formulary - (list of covered drugs) - archcare

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This document includes a list of drugs covered on our formulary 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

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This document includes a list of drugs covered on our formulary 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