain relieve ..................................... 278
eq childrens plus multi-s ..................................... 278
eq chlortabs ............................................................. 278
eq cimetidine acid reduce ................................... 278
eq clearlax ................................................................ 278
eq cold & cough dm child ................................... 278
eq cold multi-symptom day ............................... 278
eq cold multi-symptom sev ............................... 278
eq cold plus .............................................................. 278
eq cold relief ............................................................ 278
EQ COLD RELIEF COMPLETE ............................. 278
eq cold/allergy childrens ..................................... 278
eq cold/cough dm .................................................. 278
eq cold/cough plus ................................................ 278
eq complete chewable mult ............................... 278
eq complete lice treatmen .................................. 278
eq complete multivitamin ................................... 278
EQ COMPLETE MULTIVITAMIN .......................... 278
eq cough childrens ................................................ 278
eq cough dm ............................................................ 278
eq cough drops sugar free ................................. 278
eq daily fiber ............................................................ 278
eq dayhist allergy .................................................. 278
eq daytime cold & flu mul .................................. 279
eq daytime cold & flu rel ..................................... 279
eq daytime cold/flu relie ..................................... 279
eq daytime sinus .................................................... 279
eq daytime/nighttime cold ................................. 279
eq daytime/nitetime cold .................................... 279
eq daytime/nitetime sinus.................................. 279
eq diaper rash ......................................................... 279
eq ear wax removal aid ....................................... 279
eq effervescent cold reli ...................................... 279
eq effervescent pain reli ..................................... 279
eq enema .................................................................. 279
EQ EVERYDAY LINERS/LONG ............................ 279
eq eye allergy relief .............................................. 279
eq eye drops ............................................................ 279
eq eye itch relief .................................................... 279
eq fiber laxative...................................................... 279
eq fiber powder ...................................................... 279
eq fiber supplement .............................................. 279
eq fiber therapy ...................................................... 279
eq first aid antiseptic ............................................ 279
eq flu & severe cold & co .................................... 279
eq flu relief ............................................................... 279
EQ FLU/SEVERE COLD/CONGES ...................... 280
eq gas relief ............................................................. 280
eq gas relief extra stren ...................................... 280
eq gentle laxative .................................................. 280
eq gentle lubricant ................................................ 280
eq headache relief ................................................. 280
eq heartburn relief ................................................ 280
eq hemorrhoidal ..................................................... 280
eq hemorrhoidal maximum s ............................ 280
eq hemorrhoidal pads .......................................... 280
eq hemorrhoidal supposito ................................. 280
eq hydrocortisone maximu ................................ 280
eq hydrocortisone plus ........................................ 280
eq hydrogen peroxide .......................................... 280
eq hydrogen peroxide clea ................................. 280
eq hygienic cleansing wip ................................... 280
eq ibuprofen ............................................................. 280
eq ibuprofen childrens ......................................... 280
eq ibuprofen cold childre .................................... 280
eq ibuprofen cold/sinus ....................................... 280
eq ibuprofen infants .............................................. 280
eq ibuprofen junior stren .................................... 280
eq ibuprofen pm ..................................................... 280
eq infants gas relief .............................................. 281
eq infants pain reliever ........................................ 281
eq itchy eye drops ................................................. 281
eq jock itch ............................................................... 281
eq lansoprazole....................................................... 281
eq laxative ................................................................ 281
eq laxative maximum stren ......................... 89, 281
eq lice killing maximum s ................................... 281
eq loperamide hcl .................................................. 281
eq loratadine............................................................ 281
eq lubricant eye drops hi .................................... 281
eq lubricant eye drops lo .................................... 281
eq lubricating & rewettin .................................... 281
eq lubricating eye drops ...................................... 281
eq magnesium citrate .......................................... 281
EQ MAXI LONG SUPER/FLEXI- .......................... 281
EQ MAXI OVERNIGHT EXTRA H ........................ 281
EQ MAXI OVERNIGHT/FLEXI-W ........................ 281
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 743
EQ MAXI REGULAR/FLEXI-WIN ........................ 281
EQ MAXI SUPER...................................................... 281
eq medicated body powder ................................ 281
eq medicated chest rub ....................................... 281
eq menstrual complete ........................................ 281
eq miconazole 1 ..................................................... 282
eq miconazole 3 combo pac .............................. 282
eq miconazole 7 ..................................................... 282
eq miconazole 7 day treat .................................. 282
eq migraine relief ................................................... 282
eq milk of magnesia ............................................. 282
eq mineral oil .......................................................... 282
eq motion sickness ................................................ 282
eq motion sickness relief .................................... 282
eq mucus er ............................................................. 282
eq mucus relief cold flu ....................................... 282
eq mucus relief dm ............................................... 282
eq mucus relief severe co................................... 282
EQ MULTI-PURPOSE SOLUTION ....................... 282
eq multi-symptom cold & f ................................ 282
eq multi-symptom cold chi ................................ 282
eq multi-symptom cold flu ................................. 282
eq multivitamin gummies c ............................... 282
EQ MULTIVITAMINS ADULT GU ........................ 282
eq multivitamins children ................................... 282
eq naproxen sodium ............................................. 282
eq nasal allergy spray .......................................... 282
eq nasal decongestant pe ................................... 282
eq nasal spray ......................................................... 283
eq nasal spray fast actin ..................................... 283
eq natural fiber laxative ...................................... 283
eq natural laxative ................................................ 283
eq natural vegetable laxa ................................... 283
eq nicotine ................................................................ 283
eq nicotine gum ...................................................... 283
eq nicotine gum refill ........................................... 283
eq nicotine gum starter ....................................... 283
eq nicotine lozenges ............................................. 283
eq nicotine polacrilex ........................................... 283
eq nicotine step 3 .................................................. 283
eq night time cold & coug .................................. 283
eq night time cough .............................................. 283
eq nighttime sleep aid ......................................... 283
eq nighttime sleep aid ma .................................. 283
eq nite time cold/flu rel ....................................... 283
eq nitetime cold & flu mu ................................... 283
eq non-drying sinus .............................................. 283
EQ OMEPRAZOLE ................................................... 283
eq omeprazole magnesium ................................ 283
EQ ONE DAILY MENS 50+ .................................. 283
EQ ONE DAILY MENS HEALTH .......................... 283
EQ ONE DAILY WOMENS 50+ ........................... 284
eq one daily womens healt ................................ 284
EQ ONE DAILY WOMENS HEALT ...................... 284
eq one daily womens pro-a ............................... 284
EQ OPTIONS LINERS LONG/VE ........................ 284
EQ OPTIONS LINERS REGULAR ........................ 284
EQ OPTIONS PADS LONG/MAXI ....................... 284
EQ OPTIONS PADS LONG/MODE ..................... 284
EQ OPTIONS PADS LONG/ULTI ........................ 284
EQ OPTIONS PADS REGULAR/M....................... 284
EQ OPTIONS ULTRA THINS PA ......................... 284
eq pain & fever childrens .................................... 284
eq pain & fever infants ........................................ 284
eq pain relief adult/rapi ....................................... 284
eq pain reliever ....................................................... 284
eq pain reliever extra st ...................................... 284
eq pain reliever junior .......................................... 284
EQ PANTILINERS/LONG ...................................... 284
EQ PANTILINERS/REGULAR ............................... 284
EQ PANTILINERS/REGULAR/ME ....................... 284
EQ PERSONAL CLEANSING CLO ....................... 284
eq personal lubricant jel...................................... 284
eq petroleum jelly.................................................. 284
eq pink-bismuth ..................................................... 285
eq povidone-iodine ................................................ 285
eq probiotic digestive sy ..................................... 285
EQ PROBIOTIC DIGESTIVE SY .......................... 285
eq ranitidine ............................................................. 285
eq restore plus lubricant ..................................... 285
eq restore pm .......................................................... 285
eq restore tears ...................................................... 285
eq revive plus .......................................................... 285
eq revive plus lubricant ....................................... 285
eq saline nasal spray ............................................ 285
EQ SALINE SOLUTION/SENSIT......................... 285
eq senna-s ................................................................ 285
eq severe allergy & sinus .................................... 285
eq sinus congestion & pai ................................... 285
eq sinus maximum strength .............................. 285
EQ SINUS RELIEF MAXIMUM S ......................... 285
eq sleep aid .............................................................. 285
eq sleep-aid nighttime ......................................... 285
eq slow-release iron ............................................. 285
eq sore throat spray ............................................. 285
eq stay awake ......................................................... 285
eq stomach relief ................................................... 285
eq stomach relief maximum .............................. 286
eq stool softener .................................................... 286
eq stool softener/stimula .................................... 286
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 744
eq suphedrine ......................................................... 286
eq suphedrine pe ................................................... 286
eq suphedrine pe sinus & ................................... 286
EQ THERAPEUTIC DRY SKIN ............................. 286
EQ THERAPEUTIC MOISTURIZI ........................ 286
EQ THIN LINER/REGULAR .................................. 286
eq tioconazole 1 ..................................................... 286
eq tolnaftate ............................................................ 286
EQ TRIACTING COLD/ALLERGY ........................ 286
eq triacting cold/cough ........................................ 286
eq triacting night time ......................................... 286
eq triple antibiotic.................................................. 286
eq tussin .................................................................... 286
eq tussin cf cough & cold .................................... 286
eq tussin cf multi-sympto ................................... 286
eq tussin dm cough/chest .................................. 286
eq tussin dm max cough an .............................. 286
EQ ULTRA THIN OVERNIGHT/ ........................... 286
EQ ULTRA THIN REGULAR/FLE ......................... 286
EQ ULTRA THIN SUPER LONG/ ......................... 286
eq urinary pain relief ............................................ 287
eq vaporizing rub ................................................... 287
eq vegetable laxative ........................................... 287
eq vision formula 50+ ......................................... 287
eq vitamins a & d ................................................... 287
eq wart remover .................................................... 287
eq womans laxative .............................................. 287
eq womens laxative .............................................. 287
eql 12 hour cold ..................................................... 287
eql 12 hour decongestant ................................... 287
EQL 2 IN 1 PROBIOTIC ........................................ 287
EQL 4X PROBIOTIC ............................................... 287
eql absolute moisture dry ................................... 287
eql acetaminophen ................................................ 287
eql acetaminophen 8 hour ................................. 287
eql acetaminophen childre ................................. 287
eql acetaminophen extra s ................................. 287
eql acetaminophen infants ................................. 287
eql acetaminophen rapid t ................................. 287
eql acid reducer ...................................................... 287
eql acid reducer maximum ................................ 287
EQL ACIDOPHILUS EXTRA STR ........................ 287
eql acne scrub pink grape .................................. 287
eql adult aspirin low str ....................................... 288
eql advanced healing oint................................... 288
eql advanced recovery ski .................................. 288
EQL ADVANCED RECOVERY SKI ...................... 288
eql advanced skin therapy ................................. 288
eql air protector ...................................................... 288
eql all day allergy .................................................. 288
eql all day allergy child ........................................ 288
eql all day allergy-d .............................................. 288
eql all day pain relief ............................................ 288
eql all day relief ...................................................... 288
eql aller-ease ........................................................... 288
eql allergy ................................................................. 288
eql allergy childrens .............................................. 288
eql allergy relief ...................................................... 288
eql allergy relief childr ......................................... 288
eql allergy/congestion re .................................... 288
eql allergy/sinus headach ................................... 288
eql aloe after sun ................................................... 288
eql antacid ................................................................ 288
eql antacid advanced maxi ................................ 288
eql antacid extra strengt..................................... 288
eql antacid maximum stren ............................... 288
eql antacid ultra strengt ...................................... 289
eql antacid/anti-gas .............................................. 289
eql antacid/pain relief .......................................... 289
eql antibiotic + pain rel ....................................... 289
eql anticavity fluoride r........................................ 289
eql anti-diarrheal ................................................... 289
eql antifungal .......................................................... 289
eql anti-itch extra stren ...................................... 289
eql anti-itch intensive h ....................................... 289
eql anti-itch maximum str .................................. 289
eql anti-nausea ....................................................... 289
eql antiseptic mouthrinse ................................... 289
eql apricot scrub..................................................... 289
eql arthritis pain relief ......................................... 289
eql aspirin ................................................................. 289
eql aspirin ec ........................................................... 289
eql aspirin low dose .............................................. 289
eql athletes foot ..................................................... 289
eql athletes foot spray ......................................... 289
eql b complex .......................................................... 289
eql b complex 100 ................................................. 289
eql b complex 50 ................................................... 289
eql b-100 complex tr ............................................ 290
eql b-12 ..................................................................... 290
eql b-6 ........................................................................ 289
eql baby basics diaper ra .................................... 290
eql bacitracin zinc .................................................. 290
EQL BELTED UNDERGARMENTS/ ..................... 290
EQL BELTLESS UNDERGARMENT ..................... 290
eql beta carotene ................................................... 290
eql biotin ................................................................... 290
EQL BLADDER CONTROL PADS/ ....................... 290
EQL BODY WASH/SENSITIVE S ........................ 290
EQL BODY WASH/SHEA BUTTER...................... 290
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 745
eql buffered aspirin ............................................... 290
eql calamine medicated ....................................... 290
eql calcium ............................................................... 290
eql calcium 600mg/vitamin ............................... 290
eql calcium citrate w/vit ...................................... 290
eql calcium citrate/ vita ....................................... 290
eql calcium gummies ............................................ 290
eql calcium soft chews ......................................... 290
eql calcium/magnesium/zin ............................... 290
eql calcium/vitamin d ........................................... 290
EQL CALCIUM/VITAMIN D .................................. 290
eql calcium/vitamin d/min ................................. 290
eql callus remover pads/e .................................. 291
eql carbonyl iron .................................................... 291
eql castor oil ............................................................ 291
eql century ............................................................... 291
eql century mature................................................ 291
EQL CENTURY MATURE ADULTS ...................... 291
eql century mature men 50 ............................... 291
eql century mature women ................................ 291
EQL CENTURY MENS ............................................. 291
EQL CENTURY WOMENS ...................................... 291
eql childrens allergy .............................................. 291
eql childrens aspirin .............................................. 291
eql childrens c ......................................................... 291
EQL CHILDRENS CALCIUM GUM ...................... 291
eql childrens ibuprofen ........................................ 291
eql childrens immunity c ..................................... 291
eql childrens loratadine ....................................... 291
eql childrens multivitami ..................................... 291
EQL CHILDRENS MULTIVITAMI ........................ 291
eql childrens pain relief ....................................... 291
eql childrens plus cold m .................................... 291
eql childrens vitamin d g..................................... 291
eql chromium picolinate p .................................. 291
eql cleaning & disinfecti ...................................... 292
EQL CLEAR HAND SOAP REFIL ......................... 292
eql clearlax ............................................................... 292
eql cold & allergy ................................................... 292
eql cold & allergy pe ............................................. 292
eql cold & cough children ................................... 292
eql cold head congestion .................................... 292
eql cold multi-symptom da ................................ 292
eql cold multi-symptom se ................................. 292
eql cold/allergy children ...................................... 292
eql congestion relief ............................................. 292
eql cool heat extra stren ..................................... 292
eql coq10 .................................................................. 292
eql coq10 maximum strengt ............................. 292
eql cough & cold pe multi ................................... 292
eql cough & cold relief h ..................................... 292
eql cough dm ........................................................... 292
eql cough drops ...................................................... 292
EQL DAILY PROBIOTIC ........................................ 292
eql dayhist allergy ................................................. 292
eql daytime & nighttime c .................................. 292
eql daytime cold & flu re ..................................... 292
eql daytime cold/flu reli ...................................... 292
eql daytime multi-symptom .............................. 293
eql daytime severe cold & .................................. 293
eql digestive probiotic .......................................... 293
EQL DRY MOUTH ORAL RINSE .......................... 293
eql dual action complete ..................................... 293
eql ear drops ........................................................... 293
eql effervescent cold rel ...................................... 293
eql effervescent plus col ..................................... 293
EQL EPSOM SALT ................................................... 293
eql ester-c ................................................................ 293
eql eye drops ........................................................... 293
eql eye drops ac ..................................................... 293
eql fiber laxative .................................................... 293
eql fiber supplement ............................................. 293
eql fiber therapy ..................................................... 293
eql first aid antibiotic ............................................ 293
eql fish oil ................................................................. 293
EQL FITTED BRIEFS/EXTRA L ........................... 293
eql flu & severe cold & c ..................................... 293
eql flu & severe cold mul .................................... 293
eql flu/severe cold/conge ................................... 293
eql fluticasone propionat..................................... 293
eql folic acid ............................................................. 293
eql gas gone extra streng................................... 294
eql gas prevention ................................................. 294
eql gas relief ............................................................ 294
eql gas relief extra stre ....................................... 294
eql gas relief ultra stre ........................................ 294
eql gentle laxative ................................................. 294
eql gentle skin cleanser ....................................... 294
eql glucosamine chondroit ................................. 294
eql gummies childrens ......................................... 294
eql gummy adult .................................................... 294
eql headache formula ........................................... 294
eql headache pm .................................................... 294
eql headache relief extra .................................... 294
eql heartburn prevention .................................... 294
eql heartburn prevention/ .................................. 294
eql heartburn relief ............................................... 294
eql heartburn relief maxi .................................... 294
eql hemorrhoidal .................................................... 294
eql hemorrhoidal cooling .................................... 294
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 746
eql hemorrhoidal maximum............................... 294
eql high power body wash ................................. 294
eql hydrating beauty ............................................ 294
eql hydrogen peroxide ......................................... 294
eql ibuprofen ........................................................... 295
eql ibuprofen cold & sinu .................................... 295
eql ibuprofen cold childr ...................................... 295
eql ibuprofen cold/sinus ...................................... 295
eql ibuprofen infants............................................. 295
eql ibuprofen junior stre ..................................... 295
eql ibuprofen pm .................................................... 295
EQL INFANTS DECONGESTANT/ ...................... 295
eql infants gas relief ............................................. 295
EQL INVIGORATING MAKEUP R ....................... 295
eql iron supplement thera .................................. 295
eql isopropyl alcohol ............................................. 295
eql isopropyl rubbing alc ..................................... 295
eql jock itch.............................................................. 295
eql laxative ............................................................... 295
eql laxative eql laxative ...................................... 295
eql laxative maximum stre .......................... 89, 295
eql lice killing maximum ..................................... 295
eql lice solution kit ................................................ 295
eql lice treatment .................................................. 295
eql lice treatment maximu ................................. 295
EQL LINERS LONG LENGTH/VE ........................ 295
EQL LIQUID HAND SOAP .................................... 296
EQL LIQUID HAND SOAP REFI .......................... 296
eql l-lysine ................................................................ 295
eql loperamide hcl ................................................. 296
eql lubricating jelly ................................................ 296
eql magnesium ....................................................... 296
eql magnesium citrate ......................................... 296
EQL MAKEUP REMOVER TOWELE ..................... 296
EQL MAXI FLEXI-WINGS ULTR ......................... 296
EQL MAXI FLEXI-WINGS/LONG ........................ 296
EQL MAXI FLEXI-WINGS/OVER ........................ 296
EQL MAXI/FLEXI-WINGS/LONG ....................... 296
EQL MAXI/MODERATE .......................................... 296
EQL MAXI/REGULAR ............................................. 296
eql medicated chest rub ...................................... 296
eql medicated dandruff ....................................... 296
eql medicated wipes ............................................. 296
eql melatonin/vitamin b-6 .................................. 296
eql menstrual relief maxi .................................... 296
eql miconazole 1 .................................................... 296
eql miconazole 3 .................................................... 296
eql miconazole 7 .................................................... 296
eql migraine formula ............................................ 296
eql milk of magnesia ............................................ 296
EQL MOISTURIZING CREAM .............................. 297
eql motion sickness relie ..................................... 297
eql mouthwash/gargle ......................................... 297
eql mucus relief children ..................................... 297
eql mucus relief maximum ................................. 297
eql mucus-dm ......................................................... 297
eql mucus-dm maximum stre ........................... 297
eql mucus-er 12 hour ........................................... 297
eql mucus-er maximum stre ............................. 297
EQL MULTI-PURPOSE DISINFE ......................... 297
eql multi-purpose solutio .................................... 297
EQL MULTI-PURPOSE SOLUTIO ........................ 297
eql multi-symptom daytime .............................. 297
eql multi-symptom nightti .................................. 297
eql muscle rub pain relie .................................... 297
eql naproxen sodium ............................................ 297
eql nasal decongestant ........................................ 297
eql nasal decongestant ma ................................ 297
eql nasal decongestant pe .................................. 297
eql nasal four ........................................................... 297
eql nasal spray 12 hour ....................................... 297
eql nasal spray 12 hour/n .................................. 297
eql nasal spray fast acti ...................................... 297
eql nasal spray no drip ........................................ 298
eql nasal spray no drip 1 .................................... 298
eql natural fiber ...................................................... 298
EQL NATURAL FIBER ............................................ 298
eql natural zinc ....................................................... 298
eql niacin ................................................................... 298
eql niacin flush free ............................................... 298
eql nicotine ............................................................... 298
eql nicotine polacrilex .......................................... 298
eql nicotine polacrilex r ....................................... 298
eql nicotine polacrilex s ....................................... 298
eql night time cough ............................................. 298
eql nighttime cold & flu ....................................... 298
eql nighttime cold multi- ..................................... 298
eql nighttime cold/flu re ...................................... 298
eql nighttime cough relie .................................... 298
eql nighttime severe cold ................................... 298
eql nighttime sleep aid ........................................ 298
eql non-drying sinus ............................................. 298
eql omega 3 fish oil ............................................... 298
eql omega-3 fish oil .............................................. 298
EQL OMEPRAZOLE ................................................. 298
EQL ONE DAILY ADULT GUMMI ........................ 298
eql one daily energy ............................................. 299
eql one daily essential ......................................... 299
EQL ONE DAILY MENS ......................................... 299
eql one daily mens 50+ ad ................................ 299
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 747
eql one daily mens health .................................. 299
eql one daily womens .......................................... 299
eql one daily womens 50+ ................................. 299
EQL OVERNIGHT PROTECTIVE ......................... 299
eql oyster shell calcium/ ..................................... 299
EQL PADS BLADDER PROTECTI ........................ 299
eql pain & fever children ..................................... 299
eql pain & fever infants ....................................... 299
eql pain relief .......................................................... 299
eql pain relief allergy m ...................................... 299
eql pain relief chest con ...................................... 299
eql pain relief extra str ........................................ 299
eql pain relief plus cold........................................ 299
eql pain relief pm ................................................... 299
eql pain relief pm extra ....................................... 299
eql pain relief/cold ................................................. 299
eql pain relief/sinus .............................................. 299
EQL PANTILINERS LONG ..................................... 299
eql pediatric electrolyte ....................................... 299
EQL PERSONAL CONFIDENCE B ....................... 300
EQL PERSONAL CONFIDENCE E ....................... 300
EQL PERSONAL CONFIDENCE F ....................... 300
EQL PERSONAL CONFIDENCE G....................... 300
EQL PERSONAL CONFIDENCE P ....................... 300
EQL PERSONAL CONFIDENCE U ....................... 300
EQL PRENATAL FORMULA ................................... 300
eql pressure & pain pe pl .................................... 300
eql probiotic acidophilus...................................... 300
EQL PROBIOTIC COLON SUPPO ....................... 300
EQL PURSEREADY UNDERWEAR ...................... 300
eql ready-to-use enema ...................................... 300
eql redness relief ................................................... 300
eql saline nasal spray ........................................... 300
eql scalp relief maximum .................................... 300
eql scar gel ............................................................... 300
eql senna laxative.................................................. 300
eql senna-s ............................................................... 300
eql severe allergy pain r ..................................... 300
eql severe cold ........................................................ 300
eql severe cold pe multi- .................................... 300
eql severe cold/flu ................................................. 300
eql sinus & allergy pe ........................................... 300
eql sinus congestion & pa ................................... 301
eql sinus headache maximu .............................. 301
eql sinus headache pe max ............................... 301
eql sinus nasal spray ............................................ 301
eql sinus relief 12 hour ........................................ 301
EQL SKIN ASTRINGENT ....................................... 301
eql sleep aid ............................................................. 301
eql sleep aid maximum str ................................. 301
eql sleep aid nighttime ........................................ 301
EQL SLIP-ON UNDERGARMENTS ..................... 301
eql slow release iron ............................................. 301
eql sore throat ........................................................ 301
eql sore throat & cough l .................................... 301
eql sore throat spray ............................................ 301
eql sour gummies children ................................. 301
eql stay awake ........................................................ 301
eql stay awake maximum st .............................. 301
eql stomach relief .................................................. 301
eql stomach relief maximu ................................. 301
eql stool softener ................................................... 301
eql stool softener/stimul ..................................... 301
eql stress b-complex/vita ................................... 301
eql super b complex/vitam ................................ 301
EQL SUPER ENERGY BOOSTER ......................... 302
EQL SUPER MAXI ................................................... 302
EQL SUPER PLUS PROTECTIVE ......................... 302
eql therapeutic ........................................................ 302
EQL THIN LINERS REGULAR .............................. 302
eql tioconazole-1 .................................................... 302
eql triacting cold/allerg ........................................ 302
eql triacting cold/cough ....................................... 302
eql triacting cold/night ......................................... 302
EQL TRUE2GO BLOOD GLUCOSE ..................... 302
EQL TRUETEST BLOOD GLUCOS ...................... 302
EQL TRUETRACK TEST ......................................... 302
eql tussin cf cough/cold/ ..................................... 302
eql tussin chest congesti ..................................... 302
eql tussin cough & chest ..................................... 302
eql tussin cough & cold c .................................... 302
eql tussin cough long-act.................................... 302
eql tussin cough/chest co ................................... 302
eql tussin cough/cold max ................................. 302
eql tussin dm cough/chest ................................. 302
eql tussin mucus+chest co ................................ 302
eql tussin ped cough/cold ................................... 302
EQL ULTRA MOISTURIZING DA ........................ 302
EQL ULTRA THIN PADS/LIGHT.......................... 303
EQL ULTRA THIN/FLEXI-WING ......................... 303
EQL UNDERWEAR FOR MEN/LAR ..................... 303
EQL UNDERWEAR FOR MEN/SMA .................... 303
EQL UNDERWEAR FOR WOMEN/ ...................... 303
EQL UNDERWEAR FOR WOMEN/X ................... 303
eql vapor inhaler nasal d .................................... 303
eql vision formula .................................................. 303
eql vitamin b-12 ..................................................... 303
eql vitamin b-12 tr ................................................ 303
eql vitamin c ............................................................ 303
EQL VITAMIN C DROPS ....................................... 303
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 748
eql vitamin c gummies ........................................ 303
eql vitamin c/rose hips ........................................ 303
eql vitamin d3 ......................................................... 303
eql vitamin d-3 ....................................................... 303
eql vitamin d3 gummies ..................................... 303
EQL VITAMIN D-3 HIGH POTE .......................... 303
eql vitamin e ............................................................ 303
eql vitamin e ultra stren...................................... 303
eql witch hazel ........................................................ 303
eql womans laxative ............................................. 303
eql zinc ....................................................................... 303
eql zinc cold relief .................................................. 304
EQUALACTIN ............................................................ 304
equalizer gas relief ................................................ 304
EQUALYTE ................................................................. 304
EQUALYTE SOL RTH .............................................. 304
ergocalciferol ................................................... 304, 669
ergotamine w/ caffeine .......................................... 67
ERIVEDGE ................................................................... 35
ERLEADA ..................................................................... 36
e-r-o ear drops ....................................................... 266
e-r-o ear wax removal sys ................................. 266
ertapenem sodium .................................................. 21
ery pad 2% .............................................................. 688
ery-tab ......................................................................... 30
ERYTHROCIN LACTOBIONATE ............................ 31
erythrocin stearate .................................................. 31
erythromycin (acne aid)...................................... 688
erythromycin (ophth) ........................................... 672
erythromycin base................................................... 31
erythromycin cap 250mg ec ................................ 31
erythromycin ethylsuccinate ............................... 31
ESBRIET .................................................................... 686
escitalopram oxalate .............................................. 57
ESOCOR P ................................................................. 304
esomeprazole magnesium ............................ 94, 304
esomeprazole sodium inj ...................................... 94
essentia ..................................................................... 304
ESSENTIAL AMINO ACID MIX ........................... 304
essential balance ................................................... 304
essential magnesium ............................................ 304
essential one daily multi ..................................... 304
ester-c ........................................................................ 304
ESTER-C .................................................................... 304
ester-c/bioflavonoids ............................................ 304
ester-e ....................................................................... 304
estradiol....................................................................... 78
estradiol vaginal cream ......................................... 78
estradiol vaginal tab ............................................... 78
estradiol valerate ..................................................... 78
ESTROFACTORS ..................................................... 304
eszopiclone ................................................................. 66
ethambutol hcl .......................................................... 27
ethosuximide ............................................................. 53
etodolac ....................................................................... 15
etodolac er.................................................................. 15
etoposide..................................................................... 41
EUCALYPTUS OIL ................................................... 304
EUCERIN .................................................................... 304
EUCERIN ADVANCED CLEANSIN ...................... 304
EUCERIN BABY ........................................................ 305
EUCERIN CALMING DAILY MOI ........................ 305
EUCERIN DAILY PROTECTION/ ......................... 305
eucerin eczema relief ........................................... 305
EUCERIN INTENSIVE REPAIR ............................ 305
EUCERIN ORIGINAL HEALING........................... 305
EUCERIN PLUS ........................................................ 305
EUCERIN PLUS INTENSIVE RE .......................... 305
EUCERIN PROFESSIONAL REPA ....................... 305
EUCERIN SKIN CALMING BODY ....................... 305
EUCERIN SKIN CALMING DAIL ......................... 305
EUCERIN SMOOTHING REPAIR ......................... 305
EVAC ........................................................................... 305
evac-u-gen ............................................................... 305
EVAC-U-GEN ............................................................ 305
EVENCARE + BLOOD GLUCOSE ....................... 305
EVENCARE BLOOD GLUCOSE TE ...................... 305
EVENCARE G2 BLOOD GLUCOSE ..................... 305
EVENCARE G2 TEST STRIPS .............................. 305
EVENCARE G3 BLOOD GLUCOSE ..................... 305
EVENCARE G3 TEST STRIPS .............................. 305
EVENCARE MINI BLOOD GLUCO ...................... 305
EVERYDAY LONG PANTILINERS ....................... 305
EVOLUTION AUTOCODE ...................................... 306
EVOLUTION60 ......................................................... 306
EVOTAZ ....................................................................... 26
EXACTECH R-S-G TEST STRIP .......................... 306
EXACTECH TEST STRIPS ..................................... 306
EXACTUSS TR .......................................................... 306
EXAPHEN ................................................................... 306
EXAPHEN CH ............................................................ 306
EXAPHEX TR ............................................................. 306
EXCEDRIN EXTRA STRENGTH ........................... 306
EXCEDRIN MENSTRUAL COMPLE ..................... 306
EXCEDRIN MIGRAINE ........................................... 306
EXCEDRIN PM .......................................................... 306
EXCEDRIN SINUS HEADACHE ........................... 306
EXCEDRIN TENSION HEADACHE ..................... 306
exefen-ir .................................................................... 306
exemestane................................................................ 36
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 749
EX-LAX ....................................................................... 306
EX-LAX MAXIMUM STRENGTH .......................... 306
ex-lax ultra ............................................................... 306
exocaine medicated rub ...................................... 306
EXPIRATORY MOUTHPIECE ................................ 306
extra action cough................................................. 682
extra strength acetaminop ................................. 306
extra strength bayer............................................. 306
extra strength bayer arth ................................... 306
extra strength pain relie ..................................... 307
extraprin.................................................................... 307
extraprin extra strength ...................................... 307
extress ....................................................................... 307
EXTRESS-30 ............................................................ 307
extress-super .......................................................... 307
extussive ................................................................... 307
EXU-DRY 15 ............................................................. 307
EXU-DRY 20 ............................................................. 307
EXU-DRY 3 ................................................................ 307
EXU-DRY 4 ................................................................ 307
EXU-DRY 6 ................................................................ 307
EXU-DRY 9 ................................................................ 307
EXU-DRY ARM 27 ................................................... 307
EXU-DRY ARM/SHOULDER TIES ...................... 307
EXU-DRY BURN JACKET 31 ................................ 307
EXU-DRY BURN JACKET CHILD ........................ 307
EXU-DRY BUTTOCKS 23 ...................................... 307
EXU-DRY ELBOW/KNEE/HEEL 1 ....................... 307
EXU-DRY FACE 9 .................................................... 307
EXU-DRY INCISION 3 ........................................... 307
EXU-DRY NON-PERMEABLE PAD ...................... 307
EXU-DRY PADDED HAND 12 .............................. 308
EXU-DRY PADDED HAND CHILD ...................... 308
EXU-DRY PADDED NECK 6 ................................. 308
EXU-DRY PERMEABLE PAD 24 .......................... 308
EXU-DRY SCALP 3 ................................................. 308
EXU-DRY SLIT TUBE 2 ......................................... 308
exuviance blemish treatme ................................ 308
eye allergy relief .................................................... 308
eye drops .................................................................. 308
eye drops allergy relief ........................................ 308
eye drops ar ............................................................. 308
eye drops extra ...................................................... 308
eye drops relief ....................................................... 308
EYE HEALTH ............................................................. 308
eye irrigating solution .......................................... 308
eye itch relief ........................................................... 308
eye lubricant ............................................................ 308
EYE STREAM ............................................................ 308
eye vitamins ............................................................ 308
eye vitamins & minerals ...................................... 308
eye wash ................................................................... 308
eye wash sterile ..................................................... 308
EYEAID IRRIGATING SOLUTIO ......................... 309
eyeprotect................................................................. 309
EYESCRUB ................................................................ 309
EYE-SCRUB ............................................................... 308
eye-vites ................................................................... 309
EZ SMART BLOOD GLUCOSE TE ...................... 309
EZ SMART DIABETES MONITOR....................... 309
EZ SMART PLUS BLOOD GLUCO ...................... 309
EZ SMART PLUS DIABETES MO ........................ 309
ezetimibe .................................................................... 46
ezetimibe-simvastatin ............................................ 46
EZFE 200 ................................................................... 309
EZFE FORTE ............................................................. 309
EZ-SORB UNDERPAD ............................................ 309
F
fa-8 .............................................................................. 309
FABRAZYME................................................................ 77
FACE MASK EARLOOP-STYLE ............................ 309
FACE MASK RESPIRATOR N-10 ........................ 309
FACE MASK RESPIRATOR R-95 ........................ 309
famciclovir .................................................................. 28
famotidine ........................................................... 87, 309
famotidine in nacl .................................................... 87
famotidine inj ............................................................ 87
FAMOTIDINE TAB 10 MG .................................... 309
FANAPT ........................................................................ 61
FANAPT TITRATION PACK..................................... 61
FARESTON .................................................................. 36
FARXIGA ...................................................................... 73
FARYDAK ..................................................................... 35
FASLODEX .................................................................. 36
fast acting antacid anti- ...................................... 309
fast acting antacid plus ....................................... 309
FAST ACTING B12 ................................................. 309
fast dissolve antacid ............................................. 309
fast freeze pro style the ...................................... 309
FAT BLOCKER PLUS .............................................. 309
father johns medicine .......................................... 310
FATHER JOHNS MEDICINE PLU ........................ 310
FATTIBASE................................................................ 310
FE ASPARTATE ........................................................ 310
fe c .............................................................................. 310
fe c tab ....................................................................... 310
fe c tab plus ............................................................. 310
FE CAPS/STOOL SOFTENER ............................... 310
FE GLUCONATE ....................................................... 310
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 750
FE PLUS PROTEIN .................................................. 310
fe tabs ........................................................................ 310
FEBROL ...................................................................... 310
feenamint .................................................................. 310
felbamate .............................................................. 53, 54
felodipine .................................................................... 48
FEM-CAL CITRATE ................................................. 310
FEMININE GUARDS/REGULAR .......................... 310
FEMININE GUARDS/SUPER ................................ 310
feminine moisturizer & lu ................................... 310
FEMININE PADS ..................................................... 310
FEMININE PADS EXTRA PLUS ........................... 310
FEMININE PADS REGULAR ................................. 310
FEMININE PADS SUPER ....................................... 310
FEMININE WIPES/ALOE VERA/ ......................... 310
FEMIRON ................................................................... 310
fenesin dm ir ........................................................... 311
FENESIN DM IR ...................................................... 311
fenesin ir ................................................................... 311
fenesin pe ir ............................................................. 311
fenofibrate .................................................................. 46
fenofibrate micronized ........................................... 46
fentanyl citrate ......................................................... 17
fentanyl patch 100 mcg/hr .................................. 17
fentanyl patch 12 mcg/hr ..................................... 17
fentanyl patch 25 mcg/hr ..................................... 17
fentanyl patch 50 mcg/hr ..................................... 17
fentanyl patch 75 mcg/hr ..................................... 17
FENTORA ..................................................................... 17
feosol .......................................................................... 311
FEOSOL ...................................................................... 311
FEOSOL BIFERA ...................................................... 311
FEOSTAT ................................................................... 311
FEOSTAT CHW 100MG ......................................... 311
FERAHEME ................................................................ 311
ferate .......................................................................... 311
fergon ......................................................................... 311
FERGON ..................................................................... 311
FER-IN-SOL .............................................................. 311
fer-iron ....................................................................... 311
ferosul .................................................................. 98, 311
FERRETTS ................................................................. 311
FERRETTS CHEWABLE IRON .............................. 311
FERRETTS IPS ......................................................... 311
ferrex 150 ................................................................. 311
ferrex 150 forte ...................................................... 311
FERREX 150 FORTE ............................................... 311
FERREX 150 FORTE PLUS ................................... 312
FERREX 150 PLUS .................................................. 312
FERREX 28 ................................................................ 311
FERRIC SUBSULFATE ........................................... 312
ferric x-150 .............................................................. 312
FERRIMIN 150 ......................................................... 312
FERRLECIT ................................................................ 312
ferro-bob ................................................................... 312
ferrocite ..................................................................... 312
FERRO-SEQUELS .................................................... 312
ferrotabs .................................................................... 312
ferrous fumarate .............................................. 98, 312
FERROUS FUMARATE ............................................ 312
ferrous gluconate ............................................. 98, 312
FERROUS GLUCONATE................................... 98, 312
ferrous sulfate ........................................... 98, 312, 313
FERROUS SULFATE ................................. 98, 312, 313
FERROUS SULFATE ANHYDROUS .................... 313
ferrous sulfate iron ................................................ 313
ferrousul ...................................................................... 98
FETZIMA ................................................................ 57, 58
FETZIMA TITRATION PACK .................................. 58
fever reducer childrens ........................................ 313
feverall adults............................................................ 11
feverall childrens ...................................................... 11
FEVERALL INFANTS ......................................... 11, 313
feverall junior strength .......................................... 11
fexofenadine hcl ............................................. 313, 678
fexofenadine hcl children ............................ 313, 678
fexofenadine-pseudoephedrine ........................ 313
FIASP ............................................................................ 72
FIASP FLEXTOUCH ................................................... 72
fiber ............................................................................. 313
FIBER .......................................................................... 313
fiber adult gummies .............................................. 313
FIBER CON TAB 625MG ....................................... 313
fiber laxative ...................................................... 89, 313
fiber select gummies ............................................ 313
fiber therapy ............................................................ 313
fiber-caps .................................................................. 313
fiberchoice weight manage ................................ 314
FIBERCON ................................................................. 314
fibergen ..................................................................... 314
fiber-lax ............................................................... 89, 313
FIBRACOL COLLAGEN-ALGINAT ....................... 314
FIFTY50 GLUCOSE METER 2.0 .......................... 314
FIFTY50 GLUCOSE TEST STRI .......................... 314
FIFTY50 LANCING DEVICE ................................. 314
FILTER AIR PP ......................................................... 314
finasteride ................................................................... 95
FIRAZYR ...................................................................... 99
first aid antibiotic ................................................... 314
first aid antiseptic spra ........................................ 314
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 751
first aid plus lidocaine .......................................... 314
FIRST QUALITY PERSONAL CL .......................... 314
FIRST QUALITY WASHCLOTHS ......................... 314
fish oil burp-less ..................................................... 314
fish oil concentrate ................................................ 314
fish oil double strength ........................................ 314
fish oil extra strength ........................................... 314
fish oil maximum strength ................................. 314
fish oil pearls ........................................................... 314
FITNESS TABS FOR MEN AM/P ......................... 314
FITNESS TABS FOR WOMEN A ......................... 314
FITTED BRIEF W/ALOE/LARGE ......................... 314
FITTED BRIEFS LARGE......................................... 314
FITTED BRIEFS MAXIMUM LAR ......................... 315
FITTED BRIEFS MAXIMUM MED ....................... 315
FITTED BRIEFS MAXIMUM XL ........................... 315
FITTED BRIEFS MEDIUM ..................................... 315
FITTED BRIEFS SMALL ......................................... 315
flac ............................................................................... 696
flanax heartburn relief ......................................... 315
flanax pain relief .................................................... 315
flanax pain relief linime ....................................... 315
flanders buttocks ................................................... 315
FLAVOR PACKETS .................................................. 315
FLAVOUR PAC .......................................................... 315
FLEBOGAMMA DIF ................................................. 101
flecainide acetate ..................................................... 44
FLEET BISACODYL ................................................... 89
FLEET ENEMA .......................................................... 315
FLEET ENEMA SIX PACK ...................................... 315
fleet laxative ............................................................ 315
FLEET LIQUID GLYCERIN SUP .......................... 315
FLEET MINERAL OIL .............................................. 315
FLEET MO ENE ........................................................ 315
FLEET OIL ................................................................. 315
FLEET PEDIATRIC .................................................. 315
flexgen ....................................................................... 315
FLEXICHAMBER ADULT MASK/S ...................... 315
FLEXICHAMBER CHILD MASK/L ....................... 315
FLEXICHAMBER CHILD MASK/S ....................... 315
flintstones complete ............................................. 316
FLINTSTONES GUMMIES ..................................... 316
FLINTSTONES GUMMIES COMPL ..................... 316
flintstones gummies plus .................................... 316
FLINTSTONES GUMMIES PLUS ......................... 316
flintstones plus calcium ....................................... 316
flintstones plus extra c ........................................ 316
flintstones plus iron .............................................. 316
FLINTSTONES SOUR GUMMIES ........................ 316
FLINTSTONES TODDLER/TASTI ....................... 316
flintstones/my first ................................................ 316
flogen ......................................................................... 316
FLONASE ALLERGY RELIEF................................. 316
FLONASE ALLERGY RELIEF CH ......................... 316
FLONASE SENSIMIST ........................................... 316
flora assist ................................................................ 316
FLORA VANCE .......................................................... 316
FLORAJEN ACIDOPHILUS .................................... 316
FLORAJEN BIFIDOBLEND .................................... 316
FLORAJEN3 ............................................................... 316
FLORAJEN4KIDS ..................................................... 316
floranex...................................................................... 317
FLORA-Q .................................................................... 316
FLORA-Q 2 ................................................................ 316
FLORASTOR .............................................................. 317
FLORASTOR KIDS .................................................. 317
FLOVENT DISKUS .................................................. 687
FLOVENT HFA .......................................................... 687
FLOWTUSS ............................................................... 317
FLU & SORE THROAT ............................................ 317
flu & sore throat relief .......................................... 317
flu bp maximum strength ................................... 317
flu hbp ........................................................................ 317
flu relief therapy daytim ..................................... 317
flu relief therapy nightt ....................................... 317
flu/severe cold & cough d ................................... 317
fluconazole ................................................................. 23
fluconazole in dextrose .......................................... 23
fluconazole inj nacl 200 ......................................... 23
fluconazole inj nacl 400 ......................................... 23
flucytosine .................................................................. 23
fludrocortisone acetate .......................................... 78
flunisolide (nasal) .................................................. 687
fluocinolone acetonide ......................................... 691
fluocinolone acetonide (otic) ............................. 696
fluocinolone acetonide oil body ........................ 691
fluocinonide .............................................................. 691
fluocinonide emulsified base ............................. 691
fluoridex daily renewal......................................... 317
fluorigard................................................................... 317
fluorometholone ..................................................... 673
fluorouracil ................................................................. 34
fluorouracil (topical) ............................................. 693
fluoxetine cap 10mg ............................................... 58
fluoxetine cap 20mg ............................................... 58
fluoxetine cap 40mg ............................................... 58
fluoxetine hcl ............................................................. 58
fluphenazine decanoate......................................... 61
fluphenazine hcl ....................................................... 61
flurbiprofen ................................................................. 15
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 752
flurbiprofen sodium ............................................... 673
flutamide ..................................................................... 36
fluticasone propionate ......................................... 691
fluticasone propionate (nasal) .................. 317, 687
fluvoxamine maleate .............................................. 51
FOAM DRESSING BORDERED ........................... 317
FOAM DRESSING CIRCULAR BO ...................... 317
FOAM DRESSING NON-BORDERE .................... 317
foaming antacid extra str ................................... 317
foaming antacid maximum s ............................. 317
FOLGARD .................................................................. 317
FOLIC + B12 ............................................................ 317
folic acid .................................................... 317, 318, 669
FOLIC ACID ...................................................... 317, 318
FOLIC ACID XTRA .................................................. 318
FOLIC ACID/B-6/B-12 .......................................... 318
FOLINIC-PLUS ......................................................... 318
FOLITAB 500............................................................ 318
foltabs 800 ............................................................... 318
FOLTRATE ................................................................. 318
fondaparinux sodium .............................................. 97
for sty relief ............................................................. 318
FORA BLOOD GLUCOSE TEST S ....................... 318
FORA D15G BLOOD GLUCOSE T ...................... 318
FORA D20 BLOOD GLUCOSE TE ....................... 318
FORA D40/G31 BLOOD GLUCOS...................... 318
FORA G20 BLOOD GLUCOSE MO ..................... 318
FORA G20 BLOOD GLUCOSE TE ....................... 318
FORA G30/PREMIUM V10 BLOO ....................... 318
FORA G30A BLOOD GLUCOSE M ..................... 318
FORA GD20 BLOOD GLUCOSE M ..................... 318
FORA GD20 TEST STRIPS ................................... 318
FORA GD50 BLOOD GLUCOSE M ..................... 318
FORA GD50 BLOOD GLUCOSE T ...................... 318
FORA LANCING DEVICE ...................................... 318
FORA LANCING DEVICE/CLEAR ........................ 319
FORA PREMIUM V10 BLE BLOO ........................ 319
FORA TEST N' GO VOICE BLO ........................... 319
FORA TN'G VOICE BLOOD GLU ........................ 319
FORA TN'G/TN'G VOICE BLOO .......................... 319
FORA V10 BLOOD GLUCOSE MO ..................... 319
FORA V10 BLOOD GLUCOSE TE ....................... 319
FORA V12 BLOOD GLUCOSE MO ..................... 319
FORA V12 BLOOD GLUCOSE TE ....................... 319
FORA V20 BLOOD GLUCOSE MO ..................... 319
FORA V20 BLOOD GLUCOSE TE ....................... 319
FORA V30A BLOOD GLUCOSE M ...................... 319
FORA V30A BLOOD GLUCOSE T ....................... 319
FORACARE GD40 ................................................... 319
FORACARE GD40 BLOOD GLUCO .................... 319
FORACARE PREMIUM V10 BLOO ...................... 319
FORACARE PREMIUM V10 TEST ....................... 319
FORACARE TEST N GO BLOOD ......................... 319
FORACARE TEST N GO TEST S ......................... 319
FORMALDEHYDE ..................................................... 319
FORMULA 405 A.H.A FACIAL ............................. 319
FORMULA 405 BODY SMOOTHIN ..................... 319
FORMULA 405 ENRICHED EYE .......................... 319
FORMULA 405 FACE CREAM .............................. 320
FORMULA 405 FACIAL & BODY ......................... 320
FORMULA 405 LIGHT TEXTURE ........................ 320
FORMULA 405 MOISTURIZING ......................... 320
formula d................................................................... 320
formula e 400 .......................................................... 320
formula em ............................................................... 320
FORTAVIT .................................................................. 320
FORTEO ....................................................................... 80
FORTIFY DAILY PROBIOTIC ............................... 320
FORTISCARE BLOOD GLUCOSE ........................ 320
FORTISCARE SELF-MONITORIN ....................... 320
fosamprenavir tab 700 mg................................... 24
FOSFREE.................................................................... 320
fosinopril sodium ...................................................... 42
fosinopril sodium & hydrochlorothiazide ......... 42
fp allergy/congestion rel ..................................... 320
fp bladder control pads r .................................... 320
fp calcium 500 ........................................................ 320
fp clotrimazole 3 .................................................... 320
FP CLOTRIMAZOLE 3 ............................................ 320
fp elixir ....................................................................... 320
FP FOAMICON .......................................................... 320
fp glucosamine ........................................................ 320
fp glucosamine/chondroiti .................................. 320
FP GLUCOSE ............................................................ 320
fp honey tussin cough .......................................... 320
fp hydrocortisone ................................................... 321
fp incontinent brief/xlar....................................... 321
fp incontinent undergarme................................. 321
fp loratadine allergy rel ....................................... 321
fp multi-purpose solution ................................... 321
FP MULTI-PURPOSE SOLUTION ........................ 321
fp multi-symptom pms ........................................ 321
FP MULTI-SYMPTOM PMS .................................... 321
fp nasal allergy ....................................................... 321
fp nicotine ................................................................. 321
fp oyster shell calcium/d ..................................... 321
fp pediatric electrolyte ......................................... 321
fp permethrin .......................................................... 321
fp povidone-iodine ................................................. 321
fp protective underwear/l ................................... 321
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 753
fp protective underwear/s .................................. 321
fp triacting chest conges ..................................... 321
fp triacting cold & aller ........................................ 321
fp tusssin severe congest ................................... 321
fp vitamin c drops .................................................. 321
fp zinc lozenges ...................................................... 321
FQ AIR PERMEABLE UNDERPAD ....................... 321
FQ BELTED UNDERGARMENT SU ..................... 321
FQ FRONTAL TAPE BRIEF X-L ........................... 322
FQ FULL MAT BRIEF ADULT S ........................... 322
FQ FULL MAT BRIEF ADULT X ........................... 322
FQ FULL MAT BRIEF YOUTH ............................... 322
FQ NU-FIT ADULT BRIEF X-L ............................. 322
FQ PANT LINER LARGE ........................................ 322
FQ PANT LINER LARGE PLUS............................. 322
FQ PANT LINER LARGE W/ LE ........................... 322
FQ PANT LINER MEDIUM ..................................... 322
FQ PANT LINER SMALL ELAST .......................... 322
FQ PERFIT LIMITED MAT ADU........................... 322
FQ PREMIUM UNDERPAD .................................... 322
FQ PREVAIL BELTED UNDERGA ........................ 322
FQ PREVAIL BLADDER CONTR .......................... 322
FQ PROTECTIVE UNDERWEAR L ...................... 322
FQ PROTECTIVE UNDERWEAR S ...................... 322
FQ PROTECTIVE UNDERWEAR X ...................... 322
FQ PROTECTIVE UNDERWEAR Y ...................... 322
FREAMINE HBC 6.9% ........................................... 665
FREAMINE III........................................................... 665
FREDS PHARMACY AUTOLET LA ....................... 322
FREE & ACTIV PAD REGULAR ............................ 322
FREE & ACTIVE FEMALE PANT .......................... 322
FREE & ACTIVE MALE BRIEF .............................. 322
FREE & ACTIVE PADS ........................................... 322
free & clear ............................................................... 323
FREE & CLEAR ......................................................... 323
FREE & CLEAR FOR SENSITIV ........................... 323
FREEDAVITE ............................................................ 323
FREESTYLE FREEDOM .......................................... 323
FREESTYLE FREEDOM LITE ................................ 323
FREESTYLE INSULINX BLOOD .......................... 323
FREESTYLE LITE BLOOD GLUC ......................... 323
FREESTYLE LITE TEST STRIP ............................ 323
FREESTYLE PRECISION NEO B ......................... 323
FREESTYLE SIDEKICK II VAL ............................ 323
FREESTYLE TEST STRIPS .................................... 323
freeze dried acidophilus ...................................... 323
FREEZE IT ................................................................. 323
freezone callus remover ...................................... 323
FRESHKOTE .............................................................. 323
FRUIT C 200 ............................................................ 323
fruit c 500 ................................................................. 323
fruit c-100 ................................................................. 323
FRUIT OF THE EARTH/ALOE V .......................... 323
fruity c ........................................................................ 323
fruity chewables multivit ..................................... 323
fruity chews ............................................................. 323
fruity chews/iron .................................................... 324
FULL KIT NEBULIZER SET .................................. 324
FULL MAT BRIEF REGULAR................................. 324
FULL SPECTRUM B/VITAMIN C ......................... 324
fungi guard ............................................................... 324
fungicure intensive with ...................................... 324
fungi-guard .............................................................. 324
FUNGOID TINCTURE ............................................. 324
fungoid-d ................................................................... 324
furosemide ................................................................. 49
furosemide inj ........................................................... 49
FUSION ...................................................................... 324
FUZEON ....................................................................... 24
FV BENZOIN TINCTURE ....................................... 324
FV EPSOM SALT ...................................................... 324
FV GENTIAN VIOLET ............................................. 324
FV HYDROGEN PEROXIDE .................................. 324
FV IODINE TINCTURE .......................................... 324
FV IPECAC ................................................................ 324
FV ISOPROPYL ALCOHOL .................................... 324
FV ISOPROPYL ALCOHOL/WINT ....................... 324
fv laxative vegetable ............................................ 324
fv suphedrine........................................................... 324
FV WITCH HAZEL ................................................... 324
fyavolv ......................................................................... 78
FYCOMPA ..................................................................... 54
G
g tussin ac ................................................................ 324
gabapentin ................................................................. 54
galantamine hydrobromide .................................. 56
galantamine hydrobromide er ............................ 56
GALZIN ...................................................................... 325
GAMASTAN S/D ...................................................... 101
GAMMAGARD LIQUID ........................................... 101
GAMMAGARD S/D .................................................. 101
GAMMAKED .............................................................. 101
GAMMAPLEX ............................................................. 101
GAMMAPLEX 10GM/100ML ................................. 101
GAMUNEX-C ............................................................. 101
ganciclovir sodium ................................................... 28
GARDASIL 9 ............................................................. 102
gas free extra strength ........................................ 325
gas relief ................................................................... 325
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 754
gas relief extra strength ............................... 93, 325
gas relief infants .................................................... 325
gas relief maximum streng ................................ 325
gas relief ultra strength ....................................... 325
gasaid ......................................................................... 326
GAS-X ......................................................................... 325
gas-x extra strength ............................................. 325
GAS-X EXTRA STRENGTH ................................... 325
gas-x infant drops ................................................. 325
GAS-X PREVENTION ............................................. 325
gas-x ultra strength .............................................. 326
gatifloxacin (ophth) .............................................. 673
GATTEX ........................................................................ 94
GAUZE PADS 2 .......................................................... 72
gavilax .................................................................. 89, 326
gavilyte-c .................................................................... 89
gavilyte-g .................................................................... 89
gavilyte-n/flavor pack ............................................ 89
gavis-care ................................................................. 326
GAVISCON .......................................................... 83, 326
GAVISCON EXTRA STRENGTH .......................... 326
GAVISCON EXTRA STRENGTH R ................ 83, 326
G-DOLOGEN ............................................................. 324
GE100 BLOOD GLUCOSE MONIT ..................... 326
GE100 BLOOD GLUCOSE TEST ......................... 326
GE-150 ....................................................................... 326
gel callus removers ............................................... 326
GEL CORN CUSHIONS .......................................... 326
GEL HEEL CUSHIONS ........................................... 326
GEL HEEL CUSHIONS MENS .............................. 326
GEL HEEL CUSHIONS WOMENS ....................... 326
GEL-KAM ................................................................... 326
gel-tin ......................................................................... 326
GELUSIL .................................................................... 326
gemcitabine inj soln ................................................ 34
gemcitabine inj solr ................................................ 34
gemfibrozil .................................................................. 46
genac .......................................................................... 326
genahist ..................................................................... 326
genaphed .................................................................. 326
gencontuss ............................................................... 327
generlac ....................................................................... 89
gengraf ...................................................................... 101
genicin ........................................................................ 327
GENOTROPIN ............................................................. 80
GENOTROPIN MINIQUICK .................................... 80
genpril ........................................................................ 327
GENSTRIP 50 ........................................................... 327
gentak ........................................................................ 673
gentamicin in saline ................................................ 20
gentamicin sulfate ................................................... 20
gentamicin sulfate (topical) ............................... 689
gentamicin sulfate soln (ophth) ....................... 673
GENTEAL ................................................................... 327
GENTEAL MILD ........................................................ 327
GENTEAL MILD TO MODERATE ......................... 327
GENTEAL SEVERE .......................................... 327, 675
genteal tears liquid drop ............................. 327, 675
genteal tears mild .......................................... 327, 675
GENTEAL TEARS MODERATE PF ....................... 327
genteal tears night-time ..................................... 327
GENTEEL LANCING DEVICE/BU ........................ 327
GENTEEL LANCING DEVICE/GL ........................ 327
GENTEEL LANCING DEVICE/PL ......................... 327
GENTEEL LANCING DEVICE/PR ........................ 327
GENTEEL LANCING DEVICE/ST ........................ 327
GENTEEL LANCING DEVICE/WI ........................ 327
GENTIAN VIOLET ................................................... 327
GENTLE ...................................................................... 327
GENTLE CLEANSING SKIN CRE ........................ 327
gentle iron ................................................................ 327
gentle laxative ........................................................ 327
gentle laxative for women .................................. 328
gentle laxative overnight .................................... 328
GENTLE RAIN EXTRA MILD ................................ 328
GENTLE RAIN SHAMPOO AND S ...................... 328
gentle skin cleanser .............................................. 328
GENTLE SKIN CLEANSER .................................... 328
gentle stool softener ............................................. 328
gentlelax.................................................................... 328
GENULTIMATE TEST STRIPS ............................. 328
GENVOYA .................................................................... 26
GEODON ...................................................................... 61
geravim...................................................................... 328
GERAVINE ................................................................. 328
GERI PROTECT ........................................................ 328
GERIAIDE .................................................................. 329
geriaton ..................................................................... 329
GERIATRIC VITAMIN ............................................ 329
geri-dryl ..................................................................... 328
geri-dryl allergy relief .......................................... 328
GERI-FREEDA SENIOR FORMUL ....................... 328
geri-hydrolac 12 ..................................................... 328
geri-hydrolac 5 ....................................................... 328
geri-kot ...................................................................... 328
geri-lanta .................................................................. 328
geri-lanta supreme ................................................ 328
geri-lub ...................................................................... 328
geri-mox .................................................................... 328
geri-mucil .................................................................. 329
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 755
geri-pectate ............................................................. 329
GERI-SHAMPOO/SHEA BUTTER ........................ 329
GERISILK BATH OIL .............................................. 329
GERI-SOFT ............................................................... 329
GERITOL COMPLETE ............................................. 329
GERITOL TONIC ..................................................... 329
geri-tonic ................................................................... 329
geri-tussin ................................................................ 329
geri-tussin dm ......................................................... 329
gerivite complete ................................................... 329
GERI-WASH.............................................................. 329
GERM DEFENSE PM ............................................... 329
gets-it corn and callus r .......................................................... 329
g-fen dm ................................................................... 325
g-fen ex ..................................................................... 325
GHT BLOOD GLUCOSE MONITO ....................... 329
GHT TEST STRIPS .................................................. 329
GILENYA CAP 0.5MG .............................................. 68
GILOTRIF TAB 20MG .............................................. 38
GILOTRIF TAB 30MG .............................................. 38
GILOTRIF TAB 40MG .............................................. 38
GILTUSS ALLERGY & SINUS .............................. 329
giltuss cough & chest con ................................... 329
giltuss cough & cold .............................................. 329
GILTUSS COUGH & COLD ........................... 329, 330
giltuss cough & cold chil ...................................... 330
GILTUSS COUGH ALLERGY & S ........................ 330
GILTUSS SINUS & CONGESTIO........................ 330
glatiramer acetate 20mg/ml ............................... 68
glatiramer acetate 40mg/ml ............................... 68
glatopa ......................................................................... 68
GLEN PE ..................................................................... 330
GLENMAX PEB ......................................................... 330
GLENMAX PEB DM ................................................. 330
glenmax peb dm forte ......................................... 330
glentuss ..................................................................... 330
GLEOSTINE ................................................................ 33
glimepiride .................................................................. 73
glip/metform tab 2.5-250mg .............................. 73
glip/metform tab 2.5-500mg .............................. 73
glip/metform tab 5-500mg .................................. 73
glipizide ....................................................................... 73
glipizide xl ............................................................. 73, 74
GLOBAL LANCING DEVICE ................................. 330
GLUCAGEN HYPOKIT .............................................. 80
GLUCAGON EMERGENCY KIT .............................. 80
gluco burst ............................................................... 330
GLUCO COR.............................................................. 330
GLUCO PERFECT 3 BLOOD GLU ....................... 330
GLUCO PERFECT 3 TEST STRI .......................... 330
GLUCOCARD 01 BLOOD GLUCOS .................... 330
GLUCOCARD 01 SENSOR PLUS ........................ 330
GLUCOCARD 01-MINI BLOOD G ...................... 330
GLUCOCARD EXPRESSION AUDI ..................... 330
GLUCOCARD EXPRESSION BLOO .................... 330
GLUCOCARD SHINE .............................................. 330
GLUCOCARD SHINE CONNEX BL ..................... 330
GLUCOCARD SHINE EXPRESS B ...................... 330
GLUCOCARD SHINE TEST STRI ........................ 330
GLUCOCARD SHINE XL ........................................ 331
GLUCOCARD VITAL BLOOD GLU ...................... 331
GLUCOCARD VITAL TEST STRI ......................... 331
GLUCOCARD X-METER ......................................... 331
GLUCOCARD X-SENSOR ...................................... 331
GLUCOCOM BLOOD GLUCOSE MO .................. 331
GLUCOCOM TEST STRIPS ................................... 331
GLUCOFILM TEST STRIPS................................... 331
GLUCOLET 2 AUTOMATIC LANC ....................... 331
GLUCOMETER KIT .................................................. 331
GLUCONAVII BLOOD GLUCOSE ........................ 331
glucosamine chondroitin c .................................. 331
glucosamine hydrochloride ................................ 331
glucosamine maximum stren ............................ 331
glucosamine relief.................................................. 331
glucosamine sulfate .............................................. 331
glucosamine/chondroitin d ................................. 331
glucosamine/chondroitin p ................................. 331
glucosamine-chondroitin ..................................... 331
GLUCOSE .................................................................. 331
GLUCOSE CHW 4GM ............................................. 331
GLUCOSE INSTANT ENERGY ............................. 331
GLUCOSE METER TEST STRIPS ........................ 331
GLUCOSOURCE LANCET DEVICE ..................... 332
GLUCOSTIX .............................................................. 332
glucoten ..................................................................... 332
GLUTAMENT ............................................................. 332
glutamine .................................................................. 332
GLUTAMINE .............................................................. 332
GLUTARADE AMINO ACID BLEN ....................... 332
GLUTARADE ESSENTIAL GA-1 .......................... 332
GLUTARADE JUNIOR GA-1 ................................. 332
glutimmune .............................................................. 332
glutose 15 ................................................................. 332
glutose 45 ................................................................. 332
glyburide ..................................................................... 74
glyburide micronized .............................................. 74
glyburide-metformin tab 1.25-250 mg ........... 74
glyburide-metformin tab 2.5-500 mg .............. 74
glyburide-metformin tab 5-500mg ................... 74
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 756
glycerin (laxative) ........................................... 89, 332
glycerin (topical) .................................................... 332
glycerin adult ........................................................... 332
GLYCERIN ADULT................................................... 332
GLYCINE .................................................................... 332
GLYCINE (L) ............................................................. 332
GLYCINE500 ............................................................ 332
glycolax ....................................................................... 90
GLYCOLIC ACD SOL 70% TECH ....................... 333
glycolic acid .............................................................. 333
GLYCOLIC ACID ...................................................... 333
GLYCOLIC ACID 70% HIGH PU ........................ 333
glycopyrrolate tab 1mg ......................................... 86
glycopyrrolate tab 2mg ......................................... 87
GLYCO-TECH............................................................ 332
GLYCOTROL.............................................................. 333
GLYCOTROL COMPLETE ....................................... 333
glydo ........................................................................... 692
gly-oxide ................................................................... 332
GMATE BLOOD GLUCOSE TEST ........................ 333
GMATE LANCING DEVICE ................................... 333
GMATE SMART METER KIT ................................. 333
GMATE SMART STARTER KIT ............................ 333
GMATE VOICE BLOOD GLUCOSE ..................... 333
gnc potassium gluconate 9 ................................ 333
gnp 12 hour nasal spray ..................................... 333
gnp 24 hour nasal allerg ..................................... 333
GNP 4X PROBIOTIC............................................... 333
gnp 8 hour pain relief........................................... 333
gnp 8 hour pain reliever...................................... 333
gnp acetaminophen .............................................. 333
gnp acetaminophen extra s ............................... 333
gnp acid control 150 maxi .................................. 333
gnp acid control 75 ............................................... 333
gnp acid reducer .............................................. 87, 333
gnp acid reducer maximum ......................... 87, 333
GNP ACIDOPHILUS HIGH POTE ........................ 334
gnp acne treatment maximu ............................. 334
gnp adult aspirin low str ............................... 11, 334
GNP ADVANCED RECOVERY .............................. 334
gnp all day allergy ......................................... 334, 678
gnp all day allergy child .............................. 334, 679
gnp all day allergy-d ..................................... 334, 682
gnp all day pain relief .......................................... 334
gnp allergy ....................................................... 334, 679
gnp allergy & congestion .................................... 334
gnp allergy & sinus heada .................................. 334
gnp allergy antihistamine ................................... 334
gnp allergy multi-symptom ............................... 334
gnp allergy plus severe s .................................... 334
gnp allergy plus sinus he .................................... 334
gnp allergy relief ............................................ 334, 679
gnp allergy relief for ki ........................................ 334
gnp allergy relief multi- ....................................... 334
gnp allergy-d 12 hour all .................................... 335
gnp animal shapes ................................................ 335
gnp animal shapes plus ex ................................. 335
gnp animal shapes plus ir ................................... 335
gnp antacid .............................................................. 335
and anti-gas/ ...................................................... 335
gnp antacid & anti-gas ma ................................. 335
gnp antacid & anti-gas/re ................................... 335
gnp antacid anti-gas ....................................... 83, 335
gnp antacid anti-gas/maxi ................................. 335
gnp antacid extra strengt ............................. 83, 335
gnp antacid maximum stren ............................. 335
gnp antacid ultra strengt .................................... 335
gnp antacid/regular stren ................................... 335
gnp antibiotic plus pramo ................................... 335
gnp anti-diarrheal ............................................ 84, 335
gnp anti-gas ............................................................. 335
gnp anti-itch ............................................................ 335
gnp anti-nausea ..................................................... 335
gnp antiseptic skin clean .................................... 335
gnp arthricream ...................................................... 335
gnp arthritis pain relief .................................. 11, 336
gnp artificial tears .................................................. 336
gnp aspirin .......................................................... 11, 336
gnp aspirin low dose ....................................... 11, 336
gnp athletes foot ............................................ 336, 689
gnp athlete's foot relief ....................................... 336
gnp b-100 balanced tr ......................................... 336
gnp b-100 complex prolong ............................... 336
gnp b-12 .................................................................... 336
gnp b-50 balanced ................................................ 336
gnp b-50 complex prolonge ............................... 336
gnp bacitracin zinc ........................................ 336, 689
GNP BATHING CLOTHS/RINSE- ....................... 336
gnp b-complex plus vitami ................................. 336
gnp best fiber .......................................................... 336
gnp biotin .................................................................. 336
gnp bisa-lax ....................................................... 90, 336
gnp brewers yeast ................................................. 336
gnp budesonide nasal spra ................................ 336
gnp cal mag zinc +d3 .......................................... 336
GNP CALAMINE ....................................................... 336
GNP CALAMINE PHENOLATED ........................... 336
gnp calcium .............................................................. 337
gnp calcium 1200 .................................................. 337
gnp calcium 500 ..................................................... 337
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 757
gnp calcium 500 +d3 ........................................... 337
gnp calcium 500/d................................................. 337
gnp calcium 600 + d ............................................ 337
gnp calcium 600 + soy ........................................ 337
gnp calcium 600 +d .............................................. 337
gnp calcium 600 +d/minera .............................. 337
gnp calcium 600 +d3 ........................................... 337
gnp calcium 600 +d3/miner .............................. 337
gnp calcium 600 plus d/mi ................................. 337
gnp calcium 600/d................................................. 337
gnp calcium citrate +d3 ...................................... 337
gnp calcium citrate+d max ................................ 337
gnp calcium citrate+d3 ma ................................ 337
gnp calcium plus 600 +d .................................... 337
gnp calcium/magnesium/zin ............................. 337
gnp calcuim/vitamin d/min ................................ 337
gnp caldyphen ......................................................... 337
gnp capsaicin ........................................................... 337
GNP CAPSAICIN ..................................................... 337
gnp castor oil ........................................................... 337
gnp century .............................................................. 338
gnp century adult formula .................................. 338
gnp century adults 50+ se ................................. 338
gnp century cardio health .................................. 338
GNP CENTURY ENERGY METABO ..................... 338
gnp century mature .............................................. 338
gnp century mature formul ................................ 338
gnp century ultimate mens ................................ 338
gnp century ultimate wome ............................... 338
gnp chest rub .......................................................... 338
gnp childrens allergy ............................................ 338
gnp childrens chewables w ................................ 338
gnp childrens chewables/e ................................. 338
gnp childrens chewables/i .................................. 338
GNP CHILDRENS COMPLETE CH ...................... 338
gnp childrens easy-melts .................................... 338
gnp childrens ibuprofen ................................. 15, 338
gnp childrens ibuprofen c ................................... 338
gnp childrens pain relief ...................................... 338
gnp childrens plus cough .................................... 338
gnp childrens plus multi- .................................... 338
gnp chromium picolinate .................................... 338
gnp cimetidine ........................................................ 338
gnp clearlax ....................................................... 90, 339
gnp clotrimazole 3 ................................................. 339
gnp co q10 ............................................................... 339
gnp cod liver oil ...................................................... 339
gnp coenzyme q-10 .............................................. 339
gnp cold & allergy childr ............................. 339, 682
gnp cold & allergy maximu ................................ 339
gnp cold & allergy pe ........................................... 339
gnp cold & cough children .......................... 339, 682
gnp cold & hot therapy ba .................................. 339
gnp cold + flu severe ........................................... 339
gnp cold + head congestio ................................. 339
gnp cold head congestion ................................... 339
gnp cold max day/night ad ................................ 339
gnp cold max daytime for .................................. 339
gnp cold multi-symptom da ............................... 339
gnp cold multi-symptom ni ................................ 339
gnp cold relief cold & fl ........................................ 339
gnp cold relief head cong ................................... 339
gnp cold relief multi-sym .................................... 339
GNP COLD RELIEF PLUS ...................................... 339
gnp cold severe congestio .................................. 339
gnp cough dm er .................................................... 340
gnp cough drops .................................................... 340
gnp cough drops sugar fre ................................. 340
gnp cough gels........................................................ 340
gnp cough relief...................................................... 340
gnp d 1000 ............................................................... 340
gnp d 2000 ............................................................... 340
GNP DAILY PRENATAL .......................................... 340
gnp day time cold & flu ....................................... 340
gnp day time cold/flu ........................................... 340
gnp day time cold/flu rel ..................................... 340
gnp day time d cold/flu ....................................... 340
GNP DAY TIME MUCUS RELIEF ......................... 340
gnp day time sinus ................................................ 340
gnp dayhist allergy ................................................ 340
gnp diabetic support form .................................. 340
gnp diaper rash ...................................................... 340
gnp diaper rash creamy ...................................... 340
gnp docusate calcium ........................................... 340
gnp dry mouth mouthwash ................................ 340
gnp dual action complete ................................... 340
gnp ear drops .......................................................... 340
gnp ear systems ..................................................... 340
GNP EASY TOUCH GLUCOSE MO ..................... 341
GNP EASY TOUCH GLUCOSE TE ....................... 341
gnp effervescent antacid/ ................................... 341
gnp enema ............................................................... 341
gnp enema mineral oil lax .................................. 341
gnp epsom salt ....................................................... 341
gnp esomeprazole magnesiu ............................. 341
gnp essential one daily ........................................ 341
gnp eye drops ......................................................... 341
gnp eye itch relief .................................................. 341
gnp eye wash .......................................................... 341
gnp fiber therapy ................................................... 341
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 758
gnp fiber-caps ................................................... 90, 341
GNP FINGER CREAM ............................................. 341
gnp first aid antibiotic .......................................... 341
gnp fish oil ................................................................ 341
gnp fish oil maximum stre ................................. 341
gnp flu & severe cold & c .................................... 341
GNP FLU & SORE THROAT .................................. 341
gnp flu relief therapy se ...................................... 341
gnp flu/severe cold & c o .................................... 341
gnp flu/severe cold dayti .................................... 341
gnp fluticasone propionat ................................... 341
gnp foaming antacid ............................................. 342
gnp folic acid ........................................................... 342
gnp gas relief........................................................... 342
gnp gas relief extra stre ...................................... 342
gnp gas relief maximum st ................................ 342
GNP GENTIAN VIOLET ......................................... 342
gnp gentle laxative................................................ 342
gnp glucosamine/chondroit ............................... 342
GNP GLUCOSE......................................................... 342
gnp glycerin ............................................................. 342
gnp glycerin adult .................................................. 342
gnp glycerin child ................................................... 342
gnp glycerin infant ................................................ 342
gnp hair/skin/nails ................................................ 342
gnp headache pm .................................................. 342
gnp headache relief .............................................. 342
gnp headache relief added ................................. 342
gnp headache relief extra ................................... 342
gnp healthy eyes.................................................... 342
gnp healthy eyes supervis ................................. 342
gnp heartburn relief ........................................ 87, 342
gnp heartburn relief 200 ..................................... 342
gnp hemorrhoidal .................................................. 342
gnp hemorrhoidal cooling ................................... 343
gnp histafed ............................................................. 343
gnp hydrocortisone ............................................... 343
gnp hydrocortisone maximu ...................... 343, 691
gnp hydrocortisone plus ...................................... 343
gnp hydrocortisone/aloe ............................. 343, 691
gnp hydrogen peroxide ....................................... 343
gnp hydro-lotion..................................................... 343
gnp hygienic cleansing ........................................ 343
gnp hygienic cleansing pa .................................. 343
gnp ibuprofen .................................................... 15, 343
gnp ibuprofen cold/sinus .................................... 343
gnp ibuprofen infants ........................................... 343
gnp ibuprofen junior stre .................................... 343
gnp ibuprofen pm .................................................. 343
gnp immune support ............................................ 343
gnp infants gas relief ............................................ 343
gnp infants pain relief .......................................... 343
gnp infants pain/fever.......................................... 343
GNP IODIDES TINCTURE .................................... 343
GNP IODINE TINCTURE ....................................... 343
gnp iron ..................................................................... 343
gnp isopropyl alcohol ........................................... 344
GNP ISOPROPYL ALCOHOL................................. 344
gnp itch relief extra str ........................................ 344
gnp itchy eye ........................................................... 344
gnp k-pec .................................................................. 344
GNP LANCING SYSTEM DEVICE ....................... 344
gnp lansoprazole .............................................. 94, 344
gnp laxative ....................................................... 90, 344
gnp laxative pills ...................................................... 90
gnp lice bedding ..................................................... 344
gnp lice egg remover ........................................... 344
gnp lice solution kit ............................................... 344
gnp lice treatment ......................................... 344, 695
gnp little ones childrens ...................................... 344
gnp l-lysine............................................................... 344
gnp loperamide hcl ................................................ 344
gnp loratadine ................................................. 344, 679
gnp loratadine allergy re ..................................... 344
gnp loratadine childrens ...................................... 344
gnp loratadine-d 12hr .................................. 344, 682
gnp loratadine-d 24 hour .................................... 344
gnp lubricant eye drops....................................... 345
gnp lubricant pm ............................................ 345, 675
gnp lubricating jelly .............................................. 345
gnp lubricating plus eye .............................. 345, 675
gnp magnesium ...................................................... 345
gnp magnesium citrate ........................................ 345
gnp masanti maximum stren ............................ 345
gnp masanti regular stren ............................ 83, 345
gnp maximum one daily ..................................... 345
gnp medicated first aid s .................................... 345
gnp medicated wipes ............................................ 345
gnp mega multi for men ..................................... 345
gnp mega multi for women ................................ 345
gnp melatonin ......................................................... 345
gnp melatonin maximum str ............................. 345
gnp miconazole 1 ................................................... 345
gnp miconazole 3 ................................................... 345
gnp miconazole 3 combinat ............................... 345
gnp miconazole 7 ............................................. 96, 345
gnp miconazole nitrate ........................................ 345
gnp miconazorb af ................................................. 345
gnp migraine formula ........................................... 345
gnp migraine relief ................................................ 345
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 759
gnp milk of magnesia ..................................... 90, 346
gnp mineral oil enema ......................................... 346
gnp mineral oil heavy........................................... 346
gnp motion sickness relie ............................. 85, 346
gnp mucus d 12 hr ................................................ 346
gnp mucus dm maximum stre .......................... 346
gnp mucus er .......................................................... 346
gnp mucus relief ............................................ 346, 683
gnp mucus relief children ................................... 346
gnp mucus relief cold & s ................................... 346
gnp mucus relief cold flu ..................................... 346
gnp mucus relief cough ch ................................. 346
gnp mucus relief dm ..................................... 346, 683
gnp mucus relief dm max ................................... 346
gnp mucus relief pe ...................................... 346, 683
gnp mucus relief severe c .................................. 346
gnp mucus-er .......................................................... 346
gnp multi-purpose ................................................. 346
gnp multi-symptom cold da ............................... 346
gnp multi-symptom cold ni ................................ 346
gnp muscle rub ....................................................... 346
gnp naproxen sodium .......................................... 346
gnp nasal decongestant .............................. 346, 683
gnp nasal decongestant pe ................................ 347
gnp nasal decongestant/ma .............................. 347
gnp nasal moisturizing ......................................... 347
gnp nasal spray ...................................................... 347
gnp nasal spray extra moi.................................. 347
gnp nasal spray fast acti ..................................... 347
gnp natural fiber .................................................... 347
gnp nausea relief ................................................... 347
gnp niacin ................................................................. 347
gnp niacin flush free ............................................. 347
gnp niacin tr............................................................. 347
gnp nicotine gum ................................................... 347
gnp nicotine mini lozenge ............................. 69, 347
gnp nicotine polacrilex ................................... 69, 347
gnp nicotine polacrilex m .............................. 69, 347
gnp nicotine transdermal .................................... 347
gnp night time cold & flu .................................... 347
gnp night time cold/flu r ..................................... 347
gnp night time cough ........................................... 347
gnp night time sinus ............................................. 347
gnp nighttime sleep aid ................................. 69, 347
gnp no drip nasal spray ....................................... 347
gnp norwegian cod liver o .................................. 348
gnp nose drops extra stre .................................. 348
GNP OMEPRAZOLE .......................................... 94, 348
gnp one daily maximum ..................................... 348
gnp one daily mens 50+ ad ............................... 348
gnp one daily mens health ................................. 348
gnp one daily plus iron ........................................ 348
gnp one daily womens 50+ ............................... 348
gnp one daily womens heal ............................... 348
gnp one daily womens meta ............................. 348
gnp opti-vitamins ................................................... 348
gnp pain & fever children ............................. 11, 348
gnp pain relief ................................................... 11, 348
gnp pain relief extra str ................................. 11, 348
gnp pain relief infants .......................................... 348
gnp pain relief pm extra...................................... 348
gnp pain reliever extra s ..................................... 348
gnp pediatric electrolyte ..................................... 348
GNP PERSONAL CLEANSING WI ...................... 348
gnp petroleum jelly ............................................... 348
gnp pink bismuth ................................................... 348
gnp potassium ........................................................ 349
gnp povidone-iodine ............................................. 349
gnp pre-menstrual relief ..................................... 349
GNP PRENATAL ............................................... 349, 670
GNP PROBIOTIC COLON SUPPO ....................... 349
gnp pseudoephedrine hcl 1 ................................ 349
gnp pseudoephedrine hcl e ................................ 349
GNP QUICK DISSOLVE GLUCOS ...................... 349
GNP SALINE WOUND WASH .............................. 349
gnp scalp relief ....................................................... 349
gnp senna ................................................................. 349
gnp senna lax .......................................................... 349
gnp senna plus ................................................. 90, 349
gnp senna-lax ................................................... 90, 349
gnp severe cold/flu maxim ................................ 349
gnp severe day time cold ................................... 349
gnp sinus & allergy pe ......................................... 349
gnp sinus & cold-d ................................................. 349
gnp sinus + headache day/ ............................... 349
gnp sinus congestion & pa ................................. 349
gnp sinus congestion/pain ................................. 349
gnp sinus relief congesti ..................................... 349
gnp sinus relief pressure ..................................... 349
gnp sinus relief severe c ..................................... 350
gnp sinus severe daytime................................... 350
gnp sinus wash refill ............................................. 350
gnp sleep aid ........................................................... 350
gnp sleep time ........................................................ 350
gnp slow release iron ........................................... 350
gnp soothing bath treatme ................................ 350
gnp sore throat ....................................................... 350
gnp sore throat spray .......................................... 350
gnp stay awake ...................................................... 350
gnp stomach relief ................................................. 350
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 760
gnp stomach relief maximu ............................... 350
gnp stool softener............................................ 90, 350
gnp stool softener extra ...................................... 350
gnp stool softener/stimul.............................. 90, 350
gnp stress formula+iron ..................................... 350
gnp suphedrin ......................................................... 350
gnp tab tussin ......................................................... 350
gnp tab tussin dm ................................................. 350
gnp terbinafine hydrochlo........................... 350, 690
gnp therapeutic blue gel ..................................... 350
gnp therapeutic-m ................................................. 351
gnp tioconazole 1................................................... 351
gnp tolnaftate .......................................................... 351
gnp triacting cold/allerg ...................................... 351
gnp triacting day time co .................................... 351
gnp triacting night time ....................................... 351
gnp triple antibiotic ............................................... 351
gnp triple antibiotic plu ....................................... 351
GNP TRUETRACK SMART SYSTE ...................... 351
gnp tussin ................................................................. 351
gnp tussin cf cough & col ............................ 351, 683
gnp tussin cf max multi-s ................................... 351
gnp tussin cough long act .................................. 351
gnp tussin dm ................................................. 351, 683
gnp tussin dm cough ............................................ 351
gnp tussin dm max ....................................... 351, 683
gnp tussin dm max cough & .............................. 351
gnp tussin mucus & chest .......................... 351, 683
gnp tussin night time ........................................... 351
gnp ultra lubricant eye d .................................... 351
GNP UNDERWEAR SUPER PLUS ....................... 351
gnp urinary pain relief ......................................... 351
gnp vitamin a .......................................................... 351
gnp vitamin a & d .................................................. 352
gnp vitamin b complex ........................................ 352
gnp vitamin b1 ........................................................ 352
gnp vitamin b-1 ...................................................... 352
gnp vitamin b12 ..................................................... 352
gnp vitamin b-12 ................................................... 352
gnp vitamin b-12 prolonge ................................ 352
gnp vitamin b-12 tr ............................................... 352
gnp vitamin b-6 ...................................................... 352
gnp vitamin c........................................................... 352
gnp vitamin c drops .............................................. 352
gnp vitamin c pr ..................................................... 352
gnp vitamin c tr ...................................................... 352
gnp vitamin c w/rose hips .................................. 352
gnp vitamin c/rose hips ....................................... 352
gnp vitamin d .......................................................... 352
gnp vitamin d maximum str .............................. 352
gnp vitamin d super stren .................................. 352
gnp vitamin d3 extra stre ................................... 352
gnp vitamin d-400 ................................................. 352
gnp vitamin e .......................................................... 352
gnp vitamin e water dispe .................................. 352
gnp wart remover .................................................. 352
gnp white petrolatum ........................................... 353
gnp witch hazel ....................................................... 353
gnp womens gentle laxativ ................................ 353
gnp womens laxative ........................................... 353
gnp womens menstrual reli ............................... 353
gnp womens one daily ......................................... 353
gnp zinc ..................................................................... 353
gnp zinc chelated ................................................... 353
GNP ZINC LOZENGE W/VIT C ........................... 353
gnp zinc oxide ......................................................... 353
gnp zoochews gummies ...................................... 353
GOLD BOND ............................................................. 353
GOLD BOND EXTRA STRENGTH ....................... 353
GOLD BOND MEDICATED BODY ....................... 353
GOLD BOND ULTIMATE ....................................... 353
GOLD BOND ULTIMATE DEEP M ....................... 353
GOLD BOND ULTIMATE DIABET ....................... 353
GOLD BOND ULTIMATE HEALIN ....................... 353
GOLD BOND ULTIMATE OVERNI ...................... 353
GOLD BOND ULTIMATE PROTEC ...................... 353
GOLD BOND ULTIMATE RESTOR ...................... 353
GOLD BOND ULTIMATE SHEER ........................ 353
GOLD BOND ULTIMATE SOFTEN ...................... 353
GOLD BOND ULTIMATE SOOTHI ...................... 354
golden age vitamin/minera ................................ 354
GOLYTELY ................................................................... 90
GONAK ....................................................................... 354
goniosoft ................................................................... 354
GONIOSOL ................................................................ 354
goniotaire .................................................................. 354
goniovisc ................................................................... 354
GONIOVISC .............................................................. 354
goodsense acid reducer ....................................... 354
goodsense all day allergy ........................... 354, 679
goodsense aller-ease .................................... 354, 679
goodsense allergy relief ...................................... 354
goodsense antacid & pain ................................... 354
goodsense arthritis pain ................................ 12, 354
goodsense artificial tear ...................................... 354
goodsense aspirin ............................................ 12, 354
goodsense aspirin adult l .................................... 354
goodsense aspirin low dos ................................. 354
goodsense best fiber ............................................ 354
goodsense bisacodyl ec ....................................... 354
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 761
GOODSENSE CAPSAICIN ARTHR ..................... 355
goodsense clearlax ................................................ 355
goodsense cold & flu seve .................................. 355
goodsense cold & head con ............................... 355
goodsense cold multi-symp ............................... 355
goodsense cough dm ........................................... 355
goodsense cough dm childr ............................... 355
goodsense day time cold & ................................ 355
goodsense daytime ............................................... 355
goodsense daytime cold & ................................. 355
goodsense ear wax removal .............................. 355
goodsense epsom salt ......................................... 355
goodsense esomeprazole ma ............................ 355
goodsense eye drops ............................................ 355
goodsense fiber ...................................................... 355
goodsense flu & severe co ................................. 355
goodsense gas relief extr ................................... 355
GOODSENSE GLUCOSE ....................................... 355
goodsense headache pm .................................... 355
goodsense headache relief ................................. 355
goodsense hemorrhoidal ..................................... 355
goodsense hemorrhoidal oi ................................ 355
goodsense hydrogen peroxi ............................... 355
goodsense ibuprofen ...................................... 15, 356
goodsense ibuprofen child ............................ 15, 356
goodsense ibuprofen infan ................................. 356
goodsense ibuprofen junio ................................. 356
goodsense ibuprofen pm .................................... 356
goodsense iron ....................................................... 356
goodsense itchy eye ............................................. 356
GOODSENSE LANCING DEVICE ....................... 356
goodsense lansoprazole ........................................ 94
goodsense laxative pills ...................................... 356
goodsense lubricant eye d ................................. 356
goodsense lubricating plu ................................... 675
goodsense magnesium citra .............................. 356
goodsense menstrual relie ................................. 356
goodsense miconazole 1 ..................................... 356
goodsense migraine formul ............................... 356
goodsense mineral oil lub ................................... 356
goodsense mouthwash minty ........................... 356
goodsense mucus relief ....................................... 356
goodsense mucus relief ch ................................. 356
goodsense mucus relief dm ............................... 356
goodsense mucus relief se ................................. 356
goodsense mucus-d .............................................. 356
GOODSENSE MULTI-PURPOSE S ..................... 356
goodsense muscle rub ......................................... 357
goodsense naproxen sodium ............................. 357
goodsense nasal allergy s .................................. 357
goodsense nasoflow .............................................. 357
goodsense natural fiber ....................................... 357
goodsense nicotine ................................................ 357
goodsense nicotine gum ....................................... 69
goodsense nicotine polacr ............................ 70, 357
goodsense nighttime cold ................................... 357
goodsense nighttime sinus................................. 357
goodsense pain & fever ch ........................... 12, 357
goodsense pain & fever in ............................ 12, 357
goodsense pain relief ..................................... 12, 357
goodsense pain relief ext .............................. 12, 357
goodsense pain relief pm .................................... 357
goodsense petroleum jelly ................................. 357
GOODSENSE PREMIUM BLOOD G ................... 357
GOODSENSE PRENATAL VITAMI ...................... 357
goodsense pressure + pain ............................... 357
goodsense psyllium fiber .................................... 357
goodsense senna laxative .................................. 357
goodsense severe sinus co ................................ 357
goodsense sinus congestio ................................. 357
goodsense sinus relief ma .................................. 358
goodsense sinus severe fo ................................. 358
goodsense sleep aid ............................................. 358
goodsense sleeptime ............................................ 358
goodsense sore throat spr.................................. 358
goodsense stimulant laxat ................................. 358
goodsense stomach relief ................................... 358
goodsense tussin cf............................................... 358
GOODYS BODY PAIN ............................................ 358
GOODYS EXTRA STRENGTH .............................. 358
gordomatic ............................................................... 358
GORDONS-VITE A .................................................. 358
gordons-vite e ......................................................... 358
GORDO-POOL .......................................................... 358
gormel 10 ................................................................. 358
gormel creme .......................................................... 358
GOWEY TINCTURE ................................................. 358
G-PREPROTEIN ....................................................... 325
G-P-TUSS DXP ........................................................ 325
granisetron hcl .......................................................... 85
GRANIX ........................................................................ 97
GRAPE SYRUP .......................................................... 358
GREEN SOURCE ...................................................... 358
griseofulvin microsize ............................................. 23
griseofulvin ultramicrosize ................................... 23
grx analgesic balm ................................................ 358
GRX ASC LOTIONIZED ANTIMI ........................ 358
grx dyne .................................................................... 358
GRX HEMORRHOIDAL........................................... 358
GRX HYDROGEL GAUZE 2X2 ............................. 359
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 762
GRX HYDROGEL GAUZE 4X4 ............................. 359
grx vitamin e ........................................................... 359
GRX VITAMIN E ...................................................... 359
GRX WHITE PETROLATUM .................................. 359
g-supress dx pediatric ......................................... 325
gtf chromium ........................................................... 359
g-tron ......................................................................... 325
g-tron ped................................................................. 325
g-tron pediatric drops .......................................... 325
G-TUSICOF ............................................................... 325
guaiasorb dm .......................................................... 359
guaiatussin ac ......................................................... 359
guaicon dms ............................................................ 359
guaifenesin ....................................................... 359, 683
guaifenesin ac ......................................................... 359
guaifenesin dac ....................................................... 359
guaifenesin la .......................................................... 359
guaifenesin-codeine .............................................. 359
guanfacine er (adhd) .............................................. 65
GUARDS FOR MEN ................................................. 359
guiatuss ..................................................................... 359
guiatuss dm ............................................................. 359
gummi bear multivitamin/m.............................. 359
GYNE-LOTRIMIN ..................................................... 359
GYNE-LOTRIMIN 3 ................................................. 360
gyne-moistrin .......................................................... 360
G-ZYNCOF ................................................................ 325
H
h2q .............................................................................. 360
HAEGARDA ................................................................. 99
HAIR FARE ................................................................ 360
hair formula extra streng ................................... 360
HAIR NOURISHING SUPPLEMEN ...................... 360
hair skin and nails formu .................................................. 360
HAIR SKIN & NAILS ADVANCE ......................... 360
hair vitamins ............................................................ 360
hair/skin/nails ......................................................... 360
HAIR/SKIN/NAILS .................................................. 360
hair/skin/nails/biotin ............................................ 360
HAIR-VITES .............................................................. 360
halls cough drops ................................................... 360
halls cough drops sugar f ................................... 360
halls defense vitamin c d .................................... 360
halls-plus maximum streng ............................... 361
halobetasol propionate ........................................ 691
haloperidol .................................................................. 61
haloperidol conc 2mg/ml ...................................... 61
haloperidol decanoate ............................................ 61
haloperidol lactate inj 5mg/ml............................ 61
HAMMER TOE GEL CUSHION ............................. 361
HANKSCRAFT VAOPRIZER INHA ...................... 361
HARD NAILS............................................................. 361
HARMONIE UNDERPAD ........................................ 361
HARMONIE UNDERPAD EXTRA P...................... 361
HARMONIE UNDERPAD REGULAR.................... 361
HARMONIE UNDERPAD SECURE ...................... 361
HARMONIE UNDERPAD ULTRA ......................... 361
HARVONI ..................................................................... 28
HAVRIX ...................................................................... 103
head congestion cold reli .................................... 361
headache daytim and sinus .............................................................. 563
headache formula .................................................. 361
headache formula added st ............................... 361
headache pain-reliever ........................................ 361
headache pm ........................................................... 361
headache pm formula .......................................... 361
headache relief ....................................................... 361
headache relief pm................................................ 361
headache relief/extra str .................................... 361
headrin ex strength pain ..................................... 361
HEAL AID PLUS ....................................................... 361
HEALTH CARE LANCING DEVIC ........................ 361
HEALTHWISE LANCING PEN .............................. 361
HEALTHY ACCENTS AUTOLET I ........................ 361
healthy eyes ............................................................ 362
healthy eyes/lutein ............................................... 362
healthy hair skin & nails ...................................... 362
healthy heart ........................................................... 362
HEALTHY HEART COMPLEX ................................ 362
healthy kids cod liver oi ...................................... 362
HEALTHY KIDS GUMMIES ................................... 362
healthy kids overall hea ...................................... 362
HEALTHY KIDS VITAMIN C/RO ......................... 362
healthy kids vitamin d3 ....................................... 362
HEALTHY LIVING REPLACEMEN ........................ 362
healthy mama eazzze the p ............................... 362
healthy mama move it alon ............................... 362
healthy mama shake that a ............................... 362
healthy mama tame the fla ............................... 362
healthylax ................................................................... 90
HEART ........................................................................ 362
HEART SAVIOR ....................................................... 362
heartburn antacid extra s ............................. 83, 362
heartburn relief ................................................. 87, 362
heartburn relief 150 maxi ................................... 362
heartburn relief 24 hour ...................................... 362
heartburn relief maximum ................................. 362
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 763
heartburn treatment 24 ho .......................... 94, 362
h-e-b aspirin ............................................................ 360
H-E-B INCONTROL ADVANCED......................... 360
h-e-b oral electrolyte so ...................................... 360
HEEL LINERS ........................................................... 363
HEMA-COMBISTIX ................................................. 363
HEMATEX .................................................................. 363
hematron .................................................................. 363
HEMATRON DROPS ............................................... 363
HEMATRON-AF ........................................................ 363
hemax ........................................................................ 363
HEMOCYTE................................................................ 363
hemorrhoid ............................................................... 363
hemorrhoidal ........................................................... 363
HEMORRHOIDAL .................................................... 363
hemorrhoidal cooling ............................................ 363
hemorrhoidal cooling gel .................................... 363
hemorrhoidal hygiene pads ............................... 363
hemorrhoidal maximum stre ............................. 363
hemorrhoidal relief ................................................ 363
hemorrhoidal suppositorie .................................. 363
hem-prep .................................................................. 363
HEPAMENT ................................................................ 363
heparin sod (porcine) in d5w .............................. 97
heparin sod inj 1000/ml ........................................ 97
heparin sod inj 10000/ml ..................................... 97
heparin sod inj 20000/ml ..................................... 97
heparin sod inj 5000/ml ........................................ 97
HEPARIN SODIUM/NACL 0.45% ........................ 97
hepatamine .............................................................. 665
HERBAL EXPEC ....................................................... 363
herbiomed allergy cold & .................................... 364
HERBIOMED DEEP COLD AND F ....................... 364
HERBIOMED FAST ACTING BOD ...................... 364
herbiomed severe cold & f ................................. 364
HERCEPTIN ................................................................. 35
HETLIOZ ...................................................................... 66
HEXASORB DISPOSABLE UNDER ..................... 364
hi c-500 ..................................................................... 364
HIBERIX ..................................................................... 103
HIBICLENS ............................................................... 364
HIGH CAPACITY PADS ......................................... 364
HIGH CAPACITY PADS/TAILS ............................ 364
high potency calcium ........................................... 364
high potency iron ................................................... 364
HIGH POTENCY IRON ........................................... 364
HIGH POTENCY PROBIOTIC ............................... 364
hi-kovite 2-part formula ...................................... 364
hi-potency multi-vitamin/ ................................... 364
histafed ...................................................................... 364
HISTAFLEX ............................................................... 364
HISTEX ....................................................................... 364
HISTEX PD ................................................................ 364
HISTEX PDX ............................................................. 364
HISTEX-AC ............................................................... 364
HISTEX-DM .............................................................. 364
HISTEX-PE ................................................................ 365
hist-pse ...................................................................... 364
HM 4X PROBIOTIC ................................................. 365
hm acetaminophen children .............................. 365
hm acetaminophen pm extra ............................ 365
hm acid reducer ............................................... 87, 365
hm acid reducer maximum s ............................. 365
HM ACIDOPHILUS .................................................. 365
hm acidophilus probiotic ..................................... 365
hm advanced antacid maxim ...................... 83, 365
hm all day allergy .......................................... 365, 679
hm all day allergy childr ...................................... 365
hm allergy......................................................... 365, 679
hm allergy & congestion ..................................... 365
hm allergy childrens ..................................... 365, 679
hm allergy complete child .................................. 365
hm allergy complete-d ................................. 365, 683
hm allergy relief ............................................. 365, 679
hm allergy relief & nasal ............................. 365, 683
hm allergy relief childre ...................................... 365
hm allergy relief nasal s ...................................... 365
hm allgery multi symptom ......................... 365, 679
hm animal shapes ................................................. 366
hm antacid ................................................................. 83
hm antacid anti-gas extra ............................ 83, 366
hm antacid/antigas ......................................... 83, 366
hm anti-diarrheal ............................................. 84, 366
hm anti-nausea ...................................................... 366
hm antioxidant vitamins ..................................... 366
hm antiseptic skin cleans.................................... 366
hm arthiritis creme ............................................... 366
hm arthritis pain relief ................................... 12, 366
hm artificial tears ................................................... 366
hm aspirin ........................................................... 12, 366
hm aspirin ec ..................................................... 12, 366
hm aspirin ec low dose .................................. 12, 366
hm bacitracin ................................................... 366, 689
hm biotin ................................................................... 366
HM CALAMINE ......................................................... 366
hm calcium 600 & vitamin ................................. 366
hm calcium 600 + d plus m ............................... 366
hm calcium 600 + vitamin ................................. 366
hm calcium antacid ......................................... 83, 366
hm calcium antacid extra ............................. 83, 366
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 764
hm calcium antacid smooth ......................... 83, 366
hm calcium antacid ultra .................................... 367
hm calcium citrate + vita ................................... 367
hm calcium citrate+d3 pet ................................. 367
hm calcium magnesium & zi ............................. 367
hm calcium/vitamin d .......................................... 367
hm calcium/vitamin d/mine ............................... 367
hm cetirizine hcl childre .............................. 367, 679
hm cetirizine hydrochlori .................................... 367
hm chest congestion relie .......................... 367, 683
hm chest rub ........................................................... 367
hm clear fiber .......................................................... 367
hm clearlax ........................................................ 90, 367
hm cold & allergy childre .................................... 367
hm cold & cough childrens ................................. 367
hm cold & sinus relief ........................................... 367
hm cold flu & sore throat .................................... 367
hm complete ............................................................ 367
HM COMPLETE ......................................................... 367
hm complete 50+ .................................................. 367
HM COMPLETE 50+ MENS ULTI ....................... 367
HM COMPLETE 50+ WOMENS UL .................... 367
hm complete dual action .................................... 367
hm complete women ............................................ 367
hm coq10 .................................................................. 368
hm cough dm .......................................................... 368
hm cough relief....................................................... 368
hm day time ............................................................ 368
hm day time liquid caps ...................................... 368
hm daytime cold & flu .......................................... 368
hm double antibiotic ............................................. 368
hm dry eye relief.................................................... 368
hm e vitamin ........................................................... 368
hm earwax removal aid ....................................... 368
hm earwax removal kit ........................................ 368
hm enema ................................................................ 368
hm enema mineral oil .......................................... 368
hm enema ready-to-use ............................... 90, 368
hm enema saline laxative............................. 90, 368
HM ENTRUST PLUS BLADDER C ....................... 368
HM ENTRUST PLUS DISPOSABL ....................... 368
HM ENTRUST PLUS UNDERPAD ........................ 368
hm epsom salt ........................................................ 368
hm esomeprazole magnesium .......................... 368
HM ESTROPLUS ...................................................... 368
hm eye drops .......................................................... 368
hm eye drops redness reli .................................. 368
hm eye itch relief ................................................... 369
HM EYELID WIPES ................................................. 369
hm famotidine ................................................... 87, 369
hm fexofenadine hcl ..................................... 369, 679
hm fexofenadine hydrochlo ....................... 369, 679
hm fiber ............................................................... 90, 369
HM FIBER POWDER ............................................... 369
hm fish oil ................................................................. 369
hm folic acid ............................................................ 369
hm gas relief ............................................................ 369
hm gas relief extra stren .................................... 369
hm gas relief infants ............................................. 369
hm gas relief infants dro ..................................... 369
HM GLUCOSE ..................................................... 80, 369
hm glycerin .............................................................. 369
HM HAIR/SKIN/NAILS .......................................... 369
hm hemorrhoidal ................................................... 369
hm hydrocortisone plus ............................... 369, 691
hm hydrocortisone/aloe ma ....................... 369, 692
hm hydrogen peroxide ......................................... 369
hm ibuprofen ............................................. 15, 369, 370
hm ibuprofen childrens .................................. 15, 370
hm ibuprofen ib ................................................ 15, 370
hm ibuprofen infants ............................................ 370
hm ibuprofen pm ................................................... 370
HM IODIDES TINCTURE ...................................... 370
HM IODINE TINCTURE ......................................... 370
hm iron ...................................................................... 370
hm iron slow release ............................................ 370
hm isopropyl alcohol............................................. 370
hm isopropyl rubbing alco .................................. 370
HM ISOPROPYL RUBBING ALCO ....................... 370
HM ISOPRPYL RUBBING ALCOH ....................... 370
hm lansoprazole ............................................... 94, 370
hm laxative ........................................................ 90, 370
hm lice killing maximum s ................................. 370
hm lice treatment .......................................... 370, 695
hm loperamide hcl ................................................. 370
hm loratadine .................................................. 370, 679
hm loratadine childrens ............................... 370, 679
hm lubricating plus ....................................... 371, 675
hm lubricating tears...................................... 371, 675
hm magnesium ....................................................... 371
hm magnesium citrate ......................................... 371
hm medicated cooling pads ............................... 371
hm mens 50+ advanced one ............................ 371
HM MENS UNDERWEAR MAXIMUM.................. 371
hm migraine formula ............................................ 371
hm migraine relief ................................................. 371
hm milk of magnesia ...................................... 90, 371
hm mineral oil ......................................................... 371
hm motion relief ..................................................... 371
hm motion sickness .............................................. 371
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 765
hm motion sickness relief ................................... 371
hm mucus er ................................................... 371, 683
hm mucus relief d .................................................. 371
hm mucus relief dm maximu ............................ 371
hm mucus relief fm cold & ................................. 371
hm mucus relief fm cold/f .................................. 371
hm mucus relief fm severe ................................ 371
hm mucus relief multi-sym ................................ 371
hm multi-purpose solution ................................. 371
hm multivitamin adult gum ............................... 371
hm muscle rub ........................................................ 372
hm naproxen sodium ........................................... 372
hm nasal decongestant ............................... 372, 683
hm nasal decongestant 12 ................................. 372
hm nasal decongestant pe ................................. 372
hm nasal spray ....................................................... 372
hm niacin .................................................................. 372
hm niacin tr .............................................................. 372
hm nicotine polacrilex .................................... 70, 372
hm nicotine transdermal s ........................... 70, 372
hm night time cold & flu ..................................... 372
hm night time multi sympt ................................ 372
hm night time multi-sympt ................................ 372
hm nighttime sleep aid ........................................ 372
hm nose drops extra stren ................................. 372
HM OMEPRAZOLE............................................. 95, 372
hm one daily essential ......................................... 372
HM ONE DAILY ESSENTIAL ................................ 372
HM ONE DAILY MENS ........................................... 372
HM ONE DAILY PRENATAL COM ....................... 372
HM ONE DAILY WOMENS .................................... 372
hm one daily/iron .................................................. 372
hm pain & fever childrens ............................ 12, 373
hm pain & fever infants ................................. 12, 373
hm pain relief .......................................................... 373
hm pain relief childrens ....................................... 373
hm pain relief extra stre ............................... 12, 373
hm pain reliever ............................................... 12, 373
hm pain reliever pm extra.................................. 373
hm pediatric electrolyte ...................................... 373
hm petroleum jelly ................................................ 373
hm potassium ......................................................... 373
hm povidone-iodine .............................................. 373
HM PRENATAL ......................................................... 373
hm probiotic digestive he ................................... 373
hm rapid melts junior .......................................... 373
hm saline nasal spray .......................................... 373
hm selenium ............................................................ 373
hm senna ............................................................ 90, 373
hm senna-s .............................................................. 373
hm severe cold & flu ............................................. 373
hm severe cold cough & fl .................................. 373
hm severe cold/cough/flu ................................... 373
hm severe congestion & co ................................ 373
hm sinus & cold-d .................................................. 373
hm sinus nasal spray............................................ 374
hm sleep aid ............................................................ 374
hm slow release iron ............................................ 374
hm sore throat spray............................................ 374
hm stay awake ....................................................... 374
hm stomach relief .................................................. 374
hm stomach relief maximum ............................ 374
hm stool softener ............................................. 90, 374
hm stool softener maximum ............................. 374
hm stool softener/laxativ .................................... 374
hm stool softener/stimula .................................. 374
hm super vitamin b comple ............................... 374
hm super vitamin b12 .......................................... 374
hm triple antibiotic ................................................ 374
hm triple antibiotic plus....................................... 374
hm trueplus fiber ................................................... 374
hm tussin adult ............................................... 374, 683
hm tussin adult cough & c .......................... 374, 683
hm tussin adult multi-sym ................................. 374
hm tussin cough/chest con ................................ 374
HM UNDERPADS 23 .............................................. 374
hm vitamin b complex/vita ................................ 375
hm vitamin b1 ......................................................... 375
hm vitamin b100 complex .................................. 375
hm vitamin b12 ...................................................... 375
hm vitamin b12 tr.................................................. 375
hm vitamin b12 ultra stre .................................. 375
hm vitamin b50 complex .................................... 375
hm vitamin b6 ......................................................... 375
hm vitamin c ............................................................ 375
hm vitamin c tr ....................................................... 375
hm vitamin c/rose hips ........................................ 375
hm vitamin d ........................................................... 375
hm vitamin d3 ......................................................... 375
HM VITAMIN D3 ..................................................... 375
hm vitamin e ........................................................... 375
hm vita-mini multi comple ................................. 374
hm witch hazel ........................................................ 375
hm womens 50+ advanced on ......................... 375
hm zinc ...................................................................... 375
hm z-sleep ................................................................ 375
HOLD .......................................................................... 375
HOMOCYSTEINE FORMULA ................................ 375
HONEY BEARS ......................................................... 375
HONEY BEARS W/IRON AND ZI ....................... 375
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 766
hot pain-rel and tgt cold ......................................................... 606
hot steam.................................................................. 376
hpa lanolin ................................................................ 376
h-r lubricating jelly ................................................ 360
h-r lubricating jelly 2-x ........................................ 360
h-r lubricating jelly one ....................................... 360
HUDSON RCI SEE-THRU AEROS ...................... 376
HUGGIES DIAPER RASH CREAM ...................... 376
HUMIRA ............................................................... 99, 100
HUMIRA INJ 10MG/0.2ML ................................... 100
HUMIRA KIT 20MG/0.4ML .................................. 100
HUMIRA KIT 40MG/0.8ML .................................. 100
HUMIRA PEDIATRIC CROHNS DISEASE ........ 100
HUMIRA PEN ............................................................ 100
HUMIRA PEN CD/UC/HS STARTER .................. 100
HUMIRA PEN INJ CD/UC/HS STARTER .......... 100
HUMIRA PEN INJ PS/UV STARTER................... 100
HUMIRA PEN-PS/UV STARTER .......................... 100
humist ........................................................................ 376
HUMULIN R INJ U-500 ........................................... 72
HUMULIN R U-500 KWIKPEN .............................. 72
HW EMBRACE PRO BLOOD GLUC .................... 376
HW EMBRACE TALK BLOOD GLU ..................... 376
HYALEX ...................................................................... 376
HYCOFENIX .............................................................. 376
HYCOLOID-GRX ...................................................... 376
hydralazine hcl .......................................................... 50
HYDRALYTE .............................................................. 377
HYDRALYTE FREEZER POPS ............................... 377
HYDRASYN25........................................................... 377
HYDRAZONE LOTION ........................................... 377
hydrisalic ................................................................... 377
hydro skin maximum streng ............................. 377
hydrocerin................................................................. 377
HYDROCERIN ........................................................... 377
hydrocerin moisturizing e ................................... 377
hydrocerin plus ....................................................... 377
hydrochlorothiazide ................................................ 49
HYDROCIL INSTANT ............................................. 377
hydroco/apap tab 10-325mg .............................. 17
hydroco/apap tab 5-325mg ................................. 17
hydroco/apap tab 7.5-325 ................................... 17
HYDROCODONE BITARTRATE/GU ................... 377
hydrocodone polistirex-chlorpheniramine
polistirex ............................................................... 377
hydrocodone w/ homatropine ........................... 377
hydrocodone-acetaminophen 7.5-325
mg/15ml ................................................................. 18
hydrocodone-ibuprofen tab 7.5-200 mg......... 18
hydrocol 6 ................................................................. 377
HYDROCOL II........................................................... 377
HYDROCOL II SACRAL ......................................... 377
HYDROCOL II THIN ............................................... 377
hydrocortisone .......................................................... 79
hydrocortisone (enema) ........................................ 88
hydrocortisone (topical) ...................... 377, 378, 692
hydrocortisone 1% in abso ................................ 377
hydrocortisone acetate (topical) ...................... 378
hydrocortisone butyrate cream 0.1% ............ 692
hydrocortisone butyrate oint 0.1% ................. 692
hydrocortisone in absorba .................................. 378
hydrocortisone intensive ..................................... 378
hydrocortisone maximum st ...................... 378, 692
hydrocortisone plus ............................................... 378
hydrocortisone valerate....................................... 692
hydrocortisone-aloe vera ............................ 378, 692
HYDROCREAM BASE WATER IN ....................... 378
HYDROFERA BLUE 4 ............................................. 378
HYDROFERA BLUE FOAM DRESS ..................... 378
HYDROFERA BLUE HEAVY DRAI ....................... 378
HYDROFERA BLUE READY FOAM ...................... 378
hydrogen peroxide ................................................ 378
HYDROGEN PEROXIDE ......................................... 378
HYDRO-LAN .............................................................. 377
hydrolatum ............................................................... 378
hydromet .................................................................. 378
hydromorphone hcl ................................................. 18
hydrophor ................................................................. 378
hydroskin .......................................................... 378, 692
hydroxocobalamin acetate ......................... 378, 670
hydroxychloroquine sulfate ................................ 100
hydroxyurea ............................................................... 40
hydroxyzine hcl ...................................................... 679
hydroxyzine hcl inj ................................................ 679
hydroxyzine pamoate ........................................... 679
hylavite ...................................................................... 378
HYPAFIX/5 CM X 10M/2 ...................................... 378
HYPERSAL ................................................................. 378
HYPER-SAL ............................................................... 378
hypotears .................................................................. 379
HYPOTEARS .............................................................. 379
hysept ........................................................................ 379
HYSINGLA ER ............................................................ 18
HYVEE ADVANCED ANTACID MA ..................... 379
hy-vee all day relief .............................................. 376
HY-VEE GLUCOSE .................................................. 376
hyvee ibuprofen childrens .................................. 379
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 767
I
I.L.X. B-12 ................................................................ 379
I.S.P. HAND & BODY ............................................ 379
IB FULL MAT BRIEF LARGE ................................ 379
IB FULL MAT BRIEF MEDIUM ............................. 379
ibandronate sodium ................................................ 76
IBG STAR BLOOD GLUCOSE MO ...................... 379
IBRANCE ...................................................................... 35
ibu tab 600mg .......................................................... 15
ibu tab 800mg .......................................................... 15
ibu-200 ................................................................ 15, 379
ibu-drops ................................................................... 379
ibu-drops infants .................................................... 379
ibuprofen ............................................................. 15, 379
ibuprofen 100 junior stre .................................... 379
ibuprofen childrens ......................................... 16, 379
ibuprofen cold & sinus ......................................... 379
ibu-profen cold/sinus ........................................... 379
ibuprofen infants .................................................... 380
ibuprofen junior strength .................................... 380
ibuprofen pm ........................................................... 380
ibuprofen tab 200 mg .......................................... 380
ibuprofen/pseudoephedrine ............................... 380
icaps ............................................................................ 380
icaps areds 2 ........................................................... 380
ICAPS AREDS 2 ...................................................... 380
ICAPS AREDS FORMULA...................................... 380
icaps lutein & omega-3 ........................................ 380
ICAPS LUTEIN & ZEAXANTHIN ......................... 380
ICAPS LUTEIN/ZEAXANTHIN ............................. 380
ICAPS LUTEIN/ZEAXANTHIN F ......................... 380
icaps mv ............................................................ 380, 670
ICAPS PLUS .............................................................. 380
ICAPS TAB ................................................................ 380
ICAR ............................................................................ 380
ICAR PEDIATRIC .................................................... 380
ICAR-C ....................................................................... 380
icar-c plus ................................................................. 380
ice blue gel ............................................................... 380
ICHTHAMMOL .......................................................... 380
ICLUSIG ....................................................................... 38
icy hot balm extra streng ................................... 380
icy hot extra strength .......................................... 381
ICY HOT NO-MESS VAPOR GEL ........................ 381
IDHIFA ......................................................................... 35
iferex 150 ........................................................... 98, 381
IFEX INJ 3GM ............................................................ 33
ifosfamide inj 1gm/20ml ....................................... 33
IFOSFAMIDE INJ 3GM ............................................ 33
ifosfamide inj 3gm/60ml ....................................... 33
IGLUCOSE BLOOD GLUCOSE MO..................... 381
IGLUCOSE BLOOD GLUCOSE TE ...................... 381
ILEVRO ....................................................................... 673
ILEX SKIN PROTECTANT ..................................... 381
imatinib mesylate .................................................... 39
IMBRUVICA ................................................................ 39
imipenem-cilastatin ................................................ 21
imipramine hcl .......................................................... 58
imiquimod ................................................................. 694
IMMUNE SUPPORT ................................................. 381
IMMUNE SUPPORT VITAMIN C .......................... 381
immunicare .............................................................. 381
IMODIUM A-D .......................................................... 381
IMODIUM ADVANCED ........................................... 381
IMODIUM MULTI-SYMPTOM REL ...................... 381
IMOVAX RABIES (H.D.C.V.) ............................... 103
IN TOUCH ................................................................. 381
IN TOUCH BLOOD GLUCOSE TE ....................... 381
IN TOUCH LANCING DEVICE ............................. 381
INCONTINENCE BRIEF/LARGE .......................... 381
INCONTINENCE BRIEF/MEDIUM ...................... 381
INCRELEX .................................................................... 80
INCRUSE ELLIPTA .................................................. 677
indapamide ................................................................. 49
INFANRIX .................................................................. 103
INFANTS ADVIL ...................................................... 381
infants gas relief .................................................... 381
infants ibuprofen .................................................... 381
infants medi-tabs ................................................... 381
infants pain & fever............................................... 381
infants pain relief ................................................... 381
infants pain reliever .............................................. 382
INFANTS SILAPAP .................................................. 382
infants simethicone ............................................... 382
INFED ................................................................... 98, 382
INFINITY BLOOD GLUCOSE MO ....................... 382
INFINITY BLOOD GLUCOSE TE ......................... 382
INFINITY VOICE ..................................................... 382
INFUVITE ADULT .................................................... 382
INFUVITE PEDIATRIC ........................................... 382
INJECTAFER ............................................................. 382
INLYTA ......................................................................... 39
INNOSPIRE REPLACEMENT FIL ......................... 382
INSTACLEAN ............................................................ 382
INSTACORT 10 ........................................................ 382
instacort 5 ................................................................ 382
INSTA-GLUCOSE .................................................... 382
instant pain relief ................................................... 382
INSULIN PEN NEEDLE ............................................ 72
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 768
INSULIN SAFETY NEEDLES .................................. 72
INSULIN SYRINGE ................................................... 72
INTEGRA.................................................................... 382
INTELENCE ................................................................. 24
intense cold/flu medicine .................................... 382
intense cough reliever ......................................... 382
intense cough reliever do ................................... 382
intense cough reliever ex ................................... 382
intestinex .................................................................. 382
INTRALIPID 30% ................................................... 665
intralipid inj 20% ................................................... 665
INTRINSI B12/FOLATE ......................................... 382
INTRON-A INJ 10MU ............................................. 101
INTRON-A INJ 18MU ............................................. 101
INTRON-A INJ 25MU ............................................. 101
INTRON-A INJ 50MU ............................................. 101
INULOSE BLOOD SUGAR SUPPO ..................... 383
INVANZ ........................................................................ 21
INVEGA SUST INJ 117 MG/0.75 ML ................. 62
INVEGA SUST INJ 156MG/ML ............................. 62
INVEGA SUST INJ 234 MG/1.5 ML .................... 62
INVEGA SUST INJ 39 MG/0.25 ML .................... 61
INVEGA SUST INJ 78 MG/0.5 ML ...................... 61
INVEGA TRINZA ....................................................... 62
INVIRASE .................................................................... 24
invisible acne maximum st ................................ 383
invisible acne treatment ...................................... 383
IODEX ......................................................................... 383
IODIDES TINCTURE .............................................. 383
IODINE ....................................................................... 383
iodine (kelp) ............................................................ 383
IODINE TINCTURE ................................................. 383
IODINE TINCTURE MILD ..................................... 383
IODINE TINCTURE STRONG .............................. 383
IODINE TINCTURE STRONG DE ....................... 383
IONIL .......................................................................... 383
ionil-t .......................................................................... 383
IONOSOL-MB/DEXTROSE 5% ........................... 666
iophen c-nr ............................................................... 383
iophen dm-nr ........................................................... 383
iophen-nr .................................................................. 383
IOSAT ......................................................................... 383
ipecac ......................................................................... 383
IPECAC ....................................................................... 383
IPOL INACTIVATED IPV ....................................... 103
ipratropium bromide ............................................. 677
ipratropium bromide (nasal) ............................. 677
ipratropium-albuterol nebu ................................ 677
i-prin ........................................................................... 379
irbesartan ................................................................... 44
irbesartan-hydrochlorothiazide........................... 44
IRESSA ......................................................................... 39
irinotecan hcl ............................................................. 41
IROFOL....................................................................... 383
iromin-g ..................................................................... 383
IRON ........................................................................... 383
iron 100 plus............................................................ 384
iron 100/c ................................................................. 384
IRON 21/7 ................................................................ 384
iron 27 ........................................................................ 384
IRON CHEWS PEDIATRIC.................................... 384
iron complex ............................................................ 384
IRON FORMULA ...................................................... 384
iron slow release .................................................... 384
iron supplement ..................................................... 384
iron supplement childrens .................................. 384
IRON UP .................................................................... 384
iron w/ vitamins ..................................................... 384
IRO-PLEX................................................................... 383
ISENTRESS ................................................................. 24
ISENTRESS HD ......................................................... 24
ISOLEUCINE ............................................................. 384
ISOLEUCINE 1000 ................................................. 384
ISOLYTE P ................................................................. 666
ISOLYTE S ................................................................ 666
isoniazid....................................................................... 27
isoniazid syp 50mg/5ml ........................................ 27
isopropyl alcohol .................................................... 384
ISOPROPYL ALCOHOL .......................................... 384
isopropyl alcohol, rubbing ................................. 384
ISOPTO TEARS ........................................................ 384
isosorb mononitrate tab ........................................ 50
isosorbide dinitrate ................................................. 50
isosorbide dinitrate er ............................................ 50
isosorbide mononitrate er .................................... 50
isotretinoin ............................................................... 688
isradipine .................................................................... 48
ITCH RELIEF............................................................. 384
itch relief extra strengt ........................................ 384
ITCH-ENDER! ........................................................... 384
ITCH-X ....................................................................... 384
itraconazole ................................................................ 23
ivermectin ................................................................... 21
i-vite ........................................................................... 379
i-vite protect ............................................................ 379
IXIARO ....................................................................... 103
J
J & J BURN CREAM ................................................ 384
J & J FIRST AID CREAM ....................................... 385
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 769
J & J GERM FILTER MASK ................................... 385
J&J CREAM PROTECTANT .................................... 385
JADENU ........................................................................ 77
JADENU SPRINKLE .................................................. 77
JAKAFI .......................................................................... 39
jantoven ...................................................................... 97
JANUMET ..................................................................... 74
JANUMET XR TAB 100-1000 ................................ 74
JANUMET XR TAB 50-1000 .................................. 74
JANUMET XR TAB 50-500MG ............................... 74
JANUVIA ...................................................................... 75
JARDIANCE ................................................................. 75
JENTADUETO ............................................................. 75
JENTADUETO TAB XR 2.5-1000 MG ................. 75
JENTADUETO TAB XR 5-1000 MG ..................... 75
JESSNERS ................................................................. 385
jinteli ............................................................................. 78
J-MAX ......................................................................... 385
JOBST IT STAYS/ROLL-ON ................................. 385
jock itch ..................................................................... 385
jock itch relief ......................................................... 385
jock itch spray......................................................... 385
jock itch spray powder ........................................ 385
JOHNSONS BABY ................................................... 385
JOHNSONS BABY INTENSE MOI ....................... 385
JOHNSONS BODY CARE 24 HOU ...................... 385
JOHNSONS BODY CARE BE RAD ...................... 385
JOHNSONS BODY CARE DEEP H ...................... 385
JOHNSONS BODY CARE FOREVE ..................... 385
JOHNSONS BODY CARE MELT A ...................... 385
johnsons diaper rash ............................................ 385
JOHNSONS HEAD-TO-TOE EXTR...................... 385
johnsons no more rash ........................................ 385
jr strength non-aspirin......................................... 385
J-TAN D PD ............................................................... 385
J-TAN PD ................................................................... 385
JULUCA ........................................................................ 26
junior mapap ........................................................... 386
just d .......................................................................... 386
just for kids .............................................................. 386
just tears eye drops .............................................. 386
JUXTAPID .................................................................... 46
K
k 100 .......................................................................... 386
K2 PLUS D3 .............................................................. 386
KADCYLA ..................................................................... 35
KALA ........................................................................... 386
KALETRA TAB 100-25MG ...................................... 26
KALETRA TAB 200-50MG ...................................... 27
KALTOSTAT .............................................................. 386
KALTOSTAT FORTEX ............................................. 386
KALTOSTAT WOUND DRESSING ...................... 386
KALYDECO ................................................................ 686
kaminos ..................................................................... 386
KAOLIN ...................................................................... 387
KAOLIN COLLOIDAL .............................................. 387
KAOLIN/PECTIN ...................................................... 387
kaopectate ................................................................ 387
kaopectate extra strength .................................. 387
kaopectate stool softener ................................... 387
KAOPECTATE STOOL SOFTENER ...................... 387
kao-tin .......................................................... 91, 386, 387
KAZ BACTERIOSTATIC TREATM ....................... 387
KAZ INHALANT ....................................................... 387
KAZ WATER TREATMENT .................................... 387
kcl 0.075%/d5w/nacl 0.45% ............................ 666
KCL 0.15%/D5W/NACL 0.225% ...................... 666
kcl 0.15%/d5w/nacl 0.9% ................................. 666
kcl 0.3%/d5w/nacl 0.45% ................................. 666
KCL 0.3%/D5W/NACL 0.9% .............................. 666
kcl/d5w inj 0.3% .................................................... 667
kcl/d5w/nacl inj .15/.33%.................................. 667
kcl/d5w/nacl inj .15/.45%.................................. 667
kcl/d5w/nacl inj 0.22%/0.45% ........................ 667
kcl/nacl inj 0.15%-0.9% ..................................... 667
kcl/nacl inj 0.3-0.9 ................................................ 667
kcl0.15%/d5w/nacl0.2% .................................... 666
keep alert .................................................................. 387
KELARX ...................................................................... 387
kelo-cote ................................................................... 387
KENDALL ALGINATE HYDROCOL ...................... 387
KENDALL WASHCLOTHS ..................................... 387
KENDALL WASHCLOTHS/NOVONE .................. 387
KENDALL ZINC CALCIUM ALGI ......................... 387
KERADAN .................................................................. 387
KERALYT .................................................................... 387
KERAMATRIX REPLICINE 10CM ........................ 387
KERAMATRIX REPLICINE 5CMX ........................ 387
KERASAL FUNGAL NAIL RENEW ....................... 387
KERI ADVANCED MOISTURE TH ...................... 388
KERI BASIC ESSENTIALS ................................... 388
KERI LONG LASTING ............................................ 388
KERI NOURISHING SHEA BUTT ........................ 388
KERI ORIGINAL ...................................................... 388
KERI OVERNIGHT .................................................. 388
KERI RENEWAL MILK BODY ............................... 388
KERI RENEWAL SKIN FIRMING ........................ 388
KERI RENEWAL STRETCH MARK ...................... 388
KERI SENSITIVE SKIN ......................................... 388
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 770
kericort 10 ................................................................ 388
KERLIX SUPER SPONGE SALIN......................... 388
kerodex-51 dry/oily .............................................. 388
kerodex-71 wet ...................................................... 388
kerr insta-char ........................................................ 388
KETOCARE ................................................................ 388
ketoconazole .............................................................. 23
ketoconazole cream .............................................. 690
ketoconazole shampoo ........................................ 691
KETO-DIASTIX ........................................................ 388
KETONE TEST STRIPS .......................................... 388
ketorolac tromethamine (ophth) ..................... 674
KETOSTIX ................................................................. 388
ketotifen fumarate (ophth) ................................ 388
KEY-E .......................................................................... 388
KEYTRUDA .................................................................. 35
kidkare cough/cold ................................................ 683
KIDNEY ...................................................................... 388
kids first vitamin d3 gum .................................... 388
kids gummy bear vitamins ................................. 389
kids vitamins ........................................................... 389
kids vitamins complete ........................................ 389
kids vitamins plus extra ...................................... 389
kids vitamins plus iron ......................................... 389
KINERASE ................................................................. 389
KINRIX ....................................................................... 103
kionex sus 15gm/60ml .......................................... 77
KISQALI ....................................................................... 35
KISQALI FEMARA 200 DOSE ............................... 35
KISQALI FEMARA 400 DOSE ............................... 35
KISQALI FEMARA 600 DOSE ............................... 35
kita la tos-dm .......................................................... 389
klor-con 10 ............................................................... 663
klor-con 8 ................................................................. 663
klor-con m10 ........................................................... 663
klor-con m15 ........................................................... 663
klor-con m20 ........................................................... 663
klor-con pak 20meq .............................................. 663
klor-con spr cap 10meq ...................................... 663
klor-con spr cap 8meq ......................................... 663
KLOUT ........................................................................ 389
kls acetaminophen extra s ................................. 389
kls acid controller compl ..................................... 389
kls acid controller maxim .................................... 389
kls acid reducer ...................................................... 389
kls acid reducer maximum ................................. 389
kls allerclear ............................................................. 389
kls allerclear d-12 hr ............................................ 389
kls allerclear d-12hr .............................................. 389
kls allerclear d-24hr .............................................. 389
kls allerclear-d 24hr .............................................. 389
kls aller-fex .............................................................. 389
kls aller-flo................................................................ 389
kls allergy medicine .............................................. 390
kls aller-tec .............................................................. 389
kls aller-tec childrens ........................................... 389
kls aller-tec d ........................................................... 389
kls antacid ................................................................ 390
kls anti-diarrheal .................................................... 390
kls arthritis pain ..................................................... 390
kls aspirin ec ............................................................ 390
kls aspirin low dose ............................................... 390
kls cold & flu multi-symp .................................... 390
kls esomeprazole magnesiu ............................... 390
kls fiber-tabs............................................................ 390
kls hydrocortisone plus ........................................ 390
kls ibuprofen ............................................................ 390
kls ibuprofen ib ....................................................... 390
kls infants pain relief ............................................ 390
kls lansoprazole ...................................................... 390
kls laxaclear ............................................................. 390
kls mucus relief chest .......................................... 390
kls multi-symptom cold ch ................................. 390
kls naproxen sodium ............................................ 390
kls nasal decongestant sp .................................. 390
kls natural psyllium fibe ...................................... 390
kls nighttime cold multi- ..................................... 390
kls non aspirin ......................................................... 390
kls non-aspirin pm ................................................. 390
KLS OMEPRAZOLE ................................................. 391
kls pain & fever infants ........................................ 391
kls pain relief childrens ........................................ 391
kls quit2 ..................................................................... 391
kls quit4 ..................................................................... 391
kls rapid release pain re ...................................... 391
kls sleep aid ............................................................. 391
kls stool softener.................................................... 391
kls suphedrine pe................................................... 391
kobee .......................................................................... 391
KOKO PEAK PRO REPLACEMENT ...................... 391
konsyl ................................................................... 91, 391
KONSYL................................................................ 91, 391
konsyl daily fiber .................................................... 391
KONSYL DAILY FIBER ..................................... 91, 391
konsyl fiber ................................................................. 91
KONSYL ORIGINAL FORMULA D ....................... 391
KONSYL-D ........................................................... 91, 391
KORLYM ....................................................................... 80
kosher care .............................................................. 391
KOSHER CARE ALLERGY RELIE ........................ 391
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 771
kosher care dm ....................................................... 392
KOTEX CURVED MAXI .......................................... 392
KOTEX LIGHTDAYS EXTRA COV ....................... 392
KOTEX LIGHTDAYS PANTILINE ........................ 392
KOTEX MAXI ............................................................ 392
KOTEX MAXI LIGHTDAYS PANT ........................ 392
KOTEX MAXI OVERNITE ...................................... 392
KOTEX MAXI OVERNITE WITH .......................... 392
KOTEX MAXI PADS ................................................ 392
KOTEX MAXI WITH WINGS ................................ 392
KOTEX OVERNITE PAD ........................................ 392
KOTEX SUPER MAXI/LONG ................................ 392
KOTEX SUPER MAXI/LONG WIT ....................... 392
KOTEX THIN MAXI ................................................. 392
KOTEX ULTRA COMPACT MAXI ......................... 392
KOTEX ULTRA MAXI OVERNIGH ....................... 392
KOTEX ULTRA THIN LONG MAX ....................... 392
KOTEX ULTRA THIN MAXI .................................. 392
KOTEX ULTRA THIN MAXI WIT ......................... 392
KOTEX ULTRA THIN MAXI/LON ........................ 392
kp adults 50+ daily formu .................................. 392
kp adults daily formula ........................................ 392
kp aspirin .................................................................. 392
kp b complex/c ....................................................... 393
kp bacitracin zinc ................................................... 393
kp benzoyl peroxide .............................................. 393
kp benzoyl peroxide wash .................................. 393
kp bisacodyl ............................................................. 393
kp calcium 600+d .................................................. 393
kp calcium 600+d3 ............................................... 393
kp calcium citrate+d ............................................. 393
kp calcium/magnesium/zinc .............................. 393
kp cetirizine hcl ...................................................... 393
kp clotrimazole ....................................................... 393
kp diphenhydramine hcl ...................................... 393
kp double antibiotic............................................... 393
kp ferrous gluconate ............................................. 393
kp ferrous sulfate ................................................... 393
kp fexofenadine hcl ............................................... 393
kp fish oil .................................................................. 393
kp fluticasone propionate ................................... 393
kp folic acid .............................................................. 393
KP GENTLE SKIN CLEANSER ............................. 393
kp glucosamine chondroiti ................................. 393
kp hydrocortisone .................................................. 393
kp hydrocortisone maximum ............................. 393
kp hydrocortisone/aloe ........................................ 394
kp ketotifen fumarate .......................................... 394
kp loratadine............................................................ 394
kp mag-oxide magnesium .................................. 394
kp melatonin ............................................................ 394
kp mens 50+ daily formula ............................... 394
kp mens daily formula ......................................... 394
KP MENS DAILY PACK .......................................... 394
kp miconazole nitrate ........................................... 394
kp niacin .................................................................... 394
kp omega-3 fish oil ............................................... 394
kp omeprazole magnesium ................................ 394
KP PRENATAL MULTIVITAMINS ........................ 394
kp pseudoephedrine hcl ...................................... 394
kp senna .................................................................... 394
kp terbinafine hydrochlor ................................... 394
kp tolnaftate ............................................................ 394
kp vision formula ................................................... 394
kp vision formula w/lutei .................................... 394
kp vitamin b-12 ...................................................... 394
kp vitamin b-6 ........................................................ 394
kp vitamin d ............................................................. 394
kp vitamin d3 .......................................................... 394
kp vitamin e ............................................................. 395
kp womens 50+ daily formu ............................. 395
kp womens daily formula.................................... 395
KP WOMENS DAILY PACK ................................... 395
K-PAX IMMUNE SUPPORT FORM ...................... 386
k-pec ........................................................................... 386
KPN PRENATAL ....................................................... 395
KROGER BLOOD GLUCOSE MONI .................... 395
KROGER BLOOD GLUCOSE TEST ..................... 395
kroger glucose ........................................................ 395
KROGER GLUCOSE ................................................ 395
KROGER LANCING DEVICE ................................ 395
KROGER PREMIUM BLOOD GLUC .................... 395
KROGER TEST STRIPS ......................................... 395
ks ibuprofen ............................................................. 395
ks stool softener ..................................................... 395
KUVAN .......................................................................... 78
k-y intrigue ............................................................... 386
k-y intrigue heat .................................................... 386
k-y jelly ...................................................................... 386
k-y lubricant jelly sensi ....................................... 386
k-y lubricating jelly ............................................... 386
k-y tingling jelly ..................................................... 386
k-y ultragel ............................................................... 386
k-y warming jelly ................................................... 386
k-y yours+mine couples ..................................... 386
KYNAMRO .................................................................... 46
L
labetalol hcl ................................................................ 47
LABSTIX..................................................................... 396
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 772
LABSTIX TES ........................................................... 396
LAC-HYDRIN ............................................................ 396
lac-hydrin five ......................................................... 396
LAC-HYDRIN TWELVE ........................................... 396
lactated ringer's ..................................................... 667
lactic acid (ammonium lactate) ........................ 396
LACTICARE ............................................................... 396
lactinex ...................................................................... 396
LACTINEX .................................................................. 396
LACTINOL HX .......................................................... 396
lactobacillus ............................................................. 396
lactobacillus acidophilus-pectin ........................ 396
lactobacillus extra stren ...................................... 396
lacto-key-100 .......................................................... 396
lacto-key-600 .......................................................... 396
LACTO-PECTIN ........................................................ 396
LACTOSE MONOHYDRATE .................................. 396
lactulose ...................................................................... 91
lactulose (encephalopathy) .................................. 91
LADY DIGNITY PLUS PANTIES .......................... 396
LADY DIGNITY WOMENS PANTY ...................... 397
LADY ESTHER 4 PURPOSE FAC ......................... 397
LAMBS WOOL .......................................................... 397
LAMISIL ADVANCED ............................................. 397
lamisil af defense ........................................... 397, 690
LAMISIL AT ............................................................... 397
LAMISIL AT ATHLETES FOOT ............................ 397
LAMISIL AT JOCK ITCH ....................................... 397
LAMISIL AT SPRAY ................................................ 397
lamivudine .................................................................. 25
lamivudine (hbv) ...................................................... 28
lamivudine-zidovudine ........................................... 27
lamotrigine ................................................................. 54
lanabiotic ................................................................... 397
LANAPHILIC ............................................................. 397
LANAPHILIC/UREA ................................................. 397
LANCET DEVICE ADJUSTABLE .......................... 397
LANCET DEVICE WITH EJECTO ........................ 397
LANCING DEVICE ................................................... 397
LANCING DEVICE ADJUSTABLE ....................... 397
LAND BEFORE TIME BRIEF/JU .......................... 397
land before time multivit .................................... 397
lanolin ......................................................................... 397
LANOLOR ................................................................... 397
lan-o-soothe ............................................................ 397
lansinoh for breastfeedin .................................... 397
lansoprazole ....................................................... 95, 398
LANTISEPTIC SKIN PROTECTA ......................... 398
LANTISEPTIC THERAPEUTIC .............................. 398
LANZO ........................................................................ 398
L-ARGININE ............................................................. 395
l-arginine double strengt .................................... 395
l-arginine maximum streng ............................... 395
l-arginine-500 ......................................................... 395
larynex ....................................................................... 398
LASTACAFT ............................................................... 674
latanoprost ............................................................... 674
LATUDA ........................................................................ 62
laxa basic .................................................................. 398
laxacin ........................................................................ 398
laxative ................................................................ 91, 398
laxative feminine .................................................... 398
laxative pills maximum st ............................. 91, 398
laxative pills regular st ........................................ 398
laxative with senna ............................................... 398
lc-4 lidocaine ........................................................... 398
lc-5 lidocaine ........................................................... 398
L-CARNITINE ........................................................... 395
L-CARNITINE FUMARATE .................................... 395
L-CITRULLINE .......................................................... 395
LDR BLOOD GLUCOSE TRUETES ...................... 398
LEADER ADVANCED LANCING D ...................... 398
LEADER FINGER CREAM ...................................... 398
LEADER GLUCOSE ................................................. 398
LEADER QUICK DISSOLVE GLU ........................ 398
LECITHIN .................................................................. 398
lee saline nasal spray ........................................... 398
leflunomide ............................................................... 100
LEG-GESIC ............................................................... 398
LENVIMA 10 MG DAILY DOSE ............................. 39
LENVIMA 12MG DAILY DOSE .............................. 39
LENVIMA 14 MG DAILY DOSE ............................. 39
LENVIMA 18 MG DAILY DOSE ............................. 39
LENVIMA 20 MG DAILY DOSE ............................. 39
LENVIMA 24 MG DAILY DOSE ............................. 39
LENVIMA 4 MG DAILY DOSE ................................ 39
LENVIMA 8 MG DAILY DOSE ................................ 39
LETAIRIS ..................................................................... 51
letrozole ....................................................................... 36
LEUCINE .................................................................... 399
leucovorin calcium ................................................... 41
LEUKERAN .................................................................. 33
leuprolide inj 1mg/0.2 ........................................... 36
levalbuterol hcl ....................................................... 681
levalbuterol hcl soln nebu conc 1.25
mg/0.5ml ............................................................. 681
levalbuterol tartrate hfa ...................................... 681
LEVEMIR ...................................................................... 72
LEVEMIR FLEXTOUCH ............................................. 72
levetiracetam ............................................................. 54
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 773
levetiracetam in sodium chloride ....................... 54
levetiracetam oral soln 100 mg/ml ................... 54
LEVITRA ..................................................................... 399
levobunolol hcl ........................................................ 675
levocarnitine ............................................................ 399
levocarnitine (metabolic modifiers) .................. 78
levocetirizine dihydrochloride ........................... 679
levofloxacin ................................................................ 31
levofloxacin in d5w.................................................. 31
levofloxacin inj 25mg/ml ...................................... 31
levofloxacin oral soln 25 mg/ml ......................... 31
levo-t ............................................................................ 81
levothyroxine sodium ............................................. 81
levoxyl .......................................................................... 81
lexinal ......................................................................... 399
LEXIVA ......................................................................... 25
LIBERTY BLOOD GLUCOSE MET ....................... 399
LIBERTY BLOOD GLUCOSE MON ...................... 399
LIBERTY MINI LANCING DEVI ........................... 399
LIBERTY NEXT GENERATION B ......................... 399
LIBERTY TEST STRIPS ......................................... 399
lice egg remover .................................................... 399
lice killing maximum stre ............................ 399, 695
lice killing shampoo .............................................. 399
lice md ....................................................................... 399
lice solution complete .......................................... 399
lice solution kit ........................................................ 399
lice treatment .......................................................... 399
lice treatment creme rins ................................... 399
lice treatment maximum st ............................... 399
LICEMD ...................................................................... 399
liceout ......................................................................... 399
liceout combo pak/comb ..................................... 399
licide ........................................................................... 399
licide complete lice trea....................................... 400
licide maximum strength .................................... 400
LICIDE TREATMENT KIT ...................................... 400
lidocaine ............................................................ 400, 693
lidocaine (anorectal) ............................................. 400
lidocaine hcl ............................................................. 693
lidocaine hcl (local anesth.) ................................. 19
lidocaine hcl (mouth-throat) ............................. 696
lidocaine inj 0.5% .................................................... 20
lidocaine inj 1% ........................................................ 20
lidocaine inj 1.5% preservative free (pf) ....... 20
lidocaine oint 5% ................................................... 693
lidocaine-prilocaine ............................................... 693
lidocaine-transparent dressing ......................... 400
lidocream .................................................................. 400
LIFE PACK MENS .................................................... 400
LIFE PACK WOMENS ............................................. 400
LIGHT SHIELD ......................................................... 400
LIGHT SHIELD DELUXE SLEEP .......................... 400
LIGHTDAYS LONG PANTYLINER ....................... 400
linezolid in sodium chloride .................................. 21
linezolid inj ................................................................. 21
linezolid susp ............................................................. 21
linezolid tab 600mg ................................................ 21
LINZESS ...................................................................... 94
liothyronine sodium ................................................ 81
lip balm ...................................................................... 400
LIP BALM BASE ....................................................... 400
lip balm/vitamin e/aloe ....................................... 400
LIP MEDEX ................................................................ 400
lip treatment ............................................................ 400
lip-guard .................................................................... 400
LIPIDSHIELD PLUS ................................................ 400
lipmagik ..................................................................... 400
lipocomplex .............................................................. 400
lipoflavonoid ............................................................. 401
lipo-flavonoid plus ................................................. 400
lipoflavovit ................................................................ 401
lipogen sg ................................................................. 401
LIPOIC ACID ............................................................ 401
lipo-key ...................................................................... 400
LIPOTRIAD ................................................................ 401
LIPOTRIAD VISION SUPPORT ........................... 401
LIPOTRIAD VISIONARY........................................ 401
LIQ-10 ........................................................................ 401
LIQSORB ................................................................... 401
LIQUACEL .................................................................. 401
LIQUACEL PROTEIN FREEZE P .......................... 401
LIQUACEL PUMP + GO ......................................... 401
liqua-gel .................................................................... 401
liquibid ....................................................................... 401
liquibid d-r ................................................................ 401
LIQUIBID PD-R ....................................................... 401
liquid bandage......................................................... 401
LIQUID C ................................................................... 401
LIQUID C 500 .......................................................... 401
LIQUID CALCIUM WITH D3 MA ........................ 401
liquid calcium/d3 .................................................... 401
LIQUID CALCIUM/MAGNESIUM ........................ 401
liquid calcium/vitamin d ...................................... 402
LIQUID CALCIUM/VITAMINS A ......................... 402
liquid corn & callus remo .................................... 402
liquid pain relief ...................................................... 402
liqui-e ......................................................................... 401
liquitears ........................................................... 402, 675
liquituss gg ............................................................... 402
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 774
lisinopril ....................................................................... 42
lisinopril & hydrochlorothiazide .......................... 42
L-ISOLEUCINE ......................................................... 395
LISTERINE ................................................................ 402
LISTERINE ANTISEPTIC....................................... 402
LISTERINE NATURALS ANTISE ......................... 402
LISTERINE POCKETMIST ..................................... 402
LISTERINE ULTRACLEAN/EVER ........................ 402
LISTERINE ZERO .................................................... 402
LITE TOUCH LANCING DEVICE ......................... 402
LITE TOUCH LANCING PEN ................................ 402
LITETOUCH MASK LARGE ................................... 402
LITETOUCH MASK MEDIUM ............................... 402
LITETOUCH MASK SMALL ................................... 402
lithium carbonate ..................................................... 67
lithium carbonate er ............................................... 67
LITHIUM SOLN 8MEQ/5ML ................................... 67
little animals ............................................................ 402
little animals plus iron ......................................... 402
little animals/iron ................................................... 402
LITTLE COLDS COUGH FORMUL ....................... 402
LITTLE NOSES DECONGESTANT ...................... 402
LITTLE NOSES MOISTURIZING ........................ 402
little noses saline ................................................... 403
little noses stuffy nose ......................................... 403
little remedies fever/pai ...................................... 403
LITTLE REMEDIES FOR COLDS ......................... 403
little remedies for fever ....................................... 403
little remedies for tummy ................................... 403
little teethers oral pain ........................................ 403
little tummys gas relief ........................................ 403
little tummys nausea reli .................................... 403
little tummys yummy fiber ................................. 403
LIVE BETTER ADVANCED LANC ........................ 403
LIVER .......................................................................... 403
LIVER EXTRACT ...................................................... 403
L-LEUCINE ................................................................ 396
LMX 4 ......................................................................... 403
LMX 4 PLUS .............................................................. 403
LMX 5 ......................................................................... 403
lobana bath oil ........................................................ 403
LOBANA BODY LOTION........................................ 403
LOBANA PERI-GARDE ........................................... 403
LOBOB SOFT LENS CLEANER ............................ 403
LOCALNESIUM......................................................... 403
LOCALNESIUM-C .................................................... 403
LODRANE D .............................................................. 403
LOHIST-D .................................................................. 404
LOHIST-DM .............................................................. 404
lohist-peb .................................................................. 404
lohist-peb-dm .......................................................... 404
long acting nasal spray ........................................ 404
long lasting antacid ............................................... 404
long lasting nasal spray ...................................... 404
LONGEVITY ............................................................... 404
LONGEVITY PLUS ................................................... 404
LONGS GLUCOSE ................................................... 404
LONSURF ..................................................................... 40
loperamide a-d ....................................................... 404
loperamide hcl ............................................ 85, 94, 404
lopinavir-ritonavir .................................................... 27
loradamed ................................................................. 404
loratadine .......................................................... 404, 680
loratadine & pseudoephedrine .......................... 404
loratadine allergy relief........................................ 404
loratadine childrens ...................................... 405, 680
loratadine hives relief ........................................... 405
loratadine-d 12hr ........................................... 405, 683
loratadine-d 24hr ........................................... 405, 683
lorazepam ................................................................... 52
lorazepam intensol .................................................. 52
LORBRENA .................................................................. 39
lorcet hd tab 10-325mg ........................................ 18
lorcet plus tab 7.5-325 .......................................... 18
lorcet tab 5-325mg ................................................. 18
LORTUSS DM ........................................................... 405
LORTUSS EX ............................................................ 405
LORTUSS LQ ............................................................ 405
losartan potassium .................................................. 44
losartan-hydrochlorothiazide ............................... 44
LOTEMAX ................................................................... 674
lotrimin af ................................................................. 405
LOTRIMIN AF ........................................................... 405
lotrimin af deodorant pow .................................. 405
LOTRIMIN AF FOR HER ........................................ 405
LOTRIMIN AF JOCK ITCH .................................... 405
lotrimin af jock itch pow...................................... 405
lotrimin af powder ................................................. 405
LOTRIMIN ULTRA ................................................... 405
lovastatin .................................................................... 45
LOW DOSE ASA TAB 81MG ................................ 405
loxapine succinate ................................................... 62
L-THREONINE .......................................................... 396
L-TRYPTOPHAN ....................................................... 396
L-TYROSINE ............................................................. 396
lubricant drops ........................................................ 405
lubricant eye ............................................................ 405
lubricant eye drops ....................................... 405, 676
lubricant eye drops dry e ............................ 405, 676
lubricant eye drops/dual- ................................... 405
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 775
lubricant eye fast acting...................................... 406
lubricant eye nighttime ....................................... 406
lubricants .................................................................. 406
lubricating eye drops .................................... 406, 676
lubricating jelly ....................................................... 406
lubricating plus eye drop .................................... 406
lubricating skin lotion ........................................... 406
lubricating& rewetting dr .................................... 406
LUBRICATING/REWETTING DRO ..................... 406
LUBRIDERM .............................................................. 406
LUBRIDERM ADVANCED THERAP ..................... 406
LUBRIDERM DAILY MOISTURE ......................... 406
LUBRIDERM DAILY MOISTURE/ ........................ 406
LUBRIDERM INTENSE SKIN RE ........................ 406
LUBRIDERM MENS 3-IN-1 .................................. 406
LUBRIDERM SERIOUSLY SENSI ....................... 406
LUBRIDERM SKIN NOURISHING ...................... 406
LUBRIDERM SOOTHING RELIEF ....................... 406
LUBRIDERM SPORT/MENS .................................. 406
lubrifresh p.m. ................................................ 406, 676
lubrisilk ...................................................................... 406
lubriskin ..................................................................... 406
LUBRISOFT ............................................................... 406
LUMIGAN ................................................................... 675
LUMITENE ................................................................. 407
LUMIZYME................................................................... 78
LUNG........................................................................... 407
LUNG PERFORMANCE PEAK FLO ...................... 407
LUPRON DEPOT (1-MONTH) ................................ 37
LUPRON DEPOT INJ 11.25MG (3-MONTH) ..... 37
LUPRON DEPOT-PED (1-MONTH ........................ 80
LUPRON DEPOT-PED (3-MONTH ........................ 80
LUPRON DEP-PED INJ 11.25MG (3-MONTH) . 80
LUPRON DEP-PED INJ 7.5MG .............................. 80
LUSAIR ....................................................................... 407
L-VALINE ................................................................... 396
LYCELLE ..................................................................... 407
lycopene .................................................................... 407
LYMPH ........................................................................ 407
LYNPARZA ................................................................... 35
LYRICA ......................................................................... 54
LYRICA CR .................................................................. 67
lysine .......................................................................... 407
LYSINE4000 ............................................................. 407
lysiplex plus ............................................................. 407
LYSODREN .................................................................. 37
M
M.V.I. ADULT ........................................................... 408
M.V.I.-12 WITHOUT VITAMIN ........................... 408
m2 b125 .................................................................... 407
M2 B-60 ..................................................................... 407
M2 CALCIUM ............................................................ 407
M2 CHROMIUM ........................................................ 407
m2 magnesium ....................................................... 407
M2 POTASSIUM ...................................................... 407
m2 zinc-50 ............................................................... 407
MAALOX ..................................................................... 408
maalox advanced ................................................... 408
maalox advanced maximum s .......................... 408
MAALOX ADVANCED MAXIMUM S ................... 408
maalox childrens .................................................... 408
maalox max ............................................................. 408
MAALOX MAX ........................................................... 408
maalox multi symptom maxi ............................. 408
MAALOX QUICK DISSOLVE MAX ...................... 408
MAALOX QUICK DISSOLVE REG ...................... 408
maalox regular strength...................................... 408
MAALOX TC .............................................................. 408
macular health formula ....................................... 408
MACULAR VITAMIN BENEFIT ............................. 408
macuvite.................................................................... 408
macuvite eye care ................................................. 408
macuvite/lutein ....................................................... 408
MAG GLYCINATE .................................................... 408
MAG-200 ................................................................... 408
MAG64........................................................................ 668
MAG-AL ...................................................................... 409
mag-al plus ................................................................ 83
mag-al plus xs ........................................................ 409
magbee ...................................................................... 409
mag-caps .................................................................. 409
MAGDELAY ................................................................ 409
mag-g ......................................................................... 409
MAGINEX ................................................................... 409
magnacaps ............................................................... 409
MAGNEBIND 200 .................................................... 409
MAGNEBIND 300 .................................................... 668
magnesium ....................................................... 409, 668
MAGNESIUM ............................................................ 409
magnesium aspartate-potassium aspartate 409
MAGNESIUM CARBONATE HEAVY .................... 409
MAGNESIUM CARBONATE LIGHT ..................... 409
MAGNESIUM CARBONATE POWDE .................. 409
magnesium chloride.............................................. 409
MAGNESIUM CHLORIDE ...................................... 409
MAGNESIUM CHLORIDE/CALCIU ..................... 409
magnesium citrate .......................................... 91, 410
MAGNESIUM CITRATE .................................. 409, 410
magnesium dr ......................................................... 410
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 776
MAGNESIUM ELEMENTAL .................................... 410
magnesium gluconate .......................................... 410
MAGNESIUM GLUCONATE .................................. 410
magnesium hydroxide ......................................... 410
magnesium lactate ................................................ 410
magnesium oxide ............................................ 83, 410
MAGNESIUM OXIDE .............................................. 410
magnesium oxide (mg supplement) ...... 410, 668
MAGNESIUM OXIDE HEAVY ............................... 410
MAGNESIUM OXIDE LIGHT ................................ 410
magnesium sulfate ................................................ 663
MAGNESIUM SULFATE ................................. 410, 663
magnesium sulfate (laxative) ........................... 410
MAGNESIUM SULFATE HEPTAHY ..................... 410
MAGNESIUM SULFATE IN D5W ........................ 664
magnesium sulfate in dextrose ........................ 664
magnesium sulfate inj 50% ............................... 664
magnesium-oxide .................................................. 410
magnum-75 ............................................................. 410
magonate .................................................................. 411
MAGONATE ............................................................... 410
MAGOX 400 .............................................................. 411
mag-sr ....................................................................... 409
MAG-SR PLUS CALCIUM ...................................... 409
MAG-TAB SR ............................................................ 409
major-prep hemorrhoidal ................................... 411
malathion .................................................................. 695
maldroxal .................................................................. 411
MAMMARY ................................................................. 411
manganese chloride .............................................. 411
MANHOOD ABSORBENT POUCH ....................... 411
MAOX .......................................................................... 411
mapap .................................................................. 12, 411
mapap acetaminophen extra ............................ 411
mapap arthritis pain ....................................... 12, 411
mapap childrens ......................................... 12, 13, 411
mapap cold formula multi- ................................. 411
mapap extra strength ............................................ 13
mapap pm ................................................................ 411
mapap sinus maximum stren ............................ 411
mapo bath oil .......................................................... 411
maprotiline hcl .......................................................... 58
MAR-COF BP ............................................................ 411
MAR-COF CG EXPECTORANT ............................. 411
MARPLAN TAB 10MG .............................................. 58
mar-zinc .................................................................... 411
MASK PEDIATRIC SIZE 1 .................................... 412
MASK PEDIATRIC SIZE 3 .................................... 412
MASK VORTEX/BABY WHIRL DU ...................... 412
MASK VORTEX/CHILD/FROG ............................. 412
MASK VORTEX/SPINNER THE D ....................... 412
MASK VORTEX/TODDLER/LADY ....................... 412
masophen ................................................................. 412
MATULANE .................................................................. 40
MAVYRET ..................................................................... 28
max strength complete ....................................... 412
MAXAM ....................................................................... 412
maxapap maximum strength ............................ 412
maxapap regular strength .................................. 412
MAXFE ........................................................................ 412
MAXFE DROPS ......................................................... 412
MAXI DEET ............................................................... 412
maxi life glucosamine/cho .................................. 412
MAXI PAD DEODORANT ....................................... 412
MAXI PAD LONG ULTRA THIN ........................... 412
MAXI PAD OVERNIGHT ........................................ 412
MAXI PAD OVERNIGHT THIN ............................. 412
MAXI PAD REGULAR ............................................. 412
MAXI PAD SUPER ................................................... 412
MAXI PAD SUPER LONG ...................................... 412
MAXI PAD ULTRA THIN ........................................ 412
MAXI PAD ULTRA THIN OVERN ........................ 413
MAXI WITH FLEXI-WINGS/LON ........................ 413
MAXI WITH FLEXI-WINGS/OVE ........................ 413
MAXICARE BELTED UNDERGARM .................... 413
MAXICHLOR PEH DM ............................................ 413
MAXIFED ................................................................... 413
MAXIFED DM ............................................................ 413
MAXILIFE RICE TOCOTRIENOL ......................... 413
maxilube .................................................................... 413
MAXIMA BLOOD GLUCOSE MONI .................... 413
MAXIMA BLOOD GLUCOSE TEST ..................... 413
MAXIMA METER KIT .............................................. 413
MAXIMA STARTER KIT ......................................... 413
MAXI-MASK .............................................................. 413
MAXIMIN PACK ....................................................... 413
maximum blue label ............................................. 413
maximum d3 ........................................................... 413
maximum daily green .......................................... 413
maximum green label .......................................... 413
maximum red label ............................................... 413
MAXIPHEN DM ......................................................... 413
MAXI-TUSS CD ....................................................... 413
MAXI-TUSS DM ....................................................... 413
MAXORB EXTRA AG+ ........................................... 414
M-CLEAR WC............................................................ 407
MCT OIL ..................................................................... 414
ME-500 ...................................................................... 414
mecholyl .................................................................... 414
meclizine hcl ...................................................... 85, 414
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 777
med-derm hydrocortisone .................................. 414
MEDELA TENDER CARE LANOLI ....................... 414
MEDERMA ................................................................. 414
MEDERMA AG BODY CLEANSER ....................... 414
MEDERMA AG FACE CREAM ............................... 414
MEDERMA AG FACIAL CLEANSE ....................... 414
MEDERMA AG FACIAL TONER ........................... 414
MEDERMA AG HAND & BODY LO ..................... 414
MEDERMA FOR KIDS ............................................ 414
mederma pm ........................................................... 414
MEDERMA SPF 30 .................................................. 414
MEDERMA STRETCH MARKS THE .................... 414
medi-bismuth .......................................................... 414
medi-brom ................................................................ 414
medicated anti-fungal .......................................... 416
medicated body ...................................................... 416
medicated body lotion ......................................... 416
medicated calamine .............................................. 416
medicated callus removers ................................ 416
medicated chest rub ............................................. 416
MEDICATED CHEST RUB ..................................... 416
medicated cleansing pads .................................. 416
medicated corn removers ................................... 416
medicated douche ................................................. 416
medicated feminine douche ............................... 416
medicated first aid spray .................................... 416
medicated rash ....................................................... 416
medicated wart removers ................................... 417
medicated wipes .................................................... 417
medicated wipes pre-moist ................................ 417
medicidin-d .............................................................. 417
MEDICINE SHOPPE FINGER ............................... 417
MEDICINE SHOPPE GLUCOSE ........................... 417
medicone................................................................... 417
medi-first anti-fungal ........................................... 414
medi-first triple antibio ........................................ 414
medi-gen ................................................................... 414
medi-gesic ................................................................ 415
MEDI-GRAINE .......................................................... 415
MEDIHONEY CALCIUM ALGINAT ...................... 417
MEDIHONEY WOUND & BURN DR ................... 417
MEDIHONEY WOUND/BURN DRES .................. 417
medikoff drops ........................................................ 417
medi-lax .................................................................... 415
medi-lice combing ................................................. 415
medi-lice shampoo ................................................ 415
MEDI-LYTE ................................................................ 415
medi-meclizine ........................................................ 415
medi-milk of magnesia ........................................ 415
medi-mucil ............................................................... 415
medi-natural ............................................................ 415
medi-natural plus .................................................. 415
MEDI-PAK PERFORMANCE PLUS ...................... 415
medi-phedrine ......................................................... 415
medi-phedryl ........................................................... 415
mediplast .................................................................. 417
mediplex plus .......................................................... 417
medi-profen ............................................................. 415
medi-profen cold/sinus ........................................ 415
mediproxen .............................................................. 417
medi-seltzer ............................................................. 415
medi-sleep ................................................................ 415
medi-soothe ............................................................. 415
medi-tabs .................................................................. 415
medi-tabs childrens .............................................. 415
medi-tabs extra strength .................................... 415
MEDI-TABS EXTRA STRENGTH ......................... 415
medi-tabs junor strength .................................... 416
medi-tabs pm extra streng ................................ 416
medi-tussin .............................................................. 416
MEDI-TUSSIN COUGH/COLD ............................. 416
medi-tussin dm ....................................................... 416
medi-tussin dm diabetic ...................................... 416
medi-tussin dm double str ................................. 416
medi-tussin max strength .................................. 416
medi-tussin pe ........................................................ 416
medi-tussin severe conges ................................ 416
mediwash eye irrigant ......................................... 417
medroxyprogesterone acetate tab .................... 81
medtycholl b complex .......................................... 417
mefloquine hcl ........................................................... 24
MEGA BIOTIN .......................................................... 417
mega coq10 ............................................................. 417
mega coq-10 ........................................................... 417
MEGA MULTI FOR MEN ........................................ 417
MEGA MULTI FOR WOMEN ................................. 417
MEGA MULTI MEN .................................................. 417
MEGA MULTI WOMEN ........................................... 417
mega multiple w/chelated .................................. 418
MEGA MULTIVITAMIN ........................................... 418
MEGA MULTIVITAMIN FOR MEN ....................... 418
MEGA MULTIVITAMIN FOR WOM ..................... 418
MEGA PROBIOTIC .................................................. 418
mega stress 600/60 .............................................. 418
mega vm-80 ............................................................ 418
MEGA ZINC-100 ..................................................... 418
MEGACE ES .............................................................. 418
mega-chol ................................................................. 418
mega-marathon 100 tr ........................................ 418
MEGAVITE FRUITS & VEGGIES ......................... 418
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 778
MEGAVITE GOLDEN YEARS 55+ ...................... 418
megestrol ac sus 40mg/ml .................................. 37
megestrol ac tab 20mg ......................................... 37
megestrol ac tab 40mg ......................................... 37
megestrol acetate (appetite) ............................ 418
megestrol sus 625mg/5ml ................................... 37
meijer advanced formula .................................... 418
meijer advanced formula f ................................. 418
meijer allergy relief ............................................... 418
meijer allergy relief-d .......................................... 418
meijer allergy/congestion ................................... 418
meijer antacid anti-gas ....................................... 418
meijer antacid maximum st ............................... 418
meijer anti-diarrheal............................................. 418
meijer antihistamine alle .................................... 418
meijer aspirin ec .................................................... 419
meijer aspirin free ................................................. 419
MEIJER BLOOD GLUCOSE MONI ...................... 419
MEIJER BLOOD GLUCOSE TEST ....................... 419
meijer c ..................................................................... 419
MEIJER CALAMINE ................................................. 419
meijer cough syrup dm ....................................... 419
MEIJER ESSENTIAL BLOOD GL ......................... 419
meijer ferrous sulfate ........................................... 419
MEIJER GLUCOSE .................................................. 419
meijer hydrocortisone .......................................... 419
meijer hydrogen peroxide .................................. 419
meijer ibuprofen ..................................................... 419
meijer jr strength aspiri ...................................... 419
meijer loratadine .................................................... 419
meijer migraine formula ..................................... 419
meijer nasal decongestant ................................. 419
MEIJER PREMIUM BLOOD GLUC ....................... 419
meijer saline nasal spray .................................... 419
meijer triple antibiotic .......................................... 419
MEIJER TRUE2GO BLOOD GLUC ...................... 419
MEIJER TRUERESULT BLOOD G ....................... 419
MEIJER TRUETEST BLOOD GLU ........................ 419
MEIJER TRUETRACK BLOOD GL ....................... 420
meijer zinc oxide .................................................... 420
MEKINIST .................................................................... 39
MEKTOVI ..................................................................... 39
melatin ....................................................................... 420
melatonin .................................................................. 420
MELATONIN .............................................................. 420
melatonin extra strength .................................... 420
melatonin maximum strengt ............................. 420
MELATONIN TIMED RELEASE ............................ 420
melatonin tr ............................................................. 420
melatonin/vitamin b-6 ext ................................. 420
melatonin-pyridoxine ........................................... 420
meloxicam .................................................................. 16
memantine hcl cp24 ............................................... 56
memantine soln ........................................................ 56
memantine tabs ....................................................... 56
memantine titration pak ....................................... 56
MENACTRA ............................................................... 103
m-end dm ................................................................. 407
M-END DMX.............................................................. 407
M-END MAX D ......................................................... 407
M-END PE .................................................................. 407
m-end wc .................................................................. 407
MENOPAUSE RELIEF ............................................. 420
menopause support .............................................. 420
MENOPAUSE TRIO ................................................. 420
men-phor .................................................................. 420
MENS 50+ ADVANCED ......................................... 420
MENS 50+ MULTI VITAMIN & ........................... 420
mens daily formula/lycope ................................. 421
mens hair formula ultra m ................................. 421
mens life pack ......................................................... 421
MENS MULTI VITAMIN & MINE ......................... 421
MENS PACK .............................................................. 421
menstrual complete .............................................. 421
menstrual pain relief mul .................................... 421
menstrual pms ........................................................ 421
menstrual relief maximum ................................. 421
MENTAX ..................................................................... 421
menthoderm ............................................................ 421
menthol cough drops............................................ 421
MENVEO..................................................................... 103
MEPHYTON........................................................ 421, 670
mercaptopurine ........................................................ 34
meribin ....................................................................... 670
meropenem ................................................................ 22
mesalamine ................................................................ 88
mesalamine w/ cleanser ....................................... 88
mesehist dm ............................................................ 421
mesehist wc ............................................................. 421
MESH PANTS LARGE ............................................. 421
MESH PANTS MEDIUM ......................................... 421
MESH PANTS X-LARGE ........................................ 421
MESNEX ....................................................................... 41
META APPETITE CONTROL ................................. 421
META BIOTIC/BIO-ACTIVE 12........................... 421
metadate er tab 20mg ........................................... 65
metamucil ................................................................. 421
METAMUCIL ...................................................... 421, 422
METAMUCIL FIBER ................................................ 422
metamucil multihealth fib ................................... 422
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 779
METAMUCIL MULTIHEALTH FIB ........................ 422
metamucil original textur ................................... 422
METAMUCIL ORIGINAL TEXTUR ....................... 422
metamucil smooth texture ................................. 422
METAMUCIL SMOOTH TEXTURE ....................... 422
metformin er ............................................................. 75
metformin hcl ............................................................ 75
methacholine/liver ................................................. 422
methadone hcl .......................................................... 18
methadone hcl 10mg ............................................. 18
methadone hcl 5mg ................................................ 18
methadone hcl intensol ......................................... 18
methagual................................................................. 422
methamphetamine hcl ......................................... 422
methazolamide ......................................................... 50
methenamine hippurate ........................................ 22
methimazole .............................................................. 81
METHIONINE ........................................................... 422
METHIONINE 500................................................... 422
methocarbamol ......................................................... 69
methotrexate sodium inj ...................................... 34
methotrexate sodium tabs ................................. 100
methyclothiazide ...................................................... 50
METHYL B-12 ........................................................... 422
METHYLCELLULOSE ............................................... 422
methylcobalamin .................................................... 422
methylphenidate hcl ............................................... 65
methylphenidate hcl oral soln ............................. 65
methylphenidate tab 10mg er ............................ 66
methylphenidate tab 20mg er ............................ 66
methylpr ss inj .......................................................... 79
methylpred pak 4mg .............................................. 79
methylpred tab 16mg ............................................ 79
methylpred tab 32mg ............................................ 79
methylpred tab 4mg ............................................... 79
methylpred tab 8mg ............................................... 79
methylprednisolone acetate ................................ 79
metoclopramide hcl................................................. 85
metoclopramide hcl inj .......................................... 85
metolazone ................................................................. 50
metoprolol & hctz tab 100-25mg ...................... 46
metoprolol & hctz tab 100-50mg ...................... 46
metoprolol & hctz tab 50-25mg ......................... 46
metoprolol succinate .............................................. 47
metoprolol tartrate .................................................. 47
metronidazole ........................................................... 22
metronidazole (topical) ....................................... 694
metronidazole gel 0.75% ................................... 694
metronidazole in nacl ............................................. 22
metronidazole vaginal ............................................ 96
mexiletine hcl ............................................................ 44
MEXSANA .................................................................. 422
MG/TAURINE FORTE ............................................. 422
MG217 MEDICATED TAR SHAMP ..................... 422
mg217 psoriasis anti-itch ................................... 422
mgo ............................................................................. 422
MG-PLUS PROTEIN ................................................ 422
MH MACULAR HEALTH ......................................... 423
m-hist dm ................................................................. 408
m-hist pd .................................................................. 408
mi-acid ......................................................................... 83
MI-ACID ....................................................................... 83
mi-acid gas relief ................................................... 423
mi-acid maximum strength.......................... 83, 423
MIADERM RADIATION RELIEF .......................... 423
micaderm .................................................................. 423
MICATIN .................................................................... 423
miconazole 1............................................................ 423
miconazole 3............................................................ 423
miconazole 3 combination .................................. 423
miconazole 3 combo pack .................................. 423
miconazole 7...................................................... 96, 423
miconazole antifungal .......................................... 423
miconazole nitrate (topical) ....................... 423, 690
miconazole nitrate vaginal ........................... 96, 423
miconazorb af .......................................................... 423
micro guard .............................................................. 423
MICROCYN ................................................................ 423
MICRODOT BLOOD GLUCOSE MO ................... 423
MICRODOT TEST STRIPS .................................... 423
MICROELITE FILTER REPLACE .......................... 424
MICROELITE RECHARGEABLE B ....................... 424
MICROKLENZ ANTISEPTIC WOU ...................... 424
MICROLET NEXT ..................................................... 424
MICROLIFE DIGITAL PEAK FL............................ 424
micronefrin ............................................................... 424
midodrine hcl ............................................................. 50
midol ........................................................................... 424
midol caffeine free ................................................. 424
MIDOL COMPLETE .................................................. 424
midol extended relief............................................ 424
MIDOL MAXIMUM STRENGTH ME .................... 424
midol teen ................................................................. 424
miglustat ..................................................................... 78
migraine formula.................................................... 424
migraine relief ......................................................... 424
MIGRELIEF ................................................................ 424
MIL ADREGEN.......................................................... 424
MILADRENE FORTE ............................................... 424
MIL-A-MULSION ..................................................... 424
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 780
milantex .................................................................... 424
milantex extra strength ....................................... 424
MILCO-B-FORTE ..................................................... 424
milk of magnesia .............................................. 91, 424
MILK OF MAGNESIA CONCENTR ...................... 424
millguard ................................................................... 425
milltrium advanced formul ................................. 425
milltrium cardio ...................................................... 425
milltrium senior ...................................................... 425
milltrium stamina plus ......................................... 425
MILPAN ...................................................................... 425
MILTAB #1 ............................................................... 425
mineral freez ........................................................... 425
mineral ice ................................................................ 425
mineral oil ................................................................. 425
MINERAL OIL ........................................................... 425
MINERAL OIL HEAVY ............................................ 425
MINERAL OIL LIGHT ............................................. 425
minerin....................................................................... 425
MINI LANCING DEVICE ........................................ 425
MINI WRIGHT AFS LOW RANGE ....................... 425
MINI WRIGHT AFS PEAK FLOW ........................ 425
MINI WRIGHT PEAK FLOW MET ....................... 425
MINI WRIGHT STD PEAK FLOW ....................... 425
MINIELITE FILTER REPLACEM ........................... 425
MINIELITE RECHARGEABLE BA ........................ 425
miniprin low dose .................................................. 425
minitran ....................................................................... 50
minocycline hcl ......................................................... 33
minoxidil ...................................................................... 50
mintox .................................................................. 84, 426
mintox maximum strength ................................ 426
mintox plus ........................................................ 84, 426
MINUS WEIGHT PLUS ENERGY ......................... 426
mirafiber .................................................................... 426
MIRALAX.................................................................... 426
mirtazapine ................................................................ 58
misoprostol................................................................. 94
MISSION PRENATAL ............................................. 426
MISSION PRENATAL HP ....................................... 426
MITIGARE ................................................................... 10
mitomycin ................................................................... 34
mm anti-diarrheal.................................................. 426
mm aspirin ............................................................... 426
MM BIOTIN/KERATIN ........................................... 426
MM EASY TOUCH BLOOD GLUCO .................... 426
MM EASY TOUCH GLUCOSE TES ...................... 426
MM LANCING DEVICE ........................................... 426
mm loratadine-d 24 hour ................................... 426
mm melatonin tr .................................................... 426
mm stool softener ................................................. 426
M-M-R II .................................................................... 103
M-NATAL PLUS ........................................................ 670
MOBISYL ................................................................... 426
MODESS FEMININE NAPKINS ........................... 426
MODESS FEMININE NAPKINS H ....................... 426
moexipril hcl .............................................................. 42
moexipril-hydrochlorothiazide ............................ 42
moist skin ................................................................. 426
MOIST WIPES FLUSHABLE ................................. 426
MOI-STIR .................................................................. 426
moisture barrier ..................................................... 427
MOISTURE BARRIER ............................................. 427
MOISTURE CREAM ................................................. 427
MOISTURE EYES ..................................................... 427
MOISTURE GUARD ................................................ 427
MOISTURE LOT ....................................................... 427
moisture lotion ........................................................ 427
moisture recovery ................................................. 427
moisturel therapeutic ........................................... 427
moisturizing cream................................................ 427
MOISTURIZING CREAM ....................................... 427
moisturizing lotion ................................................. 427
moisturizing lubricant ey .................................... 427
moisturizing sensitive sk ..................................... 427
moisturizing vitamin e ha ................................... 427
MOLDED HEEL CUSHIONS/MEN ....................... 427
MOLDED HEEL CUSHIONS/WOME ................... 427
MOLESKIN PLUS ..................................................... 427
MOLESKIN PLUS ROLL ......................................... 427
molindone hcl ............................................................ 62
MOLYBDENUM ......................................................... 427
MOMENTUM MUSCULAR BACKACH ................. 427
mometasone furoate ............................................ 692
mommys bliss gas relief d .................................. 427
MOMMYS BLISS MULTIVITAMIN ...................... 427
MOMMYS BLISS PROBIOTIC .............................. 428
MOMMYS BLISS VITAMIN D OR ....................... 428
mondoxyne nl cap 100mg .................................... 33
MONISTAT 1 COMBO PACK ................................ 428
MONISTAT 1 DAY OR NIGHT C ......................... 428
monistat 1-day ....................................................... 428
MONISTAT 3 ............................................................ 428
MONISTAT 3 COMBINATION PA ....................... 428
MONISTAT 7 COMBINATION PA ....................... 428
MONISTAT 7 CRE 2% ........................................... 428
MONISTAT 7 SIMPLY CURE ................................ 428
monistat soothing care ........................................ 428
MONISTAT SOOTHING CARE IT ....................... 428
MONOCAL ................................................................. 428
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 781
monoject pharma grade flu ............................... 428
monoject sodium chloride .................................. 428
montelukast sodium ............................................. 686
MORE-DOPHILUS ACIDOPHILUS ..................... 428
morgidox cap 1x50mg ........................................... 33
morphine ext-rel tab .............................................. 18
morphine sul inj 10mg/ml .................................... 18
morphine sul inj 1mg/ml ...................................... 18
MORPHINE SUL INJ 4MG/ML ............................... 18
morphine sulfate ...................................................... 19
MORPHINE SULFATE ............................................... 19
morphine sulfate oral soln 100mg/5ml ........... 19
morphine sulfate oral soln 10mg/5ml ............. 19
morphine sulfate oral soln 20mg/5ml ............. 19
mosco one step corn remov .............................. 428
MOTHERS FRIEND ................................................. 428
motion sickness ...................................................... 428
motion sickness relief .......................................... 428
motion sickness relief ii ....................................... 428
motion-time ....................................................... 86, 428
motrin cold & sinus ............................................... 428
motrin ib .................................................................... 429
MOTRIN INFANTS .................................................. 429
MOTRIN INFANTS DROPS ................................... 429
MOTRIN JUNIOR STRENGTH ............................. 429
motrin pm ................................................................. 429
MOUTHKOTE ............................................................ 429
MOVANTIK .................................................................. 94
MOVIPREP ................................................................... 91
MOXEZA..................................................................... 673
moxifloxacin hcl ........................................................ 31
moxifloxacin hcl (ophth) ..................................... 673
MPS ............................................................................. 429
MS QUICK DISSOLVE GLUCOSE ...................... 429
ms-aid ........................................................................ 429
MSM SKIN LOTION ................................................ 429
MTERYTI .................................................................... 429
MTERYTI FOLIC 5 ................................................... 429
MTX SUPPORT ......................................................... 429
mucaphed ................................................................. 429
MUCINEX ........................................................... 429, 683
mucinex allergy ...................................................... 429
mucinex chest congestion .......................... 429, 683
MUCINEX CHILDRENS COLD CO ...................... 429
MUCINEX CHILDRENS MULTI-S ....................... 429
MUCINEX COLD FOR KIDS ................................. 429
MUCINEX CONGESTION & COUG .................... 429
mucinex cough childrens .................................... 429
mucinex cough for kids ....................................... 429
MUCINEX COUGH FOR KIDS ............................. 430
MUCINEX D .............................................................. 430
MUCINEX D MAXIMUM STRENGT ..................... 430
MUCINEX DM ................................................... 430, 684
MUCINEX DM MAXIMUM STRENG ............ 430, 684
mucinex fast-max cold & s ................................. 430
MUCINEX FAST-MAX COLD & S ........................ 430
mucinex fast-max cold flu .................................. 430
MUCINEX FAST-MAX COLD FLU ....................... 430
MUCINEX FAST-MAX COLD/FLU ....................... 430
mucinex fast-max congesti ................................ 430
mucinex fast-max day time ............................... 430
MUCINEX FAST-MAX DAY TIME ........................ 430
MUCINEX FAST-MAX DAY/NIGH ....................... 430
MUCINEX FAST-MAX DAY/NITE ........................ 430
mucinex fast-max dm max ........................ 430, 684
mucinex fast-max night ti .................................. 430
mucinex fast-max severe c ................................ 430
MUCINEX FAST-MAX SEVERE C ....................... 430
MUCINEX FOR KIDS .............................................. 430
MUCINEX MAXIMUM STRENGTH ...................... 431
mucinex multi-symptom col .............................. 431
MUCINEX MULTI-SYMPTOM COL ...................... 431
mucinex nasal spray full ..................................... 431
mucinex nasal spray moist ................................ 431
MUCINEX SINUS-MAX DAY TIM ....................... 431
mucinex sinus-max day/nig .............................. 431
MUCINEX SINUS-MAX DAY/NIG ....................... 431
mucinex sinus-max full fo .................................. 431
mucinex sinus-max moistur .............................. 431
mucinex sinus-max night t ................................ 431
mucinex sinus-max pressur ............................... 431
mucinex sinus-max severe ................................ 431
MUCINEX SINUS-MAX SEVERE ......................... 431
MUCINEX STUFFY NOSE & COL ........................ 431
mucosa ...................................................................... 431
mucosa dm ............................................................... 431
mucus & cough relief chil ................................... 431
mucus congestion & cough ................................ 431
mucus d ..................................................................... 431
mucus d maximum strength ............................. 431
mucus relief ..................................................... 431, 684
mucus relief chest conges .................................. 432
mucus relief childrens .................................. 432, 684
mucus relief cold & sinus .................................... 432
mucus relief cold flu & s ...................................... 432
mucus relief cold/flu/sor ..................................... 432
mucus relief cold/sinus m ................................... 432
mucus relief cough childr ............................ 432, 684
mucus relief d ......................................................... 432
mucus relief dm .............................................. 432, 684
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 782
mucus relief dm cough ........................................ 432
mucus relief dm max............................................ 432
mucus relief dm maximum s ............................. 432
mucus relief er ........................................................ 432
mucus relief er 12 hour m .................................. 432
mucus relief multi sympto .................................. 432
mucus relief pe ....................................................... 432
mucus relief pe sinus con ................................... 432
mucus relief plus .................................................... 432
mucus relief severe cold ..................................... 432
mucus relief severe conge ................................. 432
mucus relief severe sinus ................................... 432
mucus relief sinus pressu ................................... 432
mucus relief sinus severe ................................... 433
mucus+chest congestion/ad ............................. 433
mucus-d .................................................................... 433
mucus-dm................................................................. 433
mucus-dm max....................................................... 433
mucus-dm maximum strength ......................... 433
mucus-er ................................................................... 433
mucusrelief sinus ................................................... 684
MULTAQ ....................................................................... 45
multi + omega-3 adult gum .............................. 433
multi adult gummies............................................. 433
multi antibiotic plus .............................................. 433
multi complete ........................................................ 433
multi complete/iron .............................................. 433
multi for her ............................................................. 433
MULTI FOR HER ...................................................... 433
multi for her 50+ ................................................... 433
multi for him ............................................................ 433
MULTI FOR HIM ...................................................... 433
multi for him 50+ .................................................. 433
MULTI MEGA MINERALS ...................................... 433
MULTI PRENATAL ................................................... 433
multi symptom flu & sever ................................. 433
MULTI VITAMIN ...................................................... 433
multi vitamin daily................................................. 433
multi vitamin mens ............................................... 434
multi vitamin with iron ........................................ 434
MULTI VITAMIN/D-3 ............................................. 434
MULTI-B COMPLEX ................................................ 434
MULTI-BETIC DIABETES ..................................... 434
multi-day ................................................................... 434
multi-day plus iron ................................................ 434
multi-day plus minerals ....................................... 434
multi-day vitamins ................................................ 434
multi-day w/calcium and e ...................................................................... 434
multi-day weight trim .......................................... 434
multi-delyn ............................................................... 434
MULTI-DELYN/IRON .............................................. 434
MULTI-GLAN ............................................................ 434
MULTI-LANCET DEVICE ....................................... 434
multi-lean ................................................................. 434
multilex ...................................................................... 435
multilex-t&m ............................................................ 435
multimineral plus ................................................... 435
MULTI-MINERALS .................................................. 434
multiple minerals ................................................... 435
multiple minerals w/ vitamins .......................... 435
multiple vitamin ..................................................... 435
multiple vitamin/minerals ................................... 435
multiple vitamins essenti .................................... 435
multiple vitamins w/ calcium ............................ 435
multiple vitamins w/ iron .................................... 435
multiple vitamins w/ minerals .......... 435, 436, 670
multiple vitamins/womens ................................. 436
MULTIPURPOSE CONTACT LENS ...................... 436
multi-purpose solutio n n ................................... 434
multi-purpose solution ......................................... 434
MULTI-PURPOSE SOLUTION .............................. 434
MULTISOURCE CALCIUM MAGNE ..................... 436
MULTISTIX ................................................................ 436
MULTISTIX 10 SG .................................................. 436
MULTISTIX 5 ............................................................ 436
MULTISTIX 7 ............................................................ 436
MULTISTIX 7 TES STRIPS................................... 436
MULTISTIX 8 SG .................................................... 436
MULTISTIX 9 ............................................................ 436
MULTISTIX 9 SG .................................................... 436
MULTISTIX TES SG STRIP .................................. 436
multi-symptom allergy ........................................ 434
multi-symptom cold childr ................................. 434
MULTI-SYMPTOM COLD DAYTIM ...................... 434
multi-symptom cold plus c ................................. 435
multi-symptom cold/cough ................................ 435
multivital ................................................................... 436
multivital platinum silve ...................................... 436
multivitamin ............................................................. 436
multi-vitamin ........................................................... 435
multivitamin & mineral ........................................ 436
MULTIVITAMIN ADULT ......................................... 436
MULTIVITAMIN ADULT EXTRA .......................... 436
multivitamin adults ............................................... 436
MULTIVITAMIN ADULTS ...................................... 436
multivitamin adults 50+ ...................................... 436
multivitamin childrens ......................................... 437
multi-vitamin daily ................................................ 435
multi-vitamin gummies ....................................... 435
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 783
multivitamin gummies adul ............................... 437
multivitamin gummies chil ................................. 437
MULTIVITAMIN GUMMIES CHIL ........................ 437
multivitamin gummies mens ............................. 437
multivitamin gummies wome ............................ 437
multi-vitamin hp/minerals .................................. 435
multivitamin iron-free .......................................... 437
MULTIVITAMIN MEN ............................................. 437
multivitamin men 50+ ......................................... 437
multivitamin mens................................................. 437
MULTI-VITAMIN MONOCAPS ............................. 435
MULTIVITAMIN PLUS IRON CH ......................... 437
multivitamin women ............................................. 437
multivitamin women 50+ ................................... 437
multivitamin womens ........................................... 437
multivitamin/extra vitami ................................... 437
multi-vitamin/menopausal ................................. 435
multi-vitamin/minerals ........................................ 435
multi-vitamin/multi-miner .................................. 435
MULTIVITAMIN+ .................................................... 437
multivitamins ........................................................... 437
multi-vitamins ......................................................... 435
multivitamins pediatric ........................................ 437
multi-vitamins/iron ............................................... 435
mupirocin .................................................................. 689
MURI-LUBE ............................................................... 437
MURINE...................................................................... 437
murine ear ................................................................ 437
murine ear drops ................................................... 437
murine for ear wax remova ............................... 437
murine for red eyes .............................................. 438
murine plus .............................................................. 438
murine tears for dry eyes ................................... 438
MURINE TEARS PLUS ........................................... 438
MURO 128 ......................................................... 438, 676
muscle rub ................................................................ 438
muscle rub ultra strength ................................... 438
MUSE .......................................................................... 438
mv-one ...................................................................... 438
mvw complete formulation ................................ 438
MVW COMPLETE FORMULATION ...................... 438
MX-SOL ...................................................................... 438
MX-SOL BLEND ....................................................... 438
MX-SOL BLEND SF................................................. 438
MX-SOL SF ............................................................... 438
MX-SOL SUSPEND ................................................. 438
myamulti ................................................................... 438
MYCAMINE .................................................................. 23
MYCELEX-7 ............................................................... 438
MYCITRACIN OIN ................................................... 438
MYCITRACIN OIN PLUS ....................................... 439
mycocide clinical ns anti ..................................... 439
mycophenolate mofetil ........................................ 102
mycophenolate sodium tbec .............................. 102
myferon 150 ............................................................ 439
MYGLUCOHEALTH BLOOD GLUCO ................... 439
MYKIDZ IRON .......................................................... 439
MYKIDZ IRON 10 ................................................... 439
MYLANTA ................................................................... 439
MYLANTA CHW ........................................................ 439
MYLANTA DOUBLE-STRENGTH ......................... 439
MYLANTA GAS ......................................................... 439
MYLANTA GAS CHW 80MG ................................. 439
MYLANTA GAS RELIEF MAXIMU........................ 439
mylanta maximum strength .............................. 439
MYLANTA SUS ......................................................... 439
MYLANTA ULTRA .................................................... 439
MYLICON ................................................................... 439
MYLICON INFANTS GAS RELIE ......................... 439
MYLOTARG .................................................................. 35
MYOFLEX ................................................................... 439
myorisan ................................................................... 688
MYRBETRIQ ................................................................ 95
mytab gas ................................................................. 439
mytab gas max str ................................................ 439
mytussin dm ............................................................ 439
my-vitalife ................................................................ 438
N
nabumetone ............................................................... 16
nac ............................................................................... 440
nac 600 ...................................................................... 440
nadolol ......................................................................... 47
nafcillin sodium ................................................... 31, 32
NAFCILLIN SODIUM FOR INJ 10GM .................. 32
NAGLAZYME ............................................................... 78
NAIL SCRUB ............................................................. 440
nail-ex ........................................................................ 440
nails formu and hair skin ....................................................... 360
nalbuphine hcl ........................................................... 17
naloxone inj 0.4mg/ml .......................................... 70
naloxone inj 1mg/ml .............................................. 70
naltrexone hcl ........................................................... 70
NAMZARIC .................................................................. 56
NANOVM 1-3 YEARS ............................................. 440
NANOVM 4-8 YEARS ............................................. 440
NANOVM 9-18 YEARS ........................................... 440
NANOVM T/F ............................................................ 440
NAPHCON-A ............................................................. 440
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 784
naproxen ..................................................................... 16
naproxen dr ............................................................... 16
naproxen sodium ............................................. 16, 440
naramin ..................................................................... 440
naratriptan hcl .......................................................... 67
NARCAN ....................................................................... 70
NASACORT ALLERGY 24HR ................................ 440
NASACORT ALLERGY 24HR CHI ....................... 440
NASADROPS SALINE ON THE G ....................... 440
nasal allergy ............................................................ 440
nasal allergy 24 hour ........................................... 440
nasal allergy 24 hour mul ................................... 440
nasal antiseptic ....................................................... 440
nasal decongestant ....................................... 440, 684
NASAL DECONGESTANT .............................. 440, 684
nasal decongestant maximu ...................... 440, 684
nasal decongestant pe ................................. 441, 684
nasal decongestant pe max ....................... 441, 684
nasal decongestant spray ........................... 441, 684
nasal four .................................................................. 441
nasal moist ............................................................... 441
nasal moisturizing spray ..................................... 441
nasal relief ................................................................ 684
nasal spray 12 hour ...................................... 441, 684
nasal spray anti-drip ............................................ 441
nasal spray extra moistur ................................... 441
nasal spray long acting........................................ 441
nasal spray maximum stren .............................. 441
nasal spray moisturizing ..................................... 441
nasal spray no drip ............................................... 441
nasal spray sinus ................................................... 441
nasal spray x-moist .............................................. 441
NASALCROM ............................................................ 441
NASCOBAL ................................................................ 670
nasogel ...................................................................... 441
nasohist ..................................................................... 441
NASOHIST DM......................................................... 441
NASOPEN .................................................................. 441
NASOPEN PE ............................................................ 441
NATACYN ................................................................... 673
nateglinide .................................................................. 75
NATPARA ..................................................................... 80
NATRAPEL ................................................................. 442
NATRAPEL 12-HOUR TICK & I ........................... 694
nat-rul antioxidants c+e ..................................... 441
nat-rul b-100 ........................................................... 442
nat-rul b-125 ........................................................... 442
nat-rul b-50 ............................................................. 441
NAT-RUL C-COMPLEX ........................................... 442
NAT-RUL C-COMPLEX TR .................................... 442
nat-rul coenzyme q-10 ........................................ 442
natrul colon care .................................................... 442
nat-rul daily-vite + iron ...................................... 442
nat-rul iron ............................................................... 442
natrul magnesium ................................................. 442
nat-rul oyster calcium + ..................................... 442
NAT-RUL PRENATAL VITAMINS ........................ 442
NATRUL PROBIOTIC .............................................. 442
NAT-RUL THERAVITE-M/HIGH .......................... 442
nat-rul vitamin d .................................................... 442
NATRUL-100 ............................................................ 442
NATRUL-CAL ............................................................ 442
NATRUL-CHEWS ..................................................... 442
NATRUL-MEGA-75 ................................................. 442
NATRUL-VITES ........................................................ 442
natural balance tears ........................................... 442
natural blend e-400 .............................................. 442
natural c/rose hips ................................................ 442
natural cod liver oil ............................................... 443
natural cold sore .................................................... 443
natural fiber ............................................................. 443
natural fiber laxative ............................................ 443
natural fiber therapy ...................................... 91, 443
natural herb ............................................................. 443
natural herb cough drops ................................... 443
natural mixed tocopherols .................................. 443
natural oatmeal bath trea .................................. 443
natural oyster shell calc ...................................... 443
natural psyllium seed ind.................................... 443
natural senna laxative ......................................... 443
natural vegetable ................................................... 443
natural vegetable fiber ........................................ 443
natural vegetable laxativ .................................... 443
natural vitamin a .................................................... 443
natural vitamin d-3 ............................................... 443
natural vitamin e .................................................... 443
NATURAL VITAMIN E ............................................ 443
NATURAL WHEY ...................................................... 443
naturalyte ................................................................. 443
natures tears ................................................... 443, 676
NATURES WASH PLUS ......................................... 444
nausatrol ................................................................... 444
nausea control ........................................................ 444
na-zone ...................................................................... 439
NEBULIZER AIR TUBE/PLUGS ........................... 444
NEBULIZER PEDIATRIC MASK .......................... 444
NEBUPENT .................................................................. 22
nebusal ...................................................................... 444
nefazodone hcl .......................................................... 58
NEOMULTIVITE ....................................................... 444
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 785
neomycin sulfate ...................................................... 20
neomycin-bacitracin zn-polymyxin ................. 673
neomycin-bacitracin-polymyxin ....................... 444
neomycin-bacitracin-polymyxin w/ lidocaine ................................................................................. 444
neomycin-polymy-dexameth............................. 672
neomycin-polymyxin-gramicidin ...................... 673
neomycin-polymyxin-hc (ophth) ..................... 672
neomycin-polymyxin-hc (otic) .......................... 696
NEONATAL VITAMIN ............................................. 444
NEOQ10 ..................................................................... 444
neosporin + pain relief m ................................... 444
neosporin af jock itch ........................................... 444
neosporin eczema essentia ................................ 444
NEOSPORIN ECZEMA ESSENTIA ...................... 444
NEOSPORIN LIP HEALTH OVER ........................ 444
NEOSPORIN ORIGINAL ........................................ 444
neosporin pain/itch/scar ..................................... 444
NEOSPORIN PLUS MAXIMUM ST ...................... 444
NEOSPORIN PLUS PAIN RELIE .......................... 444
NEO-SYNEPHRINE ................................................. 444
NEO-SYNEPHRINE 12 HOUR EX ....................... 444
NEO-SYNEPHRINE COLD & SIN ........................ 444
neotuss ...................................................................... 445
NEOTUSS-D ............................................................. 445
NEPHRAMINE ........................................................... 665
nephro vitamins ..................................................... 445
NEPHRONEX ............................................................. 445
NEPHRO-VITE .......................................................... 445
NERLYNX ..................................................................... 39
nervidox-6 nr........................................................... 445
NERVO B-12 SL ...................................................... 445
NESSI SPACER/LARGE MASK ............................ 445
NESSI SPACER/MOUTHPIECE ........................... 445
NESSI SPACER/SMALL/MED MA ....................... 445
NESTLE FLAVOR ..................................................... 445
NESTLE FLAVOR EXTRA STREN ........................ 445
NESTLE FLAVOR FOR KIDS ................................ 445
NEUPOGEN ................................................................. 97
NEUPRO ....................................................................... 59
NEURO VITE ............................................................. 445
NEURO-K-250 T.D. ................................................ 445
neuro-k-250 vitamin b6 ...................................... 445
neuro-k-50 ............................................................... 445
neuro-k-500 ............................................................. 445
NEUTEK 2TEK TEST STRIPS .............................. 445
NEUTRAHIST ............................................................ 445
neutralin .................................................................... 445
NEUTRAPHOR .......................................................... 445
NEUTRAPHORUS REX ........................................... 445
neutrogena body clear acn ................................ 446
NEUTROGENA BODY LIGHT SES ...................... 446
NEUTROGENA CLEAN REPLENIS ...................... 446
NEUTROGENA DEEP CLEAN FAC ...................... 446
NEUTROGENA FRESH FOAMING....................... 446
NEUTROGENA HAND ............................................. 446
NEUTROGENA HAND/NORWEGIAN ................. 446
NEUTROGENA HEALTHY SKIN ........................... 446
NEUTROGENA HEALTHY SKIN F ....................... 446
NEUTROGENA MAKEUP REMOVER ................... 446
NEUTROGENA MOISTURE SENSI ..................... 446
neutrogena oil-free acne ..................................... 446
neutrogena rapid clear ac ................................... 446
NEUTROGENA SHAMPOO .................................... 446
NEUTROGENA T/GEL ............................................ 446
NEUTROGENA T/GEL CONDITIO ...................... 446
neutrogena t/gel extra st ................................... 446
NEUTROGENA T/GEL STUBBORN ..................... 446
NEUTROGENA T/GEL THERAPEU ...................... 446
NEUTROGENA T/SAL ............................................ 446
NEUTROGENA TRIPLE MOISTUR ...................... 446
nevirapine susp 50 mg/5ml ................................. 25
nevirapine tab 100mg er ...................................... 25
nevirapine tab 200mg ............................................ 25
nevirapine tab 400mg er ...................................... 25
NEW LIFE HAIR ....................................................... 446
new skin .................................................................... 446
new skin scar therapy .......................................... 447
NEXAFED SINUS PRESSURE + ......................... 447
NEXAVAR ..................................................................... 39
NEXCARE ALL PURPOSE MASK ......................... 447
NEXCARE EARLOOP MASK .................................. 447
nexcare liquid bandage ....................................... 447
NEXCARE WOUND CLEANSER ........................... 447
NEXGEN TEST STRIPS ......................................... 447
NEXIUM ...................................................................... 447
NEXIUM 24HR ......................................................... 447
NEXIUM 24HR CLEAR MINIS ............................. 447
NF FORMULAS CALCIUM MAGNE ..................... 447
NF FORMULAS CHILDRENS CHE ...................... 447
nf formulas nac ....................................................... 447
nia-chrom ................................................................. 447
niacin .................................................................. 447, 670
NIACIN ....................................................................... 447
niacin er (antihyperlipidemic) ............................. 46
niacin flush free ...................................................... 447
niacin flush free formula ..................................... 447
NIACIN FLUSH-FREE EXTRA S .......................... 447
NIACIN TR ................................................................ 447
niacin-50 ................................................................... 448
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 786
niacinamide ...................................................... 448, 670
NIACINAMIDE .......................................................... 448
niacor............................................................................ 46
NICADAN ................................................................... 448
NICADAN ZX ............................................................ 448
nicardipine hcl ........................................................... 48
NICAZEL .................................................................... 448
NICAZEL FORTE ...................................................... 448
NICODERM CQ ........................................................ 448
nicorelief .............................................................. 70, 448
NICORETTE .............................................................. 448
NICORETTE MINI ................................................... 448
NICORETTE STARTER KIT .................................. 448
NICOTINAMIDE ....................................................... 448
nicotine ................................................................ 70, 448
nicotine mini lozenge ........................................... 448
nicotine polacrilex ............................................ 70, 448
nicotine step 1 ........................................................ 448
nicotine step 2 ........................................................ 448
nicotine step 3 ........................................................ 448
nicotine transdermal syst ............................. 70, 449
NICOTINE TRANSDERMAL SYST ...................... 448
NICOTROL INHALER ............................................... 70
NICOTROL NS............................................................ 70
nifedipine .................................................................... 48
nifedipine er ............................................................... 48
night time cold & flu rel ....................................... 449
night time cough & cold r ................................... 449
night time multi-symptom ................................. 449
night time pain medicine .................................... 449
night time sleep aid ........................................ 70, 449
nighttime cold & flu............................................... 449
nighttime cold flu & reli ....................................... 449
nighttime cold medicine ...................................... 449
night-time cold/flu relie ....................................... 449
nighttime cold/flu relief ....................................... 449
nighttime cold/flu/maximu ................................. 449
nighttime cough ..................................................... 449
night-time cough ................................................... 449
nighttime d cold & flu re ..................................... 449
night-time multi-symptom ................................. 449
nighttime multi-symptom c ............................... 449
nighttime severe cold & f .................................... 449
night-time sinus ..................................................... 449
nighttime sinus congestio ................................... 449
nighttime sinus/multi-sym ................................. 449
nighttime sleep ....................................................... 449
nighttime sleep aid .................................. 70, 449, 450
nighttime sleep-aid ............................................... 450
nilutamide ................................................................... 37
nimodipine .................................................................. 48
NINJACOF ................................................................. 450
NINJACOF-A ............................................................. 450
NINJACOF-D ............................................................. 450
NINJACOF-XG .......................................................... 450
NINLARO ..................................................................... 35
NISEKO HYDRATING FACIAL M ........................ 450
nite time cough ....................................................... 450
nite time multi-symptom c................................. 450
nite-time cold/flu ................................................... 450
nite-time cold/flu relief ........................................ 450
NITE-TIME COLD/FLU RELIEF ........................... 450
nite-time cough ...................................................... 450
nite-time multi-symptom c ................................ 450
nitetime sleep-aid .................................................. 450
NITRATEST PAPER ................................................. 450
NITRO-BID ................................................................. 50
NITRO-DUR DIS 0.3MG/HR.................................. 51
NITRO-DUR DIS 0.8MG/HR.................................. 51
nitrofurantoin macrocrystal ................................. 22
nitrofurantoin monohyd macro ........................... 22
nitroglycerin ............................................................... 51
nitroglycerin td patch ............................................. 51
NITYR ........................................................................... 78
niva-hist dm ............................................................. 450
NIVANEX DMX ......................................................... 450
NIVA-PLUS ................................................................ 670
NIVEA ......................................................................... 450
NIVEA EXTRA ENRICHED .................................... 450
NIVEA EXTRA ENRICHED LOTI ......................... 450
NIVEA GENTLE BODY EXFOLIA ......................... 450
NIVEA LIGHT ........................................................... 450
NIVEA MOISTURIZING ......................................... 451
NIVEA MOISTURIZING BODY W ....................... 451
NIVEA ORIGINAL .................................................... 451
NIVEA ORIGINAL MOISTURE ............................. 451
NIVEA SOFT ............................................................. 451
NIVEA TOUCH OF SMOOTHNESS ..................... 451
NIVEA VISAGE ........................................................ 451
NIVEA VISAGE FOAMING FACI ......................... 451
NIVEA VISAGE GENTLE CLEAN ......................... 451
NIVEA VISAGE INNER BEAUTY ......................... 451
NIVEA VISAGE MOISTURIZING ........................ 451
NIX COMPLETE LICE TREATME ......................... 451
NIX CREME LIQ RINSE 1% ................................ 451
NIX CREME RINSE ................................................. 451
NIZATIDINE TAB 75 MG ...................................... 451
NIZORAL A-D ........................................................... 451
no doz maximum strength ................................. 451
no drip nasal spray ....................................... 451, 684
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 787
no flush niacin ......................................................... 451
NO IRON MULTIPLE VITAMIN/ .......................... 451
noble formula .......................................................... 451
noble formula hc .................................................... 451
noble formula s ....................................................... 451
noble formula shampoo ....................................... 452
NOBLE MYSTIQUE BODY CLEAN ...................... 452
NOBLE MYSTIQUE EMU-LAC .............................. 452
nohist-dm ................................................................. 452
nohist-lq .................................................................... 452
non-aspirin ............................................................... 452
non-aspirin 8 hour ................................................. 452
non-aspirin childrens ............................................ 452
non-aspirin extra strengt .................................... 452
NON-ASPIRIN EXTRA STRENGT ....................... 452
non-aspirin infant .................................................. 452
non-aspirin junior streng .................................... 452
non-aspirin pain relief .......................................... 452
non-aspirin pain relief c ...................................... 452
non-aspirin pain relief e ...................................... 452
non-aspirin pm extra stre ................................... 452
non-aspirin severe conges ................................. 452
non-drying sinus .................................................... 452
non-pseudo cold relief ......................................... 452
non-pseudo sinus deconges .............................. 452
non-pseudo sinus pain/pre ................................ 452
NOREL AD ................................................................. 452
NOREL CS ................................................................. 452
norethindrone acetate ........................................... 81
norethindrone acetate-ethinyl estradiol .......... 78
NORMALYTE ............................................................. 453
NORMLSHIELD ........................................................ 453
NORMOSOL-M IN D5W ........................................ 667
NORMOSOL-R .......................................................... 667
NORMOSOL-R IN D5W ......................................... 667
NORPACE CR.............................................................. 45
nortemp ..................................................................... 453
NORTEMP INFANTS ............................................... 453
NORTHERA ................................................................. 50
nortriptyline hcl ........................................................ 58
nortuss-de ................................................................ 453
NORVIR PACK ............................................................ 25
NORVIR SOLN ........................................................... 25
norwegian cod liver oil ......................................... 453
NORWEGIAN COD LIVER OIL ............................ 453
norwich aspirin ....................................................... 453
NOSE CLIP ................................................................ 453
nose drops extra strength .................................. 453
NOVA MAX BLOOD GLUCOSE MO .................... 453
NOVA MAX GLUCOSE TEST STR ...................... 453
NOVA SUREFLEX LANCING DEV ....................... 453
NOVAFERRUM 125 ................................................. 453
NOVAFERRUM 50 ................................................... 453
NOVAFERRUM PEDIATRIC DROP ..................... 453
novaferrum pediatric mult .................................. 453
NOVOLIN 70/30 ........................................................ 72
NOVOLIN 70/30 FLEXPEN ..................................... 72
NOVOLIN N ................................................................. 72
NOVOLIN R ................................................................. 72
NOVOLOG ................................................................... 72
NOVOLOG 70/30 FLEXPEN ................................... 72
NOVOLOG FLEXPEN ................................................ 72
NOVOLOG MIX 70/30 ............................................. 72
NOVOLOG PENFILL .................................................. 72
NOXAFIL ...................................................................... 23
nrs nasal relief ........................................................ 453
nu-copd ..................................................................... 453
NUCYNTA ER .............................................................. 19
NUEDEXTA .................................................................. 68
NU-FIT ADULT BRIEF LARGE ............................. 453
NU-FIT ADULT BRIEF MEDIUM ......................... 453
NU-GEL WOUND DRESSING/3-3 ..................... 453
NU-GEL WOUND DRESSING/6 .......................... 453
nu-iron 150 .............................................................. 454
NULOJIX .................................................................... 102
NULYTELY/FLAVOR PACKS ................................... 91
NU-MAG ..................................................................... 668
NUMOISYN ................................................................ 454
NUPERCAINAL ......................................................... 454
NUPLAZID CAPS ....................................................... 62
NUPLAZID TABS 10MG .......................................... 62
NUPLAZID TABS 17MG .......................................... 62
NUPREP 5% POVIDONE-IODINE ...................... 454
NUTRA/PRO CHOCOLATE .................................... 454
NUTRA/PRO STRAWBERRY ................................. 454
NUTRA/PRO VANILLA ........................................... 454
NUTRADERM ............................................................ 454
NUTRADERM ADVANCED FORMUL .................. 454
NUTRAMIX ................................................................ 454
nutraplus ................................................................... 454
NUTRASENTIALS .................................................... 454
NUTRA-SUPPORT BONE ....................................... 454
NUTRATEAR ............................................................. 454
nutr-e-sol .................................................................. 454
NUTRICAP ................................................................. 454
NUTRICION PORVIDA ........................................... 454
nutrifac zx ................................................................. 454
nutrilipid inj 20% ................................................... 665
NUTRISOURCE FIBER ........................................... 454
nu-way nasal decongestant ............................... 454
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 788
nyamyc ...................................................................... 690
nycair .......................................................................... 454
nycoff.......................................................................... 454
NYMALIZE ................................................................... 48
NYQUIL ...................................................................... 454
nyquil severe + vapocool ................................... 455
nyquil severe cold/flu ........................................... 455
nystatin ........................................................................ 23
nystatin (mouth-throat) ...................................... 696
nystatin (topical) .................................................... 690
nystatin pow 100000 ............................................ 690
nystop ........................................................................ 690
nytol ............................................................................ 455
NYTOL MAXIMUM STRENGTH ............................ 455
nyt-time sleep caps .............................................. 455
O
OBREDON ................................................................. 455
O-CAL FA ................................................................... 670
occlusal-hp ............................................................... 455
ocean for kids .......................................................... 455
OCEAN NASAL MOISTURIZER ........................... 455
OCEAN NASAL SPRAY .......................................... 455
oceanic selenium.................................................... 455
OCTAGAM ................................................................. 101
octreotide acetate .................................................... 80
OCULAR VITAMINS ................................................ 455
OCUSOFT BABY EYELID & EYE ......................... 455
OCUSOFT DRY EYE KIT........................................ 455
ocusoft eye wash ................................................... 455
OCUSOFT EYELID CLEANSING.......................... 455
OCUSOFT HAND SOAP ......................................... 455
OCUSOFT HYPOCHLOR ........................................ 455
ocusoft irrigating ii ................................................ 455
OCUSOFT LID SCRUB ........................................... 455
OCUSOFT LID SCRUB COMPLIA ....................... 455
OCUSOFT LID SCRUB FOAMING ...................... 455
OCUSOFT LID SCRUB ORIGINA ....................... 455
OCUSOFT LID SCRUB PLUS ............................... 456
ocutabs ...................................................................... 456
ocutabs vision formula......................................... 456
ocutabs/lutein ......................................................... 456
OCUVITE ADULT 50+ ........................................... 456
OCUVITE ADULT FORMULA ................................ 456
ocuvite extra ............................................................ 456
ocuvite eye + multi ............................................... 456
ocuvite eye health formul ................................... 456
ocuvite eye health gummie ............................... 456
OCUVITE LUTEIN ................................................... 456
ocuvite/lutein .................................................. 456, 670
ODEFSEY ..................................................................... 27
ODOMZO ..................................................................... 35
odor control foot & sneak ................................... 456
odor eaters antifungal .......................................... 456
ODOR EATERS ECONOMY ................................... 456
odor eaters foot & sneake .................................. 456
ODOR EATERS SUPER TUFF ............................... 456
ODOR EATERS ULTRA DURABLE ...................... 456
odorless coated fish oil/ ...................................... 456
OFEV ........................................................................... 686
OFF ACTIVE ...................................................... 456, 694
OFF DEEP WOODS ................................................. 694
OFF DEEP WOODS DRY ....................................... 694
OFF DEEP WOODS SPORTSMEN ...................... 694
OFF DEEP WOODS TOWELETTES ..................... 456
OFF FAMILYCARE CLEAN FEEL .......................... 694
OFF FAMILYCARE SMOOTH & D ....................... 456
OFF FAMILYCARE TROPICAL F .......................... 456
OFF FAMILYCARE UNSCENTED ................. 457, 694
OFF SMOOTH & DRY ..................................... 457, 694
OFF-EZY WART REMOVER .................................. 457
ofloxacin (ophth).................................................... 673
ofloxacin (otic) ........................................................ 696
OINTMENT BASE .................................................... 457
olanzapine .................................................................. 62
olmesartan medoxomil .......................................... 44
olmesartan medoxomil-amlodipine-
hydrochlorothiazide ............................................ 44
olmesartan medoxomil-hydrochlorothiazide . 44
olopatadine hcl 0.2% ........................................... 674
OMEGA DHA ............................................................. 457
omega-3 fatty acids .............................................. 457
omega-3 fish oil concentr ................................... 457
omeprazole ............................................................... 457
OMEPRAZOLE .................................................... 95, 457
omeprazole cap 10mg ........................................... 95
omeprazole cap 20mg ........................................... 95
omeprazole cap 40mg ........................................... 95
omeprazole magnesium ...................................... 457
omeprazole-sodium bicarbonate ...................... 457
OMNI GEL ................................................................. 457
OMNICAP ................................................................... 457
ON CALL EXPRESS BLOOD GLU ....................... 457
ON CALL LANCING DEVICE ................................ 457
ON CALL PLUS BLOOD GLUCOS ....................... 457
ON CALL PLUS LANCING DEVI .......................... 457
ON CALL VIVID BLOOD GLUCO ........................ 457
ON CALL VIVID PAL BLOOD G .......................... 457
once daily .................................................................. 457
once daily/iron ........................................................ 457
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 789
ONCOVITE ................................................................ 670
ondansetron hcl ........................................................ 86
ondansetron hcl inj ................................................. 86
ondansetron hcl oral soln ..................................... 86
ondansetron odt ....................................................... 86
ONE A DAY WOMENS PRENATAL ..................... 457
one daily ............................................................ 457, 670
one daily 50 plus .................................................... 458
one daily adults 50+ ............................................ 458
one daily complete ................................................ 458
one daily complete for me ................................. 458
one daily essential ................................................. 458
one daily for men 50+ adv ................................ 458
one daily for men/lycopen.................................. 458
one daily for women ............................................. 458
one daily for women 50+a ................................. 458
one daily healthy weight ..................................... 458
one daily maximum .............................................. 458
one daily mens ............................................... 458, 670
one daily mens 50+ multiv ................................ 458
ONE DAILY MENS FORMULA W/ ....................... 458
one daily mens health/lyc .................................. 458
one daily multivitamin ad ................................... 458
one daily multivitamin me .................................. 458
one daily multivitamin wo .................................. 458
one daily multivitamin/ir ..................................... 458
one daily plus iron ................................................. 458
ONE DAILY PLUS IRON ........................................ 458
one daily plus minerals ........................................ 458
one daily womens .................................................. 458
ONE DAILY WOMENS ............................................ 459
one daily womens 50 plus .................................. 459
one daily womens 50+ ........................................ 459
one daily/iron/calcium ......................................... 459
one daily/minerals ................................................. 459
ONE DROP BLOOD GLUCOSE MO .................... 459
ONE DROP BLOOD GLUCOSE TE ...................... 459
ONE FLOW TESTER TUBE MOUT ...................... 459
one step callus remover ...................................... 459
ONE TOUCH DELICA LANCING ......................... 459
ONE TOUCH ULTRA TEST STRI......................... 459
ONE TOUCH VERIO ............................................... 459
ONE TOUCH VERIO IQ BLOOD ......................... 459
ONE TOUCH VERIO TEST STRI ......................... 459
ONE-A-DAY ADULT VITACRAVE ....................... 459
ONE-A-DAY CHOLESTEROL PLU ....................... 459
ONE-A-DAY ENERGY ............................................. 459
ONE-A-DAY ENERGY FORMULA ........................ 459
ONE-A-DAY ESSENTIAL ....................................... 459
ONE-A-DAY FOR HER VITACRA ........................ 459
ONE-A-DAY FOR HIM/VITACRA ........................ 459
ONE-A-DAY MENOPAUSE FORMU .................... 459
ONE-A-DAY MENS .................................................. 459
ONE-A-DAY MENS 50+ ADVANT ...................... 460
ONE-A-DAY MENS HEALTH FOR ....................... 460
ONE-A-DAY MENS PRO EDGE ........................... 460
ONE-A-DAY MENS VITACRAVES....................... 460
ONE-A-DAY PROACTIVE 65+ ............................ 460
ONE-A-DAY SCOOBY-DOO GUMM ................... 460
one-a-day teen advantage ................................. 460
ONE-A-DAY TEEN ADVANTAGE ........................ 460
ONE-A-DAY VITACRAVES ................................... 460
ONE-A-DAY VITACRAVES ADUL ....................... 460
ONE-A-DAY VITACRAVES GUMM ..................... 460
ONE-A-DAY VITACRAVES SOUR ....................... 460
ONE-A-DAY VITACRAVES WOME ..................... 460
ONE-A-DAY WEIGHT SMART AD ...................... 460
ONE-A-DAY WOMENS 50+ ADVA .................... 460
ONE-A-DAY WOMENS ACTIVE M ...................... 460
ONE-A-DAY WOMENS FORMULA ...................... 460
ONE-A-DAY WOMENS PETITES......................... 460
ONE-A-DAY WOMENS PLUS HEA ..................... 460
ONE-A-DAY WOMENS PRENATAL .................... 460
ONE-A-DAY WOMENS VITACRAV ..................... 460
ONE-A-DAY/JOLLY RANCHER ............................ 460
one-daily multi vitamins ..................................... 460
one-daily/iron .......................................................... 461
ONE-STEP PREP POVIDONE-IO ........................ 461
one-step wart remover med .............................. 461
ONETOUCH BASIC/PROFILE/ON ...................... 461
ONETOUCH DELICA LANCING D ...................... 461
ONETOUCH ULTRA 2............................................. 461
ONETOUCH ULTRA BLUE ..................................... 461
ONETOUCH ULTRA MINI ..................................... 461
ONETOUCH ULTRA SYSTEM KIT ....................... 461
ONETOUCH ULTRALINK SYSTEM ..................... 461
ONETOUCH ULTRASMART .................................. 461
ONETOUCH VERIO ................................................. 461
ONETOUCH VERIO FLEX BLOOD ...................... 461
ONETOUCH VERIO IQ BLOOD G ...................... 461
ONETOUCH VERIO SYNC BLOOD ..................... 461
ONETOUCH VERIO TEST STRIP ........................ 461
ONEVITE .................................................................... 461
ONE-WAY VALVED EXPIRATORY ...................... 461
ONE-WAY VALVED INSPIRATOR ...................... 461
ONFI .............................................................................. 54
ONSET FORTE ......................................................... 461
OPCON-A ................................................................... 461
OPERAND CHLORHEXIDINE GLU ..................... 461
operand povidone/iodine .................................... 461
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 790
ophthalmic irrigation solution ........................... 462
OPSUMIT ..................................................................... 51
OPTICHAMBER FACE MASK/LAR ...................... 462
OPTICHAMBER FACE MASK/MED ..................... 462
OPTICHAMBER FACE MASK/SMA ..................... 462
OPTI-CLEAN II CLEANER .................................... 462
opti-clear ................................................................... 462
optics eye wash ...................................................... 462
optics mini drops.................................................... 463
optic-vites ................................................................. 462
optic-vites with lutein........................................... 462
OPTI-FREE DAILY CLEANER ............................... 462
OPTI-FREE EXPRESS MULTI-P .......................... 462
OPTI-FREE EXPRESS REWETTI ......................... 462
OPTI-FREE FOR DISINFECTIO .......................... 462
OPTI-FREE PUREMOIST MULTI ......................... 462
OPTI-FREE PUREMOIST REWET ....................... 462
OPTI-FREE REPLENISH ........................................ 462
OPTI-FREE REPLENISH CONVE ......................... 462
OPTI-FREE REPLENISH REWET......................... 462
OPTI-FREE SOL EXPRESS ................................... 462
opti-free supra clens ............................................ 462
OPTIMAL D3 M ........................................................ 463
optimal-d................................................................... 463
optimal-d pack ........................................................ 463
OPTIMUM AIRVITES .............................................. 463
optimum pms .......................................................... 463
OPTI-ONE .................................................................. 462
OPTI-ONE REWETTING ........................................ 462
OPTISOURCE POST BARIATRIC........................ 463
OPTIUM BLOOD GLUCOSE MONI ..................... 463
OPTIUM TEST STRIPS .......................................... 463
OPTIUMEZ TEST STRIPS ..................................... 463
OPTIVITE P.M.T. ..................................................... 463
OPTI-WOMAN .......................................................... 462
OPTUMRX BLOOD GLUCOSE MET .................... 463
OPTUMRX BLOOD GLUCOSE MON ................... 463
OPTUMRX BLOOD GLUCOSE TES ..................... 463
OPURITY .................................................................... 463
OPURITY B12/FOLIC ACID ................................. 463
OPURITY CALCIUM CITRATE P .......................... 463
opurity vitamin d ................................................... 463
OPURITY/BAND OPTIMIZED .............................. 463
OPURITY/BYPASS OPTIMIZED .......................... 463
ora relief sore throat ............................................ 463
ORA-BLEND .............................................................. 463
ORA-BLEND SF ....................................................... 463
oral electrolyte solution ....................................... 464
oral electrolytes ...................................................... 464
ORAL MIX FLAVORED SUSPEND ...................... 464
ORAL MIX SF ........................................................... 464
oral relief ................................................................... 464
ORAL RELIEF SPRAY FOR DRY .......................... 464
ORAL SUSPEND ...................................................... 464
ORAL SUSPENDING COMPOUND ..................... 464
ORAL SYRUP FLAVORED VEHIC ....................... 464
ORAL SYRUP SF ...................................................... 464
oralseptic................................................................... 464
oralyte ........................................................................ 464
oralyte freezer pops .............................................. 464
ORA-PLUS ................................................................. 464
ORASEP...................................................................... 464
ORA-SWEET ............................................................. 464
ORA-SWEET SF ....................................................... 464
orazinc ....................................................................... 464
ORAZINC ................................................................... 464
ORCHIC ...................................................................... 464
ORFADIN ..................................................................... 78
organ-i nr .................................................................. 464
original formula stomach .................................... 464
ORKAMBI ................................................................... 687
ormir ........................................................................... 464
ornithine .................................................................... 465
ORNITHINE ............................................................... 465
ortho-nesic ............................................................... 465
orthovite .................................................................... 465
os-cal .......................................................................... 465
oscal 500/200 d-3 ................................................. 465
os-cal calcium + d3 .............................................. 465
os-cal extra d3 ........................................................ 668
OS-CAL ULTRA ........................................................ 465
oseltamivir phosphate ............................................ 28
osteo bi-flex regular str ....................................... 465
OSTEO-PORETICAL ............................................... 465
OSTEOPRIME PLUS/CALCIUM & ....................... 465
osteoprime ultra ..................................................... 465
OSTIGEN ................................................................... 465
otix .............................................................................. 465
OVARY ........................................................................ 465
OVERNIGHT SLEEP GUARD UNI ....................... 465
oxacillin sodium ........................................................ 32
oxaliplatin inj 100mg .............................................. 41
oxaliplatin inj 100mg/20ml .................................. 41
oxaliplatin inj 50mg ................................................ 41
oxaliplatin inj 50mg/10ml .................................... 41
oxandrolone ............................................................... 71
oxcarbazepine ........................................................... 54
OXIPOR VHC PSORIASIS LOTI ......................... 465
oxybutynin chloride................................................. 96
oxycodone hcl ........................................................... 19
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 791
oxycodone w/ acetaminophen 10-325mg ...... 19
oxycodone w/ acetaminophen 2.5-325mg .... 19
oxycodone w/ acetaminophen 5-325mg ........ 19
oxycodone w/ acetaminophen 7.5-325mg .... 19
OXYCONTIN ............................................................... 19
oxymetazoline hcl .................................................. 465
OXYTROL ................................................................... 465
OXYTROL FOR WOMEN ........................................ 465
oysco 500 ................................................................. 668
oysco 500+d .................................................... 465, 668
oysco d....................................................................... 465
oyst-cal ...................................................................... 465
oyst-cal d .................................................................. 466
oyst-cal-d 500 ......................................................... 466
oyster calcium/d3 .................................................. 466
oyster calcium/vitamin d .................................... 466
oyster shell ....................................................... 466, 668
OYSTER SHELL CALCIUM .................................... 466
oyster shell calcium + d ...................................... 466
oyster shell calcium + d3 ................................... 466
oyster shell calcium + vi ..................................... 466
oyster shell calcium 250+ .................................. 466
oyster shell calcium 500 ..................................... 466
oyster shell calcium 500+ .................................. 466
oyster shell calcium plus ..................................... 466
OYSTER SHELL CALCIUM PLUS ........................ 466
oyster shell calcium/d .......................................... 466
oyster shell calcium/d3 ....................................... 466
OYSTER SHELL CALCIUM/MAGN ...................... 466
OYSTER SHELL CALCIUM/VITA ......................... 466
oyster shell calcium+d......................................... 466
oystercal .................................................................... 466
oyster-cal 250 + d ................................................ 466
oyster-cal 500 ......................................................... 466
oyster-cal 500 + d ................................................ 466
oystercal-d ............................................................... 467
OZEMPIC INJ 0.25 OR 0.5MG/DOSE ................ 73
OZEMPIC INJ 1MG/DOSE ...................................... 73
P
P & S ........................................................................... 467
P D NATAL VITAMINS/FOLIC ............................. 467
P-1000 ....................................................................... 467
pa b-complex with b-12 ...................................... 467
pa biotin .................................................................... 467
pa calcium 600/vitamin d ................................... 467
pa coenzyme q-10 ................................................. 467
pa glucosamine/chondroiti ................................. 467
pa l-arginine ............................................................ 467
pa melatonin ............................................................ 467
PA MENS 50 PLUS VITAPAK ............................... 467
PA MENS VITAPAK ................................................. 467
pa mucus relief ....................................................... 467
pa oyster shell calcium ........................................ 467
PA PRENATAL FORMULA ...................................... 467
PA PROBIOTIC COMPLEX .................................... 467
pa vitamin b-12 tr ................................................. 467
pa vitamin d-3 ........................................................ 467
pa vitamin d-3 gummy ........................................ 467
pa vitamin e ............................................................. 467
PA WOMENS 50 PLUS VITAPAK ........................ 467
PA WOMENS VITAPAK .......................................... 468
PABA ........................................................................... 468
p-a-c ........................................................................... 467
pacerone ..................................................................... 45
paclitaxel ..................................................................... 34
PACQUIN PLUS ........................................................ 468
PADSORBER BED PAN LINERS .......................... 468
pain & fever ............................................................... 13
pain & fever childrens .................................... 13, 468
pain & fever childrens dy .............................. 13, 468
pain & fever childrens/dy .................................... 468
pain & fever extra streng ...................................... 13
pain & fever infants......................................... 13, 468
pain & fever junior ................................................ 468
pain relief .................................................................. 468
PAIN RELIEF ............................................................. 468
pain relief 8 hour ................................................... 468
pain relief allergy sinus ....................................... 468
pain relief childrens ............................................... 468
pain relief cold pe/day ......................................... 468
pain relief cold severe c ...................................... 468
pain relief extra strengt ................................ 13, 468
PAIN RELIEF FLU .................................................... 468
pain relief pm extra stre ..................................... 468
pain relief regular stren ....................................... 468
pain relief sinus ...................................................... 468
pain relief sinus pe dayt ...................................... 469
pain reliever ............................................................. 469
pain reliever extra stren................................ 13, 469
pain reliever infants .............................................. 469
pain reliever junior ................................................ 469
pain reliever plus ................................................... 469
pain reliever pm ..................................................... 469
pain reliever pm extra st .................................... 469
pain reliever/fever reduc .................................... 469
pain relieving cream ............................................. 469
pain relieving gel.................................................... 469
PAIN-A-LAY .............................................................. 469
pain-off ...................................................................... 469
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 792
paliperidone ............................................................... 62
PALOMAR E............................................................... 469
pamidronate disodium ........................................... 76
PAMIDRONATE DISODIUM ................................... 76
pamidronate inj 30mg ........................................... 76
pamidronate inj 90mg ........................................... 76
pamix.......................................................................... 469
pamprin all day maximum s .............................. 469
pamprin max ........................................................... 469
PAMPRIN MAX PAIN FORMULA ......................... 469
PAMPRIN MULTI-SYMPTOM ................................ 469
PANATUSS DXP....................................................... 469
PANATUSS DXP PEDIATRIC ............................... 469
panatuss ped ........................................................... 469
panatuss ped drops .............................................. 470
pan-c 500/bioflavonoids...................................... 469
PANDA MASK LARGE ............................................ 470
PANDA MASK MEDIUM ......................................... 470
PANDA MASK SMALL ............................................ 470
panoxyl ...................................................................... 470
PANOXYL ................................................................... 470
panoxyl creamy wash .......................................... 470
panoxyl foaming wash ......................................... 470
panoxyl wash........................................................... 470
PANOXYL-4 CREAMY WASH ............................... 470
PANOXYL-8 CREAMY WASH ............................... 470
PANRETIN ................................................................. 694
PANTILINERS ........................................................... 470
PANTILINERS CONTOURED ................................ 470
PANTILINERS LONG .............................................. 470
PANTILINERS REGULAR ...................................... 470
PANTILINERS THONG ........................................... 470
PANTILINERS TO GO ............................................ 470
PANTILINERS UNSCENTED LON ....................... 470
PANTO-250 ............................................................... 470
pantoprazole sodium .............................................. 95
pantoprazole sodium tbec .................................... 95
pantothenic acid ..................................................... 470
PANTY LINERS REGULAR .................................... 470
PANZYGA ................................................................... 101
para-aminobenzoic acid (paba) ........................ 470
PARATHYROID ......................................................... 470
PARI ALTERA NEBULIZER HAN ......................... 471
PARI BABY CONVERSION KIT ........................... 471
PARI ERAPID NEBULIZER HAN ......................... 471
PARI EXPIRATORY FILTER VA ........................... 471
PARI MASK SET ...................................................... 471
PARI SOFT PLASTIC ADULT M .......................... 471
PARI SOFT PLASTIC PEDIATR ........................... 471
paricalcitol ................................................................ 670
paroex sol 0.12% .................................................. 696
paromomycin sulfate .............................................. 20
paroxetine hcl tabs .................................................. 58
PARVA-CAL ............................................................... 471
PARVA-CAL 250 ...................................................... 471
PARVLEX .................................................................... 471
PASER D/R .................................................................. 27
PAXIL ............................................................................ 58
PAZEO ........................................................................ 674
pc pediatric electrolyte ........................................ 471
pc-tar .......................................................................... 471
PEAK AIR PEAK FLOW METER ........................... 471
PEAK FLOW METER ............................................... 471
PEARLS IC ................................................................. 471
PECGEN DMX ........................................................... 471
pecgen pse ............................................................... 471
PECTIN ....................................................................... 471
pedia care multi-symptom ................................. 471
pedia relief cough/cold ................................ 471, 684
pedia vance .............................................................. 471
pediacare children ................................................. 472
pediacare childrens aller ..................................... 472
pediacare childrens long- ................................... 472
pediacare childrens multi .................................... 472
pediacare childrens night .................................... 472
pediacare cough & congest ................................ 472
PEDIACARE COUGH & RUNNY N ...................... 472
PEDIACARE COUGH/COLD ................................. 472
pediacare fever reducer/p .................................. 472
pediacare gas relief drop .................................... 472
pediacare infants.................................................... 472
pediacare infants gas rel ..................................... 472
pediacare multi symptom c ............................... 472
pediacold ................................................................... 472
PEDIA-LAX ................................................................ 471
pedia-lax fiber gummies ..................................... 472
PEDIALYTE ................................................................ 472
PEDIALYTE ADVANCED CARE ............................ 472
PEDIALYTE FREEZER POPS ................................ 472
PEDIALYTE SINGLES............................................. 472
PEDIALYTE SOL BUBL GUM ................................ 472
PEDIALYTE SOL UNFLAVRD ............................... 472
PEDIA-POP ORAL ELECTROLYT ......................... 472
PEDIARIX .................................................................. 103
PEDIATRIC AEROSOL MASK .............................. 472
pediatric cough/cold ............................................. 684
PEDIATRIC DISPOSABLE MOUT ....................... 473
PEDIATRIC ELECTROLYTE .................................. 473
pediatric electrolyte fre ....................................... 473
pediatric electrolyte/wit....................................... 473
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 793
pediatric electrolyte/zin ....................................... 473
pediatric enema ...................................................... 473
pediatric formula cough a ................................... 473
PEDIATRIC MEDIUM MASK................................. 473
PEDIATRIC MOUTHPIECE/DISP ........................ 473
pediatric multiple vitamin w/ minerals .......... 473
pediatric multiple vitamins w/ iron ................. 473
pedi-atric nightrest ............................................... 471
PEDIATRIC PANDA MASK.................................... 473
PEDIATRIC SMALL MASK .................................... 473
pediatric vitamins adc .......................................... 473
PEDIAVENT ............................................................... 473
pediavit ...................................................................... 473
PEDVAX HIB ............................................................. 103
PEG .............................................................................. 473
peg 3350/electrolytes ............................................ 91
peg 3350-kcl-sod bicarb-sod chloride-sod
sulfate...................................................................... 91
peg 3350-potassium chloride-sod
bicarbonate-sod chloride .................................. 91
PEGANONE ................................................................. 54
PEGASYS ..................................................................... 28
PEGASYS PROCLICK ............................................... 28
pegylax ...................................................................... 473
PELEVERUS .............................................................. 473
PELEVERUS CLEAR ................................................ 473
PELEVERUS GOLD .................................................. 473
PENICILLIN G POT IN DEXTROSE 2MU ........... 32
PENICILLIN G POT IN DEXTROSE 3MU ........... 32
PENICILLIN G PROCAINE ...................................... 32
penicillin g sodium ................................................... 32
penicillin v potassium ............................................. 32
penicilln gk inj 20mu .............................................. 32
penicilln gk inj 5mu................................................. 32
PEN-KERA ................................................................. 473
PENTACEL ................................................................. 103
PENTAM 300 .............................................................. 22
pentoxifylline ............................................................. 99
PENTRAVAN ............................................................. 473
PENTRAVAN PLUS .................................................. 474
pentrax gold ............................................................ 474
PEPCID ....................................................................... 474
PEPCID AC ................................................................ 474
PEPCID AC EZ CHEWS MAXIMU ....................... 474
PEPCID AC MAXIMUM STRENGT ...................... 474
PEPCID COMPLETE ................................................ 474
peptic relief ........................................................ 85, 474
PEPTO BISMOL ........................................................ 474
PEPTO-BISMOL ....................................................... 474
PEPTO-BISMOL INSTACOOL .............................. 474
PEPTO-BISMOL MAX STRENGTH ...................... 474
PEPTO-BISMOL TO-GO ........................................ 474
PERCOGESIC ........................................................... 474
percogesic extra strength ................................... 474
perdiem overnight relief ...................................... 474
PERFECT IRON ........................................................ 474
PER-FIT BRIEF LARGE .......................................... 474
PER-FIT BRIEF MEDIUM ...................................... 474
PER-FIT UNDERWEAR EXTRA L ........................ 474
PER-FIT UNDERWEAR LARGE ............................ 474
PER-FIT UNDERWEAR MEDIUM ........................ 474
perform pain relieving ge ................................... 474
peri-colace ................................................................ 475
PERIDIN-C ................................................................ 475
PERIFLEX LQ PKU .................................................. 475
periguard ................................................................... 475
perindopril erbumine .............................................. 42
periogard ................................................................... 696
periomed ................................................................... 475
perishield................................................................... 475
PERI-WASH .............................................................. 475
permethrin ................................................................ 475
permethrin cre 5% ................................................ 695
permethrin lice treatment .................................. 475
perox-a-mint ........................................................... 475
PEROXICLEAR CLEANING & DI ......................... 475
peroxyl ....................................................................... 475
PEROXYL .................................................................... 475
perphenazine ............................................................. 63
PERRY PRENATAL ................................................... 475
PERSONAL BEST FULL RANGE .......................... 475
PERSONAL BEST LOW RANGE .......................... 475
PERSONAL CLEANSING WASHCL ..................... 475
personal lubricant jelly ........................................ 475
personal lubricant warmin .................................. 475
PETROLATUM ........................................................... 475
PETROLEUM JELLY LIP TREAT ........................... 475
pfizerpen-g inj 20mu .............................................. 32
pfizerpen-g inj 5mu ................................................ 32
PFLEX .......................................................................... 475
PHACID ...................................................................... 475
pharbechlor .............................................................. 476
pharbedryl ........................................................ 476, 680
pharbetol ............................................................. 13, 476
pharbetol extra strength ............................... 13, 476
pharbinex .................................................................. 476
pharbinex-dm .......................................................... 476
pharbinex-pe ........................................................... 476
PHARMACIST CHOICE AUTOCOD .................... 476
PHARMACIST CHOICE MINI BL ......................... 476
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 794
PHARMACIST CHOICE NO CODI ...................... 476
pharmacists creme ................................................ 476
pharmalox................................................................. 476
phazyme .................................................................... 476
PHAZYME ................................................................... 476
PHAZYME MAXIMUM STRENGTH ...................... 476
PHAZYME ULTRA STRENGTH ............................. 476
PHENABID DM ......................................................... 476
PHENAGIL ................................................................. 476
PHENAGIL CH .......................................................... 476
phenaseptic .............................................................. 476
phenazo ..................................................................... 476
phenazopyridine hcl .............................................. 476
phenelzine sulfate.................................................... 58
phenobarbital ............................................................ 55
phenobarbital sodium ............................................ 55
PHENOBARBITAL SODIUM.................................... 55
PHENOL ..................................................................... 476
PHENYLADE .............................................................. 477
PHENYLADE AMINO ACID ................................... 477
PHENYLADE AMINO ACID BLEN ....................... 477
PHENYLADE MTE .................................................... 477
PHENYLADE MTE AMINO ACID ......................... 477
PHENYLADE PHEBLOC .......................................... 477
PHENYLADE40 DRINK MIX ................................. 477
phenylalanine .......................................................... 477
phenylephrine hcl .................................................. 477
phenylephrine hcl (oral) ...................................... 477
PHENYLEPHRINE HCL/PYRILAM ........................ 477
phenylephrine w/ dm-gg .................................... 477
phenylephrine-brompheniramine-dm ............ 477
phenylephrine-cocoa butter ............................... 477
phenylephrine-guaifenesin ................................. 477
phenylephrine-shark liver oil-glycerin-
petrolatum ........................................................... 477
PHENYLHISTINE DH .............................................. 477
phenylhistine dh modified .................................. 477
phenylpropanolamine w/ dm-gg ...................... 477
phenylpropanolamine-gg .................................... 477
phenylprop-cpm-dm w/apap ............................. 477
PHENYTEK ................................................................... 55
phenytoin .................................................................... 55
phenytoin sodium extended ................................ 55
phenytoin sodium inj 50mg/ml .......................... 55
PHILLIPS ................................................................... 477
PHILLIPS COLON HEALTH ................................... 477
phillips milk of magnesia .................................... 478
PHILLIPS MILK OF MAGNESIA .......................... 478
phillips stool softener ........................................... 478
phlexy-10 .................................................................. 478
PHLEXY-10 ................................................................ 478
PHLEXY-VITS ........................................................... 478
PHOS FLUR ............................................................... 478
PHOS-FLUR ORTHO DEFENSE ........................... 478
PHOS-NAK POWDER CONCENTRA ................... 478
PHOSPHOLINE IODIDE ........................................ 675
PHYTOMULTI ............................................................ 478
phytonadione ................................................... 478, 670
PIC 200 ...................................................................... 478
PICATO ....................................................................... 694
PIFELTRO .................................................................... 25
PIKO 1 ELECTRONIC ............................................. 478
PILLOW MASK/ADULT .......................................... 478
PILLOW MASK/CHILD ........................................... 478
PILLOW MASK/PEDIATRIC ................................. 478
pilocarpine hcl ......................................................... 675
pilocarpine hcl (oral) ............................................ 696
pimozide ...................................................................... 63
pindolol ........................................................................ 47
pink bismuth ............................................................ 478
pink bismuth maximum stre ............................. 478
pink bismuth regular stre ................................... 478
pinworm medicine ................................................. 479
pin-x ........................................................................... 478
PIN-X .......................................................................... 478
pioglitazone hcl ......................................................... 75
PIPER/TAZOBA INJ 12-1.5GM ............................. 32
piper/tazoba inj 2-0.25gm ................................... 32
piper/tazoba inj 3-0.375gm ................................. 32
piper/tazoba inj 36-4.5gm ................................... 32
piper/tazoba inj 4-0.5gm ...................................... 32
piroxicam .................................................................... 16
PITUITARY ................................................................ 479
plantar wart remover ........................................... 479
PLASMA-LYTE A ...................................................... 667
PLASMA-LYTE-148 ................................................. 667
PLO ULTRAMAX ....................................................... 479
PNV FOLIC ACID + IRON MUL .......................... 670
PNV PRENATAL PLUS ............................................ 670
PNV PRENATAL PLUS MULTIVI .......................... 479
PNV PRENATAL TAB PLUS ................................... 670
POCKET PEAK FLOW METER .............................. 479
POCKETCHEM EZ BLOOD GLUCO .................... 479
POCKETPEAK PEAK FLOW METE ...................... 479
podactin ..................................................................... 479
podactin powder ..................................................... 479
podofilox .................................................................... 694
POISE HOURGLASS SHAPE PAD ...................... 479
POISE LINERS ......................................................... 479
POISE LINERS VERY LIGHT A ........................... 479
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 795
POISE MICROLINERS/LIGHTES ........................ 479
POISE PAD ................................................................ 479
POISE PADS MAXIMUM ABSORB ..................... 479
POISE PADS MODERATE ABSOR ...................... 479
POISE PADS ULTIMATE ABSOR ........................ 479
POISE THIN-SHAPE PADS .................................. 479
POISE THIN-SHAPE PADS/MAX ........................ 479
POISE THIN-SHAPE PADS/MOD ....................... 479
POISE ULTRA THINS ............................................. 479
polar frost ................................................................. 479
POLAR FROST .......................................................... 480
poly bacitracin ......................................................... 480
POLY HIST FORTE .................................................. 480
poly vitamin ............................................................. 480
POLYBASE ................................................................. 480
polyethylene glycol 3350 .............................. 91, 480
POLYETHYLENE GLYCOL BLEND ....................... 480
POLY-HIST DM ........................................................ 480
POLY-HIST PD ......................................................... 480
poly-iron 150 ........................................................... 480
POLYMEM ALGINATE DRESSING ...................... 480
POLYMEM SILVER DRESSING/4 ....................... 481
polymyxin b-trimethoprim ................................. 673
polysaccharide iron complex ............................. 481
polysporin ................................................................. 481
POLYSPORIN ............................................................ 481
POLY-TUSSIN .......................................................... 480
POLY-TUSSIN AC ................................................... 480
POLY-TUSSIN D ...................................................... 480
POLYTUSSIN DM .................................................... 481
POLY-VENT DM ....................................................... 480
POLY-VENT IR ......................................................... 480
polyvinyl alcohol ..................................................... 481
polyvinyl alcohol-povidone (ophth) ................ 481
POLY-VI-SOL ........................................................... 480
POLY-VI-SOL/IRON ....................................... 480, 671
poly-vita drops ........................................................ 480
poly-vita/iron drops .............................................. 480
polyvitamin....................................................... 481, 671
poly-vitamin drops ................................................ 480
polyvitamin/iron ..................................................... 481
poly-vitamin/iron drops ....................................... 480
POMALYST CAP 1MG ............................................... 37
POMALYST CAP 2MG ............................................... 37
POMALYST CAP 3MG ............................................... 37
POMALYST CAP 4MG ............................................... 37
POSTURE ................................................................... 481
POSTURE-D CALCIUM/MAGNESI ..................... 481
pot chloride inj 2meq/ml .................................... 667
potassium ................................................................. 481
potassium & sodium phosphates ..................... 481
potassium chloride ........................................ 664, 667
potassium chloride in nacl .................................. 667
potassium chloride microencapsulated
crystals er ............................................................ 664
potassium chloride tab cr 10 meq ................... 664
POTASSIUM CITRATE ........................................... 481
potassium citrate (alkalinizer) er tabs ............. 95
POTASSIUM CITRATE MONOHYD..................... 481
potassium gluconate............................................. 481
POTASSIUM GLUCONATE .................................... 481
POTASSIUM GLUCONATE ER ............................. 481
POTASSIUM IODIDE ............................................. 481
poten b-150 tr......................................................... 481
povidone-iodine .............................................. 481, 482
POVIDONE-IODINE ............................................... 482
POVIDONE-IODINE PREP PAD .......................... 482
POVIDONE-IODINE PREP PADS ........................ 482
povidone-iodine vaginal ...................................... 482
PRADAXA ..................................................................... 97
PRALUENT ................................................................... 46
pramegel ................................................................... 482
pramegel hcl ............................................................ 482
pramipexole tab 0.125mg .................................... 60
pramipexole tab 0.25mg ....................................... 59
pramipexole tab 0.5mg ......................................... 59
pramipexole tab 0.75mg ....................................... 60
pramipexole tab 1.5mg ......................................... 60
pramipexole tab 1mg ............................................. 60
pramoxine hcl (rectal) ......................................... 482
pramoxine-calamine ............................................. 482
pramoxine-phenylephrine-glycerin-petrolatum ................................................................................. 482
prasterone (dhea) ................................................. 482
prasugrel hcl .............................................................. 99
pravastatin sodium ................................................. 45
PRAX ........................................................................... 482
praziquantel ............................................................... 22
prazosin hcl ................................................................ 43
pre protein ................................................................ 482
PRE PROTEIN ........................................................... 482
PRECISION LINK .................................................... 482
PRECISION LINK DIRECT .................................... 482
PRECISION PCX ...................................................... 482
PRECISION PCX PLUS TEST S ........................... 482
PRECISION POINT OF CARE T .......................... 482
PRECISION QID MONITOR ................................. 482
PRECISION QID TEST STRIPS .......................... 483
PRECISION SOF-TACT MONITO ....................... 483
PRECISION SOF-TACT TEST S .......................... 483
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 796
PRECISION XTRA ................................................... 483
PRECISION XTRA BLOOD GLUC ....................... 483
PRECISION XTRA MONITOR .............................. 483
pred sod pho sol 5mg/5ml ................................... 79
prednisolone acetate (ophth) ............................ 674
prednisolone sodium phosphate ........................ 79
PREDNISOLONE SODIUM PHOSPHATE
(OPHTH) ............................................................... 674
prednisolone sol 15mg/5ml ................................. 79
prednisolone sol 25mg/5ml ................................. 79
PREDNISONE CON 5MG/ML ................................. 79
prednisone pak 10mg ............................................ 79
prednisone pak 5mg ............................................... 79
prednisone sol 5mg/5ml ....................................... 79
prednisone tab 10mg ............................................. 79
prednisone tab 1mg ................................................ 79
prednisone tab 2.5mg ............................................ 79
prednisone tab 20mg ............................................. 79
prednisone tab 50mg ............................................. 79
prednisone tab 5mg ................................................ 79
PREFERRED PLUS GLUCOSE .............................. 483
PRELL LIQUID SHA N/O ...................................... 483
PREMASOL SOL 10% ............................................ 665
premasol sol 6% .................................................... 665
PREMIUM BLOOD GLUCOSE TES ..................... 483
PREMIUM PACKETS ............................................... 483
pre-moistened witch hazel ................................. 482
premsyn pms ........................................................... 483
PRENATAL ......................................................... 483, 671
PRE-NATAL ............................................................... 482
PRENATAL + COMPLETE MULTI ........................ 483
PRENATAL AND IRON ........................................... 483
PRENATAL COMPLETE .......................................... 483
PRENATAL FORMULA ............................................ 483
PRE-NATAL FORMULA .......................................... 482
PRENATAL FORMULA A-FREE ............................ 483
PRENATAL FORTE .................................................. 483
PRENATAL GUMMIES/DHA & FO ...................... 483
PRENATAL LOW IRON .......................................... 483
PRENATAL MULTI + DHA .................................... 483
PRENATAL MULTI +DHA ...................................... 483
PRENATAL MULTIVITAMIN ................................. 484
PRENATAL MULTIVITAMIN + D ........................ 484
PRENATAL MULTIVITAMIN PLU ......................... 484
prenatal multivit-min w/fe-fa ............................ 483
PRENATAL ONE DAILY ......................................... 484
PRENATAL PLUS ..................................................... 671
PRENATAL PLUS LOW IRON ............................... 671
PRENATAL TABLETS .............................................. 484
PRENATAL VITAMIN .............................................. 484
PRENATAL VITAMIN & MINERA ........................ 484
PRENATAL VITAMIN/IRON .................................. 484
PRENATAL VITAMINS ........................................... 484
PRENATAL+DHA ..................................................... 484
PREORBOTIC ........................................................... 484
preparation h ........................................................... 484
PREPARATION H ..................................................... 484
preparation h for women .................................... 484
preparation h hydrocortis ................................... 484
preparation h totables ......................................... 484
PREPARATION H TOTABLES BU ........................ 484
PREPARATION H TOTABLES PA ........................ 484
PREPLUS .................................................................... 671
PREPROTEIN ............................................................ 484
PREPROTEIN 20 ...................................................... 484
pres gen .................................................................... 484
pres gen pediatric .................................................. 484
PRESCRIPTIVE FORMULAS OPT ........................ 485
PRESERVISION AREDS ........................................ 485
PRESERVISION AREDS 2 .................................... 485
PRESERVISION AREDS 2 + MU ........................ 485
PRESERVISION/LUTEIN ....................................... 485
presgen b .................................................................. 485
pressure & pain maximum s .............................. 485
PRETTY FEET & HANDS ....................................... 485
PRETZ ......................................................................... 485
PRETZ IRRIGATION ............................................... 485
PREVACID 24HR ..................................................... 485
PREVAIL ADJUSTABLE UNDERW ...................... 485
PREVAIL ADULT BRIEF LARGE .......................... 485
PREVAIL ADULT BRIEF MEDIU .......................... 485
PREVAIL ADULT WASHCLOTHS ........................ 485
PREVAIL ADULT WASHCLOTHS/ ...................... 485
PREVAIL AIR PLUS STRETCHA .......................... 485
PREVAIL AIR STRETCHABLE B .......................... 485
PREVAIL ALL NITES UNDERWE ........................ 485
PREVAIL BARIATRIC A ......................................... 485
PREVAIL BARIATRIC B ......................................... 485
PREVAIL BLADDER CONTROL M ....................... 485
PREVAIL BLADDER CONTROL U ....................... 485
PREVAIL BOXERS FOR MEN L- .......................... 486
PREVAIL BOXERS FOR MEN SM ........................ 486
PREVAIL BREEZERS 360 SIZE .......................... 486
PREVAIL BREEZERS LARGE................................ 486
PREVAIL BREEZERS MEDIUM ............................ 486
PREVAIL BREEZERS REGULAR .......................... 486
PREVAIL BREEZERS XL ........................................ 486
PREVAIL BRIEF YOUTH ........................................ 486
PREVAIL BRIEF/SMALL ........................................ 486
PREVAIL CLASSIC FIT FOR W ........................... 486
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 797
PREVAIL COLOR COLLECTION .......................... 486
PREVAIL COLOR COLLECTIONS ....................... 486
PREVAIL CURVE PADS ULTIMA ......................... 486
PREVAIL EXTENDED USE BRIE ......................... 486
PREVAIL EXTRA PADS .......................................... 486
PREVAIL EXTRA PLUS PADS .............................. 486
PREVAIL FITS TO A T LARGE ............................. 486
PREVAIL FITS TO A T MEDIU ............................ 486
PREVAIL FLUFF UNDERPADS/2 ......................... 486
PREVAIL FOR MEN UNDERWEAR ..................... 486
PREVAIL FOR WOMEN UNDERWE .................... 486
PREVAIL FULL COVERAGE UND ........................ 486
PREVAIL GUARDS FOR MEN .............................. 486
PREVAIL IB FULL MAT BRIEF ............................. 487
PREVAIL IBF FULL MAT BRIE ............................. 487
PREVAIL MESH PANTS 2XL ................................ 487
PREVAIL PADS/MAXIMUM ABSO ...................... 487
PREVAIL PADS/MODERATE ABS ....................... 487
PREVAIL PADS/OVERNIGHT .............................. 487
PREVAIL PADS/ULTIMATE ABS ......................... 487
PREVAIL PANT LINER/SMALL ............................ 487
PREVAIL PANTILINER ........................................... 487
PREVAIL PER-FIT 360 UNDER ........................... 487
PREVAIL PER-FIT MEN UNDER .......................... 487
PREVAIL PER-FIT WOMEN UND ........................ 487
PREVAIL PREMIUM BRIEF ADU ......................... 487
PREVAIL PREMIUM UNDERPAD ......................... 487
PREVAIL PREMIUM WASHCLOTH ..................... 487
PREVAIL SIMPLY STRETCHFIT .......................... 487
PREVAIL SMOOTH FIT UNDERW ...................... 487
PREVAIL STRETCHFIT/SIZE A ........................... 487
PREVAIL STRETCHFIT/SIZE B ........................... 487
PREVAIL SUPER PLUS UNDERW ....................... 487
PREVAIL ULTIMATE BLADDER ........................... 487
PREVAIL ULTRA THIN PADS/L........................... 487
PREVAIL ULTRATHIN UNDERWE ...................... 487
PREVAIL UNDERPADS SUPER A ....................... 488
PREVAIL UNDERWEAR 2XL ................................ 488
PREVAIL WASHCLOTHS ....................................... 488
PREVAIL WET WIPES ............................................ 488
PREVAIL WOMENS PURSEREADY ..................... 488
PREVAIL XTREME FIT/PLUS/4 ........................... 488
PREVAIL XTREME FIT/REGULA ......................... 488
prevalite ...................................................................... 46
prevent ...................................................................... 488
PREVENT PLUS SUPERGUARD ........................... 488
PREZCOBIX ................................................................ 27
PREZISTA .................................................................... 25
PRIFTIN ....................................................................... 27
PRILOSEC OTC ........................................................ 488
PRIMACOL BORDERED DRESSIN ..................... 488
PRIMACOL DRESSING 4 ...................................... 488
PRIMACOL DRESSING 6 ...................................... 488
PRIMACOL DRESSING 8 ...................................... 488
PRIMACOL SPECIALTY DRESSI ......................... 488
primadophilus .......................................................... 488
PRIMAQUINE PHOSPHATE .................................... 24
PRIMATENE ASTHMA ............................................ 488
PRIMATENE MIST ................................................... 488
primidone .................................................................... 55
PRIVIGEN .................................................................. 101
PRO COMFORT INHALER SPACE....................... 488
pro hormone dhea antioxid ................................ 488
PRO NUTRIENTS PROBIOTIC ............................. 488
PRO VOICE V8 BLOOD GLUCOS ....................... 488
PRO VOICE V8/V9 BLOOD GLU ........................ 488
PRO VOICE V9 BLOOD GLUCOS ....................... 489
probenecid .................................................................. 10
probiata ..................................................................... 489
PROBIOMAX DAILY DF ......................................... 489
PROBIOMAX PLUS DF ........................................... 489
PROBIOTIC ............................................................... 489
PROBIOTIC & ACIDOPHILUS F ......................... 489
PROBIOTIC + COLOSTRUM ................................ 490
PROBIOTIC + OMEGA-3 ...................................... 490
probiotic acidophilus ............................................. 490
PROBIOTIC ACIDOPHILUS ................................. 490
PROBIOTIC ACIDOPHILUS BEA ........................ 490
probiotic acidophilus sup .................................... 490
PROBIOTIC ADVANCED ULTRA ......................... 490
PRO-BIOTIC BLEND .............................................. 489
probiotic chewable childr .................................... 490
PROBIOTIC COLON SUPPORT ........................... 490
PROBIOTIC COMPLEX/ACIDOPH ...................... 490
PROBIOTIC DAILY .................................................. 490
PROBIOTIC DIGESTIVE SUPPO ........................ 490
PROBIOTIC FORMULA .......................................... 490
probiotic gold extra stre ...................................... 490
PROBIOTIC GOLD EXTRA STRE ........................ 490
PROBIOTIC MATURE ADULT .............................. 490
PROBIOTIC MULTI-ENZYME ............................... 490
probiotic packets childre ..................................... 490
PROBIOTIC PEARLS .............................................. 490
PROBIOTIC PEARLS ADVANTAG ....................... 490
PROBIOTIC-10 ........................................................ 490
PROBIOTIC-10 ULTIMATE................................... 490
PRO-CAL .................................................................... 489
PROCALAMINE......................................................... 665
PROCARE ADULT BRIEFS LARG ........................ 490
PROCARE ADULT BRIEFS MEDI ........................ 491
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 798
PROCARE ADULT BRIEFS X-LA ......................... 491
PROCARE ADULT WASHCLOTHS/ .................... 491
PROCARE BARIATRIC BRIEFS ........................... 491
PROCARE BREATHABLE ADULT ........................ 491
PROCARE PLUS UNDERWEAR LA ..................... 491
PROCARE PLUS UNDERWEAR ME .................... 491
PROCARE PLUS UNDERWEAR X- ...................... 491
PROCARE PROTECTIVE UNDERW .................... 491
PROCARE UNDERPADS/21 ................................. 491
PROCEL ...................................................................... 491
PROCEL 100 ............................................................. 491
PROCERV HP ............................................................ 491
PRO-CHLO................................................................. 489
prochlorperazine inj ................................................ 86
prochlorperazine maleate ..................................... 86
prochlorperazine supp ........................................... 86
PRO-CLEAR AC ........................................................ 489
procomycin ............................................................... 491
PROCRIT ...................................................................... 97
PROCTOFOAM .......................................................... 491
procto-med hc ......................................................... 694
procto-pak ................................................................ 694
proctosol hc cre 2.5% .......................................... 694
proctozone-hc ......................................................... 694
PRODIGEN ................................................................ 491
PRODIGY AUTOCODE BLOOD GL ..................... 491
PRODIGY LANCING DEVICE ............................... 491
PRODIGY NO CODING BLOOD G ..................... 491
PRODIGY POCKET BLOOD GLUC ...................... 491
PRODIGY VOICE BLOOD GLUCO ...................... 491
prodium ..................................................................... 491
pro-ex antifungal ................................................... 489
PROFE ......................................................................... 491
PROFE FORTE .......................................................... 492
PROFERRIN ES ........................................................ 492
PROFERRIN-FORTE................................................ 492
PRO-FLORA IMMUNE ............................................ 489
PROGAINE SHA NORM/OIL ................................ 492
PROGLYCEM SUS 50MG/ML ................................. 80
PROLASTIN-C .......................................................... 687
PROLENSA ................................................................ 674
PROLIA ......................................................................... 80
PROMACTA ................................................................. 99
promethazine hcl ..................................................... 86
promethazine hcl inj ............................................... 86
promethazine vc/codeine ................................... 492
promethazine w/codeine ..................................... 492
promethazine-dm .................................................. 492
promethazine-phenylephrine-codeine ........... 492
PROMISE DAY LIGHT PAD .................................. 492
promolaxin ............................................................... 492
PRONTO ..................................................................... 492
PRONTO COMPLETE LICE KILL ......................... 492
pronto plus - lice killin ......................................... 492
pronutrients calcium+d3 ..................................... 492
pronutrients coq10 ................................................ 492
PRONUTRIENTS SUPER B-COMP ...................... 492
pronutrients vitamin d3 ....................................... 492
propa ph acne medication .................................. 492
PROPA PH PEEL-OFF ACNE MA ......................... 492
propafenone hcl ........................................................ 45
propafenone hcl 12hr ............................................. 45
proparacaine hcl ..................................................... 676
propranolol & hydrochlorothiazide .................... 46
propranolol cap er ................................................... 47
propranolol hcl .......................................................... 47
propranolol oral sol ................................................. 47
propylthiouracil ......................................................... 81
PROQUAD .................................................................. 103
PRO-RED AC ............................................................ 489
PRORENAL+D .......................................................... 492
PRORENAL+D/OMEGA-3 ..................................... 492
PROSHIELD PLUS SKIN PROTE ......................... 492
PROSHIELD PROTECTIVE HAND ...................... 492
prosight ..................................................................... 671
prosight w/lutein .................................................... 493
PROSOL ..................................................................... 665
PROSOURCE ............................................................. 493
pro-stat ...................................................................... 489
pro-stat 101 ............................................................. 489
pro-stat 64 ............................................................... 489
pro-stat awc ............................................................. 489
pro-stat max ............................................................ 489
pro-stat profile ........................................................ 489
pro-stat rc ................................................................. 489
pro-stat renal care ................................................ 489
pro-stat sugar free ................................................ 489
pro-stat/fiber ........................................................... 489
PROSTATE ................................................................. 493
PROSTEON ................................................................ 493
PROSYNMINIC ......................................................... 493
PROTECT CARDIO AF ........................................... 493
PROTECT PLUS ........................................................ 493
PROTECT PLUS NF ................................................. 493
PROTECT PLUS SO ................................................ 493
PROTECTION PLUS CLASSIC U ......................... 493
PROTECTION PLUS DELUXE UN ....................... 493
PROTECTION PLUS UNDERWEAR .................... 493
PROTECTIVE UNDERWEAR EXTR ..................... 493
PROTECTIVE UNDERWEAR LARG ..................... 493
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 799
PROTECTIVE UNDERWEAR MEDI ..................... 493
PROTECTIVE UNDERWEAR SMAL .................... 493
PROTECTIVE UNDERWEAR SU P ...................... 493
PROTECTIVE UNDERWEAR SUPE ..................... 493
PROTECTIVE UNDERWEAR XL .......................... 493
PROTECTIVE UNDERWEAR XTRA ..................... 493
PROTEGRA ................................................................ 493
protein ........................................................................ 493
PROTEIN .................................................................... 493
PROTEIN'D CHEESE SAUCE ............................... 494
proteinex ................................................................... 494
PROTEINEX ............................................................... 494
proteinex p100 ....................................................... 494
proteinex-18 ............................................................ 494
PROTEXIN ................................................................. 494
protriptyline hcl ........................................................ 58
PROVELLA ................................................................. 494
PROVIDE UNDERPAD ............................................ 494
PROVIDE UNDERPAD ULTRA ............................. 494
provil ..................................................................... 16, 494
PROVIT ....................................................................... 494
PROXACOL ................................................................ 494
PROXEED ................................................................... 494
pseudoeph-cpm-dm w/apap.............................. 494
pseudoeph-diphenhyd-dm w/apap ................. 494
pseudoephed-bromphen-dm ............................. 494
pseudoephed-cpm w/ hydrocod ....................... 494
pseudoephed-doxyl-dm w/apap ...................... 494
PSEUDOEPHEDRINE .............................................. 494
pseudoephedrine hcl .................................... 494, 684
PSEUDOEPHEDRINE HCL .................................... 494
PSEUDOEPHEDRINE HCL TAB 3 ....................... 495
pseudoephedrine w/ acetam ............................. 495
pseudoephedrine w/ apap-dm tab 30-325-15
mg ........................................................................... 495
pseudoephedrine w/ apap-dm tab 30-500-15
mg ........................................................................... 495
pseudoephedrine w/ dm-gg ............................... 495
pseudoephedrine-acetaminophen ................... 495
pseudoephedrine-acetaminophen-
dextromethorphan ............................................ 495
pseudoephedrine-chlorphen-dm ...................... 495
pseudoephedrine-dm ........................................... 495
pseudoephedrine-dm-gg w/ apap ................... 495
pseudoephedrine-guaifenesin ........................... 495
psoriasin .................................................................... 495
PSORIASIS MEDICATED SKIN .......................... 495
psudatabs ................................................................. 495
psyldex....................................................................... 495
psyllium ..................................................................... 495
PTS PANELS GLUCOSE TEST ............................. 495
PULMICORT FLEXHALER ...................................... 687
pulmosal .................................................................... 495
PULMOZYME ............................................................. 687
PURACYN PLUS DUO-CARE ................................ 495
puralube .................................................................... 495
pure & gentle enema ............................................ 495
pure & gentle lubricant ........................................ 495
pure c 500 ................................................................ 496
PURE EYES 1 CLEANER/RINSE ......................... 496
PURE EYES 2 DISINFECTANT/ .......................... 496
pure l-arginine hcl ................................................. 496
PURE L-CITRULLINE .............................................. 496
pure l-tyrosine ........................................................ 496
pureway-c ................................................................. 496
PURIXAN ...................................................................... 34
purpose ...................................................................... 496
PURPOSE GENTLE CLEANING W ...................... 496
PURPOSE MOISTURIZER ..................................... 496
pvp prep .................................................................... 496
px acid reducer ....................................................... 496
px acid reducer maximum s .............................. 496
px advanced formula multi ................................ 496
PX ADVANCED LANCING DEVIC ....................... 496
px all day relief ....................................................... 496
px allergy .................................................................. 496
px allergy relief ....................................................... 496
px allergy relief d ................................................... 496
px allergy sinus pe ................................................ 496
px antacid extra strength ................................... 496
px antacid maximum streng .............................. 496
px antacid regular streng ................................... 496
px anti-diarrheal .................................................... 497
px arthritis pain relief ........................................... 497
px artificial tears .................................................... 497
px aspirin .................................................................. 497
px athletic foot ........................................................ 497
px b complex/vitamin c ....................................... 497
px b-50 ...................................................................... 497
PX CALAMINE .......................................................... 497
px calcium antacid regula ................................... 497
px calcium&d ........................................................... 497
px childrens allergy ............................................... 497
px childrens pain relief ........................................ 497
px childrens profen ib .......................................... 497
px childrens vitamin ............................................. 497
px cold relief multi-symp .................................... 497
px cold/flu relief day/ni ....................................... 497
px complete senior multiv .................................. 497
px dayhist allergy .................................................. 497
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 800
px daytime cold ...................................................... 497
px daytime cold/flu relie ..................................... 497
PX DAYTIME MULTI-SYMPTOM ......................... 497
px daytime pe ......................................................... 497
px dibromm cold/allergy c ................................. 497
px dibromm dm cold/cough ............................... 498
px docusate sodium .............................................. 498
px dual action .......................................................... 498
px effervescent ....................................................... 498
px enteric aspirin ................................................... 498
px fiber ...................................................................... 498
px folic acid .............................................................. 498
px gas relief extra stren ...................................... 498
px gas relief infants .............................................. 498
px gas relief ultra stren ....................................... 498
px glucosamine/chondroiti ................................. 498
px glucosamine-chondroiti ................................. 498
PX GLUCOSE ............................................................ 498
px glycerin ................................................................ 498
px headache relief added ................................... 498
px hemorrhoidal ..................................................... 498
px hydrocream ........................................................ 498
px hydrogen peroxide .......................................... 498
px ibuprofen............................................................. 498
px ibuprofen cold & sinus ................................... 498
px ibuprofen junior stren .................................... 498
px infants profen ib ............................................... 498
px iron ........................................................................ 498
PX LANCET AUTO INJECTOR.............................. 499
px laxative ................................................................ 499
px medicated chestrub ........................................ 499
px mens multivitamins ........................................ 499
px miconazole 3-day combo .............................. 499
px migraine relief ................................................... 499
px milk of magnesia ............................................. 499
px nasal decongestant ......................................... 499
px nasal decongestant pe ................................... 499
px nasal four ............................................................ 499
px nasal spray extra mois .................................. 499
px niacin .................................................................... 499
px nighttime cold ................................................... 499
px nitetime cold/flu reli ....................................... 499
px nitetime cough .................................................. 499
PX NITETIME MULTI-SYMPTOM ........................ 499
px no drip nasal spray ......................................... 499
PX OMEPRAZOLE .................................................... 499
px original nasal spray......................................... 499
px pain relief extra stre ....................................... 499
px pain relief pm extra s ..................................... 499
px personal lubricant jel ..................................... 499
PX PRENATAL MULTIVITAMINS ........................ 499
px ranitidine ............................................................. 500
px saline nasal spray ............................................ 500
px severe cold ......................................................... 500
px sinus relief .......................................................... 500
px sore throat ......................................................... 500
px sterile eye drops .............................................. 500
px stomach relief ................................................... 500
px stomach relief maximum .............................. 500
px stop smoking aid.............................................. 500
px triple ointment .................................................. 500
px tussin .................................................................... 500
px tussin cf ............................................................... 500
px tussin dm ............................................................ 500
px tussin max .......................................................... 500
px vegetable laxative ........................................... 500
px vitamin a ............................................................. 500
px vitamin c ............................................................. 500
px vitamin e ............................................................. 500
pyrantel pamoate .................................................. 500
pyrazinamide ............................................................. 27
PYRETHINS/PIPERONYL BUTO .......................... 500
pyrethrins-piperonyl butoxide........................... 500
pyri 500 ..................................................................... 500
pyridostigmine tab 60mg ...................................... 68
PYRIDOXAL-5-PHOSPHATE MON ..................... 500
pyridoxine hcl .................................................. 501, 671
PYRIDOXINE HCL ................................................... 501
pyril d ......................................................................... 501
PYRIL DM .................................................................. 501
pyrilamine maleate-phenylephrine hcl tannate ................................................................................. 501
pyrroxate .................................................................. 501
Q
qc 3 day vaginal cream ....................................... 502
qc acetaminophen 8 hours ........................... 13, 502
qc acid controller ................................................... 502
qc acid controller maximu ............................ 87, 502
QC ADVANCED LANCING DEVIC ...................... 502
qc all day allergy .................................................... 502
qc allergy relief ....................................................... 502
qc allergy relief childre ........................................ 502
qc allergy relief multi-s ........................................ 502
qc allergy/sinus headache .................................. 502
qc antacid ........................................................... 84, 502
qc antacid extra strength ................................... 502
qc antacid/anti-gas ......................................... 84, 502
qc antacid/anti-gas maxim ................................ 502
qc anti-diarrheal ............................................... 85, 502
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 801
qc anti-gas ultra strengt ..................................... 502
qc anti-itch extra streng ..................................... 502
qc antiseptic pain relief ....................................... 502
qc arthritis cream .................................................. 502
qc arthritis pain relief ..................................... 13, 502
qc artificial tears .................................................... 502
qc aspirin ............................................................ 13, 503
qc aspirin low dose .......................................... 13, 503
qc athletes foot ....................................................... 503
qc azo ......................................................................... 503
qc bacitracin ............................................................ 503
QC CALAMINE ......................................................... 503
qc calcium 600 +d3 .............................................. 503
qc calcium fast dissoluti ...................................... 503
qc calcium/minerals/vitam ................................. 503
qc chewable aspirin low d............................. 13, 503
qc childrens allergy ............................................... 503
qc childrens aspirin ............................................... 503
qc childrens chewable com ................................ 503
qc childrens chewable vit .................................... 503
qc childrens ibuprofen .................................... 16, 503
qc chlor-pheniramine ........................................... 503
qc clotrimazole ........................................................ 503
QC COD LIVER OIL ................................................ 503
qc cold head congestion n .................................. 503
qc cold head congestion s .................................. 503
qc cold multi-symptom nig ................................ 503
qc cold multi-symptom sev ................................ 503
qc cold relief ............................................................ 504
qc cold relief plus ................................................... 504
qc cold relief plus multi ....................................... 504
qc complete allergy medic ................................. 504
qc cough & cold hbp ............................................. 504
qc cough relief ........................................................ 504
qc cough/sore throat nigh .................................. 504
qc daily multivitamins/ir ..................................... 504
qc daytime cold & flu ............................................ 504
qc daytime multi-symptom ................................ 504
qc diarrhea relief .................................................... 504
qc dibromm childrens cold ................................. 504
qc docusate calcium ............................................. 504
qc ear wax removal drops .................................. 504
qc effervescent antacid/p ................................... 504
qc enema ............................................................ 92, 504
qc enteric aspirin ................................................... 504
qc epsom salt .......................................................... 504
qc essentials ............................................................ 504
qc eye wash ............................................................. 504
qc ferrous sulfate ................................................... 504
qc fexofenadine hydrochlo ................................. 504
qc fiber laxative ...................................................... 504
qc flu relief therapy sev ...................................... 505
qc fluticasone propionate .................................... 505
qc gas relief ............................................................. 505
qc gas relief extra stren ...................................... 505
qc gentle laxative .................................................. 505
qc glycerin ................................................................ 505
qc headache relief ................................................. 505
qc headache relief pm .......................................... 505
qc heartburn antacid ...................................... 84, 505
qc hemorrhoidal ..................................................... 505
qc hemorrhoidal maximum f ............................. 505
qc hydrocortisone .................................................. 505
qc hydrocortisone maximum ............................. 505
qc hydrogen peroxide .......................................... 505
qc ibuprofen ....................................................... 16, 505
qc ibuprofen cold/sinus ....................................... 505
qc ibuprofen ib ........................................................ 505
qc ibuprofen infants .............................................. 505
QC IODIDES TINCTURE ....................................... 505
QC IODINE TINCTURE .......................................... 505
qc isopropyl rubbing alco .................................... 505
qc laxative .................................................................. 92
qc loratadine allergy rel .............................. 505, 680
qc loratadine-d........................................................ 506
qc magnesium citrate........................................... 506
qc maximum daily multivit ................................. 506
qc medicated pads pre-moi ............................... 506
qc medifin 400 ................................................ 506, 684
qc medifin dm ................................................. 506, 684
qc medifin mucus relief c .................................... 506
QC MEDIFIN PE ....................................................... 506
qc mens daily multivitami .................................. 506
qc miconazole 7 ...................................................... 506
qc milk of magnesia ........................................ 92, 506
qc mineral oil heavy ............................................. 506
qc mucus relief ....................................................... 506
qc mucus relief er 12 hou ................................... 506
QC MULTI-PURPOSE ............................................. 506
qc multi-vite ............................................................ 506
qc multi-vite 50 & over ........................................ 506
qc multi-vite plus ................................................... 506
qc m-zole 3 combination p ................................. 506
qc naproxen sodium ............................................. 506
qc nasal relief extra moi ..................................... 506
qc nasal relief sinus .............................................. 506
qc natural vegetable ............................................. 507
qc natural vegetable laxa ..................................... 92
qc natura-lax ..................................................... 92, 506
qc nicotine polacrilex ............................................ 507
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 802
qc nighttime cold/flu rel ...................................... 507
qc nighttime cough ............................................... 507
qc nighttime multi-sympto ................................. 507
qc no drip nasal relief .......................................... 507
qc non-aspirin 8 hour ........................................... 507
qc non-aspirin childrens ...................................... 507
qc non-aspirin extra stre .............................. 13, 507
qc non-aspirin jr strengt ..................................... 507
qc non-aspirin pm ................................................. 507
qc omeprazole magnesium ................................ 507
qc pain relief ............................................................ 507
qc pain relief childrens ................................... 13, 507
qc pain relief extra stre ....................................... 507
qc pain relief infants ....................................... 13, 507
qc pain reliever extra st ...................................... 507
qc pink bismuth ...................................................... 507
qc pm pain relief .................................................... 507
qc povidone iodine ................................................ 507
QC PRENATAL .......................................................... 507
qc rest simply .......................................................... 507
qc saline nasal relief ............................................. 507
qc senna .................................................................... 508
qc senna-s ................................................................ 508
qc severe allergy .................................................... 508
qc severe cold & cough da ................................. 508
qc severe cold & cough ni .................................. 508
qc sinus congestion & pai ................................... 508
qc sinus pain relief ................................................ 508
qc sleep aid maximum stre ................................ 508
qc sore throat .......................................................... 508
qc sore throat spray ............................................. 508
qc stool softener .................................................... 508
qc stool softener plus la ...................................... 508
qc stool softener plus st ...................................... 508
qc suphedrine .......................................................... 508
qc suphedrine cough/cold .................................. 508
qc suphedrine maximum str .............................. 508
qc suphedrine pe ................................................... 508
qc therin-m .............................................................. 508
qc tolnaftate..................................................... 508, 690
qc tussin cf ....................................................... 508, 685
qc tussin dm cough & ches ................................ 508
qc tussin mucus + chest c ................................. 508
qc urinary pain relief ............................................ 508
qc witch hazel ......................................................... 509
qc womens daily multivita .................................. 509
q-dryl .......................................................................... 501
Q-GEL ......................................................................... 501
q-gel forte ................................................................. 501
q-gel mega ............................................................... 501
q-gel ultra ................................................................. 501
QH ................................................................................ 509
qlearquil ..................................................................... 509
qlearquil all day & all n ........................................ 509
qlearquil daytime sinus & ................................... 509
qlearquil nighttime alle ........................................ 509
qlearquil nighttime sinu ....................................... 509
q-pap .......................................................................... 501
q-pap childrens ....................................................... 501
q-pap extra strength ............................................ 501
q-pap infants ........................................................... 501
q-sorb ......................................................................... 501
q-sorb co q-10 ........................................................ 501
q-tapp......................................................................... 501
q-tapp dm ................................................................. 501
q-tussin ...................................................................... 501
q-tussin dm .............................................................. 501
QUADRACEL ............................................................. 103
quenalin ..................................................................... 509
QUENCH .................................................................... 509
QUERCETIN .............................................................. 509
quetiapine fumarate ............................................... 63
QUICKABLES DRY WIPES ................................... 509
QUICKCARE .............................................................. 509
QUICKTEK ................................................................. 509
QUICKTEK TEST STRIPS ..................................... 509
QUIN B STRONG .................................................... 509
quin b strong b-25 ................................................ 509
quinapril hcl ............................................................... 42
quinapril-hydrochlorothiazide ............................. 42
quinidine gluconate ................................................. 45
quinidine sulfate ....................................................... 45
quinine sulfate .......................................................... 24
QUINTABS ................................................................ 509
quintabs-m ............................................................... 509
QUINTABS-M ........................................................... 509
QUINTET AC BLOOD GLUCOSE ........................ 509
QUINTET BLOOD GLUCOSE MON .................... 509
QUINTET BLOOD GLUCOSE TES ...................... 509
qunol coq10/ubiquinol/meg ............................... 510
q-up ............................................................................ 502
R
ra 12 hour nasal spray ........................................ 510
ra 8 hour pain relief .............................................. 510
ra acetaminophen .................................................. 510
ra acetaminophen children ................................. 510
ra acetaminophen er ............................................ 510
ra acetaminophen extra st ................................. 510
RA ACETAMINOPHEN FLU SEVE ....................... 510
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 803
ra acetaminophen pm extra .............................. 510
ra acetaminophen rapid me ............................... 510
ra acid reducer ........................................................ 510
ra acid reducer maximum s ............................... 510
ra acid reducer plus anta .................................... 510
ra acidophilus .......................................................... 510
ra acne cleanser oil-free ..................................... 510
ra acne treatment .................................................. 510
ra acta-tabs pe ....................................................... 510
RA ADULT WIPES ................................................... 510
ra advanced healing ............................................. 510
RA ADVANCED HEALING ..................................... 510
ra advanced recovery skin ................................. 510
ra allergy ................................................................... 510
ra allergy cream ..................................................... 510
ra allergy medication ............................................ 511
ra allergy medication chi .................................... 511
ra allergy multi-symptom ................................... 511
ra allergy plus sinus .............................................. 511
ra allergy relief ....................................................... 511
ra allergy relief 24 hour ...................................... 511
ra allergy relief childre ......................................... 511
ra allergy relief-d ................................................... 511
ra allergy/congestion rel ..................................... 511
ra alpha-lipoic acid ................................................ 511
ra anorectal .............................................................. 511
ra antacid .................................................................. 511
ra antacid extra strength .................................... 511
ra antacid pain relief ............................................ 511
ra antacid ultra strength ..................................... 511
ra antacid/anti-gas ................................................ 511
ra antacid/antigas maximu ................................ 511
ra antacid/gas relief max .................................... 511
ra antibiotic plus .................................................... 512
ra antibiotic/pain relief ........................................ 512
ra anticavity fluoride ri ........................................ 512
ra anti-diarrheal ..................................................... 511
ra antifungal ............................................................ 512
ra antifungal foot care ......................................... 512
ra antifungal spray ................................................ 512
ra anti-gas ................................................................ 511
ra antihistamine eye drop .................................. 512
ra anti-itch & skin prote ...................................... 511
ra anti-itch extra streng ...................................... 511
ra anti-itch maximum stre ................................. 511
ra anti-itch/maximum stre ................................. 512
ra anti-nausea ......................................................... 512
ra antiseptic ............................................................. 512
ra antiseptic mouth clean ................................... 512
ra antiseptic mouth rinse .................................... 512
ra antiseptic skin cleans ...................................... 512
ra apricot scrub ...................................................... 512
ra arthritic pain rub ............................................... 512
ra arthritis pain relief ........................................... 512
ra artificial tears eye c ......................................... 512
ra aspirin ................................................................... 512
ra aspirin adult low dose ..................................... 512
ra aspirin adult low stre ...................................... 512
ra aspirin childrens ................................................ 512
ra aspirin ec ............................................................. 512
ra aspirin ec adult low s ...................................... 512
ra athletes foot ....................................................... 513
ra athletes foot powder s .................................... 513
RA B-12 ..................................................................... 513
ra baby care oral pain re .................................... 513
ra baby care vitamins a&d ................................. 513
ra bacitracin ............................................................. 513
ra bacitracin zinc first ........................................... 513
ra back & body pain relie .................................... 513
ra backache relief .................................................. 513
ra balanced b-100 ................................................. 513
ra balanced b-100 tr ............................................. 513
ra balanced b-50 .................................................... 513
ra balanced b-50 tr ............................................... 513
ra b-complex ........................................................... 513
ra b-complex with b-12 ....................................... 513
ra b-complex/vitamin c tr ................................... 513
RA BELTED UNDERGARMENT EX ..................... 513
RA BELTED UNDERGARMENT RE ..................... 513
ra beta carotene ..................................................... 513
ra biotin ..................................................................... 513
RA BLADDER CONTROL LINERS ....................... 513
RA BLADDER CONTROL PADS ........................... 513
RA BLADDER CONTROL PADS/W ..................... 513
RA BLOOD GLUCOSE MONITOR ....................... 514
ra body powder medicated ................................ 514
RA BOXERS/MEDIUM ABSORBAN .................... 514
RA BRIEFS FOR MEN & WOMEN ....................... 514
ra budesonide nasal spray ................................. 514
RA BUNION CUSHION .......................................... 514
RA CALAMINE .......................................................... 514
ra calcium ................................................................. 514
ra calcium 600 ........................................................ 514
ra calcium 600 plus vitam .................................. 514
ra calcium 600/vit d/mine .................................. 514
ra calcium citrate plus v ...................................... 514
ra calcium citrate/vitami ..................................... 514
ra calcium hi-cal ..................................................... 514
RA CALCIUM HI-CAL/VITAMIN .......................... 514
ra calcium high potency ...................................... 514
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 804
ra calcium plus vitamin d ................................... 514
ra calcium soft chews ........................................... 514
RA CALCIUM/BORON ............................................ 514
ra calcium/magnesium/zinc ............................... 514
ra calcium/minerals/vitam ................................. 514
RA CALLUS CUSHIONS ........................................ 514
ra calming daily moisturi .................................... 514
ra capsicum hot patch ......................................... 515
ra central-vite ......................................................... 515
RA CENTRAL-VITE ................................................. 515
ra central-vite cardio ............................................ 515
ra central-vite energy .......................................... 515
ra central-vite mens matu ................................. 515
ra central-vite performan ................................... 515
ra central-vite select ............................................ 515
ra central-vite select ma ..................................... 515
ra central-vite senior ............................................ 515
RA CENTRAL-VITE UNDER 50 ........................... 515
ra central-vite womens ma ................................ 515
ra central-vite/antioxida ..................................... 515
ra cetiri-d .................................................................. 515
ra cetirizine .............................................................. 515
ra cetirizine childrens ........................................... 515
ra cetirizine hcl childre......................................... 515
ra chewable vitamins comp ............................... 515
ra childrens aspirin ................................................ 515
ra childrens chewable vit .................................... 515
ra childrens cold & aller ....................................... 515
ra childrens flu relief p ......................................... 515
ra childrens non-aspirin ...................................... 515
ra childrens plus cough/r .................................... 516
ra childrens plus multisy ..................................... 516
ra chlorpheniramine malea ................................ 516
ra chromium picolinate ........................................ 516
ra cleaning/disinfecting ....................................... 516
ra clotrimazole ........................................................ 516
ra clotrimazole 3 .................................................... 516
ra clotrimazole 7 .................................................... 516
ra cod liver oil ......................................................... 516
RA COD LIVER OIL ................................................ 516
ra coenzyme q-10 ................................................. 516
ra cold & allergy ..................................................... 516
ra cold & cough childrens ................................... 516
ra cold & cough dm ............................................... 516
ra cold & flu ............................................................. 516
ra cold multi-symptom day ................................ 516
ra cold multi-symptom nig ................................. 516
ra cold multi-symptom sev ................................ 516
ra cold/cough sinus relie ..................................... 516
ra cold/flu multi-symptom ................................. 516
ra cold/flu relief daytim ....................................... 516
ra cold/flu relief nightt ......................................... 516
ra cold/flu/sore throat m .................................... 517
ra cold/sinus max .................................................. 517
ra col-rite .................................................................. 516
ra complete allergy ............................................... 517
ra cool heat .............................................................. 517
ra coral calcium ...................................................... 517
RA CORN CUSHIONS/SMALL ............................. 517
ra corn removers ultra th ................................... 517
ra cough dm............................................................. 517
ra cough drops ........................................................ 517
ra daily face wash/deep c ................................... 517
ra dandruff shampoo ............................................ 517
ra day time cold/flu form .................................... 517
ra day/night maximum stre ............................... 517
RA DAYLOGIC HEALING DRY S ........................ 517
ra daytime cold & flu rel...................................... 517
RA DAYTIME COLD/FLU ....................................... 517
ra daytime multi-symptom ................................ 517
ra daytime/nighttime/cold ................................. 517
ra decongestant inhaler ...................................... 517
RA DELUXE UNDERPADS FOR M ...................... 517
ra derma ................................................................... 517
ra diaper rash .......................................................... 517
ra digestive health ................................................. 517
ra diphedryl allergy ............................................... 518
ra double antibiotic ............................................... 518
ra draw out salve ................................................... 518
RA DRY MOUTH ...................................................... 518
RA DRY MOUTH MOUTHWASH .......................... 518
ra dual action complete a ................................... 518
RA EAR CARE ........................................................... 518
ra ear drops ............................................................. 518
RA EAR WAX CLEANSING SYST ....................... 518
RA EAR-LOOP MASK ............................................. 518
ra earwax removal kit .......................................... 518
RA EFFERVESCENT FORMULA ........................... 518
ra enema ................................................................... 518
ra epsom salt ........................................................... 518
RA EPSOM SALT ..................................................... 518
RA EPSOM SALT LAVENDER .............................. 518
ra esomeprazole magnesium ............................ 518
RA ESSENCE-C ........................................................ 518
ra eye allergy relief ............................................... 518
ra eye itch relief ..................................................... 518
ra fast relief laxative ............................................ 518
ra fever reducer & pain r .................................... 518
ra fever reducer/pain rel ..................................... 518
ra fiber ....................................................................... 519
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 805
ra fiber laxative ...................................................... 519
ra fiber supplement............................................... 519
ra fiber therapy ...................................................... 519
ra fiber weight managemen .............................. 519
ra fiber-cap .............................................................. 519
ra fiber-tab ............................................................... 519
ra first aid anti-itch sp ......................................... 519
RA FIRST AID IODINE .......................................... 519
ra first aid saline wound ...................................... 519
ra fish oil ................................................................... 519
ra flu maximum strength .................................... 519
ra folic acid ............................................................... 519
ra foot care antifungal ......................................... 519
ra gas relief .............................................................. 519
ra gas relief extra stren....................................... 519
ra gas relief maximum str .................................. 519
ra gas relief ultra stren ........................................ 519
ra gas relief/infants ............................................... 519
ra gel hammer toe cushion ................................ 519
ra gentle skin cleanser......................................... 519
RA GENTLE SKIN CREAM .................................... 519
ra gentle skin lotion .............................................. 519
RA GERM DEFENSE ............................................... 520
ra glucosamine/chondroiti .................................. 520
ra glucose ................................................................. 520
RA GLUCOSE ........................................................... 520
ra glycerin ................................................................. 520
ra glycerin adult ..................................................... 520
ra glycerin child ...................................................... 520
RA GUARDS .............................................................. 520
RA GUARDS FOR MEN MAXIMUM .................... 520
ra gummy vitamins & miner .............................. 520
ra hair/skin/nails .................................................... 520
ra head congestion cold d .................................. 520
ra head congestion cold r ................................... 520
ra headache formula ............................................ 520
ra headache formula extra ................................. 520
ra hemorrhoid relief .............................................. 520
ra hemorrhoid relief medi ................................... 520
ra hemorrhoidal ...................................................... 520
ra hemorrhoidal cooling ...................................... 520
ra hi cal ...................................................................... 520
ra hi-cal ..................................................................... 520
ra hi-cal plus vitamin d ........................................ 520
ra high potency iron ............................................. 520
ra hydrating healing ............................................. 521
ra hydrocortisone maximum ............................. 521
ra hydrocortisone plus ......................................... 521
ra hydrocortisone plus 12 ................................... 521
ra hydrogen peroxide ........................................... 521
ra ibuprofen ............................................................. 521
ra ibuprofen childrens .......................................... 521
ra ibuprofen cold childre ..................................... 521
ra ibu-profen cold/sinus ...................................... 521
ra ibuprofen infants .............................................. 521
ra ibuprofen junior stren ..................................... 521
ra ibuprofen pm ...................................................... 521
ra intimacy gels for him ...................................... 521
ra iron......................................................................... 521
ra isopropyl alcohol ............................................... 521
ra isopropyl rubbing alco .................................... 521
ra jock itch ............................................................... 521
ra jock itch maximum stre ................................. 521
ra k-pec ..................................................................... 521
RA LAMBS WOOL ................................................... 521
RA LANCING DEVICE ............................................ 521
ra lansoprazole ....................................................... 521
ra l-arginine ............................................................. 521
ra laxative ........................................................... 92, 522
ra laxative & stool softe ...................................... 522
ra laxative extra strengt ..................................... 522
ra laxative maximum stren ................................ 522
ra lice bedding ........................................................ 522
ra lice egg remover ............................................... 522
ra lice maximum strength .................................. 522
ra lice solution kit .................................................. 522
RA LICE SOLUTION KIT ....................................... 522
ra lice treatment .................................................... 522
ra liquid antacid ...................................................... 522
ra loperamide hcl ................................................... 522
ra lorata-d ................................................................ 522
ra loratadine ............................................................ 522
ra loratadine childrens ......................................... 522
ra lubricant eye ...................................................... 522
ra lubricant eye drops .......................................... 522
ra lubricating gel .................................................... 522
ra magnesium ......................................................... 522
ra magnesium citrate ........................................... 522
RA MAKEUP REMOVER EYELID ......................... 522
ra mature womens dietary ................................. 522
RA MAXI PADS LONG ........................................... 522
RA MAXI PADS REGULAR .................................... 523
RA MAXI SUPER ...................................................... 523
ra medicated chest rub ........................................ 523
ra medicated first aid sp ..................................... 523
ra medicated wipes pre-mo ............................... 523
ra melatonin ............................................................ 523
ra menopause support ......................................... 523
ra menstrual complete pai ................................. 523
ra menstrual pain relief ....................................... 523
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 806
ra menstrual relief ................................................. 523
ra menthol nasal inhaler ..................................... 523
ra miconazole 3 combinati ................................. 523
ra miconazole 7 ...................................................... 523
ra migraine relief ................................................... 523
ra milk of magnesia .............................................. 523
ra mineral oil ........................................................... 523
ra mini nicotine ....................................................... 523
ra moisturizing oatmeal ...................................... 523
ra moisturizing therapy ....................................... 523
ra motion sickness relief ..................................... 523
ra mouthwash alcohol free ................................. 523
ra mouthwash/gargle ........................................... 523
ra mucus relief ........................................................ 523
ra mucus relief chest ............................................ 524
ra mucus relief d .................................................... 524
ra mucus relief d maximum ............................... 524
ra mucus relief dm ................................................ 524
ra mucus relief maximum s ............................... 524
ra mucus relief plus .............................................. 524
ra mucus relief sinus ............................................ 524
ra multihealth fiber supp .................................... 524
ra multi-purpose solution ................................... 524
ra multi-symptom cold rel .................................. 524
ra naproxen sodium .............................................. 524
ra nasal allergy spray ........................................... 524
ra nasal decongestant .......................................... 524
ra nasal decongestant pe ................................... 524
ra nasal spray maximum st ............................... 524
ra nasal spray/moisturizi .................................... 524
ra nasal spray/regular ......................................... 524
ra nasal spray/sinus ............................................. 524
ra natural magnesium.......................................... 524
ra natural vitamin e .............................................. 524
ra niacin..................................................................... 524
ra nicotine ................................................................. 524
ra nicotine gum ...................................................... 524
ra nicotine polacrilex ............................................ 525
ra nicotine transdermal s .................................... 525
ra night sleep aid ................................................... 525
ra nighttime cold & flu r ...................................... 525
ra nighttime cold/flu rel ...................................... 525
ra nighttime cough relief .................................... 525
ra nighttime sleep aid .......................................... 525
ra nite time cold/flu for ....................................... 525
ra nite time cough ................................................. 525
ra no flush niacin 500 .......................................... 525
ra nose drops extra stren ................................... 525
RA OMEPRAZOLE ................................................... 525
ra omeprazole/sodium bica ............................... 525
RA ONE DAILY ......................................................... 525
ra one daily energy formu .................................. 525
ra one daily essential ........................................... 525
ra one daily gummy vites ................................... 525
ra one daily maximum ......................................... 525
ra one daily mens 50+ wit ................................. 525
ra one daily mens multi ...................................... 525
ra one daily mens/vitamin ................................. 525
ra one daily multi-vitami..................................... 525
ra one daily womens/vitam ............................... 525
ra one-step corn remover .................................. 526
ra ophthalmic solution ......................................... 526
RA OVERNIGHT PADS FOR WOM ..................... 526
ra oyster shell calcium ......................................... 526
ra oyster shell calcium/v ..................................... 526
RA OYSTER SHELL CALCIUM/V ......................... 526
ra p col-rite .............................................................. 526
RA PADS FOR WOMEN MAXIMUM .................... 526
RA PADS FOR WOMEN MODERAT .................... 526
RA PADS FOR WOMEN ULTIMAT ...................... 526
ra pain relief acetaminop .................................... 526
ra pain relief ibuprofen ........................................ 526
ra pain reliever extra st ....................................... 526
ra pain reliever pm ................................................ 526
RA PANTILINERS .................................................... 526
RA PANTILINERS LONG ....................................... 526
RA PANTY LINERS .................................................. 526
RA PANTY SHIELDS ............................................... 526
ra pediatric electrolyte ......................................... 526
ra personal lubricant jel ...................................... 526
ra personal lubricant moi .................................... 526
ra personal lubricating j ...................................... 526
ra petroleum jelly .................................................. 526
ra pink bismuth ...................................................... 527
ra potassium gluconate ....................................... 527
ra potassium/magnesium as ............................. 527
ra povidone iodine ................................................. 527
RA PREMIUMPLUS FITTED BRI ......................... 527
RA PRENATAL .......................................................... 527
RA PRENATAL FORMULA/FOLIC ........................ 527
RA PROBIOTIC COLON CARE ............................ 527
RA PROBIOTIC COMPLEX .................................... 527
ra probiotic digestive ca ...................................... 527
RA PROBIOTIC DIGESTIVE CA.......................... 527
RA PROBIOTIC DIGESTIVE SU ......................... 527
RA PROBIOTIC MAXIMUM STRE ....................... 527
RA PROTECTIVE UNDERWEAR E ...................... 527
RA PROTECTIVE UNDERWEAR O ..................... 527
RA PROTECTIVE UNDERWEAR S ...................... 527
RA RENEWAL ADVANCED HEALI ...................... 527
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 807
ra renewal cocoa butter ...................................... 527
ra renewal dandruff shamp ................................ 527
RA RENEWAL DRY SKIN THERA ....................... 527
ra renewal eczema moistur ............................... 527
ra renewal medicated acne ................................ 527
ra renewal moisturizing ....................................... 527
ra renewal shower & bath .................................. 528
ra renewal soothing bath .................................... 528
ra rewetting drops ................................................. 528
ra saline enema ...................................................... 528
ra saline nasal spray............................................. 528
ra saline solution .................................................... 528
RA SALINE WOUND WASH ................................. 528
ra scalp itch/dandruff re ..................................... 528
ra scar gel ................................................................. 528
ra selenium .............................................................. 528
ra selenium natural ............................................... 528
ra senna .................................................................... 528
ra senna plus ........................................................... 528
ra sensitive anti-itch ............................................. 528
ra severe allergy plus si ...................................... 528
ra severe cold & cough da .................................. 528
ra severe cold/night time ................................... 528
ra severe cold/sinus reli ...................................... 528
ra severe congestion nasa ................................. 528
ra severe congestion/cold .................................. 528
ra severe sinus congestio ................................... 528
RA SIESTA MASK ................................................... 528
ra sinus congestion & pai ................................... 528
ra sinus pressure/congest .................................. 529
RA SINUS RELIEF DAYTIME/N .......................... 529
RA SKIN CLEANSING ............................................ 529
ra sleep aid .............................................................. 529
ra sleep aid maximum stre ................................ 529
ra sleep-aid nighttime .......................................... 529
ra slow release iron ............................................... 529
ra smooth antacid extra s .................................. 529
ra soluble fiber ........................................................ 529
ra sore throat .......................................................... 529
ra stay awake extra stren .................................. 529
ra stay awake maximum str .............................. 529
ra sterile eye wash ................................................ 529
RA STERILE SALINE NASAL M .......................... 529
ra stimulant laxative ............................................. 529
ra stomach relief .................................................... 529
ra stomach relief kids ........................................... 529
ra stomach relief maximum ............................... 529
ra stool softener ..................................................... 529
ra stress formula advance .................................. 529
ra stress formula energy..................................... 529
ra super moleskin .................................................. 529
ra suphedrine .......................................................... 529
ra suphedrine pe .................................................... 530
ra suphedrine pe day and ................................... 530
ra suphedrine pe sinus he .................................. 530
RA SURECHOICE BLADDER CO ........................ 530
RA SURECHOICE BLADDER CON ..................... 530
RA SURECHOICE PADS/LIGHT .......................... 530
RA SURECHOICE PADS/MAXIMU ..................... 530
RA SURECHOICE PADS/MODERA..................... 530
RA SURECHOICE PANTILINER .......................... 530
ra tension headache pain ................................... 530
ra therapeutic blue gel......................................... 530
ra therapeutic m plus bet ................................... 530
ra therapeutic shampoo ...................................... 530
ra tioconazole 1 ...................................................... 530
ra total moisture .................................................... 530
ra tri-buffered aspirin ........................................... 530
ra triple antibiotic .................................................. 530
ra triple antibiotic plus ......................................... 530
RA TRIPLE ANTIBIOTIC SPRA ........................... 530
RA TRUE2GO BLOOD GLUCOSE ....................... 530
RA TRUEPLUS GLUCOSE ..................................... 530
RA TRUERESULT BLOOD GLUCO ...................... 530
RA TRUETEST STRIPS .......................................... 530
ra tugaboos creamy petrol ................................. 531
ra tugaboos petroleum je ................................... 531
ra tussin .................................................................... 531
ra tussin cf ................................................................ 531
ra tussin chest congestio .................................... 531
ra tussin cough ....................................................... 531
ra tussin cough & cold mu .................................. 531
ra tussin cough adult ............................................ 531
ra tussin cough dm sugar ................................... 531
ra tussin cough/chest con .................................. 531
ra tussin dm ............................................................. 531
ra tussin long acting cou ..................................... 531
ra tussin maximum strengt................................ 531
ra tussin nighttime cough ................................... 531
RA UNDERPADS FOR MEN & WO ..................... 531
RA UNDERPADS FOR MEN/WOME ................... 531
RA UNDERPADS SUPER LARGE ........................ 531
RA UNDERWEAR FOR MEN & WO .................... 531
RA UNDERWEAR FOR MEN MAXI ..................... 531
RA UNDERWEAR FOR MEN/WOME .................. 531
RA UNDERWEAR FOR WOMEN MA .................. 531
RA UNDERWEAR FOR WOMEN MO .................. 531
ra urinary pain relief ............................................. 531
ra urinary pain relief ma ..................................... 532
ra urinary tract pain rel ....................................... 532
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 808
ra vanishing acne treatme ................................. 532
ra vaporizing steam .............................................. 532
ra vision vite plus zinc ......................................... 532
ra vitamin a .............................................................. 532
ra vitamin a & d ..................................................... 532
ra vitamin b-1 ......................................................... 532
ra vitamin b12 ........................................................ 532
ra vitamin b-12 ....................................................... 532
RA VITAMIN B-12 .................................................. 532
ra vitamin b-12 tr .................................................. 532
ra vitamin b-6 ......................................................... 532
ra vitamin b-6 tr..................................................... 532
ra vitamin c .............................................................. 532
RA VITAMIN C ......................................................... 532
ra vitamin c drops ................................................. 532
RA VITAMIN C DROPS .......................................... 532
ra vitamin c tr ......................................................... 532
ra vitamin c/acerola .............................................. 532
ra vitamin c/rose hips .......................................... 532
ra vitamin c/rose hips tr ..................................... 532
ra vitamin d-3 ......................................................... 533
ra vitamin e .............................................................. 533
ra vitamin e blend ................................................. 533
ra vitamin e natural .............................................. 533
ra vitamins a & d ................................................... 533
ra warming jelly lubrican .................................... 533
ra wart remover ..................................................... 533
ra wart remover ma ximum .............................. 533
ra whole source complete................................... 533
ra whole source dietary ....................................... 533
ra whole source dietary f .................................... 533
ra whole source dietary m.................................. 533
ra whole source womens .................................... 533
RA WIPES FLUSHABLE/MOIST .......................... 533
ra witch hazel .......................................................... 533
ra womens laxative ............................................... 533
ra zinc ........................................................................ 533
ra zinc oxide ............................................................ 533
rabano yodado ........................................................ 533
RABAVERT ................................................................ 103
rabeprazole sodium ................................................ 95
radiacream ............................................................... 533
RADIADERM SYSTEM R2 ..................................... 533
RADIAGUARD ADVANCED .................................. 533
radiaklenz ................................................................. 533
RAGUS ....................................................................... 534
raloxifene hcl ............................................................. 80
ramipril ........................................................................ 42
RANEXA ....................................................................... 50
ranitidine 150 maximum st ................................ 534
ranitidine acid reducer ......................................... 534
ranitidine hcl ...................................................... 87, 534
ranitidine hcl inj........................................................ 87
ranitidine inj ............................................................... 87
ranitidine syrup ........................................................ 87
RAPAMUNE ............................................................... 102
RAPID B-12 ENERGY ............................................ 534
rapid burst adult .................................................... 534
rasagiline mesylate ................................................. 60
RAYALDEE ................................................................. 671
RE:IIMMUNE ............................................................ 534
REALITY INCONTINENT BRIEF .......................... 534
REBETOL SOLN ......................................................... 28
RECEDO ..................................................................... 534
recofen ....................................................................... 534
RECOMBIVAX HB .................................................... 103
recort plus ................................................................ 534
rectacaine ................................................................. 534
rectasmoothe .......................................................... 534
RECTICARE ............................................................... 534
rederm ....................................................................... 534
redness reliever eye drop ................................... 534
reeses onetab congestion ................................... 534
reeses pinworm medicine ................................... 534
REESES PINWORM MEDICINE........................... 534
refenesen .................................................................. 534
refenesen 400 ......................................................... 534
REFENESEN CHEST CONGESTIO ..................... 534
refenesen dm .......................................................... 534
refenesen pe ............................................................ 535
refenesen plus......................................................... 535
REFRESH ........................................................... 535, 676
refresh celluvisc...................................................... 676
REFRESH CLEANSER ............................................. 535
REFRESH CONTACTS ............................................ 535
REFRESH DRY EYE THERAPY ............................. 535
refresh lacri-lube .................................................... 676
REFRESH LIQUIGEL .............................................. 535
REFRESH OPTIVE ................................................... 535
REFRESH OPTIVE ADVANCED ................... 535, 676
REFRESH OPTIVE ADVANCED S ....................... 535
REFRESH OPTIVE MEGA-3 .................................. 535
REFRESH OPTIVE SENSITIVE ............................ 676
refresh p.m. ............................................................. 535
REFRESH PLUS ........................................................ 535
REFRESH TEARS ..................................................... 535
refreshing aloe ........................................................ 535
refreshing facial cleanse...................................... 535
REFUAH PLUS BLOOD GLUCOSE ...................... 535
REGRANEX ................................................................ 695
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 809
reguloid ................................................................ 92, 535
rehydralyte ............................................................... 535
REHYLA HAIR + BODY CLEANS ........................ 535
REHYLA WASH ........................................................ 535
relcof c ....................................................................... 535
relcof dm ................................................................... 536
relcof ir ...................................................................... 536
RELENZA DISKHALER............................................. 29
RELHIST BP .............................................................. 536
relhist dmx ............................................................... 536
relief drops ............................................................... 536
relief eye drops ....................................................... 536
RELION 2-IN-1 LANCING DEV .......................... 536
RELION BLOOD GLUCOSE TEST ....................... 536
RELION CONFIRM BLOOD GLUC ...................... 536
RELION CONFIRM/MICRO TEST ....................... 536
relion glucose .......................................................... 536
RELION GLUCOSE .................................................. 536
relion glucose drink ............................................... 536
RELION KETONE ..................................................... 536
RELION KETONE TEST STRIPS ......................... 536
RELION LANCING DEVICE .................................. 536
RELION MICRO BLOOD GLUCOS...................... 536
RELION PREMIER BLOOD GLUC ....................... 536
RELION PREMIER BLU BLOOD .......................... 536
RELION PREMIER COMPACT BL ........................ 536
RELION PREMIER VOICE BLOO ........................ 536
RELION PRIME BLOOD GLUCOS....................... 536
RELION ULTIMA BLOOD GLUCO ....................... 536
RELION ULTIMA TEST STRIPS .......................... 537
RELISTOR ................................................................... 94
REMEDY 4-IN-1 BODY CLEANS ........................ 537
remedy antifungal ................................................. 537
remedy antifungal clear/p .................................. 537
REMEDY ANTIMICROBIAL CLEA ....................... 537
REMEDY CALAZIME ............................................... 537
REMEDY CLEANSING BODY LOT ...................... 537
REMEDY CLEAR-AID ............................................. 537
REMEDY DIMETHICONE MOISTU ..................... 537
REMEDY FOAMING BODY CLEAN ..................... 537
REMEDY NUTRASHIELD ....................................... 537
remedy phytoplex antifung ................................ 537
REMEDY SKIN REPAIR ......................................... 537
REMICADE ................................................................ 100
REMODULIN ............................................................... 51
REMOVE ADHESIVE REMOVER ......................... 537
renal ............................................................................ 537
renal multivitamin formul ................................... 537
renal vitamin ........................................................... 537
renal-vite .................................................................. 537
RENAMENT ............................................................... 537
renaplex .................................................................... 537
RENAPLEX-D ............................................................ 537
rena-vite .................................................................... 537
rena-vite rx .............................................................. 537
RENEW ADVANCED LANCING DE .................... 538
RENU MULTIPLUS .................................................. 538
RENU MULTIPLUS LUBRICATIN ........................ 538
repaglinide .................................................................. 75
REPEL 100 ................................................................ 694
REPEL FAMILY ................................................. 538, 694
REPEL FAMILY DRY ................................................ 694
REPEL HUNTERS FORMULA ................................ 694
REPEL LEMON EUCALYPTUS IN ........................ 695
REPEL MOSQUITO WIPES ................................... 538
REPEL SPORTSMEN ....................................... 538, 695
REPEL SPORTSMEN DRY ..................................... 695
REPEL SPORTSMEN MAX ..................................... 695
REPEL TICK DEFENSE .......................................... 695
REPHRESH PRO-B .................................................. 538
REPLACE .................................................................... 538
REPLACE SR ............................................................. 538
REPLACEMENT AIR FILTER ................................. 538
REPLACEMENT FILTERS ....................................... 538
REPLESTA ................................................................. 538
REPLESTA CHILDRENS ........................................ 538
REPLESTA NX .......................................................... 538
REPLICARE 1-1/2 ................................................... 538
REPLICARE 4............................................................ 538
REPLICARE 6............................................................ 538
REPLICARE 8............................................................ 538
REPLICARE THIN 2 ................................................ 538
REPLICARE THIN 3.5 ............................................ 538
REPLICARE THIN 6 ................................................ 538
REPLICARE ULTRA 4 ............................................. 538
REPLICARE ULTRA 6 ............................................. 538
REPLICARE ULTRA SACRUM 7 .......................... 539
REQ 49+ .................................................................... 539
RESCON ..................................................................... 539
RESCON DM ............................................................. 539
RESCON-GG ............................................................. 539
RESCRIPTOR .............................................................. 25
RESINOL .................................................................... 539
RESOURCE BENEPROTEIN .................................. 539
RESPA C&C IR ......................................................... 539
RESPAIRE-30 ........................................................... 539
rest simply ................................................................ 539
RESTA ......................................................................... 539
RESTA LITE .............................................................. 539
RESTA WOUND CLEANSER ................................. 539
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 810
RESTASIS ................................................................. 676
RESTASIS MULTIDOSE ........................................ 676
restfully sleep .......................................................... 539
restizan ...................................................................... 539
RESTORA ................................................................... 539
RESTORE CX WOUND CARE DRE ..................... 539
restore dimethicreme ........................................... 539
RESTORE DRESSING FOR PSOR ...................... 539
RESTORE EXTRA THIN DRESSI ........................ 539
RESTORE HYDROGEL GAUZE PA ..................... 539
RESTORE PLUS WOUND CARE D ..................... 539
RESTORE SILVER DRESSING 2 ........................ 539
RESTORE SILVER DRESSING 4 ........................ 540
RESTORE SILVER DRESSING 6 ........................ 540
RESTORE WOUND CARE DRESSI..................... 540
retaine cmc .............................................................. 540
RETAINE HPMC ....................................................... 540
RETAINE MGD ......................................................... 540
retaine pm ................................................................ 540
RETAINE VISION .................................................... 540
REVEAL BLOOD GLUCOSE MONI ..................... 540
REVEAL BLOOD GLUCOSE TEST ...................... 540
revital freezer pops ............................................... 540
revital jell cups ....................................................... 540
revital liquid squeezers ........................................ 540
REVITALENS OCUTEC........................................... 540
revive tears .............................................................. 540
REVLIMID .................................................................... 37
rewetting drops ...................................................... 540
REXALL BLOOD GLUCOSE MONI ...................... 540
REXALL BLOOD GLUCOSE TEST ....................... 540
REXULTI ...................................................................... 63
REYATAZ ..................................................................... 25
REZIRA....................................................................... 540
rhinall ......................................................................... 540
RHINARIS ................................................................. 540
RHINASE ................................................................... 540
rhinocort allergy ..................................................... 540
RHINOCORT AQUA ................................................ 541
ribasphere ................................................................... 29
RIBASPHERE .............................................................. 29
ribavirin 200mg ........................................................ 29
riboflavin ................................................................... 541
RIBOFLAVIN ............................................................. 541
RID .............................................................................. 541
RID COMPLETE LICE ELIMINA .......................... 541
RID ESSENTIAL LICE ELIMIN ............................ 541
rid lice killing shampoo ........................................ 541
rifabutin ....................................................................... 28
rifampin ....................................................................... 28
RIFATER ....................................................................... 28
ri-gel ........................................................................... 541
ri-gel ii ........................................................................ 541
RIGHT STEP PRENATAL ....................................... 541
RIGHTEST GD500 LANCING DE ....................... 541
RIGHTEST GM100 BLOOD GLUC ...................... 541
RIGHTEST GM300 BLOOD GLUC ...................... 541
RIGHTEST GM550 BLOOD GLUC ...................... 541
RIGHTEST GS100 BLOOD GLUC ...................... 541
RIGHTEST GS300 BLOOD GLUC ...................... 541
RIGHTEST GS550 BLOOD GLUC ...................... 542
RIGHTSOURCE BLOOD GLUCOSE .................... 542
riginic .......................................................................... 542
riluzole ......................................................................... 68
RI-MAG ...................................................................... 541
RI-MAG PLUS ........................................................... 541
rimantadine hydrochloride ................................... 29
ri-mox......................................................................... 541
ri-mox plus ............................................................... 541
RISABAL-PH ............................................................. 542
RISA-BID PROBIOTIC........................................... 542
RISACAL-D ............................................................... 542
RISAMINE ................................................................. 542
risanoid plus ............................................................ 542
RISAQUAD ................................................................ 542
RISAQUAD-2 ............................................................ 542
risedronate sodium ................................................. 76
RISPERDAL INJ 12.5MG ........................................ 63
RISPERDAL INJ 25MG ............................................ 63
RISPERDAL INJ 37.5MG ........................................ 63
RISPERDAL INJ 50MG ............................................ 63
risperidone ................................................................. 63
ritifed .......................................................................... 542
ritonavir ....................................................................... 25
ri-tussin ..................................................................... 541
ri-tussin dm .............................................................. 541
RITUXAN...................................................................... 36
RITUXAN HYCELA..................................................... 36
rivastigmine tartrate ............................................... 56
rivastigmine td patch 24hr 13.3 mg/24hr...... 57
rivastigmine td patch 24hr 4.6 mg/24hr ........ 56
rivastigmine td patch 24hr 9.5 mg/24hr ........ 56
rizatriptan benzoate ................................................ 67
rizatriptan benzoate odt ........................................ 67
robafen ...................................................................... 685
robafen ac ................................................................. 542
robafen cf cough & cold ....................................... 542
robafen cf multi-symptom .................................. 685
robafen cough ......................................................... 542
robafen dm ....................................................... 542, 685
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 811
robafen dm clear .................................................... 542
robafen dm cough ................................................. 542
robafen dm cough clear .............................. 542, 685
robafen dm cough/chest co ............................... 685
robafen mucus/chest conge .............................. 542
robisen ....................................................................... 542
robitussin 12 hour cough .................................... 542
ROBITUSSIN CHEST CONGESTI ...................... 542
ROBITUSSIN CHILDRENS COUG ...................... 542
robitussin cold+flu dayti ..................................... 543
robitussin cold+flu night ..................................... 543
ROBITUSSIN COUGH & ALLERG ....................... 543
robitussin cough & chest ..................................... 543
ROBITUSSIN COUGH & CHEST ......................... 543
robitussin cough & cold c .................................... 543
ROBITUSSIN COUGH & COLD D ...................... 543
robitussin cough & cold l ..................................... 543
ROBITUSSIN COUGH/COLD CF ........................ 543
ROBITUSSIN COUGH/CONGESTI ..................... 543
robitussin cough+chest co ................................. 543
ROBITUSSIN COUGH+CHEST CO .................... 543
ROBITUSSIN COUGHGELS ................................. 543
ROBITUSSIN DM .................................................... 543
robitussin head/chest con .................................. 543
robitussin lingering cold ...................................... 543
ROBITUSSIN LINGERING COLD ....................... 543
robitussin maximum streng ............................... 543
robitussin mucus+chest co ................................ 543
robitussin night time cou .................................... 543
robitussin nightime cough .................................. 543
ROBITUSSIN NIGHTTIME COUG ...................... 543
robitussin peak cold coug ................................... 543
ROBITUSSIN PEAK COLD COUG ...................... 544
ROBITUSSIN PEAK COLD DAY/ ........................ 544
ROBITUSSIN PEAK COLD DM ............................ 544
robitussin peak cold mult ................................... 544
ROBITUSSIN PEAK COLD MULT ....................... 544
robitussin peak cold nasa ................................... 544
robitussin peak cold nigh .................................... 544
ROBITUSSIN PEDIATRIC COUG ....................... 544
robitussin severe day & n ................................... 544
robitussin severe multi-s .................................... 544
robitussin to go cough & ..................................... 544
ROBITUSSIN TO GO COUGH & ......................... 544
ROC AGE DIMINISHING NIGHT ........................ 544
ROC DEEP WRINKLE SERUM ............................. 544
ROC INSTANT FACIAL SMOOTH ....................... 544
ROC MAX RESURFACING FACIA ....................... 544
ROC MULTI CORREXION 5 IN ........................... 544
ROC MULTI CORREXION LIFT ........................... 544
ROC MULTI CORREXION NOURI ...................... 544
ROC RETINOL CORREXION ................................ 544
ROC RETINOL CORREXION HAN ...................... 544
ROC RETINOL CORREXION MAX ...................... 544
ROC RETINOL CORREXION NIG ....................... 544
ROC RETINOL CORREXION SEN ....................... 545
rolaids......................................................................... 545
ROLAIDS EXTRA STRENGTH .............................. 545
RONDEC-D ................................................................ 545
ropinirole tab 0.25mg ............................................ 60
ropinirole tab 0.5mg ............................................... 60
ropinirole tab 1mg ................................................... 60
ropinirole tab 2mg ................................................... 60
ropinirole tab 3mg ................................................... 60
ropinirole tab 4mg ................................................... 60
ropinirole tab 5mg ................................................... 60
rosadan ...................................................................... 695
ROSE MILK ............................................................... 545
rosuvastatin calcium ............................................... 45
ROTARIX.................................................................... 103
ROTATEQ ................................................................... 103
roweepra ..................................................................... 55
roweepra xr ................................................................ 55
RTD WOUND CARE DRESSING 2 ..................... 545
RTD WOUND CARE DRESSING 4 ..................... 545
RUBRACA .................................................................... 36
RU-HIST D ................................................................ 545
RU-HIST-D ................................................................ 545
rulox .............................................................................. 84
rutin ............................................................................ 545
RUTIN ......................................................................... 545
rutin-50 ..................................................................... 545
rx support heartburn/acid .................................. 545
RX SUPPORT HEARTBURN/ACID ...................... 545
RYCONTUSS ............................................................. 545
RYDAPT ........................................................................ 39
RYDEX ........................................................................ 545
RYDEX G .................................................................... 545
RYMED ........................................................................ 545
rynex dm ................................................................... 545
rynex pe .................................................................... 545
rynex pse .................................................................. 545
S
s.s.s. tonic ................................................................ 545
S2 ................................................................................ 545
SABRIL ......................................................................... 55
saccharomyces boulardii ..................................... 546
SAF-CLENS AF ......................................................... 546
safe tussin 30 .......................................................... 546
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 812
safe tussin dm adult ............................................. 546
safe tussin pm......................................................... 546
SAFE WASH .............................................................. 546
salac ............................................................................ 546
SALAC ......................................................................... 546
salactic film .............................................................. 546
SALESE ...................................................................... 546
salicylic acid ............................................................. 546
SALICYLIC ACID ..................................................... 546
saline .......................................................................... 546
SALINE ....................................................................... 546
saline flush zr/sterile f ......................................... 546
saline mist ................................................................ 546
saline nasal mist .................................................... 546
saline sensitive eyes ............................................. 546
SALINE WOUND WASH ........................................ 546
SALIVA SUBSTITUTE ............................................ 546
SALJET ....................................................................... 546
SALJET RINSE ......................................................... 547
SALONPAS-HOT ...................................................... 547
sal-plant .................................................................... 546
SAMI THE SEAL REPLACEMENT ........................ 547
SANDIMMUNE ......................................................... 102
sani-supp adult ....................................................... 547
sani-supp pediatric ................................................ 547
SANTYL ...................................................................... 695
SAPHRIS ................................................................ 63, 64
SAPS HEALTH INCONTINENCE ......................... 547
saratoga .................................................................... 547
SARNA ........................................................................ 547
sarna sensitive ........................................................ 547
sarna sensitive anti-itch ...................................... 547
sarnol-hc ................................................................... 547
savision ...................................................................... 547
SAVISION ................................................................. 547
SAWYER INSECT REPELLENT ............................ 547
SAWYER INSECT REPELLENT C ........................ 547
SAWYER PREMIUM INSECT REP ....................... 547
sb 12hr nasal spray .............................................. 685
sb acid controller ................................................... 547
sb acid controller maximu .................................. 547
sb acid reducer ................................................. 87, 547
sb acid reducer ranitidin ..................................... 547
sb allerfed cold & allerg ....................................... 547
sb allergy .......................................................... 547, 680
sb allergy & cold pe .............................................. 548
sb allergy medicine ....................................... 548, 680
sb allergy multi-symptom .................................. 548
sb allergy relief ....................................................... 548
sb allergy relief/nasal d ....................................... 548
sb allergy/sinus/headache ................................. 548
sb analgesic ............................................................. 548
sb analgesic creme rub........................................ 548
sb antacid ................................................................... 84
sb antacid anti-gas ................................................ 548
sb antacid anti-gas doubl ................................... 548
sb antacid extra strength ............................. 84, 548
sb antacid/antigas ................................................. 548
sb anti-diarrhea ........................................................ 85
sb anti-fungal .......................................................... 548
sb anti-gas................................................................ 548
sb antihistamine ..................................................... 548
sb anti-itch maximum stre ................................. 548
sb anti-nausea ........................................................ 548
sb arthritis pain relief ........................................... 548
sb aspirin ............................................................ 13, 548
sb aspirin adult low stre ................................ 14, 548
sb aspirin ec ............................................................. 548
sb bacitracin ............................................................ 549
sb backache extra strengt .................................. 549
sb bisacodyl laxative ec ......................................... 92
sb bismuth ................................................................ 549
sb bismuth maximum streng ............................ 549
sb bronchial .............................................................. 549
sb calcium + d ........................................................ 549
sb cetirizine hcl childre ........................................ 549
sb childrens aspirin ............................................... 549
sb childrens ibuprofen .......................................... 549
sb childrens non-aspirin ...................................... 549
sb childrens plus cough/r ................................... 549
sb childrens plus multisy .................................... 549
sb chlorpheniramine ..................................... 549, 680
sb cimetidine ........................................................... 549
sb clotrimazole foot............................................... 549
sb cold & allergy childre ...................................... 549
sb cold & cough dm childr .................................. 549
sb cold & cough hbp ............................................. 549
sb cold & flu hbp .................................................... 549
sb cold & flu severe .............................................. 549
sb cold head congestion s .................................. 549
sb cold medicine..................................................... 549
sb cold multi-symptom day ............................... 549
sb cold multi-symptom sev ................................ 550
sb cough control ..................................................... 550
sb cough control cf ................................................ 550
sb cough control dm ............................................. 550
sb cough control dm max ................................... 550
sb cough control pe .............................................. 550
sb cough relief ........................................................ 550
sb coughtab ............................................................. 550
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 813
sb day time cold/flu reli ...................................... 550
sb daytime ................................................................ 550
sb daytime sinus .................................................... 550
sb docusate sodium .............................................. 550
sb docusate sodium/senna ................................ 550
sb ear wax remover .............................................. 550
sb effervescent pain reli ...................................... 550
sb fib lax orange .................................................... 550
sb fiber laxative ...................................................... 550
sb flu maximum strength h ............................... 550
sb flu relief therapy sev ...................................... 550
sb flu relief therapy/flu ........................................ 550
sb gas relief ............................................................. 550
sb gentle laxative womens ................................. 550
sb gentle lax-women ............................................ 550
sb glycerin adult ..................................................... 551
sb glycerin pediatric.............................................. 551
sb hemorrhoid ......................................................... 551
sb hydrocortisone .................................................. 551
sb hydrocortisone maximum ............................. 692
sb hydrocortisone plus ................................. 551, 692
sb ibuprofen ....................................................... 16, 551
sb infants ibuprofen .............................................. 551
sb itch relief maximum st ................................... 551
sb laxative ................................................................ 551
sb lice killing maximum s ................................... 551
sb lice treatment .................................................... 551
sb loratadine ............................................................ 551
sb loratadine allergy rel ...................................... 551
sb low dose asa ec .................................................. 14
sb lubricating jelly ................................................. 551
sb magnesium citrate .......................................... 551
sb milk of magnesia ........................................ 92, 551
sb motion sickness .................................................. 86
sb mucus relief ....................................................... 551
sb mucus relief dm ........................................ 551, 685
sb mucus relief pe ................................................. 551
sb multi-purpose .................................................... 551
sb naproxen sodium ............................................. 551
sb nasal spray no-drip ......................................... 551
sb natural fiber laxative ...................................... 551
sb night time cold/flu re ...................................... 552
sb nighttime cough ............................................... 552
sb nighttime sinus multi- .................................... 552
sb non-asa night time .......................................... 552
sb non-aspirin ................................................... 14, 552
sb non-aspirin extra stre .............................. 14, 552
sb non-aspirin jr strengt ..................................... 552
sb non-aspirin nighttime ..................................... 552
SB OMEPRAZOLE ................................................... 552
sb oyster shell calcium ........................................ 552
sb pain relief x-str ................................................. 552
sb pain reliever children ...................................... 552
sb pain reliever extra st ................................ 14, 552
sb pain reliever pm ............................................... 552
sb pediatric electrolyte ........................................ 552
sb peptic relief ........................................................ 552
sb polyethylene glycol 3 ...................................... 552
sb povidone-iodine ................................................ 552
sb pseudoephedrin sinus .................................... 552
sb pseudoephedrine hcl ....................................... 552
sb pseudoephedrine plus .................................... 552
sb saline nose.......................................................... 552
sb saline sensitive ................................................. 552
sb senna-lax ............................................................ 553
SB SEV/CONGEST.................................................. 553
sb severe cold congestion .................................. 553
sb severe cold pe ................................................... 553
sb sinus & allergy maximu ................................. 553
sb sinus congestion & pai ................................... 553
sb sinus relief .......................................................... 553
sb sleep ....................................................................... 70
sb sore throat spray ............................................. 553
sb stool softener .................................................... 553
sb tab tussin dm .................................................... 553
sb triple antibiotic .................................................. 553
sb urinary pain relief ............................................ 553
sb urinary pain relief ma ..................................... 553
sb vitamin c ............................................................. 553
scalp relief ................................................................ 553
scalp relief maximum stre .................................. 553
scalpicin ..................................................................... 553
scalpicin 2 in 1 ........................................................ 553
scalpicin maximum strengt ................................ 553
scar gel ...................................................................... 553
scar treatment products ...................................... 553
scaraway ................................................................... 553
SCARCIN ................................................................... 553
SCARCIN GEL .......................................................... 554
SCHOLLS CALLUS CUSHIONS ........................... 554
SCHOOLTIME SHAMPOO ..................................... 554
sclerex ........................................................................ 554
SCOOBY-DOO ONE A DAY .................................. 554
SCOPE ........................................................................ 554
scopolamine patch ................................................... 86
SCOTT MOIST WIPES ........................................... 554
SCOT-TUSSIN ......................................................... 554
scot-tussin allergy relie ....................................... 554
SCOT-TUSSIN DIABETES .................................... 554
SCOT-TUSSIN DIABETES CF ............................. 554
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 814
scot-tussin dm ........................................................ 554
SCOT-TUSSIN DM .................................................. 554
scot-tussin expectorant ....................................... 554
SCOT-TUSSIN SENIOR ........................................ 554
SCYTERA ................................................................... 554
se aspartate ............................................................. 554
SE PLUS PROTEIN .................................................. 554
SE-100 ....................................................................... 554
sea buddies daily multipl .................................... 554
sea soft nasal mist ................................................ 554
SEA-CLENS LIQ WOUND ..................................... 554
SEA-CLENS WOUND CLEANSER ....................... 554
sea-omega 30 ......................................................... 555
SEASORB-AG ........................................................... 555
sebex .......................................................................... 555
SEBULEX ................................................................... 555
secura antifungal ................................................... 555
secura antifungal extra t ..................................... 555
SECURA DIMETHICONE PROTEC ..................... 555
SECURA EXTRA PROTECTIVE ............................ 555
SECURA MOISTURIZING CLEAN ...................... 555
SECURA PERSONAL CLEANSER ........................ 555
secura protective ................................................... 555
SECURA TOTAL BODY CLEANSE ...................... 555
SECURE BELTED UNDERGARMEN .................... 555
SECURE BELTLESS UNDERGARM ..................... 555
SECURE FEMALE PANTS W/OUT ...................... 555
SECURE FEMALE PANTS W/TRI ........................ 555
SECURE FITTED BRIEFS EXTR .......................... 555
SECURE FITTED BRIEFS LARG.......................... 555
SECURE FITTED BRIEFS MEDI .......................... 555
SECURE FITTED BRIEFS SMAL ......................... 555
SECURE FITTED BRIEFS YOUT ......................... 555
SECURE GUARDS ................................................... 555
SECURE GUARDS EXTRA LENGT ...................... 555
SECURE GUARDS SUPER .................................... 556
SECURE GUARDS SUPER PLUS ......................... 556
SECURE LINERS EXTRA LENGT ........................ 556
SECURE LINERS HIGH CAPACI ......................... 556
SECURE LINERS MAXI 10 ................................... 556
SECURE LINERS MEDIUM 7 ............................... 556
SECURE LINERS SMALL 4 ................................... 556
SECURE MALE PANTS EXTRA L ......................... 556
SECURE MALE PANTS LARGE/3 ........................ 556
SECURE MALE PANTS MEDIUM/ ....................... 556
SECURE MALE PANTS SMALL/2 ........................ 556
SECURE MATTRESS COVER 36 ......................... 556
SECURE MATTRESS COVER 39 ......................... 556
SECURE MATTRESS COVER 54 ......................... 556
SECURE MATTRESS COVER 60 ......................... 556
SECURE MATTRESS COVER 75 ......................... 556
SECURE MATTRESS COVER FLA ....................... 556
SECURE PADS REGULAR ..................................... 556
SECURE PADS SUPER ........................................... 556
SECURE PLUS BELTED UNDERG ...................... 556
SECURE UNDERGARMENT STRAP .................... 556
SECURE UNDERPADS EXTRA LA ...................... 556
SECURE UNDERPADS LARGE 23 ...................... 556
SECURE UNDERPADS SMALL 17 ...................... 557
SECURELY YOURS OB PAD ................................. 557
SECURELY YOURS STRETCH BR ....................... 557
SELECT BELTED UNDERGARMEN ..................... 557
SELECT BOOSTER PADS ..................................... 557
SELECT CONTOURED SHIELD L ....................... 557
SELECT DAYTIME LINERS ................................... 557
SELECT DAYTIME PLUS LINER .......................... 557
SELECT DISPOSABLE ABSORBE ....................... 557
SELECT DISPOSABLE BRIEFS ........................... 557
SELECT EXTRA PERSONAL CAR ........................ 557
SELECT KIDS DISPOSABLE BR ......................... 557
SELECT LIGHT PERSONAL CAR ........................ 557
SELECT MESH PANTS EXTRA L ......................... 557
SELECT MESH PANTS LARGE ............................ 557
SELECT MESH PANTS MEDIUM ......................... 557
SELECT MESH PANTS XX-LARG ........................ 557
SELECT NIGHTTIME LINERS .............................. 557
SELECT REGULAR PERSONAL C ....................... 557
SELECT SHIELD PAD ............................................ 557
SELECT SLIM N' SOFT GUARD .......................... 557
SELECT SLIM N' SOFT ULTRA ........................... 557
SELECT SOFT N' BREATHABLE ......................... 557
SELECT ULTRA UNDERPADS LA ....................... 558
SELECT UNDERGARMENT STRAP ..................... 558
SELECT UNDERPADS EXTRA LA ....................... 558
SELECT UNDERPADS LARGE ............................. 558
SELECT-LITE LANCING DEVIC .......................... 558
selegiline hcl .............................................................. 60
selenicaps-200 ........................................................ 558
SELENIMIN ............................................................... 558
selenimin-200 ......................................................... 558
selenium .................................................................... 558
SELENIUM ................................................................. 558
selenium sulfide ..................................................... 691
SELENIUM-E ............................................................. 558
selenomax ................................................................ 558
SELSUN BLUE .......................................................... 558
selsun blue 3-in-1 treatm ................................... 558
SELSUN BLUE DAILY ............................................ 558
SELSUN BLUE DEEP CLEANSIN ........................ 558
SELSUN BLUE MEDICATED ................................ 558
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 815
SELSUN BLUE MOISTURIZING ......................... 558
SELSUN BLUE NATURALS ................................... 558
SELSUN BLUE NATURALS DRY ......................... 558
SELSUN BLUE SHA 1% ........................................ 558
SELZENTRY ................................................................ 25
senexon ............................................................... 92, 559
senexon-s ........................................................... 92, 559
senior tabs ................................................................ 559
senior tonic .............................................................. 559
SENIOR VITES ........................................................ 559
senna .......................................................................... 559
SENNA ........................................................................ 559
senna lax ................................................................... 559
senna laxative ......................................................... 559
SENNA LEAVES ....................................................... 559
senna maximum strength .................................. 559
senna plus .......................................................... 92, 559
SENNA PROMPT ...................................................... 559
senna s ...................................................................... 559
senna smooth .......................................................... 559
sennacon ................................................................... 559
senna-grx.................................................................. 559
senna-lax ............................................................ 92, 559
sennalax-s ................................................................ 559
sennalex .................................................................... 560
senna-plus ................................................................ 559
senna-s ...................................................................... 559
senna-tabs.......................................................... 92, 559
senna-time ................................................................. 92
senna-time s .............................................................. 92
sennazon ................................................................... 560
senno ............................................................................ 92
sennosides .......................................................... 92, 560
sennosides-docusate sodium ...................... 92, 560
SENOKOT .................................................................. 560
senokot extra strength ........................................ 560
SENOKOT S .............................................................. 560
SENOKOT TO GO ................................................... 560
SENOKOT XTRA ...................................................... 560
sen-o-tabs ................................................................ 559
SENSI-CARE BODY CREAM ................................ 560
SENSI-CARE MOISTURIZING ............................ 560
SENSI-CARE PROTECTIVE BAR ........................ 560
SENSI-CARE SEPTI-SOFT CON ......................... 560
SENSIPAR ................................................................... 77
sentry ......................................................................... 560
SENTRY ...................................................................... 560
sentry adults under 50 ........................................ 560
sentry senior ............................................................ 560
SENTRY SENIOR ..................................................... 560
SENTRY SENIOR/LUTEIN .................................... 560
SEREVENT DISKUS ............................................... 681
sertraline hcl .............................................................. 58
sevelamer carbonate .............................................. 81
severe allergy .......................................................... 560
severe cold ............................................................... 560
severe cold & cough night .................................. 560
severe cold & flu .................................................... 561
severe cold & flu daytime ................................... 561
severe cold & flu nightti ...................................... 561
severe congestion .................................................. 561
severe congestion & cough ................................ 561
severe congestion sinus r ................................... 561
severe sinus congestion & .................................. 561
SHIELD LARGE 7 .................................................... 561
SHIELD REGULAR 4-1/4 ...................................... 561
SHIELD-SECURE FULL FACE S .......................... 561
SHINGRIX ................................................................. 103
shopko allergy relief-d ......................................... 561
shopko athletes foot ............................................. 561
SHOPKO AUTOLET LANCING DE ...................... 561
shopko nasal decongestant................................ 561
SHOWER TABLETS ................................................. 561
SHUR-CLENS ........................................................... 561
SIDEROL .................................................................... 561
SIDESTREAM ADULT FACE MAS ....................... 561
SIDESTREAM PEDIATRIC FACE ........................ 561
SIDESTREAM PLUS ADULT FAC ........................ 561
SIESTA MASK .......................................................... 561
signacal ...................................................................... 561
SIGNIFOR ................................................................... 81
sigtab .......................................................................... 561
silace ..................................................................... 92, 562
siladryl allergy ......................................................... 680
sildenafil citrate tab 20 mg (pulmonary
hypertension) ....................................................... 51
SILENOR ...................................................................... 66
SILICA GEL ............................................................... 562
SILICONE MASK FOR BREATHE ........................ 562
SILICONE MASK FOR BREATHR ....................... 562
SILPHEN COUGH .................................................... 562
silphen dm cough................................................... 562
siltussin das ............................................................. 562
siltussin dm das ...................................................... 685
siltussin sa ........................................................ 562, 685
siltussin-dm.............................................................. 685
silver sulfadiazine .................................................. 689
SILVERMED .............................................................. 562
SIMBRINZA .............................................................. 675
simeped ..................................................................... 562
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 816
simethicone .............................................................. 562
SIMETHICONE ......................................................... 562
SIMILAC PRENATAL EARLY SH ......................... 562
SIMPLE DIAGNOSTICS LANCIN ........................ 562
SIMPLE SYP .............................................................. 562
SIMPLE SYRUP ........................................................ 562
SIMPLICITY ADULT BRIEFS 3 ............................ 562
SIMPLICITY ADULT BRIEFS 4 ............................ 562
SIMPLICITY ADULT FLAT FOL............................ 562
SIMPLICITY ADULT POLY BRI ........................... 562
SIMPLICITY COTTON SNAP PA ......................... 562
SIMPLICITY FLUFF UNDERPAD ......................... 562
SIMPLICITY GARMENT LINER ............................ 563
SIMPLICITY INSERT PAD 12 .............................. 563
SIMPLICITY INSERT PAD 14 .............................. 563
SIMPLICITY INSERT PAD 6-1 ............................ 563
SIMPLICITY PANT LINER/ADH .......................... 563
SIMPLICITY QUILTED ADULT ............................ 563
SIMPLICITY UNDERPADS .................................... 563
simply allergy .......................................................... 563
simply cough ........................................................... 563
SIMPLY SALINE ....................................................... 563
simply saline baby ................................................. 563
simply sleep ............................................................. 563
simply stuffy ............................................................ 563
SIMPLY STUFFY ...................................................... 563
simvastatin ................................................................. 45
SINADRIN PE COMPLETE SINU......................... 563
sinex severe+ vapocool ni ................................. 563
sinu and chest congestion ....................................... 187
SINUCLEANSE REFILL .......................................... 563
sinus ........................................................................... 563
and headache daytim ...................................... 563
sinus & allergy 12 hour ....................................... 563
sinus & allergy pe maximu ................................. 563
sinus & cold-d non-drowsy ................................. 563
sinus & congestion daytim ................................. 563
sinus congestion & pain d ................................... 564
sinus congestion & pain s ................................... 564
sinus congestion/pain day .................................. 564
sinus congestion/pain sev .................................. 564
sinus daytime/nighttime ..................................... 564
sinus headache max streng ............................... 564
sinus headache pe maximum ........................... 564
sinus maximum relief ........................................... 564
sinus maximum strength .................................... 564
sinus nasal spray ................................................... 564
sinus nasal spray 12 hour .................................. 564
sinus pain reliever maxim .................................. 564
sinus pressure/pain/adult ................................... 564
sinus relief ................................................................ 564
sinus relief extra streng ...................................... 564
sinus relief mist ...................................................... 564
sinus relief nasal spray ................................ 564, 685
sinus wash saline refills ....................................... 564
SINUS WASH SALT................................................ 564
sinus/allergy maximum str ................................ 564
sinutab sinus maximum str ............................... 564
SIR DIGNITY MENS BRIEFS E ........................... 564
SIR DIGNITY MENS BRIEFS L ........................... 564
SIR DIGNITY MENS BRIEFS M .......................... 565
SIR DIGNITY MENS BRIEFS S ........................... 565
SIR DIGNITY MENS BRIEFS X ........................... 565
SIR DIGNITY PLUS BRIEFS E ............................ 565
SIR DIGNITY PLUS BRIEFS L ............................. 565
SIR DIGNITY PLUS BRIEFS M ........................... 565
SIR DIGNITY PLUS BRIEFS S ............................ 565
SIR DIGNITY PLUS BRIEFS X ............................ 565
sirolimus .................................................................... 102
SIRTURO ..................................................................... 28
SIVEXTRO ................................................................... 22
skarjel ........................................................................ 565
SKIN BEAUTY & WELLNESS ............................... 565
skin care lotion ....................................................... 565
SKIN PROTECTANT MOISTURE ......................... 565
skin protectants, misc. ....................................... 565
SKIN REPAIR ........................................................... 565
SKINTEGRITY 2 ...................................................... 565
SKINTEGRITY 4 ...................................................... 565
SKINTEGRITY WOUND ......................................... 565
sleep aid .................................................................... 565
sleep ii ........................................................................ 565
sleep tabs ................................................................... 70
sleep-aid maximum strengt ............................... 566
sleep-tabs ................................................................. 566
SLIMLINE ADJUSTABLE BRIEF .......................... 566
SLIMLINE CONTOURED LINERS ....................... 566
SLIMLINE DISPOSABLE BRIEF .......................... 566
SLIMLINE FITTED LINERS .................................. 566
SLIMLINE PEACH SHEET CARE ......................... 566
SLIP-ON UNDERGARMENTS ............................... 566
slo-niacin ................................................................... 566
SLO-NIACIN ............................................................. 566
slow fe ........................................................................ 566
SLOW FE .................................................................... 566
slow iron .................................................................... 566
slow magnesium chloride/.................................. 566
slow release iron .................................................... 566
SLOW-MAG ............................................................... 566
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 817
slow-release iron .................................................... 566
sm 12 hour sinus deconges ............................... 566
sm 12-hour no drip ............................................... 566
sm 3-day vaginal ................................................... 566
SM 4X PROBIOTIC ................................................. 566
sm 8 hour pain relief ...................................... 14, 566
sm acid reducer ................................................ 87, 566
sm acid reducer maximum s ............................. 567
sm acidophilus ........................................................ 567
SM ACIDOPHILUS PEARLS ................................. 567
sm all day allergy .......................................... 567, 680
sm all day allergy childr .............................. 567, 680
sm all day allergy-d ...................................... 567, 685
sm all day pain relief ............................................ 567
sm allergy 4 hour .......................................... 567, 680
sm allergy maximum streng.............................. 567
sm allergy multi-symptom ................................. 567
sm allergy relief.............................................. 567, 680
sm allergy relief childre ....................................... 567
sm allergy relief nasal s ...................................... 567
sm allergy/sinus headache ................................ 567
sm animal shapes complete .............................. 567
sm animal shapes kids fir ................................... 567
sm animal shapes/iron ........................................ 567
sm antacid advanced ..................................... 84, 567
sm antacid advanced maxi ................................ 567
sm antacid anti-gas ........................................ 84, 567
sm antacid anti-gas extr ..................................... 568
sm antacid extra strength .................................. 568
sm antacid maximum streng ...................... 84, 568
sm antacid/antigas .......................................... 84, 568
sm antibiotic .................................................... 568, 689
sm antibiotic plus pain r ...................................... 568
sm anticavity fluoride ri ...................................... 568
sm anti-dandruff coal tar .................................... 568
sm anti-diarrheal ............................................. 85, 568
sm antifungal clotrimazol ........................... 568, 690
sm antifungal miconazole ................................... 568
sm antifungal tolnaftate .............................. 568, 690
sm anti-itch .............................................................. 568
sm anti-itch extra streng .................................... 568
sm anti-nausea ....................................................... 568
sm antioxidant vitamins ...................................... 568
sm antiseptic mouth rinse .................................. 568
sm arthricream rub ............................................... 568
sm arthritis pain relief ................................... 14, 568
sm arthritis pain relieve ...................................... 568
sm artificial tears ................................................... 568
sm aspirin ........................................................... 14, 569
sm aspirin adult low stre .............................. 14, 569
sm aspirin ec low strengt ................................... 569
sm aspirin enteric coated ................................... 569
sm aspirin low dose ........................................ 14, 569
sm aspirin tri-buffered ......................................... 569
sm athletes foot ............................................. 569, 690
sm b super vitamin comple................................ 569
sm balanced b-50 .................................................. 569
sm ballanced b-100 .............................................. 569
sm b-complex.......................................................... 569
SM B-COMPLEX/VITAMIN C ............................... 569
sm bedding lice treatment ................................. 569
SM BENZOIN TINCTURE ...................................... 569
sm biotin ................................................................... 569
SM BUNION CUSHIONS ....................................... 569
SM CALAMINE ......................................................... 569
SM CALAMINE PHENOLATED ............................. 569
sm calcium ............................................................... 569
sm calcium /vitamin d ......................................... 570
sm calcium 500/vitamin d3 ............................... 570
sm calcium 600 ...................................................... 570
sm calcium 600 + d plus m ............................... 570
sm calcium 600/vitamin d .................................. 570
sm calcium 600+d3 .............................................. 570
sm calcium antacid ......................................... 84, 570
sm calcium antacid extra .............................. 84, 570
sm calcium antacid ultra ..................................... 570
sm calcium citrate + d ......................................... 570
sm calcium citrate w/vita ................................... 570
sm calcium citrate/vitami ................................... 570
sm calcium citrate+ w/vit .................................. 570
sm calcium plus/vitamin d ................................. 570
sm calcium soft chews ......................................... 570
sm calcium/magnesium/zinc ............................. 570
sm calcium/vitamin d ........................................... 570
sm calcium/vitamin d3 ........................................ 570
sm caldyphen .......................................................... 570
SM CALLUS CUSHIONS........................................ 570
sm castor oil ............................................................ 570
sm chest congestion relie ........................... 570, 685
sm chewable c ........................................................ 570
sm chewable vitamin c ........................................ 571
sm childrens aspirin ........................................ 14, 571
sm childrens ibuprofen .................................. 16, 571
sm childrens loratadine ............................... 571, 680
sm childrens non-aspirin ..................................... 571
sm childrens pain relief ....................................... 571
sm chromium picolinate ...................................... 571
sm clearlax ......................................................... 92, 571
sm clotrimazole vaginal ....................................... 571
sm co q-10 ............................................................... 571
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 818
sm cod liver oil ....................................................... 571
sm coenzyme q-10 ................................................ 571
sm cold & allergy childre............................. 571, 685
sm cold & allergy pe ............................................. 571
sm cold & cough childrens ................................. 571
sm cold & cough dm childr ................................. 571
sm cold & flu severe ............................................. 571
sm cold & hot therapy pa ................................... 571
sm cold & sinus relief ........................................... 571
sm cold head congestion d ................................ 571
sm cold head congestion n ................................ 571
sm cold head congestion s ................................. 571
sm complete ............................................................ 571
sm complete 50+ .................................................. 572
sm complete 50+ ultimate ................................. 572
sm complete advanced form ............................. 572
sm complete dual action ..................................... 572
sm complete senior formul ................................ 572
sm coq-10................................................................. 572
SM CORAL CALCIUM ............................................. 572
SM CORN CUSHIONS ........................................... 572
sm cough & cold multi-sym ............................... 572
sm cough & runny nose chi ............................... 572
SM COUGH & SORE THROAT DA ...................... 572
sm cough & sore throat ni .................................. 572
sm cough drops ...................................................... 572
sm cough relief ....................................................... 572
sm daily diet support ........................................... 572
sm day time cold & flu re ................................... 572
sm day time liquid caps ...................................... 572
sm day time pe cold & flu................................... 572
sm daytime cold & cough c ................................ 572
sm daytime liquid caps ........................................ 572
sm daytime liquid caps/no ................................. 572
SM DISPOSABLE UNDERPADS/M ..................... 572
sm docusate calcium ............................................ 572
sm double antibiotic ............................................. 573
sm dry eye relief .................................................... 573
sm dry skin therapy .............................................. 573
sm ear drops ........................................................... 573
sm effervescent pain reli .................................... 573
sm enema ................................................................. 573
SM ENTRUST PLUS BLADDER C ....................... 573
sm epsom salt ......................................................... 573
sm esomeprazole magnesium .......................... 573
sm eye drops ........................................................... 573
sm eye itch relief ................................................... 573
sm eye wash ............................................................ 573
sm fexofenadine hcl ...................................... 573, 680
sm fiber ............................................................... 93, 573
sm fiber laxative .............................................. 93, 573
SM FIBER POWDER ............................................... 573
sm fish oil ................................................................. 573
sm flu relief therapy sev ..................................... 573
sm flu/cold/cough medicin ................................. 573
sm foaming antacid .............................................. 573
sm folic acid ............................................................. 573
sm gas relief ............................................................ 574
sm gas relief antiflatuen ..................................... 574
sm gas relief drops infan .................................... 574
sm gas relief extra stren ............................... 94, 574
sm gas relief infants dro ..................................... 574
sm gentle laxative ........................................... 93, 574
sm glucosamine chondroiti ................................ 574
sm glucosamine hcl............................................... 574
SM GLUCOSE ..................................................... 80, 574
SM GLUCOSE TEST STRIPS ............................... 574
sm glycerin ............................................................... 574
sm glycerin adult ................................................... 574
sm glycerin laxative pedi .................................... 574
sm glycerin pediatric ............................................ 574
sm hair/skin/nails .................................................. 574
sm headache added strengt .............................. 574
sm headache pain reliever ................................. 574
sm headache relief pm ........................................ 574
sm hemorrhoidal .................................................... 574
sm hemorrhoidal cooling g ................................. 574
sm hydrocortisone ......................................... 574, 692
sm hydrocortisone maximum ................... 574, 692
sm hydrocortisone plus ....................................... 575
sm hydrocortisone/aloe ma ............................... 575
sm hydrogen peroxide ......................................... 575
sm ibuprofen ..................................................... 16, 575
sm ibuprofen cold & sinus .................................. 575
sm ibuprofen cold childre ................................... 575
sm ibuprofen ib................................................. 16, 575
sm ibuprofen jr ....................................................... 575
sm ibuprofen pm .................................................... 575
SM INCONTINENT LINER DISP ......................... 575
sm infants ibuprofen ............................................. 575
sm infants pain reliever ....................................... 575
SM IODIDES TINCTURE ....................................... 575
SM IODINE TINCTURE ......................................... 575
SM IPECAC SYRUP ................................................. 575
sm iron ....................................................................... 575
SM IRON .................................................................... 575
sm iron slow release ............................................. 575
sm isopropyl alcohol ............................................. 575
SM ISOPROPYL ALCOHOL ................................... 575
SM ISOPROPYL ALCOHOL RUBB ...................... 575
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 819
SM LAMBS WOOL ................................................... 576
sm lansoprazole ............................................... 95, 576
sm laxative ............................................................... 576
sm laxative maximum stren .............................. 576
sm lice killing ........................................................... 576
sm lice killing maximum s .......................... 576, 695
sm lice solution kit ................................................ 576
sm lice treatment .................................................. 576
sm l-lysine ................................................................ 576
sm loperamide hcl ................................................. 576
sm loratadine .................................................. 576, 680
sm loratadine allergy rel ..................................... 576
sm lorata-dine d ............................................. 576, 685
sm loratadine d 12hr ............................................ 576
sm lubricant eye drops ................................ 576, 676
sm lubricating jelly ................................................ 576
sm lubricating plus ................................................ 576
sm lubricating tears .............................................. 576
sm magnesium ....................................................... 576
sm magnesium citrate ......................................... 576
sm medicated body powder ............................... 576
sm medicated chest rub ...................................... 577
sm medicated corn remover.............................. 577
sm medicated wipes ............................................. 577
sm melatonin ........................................................... 577
sm miconazole 3 .................................................... 577
sm miconazole 7 .............................................. 96, 577
sm migraine relief ................................................. 577
sm milk of magnesia ............................................ 577
sm mineral oil ......................................................... 577
SM MOLESKIN PLUS PADDING ......................... 577
sm motion sickness............................................... 577
sm motion sickness relief ............................. 86, 577
sm mouth rinse antiseptic .................................. 577
sm mucus er ............................................................ 577
sm mucus relief childrens ................................... 577
sm mucus relief cough chi ......................... 577, 685
sm mucus relief d .................................................. 577
sm multiple vitamins esse .................................. 577
sm multiple vitamins/iron .................................. 577
sm multi-purpose .................................................. 577
sm muscle rub ........................................................ 577
sm naproxen sodium ............................................ 577
sm nasal decongestant ........................................ 578
sm nasal decongestant max ...................... 578, 685
sm nasal decongestant pe.................................. 578
sm nasal spray ................................................ 578, 685
sm nasal spray 12 hour ............................... 578, 685
sm nasal spray moisturizi ................................... 578
sm nasal spray pump mist ................................. 578
sm nasal spray saline ........................................... 578
sm nasal spray sinus ............................................ 578
sm natural laxative plus ................................ 93, 578
sm niacin cr .............................................................. 578
sm nicotine ......................................................... 70, 578
sm nicotine polacrilex .............................. 70, 71, 578
sm nicotine transdermal s ............................ 71, 578
sm night time liquid caps ................................... 578
sm nighttime sleep aid ........................................ 578
sm nite time cold & flu ........................................ 578
sm nite time cold & flu r ..................................... 578
sm nite time cold/flu rel ...................................... 578
sm nite time cough ............................................... 578
sm non aspirin allergy si ..................................... 579
sm non-aspirin flu ................................................. 579
sm nose drops nasal decon ............................... 579
sm oatmeal bath .................................................... 579
sm omega-3 fish oil .............................................. 579
SM OMEPRAZOLE ............................................. 95, 579
SM ONE DAILY ESSENTIAL ................................ 579
SM ONE DAILY MENS ........................................... 579
SM ONE DAILY PRENATAL .................................. 579
SM ONE DAILY WOMENS .................................... 579
sm opti-vitamins .................................................... 579
sm oral cleanser ..................................................... 579
sm oyster shell calcium/v ........................... 579, 668
sm pain & fever childrens ............................. 14, 579
sm pain & fever infants ....................................... 579
sm pain relief........................................................... 579
sm pain relief extra stre ...................................... 579
sm pain reliever...................................................... 579
sm pain reliever 8 hour e ................................... 579
sm pain reliever children .................................... 579
sm pain reliever cold ............................................ 579
sm pain reliever extra st ....................... 14, 579, 580
sm pain reliever infants ....................................... 580
sm pain reliever junior s ..................................... 580
sm pain reliever pm extra .................................. 580
sm pain reliever sinus ma .................................. 580
sm pain reliever sinus pe .................................... 580
sm pedia relief for child ....................................... 580
sm pediatric electrolyte ............................... 580, 664
sm petroleum jelly ................................................ 580
SM PETROLEUM JELLY ......................................... 580
sm potassium .......................................................... 580
sm povidone-iodine ............................................... 580
SM PRENATAL VITAMINS .................................... 580
sm probiotic ............................................................. 580
sm rapid melts junior ........................................... 580
sm redness relief ................................................... 580
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 820
sm saline solution .................................................. 580
sm selenium ............................................................ 580
sm senna laxative.................................................. 580
sm senna laxative maximum .............................. 93
sm senna-s ............................................................... 580
sm severe congestion & co ................................ 580
sm sinus & allergy maximu................................ 580
sm sinus & allergy pe max ................................. 580
sm sinus & cold-d .................................................. 581
sm sinus maximum strength ............................. 581
sm sinus wash ........................................................ 581
sm skin cleanser gentle/s ................................... 581
SM SKIN CLEANSER GENTLE/S ........................ 581
sm sleep aid ............................................................. 581
sm sleep aid maximum stre .............................. 581
sm sleep aid night time ................................. 71, 581
sm slow release iron ............................................. 581
SM SLOW RELEASE IRON ................................... 581
sm smooth antacid extra s ................................ 581
sm sore throat lozenges...................................... 581
sm sore throat spray ............................................ 581
sm sports pain relief rub ..................................... 581
sm stay awake ........................................................ 581
sm stay awake maximum str ............................ 581
sm stomach relief ............................................ 85, 581
sm stomach relief liquid ...................................... 581
sm stomach relief max st ................................... 581
sm stomach relief maximum ............................. 581
sm stool softener ............................................. 93, 582
sm stool softener plus la ..................................... 582
sm super b complex-vitami ............................... 582
sm swimmers ear drops ...................................... 582
sm tension headache ........................................... 582
sm tioconazole-1 .................................................... 582
sm triacting cold & cough ................................... 582
SM TRIACTING ORANGE ..................................... 582
sm triple antibiotic ................................................ 582
sm triple antibiotic orig ....................................... 582
sm triple antibiotic plus ....................................... 582
SM TRUEDRAW LANCING DEVIC ..................... 582
sm tussin................................................................... 582
sm tussin cf ...................................................... 582, 685
sm tussin cough & cold ma ................................ 582
sm tussin dm ................................................... 582, 685
sm tussin dm cough/chest ......................... 582, 685
sm tussin dm max cough/ch ............................. 582
sm tussin mucus + chest c ................................ 582
sm urinary pain relief ........................................... 582
sm urinary pain relief ma ................................... 582
SM VAPORIZER CLEANING ................................. 582
SM VAPORIZER INHALANT ................................. 583
sm vit c/rose hips .................................................. 583
sm vitamin b1 ......................................................... 583
sm vitamin b-1 ....................................................... 583
sm vitamin b100 complex .................................. 583
sm vitamin b12 ....................................................... 583
sm vitamin b-12 ..................................................... 583
sm vitamin b12 tr .................................................. 583
sm vitamin b-12 tr ................................................ 583
sm vitamin b6 ......................................................... 583
sm vitamin b-6 ....................................................... 583
sm vitamin c ............................................................ 583
sm vitamin c cr ....................................................... 583
sm vitamin c tr ....................................................... 583
sm vitamin c/rose hips ........................................ 583
sm vitamin d ............................................................ 583
sm vitamin d3 ......................................................... 583
sm vitamin d3 maximum str ............................. 583
SM VITAMIN D3 MAXIMUM STR ....................... 583
sm vitamin e ............................................................ 583
sm vitamin e blended ........................................... 583
sm wart remover maximum s ........................... 583
sm witch hazel ........................................................ 583
sm womans laxative ............................................. 584
sm zinc ....................................................................... 584
SM ZINC PLUS......................................................... 584
sm z-sleep ................................................................ 584
SMART DIABETES VANTAGE LA ....................... 584
SMART DIABETES XPRES BLOO ....................... 584
SMART SENSE GLUCOSE .................................... 584
SMART SENSE GLUCOSE TABLE ...................... 584
SMART SENSE PREMIUM BLOOD ..................... 584
SMART SENSE VALUE BLOOD G ...................... 584
SMARTEST BLOOD GLUCOSE TE ..................... 584
SMARTEST EJECT BLOOD GLUC ....................... 584
SMARTEST EJECT STARTER KI ......................... 584
SMARTEST PERSONA STARTER ........................ 584
SMARTEST PRONTO STARTER K ...................... 584
SMARTEST PROTEGE BLOOD GL...................... 584
SMARTEST PROTEGE STARTER ........................ 584
smarty pants kids complet ................................. 584
smooth antacid extra stre .................................. 584
smooth lax ................................................................ 584
sochlor ....................................................................... 584
SODIUM ACETATE ANHYDROUS ...................... 584
SODIUM ASCORBATE ........................................... 584
SODIUM BICARBONATE ...................................... 585
sodium bicarbonate (antacid) ..................... 84, 585
sodium chlor sol 0.9% irr ................................... 695
sodium chloride .............................. 585, 664, 667, 668
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 821
SODIUM CHLORIDE .............................................. 585
sodium chloride (inhalant) ................................. 585
sodium chloride 0.45% ....................................... 667
sodium chloride flush ........................................... 585
SODIUM CHLORIDE GRANULES ....................... 585
sodium chloride hypertonic ........................ 585, 676
sodium chloride inj 0.9% .................................... 667
sodium chloride-sodium bicarbonate ............. 585
sodium ferric gluconate complex in sucrose 98, 585
sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml
soln ......................................................................... 664
sodium phenylbutyrate .......................................... 78
sodium phosphates ......................................... 93, 585
sodium polystyrene sulfonate powder ............. 77
sodium polystyrene sulfonate susp .................. 77
sof-lax ........................................................................ 585
soft lens products .................................................. 585
softden ....................................................................... 585
SOFTWEAR SALINE ............................................... 585
SOLARCAINE............................................................ 585
solfiber ....................................................................... 585
SOLIQUA 100/33 ..................................................... 73
SOLO .......................................................................... 585
SOLOCARE ................................................................ 585
SOLOSITE CONFORMABLE WOUN ................... 586
SOLTAMOX ................................................................. 37
soluble fiber ....................................................... 93, 586
SOLU-CORTEF ........................................................... 79
SOLUS V2 AUDIBLE BLOOD GL ........................ 586
SOLUS V2 AUDIBLE TEST ................................... 586
SOLUS V2 LANCING DEVICE ............................. 586
SOLVIL ....................................................................... 586
SOMATULINE DEPOT .............................................. 81
SOMAVERT ................................................................. 81
sominex ..................................................................... 586
sominex maximum strength .............................. 586
soothe ........................................................................ 586
SOOTHE ..................................................................... 586
SOOTHE & COOL FREE MEDSEP ...................... 586
SOOTHE & COOL FREE MOISTU ....................... 586
SOOTHE & COOL FREE SKIN P ......................... 586
soothe & cool inzo antifu ............................ 586, 690
SOOTHE & COOL INZO BARRIE ....................... 586
SOOTHE & COOL MOISTURE BA ...................... 586
SOOTHE & COOL MOISTURIZIN ...................... 586
SOOTHE & COOL PROTECT MOI ...................... 586
SOOTHE & COOL SHAMPOO AND .................... 586
SOOTHE & COOL SKIN CREAM ......................... 586
soothe hydration .................................................... 586
soothe maximum strength ................................. 586
soothe night time ................................................... 586
soothe nighttime dry eye .................................... 587
soothe xp .................................................................. 587
soothe xp/xtra protection ................................... 587
SOOTHENEB NBL 100 CHILD M........................ 587
SOOTHENEB NBL 100 MEDICAT ...................... 587
SOOTHENEB NBL 100 MESH CA....................... 587
SOOTHENEB NBL100 ADULT MA ...................... 587
soothing - 12 hour nasal ..................................... 587
soothing ointment ................................................. 587
SORBACELL FOAM DRESSING 4 ...................... 587
SORBACELL FOAM DRESSING S ...................... 587
SORBIDON HYDRATE ........................................... 587
SORBITOL ................................................................. 587
SORBOLENE ............................................................. 587
SORBSAN TOPICAL WOUND DRE .................... 587
sorbugen nr .............................................................. 587
sorbulax ..................................................................... 587
sorbutuss .................................................................. 587
SORBUTUSS NR ...................................................... 587
sore throat ................................................................ 587
sore throat & cough lozen .................................. 587
sore throat relief .................................................... 587
sore throat spray ................................................... 587
sorine ............................................................................ 45
sotalol hcl .................................................................... 45
sotalol hcl (afib/afl) ................................................. 45
SOURCECF ................................................................ 588
SOURCECF PEDIATRIC ........................................ 588
SP SCAR MANAGEMENT ...................................... 588
span c ......................................................................... 588
SPATONE PUR-ABSORB IRON ........................... 588
SPECIAL CARE CREAM ......................................... 588
SPENCO GEL HEEL CUSHIONS ......................... 588
SPENCO RX HEEL CUSHIONS............................ 588
spider-man complete multi ................................ 588
spironolactone ........................................................... 43
spironolactone & hydrochlorothiazide .............. 50
SPLEEN ...................................................................... 588
spongebob squarepants gum ............................ 588
sports pain relief rub ............................................ 588
SPORTS RUB INTENSE STRENG ....................... 588
SPORTSCREME ........................................................ 588
SPRITAM ...................................................................... 55
SPRYCEL ...................................................................... 40
sps susp 15gm/60ml .............................................. 77
sr anti-diarrheal...................................................... 588
sr nicotine gum ....................................................... 588
ssd ............................................................................... 689
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 822
ST IVES SWISS FORMULA 24 ........................... 588
ST JOSEPH ADULT ................................................. 588
ST JOSEPH ADULT ANALGESIC ........................ 588
st joseph aspirin ..................................................... 588
st joseph cough syrup .......................................... 588
st joseph low dose aspiri .................................... 588
stablegi ...................................................................... 588
STAFLEX .................................................................... 589
STAHIST .................................................................... 589
STAHIST AD ............................................................. 589
STANBACK ASPIRIN FREE .................................. 589
STANBACK HEADACHE POWDERS .................. 589
stannous fluoride ................................................... 589
STAPHSCRUB ........................................................... 589
STATUSS GREEN .................................................... 589
stavudine .................................................................... 25
STAXYN ...................................................................... 589
stay awake ............................................................... 589
stay awake maximum streng ............................ 589
STAYFREE MAXI REGULAR/WIN ....................... 589
STAYFREE MAXI/DEODORANT .......................... 589
STAYFREE MAXI/OVERNIGHT ........................... 589
STAYFREE MAXI/REGULAR ................................. 589
STAYFREE MAXI/SUPER ...................................... 589
STAYFREE MAXI/SUPER LONG .......................... 589
STAYFREE MAXI/THIN/DEODOR ...................... 589
STAYFREE MAXI/THIN/UNSCEN ....................... 589
STAYFREE MINI-PADS .......................................... 589
STAYFREE PANTY LINER/UNSC ........................ 589
STAYFREE SUPER MAXI ....................................... 589
STAYFREE ULTRA THIN LONG ........................... 589
STAYFREE ULTRA THIN OVERN ........................ 590
STAYFREE ULTRA THIN REGUL......................... 590
STAYFREE ULTRA THIN SUPER ......................... 590
STAYFREE ULTRA THIN/OVERN........................ 590
STENDRA................................................................... 590
STERILE LUBRICANT DROPS ............................. 590
sterile preserved saline ....................................... 590
STERILE SALINE SOLUTION .............................. 590
STERILID ................................................................... 590
sterilube .................................................................... 590
steri-strip compound benz ................................. 590
STIMATE ...................................................................... 82
stimulant laxative ............................................ 93, 590
STIVARGA ................................................................... 40
STOMACH .................................................................. 590
stomach relief ................................................... 85, 590
stomach relief maximum st ............................... 590
stomach relief plus ................................................ 590
stool softener .................................................... 93, 590
stool softener & stimulan .................................... 590
stool softener extra stre ................................ 93, 590
stool softener laxative ......................................... 590
stool softener laxative d ...................................... 590
stool softener plus laxat ...................................... 591
stool softener plus stimu .................................... 591
stool softener/laxative ......................................... 591
stop lice ..................................................................... 591
stop lice complete lice t ....................................... 591
stop lice maximum strengt ................................ 591
stop lice step 2 egg/nit ........................................ 591
stop lice step 3 ....................................................... 591
STOPAIN .................................................................... 591
STRATASORB COMPOSITE ISLA ...................... 591
streptomycin sulfate ............................................... 20
stress 500 b-complex ........................................... 591
stress b complex/iron........................................... 591
stress b/zinc ............................................................ 591
stress b-complex/c/zinc ...................................... 591
stress b-complex/vitamin ................................... 591
stress formula ................................................. 591, 671
stress formula w/iron ........................................... 671
stress formula/iron ................................................ 591
STRESS FORMULA/IRON ..................................... 591
stress formula/zinc ........................................ 591, 671
stress formula+iron .............................................. 591
stress plus zinc ....................................................... 591
STRESS-600/ZINC ................................................. 591
stresstabs ................................................................. 591
stresstabs advanced ............................................. 592
stresstabs energy .................................................. 592
STRIBILD .................................................................... 27
strip ease adhesive remov ................................. 592
STROVITE FORTE ................................................... 592
STROVITE ONE ....................................................... 592
STUART ONE ............................................................ 592
STUDIO 35 EXTRA MOISTURIZ ........................ 592
STUDIO 35 MOISTURIZING SK ........................ 592
stye ............................................................................. 592
STYGIENE STERILE EYELID C ........................... 592
SUBOXONE MIS 12-3MG ....................................... 71
SUBOXONE MIS 2-0.5MG ..................................... 71
SUBOXONE MIS 4-1MG ......................................... 71
SUBOXONE MIS 8-2MG ......................................... 71
subvenite tab ............................................................. 55
sucralfate .................................................................... 94
SUDAFED .................................................................. 592
sudafed 12 hour ..................................................... 592
SUDAFED 24 HOUR ............................................... 592
SUDAFED CHILDRENS ......................................... 592
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 823
SUDAFED CONGESTION ...................................... 592
SUDAFED NASAL DECONGESTAN ................... 592
sudafed pe cold & cough c ................................. 592
SUDAFED PE COLD/COUGH MUL ..................... 592
SUDAFED PE CONGESTION ............................... 592
SUDAFED PE DAY & NIGHT ................................ 592
SUDAFED PE DAY & NIGHT CO ........................ 592
SUDAFED PE MAXIMUM STRENG ..................... 592
sudafed pe nighttime cold .................................. 592
sudafed pe non-drying sin ................................. 593
sudafed pe preesure+pain+ .............................. 593
sudafed pe pressure+pain+ .............................. 593
SUDAFED PE SEVERE COLD MU ....................... 593
sudafed pe sinus headache ................................ 593
sudafed pe sinus pressure.................................. 593
sudafed pe sinus/allergy ..................................... 593
sudafed plus ............................................................ 593
sudafed pressure+pain 12 ................................. 593
SUDAFED TAB 30MG ............................................ 593
SUDAFED TAB 60MG ............................................ 593
SUDAFED TRIPLE ACTION .................................. 593
sudanyl ...................................................................... 593
sudogest ............................................................ 593, 686
sudogest 12 hour ................................................... 593
sudogest pe...................................................... 593, 686
sudogest sinus & allergy ............................. 593, 686
SUEDE HEEL GRIPS .............................................. 593
sulfacetamide sodium (acne) ............................ 688
sulfacetamide sodium (ophth) .......................... 673
sulfacetamide sod-prednisolone ...................... 672
SULFADIAZINE.......................................................... 20
sulfamethoxazole-trimethop ds .......................... 22
sulfamethoxazole-trimethoprim inj................... 22
sulfamethoxazole-trimethoprim susp .............. 22
sulfamethoxazole-trimethoprim tab 400-
80mg........................................................................ 22
SULFAMYLON ........................................................... 689
sulfasalazine .............................................................. 88
sulfasalazine ec ........................................................ 88
sulindac ....................................................................... 16
sumatriptan ................................................................ 67
sumatriptan inj 4mg/0.5ml .................................. 67
sumatriptan inj 6mg/0.5ml .................................. 67
sumatriptan succinate............................................ 67
SUMMERS EVE CLEANSING WAS .................... 593
summers eve medicated ..................................... 593
SUMMERS EVE NIGHT-TIME CL ........................ 593
SUNBEAM BACTERIASTAT .................................. 593
SUNBEAM HUMIDIFIER/VAPORI ...................... 593
SUNBEAM INCONTINENT UNDER .................... 594
SUNBEAM VAPORIZER INHALAN ..................... 594
sunkist vitamin c .................................................... 594
sunvite active adult 50+ ..................................... 594
sunvite advanced ................................................... 594
super 28 formula ................................................... 594
super amino acids ................................................. 594
SUPER ANTIOXIDANT........................................... 594
super antioxidant/a/c/e/s ................................... 594
super antioxidants protec ................................... 594
super aytinal 50 plus ............................................ 594
super aytinal for active ........................................ 594
super b complex maxi .......................................... 594
super b complex/c ................................................. 594
super b with c ......................................................... 594
super b-100 ............................................................. 594
super b-50 ................................................................ 594
SUPER B-50 B-COMPLEX .................................... 594
super b-50 complex .............................................. 594
SUPER B-50 COMPLEX ......................................... 594
super b-50 complex plus .................................... 594
super b-complex .................................................... 594
SUPER B-COMPLEX ............................................... 594
super b-complex/folic aci .................................... 595
super b-complex/iron/vita .................................. 595
super b-complex/vitamin c ................................ 595
super biotin .............................................................. 595
super c-1000 ........................................................... 595
super c-500 .............................................................. 595
SUPER C-500 COMPLEX ...................................... 595
super cal/mag ......................................................... 595
super calcium .......................................................... 595
super calcium 600 + d3 ...................................... 595
super calcium 600+d 400 .................................. 595
super calcium 600+d3 400 ................................ 595
SUPER CAL-MAG-D ................................................ 595
super cold tabs ....................................................... 595
SUPER D3 COMPLEX ............................................. 595
SUPER DAILY D3 .................................................... 595
super dec b-100 ..................................................... 595
SUPER E..................................................................... 595
SUPER E DAY ........................................................... 595
SUPER E EYE ............................................................ 595
SUPER E HAND/BODY .......................................... 595
SUPER E NIGHT ...................................................... 595
super moleskin ....................................................... 595
super multiple ......................................................... 596
super natrul-100 .................................................... 596
super nu-thera ........................................................ 596
SUPER NU-THERA .................................................. 596
SUPER PROBIOTIC ................................................ 596
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 824
SUPER PROBIOTIC DIGESTIVE......................... 596
super quints b-50 .................................................. 596
super strength sinadrin ....................................... 596
super stress b-complex tr .................................. 596
super thera vite m ................................................. 596
super vikaps ............................................................ 596
super vita-mins ...................................................... 596
SUPER-AMINO 1600 ............................................. 596
SUPERB NAILS ........................................................ 596
superior 35 ............................................................... 596
SUPERIORSOURCE K1 ......................................... 596
superplex-t ............................................................... 671
supersoft ................................................................... 596
SUPERSORB UNDERPAD ..................................... 596
suphedrine ................................................................ 596
SUPLEVIT .................................................................. 596
SUPPORT ................................................................... 596
SUPPOSIBASE ......................................................... 596
SUPRAX ....................................................................... 30
SUPREME TEST STRIPS ....................................... 596
SUPREP BOWEL PREP KIT .................................... 93
SUPRESS A PEDIATRIC DROPS ........................ 597
SUPRESS DM PEDIATRIC .................................... 597
supress-dx pediatric ............................................. 597
SUPRESS-PE PEDIATRIC ..................................... 597
SURE & NATURAL PANTYLINER ........................ 597
SURE & NATURAL THIN MAXI/ ......................... 597
SURE & NATURAL ULTRA THIN ........................ 597
SURE CARE BELTED UNDERGAR ...................... 597
SURE CARE BELTLESS UNDERG....................... 597
SURE CARE FLUFF AND POLYM ........................ 597
SURE CARE FLUFF UNDERPAD.......................... 597
SURE CARE PLUS PROTECTIVE ........................ 597
SURE CARE PROTECTIVE UNDE ....................... 597
SURE CARE UNDERGARMENT ........................... 597
SURE COMFORT LANCING PEN ........................ 597
SURE EDGE BLOOD GLUCOSE M ..................... 597
SURE EDGE BLOOD GLUCOSE T ...................... 597
sure guard anti-oxidant p ................................... 597
sure guard multi vitamin/................................... 597
sure result sr relief ................................................ 597
SURECHEK BLOOD GLUCOSE MO .................... 598
SURECHEK BLOOD GLUCOSE TE ..................... 598
SURE-PEN ................................................................. 597
sureprin 81 ............................................................... 598
SURESTEP PRO TEST STRIPS ........................... 598
SURE-TEST EASYPLUS MINI B .......................... 597
SURE-TEST EASYPLUS MINI S .......................... 598
SURETYS SHIELD REGULAR .............................. 598
surfak ......................................................................... 598
surgel.......................................................................... 598
surgilube ................................................................... 598
sur-q-lax.................................................................... 597
SUSPENDOL-S ......................................................... 598
SUTENT ........................................................................ 40
sv melatonin ............................................................ 598
sv vitamin b12 tr ................................................... 598
sw acid reducer 150 maxim............................... 598
sw allergy relief ...................................................... 598
sw allergy relief-d .................................................. 598
sw clearlax ................................................................ 598
sw cold & sinus pain reli ...................................... 598
sw nasal decongestant max .............................. 598
sw nicotine polacrilex ........................................... 598
SW OMEPRAZOLE .................................................. 598
sw suphedrine 12 hour nas ................................ 598
swabflush saline flush .......................................... 598
SWEEN CREAM ........................................................ 598
SWEETENING SUSPENDING COM ................... 599
SWIM EAR ................................................................. 599
swimmers ear drops ............................................. 599
swimmers instant ear dry ................................... 599
SYLATRON KIT 200MCG ........................................ 40
SYLATRON KIT 300MCG ........................................ 41
SYLATRON KIT 600MCG ........................................ 41
SYMBICORT .............................................................. 688
SYMDEKO .................................................................. 687
SYMFI ........................................................................... 27
SYMFI LO..................................................................... 27
SYMPAZAN .................................................................. 55
SYMPROIC .................................................................. 94
SYMPT-X .................................................................... 599
SYMPT-X G.I. ........................................................... 599
SYMTUZA .................................................................... 27
SYNAREL ..................................................................... 77
SYNDION ................................................................... 599
SYNDION-SF ............................................................ 599
SYNERCID ................................................................... 22
SYNERTROPIN ......................................................... 599
SYNJARDY TAB 12.5-1000MG ............................. 75
SYNJARDY TAB 12.5-500MG ............................... 75
SYNJARDY TAB 5-1000MG ................................... 75
SYNJARDY TAB 5-500MG ...................................... 75
SYNJARDY XR TAB 10-1000MG .......................... 75
SYNJARDY XR TAB 12.5-1000MG ...................... 76
SYNJARDY XR TAB 25-1000MG .......................... 76
SYNJARDY XR TAB 5-1000MG ............................ 75
synovacin .................................................................. 599
SYNRIBO ..................................................................... 41
SYNTHROID ................................................................ 81
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 825
SYRPALTA ................................................................. 599
SYRSPEND SF .......................................................... 599
SYRUP NF .................................................................. 599
SYSTANE ................................................................... 599
SYSTANE BALANCE RESTORATI ....................... 599
SYSTANE COMPLETE ............................................ 599
systane contacts soothing .................................. 599
SYSTANE GEL .......................................................... 599
SYSTANE LID WIPES ............................................ 599
SYSTANE LIQUID GEL .......................................... 599
systane nighttime .................................................. 599
SYSTANE OVERNIGHT THERAPY ...................... 676
SYSTANE PRESERVATIVE FREE ........................ 599
SYSTANE ULTRA ..................................................... 599
SYSTANE ULTRA HOME & AWAY ...................... 600
SYSTANE ULTRA PRESERVATIV ....................... 600
T
tab-a-vite .................................................................. 671
tab-a-vite maximum ............................................. 600
tab-a-vite w/beta caroten .................................. 671
TAB-A-VITE WOMENS .......................................... 600
tab-a-vite/iron ................................................ 600, 671
TABLOID ...................................................................... 34
tabtussin ................................................................... 600
tabtussin 400 .......................................................... 600
tabtussin dm ............................................................ 600
tacrolimus ................................................................. 102
tacrolimus (topical) ............................................... 695
tactinal ................................................................. 14, 600
tactinal extra strength ........................................... 14
TAFINLAR .................................................................... 40
TAGAMET HB ........................................................... 600
TAGRISSO .................................................................. 40
TALZENNA .................................................................. 36
tamoxifen citrate ...................................................... 37
tamsulosin hcl ........................................................... 95
TANDEM ..................................................................... 600
TANNIC ACID........................................................... 600
ta-poff ........................................................................ 600
TARCEVA ..................................................................... 40
TARGRETIN .............................................................. 695
TASIGNA ..................................................................... 40
TAVIST ALLERGY .................................................... 600
TAXOTERE .................................................................. 34
tazarotene ................................................................ 690
tazicef ........................................................................... 30
TAZORAC .................................................................. 691
taztia xt ....................................................................... 48
TDVAX ........................................................................ 103
tears again ............................................................... 600
tears again advanced eyel ................................. 600
TEARS AGAIN NIGHT & DAY .............................. 600
tears naturale .................................................. 600, 676
tears naturale forte ............................................... 600
TEARS NATURALE FORTE ................................... 600
tears naturale ii ...................................................... 600
TEARS NATURALE PM ........................................... 600
tears pure ................................................................. 601
TECENTRIQ................................................................. 36
TEFLARO ...................................................................... 30
TEGADERM AG MESH DRESSING .................... 601
TEGADERM ALGINATE AG DRES ...................... 601
TEGADERM HIGH GELLING ALG ....................... 601
TEGADERM HIGH INTEGRITY A ........................ 601
TEKTURNA .................................................................. 49
TEKTURNA HCT ......................................................... 49
TELCARE BLOOD GLUCOSE MON ..................... 601
TELCARE BLOOD GLUCOSE TES ...................... 601
telmisartan ................................................................. 44
telmisartan-amlodipine .......................................... 44
telmisartan-hydrochlorothiazide ........................ 44
temazepam ................................................................ 66
temp tab .................................................................... 601
TENA BELTED BRIEFS .......................................... 601
TENA CLASSIC BRIEFS/LARGE ......................... 601
TENA CLASSIC BRIEFS/MEDIU ......................... 601
TENA CLASSIC BRIEFS/X-LAR .......................... 601
TENA COMPLETE + CARE BRIE......................... 601
TENA COMPLETE BRIEF EXTRA......................... 601
TENA COMPLETE BRIEF LARGE ........................ 601
TENA COMPLETE BRIEF MEDIU ........................ 601
TENA DAY DRY COMFORT HEAV ...................... 601
TENA DAY DRY COMFORT LIGH ....................... 601
TENA DAY DRY COMFORT MODE ..................... 601
TENA DAY LIGHT PAD .......................................... 601
TENA DAY PLUS PAD ............................................ 601
TENA DAY REGULAR PAD .................................... 601
TENA DISCREET SUPER/LARGE........................ 601
TENA DISCREET SUPER/MEDIU ....................... 602
TENA DISCREET ULTRA/LARGE ........................ 602
TENA DISCREET ULTRA/MEDIU........................ 602
TENA DISCREET/LARGE ...................................... 602
TENA DISCREET/MEDIUM ................................... 602
TENA DISCREET/SMALL ...................................... 602
TENA DISCREET/XLARGE ................................... 602
TENA FLEX 12 MAXI .............................................. 602
TENA FLEX 12 PLUS .............................................. 602
TENA FLEX 12 SUPER ........................................... 602
TENA FLEX 16 MAXI .............................................. 602
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 826
TENA FLEX 16 PLUS .............................................. 602
TENA FLEX 16 SUPER ........................................... 602
TENA FLEX 20 ......................................................... 602
TENA FLEX 8 SUPER ............................................. 602
TENA FOR MEN ....................................................... 602
TENA INSTADRY PADS/HEAVY ......................... 602
TENA MEN HEAVY PROTECTION ...................... 602
TENA NIGHT DRY COMFORT .............................. 602
TENA NIGHT SUPER PAD .................................... 602
TENA OVERNIGHT UNDERWEAR ...................... 602
TENA PANTS SUPER/MEDIUM ........................... 602
TENA PANTS ULTRA/LARGE ............................... 602
TENA PANTS ULTRA/MEDIUM ........................... 603
TENA PANTS/SMALL ............................................. 603
TENA PANTS/XL-XXL ............................................ 603
TENA PANTS/YOUTH ............................................. 603
TENA PROTECTIVE UNDERWEAR ..................... 603
TENA SERENITY ACTIVE PADS ......................... 603
TENA SERENITY ACTIVE PANT ......................... 603
TENA SERENITY ANYWHERE PA ....................... 603
TENA SERENITY BRIEFS/ULTI........................... 603
TENA SERENITY INSTADRY/LO ........................ 603
TENA SERENITY MALE GUARDS ....................... 603
TENA SERENITY OVERNIGHT P ........................ 603
TENA SERENITY PADS/HEAVY .......................... 603
TENA SERENITY PADS/MODERA ...................... 603
TENA SERENITY PADS/ULTIMA ........................ 603
TENA SERENITY PANTILINERS ......................... 603
TENA SERENITY PROTECTIVE ........................... 603
TENA SERENITY STYLISH PAD.......................... 603
TENA SKIN-CARING BODY WAS ...................... 603
TENA SKIN-CARING WASH CRE ....................... 603
TENA SKIN-CARING WASHCLOT...................... 603
TENA STRETCH BRIEF 2XL/PL .......................... 603
TENA STRETCH BRIEF 2XL/UL .......................... 603
TENA STRETCH ULTRA BRIEF/ ......................... 604
TENA SUPER BRIEF/LARGE ................................ 604
TENA WASH CREAM .............................................. 604
TENA WOMEN HEAVY PROTECTI...................... 604
TENA YOUTH BRIEF EXTRA SM ........................ 604
TENDERSORB UNDERPAD .................................. 604
TENIVAC .................................................................... 103
tenofovir disoproxil fumarate .............................. 25
tension headache ................................................... 604
tension headache relief ....................................... 604
teo-tus ....................................................................... 604
tera-gel tar ............................................................... 604
terazosin hcl .............................................................. 43
terbinafine hcl ........................................................... 23
terbinafine hcl (topical) ............................... 604, 690
terbutaline sulfate ................................................. 681
terconazole vaginal ................................................. 96
TESSALON PERLES ................................................ 604
testosterone ............................................................... 71
testosterone cypionate .......................................... 71
testosterone enanthate ......................................... 71
tetrabenazine ............................................................ 68
tetracycline hcl .......................................................... 33
tetra-formula nighttime s ................................... 604
tetrahydrozoline hcl (ophth) .............................. 604
tetterine ..................................................................... 604
TEXACORT SOLN 2.5% ........................................ 692
TG 10PEH/380GFN ................................................ 604
tg 10peh/380gfn/15dm ....................................... 604
TG 45PSE/400GFN ................................................ 604
TG 45PSE/400GFN/15DM ................................... 604
tgq 7.5peh/4brm/15dm ...................................... 604
tgt 12 hour nasal deconge ................................. 604
tgt acetaminophen childre .................................. 604
tgt acetaminophen extra s ................................. 604
tgt acetaminophen infants ................................. 605
tgt acetaminophen melts c ................................ 605
tgt acid controller compl ..................................... 605
tgt acid reducer ...................................................... 605
tgt acid reducer complete ................................... 605
TGT ADVANCED LANCING DEVI ....................... 605
tgt all day allergy relie ......................................... 605
tgt all day allergy-d .............................................. 605
tgt allergy & congestion ...................................... 605
tgt allergy medication ch .................................... 605
tgt allergy melts childre ...................................... 605
tgt allergy relief ...................................................... 605
tgt allergy relief childr .......................................... 605
tgt allergy/congestion re ..................................... 605
tgt allergy+ congestion r .................................... 605
tgt analgesic rub .................................................... 605
tgt antacid ................................................................ 605
tgt antacid anti-gas regu .................................... 605
tgt antacid extra strengt ..................................... 605
tgt antacid ultra strengt ...................................... 605
tgt antibiotic ............................................................ 606
tgt anti-diarrheal .................................................... 605
tgt antifungal ........................................................... 606
tgt antifungal spray .............................................. 606
tgt antifungal spray powd .................................. 606
tgt anti-itch maximum str .................................. 605
tgt anti-itch plus oatmea .................................... 605
tgt anti-itch/aloe maximu ................................... 606
tgt anti-itch/aloe/vitami ...................................... 606
tgt arthritis pain relief .......................................... 606
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 827
tgt aspirin ................................................................. 606
tgt aspirin low dose............................................... 606
tgt athletes foot ...................................................... 606
tgt bacitracin ........................................................... 606
TGT BLOOD GLUCOSE METER M ...................... 606
TGT BLOOD GLUCOSE MONITOR..................... 606
TGT BLOOD GLUCOSE TEST ST ....................... 606
tgt calcium + vitamin d3 .................................... 606
tgt calcium dietary suppl .................................... 606
tgt childrens acetaminoph .................................. 606
tgt childrens aspirin .............................................. 606
tgt childrens ibuprofen ........................................ 606
tgt clotrimazole ....................................................... 606
tgt cold and cough relief ................................................. 606
and hot pain-rel ................................................. 606
tgt cold & hot pain relie ....................................... 606
tgt cold head congestion ..................................... 607
tgt cold relief multi-sym ...................................... 607
tgt cold/cough childrens ...................................... 607
tgt cold/flu relief day t ......................................... 607
tgt cold/flu relief day/n........................................ 607
tgt cold/flu relief multi ......................................... 607
tgt cold/flu relief night ......................................... 607
tgt cough drops ...................................................... 607
tgt cough formula dm .......................................... 607
tgt cough formula dm max ................................ 607
tgt cough suppressant/top ................................. 607
tgt cough/cold adult ............................................. 607
tgt daily multivitamin wo .................................... 607
tgt enteric-coated aspiri ...................................... 607
tgt eye allergy relief ............................................. 607
tgt eye itch relief .................................................... 607
tgt fiber laxative ..................................................... 607
tgt fiber therapy ..................................................... 607
tgt first aid antibiotic ............................................ 607
tgt flu/severe cold/cough ................................... 607
tgt gas relief extra stre........................................ 607
tgt gas relief infants dr ........................................ 607
tgt gentle laxative ................................................. 607
TGT GLUCOSE ......................................................... 608
tgt hemorrhoidal cream ...................................... 608
tgt hemorrhoidal cream ma ............................... 608
tgt hemorrhoidal supposit .................................. 608
tgt hydrogen peroxide ......................................... 608
tgt ibuprofen ............................................................ 608
tgt ibuprofen childrens ........................................ 608
tgt ibuprofen junior stre ...................................... 608
tgt ibuprofen pm .................................................... 608
tgt infants ibuprofen ............................................. 608
tgt itch relief extra str .......................................... 608
TGT LANCING DEVICE ......................................... 608
tgt laxative pills maximu .............................. 93, 608
tgt lice complete kit 1-2 ...................................... 608
tgt lice killing maximum ...................................... 608
tgt loperamide hcl ................................................. 608
tgt loratadine childrens........................................ 608
tgt lubricant eye drops/m ................................... 608
tgt lubricant eye nightti ....................................... 608
tgt medicated hemorrhoida ............................... 608
tgt medicated wipe/witch ................................... 608
tgt menstrual relief maxi .................................... 608
tgt miconazole 1..................................................... 608
tgt miconazole 3 combinat ................................. 609
tgt miconazole 7..................................................... 609
tgt migraine relief .................................................. 609
tgt mucus relief children ..................................... 609
tgt mucus relief cough ch ................................... 609
tgt mucus/cough relief......................................... 609
tgt multi-symptom cold pl .................................. 609
tgt multivitamin/multimin .................................. 609
tgt naproxen sodium ............................................ 609
tgt nasal decongestant ........................................ 609
tgt nasal decongestant 12 .................................. 609
tgt nasal decongestant pe .................................. 609
tgt nasal spray ........................................................ 609
tgt natural laxative pill .......................................... 93
tgt nicotine gum ..................................................... 609
tgt nicotine polacrilex ........................................... 609
tgt nicotine step one ............................................. 609
tgt nicotine step three ......................................... 609
tgt nicotine step two ............................................. 609
tgt nighttime sleep aid ......................................... 609
TGT OMEPRAZOLE ................................................. 609
tgt pain reliever added s ..................................... 609
tgt pain reliever jr stre ........................................ 609
tgt pain reliever pm extr ..................................... 609
tgt pain/fever acetaminop .................................. 610
tgt pain-relief .......................................................... 610
tgt pe multi-symptom seve ............................... 610
tgt powderlax .......................................................... 610
tgt psyllium fiber .................................................... 610
tgt saline laxative .................................................. 610
tgt saline nasal spray ........................................... 610
tgt senna ................................................................... 610
tgt senna laxative .................................................. 610
tgt senna laxative/stool ....................................... 610
tgt severe cold relief ............................................. 610
tgt sinus 12 hour.................................................... 610
tgt sinus congestion/pain ................................... 610
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 828
tgt sleep aid maximum str ................................. 610
tgt sore throat spray ............................................ 610
tgt stomach relief .................................................. 610
tgt stool softener ................................................... 610
tgt stool softener & stim ..................................... 610
tgt tioconazole 1 .................................................... 610
tgt tioconazole 1day ............................................. 610
tgt tussin dm cough .............................................. 610
tgt vitamin c drops ................................................ 610
tgt wart remover .................................................... 610
tgt womens laxative ............................................. 611
th 12 hour decongestant .................................... 611
th acetaminophen extra st ................................. 611
th acetaminophen pm extra .............................. 611
TH ACIDOPHILUS PROBIOTIC ........................... 611
th allergy relief ....................................................... 611
th allergy relief + cold ......................................... 611
th allergy relief + sinus ....................................... 611
th antacid .................................................................. 611
th antacid extra strength .................................... 611
th antacid regular streng .................................... 611
th antacid ultra strength ..................................... 611
th antacid/anti-gas ................................................ 611
th antacid/anti-gas extra .................................... 611
th antibiotic + pain reli ........................................ 611
th anti-diarrheal ..................................................... 611
th arthritis pain relief ........................................... 611
th aspirin ................................................................... 611
th aspirin low dose ................................................ 611
th b 100 complex ................................................... 611
th b complex/iron/vitamin.................................. 611
th bacitracin ............................................................. 611
th calcium ................................................................. 611
th calcium 600 with vitam .................................. 612
th calcium 600/vitamin d .................................... 612
th calcium citrate/vitami ..................................... 612
th calcium/magnesium/zinc ............................... 612
th calcium/vitamin d/mine ................................. 612
th cetirizine hcl ....................................................... 612
th chest congestion relie ..................................... 612
th childrens allergy................................................ 612
th childrens chewable mul .................................. 612
th childrens mucus relief..................................... 612
th childrens pain relieve ...................................... 612
th childrens plus cough & ................................... 612
th clotrimazole ........................................................ 612
th co q-10 ................................................................. 612
th cod liver oil ......................................................... 612
th cold & allergy ..................................................... 612
th congestion ........................................................... 612
th cough suppressant ........................................... 612
th cranberry/vitamin c/vi .................................... 612
th daily multiple vitamin ..................................... 612
th day time cold/flu reli ....................................... 612
th day time multi-symptom ............................... 612
th enteric aspirin .................................................... 612
th epsom salt ........................................................... 613
th eye drop original ............................................... 613
th eye drop tears ................................................... 613
th famotidine 10 ..................................................... 613
th fish oil extra strengt ........................................ 613
th folic acid ............................................................... 613
th gas relief extra stren ....................................... 613
th gentle laxative ................................................... 613
th hydrocortisone ................................................... 613
th hydrocortisone/aloe ......................................... 613
th ibuprofen ............................................................. 613
th l-lysine .................................................................. 613
th loratadine ............................................................ 613
th loratadine-d ........................................................ 613
th magnesium ......................................................... 613
th magnesium citrate ........................................... 613
th milk of magnesia .............................................. 613
th motion relief ....................................................... 613
th naproxen .............................................................. 613
th nasal decongestant pe ................................... 613
th nasal relief .......................................................... 613
th nasal relief extra moi ...................................... 613
th nasal relief sinus ............................................... 613
th natural fiber ........................................................ 614
th nighttime cold/flu rel ...................................... 614
th nighttime cough ................................................ 614
th nite time multi-sympto .................................. 614
th oyster shell calcium/v ..................................... 614
th pain reliever pm extra .................................... 614
th pediatric electrolyte/ ....................................... 614
th pink bismuth formula r................................... 614
th rest simply .......................................................... 614
th severe cold multi-symp .................................. 614
th sinus headache pe ........................................... 614
th sleep aid............................................................... 614
th sleep aid maximum stre ................................ 614
th slow release iron ............................................... 614
th sore throat spray .............................................. 614
th stay awake .......................................................... 614
th stool softener ..................................................... 614
th stool softener plus la....................................... 614
th triple antibiotic .................................................. 614
th tussin .................................................................... 614
th tussin cf ................................................................ 614
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 829
th tussin dm ............................................................. 614
th tussin dm max ................................................... 614
th urinary pain relief ............................................. 615
th vitamin b 50/b-complex ................................ 615
th vitamin b1 ........................................................... 615
th vitamin b12 ........................................................ 615
th vitamin b-12 ....................................................... 615
th vitamin b12 er ................................................... 615
th vitamin b-6 ......................................................... 615
th vitamin c .............................................................. 615
th vitamin c/rose hips/bi ..................................... 615
th vitamin d3 ........................................................... 615
th vitamin e .............................................................. 615
th vitamin e/d-alpha ............................................. 615
th womans laxative ............................................... 615
th zinc ........................................................................ 615
THALOMID ............................................................ 37, 38
the itch eraser ......................................................... 615
the magic bullet ..................................................... 615
the treatment formula 3 ..................................... 615
THEO-24 .................................................................... 687
theophylline ............................................................. 687
thera ........................................................................... 615
THERA ........................................................................ 671
THERA M PLUS ........................................................ 671
thera vital m ............................................................ 615
thera vital-m ............................................................ 615
therabasic-m ........................................................... 616
THERABETIC EYE HEALTH .................................. 616
THERABETIC MULTI-VITAMIN ........................... 616
THERABETIC SKIN CARE .................................... 616
THERABREATH ORAL RINSE/FR ....................... 616
THERACAL D2000 .................................................. 616
THERACAL D4000 .................................................. 616
THERACAL RAPID REPLETION ........................... 616
theracaps cough & cold re .................................. 616
THERACOF PLUS COUGH AND C ...................... 616
theracort ................................................................... 616
thera-d 2000 ........................................................... 615
THERA-D 4000 ........................................................ 615
thera-d rapid repletion ........................................ 615
thera-d sport ........................................................... 616
thera-derm ............................................................... 616
thera-derm bath oil ............................................... 616
theradex .................................................................... 617
thera-ear ................................................................... 616
THERAFLU COLD & COUGH ................................ 617
THERAFLU COLD & SORE THRO ....................... 617
THERAFLU COLD/COUGH DAYTI ...................... 617
theraflu expressmax ............................................. 617
theraflu expressmax sever ................................. 617
THERAFLU FLU & CHEST CONG ........................ 617
THERAFLU FLU & SORE THROA ........................ 617
THERAFLU MAX-D SEVERE COL ....................... 617
theraflu nighttime maximu ................................ 617
theraflu non drowsy formu ................................ 617
THERAFLU POWERPODS DAYTIM .................... 617
THERAFLU POWERPODS NIGHTT..................... 617
theraflu severe cold & co .................................... 617
THERAFLU SEVERE COLD & CO ........................ 617
THERAFLU SEVERE COLD DAYT ....................... 617
THERAFLU SEVERE COLD MULT ....................... 617
THERAFLU SEVERE COLD NIGH ....................... 617
THERAFLU SINUS & COLD .................................. 617
THERAFLU WARMING RELIEF C ........................ 617
theraflu warming relief f ..................................... 617
theraflu warming relief m ................................... 617
theraflu warming relief s ..................................... 618
thera-gesic ............................................................... 616
thera-gesic plus ...................................................... 616
THERAGRAN-M ........................................................ 618
THERAGRAN-M ADVANCED ................................ 618
THERAGRAN-M ADVANCED 50 P ..................... 618
theragran-m fish oil conc .................................... 618
THERAGRAN-M PREMIER .................................... 618
THERAGRAN-M PREMIER 50 PL ........................ 618
thera-m...................................................................... 616
THERA-M ................................................................... 671
thera-mill .................................................................. 616
THERAMILL FORTE ................................................ 618
thera-mill m ............................................................. 616
theramill plus........................................................... 618
THERANATAL COMPLETE..................................... 618
THERANATAL CORE NUTRITION ...................... 618
THERANATAL LACTATION COMP ...................... 618
THERANATAL LACTATION ONE ......................... 618
THERANATAL LACTATION SUPP ....................... 618
THERANATAL ONE ................................................. 618
THERANATAL OVAVITE ........................................ 618
therapeutic ............................................................... 618
therapeutic bath oil ............................................... 618
therapeutic formula/hemat ................................ 618
therapeutic ice gel ................................................. 618
THERAPEUTIC LIQUID .......................................... 618
therapeutic m .......................................................... 618
therapeutic menthol ............................................. 618
THERAPEUTIC MOISTURIZING ......................... 619
therapeutic shampoo ............................................ 619
therapeutic t+plus ................................................. 619
THERAPEUTIC T+PLUS MAXIMU ...................... 619
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 830
therapeutic-m ......................................................... 619
therapeutic-m/lutein ............................................ 619
THERAPLEX HYDROLOTION ............................... 619
THERAPLEX T ........................................................... 619
theraplex z ............................................................... 619
thera-plus ................................................................. 616
THERASEAL HAND PROTECTION ..................... 619
thera-tabs ................................................................. 616
THERA-TABS M ....................................................... 616
THERATEARS ........................................................... 619
theratears allergy eye it ...................................... 619
theratein lotion ....................................................... 619
theratrum complete .............................................. 619
theratrum complete 50 plu ................................ 619
theravim -m ............................................................. 619
therems ..................................................................... 619
THEREMS-H .............................................................. 619
THEREMS-M ............................................................. 619
THERMOTABS .......................................................... 619
THIAMINE ................................................................. 619
thiamine hcl ............................................. 619, 620, 671
THIAMINE HCL ........................................................ 619
THIAMINE HYDROCHLORIDE............................. 620
thiamine mononitrate........................................... 620
thioridazine hcl ......................................................... 64
thiothixene ................................................................. 64
THRESHOLD IMT .................................................... 620
thrive .......................................................................... 620
thrive for life womens .......................................... 620
throat discs .............................................................. 620
throat lozenges ....................................................... 620
THUM .......................................................................... 620
THYMUS ..................................................................... 620
THYROSAFE .............................................................. 620
THYROSHIELD ......................................................... 620
tiagabine hcl .............................................................. 55
TIBSOVO ..................................................................... 36
tigecycline ................................................................... 22
TIGER BALM EXTRA STRENGTH ....................... 620
TIGER BALM RED EXTRA STRE ......................... 620
TIGER BALM REGULAR STRENG ....................... 620
TIGER BALM ULTRA STRENGTH ....................... 620
timolol maleate ......................................................... 47
timolol maleate (ophth) soln ............................. 675
timolol maleate gel ............................................... 675
timolol maleate ophth soln 0.5% (once-daily) ................................................................................. 675
TINACTIN .................................................................. 620
TINACTIN DEODORANT ....................................... 620
TINACTIN JOCK ITCH ........................................... 620
tinaspore ................................................................... 620
TIN-CO-BEN ............................................................. 620
tineacide .................................................................... 620
tioconazole 1 ........................................................... 620
tioconazole-1 ........................................................... 621
tippy toes diaper rash .......................................... 621
titralac ........................................................................ 621
TIVICAY ....................................................................... 25
tizanidine hcl ............................................................. 69
tl-hem 150 ................................................................ 621
tl-hist dm .................................................................. 621
tn dickinsons witch hazel .................................... 621
TOBRADEX ................................................................ 672
TOBRADEX ST ......................................................... 672
tobramycin ................................................................. 20
tobramycin (ophth) ............................................... 673
tobramycin inj 1.2 gm/30ml................................ 20
tobramycin inj 1.2gm ............................................. 20
tobramycin inj 10mg/ml ....................................... 20
tobramycin inj 40mg/ml ....................................... 20
tobramycin inj 80mg/2ml ..................................... 20
tobramycin-dexamethasone .............................. 672
TODAYS HEALTH ADVANCED LA ...................... 621
TOE-AID .................................................................... 621
tolnaftate .......................................................... 621, 690
tolnaftate 1% antifungal ..................................... 621
tolterodine tartrate cap er .................................... 96
tolterodine tartrate tabs ........................................ 96
tolu-sed dm .............................................................. 621
TONSILINE ............................................................... 621
TOPICLEAR ............................................................... 621
topiramate .................................................................. 55
TOPLINERS ............................................................... 621
toposar ......................................................................... 41
topotecan hcl ............................................................. 41
TOPOTECAN INJ 4MG/4ML ................................... 41
toremifene citrate .................................................... 37
torsemide tabs .......................................................... 50
total allergy .............................................................. 621
total allergy medicine ........................................... 621
total b/c ............................................................. 621, 672
total fiber .................................................................. 621
total formula ............................................................ 621
total formula 2 ........................................................ 622
total formula 3 ........................................................ 622
totalday multiple .................................................... 622
TOVIAZ ........................................................................ 96
tpn electrolytes ....................................................... 664
trace minerals (ca-cu-fe-i-k-mg-mn-p-zn) .. 622
TRACER BG TES...................................................... 622
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 831
TRACLEER ................................................................... 51
TRADJENTA ................................................................ 76
tramadol hcl tab 50 mg ......................................... 17
tramadol-acetaminophen...................................... 17
trandolapril ................................................................. 42
tranexamic acid ........................................................ 99
TRANQUILITY ADULT LINER .............................. 622
TRANQUILITY AIR-PLUS BARI........................... 622
TRANQUILITY ATN ALL-THROU ........................ 622
TRANQUILITY BARIATRIC STR ......................... 622
TRANQUILITY BELTED UNDERG ....................... 622
TRANQUILITY CLEANSING WIP ........................ 622
TRANQUILITY HEAVY DUTY UN ........................ 622
TRANQUILITY HIGH CAPACITY ......................... 622
TRANQUILITY HI-RISE BARIA ........................... 622
TRANQUILITY MINI TRIMSHIE .......................... 622
TRANQUILITY PREMIUM DAYTI ........................ 622
TRANQUILITY PREMIUM OVERN....................... 622
TRANQUILITY PREMIUM PROTE ....................... 622
TRANQUILITY SLIMLINE BREA.......................... 622
TRANQUILITY SLIMLINE BRIE ........................... 622
TRANQUILITY SLIMLINE FITT ........................... 622
TRANQUILITY SLIMLINE PEAC .......................... 622
TRANQUILITY SMARTCORE DIS ....................... 622
TRANQUILITY SUPER PLUS LI ........................... 623
TRANQUILITY THINLINER 202 .......................... 623
TRANQUILITY THINLINER 610 .......................... 623
TRANQUILITY THINLINER 714 .......................... 623
TRANQUILITY TOPLINER ..................................... 623
TRANQUILITY TOPLINER BOOS ........................ 623
TRANQUILITY TOPLINER MINI .......................... 623
TRANQUILITY TRIMSHIELD JU ......................... 623
TRANQUILITY TRIMSHIELD RE ......................... 623
TRANQUILITY TRIMSHIELD SU......................... 623
TRANQUILITY XL+ BARIATRI ............................ 623
TRANSDERM-SCOP .................................................. 86
tranylcypromine sulfate ........................................ 58
TRAVASOL ................................................................ 665
TRAVATAN Z ............................................................ 675
travel sickness .................................................. 86, 623
travel-ease ............................................................... 623
trav-tabs ................................................................... 623
trazodone hcl ............................................................. 58
TRECATOR .................................................................. 28
TRELEGY ELLIPTA .................................................. 677
TRELSTAR DEP INJ 3.75MG ................................. 37
TRELSTAR LA INJ 11.25MG .................................. 37
TRESIBA FLEXTOUCH ............................................. 73
TRESIBA INJ .............................................................. 73
tretinoin ..................................................................... 688
tretinoin (chemotherapy) ..................................... 41
TREXBROM ............................................................... 623
tri super flavons ..................................................... 623
TRIACTIN CHEST CONGESTION ....................... 624
triacting cold/allergy ............................................. 624
triacting day time cold/c ..................................... 624
triacting night time cold ...................................... 624
triacting nightime cold& ...................................... 624
tri-afed allergy/head col ...................................... 623
triamcinolone acetonide (mouth) .................... 696
triamcinolone acetonide (nasal) ....................... 624
triamcinolone acetonide (topical) .................... 692
triaminic allerchews .............................................. 624
TRIAMINIC CHEST & NASAL C .......................... 624
TRIAMINIC CHEST CONGESTIO ....................... 624
TRIAMINIC CHEST/NASAL CON ....................... 624
TRIAMINIC COLD & ALLERGY............................ 624
TRIAMINIC COLD & COUGH DA ....................... 624
TRIAMINIC COLD & COUGH NI ......................... 624
TRIAMINIC COLD/COUGH DAYT ...................... 624
TRIAMINIC COLD/COUGH NIGH ...................... 624
TRIAMINIC COUGH & RUNNY N ....................... 624
triaminic cough & sore th ................................... 624
TRIAMINIC COUGH & SORE TH ........................ 624
triaminic fever & cold mu ................................... 624
TRIAMINIC FEVER REDUCER P ......................... 624
TRIAMINIC FLU COUGH & FEV.......................... 624
TRIAMINIC FLU/COUGH/FEVER ........................ 625
triaminic long acting cou ..................................... 625
TRIAMINIC LONG ACTING COU ........................ 625
TRIAMINIC MULTI-SYMPTOM F ........................ 625
TRIAMINIC NIGHT TIME COLD ......................... 625
TRIAMINIC-D ........................................................... 625
TRIAMINO ................................................................. 625
triamterene & hydrochlorothiazide cap 37.5-
25 mg ...................................................................... 50
triamterene & hydrochlorothiazide tabs .......... 50
tri-biozene ................................................................ 623
tri-buffered aspirin .......................................... 14, 623
TRICARE .................................................................... 672
TRICODE AR............................................................. 625
TRICODE GF ............................................................. 625
tri-dex pe .................................................................. 623
trientine hcl ................................................................ 77
TRIFERIC ................................................................... 625
trifluoperazine hcl .................................................... 64
trifluridine ................................................................. 673
TRIGOFEN DM ......................................................... 625
trihexyphenidyl hcl .................................................. 60
trilyte ............................................................................ 93
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 832
trimethoprim ............................................................. 22
trimipramine maleate ....................................... 58, 59
TRIMO-SAN .............................................................. 625
TRIMSHIELD JUST FOR MEN ............................. 625
TRIMSHIELD PAD REGULAR .............................. 625
TRIMSHIELD PAD SUPER-PLUS ........................ 625
TRINTELLIX ................................................................ 59
triple antibiotic ................................................ 625, 689
triple antibiotic first a ........................................... 625
triple antibiotic plus .............................................. 625
triple antibiotic plus ma ....................................... 625
triple antibiotic with pa ........................................ 625
TRIPLE CREAM ........................................................ 625
TRIPLE HELIX COLLAGEN 2 ............................... 625
TRIPLE PASTE.......................................................... 626
triple paste af .......................................................... 626
TRIPLE PASTE SP ................................................... 626
TRIPLE PROBIOTIC ................................................ 626
trip-pse ...................................................................... 625
triprolidine & pseudoephedrine ........................ 626
triprolidine hcl ......................................................... 626
TRIPROLIDINE-PSEUDOEPHEDR ...................... 626
triptone ...................................................................... 626
TRISPEC DMX .......................................................... 626
TRISPEC DMX PEDIATRIC................................... 626
trispec pse ................................................................ 626
TRISPEC PSE ........................................................... 626
trispec pse pediatric ............................................. 626
TRISPEC PSE PEDIATRIC .................................... 626
TRIUMEQ ..................................................................... 27
TRI-VI-SOL ....................................................... 623, 672
tri-vita ........................................................................ 623
tri-vitamin ................................................................. 624
tri-vitamins ............................................................... 624
TROCAL COUGH SUPPRESSANT ....................... 626
TROGARZO ................................................................. 26
trolamine salicylate ............................................... 626
TROMBONEX ............................................................ 626
trombonex-d ............................................................ 626
tronolane ................................................................... 626
TRONOLANE ............................................................. 626
TROPHAMINE INJ 10% ........................................ 665
tropical liquid nutrition ........................................ 626
trospium chloride ..................................................... 96
TRUBIOTICS ............................................................ 626
TRUE FOCUS BLOOD GLUCOSE ........................ 627
TRUE FOCUS SELF MONITORIN ....................... 627
TRUE METRIX .......................................................... 627
TRUE METRIX AIR BLOOD GLU ........................ 627
TRUE METRIX AIR W/BLUETOO........................ 627
TRUE METRIX BLOOD GLUCOSE ...................... 627
TRUE METRIX GO BLOOD GLUC ....................... 627
TRUE METRIX SELF MONITORI ......................... 627
TRUE2GO BLOOD GLUCOSE MON ................... 626
TRUEDRAW LANCING DEVICE .......................... 627
trueplus diabetic multivi ...................................... 627
TRUEPLUS GLUCOSE GEL ................................... 627
TRUERESULT BLOOD GLUCOSE ....................... 627
TRUETEST BLOOD GLUCOSE T ......................... 627
TRUETEST STRIPS ................................................. 627
TRUETRACK BLOOD GLUCOSE M ..................... 627
TRUETRACK BLOOD GLUCOSE T ..................... 627
TRUETRACK SMART SYSTEM ............................. 627
TRUETRACK TEST .................................................. 627
TRULICITY .................................................................. 73
TRUMENBA ............................................................... 103
TRUNATURE DIGESTIVE PROBI ....................... 627
TRUVADA TAB 100-150 ......................................... 27
TRUVADA TAB 133-200 ......................................... 27
TRUVADA TAB 167-250 ......................................... 27
TRUVADA TAB 200-300 ......................................... 27
TRUZONE PEAK FLOW METER ........................... 627
trymine cg ................................................................ 627
TUBING/WING TIP ................................................. 627
TUCKABLES FLUFF UNDERPAD ......................... 627
TUCKABLES UNDERPAD ...................................... 628
TUCKS ........................................................................ 628
TUCKS ANTI-ITCH ................................................. 628
TUCKS HEMORRHOIDAL...................................... 628
tucks medicated ..................................................... 628
tucks medicated cooling ...................................... 628
TUFFSORB UNDERPAD ......................................... 628
TUMS .......................................................................... 628
TUMS CALCIUM FOR LIFE BON ......................... 628
TUMS CHEWY BITES ............................................. 628
TUMS CHEWY DELIGHTS .................................... 628
tums dual action .................................................... 628
TUMS E-X 750 ......................................................... 628
TUMS EXTRA STRENGTH 750 ........................... 628
tums freshers .......................................................... 628
tums gas relief chewy bit.................................... 628
TUMS KIDS ............................................................... 628
TUMS LASTING EFFECTS .................................... 628
tums smoothies ................................................ 84, 628
TUMS SMOOTHIES ................................................ 628
TUMS ULTRA 1000 ................................................ 628
tusicof ......................................................................... 628
TUSICOF .................................................................... 628
TUSNEL ...................................................................... 629
TUSNEL C .................................................................. 629
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 833
tusnel diabetic ................................................. 629, 686
TUSNEL DM .............................................................. 629
tusnel dm pediatric ............................................... 629
TUSNEL PEDIATRIC............................................... 629
TUSNEL-DM PEDIATRIC ...................................... 629
tussafex ex ............................................................... 629
TUSSAFEX-A ............................................................ 629
TUSSICAPS ............................................................... 629
tussigon ..................................................................... 629
tussin .......................................................................... 629
tussin adult .............................................................. 629
tussin cf ............................................................. 629, 686
tussin cf cough & cold .................................. 629, 686
tussin cf cough & cold ad .................................... 629
tussin cf max multi-sympt ................................. 629
tussin cf severe multi-sy ..................................... 629
tussin chest congestion ....................................... 629
tussin cold/congestion ......................................... 630
tussin cough ............................................................ 630
tussin cough dm ..................................................... 630
tussin cough dm sugar fre ................................. 630
tussin cough long-acting ..................................... 630
tussin dm .......................................................... 630, 686
tussin dm clear ....................................................... 630
tussin dm cough + chest c ................................. 630
tussin dm max ................................................ 630, 686
tussin dm max adult ..................................... 630, 686
tussin dm maximum strengt ............................. 630
tussin expectorant ................................................. 630
tussin mucus & chest cong ................................ 630
tussin mucus + chest cong ........................ 630, 686
tussin multi-symptom cold................................. 630
tussin pe .................................................................... 630
tussin severe ........................................................... 630
tussin severe congestion .................................... 630
TUSSIONEX PENNKINETIC EXT ........................ 630
tussi-pres .................................................................. 629
tussi-pres b .............................................................. 629
tussi-pres pe pediatric ......................................... 629
TUSSI-PRES PEDIATRIC ...................................... 629
tusslin ......................................................................... 630
tusslin pediatric ...................................................... 630
T-VITES ..................................................................... 600
TWINRIX INJ ............................................................ 104
TYBOST ........................................................................ 26
TYKERB ........................................................................ 40
TYLENOL .................................................................... 631
TYLENOL 8 HOUR ................................................... 631
TYLENOL 8 HOUR ARTHRITIS ........................... 631
tylenol allergy multi-sym .................................... 631
TYLENOL ALLERGY MULTI-SYM ........................ 631
TYLENOL ARTHRITIS PAIN ................................. 631
TYLENOL CHEST CONGESTION ........................ 631
TYLENOL CHILDRENS ........................................... 631
TYLENOL CHILDRENS CHEWABL ...................... 631
TYLENOL CHILDRENS COLD PL ........................ 631
TYLENOL CHILDRENS PLUS CO ........................ 631
TYLENOL CHILDRENS PLUS FL ......................... 631
TYLENOL CHILDRENS PLUS MU........................ 631
TYLENOL CHILDRENS/FLAVOR ......................... 631
TYLENOL COLD ....................................................... 631
TYLENOL COLD & FLU SEVERE ......................... 631
TYLENOL COLD & HEAD SEVER ........................ 631
tylenol cold head congest ................................... 631
TYLENOL COLD HEAD CONGEST ...................... 631
tylenol cold max ..................................................... 631
TYLENOL COLD MAX ............................................. 631
tylenol cold multi-sympto ................................... 632
TYLENOL COLD MULTI-SYMPTO ....................... 632
TYLENOL COLD PLUS FLU SEV.......................... 632
TYLENOL COLD RELIEF ........................................ 632
TYLENOL COLD RELIEF NIGHT ......................... 632
TYLENOL COLD SEVERE CONGE ...................... 632
TYLENOL COLD/COUGH/RUNNY ....................... 632
TYLENOL COLD/COUGH/SORE T ...................... 632
tylenol cough & sore thro ................................... 632
TYLENOL COUGH & SORE THRO ...................... 632
TYLENOL EXTRA STRENGTH .............................. 632
TYLENOL EXTRA STRENGTH CA ....................... 632
TYLENOL GO TABS EXTRA STR ........................ 632
TYLENOL INFANTS ................................................. 632
TYLENOL INFANTS PAIN+FEVE ........................ 632
TYLENOL JR MELTAWAYS ................................... 632
TYLENOL PM EXTRA STRENGTH ....................... 632
TYLENOL SEVERE ALLERGY ............................... 632
tylenol sinus congestion ...................................... 632
TYLENOL SINUS CONGESTION ................. 632, 633
TYLENOL SINUS CONVENIENCE ....................... 633
TYLENOL SINUS SEVERE .................................... 633
TYLENOL SINUS SEVERE CONG ....................... 633
tylenol sinus+headache ...................................... 633
TYLENOL SORE THROAT DAYTI ........................ 633
TYLENOL SORE THROAT NIGHT ....................... 633
TYLENOL TAB 325MG ........................................... 633
TYLENOL TAB 500MG ........................................... 633
TYLENOL WARMING COLD MULT ..................... 633
TYLENOL WARMING COUGH & S ..................... 633
tyler lipoic acid ........................................................ 633
tylophen .................................................................... 633
TYMLOS ....................................................................... 81
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 834
TYPHIM VI ................................................................. 104
tyrosine ...................................................................... 633
TYROSINE ................................................................. 633
U
ubiquinol.................................................................... 633
ubqh ............................................................................ 633
UDAMIN SP............................................................... 633
UDDERLY SMOOTH ................................................ 633
UDDERLY SMOOTH EXTRA CARE ..................... 633
ULORIC ........................................................................ 10
ULTEC HYDROCOLLOID DRESSI ...................... 633
ULTI-LANCE AUTO-ADJUST DE ........................ 633
ULTI-LANCE AUTOMATIC/ CLE ......................... 633
ULTIMA INCONTINENCE PAD ............................ 634
ULTIMA TEST STRIPS ........................................... 634
ULTIMA TUCKABLES UNDERPAD...................... 634
ULTIMA UNDERPAD ............................................... 634
ultimate fat burner ................................................ 634
ultimate probiotic formul .................................... 634
ultra antioxidant formula .................................... 634
ultra b-100 complex ............................................. 634
ULTRA BIOTIN ......................................................... 634
ultra choice multivitamin .................................... 634
ULTRA COQ10 ......................................................... 634
ULTRA DERM BATH OIL ....................................... 634
ULTRA DIET AID ..................................................... 634
ultra fine mist nasal spr ...................................... 634
ultra freeda .............................................................. 634
ultra freeda/iron ..................................................... 634
ultra fresh ................................................................. 634
ultra fresh pm ......................................................... 634
ultra lubricant eye drops ............................. 634, 676
ULTRA MAN .............................................................. 634
ULTRA MEGA ............................................................ 634
ULTRA MEGA GOLD ............................................... 634
ULTRA MEGA TWO ................................................. 634
ULTRA MENS PACK ................................................ 635
ultra multi formula/iron ....................................... 635
ultra thin corn removers ..................................... 635
ULTRA THIN WITH FLEXI-WIN .......................... 635
ULTRA TRAK PRO BLOOD GLUC ....................... 635
ultra vita-time ......................................................... 635
ULTRA WOMAN ....................................................... 635
ULTRA WOMENS PACK ......................................... 635
ultrachoice advanced form ................................. 635
ultra-derm ................................................................ 635
ULTRAFLORA IMMUNE HEALTH ........................ 635
ultra-klenz ................................................................ 635
ultra-mega................................................................ 635
ULTRA-SOFT CLASSIC BRIEFS ......................... 635
ULTRA-SOFT PLUS BRIEFS LA .......................... 635
ULTRA-SOFT PLUS BRIEFS ME ......................... 635
ULTRA-SOFT PLUS BRIEFS RE .......................... 635
ULTRA-SOFT PLUS BRIEFS X- ........................... 635
ULTRA-SOFT PLUS BRIEFS XX .......................... 635
ULTRASWIM ............................................................. 635
ULTRASWIM ULTRA REPAIR .............................. 635
ULTRATHON INSECT REPELLEN ....................... 695
ULTRATRAK ACTIVE .............................................. 635
ULTRATRAK PRO .................................................... 635
ULTRATRAK PRO TEST STRIPS ......................... 636
ULTRATRAK ULTIMATE MONITO ...................... 636
ULTRATRAK ULTIMATE TEST S ......................... 636
UNDERGARMENT BELT FREE LA ....................... 636
UNDERGARMENT BELT FREE SM ..................... 636
UNDERGARMENT EXTRA ABSORB ................... 636
UNDERGARMENT REGULAR ABSO ................... 636
UNDERPAD 23 ......................................................... 636
UNDERPADS ............................................................. 636
UNDERPADS EXTRA LARGE ............................... 636
UNDERPADS/LARGE 23 ....................................... 636
UNDERPADS/REGULAR ........................................ 636
UNDERPADS/SUPER .............................................. 636
UNICOMPLEX-M ...................................................... 636
UNISOL 4 .................................................................. 636
UNISOM ..................................................................... 636
UNISOM SLEEPGELS ............................................. 636
UNISOM SLEEPMELTS .......................................... 636
UNISOM SLEEPTABS ............................................. 636
UNISTIK 2 EXTRA .................................................. 636
UNISTRIP1 GENERIC ............................................ 636
unithroid ...................................................................... 82
UNIVERSAL PH STRIPS ........................................ 636
UNJURY ...................................................................... 636
UP & UP GLUCOSE ................................................. 637
UPCAL D .................................................................... 637
UPSPRING BABY VITAMIN D ............................. 637
UPSPRINGBABY MULTIVITAMIN ....................... 637
urea ............................................................................. 637
urea 20 intensive hydrati .................................... 637
ureacin-10 ................................................................ 637
ureacin-20 ................................................................ 637
urinary pain relief .................................................. 637
urinary pain relief maxim ................................... 637
URIN-TEK .................................................................. 637
uristat ......................................................................... 637
URISTIX ..................................................................... 637
URISTIX 4 ................................................................. 637
URO MAG .................................................................. 637
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 835
UROCARE ADHESIVE REMOVER ....................... 637
UROFOAM-1 SINGLE-SIDED AD ....................... 637
UROFOAM-2 DOUBLE-SIDED AD ..................... 637
URO-MAG .................................................................. 637
urosex ........................................................................ 637
ursodiol ........................................................................ 94
UTERUS ..................................................................... 637
V
VAGISIL SCENTSITIVE SCENT .......................... 638
VAGISTAT-1 ............................................................. 639
vagistat-3 ................................................................. 639
valacyclovir hcl ......................................................... 29
VALCHLOR ................................................................ 695
valganciclovir hcl ...................................................... 29
valihist........................................................................ 639
VALINE ....................................................................... 639
VALINE 1000 ........................................................... 639
valproate sodium ..................................................... 55
valproic acid ............................................................... 55
valsartan ..................................................................... 44
valsartan-hydrochlorothiazide ............................ 44
VALUE BUY ADULT BRIEF X-L ........................... 639
VALUE BUY BRIEF LARGE ................................... 639
VALUE BUY BRIEF MEDIUM ................................ 639
value plus glucose ................................................. 639
VALUE PLUS GLUCOSE ........................................ 639
VALUE PLUS LANCING DEVICE ......................... 639
VANACLEAR PD ....................................................... 639
VANACOF .................................................................. 639
VANACOF AC............................................................ 639
VANACOF APE ......................................................... 639
VANACOF CD ........................................................... 639
VANACOF DM ........................................................... 639
VANACOF DX ........................................................... 639
VANACOF G .............................................................. 639
VANACOF GPE ......................................................... 639
VANACOF-8 .............................................................. 639
VANADIUM ................................................................ 639
VANAHIST PD .......................................................... 639
VANAMINE PD ......................................................... 640
VANATAB AC ............................................................ 640
VANATAB DM ........................................................... 640
VANATAB DX............................................................ 640
vancomycin hcl ................................................... 22, 23
VANCOMYCIN IN NACL .......................................... 23
vandazole .................................................................... 96
VANICREAM.............................................................. 640
VANICREAM LITE ................................................... 640
VANIPLY ..................................................................... 640
VANQUISH ................................................................ 640
vapor inhaler ........................................................... 640
VAPOR PATCH ......................................................... 640
vaporizing chest rub ............................................. 640
vaporizing cream ................................................... 640
vaporizing steam.................................................... 640
VAPORX BALM ......................................................... 640
VAQTA ........................................................................ 104
varisan vitality ........................................................ 640
VARIVAX .................................................................... 104
VASCEPA ..................................................................... 46
vaseline...................................................................... 640
VASELINE PETROLATUM GAUZE ...................... 640
vaseline pure ultra white .................................... 640
VASOCLEAR A ......................................................... 640
vasoflex ..................................................................... 640
VASOFLEX ................................................................. 640
VASOFLEX D1 .......................................................... 640
vasoflex forte .......................................................... 640
vasoflex hd ............................................................... 641
VASOHA ..................................................................... 641
vazobid-pd ................................................................ 641
vazotab ...................................................................... 641
VB7 MAX .................................................................... 641
v-c forte ..................................................................... 637
VELCADE ..................................................................... 36
VELVACHOL .............................................................. 641
VEMLIDY ...................................................................... 29
VENALIV .................................................................... 641
VENCLEXTA ................................................................ 36
VENCLEXTA STARTING PACK .............................. 36
venlafaxine hcl .......................................................... 59
VENOFER ............................................................. 98, 641
VENTAVIS ................................................................... 51
VENTOLIN HFA ........................................................ 681
veracolate ................................................................. 641
VERAMYST ................................................................ 641
verapamil cap er ...................................................... 48
verapamil hcl ............................................................. 48
verapamil hcl tab er ................................................ 48
VERASENS BLOOD GLUCOSE MO .................... 641
VERASENS BLOOD GLUCOSE TE ..................... 641
VERSACLOZ ............................................................... 64
vertin-32 ................................................................... 641
VERZENIO ................................................................... 36
VESICARE ................................................................... 96
vh essentials medicated d .................................. 641
VH ESSENTIALS UTI RELIEF .............................. 641
VIACTIV ..................................................................... 641
VIACTIV MULTI-VITAMIN .................................... 641
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 836
VIAGRA ...................................................................... 641
vic-forte ..................................................................... 641
VICKS BABYRUB ..................................................... 641
VICKS CASERO ....................................................... 641
vicks dayquil cold & flu ........................................ 641
VICKS DAYQUIL COUGH ..................................... 642
VICKS DAYQUIL HBP COLD & ........................... 642
VICKS DAYQUIL MUCUS CONTR ...................... 642
vicks dayquil multi-sympt .................................. 642
vicks dayquil nature fusi ..................................... 642
VICKS DAYQUIL NATURE FUSI ......................... 642
vicks dayquil severe cold .................................... 642
VICKS DAYQUIL SINEX DAYTI .......................... 642
vicks dayquil/nyquil cold ..................................... 642
VICKS DAYQUIL/NYQUIL COUG ....................... 642
VICKS DAYQUIL/NYQUIL SEVE ......................... 642
VICKS FORMULA 44 COUGH RE ....................... 642
VICKS FORMULA 44D COUGH/N ...................... 642
VICKS FORMULA 44E COUGH/C....................... 642
VICKS FORMULA 44E PEDIATR ........................ 642
VICKS NYQUIL CHILDRENS CO ........................ 642
vicks nyquil cold & flu .......................................... 642
VICKS NYQUIL COLD & FLU ............................... 642
vicks nyquil cold & flu n ...................................... 642
VICKS NYQUIL COLD & FLU N .......................... 642
VICKS NYQUIL COUGH ........................................ 642
vicks nyquil d cold & flu ...................................... 642
VICKS NYQUIL HBP COLD & F .......................... 642
VICKS NYQUIL NATURE FUSIO......................... 643
vicks nyquil severe cold ...................................... 643
VICKS NYQUIL SEVERE COLD ........................... 643
VICKS NYQUIL SINEX NIGHTT ......................... 643
VICKS SINEX ........................................................... 643
VICKS SINEX 12 HOUR DECON ........................ 643
VICKS SINEX DAYQUIL/NYQUI ......................... 643
vicks sinex daytime conge ................................. 643
VICKS SINEX DAYTIME/NIGHT ......................... 643
VICKS SINEX MOISTURIZING ........................... 643
vicks sinex nighttime con ................................... 643
VICKS SINEX SEVERE .......................................... 643
VICKS SINEX SEVERE NASAL ........................... 643
VICKS VAPO STEAM .............................................. 643
VICKS VAPODROPS ............................................... 643
VICKS VAPOINHALER ........................................... 643
VICKS VAPORUB .................................................... 643
VICKS VAPORUB CHILDRENS ........................... 643
VICTORY AGM-4000 TEST STR ........................ 643
VICTORY BLOOD GLUCOSE MON ..................... 643
VICTOZA...................................................................... 73
VIDA MIA AUTOLET LANCING ........................... 643
VIDEX EC .................................................................... 26
VIDEX PEDIATRIC .................................................... 26
vigabatrin powd pack 500mg .............................. 55
vigabatrin tab 500mg ............................................. 55
VIGILON PRIMARY WOUND DRE ...................... 643
vigor ............................................................................ 643
VIIBRYD STARTER PACK ....................................... 59
VIIBRYD TAB ............................................................. 59
VIMPAT ........................................................................ 56
VIMPAT INJ 200MG/20ML ..................................... 56
VIMPAT SOL 10MG/ML ........................................... 56
vinblastine sulfate ................................................... 35
vincasar pfs ................................................................ 35
vincristine sulfate ..................................................... 35
vinorelbine tartrate ................................................. 35
VIRACEPT .................................................................... 26
VIRAMUNE .................................................................. 26
virdec .......................................................................... 644
virdec dm .................................................................. 644
VIREAD ........................................................................ 26
virtussin a/c ............................................................. 644
virtussin dac ............................................................ 644
VISBIOME PROBIOTIC HIGH P ......................... 644
VISINE ....................................................................... 644
VISINE FOR CONTACTS ....................................... 644
VISINE PURE TEARS ............................................. 644
VISINE TEARS ......................................................... 644
VISINE TIRED EYE RELIEF ................................. 644
visine-a ...................................................................... 644
visine-ac .................................................................... 644
VISINE-LR ................................................................. 644
vision formula 2...................................................... 644
vision formula eye health ................................... 644
vision formula/lutein............................................. 644
vision plus ................................................................. 644
vision vitamins ........................................................ 644
visivites ...................................................................... 644
visivites/lutein ......................................................... 644
vita hair ..................................................................... 644
vita s forte ................................................................ 644
vitabasic complete ................................................. 645
vitabasic senior ....................................................... 645
vita-bee/c ......................................................... 644, 672
VITABEX .................................................................... 645
VITABEX PLUS ......................................................... 645
VITA-BOB .................................................................. 645
VITA-C ........................................................................ 645
VITA-CALCIUM ........................................................ 645
vitacel ......................................................................... 645
vitachew multiple vitamin .................................. 645
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 837
vitachew vitamin c citrus .................................... 645
vitajoy daily d gummies ...................................... 645
vitalee ........................................................................ 645
VITALETS .................................................................. 645
VITALETS CHILDRENS ......................................... 645
VITALINE BIOTIN FORTE .................................... 645
VITALINE BIOTIN FORTE/ZIN ........................... 645
VITALINE BUFFERED ZINC-22 .......................... 645
vitaline coq10 .......................................................... 645
VITALINE COQ10 ................................................... 646
vitaline selenium .................................................... 646
VITALINE TOTAL FORMULA 2 ............................ 646
VITALINE TOTAL FORMULA 3 ............................ 646
vitalize ........................................................................ 646
vitalize/ginseng ...................................................... 646
VITA-MAG ................................................................. 645
VITAMAX ................................................................... 646
vitamax pediatric ................................................... 646
vitamelts energy vitamin .................................... 646
VITAMELTS RELAX L-THEANIN ......................... 646
VITAMELTS VITAMIN C ........................................ 646
VITAMELTS VITAMIN D........................................ 646
VITAMELTS ZINC FAST DISSO ......................... 646
VITAMENT ................................................................. 646
vita-min ..................................................................... 645
VITAMIN & MINERAL SUPPLEM ........................ 646
vitamin a ........................................................... 646, 672
VITAMIN A ................................................................ 646
VITAMIN A 7500 UNIT FISH .............................. 646
VITAMIN A PALMITATE ........................................ 646
VITAMIN A/BETA CAROTENE ............................. 646
vitamin a-25000/d-400 ....................................... 646
VITAMIN B 12 .......................................................... 647
vitamin b complex-c ............................................. 647
VITAMIN B-1 ............................................................ 647
VITAMIN B12 ........................................................... 647
VITAMIN B-12 ......................................................... 647
vitamin b12 tr ......................................................... 647
vitamin b-12 tr ....................................................... 647
vitamin b-12 tr sunmark ..................................... 647
VITAMIN B12/FOLIC ACID.................................. 647
vitamin b50 complex tr ....................................... 647
VITAMIN B6.............................................................. 647
VITAMIN C ................................................................ 647
VITAMIN C & D3/ROSE HIPS ............................. 647
vitamin c & e combination .................................. 647
vitamin c adult gummies .................................... 647
vitamin c drops ....................................................... 647
VITAMIN C EFFERVESCENT BL ......................... 647
VITAMIN C GUMMIE .............................................. 647
vitamin c gummies ................................................ 647
vitamin c immune health .................................... 647
vitamin c plus .......................................................... 647
vitamin c plus wild rose ....................................... 647
vitamin c/bioflavonoids/w .................................. 648
VITAMIN C/ELECTROLYTES ................................ 648
vitamin c/rose hips tr ........................................... 648
vitamin c/rose hips/acero ................................... 648
VITAMIN C+ZINC ................................................... 647
VITAMIN D ................................................................ 648
vitamin d high potency ........................................ 648
vitamin d infant ...................................................... 648
vitamin d-1000 maximum st ............................. 648
VITAMIN D2 ............................................................. 648
VITAMIN D3 ............................................................. 648
vitamin d3 adult gummies ................................. 648
VITAMIN D3 COMPLETE....................................... 648
vitamin d3 gummies adult ................................. 648
vitamin d3 high potency ..................................... 648
vitamin d3 maximum streng ............................. 648
vitamin d3 super strength .................................. 648
vitamin d3 ultra potency ..................................... 648
vitamin d3 ultra strength .................................... 648
VITAMIN D3/VITAMIN C ...................................... 648
vitamin d-400 .......................................................... 648
vitamin e ........................................................... 648, 649
VITAMIN E ................................................................ 649
vitamin e (topical) ................................................. 649
vitamin e beauty oil .............................................. 649
vitamin e blend ....................................................... 649
VITAMIN E COMPLETE HIGH G ......................... 649
vitamin e complex ................................................. 649
vitamin e complex natural .................................. 649
vitamin e high potency ........................................ 649
vitamin e natural .................................................... 649
VITAMIN E SKIN CREAM ..................................... 649
vitamin e skin oil .................................................... 649
VITAMIN E WITH PANTHENOL .......................... 649
vitamin e/d-alpha natural ................................... 649
vitamin e-200 .......................................................... 649
vitamin e-400 .......................................................... 649
VITAMIN K ................................................................ 649
VITAMIN K2.............................................................. 649
VITAMIN K2 & D3 .................................................. 649
vitamin mixture ...................................................... 649
vitamin supplement e-1000............................... 650
vitamin supplement e-400 ................................. 650
vitamins a & d ......................................................... 650
vitamins a & d (topical) ....................................... 650
vitamins c & e ......................................................... 650
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 838
vitamins for hair ..................................................... 650
VITAMINS FOR THE HAIR ................................... 650
VITAMINS TO GO MAXIMUM ............................. 650
VITAMINS TO GO MEN ......................................... 650
VITAMINS TO GO WOMEN .................................. 650
vitamins w/ lipotropics ........................................ 650
vita-plus e ................................................................. 645
vita-plus g ................................................................ 645
VITA-PLUS H ............................................................ 645
VITAROCA PLUS ..................................................... 650
VITASANA ................................................................. 650
vitatrum ..................................................................... 650
VITATRUM ................................................................. 650
vitatrum complete ................................................. 650
VITEC .......................................................................... 650
viteyes areds advanced ....................................... 650
viteyes areds formula .......................................... 650
viteyes areds formula plu ................................... 650
viteyes complete .................................................... 650
viteyes multivitamin ared ................................... 650
viteyes smokers advanced ................................. 650
viteyes smokers formula p ................................. 651
VITONIC .................................................................... 651
VITRAKVI .................................................................... 40
VITRON-C ................................................................. 651
VITRUM 50+ SENIOR MULTI ............................. 651
vitrum senior ........................................................... 651
VIVA DROPS ............................................................ 651
VIVARIN .................................................................... 651
VIVITROL .................................................................... 71
VIZIMPRO ................................................................... 40
VOCAL POINT BLOOD GLUCOSE ...................... 651
VOL-PLUS .................................................................. 672
voriconazole ............................................................... 23
VOSEVI ........................................................................ 29
VOTRIENT ................................................................... 40
VP-ZEL ....................................................................... 651
v-r anti-gas maximum stre ................................ 638
v-r aspirin ec max str ........................................... 638
v-r beta carotene ................................................... 638
v-r bronchial mist .................................................. 638
v-r bronchial mist refill ........................................ 638
v-r childrens non-aspirin ..................................... 638
v-r cod liver oil........................................................ 638
v-r coenzyme q-10 ................................................ 638
V-R FATIGUE RELIEF COMPLE .......................... 638
v-r heartburn relief ............................................... 638
v-r infant non-aspirin ........................................... 638
v-r infants non-aspirin ......................................... 638
V-R IPECAC .............................................................. 638
v-r nasal allergy symptom ................................. 638
v-r pedia relief ........................................................ 638
V-R SALINE SENSITIVE EYES ........................... 638
V-R SOY FORMULA ................................................ 638
v-r throat lozenges ................................................ 638
v-r tussin honey ..................................................... 638
v-r valu-tapp ........................................................... 638
v-r vitamin a ............................................................ 638
v-r vitamin c ............................................................ 638
VRAYLAR ..................................................................... 64
VRAYLAR THERAPY PACK ...................................... 64
VSL#3 ........................................................................ 651
W
wal-act ....................................................................... 651
WAL-BORN ............................................................... 651
WAL-BORN VITAMIN C ........................................ 651
wal-dram ................................................................... 651
wal-dram ii ............................................................... 651
wal-dryl ...................................................................... 651
wal-dryl allergy ....................................................... 651
wal-dryl allergy children ...................................... 651
wal-dryl allergy dye-free ..................................... 651
wal-dryl allergy relief c ........................................ 651
wal-dryl allergy/sinus he .................................... 651
wal-dryl anti-itch .................................................... 651
wal-dryl pe allergy/sinu ....................................... 651
wal-dryl severe allergy & .................................... 652
WAL-DRYL-D ............................................................ 652
wal-dryl-d allergy/sinus ...................................... 652
wal-fex ....................................................................... 652
wal-fex 24 hour allergy ....................................... 652
wal-fex allergy ........................................................ 652
wal-fex allergy 12 hour ....................................... 652
wal-fex childrens .................................................... 652
wal-fex d 12 hour allergy ................................... 652
wal-fex d 24 hour allergy ................................... 652
wal-finate .................................................................. 652
wal-finate-d .............................................................. 652
WAL-FLU COLD & SORE THROA ....................... 652
wal-flu severe cold & cou ................................... 652
WAL-FLU SEVERE COLD DAYTI ........................ 652
WAL-FLU SEVERE COLD NIGHT ....................... 652
wal-flu warming comfort s ................................. 652
wal-four ..................................................................... 652
WALGREENS GLUCOSE ........................................ 655
wal-hist ...................................................................... 652
wal-itin ....................................................................... 652
wal-itin allergy relief r .......................................... 652
wal-itin aller-melts ................................................ 652
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 839
wal-itin childrens .................................................... 652
wal-itin d ................................................................... 653
wal-itin d 24 hour .................................................. 653
wal-mucil................................................................... 653
wal-phed ................................................................... 653
wal-phed 12 hour .................................................. 653
wal-phed d ............................................................... 653
wal-phed pe ............................................................. 653
wal-phed pe cold & cough .................................. 653
wal-phed pe daytime/night ................................ 653
wal-phed pe nighttime col .................................. 653
wal-phed pe pressure+pain ............................... 653
wal-phed pe severe cold ..................................... 653
wal-phed pe sinus headach ............................... 653
wal-phed pe sinus/allergy .................................. 653
wal-phed pe triple relief ...................................... 653
wal-phed sinus/allergy ........................................ 653
wal-profen ................................................................ 653
wal-profen cold & sinus ....................................... 653
wal-profen cold/sinus ........................................... 653
wal-sleep z ............................................................... 653
wal-som ..................................................................... 653
wal-som maximum strength ............................. 653
wal-sporin ................................................................. 653
wal-tap childrens ................................................... 654
wal-tap cold & allergy .......................................... 654
WAL-TAP COLD/ALLERGY ................................... 654
wal-tap dm cold & cough .................................... 654
wal-tap dm cold/cough ........................................ 654
wal-tussin ................................................................. 654
wal-tussin cf ............................................................ 654
wal-tussin cf max .................................................. 654
wal-tussin cf max multi-s ................................... 654
wal-tussin chest congesti ................................... 654
wal-tussin cold ........................................................ 654
wal-tussin cough .................................................... 654
wal-tussin cough & chest .................................... 654
wal-tussin cough & cold ...................................... 654
wal-tussin cough long act ................................... 654
WAL-TUSSIN COUGH RELIEF C ........................ 654
wal-tussin cough/chest co .................................. 654
wal-tussin cough/cold cf ..................................... 654
wal-tussin dm .......................................................... 654
wal-tussin dm cough & che ................................ 654
WAL-TUSSIN PEDIATRIC COUG ....................... 654
wal-vert ..................................................................... 654
wal-zan 150 maximum stren ............................ 655
wal-zan 75 ................................................................ 654
wal-zyr ....................................................................... 655
wal-zyr all day allergy c ...................................... 655
wal-zyr childrens .................................................... 655
wal-zyr d ................................................................... 655
warfarin sodium........................................................ 97
WART OFF ................................................................. 655
wart remover ........................................................... 655
wart remover maximum stre ............................ 655
wart remover medicated ..................................... 655
water for irrigation, sterile ................................ 696
WAVESENSE AMP ................................................... 655
WAVESENSE KEYNOTE ........................................ 655
WAVESENSE KEYNOTE PRO MET ..................... 655
WAVESENSE PRESTO TEST STR ...................... 655
wee care .................................................................... 655
WEGMANS COMPLETE PRENATAL .................... 655
weight loss daily multi ......................................... 655
WELCHOL PAK ........................................................... 46
WELLESSE VITAMIN D3....................................... 655
WELLNESS PROTEIN SHAKE .............................. 655
WFHC PH PAPER ..................................................... 655
wheat germ oil ........................................................ 655
WHEY PROTEIN ....................................................... 656
WHEY PROTEIN CONCENTRATE ....................... 656
WHIRL-SOL .............................................................. 656
white petrolatum .................................................... 656
WHITE PETROLATUM ............................................ 656
WHITE PETROLATUM GEL ................................... 656
WHOLE FOOD MULTIVITAMIN .......................... 656
WIBI ............................................................................ 656
WINDMILL TRAINER ............................................. 656
WINGS ADULT BRIEFS/MEDIUM ...................... 656
WINGS ADULT BRIEFS/XXL ............................... 656
WINGS ADULT QUILTED BRIEF ........................ 656
WINGS BARIATRIC ADULT BRI ........................ 656
WINGS BREATHABLE UNDERPAD .................... 656
WINGS CHOICE PLUS ADULT B ........................ 656
WINGS CHOICE PLUS YOUTH B ....................... 656
WINGS CLASSIC ADULT BRIEF ........................ 656
WINGS CONTOURED INSERT PA ..................... 656
WINGS FLUFF AND POLYMER U ....................... 656
WINGS FLUFF UNDERPAD 17 ............................ 656
WINGS FLUFF UNDERPAD 23 ............................ 656
WINGS FLUFF UNDERPAD 30 ............................ 656
WINGS HL ADULT BRIEFS/LAR......................... 656
WINGS HL ADULT BRIEFS/MED ....................... 657
WINGS HL ADULT BRIEFS/SMA ....................... 657
WINGS HL ADULT BRIEFS/XL ........................... 657
WINGS HL ULTRA ADULT BRIE......................... 657
WINGS QUILTED BREATHABLE ........................ 657
WINGS SUPREME ADULT BRIEF ....................... 657
WINGS UNDERPAD/POLYMER IM ..................... 657
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 840
WINGS WASHCLOTHS ......................................... 657
WITCH HAZEL ......................................................... 657
witch hazel (hamamelis virginiana) ................ 657
womans laxative .............................................. 93, 657
womans stool softener ........................................ 657
womens 50+ advanced ....................................... 657
WOMENS 50+ MULTI VITAMIN......................... 657
WOMENS BIOMULTIPLE ...................................... 657
womens daily formula .......................................... 657
womens daily formula/foli .................................. 657
womens laxative .................................................... 657
womens life pack ................................................... 657
WOMENS MENOPAUSE VITA PAK .................... 657
womens menstrual relief .................................... 657
womens multi .......................................................... 657
WOMENS MULTI VITAMIN & MI ....................... 657
womens multivitamin ........................................... 658
womens one daily .................................................. 658
WOMENS PACK ....................................................... 658
womens tylenol ...................................................... 658
WOMENS VITA PAK ............................................... 658
WOUND CLEANSER ............................................... 658
wound cleansers..................................................... 658
WOUND WASH ........................................................ 658
WOUND WASH SALINE ........................................ 658
WOUNDGARD 2-1/2.............................................. 658
WOUNDGARD 4 ...................................................... 658
X
XALKORI ...................................................................... 40
XARELTO ..................................................................... 97
XARELTO STARTER PACK ..................................... 97
XATMEP...................................................................... 100
XELJANZ .................................................................... 100
XELJANZ XR ............................................................. 100
XERAC AC ................................................................. 658
XEROFLO DRESSING 1 ........................................ 658
XEROFLO DRESSING 2 ........................................ 658
XEROFLO DRESSING 5 ........................................ 658
XEROSTOMIA RELIEF SPRAY ............................. 658
XGEVA .......................................................................... 81
XIFAXAN ...................................................................... 94
XIGDUO XR TAB 10-1000MG .............................. 76
XIGDUO XR TAB 10-500MG ................................. 76
XIGDUO XR TAB 2.5-1000MG ............................. 76
XIGDUO XR TAB 5-1000MG ................................. 76
XIGDUO XR TAB 5-500MG ................................... 76
XOLAIR ...................................................................... 687
XOSPATA ..................................................................... 40
xpect ........................................................................... 658
XPHE MAXAMUM ..................................................... 658
XTANDI ........................................................................ 37
xtra-care ................................................................... 658
XULTOPHY 100/3.6 ................................................. 73
XYREM .......................................................................... 69
Y
YELETS TEENAGE FORMULA .............................. 658
YF-VAX ....................................................................... 104
yl balanced b-100 .................................................. 658
yl beta carotene ..................................................... 659
yl chromium picolinate ........................................ 659
yl coenzyme q10 .................................................... 659
yl dhea ....................................................................... 659
yl folic acid ............................................................... 659
yl natural vitamin a & d ....................................... 659
yl vitamin b-6 .......................................................... 659
yl vitamin c ............................................................... 659
yl vitamin c/rose hips ........................................... 659
yl vitamin e .............................................................. 659
YODEFAN-NF CHEST CONGESTI ...................... 659
YODORA DEODORANT ......................................... 659
YOUR LIFE MULTI ADULT GUM ......................... 659
your life multi mens 50+ .................................... 659
your life multi womens 50 .................................. 659
YOUR LIFE TEEN MULTIVITAM .......................... 659
yummy-c ................................................................... 659
yuvafem vaginal tablet 10 mcg .......................... 78
Z
ZADITOR ................................................................... 659
zafirlukast ................................................................. 686
zaleplon ....................................................................... 66
ZANTAC ..................................................................... 660
ZANTAC 150 MAXIMUM STRENG ..................... 660
ZANTAC 75 ............................................................... 660
Z-BUM ........................................................................ 659
Z-CLINZ ..................................................................... 659
z-cof 12dm ............................................................... 659
zeasorb-af ................................................................. 660
ZEGERID OTC .......................................................... 660
ZEJULA ......................................................................... 36
ZELBORAF ................................................................... 40
ZEMAIRA ................................................................... 687
zenatane .................................................................... 688
ZENPEP ........................................................................ 94
ZEPATIER .................................................................... 29
ZE-PLUS .................................................................... 660
zidovudine cap 100mg ........................................... 26
zidovudine syp 50mg/5ml .................................... 26
This document includes a list of drugs covered on our formulary as of April 1, 2019. You can find
information on what the symbols and abbreviations on this table mean by going to page 7. 841
zidovudine tab 300mg ........................................... 26
ZIKS ARTHRITIS PAIN RELIE ............................ 660
ZIMS CRACK CREME DAYTIME ......................... 660
zinc .............................................................................. 660
ZINC............................................................................ 660
ZINC & C LOZENGES ............................................ 660
ZINC 15 ..................................................................... 660
zinc acetate w/ sweetleaf (stevia) .................. 660
ZINC ASPARTATE ................................................... 660
ZINC CHELATED ..................................................... 660
zinc chloride ............................................................. 660
ZINC CHLORIDE ..................................................... 660
zinc cold relief ......................................................... 660
zinc gluconate ......................................................... 660
ZINC LOZENGES/VITAMIN C ............................. 660
ZINC MAGNESIUM ASPARTATE ........................ 661
ZINC METHIONATE ............................................... 661
ZINC OXIDE ............................................................. 661
zinc oxide (topical) ........................................ 661, 695
ZINC PICOLINATE .................................................. 661
zinc sulfate ............................................................... 661
ZINC SULFATE ........................................................ 661
ZINC SULFATE HEPTAHYDRATE ....................... 661
ZINC SULFATE MONOHYDRATE........................ 661
ZINC W/A&C ............................................................ 661
ZINC/VITAMIN C .................................................... 661
zinc-220..................................................................... 661
zinc-vites ................................................................... 661
ziprasidone hcl .......................................................... 64
ZIRGAN ...................................................................... 673
ZN-50 ......................................................................... 661
ZNLIN ......................................................................... 661
ZN-PLUS .................................................................... 661
zoden .......................................................................... 661
ZODRYL AC 25 ........................................................ 661
ZODRYL AC 30 ........................................................ 661
ZODRYL AC 35 ........................................................ 661
ZODRYL AC 40 ........................................................ 662
ZODRYL DAC 25 ..................................................... 662
ZODRYL DAC 30 ..................................................... 662
ZODRYL DAC 35 ..................................................... 662
ZODRYL DAC 40 ..................................................... 662
ZODRYL DEC 25 ..................................................... 662
ZODRYL DEC 30 ..................................................... 662
ZODRYL DEC 35 ..................................................... 662
ZODRYL DEC 40 ..................................................... 662
zoledronic acid inj 5mg/100ml ........................... 76
zoledronic inj 4mg/5ml .......................................... 76
ZOLINZA ...................................................................... 36
zolmitriptan ................................................................ 67
zolmitriptan odt ........................................................ 67
zolpidem tartrate ..................................................... 66
zonisamide ................................................................. 56
ZONTIVITY.................................................................. 99
zoo friends ................................................................ 662
ZOO FRIENDS COMPLETE ................................... 662
zoo friends gummies ............................................ 662
zoo friends gummies plus ................................... 662
zoo friends multi gummies ................................. 662
zoo friends plus extra c ....................................... 662
zoo friends plus iron ............................................. 662
zoo friends/extra c ................................................ 662
ZORTRESS TAB 0.25MG ...................................... 102
ZORTRESS TAB 0.5MG ........................................ 102
ZORTRESS TAB 0.75MG ...................................... 102
ZORTRESS TAB 1MG ............................................ 102
ZOSTAVAX ................................................................ 104
zostrix ........................................................................ 662
ZOSTRIX CRE 0.025% ......................................... 662
zostrix high potency ............................................. 662
zostrix high potency foot .................................... 662
ZOSTRIX NATURAL PAIN RELI .......................... 662
ZOSTRIX-HP ............................................................ 662
Z-TUSS AC................................................................ 659
Z-TUSS E................................................................... 659
ZUTRIPRO ................................................................. 663
ZYDELIG ...................................................................... 40
ZYKADIA ...................................................................... 40
ZYLET ......................................................................... 672
zyncof ......................................................................... 663
ZYNCOF ..................................................................... 663
ZYPREXA RELPREVV ............................................... 64
ZYPREXA RELPREVV INJ 210MG ........................ 64
ZYRTEC ALLERGY ................................................... 663
ZYRTEC CHILDRENS ALLERGY .......................... 663
ZYRTEC CHILDRENS HIVES RE ........................ 663
ZYRTEC HIVES RELIEF ......................................... 663
zyrtec itchy eye ...................................................... 663
ZYRTEC-D ALLERGY/CONGESTI ....................... 663
ZYTIGA ......................................................................... 37
ZZZQUIL .................................................................... 663