kansas aca member prescription drug list 2017 · kansas aca member prescription drug list 2017 . 2...
TRANSCRIPT
HIX BCBSKC-KS 2017 10-01-2017
KANSAS ACA MEMBER
PRESCRIPTION DRUG LIST
2017
2
Table of Contents
ANTI - INFECTIVES ........................................................................................................................................ 4
ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS ..................................................................... 12
AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH ....................................................................... 18
CARDIOVASCULAR, HYPERTENSION & LIPIDS ................................................................................. 33
DERMATOLOGICALS/TOPICAL THERAPY .......................................................................................... 41
DIAGNOSTICS & MISCELLANEOUS AGENTS ...................................................................................... 50
EAR, NOSE & THROAT MEDICATIONS .................................................................................................. 52
ENDOCRINE/DIABETES .............................................................................................................................. 53
GASTROENTEROLOGY .............................................................................................................................. 69
IMMUNOLOGY, VACCINES & BIOTECHNOLOGY ............................................................................. 76
MUSCULOSKELETAL & RHEUMATOLOGY ......................................................................................... 79
OBSTETRICS & GYNECOLOGY ................................................................................................................ 80
OPHTHALMOLOGY ..................................................................................................................................... 86
RESPIRATORY, ALLERGY, COUGH & COLD ....................................................................................... 89
UROLOGICALS .............................................................................................................................................. 94
VITAMINS, HEMATINICS & ELECTROLYTES ..................................................................................... 95
Index ................................................................................................................................................................ 105
3
Please see the benefit schedule in your member certificate for member cost sharing associated with
Generic and Brand (Preferred and Non Preferred) drugs.
List of Abbreviations for Prescription Drugs
Drug Category:
1: Generic Drug and Generic Specialty Drug
2: Preferred Drug and Non Preferred Generic Drug
3: Non Preferred Drug and Preferred Specialty Drug
4: Non Preferred Specialty Drug
5: Zero Cost Share Preventive Drug
6: Medical Service Drugs
7: Infertility Drug
ACA*: Affordable Care Act is a zero cost share preventive drug.
M: Maintenance drug.
MSD: Medical Service Drug. This drug is only covered under the medical benefit.
OTC*: Over the Counter 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.
S: Specialty drug.
SLA: Specialty Limited Availability. This prescription may be available only at certain pharmacies.
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.
*Your plan has tobacco use coverage through the Routine Preventive Care benefit. Tobacco use includes two
tobacco cessation attempts per year (both prescription and over-the-counter medications) for a 90-day
treatment regimen when prescribed by an in-network health care provider without prior authorization.
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
4
Drug Name Drug
Category
Requirements
/ Limits
ANTI - INFECTIVES
ANTIFUNGAL AGENTS
AMBISOME 6 MSD
amphotericin b 6 MSD
ANCOBON 3
CANCIDAS 6 MSD
CASPOFUNGIN 6 MSD
clotrimazole 1
CRESEMBA
INTRAVENOUS
6 MSD
CRESEMBA ORAL 2
DIFLUCAN ORAL
SUSPENSION FOR
RECONSTITUTIO
N
3
DIFLUCAN ORAL
TABLET 100 MG,
200 MG, 50 MG
3
DIFLUCAN ORAL
TABLET 150 MG
3 QL
ERAXIS(WATER
DILUENT)
6 MSD
fluconazole in
dextrose(iso-o)
6 MSD
fluconazole in nacl
(iso-osm)
6 MSD
fluconazole oral
suspension for
reconstitution
1
fluconazole oral
tablet 100 mg, 200
mg, 50 mg
1
fluconazole oral
tablet 150 mg
1 QL
flucytosine 1
Drug Name Drug
Category
Requirements
/ Limits
griseofulvin
microsize
1
griseofulvin
ultramicrosize
1
GRIS-PEG
(ULTRAMICROSIZ
E)
3
itraconazole 1 QL
ketoconazole 1
LAMISIL 3
NOXAFIL 2
nystatin 1
ONMEL 3 QL
ORAVIG 3
SPORANOX 2
SPORANOX
PULSEPAK
3 QL
terbinafine hcl 1
VFEND 3
VFEND IV 6 MSD
voriconazole
intravenous
6 MSD
voriconazole oral 1
ANTIVIRALS
abacavir 1 S; QL
abacavir-lamivudine 1 S; QL
abacavir-
lamivudine-
zidovudine
1 S; QL
acyclovir 1
adefovir 1
amantadine hcl 1 M
APTIVUS 3 S; QL
ATRIPLA 3 S; QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
5
Drug Name Drug
Category
Requirements
/ Limits
BARACLUDE
ORAL SOLUTION
2
BARACLUDE
ORAL TABLET
3
cidofovir 6 MSD
COMBIVIR 4 S; QL
COMPLERA 3 S; QL
CRIXIVAN 3 S; QL
DAKLINZA 4 PA; S; SLA
DESCOVY 3 S
didanosine 1 S; QL
EDURANT 3 S; QL
EMTRIVA 3 S; QL
entecavir 1
EPCLUSA 3 ST; S; SLA
EPIVIR 4 S; QL
EPIVIR HBV
ORAL SOLUTION
2
EPIVIR HBV
ORAL TABLET
3 QL
EPZICOM 4 S; QL
EVOTAZ 4 S; QL
famciclovir 1 QL
FLUMADINE 3
foscarnet 6 MSD
FOSCAVIR 6 MSD
FUZEON 3 S; QL
GENVOYA 3 S
HARVONI 3 PA; S; SLA;
QL
HEPSERA 3
INTELENCE 3 S; QL
INVIRASE 3 S; QL
Drug Name Drug
Category
Requirements
/ Limits
ISENTRESS 3 S; QL
ISENTRESS HD 3 S; SLA
KALETRA 3 S; QL
lamivudine oral
solution
1 S; QL
lamivudine oral
tablet 100 mg
1 QL
lamivudine oral
tablet 150 mg, 300
mg
1 S; QL
lamivudine-
zidovudine
1 S; QL
LEXIVA 3 S; QL
lopinavir-ritonavir 1 S; QL
MAVYRET 4 S
nevirapine 1 S; QL
NORVIR 3 S; QL
ODEFSEY 3 S
OLYSIO 4 PA; ST; S;
SLA; QL
oseltamivir 1 QL
PREZCOBIX 4 S
PREZISTA 3 S; QL
RELENZA
DISKHALER
2 QL
RESCRIPTOR 3 S; QL
RETROVIR 4 S; QL
REYATAZ 3 S
ribavirin 1 S; SLA
rimantadine 1
SELZENTRY
ORAL SOLUTION
4 PA; S; SLA
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
6
Drug Name Drug
Category
Requirements
/ Limits
SELZENTRY
ORAL TABLET
150 MG, 300 MG
3 PA; S; QL
SELZENTRY
ORAL TABLET 25
MG, 75 MG
3 PA; S
SITAVIG 3 QL
SOVALDI 4 PA; ST; S;
SLA; QL
stavudine 1 S; QL
STRIBILD 3 S; QL
SUSTIVA 3 S; QL
SYNAGIS 6 MSD
TAMIFLU ORAL
CAPSULE
3 QL
TAMIFLU ORAL
SUSPENSION FOR
RECONSTITUTIO
N
2 QL
TECHNIVIE 3 PA; S; SLA
TIVICAY ORAL
TABLET 10 MG, 25
MG
3 S
TIVICAY ORAL
TABLET 50 MG
3 S; QL
TRIUMEQ 3 S; QL
TRIZIVIR 4 S; QL
TRUVADA ORAL
TABLET 100-150
MG, 133-200 MG,
167-250 MG
3 S
TRUVADA ORAL
TABLET 200-300
MG
3 S; QL
TYBOST 4 S; QL
valacyclovir 1 QL
VALCYTE 3
Drug Name Drug
Category
Requirements
/ Limits
valganciclovir 1
VALTREX 3 QL
VEMLIDY 2
VIDEX 2 GRAM
PEDIATRIC
3 S; QL
VIDEX EC 4 S; QL
VIEKIRA PAK 3 PA; S; SLA;
QL
VIEKIRA XR 3 PA; S; SLA
VIRACEPT 3 S; QL
VIRAMUNE 4 S; QL
VIRAMUNE XR 4 S; QL
VIRAZOLE 4 S; SLA
VIREAD 3 S; QL
VOSEVI 4 PA; S; SLA
ZEPATIER 3 PA; S; SLA
ZERIT 4 S; QL
ZIAGEN ORAL
SOLUTION
3 S; QL
ZIAGEN ORAL
TABLET
4 S; QL
zidovudine 1 S; QL
ZOVIRAX 3
CEPHALOSPORINS
AVYCAZ 6 MSD
CEDAX 3
cefaclor 1
cefadroxil 1
cefazolin 6 MSD
CEFAZOLIN IN
0.9% SOD
CHLORIDE
6 MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
7
Drug Name Drug
Category
Requirements
/ Limits
cefazolin in dextrose
(iso-os) intravenous
piggyback 1 gram/50
ml, 2 gram/50 ml
6 MSD
CEFAZOLIN IN
DEXTROSE (ISO-
OS)
INTRAVENOUS
PIGGYBACK 2
GRAM/100 ML
6 MSD
CEFAZOLIN IN
DEXTROSE 5 %
6 MSD
CEFAZOLIN IN
STERILE WATER
6 MSD
cefdinir 1
cefditoren pivoxil 1
cefepime 6 MSD
cefepime in
dextrose,iso-osm
6 MSD
cefixime 1
CEFOTAN 6 MSD
cefotaxime 6 MSD
cefotetan 6 MSD
cefoxitin 6 MSD
cefpodoxime 1
cefprozil 1
ceftibuten 1
CEFTIN 3
ceftriaxone in
dextrose,iso-os
6 MSD
ceftriaxone injection
recon soln 1 gram,
10 gram, 2 gram,
250 mg, 500 mg
6 MSD
Drug Name Drug
Category
Requirements
/ Limits
CEFTRIAXONE
INJECTION
RECON SOLN 100
GRAM
6 MSD
cefuroxime axetil 1
cefuroxime sodium 6 MSD
cephalexin 1
CLAFORAN 6 MSD
DAXBIA 3
KEFLEX 3
MAXIPIME 6 MSD
SPECTRACEF 3
SUPRAX 3
TAZICEF 6 MSD
TEFLARO 6 MSD
ZINACEF 6 MSD
ERYTHROMYCINS & OTHER
MACROLIDES
azithromycin 1
clarithromycin 1
DIFICID 3
e.e.s. 400 1
E.E.S. GRANULES 2
ERYPED 200 2
ERYPED 400 2
ery-tab oral
tablet,delayed
release (dr/ec) 250
mg, 333 mg
1
ERY-TAB ORAL
TABLET,DELAYE
D RELEASE
(DR/EC) 500 MG
2
erythrocin (as
stearate)
1
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
8
Drug Name Drug
Category
Requirements
/ Limits
erythromycin 1
erythromycin
ethylsuccinate
1
PCE 3
ZITHROMAX 3
ZITHROMAX TRI-
PAK
3
ZITHROMAX Z-
PAK
3
ZMAX 3
MISCELLANEOUS
ANTIINFECTIVES
ALBENZA 2 QL
ALINIA 2 QL
amikacin 6 MSD
atovaquone 1
atovaquone-
proguanil
1
BETHKIS 6 MSD; QL
BILTRICIDE 2
CAPASTAT 6 MSD
CAYSTON 3 S; QL
chloramphenicol sod
succinate
6 MSD
chloroquine
phosphate
1
CLEOCIN HCL 3
CLEOCIN
INJECTION
6 MSD
cleocin intravenous
solution 300 mg/2 ml
6 MSD
Drug Name Drug
Category
Requirements
/ Limits
CLEOCIN
INTRAVENOUS
SOLUTION 600
MG/4 ML, 900
MG/6 ML
6 MSD
CLEOCIN
PEDIATRIC
3
CLIN SINGLE USE 6 MSD
clindamycin hcl 1
CLINDAMYCIN IN
0.9 % SOD CHLOR
6 MSD
clindamycin
palmitate hcl
1
clindamycin
pediatric
1
clindamycin
phosphate
6 MSD
COARTEM 2
colistin
(colistimethate na)
1 MSD
COLY-MYCIN M
PARENTERAL
3 MSD
CUBICIN 6 MSD
CUBICIN RF 6 MSD
CYCLOSERINE 3
dapsone 1 M
daptomycin 6 MSD
DARAPRIM 3 PA; S
DORIBAX 6 MSD
DORIPENEM 6 MSD
EMVERM 2 QL
ethambutol 1
FLAGYL 3
gentamicin 6 MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
9
Drug Name Drug
Category
Requirements
/ Limits
gentamicin in nacl
(iso-osm)
intravenous
piggyback 100
mg/100 ml, 60 mg/50
ml, 70 mg/50 ml, 80
mg/100 ml, 80 mg/50
ml, 90 mg/100 ml
1
GENTAMICIN IN
NACL (ISO-OSM)
INTRAVENOUS
PIGGYBACK 100
MG/50 ML, 120
MG/100 ML
3
gentamicin sulfate
(ped) (pf)
1
gentamicin sulfate
(pf) intravenous
solution 100 mg/10
ml
1
GENTAMICIN
SULFATE (PF)
INTRAVENOUS
SOLUTION 60
MG/6 ML
3
hydroxychloroquine 1 M
imipenem-cilastatin 6 MSD
IMPAVIDO 3 S
INVANZ 6 MSD
isoniazid 1
ivermectin 1 QL
KITABIS PAK 3 S; SLA
LINCOCIN 6 MSD
lincomycin 6 MSD
linezolid intravenous 6 MSD
linezolid oral 1 PA
MALARONE 3
Drug Name Drug
Category
Requirements
/ Limits
MALARONE
PEDIATRIC
3
mefloquine 1
MEPRON 3
meropenem 6 MSD
MEROPENEM-
0.9% SODIUM
CHLORIDE
6 MSD
MERREM 6 MSD
metro i.v. 6 MSD
metronidazole 1
metronidazole in
nacl (iso-os)
6 MSD
MYAMBUTOL 3
MYCOBUTIN 3
NEBUPENT 2 QL
neomycin 1
paromomycin 1
PASER 3
PLAQUENIL 3 M
polymyxin b sulfate 6 MSD
PRIFTIN 2
PRIMAQUINE 3 M
PRIMAXIN IV 6 MSD
pyrazinamide 1
QUALAQUIN 3
quinine sulfate 1
rifabutin 1
RIFADIN 3
RIFAMATE 3
rifampin 1
RIFATER 3
SIRTURO 2
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
10
Drug Name Drug
Category
Requirements
/ Limits
SIVEXTRO 3 PA
STREPTOMYCIN 6 MSD
STROMECTOL 3 QL
SYNERCID 6 MSD
TIGECYCLINE 6 MSD
TINDAMAX 3 QL
tinidazole oral tablet
250 mg
1
tinidazole oral tablet
500 mg
1 QL
TOBI 3 QL
TOBI PODHALER 3 QL
tobramycin in 0.225
% nacl
1 QL
tobramycin sulfate 6 MSD
TOBRAMYCIN
WITH NEBULIZER
4 S
TRECATOR 3
TYGACIL 6 MSD
XIFAXAN 2
ZYVOX
INTRAVENOUS
6 MSD
ZYVOX ORAL 3 PA
PENICILLINS
amoxicillin 1
amoxicillin-pot
clavulanate
1
ampicillin 1
ampicillin sodium 6 MSD
ampicillin-sulbactam 6 MSD
AUGMENTIN ES-
600
3
Drug Name Drug
Category
Requirements
/ Limits
AUGMENTIN
ORAL
SUSPENSION FOR
RECONSTITUTIO
N 125-31.25 MG/5
ML
2
AUGMENTIN
ORAL
SUSPENSION FOR
RECONSTITUTIO
N 250-62.5 MG/5
ML
3
AUGMENTIN
ORAL TABLET
3
AUGMENTIN XR 3
BICILLIN C-R 6 MSD
dicloxacillin 1
MOXATAG 3
nafcillin 6 MSD
oxacillin 6 MSD
oxacillin in
dextrose(iso-osm)
6 MSD
penicillin g
potassium
6 MSD
penicillin v
potassium
1
pfizerpen-g 6 MSD
PIPERACILLIN-
TAZOBACTAM
INTRAVENOUS
RECON SOLN 13.5
GRAM
6 MSD
piperacillin-
tazobactam
intravenous recon
soln 2.25 gram,
3.375 gram, 4.5
gram, 40.5 gram
6 MSD
UNASYN 6 MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
11
Drug Name Drug
Category
Requirements
/ Limits
QUINOLONES
AVELOX 3
CIPRO 3
CIPRO XR 3
ciprofloxacin 1
ciprofloxacin
(mixture)
1
ciprofloxacin hcl 1
FACTIVE 3
LEVAQUIN 3
levofloxacin in d5w 6 MSD
levofloxacin
intravenous
6 MSD
levofloxacin oral 1
moxifloxacin 1
ofloxacin 1
SULFA'S & RELATED AGENTS
BACTRIM 3
BACTRIM DS 3
sulfadiazine 1
sulfamethoxazole-
trimethoprim
1
sulfatrim 1
TETRACYCLINES
ACTICLATE 3 ST
avidoxy 1
demeclocycline 1
DORYX 3 ST
DORYX MPC 3 ST
doxycycline hyclate 1
doxycycline
monohydrate oral
capsule
1
Drug Name Drug
Category
Requirements
/ Limits
DOXYCYCLINE
MONOHYDRATE
ORAL
CAPSULE,IR -
DELAY
REL,BIPHASE
3 ST
doxycycline
monohydrate oral
suspension for
reconstitution
1
doxycycline
monohydrate oral
tablet
1
MINOCIN 3 ST
minocycline 1
mondoxyne nl 1
MONODOX 3 ST
morgidox 1
ORACEA 3 ST
SOLODYN 3 ST
TARGADOX 3 ST
tetracycline 1
VIBRAMYCIN
ORAL CAPSULE
3 ST
VIBRAMYCIN
ORAL
SUSPENSION FOR
RECONSTITUTIO
N
3
VIBRAMYCIN
ORAL SYRUP
3
URINARY TRACT AGENTS
FURADANTIN 3
HIPREX 3
MACROBID 3
MACRODANTIN 3
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
12
Drug Name Drug
Category
Requirements
/ Limits
methenamine
hippurate
1
methenamine
mandelate
1
MONUROL 3
nitrofurantoin 1
nitrofurantoin
macrocrystal
1
nitrofurantoin
monohyd/m-cryst
1
PRIMSOL 3
trimethoprim 1
VANCOMYCIN
VANCOCIN 3
VANCOMYCIN IN
0.9% SODIUM CL
6 MSD
VANCOMYCIN IN
DEXTROSE 5 %
6 MSD
vancomycin
intravenous
6 MSD
vancomycin oral 1
VIBATIV 6 MSD
ANTINEOPLASTIC &
IMMUNOSUPPRESSANT
DRUGS
ADJUNCTIVE AGENTS
amifostine
crystalline
6 MSD
dexrazoxane hcl 6 MSD
ELITEK 6 MSD
ETHYOL 6 MSD
FUSILEV 6 MSD
KEPIVANCE 6 MSD
Drug Name Drug
Category
Requirements
/ Limits
leucovorin calcium
injection
1 S
leucovorin calcium
oral
1
LEVOLEUCOVORI
N INTRAVENOUS
RECON SOLN 175
MG
6 MSD
levoleucovorin
intravenous recon
soln 50 mg
6 MSD
levoleucovorin
intravenous solution
6 MSD
mesna 6 MSD
MESNEX
INTRAVENOUS
6 MSD
MESNEX ORAL 2
TOTECT 6 MSD
VISTOGARD 2
VORAXAZE 6 MSD
XGEVA 6 S; MSD
ZINECARD (AS
HCL)
6 MSD
ANTINEOPLASTIC &
IMMUNOSUPPRESSANT DRUGS
ABRAXANE 6 MSD
ADCETRIS 6 MSD
adriamycin 6 MSD
adrucil 6 MSD
AFINITOR 2 QL
AFINITOR
DISPERZ
2 QL
ALECENSA 4 S; SLA
ALKERAN
INTRAVENOUS
6 MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
13
Drug Name Drug
Category
Requirements
/ Limits
ALKERAN ORAL 3
ALUNBRIG 4 PA; S
anastrozole 1
ARIMIDEX 3
AROMASIN 3
ARRANON 6 MSD
ARZERRA 6 MSD
ASTAGRAF XL 3
AVASTIN 6 MSD
azacitidine 6 MSD
AZASAN 2
azathioprine 1
BAVENCIO 6 PA; MSD
BELEODAQ 6 MSD
BENDEKA 6 MSD
BESPONSA 3
bexarotene 1
bicalutamide 1
BICNU 6 MSD
bleo 15k 6 MSD
bleomycin 6 MSD
BOSULIF 3 S; SLA
busulfan 6 MSD
BUSULFEX 6 MSD
CABOMETYX 3 QL
CAMPTOSAR 6 MSD
capecitabine 1
CAPRELSA 2 QL
carboplatin 6 MSD
CASODEX 3
CELLCEPT 3
Drug Name Drug
Category
Requirements
/ Limits
CELLCEPT
INTRAVENOUS
6 S; MSD
cisplatin 6 MSD
cladribine 6 MSD
clofarabine 6 MSD
CLOLAR 6 MSD
COMETRIQ 3 QL
COSMEGEN 6 MSD
COTELLIC 3 S; SLA
cyclophosphamide
intravenous
6 MSD
CYCLOPHOSPHA
MIDE ORAL
2
cyclosporine
intravenous
1 S
cyclosporine
modified
1
cyclosporine oral 1
CYRAMZA 6 MSD
cytarabine 6 MSD
cytarabine (pf) 6 MSD
dacarbazine 6 MSD
DACOGEN 6 MSD
DARZALEX 6 MSD
daunorubicin 6 MSD
decitabine 6 MSD
DOCEFREZ 6 MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
14
Drug Name Drug
Category
Requirements
/ Limits
docetaxel
intravenous solution
160 mg/16 ml (10
mg/ml), 160 mg/8 ml
(20 mg/ml), 20 mg/2
ml (10 mg/ml), 20
mg/ml (1 ml), 80
mg/4 ml (20 mg/ml),
80 mg/8 ml (10
mg/ml)
6 MSD
DOCETAXEL
INTRAVENOUS
SOLUTION 20
MG/ML
6 MSD
DOXIL 6 MSD
doxorubicin 6 MSD
doxorubicin, peg-
liposomal
6 MSD
DROXIA 2
ELIGARD 3 S
ELIGARD (3
MONTH)
3 S
ELIGARD (4
MONTH)
3 S
ELIGARD (6
MONTH)
3 S
ELLENCE 6 MSD
EMCYT 2
EMPLICITI 6 MSD
ENVARSUS XR 3
epirubicin 6 MSD
ERBITUX 6 MSD
ERIVEDGE 3 S; SLA
ERWINAZE 6 MSD
etoposide
intravenous
6 MSD
etoposide oral 1
Drug Name Drug
Category
Requirements
/ Limits
EVOMELA 6 MSD
exemestane 1
FARESTON 2
FARYDAK 4 S
FASLODEX 6 MSD
FEMARA 3
FIRMAGON KIT W
DILUENT
SYRINGE
4 S; SLA
floxuridine 6 MSD
fludarabine 6 MSD
fluorouracil 6 MSD
flutamide 1
FOLOTYN 6 MSD
GAZYVA 6 MSD
gemcitabine 6 MSD
GEMZAR 6 MSD
gengraf 1
GILOTRIF 2
GLEEVEC 3 QL
GLEOSTINE 2
GLIADEL WAFER 3
HALAVEN 6 MSD
HERCEPTIN 6 MSD
HEXALEN 2
HYCAMTIN
INTRAVENOUS
6 MSD
HYCAMTIN ORAL 3 S
HYDREA 3
hydroxyurea 1
IBRANCE 2
ICLUSIG 3 S; SLA
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
15
Drug Name Drug
Category
Requirements
/ Limits
IDAMYCIN PFS 6 MSD
idarubicin 6 MSD
IDHIFA 4 S
IFEX 6 MSD
ifosfamide 6 MSD
ifosfamide-mesna 6 MSD
imatinib 1 QL
IMBRUVICA 3 S; SLA
IMFINZI 6 PA; MSD
IMURAN 3
INLYTA 3 S; SLA; QL
IRESSA 3 S; SLA
irinotecan 6 MSD
ISTODAX 6 MSD
IXEMPRA 6 MSD
JAKAFI 3 S; SLA; QL
JEVTANA 6 MSD
KADCYLA 6 MSD
KISQALI 4 PA; S
KISQALI FEMARA
CO-PACK
4 PA; S
KYPROLIS 6 MSD
LARTRUVO 6 MSD
LENVIMA 2
letrozole 1
LEUKERAN 2
leuprolide 1 S
lipodox 6 MSD
LONSURF 3 S
Drug Name Drug
Category
Requirements
/ Limits
LUPRON DEPOT
(3 MONTH)
INTRAMUSCULA
R SYRINGE KIT
11.25 MG
3 S
LUPRON DEPOT
(3 MONTH)
INTRAMUSCULA
R SYRINGE KIT
22.5 MG
4 S
LUPRON DEPOT
(4 MONTH)
4 S
LUPRON DEPOT
(6 MONTH)
4 S
LUPRON DEPOT
INTRAMUSCULA
R SYRINGE KIT
3.75 MG
3 S
LUPRON DEPOT
INTRAMUSCULA
R SYRINGE KIT
7.5 MG
4 S
LUPRON DEPOT-
PED
3 S
LYNPARZA ORAL
CAPSULE
3 S; SLA
LYNPARZA ORAL
TABLET
4 S; SLA
LYSODREN 2
MARQIBO 6 MSD
MATULANE 2
MEGACE ES 3
megestrol 1
MEKINIST 2
melphalan 1
melphalan hcl 6 MSD
mercaptopurine 1
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
16
Drug Name Drug
Category
Requirements
/ Limits
methotrexate sodium
(pf)
1
methotrexate sodium
injection
1 MSD
methotrexate sodium
oral
1
mitomycin 6 MSD
mitoxantrone 6 MSD
MUSTARGEN 6 MSD
mycophenolate
mofetil
1
mycophenolate
mofetil hcl
6 MSD
mycophenolate
sodium
1
MYFORTIC 3
MYLERAN 3 S
NAVELBINE 6 MSD
NEORAL 3
NERLYNX 4 S
NEXAVAR 2 QL
NILANDRON 3
nilutamide 1
NINLARO 3 S; SLA
NIPENT 6 MSD
NULOJIX 6 MSD
octreotide acetate 1 S; SLA
ODOMZO 4 S
ONCASPAR 6 MSD
ONIVYDE 6 MSD
OPDIVO 6 MSD
oxaliplatin 6 MSD
paclitaxel 6 MSD
Drug Name Drug
Category
Requirements
/ Limits
PERJETA 6 MSD
PORTRAZZA 6 MSD
PROGRAF 3
PURIXAN 3 S; SLA
RAPAMUNE
ORAL SOLUTION
2
RAPAMUNE
ORAL TABLET
3
RITUXAN 6 ST; MSD
RITUXAN
HYCELA
6 PA; MSD
RUBRACA 2 PA
RYDAPT 3 PA; S
SANDIMMUNE
INTRAVENOUS
4 S
SANDIMMUNE
ORAL CAPSULE
3
SANDIMMUNE
ORAL SOLUTION
2
SANDOSTATIN 4 S; SLA
SANDOSTATIN
LAR DEPOT
6 MSD
SIGNIFOR 6 MSD
SIGNIFOR LAR 6 MSD
SIMULECT 6 MSD
sirolimus 1
SOLTAMOX 3
SOMATULINE
DEPOT
4 S; SLA
SPRYCEL 2 QL
STIVARGA 2
SUPPRELIN LA 6 MSD
SUTENT 2 QL
SYLVANT 6 MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
17
Drug Name Drug
Category
Requirements
/ Limits
SYNRIBO 6 MSD
TABLOID 2
tacrolimus 1
TAFINLAR 2
TAGRISSO 3 S
tamoxifen 1
TARCEVA 2 QL
TARGRETIN
ORAL
3
TARGRETIN
TOPICAL
2
TASIGNA 2 QL
TAXOTERE 6 MSD
TECENTRIQ 6 MSD
TEMODAR 3
temozolomide 1
TENIPOSIDE 6 MSD
TEPADINA 6 MSD
THALOMID 2
thiotepa 6 MSD
toposar 6 MSD
topotecan 6 MSD
TORISEL 6 MSD
TREANDA 6 MSD
TRELSTAR 6 MSD
tretinoin
(chemotherapy)
1
TREXALL 2
TRISENOX 6 MSD
TYKERB 2 QL
VANTAS 6 MSD
VECTIBIX 6 MSD
Drug Name Drug
Category
Requirements
/ Limits
VELCADE 6 MSD
VENCLEXTA 2
VENCLEXTA
STARTING PACK
2
VIDAZA 6 MSD
vinblastine 6 MSD
vincasar pfs 6 MSD
vincristine 6 MSD
vinorelbine 6 MSD
VOTRIENT 2 QL
VYXEOS 6 MSD
XALKORI 2 QL
XATMEP 3
XELODA 3
XERMELO 2 PA
XTANDI 3 QL
YERVOY 6 MSD
YONDELIS 6 MSD
ZALTRAP 6 MSD
ZANOSAR 6 MSD
ZEJULA 2 PA
ZELBORAF 3 S; QL
ZOLADEX 6 MSD
ZOLINZA 2 QL
ZORTRESS 2
ZYDELIG 2
ZYKADIA 3 S; SLA
ZYTIGA ORAL
TABLET 250 MG
2 QL
ZYTIGA ORAL
TABLET 500 MG
3 S; QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
18
Drug Name Drug
Category
Requirements
/ Limits
AUTONOMIC & CNS DRUGS,
NEUROLOGY & PSYCH
ANTICONVULSANTS
APTIOM 3
BANZEL 2
BRIVIACT 3 ST
carbamazepine 1
CARBATROL 3
CELONTIN 2
clonazepam 1
DEPACON 6 MSD
DEPAKENE 3 ST
DEPAKOTE 3 ST
DEPAKOTE ER 3 ST
DEPAKOTE
SPRINKLES
3 ST
DIASTAT 3
DIASTAT
ACUDIAL
3
diazepam 1
DILANTIN 2
DILANTIN
EXTENDED
3
DILANTIN
INFATABS
3
DILANTIN-125 3
divalproex 1
epitol 1
EQUETRO 3
ethosuximide 1
felbamate 1
FELBATOL 3
Drug Name Drug
Category
Requirements
/ Limits
fosphenytoin 6 MSD
FYCOMPA 3
gabapentin 1
GABITRIL ORAL
TABLET 12 MG, 16
MG
2
GABITRIL ORAL
TABLET 2 MG, 4
MG
3
GRALISE 3 ST; QL
GRALISE 30-DAY
STARTER PACK
3 ST; QL
KEPPRA
INTRAVENOUS
6 MSD
KEPPRA ORAL 3 ST
KEPPRA XR 3 ST
KLONOPIN 3
LAMICTAL 3 ST
LAMICTAL ODT 3 ST
LAMICTAL ODT
STARTER (BLUE)
3 ST
LAMICTAL ODT
STARTER
(GREEN)
3 ST
LAMICTAL ODT
STARTER
(ORANGE)
3 ST
LAMICTAL
STARTER (BLUE)
KIT
3 ST
LAMICTAL
STARTER
(GREEN) KIT
3 ST
LAMICTAL
STARTER
(ORANGE) KIT
3 ST
LAMICTAL XR 3 ST
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
19
Drug Name Drug
Category
Requirements
/ Limits
LAMICTAL XR
STARTER (BLUE)
3 ST
LAMICTAL XR
STARTER
(GREEN)
3 ST
LAMICTAL XR
STARTER
(ORANGE)
3 ST
lamotrigine 1
levetiracetam
intravenous
6 MSD
levetiracetam oral 1
LYRICA 2 ST
MYSOLINE 3
NEURONTIN 3 ST
ONFI 2
oxcarbazepine 1
OXTELLAR XR 3 ST
PEGANONE 2
phenobarbital 1
PHENYTEK 3
phenytoin 1
phenytoin sodium
extended
1
primidone 1
QUDEXY XR 3
roweepra 1
SABRIL 3 S; SLA
TEGRETOL 3
TEGRETOL XR 3
tiagabine 1
TOPAMAX 3
topiramate oral
capsule, sprinkle
1
Drug Name Drug
Category
Requirements
/ Limits
TOPIRAMATE
ORAL
CAPSULE,SPRINK
LE,ER 24HR
3
topiramate oral
tablet
1
TRILEPTAL 3 ST
TROKENDI XR 3
valproate sodium 6 MSD
valproic acid 1
valproic acid (as
sodium salt)
1
vigabatrin 1 S; SLA
VIMPAT 2
ZARONTIN 3
ZONEGRAN 3
zonisamide 1
ANTIPARKINSONISM AGENTS
APOKYN 3 S; SLA
AZILECT 3 M
benztropine 1
bromocriptine 1
carbidopa 1 M
carbidopa-levodopa 1 M
carbidopa-levodopa-
entacapone
1 M
COMTAN 3 M
DUOPA 6 MSD; M
ELDEPRYL 3 M
entacapone 1 M
LODOSYN 3 M
MIRAPEX 3 M
MIRAPEX ER 3 M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
20
Drug Name Drug
Category
Requirements
/ Limits
NEUPRO 3 M
PARLODEL 3
pramipexole 1 M
rasagiline 1 M
REQUIP 3 M
REQUIP XL 3 M
ropinirole 1 M
RYTARY 3 M
selegiline hcl 1 M
SINEMET 3 M
SINEMET CR 3 M
STALEVO 100 3 M
STALEVO 125 3 M
STALEVO 150 3 M
STALEVO 200 3 M
STALEVO 50 3 M
STALEVO 75 3 M
TASMAR 3 M
tolcapone 1 M
trihexyphenidyl 1
XADAGO 3 PA; M
ZELAPAR 3 M
MIGRAINE & CLUSTER
HEADACHE THERAPY
almotriptan malate 1 QL
ALSUMA 3 ST; QL
AMERGE 3 ST; QL
AXERT 3 ST; QL
CAFERGOT 3
D.H.E.45 3
dihydroergotamine
injection
1
Drug Name Drug
Category
Requirements
/ Limits
dihydroergotamine
nasal
1 QL
eletriptan hbr 1 QL
ERGOMAR 3
ergotamine-caffeine 1
frovatriptan 1 QL
IMITREX 3 ST; QL
IMITREX
STATDOSE KIT
REFILL
3 ST; QL
IMITREX
STATDOSE PEN
3 ST; QL
isometh-dichloral-
acetaminophn
1
isomethepten-caf-
acetaminophen
1
MAXALT 3 ST; QL
MAXALT-MLT 3 ST; QL
migergot 1
MIGRANAL 3 QL
naratriptan 1 QL
nodolor 1
ONZETRA XSAIL 3 ST; QL
PRODRIN 3
RELPAX 3 ST; QL
rizatriptan 1 QL
sumatriptan 1 QL
sumatriptan
succinate
1 QL
SUMAVEL
DOSEPRO
3 ST; QL
TREXIMET 3 ST; QL
ZEMBRACE
SYMTOUCH
3 ST; QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
21
Drug Name Drug
Category
Requirements
/ Limits
zolmitriptan 1 QL
ZOMIG NASAL 2 ST; QL
ZOMIG ORAL 3 ST; QL
ZOMIG ZMT 3 ST; QL
MISCELLANEOUS
NEUROLOGICAL THERAPY
AMPYRA 3 PA; S; SLA;
QL
ARICEPT 3 ST; M
AUSTEDO 3 PA
donepezil oral tablet
10 mg, 5 mg
1 M
donepezil oral tablet
23 mg
1 ST; M
donepezil oral
tablet,disintegrating
1 M
EXELON 3 ST; M; QL
EXONDYS 51 6 MSD
galantamine oral
capsule,ext rel.
pellets 24 hr
1 M; QL
galantamine oral
solution
1 M; QL
galantamine oral
tablet 12 mg
1 M
galantamine oral
tablet 4 mg, 8 mg
1 M; QL
HORIZANT 3 ST; QL
INGREZZA 3 PA
KEVEYIS 3 PA
memantine oral
solution
1 M
memantine oral
tablet
1 M
Drug Name Drug
Category
Requirements
/ Limits
MEMANTINE
ORAL
TABLETS,DOSE
PACK
3 M; QL
NAMENDA 3 ST; M
NAMENDA
TITRATION PAK
3 M; QL
NAMENDA XR
ORAL
CAP,SPRINKLE,ER
24HR DOSE PACK
3 M; QL
NAMENDA XR
ORAL
CAPSULE,SPRINK
LE,ER 24HR
3 ST; M; QL
NAMZARIC 3 ST
NUEDEXTA 2 PA
RADICAVA 6 PA; MSD
RAZADYNE ER 3 ST; M; QL
RAZADYNE ORAL
TABLET 12 MG
3 ST; M
RAZADYNE ORAL
TABLET 4 MG, 8
MG
3 ST; M; QL
rivastigmine 1 M; QL
rivastigmine tartrate 1 M; QL
tetrabenazine 1 PA
TYSABRI 6 MSD
XENAZINE 3 PA
MUSCLE RELAXANTS &
ANTISPASMODIC THERAPY
AMRIX 3
baclofen 1 M
BRIDION 6 MSD
carisoprodol 1
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
22
Drug Name Drug
Category
Requirements
/ Limits
carisoprodol-asa-
codeine
1
carisoprodol-aspirin 1
chlorzoxazone 1
cyclobenzaprine 1
DANTRIUM 3 M
dantrolene 1 M
FEXMID 3
LORZONE 3
meprobamate 1
MESTINON ORAL
SYRUP
2 M
MESTINON ORAL
TABLET
3 M
MESTINON
TIMESPAN
3 M
metaxall 1
metaxalone 1
methocarbamol
injection
6 MSD
methocarbamol oral 1
orphenadrine citrate 1
PARAFON FORTE
DSC
3
pyridostigmine
bromide
1 M
ROBAXIN
INJECTION
6 MSD
ROBAXIN ORAL 3
ROBAXIN-750 3
SKELAXIN 3
SOMA 3
tizanidine 1 M
ZANAFLEX 3 M
Drug Name Drug
Category
Requirements
/ Limits
NARCOTIC ANALGESICS
ABSTRAL 3 PA; QL
acetaminophen-caff-
dihydrocod oral
capsule
1
ACETAMINOPHE
N-CAFF-
DIHYDROCOD
ORAL TABLET
3
acetaminophen-
codeine
1
ACTIQ 3 PA; QL
ALLZITAL 3
ARYMO ER 3 ST; QL
ascomp with codeine 1
aspirin-caffeine-
dihydrocodein
1
BELBUCA 3 PA; ST
BUPAP 3
BUPRENORPHINE 3 ST
buprenorphine hcl 1
butalbital compound
w/codeine
1
butalbital-
acetaminop-caf-cod
1
butalbital-
acetaminophen
1
butalbital-
acetaminophen-caff
1
butalbital-aspirin-
caffeine
1
BUTRANS 3 ST
capacet 1
CAPITAL WITH
CODEINE
3
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
23
Drug Name Drug
Category
Requirements
/ Limits
codeine sulfate 1
codeine-butalbital-
asa-caff
1
DEMEROL 3
DILAUDID 3
diskets 1 ST
DOLOPHINE 3 ST
DURAGESIC 3 ST
EMBEDA 3 ST; QL
endocet 1
ESGIC 3
EXALGO ER 3 ST; QL
FENTANYL (PF)-
BUPIVACAINE-
NACL
6 MSD
fentanyl citrate 1 PA; QL
FENTANYL
CITRATE-
0.9%NACL (PF)
INTRAVENOUS
SOLUTION 20
MCG/ML
6 MSD
fentanyl citrate-
0.9%nacl (pf)
intravenous solution
5 mcg/ml
6 MSD
fentanyl transdermal
patch 72 hour 100
mcg/hr, 12 mcg/hr,
25 mcg/hr, 50
mcg/hr, 75 mcg/hr
1 ST
FENTANYL
TRANSDERMAL
PATCH 72 HOUR
37.5 MCG/HOUR,
62.5 MCG/HOUR,
87.5 MCG/HOUR
3 ST
Drug Name Drug
Category
Requirements
/ Limits
FENTANYL-
ROPIVACAINE-
NACL (PF)
6 MSD
FENTORA 3 PA; QL
FIORICET 3
FIORINAL 3
FIORINAL-
CODEINE #3
3
hydrocodone-
acetaminophen
1
hydrocodone-
ibuprofen
1
HYDROMORPHO
NE (PF)-0.9%
NACL
6 MSD
HYDROMORPHO
NE IN 0.9 % NACL
INJECTION
6 MSD
HYDROMORPHO
NE IN 0.9 % NACL
INTRAVENOUS
PATIENT
CONTROL.ANALG
ESIA SOLN
6 MSD
HYDROMORPHO
NE IN 0.9 % NACL
INTRAVENOUS
PREFILLED PUMP
RESERVOIR
6 MSD
hydromorphone in
0.9 % nacl
intravenous pt
controlled analgesia
syring 15 mg/30 ml
(0.5 mg/ml)
6 MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
24
Drug Name Drug
Category
Requirements
/ Limits
HYDROMORPHO
NE IN 0.9 % NACL
INTRAVENOUS
PT CONTROLLED
ANALGESIA
SYRING 5 MG/25
ML (0.2 MG/ML), 6
MG/30 ML (0.2
MG/ML)
6 MSD
HYDROMORPHO
NE IN 0.9 % NACL
INTRAVENOUS
SOLUTION
6 MSD
HYDROMORPHO
NE IN 0.9 % NACL
INTRAVENOUS
SYRINGE
6 MSD
hydromorphone
injection
6 MSD
hydromorphone oral
liquid
1
hydromorphone oral
tablet
1
hydromorphone oral
tablet extended
release 24 hr
1 ST; QL
hydromorphone
rectal
1
HYSINGLA ER 3 ST; QL
IBUDONE 3
ibuprofen-oxycodone 1
IONSYS 3
KADIAN 3 ST; QL
LAZANDA 3 PA; QL
levorphanol tartrate 1
lorcet (hydrocodone) 1
lorcet hd 1
lorcet plus 1
Drug Name Drug
Category
Requirements
/ Limits
LORTAB ELIXIR 3
marten-tab 1
meperidine 1
methadone 1 ST
methadose 1 ST
MORPHABOND
ER
3 ST
morphine (pf) 6 MSD
MORPHINE (PF)
IN 0.9 % NACL
INTRAVENOUS
SOLUTION
6 MSD
morphine (pf) in 0.9
% nacl intravenous
syringe
6 MSD
morphine
concentrate
1
MORPHINE IN 0.9
% NACL
6 MSD
morphine injection 6 MSD
MORPHINE
INTRAMUSCULA
R
6 MSD
morphine
intravenous
cartridge 10 mg/ml,
2 mg/ml, 4 mg/ml
6 MSD
MORPHINE
INTRAVENOUS
CARTRIDGE 8
MG/ML
6 MSD
morphine
intravenous pt
controlled analgesia
syring
6 MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
25
Drug Name Drug
Category
Requirements
/ Limits
morphine
intravenous solution
10 mg/ml, 100 mg/4
ml, 25 mg/ml, 250
mg/10 ml, 50 mg/ml
6 MSD
MORPHINE
INTRAVENOUS
SOLUTION 4
MG/ML, 8 MG/ML
6 MSD
MORPHINE
INTRAVENOUS
SYRINGE 10
MG/ML, 8 MG/ML
6 MSD
morphine
intravenous syringe
2 mg/ml, 4 mg/ml
6 MSD
morphine oral
capsule, er
multiphase 24 hr
1 ST; QL
morphine oral
capsule,extend.relea
se pellets
1 ST; QL
morphine oral
solution
1
morphine oral tablet 1
morphine oral tablet
extended release
1 ST; QL
morphine rectal 1
MS CONTIN 3 ST; QL
NORCO 3
OPANA 3
OXAYDO 3
oxycodone oral
capsule
1
oxycodone oral
concentrate
1
oxycodone oral
solution
1
Drug Name Drug
Category
Requirements
/ Limits
oxycodone oral
tablet
1
OXYCODONE
ORAL
TABLET,ORAL
ONLY,EXT.REL.12
HR
3 ST; QL
oxycodone-
acetaminophen
1
oxycodone-aspirin 1
OXYCONTIN 3 ST; QL
oxymorphone oral
tablet
1
oxymorphone oral
tablet extended
release 12 hr
1 ST; QL
PERCOCET 3
PRIMLEV 3
PROBUPHINE 6 MSD
ROXICODONE 3
SUBSYS 3 PA; QL
SYNALGOS-DC 3
tencon 1
TREZIX 3
TYLENOL-
CODEINE #3
3
TYLENOL-
CODEINE #4
3
VANATOL LQ 3
verdrocet 1
vicodin 1
vicodin es 1
vicodin hp 1
XODOL 10/300 3
XODOL 5/300 3
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
26
Drug Name Drug
Category
Requirements
/ Limits
XODOL 7.5/300 3
XTAMPZA ER 3 ST; QL
xylon 10 1
zamicet 1
zebutal 1
ZOHYDRO ER 3 ST; QL
NON-NARCOTIC ANALGESICS
ANAPROX DS 3 ST; M
ARTHROTEC 50 3 ST; M
ARTHROTEC 75 3 ST; M
aspir-81 5 M; ACA; OTC
aspirin low dose 5 M; ACA; OTC
aspirin oral tablet 5 ACA; OTC
aspirin oral
tablet,chewable
5 M; ACA; OTC
aspirin oral
tablet,delayed
release (dr/ec) 325
mg
5 ACA; OTC
aspirin oral
tablet,delayed
release (dr/ec) 81
mg
5 M; ACA; OTC
aspir-low 5 M; ACA; OTC
aspir-trin 5 ACA; OTC
bayer aspirin 5 ACA; OTC
BUNAVAIL 3 PA; QL
buprenorphine-
naloxone
1 PA; QL
butorphanol tartrate
injection
6 MSD
butorphanol tartrate
nasal
1 QL
CAMBIA 3 ST; QL
Drug Name Drug
Category
Requirements
/ Limits
CELEBREX 3 ST; M; QL
celecoxib 1 ST; M; QL
children's aspirin 5 M; ACA; OTC
choline,magnesium
salicylate
1
CONZIP 3 ST; QL
DAYPRO 3 ST; M
DICLO GEL-
XRYLIX SHEET
3 ST; M
diclofenac potassium 1
diclofenac sodium
oral
1 M
diclofenac sodium
topical drops
1 M; QL
diclofenac sodium
topical gel
1 ST; M; QL
diclofenac-
misoprostol
1 M
diflunisal 1 M
DISALCID 3
DUEXIS 3 ST; M; QL
e.c. prin 5 ACA; OTC
EC-NAPROSYN 3 ST; M
ecotrin 5 ACA; OTC
ecotrin low strength 5 M; ACA; OTC
etodolac 1 M
EUFLEXXA 6 MSD
EVZIO INJECTION
AUTO-INJECTOR
0.4 MG/0.4 ML
3 QL
EVZIO INJECTION
AUTO-INJECTOR
2 MG/0.4 ML
3
FELDENE 3 ST; M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
27
Drug Name Drug
Category
Requirements
/ Limits
FENOPROFEN
ORAL CAPSULE
3 ST; M
fenoprofen oral
tablet
1 M
FENORTHO 3 ST; M
FLECTOR 3 ST; QL
flurbiprofen 1 M
FROTEK 3 ST; M
ibuprofen 1 M
INDOCIN 3 ST
indomethacin 1
ketoprofen 1 M
ketorolac injection 6 MSD
ketorolac
intramuscular
6 MSD
ketorolac oral 1 QL
lite coat aspirin 5 ACA; OTC
LODINE 3 ST; M
meclofenamate 1 M
mefenamic acid 1
meloxicam oral
suspension
1 M
meloxicam oral
tablet 15 mg
1 M
meloxicam oral
tablet 7.5 mg
1 M; QL
MOBIC ORAL
TABLET 15 MG
3 ST; M
MOBIC ORAL
TABLET 7.5 MG
3 ST; M; QL
nabumetone 1 M
nalbuphine 6 MSD
NALFON 3 ST; M
naloxone 1 MSD
Drug Name Drug
Category
Requirements
/ Limits
naltrexone 1
NAPRELAN CR 3 ST; M
NAPROSYN 3 ST; M
naproxen 1 M
naproxen sodium 1 M
NARCAN 2
NUCYNTA 3 QL
NUCYNTA ER 3 ST; QL
oxaprozin 1 M
PENNSAID 3 ST; M; QL
pentazocine-
naloxone
1
piroxicam 1 M
PONSTEL 3 ST
READYSHARP
KETOROLAC
6 MSD
REVIA 3
salsalate 1
SPRIX 3 ST; QL
SUBOXONE 2 PA; QL
sulindac 1 M
TALWIN 6 MSD
TIVORBEX 3 ST; M
tolmetin 1 M
TORONOVA II
SUIK
6 MSD
TORONOVA SUIK 6 MSD
TRAMADOL
ORAL
CAPSULE,ER
BIPHASE 24 HR
17-83
3 ST; QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
28
Drug Name Drug
Category
Requirements
/ Limits
TRAMADOL
ORAL
CAPSULE,ER
BIPHASE 24 HR
25-75
3 ST; QL
tramadol oral tablet 1 QL
tramadol oral tablet
extended release 24
hr
1 ST; QL
tramadol oral tablet,
er multiphase 24 hr
1 ST; QL
tramadol-
acetaminophen
1 QL
ULTRACET 3 ST; QL
ULTRAM 3 ST; QL
ULTRAM ER 3 ST; QL
VIMOVO 3 ST; M; QL
VIVITROL 6 MSD
VIVLODEX 3 ST; M
VOLTAREN 3 ST; M; QL
VOLTAREN-XR 3 ST; M
ZIPSOR 3 ST; QL
ZORVOLEX 3 ST; M; QL
ZUBSOLV
SUBLINGUAL
TABLET 0.7-0.18
MG, 11.4-2.9 MG,
2.9-0.71 MG, 8.6-
2.1 MG
2 PA
ZUBSOLV
SUBLINGUAL
TABLET 1.4-0.36
MG, 5.7-1.4 MG
2 PA; QL
PSYCHOTHERAPEUTIC DRUGS
ABILIFY 3 QL
ABILIFY
MAINTENA
6 MSD
Drug Name Drug
Category
Requirements
/ Limits
ADASUVE 3
ADDERALL 3 QL
ADDERALL XR 3 ST; QL
ADDYI 3 PA
ADZENYS XR-
ODT
3 ST
alprazolam 1
alprazolam intensol 1
AMBIEN 3 ST; QL
AMBIEN CR 3 ST; QL
amitriptyline 1
amitriptyline-
chlordiazepoxide
1
amoxapine 1
ANAFRANIL 3
APLENZIN 3 ST; M; QL
APTENSIO XR 3 ST
aripiprazole oral
solution
1
aripiprazole oral
tablet
1 QL
aripiprazole oral
tablet,disintegrating
1 QL
ARISTADA 6 MSD
armodafinil oral
tablet 150 mg, 250
mg, 50 mg
1 ST; QL
armodafinil oral
tablet 200 mg
1 PA; QL
ATIVAN 3
atomoxetine 1 QL
BELSOMRA 3 ST
BRISDELLE 3 ST; M; QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
29
Drug Name Drug
Category
Requirements
/ Limits
bupropion hcl oral
tablet
1 M
bupropion hcl oral
tablet extended
release 12 hr
1 M; QL
bupropion hcl oral
tablet extended
release 24 hr 150 mg
1 M
bupropion hcl oral
tablet extended
release 24 hr 300 mg
1 M; QL
buspirone 1 M
BUTISOL 3
CELEXA 3 ST; M; QL
chlordiazepoxide hcl 1
chlorpromazine 1
citalopram 1 M
clomipramine 1
clonidine hcl 1 QL
clorazepate
dipotassium
1
clozapine oral tablet 1
clozapine oral
tablet,disintegrating
100 mg, 12.5 mg, 25
mg
1
CLOZAPINE
ORAL
TABLET,DISINTE
GRATING 150 MG,
200 MG
3
CLOZARIL 3
CONCERTA 3 ST; QL
COTEMPLA XR-
ODT
3 ST
CYMBALTA 3 ST; M; QL
Drug Name Drug
Category
Requirements
/ Limits
DAYTRANA 3 ST; QL
desipramine 1
DESOXYN 3 QL
DESVENLAFAXIN
E
3 ST; M; QL
DESVENLAFAXIN
E FUMARATE
3 ST; M
desvenlafaxine
succinate oral tablet
extended release 24
hr 100 mg, 50 mg
1 M; QL
desvenlafaxine
succinate oral tablet
extended release 24
hr 25 mg
1 M
DEXEDRINE
SPANSULE
3 ST; QL
dexmethylphenidate 1 QL
dextroamphetamine 1 QL
dextroamphetamine-
amphetamine
1 QL
diazepam injection 6 MSD
diazepam intensol 1
diazepam oral 1
DORAL 3
doxepin 1
duloxetine oral
capsule,delayed
release(dr/ec) 20
mg, 30 mg, 60 mg
1 M; QL
duloxetine oral
capsule,delayed
release(dr/ec) 40 mg
1 M
DYANAVEL XR 3 ST
EDLUAR 3 ST; QL
EFFEXOR XR 3 ST; M; QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
30
Drug Name Drug
Category
Requirements
/ Limits
EMSAM 3 M; QL
ergoloid 1 M
escitalopram oxalate 1 M
estazolam 1
eszopiclone 1 QL
EVEKEO 3 PA
FANAPT 3 QL
FAZACLO 3
FETZIMA 3 ST; M; QL
flumazenil 6 MSD
fluoxetine oral
capsule 10 mg, 40
mg
1 M; QL
fluoxetine oral
capsule 20 mg
1 M
fluoxetine oral
capsule,delayed
release(dr/ec)
1 M; QL
fluoxetine oral
solution
1 M
fluoxetine oral tablet
10 mg
1 M; QL
fluoxetine oral tablet
20 mg
1 M
FLUOXETINE
ORAL TABLET 60
MG
3 ST
fluphenazine
decanoate
1
fluphenazine hcl 1
flurazepam 1
fluvoxamine 1 M; QL
FOCALIN 3 QL
FOCALIN XR 3 ST; QL
FORFIVO XL 3 ST; M; QL
Drug Name Drug
Category
Requirements
/ Limits
GEODON
INTRAMUSCULA
R
6 MSD
GEODON ORAL 3 QL
guanfacine 1 QL
guanidine 1
HALCION 3
HALDOL 3
HALDOL
DECANOATE
3
haloperidol 1
haloperidol
decanoate
1
haloperidol lactate 1
HETLIOZ 4 S; SLA; QL
imipramine hcl 1
imipramine pamoate 1
INTERMEZZO 3 ST; QL
INTUNIV ER 3 ST; QL
INVEGA ORAL
TABLET
EXTENDED
RELEASE 24HR
1.5 MG, 3 MG, 6
MG, 9 MG
3 QL
IRENKA 3 ST; M
KAPVAY 3 ST; QL
KHEDEZLA 3 ST; M; QL
LATUDA 3 QL
LEXAPRO 3 ST; M; QL
lithium carbonate 1
lithium citrate 1
LITHOBID 3
lorazepam 1
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
31
Drug Name Drug
Category
Requirements
/ Limits
lorazepam intensol 1
loxapine succinate 1
LUNESTA 3 ST; QL
maprotiline 1
MARPLAN 3 M
metadate er 1
methamphetamine 1 QL
METHYLIN 3 QL
methylphenidate hcl
oral capsule, er
biphasic 30-70
1
methylphenidate hcl
oral capsule,er
biphasic 50-50
1
methylphenidate hcl
oral solution
1 QL
methylphenidate hcl
oral tablet
1 QL
methylphenidate hcl
oral tablet extended
release
1
methylphenidate hcl
oral tablet extended
release 24hr
1 QL
methylphenidate hcl
oral tablet,chewable
1 QL
mirtazapine 1 QL
modafinil 1 PA; QL
MYDAYIS 3 ST
NARDIL 3 M
nefazodone 1 M
NORPRAMIN 3
nortriptyline 1
NUPLAZID 4 S; SLA
NUVIGIL 3 PA; QL
Drug Name Drug
Category
Requirements
/ Limits
olanzapine
intramuscular
6 MSD
olanzapine oral
tablet 10 mg, 15 mg,
2.5 mg, 5 mg, 7.5 mg
1 QL
olanzapine oral
tablet 20 mg
1
olanzapine oral
tablet,disintegrating
1 QL
olanzapine-
fluoxetine
1
ORAP 3
oxazepam 1
paliperidone 1 QL
PAMELOR 3
PARNATE 3 M
paroxetine hcl 1 M; QL
PAXIL CR 3 ST; M; QL
PAXIL ORAL
SUSPENSION
3 ST; M
PAXIL ORAL
TABLET
3 ST; M; QL
perphenazine 1
perphenazine-
amitriptyline
1
PEXEVA 3 ST; M; QL
phenelzine 1 M
pimozide 1
PRISTIQ ORAL
TABLET
EXTENDED
RELEASE 24 HR
100 MG, 50 MG
3 ST; M; QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
32
Drug Name Drug
Category
Requirements
/ Limits
PRISTIQ ORAL
TABLET
EXTENDED
RELEASE 24 HR
25 MG
3 ST; M
procentra 1 QL
protriptyline 1
PROVIGIL 3 PA; QL
PROZAC ORAL
CAPSULE 10 MG,
40 MG
3 ST; M; QL
PROZAC ORAL
CAPSULE 20 MG
3 ST; M
quazepam 1
quetiapine 1 QL
QUILLICHEW ER 3 ST
QUILLIVANT XR 3 ST; QL
REMERON 3 QL
REMERON
SOLTAB
3 QL
RESTORIL 3
REXULTI 3
RISPERDAL M-
TAB
3 QL
RISPERDAL ORAL
SOLUTION
3
RISPERDAL ORAL
TABLET
3 QL
risperidone oral
solution
1
risperidone oral
tablet
1 QL
risperidone oral
tablet,disintegrating
1 QL
RITALIN 3 QL
RITALIN LA 3 ST
Drug Name Drug
Category
Requirements
/ Limits
ROZEREM 2 ST; QL
SAPHRIS (BLACK
CHERRY)
SUBLINGUAL
TABLET 2.5 MG
3
SAPHRIS (BLACK
CHERRY)
SUBLINGUAL
TABLET 5 MG
3 QL
SARAFEM ORAL
TABLET 10 MG
3 ST; M; QL
SARAFEM ORAL
TABLET 20 MG
3 ST; M
seconal sodium 1
SEROQUEL 3 QL
SEROQUEL XR 3 QL
sertraline oral
concentrate
1 M
sertraline oral tablet 1 M; QL
SILENOR 3 ST; QL
SONATA 3 ST; QL
STRATTERA 3 ST; QL
SURMONTIL 3
SYMBYAX 3
temazepam 1
thioridazine 1
thiothixene 1
TOFRANIL 3
TRANXENE T-
TAB
3
tranylcypromine 1 M
trazodone 1
triazolam 1
trifluoperazine 1
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
33
Drug Name Drug
Category
Requirements
/ Limits
trimipramine 1
TRINTELLIX 3 ST; QL
VALIUM 3
venlafaxine oral
capsule,extended
release 24hr 150 mg
1 M
venlafaxine oral
capsule,extended
release 24hr 37.5
mg, 75 mg
1 M; QL
venlafaxine oral
tablet
1 M; QL
venlafaxine oral
tablet extended
release 24hr
1 M; QL
VERSACLOZ 3
VIIBRYD ORAL
TABLET
3 ST; M; QL
VIIBRYD ORAL
TABLETS,DOSE
PACK
3 ST; QL
VRAYLAR 3
VYVANSE 2 ST; QL
WELLBUTRIN SR 3 ST; M; QL
WELLBUTRIN XL 3 ST; M; QL
XANAX 3
XANAX XR 3
XYREM 3 PA; S; SLA;
QL
zaleplon 1 QL
zenzedi oral tablet
10 mg, 5 mg
1 QL
ZENZEDI ORAL
TABLET 15 MG
3 QL
Drug Name Drug
Category
Requirements
/ Limits
ZENZEDI ORAL
TABLET 2.5 MG,
20 MG, 30 MG, 7.5
MG
3
ziprasidone hcl 1 QL
ZOLOFT ORAL
CONCENTRATE
3 ST; M
ZOLOFT ORAL
TABLET
3 ST; M; QL
zolpidem 1 QL
ZOLPIMIST 3 ST
ZYPREXA
INTRAMUSCULA
R
6 MSD
ZYPREXA ORAL
TABLET 10 MG, 15
MG, 2.5 MG, 5 MG,
7.5 MG
3 QL
ZYPREXA ORAL
TABLET 20 MG
3
ZYPREXA ZYDIS 3 QL
CARDIOVASCULAR,
HYPERTENSION & LIPIDS
ANTIARRHYTHMIC AGENTS
amiodarone 1 M
BETAPACE 3 M
BETAPACE AF 3 M
disopyramide
phosphate
1 M
dofetilide 1
flecainide 1 M
mexiletine 1 M
MULTAQ 3 M
NORPACE 3 M
NORPACE CR 3 M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
34
Drug Name Drug
Category
Requirements
/ Limits
pacerone 1 M
procainamide 6 MSD
propafenone 1 M
quinidine gluconate 1 M
quinidine sulfate 1 M
RYTHMOL SR 3 M
sotalol 1 M
sotalol af 1 M
SOTYLIZE 2 M
TIKOSYN 3
ANTIHYPERTENSIVE THERAPY
ACCUPRIL 3 M
ACCURETIC 3 M
acebutolol 1 M
ADALAT CC 3 ST; M
afeditab cr 1 M
ALDACTAZIDE 3 M
ALDACTONE 3 M
ALTACE 3 M
amiloride 1 M
amiloride-
hydrochlorothiazide
1 M
amlodipine 1 M
amlodipine-
benazepril
1 M
amlodipine-
olmesartan
1 M
amlodipine-
valsartan
1 M
amlodipine-
valsartan-hcthiazid
1 M
ATACAND 3 ST; M
ATACAND HCT 3 ST; M
Drug Name Drug
Category
Requirements
/ Limits
atenolol 1 M
atenolol-
chlorthalidone
1 M
AVALIDE 3 ST; M
AVAPRO 3 ST; M
AZOR 3 ST; M
benazepril 1 M
benazepril-
hydrochlorothiazide
1 M
BENICAR 3 ST; M
BENICAR HCT 3 ST; M
betaxolol 1 M
BIDIL 3 M
bisoprolol fumarate 1 M
bisoprolol-
hydrochlorothiazide
1 M
BREVIBLOC 6 MSD
BREVIBLOC IN
NACL (ISO-OSM)
6 MSD
bumetanide 1 M
BYSTOLIC 3 ST; M
BYVALSON 3 ST; M
CALAN 3 ST; M
CALAN SR 3 ST; M
candesartan 1 M
candesartan-
hydrochlorothiazid
1 M
captopril 1 M
captopril-
hydrochlorothiazide
1 M
CARDENE IV 6 MSD
CARDENE IV IN
DEXTROSE
6 MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
35
Drug Name Drug
Category
Requirements
/ Limits
CARDENE IV IN
SODIUM
CHLORIDE
6 MSD
CARDIZEM 3 M
CARDIZEM CD 3 M
CARDIZEM LA 3 M
CARDURA 3 ST; M; QL
CARDURA XL 3 ST; M; QL
cartia xt 1 M
carvedilol 1 M
CATAPRES 3 M
CATAPRES-TTS-1 3 M; QL
CATAPRES-TTS-2 3 M; QL
CATAPRES-TTS-3 3 M; QL
chlorothiazide 1 M
chlorothiazide
sodium
6 MSD
chlorthalidone 1 M
CLEVIPREX 6 MSD
clonidine 1 M; QL
clonidine hcl 1 M
clorpres oral tablet
0.1-15 mg, 0.2-15
mg
1 M
CLORPRES ORAL
TABLET 0.3-15
MG
3 M
COREG 3 ST; M
COREG CR 3 ST; M
CORGARD 3 ST; M
CORZIDE 3 ST; M
COZAAR 3 ST; M
DEMADEX 3 M
Drug Name Drug
Category
Requirements
/ Limits
DEMSER 2
DIBENZYLINE 3
diltiazem 1 M
DILTIAZEM IN
DEXTROSE 5 %
6 MSD
dilt-xr 1 M
DIOVAN 3 ST; M
DIOVAN HCT 3 ST; M
DIURIL 3 M
DIURIL IV 6 MSD
doxazosin 1 M; QL
DUTOPROL 2 ST; M
DYAZIDE 3 M
DYRENIUM 3 M
EDARBI 3 ST; M
EDARBYCLOR 3 ST; M
EDECRIN 3 M
enalapril maleate 1 M
enalapril-
hydrochlorothiazide
1 M
EPANED 3 M
eplerenone 1 M
epoprostenol
(glycine)
6 MSD
eprosartan 1 M
esmolol 6 MSD
ethacrynate sodium 6 MSD
ethacrynic acid 1 M
EXFORGE 3 ST; M
EXFORGE HCT 3 ST; M
felodipine 1 M
FLOLAN 6 MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
36
Drug Name Drug
Category
Requirements
/ Limits
fosinopril 1 M
fosinopril-
hydrochlorothiazide
1 M
furosemide injection 6 MSD
furosemide oral 1 M
guanfacine 1 M
HEMANGEOL 3
hydralazine injection 6 MSD
hydralazine oral 1 M
hydrochlorothiazide 1 M
HYZAAR 3 ST; M
indapamide 1 M
INDERAL LA 3 ST; M
INDERAL XL 3 ST; M
INNOPRAN XL 3 ST; M
INSPRA 3 M
irbesartan 1 M
irbesartan-
hydrochlorothiazide
1 M
isradipine 1 M
labetalol 1 M
LASIX 3 M
LEVATOL 3 ST; M
lisinopril 1 M
lisinopril-
hydrochlorothiazide
1 M
LOPRESSOR 3 ST; M
LOPRESSOR HCT 3 ST; M
losartan 1 M
losartan-
hydrochlorothiazide
1 M
LOTENSIN 3 M
LOTENSIN HCT 3 M
Drug Name Drug
Category
Requirements
/ Limits
LOTREL 3 M
matzim la 1 M
MAXZIDE 3 M
MAXZIDE-25MG 3 M
methyclothiazide 1 M
methyldopa 1 M
methyldopa-
hydrochlorothiazide
1 M
methyldopate 6 MSD
metolazone 1 M
metoprolol succinate 1 M
METOPROLOL
SU-
HYDROCHLOROT
HIAZ
3 ST; M
metoprolol ta-
hydrochlorothiaz
1 M
metoprolol tartrate 1 M
MICARDIS 3 ST; M
MICARDIS HCT 3 ST; M
MICROZIDE 3 M
MINIPRESS 3 M
minoxidil 1 M
moexipril 1 M
moexipril-
hydrochlorothiazide
1 M
nadolol 1 M
nadolol-
bendroflumethiazide
1 M
nicardipine
intravenous
6 MSD
nicardipine oral 1 M
nifedipine 1 M
nimodipine 1
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
37
Drug Name Drug
Category
Requirements
/ Limits
nisoldipine 1 M
NORVASC 3 ST; M
NYMALIZE 3
olmesartan 1 M
olmesartan-
amlodipin-hcthiazid
1 M
olmesartan-
hydrochlorothiazide
1 M
ORENITRAM 4 S; M; SLA
perindopril
erbumine
1 M
phenoxybenzamine 1
phentolamine 6 MSD
pindolol 1 M
prazosin 1 M
PRESTALIA 3 ST; M
PRINIVIL 3 M
PROCARDIA 3 ST; M
PROCARDIA XL 3 ST; M
propranolol 1 M
propranolol-
hydrochlorothiazid
1 M
QBRELIS 3 M
quinapril 1 M
quinapril-
hydrochlorothiazide
1 M
ramipril 1 M
REMODULIN 6 MSD
SODIUM
EDECRIN
6 MSD
spironolactone 1 M
spironolacton-
hydrochlorothiaz
1 M
Drug Name Drug
Category
Requirements
/ Limits
SULAR 3 ST; M
TARKA 3 M
taztia xt 1 M
TEKTURNA 3 M
TEKTURNA HCT 3 M
telmisartan 1 M
telmisartan-
amlodipine
1 M
telmisartan-
hydrochlorothiazid
1 M
TENORETIC 100 3 ST; M
TENORETIC 50 3 ST; M
TENORMIN 3 ST; M
terazosin 1 M; QL
TIAZAC 3 M
timolol maleate 1 M
TOPROL XL 3 ST; M
torsemide 1 M
trandolapril 1 M
trandolapril-
verapamil
1 M
triamterene-
hydrochlorothiazid
1 M
TRIBENZOR 3 ST; M
TWYNSTA 3 ST; M
UPTRAVI 3 S; M; SLA
valsartan 1 M
valsartan-
hydrochlorothiazide
1 M
VASERETIC 3 M
VASOTEC 3 M
veletri 6 MSD
verapamil 1 M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
38
Drug Name Drug
Category
Requirements
/ Limits
VERELAN 3 ST; M
VERELAN PM 3 ST; M
ZESTORETIC 3 M
ZESTRIL 3 M
ZIAC 3 ST; M
CARDIAC GLYCOSIDES
digitek 1 M
digox 1 M
digoxin injection 6 MSD
digoxin oral 1 M
LANOXIN
INJECTION
6 MSD
LANOXIN ORAL 3 M
LANOXIN
PEDIATRIC
6 MSD
COAGULATION THERAPY
ADVATE 6 MSD
ADYNOVATE 6 MSD
AFSTYLA 6 MSD
AGGRENOX 3 M
ALPHANATE 6 MSD
ALPHANINE SD 6 MSD
ALPROLIX 6 MSD
AMICAR 2
ANGIOMAX 6 MSD
ARGATROBAN 6 MSD
ARGATROBAN IN
0.9 % SOD CHLOR
6 MSD
ARGATROBAN IN
NACL (ISO-OS)
6 MSD
ARIXTRA 3
aspirin-dipyridamole 1 M
Drug Name Drug
Category
Requirements
/ Limits
BEBULIN 6 MSD
BENEFIX 6 MSD
bivalirudin 6 MSD
BRILINTA 2 M
CEPROTIN (BLUE
BAR)
6 MSD
CEPROTIN
(GREEN BAR)
6 MSD
cilostazol 1 M
clopidogrel oral
tablet 300 mg
1
clopidogrel oral
tablet 75 mg
1 M
COAGADEX 6 MSD
CORIFACT 6 MSD
COUMADIN 3
dipyridamole 1 M
DURLAZA 3 M
EFFIENT 3 M
ELIQUIS 2 PA
ELOCTATE 6 MSD
enoxaparin
subcutaneous
solution
6 MSD
enoxaparin
subcutaneous
syringe
1
FEIBA NF 6 MSD
fondaparinux 1
FRAGMIN 3
HELIXATE FS 6 MSD
HEMOFIL M HIGH 6 MSD
HEMOFIL M LOW 6 MSD
HEMOFIL M MID 6 MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
39
Drug Name Drug
Category
Requirements
/ Limits
HEMOFIL M
SUPER HIGH
6 MSD
hep flush-10 (pf) 1
heparin (porcine) 1
HEPARIN
(PORCINE) IN
0.9% NACL
6 MSD
heparin (porcine) in
5 % dex
6 MSD
heparin (porcine) in
nacl (pf)
1
heparin
flush(porcine)-
0.9nacl
6 MSD
heparin lock flush 1
heparin lock flush
(porcine)
1
heparin
lockflush(porcine)(pf
)
1
HEPARIN(PORCIN
E) IN 0.45% NACL
INTRAVENOUS
PARENTERAL
SOLUTION 12,500
UNIT/250 ML
3
heparin(porcine) in
0.45% nacl
intravenous
parenteral solution
25,000 unit/250 ml,
25,000 unit/500 ml
1
heparin, porcine (pf) 1
HUMATE-P 6 MSD
IDELVION 6 MSD
IPRIVASK 6 MSD
IXINITY 6 MSD
jantoven 1
Drug Name Drug
Category
Requirements
/ Limits
KOATE 6 MSD
KOGENATE FS 6 MSD
KOVALTRY 6 MSD
LOVENOX
SUBCUTANEOUS
SOLUTION
6 MSD
LOVENOX
SUBCUTANEOUS
SYRINGE
3
MEPHYTON 2
MONOCLATE-P 6 MSD
MONONINE 6 MSD
NOVOEIGHT 6 MSD
NOVOSEVEN RT 6 MSD
NPLATE 6 MSD
NUWIQ 6 MSD
OBIZUR 6 MSD
pentoxifylline 1 M
PLAVIX ORAL
TABLET 300 MG
3
PLAVIX ORAL
TABLET 75 MG
3 M
PRADAXA 3 PA; M
prasugrel 1 M
PRAXBIND 6 MSD
PROFILNINE 6 MSD
PROMACTA 2 PA
RECOMBINATE 6 MSD
RIASTAP 6 MSD
RIXUBIS 6 MSD
SAVAYSA 3 PA
ticlopidine 1 M
tranexamic acid 6 MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
40
Drug Name Drug
Category
Requirements
/ Limits
TRETTEN 6 MSD
VONVENDI 6 MSD
warfarin 1
WILATE 6 MSD
XARELTO 2 PA
XYNTHA 6 MSD
XYNTHA
SOLOFUSE
6 MSD
YOSPRALA 3 M
ZONTIVITY 3 PA; M
LIPID/CHOLESTEROL LOWERING
AGENTS
ALTOPREV 3 ST; M; QL
amlodipine-
atorvastatin
1 M; QL
ANTARA 3 ST; M; QL
atorvastatin 1 M; QL
CADUET 3 ST; M; QL
cholestyramine (with
sugar)
1 M
cholestyramine light 1 M
COLESTID 3 ST; M
COLESTID
FLAVORED
3 ST; M
colestipol 1 M
CRESTOR 3 ST; M; QL
ezetimibe 1 ST; M
ezetimibe-
simvastatin
1 M; QL
fenofibrate
micronized
1 M; QL
fenofibrate
nanocrystallized
1 M; QL
Drug Name Drug
Category
Requirements
/ Limits
FENOFIBRATE
ORAL CAPSULE
3 ST; M; QL
fenofibrate oral
tablet
1 M; QL
fenofibric acid 1 M; QL
fenofibric acid
(choline)
1 M; QL
FENOGLIDE 3 ST; M; QL
FIBRICOR 3 ST; M; QL
FLOLIPID 3 ST; M
fluvastatin 1 M; QL
gemfibrozil 1 M; QL
JUXTAPID ORAL
CAPSULE 10 MG,
20 MG, 5 MG
3 PA; S; SLA;
QL
JUXTAPID ORAL
CAPSULE 30 MG,
40 MG, 60 MG
3 PA; S; SLA
KYNAMRO 4 PA; S; SLA;
QL
LESCOL 3 ST; M; QL
LESCOL XL 3 ST; M; QL
LIPITOR 3 ST; M; QL
LIPOFEN 3 ST; M; QL
LIVALO 3 ST; M; QL
LOPID 3 M; QL
lovastatin 1 M; QL
LOVAZA 3 PA; M
niacin 1 M
NIACOR 3 M
NIASPAN
EXTENDED-
RELEASE
3 M
omega-3 acid ethyl
esters
1 PA; M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
41
Drug Name Drug
Category
Requirements
/ Limits
PRALUENT PEN 3 PA; S; SLA
PRAVACHOL 3 ST; M; QL
pravastatin 1 M; QL
prevalite 1 M
QUESTRAN 3 ST; M
QUESTRAN
LIGHT
3 ST; M
REPATHA
PUSHTRONEX
3 PA; S; SLA
REPATHA
SURECLICK
3 PA; S; SLA
REPATHA
SYRINGE
3 PA; S; SLA
rosuvastatin 1 M; QL
simvastatin 1 M; QL
TRICOR 3 ST; M; QL
TRIGLIDE 3 ST; M; QL
triklo 1 PA; M
TRILIPIX 3 ST; M; QL
VASCEPA 2 PA; M
VYTORIN 10-10 3 ST; M; QL
VYTORIN 10-20 3 ST; M; QL
VYTORIN 10-40 3 ST; M; QL
VYTORIN 10-80 3 ST; M; QL
WELCHOL 3 ST; M
ZETIA 3 ST; M
ZOCOR 3 ST; M; QL
MISCELLANEOUS
CARDIOVASCULAR AGENTS
CORLANOR 2 PA; M
ENTRESTO 2 PA; M
RANEXA 3 M
VECAMYL 3
Drug Name Drug
Category
Requirements
/ Limits
NITRATES
DILATRATE-SR 3 M
GONITRO 3
ISOCHRON 3 M
ISORDIL 3 M
ISORDIL
TITRADOSE
3 M
isosorbide dinitrate 1 M
isosorbide
mononitrate
1 M
MINITRAN 3 M
nitro-bid 1 M
NITRO-DUR 3 M
nitroglycerin oral 1 M
nitroglycerin
sublingual
1
nitroglycerin
transdermal
1 M
nitroglycerin
translingual
1
NITROLINGUAL 3
NITROMIST 3
NITROSTAT 3
nitro-time 1 M
DERMATOLOGICALS/TOPICA
L THERAPY
ANTIPSORIATIC /
ANTISEBORRHEIC
acitretin 1
ANALPRAM-HC 3 ST
calcipotriene 1 QL
calcipotriene-
betamethasone
1 QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
42
Drug Name Drug
Category
Requirements
/ Limits
calcitrene 1 QL
calcitriol 1 QL
COAL TAR 2
COSENTYX 4 PA; S; SLA;
QL
COSENTYX (2
SYRINGES)
4 PA; S; SLA;
QL
COSENTYX PEN 4 PA; S; SLA;
QL
COSENTYX PEN
(2 PENS)
4 PA; S; SLA;
QL
DOVONEX 3 QL
drithocreme hp 1
ENSTILAR 3
EPIFOAM 3 ST
hydrocortisone-
pramoxine
1
OVACE 3
OVACE PLUS
SHAMPOO
3
OVACE PLUS
TOPICAL
CLEANSER,EXTE
NDED RELEASE
3
OVACE PLUS
TOPICAL CREAM
3 ST
OVACE PLUS
TOPICAL FOAM
3
OVACE PLUS
TOPICAL LOTION
3 ST
OVACE PLUS
WASH
3
PRAMOSONE 3 ST
PRAMOSONE E 3 ST
seb-prev 1
Drug Name Drug
Category
Requirements
/ Limits
selenium sulfide 1
SELRX 3
SILIQ 4 PA; ST; S;
SLA
SORIATANE 3
SORILUX 3 QL
STELARA 6 MSD
sulfacetamide
sodium
1
TACLONEX
TOPICAL
OINTMENT
3 QL
TACLONEX
TOPICAL
SUSPENSION
3
TALTZ
AUTOINJECTOR
4 ST; S; SLA
TALTZ
AUTOINJECTOR
(2 PACK)
4 ST; S; SLA
TALTZ
AUTOINJECTOR
(3 PACK)
4 ST; S; SLA
TALTZ SYRINGE 4 ST; S; SLA
TALTZ SYRINGE
(2 PACK)
4 ST; S; SLA
TALTZ SYRINGE
(3 PACK)
4 ST; S; SLA
TERSI FOAM 3
TREMFYA 4 ST; S
VECTICAL 3 QL
ZITHRANOL 3
BURN THERAPY
SILVADENE 3
silver sulfadiazine 1
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
43
Drug Name Drug
Category
Requirements
/ Limits
ssd 1
thermazene 1
KERATOLYTICS
BENSAL HP 3
INOVA 4-1 3 ST
KERALYT RX 3
PODOCON 3
POTASSIUM
HYDROXIDE
3
SALEX 3
salicylic acid 1
SALKERA 3
salvax 1
SALVAX DUO
PLUS
3
ULTRASAL-ER 3
VIRASAL 3
MISCELLANEOUS
DERMATOLOGICALS
ALEVICYN PLUS 3
AMELUZ 6 MSD
ATOPICLAIR 3
ATRAPRO CP 3
ATRAPRO
HYDROGEL
3
avo cream 1
BIAFINE
EMULSION
3
bp-50% urea 1
CARAC 3
celacyn 1
CONDYLOX 3
CORTANE-B 3
Drug Name Drug
Category
Requirements
/ Limits
DEXERYL 3
diclofenac sodium 1 PA
doxepin 1
DUPIXENT 3 PA; S; SLA
EFUDEX 3
eletone 1
ELIDEL 3 ST; QL
EPICERAM 3
EUCRISA 3 PA; ST; QL
FLUOROPLEX 3
FLUOROURACIL
TOPICAL CREAM
0.5 %
3
fluorouracil topical
cream 5 %
1
fluorouracil topical
solution
1
GORDONS UREA 3
hpr 1
hpr plus 1
hpr plus hydrogel 1
HPR PLUS-MB
HYDROGEL
3
HYDRO 35 3
HYDRO 40 3
HYLATOPIC 3
HYLATOPICPLUS 3
KERAFOAM 3
KERALAC 3
LEVULAN 6 MSD
LOUTREX 3
luxamend 1
methoxsalen 1
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
44
Drug Name Drug
Category
Requirements
/ Limits
NEOSALUS 3
nivatopic plus 1
OXSORALEN
ULTRA
3
PANRETIN 3
PICATO 3 QL
podofilox 1
PRESERA 3
PROMISEB 3
PROTOPIC 3 ST; QL
pruclair 1
prudoxin 1
prumyx 1
prutect 1
QUTENZA 6 MSD
rea lo 39 1
rea lo 40 1
REGRANEX 2 QL
RESTIZAN 3
silver nitrate 1
silver nitrate
applicators
1
SOLARAZE 3 PA
sonafine 1
sp antipruritic 1
sp scar management 1
tacrolimus 1 ST; QL
TOLAK 3
umecta 1
urea 1
urea nail stick 1
UTOPIC 3
Drug Name Drug
Category
Requirements
/ Limits
VALCHLOR 3 S; SLA
VEREGEN 3
XCLAIR 3
ZONALON 3
THERAPY FOR ACNE
ABSORICA 3 QL
ACANYA 3 ST; QL
ACZONE 3 ST
adapalene topical
cream
1 QL
adapalene topical
gel
1 QL
adapalene topical
gel with pump
1 QL
ADAPALENE
TOPICAL LOTION
3 ST; QL
adapalene-benzoyl
peroxide
1 QL
AKTIPAK 3 ST
amnesteem 1 QL
ATRALIN 3 QL
AVAR LS 3 ST
avar topical cleanser 1
AVAR TOPICAL
FOAM
3 ST
AVAR TOPICAL
PADS,
MEDICATED
3 ST
AVAR-E GREEN 3 ST
AVAR-E LS 3 ST
avita topical cream 1 QL
AVITA TOPICAL
GEL
3 QL
AZELEX 3 ST; QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
45
Drug Name Drug
Category
Requirements
/ Limits
BENZACLIN 3 ST
BENZACLIN
PUMP
3 ST; QL
BENZAMYCIN 3 ST
BENZEFOAM 3 ST
BENZEFOAM
ULTRA
3 ST
benzepro 1
bp 10-1 1
bpo 1
claravis 1 QL
cleansing wash 1
CLEOCIN T 3 ST
CLINDACIN ETZ 3 ST
clindacin p 1
CLINDACIN PAC 3 ST
CLINDAGEL 3 ST
clindamycin
phosphate
1
clindamycin-benzoyl
peroxide topical gel
1.2 %(1 % base) -5
%
1 QL
clindamycin-benzoyl
peroxide topical gel
1-5 %
1
clindamycin-benzoyl
peroxide topical gel
with pump
1 QL
clindamycin-
tretinoin
1
DIFFERIN 3 ST; QL
DUAC 3 ST; QL
EPIDUO 3 ST; QL
EPIDUO FORTE 3 ST
Drug Name Drug
Category
Requirements
/ Limits
ery pads 1
erygel 1
erythromycin with
ethanol
1
erythromycin-
benzoyl peroxide
1
EVOCLIN 3 ST
FABIOR 3 PA; QL
FINACEA 3 ST
INOVA 3 ST
METROCREAM 3 ST
METROGEL 3 ST
METROLOTION 3 ST
metronidazole 1
MIRVASO 3
neuac 1 QL
NEUAC KIT 3 ST
NORITATE 3 ST
NUOX 3 ST
ONEXTON 3 ST; QL
PLEXION 3 ST
PLEXION
CLEANSING
CLOTHS
3 ST
RETIN-A MICRO 3
RETIN-A MICRO
PUMP
3
RETIN-A TOPICAL
CREAM 0.025 %
3 QL
RETIN-A TOPICAL
CREAM 0.05 %, 0.1
%
3
RETIN-A TOPICAL
GEL 0.01 %
3
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
46
Drug Name Drug
Category
Requirements
/ Limits
RETIN-A TOPICAL
GEL 0.025 %
3 QL
RHOFADE 3 PA
rosadan topical
cream
1
rosadan topical gel 1
ROSADAN
TOPICAL KIT,
CLEANSER AND
GEL
3 ST
ROSADAN
TOPICAL
KIT,CLEANSER
AND CREAM
3 ST
ROSANIL 3 ST
ROSULA 3 ST
rosula cleansing
cloths
1
SOOLANTRA 3 ST
sss 10-5 1
sulfacetamide
sodium-sulfur
1
sulfacetamide sod-
sulfur-urea
1
sulfacleanse 8-4 1
SUMADAN 3 ST
SUMAXIN 3 ST
SUMAXIN TS 3 ST
tazarotene 1 PA; QL
TAZORAC
TOPICAL CREAM
0.05 %
2 PA; QL
TAZORAC
TOPICAL CREAM
0.1 %
3 PA; QL
Drug Name Drug
Category
Requirements
/ Limits
TAZORAC
TOPICAL GEL
2 PA; QL
tretinoin
microspheres
1
tretinoin topical
cream 0.025 %
1 QL
tretinoin topical
cream 0.05 %, 0.1 %
1
tretinoin topical gel
0.01 %
1
tretinoin topical gel
0.025 %, 0.05 %
1 QL
TRETIN-X 3
TRETIN-X CREAM
KIT
3
VANOXIDE-HC 3 ST
VELTIN 3 ST
zenatane 1 QL
ZIANA 3 ST
TOPICAL ANESTHETICS
AGONEAZE 3
ANASTIA 3
ANODYNE LPT 3
ASTERO 3
BUCALSEP 3
cidaleaze 1
DERMACINRX
EMPRICAINE
3
ethyl chloride 1
glydo 1
LDO PLUS 3
LEVA SET 3
lidocaine (pf) 6 MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
47
Drug Name Drug
Category
Requirements
/ Limits
lidocaine hcl
injection
6 MSD
lidocaine hcl
laryngotracheal
1
lidocaine hcl mucous
membrane
1
lidocaine hcl topical 1
lidocaine hcl-
hydrocortison ac
1
lidocaine topical
adhesive
patch,medicated
1 PA
lidocaine topical
ointment
1
lidocaine viscous 1
lidocaine-prilocaine 1
LIDOCAINE-
TETRACAINE
3
LIDODERM 3 PA
LIDOPAC 3
lidopin topical
cream 3 %
1
LIDOPIN TOPICAL
CREAM 3.25 %
3
LIDO-PRILO
CAINE PACK
3
LIDORX 3
LIDOTRAL 3
LIDTOPIC MAX 3
LIPROZONEPAK 3
lta pre-attached 1
MEDOLOR PAK 3
NUMBONEX 3
P-CARE X (PF) 6 MSD
PLIAGLIS 3
Drug Name Drug
Category
Requirements
/ Limits
PRILOLID 3
READYSHARP
LIDOCAINE (PF)
6 MSD
relador pak 1
relador pak plus 1
SYNERA 3
TRANZAREL 3
ZINGO 6 MSD
TOPICAL ANTIBACTERIALS
ALTABAX 3
BACTROBAN 3
CENTANY 3
CENTANY AT 3
CORTISPORIN 3
gentamicin 1
hydrocortisone-
iodoquinol-aloe
1
iodoquinol-hc 1
KLARON 3 ST
lugols 1
mupirocin 1
mupirocin calcium 1
NEO-SYNALAR 3
NEO-SYNALAR
KIT
3
SILVRSTAT 3
sulfacetamide
sodium (acne)
1
SULFAMYLON 2
TOPICAL ANTIFUNGALS
ciclodan 1
CICLODAN KIT 3
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
48
Drug Name Drug
Category
Requirements
/ Limits
ciclopirox 1
clotrimazole-
betamethasone
1
econazole 1
ECOZA 3
ERTACZO 3
EXELDERM 3
EXODERM 3
EXTINA 3
JUBLIA 3 QL
KERYDIN 3 QL
ketoconazole 1
LOPROX 3
LOPROX (AS
OLAMINE)
3
LOPROX KIT 3
LOTRISONE 3
LUZU 3 QL
naftifine topical
cream 1 %
2
naftifine topical
cream 2 %
1
NAFTIN 3
NIZORAL 3
nyamyc 1
nyata 1
nystatin 1
nystatin-
triamcinolone
1
nystop 1
oxiconazole 1
OXISTAT 3
PENLAC 3
Drug Name Drug
Category
Requirements
/ Limits
TRIACETIN 2
TRIPLE DYE 3
VUSION 3
XOLEGEL 3
TOPICAL ANTIVIRALS
acyclovir 1 QL
DENAVIR 3
XERESE 3
ZOVIRAX
TOPICAL CREAM
2 QL
ZOVIRAX
TOPICAL
OINTMENT
3 QL
TOPICAL CORTICOSTEROIDS
ala-cort 1
ALA-SCALP 3 ST
alclometasone 1
amcinonide 1
apexicon e 1 QL
AQUA GLYCOLIC
HC
3 ST
betamethasone
dipropionate
1
betamethasone
valerate
1
betamethasone,
augmented
1
CAPEX 3 ST; QL
clobetasol 1
clobetasol-emollient 1
CLOBEX 3 ST
CLOCORTOLONE
PIVALATE
3 ST; QL
clodan 1
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
49
Drug Name Drug
Category
Requirements
/ Limits
CLODAN KIT 3 ST
CLODERM 3 ST; QL
CORDRAN 3 ST
CORDRAN TAPE
LARGE ROLL
3 ST
cormax 1
CUTIVATE 3 ST
DERMA-
SMOOTHE/FS
BODY OIL
3 ST; QL
DERMA-
SMOOTHE/FS
SCALP OIL
3 ST; QL
DERMATOP 3 ST
DESONATE 3 ST
desonide 1 QL
DESOWEN 3 ST; QL
desoximetasone 1 QL
diflorasone 1 QL
DIPROLENE 3 ST
DIPROLENE AF 3 ST
ELLZIA PAK 3
ELOCON 3 ST
fluocinolone 1 QL
fluocinolone and
shower cap
1 QL
fluocinonide 1
fluocinonide-e 1
fluocinonide-
emollient
1
flurandrenolide 1
fluticasone 1
halobetasol
propionate
1 QL
Drug Name Drug
Category
Requirements
/ Limits
HALOG 3 ST
hydrocortisone 1
hydrocortisone
butyrate
1
hydrocortisone
butyr-emollient
1
hydrocortisone
valerate
1
hydrocortisone-min
oil-wht pet
1
KENALOG 3 ST
LOCOID 3 ST
LOCOID
LIPOCREAM
3 ST
LUXIQ 3 ST
mometasone 1
nolix 1
OLUX 3 ST
OLUX-E 3 ST
PANDEL 3 ST
prednicarbate 1
PSORCON 3 ST; QL
scalacort 1
SERNIVO 3 ST
SYNALAR 3 ST; QL
SYNALAR
CREAM KIT
3 ST
SYNALAR
OINTMENT KIT
3 ST
SYNALAR TS 3 ST
TEMOVATE 3 ST
TEXACORT 3 ST
TOPICORT
TOPICAL CREAM
3 ST; QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
50
Drug Name Drug
Category
Requirements
/ Limits
TOPICORT
TOPICAL GEL
3 ST; QL
TOPICORT
TOPICAL
OINTMENT
3 ST; QL
TOPICORT
TOPICAL
SPRAY,NON-
AEROSOL
3 ST
triamcinolone
acetonide
1
trianex 1
triderm 1
TRIDESILON 3 ST; QL
ULTRAVATE
TOPICAL CREAM
3 ST; QL
ULTRAVATE
TOPICAL LOTION
3 ST
ULTRAVATE
TOPICAL
OINTMENT
3 ST; QL
ULTRAVATE X 3 ST
VANOS 3 ST
VERDESO 3 ST
TOPICAL ENZYMES
SANTYL 2
TOPICAL SCABICIDES /
PEDICULICIDES
ELIMITE 3
EURAX 3
lindane 1
malathion 1
NATROBA 3 QL
OVIDE 3
permethrin 1
Drug Name Drug
Category
Requirements
/ Limits
SKLICE 3
spinosad 1 QL
ULESFIA 3
DIAGNOSTICS &
MISCELLANEOUS AGENTS
IRRIGATING SOLUTIONS
lactated ringers 1
PHYSIOLYTE 3
PHYSIOSOL
IRRIGATION
3
ringer's 1
SORBITOL-
MANNITOL
3
tis-u-sol pentalyte 1
VASHE WOUND
THERAPY
3
MISCELLANEOUS AGENTS
acamprosate 1
ACTONEL 3 ST; QL
ADAGEN 6 MSD
AGRYLIN 3 M
alendronate 1 M; QL
AMMONUL 6 MSD
AMPHADASE 6 MSD
anagrelide 1 M
ANTABUSE 3
ARALAST NP 6 MSD
BUPHENYL ORAL
POWDER
3
BUPHENYL ORAL
TABLET
2
caffeine citrate 1
CARBAGLU 3 S; SLA
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
51
Drug Name Drug
Category
Requirements
/ Limits
CARNITOR 3 M
CARNITOR
(SUGAR-FREE)
3 M
cevimeline 1 M
CHEMET 2
disulfiram 1
etidronate disodium 1 M
EVOXAC 3 M
EXJADE 3 S; SLA
FERRIPROX 3 S
FERRLECIT 6 MSD
GLASSIA 6 MSD
ic green 6 MSD
INCRELEX 3 PA; S; SLA
indocyanine green 6 MSD
INFASURF 3
JADENU 3 S
JADENU
SPRINKLE
3 S
KIT PREP OF TC-
99M-
MEBROFENIN
6 MSD
levocarnitine 1 M
levocarnitine (with
sugar)
1 M
LIPOCHOL PLUS 3
LITHOSTAT 3
METOPIRONE 3
midodrine 1
NITYR 3 PA
NORTHERA 4 S; SLA
NUTRESTORE 3
ORFADIN 3 S; SLA
Drug Name Drug
Category
Requirements
/ Limits
pilocarpine hcl 1
PROLASTIN-C 6 MSD
RADIOGARDASE 6 MSD
RAVICTI 3 S; SLA
RECLAST 6 MSD
RILUTEK 3
riluzole 1
risedronate 1 QL
SALAGEN
(PILOCARPINE)
3
sodium benzoate-sod
phenylacet
6 MSD
sodium chlor 0.9%
bacteriostat
6 MSD
sodium chloride 0.9
%
6 MSD
sodium ferric
gluconat-sucrose
6 MSD
sodium
phenylbutyrate
1
SOLIRIS 6 MSD
SURVANTA 6 MSD
SYPRINE 3 PA
THIOLA 3
water for irrigation,
sterile
1
XURIDEN 2
ZEMAIRA 6 MSD
zoledronic acid-
mannitol-water
6 MSD
SMOKING DETERRENTS
bupropion hcl
(smoking deter)
5 M; ACA
CHANTIX 5 ACA
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
52
Drug Name Drug
Category
Requirements
/ Limits
CHANTIX
CONTINUING
MONTH BOX
5 ACA
CHANTIX
STARTING
MONTH BOX
5 ACA
NICODERM CQ
TRANSDERMAL
PATCH 24 HOUR
14 MG/24 HR, 7
MG/24 HR
5 ACA; OTC
NICODERM CQ
TRANSDERMAL
PATCH 24 HOUR
21 MG/24 HR
5 M; ACA; OTC
nicorelief 5 ACA; OTC
NICORETTE
BUCCAL GUM 2
MG
5 ACA; OTC
nicorette buccal gum
4 mg
5 ACA; OTC
NICORETTE
BUCCAL
LOZENGE
5 ACA; OTC
NICORETTE
BUCCAL MINI
LOZENGE
5 ACA; OTC
nicotine (polacrilex) 5 ACA; OTC
nicotine transdermal
patch 24 hour 14
mg/24 hr, 7 mg/24
hr
5 ACA; OTC
nicotine transdermal
patch 24 hour 21
mg/24 hr
5 M; ACA; OTC
nicotine transdermal
patch, td daily,
sequential
5 ACA; OTC
NICOTROL 5 ACA
Drug Name Drug
Category
Requirements
/ Limits
NICOTROL NS 5 ACA
nts step 1 5 M; ACA; OTC
quit 2 buccal gum 5 ACA; OTC
QUIT 2 BUCCAL
LOZENGE
5 ACA; OTC
quit 4 buccal gum 5 ACA; OTC
QUIT 4 BUCCAL
LOZENGE
5 ACA; OTC
stop smoking aid 5 ACA; OTC
ZYBAN 5 M; ACA
EAR, NOSE & THROAT
MEDICATIONS
MISCELLANEOUS AGENTS
ASTEPRO 3
azelastine nasal
aerosol,spray
1 QL
azelastine nasal
spray,non-aerosol
1
BACTROBAN
NASAL
2
chlorhexidine
gluconate
1
CLINPRO 5000 3 M
DEBACTEROL 2
denta 5000 plus 1 M
dentagel 1 M
EPISIL 3
fluoride (sodium) 1 M
FLUORIDEX
DAILY DEFENSE
3 M
GELCLAIR 3
ipratropium bromide 1 QL
MUGARD 3
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
53
Drug Name Drug
Category
Requirements
/ Limits
olopatadine 1 QL
oralone 1
ORAMAGICRX 3
paroex oral rinse 1
PATANASE 3 QL
PERIDEX 3
periogard 1
pilocarpine hcl 1
PREVIDENT 3 M
PREVIDENT 5000
BOOSTER PLUS
3 M
PREVIDENT 5000
DRY MOUTH
3 M
PREVIDENT 5000
ENAMEL
PROTECT
3 M
PREVIDENT 5000
PLUS
3 M
PREVIDENT 5000
SENSITIVE
3 M
Q-CARE RX Q4 3
SALAGEN
(PILOCARPINE)
3
sf 1 M
sf 5000 plus 1 M
triamcinolone
acetonide
1
TYZINE 3
MISCELLANEOUS OTIC
PREPARATIONS
acetic acid 1
CETRAXAL 3
ciprofloxacin hcl 1
DERMOTIC OIL 3
Drug Name Drug
Category
Requirements
/ Limits
floxin 1
fluocinolone
acetonide oil
1
hydrocortisone-
acetic acid
1
ofloxacin 1
OTIPRIO 3
OTIC STEROID / ANTIBIOTIC
CIPRO HC 3
CIPRODEX 2
COLY-MYCIN S 3
neomycin-
polymyxin-hc
1
OTOVEL 3
ENDOCRINE/DIABETES
ADRENAL HORMONES
ACTHAR H.P. 6 MSD
ARZE-JECT-A 6 MSD
betamethasone
acet,sod phos
6 MSD
CELESTONE
SOLUSPAN
6 MSD
CORTEF 3 M
cortisone 1
CORTROSYN 6 MSD
cosyntropin 6 MSD
CUSHINGS
SYNDROME
DIAGNOSTIC
6 MSD
deltasone 1
dexamethasone 1
dexamethasone
intensol
1
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
54
Drug Name Drug
Category
Requirements
/ Limits
dexamethasone
sodium phos (pf)
6 MSD
dexamethasone
sodium phosphate
6 MSD
DEXPAK 10 DAY 3
DEXPAK 13 DAY 3
DEXPAK 6 DAY 3
EMFLAZA 3 PA
fludrocortisone 1 M
hydrocortisone 1 M
KENALOG 6 MSD
LOCORT 3 PA
MEDROL 3
MEDROL (PAK) 3
methylprednisolone 1
millipred dp 1
MILLIPRED ORAL
SOLUTION
3
millipred oral tablet 1
ORAPRED ODT 3
P-CARE K40 6 MSD
P-CARE K80 6 MSD
PEDIAPRED 3
POD-CARE 100K 6 MSD
prednisolone 1
prednisolone sodium
phosphate
1
prednisone 1
prednisone intensol 1
PRO-C-DURE 5 6 MSD
PRO-C-DURE 6 6 MSD
RAYOS 3
Drug Name Drug
Category
Requirements
/ Limits
READYSHARP
DEXAMETHASON
E
6 MSD
READYSHARP
TRIAMCINOLONE
6 MSD
triamcinolone
acetonide
6 MSD
veripred 20 1
ZONACORT 3 PA
ANTITHYROID AGENTS
methimazole 1 M
propylthiouracil 1 M
SSKI 3 M
TAPAZOLE 3 M
BLOOD GLUCOSE MONITORING
DEVICES & SUPPLIES
ACCU-CHEK
AVIVA PLUS
TEST STRP
3 OTC
ACCU-CHEK
COMPACT PLUS
TEST
3 OTC
ACCU-CHEK
GUIDE
3 OTC
ACCU-CHEK
SMARTVIEW
TEST STRIP
3 OTC
ACCUTREND
GLUCOSE
3 OTC
ADVANCED
GLUC METER
TEST STRIP
3 OTC
ADVOCATE REDI-
CODE
3 OTC
ADVOCATE TEST
STRIPS
3 OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
55
Drug Name Drug
Category
Requirements
/ Limits
AGAMATRIX
AMP TEST STRIPS
3 OTC
ASSURE 4 STRIPS 3 OTC
ASSURE
PLATINUM
3 OTC
ASSURE PRISM
MULTI STRIP
3 OTC
BIONIME
RIGHTEST TEST
STRIPS
3 OTC
BLOOD GLUCOSE
TEST
3 OTC
BREEZE 2 TEST
STRIPS
3 OTC
CARESENS N
TEST STRIPS
3 OTC
CLEVER CHOICE
MICRO TEST
STRIP
3 OTC
CLEVER CHOICE
PRO
3 OTC
CLEVER CHOICE
TEST STRIPS
3 OTC
CLEVER CHOICE
VOICE+ TEST
3 OTC
CONTOUR NEXT
STRIPS
3 OTC
CONTOUR TEST
STRIPS
3 OTC
COOL GLUCOSE
TEST STRIP
3 OTC
DIATRUE PLUS
TEST STRIP
3 OTC
EASY PLUS II
TEST
3 OTC
EASY STEP 3 OTC
Drug Name Drug
Category
Requirements
/ Limits
EASY TALK
GLUCOSE TEST
3 OTC
EASY TOUCH
TEST STRIP
3 OTC
EASY TRAK
GLUCOSE TEST
3 OTC
EASYGLUCO
PLUS
3 OTC
EASYGLUCO
TEST
3 OTC
EASYMAX 3 OTC
ELEMENT
COMPACT TEST
STRIPS
3 OTC
ELEMENT TEST
STRIPS
3 OTC
EMBRACE
BLOOD GLUCOSE
SYSTEM
3 OTC
EMBRACE EVO
TEST STRIPS
3 OTC
EMBRACE PRO
TEST STRIPS
3 OTC
EVENCARE G2 3 OTC
EVENCARE G3
TEST
3 OTC
EVENCARE MINI
GLUCOSE TEST
STR
3 OTC
EVOLUTION TEST
STRIPS
3 OTC
EZ SMART PLUS
TEST
3 OTC
EZ SMART TEST 3 OTC
FIFTY50 TEST
STRIP
3 OTC
FORA D15G 3 OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
56
Drug Name Drug
Category
Requirements
/ Limits
FORA D20 3 OTC
FORA D40-G31
TEST STRIPS
3 OTC
FORA G20 3 OTC
FORA G30A 3 OTC
FORA GD50 TEST
STRIPS
3 OTC
FORA TEST STRIP 3 OTC
FORA TN'G VOICE
TEST STRIPS
3 OTC
FORA V10 3 OTC
FORA V10-V12-
D10-D20 STRIPS
3 OTC
FORA V12
GLUCOSE
3 OTC
FORA V20 3 OTC
FORACARE GD20 3 OTC
FORACARE GD40 3 OTC
FORTISCARE
GLUCOSE TEST
STRIPS
3 OTC
FREESTYLE
INSULINX
2 OTC
FREESTYLE
INSULINX TEST
STRIPS
2 OTC
FREESTYLE LITE
STRIPS
2 OTC
FREESTYLE
PRECISION NEO
STRIPS
3 OTC
FREESTYLE TEST 2 OTC
GE100 BLOOD
GLUCOSE TEST
STRIP
3 OTC
Drug Name Drug
Category
Requirements
/ Limits
GENSTRIP TEST
STRIP
3 OTC
GLUCO NAVII
TEST STRIP
3 OTC
GLUCOCARD 01
SENSOR PLUS
3 OTC
GLUCOCARD
EXPRESSION
3 OTC
GLUCOCARD
SHINE TEST
STRIPS
3 OTC
GLUCOCARD
VITAL SENSOR
3 OTC
GLUCOCARD
VITAL TEST
STRIPS
3 OTC
GLUCOCOM
GLUCOSE
3 OTC
GM100 3 OTC
HEALTHPRO
TEST STRIPS
3 OTC
INFINITY TEST
STRIPS
3 OTC
MICRO BLOOD
GLUCOSE
3 OTC
MICRODOT
BLOOD GLUCOSE
SYSTEM
3 OTC
MYGLUCOHEALT
H
3 OTC
NEUTEK 2TEK
TEST STRIPS
3 OTC
NOVA MAX
GLUCOSE TEST
3 OTC
ON CALL
EXPRESS TEST
STRIP
3 OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
57
Drug Name Drug
Category
Requirements
/ Limits
ON CALL PLUS
TEST STRIP
3 OTC
ON CALL VIVID
TEST STRIP
3 OTC
ONETOUCH
ULTRA TEST
3 OTC
ONETOUCH
VERIO
3 OTC
OPTIUM EZ 3 OTC
OPTIUM TEST 3 OTC
OPTUMRX 3 OTC
PHARMACIST
CHOICE
3 OTC
PRECISION PCX
PLUS TEST
3 OTC
PRECISION PCX
TEST
3 OTC
PRECISION POINT
OF CARE TEST
3 OTC
PRECISION Q-I-D
TEST
3 OTC
PRECISION XTRA
TEST
3 OTC
PREMIUM V10 3 OTC
PRODIGY NO
CODING
3 OTC
QUINTET AC 3 OTC
REFUAH PLUS 3 OTC
RELION
CONFIRM-MICRO
3 OTC
RELION PRIME
TEST STRIPS
3 OTC
REVEAL TEST
STRIP
3 OTC
RIGHTEST GS550
TEST STRIPS
3 OTC
Drug Name Drug
Category
Requirements
/ Limits
SMART SENSE
TEST STRIPS
3 OTC
SMARTEST TEST 3 OTC
SOLUS V2 TEST
STRIPS
3 OTC
SURE-TEST
EASYPLUS MINI
3 OTC
TELCARE TEST
STRIPS
3 OTC
TEST N'GO TEST 3 OTC
TRUE METRIX
GLUCOSE TEST
STRIP
3 OTC
TRUETEST TEST
STRIPS
3 OTC
TRUETRACK
TEST
3 OTC
ULTIMA TEST
STRIPS
3 OTC
ULTRATRAK 3 OTC
ULTRATRAK
ULTIMATE
3 OTC
UNISTRIP1 TEST
STRIP
3 OTC
WAVESENSE
JAZZ
3 OTC
WAVESENSE
PRESTO
3 OTC
DIABETES, SUPPLIES, & DURABLE
MEDICAL EQUIPMENT
GLUCAGEN
DIAGNOSTIC KIT
2
GLUCAGON HCL 3
INSULIN
SYRINGE-
NEEDLE U-100
2 M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
58
Drug Name Drug
Category
Requirements
/ Limits
GLUCOSE ELEVATING AGENTS
GLUCAGEN
HYPOKIT
2
GLUCAGON
EMERGENCY KIT
(HUMAN)
2
PROGLYCEM 2 M
INSULIN
SYRINGES/MISCELLANEOUS
DURABLE MEDICAL EQU
2TEK
GLUCOSE/BLOOD
PRESSURE
3 OTC
ACCU-CHEK
AVIVA CONNECT
METER
3 OTC
ACCU-CHEK
AVIVA PLUS
METER
3 OTC
ACCU-CHEK
COMPACT PLUS
CONTROL
3 OTC
ACCU-CHEK
GUIDE GLUCOSE
METER
3 OTC
ACCU-CHEK
GUIDE L1-L2
CTRL SOL
3 OTC
ACCU-CHEK
NANO
3 OTC
ACCU-CHEK
SMARTVIEW
CONTRL SOL
3 OTC
ACCUTREND
GLUCOSE
CONTROL
3 OTC
ADVANCED
GLUCOSE METER
3 OTC
Drug Name Drug
Category
Requirements
/ Limits
ADVOCATE
BLOOD GLUCOSE
MONITOR
3 OTC
ADVOCATE DUO 3 OTC
ADVOCATE LOW
CONTROL
3 OTC
ADVOCATE REDI-
CODE DUO
METER
3 OTC
ADVOCATE REDI-
CODE GLU
MONITOR
3 OTC
ADVOCATE REDI-
CODE+ CTRL
LOW
3 OTC
AGAMATRIX
AMP GLUC
MONITOR SYS
3 OTC
AGAMATRIX
CONTROL HIGH
3 OTC
ASSURE 4
CONTROL
SOLUTION
3 OTC
ASSURE DOSE
NORMAL
CONTROL
3 OTC
ASSURE
PLATINUM
3 OTC
ASSURE PRISM
CONTROL 1-2
SOLN
3 OTC
ASSURE PRISM
MULTI METER
3 OTC
AT HOME A1C 3 OTC
AUTOJECT 2
INJECTION
DEVICE
2 OTC
AUTOPEN 1 TO 21
UNITS
2 OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
59
Drug Name Drug
Category
Requirements
/ Limits
BIONIME
RIGHTEST GM300
SYSTEM
3 OTC
BLOOD GLUCOSE
CONTROL,
NORMAL
3 OTC
BLOOD-GLUCOSE
METER
3 OTC
BREEZE 2
CONTROL
SOLUTION,HIGH
3 OTC
CARESENS
CONTROL A
NORMAL
3 OTC
CARESENS N 3 OTC
CARESENS N
VOICE
3 OTC
CLEO 90
INFUSION SET 24"
2
CLEVER CHEK
BLOOD GLUCOSE
3 OTC
CLEVER CHOICE
GLUCOSE
MONITOR
3 OTC
CLEVER CHOICE
LEVEL 2
CONTROL
3 OTC
CLEVER CHOICE
MICRO
3 OTC
CLEVER CHOICE
PRO
3 OTC
COMFORT SHORT
INSULIN PUMP
23"
2
CONTOUR
CONTROL
SOLUTION, NML
3 OTC
CONTOUR LINK 3 OTC
Drug Name Drug
Category
Requirements
/ Limits
CONTOUR NEXT
EZ METER
3 OTC
CONTOUR NEXT
LEV 2 CONTROL
SOL
3 OTC
CONTOUR NEXT
LINK
3 OTC
CONTOUR NEXT
METER
3 OTC
CONTOUR NEXT
ONE METER
3 OTC
CONTROL AST
MONITORING
SYSTEM
3 OTC
COOL BLOOD
GLUCOSE METER
3 OTC
COOL CONTROL
A SOLUTION
3 OTC
DEXCOM G5
RECEIVER
3
DIATRUE
CONTROL SOLN
NORMAL
3 OTC
DIATRUE PLUS
BLOOD GLUCOSE
MET
3 OTC
EASY PLUS II
BLOOD GLUCOSE
MET
3 OTC
EASY STEP
BLOOD GLUCOSE
METER
3 OTC
EASY TALK
BLOOD GLUCOSE
METER
3 OTC
EASY TOUCH
GLUCOSE
MONITOR
3 OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
60
Drug Name Drug
Category
Requirements
/ Limits
EASY TRAK LOW
CONTROL
3 OTC
EASYGLUCO
MONITORING
SYSTEM
3 OTC
EASYGLUCO
PLUS
3 OTC
EASYGLUCO
PLUS NORMAL
CONTROL
3 OTC
EASYMAX L
BLOOD GLUCOSE
METER
3 OTC
EASYMAX LOW
CONTROL
3 OTC
EASYMAX NG 3 OTC
EASYMAX
NORMAL
CONTROL
3 OTC
EASYMAX V
SPEAKING
GLUCOSE SYS
3 OTC
EASYMAX V2
BLOOD GLUCOSE
METER
3 OTC
ELEMENT
COMPACT
GLUCOSE METER
3 OTC
ELEMENT
COMPACT
NORMAL
CONTROL
3 OTC
ELEMENT
COMPACT V
GLUCOSE MTR
3 OTC
ELEMENT
NORMAL
CONTROL
3 OTC
Drug Name Drug
Category
Requirements
/ Limits
ELEMENT PLUS
BLOOD GLUCOSE
KIT
3 OTC
EMBRACE
BLOOD GLUCOSE
SYSTEM
3 OTC
EMBRACE EVO
LEVEL 1
3 OTC
EMBRACE
GLUCOSE
CONTROL LOW
3 OTC
EMBRACE PRO
GLUCOSE METER
3 OTC
EVENCARE G2 3 OTC
EVENCARE G3
GLUCOSE METER
3 OTC
EVENCARE MINI
MONITOR
SYSTEM
3 OTC
EVOLUTION
BLOOD GLUCOSE
METER
3 OTC
EVOLUTION
NORMAL
CONTROL
3 OTC
EZ SMART PLUS
SYSTEM
3 OTC
EZ SMART
SYSTEM
3 OTC
FORA D10 3 OTC
FORA D20 3 OTC
FORA G20 3 OTC
FORA G30A 3 OTC
FORA GD50
BLOOD GLUCOSE
SYSTEM
3 OTC
FORA NORMAL
CONTROL
3 OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
61
Drug Name Drug
Category
Requirements
/ Limits
FORA PREMIUM
V10 GLUCOSE
METER
3 OTC
FORA TEST N'GO
VOICE METER
3 OTC
FORA TN'G VOICE
METER
3 OTC
FORA V10 3 OTC
FORA V12 BLOOD
GLUCOSE
SYSTEM
3 OTC
FORA V20 3 OTC
FORA V30A 3 OTC
FORACARE GD20
GLUCOSE METER
3 OTC
FORACARE
GD40A GLUCOSE
METER
3 OTC
FORACARE
GD40B GLUCOSE
METER
3 OTC
FORACARE GDH
LOW CONTROL
3 OTC
FORTISCARE
BLOOD GLUCOSE
SYST
3 OTC
FORTISCARE
NORMAL
3 OTC
FREESTYLE
CONTROL
2 OTC
FREESTYLE
FLASH SYSTEM
2 OTC
FREESTYLE
FREEDOM
2 OTC
FREESTYLE
FREEDOM LITE
2 OTC
FREESTYLE
INSULINX
2 OTC
Drug Name Drug
Category
Requirements
/ Limits
FREESTYLE LITE
METER
2 OTC
FREESTYLE
PRECISION NEO
METER
3 OTC
FREESTYLE
SIDEKICK II
2 OTC
FREESTYLE
SYSTEM KIT
2 OTC
GE100 BLOOD
GLUCOSE
SYSTEM
3 OTC
GE100 CONTROL
SOLUTION
NORMAL
3 OTC
GLUCO NAVII
GLUCOSE
MONITOR
3 OTC
GLUCOCARD 01
METER
3 OTC
GLUCOCARD 01
NORMAL
CONTROL
3 OTC
GLUCOCARD
EXPRESSION
3 OTC
GLUCOCARD
SHINE METER
3 OTC
GLUCOCARD
VITAL
3 OTC
GLUCOCOM
BLOOD GLUCOSE
3 OTC
GLUCOCOM
CONTROL
NORMAL
3 OTC
GLUCOSE
CONTROL
3 OTC
GM100 3 OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
62
Drug Name Drug
Category
Requirements
/ Limits
HEALTHPRO
GLUCOSE
MONITOR
3 OTC
HEALTHPRO
HIGH-LOW
CONTROL
3 OTC
HUMAPEN
LUXURA HD
2
INFINITY
CONTROL
SOLUTION NORM
3 OTC
INFINITY
STARTER KIT
3 OTC
INSET 30
INFUSION SET 23"
2
INSET INFUSION
SET 23"
2
JAZZ WIRELESS 2
METER KIT
3 OTC
LANCETS 2 OTC
LANCING DEVICE 2 OTC
MEDISENSE 3 OTC
MEDISENSE
GLUCOSE
KETONE
3 OTC
MICRODOT
BLOOD GLUCOSE
SYSTEM
3 OTC
MYGLUCOHEALT
H
3 OTC
MYGLUCOHEALT
H CONTROL
SOLUTION
3 OTC
NOVA MAX
BLOOD GLUCOSE
METER
3 OTC
Drug Name Drug
Category
Requirements
/ Limits
NOVA MAX
GLUCOSE
CONTROL
3 OTC
NOVAMAX PLUS
GLU-KET
3 OTC
NOVOPEN ECHO 3
ON CALL
EXPRESS
CONTROL
3 OTC
ON CALL
EXPRESS METER
3 OTC
ON CALL PLUS
CONTROL
3 OTC
ON CALL PLUS
METER
3 OTC
ON CALL VIVID
CONTROL
3 OTC
ON CALL VIVID
METER
3 OTC
ON CALL VIVID
PAL METER
3 OTC
ONETOUCH
ULTRA CONTROL
3 OTC
ONETOUCH
ULTRA2
3 OTC
ONETOUCH
ULTRAMINI
3 OTC
ONETOUCH
VERIO FLEX
3 OTC
ONETOUCH
VERIO IQ METER
3 OTC
ONETOUCH
VERIO SYNC
3 OTC
ONETOUCH
VERIO SYSTEM
3 OTC
OPTUMRX 3 OTC
PEN NEEDLE 2 M; OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
63
Drug Name Drug
Category
Requirements
/ Limits
PHARMACIST
CHOICE
GLUCOSE SYS
3 OTC
PRECISION XTRA
MONITOR
3 OTC
PREMIUM BLOOD
GLUCOSE
MONITOR
3 OTC
PREMIUM V10 3 OTC
PRESTO PRO
BLOOD GLUCOSE
METER
3 OTC
PRODIGY
AUTOCODE
METER
3 OTC
PRODIGY
AUTOCODE
MONITOR SYST
3 OTC
PRODIGY
CONTROL
SOLUTION, LOW
3 OTC
PRODIGY
CONTROL
SOLUTION,HIGH
3 OTC
PRODIGY
POCKET METER
3 OTC
PRODIGY VOICE
GLUCOSE METER
3 OTC
QUINTET BLOOD
GLUCOSE METER
3 OTC
REFUAH PLUS
GLUCOSE
CONTROL
3 OTC
REFUAH PLUS
GLUCOSE
MONITOR
3 OTC
RELION ALL-IN-
ONE METER
3 OTC
RELION CONFIRM 3 OTC
Drug Name Drug
Category
Requirements
/ Limits
RELION MICRO
GLUCOSE
MONITOR
3 OTC
RELION PRIME
METER
3 OTC
REVEAL BLOOD
GLUCOSE METER
3 OTC
RIGHTEST
CONTROL
SOLUTION HIGH
3 OTC
RIGHTEST GM550
SYSTEM
3 OTC
SIDEKICK BLOOD
GLUCOSE
SYSTEM
3 OTC
SMART SENSE
MONITORING
SYSTEM
3 OTC
SMARTEST
CONTROL
3 OTC
SMARTEST EJECT 3 OTC
SMARTEST
PERSONA
STARTER
3 OTC
SMARTEST
PRONTO
STARTER
3 OTC
SMARTEST
PROTEGE
3 OTC
SNAP INSULIN
PUMP
CONTROLLER
2
SOLUS V2
AUDIBLE METER
3 OTC
SOLUS V2
CONTROL
SOLUTION,HIGH
3 OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
64
Drug Name Drug
Category
Requirements
/ Limits
SURE-TEST
EASYPLUS MINI
METER
3 OTC
T:30 INFUSION
SET
2
T:90 INFUSION
SET 23"
2
T:SLIM 2
T:SLIM G4 2
TELCARE BGM 3 OTC
TELCARE BLOOD
GLUCOSE KIT
3 OTC
TELCARE
CONTROL
3 OTC
TEST N'GO
BLOOD GLUCOSE
SYSTEM
3 OTC
TRUE METRIX
AIR GLUCOSE
METER
3 OTC
TRUE METRIX
GLUCOSE METER
3 OTC
TRUE METRIX GO
GLUCOSE METER
3 OTC
TRUE METRIX
LEVEL 1
3 OTC
TRUE2GO BLOOD
GLUCOSE
SYSTEM
3 OTC
TRUECONTROL
LEVEL 0
3 OTC
TRUERESULT
BLOOD GLUCOSE
SYSTM
3 OTC
TRUETRACK
BLOOD GLUCOSE
SYSTEM
3 OTC
Drug Name Drug
Category
Requirements
/ Limits
TRUETRACK
SMART SYSTEM
3 OTC
ULTIMA
MONITOR
3 OTC
ULTRATRAK
GLUCOSE METER
3 OTC
ULTRATRAK
ULTIMATE
3 OTC
UNISTRIP LOW
CONTROL
3 OTC
VGO 20 6 MSD
VGO 30 6 MSD
VGO 40 6 MSD
WAVESENSE AMP 3 OTC
WAVESENSE
CONTROL
SOLUTION
3 OTC
WAVESENSE
PRESTO
3 OTC
INSULIN THERAPY
AFREZZA
INHALATION
CARTRIDGE
WITH INHALER 12
UNIT, 4 UNIT (90)/
8 UNIT (90), 4
UNIT/8 UNIT/ 12
UNIT (60), 8 UNIT
3 M
AFREZZA
INHALATION
CARTRIDGE
WITH INHALER 4
UNIT, 4 UNIT (30)/
8 UNIT (60), 4
UNIT (60)/ 8 UNIT
(30), 8 UNIT (60)/
12 UNIT (30)
3 M; QL
APIDRA 3 M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
65
Drug Name Drug
Category
Requirements
/ Limits
APIDRA
SOLOSTAR
3 M
BASAGLAR
KWIKPEN
2 M
HUMALOG 2 M
HUMALOG
JUNIOR KWIKPEN
3 M
HUMALOG
KWIKPEN
2 M
HUMALOG MIX
50-50
2 M
HUMALOG MIX
50-50 KWIKPEN
2 M
HUMALOG MIX
75-25
2 M
HUMALOG MIX
75-25 KWIKPEN
2 M
HUMULIN 70/30 2 M; QL
HUMULIN 70/30
KWIKPEN
2 M; QL
HUMULIN N 2 M; QL
HUMULIN N
KWIKPEN
2 M
HUMULIN R U-100 2 M; QL
HUMULIN R U-500
(CONC) KWIKPEN
2 M
HUMULIN R U-500
(CONCENTRATED
)
2 M; QL
LANTUS 2 M
LANTUS
SOLOSTAR
2 M
LEVEMIR 2 M
LEVEMIR
FLEXTOUCH
2 M
NOVOLOG 3 M
Drug Name Drug
Category
Requirements
/ Limits
NOVOLOG
FLEXPEN
3 M
NOVOLOG MIX
70-30
3 M
NOVOLOG MIX
70-30 FLEXPEN
3 M
NOVOLOG
PENFILL
3 M
RELION NOVOLIN
70/30
3 M; QL
RELION NOVOLIN
N
3 M; QL
RELION NOVOLIN
R
3 M; QL
SOLIQUA 100/33 3 M
TOUJEO
SOLOSTAR
3 M
TRESIBA
FLEXTOUCH U-
100
3 M
TRESIBA
FLEXTOUCH U-
200
3 M
XULTOPHY
100/3.6
3 ST; M
MISCELLANEOUS HORMONES
ALDURAZYME 6 MSD
ANADROL-50 3
ANDRODERM 3 PA
ANDROGEL 3 PA
ANDROID 3
androxy 1
AVEED 6 MSD
AXIRON 3 PA
BRAVELLE 7 ST
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
66
Drug Name Drug
Category
Requirements
/ Limits
BRINEURA 6 PA; MSD
cabergoline 1 M; QL
calcitonin (salmon) 1 M
calcitriol 1 M
CERDELGA 3 S; SLA
CEREZYME 6 MSD
CETROTIDE 7
CHORIONIC
GONADOTROPIN,
HUMAN
7 QL
clomiphene citrate 7
danazol 1
DDAVP 3 M
DEPO-
TESTOSTERONE
3 PA
desmopressin 1 M
doxercalciferol
intravenous
6 MSD
doxercalciferol oral 1 M
ELAPRASE 6 MSD
ELELYSO 6 MSD
FABRAZYME 6 MSD
FOLLISTIM AQ 7 ST
FORTESTA 3 PA
GANIRELIX 7 ST; S
GONAL-F 7 ST
GONAL-F RFF 7 ST
GONAL-F RFF
REDI-JECT
7 ST
HECTOROL
INTRAVENOUS
6 MSD
HECTOROL ORAL 3 M
KORLYM 4 PA; S; SLA
Drug Name Drug
Category
Requirements
/ Limits
KUVAN 3 PA; S; SLA
LUMIZYME 6 MSD
MENOPUR 7
METHITEST 2
methyltestosterone 1
MIACALCIN 6 MSD
MYALEPT 3 S; SLA
NAGLAZYME 6 MSD
NATESTO 3 PA
NATPARA 3 PA; S; SLA
NOVAREL 7 QL
OVIDREL 7
OXANDRIN 3
oxandrolone 1
pamidronate 6 MSD
PARICALCITOL
HEMODIALYSIS
PORT INJECTION
6 MSD; M
paricalcitol
intravenous
6 MSD
paricalcitol oral 1 M
PREGNYL 7 QL
RAYALDEE 3 M
ROCALTROL 3 M
SAMSCA 2 PA; QL
SENSIPAR 2 PA
SOMAVERT 3 S; SLA
STIMATE 2 M
STRENSIQ 3 S; SLA
STRIANT 3 PA
SYNAREL 3
TESTIM 3 PA
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
67
Drug Name Drug
Category
Requirements
/ Limits
testosterone
cypionate
1 PA
testosterone
enanthate
1 PA
TESTOSTERONE
TRANSDERMAL
GEL
3 PA
TESTOSTERONE
TRANSDERMAL
GEL IN
METERED-DOSE
PUMP 10 MG/0.5
GRAM
/ACTUATION
3 PA
testosterone
transdermal gel in
metered-dose pump
12.5 mg/ 1.25 gram
(1 %)
1 PA
testosterone
transdermal gel in
packet
1 PA
testosterone
transdermal solution
in metered pump
w/app
1 PA
TESTRED 3
vasopressin in 0.9
% nacl
6 MSD
VIMIZIM 6 MSD
VOGELXO 3 PA
VPRIV 6 MSD
ZAVESCA 2
ZEMPLAR
INTRAVENOUS
6 MSD
ZEMPLAR ORAL 3 M
zoledronic acid 6 MSD
Drug Name Drug
Category
Requirements
/ Limits
ZOLEDRONIC AC-
MANNITOL-
0.9NACL
6 MSD
ZOMETA 6 MSD
NON-INSULIN HYPOGLYCEMIC
AGENTS
acarbose 1 M
ACTOPLUS MET 3 ST; M; QL
ACTOPLUS MET
XR
2 ST; M; QL
ACTOS 3 ST; M; QL
ADLYXIN 3 PA; M
ALOGLIPTIN 3 M; QL
ALOGLIPTIN-
METFORMIN
3 M; QL
ALOGLIPTIN-
PIOGLITAZONE
3 M; QL
AMARYL 3 M
AVANDIA 3 ST; M; QL
BYDUREON
SUBCUTANEOUS
PEN INJECTOR
2 ST; M
BYDUREON
SUBCUTANEOUS
SUSPENSION,EXT
ENDED REL
RECON
2 ST; M; QL
BYETTA 2 ST; M; QL
chlorpropamide 1 M
CYCLOSET 3 M; QL
DM2 3 M
DUETACT 3 ST; M; QL
FARXIGA 2 M; QL
FORTAMET 3 ST; M
glimepiride 1 M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
68
Drug Name Drug
Category
Requirements
/ Limits
glipizide 1 M
glipizide-metformin 1 M
GLUCOPHAGE 3 ST; M
GLUCOPHAGE XR 3 ST; M
GLUCOTROL 3 M
GLUCOTROL XL 3 M
GLUCOVANCE 3 M
GLUMETZA 3 ST; M; QL
glyburide 1 M
glyburide
micronized
1 M
glyburide-metformin 1 M
GLYNASE 3 M
GLYSET 3 M
GLYXAMBI 2 M
INVOKAMET 3 M; QL
INVOKAMET XR 3 M; QL
INVOKANA 3 M; QL
JANUMET 2 ST; M; QL
JANUMET XR 2 ST; M; QL
JANUVIA 2 ST; M; QL
JARDIANCE 2 M; QL
JENTADUETO 2 ST; M; QL
JENTADUETO XR 2 ST; M
KAZANO 3 M; QL
KOMBIGLYZE XR 3 ST; M; QL
metformin oral
tablet
1 M
metformin oral
tablet extended
release 24 hr
1 M
Drug Name Drug
Category
Requirements
/ Limits
metformin oral
tablet extended
release 24hr
1 ST; M
metformin oral
tablet,er
gast.retention 24 hr
1 ST; M; QL
miglitol 1 M
nateglinide 1 M
NESINA 3 M; QL
ONGLYZA 3 ST; M; QL
OSENI 3 M; QL
pioglitazone 1 M; QL
pioglitazone-
glimepiride
1 M; QL
pioglitazone-
metformin
1 M; QL
PRANDIN 3 M
PRECOSE 3 M
repaglinide 1 M
repaglinide-
metformin
1 M; QL
RIOMET 3 ST; M; QL
STARLIX 3 M
SYMLINPEN 120 2 ST; M; QL
SYMLINPEN 60 2 ST; M; QL
SYNJARDY 2 M
SYNJARDY XR 2 M
TANZEUM 2 ST; M; QL
tolazamide 1 M
tolbutamide 1 M
TRADJENTA 2 ST; QL
TRULICITY 3 PA; M; QL
VICTOZA 2-PAK 3 PA; M; QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
69
Drug Name Drug
Category
Requirements
/ Limits
VICTOZA 3-PAK 3 PA; M; QL
XIGDUO XR 2 M; QL
THYROID HORMONES
ARMOUR
THYROID
2 M
CYTOMEL 3 M
LEVO-T 3 M
LEVOTHYROXINE
INTRAVENOUS
RECON SOLN 100
MCG
6 MSD
levothyroxine
intravenous recon
soln 200 mcg, 500
mcg
6 MSD
levothyroxine oral 1 M
levoxyl 1 M
liothyronine 1 M
nature-throid 1 M
np thyroid 1 M
SYNTHROID 3 M
THYROLAR-1 2 M
THYROLAR-1/2 2 M
THYROLAR-1/4 2 M
THYROLAR-2 2 M
THYROLAR-3 2 M
TIROSINT 3 M
unithroid 1 M
westhroid 1 M
WP THYROID 3 M
GASTROENTEROLOGY
ANTIDIARRHEALS &
ANTISPASMODICS
Drug Name Drug
Category
Requirements
/ Limits
anaspaz 1
atropine 6 MSD
belladonna
alkaloids-opium
1
belladonna-opium 1
BENTYL
INTRAMUSCULA
R
6 MSD
BENTYL ORAL 3
chlordiazepoxide-
clidinium
1
CUVPOSA 3
dicyclomine
intramuscular
6 MSD
dicyclomine oral 1
diphenoxylate-
atropine
1
DONNATAL 3
ed-spaz 1
glycopyrrolate
injection
6 MSD
GLYCOPYRROLA
TE
INTRAVENOUS
6 MSD
glycopyrrolate oral 1
hyoscyamine sulfate 1
hyosyne 1
LEVBID 3
LEVSIN 3
LEVSIN/SL 3
LIBRAX (WITH
CLIDINIUM)
3
LOMOTIL 3
methscopolamine 1
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
70
Drug Name Drug
Category
Requirements
/ Limits
MOTOFEN 3
MYTESI 3
NULEV 3
opium tincture 1
oscimin 1
oscimin sl 1
oscimin sr 1
paregoric 1
phenobarb-hyoscy-
atropine-scop
1
phenohytro 1
propantheline 1
ROBINUL 3
ROBINUL FORTE 3
SYMAX DUOTAB 3
symax fastabs 1
symax-sl 1
symax-sr 1
MISCELLANEOUS
GASTROINTESTINAL AGENTS
ACTIGALL 3 M
AKYNZEO 2 QL
alophen 5 ACA; OTC
alosetron 1 M
ALOXI 6 MSD; QL
AMITIZA 2
ANALPRAM-HC 3
ANALPRAM-HC
SINGLES
3
anucort-hc 1
ANUSOL-HC
RECTAL
3
Drug Name Drug
Category
Requirements
/ Limits
ANUSOL-HC
TOPICAL
3 ST
ANZEMET 3 QL
aprepitant 1 QL
APRISO 2 M
ASACOL HD 3 M
AURYXIA 3
AZULFIDINE 3 M
AZULFIDINE EN-
TABS
3 M
balsalazide 1
bisacodyl 5 ACA; OTC
bisa-lax 5 ACA; OTC
budesonide 1
calcium acetate 1
CANASA 2 M
CESAMET 3 QL
CHENODAL 3 PA; S; SLA
CHOLBAM 2 PA
CIMZIA 4 PA; ST; S;
SLA
CIMZIA POWDER
FOR RECONST
4 PA; ST; S;
SLA
citrate of magnesia 5 ACA; OTC
citroma 5 ACA; OTC
clearlax 5 ACA; OTC
COLAZAL 3
colocort 1
COLYTE WITH
FLAVOR PACKS
3
COMPAZINE 3
compro 1
constulose 1
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
71
Drug Name Drug
Category
Requirements
/ Limits
CORTENEMA 3
CORTIFOAM 2
CREON 2
cromolyn 1
CYSTADANE 2
DELZICOL 3 M
DICLEGIS 3
DIPENTUM 3 M
dronabinol 1
ducodyl 5 ACA; OTC
eliphos 1
EMEND ORAL
CAPSULE 125 MG,
40 MG
2 QL
EMEND ORAL
CAPSULE 80 MG
3 QL
EMEND ORAL
CAPSULE,DOSE
PACK
3 QL
EMEND ORAL
SUSPENSION FOR
RECONSTITUTIO
N
2
ENTOCORT EC 3
ENTYVIO 6 MSD
enulose 1
fleet laxative 5 ACA; OTC
FOSRENOL 3
GASTROCROM 3
GATTEX 30-VIAL 4 S; SLA
gavilax 5 ACA; OTC
gavilyte-c 5 ACA
gavilyte-g 5 ACA
gavilyte-n 5 ACA
Drug Name Drug
Category
Requirements
/ Limits
generlac 1
gentle laxative 5 ACA; OTC
gentlelax 5 ACA; OTC
GIALAX 5 ACA
GIAZO 3
glycolax 5 ACA; OTC
GOLYTELY ORAL
POWDER IN
PACKET
5 ACA
GOLYTELY ORAL
RECON SOLN
3
granisetron hcl 1 QL
healthylax 5 ACA; OTC
hemmorex-hc 1
hydrocortisone 1
hydrocortisone
acetate
1
hydrocortisone-
pramoxine
1
INFLECTRA 6 MSD
kionex 1
kionex (with
sorbitol)
1
KRISTALOSE 3 M
lactulose 1
laxaclear 5 ACA; OTC
laxative (bisacodyl) 5 ACA; OTC
laxative feminine 5 ACA; OTC
laxative peg 3350 5 ACA; OTC
LIALDA 3 M
lidocaine hcl-
hydrocortison ac
1
LINZESS 2
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
72
Drug Name Drug
Category
Requirements
/ Limits
LOTRONEX 3 M
MAGNEBIND 400 3
magnesium citrate 5 ACA; OTC
MARINOL 3
mesalamine oral
tablet,delayed
release (dr/ec) 1.2
gram
1 M
MESALAMINE
ORAL
TABLET,DELAYE
D RELEASE
(DR/EC) 800 MG
3 M
mesalamine rectal 1
mesalamine with
cleansing wipe
1
metoclopramide hcl
injection
6 MSD
metoclopramide hcl
oral
1
MICORT-HC 3 ST
milk of magnesia 5 ACA; OTC
milk of magnesia
concentrated
5 ACA; OTC
miralax 5 ACA; OTC
MOVANTIK 2
MOVIPREP 5 ACA
natura-lax 5 ACA; OTC
NULYTELY WITH
FLAVOR PACKS
3
OCALIVA 3 PA; S; SLA
ondansetron 1 QL
ondansetron hcl (pf) 6 MSD
ondansetron hcl
intravenous
6 MSD
Drug Name Drug
Category
Requirements
/ Limits
ondansetron hcl oral 1 QL
oral saline laxative 5 ACA; OTC
OSMOPREP 5 ACA
PANCREAZE 3
peg 3350-
electrolytes
5 ACA
peg3350 5 ACA; OTC
peg-electrolyte soln 5 ACA
PENTASA 2 M
PERTZYE 3
PHOSLYRA 3
phosphate laxative 5 ACA; OTC
powderlax 5 ACA; OTC
pramcort 1
PREPOPIK 5 ACA
prochlorperazine 1
prochlorperazine
edisylate
6 MSD
prochlorperazine
maleate
1
PROCORT 3
PROCTOCORT 3
PROCTOFOAM HC 3
procto-med hc 1
proctosol hc 1
proctozone-hc 1
purelax 5 ACA; OTC
RECTIV 2
REGLAN 3
RELISTOR ORAL 3
RELISTOR
SUBCUTANEOUS
2
REMICADE 6 MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
73
Drug Name Drug
Category
Requirements
/ Limits
RENAGEL 3
RENFLEXIS 6 MSD
RENVELA ORAL
POWDER IN
PACKET
3
RENVELA ORAL
TABLET
2
ROWASA 3
SANCUSO 3 QL
scopolamine base 1
sevelamer carbonate 1
SFROWASA 3
smoothlax 5 ACA; OTC
sodium polystyrene
sulfonate oral
1
sodium polystyrene
sulfonate rectal
enema 30 gram/120
ml
1
SODIUM
POLYSTYRENE
SULFONATE
RECTAL ENEMA
50 GRAM/200 ML
3
SOLESTA 6 MSD
sps (with sorbitol) 1
SUCRAID 3 S; SLA
sulfasalazine 1 M
SUPREP BOWEL
PREP KIT
5 ACA
SUSTOL 6 MSD
SYNDROS 3 PA
TIGAN
INTRAMUSCULA
R
6 MSD
TIGAN ORAL 3
Drug Name Drug
Category
Requirements
/ Limits
TRANSDERM-
SCOP
3
trilyte with flavor
packets
5 ACA
trimethobenzamide 1
TRULANCE 3
UCERIS ORAL 2
UCERIS RECTAL 3
URSO 250 3 M
URSO FORTE 3 M
ursodiol 1 M
VARUBI 2
VELPHORO 3
VELTASSA 3 S; SLA
VIBERZI 2
VIOKACE 2
woman's laxative 5 ACA; OTC
women's gentle
laxative(bisac)
5 ACA; OTC
women's laxative
(bisacodyl)
5 ACA; OTC
ZENPEP 3
ZOFRAN (AS
HYDROCHLORID
E) INTRAVENOUS
6 MSD
ZOFRAN (AS
HYDROCHLORID
E) ORAL
3 QL
ZOFRAN ODT 3 QL
ZUPLENZ 3 QL
ULCER THERAPY
ACIPHEX 3 ST; M
ACIPHEX
SPRINKLE
3 ST; M; QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
74
Drug Name Drug
Category
Requirements
/ Limits
amoxicil-
clarithromy-
lansopraz
1
CARAFATE ORAL
SUSPENSION
1 M
CARAFATE ORAL
TABLET
3 M
cimetidine 1 M
cimetidine hcl 1 M
CYTOTEC 3 M
DEXILANT 3 ST; M; QL
esomeprazole
magnesium oral
capsule,delayed
release(dr/ec) 20 mg
1 M; QL
esomeprazole
magnesium oral
capsule,delayed
release(dr/ec) 40 mg
1 M
esomeprazole
sodium
6 MSD
ESOMEPRAZOLE
STRONTIUM
ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
24.65 MG
3 ST; M; QL
ESOMEPRAZOLE
STRONTIUM
ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
49.3 MG
3 ST; M
famotidine (pf) 6 MSD
famotidine (pf)-nacl
(iso-os)
6 MSD
Drug Name Drug
Category
Requirements
/ Limits
famotidine
intravenous
6 MSD
famotidine oral 1 M
lansoprazole oral
capsule,delayed
release(dr/ec) 15 mg
1 M; QL
lansoprazole oral
capsule,delayed
release(dr/ec) 30 mg
1 M
misoprostol 1 M
NEXIUM IV 6 MSD
NEXIUM ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
20 MG
3 ST; M; QL
NEXIUM ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
40 MG
3 ST; M
NEXIUM PACKET
ORAL GRANULES
DR FOR SUSP IN
PACKET 10 MG,
2.5 MG, 20 MG, 5
MG
3 ST; M; QL
NEXIUM PACKET
ORAL GRANULES
DR FOR SUSP IN
PACKET 40 MG
3 ST; M
nizatidine 1 M
OMECLAMOX-
PAK
3 QL
omeppi oral capsule
20-1.1 mg-gram
1 ST; M; QL
omeppi oral capsule
40-1.1 mg-gram
1 ST; M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
75
Drug Name Drug
Category
Requirements
/ Limits
omeprazole oral
capsule,delayed
release(dr/ec) 10 mg
1 M; QL
omeprazole oral
capsule,delayed
release(dr/ec) 20
mg, 40 mg
1 M
omeprazole-sodium
bicarbonate oral
capsule 20-1.1 mg-
gram
1 ST; M; QL
omeprazole-sodium
bicarbonate oral
capsule 40-1.1 mg-
gram
1 ST; M
omeprazole-sodium
bicarbonate oral
packet 20-1,680 mg
1 ST; QL
omeprazole-sodium
bicarbonate oral
packet 40-1,680 mg
1 ST
pantoprazole oral
tablet,delayed
release (dr/ec) 20
mg
1 M; QL
pantoprazole oral
tablet,delayed
release (dr/ec) 40
mg
1 M
PEPCID 3 M
PREVACID ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
15 MG
3 ST; M; QL
PREVACID ORAL
CAPSULE,DELAY
ED
RELEASE(DR/EC)
30 MG
3 ST; M
Drug Name Drug
Category
Requirements
/ Limits
PREVACID
SOLUTAB ORAL
TABLET,DISINTE
GRAT, DELAY
REL 15 MG
3 ST; M; QL
PREVACID
SOLUTAB ORAL
TABLET,DISINTE
GRAT, DELAY
REL 30 MG
3 ST; M
PREVPAC 3
PRILOSEC 3 ST; M; QL
PROTONIX ORAL
GRANULES DR
FOR SUSP IN
PACKET
3 ST; M
PROTONIX ORAL
TABLET,DELAYE
D RELEASE
(DR/EC) 20 MG
3 ST; M; QL
PROTONIX ORAL
TABLET,DELAYE
D RELEASE
(DR/EC) 40 MG
3 ST; M
PYLERA 3
rabeprazole 1 M
ranitidine hcl 1 M
sucralfate 1 M
ZANTAC 3 M
ZEGERID ORAL
CAPSULE 20-1.1
MG-GRAM
3 ST; M; QL
ZEGERID ORAL
CAPSULE 40-1.1
MG-GRAM
3 ST; M
ZEGERID ORAL
PACKET 20-1,680
MG
3 ST; QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
76
Drug Name Drug
Category
Requirements
/ Limits
ZEGERID ORAL
PACKET 40-1,680
MG
3 ST
IMMUNOLOGY, VACCINES &
BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
ARANESP (IN
POLYSORBATE)
6 MSD
EPOGEN 6 MSD
GRANIX 6 MSD
LEUKINE 6 MSD
MIRCERA 6 MSD
MOZOBIL 6 MSD
NEULASTA 6 MSD; QL
NEUPOGEN 6 MSD
PROCRIT 6 MSD
ZARXIO 6 MSD
GROWTH HORMONES
EGRIFTA 3 PA; S
GENOTROPIN 4 PA; ST; S
GENOTROPIN
MINIQUICK
4 PA; ST; S
HUMATROPE 4 PA; ST; S
NORDITROPIN
FLEXPRO
4 PA; ST; S
NUTROPIN AQ
NUSPIN
4 PA; ST; S
OMNITROPE 3 PA; S
SAIZEN 4 PA; ST; S
SAIZEN
CLICK.EASY
4 PA; ST; S
SAIZEN
SAIZENPREP
4 PA; ST; S
SEROSTIM 4 PA; S
Drug Name Drug
Category
Requirements
/ Limits
ZOMACTON 4 PA; ST; S
ZORBTIVE 4 PA; S; SLA
INTERFERONS
AUBAGIO 4 PA; S; SLA;
QL
AVONEX 3 PA; S; QL
AVONEX (WITH
ALBUMIN)
3 PA; S; QL
BETASERON 4 PA; ST; S; QL
COPAXONE 4 ST; S; QL
COPEGUS 4 ST; S; SLA
EXTAVIA 3 PA; S; QL
GILENYA 3 PA; S; SLA
glatopa 1 S; QL
LEMTRADA 6 MSD
moderiba 1 ST; S; SLA
moderiba dose pack 1 ST; S; SLA
OCREVUS 6 ST; MSD
PEGASYS 3 PA; S; SLA;
QL
PEGASYS
PROCLICK
3 PA; S; SLA;
QL
PEGINTRON 4 PA; S; SLA;
QL
PEGINTRON
REDIPEN
4 PA; S; SLA;
QL
PLEGRIDY 3 ST; S; QL
POMALYST 2 QL
REBETOL 4 ST; S; SLA
REBIF (WITH
ALBUMIN)
3 PA; S; QL
REBIF REBIDOSE 3 PA; S; QL
REBIF TITRATION
PACK
3 PA; S; QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
77
Drug Name Drug
Category
Requirements
/ Limits
REVLIMID 2
ribasphere 1 ST; S; SLA
ribasphere ribapak 1 ST; S; SLA
ribavirin 1 ST; S; SLA
SYLATRON 3 S; SLA; QL
TECFIDERA 3 PA; S; SLA;
QL
ZINBRYTA 4 ST; S; SLA
INTERLEUKINS
ACTIMMUNE 3 S; SLA
ALDARA 3 QL
ALFERON N 6 MSD
ARCALYST 3 PA; ST; S;
SLA
ILARIS (PF) 6 MSD
imiquimod 1 QL
INTRON A 3 S; SLA
KINERET 4 PA; ST; S;
SLA; QL
PROLEUKIN 6 MSD
ZYCLARA 3 QL
VACCINES & MISCELLANEOUS
IMMUNOLOGICALS
ACTHIB (PF) 6 MSD
ADACEL(TDAP
ADOLESN/ADULT
)(PF)
6 MSD
AFLURIA 2017-
2018
2
AFLURIA 2017-
2018 (PF)
2
AFLURIA QUAD
2017-2018
2
Drug Name Drug
Category
Requirements
/ Limits
AFLURIA QUAD
2017-2018 (PF)
2
ATGAM 6 MSD
BCG VACCINE,
LIVE (PF)
6 MSD
BIVIGAM 6 MSD
BOOSTRIX TDAP 6 MSD
BOTOX 6 MSD
CARIMUNE NF
NANOFILTERED
6 MSD
CUVITRU 6 MSD
DYSPORT 6 MSD
ENGERIX-B (PF) 6 MSD
ENGERIX-B
PEDIATRIC (PF)
6 MSD
FLEBOGAMMA
DIF
6 MSD
FLUAD 2017-2018
(65 YR UP)(PF)
2
FLUARIX QUAD
2017-2018 (PF)
2
FLUBLOK 2017-
2018 (PF)
2
FLUBLOK QUAD
2017-2018 (PF)
2
FLUCELVAX
QUAD 2017-2018
2
FLUCELVAX
QUAD 2017-2018
(PF)
2
FLULAVAL QUAD
2017-2018
2
FLULAVAL QUAD
2017-2018 (PF)
2
FLUVIRIN 2017-
2018
2
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
78
Drug Name Drug
Category
Requirements
/ Limits
FLUVIRIN 2017-
2018 (PF)
2
FLUZONE HIGH-
DOSE 2017-18 (PF)
2
FLUZONE
INTRADERM
QUAD 2017-18
2
FLUZONE QUAD
2017-2018
2
FLUZONE QUAD
2017-2018 (PF)
2
FLUZONE QUAD
PEDI 2017-18 (PF)
2
GAMASTAN S/D 6 MSD
GAMMAGARD
LIQUID
6 MSD
GAMMAGARD S-
D (IGA < 1
MCG/ML)
6 MSD
GAMMAKED 6 MSD
GAMMAPLEX 6 MSD
GAMMAPLEX
(WITH SORBITOL)
6 MSD
GAMUNEX-C 6 MSD
GRASTEK 2 PA
HAVRIX (PF) 6 MSD
HEPAGAM B 6 MSD
HIBERIX (PF) 6 MSD
HIZENTRA 6 MSD
HYPERHEP B S/D 6 MSD
HYPERHEP B S-D
NEONATAL
6 MSD
HYPERRAB S/D
(PF)
6 MSD
HYQVIA 6 MSD
Drug Name Drug
Category
Requirements
/ Limits
IMOGAM RABIES-
HT (PF)
6 MSD
KINRIX (PF) 6 MSD
MENACTRA (PF) 6 MSD
MENOMUNE -
A/C/Y/W-135
6 MSD
MENOMUNE -
A/C/Y/W-135 (PF)
6 MSD
MENVEO A-C-Y-
W-135-DIP (PF)
6 MSD
M-M-R II (PF) 6 MSD
MYOBLOC 6 MSD
NABI-HB 6 MSD
OCTAGAM 6 MSD
ORALAIR 4 PA; S
PEDIARIX (PF) 6 MSD
PENTACEL
ACTHIB
COMPONENT (PF)
6 MSD
PNEUMOVAX 23 6 MSD
PRIVIGEN 6 MSD
PROQUAD (PF) 6 MSD
PROVENGE 6 MSD
QUADRACEL (PF) 6 MSD
RAGWITEK 2 PA
RECOMBIVAX HB
(PF)
6 MSD
TENIVAC (PF) 6 MSD
TETANUS,DIPHTH
ERIA TOX
PED(PF)
6 MSD
TETANUS-
DIPHTHERIA
TOXOIDS-TD
6 MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
79
Drug Name Drug
Category
Requirements
/ Limits
THYMOGLOBULI
N
6 MSD
TWINRIX (PF) 6 MSD
TYPHIM VI 6 MSD
VAQTA (PF) 6 MSD
VARIZIG 6 MSD
VAXCHORA
VACCINE
6 MSD
XEOMIN 6 MSD
YF-VAX (PF) 6 MSD
ZINPLAVA 6 MSD
MUSCULOSKELETAL &
RHEUMATOLOGY
GOUT THERAPY
allopurinol 1 M
COLCHICINE 3
COLCRYS 2
KRYSTEXXA 6 MSD
MITIGARE 2
probenecid 1 M
probenecid-
colchicine
1 M
ULORIC 2 ST; M
ZURAMPIC 3 ST; M
ZYLOPRIM 3 M
OSTEOPOROSIS THERAPY
ACTONEL 3 ST; M; QL
alendronate 1 M; QL
ATELVIA 3 ST; M; QL
BINOSTO 3 ST; M; QL
BONIVA
INTRAVENOUS
6 MSD
Drug Name Drug
Category
Requirements
/ Limits
BONIVA ORAL 3 ST; M; QL
EVISTA 3 PA; M
FORTEO 4 PA; S; SLA;
QL
FOSAMAX 3 ST; M; QL
FOSAMAX PLUS
D
3 ST; M; QL
ibandronate
intravenous
6 MSD
ibandronate oral 1 M; QL
PROLIA 6 MSD
raloxifene 1 PA; M
risedronate 1 M; QL
TYMLOS 2 PA
OTHER RHEUMATOLOGICALS
ACTEMRA
INTRAVENOUS
6 ST; MSD
ACTEMRA
SUBCUTANEOUS
3 PA; ST; S;
SLA; QL
ARAVA 3 QL
BENLYSTA 6 MSD
CUPRIMINE 3 M
DEPEN
TITRATABS
2 M
ENBREL 3 PA; ST; S; QL
ENBREL
SURECLICK
3 PA; ST; S; QL
HUMIRA 3 PA; ST; S; QL
HUMIRA
PEDIATRIC
CROHN'S START
2 PA; ST; S; QL
HUMIRA PEN
CROHN'S-UC-HS
START
3 PA; ST; S; QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
80
Drug Name Drug
Category
Requirements
/ Limits
HUMIRA PEN
PSORIASIS-
UVEITIS
3 PA; ST; S; QL
KEVZARA 4 PA; ST; S;
SLA
leflunomide 1 QL
ORENCIA (WITH
MALTOSE)
6 MSD
ORENCIA
CLICKJECT
4 PA; ST; S
ORENCIA
SUBCUTANEOUS
SYRINGE 125
MG/ML
4 PA; ST; S
ORENCIA
SUBCUTANEOUS
SYRINGE 50
MG/0.4 ML, 87.5
MG/0.7 ML
4 PA; ST; S;
SLA
OTEZLA 3 PA; S; SLA;
QL
OTEZLA
STARTER
3 PA; S; SLA;
QL
OTREXUP (PF) 4 S; QL
RASUVO (PF) 4 S; QL
RIDAURA 2 M
SAVELLA ORAL
TABLET
2 ST; M; QL
SAVELLA ORAL
TABLETS,DOSE
PACK
2 ST; QL
SIMPONI 4 PA; ST; S; QL
SIMPONI ARIA 6 MSD
XELJANZ 4 ST; S; QL
XELJANZ XR 4 ST; S; QL
OBSTETRICS &
GYNECOLOGY
Drug Name Drug
Category
Requirements
/ Limits
DIAPHRAGMS AND OTHER NON-
ORAL CONTRACEPTIVES
CAYA
CONTOURED
5 ACA
FC2 FEMALE
CONDOM
5 ACA; OTC
FEMCAP 5 ACA
WIDE-SEAL
DIAPHRAGM
5 ACA
ESTROGENS & PROGESTINS
ACTIVELLA 3 M
ALORA 3 M; QL
amabelz 1 M
ANGELIQ 3 M
AYGESTIN 3 M
camila 5 M; ACA
CLIMARA 3 M; QL
CLIMARA PRO 3 M; QL
COMBIPATCH 3 M
covaryx 1
covaryx h.s. 1
CRINONE
VAGINAL GEL 4
%
2
CRINONE
VAGINAL GEL 8
%
7
deblitane 5 M; ACA
DELESTROGEN 3
DEPO-ESTRADIOL 3
DEPO-PROVERA 5 ACA; QL
DEPO-SUBQ
PROVERA 104
5 ACA; QL
DIVIGEL 3 M; QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
81
Drug Name Drug
Category
Requirements
/ Limits
DUAVEE 3
eemt 1
eemt hs 1
ELESTRIN 3 M; QL
ENDOMETRIN 7
errin 5 M; ACA
ESTRACE ORAL 3 M
ESTRACE
VAGINAL
2 M
estradiol oral 1 M
estradiol
transdermal
1 M; QL
estradiol vaginal 1 M
estradiol valerate 1
estradiol-
norethindrone acet
1 M
ESTRING 3 M
ESTROGEL 3 M; QL
estrogens-
methyltestosterone
1
estropipate 1 M
EVAMIST 3 QL
FEMHRT LOW
DOSE
3 M
FEMRING 3 M
fyavolv 1 M
heather 5 M; ACA
hydroxyprogesterone
caproate
6 MSD
jencycla 5 M; ACA
jevantique lo 1 M
jinteli 1 M
jolivette 5 M; ACA
Drug Name Drug
Category
Requirements
/ Limits
lopreeza 1 M
lyza 5 M; ACA
MAKENA 6 MSD
medroxyprogesteron
e intramuscular
5 ACA; QL
medroxyprogesteron
e oral
1 M
MENEST 2 M
MENOSTAR 3 M; QL
mimvey 1 M
mimvey lo 1 M
MINIVELLE 3 M; QL
nora-be 5 M; ACA
norethindrone
(contraceptive)
5 M; ACA
norethindrone
acetate
1 M
norethindrone ac-eth
estradiol
1 M
norlyda 5 M; ACA
norlyroc 5 M; ACA
ORTHO
MICRONOR
5 ST; M; ACA
PREFEST 3 M
PREMARIN 3 M
PREMPHASE 3 M
PREMPRO 3 M
progesterone 7
progesterone
micronized
1 M
PROMETRIUM 3 M
PROVERA 3 M
sharobel 5 M; ACA
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
82
Drug Name Drug
Category
Requirements
/ Limits
VAGIFEM 3 M
VIVELLE-DOT 3 M; QL
yuvafem 1 M
MISCELLANEOUS OB/GYN
AVC VAGINAL 3
CERVIDIL 3
CLEOCIN 3
clindamycin
phosphate
1
CLINDESSE 3
CONCEPTROL 5 ACA; OTC
fem ph 1
GYNAZOLE-1 3
gynol ii 5 ACA; OTC
INTRAROSA 3 PA
isoxsuprine 1 M
LUPANETA PACK
(1 MONTH)
3
LUPANETA PACK
(3 MONTH)
3
LYSTEDA 3
METROGEL
VAGINAL
3
metronidazole 1
MIFEPREX 4 S
NEXPLANON 6 MSD
NUVARING 5 M; ACA
NUVESSA 3
OSPHENA 3
PREPIDIL 3
PROSTIN E2 3
RELAGARD 3
Drug Name Drug
Category
Requirements
/ Limits
TERAZOL 7 3
terconazole 1
TODAY
CONTRACEPTIVE
SPONGE
5 ACA; OTC
tranexamic acid 1
vaginal
contraceptive foam
5 ACA; OTC
vandazole 1
VCF
CONTRACEPTIVE
FILM
5 ACA; OTC
VCF
CONTRACEPTIVE
GEL
5 ACA; OTC
xulane 5 M; ACA
ORAL CONTRACEPTIVES &
RELATED AGENTS
AFTERA 5 ACA; OTC;
QL
altavera (28) 5 M; ACA
alyacen 1/35 (28) 5 M; ACA
alyacen 7/7/7 (28) 5 M; ACA
amethia 5 M; ACA
amethia lo 5 M; ACA
amethyst 5 M; ACA
apri 5 M; ACA
aranelle (28) 5 M; ACA
ashlyna 5 M; ACA
aubra 5 M; ACA
aviane 5 M; ACA
azurette (28) 5 M; ACA
balziva (28) 5 M; ACA
bekyree (28) 5 M; ACA
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
83
Drug Name Drug
Category
Requirements
/ Limits
BEYAZ 5 ST; M; ACA
blisovi 24 fe 5 M; ACA
blisovi fe 1.5/30 (28) 5 M; ACA
blisovi fe 1/20 (28) 5 M; ACA
BREVICON (28) 5 ST; M; ACA
briellyn 5 M; ACA
camrese 5 M; ACA
camrese lo 5 M; ACA
caziant (28) 5 M; ACA
chateal 5 M; ACA
cryselle (28) 5 M; ACA
cyclafem 1/35 (28) 5 M; ACA
cyclafem 7/7/7 (28) 5 M; ACA
CYCLESSA (28) 5 ST; M; ACA
cyred 5 M; ACA
dasetta 1/35 (28) 5 M; ACA
dasetta 7/7/7 (28) 5 M; ACA
daysee 5 M; ACA
delyla (28) 5 M; ACA
desog-
e.estradiol/e.estradio
l
5 M; ACA
desogestrel-ethinyl
estradiol
5 M; ACA
drospirenone-
e.estradiol-lm.fa
5 M; ACA
drospirenone-ethinyl
estradiol
5 M; ACA
econtra ez 5 ACA; OTC;
QL
elinest 5 M; ACA
ELLA 5 ACA; QL
emoquette 5 M; ACA
Drug Name Drug
Category
Requirements
/ Limits
enpresse 5 M; ACA
enskyce 5 M; ACA
estarylla 5 M; ACA
ESTROSTEP FE-28 5 ST; M; ACA
ethynodiol diac-eth
estradiol
5 M; ACA
fallback solo 5 ACA; OTC;
QL
falmina (28) 5 M; ACA
fayosim 5 M; ACA
femynor 5 M; ACA
GENERESS FE 5 ST; ACA
gianvi (28) 5 M; ACA
gildagia 5 M; ACA
introvale 5 M; ACA
isibloom 5 M; ACA
jolessa 5 M; ACA
juleber 5 M; ACA
junel 1.5/30 (21) 5 M; ACA
junel 1/20 (21) 5 M; ACA
junel fe 1.5/30 (28) 5 M; ACA
junel fe 1/20 (28) 5 M; ACA
junel fe 24 5 M; ACA
kaitlib fe 5 ACA
kariva (28) 5 M; ACA
kelnor 1/35 (28) 5 M; ACA
kimidess (28) 5 M; ACA
kurvelo 5 M; ACA
l norgest/e.estradiol-
e.estrad
5 M; ACA
larin 1.5/30 (21) 5 M; ACA
larin 1/20 (21) 5 M; ACA
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
84
Drug Name Drug
Category
Requirements
/ Limits
larin 24 fe 5 M; ACA
larin fe 1.5/30 (28) 5 M; ACA
larin fe 1/20 (28) 5 M; ACA
larissia 5 M; ACA
layolis fe 5 ACA
leena 28 5 M; ACA
lessina 5 M; ACA
levonest (28) 5 M; ACA
levonorgestrel-
ethinyl estrad
5 M; ACA
levonorg-eth estrad
triphasic
5 M; ACA
levora-28 5 M; ACA
lillow 5 M; ACA
LO LOESTRIN FE 5 ST; M; ACA
LOESTRIN 1.5/30
(21)
5 ST; M; ACA
LOESTRIN 1/20
(21)
5 ST; M; ACA
LOESTRIN FE
1.5/30 (28-DAY)
5 ST; M; ACA
LOESTRIN FE 1/20
(28-DAY)
5 ST; M; ACA
lomedia 24 fe 5 M; ACA
loryna (28) 5 M; ACA
LOSEASONIQUE 5 ST; M; ACA
low-ogestrel (28) 5 M; ACA
lutera (28) 5 M; ACA
marlissa 5 M; ACA
mibelas 24 fe 5 M; ACA
microgestin 1.5/30
(21)
5 M; ACA
microgestin 1/20
(21)
5 M; ACA
Drug Name Drug
Category
Requirements
/ Limits
MICROGESTIN 24
FE
5 ST; M; ACA
microgestin fe 1.5/30
(28)
5 M; ACA
microgestin fe 1/20
(28)
5 M; ACA
MINASTRIN 24 FE 5 ST; M; ACA
MIRCETTE (28) 5 ST; M; ACA
mono-linyah 5 M; ACA
mononessa (28) 5 M; ACA
my way 5 ACA; OTC;
QL
myzilra 5 M; ACA
NATAZIA 5 ST; M; ACA
necon 0.5/35 (28) 5 M; ACA
necon 1/50 (28) 5 M; ACA
necon 7/7/7 (28) 5 M; ACA
next choice one dose 5 ACA; OTC;
QL
nikki (28) 5 M; ACA
noreth-ethinyl
estradiol-iron oral
tablet,chewable
0.4mg-35mcg(21)
and 75 mg (7)
5 M; ACA
noreth-ethinyl
estradiol-iron oral
tablet,chewable
0.8mg-25mcg(24)
and 75 mg (4)
5 ACA
norethindrone ac-eth
estradiol
5 M; ACA
norethindrone-
e.estradiol-iron
5 M; ACA
norgestimate-ethinyl
estradiol
5 M; ACA
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
85
Drug Name Drug
Category
Requirements
/ Limits
nortrel 0.5/35 (28) 5 M; ACA
nortrel 1/35 (21) 5 M; ACA
nortrel 1/35 (28) 5 M; ACA
nortrel 7/7/7 (28) 5 M; ACA
ocella 5 M; ACA
ogestrel (28) 5 M; ACA
opcicon one-step 5 ACA; OTC;
QL
option-2 5 ACA; OTC;
QL
orsythia 5 M; ACA
ORTHO TRI-
CYCLEN (28)
5 ST; M; ACA
ORTHO TRI-
CYCLEN LO (28)
5 ST; M; ACA
ORTHO-CYCLEN
(28)
5 ST; M; ACA
ORTHO-NOVUM
1/35 (28)
5 ST; M; ACA
ORTHO-NOVUM
7/7/7 (28)
5 ST; M; ACA
OVCON-35 (28) 5 ST; M; ACA
philith 5 M; ACA
pimtrea (28) 5 M; ACA
pirmella 5 M; ACA
PLAN B ONE-STEP 5 ACA; OTC;
QL
portia 5 M; ACA
previfem 5 M; ACA
QUARTETTE 5 ST; M; ACA
quasense 5 M; ACA
rajani 5 M; ACA
reclipsen (28) 5 M; ACA
rivelsa 5 M; ACA
Drug Name Drug
Category
Requirements
/ Limits
SAFYRAL 5 ST; M; ACA
SEASONIQUE 5 ST; M; ACA
setlakin 5 M; ACA
sprintec (28) 5 M; ACA
sronyx 5 M; ACA
syeda 5 M; ACA
TAKE ACTION 5 ACA; OTC;
QL
tarina fe 1/20 (28) 5 M; ACA
TAYTULLA 5 ST; M; ACA
tilia fe 5 M; ACA
tri femynor 5 M; ACA
tri-estarylla 5 M; ACA
tri-legest fe 5 M; ACA
tri-linyah 5 M; ACA
tri-lo-estarylla 5 M; ACA
tri-lo-marzia 5 M; ACA
tri-lo-sprintec 5 M; ACA
trinessa (28) 5 M; ACA
trinessa lo 5 M; ACA
TRI-NORINYL (28) 5 ST; M; ACA
tri-previfem (28) 5 M; ACA
tri-sprintec (28) 5 M; ACA
trivora (28) 5 M; ACA
velivet triphasic
regimen (28)
5 M; ACA
vestura (28) 5 M; ACA
vienva 5 M; ACA
viorele (28) 5 M; ACA
vyfemla (28) 5 M; ACA
wera (28) 5 M; ACA
wymzya fe 5 M; ACA
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
86
Drug Name Drug
Category
Requirements
/ Limits
YASMIN (28) 5 ST; M; ACA
YAZ (28) 5 ST; M; ACA
zarah 5 M; ACA
zenchent (28) 5 M; ACA
zenchent fe 5 M; ACA
zovia 1/35e (28) 5 M; ACA
zovia 1/50e (28) 5 M; ACA
OXYTOCICS
methergine 1
OPHTHALMOLOGY
ANTIBIOTICS
AZASITE 3
bacitracin 1
bacitracin-
polymyxin b
1
BESIVANCE 3
BETADINE
OPHTHALMIC
PREP
3
CEFUROXIME
SODIUM-
0.9%NACL(PF)
6 MSD
CILOXAN 3
ciprofloxacin hcl 1
erythromycin 1
gatifloxacin 1
gentak 1
gentamicin 1
levofloxacin 1
MOXEZA 3
moxifloxacin 1
MOXIFLOXACIN
(PF)-BSS NO.2
6 MSD
Drug Name Drug
Category
Requirements
/ Limits
NATACYN 2
neomycin-
bacitracin-
polymyxin
1 M
neomycin-
polymyxin-
gramicidin
1
neo-polycin 1 M
OCUFLOX 3
ofloxacin 1
polycin 1
polymyxin b sulf-
trimethoprim
1
POLYTRIM 3
tobramycin 1
TOBREX 3
VIGAMOX 3
ZYMAXID 3
ANTIVIRALS
trifluridine 1
VIROPTIC 3
ZIRGAN 3
BETA-BLOCKERS
BETAGAN 3 M
betaxolol 1 M
BETIMOL 3 M
BETOPTIC S 3 M
carteolol 1 M
ISTALOL 3 M
levobunolol 1 M
metipranolol 1 M
timolol maleate 1 M
TIMOPTIC 3 M
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
87
Drug Name Drug
Category
Requirements
/ Limits
TIMOPTIC
OCUDOSE (PF)
3 M
TIMOPTIC-XE 3 M
CHOLINESTERASE INHIBITOR
MIOTICS
PHOSPHOLINE
IODIDE
2 M
CYCLOPLEGIC MYDRIATICS
atropine 1 M
CYCLOGYL 3 M
cyclopentolate 1 M
homatropaire 1 M
homatropine hbr 1 M
MYDRIACYL 3 M
PAREMYD 3
tropicamide 1 M
DIRECT ACTING MIOTICS
ISOPTO CARPINE 3 M
MIOCHOL-E 3
pilocarpine hcl 1 M
MISCELLANEOUS
OPHTHALMOLOGICS
acuicyn 1
AKTEN (PF) 3
ALOCRIL 3
ALOMIDE 3
altacaine 1
altafluor 1
azelastine 1
BEPREVE 3
cromolyn 1
CYSTARAN 3 S
Drug Name Drug
Category
Requirements
/ Limits
ELESTAT 3
EMADINE 3
epinastine 1
EYLEA 6 MSD
flucaine 1
fluorescein-
proparacaine
1
flurox 1
JETREA (PF) 6 MSD
LACRISERT 3
LASTACAFT 3
LUCENTIS 6 MSD
MACUGEN 6 MSD
olopatadine 1
OMIDRIA 6 MSD
PATADAY 3
PATANOL 3
PAZEO 3
proparacaine 1
RESTASIS 2 PA; M; QL
RESTASIS
MULTIDOSE
2 PA; M; QL
tetcaine 1
tetracaine hcl 1
tetracaine hcl (pf) 1
TETRAVISC 3
TETRAVISC
FORTE
3
VISUDYNE 6 MSD
VITRASE 6 MSD
XIIDRA 3 M; QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
88
Drug Name Drug
Category
Requirements
/ Limits
NON-STEROIDAL ANTI-
INFLAMMATORY AGENTS
ACULAR 3
ACULAR LS 3
ACUVAIL (PF) 3
bromfenac 1
BROMSITE 3
diclofenac sodium 1 QL
flurbiprofen sodium 1
ILEVRO 3
ketorolac 1
NEVANAC 3
OCUFEN 3
PROLENSA 3
ORAL DRUGS FOR GLAUCOMA
acetazolamide 1 M
DIAMOX
SEQUELS
3 M
methazolamide 1 M
NEPTAZANE 3 M
OTHER GLAUCOMA DRUGS
AZOPT 3 M
bimatoprost 1 ST; M
COMBIGAN 3 M
COSOPT 3 M
COSOPT (PF) 3 M
dorzolamide 1 M
dorzolamide-timolol 1 M
latanoprost 1 ST; M
LUMIGAN 3 ST; M
MITOSOL 3
SIMBRINZA 3 M
Drug Name Drug
Category
Requirements
/ Limits
TRAVATAN Z 3 ST; M
TRUSOPT 3 M
XALATAN 3 ST; M
ZIOPTAN (PF) 3 ST; M
STEROID-ANTIBIOTIC
COMBINATIONS
MAXITROL 3
neomycin-
bacitracin-poly-hc
1
neomycin-polymyxin
b-dexameth
1
neomycin-
polymyxin-hc
1
neo-polycin hc 1
PRED-G 3
PRED-G S.O.P. 3
TOBRADEX 3
TOBRADEX ST 3
tobramycin-
dexamethasone
1
ZYLET 3
STEROIDS
ALREX 3
dexamethasone
sodium phosphate
1
DUREZOL 3
FLAREX 3
fluorometholone 1
FML FORTE 3
FML LIQUIFILM 3
FML S.O.P. 3
ILUVIEN 6 MSD
LOTEMAX 3
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
89
Drug Name Drug
Category
Requirements
/ Limits
MAXIDEX 3
OMNIPRED 3
OZURDEX 6 MSD
PRED FORTE 3
PRED MILD 2
prednisolone acetate 1
prednisolone sodium
phosphate
1
RETISERT 6 MSD
STEROID-SULFONAMIDE
COMBINATIONS
BLEPHAMIDE 3
BLEPHAMIDE
S.O.P.
3
sulfacetamide-
prednisolone
1
SULFONAMIDES
BLEPH-10 3
sulfacetamide
sodium
1
SYMPATHOMIMETICS
ALPHAGAN P
OPHTHALMIC
(EYE) DROPS 0.1
%
2 M
ALPHAGAN P
OPHTHALMIC
(EYE) DROPS 0.15
%
3 M
apraclonidine 1 M
brimonidine 1 M
IOPIDINE 3 M
VASOCONSTRICTOR
DECONGESTANTS
CYCLOMYDRIL 3 M
Drug Name Drug
Category
Requirements
/ Limits
phenylephrine hcl 1
RESPIRATORY, ALLERGY,
COUGH & COLD
ANTIHISTAMINE &
ANTIALLERGENIC AGENTS
ADYPHREN 3
ADYPHREN AMP 3
ADYPHREN AMP
II
3
ADYPHREN II 3
AUVI-Q 3 QL
carbinoxamine
maleate
1
cetirizine 1
CLARINEX ORAL
SYRUP
3
CLARINEX ORAL
TABLET
3 QL
clemastine 1
cyproheptadine 1
desloratadine 1 QL
diphenhydramine hcl 6 MSD
EPINEPHRINE
INJECTION AUTO-
INJECTOR 0.15
MG/0.15 ML
1 QL
EPINEPHRINE
INJECTION AUTO-
INJECTOR 0.15
MG/0.3 ML
2 QL
EPINEPHRINE
INJECTION AUTO-
INJECTOR 0.3
MG/0.3 ML
3 QL
EPINEPHRINESNA
P-V
3
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
90
Drug Name Drug
Category
Requirements
/ Limits
EPIPEN 2-PAK 2 QL
EPIPEN JR 2-PAK 2 QL
EPISNAP 6 MSD
hydroxyzine hcl 1
hydroxyzine
pamoate
1
KARBINAL ER 3
phenadoz 1
phenergan 1
promethazine 1
promethegan 1
RYVENT 3
VISTARIL 3
COUGH & COLD THERAPY
benzonatate 1
BROMFED DM 3
brompheniramine-
pseudoeph-dm
1
CAPCOF 3
centergy 1
cheratussin ac 1
CLARINEX-D 12
HOUR
3 QL
codeine-guaifenesin 1
CODITUSSIN AC 3
CODITUSSIN DAC 3
FLOWTUSS 3
g tussin ac 1
guaiatussin ac 1
guaifenesin ac 1
guaifenesin dac 1
HISTEX-AC 3
Drug Name Drug
Category
Requirements
/ Limits
HYCOFENIX 3
hydrocodone-
chlorpheniramine
1
hydrocodone-cpm-
pseudoephed
1
hydrocodone-
homatropine
1
hydromet 1
lortuss ex 1
MAR-COF BP 3
MAR-COF CG 3
m-clear wc 1
M-END PE 3
NINJACOF-XG 3
OBREDON 3
POLY-TUSSIN AC 3
promethazine vc-
codeine
1
promethazine-
codeine
1
promethazine-dm 1
promethazine-
phenyleph-codeine
1
promethazine-
phenylephrine
1
PRO-RED AC (W/
DEXCHLORPHENI
R)
3
relcof c 1
RESPA-AR 3
REZIRA 3
rydex 1
SEMPREX-D 3
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
91
Drug Name Drug
Category
Requirements
/ Limits
TESSALON
PERLES
3
tusnel c 1
TUSNEL
PEDIATRIC
3
TUSSICAPS 3
tussigon 1
TUSSIONEX
PENNKINETIC ER
3
TUZISTRA XR 3
virtussin ac 1
virtussin dac 1
VITUZ 3
ZODRYL AC 25 3
ZODRYL AC 30 3
ZODRYL AC 35 3
ZODRYL AC 40 2
ZODRYL AC 50 3
ZODRYL AC 60 3
ZODRYL AC 80 3
ZODRYL DAC 25 3
ZODRYL DAC 30 3
ZODRYL DAC 35 3
ZODRYL DAC 40 3
ZODRYL DAC 50 3
ZODRYL DAC 60 3
ZODRYL DAC 80 3
ZODRYL DEC 25 3
ZODRYL DEC 30 2
ZODRYL DEC 35 3
ZODRYL DEC 40 3
ZODRYL DEC 50 3
Drug Name Drug
Category
Requirements
/ Limits
ZODRYL DEC 60 3
ZODRYL DEC 80 3
Z-TUSS AC 3
ZUTRIPRO 3
PULMONARY AGENTS
ACCOLATE 3 M; QL
acetylcysteine 1
ADCIRCA 4 PA; ST; S; QL
ADEMPAS 3 S; M; SLA
ADRENALIN 3
ADVAIR DISKUS 3 PA; M; QL
ADVAIR HFA 3 PA; M; QL
AEROSPAN 3 M
AIRDUO
RESPICLICK
3 PA; M; QL
albuterol sulfate
inhalation
1
albuterol sulfate oral 1 M
ALVESCO 3 M; QL
ANORO ELLIPTA 2 M; QL
ARCAPTA
NEOHALER
3 M; QL
ARMONAIR
RESPICLICK
2 M
ARNUITY
ELLIPTA
3 M
ASMANEX HFA 3 M
ASMANEX
TWISTHALER
3 M; QL
ATROVENT HFA 2 M; QL
BECONASE AQ 3 ST; QL
BERINERT 6 MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
92
Drug Name Drug
Category
Requirements
/ Limits
BEVESPI
AEROSPHERE
2 M
BREO ELLIPTA 3 PA; M; QL
BROVANA 3 M; QL
budesonide
inhalation
1 M; QL
budesonide nasal 1 QL
CINRYZE 6 MSD
COMBIVENT
RESPIMAT
2 QL
cromolyn 1 M
CUROSURF 3
DALIRESP 3 PA; QL
DULERA 2 PA; M; QL
DYMISTA 3 ST; QL
ELIXOPHYLLIN 3 M
ESBRIET ORAL
CAPSULE
3 PA; S; SLA;
QL
ESBRIET ORAL
TABLET
3 PA; S; SLA
FIRAZYR 3 PA; S; SLA
FLOVENT DISKUS 3 M; QL
FLOVENT HFA 3 M; QL
flunisolide 1 QL
fluticasone 1 QL
FLUTICASONE-
SALMETEROL
2 PA; M; QL
HAEGARDA 6 PA; MSD
HYPER-SAL 3
INCRUSE
ELLIPTA
2 M
ipratropium bromide 1 M
ipratropium-
albuterol
1 QL
Drug Name Drug
Category
Requirements
/ Limits
KALBITOR 6 MSD
KALYDECO 3 PA; S; SLA
LETAIRIS 4 PA; ST; S; M
levalbuterol hcl 1
LEVALBUTEROL
TARTRATE
3
metaproterenol 1 M
mometasone 1 QL
montelukast oral
granules in packet
1 M
montelukast oral
tablet
1 M; QL
montelukast oral
tablet,chewable
1 M; QL
NASONEX 3 ST; QL
nebusal inhalation
solution for
nebulization 3 %
1
NEBUSAL
INHALATION
SOLUTION FOR
NEBULIZATION 6
%
3
NUCALA 6 MSD
OFEV 3 PA; S; SLA;
QL
OMNARIS 3 ST; QL
OPSUMIT 3 PA; ST; S; M
ORKAMBI ORAL
TABLET 100-125
MG
3 PA; S
ORKAMBI ORAL
TABLET 200-125
MG
3 PA; S; SLA
PERFOROMIST 2 M; QL
PROAIR HFA 2 QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
93
Drug Name Drug
Category
Requirements
/ Limits
PROAIR
RESPICLICK
2
PROVENTIL HFA 3 QL
PULMICORT 3 M; QL
PULMICORT
FLEXHALER
3 M; QL
pulmosal 1
PULMOZYME 2
QNASL NASAL
HFA AEROSOL
INHALER 40
MCG/ACTUATION
3 ST
QNASL NASAL
HFA AEROSOL
INHALER 80
MCG/ACTUATION
3 ST; QL
QVAR 2 M; QL
REVATIO
INTRAVENOUS
4 PA; S
REVATIO ORAL 4 PA; ST; S; QL
RUCONEST 6 MSD
SEEBRI
NEOHALER
3 M
SEREVENT
DISKUS
3 M; QL
sildenafil 1 PA; S; QL
SINGULAIR ORAL
GRANULES IN
PACKET
3 M
SINGULAIR ORAL
TABLET
3 M; QL
SINGULAIR ORAL
TABLET,CHEWAB
LE
3 M; QL
sodium chloride 1
SPIRIVA
RESPIMAT
3 M
Drug Name Drug
Category
Requirements
/ Limits
SPIRIVA WITH
HANDIHALER
3 M; QL
STIOLTO
RESPIMAT
3 M
STRIVERDI
RESPIMAT
2 M
SURFAXIN 3
SYMBICORT 2 ST; M; QL
terbutaline oral 1 M
terbutaline
subcutaneous
1
THEO-24 3 M
theochron 1 M
theophylline 1 M
TICALAST 3
TRACLEER 3 PA; S; M;
SLA
TUDORZA
PRESSAIR
2 M; QL
TYVASO 6 MSD
TYVASO REFILL
KIT
6 MSD
TYVASO
STARTER KIT
6 MSD
UTIBRON
NEOHALER
3 M
VENTAVIS 3 PA; S
VENTOLIN HFA 3 QL
XOLAIR 6 MSD; QL
XOPENEX 3
XOPENEX
CONCENTRATE
3
XOPENEX HFA 3
zafirlukast 1 M; QL
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
94
Drug Name Drug
Category
Requirements
/ Limits
ZETONNA 3 ST; QL
zileuton 1 M; QL
ZYFLO 3 M
ZYFLO CR 3 M; QL
UROLOGICALS
ANTICHOLINERGICS &
ANTISPASMODICS
darifenacin 1 M
DETROL 3 ST; M
DETROL LA 3 ST; M
DITROPAN XL 3 ST; M
ENABLEX 3 ST; M
flavoxate 1 M
GELNIQUE
TRANSDERMAL
GEL IN
METERED-DOSE
PUMP
3 ST
GELNIQUE
TRANSDERMAL
GEL IN PACKET
3 ST; M; QL
MYRBETRIQ 3 ST; M
oxybutynin chloride 1 M
OXYTROL 3 ST; M; QL
tolterodine 1 M
TOVIAZ 3 ST; M
trospium 1 M
VESICARE 3 ST; M
BENIGN PROSTATIC
HYPERPLASIA (BPH) THERAPY
alfuzosin 1 M
AVODART 3 ST; M
CIALIS 3 PA; QL
Drug Name Drug
Category
Requirements
/ Limits
dutasteride 1 ST; M
dutasteride-
tamsulosin
1 ST; M
finasteride 1 M
FLOMAX 3 ST; M
JALYN 3 ST; M
PROSCAR 3 ST; M
RAPAFLO 3 ST; M
tamsulosin 1 M
UROXATRAL 3 ST; M
CHOLINERGIC STIMULANTS
bethanechol chloride 1
URECHOLINE 3
MISCELLANEOUS UROLOGICALS
azuphen mb 1
CAVERJECT 2 QL
CAVERJECT
IMPULSE
2 QL
CIALIS 3 ST; QL
CYSTAGON 3 S; SLA
cytra k crystals 1
cytra-2 1
cytra-3 1
cytra-k 1
EDEX 3 QL
ELMIRON 2
hyolev mb 1
hyophen 1
INDIOMIN MB 3
K-PHOS NO 2 2
K-PHOS
ORIGINAL
2
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
95
Drug Name Drug
Category
Requirements
/ Limits
LEVITRA 3 ST; QL
methen-sod phos-
meth blue-hyos
1
MUSE 2 QL
ORACIT 3
PAPAVERINE-
ALPROSTADIL-
WATER
3
PAPAV-
PHENTOLAM-
ALPROST-WATER
3
PAPAV-
PHENTOLAMINE
IN WATER
3
PHENTOLAM-
ALPROSTADIL IN
WATER
3
phosphasal 1
pot,sodium citrate-
citric acid
1
potassium citrate 1 M
potassium citrate-
citric acid
1
PROCYSBI 4 S; SLA
SHOHL'S
MODIFIED
3
sodium citrate-citric
acid
1
STAXYN 3 ST; QL
STENDRA ORAL
TABLET 100 MG,
50 MG
3 ST; M; QL
STENDRA ORAL
TABLET 200 MG
3 PA; M; QL
tricitrates 1
ur n-c 1
Drug Name Drug
Category
Requirements
/ Limits
uramit mb 1
URELLE 3
uretron d-s 1
URIBEL 3
urimar-t 1
urin ds 1
uro-458 1
UROCIT-K 10 3 M
UROCIT-K 15 3 M
UROCIT-K 5 3 M
urogesic-blue 1
uro-mp 1
urophen mb 1
UROQID-ACID
NO.2
3
uryl 1
ustell 1
UTA 3
utira-c 1
VIAGRA 2 PA; QL
virtrate-2 1
virtrate-3 1
virtrate-k 1
URINARY ANESTHETICS
phenazopyridine 1
PYRIDIUM 3
VITAMINS, HEMATINICS &
ELECTROLYTES
ELECTROLYTES
calcium 500 + d 5 ACA; OTC
calcium 500 with d 5 ACA; OTC
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
96
Drug Name Drug
Category
Requirements
/ Limits
calcium 600 + d(3) 5 ACA; OTC
calcium 600 with
vitamin d3
5 ACA; OTC
calcium carb and
citrate-vitd3
5 ACA; OTC
calcium carbonate-
vitamin d3
5 ACA; OTC
calcium citrate + d 5 ACA; OTC
calcium citrate-
vitamin d2
5 ACA; OTC
calcium citrate-
vitamin d3
5 ACA; OTC
calcium gluconate in
0.9% nacl
intravenous solution
1 gram/100 ml
6 MSD
CALCIUM
GLUCONATE IN
0.9% NACL
INTRAVENOUS
SOLUTION 1
GRAM/50 ML, 2
GRAM/100 ML, 2
GRAM/50 ML, 3
GRAM/100 ML
6 MSD
CALCIUM
GLUCONATE IN
D5W
6 MSD
citrus calcium 5 ACA; OTC
EFFER-K ORAL
TABLET,
EFFERVESCENT
10 MEQ, 20 MEQ
3 M
effer-k oral tablet,
effervescent 25 meq
1 M
GALZIN 3
hi-cal plus vit d 5 ACA; OTC
k-effervescent 1 M
Drug Name Drug
Category
Requirements
/ Limits
klor-con 1 M
klor-con 10 1 M
klor-con 8 1 M
klor-con m10 1 M
klor-con m15 1 M
klor-con m20 1 M
klor-con sprinkle 1 M
KLOR-CON/25 3 M
klor-con/ef 1 M
k-phos-neutral 1
K-TAB ORAL
TABLET
EXTENDED
RELEASE 10 MEQ,
20 MEQ
3 M
k-tab oral tablet
extended release 8
meq
1 M
lugols 1
oysco 500/d 5 ACA; OTC
oyster shell + d3 5 ACA; OTC
oyster shell calcium-
vit d3
5 ACA; OTC
oystercal-d 5 ACA; OTC
phospha 250 neutral 1
POTABA 3 M
potassium acetate 6 MSD
potassium bicarb
and chloride
1 M
potassium bicarb-
citric acid
1 M
potassium chloride 1 M
potassium chloride
in 0.9%nacl
6 MSD
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
97
Drug Name Drug
Category
Requirements
/ Limits
POTASSIUM CL-
LIDO-0.9 % NACL
6 MSD
POTASSIUM PHOS
IN 0.9 % NACL
6 MSD
sodium chloride 6 MSD
sodium chloride 0.45
%
6 MSD
sodium chloride 3 % 6 MSD
sodium chloride 5 % 6 MSD
SODIUM
PHOSPHATE IN
0.9 % NACL
6 MSD
strong iodine 1
virt-phos 250 neutral 1
MISCELLANEOUS VITAMINS,
HEMATINICS, & ELECTROLYTES
FORTAVIT 3
ISOLYTE-S 6 MSD
VITAMINS & HEMATINICS
ACTIVE FE 3
ANIMI-3 WITH
VITAMIN D
3
ATABEX EC 3
b complex-vitamin
b12
5 ACA; OTC
b complex-vitamin c-
folic acid
5 ACA; OTC
B-12
COMPLIANCE
6 MSD
BACMIN 3
balanced b-100 5 ACA; OTC
balanced b-100
complex
5 ACA; OTC
balanced b-50 5 ACA; OTC
bal-care dha 1
Drug Name Drug
Category
Requirements
/ Limits
BAL-CARE DHA
ESSENTIAL
3
b-complex with
vitamin c oral tablet
5 ACA; OTC
b-complex with
vitamin c oral tablet
400-500 mcg-mg
1 OTC
BIFERA RX 3
CADEAU DHA 3
calcium pnv 1
calcium-folic acid-
vitamin d
1
centratex 1
cholecalciferol
(vitamin d3)
5 ACA; OTC
ciferex 1 M
CITRANATAL
(DUAL-IRON)
3
CITRANATAL 90
DHA (ALGAL OIL)
3
CITRANATAL
ASSURE
3
CITRANATAL B-
CALM (FE GLUC)
3
CITRANATAL
DHA (ALGAL OIL)
3
CITRANATAL
HARMONY (IRON
FUM)
3
classic prenatal 5 ACA; OTC
c-nate dha 1
complete natal dha 1
completenate 1
complex b-100 1 OTC
CONCEPT DHA 3
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
98
Drug Name Drug
Category
Requirements
/ Limits
CONCEPT OB 3
corvita 1
corvita 150 1
CORVITE 3
CORVITE 150 3
CORVITE FE 3
CORVITE FREE 3
cyanocobalamin
(vitamin b-12)
1
delta d3 5 ACA; OTC
dialyvite 1
DIALYVITE 3000 3
DIALYVITE 5000 3
dialyvite 800 5 ACA; OTC
DIALYVITE 800
WITH IRON
3
DIALYVITE
SUPREME D
3
dothelle dha 1
DUET DHA
BALANCED
3
DUET DHA WITH
OMEGA-3
3
d-vi-sol 5 ACA; OTC
ENBRACE HR 3
ergocalciferol
(vitamin d2) oral
capsule
1
ergocalciferol
(vitamin d2) oral
tablet
5 ACA; OTC
ESCAVITE 3
ESCAVITE D 3 M
ESCAVITE LQ 3 M
Drug Name Drug
Category
Requirements
/ Limits
EXTRA-VIRT
PLUS DHA
3
FERIVA 21-7
TABLET
3
ferocon 1
FERRALET 90
DUAL-IRON
DELIVERY
3
ferraplus 90 1
ferrocite plus 1
FLORIVA 3 M
FLORIVA
(FLUORIDE-
VITAMIN D3)
5 M; ACA
FLORIVA PLUS 3 M
FLUORABON 5 M; ACA
FLUOR-A-DAY 5 M; ACA
fluor-a-day (with
xylitol)
1 M
fluoride (sodium)
oral drops
5 M; ACA
fluoride (sodium)
oral tablet,chewable
0.25 mg(0.55 mg
sod. fluoride), 0.5
mg (1.1 mg sodium
fluorid)
5 M; ACA
fluoride (sodium)
oral tablet,chewable
1 mg (2.2 mg sod.
fluoride)
1 M
fluoritab oral
tablet,chewable 0.5
mg (1.1 mg sodium
fluorid)
5 M; ACA
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
99
Drug Name Drug
Category
Requirements
/ Limits
fluoritab oral
tablet,chewable 1
mg (2.2 mg sod.
fluoride)
1 M
FLURA-DROPS 5 M; ACA
focalgin 90 dha 1
focalgin ca 1
focalgin dss 1
folbee 1
folbee plus 1
FOLET ONE 3
FOLGARD OS 3
FOLGARD RX 3
folic acid oral tablet
1 mg
1 M
folic acid oral tablet
400 mcg, 800 mcg
5 M; ACA; OTC
folic acid-vit b6-vit
b12
1
folivane-f 1
folivane-ob 1
folivane-plus 1
folplex 2.2 1
foltabs 800 1 OTC
FOLTRATE 3
full spectrum b-
vitamin c
5 ACA; OTC
FUSION PLUS 3
FUSION
SPRINKLES
3
hematinic plus
vit/minerals
1
hematinic/folic acid 1
hematogen 1
Drug Name Drug
Category
Requirements
/ Limits
hematogen fa 1
hematogen forte 1
HEMATRON-AF 3
hemenatal ob 1
hemenatal ob + dha 1
hemetab 1
HEMOCYTE-F 3
HEMOCYTE-PLUS 3
ICAR-C PLUS 3
INJECTAFER 6 MSD
INTEGRA F 3
INTEGRA PLUS 3
IROSPAN 24/6 3
kobee 1 OTC
KOSHER
PRENATAL PLUS
IRON
3
kpn 1 OTC
levomefolate dha 1
ludent fluoride oral
tablet,chewable 0.25
mg(0.55 mg sod.
fluoride), 0.5 mg
(1.1 mg sodium
fluorid)
5 M; ACA
ludent fluoride oral
tablet,chewable 1
mg (2.2 mg sod.
fluoride)
1 M
MARNATAL-F 3
MAXFE (FOLATE-
DOCUSATE)
3
multigen folic 1
multigen plus 1
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
100
Drug Name Drug
Category
Requirements
/ Limits
multi-vit with
fluoride-iron
5 ACA
multi-vitamin with
fluoride oral drops
5 ACA
multi-vitamin with
fluoride oral
tablet,chewable 0.25
mg, 0.5 mg
5 ACA
multi-vitamin with
fluoride oral
tablet,chewable 1
mg
1
multivitamins with
fluoride oral
tablet,chewable 0.25
mg, 0.5 mg
5 ACA
multivitamins with
fluoride oral
tablet,chewable 1
mg
1
mvc-fluoride oral
tablet,chewable 0.25
mg, 0.5 mg
5 ACA
mvc-fluoride oral
tablet,chewable 1
mg
1
mynatal 1
mynatal advance 1
mynatal plus 1
mynatal-z 1
mynate 90 plus 1
mynephrocaps 1
mynephron 1
NASCOBAL 3 M
NATACHEW (FE
BIS-GLYCINATE)
3
NATELLE ONE 3
Drug Name Drug
Category
Requirements
/ Limits
natural b-100
complex
5 ACA; OTC
NEEVODHA
(WITH ALGAL
OIL)
3
nephplex rx 1
NEPHROCAPS 3
NEPHROCAPS QT 3
NEPHRON FA 3
nephro-vite rx 1
NESTABS 3
NESTABS ABC 3
NESTABS DHA 3
NEURIN-SL 3
newgen 1
NEXA PLUS 3
NEXAVIR 3
NIVA-PLUS 3
NUTRICAP 3
OB COMPLETE 3
OB COMPLETE
GOLD
3
OB COMPLETE
ONE
3
OB COMPLETE
PETITE
3
OB COMPLETE
PREMIER
3
OB COMPLETE
WITH DHA
3
obstetrix dha 1
OBSTETRIX EC 3
OBSTETRIX ONE 3
OBTREX DHA 3
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
101
Drug Name Drug
Category
Requirements
/ Limits
O-CAL FA 3
O-CAL
PRENATAL
3
one daily prenatal 5 ACA; OTC
ortho d 1 M
oyster shell calcium-
vit d2
5 ACA; OTC
perry prenatal 5 ACA; OTC
PHYSICIANS EZ
USE B-12
6 MSD
pnv 29-1 1
pnv ob+dha 1
pnv-dha 1
pnv-dha + docusate 1
pnv-ferrous
fumarate-docu-fa
1
pnv-omega 1
pnv-select 1
pnv-vp-u 1
POLY-VI-FLOR 3
POLY-VI-FLOR
WITH IRON
3
pr natal 400 1
pr natal 400 ec 1
pr natal 430 1
pr natal 430 ec 1
PREFERA-OB 3
PREFERA-OB ONE 3
PREFERA-OB
PLUS DHA
3
prena1 chew 1
prena1 pearl 1
prena1 true 1
Drug Name Drug
Category
Requirements
/ Limits
prenaissance 1
prenaissance plus 1
PRENATA 3
prenatabs fa 1
prenatabs rx 1
prenatal 5 ACA; OTC
prenatal complete 5 ACA; OTC
prenatal formula 5 ACA; OTC
prenatal multi-dha
(algal oil)
1 OTC
prenatal one daily 5 ACA; OTC
prenatal plus 1
prenatal plus
(calcium carb)
1
PRENATAL PLUS
DHA
3
prenatal vitamin 5 ACA; OTC
prenatal vitamin
plus low iron
1
prenatal vitamin
with minerals
5 ACA; OTC
prenatal vits96-iron
fum-folic
5 ACA; OTC
prenatal-u 1
PRENATE AM 3
PRENATE
CHEWABLE
3
PRENATE DHA
(FERR ASP
GLYCIN)
3
PRENATE ELITE
(IRON ASP GLYC)
3
PRENATE
ENHANCE
3
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
102
Drug Name Drug
Category
Requirements
/ Limits
PRENATE
ESSENTIAL(IRON-
ASP-GL)
3
PRENATE MINI
(FERR ASP
GLYCIN)
3
PRENATE PIXIE 3
PRENATE
RESTORE
3
PRENATE STAR 3
preplus 1
pretab 1
PRIMACARE 3
PROFERRIN-
FORTE
2
PROTECT IRON 3
PROVIDA DHA 3
PROVIDA OB 3
PURALOR CI 3 M
PUREFE OB PLUS 3
PUREFE PLUS 3
purevit dualfe plus 1
QUFLORA FE 3 M
QUFLORA FE
(FERROUS
SULFATE)
5 M; ACA
QUFLORA
PEDIATRIC
3 M
QUFLORA
PEDIATRIC
DROPS
3 M
relnate dha 1
renal caps 1
rena-vite 5 ACA; OTC
rena-vite rx 1
Drug Name Drug
Category
Requirements
/ Limits
reno caps 1
risacal-d 5 ACA; OTC
R-NATAL OB 3
SELECT-OB 3
SELECT-OB
(FOLIC ACID)
3
SELECT-OB +
DHA
3
se-natal 19 1
se-natal 19 (with
docusate)
1
se-tan plus 1
stress formula 5 ACA; OTC
stress formula with
iron
1 OTC
stress formula with
iron(sulf)
1 OTC
STROVITE FORTE 3
STROVITE ONE 3
super b complex-
vitamin c
1 OTC
super b maxi
complex
1 OTC
super b-50 complex
plus
1 OTC
super quints 1 OTC
super quints b-50 5 ACA; OTC
superplex-t 1 OTC
SUPERVITE 3
TANDEM PLUS 3
taron forte 1
taron-c dha 1
taron-prex prenatal-
dha
1
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affiliated companies.
103
Drug Name Drug
Category
Requirements
/ Limits
TEXAVITE LQ 3 M
THRIVITE RX 3
thrivite-19 1
tl gard rx 1
tl g-fol os 1
tl icon 1
tl-hem 150 1
total b/c 1 OTC
TRICARE 3
TRICARE
PRENATAL
3
TRICARE
PRENATAL DHA
ONE
3
tricon 1
TRIFERIC 6 MSD
trigels-f forte 1
trinatal gt 1
trinatal rx 1 1
trinate 1
triphrocaps 1
TRISTART DHA 3
tri-tabs dha 1
triveen-duo dha 1
TRI-VI-FLOR 3
tri-vit with fluoride
and iron
5 ACA
tri-vitamin with
fluoride
5 ACA
trust natal dha 1
UDAMIN SP 3
ultimatecare one 1
ultimatecare one nf 1
Drug Name Drug
Category
Requirements
/ Limits
ultra b-100 complex 1 OTC
v-c forte 1
vemavite-prx-2 1
vic-forte 1
vinate care 1
VINATE DHA RF 3
vinate ii 1
vinate m 1
vinate one 1
vinate ultra 1
virt-advance 1
virt-c dha 1
VIRT-CAPS 3
virt-gard 1
virt-nate 1
virt-nate dha 1
virt-pn 1
virt-pn dha 1
virt-pn plus 1
VIRTPREX 3
virt-select 1
virt-vite 1
virt-vite gt 1
VIRT-VITE PLUS 3 M
vit 3 1
vit b complex-folic
acid
5 ACA; OTC
VITAFOL 3
VITAFOL FE+
(WITH
DOCUSATE)
3
VITAFOL
GUMMIES
3
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affiliated companies.
104
Drug Name Drug
Category
Requirements
/ Limits
VITAFOL NANO 3
VITAFOL ULTRA 3
VITAFOL-OB 1
VITAFOL-
OB+DHA
3
VITAFOL-ONE 3
vitajoy daily d 5 ACA; OTC
VITAL-D RX 3
VITAMED MD
ONE RX
3
VITAMEDMD
REDICHEW RX
3
vitamin b complex 5 ACA; OTC
vitamin d3 5 ACA; OTC
vitamins a,c,d and
fluoride
5 ACA
VITAPEARL 3
VITA-RESPA 3
VITATRUE 3
vol-care rx 1
Drug Name Drug
Category
Requirements
/ Limits
vol-nate 1
vol-plus 1
vol-tab rx 1
vp-ch plus 1
vp-ch-pnv 1
vp-ggr-b6 1
vp-heme ob 1
vp-heme one 1
VP-PNV-DHA 3
vp-vite rx 1
zatean-ch 1
zatean-pn dha 1
zatean-pn plus 1
zavara 1 M
zingiber 1
ZOO FRIENDS
COMPLETE
3 OTC
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affiliated companies.
105
Index
2 2TEK GLUCOSE/BLOOD
PRESSURE ...................... 57
A abacavir .................................. 3
abacavir-lamivudine ............... 3
abacavir-lamivudine-
zidovudine .......................... 3
ABILIFY .............................. 27
ABILIFY MAINTENA ........ 27
ABRAXANE ........................ 11
ABSORICA .......................... 43
ABSTRAL ............................ 21
acamprosate .......................... 50
ACANYA ............................. 43
acarbose ................................ 67
ACCOLATE......................... 91
ACCU-CHEK AVIVA
CONNECT METER ........ 57
ACCU-CHEK AVIVA PLUS
METER ............................ 57
ACCU-CHEK AVIVA PLUS
TEST STRP ...................... 54
ACCU-CHEK COMPACT
PLUS CONTROL ............ 57
ACCU-CHEK COMPACT
PLUS TEST...................... 54
ACCU-CHEK GUIDE ......... 54
ACCU-CHEK GUIDE
GLUCOSE METER ......... 57
ACCU-CHEK GUIDE L1-L2
CTRL SOL ....................... 57
ACCU-CHEK NANO .......... 57
ACCU-CHEK SMARTVIEW
CONTRL SOL ................. 57
ACCU-CHEK SMARTVIEW
TEST STRIP .................... 54
ACCUPRIL .......................... 33
ACCURETIC ....................... 33
ACCUTREND GLUCOSE .. 54
ACCUTREND GLUCOSE
CONTROL ....................... 57
acebutolol ............................. 33
acetaminophen-caff-
dihydrocod ........................ 21
ACETAMINOPHEN-CAFF-
DIHYDROCOD ............... 21
acetaminophen-codeine ........ 21
acetazolamide ....................... 88
acetic acid ............................. 52
acetylcysteine ....................... 91
ACIPHEX ............................. 73
ACIPHEX SPRINKLE......... 73
acitretin ................................. 41
ACTEMRA .......................... 79
ACTHAR H.P. ..................... 53
ACTHIB (PF) ....................... 77
ACTICLATE ........................ 10
ACTIGALL .......................... 70
ACTIMMUNE ..................... 77
ACTIQ .................................. 21
ACTIVE FE .......................... 97
ACTIVELLA........................ 80
ACTONEL ..................... 50, 79
ACTOPLUS MET ................ 67
ACTOPLUS MET XR ......... 67
ACTOS ................................. 67
acuicyn.................................. 87
ACULAR.............................. 88
ACULAR LS ........................ 88
ACUVAIL (PF) .................... 88
acyclovir ........................... 3, 48
ACZONE .............................. 44
ADACEL(TDAP
ADOLESN/ADULT)(PF) 77
ADAGEN ............................. 50
ADALAT CC ....................... 33
adapalene .............................. 44
ADAPALENE ...................... 44
adapalene-benzoyl peroxide . 44
ADASUVE ........................... 27
ADCETRIS .......................... 11
ADCIRCA ............................ 91
ADDERALL ........................ 27
ADDERALL XR .................. 27
ADDYI ................................. 27
adefovir ................................... 3
ADEMPAS ........................... 91
ADLYXIN ............................ 67
ADRENALIN ....................... 91
adriamycin ............................ 11
adrucil ................................... 12
ADVAIR DISKUS ............... 91
ADVAIR HFA ..................... 91
ADVANCED GLUC METER
TEST STRIP ..................... 54
ADVANCED GLUCOSE
METER ............................. 57
ADVATE .............................. 37
ADVOCATE BLOOD
GLUCOSE MONITOR .... 58
ADVOCATE DUO .............. 58
ADVOCATE LOW
CONTROL ....................... 58
ADVOCATE REDI-CODE .. 54
ADVOCATE REDI-CODE
DUO METER ................... 58
ADVOCATE REDI-CODE
GLU MONITOR .............. 58
ADVOCATE REDI-CODE+
CTRL LOW ...................... 58
ADVOCATE TEST STRIPS 54
ADYNOVATE ..................... 37
ADYPHREN ........................ 89
ADYPHREN AMP ............... 89
ADYPHREN AMP II ........... 89
ADYPHREN II ..................... 89
ADZENYS XR-ODT ........... 27
AEROSPAN ......................... 91
afeditab cr ............................. 33
AFINITOR ........................... 12
AFINITOR DISPERZ .......... 12
AFLURIA 2017-2018 .......... 77
AFLURIA 2017-2018 (PF) .. 77
AFLURIA QUAD 2017-2018
.......................................... 77
AFLURIA QUAD 2017-2018
(PF) ................................... 77
AFREZZA ............................ 64
AFSTYLA ............................ 37
AFTERA ............................... 82
AGAMATRIX AMP GLUC
MONITOR SYS ............... 58
AGAMATRIX AMP TEST
STRIPS ............................. 54
AGAMATRIX CONTROL
HIGH ................................ 58
AGGRENOX ........................ 37
AGONEAZE ........................ 46
AGRYLIN ............................ 50
AIRDUO RESPICLICK ....... 91
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affiliated companies.
106
AKTEN (PF) ........................ 87
AKTIPAK ............................ 44
AKYNZEO........................... 70
ala-cort .................................. 48
ALA-SCALP ........................ 48
ALBENZA ............................. 7
albuterol sulfate .................... 91
alclometasone ....................... 48
ALDACTAZIDE .................. 33
ALDACTONE ..................... 33
ALDARA ............................. 77
ALDURAZYME .................. 65
ALECENSA ......................... 12
alendronate ..................... 50, 79
ALEVICYN PLUS ............... 42
ALFERON N........................ 77
alfuzosin ............................... 94
ALINIA .................................. 7
ALKERAN ........................... 12
allopurinol ............................ 79
ALLZITAL........................... 21
almotriptan malate ................ 19
ALOCRIL............................. 87
ALOGLIPTIN ...................... 67
ALOGLIPTIN-METFORMIN
.......................................... 67
ALOGLIPTIN-
PIOGLITAZONE ............. 67
ALOMIDE ........................... 87
alophen ................................. 70
ALORA ................................ 80
alosetron ............................... 70
ALOXI ................................. 70
ALPHAGAN P ..................... 89
ALPHANATE ...................... 37
ALPHANINE SD ................. 37
alprazolam ............................ 27
alprazolam intensol .............. 27
ALPROLIX .......................... 37
ALREX................................. 88
ALSUMA ............................. 19
ALTABAX ........................... 47
altacaine ................................ 87
ALTACE .............................. 33
altafluor ................................ 87
altavera (28).......................... 82
ALTOPREV ......................... 39
ALUNBRIG ......................... 12
ALVESCO............................ 91
alyacen 1/35 (28) .................. 82
alyacen 7/7/7 (28) ................. 82
amabelz ................................. 80
amantadine hcl ........................ 3
AMARYL ............................. 67
AMBIEN .............................. 27
AMBIEN CR ........................ 27
AMBISOME .......................... 3
amcinonide ........................... 48
AMELUZ ............................. 42
AMERGE ............................. 19
amethia ................................. 82
amethia lo ............................. 82
amethyst................................ 82
AMICAR .............................. 37
amifostine crystalline ........... 11
amikacin ................................. 7
amiloride ............................... 33
amiloride-hydrochlorothiazide
.......................................... 33
amiodarone ........................... 33
AMITIZA ............................. 70
amitriptyline ......................... 27
amitriptyline-chlordiazepoxide
.......................................... 27
amlodipine ............................ 33
amlodipine-atorvastatin ........ 39
amlodipine-benazepril .......... 33
amlodipine-olmesartan ......... 33
amlodipine-valsartan ............ 33
amlodipine-valsartan-hcthiazid
.......................................... 33
AMMONUL ......................... 50
amnesteem ............................ 44
amoxapine ............................ 27
amoxicil-clarithromy-lansopraz
.......................................... 73
amoxicillin .............................. 9
amoxicillin-pot clavulanate .... 9
AMPHADASE ..................... 50
amphotericin b ........................ 3
ampicillin ................................ 9
ampicillin sodium ................... 9
ampicillin-sulbactam .............. 9
AMPYRA ............................. 20
AMRIX ................................. 21
ANADROL-50 ..................... 65
ANAFRANIL ....................... 27
anagrelide ............................. 50
ANALPRAM-HC ........... 41, 70
ANALPRAM-HC SINGLES70
ANAPROX DS ..................... 25
anaspaz ................................. 69
ANASTIA ............................. 46
anastrozole ............................ 12
ANCOBON ............................ 3
ANDRODERM .................... 65
ANDROGEL ........................ 65
ANDROID ............................ 65
androxy ................................. 65
ANGELIQ ............................ 80
ANGIOMAX ........................ 37
ANIMI-3 WITH VITAMIN D
.......................................... 97
ANODYNE LPT .................. 46
ANORO ELLIPTA ............... 91
ANTABUSE ......................... 50
ANTARA ............................. 39
anucort-hc ............................. 70
ANUSOL-HC ....................... 70
ANZEMET ........................... 70
apexicon e ............................. 48
APIDRA ............................... 64
APIDRA SOLOSTAR .......... 64
APLENZIN ........................... 27
APOKYN ............................. 18
apraclonidine ........................ 89
aprepitant .............................. 70
apri ........................................ 82
APRISO ................................ 70
APTENSIO XR .................... 27
APTIOM ............................... 17
APTIVUS ............................... 3
AQUA GLYCOLIC HC ....... 48
ARALAST NP ...................... 50
aranelle (28) .......................... 82
ARANESP (IN
POLYSORBATE) ............ 75
ARAVA ................................ 79
ARCALYST ......................... 77
ARCAPTA NEOHALER ..... 91
ARGATROBAN .................. 37
ARGATROBAN IN 0.9 %
SOD CHLOR .................... 37
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affiliated companies.
107
ARGATROBAN IN NACL
(ISO-OS) .......................... 37
ARICEPT ............................. 20
ARIMIDEX .......................... 12
aripiprazole ..................... 27, 28
ARISTADA .......................... 28
ARIXTRA ............................ 37
armodafinil ........................... 28
ARMONAIR RESPICLICK 91
ARMOUR THYROID ......... 68
ARNUITY ELLIPTA ........... 91
AROMASIN......................... 12
ARRANON .......................... 12
ARTHROTEC 50 ................. 25
ARTHROTEC 75 ................. 25
ARYMO ER ......................... 21
ARZE-JECT-A ..................... 53
ARZERRA ........................... 12
ASACOL HD ....................... 70
ascomp with codeine ............ 21
ashlyna .................................. 82
ASMANEX HFA ................. 91
ASMANEX TWISTHALER 91
aspir-81 ................................. 25
aspirin ................................... 25
aspirin low dose .................... 25
aspirin-caffeine-dihydrocodein
.......................................... 21
aspirin-dipyridamole ............ 37
aspir-low ............................... 25
aspir-trin ............................... 25
ASSURE 4 CONTROL
SOLUTION ...................... 58
ASSURE 4 STRIPS ............. 54
ASSURE DOSE NORMAL
CONTROL ....................... 58
ASSURE PLATINUM ... 54, 58
ASSURE PRISM CONTROL
1-2 SOLN ......................... 58
ASSURE PRISM MULTI
METER ............................ 58
ASSURE PRISM MULTI
STRIP ............................... 54
ASTAGRAF XL .................. 12
ASTEPRO ............................ 52
ASTERO .............................. 46
AT HOME A1C ................... 58
ATABEX EC........................ 97
ATACAND .......................... 33
ATACAND HCT ................. 33
ATELVIA ............................. 79
atenolol ................................. 33
atenolol-chlorthalidone ......... 33
ATGAM ............................... 77
ATIVAN ............................... 28
atomoxetine .......................... 28
ATOPICLAIR ...................... 42
atorvastatin ........................... 39
atovaquone.............................. 7
atovaquone-proguanil ............. 7
ATRALIN ............................ 44
ATRAPRO CP ..................... 42
ATRAPRO HYDROGEL .... 42
ATRIPLA ............................... 4
atropine ........................... 69, 87
ATROVENT HFA ............... 92
AUBAGIO............................ 76
aubra ..................................... 82
AUGMENTIN ........................ 9
AUGMENTIN ES-600 ........... 9
AUGMENTIN XR ................. 9
AURYXIA............................ 70
AUSTEDO ........................... 20
AUTOJECT 2 INJECTION
DEVICE ........................... 58
AUTOPEN 1 TO 21 UNITS 58
AUVI-Q ................................ 89
AVALIDE ............................ 33
AVANDIA ........................... 67
AVAPRO.............................. 33
avar ....................................... 44
AVAR ................................... 44
AVAR LS ............................. 44
AVAR-E GREEN................. 44
AVAR-E LS ......................... 44
AVASTIN ............................ 12
AVC VAGINAL .................. 81
AVEED ................................ 65
AVELOX.............................. 10
aviane.................................... 82
avidoxy ................................. 10
avita ...................................... 44
AVITA.................................. 44
avo cream ............................. 42
AVODART .......................... 94
AVONEX ............................. 76
AVONEX (WITH ALBUMIN)
.......................................... 76
AVYCAZ ............................... 5
AXERT ................................. 19
AXIRON ............................... 65
AYGESTIN .......................... 80
azacitidine ............................. 12
AZASAN .............................. 12
AZASITE ............................. 86
azathioprine .......................... 12
azelastine ........................ 52, 87
AZELEX ............................... 44
AZILECT ............................. 18
azithromycin ........................... 6
AZOPT ................................. 88
AZOR ................................... 33
AZULFIDINE ...................... 70
AZULFIDINE EN-TABS .... 70
azuphen mb ........................... 94
azurette (28) .......................... 82
B b complex-vitamin b12 ......... 97
b complex-vitamin c-folic acid
.......................................... 97
B-12 COMPLIANCE ........... 97
bacitracin .............................. 86
bacitracin-polymyxin b ......... 86
baclofen ................................ 21
BACMIN .............................. 97
BACTRIM ............................ 10
BACTRIM DS ...................... 10
BACTROBAN ..................... 47
BACTROBAN NASAL ....... 52
balanced b-100 ...................... 97
balanced b-100 complex ....... 97
balanced b-50 ........................ 97
bal-care dha .......................... 97
BAL-CARE DHA
ESSENTIAL ..................... 97
balsalazide ............................ 70
balziva (28) ........................... 82
BANZEL .............................. 17
BARACLUDE ........................ 4
BASAGLAR KWIKPEN ..... 64
BAVENCIO ......................... 12
bayer aspirin ......................... 25
BCG VACCINE, LIVE (PF) 77
b-complex with vitamin c ..... 97
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affiliated companies.
108
BEBULIN............................. 37
BECONASE AQ .................. 92
bekyree (28).......................... 82
BELBUCA ........................... 21
BELEODAQ ........................ 12
belladonna alkaloids-opium . 69
belladonna-opium ................. 69
BELSOMRA ........................ 28
benazepril ............................. 33
benazepril-hydrochlorothiazide
.......................................... 33
BENDEKA ........................... 12
BENEFIX ............................. 37
BENICAR ............................ 33
BENICAR HCT ................... 33
BENLYSTA ......................... 79
BENSAL HP ........................ 42
BENTYL .............................. 69
BENZACLIN ....................... 44
BENZACLIN PUMP ........... 44
BENZAMYCIN ................... 44
BENZEFOAM ..................... 44
BENZEFOAM ULTRA ....... 44
benzepro ............................... 44
benzonatate ........................... 90
benztropine ........................... 18
BEPREVE ............................ 87
BERINERT .......................... 92
BESIVANCE ....................... 86
BESPONSA ......................... 12
BETADINE OPHTHALMIC
PREP ................................ 86
BETAGAN ........................... 86
betamethasone acet,sod phos 53
betamethasone dipropionate . 48
betamethasone valerate ........ 48
betamethasone, augmented... 48
BETAPACE ......................... 33
BETAPACE AF ................... 33
BETASERON ...................... 76
betaxolol ......................... 33, 86
bethanechol chloride ............ 94
BETHKIS ............................... 7
BETIMOL ............................ 86
BETOPTIC S........................ 86
BEVESPI AEROSPHERE ... 92
bexarotene ............................ 12
BEYAZ................................. 82
BIAFINE EMULSION......... 42
bicalutamide ......................... 12
BICILLIN C-R ....................... 9
BICNU.................................. 12
BIDIL ................................... 33
BIFERA RX ......................... 97
BILTRICIDE .......................... 7
bimatoprost ........................... 88
BINOSTO ............................. 79
BIONIME RIGHTEST
GM300 SYSTEM ............. 58
BIONIME RIGHTEST TEST
STRIPS ............................. 54
bisacodyl ............................... 70
bisa-lax ................................. 70
bisoprolol fumarate............... 33
bisoprolol-hydrochlorothiazide
.......................................... 33
bivalirudin ............................ 37
BIVIGAM ............................ 77
bleo 15k ................................ 12
bleomycin ............................. 12
BLEPH-10 ............................ 89
BLEPHAMIDE .................... 89
BLEPHAMIDE S.O.P. ......... 89
blisovi 24 fe .......................... 82
blisovi fe 1.5/30 (28) ............ 82
blisovi fe 1/20 (28) ............... 82
BLOOD GLUCOSE
CONTROL, NORMAL .... 58
BLOOD GLUCOSE TEST .. 54
BLOOD-GLUCOSE METER
.......................................... 58
BONIVA .............................. 79
BOOSTRIX TDAP............... 77
BOSULIF ............................. 12
BOTOX ................................ 77
bp 10-1 .................................. 44
bp-50% urea ......................... 42
bpo ........................................ 44
BRAVELLE ......................... 65
BREEZE 2 CONTROL
SOLUTION,HIGH ........... 58
BREEZE 2 TEST STRIPS ... 54
BREO ELLIPTA .................. 92
BREVIBLOC ....................... 33
BREVIBLOC IN NACL (ISO-
OSM) ................................ 34
BREVICON (28) .................. 82
BRIDION ............................. 21
briellyn .................................. 83
BRILINTA ........................... 37
brimonidine ........................... 89
BRINEURA .......................... 65
BRISDELLE ......................... 28
BRIVIACT ........................... 17
BROMFED DM ................... 90
bromfenac ............................. 88
bromocriptine ....................... 18
brompheniramine-pseudoeph-
dm ..................................... 90
BROMSITE .......................... 88
BROVANA .......................... 92
BUCALSEP .......................... 46
budesonide ...................... 70, 92
bumetanide ........................... 34
BUNAVAIL ......................... 25
BUPAP ................................. 21
BUPHENYL ......................... 50
BUPRENORPHINE ............. 21
buprenorphine hcl ................. 21
buprenorphine-naloxone ....... 25
bupropion hcl ........................ 28
bupropion hcl (smoking deter)
.......................................... 51
buspirone .............................. 28
busulfan ................................ 12
BUSULFEX ......................... 12
butalbital compound w/codeine
.......................................... 21
butalbital-acetaminop-caf-cod
.......................................... 21
butalbital-acetaminophen ..... 21
butalbital-acetaminophen-caff
.......................................... 22
butalbital-aspirin-caffeine ..... 22
BUTISOL ............................. 28
butorphanol tartrate .............. 25
BUTRANS ........................... 22
BYDUREON ........................ 67
BYETTA .............................. 67
BYSTOLIC ........................... 34
BYVALSON ........................ 34
C cabergoline ........................... 65
CABOMETYX ..................... 12
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
109
CADEAU DHA.................... 97
CADUET .............................. 39
CAFERGOT ......................... 19
caffeine citrate ...................... 50
CALAN ................................ 34
CALAN SR .......................... 34
calcipotriene ......................... 41
calcipotriene-betamethasone 41
calcitonin (salmon) ............... 65
calcitrene .............................. 41
calcitriol .......................... 41, 65
calcium 500 + d .................... 96
calcium 500 with d ............... 96
calcium 600 + d(3) ............... 96
calcium 600 with vitamin d3 96
calcium acetate ..................... 70
calcium carb and citrate-vitd3
.......................................... 96
calcium carbonate-vitamin d3
.......................................... 96
calcium citrate + d ................ 96
calcium citrate-vitamin d2 .... 96
calcium citrate-vitamin d3 .... 96
calcium gluconate in 0.9% nacl
.......................................... 96
CALCIUM GLUCONATE IN
0.9% NACL ...................... 96
CALCIUM GLUCONATE IN
D5W ................................. 96
calcium pnv .......................... 97
calcium-folic acid-vitamin d 97
CAMBIA .............................. 25
camila ................................... 80
CAMPTOSAR ..................... 12
camrese ................................. 83
camrese lo ............................. 83
CANASA ............................. 70
CANCIDAS ........................... 3
candesartan ........................... 34
candesartan-hydrochlorothiazid
.......................................... 34
capacet .................................. 22
CAPASTAT ........................... 7
CAPCOF .............................. 90
capecitabine .......................... 12
CAPEX ................................. 48
CAPITAL WITH CODEINE
.......................................... 22
CAPRELSA.......................... 12
captopril ................................ 34
captopril-hydrochlorothiazide
.......................................... 34
CARAC ................................ 42
CARAFATE ......................... 73
CARBAGLU ........................ 50
carbamazepine ...................... 17
CARBATROL ...................... 17
carbidopa .............................. 18
carbidopa-levodopa .............. 18
carbidopa-levodopa-
entacapone ........................ 18
carbinoxamine maleate ......... 89
carboplatin ............................ 12
CARDENE IV ...................... 34
CARDENE IV IN
DEXTROSE ..................... 34
CARDENE IV IN SODIUM
CHLORIDE ...................... 34
CARDIZEM ......................... 34
CARDIZEM CD................... 34
CARDIZEM LA ................... 34
CARDURA .......................... 34
CARDURA XL .................... 34
CARESENS CONTROL A
NORMAL ......................... 58
CARESENS N ...................... 58
CARESENS N TEST STRIPS
.......................................... 54
CARESENS N VOICE ........ 58
CARIMUNE NF
NANOFILTERED............ 77
carisoprodol .......................... 21
carisoprodol-asa-codeine ...... 21
carisoprodol-aspirin .............. 21
CARNITOR.......................... 50
CARNITOR (SUGAR-FREE)
.......................................... 50
carteolol ................................ 86
cartia xt ................................. 34
carvedilol .............................. 34
CASODEX ........................... 12
CASPOFUNGIN .................... 3
CATAPRES.......................... 34
CATAPRES-TTS-1 .............. 34
CATAPRES-TTS-2 .............. 34
CATAPRES-TTS-3 .............. 34
CAVERJECT ....................... 94
CAVERJECT IMPULSE ..... 94
CAYA CONTOURED ......... 80
CAYSTON ............................. 7
caziant (28) ........................... 83
CEDAX .................................. 5
cefaclor ................................... 5
cefadroxil ................................ 5
cefazolin ................................. 5
CEFAZOLIN IN 0.9% SOD
CHLORIDE ........................ 6
cefazolin in dextrose (iso-os) .. 6
CEFAZOLIN IN DEXTROSE
(ISO-OS) ............................. 6
CEFAZOLIN IN DEXTROSE
5 % ...................................... 6
CEFAZOLIN IN STERILE
WATER .............................. 6
cefdinir .................................... 6
cefditoren pivoxil .................... 6
cefepime ................................. 6
cefepime in dextrose,iso-osm . 6
cefixime .................................. 6
CEFOTAN .............................. 6
cefotaxime .............................. 6
cefotetan ................................. 6
cefoxitin .................................. 6
cefpodoxime ........................... 6
cefprozil .................................. 6
ceftibuten ................................ 6
CEFTIN .................................. 6
ceftriaxone .............................. 6
CEFTRIAXONE .................... 6
ceftriaxone in dextrose,iso-os . 6
cefuroxime axetil .................... 6
cefuroxime sodium ................. 6
CEFUROXIME SODIUM-
0.9%NACL(PF) ................ 86
celacyn .................................. 42
CELEBREX ......................... 25
celecoxib ............................... 25
CELESTONE SOLUSPAN .. 53
CELEXA .............................. 28
CELLCEPT .......................... 12
CELLCEPT INTRAVENOUS
.......................................... 12
CELONTIN .......................... 17
CENTANY ........................... 47
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affiliated companies.
110
CENTANY AT .................... 47
centergy ................................ 90
centratex ............................... 97
cephalexin............................... 6
CEPROTIN (BLUE BAR) ... 37
CEPROTIN (GREEN BAR) 37
CERDELGA......................... 65
CEREZYME ........................ 65
CERVIDIL ........................... 82
CESAMET ........................... 70
cetirizine ............................... 89
CETRAXAL......................... 52
CETROTIDE ........................ 65
cevimeline ............................ 50
CHANTIX ............................ 51
CHANTIX CONTINUING
MONTH BOX .................. 51
CHANTIX STARTING
MONTH BOX .................. 51
chateal................................... 83
CHEMET ............................. 50
CHENODAL ........................ 70
cheratussin ac ....................... 90
children's aspirin ................... 25
chloramphenicol sod succinate
............................................ 7
chlordiazepoxide hcl ............ 28
chlordiazepoxide-clidinium .. 69
chlorhexidine gluconate ....... 52
chloroquine phosphate............ 7
chlorothiazide ....................... 34
chlorothiazide sodium .......... 34
chlorpromazine ..................... 28
chlorpropamide..................... 67
chlorthalidone ....................... 34
chlorzoxazone....................... 21
CHOLBAM .......................... 70
cholecalciferol (vitamin d3) . 97
cholestyramine (with sugar) . 39
cholestyramine light ............. 39
choline,magnesium salicylate
.......................................... 25
CHORIONIC
GONADOTROPIN,
HUMAN ........................... 65
CIALIS ................................. 94
ciclodan ................................ 47
CICLODAN KIT.................. 47
ciclopirox .............................. 47
cidaleaze ............................... 46
cidofovir ................................. 4
ciferex ................................... 97
cilostazol ............................... 37
CILOXAN ............................ 86
cimetidine ............................. 73
cimetidine hcl ....................... 73
CIMZIA ................................ 70
CIMZIA POWDER FOR
RECONST ........................ 70
CINRYZE ............................. 92
CIPRO .................................. 10
CIPRO HC ............................ 53
CIPRO XR ............................ 10
CIPRODEX .......................... 53
ciprofloxacin ......................... 10
ciprofloxacin (mixture)......... 10
ciprofloxacin hcl ....... 10, 52, 86
cisplatin ................................ 12
citalopram ............................. 28
CITRANATAL (DUAL-
IRON) ............................... 97
CITRANATAL 90 DHA
(ALGAL OIL) .................. 97
CITRANATAL ASSURE .... 97
CITRANATAL B-CALM (FE
GLUC) .............................. 97
CITRANATAL DHA
(ALGAL OIL) .................. 98
CITRANATAL HARMONY
(IRON FUM) .................... 98
citrate of magnesia................ 70
citroma .................................. 70
citrus calcium ....................... 96
cladribine .............................. 12
CLAFORAN .......................... 6
claravis.................................. 44
CLARINEX .......................... 89
CLARINEX-D 12 HOUR .... 90
clarithromycin ........................ 6
classic prenatal ..................... 98
cleansing wash ...................... 44
clearlax ................................. 70
clemastine ............................. 89
CLEO 90 INFUSION SET 24
.......................................... 58
cleocin .................................... 7
CLEOCIN ......................... 7, 82
CLEOCIN HCL ...................... 7
CLEOCIN PEDIATRIC ......... 7
CLEOCIN T ......................... 44
CLEVER CHEK BLOOD
GLUCOSE ........................ 58
CLEVER CHOICE
GLUCOSE MONITOR .... 58
CLEVER CHOICE LEVEL 2
CONTROL ....................... 58
CLEVER CHOICE MICRO . 58
CLEVER CHOICE MICRO
TEST STRIP ..................... 54
CLEVER CHOICE PRO 54, 58
CLEVER CHOICE TEST
STRIPS ............................. 54
CLEVER CHOICE VOICE+
TEST ................................. 54
CLEVIPREX ........................ 34
CLIMARA ............................ 80
CLIMARA PRO ................... 80
CLIN SINGLE USE ............... 7
CLINDACIN ETZ ................ 44
clindacin p ............................ 44
CLINDACIN PAC ............... 44
CLINDAGEL ....................... 44
clindamycin hcl ...................... 7
CLINDAMYCIN IN 0.9 %
SOD CHLOR ...................... 7
clindamycin palmitate hcl ....... 7
clindamycin pediatric ............. 7
clindamycin phosphate .... 7, 44,
82
clindamycin-benzoyl peroxide
.......................................... 44
clindamycin-tretinoin ........... 44
CLINDESSE ......................... 82
CLINPRO 5000 .................... 52
clobetasol .............................. 48
clobetasol-emollient ............. 48
CLOBEX .............................. 48
CLOCORTOLONE
PIVALATE ....................... 48
clodan ................................... 48
CLODAN KIT ...................... 48
CLODERM ........................... 48
clofarabine ............................ 12
CLOLAR .............................. 12
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affiliated companies.
111
clomiphene citrate ................ 65
clomipramine ........................ 28
clonazepam ........................... 17
clonidine ............................... 34
clonidine hcl ................... 28, 34
clopidogrel ............................ 37
clorazepate dipotassium ....... 28
clorpres ................................. 34
CLORPRES .......................... 34
clotrimazole ............................ 3
clotrimazole-betamethasone . 47
clozapine............................... 28
CLOZAPINE ........................ 28
CLOZARIL .......................... 28
c-nate dha ............................. 98
COAGADEX ....................... 37
COAL TAR .......................... 41
COARTEM ............................ 7
codeine sulfate ...................... 22
codeine-butalbital-asa-caff ... 22
codeine-guaifenesin .............. 90
CODITUSSIN AC................ 90
CODITUSSIN DAC ............. 90
COLAZAL ........................... 70
COLCHICINE ...................... 79
COLCRYS ........................... 79
COLESTID........................... 39
COLESTID FLAVORED .... 39
colestipol .............................. 39
colistin (colistimethate na) ..... 7
colocort ................................. 70
COLY-MYCIN M
PARENTERAL .................. 7
COLY-MYCIN S ................. 53
COLYTE WITH FLAVOR
PACKS ............................. 70
COMBIGAN ........................ 88
COMBIPATCH .................... 80
COMBIVENT RESPIMAT . 92
COMBIVIR ............................ 4
COMETRIQ ......................... 12
COMFORT SHORT INSULIN
PUMP 23 .......................... 58
COMPAZINE....................... 70
COMPLERA .......................... 4
complete natal dha ................ 98
completenate......................... 98
complex b-100 ...................... 98
compro .................................. 70
COMTAN ............................. 18
CONCEPT DHA .................. 98
CONCEPT OB ..................... 98
CONCEPTROL .................... 82
CONCERTA ........................ 28
CONDYLOX........................ 42
constulose ............................. 70
CONTOUR CONTROL
SOLUTION, NML ........... 59
CONTOUR LINK ................ 59
CONTOUR NEXT EZ
METER ............................ 59
CONTOUR NEXT LEV 2
CONTROL SOL............... 59
CONTOUR NEXT LINK .... 59
CONTOUR NEXT METER 59
CONTOUR NEXT ONE
METER ............................ 59
CONTOUR NEXT STRIPS . 54
CONTOUR TEST STRIPS .. 54
CONTROL AST
MONITORING SYSTEM 59
CONZIP................................ 25
COOL BLOOD GLUCOSE
METER ............................ 59
COOL CONTROL A
SOLUTION ...................... 59
COOL GLUCOSE TEST
STRIP ............................... 54
COPAXONE ........................ 76
COPEGUS ............................ 76
CORDRAN .......................... 48
CORDRAN TAPE LARGE
ROLL................................ 48
COREG ................................ 34
COREG CR .......................... 34
CORGARD .......................... 34
CORIFACT .......................... 38
CORLANOR ........................ 40
cormax .................................. 48
CORTANE-B ....................... 42
CORTEF ............................... 53
CORTENEMA ..................... 70
CORTIFOAM ...................... 70
cortisone ............................... 53
CORTISPORIN .................... 47
CORTROSYN ...................... 53
corvita ................................... 98
corvita 150 ............................ 98
CORVITE ............................. 98
CORVITE 150 ...................... 98
CORVITE FE ....................... 98
CORVITE FREE .................. 98
CORZIDE ............................. 34
COSENTYX ......................... 41
COSENTYX (2 SYRINGES)
.......................................... 41
COSENTYX PEN ................ 41
COSENTYX PEN (2 PENS) 41
COSMEGEN ........................ 12
COSOPT ............................... 88
COSOPT (PF) ....................... 88
cosyntropin ........................... 53
COTELLIC ........................... 12
COTEMPLA XR-ODT ........ 28
COUMADIN ........................ 38
covaryx ................................. 80
covaryx h.s. ........................... 80
COZAAR .............................. 34
CREON ................................. 70
CRESEMBA ........................... 3
CRESTOR ............................ 39
CRINONE ............................ 80
CRIXIVAN ............................. 4
cromolyn ................... 70, 87, 92
cryselle (28) .......................... 83
CUBICIN ................................ 7
CUBICIN RF .......................... 7
CUPRIMINE ........................ 79
CUROSURF ......................... 92
CUSHINGS SYNDROME
DIAGNOSTIC .................. 53
CUTIVATE .......................... 48
CUVITRU ............................ 77
CUVPOSA ........................... 69
cyanocobalamin (vitamin b-12)
.......................................... 98
cyclafem 1/35 (28) ................ 83
cyclafem 7/7/7 (28) ............... 83
CYCLESSA (28) .................. 83
cyclobenzaprine .................... 21
CYCLOGYL ........................ 87
CYCLOMYDRIL ................. 89
cyclopentolate ....................... 87
cyclophosphamide ................ 12
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affiliated companies.
112
CYCLOPHOSPHAMIDE .... 12
CYCLOSERINE .................... 7
CYCLOSET ......................... 67
cyclosporine ......................... 12
cyclosporine modified .......... 12
CYMBALTA ....................... 28
cyproheptadine ..................... 89
CYRAMZA .......................... 12
cyred ..................................... 83
CYSTADANE ...................... 70
CYSTAGON ........................ 94
CYSTARAN ........................ 87
cytarabine ............................. 12
cytarabine (pf) ...................... 12
CYTOMEL........................... 68
CYTOTEC ........................... 73
cytra k crystals ...................... 94
cytra-2................................... 94
cytra-3................................... 94
cytra-k................................... 94
D D.H.E.45 ............................... 19
dacarbazine ........................... 12
DACOGEN .......................... 12
DAKLINZA ........................... 4
DALIRESP ........................... 92
danazol ................................. 65
DANTRIUM ........................ 21
dantrolene ............................. 21
dapsone ................................... 7
daptomycin ............................. 7
DARAPRIM ........................... 7
darifenacin ............................ 94
DARZALEX ........................ 12
dasetta 1/35 (28) ................... 83
dasetta 7/7/7 (28) .................. 83
daunorubicin ......................... 12
DAXBIA ................................ 6
DAYPRO ............................. 25
daysee ................................... 83
DAYTRANA ....................... 28
DDAVP ................................ 65
DEBACTEROL ................... 52
deblitane ............................... 80
decitabine ............................. 13
DELESTROGEN ................. 80
delta d3 ................................. 98
deltasone ............................... 53
delyla (28)............................. 83
DELZICOL .......................... 70
DEMADEX .......................... 34
demeclocycline ..................... 10
DEMEROL ........................... 22
DEMSER .............................. 34
DENAVIR ............................ 48
denta 5000 plus ..................... 52
dentagel ................................ 52
DEPACON ........................... 17
DEPAKENE ......................... 17
DEPAKOTE ......................... 17
DEPAKOTE ER ................... 17
DEPAKOTE SPRINKLES .. 17
DEPEN TITRATABS .......... 79
DEPO-ESTRADIOL ............ 80
DEPO-PROVERA................ 80
DEPO-SUBQ PROVERA 104
.......................................... 80
DEPO-TESTOSTERONE .... 65
DERMACINRX
EMPRICAINE.................. 46
DERMA-SMOOTHE/FS
BODY OIL ....................... 48
DERMA-SMOOTHE/FS
SCALP OIL ...................... 48
DERMATOP ........................ 48
DERMOTIC OIL ................. 53
DESCOVY ............................. 4
desipramine .......................... 28
desloratadine ......................... 89
desmopressin ........................ 65
desog-e.estradiol/e.estradiol . 83
desogestrel-ethinyl estradiol . 83
DESONATE ......................... 48
desonide ................................ 48
DESOWEN .......................... 48
desoximetasone .................... 48
DESOXYN ........................... 28
DESVENLAFAXINE .......... 28
DESVENLAFAXINE
FUMARATE .................... 28
desvenlafaxine succinate ...... 28
DETROL .............................. 94
DETROL LA ........................ 94
dexamethasone ..................... 53
dexamethasone intensol ........ 53
dexamethasone sodium phos
(pf) .................................... 53
dexamethasone sodium
phosphate .................... 53, 88
DEXCOM G5 RECEIVER .. 59
DEXEDRINE SPANSULE .. 28
DEXERYL ........................... 42
DEXILANT .......................... 73
dexmethylphenidate .............. 28
DEXPAK 10 DAY ............... 53
DEXPAK 13 DAY ............... 53
DEXPAK 6 DAY ................. 53
dexrazoxane hcl .................... 11
dextroamphetamine .............. 28
dextroamphetamine-
amphetamine ..................... 28
dialyvite ................................ 98
DIALYVITE 3000 ................ 98
DIALYVITE 5000 ................ 98
dialyvite 800 ......................... 98
DIALYVITE 800 WITH IRON
.......................................... 98
DIALYVITE SUPREME D . 98
DIAMOX SEQUELS ........... 88
DIASTAT ............................. 17
DIASTAT ACUDIAL .......... 17
DIATRUE CONTROL SOLN
NORMAL ......................... 59
DIATRUE PLUS BLOOD
GLUCOSE MET .............. 59
DIATRUE PLUS TEST STRIP
.......................................... 54
diazepam ................... 17, 28, 29
diazepam intensol ................. 28
DIBENZYLINE ................... 34
DICLEGIS ............................ 70
DICLO GEL-XRYLIX
SHEET .............................. 25
diclofenac potassium ............ 25
diclofenac sodium ..... 25, 42, 88
diclofenac-misoprostol ......... 25
dicloxacillin ............................ 9
dicyclomine .......................... 69
didanosine ............................... 4
DIFFERIN ............................ 44
DIFICID ................................. 6
diflorasone ............................ 48
DIFLUCAN ............................ 3
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affiliated companies.
113
diflunisal ............................... 25
digitek ................................... 37
digox ..................................... 37
digoxin .................................. 37
dihydroergotamine ............... 19
DILANTIN ........................... 17
DILANTIN EXTENDED .... 17
DILANTIN INFATABS ...... 17
DILANTIN-125 ................... 17
DILATRATE-SR ................. 40
DILAUDID .......................... 22
diltiazem ............................... 34
DILTIAZEM IN DEXTROSE
5 %.................................... 34
dilt-xr .................................... 34
DIOVAN .............................. 34
DIOVAN HCT ..................... 34
DIPENTUM ......................... 70
diphenhydramine hcl ............ 89
diphenoxylate-atropine ......... 69
DIPROLENE ........................ 48
DIPROLENE AF.................. 48
dipyridamole......................... 38
DISALCID ........................... 25
diskets ................................... 22
disopyramide phosphate ....... 33
disulfiram ............................. 50
DITROPAN XL ................... 94
DIURIL ................................ 34
DIURIL IV ........................... 34
divalproex ............................. 17
DIVIGEL .............................. 80
DM2 ..................................... 67
DOCEFREZ ......................... 13
docetaxel............................... 13
DOCETAXEL ...................... 13
dofetilide............................... 33
DOLOPHINE ....................... 22
donepezil .............................. 20
DONNATAL ........................ 69
DORAL ................................ 29
DORIBAX .............................. 7
DORIPENEM......................... 7
DORYX ................................ 10
DORYX MPC ...................... 10
dorzolamide .......................... 88
dorzolamide-timolol ............. 88
dothelle dha .......................... 98
DOVONEX .......................... 41
doxazosin .............................. 34
doxepin ........................... 29, 42
doxercalciferol ................ 65, 66
DOXIL.................................. 13
doxorubicin ........................... 13
doxorubicin, peg-liposomal .. 13
doxycycline hyclate .............. 10
doxycycline monohydrate .... 10
DOXYCYCLINE
MONOHYDRATE ........... 10
drithocreme hp ...................... 41
dronabinol ............................. 70
drospirenone-e.estradiol-lm.fa
.......................................... 83
drospirenone-ethinyl estradiol
.......................................... 83
DROXIA .............................. 13
DUAC ................................... 44
DUAVEE.............................. 80
ducodyl ................................. 70
DUET DHA BALANCED ... 98
DUET DHA WITH OMEGA-3
.......................................... 98
DUETACT ........................... 67
DUEXIS ............................... 25
DULERA .............................. 92
duloxetine ............................. 29
DUOPA ................................ 18
DUPIXENT .......................... 42
DURAGESIC ....................... 22
DUREZOL ........................... 88
DURLAZA ........................... 38
dutasteride ............................ 94
dutasteride-tamsulosin .......... 94
DUTOPROL ......................... 34
d-vi-sol.................................. 98
DYANAVEL XR ................. 29
DYAZIDE ............................ 34
DYMISTA ............................ 92
DYRENIUM ........................ 34
DYSPORT ............................ 77
E e.c. prin ................................. 25
e.e.s. 400 ................................. 6
E.E.S. GRANULES................ 6
EASY PLUS II BLOOD
GLUCOSE MET .............. 59
EASY PLUS II TEST ........... 54
EASY STEP ......................... 55
EASY STEP BLOOD
GLUCOSE METER ......... 59
EASY TALK BLOOD
GLUCOSE METER ......... 59
EASY TALK GLUCOSE
TEST ................................. 55
EASY TOUCH GLUCOSE
MONITOR ....................... 59
EASY TOUCH TEST STRIP
.......................................... 55
EASY TRAK GLUCOSE
TEST ................................. 55
EASY TRAK LOW
CONTROL ....................... 59
EASYGLUCO
MONITORING SYSTEM 59
EASYGLUCO PLUS ..... 55, 59
EASYGLUCO PLUS
NORMAL CONTROL ..... 59
EASYGLUCO TEST ........... 55
EASYMAX .......................... 55
EASYMAX L BLOOD
GLUCOSE METER ......... 59
EASYMAX LOW CONTROL
.......................................... 59
EASYMAX NG .................... 59
EASYMAX NORMAL
CONTROL ....................... 59
EASYMAX V SPEAKING
GLUCOSE SYS ............... 59
EASYMAX V2 BLOOD
GLUCOSE METER ......... 59
EC-NAPROSYN .................. 25
econazole .............................. 47
econtra ez .............................. 83
ecotrin ................................... 26
ecotrin low strength .............. 26
ECOZA ................................. 47
EDARBI ............................... 34
EDARBYCLOR ................... 34
EDECRIN ............................. 35
EDEX ................................... 94
EDLUAR .............................. 29
ed-spaz .................................. 69
EDURANT ............................. 4
eemt ...................................... 80
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affiliated companies.
114
eemt hs.................................. 80
effer-k ................................... 96
EFFER-K .............................. 96
EFFEXOR XR...................... 29
EFFIENT .............................. 38
EFUDEX .............................. 42
EGRIFTA ............................. 76
ELAPRASE .......................... 66
ELDEPRYL ......................... 18
ELELYSO ............................ 66
ELEMENT COMPACT
GLUCOSE METER ......... 59
ELEMENT COMPACT
NORMAL CONTROL ..... 59
ELEMENT COMPACT TEST
STRIPS ............................. 55
ELEMENT COMPACT V
GLUCOSE MTR .............. 60
ELEMENT NORMAL
CONTROL ....................... 60
ELEMENT PLUS BLOOD
GLUCOSE KIT ................ 60
ELEMENT TEST STRIPS... 55
ELESTAT............................. 87
ELESTRIN ........................... 80
eletone .................................. 42
eletriptan hbr ........................ 19
ELIDEL ................................ 42
ELIGARD ............................ 13
ELIGARD (3 MONTH) ....... 13
ELIGARD (4 MONTH) ....... 13
ELIGARD (6 MONTH) ....... 13
ELIMITE .............................. 49
elinest ................................... 83
eliphos .................................. 70
ELIQUIS .............................. 38
ELITEK ................................ 11
ELIXOPHYLLIN ................. 92
ELLA .................................... 83
ELLENCE ............................ 13
ELLZIA PAK ....................... 48
ELMIRON ............................ 94
ELOCON .............................. 48
ELOCTATE ......................... 38
EMADINE ........................... 87
EMBEDA ............................. 22
EMBRACE BLOOD
GLUCOSE SYSTEM . 55, 60
EMBRACE EVO LEVEL 1 . 60
EMBRACE EVO TEST
STRIPS ............................. 55
EMBRACE GLUCOSE
CONTROL LOW ............. 60
EMBRACE PRO GLUCOSE
METER ............................ 60
EMBRACE PRO TEST
STRIPS ............................. 55
EMCYT ................................ 13
EMEND .......................... 70, 71
EMFLAZA ........................... 53
emoquette ............................. 83
EMPLICITI .......................... 13
EMSAM ............................... 29
EMTRIVA .............................. 4
EMVERM .............................. 7
ENABLEX ........................... 94
enalapril maleate................... 35
enalapril-hydrochlorothiazide
.......................................... 35
ENBRACE HR ..................... 98
ENBREL .............................. 79
ENBREL SURECLICK ....... 79
endocet.................................. 22
ENDOMETRIN.................... 80
ENGERIX-B (PF) ................ 77
ENGERIX-B PEDIATRIC
(PF) ................................... 77
enoxaparin ............................ 38
enpresse ................................ 83
enskyce ................................. 83
ENSTILAR ........................... 41
entacapone ............................ 19
entecavir ................................. 4
ENTOCORT EC................... 71
ENTRESTO.......................... 40
ENTYVIO ............................ 71
enulose .................................. 71
ENVARSUS XR .................. 13
EPANED .............................. 35
EPCLUSA .............................. 4
EPICERAM .......................... 42
EPIDUO ............................... 44
EPIDUO FORTE .................. 44
EPIFOAM ............................ 41
epinastine .............................. 87
EPINEPHRINE .............. 89, 90
EPINEPHRINESNAP-V ...... 90
EPIPEN 2-PAK .................... 90
EPIPEN JR 2-PAK ............... 90
epirubicin .............................. 13
EPISIL .................................. 52
EPISNAP .............................. 90
epitol ..................................... 17
EPIVIR ................................... 4
EPIVIR HBV .......................... 4
eplerenone ............................. 35
EPOGEN .............................. 75
epoprostenol (glycine) .......... 35
eprosartan ............................. 35
EPZICOM ............................... 4
EQUETRO ........................... 17
ERAXIS(WATER DILUENT)
............................................ 3
ERBITUX ............................. 13
ergocalciferol (vitamin d2) ... 98
ergoloid ................................. 29
ERGOMAR .......................... 19
ergotamine-caffeine .............. 19
ERIVEDGE .......................... 13
errin ....................................... 80
ERTACZO ............................ 47
ERWINAZE ......................... 13
ery pads ................................. 44
erygel .................................... 44
ERYPED 200 .......................... 6
ERYPED 400 .......................... 6
ery-tab ..................................... 6
ERY-TAB ............................... 7
erythrocin (as stearate) ........... 7
erythromycin ..................... 7, 86
erythromycin ethylsuccinate ... 7
erythromycin with ethanol .... 44
erythromycin-benzoyl peroxide
.......................................... 44
ESBRIET .............................. 92
ESCAVITE ........................... 98
ESCAVITE D ....................... 98
ESCAVITE LQ .................... 98
escitalopram oxalate ............. 29
ESGIC ................................... 22
esmolol ................................. 35
esomeprazole magnesium ..... 74
esomeprazole sodium ........... 74
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
115
ESOMEPRAZOLE
STRONTIUM................... 74
estarylla ................................ 83
estazolam .............................. 29
ESTRACE ............................ 81
estradiol ................................ 81
estradiol valerate .................. 81
estradiol-norethindrone acet . 81
ESTRING ............................. 81
ESTROGEL ......................... 81
estrogens-methyltestosterone 81
estropipate ............................ 81
ESTROSTEP FE-28 ............. 83
eszopiclone ........................... 29
ethacrynate sodium ............... 35
ethacrynic acid...................... 35
ethambutol .............................. 7
ethosuximide ........................ 17
ethyl chloride ........................ 46
ethynodiol diac-eth estradiol 83
ETHYOL .............................. 11
etidronate disodium .............. 50
etodolac ................................ 26
etoposide............................... 13
EUCRISA ............................. 43
EUFLEXXA ......................... 26
EURAX ................................ 49
EVAMIST ............................ 81
EVEKEO .............................. 29
EVENCARE G2 ............. 55, 60
EVENCARE G3 GLUCOSE
METER ............................ 60
EVENCARE G3 TEST ........ 55
EVENCARE MINI
GLUCOSE TEST STR..... 55
EVENCARE MINI
MONITOR SYSTEM ...... 60
EVISTA ................................ 79
EVOCLIN ............................ 45
EVOLUTION BLOOD
GLUCOSE METER ......... 60
EVOLUTION NORMAL
CONTROL ....................... 60
EVOLUTION TEST STRIPS
.......................................... 55
EVOMELA .......................... 13
EVOTAZ ................................ 4
EVOXAC ............................. 50
EVZIO .................................. 26
EXALGO ER ....................... 22
EXELDERM ........................ 47
EXELON .............................. 20
exemestane ........................... 13
EXFORGE............................ 35
EXFORGE HCT................... 35
EXJADE ............................... 50
EXODERM .......................... 47
EXONDYS 51 ...................... 20
EXTAVIA ............................ 76
EXTINA ............................... 47
EXTRA-VIRT PLUS DHA.. 98
EYLEA ................................. 87
EZ SMART PLUS SYSTEM
.......................................... 60
EZ SMART PLUS TEST ..... 55
EZ SMART SYSTEM.......... 60
EZ SMART TEST ................ 55
ezetimibe .............................. 39
ezetimibe-simvastatin ........... 39
F FABIOR ............................... 45
FABRAZYME ..................... 66
FACTIVE ............................. 10
fallback solo ......................... 83
falmina (28) .......................... 83
famciclovir.............................. 4
famotidine ............................. 74
famotidine (pf) ...................... 74
famotidine (pf)-nacl (iso-os) 74
FANAPT .............................. 29
FARESTON ......................... 13
FARXIGA ............................ 67
FARYDAK ........................... 13
FASLODEX ......................... 13
fayosim ................................. 83
FAZACLO............................ 29
FC2 FEMALE CONDOM ... 80
FEIBA NF ............................ 38
felbamate .............................. 17
FELBATOL.......................... 17
FELDENE ............................ 26
felodipine .............................. 35
fem ph ................................... 82
FEMARA ............................. 13
FEMCAP .............................. 80
FEMHRT LOW DOSE ........ 81
FEMRING ............................ 81
femynor ................................. 83
fenofibrate ............................. 39
FENOFIBRATE ................... 39
fenofibrate micronized .......... 39
fenofibrate nanocrystallized . 39
fenofibric acid ....................... 39
fenofibric acid (choline) ....... 39
FENOGLIDE ........................ 39
fenoprofen ............................. 26
FENOPROFEN .................... 26
FENORTHO ......................... 26
fentanyl ................................. 22
FENTANYL ......................... 22
FENTANYL (PF)-
BUPIVACAINE-NACL ... 22
fentanyl citrate ...................... 22
fentanyl citrate-0.9%nacl (pf)
.......................................... 22
FENTANYL CITRATE-
0.9%NACL (PF) ............... 22
FENTANYL-
ROPIVACAINE-NACL
(PF) ................................... 22
FENTORA ............................ 22
FERIVA 21-7 TABLET ....... 98
ferocon .................................. 98
FERRALET 90 DUAL-IRON
DELIVERY ...................... 98
ferraplus 90 ........................... 98
FERRIPROX ........................ 50
FERRLECIT ......................... 50
ferrocite plus ......................... 98
FETZIMA ............................. 29
FEXMID ............................... 21
FIBRICOR ............................ 39
FIFTY50 TEST STRIP ......... 55
FINACEA ............................. 45
finasteride ............................. 94
FIORICET ............................ 22
FIORINAL ........................... 22
FIORINAL-CODEINE #3 .... 22
FIRAZYR ............................. 92
FIRMAGON KIT W
DILUENT SYRINGE ...... 13
FLAGYL ................................ 7
FLAREX ............................... 88
flavoxate ............................... 94
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
116
FLEBOGAMMA DIF .......... 77
flecainide .............................. 33
FLECTOR ............................ 26
fleet laxative ......................... 71
FLOLAN .............................. 35
FLOLIPID ............................ 39
FLOMAX ............................. 94
FLORIVA............................. 98
FLORIVA (FLUORIDE-
VITAMIN D3) ................. 98
FLORIVA PLUS .................. 98
FLOVENT DISKUS ............ 92
FLOVENT HFA ................... 92
FLOWTUSS ......................... 90
floxin .................................... 53
floxuridine ............................ 13
FLUAD 2017-2018 (65 YR
UP)(PF) ............................ 77
FLUARIX QUAD 2017-2018
(PF) ................................... 77
FLUBLOK 2017-2018 (PF) . 77
FLUBLOK QUAD 2017-2018
(PF) ................................... 77
flucaine ................................. 87
FLUCELVAX QUAD 2017-
2018 .................................. 77
FLUCELVAX QUAD 2017-
2018 (PF) .......................... 77
fluconazole ............................. 3
fluconazole in dextrose(iso-o) 3
fluconazole in nacl (iso-osm) . 3
flucytosine .............................. 3
fludarabine ............................ 13
fludrocortisone ..................... 53
FLULAVAL QUAD 2017-
2018 .................................. 77
FLULAVAL QUAD 2017-
2018 (PF) .......................... 77
FLUMADINE ........................ 4
flumazenil ............................. 29
flunisolide ............................. 92
fluocinolone .......................... 48
fluocinolone acetonide oil .... 53
fluocinolone and shower cap 48
fluocinonide .......................... 48
fluocinonide-e....................... 48
fluocinonide-emollient ......... 48
FLUORABON ..................... 98
FLUOR-A-DAY ................... 98
fluor-a-day (with xylitol) ...... 98
fluorescein-proparacaine ...... 87
fluoride (sodium) ...... 52, 98, 99
FLUORIDEX DAILY
DEFENSE ........................ 52
fluoritab ................................ 99
fluorometholone ................... 88
FLUOROPLEX .................... 43
fluorouracil ..................... 13, 43
FLUOROURACIL ............... 43
fluoxetine .............................. 29
FLUOXETINE ..................... 29
fluphenazine decanoate ........ 29
fluphenazine hcl ................... 29
FLURA-DROPS ................... 99
flurandrenolide ..................... 48
flurazepam ............................ 29
flurbiprofen ........................... 26
flurbiprofen sodium .............. 88
flurox .................................... 87
flutamide ............................... 13
fluticasone ...................... 48, 92
FLUTICASONE-
SALMETEROL................ 92
fluvastatin ............................. 39
FLUVIRIN 2017-2018 ......... 77
FLUVIRIN 2017-2018 (PF) . 77
fluvoxamine .......................... 29
FLUZONE HIGH-DOSE
2017-18 (PF)..................... 77
FLUZONE INTRADERM
QUAD 2017-18 ................ 77
FLUZONE QUAD 2017-2018
.......................................... 77
FLUZONE QUAD 2017-2018
(PF) ................................... 78
FLUZONE QUAD PEDI
2017-18 (PF)..................... 78
FML FORTE ........................ 88
FML LIQUIFILM ................ 88
FML S.O.P. .......................... 88
focalgin 90 dha ..................... 99
focalgin ca ............................ 99
focalgin dss ........................... 99
FOCALIN ............................. 29
FOCALIN XR ...................... 29
folbee .................................... 99
folbee plus ............................ 99
FOLET ONE ........................ 99
FOLGARD OS ..................... 99
FOLGARD RX ..................... 99
folic acid ............................... 99
folic acid-vit b6-vit b12 ........ 99
folivane-f .............................. 99
folivane-ob ............................ 99
folivane-plus ......................... 99
FOLLISTIM AQ .................. 66
FOLOTYN ........................... 13
folplex 2.2 ............................. 99
foltabs 800 ............................ 99
FOLTRATE .......................... 99
fondaparinux ......................... 38
FORA D10 ............................ 60
FORA D15G ......................... 55
FORA D20 ...................... 55, 60
FORA D40-G31 TEST
STRIPS ............................. 55
FORA G20 ...................... 55, 60
FORA G30A ................... 55, 60
FORA GD50 BLOOD
GLUCOSE SYSTEM ....... 60
FORA GD50 TEST STRIPS 55
FORA NORMAL CONTROL
.......................................... 60
FORA PREMIUM V10
GLUCOSE METER ......... 60
FORA TEST N'GO VOICE
METER ............................. 60
FORA TEST STRIP ............. 55
FORA TN'G VOICE METER
.......................................... 60
FORA TN'G VOICE TEST
STRIPS ............................. 55
FORA V10 ...................... 55, 60
FORA V10-V12-D10-D20
STRIPS ............................. 55
FORA V12 BLOOD
GLUCOSE SYSTEM ....... 60
FORA V12 GLUCOSE ........ 55
FORA V20 ...................... 55, 60
FORA V30A ......................... 60
FORACARE GD20 .............. 55
FORACARE GD20
GLUCOSE METER ......... 60
FORACARE GD40 .............. 55
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
117
FORACARE GD40A
GLUCOSE METER ......... 60
FORACARE GD40B
GLUCOSE METER ......... 60
FORACARE GDH LOW
CONTROL ....................... 60
FORFIVO XL ...................... 29
FORTAMET ........................ 67
FORTAVIT .......................... 97
FORTEO .............................. 79
FORTESTA .......................... 66
FORTISCARE BLOOD
GLUCOSE SYST ............. 60
FORTISCARE GLUCOSE
TEST STRIPS .................. 55
FORTISCARE NORMAL ... 60
FOSAMAX .......................... 79
FOSAMAX PLUS D ............ 79
foscarnet ................................. 4
FOSCAVIR ............................ 4
fosinopril .............................. 35
fosinopril-hydrochlorothiazide
.......................................... 35
fosphenytoin ......................... 17
FOSRENOL ......................... 71
FRAGMIN ........................... 38
FREESTYLE CONTROL .... 60
FREESTYLE FLASH
SYSTEM .......................... 61
FREESTYLE FREEDOM ... 61
FREESTYLE FREEDOM
LITE ................................. 61
FREESTYLE INSULINX ... 55,
61
FREESTYLE INSULINX
TEST STRIPS .................. 55
FREESTYLE LITE METER 61
FREESTYLE LITE STRIPS 55
FREESTYLE PRECISION
NEO METER ................... 61
FREESTYLE PRECISION
NEO STRIPS.................... 55
FREESTYLE SIDEKICK II 61
FREESTYLE SYSTEM KIT 61
FREESTYLE TEST ............. 55
FROTEK .............................. 26
frovatriptan ........................... 19
full spectrum b-vitamin c ..... 99
FURADANTIN .................... 11
furosemide ............................ 35
FUSILEV.............................. 11
FUSION PLUS ..................... 99
FUSION SPRINKLES ......... 99
FUZEON ................................ 4
fyavolv .................................. 81
FYCOMPA ........................... 17
G g tussin ac ............................. 90
gabapentin ............................ 17
GABITRIL ........................... 17
galantamine .......................... 20
GALZIN ............................... 96
GAMASTAN S/D ................ 78
GAMMAGARD LIQUID .... 78
GAMMAGARD S-D (IGA < 1
MCG/ML) ........................ 78
GAMMAKED ...................... 78
GAMMAPLEX .................... 78
GAMMAPLEX (WITH
SORBITOL) ..................... 78
GAMUNEX-C...................... 78
GANIRELIX ........................ 66
GASTROCROM .................. 71
gatifloxacin ........................... 86
GATTEX 30-VIAL .............. 71
gavilax .................................. 71
gavilyte-c .............................. 71
gavilyte-g .............................. 71
gavilyte-n .............................. 71
GAZYVA ............................. 13
GE100 BLOOD GLUCOSE
SYSTEM .......................... 61
GE100 BLOOD GLUCOSE
TEST STRIP..................... 55
GE100 CONTROL
SOLUTION NORMAL .... 61
GELCLAIR .......................... 52
GELNIQUE .......................... 94
gemcitabine .......................... 13
gemfibrozil ........................... 40
GEMZAR ............................. 13
GENERESS FE .................... 83
generlac ................................ 71
gengraf .................................. 13
GENOTROPIN .................... 76
GENOTROPIN MINIQUICK
.......................................... 76
GENSTRIP TEST STRIP ..... 56
gentak ................................... 86
gentamicin .................. 8, 47, 86
gentamicin in nacl (iso-osm) .. 8
GENTAMICIN IN NACL
(ISO-OSM) ......................... 8
gentamicin sulfate (ped) (pf) .. 8
gentamicin sulfate (pf) ............ 8
GENTAMICIN SULFATE
(PF) ..................................... 8
gentle laxative ....................... 71
gentlelax ............................... 71
GENVOYA ............................ 4
GEODON ............................. 29
GIALAX ............................... 71
gianvi (28) ............................ 83
GIAZO .................................. 71
gildagia ................................. 83
GILENYA ............................ 76
GILOTRIF ............................ 13
GLASSIA ............................. 50
glatopa .................................. 76
GLEEVEC ............................ 13
GLEOSTINE ........................ 13
GLIADEL WAFER .............. 13
glimepiride ............................ 67
glipizide ................................ 67
glipizide-metformin .............. 67
GLUCAGEN DIAGNOSTIC
KIT ................................... 57
GLUCAGEN HYPOKIT ...... 57
GLUCAGON EMERGENCY
KIT (HUMAN) ................. 57
GLUCAGON HCL ............... 57
GLUCO NAVII GLUCOSE
MONITOR ....................... 61
GLUCO NAVII TEST STRIP
.......................................... 56
GLUCOCARD 01 METER .. 61
GLUCOCARD 01 NORMAL
CONTROL ....................... 61
GLUCOCARD 01 SENSOR
PLUS ................................ 56
GLUCOCARD EXPRESSION
.................................... 56, 61
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affiliated companies.
118
GLUCOCARD SHINE
METER ............................ 61
GLUCOCARD SHINE TEST
STRIPS ............................. 56
GLUCOCARD VITAL ........ 61
GLUCOCARD VITAL
SENSOR........................... 56
GLUCOCARD VITAL TEST
STRIPS ............................. 56
GLUCOCOM BLOOD
GLUCOSE ....................... 61
GLUCOCOM CONTROL
NORMAL......................... 61
GLUCOCOM GLUCOSE.... 56
GLUCOPHAGE ................... 67
GLUCOPHAGE XR ............ 67
GLUCOSE CONTROL........ 61
GLUCOTROL ...................... 67
GLUCOTROL XL ............... 67
GLUCOVANCE .................. 67
GLUMETZA ........................ 67
glyburide............................... 67
glyburide micronized............ 67
glyburide-metformin ............ 67
glycolax ................................ 71
glycopyrrolate....................... 69
GLYCOPYRROLATE......... 69
glydo ..................................... 46
GLYNASE ........................... 67
GLYSET............................... 67
GLYXAMBI ........................ 67
GM100 ........................... 56, 61
GOLYTELY......................... 71
GONAL-F ............................ 66
GONAL-F RFF .................... 66
GONAL-F RFF REDI-JECT 66
GONITRO ............................ 40
GORDONS UREA ............... 43
GRALISE ............................. 17
GRALISE 30-DAY STARTER
PACK ............................... 17
granisetron hcl ...................... 71
GRANIX .............................. 76
GRASTEK ........................... 78
griseofulvin microsize ............ 3
griseofulvin ultramicrosize ..... 3
GRIS-PEG
(ULTRAMICROSIZE) ...... 3
guaiatussin ac ....................... 90
guaifenesin ac ....................... 90
guaifenesin dac ..................... 90
guanfacine ...................... 29, 35
guanidine .............................. 29
GYNAZOLE-1 ..................... 82
gynol ii .................................. 82
H HAEGARDA........................ 92
HALAVEN ........................... 13
HALCION ............................ 29
HALDOL.............................. 29
HALDOL DECANOATE .... 29
halobetasol propionate .......... 48
HALOG ................................ 48
haloperidol ............................ 29
haloperidol decanoate ........... 29
haloperidol lactate ................ 29
HARVONI.............................. 4
HAVRIX (PF) ...................... 78
HEALTHPRO GLUCOSE
MONITOR ....................... 61
HEALTHPRO HIGH-LOW
CONTROL ....................... 61
HEALTHPRO TEST STRIPS
.......................................... 56
healthylax ............................. 71
heather .................................. 81
HECTOROL ......................... 66
HELIXATE FS ..................... 38
HEMANGEOL ..................... 35
hematinic plus vit/minerals .. 99
hematinic/folic acid .............. 99
hematogen ............................ 99
hematogen fa ........................ 99
hematogen forte .................... 99
HEMATRON-AF ................. 99
hemenatal ob......................... 99
hemenatal ob + dha .............. 99
hemetab ................................ 99
hemmorex-hc ........................ 71
HEMOCYTE-F .................... 99
HEMOCYTE-PLUS ............. 99
HEMOFIL M HIGH ............. 38
HEMOFIL M LOW.............. 38
HEMOFIL M MID ............... 38
HEMOFIL M SUPER HIGH38
hep flush-10 (pf) ................... 38
HEPAGAM B ....................... 78
heparin (porcine) .................. 38
HEPARIN (PORCINE) IN
0.9% NACL ...................... 38
heparin (porcine) in 5 % dex 38
heparin (porcine) in nacl (pf) 38
heparin flush(porcine)-0.9nacl
.......................................... 38
heparin lock flush ................. 38
heparin lock flush (porcine) .. 38
heparin lockflush(porcine)(pf)
.......................................... 38
heparin(porcine) in 0.45% nacl
.......................................... 38
HEPARIN(PORCINE) IN
0.45% NACL .................... 38
heparin, porcine (pf) ............. 38
HEPSERA .............................. 4
HERCEPTIN ........................ 13
HETLIOZ ............................. 29
HEXALEN ........................... 13
HIBERIX (PF) ...................... 78
hi-cal plus vit d ..................... 96
HIPREX ................................ 11
HISTEX-AC ......................... 90
HIZENTRA .......................... 78
homatropaire ......................... 87
homatropine hbr .................... 87
HORIZANT .......................... 20
hpr ......................................... 43
hpr plus ................................. 43
hpr plus hydrogel .................. 43
HPR PLUS-MB HYDROGEL
.......................................... 43
HUMALOG .......................... 64
HUMALOG JUNIOR
KWIKPEN ........................ 64
HUMALOG KWIKPEN ...... 64
HUMALOG MIX 50-50 ....... 64
HUMALOG MIX 50-50
KWIKPEN ........................ 64
HUMALOG MIX 75-25 ....... 64
HUMALOG MIX 75-25
KWIKPEN ........................ 64
HUMAPEN LUXURA HD .. 61
HUMATE-P ......................... 38
HUMATROPE ..................... 76
HUMIRA .............................. 79
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affiliated companies.
119
HUMIRA PEDIATRIC
CROHN'S START ........... 79
HUMIRA PEN CROHN'S-
UC-HS START ................ 79
HUMIRA PEN PSORIASIS-
UVEITIS .......................... 79
HUMULIN 70/30 ................. 64
HUMULIN 70/30 KWIKPEN
.......................................... 64
HUMULIN N ....................... 65
HUMULIN N KWIKPEN .... 65
HUMULIN R U-100 ............ 65
HUMULIN R U-500 (CONC)
KWIKPEN ....................... 65
HUMULIN R U-500
(CONCENTRATED) ....... 65
HYCAMTIN ........................ 13
HYCOFENIX ....................... 90
hydralazine ........................... 35
HYDREA ............................. 13
HYDRO 35 ........................... 43
HYDRO 40 ........................... 43
hydrochlorothiazide .............. 35
hydrocodone-acetaminophen 22
hydrocodone-chlorpheniramine
.......................................... 90
hydrocodone-cpm-
pseudoephed ..................... 90
hydrocodone-homatropine ... 90
hydrocodone-ibuprofen ........ 22
hydrocortisone .......... 48, 53, 71
hydrocortisone acetate .......... 71
hydrocortisone butyrate ........ 49
hydrocortisone butyr-emollient
.......................................... 49
hydrocortisone valerate ........ 49
hydrocortisone-acetic acid.... 53
hydrocortisone-iodoquinol-aloe
.......................................... 47
hydrocortisone-min oil-wht pet
.......................................... 49
hydrocortisone-pramoxine .. 41,
71
hydromet............................... 90
hydromorphone .................... 23
HYDROMORPHONE (PF)-
0.9% NACL ...................... 22
hydromorphone in 0.9 % nacl
.......................................... 23
HYDROMORPHONE IN 0.9
% NACL ..................... 22, 23
hydroxychloroquine................ 8
hydroxyprogesterone caproate
.......................................... 81
hydroxyurea .......................... 14
hydroxyzine hcl .................... 90
hydroxyzine pamoate ........... 90
HYLATOPIC ....................... 43
HYLATOPICPLUS.............. 43
hyolev mb ............................. 94
hyophen ................................ 95
hyoscyamine sulfate ............. 69
hyosyne ................................. 69
HYPERHEP B S/D .............. 78
HYPERHEP B S-D
NEONATAL .................... 78
HYPERRAB S/D (PF) ......... 78
HYPER-SAL ........................ 92
HYQVIA .............................. 78
HYSINGLA ER ................... 23
HYZAAR ............................. 35
I ibandronate ........................... 79
IBRANCE ............................ 14
IBUDONE ............................ 23
ibuprofen .............................. 26
ibuprofen-oxycodone............ 23
ic green ................................. 50
ICAR-C PLUS ...................... 99
ICLUSIG .............................. 14
IDAMYCIN PFS .................. 14
idarubicin .............................. 14
IDELVION ........................... 38
IDHIFA ................................ 14
IFEX ..................................... 14
ifosfamide ............................. 14
ifosfamide-mesna ................. 14
ILARIS (PF) ......................... 77
ILEVRO ............................... 88
ILUVIEN .............................. 88
imatinib ................................. 14
IMBRUVICA ....................... 14
IMFINZI ............................... 14
imipenem-cilastatin ................ 8
imipramine hcl ...................... 29
imipramine pamoate ............. 29
imiquimod ............................. 77
IMITREX ............................. 19
IMITREX STATDOSE KIT
REFILL ............................. 19
IMITREX STATDOSE PEN 19
IMOGAM RABIES-HT (PF)
.......................................... 78
IMPAVIDO ............................ 8
IMURAN .............................. 14
INCRELEX .......................... 50
INCRUSE ELLIPTA ............ 92
indapamide ........................... 35
INDERAL LA ...................... 35
INDERAL XL ...................... 35
INDIOMIN MB .................... 95
INDOCIN ............................. 26
indocyanine green ................. 50
indomethacin ........................ 26
INFASURF ........................... 50
INFINITY CONTROL
SOLUTION NORM ......... 61
INFINITY STARTER KIT .. 61
INFINITY TEST STRIPS .... 56
INFLECTRA ........................ 71
INGREZZA .......................... 20
INJECTAFER ....................... 99
INLYTA ............................... 14
INNOPRAN XL ................... 35
INOVA ................................. 45
INOVA 4-1 ........................... 42
INSET 30 INFUSION SET 23
.......................................... 61
INSET INFUSION SET 23 .. 61
INSPRA ................................ 35
INSULIN SYRINGE-
NEEDLE U-100 ............... 57
INTEGRA F ......................... 99
INTEGRA PLUS .................. 99
INTELENCE .......................... 4
INTERMEZZO ..................... 29
INTRAROSA ....................... 82
INTRON A ........................... 77
introvale ................................ 83
INTUNIV ER ....................... 29
INVANZ ................................. 8
INVEGA ............................... 30
INVIRASE ............................. 4
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affiliated companies.
120
INVOKAMET ...................... 68
INVOKAMET XR ............... 68
INVOKANA ........................ 68
iodoquinol-hc ....................... 47
IONSYS ............................... 23
IOPIDINE............................. 89
ipratropium bromide ....... 52, 92
ipratropium-albuterol ........... 92
IPRIVASK ........................... 38
irbesartan .............................. 35
irbesartan-hydrochlorothiazide
.......................................... 35
IRENKA ............................... 30
IRESSA ................................ 14
irinotecan .............................. 14
IROSPAN 24/6 ..................... 99
ISENTRESS ........................... 4
ISENTRESS HD .................... 4
isibloom ................................ 83
ISOCHRON ......................... 40
ISOLYTE-S .......................... 97
isometh-dichloral-
acetaminophn ................... 19
isomethepten-caf-
acetaminophen .................. 19
isoniazid ................................. 8
ISOPTO CARPINE .............. 87
ISORDIL .............................. 40
ISORDIL TITRADOSE ....... 40
isosorbide dinitrate ............... 40
isosorbide mononitrate ......... 41
isoxsuprine ........................... 82
isradipine .............................. 35
ISTALOL ............................. 86
ISTODAX ............................ 14
itraconazole ............................ 3
ivermectin ............................... 8
IXEMPRA ............................ 14
IXINITY ............................... 38
J JADENU .............................. 50
JADENU SPRINKLE .......... 50
JAKAFI ................................ 14
JALYN ................................. 94
jantoven ................................ 38
JANUMET ........................... 68
JANUMET XR ..................... 68
JANUVIA............................. 68
JARDIANCE ........................ 68
JAZZ WIRELESS 2 METER
KIT ................................... 61
jencycla ................................. 81
JENTADUETO .................... 68
JENTADUETO XR .............. 68
JETREA (PF) ....................... 87
jevantique lo ......................... 81
JEVTANA ............................ 14
jinteli ..................................... 81
jolessa ................................... 83
jolivette ................................. 81
JUBLIA ................................ 47
juleber ................................... 83
junel 1.5/30 (21) ................... 83
junel 1/20 (21) ...................... 83
junel fe 1.5/30 (28) ............... 83
junel fe 1/20 (28) .................. 83
junel fe 24 ............................. 83
JUXTAPID ........................... 40
K KADCYLA .......................... 14
KADIAN .............................. 23
kaitlib fe ................................ 83
KALBITOR .......................... 92
KALETRA ............................. 4
KALYDECO ........................ 92
KAPVAY ............................. 30
KARBINAL ER ................... 90
kariva (28) ............................ 83
KAZANO ............................. 68
k-effervescent ....................... 96
KEFLEX ................................. 6
kelnor 1/35 (28) .................... 83
KENALOG ..................... 49, 53
KEPIVANCE ....................... 11
KEPPRA ............................... 17
KEPPRA XR ........................ 17
KERAFOAM........................ 43
KERALAC ........................... 43
KERALYT RX ..................... 42
KERYDIN ............................ 47
ketoconazole ..................... 3, 47
ketoprofen ............................. 26
ketorolac ......................... 26, 88
KEVEYIS ............................. 20
KEVZARA ........................... 79
KHEDEZLA ......................... 30
kimidess (28) ........................ 83
KINERET ............................. 77
KINRIX (PF) ........................ 78
kionex ................................... 71
kionex (with sorbitol) ........... 71
KISQALI .............................. 14
KISQALI FEMARA CO-
PACK ............................... 14
KIT PREP OF TC-99M-
MEBROFENIN ................ 50
KITABIS PAK ....................... 8
KLARON ............................. 47
KLONOPIN .......................... 17
klor-con ................................. 96
klor-con 10 ............................ 96
klor-con 8 .............................. 96
klor-con m10 ........................ 96
klor-con m15 ........................ 96
klor-con m20 ........................ 96
klor-con sprinkle ................... 96
KLOR-CON/25 .................... 96
klor-con/ef ............................ 96
KOATE ................................. 38
kobee ..................................... 99
KOGENATE FS ................... 38
KOMBIGLYZE XR ............. 68
KORLYM ............................. 66
KOSHER PRENATAL PLUS
IRON ................................ 99
KOVALTRY ........................ 38
K-PHOS NO 2 ...................... 95
K-PHOS ORIGINAL ........... 95
k-phos-neutral ....................... 96
kpn ........................................ 99
KRISTALOSE ...................... 71
KRYSTEXXA ...................... 79
k-tab ...................................... 96
K-TAB .................................. 96
kurvelo .................................. 83
KUVAN ................................ 66
KYNAMRO ......................... 40
KYPROLIS ........................... 14
L l norgest/e.estradiol-e.estrad . 83
labetalol ................................ 35
LACRISERT ........................ 87
lactated ringers ...................... 50
lactulose ................................ 71
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
121
LAMICTAL ......................... 17
LAMICTAL ODT ................ 17
LAMICTAL ODT STARTER
(BLUE) ............................. 17
LAMICTAL ODT STARTER
(GREEN) .......................... 17
LAMICTAL ODT STARTER
(ORANGE)....................... 17
LAMICTAL STARTER
(BLUE) KIT ..................... 17
LAMICTAL STARTER
(GREEN) KIT .................. 17
LAMICTAL STARTER
(ORANGE) KIT ............... 18
LAMICTAL XR ................... 18
LAMICTAL XR STARTER
(BLUE) ............................. 18
LAMICTAL XR STARTER
(GREEN) .......................... 18
LAMICTAL XR STARTER
(ORANGE)....................... 18
LAMISIL ................................ 3
lamivudine .............................. 4
lamivudine-zidovudine ........... 4
lamotrigine ........................... 18
LANCETS ............................ 61
LANCING DEVICE ............ 61
LANOXIN ............................ 37
LANOXIN PEDIATRIC ...... 37
lansoprazole .......................... 74
LANTUS .............................. 65
LANTUS SOLOSTAR ........ 65
larin 1.5/30 (21) .................... 83
larin 1/20 (21) ....................... 83
larin 24 fe ............................. 83
larin fe 1.5/30 (28) ................ 83
larin fe 1/20 (28) ................... 83
larissia................................... 83
LARTRUVO ........................ 14
LASIX .................................. 35
LASTACAFT ....................... 87
latanoprost ............................ 88
LATUDA ............................. 30
laxaclear ............................... 71
laxative (bisacodyl) .............. 71
laxative feminine .................. 71
laxative peg 3350 ................. 71
layolis fe ............................... 84
LAZANDA ........................... 23
LDO PLUS ........................... 46
leena 28................................. 84
leflunomide ........................... 79
LEMTRADA ........................ 76
LENVIMA............................ 14
LESCOL ............................... 40
LESCOL XL......................... 40
lessina ................................... 84
LETAIRIS ............................ 92
letrozole ................................ 14
leucovorin calcium ............... 11
LEUKERAN ........................ 14
LEUKINE ............................. 76
leuprolide .............................. 14
LEVA SET ........................... 46
levalbuterol hcl ..................... 92
LEVALBUTEROL
TARTRATE ..................... 92
LEVAQUIN ......................... 10
LEVATOL............................ 35
LEVBID ............................... 69
LEVEMIR ............................ 65
LEVEMIR FLEXTOUCH ... 65
levetiracetam ........................ 18
LEVITRA ............................. 95
levobunolol ........................... 86
levocarnitine ......................... 50
levocarnitine (with sugar) ..... 50
levofloxacin .................... 10, 86
levofloxacin in d5w .............. 10
levoleucovorin ...................... 11
LEVOLEUCOVORIN ......... 11
levomefolate dha .................. 99
levonest (28) ......................... 84
levonorgestrel-ethinyl estrad 84
levonorg-eth estrad triphasic 84
levora-28 ............................... 84
levorphanol tartrate............... 23
LEVO-T................................ 68
levothyroxine ........................ 68
LEVOTHYROXINE ............ 68
levoxyl .................................. 68
LEVSIN ................................ 69
LEVSIN/SL .......................... 69
LEVULAN ........................... 43
LEXAPRO............................ 30
LEXIVA ................................. 4
LIALDA ............................... 71
LIBRAX (WITH
CLIDINIUM) ................... 69
lidocaine ............................... 46
lidocaine (pf) ........................ 46
lidocaine hcl .......................... 46
lidocaine hcl-hydrocortison ac
.................................... 46, 71
lidocaine viscous .................. 46
lidocaine-prilocaine .............. 46
LIDOCAINE-TETRACAINE
.......................................... 46
LIDODERM ......................... 46
LIDOPAC ............................. 46
lidopin ................................... 46
LIDOPIN .............................. 46
LIDO-PRILO CAINE PACK
.......................................... 46
LIDORX ............................... 46
LIDOTRAL .......................... 46
LIDTOPIC MAX .................. 46
lillow ..................................... 84
LINCOCIN ............................. 8
lincomycin .............................. 8
lindane .................................. 49
linezolid .................................. 8
LINZESS .............................. 71
liothyronine ........................... 68
LIPITOR ............................... 40
LIPOCHOL PLUS ................ 50
lipodox .................................. 14
LIPOFEN .............................. 40
LIPROZONEPAK ................ 46
lisinopril ................................ 35
lisinopril-hydrochlorothiazide
.......................................... 35
lite coat aspirin ..................... 26
lithium carbonate .................. 30
lithium citrate ........................ 30
LITHOBID ........................... 30
LITHOSTAT ........................ 50
LIVALO ............................... 40
LO LOESTRIN FE ............... 84
LOCOID ............................... 49
LOCOID LIPOCREAM ....... 49
LOCORT .............................. 53
LODINE ............................... 26
LODOSYN ........................... 19
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affiliated companies.
122
LOESTRIN 1.5/30 (21) ........ 84
LOESTRIN 1/20 (21) ........... 84
LOESTRIN FE 1.5/30 (28-
DAY) ................................ 84
LOESTRIN FE 1/20 (28-DAY)
.......................................... 84
lomedia 24 fe ........................ 84
LOMOTIL ............................ 69
LONSURF ............................ 14
LOPID .................................. 40
lopinavir-ritonavir .................. 4
lopreeza ................................ 81
LOPRESSOR ....................... 35
LOPRESSOR HCT .............. 35
LOPROX .............................. 47
LOPROX (AS OLAMINE) .. 47
LOPROX KIT ...................... 47
lorazepam ............................. 30
lorazepam intensol................ 30
lorcet (hydrocodone) ............ 23
lorcet hd ................................ 23
lorcet plus ............................. 23
LORTAB ELIXIR ................ 23
lortuss ex .............................. 90
loryna (28) ............................ 84
LORZONE ........................... 21
losartan ................................. 35
losartan-hydrochlorothiazide 35
LOSEASONIQUE ............... 84
LOTEMAX .......................... 89
LOTENSIN .......................... 35
LOTENSIN HCT ................. 35
LOTREL............................... 35
LOTRISONE ........................ 47
LOTRONEX ........................ 71
LOUTREX ........................... 43
lovastatin .............................. 40
LOVAZA ............................. 40
LOVENOX........................... 38
low-ogestrel (28) .................. 84
loxapine succinate ................ 30
lta pre-attached ..................... 46
LUCENTIS........................... 87
ludent fluoride .................... 100
lugols .............................. 47, 96
LUMIGAN ........................... 88
LUMIZYME ........................ 66
LUNESTA ............................ 30
LUPANETA PACK (1
MONTH) .......................... 82
LUPANETA PACK (3
MONTH) .......................... 82
LUPRON DEPOT ................ 14
LUPRON DEPOT (3
MONTH) .......................... 14
LUPRON DEPOT (4
MONTH) .......................... 14
LUPRON DEPOT (6
MONTH) .......................... 14
LUPRON DEPOT-PED ....... 14
lutera (28) ............................. 84
luxamend .............................. 43
LUXIQ.................................. 49
LUZU ................................... 47
LYNPARZA ......................... 14
LYRICA ............................... 18
LYSODREN ......................... 14
LYSTEDA ............................ 82
lyza ....................................... 81
M MACROBID ........................ 11
MACRODANTIN ................ 11
MACUGEN .......................... 87
MAGNEBIND 400............... 71
magnesium citrate................. 71
MAKENA ............................ 81
MALARONE ......................... 8
MALARONE PEDIATRIC ... 8
malathion .............................. 49
maprotiline............................ 30
MAR-COF BP ...................... 90
MAR-COF CG ..................... 90
MARINOL ........................... 71
marlissa ................................. 84
MARNATAL-F .................. 100
MARPLAN .......................... 30
MARQIBO ........................... 14
marten-tab ............................. 23
MATULANE........................ 14
matzim la .............................. 35
MAVYRET ............................ 4
MAXALT ............................. 19
MAXALT-MLT ................... 19
MAXFE (FOLATE-
DOCUSATE) ................. 100
MAXIDEX ........................... 89
MAXIPIME ............................ 6
MAXITROL ......................... 88
MAXZIDE ............................ 35
MAXZIDE-25MG ................ 35
m-clear wc ............................ 90
meclofenamate ...................... 26
MEDISENSE ........................ 61
MEDISENSE GLUCOSE
KETONE .......................... 61
MEDOLOR PAK ................. 46
MEDROL ............................. 53
MEDROL (PAK) .................. 53
medroxyprogesterone ........... 81
mefenamic acid ..................... 26
mefloquine .............................. 8
MEGACE ES ........................ 14
megestrol .............................. 14
MEKINIST ........................... 14
meloxicam ............................ 26
melphalan ............................. 14
melphalan hcl ........................ 14
memantine ............................ 20
MEMANTINE ...................... 20
MENACTRA (PF) ................ 78
M-END PE ........................... 90
MENEST .............................. 81
MENOMUNE - A/C/Y/W-135
.......................................... 78
MENOMUNE - A/C/Y/W-135
(PF) ................................... 78
MENOPUR ........................... 66
MENOSTAR ........................ 81
MENVEO A-C-Y-W-135-DIP
(PF) ................................... 78
meperidine ............................ 23
MEPHYTON ........................ 38
meprobamate ........................ 21
MEPRON ............................... 8
mercaptopurine ..................... 15
meropenem ............................. 8
MEROPENEM-0.9%
SODIUM CHLORIDE ....... 8
MERREM ............................... 8
mesalamine ........................... 71
MESALAMINE ................... 71
mesalamine with cleansing
wipe .................................. 71
mesna .................................... 11
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affiliated companies.
123
MESNEX ............................. 11
MESTINON ......................... 21
MESTINON TIMESPAN .... 21
metadate er ........................... 30
metaproterenol ...................... 92
metaxall ................................ 21
metaxalone ........................... 21
metformin ............................. 68
methadone ............................ 23
methadose ............................. 23
methamphetamine ................ 30
methazolamide ..................... 88
methenamine hippurate ........ 11
methenamine mandelate ....... 11
methen-sod phos-meth blue-
hyos .................................. 95
methergine ............................ 86
methimazole ......................... 54
METHITEST ........................ 66
methocarbamol ..................... 21
methotrexate sodium ............ 15
methotrexate sodium (pf) ..... 15
methoxsalen .......................... 43
methscopolamine .................. 69
methyclothiazide .................. 35
methyldopa ........................... 35
methyldopa-
hydrochlorothiazide .......... 35
methyldopate ........................ 35
METHYLIN ......................... 30
methylphenidate hcl ............. 30
methylprednisolone .............. 53
methyltestosterone ................ 66
metipranolol ......................... 86
metoclopramide hcl .............. 72
metolazone ........................... 35
METOPIRONE .................... 50
metoprolol succinate ............ 35
METOPROLOL SU-
HYDROCHLOROTHIAZ 35
metoprolol ta-hydrochlorothiaz
.......................................... 36
metoprolol tartrate ................ 36
metro i.v. ................................ 8
METROCREAM .................. 45
METROGEL ........................ 45
METROGEL VAGINAL ..... 82
METROLOTION ................. 45
metronidazole ............. 8, 45, 82
metronidazole in nacl (iso-os) 8
mexiletine ............................. 33
MIACALCIN ....................... 66
mibelas 24 fe ........................ 84
MICARDIS .......................... 36
MICARDIS HCT ................. 36
MICORT-HC........................ 72
MICRO BLOOD GLUCOSE
.......................................... 56
MICRODOT BLOOD
GLUCOSE SYSTEM . 56, 61
microgestin 1.5/30 (21) ........ 84
microgestin 1/20 (21) ........... 84
MICROGESTIN 24 FE ........ 84
microgestin fe 1.5/30 (28) .... 84
microgestin fe 1/20 (28) ....... 84
MICROZIDE ........................ 36
midodrine.............................. 50
MIFEPREX .......................... 82
migergot................................ 19
miglitol ................................. 68
MIGRANAL ........................ 19
milk of magnesia .................. 72
milk of magnesia concentrated
.......................................... 72
millipred ............................... 53
MILLIPRED ......................... 53
millipred dp .......................... 53
mimvey ................................. 81
mimvey lo ............................. 81
MINASTRIN 24 FE ............. 84
MINIPRESS ......................... 36
MINITRAN .......................... 41
MINIVELLE ........................ 81
MINOCIN ............................ 10
minocycline .......................... 10
minoxidil .............................. 36
MIOCHOL-E........................ 87
miralax .................................. 72
MIRAPEX ............................ 19
MIRAPEX ER ...................... 19
MIRCERA ............................ 76
MIRCETTE (28) .................. 84
mirtazapine ........................... 30
MIRVASO............................ 45
misoprostol ........................... 74
MITIGARE .......................... 79
mitomycin ............................. 15
MITOSOL ............................ 88
mitoxantrone ......................... 15
M-M-R II (PF) ...................... 78
MOBIC ................................. 26
modafinil ............................... 30
moderiba ............................... 76
moderiba dose pack .............. 76
moexipril ............................... 36
moexipril-hydrochlorothiazide
.......................................... 36
mometasone .................... 49, 92
mondoxyne nl ....................... 10
MONOCLATE-P ................. 38
MONODOX ......................... 10
mono-linyah .......................... 84
mononessa (28) ..................... 84
MONONINE ........................ 38
montelukast ........................... 92
MONUROL .......................... 11
morgidox ............................... 10
MORPHABOND ER ............ 23
morphine ......................... 23, 24
MORPHINE ................... 23, 24
morphine (pf) ........................ 23
morphine (pf) in 0.9 % nacl .. 23
MORPHINE (PF) IN 0.9 %
NACL ............................... 23
morphine concentrate ........... 23
MORPHINE IN 0.9 % NACL
.......................................... 23
MOTOFEN ........................... 69
MOVANTIK ........................ 72
MOVIPREP .......................... 72
MOXATAG ............................ 9
MOXEZA ............................. 86
moxifloxacin ................... 10, 86
MOXIFLOXACIN (PF)-BSS
NO.2 ................................. 86
MOZOBIL ............................ 76
MS CONTIN ........................ 24
MUGARD ............................ 52
MULTAQ ............................. 33
multigen folic ...................... 100
multigen plus ...................... 100
multi-vit with fluoride-iron . 100
multi-vitamin with fluoride 100
multivitamins with fluoride 100
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affiliated companies.
124
mupirocin ............................. 47
mupirocin calcium ................ 47
MUSE ................................... 95
MUSTARGEN ..................... 15
mvc-fluoride ....................... 100
my way ................................. 84
MYALEPT ........................... 66
MYAMBUTOL ...................... 8
MYCOBUTIN ........................ 8
mycophenolate mofetil ......... 15
mycophenolate mofetil hcl ... 15
mycophenolate sodium ......... 15
MYDAYIS ........................... 30
MYDRIACYL ...................... 87
MYFORTIC ......................... 15
MYGLUCOHEALTH .... 56, 62
MYGLUCOHEALTH
CONTROL SOLUTION .. 62
MYLERAN .......................... 15
mynatal ............................... 100
mynatal advance ................. 100
mynatal plus ....................... 100
mynatal-z ............................ 100
mynate 90 plus ................... 100
mynephrocaps..................... 100
mynephron .......................... 100
MYOBLOC .......................... 78
MYRBETRIQ ...................... 94
MYSOLINE ......................... 18
MYTESI ............................... 69
myzilra .................................. 84
N NABI-HB ............................. 78
nabumetone .......................... 26
nadolol .................................. 36
nadolol-bendroflumethiazide 36
nafcillin................................... 9
naftifine ................................ 47
NAFTIN ............................... 47
NAGLAZYME..................... 66
nalbuphine ............................ 26
NALFON .............................. 26
naloxone ............................... 26
naltrexone ............................. 26
NAMENDA ......................... 20
NAMENDA TITRATION
PAK .................................. 20
NAMENDA XR ................... 20
NAMZARIC ......................... 20
NAPRELAN CR .................. 26
NAPROSYN ........................ 26
naproxen ............................... 26
naproxen sodium .................. 26
naratriptan ............................. 19
NARCAN ............................. 26
NARDIL ............................... 30
NASCOBAL ...................... 100
NASONEX ........................... 92
NATACHEW (FE BIS-
GLYCINATE) ................ 100
NATACYN .......................... 86
NATAZIA ............................ 84
nateglinide ............................ 68
NATELLE ONE ................. 100
NATESTO ............................ 66
NATPARA ........................... 66
NATROBA ........................... 49
natural b-100 complex ........ 100
natura-lax .............................. 72
nature-throid ......................... 69
NAVELBINE ....................... 15
NEBUPENT ........................... 8
nebusal .................................. 92
NEBUSAL............................ 92
necon 0.5/35 (28) .................. 84
necon 1/50 (28) ..................... 84
necon 7/7/7 (28).................... 84
NEEVODHA (WITH ALGAL
OIL) ................................ 100
nefazodone............................ 30
neomycin ................................ 8
neomycin-bacitracin-poly-hc 88
neomycin-bacitracin-
polymyxin ......................... 86
neomycin-polymyxin b-
dexameth .......................... 88
neomycin-polymyxin-
gramicidin ......................... 86
neomycin-polymyxin-hc 53, 88
neo-polycin ........................... 86
neo-polycin hc ...................... 88
NEORAL .............................. 15
NEOSALUS ......................... 43
NEO-SYNALAR.................. 47
NEO-SYNALAR KIT .......... 47
nephplex rx ......................... 100
NEPHROCAPS .................. 100
NEPHROCAPS QT ............ 100
NEPHRON FA ................... 100
nephro-vite rx ..................... 100
NEPTAZANE ....................... 88
NERLYNX ........................... 15
NESINA ............................... 68
NESTABS .......................... 100
NESTABS ABC ................. 100
NESTABS DHA ................. 100
neuac ..................................... 45
NEUAC KIT ......................... 45
NEULASTA ......................... 76
NEUPOGEN ......................... 76
NEUPRO .............................. 19
NEURIN-SL ....................... 100
NEURONTIN ....................... 18
NEUTEK 2TEK TEST
STRIPS ............................. 56
NEVANAC ........................... 88
nevirapine ............................... 4
newgen ................................ 100
NEXA PLUS ...................... 100
NEXAVAR ........................... 15
NEXAVIR .......................... 100
NEXIUM .............................. 74
NEXIUM IV ......................... 74
NEXIUM PACKET .............. 74
NEXPLANON ...................... 82
next choice one dose ............. 84
niacin .................................... 40
NIACOR ............................... 40
NIASPAN EXTENDED-
RELEASE ......................... 40
nicardipine ............................ 36
NICODERM CQ .................. 51
nicorelief ............................... 51
nicorette ................................ 51
NICORETTE ........................ 51
nicotine ................................. 51
nicotine (polacrilex) .............. 51
NICOTROL .......................... 52
NICOTROL NS .................... 52
nifedipine .............................. 36
nikki (28) .............................. 84
NILANDRON ...................... 15
nilutamide ............................. 15
nimodipine ............................ 36
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affiliated companies.
125
NINJACOF-XG ................... 90
NINLARO ............................ 15
NIPENT ................................ 15
nisoldipine ............................ 36
nitro-bid ................................ 41
NITRO-DUR ........................ 41
nitrofurantoin ........................ 11
nitrofurantoin macrocrystal .. 11
nitrofurantoin monohyd/m-
cryst .................................. 11
nitroglycerin ......................... 41
NITROLINGUAL ................ 41
NITROMIST ........................ 41
NITROSTAT ........................ 41
nitro-time .............................. 41
NITYR .................................. 50
NIVA-PLUS ....................... 100
nivatopic plus ....................... 43
nizatidine .............................. 74
NIZORAL ............................ 47
nodolor ................................. 19
nolix ...................................... 49
nora-be .................................. 81
NORCO ................................ 24
NORDITROPIN FLEXPRO 76
noreth-ethinyl estradiol-iron . 84
norethindrone (contraceptive)
.......................................... 81
norethindrone acetate ........... 81
norethindrone ac-eth estradiol
.................................... 81, 84
norethindrone-e.estradiol-iron
.......................................... 84
norgestimate-ethinyl estradiol
.......................................... 84
NORITATE .......................... 45
norlyda .................................. 81
norlyroc ................................ 81
NORPACE ........................... 33
NORPACE CR ..................... 33
NORPRAMIN ...................... 30
NORTHERA ........................ 50
nortrel 0.5/35 (28) ................ 84
nortrel 1/35 (21) ................... 84
nortrel 1/35 (28) ................... 84
nortrel 7/7/7 (28) .................. 85
nortriptyline .......................... 30
NORVASC ........................... 36
NORVIR ................................. 4
NOVA MAX BLOOD
GLUCOSE METER ......... 62
NOVA MAX GLUCOSE
CONTROL ....................... 62
NOVA MAX GLUCOSE
TEST ................................ 56
NOVAMAX PLUS GLU-KET
.......................................... 62
NOVAREL ........................... 66
NOVOEIGHT ...................... 39
NOVOLOG .......................... 65
NOVOLOG FLEXPEN ........ 65
NOVOLOG MIX 70-30 ....... 65
NOVOLOG MIX 70-30
FLEXPEN ........................ 65
NOVOLOG PENFILL ......... 65
NOVOPEN ECHO ............... 62
NOVOSEVEN RT ............... 39
NOXAFIL .............................. 3
np thyroid ............................. 69
NPLATE ............................... 39
nts step 1 ............................... 52
NUCALA ............................. 92
NUCYNTA .......................... 26
NUCYNTA ER .................... 26
NUEDEXTA ........................ 20
NULEV ................................ 69
NULOJIX ............................. 15
NULYTELY WITH FLAVOR
PACKS ............................. 72
NUMBONEX ....................... 46
NUOX .................................. 45
NUPLAZID .......................... 30
NUTRESTORE .................... 50
NUTRICAP ........................ 100
NUTROPIN AQ NUSPIN.... 76
NUVARING ......................... 82
NUVESSA............................ 82
NUVIGIL ............................. 30
NUWIQ ................................ 39
nyamyc ................................. 47
nyata ..................................... 47
NYMALIZE ......................... 36
nystatin ............................. 3, 47
nystatin-triamcinolone .......... 47
nystop ................................... 47
O OB COMPLETE ................ 101
OB COMPLETE GOLD .... 101
OB COMPLETE ONE ....... 101
OB COMPLETE PETITE .. 101
OB COMPLETE PREMIER
........................................ 101
OB COMPLETE WITH DHA
........................................ 101
OBIZUR ............................... 39
OBREDON ........................... 90
obstetrix dha ....................... 101
OBSTETRIX EC ................ 101
OBSTETRIX ONE ............. 101
OBTREX DHA .................. 101
O-CAL FA .......................... 101
O-CAL PRENATAL .......... 101
OCALIVA ............................ 72
ocella ..................................... 85
OCREVUS ........................... 76
OCTAGAM .......................... 78
octreotide acetate .................. 15
OCUFEN .............................. 88
OCUFLOX ........................... 86
ODEFSEY .............................. 4
ODOMZO ............................. 15
OFEV .................................... 92
ofloxacin ................... 10, 53, 86
ogestrel (28) .......................... 85
olanzapine ............................. 30
olanzapine-fluoxetine ........... 30
olmesartan ............................. 36
olmesartan-amlodipin-
hcthiazid ........................... 36
olmesartan-
hydrochlorothiazide .......... 36
olopatadine ..................... 52, 87
OLUX ................................... 49
OLUX-E ............................... 49
OLYSIO ................................. 4
OMECLAMOX-PAK ........... 74
omega-3 acid ethyl esters ..... 40
omeppi .................................. 74
omeprazole ........................... 74
omeprazole-sodium
bicarbonate ................. 74, 75
OMIDRIA ............................. 87
OMNARIS ............................ 92
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affiliated companies.
126
OMNIPRED ......................... 89
OMNITROPE....................... 76
ON CALL EXPRESS
CONTROL ....................... 62
ON CALL EXPRESS METER
.......................................... 62
ON CALL EXPRESS TEST
STRIP ............................... 56
ON CALL PLUS CONTROL
.......................................... 62
ON CALL PLUS METER ... 62
ON CALL PLUS TEST STRIP
.......................................... 56
ON CALL VIVID CONTROL
.......................................... 62
ON CALL VIVID METER .. 62
ON CALL VIVID PAL
METER ............................ 62
ON CALL VIVID TEST
STRIP ............................... 56
ONCASPAR ........................ 15
ondansetron .......................... 72
ondansetron hcl .................... 72
ondansetron hcl (pf) ............. 72
one daily prenatal ............... 101
ONETOUCH ULTRA
CONTROL ....................... 62
ONETOUCH ULTRA TEST
.......................................... 56
ONETOUCH ULTRA2........ 62
ONETOUCH ULTRAMINI 62
ONETOUCH VERIO ........... 56
ONETOUCH VERIO FLEX 62
ONETOUCH VERIO IQ
METER ............................ 62
ONETOUCH VERIO SYNC
.......................................... 62
ONETOUCH VERIO
SYSTEM .......................... 62
ONEXTON........................... 45
ONFI..................................... 18
ONGLYZA........................... 68
ONIVYDE ............................ 15
ONMEL .................................. 3
ONZETRA XSAIL .............. 19
OPANA ................................ 24
opcicon one-step ................... 85
OPDIVO ............................... 15
opium tincture....................... 69
OPSUMIT ............................ 92
option-2 ................................ 85
OPTIUM EZ ......................... 56
OPTIUM TEST .................... 56
OPTUMRX .................... 56, 62
ORACEA.............................. 10
ORACIT ............................... 95
oral saline laxative ................ 72
ORALAIR ............................ 78
oralone .................................. 52
ORAMAGICRX ................... 52
ORAP ................................... 30
ORAPRED ODT .................. 53
ORAVIG ................................ 3
ORENCIA ............................ 80
ORENCIA (WITH
MALTOSE) ...................... 79
ORENCIA CLICKJECT ...... 80
ORENITRAM ...................... 36
ORFADIN ............................ 51
ORKAMBI ..................... 92, 93
orphenadrine citrate .............. 21
orsythia ................................. 85
ortho d................................. 101
ORTHO MICRONOR .......... 81
ORTHO TRI-CYCLEN (28) 85
ORTHO TRI-CYCLEN LO
(28) ................................... 85
ORTHO-CYCLEN (28) ....... 85
ORTHO-NOVUM 1/35 (28) 85
ORTHO-NOVUM 7/7/7 (28)
.......................................... 85
oscimin ................................. 69
oscimin sl .............................. 69
oscimin sr ............................. 69
oseltamivir .............................. 4
OSENI .................................. 68
OSMOPREP ......................... 72
OSPHENA............................ 82
OTEZLA .............................. 80
OTEZLA STARTER ............ 80
OTIPRIO .............................. 53
OTOVEL .............................. 53
OTREXUP (PF) ................... 80
OVACE ................................ 41
OVACE PLUS ..................... 41
OVACE PLUS SHAMPOO . 41
OVACE PLUS WASH ......... 41
OVCON-35 (28) ................... 85
OVIDE .................................. 49
OVIDREL ............................. 66
oxacillin .................................. 9
oxacillin in dextrose(iso-osm) 9
oxaliplatin ............................. 15
OXANDRIN ......................... 66
oxandrolone .......................... 66
oxaprozin .............................. 26
OXAYDO ............................. 24
oxazepam .............................. 30
oxcarbazepine ....................... 18
oxiconazole ........................... 47
OXISTAT ............................. 47
OXSORALEN ULTRA ........ 43
OXTELLAR XR .................. 18
oxybutynin chloride .............. 94
oxycodone ............................. 24
OXYCODONE ..................... 24
oxycodone-acetaminophen ... 24
oxycodone-aspirin ................ 24
OXYCONTIN ...................... 24
oxymorphone ........................ 24
OXYTROL ........................... 94
oysco 500/d ........................... 96
oyster shell + d3.................... 96
oyster shell calcium-vit d2 .. 101
oyster shell calcium-vit d3 .... 96
oystercal-d ............................ 96
OZURDEX ........................... 89
P pacerone ................................ 33
paclitaxel ............................... 15
paliperidone .......................... 30
PAMELOR ........................... 30
pamidronate .......................... 66
PANCREAZE ....................... 72
PANDEL .............................. 49
PANRETIN .......................... 43
pantoprazole ......................... 75
PAPAVERINE-
ALPROSTADIL-WATER
.......................................... 95
PAPAV-PHENTOLAM-
ALPROST-WATER ......... 95
PAPAV-PHENTOLAMINE
IN WATER ....................... 95
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affiliated companies.
127
PARAFON FORTE DSC ..... 21
paregoric ............................... 69
PAREMYD .......................... 87
paricalcitol ............................ 66
PARICALCITOL ................. 66
PARLODEL ......................... 19
PARNATE ........................... 30
paroex oral rinse ................... 52
paromomycin .......................... 8
paroxetine hcl ....................... 30
PASER ................................... 8
PATADAY ........................... 87
PATANASE ......................... 52
PATANOL ........................... 87
PAXIL .................................. 31
PAXIL CR ............................ 31
PAZEO ................................. 87
P-CARE K40 ........................ 53
P-CARE K80 ........................ 53
P-CARE X (PF) .................... 46
PCE......................................... 7
PEDIAPRED ........................ 53
PEDIARIX (PF) ................... 78
peg 3350-electrolytes ........... 72
peg3350 ................................ 72
PEGANONE ........................ 18
PEGASYS ............................ 76
PEGASYS PROCLICK ....... 76
peg-electrolyte soln .............. 72
PEGINTRON ....................... 76
PEGINTRON REDIPEN ..... 76
PEN NEEDLE ...................... 62
penicillin g potassium............. 9
penicillin v potassium............. 9
PENLAC .............................. 47
PENNSAID .......................... 26
PENTACEL ACTHIB
COMPONENT (PF) ......... 78
PENTASA ............................ 72
pentazocine-naloxone ........... 26
pentoxifylline ....................... 39
PEPCID ................................ 75
PERCOCET ......................... 24
PERFOROMIST .................. 93
PERIDEX ............................. 52
perindopril erbumine ............ 36
periogard............................... 52
PERJETA ............................. 15
permethrin ............................ 49
perphenazine ......................... 31
perphenazine-amitriptyline ... 31
perry prenatal ...................... 101
PERTZYE ............................ 72
PEXEVA .............................. 31
pfizerpen-g.............................. 9
PHARMACIST CHOICE .... 56
PHARMACIST CHOICE
GLUCOSE SYS ............... 62
phenadoz ............................... 90
phenazopyridine ................... 95
phenelzine ............................. 31
phenergan ............................. 90
phenobarb-hyoscy-atropine-
scop ................................... 69
phenobarbital ........................ 18
phenohytro ............................ 69
phenoxybenzamine ............... 36
PHENTOLAM-
ALPROSTADIL IN
WATER ............................ 95
phentolamine ........................ 36
phenylephrine hcl ................. 89
PHENYTEK ......................... 18
phenytoin .............................. 18
phenytoin sodium extended .. 18
philith.................................... 85
PHOSLYRA ......................... 72
phospha 250 neutral.............. 96
phosphasal ............................ 95
phosphate laxative ................ 72
PHOSPHOLINE IODIDE .... 87
PHYSICIANS EZ USE B-12
........................................ 101
PHYSIOLYTE ..................... 50
PHYSIOSOL IRRIGATION 50
PICATO................................ 43
pilocarpine hcl .......... 51, 52, 87
pimozide ............................... 31
pimtrea (28) .......................... 85
pindolol ................................. 36
pioglitazone .......................... 68
pioglitazone-glimepiride ...... 68
pioglitazone-metformin ........ 68
piperacillin-tazobactam ........ 10
PIPERACILLIN-
TAZOBACTAM ................ 9
pirmella ................................. 85
piroxicam .............................. 26
PLAN B ONE-STEP ............ 85
PLAQUENIL .......................... 8
PLAVIX ............................... 39
PLEGRIDY .......................... 76
PLEXION ............................. 45
PLEXION CLEANSING
CLOTHS ........................... 45
PLIAGLIS ............................ 46
PNEUMOVAX 23 ................ 78
pnv 29-1 .............................. 101
pnv ob+dha ......................... 101
pnv-dha ............................... 101
pnv-dha + docusate ............. 101
pnv-ferrous fumarate-docu-fa
........................................ 101
pnv-omega .......................... 101
pnv-select ............................ 101
pnv-vp-u ............................. 101
POD-CARE 100K ................ 53
PODOCON ........................... 42
podofilox ............................... 43
polycin .................................. 86
polymyxin b sulfate ................ 8
polymyxin b sulf-trimethoprim
.......................................... 86
POLYTRIM .......................... 86
POLY-TUSSIN AC .............. 90
POLY-VI-FLOR ................. 101
POLY-VI-FLOR WITH IRON
........................................ 101
POMALYST ......................... 76
PONSTEL ............................. 26
portia ..................................... 85
PORTRAZZA ....................... 15
pot,sodium citrate-citric acid 95
POTABA .............................. 97
potassium acetate .................. 97
potassium bicarb and chloride
.......................................... 97
potassium bicarb-citric acid .. 97
potassium chloride ................ 97
potassium chloride in 0.9%nacl
.......................................... 97
potassium citrate ................... 95
potassium citrate-citric acid .. 95
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affiliated companies.
128
POTASSIUM CL-LIDO-0.9 %
NACL ............................... 97
POTASSIUM HYDROXIDE
.......................................... 42
POTASSIUM PHOS IN 0.9 %
NACL ............................... 97
powderlax ............................. 72
pr natal 400 ......................... 101
pr natal 400 ec .................... 101
pr natal 430 ......................... 101
pr natal 430 ec .................... 101
PRADAXA........................... 39
PRALUENT PEN ................ 40
pramcort ............................... 72
pramipexole .......................... 19
PRAMOSONE ..................... 41
PRAMOSONE E .................. 41
PRANDIN ............................ 68
prasugrel ............................... 39
PRAVACHOL ..................... 40
pravastatin ............................ 40
PRAXBIND ......................... 39
prazosin ................................ 36
PRECISION PCX PLUS TEST
.......................................... 56
PRECISION PCX TEST ...... 56
PRECISION POINT OF
CARE TEST ..................... 56
PRECISION Q-I-D TEST .... 56
PRECISION XTRA
MONITOR ....................... 62
PRECISION XTRA TEST ... 56
PRECOSE ............................ 68
PRED FORTE ...................... 89
PRED MILD ........................ 89
PRED-G ............................... 88
PRED-G S.O.P. .................... 88
prednicarbate ........................ 49
prednisolone ......................... 53
prednisolone acetate ............. 89
prednisolone sodium phosphate
.................................... 53, 89
prednisone ............................ 53
prednisone intensol ............... 53
PREFERA-OB ................... 101
PREFERA-OB ONE .......... 101
PREFERA-OB PLUS DHA
........................................ 101
PREFEST ............................. 81
PREGNYL............................ 66
PREMARIN ......................... 81
PREMIUM BLOOD
GLUCOSE MONITOR .... 62
PREMIUM V10 ............. 56, 62
PREMPHASE ...................... 81
PREMPRO ........................... 81
prena1 chew ........................ 101
prena1 pearl ........................ 101
prena1 true .......................... 101
prenaissance........................ 101
prenaissance plus ................ 101
PRENATA.......................... 101
prenatabs fa......................... 101
prenatabs rx ........................ 101
prenatal ............................... 101
prenatal complete ............... 101
prenatal formula ................. 101
prenatal multi-dha (algal oil)
........................................ 101
prenatal one daily ............... 101
prenatal plus ....................... 101
prenatal plus (calcium carb)101
PRENATAL PLUS DHA ... 101
prenatal vitamin .................. 101
prenatal vitamin plus low iron
........................................ 101
prenatal vitamin with minerals
........................................ 102
prenatal vits96-iron fum-folic
........................................ 102
prenatal-u ............................ 102
PRENATE AM................... 102
PRENATE CHEWABLE ... 102
PRENATE DHA (FERR ASP
GLYCIN)........................ 102
PRENATE ELITE (IRON ASP
GLYC) ............................ 102
PRENATE ENHANCE ...... 102
PRENATE
ESSENTIAL(IRON-ASP-
GL) ................................. 102
PRENATE MINI (FERR ASP
GLYCIN)........................ 102
PRENATE PIXIE ............... 102
PRENATE RESTORE ....... 102
PRENATE STAR ............... 102
PREPIDIL ............................. 82
preplus ................................ 102
PREPOPIK ........................... 72
PRESERA ............................. 43
PRESTALIA ......................... 36
PRESTO PRO BLOOD
GLUCOSE METER ......... 62
pretab .................................. 102
PREVACID .......................... 75
PREVACID SOLUTAB ....... 75
prevalite ................................ 40
PREVIDENT ........................ 52
PREVIDENT 5000 BOOSTER
PLUS ................................ 52
PREVIDENT 5000 DRY
MOUTH ........................... 52
PREVIDENT 5000 ENAMEL
PROTECT ........................ 52
PREVIDENT 5000 PLUS .... 52
PREVIDENT 5000
SENSITIVE ...................... 52
previfem ................................ 85
PREVPAC ............................ 75
PREZCOBIX .......................... 4
PREZISTA ............................. 4
PRIFTIN ................................. 8
PRILOLID ............................ 46
PRILOSEC ........................... 75
PRIMACARE ..................... 102
PRIMAQUINE ....................... 8
PRIMAXIN IV ....................... 8
primidone .............................. 18
PRIMLEV ............................. 24
PRIMSOL ............................. 11
PRINIVIL ............................. 36
PRISTIQ ............................... 31
PRIVIGEN ........................... 78
PROAIR HFA ...................... 93
PROAIR RESPICLICK ........ 93
probenecid ............................ 79
probenecid-colchicine ........... 79
PROBUPHINE ..................... 24
procainamide ........................ 33
PROCARDIA ....................... 36
PROCARDIA XL ................. 36
PRO-C-DURE 5 ................... 53
PRO-C-DURE 6 ................... 54
procentra ............................... 31
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affiliated companies.
129
prochlorperazine ................... 72
prochlorperazine edisylate.... 72
prochlorperazine maleate ..... 72
PROCORT ........................... 72
PROCRIT ............................. 76
PROCTOCORT ................... 72
PROCTOFOAM HC ............ 72
procto-med hc ....................... 72
proctosol hc .......................... 72
proctozone-hc ....................... 72
PROCYSBI .......................... 95
PRODIGY AUTOCODE
METER ............................ 62
PRODIGY AUTOCODE
MONITOR SYST ............ 62
PRODIGY CONTROL
SOLUTION, LOW ........... 62
PRODIGY CONTROL
SOLUTION,HIGH ........... 62
PRODIGY NO CODING ..... 56
PRODIGY POCKET METER
.......................................... 62
PRODIGY VOICE GLUCOSE
METER ............................ 62
PRODRIN ............................ 19
PROFERRIN-FORTE ........ 102
PROFILNINE....................... 39
progesterone ......................... 81
progesterone micronized ...... 81
PROGLYCEM ..................... 57
PROGRAF ........................... 15
PROLASTIN-C .................... 51
PROLENSA ......................... 88
PROLEUKIN ....................... 77
PROLIA ............................... 79
PROMACTA ........................ 39
promethazine ........................ 90
promethazine vc-codeine...... 90
promethazine-codeine .......... 90
promethazine-dm .................. 90
promethazine-phenyleph-
codeine ............................. 90
promethazine-phenylephrine 90
promethegan ......................... 90
PROMETRIUM ................... 81
PROMISEB .......................... 43
propafenone .......................... 33
propantheline ........................ 69
proparacaine ......................... 87
propranolol ........................... 36
propranolol-hydrochlorothiazid
.......................................... 36
propylthiouracil .................... 54
PROQUAD (PF)................... 78
PRO-RED AC (W/
DEXCHLORPHENIR) .... 90
PROSCAR ............................ 94
PROSTIN E2 ........................ 82
PROTECT IRON ............... 102
PROTONIX .......................... 75
PROTOPIC ........................... 43
protriptyline .......................... 31
PROVENGE ......................... 78
PROVENTIL HFA ............... 93
PROVERA ........................... 81
PROVIDA DHA................. 102
PROVIDA OB .................... 102
PROVIGIL ........................... 31
PROZAC .............................. 31
pruclair.................................. 43
prudoxin................................ 43
prumyx.................................. 43
prutect ................................... 43
PSORCON............................ 49
PULMICORT ....................... 93
PULMICORT FLEXHALER
.......................................... 93
pulmosal ............................... 93
PULMOZYME ..................... 93
PURALOR CI .................... 102
PUREFE OB PLUS ............ 102
PUREFE PLUS .................. 102
purelax .................................. 72
purevit dualfe plus .............. 102
PURIXAN ............................ 15
PYLERA .............................. 75
pyrazinamide .......................... 8
PYRIDIUM .......................... 96
pyridostigmine bromide ....... 21
Q QBRELIS ............................. 36
Q-CARE RX Q4 ................... 52
QNASL ................................. 93
QUADRACEL (PF) ............. 78
QUALAQUIN ........................ 8
QUARTETTE ...................... 85
quasense ................................ 85
quazepam .............................. 31
QUDEXY XR ....................... 18
QUESTRAN ......................... 40
QUESTRAN LIGHT ............ 40
quetiapine ............................. 31
QUFLORA FE .................... 102
QUFLORA FE (FERROUS
SULFATE) ..................... 102
QUFLORA PEDIATRIC ... 102
QUFLORA PEDIATRIC
DROPS ........................... 102
QUILLICHEW ER ............... 31
QUILLIVANT XR ............... 31
quinapril ................................ 36
quinapril-hydrochlorothiazide
.......................................... 36
quinidine gluconate .............. 33
quinidine sulfate ................... 33
quinine sulfate ........................ 8
QUINTET AC ...................... 56
QUINTET BLOOD
GLUCOSE METER ......... 63
quit 2 ..................................... 52
QUIT 2 .................................. 52
quit 4 ..................................... 52
QUIT 4 .................................. 52
QUTENZA ........................... 43
QVAR ................................... 93
R rabeprazole ........................... 75
RADICAVA ......................... 20
RADIOGARDASE ............... 51
RAGWITEK ......................... 78
rajani ..................................... 85
raloxifene .............................. 79
ramipril ................................. 36
RANEXA ............................. 40
ranitidine hcl ......................... 75
RAPAFLO ............................ 94
RAPAMUNE ........................ 15
rasagiline ............................... 19
RASUVO (PF) ...................... 80
RAVICTI .............................. 51
RAYALDEE ......................... 66
RAYOS ................................. 54
RAZADYNE ........................ 20
RAZADYNE ER .................. 20
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affiliated companies.
130
rea lo 39 ................................ 43
rea lo 40 ................................ 43
READYSHARP
DEXAMETHASONE ...... 54
READYSHARP
KETOROLAC .................. 26
READYSHARP LIDOCAINE
(PF) ................................... 46
READYSHARP
TRIAMCINOLONE......... 54
REBETOL ............................ 76
REBIF (WITH ALBUMIN) . 76
REBIF REBIDOSE .............. 76
REBIF TITRATION PACK 76
RECLAST ............................ 51
reclipsen (28) ........................ 85
RECOMBINATE ................. 39
RECOMBIVAX HB (PF) .... 78
RECTIV ............................... 72
REFUAH PLUS ................... 56
REFUAH PLUS GLUCOSE
CONTROL ....................... 63
REFUAH PLUS GLUCOSE
MONITOR ....................... 63
REGLAN .............................. 72
REGRANEX ........................ 43
relador pak ............................ 46
relador pak plus .................... 46
RELAGARD ........................ 82
relcof c .................................. 90
RELENZA DISKHALER ...... 4
RELION ALL-IN-ONE
METER ............................ 63
RELION CONFIRM ............ 63
RELION CONFIRM-MICRO
.......................................... 56
RELION MICRO GLUCOSE
MONITOR ....................... 63
RELION NOVOLIN 70/30 .. 65
RELION NOVOLIN N ........ 65
RELION NOVOLIN R ........ 65
RELION PRIME METER ... 63
RELION PRIME TEST
STRIPS ............................. 56
RELISTOR ........................... 72
relnate dha .......................... 102
RELPAX .............................. 19
REMERON .......................... 31
REMERON SOLTAB .......... 31
REMICADE ......................... 72
REMODULIN ...................... 36
RENAGEL ........................... 72
renal caps ............................ 102
rena-vite .............................. 102
rena-vite rx ......................... 102
RENFLEXIS ........................ 72
reno caps ............................. 102
RENVELA ........................... 72
repaglinide ............................ 68
repaglinide-metformin .......... 68
REPATHA PUSHTRONEX 40
REPATHA SURECLICK .... 40
REPATHA SYRINGE ......... 40
REQUIP................................ 19
REQUIP XL ......................... 19
RESCRIPTOR ........................ 4
RESPA-AR ........................... 91
RESTASIS............................ 87
RESTASIS MULTIDOSE ... 87
RESTIZAN ........................... 43
RESTORIL ........................... 31
RETIN-A .............................. 45
RETIN-A MICRO ................ 45
RETIN-A MICRO PUMP .... 45
RETISERT ........................... 89
RETROVIR ............................ 4
REVATIO ............................ 93
REVEAL BLOOD GLUCOSE
METER ............................ 63
REVEAL TEST STRIP ........ 56
REVIA .................................. 26
REVLIMID .......................... 76
REXULTI ............................. 31
REYATAZ ............................. 4
REZIRA................................ 91
RHOFADE ........................... 45
RIASTAP ............................. 39
ribasphere ............................. 76
ribasphere ribapak ................ 76
ribavirin ............................ 4, 76
RIDAURA ............................ 80
rifabutin .................................. 8
RIFADIN ................................ 8
RIFAMATE............................ 8
rifampin .................................. 8
RIFATER ............................... 9
RIGHTEST CONTROL
SOLUTION HIGH ........... 63
RIGHTEST GM550 SYSTEM
.......................................... 63
RIGHTEST GS550 TEST
STRIPS ............................. 56
RILUTEK ............................. 51
riluzole .................................. 51
rimantadine ............................. 4
ringer's .................................. 50
RIOMET ............................... 68
risacal-d .............................. 102
risedronate ...................... 51, 79
RISPERDAL ........................ 31
RISPERDAL M-TAB .......... 31
risperidone ............................ 31
RITALIN .............................. 31
RITALIN LA ........................ 31
RITUXAN ............................ 15
RITUXAN HYCELA ........... 15
rivastigmine .......................... 20
rivastigmine tartrate .............. 20
rivelsa ................................... 85
RIXUBIS .............................. 39
rizatriptan .............................. 19
R-NATAL OB .................... 102
ROBAXIN ............................ 21
ROBAXIN-750 ..................... 21
ROBINUL ............................ 69
ROBINUL FORTE ............... 69
ROCALTROL ...................... 66
ropinirole .............................. 19
rosadan .................................. 45
ROSADAN ........................... 45
ROSANIL ............................. 45
ROSULA .............................. 45
rosula cleansing cloths .......... 45
rosuvastatin ........................... 40
ROWASA ............................. 72
roweepra ............................... 18
ROXICODONE .................... 24
ROZEREM ........................... 31
RUBRACA ........................... 15
RUCONEST ......................... 93
RYDAPT .............................. 15
rydex ..................................... 91
RYTARY .............................. 19
RYTHMOL SR .................... 33
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affiliated companies.
131
RYVENT .............................. 90
S SABRIL ................................ 18
SAFYRAL ............................ 85
SAIZEN ................................ 76
SAIZEN CLICK.EASY ....... 76
SAIZEN SAIZENPREP ....... 76
SALAGEN (PILOCARPINE)
.................................... 51, 52
SALEX ................................. 42
salicylic acid ......................... 42
SALKERA ........................... 42
salsalate ................................ 26
salvax .................................... 42
SALVAX DUO PLUS ......... 42
SAMSCA ............................. 66
SANCUSO ........................... 72
SANDIMMUNE .................. 15
SANDOSTATIN .................. 15
SANDOSTATIN LAR
DEPOT ............................. 15
SANTYL .............................. 49
SAPHRIS (BLACK
CHERRY) ........................ 31
SARAFEM ........................... 31
SAVAYSA ........................... 39
SAVELLA ............................ 80
scalacort ................................ 49
scopolamine base.................. 72
SEASONIQUE ..................... 85
seb-prev ................................ 41
seconal sodium ..................... 31
SEEBRI NEOHALER.......... 93
SELECT-OB ...................... 102
SELECT-OB (FOLIC ACID)
........................................ 102
SELECT-OB + DHA ......... 102
selegiline hcl ......................... 19
selenium sulfide.................... 41
SELRX ................................. 41
SELZENTRY ......................... 5
SEMPREX-D ....................... 91
se-natal 19 .......................... 102
se-natal 19 (with docusate) . 102
SENSIPAR ........................... 66
SEREVENT DISKUS .......... 93
SERNIVO............................. 49
SEROQUEL ......................... 31
SEROQUEL XR................... 31
SEROSTIM .......................... 76
sertraline ............................... 31
se-tan plus ........................... 102
setlakin.................................. 85
sevelamer carbonate ............. 72
sf 52
sf 5000 plus .......................... 52
SFROWASA ........................ 72
sharobel ................................ 81
SHOHL'S MODIFIED ......... 95
SIDEKICK BLOOD
GLUCOSE SYSTEM ....... 63
SIGNIFOR............................ 15
SIGNIFOR LAR................... 15
sildenafil ............................... 93
SILENOR ............................. 31
SILIQ .................................... 41
SILVADENE........................ 42
silver nitrate .......................... 43
silver nitrate applicators ....... 43
silver sulfadiazine ................. 42
SILVRSTAT ........................ 47
SIMBRINZA ........................ 88
SIMPONI.............................. 80
SIMPONI ARIA ................... 80
SIMULECT .......................... 15
simvastatin ............................ 40
SINEMET ............................. 19
SINEMET CR ...................... 19
SINGULAIR ........................ 93
sirolimus ............................... 15
SIRTURO ............................... 9
SITAVIG ................................ 5
SIVEXTRO ............................ 9
SKELAXIN .......................... 21
SKLICE ................................ 49
SMART SENSE
MONITORING SYSTEM 63
SMART SENSE TEST
STRIPS ............................. 57
SMARTEST CONTROL ..... 63
SMARTEST EJECT............. 63
SMARTEST PERSONA
STARTER ........................ 63
SMARTEST PRONTO
STARTER ........................ 63
SMARTEST PROTEGE ...... 63
SMARTEST TEST ............... 57
smoothlax ............................. 72
SNAP INSULIN PUMP
CONTROLLER ................ 63
sodium benzoate-sod
phenylacet ......................... 51
sodium chlor 0.9% bacteriostat
.......................................... 51
sodium chloride .............. 93, 97
sodium chloride 0.45 % ........ 97
sodium chloride 0.9 % .......... 51
sodium chloride 3 % ............. 97
sodium chloride 5 % ............. 97
sodium citrate-citric acid ...... 95
SODIUM EDECRIN ............ 36
sodium ferric gluconat-sucrose
.......................................... 51
sodium phenylbutyrate ......... 51
SODIUM PHOSPHATE IN
0.9 % NACL ..................... 97
sodium polystyrene sulfonate
.......................................... 73
SODIUM POLYSTYRENE
SULFONATE ................... 73
SOLARAZE ......................... 43
SOLESTA ............................. 73
SOLIQUA 100/33 ................ 65
SOLIRIS ............................... 51
SOLODYN ........................... 10
SOLTAMOX ........................ 15
SOLUS V2 AUDIBLE
METER ............................. 63
SOLUS V2 CONTROL
SOLUTION,HIGH ........... 63
SOLUS V2 TEST STRIPS ... 57
SOMA ................................... 21
SOMATULINE DEPOT ...... 15
SOMAVERT ........................ 66
sonafine ................................. 43
SONATA .............................. 32
SOOLANTRA ...................... 45
SORBITOL-MANNITOL .... 50
SORIATANE ....................... 41
SORILUX ............................. 41
sotalol ................................... 33
sotalol af ............................... 33
SOTYLIZE ........................... 33
SOVALDI ............................... 5
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affiliated companies.
132
sp antipruritic........................ 43
sp scar management ............. 43
SPECTRACEF ....................... 6
spinosad ................................ 50
SPIRIVA RESPIMAT ......... 93
SPIRIVA WITH
HANDIHALER ................ 93
spironolactone ...................... 36
spironolacton-hydrochlorothiaz
.......................................... 36
SPORANOX .......................... 3
SPORANOX PULSEPAK ..... 3
sprintec (28).......................... 85
SPRIX................................... 26
SPRYCEL ............................ 15
sps (with sorbitol) ................. 73
sronyx ................................... 85
ssd ......................................... 42
SSKI ..................................... 54
sss 10-5 ................................. 45
STALEVO 100 ..................... 19
STALEVO 125 ..................... 19
STALEVO 150 ..................... 19
STALEVO 200 ..................... 19
STALEVO 50 ....................... 19
STALEVO 75 ....................... 19
STARLIX ............................. 68
stavudine................................. 5
STAXYN .............................. 95
STELARA ............................ 41
STENDRA ........................... 95
STIMATE............................. 66
STIOLTO RESPIMAT ........ 93
STIVARGA .......................... 15
stop smoking aid................... 52
STRATTERA ....................... 32
STRENSIQ ........................... 66
STREPTOMYCIN ................. 9
stress formula ..................... 102
stress formula with iron ...... 102
stress formula with iron(sulf)
........................................ 102
STRIANT ............................. 66
STRIBILD .............................. 5
STRIVERDI RESPIMAT .... 93
STROMECTOL ..................... 9
strong iodine ......................... 97
STROVITE FORTE ........... 102
STROVITE ONE ............... 102
SUBOXONE ........................ 26
SUBSYS ............................... 24
SUCRAID ............................ 73
sucralfate .............................. 75
SULAR ................................. 36
sulfacetamide sodium ..... 41, 89
sulfacetamide sodium (acne) 47
sulfacetamide sodium-sulfur 45
sulfacetamide sod-sulfur-urea
.......................................... 45
sulfacetamide-prednisolone .. 89
sulfacleanse 8-4 .................... 45
sulfadiazine ........................... 10
sulfamethoxazole-trimethoprim
.......................................... 10
SULFAMYLON ................... 47
sulfasalazine ......................... 73
sulfatrim................................ 10
sulindac ................................. 26
SUMADAN .......................... 45
sumatriptan ........................... 19
sumatriptan succinate ........... 20
SUMAVEL DOSEPRO ....... 20
SUMAXIN ........................... 45
SUMAXIN TS ...................... 45
super b complex-vitamin c . 103
super b maxi complex......... 103
super b-50 complex plus..... 103
super quints......................... 103
super quints b-50 ................ 103
superplex-t .......................... 103
SUPERVITE ...................... 103
SUPPRELIN LA .................. 15
SUPRAX ................................ 6
SUPREP BOWEL PREP KIT
.......................................... 73
SURE-TEST EASYPLUS
MINI ................................. 57
SURE-TEST EASYPLUS
MINI METER .................. 63
SURFAXIN .......................... 93
SURMONTIL ....................... 32
SURVANTA ........................ 51
SUSTIVA ............................... 5
SUSTOL ............................... 73
SUTENT ............................... 16
syeda ..................................... 85
SYLATRON ......................... 76
SYLVANT ........................... 16
SYMAX DUOTAB .............. 69
symax fastabs ........................ 69
symax-sl ................................ 70
symax-sr ............................... 70
SYMBICORT ....................... 93
SYMBYAX .......................... 32
SYMLINPEN 120 ................ 68
SYMLINPEN 60 .................. 68
SYNAGIS ............................... 5
SYNALAR ........................... 49
SYNALAR CREAM KIT .... 49
SYNALAR OINTMENT KIT
.......................................... 49
SYNALAR TS ...................... 49
SYNALGOS-DC .................. 24
SYNAREL ............................ 66
SYNDROS ........................... 73
SYNERA .............................. 47
SYNERCID ............................ 9
SYNJARDY ......................... 68
SYNJARDY XR ................... 68
SYNRIBO ............................. 16
SYNTHROID ....................... 69
SYPRINE ............................. 51
T T
30 INFUSION SET .......... 63
90 INFUSION SET 23 ..... 63
SLIM ................................. 63
SLIM G4 ........................... 63
TABLOID ............................. 16
TACLONEX ......................... 42
tacrolimus ....................... 16, 43
TAFINLAR .......................... 16
TAGRISSO ........................... 16
TAKE ACTION ................... 85
TALTZ AUTOINJECTOR .. 42
TALTZ AUTOINJECTOR (2
PACK) .............................. 42
TALTZ AUTOINJECTOR (3
PACK) .............................. 42
TALTZ SYRINGE ............... 42
TALTZ SYRINGE (2 PACK)
.......................................... 42
TALTZ SYRINGE (3 PACK)
.......................................... 42
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affiliated companies.
133
TALWIN .............................. 27
TAMIFLU .............................. 5
tamoxifen .............................. 16
tamsulosin............................. 94
TANDEM PLUS ................ 103
TANZEUM .......................... 68
TAPAZOLE ......................... 54
TARCEVA ........................... 16
TARGADOX ....................... 10
TARGRETIN ....................... 16
tarina fe 1/20 (28) ................. 85
TARKA ................................ 36
taron forte ........................... 103
taron-c dha .......................... 103
taron-prex prenatal-dha ...... 103
TASIGNA ............................ 16
TASMAR ............................. 19
TAXOTERE ......................... 16
TAYTULLA......................... 85
tazarotene ............................. 45
TAZICEF ............................... 6
TAZORAC ........................... 45
taztia xt ................................. 36
TECENTRIQ ........................ 16
TECFIDERA ........................ 76
TECHNIVIE........................... 5
TEFLARO .............................. 6
TEGRETOL ......................... 18
TEGRETOL XR ................... 18
TEKTURNA ........................ 36
TEKTURNA HCT ............... 36
TELCARE BGM .................. 63
TELCARE BLOOD
GLUCOSE KIT ................ 63
TELCARE CONTROL ........ 63
TELCARE TEST STRIPS ... 57
telmisartan ............................ 36
telmisartan-amlodipine ......... 36
telmisartan-hydrochlorothiazid
.......................................... 36
temazepam ............................ 32
TEMODAR .......................... 16
TEMOVATE ........................ 49
temozolomide ....................... 16
tencon ................................... 24
TENIPOSIDE ....................... 16
TENIVAC (PF) .................... 78
TENORETIC 100 ................. 36
TENORETIC 50 ................... 36
TENORMIN ......................... 36
TEPADINA .......................... 16
TERAZOL 7 ......................... 82
terazosin................................ 36
terbinafine hcl ......................... 3
terbutaline ............................. 93
terconazole............................ 82
TERSI FOAM ...................... 42
TESSALON PERLES .......... 91
TEST N'GO BLOOD
GLUCOSE SYSTEM ....... 63
TEST N'GO TEST ............... 57
TESTIM................................ 66
testosterone ..................... 66, 67
TESTOSTERONE................ 66
testosterone cypionate .......... 66
testosterone enanthate........... 66
TESTRED ............................ 67
TETANUS,DIPHTHERIA
TOX PED(PF) .................. 78
TETANUS-DIPHTHERIA
TOXOIDS-TD .................. 78
tetcaine.................................. 87
tetrabenazine ......................... 20
tetracaine hcl......................... 87
tetracaine hcl (pf).................. 87
tetracycline ........................... 10
TETRAVISC ........................ 87
TETRAVISC FORTE .......... 87
TEXACORT ......................... 49
TEXAVITE LQ .................. 103
THALOMID ......................... 16
THEO-24 .............................. 93
theochron .............................. 93
theophylline .......................... 93
thermazene............................ 42
THIOLA ............................... 51
thioridazine ........................... 32
thiotepa ................................. 16
thiothixene ............................ 32
THRIVITE RX ................... 103
thrivite-19 ........................... 103
THYMOGLOBULIN ........... 78
THYROLAR-1 ..................... 69
THYROLAR-1/2 .................. 69
THYROLAR-1/4 .................. 69
THYROLAR-2 ..................... 69
THYROLAR-3 ..................... 69
tiagabine ............................... 18
TIAZAC ............................... 37
TICALAST ........................... 93
ticlopidine ............................. 39
TIGAN .................................. 73
TIGECYCLINE ...................... 9
TIKOSYN ............................. 33
tilia fe .................................... 85
timolol maleate ............... 37, 86
TIMOPTIC ........................... 87
TIMOPTIC OCUDOSE (PF)
.......................................... 87
TIMOPTIC-XE ..................... 87
TINDAMAX .......................... 9
tinidazole ................................ 9
TIROSINT ............................ 69
tis-u-sol pentalyte ................. 50
TIVICAY ................................ 5
TIVORBEX .......................... 27
tizanidine .............................. 21
tl gard rx ............................. 103
tl g-fol os ............................. 103
tl icon .................................. 103
tl-hem 150 ........................... 103
TOBI ....................................... 9
TOBI PODHALER ................ 9
TOBRADEX ........................ 88
TOBRADEX ST ................... 88
tobramycin ............................ 86
tobramycin in 0.225 % nacl .... 9
tobramycin sulfate .................. 9
TOBRAMYCIN WITH
NEBULIZER ...................... 9
tobramycin-dexamethasone .. 88
TOBREX .............................. 86
TODAY CONTRACEPTIVE
SPONGE ........................... 82
TOFRANIL .......................... 32
TOLAK ................................. 43
tolazamide ............................. 68
tolbutamide ........................... 68
tolcapone ............................... 19
tolmetin ................................. 27
tolterodine ............................. 94
TOPAMAX .......................... 18
TOPICORT ........................... 49
topiramate ............................. 18
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affiliated companies.
134
TOPIRAMATE .................... 18
toposar .................................. 16
topotecan .............................. 16
TOPROL XL ........................ 37
TORISEL ............................. 16
TORONOVA II SUIK ......... 27
TORONOVA SUIK ............. 27
torsemide .............................. 37
total b/c ............................... 103
TOTECT............................... 11
TOUJEO SOLOSTAR ......... 65
TOVIAZ ............................... 94
TRACLEER ......................... 93
TRADJENTA ....................... 68
tramadol ................................ 27
TRAMADOL ....................... 27
tramadol-acetaminophen ...... 27
trandolapril ........................... 37
trandolapril-verapamil .......... 37
tranexamic acid .............. 39, 82
TRANSDERM-SCOP .......... 73
TRANXENE T-TAB............ 32
tranylcypromine ................... 32
TRANZAREL ...................... 47
TRAVATAN Z .................... 88
trazodone .............................. 32
TREANDA ........................... 16
TRECATOR ........................... 9
TRELSTAR .......................... 16
TREMFYA ........................... 42
TRESIBA FLEXTOUCH U-
100 .................................... 65
TRESIBA FLEXTOUCH U-
200 .................................... 65
tretinoin .......................... 45, 46
tretinoin (chemotherapy) ...... 16
tretinoin microspheres .......... 45
TRETIN-X ........................... 46
TRETIN-X CREAM KIT..... 46
TRETTEN ............................ 39
TREXALL ............................ 16
TREXIMET .......................... 20
TREZIX ................................ 24
tri femynor ............................ 85
TRIACETIN ......................... 47
triamcinolone acetonide 49, 52,
54
triamterene-hydrochlorothiazid
.......................................... 37
trianex ................................... 49
triazolam ............................... 32
TRIBENZOR........................ 37
TRICARE ........................... 103
TRICARE PRENATAL ..... 103
TRICARE PRENATAL DHA
ONE ................................ 103
tricitrates ............................... 95
tricon ................................... 103
TRICOR ............................... 40
triderm .................................. 49
TRIDESILON ...................... 49
tri-estarylla............................ 85
TRIFERIC .......................... 103
trifluoperazine ...................... 32
trifluridine ............................. 86
trigels-f forte ....................... 103
TRIGLIDE............................ 40
trihexyphenidyl ..................... 19
triklo ..................................... 40
tri-legest fe ............................ 85
TRILEPTAL ......................... 18
tri-linyah ............................... 85
TRILIPIX ............................. 40
tri-lo-estarylla ....................... 85
tri-lo-marzia .......................... 85
tri-lo-sprintec ........................ 85
trilyte with flavor packets ..... 73
trimethobenzamide ............... 73
trimethoprim ......................... 11
trimipramine ......................... 32
trinatal gt............................. 103
trinatal rx 1 ......................... 103
trinate .................................. 103
trinessa (28) .......................... 85
trinessa lo .............................. 85
TRI-NORINYL (28)............. 85
TRINTELLIX ....................... 32
triphrocaps .......................... 103
TRIPLE DYE ....................... 47
tri-previfem (28) ................... 85
TRISENOX .......................... 16
tri-sprintec (28) ..................... 85
TRISTART DHA ............... 103
tri-tabs dha .......................... 103
TRIUMEQ .............................. 5
triveen-duo dha ................... 103
TRI-VI-FLOR ..................... 103
tri-vit with fluoride and iron
........................................ 103
tri-vitamin with fluoride ..... 103
trivora (28) ............................ 85
TRIZIVIR ............................... 5
TROKENDI XR ................... 18
tropicamide ........................... 87
trospium ................................ 94
TRUE METRIX AIR
GLUCOSE METER ......... 63
TRUE METRIX GLUCOSE
METER ............................. 63
TRUE METRIX GLUCOSE
TEST STRIP ..................... 57
TRUE METRIX GO
GLUCOSE METER ......... 63
TRUE METRIX LEVEL 1 ... 63
TRUE2GO BLOOD
GLUCOSE SYSTEM ....... 64
TRUECONTROL LEVEL 0 64
TRUERESULT BLOOD
GLUCOSE SYSTM ......... 64
TRUETEST TEST STRIPS . 57
TRUETRACK BLOOD
GLUCOSE SYSTEM ....... 64
TRUETRACK SMART
SYSTEM .......................... 64
TRUETRACK TEST ............ 57
TRULANCE ......................... 73
TRULICITY ......................... 68
TRUSOPT ............................ 88
trust natal dha ..................... 103
TRUVADA ............................. 5
TUDORZA PRESSAIR ....... 93
tusnel c .................................. 91
TUSNEL PEDIATRIC ......... 91
TUSSICAPS ......................... 91
tussigon ................................. 91
TUSSIONEX PENNKINETIC
ER ..................................... 91
TUZISTRA XR .................... 91
TWINRIX (PF) ..................... 78
TWYNSTA ........................... 37
TYBOST ................................. 5
TYGACIL ............................... 9
TYKERB .............................. 16
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affiliated companies.
135
TYLENOL-CODEINE #3.... 25
TYLENOL-CODEINE #4.... 25
TYMLOS ............................. 79
TYPHIM VI ......................... 78
TYSABRI ............................. 20
TYVASO .............................. 93
TYVASO REFILL KIT ....... 93
TYVASO STARTER KIT ... 93
TYZINE ............................... 52
U UCERIS ................................ 73
UDAMIN SP ...................... 103
ULESFIA ............................. 50
ULORIC ............................... 79
ULTIMA MONITOR ........... 64
ULTIMA TEST STRIPS ...... 57
ultimatecare one ................. 103
ultimatecare one nf ............. 103
ultra b-100 complex ........... 103
ULTRACET ......................... 27
ULTRAM ............................. 27
ULTRAM ER ....................... 27
ULTRASAL-ER................... 42
ULTRATRAK ...................... 57
ULTRATRAK GLUCOSE
METER ............................ 64
ULTRATRAK ULTIMATE 57,
64
ULTRAVATE ...................... 49
ULTRAVATE X .................. 49
umecta .................................. 43
UNASYN ............................. 10
UNISTRIP LOW CONTROL
.......................................... 64
UNISTRIP1 TEST STRIP ... 57
unithroid ............................... 69
UPTRAVI............................. 37
ur n-c .................................... 95
uramit mb ............................. 95
urea ....................................... 43
urea nail stick ....................... 43
URECHOLINE .................... 94
URELLE............................... 95
uretron d-s ............................ 95
URIBEL ............................... 95
urimar-t ................................. 95
urin ds ................................... 95
uro-458 ................................. 95
UROCIT-K 10 ...................... 95
UROCIT-K 15 ...................... 95
UROCIT-K 5 ........................ 95
urogesic-blue ........................ 95
uro-mp .................................. 95
urophen mb ........................... 95
UROQID-ACID NO.2.......... 95
UROXATRAL ..................... 94
URSO 250 ............................ 73
URSO FORTE ...................... 73
ursodiol ................................. 73
uryl........................................ 95
ustell ..................................... 95
UTA ...................................... 95
UTIBRON NEOHALER ...... 93
utira-c.................................... 95
UTOPIC................................ 43
V VAGIFEM ............................ 81
vaginal contraceptive foam .. 82
valacyclovir ............................ 5
VALCHLOR ........................ 43
VALCYTE ............................. 5
valganciclovir ......................... 5
VALIUM .............................. 32
valproate sodium .................. 18
valproic acid ......................... 18
valproic acid (as sodium salt)
.......................................... 18
valsartan................................ 37
valsartan-hydrochlorothiazide
.......................................... 37
VALTREX ............................. 5
VANATOL LQ .................... 25
VANCOCIN ......................... 11
vancomycin .......................... 11
VANCOMYCIN IN 0.9%
SODIUM CL .................... 11
VANCOMYCIN IN
DEXTROSE 5 % .............. 11
vandazole .............................. 82
VANOS ................................ 49
VANOXIDE-HC .................. 46
VANTAS .............................. 16
VAQTA (PF) ........................ 78
VARIZIG.............................. 78
VARUBI ............................... 73
VASCEPA ............................ 40
VASERETIC ........................ 37
VASHE WOUND THERAPY
.......................................... 50
vasopressin in 0.9 % nacl .... 67
VASOTEC ............................ 37
VAXCHORA VACCINE ..... 78
v-c forte .............................. 103
VCF CONTRACEPTIVE
FILM ................................. 82
VCF CONTRACEPTIVE GEL
.......................................... 82
VECAMYL .......................... 40
VECTIBIX ........................... 16
VECTICAL .......................... 42
VELCADE ........................... 16
veletri .................................... 37
velivet triphasic regimen (28)
.......................................... 85
VELPHORO ......................... 73
VELTASSA .......................... 73
VELTIN ................................ 46
vemavite-prx-2 ................... 103
VEMLIDY .............................. 5
VENCLEXTA ...................... 16
VENCLEXTA STARTING
PACK ............................... 16
venlafaxine ........................... 32
VENTAVIS .......................... 93
VENTOLIN HFA ................. 93
verapamil .............................. 37
VERDESO ............................ 49
verdrocet ............................... 25
VEREGEN ........................... 43
VERELAN ........................... 37
VERELAN PM ..................... 37
veripred 20 ............................ 54
VERSACLOZ ....................... 32
VESICARE ........................... 94
vestura (28) ........................... 85
VFEND ................................... 3
VFEND IV .............................. 3
VGO 20 ................................ 64
VGO 30 ................................ 64
VGO 40 ................................ 64
VIAGRA ............................... 95
VIBATIV .............................. 11
VIBERZI .............................. 73
VIBRAMYCIN .............. 10, 11
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
136
vic-forte .............................. 103
vicodin .................................. 25
vicodin es.............................. 25
vicodin hp ............................. 25
VICTOZA 2-PAK ................ 68
VICTOZA 3-PAK ................ 68
VIDAZA............................... 16
VIDEX 2 GRAM PEDIATRIC
............................................ 5
VIDEX EC ............................. 5
VIEKIRA PAK ...................... 5
VIEKIRA XR ......................... 5
vienva ................................... 85
vigabatrin .............................. 18
VIGAMOX........................... 86
VIIBRYD ............................. 32
VIMIZIM ............................. 67
VIMOVO ............................. 27
VIMPAT............................... 18
vinate care .......................... 103
VINATE DHA RF ............. 103
vinate ii ............................... 103
vinate m .............................. 103
vinate one ........................... 103
vinate ultra .......................... 103
vinblastine ............................ 16
vincasar pfs ........................... 16
vincristine ............................. 16
vinorelbine ............................ 16
VIOKACE ............................ 73
viorele (28) ........................... 85
VIRACEPT ............................ 5
VIRAMUNE .......................... 5
VIRAMUNE XR .................... 5
VIRASAL............................. 42
VIRAZOLE ............................ 5
VIREAD ................................. 5
VIROPTIC ........................... 86
virt-advance ........................ 103
virt-c dha ............................ 103
VIRT-CAPS ....................... 103
virt-gard .............................. 103
virt-nate .............................. 103
virt-nate dha........................ 103
virt-phos 250 neutral ............ 97
virt-pn ................................. 104
virt-pn dha .......................... 104
virt-pn plus ......................... 104
VIRTPREX ........................ 104
virtrate-2 ............................... 95
virtrate-3 ............................... 95
virtrate-k ............................... 95
virt-select ............................ 104
virtussin ac ............................ 91
virtussin dac .......................... 91
virt-vite ............................... 104
virt-vite gt ........................... 104
VIRT-VITE PLUS ............. 104
VISTARIL ............................ 90
VISTOGARD ....................... 11
VISUDYNE.......................... 87
vit 3 ..................................... 104
vit b complex-folic acid ...... 104
VITAFOL ........................... 104
VITAFOL FE+ (WITH
DOCUSATE) ................. 104
VITAFOL GUMMIES ....... 104
VITAFOL NANO .............. 104
VITAFOL ULTRA............. 104
VITAFOL-OB .................... 104
VITAFOL-OB+DHA ......... 104
VITAFOL-ONE ................. 104
vitajoy daily d ..................... 104
VITAL-D RX ..................... 104
VITAMED MD ONE RX .. 104
VITAMEDMD REDICHEW
RX .................................. 104
vitamin b complex .............. 104
vitamin d3 ........................... 104
vitamins a,c,d and fluoride . 104
VITAPEARL ...................... 104
VITA-RESPA ..................... 104
VITATRUE ........................ 104
VITRASE ............................. 87
VITUZ .................................. 91
VIVELLE-DOT.................... 81
VIVITROL ........................... 27
VIVLODEX ......................... 27
VOGELXO ........................... 67
vol-care rx........................... 104
vol-nate ............................... 104
vol-plus ............................... 104
vol-tab rx ............................ 104
VOLTAREN ........................ 27
VOLTAREN-XR.................. 27
VONVENDI ......................... 39
VORAXAZE ........................ 11
voriconazole ........................... 3
VOSEVI ................................. 5
VOTRIENT .......................... 16
vp-ch plus ........................... 104
vp-ch-pnv ............................ 104
vp-ggr-b6 ............................ 104
vp-heme ob ......................... 104
vp-heme one ....................... 104
VP-PNV-DHA .................... 104
VPRIV .................................. 67
vp-vite rx ............................ 104
VRAYLAR ........................... 32
VUSION ............................... 47
vyfemla (28) ......................... 85
VYTORIN 10-10 .................. 40
VYTORIN 10-20 .................. 40
VYTORIN 10-40 .................. 40
VYTORIN 10-80 .................. 40
VYVANSE ........................... 32
VYXEOS .............................. 16
W warfarin ................................. 39
water for irrigation, sterile .... 51
WAVESENSE AMP ............ 64
WAVESENSE CONTROL
SOLUTION ...................... 64
WAVESENSE JAZZ ............ 57
WAVESENSE PRESTO 57, 64
WELCHOL ........................... 40
WELLBUTRIN SR .............. 32
WELLBUTRIN XL .............. 32
wera (28) ............................... 85
westhroid .............................. 69
WIDE-SEAL DIAPHRAGM
.......................................... 80
WILATE ............................... 39
woman's laxative .................. 73
women's gentle laxative(bisac)
.......................................... 73
women's laxative (bisacodyl)73
WP THYROID ..................... 69
wymzya fe ............................ 85
X XADAGO ............................. 19
XALATAN ........................... 88
XALKORI ............................ 16
XANAX ................................ 32
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
137
XANAX XR ......................... 32
XARELTO ........................... 39
XATMEP ............................. 16
XCLAIR ............................... 43
XELJANZ ............................ 80
XELJANZ XR ...................... 80
XELODA ............................. 16
XENAZINE .......................... 20
XEOMIN .............................. 79
XERESE ............................... 48
XERMELO........................... 16
XGEVA ................................ 11
XIFAXAN .............................. 9
XIGDUO XR........................ 68
XIIDRA ................................ 87
XODOL 10/300 .................... 25
XODOL 5/300 ...................... 25
XODOL 7.5/300 ................... 25
XOLAIR ............................... 93
XOLEGEL ........................... 47
XOPENEX ........................... 94
XOPENEX CONCENTRATE
.......................................... 94
XOPENEX HFA .................. 94
XTAMPZA ER .................... 25
XTANDI............................... 16
xulane ................................... 82
XULTOPHY 100/3.6 ........... 65
XURIDEN ............................ 51
xylon 10 ................................ 25
XYNTHA ............................. 39
XYNTHA SOLOFUSE ........ 39
XYREM ............................... 32
Y YASMIN (28) ...................... 85
YAZ (28) .............................. 86
YERVOY ............................. 16
YF-VAX (PF) ....................... 79
YONDELIS .......................... 16
YOSPRALA ......................... 39
yuvafem ................................ 81
Z zafirlukast ............................. 94
zaleplon ................................ 32
ZALTRAP ............................ 16
zamicet ................................. 25
ZANAFLEX ......................... 21
ZANOSAR ........................... 16
ZANTAC .............................. 75
zarah ..................................... 86
ZARONTIN.......................... 18
ZARXIO ............................... 76
zatean-ch ............................. 104
zatean-pn dha ...................... 104
zatean-pn plus ..................... 104
zavara.................................. 104
ZAVESCA............................ 67
zebutal .................................. 25
ZEGERID ............................. 75
ZEJULA ............................... 16
ZELAPAR ............................ 19
ZELBORAF ......................... 16
ZEMAIRA ............................ 51
ZEMBRACE SYMTOUCH . 20
ZEMPLAR ........................... 67
zenatane ................................ 46
zenchent (28) ........................ 86
zenchent fe ............................ 86
ZENPEP ............................... 73
zenzedi .................................. 32
ZENZEDI ............................. 32
ZEPATIER ............................. 5
ZERIT ..................................... 5
ZESTORETIC ...................... 37
ZESTRIL .............................. 37
ZETIA .................................. 40
ZETONNA ........................... 94
ZIAC ..................................... 37
ZIAGEN ................................. 5
ZIANA.................................. 46
zidovudine .............................. 5
zileuton ................................. 94
ZINACEF ............................... 6
ZINBRYTA .......................... 77
ZINECARD (AS HCL) ........ 11
zingiber ............................... 104
ZINGO.................................. 47
ZINPLAVA .......................... 79
ZIOPTAN (PF) ..................... 88
ziprasidone hcl ...................... 32
ZIPSOR ................................ 27
ZIRGAN ............................... 86
ZITHRANOL ....................... 42
ZITHROMAX ........................ 7
ZITHROMAX TRI-PAK ....... 7
ZITHROMAX Z-PAK ........... 7
ZMAX .................................... 7
ZOCOR ................................. 40
ZODRYL AC 25 .................. 91
ZODRYL AC 30 .................. 91
ZODRYL AC 35 .................. 91
ZODRYL AC 40 .................. 91
ZODRYL AC 50 .................. 91
ZODRYL AC 60 .................. 91
ZODRYL AC 80 .................. 91
ZODRYL DAC 25 ............... 91
ZODRYL DAC 30 ............... 91
ZODRYL DAC 35 ............... 91
ZODRYL DAC 40 ............... 91
ZODRYL DAC 50 ............... 91
ZODRYL DAC 60 ............... 91
ZODRYL DAC 80 ............... 91
ZODRYL DEC 25 ................ 91
ZODRYL DEC 30 ................ 91
ZODRYL DEC 35 ................ 91
ZODRYL DEC 40 ................ 91
ZODRYL DEC 50 ................ 91
ZODRYL DEC 60 ................ 91
ZODRYL DEC 80 ................ 91
ZOFRAN (AS
HYDROCHLORIDE) ...... 73
ZOFRAN ODT ..................... 73
ZOHYDRO ER .................... 25
ZOLADEX ........................... 16
zoledronic acid ...................... 67
zoledronic acid-mannitol-water
.......................................... 51
ZOLEDRONIC AC-
MANNITOL-0.9NACL .... 67
ZOLINZA ............................. 16
zolmitriptan ........................... 20
ZOLOFT ............................... 32
zolpidem ............................... 32
ZOLPIMIST ......................... 32
ZOMACTON ....................... 76
ZOMETA ............................. 67
ZOMIG ................................. 20
ZOMIG ZMT ........................ 20
ZONACORT ........................ 54
ZONALON ........................... 43
ZONEGRAN ........................ 18
zonisamide ............................ 18
ZONTIVITY ......................... 39
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not
affiliated companies.
138
ZOO FRIENDS COMPLETE
........................................ 104
ZORBTIVE .......................... 76
ZORTRESS .......................... 16
ZORVOLEX ........................ 27
zovia 1/35e (28) .................... 86
zovia 1/50e (28) .................... 86
ZOVIRAX ........................ 5, 48
Z-TUSS AC .......................... 91
ZUBSOLV............................ 27
ZUPLENZ ............................ 73
ZURAMPIC ......................... 79
ZUTRIPRO .......................... 91
ZYBAN ................................ 52
ZYCLARA ........................... 77
ZYDELIG ............................. 16
ZYFLO ................................. 94
ZYFLO CR ........................... 94
ZYKADIA ............................ 16
ZYLET ................................. 88
ZYLOPRIM .......................... 79
ZYMAXID ........................... 86
ZYPREXA ............................ 32
ZYPREXA ZYDIS ............... 32
ZYTIGA ......................... 16, 17
ZYVOX .................................. 9
Insured/CP-10.14.2016
Discrimination is Against the Law Blue KC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Blue KC does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Blue KC:
• Provides free aids and services to people with disabilities to communicate effectively with us, such as:
○ Qualified sign language interpreters ○ Written information in other formats (large print, audio, accessible electronic
formats, other formats) • Provides free language services to people whose primary language is not English, such
as: ○ Qualified interpreters ○ Information written in other languages
If you need these services, contact Customer Service, 844-395-7126 (Toll free), [email protected]. If you believe that Blue KC 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 the Appeals Department, PO Box 419169, Kansas City, MO 64141-6169, 816-395-3537, TTY: 816-842-5607, [email protected]. You can file a grievance in person or by mail, or email. If you need help filing a grievance, the 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 for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://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, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. If you, or someone you’re helping, has questions about Blue KC, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 1-844-395-7126. Spanish: Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Blue KC, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 1-844-395-7126. Chinese: 如果您,或是您正在協助的對象,有關於 Blue KC方面的問題,您 有權利免費以您的母語得到幫
助和訊息。洽詢一位翻譯員,請撥電話1-844-395-7126。 Vietnamese: Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về Blue KC, quý vị sẽ có quyền được giúp và có thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi 1-844-395-7126. German: Falls Sie oder jemand, dem Sie helfen, Fragen zum Blue KC haben, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 1-844-395-7126 an.
Insured/CP-10.14.2016
Korean: 만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 [Blue KC]에 관해서 질문이 있다면 귀하는 그러한
도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 그렇게 통역사와 얘기하기
위해서는 1-844-395-7126 로 전화하십시오. Serbo-Croatian: Ukoliko Vi ili neko kome Vi pomažete ima pitanje o Blue KC, imate pravo da besplatno dobijete pomoć i informacije na Vašem jeziku. Da biste razgovarali sa prevodiocem, nazovite 1-844-395-7126. Arabic:
الضرورية بلغتك من دون اية تكلفة. ، فلديك الحق في الحصول على المساعدة والمعلومات Blue KC إن كان لديك أو لدى شخص تساعده أسئلة بخصوص .7126-395-844-1. للتحدث مع مترجم اتصل بـ
Russian: Если у вас или лица, которому вы помогаете, имеются вопросы по поводу Blue KC, то вы имеете право на бесплатное получение помощи и информации на вашем языке. Для разговора с переводчиком позвоните по телефону1-844-395-7126. French: Si vous, ou quelqu'un que vous êtes en train d’aider, a des questions à propos de Blue KC, vous avez le droit d'obtenir de l'aide et l'information dans votre langue à aucun coût. Pour parler à un interprète, appelez 1-844-395-7126. Tagalog: Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Blue KC, may karapatan ka na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa1-844-395-7126. Laotian: ຖ້ າທ່ ານ, ຫຼື ຄົນ ◌່ ທທ່ ານກໍ າລັງຊ່ ວຍເຫືຼ ອ, ມ ◌ໍ ຄາຖາມກ່ ຽວກັບ Blue KC, ທ່ ານມ ◌ິ ສດ ◌່ ທຈະໄດ້ຮັບການຊ່ ວຍເຫືຼ ອແລະ◌ໍ ຂ້ ມູ ນຂ່ າວສານ ◌່ ທເປັ ນພາສາຂອງທ່ ານໍ ◌່ ບມ ຄ່ າໃຊ້ຈ່ າຍ. ການໂອ້ລົມກັບນາຍພາສາ, ໃຫ້ ໂທຫາ 1-844-395-7126. Pennsylvanian Dutch: Wann du hoscht en Froog, odder ebber, wu du helfscht, hot en Froog baut Blue KC, hoscht du es Recht fer Hilf un Information in deinre eegne Schprooch griege, un die Hilf koschtet nix. Wann du mit me Interpreter schwetze witt, kannscht du 1-844-395-7126 uffrufe. Persian:
زبان خود را به طور ، داشته باشيد حق اين را داريد که کمکو اطالعات به Blue KC اگر شما، يا کسی که شما به او کمک ميکنيد ، سوال در مورد .تماس حاصل نماييد 7126-395-844-1.رايگان دريافت نماييد
Cushite: Isin yookan namni biraa isin deeggartan Blue KC irratti gaaffii yo qabaattan, kaffaltii irraa bilisa haala ta’een afaan keessaniin odeeffannoo argachuu fi deeggarsa argachuuf mirga ni qabdu. Nama isiniif ibsu argachuuf, lakkoofsa bilbilaa 1-844-395-7126 tiin bilbilaa. Portuguese: Se você, ou alguém a quem você está ajudando, tem perguntas sobre o Blue KC, você tem o direito de obter ajuda e informação em seu idioma e sem custos. Para falar com um intérprete, ligue para 1-844-395-7126. For TTY services, please call 1-816-842-5607.