enhanced care (medicaid) enhanced care plus …...i emblemhealth enhanced care and enhanced care...
TRANSCRIPT
Enhanced Care (Medicaid) Enhanced Care Plus (HARP) 2020 Drug Formulary
i
EmblemHealth Enhanced Care and Enhanced Care Plus Formulary2020 Formulary (List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT some of the drugs covered by your plan
When this drug list (formulary) refers to “we,” “us,” or “our,” it means EmblemHealth. When it refers to “plan” or “our plan,” it means EmblemHealth Enhanced Care (Medicaid) or Enhanced Care Plus (HARP).
This document includes a list of the drugs (formulary) for our plan which is current as of 4/1/2020. For a complete updated formulary, please call Customer Service at 888-447-7364 (TTY: 711). Our hours are 8 am to 6 pm, Monday through Friday and 10 am to 1 pm, Saturday and Sunday. A representative will be happy to help. You can also check our website at emblemhealth.com.
You must use network pharmacies to use your prescription drug benefit.
The formulary and pharmacy network may change.
ii
What is the EmblemHealth Enhanced Care and Enhanced Care Plus Formulary?A formulary is a list of covered drugs selected by our plan with help from a team of health care professionals. It represents the prescription therapies believed to be a necessary part of a quality treatment program. Our plan will cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Member Handbook.
How do I use the Formulary?There are two ways to find your drug within the formulary:
Medical ConditionThe formulary begins on page 3. 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-Hypertensive/Lipids. If you know what conditions your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., SYNTHROID and generic drugs are listed in lower-case italics (e.g., levothyroxine).
The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug.
Alphabetical ListingIf you are not sure what category to look under, you should look for your drug in the Index. 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?Our plan 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:
• Prior Authorization: Our plan requires your doctor get prior authorization for certain drugs. Thismeans that you will need to get approval from our plan before you fill your prescriptions. If youdon’t get approval, our plan may not cover the drug.
• Quantity Limits: For certain drugs our plan limits the amount of the drug that we will cover. Forexample, our plan provides 30 tablets per prescription for Januvia. This may be in addition to astandard one-month or three-month supply.
• Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your medicalcondition before we will cover another drug for that condition. For example, if Drug A and Drug Bboth treat your medical condition, our plan may not cover Drug B unless you try Drug A first. If DrugA does not work for you, we will then cover Drug B.
You can find out if your drug has any other requirements or limits by looking in the formulary that begins on page 3.
EMBLEMHEALTH ENHANCED CARE AND ENHANCED CARE PLUS FORMULARY
iii
You can ask us to make an exception (change a ruling) 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 ask for an exception to the EmblemHealth Enhanced Care/Enhanced Care Plus formulary?” on this page for information about how to ask for an exception.
What if my drug is not on the Formulary?If your drug is not included in this formulary you should first call Customer Service and ask if your drug is covered.
If you learn that our plan does not cover your drug, you have two options:
• You can ask Customer Service for a list of similar drugs that are covered by our plan. When youreceive the list, show it to your doctor and ask him or her to prescribe a similar drug that is coveredby our plan.
• You can ask our plan to make an exception and cover your drug. See below for information abouthow to ask for an exception.
How do I ask for an exception (change a ruling) to the EmblemHealth Enhanced Care/Enhanced Care Plus Formulary?You can ask us to make an exception to our coverage rules for the following:
• You can ask us to cover a drug even if it is not on our formulary.• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs
our plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you canask us to waive the limit, and cover a greater amount.
Generally, we will only approve your request for an exception if the other drug is:
• Included on the plan’s formulary,• The lower cost-sharing drug (you and your insurance company share the costs of some of the drugs
that your plan covers based on the drug’s level), or• Prior authorization, quantity limit or step therapy would not be as effective in treating your
condition and/or would cause you to have a negative effects.
You should contact us to ask for an initial coverage decision for a formulary or utilization restriction exception. When you ask for a formulary or prior authorization, quantity limit, or step therapy exception, you should submit a statement from your prescriber or doctor 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 within 24 hours after we get a supporting statement from your doctor or other prescriber, but no later than 72 hours from receipt of the request.
What do I do before I can talk to my doctor about changing my drugs or asking for 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 ask for 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.
EMBLEMHEALTH ENHANCED CARE AND ENHANCED CARE PLUS FORMULARY
iv
EMBLEMHEALTH ENHANCED CARE AND ENHANCED CARE PLUS FORMULARY
For each of your drugs that is not on our formulary, or if your ability to get your drugs is limited, we may cover a 30-day supply of your drug in certain cases during the first 90 days you are a member of our plan.
List of abbreviationsBelow is a list of abbreviations that may appear on the following pages in the Requirements/Limits column. They tell you if there are any special requirements for coverage of your drug.
Brand: Brand Drug
Generic: Generic Drug
OTC: Over the Counter. An OTC drug is a non-prescription drug.
PA: Prior Authorization. The plan requires you or your doctor to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescription. If you don’t get approval, we may not cover the drug.
QL: Quantity Limit. For certain drugs the plan limits the amount of the drug that we will cover.
ST: Step Therapy. In some cases, the plan 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, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.
ContinuedGroup Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.
10-9127 6/18
ATTENTION: Language assistance services, free of charge, are available to you. Call 1-877-411-3625 (TTY/TDD: 711). Español (Spanish) ATENCIÓN: Usted tiene a su disposición, gratis, servicios de ayuda para idiomas. Llame al 1-877-411-3625 (TTY/TDD: 711).
中文 (Traditional Chinese) 注意:我們免費提供相關的語言協助服務。請致電 1-877-411-3625 (TTY/TDD: 711)。
Pусский (Russian) ВНИМАНИЕ! Вам доступны бесплатные услуги переводчика. Звоните по тел. 1-877-411-3625 (служба текстового телефона TTY/TDD: 711).
Kreyòl Ayisyen (Haitian Creole) ATANSYON: Gen sèvis èd nan lang gratis ki disponib pou ou. Rele nimewo 1-877-411-3625 (TTY/TDD: 711).
한국어 (Korean) 주의: 귀하에게 언어 지원 서비스가 무료로 제공됩니다. 1-877-411-3625(TTY/TDD: 711)번으로 전화하십시오.
Italiano (Italian) ATTENZIONE: sono disponibili servizi gratuiti di assistenza linguistica. Chiami il numero 1-877-411-3625 (TTY/TDD: 711).
(Yiddish) אידיש 1-877-411-3625 רופט. זיינען דא צו באקומען פאר אייך, אהן קיין פרייז, שפראך הילף סערוויסעס: אכטונג
(TTY/TDD: 711).
বাাংলা (Bengali) মন োন োগ দি : ভোষো সহোয়তো পদিনষবোগুদি আপ োি জ য দব োমূনিয উপিব্ধ আনে। 1-877-411-3625(TTY/TDD: 711) ম্বনি ফ ো করু ।
Polski (Polish) UWAGA: dostępna jest bezpłatna pomoc językowa. Prosimy zadzwonić pod numer 1-877-411-3625 (TTY/TDD: 711).
(Arabic) العربية . (TTY/TDD: 711)أو 3625-411-877-1 الرقمعلى اتصل ،رجى االنتباه: تتوفر لك خدمات المساعدة اللغوية مجانا ي
Français (French) ATTENTION : une assistance d’interprétation gratuite est à votre disposition. Veuillez composer le 1-877-411-3625 (TTY/TDD : 711).
(Urdu)اردو بان لیے کے آپ دیں: وجہ یں۔ کال پر (TTY/TDD: 711) 1-877- 411-3625 ہیں۔ دستیاب مفت ،خدمات کی اعانت متعلق سے ز کر
Tagalog (Tagalog) NANANAWAGAN NG PANSIN: Mayroon kang magagamit na mga serbisyo para sa tulong sa wika nang walang bayad. Tawagan ang 1-877-411-3625 (TTY/TDD: 711).
Ελληνικά (Greek) ΠΡΟΣΟΧΗ: Διατίθενται για σας υπηρεσίες γλωσσικής βοήθειας, δωρεάν. Καλέστε το 1-877-411-3625 (για άτομα με προβλήματα ακοής (TTY/TDD): 711).
Shqip (Albanian) VINI RE: Shërbime ndihmore për gjuhën, falas, janë në dispozicionin tuaj. Telefononi në 1-877-411-3625 (TTY/TDD: 711).
NOTICE OF NONDISCRIMINATION POLICY EmblemHealth complies with Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. EmblemHealth does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
EmblemHealth: Provides free aids and services to people with disabilities to
help– Qualified sign language interpreters– Written information in other formats (large print, audio,
accessible electronic formats, other formats) Provides free language services to people whose first
language is not English, such as:– Qualified interpreters– Information written in other languages
If you need these services, please call member services at 1-877-411-3625 (TTY/TDD: 711).If you believe that EmblemHealth has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with EmblemHealth Grievance and Appeals Department, PO Box 2844, New York, NY 10116, or call member services at 1-877-411-3625. (Dial 711 for TTY/TDD services.) You can file a grievance in person, by mail or by phone. If you need help filing a grievance, EmblemHealth’s Grievance and Appeals Department is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office of Civil Rights electronically through the Office of Civil Rights Complaint Portal, available at ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201; 1-800-368-1019, (dial 1-800-537-7697 for TTY services).
Complaint forms are available at hhs.gov/ocr/office/file/index.html.
1
Table of Contents
ANTI - INFECTIVES ....................................................................................................................................... 3
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ......................................................................... 9
AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH .......................................................................... 13
CARDIOVASCULAR, HYPERTENSION / LIPIDS .................................................................................. 27
DERMATOLOGICALS/TOPICAL THERAPY ......................................................................................... 33
DIAGNOSTICS / MISCELLANEOUS AGENTS ....................................................................................... 50
EAR, NOSE / THROAT MEDICATIONS ................................................................................................... 53
ENDOCRINE/DIABETES ............................................................................................................................. 56
GASTROENTEROLOGY .............................................................................................................................. 60
IMMUNOLOGY, VACCINES / BIOTECHNOLOGY ............................................................................... 73
MUSCULOSKELETAL / RHEUMATOLOGY .......................................................................................... 74
OBSTETRICS / GYNECOLOGY ................................................................................................................. 76
OPHTHALMOLOGY ..................................................................................................................................... 81
RESPIRATORY AND ALLERGY ................................................................................................................ 85
UROLOGICALS ........................................................................................................................................... 103
VITAMINS, HEMATINICS / ELECTROLYTES ..................................................................................... 104
Index ............................................................................................................................................................... 136
2
List of Abbreviations
Brand: Brand
Generic: Generic
NC: NC
NF: NF
OTC: Over the Counter. An OTC drug is a non-prescription drug.
PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we may not cover the drug.
QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover.
ST: Step Therapy. In some cases, the Plan 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, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
3
Drug Name Drug Tier Requirements / Limits
ANTI - INFECTIVES
ANTIFUNGAL AGENTS
clotrimazole mucous membrane Generic
CRESEMBA ORAL Brand PA
fluconazole oral suspension for reconstitution Generic
fluconazole oral tablet 100 mg, 200 mg, 50 mg Generic
fluconazole oral tablet 150 mg Generic QL
flucytosine Generic
griseofulvin microsize oral suspension Generic
itraconazole oral capsule Generic QL
itraconazole oral solution Generic
ketoconazole oral Generic
NOXAFIL ORAL SUSPENSION Brand PA
nystatin oral suspension Generic
nystatin oral tablet Generic
posaconazole oral tablet,delayed release (dr/ec) Generic PA
terbinafine hcl oral Generic
TOLSURA Brand PA; QL
voriconazole oral Generic PA
ANTIVIRALS
abacavir Generic QL
abacavir-lamivudine Generic QL
abacavir-lamivudine-zidovudine Generic QL
acyclovir oral capsule Generic
acyclovir oral suspension 200 mg/5 ml Generic
acyclovir oral tablet Generic
adefovir Generic
amantadine hcl Generic
APTIVUS Brand QL
APTIVUS (WITH VITAMIN E) Brand QL
atazanavir Generic QL
ATRIPLA Brand QL
BARACLUDE ORAL SOLUTION Brand
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 4
Drug Name Drug Tier Requirements / Limits
BIKTARVY Brand QL
CIMDUO Brand QL
COMBIVIR Brand QL
COMPLERA Brand QL
CRIXIVAN ORAL CAPSULE 200 MG, 400 MG Brand QL
DELSTRIGO Brand QL
DESCOVY Brand QL
didanosine Generic QL
DOVATO Brand QL
EDURANT Brand QL
efavirenz Generic QL
EMTRIVA Brand QL
entecavir Generic
EPIVIR Brand QL
EPIVIR HBV ORAL SOLUTION Brand
EPZICOM Brand QL
EVOTAZ Brand QL
famciclovir Generic QL
fosamprenavir Generic QL
FUZEON SUBCUTANEOUS RECON SOLN Brand QL
GENVOYA Brand QL
INTELENCE Brand QL
INVIRASE ORAL TABLET Brand QL
ISENTRESS Brand QL
ISENTRESS HD Brand QL
JULUCA Brand QL
KALETRA Brand QL
lamivudine oral solution Generic QL
lamivudine oral tablet 100 mg Generic
lamivudine oral tablet 150 mg, 300 mg Generic QL
lamivudine-zidovudine Generic QL
LEXIVA Brand QL
lopinavir-ritonavir Generic QL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
5
Drug Name Drug Tier Requirements / Limits
MAVYRET Brand PA; QL
nevirapine Generic QL
NORVIR ORAL POWDER IN PACKET Brand QL
NORVIR ORAL SOLUTION Brand QL
NORVIR ORAL TABLET Brand QL
ODEFSEY Brand QL
oseltamivir Generic QL
PIFELTRO Brand QL
PREVYMIS ORAL Brand PA; QL
PREZCOBIX Brand QL
PREZISTA ORAL SUSPENSION Brand QL
PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG
Brand QL
RELENZA DISKHALER Brand
RETROVIR ORAL CAPSULE Brand QL
RETROVIR ORAL SYRUP Brand QL
REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG
Brand QL
REYATAZ ORAL POWDER IN PACKET Brand QL
ribavirin oral capsule Generic PA
ribavirin oral tablet 200 mg Generic PA
rimantadine Generic
ritonavir Generic QL
SELZENTRY Brand QL
SOFOSBUVIR-VELPATASVIR Brand PA; QL
stavudine oral capsule Generic QL
STRIBILD Brand QL
SUSTIVA ORAL CAPSULE Brand QL
SYMFI Brand QL
SYMFI LO Brand QL
SYMTUZA Brand QL
TEMIXYS Brand QL
tenofovir disoproxil fumarate Generic QL
TIVICAY Brand QL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 6
Drug Name Drug Tier Requirements / Limits
TRIUMEQ Brand QL
TRIZIVIR Brand QL
TRUVADA Brand QL
valacyclovir Generic QL
valganciclovir Generic
VEMLIDY Brand PA
VIDEX 2 GRAM PEDIATRIC Brand QL
VIRACEPT ORAL TABLET Brand QL
VIREAD ORAL POWDER Brand QL
VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG
Brand QL
VOSEVI Brand PA
XOFLUZA Brand QL
zidovudine Generic QL
CEPHALOSPORINS
cefaclor oral capsule Generic
cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml
Generic
cefaclor oral tablet extended release 12 hr Generic
cefadroxil oral capsule Generic
cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml
Generic
cefadroxil oral tablet Generic
cefdinir Generic
cefditoren pivoxil Generic
cefprozil Generic
cefuroxime axetil oral tablet Generic
cephalexin Generic
ERYTHROMYCINS / OTHER MACROLIDES
azithromycin oral Generic
clarithromycin Generic
e.e.s. 400 oral tablet Generic
ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg
Generic
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
7
Drug Name Drug Tier Requirements / Limits
erythrocin (as stearate) oral tablet 250 mg Generic
erythromycin ethylsuccinate oral suspension for reconstitution
Generic
erythromycin ethylsuccinate oral tablet Generic
erythromycin oral Generic
MISCELLANEOUS ANTIINFECTIVES
AEMCOLO Brand PA; QL
albendazole Generic QL
ALINIA Brand PA; QL
ARIKAYCE Brand PA; QL
atovaquone Generic
atovaquone-proguanil Generic QL
CAYSTON Brand QL
chloroquine phosphate Generic
clindamycin hcl Generic
clindamycin palmitate hcl Generic
COARTEM Brand QL
dapsone oral Generic
DARAPRIM Brand PA
EMVERM Brand QL
ethambutol Generic
hydroxychloroquine Generic
isoniazid oral Generic
ivermectin oral Generic QL
KITABIS PAK Brand QL
linezolid Generic PA
mefloquine Generic QL
metronidazole oral tablet Generic
NEBUPENT Brand QL
neomycin Generic
paromomycin Generic
praziquantel Generic
PRIFTIN Brand
pyrazinamide Generic
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 8
Drug Name Drug Tier Requirements / Limits
quinine sulfate Generic QL
rifabutin Generic
rifampin oral Generic
SIRTURO Brand
tinidazole Generic QL
tobramycin in 0.225 % nacl Generic QL
XIFAXAN Brand PA; QL
PENICILLINS
amoxicillin oral capsule Generic
amoxicillin oral suspension for reconstitution Generic
amoxicillin oral tablet Generic
amoxicillin oral tablet,chewable 125 mg, 250 mg Generic
amoxicillin-pot clavulanate Generic
ampicillin oral capsule Generic
AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 125-31.25 MG/5 ML
Brand
dicloxacillin Generic
penicillin v potassium Generic
QUINOLONES
BAXDELA ORAL Brand PA; QL
ciprofloxacin Generic
ciprofloxacin hcl oral Generic
levofloxacin oral Generic
moxifloxacin oral Generic
ofloxacin oral tablet 300 mg, 400 mg Generic
SULFA'S / RELATED AGENTS
sulfadiazine Generic
sulfamethoxazole-trimethoprim oral Generic
sulfatrim Generic
TETRACYCLINES
avidoxy Generic
demeclocycline Generic
doxycycline hyclate oral capsule Generic
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
9
Drug Name Drug Tier Requirements / Limits
doxycycline hyclate oral tablet 100 mg, 20 mg Generic
doxycycline monohydrate oral capsule Generic
doxycycline monohydrate oral tablet Generic
minocycline oral capsule Generic
minocycline oral tablet Generic
mondoxyne nl oral capsule 100 mg, 75 mg Generic
morgidox oral capsule 100 mg Generic
tetracycline Generic
URINARY TRACT AGENTS
methenamine hippurate Generic
methenamine mandelate Generic
nitrofurantoin macrocrystal Generic
nitrofurantoin monohyd/m-cryst Generic
trimethoprim Generic
VANCOMYCIN
vancomycin oral capsule Generic
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ADJUNCTIVE AGENTS
leucovorin calcium oral Generic
MESNEX ORAL Brand
VISTOGARD Brand PA
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
abiraterone Generic PA
AFINITOR 10 MG TABLET Brand PA
AFINITOR DISPERZ Brand PA
ALECENSA Brand PA
anastrozole Generic QL
AZASAN Brand
azathioprine Generic
BALVERSA Brand PA
bexarotene Generic PA
bicalutamide Generic QL
BOSULIF Brand PA
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 10
Drug Name Drug Tier Requirements / Limits
BRAFTOVI Brand PA; QL
BRUKINSA Brand PA; QL
CALQUENCE Brand PA; QL
capecitabine Generic
CAPRELSA Brand PA; QL
COPIKTRA Brand PA; QL
COTELLIC Brand PA; QL
cyclophosphamide oral capsule Generic
cyclosporine modified Generic
cyclosporine oral capsule Generic
DAURISMO Brand PA; QL
DROXIA Brand
EMCYT Brand
ERIVEDGE Brand PA; QL
ERLEADA Brand PA; QL
erlotinib Generic PA
etoposide oral Generic
everolimus (antineoplastic) Generic PA
exemestane Generic QL
flutamide Generic QL
gengraf oral capsule 100 mg, 25 mg Generic
gengraf oral solution Generic
GILOTRIF Brand PA; QL
HYCAMTIN ORAL Brand
hydroxyurea Generic
IBRANCE ORAL CAPSULE Brand PA; QL
ICLUSIG Brand PA
IDHIFA Brand PA
imatinib Generic PA
IMBRUVICA Brand PA
INLYTA Brand PA; QL
INREBIC Brand PA; QL
IRESSA Brand PA; QL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
11
Drug Name Drug Tier Requirements / Limits
JAKAFI Brand PA; QL
LENVIMA Brand PA; QL
letrozole Generic PA; QL
LEUKERAN Brand
leuprolide subcutaneous kit Generic PA
LONSURF Brand PA; QL
LORBRENA Brand PA
LYNPARZA ORAL TABLET Brand PA
LYSODREN Brand QL
MATULANE Brand
megestrol oral suspension 400 mg/10 ml (40 mg/ml)
Generic QL
megestrol oral suspension 625 mg/5 ml Generic
megestrol oral tablet Generic QL
MEKINIST Brand PA; QL
MEKTOVI Brand PA; QL
melphalan Generic
mercaptopurine Generic
methotrexate sodium oral Generic
mycophenolate mofetil Generic
mycophenolate sodium Generic
MYLERAN Brand
NERLYNX Brand PA
NEXAVAR Brand PA
nilutamide Generic QL
NINLARO Brand PA; QL
NUBEQA Brand PA; QL
octreotide acetate Generic PA
PIQRAY Brand PA; QL
POMALYST Brand PA; QL
PURIXAN Brand
REVLIMID Brand PA; QL
ROZLYTREK Brand PA; QL
RUBRACA Brand PA; QL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 12
Drug Name Drug Tier Requirements / Limits
RYDAPT Brand PA; QL
SANDIMMUNE ORAL SOLUTION Brand
SIGNIFOR Brand PA
sirolimus Generic
SPRYCEL Brand PA
STIVARGA Brand PA; QL
SUTENT Brand PA
TABLOID Brand
tacrolimus oral Generic
TAFINLAR Brand PA
TAGRISSO Brand PA
TALZENNA Brand PA; QL
tamoxifen Generic PA; QL
TASIGNA Brand PA
temozolomide Generic PA
THALOMID Brand PA; QL
TIBSOVO Brand PA; QL
toremifene Generic QL
tretinoin (chemotherapy) Generic
TREXALL Brand
TURALIO Brand PA; QL
TYKERB Brand PA
VENCLEXTA Brand PA; QL
VENCLEXTA STARTING PACK Brand PA; QL
VERZENIO Brand PA; QL
VITRAKVI Brand PA; QL
VIZIMPRO Brand PA; QL
VOTRIENT Brand PA
XALKORI Brand PA; QL
XERMELO Brand PA
XPOVIO Brand PA
XTANDI Brand PA
ZEJULA Brand PA; QL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
13
Drug Name Drug Tier Requirements / Limits
ZELBORAF Brand PA
ZOLINZA Brand PA
ZORTRESS Brand
ZYDELIG Brand PA; QL
ZYKADIA ORAL TABLET Brand PA
ZYTIGA ORAL TABLET 500 MG Brand PA
AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
carbamazepine oral capsule, er multiphase 12 hr Generic
carbamazepine oral suspension 100 mg/5 ml Generic
carbamazepine oral tablet Generic
carbamazepine oral tablet extended release 12 hr Generic
carbamazepine oral tablet,chewable Generic
clonazepam Generic
DIACOMIT Brand PA; QL
diazepam rectal Generic
DILANTIN Brand
divalproex Generic
epitol Generic
ethosuximide Generic
felbamate Generic
gabapentin oral capsule Generic QL
gabapentin oral solution 250 mg/5 ml Generic QL
gabapentin oral tablet 600 mg, 800 mg Generic QL
lamotrigine oral tablet Generic
lamotrigine oral tablet disintegrating, dose pk Generic
lamotrigine oral tablet extended release 24hr Generic
lamotrigine oral tablet, chewable dispersible Generic
lamotrigine oral tablet,disintegrating Generic
levetiracetam oral Generic
NAYZILAM Brand PA; QL
oxcarbazepine Generic
phenobarbital Generic
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 14
Drug Name Drug Tier Requirements / Limits
phenytoin oral suspension 125 mg/5 ml Generic
phenytoin oral tablet,chewable Generic
phenytoin sodium extended Generic
pregabalin Generic QL
primidone Generic
roweepra Generic
tiagabine Generic
topiramate oral capsule, sprinkle Generic
topiramate oral tablet Generic
valproic acid Generic
valproic acid (as sodium salt) oral solution 250 mg/5 ml
Generic
VALTOCO Brand PA
vigabatrin Generic PA
VIMPAT ORAL SOLUTION Brand PA
VIMPAT ORAL TABLET Brand PA
zonisamide Generic
ANTIPARKINSONISM AGENTS
APOKYN Brand
benztropine oral Generic
bromocriptine Generic PA
carbidopa Generic
carbidopa-levodopa Generic
carbidopa-levodopa-entacapone Generic
entacapone Generic
INBRIJA INHALATION CAPSULE, W/INHALATION DEVICE
Brand PA; QL
pramipexole Generic
rasagiline Generic
ropinirole Generic
selegiline hcl Generic
tolcapone Generic
trihexyphenidyl Generic
MIGRAINE / CLUSTER HEADACHE THERAPY
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
15
Drug Name Drug Tier Requirements / Limits
AIMOVIG AUTOINJECTOR Brand PA; QL
AJOVY SYRINGE Brand PA; QL
EMGALITY PEN Brand PA; QL
EMGALITY SYRINGE Brand PA; QL
ergotamine-caffeine Generic
isometh-dichloral-acetaminophn Generic
migergot Generic
naratriptan Generic QL
rizatriptan Generic QL
sumatriptan Generic QL
sumatriptan succinate oral Generic QL
sumatriptan succinate subcutaneous cartridge Generic QL
sumatriptan succinate subcutaneous pen injector Generic QL
sumatriptan succinate subcutaneous solution Generic QL
sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml
Generic QL
zolmitriptan Generic QL
MISCELLANEOUS NEUROLOGICAL THERAPY
dalfampridine Generic PA
donepezil Generic
galantamine Generic
GILENYA ORAL CAPSULE 0.5 MG Brand PA
glatopa Generic PA; QL
INGREZZA Brand PA
INGREZZA INITIATION PACK Brand PA
MAVENCLAD (4 TABLET PACK) Brand PA
MAYZENT Brand PA; QL
memantine oral solution Generic
memantine oral tablet Generic
NUEDEXTA Brand PA; QL
rivastigmine Generic
rivastigmine tartrate Generic
TECFIDERA Brand PA
TEGSEDI Brand PA
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 16
Drug Name Drug Tier Requirements / Limits
tetrabenazine Generic PA
VUMERITY Brand PA; QL
MUSCLE RELAXANTS / ANTISPASMODIC THERAPY
baclofen oral tablet 10 mg, 20 mg Generic
BACLOFEN ORAL TABLET 5 MG Brand
chlorzoxazone oral tablet 500 mg Generic
cyclobenzaprine oral tablet Generic
dantrolene oral Generic
metaxall Generic
methocarbamol oral Generic
orphenadrine citrate oral Generic
pyridostigmine bromide oral syrup Generic
pyridostigmine bromide oral tablet 60 mg Generic
pyridostigmine bromide oral tablet extended release
Generic
tizanidine oral tablet Generic
NARCOTIC ANALGESICS
acetaminophen-codeine oral solution 120-12 mg/5 ml
Generic PA
acetaminophen-codeine oral tablet Generic PA
ascomp with codeine Generic PA
buprenorphine hcl sublingual Generic
butalbital compound w/codeine Generic PA
butalbital-acetaminop-caf-cod Generic PA
butalbital-acetaminophen oral tablet 50-325 mg Generic
butalbital-acetaminophen-caff oral capsule 50-325-40 mg
Generic
butalbital-acetaminophen-caff oral tablet 50-325-40 mg
Generic
butalbital-aspirin-caffeine Generic
codeine sulfate oral tablet Generic PA
codeine-butalbital-asa-caff Generic PA
diskets Generic PA
endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
Generic PA
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
17
Drug Name Drug Tier Requirements / Limits
fentanyl Generic PA; QL
fentanyl citrate buccal lozenge on a handle Generic PA; QL
hydrocodone-acetaminophen oral solution 10-325 mg/15 ml(15 ml), 7.5-325 mg/15 ml
Generic PA
hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 2.5-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg
Generic PA
hydromorphone oral liquid Generic PA
hydromorphone oral tablet Generic PA
hydromorphone rectal Generic PA
lorcet (hydrocodone) Generic PA
lorcet hd Generic PA
lorcet plus oral tablet 7.5-325 mg Generic PA
methadone oral concentrate Generic PA
methadone oral solution Generic PA
methadone oral tablet Generic PA
methadone oral tablet,soluble Generic PA
methadose oral concentrate Generic PA
methadose oral tablet,soluble Generic PA
morphine concentrate oral solution Generic PA
morphine oral solution Generic PA
morphine oral tablet Generic PA
morphine oral tablet extended release Generic PA; QL
morphine rectal Generic PA
oxycodone oral capsule Generic PA
oxycodone oral concentrate Generic PA
oxycodone oral solution Generic PA
oxycodone oral tablet Generic PA
oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
Generic PA
oxycodone-aspirin Generic PA
tencon oral tablet 50-325 mg Generic
zebutal oral capsule 50-325-40 mg Generic
NON-NARCOTIC ANALGESICS
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 18
Drug Name Drug Tier Requirements / Limits
8 hour pain reliever Generic OTC
acetadryl Generic OTC
acetaminophen oral elixir Generic OTC
acetaminophen oral liquid 500 mg/15 ml Generic OTC
acetaminophen oral solution 325 mg/10.15 ml Generic OTC
acetaminophen oral suspension 160 mg/5 ml Generic OTC
acetaminophen oral tablet Generic OTC
acetaminophen oral tablet extended release Generic OTC
acetaminophen oral tablet,disintegrating 80 mg Generic OTC
acetaminophen pm extra str Generic OTC
acetaminophen rectal Generic OTC
added strength headache relief Generic OTC
ADVIL LIQUI-GEL Brand OTC
ADVIL MIGRAINE Brand OTC
advil oral tablet 100 mg Generic OTC
ADVIL ORAL TABLET 200 MG Brand OTC
advil oral tablet,chewable Generic OTC
ADVIL PM Brand OTC
ALEVE Brand OTC
alka-seltzer original Generic OTC
all day pain relief Generic OTC
all day relief Generic OTC
arthritis pain relief (acetam) Generic OTC
aspir-81 Generic OTC
aspirin childrens Generic OTC
aspirin low dose Generic OTC
aspirin oral tablet Generic OTC
aspirin oral tablet,chewable Generic OTC
aspirin oral tablet,delayed release (dr/ec) 325 mg, 500 mg, 650 mg, 81 mg
Generic OTC
aspirin rectal Generic OTC
aspirin,buffd-calcium carb-mag Generic OTC
aspir-trin Generic OTC
athenol Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
19
Drug Name Drug Tier Requirements / Limits
back and body pain reliever Generic OTC
backache relief extra strength Generic OTC
bayer advanced Generic OTC
BAYER CHEWABLE ASPIRIN Brand OTC
bayer plus extra strength Generic OTC
betatemp Generic OTC
bufferin Generic OTC
buprenorphine-naloxone Generic QL
butorphanol tartrate nasal Generic PA; QL
celecoxib Generic ST
child pain rel-fever reducer Generic OTC
children's acetaminophen oral liquid Generic OTC
children's acetaminophen oral tablet,chewable 160 mg
Generic OTC
children's advil Generic OTC
children's easy-melts Generic OTC
children's ibuprofen Generic OTC
children's mapap oral tablet,chewable Generic OTC
CHILDREN'S MOTRIN Brand OTC
children's non-aspirin oral suspension Generic OTC
children's pain relief oral suspension Generic OTC
children's pain-fever relief oral suspension Generic OTC
children's pain-fever relief oral tablet,chewable 160 mg
Generic OTC
children's profen ib Generic OTC
children's silapap Generic OTC
children's tactinal Generic OTC
CHILDREN'S TYLENOL ORAL SUSPENSION Brand OTC
choline,magnesium salicylate Generic
cidatrine Generic OTC
diclofenac potassium Generic
diclofenac sodium oral Generic
diclofenac sodium topical drops Generic QL
diclofenac sodium topical gel 1 % Generic ST; QL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 20
Drug Name Drug Tier Requirements / Limits
diclofenac-misoprostol Generic
diflunisal Generic
diphenhydramine-acetaminophen Generic OTC
DONA ORAL POWDER IN PACKET Brand OTC
dona oral tablet Generic OTC
e.c. prin Generic OTC
eazzze the pain Generic OTC
ecotrin low strength Generic OTC
ed-apap Generic OTC
efferves pain relief antacid Generic OTC
effervescent pain relief oral tablet, effervescent 324 mg
Generic OTC
etodolac oral capsule Generic
etodolac oral tablet Generic
EXCEDRIN EXTRA STRENGTH Brand OTC
EXCEDRIN MIGRAINE Brand OTC
EXCEDRIN TENSION HEADACHE Brand OTC
fenoprofen oral tablet Generic ST
fever reducer an pain reliever oral suspension Generic OTC
feverall rectal suppository 120 mg, 325 mg, 650 mg
Generic OTC
FEVERALL RECTAL SUPPOSITORY 80 MG Brand OTC
flanax (naproxen) Generic OTC
flurbiprofen oral tablet 100 mg Generic
genicin Generic OTC
glucosamine relief oral capsule Generic OTC
glucosamine sulfate oral capsule 500 mg Generic OTC
glucosamine sulfate oral tablet Generic OTC
headache pm Generic OTC
headache relief (asa-acet-caf) Generic OTC
headache relief pm Generic OTC
ibu Generic
ibuprofen ib Generic OTC
ibuprofen jr strength Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
21
Drug Name Drug Tier Requirements / Limits
ibuprofen oral capsule Generic OTC
ibuprofen oral suspension Generic OTC
ibuprofen oral tablet 100 mg, 200 mg Generic OTC
ibuprofen oral tablet 400 mg, 600 mg, 800 mg Generic
ibuprofen pm oral tablet Generic OTC
indomethacin oral Generic
infant fever reducer-pain relf Generic OTC
infant pain reliever Generic OTC
infant's advil Generic OTC
infant's ibuprofen Generic OTC
infant's motrin Generic OTC
infants' pain and fever Generic OTC
infants' pain relief Generic OTC
infant's pain reliever Generic OTC
infants profenib Generic OTC
jr. acetaminophen Generic OTC
jr. str non-aspirin pain Generic OTC
jr. strength pain reliever Generic OTC
ketoprofen oral capsule 50 mg, 75 mg Generic
ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg
Generic ST
ketorolac oral Generic QL
lite coat aspirin Generic OTC
little remedies fever and pain Generic OTC
LUCEMYRA Brand PA; QL
mapap (acetaminophen) oral capsule Generic OTC
mapap (acetaminophen) oral liquid 500 mg/15 ml Generic OTC
mapap (acetaminophen) oral tablet Generic OTC
mapap arthritis pain Generic OTC
mapap extra strength Generic OTC
mapap pm Generic OTC
masophen Generic OTC
meclofenamate Generic
mediproxen Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 22
Drug Name Drug Tier Requirements / Limits
medi-seltzer Generic OTC
meloxicam oral tablet 15 mg Generic
meloxicam oral tablet 7.5 mg Generic QL
midol pm Generic OTC
migraine formula Generic OTC
migraine relief Generic OTC
MOTRIN IB ORAL TABLET Brand OTC
motrin pm Generic OTC
nabumetone Generic
NALOXONE INJECTION AUTO-INJECTOR Brand QL
naloxone injection solution Generic
naloxone injection syringe Generic
naltrexone Generic
naproxen oral suspension Generic ST
naproxen oral tablet Generic
naproxen oral tablet,delayed release (dr/ec) Generic
naproxen sodium oral capsule Generic OTC
naproxen sodium oral tablet 220 mg Generic OTC
naproxen sodium oral tablet 550 mg Generic
NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION
Brand QL
night time pain medicine Generic OTC
non-aspirin childrens Generic OTC
non-aspirin extra strength oral liquid Generic OTC
non-aspirin extra strength oral tablet Generic OTC
non-aspirin oral elixir Generic OTC
non-aspirin oral tablet Generic OTC
non-aspirin oral tablet,chewable 80 mg Generic OTC
non-aspirin pain relief oral tablet 500 mg Generic OTC
non-aspirin pm Generic OTC
nortemp Generic OTC
pain relief adult Generic OTC
pain relief oral liquid Generic OTC
pain relief oral tablet Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
23
Drug Name Drug Tier Requirements / Limits
pain relief oral tablet extended release Generic OTC
pain relief pm Generic OTC
pain relief pm rapid release Generic OTC
pain relief regular strength Generic OTC
pain reliever (acetam-aspirin) Generic OTC
pain reliever extra strength Generic OTC
pain reliever oral tablet 325 mg Generic OTC
pain reliever plus Generic OTC
pain-off Generic OTC
pediacare fever reducer Generic OTC
percogesic Generic OTC
percogesic extra strength Generic OTC
pharbetol Generic OTC
piroxicam Generic
pre-menstrual relief Generic OTC
premsyn pms Generic OTC
provil Generic OTC
salsalate Generic
severe allergy Generic OTC
shake that ache Generic OTC
sulindac Generic
synovacin Generic OTC
tactinal Generic OTC
tactinal extra strength Generic OTC
TENSION HEADACHE Brand OTC
TENSION HEADACHE PAIN RELIEVER Brand OTC
tolmetin oral capsule Generic ST
tolmetin oral tablet 200 mg Generic
tolmetin oral tablet 600 mg Generic ST
tramadol oral tablet 50 mg Generic PA; QL
tramadol oral tablet extended release 24 hr Generic PA; QL
tramadol oral tablet, er multiphase 24 hr Generic PA; QL
tramadol-acetaminophen Generic PA; QL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 24
Drug Name Drug Tier Requirements / Limits
tri-buffered aspirin Generic OTC
TYLENOL ARTHRITIS PAIN Brand OTC
TYLENOL EXTRA STRENGTH ORAL TABLET
Brand OTC
TYLENOL ORAL TABLET Brand OTC
TYLENOL PM EXTRA STRENGTH Brand OTC
tylophen Generic OTC
VIVITROL Brand
wal-profen Generic OTC
wal-proxen Generic OTC
PSYCHOTHERAPEUTIC DRUGS
ABILIFY MAINTENA Brand PA
alprazolam Generic
alprazolam intensol Generic
amitriptyline Generic
amitriptyline-chlordiazepoxide Generic
amoxapine Generic
aripiprazole Generic
ARISTADA Brand
ARISTADA INITIO Brand
armodafinil Generic PA; QL
atomoxetine Generic QL
bupropion hcl oral tablet Generic
bupropion hcl oral tablet extended release 24 hr 150 mg, 300 mg
Generic
bupropion hcl oral tablet sustained-release 12 hr Generic
buspirone Generic
chlordiazepoxide hcl Generic
chlorpromazine oral Generic
citalopram Generic
clomipramine Generic
clorazepate dipotassium Generic
clozapine oral tablet Generic
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
25
Drug Name Drug Tier Requirements / Limits
clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg
Generic
desipramine Generic
desvenlafaxine succinate Generic
dexmethylphenidate Generic QL
dextroamphetamine oral solution Generic QL
dextroamphetamine-amphetamine Generic QL
diazepam intensol Generic
diazepam oral solution 5 mg/5 ml (1 mg/ml) Generic
diazepam oral tablet Generic
doxepin oral capsule Generic
doxepin oral concentrate Generic
duloxetine Generic
ergoloid Generic
escitalopram oxalate Generic
estazolam Generic
fluoxetine Generic
fluphenazine decanoate Generic
fluphenazine hcl oral Generic
flurazepam Generic
fluvoxamine Generic
guanfacine oral tablet extended release 24 hr Generic QL
guanidine Generic
haloperidol Generic
haloperidol decanoate Generic
haloperidol lactate oral Generic
HETLIOZ Brand PA; QL
imipramine hcl Generic
imipramine pamoate Generic
lithium carbonate Generic
lithium citrate oral solution 8 meq/5 ml Generic
lorazepam intensol Generic
lorazepam oral Generic
loxapine succinate Generic
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 26
Drug Name Drug Tier Requirements / Limits
maprotiline Generic
metadate er Generic QL
methamphetamine Generic QL
methylphenidate hcl oral capsule, er biphasic 30-70
Generic QL
methylphenidate hcl oral capsule,er biphasic 50-50
Generic QL
methylphenidate hcl oral solution Generic QL
methylphenidate hcl oral tablet Generic QL
methylphenidate hcl oral tablet extended release Generic QL
methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg, 36 mg, 54 mg
Generic QL
methylphenidate hcl oral tablet,chewable Generic QL
midazolam oral syrup 2 mg/ml Generic
mirtazapine Generic
modafinil Generic PA; QL
molindone Generic
nortriptyline Generic
olanzapine oral Generic
olanzapine-fluoxetine Generic
oxazepam Generic
paliperidone Generic
paroxetine hcl oral tablet Generic
paroxetine hcl oral tablet extended release 24 hr Generic
perphenazine Generic
perphenazine-amitriptyline Generic
phenelzine Generic
pimozide Generic
procentra Generic QL
protriptyline Generic
quazepam Generic
quetiapine oral tablet 100 mg, 25 mg, 50 mg Generic ST
quetiapine oral tablet 200 mg, 300 mg, 400 mg Generic
quetiapine oral tablet extended release 24 hr Generic
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
27
Drug Name Drug Tier Requirements / Limits
ramelteon Generic ST; QL
risperidone oral solution Generic
risperidone oral tablet Generic
risperidone oral tablet,disintegrating Generic
seconal sodium Generic QL
SECUADO Brand PA; QL
sertraline Generic
temazepam Generic
thioridazine Generic
thiothixene Generic
tranylcypromine Generic
trazodone Generic
triazolam Generic
trifluoperazine Generic
trimipramine Generic
venlafaxine Generic
VYVANSE Brand ST; QL
XYREM Brand PA
zaleplon Generic QL
zenzedi oral tablet 10 mg, 5 mg Generic QL
ziprasidone hcl Generic
zolpidem oral tablet Generic QL
CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
amiodarone oral Generic
dofetilide Generic
flecainide Generic
mexiletine Generic
pacerone oral tablet 100 mg, 200 mg, 400 mg Generic
propafenone Generic
quinidine gluconate oral Generic
quinidine sulfate oral tablet Generic
sotalol af Generic
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 28
Drug Name Drug Tier Requirements / Limits
sotalol oral Generic
SOTYLIZE Brand
ANTIHYPERTENSIVE THERAPY
acebutolol Generic
amiloride Generic
amiloride-hydrochlorothiazide Generic
amlodipine Generic
amlodipine-benazepril Generic
amlodipine-olmesartan Generic
amlodipine-valsartan Generic
amlodipine-valsartan-hcthiazid Generic
atenolol Generic
atenolol-chlorthalidone Generic
benazepril Generic
benazepril-hydrochlorothiazide Generic
betaxolol oral Generic
bisoprolol fumarate Generic
bisoprolol-hydrochlorothiazide Generic
bumetanide oral Generic
captopril Generic
captopril-hydrochlorothiazide Generic
cartia xt Generic
carvedilol Generic
chlorothiazide oral tablet 500 mg Generic
chlorthalidone oral tablet 25 mg, 50 mg Generic
clonidine Generic QL
clonidine hcl oral tablet Generic
DEMSER Brand PA
diltiazem hcl oral Generic
dilt-xr Generic
doxazosin Generic QL
enalapril maleate Generic
enalapril-hydrochlorothiazide Generic
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
29
Drug Name Drug Tier Requirements / Limits
eprosartan Generic
ethacrynic acid Generic
felodipine Generic
fosinopril Generic
fosinopril-hydrochlorothiazide Generic
furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml)
Generic
furosemide oral tablet Generic
guanfacine oral tablet Generic
hydralazine oral Generic
hydrochlorothiazide Generic
indapamide Generic
irbesartan Generic
irbesartan-hydrochlorothiazide Generic
isradipine Generic
labetalol oral Generic
lisinopril Generic
lisinopril-hydrochlorothiazide Generic
losartan Generic
losartan-hydrochlorothiazide Generic
matzim la Generic
methyldopa Generic
methyldopa-hydrochlorothiazide Generic
metolazone Generic
metoprolol succinate Generic
metoprolol ta-hydrochlorothiaz Generic
metoprolol tartrate oral Generic
minoxidil oral Generic
moexipril Generic
nadolol Generic
nadolol-bendroflumethiazide oral tablet 80-5 mg Generic
nifedipine oral tablet extended release Generic
nifedipine oral tablet extended release 24hr Generic
olmesartan-amlodipin-hcthiazid Generic
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 30
Drug Name Drug Tier Requirements / Limits
perindopril erbumine Generic
phenoxybenzamine Generic PA
pindolol Generic
prazosin Generic
propranolol oral Generic
propranolol-hydrochlorothiazid Generic
quinapril Generic
quinapril-hydrochlorothiazide Generic
ramipril Generic
spironolactone Generic
spironolacton-hydrochlorothiaz Generic
taztia xt Generic
telmisartan-amlodipine Generic
terazosin Generic QL
timolol maleate oral Generic
torsemide oral Generic
trandolapril Generic
trandolapril-verapamil Generic
triamterene-hydrochlorothiazid oral capsule 37.5-25 mg
Generic
triamterene-hydrochlorothiazid oral tablet Generic
UPTRAVI Brand PA
valsartan Generic
valsartan-hydrochlorothiazide Generic
verapamil oral Generic
CARDIAC GLYCOSIDES
digitek Generic
digox Generic
digoxin oral solution 50 mcg/ml (0.05 mg/ml) Generic
digoxin oral tablet Generic
COAGULATION THERAPY
aminocaproic acid oral Generic
BRILINTA Brand
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
31
Drug Name Drug Tier Requirements / Limits
cilostazol Generic
clopidogrel Generic
dipyridamole oral Generic
ELIQUIS Brand
ELIQUIS DVT-PE TREAT 30D START Brand
enoxaparin Generic
fondaparinux Generic
jantoven Generic
MULPLETA Brand PA; QL
pentoxifylline Generic
PHYTONADIONE (VITAMIN K1) ORAL TABLET 100 MCG
Brand OTC
phytonadione (vitamin k1) oral tablet 5 mg Generic
PROMACTA Brand PA
warfarin Generic
XARELTO Brand
LIPID/CHOLESTEROL LOWERING AGENTS
amlodipine-atorvastatin Generic QL
atorvastatin Generic QL
cholestyramine (with sugar) Generic
cholestyramine light Generic
colestipol Generic
endur-acin Generic OTC
ezetimibe Generic QL
fenofibrate micronized Generic
fenofibrate nanocrystallized oral tablet 145 mg, 48 mg
Generic
fenofibrate oral tablet Generic
fenofibric acid Generic
fenofibric acid (choline) Generic
fish oil concentrate Generic OTC
gemfibrozil Generic
JUXTAPID Brand PA
lovastatin Generic QL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 32
Drug Name Drug Tier Requirements / Limits
maxepa Generic OTC
niacin (inositol niacinate) oral capsule 500 mg Generic OTC
niacin (niacinamide) Generic OTC
niacin oral capsule, extended release 250 mg, 500 mg
Generic OTC
niacin oral tablet Generic OTC
NIACIN ORAL TABLET EXTENDED RELEASE 1,000 MG
Brand OTC
niacin oral tablet extended release 24 hr Generic
niacin oral tablet extended release 250 mg, 500 mg, 750 mg
Generic OTC
niacinamide oral tablet 500 mg Generic OTC
omega-3 acid ethyl esters Generic PA
omega-3 fatty acids oral capsule Generic OTC
PRALUENT PEN Brand PA
pravastatin Generic QL
prevalite Generic
REPATHA PUSHTRONEX Brand PA
REPATHA SURECLICK Brand PA
REPATHA SYRINGE Brand PA
rosuvastatin Generic QL
simvastatin oral tablet Generic QL
SLO-NIACIN ORAL TABLET EXTENDED RELEASE 250 MG, 750 MG
Brand OTC
slo-niacin oral tablet extended release 500 mg Generic OTC
super omega-3 oral capsule 1,000 mg Generic OTC
MISCELLANEOUS CARDIOVASCULAR AGENTS
CORLANOR Brand PA
ENTRESTO Brand
VYNDAMAX Brand PA; QL
VYNDAQEL Brand PA; QL
NITRATES
isosorbide dinitrate oral Generic
isosorbide mononitrate Generic
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
33
Drug Name Drug Tier Requirements / Limits
nitro-bid Generic
nitroglycerin oral Generic
nitroglycerin sublingual Generic
nitroglycerin transdermal patch 24 hour Generic
nitro-time Generic
DERMATOLOGICALS/TOPICAL THERAPY
ANTIPSORIATIC / ANTISEBORRHEIC
acitretin Generic
calcipotriene scalp Generic QL
calcipotriene topical cream Generic QL
calcipotriene topical ointment Generic QL
calcipotriene-betamethasone topical ointment Generic QL
calcitriol topical Generic
hydrocortisone-pramoxine topical Generic
selenium sulfide topical lotion Generic
selenium sulfide topical shampoo 2.25 %, 2.3 % Generic
SKYRIZI SUBCUTANEOUS SYRINGE KIT Brand PA; QL
sulfacetamide sodium topical Generic
BURN THERAPY
silver sulfadiazine Generic
ssd Generic
KERATOLYTICS
callus removers Generic OTC
compound w topical liquid Generic OTC
duofilm Generic OTC
liquid corn and callus remover topical liquid 17 % Generic OTC
mosco callus-corn remover Generic OTC
SCALP RELIEF TOPICAL LIQUID Brand OTC
sulfo-lo Generic OTC
wart remover topical liquid Generic OTC
MISCELLANEOUS DERMATOLOGICALS
4-n-1 no rinse wash topical cream Generic OTC
a and d (lan, pet) Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 34
Drug Name Drug Tier Requirements / Limits
ABSORBASE Brand OTC
absorbine pain relieving Generic OTC
advanced healing (petrolatum) Generic OTC
ALOE GRANDE Brand OTC
ALOE VERA TOPICAL GEL Brand OTC
ALOE VESTA CLEANSING Brand OTC
ALOE VESTA PERINEAL Brand OTC
ALOE VESTA PROTECTANT OINTMENT Brand OTC
alphabath Generic OTC
amerigel Generic OTC
ameriphor Generic OTC
AMERISTORE Brand OTC
ammonium lactate Generic OTC
analgesic creme Generic OTC
analgesic grx balm topical ointment Generic OTC
anti-itch (menthol/camphor) Generic OTC
antiseptic skin clnsr(chlorhe) Generic OTC
aqua care Generic OTC
aqua glycolic face Generic OTC
aqua glycolic topical shampoo Generic OTC
AQUA LACTEN Brand OTC
AQUA LUBE Brand OTC
AQUANIL SKIN CLEANSER Brand OTC
AQUAPHOR HEALING Brand OTC
AQUAPHOR ORIGINAL Brand OTC
arthricream rub Generic OTC
arthritis pain relief(capsaic) topical cream 0.1 % Generic OTC
ASPERCREME HEAT Brand OTC
ASPERCREME WITH ALOE Brand OTC
asper-flex Generic OTC
astringent Generic OTC
ATRAC-TAIN (WITH AHA) Brand OTC
AVEENO BABY TOPICAL CREAM Brand OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
35
Drug Name Drug Tier Requirements / Limits
AVEENO DAILY MOISTURIZING Brand OTC
aveeno intense relief Generic OTC
AVEENO MOISTURIZING Brand OTC
AVEENO SOOTHING BATH Brand OTC
AVOSIL Brand OTC
baby wash Generic OTC
BALNEOL TOPICAL LOTION Brand OTC
BENGAY GREASELESS Brand OTC
BENGAY ULTRA STRENGTH Brand OTC
bengay ultra strength(menthol) Generic OTC
BENGAY VANISHING SCENT Brand OTC
benzoin Generic OTC
benzoin compound topical tincture 10-2-8-4 % Generic OTC
beta care Generic OTC
BETAMIDE Brand OTC
betasept surgical scrub Generic OTC
blue gel Generic OTC
boro-packs Generic OTC
BOUDREAUXS BUTT PASTE TOPICAL OINTMENT
Brand OTC
calahist Generic OTC
calamine phenolated Generic OTC
calamine-zinc oxide topical lotion 8-8 % Generic OTC
calamine-zinc oxide-phenol Generic OTC
caldyphen clear topical lotion 1-0.1 % Generic OTC
calmoseptine topical ointment Generic OTC
cam Generic OTC
CAMPHO-PHENIQUE TOPICAL SOLUTION Brand OTC
capsaicin topical adhesive patch,medicated Generic OTC
capsaicin topical cream 0.1 % Generic OTC
capsicum Generic OTC
capzasin-hp Generic OTC
CAVILON DURABLE BARRIER Brand OTC
CERAVE Brand OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 36
Drug Name Drug Tier Requirements / Limits
CETA-KLENZ GENTLE Brand OTC
ceta-klenz mild Generic OTC
CETAPHIL Brand OTC
CETAPHIL DAILYADVANCE Brand OTC
cetaphil gentle cleanser Generic OTC
CETAPHIL HAND Brand OTC
cetaphil moisturizing topical cream Generic OTC
CETAPHIL MOISTURIZING TOPICAL LOTION
Brand OTC
CETAPHIL RESTORADERM TOPICAL CLEANSER
Brand OTC
chlorhexidine gluconate topical liquid Generic OTC
clear anti-itch Generic OTC
COATS ALOE Brand OTC
COATS ALOE MOISTURIZING Brand OTC
COCOA BUTTER TOPICAL Brand OTC
COCONUT OIL CREAM Brand OTC
cold and hot (m.salic-menthol) Generic OTC
cold and hot pain relief topical cream Generic OTC
cold and hot therapy balm Generic OTC
COMPLEX 15 Brand OTC
conti castile soap Generic OTC
cool bottoms Generic OTC
cool heat (m-salicylate-menth) Generic OTC
CUTEMOL Brand OTC
CUTTER BACKWOODS Brand OTC; QL
CUTTER BACKWOODS DRY Brand OTC; QL
CUTTER LEMON EUCALYPTUS Brand OTC; QL
CUTTER NATURAL INSECT REPELLNT Brand OTC; QL
CUTTER NATURAL REPELLENT2 Brand OTC; QL
CUTTER SKINSATIONS Brand OTC; QL
daily moisturizing lotion Generic OTC
dermabase Generic OTC
dermacerin Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
37
Drug Name Drug Tier Requirements / Limits
DERMACLOUD Brand OTC
dermadrox topical ointment Generic OTC
dermamed (aluminum hydroxide) Generic OTC
dermaphor topical ointment Generic OTC
DERMAPHOR TOPICAL OINTMENT 44 % Brand OTC
dermasarra Generic OTC
dermavantage Generic OTC
DESITIN Brand OTC
diaper rash relief Generic OTC
diaper rash topical ointment Generic OTC
DIAPER RASH TOPICAL PASTE Brand OTC
DML Brand OTC
DML FACIAL MOISTURIZER Brand OTC
DML FORTE Brand OTC
DOMEBORO Brand OTC
doxepin topical Generic PA; QL
DR. SMITH'S DIAPER Brand OTC
dry skin therapy Generic OTC
dry skin therapy moisturizing Generic OTC
DUPIXENT Brand PA
ECZEMA RELIEF Brand OTC
ELON Brand OTC
emollient Generic OTC
EUCERIN Brand OTC
EUCERIN ECZEMA RELIEF Brand OTC
eucerin original Generic OTC
EUCERIN SKIN CALMING Brand OTC
excel-gel Generic OTC
finger cream Generic OTC
fluorouracil topical cream 5 % Generic
fluorouracil topical solution Generic
gentle skin cleanser Generic OTC
geri-hydrolac Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 38
Drug Name Drug Tier Requirements / Limits
GOLD BOND MEDICATED Brand OTC
GOLD BOND ULTIMATE ECZEMA RLF Brand OTC
GOLD BOND ULTIMATE HEALING TOPICAL LIQUID
Brand OTC
gordon's vite a topical cream Generic OTC
gordons-vite e Generic OTC
gormel Generic OTC
gormel ten Generic OTC
green soap Generic OTC
hand wash Generic OTC
hibiclens Generic OTC
hydrocerin Generic OTC
hydrocerin (with petrolatum) Generic OTC
hydrolatum Generic OTC
HYDROPHOR Brand OTC
HYPER-HEAL Brand OTC
ice blue gel Generic OTC
icy hot (menthol) topical adhesive patch,medicated Generic OTC
ICY HOT PAIN RELIEVING Brand OTC
ICY HOT TOPICAL CREAM Brand OTC
ICY HOT TOPICAL OINTMENT Brand OTC
imiquimod topical cream in packet Generic
INSECT REPELLENT (DEET) Brand OTC; QL
INSECT REPELLENT (PICARIDIN) Brand OTC; QL
iodine-sodium iodide topical tincture 2 % Generic
itch relief (pramoxine-zinc) Generic OTC
johnson's baby oil Generic OTC
LAC-HYDRIN FIVE Brand OTC
lan-o-soothe Generic OTC
LANTISEPTIC DRY SKIN THERAPY Brand OTC
LANTISEPTIC SKIN PROTECTANT Brand OTC
lubriderm daily moisture (pet) Generic OTC
LUBRIDERM SENSITIVE SKIN Brand OTC
lubriderm skin nourishing Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
39
Drug Name Drug Tier Requirements / Limits
lubrisilk Generic OTC
lubrisoft Generic OTC
mapo bath Generic OTC
MEDERMA Brand OTC
MEDERMA FOR KIDS Brand OTC
medicated body powder topical powder 0.15-1 % Generic OTC
medicated chest rub Generic OTC
MEDICATED HEAT PATCH Brand OTC
MEDROX (WITHOUT METHYL SALICY) Brand OTC
men-phor Generic OTC
MENTHODERM Brand OTC
menthol topical gel 2 % Generic OTC
methoxsalen Generic
methyl salicylate Generic
methyl salicylate topical liquid Generic OTC
MIADERM Brand OTC
mineral oil light topical Generic OTC
minerin Generic OTC
minerin creme Generic OTC
mobisyl Generic OTC
moisture barrier ointment Generic OTC
moiturizing lotion Generic OTC
MONSEL'S Brand
muscle rub (with camphor) Generic OTC
muscle rub topical cream 15-10 % Generic OTC
muscle rub ultra-strength Generic OTC
NATRAPEL Brand OTC; QL
natural oatmeal bath treatment Generic OTC
NEOSPORIN MOISTURIZING Brand OTC
neutraphor Generic OTC
NEUTROGENA ACNE CLEANSING SOAP Brand OTC
NEUTROGENA FACIAL SOAP Brand OTC
NEUTROGENA LIP MOISTURIZER Brand OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 40
Drug Name Drug Tier Requirements / Limits
NEUTROGENA SENSITIVE SKN MOIST Brand OTC
NEUTROGENA TOPICAL SHAMPOO Brand OTC
NIVEA SOFT Brand OTC
oatmeal bath regular Generic OTC
ocusoft hand soap Generic OTC
OFF ACTIVE Brand OTC; QL
OFF DEEP WOODS Brand OTC; QL
OFF DEEP WOODS DRY Brand OTC; QL
OFF FAMILYCARE (WITH DEET) Brand OTC; QL
pain relief (menthol) Generic OTC
pain relief (trolamine salicy) Generic OTC
pain relief cream Generic OTC
pain relieving (menthol) topical adhesive patch,medicated
Generic OTC
pain relieving (menthol) topical gel Generic OTC
pain relieving cream Generic OTC
pain relieving(cam-m.sal-ment) topical adhesive patch,medicated
Generic OTC
pediatric oint (cod liver oil) Generic OTC
PEDI-BORO SOAK Brand OTC
PEN-KERA Brand OTC
PERIANAL CLEANSING Brand OTC
PERIFRESH Brand OTC
PERISCENT Brand OTC
petrolatum Generic OTC
petrolatum, yellow (bulk) Generic OTC
PETROLEUM JELLY, WHITE Brand OTC
podofilox Generic
PRETTY FEET HANDS Brand OTC
PROSHIELD FOAM/SPRAY CLEANSER Brand OTC
protective ointment Generic OTC
prudoxin Generic PA; QL
REGRANEX Brand PA; QL
REJUVENESS Brand OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
41
Drug Name Drug Tier Requirements / Limits
remedy cleansing body Generic OTC
REMEDY NUTRASHIELD SKIN PROTEC Brand OTC
RENEWAL BATH TREATMENT Brand OTC
REPEL 100 Brand OTC; QL
REPEL FAMILY Brand OTC; QL
REPEL HUNTER'S Brand OTC; QL
REPEL SPORTSMEN DRY Brand OTC; QL
REPEL SPORTSMEN MAX Brand OTC; QL
REPEL TICK DEFENSE Brand OTC; QL
risamine Generic OTC
SAF-CLENS AF DERMAL WOUND Brand
SALONPAS-HOT Brand OTC
SARNA ORIGINAL Brand OTC
scar gel Generic OTC
SECURA EXTRA PROTECTIVE Brand OTC
secura protective Generic OTC
SENSI-CARE TOPICAL SOLUTION Brand OTC
SILICONE SCAR Brand OTC
skin cleanser Generic OTC
skin protectant a and d Generic OTC
skin treatment Generic OTC
SOOTHING BATH TREATMENT Brand OTC
sorbidon hydrate Generic OTC
sports pain relief rub Generic OTC
sportscreme Generic OTC
STUDIO 35 BEAUTY COCOA BUTTER Brand OTC
STUDIO 35 MOISTURIZING SKIN Brand OTC
SUPERSOFT Brand OTC
SWEEN 24 Brand OTC
sween cream Generic OTC
tacrolimus topical Generic ST; QL
thera bath Generic OTC
thera-derm Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 42
Drug Name Drug Tier Requirements / Limits
THERA-GESIC TOPICAL CREAM 15-1 % Brand OTC
therapeutic blue Generic OTC
THERAPEUTIC MINERAL ICE Brand OTC
therapeutic moisturizing Generic OTC
theraseal Generic OTC
thritex Generic OTC
TIGER BALM TOPICAL CREAM 3-15-5 % Brand OTC
tiger balm topical ointment Generic OTC
TOTAL HOME INSECT REPELLENT Brand OTC; QL
TRIAD WOUND DRESSING Brand OTC
TRIPLE PASTE TOPICAL OINTMENT 12.8 % Brand OTC
trolamine salicylate Generic OTC
tru-micin topical lotion Generic OTC
ultra mide 25 Generic OTC
ultracin t Generic OTC
ULTRATHON TOPICAL AEROSOL,SPRAY Brand OTC; QL
unscented cold cream Generic OTC
urea topical cream 10 %, 20 % Generic OTC
urea topical lotion 10 % Generic OTC
UREACIN-10 Brand OTC
ureacin-20 Generic OTC
vanicream Generic OTC
VANICREAM LITE Brand OTC
vitamin a and d Generic OTC
vitamin a and d diaper rash Generic OTC
VITAMIN A AND D GRX Brand OTC
VITAMIN E (DL, ACETATE) TOPICAL Brand OTC
vitamin e plus Generic OTC
vitamin e topical cream Generic OTC
VITAMIN E-SAFFLOWER OIL Brand OTC
VITA-RAY Brand OTC
vits a and d-white pet-lanolin topical ointment Generic OTC
walgreens dry skin treatment Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
43
Drug Name Drug Tier Requirements / Limits
white petrolatum topical gel Generic OTC
white petrolatum topical ointment Generic OTC
white petroleum jelly Generic OTC
WIBI Brand OTC
wintergreen oil Generic
witch hazel topical liquid Generic OTC
WOUND WASH SALINE Brand OTC
z-clinz Generic OTC
zinc oxide topical ointment Generic OTC
zostrix Generic OTC
zostrix-hp Generic OTC
THERAPY FOR ACNE
acne cleansing bar Generic OTC
acne foaming wash Generic OTC
acne treatment (benzoyl perox) topical gel Generic OTC
acne vanishing Generic OTC
acne-clear Generic OTC
advanced exfoliating cleanser Generic OTC
amnesteem Generic
avita topical cream Generic PA
benzepro topical foam 5.3 %, 9.8 % Generic OTC
benzepro topical towelette Generic
benzoyl peroxide topical cleanser 10 %, 5 %, 6 % Generic OTC
benzoyl peroxide topical foam 5.3 % Generic
benzoyl peroxide topical gel 10 %, 2.5 %, 5 % Generic OTC
bp Generic OTC
bp wash acne treatment Generic OTC
bp wash topical cleanser 10 %, 5 % Generic OTC
bpo-10 Generic OTC
bpo-5 Generic OTC
claravis Generic
clearasil daily clear(benzoyl) Generic OTC
clindacin p Generic
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 44
Drug Name Drug Tier Requirements / Limits
clindamycin phosphate topical solution Generic QL
clindamycin phosphate topical swab Generic
creamy acne face Generic OTC
ery pads Generic
erythromycin with ethanol topical solution Generic
foaming acne face wash Generic OTC
metronidazole topical Generic
myorisan Generic
NEUTROGENA ON THE SPOT Brand OTC
OC8 Brand OTC
panoxyl topical bar Generic OTC
panoxyl topical cleanser 10 % Generic OTC
persa-gel Generic OTC
rosadan topical cream Generic
rosadan topical gel Generic
rosula cleansing cloths Generic
sss 10-5 topical foam Generic
sulfacetamide sodium-sulfur topical cleanser 10-5 % (w/w)
Generic
sulfacetamide sodium-sulfur topical lotion Generic
targeted acne spot treatment Generic OTC
tazarotene Generic PA
TAZORAC TOPICAL CREAM 0.05 % Brand PA
TAZORAC TOPICAL GEL Brand PA
tretinoin Generic PA
zenatane Generic
TOPICAL ANESTHETICS
ASPERCREME (LIDOCAINE) TOPICAL ADHESIVE PATCH,MEDICATED
Brand PA; OTC
calaclear Generic OTC
CALADRYL Brand OTC
calagesic Generic OTC
calahist clear Generic OTC
calahist with pramoxine Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
45
Drug Name Drug Tier Requirements / Limits
calamine medicated Generic OTC
calamine plus (pramox-calamin) Generic OTC
caldyphen clear topical lotion Generic OTC
caldyphen topical lotion 1-8 % Generic OTC
callergy clear Generic OTC
glydo Generic QL
lidocaine hcl laryngotracheal Generic
lidocaine hcl mucous membrane jelly Generic QL
lidocaine hcl mucous membrane jelly in applicator Generic QL
lidocaine hcl mucous membrane solution 4 % (40 mg/ml)
Generic
lidocaine hcl topical cream 3 % Generic
lidocaine hcl-hydrocortison ac topical Generic
LIDOCAINE PAIN RELIEF Brand PA; OTC
lidocaine topical adhesive patch,medicated 5 % Generic PA
lidocaine viscous Generic
lidocaine-prilocaine topical cream Generic QL
lidocaine-prilocaine topical kit Generic
LIDOCARE Brand PA; OTC
lta pre-attached Generic
TOPICAL ANTIBACTERIALS
antibiotic (bacitracin zinc) Generic OTC
antibiotic (neomy-bacit-polym) Generic OTC
antibiotic plus pain rel(pram) Generic OTC
antiseptic topical solution Generic OTC
bacitracin topical Generic OTC
bacitracin zinc topical ointment Generic OTC
bacitracin zinc-polymyxin b Generic OTC
bacitraycin plus topical ointment 500 unit/gram Generic OTC
BETADINE Brand OTC
BETADINE SURGICAL SCRUB Brand OTC
BETADINE SWABSTICKS Brand OTC
first aid antibiotic-pain rlf Generic OTC
first aid antiseptic topical solution Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 46
Drug Name Drug Tier Requirements / Limits
gentamicin topical Generic
mafenide acetate Generic
multi antibiotic plus Generic OTC
mupirocin Generic QL
NEOSPORIN (NEO-BAC-POLYM) TOPICAL OINTMENT
Brand OTC
neosporin (neo-bac-polym) topical ointment in packet
Generic OTC
NEOSPORIN + PAIN RELIEF Brand OTC
POLYSPORIN (BACITRACIN ZINC) Brand OTC
povidone-iodine topical liquid in packet Generic OTC
povidone-iodine topical ointment Generic OTC
povidone-iodine topical solution Generic OTC
povidone-iodine topical spray,non-aerosol Generic OTC
povidone-iodine topical swab 10 % Generic OTC
SILVASORB Brand OTC
SILVERMED TOPICAL GEL,EXTENDED RELEASE
Brand OTC
strong iodine topical Generic
sulfacetamide sodium (acne) Generic
SULFAMYLON TOPICAL CREAM Brand
triple antibiotic plus Generic OTC
triple antibiotic topical ointment Generic OTC
triple antibiotic topical ointment in packet Generic OTC
triple antibiotic-pain relief Generic OTC
wal-sporin Generic OTC
TOPICAL ANTIFUNGALS
af Generic OTC
ALOE VESTA ANTIFUNGAL (MICON) Brand OTC
antifungal (tolnaftate) Generic OTC
antifungal spray Generic OTC
anti-fungal topical powder Generic OTC
athlete's foot Generic OTC
athlete's foot (clotrimazole) Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
47
Drug Name Drug Tier Requirements / Limits
athlete's foot (tolnaftate) Generic OTC
athletic foot cream Generic OTC
azolen tincture Generic OTC
baza antifungal Generic OTC
blis-to-sol (tolnaftate) Generic OTC
ciclodan topical cream Generic QL
ciclodan topical solution Generic
ciclopirox topical cream Generic QL
ciclopirox topical gel Generic QL
ciclopirox topical solution Generic
clotrimazole-betamethasone topical cream Generic QL
critic-aid clear af Generic OTC
DERMAFUNGAL Brand OTC
desenex topical powder Generic OTC
foot and sneaker Generic OTC
formula 3 Generic OTC
fungoid tincture topical tincture Generic OTC
fungoid-d Generic OTC
inzo antifungal Generic OTC
jock itch Generic OTC
jock itch (clotrimazole) Generic OTC
jock itch (terbinafine) Generic OTC
ketoconazole topical cream Generic QL
ketoconazole topical shampoo Generic QL
ketodan Generic QL
lamisil af Generic OTC
lamisil at topical cream Generic OTC
LOTRIMIN AF Brand OTC
LOTRIMIN AF (CLOTRIMAZOLE) TOPICAL CREAM
Brand OTC
lotrimin af powder Generic OTC
micatin Generic OTC
miconazole nitrate topical aerosol powder Generic OTC
miconazorb af Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 48
Drug Name Drug Tier Requirements / Limits
micro-guard Generic OTC
NIZORAL A-D Brand OTC
nyamyc Generic
nystatin topical cream Generic QL
nystatin topical ointment Generic QL
nystatin topical powder Generic
nystop Generic
odor control foot-sneaker Generic OTC
remedy antifungal Generic OTC
remedy phytoplex antifungal topical powder Generic OTC
ringworm Generic OTC
secura antifungal Generic OTC
sween prep Generic OTC
tinactin topical aerosol powder Generic OTC
TINACTIN TOPICAL AEROSOL,SPRAY Brand OTC
TINACTIN TOPICAL CREAM Brand OTC
tinactin topical powder Generic OTC
tolnaftate topical aerosol powder Generic OTC
tolnaftate topical cream Generic OTC
triple paste af Generic OTC
TOPICAL ANTIVIRALS
ABREVA Brand OTC
TOPICAL CORTICOSTEROIDS
ala-cort topical cream 1 % Generic
amcinonide Generic ST
anti-itch (hc) topical cream Generic OTC
anti-itch (hc) topical ointment Generic OTC
ANTI-ITCH PLUS Brand OTC
AQUANIL HC Brand OTC
beta-hc Generic OTC
betamethasone dipropionate Generic
betamethasone valerate topical cream Generic
betamethasone valerate topical lotion Generic
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
49
Drug Name Drug Tier Requirements / Limits
betamethasone valerate topical ointment Generic
betamethasone, augmented topical cream Generic
betamethasone, augmented topical ointment Generic
clobetasol scalp Generic QL
clobetasol topical cream Generic QL
clobetasol-emollient topical cream Generic QL
cortisone (hydrocortisone) topical cream Generic OTC
cortisone (hydrocortisone) topical lotion Generic OTC
cortisone cooling Generic OTC
cortisone with aloe Generic OTC
cortizone-10 topical cream Generic OTC
cortizone-10 topical gel Generic OTC
cortizone-10 topical ointment Generic OTC
dermarest eczema (hydrocort) Generic OTC
desoximetasone topical cream 0.25 % Generic ST
fluocinolone topical cream 0.025 % Generic
fluocinolone topical ointment Generic
fluocinonide topical cream 0.05 % Generic QL
fluocinonide topical solution Generic QL
fluticasone propionate topical cream Generic
fluticasone propionate topical ointment Generic
hydrocortisone acetate topical cream Generic OTC
hydrocortisone acetate topical ointment Generic OTC
hydrocortisone plus Generic OTC
hydrocortisone topical cream 0.5 % Generic OTC
hydrocortisone topical cream 1 %, 2.5 % Generic
hydrocortisone topical lotion 1 % Generic OTC
hydrocortisone topical lotion 2.5 % Generic
hydrocortisone topical ointment 0.5 % Generic OTC
hydrocortisone topical ointment 1 %, 2.5 % Generic
hydrocortisone-aloe vera Generic OTC
hydrocream Generic OTC
mometasone topical Generic
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 50
Drug Name Drug Tier Requirements / Limits
noble formula hc topical cream Generic OTC
prednicarbate Generic
PREPARATION H HYDROCORTISONE Brand OTC
scalacort Generic
scalp relief topical solution Generic OTC
scalpicin anti-itch Generic OTC
soothing care (hydrocortisone) Generic OTC
triamcinolone acetonide topical cream Generic
triamcinolone acetonide topical lotion Generic
triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 %
Generic
triderm topical cream Generic
TOPICAL ENZYMES
SANTYL Brand QL
TOPICAL SCABICIDES / PEDICULICIDES
complete lice treatment Generic OTC
lice bedding spray Generic OTC
lice complete kit 1-2-3 Generic OTC
lice killing Generic OTC
lice killing (permethrin) Generic OTC
lice pyrinyl shampoo Generic OTC
lice solution Generic OTC
lice treatment topical liquid 1 % Generic OTC
lice treatment topical shampoo Generic OTC
NIX CREME RINSE Brand OTC
noble formula topical bar Generic OTC
permethrin topical cream Generic
RID COMPLETE LICE ELIM KIT AEROSOL,SPRAY
Brand OTC
rid complete lice elim kit topical Generic OTC
DIAGNOSTICS / MISCELLANEOUS AGENTS
MISCELLANEOUS AGENTS
acamprosate Generic
anagrelide Generic
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
51
Drug Name Drug Tier Requirements / Limits
ANASEPT SKIN-WOUND CLEANSER Brand OTC
ANASEPT TOPICAL Brand OTC
ANTICOAG CITRATE PHOS DEXTROSE Brand
caffeine citrate oral Generic
CARBAGLU Brand
cevimeline Generic
CHEMET Brand
corn starch Generic OTC
cryoserv Generic
DAKIN'S SOLUTION SOLUTION 0.125 %, 0.25 %
Brand OTC
dakin's solution solution 0.5 % Generic OTC
deferasirox oral tablet 360 mg, 90 mg Generic PA
deferasirox oral tablet, dispersible Generic PA
dex4 glucose bits Generic OTC
dex4 glucose oral gel Generic OTC
dex4 glucose oral tablet,chewable Generic OTC
DI-DAK-SOL Brand OTC
disulfiram Generic
ENDARI Brand PA; QL
ENFAMIL GLUCOSE Brand OTC
enfamil water Generic OTC
etidronate disodium oral tablet 200 mg Generic
FERRIPROX Brand PA
forane Generic
gerber good start water Generic OTC
gluco burst Generic OTC
glucose bits Generic OTC
glucose gel Generic OTC
glucose oral tablet,chewable 4 gram Generic OTC
GLUTOSE-15 Brand OTC
h-chlor 12 Generic OTC
H-CHLOR 6 Brand OTC
hydrogen peroxide Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 52
Drug Name Drug Tier Requirements / Limits
hysept Generic OTC
INCRELEX Brand PA
isoflurane Generic
JADENU 180 MG TABLET Brand PA
JADENU SPRINKLE Brand PA
kionex (with sorbitol) Generic
l-carnitine oral tablet Generic OTC
levocarnitine (with sugar) Generic
levocarnitine oral tablet Generic
midodrine Generic
mineral oil light Generic OTC
MURI-LUBE Brand
nitisinone Generic PA
ORFADIN ORAL CAPSULE 20 MG Brand PA
ORFADIN ORAL SUSPENSION Brand PA
OXBRYTA Brand PA; QL
pilocarpine hcl oral Generic
RAVICTI Brand
riluzole Generic PA
risedronate oral tablet 30 mg Generic QL
safe wash Generic OTC
saline wound wash Generic OTC
sevelamer carbonate Generic
sevoflurane Generic
similac sterilized water Generic OTC
sodium phenylbutyrate Generic
sodium polystyrene sulfonate oral powder Generic
soothe and cool body powder Generic OTC
sps (with sorbitol) Generic
terrell Generic
VELTASSA Brand PA
XURIDEN Brand PA
MISCELLANEOUS DEVICES
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
53
Drug Name Drug Tier Requirements / Limits
dy-o-derm Generic OTC
INSTACLEAN Brand OTC
NEUTRACEUTICALS
arnica Generic OTC
complete premium vitamin Generic OTC
flaxseed oil oral capsule 1,000 mg Generic OTC
garlic oral capsule 1,000 mg, 1,500 mg, 500 mg Generic OTC
ODORLESS GARLIC ORAL CAPSULE Brand OTC
omega-3 flaxseed oil Generic OTC
SMOKING DETERRENTS
bupropion hcl (smoking deter) Generic
CHANTIX CONTINUING MONTH BOX Brand
CHANTIX ORAL TABLET 0.5 MG Brand
CHANTIX STARTING MONTH BOX Brand
NICODERM CQ Brand OTC
nicorelief buccal gum 2 mg Generic OTC
NICORETTE BUCCAL GUM 2 MG Brand OTC
NICORETTE BUCCAL LOZENGE Brand OTC
NICORETTE BUCCAL MINI LOZENGE Brand OTC
nicotine (polacrilex) buccal gum Generic OTC
NICOTINE (POLACRILEX) BUCCAL LOZENGE 4 MG
Brand OTC
nicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr
Generic OTC
nicotine transdermal patch, td daily, sequential Generic OTC
NICOTROL Brand
NICOTROL NS Brand
quit 2 buccal gum Generic OTC
quit 4 buccal gum Generic OTC
stop smoking aid Generic OTC
EAR, NOSE / THROAT MEDICATIONS
MISCELLANEOUS AGENTS
12 hour nasal spray Generic OTC
4 way Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 54
Drug Name Drug Tier Requirements / Limits
AFRIN (OXYMETAZOLINE) NASAL SPRAY,NON-AEROSOL
Brand OTC
afrin no drip(oxymetazolin) Generic OTC
altamist Generic OTC
anefrin Generic OTC
anti-itch medicated Generic OTC
ayr saline nasal aerosol,spray Generic OTC
ayr saline nasal drops Generic OTC
ayr saline nasal neti rinse Generic OTC
AYR SINUS RINSE Brand OTC
AYR SINUS RINSE REFILL Brand OTC
azelastine nasal Generic QL
baby ayr saline Generic OTC
children's saline nasal spray Generic OTC
chlorhexidine gluconate mucous membrane Generic
decongestant inhaler Generic OTC
deep sea nasal Generic OTC
denta 5000 plus Generic
dentagel Generic
dristan long lasting Generic OTC
ephrine Generic OTC
FAST ACTING NASAL Brand OTC
fluoride (sodium) dental cream Generic
fluoride (sodium) dental gel Generic
GOLD BOND MEDICATED ANTI-ITCH Brand OTC
ipratropium bromide nasal Generic QL
LITTLE NOSES Brand OTC
little remedies Generic OTC
mucinex sinus-max Generic OTC
nasadock plus kit Generic OTC
nasaflo porcelain kit Generic OTC
nasal decongestant (oxymetazl) Generic OTC
nasal four Generic OTC
nasal mist Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
55
Drug Name Drug Tier Requirements / Limits
nasal moisturizing Generic OTC
nasal relief Generic OTC
nasal relief sinus wash w/neti Generic OTC
nasal relief sinus wash-bottle Generic OTC
nasal spray (oxymetazoline) Generic OTC
nasal spray (sodium chloride) Generic OTC
nasal spray 12hr(oxymetazoline nasal mist Generic OTC
nasal spray long acting Generic OTC
neilmed nasaflo Generic OTC
neilmed pediat sinus rinse ref Generic OTC
neilmed sinus rinse complete Generic OTC
neilmed sinus rinse refill Generic OTC
NEO-SYNEPHRINE (PHENYLEPHRINE) NASAL
Brand OTC
no drip Generic OTC
nose drops Generic OTC
ocean nasal Generic OTC
olopatadine nasal Generic QL
oralone Generic
original nasal spray Generic OTC
oxymetazoline Generic OTC
periogard Generic
saline mist Generic OTC
saline nasal Generic OTC
sf Generic
sf 5000 plus Generic
sinugator nasal wash kit Generic OTC
sinus nasal spray Generic OTC
sinus relief (oxymetazoline) Generic OTC
sinus rinse pediatric Generic OTC
sinus rinse pediatric starter Generic OTC
sinus wash sinus irrigation packet Generic OTC
sterile saline nasal Generic OTC
triamcinolone acetonide dental Generic
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 56
Drug Name Drug Tier Requirements / Limits
vicks qlearquil(oxymetazoline) Generic OTC
vicks sinex 12-hour Generic OTC
vicks sinex ultra fine mist 12 Generic OTC
wal-four Generic OTC
MISCELLANEOUS OTIC PREPARATIONS
acetic acid otic (ear) Generic
ciprofloxacin hcl otic (ear) Generic
fluocinolone acetonide oil Generic
ofloxacin otic (ear) Generic
OTIC STEROID / ANTIBIOTIC
neomycin-polymyxin-hc otic (ear) Generic
ENDOCRINE/DIABETES
ADRENAL HORMONES
cortisone Generic
dexamethasone intensol Generic
dexamethasone oral elixir Generic
dexamethasone oral solution Generic
dexamethasone oral tablet Generic
EMFLAZA Brand PA
fludrocortisone Generic
hydrocortisone oral Generic
methylprednisolone Generic
millipred dp Generic
millipred oral tablet Generic
prednisolone oral solution 15 mg/5 ml Generic
prednisolone sodium phosphate oral solution 10 mg/5 ml, 15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)
Generic
prednisolone sodium phosphate oral tablet,disintegrating
Generic
prednisone Generic
prednisone intensol Generic
veripred 20 Generic
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
57
Drug Name Drug Tier Requirements / Limits
ANTITHYROID AGENTS
methimazole oral tablet 10 mg, 5 mg Generic
propylthiouracil Generic
DIABETES THERAPY
acarbose Generic
ACD-A Brand
ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 24 HR 15-1,000 MG
Brand ST; QL
ADMELOG SOLOSTAR U-100 INSULIN Brand
ADMELOG U-100 INSULIN LISPRO Brand
BASAGLAR KWIKPEN U-100 INSULIN Brand
BYDUREON BCISE Brand PA; QL
BYDUREON SUBCUTANEOUS PEN INJECTOR
Brand PA; QL
glimepiride Generic
glipizide Generic
glipizide-metformin Generic
GLUCAGEN HYPOKIT Brand
GLUCAGON (HCL) EMERGENCY KIT Brand
GLUCAGON EMERGENCY KIT (HUMAN) Brand
glyburide Generic
glyburide micronized Generic
glyburide-metformin Generic
GLYXAMBI Brand ST; QL
HUMALOG MIX 50-50 INSULN U-100 Brand
HUMALOG MIX 50-50 KWIKPEN Brand
HUMALOG MIX 75-25 KWIKPEN Brand
HUMALOG MIX 75-25(U-100)INSULN Brand
HUMULIN 70/30 U-100 INSULIN Brand
HUMULIN 70/30 U-100 KWIKPEN Brand
HUMULIN N NPH INSULIN KWIKPEN Brand
HUMULIN N NPH U-100 INSULIN Brand
HUMULIN R REGULAR U-100 INSULN Brand
HUMULIN R U-500 (CONC) INSULIN Brand
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 58
Drug Name Drug Tier Requirements / Limits
HUMULIN R U-500 (CONC) KWIKPEN Brand
JANUMET Brand ST; QL
JANUMET XR Brand ST; QL
JANUVIA Brand ST; QL
JARDIANCE Brand ST; QL
metformin oral tablet Generic
metformin oral tablet extended release 24 hr Generic QL
miglitol Generic
nateglinide Generic
pioglitazone Generic QL
pioglitazone-glimepiride Generic QL
pioglitazone-metformin Generic QL
PROGLYCEM Brand
repaglinide Generic
repaglinide-metformin Generic QL
SEGLUROMET Brand ST; QL
STEGLATRO Brand ST; QL
SYMLINPEN 120 Brand PA; QL
SYMLINPEN 60 Brand PA; QL
SYNJARDY Brand ST; QL
SYNJARDY XR Brand ST; QL
MISCELLANEOUS HORMONES
cabergoline Generic QL
calcitonin (salmon) Generic
calcitriol oral Generic
CERDELGA Brand
cinacalcet Generic PA
clomiphene citrate Generic PA
danazol Generic
desmopressin nasal spray,non-aerosol Generic
desmopressin oral Generic
doxercalciferol oral Generic
GALAFOLD Brand PA; QL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
59
Drug Name Drug Tier Requirements / Limits
JYNARQUE ORAL TABLET Brand PA; QL
JYNARQUE ORAL TABLETS, SEQUENTIAL Brand PA
KUVAN Brand PA
METHITEST Brand PA
methyltestosterone oral capsule Generic PA
miglustat Generic
NATPARA Brand PA
ORILISSA Brand PA; QL
oxandrolone Generic PA
SAMSCA Brand PA; QL
serophene Generic PA
SOMAVERT Brand
STIMATE Brand
STRENSIQ Brand PA
testosterone cypionate intramuscular oil 100 mg/ml, 200 mg/ml
Generic PA
testosterone enanthate Generic PA
testosterone transdermal gel in metered-dose pump 10 mg/0.5 gram /actuation, 20.25 mg/1.25 gram (1.62 %)
Generic PA
testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1 %)
Generic PA; QL
testosterone transdermal gel in packet 1 % (25 mg/2.5gram), 1 % (50 mg/5 gram)
Generic PA; QL
testosterone transdermal gel in packet 1.62 % (20.25 mg/1.25 gram), 1.62 % (40.5 mg/2.5 gram)
Generic PA
THYROID HORMONES
ARMOUR THYROID Brand
levothyroxine oral Generic
levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg
Generic
liothyronine oral Generic
nature-throid Generic
np thyroid Generic
thyroid (pork) Generic
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 60
Drug Name Drug Tier Requirements / Limits
THYROLAR-1 Brand
THYROLAR-1/2 Brand
THYROLAR-1/4 Brand
THYROLAR-2 Brand
THYROLAR-3 Brand
unithroid Generic
westhroid oral tablet 130 mg, 195 mg, 32.5 mg, 65 mg, 97.5 mg
Generic
GASTROENTEROLOGY
ANTIDIARRHEALS / ANTISPASMODICS
acidophilus-pectin oral capsule 75 million cell -100 mg
Generic OTC
ACIDOPHILUS-PECTIN, CITRUS ORAL TABLET
Brand OTC
anaspaz Generic
anti-diarrheal Generic OTC
anti-diarrheal (loperamide) Generic OTC
BACID Brand OTC
belladonna alkaloids-opium Generic PA
bismatrol Generic OTC
bismuth oral tablet,chewable Generic OTC
diamode Generic OTC
diarrhea relief (bismuth subs) Generic OTC
dicyclomine oral capsule Generic
dicyclomine oral solution Generic
dicyclomine oral tablet Generic
DIGESTIVE PROBIOTIC ORAL CAPSULE 10 BILLION CELL
Brand OTC
digestive relief oral tablet Generic OTC
diotame Generic OTC
diphenoxylate-atropine Generic
ed-spaz Generic
florastor Generic OTC
geri-pectate Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
61
Drug Name Drug Tier Requirements / Limits
glycopyrrolate oral tablet 1 mg, 2 mg Generic
hyoscyamine sulfate oral Generic
hyoscyamine sulfate sublingual Generic
hyosyne Generic
IMODIUM A-D ORAL LIQUID Brand OTC
IMODIUM A-D ORAL TABLET Brand OTC
IMODIUM MULTI-SYMPTOM RELIEF ORAL TABLET
Brand OTC
kaolin-pectin Generic OTC
kaopectate (bismuth subsalicy) oral suspension Generic OTC
kaopectate ex str (bismuth ss) Generic OTC
k-pec antidiarrheal (bism sub) Generic OTC
l.acidophilus-bifido.longum oral capsule,delayed release(dr/ec) 16 mg
Generic OTC
loperamide oral capsule Generic
loperamide oral tablet Generic OTC
ONE-A-DAY TRUBIOTICS ORAL CAPSULE Brand OTC
oscimin Generic
oscimin sl Generic
oscimin sr Generic
paregoric Generic
peptic relief oral tablet,chewable Generic OTC
PEPTO-BISMOL MAX ST Brand OTC
PEPTO-BISMOL ORAL SUSPENSION Brand OTC
PEPTO-BISMOL ORAL TABLET Brand OTC
pepto-bismol to-go Generic OTC
phenohytro oral tablet Generic
PHILLIPS' COLON HEALTH Brand OTC
pink bismuth oral suspension 262 mg/15 ml Generic OTC
pink bismuth oral tablet Generic OTC
pink bismuth oral tablet,chewable Generic OTC
probiotic colon care Generic OTC
probiotic oral capsule 20 billion cell, 3 billion cell Generic OTC
probiotic oral capsule, sprinkle 20 billion cell Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 62
Drug Name Drug Tier Requirements / Limits
RISA-BID Brand OTC
risaquad Generic OTC
risaquad-2 Generic OTC
senior probiotic Generic OTC
soothe (bismuth subsalicylate) Generic OTC
soothe regular strength Generic OTC
stomach relief max strength Generic OTC
stomach relief oral suspension 262 mg/15 ml Generic OTC
stomach relief oral tablet Generic OTC
stomach relief oral tablet,chewable Generic OTC
super probiotic Generic OTC
symax fastabs Generic
symax-sl Generic
symax-sr Generic
MISCELLANEOUS GASTROINTESTINAL AGENTS
acid gone antacid Generic OTC
acid gone antacid e.strength Generic OTC
advanced antacid-antigas Generic OTC
almacone oral suspension Generic OTC
almacone-2 Generic OTC
alophen (bisacodyl) Generic OTC
alosetron Generic
aluminum hydroxide gel Generic OTC
antacid (calcium carb-mag hyd) oral tablet,chewable 550-110 mg
Generic OTC
antacid anti-gas Generic OTC
antacid exst (mag carb-al hyd) Generic OTC
antacid m Generic OTC
antacid maximum strength Generic OTC
antacid plus anti-gas Generic OTC
antacid regular strength Generic OTC
antacid supreme Generic OTC
antacid ultra strength oral tablet,chewable 1,177 mg
Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
63
Drug Name Drug Tier Requirements / Limits
antacid-antigas oral suspension 200-200-20 mg/5 ml
Generic OTC
antacid-simethicone Generic OTC
anti-nausea Generic OTC
anucort-hc Generic
aprepitant Generic QL
BEANO ORAL TABLET Brand OTC
BENEFIBER SUGAR FREE (DEXTRIN) ORAL POWDER
Brand OTC
best fiber Generic OTC
bisacodyl rectal Generic OTC
bisa-lax (bisacodyl) Generic OTC
budesonide oral capsule,delayed,extend.release Generic
calcium polycarbophil Generic OTC
castor oil Generic OTC
castor oil oral oil , 100 % Generic OTC
CHENODAL Brand PA
children's pepto Generic OTC
children's soothe Generic OTC
chocolate laxative Generic OTC
CHOLBAM ORAL CAPSULE 250 MG Brand PA
CHOLBAM ORAL CAPSULE 50 MG Brand PA; QL
citrate of magnesia Generic OTC
citroma Generic OTC
citrucel Generic OTC
CITRUCEL (SUCROSE) Brand OTC
CITRUCEL SUGAR FREE Brand OTC
clearlax oral powder Generic OTC
COLACE ORAL CAPSULE 100 MG Brand OTC
col-rite oral capsule 100 mg, 250 mg Generic OTC
comfort gel Generic OTC
comfort gel extra strength Generic OTC
compro Generic
constulose Generic
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 64
Drug Name Drug Tier Requirements / Limits
CORRECTOL Brand OTC
CORTIFOAM Brand
CREON Brand
cromolyn oral Generic
CYSTADANE Brand
dimenhydrinate oral Generic OTC
diocto Generic OTC
dioctyl Generic OTC
docu Generic OTC
docuprene Generic OTC
docusate sodium oral capsule Generic OTC
docusate sodium oral liquid Generic OTC
docusate sodium oral tablet Generic OTC
docusil Generic OTC
DOCUSOL Brand OTC
dok Generic OTC
dok plus Generic OTC
dramamine less drowsy Generic OTC
dramamine oral tablet Generic OTC
driminate Generic OTC
dss Generic OTC
ducodyl (bisacodyl) Generic OTC
dulcoease Generic OTC
DULCOLAX (BISACODYL) Brand OTC
easy fiber oral powder Generic OTC
EMEND ORAL SUSPENSION FOR RECONSTITUTION
Brand QL
EMETROL Brand OTC
enema disposable Generic OTC
enema rectal enema 19-7 gram/118 ml Generic OTC
ENEMEEZ Brand OTC
ENEMEEZ PLUS Brand OTC
enulose Generic
epsom salt oral Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
65
Drug Name Drug Tier Requirements / Limits
evac-u-gen (sennosides) Generic OTC
EX-LAX (SENNOSIDES) Brand OTC
EX-LAX MAXIMUM STRENGTH Brand OTC
fiber (calcium polycarbophil) Generic OTC
fiber (dextrin) Generic OTC
fiber (psyllium husk) oral capsule 0.52 gram Generic OTC
fiber (psyllium husk/sugar) Generic OTC
fiber (with aspartame) oral powder 3.4 gram/5.8 gram
Generic OTC
fiber laxative (ca polycarbo) Generic OTC
fiber laxative (methylcellulo) Generic OTC
fiber laxative (psyllium husk) Generic OTC
fiber oral powder Generic OTC
fiber smooth Generic OTC
fiber smooth (sucrose) Generic OTC
fiber supplement (inulin) Generic OTC
fiber therapy (ca polycarboph) Generic OTC
fiber therapy (m-cell/sugar) oral powder 2 gram/19 gram
Generic OTC
fiber therapy (m-cellulose) Generic OTC
fiber therapy laxative (husk) Generic OTC
FIBERCON Brand OTC
fiber-tabs Generic OTC
fleet enema Generic OTC
fleet glycerin (adult) Generic OTC
FLEET GLYCERIN (CHILD) Brand OTC
fleet laxative (bisacodyl) Generic OTC
FLEET MINERAL OIL Brand OTC
FLEET PEDIATRIC Brand OTC
foaming antacid Generic OTC
formula em Generic OTC
gavilax oral powder Generic OTC
gavilyte-c Generic
gavilyte-g Generic
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 66
Drug Name Drug Tier Requirements / Limits
gavilyte-n Generic
GAVISCON Brand OTC
GAVISCON EXTRA STRENGTH Brand OTC
GELUSIL ANTACID AND ANTI-GAS ORAL TABLET,CHEWABLE
Brand OTC
generlac Generic
gentle laxative (bisacodyl) Generic OTC
gentlelax Generic OTC
geri-kot Generic OTC
geri-lanta Generic OTC
geri-mox antacid-antigas Generic OTC
GERI-MUCIL (ASPARTAME) Brand OTC
glycerin (adult) Generic OTC
glycerin (child) Generic OTC
glycolax oral powder Generic OTC
granisetron hcl oral Generic QL
healthylax Generic OTC
heartburn antacid Generic OTC
heartburn relief oral tablet,chewable Generic OTC
hemmorex-hc rectal suppository 25 mg Generic
HYDROCIL Brand OTC
HYDROCIL INSTANT Brand OTC
hydrocortisone acetate rectal Generic
hydrocortisone rectal Generic
hydrocortisone topical cream with perineal applicator
Generic
hydrocortisone-pramoxine rectal Generic
ipecac Generic OTC
KAOPECTATE (DOCUSATE CALCIUM) Brand OTC
kao-tin (docusate calcium) Generic OTC
konsyl (sugar) oral powder 3.4 gram/12 gram Generic OTC
konsyl (sugar) oral powder in packet Generic OTC
konsyl fiber Generic OTC
konsyl sugar-free oral powder in packet Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
67
Drug Name Drug Tier Requirements / Limits
lactulose oral solution 10 gram/15 ml Generic
laxacin Generic OTC
laxaclear Generic OTC
laxative (bisacodyl) Generic OTC
laxative (glycerin-pediatric) Generic OTC
laxative (sennosides) oral tablet 15 mg Generic OTC
laxative (sennosides) oral tablet,chewable Generic OTC
laxative peg 3350 oral powder Generic OTC
laxative pills Generic OTC
laxative pills regular Generic OTC
laxative plus stool softener Generic OTC
lidocaine hcl-hydrocortison ac rectal cream 3-0.5 %
Generic
lidocaine hcl-hydrocortison ac rectal kit Generic
lidocaine-hydrocortisone-aloe rectal gel Generic
lidocaine-hydrocortisone-aloe rectal kit 3-2.5 % (7 gram)
Generic
liquid antacid oral suspension 200-200-20 mg/5 ml
Generic OTC
MAALOX ADVANCED Brand OTC
maalox maximum strength Generic OTC
MAG-AL Brand OTC
magnesium citrate oral solution Generic OTC
magnesium oral tablet 250 mg Generic OTC
masanti double strength Generic OTC
meclizine oral tablet 12.5 mg, 25 mg Generic
meclizine oral tablet,chewable Generic OTC
medi-meclizine Generic OTC
mesalamine rectal enema Generic
mesalamine rectal suppository Generic QL
METAMUCIL (WITH SUGAR) ORAL POWDER 3.4 GRAM/12 GRAM, 3.4 GRAM/7 GRAM
Brand OTC
METAMUCIL (WITH SUGAR) ORAL POWDER IN PACKET
Brand OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 68
Drug Name Drug Tier Requirements / Limits
METAMUCIL FIBER THIN Brand OTC
METAMUCIL FREE Brand OTC
METAMUCIL MULTIHEALTH FIBER Brand OTC
METAMUCIL ORAL CAPSULE Brand OTC
METAMUCIL SUGAR-FREE (ASPART) ORAL POWDER 3.4 GRAM/5.8 GRAM
Brand OTC
METAMUCIL SUNRISE Brand OTC
metoclopramide hcl oral Generic
mi-acid Generic OTC
milk of magnesia Generic OTC
milk of magnesia concentrated Generic OTC
mineral oil extra heavy Generic OTC
MINERAL OIL HEAVY ORAL Brand OTC
mintox Generic OTC
mintox maximum strength Generic OTC
mintox plus Generic OTC
MIRALAX ORAL POWDER Brand OTC
miralax oral powder in packet Generic OTC
motion relief (meclizine) Generic OTC
motion sickness Generic OTC
motion sickness (meclizine) Generic OTC
motion sickness ii Generic OTC
motion sickness relief Generic OTC
motion sickness relief(mecliz) Generic OTC
motion-time Generic OTC
MOVANTIK Brand
move it along Generic OTC
natural fiber laxative Generic OTC
NATURAL FIBER LAXATIVE (SUGAR) ORAL POWDER 3.4 GRAM/12 GRAM
Brand OTC
natural fiber laxative (sugar) oral powder 3.4 gram/7 gram
Generic OTC
natural fiber laxative therapy Generic OTC
natural fiber laxative(aspart) oral powder Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
69
Drug Name Drug Tier Requirements / Limits
natural fiber supplemnt(asprt) oral powder in packet
Generic OTC
NATURAL PSYLLIUM FIBER Brand OTC
natural veg laxative(sennosid) Generic OTC
natural vegetable Generic OTC
natural vegetable (psyllium) Generic OTC
natural vegetable powder Generic OTC
natura-lax Generic OTC
nausea control Generic OTC
nausea relief Generic OTC
OCALIVA Brand PA; QL
ondansetron Generic QL
ondansetron hcl oral Generic QL
oral saline laxative oral liquid Generic OTC
p-col rite Generic OTC
PEDIA-LAX ORAL Brand OTC
PEDIA-LAX STOOL SOFTENER Brand OTC
pediatric enema Generic OTC
peg 3350-electrolytes oral recon soln 236-22.74-6.74 -5.86 gram
Generic
peg-electrolyte soln Generic
peg-prep Generic
perdiem overnight relief Generic OTC
PHILLIPS' LIQUI-GELS Brand OTC
PHILLIPS MILK OF MAGNESIA ORAL SUSPENSION 400 MG/5 ML
Brand OTC
phosphate laxative oral liquid Generic OTC
polyethylene glycol 3350 oral powder Generic OTC
polyethylene glycol 3350 oral powder in packet Generic
powderlax oral powder Generic OTC
prochlorperazine Generic
prochlorperazine maleate Generic
procto-med hc Generic
procto-pak Generic
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 70
Drug Name Drug Tier Requirements / Limits
proctosol hc topical Generic
proctozone-hc Generic
promolaxin Generic OTC
psyllium husk oral capsule 0.52 gram Generic OTC
purelax Generic OTC
RECTIV Brand
reguloid (psyllium husk-sucro) oral powder 3.4 gram/12 gram, 3.4 gram/7 gram
Generic OTC
reguloid, sugar free Generic OTC
ri-gel Generic OTC
ri-gel ii Generic OTC
riginic Generic OTC
ri-mag Generic OTC
ri-mag plus Generic OTC
ri-mox Generic OTC
ri-mox plus Generic OTC
ROLAIDS Brand OTC
senexon-s Generic OTC
senna lax Generic OTC
senna laxative oral tablet 8.6 mg Generic OTC
senna oral tablet Generic OTC
senna plus oral tablet Generic OTC
senna with docusate sodium Generic OTC
senna-s Generic OTC
senna-time s Generic OTC
senno Generic OTC
sennosides-docusate sodium Generic OTC
SENOKOT Brand OTC
SENOKOT EXTRA STRENGTH Brand OTC
SENOKOT-S Brand OTC
sen-o-tab Generic OTC
silace Generic OTC
smoothlax Generic OTC
sodium bicarbonate oral Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
71
Drug Name Drug Tier Requirements / Limits
sof-lax Generic OTC
stimulant laxative plus Generic OTC
stool softener (docusate cal) Generic OTC
stool softener oral capsule 250 mg Generic OTC
STOOL SOFTENER ORAL CAPSULE 50 MG Brand OTC
stool softener oral liquid Generic OTC
stool softener oral syrup Generic OTC
stool softener oral tablet Generic OTC
stool softener-laxative Generic OTC
stool softener-stimulant laxat oral tablet Generic OTC
SUCRAID Brand PA
sulfasalazine Generic
surfak Generic OTC
the magic bullet Generic OTC
travel sickness Generic OTC
travel sickness (meclizine) Generic OTC
trilyte with flavor packets Generic
trimethobenzamide oral Generic
TRULANCE Brand
tums ultra oral tablet,chewable 1,177 mg Generic OTC
UNIFIBER Brand OTC
ursodiol Generic
VARUBI ORAL Brand QL
vegetable laxative Generic OTC
VIBERZI Brand
VIOKACE Brand
wal-dram Generic OTC
wal-mucil fiber Generic OTC
wal-mucil fiber (aspartame) Generic OTC
wal-mucil fiber (sugar) Generic OTC
wal-mucil natural fiber lax Generic OTC
woman's laxative (bisacodyl) oral tablet Generic OTC
women's gentle laxative(bisac) Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 72
Drug Name Drug Tier Requirements / Limits
women's laxative (bisacodyl) Generic OTC
ULCER THERAPY
acid control (ranitidine) oral tablet 150 mg Generic OTC
acid controller Generic OTC
acid reducer (cimetidine) Generic OTC
acid reducer (famotidine) Generic OTC
acid reducer (ranitidine) Generic OTC
amoxicil-clarithromy-lansopraz Generic QL
cimetidine hcl oral Generic
cimetidine oral tablet 200 mg Generic OTC
cimetidine oral tablet 300 mg, 400 mg, 800 mg Generic
esomeprazole magnesium oral capsule,delayed release(dr/ec) 20 mg
Generic QL
esomeprazole magnesium oral capsule,delayed release(dr/ec) 40 mg
Generic
famotidine oral suspension Generic
famotidine oral tablet 10 mg Generic OTC
famotidine oral tablet 20 mg, 40 mg Generic
heartburn prevention Generic OTC
heartburn relief (cimetidine) Generic OTC
heartburn relief (famotidine) Generic OTC
heartburn relief (ranitidine) Generic OTC
lansoprazole oral capsule,delayed release(dr/ec) 15 mg
Generic QL
lansoprazole oral capsule,delayed release(dr/ec) 30 mg
Generic
misoprostol Generic
NEXIUM 24HR Brand ST; OTC
nizatidine Generic
omeprazole magnesium Generic OTC
omeprazole oral capsule,delayed release(dr/ec) 10 mg
Generic QL
omeprazole oral capsule,delayed release(dr/ec) 20 mg, 40 mg
Generic
omeprazole oral tablet,delayed release (dr/ec) Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
73
Drug Name Drug Tier Requirements / Limits
pantoprazole oral tablet,delayed release (dr/ec) 20 mg
Generic QL
pantoprazole oral tablet,delayed release (dr/ec) 40 mg
Generic
PEPCID AC ORAL TABLET 10 MG Brand OTC
pepcid ac oral tablet 20 mg Generic OTC
PREVACID 24HR Brand ST; OTC
PRILOSEC OTC Brand ST; OTC
rabeprazole oral tablet,delayed release (dr/ec) Generic
ranitidine hcl oral capsule Generic
ranitidine hcl oral syrup Generic
ranitidine hcl oral tablet 150 mg, 300 mg Generic
ranitidine hcl oral tablet 75 mg Generic OTC
sucralfate oral tablet Generic
tagamet hb Generic OTC
wal-zan 150 Generic OTC
wal-zan 75 Generic OTC
ZANTAC 75 Brand OTC
zantac maximum strength Generic OTC
ZANTAC ORAL TABLET 150 MG Brand OTC
ZEGERID OTC Brand ST; OTC
IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
ACTIMMUNE Brand PA
ARCALYST Brand PA
AVONEX INTRAMUSCULAR PEN INJECTOR KIT
Brand PA; QL
AVONEX INTRAMUSCULAR SYRINGE KIT Brand PA; QL
EGRIFTA SUBCUTANEOUS RECON SOLN 1 MG
Brand PA
EGRIFTA SV Brand PA
EXTAVIA Brand ST; QL
INTRON A INJECTION Brand PA
NORDITROPIN FLEXPRO Brand PA
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 74
Drug Name Drug Tier Requirements / Limits
OMNITROPE Brand PA
PEGASYS Brand PA; QL
PLEGRIDY Brand PA; QL
REBIF (WITH ALBUMIN) Brand PA; QL
REBIF REBIDOSE Brand PA; QL
REBIF TITRATION PACK Brand PA; QL
SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG
Brand PA
VACCINES / MISCELLANEOUS IMMUNOLOGICALS
AFLURIA QD 2019-20(3YR UP)(PF) Brand
AFLURIA QD 2019-20(6-35MO)(PF) Brand
AFLURIA QUAD 2019-20(6MO UP) Brand
BEXSERO Brand
FLUAD 2019-2020 (65 YR UP)(PF) Brand
FLUARIX QUAD 2019-2020 (PF) Brand
FLUBLOK QUAD 2019-2020 (PF) Brand
FLUCELVAX QUAD 2019-2020 Brand
FLUCELVAX QUAD 2019-2020 (PF) Brand
FLULAVAL QUAD 2019-2020 Brand
FLULAVAL QUAD 2019-2020 (PF) Brand
FLUMIST QUAD 2019-2020 Brand
FLUZONE HIGH-DOSE 2019-20 (PF) Brand
FLUZONE QUAD 2019-2020 Brand
FLUZONE QUAD 2019-2020 (PF) Brand
FLUZONE QUAD PEDI 2019-20 (PF) Brand
MENACTRA (PF) INTRAMUSCULAR SOLUTION
Brand
PNEUMOVAX-23 Brand
PREVNAR 13 (PF) Brand
SHINGRIX (PF) Brand
TRUMENBA Brand
ZOSTAVAX (PF) Brand
MUSCULOSKELETAL / RHEUMATOLOGY
GOUT THERAPY
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
75
Drug Name Drug Tier Requirements / Limits
allopurinol Generic
COLCHICINE ORAL CAPSULE Brand
febuxostat Generic ST
probenecid Generic
probenecid-colchicine Generic
OSTEOPOROSIS THERAPY
alendronate oral solution Generic QL
alendronate oral tablet 10 mg, 35 mg, 5 mg, 70 mg Generic QL
ibandronate oral Generic QL
raloxifene Generic
risedronate oral tablet 150 mg, 35 mg, 5 mg Generic QL
risedronate oral tablet,delayed release (dr/ec) Generic QL
TYMLOS Brand PA; QL
OTHER RHEUMATOLOGICALS
BENLYSTA SUBCUTANEOUS Brand PA
DEPEN TITRATABS Brand PA
ENBREL Brand PA; QL
ENBREL MINI Brand PA; QL
ENBREL SURECLICK Brand PA; QL
HUMIRA Brand PA; QL
HUMIRA PEN Brand PA; QL
HUMIRA(CF) Brand PA; QL
HUMIRA(CF) PEDI CROHNS STARTER Brand PA; QL
HUMIRA(CF) PEN CROHNS-UC-HS Brand PA; QL
HUMIRA(CF) PEN PSOR-UV-ADOL HS Brand PA; QL
HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.4 ML
Brand PA; QL
leflunomide Generic QL
OTEZLA Brand PA
OTEZLA STARTER Brand PA
penicillamine oral tablet Generic PA
RIDAURA Brand
SAVELLA Brand ST
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 76
Drug Name Drug Tier Requirements / Limits
OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
amabelz Generic
camila Generic
covaryx Generic
covaryx h.s. Generic
CRINONE VAGINAL GEL 4 % Brand
deblitane Generic
errin Generic
estradiol oral Generic
estradiol transdermal Generic QL
estradiol vaginal Generic
estradiol-norethindrone acet Generic
estrogens-methyltestosterone Generic
fyavolv Generic
heather Generic
jencycla Generic
jinteli Generic
lopreeza oral tablet 1-0.5 mg Generic
lyza Generic
medroxyprogesterone intramuscular Generic QL
medroxyprogesterone oral Generic
MENEST Brand
mimvey Generic
nora-be Generic
norethindrone (contraceptive) Generic
norethindrone acetate Generic
norethindrone ac-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg
Generic
norlyda Generic
progesterone micronized Generic
sharobel Generic
yuvafem Generic
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
77
Drug Name Drug Tier Requirements / Limits
MISCELLANEOUS OB/GYN
1-DAY Brand OTC
3 day vaginal Generic OTC
3-day vaginal Generic OTC
clindamycin phosphate vaginal Generic
clotrimazole-3 Generic OTC
eluryng Generic QL
etonogestrel-ethinyl estradiol Generic QL
fem ph Generic
GYNE-LOTRIMIN Brand OTC
GYNE-LOTRIMIN 7 Brand OTC
gynol ii Generic OTC
isoxsuprine Generic
metronidazole vaginal Generic
miconazole 7 Generic OTC; QL
miconazole nitrate vaginal comb pack,prefill appl, cream
Generic OTC; QL
miconazole-3 vaginal kit Generic OTC; QL
miconazole-3 vaginal suppository Generic QL
MONISTAT 1 COMBO PACK Brand OTC; QL
MONISTAT 3 VAGINAL CREAM Brand OTC
MONISTAT 3 VAGINAL KIT Brand OTC; QL
MONISTAT 7 VAGINAL CREAM Brand OTC; QL
terconazole Generic QL
tioconazole-1 Generic OTC
tranexamic acid oral Generic
TRIMO-SAN JELLY Brand
vaginal contraceptive foam Generic OTC
vandazole Generic
xulane Generic
ORAL CONTRACEPTIVES / RELATED AGENTS
altavera (28) Generic
alyacen 1/35 (28) Generic
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 78
Drug Name Drug Tier Requirements / Limits
alyacen 7/7/7 (28) Generic
amethia Generic
amethia lo Generic
amethyst (28) Generic
apri Generic
aranelle (28) Generic
ashlyna Generic
aubra Generic
aviane Generic
azurette (28) Generic
balziva (28) Generic
bekyree (28) Generic
blisovi 24 fe Generic
blisovi fe 1.5/30 (28) Generic
blisovi fe 1/20 (28) Generic
briellyn Generic
camrese Generic
camrese lo Generic
caziant (28) Generic
chateal (28) Generic
cryselle (28) Generic
cyclafem 1/35 (28) Generic
cyclafem 7/7/7 (28) Generic
cyred Generic
dasetta 1/35 (28) Generic
dasetta 7/7/7 (28) Generic
daysee Generic
desog-e.estradiol/e.estradiol Generic
desogestrel-ethinyl estradiol Generic
drospirenone-ethinyl estradiol Generic
econtra ez Generic OTC
elinest Generic
ELLA Brand
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
79
Drug Name Drug Tier Requirements / Limits
emoquette Generic
enpresse Generic
enskyce Generic
estarylla Generic
ethynodiol diac-eth estradiol Generic
falmina (28) Generic
fayosim Generic
femynor Generic
gianvi (28) Generic
introvale Generic
jolessa Generic
juleber Generic
junel 1.5/30 (21) Generic
junel 1/20 (21) Generic
junel fe 1.5/30 (28) Generic
junel fe 1/20 (28) Generic
junel fe 24 Generic
kaitlib fe Generic
kariva (28) Generic
kelnor 1/35 (28) Generic
kurvelo (28) Generic
l norgest/e.estradiol-e.estrad Generic
larin 1.5/30 (21) Generic
larin 1/20 (21) Generic
larin 24 fe Generic
larin fe 1.5/30 (28) Generic
larin fe 1/20 (28) Generic
larissia Generic
leena 28 Generic
lessina Generic
levonest (28) Generic
levonorgestrel oral tablet 1.5 mg Generic OTC
levonorgestrel-ethinyl estrad Generic
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 80
Drug Name Drug Tier Requirements / Limits
levonorg-eth estrad triphasic Generic
levora-28 Generic
loryna (28) Generic
low-ogestrel (28) Generic
lutera (28) Generic
marlissa (28) Generic
microgestin 1.5/30 (21) Generic
microgestin 1/20 (21) Generic
microgestin fe 1.5/30 (28) Generic
microgestin fe 1/20 (28) Generic
mono-linyah Generic
my way Generic OTC
necon 0.5/35 (28) Generic
nikki (28) Generic
norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg, 1.5-30 mg-mcg
Generic
norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg (21)/75 mg (7), 1.5 mg-30 mcg (21)/75 mg (7)
Generic
norgestimate-ethinyl estradiol Generic
nortrel 0.5/35 (28) Generic
nortrel 1/35 (21) Generic
nortrel 1/35 (28) Generic
nortrel 7/7/7 (28) Generic
ocella Generic
ogestrel (28) Generic
opcicon one-step Generic OTC
option-2 Generic OTC
orsythia Generic
philith Generic
pimtrea (28) Generic
pirmella Generic
PLAN B ONE-STEP Brand OTC
portia 28 Generic
previfem Generic
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
81
Drug Name Drug Tier Requirements / Limits
reclipsen (28) Generic
rivelsa Generic
setlakin Generic
sprintec (28) Generic
sronyx Generic
syeda Generic
tarina 24 fe Generic
tarina fe 1/20 (28) Generic
tilia fe Generic
tri femynor Generic
tri-estarylla Generic
tri-legest fe Generic
tri-linyah Generic
tri-lo-estarylla Generic
tri-lo-marzia Generic
tri-lo-sprintec Generic
tri-previfem (28) Generic
tri-sprintec (28) Generic
trivora (28) Generic
velivet triphasic regimen (28) Generic
vienva Generic
viorele (28) Generic
vyfemla (28) Generic
wera (28) Generic
wymzya fe Generic
zarah Generic
zovia 1/35e (28) Generic
OXYTOCICS
methergine Generic
methylergonovine oral Generic
OPHTHALMOLOGY
ANTIBIOTICS
ak-poly-bac Generic
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 82
Drug Name Drug Tier Requirements / Limits
bacitracin ophthalmic (eye) Generic
bacitracin-polymyxin b ophthalmic (eye) Generic
ciprofloxacin hcl ophthalmic (eye) Generic
erythromycin ophthalmic (eye) Generic
gentak ophthalmic (eye) ointment Generic
gentamicin ophthalmic (eye) Generic
levofloxacin ophthalmic (eye) Generic
NATACYN Brand
neomycin-bacitracin-polymyxin Generic
neomycin-polymyxin-gramicidin Generic
neo-polycin Generic
ofloxacin ophthalmic (eye) Generic
polycin Generic
polymyxin b sulf-trimethoprim Generic
tobramycin Generic
ANTIVIRALS
trifluridine Generic
BETA-BLOCKERS
betaxolol ophthalmic (eye) Generic
carteolol Generic
levobunolol ophthalmic (eye) drops 0.5 % Generic
metipranolol Generic
timolol maleate ophthalmic (eye) drops Generic
timolol maleate ophthalmic (eye) gel forming solution
Generic
CHOLINESTERASE INHIBITOR MIOTICS
PHOSPHOLINE IODIDE Brand
CYCLOPLEGIC MYDRIATICS
atropine ophthalmic (eye) drops Generic
atropine ophthalmic (eye) ointment Generic
cyclopentolate Generic
homatropaire Generic
tropicamide Generic
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
83
Drug Name Drug Tier Requirements / Limits
DIRECT ACTING MIOTICS
pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 %
Generic
MISCELLANEOUS OPHTHALMOLOGICS
advanced eye relief Generic OTC
altacaine Generic
artificial tears (petro/min) Generic OTC
artificial tears (pf) ophthalmic (eye) dropperette Generic OTC
artificial tears (polyvin alc) Generic OTC
artificial tears(dext70-hypro) Generic OTC
artificial tears(glycerin-peg) Generic OTC
artificial tears(pg-hypm-glyc) Generic OTC
artificial tears(pvalch-povid) Generic OTC
azelastine ophthalmic (eye) Generic
bion tears (pf) Generic OTC
bss Generic
cromolyn ophthalmic (eye) Generic
CYSTARAN Brand
dry eye relief Generic OTC
epinastine Generic
eye drop tears Generic OTC
fluorescein-proparacaine Generic
for sty relief Generic OTC
gonak Generic OTC
goniotaire Generic OTC
goniovisc Generic OTC
ISOPTO TEARS Brand OTC
lubricant (p-glycol-glycerin) Generic OTC
lubricant eye drops ophthalmic (eye) dropperette Generic OTC
LUBRICANT EYE DROPS OPHTHALMIC (EYE) DROPS 0.25 %
Brand OTC
LUBRICANT EYE OPHTHALMIC (EYE) OINTMENT 57.7-31.9 %
Brand OTC
lubricating plus Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 84
Drug Name Drug Tier Requirements / Limits
lubrifresh pm Generic OTC
moisture drops Generic OTC
natural tears (pf) Generic OTC
olopatadine ophthalmic (eye) Generic
OXERVATE Brand PA; QL
polyvinyl alcohol Generic OTC
proparacaine Generic
pure and gentle eye Generic OTC
REFRESH CELLUVISC Brand OTC
REFRESH CONTACTS Brand OTC
REFRESH LACRI-LUBE Brand OTC
REFRESH LIQUIGEL Brand OTC
REFRESH P.M. Brand OTC
REFRESH PLUS Brand OTC
REFRESH TEARS Brand OTC
RETAINE PM Brand OTC
revive plus Generic OTC
SOOTHE NIGHT TIME LUBRICANT Brand OTC
SYSTANE (PROPYLENE GLYCOL) Brand OTC
SYSTANE NIGHTTIME Brand OTC
SYSTANE ULTRA Brand OTC
tetracaine hcl Generic
THERATEARS Brand OTC
ultra fresh Generic OTC
ULTRA FRESH PM Brand OTC
ULTRA LUBRICANT EYE Brand OTC
VISINE TEARS Brand OTC
VISINE TIRED EYE RELIEF Brand OTC
XIIDRA Brand QL
NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
diclofenac sodium ophthalmic (eye) Generic
flurbiprofen sodium Generic
ketorolac ophthalmic (eye) Generic
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
85
Drug Name Drug Tier Requirements / Limits
ORAL DRUGS FOR GLAUCOMA
acetazolamide Generic
OTHER GLAUCOMA DRUGS
bimatoprost ophthalmic (eye) Generic
dorzolamide Generic
dorzolamide-timolol Generic
latanoprost Generic
STEROID-ANTIBIOTIC COMBINATIONS
neomycin-bacitracin-poly-hc Generic
neomycin-polymyxin b-dexameth Generic
neomycin-polymyxin-hc ophthalmic (eye) Generic
neo-polycin hc Generic
tobramycin-dexamethasone Generic
STEROIDS
dexamethasone sodium phosphate ophthalmic (eye)
Generic
fluorometholone Generic
PRED MILD Brand
prednisolone acetate Generic
prednisolone sodium phosphate ophthalmic (eye) Generic
STEROID-SULFONAMIDE COMBINATIONS
sulfacetamide-prednisolone Generic
SULFONAMIDES
sulfacetamide sodium ophthalmic (eye) Generic
SYMPATHOMIMETICS
ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 %
Brand
apraclonidine Generic
brimonidine Generic
VASOCONSTRICTOR DECONGESTANTS
phenylephrine hcl ophthalmic (eye) Generic
RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 86
Drug Name Drug Tier Requirements / Limits
12 hour decongestant Generic OTC
24hour allergy Generic OTC; QL
abanatuss ped oral liquid Generic OTC
acticon (dexbromph-pse) oral tablet Generic OTC
actidom dmx Generic OTC
adult robitussin peak cold dm Generic OTC
adult robitussin peak cold m-s Generic OTC
adult tussin chest congestion Generic OTC
adult tussin cough congest dm Generic OTC
adult tussin dm Generic OTC
adult tussin multi-symp cold Generic OTC
adult wal-tussin Generic OTC
adult wal-tussin dm max Generic OTC
ADVIL COLD AND SINUS ORAL CAPSULE Brand OTC
advil cold and sinus oral tablet Generic OTC
ala-hist ir Generic OTC
alavert Generic OTC; QL
alavert d-12 allergy-sinus Generic OTC; QL
aler-cap Generic OTC
ALEVE COLD AND SINUS Brand OTC
ALEVE SINUS AND HEADACHE Brand OTC
ALEVE-D SINUS AND COLD Brand OTC
ALEVE-D SINUS AND HEADACHE Brand OTC
alka-seltzer plus allergy Generic OTC
ALKA-SELTZER PLUS COLD/COUGHFM Brand OTC
ALKA-SELTZER PLUS DAY Brand OTC
alka-seltzer plus mucus-conges Generic OTC
ALKA-SELTZER PLUS SINUS-COUGH Brand OTC
all day allergy (cetirizine) oral solution Generic OTC
all day allergy (cetirizine) oral tablet Generic OTC; QL
all day allergy-d Generic OTC; QL
ALLEGRA ALLERGY Brand OTC; QL
ALLEGRA-D 12 HOUR Brand OTC; QL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
87
Drug Name Drug Tier Requirements / Limits
ALLEGRA-D 24 HOUR Brand OTC; QL
aller-chlor oral tablet Generic OTC
allerclear Generic OTC; QL
allerclear d-12hr Generic OTC; QL
allerclear d-24hr Generic OTC; QL
aller-ease oral tablet Generic OTC; QL
aller-fex Generic OTC; QL
aller-g-time Generic OTC
allergy (chlorpheniramine) Generic OTC
allergy (diphenhydramine) oral capsule Generic OTC
allergy (diphenhydramine) oral tablet Generic OTC
allergy 4-hour Generic OTC
allergy and congestion relief Generic OTC; QL
allergy and sinus relief Generic OTC
allergy complete-d Generic OTC; QL
allergy medication Generic OTC
allergy medicine oral tablet Generic OTC
allergy multi-symptom Generic OTC
allergy plus severe sinus ha Generic OTC
allergy relief (cetirizine) oral capsule Generic OTC; QL
allergy relief (cetirizine) oral solution Generic OTC
allergy relief (cetirizine) oral tablet Generic OTC; QL
allergy relief (clemastine) Generic OTC
allergy relief (fexofenadine) Generic OTC; QL
allergy relief (loratadine) oral solution Generic OTC
allergy relief (loratadine) oral tablet Generic OTC; QL
allergy relief (loratadine) oral tablet,disintegrating
Generic OTC; QL
allergy relief d-24hr Generic OTC; QL
allergy relief multi-symptom Generic OTC
allergy relief(chlorpheniramn) oral tablet Generic OTC
allergy relief(diphenhydramin) Generic OTC
allergy relief,nasal decongest Generic OTC; QL
allergy relief-d (cetirizine) Generic OTC; QL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 88
Drug Name Drug Tier Requirements / Limits
allergy relief-d (loratadine) Generic OTC; QL
allergy sinus pe Generic OTC
allergy sinus-d Generic OTC
allergy-congestion relief-d oral tablet extended release 24 hr
Generic OTC; QL
allergy-time Generic OTC
aller-tec Generic OTC; QL
aller-tec d Generic OTC; QL
ALL-NITE COLD-FLU Brand OTC
antitussive dm Generic OTC
ap-hist dm Generic OTC
aprodine Generic OTC
banophen oral capsule Generic OTC
banophen oral tablet Generic OTC
BENADRYL ALLERGY Brand OTC
BENADRYL ORAL Brand OTC
benzonatate Generic
biocotron Generic OTC
biogil Generic OTC
BIONATUSS DXP Brand OTC
bionel Generic OTC
brohist d Generic OTC
brompheniramine-pseudoeph-dm oral syrup Generic
brompheniramin-phenylephrin-dm oral liquid 2-5-10 mg/5 ml
Generic OTC
broncotron ped oral liquid Generic OTC
BRONKIDS Brand OTC
brotapp dm Generic OTC
carbinoxamine maleate oral liquid Generic
carbinoxamine maleate oral tablet 4 mg Generic
cetiri-d Generic OTC; QL
cetirizine oral solution 1 mg/ml Generic
cetirizine oral tablet Generic OTC; QL
cetirizine oral tablet,chewable 5 mg Generic OTC; QL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
89
Drug Name Drug Tier Requirements / Limits
cetirizine-pseudoephedrine Generic OTC; QL
chest congestion relief Generic OTC
chest congestion relief dm Generic OTC
chest congestion relief pe Generic OTC
chest congestion-cough relief Generic OTC
chest-sinus congestion relief Generic OTC
child allergy relf(cetirizine) oral solution Generic OTC
child allergy relief (diphen) Generic OTC
child benadryl plus congestion Generic OTC
child chest congestion-cough Generic OTC
CHILD MUCINEX COUGH MINI-MELTS Brand OTC
child mucus relief cough Generic OTC
child mucus relief expectorant Generic OTC
child triaminic cold-allergy Generic OTC
child wal-tap cold-allergy Generic OTC
children's allegra allergy oral suspension Generic OTC
children's allegra allergy oral tablet,disintegrating Generic OTC; QL
children's allergy (diphenhyd) oral liquid Generic OTC
children's allergy relief(lor) oral solution Generic OTC
children's benadryl allergy oral tablet,chewable Generic OTC
children's cetirizine oral solution Generic OTC
children's cetirizine oral tablet,chewable Generic OTC; QL
children's chest congestion Generic OTC
CHILDREN'S CLARITIN ORAL SOLUTION Brand OTC
CHILDREN'S CLARITIN ORAL TABLET,CHEWABLE
Brand OTC; QL
children's cold and cough (pe) Generic OTC
children's cold-allergy (pe) Generic OTC
CHILDREN'S COLD-COUGH-SORE Brand OTC
children's cough Generic OTC
CHILDREN'S COUGH DM ER Brand OTC
CHILDREN'S DELSYM COUGH Brand OTC
children's dibromm cold-allerg Generic OTC
children's dibromm dm cold-cou Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 90
Drug Name Drug Tier Requirements / Limits
children's flu relief Generic OTC
CHILDREN'S MUCINEX COLD-FEVER Brand OTC
children's mucinex cough Generic OTC
CHILDREN'S MUCINEX MULTI-SYMP Brand OTC
childrens plus cold Generic OTC
children's plus flu Generic OTC
CHILDREN'S ROBITUSSIN ER Brand OTC
children's silfedrine Generic OTC
CHILDREN'S SUDAFED Brand OTC
children's sudafed pe cough Generic OTC
CHILDREN'S SUDAFED PE NASAL Brand OTC
children's wal-dryl allergy Generic OTC
children's wal-zyr oral solution Generic OTC
child's all day allergy(cetir) Generic OTC
childs triacting cold-cough Generic OTC
chlorhist Generic OTC
chlorpheniramine maleate oral tablet Generic OTC
chlorpheniramine maleate oral tablet extended release
Generic OTC
chlortabs Generic OTC
CHLOR-TRIMETON Brand OTC
CLARITIN LIQUI-GEL Brand OTC; QL
CLARITIN ORAL SOLUTION Brand OTC
CLARITIN ORAL TABLET Brand OTC; QL
CLARITIN REDITABS ORAL TABLET,DISINTEGRATING 10 MG
Brand OTC; QL
CLARITIN REDITABS ORAL TABLET,DISINTEGRATING 5 MG
Brand OTC
CLARITIN-D 12 HOUR Brand OTC; QL
CLARITIN-D 24 HOUR Brand OTC; QL
clemastine oral tablet 2.68 mg Generic
codeine-guaifenesin Generic
cold and allergy Generic OTC
cold and allergy (bromphen-pe) Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
91
Drug Name Drug Tier Requirements / Limits
cold and allergy pe Generic OTC
cold and cough (diphenhydr-pe) Generic OTC
cold and cough dm Generic OTC
cold and cough elixir Generic OTC
COLD AND FLU SEVERE Brand OTC
cold and sinus pain relief Generic OTC
COLD HEAD CONGESTION DAY/NITE Brand OTC
COLD HEAD CONGESTION DAYTIME Brand OTC
cold head congestion nighttime Generic OTC
COLD MULTI-SYMPTOM (CHLORPHEN) Brand OTC
COLD MULTI-SYMPTOM DAY/NIGHT Brand OTC
cold relief m/s day/night Generic OTC
COLD RELIEF ORAL TABLET, EFFERVESCENT
Brand OTC
cold relief plus Generic OTC
cold-flu relief oral liquid 12.5-30-1,000 mg/30 ml Generic OTC
cold-sinus relief Generic OTC
complete allergy oral capsule Generic OTC
COMPOZ Brand OTC
conex oral tablet Generic OTC
CONTAC COLD-FLU NIGHT Brand OTC
CORICIDIN HBP CHEST CONG-COUGH Brand OTC
CORICIDIN HBP COLD-MULTI SYMPT Brand OTC
CORICIDIN HBP COUGH AND COLD Brand OTC
COUGH AND COLD MUCUS RELIEF CF Brand OTC
cough formula dm Generic OTC
cough syrup dm Generic OTC
cough-sore throat night Generic OTC
cyproheptadine oral tablet Generic
DAY TIME PE Brand OTC
dayhist allergy Generic OTC
day-time cough Generic OTC
DECONEX DMX ORAL TABLET 10-17.5-385 MG, 10-17.5-400 MG
Brand OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 92
Drug Name Drug Tier Requirements / Limits
DECONEX IR ORAL TABLET 10-385 MG Brand OTC
DELSYM 12 HOUR Brand OTC
delsym cough-chest congest dm Generic OTC
desgen dm oral liquid 5-10-100 mg/5 ml Generic OTC
desloratadine Generic QL
despec dm-g Generic OTC
despec eda cough-cold drops Generic OTC
despec-dm (phenyleph-dm-guaif) oral liquid 5-10-100 mg/5 ml
Generic OTC
DESPEC-DM (PSEUDOEPH-DM-GUAIF) ORAL TABLET 30-10-200 MG
Brand OTC
dextromethorphan polistirex Generic OTC
dextromethorphan-guaifenesin oral syrup Generic OTC
dextromethorphan-guaifenesin oral tablet Generic OTC
diabetic siltussin-dm max str Generic OTC
diabetic tussin dm Generic OTC
diabetic tussin ex Generic OTC
dimaphen (pe) Generic OTC
dimaphen dm Generic OTC
DIMETAPP COLD-ALLERGY (PE) Brand OTC
dimetapp cold-congestion Generic OTC
dimetapp dm cold-cough (pe) Generic OTC
DIMETAPP LONG-ACTING (CPM-DM) Brand OTC
diphedryl allergy Generic OTC
diphedryl oral capsule Generic OTC
diphedryl oral tablet Generic OTC
diphen oral tablet Generic OTC
diphenhist oral capsule Generic OTC
diphenhydramine hcl oral capsule 25 mg Generic OTC
diphenhydramine hcl oral capsule 50 mg Generic
diphenhydramine hcl oral elixir Generic OTC
diphenhydramine hcl oral liquid Generic OTC
diphenhydramine hcl oral syrup Generic OTC
diphenhydramine hcl oral tablet 25 mg Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
93
Drug Name Drug Tier Requirements / Limits
dm max Generic OTC
dometuss-dmx Generic OTC
dristan cold Generic OTC
DURAFLU ORAL TABLET 60-20-200-325 MG Brand OTC
ed a-hist Generic OTC
ed a-hist dm oral liquid Generic OTC
ed bron gp Generic OTC
ed chlorped jr Generic OTC
endacof - dm Generic OTC
ENTEX T Brand OTC
epinephrine injection auto-injector 0.15 mg/0.3 ml, 0.3 mg/0.3 ml
Generic QL
expectorant oral liquid Generic OTC
fenesin dm ir oral tablet 20-400 mg Generic OTC
fenesin ir Generic OTC
fenesin pe ir Generic OTC
fexofenadine oral tablet 180 mg, 60 mg Generic OTC; QL
fexofenadine-pseudoephedrine Generic OTC; QL
flu relief therapy daytime Generic OTC
flu relief therapy nighttime Generic OTC
flu severe cold-night(diph-pe) Generic OTC
FLU-SEVERE COLD-COUGH DAYTIME Brand OTC
g tussin ac Generic
geri-dryl oral tablet Generic OTC
glenmax peb dm Generic OTC
g-tron ped oral drops Generic OTC
G-TUSICOF Brand OTC
guaiasorb dm Generic OTC
guaiatussin ac Generic
guaifenesin ac Generic
guaifenesin dac Generic
guaifenesin oral liquid Generic OTC
guaifenesin oral tablet Generic OTC
G-ZYNCOF Brand OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 94
Drug Name Drug Tier Requirements / Limits
hydrocodone-chlorpheniramine Generic
hydrocodone-homatropine oral syrup 5-1.5 mg/5 ml
Generic
hydrocodone-homatropine oral tablet Generic
hydromet Generic
hydroxyzine hcl oral tablet Generic
hydroxyzine pamoate Generic
ibuprofen cold-sinus(with pse) Generic OTC
levocetirizine oral solution Generic
levocetirizine oral tablet Generic QL
liquibid d-r Generic OTC
LIQUIBID PD-R Brand OTC
lohist - d Generic OTC
lohist-dm Generic OTC
lorata-d Generic OTC; QL
loratadine oral solution Generic OTC
loratadine oral tablet Generic OTC; QL
loratadine oral tablet,disintegrating Generic OTC; QL
loratadine-d Generic OTC; QL
lortuss ex oral syrup Generic
mapap cold formula Generic OTC
m-clear wc Generic
mucinex d Generic OTC
mucinex d maximum strength Generic OTC
mucinex dm oral tablet extended release 12 hr 30-600 mg
Generic OTC
MUCINEX DM ORAL TABLET EXTENDED RELEASE 12 HR 60-1,200 MG
Brand OTC
mucinex fast-max cold-flu-thrt oral tablet Generic OTC
MUCINEX FAST-MAX COLD-SINUS Brand OTC
MUCINEX FAST-MAX CONGEST-COUGH ORAL LIQUID
Brand OTC
mucinex fast-max dm max Generic OTC
MUCINEX ORAL TABLET EXTENDED RELEASE 12HR 1,200 MG
Brand OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
95
Drug Name Drug Tier Requirements / Limits
mucinex oral tablet extended release 12hr 600 mg Generic OTC
MUCINEX SINUS-MAX SEV CONGESTN ORAL TABLET
Brand OTC
mucosa Generic OTC
mucosa dm Generic OTC
MUCUS RELIEF COLD AND SINUS Brand OTC
MUCUS RELIEF COLD-FLU-SORE THR Brand OTC
MUCUS RELIEF CONGESTION-COUGH Brand OTC
mucus relief cough Generic OTC
mucus relief d (pseudoephed) oral tablet Generic OTC
mucus relief dm Generic OTC
mucus relief dm max Generic OTC
mucus relief er oral tablet extended release 12hr 600 mg
Generic OTC
mucus relief oral tablet 400 mg Generic OTC
mucus relief pe Generic OTC
MUCUS RELIEF SEV CONGEST-COLD Brand OTC
mucus relief sinus Generic OTC
nasal decongestant (pe) oral tablet 10 mg Generic OTC
nasal decongestant (pseudoeph) oral tablet Generic OTC
nasal decongestant (pseudoeph) oral tablet extended release
Generic OTC
neo-tuss Generic OTC
NEOTUSS PLUS Brand OTC
NEOTUSS-D (IMPROVED FORMULA) Brand OTC
night time cold and flu relief Generic OTC
night time cold-flu oral capsule Generic OTC
night time oral capsule 6.25-15-325 mg Generic OTC
nightime sleep Generic OTC
nighttime allergy relief Generic OTC
nighttime cold-flu Generic OTC
NIGHTTIME COLD-FLU RELIEF Brand OTC
nighttime cough Generic OTC
nighttime sleep aid (diphen) oral capsule 50 mg Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 96
Drug Name Drug Tier Requirements / Limits
nighttime sleep aid (diphen) oral tablet Generic OTC
NITE TIME COLD-FLU RELIEF ORAL LIQUID Brand OTC
nite time-d cold-flu relief Generic OTC
nitetime multi-symptom Generic OTC
nohist-dm Generic OTC
nohist-lq Generic OTC
non-aspirin flu oral tablet 30-15-500 mg Generic OTC
NOREL AD Brand OTC
pain relief allergy sinus Generic OTC
PECGEN DMX ORAL LIQUID 10-187 MG/5 ML
Brand OTC
pedia relief infant nasal Generic OTC
pediacare multi-symptom cold Generic OTC
pediatric cough and cold oral liquid 1-15-5 mg/5 ml
Generic OTC
pharbechlor Generic OTC
pharbedryl Generic OTC
phenadoz Generic
PHENAGIL Brand OTC
pres gen Generic OTC
PRES GEN PEDIATRIC Brand OTC
PRESGEN B Brand OTC
promethazine oral Generic
promethazine rectal Generic
promethazine vc Generic
promethazine-codeine Generic
promethazine-dm Generic
promethazine-phenyleph-codeine Generic
promethegan Generic
pseudoephedrine hcl oral tablet Generic OTC
refenesen dm Generic OTC
refenesen oral tablet 400 mg Generic OTC
refenesen pe Generic OTC
RESCON-DM Brand OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
97
Drug Name Drug Tier Requirements / Limits
rescon-gg Generic OTC
ritifed Generic OTC
ri-tussin Generic OTC
ri-tussin dm Generic OTC
robafen Generic OTC
robafen cf (phenylephrine) Generic OTC
robafen cough Generic OTC
robafen dm cough Generic OTC
robafen dm cough-chest congest Generic OTC
robitussin cough and cold cf Generic OTC
robitussin cough-chest cong dm oral capsule Generic OTC
robitussin cough-chest cong dm oral liquid 5-100 mg/5 ml
Generic OTC
ROBITUSSIN COUGHGEL Brand OTC
ROBITUSSIN LONG-ACTING Brand OTC
robitussin pediatric Generic OTC
RU-HIST D Brand OTC
rydex Generic
rynex dm Generic OTC
rynex pe Generic OTC
rynex pse Generic OTC
SAFE TUSSIN DM Brand OTC
SCOT-TUSSIN DIABETES CF Brand OTC
scot-tussin dm Generic OTC
scot-tussin expectorant Generic OTC
SCOT-TUSSIN SENIOR Brand OTC
SEVERE ALLERGY-SINUS HEADACHE Brand OTC
severe cold Generic OTC
SEVERE COLD AND FLU-DAY (DM) Brand OTC
siladryl sa Generic OTC
siltussin dm das Generic OTC
siltussin sa Generic OTC
siltussin-dm Generic OTC
simply sleep Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 98
Drug Name Drug Tier Requirements / Limits
sinus 12 hour Generic OTC
sinus and allergy pe Generic OTC
sinus congestion-pain(chlorph) Generic OTC
sinus decongestant (pe) Generic OTC
sinus headache pe Generic OTC
sinus pain relief Generic OTC
sinus pe decongestant Generic OTC
sinus relief (non-drowsy) Generic OTC
sinus-allergy (phenylephrine) Generic OTC
sleep aid (diphenhydramine) oral capsule 50 mg Generic OTC
SLEEP AID (DIPHENHYDRAMINE) ORAL LIQUID
Brand OTC
sleep aid (diphenhydramine) oral tablet Generic OTC
sleep ii Generic OTC
SLEEP TIME ORAL LIQUID Brand OTC
sleep-tabs Generic OTC
sorbugen nr Generic OTC
SUDAFED Brand OTC
SUDAFED 12 HOUR Brand OTC
SUDAFED 24 HOUR Brand OTC
sudogest Generic OTC
sudogest 12-hour Generic OTC
sudogest cold and allergy Generic OTC
sudogest pe Generic OTC
sudogest sinus and allergy Generic OTC
suphedrin Generic OTC
suphedrine Generic OTC
suphedrine 12 hour Generic OTC
suphedrine pe Generic OTC
suphedrine pe cold and allergy Generic OTC
supress dx Generic OTC
tg 10peh-380gfn-15dm Generic OTC
THERAFLU EXPRESSMAX COLD DAY Brand OTC
THERAFLU FLU-SORE THROAT Brand OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
99
Drug Name Drug Tier Requirements / Limits
total allergy medicine Generic OTC
TRIAMINIC COLD AND COUGH (PE) Brand OTC
TUSICOF ORAL LIQUID Brand OTC
tusnel diabetic Generic OTC
TUSNEL NEW FORMULA ORAL TABLET Brand OTC
tusnel pediatric oral drops Generic OTC
tussi pres-b oral liquid 4-10-20 mg/5 ml Generic OTC
TUSSI PRES-B ORAL LIQUID 4-10-30 MG/5 ML
Brand OTC
tussin Generic OTC
tussin cf (pe-dm-guaif) Generic OTC
tussin chest congestion Generic OTC
tussin cough (dm only) Generic OTC
tussin cough-chest congestion Generic OTC
tussin dm clear Generic OTC
tussin dm cough and chest oral liquid 5-100 mg/5 ml
Generic OTC
tussin dm cough and chest oral syrup Generic OTC
tussin dm max oral liquid 10-200 mg/5 ml Generic OTC
tussin dm oral liquid Generic OTC
tussin dm oral syrup 10-100 mg/5 ml Generic OTC
tussin dm oral tablet Generic OTC
tussin honey Generic OTC
tussin long-acting Generic OTC
tussin maximum strength cough Generic OTC
tussi-pres oral liquid Generic OTC
TUSSI-PRES PEDIATRIC Brand OTC
unisom sleepgels Generic OTC
valu-tapp Generic OTC
VANACOF Brand OTC
vicks dayquil cold-flu relief oral liquid Generic OTC
vicks dayquil cough Generic OTC
VICKS DAYQUIL SEVERE COLD-FLU Brand OTC
vicks nyquil cold/flu liquicap Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 100
Drug Name Drug Tier Requirements / Limits
VICKS NYQUIL SEVERE COLD-FLU ORAL LIQUID
Brand OTC
virtussin ac Generic
virtussin dac Generic
wal-act d cold and allergy Generic OTC
wal-dryl allergy Generic OTC
wal-dryl severe allergy-sinus Generic OTC
wal-dryl-d allergy and sinus Generic OTC
wal-fex allergy Generic OTC; QL
wal-fex d 12 hour Generic OTC; QL
wal-fex d 24 hour Generic OTC; QL
wal-finate Generic OTC
wal-finate-d Generic OTC
wal-flu night severe cold Generic OTC
WAL-FLU NIGHT TIME Brand OTC
WAL-FLU SEVERE COLD-COUGH Brand OTC
wal-itin d Generic OTC; QL
wal-itin d 12 hour Generic OTC; QL
wal-itin oral solution Generic OTC
wal-itin oral tablet Generic OTC; QL
wal-phed Generic OTC
wal-phed 12 hour Generic OTC
wal-phed pe Generic OTC
wal-phed pe nighttime cold Generic OTC
wal-phed pe sinus and allergy Generic OTC
wal-profen cold-sinus Generic OTC
wal-profen d cold and sinus Generic OTC
WAL-SLEEP Z ORAL LIQUID Brand OTC
wal-som (diphenhydramine) oral capsule Generic OTC
wal-tap dm Generic OTC
wal-tussin cough Generic OTC
wal-tussin cough and cold cf Generic OTC
wal-tussin dm Generic OTC
wal-tussin max strength cough Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
101
Drug Name Drug Tier Requirements / Limits
wal-zyr (cetirizine) oral capsule Generic OTC; QL
wal-zyr (cetirizine) oral solution Generic OTC
wal-zyr (cetirizine) oral tablet Generic OTC; QL
wal-zyr d Generic OTC; QL
ZYNCOF ORAL LIQUID Brand OTC
zyncof oral tablet Generic OTC
ZYRTEC ORAL CAPSULE Brand OTC; QL
ZYRTEC ORAL TABLET Brand OTC; QL
ZYRTEC-D Brand OTC; QL
ZZZQUIL ORAL LIQUID Brand OTC
PULMONARY AGENTS
albuterol sulfate inhalation hfa aerosol inhaler Generic QL
albuterol sulfate inhalation solution for nebulization
Generic
albuterol sulfate oral Generic
aller-flo Generic OTC; QL
ambrisentan Generic PA
ANORO ELLIPTA Brand QL
ARNUITY ELLIPTA Brand QL
ATROVENT HFA Brand QL
BEVESPI AEROSPHERE Brand QL
budesonide inhalation Generic QL
budesonide nasal Generic OTC; QL
COMBIVENT RESPIMAT Brand QL
cromolyn inhalation Generic
ESBRIET ORAL CAPSULE Brand PA; QL
ESBRIET ORAL TABLET Brand PA
FLOVENT DISKUS Brand QL
FLOVENT HFA Brand QL
flunisolide nasal spray,non-aerosol 25 mcg (0.025 %)
Generic QL
icatibant Generic PA
INCRUSE ELLIPTA Brand QL
ipratropium bromide inhalation Generic
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 102
Drug Name Drug Tier Requirements / Limits
ipratropium-albuterol Generic QL
KALYDECO Brand PA; QL
metaproterenol oral syrup Generic
montelukast Generic
nasal allergy Generic OTC; QL
nasal allergy symptom control Generic OTC
NASALCROM Brand OTC
nebusal inhalation solution for nebulization 3 % Generic
OFEV Brand PA; QL
OPSUMIT Brand PA
ORKAMBI ORAL TABLET Brand PA; QL
PERFOROMIST Brand QL
PROAIR RESPICLICK Brand QL
pulmosal Generic
PULMOZYME Brand
sildenafil (pulm.hypertension) oral tablet Generic PA; QL
sodium chloride inhalation Generic
STRIVERDI RESPIMAT Brand QL
SYMDEKO Brand PA; QL
terbutaline Generic
theochron oral tablet extended release 12 hr 100 mg, 200 mg
Generic
theophylline oral elixir Generic
theophylline oral solution Generic
theophylline oral tablet extended release 12 hr Generic
theophylline oral tablet extended release 24 hr Generic
TRACLEER ORAL TABLET FOR SUSPENSION
Brand PA
triamcinolone acetonide nasal Generic OTC; QL
TRIKAFTA Brand PA; QL
TYVASO Brand PA
TYVASO REFILL KIT Brand PA
TYVASO STARTER KIT Brand PA
VENTAVIS Brand PA
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
103
Drug Name Drug Tier Requirements / Limits
wixela inhub Generic QL
zafirlukast Generic
UROLOGICALS
ANTICHOLINERGICS / ANTISPASMODICS
darifenacin Generic
flavoxate Generic
oxybutynin chloride oral syrup Generic
oxybutynin chloride oral tablet Generic
oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg
Generic
oxybutynin chloride oral tablet extended release 24hr 5 mg
Generic QL
BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY
alfuzosin Generic
dutasteride Generic ST
dutasteride-tamsulosin Generic ST
finasteride oral tablet 5 mg Generic
tamsulosin Generic
CHOLINERGIC STIMULANTS
bethanechol chloride Generic
MISCELLANEOUS UROLOGICALS
CYSTAGON Brand
cytra k crystals Generic
cytra-2 Generic OTC
cytra-3 Generic OTC
cytra-k Generic OTC
ELMIRON Brand
glycine urologic Generic
glycine urologic solution Generic
hyophen Generic
K-PHOS NO 2 Brand
K-PHOS ORIGINAL Brand
methen-sod phos-meth blue-hyos Generic
phosphasal Generic
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 104
Drug Name Drug Tier Requirements / Limits
pot,sodium citrate-citric acid Generic OTC
potassium citrate-citric acid oral solution Generic OTC
RENACIDIN IRRIGATION SOLUTION 1980.6 MG-59.4 MG-980.4MG/30ML
Brand
sodium citrate-citric acid Generic OTC
tricitrates Generic OTC
uretron d-s oral tablet 81.6-10.8-40.8 mg Generic
urimar-t Generic
urin ds Generic
uro-458 Generic
urogesic-blue Generic
uro-mp Generic
uryl Generic
ustell Generic
utira-c Generic
virtrate-2 Generic OTC
virtrate-3 Generic OTC
virtrate-k Generic OTC
URINARY ANESTHETICS
phenazopyridine oral tablet 100 mg, 200 mg Generic
VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
alcalak Generic OTC
antacid (calcium carbonate) Generic OTC
antacid ext str (calcium carb) Generic OTC
antacid extra-strength oral tablet,chewable 168 mg calcium (420 mg), 300 mg (750 mg)
Generic OTC
antacid ultra strength oral tablet,chewable 400 mg calcium (1,000 mg), 430 mg calcium (1,000 mg)
Generic OTC
CALCI-MIX Brand OTC
calcitrate Generic OTC
calcium 500 + d oral tablet 500 mg(1,250mg) -200 unit
Generic OTC
calcium 500 with d Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
105
Drug Name Drug Tier Requirements / Limits
calcium 600 + d(3) oral capsule Generic OTC
calcium 600 + d(3) oral tablet 600 mg(1,500mg) -400 unit
Generic OTC
calcium 600 with vitamin d3 oral tablet,chewable Generic OTC
calcium acetate(phosphat bind) Generic
calcium antacid oral tablet,chewable 200 mg calcium (500 mg), 300 mg (750 mg), 320 mg calcium (750 mg), 430 mg calcium (1,000 mg)
Generic OTC
calcium antacid ultra max st Generic OTC
calcium carb and citrate-vitd3 Generic OTC
calcium carbonate oral suspension Generic OTC
calcium carbonate oral tablet 260 mg calcium (648 mg), 500 mg calcium (1,250 mg), 600 mg calcium (1,500 mg)
Generic OTC
calcium carbonate oral tablet,chewable 200 mg calcium (500 mg), 300 mg (750 mg), 400 mg calcium (1,000 mg), 500 mg calcium (1,250 mg)
Generic OTC
CALCIUM CARBONATE-VITAMIN D3 ORAL CAPSULE 600 MG (1,500 MG)-2,500 UNIT, 600MG (1,500MG) -1,000 UNIT
Brand OTC
calcium carbonate-vitamin d3 oral capsule 600 mg(1,500mg) -400 unit
Generic OTC
CALCIUM CARBONATE-VITAMIN D3 ORAL TABLET 1,000 MG(2,500 MG)-800 UNIT
Brand OTC
calcium carbonate-vitamin d3 oral tablet 250-125 mg-unit, 500 mg(1,250mg) -125 unit, 600 mg(1,500mg) -200 unit, 600 mg(1,500mg) -400 unit
Generic OTC
calcium carbonate-vitamin d3 oral tablet,chewable 500 mg(1,250mg) -400 unit
Generic OTC
calcium citrate + d Generic OTC
calcium citrate oral tablet Generic OTC
calcium citrate plus (vit b6) Generic OTC
calcium citrate-vitamin d3 oral tablet 200-125 mg-unit, 250 mg calcium- 200 unit, 315-200 mg-unit
Generic OTC
CALCIUM GLUCONATE ORAL TABLET 50 MG CALCIUM
Brand OTC
calcium gluconate oral tablet 60 mg calcium (650 mg)
Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 106
Drug Name Drug Tier Requirements / Limits
calcium magnesium Generic OTC
calcium-magnesium-zinc oral tablet 333-133-5 mg, 333-133-8.3 mg
Generic OTC
cal-gest antacid Generic OTC
CALPHRON Brand OTC
CALTRATE 600 PLUS D Brand OTC
CALTRATE WITH VITAMIN D3 Brand OTC
CITRACAL + D MAXIMUM Brand OTC
CITRACAL REGULAR Brand OTC
CITRACAL-D3 PETITES Brand OTC
CITRACAL-D3 SLOW RELEASE Brand OTC
citrus calcium-vitamin d3 oral tablet 200 mg calcium -250 unit
Generic OTC
effer-k oral tablet, effervescent 25 meq Generic
ENFAMIL ENFALYTE Brand OTC
flavor chews antacid Generic OTC
hi-cal plus vit d Generic OTC
klor-con Generic
klor-con 10 Generic
klor-con 8 Generic
klor-con m10 Generic
klor-con m15 Generic
klor-con m20 Generic
klor-con/ef Generic
k-phos-neutral Generic OTC
k-tab oral tablet extended release 8 meq Generic
LIQUID CALCIUM WITH VITAMIN D Brand OTC
lugols oral Generic
mag-g Generic OTC
magnesium gluconate oral tablet 27 mg magnesium (500 mg), 27.5 mg magne- sium (500 mg)
Generic OTC
MAGNESIUM GLUCONATE ORAL TABLET 30 MG (550 MG)
Brand OTC
magnesium oral tablet 200 mg Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
107
Drug Name Drug Tier Requirements / Limits
magnesium oxide oral capsule 500 mg Generic OTC
magnesium oxide oral tablet 200 mg magnesium, 250 mg magnesium, 400 mg magnesium, 420 mg, 500 mg
Generic OTC
MAGOX Brand OTC
mgo Generic OTC
MG-PLUS-PROTEIN Brand OTC
oralyte Generic OTC
OS-CAL 500 + D3 Brand OTC
oysco 500/d oral tablet Generic OTC
oysco-500 Generic OTC
oyster shell calcium 500 Generic OTC
oyster shell calcium-vit d3 oral tablet 500 mg(1,250mg) -200 unit, 500 mg(1,250mg) -400 unit
Generic OTC
oystercal-d Generic OTC
PEDIALYTE ADVANCED CARE Brand OTC
pedialyte oral solution Generic OTC
pedialyte singles Generic OTC
pediatric electrolyte oral solution Generic OTC
pediatric freezer pops Generic OTC
PHILLIPS Brand OTC
phos-nak Generic OTC
phospha 250 neutral Generic OTC
phospho-trin 250 neutral Generic OTC
potassium chloride oral Generic
potassium gluconate oral tablet 2.5 meq, 500 mg (83 mg), 550 mg (90 mg), 595 mg (99 mg)
Generic OTC
PROVIMIN Brand OTC
strong iodine oral Generic
super calcium Generic OTC
thermotabs Generic OTC
TUMS Brand OTC
TUMS E-X Brand OTC
TUMS EXTRA STRENGTH SMOOTHIES Brand OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 108
Drug Name Drug Tier Requirements / Limits
tums ultra oral tablet,chewable 400 mg calcium (1,000 mg)
Generic OTC
URO-MAG Brand OTC
virt-phos 250 neutral Generic OTC
zinc Generic OTC
zinc gluconate oral tablet Generic OTC
MISCELLANEOUS NUTRITION PRODUCTS
5-htp Generic OTC
ACERFLEX Brand OTC
acidophilus oral capsule Generic OTC
ADVANTAGE WITH IRON Brand OTC
ALFAMINO JUNIOR Brand OTC
arginine (l-arginine) oral tablet Generic OTC
ARGININE HCL (L-ARGININE) ORAL TABLET
Brand OTC
BCAD 1 Brand OTC
benecalorie Generic OTC
bioflex Generic OTC
biotect plus Generic OTC
BOOST BREEZE NUTRITIONAL Brand OTC
BOOST CALORIE SMART ORAL LIQUID Brand OTC
BOOST HIGH PROTEIN ORAL LIQUID 0.06 GRAM- 1 KCAL/ML
Brand OTC
boost kid essentials oral liquid 0.03-1 gram-kcal/ml
Generic OTC
BOOST KID ESSENTIALS W-FIBER Brand OTC
boost oral liquid 0.04 gram- 1 kcal/ml Generic OTC
BOOST PUDDING Brand OTC
BOOST VHC Brand OTC
BREAKFAST ESSENTIALS Brand OTC
bright beginnings soy Generic OTC
CALCILO XD Brand OTC
COMPLEAT FEEDING TUBE Brand OTC
compleat pediatric reduced cal Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
109
Drug Name Drug Tier Requirements / Limits
complete amino acid mix Generic OTC
CYCLINEX-1 Brand OTC
CYCLINEX-2 Brand OTC
DIABETISOURCE AC Brand OTC
DUOCAL Brand OTC
EAA SUPPLEMENT Brand OTC
ear care Generic OTC
ear health formula Generic OTC
ELECARE INFANT FORMULA Brand OTC
ELECARE JR Brand OTC
ENFAGROW TODDLR TRANSITION SOY Brand OTC
enfamil a.r. oral powder Generic OTC
enfamil enfacare oral liquid Generic OTC
ENFAMIL ENFACARE ORAL POWDER Brand OTC
ENFAMIL GENTLEASE ORAL LIQUID Brand OTC
ENFAMIL GENTLEASE ORAL POWDER Brand OTC
ENFAMIL INFANT Brand OTC
ENFAMIL NEWBORN NON-GMO Brand OTC
ENFAMIL NEWBORN ORAL LIQUID Brand OTC
ENFAMIL PROSOBEE LIPIL Brand OTC
ENFAPORT Brand OTC
ensure active heart health Generic OTC
ensure active light Generic OTC
ENSURE ACTIVE MUSCLE HEALTH Brand OTC
ensure active protein-muscle Generic OTC
ensure clear oral liquid Generic OTC
ENSURE CLEAR ORAL LIQUID 0.035-1 GRAM-KCAL/ML
Brand OTC
ensure compact Generic OTC
ENSURE ENLIVE Brand OTC
ensure high protein Generic OTC
ENSURE MUSCLE HEALTH ORAL LIQUID Brand OTC
ensure oral liquid Generic OTC
ENSURE ORAL POWDER Brand OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 110
Drug Name Drug Tier Requirements / Limits
ENSURE ORIGINAL ORAL POWDER Brand OTC
ENSURE PLUS Brand OTC
ENSURE PUDDING Brand OTC
EO28 SPLASH Brand OTC
essential amino acid mix Generic OTC
FIBERSOURCE HN FEEDING TUBE Brand OTC
fish oil extra strength Generic OTC
fish oil oral capsule 100-160-1,000 mg, 120-180 mg, 300-1,000 mg, 300-500 mg, 340-1,000 mg
Generic OTC
FISH OIL ORAL CAPSULE 120-180-500 MG, 183.3 MG-75 MG -91.6 MG-306 MG, 60-90-500 MG, 900 MG (320 MG- 580MG)-1,360 MG, 900 MG-360 MG- 455 MG-1,000 MG
Brand OTC
FISH OIL ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG-180 MG- 60 MG-1,200 MG, 150-217-840 MG, 300-108-162-600 MG, 360 MG-144 MG- 216 MG-1,200 MG, 360-1,200 MG, 900-1,400 MG
Brand OTC
fish oil oral capsule,delayed release(dr/ec) 60-90-500 mg
Generic OTC
FLEXGEN Brand OTC
floranex oral tablet Generic OTC
GA GEL Brand OTC
GA POWDER Brand OTC
GERBER GOOD START GENTLE ORAL LIQUID
Brand OTC
GERBER GOOD START GENTLE ORAL POWDER
Brand OTC
GERBER GOOD START SOY ORAL LIQUID Brand OTC
GERBER GOOD START SOY ORAL POWDER Brand OTC
GLUCERNA ADVANCE Brand OTC
GLUCERNA HUNGER SMART Brand OTC
GLUCERNA ORAL BAR Brand OTC
GLUCERNA THERAPEUTIC NUTRITION Brand OTC
GLUTARADE JUNIOR Brand OTC
GLUTAREX-1 Brand OTC
GLUTAREX-2 Brand OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
111
Drug Name Drug Tier Requirements / Limits
GLYCOSADE Brand OTC
GLYTACTIN 15 PE COMPLETE Brand OTC
GLYTACTIN 20PE BETTERMILK LITE Brand OTC
G-PREPROTEIN Brand OTC
HCU COOLER Brand OTC
hcu express powder Generic OTC
HCU GEL POWDER Brand OTC
HCU LOPHLEX Brand OTC
HCY 1 POWDER Brand OTC
HCY 2 Brand OTC
HI-CAL Brand OTC
high-protein nutritional shake Generic OTC
HOMINEX-1 Brand OTC
HOMINEX-2 Brand OTC
immulife Generic OTC
IMPACT ADVANCED RECOVERY ORAL LIQUID 0.1 GRAM-1.12 KCAL/ML
Brand OTC
IMPACT PEPTIDE 1.5 CAL Brand OTC
inositol Generic OTC
ISOLEUCINE Brand OTC
ISOMIL ADVANCE Brand OTC
ISOMIL DF Brand OTC
ISOMIL/IRON Brand OTC
isosource hn feeding tube Generic OTC
I-VALEX-1 Brand OTC
I-VALEX-2 Brand OTC
JEVITY 1 CAL Brand OTC
JEVITY 1.2 CAL Brand OTC
JEVITY 1.5 CAL Brand OTC
JUVEN Brand OTC
KETONEX-1 Brand OTC
KETONEX-2 Brand OTC
KETOVOLVE ORAL POWDER 14.5 GRAM-686 KCAL/100 GRAM
Brand OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 112
Drug Name Drug Tier Requirements / Limits
LACTINEX Brand OTC
lactobacillus acidophilus oral capsule 100 million cell
Generic OTC
lactobacillus acidophilus oral tablet 0.5 mg (100 million cell), 1 billion cell
Generic OTC
LACTOBACILLUS ACIDOPHILUS ORAL TABLET 2 BILLION CELL, 500 MILLION CELL
Brand OTC
LANAFLEX Brand OTC
lecithin oral capsule 1,200 mg Generic OTC
LEU-FREE COOLER Brand OTC
lipistart Generic OTC
LIPO-FLAVONOID PLUS Brand OTC
l-lysine oral tablet Generic OTC
LMD POWDER Brand OTC
LOPHLEX Brand OTC
l-phenylalanine Generic OTC
lysine hcl oral tablet 1,000 mg Generic OTC
LYSINE HCL ORAL TABLET 500 MG Brand OTC
lysine oral tablet 1,000 mg, 500 mg Generic OTC
mct pro-cal Generic OTC
metafolbic plus Generic OTC
METHIONAID Brand OTC
MMA-PA COOLER15 Brand OTC
MMA-PA EXPRESS15 Brand OTC
MMA-PA GEL Brand OTC
MSUD AID Brand OTC
MSUD ANALOG Brand OTC
MSUD COOLER Brand OTC
MSUD EXPRESS COOLER Brand OTC
MSUD GEL POWDER Brand OTC
MSUD LOPHLEX Brand OTC
MSUD MAXAMAID Brand OTC
MSUD MAXAMUM Brand OTC
NEOCATE INFANT DHA-ARA Brand OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
113
Drug Name Drug Tier Requirements / Limits
NEOCATE JUNIOR Brand OTC
NEOCATE JUNIOR WITH PREBIOTICS Brand OTC
NEOCATE NUTRA Brand OTC
NEOCATE SPLASH Brand OTC
NEPRO CARB STEADY Brand OTC
niacin (inositol niacinate) oral capsule 400 mg niacin (500 mg)
Generic OTC
niacin flush free oral capsule 400 mg niacin (500 mg)
Generic OTC
NIACIN FLUSH FREE ORAL CAPSULE 750 MG
Brand OTC
NIACIN NO FLUSH Brand OTC
NOURISH Brand OTC
novasource renal 2 cal Generic OTC
NUTRA PRO HIGH PROTEIN Brand OTC
nutrafit Generic OTC
nutrafit plus Generic OTC
NUTRAMIGEN DHA-ARA Brand OTC
NUTRAMIGEN TODDLER ENFLORA-LGG Brand OTC
NUTRAMIGEN WITH ENFLORA LGG Brand OTC
nutren 1.0 feeding tube Generic OTC
nutren 1.5 feeding tube Generic OTC
nutren 2.0 feeding tube Generic OTC
nutren junior fiber Generic OTC
nutren junior oral liquid 0.03-1 gram-kcal/ml Generic OTC
NUTREN PULMONARY Brand OTC
NUTRIHEP ORAL LIQUID 0.04-1.5 GRAM-KCAL/ML
Brand OTC
nutritional drink mix Generic OTC
nutritional drink plus Generic OTC
nutritional shake oral liquid Generic OTC
NUTRITIONAL SHAKE ORAL LIQUID 0.04-0.93 GRAM-KCAL/ML
Brand OTC
nutritional shake plus oral liquid Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 114
Drug Name Drug Tier Requirements / Limits
NUTRITIONAL SHAKE PLUS ORAL LIQUID 0.05-1.5 GRAM-KCAL/ML
Brand OTC
OA 1 POWDER Brand OTC
OA2 POWDER Brand OTC
omega 3-6-9 complex Generic OTC
OMEGA 3-DHA-EPA-FISH OIL ORAL CAPSULE 1,200 (144-216) MG, 100-150-750 MG, 250-500-1,000 MG, 356 MG (100 MG- 256 MG)-554 MG
Brand OTC
omega 3-dha-epa-fish oil oral capsule 300-1,000 mg, 500-1,000 mg
Generic OTC
omega 3-dha-epa-fish oil oral capsule,delayed release(dr/ec) 300 mg (120 mg- 180mg)-1,000 mg
Generic OTC
OMEGA 3-DHA-EPA-FISH OIL ORAL CAPSULE,DELAYED RELEASE(DR/EC) 600 MG-216 MG- 324 MG-1,200 MG
Brand OTC
omega-3 fatty acids-fish oil oral capsule 300-1,000 mg
Generic OTC
OMEGA-3 FATTY ACIDS-FISH OIL ORAL CAPSULE 440-880 MG
Brand OTC
OMEGA-3 FISH OIL ORAL CAPSULE 910-1,400 MG
Brand OTC
OMEGA-3S-DHA-EPA-FISH OIL ORAL CAPSULE,DELAYED RELEASE(DR/EC) 300-1,000 MG, 720-1,200 MG, 980-253-647 MG
Brand OTC
ORANGE CHICKN-CARROT-BRWN RICE Brand OTC
OSMOLITE 1 CAL Brand OTC
OSMOLITE 1.2 CAL Brand OTC
OXEPA Brand OTC
PEDIASURE ENTERAL Brand OTC
PEDIASURE GROW-GAIN ORAL LIQUID Brand OTC
PEDIASURE ORAL LIQUID 0.06-1.5 GRAM-KCAL/ML
Brand OTC
pediasure peptide 1.0 cal Generic OTC
PEDIASURE PEPTIDE 1.5 CAL Brand OTC
PEDIASURE SIDEKICKS Brand OTC
pediatric balanced nutrition Generic OTC
PEPTAMEN AF Brand OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
115
Drug Name Drug Tier Requirements / Limits
PEPTAMEN JUNIOR 1.5 Brand OTC
peptamen junior fiber Generic OTC
PEPTAMEN JUNIOR ORAL LIQUID 0.03-1 GRAM-KCAL/ML
Brand OTC
PEPTAMEN ORAL LIQUID 0.04 GRAM- 1 KCAL/ML
Brand OTC
PERATIVE Brand OTC
PERIFLEX ADVANCE Brand OTC
PERIFLEX INFANT Brand OTC
PERIFLEX JUNIOR Brand OTC
PFD 2 Brand OTC
PFD TODDLER Brand OTC
PHENEX-1 Brand OTC
PHENEX-2 Brand OTC
PHENYLADE 60 Brand OTC
PHENYLADE ESSENTIAL Brand OTC
PHENYL-FREE 1 Brand OTC
PHENYL-FREE 2 PKU Brand OTC
PHLEXY-10 DRINK MIX POWDER Brand OTC
phlexy-vits Generic OTC
PKU COOLER 10 Brand OTC
PKU COOLER 15 Brand OTC
PKU COOLER 20 Brand OTC
PKU LOPHLEX Brand OTC
PREGESTIMIL Brand OTC
PREMIUM INFANT FORMULA Brand OTC
pre-protein oral liquid Generic OTC
probiotic oral capsule 10 billion cell Generic OTC
procel Generic OTC
PRODUCT 3232A Brand OTC
PROMOD PROTEIN Brand OTC
PROMOTE Brand OTC
PROMOTE WITH FIBER Brand OTC
PRO-PHREE Brand OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 116
Drug Name Drug Tier Requirements / Limits
PROPIMEX-1 Brand OTC
PROPIMEX-2 Brand OTC
prosource no carb Generic OTC
PROSOURCE ORAL LIQUID Brand OTC
prosource oral powder Generic OTC
pro-stat awc Generic OTC
PRO-STAT SUGAR FREE Brand OTC
protein oral powder Generic OTC
PROTEINEX ORAL LIQUID Brand OTC
PROTEINEX-100 Brand OTC
PROTEINEX-18 Brand OTC
PULMOCARE Brand OTC
PURAMINO TODDLER Brand OTC
QUINOA-KALE-HEMP Brand OTC
RCF SOY PROTEIN FORMULA BASE Brand OTC
RENA START Brand OTC
replete fiber Generic OTC
replete oral liquid 0.06 gram-1 kcal/ml Generic OTC
resource 2.0 Generic OTC
SALMON-OATS-SQUASH Brand OTC
scandishake (lactose free) Generic OTC
SCANDISHAKE ORAL PACKET Brand OTC
scandishake oral powder Generic OTC
sea-omega 30 Generic OTC
SIMILAC ADVANCE Brand OTC
SIMILAC ADVANCE ORGANIC ORAL LIQUID
Brand OTC
similac advance organic oral powder Generic OTC
SIMILAC ADVANCE WITH IRON Brand OTC
similac alimentum Generic OTC
SIMILAC EXPERT CARE ALIMENTUM ORAL SUSPENSION
Brand OTC
SIMILAC EXPERT CARE NEOSURE Brand OTC
SIMILAC EXPERT CARE ORAL LIQUID Brand OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
117
Drug Name Drug Tier Requirements / Limits
SIMILAC FOR SPIT-UP ORAL LIQUID 2.14-5.4-11 GRAM/100 KCAL
Brand OTC
SIMILAC FOR SPIT-UP ORAL POWDER Brand OTC
SIMILAC HUMAN MILK FORTIFIER ORAL POWDER IN PACKET
Brand OTC
SIMILAC LOW-IRON Brand OTC
SIMILAC PM Brand OTC
SIMILAC PRO-ADVANCE NON-GMO ORAL LIQUID
Brand OTC
SIMILAC PRO-SENSITIVE NON-GMO ORAL LIQUID
Brand OTC
SIMILAC SENSITIVE Brand OTC
similac sensitive fuss and gas oral concentrate 2.1-5.4-11.1 gram/100 kcal
Generic OTC
SIMILAC SENSITIVE FUSS AND GAS ORAL LIQUID
Brand OTC
SIMILAC SENSITIVE FUSS AND GAS ORAL POWDER 2.2-5.4-11 GRAM/100 KCAL
Brand OTC
SIMILAC SENSITIVE ISOMIL SOY Brand OTC
SIMILAC SOY ISOMIL Brand OTC
SIMILAC SPECIAL CARE 24 Brand OTC
SIMILAC SPECIAL CARE 30 Brand OTC
SIMILAC SUPPLEMENTATION Brand OTC
SIMILAC TOTAL COMFORT NON-GMO Brand OTC
SIMILAC TOTAL COMFORT ORAL LIQUID Brand OTC
SOOTHE XP Brand OTC
SUPLENA CARB STEADY Brand OTC
TOLEREX ORAL POWDER IN PACKET Brand OTC
triple omega 3-6-9 Generic OTC
TWOCAL HN Brand OTC
tyr cooler oral liquid Generic OTC
TYR EXPRESS20 Brand OTC
TYR GEL POWDER Brand OTC
TYREX-1 Brand OTC
TYREX-2 Brand OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 118
Drug Name Drug Tier Requirements / Limits
TYROS 1 Brand OTC
TYROS 2 Brand OTC
UCD ANAMIX JUNIOR Brand OTC
ultra omega-3 oral capsule 500-1,000 mg Generic OTC
VASOFLEX ORAL TABLET Brand OTC
VITAL 1.0 CAL Brand OTC
VITAL 1.5 CAL Brand OTC
VITAL AF 1.2 CAL Brand OTC
VITAL HIGH NITROGEN Brand OTC
VITAL HIGH PROTEIN Brand OTC
VIVONEX PEDIATRIC ORAL POWDER IN PACKET
Brand OTC
VIVONEX PLUS ORAL POWDER IN PACKET Brand OTC
vivonex rtf Generic OTC
VIVONEX T.E.N. ORAL POWDER IN PACKET Brand OTC
WND 2 Brand OTC
XLEU ANALOG Brand OTC
XLEU MAXAMAID Brand OTC
XLYS- XTRP ANALOG Brand OTC
XLYS, XTRP MAXAMAID Brand OTC
XLYS, XTRP MAXAMUM Brand OTC
XMET ANALOG Brand OTC
XMET MAXAMUM Brand OTC
XMTVI ANALOG Brand OTC
xmtvi maxamaid Generic OTC
xmtvi maxamum Generic OTC
XPHE MAXAMAID Brand OTC
XPHE, XTRP MAXAMAID Brand OTC
XPHE, XTYR ANALOG Brand OTC
XPTM ANALOG Brand OTC
XTRACAL PLUS Brand OTC
VITAMINS / HEMATINICS
a thru z Generic OTC
a thru z advanced formula Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
119
Drug Name Drug Tier Requirements / Limits
a thru z high potency Generic OTC
A THRU Z MEN'S ULTIMATE Brand OTC
a thru z select 50plus formula Generic OTC
a thru z select oral tablet , 500-300-250 mcg Generic OTC
a thru z select women's Generic OTC
abc plus Generic OTC
acerola c-500 Generic OTC
actical Generic OTC
adults 50 plus Generic OTC
ALGAL OMEGA-3 DHA Brand OTC
ALGAL-900 DHA ORAL CAPSULE 450 MG Brand OTC
animal chews Generic OTC
animal shapes Generic OTC
apatate forte Generic OTC
APETEX Brand OTC
APETIGEN Brand OTC
apetigen plus oral liquid Generic OTC
ascorbate calcium (vitamin c) Generic OTC
ascorbic acid (vitamin c) oral tablet 500 mg Generic OTC
ascorbic acid (vitamin c) oral tablet extended release 1,500 mg
Generic OTC
b complex 1 (with folic acid) Generic OTC
b complex-vitamin b12 Generic OTC
b complex-vitamin c-folic acid oral tablet Generic OTC
B COMPLEX-VITAMIN C-FOLIC ACID ORAL TABLET EXTENDED RELEASE
Brand OTC
b-12 dots Generic OTC
balanced b-100 complex oral tablet extended release 100 mg
Generic OTC
balanced b-100 oral tablet 0.4 mg Generic OTC
balanced b-50 oral tablet Generic OTC
bal-care dha Generic
b-complex with vitamin c oral capsule Generic OTC
b-complex with vitamin c oral tablet Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 120
Drug Name Drug Tier Requirements / Limits
b-complex with vitamin c oral tablet extended release
Generic OTC
biosupp Generic OTC
biotin oral capsule 2,500 mcg, 5 mg Generic OTC
biotin oral tablet 1 mg, 300 mcg, 800 mcg Generic OTC
BIOTIN ORAL TABLET 10 MG, 5 MG Brand OTC
biovol Generic OTC
BLADDER 2.2 Brand OTC
c complex Generic OTC
c-1000 oral tablet Generic OTC
c-1000 with rose hips Generic OTC
c-500 oral tablet Generic OTC
c-500 oral tablet,chewable Generic OTC
ca-d3-mag ox-zinc-cop-mang-bor Generic OTC
calcidol Generic OTC
calcium 600 + minerals Generic OTC
calcium 600-d3 plus (mag-zinc) Generic OTC
calcium carbonate-vit d3-min oral tablet Generic OTC
calcium for women Generic OTC
calcium soft chew oral tablet,chewable 500-100-40 mg-unit-mcg, 500-200-40 mg-unit-mcg
Generic OTC
calcium-folic acid-vitamin d Generic OTC
calcium-magnesium-copper-zinc Generic OTC
CALCIUM-VITAMIN D3-VITAMIN K ORAL TABLET,CHEWABLE 500 MG-1,000 UNIT-40 MCG
Brand OTC
calcium-vitamin d3-vitamin k oral tablet,chewable 500-200-40 mg-unit-mcg, 500-500-40 mg-unit-mcg
Generic OTC
CALTRATE 600-D PLUS MINERALS ORAL TABLET
Brand OTC
centamin Generic OTC
centratex Generic OTC
centravites Generic OTC
centravites 50 plus oral tablet Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
121
Drug Name Drug Tier Requirements / Limits
CENTRUM COMPLETE Brand OTC
CENTRUM MEN Brand OTC
CENTRUM ORAL LIQUID 9 MG IRON/15 ML Brand OTC
CENTRUM SILVER Brand OTC
CENTRUM SILVER ULTRA MEN'S Brand OTC
CENTRUM SPECIALIST HEART Brand OTC
CENTRUM SPECIALIST PRENATAL Brand OTC
CENTRUM ULTRA MEN'S Brand OTC
centrum women Generic OTC
century adults 50 plus Generic OTC
century cardio Generic OTC
century mature oral tablet 0.4-300-250 mg-mcg-mcg
Generic OTC
century oral tablet 18-400 mg-mcg Generic OTC
CENTURY ULTIMATE MEN'S ORAL TABLET 8 MG IRON- 200 MCG-600 MCG
Brand OTC
century ultimate women's oral tablet 18-400 mg-mcg
Generic OTC
cerovite advanced formula Generic OTC
cerovite jr oral tablet,chewable 18 mg iron- 10 mcg
Generic OTC
cerovite senior Generic OTC
certa plus Generic OTC
certavite senior-antioxidant Generic OTC
certavite-antioxidant Generic OTC
chewable-vite Generic OTC
children's iron Generic OTC
childs/iron Generic OTC
cholecalciferol (vitamin d3) oral capsule 125 mcg (5,000 unit), 25 mcg (1,000 unit), 250 mcg (10,000 unit), 50 mcg (2,000 unit)
Generic OTC
cholecalciferol (vitamin d3) oral drops 10 mcg/ml (400 unit/ml), 125 mcg/ml (5,000 unit/ml)
Generic OTC
cholecalciferol (vitamin d3) oral tablet 125 mcg (5,000 unit), 25 mcg (1,000 unit), 50 mcg (2,000 unit)
Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 122
Drug Name Drug Tier Requirements / Limits
cholecalciferol (vitamin d3) oral tablet,chewable 10 mcg (400 unit), 25 mcg (1,000 unit)
Generic OTC
CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET,CHEWABLE 50 MCG (2,000 UNIT)
Brand OTC
classic prenatal Generic OTC
c-nate dha Generic
cod liver oil oral capsule , 1,250-135 unit Generic OTC
cod liver oil oral oil Generic OTC
complete 50 plus Generic OTC
complete multi Generic OTC
complete multi 50+ Generic OTC
complete multivitamin oral tablet Generic OTC
complete multivitamin-mineral oral tablet Generic OTC
complete mv adult 50 plus Generic OTC
complete natal dha Generic
complete oral tablet 18-500-300-250 mg-mcg-mcg-mcg
Generic OTC
complete senior Generic OTC
complete women Generic OTC
completenate Generic OTC
complex b-100 oral tablet extended release Generic OTC
corvita Generic OTC
corvita 150 Generic OTC
CYANOCOBALAMIN (VITAMIN B-12) ORAL LOZENGE
Brand OTC
cyanocobalamin (vitamin b-12) oral tablet 1,000 mcg
Generic OTC
cyanocobalamin (vitamin b-12) oral tablet extended release 1,000 mcg
Generic OTC
cyanocobalamin (vitamin b-12) sublingual tablet 1,000 mcg
Generic OTC
CYANOCOBALAMIN (VITAMIN B-12) SUBLINGUAL TABLET 3,000 MCG, 500 MCG
Brand OTC
d3-2000 Generic OTC
daily multiple for men Generic OTC
DAILY MULTIPLE FOR WOMEN Brand OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
123
Drug Name Drug Tier Requirements / Limits
daily multiple oral tablet , 18-400 mg-mcg Generic OTC
DAILY MULTIPLE ORAL TABLET 400-120 MCG-MG
Brand OTC
daily multivitamin with iron Generic OTC
daily multivitamin-minerals Generic OTC
daily value Generic OTC
daily vitamin formula Generic OTC
daily vitamin formula-iron Generic OTC
daily vites/iron Generic OTC
daily-vite Generic OTC
DECARA ORAL CAPSULE 1,250 MCG (50,000 UNIT), 625 MCG (25,000 UNIT)
Brand OTC
delta d3 Generic OTC
DHA ALGAL-900 Brand OTC
dialyvite Generic OTC
dialyvite 800 oral tablet Generic OTC
dialyvite vitamin d Generic OTC
dino-life Generic OTC
dino-life with extra c Generic OTC
dino-life with iron-zinc Generic OTC
duofer Generic OTC
d-vi-sol Generic OTC
eldertonic Generic OTC
elfolate oral tablet 7.5 mg Generic OTC
ergocalciferol (vitamin d2) oral capsule 1,250 mcg (50,000 unit)
Generic
ergocalciferol (vitamin d2) oral drops Generic OTC
ergocalciferol (vitamin d2) oral tablet 10 mcg (400 unit)
Generic OTC
ERGOCALCIFEROL (VITAMIN D2) ORAL TABLET 50 MCG (2,000 UNIT)
Brand OTC
essentia Generic OTC
ESSENTIAL BALANCE WITH LUTEIN Brand OTC
essential daily Generic OTC
ESTER-C WITH BIOFLAVONOIDS Brand OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 124
Drug Name Drug Tier Requirements / Limits
estronatural Generic OTC
EXPECTA PRENATAL Brand OTC
eye health plus lutein Generic OTC
ezfe 200 Generic OTC
fabb Generic OTC
fe c Generic OTC
fe c plus Generic OTC
FEOSOL BIFERA Brand OTC
feosol oral tablet 325 mg (65 mg iron) Generic OTC
FEOSOL ORAL TABLET 45 MG Brand OTC
ferate oral tablet 240 mg (27 mg iron) Generic OTC
FERGON ORAL TABLET 240 MG (27 MG IRON)
Brand OTC
FER-IN-SOL Brand OTC
ferocon Generic OTC
ferosul oral tablet Generic OTC
ferraplus 90 Generic OTC
ferretts Generic OTC
ferrex 150 Generic OTC
ferrex 150 forte Generic OTC
ferrex 150 forte plus Generic OTC
ferrex 150 plus Generic OTC
ferrex 28 Generic OTC
ferric x-150 Generic OTC
FERRIMIN 150 Brand OTC
ferrocite Generic OTC
ferro-time Generic OTC
ferrous fumarate oral tablet 324 mg (106 mg iron) Generic OTC
ferrous gluconate oral tablet 236 mg (27 mg iron), 240 mg (27 mg iron), 256 mg (28 mg iron), 324 mg (37.5 mg iron), 324 mg (38 mg iron)
Generic OTC
ferrous sulfate oral drops Generic OTC
ferrous sulfate oral elixir Generic OTC
ferrous sulfate oral liquid Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
125
Drug Name Drug Tier Requirements / Limits
ferrous sulfate oral solution Generic OTC
ferrous sulfate oral tablet 325 mg (65 mg iron) Generic OTC
ferrous sulfate oral tablet,delayed release (dr/ec) Generic OTC
ferrousul Generic OTC
fish oil-dha-epa Generic OTC
FLINTSTONES COMPLETE (IRON) ORAL TABLET,CHEWABLE
Brand OTC
FLINTSTONES MULTIVITAMIN ORAL TABLET,CHEWABLE
Brand OTC
FLINTSTONES/EXTRA C ORAL TABLET,CHEWABLE
Brand OTC
fluoride (sodium) oral drops Generic OTC
fluoride (sodium) oral tablet,chewable Generic OTC
fluoritab oral tablet,chewable Generic OTC
folbee Generic OTC
folbee plus Generic OTC
folbic Generic OTC
folic acid oral tablet Generic OTC
folitab Generic OTC
folivane-f Generic OTC
folivane-ob Generic
folivane-plus Generic OTC
folplex 2.2 Generic OTC
foltabs 800 Generic OTC
foltanx Generic OTC
fosfree Generic OTC
fruit c Generic OTC
fruit c-500 Generic OTC
full spectrum b-vitamin c Generic OTC
GERITOL COMPLETE Brand OTC
GERITOL TONIC WITH FERREX 18 Brand OTC
gummi bear multivitamin Generic OTC
gummy dinos oral tablet,chewable 200 mcg Generic OTC
hair vitamins Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 126
Drug Name Drug Tier Requirements / Limits
hair,skin and nails oral tablet Generic OTC
halls defense Generic OTC
healthy eyes supervision Generic OTC
hematinic plus vit/minerals Generic OTC
hematinic/folic acid Generic OTC
hematogen Generic OTC
hematogen fa Generic OTC
hematogen forte Generic OTC
hemetab Generic OTC
HEMOCYTE Brand OTC
high potency iron oral tablet 134 mg (27 mg iron) Generic OTC
honey bears Generic OTC
honey bears with iron-zinc Generic OTC
icaps areds oral capsule Generic OTC
ICAR ORAL SUSPENSION Brand OTC
ICAR-C Brand OTC
iferex 150 Generic OTC
iferex 150 forte Generic OTC
iron (dried) Generic OTC
iron 100 plus Generic OTC
iron chews Generic OTC
iron oral tablet 325 mg (65 mg iron) Generic OTC
iron oral tablet extended release 159 mg (45 mg iron)
Generic OTC
iron, carbonyl Generic OTC
iron,carbonyl-vitamin c Generic OTC
i-vite Generic OTC
i-vite protect Generic OTC
KIDS MULTIVITAMIN-MINERALS Brand OTC
kobee Generic OTC
kpn oral tablet Generic OTC
KPN ORAL TABLET 9 MG IRON- 267 MCG Brand OTC
little animals Generic OTC
little animals-iron oral tablet,chewable Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
127
Drug Name Drug Tier Requirements / Limits
ludent fluoride Generic OTC
lysiplex plus oral liquid Generic OTC
macuvite eye care Generic OTC
MAXIMUM D3 Brand OTC
maximum daily multivitamin Generic OTC
mega multiple/chelated mineral Generic OTC
men's daily multivit-mineral Generic OTC
men's one daily oral tablet Generic OTC
MERIBIN Brand OTC
metafolbic Generic OTC
milltrium senior Generic OTC
multi complete with iron Generic OTC
multi for her oral tablet Generic OTC
multi-day with iron Generic OTC
multi-delyn with iron Generic OTC
multigen Generic OTC
multigen folic Generic OTC
multigen plus Generic OTC
multilex Generic OTC
multiple vitamin-minerals Generic OTC
multiple vitamins Generic OTC
multi-vit with fluoride-iron Generic OTC
multivitamin 50 plus Generic OTC
multivitamin oral tablet Generic OTC
multivitamin with fluoride Generic OTC
multi-vitamin with fluoride oral drops Generic OTC
multivitamin with iron Generic OTC
multivitamin with minerals oral liquid Generic OTC
multivitamins with fluoride Generic OTC
mvc-fluoride Generic OTC
myferon 150 Generic OTC
myferon 150 forte Generic OTC
mynatal Generic
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 128
Drug Name Drug Tier Requirements / Limits
mynatal advance Generic
mynatal plus Generic
mynatal-z Generic
mynate 90 plus Generic
mynephrocaps Generic OTC
mynephron Generic OTC
my-vitalife Generic OTC
natural b-100 complex Generic OTC
nephplex rx Generic OTC
nephronex Generic OTC
NEPHRO-VITE Brand OTC
nephro-vite rx Generic OTC
newgen Generic
norwegian cod liver oil Generic OTC
NOVAFERRUM ORAL DROPS Brand OTC
NU-IRON Brand OTC
obstetrix dha Generic
ocutabs Generic OTC
OCUVITE WITH LUTEIN Brand OTC
omnicap Generic OTC
once daily Generic OTC
ONCOVITE Brand OTC
one daily calcium/iron Generic OTC
one daily complete Generic OTC
one daily energy oral tablet Generic OTC
one daily essential oral tablet , 0.4 mg Generic OTC
one daily for men Generic OTC
one daily for men 50+ advanced Generic OTC
one daily for women Generic OTC
one daily maximum Generic OTC
one daily men's 50 plus memory Generic OTC
one daily multi-vit w-mineral oral tablet Generic OTC
one daily multivit-iron(folic) Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
129
Drug Name Drug Tier Requirements / Limits
one daily oral tablet 0.4-600 mg-mcg Generic OTC
one daily plus iron oral tablet 18-400 mg-mcg Generic OTC
one daily plus minerals Generic OTC
one daily womens 50 plus Generic OTC
one daily women's health Generic OTC
one daily women's oral tablet 18 mg iron-400 mcg-450 mg ca, 27-0.4 mg
Generic OTC
one-a-day essential Generic OTC
one-a-day maximum formula Generic OTC
ONE-A-DAY MEN 50 PLUS (GINKGO) Brand OTC
one-a-day teen advantage Generic OTC
ONE-A-DAY WOMENS FORMULA ORAL TABLET 18 MG IRON-400 MCG-500 MG CA
Brand OTC
opti-vitamins Generic OTC
pantothenic acid (vit b5) Generic OTC
perry prenatal Generic OTC
pnv 29-1 Generic
pnv-dha Generic
pnv-dha + docusate Generic
pnv-omega Generic
pnv-select Generic
poly-iron 150 forte Generic OTC
poly-vitamins Generic OTC
pr natal 400 Generic
pr natal 400 ec Generic
pr natal 430 Generic
pr natal 430 ec Generic
prena1 chew Generic
prena1 pearl Generic
prena1 true Generic
prenaissance Generic
prenaissance plus Generic
prenatabs fa Generic
prenatabs rx Generic
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 130
Drug Name Drug Tier Requirements / Limits
prenatal + dha oral combo pack 28 mg iron- 975 mcg-200 mg
Generic OTC
PRENATAL + DHA ORAL COMBO PACK 28 MG IRON-800 MCG-200 MG
Brand OTC
prenatal 19 Generic OTC
prenatal 19 (with docusate) Generic OTC
prenatal complete Generic OTC
prenatal dha oral capsule 200 mg Generic OTC
prenatal formula oral tablet 28 mg iron- 800 mcg Generic OTC
PRENATAL FORMULA ORAL TABLET 9 MG IRON- 267 MCG
Brand OTC
prenatal low iron Generic
PRENATAL MULTI-DHA(WITH VIT K) Brand OTC
prenatal multivitamins Generic OTC
prenatal one daily Generic OTC
prenatal oral tablet 28 mg iron- 800 mcg Generic OTC
prenatal plus Generic
prenatal plus (calcium carb) Generic
prenatal tablet Generic OTC
prenatal vitamin oral tablet 27 mg iron- 0.8 mg Generic OTC
prenatal vitamin plus low iron Generic
prenatal vits96-iron fum-folic Generic OTC
prenatal-u Generic
preplus Generic
PRESERVISION AREDS Brand OTC
pretab Generic
PRO FE Brand OTC
PROFERRIN-FORTE Brand OTC
purevit dualfe plus Generic OTC
pyridoxine (vitamin b6) oral tablet 100 mg, 25 mg, 250 mg, 50 mg
Generic OTC
quintabs-m iron free Generic OTC
renal caps Generic OTC
rena-vite Generic OTC
rena-vite rx Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
131
Drug Name Drug Tier Requirements / Limits
reno caps Generic OTC
replesta Generic OTC
REPLESTA NX Brand OTC
riboflavin (vitamin b2) oral tablet 100 mg, 50 mg Generic OTC
risacal-d Generic OTC
SAVISION Brand OTC
SCOOBY-DOO ONE A DAY Brand OTC
se-natal 19 chewable Generic
senior tabs Generic OTC
sentry Generic OTC
sentry senior oral tablet 0.4-300-250 mg-mcg-mcg Generic OTC
se-tan plus Generic OTC
SLOW FE Brand OTC
SLOW RELEASE IRON ORAL TABLET EXTENDED RELEASE 140 MG (45 MG IRON), 144 MG (45 MG IRON), 159 MG (45 MG IRON), 168 MG (50 MG IRON)
Brand OTC
slow release iron oral tablet extended release 143 mg (45 mg iron), 160 mg (50 mg iron), 250 mg (50 mg iron)
Generic OTC
soothing pureway-c Generic OTC
spectravite adult 50 plus Generic OTC
spectravite advanced formula oral tablet 18-400 mg-mcg
Generic OTC
spectravite men's Generic OTC
spectravite senior oral tablet 500-300-250 mcg Generic OTC
spectravite ultra women Generic OTC
stress b plus zinc Generic OTC
stress b with zinc Generic OTC
stress formula Generic OTC
stress formula with iron Generic OTC
stress formula with iron(sulf) Generic OTC
stress formula with zinc Generic OTC
sunvite Generic OTC
super b complex-vitamin c Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 132
Drug Name Drug Tier Requirements / Limits
super b maxi complex Generic OTC
super b/c Generic OTC
super b-50 complex Generic OTC
super multiple oral tablet Generic OTC
super multivitamin Generic OTC
super quints Generic OTC
super quints b-50 Generic OTC
super thera vite m Generic OTC
support Generic OTC
tab-a-vite Generic OTC
tab-a-vite/iron Generic OTC
taron forte Generic OTC
taron-c dha Generic
taron-prex prenatal-dha Generic
thera oral tablet Generic OTC
thera-d Generic OTC
theralogix companion Generic OTC
thera-m Generic OTC
therapeutic liquid Generic OTC
therapeutic-m oral tablet 9 mg iron-400 mcg Generic OTC
therapeutic-m vitamin/minerals Generic OTC
thera-tabs Generic OTC
thera-tabs m Generic OTC
theratrum complete 50 plus/lut Generic OTC
theratrum complete 50 plus-lyc Generic OTC
theratrum complete with lutein Generic OTC
therems Generic OTC
therems-m Generic OTC
thiamine hcl (vitamin b1) oral tablet 100 mg, 250 mg
Generic OTC
thrivite-19 Generic OTC
total b/c Generic OTC
tricon Generic OTC
trigels-f forte Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
133
Drug Name Drug Tier Requirements / Limits
trinatal rx 1 Generic
trinate Generic
triphrocaps Generic OTC
triveen-duo dha Generic
tri-vitamin with fluoride Generic OTC
trust natal dha Generic
unicomplex-m Generic OTC
v-c forte Generic OTC
vic-forte Generic OTC
vinate m Generic OTC
vinate one Generic OTC
virt-c dha Generic
virt-gard Generic OTC
virt-nate dha Generic
virt-pn dha Generic
virt-pn plus Generic
virt-vite Generic OTC
VISION PLUS LUTEIN Brand OTC
vit 3 Generic OTC
vita-c Generic OTC
vitacel (with lutein) Generic OTC
VITAFOL-OB Brand
vitajoy daily d Generic OTC
vitalee Generic OTC
vitalets Generic OTC
vitamin b complex Generic OTC
vitamin b complex-folic acid oral tablet Generic OTC
vitamin b-1 Generic OTC
VITAMIN B-12 ORAL LOZENGE 50 MCG Brand OTC
vitamin b-12 oral lozenge 500 mcg Generic OTC
vitamin b-12 oral tablet 100 mcg, 250 mcg, 50 mcg, 500 mcg
Generic OTC
vitamin b-12 oral tablet extended release 2,000 mcg
Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 134
Drug Name Drug Tier Requirements / Limits
vitamin b-12 sublingual tablet 2,500 mcg Generic OTC
vitamin b-2 Generic OTC
vitamin b-6 oral tablet 25 mg, 250 mg, 50 mg Generic OTC
vitamin c drops Generic OTC
vitamin c oral capsule, extended release Generic OTC
vitamin c oral powder Generic OTC
vitamin c oral tablet Generic OTC
vitamin c oral tablet extended release Generic OTC
vitamin c oral tablet,chewable 250 mg, 500 mg Generic OTC
vitamin c with rose hips oral tablet 500 mg Generic OTC
vitamin c with rose hips oral tablet extended release
Generic OTC
vitamin d3 oral capsule 10 mcg (400 unit) Generic OTC
vitamin d3 oral tablet 10 mcg (400 unit) Generic OTC
vitamin d3 oral tablet,chewable 25 mcg (1,000 unit)
Generic OTC
vitamin e (dl, acetate) oral capsule 100 unit, 200 unit, 400 unit
Generic OTC
vitamin e acetate Generic OTC
vitamin e mixed oral capsule 400 unit Generic OTC
vitamin e oral capsule Generic OTC
VITAMIN E ORAL DROPS Brand OTC
vitamins a and d Generic OTC
vitamins a,c,d and fluoride Generic OTC
vitamins and minerals Generic OTC
vitamins b complex oral capsule Generic OTC
VITAMINS B COMPLEX ORAL TABLET 500 MG-400 MCG- 18 MG IRON
Brand OTC
vitamins for hair oral tablet Generic OTC
vitatrum Generic OTC
vitrum senior oral tablet Generic OTC
VITRUM SENIOR ORAL TABLET 500-300-250 MCG
Brand OTC
vp-ch-pnv Generic
vp-vite rx Generic OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
135
Drug Name Drug Tier Requirements / Limits
wee care Generic OTC
WOMEN'S DAILY CAPLET Brand OTC
WOMEN'S DAILY FORMULA ORAL TABLET 18 MG IRON-400 MCG-500 MG CA
Brand OTC
women's daily formula oral tablet 27-0.4 mg Generic OTC
women's prenatal plus dha Generic OTC
yelets Generic OTC
zatean-pn dha Generic
zatean-pn plus Generic
zingiber Generic
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 136
Index
1 12 hour decongestant ............ 86 12 hour nasal spray ............... 53 1-DAY .................................. 77 2 24hour allergy ....................... 86 3 3 day vaginal ......................... 77 3-day vaginal ........................ 77 4 4 way ..................................... 53 4-n-1 no rinse wash ............... 33 5 5-htp .................................... 108 8 8 hour pain reliever ............... 18 A a and d (lan, pet) ................... 33 a thru z ................................ 118 a thru z advanced formula .. 118 a thru z high potency .......... 119 A THRU Z MEN'S
ULTIMATE .................... 119 a thru z select ...................... 119 a thru z select 50plus formula
........................................ 119 a thru z select women's ....... 119 abacavir ................................... 3 abacavir-lamivudine ............... 3 abacavir-lamivudine-
zidovudine .......................... 3 abanatuss ped ........................ 86 abc plus ............................... 119 ABILIFY MAINTENA ........ 24 abiraterone .............................. 9 ABREVA .............................. 48 ABSORBASE ....................... 34 absorbine pain relieving ........ 34 acamprosate .......................... 50 acarbose ................................ 57 ACD-A .................................. 57 acebutolol .............................. 28 ACERFLEX ........................ 108 acerola c-500 ....................... 119 acetadryl ................................ 18 acetaminophen ...................... 18 acetaminophen pm extra str .. 18 acetaminophen-codeine ........ 16
acetazolamide ...................... 85 acetic acid ............................ 56 acid control (ranitidine) ....... 72 acid controller ...................... 72 acid gone antacid ................. 62 acid gone antacid e.strength . 62 acid reducer (cimetidine) ..... 72 acid reducer (famotidine) ..... 72 acid reducer (ranitidine) ....... 72 acidophilus ......................... 108 acidophilus-pectin ................ 60 ACIDOPHILUS-PECTIN,
CITRUS ........................... 60 acitretin ................................ 33 acne cleansing bar ................ 43 acne foaming wash .............. 43 acne treatment (benzoyl perox)
......................................... 43 acne vanishing ..................... 43 acne-clear ............................. 43 actical ................................. 119 acticon (dexbromph-pse) ..... 86 actidom dmx ........................ 86 ACTIMMUNE ..................... 73 ACTOPLUS MET XR ......... 57 acyclovir ................................ 3 added strength headache relief
......................................... 18 adefovir .................................. 3 ADMELOG SOLOSTAR U-
100 INSULIN .................. 57 ADMELOG U-100 INSULIN
LISPRO ............................ 57 adult robitussin peak cold dm
......................................... 86 adult robitussin peak cold m-s
......................................... 86 adult tussin chest congestion 86 adult tussin cough congest dm
......................................... 86 adult tussin dm ..................... 86 adult tussin multi-symp cold 86 adult wal-tussin .................... 86 adult wal-tussin dm max ...... 86 adults 50 plus ..................... 119 advanced antacid-antigas ..... 62 advanced exfoliating cleanser
......................................... 43
advanced eye relief .............. 83 advanced healing (petrolatum)
......................................... 34 ADVANTAGE WITH IRON
....................................... 108 advil ..................................... 18 ADVIL ................................. 18 advil cold and sinus .............. 86 ADVIL COLD AND SINUS 86 ADVIL LIQUI-GEL ............ 18 ADVIL MIGRAINE ............ 18 ADVIL PM .......................... 18 AEMCOLO ............................ 7 af 46 AFINITOR ............................. 9 AFINITOR DISPERZ ............ 9 AFLURIA QD 2019-20(3YR
UP)(PF) ............................ 74 AFLURIA QD 2019-20(6-
35MO)(PF) ....................... 74 AFLURIA QUAD 2019-
20(6MO UP) .................... 74 AFRIN (OXYMETAZOLINE)
......................................... 54 afrin no drip(oxymetazolin) . 54 AIMOVIG AUTOINJECTOR
......................................... 15 AJOVY SYRINGE .............. 15 ak-poly-bac .......................... 81 ala-cort ................................. 48 ala-hist ir .............................. 86 alavert ................................... 86 alavert d-12 allergy-sinus ..... 86 albendazole ............................ 7 albuterol sulfate .................. 101 alcalak ................................ 104 ALECENSA ........................... 9 alendronate ........................... 75 aler-cap ................................. 86 ALEVE ................................ 18 ALEVE COLD AND SINUS
......................................... 86 ALEVE SINUS AND
HEADACHE ................... 86 ALEVE-D SINUS AND
COLD ............................... 86 ALEVE-D SINUS AND
HEADACHE ................... 86
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
137
ALFAMINO JUNIOR ........ 108 alfuzosin .............................. 103 ALGAL OMEGA-3 DHA .. 119 ALGAL-900 DHA .............. 119 ALINIA .................................. 7 alka-seltzer original .............. 18 alka-seltzer plus allergy ........ 86 ALKA-SELTZER PLUS
COLD/COUGHFM .......... 86 ALKA-SELTZER PLUS DAY
.......................................... 86 alka-seltzer plus mucus-conges
.......................................... 86 ALKA-SELTZER PLUS
SINUS-COUGH ............... 86 all day allergy (cetirizine) ..... 86 all day allergy-d .................... 86 all day pain relief .................. 18 all day relief .......................... 18 ALLEGRA ALLERGY ........ 86 ALLEGRA-D 12 HOUR ...... 86 ALLEGRA-D 24 HOUR ...... 87 aller-chlor .............................. 87 allerclear ............................... 87 allerclear d-12hr .................... 87 allerclear d-24hr .................... 87 aller-ease ............................... 87 aller-fex ................................. 87 aller-flo ............................... 101 aller-g-time ........................... 87 allergy (chlorpheniramine) ... 87 allergy (diphenhydramine) ... 87 allergy 4-hour ....................... 87 allergy and congestion relief . 87 allergy and sinus relief .......... 87 allergy complete-d ................ 87 allergy medication ................ 87 allergy medicine ................... 87 allergy multi-symptom ......... 87 allergy plus severe sinus ha .. 87 allergy relief (cetirizine) ....... 87 allergy relief (clemastine) ..... 87 allergy relief (fexofenadine) . 87 allergy relief (loratadine) ...... 87 allergy relief d-24hr .............. 87 allergy relief multi-symptom 87 allergy relief(chlorpheniramn)
.......................................... 87 allergy relief(diphenhydramin)
.......................................... 87
allergy relief,nasal decongest87 allergy relief-d (cetirizine) ... 87 allergy relief-d (loratadine) .. 88 allergy sinus pe .................... 88 allergy sinus-d ...................... 88 allergy-congestion relief-d ... 88 allergy-time .......................... 88 aller-tec ................................ 88 aller-tec d ............................. 88 ALL-NITE COLD-FLU ...... 88 allopurinol ............................ 75 almacone .............................. 62 almacone-2 ........................... 62 ALOE GRANDE ................. 34 ALOE VERA ....................... 34 ALOE VESTA
ANTIFUNGAL (MICON)46 ALOE VESTA CLEANSING
......................................... 34 ALOE VESTA PERINEAL 34 ALOE VESTA
PROTECTANT OINTMENT .................... 34
alophen (bisacodyl) .............. 62 alosetron ............................... 62 alphabath .............................. 34 ALPHAGAN P .................... 85 alprazolam ............................ 24 alprazolam intensol .............. 24 altacaine ............................... 83 altamist ................................. 54 altavera (28) ......................... 77 aluminum hydroxide gel ...... 62 alyacen 1/35 (28) ................. 77 alyacen 7/7/7 (28) ................ 78 amabelz ................................ 76 amantadine hcl ....................... 3 ambrisentan ........................ 101 amcinonide ........................... 48 amerigel ............................... 34 ameriphor ............................. 34 AMERISTORE .................... 34 amethia ................................. 78 amethia lo ............................. 78 amethyst (28) ....................... 78 amiloride .............................. 28 amiloride-hydrochlorothiazide
......................................... 28 aminocaproic acid ................ 30 amiodarone .......................... 27
amitriptyline ......................... 24 amitriptyline-chlordiazepoxide
......................................... 24 amlodipine ........................... 28 amlodipine-atorvastatin ....... 31 amlodipine-benazepril ......... 28 amlodipine-olmesartan ......... 28 amlodipine-valsartan ............ 28 amlodipine-valsartan-hcthiazid
......................................... 28 ammonium lactate ................ 34 amnesteem ........................... 43 amoxapine ............................ 24 amoxicil-clarithromy-lansopraz
......................................... 72 amoxicillin ............................. 8 amoxicillin-pot clavulanate .... 8 ampicillin ............................... 8 anagrelide ............................. 50 analgesic creme .................... 34 analgesic grx balm ............... 34 ANASEPT ........................... 51 ANASEPT SKIN-WOUND
CLEANSER ..................... 51 anaspaz ................................. 60 anastrozole ............................. 9 anefrin .................................. 54 animal chews ...................... 119 animal shapes ..................... 119 ANORO ELLIPTA ............ 101 antacid (calcium carb-mag
hyd) .................................. 62 antacid (calcium carbonate) 104 antacid anti-gas .................... 62 antacid exst (mag carb-al hyd)
......................................... 62 antacid ext str (calcium carb)
....................................... 104 antacid extra-strength ......... 104 antacid m .............................. 62 antacid maximum strength ... 62 antacid plus anti-gas ............. 62 antacid regular strength ........ 62 antacid supreme ................... 62 antacid ultra strength .... 62, 104 antacid-antigas ..................... 63 antacid-simethicone ............. 63 antibiotic (bacitracin zinc) ... 45 antibiotic (neomy-bacit-polym)
......................................... 45
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 138
antibiotic plus pain rel(pram)45 ANTICOAG CITRATE PHOS
DEXTROSE ..................... 51 anti-diarrheal ......................... 60 anti-diarrheal (loperamide) ... 60 anti-fungal ............................. 46 antifungal (tolnaftate) ........... 46 antifungal spray .................... 46 anti-itch (hc) ......................... 48 anti-itch (menthol/camphor) . 34 anti-itch medicated ............... 54 ANTI-ITCH PLUS ............... 48 anti-nausea ............................ 63 antiseptic ............................... 45 antiseptic skin clnsr(chlorhe) 34 antitussive dm ....................... 88 anucort-hc ............................. 63 apatate forte ........................ 119 APETEX ............................. 119 APETIGEN ......................... 119 apetigen plus ....................... 119 ap-hist dm ............................. 88 APOKYN .............................. 14 apraclonidine ........................ 85 aprepitant .............................. 63 apri ........................................ 78 aprodine ................................ 88 APTIVUS ............................... 3 APTIVUS (WITH VITAMIN
E) ........................................ 3 aqua care ............................... 34 aqua glycolic ......................... 34 aqua glycolic face ................. 34 AQUA LACTEN .................. 34 AQUA LUBE ....................... 34 AQUANIL HC ..................... 48 AQUANIL SKIN CLEANSER
.......................................... 34 AQUAPHOR HEALING ..... 34 AQUAPHOR ORIGINAL .... 34 aranelle (28) .......................... 78 ARCALYST ......................... 73 arginine (l-arginine) ............ 108 ARGININE HCL (L-
ARGININE) .................... 108 ARIKAYCE ............................ 7 aripiprazole ........................... 24 ARISTADA .......................... 24 ARISTADA INITIO ............. 24 armodafinil ............................ 24
ARMOUR THYROID ......... 59 arnica .................................... 53 ARNUITY ELLIPTA ........ 101 arthricream rub ..................... 34 arthritis pain relief (acetam) . 18 arthritis pain relief(capsaic) . 34 artificial tears (petro/min) .... 83 artificial tears (pf) ................ 83 artificial tears (polyvin alc) .. 83 artificial tears(dext70-hypro) 83 artificial tears(glycerin-peg) 83 artificial tears(pg-hypm-glyc)
......................................... 83 artificial tears(pvalch-povid) 83 ascomp with codeine ............ 16 ascorbate calcium (vitamin c)
....................................... 119 ascorbic acid (vitamin c) .... 119 ashlyna ................................. 78 ASPERCREME
(LIDOCAINE) ................. 44 ASPERCREME HEAT ....... 34 ASPERCREME WITH ALOE
......................................... 34 asper-flex ............................. 34 aspir-81 ................................ 18 aspirin .................................. 18 aspirin childrens ................... 18 aspirin low dose ................... 18 aspirin,buffd-calcium carb-mag
......................................... 18 aspir-trin ............................... 18 astringent .............................. 34 atazanavir ............................... 3 atenolol ................................ 28 atenolol-chlorthalidone ........ 28 athenol .................................. 18 athlete's foot ......................... 46 athlete's foot (clotrimazole) . 46 athlete's foot (tolnaftate) ...... 47 athletic foot cream ............... 47 atomoxetine .......................... 24 atorvastatin ........................... 31 atovaquone ............................. 7 atovaquone-proguanil ............ 7 ATRAC-TAIN (WITH AHA)
......................................... 34 ATRIPLA .............................. 3 atropine ................................ 82 ATROVENT HFA ............. 101
aubra ..................................... 78 AUGMENTIN ....................... 8 AVEENO BABY ................. 34 AVEENO DAILY
MOISTURIZING ............. 35 aveeno intense relief ............ 35 AVEENO MOISTURIZING 35 AVEENO SOOTHING BATH
......................................... 35 aviane ................................... 78 avidoxy ................................... 8 avita ...................................... 43 AVONEX ............................. 73 AVOSIL ............................... 35 ayr saline .............................. 54 ayr saline nasal neti rinse ..... 54 AYR SINUS RINSE ............ 54 AYR SINUS RINSE REFILL
......................................... 54 AZASAN ............................... 9 azathioprine ............................ 9 azelastine ........................ 54, 83 azithromycin .......................... 6 azolen tincture ...................... 47 azurette (28) ......................... 78 B b complex 1 (with folic acid)
....................................... 119 b complex-vitamin b12 ...... 119 b complex-vitamin c-folic acid
....................................... 119 B COMPLEX-VITAMIN C-
FOLIC ACID ................. 119 b-12 dots ............................ 119 baby ayr saline ..................... 54 baby wash ............................ 35 BACID ................................. 60 bacitracin ........................ 45, 82 bacitracin zinc ...................... 45 bacitracin zinc-polymyxin b 45 bacitracin-polymyxin b ........ 82 bacitraycin plus .................... 45 back and body pain reliever . 19 backache relief extra strength
......................................... 19 baclofen ................................ 16 BACLOFEN ........................ 16 balanced b-100 ................... 119 balanced b-100 complex .... 119 balanced b-50 ..................... 119
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
139
bal-care dha ......................... 119 BALNEOL ............................ 35 BALVERSA ........................... 9 balziva (28) ........................... 78 banophen ............................... 88 BARACLUDE ........................ 3 BASAGLAR KWIKPEN U-
100 INSULIN ................... 57 BAXDELA ............................. 8 bayer advanced ..................... 19 BAYER CHEWABLE
ASPIRIN ........................... 19 bayer plus extra strength ....... 19 baza antifungal ...................... 47 BCAD 1 .............................. 108 b-complex with vitamin c .. 119,
120 BEANO ................................ 63 bekyree (28) .......................... 78 belladonna alkaloids-opium .. 60 BENADRYL ........................ 88 BENADRYL ALLERGY ..... 88 benazepril .............................. 28 benazepril-hydrochlorothiazide
.......................................... 28 benecalorie .......................... 108 BENEFIBER SUGAR FREE
(DEXTRIN) ...................... 63 BENGAY GREASELESS .... 35 BENGAY ULTRA
STRENGTH ..................... 35 bengay ultra strength(menthol)
.......................................... 35 BENGAY VANISHING
SCENT .............................. 35 BENLYSTA ......................... 75 benzepro ................................ 43 benzoin .................................. 35 benzoin compound ................ 35 benzonatate ........................... 88 benzoyl peroxide ................... 43 benztropine ........................... 14 best fiber ............................... 63 beta care ................................ 35 BETADINE .......................... 45 BETADINE SURGICAL
SCRUB ............................. 45 BETADINE SWABSTICKS 45 beta-hc .................................. 48 betamethasone dipropionate . 48
betamethasone valerate .. 48, 49 betamethasone, augmented .. 49 BETAMIDE ......................... 35 betasept surgical scrub ......... 35 betatemp ............................... 19 betaxolol ........................ 28, 82 bethanechol chloride .......... 103 BEVESPI AEROSPHERE 101 bexarotene .............................. 9 BEXSERO ........................... 74 bicalutamide ........................... 9 BIKTARVY ........................... 4 bimatoprost .......................... 85 biocotron .............................. 88 bioflex ................................ 108 biogil .................................... 88 bion tears (pf) ....................... 83 BIONATUSS DXP .............. 88 bionel ................................... 88 biosupp ............................... 120 biotect plus ......................... 108 biotin .................................. 120 BIOTIN .............................. 120 biovol ................................. 120 bisacodyl .............................. 63 bisa-lax (bisacodyl) .............. 63 bismatrol .............................. 60 bismuth ................................ 60 bisoprolol fumarate .............. 28 bisoprolol-hydrochlorothiazide
......................................... 28 BLADDER 2.2 .................. 120 blisovi 24 fe ......................... 78 blisovi fe 1.5/30 (28) ............ 78 blisovi fe 1/20 (28) ............... 78 blis-to-sol (tolnaftate) .......... 47 blue gel ................................. 35 boost ................................... 108 BOOST BREEZE
NUTRITIONAL ............ 108 BOOST CALORIE SMART
....................................... 108 BOOST HIGH PROTEIN . 108 boost kid essentials ............ 108 BOOST KID ESSENTIALS
W-FIBER ....................... 108 BOOST PUDDING ........... 108 BOOST VHC ..................... 108 boro-packs ............................ 35 BOSULIF ............................... 9
BOUDREAUXS BUTT PASTE ............................. 35
bp ......................................... 43 bp wash ................................ 43 bp wash acne treatment ........ 43 bpo-10 .................................. 43 bpo-5 .................................... 43 BRAFTOVI ......................... 10 BREAKFAST ESSENTIALS
....................................... 108 briellyn ................................. 78 bright beginnings soy ......... 108 BRILINTA ........................... 30 brimonidine .......................... 85 brohist d ............................... 88 bromocriptine ....................... 14 brompheniramine-pseudoeph-
dm .................................... 88 brompheniramin-phenylephrin-
dm .................................... 88 broncotron ped ..................... 88 BRONKIDS ......................... 88 brotapp dm ........................... 88 BRUKINSA ......................... 10 bss ........................................ 83 budesonide ................... 63, 101 bufferin ................................. 19 bumetanide ........................... 28 buprenorphine hcl ................ 16 buprenorphine-naloxone ...... 19 bupropion hcl ....................... 24 bupropion hcl (smoking deter)
......................................... 53 buspirone .............................. 24 butalbital compound w/codeine
......................................... 16 butalbital-acetaminop-caf-cod
......................................... 16 butalbital-acetaminophen ..... 16 butalbital-acetaminophen-caff
......................................... 16 butalbital-aspirin-caffeine .... 16 butorphanol tartrate .............. 19 BYDUREON ....................... 57 BYDUREON BCISE ........... 57 C c complex ........................... 120 c-1000 ................................ 120 c-1000 with rose hips ......... 120 c-500 .................................. 120
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 140
cabergoline ............................ 58 ca-d3-mag ox-zinc-cop-mang-
bor ................................... 120 caffeine citrate ...................... 51 calaclear ................................ 44 CALADRYL ........................ 44 calagesic ................................ 44 calahist .................................. 35 calahist clear ......................... 44 calahist with pramoxine ........ 44 calamine medicated .............. 45 calamine phenolated ............. 35 calamine plus (pramox-
calamin) ............................ 45 calamine-zinc oxide .............. 35 calamine-zinc oxide-phenol .. 35 calcidol ................................ 120 CALCILO XD .................... 108 CALCI-MIX ....................... 104 calcipotriene .......................... 33 calcipotriene-betamethasone 33 calcitonin (salmon) ............... 58 calcitrate .............................. 104 calcitriol .......................... 33, 58 calcium 500 + d .................. 104 calcium 500 with d ............. 104 calcium 600 + d(3) .............. 105 calcium 600 + minerals ...... 120 calcium 600 with vitamin d3
........................................ 105 calcium 600-d3 plus (mag-
zinc) ................................ 120 calcium acetate(phosphat bind)
........................................ 105 calcium antacid ................... 105 calcium antacid ultra max st
........................................ 105 calcium carb and citrate-vitd3
........................................ 105 calcium carbonate ............... 105 calcium carbonate-vit d3-min
........................................ 120 calcium carbonate-vitamin d3
........................................ 105 CALCIUM CARBONATE-
VITAMIN D3 ................. 105 calcium citrate ..................... 105 calcium citrate + d .............. 105 calcium citrate plus (vit b6) 105 calcium citrate-vitamin d3 .. 105
calcium for women ............ 120 calcium gluconate .............. 105 CALCIUM GLUCONATE 105 calcium magnesium ........... 106 calcium polycarbophil ......... 63 calcium soft chew .............. 120 calcium-folic acid-vitamin d
....................................... 120 calcium-magnesium-copper-
zinc ................................. 120 calcium-magnesium-zinc ... 106 calcium-vitamin d3-vitamin k
....................................... 120 CALCIUM-VITAMIN D3-
VITAMIN K .................. 120 caldyphen ............................. 45 caldyphen clear .............. 35, 45 cal-gest antacid .................. 106 callergy clear ........................ 45 callus removers .................... 33 calmoseptine ........................ 35 CALPHRON ...................... 106 CALQUENCE ..................... 10 CALTRATE 600 PLUS D . 106 CALTRATE 600-D PLUS
MINERALS ................... 120 CALTRATE WITH VITAMIN
D3 .................................. 106 cam ....................................... 35 camila ................................... 76 CAMPHO-PHENIQUE ....... 35 camrese ................................ 78 camrese lo ............................ 78 capecitabine ......................... 10 CAPRELSA ......................... 10 capsaicin .............................. 35 capsicum .............................. 35 captopril ............................... 28 captopril-hydrochlorothiazide
......................................... 28 capzasin-hp .......................... 35 CARBAGLU ....................... 51 carbamazepine ..................... 13 carbidopa .............................. 14 carbidopa-levodopa .............. 14 carbidopa-levodopa-
entacapone ....................... 14 carbinoxamine maleate ........ 88 carteolol ............................... 82 cartia xt ................................ 28
carvedilol ............................. 28 castor oil ............................... 63 CAVILON DURABLE
BARRIER ........................ 35 CAYSTON ............................. 7 caziant (28) .......................... 78 cefaclor ................................... 6 cefadroxil ............................... 6 cefdinir ................................... 6 cefditoren pivoxil ................... 6 cefprozil ................................. 6 cefuroxime axetil ................... 6 celecoxib .............................. 19 centamin ............................. 120 centratex ............................. 120 centravites .......................... 120 centravites 50 plus ............. 120 CENTRUM ........................ 121 CENTRUM COMPLETE .. 121 CENTRUM MEN .............. 121 CENTRUM SILVER ......... 121 CENTRUM SILVER ULTRA
MEN'S ............................ 121 CENTRUM SPECIALIST
HEART .......................... 121 CENTRUM SPECIALIST
PRENATAL ................... 121 CENTRUM ULTRA MEN'S
....................................... 121 centrum women .................. 121 century ............................... 121 century adults 50 plus ........ 121 century cardio .................... 121 century mature ................... 121 CENTURY ULTIMATE
MEN'S ............................ 121 century ultimate women's .. 121 cephalexin .............................. 6 CERAVE ............................. 35 CERDELGA ........................ 58 cerovite advanced formula . 121 cerovite jr ........................... 121 cerovite senior .................... 121 certa plus ............................ 121 certavite senior-antioxidant 121 certavite-antioxidant .......... 121 CETA-KLENZ GENTLE .... 36 ceta-klenz mild ..................... 36 CETAPHIL .......................... 36
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
141
CETAPHIL DAILYADVANCE .......... 36
cetaphil gentle cleanser ......... 36 CETAPHIL HAND .............. 36 cetaphil moisturizing ............ 36 CETAPHIL MOISTURIZING
.......................................... 36 CETAPHIL RESTORADERM
.......................................... 36 cetiri-d ................................... 88 cetirizine ............................... 88 cetirizine-pseudoephedrine ... 89 cevimeline ............................. 51 CHANTIX ............................ 53 CHANTIX CONTINUING
MONTH BOX .................. 53 CHANTIX STARTING
MONTH BOX .................. 53 chateal (28) ........................... 78 CHEMET .............................. 51 CHENODAL ........................ 63 chest congestion relief .......... 89 chest congestion relief dm .... 89 chest congestion relief pe ..... 89 chest congestion-cough relief
.......................................... 89 chest-sinus congestion relief . 89 chewable-vite ...................... 121 child allergy relf(cetirizine) .. 89 child allergy relief (diphen) .. 89 child benadryl plus congestion
.......................................... 89 child chest congestion-cough 89 CHILD MUCINEX COUGH
MINI-MELTS ................... 89 child mucus relief cough ....... 89 child mucus relief expectorant
.......................................... 89 child pain rel-fever reducer ... 19 child triaminic cold-allergy .. 89 child wal-tap cold-allergy ..... 89 children's acetaminophen ...... 19 children's advil ...................... 19 children's allegra allergy ....... 89 children's allergy (diphenhyd)
.......................................... 89 children's allergy relief(lor) .. 89 children's benadryl allergy .... 89 children's cetirizine ............... 89 children's chest congestion ... 89
CHILDREN'S CLARITIN .. 89 children's cold and cough (pe)
......................................... 89 children's cold-allergy (pe) .. 89 CHILDREN'S COLD-
COUGH-SORE ................ 89 children's cough ................... 89 CHILDREN'S COUGH DM
ER .................................... 89 CHILDREN'S DELSYM
COUGH ........................... 89 children's dibromm cold-allerg
......................................... 89 children's dibromm dm cold-
cou .................................... 89 children's easy-melts ............ 19 children's flu relief ............... 90 children's ibuprofen ............. 19 children's iron .................... 121 children's mapap .................. 19 CHILDREN'S MOTRIN ..... 19 CHILDREN'S MUCINEX
COLD-FEVER ................ 90 children's mucinex cough .... 90 CHILDREN'S MUCINEX
MULTI-SYMP ................ 90 children's non-aspirin ........... 19 children's pain relief ............. 19 children's pain-fever relief ... 19 children's pepto .................... 63 childrens plus cold ............... 90 children's plus flu ................. 90 children's profen ib .............. 19 CHILDREN'S ROBITUSSIN
ER .................................... 90 children's saline nasal spray . 54 children's silapap .................. 19 children's silfedrine .............. 90 children's soothe .................. 63 CHILDREN'S SUDAFED ... 90 children's sudafed pe cough . 90 CHILDREN'S SUDAFED PE
NASAL ............................ 90 children's tactinal ................. 19 CHILDREN'S TYLENOL ... 19 children's wal-dryl allergy ... 90 children's wal-zyr ................. 90 child's all day allergy(cetir) . 90 childs triacting cold-cough .. 90 childs/iron .......................... 121
chlordiazepoxide hcl ............ 24 chlorhexidine gluconate . 36, 54 chlorhist ............................... 90 chloroquine phosphate ........... 7 chlorothiazide ....................... 28 chlorpheniramine maleate .... 90 chlorpromazine .................... 24 chlortabs ............................... 90 chlorthalidone ...................... 28 CHLOR-TRIMETON .......... 90 chlorzoxazone ...................... 16 chocolate laxative ................ 63 CHOLBAM ......................... 63 cholecalciferol (vitamin d3)
............................... 121, 122 CHOLECALCIFEROL
(VITAMIN D3) .............. 122 cholestyramine (with sugar) . 31 cholestyramine light ............. 31 choline,magnesium salicylate
......................................... 19 ciclodan ................................ 47 ciclopirox ............................. 47 cidatrine ............................... 19 cilostazol .............................. 31 CIMDUO ............................... 4 cimetidine ............................. 72 cimetidine hcl ....................... 72 cinacalcet ............................. 58 ciprofloxacin .......................... 8 ciprofloxacin hcl ........ 8, 56, 82 citalopram ............................ 24 CITRACAL + D MAXIMUM
....................................... 106 CITRACAL REGULAR .... 106 CITRACAL-D3 PETITES . 106 CITRACAL-D3 SLOW
RELEASE ...................... 106 citrate of magnesia ............... 63 citroma ................................. 63 citrucel ................................. 63 CITRUCEL (SUCROSE) .... 63 CITRUCEL SUGAR FREE . 63 citrus calcium-vitamin d3 .. 106 claravis ................................. 43 clarithromycin ........................ 6 CLARITIN ........................... 90 CLARITIN LIQUI-GEL ...... 90 CLARITIN REDITABS ...... 90 CLARITIN-D 12 HOUR ..... 90
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 142
CLARITIN-D 24 HOUR ...... 90 classic prenatal .................... 122 clear anti-itch ........................ 36 clearasil daily clear(benzoyl) 43 clearlax .................................. 63 clemastine ............................. 90 clindacin p ............................. 43 clindamycin hcl ....................... 7 clindamycin palmitate hcl ....... 7 clindamycin phosphate ... 44, 77 clobetasol .............................. 49 clobetasol-emollient .............. 49 clomiphene citrate ................. 58 clomipramine ........................ 24 clonazepam ........................... 13 clonidine ............................... 28 clonidine hcl ......................... 28 clopidogrel ............................ 31 clorazepate dipotassium ........ 24 clotrimazole ............................ 3 clotrimazole-3 ....................... 77 clotrimazole-betamethasone . 47 clozapine ......................... 24, 25 c-nate dha ............................ 122 COARTEM ............................. 7 COATS ALOE ..................... 36 COATS ALOE
MOISTURIZING ............. 36 COCOA BUTTER ................ 36 COCONUT OIL CREAM .... 36 cod liver oil ......................... 122 codeine sulfate ...................... 16 codeine-butalbital-asa-caff ... 16 codeine-guaifenesin .............. 90 COLACE .............................. 63 COLCHICINE ...................... 75 cold and allergy .................... 90 cold and allergy (bromphen-pe)
.......................................... 90 cold and allergy pe ................ 91 cold and cough (diphenhydr-
pe) ..................................... 91 cold and cough dm ................ 91 cold and cough elixir ............ 91 COLD AND FLU SEVERE . 91 cold and hot (m.salic-menthol)
.......................................... 36 cold and hot pain relief ......... 36 cold and hot therapy balm .... 36 cold and sinus pain relief ...... 91
COLD HEAD CONGESTION DAY/NITE ...................... 91
COLD HEAD CONGESTION DAYTIME ....................... 91
cold head congestion nighttime ......................................... 91
COLD MULTI-SYMPTOM (CHLORPHEN) ............... 91
COLD MULTI-SYMPTOM DAY/NIGHT ................... 91
COLD RELIEF .................... 91 cold relief m/s day/night ...... 91 cold relief plus ..................... 91 cold-flu relief ....................... 91 cold-sinus relief ................... 91 colestipol .............................. 31 col-rite .................................. 63 COMBIVENT RESPIMAT 101 COMBIVIR ........................... 4 comfort gel ........................... 63 comfort gel extra strength .... 63 COMPLEAT ...................... 108 compleat pediatric reduced cal
....................................... 108 COMPLERA .......................... 4 complete ............................. 122 complete 50 plus ................ 122 complete allergy ................... 91 complete amino acid mix ... 109 complete lice treatment ........ 50 complete multi ................... 122 complete multi 50+ ............ 122 complete multivitamin ....... 122 complete multivitamin-mineral
....................................... 122 complete mv adult 50 plus . 122 complete natal dha ............. 122 complete premium vitamin .. 53 complete senior .................. 122 complete women ................ 122 completenate ...................... 122 COMPLEX 15 ..................... 36 complex b-100 ................... 122 compound w ......................... 33 COMPOZ ............................. 91 compro ................................. 63 conex .................................... 91 constulose ............................ 63 CONTAC COLD-FLU NIGHT
......................................... 91
conti castile soap .................. 36 cool bottoms ......................... 36 cool heat (m-salicylate-menth)
......................................... 36 COPIKTRA ......................... 10 CORICIDIN HBP CHEST
CONG-COUGH ............... 91 CORICIDIN HBP COLD-
MULTI SYMPT .............. 91 CORICIDIN HBP COUGH
AND COLD ..................... 91 CORLANOR ....................... 32 corn starch ............................ 51 CORRECTOL ...................... 64 CORTIFOAM ...................... 64 cortisone ............................... 56 cortisone (hydrocortisone) ... 49 cortisone cooling .................. 49 cortisone with aloe ............... 49 cortizone-10 ......................... 49 corvita ................................ 122 corvita 150 ......................... 122 COTELLIC .......................... 10 COUGH AND COLD
MUCUS RELIEF CF ....... 91 cough formula dm ................ 91 cough syrup dm .................... 91 cough-sore throat night ........ 91 covaryx ................................. 76 covaryx h.s. .......................... 76 creamy acne face .................. 44 CREON ................................ 64 CRESEMBA .......................... 3 CRINONE ............................ 76 critic-aid clear af .................. 47 CRIXIVAN ............................ 4 cromolyn ................ 64, 83, 101 cryoserv ................................ 51 cryselle (28) ......................... 78 CUTEMOL .......................... 36 CUTTER BACKWOODS ... 36 CUTTER BACKWOODS
DRY ................................. 36 CUTTER LEMON
EUCALYPTUS ............... 36 CUTTER NATURAL INSECT
REPELLNT ..................... 36 CUTTER NATURAL
REPELLENT2 ................. 36 CUTTER SKINSATIONS ... 36
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
143
cyanocobalamin (vitamin b-12) ........................................ 122
CYANOCOBALAMIN (VITAMIN B-12) ........... 122
cyclafem 1/35 (28) ................ 78 cyclafem 7/7/7 (28) ............... 78 CYCLINEX-1 ..................... 109 CYCLINEX-2 ..................... 109 cyclobenzaprine .................... 16 cyclopentolate ....................... 82 cyclophosphamide ................ 10 cyclosporine .......................... 10 cyclosporine modified .......... 10 cyproheptadine ...................... 91 cyred ..................................... 78 CYSTADANE ...................... 64 CYSTAGON ...................... 103 CYSTARAN ......................... 83 cytra k crystals .................... 103 cytra-2 ................................. 103 cytra-3 ................................. 103 cytra-k ................................. 103 D d3-2000 ............................... 122 daily moisturizing lotion ....... 36 daily multiple ...................... 123 DAILY MULTIPLE ........... 123 daily multiple for men ........ 122 DAILY MULTIPLE FOR
WOMEN ......................... 122 daily multivitamin with iron
........................................ 123 daily multivitamin-minerals123 daily value ........................... 123 daily vitamin formula ......... 123 daily vitamin formula-iron .. 123 daily vites/iron .................... 123 daily-vite ............................. 123 dakin's solution ..................... 51 DAKIN'S SOLUTION ......... 51 dalfampridine ........................ 15 danazol .................................. 58 dantrolene ............................. 16 dapsone ................................... 7 DARAPRIM ........................... 7 darifenacin .......................... 103 dasetta 1/35 (28) ................... 78 dasetta 7/7/7 (28) .................. 78 DAURISMO ......................... 10 DAY TIME PE ..................... 91
dayhist allergy ...................... 91 daysee .................................. 78 day-time cough .................... 91 deblitane ............................... 76 DECARA ........................... 123 DECONEX DMX ................ 91 DECONEX IR ..................... 92 decongestant inhaler ............ 54 deep sea nasal ...................... 54 deferasirox ........................... 51 DELSTRIGO ......................... 4 DELSYM 12 HOUR ............ 92 delsym cough-chest congest
dm .................................... 92 delta d3 ............................... 123 demeclocycline ...................... 8 DEMSER ............................. 28 denta 5000 plus .................... 54 dentagel ................................ 54 DEPEN TITRATABS ......... 75 dermabase ............................ 36 dermacerin ........................... 36 DERMACLOUD ................. 37 dermadrox ............................ 37 DERMAFUNGAL ............... 47 dermamed (aluminum
hydroxide) ........................ 37 dermaphor ............................ 37 DERMAPHOR .................... 37 dermarest eczema (hydrocort)
......................................... 49 dermasarra ............................ 37 dermavantage ....................... 37 DESCOVY ............................ 4 desenex ................................ 47 desgen dm ............................ 92 desipramine .......................... 25 DESITIN .............................. 37 desloratadine ........................ 92 desmopressin ........................ 58 desog-e.estradiol/e.estradiol 78 desogestrel-ethinyl estradiol 78 desoximetasone .................... 49 despec dm-g ......................... 92 despec eda cough-cold drops 92 despec-dm (phenyleph-dm-
guaif) ................................ 92 DESPEC-DM (PSEUDOEPH-
DM-GUAIF) .................... 92 desvenlafaxine succinate ..... 25
dex4 glucose ........................ 51 dex4 glucose bits .................. 51 dexamethasone ..................... 56 dexamethasone intensol ....... 56 dexamethasone sodium
phosphate ......................... 85 dexmethylphenidate ............. 25 dextroamphetamine .............. 25 dextroamphetamine-
amphetamine .................... 25 dextromethorphan polistirex 92 dextromethorphan-guaifenesin
......................................... 92 DHA ALGAL-900 ............. 123 diabetic siltussin-dm max str 92 diabetic tussin dm ................ 92 diabetic tussin ex .................. 92 DIABETISOURCE AC ..... 109 DIACOMIT ......................... 13 dialyvite ............................. 123 dialyvite 800 ...................... 123 dialyvite vitamin d ............. 123 diamode ................................ 60 diaper rash ............................ 37 DIAPER RASH ................... 37 diaper rash relief .................. 37 diarrhea relief (bismuth subs)
......................................... 60 diazepam ........................ 13, 25 diazepam intensol ................ 25 diclofenac potassium ............ 19 diclofenac sodium .......... 19, 84 diclofenac-misoprostol ......... 20 dicloxacillin ........................... 8 dicyclomine .......................... 60 DI-DAK-SOL ...................... 51 didanosine .............................. 4 diflunisal .............................. 20 DIGESTIVE PROBIOTIC .. 60 digestive relief ...................... 60 digitek .................................. 30 digox .................................... 30 digoxin ................................. 30 DILANTIN .......................... 13 diltiazem hcl ......................... 28 dilt-xr ................................... 28 dimaphen (pe) ...................... 92 dimaphen dm ........................ 92 dimenhydrinate .................... 64
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 144
DIMETAPP COLD-ALLERGY (PE) ............... 92
dimetapp cold-congestion ..... 92 dimetapp dm cold-cough (pe)
.......................................... 92 DIMETAPP LONG-ACTING
(CPM-DM) ....................... 92 dino-life .............................. 123 dino-life with extra c ........... 123 dino-life with iron-zinc ....... 123 diocto .................................... 64 dioctyl ................................... 64 diotame ................................. 60 diphedryl ............................... 92 diphedryl allergy ................... 92 diphen ................................... 92 diphenhist .............................. 92 diphenhydramine hcl ............ 92 diphenhydramine-
acetaminophen .................. 20 diphenoxylate-atropine ......... 60 dipyridamole ......................... 31 diskets ................................... 16 disulfiram .............................. 51 divalproex ............................. 13 dm max ................................. 93 DML ..................................... 37 DML FACIAL
MOISTURIZER ............... 37 DML FORTE ........................ 37 docu ...................................... 64 docuprene .............................. 64 docusate sodium ................... 64 docusil ................................... 64 DOCUSOL ........................... 64 dofetilide ............................... 27 dok ........................................ 64 dok plus ................................. 64 DOMEBORO ....................... 37 dometuss-dmx ....................... 93 dona ...................................... 20 DONA ................................... 20 donepezil ............................... 15 dorzolamide .......................... 85 dorzolamide-timolol ............. 85 DOVATO ............................... 4 doxazosin .............................. 28 doxepin ........................... 25, 37 doxercalciferol ...................... 58 doxycycline hyclate ............ 8, 9
doxycycline monohydrate ...... 9 DR. SMITH'S DIAPER ....... 37 dramamine ........................... 64 dramamine less drowsy ........ 64 driminate .............................. 64 dristan cold ........................... 93 dristan long lasting ............... 54 drospirenone-ethinyl estradiol
......................................... 78 DROXIA .............................. 10 dry eye relief ........................ 83 dry skin therapy ................... 37 dry skin therapy moisturizing
......................................... 37 dss ........................................ 64 ducodyl (bisacodyl) ............. 64 dulcoease .............................. 64 DULCOLAX (BISACODYL)
......................................... 64 duloxetine ............................ 25 DUOCAL ........................... 109 duofer ................................. 123 duofilm ................................. 33 DUPIXENT ......................... 37 DURAFLU .......................... 93 dutasteride .......................... 103 dutasteride-tamsulosin ....... 103 d-vi-sol ............................... 123 dy-o-derm ............................ 53 E e.c. prin ................................ 20 e.e.s. 400 ................................ 6 EAA SUPPLEMENT ........ 109 ear care ............................... 109 ear health formula .............. 109 easy fiber .............................. 64 eazzze the pain ..................... 20 econtra ez ............................. 78 ecotrin low strength ............. 20 ECZEMA RELIEF .............. 37 ed a-hist ................................ 93 ed a-hist dm .......................... 93 ed bron gp ............................ 93 ed chlorped jr ....................... 93 ed-apap ................................. 20 ed-spaz ................................. 60 EDURANT ............................ 4 efavirenz ................................ 4 effer-k ................................ 106 efferves pain relief antacid ... 20
effervescent pain relief ......... 20 EGRIFTA ............................. 73 EGRIFTA SV ...................... 73 eldertonic ........................... 123 ELECARE INFANT
FORMULA .................... 109 ELECARE JR .................... 109 elfolate ............................... 123 elinest ................................... 78 ELIQUIS .............................. 31 ELIQUIS DVT-PE TREAT
30D START ..................... 31 ELLA ................................... 78 ELMIRON ......................... 103 ELON ................................... 37 eluryng ................................. 77 EMCYT ............................... 10 EMEND ............................... 64 EMETROL ........................... 64 EMFLAZA ........................... 56 EMGALITY PEN ................ 15 EMGALITY SYRINGE ...... 15 emollient .............................. 37 emoquette ............................. 79 EMTRIVA ............................. 4 EMVERM .............................. 7 enalapril maleate .................. 28 enalapril-hydrochlorothiazide
......................................... 28 ENBREL .............................. 75 ENBREL MINI .................... 75 ENBREL SURECLICK ....... 75 endacof - dm ........................ 93 ENDARI .............................. 51 endocet ................................. 16 endur-acin ............................ 31 enema ................................... 64 enema disposable ................. 64 ENEMEEZ ........................... 64 ENEMEEZ PLUS ................ 64 ENFAGROW TODDLR
TRANSITION SOY ...... 109 enfamil a.r. ......................... 109 enfamil enfacare ................. 109 ENFAMIL ENFACARE .... 109 ENFAMIL ENFALYTE .... 106 ENFAMIL GENTLEASE .. 109 ENFAMIL GLUCOSE ........ 51 ENFAMIL INFANT .......... 109 ENFAMIL NEWBORN .... 109
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
145
ENFAMIL NEWBORN NON-GMO ............................... 109
ENFAMIL PROSOBEE LIPIL ........................................ 109
enfamil water ........................ 51 ENFAPORT ........................ 109 enoxaparin ............................ 31 enpresse ................................ 79 enskyce ................................. 79 ensure .................................. 109 ENSURE ............................. 109 ensure active heart health ... 109 ensure active light ............... 109 ENSURE ACTIVE MUSCLE
HEALTH ........................ 109 ensure active protein-muscle
........................................ 109 ensure clear ......................... 109 ENSURE CLEAR ............... 109 ensure compact ................... 109 ENSURE ENLIVE ............. 109 ensure high protein ............. 109 ENSURE MUSCLE HEALTH
........................................ 109 ENSURE ORIGINAL ........ 110 ENSURE PLUS .................. 110 ENSURE PUDDING .......... 110 entacapone ............................ 14 entecavir .................................. 4 ENTEX T .............................. 93 ENTRESTO .......................... 32 enulose .................................. 64 EO28 SPLASH ................... 110 ephrine .................................. 54 epinastine .............................. 83 epinephrine ........................... 93 epitol ..................................... 13 EPIVIR ................................... 4 EPIVIR HBV .......................... 4 eprosartan .............................. 29 epsom salt ............................. 64 EPZICOM ............................... 4 ergocalciferol (vitamin d2) . 123 ERGOCALCIFEROL
(VITAMIN D2) .............. 123 ergoloid ................................. 25 ergotamine-caffeine .............. 15 ERIVEDGE .......................... 10 ERLEADA ............................ 10 erlotinib ................................. 10
errin ...................................... 76 ery pads ................................ 44 ery-tab .................................... 6 erythrocin (as stearate) ........... 7 erythromycin .................... 7, 82 erythromycin ethylsuccinate .. 7 erythromycin with ethanol ... 44 ESBRIET ........................... 101 escitalopram oxalate ............ 25 esomeprazole magnesium .... 72 essentia ............................... 123 essential amino acid mix .... 110 ESSENTIAL BALANCE
WITH LUTEIN ............. 123 essential daily ..................... 123 estarylla ................................ 79 estazolam ............................. 25 ESTER-C WITH
BIOFLAVONOIDS ....... 123 estradiol ................................ 76 estradiol-norethindrone acet 76 estrogens-methyltestosterone 76 estronatural ........................ 124 ethacrynic acid ..................... 29 ethambutol ............................. 7 ethosuximide ........................ 13 ethynodiol diac-eth estradiol 79 etidronate disodium ............. 51 etodolac ................................ 20 etonogestrel-ethinyl estradiol77 etoposide .............................. 10 EUCERIN ............................ 37 EUCERIN ECZEMA RELIEF
......................................... 37 eucerin original .................... 37 EUCERIN SKIN CALMING
......................................... 37 evac-u-gen (sennosides) ....... 65 everolimus (antineoplastic) .. 10 EVOTAZ ............................... 4 EXCEDRIN EXTRA
STRENGTH .................... 20 EXCEDRIN MIGRAINE .... 20 EXCEDRIN TENSION
HEADACHE ................... 20 excel-gel ............................... 37 exemestane ........................... 10 EX-LAX (SENNOSIDES) .. 65 EX-LAX MAXIMUM
STRENGTH .................... 65
EXPECTA PRENATAL .... 124 expectorant ........................... 93 EXTAVIA ............................ 73 eye drop tears ....................... 83 eye health plus lutein ......... 124 ezetimibe .............................. 31 ezfe 200 .............................. 124 F fabb .................................... 124 falmina (28) .......................... 79 famciclovir ............................. 4 famotidine ............................ 72 FAST ACTING NASAL ..... 54 fayosim ................................. 79 fe c ...................................... 124 fe c plus .............................. 124 febuxostat ............................. 75 felbamate .............................. 13 felodipine ............................. 29 fem ph .................................. 77 femynor ................................ 79 fenesin dm ir ........................ 93 fenesin ir .............................. 93 fenesin pe ir .......................... 93 fenofibrate ............................ 31 fenofibrate micronized ......... 31 fenofibrate nanocrystallized . 31 fenofibric acid ...................... 31 fenofibric acid (choline) ....... 31 fenoprofen ............................ 20 fentanyl ................................ 17 fentanyl citrate ..................... 17 feosol .................................. 124 FEOSOL ............................ 124 FEOSOL BIFERA ............. 124 ferate .................................. 124 FERGON ........................... 124 FER-IN-SOL ...................... 124 ferocon ............................... 124 ferosul ................................ 124 ferraplus 90 ........................ 124 ferretts ................................ 124 ferrex 150 ........................... 124 ferrex 150 forte .................. 124 ferrex 150 forte plus ........... 124 ferrex 150 plus ................... 124 ferrex 28 ............................. 124 ferric x-150 ........................ 124 FERRIMIN 150 ................. 124 FERRIPROX ....................... 51
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 146
ferrocite ............................... 124 ferro-time ............................ 124 ferrous fumarate .................. 124 ferrous gluconate ................ 124 ferrous sulfate ............. 124, 125 ferrousul .............................. 125 fever reducer an pain reliever
.......................................... 20 feverall .................................. 20 FEVERALL .......................... 20 fexofenadine ......................... 93 fexofenadine-pseudoephedrine
.......................................... 93 fiber ....................................... 65 fiber (calcium polycarbophil)
.......................................... 65 fiber (dextrin) ........................ 65 fiber (psyllium husk) ............ 65 fiber (psyllium husk/sugar) ... 65 fiber (with aspartame) ........... 65 fiber laxative (ca polycarbo) . 65 fiber laxative (methylcellulo)
.......................................... 65 fiber laxative (psyllium husk)
.......................................... 65 fiber smooth .......................... 65 fiber smooth (sucrose) .......... 65 fiber supplement (inulin) ...... 65 fiber therapy (ca polycarboph)
.......................................... 65 fiber therapy (m-cell/sugar) .. 65 fiber therapy (m-cellulose) ... 65 fiber therapy laxative (husk) . 65 FIBERCON .......................... 65 FIBERSOURCE HN .......... 110 fiber-tabs ............................... 65 finasteride ........................... 103 finger cream .......................... 37 first aid antibiotic-pain rlf ..... 45 first aid antiseptic .................. 45 fish oil ................................. 110 FISH OIL ............................ 110 fish oil concentrate ................ 31 fish oil extra strength .......... 110 fish oil-dha-epa ................... 125 flanax (naproxen) .................. 20 flavor chews antacid ........... 106 flavoxate ............................. 103 flaxseed oil ............................ 53 flecainide .............................. 27
fleet enema ........................... 65 fleet glycerin (adult) ............ 65 FLEET GLYCERIN (CHILD)
......................................... 65 fleet laxative (bisacodyl) ...... 65 FLEET MINERAL OIL ...... 65 FLEET PEDIATRIC ........... 65 FLEXGEN ......................... 110 FLINTSTONES COMPLETE
(IRON) ........................... 125 FLINTSTONES
MULTIVITAMIN ......... 125 FLINTSTONES/EXTRA C 125 floranex .............................. 110 florastor ................................ 60 FLOVENT DISKUS .......... 101 FLOVENT HFA ................ 101 flu relief therapy daytime ..... 93 flu relief therapy nighttime .. 93 flu severe cold-night(diph-pe)
......................................... 93 FLUAD 2019-2020 (65 YR
UP)(PF) ............................ 74 FLUARIX QUAD 2019-2020
(PF) .................................. 74 FLUBLOK QUAD 2019-2020
(PF) .................................. 74 FLUCELVAX QUAD 2019-
2020 ................................. 74 FLUCELVAX QUAD 2019-
2020 (PF) ......................... 74 fluconazole ............................. 3 flucytosine .............................. 3 fludrocortisone ..................... 56 FLULAVAL QUAD 2019-
2020 ................................. 74 FLULAVAL QUAD 2019-
2020 (PF) ......................... 74 FLUMIST QUAD 2019-2020
......................................... 74 flunisolide .......................... 101 fluocinolone ......................... 49 fluocinolone acetonide oil .... 56 fluocinonide ......................... 49 fluorescein-proparacaine ...... 83 fluoride (sodium) ......... 54, 125 fluoritab .............................. 125 fluorometholone ................... 85 fluorouracil .......................... 37 fluoxetine ............................. 25
fluphenazine decanoate ........ 25 fluphenazine hcl ................... 25 flurazepam ........................... 25 flurbiprofen .......................... 20 flurbiprofen sodium ............. 84 FLU-SEVERE COLD-
COUGH DAYTIME ........ 93 flutamide .............................. 10 fluticasone propionate .......... 49 fluvoxamine ......................... 25 FLUZONE HIGH-DOSE
2019-20 (PF) .................... 74 FLUZONE QUAD 2019-2020
......................................... 74 FLUZONE QUAD 2019-2020
(PF) .................................. 74 FLUZONE QUAD PEDI
2019-20 (PF) .................... 74 foaming acne face wash ....... 44 foaming antacid .................... 65 folbee ................................. 125 folbee plus .......................... 125 folbic .................................. 125 folic acid ............................ 125 folitab ................................. 125 folivane-f ............................ 125 folivane-ob ......................... 125 folivane-plus ...................... 125 folplex 2.2 .......................... 125 foltabs 800 .......................... 125 foltanx ................................ 125 fondaparinux ........................ 31 foot and sneaker ................... 47 for sty relief .......................... 83 forane ................................... 51 formula 3 .............................. 47 formula em ........................... 65 fosamprenavir ........................ 4 fosfree ................................ 125 fosinopril .............................. 29 fosinopril-hydrochlorothiazide
......................................... 29 fruit c .................................. 125 fruit c-500 .......................... 125 full spectrum b-vitamin c ... 125 fungoid tincture .................... 47 fungoid-d .............................. 47 furosemide ........................... 29 FUZEON ................................ 4 fyavolv ................................. 76
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
147
G g tussin ac ............................. 93 GA GEL .............................. 110 GA POWDER ..................... 110 gabapentin ............................. 13 GALAFOLD ......................... 58 galantamine ........................... 15 garlic ..................................... 53 gavilax .................................. 65 gavilyte-c .............................. 65 gavilyte-g .............................. 65 gavilyte-n .............................. 66 GAVISCON .......................... 66 GAVISCON EXTRA
STRENGTH ..................... 66 GELUSIL ANTACID AND
ANTI-GAS ....................... 66 gemfibrozil ............................ 31 generlac ................................. 66 gengraf .................................. 10 genicin .................................. 20 gentak .................................... 82 gentamicin ...................... 46, 82 gentle laxative (bisacodyl) .... 66 gentle skin cleanser ............... 37 gentlelax ................................ 66 GENVOYA ............................ 4 GERBER GOOD START
GENTLE ......................... 110 GERBER GOOD START
SOY ................................ 110 gerber good start water ......... 51 geri-dryl ................................ 93 geri-hydrolac ......................... 37 geri-kot .................................. 66 geri-lanta ............................... 66 geri-mox antacid-antigas ...... 66 GERI-MUCIL
(ASPARTAME) ............... 66 geri-pectate ........................... 60 GERITOL COMPLETE ..... 125 GERITOL TONIC WITH
FERREX 18 .................... 125 gianvi (28) ............................. 79 GILENYA ............................ 15 GILOTRIF ............................ 10 glatopa .................................. 15 glenmax peb dm .................... 93 glimepiride ............................ 57 glipizide ................................ 57
glipizide-metformin ............. 57 GLUCAGEN HYPOKIT ..... 57 GLUCAGON (HCL)
EMERGENCY KIT ......... 57 GLUCAGON EMERGENCY
KIT (HUMAN) ................ 57 GLUCERNA ...................... 110 GLUCERNA ADVANCE . 110 GLUCERNA HUNGER
SMART .......................... 110 GLUCERNA THERAPEUTIC
NUTRITION .................. 110 gluco burst ........................... 51 glucosamine relief ................ 20 glucosamine sulfate ............. 20 glucose ................................. 51 glucose bits .......................... 51 glucose gel ........................... 51 GLUTARADE JUNIOR .... 110 GLUTAREX-1 .................. 110 GLUTAREX-2 .................. 110 GLUTOSE-15 ...................... 51 glyburide .............................. 57 glyburide micronized ........... 57 glyburide-metformin ............ 57 glycerin (adult) ..................... 66 glycerin (child) ..................... 66 glycine urologic ................. 103 glycine urologic solution ... 103 glycolax ................................ 66 glycopyrrolate ...................... 61 GLYCOSADE ................... 111 glydo .................................... 45 GLYTACTIN 15 PE
COMPLETE .................. 111 GLYTACTIN 20PE
BETTERMILK LITE .... 111 GLYXAMBI ........................ 57 GOLD BOND MEDICATED
......................................... 38 GOLD BOND MEDICATED
ANTI-ITCH ..................... 54 GOLD BOND ULTIMATE
ECZEMA RLF ................. 38 GOLD BOND ULTIMATE
HEALING ........................ 38 gonak .................................... 83 goniotaire ............................. 83 goniovisc .............................. 83 gordon's vite a ...................... 38
gordons-vite e ...................... 38 gormel .................................. 38 gormel ten ............................ 38 G-PREPROTEIN ............... 111 granisetron hcl ...................... 66 green soap ............................ 38 griseofulvin microsize ............ 3 g-tron ped ............................. 93 G-TUSICOF ......................... 93 guaiasorb dm ........................ 93 guaiatussin ac ....................... 93 guaifenesin ........................... 93 guaifenesin ac ...................... 93 guaifenesin dac .................... 93 guanfacine ...................... 25, 29 guanidine .............................. 25 gummi bear multivitamin ... 125 gummy dinos ...................... 125 GYNE-LOTRIMIN ............. 77 GYNE-LOTRIMIN 7 .......... 77 gynol ii ................................. 77 G-ZYNCOF ......................... 93 H hair vitamins ...................... 125 hair,skin and nails .............. 126 halls defense ....................... 126 haloperidol ........................... 25 haloperidol decanoate .......... 25 haloperidol lactate ................ 25 hand wash ............................ 38 h-chlor 12 ............................. 51 H-CHLOR 6 ......................... 51 HCU COOLER .................. 111 hcu express powder ............ 111 HCU GEL POWDER ........ 111 HCU LOPHLEX ................ 111 HCY 1 POWDER .............. 111 HCY 2 ................................ 111 headache pm ........................ 20 headache relief (asa-acet-caf)
......................................... 20 headache relief pm ............... 20 healthy eyes supervision .... 126 healthylax ............................. 66 heartburn antacid .................. 66 heartburn prevention ............ 72 heartburn relief ..................... 66 heartburn relief (cimetidine) 72 heartburn relief (famotidine) 72 heartburn relief (ranitidine) .. 72
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 148
heather .................................. 76 hematinic plus vit/minerals . 126 hematinic/folic acid ............ 126 hematogen ........................... 126 hematogen fa ....................... 126 hematogen forte .................. 126 hemetab ............................... 126 hemmorex-hc ........................ 66 HEMOCYTE ...................... 126 HETLIOZ ............................. 25 hibiclens ................................ 38 HI-CAL ............................... 111 hi-cal plus vit d ................... 106 high potency iron ................ 126 high-protein nutritional shake
........................................ 111 homatropaire ......................... 82 HOMINEX-1 ...................... 111 HOMINEX-2 ...................... 111 honey bears ......................... 126 honey bears with iron-zinc . 126 HUMALOG MIX 50-50
INSULN U-100 ................ 57 HUMALOG MIX 50-50
KWIKPEN ........................ 57 HUMALOG MIX 75-25
KWIKPEN ........................ 57 HUMALOG MIX 75-25(U-
100)INSULN .................... 57 HUMIRA .............................. 75 HUMIRA PEN ..................... 75 HUMIRA(CF) ...................... 75 HUMIRA(CF) PEDI
CROHNS STARTER ....... 75 HUMIRA(CF) PEN .............. 75 HUMIRA(CF) PEN
CROHNS-UC-HS ............. 75 HUMIRA(CF) PEN PSOR-
UV-ADOL HS .................. 75 HUMULIN 70/30 U-100
INSULIN .......................... 57 HUMULIN 70/30 U-100
KWIKPEN ........................ 57 HUMULIN N NPH INSULIN
KWIKPEN ........................ 57 HUMULIN N NPH U-100
INSULIN .......................... 57 HUMULIN R REGULAR U-
100 INSULN ..................... 57
HUMULIN R U-500 (CONC) INSULIN ......................... 57
HUMULIN R U-500 (CONC) KWIKPEN ....................... 58
HYCAMTIN ........................ 10 hydralazine ........................... 29 hydrocerin ............................ 38 hydrocerin (with petrolatum) 38 hydrochlorothiazide ............. 29 HYDROCIL ......................... 66 HYDROCIL INSTANT ....... 66 hydrocodone-acetaminophen 17 hydrocodone-chlorpheniramine
......................................... 94 hydrocodone-homatropine ... 94 hydrocortisone ......... 49, 56, 66 hydrocortisone acetate ... 49, 66 hydrocortisone plus .............. 49 hydrocortisone-aloe vera ..... 49 hydrocortisone-pramoxine .. 33,
66 hydrocream .......................... 49 hydrogen peroxide ............... 51 hydrolatum ........................... 38 hydromet .............................. 94 hydromorphone .................... 17 HYDROPHOR .................... 38 hydroxychloroquine ............... 7 hydroxyurea ......................... 10 hydroxyzine hcl ................... 94 hydroxyzine pamoate ........... 94 hyophen .............................. 103 hyoscyamine sulfate ............. 61 hyosyne ................................ 61 HYPER-HEAL .................... 38 hysept ................................... 52 I ibandronate .......................... 75 IBRANCE ............................ 10 ibu ........................................ 20 ibuprofen .............................. 21 ibuprofen cold-sinus(with pse)
......................................... 94 ibuprofen ib .......................... 20 ibuprofen jr strength ............ 20 ibuprofen pm ........................ 21 icaps areds .......................... 126 ICAR .................................. 126 ICAR-C .............................. 126 icatibant .............................. 101
ice blue gel ........................... 38 ICLUSIG .............................. 10 ICY HOT ............................. 38 icy hot (menthol) .................. 38 ICY HOT PAIN RELIEVING
......................................... 38 IDHIFA ................................ 10 iferex 150 ........................... 126 iferex 150 forte ................... 126 imatinib ................................ 10 IMBRUVICA ....................... 10 imipramine hcl ..................... 25 imipramine pamoate ............ 25 imiquimod ............................ 38 immulife ............................. 111 IMODIUM A-D ................... 61 IMODIUM MULTI-
SYMPTOM RELIEF ....... 61 IMPACT ADVANCED
RECOVERY .................. 111 IMPACT PEPTIDE 1.5 CAL
....................................... 111 INBRIJA .............................. 14 INCRELEX .......................... 52 INCRUSE ELLIPTA ......... 101 indapamide ........................... 29 indomethacin ........................ 21 infant fever reducer-pain relf 21 infant pain reliever ............... 21 infant's advil ......................... 21 infant's ibuprofen ................. 21 infant's motrin ...................... 21 infants' pain and fever .......... 21 infants' pain relief ................ 21 infant's pain reliever ............. 21 infants profenib .................... 21 INGREZZA ......................... 15 INGREZZA INITIATION
PACK ............................... 15 INLYTA ............................... 10 inositol ............................... 111 INREBIC ............................. 10 INSECT REPELLENT
(DEET) ............................. 38 INSECT REPELLENT
(PICARIDIN) ................... 38 INSTACLEAN .................... 53 INTELENCE ......................... 4 INTRON A .......................... 73 introvale ............................... 79
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
149
INVIRASE .............................. 4 inzo antifungal ...................... 47 iodine-sodium iodide ............ 38 ipecac .................................... 66 ipratropium bromide ..... 54, 101 ipratropium-albuterol .......... 102 irbesartan .............................. 29 irbesartan-hydrochlorothiazide
.......................................... 29 IRESSA ................................ 10 iron ...................................... 126 iron (dried) .......................... 126 iron 100 plus ....................... 126 iron chews ........................... 126 iron, carbonyl ...................... 126 iron,carbonyl-vitamin c ...... 126 ISENTRESS ........................... 4 ISENTRESS HD ..................... 4 isoflurane .............................. 52 ISOLEUCINE ..................... 111 isometh-dichloral-
acetaminophn .................... 15 ISOMIL ADVANCE .......... 111 ISOMIL DF ........................ 111 ISOMIL/IRON .................... 111 isoniazid .................................. 7 ISOPTO TEARS ................... 83 isosorbide dinitrate ............... 32 isosorbide mononitrate ......... 32 isosource hn ........................ 111 isoxsuprine ............................ 77 isradipine .............................. 29 itch relief (pramoxine-zinc) .. 38 itraconazole ............................. 3 I-VALEX-1 ......................... 111 I-VALEX-2 ......................... 111 ivermectin ............................... 7 i-vite .................................... 126 i-vite protect ........................ 126 J JADENU ............................... 52 JADENU SPRINKLE ........... 52 JAKAFI ................................ 11 jantoven ................................ 31 JANUMET ............................ 58 JANUMET XR ..................... 58 JANUVIA ............................. 58 JARDIANCE ........................ 58 jencycla ................................. 76 JEVITY 1 CAL ................... 111
JEVITY 1.2 CAL ............... 111 JEVITY 1.5 CAL ............... 111 jinteli .................................... 76 jock itch ............................... 47 jock itch (clotrimazole) ........ 47 jock itch (terbinafine) .......... 47 johnson's baby oil ................ 38 jolessa .................................. 79 jr. acetaminophen ................. 21 jr. str non-aspirin pain .......... 21 jr. strength pain reliever ....... 21 juleber .................................. 79 JULUCA ................................ 4 junel 1.5/30 (21) ................... 79 junel 1/20 (21) ...................... 79 junel fe 1.5/30 (28) .............. 79 junel fe 1/20 (28) ................. 79 junel fe 24 ............................ 79 JUVEN ............................... 111 JUXTAPID .......................... 31 JYNARQUE ........................ 59 K kaitlib fe ............................... 79 KALETRA ............................. 4 KALYDECO ..................... 102 kaolin-pectin ........................ 61 kaopectate (bismuth subsalicy)
......................................... 61 KAOPECTATE (DOCUSATE
CALCIUM) ...................... 66 kaopectate ex str (bismuth ss)
......................................... 61 kao-tin (docusate calcium) ... 66 kariva (28) ............................ 79 kelnor 1/35 (28) ................... 79 ketoconazole .................... 3, 47 ketodan ................................. 47 KETONEX-1 ..................... 111 KETONEX-2 ..................... 111 ketoprofen ............................ 21 ketorolac ........................ 21, 84 KETOVOLVE ................... 111 KIDS MULTIVITAMIN-
MINERALS ................... 126 kionex (with sorbitol) .......... 52 KITABIS PAK ....................... 7 klor-con .............................. 106 klor-con 10 ......................... 106 klor-con 8 ........................... 106 klor-con m10 ...................... 106
klor-con m15 ...................... 106 klor-con m20 ...................... 106 klor-con/ef .......................... 106 kobee .................................. 126 konsyl (sugar) ...................... 66 konsyl fiber .......................... 66 konsyl sugar-free .................. 66 k-pec antidiarrheal (bism sub)
......................................... 61 K-PHOS NO 2 ................... 103 K-PHOS ORIGINAL ......... 103 k-phos-neutral .................... 106 kpn ..................................... 126 KPN ................................... 126 k-tab ................................... 106 kurvelo (28) .......................... 79 KUVAN ............................... 59 L l norgest/e.estradiol-e.estrad 79 l.acidophilus-bifido.longum . 61 labetalol ................................ 29 LAC-HYDRIN FIVE ........... 38 LACTINEX ....................... 112 lactobacillus acidophilus .... 112 LACTOBACILLUS
ACIDOPHILUS ............. 112 lactulose ............................... 67 lamisil af .............................. 47 lamisil at ............................... 47 lamivudine ............................. 4 lamivudine-zidovudine .......... 4 lamotrigine ........................... 13 LANAFLEX ...................... 112 lan-o-soothe ......................... 38 lansoprazole ......................... 72 LANTISEPTIC DRY SKIN
THERAPY ....................... 38 LANTISEPTIC SKIN
PROTECTANT ............... 38 larin 1.5/30 (21) ................... 79 larin 1/20 (21) ...................... 79 larin 24 fe ............................. 79 larin fe 1.5/30 (28) ............... 79 larin fe 1/20 (28) .................. 79 larissia .................................. 79 latanoprost ............................ 85 laxacin .................................. 67 laxaclear ............................... 67 laxative (bisacodyl) .............. 67 laxative (glycerin-pediatric) . 67
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 150
laxative (sennosides) ............. 67 laxative peg 3350 .................. 67 laxative pills .......................... 67 laxative pills regular ............. 67 laxative plus stool softener ... 67 l-carnitine .............................. 52 lecithin ................................ 112 leena 28 ................................. 79 leflunomide ........................... 75 LENVIMA ............................ 11 lessina ................................... 79 letrozole ................................ 11 leucovorin calcium ................. 9 LEU-FREE COOLER ........ 112 LEUKERAN ......................... 11 leuprolide .............................. 11 levetiracetam ......................... 13 levobunolol ........................... 82 levocarnitine ......................... 52 levocarnitine (with sugar) ..... 52 levocetirizine ........................ 94 levofloxacin ...................... 8, 82 levonest (28) ......................... 79 levonorgestrel ....................... 79 levonorgestrel-ethinyl estrad 79 levonorg-eth estrad triphasic 80 levora-28 ............................... 80 levothyroxine ........................ 59 levoxyl .................................. 59 LEXIVA ................................. 4 lice bedding spray ................. 50 lice complete kit 1-2-3 .......... 50 lice killing ............................. 50 lice killing (permethrin) ........ 50 lice pyrinyl shampoo ............ 50 lice solution ........................... 50 lice treatment ........................ 50 lidocaine ................................ 45 lidocaine hcl .......................... 45 lidocaine hcl-hydrocortison ac
.................................... 45, 67 LIDOCAINE PAIN RELIEF 45 lidocaine viscous ................... 45 lidocaine-hydrocortisone-aloe
.......................................... 67 lidocaine-prilocaine .............. 45 LIDOCARE .......................... 45 linezolid .................................. 7 liothyronine ........................... 59 lipistart ................................ 112
LIPO-FLAVONOID PLUS 112 liquibid d-r ........................... 94 LIQUIBID PD-R ................. 94 liquid antacid ....................... 67 LIQUID CALCIUM WITH
VITAMIN D .................. 106 liquid corn and callus remover
......................................... 33 lisinopril ............................... 29 lisinopril-hydrochlorothiazide
......................................... 29 lite coat aspirin ..................... 21 lithium carbonate ................. 25 lithium citrate ....................... 25 little animals ....................... 126 little animals-iron ............... 126 LITTLE NOSES .................. 54 little remedies ....................... 54 little remedies fever and pain 21 l-lysine ............................... 112 LMD POWDER ................. 112 lohist - d ............................... 94 lohist-dm .............................. 94 LONSURF ........................... 11 loperamide ........................... 61 LOPHLEX ......................... 112 lopinavir-ritonavir .................. 4 lopreeza ................................ 76 lorata-d ................................. 94 loratadine ............................. 94 loratadine-d .......................... 94 lorazepam ............................. 25 lorazepam intensol ............... 25 LORBRENA ........................ 11 lorcet (hydrocodone) ............ 17 lorcet hd ............................... 17 lorcet plus ............................. 17 lortuss ex .............................. 94 loryna (28) ........................... 80 losartan ................................. 29 losartan-hydrochlorothiazide 29 LOTRIMIN AF .................... 47 LOTRIMIN AF
(CLOTRIMAZOLE) ........ 47 lotrimin af powder ............... 47 lovastatin .............................. 31 low-ogestrel (28) .................. 80 loxapine succinate ................ 25 l-phenylalanine .................. 112 lta pre-attached ..................... 45
lubricant (p-glycol-glycerin) 83 LUBRICANT EYE .............. 83 lubricant eye drops ............... 83 LUBRICANT EYE DROPS 83 lubricating plus .................... 83 lubriderm daily moisture (pet)
......................................... 38 LUBRIDERM SENSITIVE
SKIN ................................ 38 lubriderm skin nourishing .... 38 lubrifresh pm ........................ 84 lubrisilk ................................ 39 lubrisoft ................................ 39 LUCEMYRA ....................... 21 ludent fluoride .................... 127 lugols .................................. 106 lutera (28) ............................. 80 LYNPARZA ........................ 11 lysine .................................. 112 lysine hcl ............................ 112 LYSINE HCL .................... 112 lysiplex plus ....................... 127 LYSODREN ........................ 11 lyza ....................................... 76 M MAALOX ADVANCED .... 67 maalox maximum strength ... 67 macuvite eye care ............... 127 mafenide acetate .................. 46 MAG-AL ............................. 67 mag-g ................................. 106 magnesium ................... 67, 106 magnesium citrate ................ 67 magnesium gluconate ........ 106 MAGNESIUM GLUCONATE
....................................... 106 magnesium oxide ............... 107 MAGOX ............................ 107 mapap (acetaminophen) ....... 21 mapap arthritis pain ............. 21 mapap cold formula ............. 94 mapap extra strength ............ 21 mapap pm ............................. 21 mapo bath ............................. 39 maprotiline ........................... 26 marlissa (28) ........................ 80 masanti double strength ....... 67 masophen ............................. 21 MATULANE ....................... 11 matzim la .............................. 29
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
151
MAVENCLAD (4 TABLET PACK) .............................. 15
MAVYRET ............................ 5 maxepa .................................. 32 MAXIMUM D3 .................. 127 maximum daily multivitamin
........................................ 127 MAYZENT ........................... 15 m-clear wc ............................ 94 mct pro-cal .......................... 112 meclizine ............................... 67 meclofenamate ...................... 21 MEDERMA .......................... 39 MEDERMA FOR KIDS ....... 39 medicated body powder ........ 39 medicated chest rub .............. 39 MEDICATED HEAT PATCH
.......................................... 39 medi-meclizine ..................... 67 mediproxen ........................... 21 medi-seltzer .......................... 22 MEDROX (WITHOUT
METHYL SALICY) ......... 39 medroxyprogesterone ........... 76 mefloquine .............................. 7 mega multiple/chelated mineral
........................................ 127 megestrol .............................. 11 MEKINIST ........................... 11 MEKTOVI ............................ 11 meloxicam ............................ 22 melphalan .............................. 11 memantine ............................ 15 MENACTRA (PF) ................ 74 MENEST .............................. 76 men-phor ............................... 39 men's daily multivit-mineral
........................................ 127 men's one daily ................... 127 MENTHODERM .................. 39 menthol ................................. 39 mercaptopurine ..................... 11 MERIBIN ........................... 127 mesalamine ........................... 67 MESNEX ................................ 9 metadate er ............................ 26 metafolbic ........................... 127 metafolbic plus ................... 112 METAMUCIL ...................... 68
METAMUCIL (WITH SUGAR) .......................... 67
METAMUCIL FIBER THIN ......................................... 68
METAMUCIL FREE .......... 68 METAMUCIL
MULTIHEALTH FIBER 68 METAMUCIL SUGAR-FREE
(ASPART) ....................... 68 METAMUCIL SUNRISE ... 68 metaproterenol ................... 102 metaxall ................................ 16 metformin ............................ 58 methadone ............................ 17 methadose ............................ 17 methamphetamine ................ 26 methenamine hippurate .......... 9 methenamine mandelate ........ 9 methen-sod phos-meth blue-
hyos ................................ 103 methergine ........................... 81 methimazole ......................... 57 METHIONAID .................. 112 METHITEST ....................... 59 methocarbamol .................... 16 methotrexate sodium ............ 11 methoxsalen ......................... 39 methyl salicylate .................. 39 methyldopa .......................... 29 methyldopa-
hydrochlorothiazide ......... 29 methylergonovine ................ 81 methylphenidate hcl ............. 26 methylprednisolone .............. 56 methyltestosterone ............... 59 metipranolol ......................... 82 metoclopramide hcl ............. 68 metolazone ........................... 29 metoprolol succinate ............ 29 metoprolol ta-hydrochlorothiaz
......................................... 29 metoprolol tartrate ............... 29 metronidazole ............ 7, 44, 77 mexiletine ............................ 27 mgo .................................... 107 MG-PLUS-PROTEIN ........ 107 mi-acid ................................. 68 MIADERM .......................... 39 micatin ................................. 47 miconazole 7 ........................ 77
miconazole nitrate .......... 47, 77 miconazole-3 ........................ 77 miconazorb af ...................... 47 microgestin 1.5/30 (21) ........ 80 microgestin 1/20 (21) ........... 80 microgestin fe 1.5/30 (28) .... 80 microgestin fe 1/20 (28) ....... 80 micro-guard .......................... 48 midazolam ............................ 26 midodrine ............................. 52 midol pm .............................. 22 migergot ............................... 15 miglitol ................................. 58 miglustat ............................... 59 migraine formula .................. 22 migraine relief ...................... 22 milk of magnesia .................. 68 milk of magnesia concentrated
......................................... 68 millipred ............................... 56 millipred dp .......................... 56 milltrium senior .................. 127 mimvey ................................ 76 mineral oil extra heavy ........ 68 MINERAL OIL HEAVY ..... 68 mineral oil light .............. 39, 52 minerin ................................. 39 minerin creme ...................... 39 minocycline ............................ 9 minoxidil .............................. 29 mintox .................................. 68 mintox maximum strength ... 68 mintox plus .......................... 68 miralax ................................. 68 MIRALAX ........................... 68 mirtazapine ........................... 26 misoprostol ........................... 72 MMA-PA COOLER15 ...... 112 MMA-PA EXPRESS15 ..... 112 MMA-PA GEL .................. 112 mobisyl ................................. 39 modafinil .............................. 26 moexipril .............................. 29 moisture barrier ointment ..... 39 moisture drops ...................... 84 moiturizing lotion ................ 39 molindone ............................ 26 mometasone ......................... 49 mondoxyne nl ........................ 9
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 152
MONISTAT 1 COMBO PACK ................................ 77
MONISTAT 3 ....................... 77 MONISTAT 7 ....................... 77 mono-linyah .......................... 80 MONSEL'S ........................... 39 montelukast ......................... 102 morgidox ................................. 9 morphine ............................... 17 morphine concentrate ........... 17 mosco callus-corn remover ... 33 motion relief (meclizine) ...... 68 motion sickness ..................... 68 motion sickness (meclizine) . 68 motion sickness ii ................. 68 motion sickness relief ........... 68 motion sickness relief(mecliz)
.......................................... 68 motion-time .......................... 68 MOTRIN IB ......................... 22 motrin pm ............................. 22 MOVANTIK ........................ 68 move it along ........................ 68 moxifloxacin ........................... 8 MSUD AID ......................... 112 MSUD ANALOG ............... 112 MSUD COOLER ................ 112 MSUD EXPRESS COOLER
........................................ 112 MSUD GEL POWDER ...... 112 MSUD LOPHLEX ............. 112 MSUD MAXAMAID ......... 112 MSUD MAXAMUM ......... 112 mucinex ................................ 95 MUCINEX ............................ 94 mucinex d ............................. 94 mucinex d maximum strength
.......................................... 94 mucinex dm .......................... 94 MUCINEX DM .................... 94 mucinex fast-max cold-flu-thrt
.......................................... 94 MUCINEX FAST-MAX
COLD-SINUS .................. 94 MUCINEX FAST-MAX
CONGEST-COUGH ........ 94 mucinex fast-max dm max ... 94 mucinex sinus-max ............... 54 MUCINEX SINUS-MAX SEV
CONGESTN ..................... 95
mucosa ................................. 95 mucosa dm ........................... 95 mucus relief ......................... 95 MUCUS RELIEF COLD AND
SINUS .............................. 95 MUCUS RELIEF COLD-
FLU-SORE THR ............. 95 MUCUS RELIEF
CONGESTION-COUGH 95 mucus relief cough ............... 95 mucus relief d (pseudoephed)
......................................... 95 mucus relief dm ................... 95 mucus relief dm max ........... 95 mucus relief er ..................... 95 mucus relief pe ..................... 95 MUCUS RELIEF SEV
CONGEST-COLD ........... 95 mucus relief sinus ................ 95 MULPLETA ........................ 31 multi antibiotic plus ............. 46 multi complete with iron .... 127 multi for her ....................... 127 multi-day with iron ............ 127 multi-delyn with iron ......... 127 multigen ............................. 127 multigen folic ..................... 127 multigen plus ..................... 127 multilex .............................. 127 multiple vitamin-minerals .. 127 multiple vitamins ............... 127 multi-vit with fluoride-iron 127 multivitamin ....................... 127 multivitamin 50 plus .......... 127 multivitamin with fluoride . 127 multi-vitamin with fluoride 127 multivitamin with iron ....... 127 multivitamin with minerals 127 multivitamins with fluoride 127 mupirocin ............................. 46 MURI-LUBE ....................... 52 muscle rub ............................ 39 muscle rub (with camphor) .. 39 muscle rub ultra-strength ..... 39 mvc-fluoride ...................... 127 my way ................................. 80 mycophenolate mofetil ........ 11 mycophenolate sodium ........ 11 myferon 150 ....................... 127 myferon 150 forte .............. 127
MYLERAN .......................... 11 mynatal ............................... 127 mynatal advance ................ 128 mynatal plus ....................... 128 mynatal-z ........................... 128 mynate 90 plus ................... 128 mynephrocaps .................... 128 mynephron ......................... 128 myorisan ............................... 44 my-vitalife .......................... 128 N nabumetone .......................... 22 nadolol ................................. 29 nadolol-bendroflumethiazide 29 naloxone ............................... 22 NALOXONE ....................... 22 naltrexone ............................. 22 naproxen ............................... 22 naproxen sodium .................. 22 naratriptan ............................ 15 NARCAN ............................. 22 nasadock plus kit .................. 54 nasaflo porcelain kit ............. 54 nasal allergy ....................... 102 nasal allergy symptom control
....................................... 102 nasal decongestant (oxymetazl)
......................................... 54 nasal decongestant (pe) ........ 95 nasal decongestant
(pseudoeph) ...................... 95 nasal four .............................. 54 nasal mist ............................. 54 nasal moisturizing ................ 55 nasal relief ............................ 55 nasal relief sinus wash w/neti
......................................... 55 nasal relief sinus wash-bottle 55 nasal spray (oxymetazoline) 55 nasal spray (sodium chloride)
......................................... 55 nasal spray
12hr(oxymetazoline ......... 55 nasal spray long acting ......... 55 NASALCROM .................. 102 NATACYN .......................... 82 nateglinide ............................ 58 NATPARA ........................... 59 NATRAPEL ......................... 39 natural b-100 complex ....... 128
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
153
natural fiber laxative ............. 68 natural fiber laxative (sugar) . 68 NATURAL FIBER
LAXATIVE (SUGAR) ..... 68 natural fiber laxative therapy 68 natural fiber laxative(aspart) . 68 natural fiber supplemnt(asprt)
.......................................... 69 natural oatmeal bath treatment
.......................................... 39 NATURAL PSYLLIUM
FIBER ............................... 69 natural tears (pf) .................... 84 natural veg laxative(sennosid)
.......................................... 69 natural vegetable ................... 69 natural vegetable (psyllium) . 69 natural vegetable powder ...... 69 natura-lax .............................. 69 nature-throid ......................... 59 nausea control ....................... 69 nausea relief .......................... 69 NAYZILAM ......................... 13 NEBUPENT ........................... 7 nebusal ................................ 102 necon 0.5/35 (28) .................. 80 neilmed nasaflo ..................... 55 neilmed pediat sinus rinse ref
.......................................... 55 neilmed sinus rinse complete 55 neilmed sinus rinse refill ....... 55 NEOCATE INFANT DHA-
ARA ................................ 112 NEOCATE JUNIOR .......... 113 NEOCATE JUNIOR WITH
PREBIOTICS ................. 113 NEOCATE NUTRA ........... 113 NEOCATE SPLASH .......... 113 neomycin ................................ 7 neomycin-bacitracin-poly-hc 85 neomycin-bacitracin-
polymyxin ......................... 82 neomycin-polymyxin b-
dexameth ........................... 85 neomycin-polymyxin-
gramicidin ......................... 82 neomycin-polymyxin-hc . 56, 85 neo-polycin ........................... 82 neo-polycin hc ...................... 85 neosporin (neo-bac-polym) ... 46
NEOSPORIN (NEO-BAC-POLYM) .......................... 46
NEOSPORIN + PAIN RELIEF ......................................... 46
NEOSPORIN MOISTURIZING ............ 39
NEO-SYNEPHRINE (PHENYLEPHRINE) ...... 55
neo-tuss ................................ 95 NEOTUSS PLUS ................. 95 NEOTUSS-D (IMPROVED
FORMULA) .................... 95 nephplex rx ........................ 128 nephronex .......................... 128 NEPHRO-VITE ................. 128 nephro-vite rx ..................... 128 NEPRO CARB STEADY .. 113 NERLYNX .......................... 11 neutraphor ............................ 39 NEUTROGENA .................. 40 NEUTROGENA ACNE
CLEANSING SOAP ....... 39 NEUTROGENA FACIAL
SOAP ............................... 39 NEUTROGENA LIP
MOISTURIZER .............. 39 NEUTROGENA ON THE
SPOT ................................ 44 NEUTROGENA SENSITIVE
SKN MOIST .................... 40 nevirapine .............................. 5 newgen ............................... 128 NEXAVAR .......................... 11 NEXIUM 24HR ................... 72 niacin .................................... 32 NIACIN ............................... 32 niacin (inositol niacinate) ... 32,
113 niacin (niacinamide) ............ 32 niacin flush free ................. 113 NIACIN FLUSH FREE ..... 113 NIACIN NO FLUSH ......... 113 niacinamide .......................... 32 NICODERM CQ ................. 53 nicorelief .............................. 53 NICORETTE ....................... 53 nicotine ................................ 53 nicotine (polacrilex) ............. 53 NICOTINE (POLACRILEX)
......................................... 53
NICOTROL ......................... 53 NICOTROL NS ................... 53 nifedipine ............................. 29 night time ............................. 95 night time cold and flu relief 95 night time cold-flu ............... 95 night time pain medicine ...... 22 nightime sleep ...................... 95 nighttime allergy relief ......... 95 nighttime cold-flu ................ 95 NIGHTTIME COLD-FLU
RELIEF ............................ 95 nighttime cough ................... 95 nighttime sleep aid (diphen) 95,
96 nikki (28) .............................. 80 nilutamide ............................ 11 NINLARO ........................... 11 NITE TIME COLD-FLU
RELIEF ............................ 96 nite time-d cold-flu relief ..... 96 nitetime multi-symptom ....... 96 nitisinone .............................. 52 nitro-bid ............................... 33 nitrofurantoin macrocrystal .... 9 nitrofurantoin monohyd/m-
cryst .................................... 9 nitroglycerin ......................... 33 nitro-time ............................. 33 NIVEA SOFT ...................... 40 NIX CREME RINSE ........... 50 nizatidine .............................. 72 NIZORAL A-D .................... 48 no drip .................................. 55 noble formula ....................... 50 noble formula hc .................. 50 nohist-dm ............................. 96 nohist-lq ............................... 96 non-aspirin ........................... 22 non-aspirin childrens ............ 22 non-aspirin extra strength .... 22 non-aspirin flu ...................... 96 non-aspirin pain relief .......... 22 non-aspirin pm ..................... 22 nora-be ................................. 76 NORDITROPIN FLEXPRO 73 NOREL AD ......................... 96 norethindrone (contraceptive)
......................................... 76 norethindrone acetate ........... 76
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 154
norethindrone ac-eth estradiol .................................... 76, 80
norethindrone-e.estradiol-iron .......................................... 80
norgestimate-ethinyl estradiol .......................................... 80
norlyda .................................. 76 nortemp ................................. 22 nortrel 0.5/35 (28) ................. 80 nortrel 1/35 (21) .................... 80 nortrel 1/35 (28) .................... 80 nortrel 7/7/7 (28) ................... 80 nortriptyline .......................... 26 NORVIR ................................. 5 norwegian cod liver oil ....... 128 nose drops ............................. 55 NOURISH .......................... 113 NOVAFERRUM ................ 128 novasource renal 2 cal ........ 113 NOXAFIL ............................... 3 np thyroid .............................. 59 NUBEQA .............................. 11 NUEDEXTA ........................ 15 NU-IRON ........................... 128 NUTRA PRO HIGH
PROTEIN ....................... 113 nutrafit ................................ 113 nutrafit plus ......................... 113 NUTRAMIGEN DHA-ARA
........................................ 113 NUTRAMIGEN TODDLER
ENFLORA-LGG ............ 113 NUTRAMIGEN WITH
ENFLORA LGG ............. 113 nutren 1.0 ............................ 113 nutren 1.5 ............................ 113 nutren 2.0 ............................ 113 nutren junior ....................... 113 nutren junior fiber ............... 113 NUTREN PULMONARY .. 113 NUTRIHEP ........................ 113 nutritional drink mix ........... 113 nutritional drink plus .......... 113 nutritional shake ................. 113 NUTRITIONAL SHAKE ... 113 nutritional shake plus .......... 113 NUTRITIONAL SHAKE
PLUS .............................. 114 nyamyc .................................. 48 nystatin .............................. 3, 48
nystop ................................... 48 O OA 1 POWDER ................. 114 OA2 POWDER .................. 114 oatmeal bath regular ............ 40 obstetrix dha ....................... 128 OC8 ...................................... 44 OCALIVA ........................... 69 ocean nasal ........................... 55 ocella .................................... 80 octreotide acetate ................. 11 ocusoft hand soap ................ 40 ocutabs ............................... 128 OCUVITE WITH LUTEIN 128 ODEFSEY ............................. 5 odor control foot-sneaker ..... 48 ODORLESS GARLIC ......... 53 OFEV ................................. 102 OFF ACTIVE ...................... 40 OFF DEEP WOODS ........... 40 OFF DEEP WOODS DRY .. 40 OFF FAMILYCARE (WITH
DEET) .............................. 40 ofloxacin .................... 8, 56, 82 ogestrel (28) ......................... 80 olanzapine ............................ 26 olanzapine-fluoxetine .......... 26 olmesartan-amlodipin-
hcthiazid ........................... 29 olopatadine ..................... 55, 84 omega 3-6-9 complex ........ 114 omega 3-dha-epa-fish oil ... 114 OMEGA 3-DHA-EPA-FISH
OIL ................................. 114 omega-3 acid ethyl esters ..... 32 omega-3 fatty acids .............. 32 omega-3 fatty acids-fish oil 114 OMEGA-3 FATTY ACIDS-
FISH OIL ....................... 114 OMEGA-3 FISH OIL ........ 114 omega-3 flaxseed oil ............ 53 OMEGA-3S-DHA-EPA-FISH
OIL ................................. 114 omeprazole ........................... 72 omeprazole magnesium ....... 72 omnicap .............................. 128 OMNITROPE ...................... 74 once daily ........................... 128 ONCOVITE ....................... 128 ondansetron .......................... 69
ondansetron hcl .................... 69 one daily ............................. 129 one daily calcium/iron ....... 128 one daily complete ............. 128 one daily energy ................. 128 one daily essential .............. 128 one daily for men ............... 128 one daily for men 50+
advanced ........................ 128 one daily for women .......... 128 one daily maximum ........... 128 one daily men's 50 plus
memory .......................... 128 one daily multi-vit w-mineral
....................................... 128 one daily multivit-iron(folic)
....................................... 128 one daily plus iron .............. 129 one daily plus minerals ...... 129 one daily women's .............. 129 one daily womens 50 plus .. 129 one daily women's health ... 129 one-a-day essential ............. 129 one-a-day maximum formula
....................................... 129 ONE-A-DAY MEN 50 PLUS
(GINKGO) ..................... 129 one-a-day teen advantage ... 129 ONE-A-DAY TRUBIOTICS
......................................... 61 ONE-A-DAY WOMENS
FORMULA .................... 129 opcicon one-step .................. 80 OPSUMIT .......................... 102 option-2 ................................ 80 opti-vitamins ...................... 129 oral saline laxative ............... 69 oralone ................................. 55 oralyte ................................ 107 ORANGE CHICKN-
CARROT-BRWN RICE 114 ORFADIN ............................ 52 original nasal spray .............. 55 ORILISSA ........................... 59 ORKAMBI ......................... 102 orphenadrine citrate ............. 16 orsythia ................................. 80 OS-CAL 500 + D3 ............. 107 oscimin ................................. 61 oscimin sl ............................. 61
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
155
oscimin sr .............................. 61 oseltamivir .............................. 5 OSMOLITE 1 CAL ............ 114 OSMOLITE 1.2 CAL ......... 114 OTEZLA ............................... 75 OTEZLA STARTER ............ 75 oxandrolone .......................... 59 oxazepam .............................. 26 OXBRYTA ........................... 52 oxcarbazepine ....................... 13 OXEPA ............................... 114 OXERVATE ......................... 84 oxybutynin chloride ............ 103 oxycodone ............................. 17 oxycodone-acetaminophen ... 17 oxycodone-aspirin ................ 17 oxymetazoline ....................... 55 oysco 500/d ......................... 107 oysco-500 ............................ 107 oyster shell calcium 500 ..... 107 oyster shell calcium-vit d3 .. 107 oystercal-d .......................... 107 P pacerone ................................ 27 pain relief ........................ 22, 23 pain relief (menthol) ............. 40 pain relief (trolamine salicy) . 40 pain relief adult ..................... 22 pain relief allergy sinus ......... 96 pain relief cream ................... 40 pain relief pm ........................ 23 pain relief pm rapid release .. 23 pain relief regular strength .... 23 pain reliever .......................... 23 pain reliever (acetam-aspirin)
.......................................... 23 pain reliever extra strength ... 23 pain reliever plus .................. 23 pain relieving (menthol) ....... 40 pain relieving cream ............. 40 pain relieving(cam-m.sal-ment)
.......................................... 40 pain-off ................................. 23 paliperidone .......................... 26 panoxyl ................................. 44 pantoprazole .......................... 73 pantothenic acid (vit b5) ..... 129 paregoric ............................... 61 paromomycin .......................... 7 paroxetine hcl ....................... 26
p-col rite ............................... 69 PECGEN DMX ................... 96 pedia relief infant nasal ........ 96 pediacare fever reducer ........ 23 pediacare multi-symptom cold
......................................... 96 PEDIA-LAX ........................ 69 PEDIA-LAX STOOL
SOFTENER ..................... 69 pedialyte ............................. 107 PEDIALYTE ADVANCED
CARE ............................. 107 pedialyte singles ................. 107 PEDIASURE ..................... 114 PEDIASURE ENTERAL .. 114 PEDIASURE GROW-GAIN
....................................... 114 pediasure peptide 1.0 cal .... 114 PEDIASURE PEPTIDE 1.5
CAL ............................... 114 PEDIASURE SIDEKICKS 114 pediatric balanced nutrition 114 pediatric cough and cold ...... 96 pediatric electrolyte ........... 107 pediatric enema .................... 69 pediatric freezer pops ......... 107 pediatric oint (cod liver oil) . 40 PEDI-BORO SOAK ............ 40 peg 3350-electrolytes ........... 69 PEGASYS ............................ 74 peg-electrolyte soln .............. 69 peg-prep ............................... 69 penicillamine ........................ 75 penicillin v potassium ............ 8 PEN-KERA .......................... 40 pentoxifylline ....................... 31 pepcid ac .............................. 73 PEPCID AC ......................... 73 PEPTAMEN ...................... 115 PEPTAMEN AF ................ 114 PEPTAMEN JUNIOR ....... 115 PEPTAMEN JUNIOR 1.5 . 115 peptamen junior fiber ......... 115 peptic relief .......................... 61 PEPTO-BISMOL ................. 61 PEPTO-BISMOL MAX ST . 61 pepto-bismol to-go ............... 61 PERATIVE ........................ 115 percogesic ............................ 23 percogesic extra strength ..... 23
perdiem overnight relief ....... 69 PERFOROMIST ................ 102 PERIANAL CLEANSING .. 40 PERIFLEX ADVANCE .... 115 PERIFLEX INFANT ......... 115 PERIFLEX JUNIOR .......... 115 PERIFRESH ........................ 40 perindopril erbumine ............ 30 periogard .............................. 55 PERISCENT ........................ 40 permethrin ............................ 50 perphenazine ........................ 26 perphenazine-amitriptyline .. 26 perry prenatal ..................... 129 persa-gel ............................... 44 petrolatum ............................ 40 petrolatum, yellow (bulk) .... 40 PETROLEUM JELLY,
WHITE ............................. 40 PFD 2 ................................. 115 PFD TODDLER ................ 115 pharbechlor .......................... 96 pharbedryl ............................ 96 pharbetol .............................. 23 phenadoz .............................. 96 PHENAGIL ......................... 96 phenazopyridine ................. 104 phenelzine ............................ 26 PHENEX-1 ........................ 115 PHENEX-2 ........................ 115 phenobarbital ....................... 13 phenohytro ........................... 61 phenoxybenzamine .............. 30 PHENYLADE 60 .............. 115 PHENYLADE ESSENTIAL
....................................... 115 phenylephrine hcl ................. 85 PHENYL-FREE 1 .............. 115 PHENYL-FREE 2 PKU ..... 115 phenytoin ............................. 14 phenytoin sodium extended . 14 philith ................................... 80 PHILLIPS .......................... 107 PHILLIPS' COLON HEALTH
......................................... 61 PHILLIPS' LIQUI-GELS .... 69 PHILLIPS MILK OF
MAGNESIA .................... 69 PHLEXY-10 DRINK MIX
POWDER ....................... 115
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 156
phlexy-vits .......................... 115 phos-nak .............................. 107 phospha 250 neutral ............ 107 phosphasal .......................... 103 phosphate laxative ................ 69 PHOSPHOLINE IODIDE .... 82 phospho-trin 250 neutral ..... 107 phytonadione (vitamin k1) .... 31 PHYTONADIONE
(VITAMIN K1) ................ 31 PIFELTRO .............................. 5 pilocarpine hcl ................ 52, 83 pimozide ............................... 26 pimtrea (28) .......................... 80 pindolol ................................. 30 pink bismuth ......................... 61 pioglitazone .......................... 58 pioglitazone-glimepiride ....... 58 pioglitazone-metformin ........ 58 PIQRAY ............................... 11 pirmella ................................. 80 piroxicam .............................. 23 PKU COOLER 10 .............. 115 PKU COOLER 15 .............. 115 PKU COOLER 20 .............. 115 PKU LOPHLEX ................. 115 PLAN B ONE-STEP ............ 80 PLEGRIDY .......................... 74 PNEUMOVAX-23 ............... 74 pnv 29-1 .............................. 129 pnv-dha ............................... 129 pnv-dha + docusate ............. 129 pnv-omega .......................... 129 pnv-select ............................ 129 podofilox ............................... 40 polycin .................................. 82 polyethylene glycol 3350 ...... 69 poly-iron 150 forte .............. 129 polymyxin b sulf-trimethoprim
.......................................... 82 POLYSPORIN
(BACITRACIN ZINC) ..... 46 polyvinyl alcohol .................. 84 poly-vitamins ...................... 129 POMALYST ......................... 11 portia 28 ................................ 80 posaconazole ........................... 3 pot,sodium citrate-citric acid
........................................ 104 potassium chloride .............. 107
potassium citrate-citric acid 104 potassium gluconate ........... 107 povidone-iodine ................... 46 powderlax ............................ 69 pr natal 400 ........................ 129 pr natal 400 ec .................... 129 pr natal 430 ........................ 129 pr natal 430 ec .................... 129 PRALUENT PEN ................ 32 pramipexole ......................... 14 pravastatin ............................ 32 praziquantel ............................ 7 prazosin ................................ 30 PRED MILD ........................ 85 prednicarbate ........................ 50 prednisolone ......................... 56 prednisolone acetate ............. 85 prednisolone sodium phosphate
................................... 56, 85 prednisone ............................ 56 prednisone intensol .............. 56 pregabalin ............................ 14 PREGESTIMIL ................. 115 pre-menstrual relief .............. 23 PREMIUM INFANT
FORMULA .................... 115 premsyn pms ........................ 23 prena1 chew ....................... 129 prena1 pearl ....................... 129 prena1 true ......................... 129 prenaissance ....................... 129 prenaissance plus ............... 129 prenatabs fa ........................ 129 prenatabs rx ........................ 129 prenatal .............................. 130 prenatal + dha .................... 130 PRENATAL + DHA ......... 130 prenatal 19 ......................... 130 prenatal 19 (with docusate) 130 prenatal complete ............... 130 prenatal dha ........................ 130 prenatal formula ................. 130 PRENATAL FORMULA .. 130 prenatal low iron ................ 130 PRENATAL MULTI-
DHA(WITH VIT K) ...... 130 prenatal multivitamins ....... 130 prenatal one daily ............... 130 prenatal plus ....................... 130 prenatal plus (calcium carb)130
prenatal tablet ..................... 130 prenatal vitamin ................. 130 prenatal vitamin plus low iron
....................................... 130 prenatal vits96-iron fum-folic
....................................... 130 prenatal-u ........................... 130 PREPARATION H
HYDROCORTISONE ..... 50 preplus ................................ 130 pre-protein .......................... 115 pres gen ................................ 96 PRES GEN PEDIATRIC ..... 96 PRESERVISION AREDS . 130 PRESGEN B ........................ 96 pretab ................................. 130 PRETTY FEET HANDS ..... 40 PREVACID 24HR ............... 73 prevalite ............................... 32 previfem ............................... 80 PREVNAR 13 (PF) .............. 74 PREVYMIS ........................... 5 PREZCOBIX ......................... 5 PREZISTA ............................. 5 PRIFTIN ................................ 7 PRILOSEC OTC .................. 73 primidone ............................. 14 PRO FE .............................. 130 PROAIR RESPICLICK ..... 102 probenecid ............................ 75 probenecid-colchicine .......... 75 probiotic ....................... 61, 115 probiotic colon care ............. 61 procel ................................. 115 procentra .............................. 26 prochlorperazine .................. 69 prochlorperazine maleate ..... 69 procto-med hc ...................... 69 procto-pak ............................ 69 proctosol hc .......................... 70 proctozone-hc ....................... 70 PRODUCT 3232A ............. 115 PROFERRIN-FORTE ....... 130 progesterone micronized ...... 76 PROGLYCEM ..................... 58 PROMACTA ....................... 31 promethazine ........................ 96 promethazine vc ................... 96 promethazine-codeine .......... 96 promethazine-dm ................. 96
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
157
promethazine-phenyleph-codeine .............................. 96
promethegan ......................... 96 PROMOD PROTEIN ......... 115 promolaxin ............................ 70 PROMOTE ......................... 115 PROMOTE WITH FIBER . 115 propafenone .......................... 27 proparacaine .......................... 84 PRO-PHREE ...................... 115 PROPIMEX-1 ..................... 116 PROPIMEX-2 ..................... 116 propranolol ............................ 30 propranolol-hydrochlorothiazid
.......................................... 30 propylthiouracil .................... 57 PROSHIELD FOAM/SPRAY
CLEANSER ...................... 40 prosource ............................ 116 PROSOURCE ..................... 116 prosource no carb ................ 116 pro-stat awc ......................... 116 PRO-STAT SUGAR FREE 116 protective ointment ............... 40 protein ................................. 116 PROTEINEX ...................... 116 PROTEINEX-100 ............... 116 PROTEINEX-18 ................. 116 protriptyline .......................... 26 provil ..................................... 23 PROVIMIN ........................ 107 prudoxin ................................ 40 pseudoephedrine hcl ............. 96 psyllium husk ........................ 70 PULMOCARE .................... 116 pulmosal .............................. 102 PULMOZYME ................... 102 PURAMINO TODDLER ... 116 pure and gentle eye ............... 84 purelax .................................. 70 purevit dualfe plus .............. 130 PURIXAN ............................ 11 pyrazinamide .......................... 7 pyridostigmine bromide ........ 16 pyridoxine (vitamin b6) ...... 130 Q quazepam .............................. 26 quetiapine .............................. 26 quinapril ................................ 30
quinapril-hydrochlorothiazide ......................................... 30
quinidine gluconate .............. 27 quinidine sulfate ................... 27 quinine sulfate ........................ 8 QUINOA-KALE-HEMP ... 116 quintabs-m iron free ........... 130 quit 2 .................................... 53 quit 4 .................................... 53 R rabeprazole ........................... 73 raloxifene ............................. 75 ramelteon ............................. 27 ramipril ................................ 30 ranitidine hcl ........................ 73 rasagiline .............................. 14 RAVICTI ............................. 52 RCF SOY PROTEIN
FORMULA BASE ......... 116 REBIF (WITH ALBUMIN) 74 REBIF REBIDOSE ............. 74 REBIF TITRATION PACK 74 reclipsen (28) ....................... 81 RECTIV ............................... 70 refenesen .............................. 96 refenesen dm ........................ 96 refenesen pe ......................... 96 REFRESH CELLUVISC ..... 84 REFRESH CONTACTS ...... 84 REFRESH LACRI-LUBE ... 84 REFRESH LIQUIGEL ........ 84 REFRESH P.M. ................... 84 REFRESH PLUS ................. 84 REFRESH TEARS .............. 84 REGRANEX ........................ 40 reguloid (psyllium husk-sucro)
......................................... 70 reguloid, sugar free .............. 70 REJUVENESS ..................... 40 RELENZA DISKHALER ..... 5 remedy antifungal ................ 48 remedy cleansing body ........ 41 REMEDY NUTRASHIELD
SKIN PROTEC ................ 41 remedy phytoplex antifungal 48 RENA START ................... 116 RENACIDIN ..................... 104 renal caps ........................... 130 rena-vite ............................. 130 rena-vite rx ......................... 130
RENEWAL BATH TREATMENT ................. 41
reno caps ............................ 131 repaglinide ........................... 58 repaglinide-metformin ......... 58 REPATHA PUSHTRONEX 32 REPATHA SURECLICK .... 32 REPATHA SYRINGE ......... 32 REPEL 100 .......................... 41 REPEL FAMILY ................. 41 REPEL HUNTER'S ............. 41 REPEL SPORTSMEN DRY 41 REPEL SPORTSMEN MAX
......................................... 41 REPEL TICK DEFENSE .... 41 replesta ............................... 131 REPLESTA NX ................. 131 replete ................................. 116 replete fiber ........................ 116 RESCON-DM ...................... 96 rescon-gg .............................. 97 resource 2.0 ........................ 116 RETAINE PM ...................... 84 RETROVIR ........................... 5 revive plus ............................ 84 REVLIMID .......................... 11 REYATAZ ............................. 5 ribavirin .................................. 5 riboflavin (vitamin b2) ....... 131 rid complete lice elim kit ..... 50 RID COMPLETE LICE ELIM
KIT ................................... 50 RIDAURA ........................... 75 rifabutin .................................. 8 rifampin .................................. 8 ri-gel ..................................... 70 ri-gel ii .................................. 70 riginic ................................... 70 riluzole ................................. 52 ri-mag ................................... 70 ri-mag plus ........................... 70 rimantadine ............................ 5 ri-mox ................................... 70 ri-mox plus ........................... 70 ringworm .............................. 48 RISA-BID ............................ 62 risacal-d .............................. 131 risamine ................................ 41 risaquad ................................ 62 risaquad-2 ............................. 62
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 158
risedronate ...................... 52, 75 risperidone ............................ 27 ritifed .................................... 97 ritonavir .................................. 5 ri-tussin ................................. 97 ri-tussin dm ........................... 97 rivastigmine .......................... 15 rivastigmine tartrate .............. 15 rivelsa .................................... 81 rizatriptan .............................. 15 robafen .................................. 97 robafen cf (phenylephrine) ... 97 robafen cough ....................... 97 robafen dm cough ................. 97 robafen dm cough-chest
congest .............................. 97 robitussin cough and cold cf . 97 robitussin cough-chest cong
dm ..................................... 97 ROBITUSSIN COUGHGEL 97 ROBITUSSIN LONG-
ACTING ........................... 97 robitussin pediatric ............... 97 ROLAIDS ............................. 70 ropinirole .............................. 14 rosadan .................................. 44 rosula cleansing cloths .......... 44 rosuvastatin ........................... 32 roweepra ............................... 14 ROZLYTREK ...................... 11 RUBRACA ........................... 11 RU-HIST D ........................... 97 RYDAPT .............................. 12 rydex ..................................... 97 rynex dm ............................... 97 rynex pe ................................ 97 rynex pse ............................... 97 S SAF-CLENS AF DERMAL
WOUND ........................... 41 SAFE TUSSIN DM .............. 97 safe wash ............................... 52 saline mist ............................. 55 saline nasal ............................ 55 saline wound wash ................ 52 SALMON-OATS-SQUASH
........................................ 116 SALONPAS-HOT ................ 41 salsalate ................................. 23 SAMSCA .............................. 59
SANDIMMUNE .................. 12 SANTYL .............................. 50 SARNA ORIGINAL ........... 41 SAVELLA ........................... 75 SAVISION ......................... 131 scalacort ............................... 50 scalp relief ............................ 50 SCALP RELIEF .................. 33 scalpicin anti-itch ................. 50 scandishake ........................ 116 SCANDISHAKE ............... 116 scandishake (lactose free) .. 116 scar gel ................................. 41 SCOOBY-DOO ONE A DAY
....................................... 131 SCOT-TUSSIN DIABETES
CF .................................... 97 scot-tussin dm ...................... 97 scot-tussin expectorant ......... 97 SCOT-TUSSIN SENIOR .... 97 sea-omega 30 ..................... 116 seconal sodium ..................... 27 SECUADO .......................... 27 secura antifungal .................. 48 SECURA EXTRA
PROTECTIVE ................. 41 secura protective .................. 41 SEGLUROMET .................. 58 selegiline hcl ........................ 14 selenium sulfide ................... 33 SELZENTRY ........................ 5 se-natal 19 chewable .......... 131 senexon-s ............................. 70 senior probiotic .................... 62 senior tabs .......................... 131 senna .................................... 70 senna lax .............................. 70 senna laxative ....................... 70 senna plus ............................. 70 senna with docusate sodium 70 senna-s ................................. 70 senna-time s ......................... 70 senno .................................... 70 sennosides-docusate sodium 70 SENOKOT ........................... 70 SENOKOT EXTRA
STRENGTH .................... 70 SENOKOT-S ....................... 70 sen-o-tab .............................. 70 SENSI-CARE ...................... 41
sentry .................................. 131 sentry senior ....................... 131 serophene ............................. 59 sertraline ............................... 27 se-tan plus .......................... 131 setlakin ................................. 81 sevelamer carbonate ............. 52 severe allergy ....................... 23 SEVERE ALLERGY-SINUS
HEADACHE ................... 97 severe cold ........................... 97 SEVERE COLD AND FLU-
DAY (DM) ....................... 97 sevoflurane ........................... 52 sf 55 sf 5000 plus .......................... 55 shake that ache ..................... 23 sharobel ................................ 76 SHINGRIX (PF) .................. 74 SIGNIFOR ........................... 12 silace .................................... 70 siladryl sa ............................. 97 sildenafil (pulm.hypertension)
....................................... 102 SILICONE SCAR ................ 41 siltussin dm das .................... 97 siltussin sa ............................ 97 siltussin-dm .......................... 97 SILVASORB ....................... 46 silver sulfadiazine ................ 33 SILVERMED ....................... 46 SIMILAC ADVANCE ...... 116 similac advance organic ..... 116 SIMILAC ADVANCE
ORGANIC ..................... 116 SIMILAC ADVANCE WITH
IRON .............................. 116 similac alimentum .............. 116 SIMILAC EXPERT CARE 116 SIMILAC EXPERT CARE
ALIMENTUM ............... 116 SIMILAC EXPERT CARE
NEOSURE ..................... 116 SIMILAC FOR SPIT-UP ... 117 SIMILAC HUMAN MILK
FORTIFIER ................... 117 SIMILAC LOW-IRON ...... 117 SIMILAC PM .................... 117 SIMILAC PRO-ADVANCE
NON-GMO .................... 117
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
159
SIMILAC PRO-SENSITIVE NON-GMO ..................... 117
SIMILAC SENSITIVE ....... 117 similac sensitive fuss and gas
........................................ 117 SIMILAC SENSITIVE FUSS
AND GAS ....................... 117 SIMILAC SENSITIVE
ISOMIL SOY ................. 117 SIMILAC SOY ISOMIL .... 117 SIMILAC SPECIAL CARE 24
........................................ 117 SIMILAC SPECIAL CARE 30
........................................ 117 similac sterilized water ......... 52 SIMILAC
SUPPLEMENTATION .. 117 SIMILAC TOTAL
COMFORT ..................... 117 SIMILAC TOTAL
COMFORT NON-GMO . 117 simply sleep .......................... 97 simvastatin ............................ 32 sinugator nasal wash kit ........ 55 sinus 12 hour ......................... 98 sinus and allergy pe .............. 98 sinus congestion-pain(chlorph)
.......................................... 98 sinus decongestant (pe) ......... 98 sinus headache pe ................. 98 sinus nasal spray ................... 55 sinus pain relief ..................... 98 sinus pe decongestant ........... 98 sinus relief (non-drowsy) ...... 98 sinus relief (oxymetazoline) . 55 sinus rinse pediatric .............. 55 sinus rinse pediatric starter ... 55 sinus wash ............................. 55 sinus-allergy (phenylephrine)
.......................................... 98 sirolimus ............................... 12 SIRTURO ............................... 8 skin cleanser ......................... 41 skin protectant a and d .......... 41 skin treatment ....................... 41 SKYRIZI .............................. 33 sleep aid (diphenhydramine) 98 SLEEP AID
(DIPHENHYDRAMINE) 98 sleep ii ................................... 98
SLEEP TIME ....................... 98 sleep-tabs ............................. 98 slo-niacin .............................. 32 SLO-NIACIN ...................... 32 SLOW FE .......................... 131 slow release iron ................ 131 SLOW RELEASE IRON ... 131 smoothlax ............................. 70 sodium bicarbonate .............. 70 sodium chloride ................. 102 sodium citrate-citric acid ... 104 sodium phenylbutyrate ......... 52 sodium polystyrene sulfonate
......................................... 52 sof-lax .................................. 71 SOFOSBUVIR-
VELPATASVIR ................ 5 SOMAVERT ....................... 59 soothe (bismuth subsalicylate)
......................................... 62 soothe and cool body powder
......................................... 52 SOOTHE NIGHT TIME
LUBRICANT .................. 84 soothe regular strength ......... 62 SOOTHE XP ..................... 117 SOOTHING BATH
TREATMENT ................. 41 soothing care (hydrocortisone)
......................................... 50 soothing pureway-c ............ 131 sorbidon hydrate .................. 41 sorbugen nr .......................... 98 sotalol ................................... 28 sotalol af ............................... 27 SOTYLIZE .......................... 28 spectravite adult 50 plus .... 131 spectravite advanced formula
....................................... 131 spectravite men's ................ 131 spectravite senior ............... 131 spectravite ultra women ..... 131 spironolactone ...................... 30 spironolacton-hydrochlorothiaz
......................................... 30 sports pain relief rub ............ 41 sportscreme .......................... 41 sprintec (28) ......................... 81 SPRYCEL ............................ 12 sps (with sorbitol) ................ 52
sronyx ................................... 81 ssd ........................................ 33 sss 10-5 ................................ 44 stavudine ................................ 5 STEGLATRO ...................... 58 sterile saline ......................... 55 STIMATE ............................ 59 stimulant laxative plus ......... 71 STIVARGA ......................... 12 stomach relief ....................... 62 stomach relief max strength . 62 stool softener ........................ 71 STOOL SOFTENER ........... 71 stool softener (docusate cal) 71 stool softener-laxative .......... 71 stool softener-stimulant laxat 71 stop smoking aid .................. 53 STRENSIQ .......................... 59 stress b plus zinc ................ 131 stress b with zinc ................ 131 stress formula ..................... 131 stress formula with iron ..... 131 stress formula with iron(sulf)
....................................... 131 stress formula with zinc ..... 131 STRIBILD ............................. 5 STRIVERDI RESPIMAT .. 102 strong iodine ................ 46, 107 STUDIO 35 BEAUTY
COCOA BUTTER ........... 41 STUDIO 35 MOISTURIZING
SKIN ................................ 41 SUCRAID ............................ 71 sucralfate .............................. 73 SUDAFED ........................... 98 SUDAFED 12 HOUR .......... 98 SUDAFED 24 HOUR .......... 98 sudogest ............................... 98 sudogest 12-hour .................. 98 sudogest cold and allergy ..... 98 sudogest pe ........................... 98 sudogest sinus and allergy ... 98 sulfacetamide sodium .... 33, 85 sulfacetamide sodium (acne) 46 sulfacetamide sodium-sulfur 44 sulfacetamide-prednisolone . 85 sulfadiazine ............................ 8 sulfamethoxazole-trimethoprim
........................................... 8 SULFAMYLON .................. 46
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 160
sulfasalazine .......................... 71 sulfatrim .................................. 8 sulfo-lo .................................. 33 sulindac ................................. 23 sumatriptan ........................... 15 sumatriptan succinate ........... 15 sunvite ................................. 131 super b complex-vitamin c . 131 super b maxi complex ......... 132 super b/c .............................. 132 super b-50 complex ............ 132 super calcium ...................... 107 super multiple ..................... 132 super multivitamin .............. 132 super omega-3 ....................... 32 super probiotic ...................... 62 super quints ......................... 132 super quints b-50 ................ 132 super thera vite m ............... 132 SUPERSOFT ........................ 41 suphedrin .............................. 98 suphedrine ............................. 98 suphedrine 12 hour ............... 98 suphedrine pe ........................ 98 suphedrine pe cold and allergy
.......................................... 98 SUPLENA CARB STEADY
........................................ 117 support ................................ 132 supress dx ............................. 98 surfak .................................... 71 SUSTIVA ............................... 5 SUTENT ............................... 12 SWEEN 24 ........................... 41 sween cream ......................... 41 sween prep ............................ 48 syeda ..................................... 81 SYLATRON ......................... 74 symax fastabs ........................ 62 symax-sl ................................ 62 symax-sr ................................ 62 SYMDEKO ........................ 102 SYMFI .................................... 5 SYMFI LO .............................. 5 SYMLINPEN 120 ................ 58 SYMLINPEN 60 .................. 58 SYMTUZA ............................. 5 SYNJARDY ......................... 58 SYNJARDY XR ................... 58 synovacin .............................. 23
SYSTANE (PROPYLENE GLYCOL) ........................ 84
SYSTANE NIGHTTIME .... 84 SYSTANE ULTRA ............. 84 T tab-a-vite ............................ 132 tab-a-vite/iron .................... 132 TABLOID ............................ 12 tacrolimus ...................... 12, 41 tactinal .................................. 23 tactinal extra strength ........... 23 TAFINLAR .......................... 12 tagamet hb ............................ 73 TAGRISSO .......................... 12 TALZENNA ........................ 12 tamoxifen ............................. 12 tamsulosin .......................... 103 targeted acne spot treatment 44 tarina 24 fe ........................... 81 tarina fe 1/20 (28) ................ 81 taron forte ........................... 132 taron-c dha ......................... 132 taron-prex prenatal-dha ...... 132 TASIGNA ............................ 12 tazarotene ............................. 44 TAZORAC .......................... 44 taztia xt ................................. 30 TECFIDERA ....................... 15 TEGSEDI ............................. 15 telmisartan-amlodipine ........ 30 temazepam ........................... 27 TEMIXYS .............................. 5 temozolomide ...................... 12 tencon ................................... 17 tenofovir disoproxil fumarate 5 TENSION HEADACHE ..... 23 TENSION HEADACHE PAIN
RELIEVER ...................... 23 terazosin ............................... 30 terbinafine hcl ........................ 3 terbutaline .......................... 102 terconazole ........................... 77 terrell .................................... 52 testosterone .......................... 59 testosterone cypionate .......... 59 testosterone enanthate .......... 59 tetrabenazine ........................ 16 tetracaine hcl ........................ 84 tetracycline ............................. 9 tg 10peh-380gfn-15dm ........ 98
THALOMID ........................ 12 the magic bullet .................... 71 theochron ........................... 102 theophylline ....................... 102 thera ................................... 132 thera bath .............................. 41 thera-d ................................ 132 thera-derm ............................ 41 THERAFLU EXPRESSMAX
COLD DAY ..................... 98 THERAFLU FLU-SORE
THROAT ......................... 98 THERA-GESIC ................... 42 theralogix companion ........ 132 thera-m ............................... 132 therapeutic blue .................... 42 therapeutic liquid ............... 132 THERAPEUTIC MINERAL
ICE ................................... 42 therapeutic moisturizing ...... 42 therapeutic-m ..................... 132 therapeutic-m vitamin/minerals
....................................... 132 theraseal ............................... 42 thera-tabs ............................ 132 thera-tabs m ........................ 132 THERATEARS ................... 84 theratrum complete 50 plus/lut
....................................... 132 theratrum complete 50 plus-lyc
....................................... 132 theratrum complete with lutein
....................................... 132 therems ............................... 132 therems-m .......................... 132 thermotabs .......................... 107 thiamine hcl (vitamin b1) ... 132 thioridazine .......................... 27 thiothixene ........................... 27 thritex ................................... 42 thrivite-19 ........................... 132 thyroid (pork) ....................... 59 THYROLAR-1 .................... 60 THYROLAR-1/2 ................. 60 THYROLAR-1/4 ................. 60 THYROLAR-2 .................... 60 THYROLAR-3 .................... 60 tiagabine ............................... 14 TIBSOVO ............................ 12 tiger balm ............................. 42
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
161
TIGER BALM ...................... 42 tilia fe .................................... 81 timolol maleate ............... 30, 82 tinactin .................................. 48 TINACTIN ........................... 48 tinidazole ................................ 8 tioconazole-1 ........................ 77 TIVICAY ................................ 5 tizanidine .............................. 16 tobramycin ............................ 82 tobramycin in 0.225 % nacl .... 8 tobramycin-dexamethasone .. 85 tolcapone ............................... 14 TOLEREX .......................... 117 tolmetin ................................. 23 tolnaftate ............................... 48 TOLSURA .............................. 3 topiramate ............................. 14 toremifene ............................. 12 torsemide .............................. 30 total allergy medicine ........... 99 total b/c ............................... 132 TOTAL HOME INSECT
REPELLENT .................... 42 TRACLEER ........................ 102 tramadol ................................ 23 tramadol-acetaminophen ...... 23 trandolapril ............................ 30 trandolapril-verapamil .......... 30 tranexamic acid ..................... 77 tranylcypromine .................... 27 travel sickness ....................... 71 travel sickness (meclizine) .... 71 trazodone .............................. 27 tretinoin ................................. 44 tretinoin (chemotherapy) ...... 12 TREXALL ............................ 12 tri femynor ............................ 81 TRIAD WOUND DRESSING
.......................................... 42 triamcinolone acetonide . 50, 55,
102 TRIAMINIC COLD AND
COUGH (PE) .................... 99 triamterene-hydrochlorothiazid
.......................................... 30 triazolam ............................... 27 tri-buffered aspirin ................ 24 tricitrates ............................. 104 tricon ................................... 132
triderm .................................. 50 tri-estarylla ........................... 81 trifluoperazine ...................... 27 trifluridine ............................ 82 trigels-f forte ...................... 132 trihexyphenidyl .................... 14 TRIKAFTA ........................ 102 tri-legest fe ........................... 81 tri-linyah .............................. 81 tri-lo-estarylla ...................... 81 tri-lo-marzia ......................... 81 tri-lo-sprintec ....................... 81 trilyte with flavor packets .... 71 trimethobenzamide .............. 71 trimethoprim .......................... 9 trimipramine ........................ 27 TRIMO-SAN JELLY .......... 77 trinatal rx 1 ......................... 133 trinate ................................. 133 triphrocaps ......................... 133 triple antibiotic ..................... 46 triple antibiotic plus ............. 46 triple antibiotic-pain relief ... 46 triple omega 3-6-9 .............. 117 TRIPLE PASTE ................... 42 triple paste af ........................ 48 tri-previfem (28) .................. 81 tri-sprintec (28) .................... 81 TRIUMEQ ............................. 6 triveen-duo dha .................. 133 tri-vitamin with fluoride .... 133 trivora (28) ........................... 81 TRIZIVIR .............................. 6 trolamine salicylate .............. 42 tropicamide .......................... 82 TRULANCE ........................ 71 TRUMENBA ....................... 74 tru-micin .............................. 42 trust natal dha ..................... 133 TRUVADA ............................ 6 TUMS ................................ 107 TUMS E-X ......................... 107 TUMS EXTRA STRENGTH
SMOOTHIES ................ 107 tums ultra ..................... 71, 108 TURALIO ............................ 12 TUSICOF ............................. 99 tusnel diabetic ...................... 99 TUSNEL NEW FORMULA 99 tusnel pediatric ..................... 99
tussi pres-b ........................... 99 TUSSI PRES-B .................... 99 tussin .................................... 99 tussin cf (pe-dm-guaif) ......... 99 tussin chest congestion ......... 99 tussin cough (dm only) ........ 99 tussin cough-chest congestion
......................................... 99 tussin dm .............................. 99 tussin dm clear ..................... 99 tussin dm cough and chest ... 99 tussin dm max ...................... 99 tussin honey ......................... 99 tussin long-acting ................. 99 tussin maximum strength
cough ................................ 99 tussi-pres .............................. 99 TUSSI-PRES PEDIATRIC .. 99 TWOCAL HN .................... 117 TYKERB ............................. 12 TYLENOL ........................... 24 TYLENOL ARTHRITIS PAIN
......................................... 24 TYLENOL EXTRA
STRENGTH ..................... 24 TYLENOL PM EXTRA
STRENGTH ..................... 24 tylophen ............................... 24 TYMLOS ............................. 75 tyr cooler ............................ 117 TYR EXPRESS20 ............. 117 TYR GEL POWDER ......... 117 TYREX-1 ........................... 117 TYREX-2 ........................... 117 TYROS 1 ........................... 118 TYROS 2 ........................... 118 TYVASO ........................... 102 TYVASO REFILL KIT ..... 102 TYVASO STARTER KIT . 102 U UCD ANAMIX JUNIOR .. 118 ultra fresh ............................. 84 ULTRA FRESH PM ............ 84 ULTRA LUBRICANT EYE 84 ultra mide 25 ........................ 42 ultra omega-3 ..................... 118 ultracin t ............................... 42 ULTRATHON ..................... 42 unicomplex-m .................... 133 UNIFIBER ........................... 71
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 162
unisom sleepgels ................... 99 unithroid ................................ 60 unscented cold cream ............ 42 UPTRAVI ............................. 30 urea ....................................... 42 UREACIN-10 ....................... 42 ureacin-20 ............................. 42 uretron d-s ........................... 104 urimar-t ............................... 104 urin ds ................................. 104 uro-458 ................................ 104 urogesic-blue ...................... 104 URO-MAG ......................... 108 uro-mp ................................ 104 ursodiol ................................. 71 uryl ...................................... 104 ustell .................................... 104 utira-c .................................. 104 V vaginal contraceptive foam ... 77 valacyclovir ............................ 6 valganciclovir ......................... 6 valproic acid ......................... 14 valproic acid (as sodium salt)
.......................................... 14 valsartan ................................ 30 valsartan-hydrochlorothiazide
.......................................... 30 VALTOCO ........................... 14 valu-tapp ............................... 99 VANACOF ........................... 99 vancomycin ............................. 9 vandazole .............................. 77 vanicream .............................. 42 VANICREAM LITE ............ 42 VARUBI ............................... 71 VASOFLEX ....................... 118 v-c forte ............................... 133 vegetable laxative ................. 71 velivet triphasic regimen (28)
.......................................... 81 VELTASSA .......................... 52 VEMLIDY .............................. 6 VENCLEXTA ...................... 12 VENCLEXTA STARTING
PACK ................................ 12 venlafaxine ............................ 27 VENTAVIS ........................ 102 verapamil .............................. 30 veripred 20 ............................ 56
VERZENIO ......................... 12 VIBERZI .............................. 71 vic-forte .............................. 133 vicks dayquil cold-flu relief . 99 vicks dayquil cough ............. 99 VICKS DAYQUIL SEVERE
COLD-FLU ...................... 99 vicks nyquil cold/flu liquicap
......................................... 99 VICKS NYQUIL SEVERE
COLD-FLU .................... 100 vicks qlearquil(oxymetazoline)
......................................... 56 vicks sinex 12-hour .............. 56 vicks sinex ultra fine mist 12 56 VIDEX 2 GRAM PEDIATRIC
........................................... 6 vienva ................................... 81 vigabatrin ............................. 14 VIMPAT .............................. 14 vinate m ............................. 133 vinate one ........................... 133 VIOKACE ........................... 71 viorele (28) ........................... 81 VIRACEPT ............................ 6 VIREAD ................................ 6 virt-c dha ............................ 133 virt-gard ............................. 133 virt-nate dha ....................... 133 virt-phos 250 neutral .......... 108 virt-pn dha .......................... 133 virt-pn plus ......................... 133 virtrate-2 ............................ 104 virtrate-3 ............................ 104 virtrate-k ............................ 104 virtussin ac ......................... 100 virtussin dac ....................... 100 virt-vite .............................. 133 VISINE TEARS ................... 84 VISINE TIRED EYE RELIEF
......................................... 84 VISION PLUS LUTEIN .... 133 VISTOGARD ........................ 9 vit 3 .................................... 133 vita-c .................................. 133 vitacel (with lutein) ............ 133 VITAFOL-OB ................... 133 vitajoy daily d .................... 133 VITAL 1.0 CAL ................ 118 VITAL 1.5 CAL ................ 118
VITAL AF 1.2 CAL .......... 118 VITAL HIGH NITROGEN 118 VITAL HIGH PROTEIN ... 118 vitalee ................................. 133 vitalets ................................ 133 vitamin a and d ..................... 42 vitamin a and d diaper rash .. 42 VITAMIN A AND D GRX . 42 vitamin b complex ............. 133 vitamin b complex-folic acid
....................................... 133 vitamin b-1 ......................... 133 vitamin b-12 ............... 133, 134 VITAMIN B-12 ................. 133 vitamin b-2 ......................... 134 vitamin b-6 ......................... 134 vitamin c ............................ 134 vitamin c drops ................... 134 vitamin c with rose hips ..... 134 vitamin d3 .......................... 134 vitamin e ...................... 42, 134 VITAMIN E ....................... 134 vitamin e (dl, acetate) ......... 134 VITAMIN E (DL, ACETATE)
......................................... 42 vitamin e acetate ................ 134 vitamin e mixed ................. 134 vitamin e plus ....................... 42 VITAMIN E-SAFFLOWER
OIL ................................... 42 vitamins a and d ................. 134 vitamins a,c,d and fluoride . 134 vitamins and minerals ........ 134 vitamins b complex ............ 134 VITAMINS B COMPLEX 134 vitamins for hair ................. 134 VITA-RAY .......................... 42 vitatrum .............................. 134 VITRAKVI .......................... 12 vitrum senior ...................... 134 VITRUM SENIOR ............ 134 vits a and d-white pet-lanolin
......................................... 42 VIVITROL ........................... 24 VIVONEX PEDIATRIC ... 118 VIVONEX PLUS .............. 118 vivonex rtf .......................... 118 VIVONEX T.E.N. ............. 118 VIZIMPRO .......................... 12 voriconazole ........................... 3
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
163
VOSEVI .................................. 6 VOTRIENT .......................... 12 vp-ch-pnv ............................ 134 vp-vite rx ............................. 134 VUMERITY ......................... 16 vyfemla (28) ......................... 81 VYNDAMAX ...................... 32 VYNDAQEL ........................ 32 VYVANSE ........................... 27 W wal-act d cold and allergy ... 100 wal-dram ............................... 71 wal-dryl allergy ................... 100 wal-dryl severe allergy-sinus
........................................ 100 wal-dryl-d allergy and sinus
........................................ 100 wal-fex allergy .................... 100 wal-fex d 12 hour ................ 100 wal-fex d 24 hour ................ 100 wal-finate ............................ 100 wal-finate-d ......................... 100 wal-flu night severe cold .... 100 WAL-FLU NIGHT TIME .. 100 WAL-FLU SEVERE COLD-
COUGH .......................... 100 wal-four ................................ 56 walgreens dry skin treatment 42 wal-itin ................................ 100 wal-itin d ............................. 100 wal-itin d 12 hour ............... 100 wal-mucil fiber ..................... 71 wal-mucil fiber (aspartame) .. 71 wal-mucil fiber (sugar) ......... 71 wal-mucil natural fiber lax ... 71 wal-phed ............................. 100 wal-phed 12 hour ................ 100 wal-phed pe ......................... 100 wal-phed pe nighttime cold 100 wal-phed pe sinus and allergy
........................................ 100 wal-profen ............................. 24 wal-profen cold-sinus ......... 100 wal-profen d cold and sinus 100 wal-proxen ............................ 24 WAL-SLEEP Z ................... 100 wal-som (diphenhydramine)
........................................ 100 wal-sporin ............................. 46 wal-tap dm .......................... 100
wal-tussin cough ................ 100 wal-tussin cough and cold cf
....................................... 100 wal-tussin dm ..................... 100 wal-tussin max strength cough
....................................... 100 wal-zan 150 .......................... 73 wal-zan 75 ............................ 73 wal-zyr (cetirizine) ............. 101 wal-zyr d ............................ 101 warfarin ................................ 31 wart remover ........................ 33 wee care ............................. 135 wera (28) .............................. 81 westhroid .............................. 60 white petrolatum .................. 43 white petroleum jelly ........... 43 WIBI .................................... 43 wintergreen oil ..................... 43 witch hazel ........................... 43 wixela inhub ....................... 103 WND 2 ............................... 118 woman's laxative (bisacodyl)71 WOMEN'S DAILY CAPLET
....................................... 135 women's daily formula ....... 135 WOMEN'S DAILY
FORMULA .................... 135 women's gentle laxative(bisac)
......................................... 71 women's laxative (bisacodyl)72 women's prenatal plus dha . 135 WOUND WASH SALINE .. 43 wymzya fe ............................ 81 X XALKORI ........................... 12 XARELTO ........................... 31 XERMELO .......................... 12 XIFAXAN ............................. 8 XIIDRA ............................... 84 XLEU ANALOG ............... 118 XLEU MAXAMAID ......... 118 XLYS- XTRP ANALOG .. 118 XLYS, XTRP MAXAMAID
....................................... 118 XLYS, XTRP MAXAMUM
....................................... 118 XMET ANALOG .............. 118 XMET MAXAMUM ......... 118 XMTVI ANALOG ............ 118
xmtvi maxamaid ................ 118 xmtvi maxamum ................ 118 XOFLUZA ............................. 6 XPHE MAXAMAID ......... 118 XPHE, XTRP MAXAMAID
....................................... 118 XPHE, XTYR ANALOG .. 118 XPOVIO .............................. 12 XPTM ANALOG .............. 118 XTANDI .............................. 12 XTRACAL PLUS .............. 118 xulane ................................... 77 XURIDEN ........................... 52 XYREM ............................... 27 Y yelets .................................. 135 yuvafem ............................... 76 Z zafirlukast ........................... 103 zaleplon ................................ 27 ZANTAC ............................. 73 ZANTAC 75 ........................ 73 zantac maximum strength .... 73 zarah ..................................... 81 zatean-pn dha ..................... 135 zatean-pn plus .................... 135 z-clinz ................................... 43 zebutal .................................. 17 ZEGERID OTC ................... 73 ZEJULA ............................... 12 ZELBORAF ......................... 13 zenatane ............................... 44 zenzedi ................................. 27 zidovudine .............................. 6 zinc ..................................... 108 zinc gluconate .................... 108 zinc oxide ............................. 43 zingiber .............................. 135 ziprasidone hcl ..................... 27 ZOLINZA ............................ 13 zolmitriptan .......................... 15 zolpidem ............................... 27 zonisamide ........................... 14 ZORTRESS ......................... 13 ZOSTAVAX (PF) ................ 74 zostrix ................................... 43 zostrix-hp ............................. 43 zovia 1/35e (28) ................... 81 ZYDELIG ............................ 13 ZYKADIA ........................... 13
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 164
zyncof ................................. 101 ZYNCOF ............................ 101
ZYRTEC ............................ 101 ZYRTEC-D ........................ 101
ZYTIGA ............................... 13 ZZZQUIL ........................... 101
55 Water Street, New York, NY 10041-8190 | emblemhealth.com
This formulary was updated on 4/1/2020. For more recent information or other questions, please contact EmblemHealth Medicaid at 855-283-2146 or for TTY users: 711, Monday to Friday, 8 am to 6 pm, or visit emblemhealth.com/medicaid.EmblemHealth insurance plans are underwritten by Group Health Incorporated (GHI), HIP Health Plan of New York (HIP) and HIP Insurance Company of New York.
45-9360PD 4/20