arizona complete health-complete care plan comprehensive ......sp specialty product these drugs are...

Arizona Complete Health-Complete Care Plan Comprehensive Preferred Drug List The Arizona Complete Health-Complete Care Plan Comprehensive Drug List includes drugs that have been reviewed and approved by a committee of doctors and pharmacists. This is not a complete list of all covered drugs. If you need a drug that is not in the drug list, call Arizona Complete Health-Complete Care Plan Member Services and ask if it is covered. If the drug is not covered, your doctor may request prior authorization to cover the drug.

The drug list is updated often and may change. You can view the latest drug list at www.azcompletehealth.com/providers/pharmacy.html

https://www.azcompletehealth.com/providers/pharmacy.html

Pharmacy Program Arizona Complete Health-Complete Care Plan provides appropriate, high quality, and cost effective drug therapy to all Arizona Complete Health-Complete Care Plan members. Arizona Complete Health-Complete Care Plan covers prescription drugs and certain over-the-counter (OTC) drugs when ordered by a doctor. Some drugs require prior authorization (PA) or have limits on age, dosage and maximum amounts.

Generic drugs have the same active ingredient as their brand name equivalents and should be used as the first line of treatment. This is unless a drug specifically notes brand is preferred. If there is no generic available, there may be more than one brand name drug that can be used in your treatment. The Arizona Complete Health-Complete Care Comprehensive PDL is reviewed often by our Arizona Complete Health Pharmacy and Therapeutics (P&T) Committee. This helps promote the appropriate and cost-effective use of medications.

Dispensing Limits You can get up to a maximum thirty (30) day supply for each new prescription or refill of most medications. You can get up to a ninety (90) day supply if:

• The medication is prescribed for chronic illness • You will be out of the service area for an extended period of time • The prescription is limited to the extended time period • The medication is prescribed for contraception

A total of 85% of the 30 day supply must have elapsed before the prescription can be refilled for most drugs.

Prior Authorization and Other Limits Some drugs listed on the Arizona Complete Health-Complete Care Plan Comprehensive PDL may require Prior Authorization (PA). Your doctor or pharmacist will request a PA for you. The information should be submitted by the practitioner or pharmacist on the Medication Prior Authorization Form. This document is located on the Arizona Complete Health-Complete Care Plan web-site at https://www.azcompletehealth.com/providers/pharmacy.html. They may fax the PA form to 1-855-554-5233 or your provider can send a PA request electronically to https://www.covermymeds.com/epa/envolverx/

Not all oncology drugs are listed below. All federally reimbursable oncology (antineoplastic) agents are available through prior authorization.

https://www.azcompletehealth.com/providers/pharmacy.html

https://www.covermymeds.com/main/prior-authorization-forms/envolverx/

Arizona Complete Health-Complete Care Plan will cover the medication(s) if:

1. There is a medical reason that requires the specific medication(s) 2. Depending on the medication, other medications on the PDL have not worked

If the request is approved, Arizona Complete Health-Complete Care Plan notifies your prescriber by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, Arizona Complete Health-Complete Care Plan will:

• Review the request and notify you and your prescriber of our decision • Let you know about alternative medications if available • Provide information about what you can do to appeal our decision if you do not agree with it.

Abbreviation What it means How it works

AL Age Limit Some drugs are only covered for certain ages.

F Formulary These drugs are covered by Arizona Complete Health-Complete Care Plan.

MP Maintenance Product

These drugs are used to treat long-term conditions or illnesses.

NF Non-Formulary These drugs require authorization to be covered by Arizona Complete Health-Complete Care Plan.

PA Prior Authorization

Your doctor must ask for approval from Arizona Complete Health-Complete Care Plan before some drugs will be covered.

QL Quantity Limit Some drugs are only covered for a certain amount.

SP Specialty Product

These drugs are used to treat complex or rare conditions such as hepatitis C or rheumatoid arthritis.

ST Step Therapy

In some cases, you must first try certain drugs before Arizona Complete Health-Complete Care Plan covers another drug for your medical condition.

For example, if Drug A and Drug B both treat your medical condition, the plan may not cover Drug B unless you try Drug A first.

Medical Necessity Requests If you require a medication to treat a condition that does not appear on the PDL, your doctor can make a medical necessity (MN) request for the medication.

Emergency Supply Policy State and Federal laws require that a pharmacy dispense up to a 4 day supply of medication to any member awaiting PA determination .The purpose is to avoid interruption of current therapy or delay in the start of therapy. Network pharmacies are authorized to provide up to a 4 day supply of traditional (non-specialty) drugs. Have your Pharmacy call the Pharmacy Help Desk at 1-888-624-1131 for help filling a 4 day emergency supply.

Exclusions The Arizona Complete Health-Complete Care Plan Drug List does not include certain drugs. The following types of drugs are excluded from coverage. They are also not available for a 4 day emergency supply.

• Drugs that are considered experimental or investigational (Members who are enrolled may participate in experimental services; however, AHCCCS will not reimburse for the experimental service as per A.A.C. R9-22-203)

• Drug Efficacy Study and Implementation (DESI) drugs • Prosthesis, appliances and devices • Drugs prescribed for infertility • Drugs prescribed for erectile or sexual dysfunction • Drugs prescribed solely for cosmetic purposes or hair growth • Oral vitamins and minerals or OTC drugs with the exception of those listed on the PDL or if a member has a deficiency of a vitamin not listed on the PDL

• Nutritional supplements • Medical marijuana • Drugs eligible for coverage under Medicare Part D (for Medicare eligible members); copayments and cost-sharing for behavioral health drugs are covered for SMI members who are also eligible for Medicare.

Newly Approved Products Arizona Complete Health-Complete Care Plan reviews new drugs for safety and effectiveness before adding them to the PDL. During this period, access to these drugs will be considered through the PA review process.

Filling a Prescription

You can have prescriptions filled at an Arizona Complete Health-Complete Care Plan network pharmacy. To find a network pharmacy, visit the Arizona Complete Health-Complete Care Plan website https://providersearch.azcompletehealth.com. You may also call member services for help finding a network pharmacy near you. When you pick a pharmacy, please bring your Arizona Complete Health-Complete Care Plan ID card with you. The pharmacy will need the information located on the card to

https://findaprovider.azcompletehealth.com/location

fill your prescription.

For More information about your pharmacy benefits, please review your Member Handbook or call Member Services at 888-788-4408 (TTY/TDY 711).

Drug Name DrugTier

Requirements/Limits

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS - Drugs to TreatADHD, Sleep and Eating Disorders

Amphetamines ADDERALL TABS (amphetamine-dextroamphetamine)

F QL(2 ea daily);AL(At least 6yrs old)

ADDERALL XR CP24 2.5 MG-2.5 MG-2.5 MG-2.5 MG, 7.5 MG-7.5 MG-7.5 MG-7.5 MG, 1.25 MG-1.25 MG-1.25 MG-1.25 MG, 3.75 MG-3.75 MG-3.75 MG-3.75 MG, 6.25 MG-6.25 MG-6.25 MG-6.25 MG (amphetamine-dextroamphetamine)

F

QL(1 ea daily);AL(At least 6yrs old)

ADDERALL XR CP24 5 MG-5 MG-5 MG-5 MG (amphetamine-dextroamphetamine)

F


amphetamine-dextroamphetamine tabs 5mg-5 mg-5 mg-5 mg, 2.5mg-2.5 mg-2.5 mg-2.5 mg,7.5 mg-7.5 mg-7.5 mg-7.5mg, 1.25 mg-1.25 mg-1.25mg-1.25 mg, 3.75 mg-3.75mg-3.75 mg-3.75 mg,1.875 mg-1.875 mg-1.875mg-1.875 mg, 3.125 mg-3.125 mg-3.125 mg-3.125 mg

F


dextroamphetamine sulfatetabs 5 mg, 10 mg F


DYANAVEL XR SUER 2.5 MG/ML F

QL(5 ml daily);AL(At least 6yrs old)

VYVANSE CAPS F QL(1 ea daily);AL(At least 6yrs old)

VYVANSE CHEW F QL(1 ea daily);AL(At least 6yrs old)

Attention-Deficit/Hyperactivity Disorder (ADHD)

Drug Name DrugTier

Requirements/Limits

atomoxetine hcl caps F QL(1 ea daily);AL(At least 6yrs old)

clonidine hcl (adhd) tb120.1 mg F


guanfacine hcl (adhd) tb24 F QL(1 ea daily);AL(At least 6yrs old)

INTUNIV TB24 (guanfacinehcl (adhd)) NF


STRATTERA CAPS (atomoxetine hcl) NF


Stimulants - Misc.

APTENSIO XR CP24 F QL(1 ea daily);AL(At least 6yrs old)

CONCERTA TBCR (methylphenidate hcl) F


DAYTRANA PTCH F QL(1 ea daily);AL(At least 6yrs old)

dexmethylphenidate hcltabs 5 mg, 10 mg, 2.5 mg F


FOCALIN TABS (dexmethylphenidate hcl) NF


FOCALIN XR CP24 (dexmethylphenidate hcl) F


METHYLIN SOLN (methylphenidate hcl) F

QL(10 mldaily); AL(Atleast 6 yrs old)

methylphenidate hcl cp24or 10 mg, 20 mg, 30 mg, 40mg, 60 mg


methylphenidate hcl cpcr or10 mg, 20 mg, 30 mg, 40mg, 50 mg, 60 mg


methylphenidate hcl tabs or5 mg, 10 mg, 20 mg F


Arizona Complete Health - Complete Care Plan Effective September 1, 2020

1

Drug Name DrugTier

Requirements/Limits

QUILLICHEW ER CHER F QL(1 ea daily);AL(At least 6yrs old)

QUILLIVANT XR SRER F QL(5 ml daily);AL(At least 6yrs old)

RITALIN LA CP24 10 MG (methylphenidate hcl) F


RITALIN LA CP24 20 MG, 30 MG, 40 MG (methylphenidate hcl)

NF QL(2 ea daily);AL(At least 6yrs old)

RITALIN TABS (methylphenidate hcl) NF


AMINOGLYCOSIDES - Drugs to Treat BacterialInfections

Aminoglycosides AMIKACIN SULFATE POWD XX F

amikacin sulfate soln ij 1gm/4ml, 500 mg/2ml F

BETHKIS NEBU F SP

gentamicin in saline soln F

GENTAMICIN SULFATE PEDIATRIC SOLN F

gentamicin sulfate soln ij10 mg/ml, 40 mg/ml F

GENTAMICIN SULFATE/0.9% SODIUMCHLORIDE SOLN

F

KITABIS PAK NEBU (tobramycin) F SP

neomycin sulfate tabs or F

paromomycin sulfate caps or F

STREPTOMYCIN SULFATE POWD XX F

streptomycin sulfate solr im F

TOBI NEBU (tobramycin) F SP

tobramycin nebu in F SP

Drug Name DrugTier

Requirements/Limits

TOBRAMYCIN SULFATE POWD XX F

tobramycin sulfate soln ij10 mg/ml, 80 mg/2ml, 1.2gm/30ml

F

TOBRAMYCIN SULFATE SOLN IJ 40 MG/ML F

tobramycin sulfate solr ij1.2 gm F

ZEMDRI SOLN F

ANALGESICS - ANTI-INFLAMMATORY - Drugsto Treat Pain, Swelling, Muscle and JointConditions

Anti-TNF-alpha - Monoclonal Antibodies HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK PSKT

F PA; SP

HUMIRA PEN PNKT F PA; SP

HUMIRA PEN-CD/UC/HSSTARTER PNKT F PA; SP

HUMIRA PEN-PS/UVSTARTER PNKT F PA; SP

HUMIRA PSKT F PA; SP

Antirheumatic - Enzyme Inhibitors

XELJANZ TABS F PA; SP

Nonsteroidal Anti-inflammatory Agents (NSAIDs) ADVIL CAPS (ibuprofen) NF

ADVIL MIGRAINE CAPS (ibuprofen) NF

ADVIL TABS (ibuprofen) NF

ALEVE ARTHRITIS TABS (naproxen sodium) NF

ALEVE CAPS (naproxensodium) NF

ALEVE TABS (naproxensodium) NF

ANAPROX DS TABS (naproxen sodium) NF

ARTHROTEC 50 TBEC (diclofenac w/ misoprostol) NF


2

Drug Name DrugTier

Requirements/Limits

ARTHROTEC 75 TBEC (diclofenac w/ misoprostol) NF

CELEBREX CAPS (celecoxib) NF QL(2 ea daily)

celecoxib caps or 50 mg,100 mg, 200 mg, 400 mg F QL(2 ea daily)

CHILDRENS ADVIL SUSP (ibuprofen) NF RX/OTC

CHILDRENS MOTRIN SUSP (ibuprofen) NF RX/OTC

DAYPRO TABS (oxaprozin) NF

diclofenac potassium tabs50 mg F

diclofenac sodium tb24 or 100 mg F

diclofenac sodium tbec or 25 mg, 50 mg, 75 mg F

diclofenac w/ misoprostoltbec F

EC-NAPROSYN TBEC (naproxen) NF

etodolac caps 200 mg, 300 mg F

etodolac tabs 400 mg, 500 mg F

FELDENE CAPS (piroxicam) NF

FENOPROFEN CALCIUM CAPS OR 400 MG F

fenoprofen calcium tabs or600 mg F

flurbiprofen tabs or 50 mg,100 mg F

ibuprofen caps or 200 mg F

ibuprofen chew or 100 mg F

ibuprofen susp or 100mg/5ml F RX/OTC

ibuprofen susp or 40mg/ml, 50 mg/1.25ml F

ibuprofen tabs or 200 mg,400 mg, 600 mg, 800 mg F

INDOCIN SUPP F

Drug Name DrugTier

Requirements/Limits

INDOCIN SUSP F

indomethacin caps or 25mg, 50 mg F

indomethacin cpcr or 75 mg F

INFANTS ADVIL SUSP (ibuprofen) NF

ketoprofen caps or 50 mg,75 mg F

KETOPROFEN ER CP24 F

ketorolac tromethamine tabs or 10 mg F QL(20 ea per

30 days retail)

LODINE TABS (etodolac) NF

meclofenamate sodium caps or 50 mg, 100 mg F

mefenamic acid caps or250 mg F

meloxicam tabs or 15 mg,7.5 mg F

MOBIC TABS (meloxicam) NF

MOTRIN CHILDRENS CHEW (ibuprofen) NF

MOTRIN INFANTS DROPS SUSP (ibuprofen) NF

nabumetone tabs or 500 mg, 750 mg F

NALFON CAPS 400 MG F

NALFON TABS 600 MG (fenoprofen calcium) NF

NAPROSYN SUSP (naproxen) NF

NAPROSYN TABS (naproxen) NF

naproxen sodium caps or220 mg F

naproxen sodium tabs or220 mg, 275 mg, 550 mg F

naproxen susp or 125mg/5ml F

naproxen tabs or 250 mg,375 mg, 500 mg F


3

Drug Name DrugTier

Requirements/Limits

naproxen tbec or 375 mg,500 mg F

oxaprozin tabs 600 mg F

piroxicam caps or 10 mg,20 mg F

sulindac tabs or 150 mg,200 mg F

tolmetin sodium caps F

tolmetin sodium tabs F

Phosphodiesterase 4 (PDE4) Inhibitors

OTEZLA TABS F PA; SP

OTEZLA TBPK F PA; SP

Pyrimidine Synthesis Inhibitors ARAVA TABS (leflunomide) NF

leflunomide tabs or 10 mg,20 mg F

Soluble Tumor Necrosis Factor Receptor Agents

ENBREL MINI SOCT F PA; SP

ENBREL SOLR F PA; SP

ENBREL SOSY F PA; SP

ENBREL SURECLICK SOAJ F PA; SP

ANALGESICS - NonNarcotic - Drugs to TreatPain, Muscle and Joint Conditions

Analgesic Combinations butalbital-acetaminophen-caffeine tabs 325 mg-50mg-40 mg

F QL(4 ea daily)

butalbital-aspirin-caffeinecaps 50 mg-40 mg-325 mg F QL(6 ea daily)

BUTALBITAL/ASPIRIN/CAFFEINE TABS 50 MG-40 MG-325 MG

F QL(6 ea daily)

ESGIC TABS (butalbital-acetaminophen-caffeine) NF QL(4 ea daily)

FIORINAL CAPS (butalbital-aspirin-caffeine) NF QL(6 ea daily)

Drug Name DrugTier

Requirements/Limits

Analgesics Other acetaminophen caps or500 mg F

acetaminophen chew or 80 mg F

acetaminophen elix or 160mg/5ml, 80 mg/2.5ml F

acetaminophen liqd or 160mg/5ml F

acetaminophen soln or 160mg/5ml, 650 mg/20.3ml,325 mg/10.15ml

F

acetaminophen supp re120 mg, 650 mg F

acetaminophen susp or160 mg/5ml, 80 mg/2.5ml,650 mg/20.3ml

F

acetaminophen tabs or 325mg, 500 mg F

FEVERALL JUNIOR STRENGTH SUPP F

TYLENOL CHILDRENS SUSP (acetaminophen) NF

TYLENOL EXTRA STRENGTH TABS (acetaminophen)

NF

TYLENOL INFANTS PAIN+FEVER SUSP (acetaminophen)

NF

TYLENOL INFANTS SUSP (acetaminophen) NF

TYLENOL TABS (acetaminophen) NF

Salicylates aspirin buffered (cal carb-mag carb-mag oxide) tabs F

aspirin chew or 81 mg F

ASPIRIN SUPP RE 300 MG, 600 MG F

aspirin tabs or 325 mg F

aspirin tbec or 81 mg, 324mg, 325 mg, 500 mg F


4

Drug Name DrugTier

Requirements/Limits

BUFFERIN TABS (aspirinbuffered (cal carb-magcarb-mag oxide))

NF

diflunisal tabs F

ECOTRIN MAXIMUM STRENGTH TBEC (aspirin)

NF

ECOTRIN REGULAR STRENGTH TBEC (aspirin)

NF

salsalate tabs or 500 mg,750 mg F

ANALGESICS - OPIOID - Drugs to Treat Pain,Muscle and Joint Conditions

Opioid Agonists DILAUDID LIQD OR 1 MG/ML (hydromorphonehcl)

NF QL(16 ml daily)

DILAUDID TABS OR 2 MG, 4 MG, 8 MG (hydromorphone hcl)

NF QL(6 ea daily)

DURAGESIC PT72 (fentanyl) NF PA

EMBEDA CPCR F PA

fentanyl pt72 12 mcg/hr, 25mcg/hr, 50 mcg/hr, 75mcg/hr, 100 mcg/hr

F PA

hydromorphone hcl liqd or1 mg/ml F QL(16 ml daily)

HYDROMORPHONE HCL SUPP RE 3 MG F

12 permonth;QL(0.4ea daily,12 eaper fill retail)

hydromorphone hcl tabs or2 mg, 4 mg, 8 mg F QL(6 ea daily)

meperidine hcl tabs or 50mg, 100 mg F

morphine sulfate soln or 10mg/5ml, 20 mg/5ml F

500 permonth;QL(16.67 ml daily)

morphine sulfate soln or 20mg/ml, 100 mg/5ml F

MORPHINE SULFATE SUPP RE 5 MG, 10 MG, 20 MG, 30 MG

F QL(6 ea daily)

Drug Name DrugTier

Requirements/Limits

morphine sulfate tabs or 15mg, 30 mg F QL(6 ea daily)

MORPHINE SULFATE TABS OR 15 MG, 30 MG (morphine sulfate)

NF QL(6 ea daily)

morphine sulfate tbcr or 15mg, 30 mg, 60 mg, 100 mg,200 mg

F PA

MS CONTIN TBCR (morphine sulfate) NF PA

oxycodone hcl caps or 5 mg F QL(6 ea daily)

oxycodone hcl conc or 100mg/5ml F QL(6 ml daily)

oxycodone hcl soln or 5mg/5ml F QL(6 ml daily)

oxycodone hcl tabs or 5mg, 10 mg, 15 mg, 20 mg,30 mg

F QL(6 ea daily)

ROXICODONE TABS (oxycodone hcl) NF QL(6 ea daily)

tramadol hcl tabs or 50 mg F QL(6 ea daily)

tramadol hcl tb24 or 100 mg, 200 mg, 300 mg F PA

ULTRAM TABS (tramadol hcl) NF QL(6 ea daily)

XTAMPZA ER C12A F PA

Opioid Combinations acetaminophen w/ codeinesoln 120 mg/5ml-12mg/5ml

F QL(16 ml daily)

acetaminophen w/ codeinetabs 300 mg-15 mg, 300mg-30 mg, 300 mg-60 mg

F QL(6 ea daily)

butalbital-acetaminophen-caffeine w/ codeine caps F QL(6 ea daily)

butalbital-aspirin-caffeinew/cod caps 50 mg-40 mg-30 mg-325 mg

F QL(6 ea daily)

FIORICET/CODEINECAPS (butalbital-acetaminophen-caffeine w/codeine)

NF

QL(6 ea daily)


5

Drug Name DrugTier

Requirements/Limits

FIORINAL/CODEINE #3CAPS (butalbital-aspirin-caffeine w/cod)

NF QL(6 ea daily)

hydrocodone-acetaminophen soln 2.5mg/5ml-108 mg/5ml, 5mg/10ml-217 mg/10ml, 7.5mg/15ml-325 mg/15ml

F

QL(16 ml daily)

hydrocodone-acetaminophen tabs 5 mg-300 mg, 5 mg-325 mg, 10mg-300 mg, 10 mg-325mg, 2.5 mg-325 mg, 7.5mg-300 mg, 7.5 mg-325 mg

F

QL(6 ea daily)

hydrocodone-ibuprofentabs F QL(6 ea daily)

NORCO TABS (hydrocodone-acetaminophen)

NF QL(6 ea daily)

oxycodone w/acetaminophen tabs 5 mg-325 mg, 10 mg-325 mg,2.5 mg-325 mg, 7.5 mg-325 mg

F

QL(6 ea daily)

oxycodone-aspirin tabs F QL(6 ea daily)

OXYCODONE/ASPIRINTABS F QL(6 ea daily)

PERCOCET TABS (oxycodone w/acetaminophen)

NF QL(6 ea daily)

PRIMLEV TABS 5 MG-300 MG, 10 MG-300 MG F QL(6 ea daily)

PROLATE TABS 5 MG-300 MG, 10 MG-300 MG F QL(6 ea daily)

ROXICET SOLN F 200 permonth;QL(6.67ml daily)

tramadol-acetaminophentabs 37.5 mg-325 mg F QL(3 ea daily)

TYLENOL/CODEINE #3TABS (acetaminophen w/codeine)

NF QL(6 ea daily)

TYLENOL/CODEINE #4TABS (acetaminophen w/codeine)

NF QL(6 ea daily)

Drug Name DrugTier

Requirements/Limits

ULTRACET TABS (tramadol-acetaminophen) NF QL(3 ea daily)

Opioid Partial Agonists

buprenorphine hcl subl sl 2 mg F

Smart PA Required;QL(12 ea daily)

buprenorphine hcl subl sl 8 mg F

Smart PA Required;QL(3ea daily)

buprenorphine hcl-naloxone hcl dihydrate subl2 mg-0.5 mg

F QL(12 ea daily)

buprenorphine hcl-naloxone hcl dihydrate subl8 mg-2 mg

F QL(3 ea daily)

BUTRANS PTWK (buprenorphine) F PA

SUBLOCADE SOSY F PA; SP

SUBOXONE FILM 12 MG-3 MG (buprenorphine hcl-naloxone hcl dihydrate)


SUBOXONE FILM 2 MG-0.5 MG (buprenorphine hcl-naloxone hcl dihydrate)

F QL(12 eadaily); AL(Atleast 6 yrs old)





ANDROGENS-ANABOLIC - Drugs to RegulateHormones

Androgens

ANDRODERM PT24 F PA

ANDROGEL GEL 25 MG/2.5GM, 40.5MG/2.5GM, 20.25MG/1.25GM (testosterone)

NF

PA

ANDROGEL PUMP GEL (testosterone) NF PA

danazol caps or 50 mg,100 mg, 200 mg F


6

Drug Name DrugTier

Requirements/Limits

DEPO-TESTOSTERONE SOLN (testosterone cypionate)

NF PA

testosterone cypionate solnim 100 mg/ml, 200 mg/ml F PA

testosterone enanthate soln im 200 mg/ml F PA

testosterone gel td 1.62 %,25 mg/2.5gm, 40.5mg/2.5gm, 20.25mg/1.25gm

F

PA

TESTOSTERONE GEL TD 25 MG/2.5GM F PA

testosterone soln td 30 mg/act F PA

ANORECTAL AND RELATED PRODUCTS -Rectal Drugs to Treat Pain, Swelling and Itching

Intrarectal Steroids CORTENEMA ENEM (hydrocortisone(intrarectal))

NF

CORTIFOAM FOAM F

hydrocortisone (intrarectal)enem 100 mg/60ml F

Rectal Combinations ANALPRAM HC CREA (hydrocortisone acetate w/pramoxine)

NF

ANALPRAM HC SINGLES CREA (hydrocortisoneacetate w/ pramoxine)

NF

ANALPRAM-HC CREA 1 %-1 % (hydrocortisoneacetate w/ pramoxine)

NF

hydrocortisone acetate w/pramoxine crea F

PROCORT CREA F

Rectal Steroids ANUSOL-HC CREA (hydrocortisone (rectal)) NF

hydrocortisone (rectal) crea F

Drug Name DrugTier

Requirements/Limits

PROCTOCORT CREA EX 1 % (hydrocortisone(rectal))

NF

ANTACIDS

Antacid Combinations alum & mag hydrox-simethicone liqd 200mg/5ml-20 mg/5ml-200mg/5ml, 400 mg/5ml-40mg/5ml-400 mg/5ml

F

alum & mag hydrox-simethicone susp 200mg/5ml-20 mg/5ml-200mg/5ml, 40 mg/5ml-400mg/5ml-400 mg/5ml, 400mg/5ml-40 mg/5ml-400mg/5ml, 1200 mg/30ml-120mg/30ml-1200 mg/30ml,2400 mg/30ml-240mg/30ml-2400 mg/30ml,400 mg/10ml-40 mg/10ml-400 mg/10ml-0.2 %, 200mg/5ml-200 mg/5ml-20mg/5ml-20 mg/5ml-200mg/5ml-200 mg/5ml, 400mg/5ml-400 mg/5ml-40mg/5ml-40 mg/5ml-400mg/5ml-400 mg/5ml

F

HYVEE ADVANCED ANTACID MAXIMUM STRENGTH SUSP (alum & mag hydrox-simethicone)

NF

Antacids - Aluminum Salts ALUMINUM HYDROXIDE SUSP OR F

Antacids - Calcium Salts

ANTACID CHEW F

ANTACID SOFT CHEWS CHEW F

calcium carbonate (antacid)chew 400 mg, 420 mg, 500mg, 750 mg, 1000 mg

F

CALCIUM CARBONATE TABS OR 648 MG F


7

Drug Name DrugTier

Requirements/Limits

CVS ANTACID SOFT CHEWS ULTRA STRENGTH CHEW

F

MAALOX CHEW F

TUMS CHEW (calcium carbonate (antacid)) NF

TUMS CHEWY BITES CHEW (calcium carbonate (antacid))

NF

TUMS CHEWY DELIGHTS CHEW F

TUMS E-X 750 CHEW (calcium carbonate (antacid))

NF

TUMS EXTRA STRENGTH 750 CHEW (calcium carbonate (antacid))

NF

TUMS KIDS CHEW (calcium carbonate (antacid))

NF

TUMS LASTING EFFECTS CHEW (calcium carbonate (antacid))

NF

TUMS SMOOTHIES CHEW (calcium carbonate (antacid))

NF

TUMS ULTRA 1000 CHEW (calcium carbonate (antacid))

NF

Antacids - Magnesium Salts magnesium oxide tabs 400 mg F

ANTHELMINTICS - Drugs to Treat WormInfections

Anthelmintics albendazole tabs or 200 mg F PA

ALBENZA TABS (albendazole) NF PA

BILTRICIDE TABS (praziquantel) NF

ivermectin tabs or 3 mg F PA

praziquantel tabs or 600 mg F

Drug Name DrugTier

Requirements/Limits

pyrantel pamoate susp or F

REESES PINWORM MEDICINE TABS F

STROMECTOL TABS (ivermectin) NF PA

ANTI-INFECTIVE AGENTS - MISC. - Drugs toTreat Bacterial Infections

Anti-infective Agents - Misc. AEMCOLO TBEC F

bacitracin solr im F

FIRST-METRONIDAZOLE 100 SUSR F

FIRST-METRONIDAZOLE 50 SUSR F

FLAGYL CAPS (metronidazole) NF

FLAGYL TABS (metronidazole) NF

IMPAVIDO CAPS F

METRONIDAZOLE BENZOATE/SYRSPENDSF PH4 SUSR

F

metronidazole caps or 375 mg F

metronidazole in nacl soln F

METRONIDAZOLE SOLN IV 0.74 %-500 MG/100ML(metronidazole in nacl)

NF

METRONIDAZOLE SOLN IV 5 MG/ML F

metronidazole tabs or 250 mg, 500 mg F

NEBUPENT SOLR (pentamidine isethionate) NF

PENTAM 300 SOLR (pentamidine isethionate) NF

pentamidine isethionatesolr 300 mg F

PRIMSOL SOLN F


8

Drug Name DrugTier

Requirements/Limits

TINDAMAX TABS (tinidazole) NF

tinidazole tabs or 250 mg,500 mg F

TRIMETHOPRIM POWD XX F

trimethoprim tabs or F

TRIMPEX SOLN F

vancomycin hcl solr F

XIFAXAN TABS F

Anti-infective Misc. - Combinations BACTRIM DS TABS (sulfamethoxazole-trimethoprim)

NF

BACTRIM TABS (sulfamethoxazole-trimethoprim)

NF

sulfamethoxazole-trimethoprim soln F

sulfamethoxazole-trimethoprim susp F

sulfamethoxazole-trimethoprim tabs F

Antiprotozoal Agents

ALINIA SUSR F

ALINIA TABS F

atovaquone susp or 750mg/5ml F

MEPRON SUSP (atovaquone) NF

Carbapenems

DORIPENEM SOLR F

imipenem-cilastatin solr F

meropenem solr F

MEROPENEM/SODIUMCHLORIDE SOLR F

Drug Name DrugTier

Requirements/Limits

MERREM SOLR (meropenem) NF

PRIMAXIN IV SOLR (imipenem-cilastatin) NF

RECARBRIO SOLR F

VABOMERE SOLR F

Chloramphenicols chloramphenicol sodiumsuccinate solr F

Cyclic Lipopeptides CUBICIN RF SOLR (daptomycin) NF

CUBICIN SOLR (daptomycin) NF

DAPTOMYCIN SOLR 350 MG F

DAPTOMYCIN SOLR 350 MG (daptomycin) NF

daptomycin solr 350 mg,500 mg F

Glycopeptides FIRST-VANCOMYCIN 25 SOLN F

FIRST-VANCOMYCIN 50 SOLN F

FIRVANQ SOLR F

VANCOCIN CAPS (vancomycin hcl) NF

VANCOCIN HCL CAPS (vancomycin hcl) NF

VANCOMYCIN HCL + SYRSPENDSF PH4 SUSP F

vancomycin hcl caps F

vancomycin hcl solr F


9

Drug Name DrugTier

Requirements/Limits

VANCOMYCIN HYDROCHLORIDE SOLN 1000 MG/10ML, 1500MG/15ML, 2000 MG/20ML,500 MG/100ML, 750MG/7.5ML, 1000MG/200ML, 1500MG/300ML, 1250MG/12.5ML, 1750MG/17.5ML

F

VANCOMYCIN HYDROCHLORIDE SOLR 1.5 GM, 750 MG, 1.25 GM

F

VANCOMYCIN HYDROCHLORIDE/DEXTROSE SOLN

F

VANCOMYCIN SOLN F

Leprostatics dapsone tabs or 25 mg,100 mg F

Lincosamides CLEOCIN CAPS OR 75 MG, 150 MG, 300 MG (clindamycin hcl)

NF

CLEOCIN IN D5W SOLN (clindamycin phosphate ind5w)

NF

CLEOCIN PEDIATRIC GRANULES SOLR (clindamycin palmitatehydrochloride)

NF

CLEOCIN PHOSPHATE SOLN IJ 9 GM/60ML, 300MG/2ML, 600 MG/4ML,900 MG/6ML (clindamycinphosphate)

NF

CLEOCIN PHOSPHATE SOLN IV 300 MG/2ML, 600MG/4ML, 900 MG/6ML

F

CLEOCIN PHOSPHATE SOLN IV 300 MG/50ML-5%, 600 MG/50ML-5 %(clindamycin phosphate ind5w)

NF

CLIN SINGLE USE KIT KIT F

Drug Name DrugTier

Requirements/Limits

clindamycin hcl caps or 75mg, 150 mg, 300 mg F

clindamycin palmitatehydrochloride solr 75mg/5ml

F

clindamycin phosphate ind5w soln F

clindamycin phosphate solnij 9 gm/60ml, 300 mg/2ml,600 mg/4ml, 900 mg/6ml,9000 mg/60ml

F

clindamycin phosphate solniv 300 mg/2ml, 600 mg/4ml,900 mg/6ml

F

CLINDAMYCIN/SODIUMCHLORIDE SOLN F

LINCOCIN SOLN (lincomycin hcl) NF

lincomycin hcl soln ij 300mg/ml F

Monobactams AZACTAM SOLR (aztreonam) NF

AZACTAMIN ISO-OSMOTIC DEXTROSE SOLN

F

aztreonam solr F

Oxazolidinones linezolid soln iv 600 mg/300ml F

LINEZOLID SOLN IV 600 MG/300ML-0.9 % F

linezolid susr or 100 mg/5ml F

linezolid tabs or 600 mg F

SIVEXTRO SOLR F

SIVEXTRO TABS F

ZYVOX SOLN IV 200 MG/100ML F

ZYVOX SOLN IV 600 MG/300ML (linezolid) NF


10

Drug Name DrugTier

Requirements/Limits

ZYVOX SUSR OR 100 MG/5ML (linezolid) NF

ZYVOX TABS OR 600 MG (linezolid) NF

Pleuromutilins

XENLETA SOLN F

Polymyxins colistimethate sodium solr ij150 mg F

COLY-MYCIN M SOLR (colistimethate sodium) NF

POLYMYXIN B SULFATE POWD XX 100 MU, F

polymyxin b sulfate solr ij500000 unit F

Streptogramins

SYNERCID SOLR F

ANTIANGINAL AGENTS - Drugs to Treat ChestPain

Antianginals-Other RANEXA TB12 (ranolazine) NF PA

ranolazine tb12 F PA

Nitrates

DILATRATE SR CPCR F

ISORDIL TITRADOSE TABS 5 MG (isosorbide dinitrate)

NF MP

isosorbide dinitrate tabs 5 mg, 10 mg, 20 mg, 30 mg F MP

isosorbide dinitrate tbcr 40 mg F MP

isosorbide mononitrate tabs F MP

isosorbide mononitrate tb24 F MP

NITRO-BID OINT F

Drug Name DrugTier

Requirements/Limits

NITRO-DUR PT24 0.1 MG/HR, 0.2 MG/HR, 0.4MG/HR, 0.6 MG/HR(nitroglycerin)

NF

MP

NITRO-DUR PT24 0.3 MG/HR, 0.8 MG/HR F

nitroglycerin cpcr or 9 mg,2.5 mg, 6.5 mg F MP

nitroglycerin pt24 td 0.1mg/hr, 0.2 mg/hr, 0.4mg/hr, 0.6 mg/hr

F MP

nitroglycerin subl sl 0.3 mg,0.4 mg, 0.6 mg F MP

NITROSTAT SUBL (nitroglycerin) NF MP

ANTIANXIETY AGENTS - Drugs to Treat Anxiety

Antianxiety Agents - Misc.

buspirone hcl tabs or 30 mg F


buspirone hcl tabs or 5 mg,10 mg, 15 mg, 7.5 mg F


hydroxyzine hcl syrp or 10mg/5ml F QL(10 ml daily)

hydroxyzine hcl tabs or 10mg, 25 mg, 50 mg F QL(8 ea daily)

hydroxyzine pamoate capsor 25 mg, 50 mg, 100 mg F QL(4 ea daily)

VISTARIL CAPS (hydroxyzine pamoate) NF QL(4 ea daily)

Benzodiazepines

ALPRAZOLAM INTENSOL CONC F

Limit 1 anxiolytic per30 days;QL(60ml per 15 daysretail); AL(Atleast 6 yrs old)

alprazolam tabs or 0.25mg, 0.5 mg, 1 mg F

Limit 1 anxiolytic per30 days;QL(4ea daily); AL(Atleast 6 yrs old)


11

Drug Name DrugTier

Requirements/Limits

alprazolam tabs or 2 mg F


alprazolam tb24 or 0.5 mg,1 mg, 2 mg, 3 mg F


alprazolam tbdp or 0.25mg, 0.5 mg, 1 mg F


alprazolam tbdp or 2 mg F


ATIVAN TABS OR 0.5 MG, 1 MG (lorazepam) NF


ATIVAN TABS OR 2 MG (lorazepam) NF


chlordiazepoxide hcl caps F QL(2 ea daily);AL(At least 6yrs old)

clorazepate dipotassiumtabs 15 mg F


clorazepate dipotassiumtabs 7.5 mg, 3.75 mg F


diazepam conc or 5 mg/ml F QL(2 ml daily)

diazepam soln or 5 mg/5ml F QL(10 ml daily)

diazepam tabs or 2 mg, 5mg, 10 mg F


lorazepam conc or 2 mg/ml F QL(2 ml daily);AL(At least 6yrs old)

Drug Name DrugTier

Requirements/Limits

lorazepam tabs or 0.5 mg,1 mg F


lorazepam tabs or 2 mg F


oxazepam caps F QL(2 ea daily);AL(At least 6yrs old)

TRANXENE T TABS (clorazepate dipotassium) NF


VALIUM TABS (diazepam) NF QL(4 ea daily);AL(At least 6yrs old)

XANAX TABS 0.25 MG, 0.5 MG, 1 MG (alprazolam) NF


XANAX TABS 2 MG (alprazolam) NF


XANAX XR TB24 (alprazolam) NF


ANTIARRHYTHMICS - Drugs to treat abnormalheart rhythms

Antiarrhythmics Type I-A disopyramide phosphate caps F

NORPACE CAPS (disopyramide phosphate) NF

NORPACE CR CP12 F

quinidine gluconate tbcr or324 mg F

quinidine sulfate tabs or200 mg, 300 mg F

Antiarrhythmics Type I-B


12

Drug Name DrugTier

Requirements/Limits

mexiletine hcl caps 150mg, 200 mg, 250 mg F

Antiarrhythmics Type I-C

flecainide acetate tabs F

propafenone hcl cp12 F

propafenone hcl tabs F

RYTHMOL SR CP12 (propafenone hcl) NF

Antiarrhythmics Type III amiodarone hcl tabs or 100 mg, 200 mg F

CORDARONE TABS (amiodarone hcl) NF

dofetilide caps F PA

MULTAQ TABS F PA

TIKOSYN CAPS (dofetilide) NF PA

ANTIASTHMATIC AND BRONCHODILATOR AGENTS - Drugs to Treat Lung Conditions

Anti-Inflammatory Agents CROMOLYN SODIUM NEBU IN F

cromolyn sodium nebu in F

CROMOLYN SODIUM POWD XX F

Bronchodilators - Anticholinergics

ATROVENT HFA AERS F

INCRUSE ELLIPTA AEPB F

IPRATROPIUM BROMIDE MONOHYDRATE POWD F

IPRATROPIUM BROMIDE POWD XX F

ipratropium bromide soln in F

LONHALA MAGNAIR REFILL KIT SOLN F

LONHALA MAGNAIR STARTER KIT SOLN F

Drug Name DrugTier

Requirements/Limits

SEEBRI NEOHALER CAPS F

SPIRIVA HANDIHALER CAPS F QL(1 ea daily)

SPIRIVA RESPIMAT AERS F

TUDORZA PRESSAIR AEPB F

YUPELRI SOLN F

Leukotriene Modulators ACCOLATE TABS (zafirlukast) NF

montelukast sodium chew or 4 mg, 5 mg F QL(1 ea daily)

montelukast sodium packor 4 mg F

QL(1 ea daily);AL(Up to 3 yrsold )

montelukast sodium tabs or 10 mg F QL(1 ea daily)

SINGULAIR CHEW 4 MG, 5 MG (montelukast sodium) NF QL(1 ea daily)

SINGULAIR PACK 4 MG (montelukast sodium) NF

QL(1 ea daily);AL(Up to 3 yrsold )

SINGULAIR TABS 10 MG (montelukast sodium) NF QL(1 ea daily)

zafirlukast tabs F

Selective Phosphodiesterase 4 (PDE4) Inhibitors

DALIRESP TABS F

Steroid Inhalants

ALVESCO AERS F

ARMONAIR RESPICLICK 113 AEPB F



ARNUITY ELLIPTA AEPB F

ASMANEX HFA AERO F


13

Drug Name DrugTier

Requirements/Limits

ASMANEX TWISTHALER 120 METERED DOSES AEPB

F


F


F


F


F

budesonide (inhalation) susp F AL(Up to 4 yrs

old )

FLOVENT DISKUS AEPB F

FLOVENT HFA AERO F

FLUNISOLIDE ANHYDROUS POWD F

PULMICORT FLEXHALER AEPB F

PULMICORT SUSP 0.25 MG/2ML, 0.5 MG/2ML(budesonide (inhalation))

F AL(Up to 4 yrsold )

PULMICORT SUSP 1 MG/2ML (budesonide (inhalation))

NF AL(Up to 4 yrsold )

Sympathomimetics

ADVAIR HFA AERO F

AIRDUO RESPICLICK 113/14 AEPB F



albuterol sulfate aers in 108 mcg/act F

6 rtl pack lmtamt,90 rtl packlmt day(s),

ALBUTEROL SULFATE NEBU IN 0.5 % F

Drug Name DrugTier

Requirements/Limits

albuterol sulfate nebu in 0.63 mg/3ml, 0.083 %, 0.5%, 1.25 mg/3ml, 2.5mg/0.5ml

F

ALBUTEROL SULFATE POWD XX F

albuterol sulfate syrp or 2mg/5ml F

albuterol sulfate tb12 or 4 mg, 8 mg F

ANORO ELLIPTA AEPB F

ARCAPTA NEOHALER CAPS F

BEVESPI AEROSPHERE AERO F

BREO ELLIPTA AEPB F

BROVANA NEBU F

budesonide-formoterol fumarate dihydrate aero F

COMBIVENT RESPIMAT AERS F

1 rtl pack lmtamt,30 rtl packlmt day(s),

DUAKLIR PRESSAIR AEPB F

DULERA AERO F

EPHEDRINE HCL POWD F

EPHEDRINE SULFATE POWD XX F

FLUTICASONE PROPIONATE/SALMETEROL AEPB

F

ipratropium-albuterol soln F

isoproterenol hcl soln ij 0.2mg/ml F

ISUPREL SOLN (isoproterenol hcl) NF

levalbuterol tartrate aero F

METAPROTERENOL SULFATE POWD XX F


14

Drug Name DrugTier

Requirements/Limits

metaproterenol sulfate syrpor 10 mg/5ml F

metaproterenol sulfate tabsor 10 mg, 20 mg F

PERFOROMIST NEBU F

PROAIR DIGIHALER AEPB F

PROAIR HFA AERS F 6 rtl pack lmtamt,90 rtl packlmt day(s),

PROAIR RESPICLICK AEPB F

racepinephrine hcl nebu in2.25 % F

S2 NEBU (racepinephrinehcl) NF

SEREVENT DISKUS AEPB F

STIOLTO RESPIMAT AERS F

STRIVERDI RESPIMAT AERS F

SYMBICORT AERO F

TERBUTALINE SULFATE POWD XX F

terbutaline sulfate soln ij 1mg/ml F

terbutaline sulfate tabs or 5 mg, 2.5 mg F

TRELEGY ELLIPTA AEPB F

UTIBRON NEOHALER CAPS F

XOPENEX HFA AERO F

Xanthines AMINOPHYLLINE ANHYDROUS POWD F

AMINOPHYLLINE POWD XX F

aminophylline soln iv F

ELIXOPHYLLIN ELIX F

Drug Name DrugTier

Requirements/Limits

THEO-24 CP24 F

THEOPHYLLINE ETHYLENEDIAMINE EP POWD

F

theophylline soln F

theophylline tb12 F

theophylline tb24 F

THEOPHYLLINE/D5WSOLN F

ANTICOAGULANTS - Blood Thinners

Coumarin Anticoagulants COUMADIN TABS (warfarin sodium) NF

warfarin sodium tabs F

Direct Factor Xa Inhibitors ELIQUIS STARTER PACK TABS F QL(74 ea per

30 days retail)

ELIQUIS TABS 2.5 MG F QL(2 ea daily)

ELIQUIS TABS 5 MG F QL(74 ea per30 days retail)

XARELTO STARTER PACK TBPK F

51 per monthQL(1.7 eadaily)

XARELTO TABS F QL(2 ea daily)

Heparins And Heparinoid-Like Agents

enoxaparin sodium soln ij300 mg/3ml F

QL(180 ml per30 days retail);SP

enoxaparin sodium soln sc100 mg/ml, 150 mg/ml F


enoxaparin sodium soln sc30 mg/0.3ml F





15

Drug Name DrugTier

Requirements/Limits



enoxaparin sodium soln sc80 mg/0.8ml, 120 mg/0.8ml F


heparin (porcine) in sodiumchloride soln F

HEPARIN LOCK FLUSH SOLN NF

HEPARIN LOCK FLUSH SOLN F

heparin sod (porcine) ind5w soln F

heparin sodium (porcine)lock flush soln F

heparin sodium (porcine)soln F

HEPARIN SODIUM/D5WSOLN 100 UNIT/ML-5 %, 5%-12500 UNIT/250ML, 5%-25000 UNIT/500ML

F

HEPARIN SODIUM/D5WSOLN 5 %-12500 UNIT/250ML

NF

HEPARIN SODIUM/DEXTROSESOLN 25000 UNIT/250ML-5 %, 5 %-25000 UNIT/500ML

F

HEPARIN SODIUM/NACL0.45% SOLN 12500 UNIT/250ML-0.45 %

F

HEPARIN SODIUM/SODIUMCHLORIDE 0.9% SOLN (heparin (porcine) in sodium chloride)

NF

HEPARIN SODIUM/SODIUMCHLORIDE SOLN 2000 UNIT/L-0.9 %, 1000UNIT/500ML-0.9 %

F

LOVENOX SOLN IJ 300 MG/3ML (enoxaparinsodium)

NF QL(180 ml per30 days retail);SP

Drug Name DrugTier

Requirements/Limits

LOVENOX SOLN SC 100 MG/ML, 150 MG/ML(enoxaparin sodium)


LOVENOX SOLN SC 30 MG/0.3ML (enoxaparinsodium)






LOVENOX SOLN SC 80 MG/0.8ML, 120 MG/0.8ML(enoxaparin sodium)


Thrombin Inhibitors

PRADAXA CAPS F QL(2 ea daily)

ANTICONVULSANTS - Drugs to Treat Seizures

Anticonvulsants - Benzodiazepines

clobazam susp F PA

clobazam tabs F PA

clonazepam tabs or 0.5mg, 1 mg F


clonazepam tabs or 2 mg F QL(2 ea daily);AL(At least 6yrs old)

clonazepam tbdp or 0.125mg, 0.25 mg, 0.5 mg, 1 mg F


clonazepam tbdp or 2 mg F QL(2 ea daily);AL(At least 6yrs old)

DIASTAT ACUDIAL GEL 10 MG F QL(2 ea per 30

days retail) DIASTAT ACUDIAL GEL 20 MG F QL(2 ea per 30

days retail)

DIASTAT PEDIATRIC GEL F QL(2 ea per 30days retail)

diazepam (anticonvulsant)gel F QL(2 ea per 30

days retail)


16

Drug Name DrugTier

Requirements/Limits

KLONOPIN TABS 0.5 MG, 1 MG (clonazepam) NF


KLONOPIN TABS 2 MG (clonazepam) NF


ONFI SUSP (clobazam) NF PA

ONFI TABS (clobazam) NF PA

Anticonvulsants - Misc. BANZEL SUSP F PA; SP

BANZEL TABS F PA; SP

carbamazepine chew or100 mg F

carbamazepine cp12 or100 mg, 200 mg, 300 mg F

carbamazepine susp or100 mg/5ml F

carbamazepine tabs or 200 mg F

carbamazepine tb12 or 100mg, 200 mg, 400 mg F

CARBATROL CP12 (carbamazepine) NF

gabapentin caps or 100mg, 300 mg, 400 mg F

gabapentin soln or 250mg/5ml, 300 mg/6ml F

gabapentin tabs or 600 mg,800 mg F

KEPPRA SOLN OR 100 MG/ML (levetiracetam) NF

KEPPRA TABS OR 250 MG, 500 MG, 750 MG, 1000 MG (levetiracetam)

NF

KEPPRA XR TB24 (levetiracetam) NF

LAMICTAL CHEWABLE DISPERSIBLE CHEW (lamotrigine)

NF

LAMICTAL ODT TBDP 25 MG, 50 MG, 100 MG, 200 MG (lamotrigine)

NF

Drug Name DrugTier

Requirements/Limits

LAMICTAL TABS (lamotrigine) NF

LAMICTAL XR TB24 200 MG, 250 MG, 300 MG (lamotrigine)

NF QL(2 ea daily)

LAMICTAL XR TB24 25 MG, 50 MG, 100 MG (lamotrigine)

NF QL(3 ea daily)

lamotrigine chew or 5 mg,25 mg F

lamotrigine tabs or 25 mg,100 mg, 150 mg, 200 mg F

lamotrigine tb24 or 200 mg,250 mg, 300 mg F QL(2 ea daily)

lamotrigine tb24 or 25 mg,50 mg, 100 mg F QL(3 ea daily)

lamotrigine tbdp or 25 mg,50 mg, 100 mg, 200 mg F

levetiracetam soln or 100 mg/ml, 500 mg/5ml F

levetiracetam tabs or 250 mg, 500 mg, 750 mg, 1000 mg

F

levetiracetam tb24 or 500 mg, 750 mg F

LYRICA CAPS (pregabalin) NF PA

LYRICA SOLN (pregabalin) NF PA

MYSOLINE TABS (primidone) NF

NEURONTIN CAPS (gabapentin) NF

NEURONTIN SOLN (gabapentin) NF

NEURONTIN TABS (gabapentin) NF

oxcarbazepine susp F

oxcarbazepine tabs F

pregabalin caps or 25 mg,50 mg, 75 mg, 100 mg, 150mg, 200 mg, 225 mg, 300 mg

F

PA

pregabalin soln or 20mg/ml F PA


17

Drug Name DrugTier

Requirements/Limits

primidone tabs or 50 mg,250 mg F

TEGRETOL SUSP (carbamazepine) NF

TEGRETOL TABS (carbamazepine) NF

TEGRETOL-XR TB12 (carbamazepine) NF

TOPAMAX SPRINKLE CPSP (topiramate) NF

TOPAMAX TABS (topiramate) NF

topiramate cpsp or 15 mg,25 mg F

topiramate tabs or 25 mg,50 mg, 100 mg, 200 mg F

TRILEPTAL SUSP (oxcarbazepine) NF

TRILEPTAL TABS (oxcarbazepine) NF

VIMPAT SOLN OR 10 MG/ML F PA

VIMPAT TABS OR 50 MG, 100 MG, 150 MG, 200 MG F PA

ZONEGRAN CAPS (zonisamide) NF

zonisamide caps or 25 mg,50 mg, 100 mg F

Carbamates felbamate susp 600mg/5ml F

felbamate tabs 400 mg F QL(9 ea daily)

felbamate tabs 600 mg F QL(6 ea daily)

FELBATOL SUSP 600 MG/5ML (felbamate) NF

FELBATOL TABS 400 MG (felbamate) NF QL(9 ea daily)

FELBATOL TABS 600 MG (felbamate) NF QL(6 ea daily)

GABA Modulators GABITRIL TABS (tiagabinehcl) NF PA

tiagabine hcl tabs F PA

Drug Name DrugTier

Requirements/Limits

Hydantoins DILANTIN CAPS 100 MG (phenytoin sodiumextended)

NF

DILANTIN CAPS 30 MG F

DILANTIN INFATABS CHEW (phenytoin) NF

DILANTIN-125 SUSP (phenytoin) NF

PHENYTEK CAPS (phenytoin sodiumextended)

NF

phenytoin chew or 50 mg F

phenytoin sodium extended caps F

phenytoin susp or 100mg/4ml, 125 mg/5ml F

Succinimides ethosuximide caps or 250 mg F

ethosuximide soln or 250 mg/5ml F

ZARONTIN CAPS (ethosuximide) NF

ZARONTIN SOLN (ethosuximide) NF

Valproic Acid DEPAKENE CAPS (valproic acid) NF

DEPAKENE SOLN (valproate sodium) NF

DEPAKOTE ER TB24 (divalproex sodium) NF

DEPAKOTE SPRINKLES CSDR (divalproex sodium) NF

DEPAKOTE TBEC 125 MG, 250 MG (divalproexsodium)

NF QL(16 ea daily)

DEPAKOTE TBEC 500 MG (divalproex sodium) NF QL(8 ea daily)

divalproex sodium csdr or125 mg F


18

Drug Name DrugTier

Requirements/Limits

divalproex sodium tb24 or250 mg, 500 mg F

divalproex sodium tbec or125 mg, 250 mg F QL(16 ea daily)

divalproex sodium tbec or500 mg F QL(8 ea daily)

valproate sodium soln or250 mg/5ml F

valproic acid caps or 250 mg F

ANTIDEPRESSANTS - Drugs to TreatDepression

Alpha-2 Receptor Antagonists (Tetracyclics)

mirtazapine tabs or 15 mg,30 mg, 45 mg F


mirtazapine tabs or 7.5 mg F QL(1 ea daily)

mirtazapine tbdp or 15 mg,30 mg, 45 mg F


REMERON SOLTAB TBDP (mirtazapine) NF


REMERON TABS (mirtazapine) NF


Antidepressants - Misc.

bupropion hcl tabs or 75mg, 100 mg F


bupropion hcl tb12 or 100mg, 150 mg, 200 mg F


bupropion hcl tb24 or 150mg, 300 mg F


maprotiline hcl tabs F AL(At least 6yrs old)

WELLBUTRIN SR TB12 (bupropion hcl) NF


WELLBUTRIN XL TB24 (bupropion hcl) NF


N-Methyl-D-aspartic acid (NMDA) Receptor

Drug Name DrugTier

Requirements/Limits

SPRAVATO 56MG DOSE SOPK F PA; SP

SPRAVATO 84MG DOSE SOPK F PA; SP

Selective Serotonin Reuptake Inhibitors (SSRIs)

CELEXA TABS 10 MG (citalopram hydrobromide) NF


CELEXA TABS 20 MG, 40 MG (citalopramhydrobromide)


citalopram hydrobromidesoln 10 mg/5ml F

QL(20 mldaily); AL(Atleast 6 yrs old -Up to 12 yrsold)

citalopram hydrobromidetabs 10 mg F


citalopram hydrobromidetabs 20 mg, 40 mg F


escitalopram oxalate tabs10 mg F

45 permonth;QL(1.5ea daily); AL(Atleast 6 yrs old)

escitalopram oxalate tabs20 mg F


escitalopram oxalate tabs 5 mg F


fluoxetine hcl caps or 10mg, 40 mg F


fluoxetine hcl caps or 20 mg F


fluoxetine hcl soln or 20 mg/5ml F


FLUOXETINE HYDROCHLORIDE TABS (fluoxetine hcl)

NF QL(1 ea daily)


19

Drug Name DrugTier

Requirements/Limits

fluvoxamine maleate tabs 100 mg F






LEXAPRO TABS 10 MG (escitalopram oxalate) NF






paroxetine hcl tabs 10 mg,20 mg, 30 mg F


paroxetine hcl tabs 40 mg F


PAXIL TABS 10 MG, 20 MG, 30 MG (paroxetinehcl)


PAXIL TABS 40 MG (paroxetine hcl) NF


PROZAC CAPS 10 MG, 40 MG (fluoxetine hcl) NF


PROZAC CAPS 20 MG (fluoxetine hcl) NF


sertraline hcl conc or 20 mg/ml F


sertraline hcl tabs or 100 mg F


Drug Name DrugTier

Requirements/Limits

sertraline hcl tabs or 25 mg F QL(3 ea daily);AL(At least 6yrs old)

sertraline hcl tabs or 50 mg F QL(4 ea daily);AL(At least 6yrs old)

ZOLOFT CONC 20 MG/ML(sertraline hcl) NF


ZOLOFT TABS 100 MG (sertraline hcl) NF






Serotonin Modulators

trazodone hcl tabs or 100 mg F








Serotonin-Norepinephrine Reuptake Inhibitors

CYMBALTA CPEP 20 MG, 30 MG (duloxetine hcl) NF


CYMBALTA CPEP 60 MG (duloxetine hcl) NF


duloxetine hcl cpep or 20mg, 30 mg F


duloxetine hcl cpep or 60 mg F



20

Drug Name DrugTier

Requirements/Limits

EFFEXOR XR CP24 150 MG (venlafaxine hcl) NF


EFFEXOR XR CP24 75 MG, 37.5 MG (venlafaxine hcl)


venlafaxine hcl cp24 150 mg F


venlafaxine hcl cp24 75mg, 37.5 mg F


venlafaxine hcl tabs 25 mg F QL(4 ea daily);AL(At least 6yrs old)

venlafaxine hcl tabs 50 mg,100 mg, 37.5 mg F


venlafaxine hcl tabs 75 mg F QL(5 ea daily);AL(At least 6yrs old)

Tricyclic Agents amitriptyline hcl tabs or 10mg, 25 mg, 50 mg, 75 mg,100 mg, 150 mg

F AL(At least 6yrs old)

amoxapine tabs F AL(At least 6yrs old)

ANAFRANIL CAPS (clomipramine hcl) NF AL(At least 6

yrs old) clomipramine hcl caps or25 mg, 50 mg, 75 mg F AL(At least 6

yrs old) desipramine hcl tabs or 10mg, 25 mg, 50 mg, 75 mg,100 mg, 150 mg


doxepin hcl caps or 10 mg,25 mg, 50 mg, 75 mg, 100mg, 150 mg


doxepin hcl conc or 10mg/ml F

QL(6 ml daily);AL(At least 6yrs old)

imipramine hcl tabs or 10mg, 25 mg, 50 mg F AL(At least 6

yrs old)

imipramine pamoate caps F AL(At least 6yrs old)

NORPRAMIN TABS (desipramine hcl) NF AL(At least 6

yrs old)

Drug Name DrugTier

Requirements/Limits

nortriptyline hcl caps or 10mg, 25 mg, 50 mg, 75 mg F AL(At least 6

yrs old) nortriptyline hcl soln or 10mg/5ml F AL(At least 6

yrs old) PAMELOR CAPS (nortriptyline hcl) NF AL(At least 6

yrs old)

protriptyline hcl tabs F AL(At least 6yrs old)

SURMONTIL CAPS (trimipramine maleate) NF AL(At least 6

yrs old) TOFRANIL TABS (imipramine hcl) NF AL(At least 6

yrs old) trimipramine maleate capsor 25 mg, 50 mg, 100 mg F AL(At least 6

yrs old) ANTIDIABETICS - Drugs to Regulate BloodSugar Alpha-Glucosidase Inhibitors

acarbose tabs F MP

PRECOSE TABS (acarbose) NF MP

Antidiabetic - Amylin Analogs

SYMLINPEN 120 SOPN F PA

SYMLINPEN 60 SOPN F PA

Antidiabetic Combinations ACTOPLUS MET TABS (pioglitazone hcl-metforminhcl)

NF MP

ACTOPLUS MET XR TB24 F

GLUCOVANCE TABS (glyburide-metformin) NF MP

glyburide-metformin tabs F MP

GLYXAMBI TABS F PA

JANUMET TABS F PA

JANUMET XR TB24 F PA

JENTADUETO TABS F PA

KOMBIGLYZE XR TB24 F PA


21

Drug Name DrugTier

Requirements/Limits

pioglitazone hcl-metforminhcl tabs F MP

Biguanides GLUCOPHAGE TABS (metformin hcl) NF MP

GLUCOPHAGE XR TB24 (metformin hcl) NF MP

metformin hcl tabs or 500 mg, 850 mg, 1000 mg F MP

metformin hcl tb24 or 500 mg, 750 mg F MP

Diabetic Other CVS GLUCOSE BITS CHEW F

CVS GLUCOSE CHEW 4 GM F

CVS SOFT GLUCOSE CHEW F

DEX4 FAST ACTING GLUCOSEGO-POUCH GEL

F

DEX4 QUICK DISSOLVE GLUCOSE CHEW F

dextrose (diabetic use) gel40 %, 15 gm/38gm F MP

GLUCAGON EMERGENCY KIT KIT F

1 permonth;QL(0.034 ea daily)

GLUCOSE CHEW 4 GM F

GLUCOSE GEL 15 GM/33GM F

GNP GLUCOSE CHEW 4 GM F

GNP QUICK DISSOLVE GLUCOSE CHEW F

INSTA-GLUCOSE GEL F

LEADER QUICK DISSOLVE GLUCOSE CHEW

F

SM GLUCOSE CHEW 4 GM F

WALGREENS GLUCOSE CHEW 4 GM F

Drug Name DrugTier

Requirements/Limits

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors

JANUVIA TABS F PA

ONGLYZA TABS F PA

TRADJENTA TABS F PA

Incretin Mimetic Agents (GLP-1 Receptor BYDUREON PEN PEN F PA

BYDUREON SRER F PA

BYETTA SOPN F PA

VICTOZA SOPN F PA

Insulin Sensitizing Agents ACTOS TABS (pioglitazonehcl) NF MP

pioglitazone hcl tabs F MP

Insulin

HUMALOG KWIKPEN SOPN 100 UNIT/ML F

Limit 1.0 ml perday;QL(1 mldaily)

HUMALOG MIX 50/50KWIKPEN SUPN F


HUMALOG MIX 50/50SUSP F


HUMALOG MIX 75/25KWIKPEN SUPN F


HUMALOG MIX 75/25SUSP F


HUMALOG SOLN 100 UNIT/ML F


HUMULIN 70/30 SUSP 70UNIT/ML-30 UNIT/ML F


HUMULIN N SUSP 100 UNIT/ML F



22

Drug Name DrugTier

Requirements/Limits

HUMULIN R SOLN F Limit 1.0 ml perday;QL(1 mldaily)

HUMULIN R U-500 (CONCENTRATED) SOLN F PA

HUMULIN R U-500 KWIKPEN SOPN F PA

LANTUS SOLN 100 UNIT/ML F


LANTUS SOLOSTAR SOPN 100 UNIT/ML F


LEVEMIR FLEXTOUCH SOPN F


LEVEMIR SOLN F Limit 1.0 ml perday;QL(1 mldaily)

NOVOLIN 70/30 SUSP 70UNIT/ML-30 UNIT/ML F


NOVOLIN N SUSP 100 UNIT/ML F


NOVOLIN R SOLN F Limit 1.0 ml perday;QL(1 mldaily)

NOVOLOG FLEXPEN SOPN 100 UNIT/ML F


NOVOLOG MIX 70/30PREFILLED FLEXPEN SUPN

F Limit 1.0 ml perday;QL(1 mldaily)

NOVOLOG MIX 70/30SUSP F


NOVOLOG PENFILL SOCT 100 UNIT/ML F


NOVOLOG SOLN 100 UNIT/ML F


Meglitinide Analogues

nateglinide tabs F MP

Drug Name DrugTier

Requirements/Limits

PRANDIN TABS (repaglinide) NF MP

repaglinide tabs F MP

STARLIX TABS (nateglinide) NF MP

Sodium-Glucose Co-Transporter 2 (SGLT2) FARXIGA TABS F PA

INVOKANA TABS F PA

JARDIANCE TABS F PA

Sulfonylureas AMARYL TABS (glimepiride) NF MP

glimepiride tabs F MP

glipizide tabs or 5 mg, 10 mg F MP

glipizide tb24 or 5 mg, 10mg, 2.5 mg F MP

GLUCOTROL TABS (glipizide) NF MP

GLUCOTROL XL TB24 (glipizide) NF MP

glyburide micronized tabs F MP

glyburide tabs or 5 mg, 2.5mg, 1.25 mg F MP

GLYNASE TABS (glyburidemicronized) NF MP

tolazamide tabs F MP

TOLBUTAMIDE TABS F

ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugsto Treat Diarrhea

Antidiarrheal/Probiotic Agents - Misc. bismuth subsalicylate chewor 262 mg F

bismuth subsalicylate suspor 262 mg/15ml, 525mg/15ml, 525 mg/30ml,527 mg/30ml, 1050mg/30ml

F


23

Drug Name DrugTier

Requirements/Limits

bismuth subsalicylate tabsor 262 mg F

FORTIFY OPTIMA PROBIOTIC CPDR F

FORTIFY PROBIOTIC WOMENSEXTRA STRENGTH CPDR

F

MVW COMPLETE PROBIOTIC FORMULATION CPDR

F

NEXABIOTIC CPDR F

PEPTO BISMOL TABS (bismuth subsalicylate) NF

PEPTO-BISMOL CHEW (bismuth subsalicylate) NF

PEPTO-BISMOL MAX STRENGTH SUSP (bismuth subsalicylate)

NF

PEPTO-BISMOL SUSP (bismuth subsalicylate) NF

PEPTO-BISMOL TO-GO CHEW (bismuth subsalicylate)

NF

Antiperistaltic Agents diphenoxylate w/ atropineliqd F

diphenoxylate w/ atropinetabs F

IMODIUM A-D CAPS 2 MG (loperamide hcl) NF RX/OTC

IMODIUM A-D LIQD 1 MG/7.5ML (loperamide hcl) NF

IMODIUM A-D TABS 2 MG (loperamide hcl) NF

LOMOTIL TABS (diphenoxylate w/ atropine) NF

loperamide hcl caps or 2 mg F RX/OTC

loperamide hcl liqd or 1mg/5ml, 1 mg/7.5ml F

loperamide hcl susp or 1mg/7.5ml F

loperamide hcl tabs or 2 mg F

Drug Name DrugTier

Requirements/Limits

ANTIDOTES AND SPECIFIC ANTAGONISTS

Opioid Antagonists NALOXONE HCL SOCT IJ 0.4 MG/ML F

naloxone hcl soln ij 0.4mg/ml, 4 mg/10ml F

naloxone hcl sosy ij 2mg/2ml F

naltrexone hcl tabs or F

NARCAN LIQD F

VIVITROL SUSR F SP

ANTIEMETICS - Drugs to Treat Nausea andVomiting

5-HT3 Receptor Antagonists

ANZEMET TABS F PA

granisetron hcl tabs or 1 mg F PA

ondansetron hcl soln or 4 mg/5ml F

ondansetron hcl tabs or 4 mg, 8 mg F QL(3 ea daily)

ondansetron tbdp F QL(1 ea daily)

ZOFRAN ODT TBDP (ondansetron) NF QL(1 ea daily)

ZOFRAN SOLN 4 MG/5ML(ondansetron hcl) NF

ZOFRAN TABS 4 MG, 8 MG (ondansetron hcl) NF QL(3 ea daily)

Antiemetics - Anticholinergic dimenhydrinate tabs or 50 mg F

DRAMAMINE CHEW 50 MG F

DRAMAMINE TABS (dimenhydrinate) NF

meclizine hcl chew or 25 mg F

meclizine hcl tabs or 25 mg, 12.5 mg F RX/OTC


24

Drug Name DrugTier

Requirements/Limits

TIGAN CAPS OR 300 MG (trimethobenzamide hcl) NF

trimethobenzamide hcl caps or 300 mg F

Substance P/Neurokinin 1 (NK1) Receptor aprepitant caps 40 mg, 80 mg, F QL(6 ea per 21

days retail) EMEND CAPS OR 40 MG, 80 MG (aprepitant) NF QL(6 ea per 21

days retail) EMEND TRIPACK CAPS (aprepitant) NF QL(6 ea per 21

days retail)

ANTIFUNGALS - Drugs to Treat Fungal Infections

Antifungals

griseofulvin microsize susp F

griseofulvin microsize tabs F

nystatin tabs or 500000unit F

terbinafine hcl tabs or F QL(90 ea per365 days retail)

Imidazole-Related Antifungals DIFLUCAN SUSR 10 MG/ML, 40 MG/ML(fluconazole)

NF QL(20 ml daily)

DIFLUCAN TABS 50 MG, 100 MG, 150 MG, 200 MG (fluconazole)

NF QL(2 ea daily)

fluconazole susr or 10 mg/ml, 40 mg/ml F QL(20 ml daily)

fluconazole tabs or 50 mg,100 mg, 150 mg, 200 mg F QL(2 ea daily)

ANTIHISTAMINES - Drugs to Treat Allergies

Antihistamines - Alkylamines

ALA-HIST IR TABS F

BROMPHENIRAMINE MALEATE POWD F

BROMPHENIRAMINE SOLN F

BROMPHENIRAMINE TANNATE CHEW F

Drug Name DrugTier

Requirements/Limits

CHLOR-TRIMETON ALLERGY TBCR (chlorpheniramine maleate)

NF

CHLOR-TRIMETON SYRP (chlorpheniramine maleate) NF

CHLOR-TRIMETON TABS (chlorpheniramine maleate) NF

CHLORPHENIRAMINE MALEATE POWD XX F

chlorpheniramine maleatesyrp or 2 mg/5ml F

chlorpheniramine maleatetabs or 4 mg F

chlorpheniramine maleatetbcr or 12 mg F

dexchlorpheniraminemaleate soln or F

ED CHLORPED LIQD F

HISTEX CHEW F

HISTEX PD LIQD (triprolidine hcl) NF

HISTEX PDX LIQD F

HISTEX SYRP F

PEDIAVENT CHEW F

PEDIAVENT SYRP F

triprolidine hcl liqd or 0.313mg/ml, 0.625 mg/ml, 0.938mg/ml

F

triprolidine hcl syrp or 2.5mg/5ml F

VANACLEAR PD LIQD (triprolidine hcl) NF

VANAHIST PD LIQD (triprolidine hcl) NF

Antihistamines - Ethanolamines

ALER-DRYL TABS F

BENADRYL ALLERGY CAPS (diphenhydraminehcl)

NF


25

Drug Name DrugTier

Requirements/Limits

BENADRYL ALLERGY CHILDRENS CHEW (diphenhydramine hcl)

NF

BENADRYL ALLERGY CHILDRENS LIQD (diphenhydramine hcl)

NF

BENADRYL ALLERGY TABS (diphenhydraminehcl)

NF

carbinoxamine maleate soln 4 mg/5ml F

carbinoxamine maleate tabs 4 mg F

CARBINOXAMINE MALEATE TABS 6 MG F

CLEMASTINE FUMARATE POWD XX F

clemastine fumarate tabs or 1.34 mg, 2.68 mg F

DICOPANOL FUSEPAQ SUSR F

DICOPANOL RAPIDPAQ SUSR F

diphenhydramine hcl capsor 25 mg, 50 mg F

diphenhydramine hcl chewor 12.5 mg F

diphenhydramine hcl elix or12.5 mg/5ml F RX/OTC

diphenhydramine hcl liqd or25 mg/10ml, 50 mg/20ml,6.25 mg/ml, 12.5 mg/5ml

F

DIPHENHYDRAMINE HCL POWD XX F

diphenhydramine hcl soln ij50 mg/ml F

diphenhydramine hcl tabsor 25 mg F

diphenhydramine hcl tbdpor 12.5 mg F

DOXYLAMINE SUCCINATE POWD F RX/OTC

KARBINAL ER SUER F

RYVENT TABS F

Drug Name DrugTier

Requirements/Limits

VANAMINE PD LIQD (diphenhydramine hcl) NF

Antihistamines - Ethylenediamines PYRILAMINE MALEATE CRYS F

PYRILAMINE MALEATE POWD F

TRIPELENNAMINE HCL POWD F

Antihistamines - Non-Sedating ALLEGRA ALLERGY CHILDRENS SUSP 30 MG/5ML (fexofenadine hcl)

NF QL(5 ml daily)

ALLEGRA ALLERGY CHILDRENS TBDP 30 MG F QL(1 ea daily)

ALLEGRA ALLERGY TABS (fexofenadine hcl) NF QL(1 ea daily)

cetirizine hcl caps 10 mg F QL(1 ea daily)

cetirizine hcl chew 5 mg, 10 mg F QL(1 ea daily)

cetirizine hcl soln 1 mg/ml,5 mg/5ml F QL(5 ml daily);

RX/OTC cetirizine hcl syrp 1 mg/ml,5 mg/5ml F QL(5 ml daily);

RX/OTC cetirizine hcl tabs 5 mg, 10 mg F QL(1 ea daily)

CLARINEX SYRP 0.5 MG/ML F

CLARINEX TABS 5 MG (desloratadine) NF

CLARITIN ALLERGY CHILDRENS SYRP (loratadine)

NF QL(5 ml daily)

CLARITIN CAPS 10 MG (loratadine) NF QL(1 ea daily)

CLARITIN CHEW 5 MG (loratadine) NF QL(1 ea daily)

CLARITIN CHILDRENS CHEW (loratadine) NF QL(1 ea daily)

CLARITIN REDITABS TBDP 10 MG (loratadine) NF QL(1 ea daily)

CLARITIN REDITABS TBDP 5 MG F QL(1 ea daily)


26

Drug Name DrugTier

Requirements/Limits

CLARITIN SYRP 5 MG/5ML (loratadine) NF QL(5 ml daily)

CLARITIN TABS 10 MG (loratadine) NF QL(1 ea daily)

DESLORATADINE ODT TBDP F

desloratadine tabs F

fexofenadine hcl susp or 30mg/5ml F QL(5 ml daily)

fexofenadine hcl tabs or 60 mg, 180 mg F QL(1 ea daily)

levocetirizine dihydrochloride soln or 2.5mg/5ml

F RX/OTC

levocetirizine dihydrochloride tabs or 5 mg

F RX/OTC

loratadine caps or 10 mg F QL(1 ea daily)

loratadine chew or 5 mg F QL(1 ea daily)

loratadine soln or 5 mg/5ml F QL(5 ml daily)

loratadine syrp or 5 mg/5ml F QL(5 ml daily)

loratadine tabs or 10 mg F QL(1 ea daily)

loratadine tbdp or 10 mg F QL(1 ea daily)

QUZYTTIR SOLN F QL(5 ml daily)

XYZAL ALLERGY 24HR CHILDRENS SOLN (levocetirizine dihydrochloride)

NF

RX/OTC

XYZAL ALLERGY 24HR TABS (levocetirizine dihydrochloride)

NF RX/OTC

ZYRTEC ALLERGY CAPS (cetirizine hcl) NF QL(1 ea daily)

ZYRTEC ALLERGY CHILDRENS TBDP F QL(1 ea daily)

ZYRTEC ALLERGY TABS (cetirizine hcl) NF QL(1 ea daily)

ZYRTEC ALLERGY TBDP F QL(1 ea daily)

Drug Name DrugTier

Requirements/Limits

ZYRTEC CHILDRENS ALLERGY SOLN (cetirizine hcl)

NF QL(5 ml daily);RX/OTC

Antihistamines - Phenothiazines PHENERGAN SOLN (promethazine hcl) NF

promethazine hcl soln ij 25mg/ml, 50 mg/ml F

promethazine hcl soln or6.25 mg/5ml F

promethazine hcl supp re25 mg, 50 mg, 12.5 mg F

promethazine hcl syrp or6.25 mg/5ml F

promethazine hcl tabs or25 mg, 50 mg, 12.5 mg F

Antihistamines - Piperazines

AHIST TABS F

Antihistamines - Piperidines cyproheptadine hcl syrp or2 mg/5ml F

cyproheptadine hcl tabs or4 mg F

ANTIHYPERLIPIDEMICS - Drugs to Treat HighCholesterol Bile Acid Sequestrants

cholestyramine light pack F MP

cholestyramine light powd F MP

cholestyramine pack or 4 gm F MP

cholestyramine powd or 4gm/dose F MP

COLESTID FLAVORED GRAN (colestipol hcl) NF MP

COLESTID FLAVORED PACK (colestipol hcl) NF MP

COLESTID GRAN (colestipol hcl) NF MP

COLESTID PACK (colestipol hcl) NF MP

COLESTID TABS (colestipol hcl) NF MP


27

Drug Name DrugTier

Requirements/Limits

colestipol hcl gran F MP

colestipol hcl pack F MP

colestipol hcl tabs F MP

QUESTRAN LIGHT POWD (cholestyramine light) NF MP

QUESTRAN PACK (cholestyramine) NF MP

QUESTRAN POWD (cholestyramine) NF MP

Fibric Acid Derivatives fenofibrate micronized caps67 mg, 134 mg, 200 mg F MP

FENOFIBRATE TABS OR 160 MG F MP

fenofibrate tabs or 48 mg,54 mg, 145 mg, 160 mg F MP

FENOFIBRIC ACID TABS F

FIBRICOR TABS 35 MG, 105 MG F

gemfibrozil tabs or 600 mg F MP

LOPID TABS (gemfibrozil) NF MP

TRICOR TABS (fenofibrate) NF MP

TRIGLIDE TABS F MP

HMG CoA Reductase Inhibitors atorvastatin calcium tabs or 10 mg, 20 mg, 40 mg, 80 mg

F QL(1 ea daily);MP

LIPITOR TABS (atorvastatin calcium) NF QL(1 ea daily);

MP

lovastatin tabs F MP

PRAVACHOL TABS (pravastatin sodium) NF MP

pravastatin sodium tabs F MP

simvastatin tabs or 5 mg,10 mg, 20 mg, 40 mg, 80 mg

F MP

Drug Name DrugTier

Requirements/Limits

ZOCOR TABS (simvastatin) NF MP

Intestinal Cholesterol Absorption Inhibitors

ezetimibe tabs 10 mg F PA

ZETIA TABS (ezetimibe) NF PA

ANTIHYPERTENSIVES - Drugs to Treat HighBlood Pressure

ACE Inhibitors ACCUPRIL TABS (quinapril hcl) NF MP

ALTACE CAPS (ramipril) NF MP

benazepril hcl tabs or 5 mg,10 mg, 20 mg, 40 mg F MP

captopril tabs or 25 mg, 50mg, 100 mg, 12.5 mg F MP

enalapril maleate tabs or 5mg, 10 mg, 20 mg, 2.5 mg F MP

EPANED SOLN F

fosinopril sodium tabs F MP

lisinopril tabs or 5 mg, 10mg, 20 mg, 30 mg, 40 mg,2.5 mg

F MP

LOTENSIN TABS (benazepril hcl) NF MP

moexipril hcl tabs F MP

perindopril erbumine tabs F MP

PRINIVIL TABS (lisinopril) NF MP

quinapril hcl tabs F MP

ramipril caps F MP

trandolapril tabs F MP

VASOTEC TABS (enalaprilmaleate) NF MP

ZESTRIL TABS (lisinopril) NF MP

Angiotensin II Receptor Antagonists


28

Drug Name DrugTier

Requirements/Limits

AVAPRO TABS (irbesartan) NF MP

COZAAR TABS (losartan potassium) NF MP

DIOVAN TABS (valsartan) NF MP

irbesartan tabs F MP

losartan potassium tabs or25 mg, 50 mg, 100 mg F MP

valsartan tabs F MP

Antiadrenergic Antihypertensives CARDURA TABS (doxazosin mesylate) NF MP

CATAPRES TABS (clonidine hcl) NF MP

CATAPRES-TTS-1 PTWK (clonidine) NF

QL(0.15 eadaily); AL(Atleast 6 yrs old);MP





clonidine hcl tabs or 0.1 mg, 0.2 mg, 0.3 mg F MP

clonidine ptwk F


doxazosin mesylate tabs or1 mg, 2 mg, 4 mg, 8 mg F MP

guanfacine hcl tabs F MP

methyldopa tabs F MP

MINIPRESS CAPS (prazosin hcl) NF MP

prazosin hcl caps F MP

terazosin hcl caps F MP

Drug Name DrugTier

Requirements/Limits

Antihypertensive Combinations ACCURETIC TABS (quinapril-hydrochlorothiazide)

NF MP

amlodipine besylate-benazepril hcl caps F MP

atenolol & chlorthalidone tabs F MP

AVALIDE TABS (irbesartan-hydrochlorothiazide)

NF MP

benazepril &hydrochlorothiazide tabs F MP

bisoprolol &hydrochlorothiazide tabs F MP

CAPTOPRIL/HYDROCHLOROTHIAZIDE TABS F MP

DIOVAN HCT TABS (valsartan-hydrochlorothiazide)

NF MP

enalapril maleate &hydrochlorothiazide tabs F MP

fosinopril sodium &hydrochlorothiazide tabs F MP

HYZAAR TABS (losartan potassium &hydrochlorothiazide)

NF MP

irbesartan-hydrochlorothiazide tabs F MP

lisinopril &hydrochlorothiazide tabs F MP

LOPRESSOR HCT TABS (metoprolol &hydrochlorothiazide)

NF MP

losartan potassium &hydrochlorothiazide tabs F MP

LOTENSIN HCT TABS (benazepril &hydrochlorothiazide)

NF MP

LOTREL CAPS (amlodipine besylate-benazepril hcl)

NF MP

metoprolol &hydrochlorothiazide tabs F MP

moexipril-hydrochlorothiazide tabs F MP


29

Drug Name DrugTier

Requirements/Limits

PROPRANOLOL/HYDROCHLOROTHIAZIDE TABS F MP

quinapril-hydrochlorothiazide tabs F MP

TENORETIC 100 TABS (atenolol & chlorthalidone) NF MP

TENORETIC 50 TABS (atenolol & chlorthalidone) NF MP

valsartan-hydrochlorothiazide tabs F MP

VASERETIC TABS (enalapril maleate &hydrochlorothiazide)

NF MP

ZESTORETIC TABS (lisinopril &hydrochlorothiazide)

NF MP

ZIAC TABS (bisoprolol &hydrochlorothiazide) NF MP

Direct Renin Inhibitors TEKTURNA TABS (aliskiren fumarate) NF

Selective Aldosterone Receptor Antagonists

eplerenone tabs F PA

INSPRA TABS (eplerenone) NF PA

Vasodilators hydralazine hcl tabs or 10mg, 25 mg, 50 mg, 100 mg F MP

minoxidil tabs or 10 mg, 2.5 mg F MP

ANTIMALARIALS - Drugs to Treat Malaria(Parasitic Infections) Antimalarial Combinations atovaquone-proguanil hcltabs F

COARTEM TABS F

MALARONE TABS (atovaquone-proguanil hcl) NF

PYRIMETHAMINE/LEUCOVORIN CAPS F

Antimalarials

ARAKODA TABS F

Drug Name DrugTier

Requirements/Limits

CHLOROQUINE PHOSPHATE POWD XX F

chloroquine phosphate tabsor 250 mg, 500 mg F

QL(30 ea per90 daysretail,30 ea per90 days mail)

CHLOROQUINE PHOSPHATE TABS OR 500 MG

F


hydroxychloroquine sulfatetabs or 200 mg F


KRINTAFEL TABS F

mefloquine hcl tabs F

PLAQUENIL TABS (hydroxychloroquinesulfate)

NF


PRIMAQUINE PHOSPHATE TABS (primaquine phosphate)

NF

primaquine phosphate tabs26.3 mg F

QUALAQUIN CAPS (quinine sulfate) NF

QUINACRINE DIHYDROCHLORIDE POWD

F

QUINACRINE HCL POWD F

quinine sulfate caps or F

QUININE SULFATE DIHYDRATE POWD F

QUININE SULFATE POWD XX F

ANTIMYASTHENIC/CHOLINERGIC AGENTS

Antimyasthenic/Cholinergic Agents MESTINON SOLN (pyridostigmine bromide) NF

MESTINON TABS (pyridostigmine bromide) NF


30

Drug Name DrugTier

Requirements/Limits

MESTINON TIMESPAN TBCR (pyridostigminebromide)

NF

pyridostigmine bromidesoln or 60 mg/5ml F

pyridostigmine bromidetabs or 60 mg F

pyridostigmine bromidetbcr or 180 mg F

ANTIMYCOBACTERIAL AGENTS - Drugs toTreat Tuberculosis (Bacterial Infections) Antimycobacterial Agents ethambutol hcl tabs or 100 mg, 400 mg F

isoniazid syrp or 50 mg/5ml F

ISONIAZID TABS OR 100 MG F

isoniazid tabs or 100 mg,300 mg F

MYAMBUTOL TABS (ethambutol hcl) NF

pyrazinamide tabs or F

RIFADIN CAPS OR 150 MG, 300 MG (rifampin) NF

rifampin caps or 150 mg,300 mg F

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - Drugs to Treat Cancer Antimetabolites

mercaptopurine tabs or F

methotrexate sodium tabs or 2.5 mg F

Antineoplastic - Antibodies

RITUXAN SOLN F PA; SP

Antineoplastic - Hormonal and Related Agents

anastrozole tabs or 1 mg F PA

ARIMIDEX TABS (anastrozole) NF PA

ELIGARD KIT F PA; SP

Drug Name DrugTier

Requirements/Limits

FARESTON TABS (toremifene citrate) NF PA

FASLODEX SOLN (fulvestrant) NF

FEMARA TABS (letrozole) NF

flutamide caps F

letrozole tabs or 2.5 mg F

leuprolide acetate kit ij F PA; SP

LUPRON DEPOT (1-MONTH) KIT F PA; SP




megestrol acetate susp or40 mg/ml, 400 mg/10ml F

megestrol acetate tabs or20 mg, 40 mg F

tamoxifen citrate tabs or 10 mg, 20 mg F

toremifene citrate tabs 60 mg F PA

Antineoplastic Enzyme Inhibitors

AFINITOR DISPERZ TBSO F PA; SP

AFINITOR TABS 10 MG F PA; SP

AFINITOR TABS 5 MG, 2.5 MG, 7.5 MG (everolimus) NF PA; SP

ALECENSA CAPS F PA; SP

BELEODAQ SOLR F PA; SP

CAPRELSA TABS F PA; SP

COTELLIC TABS F PA; SP

erlotinib hcl tabs F PA; SP

everolimus tabs F PA; SP


31

Drug Name DrugTier

Requirements/Limits

GLEEVEC TABS (imatinib mesylate) NF PA; SP

ICLUSIG TABS 15 MG, 45 MG F PA; SP

imatinib mesylate tabs F PA; SP

IMBRUVICA CAPS F PA; SP

IMBRUVICA TABS F PA; SP

INLYTA TABS F PA; SP

IRESSA TABS F PA; SP

JAKAFI TABS F PA; SP

NEXAVAR TABS F PA; SP

NINLARO CAPS F PA; SP

SPRYCEL TABS F PA; SP

SUTENT CAPS F PA; SP

TARCEVA TABS (erlotinib hcl) NF PA; SP

TASIGNA CAPS F PA; SP

TYKERB TABS F PA; SP

VOTRIENT TABS F PA; SP

XALKORI CAPS F PA; SP

ZOLINZA CAPS F PA; SP

Antineoplastics Misc. ACTIMMUNE SOLN F PA; SP

ALFERON N SOLN F PA; SP

bexarotene caps 75 mg F PA; SP

HYDREA CAPS (hydroxyurea) NF

hydroxyurea caps or 500 mg F

INTRON A SOLN F PA; SP

Drug Name DrugTier

Requirements/Limits

INTRON A SOLR F PA; SP

MATULANE CAPS F SP

SYLATRON KIT F PA; SP

TARGRETIN CAPS (bexarotene) NF PA; SP

tretinoin (chemotherapy) caps F SP

Chemotherapy Rescue/Antidote Agents leucovorin calcium tabs or 5 mg, 10 mg, 15 mg, 25 mg F PA

Mitotic Inhibitors

etoposide caps or F PA; SP

ANTIPARKINSON AND RELATED THERAPY AGENTS - Drugs to Treat Parkinson's Disease

Antiparkinson Anticholinergics benztropine mesylate tabsor 0.5 mg, 1 mg, 2 mg F

trihexyphenidyl hcl soln F

trihexyphenidyl hcl tabs F

Antiparkinson COMT Inhibitors COMTAN TABS (entacapone) NF

entacapone tabs 200 mg F

Antiparkinson Dopaminergics amantadine hcl caps or 100 mg F

amantadine hcl syrp or 50mg/5ml F

amantadine hcl tabs or 100 mg F

bromocriptine mesylatecaps or 5 mg F

bromocriptine mesylatetabs or 2.5 mg F

carbidopa-levodopa tabs F

carbidopa-levodopa tbcr F


32

Drug Name DrugTier

Requirements/Limits

carbidopa-levodopa tbdp F

MIRAPEX TABS (pramipexoledihydrochloride)

NF

PARLODEL CAPS (bromocriptine mesylate) NF

PARLODEL TABS (bromocriptine mesylate) NF

pramipexoledihydrochloride tabs 0.125mg, 0.25 mg, 0.75 mg, 0.5mg, 1 mg, 1.5 mg

F

REQUIP TABS (ropinirolehydrochloride) NF

ropinirole hydrochloridetabs 0.25 mg, 0.5 mg, 1mg, 2 mg, 3 mg, 4 mg, 5 mg

F

SINEMET CR TBCR (carbidopa-levodopa) NF

SINEMET TABS (carbidopa-levodopa) NF

STALEVO 100 TABS NF PA






ANTIPSYCHOTICS/ANTIMANIC AGENTS -Drugs to Treat Mood Disorders

Antimanic Agents lithium carbonate caps or150 mg, 300 mg, 600 mg F AL(At least 6

yrs old) lithium carbonate tabs or 300 mg F AL(At least 6

yrs old) lithium carbonate tbcr or 300 mg, 450 mg F AL(At least 6

yrs old)

LITHIUM SOLN F AL(At least 6yrs old)

Drug Name DrugTier

Requirements/Limits

LITHOBID TBCR (lithium carbonate) NF AL(At least 6

yrs old) Antipsychotics - Misc. GEODON CAPS OR 20 MG, 40 MG, 60 MG (ziprasidone hcl)


GEODON CAPS OR 80 MG (ziprasidone hcl) NF


LATUDA TABS F QL(1 ea daily);AL(At least 6yrs old)

ziprasidone hcl caps 20mg, 40 mg, 60 mg F


ziprasidone hcl caps 80 mg F QL(2 ea daily);AL(At least 6yrs old)

Benzisoxazoles

INVEGA SUSTENNA SUSY F

1 rtl pack lmtamt,28 rtl packlmt day(s),;AL(At least 18yrs old); SP

INVEGA TRINZA SUSY F

Try InvegaSustenna first; Limit 1 per 3months;1 rtl pack lmtamt,90 rtl packlmt day(s),;AL(At least 18yrs old); SP

RISPERDAL CONSTA SRER F

Limit 2 per 4weeks 2 rtl MAX fill,28 rtl day(s) supply,;AL(At least 18yrs old); SP

RISPERDAL SOLN 1 MG/ML (risperidone) NF

QL(8 mldaily,240 mlper 30 daysretail); AL(Atleast 6 yrs old)

RISPERDAL TABS 0.25 MG, 0.5 MG (risperidone) NF



33

Drug Name DrugTier

Requirements/Limits

RISPERDAL TABS 1 MG, 2 MG (risperidone) NF


RISPERDAL TABS 3 MG, 4 MG (risperidone) NF


risperidone soln 1 mg/ml F

QL(8 mldaily,240 mlper 30 daysretail); AL(Atleast 6 yrs old)

risperidone tabs 0.25 mg,0.5 mg F


risperidone tabs 1 mg, 2 mg F


risperidone tabs 3 mg, 4 mg F


risperidone tbdp 0.25 mg,0.5 mg F


risperidone tbdp 1 mg, 2 mg F


risperidone tbdp 3 mg, 4 mg F


Butyrophenones HALDOL DECANOATE 100 SOLN (haloperidoldecanoate)

NF AL(At least 18yrs old); SP

HALDOL DECANOATE 50 SOLN (haloperidoldecanoate)

NF AL(At least 18yrs old); SP

HALDOL SOLN (haloperidol lactate) NF AL(At least 6

yrs old); SP haloperidol decanoate solnim 50 mg/ml, 100 mg/ml F AL(At least 18

yrs old); SP haloperidol lactate conc or2 mg/ml F AL(At least 6

yrs old) haloperidol lactate soln ij 5mg/ml F AL(At least 6

yrs old); SP haloperidol tabs or 0.5 mg,1 mg, 2 mg, 5 mg, 10 mg,20 mg


Drug Name DrugTier

Requirements/Limits

Dibenzapines

CLOZAPINE ODT TBDP 150 MG, 200 MG F


clozapine tabs F QL(5 ea daily);AL(At least 18yrs old)

clozapine tbdp F QL(5 ea daily);AL(At least 18yrs old)

CLOZARIL TABS (clozapine) NF


FAZACLO TBDP 150 MG F QL(5 ea daily);AL(At least 18yrs old)

FAZACLO TBDP 25 MG, 100 MG, 12.5 MG (clozapine)


loxapine succinate caps F AL(At least 6yrs old)

olanzapine tabs or 15 mg,20 mg, 2.5 mg, 7.5 mg F


olanzapine tabs or 5 mg,10 mg F


olanzapine tbdp or 15 mg,20 mg F


olanzapine tbdp or 5 mg,10 mg F


quetiapine fumarate tabs25 mg, 50 mg, 100 mg, 200 mg


quetiapine fumarate tabs300 mg, 400 mg F


SEROQUEL TABS 25 MG, 50 MG, 100 MG, 200 MG (quetiapine fumarate)


SEROQUEL TABS 300 MG, 400 MG (quetiapinefumarate)



34

Drug Name DrugTier

Requirements/Limits

ZYPREXA TABS OR 15 MG, 20 MG, 2.5 MG, 7.5 MG (olanzapine)


ZYPREXA TABS OR 5 MG, 10 MG (olanzapine) NF


ZYPREXA ZYDIS TBDP 15 MG, 20 MG (olanzapine) NF


ZYPREXA ZYDIS TBDP 5 MG, 10 MG (olanzapine) NF


Phenothiazines chlorpromazine hcl tabs or10 mg, 25 mg, 50 mg, 100mg, 200 mg


fluphenazine decanoatesoln ij F AL(At least 18

yrs old); SP fluphenazine hcl conc or 5mg/ml F AL(At least 6

yrs old) fluphenazine hcl elix or 2.5mg/5ml F AL(At least 6

yrs old) fluphenazine hcl tabs or 1mg, 5 mg, 10 mg, 2.5 mg F AL(At least 6

yrs old) perphenazine tabs or 2 mg,4 mg, 8 mg, 16 mg F AL(At least 6

yrs old) prochlorperazine maleatetabs or 5 mg, 10 mg F AL(At least 6

yrs old)

prochlorperazine supp F AL(At least 6yrs old)

thioridazine hcl tabs or 10 mg, 25 mg, 50 mg, 100 mg F AL(At least 6

yrs old)

trifluoperazine hcl tabs F AL(At least 6yrs old)

Quinolinone Derivatives

ABILIFY MAINTENA PRSY F


ABILIFY MAINTENA SRER F


Drug Name DrugTier

Requirements/Limits

ABILIFY TABS (aripiprazole) NF


aripiprazole tabs F QL(1 ea daily);AL(At least 6yrs old)

ARISTADA INITIO PRSY F

Limit 2 doses per 365 Days;2rtl MAX fill,365 rtl day(s)supply,; AL(Atleast 18 yrsold); SP

ARISTADA PRSY 1064 MG/3.9ML F

Limit 1 per 8weeks;1 rtl pack lmtamt,56 rtl packlmt day(s),;AL(At least 18yrs old); SP

ARISTADA PRSY 441 MG/1.6ML, 662 MG/2.4ML,882 MG/3.2ML

F


Thioxanthenes

thiothixene caps F AL(At least 6yrs old)

ANTISEPTICS & DISINFECTANTS

Antiseptics & Disinfectants hydrogen peroxide soln ex3 % F

HYDROGEN PEROXIDE SOLN EX 3 % F

ANTIVIRALS - Drugs to Treat Viral Infections

Antiretrovirals

abacavir sulfate soln F

abacavir sulfate tabs F

abacavir sulfate-lamivudine tabs 600 mg-300 mg F

abacavir sulfate-lamivudine-zidovudine tabs 300 mg-150 mg-300 mg

F


35

Drug Name DrugTier

Requirements/Limits

APTIVUS CAPS F

APTIVUS SOLN F

atazanavir sulfate caps F

ATRIPLA TABS F

BIKTARVY TABS F QL(1 ea daily)

COMBIVIR TABS (lamivudine-zidovudine) NF

COMPLERA TABS F

CRIXIVAN CAPS F

DESCOVY TABS F

didanosine cpdr 200 mg,400 mg F

EDURANT TABS F

efavirenz caps F

efavirenz tabs F

EMTRIVA CAPS F

EMTRIVA SOLN F

EPIVIR SOLN (lamivudine) NF

EPIVIR TABS (lamivudine) NF

EPZICOM TABS (abacavir sulfate-lamivudine) NF

EVOTAZ TABS F

fosamprenavir calcium tabs F

FUZEON SOLR F 1 rtl pack lmtamt,30 rtl packlmt day(s),; SP

GENVOYA TABS F

INTELENCE TABS F

INVIRASE CAPS F

Drug Name DrugTier

Requirements/Limits

INVIRASE TABS F

ISENTRESS CHEW F

ISENTRESS PACK F

ISENTRESS TABS F

KALETRA SOLN 400 MG/5ML-100 MG/5ML(lopinavir-ritonavir)

NF

KALETRA TABS 100 MG-25 MG, 200 MG-50 MG F

lamivudine soln F

lamivudine tabs F

lamivudine-zidovudine tabs 150 mg-300 mg F

LEXIVA SUSP 50 MG/ML F

LEXIVA TABS 700 MG (fosamprenavir calcium) NF

lopinavir-ritonavir soln F

nevirapine susp 50 mg/5ml F

nevirapine tabs 200 mg F

nevirapine tb24 400 mg F

NORVIR CAPS 100 MG F

NORVIR SOLN 80 MG/ML F

NORVIR TABS 100 MG (ritonavir) NF

ODEFSEY TABS F

PIFELTRO TABS F

PREZCOBIX TABS F

PREZISTA SUSP 100 MG/ML F

PREZISTA TABS 75 MG, 600 MG, 800 MG F

RESCRIPTOR TABS F


36

Drug Name DrugTier

Requirements/Limits

RETROVIR CAPS (zidovudine) NF

RETROVIR SYRP (zidovudine) NF

REYATAZ CAPS 150 MG, 200 MG, 300 MG (atazanavir sulfate)

NF

REYATAZ PACK 50 MG F

ritonavir tabs F

SELZENTRY SOLN F

SELZENTRY TABS F

stavudine caps F

STRIBILD TABS F

SUSTIVA CAPS (efavirenz) NF

SUSTIVA TABS (efavirenz) NF

tenofovir disoproxilfumarate tabs F

TIVICAY TABS 50 MG F

TRIUMEQ TABS F

TRIZIVIR TABS (abacavir sulfate-lamivudine-zidovudine)

NF

TRUVADA TABS F

TYBOST TABS F QL(1 ea daily)

VIDEX EC CPDR 125 MG F

VIDEX EC CPDR 200 MG, 250 MG, 400 MG NF

VIDEXPEDIATRIC SOLR 4 GM F

VIRACEPT TABS F

VIRAMUNE SUSP (nevirapine) NF

VIRAMUNE TABS (nevirapine) NF

Drug Name DrugTier

Requirements/Limits

VIRAMUNE XR TB24 (nevirapine) NF

VIREAD POWD 40 MG/GM F

VIREAD TABS 300 MG (tenofovir disoproxilfumarate)

NF

ZERIT CAPS 15 MG, 20 MG, 30 MG, 40 MG (stavudine)

NF

ZERIT SOLR 1 MG/ML F

ZIAGEN SOLN (abacavir sulfate) NF

ZIAGEN TABS (abacavir sulfate) NF

zidovudine caps F

zidovudine syrp F

zidovudine tabs F

CMV Agents

cidofovir soln F

CYTOVENE SOLR (ganciclovir sodium) NF

FOSCAVIR SOLN F

ganciclovir sodium solr 500 mg F

VALCYTE SOLR (valganciclovir hcl) NF

VALCYTE TABS (valganciclovir hcl) NF

valganciclovir hcl solr F

valganciclovir hcl tabs F

Hepatitis Agents adefovir dipivoxil tabs 10 mg F PA

BARACLUDE SOLN 0.05 MG/ML F PA

BARACLUDE TABS 0.5 MG, 1 MG (entecavir) NF PA


37

Drug Name DrugTier

Requirements/Limits

entecavir tabs F PA

EPIVIR HBV SOLN 5 MG/ML F

EPIVIR HBV TABS 100 MG (lamivudine (hbv)) NF

HEPSERA TABS (adefovir dipivoxil) NF PA

lamivudine (hbv) tabs F

MAVYRET TABS F PA; SP

MODERIBA 1200 DOSE PACK TBPK F PA; SP

PEGASYS PROCLICK SOLN F PA; SP

PEGASYS SOLN F PA; SP

PEGINTRON KIT F PA; SP

REBETOL CAPS 200 MG (ribavirin (hepatitis c)) NF PA; SP

REBETOL SOLN 40 MG/ML F PA; SP

RIBASPHERE RIBAPAK TBPK F PA; SP

RIBASPHERE TABS F PA; SP

ribavirin (hepatitis c) caps F PA; SP

ribavirin (hepatitis c) tabs F PA; SP

SOFOSBUVIR/VELPATASVIR TABS F PA; SP

VEMLIDY TABS F PA; SP

Herpes Agents

acyclovir caps or 200 mg F

acyclovir sodium soln F

acyclovir susp or 200mg/5ml F

acyclovir tabs or 400 mg,800 mg F

famciclovir tabs or 125 mg,250 mg, 500 mg F

Drug Name DrugTier

Requirements/Limits

SITAVIG TABS F

valacyclovir hcl tabs or 1gm, 500 mg, 1000 mg F

VALTREX TABS (valacyclovir hcl) NF

ZOVIRAX CAPS OR 200 MG (acyclovir) NF

ZOVIRAX SUSP OR 200 MG/5ML (acyclovir) NF

ZOVIRAX TABS OR 400 MG, 800 MG (acyclovir) NF

Influenza Agents

FLUMADINE TABS NF

oseltamivir phosphate capsor 30 mg, 45 mg, 75 mg F QL(2 ea daily)

oseltamivir phosphate susror 6 mg/ml F QL(25 ml daily)

RAPIVAB SOLN F

RELENZA DISKHALER AEPB F

rimantadine hydrochloridetabs 100 mg F

TAMIFLU CAPS 30 MG, 45 MG, 75 MG (oseltamivir phosphate)

F QL(2 ea daily)

TAMIFLU SUSR 6 MG/ML(oseltamivir phosphate) F QL(25 ml daily)

XOFLUZA TBPK F

Respiratory Syncytial Virus (RSV) Agents

ribavirin solr in 6 gm F

VIRAZOLE SOLR (ribavirin) NF

BETA BLOCKERS - Drugs to Treat High BloodPressure

Alpha-Beta Blockers

carvedilol tabs F MP

COREG TABS (carvedilol) NF MP

labetalol hcl tabs or 100 mg, 200 mg, 300 mg F MP


38

Drug Name DrugTier

Requirements/Limits

Beta Blockers Cardio-Selective atenolol tabs or 25 mg, 50mg, 100 mg F MP

bisoprolol fumarate tabs F MP

LOPRESSOR TABS (metoprolol tartrate) NF MP

metoprolol succinate tb24 F MP

metoprolol tartrate tabs or25 mg, 50 mg, 75 mg, 100mg, 37.5 mg

F MP

TENORMIN TABS (atenolol) NF MP

TOPROL XL TB24 (metoprolol succinate) NF MP

Beta Blockers Non-Selective BETAPACE AF TABS (sotalol hcl (afib/afl)) NF MP

BETAPACE TABS (sotalol hcl) NF MP

INDERAL LA CP24 (propranolol hcl) NF MP

propranolol hcl cp24 or 60mg, 80 mg, 120 mg, 160 mg

F MP

propranolol hcl soln or 20mg/5ml F

propranolol hcl soln or 40mg/5ml F MP

propranolol hcl tabs or 10mg, 20 mg, 40 mg, 60 mg,80 mg

F MP

sotalol hcl (afib/afl) tabs F MP

sotalol hcl tabs F MP

CALCIUM CHANNEL BLOCKERS - Drugs toTreat High Blood Pressure

Calcium Channel Blockers ADALAT CC TB24 (nifedipine) NF QL(2 ea daily);

MP amlodipine besylate tabs or5 mg, 10 mg, 2.5 mg F QL(1 ea daily);

MP CALAN SR TBCR (verapamil hcl) NF MP

Drug Name DrugTier

Requirements/Limits

CALAN TABS (verapamilhcl) NF MP

CARDIZEM CD CP24 (diltiazem hcl coated beads)

NF QL(1 ea daily);MP

CARDIZEM TABS (diltiazem hcl) NF MP

diltiazem hcl coated beads cp24 120 mg, 180 mg, 240mg, 300 mg, 360 mg

F QL(1 ea daily);MP

diltiazem hcl cp12 or 120 mg F MP

diltiazem hcl cp12 or 60mg, 90 mg F QL(2 ea daily);

MP diltiazem hcl cp24 or 120 mg F QL(2 ea daily);

MP diltiazem hcl cp24 or 180mg, 240 mg F QL(1 ea daily);

MP diltiazem hcl extended release beads cp24 F QL(1 ea daily);

MP diltiazem hcl tabs or 30 mg,60 mg, 90 mg, 120 mg F MP

felodipine tb24 F MP

nifedipine caps or 10 mg,20 mg F MP

nifedipine tb24 or 30 mg,60 mg, 90 mg F QL(2 ea daily);

MP nifedipine tb24 or 30 mg,60 mg, 90 mg F QL(2 ea daily)

NORVASC TABS (amlodipine besylate) NF QL(1 ea daily);

MP PROCARDIA CAPS (nifedipine) NF MP

PROCARDIA XL TB24 (nifedipine) NF QL(2 ea daily)

TIAZAC CP24 (diltiazem hcl extended release beads)

NF QL(1 ea daily);MP

verapamil hcl cp24 or 100mg, 200 mg, 300 mg F QL(1 ea daily);

MP verapamil hcl cp24 or 100mg, 200 mg, 300 mg F MP

verapamil hcl cp24 or 120mg, 180 mg, 240 mg F QL(1 ea daily)


39

Drug Name DrugTier

Requirements/Limits

verapamil hcl cp24 or 360 mg F

verapamil hcl tabs or 40mg, 80 mg, 120 mg F MP

verapamil hcl tbcr or 120mg, 180 mg, 240 mg F MP

VERELAN CP24 120 MG, 180 MG, 240 MG (verapamil hcl)

NF QL(1 ea daily)

VERELAN CP24 360 MG F

VERELAN PM CP24 (verapamil hcl) F MP

CARDIOTONICS - Drugs to Treat Heart Failureand Abnormal Heart Rhythm

Cardiac Glycosides

digoxin soln or 0.05 mg/ml F MP

digoxin tabs or 0.125 mg,125 mcg F MP

digoxin tabs or 0.25 mg,250 mcg F

LANOXIN TABS OR 125 MCG (digoxin) NF MP

LANOXIN TABS OR 250 MCG (digoxin) NF

LANOXIN TABS OR 62.5 MCG F

CARDIOVASCULAR AGENTS - MISC. - Drugs toTreat Heart and Circulation Conditions

Pulmonary Hypertension - Endothelin Receptor LETAIRIS TABS (ambrisentan) F PA; SP

TRACLEER TABS 125 MG, 62.5 MG (bosentan) F PA; SP

TRACLEER TBSO 32 MG F PA; SP

Pulmonary Hypertension - Phosphodiesterase ADCIRCA TABS 20 MG (tadalafil (pulmonaryhypertension))

F PA; SP

REVATIO SUSR 10 MG/ML (sildenafil citrate (pulmonary hypertension))

F AL(Up to 11 yrsold ); SP

Drug Name DrugTier

Requirements/Limits

REVATIO TABS 20 MG (sildenafil citrate (pulmonary hypertension))

NF PA; SP

sildenafil citrate (pulmonaryhypertension) tabs 20 mg F PA; SP

CEPHALOSPORINS - Drugs to Treat BacterialInfections

Cephalosporin Combinations

AVYCAZ SOLR F

ZERBAXA SOLR F

Cephalosporins - 1st Generation

cefadroxil caps F

cefadroxil susr F

cefadroxil tabs F

CEFAZOLIN SODIUM SOLN IV 1 GM/50ML-4 % F

cefazolin sodium solr ij 1gm, 10 gm, 20 gm, 500 mg F

CEFAZOLIN SODIUM SOLR IJ 100 GM, 300 GM F

CEFAZOLIN SODIUM SOLR IV 1 GM F

CEFAZOLIN SODIUM SOSY IV 1 GM/10ML, 2GM/20ML, 3 GM/20ML

F

CEFAZOLIN SODIUM/DEXTROSESOLN

F

CEFAZOLIN SODIUM/DEXTROSESOLR

F

CEFAZOLIN SODIUM/SODIUMCHLORIDE SOLN

F

CEFAZOLIN SODIUM/SODIUMCHLORIDE SOSY

F

CEFAZOLIN SOLN F

CEFAZOLIN/SODIUMCHLORIDE SOLN F


40

Drug Name DrugTier

Requirements/Limits

cephalexin caps F

cephalexin susr F

cephalexin tabs F

DAXBIA CAPS F

KEFLEX CAPS (cephalexin) NF

Cephalosporins - 2nd Generation

cefaclor caps F

CEFACLOR ER TB12 F

cefaclor susr F

CEFOTAN SOLR (cefotetan disodium) NF

cefotetan disodium solr F

CEFOTETAN/DEXTROSESOLR F

cefoxitin sodium solr ij 10 gm F

cefoxitin sodium solr iv 1 gm, 2 gm F

CEFOXITIN SODIUM SOLR IV 1 GM-4 %, 2 GM-2.2 %

F

cefprozil susr F

cefprozil tabs F

cefuroxime axetil tabs F

cefuroxime sodium solr F

Cephalosporins - 3rd Generation

cefdinir caps F

cefdinir susr F

cefditoren pivoxil tabs F

cefixime caps 400 mg F

Drug Name DrugTier

Requirements/Limits

cefixime susr 100 mg/5ml F 50ml permonth;QL(1.67ml daily)

cefixime susr 200 mg/5ml F QL(10 ml daily)

cefotaxime sodium solr 1 gm, 2 gm, 10 gm, 500 mg F

CEFOTAXIME SODIUM SOLR 500 MG F

cefpodoxime proxetil susr F

cefpodoxime proxetil tabs F

ceftazidime solr ij 1 gm, 2gm, 6 gm F

CEFTAZIDIME/DEXTROSE SOLR F

CEFTRI-IM KIT F

CEFTRIAXONE IN ISO-OSMOTIC DEXTROSE SOLN

F

ceftriaxone sodium solr ij 1gm, 2 gm, 250 mg, 500 mg F

CEFTRIAXONE SODIUM SOLR IJ 100 GM F

ceftriaxone sodium solr iv 1 gm, 2 gm, 10 gm F

CEFTRIAXONE/DEXTROSE SOLR F

CEFTRISOL PLUS KIT F

CLAFORAN SOLR (cefotaxime sodium) NF

FORTAZ SOLR IJ 1 GM (ceftazidime) NF

FORTAZ SOLR IV 2 GM F

SUPRAX CAPS 400 MG (cefixime) NF

SUPRAX CHEW 100 MG, 200 MG F

SUPRAX SUSR 100 MG/5ML (cefixime) NF

50ml permonth;QL(1.67ml daily)

SUPRAX SUSR 200 MG/5ML (cefixime) NF QL(10 ml daily)


41

Drug Name DrugTier

Requirements/Limits

SUPRAX SUSR 500 MG/5ML F

TAZICEF SOLN F

TAZICEF SOLR F

Cephalosporins - 4th Generation

cefepime hcl solr F

CEFEPIME SOLN F

CEFEPIME/DEXTROSESOLR F

MAXIPIME SOLR IJ 1 GM, 2 GM (cefepime hcl) NF

MAXIPIME SOLR IV 1 GM, 2 GM F

Cephalosporins - 5th Generation

TEFLARO SOLR F

Cephalosporins - Siderophores

FETROJA SOLR F

CONTRACEPTIVES - Drugs to PreventPregnancy

Combination Contraceptives - Oral desogestrel & ethinylestradiol tabs F

desogestrel-ethinylestradiol (biphasic) tabs F

desogestrel-ethinylestradiol (triphasic) tabs F

drospirenone-ethinylestradiol tabs F

ESTROSTEP FE TABS (norethindrone acetate-ethinyl estradiol-fe)

NF

ethynodiol diacet & ethestrad tabs F

levonorgestrel & ethestradiol tabs F

levonorgestrel-eth estradiol(triphasic) tabs F

levonorgestrel-ethinylestradiol (91-day) tabs F

Drug Name DrugTier

Requirements/Limits

levonorgestrel-ethinylestradiol (continuous) tabs F

LOESTRIN 1.5/30-21TABS (norethindrone acet & eth estra)

NF

LOESTRIN 1/20-21 TABS(norethindrone acet & eth estra)

NF

LOESTRIN FE 1.5/30TABS (norethin acet & estrad-fe)

NF

LOESTRIN FE 1/20 TABS(norethin acet & estrad-fe) NF QL(1 ea daily)

LOSEASONIQUE TABS (levonorgestrel-ethinylestradiol (91-day))

NF

MIRCETTE TABS (desogestrel-ethinylestradiol (biphasic))

NF

norethin acet & estrad-fe tabs 75 mg-20 mcg-1 mg F QL(1 ea daily)

norethin acet & estrad-fe tabs 75 mg-30 mcg-1.5 mg F

norethindrone & eth estradiol tabs F

norethindrone acet & eth estra tabs F

norethindrone acetate-ethinyl estradiol-fe tabs 75mg-1 mg

F

norethindrone-eth estradiol (triphasic) tabs F

norgestimate-ethinylestradiol (triphasic) tabs F

norgestimate-ethinylestradiol tabs 0.25 mg-35 mcg

F

norgestrel & ethinylestradiol tabs 0.3 mg-30 mcg

F

norgestrel & ethinylestradiol tabs 0.5 mg-50 mcg

3

ORTHO TRI-CYCLEN LO TABS (norgestimate-ethinylestradiol (triphasic))

NF


42

Drug Name DrugTier

Requirements/Limits

ORTHO TRI-CYCLEN TABS (norgestimate-ethinylestradiol (triphasic))

NF

ORTHO-CYCLEN TABS (norgestimate-ethinylestradiol)

NF

ORTHO-NOVUM 1/35TABS (norethindrone & eth estradiol)

NF

ORTHO-NOVUM 7/7/7TABS (norethindrone-eth estradiol (triphasic))

NF

SEASONIQUE TABS (levonorgestrel-ethinylestradiol (91-day))

NF

TRI-NORINYL 28 TABS (norethindrone-eth estradiol (triphasic))

NF

YASMIN 28 TABS (drospirenone-ethinylestradiol)

NF

YAZ TABS (drospirenone-ethinyl estradiol) NF

Combination Contraceptives - Vaginal etonogestrel-ethinylestradiol ring 0.12 mg/24hr-0.015 mg/24hr

F

NUVARING RING (etonogestrel-ethinylestradiol)

NF

Emergency Contraceptives levonorgestrel (emergencyoc) tabs 1.5 mg F

PLAN B ONE-STEP TABS (levonorgestrel (emergency oc))

NF

Progestin Contraceptives - Injectable DEPO-PROVERA CONTRACEPTIVE SUSP (medroxyprogesteroneacetate (contraceptive))

NF

DEPO-PROVERA CONTRACEPTIVE SUSY (medroxyprogesteroneacetate (contraceptive))

NF

Drug Name DrugTier

Requirements/Limits

DEPO-SUBQ PROVERA 104 SUSY F

medroxyprogesteroneacetate (contraceptive) susp

F

medroxyprogesteroneacetate (contraceptive) susy

F

Progestin Contraceptives - Oral norethindrone (contraceptive) tabs 0.35 mg

F

ORTHO MICRONOR TABS (norethindrone (contraceptive))

NF

CORTICOSTEROIDS - Steroid Hormone Drugs toTreat Systemic Swelling Conditions

Glucocorticosteroids

budesonide cpep or 3 mg F QL(3 ea daily)

CORTEF TABS (hydrocortisone) NF

DEPO-MEDROL SUSP 40 MG/ML(methylprednisolone acetate)

NF

DEXAMETHASONE 13-DAY DOSE PACK TBPK F

dexamethasone elix or 0.5 mg/5ml F

DEXAMETHASONE INTENSOL CONC F

dexamethasone soln or 0.5 mg/5ml F

dexamethasone tabs or 0.75 mg, 0.5 mg, 1 mg, 2mg, 4 mg, 6 mg, 1.5 mg

F

dexamethasone tbpk or 1.5 mg F

ENTOCORT EC CPEP (budesonide) NF QL(3 ea daily)

hydrocortisone tabs or 5mg, 10 mg, 20 mg F

KENALOG-10 SUSP F PA


43

Drug Name DrugTier

Requirements/Limits

KENALOG-40 SUSP (triamcinolone acetonide) NF

MEDROL DOSEPAK TBPK (methylprednisolone) NF

MEDROL TABS 2 MG F

MEDROL TABS 4 MG, 8 MG, 16 MG, 32 MG (methylprednisolone)

NF

methylprednisolone sodsucc solr F PA

methylprednisolone tabs or4 mg, 8 mg, 16 mg, 32 mg F

methylprednisolone tbpk or4 mg F

MILLIPRED TABS 5 MG F

ORAPRED ODT TBDP (prednisolone sodiumphosphate)

NF

PEDIAPRED SOLN (prednisolone sodiumphosphate)

NF

prednisolone sodiumphosphate soln or 5mg/5ml, 15 mg/5ml

F

prednisolone sodiumphosphate tbdp or 10 mg,15 mg, 30 mg

F

prednisolone soln or F

PREDNISONE INTENSOL CONC F

prednisone soln or 5mg/5ml F

prednisone tabs or 1 mg, 5mg, 10 mg, 20 mg, 50 mg,2.5 mg

F

prednisone tbpk or 5 mg,10 mg F

SOLU-CORTEF SOLR F PA

SOLU-MEDROL SOLR 2 GM F PA

Drug Name DrugTier

Requirements/Limits

SOLU-MEDROL SOLR 40 MG, 125 MG, 500 MG, 1000 MG (methylprednisolone sod succ)

NF

PA

TRIAMCINOLONE ACETONIDE PF SUSP F PA

TRIAMCINOLONE ACETONIDE SUSP IJ 50 MG/ML

F PA

Mineralocorticoids fludrocortisone acetate tabs or 0.1 mg F

COUGH/COLD/ALLERGY - Drugs to TreatCough, Cold and Allergy Symptoms

Antitussives

benzonatate caps F

BUCKLEYS COUGH LIQD F

CREO-TERPIN SYRP F

DELSYM COUGH CHILDRENS SUER (dextromethorphanpolistirex)

NF

DELSYM SUER (dextromethorphanpolistirex)

NF

dextromethorphan hbr capsor 15 mg F

dextromethorphan hbr liqdor 15 mg/5ml, 15 mg/15ml,7.5 mg/5ml

F

DEXTROMETHORPHAN HBR MONOHYDRATE CRYS

F

DEXTROMETHORPHAN HBR MONOHYDRATE POWD

F

DEXTROMETHORPHAN HBR POWD XX F

dextromethorphan hbr syrpor 10 mg/5ml, 15 mg/5ml F

dextromethorphanpolistirex lqcr 30 mg/5ml F


44

Drug Name DrugTier

Requirements/Limits

dextromethorphanpolistirex suer 30 mg/5ml F

ELIXSURE COUGH GEL F

HOLD LOZG NF

hydrocodone w/homatropine syrp 5mg/5ml-1.5 mg/5ml

F

QL(240 ml per12 days retail);AL(At least 18yrs old)

hydrocodone w/homatropine tabs 5 mg-1.5 mg


LITTLE COLDS COUGH FORMULA LIQD F

ROBITUSSIN CHILDRENS COUGH LONG-ACTING SYRP

F

ROBITUSSIN LINGERING COLDLONG-ACTING COUGHGELS CAPS (dextromethorphan hbr)

NF

SCOT-TUSSIN DIABETES LIQD F

TESSALON PERLES CAPS (benzonatate) NF

TRIAMINIC LONG ACTING COUGH LIQD 7.5 MG/5ML(dextromethorphan hbr)

NF

TRIAMINIC LONG ACTING COUGH STRP 7.5 MG F

VICKS DAYQUIL COUGH LIQD (dextromethorphanhbr)

NF

WAL-TUSSIN COUGH RELIEF CHILDRENS CHEW

F

Cough/Cold/Allergy Combinations

acetaminophen w/ dm susp F

ACTICON SOLN F

ACTICON TABS F

ACTIDOGESIC TABS F

ACTIDOGESIC-DF TABS F

Drug Name DrugTier

Requirements/Limits

ACTIDOM DMX LIQD F QL(16 ml daily)

ACTINEL DM LIQD F QL(16 ml daily)

ACTINEL LIQD F

ACTINEL PEDIATRIC LIQD F

ADVIL ALLERGY & CONGESTION TABS F

ADVIL ALLERGY SINUS TABS F

ADVIL COLD & SINUS CAPS 200 MG-30 MG F

ADVIL COLD & SINUS TABS (pseudoephedrine-ibuprofen)

NF

ADVIL MULTI-SYMPTOM COLD& FLU TABS F

ADVIL SINUS CONGESTION &PAIN TABS (phenylephrine-ibuprofen)

NF

ALA-HIST PE TABS (dexbrompheniramine-phenylephrine)

NF

ALAHIST CF TABS F

ALAHIST DM LIQD F

ALEVE-D SINUS & COLD TB12 (pseudoephedrine-naproxen sodium)

NF

ALEVE-D SINUS & HEADACHE TB12 (pseudoephedrine-naproxen sodium)

NF

ALKA-SELTZER PLUS COLD &COUGH CAPS F

ALKA-SELTZER PLUS COLD &COUGH FORMULA CAPS

F

ALKA-SELTZER PLUS COLD TBEF (chlorpheniramine-phenylephrine-asa)

NF


45

Drug Name DrugTier

Requirements/Limits

ALKA-SELTZER PLUS DAY/NIGHT MULTI-SYMPTOM COLD/FLUCAPS

F

ALKA-SELTZER PLUS SEVERECOLD & FLU NIGHT PACK

F

ALKA-SELTZER PLUS SINUS FORMULA TBEF F

ALLEGRA-D 12 HOUR ALLERGY & CONGESTION TB12 (fexofenadine-pseudoephedrine)

NF

QL(2 ea daily)

ALLEGRA-D 24 HOUR ALLERGY & CONGESTION TB24 (fexofenadine-pseudoephedrine)

NF

QL(1 ea daily)

ALLERGY MULTI-SYMPTOM DAY/NIGHTMISC

F

AP-HIST DM LIQD F

AQUANAZ TABS F

ATUSS DA LIQD F

BALAMINE DM SYRP F

BENADRYL ALLERGY PLUS CONGESTION CHILDRENS SOLN (diphenhydramine-phenylephrine)

NF

BIOBRON SF SYRP F QL(16 ml daily)

BIODESP DM SYRP F QL(16 ml daily)

BIONATUSS DXP LIQD F

BIONEL LIQD F

BIONEL PEDIATRIC LIQD F

BIOSPEC DMX LIQD F

BROHIST D TABS F

Drug Name DrugTier

Requirements/Limits

brompheniramine &phenyleph elix F

brompheniramine &phenyleph liqd F

brompheniramine &pseudoeph elix F QL(8 ml daily)

brompheniramine &pseudoeph liqd F QL(8 ml daily)

BRONKAID TABS F

BRONKIDS LIQD F

BRONTUSS DX LIQD F QL(16 ml daily)

BROTAPP DM LIQD F

CAPCOF SYRP F

CAPMIST DM TABS F

CAPRON DM LIQD F

CAPRON DMT TABS F

CARBAPHEN 12 LIQD F

CARBAPHEN 12 PED SUSP F

CARBAPHEN CH SUSP F

CARBAPHEN PED CH SUSP F

cetirizine-pseudoephedrinetb12 F QL(2 ea daily)

CHERACOL PLUS LIQD (dextromethorphan-guaifenesin)

NF QL(16 ml daily)

CHERACOL-D COUGH LIQD (dextromethorphan-guaifenesin)

NF QL(16 ml daily)

CHLO HIST SOLN F

CHLO TUSS LIQD F

CHLOPHED LIQD F

chlorpheniramine &phenylephrine liqd F


46

Drug Name DrugTier

Requirements/Limits

chlorpheniramine &phenylephrine tabs F

chlorpheniramine &pseudoeph tabs F

chlorpheniramine-acetaminophen tabs F

chlorpheniramine-dm liqd F

chlorpheniramine-dm tabs F

chlorpheniramine-phenylephrine-acetaminophen misc

F

chlorpheniramine-phenylephrine-acetaminophen tabs

F

chlorpheniramine-phenylephrine-asa tbef 7.8mg-2 mg-325 mg

F

CLARINEX-D 12 HOUR TB12 F

CLARITIN-D 12 HOUR TB12 (loratadine & pseudoephedrine)

NF QL(2 ea daily)

CLARITIN-D 24 HOUR TB24 (loratadine & pseudoephedrine)

NF QL(1 ea daily)

CLEAR COUGH PM MULTI-SYMPTOM LIQD (dextromethorphan-doxylamine-acetaminophen)

NF

CODAR AR LIQD F

CODITUSSIN AC LIQD F

CODITUSSIN DAC LIQD F

COLD & COUGH DAYTIME/NIGHTIMECHILDRENS MISC 6.25 MG/5ML-5 MG/5ML-2.5MG/5ML

F

COLD & FLU RELIEF NIGHTTIME D LIQD F

Drug Name DrugTier

Requirements/Limits

COMTREX COLD & COUGH DAY/NIGHTMAXIMUM STRENGTH MISC (phenylephrine-chlorpheniramine-dm w/ apap)

NF

COMTREX COLD & COUGH MAXIMUM STRENGTH TABS (dextromethorphan-phenylephrine-acetaminophen)

NF

COMTREX COLD & COUGH NIGHTTIME MAXIMUM STRENGTH TABS (phenylephrine-chlorpheniramine-dm w/ apap)

NF

COMTREX DEEP CHEST COLD MULTI-SYMPTOM TABS

F

CONEX COLD/ALLERGYSOLN F

CONEX COLD/ALLERGYTABS F

CONTAC COLD/FLU DAY& NIGHT MISC F

CONTAC COLD/FLUDAY/NIGHT TABS F

CONTAC COLD/FLUMAXIMUM STRENGTH TABS

F

CORICIDIN HBP COLD & FLU TABS (chlorpheniramine-acetaminophen)

NF

CORICIDIN HBP COUGH & COLD TABS (chlorpheniramine-dm)

NF

CORICIDIN HBP DAY & NIGHTMULTI-SYMPTOM COLD MISC

F

CORICIDIN HBP FLU TABS (dextromethorphan-acetaminophen-chlorpheniramine)

NF


47

Drug Name DrugTier

Requirements/Limits

CVS COUGH/CHESTCONGESTION DM CHILDRENS SOPK

F

CVS NON-DRYING SINUS PE TABS F

CVS SINUS RELIEF DAYTIME/NIGHTTIMEMISC

F

CVS TUSSIN DM DAY/NIGHT PACK LQPK F

DAY TIME MULTI-SYMPTOM COLD/FLURELIEF CAPS (dextromethorphan-phenylephrine-acetaminophen)

NF

DAYTIME COLD MEDICINE LIQD F

DECONEX DMX TABS (phenylephrine w/ dm-gg) NF

DECONEX IR TABS F

DELSYM CHILDRENS DAY NIGHT MISC F

DELSYM DAY NIGHT MISC F

DELTUSS DP LIQD F

DESGEN DM SYRP 15 MG/5ML-100 MG/5ML-5MG/5ML

F QL(16 ml daily)

DESGEN DM TABS 30 MG-10 MG-200 MG F

dexbrompheniramine-phenylephrine tabs 2 mg-10 mg

F

dextromethorphan-acetaminophen-chlorpheniramine susp

F

dextromethorphan-acetaminophen-chlorpheniramine tabs

F

dextromethorphan-doxylamine-acetaminophen caps

F

Drug Name DrugTier

Requirements/Limits

dextromethorphan-doxylamine-acetaminophenliqd

F

dextromethorphan-guaifenesin caps 10 mg-200 mg

F

dextromethorphan-guaifenesin liqd 10 mg/5ml-100 mg/5ml, 10 mg/5ml-200 mg/5ml, 20 mg/10ml-200 mg/10ml, 20 mg/10ml-400 mg/10ml, 15 mg/7.5ml-150 mg/7.5ml

F

QL(16 ml daily)

dextromethorphan-guaifenesin liqd 5 mg/5ml-100 mg/5ml, 20 mg/5ml-300 mg/5ml, 30 mg/5ml-200 mg/5ml, 20 mg/20ml-400 mg/20ml, 20 mg/5ml-20 mg/5ml-300 mg/5ml-300mg/5ml, 30 mg/5ml-30mg/5ml-200 mg/5ml-200mg/5ml

F

dextromethorphan-guaifenesin syrp 10mg/5ml-100 mg/5ml, 10mg/5ml-10 mg/5ml-100mg/5ml-100 mg/5ml

F

dextromethorphan-guaifenesin tabs 20 mg-400 mg, 20 mg-20 mg-400mg-400 mg

F

QL(2 ea daily)

dextromethorphan-guaifenesin tb12 30 mg-600 mg

F QL(2 ea daily)

dextromethorphan-guaifenesin tb12 60 mg-1200 mg

F

dextromethorphan-phenylephrine-acetaminophen caps

F

dextromethorphan-phenylephrine-acetaminophen liqd

F

dextromethorphan-phenylephrine-acetaminophen pack

F


48

Drug Name DrugTier

Requirements/Limits

dextromethorphan-phenylephrine-acetaminophen tabs

F

DIABETIC TUSSIN COLD & FLU LIQD F

DIABETIC TUSSIN COLD/FLU CAPS F

DIABETIC TUSSIN NIGHT TIME COLD/FLU RELIEFLIQD

F

DIMETAPP COLD & ALLERGY ELIX (brompheniramine &phenyleph)

NF

DIMETAPP DM COLD & COUGH LIQD (phenylephrine-brompheniramine-dm)

NF

DIMETAPP LONG ACTING COUGH PLUS COLD SYRP

F

DIMETAPP MULTI-SYMPTOM COLD & FLU LIQD

F

DIMETAPP MULTI-SYMPTOM COLD RELIEF CHILDRENS LIQD (phenylephrine-brompheniramine-dm)

NF

diphenhydramine-acetaminophen tabs F

diphenhydramine-phenylephrine liqd F

diphenhydramine-phenylephrine soln F

diphenhydramine-phenylephrine tabs F

diphenhydramine-phenylephrine-acetaminophen liqd

F

diphenhydramine-phenylephrine-acetaminophen pack

F

diphenhydramine-phenylephrine-acetaminophen tabs

F

Drug Name DrugTier

Requirements/Limits

DOCTOR MANZANILLA PE SYRUP ANTIHISTAMINE/DECONGESTANT LIQD 2.5 MG/5ML-10 MG/5ML

F

DOLOGEN TABS F

DOLOGESIC LIQD F

DOLOGESIC TABS F

DOLOGESIC-DF TABS F

DOMETUSS-DA/CHILDREN LIQD F

DOMETUSS-DMX LIQD F QL(16 ml daily)

DOMETUSS-NR TABS F

DOUBLE-TUSSIN DM LIQD (dextromethorphan-guaifenesin)

NF

doxylamine-dm liqd F

doxylamine-dm lqpk F

doxylamine-phenylephrinetabs 7.5 mg-10 mg F

doxylamine-phenylephrine-acetaminophen misc F

DRIXORAL COLD/ALLERGY TB12 F

DRIXORAL COUGH & SORE THROAT CAPS F

DURAFLU TABS F

DURAVENT DM TABS F

DURAVENT PE TABS F

ED A-HIST DM TABS F

ED A-HIST LIQD (chlorpheniramine &phenylephrine)

NF

ED BRON GP LIQD F

ED CHLORPED D LIQD F


49

Drug Name DrugTier

Requirements/Limits

ENTEX T TABS (pseudoephedrine-guaifenesin)

NF

ephedrine-guaifenesin tabs F

EQ ALLERGY/SINUSHEADACHE TABS F

EQ SINUS RELIEF MAXIMUM STRENGTH TABS

F

EXACTUSS LIQD (phenylephrine w/ dm-gg) NF QL(16 ml

daily); RX/OTC

EXACTUSS TR TABS F RX/OTC

EXAPHEN CH TABS F

EXAPHEN TABS F

EXAPHEX TR TABS F RX/OTC

FATHER JOHNS MEDICINE PLUS SOLN F

fexofenadine-pseudoephedrine tb12 60mg-120 mg

F QL(2 ea daily)

fexofenadine-pseudoephedrine tb24 180mg-240 mg

F QL(1 ea daily)

G-DOLOGEN TABS F

G-P-TUSS DXP LIQD F

G-TUSICOF LIQD F QL(16 ml daily)

G-ZYNCOF SYRP F

GCON IR TABS F

GILPHEX TR TABS F RX/OTC

GILTUSS ALLERGY & SINUS TABS F

GILTUSS COUGH & COLD LIQD 29 MG/5ML-390MG/5ML-10 MG/5ML

F QL(16 ml daily)

GILTUSS COUGH & COLD TABS 28 MG-388 MG-10 MG

F RX/OTC

Drug Name DrugTier

Requirements/Limits

GILTUSS COUGH ALLERGY & SINUS TABS F

GILTUSS LIQD (phenylephrine w/ dm-gg) NF QL(16 ml

daily); RX/OTC GILTUSS SINUS & CONGESTION TABS F RX/OTC

GILTUSS TR TABS F RX/OTC

GLEN PE LIQD F

GLENMAX PEB DM LIQD F

GLENMAX PEB LIQD F

GLENTUSS LIQD 6.25 MG/5ML-30 MG/5ML-15MG/5ML

F

GNP COLD RELIEF PLUS TBEF F

guaifenesin-codeine liqd100 mg/5ml-10 mg/5ml F


guaifenesin-codeine liqd225 mg/5ml-7.5 mg/5ml F

guaifenesin-codeine soln100 mg/5ml-10 mg/5ml F


guaifenesin-codeine syrp100 mg/5ml-10 mg/5ml F


HERBIOMED DEEP COLD AND FLU NIGHTTIME LIQD

F

HERBIOMED FAST ACTING BODY ACHES & SINUS LIQD

F

HISTEX-AC SYRP F

HISTEX-DM SYRP F

HISTEX-PE SYRP NF


50

Drug Name DrugTier

Requirements/Limits

HYDROCODONE BITARTRATE/CHLORPHENIRAMINE MALEATE/PSESOLN

F

HYDROCODONE BITARTRATE/GUAIFENESIN SOLN

F

hydrocodone polistirex-chlorpheniramine polistirex suer

F

LITTLE REMEDIES FOR COLDSMULTI SYMPTOM LIQD

F

LODRANE D CAPS F

LOHIST-D LIQD F QL(16 ml daily)

LOHIST-DM SYRP F QL(16 ml daily)

loratadine & pseudoephedrine tb12 5mg-120 mg

F QL(2 ea daily)

loratadine & pseudoephedrine tb24 10mg-240 mg, 10 mg-10 mg-240 mg-240 mg

F

QL(1 ea daily)

LORTUSS DM LIQD NF

LORTUSS EX LIQD F

LORTUSS LQ LIQD F

M-CLEAR WC SOLN F

M-END DMX LIQD F

M-END PE LIQD F

MAR-COF BP LIQD F

MAR-COF CG EXPECTORANT LIQD (guaifenesin-codeine)

NF

MAXI-TUSS CD LIQD F

MAXI-TUSS DM LIQD F

MAXI-TUSS PE ELIX F

Drug Name DrugTier

Requirements/Limits

MAXI-TUSS PE JR LIQD F

MAXI-TUSS PE MAX LIQD F

MAXICHLOR PEH DM TABS F

MAXIFED TABS F

MUCINEX CHILDRENS COLD COUGH & SORE THROAT LIQD (phenylephrine-dm-gg w/ apap)

NF

MUCINEX CHILDRENS MULTI-SYMPTOM COLD & FEVER LIQD (phenylephrine-dm-gg w/ apap)

NF

MUCINEX CHILDRENS MULTI-SYMPTOM COLD LIQD (phenylephrine w/dm-gg)

NF

QL(16 ml daily)

MUCINEX CONGESTION & COUGH CHILDRENS LIQD (phenylephrine w/dm-gg)

NF

QL(16 ml daily)

MUCINEX COUGH & CONGESTION CHILDRENS LIQD (phenylephrine w/ dm-gg)

NF

QL(16 ml daily)

MUCINEX COUGH FOR KIDS PACK F

MUCINEX D MAXIMUM STRENGTH TB12 (pseudoephedrine-guaifenesin)

NF

MUCINEX D TB12 (pseudoephedrine-guaifenesin)

NF

MUCINEX DM MAXIMUM STRENGTH TB12 (dextromethorphan-guaifenesin)

NF

MUCINEX DM TB12 (dextromethorphan-guaifenesin)

NF QL(2 ea daily)


51

Drug Name DrugTier

Requirements/Limits

MUCINEX FAST-MAX COLD & SINUS LIQD (phenylephrine-acetaminophen-guaifenesin)

NF

MUCINEX FAST-MAX COLD FLU& SORE THROAT CLEAR & COOL LIQD (phenylephrine-dm-gg w/ apap)

NF

MUCINEX FAST-MAX COLD FLU& SORE THROAT LIQD (phenylephrine-dm-gg w/ apap)

NF

MUCINEX FAST-MAX COLD/FLU LIQD(phenylephrine-dm-gg w/ apap)

NF

MUCINEX FAST-MAX COLD/FLU/SORETHROAT CAPS (phenylephrine-dm-gg w/ apap)

NF

MUCINEX FAST-MAX DAY TIME/NIGHT TIME MISC F

MUCINEX FAST-MAX DAY TIME/NIGHT TIME MISC(phenylephrine-diphenhydramine-dm-guaifenesin-apap)

NF

MUCINEX FAST-MAX DAY/NIGHT CPPK(phenylephrine-doxylamine-dm-guaifenesin-apap)

NF

MUCINEX FAST-MAX DAY/NIGHT MAXIMUMSTRENGTH MISC

F

MUCINEX FAST-MAX DAY/NITE M/S MISC F

MUCINEX FAST-MAX SEVERE COLD LIQD (phenylephrine-dm-gg w/ apap)

NF

Drug Name DrugTier

Requirements/Limits

MUCINEX FAST-MAX SEVERE CONGESTION & COUGH CLEAR & COOL LIQD (phenylephrine w/dm-gg)

NF

QL(16 ml daily)

MUCINEX FAST-MAX SEVERE CONGESTION & COUGH LIQD 5 MG/5ML-100 MG/5ML-2.5 MG/5ML,20 MG/20ML-400MG/20ML-10 MG/20ML(phenylephrine w/ dm-gg)

NF

QL(16 ml daily)

MUCINEX FAST-MAX SEVERE CONGESTION & COUGH TABS 10 MG-200 MG-5 MG

F

MUCINEX MULTI-SYMPTOM COLD DAY/NIGHT PACK MISC

F

MUCINEX SINUS-MAX DAY TIME/NIGHT TIMEMISC

F

MUCINEX SINUS-MAX DAY/NIGHT CPPK 6.25MG-10 MG-325 MG-200 MG-5 MG (phenylephrine-doxylamine-dm-guaifenesin-apap)

NF

MUCINEX SINUS-MAX DAY/NIGHT MISC 12.5MG-325 MG-200 MG-5 MG

F

MUCINEX SINUS-MAX SEVERECONGESTION RELIEF CAPS (phenylephrine-dm-gg w/ apap)

NF

MUCINEX STUFFY NOSE & COLD CHILDRENS LIQD (phenylephrine-guaifenesin)

NF

MULTI-SYMPTOM COLD DAYTIME/NIGHTTIMECHILDRENS MISC

F

NASOPEN PE LIQD F

NEOTUSS PLUS LIQD F

NEOTUSS-D LIQD F QL(16 ml daily)


52

Drug Name DrugTier

Requirements/Limits

NEXAFED SINUS PRESSURE +PAIN TABS F

NINJACOF LIQD F

NINJACOF-A LIQD F

NINJACOF-XG LIQD F

NITE-TIME COLD/FLURELIEF LIQD F

NIVANEX DMX TABS F

NOREL AD TABS F

NOREL CS LIQD F

PANATUSS PED DROPS LIQD F

PANATUSS PED LIQD F

PECGEN DMX LIQD F

PEDIACARE COUGH & RUNNY NOSE LIQD F

PEDIATRIC COUGH/COLD LIQD F

PERCOGESIC TABS F

PHENAGIL CH TABS F

PHENAGIL TABS F

PHENYLEPHRINE HCL/PYRILAMINEMALEATE TABS

F

phenylephrine w/acetaminophen caps F

phenylephrine w/acetaminophen tabs F

phenylephrine w/ dm-ggliqd 18 mg/15ml-200mg/15ml-10 mg/15ml

F

Drug Name DrugTier

Requirements/Limits

phenylephrine w/ dm-ggliqd 5 mg/ml-100 mg/ml-2.5mg/ml, 10 mg/5ml-100mg/5ml-5 mg/5ml, 10mg/5ml-200 mg/5ml-5mg/5ml, 5 mg/5ml-75mg/5ml-2.5 mg/5ml, 15mg/5ml-350 mg/5ml-10mg/5ml, 5 mg/5ml-100mg/5ml-2.5 mg/5ml, 20mg/10ml-200 mg/10ml-10mg/10ml, 20 mg/20ml-400mg/20ml-10 mg/20ml, 10mg/5ml-10 mg/5ml-100mg/5ml-100 mg/5ml-5mg/5ml-5 mg/5ml

F

QL(16 ml daily)

phenylephrine w/ dm-ggliqd 5 mg/ml-50 mg/ml-2.5mg/ml, 7.5 mg/ml-88mg/ml-2.5 mg/ml, 15mg/5ml-300 mg/5ml-10mg/5ml, 28 mg/5ml-388mg/5ml-10 mg/5ml, 7.5mg/2.5ml-150 mg/2.5ml-5mg/2.5ml

F

QL(16 mldaily); RX/OTC

phenylephrine w/ dm-ggsyrp 10 mg/5ml-100mg/5ml-5 mg/5ml

F QL(16 ml daily)

phenylephrine w/ dm-ggtabs 20 mg-400 mg-10 mg,17.5 mg-385 mg-10 mg

F

phenylephrine-acetaminophen-guaifenesinliqd

F

phenylephrine-acetaminophen-guaifenesintabs

F

phenylephrine-brompheniramine-dm elix 1mg/5ml-5 mg/5ml-2.5mg/5ml

F

QL(16 ml daily)

phenylephrine-brompheniramine-dm liqd 1mg/5ml-5 mg/5ml-2.5mg/5ml, 4 mg/5ml-20mg/5ml-10 mg/5ml, 1mg/5ml-1 mg/5ml-5mg/5ml-5 mg/5ml-2.5mg/5ml-2.5 mg/5ml

F


53

Drug Name DrugTier

Requirements/Limits

phenylephrine-chlorphen-dm liqd F

phenylephrine-chlorpheniramine w/ dm-gg& apap tbpk 10 mg-2 mg-325 mg-200 mg-5 mg

F

phenylephrine-chlorpheniramine-dm w/apap liqd

F

phenylephrine-chlorpheniramine-dm w/apap misc

F

phenylephrine-chlorpheniramine-dm w/ apap susp

F

phenylephrine-chlorpheniramine-dm w/apap tabs

F

phenylephrine-diphenhydramine-dm w/apap misc

F

phenylephrine-diphenhydramine-dm-guaifenesin-apap misc

F

phenylephrine-diphenhydramine-dm-guaifenesin-apap tbpk

F

phenylephrine-diphenhydramine-gg w/apap misc

F

phenylephrine-dm liqd F

phenylephrine-dm soln F

phenylephrine-dm-gg w/ apap caps F

phenylephrine-dm-gg w/apap liqd F

phenylephrine-dm-gg w/apap tabs F

phenylephrine-doxylamine-dextromethorphan-acetaminophen caps

F

phenylephrine-doxylamine-dextromethorphan-acetaminophen liqd

F

Drug Name DrugTier

Requirements/Limits

phenylephrine-doxylamine-dextromethorphan-acetaminophen misc

F

phenylephrine-doxylamine-dm-guaifenesin-apap cppk F

phenylephrine-doxylamine-dm-guaifenesin-apap lqpk F

phenylephrine-guaifenesinliqd F

phenylephrine-guaifenesintabs F

phenylephrine-ibuprofentabs 200 mg-10 mg F

phenylephrine-triprolidine-dextromethorphan syrp F

POLY HIST FORTE TABS (doxylamine-phenylephrine)

NF

POLY-HIST DM LIQD F

POLY-HIST PD LIQD F

POLY-TUSSIN AC LIQD F

POLY-VENT DM TABS F

POLY-VENT IR TABS F

POLYTUSSIN DM SYRP F

PRIMATENE ASTHMA TABS (ephedrine-guaifenesin)

NF

PRO-RED AC SYRP F

promethazine &phenylephrine soln F QL(16 ml daily)

promethazine w/codeinesoln F


promethazine w/codeine syrp F


promethazine-dm syrp F QL(16 ml daily)


54

Drug Name DrugTier

Requirements/Limits

promethazine-phenylephrine-codeine syrp

F

PROMETHAZINE/DEXTROMETHORPHAN SOLN F QL(16 ml daily)

PROMETHAZINE/PHENYLEPHRINE SYRP F QL(16 ml daily)

PROMETHAZINE/PHENYLEPHRINE/CODEINE SYRP F

pseudoephed-bromphen-dm syrp F

pseudoephedrine w/codeine-gg soln F


pseudoephedrine w/ dm-ggliqd F

pseudoephedrine-acetaminophen tabs F

pseudoephedrine-chlorphen-dm liqd F

pseudoephedrine-dexchlorpheniramine-chlophedianol liqd

F

pseudoephedrine-dexchlorpheniramine-dextromethorphan liqd

F

pseudoephedrine-guaifenesin syrp F

pseudoephedrine-guaifenesin tabs F

pseudoephedrine-guaifenesin tb12 F

pseudoephedrine-ibuprofentabs 200 mg-30 mg F

pseudoephedrine-naproxensodium tb12 220 mg-120 mg

F

PX DAYTIME MULTI-SYMPTOM CAPS F

PX NITETIME MULTI-SYMPTOM CAPS F

QC MEDIFIN PE TABS (phenylephrine-guaifenesin)

NF

QC TRIACTING DAYTIME CHILDRENS SYRP F

Drug Name DrugTier

Requirements/Limits

RA ACETAMINOPHEN FLU SEVERE COLD TABS F

RA SINUS RELIEF DAYTIME/NIGHTTIMEMISC

F

REFENESEN CHEST CONGESTION & PAIN RELIEF PE TABS

F

REFENESEN CHEST CONGESTION & PAIN RELIEF TABS

F

RESCON TABS F

RESPAIRE-30 CAPS F

ROBITUSSIN CHILDRENS COUGH & COLD CF LIQD F QL(16 ml daily)

ROBITUSSIN CHILDRENS COUGH/COLD LONG-ACTING LIQD

F

ROBITUSSIN COUGH & COLD DAY/NIGHT PACKMISC

F

ROBITUSSIN NIGHTTIME COUGH DM LIQD (doxylamine-dm)

NF

ROBITUSSIN NIGHTTIME COUGH LONG-ACTING DM CHILDRENS LIQD

F

ROBITUSSIN PEAK COLD COUGH+ CHEST CONGESTION DM MAX STRENGTH LIQD (dextromethorphan-guaifenesin)

NF

QL(16 ml daily)

ROBITUSSIN PEAK COLD DAY/NIGHT PACK DMMISC

F

ROBITUSSIN PEAK COLD DAY/NIGHT PACKMAXIMUM STRENGTH MISC

F

ROBITUSSIN PEAK COLD DM SYRP (dextromethorphan-guaifenesin)

NF


55

Drug Name DrugTier

Requirements/Limits

ROBITUSSIN PEAK COLD MULTI-SYMPTOM COLD LIQD (phenylephrine w/dm-gg)

NF

QL(16 ml daily)

ROBITUSSIN TO GO COUGH &COLD CF LIQD (phenylephrine w/ dm-gg)

NF QL(16 ml daily)

RONDEC-D LIQD F

RU-HIST D TABS F

RYCONTUSS LIQD (phenylephrine-chlorphen-dm)

NF

RYDEX G TABS F

RYDEX LIQD F

RYMED TABS F

SB NIGHTTIME SINUS MULTI-SYMPTOM CAPS F

SCOT-TUSSIN DM LIQD F

SCOT-TUSSIN SENIOR LIQD F

SEMPREX-D CAPS F

SINADRIN PE COMPLETE SINUS RELIEF TABS F

SM COUGH & SORE THROAT DAYTIME PAIN RELIEVER LIQD

F

SORBUTUSS NR LIQD F

STAHIST AD LIQD F

STAHIST AD TABS F

STAHIST LIQD F

SUDAFED PE SINUS CONGESTION DAYTIME/NIGHTTIMETABS

F

SUPRESS A PEDIATRIC DROPS LIQD F

Drug Name DrugTier

Requirements/Limits

SUPRESS DM PEDIATRIC LIQD F

SUPRESS-PE PEDIATRIC LIQD F

THERACOF PLUS COUGH AND COLD RELIEVER LIQD

F

THERAFLU COLD & COUGH PACK F

THERAFLU FLU & SORE THROAT PACK F

THERAFLU POWERPODS DAYTIME SEVERE COLD MISC

F

THERAFLU POWERPODS NIGHTTIME SEVERE COLD MISC

F

THERAFLU SEVERE COLD & COUGH DAYTIME/NIGHTTIMEMISC (phenylephrine-diphenhydramine-dm w/ apap)

NF

THERAFLU SEVERE COLD & COUGH NIGHTTIME PACK (diphenhydramine-phenylephrine-acetaminophen)

NF

THERAFLU SEVERE COLD DAYTIME TABS F

THERAFLU SEVERE COLD MULTI SYMPTOM NIGHTTIME PACK

F

THERAFLU SEVERE COLD MULTI SYMPTOM PACK (dextromethorphan-phenylephrine-acetaminophen)

NF

THERAFLU SEVERE COLD NIGHTTIME TABS (phenylephrine-chlorpheniramine-dm w/ apap)

NF

TRIAMINIC CHEST/NASALCONGESTION LIQD

F


56

Drug Name DrugTier

Requirements/Limits

TRIAMINIC COLD & ALLERGY SYRP F

TRIAMINIC COLD & COUGH DAY TIME CHILDRENS SYRP

F

TRIAMINIC COLD & COUGH DAY/NIGHTCHILDRENS MISC

NF

TRIAMINIC COUGH & RUNNY NOSE CHILDRENS CHEW

F

TRIAMINIC COUGH & SORE THROAT CHEW F

TRIAMINIC FLU COUGH & FEVER SYRP F

TRIAMINIC FLU/COUGH/FEVER LIQD F

TRIAMINIC NIGHT TIME COLD & COUGH SYRP F

triprolidine &pseudoephedrine tabs F

TRISPEC DMX LIQD F

TRISPEC DMX PEDIATRIC LIQD F

TUSICOF LIQD F QL(16 ml daily)

TUSNEL C SYRP F


TUSNEL DM LIQD F QL(16 ml daily)

TUSNEL LIQD F

TUSNEL PEDIATRIC LIQD F

TUSNEL TABS F

TUSNEL-DM PEDIATRIC LIQD F

TUSSI-PRES PEDIATRIC LIQD (phenylephrine w/dm-gg)

NF QL(16 ml daily)

TUSSICAPS CP12 F

Drug Name DrugTier

Requirements/Limits

TUSSIONEX PENNKINETIC EXTENDED RELEASE SUER (hydrocodonepolistirex-chlorpheniraminepolistirex)

NF

TUSSLIN LIQD F QL(16 mldaily); RX/OTC

TUSSLIN PEDIATRIC LIQD F QL(16 ml

daily); RX/OTC

TUXARIN ER TB12 F

TUZISTRA XR SUER F

TYLENOL CHILDRENS COLD/FLU SUSP(phenylephrine-chlorpheniramine-dm w/ apap)

NF

TYLENOL CHILDRENS PLUS MULTI-SYMPTOM COLD SUSP (phenylephrine-chlorpheniramine-dm w/ apap)

NF

TYLENOL COLD & FLU SEVERE TABS (phenylephrine-dm-gg w/ apap)

NF

TYLENOL COLD & HEAD SEVERE CONGESTION TABS (phenylephrine-acetaminophen-guaifenesin)

NF

TYLENOL COLD + FLU + COUGH FOR ADULTS/NIGHT LIQD(phenylephrine-doxylamine-dextromethorphan-acetaminophen)

NF

TYLENOL COLD MAX LIQD (dextromethorphan-phenylephrine-acetaminophen)

NF


57

Drug Name DrugTier

Requirements/Limits

TYLENOL COLD MULTI-SYMPTOM NIGHTTIME LIQD (phenylephrine-doxylamine-dextromethorphan-acetaminophen)

NF

TYLENOL COLD MULTI-SYMPTOM SEVERE DAYTIME LIQD (phenylephrine-dm-gg w/ apap)

NF

TYLENOL COLD PLUS FLU SEVERE FOR ADULTS DAY/NIGHTTBPK (phenylephrine-chlorpheniramine w/ dm-gg& apap)

NF

TYLENOL COLD/COUGH/RUNNYNOSE CHILDRENS SUSP (dextromethorphan-acetaminophen-chlorpheniramine)

NF

TYLENOL COLD/COUGH/SORETHROAT CHILDRENS SUSP (acetaminophen w/dm)

NF

TYLENOL SINUS SEVERE TABS (phenylephrine-acetaminophen-guaifenesin)

NF

TYLENOL WARMING COUGH & SEVER CONGESTION DAYTIME LIQD (phenylephrine-dm-gg w/ apap)

NF

VANACOF AC LIQD F

VANACOF DM LIQD (phenylephrine w/ dm-gg) NF

VANACOF LIQD F

VANACOF-8 LIQD F

VANATAB AC TABS F

VANATAB DM TABS F

Drug Name DrugTier

Requirements/Limits

VICKS DAYQUIL MUCUS CONTROL DM LIQD F

VICKS DAYQUIL/NYQUILCOUGH LQPK (doxylamine-dm)

NF

VICKS DAYQUIL/NYQUILSEVERE LQPK (phenylephrine-doxylamine-dm-guaifenesin-apap)

NF

VICKS NYQUIL CHILDRENS COLD/COUGH LIQD

F

VICKS NYQUIL COLD & FLU LIQD (dextromethorphan-doxylamine-acetaminophen)

NF

VICKS NYQUIL COLD & FLU NIGHTTIME RELIEF LIQD 30 MG/30ML-4MG/30ML-650 MG/30ML

F

VICKS NYQUIL COLD & FLU NIGHTTIME RELIEF LIQD 6.25 MG/15ML-15MG/15ML-325 MG/15ML(dextromethorphan-doxylamine-acetaminophen)

NF

VICKS NYQUIL COUGH LIQD (doxylamine-dm) NF

VICKS NYQUIL HBP COLD & FLU LIQD (dextromethorphan-doxylamine-acetaminophen)

NF

VICKS NYQUIL SEVERE COLD& FLU MAX STRENGTH TABS

F

VICKS SINEX DAYQUIL/NYQUILDAYTIME/NIGHTTIMESINUS RELIEF MISC (doxylamine-phenylephrine-acetaminophen)

NF


58

Drug Name DrugTier

Requirements/Limits

VICKS SINEX DAYTIME/NIGHTTIME/CONGESTION/PRESSURE & PAIN MISC (doxylamine-phenylephrine-acetaminophen)

NF

WAL-FLU COLD & SORE THROAT PACK F

WAL-FLU SEVERE COLD DAYTIME PACK F

WAL-FLU SEVERE COLD NIGHT TIME PACK F

Y-TUSS LIQD F

Z-TUSS AC LIQD F

ZYNCOF SYRP F

ZYRTEC-D ALLERGY/CONGESTIONTB12 (cetirizine-pseudoephedrine)

NF

QL(2 ea daily)

Expectorants BROMHEXINE HCL POWD F

guaifenesin liqd or 100mg/5ml, 200 mg/5ml, 200mg/10ml, 400 mg/20ml

F QL(16 ml daily)

GUAIFENESIN POWD XX F

guaifenesin soln or 100mg/5ml, 200 mg/10ml, 300mg/15ml

F QL(16 ml daily)

guaifenesin syrp or 100mg/5ml, 200 mg/10ml F QL(16 ml daily)

guaifenesin tabs or 200mg, 400 mg F

guaifenesin tb12 or 600mg, 1200 mg F

HERBAL EXPEC LIQD F QL(16 ml daily)

MUCINEX FOR KIDS PACK F

MUCINEX MAXIMUM STRENGTH TB12 (guaifenesin)

NF

Drug Name DrugTier

Requirements/Limits

MUCINEX TB12 (guaifenesin) NF

SSKI SOLN F

TERPIN HYDRATE MONOHYDRATE POWD F

TERPIN HYDRATE POWD F

Misc. Respiratory Inhalants HYPER-SAL NEBU (sodium chloride (inhalant)) NF

HYPERSAL NEBU 7 % (sodium chloride (inhalant)) NF

sodium chloride (inhalant)nebu 0.9 %, 3 %, 7 % F

Mucolytics ACETYLCYSTEINE POWD XX F

acetylcysteine soln in 10 %,20 % F

N-ACETYL-L-CYSTEINE POWD F

DERMATOLOGICALS - Drugs to Treat SkinConditions

Acne Products

ABSORICA CAPS F PA

ACNE MEDICATION 10 LOTN F

ACNE MEDICATION 5 LOTN F

BENZAC AC WASH LIQD (benzoyl peroxide) NF RX/OTC

BENZEFOAM FOAM (benzoyl peroxide) NF RX/OTC

BENZEFOAM ULTRA FOAM (benzoyl peroxide) NF

BENZIQ GEL F

BENZIQ LS GEL F

BENZIQ WASH LIQD F

benzoyl peroxide bar ex 10% F


59

Drug Name DrugTier

Requirements/Limits

BENZOYL PEROXIDE CLEANSER LIQD F

benzoyl peroxide crea ex10 %, 2.5 % F

benzoyl peroxide foam ex5.3 % F RX/OTC

benzoyl peroxide foam ex9.8 % F

benzoyl peroxide gel ex 5%, 10 %, 2.5 % F

benzoyl peroxide liqd ex 4%, 7 %, 10 % F

benzoyl peroxide liqd ex 5%, 2.5 % F RX/OTC

CLEOCIN-T GEL (clindamycin phosphate(topical))

NF

CLEOCIN-T LOTN (clindamycin phosphate(topical))

NF

CLEOCIN-T SOLN (clindamycin phosphate(topical))

NF

CLINDAGEL GEL 1 % (clindamycin phosphate(topical))

F

clindamycin phosphate(topical) gel 1 % F

clindamycin phosphate(topical) lotn 1 % F

clindamycin phosphate(topical) soln 1 % F

ERYGEL GEL (erythromycin (acne aid)) NF

erythromycin (acne aid) gel2 % F

erythromycin (acne aid)pads 2 % F

erythromycin (acne aid)soln 2 % F

isotretinoin caps or 10 mg,20 mg, 30 mg, 40 mg F PA

KLARON LOTN (sulfacetamide sodium (acne))

NF

Drug Name DrugTier

Requirements/Limits

NEUTROGENA ON-THE-SPOT ACNE TREATMENT CREA (benzoyl peroxide)

NF

OC8 GEL F

PANOXYL LIQD (benzoylperoxide) NF RX/OTC

PANOXYL-4 CREAMY WASH LIQD (benzoylperoxide)

NF

RETIN-A CREA (tretinoin) NF AL(Up to 26 yrsold )

RETIN-A GEL (tretinoin) NF AL(Up to 26 yrsold )

RETIN-A MICRO GEL (tretinoin microsphere) NF AL(Up to 26 yrs

old ) RETIN-A MICRO PUMP GEL 0.04 %, 0.1 % (tretinoin microsphere)

NF AL(Up to 26 yrsold )

RETIN-A MICRO PUMP GEL 0.08 % F AL(Up to 26 yrs

old )

RIAX FOAM F

sulfacetamide sodium (acne) lotn 10 % F

tretinoin crea ex 0.025 %,0.05 %, 0.1 % F AL(Up to 26 yrs

old ) tretinoin gel ex 0.025 %,0.01 % F AL(Up to 26 yrs

old )

tretinoin microsphere gel F AL(Up to 26 yrsold )

ZACLIR CLEANSING LOTN F

Anti-inflammatory Agents - Topical

diclofenac sodium (topical)gel 1 % F

QL(200 gm per30 days retail);RX/OTC

FLECTOR PTCH NF

VOLTAREN GEL (diclofenac sodium (topical))

NF QL(200 gm per30 days retail);RX/OTC

Antibiotics - Topical BACIGUENT OINT EX (bacitracin (topical)) NF


60

Drug Name DrugTier

Requirements/Limits

bacitracin (topical) oint 500unit/gm F

bacitracin zinc oint ex 500 unit/gm F

bacitracin-polymyxin b oint F

BACTROBAN CREA (mupirocin calcium(topical))

NF QL(1 gm daily)

CENTANY OINT 2 % F

gentamicin sulfate (topical)crea 0.1 % F

gentamicin sulfate (topical)oint 0.1 % F

mupirocin calcium (topical)crea 2 % F QL(1 gm daily)

mupirocin oint ex 2 % F

neomycin-bacitracin-polymyxin oint F

neomycin-bacitracin-polymyxin-pramoxine oint F

NEOSPORIN ORIGINAL OINT (neomycin-bacitracin-polymyxin)

NF

POLYSPORIN OINT (bacitracin-polymyxin b) NF

Antifungals - Topical butenafine hcl crea 1 % F RX/OTC

ciclopirox olamine crea ex0.77 % F

ciclopirox olamine susp ex0.77 % F

ciclopirox soln 8 % F

clotrimazole (topical) crea 1% F RX/OTC

clotrimazole (topical) soln 1% F RX/OTC

clotrimazole w/betamethasone crea 1 %-0.05 %

F

EXELDERM CREA NF

Drug Name DrugTier

Requirements/Limits

ketoconazole (topical) crea2 % F

ketoconazole (topical)sham 2 % F

LAMISIL AT CREA (terbinafine hcl (topical)) NF

LAMISIL AT JOCK ITCH CREA (terbinafine hcl (topical))

NF

LOPROX CREA (ciclopiroxolamine) NF

LOPROX SUSP (ciclopiroxolamine) NF

LOTRIMIN AF CREA (clotrimazole (topical)) NF RX/OTC

LOTRIMIN AF JOCK ITCH CREA (clotrimazole (topical))

NF RX/OTC

LOTRIMIN ANTIFUNGAL AERO (miconazole nitrate (topical))

NF

LOTRIMIN ULTRA CREA (butenafine hcl) NF RX/OTC

LOTRISONE CREA (clotrimazole w/betamethasone)

NF

LUZU CREA NF

MICATIN CREA (miconazole nitrate (topical))

NF

miconazole nitrate (topical) aero F

miconazole nitrate (topical) crea F

miconazole nitrate (topical)powd F

MICONAZOLE NITRATE POWD F

NIZORAL SHAM (ketoconazole (topical)) NF

nystatin (topical) crea F

nystatin (topical) oint F

nystatin (topical) powd F


61

Drug Name DrugTier

Requirements/Limits

PENLAC NAIL LACQUER SOLN (ciclopirox) NF

terbinafine hcl (topical)crea 1 % F

TINACTIN AERO (tolnaftate) NF

TINACTIN AERP (tolnaftate) NF

TINACTIN CREA (tolnaftate) NF

TINACTIN DEODORANT AERP (tolnaftate) NF

TINACTIN JOCK ITCH AERP (tolnaftate) NF

tolnaftate aero ex 1 % F

tolnaftate aerp ex 1 % F

tolnaftate crea ex 1 % F

tolnaftate liqd ex 1 % F

tolnaftate soln ex 1 % F

XOLEGEL GEL 2 % F

Antihistamines-Topical diphenhydramine hcl(topical) gel F

diphenhydramine hcl(topical) soln F

ITCH RELIEF CREA F

Antineoplastic or Premalignant Lesion Agents -CARAC CREA NF

EFUDEX CREA (fluorouracil (topical)) NF

fluorouracil (topical) crea 5% F

Antipsoriatics

VECTICAL OINT NF

Antiseborrheic Products OVACE PLUS WASH LIQD (sulfacetamide sodium) NF

Drug Name DrugTier

Requirements/Limits

OVACE WASH LIQD (sulfacetamide sodium) NF

selenium sulfide lotn ex 1 %, 2.5 % F

selenium sulfide sham ex 1 % F

SELSUN BLUE DAILY LOTN (selenium sulfide) NF

SELSUN BLUE LOTN (selenium sulfide) NF

SELSUN BLUE MEDICATED LOTN (selenium sulfide)

NF

SELSUN BLUE MOISTURIZING LOTN (selenium sulfide)

NF

sulfacetamide sodium liqdex 10 % F

Antivirals - Topical

ABREVA CREA (docosanol) NF

Limit 2 permonth;QL(0.067 gm daily)

acyclovir topical oint 5 % F QL(0.5 gmdaily)

docosanol crea ex 10 % F Limit 2 permonth;QL(0.067 gm daily)

ZOVIRAX OINT EX 5 % (acyclovir topical) NF QL(0.5 gm

daily) Burn Products SILVADENE CREA (silver sulfadiazine) NF

silver sulfadiazine crea ex 1 % F

Corticosteroids - Topical betamethasone dipropionate (topical) lotn0.05 %

F

betamethasone dipropionate augmentedcrea 0.05 %

F

betamethasone valerate crea ex 0.1 % F

betamethasone valerate lotn ex 0.1 % F


62

Drug Name DrugTier

Requirements/Limits

betamethasone valerate oint ex 0.1 % F

clobetasol propionate creaex 0.05 % F QL(3.34 gm

daily) clobetasol propionateemollient base crea F QL(3.34 gm

daily) clobetasol propionate gelex 0.05 % F QL(118 gm per

fill retail) clobetasol propionate ointex 0.05 % F QL(3.34 gm

daily) clobetasol propionate solnex 0.05 % F QL(3.34 ml

daily)

CLODERM CREA NF

DERMA-SMOOTHE/FSBODY OIL 0.01 % (fluocinolone acetonide)

F 1 rtl pack lmtamt,30 rtl packlmt day(s),

DERMA-SMOOTHE/FSSCALP OIL 0.01 % (fluocinolone acetonide)

F 1 rtl pack lmtamt,30 rtl packlmt day(s),

DIPROLENE AF CREA (betamethasone dipropionate augmented)

NF

ELOCON CREA (mometasone furoate) NF

ELOCON OINT (mometasone furoate) NF

fluocinonide crea ex 0.05 % F QL(2 gm daily)

fluocinonide oint ex 0.05 % F QL(60 gm perfill retail)

fluocinonide soln ex 0.05 % F

fluticasone propionate creaex 0.05 % F

fluticasone propionate ointex 0.005 % F

halobetasol propionatecrea 0.05 % F QL(2 gm daily)

halobetasol propionate oint0.05 % F QL(2 gm daily)

hydrocortisone (topical)crea 0.5 %, 2.5 % F

hydrocortisone (topical)crea 1 % F RX/OTC

Drug Name DrugTier

Requirements/Limits

hydrocortisone (topical) gel1 % F

hydrocortisone (topical) lotn1 %, 2.5 % F

hydrocortisone (topical) oint0.5 %, 2.5 % F

hydrocortisone (topical) oint1 % F RX/OTC

hydrocortisone acetate(topical) crea 1 % F

hydrocortisone-aloe veracrea 1 % F

mometasone furoate crea ex 0.1 % F

mometasone furoate oint ex 0.1 % F

mometasone furoate soln ex 0.1 % F

MONISTAT SOOTHING CARE ITCH RELIEF CREA (hydrocortisone (topical))

NF RX/OTC

TACLONEX SUSP (calcipotriene-betamethasone dipropionate)

NF

TEMOVATE CREA (clobetasol propionate) NF QL(3.34 gm

daily) TEMOVATE OINT (clobetasol propionate) NF QL(3.34 gm

daily) triamcinolone acetonide (topical) crea 0.025 %, 0.1%, 0.5 %

F

triamcinolone acetonide (topical) lotn 0.025 %, 0.1%

F

triamcinolone acetonide (topical) oint 0.025 %, 0.05%, 0.1 %, 0.5 %

F

ULTRAVATE CREA (halobetasol propionate) NF QL(2 gm daily)

ULTRAVATE OINT (halobetasol propionate) NF QL(2 gm daily)

Emollient/Keratolytic Agents ATRAC-TAIN CREA 10 % (urea) NF


63

Drug Name DrugTier

Requirements/Limits

REA-LO CREA F

URE-K CREA F

urea crea ex 10 %, 20 %,50 % F

urea crea ex 40 % F RX/OTC

urea lotn ex 40 % F

Emollients LAC-HYDRIN CREA (lactic acid (ammonium lactate)) NF RX/OTC

LAC-HYDRIN TWELVE LOTN (lactic acid (ammonium lactate))

NF RX/OTC

lactic acid (ammoniumlactate) crea 12 % F RX/OTC

lactic acid (ammoniumlactate) lotn 10 % F

lactic acid (ammoniumlactate) lotn 12 % F RX/OTC

NOBLE MYSTIQUE EMU-LAC CREA F

Immunomodulating Agents - Topical ALDARA CREA (imiquimod) NF

imiquimod crea ex 5 % F

Keratolytic/Antimitotic Agents AMBI EVEN & CLEAR EXFOLIATING WASH LIQD

F

AMBI EVEN & CLEAR FOAMINGCLEANSER LIQD

F

BETASAL SHAM F

CLEAN & CLEAR ACNE TRIPLECLEAR BUBBLE FOAM CLEANSER FOAM

F

CLEAN & CLEAR ADVANTAGE OIL ABSORBING CLEANSER CREA

F

Drug Name DrugTier

Requirements/Limits

CLEAN & CLEAR BLACKHEAD ERASER SCRUB CREA

F

CLEAN & CLEAR DEEP CLEANING ASTRINGENT SENSITIVE SKIN LIQD

F

CLEARASIL DAILY CLEAN GENTLE PREVENTION LIQD

F

CLN ACNE CLEANSER LIQD F

COMPOUND W LIQD (salicylic acid) NF

COMPOUND W MAXIMUM STRENGTH GEL (salicylicacid)

NF

CORN & CALLUS REMOVER SOLN F

CVS PSORIASIS MEDICATED SHAMPOO PLUS CONDITIONER SHAM

F

CVS THERAPEUTIC DANDRUFFMAXIMUM STRENGTH SHAM

F

DENOREX EXTRA STRENGTH 2-IN-1 SHAM F

DERMAREST PSORIASIS GEL F

DERMAREST PSORIASIS MEDICATED SHAMPOO PLUS CONDITIONER SHAM

F

FREEZONE LIQD F

GOLD BOND PSORIASIS RELIEF MULTI-SYMPTOM CREA

F

KERALYT GEL 3 % F

KERALYT GEL 6 % (salicylic acid) NF

MG217 PSORIASIS MULTI-SYMPTOM CREA 3 %

F

MOSCO CALLUS/CORNREMOVER SOLN F


64

Drug Name DrugTier

Requirements/Limits

NEUTROGENA T/SALSHAM F

P & S SHAM F

podofilox soln ex 0.5 % F

SALAC FOAM F

SALEX SHAM (salicylicacid) NF

salicylic acid crea ex 2 %, 6% F

salicylic acid foam ex 6 % F PA

salicylic acid gel ex 2 %, 6%, 17 % F

salicylic acid liqd ex 2 %, 3%, 17 % F

salicylic acid lotn ex 0.5 %,6 % F

SALICYLIC ACID LOTN EX 6 % F

salicylic acid sham ex 6 % F

salicylic acid soln ex 17 %,26 % F

SALICYLIC ACID SOLN EX 26 % F

SALVAX FOAM (salicylicacid) NF PA

SELSUN BLUE DEEP CLEANSING SHAM F

SELSUN BLUE NATURALS DRYSCALP SHAM

F

THERAPEUTIC T+PLUS MAXIMUM STRENGTH SHAM

F

Local Anesthetics - Topical lidocaine crea ex 4 % F

lidocaine hcl crea ex 4 % F

Max 2 tubes per 30days;QL(266gm per 30 daysretail)

Drug Name DrugTier

Requirements/Limits


Max 3 tubes per 30days;QL(230gm per 30 daysretail)


lidocaine hcl gel ex 2 % F QL(60 ml per30 days retail);RX/OTC

lidocaine hcl gel ex 2 % F

lidocaine hcl prsy ex 2 % F

lidocaine hcl soln ex 4 % F

lidocaine oint ex 5 % F PA; QL(50 gmper fill retail)

lidocaine ptch ex 5 % F PA; QL(3 eadaily)

lidocaine-prilocaine crea2.5 %-2.5 % F QL(30 gm per

30 days retail) LIDODERM PTCH (lidocaine) NF PA; QL(3 ea

daily)

LMX 4 CREA (lidocaine) NF

PREDATOR CREA (lidocaine hcl) NF

XOLIDO CREA F

Misc. Topical CALAMINE LOTN EX F

DESITIN RAPID RELIEF CREA F

DRYSOL SOLN 20 % F

GNP CALAMINE LOTN F

HM CALAMINE LOTN F

JOHNSONS NO MORE RASH CREA F

MEIJER CALAMINE LOTN F

PX CALAMINE LOTN F


65

Drug Name DrugTier

Requirements/Limits

QC CALAMINE LOTN F

RA CALAMINE LOTN 6.971 %-6.971 % F

SM CALAMINE LOTN F

zinc oxide (topical) crea 13% F

zinc oxide (topical) oint 20%, 40 % F

Rosacea Agents METROCREAM CREA (metronidazole (topical)) NF

METROLOTION LOTN (metronidazole (topical)) NF

metronidazole (topical)crea 0.75 % F

metronidazole (topical) gel0.75 % F

metronidazole (topical) lotn0.75 % F

Scabicides & Pediculicides

crotamiton lotn ex 10 % F PA

ELIMITE CREA (permethrin) NF

EURAX CREA 10 % F PA

EURAX LOTN NF PA

LICEMD GEL F

lindane sham F

LYCELLE GEL F

NATROBA SUSP F PA

nit remover gel F

NIX CREME RINSE LIQD (permethrin) NF

permethrin crea ex 5 % F

permethrin liqd ex 1 % F

Drug Name DrugTier

Requirements/Limits

permethrin lotn ex 1 % F

pyrethrins-piperonylbutoxide sham 0.3 %-0.33 %-4 %, 0.33 %-4 %

F

pyrethrins-piperonylbutoxide-permethrin-nitremover kit 0.5 %-0.33 %-4 %

F

RA LICE SOLUTION KIT KIT F

RID COMPLETE LICE ELIMINATION KIT (pyrethrins-piperonylbutoxide-permethrin-nit remover)

NF

SCHOOLTIME SHAMPOO SHAM F

SKLICE LOTN F PA

spinosad susp F PA

DIAGNOSTIC PRODUCTS

Diagnostic Tests

ALBUSTIX STRP F

CHEMSTRIP MICRAL STRP F

CHEMSTRIP-K STRP F

KETONE STRP F

KETONE TEST STRIPS STRP F

KETOSTIX STRP F

RELION KETONE STRP F

RELION KETONE TEST STRIPS STRP F


66

Drug Name DrugTier

Requirements/Limits

TRUE METRIX BLOOD GLUCOSETEST STRIPS STRP

F

INSULIN USERS LIMITED TO 150 PER 30 DAYS, NON-INSULIN USERS LIMITED TO 100 PER 90 DAYS;RX/OTC

TRUETRACK TEST STRP F

INSULIN USERS LIMITED TO 150 PER 30 DAYS, NON-INSULIN USERS LIMITED TO 100 PER 90 DAYS;RX/OTC

DIGESTIVE AIDS - Drugs to Treat Low DigestiveEnzymes

Digestive Enzymes

CREON CPEP F 500 permonth;QL(16.67 ea daily)

SUCRAID SOLN F PA; SP

ZENPEP CPEP 10000 UNIT-3000 UNIT-14000 UNIT, 32000 UNIT-10000 UNIT-42000 UNIT, 63000 UNIT-20000 UNIT-84000 UNIT, 126000 UNIT-40000 UNIT-168000 UNIT

F

500 permonth;;QL(16.67 ea daily)

ZENPEP CPEP 17000 UNIT-5000 UNIT-24000 UNIT, 47000 UNIT-15000 UNIT-63000 UNIT, 79000 UNIT-25000 UNIT-105000 UNIT

F

500 permonth;QL(16.67 ea daily)

DIURETICS - Drugs to Treat Heart, CirculationConditions and Blood Pressure

Carbonic Anhydrase Inhibitors acetazolamide cp12 or 500 mg F MP

acetazolamide tabs or 125 mg, 250 mg F MP

Drug Name DrugTier

Requirements/Limits

methazolamide tabs or 25 mg, 50 mg F MP

Diuretic Combinations ALDACTAZIDE TABS 25 MG-25 MG (spironolactone& hydrochlorothiazide)

NF MP

ALDACTAZIDE TABS 50 MG-50 MG F

amiloride & hydrochlorothiazide tabs F MP

DYAZIDE CAPS (triamterene & hydrochlorothiazide)

NF MP

MAXZIDE TABS (triamterene & hydrochlorothiazide)

NF MP

MAXZIDE-25 TABS (triamterene & hydrochlorothiazide)

NF MP

spironolactone &hydrochlorothiazide tabs F MP

triamterene & hydrochlorothiazide caps F MP

triamterene & hydrochlorothiazide tabs F MP

Loop Diuretics bumetanide tabs or 0.5 mg,1 mg, 2 mg F MP

BUMEX TABS (bumetanide) NF MP

DEMADEX TABS (torsemide) NF MP

furosemide soln or 8 mg/ml, 10 mg/ml F MP

furosemide tabs or 20 mg,40 mg, 80 mg F MP

LASIX TABS (furosemide) NF MP

torsemide tabs F MP

Potassium Sparing Diuretics ALDACTONE TABS (spironolactone) NF MP

amiloride hcl tabs or 5 mg F MP


67

Drug Name DrugTier

Requirements/Limits

DYRENIUM CAPS (triamterene) NF MP

spironolactone tabs or 25mg, 50 mg, 100 mg F MP

triamterene caps or 50 mg,100 mg F MP

Thiazides and Thiazide-Like Diuretics

chlorothiazide tabs F MP

chlorthalidone tabs F MP

DIURIL SUSP F

hydrochlorothiazide caps or12.5 mg F MP

hydrochlorothiazide tabs or25 mg, 50 mg F MP

indapamide tabs F MP

methyclothiazide tabs F

metolazone tabs F MP

MICROZIDE CAPS (hydrochlorothiazide) NF MP

ENDOCRINE AND METABOLIC AGENTS -MISC. - Drugs to Treat Bone Disease andRegulate Hormones

Bone Density Regulators ALENDRONATE SODIUM SOLN 70 MG/75ML F

alendronate sodium tabs 5 mg, 10 mg, 35 mg, 40 mg,70 mg

F

BONIVA TABS (ibandronate sodium) NF QL(1 ea per 30

days retail)

calcitonin (salmon) soln F

FORTEO SOPN F PA; SP

FOSAMAX TABS (alendronate sodium) NF

ibandronate sodium tabs 150 mg F QL(1 ea per 30

days retail)

PROLIA SOSY F PA; SP

Drug Name DrugTier

Requirements/Limits

Growth Hormones GENOTROPIN MINIQUICK SOLR F PA; SP

GENOTROPIN SOLR F PA; SP

NORDITROPIN FLEXPRO SOLN F PA; SP

Hormone Receptor Modulators EVISTA TABS (raloxifene hcl) NF

raloxifene hcl tabs 60 mg F

Insulin-Like Growth Factors (Somatomedins) INCRELEX SOLN F PA; SP

LHRH/GnRH Agonist Analog Pituitary

FENSOLVI KIT F PA; SP

Metabolic Modifiers calcitriol caps or 0.25 mcg,0.5 mcg F

calcitriol soln or 1 mcg/ml F

CARNITOR SF SOLN (levocarnitine (metabolicmodifiers))

NF

CARNITOR SOLN OR 1 GM/10ML (levocarnitine (metabolic modifiers))

NF

cinacalcet hcl tabs F PA; SP

ELAPRASE SOLN F PA; SP

levocarnitine (metabolicmodifiers) soln 1 gm/10ml F

paricalcitol caps 1 mcg F

ROCALTROL CAPS (calcitriol) NF

ROCALTROL SOLN (calcitriol) NF

SENSIPAR TABS (cinacalcet hcl) NF PA; SP

ZEMPLAR CAPS 1 MCG (paricalcitol) NF


68

Drug Name DrugTier

Requirements/Limits

Posterior Pituitary Hormones

DDAVP SOLN NA 0.01 % F

DDAVP SOLN NA 0.01 % (desmopressin acetate spray)

NF

DDAVP TABS OR 0.1 MG, 0.2 MG (desmopressin acetate)

NF PA

desmopressin acetatespray refrigerated soln F

desmopressin acetatespray soln 0.01 % F

desmopressin acetate tabsor 0.1 mg, 0.2 mg F PA

STIMATE SOLN F SP

ESTROGENS - Hormone Replacement/ModifyingDrugs

Estrogen Combinations

CLIMARA PRO PTWK F

PREMPRO TABS F QL(1 ea daily)

Estrogens

ALORA PTTW F

CLIMARA PTWK (estradiol) NF

ESTRACE TABS (estradiol) NF

estradiol pttw td 0.0375mg/24hr, 0.025 mg/24hr,0.075 mg/24hr, 0.05mg/24hr, 0.1 mg/24hr

F

estradiol ptwk td 0.025mg/24hr, 0.075 mg/24hr,0.05 mg/24hr, 0.06mg/24hr, 0.1 mg/24hr, 37.5mcg/24hr

F

estradiol tabs or 0.5 mg, 1mg, 2 mg F

MENEST TABS F

MENOSTAR PTWK F

Drug Name DrugTier

Requirements/Limits

MINIVELLE PTTW (estradiol) NF

PREMARIN TABS OR 0.625 MG, 0.45 MG, 0.3 MG, 0.9 MG, 1.25 MG

F

VIVELLE-DOT PTTW (estradiol) NF

FLUOROQUINOLONES - Drugs to Treat BacterialInfections

Fluoroquinolones

AVELOX SOLN NF

AVELOX TABS (moxifloxacin hcl) NF

BAXDELA SOLR F

BAXDELA TABS F

CIPRO I.V.-IN D5W SOLN (ciprofloxacin in d5w) NF

CIPRO SUSR 5 GM/100ML, 500 MG/5ML F

CIPRO TABS 250 MG, 500 MG (ciprofloxacin hcl) NF

ciprofloxacin hcl tabs or100 mg, 250 mg, 500 mg,750 mg

F

ciprofloxacin in d5w soln F

ciprofloxacin susr or F

ciprofloxacin-ciprofloxacinhcl tb24 F

LEVAQUIN TABS (levofloxacin) NF

levofloxacin in d5w soln F

levofloxacin soln F

levofloxacin tabs F

MOXIFLOXACIN HYDROCHLORIDE/SODIUM HYDROCHLORIDE SOLN 400 MG/250ML-0.8%

F


69

Drug Name DrugTier

Requirements/Limits

moxifloxacin hcl tabs or F

MOXIFLOXACIN HYDROCHLORIDE SOLN IV 400 MG/250ML

F

ofloxacin tabs F

GASTROINTESTINAL AGENTS - MISC. -Miscellaneous Gastrointestinal Drugs

Antiflatulents GAS-X CHEW (simethicone) NF

GAS-X EXTRA STRENGTH CHEW 125 MG (simethicone)

NF

MYLICON INFANTS GAS RELIEF DYE FREE SUSP (simethicone)

NF

MYLICON INFANTS GAS RELIEF SUSP (simethicone)

NF

PHAZYME CAPS (simethicone) NF

PHAZYME ULTRA STRENGTH CAPS (simethicone)

NF

simethicone caps or 125mg, 180 mg F

simethicone chew or 80 mg, 125 mg F

simethicone susp or 20mg/0.3ml, 40 mg/0.6ml F

Gallstone Solubilizing Agents ACTIGALL CAPS (ursodiol) NF

URSO 250 TABS (ursodiol) NF

URSO FORTE TABS (ursodiol) NF

ursodiol caps or 300 mg F

ursodiol tabs or 250 mg,500 mg F

Gastrointestinal Chloride Channel Activators

AMITIZA CAPS F PA

Drug Name DrugTier

Requirements/Limits

Gastrointestinal Stimulants metoclopramide hcl soln or5 mg/5ml, 10 mg/10ml F

metoclopramide hcl tabs or5 mg, 10 mg F

METOCLOPRAMIDE ODT TBDP F

REGLAN TABS (metoclopramide hcl) NF

Inflammatory Bowel Agents ASACOL HD TBEC (mesalamine) NF QL(9 ea daily)

AZULFIDINE EN-TABS TBEC (sulfasalazine) NF QL(8 ea daily)

AZULFIDINE TABS (sulfasalazine) NF QL(8 ea daily)

balsalazide disodium caps750 mg F QL(9 ea daily)

COLAZAL CAPS (balsalazide disodium) NF QL(9 ea daily)

DIPENTUM CAPS F QL(4 ea daily)

mesalamine enem re 4 gm F QL(60 ml daily)

mesalamine tbec or 800 mg F QL(9 ea daily)

PENTASA CPCR F QL(9 ea daily)

RENFLEXIS SOLR F PA; SP

SFROWASA ENEM F QL(60 ml daily)

sulfasalazine tabs or 500 mg F QL(8 ea daily)

sulfasalazine tbec or 500 mg F QL(8 ea daily)

Intestinal Acidifiers lactulose (encephalopathy)soln F

Irritable Bowel Syndrome (IBS) Agents

LINZESS CAPS F PA

Phosphate Binder Agents calcium acetate (phosphatebinder) caps 667 mg F


70

Drug Name DrugTier

Requirements/Limits

calcium acetate (phosphatebinder) tabs 667 mg F RX/OTC

RENVELA TABS (sevelamer carbonate) NF

sevelamer carbonate tabs 800 mg F

GENITOURINARY AGENTS - MISCELLANEOUS - Miscellaneous Drugs to Treat ReproductiveOrgans and Urinary System

Alkalinizers potassium citrate(alkalinizer) tbcr F

potassium citrate-citric acidsoln 1100 mg/5ml-334mg/5ml, 1100 mg/5ml-1100mg/5ml-334 mg/5ml-334mg/5ml

F

RX/OTC

sodium citrate & citric acid soln F RX/OTC

UROCIT-K 10 TBCR (potassium citrate(alkalinizer))

NF


NF


NF

Interstitial Cystitis Agents

ELMIRON CAPS 100 MG F PA

Prostatic Hypertrophy Agents

alfuzosin hcl tb24 10 mg F

AVODART CAPS (dutasteride) NF

dutasteride caps or 0.5 mg F

finasteride tabs or 5 mg F

FLOMAX CAPS (tamsulosin hcl) NF

PROSCAR TABS (finasteride) NF

RAPAFLO CAPS 4 MG (silodosin) NF

Drug Name DrugTier

Requirements/Limits

tamsulosin hcl caps 0.4 mg F

UROXATRAL TB24 (alfuzosin hcl) NF

Urinary Analgesics phenazopyridine hcl tabs or100 mg, 200 mg F

PYRIDIUM TABS (phenazopyridine hcl) NF

GOUT AGENTS - Drugs to Treat Gout

Gout Agents allopurinol tabs or 100 mg,300 mg F

colchicine tabs or 0.6 mg F PA

COLCRYS TABS (colchicine) NF PA

febuxostat tabs F PA

ULORIC TABS (febuxostat) NF PA

ZYLOPRIM TABS (allopurinol) NF

Uricosurics

probenecid tabs F

HEMATOLOGICAL AGENTS - MISC. - Drugs toTreat Blood Disorders

Hematorheologic Agents

pentoxifylline tbcr or F

Platelet Aggregation Inhibitors

BRILINTA TABS F PA

cilostazol tabs F

clopidogrel bisulfate tabs or75 mg, 300 mg F

dipyridamole tabs or 25mg, 50 mg, 75 mg F

PLAVIX TABS (clopidogrelbisulfate) NF

HEMATOPOIETIC AGENTS - Drugs to TreatBlood Disorders


71

Drug Name DrugTier

Requirements/Limits

Agents for Gaucher Disease

CERDELGA CAPS F PA; SP

CEREZYME SOLR F PA; SP

ELELYSO SOLR F PA; SP

miglustat caps F PA; SP

VPRIV SOLR F PA; SP

Cobalamins

B-12 TABS F

cyanocobalamin soln ij1000 mcg/ml F

cyanocobalamin tabs or 50mcg, 100 mcg, 250 mcg,500 mcg, 1000 mcg, 2000 mcg

F

Folic Acid/Folates

folic acid tabs 1 mg F RX/OTC

folic acid tabs 400 mcg,800 mcg F

Hematopoietic Growth Factors

FULPHILA SOSY F PA; SP

NEUPOGEN SOLN F PA; SP

NEUPOGEN SOSY F PA; SP

NPLATE SOLR F PA; SP

PROMACTA TABS F PA; SP

RETACRIT SOLN 2000 UNIT/ML, 3000 UNIT/ML,4000 UNIT/ML, 10000UNIT/ML, 40000 UNIT/ML

F

PA; SP

UDENYCA SOSY F PA; SP

Iron

FEMIRON TABS F

FER-IN-SOL SOLN (ferrous sulfate) NF

Drug Name DrugTier

Requirements/Limits

FERRETTS TABS F

FERRIMIN 150 TABS F

FERROUS FUMARATE TABS OR 29 MG F

ferrous fumarate tabs or 324 mg F

ferrous gluconate tabs or27 mg, 240 mg, 324 mg F

FERROUS GLUCONATE TABS OR 324 MG F

FERROUS SULFATE LIQD 220 MG/5ML F

ferrous sulfate soln 15 mg/ml F

ferrous sulfate tabs 27 mg,65 mg, 325 mg F

ferrous sulfate tbec 325 mg F

HEMOCYTE TABS (ferrous fumarate) NF

HEMOSTATICS - Drugs to Stop Bleeding/TreatBlood Disorders

Hemostatics - Systemic AMICAR SOLN (aminocaproic acid) NF SP

AMICAR TABS (aminocaproic acid) NF SP

aminocaproic acid soln or0.25 gm/ml F SP

aminocaproic acid tabs or500 mg F SP

HYPNOTICS/SEDATIVES/SLEEP DISORDERAGENTS

Antihistamine Hypnotics diphenhydramine hcl(sleep) caps 25 mg F QL(2 ea daily)

diphenhydramine hcl(sleep) caps 50 mg F QL(1 ea daily)

diphenhydramine hcl(sleep) liqd 50 mg/30ml F QL(30 ml daily)

diphenhydramine hcl(sleep) tabs 25 mg F QL(2 ea daily)


72

Drug Name DrugTier

Requirements/Limits

diphenhydramine hcl(sleep) tabs 50 mg F QL(1 ea daily)

diphenhydramine hcl(sleep) tbdp 25 mg F QL(2 ea daily)

doxylamine succinate(sleep) tabs 25 mg F

NYTOL MAXIMUM STRENGTH TABS (diphenhydramine hcl(sleep))

NF

QL(1 ea daily)

UNISOM SLEEPGELS CAPS (diphenhydraminehcl (sleep))

NF QL(1 ea daily)

UNISOM SLEEPMELTS TBDP (diphenhydraminehcl (sleep))

NF QL(2 ea daily)

UNISOM SLEEPTABS TABS (doxylaminesuccinate (sleep))

NF

WAL-SLEEP Z LIQUID SHOTS LIQD F QL(50 ml daily)

ZZZQUIL CAPS 25 MG (diphenhydramine hcl(sleep))

NF QL(2 ea daily)

ZZZQUIL LIQD 50 MG/30ML(diphenhydramine hcl(sleep))

NF

QL(30 ml daily)

Barbiturate Hypnotics phenobarbital elix or 20mg/5ml F

phenobarbital soln or 20mg/5ml F

phenobarbital tabs or 15mg, 30 mg, 60 mg, 100 mg,16.2 mg, 32.4 mg, 64.8 mg,97.2 mg

F

Non-Barbiturate Hypnotics

AMBIEN TABS 10 MG (zolpidem tartrate) NF


AMBIEN TABS 5 MG (zolpidem tartrate) NF


eszopiclone tabs F QL(1 ea daily);AL(At least 6yrs old)

Drug Name DrugTier

Requirements/Limits

LUNESTA TABS (eszopiclone) NF


RESTORIL CAPS 15 MG, 30 MG (temazepam) NF


temazepam caps 15 mg,30 mg F


zolpidem tartrate tabs or 10 mg F


zolpidem tartrate tabs or 5 mg F


Selective Melatonin Receptor Agonists

ROZEREM TABS 8 MG (ramelteon) F

ST; Must tryTemazepamand Zolpidemfirst;QL(1 eadaily); AL(Atleast 6 yrs old)

LAXATIVES - Bowel Treatment Drugs

Bulk Laxatives

EVAC POWD (psyllium) NF

KONSYL DAILY FIBER POWD 100 % (psyllium) NF

KONSYL ORIGINAL FORMULADAILY FIBER POWD (psyllium)

NF

METAMUCIL CAPS 0.52 GM (psyllium) NF

METAMUCIL ORIGINAL TEXTURE POWD (psyllium)

NF

METAMUCIL POWD 48.57 % (psyllium) NF

psyllium caps 0.52 gm, 520 mg F

psyllium powd 30 %, 33 %,68 %, 100 %, 28.3 %, 30.9%, 58.6 %, 48.57 %,

F

Laxative Combinations


73

Drug Name DrugTier

Requirements/Limits

COLYTE-FLAVOR PACKS SOLR (peg 3350-kcl-sodbicarb-sod chloride-sod sulfate)

NF

GAVILYTE-C SOLR F

GOLYTELY SOLR 236 GM-22.74 GM-5.86 GM-2.97 GM-6.74 GM (peg3350-kcl-sod bicarb-sod chloride-sod sulfate)

NF

NULYTELY SOLR (peg3350-potassium chloride-sod bicarbonate-sod chloride)

NF

NULYTELY/FLAVORPACKS SOLR (peg 3350-potassium chloride-sodbicarbonate-sod chloride)

NF

peg 3350-kcl-sod bicarb-sod chloride-sod sulfate solr

F

peg 3350-potassiumchloride-sod bicarbonate-sod chloride solr 420 gm-11.2 gm-1.48 gm-5.72 gm

F

sennosides-docusate sodium tabs F

SENOKOT S TABS (sennosides-docusate sodium)

NF

Laxatives - Miscellaneous lactulose soln 10 gm/15ml,20 gm/30ml F

MIRALAX PACK (polyethylene glycol 3350) NF RX/OTC

MIRALAX POWD (polyethylene glycol 3350) NF RX/OTC

polyethylene glycol 3350pack or 17 gm F RX/OTC

polyethylene glycol 3350powd or 17 gm/scoop, F RX/OTC

Saline Laxatives FLEET ENEMA ENEM (sodium phosphates) NF

Drug Name DrugTier

Requirements/Limits

FLEET ENEMA SIX PACK ENEM (sodium phosphates)

NF

FLEET PEDIATRIC ENEM (sodium phosphates) NF

magnesium citrate soln or1.745 gm/30ml, F

magnesium hydroxide suspor 7.75 %, 400 mg/5ml,1200 mg/15ml, 2400mg/10ml, 2400 mg/30ml,

F

sodium phosphates enem F

Stimulant Laxatives

bisacodyl supp re 10 mg F

bisacodyl tbec or 5 mg F

DULCOLAX SUPP (bisacodyl) NF

DULCOLAX TBEC (bisacodyl) NF

EX-LAX MAXIMUM STRENGTH TABS (sennosides)

NF

EX-LAX TABS (sennosides) NF

sennosides liqd 8.8 mg/5ml F

sennosides syrp 8.8mg/5ml F

sennosides tabs 15 mg, 25mg, 8.6 mg, 17.2 mg F

SENOKOT TABS (sennosides) NF

Surfactant Laxatives COLACE CAPS (docusate sodium) NF

COLACE CLEAR CAPS (docusate sodium) NF

docusate calcium caps F

docusate sodium caps or50 mg, 100 mg, 250 mg F

LOCAL ANESTHETICS-Parenteral - Drugs forNumbing


74

Drug Name DrugTier

Requirements/Limits

Local Anesthetics - Amides lidocaine hcl (local anesth.)soln 0.5 %, 1 %, 2 % F PA

LIDOCAINE HCL SOLN IJ 4 % F PA

LIDOCAINE HYDROCHLORIDE SOLN IJ 1 %, 2 %

F PA

XYLOCAINE SOLN (lidocaine hcl (localanesth.))

NF PA

XYLOCAINE-MPF SOLN 0.5 %, 1 %, 2 % (lidocaine hcl (local anesth.))

NF PA

MACROLIDES - Drugs to Treat BacterialInfections

Azithromycin

azithromycin pack or 1 gm F

azithromycin solr iv 500 mg F

azithromycin susr or 100mg/5ml, 200 mg/5ml F

azithromycin tabs or 250mg, 500 mg, 600 mg F

ZITHROMAX PACK OR 1 GM F

ZITHROMAX SOLR IV 500 MG (azithromycin) NF

ZITHROMAX SUSR OR 100 MG/5ML, 200 MG/5ML(azithromycin)

NF

ZITHROMAX TABS OR 250 MG, 500 MG, 600 MG (azithromycin)

NF

ZITHROMAX TRI-PAK TABS (azithromycin) NF

ZITHROMAX Z-PAK TABS (azithromycin) NF

Clarithromycin clarithromycin susr or 125mg/5ml, 250 mg/5ml F

clarithromycin tabs or 250mg, 500 mg F

Drug Name DrugTier

Requirements/Limits

clarithromycin tb24 or 500 mg F

Erythromycins E.E.S. GRANULES SUSR (erythromycinethylsuccinate)

NF

ERYPED 200 SUSR (erythromycinethylsuccinate)

NF

ERYPED 400 SUSR (erythromycinethylsuccinate)

NF

ERYTHROCIN LACTOBIONATE SOLR F

ERYTHROCIN STEARATE TABS F

erythromycin base cpep F

erythromycin base tabs F

erythromycin base tbec F

ERYTHROMYCIN CPEP F

ERYTHROMYCIN ETHYLSUCCINATE POWD XX

F

erythromycinethylsuccinate susr or 200mg/5ml, 400 mg/5ml

F

erythromycinethylsuccinate tabs or 400 mg

F

ERYTHROMYCIN POWD F

Fidaxomicin

DIFICID TABS F

MEDICAL DEVICES AND SUPPLIES

Contraceptives OMNIFLEX DIAPHRAGM DPRH F

Diabetic Supplies


75

Drug Name DrugTier

Requirements/Limits

TRUE METRIX CONTROL SOLUTION LEVEL 1 SOLN

F 1/ 90days;QL(0.012ea daily)





TRUECONTROL GLUCOSE CONTROL LEVEL 0 LIQD


TRUECONTROL GLUCOSE CONTROL LEVEL 1 LIQD


Parenteral Therapy Supplies 1ML TB SYRINGE/25G X5/8"/LUER SLIP TIP MISC F RX/OTC

1ML TB SYRINGE/27G X1/2"/LUER SLIP TIP MISC F RX/OTC

1ML TUBERCULIN SYRINGE DETACHABLE NEEDLE SLIP TIP 25GX5/8" MISC

F

RX/OTC

1ML VANISHPOINT TUBERCULIN SYRINGE 25GX5/8" MISC

F RX/OTC

1ML VANISHPOINT TUBERCULIN SYRINGE 27GX1/2" MISC

F RX/OTC

2-3ML SYRINGE/LUERLOCK TIP MISC F RX/OTC

2-3ML SYRINGE/LUERSLIP TIP MISC F RX/OTC

3ML LUER LOCK SAFETY SYRINGES 3ML/22G X 11/2" MISC

F RX/OTC

3ML LUER LOCK SAFETY SYRINGES MISC F RX/OTC

3ML LUER LOCK SAFETY SYRINGES/3ML/21G X 11/2" MISC

F RX/OTC

3ML LUER LOCK SAFETY SYRINGES/3ML/22G X 1"MISC

F

Drug Name DrugTier

Requirements/Limits


F RX/OTC


F RX/OTC

3ML LUER LOCK SAFETY SYRINGES/3ML/25G X5/8" MISC

F RX/OTC

3ML LUER-LOK SYRINGE 22GX 1-1/2" MISC F RX/OTC

3ML LUER-LOK SYRINGE21G X 1-1/2"MISC

F RX/OTC

3ML LUER-LOK SYRINGE22G X 1" MISC F

3ML LUER-LOK SYRINGE25G X 5/8" MISC F RX/OTC

3ML LUER-LOK TIP SYRINGE25G X 1-1/2"MISC

F

3ML SYRINGE/18G X 1-1/2"/LUER LOCK TIP MISC F

3ML SYRINGE/20G X1"/LUER LOCK TIP MISC F RX/OTC

3ML SYRINGE/20G X1"/LUER SLIP TIP MISC F RX/OTC

3ML SYRINGE/21G X 1-1/2"/LUER LOCK TIP MISC F RX/OTC

3ML SYRINGE/22G 1-1/2"/LUER LOCK TIP MISC F RX/OTC

3ML SYRINGE/22G X1"/LUER LOCK TIP MISC F

3ML SYRINGE/25G X1"/LUER LOCK TIP MISC F RX/OTC

3ML SYRINGE/INTERLINKSYRINGE CANNULA MISC

F RX/OTC

3ML SYRINGE/INTERLINKVIAL ACCESS CANNULA MISC

F RX/OTC

3ML SYRINGE/LUERLOCK TIP MISC F RX/OTC

3ML SYRINGE/LUERLOCK TIP23GX1" MISC F RX/OTC


76

Drug Name DrugTier

Requirements/Limits

3ML SYRINGE/LUERLOCK TIP25G X 1-1/2"MISC

F

3ML SYRINGE/LUER SLIPTIP23GX1" MISC F RX/OTC

3ML SYRINGE/NEEDLEREGULAR WALL LUER-LOK 25GX5/8" SUB-QMISC

F

RX/OTC

ALLERGY SYRINGE/1ML/27G X 1/2"MISC

F RX/OTC

AXILLARY BLOCK NEEDLE BLOCK BEVEL 25GX1" MISC

F RX/OTC

BD 1ML TUBERCULIN SYRINGE/SAFETYGLIDETB NEEDLE 27GX1/2"MISC

F

RX/OTC

BD 1ML TUBERCULIN SYRINGEDETACHABLE NEEDLE SLIP TIP 27GX1/2" MISC

F

RX/OTC

BD 1ML TUBERCULIN SYRINGESLIP-TIP MISC F RX/OTC

BD 3ML LUER-LOCK SYRINGE18G X 1 1/2"MISC

F

BD 3ML LUER-LOK SYRINGE 18G X 1 1/2"MISC

F

BD 3ML LUER-LOK SYRINGE/20G X 1" MISC F RX/OTC

BD 3ML LUER-LOK SYRINGE/21G X 1-1/2"MISC

F RX/OTC


BD 3ML LUER-LOK SYRINGE/23G X 1-1/2"MISC

F


BD 3ML SYRINGE LUER-LOK TIP MISC F RX/OTC

BD 3ML SYRINGE SLIP TIP MISC F RX/OTC

Drug Name DrugTier

Requirements/Limits

BD 3ML SYRINGE/SAFETYGLIDESHIELDING IM NEEDLE 22GX1-1/2" MISC

F

RX/OTC

BD 3ML SYRINGE/SAFETYGLIDESHIELDING IM NEEDLE 23GX1" MISC

F

RX/OTC

BD 3ML SYRINGE/SAFETYGLIDESHIELDING NEEDLE 25GX5/8" MISC

F

RX/OTC

BD ALLERGY/SYRINGE/NEEDLE/1ML/28G X 1/2" MISC

F RX/OTC

BD BLUNT FILL NEEDLE MISC F RX/OTC

BD DISPOSABLE NEEDLE REGULAR BEVEL 25GX1" MISC

F RX/OTC

BD DISPOSABLE NEEDLE REGULAR BEVEL THIN WALL 18G X 1" MISC

F RX/OTC

BD ECLIPSE 18G X 1-1/2"MISC F RX/OTC

BD ECLIPSE NEEDLE 25G X 1.5" MISC F RX/OTC

BD ECLIPSE NEEDLE 25GX1" MISC F RX/OTC

BD ECLIPSE NEEDLE 27G X 1/2" MISC F RX/OTC

BD ECLIPSE NEEDLE/22G X 1-1/2"MISC

F RX/OTC

BD ECLIPSE NEEDLE/25G X5/8" MISC F RX/OTC

BD ECLIPSE NEEDLE/27G X 1/2" MISC F RX/OTC

BD ECLIPSE SYRINGE LUER-LOK/3ML/22G X 1"MISC

F

BD ECLIPSE SYRINGE LUER-LOK/3ML/25G X 1"MISC

F RX/OTC

BD ECLIPSE SYRINGE/3ML/23G X 1"MISC

F RX/OTC


77

Drug Name DrugTier

Requirements/Limits

BD ECLIPSE SYRINGE/3ML/25GX5/8"MISC

F RX/OTC

BD ECLIPSE SYRINGE/LUER-LOK/3ML/22G X 1-1/2"MISC

F

RX/OTC

BD HYPODERMIC NEEDLE REGULAR BEVEL 18G X 1-1/2" MISC

F RX/OTC

BD HYPODERMIC NEEDLE REGULAR BEVEL 22GX1-1/2" MISC

F RX/OTC

BD HYPODERMIC NEEDLE REGULAR BEVEL 25GX1" MISC

F RX/OTC

BD HYPODERMIC NEEDLE REGULAR BEVEL 25GX5/8" MISC

F RX/OTC

BD HYPODERMIC NEEDLE REGULAR BEVEL THIN WALL 18G X 1-1/2" MISC

F

RX/OTC

BD HYPODERMIC NEEDLE SHORT BEVEL 18G X 1-1/2" MISC

F RX/OTC

BD HYPODERMIC NEEDLE SHORT BEVEL 22GX1-1/2" MISC

F RX/OTC

BD HYPODERMIC NEEDLES 18GX1" MISC F RX/OTC

BD HYPODERMIC NEEDLES 18GX1.5" MISC F RX/OTC

BD HYPODERMIC NEEDLES 19GX1" MISC F RX/OTC



BD INTEGRA 3ML SYRINGE W/RETRACTINGNEEDLE/21G X 1-1/2"MISC

F

RX/OTC

BD INTEGRA 3ML SYRINGE W/RETRACTINGNEEDLE/25G X 1" MISC

F

RX/OTC

Drug Name DrugTier

Requirements/Limits

BD INTEGRA NEEDLE/25G X5/8" MISC F RX/OTC

BD INTEGRA SYRINGE/3ML/22G X 1.5"MISC

F RX/OTC

BD INTEGRA SYRINGE/3ML/23G X 1"MISC

F RX/OTC

BD INTEGRA SYRINGE/3ML/25G X 5/8MISC

F RX/OTC

BD NEEDLE/18G 1-1/2"MISC F RX/OTC

BD NEEDLE/19G X 1"MISC F RX/OTC

BD NEEDLE/22G X 1-1/2"MISC F RX/OTC

BD NEEDLE/25G X 5/8"MISC F RX/OTC

BD NEEDLE/27G X 1/2"MISC F RX/OTC

BD PLASTIPAK SYRINGES ALLERGY 28GX1/2 MISC

F RX/OTC

BD SAFETYGLIDE 27G X 5/8"NEEDLE MISC F

BD SAFETYGLIDE ALLERGY SYRINGE/1ML/27GX1/2"MISC

F

RX/OTC

BD SAFETYGLIDE HYPODERMICNEEDLE 18G X 1-1/2" MISC

F RX/OTC

BD SAFETYGLIDE HYPODERMICNEEDLE 25GX5/8" MISC

F RX/OTC

BD SAFETYGLIDE INJECTIONNEEDLE 22GX1-1/2" MISC

F RX/OTC

BD SAFETYGLIDE INJECTIONNEEDLE 25GX1" MISC

F RX/OTC

BD SAFETYGLIDE SYRINGE 3ML/25GX1"MISC

F RX/OTC

BD SYRINGE LUER-LOK/1ML MISC F RX/OTC


78

Drug Name DrugTier

Requirements/Limits

BD SYRINGE SLIP TIP 1ML MISC F RX/OTC

DIALYSIS SAFETY SYRINGES/LOW DEADSPACE 3ML/22GX1-1/2"MISC

F

RX/OTC

EASY GLIDE LUER LOCK 1MLSYRINGE MISC F RX/OTC

EASY TOUCH ALLERGY TRAY SAFETY SYRINGE/1ML/27G X 1/2"MISC

F

RX/OTC

EASY TOUCH FLIPLOCK NEEDLES 18GX1" MISC F RX/OTC

EASY TOUCH FLIPLOCK NEEDLES 18GX1-1/2"MISC

F RX/OTC



F RX/OTC



F RX/OTC

EASY TOUCH FLIPLOCK NEEDLES 25GX5/8" MISC F RX/OTC

EASY TOUCH FLIPLOCK NEEDLES 27GX1/2" MISC F RX/OTC

EASY TOUCH FLIPLOCK SAFETTY SYRINGES 3ML/18GX1-1/2" MISC

F

EASY TOUCH FLIPLOCK SAFETY SYRINGE 3ML/22GX1" MISC

F

EASY TOUCH FLIPLOCK SAFETY SYRINGE 3ML/22GX1-1/2" MISC

F RX/OTC


F RX/OTC

EASY TOUCH FLIPLOCK SAFETY SYRINGE 3ML/23GX1-1/2" MISC

F

Drug Name DrugTier

Requirements/Limits


F RX/OTC

EASY TOUCH FLIPLOCK SAFETY SYRINGE 3ML/25GX5/8" MISC

F RX/OTC

EASY TOUCH FLIPLOCK SAFETY SYRINGES 3ML/20GX1" MISC

F RX/OTC

EASY TOUCH FLIPLOCK SAFETY SYRINGES 3ML/21GX1-1/2" MISC

F RX/OTC

EASY TOUCH HYPODERMIC NEEDLES 18GX1" MISC

F RX/OTC

EASY TOUCH HYPODERMIC NEEDLES 18GX1-1/2" MISC

F RX/OTC


F RX/OTC


F RX/OTC


F RX/OTC


F RX/OTC

EASY TOUCH HYPODERMIC NEEDLES 25GX5/8" MISC

F RX/OTC

EASY TOUCH HYPODERMIC NEEDLES 27GX1/2" MISC

F RX/OTC

EASY TOUCH SAFETY SYRINGE/3ML/20G X 1"MISC

F RX/OTC


F

EASY TOUCH SAFETY SYRINGE/3ML/22G X 1-1/2" MISC

F RX/OTC


F RX/OTC


79

Drug Name DrugTier

Requirements/Limits


F RX/OTC

EASY TOUCH SAFETY SYRINGE/3ML/25G X 5/8"MISC

F RX/OTC

EASY TOUCH SHEATHLOCK SAFETY SYRINGE 3ML/21GX1-1/2"MISC

F

RX/OTC

EASY TOUCH SHEATHLOCK SAFETY SYRINGE 3ML/22GX1"MISC

F

EASY TOUCH SHEATHLOCK SAFETY SYRINGE 3ML/22GX1-1/2"MISC

F

RX/OTC


F

RX/OTC


F

RX/OTC

EASY TOUCH SHEATHLOCK SAFETY SYRINGE 3ML/25GX5/8"MISC

F

RX/OTC

EASY TOUCH TUBERCULIN FLIPLOCK SAFETY SYRINGE 1ML/27GX1/2" MISC

F

RX/OTC

EASY TOUCH TUBERCULIN FLIPLOCK SAFETY SYRINGE 1ML/28GX1/2" MISC

F

RX/OTC

EASY TOUCH TUBERCULIN SHEATHLOCK SAFETY SYRINGE 1ML/25GX5/8"MISC

F

RX/OTC


F

RX/OTC

Drug Name DrugTier

Requirements/Limits


F

RX/OTC

EASYPOINT NEEDLE 25G X 1" MISC F RX/OTC

EASYPOINT NEEDLE 25G X 5/8" MISC F RX/OTC

EASYPOINT NEEDLE 25GX1-1/2" MISC F RX/OTC

EASYPOINT NEEDLE/18GX 1" MISC F RX/OTC

EASYPOINT NEEDLE/18GX 1-1/2" MISC F RX/OTC

EASYPOINT NEEDLE/22GX 1-1/2" MISC F RX/OTC

HUBER NEEDLE/RIGHTANGLE19G X 1" MISC F RX/OTC

HUBER NEEDLE/RIGHTANGLE22G X 1-1/2" MISC F RX/OTC

HUBER NEEDLE/STRAIGHT22GX1-1/2" MISC

F RX/OTC

HYPODERMIC NEEDLE 18G X 1" MISC F RX/OTC

HYPODERMIC NEEDLE 18G X 1-1/2" MISC F RX/OTC

HYPODERMIC NEEDLE 19G X 1" MISC F RX/OTC

HYPODERMIC NEEDLE 22GX1-1/2" MISC F RX/OTC

HYPODERMIC NEEDLE 25GX1" MISC F RX/OTC

HYPODERMIC NEEDLE 25GX1-1/2" MISC F RX/OTC

HYPODERMIC NEEDLE 25GX5/8" MISC F RX/OTC

HYPODERMIC NEEDLE 27GX1/2" MISC F RX/OTC

HYPODERMIC NEEDLES 18GX1" MISC F RX/OTC

HYPODERMIC NEEDLES 18GX1-1/2" MISC F RX/OTC

HYPODERMIC NEEDLES 19GX1" MISC F RX/OTC


80

Drug Name DrugTier

Requirements/Limits



HYPODERMIC NEEDLES 25GX5/8" MISC F RX/OTC

HYPODERMIC NEEDLES 27GX1/2" MISC F RX/OTC

MAGELLAN TUBERCULIN SAFETY SYRINGE/1ML/27G X 1/2"MISC

F

RX/OTC

MAGELLAN TUBERCULIN SAFETY SYRINGE/1ML/28G X 1/2"MISC

F

RX/OTC

MONOJECT 1ML LUER LOCK TUBERCULIN SYRINGE/TIP CAP MISC

F RX/OTC

MONOJECT 3ML SYRINGE/STANDARDHYPODERMIC NEEDLE/21GX1-1/2" MISC

F

RX/OTC

MONOJECT BLUNTIP SYRINGE/3ML/CANNULA/IV ACCESS MISC

F RX/OTC

MONOJECT HYPO/ALUMHUB/18G X 1-1/2" MISC F RX/OTC

MONOJECT HYPO/ALUMHUB/LUER LOCK/INTMBEVEL/27G X 1/2" MISC

F RX/OTC

MONOJECT HYPO/ALUMHUB/LUER LOCK/REGBEVEL/18G X 1" MISC

F RX/OTC

MONOJECT HYPO/ALUMHUB/LUER LOCK/REGBEVEL/22G X 1-1/2" MISC

F RX/OTC

MONOJECT HYPO/ALUMHUB/LUER LOCK/REGBEVEL/25G X 5/8" MISC

F RX/OTC

MONOJECT HYPO/ALUMHUB/LUER LOCK/SHORTBEVEL/18G X 1" MISC

F RX/OTC

MONOJECT HYPO/ALUMHUB/LUER LOCK/SHORTBEVEL/18G X 1-1/2" MISC

F RX/OTC

Drug Name DrugTier

Requirements/Limits

MONOJECT HYPO/ALUMHUB/LUER LOCK/SPECBEVEL/19G TW X 1" MISC

F RX/OTC

MONOJECT HYPO/POLYPROPYLENEHUB/18G X 1" MISC

F RX/OTC

MONOJECT HYPO/POLYPROPYLENEHUB/18G X 1-1/2" MISC

F RX/OTC

MONOJECT HYPO/POLYPROPYLENEHUB/LL/BEVEL/25G X 1-1/2" MISC

F

RX/OTC

MONOJECT HYPO/POLYPROPYLENEHUB/LL/INTM BEVEL/25GX 5/8" MISC

F

RX/OTC

MONOJECT HYPO/POLYPROPYLENEHUB/LL/REG BEVEL/19GTW X 1" MISC

F

RX/OTC

MONOJECT HYPO/POLYPROPYLENEHUB/LL/REG BEVEL/25GX 1" MISC

F

RX/OTC

MONOJECT HYPO/POLYPROPYLENEHUB/LL/SHORTBEVEL/18G X 1" MISC

F

RX/OTC

MONOJECT HYPO/POLYPROPYLENEHUB/LL/SHORTBEVEL/18G X 1-1/2" MISC

F

RX/OTC

MONOJECT HYPO/POLYPROPYLENEHUB/LL/SHORTBEVEL/19G TW X 1" MISC

F

RX/OTC

MONOJECT HYPO/POLYPROPYLENEHUB/LL/SHORTBEVEL/22G X 1-1/2" MISC

F

RX/OTC

MONOJECT HYPO/POLYPROPYLENEHUB/REG BEVEL/27G X1/2" MISC

F

RX/OTC

MONOJECT HYPODERMIC NEEDL3 18G X 1" MISC

F RX/OTC


81

Drug Name DrugTier

Requirements/Limits

MONOJECT MAGELLAN SAFETYNEEDLE 18GX1" MISC

F RX/OTC

MONOJECT MAGELLAN SAFETYNEEDLE 18GX1-1/2" MISC

F RX/OTC


F RX/OTC

MONOJECT MAGELLAN SAFETYNEEDLE 22GX1-1/2" MISC

F RX/OTC


F RX/OTC

MONOJECT MAGELLAN SAFETYNEEDLE 25GX5/8" MISC

F RX/OTC

MONOJECT MAGELLAN SYRINGE/SAFETYNEEDLE/3ML/20G X 1"MISC

F

RX/OTC

MONOJECT MAGELLAN SYRINGE/SAFETYNEEDLE/3ML/21G X 1-1/2"MISC

F

RX/OTC


F

MONOJECT MAGELLAN SYRINGE/SAFETYNEEDLE/3ML/22G X 1-1/2"MISC

F

RX/OTC


F

RX/OTC


F

RX/OTC

MONOJECT MAGELLAN SYRINGE/SAFETYNEEDLE/3ML/25G X 5/8"MISC

F

RX/OTC

Drug Name DrugTier

Requirements/Limits

MONOJECT PHARMACY TRAY/LUER LOCK/3MLMISC

F RX/OTC

MONOJECT PHARMACY TRAY/REG LUER/1MLMISC

F RX/OTC

MONOJECT STANDARD HYPODERMIC NEEDLE/POLYPROPYLEN/22G X1-1/2" MISC

F

RX/OTC

MONOJECT STANDARD HYPODERMIC NEEDLE/POLYPROPYLENE HUB/18GX1" MISC

F

RX/OTC

MONOJECT STANDARD HYPODERMIC NEEDLE/POLYPROPYLENE HUB/19GX1" MISC

F

RX/OTC

MONOJECT STANDARD HYPODERMIC NEEDLE/POLYPROPYLENE/18GX1-1/2" MISC

F

RX/OTC


F

RX/OTC

MONOJECT STANDARD HYPODERMIC NEEDLE/POLYPROPYLENE/25GX1" MISC

F

RX/OTC


F

RX/OTC

MONOJECT STANDARD HYPODERMIC NEEDLE/POLYPROPYLENE/25GX5/8" MISC

F

RX/OTC

MONOJECT STANDARD HYPODERMIC NEEDLE/POLYPROPYLENE/27GX1/2" MISC

F

RX/OTC

MONOJECT SYRINGE PHARMACY TRAY/1MLLUER LOCK MISC

F RX/OTC

MONOJECT SYRINGE/LUERLOCK/3ML MISC

F RX/OTC


82

Drug Name DrugTier

Requirements/Limits

MONOJECT SYRINGE/LUERLOCK/3ML/20G X 1" MISC

F RX/OTC


F

MONOJECT SYRINGE/LUERLOCK/3ML/22G X 1-1/2"MISC

F

RX/OTC


F RX/OTC


F RX/OTC

MONOJECT SYRINGE/LUERLOCK/3ML/25G X 5/8"MISC

F

RX/OTC

MONOJECT SYRINGE/LUER-LOCKTIP/3ML MISC

F RX/OTC

MONOJECT SYRINGE/LUER-LOCK/3ML/21G X 1-1/2"MISC

F

RX/OTC

MONOJECT SYRINGE/REG LUER/3MLMISC

F RX/OTC

MONOJECT SYRINGE/REGULARTIP/3ML MISC

F RX/OTC

MONOJECT SYRINGE/STANDARDHYPODERMIC NEEDLE/3ML/20GX1"MISC

F

RX/OTC


F

MONOJECT SYRINGE/STANDARDHYPODERMIC NEEDLE/3ML/22GX1-1/2"MISC

F

RX/OTC

Drug Name DrugTier

Requirements/Limits


F

RX/OTC


F

RX/OTC

MONOJECT SYRINGE/STANDARDHYPODERMIC NEEDLE/3ML/25GX5/8"MISC

F

RX/OTC

MONOJECT TB SYRINGE-NDL 1ML 27GX1/2" MISC F RX/OTC

MONOJECT TUBERCULIN SAFETY SYRINGE/1ML/25G X 5/8"MISC

F

RX/OTC

MONOJECT TUBERCULIN SAFETY SYRINGE/1ML/28G X 1/2"MISC

F

RX/OTC

MONOJECT TUBERCULIN SYRINGE SOFTPACK 1ML REGULAR LUER TIP MISC

F

RX/OTC

MONOJECT TUBERCULIN SYRINGE/1ML/25GX5/8"MISC

F RX/OTC

MONOJECT TUBERCULIN SYRINGE/1ML/28G X 1/2"MISC

F RX/OTC

MONOJECT TUBERCULIN SYRINGE/DETACHNEEDLE/1ML/25G X 5/8"MISC

F

RX/OTC

MONOJECT TUBERCULIN SYRINGE/DETACHNEEDLE/1ML/27G X 1/2"MISC

F

RX/OTC

MONOJECT TUBERCULIN SYRINGE/PERMNEEDLE/1ML/28G X 1/2"MISC

F

RX/OTC


83

Drug Name DrugTier

Requirements/Limits

MONOJECT TUBERCULIN SYRINGE/WITHOUTNEEDLE/REG LUER/1MLMISC

F

RX/OTC

MULTI-DRAW NEEDLE 22GX1-1/2" MISC F RX/OTC

NOKOR ADMIX NEEDLE THIN WALL NON-CORING 18G X 1-1/2" MISC

F RX/OTC

NOKOR VENTED NEEDLE THINWALL NON-CORING 18G X 1" MISC

F RX/OTC

NOKOR VENTED NEEDLE THINWALL NON-CORING 18GX1-1/2" MISC

F RX/OTC

NORM-JECT TUBERKULIN 1MLLUER SLIP MISC

F RX/OTC

PATIENT SAFE SYRINGE 3ML MISC F RX/OTC

POLY HUB NEEDLE/18GX 1" MISC F RX/OTC

POLY HUB NEEDLE/18GX 1-1-1/2" MISC F RX/OTC

POLY HUB NEEDLE/22GX 1-1/2" MISC F RX/OTC

POLY HUB NEEDLE/25GX 1" MISC F RX/OTC

POLY HUB NEEDLE/25GX 1-1/2" MISC F RX/OTC

POLY HUB NEEDLE/25GX 5/8" MISC F RX/OTC

POLY HUB NEEDLE/27GX 1/2" MISC F RX/OTC

REGIONAL BLOCK NEEDLE SAFETY BEAD BLOCK BEVEL 22GX1-1/2" MISC

F

RX/OTC

RETROBULBAR NEEDLE 25G TWX 1-1/2" MISC F RX/OTC

SAFESNAP ALLERGY SYRINGE/1ML/27G X 1/2"MISC

F RX/OTC

SAFESNAP SYRINGE/3ML MISC F RX/OTC

Drug Name DrugTier

Requirements/Limits

SAFESNAP SYRINGE/NEEDLE/3ML/20G X 1" MISC

F RX/OTC

SAFESNAP SYRINGE/NEEDLE/3ML/21G X 1-1/2" MISC

F RX/OTC


F


F RX/OTC


F RX/OTC


F


F RX/OTC

SAFESNAP SYRINGE/NEEDLE/3ML/25G X 5/8" MISC

F RX/OTC

SAFESNAP TUBERCULIN SYRINGE/1ML/25G X 5/8"MISC

F RX/OTC

SAFESNAP TUBERCULIN SYRINGE/1ML/27G X 1/2"MISC

F RX/OTC

SAFETY SYRINGES/NEEDLE3ML/20GX1" MISC

F RX/OTC

SAFETY SYRINGES/NEEDLE3ML/21GX1-1/2" MISC

F RX/OTC


F

SAFETY SYRINGES/NEEDLE3ML/22GX1-1/2" MISC

F RX/OTC


F RX/OTC

SAFETY SYRINGES/NEEDLE3ML/25GX5/8" MISC

F RX/OTC


84

Drug Name DrugTier

Requirements/Limits

SAFETY-LOK SAFETY SYRINGE/1ML/25G X 5/8"MISC

F RX/OTC

SAFETY-LOK SYRINGE 3ML LUER-LOK MISC F RX/OTC

SAFETY-LOK SYRINGE/NEEDLE3MLLUER-LOK 21GX1-1/2"MISC

F

RX/OTC

SAFETY-LOK SYRINGE/NEEDLE3MLLUER-LOK 22GX1" MISC

F

SAFETY-LOK SYRINGE/NEEDLE3MLLUER-LOK 22GX1-1/2"MISC

F

RX/OTC

SAFETY-LOK SYRINGE/NEEDLE3MLLUER-LOK 23GX1" MISC

F RX/OTC

SAFETY-LOK SYRINGE/NEEDLE3MLLUER-LOK 25GX5/8"MISC

F

RX/OTC

SAFETY-LOK TB SYRINGE PERM NEEDLE 1ML 27GX1/2" MISC

F RX/OTC

SECURESAFE SAFETY HYPODERMIC NEEDLE/18G X 1" MISC

F RX/OTC

SECURESAFE SAFETY HYPODERMIC NEEDLE/18G X 1-1/2"MISC

F

RX/OTC

SECURESAFE SAFETY HYPODERMIC NEEDLE/19G X 1" MISC

F RX/OTC


F

RX/OTC


F

RX/OTC

SECURESAFE SAFETY HYPODERMIC NEEDLE/25G X 5/8" MISC

F RX/OTC

Drug Name DrugTier

Requirements/Limits

SECURESAFE SAFETY HYPODERMIC NEEDLE/27G X 1/2" MISC

F RX/OTC

SECURESAFE SYRINGE/NEEDLE/3ML/20G X 1" MISC

F RX/OTC

SECURESAFE SYRINGE/NEEDLE/3ML/21G X 1-1/2" MISC

F RX/OTC


F

SECURESAFE SYRINGE/NEEDLE/3ML/22G X 1-1/2" MISC

F RX/OTC


F RX/OTC

SECURESAFE SYRINGE/NEEDLE/3ML/25G X 5/8" MISC

F RX/OTC

SECURESAFE TUBERCULIN INSULIN SYRINGE/1ML/25G X 5/8"MISC

F

RX/OTC

SECURESAFE TUBERCULIN INSULIN SYRINGE/1ML/27G X 1/2"MISC

F

RX/OTC

STIMEX INSULATED NEEDLE TEFLON-COATED BLOCK BEVEL 22GX1-1/2" MISC

F

RX/OTC

SYRINGE/BLUNTPLASTIC CANNULA MISC F RX/OTC

SYRINGE/LUERLOCK/3ML MISC F RX/OTC

SYRINGE/LUERLOCK/3ML/20G X 1" MISC F RX/OTC

SYRINGE/LUERLOCK/3ML/21G X 1-1/2"MISC

F RX/OTC

SYRINGE/LUERLOCK/3ML/21GX1-1/2"MISC

F RX/OTC

SYRINGE/LUERLOCK/3ML/22G X 1" MISC F


85

Drug Name DrugTier

Requirements/Limits


F RX/OTC

SYRINGE/LUERLOCK/3ML/22GX1" MISC F

SYRINGE/LUERLOCK/3ML/22GX1-1/2"MISC

F RX/OTC



F

SYRINGE/LUERLOCK/3ML/23GX1" MISC F RX/OTC



F

SYRINGE/LUERLOCK/3ML/25G X 5/8"MISC

F RX/OTC

SYRINGE/LUERLOCK/3ML/25GX1" MISC F RX/OTC

SYRINGE/LUERLOCK/3ML/25GX5/8"MISC

F RX/OTC

SYRINGE/LUER SLIP/1MLMISC F RX/OTC

SYRINGE/LUER SLIP/3MLMISC F RX/OTC

SYRINGES/LUERLOCK/1ML/20GX1" MISC F RX/OTC

SYRINGES/LUERLOCK/WITHOUTNEEDLE/3ML MISC

F RX/OTC

SYRINGES/LUERSLIP/WITHOUTNEEDLE/1ML MISC

F RX/OTC

ULTICARE SYRINGE/LOWDEADSPACE/3ML/22GX1-1/2" MISC

F RX/OTC

ULTICARE TUBERCULIN SAFETY SYRINGE/1ML/25G X 5/8"MISC

F

RX/OTC

Drug Name DrugTier

Requirements/Limits

VANISHPOINT SAFETY SYRINGE/3ML/20GX1"MISC

F RX/OTC

VANISHPOINT SAFETY SYRINGE/3ML/21GX1-1/2"MISC

F RX/OTC


F


F RX/OTC


F RX/OTC


F


F RX/OTC


F

VANISHPOINT SAFETY SYRINGE/3ML/25GX5/8"MISC

F RX/OTC

VANISHPOINT SYRINGE/3ML/20G X 1"MISC

F RX/OTC

VANISHPOINT SYRINGE/3ML/21G X 1-1/2" MISC

F RX/OTC


F


F RX/OTC


F RX/OTC


F


F RX/OTC


86

Drug Name DrugTier

Requirements/Limits


F

VANISHPOINT SYRINGE/3ML/25G X 5/8"MISC

F RX/OTC

VANISHPOINT TUBERCULIN SYRINGE 1ML/25G X 5/8" MISC

F RX/OTC

VANISHPOINT TUBERCULIN SYRINGE 1ML/27GX1/2" MISC

F RX/OTC

Respiratory Therapy Supplies AEROECLIPSE II BREATH ACTUATED NEBULIZER DISPOSABLE MISC

F RX/OTC

AERONEB GO COMPLETE SYSTEM MISC

F RX/OTC

AERONEB GO CONVENIENCE UNIT MISC

F RX/OTC

AERONEB GO NEBULIZER HANDSET MISC

F RX/OTC

AERONEB GO NEBULIZER HANDSET/CONNECTORCABLE MISC

F

RX/OTC

AIRIAL COMPACT COMPRESSORNEBULIZE R SYSTEM MISC

F RX/OTC

AIRIAL COMPACT MINI NEBULIZER MISC F RX/OTC

AIRIAL COMPARTMENT COMPRESSOR PEDIATRIC NEBULIZER MISC

F

RX/OTC

AIRIAL PEDIATRIC NEBULIZER/BUILDINGBLOCK MISC

F RX/OTC

AIRIAL PEDIATRIC NEBULIZER/DUCK MISC F RX/OTC

AIRIAL PEDIATRIC NEBULIZER/FIRE ENGINEMISC

F RX/OTC

Drug Name DrugTier

Requirements/Limits

AIRIAL PEDIATRIC NEBULIZER/PANDA MISC F RX/OTC

AIRIAL PEDIATRIC NEBULIZER/PENELOPEPANDA MISC

F RX/OTC

AIRIAL PEDIATRIC NEBULIZER/PENGUINMISC

F RX/OTC

AIRIAL VOYAGER PORTABLE NEBULIZER MISC

F RX/OTC

AIRS DISPOSABLE NEBULIZER MISC F RX/OTC

ALL-IN-ONE NEBULIZER SYSTEM MISC F RX/OTC

AURA PORTANEB MISC F RX/OTC

BENTLEY THE BEAR MISC F RX/OTC

CAPTAIN EAGLE MISC F RX/OTC

CLEVER CHOICE NEBULIZER MISC F RX/OTC

CLEVER CHOICE WHISPER AIRE AEROSOL DELIVERY SYSTEM MISC

F

RX/OTC

CLEVER CHOICE WHISPER AIRE PEDIATRIC AEROSOL DELIVERY SYSTEM MISC

F

RX/OTC

CLEVER CHOICE WHISPER AIRE PEDIATRIC COMPRESSOR NEBULIZER MISC

F

RX/OTC

COMP A-I-R COMPRESSOR NEBULIZER MISC

F RX/OTC

COMP AIR COMPRESSOR NEBULIZER MISC

F RX/OTC

COMP AIR ELITE COMPACT COMPRESSOR/NEBULIZER MISC

F

RX/OTC

COMPAIR COMPRESSOR NEBULIZER MISC F RX/OTC


87

Drug Name DrugTier

Requirements/Limits

COMPAIR XL COMPRESSOR NEBULIZER SYSTEM MISC

F

RX/OTC

COMPAIR XLT COMPRESSOR NEBULIZER SYSTEM MISC

F

RX/OTC

COMPMIST COMPRESSOR NEBULIZER MISC

F RX/OTC

COMPRESSOR NEBULIZER MISC F RX/OTC

COMPRESSOR/NEBULIZER MISC F RX/OTC

EASY AIR COMPRESSOR NEBULIZER MISC F RX/OTC

EASY NEB MISC F RX/OTC

EFLOW SCF ELECTRONIC NEBULIZER SYSTEM MISC

F

RX/OTC

EFLOW SCF NEBULIZER HANDSET MISC F RX/OTC

ELITE COMPRESSOR NEBULIZER MISC F RX/OTC

ELITE NEBULIZER SYSTEM MISC F RX/OTC

FLYP NEBULIZER MISC F RX/OTC

HOMENEB WITH SIDESTREAM/DISPOSABLE MISC

F RX/OTC

HOMENEB WITH SIDESTREAM/REUSABLE& DISPOSABLE MISC

F RX/OTC

INNOSPIRE DELUXE COMPRESSOR NEBULIZER SYSTEM MISC

F

RX/OTC

INNOSPIRE ELEGANCE COMPRESSOR NEBULIZER SYSTEM MISC

F

RX/OTC

Drug Name DrugTier

Requirements/Limits

INNOSPIRE ESSENCE COMPRESSOR NEBULIZER SYSTEM MISC

F

RX/OTC

INNOSPIRE GO PORTABLE MESH NEBULIZER MISC

F RX/OTC

INNOSPIRE MINI PORTABLE COMPRESSOR NEBULIZER MISC

F

RX/OTC

INNOSPIRE MINI PORTABLE COMPRESSOR NEBULIZER/BATTERYMISC

F

RX/OTC

INSPIRATION COMPRESSOR NEBULIZER SYSTEM MISC

F

RX/OTC

INSPIRATION ELITE COMPRESSOR NEBULIZER SYSTEM MISC

F

RX/OTC

LUMINEB II PISTON NEBULIZER MISC F RX/OTC

MABIS COMPXP COMPRESSOR NEBULIZER MISC

F RX/OTC

MABIS COSMOCOMP NEBULIZER MISC F RX/OTC

MARGO MOO COMPRESSOR NEBULIZER MISC

F RX/OTC

MICRO AIR NEBULIZER MISC F RX/OTC

MICRO PLUS HIGH EFFICIENCY NEBULIZER/REUSABLEMISC

F

RX/OTC

MICROAIR VIBRATING MESH NEBULIZER MISC F RX/OTC

MICROELITE COMPRESSOR NEBULIZER SYSTEM MISC

F

RX/OTC


88

Drug Name DrugTier

Requirements/Limits

MICROELITE COMPRESSOR NEBULIZER SYSTEM WITH BATTERY MISC

F

RX/OTC

MICRONEB MISC F RX/OTC

MINI COMPRESSOR MISC F RX/OTC

MINI PLUS REUSABLE HIGH EFFICIENCY NEBULIZER MISC

F RX/OTC

MINIBREEZE ULTRASONIC NEBULIZER MISC

F RX/OTC

MINIELITE COMPRESSOR NEBULIZER SYSTEM MISC

F

RX/OTC

MINIELITE COMPRESSOR NEBULIZER SYSTEM WITH BATTERY MISC

F

RX/OTC

MISTERNEB COMPRESSOR NEBULIZER SYSTEM MISC

F

RX/OTC

MY MDI PORTABLE NEBULISER PROCEDURE PACK MISC

F RX/OTC

NEB-RITE4 MISC F RX/OTC

NEBULIZER MISC F RX/OTC

NEBULIZER PED FROG MISC F RX/OTC

NEBULIZER PED FROG SYS W/DISP&REUSE NEBKIT MISC

F RX/OTC

NEBULIZER SYSTEM ALL-IN-ONE MISC F RX/OTC

OPTIONHOME COMPRESSOR NEBULIZER SYSTEM MISC

F

RX/OTC

PARI ALTERA NEBULIZER SYSTEM MISC

F RX/OTC

Drug Name DrugTier

Requirements/Limits

PARI BABY DEVI F RX/OTC

PARI BABY SIZE 1/PARILCPLUS DEVI F RX/OTC

PARI ERAPID NEBULIZER SYSTEM MISC F RX/OTC

PARI LC D NEBULIZER MISC F RX/OTC

PARI LC PLUS MISC F RX/OTC

PARI LC PLUS NEBULIZER MISC F RX/OTC

PARI LC PLUS NEBULIZER SET/PEDIATRIC MASKMISC

F

RX/OTC

PARI LC PLUS NEBULIZER VIOS PRO/REUSABLE MISC

F RX/OTC

PARI LC SPRINT NEBULIZERSET MISC F RX/OTC

PARI LC STAR MISC F RX/OTC

PARI LC STAR NEBULIZER MISC F RX/OTC

PARI PRONEB ULTRA II MISC F RX/OTC

PARI SINUS PULSATING AEROSOL SYSTEM MISC F RX/OTC

PARI TREK S COMPACT COMPRESSOR W/ 12VDC ADAPTOR DEVI

F RX/OTC

PARI VIOS PRO LC PLUS AEROSOL DELIVERY SYSTEM MISC

F RX/OTC

PARI VIOS PRO LC SPRINT AEROSOL DELIVERY SYSTEM MISC

F RX/OTC

PHILLIPS WILLIS THE WHALENEBULIZER MISC F RX/OTC

PORTABLE COMPRESSOR NEBULIZER MISC

F RX/OTC

PROCARE COMPRESSOR NEBULIZER MISC

F RX/OTC


89

Drug Name DrugTier

Requirements/Limits

PRODIGY MINI-MIST PORTABLE NEBULIZER MISC

F RX/OTC

PRODIGY MINI-MIST PORTABLE NEBULIZER SPANISH MISC

F RX/OTC

PRONEB ULTRA II DELUXE/LC SPRINT DEVI F RX/OTC

PRONEB ULTRA II DELUXE/LC STAR MISC F RX/OTC

PRONEB ULTRA II DELUXE/LCD DEVI F RX/OTC

PRONEB ULTRA II PEDIATRIC DEVI F RX/OTC

PRONEB ULTRA II WITH LC PLUS DEVI F RX/OTC

PRONEB ULTRA II/LCSPRINT MISC F RX/OTC

PRONEB ULTRA II/LCSPRINT PEDIATRIC MISC F RX/OTC

PURE AIR MINI NEBULIZER MISC F RX/OTC

SIDESTREAM NEBULIZER/DISPOSABLEMISC

F RX/OTC

SIDESTREAM NEBULIZER/REUSABLEMISC

F RX/OTC

SIDESTREAM PLUS REUSABLEHIGH EFFICIENCY NEBULIZER MISC

F

RX/OTC

SOOTHE NEB MESH NEBULIZER MISC F RX/OTC

SOOTHENEB COMPRESSOR NEBULIZER MISC

F RX/OTC

SPARKY THE DOG MISC F RX/OTC

VERSA-NEB COMPRESSOR/NEBULIZER SYSTEM MISC

F RX/OTC

VIOS AEROSOL DELIVERY SYSTEM MISC F RX/OTC

VIOS LC PLUS AEROSOL DELIVERY SYSTEM DELUXE MISC

F RX/OTC

Drug Name DrugTier

Requirements/Limits

VIOS LC PLUS AEROSOL DELIVERY SYSTEM MISC F RX/OTC

VIOS LC PLUS AEROSOL DELIVERY SYSTEM PEDIATRIC MISC

F RX/OTC

VIOS LC SPRINT AEROSOL DELIVERY SYSTEM MISC

F RX/OTC

VIOS LC SPRINT AEROSOL DELIVERY SYSTEM PEDIATRIC MISC

F

RX/OTC

VIOS LC SPRINT DELUXE AEROSOL DELIVERY SYSTEM MISC

F RX/OTC

MIGRAINE PRODUCTS - Drugs to Treat MigraineHeadaches

Calcitonin Gene-Related Peptide (CGRP) AIMOVIG SOAJ F PA; SP

EMGALITY SOAJ F PA; SP

EMGALITY SOSY F PA; SP

Migraine Combinations

CAFERGOT TABS (ergotamine w/ caffeine) NF

10 permonth;QL(0.34ea daily)

ergotamine w/ caffeine tabs F 10 permonth;QL(0.34ea daily)

MIGERGOT SUPP F 12 per month

Serotonin Agonists

AMERGE TABS (naratriptan hcl) NF

9 permonth;;QL(0.3ea daily)

IMITREX SOLN NA 5 MG/ACT, 20 MG/ACT(sumatriptan)

F Limit 6 permonth;QL(0.2ea daily)

IMITREX SOLN SC 6 MG/0.5ML (sumatriptansuccinate)

NF

2 doses (1ml) permonth;QL(0.034 ml daily)


90

Drug Name DrugTier

Requirements/Limits

IMITREX STATDOSE REFILL SOCT (sumatriptan succinate)

NF


IMITREX STATDOSE SYSTEM SOAJ (sumatriptan succinate)

NF

Max 1 device per 90 days;Use refill cartridges;QL(1ml per 90 daysretail)

IMITREX TABS OR 25 MG, 50 MG, 100 MG (sumatriptan succinate)

NF 9 permonth;QL(0.3ea daily)

MAXALT TABS (rizatriptanbenzoate) NF


MAXALT-MLT TBDP (rizatriptan benzoate) NF


naratriptan hcl tabs F 9 permonth;;QL(0.3ea daily)

rizatriptan benzoate tabs F 9 per monthQL(0.3 eadaily)

rizatriptan benzoate tbdp F 9 per monthQL(0.3 eadaily)

sumatriptan succinate soajsc 4 mg/0.5ml, 6 mg/0.5ml F

Max 1 device per 90 days;Use refill cartridges;QL(1ml per 90 daysretail)

sumatriptan succinate soctsc 4 mg/0.5ml, 6 mg/0.5ml F


sumatriptan succinate solnsc 6 mg/0.5ml F


sumatriptan succinate tabsor 25 mg, 50 mg, 100 mg F

9 permonth;QL(0.3ea daily)

zolmitriptan tabs or 5 mg,2.5 mg F


Drug Name DrugTier

Requirements/Limits

zolmitriptan tbdp or 2.5 mg F 9 permonth;;QL(0.3ea daily)

zolmitriptan tbdp or 5 mg F

9 permonth;;QL(0.3ea daily,9 eaper 30 daysretail)

ZOMIG SOLN NA 5 MG, 2.5 MG F


ZOMIG TABS OR 5 MG, 2.5 MG (zolmitriptan) NF


ZOMIG ZMT TBDP 2.5 MG (zolmitriptan) NF


ZOMIG ZMT TBDP 5 MG (zolmitriptan) NF

9 permonth;;QL(0.3ea daily,9 eaper 30 daysretail)

MINERALS & ELECTROLYTES

Calcium

CAL-CITRATE CAPS F

CAL-LAC CAPS F

CAL-MINT CHEW F

CALCI-CHEW CHEW F

CALCIUM ACETATE TABS OR F

CALCIUM CAPS 250 MG F

CALCIUM CARBONATE CHEW OR 260 MG, 500 MG

F

calcium carbonate tabs or 500 mg, 600 mg, 1250 mg,1500 mg

F

calcium carbonate-vitamin d caps F

calcium carbonate-vitamin d chew F


91

Drug Name DrugTier

Requirements/Limits

calcium carbonate-vitamin d tabs F

CALCIUM CHEW 500 MG F

CALCIUM CITRATE TABS OR 200 MG, 250 MG, 1040 MG

F

calcium citrate tabs or 200 mg, 950 mg F

calcium citrate-vitamin d tabs 250 mg-200 unit F

CALCIUM GLUCONATE TABS OR 50 MG, 500 MG F

CALCIUM LACTATE TABS 100 MG, 750 MG F

CALCIUM PLUS VITAMIN D CAPS F

calcium tabs 500 mg, 600 mg F

CALCIUM TABS 600 MG-200 UNIT F

CHELATED CALCIUM TABS F

oyster shell tabs F

RA CALCIUM HI-CAL/VITAMIND TABS 500MG-125 UNIT

F

Electrolyte Mixtures CERALYTE 70 SOLN 60 MEQ/L-70 MEQ/L-20MEQ/L-30 MEQ/L

F

CERASPORT EX1 SOLN F

CERASPORT SOLN 4 MEQ/L-18 MEQ/L-20MEQ/L-6 MEQ/L

F

ENFAMIL ENFALYTE SOLN F

EQUALYTE SOLN (oral electrolytes) NF

HYDRALYTE FREEZER POPS SOLN F

Drug Name DrugTier

Requirements/Limits

HYDRALYTE SOLN 270 MG/250ML-210MG/250ML, 45 MEQ/L-45MEQ/L-20 MEQ/L-90MEQ/L-16 GM/L

F

oral electrolytes soln F

PEDIALYTE ADVANCED CARE SOLN (oral electrolytes)

NF

PEDIALYTE FREEZER POPS SOLN (oral electrolytes)

NF

PEDIALYTE SINGLES SOLN (oral electrolytes) NF

PEDIALYTE SOLN 20 MEQ/L-45 MEQ/L-35MEQ/L-5 GM/L-20 GM/L,4.7 MEQ/237ML-10.6MEQ/237ML-8.3MEQ/237ML, 20 MEQ/L-45MEQ/L-35 MEQ/L-30MEQ/L-25 GM/L, 35MEQ/L-45 MEQ/L-7.8MG/L-20 MEQ/L-25 GM/L,2.1 MEQ/59ML-2.7MEQ/59ML-0.5 MG/59ML-1.2 MEQ/59ML-1.5GM/59ML (oral electrolytes)

NF

Fluoride sodium fluoride chew or 0.25 mg, 0.5 mg, 1 mg, 2.2 mg

F

sodium fluoride soln or 0.5 mg/ml F

SODIUM FLUORIDE TABS OR 0.5 MG, 1 MG F

Magnesium MAG-200 TABS (magnesium oxide (mgsupplement))

NF

MAGNESIUM CAPS 400 MG F

magnesium oxide (mgsupplement) caps F

magnesium oxide (mgsupplement) tabs F


92

Drug Name DrugTier

Requirements/Limits

MAGNESIUM OXIDE CAPS 400 MG F

MAGOX 400 TABS (magnesium oxide (mgsupplement))

NF

Mineral Combinations

BONE ESSENTIALS CAPS F

CAL-MAG-K CHELA MAX CAPS F

CALCIUM & VITAMIN D3 BONEHEALTH LIQD F

COLAMINE TABS F

CVS CALCIUM CHEWABLES 600PLUS CHEW

F

MULTI-MINERALS TABS F

multiple minerals tabs F

NF FORMULAS CALCIUM MAGNESIUM LIQD F

NUTRA-SUPPORT BONE CAPS F

Phosphate K-PHOS NEUTRAL TABS (pot phosphate monobasicw/ sod phosphate dibasic &monobasic)

NF

pot phosphate monobasicw/ sod phosphate dibasic &monobasic tabs 130 mg-155 mg-852 mg

F

Potassium CHELATED POTASSIUM TABS F

K-TAB TBCR 10 MEQ, 20 MEQ (potassium chloride) NF

K-TAB TBCR 8 MEQ (potassium chloride) F

potassium chloride cpcr or8 meq, 10 meq F

POTASSIUM CHLORIDE GRAN XX F RX/OTC

Drug Name DrugTier

Requirements/Limits

potassium chloridemicroencapsulated crystalser tbcr

F

potassium chloride pack or20 meq F

potassium chloride soln or10 %, 20 % F

potassium chloride tbcr or 8meq, 10 meq, 20 meq F

potassium tabs 75 mg, 99 mg F

POTASSIUM TABS 99 MG F

Sodium sodium chloride soln ij 0.9% F

SODIUM CHLORIDE SOLN IJ 0.9 % F

sodium chloride soln iv 0.9 % F

MISCELLANEOUS THERAPEUTIC CLASSES

Chelating Agents CUPRIMINE CAPS (penicillamine) NF

penicillamine caps or 250 mg F

Immunomodulators

REVLIMID CAPS F PA; SP

THALOMID CAPS F PA; SP

Immunosuppressive Agents

ASTAGRAF XL CP24 F

azathioprine tabs or 50 mg F

CELLCEPT CAPS (mycophenolate mofetil) NF

CELLCEPT SUSR (mycophenolate mofetil) NF

CELLCEPT TABS (mycophenolate mofetil) NF

cyclosporine caps or 25mg, 100 mg F


93

Drug Name DrugTier

Requirements/Limits

cyclosporine modified (formicroemulsion) caps F

cyclosporine modified (formicroemulsion) soln F

everolimus (immunosuppressant) tabs F PA

IMURAN TABS (azathioprine) NF

mycophenolate mofetil caps F

mycophenolate mofetil susr F

mycophenolate mofetil tabs F

NEORAL CAPS (cyclosporine modified (formicroemulsion))

NF

NEORAL SOLN (cyclosporine modified (formicroemulsion))

NF

PROGRAF CAPS (tacrolimus) NF

RAPAMUNE SOLN 1 MG/ML (sirolimus) NF

RAPAMUNE TABS 0.5 MG, 1 MG, 2 MG (sirolimus)

NF QL(1 ea daily)

SANDIMMUNE CAPS 25 MG, 100 MG (cyclosporine) NF

SANDIMMUNE SOLN 100 MG/ML F

sirolimus soln or 1 mg/ml F

sirolimus tabs or 0.5 mg, 1mg, 2 mg F QL(1 ea daily)

tacrolimus caps or 0.5 mg,1 mg, 5 mg F

ZORTRESS TABS 0.25 MG, 0.75 MG, 0.5 MG (everolimus (immunosuppressant))

NF

PA

ZORTRESS TABS 1 MG F PA

Potassium Removing Agents sodium polystyrenesulfonate powd or F

Drug Name DrugTier

Requirements/Limits

sodium polystyrenesulfonate susp or 15gm/60ml

F

MOUTH/THROAT/DENTAL AGENTS

Anesthetics Topical Oral lidocaine hcl (mouth-throat)soln 2 % F QL(100 ml per

30 days retail) Anti-infectives - Throat clotrimazole troc mt F

nystatin (mouth-throat) susp F

Antiseptics - Mouth/Throat chlorhexidine gluconate(mouth-throat) soln 0.12 % F

PERIDEX SOLN (chlorhexidine gluconate(mouth-throat))

NF

Steroids - Mouth/Throat/Dental triamcinolone acetonide (mouth) pste F

Throat Products - Misc. AQUORAL SOLN F RX/OTC

BIOTENE DRY MOUTH MOISTURIZING SPRAY SOLN

F RX/OTC

CAPHOSOL SOLN F RX/OTC

CVS DRY MOUTH SPRAY SOLN F RX/OTC

EQL DRY MOUTH ORAL RINSE SOLN F RX/OTC

MOI-STIR SOLN F RX/OTC

MOUTH KOTE REMINT SOLN F RX/OTC

MOUTH KOTE SOLN F RX/OTC

NUMOISYN LIQD F RX/OTC

ORAL RELIEF SPRAY FOR DRYMOUTH & DISCOMFORT SOLN

F RX/OTC


94

Drug Name DrugTier

Requirements/Limits

RA DRY MOUTH SOLN F RX/OTC

XEROSTOMIA RELIEF SPRAY SOLN F RX/OTC

MULTIVITAMINS

B-Complex w/ Folic Acid b-complex w/ c & folic acid caps F RX/OTC

NEPHROCAPS CAPS (b-complex w/ c & folic acid) NF RX/OTC

Multiple Vitamins w/ Minerals

ONEVITE TABS F

THRIVITE 19 TABS F

UDAMIN SP TABS F

Ped MV w/ Iron BPROTECTED PEDIA POLY-VITE/IRON SOLN F

pediatric multiple vitaminsw/ iron soln F

Pediatric Multiple Vitamins pediatric multiple vitamin w/c soln F

POLY-VI-SOL SOLN F

Prenatal Vitamins CLASSIC PRENATAL TABS F

CO-NATAL FA TABS F RX/OTC

COMPLETENATE CHEW F

CVS PRENATAL TABS F

EQL PRENATAL FORMULA TABS F

GNP DAILY PRENATAL MISC F

GNP PRENATAL TABS F

GOODSENSE PRENATAL VITAMINS TABS F

Drug Name DrugTier

Requirements/Limits

HM ONE DAILY PRENATAL COMBO MISC F

HM PRENATAL TABS F

INATAL GT TABS F

KP PRENATAL MULTIVITAMINS TABS F

KPN PRENATAL TABS F

M-NATAL PLUS TABS F RX/OTC

M-VIT TABS F RX/OTC

MULTI PRENATAL TABS F

MYNATAL ADVANCE TABS F

MYNATAL CAPS F

MYNATAL PLUS TABS F

MYNATAL ULTRACAPLET TABS F

MYNATAL-Z TABS F

MYNATE 90 PLUS TBCR F

NATALVIT TABS F

NEONATAL COMPLETE TABS F RX/OTC

NEONATAL PLUS TABS F RX/OTC

NEONATAL VITAMIN TABS F

NIVA-PLUS TABS F RX/OTC

O-CAL FA TABS F RX/OTC

O-CAL PRENATAL TABS F

ONE VITE WOMENS PRENATALVITAMIN PLUS TABS

F RX/OTC

ONE VITE WOMENS PRENATALVITAMIN TABS F


95

Drug Name DrugTier

Requirements/Limits

ONE-A-DAY WOMENS PRENATAL MISC F

PERRY PRENATAL CAPS F

PNV FOLIC ACID + IRON MULTIVITAMIN TABS F RX/OTC

PNV PRENATAL PLUS MULTIVITAMIN TABS F RX/OTC

PNV TABS 29-1 TABS F

PRE-NATAL FORMULA TABS F RX/OTC

PRENATABS FA TABS F RX/OTC

PRENATABS RX TABS F

PRENATAL 19 CHEW F

PRENATAL 19 TABS F

PRENATAL AND IRON TABS F RX/OTC

PRENATAL FORTE TABS F RX/OTC

PRENATAL LOW IRON TABS F

PRENATAL MULTIVITAMIN TABS F

PRENATAL ONE DAILY TABS F

PRENATAL PLUS IRON TABS F

PRENATAL PLUS TABS F RX/OTC

Drug Name DrugTier

Requirements/Limits

PRENATAL TABS 11 UNIT-263 MG-25 MG-1.5 MG-27 MG-4000 UNIT-18 MG-1.7 MG-4 MCG-400 UNIT-0.8 MG-2.6 MG-100 MG, 30 UNIT-4000 UNIT-25 MG-1.8 MG-200 MG-28 MG-20 MG-1.7 MG-8 MCG-400 UNIT-0.8 MG-2.6 MG-120 MG, 30 UNIT-25 MG-1.8 MG-200 MG-28 MG-20 MG-1.7 MG-4000 UNIT-8 MCG-400 UNIT-800 MCG-2.6 MG-120 MG, 30 UNIT-4000 UNIT-25 MG-1.8 MG-200 MG-28 MG-20 MG-1.7 MG-8 F MCG-400 UNIT-800 MCG-2.6 MG-120 MG, 4000 UNIT-30 UNIT-200 MG-25 MG-1.8 MG-28 MG-20 MG-1.7 MG-8 MCG-400 UNIT-800 MCG-2.6 MG-120 MG, 4000 UNIT-30 UNIT-25 MG-1.8 MG-200 MG-28 MG-20 MG-1.7 MG-8 MCG-400 UNIT-800 MCG-2.6 MG-120 MG, 160 MG-11 UNIT-200 MG-25 MG-1.84 MG-27 MG-4000 UNIT-18 MG-1.7 MG-4 MCG-400 UNIT-800 MCG-2.6 MG-100 MG PRENATAL TABS 22 MG-2 MG-25 MG-1.84 MG-200 MG-27 MG-4000 UNIT-20 MG-3 MG-12 MCG-400 UNIT-1 MG-10 MG-120 MG

F

RX/OTC

PRENATAL TABS 4000 UNIT-200 MG-11 UNIT-27 MG-25 MG-1.84 MG-18 MG-1.7 MG-4 MCG-400 UNIT-0.8 MG-2.6 MG-100 MG

F

RX/OTC

PRENATAL VITAMIN & MINERAL TABS F

PRENATAL VITAMIN TABS F


96

Drug Name DrugTier

Requirements/Limits

PRENATAL VITAMIN/IRON TABS F

PRENATAL VITAMINS PLUS LOW IRON TABS F RX/OTC

PRENATAL VITAMINS TABS F

PRENATAL-U CAPS 1.3 MG-0.8 MG-10 MG-106.5 MG-10 MG-200 MG-30 MG-6 MG-15 MCG-1 MG-5 MG

F

PRENATVITE RX TABS F RX/OTC

PREPLUS TABS F RX/OTC

PRETAB TABS F RX/OTC

PX PRENATAL MULTIVITAMINS TABS F

QC PRENATAL TABS F

RA ONE DAILY MISC F

RA PRENATAL FORMULA/FOLICACIDTABS

F

RA PRENATAL TABS F

RIGHT STEP PRENATAL TABS F

SE-NATAL 19 CHEW F

SE-NATAL 19 TABS F

SM ONE DAILY PRENATAL MISC F

SM PRENATAL VITAMINS TABS F

THERANATAL CORE NUTRITION TABS F RX/OTC

THRIVITE RX TABS F

TRICARE TABS F RX/OTC

TRINATAL RX 1 TABS F

TRINATE TABS F

Drug Name DrugTier

Requirements/Limits

VIL-RX TABS F

VINATE M TABS F

VINATE ONE TABS F

VITAFOL-OB TABS F

VITATHELY/GINGERTABS F RX/OTC

VOL-NATE TABS F

VOL-PLUS TABS F RX/OTC

VOL-TAB RX TABS F

MUSCULOSKELETAL THERAPY AGENTS -Drugs to Treat Spasms

Central Muscle Relaxants baclofen tabs or 10 mg, 20 mg F

cyclobenzaprine hcl tabs or5 mg, 10 mg F

methocarbamol tabs or 500 mg, 750 mg F

ROBAXIN TABS OR 500 MG (methocarbamol) NF

ROBAXIN-750 TABS (methocarbamol) NF

tizanidine hcl tabs or 2 mg,4 mg F

ZANAFLEX TABS 4 MG (tizanidine hcl) NF

Direct Muscle Relaxants DANTRIUM CAPS 25 MG (dantrolene sodium) NF

dantrolene sodium caps or25 mg, 100 mg F

NASAL AGENTS - SYSTEMIC AND TOPICAL -Drugs to treat the Nose or Sinus

Nasal Agent Combinations

AFRIN MENTHOL SOLN F

azelastine hcl-fluticasone propionate susp 50mcg/act-137 mcg/act

F


97

Drug Name DrugTier

Requirements/Limits

DERMACINRX AZENASE PAK THPK 50 MCG/ACT-137 MCG/ACT

F

DYMISTA SUSP (azelastine hcl-fluticasone propionate)

NF

TICALAST KIT F

Nasal Agents - Misc. 4-WAY SALINE SOLN F

ALKALOL SOLN F

ALZAIR ALLERGY BLOCKER NASAL SPRAY POWD

F

AYR NASAL DROPS SOLN F

AYR NASAL MIST ALLERGY &SINUS HYPERTONIC SALINE SOLN

F

AYR SALINE NASAL GEL SWAB F

AYR SALINE NASAL NETI RINSE KIT PACK F

AYR SALINE NASAL RINSE KIT PACK F

AYR SALINE NASAL RINSE KIT REFILL PACK F

CVS NASAL MIST AERS F

DERMACINRX TICANASE PAK THPK F

ENTSOL NASAL SPRAY SOLN F

GELONASAL SOLN F

LITTLE NOSES MOISTURIZINGNASAL GEL GEL

F

LITTLE NOSES STERILE SALINE NASAL MIST AERS

F

LITTLE REMEDIES BABY STERILE SALINE MIST FOR NOSES AERS

F

Drug Name DrugTier

Requirements/Limits

LITTLE REMEDIES FOR NOSES SOLN F

NASADOCK PLUS PACK F

NASADROPS SALINE ON THE GO SOLN F

NASAFLO NETI POT NASAL WASH SYSTEM PACK

F

NASAFLO PORCELAIN NASAL RINSE PACK F

NASAL CLEANSE RINSE MIX PACK F

NASAL MOIST GEL GEL F

NASALCARE FOR KIDS PACK F

NASALCARE FOR KIDS STARTER KIT PACK F

NASALCARE NASALCLEANSE KIT PACK

F

NASALCARE PACK F

NASAMIST ALL-IN-ONE AERS F

NASAMIST HYPERTONIC AERS F

NASAMIST ISOTONIC AERS F

NOSE BETTER GEL F

NOSE BETTER NATURAL MIST SOLN F

NOSE BETTER SOLN F

OCEAN COMPLETE SINUS RINSE AERS F

OCEAN NASAL MOISTURIZER GEL F

OCEAN NASAL SPRAY SOLN (saline) NF

OCEAN ULTRA SALINE NASALMIST SOLN F

PONARIS SOLN F


98

Drug Name DrugTier

Requirements/Limits

PRETZ IRRIGATION SOLN F

PRETZ NATURAL MOISTURIZING NASAL SPRAY/YERBASANTA/SEA SALT SOLN

F

PRETZ SOLN NA F

RA SINUS WASH NASAL RELIEF REFILL PACK F

RA SINUS WASH NETI POT PACK F

RA STERILE SALINE NASAL MIST SOLN F

RHINARIS SOLN F

RHINASE GEL F

RHINASE SOLN F

saline gel na F

saline soln na 0.65 %-0.002 %, 0.65 % F

SALTAIRE SOLN F

SIMPLY SALINE AERS F

SINUCLEANSE NETI POT KIT (sodium chloride-sodium bicarbonate)

NF

SINUCLEANSE REFILL PACK (sodium chloride-sodium bicarbonate)

NF

SINUCLEANSE SQUEEZE KIT (sodium chloride-sodium bicarbonate)

NF

SINUFLO READYRINSE KIT F

SINUGATOR NASAL WASH PACK F

SINUS RINSE BOTTLE KIT PACK F

SINUS RINSE KIT PACK F

SINUS RINSE KIT PEDIATRIC PACK F

Drug Name DrugTier

Requirements/Limits

SINUS RINSE PACK F

SINUS RINSE PEDIATRIC STARTER KIT PACK F

SINUS RINSE REFILL PACK F

SINUS RINSE REFILL PEDIATRIC PACK F

SINUS WASH SALT CRYS F

sodium chloride-sodium bicarbonate kit F

sodium chloride-sodium bicarbonate pack F

TICASPRAY THPK F

XLEAR SINUS CARE SPRAY SOLN F

XLEAR SINUS CARE SPRAY/KIDS SOLN F

Nasal Anesthetics COCAINE HYDROCHLORIDE SOLN F

GOPRELTO SOLN F

NUMBRINO SOLN F

Nasal Anti-infectives BACTROBAN NASAL OINT F

Nasal Antiallergy ASTEPRO SOLN (azelastine hcl) NF

azelastine hcl soln na 0.15 %, 0.1 %, 137 mcg/spray F

cromolyn sodium (nasal)aers 5.2 mg/act F

NASALCROM AERS (cromolyn sodium (nasal)) NF

olopatadine hcl (nasal) soln0.6 % F

PATANASE SOLN (olopatadine hcl (nasal)) NF

Nasal Anticholinergics


99

Drug Name DrugTier

Requirements/Limits

ipratropium bromide (nasal)soln F

Nasal Steroids

BECONASE AQ SUSP F

budesonide (nasal) susp F

FLONASE ALLERGY RELIEF CHILDRENS SUSP (fluticasone propionate (nasal))

NF

RX/OTC

FLONASE ALLERGY RELIEF SUSP (fluticasone propionate (nasal))

NF RX/OTC

FLONASE SENSIMIST SUSP F

flunisolide (nasal) soln F

fluticasone propionate(nasal) susp F RX/OTC

mometasone furoate (nasal) susp F

NASACORT ALLERGY 24HR AERO (triamcinolone acetonide (nasal))

NF RX/OTC

NASACORT ALLERGY 24HR AERO 55 MCG/ACT F RX/OTC

NASACORT ALLERGY 24HR CHILDRENS AERO (triamcinolone acetonide (nasal))

NF

RX/OTC

NASONEX SUSP (mometasone furoate (nasal))

NF

OMNARIS SUSP F

PROPEL IMPL F

PROPEL MINI IMPL F

QNASL AERS F

QNASL CHILDRENS AERS F

SINUVA IMPL F

triamcinolone acetonide (nasal) aero 55 mcg/act F RX/OTC

Drug Name DrugTier

Requirements/Limits

XHANCE EXHU F

ZETONNA AERS F

Sympathomimetic Decongestants ADRENALIN SOLN NA 0.1 % F

AFRIN 12 HOUR SOLN (oxymetazoline hcl) NF

AFRIN ALL NIGHT NODRIP SOLN (oxymetazoline hcl)

NF

AFRIN CHILDRENS SOLN F

AFRIN NASAL SPRAY SOLN (oxymetazoline hcl) NF

AFRIN NODRIP EXTRA MOISTURIZING SOLN (oxymetazoline hcl)

NF

AFRIN NODRIP ORIGINAL SOLN (oxymetazoline hcl) NF

AFRIN NODRIP SEVERE CONGESTION SOLN (oxymetazoline hcl)

NF

AFRIN NODRIP SINUS SOLN (oxymetazoline hcl) NF

AFRIN PUMP MIST SOLN (oxymetazoline hcl) NF

AFRIN SINUS SOLN (oxymetazoline hcl) NF

AFRIN SOLN (oxymetazoline hcl) NF

BENZEDREX INHALER INHA F

CVS NASAL DECONGESTANT CAPS F

DRISTAN SPRAY SOLN (oxymetazoline hcl) NF

DURATION 12 HOUR SOLN (oxymetazoline hcl) NF

DURATION SPRAY SOLN (oxymetazoline hcl) NF

LITTLE COLDS DECONGESTANTFORMU LA LIQD

F


100

Drug Name DrugTier

Requirements/Limits

LITTLE NOSES DECONGESTANTNOSE DROPS SOLN

F

NASAL DECONGESTANT LIQD F

NASAL DECONGESTANT SYRP F

NEO-SYNEPHRINE COLD+ALLERGY EXTRA STRENGTH SOLN (phenylephrine hcl)

NF

NEO-SYNEPHRINE COLD+ALLERGY MILD STRENGTH SOLN

F

NEO-SYNEPHRINE COLD+ALLERGY REGULAR STRENGTH SOLN

F

oxymetazoline hcl soln na0.05 % F

phenylephrine hcl (oral)tabs F

PHENYLEPHRINE HCL CRYS XX F

PHENYLEPHRINE HCL POWD XX F RX/OTC

phenylephrine hcl soln na F

PHENYLEPHRINE HYDROCHLORIDE POWD XX

F RX/OTC

PHENYLPROPANOLAMIN E HYDROCHLORIDE USP POWD

F

PSEUDOEPHEDRINE HCL CRYS XX F

pseudoephedrine hcl liqdor 15 mg/5ml F

PSEUDOEPHEDRINE HCL POWD XX F

pseudoephedrine hcl tabaor 30 mg F

pseudoephedrine hcl tabsor 30 mg, 60 mg F

pseudoephedrine hcl tb12or 120 mg F

Drug Name DrugTier

Requirements/Limits

SUDAFED CHILDRENS LIQD (pseudoephedrinehcl)

NF

SUDAFED CONGESTION TABS (pseudoephedrinehcl)

NF

SUDAFED PE CHILDRENS NASAL DECONGESTANT SOLN

F

SUDAFED PE SINUS CONGESTION TABS (phenylephrine hcl (oral))

NF

SUDAFED SINUS CONGESTION TABS (pseudoephedrine hcl)

NF

SUDAFED SINUS CONGESTION24 HOUR TB24

F

VICKS SINEX 12 HOUR DECONGESTANT SOLN (oxymetazoline hcl)

NF

VICKS SINEX MOISTURIZING SOLN (oxymetazoline hcl)

NF

VICKS SINEX SEVERE NASALDECONGESTANT SOLN (oxymetazoline hcl)

NF

VICKS SINEX SEVERE SOLN (oxymetazoline hcl) NF

NEUROMUSCULAR AGENTS - Drugs toRelax/Paralyze Muscles

ALS Agents

RILUTEK TABS (riluzole) NF

riluzole tabs 50 mg F

NUTRIENTS

Misc. Nutritional Substances

FISH OIL CAPS F

FISH OIL CHEW F

FISH OIL PEARLS CAPS F

FISH OIL TRIPLE STRENGTH CAPS F


101

Drug Name DrugTier

Requirements/Limits

FISH OIL ULTRA CAPS F

HM FISH OIL CAPS F

OMEGA POWER CAPS F

OMEGA-3 2100 CAPS F

OMEGA-3 CAPS F

OMEGA-3 EPA FISH OIL CAPS F

omega-3 fatty acids caps F

omega-3 fatty acids chew F

OMEGA-3 FISH OIL EXTRA STRENGTH CAPS F

RA FISH OIL EXTRA STRENGTH CAPS F

RA TRIPLE STRENGTH FISH OIL CAPS F

SALMON CAPS F

SALMON OIL CAPS F

SALMON OIL-1000 CAPS F

SM FISH OIL CAPS F

SUPER TWIN EPA/DHACAPS F

ULTRA OMEGA 3 CAPS F

ULTRA OMEGA-3 FISH OIL BURP-LESS CAPS F

OPHTHALMIC AGENTS - Drugs to Treat the Eye

Artificial Tears and Lubricants

artificial tear ointment oint F

artificial tear solution soln F

ARTIFICIAL TEARS SOLN F

carboxymethylcellulosesodium (ophth) gel 1 % F

Drug Name DrugTier

Requirements/Limits

carboxymethylcellulosesodium (ophth) soln 0.25%, 0.5 %

F

GENTEAL MILD SOLN F

GENTEAL MILD TO MODERATE SOLN (hypromellose (ophth))

NF

GENTEAL SEVERE GEL F

GENTEAL SEVERE TEARS GEL F

GONIOVISC SOLN F

hypromellose (ophth) soln F

ISOPTO TEARS SOLN F

polyethylene glycol-propylene glycol (ophth)soln 0.4 %-0.3 %

F

polyvinyl alcohol soln op1.4 % F

REFRESH LIQUIGEL GEL (carboxymethylcellulosesodium (ophth))

NF

REFRESH TEARS SOLN (carboxymethylcellulosesodium (ophth))

NF

SYSTANE OVERNIGHT THERAPY LUBRICANT EYE GEL

F

SYSTANE SOLN (polyethylene glycol-propylene glycol (ophth))

NF

SYSTANE ULTRA HOME & AWAY PACK SOLN (polyethylene glycol-propylene glycol (ophth))

NF

SYSTANE ULTRA SOLN (polyethylene glycol-propylene glycol (ophth))

NF

THERATEARS SOLN 0.25 % (carboxymethylcellulosesodium (ophth))

NF

Beta-blockers - Ophthalmic BETAGAN SOLN (levobunolol hcl) NF


102

Drug Name DrugTier

Requirements/Limits

betaxolol hcl (ophth) soln F

BETIMOL SOLN F

BETOPTIC-S SUSP F

carteolol hcl (ophth) soln F

COSOPT SOLN (dorzolamide hcl-timolol maleate)

NF

dorzolamide hcl-timolol maleate soln 2 %-0.5 %, 20mg/ml-5 mg/ml, 22.3mg/ml-6.8 mg/ml

F

ISTALOL SOLN (timolol maleate (ophth)) NF

levobunolol hcl soln 0.5 % F

metipranolol soln F

timolol maleate (ophth)solg F

timolol maleate (ophth)soln F

TIMOPTIC OCUDOSE SOLN F

TIMOPTIC SOLN (timolol maleate (ophth)) NF

TIMOPTIC-XE SOLG F

Cycloplegic Mydriatics ATROPINE SULFATE OINT OP 1 % F

ATROPINE SULFATE SOLN OP 1 % F

CYCLOGYL SOLN 1 %, 2 % (cyclopentolate hcl) NF

cyclopentolate hcl soln op1 %, 2 % F

HOMATROPAIRE SOLN F

homatropine hbr soln F

ISOPTO ATROPINE SOLN 1 % F

Drug Name DrugTier

Requirements/Limits

MYDRIACYL SOLN (tropicamide) NF

phenylephrine hcl(mydriatic) soln 10 % F

phenylephrine hcl(mydriatic) soln 2.5 % F QL(16 ml daily)

tropicamide soln op 0.5 %,1 % F

Miotics ISOPTO CARPINE SOLN (pilocarpine hcl) NF

pilocarpine hcl soln op 1 %,2 %, 4 % F

Ophthalmic Adrenergic Agents apraclonidine hcl soln 0.5% F

brimonidine tartrate soln op0.2 % F

IOPIDINE SOLN 0.5 % (apraclonidine hcl) NF

Ophthalmic Anti-infectives bacitracin (ophthalmic) oint500 unit/gm F QL(4 gm per 7

days retail) bacitracin-polymyxin b(ophth) oint F

BLEPH-10 SOLN (sulfacetamide sodium (ophth))

NF

CILOXAN OINT 0.3 % F

CILOXAN SOLN (ciprofloxacin hcl (ophth)) NF

ciprofloxacin hcl (ophth)soln 0.3 % F

erythromycin (ophth) oint F

gentamicin sulfate (ophth)oint F

gentamicin sulfate (ophth)soln F

levofloxacin (ophth) soln F

moxifloxacin hcl (ophth)soln 0.5 % F

NATACYN SUSP F


103

Drug Name DrugTier

Requirements/Limits

neomycin-bacitracin zn-polymyxin oint F

NEOMYCIN/POLYMYXIN/GRAMICIDIN SOLN 0.025 MG/ML-10000 UNIT/ML-1.75 MG/ML

F

NEOSPORIN SOLN NF

OCUFLOX SOLN (ofloxacin (ophth)) NF

ofloxacin (ophth) soln 0.3% F

polymyxin b-trimethoprimsoln 0.1 %-10000 unit/ml F

POLYTRIM SOLN (polymyxin b-trimethoprim) NF

sulfacetamide sodium (ophth) soln 10 % F

SULFACETAMIDE SODIUM OINT OP 10 % F

tobramycin (ophth) soln 0.3% F

TOBREX OINT 0.3 % F 1 rtl pack lmtamt,7 rtl packlmt day(s),

TOBREX SOLN (tobramycin (ophth)) NF

trifluridine soln op 1 % F

VIGAMOX SOLN (moxifloxacin hcl (ophth)) NF

VIROPTIC SOLN NF

Ophthalmic Decongestants naphazoline w/pheniramine soln F

NAPHCON-A SOLN (naphazoline w/pheniramine)

NF

OPCON-A SOLN (naphazoline w/pheniramine)

NF

Ophthalmic Immunomodulators

RESTASIS EMUL F PA

Ophthalmic Local Anesthetics

Drug Name DrugTier

Requirements/Limits

tetracaine hcl (ophth) soln F

Ophthalmic Steroids bacitracin-poly-neomycin-hc oint F

BLEPHAMIDE S.O.P. OINT F

BLEPHAMIDE SUSP F

dexamethasone sodium phosphate (ophth) soln F

fluorometholone (ophth) susp F

FML FORTE SUSP F

FML LIQUIFILM SUSP (fluorometholone (ophth)) NF

FML OINT F

MAXIDEX SUSP F

MAXITROL OINT (neomycin-polymy-dexameth)

NF

MAXITROL SUSP (neomycin-polymy-dexameth)

NF

neomycin-polymy-dexameth oint F

neomycin-polymy-dexameth susp F

neomycin-polymyxin-hc(ophth) susp F

OMNIPRED SUSP NF

PRED FORTE SUSP F

PRED FORTE SUSP NF

PRED MILD SUSP F

PRED-G S.O.P. OINT F

PRED-G SUSP F

prednisolone acetate(ophth) susp F


104

Drug Name DrugTier

Requirements/Limits

PREDNISOLONE ACETATE P-F SUSP F

PREDNISOLONE SODIUM PHOSPHATE SOLN OP 1 %

F

sulfacetamide sod-prednisolone soln F

SULFACETAMIDE SODIUM/PREDNISOLONESODIUM PHOSPHATE SOLN

F

TOBRADEX OINT F QL(4 gm per 7days retail)

TOBRADEX ST SUSP F

TOBRADEX SUSP (tobramycin-dexamethasone)

NF

tobramycin-dexamethasone susp F

Ophthalmics - Misc. ACULAR LS SOLN (ketorolac tromethamine (ophth))

NF

ACULAR SOLN (ketorolac tromethamine (ophth)) NF

azelastine hcl (ophth) soln F

AZOPT SUSP F PA

cromolyn sodium (ophth)soln F

diclofenac sodium (ophth)soln F

dorzolamide hcl soln 2 % F

DORZOLAMIDE HCL SOLN 2 % F

flurbiprofen sodium soln F

ketorolac tromethamine (ophth) soln F

ketotifen fumarate (ophth)soln 0.025 % F

TRUSOPT SOLN (dorzolamide hcl) NF

Drug Name DrugTier

Requirements/Limits

ZADITOR SOLN (ketotifen fumarate (ophth)) NF

Prostaglandins - Ophthalmic latanoprost soln op 0.005% F QL(2.5 ml per

fill retail) TRAVATAN Z SOLN (travoprost) NF PA

travoprost soln 0.004 % F PA

XALATAN SOLN (latanoprost) NF QL(2.5 ml per

fill retail)

ZIOPTAN SOLN F PA

OTIC AGENTS - Drugs to Treat the Ear

Otic Agents - Miscellaneous

acetic acid (otic) soln F

carbamide peroxide (otic)soln 6.5 % F

DEBROX SOLN (carbamide peroxide (otic)) NF

Otic Anti-infectives

ciprofloxacin hcl (otic) soln F

Otic Combinations CIPRODEX SUSP 0.3 %-0.1 % (ciprofloxacin-dexamethasone)

F

neomycin-polymyxin-hc(otic) soln F

neomycin-polymyxin-hc(otic) susp F

Otic Steroids hydrocortisone w/aceticacid soln F

OXYTOCICS - Drugs to Prevent/Control UterineBleeding

Oxytocics methylergonovine maleatetabs or 0.2 mg F

PASSIVE IMMUNIZING AND TREATMENT AGENTS - Antibody Drugs to Treat Low ImmuneSystem


105

Drug Name DrugTier

Requirements/Limits

Immune Serums

BIVIGAM SOLN F PA; SP

FLEBOGAMMA DIF SOLN F PA; SP

GAMASTAN INJ F PA; SP

GAMMAGARD LIQUID SOLN F PA; SP

GAMMAGARD S/D IGALESS THAN 1MCG/MLSOLR

F PA; SP

GAMUNEX-C SOLN F PA; SP

HIZENTRA SOLN F PA; SP

Monoclonal Antibodies

SYNAGIS SOLN F PA; SP

PENICILLINS - Drugs to Treat Bacterial Infections

Aminopenicillins

amoxicillin caps F

amoxicillin chew F

amoxicillin susr F

amoxicillin tabs F

AMOXICILLIN TRIHYDRATE POWD F

ampicillin caps F

ampicillin sodium solr ij 1gm, 2 gm, 250 mg, 500 mg F

AMPICILLIN SODIUM SOLR IJ 125 MG F

AMPICILLIN SODIUM SOLR IV 1 GM F

ampicillin sodium solr iv 2gm, 10 gm F

MOXATAG TB24 F

Natural Penicillins

BICILLIN L-A SUSP F

Drug Name DrugTier

Requirements/Limits

PENICILLIN G POTASSIUM IN ISO-OSMOTIC DEXTROSE SOLN

F

penicillin g potassium solr F

PENICILLIN G PROCAINE SUSP F

penicillin g sodium solr F

penicillin v potassium solr F

penicillin v potassium tabs F

PFIZERPEN SOLR (penicillin g potassium) NF

Penicillin Combinations amoxicillin & potclavulanate chew F

amoxicillin & potclavulanate susr F

amoxicillin & potclavulanate tabs F

amoxicillin & potclavulanate tb12 F

ampicillin & sulbactamsodium solr F

AMPICILLIN-SULBACTAM SOLR F

AUGMENTIN ES-600 SUSR (amoxicillin & potclavulanate)

NF

AUGMENTIN SUSR 125 MG/5ML-31.25 MG/5ML F

AUGMENTIN SUSR 250 MG/5ML-62.5 MG/5ML(amoxicillin & potclavulanate)

NF

AUGMENTIN TABS 500 MG-125 MG, 875 MG-125 MG (amoxicillin & potclavulanate)

NF

AUGMENTIN XR TB12 (amoxicillin & potclavulanate)

NF

BICILLIN C-R SUSP F


106

Drug Name DrugTier

Requirements/Limits

piperacillin sodium-tazobactam sodium solr F

UNASYN BULK PACK SOLR (ampicillin &sulbactam sodium)

NF

UNASYN SOLR (ampicillin& sulbactam sodium) NF

ZOSYN SOLN 0.375 GM/50ML-3 GM/50ML-5%, 0.5 GM/100ML-4GM/100ML-5 %, 0.25GM/50ML-2 GM/50ML-5 %

F

ZOSYN SOLR 0.375 GM-3 GM, 0.25 GM-2 GM, 0.5 GM-4 GM, 4.5 GM-36 GM (piperacillin sodium-tazobactam sodium)

NF

Penicillinase-Resistant Penicillins

dicloxacillin sodium caps F

nafcillin sodium solr ij 1 gm,2 gm F

NAFCILLIN SODIUM SOLR IV 1 GM, 2 GM F

nafcillin sodium solr iv 10 gm F

NAFCILLIN SOLN F

OXACILLIN SODIUM SOLN IV 1.5 GM/50ML-1GM/50ML, 300 MG/50ML-2GM/50ML

F

oxacillin sodium solr ij 1gm, 2 gm F

oxacillin sodium solr iv 10 gm F

PROGESTINS - Hormone Replacement/ModifyingDrugs

Progestins AYGESTIN TABS (norethindrone acetate) NF

MAKENA OIL IM 250 MG/ML(hydroxyprogesterone caproate)

F

PA; SP

Drug Name DrugTier

Requirements/Limits

MAKENA SOAJ SC 275 MG/1.1ML F PA; SP

medroxyprogesteroneacetate tabs or 5 mg, 10mg, 2.5 mg

F

norethindrone acetate tabs or 5 mg F

progesterone micronizedcaps or 100 mg, 200 mg F QL(2 ea daily)

PROMETRIUM CAPS (progesterone micronized) NF QL(2 ea daily)

PROVERA TABS (medroxyprogesterone acetate)

NF

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. - Drugs to Treat Mental andEmotional Conditions

Agents for Chemical Dependency

acamprosate calcium tbec F

ANTABUSE TABS (disulfiram) NF

disulfiram tabs or 250 mg,500 mg F

Antidementia Agents ARICEPT TABS (donepezilhydrochloride) NF PA

donepezil hydrochloridetabs F PA

donepezil hydrochloridetbdp F PA

EXELON PT24 (rivastigmine) NF PA

galantamine hydrobromidecp24 8 mg, 16 mg, 24 mg F PA

GALANTAMINE HYDROBROMIDE SOLN 4 MG/ML

F PA

galantamine hydrobromidetabs 4 mg, 8 mg, 12 mg F PA

memantine hcl soln 2 mg/ml, 10 mg/5ml F PA

memantine hcl tabs 10 mg F QL(6 ea daily)

memantine hcl tabs 5 mg F PA; QL(6 eadaily)


107

Drug Name DrugTier

Requirements/Limits

NAMENDA TABS 10 MG (memantine hcl) NF QL(6 ea daily)

NAMENDA TABS 5 MG (memantine hcl) NF PA; QL(6 ea

daily) RAZADYNE ER CP24 (galantaminehydrobromide)

NF PA

RAZADYNE TABS (galantaminehydrobromide)

NF PA

rivastigmine pt24 F PA

rivastigmine tartrate caps F PA

Multiple Sclerosis Agents

AVONEX KIT F PA; SP

AVONEX PEN AJKT F PA; SP

AVONEX PSKT F PA; SP

BETASERON KIT F PA; SP

COPAXONE SOSY 20 MG/ML (glatiramer acetate) F PA; SP

COPAXONE SOSY 40 MG/ML (glatiramer acetate) NF SP

EXTAVIA KIT F PA; SP

GILENYA CAPS F PA; SP

glatiramer acetate sosy 40mg/ml F PA; SP

REBIF REBIDOSE SOAJ F PA; SP

REBIF REBIDOSE TITRATIONPACK SOAJ F PA; SP

REBIF SOSY F PA; SP

REBIF TITRATION PACK SOSY F PA; SP

Postherpetic Neuralgia (PHN)/Neuropathic Pain

GRALISE TABS F PA

Psychotherapeutic and Neurological Agents -

ORAP TABS NF AL(At least 6yrs old)

Drug Name DrugTier

Requirements/Limits

pimozide tabs F AL(At least 6yrs old)

Restless Leg Syndrome (RLS) Agents

HORIZANT TBCR F PA

Smoking Deterrents

bupropion hcl (smokingdeterrent) tb12 150 mg F

QL(2 eadaily)84 rtlMAX day(s)supply,180 rtllmt day(s),

CHANTIX CONTINUING MONTHPAK TABS F


CHANTIX STARTING MONTH PAK TABS F


CHANTIX TABS F


NICODERM CQ PT24 (nicotine) NF


NICORETTE GUM 2 MG, 4 MG (nicotine polacrilex) NF


NICORETTE LOZG 2 MG, 4 MG (nicotine polacrilex) NF


NICORETTE MINI LOZG (nicotine polacrilex) NF



108

Drug Name DrugTier

Requirements/Limits

NICORETTE STARTER KIT GUM (nicotine polacrilex)

NF


nicotine polacrilex gum mt2 mg, 4 mg F


nicotine polacrilex lozg mt2 mg, 4 mg F


nicotine pt24 F


NICOTINE TRANSDERMAL SYSTEM KIT

F


NICOTROL INHALER INHA F

QL(16.8 eadaily)84 rtlMAX day(s)supply,180 rtllmt day(s),

NICOTROL NS SOLN F

QL(4 mldaily)84 rtlMAX day(s)supply,180 rtllmt day(s),

ZYBAN TB12 (bupropionhcl (smoking deterrent)) NF


RESPIRATORY AGENTS - MISC. - Drugs toTreat Lung Conditions

Alpha-Proteinase Inhibitor (Human) ARALAST NP SOLR F PA; SP

GLASSIA SOLN F PA; SP

PROLASTIN-C SOLR F PA; SP

Drug Name DrugTier

Requirements/Limits

ZEMAIRA SOLR F PA; SP

Cystic Fibrosis Agents

PULMOZYME SOLN F PA; SP

SULFONAMIDES - Drugs to Treat BacterialInfections

Sulfonamides

SULFADIAZINE POWD F

SULFADIAZINE SODIUM POWD F

SULFADIAZINE TABS F

SULFAMETHOXAZOLE MICRO POWD F

SULFAMETHOXAZOLE POWD F

SULFAPYRIDINE POWD F

SULFATHIAZOLE POWD F

SULFISOXIZOLE CRYS F

TETRACYCLINES - Drugs to Treat BacterialInfections

Aminomethylcyclines

NUZYRA SOLR F

NUZYRA TABS F

Fluorocyclines

XERAVA SOLR F

Glycylcyclines

tigecycline solr 50 mg F

TIGECYCLINE SOLR 50 MG F

TYGACIL SOLR (tigecycline) NF

Tetracycline Combinations

AVIDOXY DK KIT F


109

Drug Name DrugTier

Requirements/Limits

BENZODOX 30 KIT THPK F

BENZODOX 60 KIT THPK F

Tetracyclines

demeclocycline hcl tabs F

doxycycline (monohydrate) caps F

doxycycline (monohydrate) susr F

doxycycline (monohydrate)tabs F

doxycycline hyclate caps or50 mg, 100 mg F

DOXYCYCLINE HYCLATE DR TBEC F

DOXYCYCLINE HYCLATE POWD XX F

doxycycline hyclate solr iv100 mg F

doxycycline hyclate tabs or20 mg, 100 mg F

MINOCIN CAPS OR 50 MG (minocycline hcl) NF

MINOCIN SOLR IV 100 MG F

minocycline hcl caps or 50mg, 75 mg, 100 mg F

MINOCYCLINE HCL POWD XX F

minocycline hcl tabs or 50mg, 75 mg, 100 mg F

minocycline hcl tb24 or 45mg, 55 mg, 65 mg, 80 mg,90 mg, 105 mg, 115 mg,135 mg

F

MINOCYCLINE HYDROCHLORIDEER CP24

F

MINOLIRA TB24 F

MORGIDOX 1X100MG KIT F

MORGIDOX 1X50MG KIT KIT F

Drug Name DrugTier

Requirements/Limits

MORGIDOX 2X100MG KIT F

NUTRIDOX KIT F

OXYTETRACYCLINE HCL POWD F

SEYSARA TABS F

SOLODYN TB24 (minocycline hcl) NF

tetracycline hcl caps or 250mg, 500 mg F

VIBRAMYCIN CAPS 100 MG (doxycycline hyclate) NF

VIBRAMYCIN SUSR 25 MG/5ML (doxycycline(monohydrate))

NF

VIBRAMYCIN SYRP 50 MG/5ML F

XIMINO CP24 F

THYROID AGENTS - Drugs to Regulate ThyroidHormones

Antithyroid Agents methimazole tabs or 5 mg,10 mg F

propylthiouracil tabs or F

TAPAZOLE TABS (methimazole) NF

Thyroid Hormones ARMOUR THYROID TABS 15 MG, 30 MG, 60 MG, 90 MG, 120 MG (thyroid)

NF

ARMOUR THYROID TABS 180 MG, 240 MG F

CYTOMEL TABS (liothyronine sodium) NF

levothyroxine sodium tabsor 25 mcg, 50 mcg, 75mcg, 88 mcg, 100 mcg,112 mcg, 125 mcg, 137mcg, 150 mcg, 175 mcg,200 mcg, 300 mcg

F

liothyronine sodium tabs or5 mcg, 25 mcg, 50 mcg F


110

Drug Name DrugTier

Requirements/Limits

NATURE-THROID NT-2.5 TABS F

NATURE-THROID TABS F

SYNTHROID TABS (levothyroxine sodium) NF

thyroid tabs or 15 mg, 30mg, 60 mg, 90 mg, 120 mg F

WESTHROID TABS F

WP THYROID TABS F

TOXOIDS

Toxoid Combinations

ADACEL SUSP F

Limit 1 dose per 10 years;1rtl MAX fill,999 rtl day(s)supply,; AL(Atleast 19 yrsold)

BOOSTRIX SUSP F


DAPTACEL SUSP F


TDVAX SUSP F


Drug Name DrugTier

Requirements/Limits

TENIVAC INJ F


ULCER DRUGS - Drugs to Treat Bowel, Intestineand Stomach Conditions

Antispasmodics ANASPAZ TBDP (hyoscyamine sulfate) NF QL(4 ea daily)

BENTYL CAPS OR 10 MG (dicyclomine hcl) NF

CUVPOSA SOLN F

dicyclomine hcl caps or 10 mg F

dicyclomine hcl soln or 10mg/5ml F

dicyclomine hcl tabs or 20 mg F

glycopyrrolate tabs or 1mg, 2 mg F

hyoscyamine sulfate elix or0.125 mg/5ml F

hyoscyamine sulfate solnor 0.125 mg/ml F QL(8 ml daily)

hyoscyamine sulfate subl sl0.125 mg F QL(4 ea daily)

hyoscyamine sulfate tabsor 0.125 mg F QL(4 ea daily)

hyoscyamine sulfate tb12or 0.375 mg F QL(2 ea daily)

hyoscyamine sulfate tbdpor 0.125 mg F QL(4 ea daily)

LEVBID TB12 (hyoscyamine sulfate) NF QL(2 ea daily)

LEVSIN TABS OR 0.125 MG (hyoscyamine sulfate) NF QL(4 ea daily)

LEVSIN/SL SUBL(hyoscyamine sulfate) NF QL(4 ea daily)

methscopolamine bromidetabs or 5 mg, 2.5 mg F


111

Drug Name DrugTier

Requirements/Limits

PROPANTHELINE BROMIDE TABS OR 15 MG

F

ROBINUL FORTE TABS (glycopyrrolate) NF

ROBINUL TABS OR 1 MG (glycopyrrolate) NF

SYMAX DUOTAB TBCR F

H-2 Antagonists DEPRIZINE FUSEPAQ SUSR F

famotidine susr or 40 mg/5ml F

famotidine tabs or 10 mg,40 mg F

famotidine tabs or 20 mg F RX/OTC

PEPCID AC MAXIMUM STRENGTH TABS (famotidine)

NF RX/OTC

PEPCID AC TABS (famotidine) NF

PEPCID SUSR 40 MG/5ML(famotidine) NF

PEPCID TABS 20 MG (famotidine) NF RX/OTC

PEPCID TABS 40 MG (famotidine) NF

ranitidine hcl caps or 150mg, 300 mg F

ranitidine hcl syrp or 15mg/ml, 75 mg/5ml, 150mg/10ml

F

ranitidine hcl tabs or 150 mg F RX/OTC

ranitidine hcl tabs or 75 mg, 300 mg F

ZANTAC 150 MAXIMUM STRENGTH TABS (ranitidine hcl)

NF RX/OTC

ZANTAC 75 TABS (ranitidine hcl) NF

ZANTAC TABS OR 300 MG (ranitidine hcl) NF

Misc. Anti-Ulcer

Drug Name DrugTier

Requirements/Limits

CARAFATE TABS 1 GM (sucralfate) NF

sucralfate tabs or 1 gm F

Proton Pump Inhibitors

lansoprazole cpdr or 15 mg F RX/OTC

lansoprazole cpdr or 30 mg F

omeprazole cpdr or 10 mg,40 mg F

omeprazole cpdr or 20 mg F RX/OTC

omeprazole magnesiumcpdr 20 mg, 20.6 mg F

omeprazole tbec or 20 mg F

pantoprazole sodium packor 40 mg F

pantoprazole sodium tbecor 20 mg, 40 mg F

PREVACID 24HR CPDR (lansoprazole) NF RX/OTC

PREVACID CPDR 15 MG (lansoprazole) NF RX/OTC

PREVACID CPDR 30 MG (lansoprazole) NF

PROTONIX PACK OR 40 MG (pantoprazole sodium) NF

PROTONIX TBEC OR 20 MG, 40 MG (pantoprazolesodium)

NF

Ulcer Drugs - Prostaglandins CYTOTEC TABS (misoprostol) NF

misoprostol tabs or 100mcg, 200 mcg F

URINARY ANTI-INFECTIVES - Drugs to TreatBladder/Kidney Infections

Urinary Anti-infectives FURADANTIN SUSP (nitrofurantoin) NF

MACROBID CAPS (nitrofurantoin monohyd macro)

NF


112

Drug Name DrugTier

Requirements/Limits

MACRODANTIN CAPS (nitrofurantoin macrocrystal)

NF

nitrofurantoin macrocrystalcaps or 25 mg, 50 mg, 100 mg

F

nitrofurantoin monohydmacro caps 100 mg F

nitrofurantoin susp or 25mg/5ml F

URINARY ANTISPASMODICS - Drugs to TreatMiscellaneous Bladder Spasms

Urinary Antispasmodic - Antimuscarinics

DETROL LA CP24 (tolterodine tartrate) NF

ST; Tryoxybutynin or tolterodine IR first

DETROL TABS (tolterodine tartrate) NF ST

DITROPAN XL TB24 (oxybutynin chloride) NF QL(1 ea daily)

oxybutynin chloride syrp or5 mg/5ml F

oxybutynin chloride tabs or5 mg F

oxybutynin chloride tb24 or5 mg, 10 mg, 15 mg F QL(1 ea daily)

tolterodine tartrate cp24 2mg, 4 mg F

ST; Tryoxybutynin or tolterodine IR first

tolterodine tartrate tabs 1 mg, 2 mg F ST

trospium chloride tabs 20 mg F

Urinary Antispasmodics - Cholinergic Agonists bethanechol chloride tabs or 5 mg, 10 mg, 25 mg, 50 mg

F

URECHOLINE TABS (bethanechol chloride) NF

VACCINES

Bacterial Vaccines

Drug Name DrugTier

Requirements/Limits

BEXSERO SUSY F

Limit 2 doses per lifetime;2 rtlMAX fill,999 rtl day(s) supply,;AL(At least 19yrs old)

MENACTRA INJ F

Limit 1 dose per lifetime;1 rtlMAX fill,999 rtl day(s) supply,;AL(At least 19yrs old)

MENVEO SOLR F


PNEUMOVAX 23 INJ F


PNEUMOVAX 23/1 DOSEINJ F


PREVNAR 13 SUSP F


TRUMENBA SUSY F


Viral Vaccines


113

Drug Name DrugTier

Requirements/Limits

AFLURIA 2018-2019 SUSP F

Limit 1 dose perseason;QL(0.5ml per fillretail); AL(Atleast 19 yrsold)

AFLURIA PF 2018-2019 SUSY F


AFLURIA QUADRIVALENT 2018-2019 SUSP F


AFLURIA QUADRIVALENT 2018-2019 SUSY F








Drug Name DrugTier

Requirements/Limits



ENGERIX-B INJ F


ENGERIX-B SUSP F


FLUAD 2018-2019 SUSY F






FLUAD QUADRIVALENT INFLUENZA VACCINE FOR ADULTS PRSY

F



114

Drug Name DrugTier

Requirements/Limits

FLUARIX QUADRIVALENT 2018-2019 SUSY F






FLUBLOK QUADRIVALENT 2018-2019 SOSY

F



F



F


FLUCELVAX QUADRIVALENT 2018-2019 SUSP

F


Drug Name DrugTier

Requirements/Limits

FLUCELVAX QUADRIVALENT 2018-2019 SUSY

F



F



F



F



F


FLULAVAL QUADRIVALENT 2018-2019 SUSP

F


FLULAVAL QUADRIVALENT 2018-2019 SUSY

F



115

Drug Name DrugTier

Requirements/Limits

FLULAVAL QUADRIVALENT 2019-2020 SUSP

F



F



F


FLUZONE HIGH-DOSE PF 2020-2021 SUSY F

Limit 1 dose per season age65 and up;QL(0.7 mlper fill retail);AL(At least 65yrs old)

FLUZONE QUADRIVALENT 2018-2019 SUSP

F


FLUZONE QUADRIVALENT 2018-2019 SUSY

F



F


Drug Name DrugTier

Requirements/Limits


F



F



F


GARDASIL 9 SUSP F


GARDASIL 9 SUSY F


HAVRIX SUSP F


HEPLISAV-B SOLN F



116

Drug Name DrugTier

Requirements/Limits

HEPLISAV-B SOSY F


M-M-R II SOLR F


RECOMBIVAX HB SUSP F


SHINGRIX SUSR F

Limit 2 doses perlifetime;QL(1ea per fillretail); AL(Atleast 50 yrsold)

TWINRIX SUSP F


TWINRIX SUSY F


VAQTA SUSP F


VARIVAX INJ F


Drug Name DrugTier

Requirements/Limits

VAGINAL AND RELATED PRODUCTS

Vaginal Anti-infectives

AVC CREA F

CLEOCIN CREA VA 2 % (clindamycin phosphatevaginal)

NF

CLEOCIN SUPP VA 100 MG F

clindamycin phosphatevaginal crea F

clotrimazole vaginal crea F

GYNE-LOTRIMIN 3 CREA (clotrimazole vaginal) NF

GYNE-LOTRIMIN CREA (clotrimazole vaginal) NF

METROGEL-VAGINAL GEL (metronidazole vaginal)

NF

metronidazole vaginal gel0.75 % F

miconazole nitrate vaginal crea F

miconazole nitrate vaginalkit F

miconazole nitrate vaginal supp F

MONISTAT 1 COMBO PACK KIT (miconazole nitrate vaginal)

NF

MONISTAT 1 DAY OR NIGHT COMBO PACK KIT (miconazole nitrate vaginal)

NF

MONISTAT 3 COMBINATION PACK KIT (miconazole nitrate vaginal)

NF

MONISTAT 3 CREA (miconazole nitrate vaginal) NF

MONISTAT 7 COMBINATION PACK KIT F

MONISTAT 7 SIMPLY CURE CREA (miconazole nitrate vaginal)

NF

terconazole vaginal crea0.4 %, 0.8 % F


117

Drug Name DrugTier

Requirements/Limits

Vaginal Estrogens ESTRACE CREA (estradiol vaginal) NF

estradiol vaginal crea 0.1mg/gm F

estradiol vaginal tabs 10 mcg F QL(58 ea per

168 days retail)

ESTRING RING F

FEMRING RING 0.1 MG/24HR F PA

PREMARIN CREA VA 0.625 MG/GM F PA

VAGIFEM TABS (estradiol vaginal) NF QL(58 ea per

168 days retail) VASOPRESSORS - Drugs to Treat Heart andCirculation Conditions

Anaphylaxis Therapy Agents epinephrine (anaphylaxis)soaj 0.15 mg/0.3ml F QL(0.067 ea

daily) epinephrine (anaphylaxis)soaj 0.15 mg/0.3ml, 0.3mg/0.3ml

F QL(2 ea per 30days retail)

SYMJEPI SOSY F QL(2 ea per 30days retail)

Vasopressors

midodrine hcl tabs F QL(3 ea daily)

VITAMINS

Oil Soluble Vitamins

BABY DDROPS LIQD F

cholecalciferol caps or 25mcg, 50 mcg, 1.25 mg, 125mcg, 250 mcg, 400 unit,1000 unit, 2000 unit, 4000unit, 5000 unit, 10000 unit,50000 unit

F

cholecalciferol liqd or 400unit/ml F

cholecalciferol tabs or 25 mcg, 50 mcg, 400 unit,1000 unit, 2000 unit, 5000unit, 50000 unit

F

Drug Name DrugTier

Requirements/Limits

D-VI-SOL LIQD (cholecalciferol) NF

DECARA CAPS F

DRISDOL CAPS (ergocalciferol) NF

ergocalciferol caps F

KEY-E CHEW OR F AL(At least 6yrs old)

MAXIMUM D3 CAPS F

MEPHYTON TABS (phytonadione) NF

NATURAL VITAMIN E TABS F

OPTIMAL D3 M CAPS F

phytonadione tabs or 5 mg F

THERA-D 4000 TABS F

VITAMIN D2 TABS F

VITAMIN D3 TABS OR 3000 UNIT, 10000 UNIT F

vitamin e caps or 100 unit,200 unit, 400 unit, 600 unit,1000 unit

F

VITAMIN E CHEW OR 400 UNIT F AL(At least 6

yrs old) VITAMIN E TABS OR 100 UNIT, 200 UNIT F

vitamin e tabs or 400 unit F

Water Soluble Vitamins

B-1 TABS F

niacin cpcr 250 mg, 500 mg F

niacin tabs 50 mg, 100 mg,250 mg, 500 mg F

niacin tbcr 250 mg, 500mg, 750 mg F

niacinamide tabs F


118

Drug Name DrugTier

Requirements/Limits

niacinamide tbcr F

pyridoxine hcl tabs F

SLO-NIACIN TBCR (niacin) NF

thiamine hcl tabs F


119

Index 1ML TB SYRINGE/25G X 3ML SYRINGE/INTERLINK ACULAR LS 105 5/8"/LUER SLIP TIP 76 VIAL ACCESS CANNULA 76 acyclovir 381ML TB SYRINGE/27G X 3ML SYRINGE/LUER LOCK

acyclovir sodium 381/2"/LUER SLIP TIP 76 TIP 76 1ML TUBERCULIN SYRINGE 3ML SYRINGE/LUER LOCK acyclovir topical 62 DETACHABLE NEEDLE SLIP TIP23GX1" 76 ADACEL 111TIP 25GX5/8" 76 3ML SYRINGE/LUER LOCK ADALAT CC 391ML VANISHPOINT TIP25G X 1-1/2" 77 TUBERCULIN SYRINGE 3ML SYRINGE/LUER SLIP ADCIRCA 40 25GX5/8" 76 TIP23GX1" 77 ADDERALL 1 1ML VANISHPOINT 3ML SYRINGE/NEEDLE ADDERALL XR 1TUBERCULIN SYRINGE REGULAR WALL LUER-LOK 27GX1/2" 76 25GX5/8" SUB-Q 77 adefovir dipivoxil 37 2-3ML SYRINGE/LUER LOCK 4-WAY SALINE 98 ADRENALIN 100 TIP 76 abacavir sulfate 35 ADVAIR HFA 142-3ML SYRINGE/LUER SLIP TIP abacavir sulfate- ADVIL 276 lamivudine 35 ADVIL ALLERGY &3ML LUER LOCK SAFETY abacavir sulfate-lamivudine- CONGESTION 45SYRINGES 76 zidovudine 353ML LUER LOCK SAFETY ADVIL ALLERGY SINUS 45 SYRINGES 3ML/22G X 1 1/2" ABILIFY 35 ADVIL COLD & SINUS 45

76 ABILIFY MAINTENA 35 ADVIL MIGRAINE 23ML LUER LOCK SAFETY ABREVA 62 ADVIL MULTI-SYMPTOMSYRINGES/3ML/21G X 1 1/2" ABSORICA 59 COLD& FLU 4576 ADVIL SINUS CONGESTION3ML LUER LOCK SAFETY acamprosate calcium 107 &PAIN 45SYRINGES/3ML/22G X 1" 76 acarbose 21 AEMCOLO 83ML LUER LOCK SAFETY ACCOLATE 13SYRINGES/3ML/23G X 1" 76 AEROECLIPSE II BREATH

3ML LUER LOCK SAFETY ACCUPRIL 28 ACTUATED NEBULIZER SYRINGES/3ML/25G X 1" 76 ACCURETIC 29 DISPOSABLE 87 3ML LUER LOCK SAFETY acetaminophen 4 AERONEB GO COMPLETE SYRINGES/3ML/25G X 5/8" 76 SYSTEM 87acetaminophen w/ codeine 53ML LUER-LOK SYRINGE 22GX AERONEB GO CONVENIENCE 1-1/2" 76 acetaminophen w/ dm 45 UNIT 87 3ML LUER-LOK SYRINGE21G X acetazolamide 67 AERONEB GO NEBULIZER 1-1/2" 76 HANDSET 87acetic acid (otic) 105 AERONEB GO NEBULIZER3ML LUER-LOK SYRINGE22G X ACETYLCYSTEINE 59 HANDSET/CONNECTOR1" 76 3ML LUER-LOK SYRINGE25G X acetylcysteine 59 CABLE 87 5/8" 76 ACNE MEDICATION 10 59 AFINITOR 31 3ML LUER-LOK TIP AFINITOR DISPERZ 31ACNE MEDICATION 5 59SYRINGE25G X 1-1/2" 76 AFLURIA 2018-2019 1143ML SYRINGE/18G X 1- ACTICON 45 1/2"/LUER LOCK TIP 76 ACTIDOGESIC 45 AFLURIA PF 2018-2019 114 3ML SYRINGE/20G X 1"/LUER AFLURIA QUADRIVALENTACTIDOGESIC-DF 45LOCK TIP 76 2018-2019 114ACTIDOM DMX 453ML SYRINGE/20G X 1"/LUER AFLURIA QUADRIVALENT SLIP TIP 76 ACTIGALL 70 2019-2020 114 3ML SYRINGE/21G X 1- ACTIMMUNE AFLURIA QUADRIVALENT321/2"/LUER LOCK TIP 76 2020-2021 114ACTINEL 453ML SYRINGE/22G 1-1/2"/LUER AFRIN 100 LOCK TIP 76 ACTINEL DM 45 AFRIN 12 HOUR 1003ML SYRINGE/22G X 1"/LUER ACTINEL PEDIATRIC 45 AFRIN ALL NIGHTLOCK TIP 76 ACTOPLUS MET 21 NODRIP 1003ML SYRINGE/25G X 1"/LUER

ACTOPLUS MET XR 21 AFRIN CHILDRENS 100LOCK TIP 76 3ML SYRINGE/INTERLINK ACTOS 22 AFRIN MENTHOL 97 SYRINGE CANNULA 76 ACULAR 105 AFRIN NASAL SPRAY 100

Index 1

AFRIN NODRIP EXTRA ALDACTONE 67 ALZAIR ALLERGY BLOCKER MOISTURIZING 100 NASAL SPRAY 98ALDARA 64AFRIN NODRIP ORIGINAL 100 amantadine hcl 32ALECENSA 31AFRIN NODRIP SEVERE AMARYL 23ALENDRONATE SODIUM 68CONGESTION 100 AMBI EVEN & CLEAR AFRIN NODRIP SINUS 100 alendronate sodium 68 EXFOLIATING WASH 64 AFRIN PUMP MIST 100 ALER-DRYL 25 AMBI EVEN & CLEAR

FOAMINGCLEANSER 64AFRIN SINUS 100 ALEVE 2 AMBIEN 73AHIST 27 ALEVE ARTHRITIS 2 AMERGE 90AIMOVIG 90 ALEVE-D SINUS & COLD 45 AMICAR 72AIRDUO RESPICLICK ALEVE-D SINUS &

113/14 14 HEADACHE 45 AMIKACIN SULFATE 2 AIRDUO RESPICLICK ALFERON N 32 amikacin sulfate 2 232/14 14 alfuzosin hcl 71 amiloride & AIRDUO RESPICLICK 55/1414 hydrochlorothiazide 67ALINIA 9AIRIAL COMPACT amiloride hcl 67ALKA-SELTZER PLUSCOMPRESSORNEBULIZER COLD 45 aminocaproic acid 72SYSTEM 87 ALKA-SELTZER PLUS COLD AMINOPHYLLINE 15AIRIAL COMPACT MINI &COUGH 45NEBULIZER 87 aminophylline 15ALKA-SELTZER PLUS COLDAIRIAL COMPARTMENT AMINOPHYLLINE&COUGH FORMULA 45COMPRESSOR PEDIATRIC ANHYDROUS 15ALKA-SELTZER PLUSNEBULIZER 87 DAY/NIGHT MULTI-SYMPTOM amiodarone hcl 13AIRIAL PEDIATRIC COLD/FLU 46 AMITIZA 70NEBULIZER/BUILDING ALKA-SELTZER PLUSBLOCK 87 amitriptyline hcl 21SEVERECOLD & FLUAIRIAL PEDIATRIC amlodipine besylate 39NIGHT 46NEBULIZER/DUCK 87 ALKA-SELTZER PLUS SINUS amlodipine besylate-benazeprilAIRIAL PEDIATRIC FORMULA 46 hcl 29NEBULIZER/FIRE ENGINE 87 ALKALOL 98 amoxapine 21AIRIAL PEDIATRIC

ALL-IN-ONE NEBULIZER amoxicillin 106NEBULIZER/PANDA 87 AIRIAL PEDIATRIC SYSTEM 87 amoxicillin & potNEBULIZER/PENELOPE ALLEGRA ALLERGY 26 clavulanate 106 PANDA 87 ALLEGRA ALLERGY AMOXICILLIN AIRIAL PEDIATRIC CHILDRENS 26 TRIHYDRATE 106 NEBULIZER/PENGUIN 87 ALLEGRA-D 12 HOUR amphetamine-AIRIAL VOYAGER PORTABLE ALLERGY & dextroamphetamine 1 NEBULIZER 87 CONGESTION 46 ampicillin 106 AIRS DISPOSABLE ALLEGRA-D 24 HOUR ampicillin & sulbactamNEBULIZER 87 ALLERGY & sodium 106 ALA-HIST IR 25 CONGESTION 46 ampicillin sodium 106

ALLERGY MULTI-SYMPTOMALA-HIST PE 45 AMPICILLIN SODIUM 106DAY/NIGHT 46ALAHIST CF 45 ALLERGY SYRINGE/1ML/27G ampicillin sodium 106 ALAHIST DM 45 X 1/2" 77 AMPICILLIN-SULBACTAM 106 albendazole 8 allopurinol 71 ANAFRANIL 21 ALBENZA 8 ALORA 69 ANALPRAM HC 7 ALBUSTIX 66 alprazolam 11,12 ANALPRAM HC SINGLES 7 albuterol sulfate 14 ALPRAZOLAM INTENSOL11 ANALPRAM-HC 7 ALBUTEROL SULFATE 14 ALTACE 28 ANAPROX DS 2

alum & mag hydrox-albuterol sulfate 14 ANASPAZ 111simethicone 7ALBUTEROL SULFATE 14 anastrozole 31ALUMINUM HYDROXIDE 7albuterol sulfate 14 ANDRODERM 6ALVESCO 13ALDACTAZIDE 67

Index 2

ANDROGEL 6 ASPIRIN 4 azathioprine 93 ANDROGEL PUMP ANORO ELLIPTA ANTABUSE ANTACID ANTACID SOFT CHEWS ANUSOL-HC ANZEMET AP-HIST DM apraclonidine hcl aprepitant APTENSIO XR APTIVUS AQUANAZ AQUORAL ARAKODA ARALAST NP ARAVA ARCAPTA NEOHALER ARICEPT ARIMIDEX aripiprazole ARISTADA ARISTADA INITIO ARMONAIR RESPICLICK

6 14

107 7 7 7

24 46

103 25

1 36 46 94 30

109 4

14 107

31 35 35 35

aspirin 4 aspirin buffered (cal carb-magcarb-mag oxide) 4 ASTAGRAF XL 93 ASTEPRO 99 atazanavir sulfate 36 atenolol 39 atenolol & chlorthalidone 29 ATIVAN 12 atomoxetine hcl 1 atorvastatin calcium 28 atovaquone 9 atovaquone-proguanil hcl 30 ATRAC-TAIN 63 ATRIPLA 36 ATROPINE SULFATE 103 ATROVENT HFA 13 ATUSS DA 46 AUGMENTIN 106 AUGMENTIN ES-600 106 AUGMENTIN XR 106 AURA PORTANEB 87 AVALIDE 29 AVAPRO 29

azelastine hcl 99 azelastine hcl (ophth) 105 azelastine hcl-fluticasone propionate 97 azithromycin 75 AZOPT 105 aztreonam 10 AZULFIDINE 70 AZULFIDINE EN-TABS 70 B-1 118 B-12 72 b-complex w/ c & folic acid 95 BABY DDROPS 118 BACIGUENT 60 bacitracin 8 bacitracin (ophthalmic) 103 bacitracin (topical) 61 bacitracin zinc 61 bacitracin-poly-neomycin-hc

104 bacitracin-polymyxin b 61 bacitracin-polymyxin b(ophth) 103 baclofen 97 BACTRIM 9

113 13 AVC 117 BACTRIM DS 9 ARMONAIR RESPICLICK 232 ARMONAIR RESPICLICK 55

13

13

AVELOX AVIDOXY DK AVODART

69 109

71

BACTROBAN BACTROBAN NASAL BALAMINE DM

61 99 46

ARMOUR THYROID 110 AVONEX 108 balsalazide disodium 70 ARNUITY ELLIPTA 13 AVONEX PEN 108 BANZEL 17 ARTHROTEC 50 2 AVYCAZ 40 BARACLUDE 37 ARTHROTEC 75 artificial tear ointment artificial tear solution ARTIFICIAL TEARS

3 102 102 102

AXILLARY BLOCK NEEDLE BLOCK BEVEL 25GX1" 77 AYGESTIN 107 AYR NASAL DROPS 98 AYR NASAL MIST ALLERGY

BAXDELA 69 BD 1ML TUBERCULIN SYRINGE/SAFETYGLIDE TBNEEDLE 27GX1/2" 77 BD 1ML TUBERCULIN

ASACOL HD 70 &SINUS HYPERTONIC SYRINGEDETACHABLE ASMANEX HFA 13 ASMANEX TWISTHALER 120 METERED DOSES 14 ASMANEX TWISTHALER 14 METERED DOSES 14 ASMANEX TWISTHALER 30 METERED DOSES 14 ASMANEX TWISTHALER 60 METERED DOSES 14 ASMANEX TWISTHALER 7 METERED DOSES 14 aspirin 4

SALINE 98 AYR SALINE NASAL GEL 98 AYR SALINE NASAL NETI RINSE KIT 98 AYR SALINE NASAL RINSE KIT 98 AYR SALINE NASAL RINSE KIT REFILL 98 AZACTAM 10 AZACTAMIN ISO-OSMOTIC DEXTROSE 10

NEEDLE SLIP TIP 27GX1/2"77 BD 1ML TUBERCULIN SYRINGESLIP-TIP 77 BD 3ML LUER-LOCK SYRINGE18G X 1 1/2" 77 BD 3ML LUER-LOK SYRINGE 18G X 1 1/2" 77 BD 3ML LUER-LOK SYRINGE/20G X 1" 77 BD 3ML LUER-LOK SYRINGE/21G X 1-1/2" 77

Index 3

BD 3ML LUER-LOK BD HYPODERMIC NEEDLE BD SAFETYGLIDE SYRINGE/23G X 1" 77 REGULAR BEVEL 22GX1- HYPODERMICNEEDLE BD 3ML LUER-LOK 1/2" 78 25GX5/8" 78 SYRINGE/23G X 1-1/2" 77 BD HYPODERMIC NEEDLE BD SAFETYGLIDE BD 3ML LUER-LOK REGULAR BEVEL INJECTIONNEEDLE 22GX1-SYRINGE/25G X 1" 77 25GX1" 78 1/2" 78 BD 3ML SYRINGE LUER-LOK BD HYPODERMIC NEEDLE BD SAFETYGLIDE TIP 77 REGULAR BEVEL INJECTIONNEEDLE BD 3ML SYRINGE SLIP TIP 77 25GX5/8" 78 25GX1" 78 BD 3ML BD HYPODERMIC NEEDLE BD SAFETYGLIDE SYRINGE SYRINGE/SAFETYGLIDE REGULAR BEVEL THIN WALL 3ML/25GX1" 78 SHIELDING IM NEEDLE 22GX1- 18G X 1-1/2" 78 BD SYRINGE LUER-1/2" 77 BD HYPODERMIC NEEDLE LOK/1ML 78 BD 3ML SHORT BEVEL 18G X 1- BD SYRINGE SLIP TIP 1ML 79 SYRINGE/SAFETYGLIDE 1/2" 78 BECONASE AQ 100BD HYPODERMIC NEEDLESHIELDING IM NEEDLE BELEODAQ 31SHORT BEVEL 22GX1-23GX1" 77 BD 3ML 1/2" 78 BENADRYL ALLERGY 25 SYRINGE/SAFETYGLIDE BD HYPODERMIC NEEDLES BENADRYL ALLERGY SHIELDING NEEDLE 18GX1" 78 CHILDRENS 26

BD HYPODERMIC NEEDLES BENADRYL ALLERGY PLUS25GX5/8" 77 BD 18GX1.5" 78 CONGESTION CHILDRENS 46

BD HYPODERMIC NEEDLES benazepril &ALLERGY/SYRINGE/NEEDLE/1ML/28G X 1/2" 77 19GX1" 78 hydrochlorothiazide 29

BD HYPODERMIC NEEDLESBD BLUNT FILL NEEDLE 77 benazepril hcl 28 22GX1.5" 78BD DISPOSABLE NEEDLE BENTLEY THE BEAR 87BD HYPODERMIC NEEDLESREGULAR BEVEL 25GX1" 77 BENTYL 11125GX1.5" 78BD DISPOSABLE NEEDLE BD INTEGRA 3ML SYRINGE BENZAC AC WASH 59REGULAR BEVEL THIN WALL W/RETRACTING NEEDLE/21G BENZEDREX INHALER 10018G X 1" 77 X 1-1/2" 78

BD ECLIPSE 18G X 1-1/2" 77 BD INTEGRA 3ML SYRINGE BENZEFOAM 59 BD ECLIPSE NEEDLE 25G X W/RETRACTING NEEDLE/25G BENZEFOAM ULTRA 59 1.5" 77 X 1" 78 BENZIQ 59BD ECLIPSE NEEDLE BD INTEGRA NEEDLE/25G BENZIQ LS 5925GX1" 77 X5/8" 78 BD ECLIPSE NEEDLE 27G X BD INTEGRA BENZIQ WASH 59 1/2" 77 SYRINGE/3ML/22G X 1.5" 78 BENZODOX 30 KIT 110 BD ECLIPSE NEEDLE/22G X 1- BD INTEGRA BENZODOX 60 KIT 1101/2" 77 SYRINGE/3ML/23G X 1" 78 BD ECLIPSE NEEDLE/25G BD INTEGRA benzonatate 44 X5/8" 77 SYRINGE/3ML/25G X 5/8 78 benzoyl peroxide 59,60BD ECLIPSE NEEDLE/27G X 78 BENZOYL PEROXIDEBD NEEDLE/18G 1-1/2"1/2" 77 CLEANSER 60BD NEEDLE/19G X 1" 78BD ECLIPSE SYRINGE LUER- benztropine mesylate 32LOK/3ML/22G X 1" 77 BD NEEDLE/22G X 1-1/2" 78

BETAGAN 102BD ECLIPSE SYRINGE LUER- BD NEEDLE/25G X 5/8" 78 LOK/3ML/25G X 1" 77 betamethasone dipropionateBD NEEDLE/27G X 1/2" 78BD ECLIPSE (topical) 62 SYRINGE/3ML/23G X 1" 77 BD PLASTIPAK SYRINGES betamethasone dipropionate

ALLERGY 28GX1/2 78 augmented 62BD ECLIPSE BD SAFETYGLIDE 27G XSYRINGE/3ML/25GX5/8" 78 betamethasone valerate 625/8"NEEDLE 78BD ECLIPSE SYRINGE/LUER- BETAPACE 39BD SAFETYGLIDE ALLERGYLOK/3ML/22G X 1-1/2" 78 SYRINGE/1ML/27GX1/2" 78 BETAPACE AF 39BD HYPODERMIC NEEDLE BD SAFETYGLIDE BETASAL 64REGULAR BEVEL 18G X 1- HYPODERMICNEEDLE 18G X1/2" 78 BETASERON 1081-1/2" 78 betaxolol hcl (ophth) 103 bethanechol chloride 113

Index 4

BETHKIS 2 BETIMOL 103 BETOPTIC-S 103 BEVESPI AEROSPHERE 14 bexarotene 32 BEXSERO 113 BICILLIN C-R 106 BICILLIN L-A 106 BIKTARVY 36 BILTRICIDE 8 BIOBRON SF 46 BIODESP DM 46 BIONATUSS DXP 46 BIONEL 46 BIONEL PEDIATRIC 46 BIOSPEC DMX 46 BIOTENE DRY MOUTH MOISTURIZING SPRAY 94 bisacodyl 74 bismuth subsalicylate 23 bisoprolol &hydrochlorothiazide 29 bisoprolol fumarate 39 BIVIGAM 106 BLEPH-10 103 BLEPHAMIDE 104 BLEPHAMIDE S.O.P. 104 BONE ESSENTIALS 93 BONIVA 68 BOOSTRIX 111 BPROTECTED PEDIA POLY-VITE/IRON 95 BREO ELLIPTA 14 BRILINTA 71 brimonidine tartrate 103 BROHIST D 46 BROMHEXINE HCL 59 bromocriptine mesylate 32 BROMPHENIRAMINE 25 brompheniramine &phenyleph 46 brompheniramine &pseudoeph 46 BROMPHENIRAMINE MALEATE 25 BROMPHENIRAMINE TANNATE 25 BRONKAID 46 BRONKIDS 46

BRONTUSS DX 46 BROTAPP DM 46 BROVANA 14 BUCKLEYS COUGH 44 budesonide 43 budesonide (inhalation) 14 budesonide (nasal) 100 budesonide-formoterol fumarate dihydrate 14 BUFFERIN 5 bumetanide 67 BUMEX 67 buprenorphine hcl 6 buprenorphine hcl-naloxone hcldihydrate 6 bupropion hcl 19 bupropion hcl (smokingdeterrent) 108 buspirone hcl 11 butalbital-acetaminophen-caffeine 4 butalbital-acetaminophen-caffeine w/ codeine 5 butalbital-aspirin-caffeine 4 butalbital-aspirin-caffeinew/cod 5 BUTALBITAL/ASPIRIN/CAFFEINE 4 butenafine hcl 61 BUTRANS 6 BYDUREON 22 BYDUREON PEN 22 BYETTA 22 CAFERGOT 90 CAL-CITRATE 91 CAL-LAC 91 CAL-MAG-K CHELA MAX 93 CAL-MINT 91 CALAMINE 65 CALAN 39 CALAN SR 39 CALCI-CHEW 91 calcitonin (salmon) 68 calcitriol 68 CALCIUM 91,92 calcium 92 CALCIUM 92 CALCIUM & VITAMIN D3 BONEHEALTH 93 CALCIUM ACETATE 91

calcium acetate (phosphatebinder) 70 CALCIUM CARBONATE 7,91 calcium carbonate 91 calcium carbonate (antacid) 7 calcium carbonate-vitamin d 91 CALCIUM CITRATE 92 calcium citrate 92 calcium citrate-vitamin d 92 CALCIUM GLUCONATE 92 CALCIUM LACTATE 92 CALCIUM PLUS VITAMIN D 92 CAPCOF 46 CAPHOSOL 94 CAPMIST DM 46 CAPRELSA 31 CAPRON DM 46 CAPRON DMT 46 CAPTAIN EAGLE 87 captopril 28 CAPTOPRIL/HYDROCHLOROTHIAZIDE 29 CARAC 62 CARAFATE 112 carbamazepine 17 carbamide peroxide (otic) 105 CARBAPHEN 12 46 CARBAPHEN 12 PED 46 CARBAPHEN CH 46 CARBAPHEN PED CH 46 CARBATROL 17 carbidopa-levodopa 32 carbinoxamine maleate 26 CARBINOXAMINE MALEATE 26 carboxymethylcellulose sodium(ophth) 102 CARDIZEM 39 CARDIZEM CD 39 CARDURA 29 CARNITOR 68 CARNITOR SF 68 carteolol hcl (ophth) 103 carvedilol 38 CATAPRES 29 CATAPRES-TTS-1 29 CATAPRES-TTS-2 29 CATAPRES-TTS-3 29

Index 5

cefaclor 41 CERASPORT 92 chlorpromazine hcl 35 CEFACLOR ER 41 CERASPORT EX1 92 chlorthalidone 68 cefadroxil 40 CERDELGA 72 cholecalciferol 118 CEFAZOLIN 40 CEREZYME 72 cholestyramine 27 CEFAZOLIN SODIUM 40 cetirizine hcl 26 cholestyramine light 27 cefazolin sodium 40 cetirizine-pseudoephedrine ciclopirox 61 CEFAZOLIN SODIUM 40 46 ciclopirox olamine 61

CHANTIX 108CEFAZOLIN cidofovir 37CHANTIX CONTINUINGSODIUM/DEXTROSE 40 cilostazol 71CEFAZOLIN SODIUM/SODIUM MONTHPAK 108 CHANTIX STARTING MONTH CILOXAN 103CHLORIDE 40

CEFAZOLIN/SODIUM PAK 108 cinacalcet hcl 68 CHLORIDE 40 CHELATED CALCIUM 92 CIPRO 69 cefdinir 41 CHELATED POTASSIUM 93 CIPRO I.V.-IN D5W 69 cefditoren pivoxil 41 CHEMSTRIP MICRAL 66 CIPRODEX 105 CEFEPIME 42 CHEMSTRIP-K 66 ciprofloxacin 69 cefepime hcl 42 CHERACOL PLUS 46 ciprofloxacin hcl 69 CEFEPIME/DEXTROSE 42 CHERACOL-D COUGH 46 ciprofloxacin hcl (ophth) 103 cefixime 41 CHILDRENS ADVIL 3 ciprofloxacin hcl (otic) 105 CEFOTAN 41 CHILDRENS MOTRIN 3 ciprofloxacin in d5w 69 cefotaxime sodium 41 CHLO HIST 46 ciprofloxacin-ciprofloxacinCEFOTAXIME SODIUM 41 CHLO TUSS 46 hcl 69 cefotetan disodium 41 CHLOPHED 46 citalopram hydrobromide 19 CEFOTETAN/DEXTROSE 41 CHLOR-TRIMETON 25 CLAFORAN 41 cefoxitin sodium 41 CHLOR-TRIMETON CLARINEX 26

ALLERGY 25CEFOXITIN SODIUM 41 CLARINEX-D 12 HOUR 47chloramphenicol sodiumcefpodoxime proxetil 41 clarithromycin 75succinate 9 cefprozil 41 chlordiazepoxide hcl 12 CLARITIN 26,27 ceftazidime 41 chlorhexidine gluconate CLARITIN ALLERGY

CEFTAZIDIME/DEXTROSE 41 (mouth-throat) 94 CHILDRENS 26 CHLOROQUINE CLARITIN CHILDRENS 26

CEFTRI-IM 41 PHOSPHATE 30 CLARITIN REDITABS 26CEFTRIAXONE IN ISO- chloroquine phosphate 30 CLARITIN-D 12 HOUR 47OSMOTIC DEXTROSE 41 CHLOROQUINEceftriaxone sodium 41 CLARITIN-D 24 HOUR 47PHOSPHATE 30 CEFTRIAXONE SODIUM 41 CLASSIC PRENATAL 95chlorothiazide 68 ceftriaxone sodium 41 chlorpheniramine & CLEAN & CLEAR ACNE

TRIPLECLEAR BUBBLE FOAMCEFTRIAXONE/DEXTROSE phenylephrine 46 CLEANSER 6441 chlorpheniramine & CLEAN & CLEAR ADVANTAGECEFTRISOL PLUS 41 pseudoeph 47 OIL ABSORBINGCHLORPHENIRAMINEcefuroxime axetil 41 CLEANSER 64MALEATE 25cefuroxime sodium 41 CLEAN & CLEAR BLACKHEADchlorpheniramine maleate 25 ERASER SCRUB 64CELEBREX 3 chlorpheniramine- CLEAN & CLEAR DEEPcelecoxib 3 acetaminophen 47 CLEANING ASTRINGENT

chlorpheniramine-dm 47CELEXA 19 SENSITIVE SKIN 64 CELLCEPT 93 chlorpheniramine- CLEAR COUGH PM MULTI-

phenylephrine-acetaminophen SYMPTOM 47CENTANY 61 47 CLEARASIL DAILY CLEAN cephalexin 41 chlorpheniramine- GENTLE PREVENTION 64 CERALYTE 70 92 phenylephrine-asa 47 CLEMASTINE FUMARATE 26

Index 6

clemastine fumarate 26 CLEOCIN 10,117 CLEOCIN IN D5W 10 CLEOCIN PEDIATRIC GRANULES 10 CLEOCIN PHOSPHATE 10 CLEOCIN-T 60

clotrimazole w/betamethasone clozapine CLOZAPINE ODT CLOZARIL CO-NATAL FA COARTEM

61 34 34 34 95 30

COMPRESSOR NEBULIZER 88 COMPRESSOR/NEBULIZER

88 COMTAN 32 COMTREX COLD & COUGH DAY/NIGHT MAXIMUMSTRENGTH 47

CLEVER CHOICE COCAINE COMTREX COLD & COUGH NEBULIZER 87 HYDROCHLORIDE 99 MAXIMUM STRENGTH 47 CLEVER CHOICE WHISPER AIRE AEROSOL DELIVERY SYSTEM 87 CLEVER CHOICE WHISPER

CODAR AR CODITUSSIN AC CODITUSSIN DAC

47 47 47

COMTREX COLD & COUGH NIGHTTIME MAXIMUM STRENGTH 47 COMTREX DEEP CHEST COLD

AIRE PEDIATRIC AEROSOL COLACE 74 MULTI-SYMPTOM 47 DELIVERY SYSTEM 87 CLEVER CHOICE WHISPER AIRE PEDIATRIC COMPRESSOR NEBULIZER 87 CLIMARA 69 CLIMARA PRO 69 CLIN SINGLE USE KIT 10 CLINDAGEL 60 clindamycin hcl 10 clindamycin palmitatehydrochloride 10 clindamycin phosphate 10 clindamycin phosphate(topical) 60 clindamycin phosphate ind5w 10 clindamycin phosphatevaginal 117 CLINDAMYCIN/SODIUMCHLORIDE 10

COLACE CLEAR 74 COLAMINE 93 COLAZAL 70 colchicine 71 COLCRYS 71 COLD & COUGH DAYTIME/NIGHTIMECHILDRENS 47 COLD & FLU RELIEF NIGHTTIME D 47 COLESTID 27 COLESTID FLAVORED 27 colestipol hcl 28 colistimethate sodium 11 COLY-MYCIN M 11 COLYTE-FLAVOR PACKS74 COMBIVENT RESPIMAT 14 COMBIVIR 36 COMP A-I-R COMPRESSOR

CONCERTA 1 CONEX COLD/ALLERGY 47 CONTAC COLD/FLU DAY &NIGHT 47 CONTAC COLD/FLUDAY/NIGHT 47 CONTAC COLD/FLU MAXIMUMSTRENGTH 47 COPAXONE 108 CORDARONE 13 COREG 38 CORICIDIN HBP COLD & FLU 47 CORICIDIN HBP COUGH & COLD 47 CORICIDIN HBP DAY & NIGHTMULTI-SYMPTOM COLD 47 CORICIDIN HBP FLU 47 CORN & CALLUS REMOVER 64

CLN ACNE CLEANSER 64 NEBULIZER 87 CORTEF 43 clobazam 16 clobetasol propionate 63 clobetasol propionate emollientbase 63

COMP AIR COMPRESSOR NEBULIZER 87 COMP AIR ELITE COMPACT COMPRESSOR/NEBULIZER

87

CORTENEMA CORTIFOAM COSOPT COTELLIC

7 7

103 31

CLODERM clomipramine hcl clonazepam clonidine

63 21 16 29

COMPAIR COMPRESSOR NEBULIZER 87 COMPAIR XL COMPRESSOR NEBULIZER SYSTEM 88 COMPAIR XLT

COUMADIN COZAAR CREO-TERPIN CREON

15 29 44 67

clonidine hcl clonidine hcl (adhd) clopidogrel bisulfate clorazepate dipotassium clotrimazole clotrimazole (topical)

29 1

71 12 94 61

COMPRESSOR NEBULIZER SYSTEM 88 COMPLERA 36 COMPLETENATE 95 COMPMIST COMPRESSOR NEBULIZER 88 COMPOUND W 64

CRIXIVAN CROMOLYN SODIUM cromolyn sodium cromolyn sodium (nasal) cromolyn sodium (ophth) crotamiton

36 13 13 99

105 66

clotrimazole vaginal 117 COMPOUND W MAXIMUM STRENGTH 64

CUBICIN 9

Index 7

CUBICIN RF 9 CUPRIMINE 93 CUVPOSA 111 CVS ANTACID SOFT CHEWS ULTRA STRENGTH 8 CVS CALCIUM CHEWABLES 600PLUS 93 CVS COUGH/CHESTCONGESTION DM CHILDRENS 48 CVS DRY MOUTH SPRAY 94 CVS GLUCOSE 22 CVS GLUCOSE BITS 22 CVS NASAL DECONGESTANT 100 CVS NASAL MIST 98 CVS NON-DRYING SINUS PE 48 CVS PRENATAL 95 CVS PSORIASIS MEDICATED SHAMPOO PLUS CONDITIONER 64 CVS SINUS RELIEF DAYTIME/NIGHTTIME 48 CVS SOFT GLUCOSE 22 CVS THERAPEUTIC DANDRUFFMAXIMUM STRENGTH 64 CVS TUSSIN DM DAY/NIGHTPACK 48 cyanocobalamin 72 cyclobenzaprine hcl 97 CYCLOGYL 103 cyclopentolate hcl 103 cyclosporine 93 cyclosporine modified (formicroemulsion) 94 CYMBALTA 20 cyproheptadine hcl 27 CYTOMEL 110 CYTOTEC 112 CYTOVENE 37 D-VI-SOL 118 DALIRESP 13 danazol 6 DANTRIUM 97 dantrolene sodium 97 dapsone 10 DAPTACEL 111 DAPTOMYCIN 9 daptomycin 9

DAXBIA 41 DAY TIME MULTI-SYMPTOM COLD/FLU RELIEF 48 DAYPRO 3 DAYTIME COLD MEDICINE 48 DAYTRANA 1 DDAVP 69 DEBROX 105 DECARA 118 DECONEX DMX 48 DECONEX IR 48 DELSYM 44 DELSYM CHILDRENS DAY NIGHT 48 DELSYM COUGH CHILDRENS 44 DELSYM DAY NIGHT 48 DELTUSS DP 48 DEMADEX 67 demeclocycline hcl 110 DENOREX EXTRA STRENGTH 2-IN-1 64 DEPAKENE 18 DEPAKOTE 18 DEPAKOTE ER 18 DEPAKOTE SPRINKLES 18 DEPO-MEDROL 43 DEPO-PROVERA CONTRACEPTIVE 43 DEPO-SUBQ PROVERA 104 43 DEPO-TESTOSTERONE 7 DEPRIZINE FUSEPAQ 112 DERMA-SMOOTHE/FSBODY 63 DERMA-SMOOTHE/FSSCALP 63 DERMACINRX AZENASE PAK 98 DERMACINRX TICANASE PAK 98 DERMAREST PSORIASIS 64 DERMAREST PSORIASIS MEDICATED SHAMPOO PLUS CONDITIONER 64 DESCOVY 36 DESGEN DM 48 desipramine hcl 21 DESITIN RAPID RELIEF 65 desloratadine 27 DESLORATADINE ODT 27

desmopressin acetate 69 desmopressin acetate spray 69 desmopressin acetate sprayrefrigerated 69 desogestrel & ethinylestradiol 42 desogestrel-ethinyl estradiol(biphasic) 42 desogestrel-ethinyl estradiol(triphasic) 42 DETROL 113 DETROL LA 113 DEX4 FAST ACTING GLUCOSEGO-POUCH 22 DEX4 QUICK DISSOLVE GLUCOSE 22 dexamethasone 43 DEXAMETHASONE 13-DAY DOSE PACK 43 DEXAMETHASONE INTENSOL 43 dexamethasone sodium phosphate (ophth) 104 dexbrompheniramine-phenylephrine 48 dexchlorpheniraminemaleate 25 dexmethylphenidate hcl 1 dextroamphetamine sulfate 1 dextromethorphan hbr 44 DEXTROMETHORPHAN HBR 44 dextromethorphan hbr 44 DEXTROMETHORPHAN HBR MONOHYDRATE 44 dextromethorphan polistirex 44 dextromethorphan-acetaminophen-chlorpheniramine

48 dextromethorphan-doxylamine-acetaminophen 48 dextromethorphan-guaifenesin

48 dextromethorphan-phenylephrine-acetaminophen

48 dextrose (diabetic use) 22 DIABETIC TUSSIN COLD & FLU 49 DIABETIC TUSSIN COLD/FLU 49 DIABETIC TUSSIN NIGHT TIME COLD/FLU RELIEF 49 DIALYSIS SAFETY SYRINGES/LOW DEAD SPACE3ML/22GX1-1/2" 79

Index 8

DIASTAT ACUDIAL 16 DIASTAT PEDIATRIC 16 diazepam 12 diazepam (anticonvulsant) 16 diclofenac potassium 3 diclofenac sodium 3 diclofenac sodium (ophth) 105 diclofenac sodium (topical) 60 diclofenac w/ misoprostol 3 dicloxacillin sodium 107

diphenhydramine-phenylephrine 49 diphenhydramine-phenylephrine-acetaminophen

49 diphenoxylate w/ atropine 24 DIPROLENE AF 63 dipyridamole 71 disopyramide phosphate 12 disulfiram 107 DITROPAN XL 113

doxylamine-phenylephrine-acetaminophen 49 DRAMAMINE 24 DRISDOL 118 DRISTAN SPRAY 100 DRIXORAL COLD/ALLERGY 49 DRIXORAL COUGH & SORE THROAT 49 drospirenone-ethinylestradiol 42 DRYSOL 65

DICOPANOL FUSEPAQ 26 DIURIL 68 DUAKLIR PRESSAIR 14 DICOPANOL RAPIDPAQ 26 divalproex sodium 18,19 DULCOLAX 74 dicyclomine hcl didanosine DIFICID DIFLUCAN

111 36 75 25

docosanol 62 DOCTOR MANZANILLA PE SYRUP ANTIHISTAMINE/DECONGESTANT 49

DULERA duloxetine hcl DURAFLU DURAGESIC

14 20 49

5 diflunisal 5 docusate calcium 74 DURATION 12 HOUR 100 digoxin 40 docusate sodium 74 DURATION SPRAY 100 DILANTIN 18 dofetilide 13 DURAVENT DM 49 DILANTIN INFATABS 18 DOLOGEN 49 DURAVENT PE 49 DILANTIN-125 18 DOLOGESIC 49 dutasteride 71 DILATRATE SR 11 DOLOGESIC-DF 49 DYANAVEL XR 1 DILAUDID 5 diltiazem hcl 39 diltiazem hcl coated beads 39 diltiazem hcl extended release beads 39 dimenhydrinate 24 DIMETAPP COLD & ALLERGY 49 DIMETAPP DM COLD & COUGH 49 DIMETAPP LONG ACTING COUGH PLUS COLD 49 DIMETAPP MULTI-SYMPTOM COLD & FLU 49 DIMETAPP MULTI-SYMPTOM COLD RELIEF CHILDRENS 49 DIOVAN 29 DIOVAN HCT 29 DIPENTUM 70 diphenhydramine hcl 26 DIPHENHYDRAMINE HCL 26 diphenhydramine hcl 26 diphenhydramine hcl (sleep) 72 diphenhydramine hcl(topical) 62 diphenhydramine-acetaminophen

49

DOMETUSS-DA/CHILDREN49

DOMETUSS-DMX 49 DOMETUSS-NR 49 donepezil hydrochloride 107 DORIPENEM 9 dorzolamide hcl 105 DORZOLAMIDE HCL 105 dorzolamide hcl-timolol maleate 103 DOUBLE-TUSSIN DM 49 doxazosin mesylate 29 doxepin hcl 21 doxycycline(monohydrate) 110 doxycycline hyclate 110 DOXYCYCLINE HYCLATE 110 doxycycline hyclate 110 DOXYCYCLINE HYCLATE DR 110 DOXYLAMINE SUCCINATE 26 doxylamine succinate(sleep) 73 doxylamine-dm 49 doxylamine-phenylephrine 49

DYAZIDE 67 DYMISTA 98 DYRENIUM 68 E.E.S. GRANULES 75 EASY AIR COMPRESSOR NEBULIZER 88 EASY GLIDE LUER LOCK 1MLSYRINGE 79 EASY NEB 88 EASY TOUCH ALLERGY TRAY SAFETY SYRINGE/1ML/27G X1/2" 79 EASY TOUCH FLIPLOCK NEEDLES 18GX1" 79 EASY TOUCH FLIPLOCK NEEDLES 18GX1-1/2" 79 EASY TOUCH FLIPLOCK NEEDLES 19GX1" 79 EASY TOUCH FLIPLOCK NEEDLES 22GX1-1/2" 79 EASY TOUCH FLIPLOCK NEEDLES 25GX1" 79 EASY TOUCH FLIPLOCK NEEDLES 25GX1-1/2" 79 EASY TOUCH FLIPLOCK NEEDLES 25GX5/8" 79 EASY TOUCH FLIPLOCK NEEDLES 27GX1/2" 79

Index 9

EASY TOUCH FLIPLOCK SAFETTY SYRINGES 3ML/18GX1-1/2" 79 EASY TOUCH FLIPLOCK SAFETY SYRINGE 3ML/22GX1" 79 EASY TOUCH FLIPLOCK SAFETY SYRINGE 3ML/22GX1-1/2" 79 EASY TOUCH FLIPLOCK SAFETY SYRINGE 3ML/23GX1" 79 EASY TOUCH FLIPLOCK SAFETY SYRINGE 3ML/23GX1-1/2" 79 EASY TOUCH FLIPLOCK SAFETY SYRINGE 3ML/25GX1" 79 EASY TOUCH FLIPLOCK SAFETY SYRINGE 3ML/25GX5/8" 79 EASY TOUCH FLIPLOCK SAFETY SYRINGES 3ML/20GX1" 79 EASY TOUCH FLIPLOCK SAFETY SYRINGES 3ML/21GX1-1/2" 79 EASY TOUCH HYPODERMIC NEEDLES 18GX1" 79 EASY TOUCH HYPODERMIC NEEDLES 18GX1-1/2" 79 EASY TOUCH HYPODERMIC NEEDLES 19GX1" 79 EASY TOUCH HYPODERMIC NEEDLES 22GX1-1/2" 79 EASY TOUCH HYPODERMIC NEEDLES 25GX1" 79 EASY TOUCH HYPODERMIC NEEDLES 25GX1-1/2" 79 EASY TOUCH HYPODERMIC NEEDLES 25GX5/8" 79 EASY TOUCH HYPODERMIC NEEDLES 27GX1/2"EASY TOUCH SAFETY

79

SYRINGE/3ML/20G X 1"EASY TOUCH SAFETY

79

SYRINGE/3ML/22G X 1"EASY TOUCH SAFETY

79

SYRINGE/3ML/22G X 1-1/2" 79 EASY TOUCH SAFETY SYRINGE/3ML/23G X 1" 79 EASY TOUCH SAFETY SYRINGE/3ML/25G X 1" 80 EASY TOUCH SAFETY SYRINGE/3ML/25G X 5/8" 80 EASY TOUCH SHEATHLOCK SAFETY SYRINGE 3ML/21GX1-1/2" 80

EASY TOUCH SHEATHLOCK SAFETY SYRINGE 3ML/22GX1" 80 EASY TOUCH SHEATHLOCK SAFETY SYRINGE 3ML/22GX1-1/2" 80 EASY TOUCH SHEATHLOCK SAFETY SYRINGE 3ML/23GX1" 80 EASY TOUCH SHEATHLOCK SAFETY SYRINGE 3ML/25GX1" 80 EASY TOUCH SHEATHLOCK SAFETY SYRINGE 3ML/25GX5/8" 80 EASY TOUCH TUBERCULIN FLIPLOCK SAFETY SYRINGE 1ML/27GX1/2" 80 EASY TOUCH TUBERCULIN FLIPLOCK SAFETY SYRINGE 1ML/28GX1/2" 80 EASY TOUCH TUBERCULIN SHEATHLOCK SAFETY SYRINGE 1ML/25GX5/8" 80 EASY TOUCH TUBERCULIN SHEATHLOCK SAFETY SYRINGE 1ML/27GX1/2" 80 EASY TOUCH TUBERCULIN SHEATHLOCK SAFETY SYRINGE 1ML/28GX1/2" 80 EASYPOINT NEEDLE 25G X 1" 80 EASYPOINT NEEDLE 25G X 5/8" 80 EASYPOINT NEEDLE 25GX1-1/2" 80 EASYPOINT NEEDLE/18G X1" 80 EASYPOINT NEEDLE/18G X1-1/2" 80 EASYPOINT NEEDLE/22G X1-1/2" 80 EC-NAPROSYN 3 ECOTRIN MAXIMUM STRENGTH 5 ECOTRIN REGULAR STRENGTH 5 ED A-HIST 49 ED A-HIST DM 49 ED BRON GP 49 ED CHLORPED 25 ED CHLORPED D 49 EDURANT 36 efavirenz 36 EFFEXOR XR 21 EFLOW SCF ELECTRONIC NEBULIZER SYSTEM 88

EFLOW SCF NEBULIZER HANDSET 88 EFUDEX 62 ELAPRASE 68 ELELYSO 72 ELIGARD 31 ELIMITE 66 ELIQUIS 15 ELIQUIS STARTER PACK 15 ELITE COMPRESSOR NEBULIZER 88 ELITE NEBULIZER SYSTEM 88 ELIXOPHYLLIN 15 ELIXSURE COUGH 45 ELMIRON 71 ELOCON 63 EMBEDA 5 EMEND 25 EMEND TRIPACK 25 EMGALITY 90 EMTRIVA 36 enalapril maleate 28 enalapril maleate &hydrochlorothiazide 29 ENBREL 4 ENBREL MINI 4 ENBREL SURECLICK 4 ENFAMIL ENFALYTE 92 ENGERIX-B 114 enoxaparin sodium 15,16 entacapone 32 entecavir 38 ENTEX T 50 ENTOCORT EC 43 ENTSOL NASAL SPRAY 98 EPANED 28 EPHEDRINE HCL 14 EPHEDRINE SULFATE 14 ephedrine-guaifenesin 50 epinephrine (anaphylaxis) 118 EPIVIR 36 EPIVIR HBV 38 eplerenone 30 EPZICOM 36 EQ ALLERGY/SINUSHEADACHE 50 EQ SINUS RELIEF MAXIMUM STRENGTH 50

Index 10

EQL DRY MOUTH ORAL EXAPHEX TR 50 FIORINAL 4 RINSE 94 EQL PRENATAL FORMULA 95 EQUALYTE 92 ergocalciferol 118 ergotamine w/ caffeine 90 erlotinib hcl 31 ERYGEL 60 ERYPED 200 75 ERYPED 400 75 ERYTHROCIN LACTOBIONATE 75 ERYTHROCIN STEARATE 75 ERYTHROMYCIN 75 erythromycin (acne aid) 60 erythromycin (ophth) 103 erythromycin base 75 ERYTHROMYCIN ETHYLSUCCINATE 75 erythromycin ethylsuccinate 75 escitalopram oxalate 19 ESGIC 4 ESTRACE 69

EXELDERM 61 EXELON 107 EXTAVIA 108 ezetimibe 28 famciclovir 38 famotidine 112 FARESTON 31 FARXIGA 23 FASLODEX 31 FATHER JOHNS MEDICINE PLUS 50 FAZACLO 34 febuxostat 71 felbamate 18 FELBATOL 18 FELDENE 3 felodipine 39 FEMARA 31 FEMIRON 72 FEMRING 118 FENOFIBRATE 28

FIORINAL/CODEINE #3 6 FIRST-METRONIDAZOLE 100 8 FIRST-METRONIDAZOLE 50 8 FIRST-VANCOMYCIN 25 9 FIRST-VANCOMYCIN 50 9 FIRVANQ 9 FISH OIL 101 FISH OIL PEARLS 101 FISH OIL TRIPLE STRENGTH 101 FISH OIL ULTRA 102 FLAGYL 8 FLEBOGAMMA DIF 106 flecainide acetate 13 FLECTOR 60 FLEET ENEMA 74 FLEET ENEMA SIX PACK 74 FLEET PEDIATRIC 74 FLOMAX 71 FLONASE ALLERGY RELIEF 100

estradiol 69 fenofibrate 28 FLONASE ALLERGY RELIEF

estradiol vaginal 118 ESTRING 118 ESTROSTEP FE 42 eszopiclone 73 ethambutol hcl 31 ethosuximide 18 ethynodiol diacet & ethestrad 42 etodolac 3 etonogestrel-ethinyl estradiol43 etoposide 32 EURAX 66 EVAC 73 everolimus 31 everolimus (immunosuppressant) 94 EVISTA 68 EVOTAZ 36 EX-LAX 74 EX-LAX MAXIMUM STRENGTH 74 EXACTUSS 50 EXACTUSS TR 50 EXAPHEN 50 EXAPHEN CH 50

fenofibrate micronized 28 FENOFIBRIC ACID 28 FENOPROFEN CALCIUM 3 fenoprofen calcium 3 FENSOLVI 68 fentanyl 5 FER-IN-SOL 72 FERRETTS 72 FERRIMIN 150 72 FERROUS FUMARATE 72 ferrous fumarate 72 ferrous gluconate 72 FERROUS GLUCONATE 72 FERROUS SULFATE 72 ferrous sulfate 72 FETROJA 42 FEVERALL JUNIOR STRENGTH 4 fexofenadine hcl 27 fexofenadine-pseudoephedrine

50 FIBRICOR 28 finasteride 71 FIORICET/CODEINE 5

CHILDRENS 100 FLONASE SENSIMIST 100 FLOVENT DISKUS 14 FLOVENT HFA 14 FLUAD 2018-2019 114 FLUAD 2019-2020 114 FLUAD 2020-2021 114 FLUAD QUADRIVALENT INFLUENZA VACCINE FOR ADULTS 114 FLUARIX QUADRIVALENT 2018-2019 115 FLUARIX QUADRIVALENT 2019-2020 115 FLUARIX QUADRIVALENT 2020-2021 115 FLUBLOK QUADRIVALENT 2018-2019 115 FLUBLOK QUADRIVALENT 2019-2020 115 FLUBLOK QUADRIVALENT 2020-2021 115 FLUCELVAX QUADRIVALENT 2018-2019 115 FLUCELVAX QUADRIVALENT 2019-2020 115 FLUCELVAX QUADRIVALENT 2020-2021 115

Index 11

fluconazole 25 FOSAMAX 68 GENTEAL MILD TO MODERATE 102fludrocortisone acetate 44 fosamprenavir calcium 36 GENTEAL SEVERE 102FLULAVAL QUADRIVALENT FOSCAVIR 37 GENTEAL SEVERE2018-2019 115 fosinopril sodium 28 TEARS 102FLULAVAL QUADRIVALENT fosinopril sodium &2019-2020 116 GENVOYA 36

hydrochlorothiazide 29FLULAVAL QUADRIVALENT GEODON 33FREEZONE 642020-2021 116 GILENYA 108FLUMADINE 38 FULPHILA 72

GILPHEX TR 50flunisolide (nasal) 100 FURADANTIN 112

GILTUSS 50FLUNISOLIDE furosemide 67 GILTUSS ALLERGY &ANHYDROUS 14 FUZEON 36 SINUS 50fluocinonide 63 G-DOLOGEN 50 GILTUSS COUGH & COLD 50fluorometholone (ophth) 104 G-P-TUSS DXP 50 GILTUSS COUGH ALLERGY & fluorouracil (topical) 62 SINUS 50G-TUSICOF 50 fluoxetine hcl 19 GILTUSS SINUS &G-ZYNCOF 50 CONGESTION 50FLUOXETINE gabapentin 17HYDROCHLORIDE 19 GILTUSS TR 50 fluphenazine decanoate 35 GABITRIL 18 GLASSIA 109

galantaminefluphenazine hcl 35 glatiramer acetate 108hydrobromide 107flurbiprofen 3 GLEEVEC 32GALANTAMINE flurbiprofen sodium 105 HYDROBROMIDE 107 GLEN PE 50

galantamineflutamide 31 GLENMAX PEB 50hydrobromide 107fluticasone propionate 63 GLENMAX PEB DM 50GAMASTAN 106fluticasone propionate GLENTUSS 50GAMMAGARD LIQUID 106(nasal) 100 glimepiride 23FLUTICASONE GAMMAGARD S/D IGA LESS

PROPIONATE/SALMETEROL THAN 1MCG/ML 106 glipizide 23 14 GAMUNEX-C 106 GLUCAGON EMERGENCY

fluvoxamine maleate 20 ganciclovir sodium 37 KIT 22 GLUCOPHAGE 22FLUZONE HIGH-DOSE PF 2020- GARDASIL 9 116

2021 116 GLUCOPHAGE XR 22GAS-X 70FLUZONE QUADRIVALENT GLUCOSE 22GAS-X EXTRA2018-2019 116 STRENGTH 70 GLUCOTROL 23FLUZONE QUADRIVALENT

2019-2020 116 GAVILYTE-C 74 GLUCOTROL XL 23 FLUZONE QUADRIVALENT GCON IR 50 GLUCOVANCE 21 2020-2021 116 GELONASAL 98 glyburide 23FLYP NEBULIZER 88 gemfibrozil 28 glyburide micronized 23FML 104 GENOTROPIN 68 glyburide-metformin 21FML FORTE 104 GENOTROPIN glycopyrrolate 111FML LIQUIFILM 104 MINIQUICK 68 GLYNASE 23FOCALIN 1 gentamicin in saline 2 GLYXAMBI 21FOCALIN XR 1 gentamicin sulfate 2 GNP CALAMINE 65folic acid 72 gentamicin sulfate

GNP COLD RELIEF PLUS 50(ophth) 103FORTAZ 41 gentamicin sulfate (topical) 61 GNP DAILY PRENATAL 95

FORTEO 68 GENTAMICIN SULFATE GNP GLUCOSE 22FORTIFY OPTIMA PEDIATRIC 2 GNP PRENATAL 95PROBIOTIC 24 GENTAMICIN SULFATE/0.9%FORTIFY PROBIOTIC GNP QUICK DISSOLVESODIUM CHLORIDE 2WOMENSEXTRA GLUCOSE 22GENTEAL MILD 102 GOLD BOND PSORIASISSTRENGTH 24 RELIEF MULTI-SYMPTOM 64

Index 12

GOLYTELY 74 HISTEX PDX 25 HYDREA 32 GONIOVISC 102 HISTEX-AC 50 hydrochlorothiazide 68 GOODSENSE PRENATAL HISTEX-DM 50 HYDROCODONE VITAMINS 95 BITARTRATE/CHLORPHENIRAHISTEX-PE 50GOPRELTO 99 MINE MALEATE/PSE 51HIZENTRA 106 HYDROCODONEGRALISE 108 HM CALAMINE 65 BITARTRATE/GUAIFENESINgranisetron hcl 24 51HM FISH OIL 102griseofulvin microsize 25 hydrocodone polistirex-HM ONE DAILY PRENATAL guaifenesin 59 COMBO 95 chlorpheniramine polistirex 51

hydrocodone w/GUAIFENESIN 59 HM PRENATAL 95 homatropine 45 guaifenesin 59 HOLD 45 hydrocodone-acetaminophen 6 guaifenesin-codeine 50 HOMATROPAIRE 103 hydrocodone-ibuprofen 6 guanfacine hcl 29 homatropine hbr 103 hydrocortisone 43 guanfacine hcl (adhd) 1 HOMENEB WITH hydrocortisone (intrarectal) 7SIDESTREAM/DISPOSABLEGYNE-LOTRIMIN 117 hydrocortisone (rectal) 788GYNE-LOTRIMIN 3 117 HOMENEB WITH hydrocortisone (topical) 63 HALDOL 34 SIDESTREAM/REUSABLE & hydrocortisone acetateHALDOL DECANOATE 100 34 DISPOSABLE 88 (topical) 63

HORIZANT 108 hydrocortisone acetate w/HALDOL DECANOATE 50 34 HUBER NEEDLE/RIGHT pramoxine 7halobetasol propionate 63 ANGLE19G X 1" 80 hydrocortisone w/acetic

haloperidol 34 HUBER NEEDLE/RIGHT acid 105 haloperidol decanoate 34 ANGLE22G X 1-1/2" 80 hydrocortisone-aloe vera 63

HUBER NEEDLE/STRAIGHThaloperidol lactate 34 hydrogen peroxide 3522GX1-1/2" 80HAVRIX 116 HYDROGEN PEROXIDE 35HUMALOG 22

HEMOCYTE 72 hydromorphone hcl 5HUMALOG KWIKPEN 22heparin (porcine) in sodium HYDROMORPHONE HCL 5HUMALOG MIX 50/50 22chloride 16 hydromorphone hcl 5HUMALOG MIX 50/50HEPARIN LOCK FLUSH 16 KWIKPEN 22 hydroxychloroquine sulfate 30 heparin sod (porcine) in d5w 16 HUMALOG MIX 75/25 22 hydroxyurea 32 heparin sodium (porcine) 16 HUMALOG MIX 75/25 hydroxyzine hcl 11heparin sodium (porcine) lock KWIKPEN 22 hydroxyzine pamoate 11flush 16 HUMIRA 2 HEPARIN SODIUM/D5W 16 hyoscyamine sulfate 111HUMIRA PEDIATRIC CROHNS HEPARIN HYPER-SAL 59DISEASE STARTER PACK 2 SODIUM/DEXTROSE 16 HYPERSAL 59HUMIRA PEN 2HEPARIN SODIUM/NACL HUMIRA PEN-CD/UC/HS HYPODERMIC NEEDLE 18G X0.45% 16 STARTER 2 1" 80HEPARIN SODIUM/SODIUM HUMIRA PEN-PS/UV HYPODERMIC NEEDLE 18G XCHLORIDE 16 STARTER 2 1-1/2" 80HEPARIN SODIUM/SODIUM HYPODERMIC NEEDLE 19G XHUMULIN 70/30 22CHLORIDE 0.9% 16 1" 80HUMULIN N 22HEPLISAV-B 116 HYPODERMIC NEEDLE 22GX1-HEPSERA 38 HUMULIN R 23 1/2" 80

HUMULIN R U-500 HYPODERMIC NEEDLEHERBAL EXPEC 59 (CONCENTRATED) 23 25GX1" 80HERBIOMED DEEP COLD AND HUMULIN R U-500 HYPODERMIC NEEDLE 25GX1-FLU NIGHTTIME 50 KWIKPEN 23 1/2" 80HERBIOMED FAST ACTING hydralazine hcl 30 HYPODERMIC NEEDLEBODY ACHES & SINUS 50 25GX5/8" 80HYDRALYTE 92HISTEX 25 HYPODERMIC NEEDLEHYDRALYTE FREEZERHISTEX PD 25 27GX1/2" 80POPS 92

Index 13

HYPODERMIC NEEDLES INNOSPIRE ESSENCE ITCH RELIEF 62 18GX1" HYPODERMIC NEEDLES 18GX1-1/2"HYPODERMIC NEEDLES

80

80

COMPRESSOR NEBULIZER SYSTEM 88 INNOSPIRE GO PORTABLE MESH NEBULIZER 88

ivermectin JAKAFI JANUMET

8 32 21

19GX1" HYPODERMIC NEEDLES 22GX1-1/2"HYPODERMIC NEEDLES

80

81

INNOSPIRE MINI PORTABLE COMPRESSOR NEBULIZER 88 INNOSPIRE MINI PORTABLE

JANUMET XR JANUVIA JARDIANCE

21 22 23

25GX1-1/2" 81 HYPODERMIC NEEDLES 25GX5/8" 81 HYPODERMIC NEEDLES 27GX1/2" 81 hypromellose (ophth) 102 HYVEE ADVANCED ANTACID

COMPRESSOR NEBULIZER/BATTERY 88 INSPIRATION COMPRESSOR NEBULIZER SYSTEM 88 INSPIRATION ELITE COMPRESSOR NEBULIZER SYSTEM 88

JENTADUETO JOHNSONS NO MORE RASH K-PHOS NEUTRAL K-TAB KALETRA

21

65 93 93 36

MAXIMUM STRENGTH 7 INSPRA 30 KARBINAL ER 26 HYZAAR 29 INSTA-GLUCOSE 22 KEFLEX 41 ibandronate sodium 68 INTELENCE 36 KENALOG-10 43 ibuprofen 3 INTRON A 32 KENALOG-40 44 ICLUSIG 32 INTUNIV 1 KEPPRA 17 imatinib mesylate 32 INVEGA SUSTENNA 33 KEPPRA XR 17 IMBRUVICA 32 INVEGA TRINZA 33 KERALYT 64 imipenem-cilastatin imipramine hcl

9 21

INVIRASE INVOKANA

36 23

ketoconazole (topical) KETONE

61 66

imipramine pamoate 21 IOPIDINE 103 KETONE TEST STRIPS 66 imiquimod IMITREX IMITREX STATDOSE REFILL IMITREX STATDOSE SYSTEM IMODIUM A-D IMPAVIDO IMURAN INATAL GT INCRELEX INCRUSE ELLIPTA indapamide INDERAL LA INDOCIN indomethacin INFANTS ADVIL

64 90,91

91

91 24

8 94 95 68 13 68 39

3 3 3

IPRATROPIUM BROMIDE 13 ipratropium bromide 13 ipratropium bromide(nasal) 100 IPRATROPIUM BROMIDE MONOHYDRATE 13 ipratropium-albuterol 14 irbesartan 29 irbesartan-hydrochlorothiazide

29 IRESSA 32 ISENTRESS 36 isoniazid 31 ISONIAZID 31 isoniazid 31 isoproterenol hcl 14 ISOPTO ATROPINE 103

ketoprofen KETOPROFEN ER ketorolac tromethamine ketorolac tromethamine (ophth) KETOSTIX ketotifen fumarate (ophth) KEY-E KITABIS PAK KLARON KLONOPIN KOMBIGLYZE XR KONSYL DAILY FIBER KONSYL ORIGINAL FORMULADAILY FIBER KP PRENATAL MULTIVITAMINS

3 3 3

105 66

105 118

2 60 17 21 73

73

95

INLYTA 32 ISOPTO CARPINE 103 KPN PRENATAL 95

INNOSPIRE DELUXE ISOPTO TEARS 102 KRINTAFEL 30 COMPRESSOR NEBULIZER ISORDIL TITRADOSE 11 labetalol hcl 38 SYSTEM 88 INNOSPIRE ELEGANCE COMPRESSOR NEBULIZER SYSTEM 88

isosorbide dinitrate isosorbide mononitrate isotretinoin ISTALOL ISUPREL

11 11 60

103 14

LAC-HYDRIN LAC-HYDRIN TWELVE lactic acid (ammoniumlactate) lactulose

64 64

64 74

Index 14

lactulose (encephalopathy) 70 LEVSIN 111 LODINE 3 LAMICTAL 17 LEVSIN/SL 111 LODRANE D 51 LAMICTAL CHEWABLE LEXAPRO 20 LOESTRIN 1.5/30-21 42 DISPERSIBLE 17 LEXIVA 36 LOESTRIN 1/20-21 42LAMICTAL ODT 17 LICEMD 66 LOESTRIN FE 1.5/30 42LAMICTAL XR 17 lidocaine 65 LOESTRIN FE 1/20 42LAMISIL AT 61 lidocaine hcl 65 LOHIST-D 51LAMISIL AT JOCK ITCH 61 LIDOCAINE HCL 75 LOHIST-DM 51lamivudine 36 lidocaine hcl (local LOMOTIL 24lamivudine (hbv) 38 75anesth.) LONHALA MAGNAIR REFILL lamivudine-zidovudine 36 lidocaine hcl (mouth- KIT 13 lamotrigine 17 throat) 94 LONHALA MAGNAIR STARTER

LIDOCAINE KIT 13LANOXIN 40 HYDROCHLORIDE 75 loperamide hcl 24lansoprazole 112 lidocaine-prilocaine 65 LOPID 28LANTUS 23 LIDODERM 65 lopinavir-ritonavir 36LANTUS SOLOSTAR 23 LINCOCIN 10 LOPRESSOR 39LASIX 67 lincomycin hcl 10 LOPRESSOR HCT 29latanoprost 105 lindane 66 LOPROX 61LATUDA 33 linezolid 10 loratadine 27LEADER QUICK DISSOLVE LINEZOLID 10 loratadine &GLUCOSE 22 linezolid 10 pseudoephedrine 51leflunomide 4 LINZESS 70 lorazepam 12LETAIRIS 40 liothyronine sodium 110 LORTUSS DM 51letrozole 31 LIPITOR 28 LORTUSS EX 51leucovorin calcium 32 lisinopril 28 LORTUSS LQ 51leuprolide acetate 31 lisinopril & losartan potassium 29levalbuterol tartrate 14 hydrochlorothiazide 29 losartan potassium &

LEVAQUIN 69 LITHIUM 33 hydrochlorothiazide 29 LEVBID 111 lithium carbonate 33 LOSEASONIQUE 42 LEVEMIR 23 LITHOBID 33 LOTENSIN 28 LEVEMIR FLEXTOUCH 23 LITTLE COLDS COUGH LOTENSIN HCT 29

FORMULA 45levetiracetam 17 LOTREL 29LITTLE COLDSlevobunolol hcl 103 LOTRIMIN AF 61DECONGESTANTFORMULAlevocarnitine (metabolic 100 LOTRIMIN AF JOCK ITCH 61modifiers) 68 LITTLE NOSES LOTRIMIN ANTIFUNGAL 61levocetirizine dihydrochloride27 DECONGESTANTNOSE LOTRIMIN ULTRA 61levofloxacin 69 DROPS 101

LITTLE NOSES LOTRISONE 61levofloxacin (ophth) 103 MOISTURIZINGNASAL lovastatin 28levofloxacin in d5w 69 GEL 98 LOVENOX 16levonorgestrel & eth LITTLE NOSES STERILE loxapine succinate 34estradiol 42 SALINE NASAL MIST 98levonorgestrel (emergency LITTLE REMEDIES BABY LUMINEB II PISTON oc) 43 STERILE SALINE MIST FOR NEBULIZER 88 levonorgestrel-eth estradiol NOSES 98 LUNESTA 73 (triphasic) 42 LITTLE REMEDIES FOR LUPRON DEPOT (1-levonorgestrel-ethinyl estradiol COLDSMULTI SYMPTOM 51 MONTH) 31(91-day) 42 LITTLE REMEDIES FOR LUPRON DEPOT (3-levonorgestrel-ethinyl estradiol NOSES 98 MONTH) 31(continuous) 42 LMX 4 65 LUPRON DEPOT (4-levothyroxine sodium 110 MONTH) 31

Index 15

LUPRON DEPOT (6-MONTH) 31 LUZU 61 LYCELLE 66 LYRICA 17 M-CLEAR WC 51 M-END DMX 51 M-END PE 51 M-M-R II 117 M-NATAL PLUS 95 M-VIT 95 MAALOX 8 MABIS COMPXP COMPRESSOR NEBULIZER 88 MABIS COSMOCOMP NEBULIZER 88 MACROBID 112 MACRODANTIN 113 MAG-200 92 MAGELLAN TUBERCULIN

MAXI-TUSS PE MAX 51 MAXICHLOR PEH DM 51 MAXIDEX 104 MAXIFED 51 MAXIMUM D3 118 MAXIPIME 42 MAXITROL 104 MAXZIDE 67 MAXZIDE-25 67 meclizine hcl 24 meclofenamate sodium 3 MEDROL 44 MEDROL DOSEPAK 44 medroxyprogesterone acetate 107 medroxyprogesterone acetate(contraceptive) 43 mefenamic acid 3 mefloquine hcl 30 megestrol acetate 31

methotrexate sodium 31 methscopolamine bromide 111 methyclothiazide 68 methyldopa 29 methylergonovine maleate 105 METHYLIN 1 methylphenidate hcl 1 methylprednisolone 44 methylprednisolone sod succ 44 metipranolol 103 metoclopramide hcl 70 METOCLOPRAMIDE ODT 70 metolazone 68 metoprolol &hydrochlorothiazide 29 metoprolol succinate 39 metoprolol tartrate 39 METROCREAM 66 METROGEL-VAGINAL 117

SAFETY SYRINGE/1ML/27G X1/2" 81 MAGELLAN TUBERCULIN SAFETY SYRINGE/1ML/28G X1/2" 81 MAGNESIUM 92 magnesium citrate 74 magnesium hydroxide 74 magnesium oxide 8 MAGNESIUM OXIDE 93 magnesium oxide (mgsupplement) 92 MAGOX 400 93 MAKENA 107 MALARONE 30

MEIJER CALAMINE meloxicam memantine hcl MENACTRA MENEST MENOSTAR MENVEO meperidine hcl MEPHYTON MEPRON mercaptopurine meropenem MEROPENEM/SODIUMCHLORIDE

65 3

107 113

69 69

113 5

118 9

31 9

9

METROLOTION 66 metronidazole 8 METRONIDAZOLE 8 metronidazole 8 metronidazole (topical) 66 METRONIDAZOLE BENZOATE/SYRSPEND SFPH4 8 metronidazole in nacl 8 metronidazole vaginal 117 mexiletine hcl 13 MG217 PSORIASIS MULTI-SYMPTOM 64 MICATIN 61 MICONAZOLE NITRATE 61

maprotiline hcl 19 MAR-COF BP 51 MAR-COF CG EXPECTORANT 51 MARGO MOO COMPRESSOR NEBULIZER 88 MATULANE 32 MAVYRET 38

MERREM mesalamine MESTINON MESTINON TIMESPAN METAMUCIL METAMUCIL ORIGINAL TEXTURE METAPROTERENOL

9 70 30 31 73

73

miconazole nitrate (topical) 61 miconazole nitrate vaginal 117 MICRO AIR NEBULIZER 88 MICRO PLUS HIGH EFFICIENCY NEBULIZER/REUSABLE 88 MICROAIR VIBRATING MESH NEBULIZER 88

MAXALT 91 SULFATE 14 MICROELITE COMPRESSOR MAXALT-MLT MAXI-TUSS CD MAXI-TUSS DM

91 51 51

metaproterenol sulfate metformin hcl methazolamide

15 22 67

NEBULIZER SYSTEM 88 MICROELITE COMPRESSOR NEBULIZER SYSTEM WITH BATTERY 89

MAXI-TUSS PE 51 methimazole 110 MICRONEB 89 MAXI-TUSS PE JR 51 methocarbamol 97 MICROZIDE 68

Index 16

midodrine hcl 118 MONISTAT SOOTHING CARE MONOJECT

MIGERGOT miglustat MILLIPRED

90 72 44

ITCH RELIEF 63 MONOJECT 1ML LUER LOCK TUBERCULIN SYRINGE/TIPCAP 81

HYPO/POLYPROPYLENEHUB/LL/SHORT BEVEL/18G X1" 81 MONOJECT

MINI COMPRESSOR 89 MINI PLUS REUSABLE HIGH EFFICIENCY NEBULIZER 89 MINIBREEZE ULTRASONIC NEBULIZER 89 MINIELITE COMPRESSOR NEBULIZER SYSTEM 89 MINIELITE COMPRESSOR NEBULIZER SYSTEM WITH BATTERY 89 MINIPRESS 29 MINIVELLE 69 MINOCIN 110 minocycline hcl 110 MINOCYCLINE HCL 110 minocycline hcl 110 MINOCYCLINE HYDROCHLORIDEER 110 MINOLIRA 110 minoxidil 30 MIRALAX 74 MIRAPEX 33 MIRCETTE 42 mirtazapine 19 misoprostol 112 MISTERNEB COMPRESSOR NEBULIZER SYSTEM 89 MOBIC 3 MODERIBA 1200 DOSE PACK 38 moexipril hcl 28 moexipril-hydrochlorothiazide

29 MOI-STIR 94 mometasone furoate 63 mometasone furoate

MONOJECT 3ML SYRINGE/STANDARDHYPODERMIC NEEDLE/21GX1-1/2" 81 MONOJECT BLUNTIP SYRINGE/3ML/CANNULA/IVACCESS 81 MONOJECT HYPO/ALUMHUB/18G X 1-1/2" 81 MONOJECT HYPO/ALUMHUB/LUER LOCK/INTMBEVEL/27G X 1/2" 81 MONOJECT HYPO/ALUMHUB/LUER LOCK/REGBEVEL/18G X 1" 81 MONOJECT HYPO/ALUMHUB/LUER LOCK/REGBEVEL/22G X 1-1/2" 81 MONOJECT HYPO/ALUMHUB/LUER LOCK/REGBEVEL/25G X 5/8" 81 MONOJECT HYPO/ALUMHUB/LUER LOCK/SHORTBEVEL/18G X 1" 81 MONOJECT HYPO/ALUMHUB/LUER LOCK/SHORTBEVEL/18G X 1-1/2" 81 MONOJECT HYPO/ALUMHUB/LUER LOCK/SPECBEVEL/19G TW X 1" 81 MONOJECT HYPO/POLYPROPYLENEHUB/18G X 1" 81 MONOJECT HYPO/POLYPROPYLENEHUB/18G X 1-1/2" 81 MONOJECT HYPO/POLYPROPYLENEHUB/LL/BEVEL/25G X 1-1/2" 81 MONOJECT

HYPO/POLYPROPYLENEHUB/LL/SHORT BEVEL/18G X1-1/2" 81 MONOJECT HYPO/POLYPROPYLENEHUB/LL/SHORT BEVEL/19G TWX 1" 81 MONOJECT HYPO/POLYPROPYLENEHUB/LL/SHORT BEVEL/22G X1-1/2" 81 MONOJECT HYPO/POLYPROPYLENEHUB/REG BEVEL/27G X1/2" 81 MONOJECT HYPODERMIC NEEDL3 18G X 1" 81 MONOJECT MAGELLAN SAFETYNEEDLE 18GX1" 82 MONOJECT MAGELLAN SAFETYNEEDLE 18GX1-1/2" 82 MONOJECT MAGELLAN SAFETYNEEDLE 19GX1" 82 MONOJECT MAGELLAN SAFETYNEEDLE 22GX1-1/2" 82 MONOJECT MAGELLAN SAFETYNEEDLE 25GX1" 82 MONOJECT MAGELLAN SAFETYNEEDLE 25GX5/8" 82 MONOJECT MAGELLAN SYRINGE/SAFETYNEEDLE/3ML/20G X 1" 82 MONOJECT MAGELLAN SYRINGE/SAFETYNEEDLE/3ML/21G X 1-1/2" 82 MONOJECT MAGELLAN SYRINGE/SAFETYNEEDLE/3ML/22G X 1" 82 MONOJECT MAGELLAN

(nasal) 100 MONISTAT 1 COMBO PACK 117 MONISTAT 1 DAY OR NIGHT COMBO PACK 117 MONISTAT 3 117 MONISTAT 3 COMBINATION PACK 117 MONISTAT 7 COMBINATION PACK 117 MONISTAT 7 SIMPLY CURE 117

HYPO/POLYPROPYLENEHUB/LL/INTM BEVEL/25G X5/8" 81 MONOJECT HYPO/POLYPROPYLENEHUB/LL/REG BEVEL/19G TWX 1" 81 MONOJECT HYPO/POLYPROPYLENEHUB/LL/REG BEVEL/25G X1" 81

SYRINGE/SAFETYNEEDLE/3ML/22G X 1-1/2"MONOJECT MAGELLAN SYRINGE/SAFETYNEEDLE/3ML/23G X 1"MONOJECT MAGELLAN SYRINGE/SAFETYNEEDLE/3ML/25G X 1"MONOJECT MAGELLAN SYRINGE/SAFETYNEEDLE/3ML/25G X 5/8"MONOJECT PHARMACY

82

82

82

82

TRAY/LUER LOCK/3ML 82

Index 17

MONOJECT PHARMACY MONOJECT SYRINGE/REG MORGIDOX 1X50MG KIT 110 TRAY/REG LUER/1ML 82 LUER/3ML 83 MORGIDOX 2X100MG 110MONOJECT STANDARD MONOJECT

morphine sulfate 5HYPODERMIC SYRINGE/REGULARTIP/3MLNEEDLE/POLYPROPYLEN/22G 83 MORPHINE SULFATE 5 X1-1/2" 82 MONOJECT morphine sulfate 5MONOJECT STANDARD SYRINGE/STANDARDHYPOD MORPHINE SULFATE 5HYPODERMIC ERMIC NEEDLE/POLYPROPYLENE NEEDLE/3ML/20GX1" 83 morphine sulfate 5 HUB/18GX1" 82 MONOJECT MOSCO CALLUS/CORNMONOJECT STANDARD SYRINGE/STANDARDHYPOD REMOVER 64 HYPODERMIC ERMIC MOTRIN CHILDRENS 3 NEEDLE/POLYPROPYLENE NEEDLE/3ML/22GX1" 83 MOTRIN INFANTS DROPS 3HUB/19GX1" 82 MONOJECT MOUTH KOTE 94MONOJECT STANDARD SYRINGE/STANDARDHYPODHYPODERMIC ERMIC NEEDLE/3ML/22GX1- MOUTH KOTE REMINT 94 NEEDLE/POLYPROPYLENE/18 1/2" 83 MOXATAG 106 GX1-1/2" 82 MONOJECT MOXIFLOXACINMONOJECT STANDARD SYRINGE/STANDARDHYPOD HYDROCHLORIDE/SODIUMHYPODERMIC ERMIC HYDROCHLORIDE 69NEEDLE/POLYPROPYLENE/22 NEEDLE/3ML/23GX1" 83 moxifloxacin hcl 70GX1-1/2" 82 MONOJECT moxifloxacin hcl (ophth) 103MONOJECT STANDARD SYRINGE/STANDARDHYPOD

MOXIFLOXACINHYPODERMIC ERMIC NEEDLE/POLYPROPYLENE/25 NEEDLE/3ML/25GX1" 83 HYDROCHLORIDE 70 GX1" 82 MONOJECT MS CONTIN 5 MONOJECT STANDARD SYRINGE/STANDARDHYPOD MUCINEX 59 HYPODERMIC ERMIC MUCINEX CHILDRENS COLDNEEDLE/POLYPROPYLENE/25 NEEDLE/3ML/25GX5/8" 83 COUGH & SORE THROAT 51GX1-1/2" 82 MONOJECT TB SYRINGE- MUCINEX CHILDRENS MULTI-MONOJECT STANDARD NDL 1ML 27GX1/2" 83 SYMPTOM COLD 51HYPODERMIC MONOJECT TUBERCULIN MUCINEX CHILDRENS MULTI-NEEDLE/POLYPROPYLENE/25 SAFETY SYRINGE/1ML/25G X SYMPTOM COLD & FEVER 51 GX5/8" 82 5/8" 83 MUCINEX CONGESTION & MONOJECT STANDARD MONOJECT TUBERCULIN COUGH CHILDRENS 51 HYPODERMIC SAFETY SYRINGE/1ML/28G X MUCINEX COUGH & NEEDLE/POLYPROPYLENE/27 1/2" 83 CONGESTION CHILDRENS 51 GX1/2" 82 MONOJECT TUBERCULIN MUCINEX COUGH FOR MONOJECT SYRINGE SYRINGE SOFTPACK 1ML KIDS 51 PHARMACY TRAY/1ML LUER REGULAR LUER TIP 83 MUCINEX D 51 LOCK 82 MONOJECT TUBERCULIN MUCINEX D MAXIMUMMONOJECT SYRINGE/LUER SYRINGE/1ML/25GX5/8" 83 STRENGTH 51LOCK/3ML 82 MONOJECT TUBERCULIN MUCINEX DMMONOJECT SYRINGE/LUER SYRINGE/1ML/28G X 1/2" 83 51

MUCINEX DM MAXIMUMLOCK/3ML/20G X 1" 83 MONOJECT TUBERCULIN STRENGTH 51MONOJECT SYRINGE/LUER SYRINGE/DETACHMUCINEX FAST-MAX COLD &LOCK/3ML/22G X 1" 83 NEEDLE/1ML/25G X 5/8" 83 SINUS 52MONOJECT SYRINGE/LUER MONOJECT TUBERCULIN MUCINEX FAST-MAX COLDLOCK/3ML/22G X 1-1/2" 83 SYRINGE/DETACH

MONOJECT SYRINGE/LUER NEEDLE/1ML/27G X 1/2" 83 FLU& SORE THROAT 52 MUCINEX FAST-MAX COLDLOCK/3ML/23G X 1" 83 MONOJECT TUBERCULIN FLU& SORE THROAT CLEAR &MONOJECT SYRINGE/LUER SYRINGE/PERMCOOL 52LOCK/3ML/25G X 1" 83 NEEDLE/1ML/28G X 1/2" 83 MUCINEX FAST-MAXMONOJECT SYRINGE/LUER MONOJECT TUBERCULIN

LOCK/3ML/25G X 5/8" 83 SYRINGE/WITHOUT COLD/FLU 52 MUCINEX FAST-MAXMONOJECT SYRINGE/LUER- NEEDLE/REG LUER/1ML 84 COLD/FLU/SORE THROAT 52LOCK TIP/3ML 83 montelukast sodium 13 MUCINEX FAST-MAX DAYMONOJECT SYRINGE/LUER- MORGIDOX 1X100MG 110 TIME/NIGHT TIME 52LOCK/3ML/21G X 1-1/2" 83

Index 18

MUCINEX FAST-MAX MYNATAL-Z 95 NATACYN 103 DAY/NIGHT 52 MYNATE 90 PLUS 95 NATALVIT 95MUCINEX FAST-MAX

MYSOLINE 17 nateglinide 23DAY/NIGHT MAXIMUMSTRENGTH 52 N-ACETYL-L-CYSTEINE 59 NATROBA 66 MUCINEX FAST-MAX DAY/NITE nabumetone 3 NATURAL VITAMIN E 118M/S 52 NAFCILLIN 107 NATURE-THROID 111MUCINEX FAST-MAX SEVERE COLD 52 nafcillin sodium 107 NATURE-THROID NT-2.5 111 MUCINEX FAST-MAX SEVERE NAFCILLIN SODIUM 107 NEB-RITE4 89 CONGESTION & COUGH 52 nafcillin sodium 107 NEBULIZER 89MUCINEX FAST-MAX SEVERE

NALFON 3 NEBULIZER PED FROG 89CONGESTION & COUGH CLEAR & COOL 52 NALOXONE HCL 24 NEBULIZER PED FROG SYS

W/DISP&REUSE NEB KIT 89MUCINEX FOR KIDS 59 naloxone hcl 24 NEBULIZER SYSTEM ALL-IN-MUCINEX MAXIMUM naltrexone hcl 24 ONE 89STRENGTH 59 NAMENDA 108 NEBUPENT 8MUCINEX MULTI-SYMPTOM COLD DAY/NIGHT PACK 52 naphazoline w/ NEO-SYNEPHRINE MUCINEX SINUS-MAX DAY pheniramine 104 COLD+ALLERGY EXTRA TIME/NIGHT TIME 52 NAPHCON-A 104 STRENGTH 101 MUCINEX SINUS-MAX NAPROSYN 3 NEO-SYNEPHRINE DAY/NIGHT 52 COLD+ALLERGY MILD naproxen 3,4MUCINEX SINUS-MAX STRENGTH 101

naproxen sodiumSEVERECONGESTION 3 NEO-SYNEPHRINE RELIEF 52 naratriptan hcl 91 COLD+ALLERGY REGULAR MUCINEX STUFFY NOSE & STRENGTH 101NARCAN 24COLD CHILDRENS 52 neomycin sulfate 2NASACORT ALLERGYMULTAQ 13 24HR 100 neomycin-bacitracin zn-MULTI PRENATAL 95 NASACORT ALLERGY 24HR polymyxin 104

CHILDRENS 100 neomycin-bacitracin-polymyxinMULTI-DRAW NEEDLE 22GX1-1/2" 84 NASADOCK PLUS 98 61

neomycin-bacitracin-polymyxin-MULTI-MINERALS 93 NASADROPS SALINE ON THE pramoxine 61MULTI-SYMPTOM COLD GO 98 neomycin-polymy-DAYTIME/NIGHTTIME NASAFLO NETI POT NASAL dexameth 104CHILDRENS 52 WASH SYSTEM 98 neomycin-polymyxin-hcNASAFLO PORCELAINmultiple minerals 93 (ophth) 104NASAL RINSE 98mupirocin 61 neomycin-polymyxin-hcNASAL CLEANSE RINSE (otic) 105mupirocin calcium (topical) 61 MIX 98 NEOMYCIN/POLYMYXIN/GRAMMVW COMPLETE PROBIOTIC NASAL ICIDIN 104FORMULATION 24 DECONGESTANT 101 NEONATAL COMPLETE 95MY MDI PORTABLE NASAL MOIST GEL 98 NEBULISER PROCEDURE NEONATAL PLUS 95NASALCARE 98PACK 89 NEONATAL VITAMIN 95NASALCARE FOR KIDS 98MYAMBUTOL 31 NEORAL 94NASALCARE FOR KIDSmycophenolate mofetil 94 NEOSPORIN 104STARTER KIT 98 MYDRIACYL 103 NASALCARE NEOSPORIN ORIGINAL 61 MYLICON INFANTS GAS NASALCLEANSE KIT 98 NEOTUSS PLUS 52RELIEF 70 NASALCROM 99 NEOTUSS-D 52MYLICON INFANTS GAS NASAMIST ALL-IN-ONE 98RELIEF DYE FREE 70 NEPHROCAPS 95NASAMIST HYPERTONIC 98MYNATAL 95 NEUPOGEN 72NASAMIST ISOTONIC 98MYNATAL ADVANCE 95 NEURONTIN 17NASONEX 100MYNATAL PLUS 95 NEUTROGENA ON-THE-SPOT

NASOPEN PE 52 ACNE TREATMENT 60MYNATAL ULTRACAPLET 95

Index 19

NEUTROGENA T/SAL 65 NOKOR VENTED NEEDLE NUTRIDOX 110 THINWALL NON-CORINGnevirapine 36 NUVARING 4318GX1-1/2" 84NEXABIOTIC 24 NUZYRA 109NORCO 6NEXAFED SINUS PRESSURE nystatin 25NORDITROPIN FLEXPRO 68+PAIN 53 nystatin (mouth-throat) 94NOREL AD 53NEXAVAR 32 nystatin (topical) 61NF FORMULAS CALCIUM NOREL CS 53 NYTOL MAXIMUMMAGNESIUM 93 norethin acet & estrad-fe 42 STRENGTH 73niacin 118 norethindrone & eth O-CAL FA 95

niacinamide 118 estradiol 42 O-CAL PRENATAL 95norethindroneNICODERM CQ 108 (contraceptive) 43 OC8 60NICORETTE 108 norethindrone acet & eth OCEAN COMPLETE SINUS NICORETTE MINI 108 estra 42 RINSE 98 NICORETTE STARTER norethindrone acetate 107 OCEAN NASAL KIT 109 norethindrone acetate-ethinyl MOISTURIZER 98 nicotine 109 estradiol-fe 42 OCEAN NASAL SPRAY 98

norethindrone-eth estradiol OCEAN ULTRA SALINEnicotine polacrilex 109 (triphasic) 42 NASALMIST 98NICOTINE TRANSDERMAL

SYSTEM 109 norgestimate-ethinyl OCUFLOX 104estradiol 42NICOTROL INHALER 109 ODEFSEY 36norgestimate-ethinyl estradiol

NICOTROL NS 109 (triphasic) 42 ofloxacin 70 nifedipine 39 norgestrel & ethinyl ofloxacin (ophth) 104

estradiol 42NINJACOF 53 olanzapine 34NORM-JECT TUBERKULINNINJACOF-A 53 olopatadine hcl (nasal) 991MLLUER SLIP 84 NINJACOF-XG 53 NORPACE 12 OMEGA POWER 102 NINLARO 32 NORPACE CR 12 OMEGA-3 102 nit remover 66 NORPRAMIN 21 OMEGA-3 2100 102 NITE-TIME COLD/FLU nortriptyline hcl 21 OMEGA-3 EPA FISH OIL 102 RELIEF 53 NORVASC 39 omega-3 fatty acids 102NITRO-BID 11 OMEGA-3 FISH OIL EXTRANORVIR 36NITRO-DUR 11 STRENGTH 102NOSE BETTER 98nitrofurantoin 113 omeprazole 112NOSE BETTER NATURALnitrofurantoin macrocrystal 113 omeprazole magnesium 112MIST 98 nitrofurantoin monohyd NOVOLIN 70/30 23 OMNARIS 100 macro 113 NOVOLIN N 23 OMNIFLEX DIAPHRAGM 75nitroglycerin 11

NOVOLIN R 23 OMNIPRED 104NITROSTAT 11

NOVOLOG 23 ondansetron 24NIVA-PLUS 95

NOVOLOG FLEXPEN 23 ondansetron hcl 24NIVANEX DMX 53 ONE VITE WOMENSNOVOLOG MIX 70/30 23NIX CREME RINSE 66 PRENATALVITAMINNOVOLOG MIX 70/30 95 NIZORAL 61 ONE VITE WOMENSPREFILLED FLEXPEN 23 PRENATALVITAMIN PLUS 95NOBLE MYSTIQUE EMU- NOVOLOG PENFILL 23 ONE-A-DAY WOMENSLAC 64 NPLATE 72 PRENATAL 96NOKOR ADMIX NEEDLE THIN WALL NON-CORING 18G X 1- NULYTELY 74 ONEVITE 95 1/2" 84 NULYTELY/FLAVOR ONFI 17 NOKOR VENTED NEEDLE PACKS 74 ONGLYZA 22THINWALL NON-CORING 18G X NUMBRINO 99 OPCON-A 1041" 84 NUMOISYN 94 OPTIMAL D3 M 118

NUTRA-SUPPORT BONE 93

Index 20

OPTIONHOME COMPRESSOR NEBULIZER SYSTEM 89 oral electrolytes 92 ORAL RELIEF SPRAY FOR DRYMOUTH & DISCOMFORT 94 ORAP 108 ORAPRED ODT 44 ORTHO MICRONOR 43 ORTHO TRI-CYCLEN 43 ORTHO TRI-CYCLEN LO 42 ORTHO-CYCLEN 43 ORTHO-NOVUM 1/35 43 ORTHO-NOVUM 7/7/7 43 oseltamivir phosphate 38 OTEZLA 4 OVACE PLUS WASH 62

PARI LC PLUS NEBULIZER SET/PEDIATRIC MASK 89 PARI LC PLUS NEBULIZER VIOS PRO/REUSABLE 89 PARI LC SPRINT NEBULIZERSET 89 PARI LC STAR 89 PARI LC STAR NEBULIZER 89 PARI PRONEB ULTRA II 89 PARI SINUS PULSATING AEROSOL SYSTEM 89 PARI TREK S COMPACT COMPRESSOR W/ 12V DCADAPTOR 89 PARI VIOS PRO LC PLUS AEROSOL DELIVERY SYSTEM 89 PARI VIOS PRO LC SPRINT AEROSOL DELIVERY

penicillamine 93 penicillin g potassium 106 PENICILLIN G POTASSIUM IN ISO-OSMOTIC DEXTROSE 106 PENICILLIN G PROCAINE 106 penicillin g sodium 106 penicillin v potassium 106 PENLAC NAIL LACQUER 62 PENTAM 300 8 pentamidine isethionate 8 PENTASA 70 pentoxifylline 71 PEPCID 112 PEPCID AC 112 PEPCID AC MAXIMUM STRENGTH 112

OVACE WASH 62 SYSTEM 89 PEPTO BISMOL 24 OXACILLIN SODIUM 107 paricalcitol 68 PEPTO-BISMOL 24 oxacillin sodium 107 PARLODEL 33 PEPTO-BISMOL MAX

oxaprozin 4 oxazepam 12 oxcarbazepine 17 oxybutynin chloride 113 oxycodone hcl 5 oxycodone w/ acetaminophen 6 oxycodone-aspirin 6 OXYCODONE/ASPIRIN 6 oxymetazoline hcl 101 OXYTETRACYCLINE HCL 110 oyster shell 92 P & S 65 PAMELOR 21

paromomycin sulfate 2 paroxetine hcl 20 PATANASE 99 PATIENT SAFE SYRINGE 3ML 84 PAXIL 20 PECGEN DMX 53 PEDIACARE COUGH & RUNNY NOSE 53 PEDIALYTE 92 PEDIALYTE ADVANCED CARE 92 PEDIALYTE FREEZER POPS 92 PEDIALYTE SINGLES 92

STRENGTH PEPTO-BISMOL TO-GO PERCOCET PERCOGESIC PERFOROMIST PERIDEX perindopril erbumine permethrin perphenazine PERRY PRENATAL PFIZERPEN PHAZYME PHAZYME ULTRA STRENGTH

24 24

6 53 15 94 28 66 35 96

106 70

70 PANATUSS PED 53 PEDIAPRED 44 PHENAGIL 53 PANATUSS PED DROPS 53 PEDIATRIC PHENAGIL CH 53 PANOXYL 60 PANOXYL-4 CREAMY WASH 60 pantoprazole sodium 112 PARI ALTERA NEBULIZER SYSTEM 89 PARI BABY 89 PARI BABY SIZE 1/PARILCPLUS 89 PARI ERAPID NEBULIZER SYSTEM 89 PARI LC D NEBULIZER 89 PARI LC PLUS 89 PARI LC PLUS NEBULIZER 89

COUGH/COLD 53 pediatric multiple vitamin w/ c 95 pediatric multiple vitamins w/iron 95 PEDIAVENT 25 peg 3350-kcl-sod bicarb-sodchloride-sod sulfate 74 peg 3350-potassium chloride-sod bicarbonate-sod chloride 74 PEGASYS 38 PEGASYS PROCLICK 38 PEGINTRON 38

phenazopyridine hcl PHENERGAN phenobarbital PHENYLEPHRINE HCL phenylephrine hcl phenylephrine hcl(mydriatic) phenylephrine hcl (oral) PHENYLEPHRINE HCL/PYRILAMINEMALEATE PHENYLEPHRINE HYDROCHLORIDE

71 27 73

101 101

103 101

53

101

Index 21

phenylephrine w/acetaminophen 53 phenylephrine w/ dm-gg 53 phenylephrine-acetaminophen-guaifenesin 53 phenylephrine-brompheniramine-dm 53 phenylephrine-chlorphen-dm

54 phenylephrine-chlorpheniraminew/ dm-gg & apap 54 phenylephrine-chlorpheniramine-dm w/ apap 54 phenylephrine-diphenhydramine-dm w/ apap 54 phenylephrine-diphenhydramine-dm-guaifenesin-apap 54 phenylephrine-diphenhydramine-gg w/ apap 54 phenylephrine-dm 54 phenylephrine-dm-gg w/ apap 54 phenylephrine-doxylamine-dextromethorphan-acetaminophen 54 phenylephrine-doxylamine-dm-guaifenesin-apap 54 phenylephrine-guaifenesin 54 phenylephrine-ibuprofen 54 phenylephrine-triprolidine-dextromethorphan 54 PHENYLPROPANOLAMINE HYDROCHLORIDE USP 101 PHENYTEK 18 phenytoin 18 phenytoin sodium extended 18 PHILLIPS WILLIS THE WHALENEBULIZER 89 phytonadione 118 PIFELTRO 36 pilocarpine hcl 103 pimozide 108 pioglitazone hcl 22 pioglitazone hcl-metforminhcl 22 piperacillin sodium-tazobactamsodium 107 piroxicam 4 PLAN B ONE-STEP 43 PLAQUENIL 30 PLAVIX 71 PNEUMOVAX 23 113 PNEUMOVAX 23/1 DOSE 113

PNV FOLIC ACID + IRON MULTIVITAMIN 96 PNV PRENATAL PLUS MULTIVITAMIN 96 PNV TABS 29-1 96 podofilox 65 POLY HIST FORTE 54 POLY HUB NEEDLE/18G X1" 84 POLY HUB NEEDLE/18G X 1-1-1/2" 84 POLY HUB NEEDLE/22G X 1-1/2" 84 POLY HUB NEEDLE/25G X1" 84 POLY HUB NEEDLE/25G X 1-1/2" 84 POLY HUB NEEDLE/25G X5/8" 84 POLY HUB NEEDLE/27G X1/2" 84 POLY-HIST DM 54 POLY-HIST PD 54 POLY-TUSSIN AC 54 POLY-VENT DM 54 POLY-VENT IR 54 POLY-VI-SOL 95 polyethylene glycol 3350 74 polyethylene glycol-propyleneglycol (ophth) 102 POLYMYXIN B SULFATE 11 polymyxin b sulfate 11 polymyxin b-trimethoprim 104 POLYSPORIN 61 POLYTRIM 104 POLYTUSSIN DM 54 polyvinyl alcohol 102 PONARIS 98 PORTABLE COMPRESSOR NEBULIZER 89 pot phosphate monobasic w/sod phosphate dibasic &monobasic 93 potassium 93 POTASSIUM 93 potassium chloride 93 POTASSIUM CHLORIDE 93 potassium chloride 93 potassium chloridemicroencapsulated crystals er 93 potassium citrate(alkalinizer) 71

potassium citrate-citric acid 71 PRADAXA 16 pramipexole dihydrochloride 33 PRANDIN 23 PRAVACHOL 28 pravastatin sodium 28 praziquantel 8 prazosin hcl 29 PRE-NATAL FORMULA 96 PRECOSE 21 PRED FORTE 104 PRED MILD 104 PRED-G 104 PRED-G S.O.P. 104 PREDATOR 65 prednisolone 44 prednisolone acetate(ophth) 104 PREDNISOLONE ACETATE P-F 105 prednisolone sodiumphosphate 44 PREDNISOLONE SODIUM PHOSPHATE 105 prednisone 44 PREDNISONE INTENSOL 44 pregabalin 17 PREMARIN 69,118 PREMPRO 69 PRENATABS FA 96 PRENATABS RX 96 PRENATAL 96 PRENATAL 19 96 PRENATAL AND IRON 96 PRENATAL FORTE 96 PRENATAL LOW IRON 96 PRENATAL MULTIVITAMIN 96 PRENATAL ONE DAILY 96 PRENATAL PLUS 96 PRENATAL PLUS IRON 96 PRENATAL VITAMIN 96 PRENATAL VITAMIN & MINERAL 96 PRENATAL VITAMIN/IRON 97 PRENATAL VITAMINS 97 PRENATAL VITAMINS PLUS LOW IRON 97 PRENATAL-U 97 PRENATVITE RX 97

Index 22

PREPLUS 97 promethazine-dm 54 pseudoephedrine-PRETAB 97 promethazine-phenylephrine- dexchlorpheniramine-

codeine 55 dextromethorphan 55PRETZ 99 PROMETHAZINE/DEXTROME pseudoephedrine-guaifenesinPRETZ IRRIGATION 99 55THORPHAN 55 PRETZ NATURAL PROMETHAZINE/PHENYLEP pseudoephedrine-ibuprofen 55 MOISTURIZING NASAL HRINE 55 pseudoephedrine-naproxenSPRAY/YERBA SANTA/SEA PROMETHAZINE/PHENYLEP sodium 55 SALT 99 HRINE/CODEINE 55 psyllium 73 PREVACID 112 PROMETRIUM 107 PULMICORT 14 PREVACID 24HR 112 PRONEB ULTRA II PULMICORT FLEXHALER 14DELUXE/LC SPRINT 90PREVNAR 13 113 PULMOZYME 109PRONEB ULTRA IIPREZCOBIX 36 DELUXE/LC STAR 90 PURE AIR MINI PREZISTA 36 PRONEB ULTRA II NEBULIZER 90 PRIMAQUINE PHOSPHATE 30 DELUXE/LCD 90 PX CALAMINE 65

PRONEB ULTRA II PX DAYTIME MULTI-primaquine phosphate 30 PEDIATRIC 90 SYMPTOM 55PRIMATENE ASTHMA 54 PRONEB ULTRA II WITH LC PX NITETIME MULTI-PRIMAXIN IV 9 PLUS 90 SYMPTOM 55

PRONEB ULTRA II/LCprimidone 18 PX PRENATAL SPRINT 90 MULTIVITAMINS 97PRIMLEV 6 PRONEB ULTRA II/LC SPRINT pyrantel pamoate 8PRIMSOL 8 PEDIATRIC 90 pyrazinamide 31PRINIVIL 28 propafenone hcl 13

pyrethrins-piperonyl butoxide66PROPANTHELINEPRO-RED AC 54 BROMIDE 112 pyrethrins-piperonyl butoxide-

PROAIR DIGIHALER 15 permethrin-nit remover 66PROPEL 100PROAIR HFA 15 PYRIDIUM 71PROPEL MINI 100PROAIR RESPICLICK 15 pyridostigmine bromide 31propranolol hcl 39probenecid 71 pyridoxine hcl 119PROPRANOLOL/HYDROCHLPROCARDIA 39 OROTHIAZIDE 30 PYRILAMINE MALEATE 26 PROCARDIA XL 39 propylthiouracil 110 PYRIMETHAMINE/LEUCOVORIPROCARE COMPRESSOR PROSCAR 71 N 30 NEBULIZER 89 QC CALAMINE 66PROTONIX 112prochlorperazine 35 QC MEDIFIN PE 55protriptyline hcl 21prochlorperazine maleate 35 QC PRENATAL 97PROVERA 107PROCORT 7 QC TRIACTING DAYTIMEPROZAC 20 CHILDRENS 55PROCTOCORT 7 pseudoephed-bromphen- QNASL 100PRODIGY MINI-MIST dm 55PORTABLE NEBULIZER 90 QNASL CHILDRENS 100PSEUDOEPHEDRINEPRODIGY MINI-MIST 101 QUALAQUINHCL 30 PORTABLE NEBULIZER pseudoephedrine hcl 101 QUESTRAN 28SPANISH 90 pseudoephedrine w/ codeine- QUESTRAN LIGHT 28progesterone micronized 107 gg 55 quetiapine fumarate 34PROGRAF 94 pseudoephedrine w/ dm-

QUILLICHEW ER 2PROLASTIN-C 109 gg 55 pseudoephedrine- QUILLIVANT XR 2PROLATE 6 acetaminophen 55 QUINACRINEPROLIA 68 pseudoephedrine-chlorphen- DIHYDROCHLORIDE 30

PROMACTA 72 dm 55 QUINACRINE HCL 30 promethazine & pseudoephedrine- quinapril hcl 28phenylephrine 54 dexchlorpheniramine-

quinapril-hydrochlorothiazidepromethazine hcl 27 chlophedianol 55 30

promethazine w/codeine 54 quinidine gluconate 12

Index 23

quinidine sulfate 12 REFENESEN CHEST RILUTEK 101 CONGESTION & PAINquinine sulfate 30 riluzole 101RELIEF 55QUININE SULFATE 30 rimantadine hydrochloride 38REFENESEN CHEST

QUININE SULFATE CONGESTION & PAIN RELIEF RISPERDAL 33,34DIHYDRATE 30 PE 55 RISPERDAL CONSTA 33QUZYTTIR 27 REFRESH LIQUIGEL 102 risperidone 34RA ACETAMINOPHEN FLU REFRESH TEARS 102 RITALIN 2SEVERE COLD 55 REGIONAL BLOCK NEEDLERA CALAMINE 66 RITALIN LA 2SAFETY BEAD BLOCK BEVELRA CALCIUM HI- 22GX1-1/2" 84 ritonavir 37 CAL/VITAMIND 92 REGLAN 70 RITUXAN 31 RA DRY MOUTH 95 RELENZA DISKHALER 38 rivastigmine 108RA FISH OIL EXTRA RELION KETONE 66 rivastigmine tartrate 108STRENGTH 102 RA LICE SOLUTION KIT 66 RELION KETONE TEST rizatriptan benzoate 91

STRIPS 66 ROBAXIN 97RA ONE DAILY 97 REMERON 19 ROBAXIN-750 97RA PRENATAL 97 REMERON SOLTAB 19RA PRENATAL ROBINUL 112RENFLEXIS 70FORMULA/FOLICACID 97 ROBINUL FORTE 112

RA SINUS RELIEF RENVELA 71 ROBITUSSIN CHILDRENSDAYTIME/NIGHTTIME 55 repaglinide 23 COUGH & COLD CF 55RA SINUS WASH NASAL REQUIP 33 ROBITUSSIN CHILDRENSRELIEF REFILL 99 COUGH LONG-ACTING 45RESCON 55RA SINUS WASH NETI POT99 ROBITUSSIN CHILDRENS RA STERILE SALINE NASAL RESCRIPTOR 36 COUGH/COLD LONG-MIST 99 RESPAIRE-30 55 ACTING 55 RA TRIPLE STRENGTH FISH ROBITUSSIN COUGH & COLDRESTASIS 104OIL 102 DAY/NIGHT PACK 55RESTORIL 73racepinephrine hcl 15 ROBITUSSIN LINGERING

RETACRIT 72 COLDLONG-ACTINGraloxifene hcl 68 RETIN-A 60 COUGHGELS 45ramipril 28 ROBITUSSIN NIGHTTIMERETIN-A MICRO 60RANEXA 11 COUGH DM 55RETIN-A MICRO PUMP 60 ROBITUSSIN NIGHTTIMEranitidine hcl 112 RETROBULBAR NEEDLE 25G COUGH LONG-ACTING DMranolazine 11 TWX 1-1/2" 84 CHILDRENS 55

RAPAFLO 71 RETROVIR 37 ROBITUSSIN PEAK COLD RAPAMUNE 94 COUGH+ CHEST CONGESTIONREVATIO 40

DM MAX STRENGTH 55RAPIVAB 38 REVLIMID 93 ROBITUSSIN PEAK COLDRAZADYNE 108 REYATAZ 37 DAY/NIGHT PACK DM 55 RAZADYNE ER 108 RHINARIS 99 ROBITUSSIN PEAK COLD REA-LO 64 DAY/NIGHT PACK MAXIMUMRHINASE 99 STRENGTH 55REBETOL 38 RIAX 60 ROBITUSSIN PEAK COLDREBIF 108 RIBASPHERE 38 DM 55 REBIF REBIDOSE 108 ROBITUSSIN PEAK COLDRIBASPHERE RIBAPAK 38 REBIF REBIDOSE MULTI-SYMPTOM COLD 56ribavirin 38TITRATIONPACK 108 ROBITUSSIN TO GO COUGH

ribavirin (hepatitis c) 38 &COLD CF 56REBIF TITRATION PACK 108 RID COMPLETE LICE ROCALTROL 68RECARBRIO 9 ELIMINATION 66 RONDEC-D 56RECOMBIVAX HB 117 RIFADIN 31 ropinirole hydrochloride 33REESES PINWORM rifampin 31MEDICINE 8 ROXICET 6RIGHT STEP PRENATAL 97 ROXICODONE 5

Index 24

ROZEREM 73 SAFETY-LOK

RU-HIST D RYCONTUSS

56 56

SYRINGE/NEEDLE3ML LUER-LOK 21GX1-1/2" 85 SAFETY-LOK

RYDEX RYDEX G RYMED RYTHMOL SR RYVENT

56 56 56 13 26

SYRINGE/NEEDLE3ML LUER-LOK 22GX1" 85 SAFETY-LOK SYRINGE/NEEDLE3ML LUER-LOK 22GX1-1/2" 85 SAFETY-LOK

SECURESAFE SAFETY HYPODERMIC NEEDLE/25G X1-1/2" 85 SECURESAFE SAFETY HYPODERMIC NEEDLE/25G X5/8" 85 SECURESAFE SAFETY HYPODERMIC NEEDLE/27G X1/2" 85 SECURESAFE

SYRINGE/NEEDLE3ML LUER- SYRINGE/NEEDLE/3ML/20G XS2 15 LOK 23GX1" 85 1" 85SAFESNAP ALLERGY SAFETY-LOK SECURESAFESYRINGE/1ML/27G X 1/2" 84 SYRINGE/NEEDLE3ML LUER- SYRINGE/NEEDLE/3ML/21G XSAFESNAP SYRINGE/3ML 84 LOK 25GX5/8" 85 1-1/2" 85SAFESNAP SAFETY-LOK TB SYRINGE SECURESAFESYRINGE/NEEDLE/3ML/20G X PERM NEEDLE 1ML SYRINGE/NEEDLE/3ML/22G X1" 84 27GX1/2" 85 1" 85SAFESNAP SALAC 65 SECURESAFESYRINGE/NEEDLE/3ML/21G X SYRINGE/NEEDLE/3ML/22G XSALEX 651-1/2" 84 1-1/2" 85SAFESNAP salicylic acid 65 SECURESAFESYRINGE/NEEDLE/3ML/22G X SALICYLIC ACID 65 SYRINGE/NEEDLE/3ML/23G X1" 84 salicylic acid 65 1" 85SAFESNAP SECURESAFESYRINGE/NEEDLE/3ML/22G X SALICYLIC ACID 65 SYRINGE/NEEDLE/3ML/25G X1-1/2" 84 saline 99 5/8" 85SAFESNAP SALMON 102 SECURESAFE TUBERCULINSYRINGE/NEEDLE/3ML/23G X INSULIN SYRINGE/1ML/25G XSALMON OIL 1021" 84 5/8" 85SAFESNAP SALMON OIL-1000 102 SECURESAFE TUBERCULINSYRINGE/NEEDLE/3ML/23G X salsalate 5 INSULIN SYRINGE/1ML/27G X1-1/2" 84 SALTAIRE 99 1/2" 85SAFESNAP SEEBRI NEOHALER 13SYRINGE/NEEDLE/3ML/25G X SALVAX 65

selenium sulfide 621" 84 SANDIMMUNE 94 SAFESNAP SB NIGHTTIME SINUS MULTI- SELSUN BLUE 62 SYRINGE/NEEDLE/3ML/25G X SYMPTOM 56 SELSUN BLUE DAILY 62 5/8" 84 SCHOOLTIME SHAMPOO66 SELSUN BLUE DEEPSAFESNAP TUBERCULIN SCOT-TUSSIN DIABETES45 CLEANSING 65SYRINGE/1ML/25G X 5/8" 84 SELSUN BLUESAFESNAP TUBERCULIN SCOT-TUSSIN DM 56 MEDICATED 62SYRINGE/1ML/27G X 1/2" 84 SCOT-TUSSIN SENIOR 56 SELSUN BLUESAFETY SYRINGES/NEEDLE SE-NATAL 19 97 MOISTURIZING 623ML/20GX1" 84 SELSUN BLUE NATURALSSAFETY SYRINGES/NEEDLE SEASONIQUE 43 DRYSCALP 653ML/21GX1-1/2" 84 SECURESAFE SAFETY SELZENTRY 37SAFETY SYRINGES/NEEDLE HYPODERMIC NEEDLE/18G X3ML/22GX1" 84 1" 85 SEMPREX-D 56 SAFETY SYRINGES/NEEDLE SECURESAFE SAFETY sennosides 74

HYPODERMIC NEEDLE/18G X3ML/22GX1-1/2" 84 sennosides-docusateSAFETY SYRINGES/NEEDLE 1-1/2" 85 sodium 743ML/23GX1" 84 SECURESAFE SAFETY SENOKOT 74SAFETY SYRINGES/NEEDLE HYPODERMIC NEEDLE/19G X

SENOKOT S 743ML/25GX5/8" 84 1" 85 SAFETY-LOK SAFETY SECURESAFE SAFETY SENSIPAR 68 SYRINGE/1ML/25G X 5/8" 85 HYPODERMIC NEEDLE/22G X SEREVENT DISKUS 15SAFETY-LOK SYRINGE 3ML 1-1/2" 85 SEROQUEL 34LUER-LOK 85

Index 25

sertraline hcl 20 SM GLUCOSE 22 STIMEX INSULATED NEEDLE TEFLON-COATED BLOCKsevelamer carbonate 71 SM ONE DAILY

PRENATAL 97 BEVEL 22GX1-1/2" 85SEYSARA 110 STIOLTO RESPIMAT 15SM PRENATAL VITAMINS97SFROWASA 70 STRATTERA 1sodium chloride 93SHINGRIX 117 STREPTOMYCIN SULFATE 2SODIUM CHLORIDE 93SIDESTREAM NEBULIZER/DISPOSABLE 90 sodium chloride (inhalant) 59 streptomycin sulfate 2 SIDESTREAM sodium chloride-sodium STRIBILD 37 NEBULIZER/REUSABLE 90 bicarbonate 99 STRIVERDI RESPIMAT 15 SIDESTREAM PLUS sodium citrate & citric acid 71 STROMECTOL 8REUSABLEHIGH EFFICIENCY sodium fluoride 92 SUBLOCADE 6NEBULIZER 90 SODIUM FLUORIDE 92sildenafil citrate (pulmonary SUBOXONE 6 hypertension) 40 sodium phosphates 74 SUCRAID 67 SILVADENE 62 sodium polystyrene sucralfate 112sulfonate 94silver sulfadiazine 62 SOFOSBUVIR/VELPATASVIR SUDAFED CHILDRENS 101 simethicone 70 38 SUDAFED CONGESTION 101 SIMPLY SALINE 99 SOLODYN 110 SUDAFED PE CHILDRENS simvastatin 28 NASAL DECONGESTANT 101SOLU-CORTEF 44 SINADRIN PE COMPLETE SUDAFED PE SINUSSOLU-MEDROL 44SINUS RELIEF 56 CONGESTION 101SOOTHE NEB MESH SUDAFED PE SINUSSINEMET 33 NEBULIZER 90 CONGESTIONSINEMET CR 33 SOOTHENEB COMPRESSOR DAYTIME/NIGHTTIME 56NEBULIZER 90SINGULAIR 13 SUDAFED SINUS

SORBUTUSS NR 56SINUCLEANSE NETI POT 99 CONGESTION 101 sotalol hcl 39 SUDAFED SINUSSINUCLEANSE REFILL 99 CONGESTION24 HOUR 101sotalol hcl (afib/afl) 39SINUCLEANSE SQUEEZE 99 sulfacetamide sod-SPARKY THE DOG 90SINUFLO READYRINSE 99 prednisolone 105 spinosad 66SINUGATOR NASAL WASH 99 sulfacetamide sodium 62 SPIRIVA HANDIHALER 13 SULFACETAMIDESINUS RINSE 99

SODIUM 104SPIRIVA RESPIMAT 13SINUS RINSE BOTTLE KIT 99 sulfacetamide sodium (acne)60spironolactone 68SINUS RINSE KIT 99 sulfacetamide sodiumspironolactone &SINUS RINSE KIT (ophth) 104hydrochlorothiazide 67PEDIATRIC 99 SULFACETAMIDESINUS RINSE PEDIATRIC SPRAVATO 56MG DOSE 19 SODIUM/PREDNISOLONESTARTER KIT 99 SPRAVATO 84MG DOSE 19 SODIUM PHOSPHATE 105 SINUS RINSE REFILL 99 SPRYCEL 32 SULFADIAZINE 109 SINUS RINSE REFILL SSKI 59 SULFADIAZINE SODIUM 109PEDIATRIC 99 STAHIST 56 SULFAMETHOXAZOLE 109SINUS WASH SALT 99

STAHIST AD 56 SULFAMETHOXAZOLESINUVA 100 MICRO 109STALEVO 100 33sirolimus 94 sulfamethoxazole-STALEVO 125 33SITAVIG 38 trimethoprim 9 STALEVO 150 33 SULFAPYRIDINE 109SIVEXTRO 10 STALEVO 200 33 sulfasalazine 70SKLICE 66 STALEVO 50 33 SULFATHIAZOLE 109SLO-NIACIN 119 STALEVO 75 33 SULFISOXIZOLE 109SM CALAMINE 66

23SM COUGH & SORE THROAT STARLIX sulindac 4 DAYTIME PAIN RELIEVER 56 stavudine 37 sumatriptan succinate 91 SM FISH OIL 102 STIMATE 69 SUPER TWIN EPA/DHA 102

Index 26

SUPRAX 41,42 SUPRESS A PEDIATRIC DROPS 56 SUPRESS DM PEDIATRIC 56 SUPRESS-PE PEDIATRIC 56 SURMONTIL 21 SUSTIVA 37 SUTENT 32 SYLATRON 32 SYMAX DUOTAB 112 SYMBICORT 15 SYMJEPI 118 SYMLINPEN 120 21 SYMLINPEN 60 21 SYNAGIS 106 SYNERCID 11 SYNTHROID 111 SYRINGE/BLUNT PLASTICCANNULA 85 SYRINGE/LUER LOCK/3ML 85 SYRINGE/LUER LOCK/3ML/20GX 1" 85 SYRINGE/LUER LOCK/3ML/21GX 1-1/2" 85 SYRINGE/LUERLOCK/3ML/21GX1-1/2" 85 SYRINGE/LUER LOCK/3ML/22GX 1" 85 SYRINGE/LUER LOCK/3ML/22GX 1-1/2" 86 SYRINGE/LUERLOCK/3ML/22GX1" 86 SYRINGE/LUERLOCK/3ML/22GX1-1/2" 86 SYRINGE/LUER LOCK/3ML/23GX 1" 86 SYRINGE/LUER LOCK/3ML/23GX 1-1/2" 86 SYRINGE/LUERLOCK/3ML/23GX1" 86 SYRINGE/LUER LOCK/3ML/25GX 1" 86 SYRINGE/LUER LOCK/3ML/25GX 1-1/2" 86 SYRINGE/LUER LOCK/3ML/25GX 5/8" 86 SYRINGE/LUERLOCK/3ML/25GX1" 86 SYRINGE/LUERLOCK/3ML/25GX5/8" 86 SYRINGE/LUER SLIP/1ML 86 SYRINGE/LUER SLIP/3ML 86 SYRINGES/LUERLOCK/1ML/20GX1" 86

SYRINGES/LUERLOCK/WITHOUTNEEDLE/3ML 86 SYRINGES/LUERSLIP/WITHOUTNEEDLE/1ML 86 SYSTANE 102 SYSTANE OVERNIGHT THERAPY LUBRICANT EYE 102 SYSTANE ULTRA 102 SYSTANE ULTRA HOME & AWAY PACK 102 TACLONEX 63 tacrolimus 94 TAMIFLU 38 tamoxifen citrate 31 tamsulosin hcl 71 TAPAZOLE 110 TARCEVA 32 TARGRETIN 32 TASIGNA 32 TAZICEF 42 TDVAX 111 TEFLARO 42 TEGRETOL 18 TEGRETOL-XR 18 TEKTURNA 30 temazepam 73 TEMOVATE 63 TENIVAC 111 tenofovir disoproxilfumarate 37 TENORETIC 100 30 TENORETIC 50 30 TENORMIN 39 terazosin hcl 29 terbinafine hcl 25 terbinafine hcl (topical) 62 TERBUTALINE SULFATE 15 terbutaline sulfate 15 terconazole vaginal 117 TERPIN HYDRATE 59 TERPIN HYDRATE MONOHYDRATE 59 TESSALON PERLES 45 testosterone 7 TESTOSTERONE 7 testosterone 7

testosterone cypionate 7 testosterone enanthate 7 tetracaine hcl (ophth) 104 tetracycline hcl 110 THALOMID 93 THEO-24 15 theophylline 15 THEOPHYLLINE ETHYLENEDIAMINE EP 15 THEOPHYLLINE/D5W 15 THERA-D 4000 118 THERACOF PLUS COUGH AND COLD RELIEVER 56 THERAFLU COLD & COUGH 56 THERAFLU FLU & SORE THROAT 56 THERAFLU POWERPODS DAYTIME SEVERE COLD 56 THERAFLU POWERPODS NIGHTTIME SEVERE COLD56 THERAFLU SEVERE COLD & COUGH DAYTIME/NIGHTTIME 56 THERAFLU SEVERE COLD & COUGH NIGHTTIME 56 THERAFLU SEVERE COLD DAYTIME 56 THERAFLU SEVERE COLD MULTI SYMPTOM 56 THERAFLU SEVERE COLD MULTI SYMPTOM NIGHTTIME 56 THERAFLU SEVERE COLD NIGHTTIME 56 THERANATAL CORE NUTRITION 97 THERAPEUTIC T+PLUS MAXIMUM STRENGTH 65 THERATEARS 102 thiamine hcl 119 thioridazine hcl 35 thiothixene 35 THRIVITE 19 95 THRIVITE RX 97 thyroid 111 tiagabine hcl 18 TIAZAC 39 TICALAST 98 TICASPRAY 99 TIGAN 25 tigecycline 109 TIGECYCLINE 109

Index 27

TIKOSYN 13 tretinoin 60 triprolidine hcl 25 timolol maleate (ophth) 103 tretinoin (chemotherapy) 32 TRISPEC DMX 57 TIMOPTIC 103 tretinoin microsphere 60 TRISPEC DMX PEDIATRIC 57 TIMOPTIC OCUDOSE 103 TRI-NORINYL 28 43 TRIUMEQ 37 TIMOPTIC-XE 103 TRIAMCINOLONE TRIZIVIR 37 TINACTIN TINACTIN DEODORANT TINACTIN JOCK ITCH

62 62 62

ACETONIDE triamcinolone acetonide (mouth)triamcinolone acetonide

44

94

tropicamide trospium chloride TRUE METRIX BLOOD

103 113

TINDAMAX tinidazole TIVICAY

9 9

37

(nasal)triamcinolone acetonide (topical)TRIAMCINOLONE

100

63

GLUCOSETEST STRIPS TRUE METRIX CONTROL SOLUTION LEVEL 1 TRUE METRIX CONTROL

67

76

tizanidine hcl TOBI TOBRADEX

97 2

105

ACETONIDE PF 44 TRIAMINIC CHEST/NASALCONGESTION 56 TRIAMINIC COLD &

SOLUTION LEVEL 2 76 TRUE METRIX CONTROL SOLUTION LEVEL 3 76 TRUECONTROL GLUCOSE

TOBRADEX ST tobramycin tobramycin (ophth)

105 2

104

ALLERGY 57 TRIAMINIC COLD & COUGH DAY TIME CHILDRENS 57 TRIAMINIC COLD & COUGH

CONTROL LEVEL 0 76 TRUECONTROL GLUCOSE CONTROL LEVEL 1 76 TRUETRACK TEST 67

TOBRAMYCIN SULFATE tobramycin sulfate TOBRAMYCIN SULFATE tobramycin sulfate tobramycin-dexamethasone TOBREX

2 2 2 2

105 104

DAY/NIGHT CHILDRENS 57 TRIAMINIC COUGH & RUNNY NOSE CHILDRENS 57 TRIAMINIC COUGH & SORE THROAT 57 TRIAMINIC FLU COUGH & FEVER 57 TRIAMINIC

TRUMENBA TRUSOPT TRUVADA TUDORZA PRESSAIR TUMS TUMS CHEWY BITES

113 105

37 13

8 8

TOFRANIL tolazamide TOLBUTAMIDE tolmetin sodium tolnaftate tolterodine tartrate TOPAMAX

21 23 23

4 62

113 18

FLU/COUGH/FEVER 57 TRIAMINIC LONG ACTING COUGH 45 TRIAMINIC NIGHT TIME COLD & COUGH 57 triamterene 68 triamterene & hydrochlorothiazide 67 TRICARE 97

TUMS CHEWY DELIGHTS TUMS E-X 750 TUMS EXTRA STRENGTH 750 TUMS KIDS TUMS LASTING EFFECTS TUMS SMOOTHIES TUMS ULTRA 1000

8 8

8 8 8 8 8

TOPAMAX SPRINKLE 18 TRICOR 28 TUSICOF 57 topiramate TOPROL XL

18 39

trifluoperazine hcl trifluridine

35 104

TUSNEL TUSNEL C

57 57

toremifene citrate 31 TRIGLIDE 28 TUSNEL DM 57 torsemide TRACLEER

67 40

trihexyphenidyl hcl TRILEPTAL

32 18

TUSNEL PEDIATRIC TUSNEL-DM PEDIATRIC

57 57

TRADJENTA 22 trimethobenzamide hcl 25 TUSSI-PRES PEDIATRIC 57 tramadol hcl 5 TRIMETHOPRIM 9 TUSSICAPS 57 tramadol-acetaminophen trandolapril TRANXENE T TRAVATAN Z travoprost trazodone hcl TRELEGY ELLIPTA

6 28 12

105 105

20 15

trimethoprim trimipramine maleate TRIMPEX TRINATAL RX 1 TRINATE TRIPELENNAMINE HCL triprolidine &pseudoephedrine

9 21

9 97 97 26

57

TUSSIONEX PENNKINETIC EXTENDED RELEASE 57 TUSSLIN 57 TUSSLIN PEDIATRIC 57 TUXARIN ER 57 TUZISTRA XR 57 TWINRIX 117 TYBOST 37

Index 28

TYGACIL 109 TYKERB 32 TYLENOL 4 TYLENOL CHILDRENS 4 TYLENOL CHILDRENS COLD/FLU 57 TYLENOL CHILDRENS PLUS MULTI-SYMPTOM COLD 57 TYLENOL COLD & FLU SEVERE 57 TYLENOL COLD & HEAD SEVERE CONGESTION 57 TYLENOL COLD + FLU + COUGH FOR ADULTS/NIGHT 57 TYLENOL COLD MAX 57 TYLENOL COLD MULTI-SYMPTOM NIGHTTIME 58 TYLENOL COLD MULTI-SYMPTOM SEVERE DAYTIME 58 TYLENOL COLD PLUS FLU SEVERE FOR ADULTS DAY/NIGHT 58 TYLENOL COLD/COUGH/RUNNYNOSECHILDRENS 58 TYLENOL COLD/COUGH/SORETHROAT CHILDRENS 58 TYLENOL EXTRA STRENGTH 4 TYLENOL INFANTS 4 TYLENOL INFANTS PAIN+FEVER 4 TYLENOL SINUS SEVERE 58 TYLENOL WARMING COUGH & SEVER CONGESTION DAYTIME 58 TYLENOL/CODEINE #3 6 TYLENOL/CODEINE #4 6 UDAMIN SP 95 UDENYCA 72 ULORIC 71 ULTICARE SYRINGE/LOWDEADSPACE/3ML/22G X1-1/2" 86 ULTICARE TUBERCULIN SAFETY SYRINGE/1ML/25G X5/8" 86 ULTRA OMEGA 3 102 ULTRA OMEGA-3 FISH OIL BURP-LESS 102 ULTRACET 6 ULTRAM 5 ULTRAVATE 63

UNASYN 107 UNASYN BULK PACK 107 UNISOM SLEEPGELS 73 UNISOM SLEEPMELTS 73 UNISOM SLEEPTABS 73 URE-K 64 urea 64 URECHOLINE 113 UROCIT-K 10 71 UROCIT-K 15 71 UROCIT-K 5 71 UROXATRAL 71 URSO 250 70 URSO FORTE 70 ursodiol 70 UTIBRON NEOHALER 15 VABOMERE 9 VAGIFEM 118 valacyclovir hcl 38 VALCYTE 37 valganciclovir hcl 37 VALIUM 12 valproate sodium 19 valproic acid 19 valsartan 29 valsartan-hydrochlorothiazide

30 VALTREX 38 VANACLEAR PD 25 VANACOF 58 VANACOF AC 58 VANACOF DM 58 VANACOF-8 58 VANAHIST PD 25 VANAMINE PD 26 VANATAB AC 58 VANATAB DM 58 VANCOCIN 9 VANCOCIN HCL 9 VANCOMYCIN 10 vancomycin hcl 9 VANCOMYCIN HCL + SYRSPENDSF PH4 9 VANCOMYCIN HYDROCHLORIDE 10 VANCOMYCIN HYDROCHLORIDE/DEXTROSE 10

VANISHPOINT SAFETY SYRINGE/3ML/20GX1" 86 VANISHPOINT SAFETY SYRINGE/3ML/21GX1-1/2" 86 VANISHPOINT SAFETY SYRINGE/3ML/22GX1" 86 VANISHPOINT SAFETY SYRINGE/3ML/22GX1-1/2" 86 VANISHPOINT SAFETY SYRINGE/3ML/23GX1" 86 VANISHPOINT SAFETY SYRINGE/3ML/23GX1-1/2" 86 VANISHPOINT SAFETY SYRINGE/3ML/25GX1" 86 VANISHPOINT SAFETY SYRINGE/3ML/25GX1-1/2" 86 VANISHPOINT SAFETY SYRINGE/3ML/25GX5/8"VANISHPOINT

86

SYRINGE/3ML/20G X 1"VANISHPOINT

86

SYRINGE/3ML/21G X 1-1/2" 86 VANISHPOINT SYRINGE/3ML/22G X 1" 86 VANISHPOINT SYRINGE/3ML/22G X 1-1/2" 86 VANISHPOINT SYRINGE/3ML/23G X 1" 86 VANISHPOINT SYRINGE/3ML/23G X 1-1/2" 86 VANISHPOINT SYRINGE/3ML/25G X 1" 86 VANISHPOINT SYRINGE/3ML/25G X 1-1/2" 87 VANISHPOINT SYRINGE/3ML/25G X 5/8" 87 VANISHPOINT TUBERCULIN SYRINGE 1ML/25G X 5/8" 87 VANISHPOINT TUBERCULIN SYRINGE 1ML/27GX1/2" 87 VAQTA 117 VARIVAX 117 VASERETIC 30 VASOTEC 28 VECTICAL 62 VEMLIDY 38 venlafaxine hcl 21 verapamil hcl 39,40 VERELAN 40 VERELAN PM 40 VERSA-NEB COMPRESSOR/NEBULIZERSYSTEM 90 VIBRAMYCIN 110 VICKS DAYQUIL COUGH 45

Index 29

VICKS DAYQUIL MUCUS CONTROL DM 58 VICKS DAYQUIL/NYQUILCOUGH 58 VICKS DAYQUIL/NYQUILSEVERE 58 VICKS NYQUIL CHILDRENS COLD/COUGH 58 VICKS NYQUIL COLD & FLU 58 VICKS NYQUIL COLD & FLU NIGHTTIME RELIEF 58 VICKS NYQUIL COUGH 58 VICKS NYQUIL HBP COLD & FLU 58 VICKS NYQUIL SEVERE COLD& FLU MAX

VIOS LC SPRINT DELUXE AEROSOL DELIVERY SYSTEM 90 VIRACEPT 37 VIRAMUNE 37 VIRAMUNE XR 37 VIRAZOLE 38 VIREAD 37 VIROPTIC 104 VISTARIL 11 VITAFOL-OB 97 VITAMIN D2 118 VITAMIN D3 118 vitamin e 118

XELJANZ XENLETA XERAVA XEROSTOMIA RELIEF SPRAY XHANCE XIFAXAN XIMINO XLEAR SINUS CARE SPRAY XLEAR SINUS CARE SPRAY/KIDS XOFLUZA XOLEGEL XOLIDO

2 11

109

95 100

9 110

99

99 38 62 65

STRENGTH 58 VICKS SINEX 12 HOUR DECONGESTANT 101 VICKS SINEX DAYQUIL/NYQUILDAYTIME/NIGHTTIME SINUSRELIEF 58 VICKS SINEX DAYTIME/NIGHTTIME/CONGESTION/PRESSURE &PAIN 59

VITAMIN E vitamin e VITATHELY/GINGER VIVELLE-DOT VIVITROL VOL-NATE VOL-PLUS VOL-TAB RX

118 118

97 69 24 97 97 97

XOPENEX HFA XTAMPZA ER XYLOCAINE XYLOCAINE-MPF XYZAL ALLERGY 24HR XYZAL ALLERGY 24HR CHILDRENS Y-TUSS

15 5

75 75 27

27 59

VICKS SINEX MOISTURIZING VICKS SINEX SEVERE VICKS SINEX SEVERE NASALDECONGESTANT

101 101

101

VOLTAREN VOTRIENT VPRIV VYVANSE

60 32 72

1

YASMIN 28 YAZ YUPELRI Z-TUSS AC

43 43 13 59

VICTOZA 22 WAL-FLU COLD & SORE ZACLIR CLEANSING 60

VIDEX EC VIDEXPEDIATRIC VIGAMOX

37 37

104

THROAT 59 WAL-FLU SEVERE COLD DAYTIME 59 WAL-FLU SEVERE COLD

ZADITOR zafirlukast ZANAFLEX

105 13 97

VIL-RX 97 VIMPAT 18 VINATE M 97 VINATE ONE 97 VIOS AEROSOL DELIVERY SYSTEM 90 VIOS LC PLUS AEROSOL DELIVERY SYSTEM 90 VIOS LC PLUS AEROSOL DELIVERY SYSTEM DELUXE 90 VIOS LC PLUS AEROSOL DELIVERY SYSTEM PEDIATRIC 90 VIOS LC SPRINT AEROSOL DELIVERY SYSTEM 90 VIOS LC SPRINT AEROSOL DELIVERY SYSTEM PEDIATRIC 90

NIGHT TIME 59 WAL-SLEEP Z LIQUID SHOTS 73 WAL-TUSSIN COUGH RELIEF CHILDRENS 45 WALGREENS GLUCOSE 22 warfarin sodium 15 WELLBUTRIN SR 19 WELLBUTRIN XL 19 WESTHROID 111 WP THYROID 111 XALATAN 105 XALKORI 32 XANAX 12 XANAX XR 12 XARELTO 15 XARELTO STARTER PACK 15

ZANTAC ZANTAC 150 MAXIMUM STRENGTH ZANTAC 75 ZARONTIN ZEMAIRA ZEMDRI ZEMPLAR ZENPEP ZERBAXA ZERIT ZESTORETIC ZESTRIL ZETIA ZETONNA ZIAC ZIAGEN

112

112 112

18 109

2 68 67 40 37 30 28 28

100 30 37

Index 30

zidovudine 37 zinc oxide (topical) 66 ZIOPTAN 105 ziprasidone hcl 33 ZITHROMAX 75 ZITHROMAX TRI-PAK 75 ZITHROMAX Z-PAK 75 ZOCOR 28 ZOFRAN 24 ZOFRAN ODT 24 ZOLINZA 32 zolmitriptan 91 ZOLOFT 20 zolpidem tartrate 73 ZOMIG 91 ZOMIG ZMT 91 ZONEGRAN 18 zonisamide 18 ZORTRESS 94 ZOSYN 107 ZOVIRAX 38,62 ZYBAN 109 ZYLOPRIM 71 ZYNCOF 59 ZYPREXA 35 ZYPREXA ZYDIS 35 ZYRTEC ALLERGY 27 ZYRTEC ALLERGY CHILDRENS 27 ZYRTEC CHILDRENS

ZYRTEC-D

ZYVOX 10,11

ALLERGY 27

ALLERGY/CONGESTION 59

ZZZQUIL 73

Index 31

arizona complete health-complete care plan comprehensive ......sp specialty product these drugs are...

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