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Enhanced Care (Medicaid) Enhanced Care Plus (HARP) 2020 Drug Formulary

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Page 1: Enhanced Care (Medicaid) Enhanced Care Plus …...i EmblemHealth Enhanced Care and Enhanced Care Plus Formulary 2020 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS

Enhanced Care (Medicaid) Enhanced Care Plus (HARP) 2020 Drug Formulary

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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.

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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

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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

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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.

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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).

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(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.

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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

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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.

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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

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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

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You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

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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

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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

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You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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zyncof ................................. 101 ZYNCOF ............................ 101

ZYRTEC ............................ 101 ZYRTEC-D ........................ 101

ZYTIGA ............................... 13 ZZZQUIL ........................... 101

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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