kansas aca member prescription drug list 2019hix 2019 bcbskc ks eff dte 07-01-2019.docx . kansas aca...
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HIX 2019 BCBSKC KS eff dte 07-01-2019.docx
KANSAS ACA MEMBER
PRESCRIPTION DRUG LIST
2019
2
Table of Contents
ANTI - INFECTIVES ........................................................................................................................................ 4
ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS ..................................................................... 13
AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH ....................................................................... 20
CARDIOVASCULAR, HYPERTENSION & LIPIDS ................................................................................. 39
DERMATOLOGICALS/TOPICAL THERAPY .......................................................................................... 47
DIAGNOSTICS & MISCELLANEOUS AGENTS ...................................................................................... 57
EAR, NOSE & THROAT MEDICATIONS .................................................................................................. 60
ENDOCRINE/DIABETES .............................................................................................................................. 61
GASTROENTEROLOGY .............................................................................................................................. 79
IMMUNOLOGY, VACCINES & BIOTECHNOLOGY ............................................................................. 85
MUSCULOSKELETAL & RHEUMATOLOGY ......................................................................................... 89
OBSTETRICS & GYNECOLOGY ................................................................................................................ 91
OPHTHALMOLOGY ..................................................................................................................................... 97
RESPIRATORY, ALLERGY, COUGH & COLD ..................................................................................... 101
UROLOGICALS ............................................................................................................................................ 106
VITAMINS, HEMATINICS & ELECTROLYTES ................................................................................... 108
Index ................................................................................................................................................................ 115
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 RECONSTITUTION
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
itraconazole oral
capsule 1 QL
itraconazole oral
solution 1
ketoconazole 1
NOXAFIL 2
nystatin 1
ONMEL 3 QL
ORAVIG 3
SPORANOX 3
SPORANOX PULSEPAK
3 QL
terbinafine hcl 1
TOLSURA 3
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
atazanavir 1 S
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
ATRIPLA 4 S; QL
BARACLUDE ORAL SOLUTION
2
BARACLUDE ORAL TABLET
3
BIKTARVY 3 S
cidofovir 6 MSD
CIMDUO 3 S
COMBIVIR 4 S; QL
COMPLERA 3 S; QL
CRIXIVAN 3 S; QL
CYTOVENE 6 MSD
DAKLINZA 4 PA; ST; S; SLA
DELSTRIGO 4 S
DESCOVY 3 S
didanosine 1 S; QL
DOVATO 3 S
EDURANT 3 S; QL
efavirenz 1 S; QL
EMTRIVA 3 S; QL
entecavir 1
EPCLUSA 3 PA; 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
fosamprenavir 1 S; QL
Drug Name Drug
Category Requirements
/ Limits
FOSCAVIR 6 MSD
FUZEON 3 S; QL
GANCICLOVIR 6 MSD
ganciclovir sodium 6 MSD
GENVOYA 3 S
HARVONI 3 PA; S; SLA; QL
HEPSERA 3
INTELENCE 3 S; QL
INVIRASE 3 S; QL
ISENTRESS 3 S; QL
ISENTRESS HD 3 S
JULUCA 3 S
KALETRA ORAL SOLUTION
4 S; QL
KALETRA ORAL TABLET
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
LEDIPASVIR-SOFOSBUVIR
4 PA; S; QL
LEXIVA ORAL SUSPENSION
3 S; QL
LEXIVA ORAL TABLET
4 S; QL
lopinavir-ritonavir 1 S; QL
MAVYRET 4 ST; S
nevirapine 1 S; QL
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
NORVIR ORAL CAPSULE
3 S; QL
NORVIR ORAL POWDER IN PACKET
3 S
NORVIR ORAL SOLUTION
3 S; QL
NORVIR ORAL TABLET
4 S; QL
ODEFSEY 3 S
oseltamivir 1 QL
PIFELTRO 4 S
PREVYMIS INTRAVENOUS
6 MSD
PREVYMIS ORAL 2 QL
PREZCOBIX 4 S
PREZISTA 3 S; QL
RELENZA DISKHALER
2 QL
RESCRIPTOR 3 S; QL
RETROVIR INTRAVENOUS
6 MSD
RETROVIR ORAL 4 S; QL
REYATAZ ORAL CAPSULE
4 S
REYATAZ ORAL POWDER IN PACKET
3 S
ribavirin 1 S; SLA
rimantadine 1
ritonavir 1 S; QL
SELZENTRY ORAL SOLUTION
3 S
SELZENTRY ORAL TABLET 150 MG, 300 MG
3 S; QL
Drug Name Drug
Category Requirements
/ Limits
SELZENTRY ORAL TABLET 25 MG, 75 MG
3 S
SOFOSBUVIR-VELPATASVIR
4 PA; S
SOVALDI 4 PA; S; SLA; QL
stavudine 1 S; QL
STRIBILD 3 S; QL
SUSTIVA 4 S; QL
SYMFI 3 S
SYMFI LO 3 S
SYMTUZA 4 S
SYNAGIS 6 MSD
TAMIFLU 3 QL
tenofovir disoproxil
fumarate 1 S; QL
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
TROGARZO 6 PA; MSD
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
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
valganciclovir 1
VALTREX 3 ST; QL
VEMLIDY 2
VIDEX 2 GRAM PEDIATRIC
3 S; QL
VIDEX EC 4 S; QL
VIEKIRA PAK 4 PA; S; SLA; QL
VIRACEPT 3 S; QL
VIRAMUNE 4 S; QL
VIRAMUNE XR 4 S; QL
VIRAZOLE 4 S; SLA
VIREAD ORAL POWDER
3 S; QL
VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG
3 S; QL
VIREAD ORAL TABLET 300 MG
4 S; QL
VOSEVI 3 S; SLA
XOFLUZA 2 QL
ZEPATIER 3 PA; ST; S; SLA
ZERIT 4 S; QL
ZIAGEN 4 S; QL
zidovudine 1 S; QL
ZOVIRAX 3
CEPHALOSPORINS
AVYCAZ 6 MSD
cefaclor 1
cefadroxil 1
cefazolin 6 MSD
Drug Name Drug
Category Requirements
/ Limits
CEFAZOLIN IN 0.9% SOD CHLORIDE
6 MSD
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
ceftriaxone in
dextrose,iso-os 6 MSD
ceftriaxone injection
recon soln 1 gram,
10 gram, 2 gram,
250 mg, 500 mg
6 MSD
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
CEFTRIAXONE INJECTION RECON SOLN 100 GRAM
6 MSD
cefuroxime axetil 1
cefuroxime sodium 6 MSD
cephalexin 1
CLAFORAN 6 MSD
KEFLEX 3
MAXIPIME 6 MSD
SPECTRACEF 3
SUPRAX 3
TAZICEF 6 MSD
TEFLARO 6 MSD
ERYTHROMYCINS & OTHER
MACROLIDES
azithromycin
intravenous 6 MSD
azithromycin oral 1
clarithromycin 1
DIFICID 3
e.e.s. 400 1
E.E.S. GRANULES 3
ERYPED 200 3
ERYPED 400 3
ery-tab oral
tablet,delayed
release (dr/ec) 250
mg, 333 mg
1
ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 500 MG
3
erythrocin (as
stearate) 1
Drug Name Drug
Category Requirements
/ Limits
erythromycin 1
erythromycin
ethylsuccinate 1
ZITHROMAX INTRAVENOUS
6 MSD
ZITHROMAX ORAL
3
ZITHROMAX TRI-PAK
3
ZITHROMAX Z-PAK
3
MISCELLANEOUS
ANTIINFECTIVES
AEMCOLO 3
albendazole 1
ALBENZA 3 QL
ALINIA 2 QL
amikacin 6 MSD
ARAKODA 3
ARIKAYCE 2 SLA
atovaquone 1
atovaquone-
proguanil 1 QL
BENZNIDAZOLE 2 PA
BETHKIS 6 MSD
BILTRICIDE 3
CAPASTAT 6 MSD
CAYSTON 3 S; SLA; QL
chloramphenicol sod
succinate 6 MSD
chloroquine
phosphate 1
CLEOCIN HCL 3
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
CLEOCIN INJECTION
6 MSD
cleocin intravenous
solution 300 mg/2 ml 6 MSD
CLEOCIN INTRAVENOUS SOLUTION 600 MG/4 ML, 900 MG/6 ML
6 MSD
CLEOCIN PEDIATRIC
3
clindamycin hcl 1
CLINDAMYCIN IN 0.9 % SOD CHLOR
6 MSD
clindamycin in 5 %
dextrose 6 MSD
clindamycin
palmitate hcl 1
clindamycin
pediatric 1
clindamycin
phosphate 6 MSD
COARTEM 2 QL
colistin
(colistimethate na) 1
COLY-MYCIN M PARENTERAL
3
CUBICIN 6 MSD
CUBICIN RF 6 MSD
CYCLOSERINE 3
dapsone 1 M
daptomycin 6 MSD
DARAPRIM 2 PA; SLA; QL
DORIPENEM 6 MSD
EMVERM 2 QL
ertapenem 6 MSD
Drug Name Drug
Category Requirements
/ Limits
ethambutol 1
FLAGYL 3
gentamicin 6 MSD
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
2
GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 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
GENTAMICIN-SODIUM CITRATE
6 PA; MSD
hydroxychloroquine 1 M
imipenem-cilastatin 6 MSD
IMPAVIDO 3 S; QL
INVANZ 6 MSD
isoniazid 1
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
ivermectin 1 QL
KITABIS PAK 3 S; SLA
KRINTAFEL 3
LINCOCIN 6 MSD
lincomycin 6 MSD
linezolid 1 PA
linezolid in dextrose
5% 6 MSD
MALARONE 3 QL
MALARONE PEDIATRIC
3 QL
mefloquine 1 QL
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 ST; M
polymyxin b sulfate 6 MSD
praziquantel 1
PRIFTIN 2
PRIMAQUINE 2 M; QL
Drug Name Drug
Category Requirements
/ Limits
PRIMAXIN IV 6 MSD
pyrazinamide 1
QUALAQUIN 3 QL
quinine sulfate 1 QL
rifabutin 1
RIFADIN INTRAVENOUS
6 MSD
RIFADIN ORAL 3
RIFAMATE 3
rifampin intravenous 6 MSD
rifampin oral 1
RIFATER 3
SIRTURO 2 SLA
SIVEXTRO 3 PA
SOLOSEC 3 PA
STREPTOMYCIN 6 MSD
STROMECTOL 3 QL
SYNERCID 6 MSD
tigecycline 6 MSD
tinidazole 1 QL
TOBI 3 ST; QL
TOBI PODHALER 2 QL
tobramycin in 0.225
% nacl 1 QL
tobramycin sulfate 6 MSD
TOBRAMYCIN WITH NEBULIZER
4 S
TRECATOR 3
TYGACIL 6 MSD
VABOMERE 6 MSD
XIFAXAN 2
ZEMDRI 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
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
AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 125-31.25 MG/5 ML
2
AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 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
Drug Name Drug
Category Requirements
/ Limits
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
QUINOLONES
AVELOX 3
AVELOX IN NACL (ISO-OSMOTIC)
6 MSD
BAXDELA INTRAVENOUS
6 MSD
BAXDELA ORAL 3
CIPRO 3
CIPRO XR 3
ciprofloxacin 1
ciprofloxacin
(mixture) 1
ciprofloxacin hcl 1
FACTIVE 3 QL
LEVAQUIN 3
levofloxacin in d5w 6 MSD
levofloxacin
intravenous 6 MSD
levofloxacin oral 1
moxifloxacin 1
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
moxifloxacin-
sod.chloride(iso) 6 MSD
ofloxacin 1
SULFA'S & RELATED AGENTS
BACTRIM 3
BACTRIM DS 3
sulfadiazine 1
sulfamethoxazole-
trimethoprim
intravenous
6 MSD
sulfamethoxazole-
trimethoprim oral 1
sulfatrim 1
TETRACYCLINES
ACTICLATE 3 ST
avidoxy 1
coremino 1 ST; QL
demeclocycline 1
DORYX 3 ST
DORYX MPC 3 ST
doxycycline hyclate 1
doxycycline
monohydrate oral
capsule
1
DOXYCYCLINE MONOHYDRATE ORAL CAPSULE,IR - DELAY REL,BIPHASE
3 ST
doxycycline
monohydrate oral
suspension for
reconstitution
1
Drug Name Drug
Category Requirements
/ Limits
doxycycline
monohydrate oral
tablet
1
MINOCIN 3 ST
minocycline oral
capsule 1
minocycline oral
tablet 1
minocycline oral
tablet extended
release 24 hr 105
mg, 115 mg, 135 mg,
45 mg, 65 mg, 80
mg, 90 mg
1 ST; QL
minocycline oral
tablet extended
release 24 hr 55 mg
2 ST; QL
MINOLIRA ER 3
mondoxyne nl 1
MONODOX 3 ST
morgidox 1
NUZYRA (7 DAY WITH LOAD DOSE)
3
ORACEA 2 ST
SEYSARA 3 ST
SOLODYN 2 ST; QL
soloxide 1
TARGADOX 3 ST
tetracycline 1
VIBRAMYCIN 3 ST
XERAVA 6 MSD
XIMINO 3 ST
URINARY TRACT AGENTS
FURADANTIN 3
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
HIPREX 3
MACROBID 3
MACRODANTIN 3
methenamine
hippurate 1
methenamine
mandelate 1
MONUROL 3
nitrofurantoin 1
nitrofurantoin
macrocrystal 1
nitrofurantoin
monohyd/m-cryst 1
PRIMSOL 3
trimethoprim 1
TRIMPEX 3
VANCOMYCIN
FIRVANQ 3
VANCOCIN 3
VANCOMYCIN HCL IN WATER
6 MSD
VANCOMYCIN IN 0.9 % SODIUM CHL
6 MSD
VANCOMYCIN IN DEXTROSE 5 %
6 MSD
VANCOMYCIN INJECTION
6 MSD
vancomycin
intravenous recon
soln 1,000 mg, 10
gram, 5 gram, 500
mg, 750 mg
6 MSD
Drug Name Drug
Category Requirements
/ Limits
VANCOMYCIN INTRAVENOUS RECON SOLN 1.25 GRAM, 1.5 GRAM, 250 MG
6 MSD
vancomycin oral 1
VANCOMYCIN-WATER INJECT (PEG)
6 MSD
VIBATIV 6 MSD
ANTINEOPLASTIC &
IMMUNOSUPPRESSANT
DRUGS
ADJUNCTIVE AGENTS
amifostine
crystalline 6 MSD
dexrazoxane hcl 6 MSD
ELITEK 6 MSD
ETHYOL 6 MSD
FUSILEV 6 PA; MSD
KEPIVANCE 6 MSD
KHAPZORY 6 MSD
leucovorin calcium
injection 6 MSD
leucovorin calcium
oral 1
LEVOLEUCOVORIN CALCIUM INTRAVENOUS RECON SOLN 175 MG
6 MSD
levoleucovorin
calcium intravenous
recon soln 50 mg
6 MSD
levoleucovorin
calcium intravenous
solution
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
mesna 6 MSD
MESNEX INTRAVENOUS
6 PA; MSD
MESNEX ORAL 2
TOTECT 6 MSD
VISTOGARD 2 SLA
VORAXAZE 6 MSD
XGEVA 6 PA; MSD
ZINECARD (AS HCL)
6 MSD
ANTINEOPLASTIC &
IMMUNOSUPPRESSANT DRUGS
abiraterone 1 S; QL
ABRAXANE 6 PA; MSD
ADCETRIS 6 PA; MSD
adriamycin
intravenous recon
soln 10 mg
6 PA; MSD
ADRIAMYCIN INTRAVENOUS RECON SOLN 50 MG
6 PA; MSD
adriamycin
intravenous solution 6 MSD
adrucil 6 MSD
AFINITOR 3 S; QL
AFINITOR DISPERZ
3 S; QL
ALECENSA 3 S; SLA
ALIQOPA 6 PA; MSD
ALKERAN 3
ALKERAN (AS HCL)
6 MSD
ALUNBRIG 4 PA; S
anastrozole 1
Drug Name Drug
Category Requirements
/ Limits
ARIMIDEX 3
AROMASIN 4 S
ARRANON 6 PA; MSD
ARSENIC TRIOXIDE
6 MSD
ARZERRA 6 MSD
ASTAGRAF XL 3 ST
AVASTIN 6 PA; MSD
azacitidine 6 MSD
AZASAN 3
azathioprine 1
BALVERSA 3
BAVENCIO 6 PA; MSD
BELEODAQ 6 MSD
BENDAMUSTINE 6 MSD
BENDEKA 6 MSD
BESPONSA 6 PA; MSD
bexarotene 1 S
bicalutamide 1
BICNU 6 PA; MSD
bleomycin 6 PA; MSD
BLINCYTO 6 PA; MSD
BORTEZOMIB 6 MSD
BOSULIF 3 S; SLA
BRAFTOVI 3
busulfan 6 MSD
BUSULFEX 6 MSD
CABOMETYX 3 S
CALQUENCE 3 SLA
CAMPTOSAR 6 PA; MSD
capecitabine 1 S
CAPRELSA 3 S; SLA; QL
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
carboplatin 6 PA; MSD
carmustine 6 MSD
CASODEX 3
CELLCEPT 3
CELLCEPT INTRAVENOUS
6 MSD
cisplatin 6 PA; MSD
cladribine 6 PA; MSD
clofarabine 6 MSD
CLOLAR 6 PA; MSD
COMETRIQ 2 SLA; QL
COPIKTRA 4 SLA
COSMEGEN 6 PA; MSD
COTELLIC 3 S; SLA
cyclophosphamide
intravenous 6 MSD
cyclophosphamide
oral 1
cyclosporine
intravenous 6 MSD
cyclosporine
modified 1
cyclosporine oral 1
CYRAMZA 6 MSD
cytarabine 6 PA; MSD
cytarabine (pf)
injection solution 100 mg/5 ml (20
mg/ml)
6 MSD
cytarabine (pf)
injection solution 2
gram/20 ml (100
mg/ml), 20 mg/ml
6 PA; MSD
dacarbazine 6 PA; MSD
DACOGEN 6 PA; MSD
Drug Name Drug
Category Requirements
/ Limits
dactinomycin 6 MSD
DARZALEX 6 MSD
daunorubicin
intravenous recon
soln
6 PA; MSD
daunorubicin
intravenous solution 6 MSD
DAURISMO 4 S
decitabine 6 MSD
DOCEFREZ 6 MSD
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 PA; MSD
doxorubicin
intravenous recon
soln
6 MSD
doxorubicin
intravenous solution 10 mg/5 ml, 2 mg/ml
6 MSD
doxorubicin
intravenous solution 20 mg/10 ml, 50
mg/25 ml
6 PA; MSD
doxorubicin, peg-
liposomal 6 PA; MSD
DROXIA 3 S
ELIGARD 3 S
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
ELIGARD (3 MONTH)
3 S; QL
ELIGARD (4 MONTH)
3 S
ELIGARD (6 MONTH)
3 S
ELLENCE 6 PA; MSD
ELZONRIS 6 MSD
EMCYT 3 S
EMPLICITI 6 MSD
ENVARSUS XR 3 ST
epirubicin 6 MSD
ERBITUX INTRAVENOUS SOLUTION 100 MG/50 ML
6 MSD
ERBITUX INTRAVENOUS SOLUTION 200 MG/100 ML
6 PA; MSD
ERIVEDGE 3 S; SLA
ERLEADA 3 PA; S
ERWINAZE 6 PA; MSD
etoposide
intravenous 6 MSD
etoposide oral 1 S
EVOMELA 6 MSD
exemestane 1 S
FARESTON 4 S
FARYDAK 4 S
FASLODEX 6 PA; MSD
FEMARA 3
FIRMAGON KIT W DILUENT SYRINGE
3 PA; S; SLA
Drug Name Drug
Category Requirements
/ Limits
floxuridine 6 PA; MSD
fludarabine 6 MSD
fluorouracil 6 MSD
flutamide 1
FOLOTYN 6 PA; MSD
GAMIFANT 2
GAZYVA 6 PA; MSD
gemcitabine
intravenous recon
soln
6 MSD
gemcitabine
intravenous solution 1 gram/26.3 ml (38
mg/ml), 2 gram/52.6
ml (38 mg/ml), 200
mg/5.26 ml (38
mg/ml)
6 MSD
GEMCITABINE INTRAVENOUS SOLUTION 100 MG/ML
6 MSD
gengraf 1 PA
GILOTRIF 3 S
GLEEVEC 4 S; QL
GLEOSTINE 3 S
GLIADEL WAFER 6 MSD
HALAVEN 6 PA; MSD
HERCEPTIN HYLECTA
6 PA; MSD
HERCEPTIN INTRAVENOUS RECON SOLN 150 MG
6 PA; MSD
HERCEPTIN INTRAVENOUS RECON SOLN 440 MG
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
HYCAMTIN INTRAVENOUS
6 MSD
HYCAMTIN ORAL 3 S
HYDREA 3
hydroxyurea 1
IBRANCE 3 S
ICLUSIG 2 SLA
IDAMYCIN PFS 6 PA; MSD
idarubicin 6 PA; MSD
IDHIFA 3 PA; S
IFEX 6 PA; MSD
ifosfamide 6 MSD
ifosfamide-mesna 6 MSD
imatinib 1 S; QL
IMBRUVICA 2 SLA
IMFINZI 6 PA; MSD
IMLYGIC 6 MSD
IMURAN 3
INFUGEM 6 MSD
INLYTA 3 S; SLA; QL
IRESSA 3 S; SLA
irinotecan 6 MSD
ISTODAX 6 PA; MSD
IXEMPRA 6 PA; MSD
JAKAFI 3 S; SLA; QL
JEVTANA 6 PA; MSD
KADCYLA 6 PA; MSD
KISQALI 4 PA; S
KISQALI FEMARA CO-PACK
4 PA; S
KYMRIAH 6 MSD
KYPROLIS 6 MSD
Drug Name Drug
Category Requirements
/ Limits
LARTRUVO 6 MSD
LENVIMA 3 S
letrozole 1
LEUKERAN 2
leuprolide 1 S
LIBTAYO 6 MSD
lipodox 6 PA; MSD
lipodox 50 6 PA; MSD
LONSURF 3 S
LORBRENA 3 S
LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 11.25 MG
3 S; QL
LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 22.5 MG
4 S; QL
LUPRON DEPOT (4 MONTH)
4 S
LUPRON DEPOT (6 MONTH)
4 S
LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG
3 S
LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 7.5 MG
4 S
LUPRON DEPOT-PED
3 S
LYNPARZA 3 S
LYSODREN 3 S
MARQIBO 6 PA; MSD
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
MATULANE 2 SLA
megestrol oral
suspension 1
megestrol oral tablet 1 S
MEKINIST 3 S
MEKTOVI 3
melphalan 1
melphalan hcl 6 MSD
mercaptopurine 1
methotrexate sodium 1
methotrexate sodium
(pf) 1
mitomycin 6 PA; MSD
mitoxantrone 6 PA; MSD
MUTAMYCIN 6 MSD
mycophenolate
mofetil 1
mycophenolate
mofetil hcl 6 MSD
mycophenolate
sodium 1
MYFORTIC 3
MYLERAN 3 S
MYLOTARG 6 PA; MSD
NAVELBINE 6 PA; MSD
NEORAL 3 PA
NERLYNX 3 PA; S
NEXAVAR 3 S; QL
NILANDRON 4 S
nilutamide 1 S
NINLARO 3 S; SLA
NIPENT 6 PA; MSD
NULOJIX 6 MSD
Drug Name Drug
Category Requirements
/ Limits
octreotide acetate 1 S; SLA
ODOMZO 4 S
ONCASPAR 6 PA; MSD
ONIVYDE 6 MSD
OPDIVO INTRAVENOUS SOLUTION 100 MG/10 ML, 40 MG/4 ML
6 MSD
OPDIVO INTRAVENOUS SOLUTION 240 MG/24 ML
6 PA; MSD
oxaliplatin 6 PA; MSD
paclitaxel 6 MSD
PERJETA 6 PA; MSD
PORTRAZZA 6 MSD
POTELIGEO 6 MSD
PROGRAF ORAL CAPSULE
3
PROGRAF ORAL GRANULES IN PACKET
2
PURIXAN 2 SLA
RAPAMUNE ORAL SOLUTION
2
RAPAMUNE ORAL TABLET
3
RITUXAN 6 PA; MSD
RITUXAN HYCELA
6 PA; MSD
ROMIDEPSIN 6 MSD
RUBRACA 2 PA; SLA
RYDAPT 3 PA; S
SANDIMMUNE INTRAVENOUS
6 MSD
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
SANDIMMUNE ORAL CAPSULE
3
SANDIMMUNE ORAL SOLUTION
2
SANDOSTATIN 4 PA; S; SLA
SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 10 MG
6 MSD
SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 20 MG, 30 MG
6 PA; MSD
SIGNIFOR 6 MSD
SIGNIFOR LAR 6 MSD
SIKLOS 4 ST; S
SIMULECT 6 MSD
sirolimus 1
SOLTAMOX 3
SOMATULINE DEPOT
3 PA; S; SLA
SPRYCEL 3 S; QL
STIVARGA 3 S
SUPPRELIN LA 6 MSD
SUTENT 3 S; QL
SYLVANT 6 PA; MSD
SYNRIBO 6 MSD
TABLOID 3 S
tacrolimus 1
Drug Name Drug
Category Requirements
/ Limits
TAFINLAR 3 S
TAGRISSO 3 S
TALZENNA 3 S
tamoxifen 1
TARCEVA 3 S; QL
TARGRETIN ORAL
4 S
TARGRETIN TOPICAL
2 PA
TASIGNA 3 S; QL
TAXOTERE 6 PA; MSD
TECENTRIQ 6 MSD
TEMODAR 4 S
temozolomide 1 S
temsirolimus 6 MSD
TENIPOSIDE 6 PA; MSD
TEPADINA 6 MSD
THALOMID 3 S
thiotepa 6 PA; MSD
TIBSOVO 2 S
toposar 6 MSD
topotecan 6 MSD
toremifene 1 S
TORISEL 6 PA; MSD
TREANDA 6 MSD
TRELSTAR 6 PA; MSD
tretinoin
(chemotherapy) 1 S
TREXALL 3
TRIPTODUR 6 MSD
TRISENOX 6 PA; MSD
TYKERB 3 S; QL
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
UNITUXIN 6 MSD
VANTAS 6 PA; MSD
VECTIBIX 6 MSD
VELCADE 6 PA; MSD
VENCLEXTA 2 SLA
VENCLEXTA STARTING PACK
2 SLA
VERZENIO 3 S
VIDAZA 6 PA; MSD
vinblastine 6 PA; MSD
vincasar pfs 6 MSD
vincristine 6 PA; MSD
vinorelbine 6 MSD
VITRAKVI 3 S
VIZIMPRO 3 S
VOTRIENT 3 S; QL
VYXEOS 6 PA; MSD
XALKORI 3 PA; S; QL
XATMEP 4 ST; S
XELODA 4 S
XERMELO 2 PA; SLA
XOSPATA 3 S
XTANDI 3 S; QL
YERVOY 6 PA; MSD
YONDELIS 6 MSD
YONSA 3 PA; S
ZALTRAP 6 MSD
ZANOSAR 6 MSD
ZEJULA 2 PA; SLA
ZELBORAF 3 S; QL
ZEVALIN (Y-90) 6 MSD
ZOLADEX 6 PA; MSD
Drug Name Drug
Category Requirements
/ Limits
ZOLINZA 3 S; QL
ZORTRESS 2
ZYDELIG 2 SLA
ZYKADIA 3 S; SLA
ZYTIGA ORAL TABLET 250 MG
4 S; QL
ZYTIGA ORAL TABLET 500 MG
3 S; QL
AUTONOMIC & CNS DRUGS,
NEUROLOGY & PSYCH
ANTICONVULSANTS
APTIOM 3
BANZEL 2
BRIVIACT 3 ST
carbamazepine 1
CARBATROL 3
CELONTIN 2
clobazam 1
clonazepam 1
DEPACON 6 MSD
DEPAKENE 3 ST
DEPAKOTE 3 ST
DEPAKOTE ER 3 ST
DEPAKOTE SPRINKLES
3 ST
DIACOMIT 2
DIASTAT 3
DIASTAT ACUDIAL
3
diazepam 1
DILANTIN 2
DILANTIN EXTENDED
3
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
DILANTIN INFATABS
3
DILANTIN-125 3
divalproex 1
EPIDIOLEX 3 S
epitol 1
EQUETRO 3
ethosuximide 1
felbamate 1
FELBATOL 3
fosphenytoin 6 MSD
FYCOMPA 2
gabapentin 1
GABITRIL 3
GRALISE 2 ST; QL
GRALISE 30-DAY STARTER PACK
2 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
Drug Name Drug
Category Requirements
/ Limits
LAMICTAL STARTER (BLUE) KIT
3 ST
LAMICTAL STARTER (GREEN) KIT
3 ST
LAMICTAL STARTER (ORANGE) KIT
3 ST
LAMICTAL XR 3 ST
LAMICTAL XR STARTER (BLUE)
3 ST
LAMICTAL XR STARTER (GREEN)
3 ST
LAMICTAL XR STARTER (ORANGE)
3 ST
lamotrigine 1
levetiracetam in nacl
(iso-os) 6 MSD
levetiracetam
intravenous 6 MSD
levetiracetam oral 1
LYRICA 2 ST
LYRICA CR 3 ST
MYSOLINE 3
NEURONTIN 3 ST
ONFI 3
oxcarbazepine 1
OXTELLAR XR 3 ST
PEGANONE 2
phenobarbital 1
PHENYTEK 3
phenytoin 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
phenytoin sodium
extended 1
primidone 1
QUDEXY XR 2 ST
roweepra 1
roweepra xr 1
SABRIL 3 PA; S; SLA
SPRITAM 3 ST
subvenite 1
subvenite starter
(blue) kit 1
subvenite starter
(green) kit 1
subvenite starter
(orange) kit 1
SYMPAZAN 3
TEGRETOL 3
TEGRETOL XR 3
tiagabine 1
TOPAMAX 3 ST
topiramate oral
capsule, sprinkle 1 PA
TOPIRAMATE ORAL CAPSULE,SPRINKLE,ER 24HR
3 ST
topiramate oral
tablet 1 PA
TRILEPTAL 3 ST
TROKENDI XR 3 ST
valproate sodium 6 MSD
valproic acid 1
valproic acid (as
sodium salt) 1
Drug Name Drug
Category Requirements
/ Limits
vigabatrin 1 PA; S; SLA
vigadrone 1 PA; S; SLA
VIMPAT 2
ZARONTIN 3
ZONEGRAN ORAL CAPSULE 100 MG
3 PA
ZONEGRAN ORAL CAPSULE 25 MG
3
zonisamide 1 PA
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
entacapone 1 M
GOCOVRI 3 PA; ST; SLA
INBRIJA 2 M
LODOSYN 3 M
MIRAPEX 3 M
MIRAPEX ER 3 M
NEUPRO 3 ST; M
OSMOLEX ER 3 PA; ST; M
PARLODEL 3
pramipexole 1 M
rasagiline 1 M
REQUIP 3 M
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
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 ST; M
ZELAPAR 3 M
MIGRAINE & CLUSTER
HEADACHE THERAPY
AIMOVIG AUTOINJECTOR
2 M; QL
AJOVY 2 ST; M; QL
almotriptan malate 1 QL
AMERGE 3 ST; QL
CAFERGOT 3
D.H.E.45 3
dihydroergotamine
injection 1
dihydroergotamine
nasal 1 QL
eletriptan 1 QL
EMGALITY PEN 2 M; QL
Drug Name Drug
Category Requirements
/ Limits
EMGALITY SYRINGE
2 M; QL
ERGOMAR 3
ergotamine-caffeine 1
FROVA 3 ST; QL
frovatriptan 1 QL
IMITREX 3 ST; QL
IMITREX STATDOSE PEN
3 ST; QL
IMITREX STATDOSE REFILL
3 ST; QL
MAXALT 3 ST; QL
MAXALT-MLT 3 ST; QL
migergot 1
MIGRANAL 3 QL
naratriptan 1 QL
ONZETRA XSAIL 3 ST; QL
RELPAX 3 ST; QL
rizatriptan 1 QL
sumatriptan 1 QL
sumatriptan
succinate 1 QL
sumatriptan-
naproxen 1 QL
SUMAVEL DOSEPRO
3 ST; QL
TREXIMET 3 ST; QL
ZEMBRACE SYMTOUCH
3 ST; QL
zolmitriptan 1 QL
ZOMIG NASAL 2 ST; QL
ZOMIG ORAL 3 ST; QL
ZOMIG ZMT 3 ST; QL
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
MISCELLANEOUS
NEUROLOGICAL THERAPY
AMPYRA 4 PA; ST; S; SLA; QL
ARICEPT 3 ST; M
AUSTEDO 3 PA; S; SLA
dalfampridine 1 PA; ST; S; SLA; QL
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
FIRDAPSE 2
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; SLA
INGREZZA INITIATION PACK
3
KEVEYIS 3 PA; SLA
memantine oral
capsule,sprinkle,er
24hr
1 M; QL
memantine oral
solution 1 M
Drug Name Drug
Category Requirements
/ Limits
memantine oral
tablet 1 M
MEMANTINE ORAL TABLETS,DOSE PACK
3 M; QL
NAMENDA 3 ST; M
NAMENDA TITRATION PAK
3 M; QL
NAMENDA XR 3 ST; M; QL
NAMZARIC 2 ST
NUEDEXTA 2 PA
ONPATTRO 6 MSD
RADICAVA 6 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
TEGSEDI 4 S
tetrabenazine 1 PA
TYSABRI 6 MSD
XENAZINE 3 PA; ST
MUSCLE RELAXANTS &
ANTISPASMODIC THERAPY
AMRIX 3 ST
atracurium 6 MSD
baclofen oral tablet 10 mg, 20 mg
1 M
BACLOFEN ORAL TABLET 5 MG
3 M
BRIDION 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
carisoprodol 1
carisoprodol-asa-
codeine 1
carisoprodol-aspirin 1
chlorzoxazone oral
tablet 250 mg 1 PA
chlorzoxazone oral
tablet 375 mg, 500
mg, 750 mg
1
cisatracurium 6 MSD
cyclobenzaprine 1
CYCLOTENS REFILL
3
CYCLOTENS STARTER
3
DANTRIUM 3 M
dantrolene 1 M
FEXMID 3 ST
LORZONE 3 ST
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
NIMBEX 6 MSD
NORGESIC FORTE 3
orphenadrine citrate 1
Drug Name Drug
Category Requirements
/ Limits
pyridostigmine
bromide 1 M
ROBAXIN INJECTION
6 MSD
ROBAXIN ORAL 3
ROBAXIN-750 3
SKELAXIN 3
SOMA 3
tizanidine 1
ZANAFLEX 3
NARCOTIC ANALGESICS
ABSTRAL 3 ST; QL
acetaminophen-caff-
dihydrocod 1 QL
acetaminophen-
codeine 1 QL
ACTIQ 3 ST; QL
ALLZITAL 3 ST; QL
APADAZ 3
ARYMO ER 3 ST; QL
ascomp with codeine 1
BELBUCA 2 PA; ST
BENZHYDROCODONE-ACETAMINOPHEN
3
BUPAP 3 ST; QL
BUPRENEX 6 MSD
buprenorphine hcl
injection 6 MSD
buprenorphine hcl
sublingual 1
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
buprenorphine
transdermal patch
weekly 10 mcg/hour,
15 mcg/hour, 20
mcg/hour, 5
mcg/hour
2 ST; QL
BUPRENORPHINE TRANSDERMAL PATCH WEEKLY 7.5 MCG/HOUR
3 ST; QL
butalbital compound
w/codeine 1
butalbital-
acetaminop-caf-cod 1 QL
butalbital-
acetaminophen 1 QL
butalbital-
acetaminophen-caff 1 QL
butalbital-aspirin-
caffeine 1
BUTRANS 3 ST; QL
codeine sulfate 1
DEMEROL 3
DEMEROL (PF) 6 MSD
DILAUDID (PF) 6 MSD
DILAUDID ORAL LIQUID
3
DILAUDID ORAL TABLET 2 MG, 4 MG
3
DILAUDID ORAL TABLET 8 MG
3 QL
diskets 1 ST
DOLOPHINE 3 ST
DSUVIA 3
DURAGESIC 3 ST
dvorah 1 QL
Drug Name Drug
Category Requirements
/ Limits
EMBEDA 3 ST; QL
endocet 1 QL
ESGIC 3 ST; QL
EXALGO ER 3 ST; QL
fentanyl 1 ST
FENTANYL (PF)-BUPIVACAINE-NACL
6 MSD
fentanyl citrate 1 ST; QL
FENTANYL CITRATE (PF) INTRAVENOUS PT CONTROLLED ANALGESIA SYRING
6 MSD
fentanyl citrate (pf)
intravenous syringe 100 mcg/2 ml (50
mcg/ml)
6 MSD
FENTANYL CITRATE (PF) INTRAVENOUS SYRINGE 250 MCG/5 ML (50 MCG/ML), 50 MCG/ML
6 MSD
FENTANYL CITRATE (PF)-0.9%NACL INTRAVENOUS SOLUTION 10 MCG/ML, 20 MCG/ML
6 MSD
fentanyl citrate (pf)-
0.9%nacl
intravenous solution 5 mcg/ml
6 MSD
fentanyl citrate (pf)-
0.9%nacl
intravenous syringe
6 MSD
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
FENTANYL-ROPIVACAINE-NACL (PF)
6 MSD
FENTORA 3 ST; QL
FIORICET 3 ST; QL
FIORINAL 3 ST
FIORINAL-CODEINE #3
3
hydrocodone-
acetaminophen 1 QL
hydrocodone-
ibuprofen 1
HYDROMORPHONE (PF) IN WATER
6 MSD
HYDROMORPHONE (PF) INJECTION SOLUTION 1 MG/ML, 4 MG/ML
6 MSD
hydromorphone (pf)
injection solution 2
mg/ml
6 MSD
HYDROMORPHONE (PF)-0.9 % NACL
6 MSD
HYDROMORPHONE IN 0.9 % NACL INJECTION
6 MSD
HYDROMORPHONE IN 0.9 % NACL INTRAVENOUS PATIENT CONTROL.ANALGESIA SOLN
6 MSD
HYDROMORPHONE IN 0.9 % NACL INTRAVENOUS PREFILLED PUMP RESERVOIR
6 MSD
Drug Name Drug
Category Requirements
/ Limits
hydromorphone in
0.9 % nacl
intravenous pt
controlled analgesia
syring 15 mg/30 ml
(0.5 mg/ml)
6 MSD
HYDROMORPHONE 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
HYDROMORPHONE IN 0.9 % NACL INTRAVENOUS SOLUTION
6 MSD
HYDROMORPHONE IN 0.9 % NACL INTRAVENOUS SYRINGE
6 MSD
hydromorphone
injection solution 6 MSD
HYDROMORPHONE INJECTION SYRINGE 0.5 MG/0.5 ML
6 MSD
hydromorphone
injection syringe 1
mg/ml, 2 mg/ml, 4
mg/ml
6 MSD
HYDROMORPHONE INTRAVENOUS
6 MSD
hydromorphone oral
liquid 1
hydromorphone oral
tablet 2 mg, 4 mg 1
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
hydromorphone oral
tablet 8 mg 1 QL
hydromorphone oral
tablet extended
release 24 hr
1 ST; QL
hydromorphone
rectal 1
HYSINGLA ER 2 ST; QL
IBUDONE 3
ibuprofen-oxycodone 1
KADIAN 3 ST; QL
LAZANDA 3 ST; QL
levorphanol tartrate
oral tablet 2 mg 1
LEVORPHANOL TARTRATE ORAL TABLET 3 MG
3
lorcet (hydrocodone) 1 QL
lorcet hd 1 QL
lorcet plus 1 QL
LORTAB ELIXIR 3 QL
meperidine 1
methadone 1 ST
methadose 1 ST
MITIGO (PF) 6 MSD
MORPHABOND ER
3 ST; QL
morphine (pf) in 0.9
% nacl intravenous
pt controlled
analgesia syring 30
mg/30 ml (1 mg/ml)
6 MSD
Drug Name Drug
Category Requirements
/ Limits
MORPHINE (PF) IN 0.9 % NACL INTRAVENOUS PT CONTROLLED ANALGESIA SYRING 55 MG/55 ML (1 MG/ML)
6 MSD
morphine (pf) in 0.9
% nacl intravenous
solution 1 mg/ml
6 MSD
MORPHINE (PF) IN 0.9 % NACL INTRAVENOUS SOLUTION 5 MG/ML
6 MSD
morphine (pf) in 0.9
% nacl intravenous
syringe 0.5 mg/ml, 2
mg/2 ml (1 mg/ml)
6 MSD
MORPHINE (PF) IN 0.9 % NACL INTRAVENOUS SYRINGE 2 MG/ML, 4 MG/ML, 5 MG/5 ML (1 MG/ML)
6 MSD
morphine (pf)
injection 6 MSD
morphine (pf)
intravenous patient
control.analgesia
soln
6 MSD
MORPHINE (PF) INTRAVENOUS SYRINGE
6 MSD
morphine
concentrate 1
MORPHINE IN 0.9 % SODIUM CHLOR
6 MSD
morphine injection 6 MSD
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
MORPHINE INTRAMUSCULAR
6 MSD
morphine
intravenous pt
controlled analgesia
syring
6 MSD
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, 2 mg/ml, 4
mg/ml
6 MSD
MORPHINE INTRAVENOUS SYRINGE 8 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
NALOCET 3 QL
NORCO 3 ST; QL
Drug Name Drug
Category Requirements
/ Limits
OPANA 3
OXAYDO ORAL TABLET, ORAL ONLY 5 MG
3 QL
OXAYDO ORAL TABLET, ORAL ONLY 7.5 MG
3
oxycodone oral
capsule 1 QL
oxycodone oral
concentrate 1 QL
oxycodone oral
solution 1
oxycodone oral
tablet 10 mg, 20 mg 1
oxycodone oral
tablet 15 mg, 30 mg,
5 mg
1 QL
OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.12 HR
3 ST; QL
oxycodone-
acetaminophen 1 QL
oxycodone-aspirin 1
OXYCONTIN 2 ST; QL
oxymorphone oral
tablet 1
oxymorphone oral
tablet extended
release 12 hr
1 ST; QL
PERCOCET 3 QL
phrenilin forte(with
caffeine) 1 QL
PRIMLEV 3 QL
PROBUPHINE 6 MSD
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
ROXICODONE 3 QL
ROXYBOND ORAL TABLET, ORAL ONLY 15 MG, 30 MG
3
ROXYBOND ORAL TABLET, ORAL ONLY 5 MG
3 QL
SUBLOCADE 6 MSD
SUBSYS 3 ST; QL
tencon 1 QL
TREZIX 3 QL
TYLENOL-CODEINE #3
3 QL
TYLENOL-CODEINE #4
3 QL
VANATOL LQ 3 ST; QL
VANATOL S 3 ST; QL
vicodin 1 QL
vicodin es 1 QL
vicodin hp 1 QL
XTAMPZA ER 3 ST; QL
xylon 10 1
zebutal 1 QL
ZOHYDRO ER 3 ST; QL
NON-NARCOTIC ANALGESICS
adult aspirin
regimen 5 M; ACA; OTC
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
Drug Name Drug
Category Requirements
/ Limits
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 BUCCAL FILM 2.1-0.3 MG, 4.2-0.7 MG
3 QL
BUNAVAIL BUCCAL FILM 6.3-1 MG
3
buprenorphine-
naloxone sublingual
film 12-3 mg
1
buprenorphine-
naloxone sublingual
film 2-0.5 mg, 4-1
mg, 8-2 mg
1 QL
buprenorphine-
naloxone sublingual
tablet 2-0.5 mg
1 QL
buprenorphine-
naloxone sublingual
tablet 8-2 mg
1
butorphanol tartrate
injection 6 MSD
butorphanol tartrate
nasal 1 QL
CAMBIA 3 ST; QL
CAPSFENAC PAK 3 ST; M
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
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 3 ST; M
DICLO GEL-XRYLIX SHEET
3 ST; M
DICLOFENAC EPOLAMINE
3 ST; QL
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
DICLOFEX DC 3 ST; M
DICLOFONO 3 ST; M
DICLOPAK 3 ST; M
DICLOPR 3 ST; M
diflunisal 1 M
DISALCID 3
DITHOL 3 ST; M
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
Drug Name Drug
Category Requirements
/ Limits
etodolac 1 M
EUFLEXXA 6 MSD
EVZIO 3 ST
FELDENE 3 ST; M
FENOPROFEN ORAL CAPSULE
3 ST; M
fenoprofen oral
tablet 1 M
FENORTHO 3 ST; M
FLECTOR 2 ST; QL
flurbiprofen 1 M
FROTEK 3 ST; M
ibu 1 M
ibuprofen 1 M
INDOCIN 3 ST
indomethacin 1
ketoprofen 1 M
ketorolac injection 6 MSD
ketorolac
intramuscular 6 MSD
ketorolac oral 1 QL
LEXIXRYL 3 ST; M
lite coat aspirin 5 ACA; OTC
LODINE 3 ST; M
LUCEMYRA 3 ST
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
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
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
naltrexone 1
NAPRELAN CR 3 ST; M
NAPROSYN 3 ST; M
naproxen 1 M
naproxen sodium 1 M
NARCAN 2
NUCYNTA 2 QL
NUCYNTA ER 2 ST; QL
NUDROXIPAK 3 ST
oxaprozin 1 M
PENNSAID 3 ST; M; QL
pentazocine-
naloxone 1
piroxicam 1 M
QMIIZ ODT 3 ST; M
READYSHARP KETOROLAC
6 MSD
salsalate 1
SPRIX 3 ST; SLA; QL
st joseph aspirin 5 M; ACA; OTC
SUBOXONE SUBLINGUAL FILM 12-3 MG
2
Drug Name Drug
Category Requirements
/ Limits
SUBOXONE SUBLINGUAL FILM 2-0.5 MG, 4-1 MG, 8-2 MG
2 QL
sulindac 1 M
TALWIN 6 MSD
TIVORBEX 3 ST; M
tolmetin 1 M
TRAMADOL ORAL CAPSULE,ER BIPHASE 24 HR 17-83
3 ST; QL
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 QL
ULTRAM 3 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
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
ZUBSOLV SUBLINGUAL TABLET 0.7-0.18 MG, 11.4-2.9 MG, 2.9-0.71 MG, 8.6-2.1 MG
2
ZUBSOLV SUBLINGUAL TABLET 1.4-0.36 MG, 5.7-1.4 MG
2 QL
PSYCHOTHERAPEUTIC DRUGS
ABILIFY 3 ST; QL
ABILIFY MAINTENA
6 MSD
ABILIFY MYCITE ORAL TABLET WITH SENSOR AND PATCH 10 MG, 15 MG, 5 MG
3
ABILIFY MYCITE ORAL TABLET WITH SENSOR AND PATCH 2 MG, 20 MG, 30 MG
3 QL
ADASUVE 3
ADDERALL 3 ST; QL
ADDERALL XR 3 ST; QL
ADDYI 3 PA
ADZENYS ER 3 ST
ADZENYS XR-ODT
3 ST
alprazolam 1
alprazolam intensol 1
AMBIEN 3 ST; QL
AMBIEN CR 3 ST; QL
amitriptyline 1
Drug Name Drug
Category Requirements
/ Limits
amitriptyline-
chlordiazepoxide 1
amoxapine 1
amphetamine sulfate 1 PA
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
ARISTADA INITIO 6 MSD
armodafinil 1 PA; QL
ATIVAN INJECTION
6 MSD
ATIVAN ORAL 3
atomoxetine 1 QL
BELSOMRA 3 ST
BRISDELLE 3 ST; M; QL
bupropion hcl oral
tablet 1 M
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
BUPROPION HCL ORAL TABLET EXTENDED RELEASE 24 HR 450 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.
34
Drug Name Drug
Category Requirements
/ Limits
bupropion hcl oral
tablet sustained-
release 12 hr
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,DISINTEGRATING 150 MG, 200 MG
3
CLOZARIL 3
CONCERTA 3 ST; QL
COTEMPLA XR-ODT
3 ST
CYMBALTA 3 ST; M; QL
DAYTRANA 2 ST; QL
desipramine 1
DESOXYN 3 QL
DESVENLAFAXINE
3 ST; M; QL
desvenlafaxine
succinate 1 M; QL
Drug Name Drug
Category Requirements
/ Limits
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
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 2 ST; M; QL
flumazenil 6 MSD
fluoxetine oral
capsule 1 M; QL
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
fluoxetine oral
capsule,delayed
release(dr/ec)
1 M; QL
fluoxetine oral
solution 1 M
fluoxetine oral tablet 10 mg, 20 mg
1 M; QL
fluoxetine oral tablet 60 mg
1
fluphenazine
decanoate 6 MSD
fluphenazine hcl 1
flurazepam 1
fluvoxamine 1 M; QL
FOCALIN 3 QL
FOCALIN XR 3 ST; QL
FORFIVO XL 3 ST; M; QL
GEODON INTRAMUSCULAR
6 MSD
GEODON ORAL 3 QL
guanfacine 1 QL
guanidine 1
HALCION 3
HALDOL 6 MSD
HALDOL DECANOATE
3
haloperidol 1
haloperidol
decanoate 1
haloperidol lactate
injection 6 MSD
haloperidol lactate
oral 1
HETLIOZ 4 S; SLA; QL
Drug Name Drug
Category Requirements
/ Limits
imipramine hcl 1
imipramine pamoate 1
INTERMEZZO 3 ST; QL
INTUNIV ER 3 ST; QL
INVEGA 3 QL
KAPVAY 3 ST; QL
KHEDEZLA 3 ST; M; QL
LATUDA 2 QL
LEXAPRO 3 ST; M; QL
lithium carbonate 1
lithium citrate 1
LITHOBID 3
LORAZEPAM IN 0.9% SOD CHLORIDE
6 MSD
LORAZEPAM IN DEXTROSE 5 %
6 MSD
lorazepam injection 6 MSD
lorazepam intensol 1
lorazepam oral 1
loxapine succinate 1
LUNESTA 3 ST; QL
maprotiline 1
MARPLAN 3 M
metadate er 1 QL
methamphetamine 1 QL
METHYLIN 3 QL
methylphenidate hcl
oral capsule, er
biphasic 30-70 10
mg, 30 mg, 40 mg,
50 mg, 60 mg
1
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
methylphenidate hcl
oral capsule, er
biphasic 30-70 20
mg
1 QL
methylphenidate hcl
oral capsule,er
biphasic 50-50 10
mg, 30 mg, 40 mg,
60 mg
1
methylphenidate hcl
oral capsule,er
biphasic 50-50 20
mg
1 QL
methylphenidate hcl
oral solution 1 QL
methylphenidate hcl
oral tablet 1 QL
methylphenidate hcl
oral tablet extended
release 10 mg
1
methylphenidate hcl
oral tablet extended
release 20 mg
1 QL
methylphenidate hcl
oral tablet extended
release 24hr 18 mg,
27 mg, 36 mg, 54 mg
1 QL
METHYLPHENIDATE HCL ORAL TABLET EXTENDED RELEASE 24HR 72 MG
3 ST
methylphenidate hcl
oral tablet,chewable 1 QL
midazolam 6 MSD
midazolam (pf) 6 MSD
midazolam (pf) in
0.9 % nacl
intravenous solution
6 MSD
Drug Name Drug
Category Requirements
/ Limits
MIDAZOLAM (PF) IN 0.9 % NACL INTRAVENOUS SYRINGE
6 MSD
MIDAZOLAM IN 0.9 % SOD CHLORID
6 MSD
MIDAZOLAM IN DEXTROSE 5 %
6 MSD
mirtazapine 1 QL
modafinil 1 PA; QL
molindone 1
MYDAYIS 2 ST
NARDIL 3 M
nefazodone 1 M
NORPRAMIN 3
nortriptyline 1
NUPLAZID 4 S; SLA
NUVIGIL 3 PA; ST; QL
olanzapine
intramuscular 6 MSD
olanzapine oral 1 QL
olanzapine-
fluoxetine 1
ORAP 3
oxazepam 1
paliperidone 1 QL
PAMELOR 3
PARNATE 3 M
paroxetine hcl 1 M; QL
paroxetine
mesylate(menop.sym
)
1 M; QL
PAXIL CR 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.
37
Drug Name Drug
Category Requirements
/ Limits
PAXIL ORAL SUSPENSION
3 ST; M
PAXIL ORAL TABLET
3 ST; M; QL
perphenazine 1
perphenazine-
amitriptyline 1
PERSERIS 3
PEXEVA 3 ST; M; QL
phenelzine 1 M
pimozide 1
PRISTIQ 3 ST; M; QL
procentra 1 QL
protriptyline 1
PROVIGIL ORAL TABLET 100 MG
3 ST; QL
PROVIGIL ORAL TABLET 200 MG
3 PA; QL
PROZAC ORAL CAPSULE 10 MG, 40 MG
3 ST; M; QL
PROZAC ORAL CAPSULE 20 MG
3 ST; M
QUAZEPAM 3
quetiapine oral
tablet 100 mg, 25
mg, 50 mg
1 PA; QL
quetiapine oral
tablet 200 mg, 300
mg, 400 mg
1 QL
quetiapine oral
tablet extended
release 24 hr
1 QL
QUILLICHEW ER 2 ST
QUILLIVANT XR 2 ST; QL
RELEXXII 3 ST
Drug Name Drug
Category Requirements
/ Limits
REMERON 3 QL
REMERON SOLTAB
3 QL
RESTORIL 3
REXULTI 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 ORAL CAPSULE,ER BIPHASIC 50-50 10 MG, 30 MG, 40 MG
3 ST
RITALIN LA ORAL CAPSULE,ER BIPHASIC 50-50 20 MG
3 ST; QL
ROZEREM 2 ST; QL
SAPHRIS 3 QL
SARAFEM 3 ST; M; QL
seconal sodium 1
SEROQUEL ORAL TABLET 100 MG, 25 MG, 50 MG
3 PA; ST; QL
SEROQUEL ORAL TABLET 200 MG, 300 MG, 400 MG
3 ST; QL
SEROQUEL XR 3 ST; QL
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
sertraline oral
concentrate 1 M
sertraline oral tablet 1 M; QL
SILENOR 3 ST; QL
SPRAVATO 4 S; SLA
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
trimipramine 1
TRINTELLIX 3 ST; QL
VALIUM 3 ST
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 ST; M; QL
VERSACLOZ 3
Drug Name Drug
Category Requirements
/ Limits
VIIBRYD ORAL TABLET
2 ST; M; QL
VIIBRYD ORAL TABLETS,DOSE PACK
2 ST; QL
VRAYLAR 3
VYVANSE 2 ST; QL
WELLBUTRIN SR 3 ST; M; QL
WELLBUTRIN XL 3 ST; M; QL
XANAX 3 ST
XANAX XR 3 ST
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
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; QL
ZYPREXA INTRAMUSCULAR
6 MSD
ZYPREXA ORAL 3 QL
ZYPREXA ZYDIS 3 QL
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
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
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 ST
ANTIHYPERTENSIVE THERAPY
ACCUPRIL 3 M
ACCURETIC 3 M
acebutolol 1 M
ADALAT CC 3 ST; M
afeditab cr 1 M
ALDACTAZIDE 3 M
Drug Name Drug
Category Requirements
/ Limits
ALDACTONE 3 M
aliskiren 1 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
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
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
BREVIBLOC IN NACL (ISO-OSM)
6 MSD
bumetanide 1 M
BYSTOLIC 2 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
CARDIZEM 3 M
CARDIZEM CD 3 M
CARDIZEM LA 3 M
CARDURA 3 ST; M; QL
CARDURA XL 3 M; QL
CAROSPIR 3 ST; M
cartia xt 1 M
carvedilol 1 M
carvedilol phosphate 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
clonidine 1 M; QL
clonidine hcl 1 M
COREG 3 ST; M
COREG CR 3 ST; M
Drug Name Drug
Category Requirements
/ Limits
CORGARD 3 ST; M
COZAAR 3 ST; M
DEMADEX 3 M
DEMSER 2
DIBENZYLINE 3
diltiazem 1 M
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 3 ST; M
DYAZIDE 3 M
DYRENIUM 3 M
EDARBI 2 ST; M
EDARBYCLOR 2 ST; M
EDECRIN 3 M
enalapril maleate 1 M
enalaprilat 6 MSD
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
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
felodipine 1 M
FLOLAN 6 MSD
fosinopril 1 M
fosinopril-
hydrochlorothiazide 1 M
FUROSEMIDE IN 0.9 % NACL
6 MSD
furosemide injection 6 MSD
furosemide oral 1 M
guanfacine 1 M
HEMANGEOL 3 SLA
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
KAPSPARGO SPRINKLE
3 ST; M
LABETALOL IN DEXTROSE 5 %
6 MSD
labetalol
intravenous solution 6 MSD
Drug Name Drug
Category Requirements
/ Limits
labetalol
intravenous syringe 20 mg/4 ml (5
mg/ml), 25 mg/5 ml
(5 mg/ml)
6 MSD
LABETALOL INTRAVENOUS SYRINGE 50 MG/10 ML (5 MG/ML)
6 MSD
labetalol oral 1 M
LASIX 3 M
lisinopril 1 M
lisinopril-
hydrochlorothiazide 1 M
LOPRESSOR INTRAVENOUS
6 MSD
LOPRESSOR ORAL
3 ST; M
losartan 1 M
losartan-
hydrochlorothiazide 1 M
LOTENSIN 3 M
LOTENSIN HCT 3 M
LOTREL 3 ST; 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
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
METOPROLOL SU-HYDROCHLOROTHIAZ
3 ST; M
metoprolol ta-
hydrochlorothiaz 1 M
metoprolol tartrate
intravenous 6 MSD
metoprolol tartrate
oral 1 M
MICARDIS 3 ST; M
MICARDIS HCT 3 ST; M
MICROZIDE 3 M
MINIPRESS 3 M
minoxidil 1 M
moexipril 1 M
nadolol 1 M
nadolol-
bendroflumethiazide 1 M
nicardipine 1 M
nifedipine 1 M
nimodipine 1
nisoldipine 1 M
NORVASC 3 ST; M
NYMALIZE 3
olmesartan 1 M
olmesartan-
amlodipin-hcthiazid 1 M
olmesartan-
hydrochlorothiazide 1 M
ORENITRAM 4 PA; S; SLA
osmitrol 20 % 6 MSD
perindopril
erbumine 1 M
Drug Name Drug
Category Requirements
/ Limits
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
SULAR 3 ST; M
TARKA 3 M
taztia xt 1 M
TEKTURNA 2 ST; M
TEKTURNA HCT 2 ST; M
telmisartan 1 M
telmisartan-
amlodipine 1 M
telmisartan-
hydrochlorothiazid 1 M
TENORETIC 100 3 ST; M
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
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
treprostinil sodium 6 MSD
triamterene-
hydrochlorothiazid 1 M
TRIBENZOR 3 ST; M
TWYNSTA 3 ST; M
UPTRAVI 3 PA; S; SLA
valsartan 1 M
valsartan-
hydrochlorothiazide 1 M
VASERETIC 3 M
VASOTEC 3 M
veletri 6 MSD
verapamil 1 M
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
Drug Name Drug
Category Requirements
/ Limits
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 ORAL SOLUTION
2
AMICAR ORAL TABLET
3
aminocaproic acid 1
ANDEXXA 6 MSD
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
BENEFIX 6 MSD
BEVYXXA 3 QL
BIVALIRUDIN 6 MSD
BIVALIRUDIN-0.9 % SODIUM CHLOR
6 MSD
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
BRILINTA 2 M
CABLIVI 6 MSD
CEPROTIN (BLUE BAR)
6 MSD
CEPROTIN (GREEN BAR)
6 MSD
cilostazol 1 M
clopidogrel oral
tablet 300 mg 1 QL
clopidogrel oral
tablet 75 mg 1 M; QL
COAGADEX 6 MSD
CORIFACT 6 MSD
COUMADIN 3
DEFITELIO 6 MSD
dipyridamole 1 M
DOPTELET (15 TAB PACK)
3 PA; S
EFFIENT 3 M
ELIQUIS ORAL TABLET
2 PA; M
ELIQUIS ORAL TABLETS,DOSE PACK
2 PA
ELOCTATE 6 MSD
enoxaparin
subcutaneous
solution
6 MSD
enoxaparin
subcutaneous
syringe
1
FEIBA NF 6 MSD
FIBRYGA 6 MSD
fondaparinux 1
FRAGMIN 2
Drug Name Drug
Category Requirements
/ Limits
HELIXATE FS 6 MSD
HEMLIBRA 6 MSD
HEMOFIL M HIGH 6 MSD
HEMOFIL M LOW 6 MSD
HEMOFIL M MID 6 MSD
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(PORCINE) IN 0.45% NACL
6 MSD
heparin, porcine (pf)
injection 1
heparin, porcine (pf)
intravenous 1
HEPARIN, PORCINE (PF) SUBCUTANEOUS
3
HUMATE-P 6 MSD
IDELVION 6 MSD
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
IXINITY 6 MSD
jantoven 1
JIVI 6 MSD
KOATE 6 MSD
KOGENATE FS 6 MSD
KOVALTRY 6 MSD
LOVENOX SUBCUTANEOUS SOLUTION
6 MSD
LOVENOX SUBCUTANEOUS SYRINGE
3 ST
MEPHYTON 3
MONONINE 6 MSD
MULPLETA 3 PA; S
NOVOEIGHT 6 MSD
NOVOSEVEN RT 6 MSD
NPLATE 6 MSD
NUWIQ 6 MSD
OBIZUR 6 MSD
pentoxifylline 1 M
phytonadione
(vitamin k1) 1
PLAVIX 3 ST; M; QL
PRADAXA 3 PA; M
prasugrel 1 M
PRAXBIND 6 MSD
PROFILNINE 6 MSD
PROMACTA 2 PA
REBINYN 6 MSD
RECOMBINATE 6 MSD
RIASTAP 6 MSD
RIXUBIS 6 MSD
Drug Name Drug
Category Requirements
/ Limits
SAVAYSA 3 PA; M
TAVALISSE 3 PA
tranexamic acid 6 MSD
TRETTEN 6 MSD
VONVENDI 6 MSD
warfarin 1
WILATE 6 MSD
XARELTO ORAL TABLET
2 PA; M
XARELTO ORAL TABLETS,DOSE PACK
2 PA
XYNTHA 6 MSD
XYNTHA SOLOFUSE
6 MSD
YOSPRALA 3 ST; M
ZONTIVITY 2 PA; M
LIPID/CHOLESTEROL LOWERING
AGENTS
ALTOPREV 3 ST; M; QL
amlodipine-
atorvastatin 1 M; QL
ANTARA 3 ST; M; QL
atorvastatin oral
tablet 10 mg, 20 mg 5 M; ACA; QL
atorvastatin oral
tablet 40 mg, 80 mg 1 M; QL
CADUET 3 ST; M; QL
cholestyramine (with
sugar) 1 M
cholestyramine light 1 M
colesevelam 1 M
COLESTID 3 ST; M
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
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
oral tablet 145 mg,
48 mg
1 M; QL
FENOFIBRATE NANOCRYSTALLIZED ORAL TABLET 160 MG
3 ST; M; QL
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 5 M; ACA; QL
gemfibrozil 1 M; QL
JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 5 MG
3 PA; S; QL
JUXTAPID ORAL CAPSULE 30 MG, 40 MG, 60 MG
3 PA; S
LESCOL XL 3 ST; M; QL
Drug Name Drug
Category Requirements
/ Limits
LIPITOR 3 ST; M; QL
LIPOFEN 2 ST; M; QL
LIVALO 2 ST; M; QL
LOPID 3 M; QL
lovastatin 5 M; ACA; QL
LOVAZA 3 PA; M
niacin 1 M
NIACOR 3 M
NIASPAN EXTENDED-RELEASE
3 M
omega-3 acid ethyl
esters 1 PA; M
PRALUENT PEN 3 PA; S; SLA
PRAVACHOL 3 ST; M; QL
pravastatin 5 M; ACA; QL
prevalite 1 M
QUESTRAN 3 ST; M
QUESTRAN LIGHT
3 ST; M
REPATHA PUSHTRONEX
4 PA; S; SLA
REPATHA SURECLICK
4 PA; S; SLA
REPATHA SYRINGE
4 PA; S; SLA
rosuvastatin oral
tablet 10 mg, 5 mg 5 M; ACA; QL
rosuvastatin oral
tablet 20 mg, 40 mg 1 M; QL
simvastatin oral
tablet 10 mg, 20 mg,
40 mg, 5 mg
5 M; ACA; QL
simvastatin oral
tablet 80 mg 1 M; QL
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
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
ZYPITAMAG 3 ST; M
MISCELLANEOUS
CARDIOVASCULAR AGENTS
CORLANOR 2 PA; M
ENTRESTO 2 PA; M
GIAPREZA 6 MSD
NIPRIDE RTU 6 MSD
RANEXA 2 M
ranolazine 1 M
VECAMYL 3 SLA
NITRATES
DILATRATE-SR 2 M
GONITRO 3
ISOCHRON 3 M
ISORDIL 3 M
ISORDIL TITRADOSE
3 M
isosorbide dinitrate 1 M
isosorbide
mononitrate 1 M
Drug Name Drug
Category Requirements
/ Limits
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
calcitrene 1 QL
calcitriol 1 QL
COAL TAR 2
COSENTYX 3 ST; S; SLA; QL
COSENTYX (2 SYRINGES)
3 ST; S; SLA; QL
COSENTYX PEN 3 ST; S; SLA; QL
COSENTYX PEN (2 PENS)
3 ST; S; SLA; QL
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
DOVONEX 3 QL
drithocreme hp 1
ENSTILAR 2
EPIFOAM 3 ST
hydrocortisone-
pramoxine 1
ILUMYA 6 PA; ST; S; MSD
OVACE 3
OVACE PLUS SHAMPOO
3
OVACE PLUS TOPICAL CLEANSER
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
selenium sulfide 1
SELRX 3
SILIQ 4 ST; S
SKYRIZI 3 PA; ST; S
SORIATANE 3
SORILUX 3 QL
STELARA INTRAVENOUS
6 MSD
STELARA SUBCUTANEOUS
3 PA; ST; S
sulfacetamide
sodium 1
Drug Name Drug
Category Requirements
/ Limits
TACLONEX TOPICAL OINTMENT
3 QL
TACLONEX TOPICAL SUSPENSION
2
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
TERSI FOAM 3
TREMFYA SUBCUTANEOUS AUTO-INJECTOR
3 ST; S
TREMFYA SUBCUTANEOUS SYRINGE
3 PA; ST; S
VECTICAL 3 QL
ZITHRANOL 3
BURN THERAPY
SILVADENE 3
silver sulfadiazine 1
ssd 1
KERATOLYTICS
BENSAL HP 3
INOVA 4-1 3 ST
KERALYT RX 3
PODOCON 3
SALEX 3
salicylic acid 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
salimez 1
SALIMEZ FORTE 3
SALKERA 3
salvax 1
SALVAX DUO PLUS
3
ULTRASAL-ER 3
VIRASAL 3
MISCELLANEOUS
DERMATOLOGICALS
ALEVICYN PLUS 3
AMELUZ 6 MSD
ATOPADERM 3
ATOPICLAIR 3
ATRAPRO CP 3
ATRAPRO HYDROGEL
3
avo cream 1
BIAFINE EMULSION
3
CARAC 2
celacyn 1
CERAMAX 3
CONDYLOX 3
CORTANE-B 3
DEXERYL 3
diclofenac sodium 1 PA
doxepin 1 ST; QL
DUPIXENT 3 PA; S
EFUDEX 3
eletone 1
ELIDEL 2 ST; QL
Drug Name Drug
Category Requirements
/ Limits
EPICERAM 3
EUCRISA 3 PA; ST; QL
FLUOROPLEX 3
FLUOROURACIL TOPICAL CREAM 0.5 %
3 ST
fluorouracil topical
cream 5 % 1 PA
fluorouracil topical
solution 1 PA
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
LEVICYN ANTIPRURITIC
3
LEVICYN ANTIPRURITIC SG
3
LEVULAN 6 MSD
LOUTREX 3
LOYON 3
luxamend 1
methoxsalen 1
MIMYX 3
NEOCERA 3
NEOSALUS 3
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
nivatopic plus 1
NUTRASEB 3
OXSORALEN ULTRA
3
PANRETIN 3
PENLEN 3
PICATO 2 QL
pimecrolimus 1 ST; QL
podofilox 1
PRESERA 3
PROMISEB 3
PROTOPIC 3 ST; QL
pruclair 1
prudoxin 1 ST; QL
prumyx 1
prutect 1
QBREXZA 2
QUTENZA 6 MSD
REGRANEX 2 QL
RESTIZAN 3
silver nitrate 1
silver nitrate
applicators 1
SOLARAZE 3 PA
SOLOX GEL 3
sonafine 1
sp antipruritic 1
sp scar management 1
tacrolimus 1 ST; QL
TOLAK 3
TRIXYLITRAL 3
umecta 1
Drug Name Drug
Category Requirements
/ Limits
urea 1
urea nail stick 1
UTOPIC 3
VALCHLOR 3 PA; S; SLA
VEREGEN 3
XCLAIR 3
ZONALON 3 ST; QL
THERAPY FOR ACNE
ABSORICA 2 QL
ACANYA 2 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 topical
solution 1
adapalene topical
swab 1
adapalene-benzoyl
peroxide 1 QL
AKTIPAK 3 ST
ALTRENO 3
amnesteem 1 QL
ATRALIN 3 QL
AVAR LS 3 ST
avar topical cleanser 1
AVAR TOPICAL PADS, MEDICATED
3 ST
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
AVAR-E GREEN 3 ST
AVAR-E LS 3 ST
avita topical cream 1 QL
AVITA TOPICAL GEL
3 QL
azelaic acid 2
AZELEX 3 ST; QL
BENZACLIN 3 ST
BENZACLIN PUMP
3 ST; QL
BENZAMYCIN 3 ST
benzepro 1
benzoyl peroxide 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 topical
foam
1
clindamycin
phosphate topical
gel
1
CLINDAMYCIN PHOSPHATE TOPICAL GEL, ONCE DAILY
3 ST
clindamycin
phosphate topical
lotion
1
Drug Name Drug
Category Requirements
/ Limits
clindamycin
phosphate topical
solution
1
clindamycin
phosphate topical
swab
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
dapsone 1
DIFFERIN 3 ST; QL
DUAC 3 ST; QL
EPIDUO 3 ST; QL
EPIDUO FORTE 2 ST
ery pads 1
erygel 1
erythromycin with
ethanol 1
erythromycin-
benzoyl peroxide 1
EVOCLIN 3 ST
FABIOR 3 PA; QL
FINACEA TOPICAL FOAM
2 ST
FINACEA TOPICAL GEL
3 ST
INOVA 3 ST
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
isotretinoin 1 QL
METROCREAM 3 ST
METROGEL 3 ST
METROLOTION 3 ST
metronidazole 1
MIRVASO 2 ST
myorisan 1 QL
neuac 1 QL
NEUAC KIT 3 ST
NORITATE 3 ST
ONEXTON 2 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
RETIN-A TOPICAL GEL 0.025 %
3 QL
RHOFADE 3 ST
rosadan topical
cream 1
rosadan topical gel 1
ROSADAN TOPICAL KIT, CLEANSER AND GEL
3 ST
Drug Name Drug
Category Requirements
/ Limits
ROSADAN TOPICAL KIT,CLEANSER AND CREAM
3 ST
ROSANIL 3 ST
ROSULA 3 ST
rosula cleansing
cloths 1
SOOLANTRA 2 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
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
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
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
DERMACINRX EMPRICAINE
3
DOLOTRANZ 3
ethyl chloride 1
glydo 1
LDO PLUS 3
LEVA SET 3
lidocaine (pf)
injection solution 6 MSD
LIDOCAINE (PF) INJECTION SYRINGE 100 MG/5 ML (2 %), 200 MG/10 ML (2 %), 200 MG/20 ML (1 %), 40 MG/2 ML (2%), 400 MG/20 ML (2 %)
6 MSD
lidocaine (pf)
injection syringe 50
mg/5 ml (1 %)
6 MSD
Drug Name Drug
Category Requirements
/ Limits
lidocaine hcl
injection solution 6 MSD
lidocaine hcl
injection syringe 10
mg/ml (1 %), 100
mg/10 ml (1 %)
6 MSD
LIDOCAINE HCL INJECTION SYRINGE 100 MG/5 ML (2 %), 30 MG/3 ML (1%), 50 MG/5 ML (1 %)
6 MSD
LIDOCAINE HCL INTRADERMAL
6 MSD
lidocaine hcl
laryngotracheal 1
lidocaine hcl mucous
membrane 1
lidocaine hcl topical
cream 3 % 1
LIDOCAINE HCL TOPICAL CREAM 3.88 %
3
lidocaine hcl-
hydrocortison ac 1
lidocaine topical
adhesive
patch,medicated
1 PA
lidocaine topical
ointment 1
lidocaine viscous 1
lidocaine-prilocaine 1
LIDODERM 3 ST
LIDOPAC 3
lidopin topical
cream 3 % 1
LIDOPIN TOPICAL CREAM 3.25 %
3
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
LIDO-PRILO CAINE PACK
3
LIDORX 3
LIDOTRAL 3
lidozion 1
LIDTOPIC MAX 3
LIPROZONEPAK 3
lta pre-attached 1
MEDOLOR PAK 3
NUMBONEX 3
P-CARE X (PF) 6 MSD
PLIAGLIS 3 ST
PRIKAAN 3
PRIKAAN LITE 3
PRILOLID 3
PRILOVIX 3
PRILOVIX LITE 3
READYSHARP LIDOCAINE (PF)
6 MSD
relador pak 1
relador pak plus 1
SYNERA 3
TRANZAREL 3
XYLOCAINE 6 MSD
XYLOCAINE-MPF 6 MSD
ZINGO 6 MSD
ZTLIDO 2
TOPICAL ANTIBACTERIALS
ALTABAX 3
CENTANY 3
CENTANY AT 3
CORTISPORIN 3
Drug Name Drug
Category Requirements
/ Limits
dermazene 1
gentamicin 1
hydrocortisone-
iodoquinol 1
hydrocortisone-
iodoquinol-aloe 1
KLARON 3 ST
lugols 1
mafenide acetate 1
mupirocin 1
mupirocin calcium 1
NEO-SYNALAR 3
NEO-SYNALAR KIT
3
SILVRSTAT 3
sulfacetamide
sodium (acne) 1
SULFAMYLON TOPICAL CREAM
2
SULFAMYLON TOPICAL PACKET
3
XEPI 3
TOPICAL ANTIFUNGALS
ciclodan 1
CICLODAN KIT TOPICAL COMBO PACK
3
CICLODAN KIT TOPICAL SOLUTION
3 ST
ciclopirox 1
clotrimazole-
betamethasone 1
econazole 1
ECOZA 3
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
ERTACZO 3
EXELDERM 3
EXODERM 3
EXTINA 3
JUBLIA 3 ST; QL
KERYDIN 3 ST; QL
ketoconazole 1
LOPROX 3
LOPROX (AS OLAMINE)
3
LOPROX KIT 3
LOTRISONE 3
LULICONAZOLE 3 ST; QL
LUZU 3 QL
MICONAZOLE NITRATE-ZINC OX-PET
3
naftifine 1
NAFTIN 3
NIZORAL 3
nyamyc 1
nystatin 1
nystatin-
triamcinolone 1
nystop 1
oxiconazole 1
OXISTAT 3
PENLAC 3 ST
TRIACETIN 2
TRIPLE DYE 3
VUSION 3
XOLEGEL 3
Drug Name Drug
Category Requirements
/ Limits
TOPICAL ANTIVIRALS
acyclovir 1 QL
DENAVIR 3
XERESE 3 ST
ZOVIRAX TOPICAL CREAM
2 QL
ZOVIRAX TOPICAL OINTMENT
3 QL
TOPICAL CORTICOSTEROIDS
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
BRYHALI 3 ST
CAPEX 3 ST; QL
clobetasol 1
clobetasol-emollient 1
CLOBEX 3 ST
CLOCORTOLONE PIVALATE
3 ST; QL
clodan 1
CLODAN KIT 3 ST
CLODERM 3 ST; QL
CORDRAN 3 ST
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
CORDRAN TAPE LARGE ROLL
3 ST; QL
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
topical cream 1 QL
desoximetasone
topical gel 1 QL
desoximetasone
topical ointment 1 QL
desoximetasone
topical spray,non-
aerosol
1
diflorasone 1 QL
DIPROLENE 3 ST
DUOBRII 3
ELLZIA PAK 3
ELOCON 3 ST
fluocinolone 1 QL
fluocinolone and
shower cap 1 QL
fluocinonide 1
fluocinonide-
emollient 1
flurandrenolide 1
Drug Name Drug
Category Requirements
/ Limits
fluticasone
propionate 1
halobetasol
propionate topical
cream
1 QL
HALOBETASOL PROPIONATE TOPICAL FOAM
3 ST
halobetasol
propionate topical
ointment
1 QL
HALOG 3 ST
hydrocortisone 1
hydrocortisone
butyrate 1
hydrocortisone
butyr-emollient 1
hydrocortisone
valerate 1
IMPOYZ 3 ST
KENALOG 3 ST
LEXETTE 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
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
SILALITE PAK 3
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
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; QL
VERDESO 3 ST
TOPICAL ENZYMES
Drug Name Drug
Category Requirements
/ Limits
SANTYL 2
TOPICAL SCABICIDES /
PEDICULICIDES
crotan 1
ELIMITE 3
EURAX 3
lindane 1
malathion 1
NATROBA 3 QL
OVIDE 3
permethrin 1
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
6 MSD
MISCELLANEOUS AGENTS
ABLYSINOL 6 MSD
acamprosate 1
ADAGEN 6 MSD
AGRYLIN 3 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
alendronate 1 M; QL
AMMONUL 6 MSD
AMPHADASE 6 MSD
anagrelide 1 M
ANTABUSE 3
aqua care sterile
water 1
ARALAST NP 6 MSD
BUPHENYL 3
caffeine citrate 1
CARBAGLU 3 PA; S; SLA
CARNITOR 3 M
CARNITOR (SUGAR-FREE)
3 M
cevimeline 1 M
CHEMET 2
CHOLETEC 6 MSD
deferasirox 1 S
disulfiram 1
ENDARI 3 PA; ST; SLA
etidronate disodium 1 M
EVOXAC 3 M
EXJADE 4 S; SLA
FERRIPROX 3 S; SLA
FERRLECIT 6 MSD
GLASSIA 6 MSD
GLEOLAN 3
ic green 6 MSD
INCRELEX 3 PA; ST; S; SLA
indocyanine green 6 MSD
INFASURF 6 MSD
Drug Name Drug
Category Requirements
/ Limits
JADENU 3 S
JADENU SPRINKLE
3 S
KIT FOR TC 99M-SESTAMIBI NO.1
6 MSD
KIT PREP OF TC-99M-MEBROFENIN
6 MSD
KIT PREP OF TC-99M-SOD PYROPH
6 MSD
levocarnitine 1 M
levocarnitine (with
sugar) 1 M
LIPOCHOL PLUS 3
LIQUIVIDA HYDRATION KIT
6 MSD
LITHOSTAT 3
METOPIRONE 3 SLA
midodrine 1
NITYR 2 SLA
NORTHERA 4 PA; S; SLA
ORFADIN 2 SLA
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
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
sodium chlor 0.9%
bacteriostat 6 MSD
sodium chloride 0.9
% 6 MSD
sodium chloride 0.9
% (flush) 1
sodium ferric
gluconat-sucrose 6 MSD
sodium
phenylbutyrate 1
SOLIRIS 6 MSD
SURVANTA 6 MSD
SYPRINE 3 PA; QL
THALLOUS CHLORIDE TL-201
6 MSD
THIOLA 3 SLA
TIGLUTIK 3
trientine 1 PA; QL
ULTOMIRIS 6 MSD
water for irrigation,
sterile 1
XURIDEN 2 SLA
ZEMAIRA 6 MSD
zoledronic acid-
mannitol-water 6 MSD
SMOKING DETERRENTS
bupropion hcl
(smoking deter) 5 M; ACA
CHANTIX 5 ACA
CHANTIX CONTINUING MONTH BOX
5 ACA
CHANTIX STARTING MONTH BOX
5 ACA
Drug Name Drug
Category Requirements
/ Limits
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
NICOTROL NS 5 ACA
quit 2 buccal gum 5 ACA; OTC
QUIT 2 BUCCAL LOZENGE
5 ACA; OTC
quit 4 buccal gum 5 ACA; 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
QUIT 4 BUCCAL LOZENGE
5 ACA; OTC
stop smoking aid 5 ACA; OTC
ZYBAN 5 M; ACA
EAR, NOSE & THROAT
MEDICATIONS
MISCELLANEOUS AGENTS
ARESTIN 6 MSD
ASTEPRO 3 QL
azelastine 1 QL
chlorhexidine
gluconate 1
CLINPRO 5000 3 M
DEBACTEROL 3
denta 5000 plus 1 M
dentagel 1 M
EPISIL 3
FLUORIDEX DAILY DEFENSE
3 M
GELCLAIR 3
ipratropium bromide 1 QL
MUGARD 3
olopatadine 1 QL
oralone 1
ORAMAGICRX 3
paroex oral rinse 1
PATANASE 3 QL
PERIDEX 3
periogard 1
pilocarpine hcl 1
PREVIDENT 3 M
Drug Name Drug
Category Requirements
/ Limits
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
PROTHELIAL 4 S; SLA
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 ST
ciprofloxacin hcl 1
DERMOTIC OIL 3
flac otic oil 1
fluocinolone
acetonide oil 1
hydrocortisone-
acetic acid 1
ofloxacin 1
OTIPRIO 3
OTIC STEROID / ANTIBIOTIC
CIPRO HC 3
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
CIPRODEX 2
COLY-MYCIN S 3
neomycin-
polymyxin-hc 1
OTOVEL 2
ENDOCRINE/DIABETES
ADRENAL HORMONES
ACTHAR H.P. 6 MSD
BETAMETH AC,SOD PHOS(PF)-WATER
6 MSD
BETAMETHASONE ACE,SOD PHOS-WTR
6 MSD
betamethasone
acet,sod phos 6 MSD
BETAMETHASONE SOD PHOSPH-WATER
6 PA; MSD
CELESTONE SOLUSPAN
6 MSD
CORTEF 3 M
cortisone 1
CORTROSYN 6 MSD
cosyntropin 6 MSD
decadron 1
deltasone 1
DEXAMETHASONE AC, SOD PH-WATER
6 MSD
DEXAMETHASONE ACE-NACL,ISO-OSM
6 MSD
dexamethasone
intensol 1
Drug Name Drug
Category Requirements
/ Limits
dexamethasone oral
elixir 1
dexamethasone oral
solution 1
dexamethasone oral
tablet 1
dexamethasone oral
tablets,dose pack 1 ST
dexamethasone
sodium phosphate 6 MSD
DEXPAK 10 DAY 3 ST
DEXPAK 13 DAY 3 ST
DEXPAK 6 DAY 3 ST
DXEVO 3 ST
EMFLAZA 3 PA; ST; SLA
fludrocortisone 1 M
hidex 1 ST
hydrocortisone 1 M
KENALOG 6 MSD
MEDROL 3
MEDROL (PAK) 3
METHYLPRED AC(PF)-NACL,ISO-OSM
6 MSD
METHYLPREDNISOL AC-BUPIVAC-WAT
6 MSD
methylprednisolone 1
METHYLPREDNISOLONE ACET-WATER
6 MSD
millipred 1
millipred dp 1
ORAPRED ODT 3
P-CARE K40 6 MSD
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
P-CARE K80 6 MSD
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 ST
READYSHARP DEXAMETHASONE
6 MSD
TAPERDEX 3 ST
TRIAMCINOL AC (PF) IN 0.9%NACL
6 MSD
TRIAMCINOL ACE-BUPIV-0.9% NACL
6 MSD
TRIAMCINOLONE ACETON-0.9% NACL
6 MSD
triamcinolone
acetonide 6 MSD
TRIAMCINOLONE DIA(PF)-0.9%NACL
6 MSD
TRIAMCINOLONE DIACET-0.9% NACL
6 MSD
veripred 20 1
ANTITHYROID AGENTS
methimazole 1 M
propylthiouracil 1 M
SSKI 3 M
Drug Name Drug
Category Requirements
/ Limits
TAPAZOLE 3 M
BLOOD GLUCOSE MONITORING
DEVICES & SUPPLIES
ACCU-CHEK AVIVA PLUS TEST STRP
3 ST; OTC; QL
ACCU-CHEK COMPACT PLUS TEST
3 ST; OTC; QL
ACCU-CHEK GUIDE
3 ST; OTC
ACCU-CHEK SMARTVIEW TEST STRIP
3 ST; OTC; QL
ACCUTREND GLUCOSE
3 ST; OTC; QL
ADVANCED GLUC METER TEST STRIP
3 ST; OTC
ADVOCATE REDI-CODE
3 ST; OTC; QL
ADVOCATE TEST STRIPS
3 ST; OTC; QL
AGAMATRIX AMP TEST STRIPS
3 ST; OTC; QL
ASSURE 4 STRIPS 3 ST; OTC; QL
ASSURE PLATINUM
3 ST; OTC; QL
ASSURE PRISM MULTI STRIP
3 ST; OTC
BIONIME RIGHTEST TEST STRIPS
3 ST; OTC; QL
BLOOD GLUCOSE TEST
3 ST; OTC; QL
CARESENS N TEST STRIPS
3 ST; OTC; QL
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
CARETOUCH TEST STRIP
3 ST; OTC
CLEVER CHOICE MICRO TEST STRIP
3 ST; OTC; QL
CLEVER CHOICE PRO
3 ST; OTC; QL
CLEVER CHOICE TALK TEST
3 ST; OTC
CLEVER CHOICE TEST STRIPS
3 ST; OTC; QL
CLEVER CHOICE VOICE+ TEST
3 ST; OTC; QL
CONTOUR NEXT TEST STRIPS
3 ST; OTC; QL
CONTOUR TEST STRIPS
3 ST; OTC; QL
COOL GLUCOSE TEST STRIP
3 ST; OTC; QL
DIATRUE PLUS TEST STRIP
3 ST; OTC
EASY PLUS II TEST
3 ST; OTC; QL
EASY STEP 3 ST; OTC; QL
EASY TALK GLUCOSE TEST
3 ST; OTC; QL
EASY TOUCH TEST STRIP
3 ST; OTC; QL
EASY TRAK GLUCOSE TEST
3 ST; OTC; QL
EASYGLUCO PLUS
3 ST; OTC
EASYGLUCO TEST
3 ST; OTC; QL
EASYMAX 3 ST; OTC; QL
Drug Name Drug
Category Requirements
/ Limits
ELEMENT COMPACT TEST STRIPS
3 ST; OTC
ELEMENT TEST STRIPS
3 ST; OTC; QL
EMBRACE BLOOD GLUCOSE SYSTEM
3 ST; OTC; QL
EMBRACE EVO TEST STRIPS
3 ST; OTC
EMBRACE PRO TEST STRIPS
3 ST; OTC
EMBRACE TALK TEST STRIPS
3 ST; OTC
EVENCARE G2 3 ST; OTC; QL
EVENCARE G3 TEST
3 ST; OTC; QL
EVENCARE MINI GLUCOSE TEST STR
3 ST; OTC
EVOLUTION TEST STRIPS
3 ST; OTC; QL
EZ SMART PLUS TEST
3 ST; OTC; QL
EZ SMART TEST 3 ST; OTC; QL
FIFTY50 TEST STRIP
3 ST; OTC; QL
FORA D15G STRIPS
3 ST; OTC; QL
FORA D20 3 ST; OTC; QL
FORA D40-G31 TEST STRIPS
3 ST; OTC; QL
FORA G20 3 ST; OTC; QL
FORA G30-PREMIUM V10 TEST STRP
3 ST; OTC; QL
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
FORA GD50 TEST STRIPS
3 ST; OTC
FORA GTEL GLUCOSE TEST STRIP
3 ST; OTC
FORA TEST STRIP 3 ST; OTC; QL
FORA TN'G VOICE TEST STRIPS
3 ST; OTC
FORA V10 3 ST; OTC
FORA V10-V12-D10-D20 STRIPS
3 ST; OTC
FORA V12 GLUCOSE
3 ST; OTC
FORA V20 3 ST; OTC; QL
FORACARE GD20 3 ST; OTC; QL
FORACARE GD40 3 ST; OTC; QL
FORTISCARE GLUCOSE TEST STRIPS
3 ST; OTC
FREESTYLE INSULINX
3 ST; OTC; QL
FREESTYLE INSULINX TEST STRIPS
3 ST; OTC; QL
FREESTYLE LITE STRIPS
3 ST; OTC; QL
FREESTYLE PRECISION NEO STRIPS
3 ST; OTC
FREESTYLE TEST 3 ST; OTC; QL
GE100 BLOOD GLUCOSE TEST STRIP
3 ST; OTC; QL
GENSTRIP TEST STRIP
3 ST; OTC
GLUCO NAVII TEST STRIP
3 ST; OTC; QL
Drug Name Drug
Category Requirements
/ Limits
GLUCOCARD 01 SENSOR PLUS
3 ST; OTC
GLUCOCARD EXPRESSION
3 ST; OTC; QL
GLUCOCARD SHINE TEST STRIPS
3 ST; OTC
GLUCOCARD VITAL SENSOR
3 ST; OTC; QL
GLUCOCARD VITAL TEST STRIPS
3 ST; OTC; QL
GLUCOCOM GLUCOSE
3 ST; OTC; QL
GM100 3 ST; OTC; QL
HEALTHPRO TEST STRIPS
3 ST; OTC
IGLUCOSE TEST STRIP
3 ST; OTC
INFINITY TEST STRIPS
3 ST; OTC; QL
INFINITY VOICE TEST STRIP
3 ST; OTC
MICRO BLOOD GLUCOSE
3 ST; OTC
MICRODOT BLOOD GLUCOSE SYSTEM
3 ST; OTC; QL
MYGLUCOHEALTH
3 ST; OTC; QL
NEUTEK 2TEK TEST STRIPS
3 ST; OTC; QL
NOVA MAX GLUCOSE TEST
3 ST; OTC; QL
ON CALL EXPRESS TEST STRIP
3 ST; OTC
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
ON CALL PLUS TEST STRIP
3 ST; OTC; QL
ON CALL VIVID TEST STRIP
3 ST; OTC; QL
ONETOUCH ULTRA BLUE TEST STRIP
2 ST; OTC; QL
ONETOUCH VERIO
2 ST; OTC; QL
OPTIUM EZ 3 ST; OTC; QL
OPTIUM TEST 3 ST; OTC; QL
OPTUMRX 3 ST; OTC; QL
PHARMACIST CHOICE
3 ST; OTC; QL
PRECISION PCX PLUS TEST
3 ST; OTC; QL
PRECISION PCX TEST
3 ST; OTC; QL
PRECISION POINT OF CARE TEST
3 ST; OTC; QL
PRECISION Q-I-D TEST
3 ST; OTC; QL
PRECISION XTRA TEST
3 ST; OTC; QL
PREMIER TEST STRIP
3 ST; OTC
PREMIUM V10 3 ST; OTC; QL
PRO VOICE V8-V9 TEST STRIP
3 ST; OTC
PRODIGY NO CODING
3 ST; OTC; QL
QUINTET AC 3 ST; OTC
REFUAH PLUS 3 ST; OTC; QL
RELION CONFIRM-MICRO
3 ST; OTC; QL
Drug Name Drug
Category Requirements
/ Limits
RELION PRIME TEST STRIPS
3 ST; OTC; QL
REVEAL TEST STRIP
3 ST; OTC; QL
RIGHTEST GS550 TEST STRIPS
3 ST; OTC; QL
SMART SENSE TEST STRIPS
3 ST; OTC
SMARTEST TEST 3 ST; OTC; QL
SOLUS V2 TEST STRIPS
3 ST; OTC; QL
SURE-TEST EASYPLUS MINI
3 ST; OTC; QL
TELCARE TEST STRIPS
3 ST; OTC; QL
TEST N'GO TEST 3 ST; OTC; QL
TRUE METRIX GLUCOSE TEST STRIP
3 ST; OTC
TRUETEST TEST STRIPS
3 ST; OTC
TRUETRACK TEST
3 ST; OTC; QL
ULTIMA TEST STRIPS
3 ST; OTC
ULTRATRAK 3 ST; OTC
ULTRATRAK ULTIMATE
3 ST; OTC; QL
UNISTRIP1 TEST STRIP
3 ST; OTC
VERASENS TEST STRIP
3 ST; OTC
WAVESENSE JAZZ
3 ST; OTC
WAVESENSE PRESTO
3 ST; OTC; QL
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
DIABETES, SUPPLIES, & DURABLE
MEDICAL EQUIPMENT
GLUCAGEN DIAGNOSTIC KIT
2
GLUCAGON HCL 3
INSULIN SYRINGE-NEEDLE U-100
3 M
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 ST; OTC; QL
ACCU-CHEK AVIVA PLUS METER
3 ST; OTC; QL
ACCU-CHEK COMPACT PLUS CONTROL
3 OTC
ACCU-CHEK GUIDE GLUCOSE METER
3 ST; OTC
ACCU-CHEK GUIDE L1-L2 CTRL SOL
3 OTC
ACCU-CHEK GUIDE ME GLUCOSE MTR
3 ST; OTC
ACCU-CHEK NANO
3 ST; OTC; QL
Drug Name Drug
Category Requirements
/ Limits
ACCU-CHEK SMARTVIEW CONTRL SOL
3 OTC
ACCUTREND GLUCOSE CONTROL
3 OTC
ADVANCED GLUCOSE METER
3 ST; OTC
ADVOCATE BLOOD GLUCOSE MONITOR
3 ST; OTC; QL
ADVOCATE DUO 3 ST; OTC; QL
ADVOCATE LOW CONTROL
3 OTC
ADVOCATE REDI-CODE DUO METER
3 ST; OTC; QL
ADVOCATE REDI-CODE GLU MONITOR
3 ST; OTC; QL
ADVOCATE REDI-CODE+ CTRL LOW
3 OTC
AGAMATRIX AMP GLUC MONITOR SYS
3 ST; OTC
AGAMATRIX CONTROL HIGH
3 OTC
ASSURE 4 CONTROL SOLUTION
3 OTC
ASSURE DOSE NORMAL CONTROL
3 OTC
ASSURE PLATINUM
3 ST; OTC; QL
ASSURE PRISM CONTROL 1-2 SOLN
3 OTC
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
ASSURE PRISM MULTI METER
3 ST; OTC
AUTOJECT 2 INJECTION DEVICE
2 OTC
AUTOPEN 1 TO 21 UNITS
2 OTC
AUTOSOFT 30 6 MSD
AUTOSOFT 90 6 MSD
BD MICROTAINER LANCET
2 OTC
BD ULTRA FINE LANCETS
2 OTC
BD ULTRA-FINE NANO PEN NEEDLE
2 M; OTC
BIONIME RIGHTEST GM300 SYSTEM
3 ST; OTC
BLOOD GLUCOSE CONTROL, NORMAL
3 OTC
BLOOD-GLUCOSE METER
3 ST; OTC; QL
BREEZE 2 CONTROL SOLUTION,HIGH
3 OTC
CARESENS CONTROL A NORMAL
3 OTC
CARESENS N 3 ST; OTC
CARESENS N VOICE
3 ST; OTC
CARETOUCH GLUCOSE MONITORING
3 ST; OTC
Drug Name Drug
Category Requirements
/ Limits
CLEVER CHEK BLOOD GLUCOSE
3 ST; OTC
CLEVER CHOICE GLUCOSE MONITOR
3 ST; OTC; QL
CLEVER CHOICE LEVEL 2 CONTROL
3 OTC
CLEVER CHOICE MICRO
3 ST; OTC; QL
CLEVER CHOICE PRO
3 ST; OTC; QL
CLEVER CHOICE TALK GLUCOSE SYS
3 ST; OTC
CONTOUR CONTROL SOLUTION, NML
3 OTC
CONTOUR LINK 3 ST; OTC; QL
CONTOUR NEXT EZ METER
3 ST; OTC; QL
CONTOUR NEXT LEV 2 CONTROL SOL
3 OTC
CONTOUR NEXT LINK
3 ST; OTC; QL
CONTOUR NEXT LINK 2.4
3 ST; OTC; QL
CONTOUR NEXT METER
3 ST; OTC
CONTOUR NEXT ONE METER
3 ST; OTC
COOL BLOOD GLUCOSE METER
3 ST; OTC; QL
COOL CONTROL A SOLUTION
3 OTC
DEXCOM G6 RECEIVER
6 MSD
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
DIATRUE CONTROL SOLN NORMAL
3 OTC
DIATRUE PLUS BLOOD GLUCOSE MET
3 ST; OTC; QL
EASY PLUS II HIGH CONTROL
3 ST; OTC
EASY STEP BLOOD GLUCOSE METER
3 ST; OTC; QL
EASY STEP HIGH CONTROL SOLN
3 OTC
EASY TALK HIGH CONTROL
3 OTC
EASY TOUCH GLUCOSE MONITOR
3 ST; OTC; QL
EASY TRAK LOW CONTROL
3 OTC
EASYGLUCO MONITORING SYSTEM
3 ST; OTC; QL
EASYGLUCO PLUS NORMAL CONTROL
3 OTC
EASYMAX L BLOOD GLUCOSE METER
3 ST; OTC
EASYMAX LOW CONTROL
3 OTC
EASYMAX NG 3 ST; OTC
EASYMAX NORMAL CONTROL
3 OTC
EASYMAX V SPEAKING GLUCOSE SYS
3 ST; OTC; QL
Drug Name Drug
Category Requirements
/ Limits
EASYMAX V2 BLOOD GLUCOSE METER
3 ST; OTC; QL
ECLIPSE NEEDLE 3 M
ELEMENT COMPACT GLUCOSE METER
3 ST; OTC; QL
ELEMENT COMPACT NORMAL CONTROL
3 OTC
ELEMENT COMPACT V GLUCOSE MTR
3 ST; OTC
ELEMENT NORMAL CONTROL
3 OTC
ELEMENT PLUS BLOOD GLUCOSE KIT
3 ST; OTC; QL
EMBRACE BLOOD GLUCOSE SYSTEM
3 ST; OTC; QL
EMBRACE EVO LEVEL 1
3 OTC
EMBRACE GLUCOSE CONTROL LOW
3 OTC
EMBRACE PRO GLUCOSE METER
3 ST; OTC
EMBRACE TALK BLOOD GLUCOSE SYS
3 ST; OTC
EMBRACE TALK CONTROL-LOW (L1)
3 OTC
EVENCARE G2 3 ST; OTC; QL
EVENCARE G3 GLUCOSE METER
3 ST; OTC
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
EVENCARE MINI MONITOR SYSTEM
3 ST; OTC
EVERSENSE SENSOR-HOLDER
6 MSD
EVOLUTION BLOOD GLUCOSE METER
3 ST; OTC; QL
EVOLUTION NORMAL CONTROL
3 OTC
EZ SMART PLUS SYSTEM
3 ST; OTC
EZ SMART SYSTEM
3 ST; OTC; QL
FORA D10 3 ST; OTC; QL
FORA D20 3 ST; OTC; QL
FORA G20 3 ST; OTC
FORA G30A 3 ST; OTC; QL
FORA GD50 BLOOD GLUCOSE SYSTEM
3 ST; OTC
FORA NORMAL CONTROL
3 OTC
FORA PREMIUM V10 GLUCOSE METER
3 ST; OTC
FORA TEST N'GO VOICE METER
3 ST; OTC
FORA TN'G VOICE METER
3 ST; OTC
FORA V10 3 ST; OTC; QL
FORA V12 BLOOD GLUCOSE SYSTEM
3 ST; OTC
FORA V20 3 ST; OTC; QL
FORA V30A 3 ST; OTC
Drug Name Drug
Category Requirements
/ Limits
FORACARE GD20 GLUCOSE METER
3 ST; OTC; QL
FORACARE GD40A GLUCOSE METER
3 ST; OTC
FORACARE GD40B GLUCOSE METER
3 ST; OTC
FORACARE GDH LOW CONTROL
3 OTC
FORTISCARE BLOOD GLUCOSE SYST
3 ST; OTC
FORTISCARE NORMAL
3 OTC
FREESTYLE CONTROL
3 OTC
FREESTYLE FLASH SYSTEM
3 ST; OTC; QL
FREESTYLE FREEDOM
3 ST; OTC; QL
FREESTYLE FREEDOM LITE
3 ST; OTC; QL
FREESTYLE INSULINX
3 ST; OTC; QL
FREESTYLE LIBRE 10 DAY READER
6 MSD
FREESTYLE LIBRE 10 DAY SENSOR
6 MSD
FREESTYLE LITE METER
3 ST; OTC; QL
FREESTYLE PRECISION NEO METER
3 ST; OTC
FREESTYLE SIDEKICK II
3 ST; OTC; QL
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
FREESTYLE SYSTEM KIT
3 ST; OTC; QL
GE100 BLOOD GLUCOSE SYSTEM
3 ST; OTC; QL
GE100 CONTROL SOLUTION NORMAL
3 OTC
GLUCO NAVII GLUCOSE MONITOR
3 ST; OTC
GLUCOCARD 01 METER
3 ST; OTC; QL
GLUCOCARD 01 NORMAL CONTROL
3 OTC
GLUCOCARD EXPRESSION
3 ST; OTC; QL
GLUCOCARD SHINE CONNEX METER
3 ST; OTC
GLUCOCARD SHINE EXPRESS METER
3 ST; OTC
GLUCOCARD SHINE METER
3 ST; OTC
GLUCOCARD SHINE XL METER
3 ST; OTC
GLUCOCARD VITAL
3 ST; OTC; QL
GLUCOCOM BLOOD GLUCOSE
3 ST; OTC; QL
GLUCOCOM CONTROL NORMAL
3 OTC
GLUCOSE CONTROL
3 OTC
GM100 3 ST; OTC; QL
Drug Name Drug
Category Requirements
/ Limits
HEALTHPRO GLUCOSE MONITOR
3 ST; OTC
HEALTHPRO HIGH-LOW CONTROL
3 OTC
IGLUCOSE BLOOD GLUCOSE MONITOR
3 ST; OTC
INFINITY CONTROL SOLUTION NORM
3 OTC
INFINITY STARTER KIT
3 ST; OTC; QL
INFINITY VOICE CTRL SOLN-LVL 2
3 OTC
INFINITY VOICE GLUCOSE MONITOR
3 ST; OTC
JAZZ WIRELESS 2 METER KIT
3 ST; OTC; QL
LANCETS 2 OTC
LANCING DEVICE 2 OTC
MEDISENSE 3 OTC
MEDISENSE GLUCOSE KETONE
3 OTC
MICRODOT BLOOD GLUCOSE SYSTEM
3 ST; OTC
MYGLUCOHEALTH
3 ST; OTC; QL
MYGLUCOHEALTH CONTROL SOLUTION
3 OTC
NOVA MAX BLOOD GLUCOSE METER
3 ST; OTC; QL
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
NOVA MAX GLUCOSE CONTROL
3 OTC
NOVAMAX PLUS GLU-KET
3 OTC
NOVOPEN ECHO 3
OMNIPOD DASH INSULIN POD
6 MSD
ON CALL EXPRESS CONTROL
3 OTC
ON CALL EXPRESS METER
3 ST; OTC
ON CALL PLUS CONTROL
3 OTC
ON CALL PLUS METER
3 ST; OTC
ON CALL VIVID CONTROL
3 OTC
ON CALL VIVID METER
3 ST; OTC; QL
ON CALL VIVID PAL METER
3 ST; OTC; QL
ONETOUCH ULTRA CONTROL
2 OTC
ONETOUCH ULTRA2 METER
2 ST; OTC; QL
ONETOUCH ULTRAMINI
2 ST; OTC; QL
ONETOUCH VERIO FLEX
2 ST; OTC
ONETOUCH VERIO IQ METER
2 ST; OTC; QL
ONETOUCH VERIO SYSTEM
2 ST; OTC
OPTUMRX 3 ST; OTC
Drug Name Drug
Category Requirements
/ Limits
PEN NEEDLE, DIABETIC
3 M; OTC
PHARMACIST CHOICE GLUCOSE SYS
3 ST; OTC; QL
PRECISION XTRA MONITOR
2 ST; OTC; QL
PREMIER BLU GLUCOSE METER
3 ST; OTC
PREMIER VOICE GLUCOSE METER
3 ST; OTC
PREMIUM BLOOD GLUCOSE MONITOR
3 ST; OTC; QL
PREMIUM V10 3 ST; OTC; QL
PRESTO PRO BLOOD GLUCOSE METER
3 ST; OTC; QL
PRO VOICE V8 GLUCOSE MONITOR
3 ST; OTC
PRO VOICE V9 GLUCOSE MONITOR
3 ST; OTC
PRODIGY AUTOCODE METER
3 ST; OTC; QL
PRODIGY AUTOCODE MONITOR SYST
3 ST; OTC
PRODIGY CONTROL SOLUTION, LOW
3 OTC
PRODIGY CONTROL SOLUTION,HIGH
3 OTC
PRODIGY POCKET METER
3 ST; OTC; QL
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
PRODIGY VOICE GLUCOSE METER
3 ST; OTC; QL
QUINTET BLOOD GLUCOSE METER
3 ST; OTC
REFUAH PLUS GLUCOSE CONTROL
3 OTC
REFUAH PLUS GLUCOSE MONITOR
3 ST; OTC
RELION ALL-IN-ONE METER
3 ST; OTC
RELION CONFIRM 3 ST; OTC; QL
RELION MICRO GLUCOSE MONITOR
3 ST; OTC; QL
RELION PRIME METER
3 ST; OTC; QL
REVEAL BLOOD GLUCOSE METER
3 ST; OTC; QL
RIGHTEST CONTROL SOLUTION HIGH
3 OTC
RIGHTEST GM550 SYSTEM
3 ST; OTC; QL
SIDEKICK BLOOD GLUCOSE SYSTEM
3 ST; OTC
SMART SENSE MONITORING SYSTEM
3 ST; OTC
SMARTEST CONTROL
3 OTC
SMARTEST EJECT 3 ST; OTC
SMARTEST PERSONA STARTER
3 ST; OTC; QL
Drug Name Drug
Category Requirements
/ Limits
SMARTEST PRONTO STARTER
3 ST; OTC; QL
SMARTEST PROTEGE
3 ST; OTC
SOLUS V2 AUDIBLE METER
3 ST; OTC
SOLUS V2 AUDIBLE METER KIT
3 ST; OTC; QL
SOLUS V2 CONTROL SOLUTION,HIGH
3 OTC
SURE-TEST EASYPLUS MINI METER
3 ST; OTC
T:SLIM X2 BASAL-IQ INSULIN PMP
6 MSD
TELCARE BGM 3 ST; OTC
TELCARE BLOOD GLUCOSE KIT
3 ST; OTC; QL
TELCARE CONTROL
3 OTC
TEST N'GO BLOOD GLUCOSE SYSTEM
3 ST; OTC
TRUE METRIX AIR GLUCOSE METER
3 ST; OTC
TRUE METRIX GLUCOSE METER
3 ST; OTC
TRUE METRIX GO GLUCOSE METER
3 ST; OTC
TRUE METRIX LEVEL 1
3 OTC
TRUECONTROL LEVEL 0
3 OTC
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
TRUERESULT BLOOD GLUCOSE SYSTM
3 ST; OTC; QL
TRUETRACK BLOOD GLUCOSE SYSTEM
3 ST; OTC; QL
TRUETRACK SMART SYSTEM
3 ST; OTC; QL
TRUSTEEL INFUSION SET 32"
6 MSD
ULTIMA MONITOR
3 ST; OTC; QL
ULTRATRAK GLUCOSE METER
3 ST; OTC; QL
ULTRATRAK ULTIMATE
3 ST; OTC
UNISTRIP LOW CONTROL
3 OTC
VARISOFT INFUSION SET 43"
6 MSD
VERASENS BLOOD GLUCOSE METER
3 ST; OTC
VERASENS CONTROL SOLN-LEVEL 1
3 OTC
VERASENS METER STARTER KIT
3 ST; OTC
V-GO 20 6 MSD
V-GO 30 6 MSD
V-GO 40 6 MSD
WAVESENSE AMP 3 ST; OTC
WAVESENSE CONTROL SOLUTION
3 OTC
WAVESENSE PRESTO
3 ST; OTC; QL
Drug Name Drug
Category Requirements
/ Limits
INSULIN THERAPY
ADMELOG SOLOSTAR U-100 INSULIN
3 ST; M; QL
ADMELOG U-100 INSULIN LISPRO
3 ST; M; QL
AFREZZA INHALATION CARTRIDGE WITH INHALER 12 UNIT, 4 UNIT (90)/ 8 UNIT (90), 4 UNIT/8 UNIT/ 12 UNIT (60), 8 UNIT, 8 UNIT (90)/ 12 UNIT (90)
3 M
AFREZZA INHALATION CARTRIDGE WITH INHALER 4 UNIT
3 M; QL
APIDRA SOLOSTAR U-100 INSULIN
3 ST; M; QL
APIDRA U-100 INSULIN
3 ST; M; QL
BASAGLAR KWIKPEN U-100 INSULIN
3 M; QL
FIASP FLEXTOUCH U-100 INSULIN
3 ST; M
FIASP U-100 INSULIN
3 ST; M
HUMALOG JUNIOR KWIKPEN U-100
2 M
HUMALOG KWIKPEN INSULIN
2 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
HUMALOG MIX 50-50 INSULN U-100
2 M; QL
HUMALOG MIX 50-50 KWIKPEN
2 M; QL
HUMALOG MIX 75-25 KWIKPEN
2 M; QL
HUMALOG MIX 75-25(U-100)INSULN
2 M; QL
HUMALOG U-100 INSULIN
2 M; QL
HUMULIN 70/30 U-100 INSULIN
2 M; QL
HUMULIN 70/30 U-100 KWIKPEN
2 M; QL
HUMULIN N NPH INSULIN KWIKPEN
2 M
HUMULIN N NPH U-100 INSULIN
2 M; QL
HUMULIN R REGULAR U-100 INSULN
2 M; QL
HUMULIN R U-500 (CONC) INSULIN
2 M; QL
HUMULIN R U-500 (CONC) KWIKPEN
2 M
INSULIN LISPRO 3 M; QL
LANTUS SOLOSTAR U-100 INSULIN
2 M; QL
LANTUS U-100 INSULIN
2 M; QL
LEVEMIR FLEXTOUCH U-100 INSULN
2 M; QL
Drug Name Drug
Category Requirements
/ Limits
LEVEMIR U-100 INSULIN
2 M; QL
NOVOLIN 70-30 FLEXPEN U-100
3 ST; M; QL
NOVOLOG FLEXPEN U-100 INSULIN
3 ST; M; QL
NOVOLOG MIX 70-30 U-100 INSULN
3 ST; M; QL
NOVOLOG MIX 70-30FLEXPEN U-100
3 ST; M; QL
NOVOLOG PENFILL U-100 INSULIN
3 ST; M; QL
NOVOLOG U-100 INSULIN ASPART
3 ST; M; QL
RELION NOVOLIN 70/30
3 ST; M; QL
RELION NOVOLIN N
3 ST; M; QL
RELION NOVOLIN R
3 ST; M; QL
SOLIQUA 100/33 2 ST; M
TOUJEO MAX U-300 SOLOSTAR
2 M; QL
TOUJEO SOLOSTAR U-300 INSULIN
2 M; QL
TRESIBA FLEXTOUCH U-100
2 M
TRESIBA FLEXTOUCH U-200
2 M
TRESIBA U-100 INSULIN
2 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
XULTOPHY 100/3.6
2 ST; M
MISCELLANEOUS HORMONES
ALDURAZYME 6 MSD
ANADROL-50 3
ANDRODERM 2 PA
ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP
2
ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (25 MG/2.5GRAM), 1 % (50 MG/5 GRAM)
3 ST
ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM)
2
ANDROID 3 ST
AVEED 6 PA; MSD
BRAVELLE 7 ST
BRINEURA 6 MSD
cabergoline 1 M; QL
calcitonin (salmon) 1 M
calcitriol 1 M
CERDELGA 3 S; SLA
CEREZYME 6 MSD
CETROTIDE 7
Drug Name Drug
Category Requirements
/ Limits
CHORIONIC GONADOTROPIN, HUMAN
7
cinacalcet 1 PA
clomiphene citrate 7
CRYSVITA 6 MSD
danazol 1
DDAVP NASAL SOLUTION
2 M
DDAVP NASAL SPRAY WITH PUMP
3 M
DDAVP ORAL 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 ST
GALAFOLD 4 PA; S
ganirelix 7 ST; S
GONAL-F 7
GONAL-F RFF 7
GONAL-F RFF REDI-JECT
7
HECTOROL 6 MSD
JYNARQUE ORAL TABLET
4 PA; SLA; 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
JYNARQUE ORAL TABLETS, SEQUENTIAL
3 PA; SLA
KANUMA 6 MSD
KORLYM 3 PA; SLA
KUVAN 3 PA; S; SLA
LUMIZYME 6 MSD
MENOPUR 7
MEPSEVII 6 MSD
METHITEST 2
methyltestosterone 1
MIACALCIN 6 MSD
miglustat 1 S
MYALEPT 3 PA; S; SLA
NAGLAZYME 6 MSD
NATESTO 3 ST
NATPARA 3 PA; S; SLA
NOCDURNA (MEN)
3 M
NOCDURNA (WOMEN)
3 M
NOCTIVA 3 ST; M
NOVAREL 7
ORILISSA 3 PA; S
OVIDREL 7
OXANDRIN 3
oxandrolone 1
PALYNZIQ 3 PA; S
pamidronate
intravenous recon
soln
6 PA; MSD
Drug Name Drug
Category Requirements
/ Limits
pamidronate
intravenous solution 30 mg/10 ml (3
mg/ml), 90 mg/10 ml
(9 mg/ml)
6 PA; MSD
pamidronate
intravenous solution 60 mg/10 ml (6
mg/ml)
6 MSD
PARICALCITOL HEMODIALYSIS PORT INJECTION
6 MSD
paricalcitol
intravenous 6 MSD
paricalcitol oral 1 M
PREGNYL 7
RAYALDEE 3 M
ROCALTROL 3 M
SAMSCA 3 PA; S; QL
SENSIPAR 2 PA
serophene 7
SOMAVERT 3 S; SLA
STIMATE 2
STRENSIQ 2 SLA
STRIANT 3 PA
SYNAREL 2
TESTIM 3 ST
testosterone 1
testosterone
cypionate 1 PA
testosterone
enanthate 1 PA
TESTRED 3 ST
VIMIZIM 6 MSD
VOGELXO 3 ST
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
VPRIV 6 MSD
XYOSTED 3 PA
ZAVESCA 4 S
ZEMPLAR INTRAVENOUS
6 MSD
ZEMPLAR ORAL 3 M
zoledronic acid 6 MSD
zoledronic acid-
mannitol-water 6 MSD
ZOLEDRONIC AC-MANNITOL-0.9NACL
6 MSD
NON-INSULIN HYPOGLYCEMIC
AGENTS
acarbose 1 M
ACTOPLUS MET 3 ST; M; QL
ACTOPLUS MET XR
3 ST; M; QL
ACTOS 3 ST; M; QL
ADLYXIN 3 ST; M
ALOGLIPTIN 3 ST; M; QL
ALOGLIPTIN-METFORMIN
3 ST; M; QL
ALOGLIPTIN-PIOGLITAZONE
3 M; QL
AMARYL 3 M
AVANDIA 3 ST; M; QL
BYDUREON 2 ST; M
BYDUREON BCISE
2 ST; M
BYETTA 2 ST; M; QL
chlorpropamide 1 M
CYCLOSET 3 M; QL
DM2 3 M
Drug Name Drug
Category Requirements
/ Limits
DUETACT 3 ST; M; QL
FARXIGA 2 ST; M; QL
FORTAMET 3 ST; M
glimepiride 1 M
glipizide 1 M
glipizide-metformin 1 M
GLUCOPHAGE 3 ST; M
GLUCOPHAGE XR 3 ST; M
GLUCOTROL 3 M
GLUCOTROL XL 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 ST; M
INVOKAMET 2 ST; M; QL
INVOKAMET XR 2 ST; M; QL
INVOKANA 2 ST; M; QL
JANUMET 2 ST; M; QL
JANUMET XR 2 ST; M; QL
JANUVIA 2 ST; M; QL
JARDIANCE 2 ST; M; QL
JENTADUETO 2 ST; M; QL
JENTADUETO XR 2 ST; M
KAZANO 3 ST; M; QL
KOMBIGLYZE XR 3 ST; M; QL
METFORMIN ORAL SOLUTION
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.
78
Drug Name Drug
Category Requirements
/ Limits
metformin oral
tablet 1 M
metformin oral
tablet extended
release 24 hr
1 M
metformin oral
tablet extended
release 24hr
1 ST; M
metformin oral
tablet,er
gast.retention 24 hr
1 M; QL
miglitol 1 M
nateglinide 1 M
NESINA 3 ST; M; QL
ONGLYZA 3 ST; M; QL
OSENI 3 M; QL
OZEMPIC 2 ST; M
pioglitazone 1 M; QL
pioglitazone-
glimepiride 1 M; QL
pioglitazone-
metformin 1 M; QL
PRANDIN 3 M
PRECOSE 3 M
QTERN 3 PA; ST; M
repaglinide 1 M
repaglinide-
metformin 1 M; QL
RIOMET 3 ST; M; QL
SEGLUROMET 2 ST; M
STARLIX 3 M
STEGLATRO 2 ST; M
STEGLUJAN 3 ST; M
SYMLINPEN 120 2 ST; M; QL
Drug Name Drug
Category Requirements
/ Limits
SYMLINPEN 60 2 ST; M; QL
SYNJARDY 2 ST; M
SYNJARDY XR 2 ST; M
tolazamide 1 M
tolbutamide 1 M
TRADJENTA 2 ST; QL
TRULICITY 2 ST; M; QL
VICTOZA 2-PAK 3 ST; M; QL
VICTOZA 3-PAK 3 ST; M; QL
XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 10-500 MG, 5-1,000 MG, 5-500 MG
2 ST; M; QL
XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG
2 ST; M
THYROID HORMONES
ARMOUR THYROID
2 M
CYTOMEL 3 ST; M
EUTHYROX 3 M
LEVO-T 3 M
levothyroxine
intravenous 6 MSD
levothyroxine oral 1 M
levoxyl 1 M
liothyronine 1 M
nature-throid 1 M
np thyroid 1 M
SYNTHROID 3 M
thyroid (pork) 1 M
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
THYROLAR-1 3 M
THYROLAR-1/2 3 M
THYROLAR-1/4 3 M
THYROLAR-2 3 M
THYROLAR-3 3 M
TIROSINT 3 M
TIROSINT-SOL 3 M
unithroid 1 M
westhroid 1 M
WP THYROID 3 M
GASTROENTEROLOGY
ANTIDIARRHEALS &
ANTISPASMODICS
anaspaz 1
atropine 6 MSD
atropine in 0.9 %
sod chloride
intravenous syringe 0.8 mg/2 ml (0.4
mg/ml)
6 MSD
ATROPINE IN 0.9 % SOD CHLORIDE INTRAVENOUS SYRINGE 1 MG/2.5 ML (0.4 MG/ML), 2 MG/5 ML (0.4 MG/ML)
6 MSD
belladonna
alkaloids-opium 1
BENTYL 6 MSD
chlordiazepoxide-
clidinium 1
CUVPOSA 3
dicyclomine
intramuscular 6 MSD
Drug Name Drug
Category Requirements
/ Limits
dicyclomine oral 1
diphenoxylate-
atropine 1
DONNATAL 3
ed-spaz 1
GLYCATE 3
GLYCOPYRROLATE (PF) IN WATER INJECTION
6 MSD
glycopyrrolate (pf)
in water intravenous
syringe 0.4 mg/2 ml
(0.2 mg/ml), 1 mg/5
ml (0.2 mg/ml)
6 MSD
GLYCOPYRROLATE (PF) IN WATER INTRAVENOUS SYRINGE 0.6 MG/3 ML (0.2 MG/ML)
6 MSD
glycopyrrolate
injection 6 MSD
GLYCOPYRROLATE INTRAVENOUS
6 MSD
glycopyrrolate oral 1
GLYRX-PF 6 MSD
hyoscyamine sulfate 1
hyosyne 1
LEVBID 3
LEVSIN INJECTION
6 MSD
LEVSIN ORAL 3
LEVSIN/SL 3
LIBRAX (WITH CLIDINIUM)
3 ST
LOMOTIL 3
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
methscopolamine 1
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
SYMAX DUOTAB 3
symax fastabs 1
symax-sl 1
symax-sr 1
MISCELLANEOUS
GASTROINTESTINAL AGENTS
ACTIGALL 3 M
AKYNZEO (FOSNETUPITANT)
6 MSD
AKYNZEO (NETUPITANT)
2 QL
alophen 5 ACA; OTC
alosetron 1
ALOXI 6 MSD
AMITIZA 2
ANALPRAM-HC 3
ANALPRAM-HC SINGLES
3
anucort-hc 1
Drug Name Drug
Category Requirements
/ Limits
ANUSOL-HC 3 ST
aprepitant 1 QL
APRISO 2 M
ASACOL HD 3 ST; M
AURYXIA 3
AZULFIDINE 3 M
AZULFIDINE EN-TABS
3 M
balsalazide 1
bisacodyl 5 ACA; OTC
bisa-lax 5 ACA; OTC
BONJESTA 3
budesonide 1
calcium acetate 1
CANASA 2
CESAMET 3 QL
CHENODAL 2 PA; SLA
CHOLBAM 2 PA; SLA
CIMZIA 4 PA; ST; S; SLA
CIMZIA POWDER FOR RECONST
4 PA; ST; S; SLA
CINVANTI 6 MSD
citrate of magnesia 5 ACA; OTC
citroma 5 ACA; OTC
clearlax 5 ACA; OTC
CLENPIQ 5 ACA
COLAZAL 3
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.
81
Drug Name Drug
Category Requirements
/ Limits
CORTENEMA 3
CORTIFOAM 3 ST
CREON 2
cromolyn 1
CYSTADANE 2 SLA
DELZICOL 3 ST; M
DICLEGIS 3
DIPENTUM 3 ST; M
dronabinol 1
ducodyl 5 ACA; OTC
EMEND (FOSAPREPITANT)
6 MSD
EMEND ORAL CAPSULE
3 QL
EMEND ORAL CAPSULE,DOSE PACK
3 QL
EMEND ORAL SUSPENSION FOR RECONSTITUTION
3
ENTOCORT EC 3
ENTYVIO 6 MSD
enulose 1
fleet laxative 5 ACA; OTC
FOSRENOL 3 ST
GASTROCROM 3
GATTEX 30-VIAL 4 S; SLA
gavilax 5 ACA; OTC
gavilyte-c 5 ACA
gavilyte-g 5 ACA
gavilyte-n 5 ACA
generlac 1
Drug Name Drug
Category Requirements
/ Limits
gentle laxative 5 ACA; OTC
gentlelax 5 ACA; OTC
GIALAX 5 ACA
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
KRISTALOSE 3 M
lactulose oral packet 1 M
lactulose oral
solution 1
lanthanum 1
laxaclear 5 PA; 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
LOKELMA 2
LOTRONEX 3
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
magnesium citrate 5 ACA; OTC
MARINOL 3
mesalamine oral
tablet,delayed
release (dr/ec) 1.2
gram
1 M
mesalamine oral
tablet,delayed
release (dr/ec) 800
mg
2 ST; 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
MOTEGRITY 3
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
ondansetron hcl oral 1 QL
oral saline laxative 5 ACA; OTC
Drug Name Drug
Category Requirements
/ Limits
OSMOPREP 5 ACA
PALONOSETRON INTRAVENOUS SOLUTION 0.25 MG/2 ML
6 MSD
palonosetron
intravenous solution 0.25 mg/5 ml
6 MSD
palonosetron
intravenous syringe 6 MSD
PANCREAZE 3 ST
peg 3350-
electrolytes 5 ACA
peg-electrolyte soln 5 ACA
PENTASA 2 M
PERTZYE 3 ST
PHOSLYRA 2
phosphate laxative 5 ACA; OTC
PLENVU 5 ACA
polyethylene glycol
3350 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
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
proctozone-hc 1
purelax 5 ACA; OTC
RECTIV 2
REGLAN 3
RELISTOR ORAL 3
RELISTOR SUBCUTANEOUS
2
REMICADE 6 MSD
RENAGEL 3 ST
RENFLEXIS 6 PA; ST; MSD
RENVELA 3
ROWASA 3
SANCUSO 2 QL
sevelamer carbonate 1
sevelamer hcl 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
Drug Name Drug
Category Requirements
/ Limits
SUSTOL 6 MSD
SYMPROIC 2
SYNDROS 3 PA
TIGAN INTRAMUSCULAR
6 MSD
TIGAN ORAL 3
TRANSDERM-SCOP
3
trilyte with flavor
packets 5 ACA
trimethobenzamide 1
TRULANCE 2 ST
UCERIS ORAL 3
UCERIS RECTAL 2
URSO 250 3 M
URSO FORTE 3 M
ursodiol 1 M
VARUBI 2
VELPHORO 2
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 2
ZOFRAN 3 QL
ZUPLENZ 3 QL
ULCER THERAPY
ACIPHEX 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.
84
Drug Name Drug
Category Requirements
/ Limits
ACIPHEX SPRINKLE
3 ST; M; QL
amoxicil-
clarithromy-
lansopraz
1 QL
CARAFATE ORAL SUSPENSION
2 M
CARAFATE ORAL TABLET
3 M
cimetidine 1 M
cimetidine hcl 1 M
CYTOTEC 3 M
DEXILANT 3 ST; M; QL
ESOMEP-EZS 3 ST; M; QL
esomeprazole
magnesium 1 M; QL
esomeprazole
sodium 6 MSD
ESOMEPRAZOLE STRONTIUM
3 ST; M; QL
famotidine (pf) 6 MSD
famotidine (pf)-nacl
(iso-os) 6 MSD
FAMOTIDINE IN 0.9 % NACL
6 MSD
famotidine
intravenous 6 MSD
famotidine oral 1 M
lansoprazole oral
capsule,delayed
release(dr/ec)
1 M; QL
lansoprazole oral
tablet,disintegrat,
delay rel
1 ST; M; QL
misoprostol 1 M
NEXIUM 3 ST; M; QL
Drug Name Drug
Category Requirements
/ Limits
NEXIUM IV 6 MSD
NEXIUM PACKET 2 ST; M; QL
nizatidine 1 M
OMECLAMOX-PAK
3 QL
omeppi 1 ST; M; QL
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
1 ST; M; QL
omeprazole-sodium
bicarbonate oral
packet
1 ST; QL
pantoprazole 1 M; QL
PEPCID 3 M
PREVACID 3 ST; M; QL
PREVACID SOLUTAB
3 ST; M; QL
PRILOSEC 3 ST; M; QL
PROTONIX 3 ST; M; QL
PYLERA 2
rabeprazole 1 M; QL
ranitidine hcl
injection 6 MSD
ranitidine hcl oral 1 M
sucralfate 1 M
ZANTAC 6 MSD
ZEGERID ORAL CAPSULE
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.
85
Drug Name Drug
Category Requirements
/ Limits
ZEGERID ORAL PACKET
3 ST; QL
IMMUNOLOGY, VACCINES &
BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
ARANESP (IN POLYSORBATE)
6 MSD
EPOGEN 6 MSD
FULPHILA 6 MSD
GRANIX SUBCUTANEOUS SOLUTION
6 MSD
GRANIX SUBCUTANEOUS SYRINGE
6 PA; MSD
LEUKINE 6 PA; MSD
MACRILEN 6 MSD
MIRCERA 6 MSD
MOZOBIL 6 MSD
NEULASTA 6 MSD
NEUPOGEN 6 MSD
NIVESTYM INJECTION
6 MSD
NIVESTYM SUBCUTANEOUS
6 PA; MSD
PROCRIT 6 MSD
UDENYCA 6 MSD
GROWTH HORMONES
EGRIFTA 3 PA; S
GENOTROPIN 3 PA; S
GENOTROPIN MINIQUICK
3 PA; S
HUMATROPE 4 PA; ST; S
Drug Name Drug
Category Requirements
/ Limits
NORDITROPIN FLEXPRO
3 PA; ST; S
NUTROPIN AQ NUSPIN
4 PA; ST; S
OMNITROPE 4 PA; ST; S
SAIZEN 4 PA; ST; S
SAIZEN SAIZENPREP
4 PA; ST; S
SEROSTIM 3 PA; ST; S
ZOMACTON 4 PA; ST; S
ZORBTIVE 4 PA; ST; S; SLA
INTERFERONS
AUBAGIO 4 ST; S; SLA; QL
AVONEX 3 PA; ST; S; QL
AVONEX (WITH ALBUMIN)
3 PA; ST; S; QL
BETASERON 3 PA; ST; S; QL
COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML
4 ST; S; QL
COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML
3 PA; ST; S; QL
EXTAVIA SUBCUTANEOUS KIT
4 PA; S; QL
EXTAVIA SUBCUTANEOUS RECON SOLN
4 PA; ST; S; QL
GILENYA 3 PA; ST; S; SLA; QL
glatiramer 1 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.
86
Drug Name Drug
Category Requirements
/ Limits
glatopa
subcutaneous
syringe 20 mg/ml
1 PA; ST; S; QL
glatopa
subcutaneous
syringe 40 mg/ml
1 ST; S; QL
LEMTRADA 6 MSD
MAVENCLAD (10 TABLET PACK)
3 ST
MAYZENT 4 ST; S
moderiba 1 ST; S; SLA
OCREVUS 6 MSD
PEGASYS 3 PA; S; SLA; QL
PEGASYS PROCLICK
3 PA; S; SLA; QL
PEGINTRON 4 PA; S; SLA; QL
PLEGRIDY 3 ST; S; QL
POMALYST 3 S; QL
REBETOL 4 ST; S; SLA
REBIF (WITH ALBUMIN)
3 PA; ST; S; QL
REBIF REBIDOSE 3 PA; ST; S; QL
REBIF TITRATION PACK
3 PA; ST; S; QL
REVLIMID 3 S
ribasphere 1 ST; S; SLA
ribasphere ribapak 1 ST; S; SLA
ribavirin 1 S; SLA
SYLATRON 3 PA; S; SLA; QL
TECFIDERA 3 ST; S; SLA; QL
INTERLEUKINS
Drug Name Drug
Category Requirements
/ Limits
ACTIMMUNE 6 MSD; SLA
ALDARA 3 QL
ALFERON N 6 MSD
ARCALYST 4 PA; ST; S; SLA
ILARIS (PF) 6 MSD
IMIQUIMOD TOPICAL CREAM IN METERED-DOSE PUMP
3 ST; QL
imiquimod topical
cream in packet 1 QL
INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML)
3 S; SLA
INTRON A INJECTION RECON SOLN 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML)
3 PA; S; SLA
INTRON A INJECTION SOLUTION
3 S; SLA
KINERET 3 PA; ST; SLA; QL
PROLEUKIN 6 PA; MSD
ZYCLARA 3 ST; QL
VACCINES & MISCELLANEOUS
IMMUNOLOGICALS
ACTHIB (PF) 5 MSD; ACA
ADACEL(TDAP ADOLESN/ADULT)(PF)
5 MSD; ACA
AFLURIA 2018-2019
5 ACA
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
AFLURIA 2018-2019 (PF)
5 ACA
AFLURIA QUAD 2018-2019
5 ACA
AFLURIA QUAD 2018-2019 (PF)
5 ACA
ATGAM 6 MSD
BCG VACCINE, LIVE (PF)
6 MSD
BEXSERO 5 MSD; ACA
BIVIGAM 6 MSD
BOOSTRIX TDAP 5 MSD; ACA
BOTOX 6 MSD
BOTOX COSMETIC
6 MSD
CUVITRU 6 MSD
DAPTACEL (DTAP PEDIATRIC) (PF)
5 MSD; ACA
DYSPORT 6 MSD
ENGERIX-B (PF) 5 MSD; ACA
ENGERIX-B PEDIATRIC (PF)
5 MSD; ACA
EZ FLU 2018-19(FLUCELVAX)(PF)
5 ACA
FLEBOGAMMA DIF
6 MSD
FLUAD 2018-2019 (65 YR UP)(PF)
5 ACA
FLUARIX QUAD 2018-2019 (PF)
5 ACA
FLUBLOK QUAD 2018-2019 (PF)
5 ACA
FLUCELVAX QUAD 2018-2019
5 ACA
Drug Name Drug
Category Requirements
/ Limits
FLUCELVAX QUAD 2018-2019 (PF)
5 ACA
FLULAVAL QUAD 2018-2019
5 ACA
FLULAVAL QUAD 2018-2019 (PF)
5 ACA
FLUMIST QUAD 2018-2019
5 ACA
FLUZONE HIGH-DOSE 2018-19 (PF)
5 ACA
FLUZONE QUAD 2018-2019
5 ACA
FLUZONE QUAD 2018-2019 (PF)
5 ACA
FLUZONE QUAD PEDI 2018-19 (PF)
5 ACA
GAMASTAN 6 MSD
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
GARDASIL 9 (PF) 5 ACA
GRASTEK 2 PA
HAVRIX (PF) 5 MSD; ACA
HEPAGAM B 6 MSD
HEPLISAV-B (PF) 5 MSD; ACA
HIBERIX (PF) 5 MSD; ACA
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
HIZENTRA 6 MSD
HYPERHEP B S/D 6 MSD
HYPERHEP B S-D NEONATAL
6 MSD
HYPERRAB (PF) 6 MSD
HYPERRAB S/D (PF)
6 MSD
HYPERTET S/D (PF)
6 MSD
HYQVIA 6 MSD
IMOGAM RABIES-HT (PF)
6 MSD
INFANRIX (DTAP) (PF)
5 MSD; ACA
IPOL 5 ACA
KEDRAB (PF) 6 MSD
KINRIX (PF) 5 MSD; ACA
MENACTRA (PF) 5 MSD; ACA
MENVEO A-C-Y-W-135-DIP (PF)
5 MSD; ACA
M-M-R II (PF) 5 MSD; ACA
MYOBLOC 6 MSD
NABI-HB 6 MSD
OCTAGAM 6 MSD
ODACTRA 2
ORALAIR 3 PA; SLA
PEDIARIX (PF) 5 MSD; ACA
PEDVAX HIB (PF) 5 ACA
PENTACEL (PF) 5 ACA
PENTACEL ACTHIB COMPONENT (PF)
5 MSD; ACA
PNEUMOVAX 23 5 MSD; ACA
PREVNAR 13 (PF) 5 ACA
Drug Name Drug
Category Requirements
/ Limits
PRIVIGEN 6 MSD
PROQUAD (PF) 5 MSD; ACA
PROVENGE 6 PA; MSD
QUADRACEL (PF) 5 MSD; ACA
RABAVERT (PF) 6 MSD
RAGWITEK 2 PA
RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML
5 MSD; ACA
RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 5 MCG/0.5 ML
2 MSD
RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML
5 MSD; ACA
RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 5 MCG/0.5 ML
2 MSD
ROTARIX 5 MSD; ACA
ROTATEQ VACCINE
5 MSD; ACA
SHINGRIX (PF) 5 MSD; ACA
TDVAX 5 MSD; ACA
TENIVAC (PF) 5 MSD; ACA
TETANUS,DIPHTHERIA TOX PED(PF)
5 MSD; ACA
THYMOGLOBULIN
6 MSD
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
TICE BCG 6 MSD
TRUMENBA 5 ACA
TWINRIX (PF) 5 MSD; ACA
TYPHIM VI 6 MSD
VAQTA (PF) 5 MSD; ACA
VARIVAX (PF) 5 ACA
VARIZIG 5 MSD; ACA
VAXCHORA VACCINE
6 MSD
VIVOTIF 6 MSD
XEOMIN 6 MSD
YF-VAX (PF) 6 MSD
ZINPLAVA 6 MSD
ZOSTAVAX (PF) 5 ACA
MUSCULOSKELETAL &
RHEUMATOLOGY
GOUT THERAPY
allopurinol 1 M
COLCHICINE 3 ST
COLCRYS 2
DUZALLO 3 ST
KRYSTEXXA 6 MSD
MITIGARE 2
probenecid 1 M
probenecid-
colchicine 1 M
ULORIC 2 ST; M
ZYLOPRIM 3 M
OSTEOPOROSIS THERAPY
ACTONEL 3 ST; M; QL
alendronate 1 M; QL
ATELVIA 3 ST; M; QL
Drug Name Drug
Category Requirements
/ Limits
BINOSTO 3 ST; M; QL
BONIVA INTRAVENOUS
6 MSD
BONIVA ORAL 3 ST; M; QL
EVENITY 6 MSD
EVISTA 3 PA; M
FORTEO 3 PA; ST; 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 PA; MSD
raloxifene 1 PA; M
risedronate 1 M; QL
TYMLOS 3 S
OTHER RHEUMATOLOGICALS
ACTEMRA ACTPEN
3 PA; ST; S; SLA
ACTEMRA INTRAVENOUS
6 MSD
ACTEMRA SUBCUTANEOUS
3 PA; ST; S; SLA; QL
ARAVA 3 QL
BENLYSTA INTRAVENOUS
6 MSD
BENLYSTA SUBCUTANEOUS
3 PA; S; SLA
CUPRIMINE 3 ST; M
DEPEN TITRATABS
2 M
D-PENAMINE 2 M
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
ENBREL 3 PA; ST; S; QL
ENBREL MINI 3 PA; ST; S; QL
ENBREL SURECLICK
3 PA; ST; S; QL
HUMIRA 3 PA; ST; S; QL
HUMIRA PEDIATRIC CROHNS START
3 PA; ST; S; QL
HUMIRA PEN 3 PA; ST; S; QL
HUMIRA PEN CROHNS-UC-HS START
3 PA; ST; S; QL
HUMIRA PEN PSOR-UVEITS-ADOL HS
3 PA; ST; S; QL
HUMIRA(CF) 3 PA; ST; S; QL
HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML
3 PA; ST; S
HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML-40 MG/0.4 ML
3 PA; ST; S; QL
HUMIRA(CF) PEN 3 PA; ST; S; QL
HUMIRA(CF) PEN CROHNS-UC-HS
3 PA; ST; S
HUMIRA(CF) PEN PSOR-UV-ADOL HS
3 PA; ST; S
KEVZARA 4 ST; S
leflunomide 1 QL
OLUMIANT 4 ST; S
Drug Name Drug
Category Requirements
/ Limits
ORENCIA 4 PA; ST; S
ORENCIA (WITH MALTOSE)
6 MSD
ORENCIA CLICKJECT
4 PA; ST; S
OTEZLA 3 PA; ST; S; SLA; QL
OTEZLA STARTER
3 PA; ST; S; SLA; QL
OTREXUP (PF) 3 S; QL
RASUVO (PF) 3 S; QL
RIDAURA 2 M
SAVELLA ORAL TABLET
2 ST; M; QL
SAVELLA ORAL TABLETS,DOSE PACK
2 ST; QL
SIMPONI ARIA 6 MSD
SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MG/ML
3 PA; ST; S; QL
SIMPONI SUBCUTANEOUS PEN INJECTOR 50 MG/0.5 ML
4 PA; ST; S; QL
SIMPONI SUBCUTANEOUS SYRINGE 100 MG/ML
3 PA; ST; S; QL
SIMPONI SUBCUTANEOUS SYRINGE 50 MG/0.5 ML
4 PA; ST; S; QL
XELJANZ 3 ST; S; QL
XELJANZ XR 3 ST; S; QL
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
OBSTETRICS &
GYNECOLOGY
DIAPHRAGMS AND OTHER NON-
ORAL CONTRACEPTIVES
CAYA CONTOURED
5 ACA
FC2 FEMALE CONDOM
5 ACA; OTC
FEMCAP 5 ACA
KYLEENA 6 MSD
LILETTA 6 MSD
MIRENA 6 MSD
PARAGARD T 380A
6 MSD
SKYLA 6 MSD
WIDE-SEAL DIAPHRAGM
5 ACA
ESTROGENS & PROGESTINS
ACTIVELLA 3 M
ALORA 3 M; QL
amabelz 1 M
ANGELIQ 3 M
AYGESTIN 3 M
BIJUVA 3
camila 5 M; ACA; QL
CLIMARA 3 M; QL
CLIMARA PRO 3 ST; M; QL
COMBIPATCH 2 M
covaryx 1
covaryx h.s. 1
CRINONE VAGINAL GEL 4 %
2
Drug Name Drug
Category Requirements
/ Limits
CRINONE VAGINAL GEL 8 %
7
deblitane 5 M; ACA; QL
DELESTROGEN 3
DEPO-ESTRADIOL 2
DEPO-PROVERA 5 ACA; QL
DEPO-SUBQ PROVERA 104
5 ACA; QL
DIVIGEL TRANSDERMAL GEL IN PACKET 0.25 MG/0.25 GRAM (0.1 %), 0.5 MG/0.5 GRAM (0.1 %), 1 MG/GRAM (0.1 %)
2 M; QL
DIVIGEL TRANSDERMAL GEL IN PACKET 0.75 MG/0.75 GRAM (0.1%)
2 M
DUAVEE 2
eemt 1
eemt hs 1
ELESTRIN 3 M; QL
ENDOMETRIN 7 ST
errin 5 M; ACA; QL
ESTRACE 3 M
estradiol oral 1 M
estradiol
transdermal 1 M; QL
estradiol vaginal 1 M
estradiol valerate 1
estradiol-
norethindrone acet 1 M
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
ESTRING 2 M; QL
ESTROGEL 3 ST; M; QL
estrogens-
methyltestosterone 1
EVAMIST 3 QL
FEMHRT LOW DOSE
3 M
FEMRING 3 ST; M; QL
fyavolv 1 M
heather 5 M; ACA; QL
hydroxyprogest(pf)(p
reg presv) 6 MSD
hydroxyprogesterone
cap(ppres) 6 MSD
hydroxyprogesterone
caproate 6 MSD
IMVEXXY MAINTENANCE PACK
3
IMVEXXY STARTER PACK
3
incassia 5 M; ACA; QL
jencycla 5 M; ACA; QL
jinteli 1 M
jolivette 5 M; ACA; QL
lopreeza 1 M
lyza 5 M; ACA; QL
MAKENA 6 MSD
MAKENA (PF) 6 MSD
medroxyprogesteron
e intramuscular 5 ACA; QL
medroxyprogesteron
e oral 1 M
MENEST 3 M
Drug Name Drug
Category Requirements
/ Limits
MENOSTAR 3 M; QL
mimvey 1 M
mimvey lo 1 M
MINIVELLE 3 M; QL
nora-be 5 M; ACA; QL
norethindrone
(contraceptive) 5 M; ACA; QL
norethindrone
acetate 1 M
norethindrone ac-eth
estradiol 1 M
norlyda 5 M; ACA; QL
norlyroc 5 M; ACA; QL
ORTHO MICRONOR
5 ST; M; ACA; QL
PREFEST 3 M
PREMARIN 2 M
PREMPHASE 2 M
PREMPRO 2 M
progesterone 7
progesterone
micronized 1 M
PROMETRIUM 3 M
PROVERA 3 M
sharobel 5 M; ACA; QL
tulana 5 M; ACA; QL
VAGIFEM 3 M
VIVELLE-DOT 3 M; QL
yuvafem 1 M
MISCELLANEOUS OB/GYN
AVC VAGINAL 3
CERVIDIL 3
CLEOCIN 3
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
clindamycin
phosphate 1
CLINDESSE 3
fem ph 1
GYNAZOLE-1 3
gynol ii 5 ACA; OTC
INTRAROSA 3
isoxsuprine 1 M
LUPANETA PACK (1 MONTH)
3 QL
LUPANETA PACK (3 MONTH)
3 QL
LYSTEDA 3
METROGEL VAGINAL
3
metronidazole 1
NEXPLANON 6 MSD
NUVARING 5 M; ACA; QL
NUVESSA 3
OSPHENA 3
PREPIDIL 3
PROSTIN E2 3
RELAGARD 3
terconazole 1 QL
TODAY CONTRACEPTIVE SPONGE
5 ACA; OTC
tranexamic acid 1
TRIMO-SAN JELLY
2
vaginal
contraceptive foam 5 ACA; OTC
vandazole 1
Drug Name Drug
Category Requirements
/ Limits
VCF CONTRACEPTIVE FILM
5 ACA; OTC
VCF CONTRACEPTIVE GEL
5 ACA; OTC
xulane 5 M; ACA; QL
ORAL CONTRACEPTIVES &
RELATED AGENTS
AFTERA 5 ACA; OTC; QL
altavera (28) 5 M; ACA; QL
alyacen 1/35 (28) 5 M; ACA; QL
alyacen 7/7/7 (28) 5 M; ACA; QL
amethia 5 M; ACA; QL
amethia lo 5 M; ACA; QL
amethyst (28) 5 M; ACA; QL
apri 5 M; ACA; QL
aranelle (28) 5 M; ACA; QL
ashlyna 5 M; ACA; QL
aubra 5 M; ACA; QL
aubra eq 5 M; ACA; QL
aurovela 1.5/30 (21) 5 M; ACA; QL
aurovela 24 fe 5 M; ACA; QL
aurovela fe 1-20
(28) 5 M; ACA; QL
aviane 5 M; ACA; QL
azurette (28) 5 M; ACA; QL
BALCOLTRA 5 ST; M; ACA; QL
balziva (28) 5 M; ACA; QL
bekyree (28) 5 M; ACA; QL
BEYAZ 5 ST; M; ACA; 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
blisovi 24 fe 5 M; ACA; QL
blisovi fe 1.5/30 (28) 5 M; ACA; QL
blisovi fe 1/20 (28) 5 M; ACA; QL
briellyn 5 M; ACA; QL
camrese 5 M; ACA; QL
camrese lo 5 M; ACA; QL
caziant (28) 5 M; ACA; QL
chateal (28) 5 M; ACA; QL
chateal eq (28) 5 M; ACA; QL
cryselle (28) 5 M; ACA; QL
cyclafem 1/35 (28) 5 M; ACA; QL
cyclafem 7/7/7 (28) 5 M; ACA; QL
CYCLESSA (28) 5 ST; M; ACA; QL
cyred 5 M; ACA; QL
cyred eq 5 M; ACA; QL
dasetta 1/35 (28) 5 M; ACA; QL
dasetta 7/7/7 (28) 5 M; ACA; QL
daysee 5 M; ACA; QL
delyla (28) 5 M; ACA; QL
desog-
e.estradiol/e.estradio
l
5 M; ACA; QL
desogestrel-ethinyl
estradiol 5 M; ACA; QL
drospirenone-
e.estradiol-lm.fa 5 M; ACA; QL
drospirenone-ethinyl
estradiol 5 M; ACA; QL
econtra ez 5 ACA; OTC; QL
econtra one-step 5 ACA; OTC; QL
elinest 5 M; ACA; QL
Drug Name Drug
Category Requirements
/ Limits
ELLA 5 ACA; QL
emoquette 5 M; ACA; QL
enpresse 5 M; ACA; QL
enskyce 5 M; ACA; QL
estarylla 5 M; ACA; QL
ESTROSTEP FE-28 5 ST; M; ACA; QL
ethynodiol diac-eth
estradiol 5 M; ACA; QL
falmina (28) 5 M; ACA; QL
fayosim 5 M; ACA; QL
femynor 5 M; ACA; QL
GENERESS FE 5 ST; M; ACA; QL
gianvi (28) 5 M; ACA; QL
hailey 24 fe 5 M; ACA; QL
introvale 5 M; ACA; QL
isibloom 5 M; ACA; QL
jasmiel (28) 5 M; ACA; QL
jolessa 5 M; ACA; QL
juleber 5 M; ACA; QL
junel 1.5/30 (21) 5 M; ACA; QL
junel 1/20 (21) 5 M; ACA; QL
junel fe 1.5/30 (28) 5 M; ACA; QL
junel fe 1/20 (28) 5 M; ACA; QL
junel fe 24 5 M; ACA; QL
kaitlib fe 5 M; ACA; QL
kariva (28) 5 M; ACA; QL
kelnor 1/35 (28) 5 M; ACA; QL
kelnor 1-50 5 M; ACA; QL
kurvelo (28) 5 M; ACA; QL
l norgest/e.estradiol-
e.estrad 5 M; ACA; QL
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
larin 1.5/30 (21) 5 M; ACA; QL
larin 1/20 (21) 5 M; ACA; QL
larin 24 fe 5 M; ACA; QL
larin fe 1.5/30 (28) 5 M; ACA; QL
larin fe 1/20 (28) 5 M; ACA; QL
larissia 5 M; ACA; QL
layolis fe 5 M; ACA; QL
leena 28 5 M; ACA; QL
lessina 5 M; ACA; QL
levonest (28) 5 M; ACA; QL
levonorgestrel 5 ACA; OTC; QL
levonorgestrel-
ethinyl estrad 5 M; ACA; QL
levonorg-eth estrad
triphasic 5 M; ACA; QL
levora-28 5 M; ACA; QL
lillow (28) 5 M; ACA; QL
LO LOESTRIN FE 5 ST; M; ACA; QL
LOESTRIN 1.5/30 (21)
5 ST; M; ACA; QL
LOESTRIN 1/20 (21)
5 ST; M; ACA; QL
LOESTRIN FE 1.5/30 (28-DAY)
5 ST; M; ACA; QL
LOESTRIN FE 1/20 (28-DAY)
5 ST; M; ACA; QL
loryna (28) 5 M; ACA; QL
LOSEASONIQUE 5 ST; M; ACA; QL
low-ogestrel (28) 5 M; ACA; QL
lutera (28) 5 M; ACA; QL
marlissa (28) 5 M; ACA; QL
Drug Name Drug
Category Requirements
/ Limits
melodetta 24 fe 5 M; ACA; QL
mibelas 24 fe 5 M; ACA; QL
microgestin 1.5/30
(21) 5 M; ACA; QL
microgestin 1/20
(21) 5 M; ACA; QL
MICROGESTIN 24 FE
5 ST; M; ACA; QL
microgestin fe 1.5/30
(28) 5 M; ACA; QL
microgestin fe 1/20
(28) 5 M; ACA; QL
mili 5 M; ACA; QL
MINASTRIN 24 FE 5 ST; M; ACA; QL
MIRCETTE (28) 5 ST; M; ACA; QL
mono-linyah 5 M; ACA; QL
my choice 5 ACA; OTC; QL
my way 5 ACA; OTC; QL
NATAZIA 5 ST; M; ACA; QL
necon 0.5/35 (28) 5 M; ACA; QL
new day 5 ACA; OTC; QL
nikki (28) 5 M; ACA; QL
noreth-ethinyl
estradiol-iron 5 M; ACA; QL
norethindrone ac-eth
estradiol 5 M; ACA; QL
norethindrone-
e.estradiol-iron 5 M; ACA; QL
norgestimate-ethinyl
estradiol 5 M; ACA; QL
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
nortrel 0.5/35 (28) 5 M; ACA; QL
nortrel 1/35 (21) 5 M; ACA; QL
nortrel 1/35 (28) 5 M; ACA; QL
nortrel 7/7/7 (28) 5 M; ACA; QL
ocella 5 M; ACA; QL
ogestrel (28) 5 M; ACA; QL
opcicon one-step 5 ACA; OTC; QL
option-2 5 ACA; OTC; QL
orsythia 5 M; ACA; QL
ORTHO TRI-CYCLEN (28)
5 ST; M; ACA; QL
ORTHO TRI-CYCLEN LO (28)
5 ST; M; ACA; QL
ORTHO-CYCLEN (28)
5 ST; M; ACA; QL
ORTHO-NOVUM 1/35 (28)
5 ST; M; ACA; QL
ORTHO-NOVUM 7/7/7 (28)
5 ST; M; ACA; QL
philith 5 M; ACA; QL
pimtrea (28) 5 M; ACA; QL
pirmella 5 M; ACA; QL
PLAN B ONE-STEP 5 ACA; OTC; QL
portia 28 5 M; ACA; QL
previfem 5 M; ACA; QL
QUARTETTE 5 ST; M; ACA; QL
rajani 5 M; ACA; QL
reclipsen (28) 5 M; ACA; QL
rivelsa 5 M; ACA; QL
Drug Name Drug
Category Requirements
/ Limits
SAFYRAL 5 ST; M; ACA; QL
SEASONIQUE 5 ST; M; ACA; QL
setlakin 5 M; ACA; QL
simliya (28) 5 M; ACA; QL
sprintec (28) 5 M; ACA; QL
sronyx 5 M; ACA; QL
syeda 5 M; ACA; QL
TAKE ACTION 5 ACA; OTC; QL
tarina 24 fe 5 M; ACA; QL
tarina fe 1/20 (28) 5 M; ACA; QL
TAYTULLA 5 ST; M; ACA; QL
tilia fe 5 M; ACA; QL
tri femynor 5 M; ACA; QL
tri-estarylla 5 M; ACA; QL
tri-legest fe 5 M; ACA; QL
tri-linyah 5 M; ACA; QL
tri-lo-estarylla 5 M; ACA; QL
tri-lo-marzia 5 M; ACA; QL
tri-lo-sprintec 5 M; ACA; QL
tri-mili 5 M; ACA; QL
tri-previfem (28) 5 M; ACA; QL
tri-sprintec (28) 5 M; ACA; QL
trivora (28) 5 M; ACA; QL
tri-vylibra 5 M; ACA; QL
tri-vylibra lo 5 M; ACA; QL
tydemy 5 M; ACA; QL
velivet triphasic
regimen (28) 5 M; ACA; QL
vienva 5 M; ACA; QL
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
viorele (28) 5 M; ACA; QL
vyfemla (28) 5 M; ACA; QL
vylibra 5 M; ACA; QL
wera (28) 5 M; ACA; QL
wymzya fe 5 M; ACA; QL
YASMIN (28) 5 ST; M; ACA; QL
YAZ (28) 5 ST; M; ACA; QL
zarah 5 M; ACA; QL
zovia 1/35e (28) 5 M; ACA; QL
OXYTOCICS
methergine 1
methylergonovine 1
OPHTHALMOLOGY
ANTIBIOTICS
ak-poly-bac 1
AZASITE 2
bacitracin 1
bacitracin-
polymyxin b 1
BESIVANCE 3
BETADINE OPHTHALMIC PREP
3
CEFUROXIME (PF) IN 0.9% NACL
6 MSD
CILOXAN 3
ciprofloxacin hcl 1
erythromycin 1
gatifloxacin 1
gentak 1
gentamicin 1
Drug Name Drug
Category Requirements
/ Limits
levofloxacin 1
MOXEZA 2
moxifloxacin 1
MOXIFLOXACIN (PF)-BSS NO.2
6 MSD
MOXIFLOXACIN IN NACL,ISO-O(PF)
6 MSD
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
ZIRGAN 3
BETA-BLOCKERS
betaxolol 1 M
BETIMOL 3 M
BETOPTIC S 3 M
carteolol 1 M
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
ISTALOL 3 ST; M
levobunolol 1 M
metipranolol 1 M
timolol maleate 1 M
TIMOPTIC 3 M
TIMOPTIC OCUDOSE (PF)
3 M
TIMOPTIC-XE 3 M
CHOLINESTERASE INHIBITOR
MIOTICS
PHOSPHOLINE IODIDE
2 M
CYCLOPLEGIC MYDRIATICS
atropine 1 M
ATROPINE IN 0.9 % SOD CHLORIDE
3 M
CYCLOGYL 3 M
cyclopentolate 1 M
CYCLOPEN-TROPIC-PHENYLEPH-WATR
3 M
homatropaire 1 M
homatropine hbr 1 M
ISOPTO ATROPINE
3 M
MYDRIACYL 3 M
mydriatic3 (trop-
cyclopent-pe) 1 M
PAREMYD 3
tropicamide 1 M
DIRECT ACTING MIOTICS
ISOPTO CARPINE 3 M
MIOCHOL-E 3
Drug Name Drug
Category Requirements
/ Limits
pilocarpine hcl 1 M
MISCELLANEOUS
OPHTHALMOLOGICS
acuicyn 1
AKTEN (PF) 3
ALCAINE 3
ALOCRIL 3 ST
ALOMIDE 3 ST
altacaine 1
ALTAFLUOR BENOX
6 MSD
azelastine 1
BEPREVE 2 ST
BEVACIZUMAB 6 PA; MSD
CEQUA 3 PA; M
cromolyn 1
CYSTARAN 2 PA; SLA
DEXAMET-MOXIFL-KETORO-NACL(PF)
6 MSD
epinastine 1
EYLEA 6 MSD
flucaine 1
fluorescein-
proparacaine 1
hypocyn 1
JETREA (PF) 6 MSD
LACRISERT 3
LASTACAFT 3 ST
lidocaine-
phenylephrn in
water
6 MSD
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
LIDOCAN-PHENYLEPH-BSS NO.2(PF)
6 MSD
LUCENTIS 6 MSD
LUXTURNA 6 MSD
MACUGEN 6 MSD
olopatadine 1
OMIDRIA 6 MSD
OXERVATE 3 S
PATADAY 3 ST
PATANOL 3 ST
PAZEO 2 ST
PHOTREXA CROSS-LINKING KIT
6 MSD
PHOTREXA VISCOUS
6 MSD
PREDNISOLN SP-GATIFLOX-BROMFEN
3
PREDNISOLONE SOD PH-BROMFENAC
3
proparacaine 1
RACEPINEPH-LIDOCAINE-BSS 7(PF)
6 MSD
RESTASIS 2 PA; M; QL
RESTASIS MULTIDOSE
2 PA; M; QL
tetcaine 1
tetracaine hcl 1
TETRACAINE HCL (PF)
3
TETRAVISC 3
Drug Name Drug
Category Requirements
/ Limits
TETRAVISC FORTE
3
VISUDYNE 6 MSD
VITRASE 6 MSD
XIIDRA 2 M; QL
NON-STEROIDAL ANTI-
INFLAMMATORY AGENTS
ACULAR 3
ACULAR LS 3
ACUVAIL (PF) 3 ST
bromfenac 1
BROMSITE 3
diclofenac sodium 1 QL
flurbiprofen sodium 1
ILEVRO 2
ketorolac 1
NEVANAC 3 ST
PROLENSA 2
ORAL DRUGS FOR GLAUCOMA
acetazolamide 1 M
acetazolamide
sodium 6 MSD
methazolamide 1 M
OTHER GLAUCOMA DRUGS
AZOPT 3 M
bimatoprost 1 ST; M
COMBIGAN 2 M
COSOPT 3 M
COSOPT (PF) 3 M
dorzolamide 1 M
dorzolamide-timolol 1 M
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
dorzolamide-timolol
(pf) ophthalmic (eye)
dropperette
1 M
DORZOLAMIDE-TIMOLOL (PF) OPHTHALMIC (EYE) DROPS
3 M
latanoprost 1 ST; M
LUMIGAN 2 ST; M
MITOSOL 3
RHOPRESSA 2 M
ROCKLATAN 3 M
SIMBRINZA 3 M
TRAVATAN Z 2 ST; M
TRUSOPT 3 M
VYZULTA 3 PA; M
XALATAN 3 ST; M
XELPROS 3 ST; M
ZIOPTAN (PF) 3 ST; M
STEROID-ANTIBIOTIC
COMBINATIONS
DEXAMETH-MOXIFLOX(PF)-NACL,ISO
6 MSD
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
Drug Name Drug
Category Requirements
/ Limits
PREDNISOLONE ACET-GATIFLOXACIN
3
PREDNISOLONE SOD PH-GATIFLOXAC
3
TOBRADEX OPHTHALMIC (EYE) DROPS,SUSPENSION
3
TOBRADEX OPHTHALMIC (EYE) OINTMENT
2
TOBRADEX ST 2
tobramycin-
dexamethasone 1
TRIAMCINOLON-MOXIFLOX-WATR(PF)
6 MSD
ZYLET 2
STEROIDS
ALREX 2 ST
dexamethasone
sodium phosphate 1
DEXTENZA 6 MSD
DUREZOL 3
FLAREX 3
fluorometholone 1
FML FORTE 3
FML LIQUIFILM 3
FML S.O.P. 3
ILUVIEN 6 MSD
INVELTYS 2 ST
LOTEMAX 2
LOTEMAX SM 2
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
MAXIDEX 3
OZURDEX 6 MSD
PRED FORTE 3
PRED MILD 3
prednisolone acetate 1
prednisolone sodium
phosphate 1
RETISERT 6 MSD
YUTIQ 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 INJECTION AUTO-INJECTOR 0.1 MG/0.1 ML
3 ST
AUVI-Q INJECTION AUTO-INJECTOR 0.15 MG/0.15 ML, 0.3 MG/0.3 ML
3 ST; QL
carbinoxamine
maleate 1
cetirizine 1
CLARINEX 3 QL
clemastine 1
cyproheptadine 1
desloratadine 1 QL
dexchlorpheniramin
e maleate 1
diphenhydramine hcl 6 MSD
EPINEPHRINE INJECTION AUTO-INJECTOR 0.15 MG/0.15 ML
3 ST; QL
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
EPINEPHRINE INJECTION AUTO-INJECTOR 0.15 MG/0.3 ML
2 ST; QL
epinephrine
injection auto-
injector 0.3 mg/0.3
ml
2 ST; QL
EPINEPHRINESNAP-EMS
3
EPINEPHRINESNAP-V
3
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 INJECTION
6 MSD
phenergan rectal 1
promethazine
injection 6 MSD
promethazine oral 1
promethazine rectal 1
promethegan 1
RYCLORA 3
RYVENT 3
SYMJEPI 3
VISTARIL 3
COUGH & COLD THERAPY
benzonatate 1
BROMFED DM 3
Drug Name Drug
Category Requirements
/ Limits
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
g tussin ac 1
guaiatussin ac 1
guaifenesin ac 1
guaifenesin dac 1
HISTEX-AC 3
hydrocodone-
chlorpheniramine 1
hydrocodone-cpm-
pseudoephed 1
HYDROCODONE-GUAIFENESIN
3 ST
hydrocodone-
homatropine 1
hydromet 1
lortuss ex 1
MAR-COF CG 3
MAXI-TUSS CD 3
m-clear wc 1
M-END PE 3
NINJACOF-XG 3
OBREDON 3 ST
POLY-TUSSIN AC 3
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
103
Drug Name Drug
Category Requirements
/ Limits
promethazine-
codeine 1
promethazine-dm 1
promethazine-
phenyleph-codeine 1
promethazine-
phenylephrine 1
PRO-RED AC (W/ DEXCHLORPHENIR)
3
RESPA-AR 3
robafen ac 1
rydex 1
SEMPREX-D 3
TESSALON PERLES
3
tusnel c 1
TUSNEL PEDIATRIC
3
TUSSICAPS 3 ST
TUSSIONEX PENNKINETIC ER
3
TUXARIN ER 3
TUZISTRA XR 3 ST
virtussin ac 1
virtussin dac 1
ZODRYL AC 25 3
ZODRYL AC 30 3
ZODRYL AC 35 3
ZODRYL AC 40 3
ZODRYL AC 50 3
ZODRYL AC 60 3
ZODRYL AC 80 3
ZODRYL DAC 25 3
Drug Name Drug
Category Requirements
/ Limits
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 3
ZODRYL DEC 35 3
ZODRYL DEC 40 3
ZODRYL DEC 50 3
ZODRYL DEC 60 3
ZODRYL DEC 80 3
Z-TUSS AC 3
PULMONARY AGENTS
ACCOLATE 3 M; QL
acetylcysteine 1
ADCIRCA 4 PA; ST; S; QL
ADEMPAS 3 PA; S; SLA
ADRENALIN 3
ADVAIR DISKUS 3 ST; M; QL
ADVAIR HFA 2 ST; M; QL
AEROSPAN 3 M
AIRDUO RESPICLICK
3 ST; M; QL
ALBUTEROL SULFATE INHALATION HFA AEROSOL INHALER
3 QL
albuterol sulfate
inhalation solution
for nebulization
1
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
104
Drug Name Drug
Category Requirements
/ Limits
albuterol sulfate oral 1 M
ALVESCO 3 ST; M; QL
alyq 1 ST; S; QL
ambrisentan 1 ST; S
aminophylline 6 MSD
ANORO ELLIPTA 2 M; QL
ARCAPTA NEOHALER
2 M; QL
ARMONAIR RESPICLICK
2 M; QL
ARNUITY ELLIPTA
2 M
ASMANEX HFA 2 M
ASMANEX TWISTHALER
2 M; QL
ATROVENT HFA 2 M; QL
BECONASE AQ 3 ST; QL
BERINERT 6 MSD
BEVESPI AEROSPHERE
2 M
BREO ELLIPTA 2 ST; M; QL
BROVANA 3 M; QL
budesonide 1 M; QL
CINQAIR 6 MSD
CINRYZE 6 MSD
COMBIVENT RESPIMAT
2 QL
cromolyn 1 M
CUROSURF 3
DALIRESP ORAL TABLET 250 MCG
2 PA
DALIRESP ORAL TABLET 500 MCG
2 PA; QL
DULERA 2 ST; M; QL
Drug Name Drug
Category Requirements
/ Limits
DYMISTA 2 ST; QL
ELIXOPHYLLIN 3 M
ESBRIET ORAL CAPSULE
3 PA; S; SLA; QL
ESBRIET ORAL TABLET
3 PA; S; SLA
FASENRA 6 MSD
FIRAZYR 3 PA; S; SLA
FLOVENT DISKUS 2 M; QL
FLOVENT HFA 2 M; QL
flunisolide 1 QL
fluticasone
propionate 1 QL
FLUTICASONE PROPION-SALMETEROL INHALATION AEROSOL POWDR BREATH ACTIVATED
2 ST; M; QL
fluticasone propion-
salmeterol
inhalation blister
with device
1 PA; M; QL
HAEGARDA 6 PA; MSD
HYPER-SAL 3
INCRUSE ELLIPTA
2 M
ipratropium bromide 1 M
ipratropium-
albuterol 1 QL
KALBITOR 6 MSD
KALYDECO ORAL GRANULES IN PACKET 25 MG
3 PA; S
You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.
105
Drug Name Drug
Category Requirements
/ Limits
KALYDECO ORAL GRANULES IN PACKET 50 MG, 75 MG
3 PA; S; SLA
KALYDECO ORAL TABLET
3 PA; S; SLA
LETAIRIS 3 PA; ST; S
levalbuterol hcl 1
LEVALBUTEROL TARTRATE
3 ST; QL
LONHALA MAGNAIR REFILL
3 PA; M
LONHALA MAGNAIR STARTER
3 PA; M
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; S
Drug Name Drug
Category Requirements
/ Limits
ORKAMBI 3 S; SLA
PERFOROMIST 2 M; QL
PROAIR HFA 2 QL
PROAIR RESPICLICK
2
PROVENTIL HFA 3 ST; QL
PULMICORT 3 ST; M; QL
PULMICORT FLEXHALER
2 M; QL
pulmosal 1
PULMOZYME 2
QNASL NASAL HFA AEROSOL INHALER 40 MCG/ACTUATION
2 ST
QNASL NASAL HFA AEROSOL INHALER 80 MCG/ACTUATION
2 ST; QL
QVAR REDIHALER
2 M
REVATIO 4 PA; ST; S; QL
RUCONEST 6 MSD
SEEBRI NEOHALER
3 M
SEREVENT DISKUS
2 M; QL
sildenafil
(antihypertensive) 1 PA; S; QL
SINGULAIR ORAL GRANULES IN PACKET
3 ST; M
SINGULAIR ORAL TABLET
3 ST; M; QL
SINGULAIR ORAL TABLET,CHEWABLE
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.
106
Drug Name Drug
Category Requirements
/ Limits
sodium chloride 1
SPIRIVA RESPIMAT
2 M
SPIRIVA WITH HANDIHALER
2 ST; M; QL
STIOLTO RESPIMAT
2 M
STRIVERDI RESPIMAT
2 M
SURFAXIN 6 MSD
SYMBICORT 2 ST; M; QL
SYMDEKO 3 PA; S
tadalafil
(antihypertensive) 1 PA; ST; S; QL
TAKHZYRO 4 PA; S
terbutaline oral 1 M
terbutaline
subcutaneous 6 MSD
THEO-24 3 M
theochron 1 M
theophylline 1 M
TICALAST 3 ST
TRACLEER 3 PA; S; SLA
TRELEGY ELLIPTA
2 M
TUDORZA PRESSAIR
2 M; QL
TYVASO 6 MSD
TYVASO REFILL KIT
6 MSD
TYVASO STARTER KIT
6 MSD
UTIBRON NEOHALER
3 M
VENTAVIS 4 ST; S
Drug Name Drug
Category Requirements
/ Limits
VENTOLIN HFA 2 QL
wixela inhub 1 PA; M; QL
XHANCE 3 ST
XOLAIR 6 MSD
XOPENEX 3
XOPENEX CONCENTRATE
3
XOPENEX HFA 3 ST; QL
YUPELRI 2 M
zafirlukast 1 M; QL
ZETONNA 3 ST; QL
zileuton 1 ST; M; QL
ZYFLO 3 ST; M
UROLOGICALS
ANTICHOLINERGICS &
ANTISPASMODICS
darifenacin 1 M
DETROL 3 ST; M
DETROL LA 3 ST; M
DITROPAN XL ORAL TABLET EXTENDED RELEASE 24HR 10 MG
3 ST; M
DITROPAN XL ORAL TABLET EXTENDED RELEASE 24HR 5 MG
3 ST; M; QL
ENABLEX 3 ST; M
flavoxate 1 M
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107
Drug Name Drug
Category Requirements
/ Limits
GELNIQUE TRANSDERMAL GEL IN METERED-DOSE PUMP
2 ST
GELNIQUE TRANSDERMAL GEL IN PACKET
2 ST; M; QL
MYRBETRIQ 2 ST; M
oxybutynin chloride
oral syrup 1 M
oxybutynin chloride
oral tablet 1 M
oxybutynin chloride
oral tablet extended
release 24hr 10 mg,
15 mg
1 M
oxybutynin chloride
oral tablet extended
release 24hr 5 mg
1 M; QL
OXYTROL 3 ST; M; QL
solifenacin 1 M
tolterodine 1 M
TOVIAZ 2 ST; M
trospium 1 M
VESICARE 2 ST; M
BENIGN PROSTATIC
HYPERPLASIA (BPH) THERAPY
alfuzosin 1 M
AVODART 3 ST; M
CIALIS 3 ST; QL
dutasteride 1 ST; M
dutasteride-
tamsulosin 1 ST; M
finasteride 1 M
FLOMAX 3 ST; M
Drug Name Drug
Category Requirements
/ Limits
JALYN 3 ST; M
PROSCAR 3 ST; M
RAPAFLO 2 M
silodosin 1 M
tadalafil 1 PA; QL
tamsulosin 1 M
UROXATRAL 3 ST; M
CHOLINERGIC STIMULANTS
bethanechol chloride 1
URECHOLINE 3
MISCELLANEOUS UROLOGICALS
CYSTAGON 2 PA; SLA
cytra k crystals 1
ELMIRON 2
hyophen 1
IFE-BIMIX 30/1 6 MSD
IFE-PG20 6 MSD
K-PHOS NO 2 3
K-PHOS ORIGINAL
2
methen-sod phos-
meth blue-hyos 1
ORACIT 3
phosphasal 1
potassium citrate 1 M
PROCYSBI 4 PA; ST; S; SLA
SHOHL'S MODIFIED
3
URELLE 3
uretron d-s 1
URIBEL 3
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108
Drug Name Drug
Category Requirements
/ Limits
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
UROQID-ACID NO.2
3
uryl 1
ustell 1
utira-c 1
vardenafil 1
URINARY ANESTHETICS
phenazopyridine 1
PYRIDIUM 3
VITAMINS, HEMATINICS &
ELECTROLYTES
ELECTROLYTES
calcium 500 + d 1 OTC
calcium 600 + d(3) 1 OTC
calcium 600 with
vitamin d3 1 OTC
calcium citrate-
vitamin d2 1 OTC
calcium citrate-
vitamin d3 1 OTC
CALCIUM GLUC IN NACL, ISO-OSM
6 MSD
Drug Name Drug
Category Requirements
/ Limits
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 0.9% NACL INTRAVENOUS SYRINGE
6 MSD
CALCIUM GLUCONATE IN D5W
6 MSD
CALCIUM GLUCONATE IN WATER
6 MSD
EFFER-K ORAL TABLET, EFFERVESCENT 10 MEQ, 20 MEQ
3 M
effer-k oral tablet,
effervescent 25 meq 1 M
GALZIN 3
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/ef 1 M
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109
Drug Name Drug
Category Requirements
/ Limits
K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ, 20 MEQ
3 M
k-tab oral tablet
extended release 8
meq
1 M
lugols 1
oyster shell + d3 1 OTC
oyster shell calcium-
vit d3 1 OTC
POTABA 3 M
potassium chloride 1 M
sodium chloride 6 MSD
sodium chloride 0.45
% 6 MSD
sodium chloride 3 % 6 MSD
sodium chloride 5 % 6 MSD
strong iodine 1
MISCELLANEOUS VITAMINS,
HEMATINICS, & ELECTROLYTES
ISOLYTE-S 6 MSD
VITAMINS & HEMATINICS
AZESCO 3
b complex-vitamin
b12 5 ACA; OTC
b complex-vitamin c-
folic acid 5 ACA; OTC
balance b-100 5 ACA; OTC
balanced b-100 5 ACA; OTC
balanced b-100
complex 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
CADEAU DHA 3
calcium pnv 1
cholecalciferol
(vitamin d3) 1 OTC
CITRANATAL (DUAL-IRON)
3
CITRANATAL 90 DHA (ALGAL OIL)
3
CITRANATAL ASSURE
3
CITRANATAL B-CALM (FE GLUC)
3
CITRANATAL BLOOM
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
CONCEPT OB 3
cyanocobalamin
(vitamin b-12) 1
dialyvite 800 5 ACA; OTC
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110
Drug Name Drug
Category Requirements
/ Limits
DRISDOL 3
DUET DHA BALANCED
3
DUET DHA WITH OMEGA-3
3
ENBRACE HR 3
ergocalciferol
(vitamin d2) 1
EXTRA-VIRT PLUS DHA
3
FLORIVA (FLUORIDE-VITAMIN D3)
5 M; ACA; OTC
FLUORABON 5 M; ACA; OTC
fluoride (sodium)
oral drops 5 M; ACA; OTC
fluoride (sodium)
oral tablet,chewable 0.25 mg(0.55 mg
sod. fluoride), 0.5
mg (1.1 mg sodium
fluorid)
5 M; ACA; OTC
fluoride (sodium)
oral tablet,chewable 1 mg (2.2 mg sod.
fluoride)
1 M; OTC
fluoritab oral
tablet,chewable 0.5
mg (1.1 mg sodium
fluorid)
5 M; ACA; OTC
fluoritab oral
tablet,chewable 1
mg (2.2 mg sod.
fluoride)
1 M; OTC
FLURA-DROPS 5 M; ACA; OTC
FOLET ONE 3
folic acid oral tablet 1 mg
1 M
Drug Name Drug
Category Requirements
/ Limits
folic acid oral tablet 400 mcg, 800 mcg
5 M; ACA; OTC
folivane-ob 1
foltabs 800 1 OTC
full spectrum b-
vitamin c 5 ACA; OTC
hemenatal ob 1
hemenatal ob + dha 1
INFUVITE ADULT 6 MSD
INFUVITE PEDIATRIC
6 MSD
INJECTAFER 6 MSD
kobee 1 OTC
KOSHER PRENATAL PLUS IRON
3
kpn 1 OTC
ludent fluoride oral
tablet,chewable 0.25
mg(0.55 mg sod.
fluoride), 0.5 mg
(1.1 mg sodium
fluorid)
5 M; ACA; OTC
ludent fluoride oral
tablet,chewable 1
mg (2.2 mg sod.
fluoride)
1 M; OTC
m.v.i. adult 6 MSD
MARNATAL-F 3
m-natal plus 1
multi-vitamin with
fluoride oral drops 5 ACA; OTC
multi-vitamin with
fluoride oral
tablet,chewable 0.25
mg, 0.5 mg
5 ACA; OTC
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111
Drug Name Drug
Category Requirements
/ Limits
multi-vitamin with
fluoride oral
tablet,chewable 1
mg
1 OTC
multivitamins with
fluoride oral
tablet,chewable 0.25
mg, 0.5 mg
5 ACA; OTC
multivitamins with
fluoride oral
tablet,chewable 1
mg
1 OTC
mvc-fluoride oral
tablet,chewable 0.25
mg, 0.5 mg
5 ACA; OTC
mvc-fluoride oral
tablet,chewable 1
mg
1 OTC
mynatal 1
mynatal advance 1
mynatal plus 1
mynatal-z 1
mynate 90 plus 1
NASCOBAL 2 M
NATACHEW (FE BIS-GLYCINATE)
3
natural b-100
complex 5 ACA; OTC
NEEVODHA (WITH ALGAL OIL)
3
NESTABS 3
NESTABS ABC 3
NESTABS DHA 3
NESTABS ONE 3
newgen 1
NEXAVIR 3
Drug Name Drug
Category Requirements
/ Limits
OB COMPLETE ONE
3
OB COMPLETE PETITE
3
OB COMPLETE PREMIER
3
OB COMPLETE WITH DHA
3
obstetrix dha 1
OBSTETRIX EC 3 M
OBSTETRIX ONE 3
OBTREX DHA 3
O-CAL PRENATAL
3
one daily prenatal 5 ACA; OTC
perry prenatal 5 ACA; OTC
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
pr natal 400 1
pr natal 400 ec 1
pr natal 430 1
pr natal 430 ec 1
PREFERA-OB 3
PREFERA-OB PLUS DHA
3
prena1 chew 1
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112
Drug Name Drug
Category Requirements
/ Limits
prena1 pearl 1
prena1 true 1
prenaissance 1
prenaissance plus 1
PRENATA 3
prenatabs fa 1
prenatabs rx 1
prenatal 5 ACA; OTC
prenatal 19 1 OTC
prenatal 19 (with
docusate) 1 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
Drug Name Drug
Category Requirements
/ Limits
PRENATE DHA (FERR ASP GLYCIN)
3
PRENATE ELITE (IRON ASP GLYC)
3
PRENATE ENHANCE
3
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
PROVIDA DHA 3
PROVIDA OB 3
PUREFE OB PLUS 3
rena-vite 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
stress formula 5 ACA; OTC
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113
Drug Name Drug
Category Requirements
/ Limits
stress formula with
iron 1 OTC
stress formula with
iron(sulf) 1 OTC
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
taron-c dha 1
taron-prex prenatal-
dha 1
THRIVITE RX 3
tl g-fol os 1
total b/c 1 OTC
TRICARE 3
TRIFERIC 6 MSD
trinatal rx 1 1
trinate 1
TRISTART DHA 3
triveen-duo dha 1
tri-vitamin with
fluoride 5 ACA; OTC
trust natal dha 1
ultra b-100 complex 1 OTC
VENOFER 6 MSD
vinate care 1
VINATE DHA RF 3
vinate ii 1
Drug Name Drug
Category Requirements
/ Limits
vinate m 1 M
vinate one 1
virt-advance 1
virt-c dha 1
virt-nate dha 1
virt-pn dha 1
virt-pn plus 1
VIRTPREX 3
virt-select 1
virt-vite gt 1
VITAFOL FE+ (WITH DOCUSATE)
3
VITAFOL GUMMIES
3
VITAFOL NANO 3
VITAFOL ULTRA 3
VITAFOL-OB 3
VITAFOL-OB+DHA
3
VITAFOL-ONE 3
VITAMED MD ONE RX
3
VITAMEDMD REDICHEW RX
3
vitamin b complex 5 ACA; OTC
vitamin b complex-
folic acid 5 ACA; OTC
vitamin d3 1 OTC
vitamins a,c,d and
fluoride 5 ACA; OTC
VITAPEARL 3
VITATRUE 3
vp-ch plus 1
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114
Drug Name Drug
Category Requirements
/ Limits
vp-ch-pnv 1
VP-PNV-DHA 3
zatean-pn dha 1
zatean-pn plus 1
Drug Name Drug
Category Requirements
/ Limits
zingiber 1
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115
Index 2 2TEK GLUCOSE/BLOOD
PRESSURE ...................... 65 A abacavir .................................. 3 abacavir-lamivudine ............... 3 abacavir-lamivudine-
zidovudine .......................... 3 ABILIFY .............................. 32 ABILIFY MAINTENA ........ 32 ABILIFY MYCITE .............. 32 abiraterone ............................ 13 ABLYSINOL ....................... 56 ABRAXANE ........................ 13 ABSORICA .......................... 49 ABSTRAL ............................ 24 acamprosate .......................... 56 ACANYA ............................. 49 acarbose ................................ 76 ACCOLATE....................... 102 ACCU-CHEK AVIVA PLUS
METER ............................ 65 ACCU-CHEK AVIVA PLUS
TEST STRP ...................... 61 ACCU-CHEK COMPACT
PLUS CONTROL ............ 65 ACCU-CHEK COMPACT
PLUS TEST...................... 61 ACCU-CHEK GUIDE ......... 61 ACCU-CHEK GUIDE
GLUCOSE METER ......... 65 ACCU-CHEK GUIDE L1-L2
CTRL SOL ....................... 65 ACCU-CHEK GUIDE ME
GLUCOSE MTR .............. 65 ACCU-CHEK NANO .......... 65 ACCU-CHEK SMARTVIEW
CONTRL SOL ................. 65 ACCU-CHEK SMARTVIEW
TEST STRIP .................... 61 ACCUPRIL .......................... 38 ACCURETIC ....................... 38 ACCUTREND GLUCOSE .. 61 ACCUTREND GLUCOSE
CONTROL ....................... 65 acebutolol ............................. 38
acetaminophen-caff-dihydrocod ........................ 24
acetaminophen-codeine ........ 24 acetazolamide ....................... 98 acetazolamide sodium .......... 98 acetic acid ............................. 59 acetylcysteine ..................... 102 ACIPHEX ............................. 82 ACIPHEX SPRINKLE......... 83 acitretin ................................. 46 ACTEMRA .......................... 88 ACTEMRA ACTPEN .......... 88 ACTHAR H.P. ..................... 60 ACTHIB (PF) ....................... 85 ACTICLATE ........................ 11 ACTIGALL .......................... 79 ACTIMMUNE ..................... 85 ACTIQ .................................. 24 ACTIVELLA........................ 90 ACTONEL ........................... 88 ACTOPLUS MET ................ 76 ACTOPLUS MET XR ......... 76 ACTOS ................................. 76 acuicyn.................................. 97 ACULAR.............................. 98 ACULAR LS ........................ 98 ACUVAIL (PF) .................... 98 acyclovir ........................... 3, 54 ACZONE .............................. 49 ADACEL(TDAP
ADOLESN/ADULT)(PF) 85 ADAGEN ............................. 56 ADALAT CC ....................... 38 adapalene .............................. 49 ADAPALENE ...................... 49 adapalene-benzoyl peroxide . 49 ADASUVE ........................... 32 ADCETRIS .......................... 13 ADCIRCA .......................... 102 ADDERALL ........................ 32 ADDERALL XR .................. 32 ADDYI ................................. 32 adefovir ................................... 3 ADEMPAS ......................... 102 ADLYXIN ............................ 76 ADMELOG SOLOSTAR U-
100 INSULIN ................... 72
ADMELOG U-100 INSULIN LISPRO ............................ 72
ADRENALIN ..................... 102 adriamycin ............................ 13 ADRIAMYCIN .................... 13 adrucil ................................... 13 adult aspirin regimen ............ 29 ADVAIR DISKUS ............. 102 ADVAIR HFA .................... 102 ADVANCED GLUC METER
TEST STRIP ..................... 61 ADVANCED GLUCOSE
METER ............................. 65 ADVATE .............................. 42 ADVOCATE BLOOD
GLUCOSE MONITOR .... 65 ADVOCATE DUO .............. 65 ADVOCATE LOW
CONTROL ....................... 65 ADVOCATE REDI-CODE .. 61 ADVOCATE REDI-CODE
DUO METER ................... 65 ADVOCATE REDI-CODE
GLU MONITOR .............. 65 ADVOCATE REDI-CODE+
CTRL LOW ...................... 65 ADVOCATE TEST STRIPS 61 ADYNOVATE ..................... 42 ADYPHREN ...................... 100 ADYPHREN AMP ............. 100 ADYPHREN AMP II ......... 100 ADYPHREN II ................... 100 ADZENYS ER ..................... 32 ADZENYS XR-ODT ........... 32 AEMCOLO ............................ 7 AEROSPAN ....................... 102 afeditab cr ............................. 38 AFINITOR ........................... 13 AFINITOR DISPERZ .......... 13 AFLURIA 2018-2019 .......... 85 AFLURIA 2018-2019 (PF) .. 86 AFLURIA QUAD 2018-2019
.......................................... 86 AFLURIA QUAD 2018-2019
(PF) ................................... 86 AFREZZA ............................ 72 AFSTYLA ............................ 42
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116
AFTERA .............................. 92 AGAMATRIX AMP GLUC
MONITOR SYS ............... 65 AGAMATRIX AMP TEST
STRIPS ............................. 61 AGAMATRIX CONTROL
HIGH ................................ 65 AGGRENOX ....................... 42 AGONEAZE ........................ 52 AGRYLIN ............................ 56 AIMOVIG AUTOINJECTOR
.......................................... 22 AIRDUO RESPICLICK .... 102 AJOVY ................................. 22 ak-poly-bac ........................... 96 AKTEN (PF) ........................ 97 AKTIPAK ............................ 49 AKYNZEO
(FOSNETUPITANT) ....... 79 AKYNZEO (NETUPITANT)
.......................................... 79 ALA-SCALP ........................ 54 albendazole ............................. 7 ALBENZA ............................. 7 albuterol sulfate .......... 102, 103 ALBUTEROL SULFATE.. 102 ALCAINE ............................ 97 alclometasone ....................... 54 ALDACTAZIDE .................. 38 ALDACTONE ..................... 38 ALDARA ............................. 85 ALDURAZYME .................. 74 ALECENSA ......................... 13 alendronate ..................... 57, 88 ALEVICYN PLUS ............... 48 ALFERON N........................ 85 alfuzosin ............................. 106 ALINIA .................................. 7 ALIQOPA ............................ 13 aliskiren ................................ 38 ALKERAN ........................... 13 ALKERAN (AS HCL) ......... 13 allopurinol ............................ 88 ALLZITAL........................... 24 almotriptan malate ................ 22 ALOCRIL............................. 97 ALOGLIPTIN ...................... 76
ALOGLIPTIN-METFORMIN .......................................... 76
ALOGLIPTIN-PIOGLITAZONE ............. 76
ALOMIDE............................ 97 alophen ................................. 79 ALORA ................................ 90 alosetron ............................... 79 ALOXI.................................. 79 ALPHAGAN P ................... 100 ALPHANATE ...................... 42 ALPHANINE SD ................. 42 alprazolam ............................ 32 alprazolam intensol............... 32 ALPROLIX .......................... 42 ALREX ................................. 99 ALTABAX ........................... 53 altacaine ................................ 97 ALTACE .............................. 38 ALTAFLUOR BENOX ....... 97 altavera (28) .......................... 92 ALTOPREV ......................... 44 ALTRENO ........................... 49 ALUNBRIG ......................... 13 ALVESCO.......................... 103 alyacen 1/35 (28) .................. 92 alyacen 7/7/7 (28) ................. 92 alyq ..................................... 103 amabelz ................................. 90 amantadine hcl ........................ 3 AMARYL ............................. 76 AMBIEN .............................. 32 AMBIEN CR ........................ 32 AMBISOME .......................... 3 ambrisentan ........................ 103 amcinonide ........................... 54 AMELUZ ............................. 48 AMERGE ............................. 22 amethia ................................. 92 amethia lo ............................. 92 amethyst (28) ........................ 92 AMICAR .............................. 42 amifostine crystalline ........... 12 amikacin ................................. 7 amiloride ............................... 38 amiloride-hydrochlorothiazide
.......................................... 38 aminocaproic acid................. 42
aminophylline ..................... 103 amiodarone ........................... 38 AMITIZA ............................. 79 amitriptyline ......................... 32 amitriptyline-chlordiazepoxide
.......................................... 32 amlodipine ............................ 38 amlodipine-atorvastatin ........ 44 amlodipine-benazepril .......... 38 amlodipine-olmesartan ......... 38 amlodipine-valsartan ............ 38 amlodipine-valsartan-hcthiazid
.......................................... 38 AMMONUL ......................... 57 amnesteem ............................ 49 amoxapine ............................. 32 amoxicil-clarithromy-lansopraz
.......................................... 83 amoxicillin ............................ 10 amoxicillin-pot clavulanate .. 10 AMPHADASE ..................... 57 amphetamine sulfate ............. 32 amphotericin b ........................ 3 ampicillin .............................. 10 ampicillin sodium ................. 10 ampicillin-sulbactam ............ 10 AMPYRA ............................. 23 AMRIX ................................. 23 ANADROL-50 ..................... 74 ANAFRANIL ....................... 32 anagrelide ............................. 57 ANALPRAM-HC ........... 46, 79 ANALPRAM-HC SINGLES79 ANAPROX DS ..................... 29 anaspaz ................................. 78 ANASTIA ............................. 52 anastrozole ............................ 13 ANCOBON ............................ 3 ANDEXXA .......................... 42 ANDRODERM .................... 74 ANDROGEL ........................ 74 ANDROID ............................ 74 ANGELIQ ............................ 90 ANGIOMAX ........................ 42 ANODYNE LPT .................. 52 ANORO ELLIPTA ............. 103 ANTABUSE ......................... 57 ANTARA ............................. 44
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117
anucort-hc ............................. 79 ANUSOL-HC ....................... 79 APADAZ .............................. 24 apexicon e ............................. 54 APIDRA SOLOSTAR U-100
INSULIN .......................... 72 APIDRA U-100 INSULIN ... 72 APLENZIN .......................... 32 APOKYN ............................. 21 apraclonidine ...................... 100 aprepitant .............................. 79 apri ........................................ 92 APRISO ................................ 79 APTENSIO XR .................... 32 APTIOM............................... 19 APTIVUS ............................... 3 aqua care sterile water .......... 57 AQUA GLYCOLIC HC....... 54 ARAKODA ............................ 7 ARALAST NP ..................... 57 aranelle (28).......................... 92 ARANESP (IN
POLYSORBATE) ............ 84 ARAVA ................................ 88 ARCALYST ......................... 85 ARCAPTA NEOHALER ... 103 ARESTIN ............................. 59 ARGATROBAN .................. 42 ARGATROBAN IN 0.9 %
SOD CHLOR ................... 42 ARGATROBAN IN NACL
(ISO-OS) .......................... 42 ARICEPT ............................. 23 ARIKAYCE ........................... 7 ARIMIDEX .......................... 13 aripiprazole ........................... 32 ARISTADA .......................... 32 ARISTADA INITIO ............ 32 ARIXTRA ............................ 42 armodafinil ........................... 32 ARMONAIR RESPICLICK
........................................ 103 ARMOUR THYROID ......... 77 ARNUITY ELLIPTA ......... 103 AROMASIN......................... 13 ARRANON .......................... 13 ARSENIC TRIOXIDE ......... 13 ARTHROTEC 50 ................. 29
ARTHROTEC 75 ................. 29 ARYMO ER ......................... 24 ARZERRA ........................... 13 ASACOL HD ....................... 79 ascomp with codeine ............ 24 ashlyna .................................. 92 ASMANEX HFA ............... 103 ASMANEX TWISTHALER
........................................ 103 aspir-81 ................................. 29 aspirin ................................... 29 aspirin low dose .................... 29 aspirin-dipyridamole ............ 42 aspir-low ............................... 29 aspir-trin ............................... 29 ASSURE 4 CONTROL
SOLUTION ...................... 65 ASSURE 4 STRIPS.............. 61 ASSURE DOSE NORMAL
CONTROL ....................... 65 ASSURE PLATINUM ... 61, 65 ASSURE PRISM CONTROL
1-2 SOLN ......................... 65 ASSURE PRISM MULTI
METER ............................ 66 ASSURE PRISM MULTI
STRIP ............................... 61 ASTAGRAF XL................... 13 ASTEPRO ............................ 59 ASTERO .............................. 52 ATACAND .......................... 38 ATACAND HCT ................. 38 atazanavir................................ 3 ATELVIA ............................. 88 atenolol ................................. 38 atenolol-chlorthalidone ......... 38 ATGAM ............................... 86 ATIVAN ............................... 32 atomoxetine .......................... 32 ATOPADERM ..................... 48 ATOPICLAIR ...................... 48 atorvastatin ........................... 44 atovaquone.............................. 7 atovaquone-proguanil ............. 7 atracurium ............................. 23 ATRALIN ............................ 49 ATRAPRO CP ..................... 48 ATRAPRO HYDROGEL .... 48
ATRIPLA ............................... 4 atropine ........................... 78, 97 atropine in 0.9 % sod chloride
.......................................... 78 ATROPINE IN 0.9 % SOD
CHLORIDE ................ 78, 97 ATROVENT HFA .............. 103 AUBAGIO ............................ 84 aubra ..................................... 92 aubra eq ................................ 92 AUGMENTIN ...................... 10 AUGMENTIN ES-600 ......... 10 AUGMENTIN XR ............... 10 aurovela 1.5/30 (21) .............. 92 aurovela 24 fe ....................... 92 aurovela fe 1-20 (28) ............ 92 AURYXIA ............................ 79 AUSTEDO ........................... 23 AUTOJECT 2 INJECTION
DEVICE ........................... 66 AUTOPEN 1 TO 21 UNITS 66 AUTOSOFT 30 .................... 66 AUTOSOFT 90 .................... 66 AUVI-Q .............................. 100 AVALIDE ............................ 38 AVANDIA ........................... 76 AVAPRO .............................. 38 avar ....................................... 49 AVAR ................................... 49 AVAR LS ............................. 49 AVAR-E GREEN ................. 50 AVAR-E LS ......................... 50 AVASTIN ............................. 13 AVC VAGINAL .................. 91 AVEED ................................. 74 AVELOX .............................. 10 AVELOX IN NACL (ISO-
OSMOTIC) ....................... 10 aviane .................................... 92 avidoxy ................................. 11 avita ...................................... 50 AVITA .................................. 50 avo cream .............................. 48 AVODART ......................... 106 AVONEX ............................. 84 AVONEX (WITH ALBUMIN)
.......................................... 84 AVYCAZ ............................... 6
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AYGESTIN .......................... 90 azacitidine............................. 13 AZASAN .............................. 13 AZASITE ............................. 96 azathioprine .......................... 13 azelaic acid ........................... 50 azelastine ........................ 59, 97 AZELEX .............................. 50 AZESCO ............................ 108 AZILECT ............................. 21 azithromycin ........................... 7 AZOPT ................................. 98 AZOR ................................... 38 AZULFIDINE ...................... 79 AZULFIDINE EN-TABS .... 79 azurette (28).......................... 92 B b complex-vitamin b12....... 108 b complex-vitamin c-folic acid
........................................ 108 bacitracin .............................. 96 bacitracin-polymyxin b ........ 96 baclofen ................................ 23 BACLOFEN ......................... 23 BACTRIM ............................ 11 BACTRIM DS...................... 11 balance b-100 ..................... 108 balanced b-100 ................... 108 balanced b-100 complex..... 108 bal-care dha ........................ 108 BAL-CARE DHA
ESSENTIAL................... 108 BALCOLTRA ...................... 92 balsalazide ............................ 79 BALVERSA ......................... 13 balziva (28) ........................... 92 BANZEL .............................. 19 BARACLUDE ....................... 4 BASAGLAR KWIKPEN U-
100 INSULIN ................... 72 BAVENCIO ......................... 13 BAXDELA ........................... 10 bayer aspirin ......................... 29 BCG VACCINE, LIVE (PF) 86 b-complex with vitamin c ... 108 BD MICROTAINER
LANCET .......................... 66
BD ULTRA FINE LANCETS .......................................... 66
BD ULTRA-FINE NANO PEN NEEDLE .................. 66
BECONASE AQ ................ 103 bekyree (28) .......................... 92 BELBUCA ........................... 24 BELEODAQ ........................ 13 belladonna alkaloids-opium . 78 BELSOMRA ........................ 32 benazepril ............................. 38 benazepril-hydrochlorothiazide
.......................................... 38 BENDAMUSTINE .............. 13 BENDEKA ........................... 13 BENEFIX ............................. 42 BENICAR ............................ 38 BENICAR HCT ................... 38 BENLYSTA ......................... 88 BENSAL HP ........................ 47 BENTYL .............................. 78 BENZACLIN ....................... 50 BENZACLIN PUMP ........... 50 BENZAMYCIN ................... 50 benzepro ............................... 50 BENZHYDROCODONE-
ACETAMINOPHEN........ 24 BENZNIDAZOLE ................. 7 benzonatate ......................... 101 benzoyl peroxide .................. 50 benztropine ........................... 21 BEPREVE ............................ 97 BERINERT ........................ 103 BESIVANCE........................ 96 BESPONSA.......................... 13 BETADINE OPHTHALMIC
PREP ................................ 96 BETAMETH AC,SOD
PHOS(PF)-WATER ......... 60 BETAMETHASONE
ACE,SOD PHOS-WTR.... 60 betamethasone acet,sod phos 60 betamethasone dipropionate . 54 BETAMETHASONE SOD
PHOSPH-WATER ........... 60 betamethasone valerate......... 54 betamethasone, augmented ... 54 BETAPACE ......................... 38
BETAPACE AF ................... 38 BETASERON ....................... 84 betaxolol ......................... 38, 96 bethanechol chloride ........... 106 BETHKIS ............................... 7 BETIMOL ............................ 96 BETOPTIC S ........................ 96 BEVACIZUMAB ................. 97 BEVESPI AEROSPHERE . 103 BEVYXXA ........................... 42 bexarotene ............................. 13 BEXSERO ............................ 86 BEYAZ ................................. 92 BIAFINE EMULSION ......... 48 bicalutamide ......................... 13 BICILLIN C-R ..................... 10 BICNU .................................. 13 BIDIL ................................... 38 BIJUVA ................................ 90 BIKTARVY ........................... 4 BILTRICIDE .......................... 7 bimatoprost ........................... 98 BINOSTO ............................. 88 BIONIME RIGHTEST
GM300 SYSTEM ............. 66 BIONIME RIGHTEST TEST
STRIPS ............................. 61 bisacodyl ............................... 79 bisa-lax ................................. 79 bisoprolol fumarate ............... 38 bisoprolol-hydrochlorothiazide
.......................................... 38 BIVALIRUDIN .................... 42 BIVALIRUDIN-0.9 %
SODIUM CHLOR ............ 42 BIVIGAM ............................. 86 bleomycin ............................. 13 BLEPH-10 .......................... 100 BLEPHAMIDE .................. 100 BLEPHAMIDE S.O.P. ....... 100 BLINCYTO .......................... 13 blisovi 24 fe .......................... 93 blisovi fe 1.5/30 (28) ............ 93 blisovi fe 1/20 (28) ............... 93 BLOOD GLUCOSE
CONTROL, NORMAL .... 66 BLOOD GLUCOSE TEST .. 61
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119
BLOOD-GLUCOSE METER .......................................... 66
BONIVA .............................. 88 BONJESTA .......................... 79 BOOSTRIX TDAP .............. 86 BORTEZOMIB .................... 13 BOSULIF ............................. 13 BOTOX ................................ 86 BOTOX COSMETIC ........... 86 bp 10-1.................................. 50 bpo ........................................ 50 BRAFTOVI .......................... 13 BRAVELLE ......................... 74 BREEZE 2 CONTROL
SOLUTION,HIGH ........... 66 BREO ELLIPTA ................ 103 BREVIBLOC ....................... 38 BREVIBLOC IN NACL (ISO-
OSM) ................................ 39 BRIDION ............................. 23 briellyn ................................. 93 BRILINTA ........................... 43 brimonidine ........................ 100 BRINEURA ......................... 74 BRISDELLE ........................ 32 BRIVIACT ........................... 19 BROMFED DM ................. 101 bromfenac ............................. 98 bromocriptine ....................... 21 brompheniramine-pseudoeph-
dm ................................... 101 BROMSITE .......................... 98 BROVANA ........................ 103 BRYHALI ............................ 54 budesonide .................... 79, 103 bumetanide ........................... 39 BUNAVAIL ......................... 29 BUPAP ................................. 24 BUPHENYL......................... 57 BUPRENEX ......................... 24 buprenorphine....................... 25 BUPRENORPHINE ............. 25 buprenorphine hcl ................. 24 buprenorphine-naloxone....... 29 bupropion hcl.................. 32, 33 BUPROPION HCL .............. 32 bupropion hcl (smoking deter)
.......................................... 58
buspirone .............................. 33 busulfan ................................ 13 BUSULFEX ......................... 13 butalbital compound w/codeine
.......................................... 25 butalbital-acetaminop-caf-cod
.......................................... 25 butalbital-acetaminophen ..... 25 butalbital-acetaminophen-caff
.......................................... 25 butalbital-aspirin-caffeine .... 25 BUTISOL ............................. 33 butorphanol tartrate .............. 29 BUTRANS ........................... 25 BYDUREON ........................ 76 BYDUREON BCISE ........... 76 BYETTA .............................. 76 BYSTOLIC .......................... 39 C cabergoline ........................... 74 CABLIVI .............................. 43 CABOMETYX ..................... 13 CADEAU DHA .................. 108 CADUET .............................. 44 CAFERGOT ......................... 22 caffeine citrate ...................... 57 CALAN ................................ 39 CALAN SR .......................... 39 calcipotriene ......................... 46 calcipotriene-betamethasone 46 calcitonin (salmon) ............... 74 calcitrene .............................. 46 calcitriol .......................... 46, 74 calcium 500 + d .................. 107 calcium 600 + d(3) ............. 107 calcium 600 with vitamin d3
........................................ 107 calcium acetate ..................... 79 calcium citrate-vitamin d2 .. 107 calcium citrate-vitamin d3 .. 107 CALCIUM GLUC IN NACL,
ISO-OSM........................ 107 calcium gluconate in 0.9% nacl
........................................ 107 CALCIUM GLUCONATE IN
0.9% NACL .................... 107 CALCIUM GLUCONATE IN
D5W ............................... 107
CALCIUM GLUCONATE IN WATER .......................... 107
calcium pnv ........................ 108 CALQUENCE ...................... 13 CAMBIA .............................. 29 camila ................................... 90 CAMPTOSAR ...................... 13 camrese ................................. 93 camrese lo ............................. 93 CANASA .............................. 79 CANCIDAS ............................ 3 candesartan ........................... 39 candesartan-hydrochlorothiazid
.......................................... 39 CAPASTAT ........................... 7 CAPCOF ............................. 101 capecitabine .......................... 13 CAPEX ................................. 54 CAPRELSA .......................... 13 CAPSFENAC PAK .............. 29 captopril ................................ 39 captopril-hydrochlorothiazide
.......................................... 39 CARAC ................................ 48 CARAFATE ......................... 83 CARBAGLU ........................ 57 carbamazepine ...................... 19 CARBATROL ...................... 19 carbidopa .............................. 21 carbidopa-levodopa .............. 21 carbidopa-levodopa-
entacapone ........................ 21 carbinoxamine maleate ....... 100 carboplatin ............................ 14 CARDIZEM ......................... 39 CARDIZEM CD ................... 39 CARDIZEM LA ................... 39 CARDURA ........................... 39 CARDURA XL .................... 39 CARESENS CONTROL A
NORMAL ......................... 66 CARESENS N ...................... 66 CARESENS N TEST STRIPS
.......................................... 61 CARESENS N VOICE ......... 66 CARETOUCH GLUCOSE
MONITORING ................ 66
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CARETOUCH TEST STRIP .......................................... 62
carisoprodol .......................... 24 carisoprodol-asa-codeine ...... 24 carisoprodol-aspirin .............. 24 carmustine ............................ 14 CARNITOR ......................... 57 CARNITOR (SUGAR-FREE)
.......................................... 57 CAROSPIR .......................... 39 carteolol ................................ 96 cartia xt ................................. 39 carvedilol .............................. 39 carvedilol phosphate ............. 39 CASODEX ........................... 14 caspofungin ............................ 3 CATAPRES ......................... 39 CATAPRES-TTS-1 .............. 39 CATAPRES-TTS-2 .............. 39 CATAPRES-TTS-3 .............. 39 CAYA CONTOURED ......... 90 CAYSTON ............................. 7 caziant (28) ........................... 93 cefaclor ................................... 6 cefadroxil ................................ 6 cefazolin ................................. 6 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 ceftriaxone .............................. 6 CEFTRIAXONE .................... 7
ceftriaxone in dextrose,iso-os . 6 CEFUROXIME (PF) IN 0.9%
NACL ............................... 96 cefuroxime axetil .................... 7 cefuroxime sodium ................. 7 celacyn .................................. 48 CELEBREX ......................... 30 celecoxib ............................... 30 CELESTONE SOLUSPAN . 60 CELEXA .............................. 33 CELLCEPT .......................... 14 CELLCEPT INTRAVENOUS
.......................................... 14 CELONTIN .......................... 19 CENTANY ........................... 53 CENTANY AT..................... 53 centergy .............................. 101 cephalexin ............................... 7 CEPROTIN (BLUE BAR) ... 43 CEPROTIN (GREEN BAR) 43 CEQUA ................................ 97 CERAMAX .......................... 48 CERDELGA ......................... 74 CEREZYME ........................ 74 CERVIDIL ........................... 91 CESAMET ........................... 79 cetirizine ............................. 100 CETRAXAL ......................... 59 CETROTIDE ........................ 74 cevimeline ............................ 57 CHANTIX ............................ 58 CHANTIX CONTINUING
MONTH BOX .................. 58 CHANTIX STARTING
MONTH BOX .................. 58 chateal (28) ........................... 93 chateal eq (28) ...................... 93 CHEMET.............................. 57 CHENODAL ........................ 79 cheratussin ac ..................... 101 children's aspirin ................... 30 chloramphenicol sod succinate
............................................ 7 chlordiazepoxide hcl............. 33 chlordiazepoxide-clidinium .. 78 chlorhexidine gluconate ....... 59 chloroquine phosphate ............ 7 chlorothiazide ....................... 39
chlorothiazide sodium .......... 39 chlorpromazine ..................... 33 chlorpropamide ..................... 76 chlorthalidone ....................... 39 chlorzoxazone ....................... 24 CHOLBAM .......................... 79 cholecalciferol (vitamin d3) 108 cholestyramine (with sugar) . 44 cholestyramine light ............. 44 CHOLETEC ......................... 57 choline,magnesium salicylate
.......................................... 30 CHORIONIC
GONADOTROPIN, HUMAN ........................... 74
CIALIS ............................... 106 ciclodan ................................. 53 CICLODAN KIT .................. 53 ciclopirox .............................. 53 cidofovir ................................. 4 cilostazol ............................... 43 CILOXAN ............................ 96 CIMDUO ................................ 4 cimetidine ............................. 83 cimetidine hcl ....................... 83 CIMZIA ................................ 79 CIMZIA POWDER FOR
RECONST ........................ 79 cinacalcet .............................. 74 CINQAIR ........................... 103 CINRYZE ........................... 103 CINVANTI ........................... 79 CIPRO .................................. 10 CIPRO HC ............................ 59 CIPRO XR ............................ 10 CIPRODEX .......................... 60 ciprofloxacin ......................... 10 ciprofloxacin (mixture) ......... 10 ciprofloxacin hcl ....... 10, 59, 96 cisatracurium ........................ 24 cisplatin ................................. 14 citalopram ............................. 33 CITRANATAL (DUAL-
IRON) ............................. 108 CITRANATAL 90 DHA
(ALGAL OIL) ................ 108 CITRANATAL ASSURE .. 108
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121
CITRANATAL B-CALM (FE GLUC) ............................ 108
CITRANATAL BLOOM ... 108 CITRANATAL DHA
(ALGAL OIL) ................ 108 CITRANATAL HARMONY
(IRON FUM) .................. 108 citrate of magnesia ............... 79 citroma .................................. 79 cladribine .............................. 14 CLAFORAN .......................... 7 claravis ................................. 50 CLARINEX ........................ 100 CLARINEX-D 12 HOUR .. 101 clarithromycin ........................ 7 classic prenatal ................... 108 cleansing wash...................... 50 clearlax ................................. 79 clemastine ........................... 100 CLENPIQ ............................. 79 cleocin .................................... 8 CLEOCIN......................... 8, 91 CLEOCIN HCL...................... 7 CLEOCIN PEDIATRIC ......... 8 CLEOCIN T ......................... 50 CLEVER CHEK BLOOD
GLUCOSE ....................... 66 CLEVER CHOICE
GLUCOSE MONITOR .... 66 CLEVER CHOICE LEVEL 2
CONTROL ....................... 66 CLEVER CHOICE MICRO 66 CLEVER CHOICE MICRO
TEST STRIP .................... 62 CLEVER CHOICE PRO 62, 66 CLEVER CHOICE TALK
GLUCOSE SYS ............... 66 CLEVER CHOICE TALK
TEST ................................ 62 CLEVER CHOICE TEST
STRIPS ............................. 62 CLEVER CHOICE VOICE+
TEST ................................ 62 CLIMARA ........................... 90 CLIMARA PRO ................... 90 CLINDACIN ETZ................ 50 clindacin p ............................ 50 CLINDACIN PAC ............... 50
CLINDAGEL ....................... 50 clindamycin hcl ...................... 8 CLINDAMYCIN IN 0.9 %
SOD CHLOR ..................... 8 clindamycin in 5 % dextrose .. 8 clindamycin palmitate hcl ...... 8 clindamycin pediatric ............. 8 clindamycin phosphate .... 8, 50,
92 CLINDAMYCIN
PHOSPHATE ................... 50 clindamycin-benzoyl peroxide
.......................................... 50 clindamycin-tretinoin ........... 50 CLINDESSE ........................ 92 CLINPRO 5000 .................... 59 clobazam ............................... 19 clobetasol .............................. 54 clobetasol-emollient ............. 54 CLOBEX .............................. 54 CLOCORTOLONE
PIVALATE ...................... 54 clodan ................................... 54 CLODAN KIT ...................... 54 CLODERM .......................... 54 clofarabine ............................ 14 CLOLAR .............................. 14 clomiphene citrate ................ 74 clomipramine ........................ 33 clonazepam ........................... 19 clonidine ............................... 39 clonidine hcl ................... 33, 39 clopidogrel ............................ 43 clorazepate dipotassium ....... 33 clotrimazole ............................ 3 clotrimazole-betamethasone . 53 clozapine ............................... 33 CLOZAPINE ........................ 33 CLOZARIL .......................... 33 c-nate dha ........................... 108 COAGADEX........................ 43 COAL TAR .......................... 46 COARTEM ............................ 8 codeine sulfate ...................... 25 codeine-guaifenesin ............ 101 CODITUSSIN AC .............. 101 CODITUSSIN DAC ........... 101 COLAZAL ........................... 79
COLCHICINE ...................... 88 COLCRYS ............................ 88 colesevelam .......................... 44 COLESTID ........................... 44 COLESTID FLAVORED .... 45 colestipol ............................... 45 colistin (colistimethate na) ..... 8 COLY-MYCIN M
PARENTERAL .................. 8 COLY-MYCIN S ................. 60 COLYTE WITH FLAVOR
PACKS ............................. 79 COMBIGAN ........................ 98 COMBIPATCH .................... 90 COMBIVENT RESPIMAT 103 COMBIVIR ............................ 4 COMETRIQ ......................... 14 COMPAZINE ....................... 79 COMPLERA .......................... 4 complete natal dha .............. 108 completenate ....................... 108 complex b-100 .................... 108 compro .................................. 79 COMTAN ............................. 21 CONCEPT DHA ................ 108 CONCEPT OB ................... 108 CONCERTA ......................... 33 CONDYLOX ........................ 48 constulose ............................. 79 CONTOUR CONTROL
SOLUTION, NML ........... 66 CONTOUR LINK ................ 66 CONTOUR NEXT EZ
METER ............................. 66 CONTOUR NEXT LEV 2
CONTROL SOL ............... 66 CONTOUR NEXT LINK ..... 66 CONTOUR NEXT LINK 2.4
.......................................... 66 CONTOUR NEXT METER . 66 CONTOUR NEXT ONE
METER ............................. 66 CONTOUR NEXT TEST
STRIPS ............................. 62 CONTOUR TEST STRIPS .. 62 CONZIP ................................ 30 COOL BLOOD GLUCOSE
METER ............................. 66
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122
COOL CONTROL A SOLUTION ...................... 66
COOL GLUCOSE TEST STRIP ............................... 62
COPAXONE ........................ 84 COPIKTRA .......................... 14 CORDRAN .......................... 54 CORDRAN TAPE LARGE
ROLL ............................... 55 COREG ................................ 39 COREG CR .......................... 39 coremino ............................... 11 CORGARD .......................... 39 CORIFACT .......................... 43 CORLANOR ........................ 46 cormax .................................. 55 CORTANE-B ....................... 48 CORTEF............................... 60 CORTENEMA ..................... 80 CORTIFOAM ...................... 80 cortisone ............................... 60 CORTISPORIN .................... 53 CORTROSYN ...................... 60 COSENTYX......................... 46 COSENTYX (2 SYRINGES)
.......................................... 46 COSENTYX PEN ................ 46 COSENTYX PEN (2 PENS) 46 COSMEGEN ........................ 14 COSOPT............................... 98 COSOPT (PF) ...................... 98 cosyntropin ........................... 60 COTELLIC........................... 14 COTEMPLA XR-ODT ........ 33 COUMADIN ........................ 43 covaryx ................................. 90 covaryx h.s. .......................... 90 COZAAR ............................. 39 CREON ................................ 80 CRESEMBA .......................... 3 CRESTOR ............................ 45 CRINONE ............................ 90 CRIXIVAN ............................ 4 cromolyn................. 80, 97, 103 crotan .................................... 56 cryselle (28) .......................... 93 CRYSVITA .......................... 74 CUBICIN ............................... 8
CUBICIN RF .......................... 8 CUPRIMINE ........................ 88 CUROSURF ....................... 103 CUTIVATE .......................... 55 CUVITRU ............................ 86 CUVPOSA ........................... 78 cyanocobalamin (vitamin b-12)
........................................ 108 cyclafem 1/35 (28)................ 93 cyclafem 7/7/7 (28) .............. 93 CYCLESSA (28) .................. 93 cyclobenzaprine .................... 24 CYCLOGYL ........................ 97 CYCLOMYDRIL ............... 100 cyclopentolate ....................... 97 CYCLOPEN-TROPIC-
PHENYLEPH-WATR...... 97 cyclophosphamide ................ 14 CYCLOSERINE .................... 8 CYCLOSET ......................... 76 cyclosporine.......................... 14 cyclosporine modified .......... 14 CYCLOTENS REFILL ........ 24 CYCLOTENS STARTER .... 24 CYMBALTA........................ 33 cyproheptadine ................... 100 CYRAMZA .......................... 14 cyred ..................................... 93 cyred eq ................................ 93 CYSTADANE ...................... 80 CYSTAGON ...................... 106 CYSTARAN ........................ 97 cytarabine ............................. 14 cytarabine (pf) ...................... 14 CYTOMEL ........................... 77 CYTOTEC............................ 83 CYTOVENE .......................... 4 cytra k crystals .................... 106 D D.H.E.45 ............................... 22 dacarbazine ........................... 14 DACOGEN .......................... 14 dactinomycin ........................ 14 DAKLINZA ........................... 4 dalfampridine........................ 23 DALIRESP ......................... 103 danazol.................................. 74 DANTRIUM ........................ 24
dantrolene ............................. 24 dapsone ............................. 8, 50 DAPTACEL (DTAP
PEDIATRIC) (PF) ............ 86 daptomycin ............................. 8 DARAPRIM ........................... 8 darifenacin .......................... 105 DARZALEX ......................... 14 dasetta 1/35 (28) ................... 93 dasetta 7/7/7 (28) .................. 93 daunorubicin ......................... 14 DAURISMO ......................... 14 DAYPRO .............................. 30 daysee ................................... 93 DAYTRANA ........................ 33 DDAVP ................................ 74 DEBACTEROL .................... 59 deblitane ............................... 90 decadron ............................... 60 decitabine .............................. 14 deferasirox ............................ 57 DEFITELIO .......................... 43 DELESTROGEN ................. 90 DELSTRIGO .......................... 4 deltasone ............................... 60 delyla (28) ............................. 93 DELZICOL ........................... 80 DEMADEX .......................... 39 demeclocycline ..................... 11 DEMEROL ........................... 25 DEMEROL (PF) ................... 25 DEMSER .............................. 39 DENAVIR ............................ 54 denta 5000 plus ..................... 59 dentagel ................................. 59 DEPACON ........................... 19 DEPAKENE ......................... 19 DEPAKOTE ......................... 19 DEPAKOTE ER ................... 19 DEPAKOTE SPRINKLES ... 19 DEPEN TITRATABS .......... 88 DEPO-ESTRADIOL ............ 90 DEPO-PROVERA ................ 90 DEPO-SUBQ PROVERA 104
.......................................... 90 DEPO-TESTOSTERONE .... 74 DERMACINRX
EMPRICAINE .................. 52
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123
DERMA-SMOOTHE/FS BODY OIL ....................... 55
DERMA-SMOOTHE/FS SCALP OIL ...................... 55
DERMATOP ........................ 55 dermazene............................. 53 DERMOTIC OIL ................. 59 DESCOVY ............................. 4 desipramine .......................... 33 desloratadine....................... 100 desmopressin ........................ 74 desog-e.estradiol/e.estradiol . 93 desogestrel-ethinyl estradiol . 93 DESONATE ......................... 55 desonide ................................ 55 DESOWEN .......................... 55 desoximetasone .................... 55 DESOXYN ........................... 33 DESVENLAFAXINE .......... 33 desvenlafaxine succinate ...... 33 DETROL ............................ 105 DETROL LA ...................... 105 dexamethasone ..................... 60 DEXAMETHASONE AC,
SOD PH-WATER ............ 60 DEXAMETHASONE ACE-
NACL,ISO-OSM.............. 60 dexamethasone intensol........ 60 dexamethasone sodium
phosphate .................... 60, 99 DEXAMETH-
MOXIFLOX(PF)-NACL,ISO........................ 99
DEXAMET-MOXIFL-KETORO-NACL(PF) ...... 97
dexchlorpheniramine maleate ........................................ 100
DEXCOM G6 RECEIVER .. 66 DEXEDRINE SPANSULE .. 33 DEXERYL ........................... 48 DEXILANT .......................... 83 dexmethylphenidate ............. 33 DEXPAK 10 DAY ............... 60 DEXPAK 13 DAY ............... 60 DEXPAK 6 DAY ................. 60 dexrazoxane hcl .................... 12 DEXTENZA......................... 99 dextroamphetamine .............. 33
dextroamphetamine-amphetamine .................... 33
DIACOMIT .......................... 19 dialyvite 800 ....................... 108 DIASTAT ............................. 19 DIASTAT ACUDIAL .......... 19 DIATRUE CONTROL SOLN
NORMAL ......................... 67 DIATRUE PLUS BLOOD
GLUCOSE MET .............. 67 DIATRUE PLUS TEST STRIP
.......................................... 62 diazepam ......................... 19, 33 diazepam intensol ................. 33 DIBENZYLINE ................... 39 DICLEGIS ............................ 80 DICLO GEL ......................... 30 DICLO GEL-XRYLIX
SHEET.............................. 30 DICLOFENAC EPOLAMINE
.......................................... 30 diclofenac potassium ............ 30 diclofenac sodium..... 30, 48, 98 diclofenac-misoprostol ......... 30 DICLOFEX DC .................... 30 DICLOFONO ....................... 30 DICLOPAK .......................... 30 DICLOPR ............................. 30 dicloxacillin .......................... 10 dicyclomine .......................... 78 didanosine ............................... 4 DIFFERIN ............................ 50 DIFICID ................................. 7 diflorasone ............................ 55 DIFLUCAN ............................ 3 diflunisal ............................... 30 digitek ................................... 42 digox ..................................... 42 digoxin .................................. 42 dihydroergotamine................ 22 DILANTIN ........................... 19 DILANTIN EXTENDED..... 19 DILANTIN INFATABS ...... 20 DILANTIN-125.................... 20 DILATRATE-SR ................. 46 DILAUDID .......................... 25 DILAUDID (PF) .................. 25 diltiazem ............................... 39
dilt-xr .................................... 39 DIOVAN .............................. 39 DIOVAN HCT ..................... 39 DIPENTUM ......................... 80 diphenhydramine hcl .......... 100 diphenoxylate-atropine ......... 78 DIPROLENE ........................ 55 dipyridamole ......................... 43 DISALCID ........................... 30 diskets ................................... 25 disopyramide phosphate ....... 38 disulfiram .............................. 57 DITHOL ............................... 30 DITROPAN XL .................. 105 DIURIL ................................. 39 DIURIL IV ........................... 39 divalproex ............................. 20 DIVIGEL .............................. 90 DM2 ...................................... 76 DOCEFREZ ......................... 14 docetaxel ............................... 14 DOCETAXEL ...................... 14 dofetilide ............................... 38 DOLOPHINE ....................... 25 DOLOTRANZ ...................... 52 donepezil ............................... 23 DONNATAL ........................ 78 DOPTELET (15 TAB PACK)
.......................................... 43 DORAL ................................ 33 DORIPENEM ......................... 8 DORYX ................................ 11 DORYX MPC ...................... 11 dorzolamide .......................... 98 dorzolamide-timolol ............. 98 dorzolamide-timolol (pf) ...... 99 DORZOLAMIDE-TIMOLOL
(PF) ................................... 99 DOVATO ............................... 4 DOVONEX .......................... 47 doxazosin .............................. 39 doxepin ........................... 33, 48 doxercalciferol ...................... 74 DOXIL .................................. 14 doxorubicin ........................... 14 doxorubicin, peg-liposomal .. 14 doxycycline hyclate .............. 11 doxycycline monohydrate .... 11
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DOXYCYCLINE MONOHYDRATE........... 11
D-PENAMINE ..................... 88 DRISDOL........................... 109 drithocreme hp...................... 47 dronabinol............................. 80 drospirenone-e.estradiol-lm.fa
.......................................... 93 drospirenone-ethinyl estradiol
.......................................... 93 DROXIA .............................. 14 DSUVIA ............................... 25 DUAC................................... 50 DUAVEE ............................. 90 ducodyl ................................. 80 DUET DHA BALANCED . 109 DUET DHA WITH OMEGA-3
........................................ 109 DUETACT ........................... 76 DUEXIS ............................... 30 DULERA ............................ 103 duloxetine ............................. 33 DUOBRII ............................. 55 DUOPA ................................ 21 DUPIXENT .......................... 48 DURAGESIC ....................... 25 DUREZOL ........................... 99 dutasteride .......................... 106 dutasteride-tamsulosin ........ 106 DUTOPROL......................... 39 DUZALLO ........................... 88 dvorah ................................... 25 DXEVO ................................ 60 DYANAVEL XR ................. 33 DYAZIDE ............................ 39 DYMISTA .......................... 103 DYRENIUM ........................ 39 DYSPORT ............................ 86 E e.c. prin ................................. 30 e.e.s. 400 ................................. 7 E.E.S. GRANULES ............... 7 EASY PLUS II HIGH
CONTROL ....................... 67 EASY PLUS II TEST .......... 62 EASY STEP ......................... 62 EASY STEP BLOOD
GLUCOSE METER ......... 67
EASY STEP HIGH CONTROL SOLN ............ 67
EASY TALK GLUCOSE TEST ................................ 62
EASY TALK HIGH CONTROL ....................... 67
EASY TOUCH GLUCOSE MONITOR ....................... 67
EASY TOUCH TEST STRIP .......................................... 62
EASY TRAK GLUCOSE TEST ................................ 62
EASY TRAK LOW CONTROL ....................... 67
EASYGLUCO MONITORING SYSTEM 67
EASYGLUCO PLUS ........... 62 EASYGLUCO PLUS
NORMAL CONTROL ..... 67 EASYGLUCO TEST ........... 62 EASYMAX .......................... 62 EASYMAX L BLOOD
GLUCOSE METER ......... 67 EASYMAX LOW CONTROL
.......................................... 67 EASYMAX NG ................... 67 EASYMAX NORMAL
CONTROL ....................... 67 EASYMAX V SPEAKING
GLUCOSE SYS ............... 67 EASYMAX V2 BLOOD
GLUCOSE METER ......... 67 ECLIPSE NEEDLE .............. 67 EC-NAPROSYN .................. 30 econazole .............................. 53 econtra ez .............................. 93 econtra one-step .................... 93 ecotrin ................................... 30 ecotrin low strength .............. 30 ECOZA ................................. 53 EDARBI ............................... 39 EDARBYCLOR ................... 39 EDECRIN ............................. 39 EDLUAR .............................. 33 ed-spaz .................................. 78 EDURANT ............................. 4 eemt ...................................... 90 eemt hs .................................. 90
efavirenz ................................. 4 effer-k ................................. 107 EFFER-K ............................ 107 EFFEXOR XR ...................... 33 EFFIENT .............................. 43 EFUDEX .............................. 48 EGRIFTA ............................. 84 ELAPRASE .......................... 74 ELELYSO ............................ 74 ELEMENT COMPACT
GLUCOSE METER ......... 67 ELEMENT COMPACT
NORMAL CONTROL ..... 67 ELEMENT COMPACT TEST
STRIPS ............................. 62 ELEMENT COMPACT V
GLUCOSE MTR .............. 67 ELEMENT NORMAL
CONTROL ....................... 67 ELEMENT PLUS BLOOD
GLUCOSE KIT ................ 67 ELEMENT TEST STRIPS ... 62 ELESTRIN ........................... 90 eletone ................................... 48 eletriptan ............................... 22 ELIDEL ................................ 48 ELIGARD ............................. 14 ELIGARD (3 MONTH) ....... 15 ELIGARD (4 MONTH) ....... 15 ELIGARD (6 MONTH) ....... 15 ELIMITE .............................. 56 elinest .................................... 93 ELIQUIS ............................... 43 ELITEK ................................ 12 ELIXOPHYLLIN ............... 103 ELLA .................................... 93 ELLENCE ............................ 15 ELLZIA PAK ....................... 55 ELMIRON .......................... 106 ELOCON .............................. 55 ELOCTATE ......................... 43 ELZONRIS ........................... 15 EMBEDA ............................. 25 EMBRACE BLOOD
GLUCOSE SYSTEM . 62, 67 EMBRACE EVO LEVEL 1 . 67 EMBRACE EVO TEST
STRIPS ............................. 62
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EMBRACE GLUCOSE CONTROL LOW ............. 67
EMBRACE PRO GLUCOSE METER ............................ 67
EMBRACE PRO TEST STRIPS ............................. 62
EMBRACE TALK BLOOD GLUCOSE SYS ............... 67
EMBRACE TALK CONTROL-LOW (L1) .... 67
EMBRACE TALK TEST STRIPS ............................. 62
EMCYT ................................ 15 EMEND ................................ 80 EMEND (FOSAPREPITANT)
.......................................... 80 EMFLAZA ........................... 60 EMGALITY PEN ................ 22 EMGALITY SYRINGE ....... 22 emoquette ............................. 93 EMPLICITI .......................... 15 EMSAM ............................... 33 EMTRIVA .............................. 4 EMVERM .............................. 8 ENABLEX ......................... 105 enalapril maleate .................. 39 enalaprilat ............................. 39 enalapril-hydrochlorothiazide
.......................................... 39 ENBRACE HR ................... 109 ENBREL .............................. 89 ENBREL MINI .................... 89 ENBREL SURECLICK ....... 89 ENDARI ............................... 57 endocet ................................. 25 ENDOMETRIN ................... 90 ENGERIX-B (PF) ................ 86 ENGERIX-B PEDIATRIC
(PF) ................................... 86 enoxaparin ............................ 43 enpresse ................................ 93 enskyce ................................. 93 ENSTILAR........................... 47 entacapone ............................ 21 entecavir ................................. 4 ENTOCORT EC .................. 80 ENTRESTO ......................... 46 ENTYVIO ............................ 80
enulose .................................. 80 ENVARSUS XR .................. 15 EPANED .............................. 39 EPCLUSA .............................. 4 EPICERAM .......................... 48 EPIDIOLEX ......................... 20 EPIDUO ............................... 50 EPIDUO FORTE .................. 50 EPIFOAM ............................ 47 epinastine .............................. 97 epinephrine ......................... 101 EPINEPHRINE .......... 100, 101 EPINEPHRINESNAP-EMS
........................................ 101 EPINEPHRINESNAP-V .... 101 EPIPEN 2-PAK .................. 101 EPIPEN JR 2-PAK ............. 101 epirubicin .............................. 15 EPISIL .................................. 59 EPISNAP ............................ 101 epitol ..................................... 20 EPIVIR ................................... 4 EPIVIR HBV .......................... 4 eplerenone ............................ 39 EPOGEN .............................. 84 epoprostenol (glycine) .......... 39 eprosartan ............................. 39 EPZICOM .............................. 4 EQUETRO ........................... 20 ERAXIS(WATER DILUENT)
............................................ 3 ERBITUX ............................. 15 ergocalciferol (vitamin d2) . 109 ergoloid ................................. 33 ERGOMAR .......................... 22 ergotamine-caffeine .............. 22 ERIVEDGE .......................... 15 ERLEADA ........................... 15 errin ...................................... 90 ERTACZO............................ 54 ertapenem ............................... 8 ERWINAZE ......................... 15 ery pads................................. 50 erygel .................................... 50 ERYPED 200 ......................... 7 ERYPED 400 ......................... 7 ery-tab ..................................... 7 ERY-TAB ............................... 7
erythrocin (as stearate) ........... 7 erythromycin ..................... 7, 96 erythromycin ethylsuccinate ... 7 erythromycin with ethanol .... 50 erythromycin-benzoyl peroxide
.......................................... 50 ESBRIET ............................ 103 escitalopram oxalate ............. 33 ESGIC ................................... 25 esmolol ................................. 39 ESOMEP-EZS ...................... 83 esomeprazole magnesium ..... 83 esomeprazole sodium ........... 83 ESOMEPRAZOLE
STRONTIUM ................... 83 estarylla ................................. 93 estazolam .............................. 33 ESTRACE ............................ 90 estradiol ................................ 90 estradiol valerate ................... 90 estradiol-norethindrone acet . 90 ESTRING ............................. 91 ESTROGEL .......................... 91 estrogens-methyltestosterone 91 ESTROSTEP FE-28 ............. 93 eszopiclone ........................... 33 ethacrynate sodium ............... 39 ethacrynic acid ...................... 39 ethambutol .............................. 8 ethosuximide ......................... 20 ethyl chloride ........................ 52 ethynodiol diac-eth estradiol 93 ETHYOL .............................. 12 etidronate disodium .............. 57 etodolac ................................. 30 etoposide ............................... 15 EUCRISA ............................. 48 EUFLEXXA ......................... 30 EURAX ................................ 56 EUTHYROX ........................ 77 EVAMIST ............................ 91 EVEKEO .............................. 33 EVENCARE G2 ............. 62, 67 EVENCARE G3 GLUCOSE
METER ............................. 67 EVENCARE G3 TEST ........ 62 EVENCARE MINI
GLUCOSE TEST STR ..... 62
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EVENCARE MINI MONITOR SYSTEM ...... 68
EVENITY............................. 88 EVERSENSE SENSOR-
HOLDER .......................... 68 EVISTA ................................ 88 EVOCLIN ............................ 50 EVOLUTION BLOOD
GLUCOSE METER ......... 68 EVOLUTION NORMAL
CONTROL ....................... 68 EVOLUTION TEST STRIPS
.......................................... 62 EVOMELA .......................... 15 EVOTAZ ................................ 4 EVOXAC ............................. 57 EVZIO .................................. 30 EXALGO ER ....................... 25 EXELDERM ........................ 54 EXELON .............................. 23 exemestane ........................... 15 EXFORGE ........................... 39 EXFORGE HCT .................. 39 EXJADE ............................... 57 EXODERM .......................... 54 EXONDYS 51 ...................... 23 EXTAVIA ............................ 84 EXTINA ............................... 54 EXTRA-VIRT PLUS DHA 109 EYLEA ................................. 97 EZ FLU 2018-
19(FLUCELVAX)(PF) .... 86 EZ SMART PLUS SYSTEM
.......................................... 68 EZ SMART PLUS TEST ..... 62 EZ SMART SYSTEM ......... 68 EZ SMART TEST ................ 62 ezetimibe .............................. 45 ezetimibe-simvastatin ........... 45 F FABIOR ............................... 50 FABRAZYME ..................... 74 FACTIVE ............................. 10 falmina (28) .......................... 93 famciclovir ............................. 4 famotidine............................. 83 famotidine (pf)...................... 83 famotidine (pf)-nacl (iso-os) 83
FAMOTIDINE IN 0.9 % NACL ............................... 83
FANAPT .............................. 33 FARESTON ......................... 15 FARXIGA ............................ 76 FARYDAK ........................... 15 FASENRA .......................... 103 FASLODEX ......................... 15 fayosim ................................. 93 FAZACLO............................ 33 FC2 FEMALE CONDOM ... 90 FEIBA NF ............................ 43 felbamate .............................. 20 FELBATOL.......................... 20 FELDENE ............................ 30 felodipine .............................. 40 fem ph ................................... 92 FEMARA ............................. 15 FEMCAP .............................. 90 FEMHRT LOW DOSE ........ 91 FEMRING ............................ 91 femynor ................................ 93 fenofibrate ............................ 45 FENOFIBRATE ................... 45 fenofibrate micronized ......... 45 fenofibrate nanocrystallized . 45 FENOFIBRATE
NANOCRYSTALLIZED . 45 fenofibric acid....................... 45 fenofibric acid (choline) ....... 45 FENOGLIDE........................ 45 fenoprofen ............................ 30 FENOPROFEN .................... 30 FENORTHO ......................... 30 fentanyl ................................. 25 FENTANYL (PF)-
BUPIVACAINE-NACL ... 25 fentanyl citrate ...................... 25 fentanyl citrate (pf) ............... 25 FENTANYL CITRATE (PF)
.......................................... 25 fentanyl citrate (pf)-0.9%nacl
.......................................... 25 FENTANYL CITRATE (PF)-
0.9%NACL ....................... 25 FENTANYL-
ROPIVACAINE-NACL (PF) ................................... 26
FENTORA ............................ 26 FERRIPROX ........................ 57 FERRLECIT ......................... 57 FETZIMA ............................. 33 FEXMID ............................... 24 FIASP FLEXTOUCH U-100
INSULIN .......................... 72 FIASP U-100 INSULIN ....... 72 FIBRICOR ............................ 45 FIBRYGA ............................. 43 FIFTY50 TEST STRIP ......... 62 FINACEA ............................. 50 finasteride ........................... 106 FIORICET ............................ 26 FIORINAL ........................... 26 FIORINAL-CODEINE #3 .... 26 FIRAZYR ........................... 103 FIRDAPSE ........................... 23 FIRMAGON KIT W
DILUENT SYRINGE ...... 15 FIRVANQ ............................ 12 flac otic oil ............................ 59 FLAGYL ................................ 8 FLAREX ............................... 99 flavoxate ............................. 105 FLEBOGAMMA DIF .......... 86 flecainide .............................. 38 FLECTOR ............................ 30 fleet laxative ......................... 80 FLOLAN .............................. 40 FLOLIPID ............................ 45 FLOMAX ........................... 106 FLORIVA (FLUORIDE-
VITAMIN D3) ................ 109 FLOVENT DISKUS .......... 103 FLOVENT HFA ................. 103 floxuridine ............................ 15 FLUAD 2018-2019 (65 YR
UP)(PF) ............................. 86 FLUARIX QUAD 2018-2019
(PF) ................................... 86 FLUBLOK QUAD 2018-2019
(PF) ................................... 86 flucaine ................................. 97 FLUCELVAX QUAD 2018-
2019 .................................. 86 FLUCELVAX QUAD 2018-
2019 (PF) .......................... 86
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fluconazole ............................. 3 fluconazole in dextrose(iso-o) 3 fluconazole in nacl (iso-osm) . 3 flucytosine .............................. 3 fludarabine ............................ 15 fludrocortisone ..................... 60 FLULAVAL QUAD 2018-
2019 .................................. 86 FLULAVAL QUAD 2018-
2019 (PF) .......................... 86 FLUMADINE ........................ 4 flumazenil ............................. 33 FLUMIST QUAD 2018-2019
.......................................... 86 flunisolide ........................... 103 fluocinolone .......................... 55 fluocinolone acetonide oil .... 59 fluocinolone and shower cap 55 fluocinonide .......................... 55 fluocinonide-emollient ......... 55 FLUORABON ................... 109 fluorescein-proparacaine ...... 97 fluoride (sodium) ................ 109 FLUORIDEX DAILY
DEFENSE ........................ 59 fluoritab .............................. 109 fluorometholone ................... 99 FLUOROPLEX .................... 48 fluorouracil ..................... 15, 48 FLUOROURACIL ............... 48 fluoxetine ........................ 33, 34 fluphenazine decanoate ........ 34 fluphenazine hcl ................... 34 FLURA-DROPS ................ 109 flurandrenolide ..................... 55 flurazepam ............................ 34 flurbiprofen........................... 30 flurbiprofen sodium .............. 98 flutamide............................... 15 fluticasone propionate .. 55, 103 fluticasone propion-salmeterol
........................................ 103 FLUTICASONE PROPION-
SALMETEROL ............. 103 fluvastatin ............................. 45 fluvoxamine .......................... 34 FLUZONE HIGH-DOSE
2018-19 (PF) .................... 86
FLUZONE QUAD 2018-2019 .......................................... 86
FLUZONE QUAD 2018-2019 (PF) ................................... 86
FLUZONE QUAD PEDI 2018-19 (PF)..................... 86
FML FORTE ........................ 99 FML LIQUIFILM ................ 99 FML S.O.P. .......................... 99 FOCALIN ............................. 34 FOCALIN XR ...................... 34 FOLET ONE ...................... 109 folic acid ............................. 109 folivane-ob.......................... 109 FOLLISTIM AQ .................. 74 FOLOTYN ........................... 15 foltabs 800 .......................... 109 fondaparinux ......................... 43 FORA D10 ........................... 68 FORA D15G STRIPS .......... 62 FORA D20 ..................... 62, 68 FORA D40-G31 TEST
STRIPS ............................. 62 FORA G20 ..................... 62, 68 FORA G30A......................... 68 FORA G30-PREMIUM V10
TEST STRP ...................... 62 FORA GD50 BLOOD
GLUCOSE SYSTEM ....... 68 FORA GD50 TEST STRIPS 63 FORA GTEL GLUCOSE
TEST STRIP..................... 63 FORA NORMAL CONTROL
.......................................... 68 FORA PREMIUM V10
GLUCOSE METER ......... 68 FORA TEST N'GO VOICE
METER ............................ 68 FORA TEST STRIP ............. 63 FORA TN'G VOICE METER
.......................................... 68 FORA TN'G VOICE TEST
STRIPS ............................. 63 FORA V10 ..................... 63, 68 FORA V10-V12-D10-D20
STRIPS ............................. 63 FORA V12 BLOOD
GLUCOSE SYSTEM ....... 68
FORA V12 GLUCOSE ........ 63 FORA V20 ...................... 63, 68 FORA V30A ......................... 68 FORACARE GD20 .............. 63 FORACARE GD20
GLUCOSE METER ......... 68 FORACARE GD40 .............. 63 FORACARE GD40A
GLUCOSE METER ......... 68 FORACARE GD40B
GLUCOSE METER ......... 68 FORACARE GDH LOW
CONTROL ....................... 68 FORFIVO XL ....................... 34 FORTAMET ......................... 76 FORTEO ............................... 88 FORTESTA .......................... 74 FORTISCARE BLOOD
GLUCOSE SYST ............. 68 FORTISCARE GLUCOSE
TEST STRIPS .................. 63 FORTISCARE NORMAL ... 68 FOSAMAX ........................... 88 FOSAMAX PLUS D ............ 88 fosamprenavir ......................... 4 FOSCAVIR ............................ 4 fosinopril ............................... 40 fosinopril-hydrochlorothiazide
.......................................... 40 fosphenytoin ......................... 20 FOSRENOL ......................... 80 FRAGMIN ............................ 43 FREESTYLE CONTROL .... 68 FREESTYLE FLASH
SYSTEM .......................... 68 FREESTYLE FREEDOM .... 68 FREESTYLE FREEDOM
LITE ................................. 68 FREESTYLE INSULINX ... 63,
68 FREESTYLE INSULINX
TEST STRIPS .................. 63 FREESTYLE LIBRE 10 DAY
READER .......................... 68 FREESTYLE LIBRE 10 DAY
SENSOR ........................... 68 FREESTYLE LITE METER 68 FREESTYLE LITE STRIPS 63
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FREESTYLE PRECISION NEO METER ................... 68
FREESTYLE PRECISION NEO STRIPS.................... 63
FREESTYLE SIDEKICK II 68 FREESTYLE SYSTEM KIT 69 FREESTYLE TEST ............. 63 FROTEK .............................. 30 FROVA ................................ 22 frovatriptan ........................... 22 full spectrum b-vitamin c ... 109 FULPHILA........................... 84 FURADANTIN .................... 11 furosemide ............................ 40 FUROSEMIDE IN 0.9 %
NACL ............................... 40 FUSILEV ............................. 12 FUZEON ................................ 4 fyavolv .................................. 91 FYCOMPA .......................... 20 G g tussin ac ........................... 101 gabapentin ............................ 20 GABITRIL ........................... 20 GALAFOLD ........................ 74 galantamine .......................... 23 GALZIN ............................. 107 GAMASTAN ....................... 86 GAMASTAN S/D ................ 86 GAMIFANT ......................... 15 GAMMAGARD LIQUID .... 86 GAMMAGARD S-D (IGA < 1
MCG/ML) ........................ 86 GAMMAKED ...................... 86 GAMMAPLEX .................... 86 GAMMAPLEX (WITH
SORBITOL) ..................... 86 GAMUNEX-C ..................... 86 GANCICLOVIR .................... 4 ganciclovir sodium ................. 4 ganirelix ................................ 74 GARDASIL 9 (PF)............... 86 GASTROCROM .................. 80 gatifloxacin ........................... 96 GATTEX 30-VIAL .............. 80 gavilax .................................. 80 gavilyte-c .............................. 80 gavilyte-g .............................. 80
gavilyte-n .............................. 80 GAZYVA ............................. 15 GE100 BLOOD GLUCOSE
SYSTEM .......................... 69 GE100 BLOOD GLUCOSE
TEST STRIP..................... 63 GE100 CONTROL
SOLUTION NORMAL .... 69 GELCLAIR .......................... 59 GELNIQUE ........................ 106 gemcitabine .......................... 15 GEMCITABINE .................. 15 gemfibrozil ........................... 45 GENERESS FE .................... 93 generlac ................................ 80 gengraf .................................. 15 GENOTROPIN .................... 84 GENOTROPIN MINIQUICK
.......................................... 84 GENSTRIP TEST STRIP .... 63 gentak ................................... 96 gentamicin .................. 8, 53, 96 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 GENTAMICIN-SODIUM
CITRATE ........................... 8 gentle laxative....................... 80 gentlelax ............................... 80 GENVOYA ............................ 4 GEODON ............................. 34 GIALAX ............................... 80 gianvi (28) ............................ 93 GIAPREZA .......................... 46 GILENYA ............................ 84 GILOTRIF ............................ 15 GLASSIA ............................. 57 glatiramer.............................. 84 glatopa .................................. 85 GLEEVEC ............................ 15 GLEOLAN ........................... 57 GLEOSTINE ........................ 15 GLIADEL WAFER .............. 15 glimepiride............................ 76
glipizide ................................ 76 glipizide-metformin .............. 76 GLUCAGEN DIAGNOSTIC
KIT ................................... 65 GLUCAGEN HYPOKIT ...... 65 GLUCAGON EMERGENCY
KIT (HUMAN) ................. 65 GLUCAGON HCL ............... 65 GLUCO NAVII GLUCOSE
MONITOR ....................... 69 GLUCO NAVII TEST STRIP
.......................................... 63 GLUCOCARD 01 METER .. 69 GLUCOCARD 01 NORMAL
CONTROL ....................... 69 GLUCOCARD 01 SENSOR
PLUS ................................ 63 GLUCOCARD EXPRESSION
.................................... 63, 69 GLUCOCARD SHINE
CONNEX METER ........... 69 GLUCOCARD SHINE
EXPRESS METER .......... 69 GLUCOCARD SHINE
METER ............................. 69 GLUCOCARD SHINE TEST
STRIPS ............................. 63 GLUCOCARD SHINE XL
METER ............................. 69 GLUCOCARD VITAL ........ 69 GLUCOCARD VITAL
SENSOR ........................... 63 GLUCOCARD VITAL TEST
STRIPS ............................. 63 GLUCOCOM BLOOD
GLUCOSE ........................ 69 GLUCOCOM CONTROL
NORMAL ......................... 69 GLUCOCOM GLUCOSE .... 63 GLUCOPHAGE ................... 76 GLUCOPHAGE XR ............ 76 GLUCOSE CONTROL ........ 69 GLUCOTROL ...................... 76 GLUCOTROL XL ................ 76 GLUMETZA ........................ 76 glyburide ............................... 76 glyburide micronized ............ 76 glyburide-metformin ............. 76
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GLYCATE ........................... 78 glycolax ................................ 80 glycopyrrolate....................... 78 GLYCOPYRROLATE......... 78 glycopyrrolate (pf) in water .. 78 GLYCOPYRROLATE (PF) IN
WATER ............................ 78 glydo ..................................... 52 GLYNASE ........................... 76 GLYRX-PF .......................... 78 GLYSET............................... 76 GLYXAMBI ........................ 76 GM100 ........................... 63, 69 GOCOVRI ............................ 21 GOLYTELY......................... 80 GONAL-F ............................ 74 GONAL-F RFF .................... 74 GONAL-F RFF REDI-JECT 74 GONITRO ............................ 46 GRALISE ............................. 20 GRALISE 30-DAY STARTER
PACK ............................... 20 granisetron hcl ...................... 80 GRANIX .............................. 84 GRASTEK ........................... 86 griseofulvin microsize ............ 3 griseofulvin ultramicrosize ..... 3 guaiatussin ac ..................... 101 guaifenesin ac ..................... 101 guaifenesin dac ................... 101 guanfacine ...................... 34, 40 guanidine .............................. 34 GYNAZOLE-1 ..................... 92 gynol ii.................................. 92 H HAEGARDA ..................... 103 hailey 24 fe ........................... 93 HALAVEN........................... 15 HALCION ............................ 34 HALDOL ............................. 34 HALDOL DECANOATE .... 34 halobetasol propionate.......... 55 HALOBETASOL
PROPIONATE ................. 55 HALOG ................................ 55 haloperidol ............................ 34 haloperidol decanoate ........... 34 haloperidol lactate ................ 34
HARVONI.............................. 4 HAVRIX (PF) ...................... 86 HEALTHPRO GLUCOSE
MONITOR ....................... 69 HEALTHPRO HIGH-LOW
CONTROL ....................... 69 HEALTHPRO TEST STRIPS
.......................................... 63 healthylax ............................. 80 heather .................................. 91 HECTOROL ......................... 74 HELIXATE FS ..................... 43 HEMANGEOL ..................... 40 hemenatal ob....................... 109 hemenatal ob + dha ............ 109 HEMLIBRA ......................... 43 hemmorex-hc ........................ 80 HEMOFIL M HIGH ............. 43 HEMOFIL M LOW.............. 43 HEMOFIL M MID ............... 43 HEMOFIL M SUPER HIGH43 hep flush-10 (pf) ................... 43 HEPAGAM B....................... 86 heparin (porcine) .................. 43 HEPARIN (PORCINE) IN
0.9% NACL ...................... 43 heparin (porcine) in 5 % dex 43 heparin (porcine) in nacl (pf) 43 heparin flush(porcine)-0.9nacl
.......................................... 43 heparin lock flush ................. 43 heparin lock flush (porcine) . 43 heparin lockflush(porcine)(pf)
.......................................... 43 HEPARIN(PORCINE) IN
0.45% NACL .................... 43 heparin, porcine (pf) ............. 43 HEPARIN, PORCINE (PF) . 43 HEPLISAV-B (PF)............... 86 HEPSERA .............................. 4 HERCEPTIN ........................ 15 HERCEPTIN HYLECTA .... 15 HETLIOZ ............................. 34 HIBERIX (PF) ...................... 86 hidex ..................................... 60 HIPREX................................ 12 HISTEX-AC ....................... 101 HIZENTRA .......................... 87
homatropaire ......................... 97 homatropine hbr .................... 97 HORIZANT .......................... 23 hpr ......................................... 48 hpr plus ................................. 48 hpr plus hydrogel .................. 48 HPR PLUS-MB HYDROGEL
.......................................... 48 HUMALOG JUNIOR
KWIKPEN U-100 ............ 72 HUMALOG KWIKPEN
INSULIN .......................... 72 HUMALOG MIX 50-50
INSULN U-100 ................ 73 HUMALOG MIX 50-50
KWIKPEN ........................ 73 HUMALOG MIX 75-25
KWIKPEN ........................ 73 HUMALOG MIX 75-25(U-
100)INSULN .................... 73 HUMALOG U-100 INSULIN
.......................................... 73 HUMATE-P ......................... 43 HUMATROPE ..................... 84 HUMIRA .............................. 89 HUMIRA PEDIATRIC
CROHNS START ............ 89 HUMIRA PEN ..................... 89 HUMIRA PEN CROHNS-UC-
HS START ....................... 89 HUMIRA PEN PSOR-
UVEITS-ADOL HS ......... 89 HUMIRA(CF) ...................... 89 HUMIRA(CF) PEDI
CROHNS STARTER ....... 89 HUMIRA(CF) PEN .............. 89 HUMIRA(CF) PEN
CROHNS-UC-HS ............. 89 HUMIRA(CF) PEN PSOR-
UV-ADOL HS .................. 89 HUMULIN 70/30 U-100
INSULIN .......................... 73 HUMULIN 70/30 U-100
KWIKPEN ........................ 73 HUMULIN N NPH INSULIN
KWIKPEN ........................ 73 HUMULIN N NPH U-100
INSULIN .......................... 73
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130
HUMULIN R REGULAR U-100 INSULN .................... 73
HUMULIN R U-500 (CONC) INSULIN .......................... 73
HUMULIN R U-500 (CONC) KWIKPEN ....................... 73
HYCAMTIN ........................ 16 hydralazine ........................... 40 HYDREA ............................. 16 HYDRO 35 ........................... 48 HYDRO 40 ........................... 48 hydrochlorothiazide .............. 40 hydrocodone-acetaminophen 26 hydrocodone-chlorpheniramine
........................................ 101 hydrocodone-cpm-
pseudoephed ................... 101 HYDROCODONE-
GUAIFENESIN ............. 101 hydrocodone-homatropine . 101 hydrocodone-ibuprofen ........ 26 hydrocortisone .......... 55, 60, 80 hydrocortisone acetate .......... 80 hydrocortisone butyrate ........ 55 hydrocortisone butyr-emollient
.......................................... 55 hydrocortisone valerate ........ 55 hydrocortisone-acetic acid.... 59 hydrocortisone-iodoquinol ... 53 hydrocortisone-iodoquinol-aloe
.......................................... 53 hydrocortisone-pramoxine .. 47,
80 hydromet............................. 101 hydromorphone .............. 26, 27 HYDROMORPHONE ......... 26 hydromorphone (pf) ............. 26 HYDROMORPHONE (PF) . 26 HYDROMORPHONE (PF) IN
WATER ............................ 26 HYDROMORPHONE (PF)-
0.9 % NACL ..................... 26 hydromorphone in 0.9 % nacl
.......................................... 26 HYDROMORPHONE IN 0.9
% NACL ........................... 26 hydroxychloroquine ............... 8
hydroxyprogest(pf)(preg presv) .......................................... 91
hydroxyprogesterone cap(ppres) ......................... 91
hydroxyprogesterone caproate .......................................... 91
hydroxyurea .......................... 16 hydroxyzine hcl .................. 101 hydroxyzine pamoate ......... 101 HYLATOPIC ....................... 48 HYLATOPICPLUS.............. 48 hyophen .............................. 106 hyoscyamine sulfate ............. 78 hyosyne ................................. 78 HYPERHEP B S/D .............. 87 HYPERHEP B S-D
NEONATAL .................... 87 HYPERRAB (PF)................. 87 HYPERRAB S/D (PF) ......... 87 HYPER-SAL ...................... 103 HYPERTET S/D (PF) .......... 87 hypocyn ................................ 97 HYQVIA .............................. 87 HYSINGLA ER ................... 27 HYZAAR ............................. 40 I ibandronate ........................... 88 IBRANCE ............................ 16 ibu ......................................... 30 IBUDONE ............................ 27 ibuprofen .............................. 30 ibuprofen-oxycodone............ 27 ic green ................................. 57 ICLUSIG .............................. 16 IDAMYCIN PFS .................. 16 idarubicin .............................. 16 IDELVION ........................... 43 IDHIFA ................................ 16 IFE-BIMIX 30/1 ................. 106 IFE-PG20............................ 106 IFEX ..................................... 16 ifosfamide ............................. 16 ifosfamide-mesna ................. 16 IGLUCOSE BLOOD
GLUCOSE MONITOR .... 69 IGLUCOSE TEST STRIP .... 63 ILARIS (PF) ......................... 85 ILEVRO ............................... 98
ILUMYA .............................. 47 ILUVIEN .............................. 99 imatinib ................................. 16 IMBRUVICA ....................... 16 IMFINZI ............................... 16 imipenem-cilastatin ................ 8 imipramine hcl ...................... 34 imipramine pamoate ............. 34 imiquimod ............................. 85 IMIQUIMOD ....................... 85 IMITREX ............................. 22 IMITREX STATDOSE PEN 22 IMITREX STATDOSE
REFILL ............................. 22 IMLYGIC ............................. 16 IMOGAM RABIES-HT (PF)
.......................................... 87 IMPAVIDO ............................ 8 IMPOYZ ............................... 55 IMURAN .............................. 16 IMVEXXY MAINTENANCE
PACK ............................... 91 IMVEXXY STARTER PACK
.......................................... 91 INBRIJA ............................... 21 incassia ................................. 91 INCRELEX .......................... 57 INCRUSE ELLIPTA .......... 103 indapamide ........................... 40 INDERAL LA ...................... 40 INDERAL XL ...................... 40 INDOCIN ............................. 30 indocyanine green ................. 57 indomethacin ........................ 30 INFANRIX (DTAP) (PF) ..... 87 INFASURF ........................... 57 INFINITY CONTROL
SOLUTION NORM ......... 69 INFINITY STARTER KIT .. 69 INFINITY TEST STRIPS .... 63 INFINITY VOICE CTRL
SOLN-LVL 2 .................... 69 INFINITY VOICE GLUCOSE
MONITOR ....................... 69 INFINITY VOICE TEST
STRIP ............................... 63 INFLECTRA ........................ 80 INFUGEM ............................ 16
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INFUVITE ADULT ........... 109 INFUVITE PEDIATRIC.... 109 INGREZZA .......................... 23 INGREZZA INITIATION
PACK ............................... 23 INJECTAFER .................... 109 INLYTA ............................... 16 INNOPRAN XL ................... 40 INOVA ................................. 50 INOVA 4-1 ........................... 47 INSPRA ................................ 40 INSULIN LISPRO ............... 73 INSULIN SYRINGE-
NEEDLE U-100 ............... 65 INTELENCE .......................... 4 INTERMEZZO .................... 34 INTRAROSA ....................... 92 INTRON A ........................... 85 introvale ................................ 93 INTUNIV ER ....................... 34 INVANZ................................. 8 INVEGA............................... 34 INVELTYS .......................... 99 INVIRASE ............................. 4 INVOKAMET ...................... 76 INVOKAMET XR ............... 76 INVOKANA ........................ 76 IOPIDINE........................... 100 IPOL ..................................... 87 ipratropium bromide ..... 59, 103 ipratropium-albuterol ......... 103 irbesartan .............................. 40 irbesartan-hydrochlorothiazide
.......................................... 40 IRESSA ................................ 16 irinotecan .............................. 16 ISENTRESS ........................... 4 ISENTRESS HD .................... 4 isibloom ................................ 93 ISOCHRON ......................... 46 ISOLYTE-S ........................ 108 isoniazid ................................. 8 ISOPTO ATROPINE ........... 97 ISOPTO CARPINE .............. 97 ISORDIL .............................. 46 ISORDIL TITRADOSE ....... 46 isosorbide dinitrate ............... 46 isosorbide mononitrate ......... 46
isotretinoin ............................ 51 isoxsuprine............................ 92 isradipine .............................. 40 ISTALOL ............................. 97 ISTODAX ............................ 16 itraconazole ............................ 3 ivermectin ............................... 9 IXEMPRA ............................ 16 IXINITY ............................... 44 J JADENU .............................. 57 JADENU SPRINKLE .......... 57 JAKAFI ................................ 16 JALYN ............................... 106 jantoven ................................ 44 JANUMET ........................... 76 JANUMET XR ..................... 76 JANUVIA ............................. 76 JARDIANCE ........................ 76 jasmiel (28) ........................... 93 JAZZ WIRELESS 2 METER
KIT ................................... 69 jencycla ................................. 91 JENTADUETO .................... 76 JENTADUETO XR .............. 76 JETREA (PF) ....................... 97 JEVTANA ............................ 16 jinteli ..................................... 91 JIVI ....................................... 44 jolessa ................................... 93 jolivette ................................. 91 JUBLIA ................................ 54 juleber ................................... 93 JULUCA ................................. 4 junel 1.5/30 (21) ................... 93 junel 1/20 (21) ...................... 93 junel fe 1.5/30 (28) ............... 93 junel fe 1/20 (28) .................. 93 junel fe 24 ............................. 93 JUXTAPID ........................... 45 JYNARQUE ................... 74, 75 K KADCYLA .......................... 16 KADIAN .............................. 27 kaitlib fe ................................ 93 KALBITOR ........................ 103 KALETRA ............................. 4 KALYDECO .............. 103, 104
KANUMA ............................ 75 KAPSPARGO SPRINKLE .. 40 KAPVAY ............................. 34 KARBINAL ER ................. 101 kariva (28) ............................ 93 KAZANO ............................. 76 KEDRAB (PF) ...................... 87 KEFLEX ................................. 7 kelnor 1/35 (28) .................... 93 kelnor 1-50 ............................ 93 KENALOG ..................... 55, 60 KEPIVANCE ....................... 12 KEPPRA ............................... 20 KEPPRA XR ........................ 20 KERAFOAM ........................ 48 KERALAC ........................... 48 KERALYT RX ..................... 47 KERYDIN ............................ 54 ketoconazole ..................... 3, 54 ketoprofen ............................. 30 ketorolac ......................... 30, 98 KEVEYIS ............................. 23 KEVZARA ........................... 89 KHAPZORY ........................ 12 KHEDEZLA ......................... 34 KINERET ............................. 85 KINRIX (PF) ........................ 87 KISQALI .............................. 16 KISQALI FEMARA CO-
PACK ............................... 16 KIT FOR TC 99M-
SESTAMIBI NO.1 ........... 57 KIT PREP OF TC-99M-
MEBROFENIN ................ 57 KIT PREP OF TC-99M-SOD
PYROPH .......................... 57 KITABIS PAK ....................... 9 KLARON ............................. 53 KLONOPIN .......................... 20 klor-con ............................... 107 klor-con 10 .......................... 107 klor-con 8 ............................ 107 klor-con m10 ...................... 107 klor-con m15 ...................... 107 klor-con m20 ...................... 107 klor-con sprinkle ................. 107 klor-con/ef .......................... 107 KOATE ................................. 44
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132
kobee .................................. 109 KOGENATE FS ................... 44 KOMBIGLYZE XR ............. 76 KORLYM............................. 75 KOSHER PRENATAL PLUS
IRON .............................. 109 KOVALTRY ........................ 44 K-PHOS NO 2 .................... 106 K-PHOS ORIGINAL ......... 106 kpn ...................................... 109 KRINTAFEL .......................... 9 KRISTALOSE ..................... 80 KRYSTEXXA ...................... 88 k-tab .................................... 108 K-TAB ................................ 108 kurvelo (28) .......................... 93 KUVAN ............................... 75 KYLEENA ........................... 90 KYMRIAH ........................... 16 KYPROLIS .......................... 16 L l norgest/e.estradiol-e.estrad . 93 labetalol ................................ 40 LABETALOL ...................... 40 LABETALOL IN DEXTROSE
5 %.................................... 40 LACRISERT ........................ 97 lactated ringers ..................... 56 lactulose ................................ 80 LAMICTAL ......................... 20 LAMICTAL ODT ................ 20 LAMICTAL ODT STARTER
(BLUE) ............................. 20 LAMICTAL ODT STARTER
(GREEN) .......................... 20 LAMICTAL ODT STARTER
(ORANGE)....................... 20 LAMICTAL STARTER
(BLUE) KIT ..................... 20 LAMICTAL STARTER
(GREEN) KIT .................. 20 LAMICTAL STARTER
(ORANGE) KIT ............... 20 LAMICTAL XR ................... 20 LAMICTAL XR STARTER
(BLUE) ............................. 20 LAMICTAL XR STARTER
(GREEN) .......................... 20
LAMICTAL XR STARTER (ORANGE) ....................... 20
lamivudine .............................. 4 lamivudine-zidovudine ........... 4 lamotrigine............................ 20 LANCETS ............................ 69 LANCING DEVICE ............ 69 LANOXIN ............................ 42 LANOXIN PEDIATRIC ...... 42 lansoprazole .......................... 83 lanthanum ............................. 80 LANTUS SOLOSTAR U-100
INSULIN .......................... 73 LANTUS U-100 INSULIN .. 73 larin 1.5/30 (21) .................... 94 larin 1/20 (21) ....................... 94 larin 24 fe.............................. 94 larin fe 1.5/30 (28) ................ 94 larin fe 1/20 (28) ................... 94 larissia ................................... 94 LARTRUVO ........................ 16 LASIX .................................. 40 LASTACAFT ....................... 97 latanoprost ............................ 99 LATUDA.............................. 34 laxaclear................................ 80 laxative (bisacodyl) .............. 80 laxative feminine .................. 80 laxative peg 3350.................. 80 layolis fe ............................... 94 LAZANDA ........................... 27 LDO PLUS ........................... 52 LEDIPASVIR-SOFOSBUVIR
............................................ 4 leena 28................................. 94 leflunomide ........................... 89 LEMTRADA ........................ 85 LENVIMA............................ 16 LESCOL XL......................... 45 lessina ................................... 94 LETAIRIS .......................... 104 letrozole ................................ 16 leucovorin calcium ............... 12 LEUKERAN ........................ 16 LEUKINE ............................. 84 leuprolide .............................. 16 LEVA SET ........................... 52 levalbuterol hcl ................... 104
LEVALBUTEROL TARTRATE ................... 104
LEVAQUIN ......................... 10 LEVBID ............................... 78 LEVEMIR FLEXTOUCH U-
100 INSULN .................... 73 LEVEMIR U-100 INSULIN 73 levetiracetam ......................... 20 levetiracetam in nacl (iso-os) 20 LEVICYN ANTIPRURITIC 48 LEVICYN ANTIPRURITIC
SG ..................................... 48 levobunolol ........................... 97 levocarnitine ......................... 57 levocarnitine (with sugar) ..... 57 levofloxacin .................... 10, 96 levofloxacin in d5w .............. 10 levoleucovorin calcium ........ 12 LEVOLEUCOVORIN
CALCIUM ........................ 12 levonest (28) ......................... 94 levonorgestrel ....................... 94 levonorgestrel-ethinyl estrad 94 levonorg-eth estrad triphasic 94 levora-28 ............................... 94 levorphanol tartrate ............... 27 LEVORPHANOL
TARTRATE ..................... 27 LEVO-T ................................ 77 levothyroxine ........................ 77 levoxyl .................................. 77 LEVSIN ................................ 78 LEVSIN/SL .......................... 78 LEVULAN ........................... 48 LEXAPRO ............................ 34 LEXETTE ............................. 55 LEXIVA ................................. 4 LEXIXRYL .......................... 30 LIALDA ............................... 80 LIBRAX (WITH
CLIDINIUM) ................... 78 LIBTAYO ............................. 16 lidocaine ............................... 52 lidocaine (pf) ........................ 52 LIDOCAINE (PF) ................ 52 lidocaine hcl .......................... 52 LIDOCAINE HCL ............... 52
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lidocaine hcl-hydrocortison ac .................................... 52, 80
lidocaine viscous .................. 52 lidocaine-phenylephrn in water
.......................................... 97 lidocaine-prilocaine .............. 52 LIDOCAN-PHENYLEPH-
BSS NO.2(PF) .................. 98 LIDODERM ......................... 52 LIDOPAC............................. 52 lidopin................................... 52 LIDOPIN .............................. 52 LIDO-PRILO CAINE PACK
.......................................... 53 LIDORX ............................... 53 LIDOTRAL .......................... 53 lidozion ................................. 53 LIDTOPIC MAX ................. 53 LILETTA ............................. 90 lillow (28) ............................. 94 LINCOCIN ............................. 9 lincomycin .............................. 9 lindane .................................. 56 linezolid .................................. 9 linezolid in dextrose 5% ......... 9 LINZESS .............................. 80 liothyronine .......................... 77 LIPITOR............................... 45 LIPOCHOL PLUS ............... 57 lipodox .................................. 16 lipodox 50 ............................. 16 LIPOFEN ............................. 45 LIPROZONEPAK ................ 53 LIQUIVIDA HYDRATION
KIT ................................... 57 lisinopril ............................... 40 lisinopril-hydrochlorothiazide
.......................................... 40 lite coat aspirin ..................... 30 lithium carbonate .................. 34 lithium citrate ....................... 34 LITHOBID ........................... 34 LITHOSTAT ........................ 57 LIVALO ............................... 45 LO LOESTRIN FE............... 94 LOCOID ............................... 55 LOCOID LIPOCREAM ....... 55 LODINE ............................... 30
LODOSYN ........................... 21 LOESTRIN 1.5/30 (21) ........ 94 LOESTRIN 1/20 (21) ........... 94 LOESTRIN FE 1.5/30 (28-
DAY) ................................ 94 LOESTRIN FE 1/20 (28-DAY)
.......................................... 94 LOKELMA .......................... 80 LOMOTIL ............................ 78 LONHALA MAGNAIR
REFILL .......................... 104 LONHALA MAGNAIR
STARTER ...................... 104 LONSURF ............................ 16 LOPID .................................. 45 lopinavir-ritonavir .................. 4 lopreeza ................................ 91 LOPRESSOR ....................... 40 LOPROX .............................. 54 LOPROX (AS OLAMINE) .. 54 LOPROX KIT ...................... 54 lorazepam ............................. 34 LORAZEPAM IN 0.9% SOD
CHLORIDE ...................... 34 LORAZEPAM IN
DEXTROSE 5 % .............. 34 lorazepam intensol ................ 34 LORBRENA ........................ 16 lorcet (hydrocodone) ............ 27 lorcet hd ................................ 27 lorcet plus ............................. 27 LORTAB ELIXIR ................ 27 lortuss ex............................. 101 loryna (28) ............................ 94 LORZONE ........................... 24 losartan ................................. 40 losartan-hydrochlorothiazide 40 LOSEASONIQUE................ 94 LOTEMAX .......................... 99 LOTEMAX SM .................... 99 LOTENSIN .......................... 40 LOTENSIN HCT ................. 40 LOTREL ............................... 40 LOTRISONE ........................ 54 LOTRONEX ........................ 80 LOUTREX ........................... 48 lovastatin .............................. 45 LOVAZA.............................. 45
LOVENOX ........................... 44 low-ogestrel (28) .................. 94 loxapine succinate ................ 34 LOYON ................................ 48 lta pre-attached ..................... 53 LUCEMYRA ........................ 30 LUCENTIS ........................... 98 ludent fluoride .................... 109 lugols ............................ 53, 108 LULICONAZOLE ............... 54 LUMIGAN ........................... 99 LUMIZYME ......................... 75 LUNESTA ............................ 34 LUPANETA PACK (1
MONTH) .......................... 92 LUPANETA PACK (3
MONTH) .......................... 92 LUPRON DEPOT ................ 16 LUPRON DEPOT (3
MONTH) .......................... 16 LUPRON DEPOT (4
MONTH) .......................... 16 LUPRON DEPOT (6
MONTH) .......................... 16 LUPRON DEPOT-PED ....... 16 lutera (28) ............................. 94 luxamend .............................. 48 LUXIQ .................................. 55 LUXTURNA ........................ 98 LUZU ................................... 54 LYNPARZA ......................... 16 LYRICA ............................... 20 LYRICA CR ......................... 20 LYSODREN ......................... 16 LYSTEDA ............................ 92 lyza ....................................... 91 M m.v.i. adult .......................... 109 MACRILEN ......................... 84 MACROBID ......................... 12 MACRODANTIN ................ 12 MACUGEN .......................... 98 mafenide acetate ................... 53 magnesium citrate ................. 81 MAKENA ............................. 91 MAKENA (PF) .................... 91 MALARONE ......................... 9 MALARONE PEDIATRIC .... 9
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malathion .............................. 56 maprotiline ........................... 34 MAR-COF CG ................... 101 MARINOL ........................... 81 marlissa (28) ......................... 94 MARNATAL-F .................. 109 MARPLAN .......................... 34 MARQIBO ........................... 16 MATULANE ....................... 17 matzim la .............................. 40 MAVENCLAD (10 TABLET
PACK) .............................. 85 MAVYRET ............................ 4 MAXALT ............................. 22 MAXALT-MLT ................... 22 MAXIDEX ......................... 100 MAXIPIME ............................ 7 MAXITROL ......................... 99 MAXI-TUSS CD................ 101 MAXZIDE ........................... 40 MAXZIDE-25MG ................ 40 MAYZENT .......................... 85 m-clear wc .......................... 101 meclofenamate ..................... 30 MEDISENSE ....................... 69 MEDISENSE GLUCOSE
KETONE .......................... 69 MEDOLOR PAK ................. 53 MEDROL ............................. 60 MEDROL (PAK) ................. 60 medroxyprogesterone ........... 91 mefenamic acid .................... 30 mefloquine .............................. 9 megestrol .............................. 17 MEKINIST ........................... 17 MEKTOVI ........................... 17 melodetta 24 fe ..................... 94 meloxicam ............................ 30 melphalan ............................. 17 melphalan hcl ....................... 17 memantine ............................ 23 MEMANTINE ..................... 23 MENACTRA (PF) ............... 87 M-END PE ......................... 101 MENEST .............................. 91 MENOPUR .......................... 75 MENOSTAR ........................ 91
MENVEO A-C-Y-W-135-DIP (PF) ................................... 87
meperidine ............................ 27 MEPHYTON ........................ 44 meprobamate ........................ 24 MEPRON ............................... 9 MEPSEVII............................ 75 mercaptopurine ..................... 17 meropenem ............................. 9 MEROPENEM-0.9%
SODIUM CHLORIDE ....... 9 MERREM ............................... 9 mesalamine ........................... 81 mesalamine with cleansing
wipe .................................. 81 mesna .................................... 13 MESNEX.............................. 13 MESTINON ......................... 24 MESTINON TIMESPAN .... 24 metadate er ........................... 34 metaproterenol .................... 104 metaxall ................................ 24 metaxalone............................ 24 metformin ............................. 77 METFORMIN ...................... 76 methadone ............................ 27 methadose ............................. 27 methamphetamine ................ 34 methazolamide...................... 98 methenamine hippurate ........ 12 methenamine mandelate ....... 12 methen-sod phos-meth blue-
hyos ................................ 106 methergine ............................ 96 methimazole ......................... 61 METHITEST ........................ 75 methocarbamol ..................... 24 methotrexate sodium ............ 17 methotrexate sodium (pf) ..... 17 methoxsalen .......................... 48 methscopolamine .................. 79 methyclothiazide .................. 40 methyldopa ........................... 40 methyldopa-
hydrochlorothiazide .......... 40 methyldopate ........................ 40 methylergonovine ................. 96 METHYLIN ......................... 34
methylphenidate hcl ........ 34, 35 METHYLPHENIDATE HCL
.......................................... 35 METHYLPRED AC(PF)-
NACL,ISO-OSM .............. 60 METHYLPREDNISOL AC-
BUPIVAC-WAT .............. 60 methylprednisolone .............. 60 METHYLPREDNISOLONE
ACET-WATER ................ 60 methyltestosterone ................ 75 metipranolol .......................... 97 metoclopramide hcl .............. 81 metolazone ............................ 40 METOPIRONE .................... 57 metoprolol succinate ............. 40 METOPROLOL SU-
HYDROCHLOROTHIAZ 41 metoprolol ta-hydrochlorothiaz
.......................................... 41 metoprolol tartrate ................ 41 metro i.v. ................................. 9 METROCREAM .................. 51 METROGEL ........................ 51 METROGEL VAGINAL ..... 92 METROLOTION ................. 51 metronidazole ............. 9, 51, 92 metronidazole in nacl (iso-os) 9 mexiletine ............................. 38 MIACALCIN ....................... 75 mibelas 24 fe ......................... 94 MICARDIS ........................... 41 MICARDIS HCT .................. 41 MICONAZOLE NITRATE-
ZINC OX-PET .................. 54 MICORT-HC ........................ 81 MICRO BLOOD GLUCOSE
.......................................... 63 MICRODOT BLOOD
GLUCOSE SYSTEM . 63, 69 microgestin 1.5/30 (21) ........ 94 microgestin 1/20 (21) ........... 94 MICROGESTIN 24 FE ........ 94 microgestin fe 1.5/30 (28) .... 94 microgestin fe 1/20 (28) ....... 94 MICROZIDE ........................ 41 midazolam ............................ 35 midazolam (pf) ..................... 35
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135
midazolam (pf) in 0.9 % nacl .......................................... 35
MIDAZOLAM (PF) IN 0.9 % NACL ............................... 35
MIDAZOLAM IN 0.9 % SOD CHLORID ........................ 35
MIDAZOLAM IN DEXTROSE 5 % .............. 35
midodrine ............................. 57 migergot ............................... 22 miglitol ................................. 77 miglustat ............................... 75 MIGRANAL ........................ 22 mili ....................................... 94 milk of magnesia .................. 81 milk of magnesia concentrated
.......................................... 81 millipred ............................... 60 millipred dp .......................... 60 mimvey ................................. 91 mimvey lo ............................. 91 MIMYX ................................ 48 MINASTRIN 24 FE ............. 94 MINIPRESS ......................... 41 MINITRAN .......................... 46 MINIVELLE ........................ 91 MINOCIN ............................ 11 minocycline .......................... 11 MINOLIRA ER .................... 11 minoxidil .............................. 41 MIOCHOL-E ....................... 97 miralax .................................. 81 MIRAPEX ............................ 21 MIRAPEX ER ...................... 21 MIRCERA ............................ 84 MIRCETTE (28) .................. 94 MIRENA .............................. 90 mirtazapine ........................... 35 MIRVASO ........................... 51 misoprostol ........................... 83 MITIGARE .......................... 88 MITIGO (PF) ....................... 27 mitomycin............................. 17 MITOSOL ............................ 99 mitoxantrone......................... 17 M-M-R II (PF) ...................... 87 m-natal plus ........................ 109 MOBIC ................................. 31
modafinil .............................. 35 moderiba ............................... 85 moexipril .............................. 41 molindone ............................. 35 mometasone .................. 55, 104 mondoxyne nl ....................... 11 MONODOX ......................... 11 mono-linyah.......................... 94 MONONINE ........................ 44 montelukast ........................ 104 MONUROL .......................... 12 morgidox .............................. 11 MORPHABOND ER ........... 27 morphine ......................... 27, 28 MORPHINE ......................... 28 morphine (pf) ........................ 27 MORPHINE (PF) ................. 27 morphine (pf) in 0.9 % nacl.. 27 MORPHINE (PF) IN 0.9 %
NACL ............................... 27 morphine concentrate ........... 27 MORPHINE IN 0.9 %
SODIUM CHLOR ............ 27 MOTEGRITY ...................... 81 MOTOFEN ........................... 79 MOVANTIK ........................ 81 MOVIPREP .......................... 81 MOXATAG.......................... 10 MOXEZA ............................. 96 moxifloxacin ................... 10, 96 MOXIFLOXACIN (PF)-BSS
NO.2 ................................. 96 MOXIFLOXACIN IN
NACL,ISO-O(PF) ............ 96 moxifloxacin-sod.chloride(iso)
.......................................... 11 MOZOBIL ............................ 84 MS CONTIN ........................ 28 MUGARD ............................ 59 MULPLETA ......................... 44 MULTAQ ............................. 38 multi-vitamin with fluoride109,
110 multivitamins with fluoride 110 mupirocin.............................. 53 mupirocin calcium ................ 53 MUTAMYCIN ..................... 17 mvc-fluoride ....................... 110
my choice .............................. 94 my way ................................. 94 MYALEPT ........................... 75 MYAMBUTOL ...................... 9 MYCOBUTIN ........................ 9 mycophenolate mofetil ......... 17 mycophenolate mofetil hcl ... 17 mycophenolate sodium ......... 17 MYDAYIS ........................... 35 MYDRIACYL ...................... 97 mydriatic3 (trop-cyclopent-pe)
.......................................... 97 MYFORTIC ......................... 17 MYGLUCOHEALTH .... 63, 69 MYGLUCOHEALTH
CONTROL SOLUTION .. 69 MYLERAN .......................... 17 MYLOTARG ....................... 17 mynatal ............................... 110 mynatal advance ................. 110 mynatal plus ........................ 110 mynatal-z ............................ 110 mynate 90 plus .................... 110 MYOBLOC .......................... 87 myorisan ............................... 51 MYRBETRIQ ..................... 106 MYSOLINE ......................... 20 MYTESI ............................... 79 N NABI-HB ............................. 87 nabumetone ........................... 31 nadolol .................................. 41 nadolol-bendroflumethiazide 41 nafcillin ................................. 10 naftifine ................................. 54 NAFTIN ............................... 54 NAGLAZYME ..................... 75 nalbuphine ............................ 31 NALFON .............................. 31 NALOCET ........................... 28 naloxone ............................... 31 naltrexone ............................. 31 NAMENDA .......................... 23 NAMENDA TITRATION
PAK .................................. 23 NAMENDA XR ................... 23 NAMZARIC ......................... 23 NAPRELAN CR .................. 31
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NAPROSYN ........................ 31 naproxen ............................... 31 naproxen sodium .................. 31 naratriptan............................. 22 NARCAN ............................. 31 NARDIL ............................... 35 NASCOBAL ...................... 110 NASONEX ......................... 104 NATACHEW (FE BIS-
GLYCINATE) ................ 110 NATACYN .......................... 96 NATAZIA ............................ 94 nateglinide ............................ 77 NATESTO ............................ 75 NATPARA ........................... 75 NATROBA........................... 56 natural b-100 complex ........ 110 natura-lax .............................. 81 nature-throid ......................... 77 NAVELBINE ....................... 17 NEBUPENT ........................... 9 nebusal ................................ 104 NEBUSAL ......................... 104 necon 0.5/35 (28).................. 94 NEEVODHA (WITH ALGAL
OIL) ................................ 110 nefazodone ........................... 35 NEOCERA ........................... 48 neomycin ................................ 9 neomycin-bacitracin-poly-hc 99 neomycin-bacitracin-
polymyxin......................... 96 neomycin-polymyxin b-
dexameth .......................... 99 neomycin-polymyxin-
gramicidin......................... 96 neomycin-polymyxin-hc 60, 99 neo-polycin ........................... 96 neo-polycin hc ...................... 99 NEORAL .............................. 17 NEOSALUS ......................... 48 NEO-SYNALAR ................. 53 NEO-SYNALAR KIT .......... 53 NERLYNX ........................... 17 NESINA ............................... 77 NESTABS .......................... 110 NESTABS ABC ................. 110 NESTABS DHA ................ 110
NESTABS ONE ................. 110 neuac ..................................... 51 NEUAC KIT......................... 51 NEULASTA ......................... 84 NEUPOGEN ........................ 84 NEUPRO .............................. 21 NEURONTIN ....................... 20 NEUTEK 2TEK TEST
STRIPS ............................. 63 NEVANAC .......................... 98 nevirapine ............................... 4 new day................................. 94 newgen................................ 110 NEXAVAR .......................... 17 NEXAVIR .......................... 110 NEXIUM .............................. 83 NEXIUM IV ......................... 83 NEXIUM PACKET ............. 83 NEXPLANON...................... 92 niacin .................................... 45 NIACOR ............................... 45 NIASPAN EXTENDED-
RELEASE ........................ 45 nicardipine ............................ 41 NICODERM CQ .................. 58 nicorelief ............................... 58 nicorette ................................ 58 NICORETTE ........................ 58 nicotine ................................. 58 nicotine (polacrilex) ............. 58 NICOTROL .......................... 58 NICOTROL NS .................... 58 nifedipine .............................. 41 nikki (28) .............................. 94 NILANDRON ...................... 17 nilutamide ............................. 17 NIMBEX .............................. 24 nimodipine ............................ 41 NINJACOF-XG.................. 101 NINLARO ............................ 17 NIPENT ................................ 17 NIPRIDE RTU ..................... 46 nisoldipine ............................ 41 nitro-bid ................................ 46 NITRO-DUR ........................ 46 nitrofurantoin ........................ 12 nitrofurantoin macrocrystal .. 12
nitrofurantoin monohyd/m-cryst .................................. 12
nitroglycerin ......................... 46 NITROLINGUAL ................ 46 NITROMIST ........................ 46 NITROSTAT ........................ 46 nitro-time .............................. 46 NITYR .................................. 57 nivatopic plus ........................ 49 NIVESTYM ......................... 84 nizatidine .............................. 83 NIZORAL ............................. 54 NOCDURNA (MEN) ........... 75 NOCDURNA (WOMEN) .... 75 NOCTIVA ............................ 75 nolix ...................................... 55 nora-be .................................. 91 NORCO ................................ 28 NORDITROPIN FLEXPRO 84 noreth-ethinyl estradiol-iron . 94 norethindrone (contraceptive)
.......................................... 91 norethindrone acetate ............ 91 norethindrone ac-eth estradiol
.................................... 91, 94 norethindrone-e.estradiol-iron
.......................................... 94 NORGESIC FORTE ............ 24 norgestimate-ethinyl estradiol
.......................................... 94 NORITATE .......................... 51 norlyda .................................. 91 norlyroc ................................. 91 NORPACE ........................... 38 NORPACE CR ..................... 38 NORPRAMIN ...................... 35 NORTHERA ........................ 57 nortrel 0.5/35 (28) ................. 95 nortrel 1/35 (21) .................... 95 nortrel 1/35 (28) .................... 95 nortrel 7/7/7 (28) ................... 95 nortriptyline .......................... 35 NORVASC ........................... 41 NORVIR ................................. 5 NOVA MAX BLOOD
GLUCOSE METER ......... 69 NOVA MAX GLUCOSE
CONTROL ....................... 70
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NOVA MAX GLUCOSE TEST ................................ 63
NOVAMAX PLUS GLU-KET .......................................... 70
NOVAREL ........................... 75 NOVOEIGHT ...................... 44 NOVOLIN 70-30 FLEXPEN
U-100 ................................ 73 NOVOLOG FLEXPEN U-100
INSULIN .......................... 73 NOVOLOG MIX 70-30 U-100
INSULN ........................... 73 NOVOLOG MIX 70-
30FLEXPEN U-100 ......... 73 NOVOLOG PENFILL U-100
INSULIN .......................... 73 NOVOLOG U-100 INSULIN
ASPART........................... 73 NOVOPEN ECHO ............... 70 NOVOSEVEN RT ............... 44 NOXAFIL .............................. 3 np thyroid ............................. 77 NPLATE............................... 44 NUCALA ........................... 104 NUCYNTA .......................... 31 NUCYNTA ER .................... 31 NUDROXIPAK ................... 31 NUEDEXTA ........................ 23 NULEV ................................ 79 NULOJIX ............................. 17 NULYTELY WITH FLAVOR
PACKS ............................. 81 NUMBONEX ....................... 53 NUPLAZID .......................... 35 NUTRASEB ......................... 49 NUTROPIN AQ NUSPIN ... 84 NUVARING......................... 92 NUVESSA ........................... 92 NUVIGIL ............................. 35 NUWIQ ................................ 44 NUZYRA (7 DAY WITH
LOAD DOSE) .................. 11 nyamyc ................................. 54 NYMALIZE ......................... 41 nystatin ............................. 3, 54 nystatin-triamcinolone .......... 54 nystop ................................... 54
O OB COMPLETE ONE ....... 110 OB COMPLETE PETITE .. 110 OB COMPLETE PREMIER
........................................ 110 OB COMPLETE WITH DHA
........................................ 110 OBIZUR ............................... 44 OBREDON ......................... 101 obstetrix dha ....................... 110 OBSTETRIX EC ................ 110 OBSTETRIX ONE ............. 110 OBTREX DHA .................. 110 O-CAL PRENATAL .......... 110 OCALIVA ............................ 81 ocella .................................... 95 OCREVUS ........................... 85 OCTAGAM .......................... 87 octreotide acetate .................. 17 OCUFLOX ........................... 96 ODACTRA ........................... 87 ODEFSEY .............................. 5 ODOMZO ............................ 17 OFEV.................................. 104 ofloxacin ................... 11, 59, 96 ogestrel (28) .......................... 95 olanzapine ............................. 35 olanzapine-fluoxetine ........... 35 olmesartan ............................ 41 olmesartan-amlodipin-
hcthiazid ........................... 41 olmesartan-
hydrochlorothiazide .......... 41 olopatadine ..................... 59, 98 OLUMIANT ......................... 89 OLUX ................................... 55 OLUX-E ............................... 55 OMECLAMOX-PAK .......... 83 omega-3 acid ethyl esters ..... 45 omeppi .................................. 83 omeprazole ........................... 83 omeprazole-sodium
bicarbonate ....................... 83 OMIDRIA ............................ 98 OMNARIS.......................... 104 OMNIPOD DASH INSULIN
POD .................................. 70 OMNITROPE ....................... 84
ON CALL EXPRESS CONTROL ....................... 70
ON CALL EXPRESS METER .......................................... 70
ON CALL EXPRESS TEST STRIP ............................... 63
ON CALL PLUS CONTROL .......................................... 70
ON CALL PLUS METER .... 70 ON CALL PLUS TEST STRIP
.......................................... 64 ON CALL VIVID CONTROL
.......................................... 70 ON CALL VIVID METER .. 70 ON CALL VIVID PAL
METER ............................. 70 ON CALL VIVID TEST
STRIP ............................... 64 ONCASPAR ......................... 17 ondansetron ........................... 81 ondansetron hcl ..................... 81 ondansetron hcl (pf) .............. 81 one daily prenatal ............... 110 ONETOUCH ULTRA BLUE
TEST STRIP ..................... 64 ONETOUCH ULTRA
CONTROL ....................... 70 ONETOUCH ULTRA2
METER ............................. 70 ONETOUCH ULTRAMINI . 70 ONETOUCH VERIO ........... 64 ONETOUCH VERIO FLEX 70 ONETOUCH VERIO IQ
METER ............................. 70 ONETOUCH VERIO
SYSTEM .......................... 70 ONEXTON ........................... 51 ONFI ..................................... 20 ONGLYZA ........................... 77 ONIVYDE ............................ 17 ONMEL .................................. 3 ONPATTRO ......................... 23 ONZETRA XSAIL ............... 22 OPANA ................................ 28 opcicon one-step ................... 95 OPDIVO ............................... 17 opium tincture ....................... 79 OPSUMIT ........................... 104
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option-2 ................................ 95 OPTIUM EZ ......................... 64 OPTIUM TEST .................... 64 OPTUMRX .................... 64, 70 ORACEA ............................. 11 ORACIT ............................. 106 oral saline laxative ................ 81 ORALAIR ............................ 87 oralone .................................. 59 ORAMAGICRX................... 59 ORAP ................................... 35 ORAPRED ODT .................. 60 ORAVIG ................................ 3 ORENCIA ............................ 89 ORENCIA (WITH
MALTOSE) ...................... 89 ORENCIA CLICKJECT ...... 89 ORENITRAM ...................... 41 ORFADIN ............................ 57 ORILISSA ............................ 75 ORKAMBI ......................... 104 orphenadrine citrate .............. 24 orsythia ................................. 95 ORTHO MICRONOR.......... 91 ORTHO TRI-CYCLEN (28) 95 ORTHO TRI-CYCLEN LO
(28) ................................... 95 ORTHO-CYCLEN (28) ....... 95 ORTHO-NOVUM 1/35 (28) 95 ORTHO-NOVUM 7/7/7 (28)
.......................................... 95 oscimin ................................. 79 oscimin sl.............................. 79 oscimin sr ............................. 79 oseltamivir .............................. 5 OSENI .................................. 77 osmitrol 20 % ....................... 41 OSMOLEX ER .................... 21 OSMOPREP ......................... 81 OSPHENA ........................... 92 OTEZLA .............................. 89 OTEZLA STARTER............ 89 OTIPRIO .............................. 59 OTOVEL .............................. 60 OTREXUP (PF) ................... 89 OVACE ................................ 47 OVACE PLUS ..................... 47 OVACE PLUS SHAMPOO . 47
OVACE PLUS WASH ......... 47 OVIDE.................................. 56 OVIDREL ............................ 75 oxacillin ................................ 10 oxacillin in dextrose(iso-osm)
.......................................... 10 oxaliplatin ............................. 17 OXANDRIN ......................... 75 oxandrolone .......................... 75 oxaprozin .............................. 31 OXAYDO ............................. 28 oxazepam .............................. 35 oxcarbazepine ....................... 20 OXERVATE ........................ 98 oxiconazole ........................... 54 OXISTAT ............................. 54 OXSORALEN ULTRA ....... 49 OXTELLAR XR .................. 20 oxybutynin chloride ............ 106 oxycodone ............................ 28 OXYCODONE ..................... 28 oxycodone-acetaminophen ... 28 oxycodone-aspirin ................ 28 OXYCONTIN ...................... 28 oxymorphone ........................ 28 OXYTROL ......................... 106 oyster shell + d3 ................. 108 oyster shell calcium-vit d3 . 108 OZEMPIC ............................ 77 OZURDEX ......................... 100 P pacerone................................ 38 paclitaxel .............................. 17 paliperidone .......................... 35 palonosetron ......................... 81 PALONOSETRON .............. 81 PALYNZIQ .......................... 75 PAMELOR ........................... 35 pamidronate .......................... 75 PANCREAZE ...................... 81 PANDEL .............................. 55 PANRETIN .......................... 49 pantoprazole ......................... 83 PARAGARD T 380A ........... 90 paregoric ............................... 79 PAREMYD .......................... 97 paricalcitol ............................ 75 PARICALCITOL ................. 75
PARLODEL ......................... 21 PARNATE ............................ 35 paroex oral rinse ................... 59 paromomycin .......................... 9 paroxetine hcl ....................... 35 paroxetine
mesylate(menop.sym) ....... 35 PASER .................................... 9 PATADAY ........................... 98 PATANASE ......................... 59 PATANOL ........................... 98 PAXIL .................................. 36 PAXIL CR ............................ 35 PAZEO ................................. 98 P-CARE K40 ........................ 60 P-CARE K80 ........................ 61 P-CARE X (PF) .................... 53 PEDIARIX (PF) ................... 87 PEDVAX HIB (PF) .............. 87 peg 3350-electrolytes ............ 81 PEGANONE ......................... 20 PEGASYS ............................ 85 PEGASYS PROCLICK ........ 85 peg-electrolyte soln .............. 81 PEGINTRON ....................... 85 PEN NEEDLE, DIABETIC . 70 penicillin g potassium ........... 10 penicillin v potassium ........... 10 PENLAC ............................... 54 PENLEN ............................... 49 PENNSAID .......................... 31 PENTACEL (PF) .................. 87 PENTACEL ACTHIB
COMPONENT (PF) ......... 87 PENTASA ............................ 81 pentazocine-naloxone ........... 31 pentoxifylline ........................ 44 PEPCID ................................ 83 PERCOCET .......................... 28 PERFOROMIST ................. 104 PERIDEX ............................. 59 perindopril erbumine ............ 41 periogard ............................... 59 PERJETA ............................. 17 permethrin ............................. 56 perphenazine ......................... 36 perphenazine-amitriptyline ... 36 perry prenatal ...................... 110
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PERSERIS ............................ 36 PERTZYE ............................ 81 PEXEVA .............................. 36 pfizerpen-g ........................... 10 PHARMACIST CHOICE .... 64 PHARMACIST CHOICE
GLUCOSE SYS ............... 70 phenadoz............................. 101 phenazopyridine ................. 107 phenelzine............................. 36 phenergan ........................... 101 PHENERGAN .................... 101 phenobarb-hyoscy-atropine-
scop................................... 79 phenobarbital ........................ 20 phenohytro ............................ 79 phenoxybenzamine ............... 41 phentolamine ........................ 41 phenylephrine hcl ............... 100 PHENYTEK ......................... 20 phenytoin .............................. 20 phenytoin sodium extended .. 21 philith ................................... 95 PHOSLYRA ......................... 81 phosphasal .......................... 106 phosphate laxative ................ 81 PHOSPHOLINE IODIDE .... 97 PHOTREXA CROSS-
LINKING KIT.................. 98 PHOTREXA VISCOUS ...... 98 phrenilin forte(with caffeine) 28 PHYSIOLYTE ..................... 56 PHYSIOSOL IRRIGATION 56 phytonadione (vitamin k1) ... 44 PICATO ............................... 49 PIFELTRO ............................. 5 pilocarpine hcl .......... 57, 59, 97 pimecrolimus ........................ 49 pimozide ............................... 36 pimtrea (28) .......................... 95 pindolol................................. 41 pioglitazone .......................... 77 pioglitazone-glimepiride ...... 77 pioglitazone-metformin ........ 77 piperacillin-tazobactam ........ 10 PIPERACILLIN-
TAZOBACTAM .............. 10 pirmella................................. 95
piroxicam .............................. 31 PLAN B ONE-STEP ............ 95 PLAQUENIL.......................... 9 PLAVIX ............................... 44 PLEGRIDY .......................... 85 PLENVU .............................. 81 PLEXION ............................. 51 PLEXION CLEANSING
CLOTHS .......................... 51 PLIAGLIS ............................ 53 PNEUMOVAX 23 ............... 87 pnv 29-1 .............................. 110 pnv ob+dha ......................... 110 pnv-dha ............................... 110 pnv-dha + docusate ............. 110 pnv-ferrous fumarate-docu-fa
........................................ 110 pnv-omega .......................... 110 pnv-select............................ 110 pnv-vp-u ............................. 110 POD-CARE 100K ................ 61 PODOCON ........................... 47 podofilox .............................. 49 polycin .................................. 96 polyethylene glycol 3350 ..... 81 polymyxin b sulfate ................ 9 polymyxin b sulf-trimethoprim
.......................................... 96 POLYTRIM.......................... 96 POLY-TUSSIN AC ............ 101 POMALYST ........................ 85 portia 28 ................................ 95 PORTRAZZA ...................... 17 POTABA ............................ 108 potassium chloride .............. 108 potassium citrate ................. 106 POTELIGEO ........................ 17 powderlax ............................. 81 pr natal 400 ......................... 110 pr natal 400 ec .................... 110 pr natal 430 ......................... 110 pr natal 430 ec .................... 110 PRADAXA ........................... 44 PRALUENT PEN................. 45 pramcort................................ 81 pramipexole .......................... 21 PRAMOSONE ..................... 47 PRANDIN ............................ 77
prasugrel ............................... 44 PRAVACHOL ...................... 45 pravastatin ............................. 45 PRAXBIND .......................... 44 praziquantel ............................ 9 prazosin ................................. 41 PRECISION PCX PLUS TEST
.......................................... 64 PRECISION PCX TEST ...... 64 PRECISION POINT OF
CARE TEST ..................... 64 PRECISION Q-I-D TEST .... 64 PRECISION XTRA
MONITOR ....................... 70 PRECISION XTRA TEST ... 64 PRECOSE ............................. 77 PRED FORTE .................... 100 PRED MILD ....................... 100 PRED-G ................................ 99 PRED-G S.O.P. .................... 99 prednicarbate ........................ 55 PREDNISOLN SP-
GATIFLOX-BROMFEN . 98 prednisolone ......................... 61 prednisolone acetate ........... 100 PREDNISOLONE ACET-
GATIFLOXACIN ............ 99 PREDNISOLONE SOD PH-
BROMFENAC ................. 98 PREDNISOLONE SOD PH-
GATIFLOXAC ................. 99 prednisolone sodium phosphate
.................................. 61, 100 prednisone ............................. 61 prednisone intensol ............... 61 PREFERA-OB .................... 110 PREFERA-OB PLUS DHA
........................................ 110 PREFEST ............................. 91 PREGNYL ............................ 75 PREMARIN ......................... 91 PREMIER BLU GLUCOSE
METER ............................. 70 PREMIER TEST STRIP ...... 64 PREMIER VOICE GLUCOSE
METER ............................. 70 PREMIUM BLOOD
GLUCOSE MONITOR .... 70
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PREMIUM V10 ............. 64, 70 PREMPHASE ...................... 91 PREMPRO ........................... 91 prena1 chew........................ 110 prena1 pearl ........................ 111 prena1 true .......................... 111 prenaissance ....................... 111 prenaissance plus ................ 111 PRENATA ......................... 111 prenatabs fa ........................ 111 prenatabs rx ........................ 111 prenatal ............................... 111 prenatal 19 .......................... 111 prenatal 19 (with docusate) 111 prenatal complete ............... 111 prenatal formula ................. 111 prenatal multi-dha (algal oil)
........................................ 111 prenatal one daily ............... 111 prenatal plus ....................... 111 prenatal plus (calcium carb)111 PRENATAL PLUS DHA... 111 prenatal vitamin .................. 111 prenatal vitamin plus low iron
........................................ 111 prenatal vitamin with minerals
........................................ 111 prenatal vits96-iron fum-folic
........................................ 111 prenatal-u ............................ 111 PRENATE AM .................. 111 PRENATE CHEWABLE ... 111 PRENATE DHA (FERR ASP
GLYCIN) ....................... 111 PRENATE ELITE (IRON ASP
GLYC) ............................ 111 PRENATE ENHANCE ...... 111 PRENATE
ESSENTIAL(IRON-ASP-GL) ................................. 111
PRENATE MINI (FERR ASP GLYCIN) ....................... 111
PRENATE PIXIE ............... 111 PRENATE RESTORE ....... 111 PRENATE STAR ............... 111 PREPIDIL ............................ 92 preplus ................................ 111 PREPOPIK ........................... 81
PRESERA ............................ 49 PRESTALIA ........................ 41 PRESTO PRO BLOOD
GLUCOSE METER ......... 70 pretab .................................. 111 PREVACID .......................... 83 PREVACID SOLUTAB....... 83 prevalite ................................ 45 PREVIDENT ........................ 59 PREVIDENT 5000 BOOSTER
PLUS ................................ 59 PREVIDENT 5000 DRY
MOUTH ........................... 59 PREVIDENT 5000 ENAMEL
PROTECT ........................ 59 PREVIDENT 5000 PLUS .... 59 PREVIDENT 5000
SENSITIVE ...................... 59 previfem................................ 95 PREVNAR 13 (PF) .............. 87 PREVYMIS ............................ 5 PREZCOBIX .......................... 5 PREZISTA ............................. 5 PRIFTIN ................................. 9 PRIKAAN ............................ 53 PRIKAAN LITE................... 53 PRILOLID ............................ 53 PRILOSEC ........................... 83 PRILOVIX ........................... 53 PRILOVIX LITE .................. 53 PRIMACARE ..................... 111 PRIMAQUINE ....................... 9 PRIMAXIN IV ....................... 9 primidone.............................. 21 PRIMLEV ............................ 28 PRIMSOL ............................. 12 PRINIVIL ............................. 41 PRISTIQ ............................... 36 PRIVIGEN ........................... 87 PRO VOICE V8 GLUCOSE
MONITOR ....................... 70 PRO VOICE V8-V9 TEST
STRIP ............................... 64 PRO VOICE V9 GLUCOSE
MONITOR ....................... 70 PROAIR HFA .................... 104 PROAIR RESPICLICK ..... 104 probenecid ............................ 88
probenecid-colchicine ........... 88 PROBUPHINE ..................... 28 procainamide ........................ 38 PROCARDIA ....................... 41 PROCARDIA XL ................. 41 PRO-C-DURE 5 ................... 61 PRO-C-DURE 6 ................... 61 procentra ............................... 36 prochlorperazine ................... 81 prochlorperazine edisylate .... 81 prochlorperazine maleate ...... 81 PROCORT ............................ 81 PROCRIT ............................. 84 PROCTOCORT .................... 81 PROCTOFOAM HC ............ 81 procto-med hc ....................... 81 proctosol hc .......................... 81 proctozone-hc ....................... 82 PROCYSBI ......................... 106 PRODIGY AUTOCODE
METER ............................. 70 PRODIGY AUTOCODE
MONITOR SYST ............. 70 PRODIGY CONTROL
SOLUTION, LOW ........... 70 PRODIGY CONTROL
SOLUTION,HIGH ........... 70 PRODIGY NO CODING ..... 64 PRODIGY POCKET METER
.......................................... 70 PRODIGY VOICE GLUCOSE
METER ............................. 71 PROFILNINE ....................... 44 progesterone ......................... 91 progesterone micronized ...... 91 PROGLYCEM ..................... 65 PROGRAF ............................ 17 PROLASTIN-C .................... 57 PROLENSA ......................... 98 PROLEUKIN ....................... 85 PROLIA ................................ 88 PROMACTA ........................ 44 promethazine ...................... 101 promethazine-codeine ......... 102 promethazine-dm ................ 102 promethazine-phenyleph-
codeine ............................ 102
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promethazine-phenylephrine ........................................ 102
promethegan ....................... 101 PROMETRIUM ................... 91 PROMISEB .......................... 49 propafenone .......................... 38 propantheline ........................ 79 proparacaine ......................... 98 propranolol ........................... 41 propranolol-hydrochlorothiazid
.......................................... 41 propylthiouracil .................... 61 PROQUAD (PF) .................. 87 PRO-RED AC (W/
DEXCHLORPHENIR) .. 102 PROSCAR .......................... 106 PROSTIN E2 ........................ 92 PROTHELIAL ..................... 59 PROTONIX .......................... 83 PROTOPIC........................... 49 protriptyline .......................... 36 PROVENGE......................... 87 PROVENTIL HFA ............. 104 PROVERA ........................... 91 PROVIDA DHA ................ 111 PROVIDA OB.................... 111 PROVIGIL ........................... 36 PROZAC .............................. 36 pruclair ................................. 49 prudoxin ............................... 49 prumyx ................................. 49 prutect ................................... 49 PSORCON ........................... 55 PULMICORT ..................... 104 PULMICORT FLEXHALER
........................................ 104 pulmosal ............................. 104 PULMOZYME................... 104 PUREFE OB PLUS ............ 111 purelax .................................. 82 PURIXAN ............................ 17 PYLERA .............................. 83 pyrazinamide .......................... 9 PYRIDIUM ........................ 107 pyridostigmine bromide ....... 24 Q QBRELIS ............................. 41 QBREXZA ........................... 49
Q-CARE RX Q4 ................... 59 QMIIZ ODT ......................... 31 QNASL ............................... 104 QTERN ................................. 77 QUADRACEL (PF) ............. 87 QUALAQUIN ........................ 9 QUARTETTE ...................... 95 QUAZEPAM ........................ 36 QUDEXY XR....................... 21 QUESTRAN ......................... 45 QUESTRAN LIGHT ............ 45 quetiapine ............................. 36 QUILLICHEW ER ............... 36 QUILLIVANT XR ............... 36 quinapril................................ 41 quinapril-hydrochlorothiazide
.......................................... 41 quinidine gluconate .............. 38 quinidine sulfate ................... 38 quinine sulfate ........................ 9 QUINTET AC ...................... 64 QUINTET BLOOD
GLUCOSE METER ......... 71 quit 2 ..................................... 58 QUIT 2 ................................. 58 quit 4 ..................................... 58 QUIT 4 ................................. 59 QUTENZA ........................... 49 QVAR REDIHALER ......... 104 R RABAVERT (PF) ................ 87 rabeprazole ........................... 83 RACEPINEPH-LIDOCAINE-
BSS 7(PF) ......................... 98 RADICAVA ......................... 23 RADIOGARDASE .............. 57 RAGWITEK ......................... 87 rajani ..................................... 95 raloxifene .............................. 88 ramipril ................................. 41 RANEXA ............................. 46 ranitidine hcl ......................... 83 ranolazine ............................. 46 RAPAFLO .......................... 106 RAPAMUNE........................ 17 rasagiline .............................. 21 RASUVO (PF) ..................... 89 RAVICTI .............................. 57
RAYALDEE ......................... 75 RAYOS ................................. 61 RAZADYNE ........................ 23 RAZADYNE ER .................. 23 READYSHARP
DEXAMETHASONE ...... 61 READYSHARP
KETOROLAC .................. 31 READYSHARP LIDOCAINE
(PF) ................................... 53 REBETOL ............................ 85 REBIF (WITH ALBUMIN) . 85 REBIF REBIDOSE .............. 85 REBIF TITRATION PACK . 85 REBINYN ............................ 44 RECLAST ............................ 57 reclipsen (28) ........................ 95 RECOMBINATE ................. 44 RECOMBIVAX HB (PF) ..... 87 RECTIV ................................ 82 REFUAH PLUS ................... 64 REFUAH PLUS GLUCOSE
CONTROL ....................... 71 REFUAH PLUS GLUCOSE
MONITOR ....................... 71 REGLAN .............................. 82 REGRANEX ........................ 49 relador pak ............................ 53 relador pak plus .................... 53 RELAGARD ........................ 92 RELENZA DISKHALER ...... 5 RELEXXII ............................ 36 RELION ALL-IN-ONE
METER ............................. 71 RELION CONFIRM ............ 71 RELION CONFIRM-MICRO
.......................................... 64 RELION MICRO GLUCOSE
MONITOR ....................... 71 RELION NOVOLIN 70/30 .. 73 RELION NOVOLIN N ........ 73 RELION NOVOLIN R ......... 73 RELION PRIME METER .... 71 RELION PRIME TEST
STRIPS ............................. 64 RELISTOR ........................... 82 RELPAX ............................... 22 REMERON ........................... 36
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REMERON SOLTAB .......... 36 REMICADE ......................... 82 REMODULIN ...................... 41 RENAGEL ........................... 82 rena-vite .............................. 111 RENFLEXIS ........................ 82 RENVELA ........................... 82 repaglinide ............................ 77 repaglinide-metformin .......... 77 REPATHA PUSHTRONEX 45 REPATHA SURECLICK .... 45 REPATHA SYRINGE ......... 45 REQUIP ............................... 21 REQUIP XL ......................... 22 RESCRIPTOR ........................ 5 RESPA-AR......................... 102 RESTASIS ........................... 98 RESTASIS MULTIDOSE ... 98 RESTIZAN........................... 49 RESTORIL ........................... 36 RETIN-A .............................. 51 RETIN-A MICRO ................ 51 RETIN-A MICRO PUMP .... 51 RETISERT ......................... 100 RETROVIR ............................ 5 REVATIO .......................... 104 REVEAL BLOOD GLUCOSE
METER ............................ 71 REVEAL TEST STRIP ........ 64 REVLIMID .......................... 85 REXULTI ............................. 36 REYATAZ ............................. 5 RHOFADE ........................... 51 RHOPRESSA ....................... 99 RIASTAP ............................. 44 ribasphere ............................. 85 ribasphere ribapak ................ 85 ribavirin ............................ 5, 85 RIDAURA ............................ 89 rifabutin .................................. 9 RIFADIN ................................ 9 RIFAMATE ........................... 9 rifampin .................................. 9 RIFATER ............................... 9 RIGHTEST CONTROL
SOLUTION HIGH ........... 71 RIGHTEST GM550 SYSTEM
.......................................... 71
RIGHTEST GS550 TEST STRIPS ............................. 64
RILUTEK ............................. 57 riluzole .................................. 57 rimantadine ............................. 5 ringer's .................................. 56 RIOMET ............................... 77 risedronate ...................... 57, 88 RISPERDAL ........................ 36 risperidone ............................ 36 RITALIN .............................. 36 RITALIN LA ........................ 36 ritonavir .................................. 5 RITUXAN ............................ 17 RITUXAN HYCELA ........... 17 rivastigmine .......................... 23 rivastigmine tartrate .............. 23 rivelsa ................................... 95 RIXUBIS .............................. 44 rizatriptan.............................. 22 R-NATAL OB .................... 111 robafen ac ........................... 102 ROBAXIN ............................ 24 ROBAXIN-750 .................... 24 ROCALTROL ...................... 75 ROCKLATAN ..................... 99 ROMIDEPSIN...................... 17 ropinirole .............................. 22 rosadan.................................. 51 ROSADAN ........................... 51 ROSANIL ............................. 51 ROSULA .............................. 51 rosula cleansing cloths.......... 51 rosuvastatin ........................... 45 ROTARIX ............................ 87 ROTATEQ VACCINE......... 87 ROWASA ............................. 82 roweepra ............................... 21 roweepra xr ........................... 21 ROXICODONE.................... 29 ROXYBOND ....................... 29 ROZEREM ........................... 36 RUBRACA ........................... 17 RUCONEST ....................... 104 RYCLORA ......................... 101 RYDAPT .............................. 17 rydex ................................... 102 RYTARY.............................. 22
RYTHMOL SR .................... 38 RYVENT ............................ 101 S SABRIL ................................ 21 SAFYRAL ............................ 95 SAIZEN ................................ 84 SAIZEN SAIZENPREP ....... 84 SALAGEN (PILOCARPINE)
.................................... 57, 59 SALEX ................................. 47 salicylic acid ......................... 47 salimez .................................. 48 SALIMEZ FORTE ............... 48 SALKERA ............................ 48 salsalate ................................. 31 salvax .................................... 48 SALVAX DUO PLUS ......... 48 SAMSCA .............................. 75 SANCUSO ........................... 82 SANDIMMUNE ............. 17, 18 SANDOSTATIN .................. 18 SANDOSTATIN LAR
DEPOT ............................. 18 SANTYL .............................. 56 SAPHRIS .............................. 36 SARAFEM ........................... 36 SAVAYSA ........................... 44 SAVELLA ............................ 89 scalacort ................................ 55 SEASONIQUE ..................... 95 seconal sodium ..................... 36 SEEBRI NEOHALER ........ 104 SEGLUROMET ................... 77 SELECT-OB ....................... 111 SELECT-OB (FOLIC ACID)
........................................ 111 SELECT-OB + DHA .......... 111 selegiline hcl ......................... 22 selenium sulfide .................... 47 SELRX ................................. 47 SELZENTRY ......................... 5 SEMPREX-D ..................... 102 se-natal 19 ........................... 111 se-natal 19 (with docusate) . 111 SENSIPAR ........................... 75 SEREVENT DISKUS ........ 104 SERNIVO ............................. 55 serophene .............................. 75
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SEROQUEL ......................... 36 SEROQUEL XR .................. 36 SEROSTIM .......................... 84 sertraline ............................... 37 setlakin ................................. 95 sevelamer carbonate ............. 82 sevelamer hcl ........................ 82 SEYSARA ............................ 11 sf 59 sf 5000 plus .......................... 59 SFROWASA ........................ 82 sharobel ................................ 91 SHINGRIX (PF) ................... 87 SHOHL'S MODIFIED ....... 106 SIDEKICK BLOOD
GLUCOSE SYSTEM ....... 71 SIGNIFOR ........................... 18 SIGNIFOR LAR .................. 18 SIKLOS ................................ 18 SILALITE PAK ................... 56 sildenafil (antihypertensive)
........................................ 104 SILENOR ............................. 37 SILIQ .................................... 47 silodosin ............................. 106 SILVADENE ....................... 47 silver nitrate .......................... 49 silver nitrate applicators ....... 49 silver sulfadiazine ................. 47 SILVRSTAT ........................ 53 SIMBRINZA ........................ 99 simliya (28) .......................... 95 SIMPONI ............................. 89 SIMPONI ARIA ................... 89 SIMULECT .......................... 18 simvastatin ............................ 45 SINEMET............................. 22 SINEMET CR ...................... 22 SINGULAIR ...................... 104 sirolimus ............................... 18 SIRTURO ............................... 9 SIVEXTRO ............................ 9 SKELAXIN .......................... 24 SKLICE ................................ 56 SKYLA................................. 90 SKYRIZI .............................. 47 SMART SENSE
MONITORING SYSTEM 71
SMART SENSE TEST STRIPS ............................. 64
SMARTEST CONTROL ..... 71 SMARTEST EJECT............. 71 SMARTEST PERSONA
STARTER ........................ 71 SMARTEST PRONTO
STARTER ........................ 71 SMARTEST PROTEGE ...... 71 SMARTEST TEST............... 64 smoothlax ............................. 82 sodium benzoate-sod
phenylacet ......................... 57 sodium chlor 0.9% bacteriostat
.......................................... 58 sodium chloride .......... 105, 108 sodium chloride 0.45 % ...... 108 sodium chloride 0.9 % .......... 58 sodium chloride 0.9 % (flush)
.......................................... 58 sodium chloride 3 % ........... 108 sodium chloride 5 % ........... 108 SODIUM EDECRIN ............ 41 sodium ferric gluconat-sucrose
.......................................... 58 sodium phenylbutyrate ......... 58 sodium polystyrene sulfonate
.......................................... 82 SODIUM POLYSTYRENE
SULFONATE ................... 82 SOFOSBUVIR-
VELPATASVIR ................. 5 SOLARAZE ......................... 49 SOLESTA ............................ 82 solifenacin .......................... 106 SOLIQUA 100/33 ................ 73 SOLIRIS ............................... 58 SOLODYN ........................... 11 SOLOSEC .............................. 9 SOLOX GEL ........................ 49 soloxide ................................ 11 SOLTAMOX ........................ 18 SOLUS V2 AUDIBLE
METER ............................ 71 SOLUS V2 CONTROL
SOLUTION,HIGH ........... 71 SOLUS V2 TEST STRIPS ... 64 SOMA .................................. 24
SOMATULINE DEPOT ...... 18 SOMAVERT ........................ 75 sonafine ................................. 49 SOOLANTRA ...................... 51 SORBITOL-MANNITOL .... 56 SORIATANE ....................... 47 SORILUX ............................. 47 sotalol ................................... 38 sotalol af ............................... 38 SOTYLIZE ........................... 38 SOVALDI ............................... 5 sp antipruritic ........................ 49 sp scar management .............. 49 SPECTRACEF ....................... 7 spinosad ................................ 56 SPIRIVA RESPIMAT ........ 105 SPIRIVA WITH
HANDIHALER .............. 105 spironolactone ....................... 41 spironolacton-hydrochlorothiaz
.......................................... 41 SPORANOX ........................... 3 SPORANOX PULSEPAK ..... 3 SPRAVATO ......................... 37 sprintec (28) .......................... 95 SPRITAM ............................. 21 SPRIX ................................... 31 SPRYCEL ............................. 18 sps (with sorbitol) ................. 82 sronyx ................................... 95 ssd ......................................... 47 SSKI ..................................... 61 sss 10-5 ................................. 51 st joseph aspirin .................... 31 STALEVO 100 ..................... 22 STALEVO 125 ..................... 22 STALEVO 150 ..................... 22 STALEVO 200 ..................... 22 STALEVO 50 ....................... 22 STALEVO 75 ....................... 22 STARLIX ............................. 77 stavudine ................................. 5 STEGLATRO ....................... 77 STEGLUJAN ....................... 77 STELARA ............................ 47 STIMATE ............................. 75 STIOLTO RESPIMAT ....... 105 STIVARGA .......................... 18
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stop smoking aid................... 59 STRATTERA ....................... 37 STRENSIQ ........................... 75 STREPTOMYCIN ................. 9 stress formula ..................... 111 stress formula with iron ...... 112 stress formula with iron(sulf)
........................................ 112 STRIANT ............................. 75 STRIBILD .............................. 5 STRIVERDI RESPIMAT .. 105 STROMECTOL ..................... 9 strong iodine ....................... 108 SUBLOCADE ...................... 29 SUBOXONE ........................ 31 SUBSYS ............................... 29 subvenite............................... 21 subvenite starter (blue) kit .... 21 subvenite starter (green) kit .. 21 subvenite starter (orange) kit 21 SUCRAID ............................ 82 sucralfate .............................. 83 SULAR ................................. 41 sulfacetamide sodium ... 47, 100 sulfacetamide sodium (acne) 53 sulfacetamide sodium-sulfur 51 sulfacetamide sod-sulfur-urea
.......................................... 51 sulfacetamide-prednisolone 100 sulfacleanse 8-4 .................... 51 sulfadiazine........................... 11 sulfamethoxazole-trimethoprim
.......................................... 11 SULFAMYLON................... 53 sulfasalazine ......................... 82 sulfatrim ............................... 11 sulindac................................. 31 SUMADAN .......................... 51 sumatriptan ........................... 22 sumatriptan succinate ........... 22 sumatriptan-naproxen ........... 22 SUMAVEL DOSEPRO ....... 22 SUMAXIN ........................... 51 SUMAXIN TS...................... 51 super b complex-vitamin c . 112 super b maxi complex ........ 112 super b-50 complex plus .... 112 super quints ........................ 112
super quints b-50 ................ 112 superplex-t .......................... 112 SUPPRELIN LA .................. 18 SUPRAX ................................ 7 SUPREP BOWEL PREP KIT
.......................................... 82 SURE-TEST EASYPLUS
MINI ................................. 64 SURE-TEST EASYPLUS
MINI METER .................. 71 SURFAXIN ........................ 105 SURMONTIL ....................... 37 SURVANTA ........................ 58 SUSTIVA ............................... 5 SUSTOL ............................... 82 SUTENT ............................... 18 syeda ..................................... 95 SYLATRON ......................... 85 SYLVANT ........................... 18 SYMAX DUOTAB .............. 79 symax fastabs ....................... 79 symax-sl................................ 79 symax-sr ............................... 79 SYMBICORT ..................... 105 SYMBYAX .......................... 37 SYMDEKO ........................ 105 SYMFI .................................... 5 SYMFI LO ............................. 5 SYMJEPI ............................ 101 SYMLINPEN 120 ................ 77 SYMLINPEN 60 .................. 77 SYMPAZAN ........................ 21 SYMPROIC.......................... 82 SYMTUZA ............................. 5 SYNAGIS ............................... 5 SYNALAR ........................... 56 SYNALAR CREAM KIT .... 56 SYNALAR OINTMENT KIT
.......................................... 56 SYNALAR TS ..................... 56 SYNAREL............................ 75 SYNDROS ........................... 82 SYNERA .............................. 53 SYNERCID ............................ 9 SYNJARDY ......................... 77 SYNJARDY XR................... 77 SYNRIBO ............................ 18 SYNTHROID ....................... 77
SYPRINE ............................. 58 T T
SLIM X2 BASAL-IQ INSULIN PMP ............. 71
TABLOID ............................. 18 TACLONEX ......................... 47 tacrolimus ....................... 18, 49 tadalafil ............................... 106 tadalafil (antihypertensive) . 105 TAFINLAR .......................... 18 TAGRISSO ........................... 18 TAKE ACTION ................... 95 TAKHZYRO ...................... 105 TALTZ AUTOINJECTOR .. 47 TALTZ AUTOINJECTOR (2
PACK) .............................. 47 TALTZ AUTOINJECTOR (3
PACK) .............................. 47 TALTZ SYRINGE ............... 47 TALWIN .............................. 31 TALZENNA ......................... 18 TAMIFLU .............................. 5 tamoxifen .............................. 18 tamsulosin ........................... 106 TAPAZOLE ......................... 61 TAPERDEX ......................... 61 TARCEVA ........................... 18 TARGADOX ........................ 11 TARGRETIN ....................... 18 tarina 24 fe ............................ 95 tarina fe 1/20 (28) ................. 95 TARKA ................................ 41 taron-c dha .......................... 112 taron-prex prenatal-dha ...... 112 TASIGNA ............................. 18 TASMAR ............................. 22 TAVALISSE ........................ 44 TAXOTERE ......................... 18 TAYTULLA ......................... 95 tazarotene .............................. 51 TAZICEF ................................ 7 TAZORAC ........................... 51 taztia xt ................................. 41 TDVAX ................................ 87 TECENTRIQ ........................ 18 TECFIDERA ........................ 85 TEFLARO .............................. 7
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TEGRETOL ......................... 21 TEGRETOL XR ................... 21 TEGSEDI ............................. 23 TEKTURNA ........................ 41 TEKTURNA HCT ............... 41 TELCARE BGM .................. 71 TELCARE BLOOD
GLUCOSE KIT ................ 71 TELCARE CONTROL ........ 71 TELCARE TEST STRIPS ... 64 telmisartan ............................ 41 telmisartan-amlodipine ......... 41 telmisartan-hydrochlorothiazid
.......................................... 41 temazepam ............................ 37 TEMODAR .......................... 18 TEMOVATE ........................ 56 temozolomide ....................... 18 temsirolimus ......................... 18 tencon ................................... 29 TENIPOSIDE ....................... 18 TENIVAC (PF) .................... 87 tenofovir disoproxil fumarate . 5 TENORETIC 100 ................. 41 TENORETIC 50 ................... 42 TENORMIN ......................... 42 TEPADINA .......................... 18 terazosin ............................... 42 terbinafine hcl ......................... 3 terbutaline ........................... 105 terconazole ........................... 92 TERSI FOAM ...................... 47 TESSALON PERLES ........ 102 TEST N'GO BLOOD
GLUCOSE SYSTEM ....... 71 TEST N'GO TEST ............... 64 TESTIM ............................... 75 testosterone ........................... 75 testosterone cypionate .......... 75 testosterone enanthate .......... 75 TESTRED ............................ 75 TETANUS,DIPHTHERIA
TOX PED(PF) .................. 87 tetcaine ................................. 98 tetrabenazine......................... 23 tetracaine hcl ........................ 98 TETRACAINE HCL (PF) .... 98 tetracycline ........................... 11
TETRAVISC ........................ 98 TETRAVISC FORTE .......... 98 TEXACORT ......................... 56 THALLOUS CHLORIDE TL-
201 .................................... 58 THALOMID ......................... 18 THEO-24 ............................ 105 theochron ............................ 105 theophylline ........................ 105 THIOLA ............................... 58 thioridazine ........................... 37 thiotepa ................................. 18 thiothixene ............................ 37 THRIVITE RX ................... 112 THYMOGLOBULIN ........... 87 thyroid (pork) ....................... 77 THYROLAR-1 ..................... 78 THYROLAR-1/2 .................. 78 THYROLAR-1/4 .................. 78 THYROLAR-2 ..................... 78 THYROLAR-3 ..................... 78 tiagabine ............................... 21 TIAZAC ............................... 42 TIBSOVO ............................. 18 TICALAST ......................... 105 TICE BCG ............................ 88 TIGAN.................................. 82 tigecycline .............................. 9 TIGLUTIK ........................... 58 TIKOSYN ............................ 38 tilia fe .................................... 95 timolol maleate ............... 42, 97 TIMOPTIC ........................... 97 TIMOPTIC OCUDOSE (PF)
.......................................... 97 TIMOPTIC-XE .................... 97 tinidazole ................................ 9 TIROSINT ............................ 78 TIROSINT-SOL ................... 78 tis-u-sol pentalyte ................. 56 TIVICAY................................ 5 TIVORBEX .......................... 31 tizanidine .............................. 24 tl g-fol os ............................ 112 TOBI ....................................... 9 TOBI PODHALER ................ 9 TOBRADEX ........................ 99 TOBRADEX ST................... 99
tobramycin ............................ 96 tobramycin in 0.225 % nacl .... 9 tobramycin sulfate .................. 9 TOBRAMYCIN WITH
NEBULIZER ...................... 9 tobramycin-dexamethasone .. 99 TOBREX .............................. 96 TODAY CONTRACEPTIVE
SPONGE ........................... 92 TOFRANIL .......................... 37 TOLAK ................................. 49 tolazamide ............................. 77 tolbutamide ........................... 77 tolcapone ............................... 22 tolmetin ................................. 31 TOLSURA .............................. 3 tolterodine ........................... 106 TOPAMAX .......................... 21 TOPICORT ........................... 56 topiramate ............................. 21 TOPIRAMATE .................... 21 toposar .................................. 18 topotecan ............................... 18 TOPROL XL ........................ 42 toremifene ............................. 18 TORISEL .............................. 18 torsemide .............................. 42 total b/c ............................... 112 TOTECT ............................... 13 TOUJEO MAX U-300
SOLOSTAR ..................... 73 TOUJEO SOLOSTAR U-300
INSULIN .......................... 73 TOVIAZ ............................. 106 TRACLEER ....................... 105 TRADJENTA ....................... 77 tramadol ................................ 31 TRAMADOL ....................... 31 tramadol-acetaminophen ...... 31 trandolapril ........................... 42 trandolapril-verapamil .......... 42 tranexamic acid ............... 44, 92 TRANSDERM-SCOP .......... 82 TRANXENE T-TAB ............ 37 tranylcypromine .................... 37 TRANZAREL ...................... 53 TRAVATAN Z ..................... 99 trazodone .............................. 37
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TREANDA ........................... 18 TRECATOR ........................... 9 TRELEGY ELLIPTA ........ 105 TRELSTAR .......................... 18 TREMFYA ........................... 47 treprostinil sodium................ 42 TRESIBA FLEXTOUCH U-
100 .................................... 73 TRESIBA FLEXTOUCH U-
200 .................................... 73 TRESIBA U-100 INSULIN . 73 tretinoin .......................... 51, 52 tretinoin (chemotherapy) ...... 18 tretinoin microspheres .......... 51 TRETIN-X ........................... 52 TRETIN-X CREAM KIT..... 52 TRETTEN ............................ 44 TREXALL ............................ 18 TREXIMET .......................... 22 TREZIX ................................ 29 tri femynor ............................ 95 TRIACETIN ......................... 54 TRIAMCINOL AC (PF) IN
0.9%NACL ....................... 61 TRIAMCINOL ACE-BUPIV-
0.9% NACL ...................... 61 TRIAMCINOLONE
ACETON-0.9% NACL .... 61 triamcinolone acetonide 56, 59,
61 TRIAMCINOLONE DIA(PF)-
0.9%NACL ....................... 61 TRIAMCINOLONE DIACET-
0.9% NACL ...................... 61 TRIAMCINOLON-
MOXIFLOX-WATR(PF). 99 triamterene-hydrochlorothiazid
.......................................... 42 trianex ................................... 56 triazolam ............................... 37 TRIBENZOR ....................... 42 TRICARE ........................... 112 TRICOR ............................... 46 triderm .................................. 56 TRIDESILON ...................... 56 trientine................................. 58 tri-estarylla ........................... 95 TRIFERIC .......................... 112
trifluoperazine ...................... 37 trifluridine ............................. 96 TRIGLIDE............................ 46 trihexyphenidyl ..................... 22 triklo ..................................... 46 tri-legest fe ............................ 95 TRILEPTAL ......................... 21 tri-linyah ............................... 95 TRILIPIX ............................. 46 tri-lo-estarylla ....................... 95 tri-lo-marzia .......................... 95 tri-lo-sprintec ........................ 95 trilyte with flavor packets ..... 82 trimethobenzamide ............... 82 trimethoprim ......................... 12 tri-mili ................................... 95 trimipramine ......................... 37 TRIMO-SAN JELLY ........... 92 TRIMPEX ............................ 12 trinatal rx 1 ......................... 112 trinate .................................. 112 TRINTELLIX ....................... 37 TRIPLE DYE ....................... 54 tri-previfem (28) ................... 95 TRIPTODUR........................ 18 TRISENOX .......................... 18 tri-sprintec (28) ..................... 95 TRISTART DHA ............... 112 TRIUMEQ .............................. 5 triveen-duo dha ................... 112 tri-vitamin with fluoride ..... 112 trivora (28) ............................ 95 tri-vylibra .............................. 95 tri-vylibra lo .......................... 95 TRIXYLITRAL.................... 49 TRIZIVIR ............................... 5 TROGARZO .......................... 5 TROKENDI XR ................... 21 tropicamide ........................... 97 trospium .............................. 106 TRUE METRIX AIR
GLUCOSE METER ......... 71 TRUE METRIX GLUCOSE
METER ............................ 71 TRUE METRIX GLUCOSE
TEST STRIP..................... 64 TRUE METRIX GO
GLUCOSE METER ......... 71
TRUE METRIX LEVEL 1 ... 71 TRUECONTROL LEVEL 0 71 TRUERESULT BLOOD
GLUCOSE SYSTM ......... 72 TRUETEST TEST STRIPS . 64 TRUETRACK BLOOD
GLUCOSE SYSTEM ....... 72 TRUETRACK SMART
SYSTEM .......................... 72 TRUETRACK TEST ............ 64 TRULANCE ......................... 82 TRULICITY ......................... 77 TRUMENBA ........................ 88 TRUSOPT ............................ 99 trust natal dha ..................... 112 TRUSTEEL INFUSION SET
32 ...................................... 72 TRUVADA ............................. 5 TUDORZA PRESSAIR ..... 105 tulana .................................... 91 tusnel c ................................ 102 TUSNEL PEDIATRIC ....... 102 TUSSICAPS ....................... 102 TUSSIONEX PENNKINETIC
ER ................................... 102 TUXARIN ER .................... 102 TUZISTRA XR .................. 102 TWINRIX (PF) ..................... 88 TWYNSTA ........................... 42 TYBOST ................................. 5 tydemy .................................. 95 TYGACIL ............................... 9 TYKERB .............................. 18 TYLENOL-CODEINE #3 .... 29 TYLENOL-CODEINE #4 .... 29 TYMLOS .............................. 88 TYPHIM VI .......................... 88 TYSABRI ............................. 23 TYVASO ............................ 105 TYVASO REFILL KIT ...... 105 TYVASO STARTER KIT . 105 TYZINE ................................ 59 U UCERIS ................................ 82 UDENYCA ........................... 84 ULESFIA .............................. 56 ULORIC ............................... 88 ULTIMA MONITOR ........... 72
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ULTIMA TEST STRIPS ...... 64 ULTOMIRIS ........................ 58 ultra b-100 complex ........... 112 ULTRACET ......................... 31 ULTRAM ............................. 31 ULTRASAL-ER................... 48 ULTRATRAK ...................... 64 ULTRATRAK GLUCOSE
METER ............................ 72 ULTRATRAK ULTIMATE 64,
72 ULTRAVATE ...................... 56 ULTRAVATE X .................. 56 umecta .................................. 49 UNASYN ............................. 10 UNISTRIP LOW CONTROL
.......................................... 72 UNISTRIP1 TEST STRIP ... 64 unithroid ............................... 78 UNITUXIN .......................... 19 UPTRAVI............................. 42 urea ....................................... 49 urea nail stick ....................... 49 URECHOLINE .................. 106 URELLE............................. 106 uretron d-s .......................... 106 URIBEL ............................. 106 urimar-t ............................... 107 urin ds ................................. 107 uro-458 ............................... 107 UROCIT-K 10 .................... 107 UROCIT-K 15 .................... 107 UROCIT-K 5 ...................... 107 urogesic-blue ...................... 107 uro-mp ................................ 107 UROQID-ACID NO.2 ....... 107 UROXATRAL ................... 106 URSO 250 ............................ 82 URSO FORTE...................... 82 ursodiol ................................. 82 uryl ..................................... 107 ustell ................................... 107 UTIBRON NEOHALER.... 105 utira-c ................................. 107 UTOPIC ............................... 49 V VABOMERE ......................... 9 VAGIFEM ............................ 91
vaginal contraceptive foam .. 92 valacyclovir ............................ 5 VALCHLOR ........................ 49 VALCYTE ............................. 5 valganciclovir ......................... 6 VALIUM .............................. 37 valproate sodium .................. 21 valproic acid ......................... 21 valproic acid (as sodium salt)
.......................................... 21 valsartan................................ 42 valsartan-hydrochlorothiazide
.......................................... 42 VALTREX ............................. 6 VANATOL LQ .................... 29 VANATOL S ....................... 29 VANCOCIN ......................... 12 vancomycin .......................... 12 VANCOMYCIN .................. 12 VANCOMYCIN HCL IN
WATER ............................ 12 VANCOMYCIN IN 0.9 %
SODIUM CHL ................. 12 VANCOMYCIN IN
DEXTROSE 5 % .............. 12 VANCOMYCIN-WATER
INJECT (PEG) ................. 12 vandazole .............................. 92 VANOS ................................ 56 VANOXIDE-HC .................. 52 VANTAS .............................. 19 VAQTA (PF) ........................ 88 vardenafil ............................ 107 VARISOFT INFUSION SET
43 ...................................... 72 VARIVAX (PF) ................... 88 VARIZIG.............................. 88 VARUBI ............................... 82 VASCEPA ............................ 46 VASERETIC ........................ 42 VASHE WOUND THERAPY
.......................................... 56 VASOTEC............................ 42 VAXCHORA VACCINE..... 88 VCF CONTRACEPTIVE
FILM ................................ 92 VCF CONTRACEPTIVE GEL
.......................................... 92
VECAMYL .......................... 46 VECTIBIX ........................... 19 VECTICAL .......................... 47 VELCADE ........................... 19 veletri .................................... 42 velivet triphasic regimen (28)
.......................................... 95 VELPHORO ......................... 82 VELTASSA .......................... 82 VELTIN ................................ 52 VEMLIDY .............................. 6 VENCLEXTA ...................... 19 VENCLEXTA STARTING
PACK ............................... 19 venlafaxine ........................... 37 VENOFER .......................... 112 VENTAVIS ........................ 105 VENTOLIN HFA ............... 105 verapamil .............................. 42 VERASENS BLOOD
GLUCOSE METER ......... 72 VERASENS CONTROL
SOLN-LEVEL 1 ............... 72 VERASENS METER
STARTER KIT ................. 72 VERASENS TEST STRIP ... 64 VERDESO ............................ 56 VEREGEN ........................... 49 VERELAN ........................... 42 VERELAN PM ..................... 42 veripred 20 ............................ 61 VERSACLOZ ....................... 37 VERZENIO .......................... 19 VESICARE ......................... 106 VFEND ................................... 3 VFEND IV .............................. 3 V-GO 20 ............................... 72 V-GO 30 ............................... 72 V-GO 40 ............................... 72 VIBATIV .............................. 12 VIBERZI .............................. 82 VIBRAMYCIN .................... 11 vicodin .................................. 29 vicodin es .............................. 29 vicodin hp ............................. 29 VICTOZA 2-PAK ................ 77 VICTOZA 3-PAK ................ 77 VIDAZA ............................... 19
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148
VIDEX 2 GRAM PEDIATRIC ............................................ 6
VIDEX EC ............................. 6 VIEKIRA PAK ...................... 6 vienva ................................... 95 vigabatrin .............................. 21 vigadrone .............................. 21 VIGAMOX........................... 96 VIIBRYD ............................. 37 VIMIZIM ............................. 75 VIMOVO ............................. 31 VIMPAT............................... 21 vinate care .......................... 112 VINATE DHA RF ............. 112 vinate ii ............................... 112 vinate m .............................. 112 vinate one ........................... 112 vinblastine ............................ 19 vincasar pfs ........................... 19 vincristine ............................. 19 vinorelbine ............................ 19 VIOKACE ............................ 82 viorele (28) ........................... 96 VIRACEPT ............................ 6 VIRAMUNE .......................... 6 VIRAMUNE XR .................... 6 VIRASAL............................. 48 VIRAZOLE ............................ 6 VIREAD ................................. 6 virt-advance ........................ 112 virt-c dha ............................ 112 virt-nate dha........................ 112 virt-pn dha .......................... 112 virt-pn plus ......................... 112 VIRTPREX ........................ 112 virt-select ............................ 112 virtussin ac.......................... 102 virtussin dac........................ 102 virt-vite gt ........................... 112 VISTARIL .......................... 101 VISTOGARD ....................... 13 VISUDYNE ......................... 98 VITAFOL FE+ (WITH
DOCUSATE) ................. 112 VITAFOL GUMMIES ....... 112 VITAFOL NANO .............. 112 VITAFOL ULTRA ............ 112 VITAFOL-OB .................... 112
VITAFOL-OB+DHA ......... 112 VITAFOL-ONE ................. 112 VITAMED MD ONE RX .. 112 VITAMEDMD REDICHEW
RX .................................. 112 vitamin b complex .............. 112 vitamin b complex-folic acid
........................................ 112 vitamin d3 ........................... 112 vitamins a,c,d and fluoride . 112 VITAPEARL ...................... 112 VITATRUE ........................ 112 VITRAKVI ........................... 19 VITRASE ............................. 98 VIVELLE-DOT.................... 91 VIVITROL ........................... 31 VIVLODEX ......................... 31 VIVOTIF .............................. 88 VIZIMPRO ........................... 19 VOGELXO ........................... 75 VOLTAREN ........................ 31 VOLTAREN-XR.................. 31 VONVENDI ......................... 44 VORAXAZE ........................ 13 voriconazole ........................... 3 VOSEVI ................................. 6 VOTRIENT .......................... 19 vp-ch plus ........................... 112 vp-ch-pnv............................ 113 VP-PNV-DHA.................... 113 VPRIV .................................. 76 VRAYLAR ........................... 37 VUSION ............................... 54 vyfemla (28) ......................... 96 vylibra ................................... 96 VYTORIN 10-10 .................. 46 VYTORIN 10-20 .................. 46 VYTORIN 10-40 .................. 46 VYTORIN 10-80 .................. 46 VYVANSE ........................... 37 VYXEOS .............................. 19 VYZULTA ........................... 99 W warfarin ................................ 44 water for irrigation, sterile .... 58 WAVESENSE AMP ............ 72 WAVESENSE CONTROL
SOLUTION ...................... 72
WAVESENSE JAZZ ............ 64 WAVESENSE PRESTO 64, 72 WELCHOL ........................... 46 WELLBUTRIN SR .............. 37 WELLBUTRIN XL .............. 37 wera (28) ............................... 96 westhroid .............................. 78 WIDE-SEAL DIAPHRAGM
.......................................... 90 WILATE ............................... 44 wixela inhub ....................... 105 woman's laxative .................. 82 women's gentle laxative(bisac)
.......................................... 82 women's laxative (bisacodyl)82 WP THYROID ..................... 78 wymzya fe ............................ 96 X XADAGO ............................. 22 XALATAN ........................... 99 XALKORI ............................ 19 XANAX ................................ 37 XANAX XR ......................... 37 XARELTO ........................... 44 XATMEP .............................. 19 XCLAIR ............................... 49 XELJANZ ............................. 89 XELJANZ XR ...................... 89 XELODA .............................. 19 XELPROS ............................ 99 XENAZINE .......................... 23 XEOMIN .............................. 88 XEPI ..................................... 53 XERAVA ............................. 11 XERESE ............................... 54 XERMELO ........................... 19 XGEVA ................................ 13 XHANCE ........................... 105 XIFAXAN .............................. 9 XIGDUO XR ........................ 77 XIIDRA ................................ 98 XIMINO ............................... 11 XOFLUZA ............................. 6 XOLAIR ............................. 105 XOLEGEL ............................ 54 XOPENEX ......................... 105 XOPENEX CONCENTRATE
........................................ 105
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149
XOPENEX HFA ................ 105 XOSPATA ........................... 19 XTAMPZA ER .................... 29 XTANDI............................... 19 xulane ................................... 92 XULTOPHY 100/3.6 ........... 74 XURIDEN ............................ 58 XYLOCAINE....................... 53 XYLOCAINE-MPF ............. 53 xylon 10 ................................ 29 XYNTHA ............................. 44 XYNTHA SOLOFUSE ........ 44 XYOSTED ........................... 76 XYREM ............................... 37 Y YASMIN (28) ...................... 96 YAZ (28) .............................. 96 YERVOY ............................. 19 YF-VAX (PF) ....................... 88 YONDELIS .......................... 19 YONSA ................................ 19 YOSPRALA ......................... 44 YUPELRI ........................... 105 YUTIQ ............................... 100 yuvafem ................................ 91 Z zafirlukast ........................... 105 zaleplon ................................ 37 ZALTRAP ............................ 19 ZANAFLEX ......................... 24 ZANOSAR ........................... 19 ZANTAC .............................. 83 zarah ..................................... 96 ZARONTIN ......................... 21 zatean-pn dha...................... 113 zatean-pn plus ..................... 113 ZAVESCA ........................... 76 zebutal .................................. 29 ZEGERID ....................... 83, 84 ZEJULA ............................... 19 ZELAPAR ............................ 22 ZELBORAF ......................... 19 ZEMAIRA ............................ 58 ZEMBRACE SYMTOUCH . 22 ZEMDRI................................. 9 ZEMPLAR ........................... 76 zenatane ................................ 52
ZENPEP ............................... 82 zenzedi .................................. 37 ZENZEDI ............................. 37 ZEPATIER ............................. 6 ZERIT ..................................... 6 ZESTORETIC ...................... 42 ZESTRIL .............................. 42 ZETIA .................................. 46 ZETONNA ......................... 105 ZEVALIN (Y-90) ................. 19 ZIAC ..................................... 42 ZIAGEN ................................. 6 ZIANA.................................. 52 zidovudine .............................. 6 zileuton ............................... 105 ZINECARD (AS HCL) ........ 13 zingiber ............................... 113 ZINGO.................................. 53 ZINPLAVA .......................... 88 ZIOPTAN (PF) ..................... 99 ziprasidone hcl ...................... 37 ZIPSOR ................................ 31 ZIRGAN ............................... 96 ZITHRANOL ....................... 47 ZITHROMAX ........................ 7 ZITHROMAX TRI-PAK ....... 7 ZITHROMAX Z-PAK ........... 7 ZOCOR ................................ 46 ZODRYL AC 25 ................ 102 ZODRYL AC 30 ................ 102 ZODRYL AC 35 ................ 102 ZODRYL AC 40 ................ 102 ZODRYL AC 50 ................ 102 ZODRYL AC 60 ................ 102 ZODRYL AC 80 ................ 102 ZODRYL DAC 25 ............. 102 ZODRYL DAC 30 ............. 102 ZODRYL DAC 35 ............. 102 ZODRYL DAC 40 ............. 102 ZODRYL DAC 50 ............. 102 ZODRYL DAC 60 ............. 102 ZODRYL DAC 80 ............. 102 ZODRYL DEC 25 .............. 102 ZODRYL DEC 30 .............. 102 ZODRYL DEC 35 .............. 102 ZODRYL DEC 40 .............. 102 ZODRYL DEC 50 .............. 102
ZODRYL DEC 60 .............. 102 ZODRYL DEC 80 .............. 102 ZOFRAN .............................. 82 ZOHYDRO ER .................... 29 ZOLADEX ........................... 19 zoledronic acid ...................... 76 zoledronic acid-mannitol-water
.................................... 58, 76 ZOLEDRONIC AC-
MANNITOL-0.9NACL .... 76 ZOLINZA ............................. 19 zolmitriptan ........................... 22 ZOLOFT ............................... 37 zolpidem ............................... 37 ZOLPIMIST ......................... 37 ZOMACTON ....................... 84 ZOMIG ................................. 22 ZOMIG ZMT ........................ 22 ZONALON ........................... 49 ZONEGRAN ........................ 21 zonisamide ............................ 21 ZONTIVITY ......................... 44 ZORBTIVE .......................... 84 ZORTRESS .......................... 19 ZORVOLEX ......................... 31 ZOSTAVAX (PF) ................ 88 zovia 1/35e (28) .................... 96 ZOVIRAX ........................ 6, 54 ZTLIDO ................................ 53 Z-TUSS AC ........................ 102 ZUBSOLV ............................ 32 ZUPLENZ ............................ 82 ZYBAN ................................ 59 ZYCLARA ........................... 85 ZYDELIG ............................. 19 ZYFLO ............................... 105 ZYKADIA ............................ 19 ZYLET ................................. 99 ZYLOPRIM .......................... 88 ZYMAXID ........................... 96 ZYPITAMAG ....................... 46 ZYPREXA ............................ 37 ZYPREXA ZYDIS ............... 37 ZYTIGA ............................... 19 ZYVOX ................................ 10
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
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도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 그렇게 통역사와 얘기하기
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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.