pharmacy program preferred drug list pharmacy … drug list . the california health & wellness...

Pharmacy Program

California Health & Wellness is committed to providing appropriate, high quality, and cost effective drug therapy to all California Health & Wellness members. California Health & Wellness works with providers and pharmacists to ensure that medications used to treat a variety of conditions and diseases are covered. California Health & Wellness covers prescription medications and certain over-the-counter (OTC) medications when ordered by a licensed practitioner. The pharmacy program does not cover all medications. Some medications require prior authorization (PA) or have limitations on age, dosage, and maximum quantities.

Preferred Drug List

The California Health & Wellness Preferred Drug List (PDL) is the list of covered drugs. The PDL applies to drugs members can receive at retail pharmacies. The California Health & Wellness PDL is continually evaluated by the California Health & Wellness Pharmacy and Therapeutics (P&T) Committee to promote the appropriate and cost-effective use of medications. The Committee is composed of the California Health & Wellness Medical Director, California Health & Wellness Pharmacy Director, and several California physicians, pharmacists, and other healthcare professionals.

Pharmacy Benefit Manager

California Health & Wellness works with US Script to process pharmacy claims for prescribed drugs. Some drugs on the California Health & Wellness PDL may require PA and US Script is responsible for administering this process. US Script is our Pharmacy Benefit Manager.

Specialty Drugs

Certain medications are only covered when supplied by California Health & Wellness specialty pharmacy provider. AcariaHealth is the preferred specialty pharmacy provider of California Health & Wellness. All specialty drugs, such as biopharmaceuticals and injectables, require PA to be approved for payment by California Health & Wellness. The California Health & Wellness Medical Director and California Health & Wellness Pharmacy Director oversee the clinical review of these PA request.

AcariaHealth provides the following services:

A dedicated, multilingual team available 24 hours a day, 7 days a week to meet the unique needs of each patient

Disease-specific product education and training

Customized treatment programs and compliance monitoring

Prior authorization support

Timely delivery to your office or the patient’s home, as requested

Dispensing Limits

Drugs may be dispensed up to a maximum of thirty (30) days supply for each new prescription or refill. A total of 85% of the days supply must have elapsed before the prescription can be refilled for all drugs.

Prior Authorizations

Some medications listed on the California Health & Wellness PDL may require PA. The information should be submitted by the practitioner or pharmacist to US Script on the Medication Prior Authorization Form. This form should be faxed to US Script at 1-866-399-0929. This document can be found on the California Health & Wellness website.

California Health & Wellness will cover the medication if it is determined that:

1. There is a medical reason the member needs the specific medication.

2. Depending on the medication, other medications on the PDL have not worked.

Authorization requests are reviewed by a licensed clinical pharmacist using the criteria established by the California Health & Wellness P&T Committee. If the request is approved, US Script notifies the practitioner by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, California Health & Wellness will notify the member and their practitioner of alternatives and provide information regarding the appeal process.

Step Therapy

Some medications listed on the California Health & Wellness PDL may require specific medications to be used before the member can receive the step therapy medication. If California Health & Wellness has a record that the required medication was tried first the step therapy medications are automatically covered. If California Health & Wellness does not have a record that the required medication was tried, the member’s practitioner may be required to provide additional information. If authorization is not granted, California Health & Wellness will notify the member and their practitioner and provide information regarding the appeal process.

Quantity Limits

California Health & Wellness may limit how much of a certain medication a member can get at one time. If the practitioner feels the member has a medical reason for getting a greater amount, a PA may be requested. If California Health & Wellness does not grant PA we will notify the member and their practitioner and provide information regarding the appeal process.

Age Limits

Some medications on the California Health & Wellness PDL may have age limits. These are set for certain drugs based on FDA approved labeling and for safety concerns and quality standards of care. Age limits align with current FDA alerts for the appropriate use of pharmaceuticals.

Medical Necessity Requests

If the member requires a medication that does not appear on the PDL, the member’s practitioner can make a medical necessity (MN) request for the medication. It is anticipated that such exceptions will be rare as the PDL medications are appropriate to treat the vast majority of medical conditions.

For a MN request California Health & Wellness requires:

Documentation of failure of at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications) for the same diagnosis (e.g. migraine, neuropathic pain, etc.); or

Documented intolerance or contraindication to at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications); or

Documented clinical history or presentation where the patient is not a candidate for any of the PDL agents for the indication.

These requests are reviewed by a licensed clinical pharmacist using the criteria established by the California Health & Wellness P&T Committee. If the request is approved, US Script notifies the practitioner by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, California Health & Wellness will notify the member and their practitioner of alternatives and provide information regarding the appeal process.

72 Hour Emergency Supply Policy

State and Federal law require that a pharmacy dispense a 72 hour (3 day) supply of medication to any member awaiting PA determination. The purpose is to avoid interruption of current therapy or delay in the initiation of therapy. All participating pharmacies are authorized to provide a 72 hour supply of medication and will be reimbursed for the ingredient cost and dispensing fee of the 72 hour supply of medication, whether or not the PA request is ultimately approved or denied. The pharmacy must call US Script at 877-277-0413 for a prescription override to submit the 72 hour medication supply for payment.

Exclusions

The following drug categories are not part of the California Health & Wellness PDL and are not covered by the 72 hour emergency supply policy:

Drugs that are considered experimental

Drug Efficacy Study and Implementation (DESI) drugs

- Drugs prescribed for infertility

- Drugs prescribed for erectile dysfunction - Drugs prescribed for cosmetic purposes or hair growth -Over-the-counter (OTC) cough and cold preparations -Over-the-counter adult acetaminophen products

- Drugs carved-out of the California Health & Wellness contract with the DHCS (TARs/claims submitted to Medi-Cal Fee-For-Service directly)

o Select HIV AIDS treatment drugs

o Select alcohol and heroin detoxification and dependency treatment

o Select psychiatric drugs

Newly Approved Products

California Health & Wellness reviews new drugs for safety and effectiveness before adding them to the PDL. During this period, access to these medications will be considered through the PA review process. If California Health & Wellness does not grant PA we will notify the member and their practitioner and provide information regarding the appeal process.

Over-the-Counter Medications

California Health & Wellness covers a variety of OTC medications. These medications can be found throughout the California Health & Wellness PDL. California Health & Wellness covers OTC products listed in the PDL if the member has a prescription from a licensed practitioner that meets all the legal requirements for a prescription.

Generic Drugs

When generic drugs are available, the brand name drug will not be covered without California Health & Wellness authorization. Generic drugs have the same active ingredient and work the same as brand name drugs. If the member or their practitioner feels a brand name drug is medically necessary, the practitioner requests the drug using the PA process. We will cover the brand-name drug according to our clinical guidelines if there is a medical reason the member needs the particular brand-name drug. If California Health & Wellness does not grant authorization, we will notify the member and their practitioner and provide information regarding the appeal process.

The provision is waived for the following products due to their narrow therapeutic index (NTI) as recognized by current medical and pharmaceutical literature: Aminophylline, Carbamazepine, Cyclosporine, Digoxin, Disopyramide, Ethosuximide, Flecainide, L-Thyroxine, Lithium, Phenytoin, Procainamide, Theophylline, Thyroid, Valproic Acid, and Warfarin.

Drug Efficacy Study and Implementation Drugs

DESI products and known related drug products are defined as less than effective by the Food and Drug Administration because there is a lack of substantial evidence of effectiveness for all labeling indications and because a compelling justification for their medical need has not been established. DESI products are not covered by California Health & Wellness.

Filling a Prescription

A member can have prescriptions filled at a California Health & Wellness network pharmacy. If the member decides to have a prescription filled at a network pharmacy they can locate a pharmacy near them by contacting California Health & Wellness Member Services. At the pharmacy the member will need to provide the pharmacist with the prescription and their California Health & Wellness ID card.

Copayments

Copayments are not required for California Health & Wellness Medi-Cal members.

Abbreviations

The following notations and abbreviations may be found throughout the drug listing in the limitations and restrictions column.

DS/DU: Days Supply per Dosage Unit

Max Days Sply: Maximum Days Supply

Max Fills: Maximum Fills (per a designated time period)

Max Qty: Maximum Quantity (per claim or designated time period)

Min DS: Minimum Days Supply

PA: Prior Authorization

Pkg Size: Package Size

Contact Information

California Health & Wellness Provider Services: 1-877-658-0305

US Script Prior Authorizations: 1-877-277-0413 Fax: 1-866-399-0929

US Script Help Desk: 1-855-330-2338

AcariaHealth Prior Authorizations: 1-855-535-1815 Fax: 1-855-815-9894

Provider Administered Drug Prior Authorizations 1-877-658-0305 Fax: 1-877-259-6961

Tier Description

F Preferred Drugs

NF Non-formulary

CO Carve Out Drugs

Legend Description AL Age Limit Drug is limited to specific age.

PA Prior Authorization Prior Authorization required before prescription can be filled.

QL Quantity Limit There is a limit on the amount of drug covered per prescription, or within a specific time frame.

Rx/OTC Rx/OTC Product has both Rx and OTC National Drug Codes.

SP Specialty Drug

Specialty drugs are high-cost drugs used to treat complex or rare conditions, such as multiple sclerosis, rheumatoid arthritis, hepatitis C, and hemophilia and may be limited to a specific

pharmacy.

ST Step Therapy Requires trial and failure of one or more preferred products prior to coverage.

Drug Name DrugTier

Requirements/Limits

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

Amphetamines ADDERALL TABS (Use Amphetamine-Dextroamphetamine)

NF QL(2 ea daily);AL; At least 3 yrs old

ADDERALL XR CP24 (Use Amphetamine-Dextroamphetamine)


amphetamine-dextroamphetamine cp245mg-5mg-5mg-5mg,2.5mg-2.5mg-2.5mg-2.5mg, 7.5mg-7.5mg-7.5mg-7.5mg, 1.25mg-1.25mg-1.25mg-1.25mg,3.75mg-3.75mg-3.75mg-3.75mg, 6.25mg-6.25mg-6.25mg-6.25mg

F

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

amphetamine-dextroamphetamine tabs5mg-5mg-5mg-5mg,2.5mg-2.5mg-2.5mg-2.5mg, 7.5mg-7.5mg-7.5mg-7.5mg, 1.25mg-1.25mg-1.25mg-1.25mg,3.75mg-3.75mg-3.75mg-3.75mg, 1.875mg-1.875mg-1.875mg-1.875mg, 3.125mg-3.125mg-3.125mg-3.125mg

F


DEXEDRINE CP24 10 MG, 15 MG (Use DextroamphetamineSulfate)

NF


DEXEDRINE CP24 5 MG (Use DextroamphetamineSulfate)


dextroamphetamine sulfatecp24 10 mg, 15 mg F


dextroamphetamine sulfatecp24 5 mg F


dextroamphetamine sulfatetabs 5 mg, 10 mg F


Drug Name DrugTier

Requirements/Limits

VYVANSE CAPS 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG

F PA; QL(1 eadaily)

Analeptics

caffeine citrate soln F QL(45 ml perfill retail)

Attention-Deficit/Hyperactivity Disorder (ADHD)

atomoxetine hcl caps F ST; AL; At least 6 yrs old

clonidine hcl (adhd) tb12 F

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

INTUNIV TB24 (Use Guanfacine HCl (ADHD)) NF


KAPVAY TB12 (Use Clonidine HCl (ADHD)) NF

STRATTERA CAPS (Use Atomoxetine HCl) NF ST; AL; At least

6 yrs old

Stimulants - Misc. CONCERTA TBCR 18 MG, 27 MG, 54 MG (Use Methylphenidate HCl)


CONCERTA TBCR 36 MG (Use Methylphenidate HCl) NF


dexmethylphenidate hcltabs 5 mg, 10 mg, 2.5 mg F


FOCALIN TABS (Use Dexmethylphenidate HCl) NF


METADATE CD CPCR (Use Methylphenidate HCl) NF


methylphenidate hcl cpcr10 mg, 20 mg, 30 mg, 40mg, 50 mg, 60 mg

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

METHYLPHENIDATE HCL ER TB24 18 MG, 27 MG F


METHYLPHENIDATE HCL ER TB24 36 MG, 54 MG F AL; At least 6

yrs old

CA Health & Wellness Preferred Drug List Update July 1, 2018

1

Drug Name DrugTier

Requirements/Limits

METHYLPHENIDATE HCL ER TBCR 18 MG F


methylphenidate hcl tabs10 mg, 20 mg F


methylphenidate hcl tabs 5 mg F


methylphenidate hcl tbcr 10mg, 36 mg F


methylphenidate hcl tbcr 18mg, 27 mg, 54 mg F


methylphenidate hcl tbcr 20 mg F AL; At least 6

yrs old RITALIN TABS 10 MG, 20 MG (Use MethylphenidateHCl)


RITALIN TABS 5 MG (Use Methylphenidate HCl) NF


AMINOGLYCOSIDES - Drugs to Treat BacterialInfections

Aminoglycosides

KITABIS PAK NEBU F PA; SP

neomycin sulfate tabs F

paromomycin sulfate caps F PA

TOBI NEBU (Use Tobramycin) NF PA; SP

tobramycin nebu F PA; SP

TOBRAMYCIN NEBU F PA; SP

TOBRAMYCIN SULFATE SOLN 10 MG/ML, 40MG/ML

F PA

tobramycin sulfate soln 40mg/ml, 80 mg/2ml, 1.2gm/30ml

F PA

tobramycin sulfate solr 1.2 gm F PA

Drug Name DrugTier

Requirements/Limits

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-CROHNS DISEASESTARTER PNKT F PA; SP

HUMIRA PEN-PSORIASIS STARTER PNKT F PA; SP

HUMIRA PSKT 20 MG/0.4ML, 40 MG/0.8ML F PA; SP

Antirheumatic Antimetabolites

RHEUMATREX TABS F

Gold Compounds

RIDAURA CAPS F

Nonsteroidal Anti-inflammatory Agents (NSAIDs) ADVIL TABS (Use Ibuprofen) NF

ALEVE ARTHRITIS TABS (Use Naproxen Sodium) NF

ALEVE TABS (Use Naproxen Sodium) NF

ANAPROX DS TABS (Use Naproxen Sodium) NF

CELEBREX CAPS (Use Celecoxib) NF PA; QL(2 ea

daily)

celecoxib caps F PA; QL(2 eadaily)

CHILDRENS ADVIL SUSP (Use Ibuprofen) NF RX/OTC

CHILDRENS MOTRIN SUSP (Use Ibuprofen) NF RX/OTC

DAYPRO TABS (Use Oxaprozin) NF

diclofenac potassium tabs F

diclofenac sodium tb24 or 100 mg F


2

Drug Name DrugTier

Requirements/Limits

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

EC-NAPROSYN TBEC (Use Naproxen) NF QL(2 ea daily)

etodolac caps F

etodolac tabs F

etodolac tb24 F

FELDENE CAPS (Use Piroxicam) NF

flurbiprofen tabs F

ibuprofen chew 100 mg F

ibuprofen susp 100 mg/5ml F RX/OTC

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

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

indomethacin caps F

indomethacin cpcr F

INFANTS ADVIL SUSP (Use Ibuprofen) NF

KETOPROFEN CAPS 50 MG, 75 MG F

ketoprofen caps 50 mg, 75 mg F

KETOPROFEN ER CP24 F

ketorolac tromethamine tabs or 10 mg F AL; At least 17

yrs old LODINE TABS (Use Etodolac) NF

meloxicam tabs F

MOBIC TABS 15 MG, 7.5 MG (Use Meloxicam) NF

MOTRIN INFANTS DROPS SUSP (Use Ibuprofen)

NF

nabumetone tabs F

Drug Name DrugTier

Requirements/Limits

NAPROSYN SUSP (Use Naproxen) NF

NAPROSYN TABS (Use Naproxen) NF

naproxen sodium tabs 220mg, 275 mg, 550 mg F

naproxen susp 125 mg/5ml F

naproxen tabs 250 mg, 375mg, 500 mg F

naproxen tbec 375 mg, 500 mg F QL(2 ea daily)

oxaprozin tabs F

piroxicam caps F

sulindac tabs F

TOLMETIN SODIUM CAPS F

TOLMETIN SODIUM TABS F

Pyrimidine Synthesis Inhibitors ARAVA TABS (Use Leflunomide) NF QL(1 ea daily)

leflunomide tabs F QL(1 ea daily)

Soluble Tumor Necrosis Factor Receptor Agents

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-acetaminophentabs 325mg-50mg F

butalbital-acetaminophen-caffeine caps 325mg-50mg-40mg

F QL(4 ea daily)

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

F QL(4 ea daily)


3

Drug Name DrugTier

Requirements/Limits

butalbital-aspirin-caffeine caps F QL(4 ea daily)

ESGIC TABS (Use Butalbital-Acetaminophen-Caffeine)

NF QL(4 ea daily)

FIORINAL CAPS (Use Butalbital-Aspirin-Caffeine) NF QL(4 ea daily)

TENCON TABS F

Analgesics Other 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 F

acetaminophen susp or160 mg/5ml, 80 mg/0.8ml,80 mg/2.5ml

F

NORTEMP INFANTS SUSP F

TYLENOL CHILDRENS SUSP (Use Acetaminophen)

NF

TYLENOL INFANTS PAIN+FEVER SUSP (Use Acetaminophen)

NF

TYLENOL INFANTS SUSP (Use 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 supp re 300 mg,600 mg F

aspirin tabs or 325 mg F

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

Drug Name DrugTier

Requirements/Limits

BUFFERIN TABS (Use Aspirin Buffered (Cal Carb-Mag Carb-Mag Oxide))

NF

choline & mag salicylateliqd F

diflunisal tabs F

DISALCID TABS (Use Salsalate) NF

ECOTRIN MAXIMUM STRENGTH TBEC (Use Aspirin)

NF

ECOTRIN REGULAR STRENGTH TBEC (Use Aspirin)

NF

salsalate tabs F

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

Opioid Agonists codeine sulfate tabs 15 mg,30mg, 60mg F QL (2 ea daily)

DEMEROL TABS OR 100 MG (Use Meperidine HCl) NF QL(6 ea daily)

DILAUDID TABS 2 MG, 4 MG, 8 MG (Use Hydromorphone HCl)

NF QL(8 ea daily)

DOLOPHINE TABS 10 MG (Use Methadone HCl) NF PA; QL(10 ea

daily) DOLOPHINE TABS 5 MG (Use Methadone HCl) NF PA; QL(4 ea

daily) DURAGESIC PT72 (Use Fentanyl) NF QL(0.34 ea

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

F QL(0.34 eadaily)

HYDROMORPHONE HCL SUPP RE 3 MG F QL(12 ea per

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

MEPERIDINE HCL SOLN OR 50 MG/5ML F QL(500 ml per

fill retail) meperidine hcl tabs or 50mg, 100 mg F QL(6 ea daily)

methadone hcl tabs or 10 mg F PA; QL(10 ea

daily)


4

Drug Name DrugTier

Requirements/Limits

methadone hcl tabs or 5 mg F PA; QL(4 ea

daily) morphine sulfate soln or 10mg/5ml, 20 mg/5ml F QL(500 ml per

fill retail) morphine sulfate soln or 20mg/ml, 100 mg/5ml F QL(240 ml per

fill retail) MORPHINE SULFATE SUPP RE 5 MG, 10 MG, 20 MG, 30 MG

F QL(24 ea perfill retail)

MORPHINE SULFATE TABS OR 15 MG, 30 MG F QL(6 ea daily)

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

F QL(3 ea daily)

MS CONTIN TBCR (Use Morphine Sulfate) NF QL(3 ea daily)

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

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

OXYCODONE HCL ER T12A F PA; QL(2 ea

daily) oxycodone hcl soln 5mg/5ml F

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

F QL(6 ea daily)

ROXICODONE TABS (Use Oxycodone HCl) NF QL(6 ea daily)

tramadol hcl tabs 50 mg F QL(8 ea daily)

ULTRAM TABS (Use Tramadol HCl) NF QL(8 ea daily)

Opioid Combinations acetaminophen w/ codeinesoln 120mg/5ml-12mg/5ml F QL(30 ml daily)

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

F QL(6 ea daily)

butalbital-acetaminophen-caffeine w/ codeine caps325mg-50mg-40mg-30mg

F QL(4 ea daily)

butalbital-aspirin-caffeinew/cod caps F QL(4 ea daily)

Drug Name DrugTier

Requirements/Limits

FIORINAL/CODEINE #3CAPS (Use Butalbital-Aspirin-Caffeine w/Cod)

NF QL(4 ea daily)

hydrocodone-acetaminophen soln2.5mg/5ml-108mg/5ml,5mg/10ml-217mg/10ml,7.5mg/15ml-325mg/15ml

F

QL(180 mldaily)

hydrocodone-acetaminophen tabs 10mg-325mg

F QL(6 ea daily)

hydrocodone-acetaminophen tabs 5mg-325mg

F QL(12 ea daily)

hydrocodone-acetaminophen tabs7.5mg-325mg

F QL(8 ea daily)

NORCO TABS 10MG-325MG (Use Hydrocodone-Acetaminophen)

NF QL(6 ea daily)

NORCO TABS 5MG-325MG (Use Hydrocodone-Acetaminophen)

NF QL(12 ea daily)

NORCO TABS 7.5MG-325MG (Use Hydrocodone-Acetaminophen)

NF QL(8 ea daily)

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

F

QL(6 ea daily)

oxycodone-aspirin tabs F QL(6 ea daily)

OXYCODONE/ACETAMINOPHEN SOLN F QL(30 ml daily)

PERCOCET TABS 5MG-325MG, 10MG-325MG, 7.5MG-325MG (Use Oxycodone w/Acetaminophen)

NF

QL(6 ea daily)

tramadol-acetaminophentabs F QL(4 ea daily)

TYLENOL/CODEINE #3TABS (Use Acetaminophenw/ Codeine)

NF QL(6 ea daily)

TYLENOL/CODEINE #4TABS (Use Acetaminophenw/ Codeine)

NF QL(6 ea daily)


5

Drug Name DrugTier

Requirements/Limits

ULTRACET TABS (Use Tramadol-Acetaminophen) NF QL(4 ea daily)

Opioid Partial Agonists

BELBUCA FILM CO

BUNAVAIL FILM CO

BUPRENEX SOLN (Use Buprenorphine HCl) CO

buprenorphine hcl soln CO

buprenorphine hcl subl CO

buprenorphine hcl-naloxone hcl dihydrate film CO

buprenorphine hcl-naloxone hcl dihydrate subl CO

BUPRENORPHINE PTWK CO

BUTRANS PTWK CO

PROBUPHINE IMPLANT KIT IMPL CO

SUBLOCADE SOSY CO

SUBOXONE FILM 4MG-1MG, 12MG-3MG, 2MG-0.5MG

CO

SUBOXONE FILM 8MG-2MG (Use BuprenorphineHCl-Naloxone HCl Dihydrate)

CO

ZUBSOLV SUBL CO

ANDROGENS-ANABOLIC - Drugs to RegulateHormones

Androgens

ANDRODERM PT24 F QL(1 ea daily)

ANDROXY TABS F

DEPO-TESTOSTERONE SOLN (Use Testosterone Cypionate)

NF QL(0.134 mldaily)

METHITEST TABS F

Drug Name DrugTier

Requirements/Limits

testosterone cypionate soln F QL(0.134 mldaily)

ANORECTAL AGENTS - Rectal Drugs to TreatPain, Swelling and Itching

Intrarectal Steroids CORTENEMA ENEM (Use Hydrocortisone(Intrarectal))

NF QL(420 ml perfill retail)

hydrocortisone (intrarectal) enem F QL(420 ml per

fill retail) Rectal Combinations phenylephrine-shark liveroil-cocoa butter supp F

phenylephrine-shark liveroil-mineral oil-petrolatumoint

F QL(60 gm perfill retail)

Rectal Local Anesthetics

pramoxine hcl (rectal) foam F

PROCTOFOAM FOAM (Use Pramoxine HCl (Rectal))

NF

Rectal Steroids ANUSOL-HC CREA (Use Hydrocortisone (Rectal)) NF QL(30 gm per

fill retail) hydrocortisone (rectal) crea2.5 % F QL(30 gm per

fill retail)

ANTACIDS

Antacid Combinations alum & mag hydrox-simethicone liqd200mg/5ml-20mg/5ml-200mg/5ml

F

alum & mag hydrox-simethicone susp200mg/5ml-20mg/5ml-200mg/5ml, 200mg/5ml-200mg/5ml-20mg/5ml-20mg/5ml-200mg/5ml-200mg/5ml

F

Antacids - Aluminum Salts ALUMINUM HYDROXIDE SUSP OR F

Antacids - Bicarbonate


6

Drug Name DrugTier

Requirements/Limits

sodium bicarbonate (antacid) tabs F

Antacids - Calcium Salts calcium carbonate (antacid) chew 500 mg F

calcium carbonate (antacid) susp 1250mg/5ml

F

TUMS CHEW (Use Calcium Carbonate (Antacid))

NF

TUMS LASTING EFFECTS CHEW (Use Calcium Carbonate (Antacid))

NF

Antacids - Magnesium Salts

magnesium oxide tabs F

ANTHELMINTICS - Drugs to Treat WormInfections

Anthelmintics

EMVERM CHEW F

pyrantel pamoate susp F

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

Anti-infective Agents - Misc. FLAGYL TABS 250 MG, 500 MG (Use Metronidazole)

NF

metronidazole tabs or 250 mg, 500 mg F

trimethoprim tabs F

VANCOCIN HCL CAPS 125 MG (Use VancomycinHCl)

NF QL(4 ea daily)

VANCOCIN HCL CAPS 250 MG (Use VancomycinHCl)

NF QL(8 ea daily)

vancomycin hcl caps or125 mg F QL(4 ea daily)

vancomycin hcl caps or250 mg F QL(8 ea daily)

Drug Name DrugTier

Requirements/Limits

vancomycin hcl solr iv 500mg, 1000 mg F QL(14 ea per

fill retail) Anti-infective Misc. - Combinations BACTRIM DS TABS (Use Sulfamethoxazole-Trimethoprim)

NF

BACTRIM TABS (Use Sulfamethoxazole-Trimethoprim)

NF

sulfamethoxazole-trimethoprim susp or40mg/5ml-200mg/5ml

F

sulfamethoxazole-trimethoprim tabs or 80mg-400mg, 160mg-800mg

F

Antiprotozoal Agents

atovaquone susp F PA; QL(10 mldaily)

MEPRON SUSP (Use Atovaquone) NF PA; QL(10 ml

daily) Leprostatics

dapsone tabs F

Lincosamides CLEOCIN CAPS OR 150 MG, 300 MG (Use Clindamycin HCl)

NF

CLEOCIN PEDIATRIC GRANULES SOLR (Use Clindamycin PalmitateHydrochloride)

NF

QL(100 ml perfill retail)

clindamycin hcl caps 150mg, 300 mg F

clindamycin palmitatehydrochloride solr F QL(100 ml per

fill retail) Oxazolidinones

SIVEXTRO TABS F PA; QL(6 eaper fill retail)

ANTIANGINAL AGENTS - Drugs to Treat ChestPain

Nitrates ISORDIL TITRADOSE TABS 5 MG (Use Isosorbide Dinitrate)

NF


7

Drug Name DrugTier

Requirements/Limits

ISOSORBIDE DINITRATE ER TBCR F

isosorbide dinitrate tabs F

isosorbide mononitrate tabs 10 mg, 20 mg F QL(2 ea daily)

isosorbide mononitrate tb24 30 mg, 60 mg, 120 mg F QL(1 ea daily)

NITRO-BID OINT F

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

NF

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

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

F

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

NITROSTAT SUBL (Use Nitroglycerin) NF

ANTIANXIETY AGENTS - Drugs to Treat Anxiety

Antianxiety Agents - Misc. buspirone hcl tabs 15 mg F QL(4 ea daily)

buspirone hcl tabs 30 mg,7.5 mg F QL(3 ea daily)

buspirone hcl tabs 5 mg,10 mg F QL(6 ea daily)

hydroxyzine hcl syrp F

hydroxyzine hcl tabs F

HYDROXYZINE PAMOATE CAPS 100 MG F

hydroxyzine pamoate caps25 mg, 50 mg F

meprobamate tabs F

VISTARIL CAPS (Use Hydroxyzine Pamoate) NF

Benzodiazepines alprazolam tabs 0.25 mg,0.5 mg, 1 mg, 2 mg F QL(4 ea daily)

Drug Name DrugTier

Requirements/Limits

ATIVAN TABS 0.5 MG, 2 MG (Use Lorazepam) NF QL(3 ea daily)

ATIVAN TABS 1 MG (Use Lorazepam) NF QL(4 ea daily)

chlordiazepoxide hcl caps F QL(4 ea daily)

clorazepate dipotassiumtabs F QL(3 ea daily)

DIAZEPAM SOLN OR 1 MG/ML F QL(500 ml per

fill retail) diazepam tabs or 2 mg, 5mg, 10 mg F QL(4 ea daily)

lorazepam tabs 0.5 mg, 2 mg F QL(3 ea daily)

lorazepam tabs 1 mg F QL(4 ea daily)

oxazepam caps 10 mg, 15mg, 30 mg F QL(4 ea daily)

OXAZEPAM CAPS 30 MG F QL(4 ea daily)

TRANXENE T TABS (Use Clorazepate Dipotassium) NF QL(3 ea daily)

VALIUM TABS (Use Diazepam) NF QL(4 ea daily)

XANAX TABS (Use Alprazolam) NF QL(4 ea daily)

ANTIARRHYTHMICS - Drugs to treat abnormalheart rhythms

Antiarrhythmics Type I-A disopyramide phosphate caps F

NORPACE CAPS (Use Disopyramide Phosphate) F

NORPACE CR CP12 150 MG F

quinidine gluconate tbcr or324 mg F

QUINIDINE SULFATE TABS F

Antiarrhythmics Type I-B

mexiletine hcl caps F

Antiarrhythmics Type I-C

flecainide acetate tabs F


8

Drug Name DrugTier

Requirements/Limits

propafenone hcl tabs 150mg, 225 mg, 300 mg F

RYTHMOL TABS (Use Propafenone HCl) NF

Antiarrhythmics Type III amiodarone hcl tabs 200 mg F

dofetilide caps F

MULTAQ TABS F

TIKOSYN CAPS (Use Dofetilide) NF

ANTIASTHMATIC AND BRONCHODILATOR AGENTS - Drugs to Treat Lung Conditions

Anti-Inflammatory Agents

cromolyn sodium nebu F QL(240 ml perfill retail)

Bronchodilators - Anticholinergics

ATROVENT HFA AERS F QL(26 gm perfill retail)

INCRUSE ELLIPTA AEPB F QL(30 ea perfill retail)

ipratropium bromide soln F

TUDORZA PRESSAIR AEPB F QL(1 ea per fill

retail) Leukotriene Modulators

montelukast sodium chew F QL(1 ea daily)

montelukast sodium pack F QL(1 ea daily)

montelukast sodium tabs F QL(1 ea daily)

SINGULAIR CHEW (Use Montelukast Sodium) NF QL(1 ea daily)

SINGULAIR PACK (Use Montelukast Sodium) NF QL(1 ea daily)

SINGULAIR TABS (Use Montelukast Sodium) NF QL(1 ea daily)

Steroid Inhalants

AEROSPAN AERS F QL(8.9 gm perfill retail)

Drug Name DrugTier

Requirements/Limits

budesonide (inhalation) susp F

QL(4 ml daily);AL; At least 1 yrs old - Up to8 yrs old

FLOVENT DISKUS AEPB 100 MCG/BLIST, 250MCG/BLIST

F QL(2 ea daily)

FLOVENT DISKUS AEPB 50 MCG/BLIST F QL(60 ea per

25 days retail)

FLOVENT HFA AERO F

PULMICORT FLEXHALER AEPB F QL(1 ea per fill

retail)

PULMICORT SUSP (Use Budesonide (Inhalation)) NF

QL(4 ml daily);AL; At least 1 yrs old - Up to8 yrs old

Sympathomimetics ALBUTEROL SULFATE ER TB12 F

albuterol sulfate nebu in 0.5 % F QL(2 ml daily)

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

F

albuterol sulfate syrp or 2mg/5ml F QL(100 ml per

fill retail) albuterol sulfate tabs or 2 mg F QL(150 ea per

fill retail) albuterol sulfate tabs or 4 mg F QL(200 ea per

fill retail) albuterol sulfate tb12 or 4 mg, 8 mg F

BREO ELLIPTA AEPB 25MCG/INH-200MCG/INH F QL(60 ea per

fill retail) COMBIVENT RESPIMAT AERS F QL(4 gm per fill

retail)

DULERA AERO F QL(13 gm perfill retail)

ipratropium-albuterol soln F QL(12 ml daily)

METAPROTERENOL SULFATE SYRP 10 MG/5ML

F QL(30 ml daily)

METAPROTERENOL SULFATE TABS 10 MG, 20 MG

F


9

Drug Name DrugTier

Requirements/Limits

PROAIR HFA AERS F QL(17 gm per30 days retail)

SEREVENT DISKUS AEPB F QL(2 ea daily)

SYMBICORT AERO F QL(11 gm perfill retail)

terbutaline sulfate tabs F

VENTOLIN HFA AERS F QL(36 gm per30 days retail)

VENTOLIN HFA AERS F QL(16 gm per30 days retail)

VOSPIRE ER TB12 (Use Albuterol Sulfate) NF

Xanthines

ELIXOPHYLLIN ELIX F

THEO-24 CP24 F

theophylline soln 80mg/15ml F QL(475 ml per

fill retail) theophylline tb12 100 mg,200 mg, 300 mg, 450 mg F

theophylline tb24 400 mg,600 mg F

ANTICOAGULANTS - Blood Thinners

Coumarin Anticoagulants COUMADIN TABS (Use Warfarin Sodium) F

warfarin sodium tabs F

Direct Factor Xa Inhibitors ELIQUIS STARTER PACK TABS F QL(4 ea daily)

ELIQUIS TABS F QL(4 ea daily)

XARELTO STARTER PACK TBPK F

XARELTO TABS 10 MG F QL(1 eadaily,35 ea per180 days retail)

XARELTO TABS 15 MG F QL(2 ea daily)

XARELTO TABS 20 MG F QL(1 ea daily)

Drug Name DrugTier

Requirements/Limits

Heparins And Heparinoid-Like Agents

enoxaparin sodium soln F SP

heparin sodium (porcine)soln F

LOVENOX SOLN (Use Enoxaparin Sodium) NF SP

ANTICONVULSANTS - Drugs to Treat Seizures

Anticonvulsants - Benzodiazepines clonazepam tabs 0.5 mg, 1mg, 2 mg F QL(4 ea daily)

DIAZEPAM GEL RE 10 MG, 20 MG, 2.5 MG F

QL(1 ea per fillretail); AL; Atleast 2 yrs old

DIAZEPAM RECTAL GEL GEL F

QL(1 ea per fillretail); AL; Atleast 2 yrs old

KLONOPIN TABS (Use Clonazepam) NF QL(4 ea daily)

Anticonvulsants - Misc. carbamazepine chew 100 mg F

carbamazepine susp 100mg/5ml F

carbamazepine tabs 200 mg F

carbamazepine tb12 100mg, 200 mg, 400 mg F

gabapentin caps 100 mg,300 mg, 400 mg F QL(9 ea daily)

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

gabapentin tabs 600 mg F QL(6 ea daily)

gabapentin tabs 800 mg F QL(4 ea daily)

KEPPRA SOLN 100 MG/ML (Use Levetiracetam)

NF QL(30 ml daily)

KEPPRA TABS 1000 MG (Use Levetiracetam) NF

KEPPRA TABS 250 MG, 750 MG (Use Levetiracetam)

NF QL(4 ea daily)


10

Drug Name DrugTier

Requirements/Limits

KEPPRA TABS 500 MG (Use Levetiracetam) NF QL(6 ea daily)

KEPPRA XR TB24 (Use Levetiracetam) NF ST

LAMICTAL CHEWABLE DISPERSIBLE CHEW (Use Lamotrigine)

NF

LAMICTAL TABS (Use Lamotrigine) NF

LAMICTAL XR TB24 25 MG, 50 MG, 100 MG, 200 MG, 250 MG, 300 MG (Use Lamotrigine)

NF

ST

lamotrigine chew 5 mg, 25 mg F

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

lamotrigine tb24 25 mg, 50mg, 100 mg, 200 mg, 250mg, 300 mg

F ST

levetiracetam soln 100 mg/ml, 500 mg/5ml F QL(30 ml daily)

levetiracetam tabs 1000 mg F

levetiracetam tabs 250 mg,750 mg F QL(4 ea daily)

levetiracetam tabs 500 mg F QL(6 ea daily)

levetiracetam tb24 500 mg,750 mg F ST

MYSOLINE TABS (Use Primidone) NF

NEURONTIN CAPS 100 MG, 300 MG, 400 MG (Use Gabapentin)

NF QL(9 ea daily)

NEURONTIN SOLN 250 MG/5ML (Use Gabapentin) NF

NEURONTIN TABS 600 MG (Use Gabapentin) NF QL(6 ea daily)

NEURONTIN TABS 800 MG (Use Gabapentin) NF QL(4 ea daily)

oxcarbazepine susp F

oxcarbazepine tabs F

primidone tabs F

Drug Name DrugTier

Requirements/Limits

TEGRETOL SUSP (Use Carbamazepine) F

TEGRETOL TABS (Use Carbamazepine) F

TEGRETOL-XR TB12 (Use Carbamazepine) F

TOPAMAX SPRINKLE CPSP 15 MG (Use Topiramate)

NF QL(6 ea daily)

TOPAMAX SPRINKLE CPSP 25 MG (Use Topiramate)

NF QL(8 ea daily)

TOPAMAX TABS 100 MG (Use Topiramate) NF QL(4 ea daily)

TOPAMAX TABS 200 MG (Use Topiramate) NF QL(2 ea daily)

TOPAMAX TABS 25 MG, 50 MG (Use Topiramate) NF QL(6 ea daily)

topiramate cpsp 15 mg F QL(6 ea daily)

topiramate cpsp 25 mg F QL(8 ea daily)

topiramate tabs 100 mg F QL(4 ea daily)

topiramate tabs 200 mg F QL(2 ea daily)

topiramate tabs 25 mg, 50 mg F QL(6 ea daily)

TRILEPTAL SUSP (Use Oxcarbazepine) NF

TRILEPTAL TABS (Use Oxcarbazepine) NF

ZONEGRAN CAPS (Use Zonisamide) NF

zonisamide caps F

Carbamates

felbamate susp F

felbamate tabs F

FELBATOL SUSP (Use Felbamate) NF

FELBATOL TABS (Use Felbamate) NF

GABA Modulators


11

Drug Name DrugTier

Requirements/Limits

GABITRIL TABS (Use Tiagabine HCl) NF

tiagabine hcl tabs F

Hydantoins DILANTIN CAPS 100 MG (Use Phenytoin SodiumExtended)

F

DILANTIN CAPS 30 MG F

DILANTIN INFATABS CHEW (Use Phenytoin) F

DILANTIN-125 SUSP (Use Phenytoin) F

phenytoin chew F

phenytoin sodium extendedcaps 100 mg F

phenytoin susp F

Succinimides

ethosuximide caps F

ethosuximide soln F

ZARONTIN CAPS (Use Ethosuximide) F

ZARONTIN SOLN (Use Ethosuximide) F

Valproic Acid DEPAKENE CAPS (Use Valproic Acid) F

DEPAKENE SOLN (Use Valproate Sodium) F

DEPAKOTE ER TB24 (Use Divalproex Sodium) NF

DEPAKOTE SPRINKLES CSDR (Use DivalproexSodium)

NF

DEPAKOTE TBEC (Use Divalproex Sodium) NF

divalproex sodium csdr F

divalproex sodium tb24 F

Drug Name DrugTier

Requirements/Limits

divalproex sodium tbec F

valproate sodium soln F

valproic acid caps F

ANTIDEPRESSANTS - Drugs to TreatDepression

Alpha-2 Receptor Antagonists (Tetracyclics) mirtazapine tabs 15 mg F QL(3 ea daily)

mirtazapine tabs 30 mg F QL(1.5 eadaily)

mirtazapine tabs 45 mg,7.5 mg F QL(1 ea daily)

mirtazapine tbdp 15 mg F QL(3 ea daily)

mirtazapine tbdp 30 mg F QL(1.5 eadaily)

mirtazapine tbdp 45 mg F QL(1 ea daily)

REMERON SOLTAB TBDP 15 MG (Use Mirtazapine) NF QL(3 ea daily)

REMERON SOLTAB TBDP 30 MG (Use Mirtazapine) NF QL(1.5 ea

daily) REMERON SOLTAB TBDP 45 MG (Use Mirtazapine) NF QL(1 ea daily)

REMERON TABS 15 MG (Use Mirtazapine) NF QL(3 ea daily)

REMERON TABS 30 MG (Use Mirtazapine) NF QL(1.5 ea

daily) REMERON TABS 45 MG (Use Mirtazapine) NF QL(1 ea daily)

Antidepressants - Misc. bupropion hcl tabs 75 mg,100 mg F QL(3 ea daily)

bupropion hcl tb12 100 mg F QL(4 ea daily)






12

Drug Name DrugTier

Requirements/Limits

MAPROTILINE HCL TABS F

WELLBUTRIN SR TB12 100 MG (Use BupropionHCl)

NF QL(4 ea daily)


NF QL(3 ea daily)


NF QL(2 ea daily)

WELLBUTRIN XL TB24 150 MG (Use BupropionHCl)

NF QL(3 ea daily)

WELLBUTRIN XL TB24 300 MG (Use BupropionHCl)

NF QL(1 ea daily)

Monoamine Oxidase Inhibitors (MAOIs) EMSAM PT24 CO

MARPLAN TABS CO

NARDIL TABS (Use Phenelzine Sulfate) CO

PARNATE TABS (Use Tranylcypromine Sulfate) CO

phenelzine sulfate tabs CO

tranylcypromine sulfatetabs CO

Selective Serotonin Reuptake Inhibitors (SSRIs) CELEXA TABS 10 MG (Use CitalopramHydrobromide)

NF QL(4 ea daily)

CELEXA TABS 20 MG (Use CitalopramHydrobromide)

NF QL(2 ea daily)

CELEXA TABS 40 MG (Use CitalopramHydrobromide)

NF QL(1 ea daily)

citalopram hydrobromidesoln 10 mg/5ml F QL(8 ml daily)

citalopram hydrobromidetabs 10 mg F QL(4 ea daily)


Drug Name DrugTier

Requirements/Limits


escitalopram oxalate tabs10 mg F QL(2 ea daily)

escitalopram oxalate tabs20 mg F QL(1 ea daily)

escitalopram oxalate tabs 5 mg F QL(4 ea daily)

fluoxetine hcl caps 10 mg,20 mg F QL(4 ea daily)

fluoxetine hcl caps 40 mg F QL(2 ea daily);AL; At least 7 yrs old

fluoxetine hcl soln 20 mg/5ml F

QL(20 mldaily); AL; Atleast 7 yrs old

fluoxetine hcl tabs 10 mg F QL(1 ea daily);AL; At least 7 yrs old

fluoxetine hcl tabs 20 mg F QL(4 ea daily)

fluvoxamine maleate tabs 100 mg F QL(3 ea daily)

fluvoxamine maleate tabs 25 mg, 50 mg F QL(2 ea daily)

LEXAPRO TABS 10 MG (Use Escitalopram Oxalate) NF QL(2 ea daily)



paroxetine hcl tabs 10 mg F QL(6 ea daily)

paroxetine hcl tabs 20 mg F QL(3 ea daily)

paroxetine hcl tabs 30 mg,40 mg F QL(2 ea daily)

paroxetine hcl tb24 25 mg,12.5 mg, 37.5 mg F

PAXIL CR TB24 (Use Paroxetine HCl) NF

PAXIL SUSP 10 MG/5ML F QL(40 ml daily)

PAXIL TABS 10 MG (Use Paroxetine HCl) NF QL(6 ea daily)

PAXIL TABS 20 MG (Use Paroxetine HCl) NF QL(3 ea daily)


13

Drug Name DrugTier

Requirements/Limits

PAXIL TABS 30 MG, 40 MG (Use Paroxetine HCl) NF QL(2 ea daily)

PROZAC CAPS 10 MG, 20 MG (Use Fluoxetine HCl) NF QL(4 ea daily)

PROZAC CAPS 40 MG (Use Fluoxetine HCl) NF


sertraline hcl conc 20 mg/ml F QL(10 ml daily)

sertraline hcl tabs 100 mg F QL(2 ea daily)

sertraline hcl tabs 25 mg,50 mg F QL(4 ea daily)

ZOLOFT CONC 20 MG/ML(Use Sertraline HCl) NF QL(10 ml daily)

ZOLOFT TABS 100 MG (Use Sertraline HCl) NF QL(2 ea daily)

ZOLOFT TABS 25 MG, 50 MG (Use Sertraline HCl) NF QL(4 ea daily)

Serotonin Modulators NEFAZODONE HCL TABS 100 MG, 150 MG, 200 MG F

nefazodone hcl tabs 50 mg, 250 mg F

trazodone hcl tabs 300 mg F QL(2 ea daily)

trazodone hcl tabs 50 mg,100 mg, 150 mg F

VIIBRYD TABS F PA; QL(1 eadaily)

Serotonin-Norepinephrine Reuptake Inhibitors

CYMBALTA CPEP (Use Duloxetine HCl) NF


duloxetine hcl cpep 20 mg,30 mg, 60 mg F


EFFEXOR XR CP24 150 MG (Use Venlafaxine HCl) NF QL(2 ea daily)

EFFEXOR XR CP24 37.5 MG (Use Venlafaxine HCl) NF QL(4 ea daily)

EFFEXOR XR CP24 75 MG (Use Venlafaxine HCl) NF QL(5 ea daily)

venlafaxine hcl cp24 150 mg F QL(2 ea daily)

Drug Name DrugTier

Requirements/Limits

venlafaxine hcl cp24 37.5 mg F QL(4 ea daily)

venlafaxine hcl cp24 75 mg F QL(5 ea daily)

VENLAFAXINE HCL ER TB24 225 MG F QL(1 ea daily)

VENLAFAXINE HCL ER TB24 75 MG, 150 MG, 37.5 MG (Use Venlafaxine HCl)

NF QL(1 ea daily)

venlafaxine hcl tabs 25 mg,50 mg, 75 mg, 100 mg,37.5 mg

F

venlafaxine hcl tb24 75 mg,150 mg, 225 mg, 37.5 mg F QL(1 ea daily)

Tricyclic Agents

amitriptyline hcl tabs 10 mg F QL(20 ea perfill retail)

amitriptyline hcl tabs 150 mg F QL(100 ea per

fill retail) amitriptyline hcl tabs 25mg, 100 mg F QL(150 ea per

fill retail)



AMOXAPINE TABS F

ANAFRANIL CAPS (Use Clomipramine HCl) NF

clomipramine hcl caps F

desipramine hcl tabs 10mg, 50 mg, 75 mg, 100 mg,150 mg

F

desipramine hcl tabs 25 mg F QL(2 ea daily)

doxepin hcl caps F

doxepin hcl conc F

ELAVIL TABS (Use Amitriptyline HCl) NF QL(150 ea per

fill retail)

imipramine hcl tabs F

NORPRAMIN TABS 10 MG (Use Desipramine HCl) NF


14

Drug Name DrugTier

Requirements/Limits

NORPRAMIN TABS 25 MG (Use Desipramine HCl) NF QL(2 ea daily)

nortriptyline hcl caps 10mg, 25 mg, 50 mg, 75 mg F

nortriptyline hcl soln 10mg/5ml F QL(20 ml daily)

PAMELOR CAPS (Use Nortriptyline HCl) NF

TOFRANIL TABS (Use Imipramine HCl) NF

ANTIDIABETICS - Drugs to Regulate BloodSugar Antidiabetic - Amylin Analogs

SYMLINPEN 120 SOPN F PA; QL(10.8 mlper 30 daysretail)

SYMLINPEN 60 SOPN F PA; QL(6 mlper 30 daysretail)

Antidiabetic Combinations ACTOPLUS MET TABS (Use Pioglitazone HCl-Metformin HCl)

NF QL(2 ea daily)

ALOGLIPTIN/METFORMINHCL TABS F PA; QL(2 ea

daily) ALOGLIPTIN/PIOGLITAZONE TABS F PA; QL(1 ea

daily)

glipizide-metformin hcl tabs F

GLUCOVANCE TABS (Use Glyburide-Metformin) NF

glyburide-metformin tabs F

JENTADUETO TABS F PA; QL(2 eadaily); AL; Atleast 18 yrs old

pioglitazone hcl-metforminhcl tabs F QL(2 ea daily)

Biguanides GLUCOPHAGE TABS 1000 MG (Use Metformin HCl)

NF QL(2 ea daily)

GLUCOPHAGE TABS 500 MG (Use Metformin HCl) NF QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits

GLUCOPHAGE TABS 850 MG (Use Metformin HCl) NF QL(3 ea daily)

GLUCOPHAGE XR TB24 500 MG (Use Metformin HCl)

NF QL(4 ea daily)

GLUCOPHAGE XR TB24 750 MG (Use Metformin HCl)

NF QL(2 ea daily)

metformin hcl tabs 1000 mg F QL(2 ea daily)



metformin hcl tb24 500 mg F QL(4 ea daily)

metformin hcl tb24 750 mg F QL(2 ea daily)

Diabetic Other BD GLUCOSE CHEW F

CVS GLUCOSE CHEW 4 GM F

DEX4 QUICK DISSOLVE GLUCOSE CHEW F

GLUCAGEN HYPOKIT SOLR F

GLUCAGON EMERGENCY KIT KIT F QL(1 ea per fill

retail)

GLUCOSE CHEW 4 GM F

GNP GLUCOSE CHEW 4 GM F

GNP QUICK DISSOLVE GLUCOSE CHEW F

LEADER QUICK DISSOLVE GLUCOSE CHEW

F

SM GLUCOSE CHEW 4 GM F

WALGREENS GLUCOSE CHEW 4 GM F

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors

ALOGLIPTIN TABS F PA; QL(1 eadaily)


15

Drug Name DrugTier

Requirements/Limits

TRADJENTA TABS F PA; QL(1 eadaily); AL; Atleast 18 yrs old

Incretin Mimetic Agents (GLP-1 Receptor

BYDUREON BCISE AUIJ F

QL(18 ml per30 days retail);AL; At least 18 yrs old

BYDUREON PEN PEN F

PA; QL(4 eaper 30 daysretail); AL; Atleast 18 yrs old

BYDUREON SRER F

PA; QL(4 eaper 28 daysretail); AL; Atleast 18 yrs old

BYETTA SOPN 10 MCG/0.04ML F

PA; QL(2.4 mlper 30 daysretail); AL; Atleast 18 yrs old

BYETTA SOPN 5 MCG/0.02ML F

PA; QL(1.2 mlper 30 daysretail); AL; Atleast 18 yrs old

VICTOZA SOPN F PA; QL(1.8 mldaily)

Insulin Sensitizing Agents ACTOS TABS (Use Pioglitazone HCl) NF QL(1 ea daily)

AVANDIA TABS F QL(1 ea daily)

pioglitazone hcl tabs F QL(1 ea daily)

Insulin

ADMELOG SOLN F QL(40 ml per30 days retail)

ADMELOG SOLOSTAR SOPN F QL(30 ml per

30 days retail)

APIDRA SOLN F

APIDRA SOLOSTAR SOPN F QL(30 ml per

30 days retail)

BASAGLAR KWIKPEN SOPN F

Limit 50mls permonth;QL(1.67ml daily)

FIASP FLEXTOUCH SOPN F QL(30 ml per

30 days retail)

Drug Name DrugTier

Requirements/Limits

FIASP SOLN F QL(30 ml per30 days retail)

HUMALOG JUNIOR KWIKPEN SOPN F QL(30 ml per

30 days retail) HUMALOG KWIKPEN SOPN 100 UNIT/ML F QL(30 ml per

30 days retail) HUMALOG MIX 50/50KWIKPEN SUPN F QL(30 ml per

30 days retail) HUMALOG MIX 50/50SUSP F QL(40 ml per

30 days retail) HUMALOG MIX 75/25KWIKPEN SUPN F QL(30 ml per

30 days retail) HUMALOG MIX 75/25SUSP F QL(40 ml per

30 days retail)

HUMALOG SOCT F QL(30 ml per30 days retail)

HUMALOG SOLN F QL(40 ml per30 days retail)

HUMULIN 70/30 KWIKPENSUPN F

HUMULIN 70/30 SUSP F QL(40 ml per30 days retail)

HUMULIN N KWIKPEN SUPN F

HUMULIN N SUSP F QL(40 ml per30 days retail)

HUMULIN R SOLN F QL(40 ml per30 days retail)

NOVOLIN 70/30 RELIONSUSP F QL(40 ml per

30 days retail)

NOVOLIN 70/30 SUSP F QL(40 ml per30 days retail)

NOVOLIN N RELION SUSP F QL(40 ml per

30 days retail)

NOVOLIN N SUSP F QL(40 ml per30 days retail)

NOVOLIN R RELION SOLN F QL(40 ml per

30 days retail)

NOVOLIN R SOLN F QL(40 ml per30 days retail)

NOVOLOG FLEXPEN SOPN F QL(30 ml per

30 days retail) NOVOLOG MIX 70/30PREFILLED FLEXPEN SUPN

F QL(30 ml per30 days retail)


16

Drug Name DrugTier

Requirements/Limits

NOVOLOG MIX 70/30SUSP F QL(40 ml per

30 days retail)

NOVOLOG SOLN F QL(30 ml per30 days retail)

Meglitinide Analogues

nateglinide tabs F QL(3 ea daily)

STARLIX TABS (Use Nateglinide) NF QL(3 ea daily)

Sodium-Glucose Co-Transporter 2 (SGLT2)

JARDIANCE TABS F PA; QL(1 eadaily)

Sulfonylureas AMARYL TABS 1 MG, 2 MG (Use Glimepiride) NF QL(4 ea daily)

AMARYL TABS 4 MG (Use Glimepiride) NF QL(2 ea daily)

glimepiride tabs 1 mg, 2 mg F QL(4 ea daily)

glimepiride tabs 4 mg F QL(2 ea daily)

glipizide tabs F

glipizide tb24 F

GLUCOTROL TABS (Use Glipizide) NF

GLUCOTROL XL TB24 (Use Glipizide) NF

glyburide micronized tabs F

glyburide tabs F

GLYNASE TABS (Use Glyburide Micronized) NF

ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugsto Treat Diarrhea

Antidiarrheal/Probiotic Agents - Misc. bismuth subsalicylate chew262 mg F

bismuth subsalicylate susp262 mg/15ml, 525mg/15ml, 525 mg/30ml,527 mg/30ml

F

Drug Name DrugTier

Requirements/Limits

PEPTO-BISMOL CHEW 262 MG (Use Bismuth Subsalicylate)

NF

PEPTO-BISMOL INSTACOOL CHEW (Use Bismuth Subsalicylate)

NF

PEPTO-BISMOL MAX STRENGTH SUSP (Use Bismuth Subsalicylate)

NF

PEPTO-BISMOL SUSP 262 MG/15ML (Use Bismuth Subsalicylate)

NF

PEPTO-BISMOL TO-GO CHEW (Use Bismuth Subsalicylate)

NF

Antiperistaltic Agents diphenoxylate w/ atropinetabs F

DIPHENOXYLATE/ATROPINE LIQD F

IMODIUM A-D CAPS 2 MG (Use Loperamide HCl) NF QL(8 ea daily);

RX/OTC IMODIUM A-D TABS 2 MG (Use Loperamide HCl) NF QL(8 ea daily)

LOMOTIL TABS (Use Diphenoxylate w/ Atropine) NF

loperamide hcl caps 2 mg F QL(8 ea daily);RX/OTC

loperamide hcl liqd 1mg/5ml F QL(40 ml daily)

loperamide hcl tabs 2 mg F QL(8 ea daily)

PAREGORIC TINC F

ANTIDOTES AND SPECIFIC ANTAGONISTS

Antidotes - Chelating Agents

CHEMET CAPS F

JADENU SPRINKLE PACK F PA

JADENU TABS F PA; SP

Antidotes and Specific Antagonists

VISTOGARD PACK F


17

Drug Name DrugTier

Requirements/Limits

Opioid Antagonists NALOXONE HCL SOCT 0.4 MG/ML CO

naloxone hcl soln 0.4 mg/ml, 4 mg/10ml CO

NALOXONE HCL SOSY 2 MG/2ML CO

naltrexone hcl tabs CO

NARCAN LIQD CO

VIVITROL SUSR CO

ANTIEMETICS - Drugs to Treat Nausea andVomiting

5-HT3 Receptor Antagonists ondansetron hcl soln 4 mg/5ml F QL(50 ml per

fill retail) ondansetron hcl tabs 4 mg,8 mg F QL(20 ea per

30 days retail)

ondansetron tbdp F QL(20 ea per30 days retail)

ZOFRAN ODT TBDP (Use Ondansetron) NF QL(20 ea per

30 days retail) ZOFRAN SOLN 4 MG/5ML(Use Ondansetron HCl) NF QL(50 ml per

fill retail) ZOFRAN TABS 4 MG, 8 MG (Use Ondansetron HCl)

NF QL(20 ea per30 days retail)

Antiemetics - Anticholinergic dimenhydrinate tabs or 50 mg F

DRAMAMINE CHEW F

DRAMAMINE TABS (Use Dimenhydrinate) NF

meclizine hcl chew 25 mg F

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

Substance P/Neurokinin 1 (NK1) Receptor

aprepitant caps F 1 rtl pack lmtper fill,

aprepitant caps 40 mg, 125 mg F QL(1 ea per fill

retail)

Drug Name DrugTier

Requirements/Limits

aprepitant caps 80 mg F QL(2 ea per fillretail)

EMEND CAPS 40 MG, 125 MG (Use Aprepitant) NF QL(1 ea per fill

retail) EMEND CAPS 80 MG (Use Aprepitant) NF QL(2 ea per fill

retail) EMEND TRIPACK CAPS (Use Aprepitant) NF 1 rtl pack lmt

per fill,

ANTIFUNGALS - Drugs to Treat Fungal Infections

Antifungals GRIS-PEG TABS (Use Griseofulvin Ultramicrosize) NF

griseofulvin microsize susp F

griseofulvin microsize tabs F

griseofulvin ultramicrosizetabs F

LAMISIL TABS 250 MG (Use Terbinafine HCl) NF QL(1 ea daily)

nystatin tabs F QL(6 ea daily)

terbinafine hcl tabs F QL(1 ea daily)

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


DIFLUCAN TABS 100 MG (Use Fluconazole) NF QL(1 ea daily)

DIFLUCAN TABS 150 MG (Use Fluconazole) NF QL(2 ea per fill

retail) DIFLUCAN TABS 200 MG (Use Fluconazole) NF QL(2 ea daily)

DIFLUCAN TABS 50 MG (Use Fluconazole) NF QL(7 ea per fill

retail) fluconazole susr 10 mg/ml,40 mg/ml F QL(70 ml per

fill retail)

fluconazole tabs 100 mg F QL(1 ea daily)

fluconazole tabs 150 mg F QL(2 ea per fillretail)

fluconazole tabs 200 mg F QL(2 ea daily)


18

Drug Name DrugTier

Requirements/Limits

fluconazole tabs 50 mg F QL(7 ea per fillretail)

itraconazole caps F PA; QL(1 eadaily)

ketoconazole tabs F QL(2 ea daily)

SPORANOX CAPS 100 MG (Use Itraconazole) NF PA; QL(1 ea

daily) SPORANOX PULSEPAK CAPS (Use Itraconazole) NF PA; QL(1 ea

daily)

ANTIHISTAMINES - Drugs to Treat Allergies

Antihistamines - Alkylamines CHLOR-TRIMETON SYRP (Use ChlorpheniramineMaleate)

NF

CHLOR-TRIMETON TABS (Use ChlorpheniramineMaleate)

NF

chlorpheniramine maleatesyrp 2 mg/5ml F

chlorpheniramine maleatetabs 4 mg F

Antihistamines - Ethanolamines

ALER-DRYL TABS F

BENADRYL ALLERGY CAPS (Use Diphenhydramine HCl)

NF

BENADRYL ALLERGY CHILDRENS LIQD 12.5 MG/5ML (Use Diphenhydramine HCl)

NF

BENADRYL ALLERGY TABS (Use Diphenhydramine HCl)

NF

clemastine fumarate tabs 1.34 mg F

diphenhydramine hcl caps25 mg F

diphenhydramine hcl caps50 mg F QL(4 ea daily);

RX/OTC

diphenhydramine hcl elix12.5 mg/5ml F

QL(240 ml perfill retail);RX/OTC

Drug Name DrugTier

Requirements/Limits

diphenhydramine hcl liqd25 mg/10ml, 50 mg/20ml,12.5 mg/5ml

F

diphenhydramine hcl syrp12.5 mg/5ml F

diphenhydramine hcl tabs25 mg F

SILPHEN COUGH SYRP F

TAVIST ALLERGY TABS (Use Clemastine Fumarate) NF

Antihistamines - Non-Sedating ALLEGRA ALLERGY TABS (Use Fexofenadine HCl)

NF

cetirizine hcl chew 5 mg, 10 mg F

cetirizine hcl soln 1 mg/ml,5 mg/5ml F


cetirizine hcl syrp 1 mg/ml,5 mg/5ml F


cetirizine hcl tabs 5 mg, 10 mg F

CLARITIN ALLERGY CHILDRENS SYRP (Use Loratadine)

NF

CLARITIN REDITABS TBDP 10 MG (Use Loratadine)

NF

CLARITIN SYRP 5 MG/5ML (Use Loratadine) NF

CLARITIN TABS 10 MG (Use Loratadine) NF

fexofenadine hcl tabs 60 mg, 180 mg F

levocetirizine dihydrochloride tabs 5 mg F RX/OTC

loratadine soln 5 mg/5ml F

loratadine syrp 5 mg/5ml F

loratadine tabs 10 mg F

loratadine tbdp 10 mg F


19

Drug Name DrugTier

Requirements/Limits

XYZAL ALLERGY 24HR TABS (Use Levocetirizine Dihydrochloride)

NF RX/OTC

XYZAL TABS 5 MG (Use Levocetirizine Dihydrochloride)

NF RX/OTC

ZYRTEC ALLERGY TABS (Use Cetirizine HCl) NF

ZYRTEC CHILDRENS ALLERGY SOLN (Use Cetirizine HCl)

NF QL(240 ml perfill retail);RX/OTC

Antihistamines - Phenothiazines

promethazine hcl soln or6.25 mg/5ml F

QL(240 ml perfill retail); AL; Atleast 2 yrs old

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

QL(12 ea perfill retail); AL; Atleast 2 yrs old

promethazine hcl syrp or6.25 mg/5ml F


promethazine hcl tabs or25 mg, 50 mg, 12.5 mg F AL; At least 2

yrs old

Antihistamines - Piperidines

cyproheptadine hcl syrp F

cyproheptadine hcl tabs F

ANTIHYPERLIPIDEMICS - Drugs to Treat HighCholesterol Bile Acid Sequestrants

cholestyramine light pack F

cholestyramine light powd F

cholestyramine pack F

cholestyramine powd F

COLESTID FLAVORED GRAN 5 GM (Use Colestipol HCl)

NF

COLESTID GRAN 5 GM (Use Colestipol HCl) NF

COLESTID TABS 1 GM (Use Colestipol HCl) NF

Drug Name DrugTier

Requirements/Limits

colestipol hcl gran 5 gm F

colestipol hcl tabs 1 gm F

QUESTRAN LIGHT POWD (Use Cholestyramine Light) NF

QUESTRAN PACK (Use Cholestyramine) NF

QUESTRAN POWD (Use Cholestyramine) NF

Fibric Acid Derivatives fenofibrate micronized caps134 mg, 200 mg F QL(1 ea daily)

fenofibrate micronized caps67 mg F QL(2 ea daily)

fenofibrate tabs 160 mg F QL(1 ea daily)

fenofibrate tabs 54 mg F QL(3 ea daily)

gemfibrozil tabs F QL(2 ea daily)

LOFIBRA CAPS 134 MG, 200 MG (Use Fenofibrate Micronized)

NF QL(1 ea daily)

LOFIBRA CAPS 67 MG (Use Fenofibrate Micronized)

NF QL(2 ea daily)

LOFIBRA TABS 160 MG (Use Fenofibrate) NF QL(1 ea daily)

LOFIBRA TABS 54 MG (Use Fenofibrate) NF QL(3 ea daily)

LOPID TABS (Use Gemfibrozil) NF QL(2 ea daily)

TRIGLIDE TABS F QL(1 ea daily)

HMG CoA Reductase Inhibitors

atorvastatin calcium tabs F QL(1 ea daily)

CRESTOR TABS (Use Rosuvastatin Calcium) NF ST; QL(1 ea

daily) LIPITOR TABS (Use Atorvastatin Calcium) NF QL(1 ea daily)

lovastatin tabs 10 mg, 20 mg F QL(1 ea daily)

lovastatin tabs 40 mg F QL(2 ea daily)


20

Drug Name DrugTier

Requirements/Limits

MEVACOR TABS (Use Lovastatin) NF QL(2 ea daily)

PRAVACHOL TABS (Use Pravastatin Sodium) NF QL(1 ea daily)

pravastatin sodium tabs F QL(1 ea daily)

rosuvastatin calcium tabs F ST; QL(1 eadaily)

simvastatin tabs 5 mg, 10mg, 20 mg, 40 mg F QL(1 ea daily)

simvastatin tabs 80 mg F PA

ZOCOR TABS 5 MG, 10 MG, 20 MG, 40 MG (Use Simvastatin)

NF QL(1 ea daily)

ZOCOR TABS 80 MG (Use Simvastatin) NF PA

Nicotinic Acid Derivatives niacin (antihyperlipidemic)tbcr F

NIACOR TABS F

NIASPAN TBCR (Use Niacin (Antihyperlipidemic)) NF

ANTIHYPERTENSIVES - Drugs to Treat HighBlood Pressure

ACE Inhibitors ACCUPRIL TABS (Use Quinapril HCl) NF QL(1 ea daily)

ALTACE CAPS (Use Ramipril) NF QL(2 ea daily)

benazepril hcl tabs 40 mg F QL(2 ea daily)

benazepril hcl tabs 5 mg,10 mg, 20 mg F QL(1 ea daily)

captopril tabs F QL(3 ea daily)

enalapril maleate tabs F QL(2 ea daily)

EPANED SOLR F PA

fosinopril sodium tabs F QL(1 ea daily)

lisinopril tabs F

Drug Name DrugTier

Requirements/Limits

LOTENSIN TABS 10 MG, 20 MG (Use BenazeprilHCl)

NF QL(1 ea daily)

LOTENSIN TABS 40 MG (Use Benazepril HCl) NF QL(2 ea daily)

MAVIK TABS (Use Trandolapril) NF QL(1 ea daily)

PRINIVIL TABS (Use Lisinopril) NF

quinapril hcl tabs F QL(1 ea daily)

ramipril caps F QL(2 ea daily)

trandolapril tabs 1 mg, 2 mg F QL(1 ea daily)

trandolapril tabs 4 mg F QL(2 ea daily)

VASOTEC TABS (Use Enalapril Maleate) NF QL(2 ea daily)

ZESTRIL TABS (Use Lisinopril) NF

Angiotensin II Receptor Antagonists ATACAND TABS (Use Candesartan Cilexetil) NF

AVAPRO TABS (Use Irbesartan) NF QL(1 ea daily)

BENICAR TABS (Use Olmesartan Medoxomil) NF ST

candesartan cilexetil tabs F

COZAAR TABS (Use Losartan Potassium) NF QL(1 ea daily)

DIOVAN TABS (Use Valsartan) NF QL(1 ea daily)

irbesartan tabs F QL(1 ea daily)

losartan potassium tabs F QL(1 ea daily)

MICARDIS TABS (Use Telmisartan) NF QL(1 ea daily)

olmesartan medoxomil tabs F ST

telmisartan tabs F QL(1 ea daily)

valsartan tabs F QL(1 ea daily)

Antiadrenergic Antihypertensives


21

Drug Name DrugTier

Requirements/Limits

CARDURA TABS (Use Doxazosin Mesylate) NF

CATAPRES TABS (Use Clonidine HCl) NF

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

doxazosin mesylate tabs F

guanfacine hcl tabs F

methyldopa tabs F

MINIPRESS CAPS (Use Prazosin HCl) NF

prazosin hcl caps F

TENEX TABS (Use Guanfacine HCl) NF

terazosin hcl caps F

Antihypertensive Combinations ACCURETIC TABS 10MG-12.5MG (Use Quinapril-Hydrochlorothiazide)

NF QL(3 ea daily)

ACCURETIC TABS 20MG-12.5MG (Use Quinapril-Hydrochlorothiazide)

NF QL(4 ea daily)

ACCURETIC TABS 20MG-25MG (Use Quinapril-Hydrochlorothiazide)

NF QL(2 ea daily)

amlodipine besylate-benazepril hcl caps F QL(1 ea daily)

amlodipine besylate-olmesartan medoxomil tabs F ST

amlodipine besylate-valsartan tabs F ST

amlodipine-valsartan-hydrochlorothiazide tabs F ST

ATACAND HCT TABS (Use Candesartan Cilexetil-Hydrochlorothiazide)

NF

atenolol & chlorthalidone tabs F QL(1 ea daily)

AVALIDE TABS (Use Irbesartan-Hydrochlorothiazide)

NF QL(1 ea daily)

Drug Name DrugTier

Requirements/Limits

AZOR TABS (Use Amlodipine Besylate-Olmesartan Medoxomil)

NF ST

benazepril &hydrochlorothiazide tabs F QL(1 ea daily)

BENICAR HCT TABS (Use Olmesartan Medoxomil-Hydrochlorothiazide)

NF ST

bisoprolol &hydrochlorothiazide tabs2.5mg-6.25mg

F

bisoprolol &hydrochlorothiazide tabs5mg-6.25mg, 10mg-6.25mg

F

QL(1 ea daily)

candesartan cilexetil-hydrochlorothiazide tabs F

CAPTOPRIL/HYDROCHLOROTHIAZIDE TABS F QL(2 ea daily)

DIOVAN HCT TABS (Use Valsartan-Hydrochlorothiazide)

NF QL(1 ea daily)

enalapril maleate &hydrochlorothiazide tabs F QL(2 ea daily)

EXFORGE HCT TABS (Use Amlodipine-Valsartan-Hydrochlorothiazide)

NF ST

EXFORGE TABS (Use Amlodipine Besylate-Valsartan)

NF ST

fosinopril sodium &hydrochlorothiazide tabs F QL(1 ea daily)

HYZAAR TABS (Use Losartan Potassium & Hydrochlorothiazide)

NF QL(1 ea daily)

irbesartan-hydrochlorothiazide tabs F QL(1 ea daily)

lisinopril &hydrochlorothiazide tabs F

LOPRESSOR HCT TABS (Use Metoprolol &Hydrochlorothiazide)

NF QL(2 ea daily)

losartan potassium &hydrochlorothiazide tabs F QL(1 ea daily)

LOTENSIN HCT TABS (Use Benazepril &Hydrochlorothiazide)

NF QL(1 ea daily)


22

Drug Name DrugTier

Requirements/Limits

LOTREL CAPS (Use Amlodipine Besylate-Benazepril HCl)

NF QL(1 ea daily)

metoprolol &hydrochlorothiazide tabs F QL(2 ea daily)

METOPROLOL SUCCINATE ER/HYDROCHLOROTHIAZIDE TB24

F

QL(1 ea daily)

METOPROLOL/HYDROCHLOROTHIAZIDE TABS F QL(2 ea daily)

MICARDIS HCT TABS (Use Telmisartan-Hydrochlorothiazide)

NF QL(1 ea daily)

olmesartan medoxomil-amlodipine-hydrochlorothiazide tabs

F ST

olmesartan medoxomil-hydrochlorothiazide tabs F ST

PROPRANOLOL/HYDROCHLOROTHIAZIDE TABS F

quinapril-hydrochlorothiazide tabs10mg-12.5mg

F QL(3 ea daily)

quinapril-hydrochlorothiazide tabs20mg-12.5mg

F QL(4 ea daily)

quinapril-hydrochlorothiazide tabs20mg-25mg

F QL(2 ea daily)

TARKA TBCR (Use Trandolapril-VerapamilHCl)

NF

telmisartan-amlodipine tabs F

telmisartan-hydrochlorothiazide tabs F QL(1 ea daily)

TENORETIC 100 TABS (Use Atenolol & Chlorthalidone)

NF QL(1 ea daily)

TENORETIC 50 TABS (Use Atenolol & Chlorthalidone)

NF QL(1 ea daily)

trandolapril-verapamil hcltbcr F

TRANDOLAPRIL/VERAPAMIL HCL ER TBCR F

Drug Name DrugTier

Requirements/Limits

TRIBENZOR TABS (Use Olmesartan Medoxomil-Amlodipine-Hydrochlorothiazide)

NF

ST

TWYNSTA TABS (Use Telmisartan-Amlodipine) NF

valsartan-hydrochlorothiazide tabs F QL(1 ea daily)

VASERETIC TABS (Use Enalapril Maleate &Hydrochlorothiazide)

NF QL(2 ea daily)

ZESTORETIC TABS (Use Lisinopril &Hydrochlorothiazide)

NF

ZIAC TABS 2.5MG-6.25MG (Use Bisoprolol &Hydrochlorothiazide)

NF

ZIAC TABS 5MG-6.25MG, 10MG-6.25MG (Use Bisoprolol &Hydrochlorothiazide)

NF

QL(1 ea daily)

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

minoxidil tabs F

ANTIMALARIALS - Drugs to Treat Malaria(Parasitic Infections) Antimalarial Combinations

COARTEM TABS F QL(24 ea perfill retail)

Antimalarials CHLOROQUINE PHOSPHATE TABS 250 MG

F QL(2 ea daily)

chloroquine phosphate tabs500 mg F QL(8 ea per 56

days retail) hydroxychloroquine sulfatetabs F

mefloquine hcl tabs F

MEFLOQUINE HCL TABS F

PLAQUENIL TABS (Use HydroxychloroquineSulfate)

NF


23

Drug Name DrugTier

Requirements/Limits

ANTIMYASTHENIC/CHOLINERGIC AGENTS

Antimyasthenic/Cholinergic Agents MESTINON TABS 60 MG (Use PyridostigmineBromide)

NF

MESTINON TIMESPAN TBCR (Use PyridostigmineBromide)

NF

pyridostigmine bromidetabs F

pyridostigmine bromidetbcr F

ANTIMYCOBACTERIAL AGENTS - Drugs toTreat Tuberculosis (Bacterial Infections) Antimycobacterial Agents

ethambutol hcl tabs F

ISONIAZID SYRP OR 50 MG/5ML F

isoniazid tabs or 100 mg,300 mg F

MYAMBUTOL TABS (Use Ethambutol HCl) NF

PRIFTIN TABS F QL(72 ea per84 days retail)

pyrazinamide tabs F

RIFADIN CAPS (Use Rifampin) NF

rifampin caps F

TRECATOR TABS F

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - Drugs to Treat Cancer Alkylating Agents ALKERAN TABS (Use Melphalan) NF

LEUKERAN TABS F

melphalan tabs F

MYLERAN TABS F

Antimetabolites

Drug Name DrugTier

Requirements/Limits

mercaptopurine tabs F

methotrexate sodium soln ij1 gm/40ml, 50 mg/2ml, 100mg/4ml, 200 mg/8ml, 250mg/10ml

F

METHOTREXATE SODIUM SOLN IJ 250 MG/10ML

F

methotrexate sodium tabs or 2.5 mg F

PURIXAN SUSP F

TREXALL TABS F

Antineoplastic - Angiogenesis Inhibitors

AVASTIN SOLN F PA; SP

CYRAMZA SOLN F PA; SP

Antineoplastic - Antibodies HERCEPTIN SOLR 440 MG F PA; SP

KADCYLA SOLR F PA; SP

OPDIVO SOLN 40 MG/4ML, 100 MG/10ML F PA; SP

PERJETA SOLN F PA; SP

RITUXAN SOLN F PA; SP

Antineoplastic - Hedgehog Pathway Inhibitors

ERIVEDGE CAPS F PA; SP

Antineoplastic - Hormonal and Related Agents

anastrozole tabs F

ARIMIDEX TABS (Use Anastrozole) NF

AROMASIN TABS (Use Exemestane) NF SP

bicalutamide tabs F QL(1 ea daily)

CASODEX TABS (Use Bicalutamide) NF QL(1 ea daily)

ELIGARD KIT F PA; SP


24

Drug Name DrugTier

Requirements/Limits

exemestane tabs F SP

FARESTON TABS F PA

FEMARA TABS (Use Letrozole) NF

FIRMAGON SOLR F PA; SP

flutamide caps F

letrozole tabs F

leuprolide acetate kit F PA; SP

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




MEGACE ORAL SUSP (Use Megestrol Acetate) NF

megestrol acetate susp F

megestrol acetate tabs F

tamoxifen citrate tabs F

TRELSTAR MIXJECT SUSR F PA; SP

TRELSTAR SUSR F PA; SP

VANTAS KIT F PA; SP

XTANDI CAPS F PA; SP

ZOLADEX IMPL F PA; SP

ZYTIGA TABS 250 MG F PA; SP

Antineoplastic - Immunomodulators

POMALYST CAPS F PA; SP

Antineoplastic Enzyme Inhibitors

AFINITOR DISPERZ TBSO F PA; SP

Drug Name DrugTier

Requirements/Limits

AFINITOR TABS F PA; SP

ALECENSA CAPS F PA; SP

BOSULIF TABS 100 MG, 500 MG F PA; SP

CABOMETYX TABS F PA; SP

CAPRELSA TABS F PA; SP

COMETRIQ KIT F PA; SP

COTELLIC TABS F PA; SP

GILOTRIF TABS F PA; SP

GLEEVEC TABS (Use Imatinib Mesylate) NF PA; SP

IBRANCE CAPS F PA; SP

ICLUSIG TABS F PA; SP

imatinib mesylate tabs F PA; SP

IMBRUVICA CAPS 140 MG F PA; SP

INLYTA TABS F PA; SP

IRESSA TABS F PA; SP

MEKINIST TABS F PA; SP

NEXAVAR TABS F PA; SP

NINLARO CAPS F PA; SP

SPRYCEL TABS F PA; SP

STIVARGA TABS F PA; SP

SUTENT CAPS F PA; SP

TAFINLAR CAPS F PA; SP

TARCEVA TABS F PA; SP

TASIGNA CAPS 150 MG, 200 MG F PA; SP


25

Drug Name DrugTier

Requirements/Limits

VOTRIENT TABS F PA; SP

XALKORI CAPS F PA; SP

ZELBORAF TABS F PA; SP

ZOLINZA CAPS F PA; SP

Antineoplastics Misc. ACTIMMUNE SOLN F PA; SP

bexarotene caps F PA; SP

HYDREA CAPS (Use Hydroxyurea) NF

hydroxyurea caps F

SYLATRON KIT F PA; SP

TARGRETIN CAPS OR 75 MG (Use Bexarotene) NF PA; SP

Chemotherapy Rescue/Antidote Agents LEUCOVORIN CALCIUM TABS 10 MG, 15 MG F

leucovorin calcium tabs 5 mg, 25 mg F

Topoisomerase I Inhibitors HYCAMTIN CAPS OR 0.25 MG, 1 MG F PA; SP

HYCAMTIN SOLR IV 4 MG (Use Topotecan HCl) NF PA; SP

TOPOTECAN HCL SOLN 4 MG/4ML F PA; SP

topotecan hcl soln 4mg/4ml F PA; SP

TOPOTECAN HCL SOLN 4 MG/4ML (Use TopotecanHCl)

NF PA; SP

topotecan hcl solr 4 mg F PA; SP

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

Antiparkinson Adjuvants

carbidopa tabs F

Drug Name DrugTier

Requirements/Limits

LODOSYN TABS (Use Carbidopa) NF

Antiparkinson Anticholinergics

benztropine mesylate soln CO

benztropine mesylate tabs CO

COGENTIN SOLN (Use Benztropine Mesylate) CO

trihexyphenidyl hcl elix CO

trihexyphenidyl hcl tabs CO

Antiparkinson COMT Inhibitors COMTAN TABS (Use Entacapone) NF

entacapone tabs F

Antiparkinson Dopaminergics

amantadine hcl caps CO

amantadine hcl syrp CO

amantadine hcl tabs CO

bromocriptine mesylate caps F

bromocriptine mesylatetabs F

carbidopa-levodopa tabs10mg-100mg, 25mg-100mg, 25mg-250mg

F

carbidopa-levodopa tbcr25mg-100mg, 50mg-200mg

F

GOCOVRI CP24 CO

MIRAPEX TABS (Use PramipexoleDihydrochloride)


PARLODEL CAPS (Use Bromocriptine Mesylate) NF

PARLODEL TABS (Use Bromocriptine Mesylate) NF


26

Drug Name DrugTier

Requirements/Limits

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

F


REQUIP TABS 0.25 MG, 3 MG, 4 MG (Use RopiniroleHydrochloride)

NF QL(6 ea daily)

REQUIP TABS 0.5 MG, 1 MG, 2 MG, 5 MG (Use Ropinirole Hydrochloride)

NF QL(3 ea daily)

ropinirole hydrochloridetabs 0.25 mg, 3 mg, 4 mg F QL(6 ea daily)

ropinirole hydrochloridetabs 0.5 mg, 1 mg, 2 mg, 5 mg

F QL(3 ea daily)

SINEMET CR TBCR (Use Carbidopa-Levodopa) NF

SINEMET TABS (Use Carbidopa-Levodopa) NF

Antiparkinson Monoamine Oxidase Inhibitors ELDEPRYL CAPS (Use Selegiline HCl) NF

selegiline hcl caps F

selegiline hcl tabs F

ANTIPSYCHOTICS/ANTIMANIC AGENTS -Drugs to Treat Mood Disorders

Antimanic Agents lithium carbonate caps 150mg, 300 mg, 600 mg CO

LITHIUM CARBONATE CAPS 150 MG, 600 MG (Use Lithium Carbonate)

CO

lithium carbonate tabs 300 mg CO

lithium carbonate tbcr 300 mg, 450 mg CO

LITHIUM SOLN CO

LITHOBID TBCR (Use Lithium Carbonate) CO

Antipsychotics - Misc. EQUETRO CP12 CO

Drug Name DrugTier

Requirements/Limits

GEODON CAPS OR 20 MG, 40 MG, 60 MG, 80 MG (Use Ziprasidone HCl)

CO

GEODON SOLR IM 20 MG CO

LATUDA TABS CO

NUPLAZID TABS CO

VRAYLAR CAPS CO

VRAYLAR CPPK CO

ziprasidone hcl caps CO

Benzisoxazoles

FANAPT TABS CO

FANAPT TITRATION PACK TABS CO

INVEGA SUSTENNA SUSP CO

INVEGA TB24 (Use Paliperidone) CO

INVEGA TRINZA SUSP CO

paliperidone tb24 CO

RISPERDAL CONSTA SUSR CO

RISPERDAL M-TAB TBDP (Use Risperidone) CO

RISPERDAL SOLN (Use Risperidone) CO

RISPERDAL TABS (Use Risperidone) CO

RISPERIDONE ODT TBDP CO

risperidone soln CO

risperidone tabs CO

risperidone tbdp CO

Butyrophenones


27

Drug Name DrugTier

Requirements/Limits

HALDOL DECANOATE 100 SOLN (Use Haloperidol Decanoate)

CO

HALDOL DECANOATE 50 SOLN (Use HaloperidolDecanoate)

CO

HALDOL SOLN (Use Haloperidol Lactate) CO

haloperidol decanoate soln CO

haloperidol lactate conc CO

haloperidol lactate soln CO

haloperidol tabs or 0.5 mg,1 mg, 2 mg, 5 mg, 10 mg,20 mg

CO

Dibenzapines

ADASUVE AEPB CO

CLOZAPINE ODT TBDP CO

clozapine tabs CO

clozapine tbdp CO

CLOZARIL TABS (Use Clozapine) CO

FAZACLO TBDP 150 MG, 200 MG CO

FAZACLO TBDP 25 MG, 100 MG, 12.5 MG (Use Clozapine)

CO

loxapine succinate caps CO

olanzapine solr CO

olanzapine tabs CO

olanzapine tbdp CO

quetiapine fumarate tabs CO

quetiapine fumarate tb24 CO

SAPHRIS SUBL CO

Drug Name DrugTier

Requirements/Limits

SEROQUEL TABS (Use Quetiapine Fumarate) CO

SEROQUEL XR TB24 (Use Quetiapine Fumarate) CO

VERSACLOZ SUSP CO

ZYPREXA RELPREVV SUSR CO

ZYPREXA SOLR (Use Olanzapine) CO

ZYPREXA TABS (Use Olanzapine) CO

ZYPREXA ZYDIS TBDP (Use Olanzapine) CO

Dihydroindolones MOLINDONE HYDROCHLORIDE TABS CO

Phenothiazines CHLORPROMAZINE HCL SOLN IJ 25 MG/ML, 50MG/2ML

CO

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

CO

fluphenazine decanoatesoln CO

FLUPHENAZINE HCL CONC OR 5 MG/ML CO

FLUPHENAZINE HCL ELIX OR 2.5 MG/5ML CO

FLUPHENAZINE HCL SOLN IJ 2.5 MG/ML CO

fluphenazine hcl tabs or 1mg, 5 mg, 10 mg, 2.5 mg CO

perphenazine tabs CO

prochlorperazine maleatetabs F

prochlorperazine supp F

thioridazine hcl tabs CO

trifluoperazine hcl tabs CO

Quinolinone Derivatives


28

Drug Name DrugTier

Requirements/Limits

ABILIFY MAINTENA PRSY CO

ABILIFY MAINTENA SRER CO

ABILIFY TABS (Use Aripiprazole) CO

aripiprazole soln CO

aripiprazole tabs CO

aripiprazole tbdp CO

ARISTADA PRSY CO

REXULTI TABS CO

Thioxanthenes

thiothixene caps CO

ANTISEPTICS & DISINFECTANTS

Antiseptics & Disinfectants formaldehyde soln 10%, 10% F QL(90 ml per

fill retail)

ANTIVIRALS - Drugs to Treat Viral Infections

Antiretrovirals

abacavir sulfate soln CO

abacavir sulfate tabs CO

abacavir sulfate-lamivudine tabs CO

abacavir sulfate-lamivudine-zidovudine tabs CO

APTIVUS CAPS CO

APTIVUS SOLN CO

atazanavir sulfate caps CO

ATRIPLA TABS CO

BIKTARVY TABS CO

COMBIVIR TABS (Use Lamivudine-Zidovudine) CO

Drug Name DrugTier

Requirements/Limits

COMPLERA TABS CO

CRIXIVAN CAPS CO

DESCOVY TABS CO

EDURANT TABS CO

efavirenz caps CO

efavirenz tabs CO

EMTRIVA CAPS CO

EMTRIVA SOLN CO

EPIVIR SOLN (Use Lamivudine) CO

EPIVIR TABS (Use Lamivudine) CO

EPZICOM TABS (Use Abacavir Sulfate-Lamivudine)

CO

EVOTAZ TABS CO

fosamprenavir calcium tabs CO

FUZEON SOLR CO

GENVOYA TABS CO

INTELENCE TABS CO

INVIRASE CAPS CO

INVIRASE TABS CO

ISENTRESS CHEW CO

ISENTRESS HD TABS CO

ISENTRESS PACK CO

ISENTRESS TABS CO

JULUCA TABS CO


29

Drug Name DrugTier

Requirements/Limits

KALETRA SOLN 400MG/5ML-100MG/5ML(Use Lopinavir-Ritonavir)

CO

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

lamivudine soln CO

lamivudine tabs CO

lamivudine-zidovudine tabs CO

LEXIVA SUSP 50 MG/ML CO

LEXIVA TABS 700 MG (Use FosamprenavirCalcium)

CO

lopinavir-ritonavir soln CO

nevirapine tabs CO

nevirapine tb24 CO

NORVIR CAPS 100 MG CO

NORVIR SOLN 80 MG/ML CO

NORVIR TABS 100 MG (Use Ritonavir) CO

ODEFSEY TABS CO

PREZCOBIX TABS CO

PREZISTA SUSP CO

PREZISTA TABS CO

RESCRIPTOR TABS CO

RETROVIR CAPS (Use Zidovudine) NF SP

RETROVIR SYRP (Use Zidovudine) NF SP

REYATAZ CAPS 150 MG, 200 MG, 300 MG (Use Atazanavir Sulfate)

CO

REYATAZ PACK 50 MG CO

ritonavir tabs CO

Drug Name DrugTier

Requirements/Limits

SELZENTRY SOLN CO

SELZENTRY TABS CO

stavudine caps CO

STRIBILD TABS CO

SUSTIVA CAPS (Use Efavirenz) CO

SUSTIVA TABS (Use Efavirenz) CO

SYMFI LO TABS CO

tenofovir disoproxilfumarate tabs CO

TIVICAY TABS CO

TRIUMEQ TABS CO

TRIZIVIR TABS (Use Abacavir Sulfate-Lamivudine-Zidovudine)

CO

TROGARZO SOLN CO

TRUVADA TABS CO

TYBOST TABS CO

VIRACEPT TABS CO

VIRAMUNE SUSP 50 MG/5ML CO

VIRAMUNE TABS 200 MG (Use Nevirapine) CO

VIRAMUNE XR TB24 (Use Nevirapine) CO

VIREAD POWD 40 MG/GM CO

VIREAD TABS 150 MG, 200 MG, 250 MG CO

VIREAD TABS 300 MG (Use Tenofovir DisoproxilFumarate)

CO

VITEKTA TABS CO


30

Drug Name DrugTier

Requirements/Limits

ZERIT CAPS 15 MG, 20 MG, 30 MG, 40 MG (Use Stavudine)

CO

ZERIT SOLR 1 MG/ML CO

ZIAGEN SOLN (Use Abacavir Sulfate) CO

ZIAGEN TABS (Use Abacavir Sulfate) CO

zidovudine caps F SP

zidovudine syrp F SP

zidovudine tabs F SP

CMV Agents VALCYTE TABS (Use Valganciclovir HCl) NF QL(2 ea daily)

valganciclovir hcl tabs F QL(2 ea daily)

Hepatitis Agents

MAVYRET TABS F PA; QL(3 eadaily); SP

Herpes Agents

acyclovir caps 200 mg F QL(50 ea per30 days retail)

acyclovir susp 200 mg/5ml F QL(400 ml per30 days retail)

acyclovir tabs 400 mg F QL(3 ea daily)

acyclovir tabs 800 mg F QL(50 ea per30 days retail)

famciclovir tabs F

FAMVIR TABS (Use Famciclovir) NF

valacyclovir hcl tabs 1 gm,1000 mg F QL(42 ea per

21 days retail) valacyclovir hcl tabs 500 mg F QL(2 ea daily)

VALTREX TABS 1 GM (Use Valacyclovir HCl) NF QL(42 ea per

21 days retail) VALTREX TABS 500 MG (Use Valacyclovir HCl) NF QL(2 ea daily)

ZOVIRAX CAPS OR 200 MG (Use Acyclovir) NF QL(50 ea per

30 days retail)

Drug Name DrugTier

Requirements/Limits

ZOVIRAX SUSP OR 200 MG/5ML (Use Acyclovir) NF QL(400 ml per

30 days retail) ZOVIRAX TABS OR 400 MG (Use Acyclovir) NF QL(3 ea daily)

ZOVIRAX TABS OR 800 MG (Use Acyclovir) NF QL(50 ea per

30 days retail) Influenza Agents oseltamivir phosphate caps30 mg F QL(20 ea per

30 days retail) oseltamivir phosphate caps45 mg, 75 mg F QL(10 ea per

30 days retail) oseltamivir phosphate susr6 mg/ml F QL(120 ml per

30 days retail)

RELENZA DISKHALER AEPB F

QL(20 ea perfill retail); AL; Atleast 5 yrs old

TAMIFLU CAPS 30 MG (Use Oseltamivir Phosphate)

F QL(20 ea per30 days retail)

TAMIFLU CAPS 45 MG, 75 MG (Use Oseltamivir Phosphate)


TAMIFLU SUSR 6 MG/ML(Use Oseltamivir Phosphate)

F QL(120 ml per30 days retail)

BETA BLOCKERS - Drugs to Treat High BloodPressure

Alpha-Beta Blockers

carvedilol phosphate cp24 F QL(1 ea daily)

carvedilol tabs 12.5 mg,6.25 mg, 3.125 mg F QL(3 ea daily)

carvedilol tabs 25 mg F QL(4 ea daily)

COREG CR CP24 (Use Carvedilol Phosphate) NF QL(1 ea daily)

COREG TABS 12.5 MG, 6.25 MG, 3.125 MG (Use Carvedilol)

NF QL(3 ea daily)

COREG TABS 25 MG (Use Carvedilol) NF QL(4 ea daily)

labetalol hcl tabs 100 mg F QL(3 ea daily)



31

Drug Name DrugTier

Requirements/Limits


Beta Blockers Cardio-Selective

acebutolol hcl caps F

atenolol tabs F QL(2 ea daily)

bisoprolol fumarate tabs F QL(1 ea daily)

LOPRESSOR TABS (Use Metoprolol Tartrate) NF QL(4 ea daily)

metoprolol succinate tb24100 mg F QL(1 ea daily)

metoprolol succinate tb24200 mg F QL(2 ea daily)

metoprolol succinate tb2425 mg, 50 mg F QL(4 ea daily)

metoprolol tartrate tabs 25mg, 50 mg, 100 mg F QL(4 ea daily)

SECTRAL CAPS (Use Acebutolol HCl) NF

TENORMIN TABS (Use Atenolol) NF QL(2 ea daily)

TOPROL XL TB24 100 MG (Use Metoprolol Succinate) NF QL(1 ea daily)

TOPROL XL TB24 200 MG (Use Metoprolol Succinate) NF QL(2 ea daily)

TOPROL XL TB24 25 MG, 50 MG (Use MetoprololSuccinate)

NF QL(4 ea daily)

ZEBETA TABS (Use Bisoprolol Fumarate) NF QL(1 ea daily)

Beta Blockers Non-Selective BETAPACE AF TABS (Use Sotalol HCl (AFIB/AFL)) NF QL(2 ea daily)

BETAPACE TABS (Use Sotalol HCl) NF QL(2 ea daily)

CORGARD TABS (Use Nadolol) NF QL(2 ea daily)

HEMANGEOL SOLN F PA

INDERAL LA CP24 (Use Propranolol HCl) NF QL(2 ea daily)

nadolol tabs F QL(2 ea daily)

Drug Name DrugTier

Requirements/Limits

pindolol tabs F

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

F QL(2 ea daily)

PROPRANOLOL HCL SOLN OR 20 MG/5ML, 40MG/5ML

F

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

F

sotalol hcl (afib/afl) tabs F QL(2 ea daily)

sotalol hcl tabs 240 mg F

sotalol hcl tabs 80 mg, 120mg, 160 mg F QL(2 ea daily)

TIMOLOL MALEATE TABS F

CALCIUM CHANNEL BLOCKERS - Drugs toTreat High Blood Pressure

Calcium Channel Blockers ADALAT CC TB24 30 MG, 90 MG (Use Nifedipine) NF QL(1 ea daily)

ADALAT CC TB24 60 MG (Use Nifedipine) NF QL(2 ea daily)

amlodipine besylate tabs F QL(1 ea daily)

CALAN SR TBCR (Use Verapamil HCl) NF QL(2 ea daily)

CALAN TABS (Use Verapamil HCl) NF QL(3 ea daily)

CARDIZEM CD CP24 120 MG, 180 MG (Use Diltiazem HCl Coated Beads)

NF

QL(1 ea daily)

CARDIZEM CD CP24 240 MG (Use Diltiazem HCl Coated Beads)

NF QL(2 ea daily)

CARDIZEM TABS (Use Diltiazem HCl) NF QL(3 ea daily)

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

F QL(1 ea daily)

diltiazem hcl coated beads cp24 240 mg F QL(2 ea daily)


32

Drug Name DrugTier

Requirements/Limits

diltiazem hcl cp12 60 mg,90 mg, 120 mg F QL(2 ea daily)

diltiazem hcl cp24 120 mg,180 mg F QL(1 ea daily)

diltiazem hcl cp24 240 mg F QL(2 ea daily)

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

diltiazem hcl tabs 30 mg,60 mg, 90 mg, 120 mg F QL(3 ea daily)

felodipine tb24 F QL(1 ea daily)

nicardipine hcl caps F

nifedipine caps 10 mg, 20 mg F QL(2 ea daily)

nifedipine tb24 30 mg, 90 mg F QL(1 ea daily)

nifedipine tb24 60 mg F QL(2 ea daily)

NORVASC TABS (Use Amlodipine Besylate) NF QL(1 ea daily)

PROCARDIA CAPS (Use Nifedipine) NF QL(2 ea daily)

PROCARDIA XL TB24 30 MG, 90 MG (Use Nifedipine)

NF QL(1 ea daily)

PROCARDIA XL TB24 60 MG (Use Nifedipine) NF QL(2 ea daily)

TIAZAC CP24 (Use Diltiazem HCl Extended Release Beads)

NF QL(1 ea daily)

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

verapamil hcl cp24 or 120mg, 180 mg, 240 mg F QL(2 ea daily)

VERAPAMIL HCL SR CP24 F QL(1 ea daily)

verapamil hcl tabs or 40mg, 80 mg, 120 mg F QL(3 ea daily)

verapamil hcl tbcr or 120mg, 180 mg, 240 mg F QL(2 ea daily)

VERELAN CP24 120 MG, 180 MG, 240 MG (Use Verapamil HCl)

NF QL(2 ea daily)

VERELAN CP24 360 MG F QL(1 ea daily)

Drug Name DrugTier

Requirements/Limits

VERELAN PM CP24 (Use Verapamil HCl) NF

CARDIOTONICS - Drugs to Treat Heart Failureand Abnormal Heart Rhythm

Cardiac Glycosides DIGOXIN SOLN OR 0.05 MG/ML F

digoxin tabs or 0.125 mg,0.25 mg, 125 mcg, 250 mcg

F

LANOXIN TABS OR 125 MCG, 250 MCG (Use Digoxin)

F

CEPHALOSPORINS - Drugs to Treat BacterialInfections

Cephalosporins - 1st Generation

cefadroxil caps F

cefadroxil susr F

cefadroxil tabs F

cephalexin caps 250 mg,500 mg F

cephalexin susr 125mg/5ml, 250 mg/5ml F

KEFLEX CAPS 250 MG, 500 MG (Use Cephalexin) NF

Cephalosporins - 2nd Generation cefaclor caps 250 mg, 500 mg F

CEFACLOR SUSR 125 MG/5ML, 250 MG/5ML,375 MG/5ML

F

cefprozil susr 125 mg/5ml,250 mg/5ml F

QL(100 ml perfill retail); AL;Up to 12 yrs old

cefprozil tabs 250 mg, 500 mg F QL(20 ea per

fill retail)

CEFTIN SUSR 125 MG/5ML, 250 MG/5ML F


CEFTIN TABS 500 MG (Use Cefuroxime Axetil) NF QL(20 ea per

fill retail)


33

Drug Name DrugTier

Requirements/Limits

cefuroxime axetil tabs F QL(20 ea perfill retail)

Cephalosporins - 3rd Generation

cefdinir caps 300 mg F QL(20 ea perfill retail)

cefdinir susr 125 mg/5ml,250 mg/5ml F QL(20 ml per

fill retail) ceftriaxone sodium solr ij 1gm, 250 mg, 500 mg F QL(3 ea per fill

retail)

CHEMICALS

Bulk Chemicals - H's

HALOPERIDOL POWD XX CO

CONTRACEPTIVES - Drugs to PreventPregnancy

Combination Contraceptives - Oral BREVICON-28 TABS (Use Norethindrone & Eth Estradiol)

NF 365 day supplyallowed;QL(1ea daily)

CYCLESSA TABS (Use Desogestrel-EthinylEstradiol (Triphasic))


DESOGEN TABS (Use Desogestrel & EthinylEstradiol)


desogestrel & ethinylestradiol tabs F

365 day supplyallowed;QL(1ea daily)

desogestrel-ethinylestradiol (biphasic) tabs F


desogestrel-ethinylestradiol (triphasic) tabs F


drospirenone-ethinylestradiol tabs F


ESTROSTEP FE TABS (Use Norethindrone Acetate-Ethinyl Estradiol-Fe)

NF

365 day supplyallowed;

ethynodiol diacet & ethestrad tabs F


Drug Name DrugTier

Requirements/Limits

FEMCON FE CHEW (Use Norethindrone & EthinylEstradiol-Fe)

NF 365 day supplyallowed;

GENERESS FE CHEW (Use Norethindrone & Ethinyl Estradiol-Fe)

NF 365 day supplyallowed;

levonorgestrel & ethestradiol tabs F


levonorgestrel-eth estradiol(triphasic) tabs F


levonorgestrel-ethinylestradiol (91-day) tabs F

365 day supplyallowed;QL(1ea daily,91day(s) limit)

LOESTRIN 1.5/30-21TABS (Use Norethindrone Acet & Eth Estra)


LOESTRIN 1/20-21 TABS(Use Norethindrone Acet & Eth Estra)


LOESTRIN FE 1.5/30TABS (Use Norethin Acet & Estrad-Fe)


LOESTRIN FE 1/20 TABS(Use Norethin Acet & Estrad-Fe)


MIRCETTE TABS (Use Desogestrel-EthinylEstradiol (Biphasic))


MODICON TABS (Use Norethindrone & Eth Estradiol)


NECON 1/50-28 TABS F 365 day supplyallowed;QL(1ea daily)

NECON 10/11-28 TABS F 365 day supplyallowed;QL(1ea daily)

norethin acet & estrad-fe tabs 75mg-20mcg-1mg,75mg-30mcg-1.5mg

F 365 day supplyallowed;QL(1ea daily)

norethindrone & eth estradiol tabs F


norethindrone & ethinylestradiol-fe chew F 365 day supply

allowed;


34

Drug Name DrugTier

Requirements/Limits

norethindrone acet & eth estra tabs F


norethindrone acetate-ethinyl estradiol-fe tabs F 365 day supply

allowed;

norethindrone-eth estradiol (triphasic) tabs F


norgestimate-ethinylestradiol (triphasic) tabs F


norgestimate-ethinylestradiol (triphasic) tabs F 365 day supply

allowed;

norgestimate-ethinylestradiol tabs F


norgestrel & ethinylestradiol tabs F


NORINYL 1+35 TABS (Use Norethindrone & Eth Estradiol)


NORINYL 1+50 TABS F 365 day supplyallowed;QL(1ea daily)

OGESTREL TABS F 365 day supplyallowed;QL(1ea daily)

ORTHO TRI-CYCLEN LO TABS (Use Norgestimate-Ethinyl Estradiol(Triphasic))

NF

365 day supplyallowed;

ORTHO TRI-CYCLEN TABS (Use Norgestimate-Ethinyl Estradiol(Triphasic))

NF


ORTHO-CYCLEN TABS (Use Norgestimate-EthinylEstradiol)


ORTHO-NOVUM 1/35TABS (Use Norethindrone & Eth Estradiol)


ORTHO-NOVUM 7/7/7TABS (Use Norethindrone-Eth Estradiol (Triphasic))


OVCON-35 TABS (Use Norethindrone & Eth Estradiol)


Drug Name DrugTier

Requirements/Limits

SEASONIQUE TABS (Use Levonorgestrel-EthinylEstradiol (91-Day))

NF

365 day supplyallowed;QL(1ea daily,91day(s) limit)

TRI-NORINYL 28 TABS (Use Norethindrone-Eth Estradiol (Triphasic))


YASMIN 28 TABS (Use Drospirenone-EthinylEstradiol)


YAZ TABS (Use Drospirenone-EthinylEstradiol)


Combination Contraceptives - Transdermal

XULANE PTWK F 365 day supplyallowed;QL(3ea per fill retail)

Combination Contraceptives - Vaginal

NUVARING RING F 365 day supplyallowed;QL(1ea per fill retail)

Emergency Contraceptives

ELLA TABS F QL(4 ea per365 days retail)

levonorgestrel (emergencyoc) tabs F QL(6 ea per

365 days retail) PLAN B ONE-STEP TABS (Use Levonorgestrel(Emergency OC))


Progestin Contraceptives - Injectable DEPO-PROVERA CONTRACEPTIVE SUSP (Use MedroxyprogesteroneAcetate (Contraceptive))

NF

QL(1 ml per fillretail)

DEPO-PROVERA CONTRACEPTIVE SUSY (Use MedroxyprogesteroneAcetate (Contraceptive))

NF


DEPO-SUBQ PROVERA 104 SUSY F QL(1 ml per fill

retail) medroxyprogesteroneacetate (contraceptive) susp

F QL(1 ml per fillretail)

medroxyprogesteroneacetate (contraceptive) susy



35

Drug Name DrugTier

Requirements/Limits

Progestin Contraceptives - Oral NOR-QD TABS (Use Norethindrone (Contraceptive))


norethindrone (contraceptive) tabs F


ORTHO MICRONOR TABS (Use Norethindrone (Contraceptive))


CORTICOSTEROIDS - Steroid Hormone Drugs toTreat Systemic Swelling Conditions

Glucocorticosteroids CORTEF TABS (Use Hydrocortisone) NF

CORTISONE ACETATE TABS F

dexamethasone elix 0.5 mg/5ml F

DEXAMETHASONE INTENSOL CONC F

dexamethasone sodium phosphate soln ij 4 mg/ml,20 mg/5ml, 120 mg/30ml

F QL(5 ml daily)

DEXAMETHASONE SOLN 0.5 MG/5ML F

dexamethasone tabs 0.75 mg, 0.5 mg, 4 mg, 6 mg,1.5 mg

F

DEXAMETHASONE TABS 1 MG, 2 MG F

hydrocortisone tabs F

MEDROL DOSEPAK TBPK (Use Methylprednisolone) NF

MEDROL TABS 4 MG, 8 MG (Use Methylprednisolone)

NF

methylprednisolone tabs 4mg, 8 mg F

methylprednisolone tbpk 4 mg F

PEDIAPRED SOLN (Use Prednisolone Sodium Phosphate)

NF

Drug Name DrugTier

Requirements/Limits

prednisolone sodiumphosphate soln or 15mg/5ml

F QL(240 ml perfill retail)

prednisolone sodiumphosphate soln or 20mg/5ml


prednisolone sodiumphosphate soln or 5mg/5ml, 6.7 mg/5ml

F

prednisolone soln F

PREDNISOLONE SOLN F

prednisolone syrp F

PREDNISONE INTENSOL CONC F

PREDNISONE SOLN 5 MG/5ML F

prednisone tabs 1 mg, 5mg, 10 mg, 20 mg, 2.5 mg F

PREDNISONE TABS 50 MG F

PREDNISONE TBPK 5 MG, 10 MG F

VERIPRED 20 SOLN (Use Prednisolone Sodium Phosphate)


Mineralocorticoids

fludrocortisone acetate tabs F

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

Antitussives benzonatate caps 100 mg,200 mg F AL; At least 10

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

F

TESSALON PERLES CAPS (Use Benzonatate) NF AL; At least 10

yrs old

Cough/Cold/Allergy Combinations ADVIL COLD & SINUS TABS (Use Pseudoephedrine-Ibuprofen)

NF


36

Drug Name DrugTier

Requirements/Limits

brompheniramine &phenyleph elix F

brompheniramine &pseudoeph elix F

brompheniramine &pseudoeph liqd F

cetirizine-pseudoephedrinetb12 F

CHERACOL PLUS LIQD (Use Dextromethorphan-Guaifenesin)

NF

CHERACOL-D COUGH LIQD (Use Dextromethorphan-Guaifenesin)

NF

CLARITIN-D 12 HOUR TB12 (Use Loratadine & Pseudoephedrine)

NF

CLARITIN-D 24 HOUR TB24 (Use Loratadine & Pseudoephedrine)

NF

DECON-A ELIX F

DECON-A LIQD F

dextromethorphan-guaifenesin liqd F

dextromethorphan-guaifenesin soln F

DIMETAPP COLD & ALLERGY ELIX 1MG/5ML-2.5MG/5ML (Use Brompheniramine &Phenyleph)

NF

guaifenesin-codeine liqd F

guaifenesin-codeine soln F

guaifenesin-codeine syrp F

loratadine & pseudoephedrine tb12 F

loratadine & pseudoephedrine tb24 F

promethazine &phenylephrine soln F


Drug Name DrugTier

Requirements/Limits

promethazine &phenylephrine syrp F


promethazine w/codeinesoln F


promethazine w/codeine syrp F


PROMETHAZINE/PHENYLEPHRINE SYRP F


pseudoephedrine w/codeine-gg soln F

pseudoephedrine-ibuprofentabs F

ZYRTEC-D ALLERGY/CONGESTIONTB12 (Use Cetirizine-Pseudoephedrine)

NF

Misc. Respiratory Inhalants sodium chloride (inhalant)aers 0.9 % F

sodium chloride (inhalant)nebu 0.9 % F

Mucolytics

acetylcysteine soln F

DERMATOLOGICALS - Drugs to Treat SkinConditions

Acne Products ACNE MEDICATION 10 LOTN F

ACNE MEDICATION 5 LOTN F

BENZAC AC WASH LIQD (Use Benzoyl Peroxide) NF RX/OTC

benzoyl peroxide bar 10 % F

BENZOYL PEROXIDE CLEANSER LOTN 6 % F

benzoyl peroxide gel 10 % F RX/OTC

BENZOYL PEROXIDE GEL 2.5 % F


37

Drug Name DrugTier

Requirements/Limits

benzoyl peroxide gel 5 % F

benzoyl peroxide liqd 4 % F

benzoyl peroxide liqd 5 %,10 % F RX/OTC

benzoyl peroxide lotn 6 % F

CLEAN & CLEAR ADVANTAGE 3-IN-1 EXFOLIATING CLEANSER LOTN

F

CLEOCIN-T GEL (Use Clindamycin Phosphate(Topical))


CLEOCIN-T LOTN (Use Clindamycin Phosphate(Topical))


CLEOCIN-T SOLN (Use Clindamycin Phosphate(Topical))

NF

CLINDAGEL GEL F QL(75 ml perfill retail)

clindamycin phosphate(topical) gel F QL(75 ml per

fill retail) clindamycin phosphate(topical) lotn F QL(60 ml per

fill retail) clindamycin phosphate(topical) soln F

DESQUAM-X WASH LIQD (Use Benzoyl Peroxide) NF RX/OTC

ERYGEL GEL (Use Erythromycin (Acne Aid)) NF QL(60 gm per

fill retail)

erythromycin (acne aid) gel F QL(60 gm perfill retail)

erythromycin (acne aid)soln F

isotretinoin caps 10 mg, 20mg, 40 mg F


KLARON LOTN (Use Sulfacetamide Sodium (Acne))


PANOXYL-4 CREAMY WASH LIQD (Use BenzoylPeroxide)

NF

Drug Name DrugTier

Requirements/Limits

RETIN-A CREA (Use Tretinoin) NF

QL(45 gm perfill retail); AL;Up to 35 yrs old

RETIN-A GEL (Use Tretinoin) NF


SODIUM SULFACETAMIDE/SULFUR LOTN


SODIUM SULFACETAMIDE/SULFUR SUSP


sulfacetamide sodium (acne) lotn F QL(120 ml per

fill retail) sulfacetamide sodium w/sulfur lotn 5%-10% F QL(60 gm per

fill retail)

tretinoin crea 0.025 %, 0.05%, 0.1 % F


tretinoin gel 0.025 %, 0.01% F


Anti-inflammatory Agents - Topical diclofenac sodium (topical)gel 1 % F QL(6.68 gm

daily) VOLTAREN GEL (Use Diclofenac Sodium (Topical))

NF QL(6.68 gmdaily)

Antibiotics - Topical BACIGUENT OINT (Use Bacitracin (Topical)) NF QL(454 gm per

fill retail)

bacitracin (topical) oint F QL(454 gm perfill retail)

bacitracin zinc oint F QL(454 gm perfill retail)

BACTROBAN CREA (Use Mupirocin Calcium(Topical))

NF QL(30 gm perfill retail)

gentamicin sulfate (topical) crea F QL(30 gm per

fill retail) gentamicin sulfate (topical)oint F QL(30 gm per

fill retail) mupirocin calcium (topical) crea F QL(30 gm per

fill retail)

mupirocin oint F QL(30 gm perfill retail)


38

Drug Name DrugTier

Requirements/Limits

neomycin-bacitracin-polymyxin oint F QL(454 gm per

fill retail) neomycin-polymyxin w/pramoxine crea F QL(30 gm per

fill retail) NEOSPORIN ORIGINAL OINT (Use Neomycin-Bacitracin-Polymyxin)


NEOSPORIN PLUS PAIN RELIEF MAXIMUM STRENGTH CREA (Use Neomycin-Polymyxin w/Pramoxine)

NF

QL(30 gm perfill retail)

Antifungals - Topical

clotrimazole (topical) crea F QL(113 gm perfill retail);RX/OTC

clotrimazole (topical) soln F QL(60 ml perfill retail);RX/OTC

clotrimazole w/betamethasone crea F QL(45 gm per

fill retail) clotrimazole w/betamethasone lotn F QL(30 ml per

fill retail)

econazole nitrate crea F QL(85 gm perfill retail)

ketoconazole (topical) crea F QL(60 gm perfill retail)

ketoconazole (topical)sham F QL(120 ml per

fill retail) LAMISIL AT CREA (Use Terbinafine HCl (Topical)) NF QL(42 gm per

fill retail) LAMISIL AT JOCK ITCH CREA (Use Terbinafine HCl (Topical))


LOTRIMIN AF CREA 1 % (Use Clotrimazole (Topical))

NF QL(113 gm perfill retail);RX/OTC

LOTRIMIN AF FOR HER CREA (Use Clotrimazole (Topical))


LOTRIMIN AF JOCK ITCH CREA (Use Clotrimazole (Topical))


LOTRISONE CREA (Use Clotrimazole w/Betamethasone)


Drug Name DrugTier

Requirements/Limits

MICATIN CREA (Use Miconazole Nitrate (Topical))


miconazole nitrate (topical) crea F QL(200 ml per

fill retail)

NIZORAL A-D SHAM F QL(200 ml perfill retail)

NIZORAL SHAM (Use Ketoconazole (Topical)) NF QL(120 ml per

fill retail)

nystatin (topical) crea F QL(30 gm perfill retail)

nystatin (topical) oint F QL(30 gm perfill retail)

nystatin (topical) powd F QL(60 gm perfill retail)

nystatin-triamcinolone crea F QL(60 gm perfill retail)

nystatin-triamcinolone oint F QL(60 gm perfill retail)

terbinafine hcl (topical) crea F QL(42 gm perfill retail)

TINACTIN CREA (Use Tolnaftate) NF QL(144 gm per

fill retail) TINACTIN JOCK ITCH CREA (Use Tolnaftate) NF QL(144 gm per

fill retail)

tolnaftate crea F QL(144 gm perfill retail)

Antihistamines-Topical diphenhydramine hcl(topical) crea F

Antineoplastic or Premalignant Lesion Agents -

CARAC CREA F QL(30 gm perfill retail)

EFUDEX CREA (Use Fluorouracil (Topical)) NF QL(40 gm per

fill retail)

fluorouracil (topical) crea F QL(40 gm perfill retail)

FLUOROURACIL CREA 0.5 % F QL(30 gm per

fill retail) FLUOROURACIL SOLN 2 %, 5 % F QL(10 ml per

fill retail) Antipruritics - Topical

camphor & menthol lotn F QL(222 ml perfill retail)


39

Drug Name DrugTier

Requirements/Limits

SARNA LOTN (Use Camphor & Menthol) NF QL(222 ml per

fill retail) Antipsoriatics

calcipotriene crea F QL(60 gm perfill retail)

calcipotriene soln F QL(60 ml perfill retail)

DOVONEX CREA (Use Calcipotriene) NF QL(60 gm per

fill retail)

tazarotene crea F QL(60 gm perfill retail)

TAZORAC CREA 0.05 % F QL(60 gm perfill retail)

TAZORAC CREA 0.1 % (Use Tazarotene) NF QL(60 gm per

fill retail) TAZORAC GEL 0.05 %, 0.1 % F QL(100 gm per

fill retail) Antiseborrheic Products OVACE PLUS WASH LIQD (Use Sulfacetamide Sodium)


OVACE WASH LIQD (Use Sulfacetamide Sodium) NF QL(480 ml per

fill retail)

selenium sulfide lotn 1 % F

selenium sulfide lotn 2.5 % F QL(120 ml perfill retail)

selenium sulfide sham 1 % F

SELSUN BLUE DAILY LOTN (Use Selenium Sulfide)

NF

SELSUN BLUE LOTN (Use Selenium Sulfide) NF

SELSUN BLUE MEDICATED LOTN (Use Selenium Sulfide)

NF

SELSUN BLUE MOISTURIZING LOTN (Use Selenium Sulfide)

NF

sulfacetamide sodium liqd ex F QL(480 ml per

fill retail) Antivirals - Topical

acyclovir topical oint F QL(30 gm perfill retail)

Drug Name DrugTier

Requirements/Limits

ZOVIRAX CREA EX 5 % F QL(5 gm per fillretail)

ZOVIRAX OINT EX 5 % (Use Acyclovir Topical) NF QL(30 gm per

fill retail) Burn Products SILVADENE CREA (Use Silver Sulfadiazine) NF QL(400 gm per

fill retail)

silver sulfadiazine crea F QL(400 gm perfill retail)

Corticosteroids - Topical

APEXICON E CREA F QL(60 gm perfill retail)

betamethasone dipropionate (topical) crea F 1 rtl pack lmt

per fill, betamethasone dipropionate augmented crea


betamethasone valerate crea 0.1 % F QL(45 gm per

fill retail) betamethasone valerate lotn 0.1 % F QL(60 ml per

fill retail) betamethasone valerate oint 0.1 % F QL(45 gm per

fill retail)

clobetasol propionate crea F QL(60 gm perfill retail)

clobetasol propionateemollient base crea F QL(60 gm per

fill retail)

clobetasol propionate gel F QL(60 gm perfill retail)

clobetasol propionate oint F QL(60 gm perfill retail)

clobetasol propionate soln F QL(50 ml perfill retail)

DERMATOP CREA (Use Prednicarbate) NF QL(60 gm per

fill retail) desoximetasone crea 0.05 % F QL(300 gm per

fill retail) DIFLORASONE DIACETATE CREA F QL(60 gm per

fill retail) DIFLORASONE DIACETATE OINT F QL(60 gm per

fill retail) DIPROLENE AF CREA (Use Betamethasone Dipropionate Augmented)



40

Drug Name DrugTier

Requirements/Limits

ELOCON CREA (Use Mometasone Furoate) NF QL(50 gm per

fill retail) ELOCON OINT (Use Mometasone Furoate) NF QL(45 gm per

fill retail)

EPIFOAM FOAM F

fluocinonide crea 0.05 % F QL(120 gm perfill retail)

fluocinonide emulsified base crea F QL(60 gm per

fill retail)

fluocinonide gel 0.05 % F QL(60 gm perfill retail)

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

fluocinonide soln 0.05 % F QL(60 ml perfill retail)

fluticasone propionate crea0.05 % F QL(60 gm per

fill retail) fluticasone propionate oint0.005 % F QL(60 gm per

fill retail) hydrocortisone (topical)crea 0.5 % F

hydrocortisone (topical)crea 1%, 1 % F

QL(454 gm perfill retail);RX/OTC

hydrocortisone (topical)crea 2.5 % F QL(454 gm per

fill retail) hydrocortisone (topical)lotn 1 % F QL(120 ml per

fill retail) hydrocortisone (topical)lotn 2.5 % F QL(118 ml per

fill retail)

hydrocortisone (topical)oint 1 % F


hydrocortisone (topical)oint 2.5 % F QL(454 gm per

fill retail) hydrocortisone butyratesoln F QL(60 ml per

fill retail) hydrocortisone-aloe veracrea 1% F QL(224 gm per

fill retail) LOCOID SOLN (Use Hydrocortisone Butyrate) NF QL(60 ml per

fill retail)

mometasone furoate crea F QL(50 gm perfill retail)

mometasone furoate oint F QL(45 gm perfill retail)

Drug Name DrugTier

Requirements/Limits

mometasone furoate soln F QL(60 ml perfill retail)

MONISTAT SOOTHING CARE ITCH RELIEF CREA (Use Hydrocortisone(Topical))

NF


PREDNICARBATE CREA F QL(60 gm perfill retail)

prednicarbate crea F QL(60 gm perfill retail)

PREDNICARBATE OINT F QL(60 gm perfill retail)

PSORCON CREA F QL(60 gm perfill retail)

TEMOVATE CREA (Use Clobetasol Propionate) NF QL(60 gm per

fill retail) TEMOVATE E CREA (Use Clobetasol PropionateEmollient Base)


TEMOVATE OINT (Use Clobetasol Propionate) NF QL(60 gm per

fill retail) TOPICORT CREA 0.05 % (Use Desoximetasone) NF QL(300 gm per

fill retail) triamcinolone acetonide (topical) crea 0.025 %, 0.1%


triamcinolone acetonide (topical) crea 0.5 % F QL(15 gm per

fill retail) triamcinolone acetonide (topical) lotn 0.025 %, 0.1%


triamcinolone acetonide (topical) oint 0.025 %, 0.1%


triamcinolone acetonide (topical) oint 0.5 % F QL(15 gm per

fill retail) Emollient/Keratolytic Agents

urea crea 40 % F QL(200 gm perfill retail);RX/OTC

urea lotn 40 % F QL(325 ml perfill retail)

Emollients LAC-HYDRIN CREA (Use Lactic Acid (AmmoniumLactate))



41

Drug Name DrugTier

Requirements/Limits

LAC-HYDRIN LOTN (Use Lactic Acid (AmmoniumLactate))


LAC-HYDRIN TWELVE LOTN (Use Lactic Acid (Ammonium Lactate))


lactic acid (ammoniumlactate) crea 12 % F


lactic acid (ammoniumlactate) lotn 12 % F


Immunomodulating Agents - Topical ALDARA CREA (Use Imiquimod) NF

imiquimod crea F

Immunosuppressive Agents - Topical

ELIDEL CREA F

PA; QL(30 gmper fill retail);AL; At least 2 yrs old

Keratolytic/Antimitotic Agents CONDYLOX SOLN (Use Podofilox) NF QL(4 ml per fill

retail) KERALYT GEL (Use Salicylic Acid) NF QL(100 gm per

fill retail)

podofilox soln F QL(4 ml per fillretail)

salicylic acid gel F QL(100 gm perfill retail)

Local Anesthetics - Topical ARTHRITIS PAIN RELIEVING CREA F QL(60 gm per

fill retail)

capsaicin crea 0.025 % F

capsaicin crea 0.075 % F QL(60 gm perfill retail)

capsaicin crea 0.1 % F QL(43 gm perfill retail)

CAPZASIN-HP CREA (Use Capsaicin) NF QL(43 gm per

fill retail)

CAPZASIN-P CREA F QL(43 gm perfill retail)

Drug Name DrugTier

Requirements/Limits

dibucaine oint F QL(57 gm perfill retail)

lidocaine crea 4 % F QL(1 gm daily)

lidocaine hcl crea ex 3 % F QL(454 gm perfill retail)

lidocaine hcl crea ex 4 % F QL(2 ml daily)

lidocaine hcl gel ex 2 % F QL(30 ml perfill retail);RX/OTC

lidocaine-prilocaine crea F QL(30 gm perfill retail)

LMX 4 CREA (Use Lidocaine) NF QL(1 gm daily)

PREDATOR CREA (Use Lidocaine HCl) NF QL(2 ml daily)

Misc. Topical

DRYSOL SOLN F QL(60 ml perfill retail)

lanolin (topical) crea F

OFF DEEP WOODS AERO F QL(170 gm perfill retail)

OFF DEEP WOODS DRY AERO F QL(113 gm per

fill retail) ULTRATHON INSECT REPELLENT 8 AERO F QL(170 gm per

fill retail) zinc oxide (topical) oint 20% F QL(500 gm per

fill retail) Rosacea Agents METROCREAM CREA (Use Metronidazole (Topical))


METROLOTION LOTN (Use Metronidazole (Topical))

NF

metronidazole (topical)crea 0.75 % F QL(45 gm per

fill retail) metronidazole (topical) gel0.75 % F QL(45 gm per

fill retail) metronidazole (topical) lotn0.75 % F

Scabicides & Pediculicides

A-200 GEL EX 0.33%-4% F


42

Drug Name DrugTier

Requirements/Limits

ELIMITE CREA (Use Permethrin) NF QL(60 gm per

fill retail)

EURAX CREA F QL(60 gm perfill retail)

EURAX LOTN F QL(454 gm perfill retail)

KLOUT SHAM F

LICEMD GEL F

LICIDE TREATMENT KIT KIT F

malathion lotn F QL(59 ml perfill retail)

NIX CREME RINSE LIQD (Use Permethrin) NF

OVIDE LOTN (Use Malathion) NF QL(59 ml per

fill retail)

permethrin aero xx 0.5 % F

permethrin crea ex 5 % F QL(60 gm perfill retail)

permethrin liqd ex 1 % F

permethrin lotn ex 1 % F QL(120 ml perfill retail)

pyrethrins-piperonylbutoxide liqd 0.33%-4% F QL(240 ml per

fill retail) pyrethrins-piperonylbutoxide liqd 1.2%-0.3%-0.3%-2.4%-3%

F

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

F

pyrethrins-piperonylbutoxide sham 0.33%-4% F QL(240 ml per

fill retail) pyrethrins-piperonylbutoxide-permethrin-nitremover kit

F

RA LICE SOLUTION KIT KIT F

RID AERO XX 0.5 % (Use Permethrin) NF

Drug Name DrugTier

Requirements/Limits

RID COMPLETE LICE ELIMINATION KIT (Use Pyrethrins-PiperonylButoxide-Permethrin-Nit Remover)

NF

RID ESSENTIAL LICE ELIMINATION KIT KIT F

RID LIQD EX 0.33%-4% (Use Pyrethrins-PiperonylButoxide)


SCHOOLTIME SHAMPOO SHAM F

SPINOSAD SUSP F

QL(120 ml perfill retail,240 ml per 30 daysretail)

Tar Products

coal tar extract sham 0.5 % F

DHS TAR GEL SHAM (Use Coal Tar Extract) NF

DHS TAR SHAM (Use Coal Tar Extract) NF

NEUTROGENA T/GELSHAM (Use Coal Tar Extract)

NF

NEUTROGENA T/GELSTUBBORN ITCH CONTROL SHAM (Use Coal Tar Extract)

NF

DIAGNOSTIC PRODUCTS

Diagnostic Tests CHEK-STIX COMBO PAK URINALYSIS CONTROL STRP


CHEK-STIX CONTROL STRP F QL(50 ea per

fill retail)

CHEMSTRIP-K STRP F QL(50 ea perfill retail)

KETOCARE STRP F QL(50 ea perfill retail)

KETONE TEST STRIPS STRP F QL(50 ea per

fill retail)

KETOSTIX STRP F QL(50 ea perfill retail)


43

Drug Name DrugTier

Requirements/Limits

NOVA MAX PLUS KETONE TESTSTRIPS STRP

F

PRECISION XTRA STRP VI F

PTS PANELS KETONE TEST STRP F

RELION KETONE STRP F QL(50 ea perfill retail)

RELION KETONE TEST STRIPS STRP F QL(50 ea per

fill retail) TRUE METRIX BLOOD GLUCOSETEST STRIPS STRP

F QL(5 ea daily);RX/OTC

TRUE METRIX SELF MONITORING BLOOD GLUCOSE STRIPS STRP


TRUETEST BLOOD GLUCOSE TEST STRIPS STRP


TRUETEST BLOOD GLUCOSE TEST STRP F QL(5 ea daily);

RX/OTC

TRUETEST STRIPS STRP F QL(5 ea daily);RX/OTC

TRUETRACK BLOOD GLUCOSE TEST STRP F QL(5 ea daily);

RX/OTC

TRUETRACK TEST STRP F QL(5 ea daily);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

Drug Name DrugTier

Requirements/Limits

PANCREAZE CPEP 14200UNIT-4200UNIT-24600UNIT, 35500UNIT-10500UNIT-61500UNIT, 54700UNIT-21000UNIT-83900UNIT, 56800UNIT-16800UNIT-98400UNIT

F

DIURETICS - Drugs to Treat Heart, CirculationConditions and Blood Pressure

Carbonic Anhydrase Inhibitors

acetazolamide cp12 F

acetazolamide tabs F

DIAMOX CP12 (Use Acetazolamide) NF

methazolamide tabs F

NEPTAZANE TABS (Use Methazolamide) NF

Diuretic Combinations ALDACTAZIDE TABS 25MG-25MG (Use Spironolactone &Hydrochlorothiazide)

NF

amiloride & hydrochlorothiazide tabs F QL(1 ea daily)

DYAZIDE CAPS (Use Triamterene & Hydrochlorothiazide)

NF QL(1 ea daily)

MAXZIDE TABS (Use Triamterene & Hydrochlorothiazide)

NF QL(1 ea daily)

MAXZIDE-25 TABS (Use Triamterene & Hydrochlorothiazide)

NF QL(1 ea daily)

spironolactone &hydrochlorothiazide tabs F

triamterene & hydrochlorothiazide caps F QL(1 ea daily)

triamterene & hydrochlorothiazide tabs F QL(1 ea daily)

TRIAMTERENE/HYDROCHLOROTHIAZIDE CAPS F QL(1 ea daily)

Loop Diuretics


44

Drug Name DrugTier

Requirements/Limits

bumetanide tabs F

BUMEX TABS (Use Bumetanide) NF

DEMADEX TABS 20 MG (Use Torsemide) NF

DEMADEX TABS 5 MG, 10 MG (Use Torsemide) NF QL(1 ea daily)

furosemide soln or 10 mg/ml F

FUROSEMIDE SOLN OR 8 MG/ML F

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

LASIX TABS (Use Furosemide) NF

torsemide tabs 20 mg F

torsemide tabs 5 mg, 10mg, 100 mg F QL(1 ea daily)

Potassium Sparing Diuretics ALDACTONE TABS (Use Spironolactone) NF

amiloride hcl tabs F QL(4 ea daily)

spironolactone tabs F

Thiazides and Thiazide-Like Diuretics CHLOROTHIAZIDE TABS 250 MG F QL(2 ea daily)

chlorothiazide tabs 500 mg F QL(4 ea daily)

chlorthalidone tabs F

hydrochlorothiazide caps12.5 mg F

hydrochlorothiazide tabs 25mg, 50 mg F

indapamide tabs F

metolazone tabs F

MICROZIDE CAPS (Use Hydrochlorothiazide) NF

Drug Name DrugTier

Requirements/Limits

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

Bone Density Regulators ACTONEL TABS 35 MG (Use Risedronate Sodium) NF PA; QL(0.15 ea

daily) ACTONEL TABS 5 MG, 30 MG (Use Risedronate Sodium)

NF PA; QL(1 eadaily)

ALENDRONATE SODIUM SOLN 70 MG/75ML F QL(10.8 ml

daily) alendronate sodium tabs 35 mg, 70 mg F QL(0.15 ea

daily) ALENDRONATE SODIUM TABS 40 MG F QL(1 ea daily)

alendronate sodium tabs 5 mg, 10 mg F QL(1 ea daily)

ATELVIA TBEC (Use Risedronate Sodium) NF

calcitonin (salmon) soln F

FORTICAL SOLN F

FOSAMAX TABS (Use Alendronate Sodium) NF QL(0.15 ea

daily) MIACALCIN SOLN IJ 200 UNIT/ML F

MIACALCIN SOLN NA 200 UNIT/ACT (Use Calcitonin (Salmon))

NF

risedronate sodium tabs 35 mg F PA; QL(0.15 ea

daily) risedronate sodium tabs 5 mg, 30 mg F PA; QL(1 ea

daily) risedronate sodium tbec 35 mg F

Growth Hormones GENOTROPIN SOLR 5 MG F PA; SP

NORDITROPIN FLEXPRO SOLN F PA; SP

OMNITROPE SOLN 5 MG/1.5ML, 10 MG/1.5ML F PA; SP

ZOMACTON SOLR 5 MG F PA; SP


45

Drug Name DrugTier

Requirements/Limits

Hormone Receptor Modulators EVISTA TABS (Use Raloxifene HCl) NF QL(1 ea daily)

raloxifene hcl tabs F QL(1 ea daily)

LHRH/GnRH Agonist Analog Pituitary LUPRON DEPOT-PED (1-MONTH) KIT F PA; SP

LUPRON DEPOT-PED (3-MONTH) KIT F PA; SP

SUPPRELIN LA KIT F PA; SP

Metabolic Modifiers calcitriol caps or 0.25 mcg,0.5 mcg F

CARNITOR SF SOLN (Use Levocarnitine (MetabolicModifiers))

NF QL(30 ml daily)

CARNITOR SOLN 1 GM/10ML (Use Levocarnitine (MetabolicModifiers))

NF

QL(30 ml daily)

CARNITOR TABS 330 MG (Use Levocarnitine (Metabolic Modifiers))

NF QL(3 ea daily);RX/OTC

levocarnitine (metabolicmodifiers) soln 1 gm/10ml F QL(30 ml daily)

levocarnitine (metabolicmodifiers) tabs 330 mg F QL(3 ea daily);

RX/OTC ROCALTROL CAPS 0.25 MCG, 0.5 MCG (Use Calcitriol)

NF

SENSIPAR TABS F PA; SP

Posterior Pituitary Hormones

DDAVP SOLN NA 0.01 % F QL(5 ml per fillretail)

DDAVP SOLN NA 0.01 % (Use DesmopressinAcetate Spray)

NF QL(5 ml per fillretail)

DDAVP TABS OR 0.1 MG, 0.2 MG (Use Desmopressin Acetate)

NF QL(6 ea daily)

desmopressin acetatespray refrigerated soln F QL(5 ml per fill

retail)

Drug Name DrugTier

Requirements/Limits

desmopressin acetatespray soln F QL(5 ml per fill

retail) desmopressin acetate tabsor 0.1 mg, 0.2 mg F QL(6 ea daily)

ESTROGENS - Hormone Replacement/ModifyingDrugs

Estrogen Combinations ACTIVELLA TABS (Use Estradiol & Norethindrone Acetate)

NF QL(1 ea daily)

COMBIPATCH PTTW F QL(0.29 eadaily)

esterified estrogens &methyltestosterone tabs F QL(1 ea daily)

estradiol & norethindrone acetate tabs F QL(1 ea daily)

FEMHRT LOW DOSE TABS (Use Norethindrone Acetate-Ethinyl Estradiol)

NF

norethindrone acetate-ethinyl estradiol tabs2.5mcg-0.5mg

F

PREMPHASE TABS F QL(1 ea daily)

PREMPRO TABS F QL(1 ea daily)

Estrogens

ALORA PTTW F QL(0.29 eadaily)

CLIMARA PTWK (Use Estradiol) NF QL(0.143 ea

daily) ESTRACE TABS OR 0.5 MG, 1 MG, 2 MG (Use Estradiol)

NF

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

F

QL(0.29 eadaily)

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

QL(0.143 eadaily)

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


46

Drug Name DrugTier

Requirements/Limits

ESTROPIPATE TABS 0.75 MG, 1.5 MG F QL(1 ea daily)

ESTROPIPATE TABS 3 MG F QL(2 ea daily)

MINIVELLE PTTW F QL(0.29 eadaily)

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

F QL(1 ea daily)

VIVELLE-DOT PTTW (Use Estradiol) NF QL(0.29 ea

daily) FLUOROQUINOLONES - Drugs to Treat BacterialInfections

Fluoroquinolones CIPRO TABS 250 MG, 500 MG (Use CiprofloxacinHCl)

NF

CIPROFLOXACIN HCL TABS 100 MG F QL(6 ea per fill

retail) ciprofloxacin hcl tabs 250mg, 500 mg, 750 mg F

LEVAQUIN TABS (Use Levofloxacin) NF

QL(1 eadaily,14 ea perfill retail)

levofloxacin tabs 250 mg,500 mg, 750 mg F

QL(1 eadaily,14 ea perfill retail)

ofloxacin tabs 400 mg F QL(56 ea perfill retail)

GASTROINTESTINAL AGENTS - MISC. -Miscellaneous Gastrointestinal Drugs

Antiflatulents GAS-X CHEW (Use Simethicone) NF

MYLICON INFANTS GAS RELIEF SUSP (Use Simethicone)


MYLICON SUSP (Use Simethicone) NF QL(60 ml per

fill retail)

simethicone chew 80 mg F

simethicone liqd 20mg/0.3ml, 40 mg/0.6ml F QL(30 ml per

fill retail) simethicone susp 20mg/0.3ml, 40 mg/0.6ml F QL(60 ml per

fill retail)

Drug Name DrugTier

Requirements/Limits

Bile Acid Synthesis Disorder Agents

CHOLBAM CAPS F PA; QL(5 eadaily); SP

Gallstone Solubilizing Agents ACTIGALL CAPS (Use Ursodiol) NF QL(3 ea daily)

URSO 250 TABS (Use Ursodiol) NF QL(7 ea daily)

ursodiol caps 300 mg F QL(3 ea daily)

ursodiol tabs 250 mg F QL(7 ea daily)

Gastrointestinal Chloride Channel Activators

AMITIZA CAPS F PA

Gastrointestinal Stimulants

metoclopramide hcl soln F

metoclopramide hcl tabs F

REGLAN TABS (Use Metoclopramide HCl) NF

Inflammatory Bowel Agents AZULFIDINE EN-TABS TBEC (Use Sulfasalazine) NF

AZULFIDINE TABS (Use Sulfasalazine) NF

balsalazide disodium caps F QL(9 ea daily)

COLAZAL CAPS (Use Balsalazide Disodium) NF QL(9 ea daily)

DELZICOL CPDR F QL(6 ea daily)

MESALAMINE DR TBEC F QL(3 ea daily)

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

SFROWASA ENEM F

sulfasalazine tabs F

sulfasalazine tbec F

Intestinal Acidifiers lactulose (encephalopathy)soln F


47

Drug Name DrugTier

Requirements/Limits

Phosphate Binder Agents calcium acetate (phosphatebinder) caps F

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

Alkalinizers potassium citrate(alkalinizer) tbcr 540 mg,1080 mg

F

potassium citrate-citric acidpack 3300mg-1002mg F

SHOHLS SOLUTION MODIFIED SOLN (Use Sodium Citrate & Citric Acid)

NF


sodium citrate & citric acid soln F


UROCIT-K 10 TBCR (Use Potassium Citrate (Alkalinizer))

NF

UROCIT-K 5 TBCR (Use Potassium Citrate (Alkalinizer))

NF

Genitourinary Irrigants sodium chloride (guirrigant) soln F

Interstitial Cystitis Agents

ELMIRON CAPS F QL(3 ea daily)

Prostatic Hypertrophy Agents

finasteride tabs F QL(1 ea daily)

FLOMAX CAPS (Use Tamsulosin HCl) NF QL(2 ea daily)

PROSCAR TABS (Use Finasteride) NF QL(1 ea daily)

tamsulosin hcl caps F QL(2 ea daily)

Urinary Analgesics phenazopyridine hcl tabs100 mg, 200 mg F

PYRIDIUM TABS (Use Phenazopyridine HCl) NF

Drug Name DrugTier

Requirements/Limits

GOUT AGENTS - Drugs to Treat Gout

Gout Agent Combinations colchicine w/ probenecidtabs F

Gout Agents

allopurinol tabs F

COLCHICINE TABS F

QL(6 ea per fillretail)1 rtl MAXfill,30 rtl day(s)supply,

COLCRYS TABS F

QL(6 ea per fillretail)1 rtl MAXfill,30 rtl day(s)supply,

ZYLOPRIM TABS (Use Allopurinol) NF

Uricosurics

probenecid tabs F

HEMATOLOGICAL AGENTS - MISC. - Drugs toTreat Blood Disorders

Antihemophilic Products

ADVATE SOLR CO

ADYNOVATE SOLR CO

AFSTYLA KIT CO

ALPHANATE/VONWILLEBRANDFACTOR COMPLEX/HUMAN SOLR

CO

ALPHANINE SD SOLR CO

ALPROLIX SOLR CO

BEBULIN SOLR CO

BENEFIX KIT CO

COAGADEX SOLR CO

CORIFACT KIT CO

ELOCTATE SOLR CO


48

Drug Name DrugTier

Requirements/Limits

FEIBA SOLR CO

HELIXATE FS KIT CO

HEMOFIL M SOLR CO

HUMATE-P SOLR CO

IDELVION SOLR CO

IXINITY SOLR CO

KOATE SOLR CO

KOATE-DVI SOLR CO

KOGENATE FS BIO-SET KIT CO

KOGENATE FS KIT CO

KOVALTRY SOLR CO

MONOCLATE-P KIT CO

MONONINE SOLR CO

NOVOEIGHT SOLR CO

NOVOSEVEN RT SOLR CO

NUWIQ KIT CO

NUWIQ SOLR CO

OBIZUR SOLR CO

PROFILNINE SD SOLR CO

PROFILNINE SOLR CO

REBINYN SOLR CO

RECOMBINATE SOLR CO

RIXUBIS SOLR CO

TRETTEN SOLR CO

VONVENDI SOLR CO

Drug Name DrugTier

Requirements/Limits

WILATE KIT CO

XYNTHA KIT CO

XYNTHA SOLOFUSE KIT CO

Hematorheologic Agents

pentoxifylline tbcr F

Platelet Aggregation Inhibitors AGRYLIN CAPS (Use Anagrelide HCl) NF PA

anagrelide hcl caps F PA

BRILINTA TABS F QL(2 ea daily)

cilostazol tabs F QL(2 ea daily)

clopidogrel bisulfate tabs75 mg F QL(1 ea daily)

dipyridamole tabs F

EFFIENT TABS (Use Prasugrel HCl) NF QL(1 ea daily)

PERSANTINE TABS (Use Dipyridamole) NF

PLAVIX TABS 75 MG (Use Clopidogrel Bisulfate) NF QL(1 ea daily)

prasugrel hcl tabs F QL(1 ea daily)

HEMATOPOIETIC AGENTS - Drugs to TreatBlood Disorders

Agents for Sickle Cell Anemia

DROXIA CAPS F

Cobalamins cyanocobalamin soln ij1000 mcg/ml F

Folic Acid/Folates

folic acid tabs or 1 mg F RX/OTC

folic acid tabs or 400 mcg,800 mcg F

Hematopoietic Growth Factors

EPOGEN SOLN F SP


49

Drug Name DrugTier

Requirements/Limits

ZARXIO SOSY F PA; SP

Hematopoietic Mixtures ferrous fumarate-fa-b complex-c-zn-mg-mn-cutabs

F QL(1 ea daily)

Iron FER-IN-SOL SOLN (Use Ferrous Sulfate) NF

FERRETTS TABS F

ferrous fumarate tabs 324 mg F

ferrous gluconate tabs 27mg, 240 mg F

FERROUS GLUCONATE TABS 324 MG F

ferrous sulfate dried tbcr 160 mg F

ferrous sulfate elix 220 mg/5ml F

ferrous sulfate soln 15 mg/ml F

ferrous sulfate tabs 28 mg,65 mg, 325 mg F

FERROUS SULFATE TBEC 324 MG F

ferrous sulfate tbec 325 mg F

HEMOCYTE TABS (Use Ferrous Fumarate) NF

IRON CHEWS PEDIATRIC CHEW F

polysaccharide ironcomplex caps F

HEMOSTATICS - Drugs to Stop Bleeding/TreatBlood Disorders

Hemostatics - Systemic

AMICAR TABS 500 MG F QL(24 ea perfill retail); SP

LYSTEDA TABS (Use Tranexamic Acid) NF AL; At least 12

yrs old

tranexamic acid tabs F AL; At least 12 yrs old

Drug Name DrugTier

Requirements/Limits

HYPNOTICS/SEDATIVES/SLEEP DISORDERAGENTS

Antihistamine Hypnotics diphenhydramine hcl(sleep) caps 50 mg F

diphenhydramine hcl(sleep) tabs 25 mg, 50 mg F

doxylamine succinate(sleep) tabs F

NYTOL MAXIMUM STRENGTH TABS (Use Diphenhydramine HCl(Sleep))

NF

UNISOM SLEEPGELS CAPS (Use Diphenhydramine HCl(Sleep))

NF

UNISOM TABS (Use Doxylamine Succinate(Sleep))

NF

Barbiturate Hypnotics phenobarbital elix 20mg/5ml F

phenobarbital soln 20mg/5ml F

PHENOBARBITAL TABS 15 MG, 30 MG, 60 MG, 100 MG

F

phenobarbital tabs 16.2mg, 32.4 mg, 64.8 mg, 97.2 mg

F

Non-Barbiturate Hypnotics AMBIEN TABS (Use Zolpidem Tartrate) NF QL(1 ea daily)

FLURAZEPAM HCL CAPS F QL(1 ea daily)

HALCION TABS (Use Triazolam) NF QL(1 ea daily)

midazolam hcl soln ij 5mg/ml, 2 mg/2ml, 5mg/5ml, 10 mg/2ml, 25mg/5ml, 10 mg/10ml, 50mg/10ml

F

RESTORIL CAPS 15 MG, 30 MG (Use Temazepam) NF



50

Drug Name DrugTier

Requirements/Limits

SONATA CAPS (Use Zaleplon) NF


temazepam caps 15 mg,30 mg F


TRIAZOLAM TABS 0.125 MG F QL(1 ea daily)

triazolam tabs 0.25 mg F QL(1 ea daily)

zaleplon caps F QL(1 ea daily);AL; At least 18 yrs old

zolpidem tartrate tabs or 5mg, 10 mg F QL(1 ea daily)

LAXATIVES - Bowel Treatment Drugs

Bulk Laxatives

calcium polycarbophil tabs F

EVAC POWD (Use Psyllium) NF

FIBERCON TABS (Use Calcium Polycarbophil) NF

KONSYL POWD 100 % (Use Psyllium) NF

METAMUCIL CAPS (Use Psyllium) NF

METAMUCIL ORIGINAL TEXTURE POWD (Use Psyllium)

NF

METAMUCIL POWD (Use 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 COLYTE-FLAVOR PACKS SOLR (Use PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod Sulfate)

NF


Drug Name DrugTier

Requirements/Limits

GOLYTELY SOLR 236GM-22.74GM-5.86GM-2.97GM-6.74GM (Use PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod Sulfate)

NF


NULYTELY/FLAVORPACKS SOLR (Use PEG 3350-Potassium Chloride-Sod Bicarbonate-Sod Chloride)

NF


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


peg 3350-potassiumchloride-sod bicarbonate-sod chloride solr


sennosides-docusate sodium tabs F

SENOKOT S TABS (Use Sennosides-Docusate Sodium)

NF

Laxatives - Miscellaneous glycerin (laxative) supp 2 gm F

GLYCERIN ADULT SUPP (Use Glycerin (Laxative)) NF

lactulose soln F

MIRALAX PACK (Use Polyethylene Glycol 3350) NF RX/OTC

MIRALAX POWD (Use Polyethylene Glycol 3350) NF QL(34 gm

daily); RX/OTC polyethylene glycol 3350pack F RX/OTC

polyethylene glycol 3350powd F QL(34 gm

daily); RX/OTC SORBITOL SOLN OR 70 % F

Saline Laxatives FLEET ENEMA ENEM (Use Sodium Phosphates) NF

FLEET ENEMA SIX PACK ENEM (Use Sodium Phosphates)

NF

FLEET PEDIATRIC ENEM (Use Sodium Phosphates) NF


51

Drug Name DrugTier

Requirements/Limits

magnesium citrate soln1.745gm/30ml, 1.745gm/30ml,

F

magnesium hydroxide susp F

sodium phosphates enemre 16gm/133ml-6gm/133ml,19gm/118ml-7gm/118ml,9.5gm/59ml-3.5gm/59ml,19gm/118ml-19gm/118ml-7gm/118ml-7gm/118ml

F

Stimulant Laxatives

bisacodyl supp F

bisacodyl tbec F

DULCOLAX SUPP (Use Bisacodyl) NF

DULCOLAX TBEC (Use Bisacodyl) NF

sennosides tabs 8.6 mg F

SENOKOT TABS (Use Sennosides) NF

Surfactant Laxatives COLACE CAPS (Use Docusate Sodium) NF

COLACE CLEAR CAPS (Use Docusate Sodium) NF

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

docusate sodium liqd or 50mg/5ml, 150 mg/15ml F

docusate sodium syrp or60 mg/15ml F

docusate sodium tabs or 100 mg F

MACROLIDES - Drugs to Treat BacterialInfections

Azithromycin AZITHROMYCIN PACK 1 GM F QL(2 ea per fill

retail) azithromycin susr 100mg/5ml F QL(15 ml per

fill retail) azithromycin susr 200mg/5ml F QL(30 ml per

fill retail)

Drug Name DrugTier

Requirements/Limits

azithromycin tabs 250 mg F QL(6 ea per fillretail)

azithromycin tabs 500 mg F QL(4 ea daily)

azithromycin tabs 600 mg F

ZITHROMAX SUSR 100 MG/5ML (Use Azithromycin)


ZITHROMAX SUSR 200 MG/5ML (Use Azithromycin)


ZITHROMAX TABS 250 MG (Use Azithromycin) NF QL(6 ea per fill

retail) ZITHROMAX TABS 500 MG (Use Azithromycin) NF QL(4 ea daily)

ZITHROMAX TABS 600 MG (Use Azithromycin) NF

ZITHROMAX TRI-PAK TABS (Use Azithromycin) NF QL(4 ea daily)

ZITHROMAX Z-PAK TABS (Use Azithromycin) NF QL(6 ea per fill

retail) Clarithromycin BIAXIN SUSR 250 MG/5ML (Use Clarithromycin)


BIAXIN TABS 250 MG, 500 MG (Use Clarithromycin) NF QL(28 ea per

fill retail) CLARITHROMYCIN SUSR 125 MG/5ML F QL(100 ml per

fill retail) clarithromycin susr 125mg/5ml F QL(100 ml per

fill retail) CLARITHROMYCIN SUSR 250 MG/5ML F QL(200 ml per

fill retail) clarithromycin susr 250mg/5ml F QL(200 ml per

fill retail) clarithromycin tabs 250 mg,500 mg F QL(28 ea per

fill retail)

clarithromycin tb24 500 mg F QL(14 ea perfill retail)

Erythromycins

E.E.S. 400 TABS F

E.E.S. GRANULES SUSR (Use ErythromycinEthylsuccinate)

NF


52

Drug Name DrugTier

Requirements/Limits

ERY-TAB TBEC F

ERYPED 200 SUSR (Use ErythromycinEthylsuccinate)

NF

ERYPED 400 SUSR F

ERYTHROCIN STEARATE TABS F

erythromycin base cpep F

erythromycin base tabs F

erythromycinethylsuccinate susr 200mg/5ml

F

ERYTHROMYCIN ETHYLSUCCINATE TABS 400 MG

F

PCE TBEC F

MEDICAL DEVICES AND SUPPLIES

Bandages-Dressings-Tape ALLEVYN PLUS CAVITY PADS F RX/OTC

ALLEVYN THIN PADS F RX/OTC

AMD FOAM DRESSING 4"X4" PADS F RX/OTC

AMD FOAM DRESSING/TOPSHEET4"X4" PADS

F RX/OTC

BAND-AID GAUZE PADS LARGE4" X 4" PADS F RX/OTC

BAND-AID GAUZE PADS MEDIUM 3" X 3" PADS F

BAND-AID GAUZE PADS SMALL2" X 2" PADS F RX/OTC

BAND-AID MIRASORB GAUZE SPONGES LARGE 4" X 4" PADS

F RX/OTC

BIATAIN ADHESIVE FOAM DRESSING 4"X4" PADS

F RX/OTC

BIATAIN FOAM DRESSING 4"X4" PADS F RX/OTC

Drug Name DrugTier

Requirements/Limits

BIOGUARD GAUZE SPONGE 2"X2" 8 PLY PADS

F RX/OTC

BIOGUARD GAUZE SPONGES 4"X4" 12 PLY PADS

F RX/OTC

BORDERED GAUZE PADS F RX/OTC

CARRASMART FOAM PADS F RX/OTC

CARRASMART PADS F RX/OTC

COPA ISLAND BORDERED FOAM DRESSING 4"X4" PADS

F RX/OTC

COPA PLUS HYDROPHILIC FOAM DRESSING 4"X4" PADS

F RX/OTC

COVRSITE COVER DRESSING PADS F RX/OTC

COVRSITE PLUS COMPOSITE DRESSING PADS

F RX/OTC

CUREX ALL-PURPOSE SPONGES 4"X4" 4 PLY PADS

F RX/OTC

CURITY ALL PURPOSE SPONGES 2"X2" 4PLY PADS

F RX/OTC

CURITY ALL PURPOSE SPONGES 2"X2" PADS F RX/OTC


F

CURITY ALL PURPOSE SPONGES 4 PLY PADS F RX/OTC


F RX/OTC

CURITY ALL PURPOSE SPONGES 4"X4" 4PLY/SOFT POUCH PADS

F RX/OTC

CURITY ALL PURPOSE SPONGES 4"X4" PADS F RX/OTC


53

Drug Name DrugTier

Requirements/Limits

CURITY AMD ANTIMICROBIALGAUZE SPONGES 2"X2" 8 PLY PADS

F

RX/OTC

CURITY AMD ANTIMICROBIALGAUZE SPONGES 4"X4" 12 PLY PADS

F

RX/OTC

CURITY COVER SPONGE 4"X4" PADS F RX/OTC

CURITY COVER SPONGES 3"X3" PADS F

CURITY COVER SPONGES 4"X4" PADS F RX/OTC

CURITY DRESSING SPONGES 4"X4" 6 PLY PADS

F RX/OTC

CURITY GAUZE PADS 2"X2" 12 PLY PADS F RX/OTC

CURITY GAUZE PADS 2"X2" PADS F RX/OTC

CURITY GAUZE PADS 3"X3" PADS F

CURITY GAUZE PADS 4"X4" 12 PLY PADS F RX/OTC

CURITY GAUZE SPONGE 2"X2" 8 PLY PADS F RX/OTC

CURITY GAUZE SPONGE 2"X2"12 PLY PADS F RX/OTC

CURITY GAUZE SPONGE 3"X3" 12 PLY PADS F




CURITY GAUZE SPONGE 4"X4"16 PLY PADS F RX/OTC

CURITY GAUZE SPONGES 4"X4" 12 PLY PADS

F RX/OTC

CURITY GAUZE SPONGES 4"X4" 8 PLY PADS

F RX/OTC

CURITY NON-ADHERENT STRIPS 3"X3" PADS F

Drug Name DrugTier

Requirements/Limits

CURITY SPONGES/CELLULOSEFILLED/2"X2" PADS

F RX/OTC

CURITY SPONGES/CELLULOSEFILLED/4"X4" PADS

F RX/OTC

CVS GAUZE PAD 3"X3" PADS F

CVS GAUZE PADS 2"X2" 12-PLY PADS F RX/OTC

CVS GAUZE PADS 4"X4" 12-PLY PADS F RX/OTC

CVS GAUZE PADS STERILE 4"X4" 12-PLY PADS

F RX/OTC

DERMACEA DRAIN SPONGES 4"X4" PADS F RX/OTC

DERMACEA GAUZE SPONGE 2"X2" 12 PLY PADS

F RX/OTC


F RX/OTC


F


F


F RX/OTC


F RX/OTC


F RX/OTC

DERMACEA I.V. DRAIN SPONGES 2"X2" PADS F RX/OTC

DERMACEA I.V. DRAIN SPONGES 4"X4" PADS F RX/OTC

DERMACEA I.V. SPONGES 2"X2" PADS F RX/OTC

DERMACEA NON-WOVEN SPONGES 2"X2" 4 PLY PADS

F RX/OTC


54

Drug Name DrugTier

Requirements/Limits


F


F RX/OTC


F RX/OTC

DERMACEA TYPE VII GAUZE 2"X2" 12 PLY PADS

F RX/OTC

DERMACEA TYPE VII GAUZE 2"X2" 8 PLY PADS F RX/OTC


F

DERMACEA TYPE VII GAUZE 3"X3" 12PLY PADS

F


F RX/OTC


F RX/OTC

DERMACEA TYPE VII GAUZE 4"X4" 8 PLY PADS F RX/OTC

DERMACEA X-RAY SPONGES 4"X4" 16 PLY PADS

F RX/OTC

DERMALEVIN ADHESIVE FOAMDRESSING 4"X4" PADS

F RX/OTC

DRYMAX EXTRA PADS F RX/OTC

EQL GAUZE PADS 2"X2"/SMALL PADS F RX/OTC

EQL GAUZE PADS 4"X4"/LARGE PADS F RX/OTC

EQL GAUZE STERILE PADS 3"X3" PADS F

EXCILON AMD ANTIMICROBIALDRAIN SPONGES 4"X4" 6 PLY PADS

F

RX/OTC

Drug Name DrugTier

Requirements/Limits

EXCILON AMD ANTIMICROBIALNON-WOVEN SPONGES 4"X4" 6 PLY PADS

F

RX/OTC

EXCILON DRAIN SPONGE 4"X4" PADS F RX/OTC

EXCILON DRAIN SPONGES 4"X4" 6 PLY PADS

F RX/OTC

EXCILON I.V. SPONGES 2"X2" 6 PLY PADS F RX/OTC

FLEXZAN 4 X 4 PADS F RX/OTC

GAUZE DRESSING 4"X4" PADS F RX/OTC

GAUZE PADS 2"X2" PADS F RX/OTC

GAUZE PADS 3"X3" PADS F

GAUZE PADS 4"X4" 12 PLY PADS F RX/OTC

GAUZE PADS 4"X4" PADS F RX/OTC

GAUZE SPONGE TYPE VII MEDI-PAK 2"X2" 8PLY PADS

F RX/OTC

GAUZE SPONGES 4"X4" 12 PLY PADS F RX/OTC

GNP STERILE PADS 3"X3" PADS F

HM STERILE PADS 2"X2" PADS F RX/OTC

HM STERILE PADS PADS F RX/OTC

HYDROCELL ADHESIVE DRESSING 4"X4" PADS F RX/OTC

HYDROCELL DRESSING 4"X4" PADS F RX/OTC

J & J GAUZE 2"X2" 8 PLY PADS F RX/OTC



J & J GAUZE SPONGES 12-PLY 4" X 4" MISC F RX/OTC


55

Drug Name DrugTier

Requirements/Limits

J & J GAUZE SPONGES 16-PLY 4" X 4" MISC F RX/OTC

J & J GAUZE SPONGES 8-PLY4" X 4" MISC F RX/OTC

KENDALL HYDROPHILIC FOAMDRESSING 2"X2" PADS

F RX/OTC


F


F RX/OTC

KENDALL HYDROPHILIC FOAMPLUS DRESSING 2"X2" PADS

F RX/OTC

KENDALL HYDROPHILIC FOAMPLUS DRESSING 3"X3" PADS

F

KERLIX SPONGES 4" X 4" 12 PLY PADS F RX/OTC

KERLIX SPONGES 4" X 4" 16 PLY PADS F RX/OTC

MIRASORB SPONGES 2" X 2" MISC F RX/OTC

MIRASORB SPONGES 4" X 4" MISC F RX/OTC

NU GAUZE 4PLY 4"X4" PADS F RX/OTC

NU GAUZE GENERAL-USE SPONGES 4"X4" 4 PLY MISC

F RX/OTC

OPTIFOAM PADS F RX/OTC

POLYMEM DRESSING/3"X 3" PADS F

POLYMEM DRESSING/4"X 4" PADS F RX/OTC

QC ALL PURPOSE DRESSINGS4"X4" PADS F RX/OTC

QC BORDER ISLAND GAUZE PAD 2"X2" PADS F RX/OTC

QC STERILE PADS PADS F

QC STERILE PADS PADS F RX/OTC

Drug Name DrugTier

Requirements/Limits

RA ALL PURPOSE DRESSINGS4"X4" PADS F RX/OTC

RA DRESSING SPONGES 4"X4" PADS F RX/OTC

RA GAUZE SPONGES 4"X4" PADS F RX/OTC

RA STERILE PADS 2"X2" PADS F RX/OTC

RA STERILE PADS 3"X3" PADS F

RA STERILE PADS 4"X4" PADS F RX/OTC

RAY-TEC X-RAY DETECTABLESPONGES 4" X 4" 16 PLY MISC

F RX/OTC

RESTORE CONTACT LAYER/NON-ADHERENT2"X2" PADS

F RX/OTC

RESTORE FOAM DRESSING BORDERED 4"X4" PADS

F RX/OTC

RESTORE FOAM DRESSING NON-BORDERED 4"X4" PADS

F RX/OTC

RESTORE ODOR ABSORBING DRESSING 4"X4" PADS

F RX/OTC

RESTORE TRIO ABSORBENT DRESSING 3"X3" PADS

F

SM GAUZE PADS 2"X2" PADS F RX/OTC

SM GAUZE PADS 3"X3" PADS F

SM GAUZE PADS 4"X4" PADS F RX/OTC

SM STERILE PADS 2"X2" PADS F RX/OTC

SM STERILE PADS PADS F RX/OTC

SOF-WICK 4"X4" PADS F RX/OTC

STERILE GAUZE PADS 2"X2" PADS F RX/OTC

STERILE GAUZE PADS 3"X3" PADS F


56

Drug Name DrugTier

Requirements/Limits

STERILE PADS 2"X2" PADS F RX/OTC

STERILE PADS 3"X3" PADS F

STERILE PADS 4"X4" PADS F RX/OTC

SURGICAL GAUZE SPONGE PADS F RX/OTC

TEGADERM FOAM DRESSING 2"X2" PADS F RX/OTC

TEGADERM FOAM DRESSING 4"X4" PADS F RX/OTC

THERAGAUZE PADS F RX/OTC

TOPPER DRESSING SPONGES 4"X4" MISC F RX/OTC

VERSIVA XC 3" X 3" FOAM DRESSING/HYDROFIBERTECHNOLOGY PADS

F

VERSIVA XC 4" X 4" FOAM DRESSING/HYDROFIBERTECHNOLOGY PADS

F

RX/OTC

VISTEC X-RAY DETECTABLE SPONGES 4"X4" 16 PLY PADS

F RX/OTC

Contraceptives

CONDOMS F

Diabetic Supplies

LANCET DEVICE F

LANCETS F Limit 200 permonth

TRUE METRIX CONTROL SOLUTION LEVEL 1 SOLN

F QL(0.02 eadaily,90 day(s)limit)





TRUECONTROL GLUCOSE CONTROL LEVEL 0 LIQD


Drug Name DrugTier

Requirements/Limits

TRUECONTROL GLUCOSE CONTROL LEVEL 1 LIQD


TRUETEST GLUCOSE CONTROLLEVEL 1 LIQD F

QL(0.02 eadaily,90 day(s)limit)





Misc. Devices

ALCOHOL SWABS F

Parenteral Therapy Supplies INSULIN SYRINGE AND PEN NEEDLES F QL (5 ea daily)

Respiratory Therapy Supplies

ACE AEROSOL CLOUD ENHANCER MISC F

QL(1 ea per360 daysretail); RX/OTC

ACTIVITY POUCH MISC F QL(1 ea per360 daysretail); RX/OTC

ADULT AEROSOL MASK MISC F


ADULT MASK LARGE MISC F


ADULT MASK MISC F QL(1 ea per360 daysretail); RX/OTC

AEROTRACH PLUS MISC F QL(1 ea per360 daysretail); RX/OTC

AIRS PEDIATRIC AEROSOL MASK MISC F


ALL FLOW 1000 PULMONARY FUNCTION FILTER MISC

F QL(1 ea per360 daysretail); RX/OTC

BUBBLES THE FISH II PEDIATRIC MASK/PVCMISC



57

Drug Name DrugTier

Requirements/Limits

CO MONITOR REPLACEMENT TPIECES MISC


EBASE CONTROLLER KIT MISC F


EFLOW SCF AEROSOL HEAD MISC F


ELITE DC AUTO ADAPTER MISC F


FILTER AIR PP MISC F QL(1 ea per360 daysretail); RX/OTC

FULL KIT NEBULIZER SET MISC F


HEALTHY LIVING REPLACEMENT FILTERS MISC


HEALTHY LIVING REPLACEMENT KIT FOR NEBULIZER MISC


HEALTHY LIVING REPLACEMENT MASKS MISC


HUDSON RCI SEE-THRU AEROSOL MASK ELONGATED/ADULTMISC

F


INNOSPIRE REPLACEMENT FILTER MISC


LITETOUCH MASK LARGE MISC F


LITETOUCH MASK MEDIUM MISC F


LITETOUCH MASK SMALL MISC F


MICROELITE FILTER REPLACEMENTS MISC F


Drug Name DrugTier

Requirements/Limits

MICROELITE RECHARGEABLE BATTERY MISC


MINIELITE FILTER REPLACEMENTS MISC F


MINIELITE RECHARGEABLE BATTERY MISC


NEBULIZER AIR TUBE/PLUGS MISC F


NEBULIZER PEDIATRIC MASK MISC F


NOSE CLIP MISC F QL(1 ea per360 daysretail); RX/OTC

PARI ALTERA NEBULIZER HANDSET MISC


PARI BABY CONVERSION KITSIZE 1 MISC F






PARI ERAPID NEBULIZER HANDSET MISC F


PARI EXPIRATORY FILTER VALVE SET DEVI F


PARI MASK SET MISC F QL(1 ea per360 daysretail); RX/OTC

PARI SOFT PLASTIC ADULT MASK MISC F


PARI SOFT PLASTIC PEDIATRIC MASK MISC F


PEDIATRIC AEROSOL MASK MISC F



58

Drug Name DrugTier

Requirements/Limits

PEDIATRIC MOUTHPIECE/DISPOSABLE MISC


PFLEX MISC F QL(1 ea per360 daysretail); RX/OTC

PILLOW MASK/ADULTMISC F


PILLOW MASK/CHILDMISC F


PILLOW MASK/PEDIATRIC MISC F


REPLACEMENT AIR FILTER MISC F


REPLACEMENT FILTERS MISC F


SAMI THE SEAL REPLACEMENTFILTERS MISC


SIDESTREAM ADULT FACE MASK MISC F


SIDESTREAM PEDIATRIC FACEMASK MISC F


SIDESTREAM PEDIATRIC FACEMASK/SAMI THESEAL MISC


SIDESTREAM PEDIATRIC FACEMASK/TUCKER THETURTLE MISC


SIDESTREAM PLUS ADULT FACE MASK MISC F


SILICONE MASK FOR BREATHERITE CHAMBER/ADULT MISC


SILICONE MASK FOR BREATHERITE CHAMBER/INFANT MISC


Drug Name DrugTier

Requirements/Limits

SILICONE MASK FOR BREATHERITE CHAMBER/PEDIATRICMISC

F


SILICONE MASK FOR BREATHRITE CHAMBER/ADULT MISC


SOOTHENEB NBL 100 CHILD MASK MISC F


SOOTHENEB NBL 100 MEDICATION CUP MISC F


SOOTHENEB NBL 100 MESH CAP MISC F


SOOTHENEB NBL100 ADULT MASK MISC F


SPACER/AEROSOL-HOLDING CHAMBER F

THRESHOLD IMT MISC F QL(1 ea per360 daysretail); RX/OTC

TUBING/WING TIP MISC F QL(1 ea per360 daysretail); RX/OTC

WINDMILL TRAINER MISC F


MIGRAINE PRODUCTS - Drugs to Treat MigraineHeadaches

Migraine Combinations CAFERGOT TABS (Use Ergotamine w/ Caffeine) NF AL; At least 18

yrs old

ergotamine w/ caffeine tabs F AL; At least 18 yrs old

Migraine Products D.H.E. 45 SOLN (Use DihydroergotamineMesylate)

NF AL; At least 18 yrs old

dihydroergotaminemesylate soln ij 1 mg/ml F AL; At least 18

yrs old DIHYDROERGOTAMINE MESYLATE SOLN NA 4 MG/ML

F AL; At least 18 yrs old


59

Drug Name DrugTier

Requirements/Limits

MIGRANAL SOLN F AL; At least 18 yrs old

Serotonin Agonists AMERGE TABS (Use Naratriptan HCl) NF AL; At least 18

yrs old eletriptan hydrobromidetabs F AL; At least 18

yrs old IMITREX SOLN NA 5 MG/ACT, 20 MG/ACT (Use Sumatriptan)


IMITREX SOLN SC 6 MG/0.5ML (Use Sumatriptan Succinate)

NF

IMITREX STATDOSE SYSTEM SOAJ 6 MG/0.5ML (Use Sumatriptan Succinate)

NF

AL; At least 12 yrs old

IMITREX TABS OR 25 MG, 50 MG, 100 MG (Use Sumatriptan Succinate)


MAXALT TABS (Use Rizatriptan Benzoate) NF

QL(12 ea per30 days retail);AL; At least 6 yrs old

MAXALT-MLT TBDP (Use Rizatriptan Benzoate) NF

QL(0.4 eadaily); AL; Atleast 6 yrs old

naratriptan hcl tabs F AL; At least 18 yrs old

RELPAX TABS (Use Eletriptan Hydrobromide) NF AL; At least 18

yrs old

rizatriptan benzoate tabs 5mg, 10 mg F

QL(12 ea per30 days retail);AL; At least 6 yrs old

rizatriptan benzoate tbdp 5mg, 10 mg F

QL(0.4 eadaily); AL; Atleast 6 yrs old

sumatriptan soln F AL; At least 12 yrs old

sumatriptan succinate soajsc 6 mg/0.5ml F AL; At least 12

yrs old sumatriptan succinate solnsc 6 mg/0.5ml F

SUMATRIPTAN SUCCINATE SOSY SC 6 MG/0.5ML


Drug Name DrugTier

Requirements/Limits

sumatriptan succinate tabsor 25 mg, 50 mg, 100 mg F AL; At least 12

yrs old

zolmitriptan tabs F AL; At least 18 yrs old

zolmitriptan tbdp F AL; At least 18 yrs old

ZOMIG SOLN NA 5 MG F AL; At least 12 yrs old

ZOMIG TABS OR 5 MG, 2.5 MG (Use Zolmitriptan) NF AL; At least 18

yrs old ZOMIG ZMT TBDP (Use Zolmitriptan) NF AL; At least 18

yrs old

MINERALS & ELECTROLYTES

Calcium calcium carbonate-cholecalciferol tabs 500mg-200unit

F

calcium carbonate-vitamin d tabs 125unit-250mg,125unit-500mg, 200unit-500mg, 200unit-600mg,250mg-125unit, 400unit-600mg, 500mg-125unit,500mg-200unit, 600mg-200unit, 600mg-400unit,500mg-500mg-200unit-200unit

F

oyster shell tabs F

RA OYSTER SHELL CALCIUM/VITAMIN DTABS 500MG-200UNIT

F

Electrolyte Mixtures

CERASPORT EX1 SOLN F

CERASPORT SOLN F

ENFAMIL ENFALYTE SOLN F

oral electrolytes soln F

PEDIALYTE FREEZER POPS SOLN (Use Oral Electrolytes)

NF


60

Drug Name DrugTier

Requirements/Limits

PEDIALYTE SOLN 20MEQ/L-45MEQ/L-35MEQ/L-5GM/L-20GM/L,20MEQ/L-45MEQ/L-35MEQ/L-30MEQ/L-25GM/L (Use Oral Electrolytes)

NF

Fluoride

FLURA-DROPS SOLN F

LURIDE SOLN (Use Sodium Fluoride) NF

sodium fluoride chew 0.25 mg, 0.5 mg, 1 mg, 1.1 mg,2.2 mg

F

sodium fluoride soln 0.125 mg/drop, 0.5 mg/ml F

Magnesium MAGNESIUM CAPS 400 MG F

magnesium oxide (mgsupplement) tabs F

MAGNESIUM OXIDE CAPS F

Phosphate K-PHOS NEUTRAL TABS (Use Pot PhosphateMonobasic w/ SodPhosphate Dibasic &Monobasic)

NF

QL(8 ea daily)

pot phosphate monobasicw/ sod phosphate dibasic &monobasic tabs

F QL(8 ea daily)

Potassium K-TAB TBCR 10 MEQ (Use Potassium Chloride) NF

K-TAB TBCR 8 MEQ F

KLOR-CON M15 TBCR F

KLOR-CON/25 PACK F

MICRO-K CPCR 10 MEQ (Use Potassium Chloride) NF

MICRO-K CPCR 8 MEQ (Use Potassium Chloride) NF QL(1 ea daily)

Drug Name DrugTier

Requirements/Limits

potassium bicarbonate tbef F

potassium chloride cpcr or10 meq F

potassium chloride cpcr or8 meq F QL(1 ea daily)

POTASSIUM CHLORIDE ER TBCR 8 MEQ F

potassium chloridemicroencapsulated crystalser tbcr

F

potassium chloride pack or20 meq F

potassium chloride soln or10 %, 20 % F

POTASSIUM CHLORIDE SOLN OR 20 % F

potassium chloride tbcr or 8meq, 10 meq F

Zinc

zinc sulfate caps F

MISCELLANEOUS THERAPEUTIC CLASSES

Chelating Agents

DEPEN TITRATABS TABS F

Immunomodulators

REVLIMID CAPS F PA; SP

Immunosuppressive Agents

AZASAN TABS F QL(3 ea daily)

azathioprine tabs or 50 mg F

CELLCEPT CAPS 250 MG (Use MycophenolateMofetil)

NF QL(2 ea daily);SP

CELLCEPT SUSR 200 MG/ML (Use Mycophenolate Mofetil)

NF QL(15 mldaily); SP

CELLCEPT TABS 500 MG (Use MycophenolateMofetil)


cyclosporine caps F SP


61

Drug Name DrugTier

Requirements/Limits

cyclosporine modified (formicroemulsion) caps 25mg, 50 mg, 100 mg

F QL(4 ea daily);SP

cyclosporine modified (formicroemulsion) soln 100mg/ml

F QL(8 ml daily);SP

CYCLOSPORINE MODIFIED CAPS F QL(4 ea daily);

SP CYCLOSPORINE MODIFIED CAPS (Use Cyclosporine Modified (ForMicroemulsion))

NF

QL(4 ea daily);SP

IMURAN TABS (Use Azathioprine) NF

mycophenolate mofetilcaps 250 mg F QL(2 ea daily);

SP mycophenolate mofetil susr200 mg/ml F QL(15 ml

daily); SP mycophenolate mofetil tabs500 mg F QL(4 ea daily);

SP mycophenolate sodiumtbec 180 mg F QL(2 ea daily);

SP mycophenolate sodiumtbec 360 mg F QL(4 ea daily);

SP MYFORTIC TBEC 180 MG (Use MycophenolateSodium)


MYFORTIC TBEC 360 MG (Use MycophenolateSodium)


NEORAL CAPS 25 MG, 100 MG (Use CyclosporineModified (ForMicroemulsion))

NF

QL(4 ea daily);SP

NEORAL SOLN 100 MG/ML (Use CyclosporineModified (ForMicroemulsion))

NF

QL(8 ml daily);SP

PROGRAF CAPS (Use Tacrolimus) NF QL(3 ea daily);

SP RAPAMUNE SOLN 1 MG/ML F SP

RAPAMUNE TABS 0.5 MG, 1 MG, 2 MG (Use Sirolimus)

NF SP

Drug Name DrugTier

Requirements/Limits

SANDIMMUNE CAPS 25 MG, 100 MG (Use Cyclosporine)

F SP

SANDIMMUNE SOLN 100 MG/ML F SP

sirolimus tabs F SP

tacrolimus caps F QL(3 ea daily);SP

Potassium Removing Agents KAYEXALATE POWD (Use Sodium PolystyreneSulfonate)


sodium polystyrenesulfonate powd or F QL(454 gm per

fill retail) sodium polystyrenesulfonate susp or 15gm/60ml

F

MOUTH/THROAT/DENTAL AGENTS

Anesthetics Topical Oral lidocaine hcl (mouth-throat)soln F QL(100 ml per

fill retail) Anti-infectives - Throat nystatin (mouth-throat) susp F QL(120 ml per

fill retail) Antiseptics - Mouth/Throat chlorhexidine gluconate(mouth-throat) soln F

PERIDEX SOLN (Use Chlorhexidine Gluconate (Mouth-Throat))

NF

Dental Products GEL-KAM ORAL CARE RINSE CONC (Use Stannous Fluoride)

NF RX/OTC

PREVIDENT 5000 DRY MOUTH GEL (Use Sodium Fluoride (Dental))


PREVIDENT 5000 PLUS CREA (Use Sodium Fluoride (Dental))


PREVIDENT FLUORIDE GEL (Use Sodium Fluoride (Dental))



62

Drug Name DrugTier

Requirements/Limits

sodium fluoride (dental)crea dt 1.1 % F QL(102 gm per

fill retail) sodium fluoride (dental) geldt 1.1 % F QL(112 ml per

fill retail) sodium fluoride (dental)soln mt 0.2 % F

stannous fluoride conc F RX/OTC

THERA-FLUR-N GEL (Use Sodium Fluoride (Dental)) NF QL(112 ml per

fill retail) Steroids - Mouth/Throat triamcinolone acetonide (mouth) pste F QL(5 gm per fill

retail) Throat Products - Misc.

AQUORAL SOLN F QL(900 ml perfill retail);RX/OTC

BIOTENE DRY MOUTH MOISTURIZING SPRAY SOLN

F QL(900 ml perfill retail);RX/OTC

CAPHOSOL SOLN F QL(900 ml perfill retail);RX/OTC

CVS DRY MOUTH SPRAY SOLN F


EQL DRY MOUTH ORAL RINSE SOLN F


MOI-STIR SOLN F QL(900 ml perfill retail);RX/OTC

MOUTHKOTE SOLN F QL(900 ml perfill retail);RX/OTC

NUMOISYN LIQD F QL(900 ml perfill retail);RX/OTC

ORAL RELIEF SPRAY FOR DRYMOUTH & DISCOMFORT SOLN

F QL(900 ml perfill retail);RX/OTC

pilocarpine hcl (oral) tabs 5 mg F QL(6 ea daily)

RA DRY MOUTH SOLN F QL(900 ml perfill retail);RX/OTC

Drug Name DrugTier

Requirements/Limits

SALAGEN TABS 5 MG (Use Pilocarpine HCl(Oral))

NF QL(6 ea daily)

MULTIVITAMINS

B-Complex Vitamins

b-complex vitamins caps F

b-complex vitamins tabs F

B-Complex w/ C b complex w/ c caps 10mg-50mg-10mg-15mg-5mg-300mg, 10.2mg-10mg-15mg-50mg-5mg-300mg,10mg-50mg-10.2mg-15mg-5mg-300mg

F

B-Complex w/ Folic Acid b-complex w/ c & folic acidcaps 1.5mg-5mg-20mg-1.7mg-6mcg-1mg-150mcg-10mg-100mg, 5mg-1.7mg-6mcg-20mg-1.5mg-1mg-150mcg-10mg-100mg

F

QL(1 ea daily);RX/OTC

b-complex w/ c & folic acidtabs 1.5mg-10mg-20mg-1.7mg-6mcg-1mg-300mcg-10mg-60mg, 6mcg-1.5mg-10mg-20mg-1.7mg-1mg-300mcg-10mg-100mg,1.5mg-1.7mg-10mg-0.01mcg-20mg-1mg-300mcg-10mg-60mg,20mg-1.7mg-10mg-0.006mg-1.5mg-1mg-0.3mg-10mg-100mg

F

QL(1 ea daily)

NEPHRO-VITE RX TABS 1.5MG-10MG-20MG-1.7MG-6MCG-1MG-300MCG-10MG-60MG (Use B-Complex w/ C &Folic Acid)

NF

QL(1 ea daily)

NEPHROCAPS CAPS (Use B-Complex w/ C &Folic Acid)


Multiple Vitamins w/ Iron multiple vitamins w/ irontabs F


63

Drug Name DrugTier

Requirements/Limits

Multiple Vitamins w/ Minerals ADVANCED DIABETIC MULTIVITAMIN FORMULA TABS


ALIVE ENERGY 50+ TABS F QL(1 ea daily);RX/OTC

ALIVE MENS ENERGY TABS F QL(1 ea daily);

RX/OTC ALIVE ONCE DAILY WOMENS 50+ ULTRA POTENCY TABS


ALIVE ONCE DAILY WOMENS ULTRA POTENCY TABS


ALIVE WOMENS 50+ TABS F QL(1 ea daily);

RX/OTC ALIVE WOMENS ENERGY TABS F QL(1 ea daily);

RX/OTC ANTIOXIDANT FORTE TABS F QL(1 ea daily);

RX/OTC

AP-ZEL TABS F QL(1 ea daily);RX/OTC

BACMIN TABS F QL(1 ea daily);RX/OTC

BASIC AM TABS F QL(1 ea daily);RX/OTC

BASIC PM TABS F QL(1 ea daily);RX/OTC

CAL-DAY 1000 TABS F QL(1 ea daily);RX/OTC

CENTRAVITES 50 PLUS TABS F QL(1 ea daily);

RX/OTC CENTRAVITES ADULTS TABS F QL(1 ea daily);

RX/OTC CENTRUM ADULTS TABS (Use Multiple Vitamins w/Minerals)


CENTRUM CARDIO TABS F QL(1 ea daily);RX/OTC

CENTRUM MEN TABS F QL(1 ea daily);RX/OTC

CENTRUM SILVER ULTRA MENS TABS F QL(1 ea daily);

RX/OTC CENTRUM SILVER ULTRA WOMENS TABS F QL(1 ea daily);

RX/OTC

Drug Name DrugTier

Requirements/Limits

CENTRUM SPECIALIST HEART TABS F QL(1 ea daily);

RX/OTC CENTRUM SPECIALIST IMMUNE SUPPORT TABS F QL(1 ea daily);

RX/OTC CENTRUM SPECIALIST VISION TABS F QL(1 ea daily);

RX/OTC CENTRUM ULTRA WOMENS TABS F QL(1 ea daily);

RX/OTC CERTAVITE SENIOR/ANTIOXIDANTNUTRIENTS TABS


CLINICAL NUTRIENTS 45-PLUS WOMEN TABS F QL(1 ea daily);

RX/OTC CLINICAL NUTRIENTS 50-PLUS MEN TABS F QL(1 ea daily);

RX/OTC CLINICAL NUTRIENTS FOR FEMALE TEENS TABS


CLINICAL NUTRIENTS FOR MALE TEENS TABS F QL(1 ea daily);

RX/OTC CLINICAL NUTRIENTS FOR MEN TABS F QL(1 ea daily);

RX/OTC CLINICAL NUTRIENTS FOR WOMEN TABS F QL(1 ea daily);

RX/OTC CVS ONE DAILY MENS 50+ ADVANCED TABS F QL(1 ea daily);

RX/OTC CVS SPECTRAVITE ADULT 50+ TABS F QL(1 ea daily);

RX/OTC CVS SPECTRAVITE ULTRA MEN50+ TABS F QL(1 ea daily);

RX/OTC CVS SPECTRAVITE ULTRA MENS HEALTH SENIOR TABS


CVS SPECTRAVITE ULTRA MENS HEALTH TABS


CVS SPECTRAVITE ULTRA WOMEN TABS F QL(1 ea daily);

RX/OTC CVS SPECTRAVITE ULTRA WOMENS HEALTH SENIOR TABS


CVS SPECTRAVITE ULTRA WOMENS HEALTH TABS


DERMAVITE TABS F QL(1 ea daily);RX/OTC


64

Drug Name DrugTier

Requirements/Limits

EQ COMPLETE MULTIVITAMINADULTS UNDER 50 TABS


EQ ONE DAILY MENS 50+ TABS F QL(1 ea daily);

RX/OTC EQ ONE DAILY MENS HEALTH TABS F QL(1 ea daily);

RX/OTC EQ ONE DAILY WOMENS 50+ TABS F QL(1 ea daily);

RX/OTC EQ ONE DAILY WOMENS HEALTH TABS F QL(1 ea daily);

RX/OTC EQL CENTURY MATURE ADULTS50+ TABS F QL(1 ea daily);

RX/OTC EQL CENTURY MENS TABS F QL(1 ea daily);

RX/OTC EQL CENTURY WOMENS TABS F QL(1 ea daily);

RX/OTC EQL ONE DAILY MENS TABS F QL(1 ea daily);

RX/OTC FITNESS TABS FOR MEN AM/PM/LYCOPENE TABS F QL(1 ea daily);

RX/OTC FITNESS TABS FOR WOMEN AM/PM/LYCOPENE TABS


FREEDAVITE TABS F QL(1 ea daily);RX/OTC

GERI-FREEDA SENIOR FORMULA TABS F QL(1 ea daily);

RX/OTC

HAIR-VITES TABS F QL(1 ea daily);RX/OTC

HM COMPLETE 50+ MENS ULTIMATE TABS F QL(1 ea daily);

RX/OTC HM COMPLETE 50+ WOMENS ULTIMATE TABS


HM COMPLETE TABS F QL(1 ea daily);RX/OTC

HM HAIR/SKIN/NAILSTABS F QL(1 ea daily);

RX/OTC HM ONE DAILY MENS TABS F QL(1 ea daily);

RX/OTC HM ONE DAILY WOMENS TABS F QL(1 ea daily);

RX/OTC

HYALEX TABS F QL(1 ea daily);RX/OTC

Drug Name DrugTier

Requirements/Limits

ICAPS AREDS FORMULA TABS F QL(1 ea daily);

RX/OTC

ICAPS PLUS TABS F QL(1 ea daily);RX/OTC

K-PAX IMMUNE SUPPORT FORMULA PROFESSIONAL STRENGTH TABS

F

QL(1 ea daily);RX/OTC

MACULAR VITAMIN BENEFIT TABS F QL(1 ea daily);

RX/OTC MEGA MULTIVITAMIN FOR MEN TABS F QL(1 ea daily);

RX/OTC MEGA MULTIVITAMIN FOR WOMEN TABS F QL(1 ea daily);

RX/OTC MEGAVITE FRUITS & VEGGIES TABS F QL(1 ea daily);

RX/OTC MEGAVITE GOLDEN YEARS 55+ TABS F QL(1 ea daily);

RX/OTC MENS 50+ MULTI VITAMIN &MINERAL FORMULA TABS


MENS MULTI VITAMIN & MINERAL FORMULA TABS


MULTI-BETIC DIABETES TABS F QL(1 ea daily);

RX/OTC MULTI-VITAMIN MONOCAPS TABS F QL(1 ea daily);

RX/OTC multiple vitamins w/minerals tabs F QL(1 ea daily);

RX/OTC MULTIVITAMIN ADULTS TABS F QL(1 ea daily);

RX/OTC MULTIVITAMIN MEN TABS F QL(1 ea daily);

RX/OTC NAT-RUL THERAVITE-M/HIGHPOTENCY TABS F QL(1 ea daily);

RX/OTC

NATRUL-MEGA-75 TABS F QL(1 ea daily);RX/OTC

NATRUL-VITES TABS F QL(1 ea daily);RX/OTC

NICADAN TABS F QL(1 ea daily);RX/OTC

NICADAN ZX TABS F QL(1 ea daily);RX/OTC

NICAZEL FORTE TABS F QL(1 ea daily);RX/OTC


65

Drug Name DrugTier

Requirements/Limits

NICAZEL TABS F QL(1 ea daily);RX/OTC

NO IRON MULTIPLE VITAMIN/MINERALSTABS


NUTRICAP TABS F QL(1 ea daily);RX/OTC

OCULAR VITAMINS TABS F QL(1 ea daily);RX/OTC

ONCOVITE TABS F QL(1 ea daily);RX/OTC

ONE DAILY MENS FORMULA W/O IRONTABS


ONE DAILY PLUS IRON TABS F QL(1 ea daily);

RX/OTC ONE DAILY WOMENS TABS F QL(1 ea daily);

RX/OTC ONE-A-DAY ENERGY TABS F QL(1 ea daily);

RX/OTC ONE-A-DAY MENOPAUSE FORMULA TABS F QL(1 ea daily);

RX/OTC ONE-A-DAY MENS 50+ ADVANTAGE TABS F QL(1 ea daily);

RX/OTC ONE-A-DAY MENS HEALTH FORMULA TABS F QL(1 ea daily);

RX/OTC ONE-A-DAY MENS PRO EDGE TABS F QL(1 ea daily);

RX/OTC ONE-A-DAY PROACTIVE 65+ TABS F QL(1 ea daily);

RX/OTC ONE-A-DAY TEEN ADVANTAGEFOR HIM TABS


OPTI-WOMAN TABS F QL(1 ea daily);RX/OTC

OPURITY TABS F QL(1 ea daily);RX/OTC

PARVLEX TABS F QL(1 ea daily);RX/OTC

PHYTOMULTI TABS F QL(1 ea daily);RX/OTC

PRESERVISION AREDS TABS F QL(1 ea daily);

RX/OTC PRO-CAL TABS 145MG-187.5MG-40MG-100UNIT-7.5MG


Drug Name DrugTier

Requirements/Limits

PROCERV HP TABS F QL(1 ea daily);RX/OTC

PRORENAL+D TABS F QL(1 ea daily);RX/OTC

PROVIT TABS F QL(1 ea daily);RX/OTC

QUENCH TABS F QL(1 ea daily);RX/OTC

QUIN B STRONG TABS F QL(1 ea daily);RX/OTC

QUINTABS-M TABS F QL(1 ea daily);RX/OTC

RA CENTRAL-VITE TABS F QL(1 ea daily);RX/OTC

RA CENTRAL-VITE UNDER 50MENS TABS F QL(1 ea daily);

RX/OTC RA CENTRAL-VITE UNDER 50WOMENS TABS


RENAPLEX-D TABS F QL(1 ea daily);RX/OTC

REQ 49+ TABS F QL(1 ea daily);RX/OTC

SENTRY SENIOR TABS F QL(1 ea daily);RX/OTC

SENTRY SENIOR/LUTEINTABS F QL(1 ea daily);

RX/OTC

SENTRY TABS F QL(1 ea daily);RX/OTC

SIDEROL TABS F QL(1 ea daily);RX/OTC

SM ONE DAILY MENS TABS F QL(1 ea daily);

RX/OTC SM ONE DAILY WOMENS TABS F QL(1 ea daily);

RX/OTC

SOLO TABS F QL(1 ea daily);RX/OTC

STROVITE ONE TABS F QL(1 ea daily);RX/OTC

SUPERB NAILS TABS F QL(1 ea daily);RX/OTC

T-VITES TABS F QL(1 ea daily);RX/OTC

THERA M PLUS TABS F QL(1 ea daily);RX/OTC


66

Drug Name DrugTier

Requirements/Limits

THERA-M TABS F QL(1 ea daily);RX/OTC

THERA-TABS M TABS F QL(1 ea daily);RX/OTC

THERABETIC MULTI-VITAMIN TABS F QL(1 ea daily);

RX/OTC THERAGRAN-M ADVANCED 50 PLUS TABS


THERAGRAN-M ADVANCED TABS F QL(1 ea daily);

RX/OTC THERAGRAN-M PREMIER 50 PLUS TABS F QL(1 ea daily);

RX/OTC THERAGRAN-M PREMIER TABS F QL(1 ea daily);

RX/OTC

THERAGRAN-M TABS F QL(1 ea daily);RX/OTC

THEREMS-H TABS F QL(1 ea daily);RX/OTC

THEREMS-M TABS F QL(1 ea daily);RX/OTC

UNICOMPLEX-M TABS F QL(1 ea daily);RX/OTC

VITALINE TOTAL FORMULA 2 TABS F QL(1 ea daily);

RX/OTC VITALINE TOTAL FORMULA 3 TABS F QL(1 ea daily);

RX/OTC VITAMIN D3 COMPLETE TABS F QL(1 ea daily);

RX/OTC

VITASANA TABS F QL(1 ea daily);RX/OTC

VITATRUM TABS F QL(1 ea daily);RX/OTC

VITRUM 50+ SENIOR MULTI TABS F QL(1 ea daily);

RX/OTC

VP-ZEL TABS F QL(1 ea daily);RX/OTC

WHOLE FOOD MULTIVITAMIN TABS F QL(1 ea daily);

RX/OTC WOMENS 50+ MULTI VITAMIN& MINERAL FORMULA TABS


WOMENS BIOMULTIPLE TABS F QL(1 ea daily);

RX/OTC

Drug Name DrugTier

Requirements/Limits

WOMENS MULTI VITAMIN & MINERAL FORMULA TABS


YELETS TEENAGE FORMULA TABS F QL(1 ea daily);

RX/OTC

Multivitamins

ESTROFACTORS TABS F

MULTI VITAMIN TABS F

MULTI VITAMIN/D-3 TABS F

multiple vitamin tabs F

OMNICAP TABS F

QUINTABS TABS F

THERA TABS F

Ped MV w/ Fluoride

FLORIVA PLUS SOLN F QL(50 ml perfill retail); AL;Up to 13 yrs old

MULTIVITAMIN/FLUORIDE CHEW F

QL(1 ea daily);AL; Up to 13yrs old


67

Drug Name DrugTier

Requirements/Limits

pediatric multivitamins w/flchew 0.25mg-15unit-1.2mg-2500unit-4.5mcg-400unit-1.05mg-13.5mg-1.05mg-0.3mg-60mg,0.25mg-15unit-400unit-2500unit-1.2mg-4.5mcg-13.5mg-1.05mg-0.3mg-1.05mg-60mg, 0.5mg-15unit-1.2mg-2500unit-4.5mcg-400unit-1.05mg-13.5mg-1.05mg-0.3mg-60mg, 0.5mg-15unit-400unit-2500unit-1.2mg-4.5mcg-13.5mg-1.05mg-0.3mg-1.05mg-60mg,0.5mg-2500unit-13.5mg-1.2mg-4.5mcg-400unit-1.05mg-0.3mg-15unit-1.05mg-60mg, 15unit-1mg-2500unit-13.5mg-1.2mg-4.5mcg-400unit-1.05mg-0.3mg-1.05mg-60mg, 1mg-15unit-1.2mg-2500unit-4.5mcg-400unit-1.05mg-13.5mg-1.05mg-0.3mg-60mg, 1mg-15unit-400unit-2500unit-1.2mg-4.5mcg-13.5mg-1.05mg-0.3mg-1.05mg-60mg, 15unit-0.5mg-1.05mg-13.5mg-1.2mg-2500unit-4.5mcg-400unit-0.3mg-1.05mg-60mg, 15unit-0.5mg-2500unit-13.5mg-1.2mg-4.5mcg-400unit-1.05mg-0.3mg-1.05mg-60mg,15unit-0.25mg-2500unit-13.5mg-1.2mg-4.5mcg-400unit-1.05mg-0.3mg-1.05mg-60mg

F


Drug Name DrugTier

Requirements/Limits

pediatric multivitamins w/flsoln 0.25mg/ml-0.6mg/ml-8mg/ml-1500unit/ml-2mcg/ml-400unit/ml-0.5mg/ml-5unit/ml-0.4mg/ml-35mg/ml,0.25mg/ml-5unit/ml-0.6mg/ml-8mg/ml-1500unit/ml-2mcg/ml-400unit/ml-0.5mg/ml-0.4mg/ml-35mg/ml,0.25mg/ml-5unit/ml-8mg/ml-0.6mg/ml-1500unit/ml-2mcg/ml-400unit/ml-0.5mg/ml-0.4mg/ml-35mg/ml,0.5mg/ml-0.6mg/ml-8mg/ml-1500unit/ml-2mcg/ml-400unit/ml-0.5mg/ml-5unit/ml-0.4mg/ml-35mg/ml,0.5mg/ml-5unit/ml-0.6mg/ml-8mg/ml-1500unit/ml-2mcg/ml-400unit/ml-0.5mg/ml-0.4mg/ml-35mg/ml,0.5mg/ml-5unit/ml-8mg/ml-0.6mg/ml-1500unit/ml-2mcg/ml-400unit/ml-0.5mg/ml-0.4mg/ml-35mg/ml, 5unit/ml-0.5mg/ml-0.6mg/ml-8mg/ml-1500unit/ml-2mcg/ml-400unit/ml-0.5mg/ml-0.4mg/ml-35mg/ml, 5unit/ml-0.5mg/ml-8mg/ml-0.6mg/ml-1500unit/ml-2mcg/ml-400unit/ml-0.5mg/ml-0.4mg/ml-35mg/ml, 5unit/ml-0.25mg/ml-0.6mg/ml-8mg/ml-1500unit/ml-2mcg/ml-400unit/ml-0.5mg/ml-0.4mg/ml-35mg/ml

F


pediatric vitamins acd w/fluoride soln F



68

Drug Name DrugTier

Requirements/Limits

QUFLORA PEDIATRIC CHEW 108MCG-1MG-15UNIT-1MG-15MG-1200UNIT-5MG-1.3MG-4MCG-400UNIT-1.2MG-100MCG-1.5MG-60MG, 108MCG-1MG-15UNIT-0.5MG-15MG-1200UNIT-5MG-1.3MG-4MCG-400UNIT-1.2MG-100MCG-1.5MG-60MG, 108MCG-1MG-15UNIT-0.25MG-15MG-1200UNIT-5MG-1.3MG-4MCG-400UNIT-1.2MG-100MCG-1.5MG-60MG

F


QUFLORA PEDIATRIC SOLN 150MCG/ML-1MG/ML-0.5MG/ML-12MG/ML-1100UNIT/ML-2MG/ML-1MG/ML-3MCG/ML-400UNIT/ML-1MG/ML-81MCG/ML-12UNIT/ML-1MG/ML-45MG/ML, 65MCG/ML-1MG/ML-0.25MG/ML-10MG/ML-1000UNIT/ML-0.8MG/ML-0.6MG/ML-2MCG/ML-400UNIT/ML-0.5MG/ML-35MCG/ML-5UNIT/ML-0.4MG/ML-35MG/ML

F


TRI-VITAMIN/FLUORIDESOLN F


Ped MV w/ Iron pediatric multiple vitaminsw/ iron soln F

Ped Multi Vitamins w/Fl & FE

ped multivitamins w/fl &iron soln F


TRI-VIT/FLUORIDE/IRONSOLN F


Pediatric Multiple Vitamins pediatric multiple vitamin w/c & fa chew F

Drug Name DrugTier

Requirements/Limits

pediatric multiple vitamin w/c soln F

Pediatric Vitamins pediatric vitamins adc soln1500unit/ml-400unit/ml-35mg/ml

F

Prenatal Vitamins

CALNA TABS F

CLASSIC PRENATAL TABS F

CO-NATAL FA TABS F QL(1 ea daily)

COMPLETENATE CHEW F QL(1 ea daily)

CVS PRENATAL TABS F

EQL PRENATAL FORMULA TABS F

GNP PRENATAL TABS F

GOODSENSE PRENATAL VITAMINS TABS F

HM PRENATAL TABS F

INATAL GT TABS F QL(1 ea daily)

KP PRENATAL MULTIVITAMINS TABS F

KPN PRENATAL TABS F

M-VIT TABS F QL(1 ea daily);RX/OTC

MULTI PRENATAL TABS F

MYNATAL ADVANCE TABS F QL(1 ea daily)

MYNATAL CAPS F QL(1 ea daily)

MYNATAL PLUS TABS F QL(1 ea daily)

MYNATAL ULTRACAPLET TABS F QL(1 ea daily)

MYNATAL-Z TABS F QL(1 ea daily)

MYNATE 90 PLUS TBCR F QL(1 ea daily)


69

Drug Name DrugTier

Requirements/Limits

NAT-RUL PRENATAL VITAMINS TABS F

NATALVIT TABS F QL(1 ea daily)

NIVA-PLUS TABS F QL(1 ea daily);RX/OTC

NUTRICION PORVIDA TABS F

O-CAL FA TABS F QL(1 ea daily);RX/OTC

O-CAL PRENATAL TABS F QL(1 ea daily)

PERRY PRENATAL CAPS F

PNV FERROUS FUMARATE/DOCUSATE/FOLIC ACID TABS

F QL(1 ea daily)

PNV FOLIC ACID + IRON MULTIVITAMIN TABS F QL(1 ea daily);

RX/OTC PNV PRENATAL PLUS MULTIVITAMIN TABS F QL(1 ea daily);

RX/OTC

PNV TABS 29-1 TABS F QL(1 ea daily)

PRE-NATAL FORMULA TABS F

PRENATABS FA TABS F QL(1 ea daily)

PRENATABS RX TABS F QL(1 ea daily)

PRENATAL 19 CHEW F QL(1 ea daily)

PRENATAL 19 TABS F QL(1 ea daily)

PRENATAL AND IRON TABS F

PRENATAL FORTE TABS F

PRENATAL LOW IRON TABS F

PRENATAL MULTIVITAMIN TABS F

PRENATAL ONE DAILY TABS F

PRENATAL PLUS IRON TABS F QL(1 ea daily)

PRENATAL PLUS TABS F QL(1 ea daily);RX/OTC

Drug Name DrugTier

Requirements/Limits

PRENATAL TABS 11UNIT-263MG-25MG-1.5MG-27MG-4000UNIT-18MG-1.7MG-4MCG-400UNIT-0.8MG-2.6MG-100MG, 30UNIT-4000UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-8MCG-400UNIT-0.8MG-2.6MG-120MG, 30UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-4000UNIT-8MCG-400UNIT-800MCG-2.6MG-120MG, 30UNIT-4000UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-8MCG-400UNIT- F

800MCG-2.6MG-120MG, 4000UNIT-30UNIT-200MG-25MG-1.8MG-28MG-20MG-1.7MG-8MCG-400UNIT-800MCG-2.6MG-120MG, 4000UNIT-30UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-8MCG-400UNIT-800MCG-2.6MG-120MG, 160MG-11UNIT-200MG-25MG-1.84MG-27MG-4000UNIT-18MG-1.7MG-4MCG-400UNIT-800MCG-2.6MG-100MG PRENATAL TABS 22MG- QL(1 ea daily);2MG-25MG-1.84MG- RX/OTC200MG-27MG-4000UNIT-20MG-3MG-12MCG- F

400UNIT-1MG-10MG-120MG PRENATAL TABS 4000UNIT-200MG-11UNIT-27MG-25MG-1.84MG-18MG-1.7MG-4MCG-400UNIT-0.8MG-2.6MG-100MG

F

PRENATAL VITAMIN & MINERAL TABS F

PRENATAL VITAMIN TABS F

PRENATAL VITAMIN/IRON TABS F


70

Drug Name DrugTier

Requirements/Limits

PRENATAL VITAMINS PLUS LOW IRON TABS F QL(1 ea daily);

RX/OTC PRENATAL VITAMINS TABS F

PREPLUS TABS F QL(1 ea daily);RX/OTC

PRETAB TABS F QL(1 ea daily)

PX PRENATAL MULTIVITAMINS TABS F

QC PRENATAL TABS F

RA PRENATAL FORMULA/FOLICACIDTABS

F

RA PRENATAL TABS F

RIGHT STEP PRENATAL TABS F

SE-NATAL 19 CHEW F QL(1 ea daily)

SE-NATAL 19 TABS F QL(1 ea daily)

SM PRENATAL VITAMINS TABS F

THERANATAL CORE NUTRITION TABS F QL(1 ea daily);

RX/OTC

THRIVITE 19 TABS F QL(1 ea daily)

THRIVITE RX TABS F QL(1 ea daily)

TRIADVANCE TABS F QL(1 ea daily)

TRICARE TABS F QL(1 ea daily);RX/OTC

TRINATAL GT TABS F QL(1 ea daily)

TRINATAL RX 1 TABS F QL(1 ea daily)

VIL-RX TABS F QL(1 ea daily)

VINATE M TABS F QL(1 ea daily)

VINATE ONE TABS F QL(1 ea daily)

VIRT-ADVANCE TABS F QL(1 ea daily)

Drug Name DrugTier

Requirements/Limits

VIRT-VITE GT TABS F QL(1 ea daily)

VITAFOL-OB TABS F QL(1 ea daily)

VOL-PLUS TABS F QL(1 ea daily);RX/OTC

VOL-TAB RX TABS F QL(1 ea daily)

Vitamins w/ Lipotropics

vitamins w/ lipotropics caps F

MUSCULOSKELETAL THERAPY AGENTS -Drugs to Treat Spasms

Central Muscle Relaxants

baclofen tabs F

carisoprodol tabs 350 mg F PA

CHLORZOXAZONE TABS 500 MG F

cyclobenzaprine hcl tabs 5mg, 10 mg F QL(3 ea daily)

cyclobenzaprine hcl tabs7.5 mg F QL(4 ea daily)

FEXMID TABS (Use Cyclobenzaprine HCl) NF QL(4 ea daily)

methocarbamol tabs or 500 mg, 750 mg F

orphenadrine citrate tb12 or100 mg F

ROBAXIN TABS OR 500 MG (Use Methocarbamol) NF

ROBAXIN-750 TABS (Use Methocarbamol) NF

SOMA TABS 350 MG (Use Carisoprodol) NF PA

tizanidine hcl tabs 2 mg, 4 mg F

ZANAFLEX TABS 4 MG (Use Tizanidine HCl) NF

NASAL AGENTS - SYSTEMIC AND TOPICAL -Drugs to treat the Nose or Sinus

Nasal Agents - Misc. OCEAN NASAL SPRAY SOLN (Use Saline) NF QL(480 ml per

fill retail)


71

Drug Name DrugTier

Requirements/Limits

saline soln 0.65%-0.002%,0.65 %, 0.65% F QL(480 ml per

fill retail) Nasal Anti-infectives BACTROBAN NASAL OINT F

Nasal Antiallergy ASTEPRO SOLN (Use Azelastine HCl) NF

azelastine hcl soln F

cromolyn sodium (nasal) aers F

NASALCROM AERS (Use Cromolyn Sodium (Nasal)) NF

Nasal Anticholinergics ATROVENT SOLN 0.03 % (Use Ipratropium Bromide(Nasal))

NF

ATROVENT SOLN 0.06 % (Use Ipratropium Bromide(Nasal))


ipratropium bromide (nasal)soln 0.03 % F

ipratropium bromide (nasal)soln 0.06 % F QL(15 ml per

fill retail) Nasal Steroids FLONASE ALLERGY RELIEF CHILDRENS SUSP (Use Fluticasone Propionate (Nasal))

NF


FLONASE ALLERGY RELIEF SUSP (Use Fluticasone Propionate(Nasal))

NF


FLUNISOLIDE SOLN F QL(25 ml perfill retail)

fluticasone propionate(nasal) susp F


NASACORT ALLERGY 24HR AERO (Use Triamcinolone Acetonide (Nasal))

NF

RX/OTC

Drug Name DrugTier

Requirements/Limits

NASACORT ALLERGY 24HR CHILDRENS AERO (Use Triamcinolone Acetonide (Nasal))

NF

RX/OTC

triamcinolone acetonide (nasal) aero F


Sympathomimetic Decongestants

ADRENALIN SOLN F

NASAL DECONGESTANT LIQD F

NASAL DECONGESTANT SYRP F

phenylephrine hcl (oral)tabs F

pseudoephedrine hcl liqd15 mg/5ml F

pseudoephedrine hcl tabs30 mg, 60 mg F

pseudoephedrine hcl tb12120 mg F

SUDAFED CHILDRENS LIQD (Use Pseudoephedrine HCl)

NF

SUDAFED CONGESTION TABS (Use Pseudoephedrine HCl)

NF

SUDAFED NASAL DECONGESTANT MAXIMUM STRENGTH TABS (Use Pseudoephedrine HCl)

NF

SUDAFED PE CHILDRENS NASAL DECONGESTANT SOLN

F

SUDAFED PE CONGESTION TABS (Use Phenylephrine HCl (Oral))

NF

NEUROMUSCULAR AGENTS - Drugs toRelax/Paralyze Muscles

ALS Agents RILUTEK TABS (Use Riluzole) NF

riluzole tabs F


72

Drug Name DrugTier

Requirements/Limits

NUTRIENTS

Carbohydrates

POLYCOSE LIQD F QL(124 ml perfill retail)

POLYCOSE POWD F QL(350 gm perfill retail)

Misc. Nutritional Substances

Drug Name DrugTier

Requirements/Limits

omega-3 fatty acids caps1000mg, 1200mg, 1000mg, 1200 mg, 180mg-120mg, 1200mg-2unit,300mg-1000mg, 350mg-1000mg, 360mg-1200mg,600mg-1000mg, 600mg-1200mg, 180mg-120mg-5unit, 300mg-180mg-120mg, 300mg-200mg-1unit, 1000mg-180mg-120mg, 160mg-1000mg-100mg, 180mg-1000mg-120mg, 180mg-1200mg-144mg, 216mg-1200mg-144mg, 270mg-1000mg-180mg, 300mg-1000mg-1unit, 300mg-1000mg-200mg, 300mg-1unit-1000mg, 336mg-1200mg-276mg, 350mg-1000mg-250mg, 400mg-1000mg-300mg, 500mg-1000mg-250mg, 180mg-120mg-1.8unit, 300mg-180mg- F

1gm-120mg, 1000mg-180mg-120mg-1mg,210mg-1000mg-75mg-90mg, 60mg-180mg-1200mg-120mg, 60mg-360mg-1200mg-300mg,1000mg-180mg-120mg-1unit, 100mg-300mg-1000mg-200mg, 180mg-1000mg-120mg-1unit,180mg-1unit-1000mg-120mg, 300mg-1000mg-200mg-1unit, 300mg-180mg-1000mg-120mg,360mg-216mg-1200mg-144mg, 600mg-324mg-1200mg-216mg, 700mg-350mg-1000mg-250mg,100mg-1000mg-500mg-10unit, 216mg-1200mg-144mg-15unit, 340mg-180mg-1unit-1000mg-120mg

OPHTHALMIC AGENTS - Drugs to Treat the Eye

Artificial Tears and Lubricants


73

Drug Name DrugTier

Requirements/Limits

artificial tear ointment oint F

HYPOTEARS SOLN F QL(30 ml perfill retail)

polyvinyl alcohol soln F

TEARS NATURALE PM OINT (Use White Petrolatum-Mineral Oil)


white petrolatum-mineral oiloint F QL(42 gm per

fill retail) Beta-blockers - Ophthalmic BETAGAN SOLN (Use Levobunolol HCl) NF QL(15 ml per

fill retail)

betaxolol hcl (ophth) soln F QL(15 ml perfill retail)

BETOPTIC-S SUSP F QL(15 ml perfill retail)

carteolol hcl (ophth) soln F

CARTEOLOL HCL SOLN F

COSOPT SOLN (Use Dorzolamide HCl-Timolol Maleate)


dorzolamide hcl-timolol maleate soln F QL(10 ml per

fill retail)

levobunolol hcl soln F QL(15 ml perfill retail)

METIPRANOLOL SOLN F

timolol maleate (ophth)solg 0.5 % F QL(5 ml per fill

retail) timolol maleate (ophth)soln 0.25 %, 0.5 % F QL(15 ml per

fill retail) TIMOLOL MALEATE OPHTHALMIC GEL FORMING SOLG 0.5 %


TIMOPTIC OCUDOSE SOLN F QL(60 ea per

fill retail) TIMOPTIC SOLN (Use Timolol Maleate (Ophth)) NF QL(15 ml per

fill retail) TIMOPTIC-XE SOLG 0.5 % F QL(5 ml per fill

retail) Cycloplegic Mydriatics

Drug Name DrugTier

Requirements/Limits

ATROPINE SULFATE OINT OP 1 % F QL(4 gm per fill

retail) ATROPINE SULFATE SOLN OP 1 % F QL(10 ml per

fill retail) CYCLOGYL SOLN 0.5 %, 1 % (Use CyclopentolateHCl)


cyclopentolate hcl soln 0.5%, 1 % F QL(15 ml per

fill retail) MYDRIACYL SOLN (Use Tropicamide) NF QL(15 ml per

fill retail)

tropicamide soln F QL(15 ml perfill retail)

Miotics ISOPTO CARPINE SOLN (Use Pilocarpine HCl) NF

pilocarpine hcl soln F

Ophthalmic Adrenergic Agents

apraclonidine hcl soln F

brimonidine tartrate soln 0.2 % F QL(15 ml per

fill retail) IOPIDINE SOLN 0.5 % (Use Apraclonidine HCl) NF

IOPIDINE SOLN 1 % F

Ophthalmic Anti-infectives bacitracin-polymyxin b(ophth) oint F QL(4 gm per fill

retail) BLEPH-10 SOLN (Use Sulfacetamide Sodium (Ophth))


CILOXAN OINT F QL(4 gm per fillretail)

CILOXAN SOLN (Use Ciprofloxacin HCl (Ophth)) NF QL(10 ml per

fill retail) ciprofloxacin hcl (ophth)soln F QL(10 ml per

fill retail)

erythromycin (ophth) oint F QL(4 gm per fillretail)

GENTAK OINT F QL(4 gm per fillretail)

gentamicin sulfate (ophth)oint F QL(4 gm per fill

retail)


74

Drug Name DrugTier

Requirements/Limits

gentamicin sulfate (ophth)soln F QL(15 ml per

fill retail) moxifloxacin hcl (ophth)soln F QL(3 ml per fill

retail) neomycin-bacitracin zn-polymyxin oint F QL(4 gm per fill

retail) neomycin-polymyxin-gramicidin soln F QL(10 ml per

fill retail) NEOSPORIN SOLN (Use Neomycin-Polymyxin-Gramicidin)


OCUFLOX SOLN (Use Ofloxacin (Ophth)) NF QL(10 ml per

fill retail)

ofloxacin (ophth) soln F QL(10 ml perfill retail)

polymyxin b-trimethoprimsoln F QL(10 ml per

fill retail) POLYTRIM SOLN (Use Polymyxin B-Trimethoprim) NF QL(10 ml per

fill retail) sulfacetamide sodium (ophth) soln F QL(15 ml per

fill retail)

tobramycin (ophth) soln F QL(5 ml per fillretail)

TOBREX OINT F QL(4 gm per fillretail)

TOBREX SOLN (Use Tobramycin (Ophth)) NF QL(5 ml per fill

retail)

trifluridine soln F QL(8 ml per fillretail)

VIGAMOX SOLN (Use Moxifloxacin HCl (Ophth)) NF QL(3 ml per fill

retail) VIROPTIC SOLN (Use Trifluridine) NF QL(8 ml per fill

retail) Ophthalmic Decongestants naphazoline w/pheniramine soln F

NAPHCON-A SOLN (Use Naphazoline w/Pheniramine)

NF

OPCON-A SOLN (Use Naphazoline w/Pheniramine)

NF

phenylephrine hcl (ophth)soln 2.5 % F QL(30 ml per

fill retail) tetrahydrozoline hcl (ophth)soln F QL(30 ml per

fill retail)

Drug Name DrugTier

Requirements/Limits

VISINE EXTRA SOLN (Use Tetrahydrozoline HCl(Ophth))


VISINE SOLN (Use Tetrahydrozoline HCl(Ophth))


Ophthalmic Local Anesthetics ALCAINE SOLN (Use Proparacaine HCl) NF PA; QL(15 ml

per fill retail)

proparacaine hcl soln F PA; QL(15 mlper fill retail)

tetracaine hcl (ophth) soln F

Ophthalmic Steroids BLEPHAMIDE S.O.P. OINT F QL(4 gm per fill

retail)

BLEPHAMIDE SUSP F QL(10 ml perfill retail)

DEXAMETHASONE SODIUM PHOSPHATE SOLN OP 0.1 %


fluorometholone (ophth) susp F QL(15 ml per

fill retail) FML LIQUIFILM SUSP (Use Fluorometholone (Ophth))


FML OINT F QL(4 gm per fillretail)

MAXITROL OINT 10000UNIT/GM-3.5MG/GM-0.1% (Use Neomycin-Polymy-Dexameth)

NF

QL(4 gm per fillretail)

MAXITROL SUSP 10000UNIT/ML-3.5MG/ML-0.1% (Use Neomycin-Polymy-Dexameth)

NF


neomycin-polymy-dexameth oint 10000unit/gm-3.5mg/gm-0.1%

F

QL(4 gm per fillretail)

neomycin-polymy-dexameth susp10000unit/ml-3.5mg/ml-0.1%

F



75

Drug Name DrugTier

Requirements/Limits

NEOMYCIN/POLYMYXIN/HYDROCORTISONE SUSP


OMNIPRED SUSP (Use Prednisolone Acetate (Ophth))


PRED FORTE SUSP (Use Prednisolone Acetate (Ophth))


PRED MILD SUSP F QL(10 ml perfill retail)

PRED-G SUSP F QL(5 ml per fillretail)

prednisolone acetate(ophth) susp F QL(15 ml per

fill retail) PREDNISOLONE ACETATE P-F SUSP F QL(15 ml per

fill retail) sulfacetamide sod-prednisolone soln F QL(10 ml per

fill retail)

TOBRADEX OINT F QL(4 gm per fillretail)

TOBRADEX SUSP (Use Tobramycin-Dexamethasone)


tobramycin-dexamethasone susp F QL(10 ml per

fill retail)

VEXOL SUSP F QL(10 ml perfill retail)

Ophthalmics - Misc. ACULAR LS SOLN (Use Ketorolac Tromethamine (Ophth))

NF

ACULAR SOLN (Use Ketorolac Tromethamine (Ophth))


ALOCRIL SOLN F QL(5 ml per fillretail)

ALOMIDE SOLN F QL(10 ml perfill retail)

azelastine hcl (ophth) soln F QL(6 ml per fillretail)

AZOPT SUSP F QL(15 ml perfill retail)

cromolyn sodium (ophth)soln F QL(10 ml per

fill retail)

Drug Name DrugTier

Requirements/Limits

diclofenac sodium (ophth)soln F QL(5 ml per fill

retail)

dorzolamide hcl soln F QL(10 ml perfill retail)

flurbiprofen sodium soln F QL(3 ml per fillretail)

FLURBIPROFEN SODIUM SOLN F QL(3 ml per fill

retail) ketorolac tromethamine (ophth) soln 0.4 % F

ketorolac tromethamine (ophth) soln 0.5 % F QL(10 ml per

fill retail) ketotifen fumarate (ophth)soln F QL(240 ml per

fill retail) MURO 128 OINT 5 % (Use Sodium Chloride Hypertonic)

NF

MURO 128 SOLN 5 % (Use Sodium Chloride Hypertonic)

NF

OCUFEN SOLN (Use Flurbiprofen Sodium) NF QL(3 ml per fill

retail) sodium chloride hypertonicoint F

sodium chloride hypertonicsoln F

TRUSOPT SOLN (Use Dorzolamide HCl) NF QL(10 ml per

fill retail) ZADITOR SOLN (Use Ketotifen Fumarate (Ophth))


Prostaglandins - Ophthalmic

latanoprost soln F QL(3 ml per fillretail)

XALATAN SOLN (Use Latanoprost) NF QL(3 ml per fill

retail)

OTIC AGENTS - Drugs to Treat the Ear

Otic Agents - Miscellaneous

acetic acid (otic) soln F QL(15 ml perfill retail)

carbamide peroxide (otic)soln F

DEBROX SOLN (Use Carbamide Peroxide (Otic)) NF


76

Drug Name DrugTier

Requirements/Limits

Otic Anti-infectives FLOXIN OTIC SOLN (Use Ofloxacin (Otic)) NF QL(10 ml per

fill retail)

ofloxacin (otic) soln F QL(10 ml perfill retail)

Otic Combinations CORTANE-B AQUEOUS SOLN F QL(10 ml per

fill retail) CORTANE-B-OTIC SOLN (Use Pramoxine-HC-Chloroxylenol)


neomycin-polymyxin-hc(otic) soln F QL(10 ml per

fill retail) neomycin-polymyxin-hc(otic) susp F QL(10 ml per

fill retail) OTICIN HC NR SOLN (Use Pramoxine-HC-Chloroxylenol)


pramoxine-hc-chloroxylenolsoln F QL(15 ml per

fill retail) Otic Steroids DERMOTIC OIL (Use Fluocinolone Acetonide (Otic))


fluocinolone acetonide (otic) oil F QL(20 ml per

fill retail) hydrocortisone w/aceticacid soln F QL(10 ml per

fill retail) 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

Immune Serums

HYPERRHO S/D SOSY F SP

RHOGAM ULTRA-FILTERED PLUS SOSY F SP

PENICILLINS - Drugs to Treat Bacterial Infections

Aminopenicillins

Drug Name DrugTier

Requirements/Limits

amoxicillin caps 250 mg,500 mg F

AMOXICILLIN CHEW 125 MG, 250 MG F

amoxicillin susr 125 mg/5ml, 200 mg/5ml, 250mg/5ml, 400 mg/5ml

F

amoxicillin tabs 875 mg F

ampicillin caps 250 mg,500 mg F

AMPICILLIN CAPS 500 MG F

Natural Penicillins PENICILLIN V POTASSIUM SOLR 125 MG/5ML, 250 MG/5ML

F

penicillin v potassium solr125 mg/5ml, 250 mg/5ml F

penicillin v potassium tabs250 mg, 500 mg F

Penicillin Combinations amoxicillin & potclavulanate susr 200mg/5ml-28.5mg/5ml


amoxicillin & potclavulanate susr 250mg/5ml-62.5mg/5ml


amoxicillin & potclavulanate susr 400mg/5ml-57mg/5ml


amoxicillin & potclavulanate susr 600mg/5ml-42.9mg/5ml


amoxicillin & potclavulanate tabs 250mg-125mg


amoxicillin & potclavulanate tabs 500mg-125mg, 875mg-125mg


amoxicillin & potclavulanate tb12 1000mg-62.5mg


AMOXICILLIN/CLAVULANATE POTASSIUM CHEW F QL(20 ea per

fill retail)


77

Drug Name DrugTier

Requirements/Limits

AUGMENTIN ES-600 SUSR (Use Amoxicillin & Pot Clavulanate)


AUGMENTIN SUSR 125MG/5ML-31.25MG/5ML F QL(150 ml per

fill retail) AUGMENTIN SUSR 250MG/5ML-62.5MG/5ML(Use Amoxicillin & Pot Clavulanate)

NF


AUGMENTIN TABS 500MG-125MG, 875MG-125MG (Use Amoxicillin & Pot Clavulanate)

NF

QL(20 ea perfill retail)

AUGMENTIN XR TB12 (Use Amoxicillin & Pot Clavulanate)


Penicillinase-Resistant Penicillins

dicloxacillin sodium caps F

PHARMACEUTICAL ADJUVANTS

Internal Vehicle Ingredients/Agents SIMPLYTHICK EASY MIX GEL F

SIMPLYTHICK GEL F

Semi Solid Vehicles

lanolin oint ex F RX/OTC

PROGESTINS - Hormone Replacement/ModifyingDrugs

Progestins AYGESTIN TABS (Use Norethindrone Acetate) NF

MAKENA OIL F PA; SP

medroxyprogesteroneacetate tabs F

norethindrone acetate tabs F

progesterone micronizedcaps 100 mg F

QL(1 eadaily,30 ea per30 days retail)

progesterone micronizedcaps 200 mg F

Drug Name DrugTier

Requirements/Limits

PROMETRIUM CAPS 100 MG (Use ProgesteroneMicronized)

NF QL(1 eadaily,30 ea per30 days retail)

PROMETRIUM CAPS 200 MG (Use ProgesteroneMicronized)

NF

PROVERA TABS (Use MedroxyprogesteroneAcetate)

NF

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. - Drugs to Treat Mental andEmotional Conditions

Agents for Chemical Dependency

acamprosate calcium tbec CO

ANTABUSE TABS 250 MG (Use Disulfiram) NF

disulfiram tabs 250 mg F

Antidementia Agents ARICEPT TABS 5 MG, 10 MG (Use DonepezilHydrochloride)

NF QL(1 ea daily)

donepezil hydrochloridetabs 5 mg, 10 mg F QL(1 ea daily)

EXELON CAPS OR 3 MG, 6 MG, 1.5 MG, 4.5 MG (Use Rivastigmine Tartrate)


EXELON PT24 TD 4.6 MG/24HR, 9.5 MG/24HR(Use Rivastigmine)


galantamine hydrobromidecp24 8 mg, 16 mg, 24 mg F QL(1 ea daily)

GALANTAMINE HYDROBROMIDE SOLN 4 MG/ML

F QL(6 ml daily)

galantamine hydrobromidetabs 4 mg, 8 mg, 12 mg F QL(2 ea daily)

memantine hcl soln 2 mg/ml F QL(2 ml daily)

memantine hcl tabs F QL(49 ea perfill retail)

memantine hcl tabs 5 mg,10 mg F QL(2 ea daily)

NAMENDA TABS 5 MG, 10 MG (Use Memantine HCl) NF QL(2 ea daily)


78

Drug Name DrugTier

Requirements/Limits

NAMENDA TITRATION PAK TABS (Use Memantine HCl)

NF QL(49 ea perfill retail)

RAZADYNE ER CP24 (Use Galantamine Hydrobromide)

NF QL(1 ea daily)

RAZADYNE TABS (Use Galantamine Hydrobromide)

NF QL(2 ea daily)

rivastigmine pt24 4.6mg/24hr, 9.5 mg/24hr F PA; QL(1 ea

daily)

rivastigmine tartrate caps F PA; QL(2 eadaily)

Combination Psychotherapeutics olanzapine-fluoxetine hcl caps CO

PERPHENAZINE/AMITRIPTYLINE TABS F QL(4 ea daily)

SYMBYAX CAPS (Use Olanzapine-FluoxetineHCl)

CO

Fibromyalgia Agents

SAVELLA TABS F PA; QL(2 eadaily)

SAVELLA TITRATION PACK MISC F

PA; QL(55 eaper 365 daysretail)

Multiple Sclerosis Agents

AVONEX KIT F PA; SP

AVONEX PEN AJKT F PA; SP

AVONEX PSKT F PA; SP

COPAXONE SOSY (Use Glatiramer Acetate) NF PA; SP

GILENYA CAPS F PA; SP

glatiramer acetate sosy F PA; SP

LEMTRADA SOLN F PA; SP

PLEGRIDY SOPN F PA; SP

PLEGRIDY SOSY F PA; SP

Drug Name DrugTier

Requirements/Limits

PLEGRIDY STARTER PACK SOPN F PA; SP

PLEGRIDY STARTER PACK SOSY F PA; SP

TECFIDERA CPDR F PA; SP

TECFIDERA STARTER PACK MISC F PA; SP

Psychotherapeutic and Neurological Agents -ERGOLOID MESYLATES TABS F

ORAP TABS (Use Pimozide) CO

pimozide tabs CO

Smoking Deterrents bupropion hcl (smokingdeterrent) tb12 F QL(2 ea daily)

CHANTIX CONTINUING MONTHPAK TABS F QL(2 ea daily)

CHANTIX STARTING MONTH PAK TABS F

CHANTIX TABS F QL(2 ea daily)

NICODERM CQ PT24 (Use Nicotine) NF

NICORETTE GUM (Use Nicotine Polacrilex) NF

NICORETTE LOZG (Use Nicotine Polacrilex) NF

NICORETTE MINI LOZG (Use Nicotine Polacrilex) NF

NICORETTE STARTER KIT GUM (Use Nicotine Polacrilex)

NF

nicotine polacrilex gum F

nicotine polacrilex lozg F

nicotine pt24 F

NICOTINE TRANSDERMAL SYSTEM KIT

F

NICOTROL INHALER INHA F QL(504 ea per

30 days retail)


79

Drug Name DrugTier

Requirements/Limits

NICOTROL NS SOLN F

ZYBAN TB12 (Use Bupropion HCl (SmokingDeterrent))

NF QL(2 ea daily)

RESPIRATORY AGENTS - MISC. - Drugs toTreat Lung Conditions

Cystic Fibrosis Agents

KALYDECO PACK F PA; SP

KALYDECO TABS F PA; SP

ORKAMBI TABS 200MG-125MG F PA; SP

TETRACYCLINES - Drugs to Treat BacterialInfections

Tetracyclines doxycycline hyclate caps50 mg, 100 mg F

doxycycline hyclate tabs100 mg F

MINOCIN CAPS (Use Minocycline HCl) NF

minocycline hcl caps 50mg, 75 mg, 100 mg F

VIBRAMYCIN CAPS 100 MG (Use DoxycyclineHyclate)

NF

THYROID AGENTS - Drugs to Regulate ThyroidHormones

Antithyroid Agents

methimazole tabs F

propylthiouracil tabs F

TAPAZOLE TABS (Use Methimazole) NF

Thyroid Hormones ARMOUR THYROID TABS 15 MG, 30 MG, 60 MG, 90 MG, 120 MG (Use Thyroid)

F

ARMOUR THYROID TABS 180 MG, 240 MG, 300 MG F

CYTOMEL TABS (Use Liothyronine Sodium) NF

Drug Name DrugTier

Requirements/Limits

levothyroxine sodium tabs F

liothyronine sodium tabs F

NATURE-THROID TABS 65 MG, 130 MG, 195 MG, 32.5 MG

F

SYNTHROID TABS (Use Levothyroxine Sodium) F

thyroid tabs F

THYROLAR-1 TABS F

THYROLAR-1/2 TABS F

THYROLAR-1/4 TABS F

THYROLAR-2 TABS F

THYROLAR-3 TABS F

WESTHROID TABS 65 MG, 130 MG, 195 MG, 32.5 MG

F

WP THYROID TABS 65 MG, 130 MG, 32.5 MG F

TOXOIDS

Toxoid Combinations

ADACEL SUSP F AL; At least 19 yrs old

BOOSTRIX SUSP F AL; At least 19 yrs old

TENIVAC INJ F AL; At least 19 yrs old

TETANUS/DIPHTHERIATOXOIDS-ADSORBED SUSP


ULCER DRUGS - Drugs to Treat Bowel, Intestineand Stomach Conditions

Antispasmodics ANASPAZ TBDP (Use Hyoscyamine Sulfate) NF

BENTYL CAPS (Use Dicyclomine HCl) NF

BENTYL TABS (Use Dicyclomine HCl) NF


80

Drug Name DrugTier

Requirements/Limits

dicyclomine hcl caps 10 mg F

dicyclomine hcl soln 10mg/5ml F QL(40 ml daily)

dicyclomine hcl tabs 20 mg F

DONNATAL ELIX (Use Phenobarbital-Hyoscyamine-Atropine-Scopolamine)

NF

DONNATAL TABS (Use Phenobarbital-Hyoscyamine-Atropine-Scopolamine)

NF

glycopyrrolate tabs 1 mg, 2 mg F QL(4 ea daily)

hyoscyamine sulfate elix or0.125 mg/5ml F

hyoscyamine sulfate solnor 0.125 mg/ml F

hyoscyamine sulfate subl sl0.125 mg F

hyoscyamine sulfate tabsor 0.125 mg F

hyoscyamine sulfate tb12or 0.375 mg F QL(4 ea daily)

hyoscyamine sulfate tbdpor 0.125 mg F

LEVBID TB12 (Use Hyoscyamine Sulfate) NF QL(4 ea daily)

LEVSIN TABS (Use Hyoscyamine Sulfate) NF

LEVSIN/SL SUBL (Use Hyoscyamine Sulfate) NF

phenobarbital-hyoscyamine-atropine-scopolamine elix

F

phenobarbital-hyoscyamine-atropine-scopolamine tabs

F

ROBINUL FORTE TABS (Use Glycopyrrolate) NF QL(4 ea daily)

ROBINUL TABS (Use Glycopyrrolate) NF QL(4 ea daily)

SYMAX DUOTAB TBCR F

H-2 Antagonists

Drug Name DrugTier

Requirements/Limits

CIMETIDINE HCL SOLN F QL(27 ml daily)

cimetidine tabs 200 mg F RX/OTC

cimetidine tabs 300 mg,400 mg, 800 mg F

famotidine susr 40 mg/5ml F

famotidine tabs 10 mg, 40 mg F

famotidine tabs 20 mg F RX/OTC

PEPCID AC MAXIMUM STRENGTH TABS (Use Famotidine)

NF RX/OTC

PEPCID AC TABS (Use Famotidine) NF

PEPCID SUSR 40 MG/5ML(Use Famotidine) NF

PEPCID TABS 20 MG (Use Famotidine) NF RX/OTC

PEPCID TABS 40 MG (Use Famotidine) NF

ranitidine hcl caps or 150 mg F QL(2 ea daily)

ranitidine hcl caps or 300 mg F QL(1 ea daily)

ranitidine hcl syrp or 15mg/ml, 75 mg/5ml, 150mg/10ml

F QL(40 ml daily)

ranitidine hcl tabs or 150 mg F QL(2 ea daily);

RX/OTC ranitidine hcl tabs or 300 mg F QL(2 ea daily)

ranitidine hcl tabs or 75 mg F

TAGAMET HB TABS (Use Cimetidine) NF RX/OTC

ZANTAC 150 MAXIMUM STRENGTH TABS (Use Ranitidine HCl)


ZANTAC 75 TABS (Use Ranitidine HCl) NF

ZANTAC TABS OR 150 MG (Use Ranitidine HCl) NF QL(2 ea daily);

RX/OTC ZANTAC TABS OR 300 MG (Use Ranitidine HCl) NF QL(2 ea daily)


81

Drug Name DrugTier

Requirements/Limits

Misc. Anti-Ulcer CARAFATE SUSP 1 GM/10ML F QL(420 ml per

fill retail) CARAFATE TABS 1 GM (Use Sucralfate) NF QL(4 ea daily)

sucralfate tabs F QL(4 ea daily)

Proton Pump Inhibitors

CVS OMEPRAZOLE TBEC F QL(1 ea daily)

EQ OMEPRAZOLE TBEC F QL(1 ea daily)

EQL OMEPRAZOLE TBEC F QL(1 ea daily)

esomeprazole magnesiumcpdr 20 mg F QL(2 ea daily);

RX/OTC GNP OMEPRAZOLE TBEC F QL(1 ea daily)

HM OMEPRAZOLE TBEC F QL(1 ea daily)

KLS OMEPRAZOLE TBEC F QL(1 ea daily)

lansoprazole cpdr 15 mg F QL(2 ea daily);RX/OTC

lansoprazole cpdr 15 mg F QL(1 ea daily);RX/OTC

lansoprazole cpdr 30 mg F QL(2 ea daily)

lansoprazole tbdp 15 mg,30 mg F

QL(1 ea daily);AL; Up to 6 yrsold

NEXIUM 24HR CLEAR MINIS CPDR (Use Esomeprazole Magnesium)

NF RX/OTC

NEXIUM 24HR CPDR (Use Esomeprazole Magnesium) NF RX/OTC

NEXIUM CPDR 20 MG (Use EsomeprazoleMagnesium)

NF RX/OTC

omeprazole cpdr 10 mg, 40 mg F QL(2 ea daily)

omeprazole cpdr 20 mg F QL(2 ea daily);RX/OTC

OMEPRAZOLE TBEC 20 MG F QL(1 ea daily)

pantoprazole sodium tbec20 mg F QL(1 ea daily)

Drug Name DrugTier

Requirements/Limits

pantoprazole sodium tbec40 mg F QL(2 ea daily)

PREVACID 24HR CPDR (Use Lansoprazole) NF RX/OTC

PREVACID CPDR 15 MG (Use Lansoprazole) NF RX/OTC

PREVACID CPDR 30 MG (Use Lansoprazole) NF QL(2 ea daily)

PREVACID SOLUTAB TBDP (Use Lansoprazole) NF

QL(1 ea daily);AL; Up to 6 yrsold

PRILOSEC CPDR 10 MG, 40 MG (Use Omeprazole) NF QL(2 ea daily)

PRILOSEC CPDR 20 MG (Use Omeprazole) NF QL(2 ea daily);

RX/OTC

PRILOSEC OTC TBEC F QL(1 ea daily)

PROTONIX TBEC 20 MG (Use Pantoprazole Sodium) NF QL(1 ea daily)

PROTONIX TBEC 40 MG (Use Pantoprazole Sodium) NF QL(2 ea daily)

PX OMEPRAZOLE TBEC F QL(1 ea daily)

RA OMEPRAZOLE TBEC F QL(1 ea daily)

SB OMEPRAZOLE TBEC F QL(1 ea daily)

SM OMEPRAZOLE TBEC F QL(1 ea daily)

SW OMEPRAZOLE TBEC F QL(1 ea daily)

TGT OMEPRAZOLE TBEC F QL(1 ea daily)

Ulcer Drugs - Prostaglandins CYTOTEC TABS (Use Misoprostol) NF

misoprostol tabs F

URINARY ANTI-INFECTIVES - Drugs to TreatBladder/Kidney Infections

Urinary Anti-infective Combinations methenamine-hyosc-methylene blue-sod phos-phenyl sal tabs 40.8mg-0.12mg-36.2mg-81.6mg-10.8mg, 40.8mg-36.2mg-0.12mg-81.6mg-10.8mg

F


82

Drug Name DrugTier

Requirements/Limits

Urinary Anti-infectives FURADANTIN SUSP (Use Nitrofurantoin) NF QL(40 ml daily)

MACROBID CAPS (Use Nitrofurantoin MonohydMacro)

NF

MACRODANTIN CAPS 50 MG, 100 MG (Use Nitrofurantoin Macrocrystal)

NF

METHENAMINE MANDELATE TABS 0.5 GM

F

methenamine mandelate tabs 1 gm F

nitrofurantoin macrocrystalcaps 50 mg, 100 mg F

nitrofurantoin monohyd macro caps F

nitrofurantoin susp F QL(40 ml daily)

URINARY ANTISPASMODICS - Drugs to TreatMiscellaneous Bladder Spasms

Urinary Antispasmodic - Antimuscarinics DETROL LA CP24 (Use Tolterodine Tartrate) NF QL(1 ea daily)

DETROL TABS (Use Tolterodine Tartrate) NF QL(2 ea daily)

DITROPAN XL TB24 (Use Oxybutynin Chloride) NF QL(2 ea daily)

oxybutynin chloride syrp 5mg/5ml F QL(480 ml per

fill retail) oxybutynin chloride tabs 5 mg F QL(3 ea daily)

oxybutynin chloride tb24 5mg, 10 mg, 15 mg F QL(2 ea daily)

tolterodine tartrate cp24 2mg, 4 mg F QL(1 ea daily)

tolterodine tartrate tabs 1 mg, 2 mg F QL(2 ea daily)

trospium chloride tabs 20 mg F QL(2 ea daily)

Urinary Antispasmodics - Cholinergic Agonists

bethanechol chloride tabs F

Drug Name DrugTier

Requirements/Limits

URECHOLINE TABS (Use Bethanechol Chloride) NF

Urinary Antispasmodics - Direct Muscle Relaxants

flavoxate hcl tabs F

VACCINES

Bacterial Vaccines

ACTHIB SOLR F AL; At least 19 yrs old

BEXSERO SUSY F

Limit 2 fills perLifetime;2 rtl MAX fill,999 rtl day(s) supply,;AL; At least 19 yrs old

HIBERIX SOLR F PA; AL; At least 19 yrs old

MENACTRA INJ F AL; At least 19 yrs old

MENOMUNE-A/C/Y/W-135INJ F AL; At least 19

yrs old

MENVEO SOLR F AL; At least 19 yrs old

PNEUMOVAX 23 INJ F

Limit 5 perlifetime;5 rtl MAX fill,999 rtl day(s) supply,;AL; At least 19 yrs old

PNEUMOVAX 23/1 DOSEINJ F


PREVNAR 13 SUSP F

Limit 1 dose per lifetime;1 rtlMAX fill,999 rtl day(s) supply,;AL; At least 19 yrs old

TRUMENBA SUSY F

Limit 3 doses per lifetime;3 rtlMAX fill,999 rtl day(s) supply,;AL; At least 19 yrs old


83

Drug Name DrugTier

Requirements/Limits

Viral Vaccines AFLURIA 2015-2016 SUSP F AL; At least 19

yrs old AFLURIA 2016-2017 SUSP F AL; At least 19

yrs old AFLURIA 2017-2018 SUSP F AL; At least 19

yrs old AFLURIA PF 2015-2016 SUSY F AL; At least 19



yrs old AFLURIA QUADRIVALENT 2016-2017 SUSY F AL; At least 19

yrs old AFLURIA QUADRIVALENT 2017-2018 SUSP F AL; At least 19

yrs old AFLURIA QUADRIVALENT 2017-2018 SUSY F AL; At least 19

yrs old

CERVARIX SUSP F


ENGERIX-B INJ F AL; At least 19 yrs old

ENGERIX-B SUSP F AL; At least 19 yrs old

FLUAD 2016-2017 SUSY F AL; At least 19 yrs old

FLUAD 2017-2018 SUSY F AL; At least 19 yrs old

FLUARIX QUADRIVALENT 2015-2016 SUSY F AL; At least 19

yrs old FLUARIX QUADRIVALENT 2016-2017 SUSY F AL; At least 19

yrs old FLUARIX QUADRIVALENT 2017-2018 SUSY F AL; At least 19

yrs old FLUBLOK 2015-2016 SOLN F AL; At least 19



yrs old

Drug Name DrugTier

Requirements/Limits

FLUCELVAX 2015-2016 SUSY F AL; At least 19

yrs old FLUCELVAX QUADRIVALENT 2016-2017 SUSY


FLUCELVAX QUADRIVALENT 2017-2018 SUSP


FLUCELVAX QUADRIVALENT 2017-2018 SUSY


FLULAVAL QUADRIVALENT 2014-2015 SUSY


FLULAVAL QUADRIVALENT 2015-2016 SUSP










FLUMIST QUADRIVALENT SUSP F PA; AL; At least

19 yrs old FLUVIRIN 2015-2016 SUSP F AL; At least 19

yrs old FLUVIRIN 2015-2016 SUSY F AL; At least 19

yrs old FLUVIRIN 2016-2017 SUSP F AL; At least 19


yrs old FLUVIRIN 2017-2018 SUSP F AL; At least 19


yrs old FLUZONE HIGH-DOSE PF 2015-2016 SUSY F AL; At least 19

yrs old FLUZONE HIGH-DOSE PF 2016-2017 SUSY F AL; At least 19

yrs old


84

Drug Name DrugTier

Requirements/Limits

FLUZONE HIGH-DOSE PF 2017-2018 SUSY F AL; At least 19

yrs old FLUZONE INTRADERMAL QUADRIVALENT 2015-2016 SUPN


FLUZONE INTRADERMAL QUADRIVALENT 2016-2017 SUPN


FLUZONE INTRADERMAL QUADRIVALENT 2017-2018 SUPN


FLUZONE QUADRIVALENT 2015-2016 SUSP


FLUZONE QUADRIVALENT 2015-2016 SUSY










FLUZONE SPLIT 2015-2016 SUSP F AL; At least 19

yrs old

GARDASIL 9 SUSP F


GARDASIL 9 SUSY F


GARDASIL SUSP F AL; At least 19 yrs old

Drug Name DrugTier

Requirements/Limits

HAVRIX SUSP F


M-M-R II INJ F


MEDICAL PROVIDER EZ FLU SHOT 2015-2016 PSKT


MEDICAL PROVIDER SINGLE USE EZ FLU SHOT PSKT


RABAVERT SUSR F AL; At least 19 yrs old

RECOMBIVAX HB SUSP F AL; At least 19 yrs old

SHINGRIX SUSR F AL; At least 50 yrs old

TWINRIX SUSP F


VAQTA SUSP F


VARIVAX INJ F


ZOSTAVAX SUSR F AL; At least 50 yrs old

VAGINAL PRODUCTS - Drugs to Treat VaginalInfections and Low Hormones

Spermicides


85

Drug Name DrugTier

Requirements/Limits

ENCARE SUPP F QL(12 ea perfill retail)

nonoxynol-9 gel F

OPTIONS CONCEPTROL VAGINAL CONTRACEPTIVE GEL (Use Nonoxynol-9)

NF

OPTIONS GYNOL II VAGINALCONTRACEPTIV E GEL

F

SHUR-SEAL GEL F QL(24 gm perfill retail)

VCF VAGINAL CONTRACEPTIVE FILM FILM

F QL(9 ea per fillretail)

Vaginal Anti-infectives CLEOCIN CREA VA 2 % (Use ClindamycinPhosphate Vaginal)


clindamycin phosphatevaginal crea F QL(40 gm per

fill retail) clotrimazole vaginal crea 1% F

clotrimazole vaginal crea 2% F QL(21 gm per

fill retail)

GYNAZOLE-1 CREA F

GYNE-LOTRIMIN 3 CREA (Use Clotrimazole Vaginal) NF QL(21 gm per

fill retail) GYNE-LOTRIMIN CREA (Use Clotrimazole Vaginal) NF

METROGEL-VAGINAL GEL (Use Metronidazole Vaginal)


metronidazole vaginal gel F QL(70 gm perfill retail)

MICONAZOLE 3 SUPP F QL(3 ea per fillretail)

miconazole nitrate vaginalcrea 2 %, 4 % F

miconazole nitrate vaginalkit F QL(24 gm per

fill retail) miconazole nitrate vaginalsupp 100 mg F

Drug Name DrugTier

Requirements/Limits

MONISTAT 3 COMBINATION PACK KIT (Use Miconazole Nitrate Vaginal)

NF

QL(24 gm perfill retail)

MONISTAT 3 CREA (Use Miconazole Nitrate Vaginal) NF

MONISTAT 7 SIMPLY CURE CREA (Use Miconazole Nitrate Vaginal)

NF

TERAZOL 3 CREA (Use Terconazole Vaginal) NF QL(20 gm per

fill retail) TERAZOL 7 CREA (Use Terconazole Vaginal) NF QL(45 gm per

fill retail)

TERCONAZOLE CREA F QL(20 gm perfill retail)

terconazole vaginal crea0.4 % F QL(45 gm per

fill retail) terconazole vaginal crea0.8 % F QL(20 gm per

fill retail) terconazole vaginal supp80 mg F QL(3 ea per fill

retail)

tioconazole vaginal oint F

VAGISTAT-1 OINT (Use Tioconazole Vaginal) NF

Vaginal Estrogens ESTRACE CREA VA 0.1 MG/GM (Use Estradiol Vaginal)


estradiol vaginal crea 0.1mg/gm F QL(43 gm per

fill retail) PREMARIN CREA VA 0.625 MG/GM F QL(43 gm per

fill retail) VASOPRESSORS - Drugs to Treat Heart andCirculation Conditions

Anaphylaxis Therapy Agents

epinephrine (anaphylaxis)soaj F

QL(2 ea per fillretail,4 ea per365 days retail)

Vasopressors

midodrine hcl tabs F

VITAMINS

Oil Soluble Vitamins


86

Drug Name DrugTier

Requirements/Limits

cholecalciferol caps 1000unit, 2000 unit, 5000 unit,50000 unit

F

DRISDOL CAPS 50000 UNIT (Use Ergocalciferol) NF

ergocalciferol caps 50000unit F

KEY-E CHEW F

MEPHYTON TABS (Use Phytonadione) NF

phytonadione tabs or 5 mg F

vitamin e caps or 100 unit,200 unit, 400 unit F

VITAMIN E CHEW OR 400 UNIT F

Water Soluble Vitamins ascorbic acid tabs or 500mg, 1000mg, 250 mg,500 mg, 1000 mg, 10mg-500mg, 37mg-500mg,37mg-1000mg, 14mg-25mg-500mg

F

B-1 TABS F

niacin cpcr 250 mg, 500 mg F

niacin tabs 500 mg F

niacin tbcr 250 mg, 500mg, 750 mg F

NIACIN TR TBCR F

pyridoxine hcl tabs or 25mg, 50 mg, 100 mg F

riboflavin tabs 25 mg, 50mg, 100 mg F

SLO-NIACIN TBCR (Use Niacin) NF

thiamine hcl soln F

thiamine hcl tabs F

thiamine mononitrate tabs F


87

Index A-200 42 ADVIL COLD & SINUS 36 ALLEVYN THIN 53 abacavir sulfate 29 ADYNOVATE 48 allopurinol 48 abacavir sulfate-lamivudine 29 AEROSPAN 9 ALOCRIL 76 abacavir sulfate-lamivudine- AEROTRACH PLUS 57 ALOGLIPTIN 15 zidovudine ABILIFY ABILIFY MAINTENA acamprosate calcium ACCUPRIL ACCURETIC ACE AEROSOL CLOUD ENHANCER acebutolol hcl acetaminophen acetaminophen w/ codeine acetazolamide

29 29 29 78 21 22

57 32

4 5

44

AFINITOR 25 AFINITOR DISPERZ 25 AFLURIA 2015-2016 84 AFLURIA 2016-2017 84 AFLURIA 2017-2018 84 AFLURIA PF 2015-2016 84 AFLURIA PF 2016-2017 84 AFLURIA PF 2017-2018 84 AFLURIA QUADRIVALENT 2016-2017 84 AFLURIA QUADRIVALENT 2017-2018 84

ALOGLIPTIN/METFORMINHCL 15 ALOGLIPTIN/PIOGLITAZONE

15 ALOMIDE 76 ALORA 46 ALPHANATE/VONWILLEBRANDFACTOR COMPLEX/HUMAN 48 ALPHANINE SD 48 alprazolam 8 ALPROLIX 48 ALTACE 21

acetic acid (otic) acetylcysteine ACNE MEDICATION 10

76 37 37

AFSTYLA 48 AGRYLIN 49 AIRS PEDIATRIC AEROSOL

alum & mag hydrox-simethicone 6 ALUMINUM HYDROXIDE 6

ACNE MEDICATION 5 ACTHIB ACTIGALL ACTIMMUNE ACTIVELLA ACTIVITY POUCH ACTONEL ACTOPLUS MET ACTOS ACULAR ACULAR LS acyclovir acyclovir topical ADACEL ADALAT CC ADASUVE ADDERALL ADDERALL XR ADMELOG ADMELOG SOLOSTAR

37 83 47 26 46 57 45 15 16 76 76 31 40 80 32 28

1 1

16 16

MASK 57 albuterol sulfate 9 ALBUTEROL SULFATE ER 9 ALCAINE 75 ALCOHOL SWABS 57 ALDACTAZIDE 44 ALDACTONE 45 ALDARA 42 ALECENSA 25 ALENDRONATE SODIUM 45 alendronate sodium 45 ALENDRONATE SODIUM 45 alendronate sodium 45 ALER-DRYL 19 ALEVE 2 ALEVE ARTHRITIS 2 ALIVE ENERGY 50+ 64 ALIVE MENS ENERGY 64 ALIVE ONCE DAILY WOMENS 50+ ULTRA POTENCY 64 ALIVE ONCE DAILY WOMENS

amantadine hcl 26 AMARYL 17 AMBIEN 50 AMD FOAM DRESSING 4"X4" 53 AMD FOAM DRESSING/TOPSHEET4"X4" 53 AMERGE 60 AMICAR 50 amiloride & hydrochlorothiazide 44 amiloride hcl 45 amiodarone hcl 9 AMITIZA 47 amitriptyline hcl 14 amlodipine besylate 32 amlodipine besylate-benazeprilhcl 22 amlodipine besylate-olmesartanmedoxomil 22 amlodipine besylate-valsartan 22

ADRENALIN ADULT AEROSOL MASK ADULT MASK ADULT MASK LARGE ADVANCED DIABETIC MULTIVITAMIN FORMULA

72 57 57 57

64

ULTRA POTENCY 64 ALIVE WOMENS 50+ 64 ALIVE WOMENS ENERGY 64 ALKERAN 24 ALL FLOW 1000 PULMONARY FUNCTION FILTER 57

amlodipine-valsartan-hydrochlorothiazide 22 AMOXAPINE 14 amoxicillin 77 AMOXICILLIN 77 amoxicillin 77

ADVATE 48 ALLEGRA ALLERGY 19 amoxicillin & pot clavulanate 77 ADVIL 2 ALLEVYN PLUS CAVITY 53 AMOXICILLIN/CLAVULANATE

POTASSIUM 77

Index 1

amphetamine-dextroamphetamine ampicillin AMPICILLIN ANAFRANIL anagrelide hcl ANAPROX DS ANASPAZ anastrozole ANDRODERM ANDROXY ANTABUSE ANTIOXIDANT FORTE ANUSOL-HC AP-ZEL APEXICON E APIDRA APIDRA SOLOSTAR apraclonidine hcl aprepitant APTIVUS AQUORAL ARAVA ARICEPT ARIMIDEX aripiprazole ARISTADA ARMOUR THYROID AROMASIN ARTHRITIS PAIN RELIEVING

1 77 77 14 49

2 80 24

6 6

78 64

6 64 40 16 16 74 18 29 63

3 78 24 29 29 80 24

42

atorvastatin calcium 20 atovaquone 7 ATRIPLA 29 ATROPINE SULFATE 74 ATROVENT 72 ATROVENT HFA 9 AUGMENTIN 78 AUGMENTIN ES-600 78 AUGMENTIN XR 78 AVALIDE 22 AVANDIA 16 AVAPRO 21 AVASTIN 24 AVONEX 79 AVONEX PEN 79 AYGESTIN 78 AZASAN 61 azathioprine 61 azelastine hcl 72 azelastine hcl (ophth) 76 AZITHROMYCIN 52 azithromycin 52 AZOPT 76 AZOR 22 AZULFIDINE 47 AZULFIDINE EN-TABS 47 b complex w/ c 63 B-1 87 b-complex vitamins 63 b-complex w/ c & folic acid 63

BAND-AID MIRASORB GAUZE SPONGES LARGE 4" X 4" 53 BASAGLAR KWIKPEN 16 BASIC AM 64 BASIC PM 64 BD GLUCOSE 15 BEBULIN 48 BELBUCA 6 BENADRYL ALLERGY 19 BENADRYL ALLERGY CHILDRENS 19 benazepril &hydrochlorothiazide 22 benazepril hcl 21 BENEFIX 48 BENICAR 21 BENICAR HCT 22 BENTYL 80 BENZAC AC WASH 37 benzonatate 36 benzoyl peroxide 37 BENZOYL PEROXIDE 37 benzoyl peroxide 38 BENZOYL PEROXIDE CLEANSER 37 benztropine mesylate 26 BETAGAN 74 betamethasone dipropionate(topical) 40 betamethasone dipropionateaugmented 40 betamethasone valerate 40 BETAPACE 32

artificial tear ointment 74 BACIGUENT 38 BETAPACE AF 32 ascorbic acid 87 aspirin 4 ASPIRIN 4 aspirin 4 aspirin buffered (cal carb-magcarb-mag oxide) 4 ASTEPRO 72 ATACAND 21

bacitracin (topical) bacitracin zinc bacitracin-polymyxin b(ophth) baclofen BACMIN BACTRIM BACTRIM DS

38 38

74 71 64

7 7

betaxolol hcl (ophth) 74 bethanechol chloride 83 BETOPTIC-S 74 bexarotene 26 BEXSERO 83 BIATAIN ADHESIVE FOAM DRESSING 4"X4" 53 BIATAIN FOAM DRESSING

ATACAND HCT 22 BACTROBAN 38 4"X4" 53 atazanavir sulfate 29 BACTROBAN NASAL 72 BIAXIN 52

ATELVIA 45 balsalazide disodium 47 bicalutamide 24

atenolol atenolol & chlorthalidone ATIVAN

32 22

8

BAND-AID GAUZE PADS LARGE4" X 4" BAND-AID GAUZE PADS MEDIUM 3" X 3"

53

53

BIKTARVY 29 BIOGUARD GAUZE SPONGE 2"X2" 8 PLY 53 BIOGUARD GAUZE SPONGES

atomoxetine hcl 1 BAND-AID GAUZE PADS 4"X4" 12 PLY 53 SMALL2" X 2" 53

Index 2

BIOTENE DRY MOUTH MOISTURIZING SPRAY bisacodyl bismuth subsalicylate bisoprolol &hydrochlorothiazide bisoprolol fumarate BLEPH-10

63 52 17

22 32 74

BYETTA CABOMETYX CAFERGOT caffeine citrate CAL-DAY 1000 CALAN CALAN SR

16 25 59

1 64 32 32

carvedilol phosphate CASODEX CATAPRES cefaclor CEFACLOR cefadroxil cefdinir

31 24 22 33 33 33 34

BLEPHAMIDE 75 calcipotriene 40 cefprozil 33 BLEPHAMIDE S.O.P. 75 calcitonin (salmon) 45 CEFTIN 33 BOOSTRIX 80 calcitriol 46 ceftriaxone sodium 34 BORDERED GAUZE BOSULIF BREO ELLIPTA BREVICON-28

53 25

9 34

calcium acetate (phosphatebinder) 48 calcium carbonate (antacid) 7 calcium carbonate-cholecalciferol 60

cefuroxime axetil CELEBREX celecoxib CELEXA

34 2 2

13 BRILINTA 49 calcium carbonate-vitamin CELLCEPT 61 brimonidine tartrate bromocriptine mesylate brompheniramine &phenylephbrompheniramine &pseudoephBUBBLES THE FISH II PEDIATRIC MASK/PVC budesonide (inhalation) BUFFERIN bumetanide BUMEX BUNAVAIL

74 26

37

37

57 9 4

45 45

6

d 60 calcium polycarbophil 51 CALNA 69 camphor & menthol 39 candesartan cilexetil 21 candesartan cilexetil-hydrochlorothiazide 22 CAPHOSOL 63 CAPRELSA 25 capsaicin 42 captopril 21 CAPTOPRIL/HYDROCHLOROTHIAZIDE 22

CENTRAVITES 50 PLUS CENTRAVITES ADULTS CENTRUM ADULTS CENTRUM CARDIO CENTRUM MEN CENTRUM SILVER ULTRA MENS CENTRUM SILVER ULTRA WOMENS CENTRUM SPECIALIST HEART CENTRUM SPECIALIST IMMUNE SUPPORT CENTRUM SPECIALIST

64 64 64 64 64

64

64

64

64

BUPRENEX 6 CAPZASIN-HP 42 VISION 64 BUPRENORPHINE 6 CAPZASIN-P 42 CENTRUM ULTRA

buprenorphine hcl 6 buprenorphine hcl-naloxone hcldihydrate 6 bupropion hcl 12 bupropion hcl (smokingdeterrent) 79 buspirone hcl 8 butalbital-acetaminophen 3 butalbital-acetaminophen-caffeine 3 butalbital-acetaminophen-caffeine w/ codeine 5 butalbital-aspirin-caffeine 4 butalbital-aspirin-caffeinew/cod 5 BUTRANS 6

CARAC CARAFATE carbamazepine carbamide peroxide (otic) carbidopa carbidopa-levodopa CARDIZEM CARDIZEM CD CARDURA carisoprodol CARNITOR CARNITOR SF CARRASMART CARRASMART FOAM

39 82 10 76 26 26 32 32 22 71 46 46 53 53

WOMENS 64 cephalexin 33 CERASPORT 60 CERASPORT EX1 60 CERTAVITE SENIOR/ANTIOXIDANTNUTRIENTS 64 CERVARIX 84 cetirizine hcl 19 cetirizine-pseudoephedrine 37 CHANTIX 79 CHANTIX CONTINUING MONTHPAK 79 CHANTIX STARTING MONTH PAK 79 CHEK-STIX COMBO PAK

BYDUREON 16 URINALYSIS CONTROL 43CARTEOLOL HCL 74 CHEK-STIX CONTROL 43BYDUREON BCISE 16 carteolol hcl (ophth) 74 CHEMET 17BYDUREON PEN 16 carvedilol 31 CHEMSTRIP-K 43

Index 3

CHERACOL PLUS 37 CLEOCIN PEDIATRIC COLCHICINE 48 CHERACOL-D COUGH 37 CHILDRENS ADVIL 2 CHILDRENS MOTRIN 2 CHLOR-TRIMETON 19 chlordiazepoxide hcl 8 chlorhexidine gluconate (mouth-throat) 62 CHLOROQUINE PHOSPHATE 23 chloroquine phosphate 23 CHLOROTHIAZIDE 45

GRANULES 7 CLEOCIN-T 38 CLIMARA 46 CLINDAGEL 38 clindamycin hcl 7 clindamycin palmitatehydrochloride 7 clindamycin phosphate(topical) 38 clindamycin phosphatevaginal 86 CLINICAL NUTRIENTS 45-

colchicine w/ probenecid COLCRYS COLESTID COLESTID FLAVORED colestipol hcl COLYTE-FLAVOR PACKS COMBIPATCH COMBIVENT RESPIMAT COMBIVIR COMETRIQ

48 48 20 20 20 51 46

9 29 25

chlorothiazide chlorpheniramine maleate CHLORPROMAZINE HCL

45 19 28

PLUS WOMEN 64 CLINICAL NUTRIENTS 50-PLUS MEN 64 CLINICAL NUTRIENTS FOR

COMPLERA COMPLETENATE COMTAN

29 69 26

chlorpromazine hcl chlorthalidone CHLORZOXAZONE CHOLBAM cholecalciferol cholestyramine cholestyramine light choline & mag salicylate

28 45 71 47 87 20 20

4

FEMALE TEENS 64 CLINICAL NUTRIENTS FOR MALE TEENS 64 CLINICAL NUTRIENTS FOR MEN 64 CLINICAL NUTRIENTS FOR WOMEN 64 clobetasol propionate 40 clobetasol propionate emollientbase 40

CONCERTA 1 CONDOMS 57 CONDYLOX 42 COPA ISLAND BORDERED FOAM DRESSING 4"X4" 53 COPA PLUS HYDROPHILIC FOAM DRESSING 4"X4" 53 COPAXONE 79 COREG 31

cilostazol 49 clomipramine hcl 14 COREG CR 31 CILOXAN 74 clonazepam 10 CORGARD 32 cimetidine 81 clonidine hcl 22 CORIFACT 48 CIMETIDINE HCL 81 clonidine hcl (adhd) 1 CORTANE-B AQUEOUS 77 CIPRO 47 clopidogrel bisulfate 49 CORTANE-B-OTIC 77 CIPROFLOXACIN HCL 47 clorazepate dipotassium 8 CORTEF 36 ciprofloxacin hcl 47 clotrimazole (topical) 39 CORTENEMA 6 ciprofloxacin hcl (ophth) 74 citalopram hydrobromide 13 CLARITHROMYCIN 52 clarithromycin 52 CLARITHROMYCIN 52 clarithromycin 52 CLARITIN 19 CLARITIN ALLERGY CHILDRENS 19 CLARITIN REDITABS 19 CLARITIN-D 12 HOUR 37 CLARITIN-D 24 HOUR 37 CLASSIC PRENATAL 69 CLEAN & CLEAR ADVANTAGE 3-IN-1 EXFOLIATING CLEANSER 38 clemastine fumarate 19

clotrimazole vaginal 86 clotrimazole w/betamethasone 39 clozapine 28 CLOZAPINE ODT 28 CLOZARIL 28 CO MONITOR REPLACEMENT TPIECES58 CO-NATAL FA 69 COAGADEX 48 coal tar extract 43 COARTEM 23 codeine sulfate tabs 15 mg,30mg, 60mg 4 COGENTIN 26 COLACE 52 COLACE CLEAR 52

CORTISONE ACETATE 36 COSOPT 74 COTELLIC 25 COUMADIN 10 COVRSITE COVER DRESSING 53 COVRSITE PLUS COMPOSITE DRESSING 53 COZAAR 21 CREON 44 CRESTOR 20 CRIXIVAN 29 cromolyn sodium 9 cromolyn sodium (nasal) 72 cromolyn sodium (ophth) 76 CUREX ALL-PURPOSE SPONGES 4"X4" 4 PLY 53

COLAZAL 47 CURITY ALL PURPOSECLEOCIN 7,86 SPONGES 2"X2"

Index 4

53

CURITY ALL PURPOSE CURITY DEMADEX 45 SPONGES 2"X2" 4PLY 53 CURITY ALL PURPOSE SPONGES 3"X3" 4PLY 53 CURITY ALL PURPOSE SPONGES 4 PLY 53 CURITY ALL PURPOSE SPONGES 4"X4" 53 CURITY ALL PURPOSE SPONGES 4"X4" 4PLY 53 CURITY ALL PURPOSE SPONGES 4"X4" 4PLY/SOFTPOUCH 53

SPONGES/CELLULOSEFILLED/4"X4" 54 CVS DRY MOUTH SPRAY63 CVS GAUZE PAD 3"X3" 54 CVS GAUZE PADS 2"X2" 12-PLY 54 CVS GAUZE PADS 4"X4" 12-PLY 54 CVS GAUZE PADS STERILE 4"X4" 12-PLY 54 CVS GLUCOSE 15

DEMEROL DEPAKENE DEPAKOTE DEPAKOTE ER DEPAKOTE SPRINKLES DEPEN TITRATABS DEPO-PROVERA CONTRACEPTIVE DEPO-SUBQ PROVERA 104

4 12 12 12 12 61

35

35 CURITY AMD CVS OMEPRAZOLE 82 DEPO-TESTOSTERONE 6 ANTIMICROBIALGAUZE SPONGES 2"X2" 8 PLY 54 CURITY AMD ANTIMICROBIALGAUZE SPONGES 4"X4" 12 PLY 54 CURITY COVER SPONGE 4"X4" 54 CURITY COVER SPONGES 3"X3" 54 CURITY COVER SPONGES 4"X4" 54 CURITY DRESSING SPONGES 4"X4" 6 PLY 54 CURITY GAUZE PADS 2"X2" 54 CURITY GAUZE PADS 2"X2" 12 PLY 54 CURITY GAUZE PADS 3"X3" 54 CURITY GAUZE PADS 4"X4" 12 PLY 54 CURITY GAUZE SPONGE 2"X2" 8 PLY 54 CURITY GAUZE SPONGE 2"X2"12 PLY 54 CURITY GAUZE SPONGE 3"X3" 12 PLY 54 CURITY GAUZE SPONGE 4"X4" 12 PLY 54 CURITY GAUZE SPONGE 4"X4" 16 PLY 54 CURITY GAUZE SPONGE 4"X4" 8 PLY 54 CURITY GAUZE SPONGE 4"X4"16 PLY 54 CURITY GAUZE SPONGES 4"X4" 12 PLY 54 CURITY GAUZE SPONGES 4"X4" 8 PLY 54 CURITY NON-ADHERENT STRIPS 3"X3" 54 CURITY SPONGES/CELLULOSEFILLED/2"X2" 54

CVS ONE DAILY MENS 50+ ADVANCED 64 CVS PRENATAL 69 CVS SPECTRAVITE ADULT 50+ 64 CVS SPECTRAVITE ULTRA MEN50+ 64 CVS SPECTRAVITE ULTRA MENS HEALTH 64 CVS SPECTRAVITE ULTRA MENS HEALTH SENIOR 64 CVS SPECTRAVITE ULTRA WOMEN 64 CVS SPECTRAVITE ULTRA WOMENS HEALTH 64 CVS SPECTRAVITE ULTRA WOMENS HEALTH SENIOR 64 cyanocobalamin 49 CYCLESSA 34 cyclobenzaprine hcl 71 CYCLOGYL 74 cyclopentolate hcl 74 cyclosporine 61 CYCLOSPORINE MODIFIED 62 cyclosporine modified (formicroemulsion) 62 CYMBALTA 14 cyproheptadine hcl 20 CYRAMZA 24 CYTOMEL 80 CYTOTEC 82 D.H.E. 45 59 dapsone 7 DAYPRO 2 DDAVP 46 DEBROX 76 DECON-A 37

DERMACEA DRAIN SPONGES 4"X4" 54 DERMACEA GAUZE SPONGE 2"X2" 12 PLY 54 DERMACEA GAUZE SPONGE 2"X2" 8 PLY 54 DERMACEA GAUZE SPONGE 3"X3" 12 PLY 54 DERMACEA GAUZE SPONGE 3"X3" 8 PLY 54 DERMACEA GAUZE SPONGE 4"X4" 12 PLY 54 DERMACEA GAUZE SPONGE 4"X4" 16 PLY 54 DERMACEA GAUZE SPONGE 4"X4" 8 PLY 54 DERMACEA I.V. DRAIN SPONGES 2"X2" 54 DERMACEA I.V. DRAIN SPONGES 4"X4" 54 DERMACEA I.V. SPONGES 2"X2" 54 DERMACEA NON-WOVEN SPONGES 2"X2" 4 PLY 54 DERMACEA NON-WOVEN SPONGES 3"X3" 4 PLY 55 DERMACEA NON-WOVEN SPONGES 4"X4" 4 PLY 55 DERMACEA NON-WOVEN SPONGES 4"X4" 6 PLY 55 DERMACEA TYPE VII GAUZE 2"X2" 12 PLY 55 DERMACEA TYPE VII GAUZE 2"X2" 8 PLY 55 DERMACEA TYPE VII GAUZE 3"X3" 12 PLY 55 DERMACEA TYPE VII GAUZE 3"X3" 12PLY 55 DERMACEA TYPE VII GAUZE 4"X4" 12 PLY 55 DERMACEA TYPE VII GAUZE 4"X4" 16 PLY 55 DERMACEA TYPE VII GAUZE 4"X4" 8 PLY 55

DELZICOL 47

Index 5

DERMACEA X-RAY SPONGES 4"X4" 16 PLY 55 DERMALEVIN ADHESIVE FOAMDRESSING 4"X4" 55

diclofenac sodium (ophth) 76 diclofenac sodium (topical) 38 dicloxacillin sodium 78

DOVONEX doxazosin mesylate doxepin hcl

40 22 14

DERMATOP 40 DERMAVITE 64 DERMOTIC 77 DESCOVY 29 desipramine hcl 14 desmopressin acetate 46 desmopressin acetate spray 46 desmopressin acetate sprayrefrigerated 46 DESOGEN 34 desogestrel & ethinylestradiol 34 desogestrel-ethinyl estradiol(biphasic) 34 desogestrel-ethinyl estradiol(triphasic) 34 desoximetasone 40 DESQUAM-X WASH 38 DETROL 83

dicyclomine hcl 81 DIFLORASONE DIACETATE 40 DIFLUCAN 18 diflunisal 4 DIGOXIN 33 digoxin 33 dihydroergotaminemesylate 59 DIHYDROERGOTAMINE MESYLATE 59 DILANTIN 12 DILANTIN INFATABS 12 DILANTIN-125 12 DILAUDID 4 diltiazem hcl 33 diltiazem hcl coated beads 32 diltiazem hcl extended release beads 33

doxycycline hyclate doxylamine succinate(sleep) DRAMAMINE DRISDOL drospirenone-ethinylestradiol DROXIA DRYMAX EXTRA DRYSOL DULCOLAX DULERA duloxetine hcl DURAGESIC DYAZIDE E.E.S. 400 E.E.S. GRANULES EBASE CONTROLLER KIT

80

50 18 87

34 49 55 42 52

9 14

4 44 52 52 58

DETROL LA DEX4 QUICK DISSOLVE GLUCOSE

83

15

dimenhydrinate DIMETAPP COLD & ALLERGY

18

37

EC-NAPROSYN econazole nitrate ECOTRIN MAXIMUM

3 39

dexamethasone 36 DIOVAN 21 STRENGTH 4 DEXAMETHASONE 36 dexamethasone 36 DEXAMETHASONE 36 DEXAMETHASONE INTENSOL 36 dexamethasone sodium phosphate 36 DEXAMETHASONE SODIUM PHOSPHATE 75

DIOVAN HCT 22 diphenhydramine hcl 19 diphenhydramine hcl(sleep) 50 diphenhydramine hcl(topical) 39 diphenoxylate w/ atropine 17 DIPHENOXYLATE/ATROPINE

17

ECOTRIN REGULAR STRENGTH EDURANT efavirenz EFFEXOR XR EFFIENT EFLOW SCF AEROSOL HEAD EFUDEX

4 29 29 14 49

58 39

DEXEDRINE 1 DIPROLENE AF 40 ELAVIL 14 dexmethylphenidate hcl 1 dipyridamole 49 ELDEPRYL 27 dextroamphetamine sulfate 1 dextromethorphan-guaifenesin

37 DHS TAR 43 DHS TAR GEL 43 DIAMOX 44 DIAZEPAM 8 diazepam 8 DIAZEPAM 10 DIAZEPAM RECTAL GEL 10 dibucaine 42 diclofenac potassium 2 diclofenac sodium 2,3

DISALCID disopyramide phosphate disulfiram DITROPAN XL divalproex sodium docusate sodium dofetilide DOLOPHINE donepezil hydrochloride DONNATAL dorzolamide hcl dorzolamide hcl-timolol maleate

4 8

78 83 12 52

9 4

78 81 76

74

eletriptan hydrobromide 60 ELIDEL 42 ELIGARD 24 ELIMITE 43 ELIQUIS 10 ELIQUIS STARTER PACK 10 ELITE DC AUTO ADAPTER 58 ELIXOPHYLLIN 10 ELLA 35 ELMIRON 48 ELOCON 41 ELOCTATE 48

Index 6

EMEND 18 ERIVEDGE 24 EXFORGE HCT 22 EMEND TRIPACK 18 ERY-TAB 53 famciclovir 31 EMSAM 13 ERYGEL 38 famotidine 81 EMTRIVA 29 ERYPED 200 53 FAMVIR 31 EMVERM 7 ERYPED 400 53 FANAPT 27 enalapril maleate 21 ERYTHROCIN FANAPT TITRATION PACK 27 enalapril maleate & STEARATE 53 FARESTON 25 hydrochlorothiazide 22 erythromycin (acne aid) 38 FAZACLO 28ENBREL 3 erythromycin (ophth) 74 FEIBA 49ENBREL SURECLICK 3 erythromycin base 53 felbamate 11ENCARE 86 erythromycin

FELBATOL 11ethylsuccinate 53ENFAMIL ENFALYTE 60 ERYTHROMYCIN FELDENE 3ENGERIX-B 84 ETHYLSUCCINATE 53 felodipine 33enoxaparin sodium 10 escitalopram oxalate 13 FEMARA 25 entacapone 26 ESGIC 4 FEMCON FE 34EPANED 21 esomeprazole magnesium 82 FEMHRT LOW DOSE 46EPIFOAM 41 esterified estrogens & fenofibrate 20methyltestosterone 46epinephrine (anaphylaxis) 86 fenofibrate micronized 20ESTRACE 46,86EPIVIR 29

estradiol 46 fentanyl 4EPOGEN 49 estradiol & norethindrone FER-IN-SOL 50EPZICOM 29 acetate 46 FERRETTS 50EQ COMPLETE estradiol vaginal 86 ferrous fumarate 50MULTIVITAMINADULTS UNDER 50 65 ESTROFACTORS 67 ferrous fumarate-fa-b complex-c-EQ OMEPRAZOLE 82 ESTROPIPATE 47 zn-mg-mn-cu 50

ESTROSTEP FE ferrous gluconate 50EQ ONE DAILY MENS 50+ 65 34 FERROUS GLUCONATE 50EQ ONE DAILY MENS ethambutol hcl 24

HEALTH 65 ferrous sulfate 50ethosuximide 12EQ ONE DAILY WOMENS ethynodiol diacet & eth FERROUS SULFATE 5050+ 65 estrad 34 ferrous sulfate 50EQ ONE DAILY WOMENS etodolac 3HEALTH 65 ferrous sulfate dried 50 EQL CENTURY MATURE EURAX 43 FEXMID 71 ADULTS50+ 65 EVAC 51 fexofenadine hcl 19EQL CENTURY MENS 65 EVISTA 46 FIASP 16EQL CENTURY WOMENS 65 EVOTAZ 29 FIASP FLEXTOUCH 16EQL DRY MOUTH ORAL EXCILON AMD FIBERCON 51RINSE 63 ANTIMICROBIALDRAINEQL GAUZE PADS FILTER AIR PP 58SPONGES 4"X4" 6 PLY 552"X2"/SMALL 55 EXCILON AMD finasteride 48EQL GAUZE PADS ANTIMICROBIALNON-WOVEN FIORINAL 44"X4"/LARGE 55 SPONGES 4"X4" 6 PLY 55EQL GAUZE STERILE PADS FIORINAL/CODEINE #3 5EXCILON DRAIN SPONGE3"X3" 55 4"X4" 55 FIRMAGON 25 EQL OMEPRAZOLE 82 EXCILON DRAIN SPONGES FITNESS TABS FOR MEN EQL ONE DAILY MENS 65 4"X4" 6 PLY 55 AM/PM/LYCOPENE 65

EXCILON I.V. SPONGES 2"X2" FITNESS TABS FOR WOMENEQL PRENATAL FORMULA 69 6 PLY 55 AM/PM/LYCOPENE 65EQUETRO 27 EXELON 78 FLAGYL 7 ergocalciferol 87 exemestane 25 flavoxate hcl 83 ERGOLOID MESYLATES 79 EXFORGE 22 flecainide acetate 8 ergotamine w/ caffeine 59

Index 7

FLEET ENEMA 51 FLURA-DROPS 61 FUROSEMIDE 45 FLEET ENEMA SIX PACK 51 FLURAZEPAM HCL 50 furosemide 45 FLEET PEDIATRIC 51 flurbiprofen 3 FUZEON 29 FLEXZAN 4 X 4 55 flurbiprofen sodium 76 gabapentin 10 FLOMAX 48 FLURBIPROFEN SODIUM76 GABITRIL 12 FLONASE ALLERGY RELIEF 72 FLONASE ALLERGY RELIEF CHILDRENS 72 FLORIVA PLUS 67 FLOVENT DISKUS 9 FLOVENT HFA 9 FLOXIN OTIC 77 FLUAD 2016-2017 84 FLUAD 2017-2018 84 FLUARIX QUADRIVALENT 2015-2016 84

flutamide 25 fluticasone propionate 41 fluticasone propionate(nasal) 72 FLUVIRIN 2015-2016 84 FLUVIRIN 2016-2017 84 FLUVIRIN 2017-2018 84 fluvoxamine maleate 13 FLUZONE HIGH-DOSE PF 2015-2016 84 FLUZONE HIGH-DOSE PF 2016-2017 84

galantamine hydrobromide GALANTAMINE HYDROBROMIDE galantamine hydrobromide GARDASIL GARDASIL 9 GAS-X GAUZE DRESSING 4"X4" GAUZE PADS 2"X2" GAUZE PADS 3"X3" GAUZE PADS 4"X4"

78

78 78 85 85 47 55 55 55 55

FLUARIX QUADRIVALENT 2016-2017 84

FLUZONE HIGH-DOSE PF 2017-2018 85

GAUZE PADS 4"X4" 12 PLY 55 GAUZE SPONGE TYPE VII

FLUARIX QUADRIVALENT 2017-2018 FLUBLOK 2015-2016

84 84

FLUZONE INTRADERMAL QUADRIVALENT 2015-2016 85

MEDI-PAK 2"X2" 8PLY 55 GAUZE SPONGES 4"X4" 12 PLY 55

FLUBLOK 2016-2017 84 FLUBLOK 2017-2018 84 FLUCELVAX 2015-2016 84 FLUCELVAX QUADRIVALENT 2016-2017 84

FLUZONE INTRADERMAL QUADRIVALENT 2016-2017 85 FLUZONE INTRADERMAL QUADRIVALENT 2017-2018 85

GEL-KAM ORAL CARE RINSE gemfibrozil GENERESS FE GENOTROPIN

62 20 34 45

FLUCELVAX QUADRIVALENT 2017-2018 84 fluconazole 18,19 fludrocortisone acetate 36 FLULAVAL QUADRIVALENT 2014-2015 84 FLULAVAL QUADRIVALENT 2015-2016 84 FLULAVAL QUADRIVALENT 2016-2017 84 FLULAVAL QUADRIVALENT 2017-2018 84 FLUMIST QUADRIVALENT 84 FLUNISOLIDE 72 fluocinolone acetonide (otic) 77 fluocinonide 41 fluocinonide emulsified base 41 fluorometholone (ophth) 75 FLUOROURACIL 39 fluorouracil (topical) 39 fluoxetine hcl 13 fluphenazine decanoate 28 FLUPHENAZINE HCL 28 fluphenazine hcl 28

FLUZONE QUADRIVALENT 2015-2016 85 FLUZONE QUADRIVALENT 2016-2017 85 FLUZONE QUADRIVALENT 2017-2018 85 FLUZONE SPLIT 2015-2016 85 FML 75 FML LIQUIFILM 75 FOCALIN 1 folic acid 49 formaldehyde 29 FORTICAL 45 FOSAMAX 45 fosamprenavir calcium 29 fosinopril sodium 21 fosinopril sodium &hydrochlorothiazide 22 FREEDAVITE 65 FULL KIT NEBULIZER SET 58 FURADANTIN 83 furosemide 45

GENTAK 74 gentamicin sulfate (ophth) 74 gentamicin sulfate (topical) 38 GENVOYA 29 GEODON 27 GERI-FREEDA SENIOR FORMULA 65 GILENYA 79 GILOTRIF 25 glatiramer acetate 79 GLEEVEC 25 glimepiride 17 glipizide 17 glipizide-metformin hcl 15 GLUCAGEN HYPOKIT 15 GLUCAGON EMERGENCY KIT 15 GLUCOPHAGE 15 GLUCOPHAGE XR 15 GLUCOSE 15 GLUCOTROL 17 GLUCOTROL XL 17 GLUCOVANCE 15

Index 8

glyburide 17 HERCEPTIN 24 hydrocodone w/homatropine 36glyburide micronized 17 HIBERIX 83 hydrocodone-acetaminophen 5glyburide-metformin 15 HM COMPLETE 65 hydrocortisone 36glycerin (laxative) 51 HM COMPLETE 50+ MENS

ULTIMATE 65 hydrocortisone (intrarectal) 6GLYCERIN ADULT 51 HM COMPLETE 50+ hydrocortisone (rectal) 6glycopyrrolate 81 WOMENS ULTIMATE 65 hydrocortisone (topical) 41GLYNASE 17 HM HAIR/SKIN/NAILS 65 hydrocortisone butyrate 41GNP GLUCOSE 15 HM OMEPRAZOLE 82 hydrocortisone w/acetic acid 77GNP OMEPRAZOLE 82 HM ONE DAILY MENS 65 hydrocortisone-aloe vera 41GNP PRENATAL 69 HM ONE DAILY WOMENS65 HYDROMORPHONE HCL 4GNP QUICK DISSOLVE HM PRENATAL 69GLUCOSE 15 hydromorphone hcl 4

HM STERILE PADS 55GNP STERILE PADS 3"X3" 55 hydroxychloroquine sulfate 23HM STERILE PADS 2"X2" 55GOCOVRI 26 hydroxyurea 26HUDSON RCI SEE-THRU

GOLYTELY 51 hydroxyzine hcl 8AEROSOL MASK GOODSENSE PRENATAL ELONGATED/ADULT 58 HYDROXYZINE PAMOATE 8 VITAMINS 69 HUMALOG 16 hydroxyzine pamoate 8GRIS-PEG 18 HUMALOG JUNIOR hyoscyamine sulfate 81griseofulvin microsize 18 KWIKPEN 16 HYPERRHO S/D 77griseofulvin ultramicrosize 18 HUMALOG KWIKPEN 16

HYPOTEARS 74guaifenesin-codeine 37 HUMALOG MIX 50/50 16

HYZAAR 22HUMALOG MIX 50/50guanfacine hcl 22 KWIKPEN 16 IBRANCE 25

guanfacine hcl (adhd) 1 HUMALOG MIX 75/25 16 ibuprofen 3GYNAZOLE-1 86 HUMALOG MIX 75/25 ICAPS AREDS FORMULA 65GYNE-LOTRIMIN 86 KWIKPEN 16 ICAPS PLUS 65GYNE-LOTRIMIN 3 86 HUMATE-P 49 ICLUSIG 25HAIR-VITES 65 HUMIRA 2 IDELVION 49HALCION 50 HUMIRA PEDIATRIC CROHNS

imatinib mesylate 25DISEASE STARTER PACK 2HALDOL 28 HUMIRA PEN 2 IMBRUVICA 25

HALDOL DECANOATE 100 28 HUMIRA PEN-CROHNS imipramine hcl 14HALDOL DECANOATE 50 28 DISEASESTARTER 2 imiquimod 42haloperidol 28 HUMIRA PEN-PSORIASIS IMITREX 60STARTER 2HALOPERIDOL 34 IMITREX STATDOSEHUMULIN 70/30 16haloperidol decanoate 28 SYSTEM 60HUMULIN 70/30haloperidol lactate 28 IMODIUM A-D 17KWIKPEN 16 HAVRIX 85 IMURAN 62HUMULIN N 16 HEALTHY LIVING INATAL GT 69HUMULIN N KWIKPEN 16REPLACEMENT FILTERS 58 INCRUSE ELLIPTA 9HUMULIN R 16HEALTHY LIVING REPLACEMENT KIT FOR HYALEX 65 indapamide 45 NEBULIZER 58 INDERAL LA 32HYCAMTIN 26HEALTHY LIVING hydralazine hcl 23 indomethacin 3REPLACEMENT MASKS 58 INFANTS ADVIL 3HYDREA 26HELIXATE FS 49

HYDROCELL ADHESIVE INLYTA 25HEMANGEOL 32 DRESSING 4"X4" 55 INNOSPIRE REPLACEMENTHEMOCYTE 50 HYDROCELL DRESSING FILTER 58 HEMOFIL M 49 4"X4" 55 INSULIN SYRINGE AND PEN heparin sodium (porcine) 10 hydrochlorothiazide 45 NEEDLES 57

INTELENCE 29

Index 9

INTUNIV 1 KAPVAY 1 KPN PRENATAL 69 INVEGA 27 KAYEXALATE 62 labetalol hcl 31,32 INVEGA SUSTENNA 27 KEFLEX 33 LAC-HYDRIN 41 INVEGA TRINZA 27 KENDALL HYDROPHILIC LAC-HYDRIN TWELVE 42 INVIRASE 29 IOPIDINE 74 ipratropium bromide 9 ipratropium bromide (nasal) 72 ipratropium-albuterol 9 irbesartan 21 irbesartan-hydrochlorothiazide

22 IRESSA 25 IRON CHEWS PEDIATRIC 50 ISENTRESS 29 ISENTRESS HD 29 ISONIAZID 24 isoniazid 24 ISOPTO CARPINE 74 ISORDIL TITRADOSE 7 isosorbide dinitrate 8 ISOSORBIDE DINITRATE ER8 isosorbide mononitrate 8 isotretinoin 38 itraconazole 19 IXINITY 49 J & J GAUZE 2"X2" 8 PLY 55 J & J GAUZE 4"X4" 12 PLY 55 J & J GAUZE 4"X4" 8 PLY 55 J & J GAUZE SPONGES 12-PLY 4" X 4" 55 J & J GAUZE SPONGES 16-PLY 4" X 4" 56 J & J GAUZE SPONGES 8-PLY4" X 4" 56 JADENU 17 JADENU SPRINKLE 17 JARDIANCE 17 JENTADUETO 15 JULUCA 29 K-PAX IMMUNE SUPPORT FORMULA PROFESSIONAL STRENGTH 65 K-PHOS NEUTRAL 61 K-TAB 61 KADCYLA 24 KALETRA 30 KALYDECO 80

FOAMDRESSING 2"X2" 56 KENDALL HYDROPHILIC FOAMDRESSING 3"X3" 56 KENDALL HYDROPHILIC FOAMDRESSING 4"X4" 56 KENDALL HYDROPHILIC FOAMPLUS DRESSING 2"X2" 56 KENDALL HYDROPHILIC FOAMPLUS DRESSING 3"X3" 56 KEPPRA 10,11 KEPPRA XR 11 KERALYT 42 KERLIX SPONGES 4" X 4" 12 PLY 56 KERLIX SPONGES 4" X 4" 16 PLY 56 KETOCARE 43 ketoconazole 19 ketoconazole (topical) 39 KETONE TEST STRIPS 43 KETOPROFEN 3 ketoprofen 3 KETOPROFEN ER 3 ketorolac tromethamine 3 ketorolac tromethamine (ophth) 76 KETOSTIX 43 ketotifen fumarate (ophth) 76 KEY-E 87 KITABIS PAK 2 KLARON 38 KLONOPIN 10 KLOR-CON M15 61 KLOR-CON/25 61 KLOUT 43 KLS OMEPRAZOLE 82 KOATE 49 KOATE-DVI 49 KOGENATE FS 49 KOGENATE FS BIO-SET 49 KONSYL 51 KOVALTRY 49 KP PRENATAL MULTIVITAMINS 69

lactic acid (ammoniumlactate) 42 lactulose 51 lactulose (encephalopathy) 47 LAMICTAL 11 LAMICTAL CHEWABLE DISPERSIBLE 11 LAMICTAL XR 11 LAMISIL 18 LAMISIL AT 39 LAMISIL AT JOCK ITCH 39 lamivudine 30 lamivudine-zidovudine 30 lamotrigine 11 LANCET DEVICE 57 LANCETS 57 lanolin 78 lanolin (topical) 42 LANOXIN 33 lansoprazole 82 LASIX 45 latanoprost 76 LATUDA 27 LEADER QUICK DISSOLVE GLUCOSE 15 leflunomide 3 LEMTRADA 79 letrozole 25 LEUCOVORIN CALCIUM 26 leucovorin calcium 26 LEUKERAN 24 leuprolide acetate 25 LEVAQUIN 47 LEVBID 81 levetiracetam 11 levobunolol hcl 74 levocarnitine (metabolicmodifiers) 46 levocetirizine dihydrochloride19 levofloxacin 47 levonorgestrel & ethestradiol 34 levonorgestrel (emergencyoc) 35

Index 10

levonorgestrel-eth estradiol(triphasic) 34 levonorgestrel-ethinyl estradiol(91-day) 34 levothyroxine sodium 80 LEVSIN 81 LEVSIN/SL 81 LEXAPRO 13 LEXIVA 30 LICEMD 43 LICIDE TREATMENT KIT 43 lidocaine 42 lidocaine hcl 42 lidocaine hcl (mouth-throat) 62 lidocaine-prilocaine 42 liothyronine sodium 80 LIPITOR 20 lisinopril 21 lisinopril &hydrochlorothiazide 22 LITETOUCH MASK LARGE 58 LITETOUCH MASK MEDIUM 58 LITETOUCH MASK SMALL 58 LITHIUM 27 lithium carbonate 27 LITHIUM CARBONATE 27 lithium carbonate 27 LITHOBID 27 LMX 4 42 LOCOID 41 LODINE 3

losartan potassium 21 losartan potassium &hydrochlorothiazide 22 LOTENSIN 21 LOTENSIN HCT 22 LOTREL 23 LOTRIMIN AF 39 LOTRIMIN AF FOR HER 39 LOTRIMIN AF JOCK ITCH 39 LOTRISONE 39 lovastatin 20 LOVENOX 10 loxapine succinate 28 LUPRON DEPOT (1-MONTH) 25 LUPRON DEPOT (3-MONTH) 25 LUPRON DEPOT (4-MONTH) 25 LUPRON DEPOT (6-MONTH) 25 LUPRON DEPOT-PED (1-MONTH) 46 LUPRON DEPOT-PED (3-MONTH) 46 LURIDE 61 LYSTEDA 50 M-M-R II 85 M-VIT 69 MACROBID 83 MACRODANTIN 83 MACULAR VITAMIN BENEFIT 65 MAGNESIUM 61

MAXZIDE-25 44 meclizine hcl 18 MEDICAL PROVIDER EZ FLU SHOT 2015-2016 85 MEDICAL PROVIDER SINGLE USE EZ FLU SHOT 85 MEDROL 36 MEDROL DOSEPAK 36 medroxyprogesterone acetate 78 medroxyprogesterone acetate(contraceptive) 35 mefloquine hcl 23 MEFLOQUINE HCL 23 MEGA MULTIVITAMIN FOR MEN 65 MEGA MULTIVITAMIN FOR WOMEN 65 MEGACE ORAL 25 MEGAVITE FRUITS & VEGGIES 65 MEGAVITE GOLDEN YEARS 55+ 65 megestrol acetate 25 MEKINIST 25 meloxicam 3 melphalan 24 memantine hcl 78 MENACTRA 83 MENOMUNE-A/C/Y/W-135 83 MENS 50+ MULTI VITAMIN &MINERAL FORMULA 65 MENS MULTI VITAMIN & MINERAL FORMULA 65 MENVEO 83

LODOSYN LOESTRIN 1.5/30-21 LOESTRIN 1/20-21 LOESTRIN FE 1.5/30 LOESTRIN FE 1/20 LOFIBRA LOMOTIL loperamide hcl LOPID lopinavir-ritonavir LOPRESSOR LOPRESSOR HCT loratadine loratadine &

26 34 34 34 34 20 17 17 20 30 32 22 19

magnesium citrate magnesium hydroxide magnesium oxide MAGNESIUM OXIDE magnesium oxide (mgsupplement) MAKENA malathion MAPROTILINE HCL MARPLAN MAVIK MAVYRET MAXALT MAXALT-MLT

52 52

7 61

61 78 43 13 13 21 31 60 60

MEPERIDINE HCL meperidine hcl MEPHYTON meprobamate MEPRON mercaptopurine mesalamine MESALAMINE DR MESTINON MESTINON TIMESPAN METADATE CD METAMUCIL METAMUCIL ORIGINAL TEXTURE

4 4

87 8 7

24 47 47 24 24

1 51

51 pseudoephedrine lorazepam

37 8

MAXITROL MAXZIDE

75 44

METAPROTERENOL SULFATE 9

Index 11

metformin hcl 15 MICROELITE FILTER MULTI PRENATAL 69 methadone hcl 4,5 methazolamide 44 METHENAMINE MANDELATE 83 methenamine mandelate 83 methenamine-hyosc-methyleneblue-sod phos-phenyl sal 82 methimazole 80 METHITEST 6 methocarbamol 71 methotrexate sodium 24 METHOTREXATE SODIUM 24 methotrexate sodium 24 methyldopa 22 methylergonovine maleate 77 methylphenidate hcl 1,2 METHYLPHENIDATE HCL ER 1,2 methylprednisolone 36 METIPRANOLOL 74

REPLACEMENTS 58 MICROELITE RECHARGEABLE BATTERY 58 MICROZIDE 45 midazolam hcl 50 midodrine hcl 86 MIGRANAL 60 MINIELITE FILTER REPLACEMENTS 58 MINIELITE RECHARGEABLE BATTERY 58 MINIPRESS 22 MINIVELLE 47 MINOCIN 80 minocycline hcl 80 minoxidil 23 MIRALAX 51 MIRAPEX 26 MIRASORB SPONGES 2" X 2" 56

MULTI VITAMIN 67 MULTI VITAMIN/D-3 67 MULTI-BETIC DIABETES 65 MULTI-VITAMIN MONOCAPS 65 multiple vitamin 67 multiple vitamins w/ iron 63 multiple vitamins w/ minerals 65 MULTIVITAMIN ADULTS 65 MULTIVITAMIN MEN 65 MULTIVITAMIN/FLUORIDE 67 mupirocin 38 mupirocin calcium (topical) 38 MURO 128 76 MYAMBUTOL 24 mycophenolate mofetil 62 mycophenolate sodium 62 MYDRIACYL 74 MYFORTIC 62

metoclopramide hcl 47 metolazone 45 metoprolol &hydrochlorothiazide 23 metoprolol succinate 32 METOPROLOL SUCCINATE

MIRASORB SPONGES 4" X 4" 56 MIRCETTE 34 mirtazapine 12 misoprostol 82 MOBIC 3

MYLERAN MYLICON MYLICON INFANTS GAS RELIEF MYNATAL MYNATAL ADVANCE

24 47

47 69 69

ER/HYDROCHLOROTHIAZIDE23

metoprolol tartrate 32 METOPROLOL/HYDROCHLOROTHIAZIDE 23 METROCREAM 42 METROGEL-VAGINAL 86 METROLOTION 42

MODICON 34 MOI-STIR 63 MOLINDONE HYDROCHLORIDE 28 mometasone furoate 41 MONISTAT 3 86 MONISTAT 3 COMBINATION PACK 86

MYNATAL PLUS MYNATAL ULTRACAPLET MYNATAL-Z MYNATE 90 PLUS MYSOLINE nabumetone nadolol

69 69 69 69 11

3 32

metronidazole 7 MONISTAT 7 SIMPLY NALOXONE HCL 18 metronidazole (topical) metronidazole vaginal

42 86

CURE 86 MONISTAT SOOTHING CARE ITCH RELIEF 41

naloxone hcl NALOXONE HCL

18 18

MEVACOR 21 MONOCLATE-P 49 naltrexone hcl 18 mexiletine hcl 8 MONONINE 49 NAMENDA 78 MIACALCIN 45 montelukast sodium 9 NAMENDA TITRATION PAK79 MICARDIS MICARDIS HCT

21 23

morphine sulfate MORPHINE SULFATE

5 5

naphazoline w/ pheniramine 75 NAPHCON-A 75

MICATIN MICONAZOLE 3

39 86

morphine sulfate 5 MOTRIN INFANTS DROPS 3

NAPROSYN naproxen

3 3

miconazole nitrate (topical) 39 MOUTHKOTE 63 naproxen sodium 3 miconazole nitrate vaginal MICRO-K

86 61

moxifloxacin hcl (ophth) MS CONTIN

75 5

naratriptan hcl NARCAN

60 18

MULTAQ 9 NARDIL 13

Index 12

NASACORT ALLERGY 24HR 72 NASACORT ALLERGY 24HR CHILDRENS 72 NASAL DECONGESTANT 72 NASALCROM 72 NAT-RUL PRENATAL VITAMINS 70 NAT-RUL THERAVITE-M/HIGHPOTENCY 65 NATALVIT 70 nateglinide 17 NATRUL-MEGA-75 65 NATRUL-VITES 65 NATURE-THROID 80 NEBULIZER AIR TUBE/PLUGS 58 NEBULIZER PEDIATRIC

NEXIUM 82 NEXIUM 24HR 82 NEXIUM 24HR CLEAR MINIS 82 niacin 87 niacin (antihyperlipidemic) 21 NIACIN TR 87 NIACOR 21 NIASPAN 21 NICADAN 65 NICADAN ZX 65 nicardipine hcl 33 NICAZEL 66 NICAZEL FORTE 65 NICODERM CQ 79 NICORETTE 79

norethindrone & ethinyl estradiol-fe 34 norethindrone (contraceptive) 36 norethindrone acet & eth estra 35 norethindrone acetate 78 norethindrone acetate-ethinylestradiol 46 norethindrone acetate-ethinylestradiol-fe 35 norethindrone-eth estradiol (triphasic) 35 norgestimate-ethinylestradiol 35 norgestimate-ethinyl estradiol(triphasic) 35 norgestrel & ethinyl estradiol 35 NORINYL 1+35 35

MASK 58 NICORETTE MINI 79 NORINYL 1+50 35 NECON 1/50-28 34 NICORETTE STARTER NORPACE 8 NECON 10/11-28 34 NEFAZODONE HCL 14 nefazodone hcl 14 neomycin sulfate 2 neomycin-bacitracin zn-polymyxin 75 neomycin-bacitracin-polymyxin

39 neomycin-polymy-dexameth 75 neomycin-polymyxin w/pramoxine 39 neomycin-polymyxin-gramicidin

75 neomycin-polymyxin-hc(otic) 77 NEOMYCIN/POLYMYXIN/HYDROCORTISONE 76 NEORAL 62 NEOSPORIN 75 NEOSPORIN ORIGINAL 39 NEOSPORIN PLUS PAIN RELIEF MAXIMUM STRENGTH 39 NEPHRO-VITE RX 63 NEPHROCAPS 63 NEPTAZANE 44 NEURONTIN 11 NEUTROGENA T/GEL 43 NEUTROGENA T/GELSTUBBORN ITCH

KIT 79 nicotine 79 nicotine polacrilex 79 NICOTINE TRANSDERMAL SYSTEM 79 NICOTROL INHALER 79 NICOTROL NS 80 nifedipine 33 NINLARO 25 NITRO-BID 8 NITRO-DUR 8 nitrofurantoin 83 nitrofurantoin macrocrystal 83 nitrofurantoin monohyd macro 83 nitroglycerin 8 NITROSTAT 8 NIVA-PLUS 70 NIX CREME RINSE 43 NIZORAL 39 NIZORAL A-D 39 NO IRON MULTIPLE VITAMIN/MINERALS 66 nonoxynol-9 86 NOR-QD 36 NORCO 5 NORDITROPIN FLEXPRO 45 norethin acet & estrad-fe 34

NORPACE CR 8 NORPRAMIN 14,15 NORTEMP INFANTS 4 nortriptyline hcl 15 NORVASC 33 NORVIR 30 NOSE CLIP 58 NOVA MAX PLUS KETONE TESTSTRIPS 44 NOVOEIGHT 49 NOVOLIN 70/30 16 NOVOLIN 70/30 RELION 16 NOVOLIN N 16 NOVOLIN N RELION 16 NOVOLIN R 16 NOVOLIN R RELION 16 NOVOLOG 17 NOVOLOG FLEXPEN 16 NOVOLOG MIX 70/30 17 NOVOLOG MIX 70/30PREFILLED FLEXPEN 16 NOVOSEVEN RT 49 NU GAUZE 4PLY 4"X4" 56 NU GAUZE GENERAL-USE SPONGES 4"X4" 4 PLY 56 NULYTELY/FLAVORPACKS 51 NUMOISYN 63

CONTROL 43 norethindrone & eth NUPLAZID 27 nevirapine 30 estradiol 34 NUTRICAP 66 NEXAVAR 25

Index 13

NUTRICION PORVIDA 70 ONE-A-DAY MENS HEALTH paliperidone 27 FORMULA 66NUVARING 35 PAMELOR 15ONE-A-DAY MENS PRO

NUWIQ 49 PANCREAZE 44EDGE 66 nystatin 18 ONE-A-DAY PROACTIVE PANOXYL-4 CREAMY

65+ 66 WASH 38nystatin (mouth-throat) 62 ONE-A-DAY TEEN pantoprazole sodium 82nystatin (topical) 39 ADVANTAGEFOR HIM 66 PAREGORIC 17nystatin-triamcinolone 39 OPCON-A 75 PARI ALTERA NEBULIZERNYTOL MAXIMUM OPDIVO 24 HANDSET 58STRENGTH 50 PARI BABY CONVERSIONOPTI-WOMAN 66O-CAL FA 70 KITSIZE 1 58OPTIFOAM 56O-CAL PRENATAL 70 PARI BABY CONVERSIONOPTIONS CONCEPTROL KITSIZE 2 58OBIZUR 49 VAGINAL PARI BABY CONVERSIONOCEAN NASAL SPRAY 71 CONTRACEPTIVE 86 KITSIZE 3 58OPTIONS GYNOL IIOCUFEN 76 PARI ERAPID NEBULIZERVAGINALCONTRACEPTIVEOCUFLOX 75 HANDSET 58

86 PARI EXPIRATORY FILTEROCULAR VITAMINS 66 OPURITY 66 VALVE SET 58ODEFSEY 30 oral electrolytes 60 PARI MASK SET 58 OFF DEEP WOODS 42 ORAL RELIEF SPRAY FOR PARI SOFT PLASTIC ADULT OFF DEEP WOODS DRY 42 DRYMOUTH & MASK 58

DISCOMFORT 63 PARI SOFT PLASTICofloxacin 47 PEDIATRIC MASK 58ORAP 79ofloxacin (ophth) 75 PARLODEL 26ORKAMBI 80ofloxacin (otic) 77 PARNATE 13orphenadrine citrate 71OGESTREL 35 paromomycin sulfate 2ORTHO MICRONOR 36olanzapine 28 paroxetine hcl 13ORTHO TRI-CYCLEN 35olanzapine-fluoxetine hcl 79 PARVLEX 66ORTHO TRI-CYCLEN LO 35olmesartan medoxomil 21 PAXIL 13,14ORTHO-CYCLEN 35olmesartan medoxomil- PAXIL CR 13amlodipine-hydrochlorothiazide ORTHO-NOVUM 1/35 35 23 PCE 53ORTHO-NOVUM 7/7/7 35olmesartan medoxomil- ped multivitamins w/fl & iron 69oseltamivir phosphate 31hydrochlorothiazide 23 PEDIALYTE 61omega-3 fatty acids 73 OTICIN HC NR 77

PEDIALYTE FREEZER omeprazole 82 OVACE PLUS WASH 40 POPS 60

OVACE WASH 40OMEPRAZOLE 82 PEDIAPRED 36 OMNICAP 67 OVCON-35 35 PEDIATRIC AEROSOL

OVIDE 43 MASK 58OMNIPRED 76 PEDIATRICOMNITROPE 45 oxaprozin 3 MOUTHPIECE/DISPOSABLEoxazepam 8ONCOVITE 66 59 ondansetron 18 OXAZEPAM 8 pediatric multiple vitamin w/ ondansetron hcl 18 oxcarbazepine 11 c 69

pediatric multiple vitamin w/ c &ONE DAILY MENS FORMULA oxybutynin chloride 83 fa 69W/O IRON 66 5oxycodone hcl pediatric multiple vitamins w/ONE DAILY PLUS IRON 66 OXYCODONE HCL ER 5 iron 69 ONE DAILY WOMENS 66 oxycodone w/ pediatric multivitamins w/fl 68 ONE-A-DAY ENERGY 66 acetaminophen 5 pediatric vitamins acd w/ONE-A-DAY MENOPAUSE oxycodone-aspirin 5 fluoride 68 FORMULA 66 OXYCODONE/ACETAMINOPH pediatric vitamins adc 69 ONE-A-DAY MENS 50+ EN 5 peg 3350-kcl-sod bicarb-sodADVANTAGE 66 oyster shell 60 chloride-sod sulfate 51

Index 14

peg 3350-potassium chloride-sod pioglitazone hcl-metformin PRAVACHOL 21 bicarbonate-sod chloride 51 hcl 15 pravastatin sodium 21PENICILLIN V POTASSIUM 77 piroxicam 3 prazosin hcl 22penicillin v potassium 77 PLAN B ONE-STEP 35 PRE-NATAL FORMULA 70pentoxifylline 49 PLAQUENIL 23 PRECISION XTRA 44PEPCID 81 PLAVIX 49 PRED FORTE 76PEPCID AC 81 PLEGRIDY 79 PRED MILD 76PEPCID AC MAXIMUM PLEGRIDY STARTER

PRED-G 76STRENGTH 81 PACK 79 PEPTO-BISMOL 17 PNEUMOVAX 23 83 PREDATOR 42 PEPTO-BISMOL PNEUMOVAX 23/1 DOSE 83 PREDNICARBATE 41 INSTACOOL 17 PNV FERROUS prednicarbate 41PEPTO-BISMOL MAX FUMARATE/DOCUSATE/FOLI prednisolone 36STRENGTH 17 C ACID 70 PREDNISOLONE 36PEPTO-BISMOL TO-GO 17 PNV FOLIC ACID + IRON PERCOCET 5 MULTIVITAMIN 70 prednisolone acetate (ophth) 76

PNV PRENATAL PLUS PREDNISOLONE ACETATE P-PERIDEX 62 MULTIVITAMIN 70 F 76PERJETA 24 PNV TABS 29-1 70 prednisolone sodiumpermethrin 43 phosphate 36podofilox 42 perphenazine 28 PREDNISONE 36POLYCOSE 73PERPHENAZINE/AMITRIPTYLIN prednisone 36polyethylene glycol 3350 51E 79 PREDNISONE 36POLYMEM DRESSING/3" XPERRY PRENATAL 70 3" 56 PREDNISONE INTENSOL 36 PERSANTINE 49 POLYMEM DRESSING/4" X PREMARIN 47,86PFLEX 59 4" 56 PREMPHASE 46 phenazopyridine hcl 48 polymyxin b-trimethoprim 75 PREMPRO 46polysaccharide ironphenelzine sulfate 13 PRENATABS FA 70complex 50phenobarbital 50 POLYTRIM 75 PRENATABS RX 70 PHENOBARBITAL 50 polyvinyl alcohol 74 PRENATAL 70 phenobarbital 50 POMALYST 25 PRENATAL 19 70phenobarbital-hyoscyamine- pot phosphate monobasic w/ PRENATAL AND IRON 70atropine-scopolamine 81 sod phosphate dibasic &phenylephrine hcl (ophth) 75 PRENATAL FORTE 70

monobasic 61 phenylephrine hcl (oral) 72 potassium bicarbonate 61 PRENATAL LOW IRON 70 phenylephrine-shark liver oil- PRENATAL MULTIVITAMIN 70potassium chloride 61cocoa butter 6 PRENATAL ONE DAILY 70 phenylephrine-shark liver oil- POTASSIUM CHLORIDE 61

PRENATAL PLUS 70mineral oil-petrolatum 6 potassium chloride 61 PRENATAL PLUS IRON 70phenytoin 12 POTASSIUM CHLORIDE PRENATAL VITAMIN 70phenytoin sodium extended 12 ER 61

potassium chloride PRENATAL VITAMIN &PHYTOMULTI 66 microencapsulated crystals MINERAL 70 phytonadione 87 er 61 PRENATAL VITAMIN/IRON 70 PILLOW MASK/ADULT 59 potassium citrate PRENATAL VITAMINS 71(alkalinizer) 48PILLOW MASK/CHILD 59 PRENATAL VITAMINS PLUSpotassium citrate-citric acid48 LOW IRON 71PILLOW MASK/PEDIATRIC 59 pramipexolepilocarpine hcl 74 PREPLUS 71dihydrochloride 27 pilocarpine hcl (oral) 63 pramoxine hcl (rectal) 6 PRESERVISION AREDS 66

pimozide 79 pramoxine-hc-chloroxylenol PRETAB 71

pindolol 32 77 PREVACID 82 prasugrel hcl 49 PREVACID 24HR 82pioglitazone hcl 16

Index 15

PREVACID SOLUTAB PREVIDENT 5000 DRY MOUTH PREVIDENT 5000 PLUS PREVIDENT FLUORIDE PREVNAR 13 PREZCOBIX PREZISTA PRIFTIN PRILOSEC

82

62 62 62 83 30 30 24 82

pseudoephedrine hcl 72 pseudoephedrine w/ codeine-gg 37 pseudoephedrine-ibuprofen 37 PSORCON 41 psyllium 51 PTS PANELS KETONE TEST 44 PULMICORT 9 PULMICORT FLEXHALER 9

RA DRY MOUTH RA GAUZE SPONGES 4"X4" RA LICE SOLUTION KIT RA OMEPRAZOLE RA OYSTER SHELL CALCIUM/VITAMIN D RA PRENATAL RA PRENATAL FORMULA/FOLICACID RA STERILE PADS 2"X2"

63

56 43 82

60 71

71 56

PRILOSEC OTC 82 PURIXAN 24 RA STERILE PADS 3"X3" 56 primidone 11 PX OMEPRAZOLE 82 RA STERILE PADS 4"X4" 56 PRINIVIL 21 PX PRENATAL RABAVERT 85 PRO-CAL 66 PROAIR HFA 10 probenecid 48 PROBUPHINE IMPLANT KIT 6 PROCARDIA 33 PROCARDIA XL 33 PROCERV HP 66 prochlorperazine 28 prochlorperazine maleate 28 PROCTOFOAM 6 PROFILNINE 49 PROFILNINE SD 49 progesterone micronized 78 PROGRAF 62 promethazine &phenylephrine 37 promethazine hcl 20 promethazine w/codeine 37 PROMETHAZINE/PHENYLEPHRINE 37 PROMETRIUM 78

MULTIVITAMINS 71 pyrantel pamoate 7 pyrazinamide 24 pyrethrins-piperonylbutoxide 43 pyrethrins-piperonyl butoxide-permethrin-nit remover 43 PYRIDIUM 48 pyridostigmine bromide 24 pyridoxine hcl 87 QC ALL PURPOSE DRESSINGS4"X4" 56 QC BORDER ISLAND GAUZE PAD 2"X2" 56 QC PRENATAL 71 QC STERILE PADS 56 QUENCH 66 QUESTRAN 20 QUESTRAN LIGHT 20 quetiapine fumarate 28 QUFLORA PEDIATRIC 69 QUIN B STRONG 66

raloxifene hcl 46 ramipril 21 ranitidine hcl 81 RAPAMUNE 62 RAY-TEC X-RAY DETECTABLESPONGES 4" X 4" 16 PLY 56 RAZADYNE 79 RAZADYNE ER 79 REBINYN 49 RECOMBINATE 49 RECOMBIVAX HB 85 REGLAN 47 RELENZA DISKHALER 31 RELION KETONE 44 RELION KETONE TEST STRIPS 44 RELPAX 60 REMERON 12 REMERON SOLTAB 12 RENAPLEX-D 66

propafenone hcl 9 proparacaine hcl 75 propranolol hcl 32 PROPRANOLOL HCL 32 propranolol hcl 32 PROPRANOLOL/HYDROCHLOROTHIAZIDE 23 propylthiouracil 80 PRORENAL+D 66 PROSCAR 48 PROTONIX 82 PROVERA 78 PROVIT 66

quinapril hcl 21 quinapril-hydrochlorothiazide

23 quinidine gluconate 8 QUINIDINE SULFATE 8 QUINTABS 67 QUINTABS-M 66 RA ALL PURPOSE DRESSINGS4"X4" 56 RA CENTRAL-VITE 66 RA CENTRAL-VITE UNDER 50MENS 66 RA CENTRAL-VITE UNDER 50WOMENS 66 RA DRESSING SPONGES

REPLACEMENT AIR FILTER 59 REPLACEMENT FILTERS 59 REQ 49+ 66 REQUIP 27 RESCRIPTOR 30 RESTORE CONTACT LAYER/NON-ADHERENT2"X2" 56 RESTORE FOAM DRESSING BORDERED 4"X4" 56 RESTORE FOAM DRESSING NON-BORDERED 4"X4" 56 RESTORE ODOR ABSORBING DRESSING 4"X4" 56

PROZAC 14 4"X4" 56

Index 16

RESTORE TRIO ABSORBENT salsalate 4 SIDESTREAM PEDIATRIC DRESSING 3"X3" RESTORIL RETIN-A RETROVIR

56 50 38 30

SAMI THE SEAL REPLACEMENTFILTERS 59 SANDIMMUNE 62 SAPHRIS 28

FACEMASK/TUCKER THETURTLE 59 SIDESTREAM PLUS ADULT FACE MASK 59 SILICONE MASK FOR

REVLIMID 61 SARNA 40 BREATHERITE REXULTI 29 REYATAZ 30 RHEUMATREX 2 RHOGAM ULTRA-FILTERED PLUS 77

SAVELLA 79 SAVELLA TITRATION PACK 79 SB OMEPRAZOLE 82 SCHOOLTIME SHAMPOO43

CHAMBER/ADULTSILICONE MASK FOR BREATHERITE CHAMBER/INFANTSILICONE MASK FOR BREATHERITE

59

59

riboflavin RID RID COMPLETE LICE ELIMINATION RID ESSENTIAL LICE ELIMINATION KIT

87 43

43

43

SE-NATAL 19 SEASONIQUE SECTRAL selegiline hcl selenium sulfide

71 35 32 27 40

CHAMBER/PEDIATRICSILICONE MASK FOR BREATHRITE CHAMBER/ADULT SILPHEN COUGH SILVADENE

59

59 19 40

RIDAURA 2 SELSUN BLUE 40 silver sulfadiazine 40 RIFADIN 24 SELSUN BLUE DAILY 40 simethicone 47 rifampin RIGHT STEP PRENATAL

24 71

SELSUN BLUE MEDICATED SELSUN BLUE

40 SIMPLYTHICK SIMPLYTHICK EASY MIX

78 78

RILUTEK 72 MOISTURIZING 40 simvastatin 21 riluzole 72 SELZENTRY 30 SINEMET 27 risedronate sodium 45 sennosides 52 SINEMET CR 27 RISPERDAL RISPERDAL CONSTA RISPERDAL M-TAB risperidone RISPERIDONE ODT RITALIN ritonavir RITUXAN rivastigmine rivastigmine tartrate RIXUBIS rizatriptan benzoate ROBAXIN ROBAXIN-750 ROBINUL ROBINUL FORTE ROCALTROL ropinirole hydrochloride rosuvastatin calcium ROXICODONE

27 27 27 27 27

2 30 24 79 79 49 60 71 71 81 81 46 27 21

5

sennosides-docusate sodium 51 SENOKOT 52 SENOKOT S 51 SENSIPAR 46 SENTRY 66 SENTRY SENIOR 66 SENTRY SENIOR/LUTEIN66 SEREVENT DISKUS 10 SEROQUEL 28 SEROQUEL XR 28 sertraline hcl 14 SFROWASA 47 SHINGRIX 85 SHOHLS SOLUTION MODIFIED 48 SHUR-SEAL 86 SIDEROL 66 SIDESTREAM ADULT FACE MASK 59 SIDESTREAM PEDIATRIC FACEMASK 59

SINGULAIR 9 sirolimus 62 SIVEXTRO 7 SLO-NIACIN 87 SM GAUZE PADS 2"X2" 56 SM GAUZE PADS 3"X3" 56 SM GAUZE PADS 4"X4" 56 SM GLUCOSE 15 SM OMEPRAZOLE 82 SM ONE DAILY MENS 66 SM ONE DAILY WOMENS 66 SM PRENATAL VITAMINS 71 SM STERILE PADS 56 SM STERILE PADS 2"X2" 56 sodium bicarbonate (antacid) 7 sodium chloride (gu irrigant) 48 sodium chloride (inhalant) 37 sodium chloride hypertonic 76 sodium citrate & citric acid 48 sodium fluoride 61

RYTHMOL SALAGEN salicylic acid saline

9 63 42 72

SIDESTREAM PEDIATRIC FACEMASK/SAMI THESEAL 59

sodium fluoride (dental) sodium phosphates sodium polystyrenesulfonate

63 52

62

Index 17

SODIUM SUDAFED PE TEARS NATURALE PM 74 SULFACETAMIDE/SULFUR

38 SOF-WICK 4"X4" 56 SOLO 66 SOMA 71 SONATA 51 SOOTHENEB NBL 100 CHILD MASK 59 SOOTHENEB NBL 100

CONGESTION sulfacetamide sod-prednisolone sulfacetamide sodium sulfacetamide sodium (acne)sulfacetamide sodium (ophth)sulfacetamide sodium w/sulfur

72

76 40

38

75

38

TECFIDERA 79 TECFIDERA STARTER PACK 79 TEGADERM FOAM DRESSING 2"X2" 57 TEGADERM FOAM DRESSING 4"X4" 57 TEGRETOL 11 TEGRETOL-XR 11

MEDICATION CUP 59 sulfamethoxazole- telmisartan 21 SOOTHENEB NBL 100 MESH CAP 59 SOOTHENEB NBL100 ADULT MASK 59 SORBITOL 51 sotalol hcl 32 sotalol hcl (afib/afl) 32 SPACER/AEROSOL-HOLDINGCHAMBER 59 SPINOSAD 43

trimethoprim sulfasalazine sulindac sumatriptan sumatriptan succinate SUMATRIPTAN SUCCINATE sumatriptan succinate SUPERB NAILS

7 47

3 60 60

60 60 66

telmisartan-amlodipine 23 telmisartan-hydrochlorothiazide

23 temazepam 51 TEMOVATE 41 TEMOVATE E 41 TENCON 4 TENEX 22 TENIVAC 80

spironolactone spironolactone &hydrochlorothiazide SPORANOX SPORANOX PULSEPAK SPRYCEL stannous fluoride STARLIX stavudine STERILE GAUZE PADS

45

44 19 19 25 63 17 30

SUPPRELIN LA SURGICAL GAUZE SPONGE SUSTIVA SUTENT SW OMEPRAZOLE SYLATRON SYMAX DUOTAB SYMBICORT SYMBYAX

46

57 30 25 82 26 81 10 79

tenofovir disoproxil fumarate 30 TENORETIC 100 23 TENORETIC 50 23 TENORMIN 32 TERAZOL 3 86 TERAZOL 7 86 terazosin hcl 22 terbinafine hcl 18 terbinafine hcl (topical) 39

2"X2" 56 SYMFI LO 30 terbutaline sulfate 10 STERILE GAUZE PADS 3"X3" STERILE PADS 2"X2" STERILE PADS 3"X3" STERILE PADS 4"X4" STIVARGA STRATTERA STRIBILD STROVITE ONE SUBLOCADE SUBOXONE sucralfate SUDAFED CHILDRENS SUDAFED CONGESTION SUDAFED NASAL

56 57 57 57 25

1 30 66

6 6

82 72 72

SYMLINPEN 120 SYMLINPEN 60 SYNTHROID T-VITES tacrolimus TAFINLAR TAGAMET HB TAMIFLU tamoxifen citrate tamsulosin hcl TAPAZOLE TARCEVA TARGRETIN TARKA

15 15 80 66 62 25 81 31 25 48 80 25 26 23

TERCONAZOLE terconazole vaginal TESSALON PERLES testosterone cypionate TETANUS/DIPHTHERIATOXOIDS-ADSORBED tetracaine hcl (ophth) tetrahydrozoline hcl (ophth) TGT OMEPRAZOLE THEO-24 theophylline THERA THERA M PLUS THERA-FLUR-N THERA-M

86 86 36

6

80 75 75 82 10 10 67 66 63 67

DECONGESTANT MAXIMUM STRENGTH 72 SUDAFED PE CHILDRENS NASAL DECONGESTANT 72

TASIGNA TAVIST ALLERGY tazarotene TAZORAC

25 19 40 40

THERA-TABS M THERABETIC MULTI-VITAMIN THERAGAUZE

67

67 57

Index 18

THERAGRAN-M 67 THERAGRAN-M ADVANCED 67 THERAGRAN-M ADVANCED 50 PLUS 67 THERAGRAN-M PREMIER 67 THERAGRAN-M PREMIER 50 PLUS 67 THERANATAL CORE NUTRITION 71 THEREMS-H 67 THEREMS-M 67 thiamine hcl 87 thiamine mononitrate 87 thioridazine hcl 28 thiothixene 29

tobramycin-dexamethasone TOBREX TOFRANIL TOLMETIN SODIUM tolnaftate tolterodine tartrate TOPAMAX TOPAMAX SPRINKLE TOPICORT topiramate TOPOTECAN HCL topotecan hcl TOPPER DRESSING SPONGES 4"X4"

76 75 15

3 39 83 11 11 41 11 26 26

57

TRIBENZOR TRICARE trifluoperazine hcl trifluridine TRIGLIDE trihexyphenidyl hcl TRILEPTAL trimethoprim TRINATAL GT TRINATAL RX 1 TRIUMEQ TRIZIVIR TROGARZO tropicamide

23 71 28 75 20 26 11

7 71 71 30 30 30 74

THRESHOLD IMT THRIVITE 19 THRIVITE RX

59 71 71

TOPROL XL torsemide TRADJENTA

32 45 16

trospium chloride TRUE METRIX BLOOD GLUCOSETEST STRIPS TRUE METRIX CONTROL

83

44

thyroid THYROLAR-1 THYROLAR-1/2 THYROLAR-1/4 THYROLAR-2 THYROLAR-3 tiagabine hcl TIAZAC TIKOSYN TIMOLOL MALEATE timolol maleate (ophth) TIMOLOL MALEATE OPHTHALMIC GEL

80 80 80 80 80 80 12 33

9 32 74

tramadol hcl 5 tramadol-acetaminophen 5 trandolapril 21 trandolapril-verapamil hcl 23 TRANDOLAPRIL/VERAPAMILHCL ER 23 tranexamic acid 50 TRANXENE T 8 tranylcypromine sulfate 13 trazodone hcl 14 TRECATOR 24 TRELSTAR 25 TRELSTAR MIXJECT 25

SOLUTION LEVEL 1 57 TRUE METRIX CONTROL SOLUTION LEVEL 2 57 TRUE METRIX CONTROL SOLUTION LEVEL 3 57 TRUE METRIX SELF MONITORING BLOOD GLUCOSE STRIPS 44 TRUECONTROL GLUCOSE CONTROL LEVEL 0 57 TRUECONTROL GLUCOSE CONTROL LEVEL 1 57 TRUETEST BLOOD GLUCOSE TEST 44 TRUETEST BLOOD GLUCOSE TEST STRIPS 44

FORMING 74 tretinoin 38 TRUETEST GLUCOSE TIMOPTIC TIMOPTIC OCUDOSE TIMOPTIC-XE

74 74 74

TRETTEN TREXALL TRI-NORINYL 28

49 24 35

CONTROLLEVEL 1 TRUETEST GLUCOSE CONTROLLEVEL 2 TRUETEST GLUCOSE

57

57

TINACTIN TINACTIN JOCK ITCH tioconazole vaginal TIVICAY tizanidine hcl TOBI TOBRADEX tobramycin TOBRAMYCIN tobramycin (ophth) TOBRAMYCIN SULFATE tobramycin sulfate

39 39 86 30 71

2 76

2 2

75 2 2

TRI-VIT/FLUORIDE/IRON 69 TRI-VITAMIN/FLUORIDE 69 TRIADVANCE 71 triamcinolone acetonide (mouth) 63 triamcinolone acetonide (nasal) 72 triamcinolone acetonide (topical) 41 triamterene & hydrochlorothiazide 44 TRIAMTERENE/HYDROCHLOROTHIAZIDE 44 TRIAZOLAM 51 triazolam 51

CONTROLLEVEL 3 TRUETEST STRIPS TRUETRACK BLOOD GLUCOSE TEST TRUETRACK TEST TRUMENBA TRUSOPT TRUVADA TUBING/WING TIP TUDORZA PRESSAIR TUMS TUMS LASTING EFFECTS TWINRIX

57 44

44 44 83 76 30 59

9 7 7

85

Index 19

TWYNSTA 23 VERIPRED 20 36 VOSPIRE ER 10 TYBOST 30 VERSACLOZ 28 VOTRIENT 26 TYLENOL CHILDRENS 4 VERSIVA XC 3" X 3" FOAM VP-ZEL 67 TYLENOL INFANTS 4 TYLENOL INFANTS PAIN+FEVER 4 TYLENOL/CODEINE #3 5 TYLENOL/CODEINE #4 5 ULTRACET 6 ULTRAM 5 ULTRATHON INSECT REPELLENT 8 42 UNICOMPLEX-M 67 UNISOM 50 UNISOM SLEEPGELS 50 urea 41 URECHOLINE 83 UROCIT-K 10 48 UROCIT-K 5 48 URSO 250 47 ursodiol 47 VAGISTAT-1 86 valacyclovir hcl 31 VALCYTE 31 valganciclovir hcl 31 VALIUM 8 valproate sodium 12 valproic acid 12 valsartan 21 valsartan-hydrochlorothiazide

23

DRESSING/HYDROFIBERTECHNOLOGY 57 VERSIVA XC 4" X 4" FOAM DRESSING/HYDROFIBERTECHNOLOGY 57 VEXOL 76 VIBRAMYCIN 80 VICTOZA 16 VIGAMOX 75 VIIBRYD 14 VIL-RX 71 VINATE M 71 VINATE ONE 71 VIRACEPT 30 VIRAMUNE 30 VIRAMUNE XR 30 VIREAD 30 VIROPTIC 75 VIRT-ADVANCE 71 VIRT-VITE GT 71 VISINE 75 VISINE EXTRA 75 VISTARIL 8 VISTEC X-RAY DETECTABLE SPONGES 4"X4" 16 PLY 57 VISTOGARD 17 VITAFOL-OB 71 VITALINE TOTAL FORMULA 2 67

VRAYLAR 27 VYVANSE 1 WALGREENS GLUCOSE 15 warfarin sodium 10 WELLBUTRIN SR 13 WELLBUTRIN XL 13 WESTHROID 80 white petrolatum-mineral oil 74 WHOLE FOOD MULTIVITAMIN 67 WILATE 49 WINDMILL TRAINER 59 WOMENS 50+ MULTI VITAMIN& MINERAL FORMULA 67 WOMENS BIOMULTIPLE 67 WOMENS MULTI VITAMIN & MINERAL FORMULA 67 WP THYROID 80 XALATAN 76 XALKORI 26 XANAX 8 XARELTO 10 XARELTO STARTER PACK 10 XTANDI 25 XULANE 35 XYNTHA 49 XYNTHA SOLOFUSE 49 XYZAL 20

VALTREX 31 VITALINE TOTAL FORMULA XYZAL ALLERGY 24HR 20 VANCOCIN HCL 7 3 67 YASMIN 28 35 vancomycin hcl 7 VANTAS 25

VITAMIN D3 COMPLETE 67 vitamin e 87

YAZ 35 YELETS TEENAGE

VAQTA 85 VARIVAX 85 VASERETIC 23 VASOTEC 21 VCF VAGINAL CONTRACEPTIVE FILM 86 venlafaxine hcl 14 VENLAFAXINE HCL ER 14 VENTOLIN HFA 10 verapamil hcl 33 VERAPAMIL HCL SR 33 VERELAN 33 VERELAN PM 33

VITAMIN E 87 vitamins w/ lipotropics 71 VITASANA 67 VITATRUM 67 VITEKTA 30 VITRUM 50+ SENIOR MULTI 67 VIVELLE-DOT 47 VIVITROL 18 VOL-PLUS 71 VOL-TAB RX 71 VOLTAREN 38 VONVENDI 49

FORMULA 67 ZADITOR 76 zaleplon 51 ZANAFLEX 71 ZANTAC 81 ZANTAC 150 MAXIMUM STRENGTH 81 ZANTAC 75 81 ZARONTIN 12 ZARXIO 50 ZEBETA 32 ZELBORAF 26 ZERIT 31

Index 20

ZESTORETIC 23

ZOVIRAX 31,40

ZYRTEC CHILDRENS

ZYRTEC-D

ZESTRIL 21 ZIAC 23 ZIAGEN 31 zidovudine 31 zinc oxide (topical) 42 zinc sulfate 61 ziprasidone hcl 27 ZITHROMAX 52 ZITHROMAX TRI-PAK 52 ZITHROMAX Z-PAK 52 ZOCOR 21 ZOFRAN 18 ZOFRAN ODT 18 ZOLADEX 25 ZOLINZA 26 zolmitriptan 60 ZOLOFT 14 zolpidem tartrate 51 ZOMACTON 45 ZOMIG 60 ZOMIG ZMT 60 ZONEGRAN 11 zonisamide 11 ZOSTAVAX 85

ZUBSOLV 6 ZYBAN 80 ZYLOPRIM 48 ZYPREXA 28 ZYPREXA RELPREVV 28 ZYPREXA ZYDIS 28 ZYRTEC ALLERGY 20

ALLERGY 20

ALLERGY/CONGESTION 37 ZYTIGA 25

Index 21

pharmacy program preferred drug list pharmacy … drug list . the california health & wellness...

Documents