preferred drug list - silversummit healthplan · 2020-04-30 · preferred drug list the...

Preferred Drug List The SilverSummit Healthplan Formulary includes a list of drugs covered by your prescription benefit. The formulary is updated often and may change. To get the most up-to-date information, you may view the latest formulary on our website at silversummithealthplan.com or call us at 1-844-366-2880 (TTY/TDD: 1-844-804-6086).

Preferred Drug List Medication Locator Instructions: 1. With the PDF open, click on the Edit menu, then click Find 2. In the Find box type the name of the medication you want to locate 3. Click the Next button until you find the medication(s) you are looking for

https://www.silversummithealthplan.com

SilverSummit Healthplan Pharmacy Program

SilverSummit Healthplan, Inc. (SilverSummit) is committed to providing appropriate, high quality, and cost effective drug therapy to all SilverSummit members. SilverSummit works with providers and pharmacists

to ensure that medications used to treat a variety of conditions and diseases are covered. SilverSummit covers prescription medications and certain over- the-counter (OTC) medications when ordered by a

physician/clinician. The pharmacy program does not cover all medications. Some medications require prior authorization (PA) or have limitations on age, dosage, and maximum quantities. This section

provides an overview of the S i l v e r S u m m i t pharmacy program. For more detailed information, please visit our website at www.silversummithealthplan.com.

Plan Preferred Drug List and Prior Authorization List The SilverSummit Preferred Drug List (PDL) describes the circumstances under which contracted pharmacy providers will be reimbursed for medications dispensed to members covered under the

program. All drugs covered under the Nevada Medicaid program are available for SilverSummit members. The PDL includes all drugs available without PA and those agents that have the restrictions of

Step Therapy (ST). The PA list includes those drugs that require PA for coverage. The PDL applies to drugs you receive at retail pharmacies. The PDL is continually evaluated by the SilverSummit Pharmacy

and Therapeutics (P&T) Committee to promote the appropriate and cost-effective use of medications. The Committee is composed of the SilverSummit Medical Director, SilverSummit Pharmacy Director,

and several Nevada primary care physicians, pharmacists, and specialists. The PDL does not:

Require or prohibit the prescribing or dispensing of any medication

Substitute for the independent professional judgment of the physician/clinician or pharmacist, or

Relieve the physician/clinician or pharmacist of any obligation to the patient or others

Envolve Pharmacy Solutions

With the exceptions of biopharmaceuticals and specialty drugs, SilverSummit works with Envolve

Pharmacy Solutions to process all pharmacy claims for prescribed drugs. Some drugs on the SilverSummit PDL and PA list require a PA and Envolve Pharmacy Solutions is responsible for administering this

process. Envolve Pharmacy Solutions is our Pharmacy Benefit Manager.

Follow these guidelines for efficient processing of your authorization requests:

1. Complete the SilverSummit Healthplan/Envolve Pharmacy Solutions form:

Medication Prior Authorization Request Form.

2. Fax to Envolve Pharmacy Solutions at 1-866-399-0929.

3. Once approved, Envolve Pharmacy Solutions notifies the prescriber by fax.

4. If the clinical information provided does not explain the medical necessity for the requested PA medication, Envolve Pharmacy Solutions will deny the request and offer PDL alternatives to the

prescriber by fax.

5. For urgent or after-hours requests, a pharmacy can provide up to a 96-hour emergency supply

of medication by calling 1-844-214-2606.


Prior Authorization Process

The SilverSummit PDL includes a broad spectrum of brand name and generic drugs. Clinicians are encouraged to prescribe from the SilverSummit PDL for their patients who are members of SilverSummit. Some drugs will require PA and are listed on the PA list. In addition, all name brand drugs not listed on either the PDL or PA list will require prior authorization. If a request for authorization is

needed the information should be submitted by your physician/clinician to Envolve Pharmacy Solutions on the SilverSummit Healthplan/Envolve Pharmacy Solutions form: Medication Prior Authorization Request Form. This form should be faxed to Envolve Pharmacy Solutions at 1-866-399-0929. This document is located on the SilverSummit website at www.silversummithealthplan.com.

SilverSummit will cover the medication if it is determined that:

1. There is a medical reason you need the specific medication.

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

All reviews are performed by a licensed clinical pharmacist using the criteria established by the

SilverSummit P&T Committee. Once approved, Envolve Pharmacy Solutions notifies the physician/clinician by fax. If the clinical information provided does not meet the coverage criteria for the

requested medication, SilverSummit will notify you and your physician/clinician of alternatives and provide information, regarding the appeal process.

The P&T committee has reviewed and approved, with input from its members and in consideration of

medical evidence, the list of drugs requiring prior authorization. This PDL attempts to provide appropriate and cost-effective drug therapy to all members covered under the SilverSummit pharmacy program. If a

patient requires a brand name medication that does not appear on the PDL, the physician/clinician can make a PA request for the brand name medication. It is anticipated that such exceptions will be rare and

that PDL medications will be appropriate to treat the vast majority of medical conditions.

Clinicians are requested to utilize the PDL when prescribing medication for those patients covered by the SilverSummit pharmacy program. If a pharmacist receives a prescription for a drug that requires a PA, the

pharmacist should attempt to contact the clinician to request a change to a product included on the PDL.

Phone Numbers for SilverSummit Healthplan Member Services

The phone and fax lines listed in the Prior Authorization Process section are dedicated to clinicians requesting PA medication items only. Members cannot be assisted if they call the PA toll-free number. SilverSummit Member Services may be reached at 1-844-366-2880 (TTY 1-844-804-6086).


Transition Period

SilverSummit members new to managed care will be able to receive their prescription drugs with no new PA requirements for first 60 days they are enrolled in our plan. This will allow you and your doctor time

to consider other medications that do not require PA and to learn the proper steps for obtaining a PA. SilverSummit’s PDL and PA List identify the drugs that will require PA once you have been a managed

care member for 60 days. If you are not sure when you will need to have your medications prior authorized or you have other questions about continuing to get your medications, call member services at

1-844-366-2880 (TTY 1-844-804-6086).

96-Hour Emergency Supply Policy

State and federal law requires that a pharmacy dispense a 96-hour (4-day) supply of medication to any patient awaiting a 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 96-hour supply of medication and will be reimbursed for the ingredient cost and dispensing fee of the 96-hour supply of

medication, whether or not the PA request is ultimately approved or denied. The pharmacy must call t h e Envolve Pharmacy Solutions Pharmacy Help Desk at 1-844-214-2606 for a prescription override

to submit the 96-hour medication supply for payment.

Step Therapy

Some medications listed on the SilverSummit PDL may require specific medications to be used before you can receive the step therapy medication. If SilverSummit has a record that the required medication was tried first the ST medications are automatically covered. If SilverSummit does not have a record that the

required medication was tried, you or your physician/clinician may be required to provide additional information. If SilverSummit does not grant PA we will notify you and your physician/clinician and

provide information regarding the appeal process.

Dispensing Limits, Quantity Limits, and Age Limits

Drugs may be dispensed up to a maximum 34 day supply for each new or refill non-controlled substance.

A total of 80 percent (80%) of the days supplied must have elapsed before the prescription can be refilled. Dispensing outside the quantity limit (QL) or age limits (AL) requires PA. SilverSummit may limit how

much of a medication you can get at one time. If the physician/clinician feels you have a medical reason for getting a larger amount, he or she can ask for PA. If SilverSummit does not grant PA we will notify

you and your physician/clinician and provide information regarding the appeal process. Some medications on the SilverSummit PDL may have AL. These are set for certain drugs based on Food and

Drug Administration (FDA) approved labeling, for safety concerns and quality standards of care. The AL aligns with current FDA alerts for the appropriate use of pharmaceuticals.

Medical Necessity Requests

If you require a medication that does not appear on the PDL, you or your physician/clinician can make a

medical necessity request for the medication. It is anticipated that such exceptions will be rare and that

PDL medications will be appropriate to treat the vast majority of medical conditions. SilverSummit 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.

All reviews are performed by a licensed clinical pharmacist using the criteria established by the SilverSummit P&T Committee. If the clinical information provided does not meet the coverage criteria for the requested

medication, SilverSummit will notify you and your physician/clinician of alternatives and provide information regarding the appeal process.

Appropriate Use and Safety Edits

Your health and safety is a priority for SilverSummit. One of the ways we address your safety is through

Point-of-Sale (POS) edits at the time a prescription is processed at the pharmacy. These edits are based on FDA recommendations and promote safe and effective medication utilization.

DUR (Drug Utilization Review) Programs SilverSummit will monitor ongoing prescribing of medications for clinical appropriateness. SilverSummit

reviews prescribing retrospectively to review for both safety and efficacy. SilverSummit will work with Envolve Pharmacy Solutions to review for such things as disease management, fraud and abuse (i.e.

Coordinated Services Program), and prescriber profiling. Prescriber or member outreach may occur based on prescribing/dispensing patterns. SilverSummit will continue to monitor for issues going forward and

take action as needed.

Mandatory Generic Substitution

When generic drugs are available, the brand name drug will not be covered without SilverSummit PA.

Generic drugs have the same active ingredient and work the same as brand name drugs. If you or your

physician/clinician feels a brand name drug is medically necessary, the physician/clinician can ask for PA.

We will cover the brand name drug according to our clinical guidelines if there is a medical reason you need

the particular brand name drug. If SilverSummit does not grant PA we will notify you and your physician/clinician and provide information regarding the appeal process.

Over-The-Counter Medications

The pharmacy program covers a large selection of OTC medications. All covered OTC medications appear in the PDL. All OTC medications must be written on a valid prescription by a licensed physician/clinician in order to be reimbursed.

Filling a Prescription

You can have prescriptions filled at a SilverSummit network pharmacy. If you decide to have a

prescription filled at a network pharmacy you can locate a pharmacy near you by contacting a SilverSummit Member Services Representative. At the pharmacy, you will need to provide the pharmacist

with your prescription and your SilverSummit ID card.

Please visit the SilverSummit website at www.silversummithealthplan.com to access the SilverSummit

PDL, SilverSummit PA lists, important forms, and provider/member information 24 hours a day, seven days a week.

Mail Order Program

SilverSummit Healthplan offers a 100 day supply of maintenance medications by mail. These drugs are used

to treat long-term conditions or illnesses. You can find a list of covered maintenance medications in the Maintenance Drug Pharmacy Program document located on the SilverSummit website at www.silversummithealthplan.com.

Please contact a SilverSummit Member Service Representative if you have any questions. To transfer a

current prescription or to have you doctor phone a prescription directly to our mail order pharmacy they

may call HomeScripts at 1-800-785-4197.



SilverSummit Healthplan Pharmacy Program - Additional Information Working with Our Pharmacy Benefit Managers

SilverSummit works with two Pharmacy Benefit Managers (PBMs). Acaria Health is the preferred provider

of biopharmaceuticals and injectables for SilverSummit. Envolve Pharmacy Solutions administers all other prescribed drugs. Certain drugs require PA to be approved for payment by SilverSummit. These include:

Some SilverSummit drugs listed on the PA list

Most injectables including Procrit, Neulasta and Neupogen.

AcariaHealth – Biopharmaceuticals and Injectables

Providers can request that AcariaHealth deliver the specialty drug to the office/member. If you want AcariaHealth to deliver the specialty drug to the office/member:

AcariaHealth is the provider of biopharmaceuticals and injectables for SilverSummit. Most injectables require PA to be approved for payment. Our Medical Director oversees the clinical review. SilverSummit

provides a number of biopharmaceutical products through the Biopharmaceutical Program. Most biopharmaceuticals and injectables require a PA to be approved for payment by SilverSummit; however, PA requirements are programmed specific to the drug as indicated in the list provided in the Biopharmaceutical Program document located on the SilverSummit website at www.silversummithealthplan.com. Follow these guidelines for the most efficient processing of your

authorization requests.

1.

Fax the AcariaHealth PA form to 1-855-217-0926 for PA.

2. If approved, AcariaHealth will contact the provider or member for delivery confirmation.

Pharmacy and Therapeutics Committee

The SilverSummit Pharmacy and Therapeutics (P&T) Committee continually evaluates the therapeutic

classes included in the PDL. The Committee is composed of the SilverSummit Medical Director, SilverSummit Pharmacy Director, and several community based primary care physicians and specialists. The primary purpose of the Committee is to assist in developing and monitoring the SilverSummit PDL

and to establish programs and procedures that promote the appropriate and cost-effective use of medications. The P&T Committee schedules meetings at least quarterly and coordinates reviews with a national P&T Committee which meets at least 4 times a year. Changes to the SilverSummit PDL are done

in conjunction with the approval of the State of Nevada. SilverSummit will meet with the State quarterly to review any proposed changes and update the PDL and PA lists accordingly based on the results of both the SilverSummit P&T Committee and the requirements from the State of Nevada. SilverSummit will

follow all State policies regarding member notification when changes are made to the PA list.


Unapproved Use of Preferred Medication

Medication coverage under this program is limited to non-experimental indications as approved by the

FDA. Other indications may also be covered if they are accepted as safe and effective using current medical and pharmaceutical reference texts and evidence-based medicine. Reimbursement decisions for

specific non-approved indications will be made by SilverSummit. Experimental drugs and investigational drugs are not eligible for coverage.

Benefit ExclusionsThe following drug categories are not part of the SilverSummit PDL and are not covered by the 96-hour emergency supply policy:

Fertility enhancing drugs

Anorexia, weight loss, or weight gain drugs

Drug Efficacy Study Implementation (DESI) and Identical, Related and Similar (IRS) drugs that

are classified as ineffective

Drugs and other agents used for cosmetic purposes or for hair growth

Erectile dysfunction drugs prescribed to treat impotence

Bulk powders, 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.

Newly Approved Products

We review new drugs for safety and effectiveness for the first 12 months before adding them to the

SilverSummit PDL. During this period, access to these medications will be considered through the PA review process. If SilverSummit does not grant PA we will notify you and your physician/clinician and

provide information regarding the appeal process.

Medical Benefits

The following drugs and medical services are a part of the SilverSummit medical benefit and are not

available at the retail pharmacy:

1. Botox is a medical benefit that is covered for non-cosmetic purposes only- it requires a PA from SilverSummit.

2. Blood and blood products.

3. Those specialty injectable drugs available as a medical benefit. Most injectables require PA from

SilverSummit.

- - -

- - -

Prescribers who request medical prior authorizations at Envolve Pharmacy Solutions will be redirected to contact SilverSummit Healthplan as applicable.

DME/Home Health Benefits

The following medical services are a part of the SilverSummit medical benefit and are not

available at the retail pharmacy:

1. Enteral products

2. Nebulizers

3. Medical supplies

Injectable Drugs

Injections that are self-administered by the member and/or a family member and appear on the PDL are covered by the SilverSummit pharmacy program. Insulin vials, Glucagon Kit,

Epinephrine, Imitrex, and Depo-Provera IM are covered by SilverSummit and do not require a PA.. All other injectables require PA.

We help keep you informed

The SilverSummit Pharmacy Director, a registered pharmacist, compiles current

pharmacological policy and information about important seasonal topics such as Respiratory Syncytial Virus (RSV) and influenza. The information is consistent with published guidelines and is mailed to network providers as a service. The most current SilverSummit PDL and PA List can be downloaded from our website at www.silversummithealthplan.com.

Contacts for Pharmacy Appeals/Grievances

Members: In the event that a member disagrees with the decision regarding coverage of a

medication, the member may file an appeal with SilverSummit by calling SilverSummit Member

Services at 1-844-366-2880 (TTY 1-844-804-6086).

Physicians / Clinicians: In the event that a clinician disagrees with the decision regarding coverage of a medication, the clinician may request an appeal by submitting additional

information to SilverSummit in writing to the Appeals Department at the following address:

SilverSummit Healthplan Appeal Department

2500 North Buffalo Drive Las Vegas, NV 89128

Fax: 1-855-742-0125


A decision will be rendered and the clinician will be notified with a mailed response. An expedited

appeal may be requested at any time the provider believes the adverse determination might seriously jeopardize the life or health of a member by calling SilverSummit Healthplan at 1-844-

366-2880 ext. 24084 (TTY 1-844-804-6086). A response will be rendered the same day as receipt of complete information. In circumstances that require research, a same day response may not be

possible.

AbbreviationsThe following notations and abbreviations may be found throughout the drug listing in the

limitations and restrictions column.

AL: Age Limit

PA: Prior Authorization QL: Quantity Limit

ST: Step Therapy

Drug Tier Definitions

F:

Formulary These drugs are covered on the drug list NF: Non-Formulary These drugs are not covered on the drug list

Drug Name DrugTier

Requirements/Limits

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS - Drugs to TreatADHD, Sleep and Eating DisordersAmphetaminesADDERALL TABS (UseAmphetamine-Dextroamphetamine)

NFQL(2 ea daily);AL

ADDERALL XR CP24 (UseAmphetamine-Dextroamphetamine)

NFQL(1 ea daily);AL

amphetamine-dextroamphetamine cp24 F QL(1 ea daily);

ALamphetamine-dextroamphetamine tabs F QL(2 ea daily);

ALDEXEDRINE CP24 15 MG,10 MG (UseDextroamphetamineSulfate)

NF

QL(2 ea daily);AL

DEXEDRINE CP24 5 MG(Use DextroamphetamineSulfate)

NFQL(1 ea daily);AL

dextroamphetamine sulfatecp24 15 mg, 10 mg F QL(2 ea daily);

ALdextroamphetamine sulfatecp24 5 mg F QL(1 ea daily);

ALdextroamphetamine sulfatetabs F QL(3 ea daily);

AL

VYVANSE CAPS F PA; QL(1 eadaily)

Analeptics

caffeine citrate soln F QL(45 ml perfill retail)

Stimulants - Misc.armodafinil tabs F PA

CONCERTA TBCR 36 MG(Use Methylphenidate HCl) NF QL(2 ea daily);

ALCONCERTA TBCR 54 MG,27 MG, 18 MG (UseMethylphenidate HCl)

NFQL(1 ea daily);AL

dexmethylphenidate hcltabs F QL(2 ea daily)

FOCALIN TABS (UseDexmethylphenidate HCl) NF QL(2 ea daily)

METADATE CD CPCR(Use Methylphenidate HCl) NF QL(1 ea daily);

AL

Drug Name DrugTier

Requirements/Limits

methylphenidate hcl cpcr F QL(1 ea daily);AL

METHYLPHENIDATE HCLER TBCR F QL(1 ea daily);

AL

methylphenidate hcl tabs F QL(3 ea daily);AL

methylphenidate hcl tbcr 10mg, 36 mg F QL(2 ea daily);

ALmethylphenidate hcl tbcr 54mg, 18 mg, 20 mg, 27 mg F QL(1 ea daily);

ALNUVIGIL TABS (UseArmodafinil) NF PA

RITALIN TABS (UseMethylphenidate HCl) NF QL(3 ea daily);

AL

ALLERGENIC EXTRACTS/BIOLOGICALS MISC

Allergenic Extracts

GRASTEK SUBL F QL(1 ea daily);AL

ORALAIR ADULT SAMPLEKIT SUBL F QL(1 ea daily);

ALORALAIR ADULTSTARTER PACK SUBL F QL(1 ea daily);

ALORALAIRCHILDREN/ADOLESCENTS STARTER PACK SUBL

FQL(3 ea daily);AL

ORALAIR SUBL F QL(1 ea daily);AL

RAGWITEK SUBL F QL(1 ea daily);AL

ALTERNATIVE MEDICINES

Alternative Medicine - M'smelatonin tabs F QL(1 ea daily)

AMINOGLYCOSIDES - Drugs to Treat BacterialInfectionsAminoglycosides

BETHKIS NEBU F PA; QL(1 mldaily)

KITABIS PAK NEBU F PA; QL(1 mldaily)

neomycin sulfate tabs F

NV SilverSummit Updated June 13, 2017

1

Drug Name DrugTier

Requirements/Limits

TOBI NEBU (UseTobramycin) NF PA; QL(1 ml

daily)

TOBI PODHALER CAPS F PA; QL(2 eadaily)

tobramycin nebu F PA; QL(1 mldaily)

TOBRAMYCIN NEBU F PA; QL(1 mldaily)

tobramycin sulfate soln 10mg/ml, 1.2 gm/30ml, 80mg/2ml, 40 mg/ml

F

TOBRAMYCIN SULFATESOLN 10 MG/ML, 40MG/ML

F

tobramycin sulfate solr F

ANALGESICS - ANTI-INFLAMMATORY - Drugsto Treat Pain, Swelling, Muscle and JointConditionsAnti-TNF-alpha - Monoclonal AntibodiesHUMIRA PEDIATRICCROHNS DISEASESTARTER PACK PSKT

FPA

HUMIRA PEN PNKT F PA

HUMIRA PEN-CROHNSDISEASESTARTER PNKT F PA

HUMIRA PEN-PSORIASISSTARTER PNKT F PA

HUMIRA PSKT F PA

Antirheumatic AntimetabolitesOTREXUP SOAJ F

RASUVO SOAJ F

RHEUMATREX TABS F

Interleukin-1 Receptor Antagonist (IL-1Ra)KINERET SOSY F PA

Nonsteroidal Anti-inflammatory Agents (NSAIDs)ADVIL TABS (UseIbuprofen) NF

ALEVE ARTHRITIS TABS(Use Naproxen Sodium) NF QL(2 ea daily)

Drug Name DrugTier

Requirements/Limits

ALEVE TABS (UseNaproxen Sodium) NF QL(2 ea daily)

ANAPROX DS TABS (UseNaproxen Sodium) NF

CELEBREX CAPS 100MG, 200 MG, 50 MG (UseCelecoxib)

NFPA; QL(1 eadaily)

CELEBREX CAPS 400 MG(Use Celecoxib) NF PA; QL(2 ea

daily)

celecoxib caps 400 mg F PA; QL(2 eadaily)

celecoxib caps 50 mg, 100mg, 200 mg F PA; QL(1 ea

daily)CHILDRENS ADVIL SUSP(Use Ibuprofen) NF RX/OTC

CHILDRENS MOTRINSUSP (Use Ibuprofen) NF RX/OTC

DAYPRO TABS (UseOxaprozin) NF

diclofenac potassium tabs F

diclofenac sodium tb24 F

diclofenac sodium tbec F

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

etodolac caps F

etodolac tabs F

etodolac tb24 F FELDENE CAPS (UsePiroxicam) NF

flurbiprofen tabs F

ibuprofen chew F

ibuprofen susp 100 mg/5ml F RX/OTC

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

ibuprofen tabs F

indomethacin caps F


2

Drug Name DrugTier

Requirements/Limits

indomethacin cpcr F

INFANTS ADVIL SUSP(Use Ibuprofen) NF

ketoprofen caps F

KETOPROFEN ER CP24 F

ketorolac tromethaminetabs F

QL(20 ea per30 days retail);AL

LODINE TABS (UseEtodolac) NF

meloxicam tabs F MOBIC TABS (UseMeloxicam) NF

MOTRIN INFANTSDROPS SUSP (UseIbuprofen)

NF

nabumetone tabs F

NAPROSYN SUSP (UseNaproxen) NF

NAPROSYN TABS (UseNaproxen) NF

naproxen sodium tabs 220mg F QL(2 ea daily)

naproxen sodium tabs 275mg, 550 mg F

naproxen susp F

NAPROXEN SUSP F

naproxen tabs F

naproxen tbec F QL(2 ea daily)

oxaprozin tabs F

piroxicam caps F

sulindac tabs F

TOLMETIN SODIUMCAPS F

tolmetin sodium caps F

Drug Name DrugTier

Requirements/Limits

TOLMETIN SODIUM TABS F

VOLTAREN-XR TB24 (UseDiclofenac Sodium) NF

Soluble Tumor Necrosis Factor Receptor AgentsENBREL SOLR F PA

ENBREL SOSY F PA

ENBREL SURECLICKSOAJ F PA

ANALGESICS - NonNarcotic - Drugs to TreatPain, Muscle and Joint ConditionsAnalgesic Combinationsbutalbital-acetaminophentabs F

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

butalbital-acetaminophen-caffeine tabs F QL(4 ea daily)

butalbital-aspirin-caffeinecaps F QL(4 ea daily)

ESGIC TABS (UseButalbital-Acetaminophen-Caffeine)

NFQL(4 ea daily)

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

TENCON TABS F

Analgesics Otheracetaminophen caps F

acetaminophen chew F

acetaminophen liqd F

acetaminophen soln F

acetaminophen supp F QL(12 ea perfill retail)

acetaminophen susp F

acetaminophen tabs F

FEVERALL INFANTSSUPP F


3

Drug Name DrugTier

Requirements/Limits

INFANTS SILAPAP SOLN F QL(30 ml perfill retail)

TYLENOL CHILDRENSSUSP (UseAcetaminophen)

NF

TYLENOL EXTRASTRENGTH TABS (UseAcetaminophen)

NF

TYLENOL INFANTSPAIN+FEVER SUSP (UseAcetaminophen)

NF

TYLENOL INFANTS SUSP(Use Acetaminophen) NF

TYLENOL TABS (UseAcetaminophen) NF

Salicylatesaspirin buffered (cal carb-mag carb-mag oxide) tabs F

aspirin chew F ASPIRIN SUPP 200 MG,120 MG F QL(12 ea per

fill retail)aspirin supp 600 mg, 300mg F QL(12 ea per

fill retail)

aspirin tabs F

aspirin tbec 324 mg, 81mg, 325 mg F

BUFFERIN TABS (UseAspirin Buffered (Cal Carb-Mag Carb-Mag Oxide))

NF

choline & mag salicylateliqd F

diflunisal tabs F DISALCID TABS (UseSalsalate) NF

ECOTRIN REGULARSTRENGTH TBEC (UseAspirin)

NF

salsalate tabs F

ANALGESICS - OPIOID - Drugs to Treat Pain,Muscle and Joint ConditionsOpioid Agonists

Drug Name DrugTier

Requirements/Limits

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

CODEINE SULFATE TABS60 MG, 15 MG, 30 MG(Use Codeine Sulfate)

NFQL(2 ea daily)

DEMEROL TABS (UseMeperidine HCl) NF QL(6 ea daily)

DILAUDID TABS (UseHydromorphone 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 (UseFentanyl) NF

Limit 10patches permonth;QL(0.34ea daily)

EMBEDA CPCR F

fentanyl pt72 F

Limit 10patches permonth;QL(0.34ea daily)

HYDROMORPHONE HCLSUPP F QL(12 ea per

fill retail)

hydromorphone hcl tabs F QL(8 ea daily)

HYSINGLA ER T24A F

MEPERIDINE HCL SOLN F QL(500 ml perfill retail)

meperidine hcl tabs F QL(6 ea daily)

methadone hcl tabs 10 mg F PA; QL(10 eadaily)

methadone hcl tabs 5 mg F PA; QL(4 eadaily)

morphine sulfate soln 100mg/5ml, 20 mg/ml F QL(240 ml per

fill retail)morphine sulfate soln 20mg/5ml, 10 mg/5ml F QL(16.67 ml

daily)MORPHINE SULFATESUPP F QL(24 ea per

fill retail)MORPHINE SULFATETABS F QL(6 ea daily)

morphine sulfate tbcr F QL(3 ea daily)


4

Drug Name DrugTier

Requirements/Limits

MS CONTIN TBCR (UseMorphine Sulfate) NF QL(3 ea daily)

oxycodone hcl caps F QL(6 ea daily)

oxycodone hcl conc F QL(6 ml daily)

oxycodone hcl soln F

oxycodone hcl tabs F QL(6 ea daily)

ROXICODONE TABS (UseOxycodone HCl) NF QL(6 ea daily)

tramadol hcl tabs F QL(8 ea daily)

ULTRAM TABS (UseTramadol HCl) NF QL(8 ea daily)

Opioid Combinationsacetaminophen w/ codeinesoln F QL(30 ml daily)

acetaminophen w/ codeinetabs F QL(6 ea daily)

butalbital-acetaminophen-caffeine w/ codeine caps F QL(4 ea daily)

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

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

NFQL(4 ea daily)

HYCET SOLN (UseHydrocodone-Acetaminophen)

NFQL(180 mldaily)

hydrocodone-acetaminophen soln F QL(180 ml

daily)hydrocodone-acetaminophen tabs 10mg-325mg

FQL(6 ea daily)

hydrocodone-acetaminophen tabs 5mg-325mg

FQL(12 ea daily)

hydrocodone-acetaminophen tabs7.5mg-325mg

FQL(8 ea daily)

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

NFQL(6 ea daily)

Drug Name DrugTier

Requirements/Limits

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

NFQL(12 ea daily)

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

NFQL(8 ea daily)

oxycodone w/acetaminophen tabs F QL(6 ea daily)

oxycodone-aspirin tabs F QL(6 ea daily)

OXYCODONE/ACETAMINOPHEN SOLN F QL(30 ml daily)

PERCOCET TABS (UseOxycodone w/Acetaminophen)

NFQL(6 ea daily)

tramadol-acetaminophentabs F QL(4 ea daily)

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

NFQL(6 ea daily)

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

NFQL(6 ea daily)

ULTRACET TABS (UseTramadol-Acetaminophen) NF QL(4 ea daily)

Opioid Partial Agonistsbuprenorphine hcl subl F PA

buprenorphine hcl-naloxone hcl dihydrate subl F PA

SUBOXONE FILM 2MG-0.5MG, 4MG-1MG F PA; QL(1 ea

daily)SUBOXONE FILM 8MG-2MG, 12MG-3MG F PA; QL(2 ea

daily)ANDROGENS-ANABOLIC - Drugs to RegulateHormonesAndrogensANDRODERM PT24 F QL(1 ea daily)

ANDROXY TABS F

DEPO-TESTOSTERONESOLN (Use TestosteroneCypionate)

NFLimit 4ml permonth;QL(0.134 ml daily)

METHITEST TABS F


5

Drug Name DrugTier

Requirements/Limits

testosterone cypionate soln FLimit 4ml permonth;QL(0.134 ml daily)

ANORECTAL AGENTS - Rectal Drugs to TreatPain, Swelling and ItchingIntrarectal SteroidsCORTENEMA ENEM (UseHydrocortisone(Intrarectal))

NFQL(420 ml perfill retail)

hydrocortisone (intrarectal)enem F QL(420 ml per

fill retail)Rectal Combinationsphenylephrine-shark liveroil-cocoa butter supp F QL(12 ea per

fill retail)phenylephrine-shark liveroil-mineral oil-petrolatumoint

FQL(30 gm perfill retail)

Rectal Local Anesthetics

pramoxine hcl (rectal) foam F QL(15 gm perfill retail)

PROCTOFOAM FOAM(Use Pramoxine HCl(Rectal))

NFQL(15 gm perfill retail)

Rectal SteroidsANUSOL-HC CREA (UseHydrocortisone (Rectal)) NF QL(30 gm per

fill retail)

hydrocortisone (rectal) crea F QL(30 gm perfill retail)

ANTACIDS - Ulcer and Stomach Acid Drugs

Antacid Combinationsalum & mag hydrox-simethicone chew F

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

F

QL(24 ml daily)

alum & mag hydrox-simethicone liqd400mg/5ml-40mg/5ml-400mg/5ml

F

Drug Name DrugTier

Requirements/Limits

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

F

QL(24 ml daily)

alum & mag hydrox-simethicone susp400mg/5ml-40mg/5ml-400mg/5ml, 400mg/5ml-400mg/5ml-40mg/5ml-40mg/5ml-400mg/5ml-400mg/5ml

F

GELUSIL CHEW 200MG-25MG-200MG (Use Alum &Mag Hydrox-Simethicone)

NF

HYVEE ADVANCEDANTACID MAXIMUMSTRENGTH SUSP (UseAlum & Mag Hydrox-Simethicone)

NF

Antacids - Aluminum SaltsALUMINUM HYDROXIDESUSP F

Antacids - Bicarbonate

sodium bicarbonate(antacid) tabs F

Limit 496 permonth;QL(16.54 ea daily)

Antacids - Calcium Saltscalcium carbonate (antacid)chew F TUMS CHEW (UseCalcium Carbonate(Antacid))

NF

TUMS CHEWY BITESCHEW (Use CalciumCarbonate (Antacid))

NF

TUMS E-X 750 CHEW(Use Calcium Carbonate(Antacid))

NF

TUMS KIDS CHEW (UseCalcium Carbonate(Antacid))

NF

TUMS LASTING EFFECTSCHEW (Use CalciumCarbonate (Antacid))

NF


6

Drug Name DrugTier

Requirements/Limits

TUMS SMOOTHIESCHEW (Use CalciumCarbonate (Antacid))

NF

TUMS ULTRA 1000 CHEW(Use Calcium Carbonate(Antacid))

NF

Antacids - Magnesium Saltsmagnesium oxide tabs F

ANTI-INFECTIVE AGENTS - MISC. - Drugs toTreat Bacterial InfectionsAnti-infective Agents - Misc.FLAGYL TABS (UseMetronidazole) NF

metronidazole tabs F

trimethoprim tabs F

VANCOCIN HCL CAPS125 MG (Use VancomycinHCl)

NFQL(4 ea daily)

VANCOCIN HCL CAPS250 MG (Use VancomycinHCl)

NFQL(8 ea daily)

vancomycin hcl caps 125mg F QL(4 ea daily)

vancomycin hcl caps 250mg F QL(8 ea daily)

vancomycin hcl solr 1000mg F QL(14 ea per

fill retail)

vancomycin hcl solr 500mg F


Anti-infective Misc. - CombinationsBACTRIM DS TABS (UseSulfamethoxazole-Trimethoprim)

NF

BACTRIM TABS (UseSulfamethoxazole-Trimethoprim)

NF

sulfamethoxazole-trimethoprim susp F sulfamethoxazole-trimethoprim tabs F

Leprostatics

Drug Name DrugTier

Requirements/Limits

dapsone tabs F

LincosamidesCLEOCIN CAPS (UseClindamycin HCl) NF

CLEOCIN PEDIATRICGRANULES SOLR (UseClindamycin PalmitateHydrochloride)

NF

Limit 1 packageperclaim;QL(100ml per fill retail)

clindamycin hcl caps F

clindamycin palmitatehydrochloride solr F


Oxazolidinones

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

ANTIANGINAL AGENTS - Drugs to Treat ChestPainNitratesISORDIL TITRADOSETABS (Use IsosorbideDinitrate)

NF

ISOSORBIDE DINITRATEER TBCR F

isosorbide dinitrate tabs F

isosorbide mononitrate tabs F QL(2 ea daily)

isosorbide mononitratetb24 F QL(1 ea daily)

NITRO-BID OINT F

NITRO-DUR PT24 (UseNitroglycerin) NF

nitroglycerin cpcr F

nitroglycerin pt24 F

nitroglycerin subl F NITROSTAT SUBL (UseNitroglycerin) NF

ANTIANXIETY AGENTS - Drugs to Treat Anxiety


7

Drug Name DrugTier

Requirements/Limits

Antianxiety Agents - Misc.buspirone hcl tabs F QL(3 ea daily)

droperidol soln F

HYDROXYZINE HCLSOLN 25 MG/ML F

hydroxyzine hcl soln 50mg/ml F

hydroxyzine hcl syrp F

hydroxyzine hcl tabs F HYDROXYZINEPAMOATE CAPS 100 MG F

hydroxyzine pamoate caps25 mg, 50 mg F

meprobamate tabs F

VISTARIL CAPS (UseHydroxyzine Pamoate) NF

Benzodiazepinesalprazolam tabs F QL(4 ea daily)

ATIVAN SOLN (UseLorazepam) NF

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

ATIVAN TABS 1 MG (UseLorazepam) NF QL(4 ea daily)

chlordiazepoxide hcl caps F QL(4 ea daily)

clorazepate dipotassiumtabs F QL(3 ea daily)

DIAZEPAM SOLN IJ 5MG/ML F

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

fill retail)

diazepam tabs F QL(4 ea daily)

lorazepam conc F

lorazepam soln F

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

Drug Name DrugTier

Requirements/Limits

lorazepam tabs 1 mg F QL(4 ea daily)

oxazepam caps F QL(4 ea daily)

TRANXENE T TABS (UseClorazepate Dipotassium) NF QL(3 ea daily)

VALIUM TABS (UseDiazepam) NF QL(4 ea daily)

XANAX TABS (UseAlprazolam) NF QL(4 ea daily)

ANTIARRHYTHMICS - Drugs to treat abnormalheart rhythmsAntiarrhythmics Type I-Adisopyramide phosphatecaps F

NORPACE CAPS (UseDisopyramide Phosphate) NF

NORPACE CR CP12 F

quinidine gluconate tbcr F

QUINIDINE SULFATE ERTBCR F

quinidine sulfate tabs 300mg F

QUINIDINE SULFATETABS 300 MG, 200 MG F

Antiarrhythmics Type I-Bmexiletine hcl caps F

Antiarrhythmics Type I-Cflecainide acetate tabs F

propafenone hcl tabs F

RYTHMOL TABS (UsePropafenone HCl) NF

Antiarrhythmics Type IIIamiodarone hcl tabs F

CORDARONE TABS (UseAmiodarone HCl) NF

dofetilide caps F

TIKOSYN CAPS (UseDofetilide) NF


8

Drug Name DrugTier

Requirements/Limits

ANTIASTHMATIC AND BRONCHODILATORAGENTS - Drugs to Treat Lung ConditionsAnti-Inflammatory AgentsCROMOLYN SODIUMNEBU F QL(8 ml daily)

Bronchodilators - Anticholinergics

ATROVENT HFA AERS F

Limit 1package permonth;QL(0.87gm daily)

INCRUSE ELLIPTA AEPB F QL(1 ea daily)

ipratropium bromide soln F

Limit 1package permonth;QL(12.5ml daily)

TUDORZA PRESSAIRAEPB F

Limit 1package permonth;QL(0.034 ea daily)

Leukotriene Modulatorsmontelukast 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 (UseMontelukast Sodium) NF QL(1 ea daily)

SINGULAIR PACK (UseMontelukast Sodium) NF QL(1 ea daily)

SINGULAIR TABS (UseMontelukast Sodium) NF QL(1 ea daily)

Selective Phosphodiesterase 4 (PDE4) InhibitorsDALIRESP TABS F PA

Steroid Inhalants

AEROSPAN AERS F


budesonide (inhalation)susp F QL(4 ml daily);

AL

FLOVENT DISKUS AEPB F QL(2 ea daily)

Drug Name DrugTier

Requirements/Limits

FLOVENT HFA AERO 220MCG/ACT, 110 MCG/ACT F

Limit 1 packagepermonth;QL(0.4gm daily)

FLOVENT HFA AERO 44MCG/ACT F

Limit 1 packagepermonth;QL(0.367 gm daily)

PULMICORT FLEXHALERAEPB F

Limit 1 packagepermonth;QL(0.04ea daily)

PULMICORT SUSP (UseBudesonide (Inhalation)) NF QL(4 ml daily);

ALSympathomimeticsalbuterol sulfate nebu 0.5% F QL(2 ml daily)

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

FQL(12.5 mldaily)

albuterol sulfate syrp F

albuterol sulfate tabs F

albuterol sulfate tb12 F

ANORO ELLIPTA AEPB F PA

COMBIVENT RESPIMATAERS F


DULERA AERO F


ipratropium-albuterol soln F QL(12 ml daily)

METAPROTERENOLSULFATE SYRP F QL(30 ml daily)

METAPROTERENOLSULFATE TABS F

SEREVENT DISKUSAEPB F QL(2 ea daily)

STIOLTO RESPIMATAERS F PA


9

Drug Name DrugTier

Requirements/Limits

SYMBICORT AERO F

Limit 1package permonth;QL(0.367 gm daily)

terbutaline sulfate tabs F

VENTOLIN HFA AERS F

Limit 2packages permonth;QL(1.2gm daily,18 gmper fill retail)

VENTOLIN HFA AERS F

Limit 2packages permonth;QL(0.54gm daily,8 gmper fill retail)

VOSPIRE ER TB12 (UseAlbuterol Sulfate) NF

XanthinesELIXOPHYLLIN ELIX F

THEO-24 CP24 F

theophylline soln F QL(475 ml perfill retail)

theophylline tb12 F

theophylline tb24 F

ANTICOAGULANTS - Blood Thinners

Coumarin AnticoagulantsCOUMADIN TABS (UseWarfarin Sodium) NF

warfarin sodium tabs F

Direct Factor Xa InhibitorsELIQUIS TABS F QL(4 ea daily)

XARELTO TABS 10 MG FQL(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)

Heparins And Heparinoid-Like Agents

Drug Name DrugTier

Requirements/Limits

enoxaparin sodium soln ij300 mg/3ml F QL(42 ml per 7

days retail)enoxaparin sodium soln sc120 mg/0.8ml, 80 mg/0.8ml F QL(12 ml per 7

days retail)enoxaparin sodium soln sc150 mg/ml, 100 mg/ml F QL(14 ml per 7

days retail)enoxaparin sodium soln sc30 mg/0.3ml F QL(5 ml per 7



days retail)heparin sodium (porcine)soln F

LOVENOX SOLN IJ 300MG/3ML (Use EnoxaparinSodium)

NFQL(42 ml per 7days retail)

LOVENOX SOLN SC 150MG/ML, 100 MG/ML (UseEnoxaparin Sodium)


LOVENOX SOLN SC 30MG/0.3ML (UseEnoxaparin Sodium)






LOVENOX SOLN SC 80MG/0.8ML, 120 MG/0.8ML(Use Enoxaparin Sodium)


ANTICONVULSANTS - Drugs to Treat Seizures

Anticonvulsants - Benzodiazepinesclonazepam tabs F QL(4 ea daily)

DIASTAT ACUDIAL GEL F QL(1 ea per fillretail); AL

DIASTAT PEDIATRIC GEL F QL(1 ea per fillretail); AL

DIAZEPAM GEL F QL(1 ea per fillretail); AL

KLONOPIN TABS (UseClonazepam) NF QL(4 ea daily)

Anticonvulsants - Misc.


10

Drug Name DrugTier

Requirements/Limits

carbamazepine chew F

carbamazepine cp12 F

carbamazepine susp F

carbamazepine tabs F

carbamazepine tb12 F CARBATROL CP12 (UseCarbamazepine) NF

gabapentin caps F QL(4 ea daily)

gabapentin soln F

gabapentin tabs F QL(4 ea daily)

KEPPRA SOLN IV 500MG/5ML (UseLevetiracetam)

NF

KEPPRA SOLN OR 100MG/ML (UseLevetiracetam)

NFQL(30 ml daily)

KEPPRA TABS 1000 MG(Use Levetiracetam) NF

KEPPRA TABS 500 MG,250 MG, 750 MG (UseLevetiracetam)

NFQL(4 ea daily)

KEPPRA XR TB24 (UseLevetiracetam) NF

LAMICTAL CHEWABLEDISPERSIBLE CHEW (UseLamotrigine)

NF

LAMICTAL TABS (UseLamotrigine) NF

lamotrigine chew F

lamotrigine tabs F

levetiracetam soln iv 500mg/5ml F

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

levetiracetam tabs 1000mg F

levetiracetam tabs 250 mg,750 mg, 500 mg F QL(4 ea daily)

Drug Name DrugTier

Requirements/Limits

levetiracetam tb24 F

MYSOLINE TABS (UsePrimidone) NF

NEURONTIN CAPS (UseGabapentin) NF QL(4 ea daily)

NEURONTIN SOLN (UseGabapentin) NF

NEURONTIN TABS (UseGabapentin) NF QL(4 ea daily)

oxcarbazepine susp F

oxcarbazepine tabs F

primidone tabs F TEGRETOL SUSP (UseCarbamazepine) NF TEGRETOL TABS (UseCarbamazepine) NF

TEGRETOL-XR TB12 (UseCarbamazepine) NF

TOPAMAX SPRINKLECPSP 15 MG (UseTopiramate)

NFQL(6 ea daily)

TOPAMAX SPRINKLECPSP 25 MG (UseTopiramate)

NFQL(8 ea daily)

TOPAMAX TABS (UseTopiramate) NF QL(3 ea daily)

topiramate cpsp 15 mg F QL(6 ea daily)

topiramate cpsp 25 mg F QL(8 ea daily)

topiramate tabs F QL(3 ea daily)

TRILEPTAL SUSP (UseOxcarbazepine) NF

TRILEPTAL TABS (UseOxcarbazepine) NF ZONEGRAN CAPS (UseZonisamide) NF

zonisamide caps F

Carbamatesfelbamate susp F


11

Drug Name DrugTier

Requirements/Limits

felbamate tabs F

FELBATOL SUSP (UseFelbamate) NF

FELBATOL TABS (UseFelbamate) NF

GABA ModulatorsGABITRIL TABS 12 MG,16 MG F

GABITRIL TABS 2 MG, 4MG (Use Tiagabine HCl) NF

tiagabine hcl tabs F

HydantoinsDILANTIN CAPS 100 MG(Use Phenytoin SodiumExtended)

NF

DILANTIN CAPS 30 MG F DILANTIN INFATABSCHEW (Use Phenytoin) NF

DILANTIN-125 SUSP (UsePhenytoin) NF

phenytoin chew F

phenytoin sodium extendedcaps F

phenytoin susp F

Succinimidesethosuximide caps F

ethosuximide soln F

ZARONTIN CAPS (UseEthosuximide) NF ZARONTIN SOLN (UseEthosuximide) NF

Valproic AcidDEPACON SOLN (UseValproate Sodium) NF

DEPAKENE CAPS (UseValproic Acid) NF

DEPAKENE SOLN (UseValproate Sodium) NF

Drug Name DrugTier

Requirements/Limits

DEPAKOTE ER TB24 (UseDivalproex Sodium) NF

DEPAKOTE SPRINKLESCSDR (Use DivalproexSodium)

NF

DEPAKOTE TBEC (UseDivalproex Sodium) NF

divalproex sodium csdr F

divalproex sodium tb24 F

divalproex sodium tbec F

valproate sodium soln F

valproic acid caps F

ANTIDEPRESSANTS - Drugs to Treat Depression

Alpha-2 Receptor Antagonists (Tetracyclics)mirtazapine tabs F QL(1 ea daily)

mirtazapine tbdp F QL(1 ea daily)

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

REMERON TABS (UseMirtazapine) NF QL(1 ea daily)

Antidepressants - Misc.APLENZIN TB24 F

bupropion hcl tabs F QL(3 ea daily)

bupropion hcl tb12 F QL(2 ea daily)

bupropion hcl tb24 F QL(1 ea daily)

FORFIVO XL TB24 F

MAPROTILINE HCL TABS F

WELLBUTRIN SR TB12(Use Bupropion HCl) NF QL(2 ea daily)

WELLBUTRIN TABS (UseBupropion HCl) NF QL(3 ea daily)

WELLBUTRIN XL TB24(Use Bupropion HCl) NF QL(1 ea daily)


12

Drug Name DrugTier

Requirements/Limits

Monoamine Oxidase Inhibitors (MAOIs)EMSAM PT24 F

MARPLAN TABS F

NARDIL TABS (UsePhenelzine Sulfate) NF

PARNATE TABS (UseTranylcypromine Sulfate) NF

phenelzine sulfate tabs F

tranylcypromine sulfatetabs F

Selective Serotonin Reuptake Inhibitors (SSRIs)CELEXA TABS 10 MG, 20MG (Use CitalopramHydrobromide)

NFQL(1.5 eadaily)

CELEXA TABS 40 MG(Use CitalopramHydrobromide)

NFQL(1 ea daily)

citalopram hydrobromidesoln F QL(8 ml daily)

citalopram hydrobromidetabs 10 mg, 20 mg F QL(1.5 ea

daily)citalopram hydrobromidetabs 40 mg F QL(1 ea daily)

escitalopram oxalate soln F

escitalopram oxalate tabs F QL(1 ea daily)

FLUOXETINE DR CPDR F

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

fluoxetine hcl caps 40 mg F QL(2 ea daily)

fluoxetine hcl soln F QL(4 ml daily);AL

fluoxetine hcl tabs 10 mg F QL(1 ea daily);AL

fluoxetine hcl tabs 20 mg F FLUOXETINE HCL TABS60 MG F

fluvoxamine maleate cp24 F

Drug Name DrugTier

Requirements/Limits

fluvoxamine maleate tabs100 mg F QL(3 ea daily)

fluvoxamine maleate tabs25 mg, 50 mg F QL(2 ea daily)

LEXAPRO SOLN (UseEscitalopram Oxalate) NF

LEXAPRO TABS (UseEscitalopram Oxalate) NF QL(1 ea daily)

paroxetine hcl tabs F QL(2 ea daily)

paroxetine hcl tb24 F

PAXIL CR TB24 (UseParoxetine HCl) NF

PAXIL SUSP F QL(40 ml daily)

PAXIL TABS (UseParoxetine HCl) NF QL(2 ea daily)

PEXEVA TABS F

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

PROZAC CAPS 40 MG(Use Fluoxetine HCl) NF QL(2 ea daily)

sertraline hcl conc F QL(10 ml daily)

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

sertraline hcl tabs 50 mg,25 mg F QL(1.5 ea

daily)ZOLOFT CONC (UseSertraline HCl) NF QL(10 ml daily)

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

ZOLOFT TABS 50 MG, 25MG (Use Sertraline HCl) NF QL(1.5 ea

daily)Serotonin ModulatorsBRINTELLIX TABS F PA

NEFAZODONE HCL TABS100 MG, 200 MG, 150 MG F

nefazodone hcl tabs 50 mg,250 mg F

OLEPTRO TB24 F trazodone hcl tabs 100 mg,150 mg, 50 mg F


13

Drug Name DrugTier

Requirements/Limits

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

TRINTELLIX TABS F PA

VIIBRYD KIT FPA; QL(30 eaper 365 daysretail)

VIIBRYD STARTER PACKKIT F PA

VIIBRYD TABS F PA; QL(1 eadaily)

Serotonin-Norepinephrine Reuptake InhibitorsCYMBALTA CPEP (UseDuloxetine HCl) NF QL(1 ea daily)

DESVENLAFAXINE ERTB24 50 MG, 100 MG F

desvenlafaxine succinatetb24 F DULOXETINE HCL CPEP40 MG F

duloxetine hcl cpep 60 mg,20 mg, 30 mg F QL(1 ea daily)

EFFEXOR XR CP24 (UseVenlafaxine HCl) NF QL(1 ea daily)

FETZIMA CP24 F FETZIMA TITRATIONPACK C4PK F

KHEDEZLA TB24 F PRISTIQ TB24 (UseDesvenlafaxine Succinate) NF

venlafaxine hcl cp24 F QL(1 ea daily)

VENLAFAXINE HCL ERTB24 225 MG F QL(1 ea daily)

VENLAFAXINE HCL ERTB24 37.5 MG, 150 MG,75 MG (Use VenlafaxineHCl)

NF

QL(1 ea daily)

venlafaxine hcl tabs F

venlafaxine hcl tb24 F QL(1 ea daily)

Tricyclic Agentsamitriptyline hcl tabs F

Drug Name DrugTier

Requirements/Limits

AMOXAPINE TABS F

ANAFRANIL CAPS (UseClomipramine HCl) NF

clomipramine hcl caps F

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

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

F

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

F

DOXEPIN HCL CAPS 75MG F

doxepin hcl conc F

ELAVIL TABS (UseAmitriptyline HCl) NF

imipramine hcl tabs F

imipramine pamoate caps F NORPRAMIN TABS 150MG, 50 MG, 10 MG, 75MG, 100 MG (UseDesipramine HCl)

NF

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

nortriptyline hcl caps F

NORTRIPTYLINE HCLSOLN F QL(20 ml daily)

PAMELOR CAPS (UseNortriptyline HCl) NF

protriptyline hcl tabs F SURMONTIL CAPS (UseTrimipramine Maleate) NF

TOFRANIL TABS (UseImipramine HCl) NF

TOFRANIL-PM CAPS (UseImipramine Pamoate) NF

trimipramine maleate caps F

ANTIDIABETICS - Drugs to Regulate Blood Sugar


14

Drug Name DrugTier

Requirements/Limits

Antidiabetic - Amylin Analogs

SYMLINPEN 120 SOPN F

PA; Limit 4pens permonth;QL(0.36ml daily)

SYMLINPEN 60 SOPN F

PA; Limit 4pens permonth;QL(0.2ml daily)

Antidiabetic CombinationsACTOPLUS MET TABS(Use Pioglitazone HCl-Metformin HCl)

NFQL(2 ea daily)

alogliptin-metformin hcltabs F QL(1 ea daily)

alogliptin-pioglitazone tabs F QL(1 ea daily)

glipizide-metformin hcl tabs F GLUCOVANCE TABS (UseGlyburide-Metformin) NF

glyburide-metformin tabs F

JENTADUETO TABS F QL(2 ea daily)

KAZANO TABS (UseAlogliptin-Metformin HCl) NF QL(1 ea daily)

OSENI TABS (UseAlogliptin-Pioglitazone) NF QL(1 ea daily)

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

BiguanidesGLUCOPHAGE TABS1000 MG (Use MetforminHCl)

NFQL(2 ea daily)

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

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

GLUCOPHAGE XR TB24500 MG (Use MetforminHCl)

NFQL(4 ea daily)

GLUCOPHAGE XR TB24750 MG (Use MetforminHCl)

NFQL(2 ea daily)

Drug Name DrugTier

Requirements/Limits

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

metformin hcl tabs 500 mg F QL(5 ea daily)

metformin hcl tabs 850 mg F QL(3 ea daily)

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

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

Diabetic Other

CVS GLUCOSE CHEW FLimit 50 permonth;QL(1.67ea daily)

DEX4 QUICK DISSOLVEGLUCOSE CHEW F

Limit 50 permonth;QL(1.67ea daily)

dextrose (diabetic use) gel F

GLUCAGEN HYPOKITSOLR F QL(1 ea per fill

retail)GLUCAGONEMERGENCY KIT KIT F QL(1 ea per fill

retail)

GLUCOSE CHEW FLimit 50 permonth;QL(1.67ea daily)

GNP GLUCOSE CHEW FLimit 50 permonth;QL(1.67ea daily)

GNP QUICK DISSOLVEGLUCOSE CHEW F


LEADER QUICKDISSOLVE GLUCOSECHEW

FLimit 50 permonth;QL(1.67ea daily)

SM GLUCOSE CHEW FLimit 50 permonth;QL(1.67ea daily)

WALGREENS GLUCOSECHEW F


Dipeptidyl Peptidase-4 (DPP-4) Inhibitorsalogliptin benzoate tabs F QL(1 ea daily)

NESINA TABS (UseAlogliptin Benzoate) NF QL(1 ea daily)


15

Drug Name DrugTier

Requirements/Limits

TRADJENTA TABS F QL(1 ea daily);AL

Incretin Mimetic Agents (GLP-1 Receptor

BYDUREON PEN PEN F

Limit 1 syringepermonth;QL(0.143 ea daily)

BYDUREON SRER F

Limit 1 syringepermonth;QL(0.143 ea daily)

BYETTA SOPN 10MCG/0.04ML F

Limit 1 syringepermonth;QL(0.08ml daily)

BYETTA SOPN 5MCG/0.02ML F

Limit 1 syringepermonth;QL(0.04ml daily)

VICTOZA SOPN F

Limit 3 syringespermonth;QL(0.3ml daily)

Insulin Sensitizing AgentsACTOS TABS (UsePioglitazone HCl) NF QL(1 ea daily)

AVANDIA TABS F QL(1 ea daily)

pioglitazone hcl tabs F QL(1 ea daily)

Insulin

APIDRA SOLN FLimit 30ml permonth;QL(1 mldaily)

APIDRA SOLOSTARSOPN F QL(1 ml daily)

BASAGLAR KWIKPENSOPN F QL(1 ml daily)

HUMALOG KWIKPENSOPN F QL(1 ml daily)

HUMALOG MIX 50/50KWIKPEN SUPN F QL(1 ml daily)

HUMALOG MIX 50/50SUSP F

Limit 40ml permonth;QL(1.34ml daily)

HUMALOG MIX 75/25KWIKPEN SUPN F QL(1 ml daily)

Drug Name DrugTier

Requirements/Limits

HUMALOG MIX 75/25SUSP F


HUMALOG SOCT F QL(1 ml daily)

HUMALOG SOLN FLimit 40ml permonth;QL(1.34ml daily)

HUMULIN 70/30 KWIKPENSUPN F QL(1 ml daily)

HUMULIN 70/30 SUSP FLimit 40ml permonth;QL(1.34ml daily)

HUMULIN N KWIKPENSUPN F QL(1 ml daily)

HUMULIN N SUSP FLimit 40ml permonth;QL(1.34ml daily)

HUMULIN R SOLN FLimit 40ml permonth;QL(1.34ml daily)

LANTUS SOLN FLimit 30ml permonth;QL(1 mldaily)

NOVOLIN 70/30 RELIONSUSP F


NOVOLIN 70/30 SUSP FLimit 40ml permonth;QL(1.34ml daily)

NOVOLIN N RELIONSUSP F


NOVOLIN N SUSP FLimit 40ml permonth;QL(1.34ml daily)

NOVOLIN R RELIONSOLN F


NOVOLIN R SOLN FLimit 40ml permonth;QL(1.34ml daily)

NOVOLOG FLEXPENSOPN F QL(1 ml daily)

NOVOLOG MIX 70/30PREFILLED FLEXPENSUPN

FQL(1 ml daily)


16

Drug Name DrugTier

Requirements/Limits

NOVOLOG MIX 70/30SUSP F


NOVOLOG PENFILLSOCT F QL(1 ml daily)

NOVOLOG SOLN FLimit 30ml permonth;QL(1 mldaily)

Meglitinide Analoguesnateglinide tabs F QL(3 ea daily)

STARLIX TABS (UseNateglinide) NF QL(3 ea daily)

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

INVOKANA TABS F

SulfonylureasAMARYL TABS 1 MG, 2MG (Use Glimepiride) NF QL(1 ea daily)

AMARYL TABS 4 MG (UseGlimepiride) NF QL(2 ea daily)

DIABETA TABS F

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

glimepiride tabs 4 mg F QL(2 ea daily)

glipizide tabs F

glipizide tb24 F GLUCOTROL TABS (UseGlipizide) NF GLUCOTROL XL TB24(Use Glipizide) NF

glyburide micronized tabs F

glyburide tabs F

GLYNASE TABS (UseGlyburide Micronized) NF

ANTIDIARRHEALS - Drugs to Treat Diarrhea

Antidiarrheal Agents - Misc.

Drug Name DrugTier

Requirements/Limits

bismuth subsalicylate chew F

bismuth subsalicylate susp F

bismuth subsalicylate tabs F

PEPTO BISMOL TABS(Use BismuthSubsalicylate)

NF

PEPTO-BISMOL CHEW(Use BismuthSubsalicylate)

NF

PEPTO-BISMOLINSTACOOL CHEW (UseBismuth Subsalicylate)

NF

PEPTO-BISMOL MAXSTRENGTH SUSP (UseBismuth Subsalicylate)

NF

PEPTO-BISMOL SUSP262 MG/15ML (UseBismuth Subsalicylate)

NF

PEPTO-BISMOL TO-GOCHEW (Use BismuthSubsalicylate)

NF

Antiperistaltic Agentsdiphenoxylate w/ atropinetabs F

DIPHENOXYLATE/ATROPINE LIQD F IMODIUM A-D CAPS (UseLoperamide HCl) NF RX/OTC

IMODIUM A-D TABS (UseLoperamide HCl) NF QL(2 ea daily)

LOMOTIL TABS (UseDiphenoxylate w/ Atropine) NF

loperamide hcl caps F RX/OTC

loperamide hcl liqd F

loperamide hcl tabs F QL(2 ea daily)

ANTIDOTES AND SPECIFIC ANTAGONISTS

Antidotes - Chelating AgentsCHEMET CAPS F


17

Drug Name DrugTier

Requirements/Limits

JADENU TABS F PA

Antidotes and Specific AntagonistsSM IPECAC SYRUP SYRP F

Opioid Antagonists

naloxone hcl soln F QL(2 ml per 90days retail)

naltrexone hcl tabs F PA

NARCAN LIQD F

REVIA TABS (UseNaltrexone HCl) NF PA

VIVITROL SUSR F PA

ANTIEMETICS - Drugs to Treat Nausea andVomiting5-HT3 Receptor Antagonistsondansetron hcl soln ij 4mg/2ml, 40 mg/20ml F

ondansetron hcl soln or 4mg/5ml F QL(50 ml per

fill retail)ondansetron hcl tabs 24mg F QL(1 ea per 14

days retail)ondansetron hcl tabs 8 mg,4 mg F QL(2 ea daily)

ondansetron tbdp F QL(2 ea daily)

ZOFRAN ODT TBDP (UseOndansetron) NF QL(2 ea daily)

ZOFRAN SOLN (UseOndansetron HCl) NF QL(50 ml per

fill retail)ZOFRAN TABS (UseOndansetron HCl) NF QL(2 ea daily)

Antiemetics - Anticholinergicdimenhydrinate tabs F

DRAMAMINE TABS (UseDimenhydrinate) NF

meclizine hcl chew F

meclizine hcl tabs F RX/OTC

ANTIFUNGALS - Drugs to Treat Fungal Infections

Drug Name DrugTier

Requirements/Limits

AntifungalsGRIFULVIN V TABS (UseGriseofulvin Microsize) NF

GRIS-PEG TABS (UseGriseofulvin Ultramicrosize) NF

griseofulvin microsize susp F

griseofulvin microsize tabs F griseofulvin ultramicrosizetabs F

LAMISIL TABS (UseTerbinafine HCl) NF

QL(1 eadaily,90 ea per120 days retail)

nystatin tabs F QL(6 ea daily)

terbinafine hcl tabs FQL(1 eadaily,90 ea per120 days retail)

Imidazole-Related Antifungals

DIFLUCAN SUSR (UseFluconazole) NF

Limit 1 packageperclaim;QL(70 mlper fill retail)

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 F

Limit 1 packageperclaim;QL(70 mlper 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)

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

itraconazole caps F PA; QL(1 eadaily)


18

Drug Name DrugTier

Requirements/Limits

SPORANOX CAPS (UseItraconazole) NF PA; QL(1 ea

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

daily)

ANTIHISTAMINES - Drugs to Treat Allergies

Antihistamines - AlkylaminesCHLOR-TRIMETON SYRP(Use ChlorpheniramineMaleate)

NFQL(60 ml daily)

CHLOR-TRIMETON TABS(Use ChlorpheniramineMaleate)

NFQL(120 ea perfill retail)

chlorpheniramine maleatesyrp F QL(60 ml daily)

chlorpheniramine maleatetabs F QL(120 ea per

fill retail)Antihistamines - EthanolaminesBENADRYL ALLERGYCAPS (UseDiphenhydramine HCl)

NFQL(4 ea daily)

BENADRYL ALLERGYCHILDRENS LIQD (UseDiphenhydramine HCl)


BENADRYL ALLERGYTABS (UseDiphenhydramine HCl)

NFQL(4 ea daily)

BENADRYL DYE-FREEALLERGYLIQUID-GELSCAPS (UseDiphenhydramine HCl)

NF

QL(4 ea daily)

clemastine fumarate tabs F QL(2 ea daily)

diphenhydramine hcl caps25 mg F QL(4 ea daily)

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

RX/OTC

diphenhydramine hcl elix FQL(240 ml perfill retail);RX/OTC

diphenhydramine hcl liqd F QL(240 ml perfill retail)

diphenhydramine hcl syrp F QL(240 ml perfill retail)

diphenhydramine hcl tabs F QL(4 ea daily)

Drug Name DrugTier

Requirements/Limits

SILPHEN COUGH SYRP F QL(240 ml perfill retail)

TAVIST ALLERGY TABS(Use Clemastine Fumarate) NF QL(2 ea daily)

Antihistamines - Non-SedatingALLEGRA ALLERGYTABS 180 MG (UseFexofenadine HCl)

NFQL(1 ea daily)

ALLEGRA ALLERGYTABS 60 MG (UseFexofenadine HCl)

NFQL(2 ea daily)

cetirizine hcl chew F QL(1 ea daily)

cetirizine hcl soln FQL(240 ml perfill retail); AL;RX/OTC

cetirizine hcl syrp FQL(240 ml perfill retail); AL;RX/OTC

cetirizine hcl tabs F QL(1 ea daily)

CLARITIN REDITABSTBDP (Use Loratadine) NF

CLARITIN SYRP (UseLoratadine) NF QL(240 ml per

fill retail)CLARITIN TABS (UseLoratadine) NF

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

fexofenadine hcl tabs 60mg F QL(2 ea daily)

loratadine soln F QL(240 ml perfill retail)

loratadine syrp F QL(240 ml perfill retail)

loratadine tabs F

loratadine tbdp F

ZYRTEC ALLERGY TABS(Use Cetirizine HCl) NF QL(1 ea daily)

ZYRTEC CHILDRENSALLERGY SYRP (UseCetirizine HCl)

NFQL(240 ml perfill retail); AL;RX/OTC

Antihistamines - Phenothiazines


19

Drug Name DrugTier

Requirements/Limits

promethazine hcl soln F QL(240 ml perfill retail); AL

promethazine hcl supp F QL(12 ea perfill retail); AL

promethazine hcl syrp F QL(240 ml perfill retail); AL

promethazine hcl tabs F AL

Antihistamines - Piperidinescyproheptadine hcl syrp F

cyproheptadine hcl tabs F

ANTIHYPERLIPIDEMICS - Drugs to Treat HighCholesterolAntihyperlipidemics - Combinationsezetimibe-simvastatin tabs F PA

VYTORIN TABS (UseEzetimibe-Simvastatin) NF PA

Bile Acid Sequestrantscholestyramine light pack F

cholestyramine light powd F

cholestyramine pack F

cholestyramine powd F COLESTID FLAVOREDGRAN (Use Colestipol HCl) NF

COLESTID GRAN (UseColestipol HCl) NF

COLESTID TABS (UseColestipol HCl) NF

colestipol hcl gran F

colestipol hcl tabs F

QUESTRAN LIGHT POWD(Use Cholestyramine Light) NF

QUESTRAN PACK (UseCholestyramine) NF

QUESTRAN POWD (UseCholestyramine) NF

Fibric Acid Derivatives

Drug Name DrugTier

Requirements/Limits

fenofibrate micronized caps200 mg, 134 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 200 MG,134 MG (Use FenofibrateMicronized)

NFQL(1 ea daily)

LOFIBRA CAPS 67 MG(Use FenofibrateMicronized)

NFQL(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 (UseGemfibrozil) NF QL(2 ea daily)

TRIGLIDE TABS F QL(1 ea daily)

HMG CoA Reductase Inhibitorsatorvastatin calcium tabs F QL(1 ea daily)

LIPITOR TABS (UseAtorvastatin Calcium) NF QL(1 ea daily)

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

lovastatin tabs 40 mg F QL(2 ea daily)

MEVACOR TABS (UseLovastatin) NF QL(2 ea daily)

PRAVACHOL TABS (UsePravastatin Sodium) NF QL(1 ea daily)

pravastatin sodium tabs F QL(1 ea daily)

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

simvastatin tabs 80 mg F

ZOCOR TABS 40 MG, 10MG, 5 MG, 20 MG (UseSimvastatin)

NFQL(1 ea daily)


20

Drug Name DrugTier

Requirements/Limits

ZOCOR TABS 80 MG (UseSimvastatin) NF

Intestinal Cholesterol Absorption Inhibitorsezetimibe tabs F PA

ZETIA TABS (UseEzetimibe) NF PA

Nicotinic Acid DerivativesNIACOR TABS F

ANTIHYPERTENSIVES - Drugs to Treat HighBlood PressureACE InhibitorsACCUPRIL TABS (UseQuinapril HCl) NF QL(1 ea daily)

ALTACE CAPS (UseRamipril) NF QL(2 ea daily)

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

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

captopril tabs F QL(3 ea daily)

enalapril maleate tabs F QL(2 ea daily)

EPANED SOLR F AL

fosinopril sodium tabs F QL(1 ea daily)

lisinopril tabs 2.5 mg F QL(1 ea daily)

lisinopril tabs 5 mg, 20 mg,30 mg, 40 mg, 10 mg F QL(2 ea daily)

LOTENSIN TABS 20 MG(Use Benazepril HCl) NF QL(1 ea daily)

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

MAVIK TABS 1 MG, 2 MG(Use Trandolapril) NF QL(1 ea daily)

MAVIK TABS 4 MG (UseTrandolapril) NF QL(2 ea daily)

PRINIVIL TABS (UseLisinopril) NF QL(2 ea daily)

quinapril hcl tabs F QL(1 ea daily)

Drug Name DrugTier

Requirements/Limits

ramipril caps F QL(2 ea daily)

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

trandolapril tabs 4 mg F QL(2 ea daily)

VASOTEC TABS (UseEnalapril Maleate) NF QL(2 ea daily)

ZESTRIL TABS 10 MG, 30MG, 20 MG, 40 MG, 5 MG(Use Lisinopril)

NFQL(2 ea daily)

ZESTRIL TABS 2.5 MG(Use Lisinopril) NF QL(1 ea daily)

Angiotensin II Receptor AntagonistsAVAPRO TABS (UseIrbesartan) NF QL(1 ea daily)

COZAAR TABS (UseLosartan Potassium) NF QL(1 ea daily)

DIOVAN TABS (UseValsartan) NF QL(1 ea daily)

irbesartan tabs F QL(1 ea daily)

losartan potassium tabs F QL(1 ea daily)

valsartan tabs F QL(1 ea daily)

Antiadrenergic AntihypertensivesCARDURA TABS (UseDoxazosin Mesylate) NF CATAPRES TABS (UseClonidine HCl) NF

CATAPRES-TTS-1 PTWK(Use Clonidine HCl) NF



clonidine hcl ptwk F

clonidine hcl tabs F

doxazosin mesylate tabs F

guanfacine hcl tabs F

methyldopa tabs F


21

Drug Name DrugTier

Requirements/Limits

MINIPRESS CAPS (UsePrazosin HCl) NF

prazosin hcl caps F

RESERPINE TABS F TENEX TABS (UseGuanfacine HCl) NF

terazosin hcl caps F

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

atenolol & chlorthalidonetabs F QL(1 ea daily)

AVALIDE TABS (UseIrbesartan-Hydrochlorothiazide)

NFQL(1 ea daily)

benazepril &hydrochlorothiazide tabs F QL(1 ea daily)

bisoprolol &hydrochlorothiazide tabs F QL(1 ea daily)

CAPTOPRIL/HYDROCHLOROTHIAZIDE TABS F QL(2 ea daily)

DIOVAN HCT TABS (UseValsartan-Hydrochlorothiazide)

NFQL(1 ea daily)

DUTOPROL TB24 F QL(1 ea daily)

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

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

HYZAAR TABS (UseLosartan Potassium &Hydrochlorothiazide)

NFQL(1 ea daily)

irbesartan-hydrochlorothiazide tabs F QL(1 ea daily)

lisinopril &hydrochlorothiazide tabs10mg-12.5mg, 20mg-12.5mg

F

QL(2 ea daily)

lisinopril &hydrochlorothiazide tabs20mg-25mg

FQL(1 ea daily)

Drug Name DrugTier

Requirements/Limits

LOPRESSOR HCT TABS(Use Metoprolol &Hydrochlorothiazide)

NFQL(2 ea daily)

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

LOTENSIN HCT TABS(Use Benazepril &Hydrochlorothiazide)

NFQL(1 ea daily)

LOTREL CAPS (UseAmlodipine Besylate-Benazepril HCl)

NFQL(1 ea daily)

metoprolol &hydrochlorothiazide tabs F QL(2 ea daily)

METOPROLOLSUCCINATEER/HYDROCHLOROTHIAZIDE TB24

F

QL(1 ea daily)

METOPROLOL/HYDROCHLOROTHIAZIDE TABS F QL(2 ea daily)

PROPRANOLOL/HYDROCHLOROTHIAZIDE TABS F

TEKTURNA HCT TABS F

TENORETIC 100 TABS(Use Atenolol &Chlorthalidone)

NFQL(1 ea daily)

TENORETIC 50 TABS(Use Atenolol &Chlorthalidone)

NFQL(1 ea daily)

valsartan-hydrochlorothiazide tabs F QL(1 ea daily)

VASERETIC TABS (UseEnalapril Maleate &Hydrochlorothiazide)

NFQL(2 ea daily)

ZESTORETIC TABS20MG-12.5MG, 10MG-12.5MG (Use Lisinopril &Hydrochlorothiazide)

NF

QL(2 ea daily)

ZESTORETIC TABS20MG-25MG (UseLisinopril &Hydrochlorothiazide)

NF

QL(1 ea daily)

ZIAC TABS (Use Bisoprolol& Hydrochlorothiazide) NF QL(1 ea daily)

Direct Renin InhibitorsTEKTURNA TABS F


22

Drug Name DrugTier

Requirements/Limits

Vasodilatorshydralazine hcl tabs F

minoxidil tabs F

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

COARTEM TABS F QL(24 ea perfill retail)

AntimalarialsCHLOROQUINEPHOSPHATE TABS 250MG

FQL(2 ea daily)

chloroquine phosphatetabs 250 mg F QL(2 ea daily)

chloroquine phosphatetabs 500 mg F QL(8 ea per 56

days retail)hydroxychloroquine sulfatetabs F

mefloquine hcl tabs F

PLAQUENIL TABS (UseHydroxychloroquineSulfate)

NF

PRIMAQUINEPHOSPHATE TABS F PA

ANTIMYASTHENIC/CHOLINERGIC AGENTS

Antimyasthenic/Cholinergic AgentsMESTINON TABS (UsePyridostigmine Bromide) NF

MESTINON TIMESPANTBCR (Use PyridostigmineBromide)

NF

pyridostigmine bromidetabs F

pyridostigmine bromidetbcr F

ANTIMYCOBACTERIAL AGENTS - Drugs toTreat Tuberculosis (Bacterial Infections)Antimycobacterial Agentsethambutol hcl tabs F

Drug Name DrugTier

Requirements/Limits

ISONIAZID SYRP F

isoniazid tabs F

MYAMBUTOL TABS (UseEthambutol HCl) NF

pyrazinamide tabs F RIFADIN CAPS (UseRifampin) NF

rifampin caps F

TRECATOR TABS F

ANTINEOPLASTICS AND ADJUNCTIVETHERAPIES - Drugs to Treat CancerAlkylating AgentsALKERAN TABS F

CYCLOPHOSPHAMIDECAPS F

LEUKERAN TABS F

MYLERAN TABS F

TEMODAR CAPS (UseTemozolomide) NF PA

TEMODAR SOLR F PA

temozolomide caps F PA

Antimetabolitescapecitabine tabs F PA

mercaptopurine tabs F

methotrexate sodium soln200 mg/8ml, 100 mg/4ml, 1gm/40ml, 250 mg/10ml, 50mg/2ml

F

METHOTREXATESODIUM SOLN 250MG/10ML

F

methotrexate sodium tabs F

PURIXAN SUSP F AL


23

Drug Name DrugTier

Requirements/Limits

TREXALL TABS F

XELODA TABS (UseCapecitabine) NF PA

Antineoplastic - Hedgehog Pathway InhibitorsERIVEDGE CAPS F PA

ODOMZO CAPS F PA

Antineoplastic - Hormonal and Related Agentsanastrozole tabs F

ARIMIDEX TABS (UseAnastrozole) NF

AROMASIN TABS (UseExemestane) NF

ST; Tryanastrozole orletrozole first

bicalutamide tabs F QL(1 ea daily)

CASODEX TABS (UseBicalutamide) NF QL(1 ea daily)

ELIGARD KIT F PA

EMCYT CAPS F

exemestane tabs FST; Tryanastrozole orletrozole first

FARESTON TABS F PA

FEMARA TABS (UseLetrozole) NF

ST; Tryanastrozole orexemastanefirst

FIRMAGON SOLR F PA

flutamide caps F

HYDROXYPROGESTERONE CAPROATE SOLN F

PA; Limit 5mlpermonth;QL(0.167 ml daily); AL

letrozole tabs F

ST; Tryanastrozole orexemastanefirst

leuprolide acetate kit F PA

Drug Name DrugTier

Requirements/Limits

LUPRON DEPOT (1-MONTH) KIT F PA




LYSODREN TABS F

MEGACE ORAL SUSP(Use Megestrol Acetate) NF

megestrol acetate susp F

megestrol acetate tabs F

tamoxifen citrate tabs F TRELSTAR MIXJECTSUSR F PA

TRELSTAR SUSR F PA

VANTAS KIT F PA

XTANDI CAPS F PA

ZOLADEX IMPL F PA

ZYTIGA TABS F PA

Antineoplastic - ImmunomodulatorsPOMALYST CAPS F PA

Antineoplastic Enzyme InhibitorsAFINITOR DISPERZ TBSO F PA

AFINITOR TABS F PA

BOSULIF TABS F PA

COTELLIC TABS F PA

FARYDAK CAPS F PA

GILOTRIF TABS F PA


24

Drug Name DrugTier

Requirements/Limits

GLEEVEC TABS 100 MG,400 MG (Use ImatinibMesylate)

NFPA

GLEEVEC TABS 400 MG F PA

IBRANCE CAPS F PA

ICLUSIG TABS F PA

imatinib mesylate tabs F PA

INLYTA TABS F PA

ISTODAX (OVERFILL)SOLR F PA

ISTODAX SOLR F PA

JAKAFI TABS F PA

MEKINIST TABS F PA

NEXAVAR TABS F PA

NINLARO CAPS F PA

SPRYCEL TABS F PA

STIVARGA TABS F PA

SUTENT CAPS F PA

TAFINLAR CAPS F PA

TARCEVA TABS F PA

TASIGNA CAPS F PA

TYKERB TABS F PA

VOTRIENT TABS F PA

XALKORI CAPS F PA

ZELBORAF TABS F PA

ZOLINZA CAPS F PA

ZYKADIA CAPS F PA

Drug Name DrugTier

Requirements/Limits

Antineoplastics Misc.bexarotene caps F PA

HYDREA CAPS (UseHydroxyurea) NF

hydroxyurea caps F

MATULANE CAPS F

TARGRETIN CAPS (UseBexarotene) NF PA

tretinoin (chemotherapy)caps F

Chemotherapy Rescue/Antidote AgentsLEUCOVORIN CALCIUMTABS 10 MG, 15 MG F

leucovorin calcium tabs 5mg, 25 mg F

MESNEX TABS F

Mitotic InhibitorsETOPOSIDE CAPS F

Topoisomerase I InhibitorsHYCAMTIN CAPS F PA

ANTIPARKINSON AGENTS - Drugs to TreatParkinson's DiseaseAntiparkinson Adjuvantscarbidopa tabs F LODOSYN TABS (UseCarbidopa) NF

Antiparkinson Anticholinergicsbenztropine mesylate soln F

benztropine mesylate tabs F

COGENTIN SOLN (UseBenztropine Mesylate) NF

trihexyphenidyl hcl elix F QL(16.67 mldaily)

trihexyphenidyl hcl tabs F

Antiparkinson Dopaminergics


25

Drug Name DrugTier

Requirements/Limits

amantadine hcl caps F

amantadine hcl syrp F bromocriptine mesylatecaps F

bromocriptine mesylatetabs F

carbidopa-levodopa tabs F

carbidopa-levodopa tbcr F

MIRAPEX TABS (UsePramipexoleDihydrochloride)

NFPA; QL(3 eadaily)

PARLODEL CAPS (UseBromocriptine Mesylate) NF

PARLODEL TABS (UseBromocriptine Mesylate) NF

pramipexoledihydrochloride tabs F PA; QL(3 ea

daily)REQUIP TABS 4 MG, 3MG, 0.25 MG (UseRopinirole Hydrochloride)

NFPA; QL(6 eadaily)

REQUIP TABS 5 MG, 2MG, 1 MG, 0.5 MG (UseRopinirole Hydrochloride)

NFPA; QL(3 eadaily)

ropinirole hydrochloridetabs 4 mg, 3 mg, 0.25 mg F PA; QL(6 ea

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

FPA; QL(3 eadaily)

SINEMET CR TBCR (UseCarbidopa-Levodopa) NF

SINEMET TABS (UseCarbidopa-Levodopa) NF

Antiparkinson Monoamine Oxidase InhibitorsELDEPRYL CAPS (UseSelegiline HCl) NF

selegiline hcl caps F

selegiline hcl tabs F

ANTIPSYCHOTICS/ANTIMANIC AGENTS -Drugs to Treat Mood DisordersAntimanic Agents

Drug Name DrugTier

Requirements/Limits

lithium carbonate caps 300mg, 150 mg, 600 mg F LITHIUM CARBONATECAPS 600 MG, 150 MG(Use Lithium Carbonate)

NF

lithium carbonate tabs F

lithium carbonate tbcr F

LITHIUM SOLN F LITHOBID TBCR (UseLithium Carbonate) NF

Antipsychotics - Misc.EQUETRO CP12 F

GEODON CAPS (UseZiprasidone HCl) NF QL(2 ea daily);

AL

GEODON SOLR F

LATUDA TABS F PA

NUPLAZID TABS F PA; QL(2 eadaily)

VRAYLAR CAPS F

ziprasidone hcl caps F QL(2 ea daily);AL

BenzisoxazolesFANAPT TABS F PA

FANAPT TITRATIONPACK TABS F PA

INVEGA SUSTENNASUSP 117 MG/0.75ML F

PA; Limit 1syringe permonth;QL(0.027 ml daily)

INVEGA SUSTENNASUSP 156 MG/ML F





26

Drug Name DrugTier

Requirements/Limits





INVEGA TB24 (UsePaliperidone) NF PA

INVEGA TRINZA SUSP273 MG/0.875ML F

PA; Limit 1syringe every 3months;QL(0.875 ml per 84days retail)







paliperidone tb24 F PA

RISPERDAL CONSTASUSR F

PA; Limit 2vials permonth;QL(0.072 ea daily)

RISPERDAL M-TAB TBDP(Use Risperidone) NF QL(2 ea daily);

ALRISPERDAL SOLN (UseRisperidone) NF QL(4 ml daily);

ALRISPERDAL TABS (UseRisperidone) NF QL(2 ea daily);

AL

risperidone soln F QL(4 ml daily);AL

risperidone tabs F QL(2 ea daily);AL

risperidone tbdp 0.25 mg F QL(1 ea daily);AL

Drug Name DrugTier

Requirements/Limits

risperidone tbdp 3 mg, 1mg, 4 mg, 2 mg, 0.5 mg F QL(2 ea daily);

ALButyrophenonesHALDOL DECANOATE100 SOLN (UseHaloperidol Decanoate)

NF

HALDOL DECANOATE 50SOLN (Use HaloperidolDecanoate)

NF

HALDOL SOLN (UseHaloperidol Lactate) NF

haloperidol decanoate soln F

haloperidol lactate conc F

haloperidol lactate soln F

haloperidol tabs 1 mg, 0.5mg, 10 mg F QL(3 ea daily)

haloperidol tabs 5 mg, 2mg, 20 mg F

DibenzapinesCLOZAPINE ODT TBDP F QL(3 ea daily)

clozapine tabs 100 mg F QL(9 ea daily);AL

clozapine tabs 50 mg, 200mg, 25 mg F QL(3 ea daily);

AL

clozapine tbdp 100 mg F PA; QL(9 eadaily)

clozapine tbdp 25 mg F PA; QL(3 eadaily)

CLOZARIL TABS 100 MG(Use Clozapine) NF QL(9 ea daily);

ALCLOZARIL TABS 25 MG(Use Clozapine) NF QL(3 ea daily);

ALFAZACLO TBDP 100 MG(Use Clozapine) NF PA; QL(9 ea

daily)FAZACLO TBDP 150 MG,200 MG, 12.5 MG F QL(3 ea daily)

FAZACLO TBDP 25 MG(Use Clozapine) NF PA; QL(3 ea

daily)

loxapine succinate caps F QL(4 ea daily)

olanzapine solr F


27

Drug Name DrugTier

Requirements/Limits

olanzapine tabs F QL(1 ea daily);AL

olanzapine tbdp F QL(1 ea daily);AL

quetiapine fumarate tabs F QL(2 ea daily)

quetiapine fumarate tb24 F PA

SAPHRIS SUBL F PA

SEROQUEL TABS (UseQuetiapine Fumarate) NF QL(2 ea daily)

SEROQUEL XR TB24 (UseQuetiapine Fumarate) NF PA

VERSACLOZ SUSP F

ZYPREXA RELPREVVSUSR F

PA; Limit 2vials permonth;QL(0.072 ea daily)

ZYPREXA SOLR (UseOlanzapine) NF

ZYPREXA TABS (UseOlanzapine) NF QL(1 ea daily);

ALZYPREXA ZYDIS TBDP(Use Olanzapine) NF QL(1 ea daily);

ALDihydroindolonesMOLINDONEHYDROCHLORIDE TABS F

PhenothiazinesCHLORPROMAZINE HCLSOLN F

chlorpromazine hcl tabs 10mg F QL(10 ea daily)

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

FQL(3 ea daily)

fluphenazine decanoatesoln F

FLUPHENAZINE HCLCONC F

FLUPHENAZINE HCLELIX F

FLUPHENAZINE HCLSOLN F

Drug Name DrugTier

Requirements/Limits

fluphenazine hcl tabs F

perphenazine tabs F QL(4 ea daily)

prochlorperazine edisylatesoln F

prochlorperazine maleatetabs F

prochlorperazine supp F

thioridazine hcl tabs F QL(3 ea daily)

trifluoperazine hcl tabs F QL(3 ea daily)

Quinolinone Derivatives

ABILIFY DISCMELT TBDP F PA; QL(1 eadaily)

ABILIFY MAINTENA SUSR F

PA; Limit 1 vialpermonth;QL(0.036 ea daily)

ABILIFY SOLN F PA

ABILIFY TABS (UseAripiprazole) NF PA; QL(1 ea

daily)

aripiprazole soln F PA; QL(25 mldaily); AL

aripiprazole tabs F PA; QL(1 eadaily)

aripiprazole tbdp F PA; QL(1 eadaily)

ARISTADA PRSY 441MG/1.6ML F






REXULTI TABS F PA

Thioxanthenes


28

Drug Name DrugTier

Requirements/Limits

thiothixene caps F QL(3 ea daily)

ANTISEPTICS & DISINFECTANTS - Drugs toPrevent Bacterial Skin InfectionsAntiseptics & Disinfectants

formaldehyde soln F QL(90 ml perfill retail)

Chlorine Antisepticschlorhexidine gluconateliqd F

dakin's solution soln F

DAKINS SOLUTIONQUARTER STRENGTHSOLN (Use Dakin'sSolution)

NF

HIBICLENS LIQD (UseChlorhexidine Gluconate) NF

Iodine AntisepticsBETADINE SOLN (UsePovidone-Iodine) NF

povidone-iodine soln F

ANTIVIRALS - Drugs to Treat Viral Infections

Antiretroviralsabacavir sulfate tabs F QL(2 ea daily)

abacavir sulfate-lamivudinetabs F QL(1 ea daily)

abacavir sulfate-lamivudine-zidovudine tabs F QL(2 ea daily)

APTIVUS CAPS F QL(4 ea daily)

APTIVUS SOLN F QL(10 ml daily)

ATRIPLA TABS F QL(1 ea daily)

COMBIVIR TABS (UseLamivudine-Zidovudine) NF QL(2 ea daily)

COMPLERA TABS F QL(1 ea daily)

CRIXIVAN CAPS 200 MG F QL(9 ea daily)

CRIXIVAN CAPS 400 MG F QL(6 ea daily)

Drug Name DrugTier

Requirements/Limits

DESCOVY TABS F QL(1 ea daily)

didanosine cpdr F QL(1 ea daily)

EDURANT TABS F QL(1 ea daily)

EMTRIVA CAPS F QL(1 ea daily)

EMTRIVA SOLN F QL(24 ml daily)

EPIVIR SOLN (UseLamivudine) NF QL(30 ml daily)

EPIVIR TABS 150 MG(Use Lamivudine) NF QL(2 ea daily)

EPIVIR TABS 300 MG(Use Lamivudine) NF QL(1 ea daily)

EPZICOM TABS (UseAbacavir Sulfate-Lamivudine)

NFQL(1 ea daily)

EVOTAZ TABS F QL(1 ea daily)

FUZEON SOLR F

GENVOYA TABS F QL(1 ea daily)

INTELENCE TABS 100MG, 25 MG F QL(4 ea daily)

INTELENCE TABS 200MG F QL(2 ea daily)

INVIRASE CAPS F QL(10 ea daily)

INVIRASE TABS F QL(4 ea daily)

ISENTRESS CHEW 100MG F QL(6 ea daily)

ISENTRESS CHEW 25 MG F QL(12 ea daily)

ISENTRESS PACK F QL(2 ea daily)

ISENTRESS TABS F QL(2 ea daily)

KALETRA SOLN (UseLopinavir-Ritonavir) NF


KALETRA TABS 100MG-25MG F QL(4 ea daily)


29

Drug Name DrugTier

Requirements/Limits

KALETRA TABS 200MG-50MG F QL(6 ea daily)

lamivudine soln F QL(30 ml daily)

lamivudine tabs 150 mg F QL(2 ea daily)

lamivudine tabs 300 mg F QL(1 ea daily)

lamivudine-zidovudine tabs F QL(2 ea daily)

LEXIVA SUSP F QL(56 ml daily)

LEXIVA TABS F QL(4 ea daily)

lopinavir-ritonavir soln F

Limit 1package perclaim;QL(160ml per fill retail)

NEVIRAPINE SUSP F QL(40 ml daily)

nevirapine tabs F QL(2 ea daily)

nevirapine tb24 100 mg F QL(3 ea daily)

nevirapine tb24 400 mg F QL(1 ea daily)

NORVIR CAPS F QL(12 ea daily)

NORVIR SOLN F QL(15 ml daily)

NORVIR TABS F QL(12 ea daily)

PREZCOBIX TABS F

PREZISTA SUSP F QL(12 ml daily)

PREZISTA TABS 150 MG F QL(3 ea daily)

PREZISTA TABS 75 MG,600 MG F QL(2 ea daily)

PREZISTA TABS 800 MG F QL(1 ea daily)

RESCRIPTOR TABS 100MG F QL(12 ea daily)

RESCRIPTOR TABS 200MG F QL(6 ea daily)

RETROVIR CAPS (UseZidovudine) NF QL(6 ea daily)

Drug Name DrugTier

Requirements/Limits

RETROVIR IV INFUSIONSOLN F

RETROVIR SYRP (UseZidovudine) NF QL(60 ml daily)

REYATAZ CAPS F QL(2 ea daily)

REYATAZ PACK F QL(6 ea daily)

SELZENTRY TABS 150MG F QL(2 ea daily)

SELZENTRY TABS 300MG F QL(4 ea daily)

SELZENTRY TABS 75MG, 25 MG F

QL 2 perday;SL(2 eadaily)

stavudine caps F QL(2 ea daily)

stavudine solr F QL(80 ml daily)

STRIBILD TABS F QL(1 ea daily)

SUSTIVA CAPS 200 MG F QL(1 ea daily)

SUSTIVA CAPS 50 MG F QL(2 ea daily)

SUSTIVA TABS F QL(1 ea daily)

TIVICAY TABS F

TRIUMEQ TABS F QL(1 ea daily)

TRIZIVIR TABS (UseAbacavir Sulfate-Lamivudine-Zidovudine)

NFQL(2 ea daily)

TRUVADA TABS F QL(1 ea daily)

TYBOST TABS F QL(1 ea daily)

VIDEX EC CPDR (UseDidanosine) NF QL(1 ea daily)

VIDEXPEDIATRIC SOLR F QL(20 ml daily)

VIRACEPT TABS 250 MG F QL(9 ea daily)

VIRACEPT TABS 625 MG F QL(4 ea daily)

VIRAMUNE SUSP F QL(40 ml daily)


30

Drug Name DrugTier

Requirements/Limits

VIRAMUNE TABS (UseNevirapine) NF QL(2 ea daily)

VIRAMUNE XR TB24 100MG (Use Nevirapine) NF QL(3 ea daily)

VIRAMUNE XR TB24 400MG (Use Nevirapine) NF QL(1 ea daily)

VIREAD POWD F QL(8 gm daily)

VIREAD TABS F QL(1 ea daily)

VITEKTA TABS F QL(1 ea daily)

ZERIT CAPS (UseStavudine) NF QL(2 ea daily)

ZERIT SOLR F QL(80 ml daily)

ZIAGEN SOLN F QL(30 ml daily)

ZIAGEN TABS (UseAbacavir Sulfate) NF QL(2 ea daily)

zidovudine caps F QL(6 ea daily)

zidovudine syrp F QL(60 ml daily)

zidovudine tabs F QL(2 ea daily)

CMV AgentsVALCYTE TABS (UseValganciclovir HCl) NF QL(2 ea daily)

valganciclovir hcl tabs F QL(2 ea daily)

Hepatitis Agentsadefovir dipivoxil tabs F BARACLUDE TABS (UseEntecavir) NF

entecavir tabs F

EPCLUSA TABS F PA; QL(1 eadaily)

HEPSERA TABS (UseAdefovir Dipivoxil) NF

ZEPATIER TABS F PA; QL(1 eadaily)

Herpes Agents

Drug Name DrugTier

Requirements/Limits

acyclovir caps FLimit 50 permonth;QL(1.67ea daily)

acyclovir susp FLimit 400ml permonth;QL(13.34 ml daily)

acyclovir tabs 400 mg F QL(3 ea daily)

acyclovir tabs 800 mg FLimit 50 permonth;QL(1.67ea daily)

valacyclovir hcl tabs 1000mg, 1 gm F

Limit 21 permonth;QL(1 eadaily)

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

VALTREX TABS 1 GM(Use Valacyclovir HCl) NF

Limit 21 permonth;QL(1 eadaily)

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

ZOVIRAX CAPS (UseAcyclovir) NF


ZOVIRAX SUSP (UseAcyclovir) NF

Limit 400ml permonth;QL(13.34 ml daily)

ZOVIRAX TABS 400 MG(Use Acyclovir) NF QL(3 ea daily)

ZOVIRAX TABS 800 MG(Use Acyclovir) NF


Influenza Agents

RELENZA DISKHALERAEPB F

Limit 1 packagepermonth;QL(0.67ea daily); AL

TAMIFLU CAPS 30 MG(Use OseltamivirPhosphate)

FQL(20 ea per30 days retail)

TAMIFLU CAPS 75 MG, 45MG (Use OseltamivirPhosphate)


TAMIFLU SUSR F QL(120 ml per30 days retail)

BETA BLOCKERS - Drugs to Treat High BloodPressure


31

Drug Name DrugTier

Requirements/Limits

Alpha-Beta Blockerscarvedilol 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 F QL(1 ea daily)

COREG TABS 25 MG (UseCarvedilol) NF QL(4 ea daily)

COREG TABS 6.25 MG,12.5 MG, 3.125 MG (UseCarvedilol)

NFQL(3 ea daily)

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



Beta Blockers Cardio-Selectiveacebutolol hcl caps F

atenolol tabs F QL(2 ea daily)

bisoprolol fumarate tabs F QL(1 ea daily)

LOPRESSOR TABS 100MG (Use MetoprololTartrate)

NFQL(2 ea daily)

LOPRESSOR TABS 50MG (Use MetoprololTartrate)

NFQL(3 ea daily)

metoprolol succinate tb24200 mg F QL(2 ea daily)

metoprolol succinate tb2450 mg, 25 mg, 100 mg F QL(1 ea daily)

metoprolol tartrate tabs 25mg, 100 mg F QL(2 ea daily)

metoprolol tartrate tabs 50mg F QL(3 ea daily)

SECTRAL CAPS (UseAcebutolol HCl) NF

TENORMIN TABS (UseAtenolol) NF QL(2 ea daily)

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

Drug Name DrugTier

Requirements/Limits

TOPROL XL TB24 50 MG,25 MG, 100 MG (UseMetoprolol Succinate)

NFQL(1 ea daily)

ZEBETA TABS (UseBisoprolol Fumarate) NF QL(1 ea daily)

Beta Blockers Non-SelectiveBETAPACE AF TABS (UseSotalol HCl (AFIB/AFL)) NF QL(2 ea daily)

BETAPACE TABS (UseSotalol HCl) NF QL(2 ea daily)

CORGARD TABS (UseNadolol) NF QL(2 ea daily)

HEMANGEOL SOLN F PA

INDERAL LA CP24 (UsePropranolol HCl) NF QL(2 ea daily)

nadolol tabs F QL(2 ea daily)

pindolol tabs F

propranolol hcl cp24 F QL(2 ea daily)

PROPRANOLOL HCLSOLN F

propranolol hcl tabs 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 PressureCalcium Channel BlockersADALAT 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 (UseVerapamil HCl) NF QL(2 ea daily)


32

Drug Name DrugTier

Requirements/Limits

CALAN TABS (UseVerapamil HCl) NF QL(3 ea daily)

CARDIZEM CD CP24 180MG, 120 MG, 300 MG (UseDiltiazem HCl CoatedBeads)

NF

QL(1 ea daily)

CARDIZEM CD CP24 240MG (Use Diltiazem HClCoated Beads)

NFQL(2 ea daily)

CARDIZEM TABS (UseDiltiazem HCl) NF QL(3 ea daily)

diltiazem hcl coated beadscp24 180 mg, 300 mg, 120mg

FQL(1 ea daily)

diltiazem hcl coated beadscp24 240 mg F QL(2 ea daily)

diltiazem hcl cp12 F QL(2 ea daily)

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

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

diltiazem hcl extendedrelease beads cp24 F QL(1 ea daily)

diltiazem hcl tabs F QL(3 ea daily)

felodipine tb24 F QL(1 ea daily)

nicardipine hcl caps F

nifedipine caps F QL(4 ea daily)

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

nifedipine tb24 60 mg F QL(2 ea daily)

NORVASC TABS (UseAmlodipine Besylate) NF QL(1 ea daily)

PROCARDIA CAPS (UseNifedipine) NF QL(4 ea daily)

PROCARDIA XL TB24 30MG, 90 MG (UseNifedipine)

NFQL(1 ea daily)

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

TIAZAC CP24 (UseDiltiazem HCl ExtendedRelease Beads)

NFQL(1 ea daily)

Drug Name DrugTier

Requirements/Limits

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

verapamil hcl cp24 360 mg F QL(1 ea daily)

verapamil hcl tabs F QL(3 ea daily)

verapamil hcl tbcr F QL(2 ea daily)

VERELAN CP24 180 MG,120 MG, 240 MG (UseVerapamil HCl)

NFQL(2 ea daily)

VERELAN CP24 360 MG(Use Verapamil HCl) NF QL(1 ea daily)

CARDIOTONICS - Drugs to Treat Heart Failureand Abnormal Heart RhythmCardiac GlycosidesDIGOXIN SOLN F

digoxin tabs F

LANOXIN TABS (UseDigoxin) NF

CARDIOVASCULAR AGENTS - MISC. - Drugs toTreat Heart and Circulation ConditionsPeripheral Vasodilatorsisoxsuprine hcl tabs F

Prostaglandin VasodilatorsTYVASO REFILL SOLN F PA

TYVASO SOLN F PA

TYVASO STARTER SOLN F PA

VENTAVIS SOLN F PA

Pulmonary Hypertension - Endothelin ReceptorLETAIRIS TABS F PA

TRACLEER TABS F PA

Pulmonary Hypertension - PhosphodiesteraseREVATIO SOLN (UseSildenafil Citrate(Pulmonary Hypertension))

NFPA


33

Drug Name DrugTier

Requirements/Limits

REVATIO SUSR F PA

REVATIO TABS (UseSildenafil Citrate(Pulmonary Hypertension))

NFPA

sildenafil citrate (pulmonaryhypertension) soln F PA

sildenafil citrate (pulmonaryhypertension) tabs F PA

CEPHALOSPORINS - Drugs to Treat BacterialInfectionsCephalosporins - 1st Generationcefadroxil caps F

cefadroxil susr F

cefadroxil tabs F

cephalexin caps F

cephalexin susr F KEFLEX CAPS (UseCephalexin) NF

Cephalosporins - 2nd Generationcefaclor caps F

CEFACLOR SUSR F

cefprozil susr F

Limit 1package perclaim;QL(100ml per fillretail); AL

cefprozil tabs F QL(20 ea perfill retail)

CEFTIN SUSR F

Limit 1package perclaim;QL(100ml per fillretail); AL

CEFTIN TABS (UseCefuroxime Axetil) NF QL(20 ea per

fill retail)

cefuroxime axetil tabs F QL(20 ea perfill retail)

Cephalosporins - 3rd Generation

Drug Name DrugTier

Requirements/Limits

cefdinir caps F QL(20 ea perfill retail)

cefdinir susr F


ceftriaxone sodium solr F QL(3 ea per fillretail)

CONTRACEPTIVES - Drugs to PreventPregnancyCombination Contraceptives - OralBREVICON-28 TABS (UseNorethindrone & EthEstradiol)

NFQL(1 ea daily)

CYCLESSA TABS (UseDesogestrel-EthinylEstradiol (Triphasic))

NFQL(1 ea daily)

DESOGEN TABS (UseDesogestrel & EthinylEstradiol)

NFQL(1 ea daily)

desogestrel & ethinylestradiol tabs F QL(1 ea daily)

desogestrel-ethinylestradiol (biphasic) tabs F QL(1 ea daily)

desogestrel-ethinylestradiol (triphasic) tabs F QL(1 ea daily)

drospirenone-ethinylestradiol tabs F QL(1 ea daily)

ethynodiol diacet & ethestrad tabs F QL(1 ea daily)

levonorgestrel & ethestradiol tabs F QL(1 ea daily)

levonorgestrel-eth estradiol(triphasic) tabs F QL(1 ea daily)

levonorgestrel-ethinylestradiol (91-day) tabs F QL(1 ea daily)

levonorgestrel-ethinylestradiol (91-day) tabs F QL(91 ea per

fill retail)LOESTRIN 1.5/30-21TABS (Use NorethindroneAcet & Eth Estra)

NFQL(1 ea daily)

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

NFQL(1 ea daily)


34

Drug Name DrugTier

Requirements/Limits

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

NFQL(1 ea daily)

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

NFQL(1 ea daily)

MIRCETTE TABS (UseDesogestrel-EthinylEstradiol (Biphasic))

NFQL(1 ea daily)

MODICON TABS (UseNorethindrone & EthEstradiol)

NFQL(1 ea daily)

NECON 1/50-28 TABS F QL(1 ea daily)

NECON 10/11-28 TABS F QL(1 ea daily)

norethin acet & estrad-fetabs 75mg-20mcg-1mg F

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

FQL(1 ea daily)

norethindrone & ethestradiol tabs F QL(1 ea daily)

norethindrone acet & ethestra tabs F QL(1 ea daily)

norethindrone-eth estradiol(triphasic) tabs F QL(1 ea daily)

norgestimate-ethinylestradiol (triphasic) tabs F QL(1 ea daily)

norgestimate-ethinylestradiol (triphasic) tabs F

norgestimate-ethinylestradiol tabs F QL(1 ea daily)

norgestrel & ethinylestradiol tabs F QL(1 ea daily)

NORINYL 1+35 TABS (UseNorethindrone & EthEstradiol)

NFQL(1 ea daily)

NORINYL 1+50 TABS F QL(1 ea daily)

OGESTREL TABS F QL(1 ea daily)

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

NF

Drug Name DrugTier

Requirements/Limits

ORTHO TRI-CYCLENTABS (Use Norgestimate-Ethinyl Estradiol(Triphasic))

NF

QL(1 ea daily)

ORTHO-CEPT TABS (UseDesogestrel & EthinylEstradiol)

NFQL(1 ea daily)

ORTHO-CYCLEN TABS(Use Norgestimate-EthinylEstradiol)

NFQL(1 ea daily)

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

NFQL(1 ea daily)

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

NFQL(1 ea daily)

OVCON-35 TABS (UseNorethindrone & EthEstradiol)

NFQL(1 ea daily)

SEASONIQUE TABS (UseLevonorgestrel-EthinylEstradiol (91-Day))

NFQL(1 ea daily)

TRI-NORINYL 28 TABS(Use Norethindrone-EthEstradiol (Triphasic))

NFQL(1 ea daily)

YASMIN 28 TABS (UseDrospirenone-EthinylEstradiol)

NFQL(1 ea daily)

YAZ TABS (UseDrospirenone-EthinylEstradiol)

NFQL(1 ea daily)

Combination Contraceptives - Transdermal

XULANE PTWK F

Limit 3 patchespermonth;QL(0.11ea daily)

Combination Contraceptives - Vaginal

NUVARING RING F QL(1 ea per fillretail)

Emergency Contraceptives

ELLA TABS F QL(4 ea per365 days retail)

levonorgestrel (emergencyoc) tabs F QL(1 ea per 21

days retail)


35

Drug Name DrugTier

Requirements/Limits

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

NFQL(1 ea per 21days retail)

Progestin Contraceptives - IUDSKYLA IUD F

Progestin Contraceptives - ImplantsNEXPLANON IMPL F

Progestin Contraceptives - InjectableDEPO-PROVERACONTRACEPTIVE SUSP(Use MedroxyprogesteroneAcetate (Contraceptive))

NF

QL(1 ml per fillretail)

DEPO-PROVERACONTRACEPTIVE SUSY(Use MedroxyprogesteroneAcetate (Contraceptive))

NF

QL(1 ml per fillretail)

DEPO-SUBQ PROVERA104 SUSY F QL(1 ml per fill

retail)medroxyprogesteroneacetate (contraceptive)susp

FQL(1 ml per fillretail)

medroxyprogesteroneacetate (contraceptive)susy


Progestin Contraceptives - OralNOR-QD TABS (UseNorethindrone(Contraceptive))

NFQL(1 ea daily)

norethindrone(contraceptive) tabs F QL(1 ea daily)

ORTHO MICRONORTABS (Use Norethindrone(Contraceptive))

NFQL(1 ea daily)

CORTICOSTEROIDS - Steroid Hormone Drugs toTreat Systemic Swelling ConditionsGlucocorticosteroidsCORTEF TABS (UseHydrocortisone) NF

CORTISONE ACETATETABS F

dexamethasone elix F

Drug Name DrugTier

Requirements/Limits

DEXAMETHASONEINTENSOL CONC F

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

F

QL(5 ml daily)

DEXAMETHASONE SOLN F

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

F

DEXAMETHASONE TABS1 MG, 2 MG F

hydrocortisone tabs F

MEDROL DOSEPAK TBPK(Use Methylprednisolone) NF

MEDROL TABS (UseMethylprednisolone) NF

methylprednisolone tabs F

methylprednisolone tbpk F

MILLIPRED TABS F

PEDIAPRED SOLN (UsePrednisolone SodiumPhosphate)

NF

prednisolone sodiumphosphate soln or 15mg/5ml

FQL(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 syrp F

PREDNISONE INTENSOLCONC F

PREDNISONE SOLN F

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


36

Drug Name DrugTier

Requirements/Limits

PREDNISONE TABS 50MG F

PREDNISONE TBPK F

VERIPRED 20 SOLN (UsePrednisolone SodiumPhosphate)


Mineralocorticoidsfludrocortisone acetatetabs F

COUGH/COLD/ALLERGY - Drugs to TreatCough, Cold and Allergy SymptomsAntitussivesbenzonatate caps 100 mg F AL

benzonatate caps 200 mg F QL(1 ea daily);AL

DELSYM COUGHCHILDRENS SUER (UseDextromethorphanPolistirex)

NF

DELSYM SUER (UseDextromethorphanPolistirex)

NF

dextromethorphanpolistirex suer F

hydrocodone w/homatropine syrp F

TESSALON PERLESCAPS (Use Benzonatate) NF AL

Cough/Cold/Allergy Combinationsacetaminophen w/ dm liqd F

ADVIL COLD & SINUSTABS (UsePseudoephedrine-Ibuprofen)

NF

brompheniramine &phenyleph elix F QL(120 ml per

fill retail)brompheniramine &pseudoeph elix F QL(120 ml per

fill retail)brompheniramine &pseudoeph liqd F QL(120 ml per

fill retail)

BROTAPP DM LIQD F

Drug Name DrugTier

Requirements/Limits

cetirizine-pseudoephedrinetb12 F QL(2 ea daily)

CHERACOL PLUS LIQD(Use Dextromethorphan-Guaifenesin)

NF

CHERACOL-D COUGHLIQD (UseDextromethorphan-Guaifenesin)

NF

CLARITIN-D 12 HOURTB12 (Use Loratadine &Pseudoephedrine)

NFQL(2 ea daily)

CLARITIN-D 24 HOURTB24 (Use Loratadine &Pseudoephedrine)

NFQL(1 ea daily)

CLEAR COUGH PMMULTI-SYMPTOM LIQD(Use Dextromethorphan-Doxylamine-Acetaminophen)

NF

DAY TIME MULTI-SYMPTOM COLD/FLURELIEF CAPS (UseDextromethorphan-Phenylephrine-Acetaminophen)

NF

dextromethorphan-doxylamine-acetaminophenliqd

F

dextromethorphan-guaifenesin liqd F

dextromethorphan-guaifenesin soln F

dextromethorphan-guaifenesin syrp F

dextromethorphan-guaifenesin tabs F dextromethorphan-guaifenesin tb12 F

dextromethorphan-phenylephrine-acetaminophen caps

F

DIMETAPP COLD &ALLERGY ELIX (UseBrompheniramine &Phenyleph)

NF

QL(120 ml perfill retail)

ED BRON GP LIQD F


37

Drug Name DrugTier

Requirements/Limits

guaifenesin-codeine liqd F QL(240 ml perfill retail)

guaifenesin-codeine soln F QL(240 ml perfill retail)

guaifenesin-codeine syrp F QL(240 ml perfill retail)

LOHIST-D LIQD F

loratadine &pseudoephedrine tb12 F QL(2 ea daily)

loratadine &pseudoephedrine tb24 F QL(1 ea daily)

MUCINEX D MAXIMUMSTRENGTH TB12 (UsePseudoephedrine-Guaifenesin)

NF

MUCINEX D TB12 (UsePseudoephedrine-Guaifenesin)

NF

MUCINEX DM TB12 (UseDextromethorphan-Guaifenesin)

NF

phenylephrine-chlorphen-dm liqd F

phenylephrine-dm liqd F QL(240 ml perfill retail)

phenylephrine-dm soln F QL(240 ml perfill retail)

phenylephrine-guaifenesinliqd F

promethazine &phenylephrine syrp F QL(240 ml per

fill retail); ALpromethazine w/codeinesyrp F QL(240 ml per

fill retail); AL

promethazine-dm syrp F QL(240 ml perfill retail)

promethazine-phenylephrine-codeinesyrp

FQL(240 ml perfill retail); AL

PROMETHAZINE/PHENYLEPHRINE SYRP F QL(240 ml per

fill retail); ALpseudoephed-bromphen-dm elix F

pseudoephed-bromphen-dm syrp F

Drug Name DrugTier

Requirements/Limits

pseudoephedrine w/codeine-gg soln F QL(240 ml per

fill retail)pseudoephedrine-chlorphen-dm liqd F

pseudoephedrine-guaifenesin tb12 F

pseudoephedrine-ibuprofentabs F

RESCON-GG LIQD (UsePhenylephrine-Guaifenesin)

NF

ROBITUSSIN DM SYRP(Use Dextromethorphan-Guaifenesin)

NF

ROBITUSSIN PEAK COLDCOUGH+ CHESTCONGESTION DM MAXSTRENGTH LIQD (UseDextromethorphan-Guaifenesin)

NF

ROBITUSSIN PEAK COLDDM SYRP (UseDextromethorphan-Guaifenesin)

NF

TRIAMINIC COLD &COUGH DAY TIMECHILDRENS SOLN

F

TRIAMINIC COLD &COUGH DAY TIMECHILDRENS SYRP

F

ZYRTEC-DALLERGY/CONGESTIONTB12 (Use Cetirizine-Pseudoephedrine)

NF

QL(2 ea daily)

Expectorantsguaifenesin liqd F

guaifenesin soln F

guaifenesin syrp F

guaifenesin tb12 F MUCINEX MAXIMUMSTRENGTH TB12 (UseGuaifenesin)

NF

MUCINEX TB12 (UseGuaifenesin) NF


38

Drug Name DrugTier

Requirements/Limits

Misc. Respiratory Inhalantssodium chloride (inhalant)nebu F

Mucolyticsacetylcysteine soln F

DERMATOLOGICALS - Drugs to Treat SkinConditionsAcne ProductsACNE MEDICATION 10LOTN F

ACNE MEDICATION 5LOTN F

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

benzoyl peroxide crea F

benzoyl peroxide gel 10 % F RX/OTC

BENZOYL PEROXIDEGEL 2.5 % F

benzoyl peroxide gel 5 % F

benzoyl peroxide liqd F RX/OTC

CLEAN & CLEARADVANTAGE 3-IN-1EXFOLIATING CLEANSERLOTN

F

CLEOCIN-T GEL (UseClindamycin Phosphate(Topical))

NF

CLEOCIN-T LOTN (UseClindamycin Phosphate(Topical))


CLEOCIN-T SOLN (UseClindamycin Phosphate(Topical))

NF

clindamycin phosphate(topical) gel F

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

Drug Name DrugTier

Requirements/Limits

ERYGEL GEL (UseErythromycin (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 F PA; QL(2 eadaily); AL

KLARON LOTN (UseSulfacetamide Sodium(Acne))


RETIN-A CREA (UseTretinoin) NF QL(20 gm per

fill retail); ALRETIN-A GEL 0.01 % (UseTretinoin) NF QL(15 gm per

fill retail); ALRETIN-A GEL 0.025 %(Use Tretinoin) NF QL(20 gm per

fill retail); ALSODIUMSULFACETAMIDE/SULFUR LOTN


SODIUMSULFACETAMIDE/SULFUR SUSP


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

fill retail)sulfacetamide sodium(acne) susp F QL(120 ml per

fill retail)sulfacetamide sodium w/sulfur lotn F QL(60 gm per

fill retail)

tretinoin crea F QL(20 gm perfill retail); AL

tretinoin gel 0.01 % F QL(15 gm perfill retail); AL

tretinoin gel 0.025 % F QL(20 gm perfill retail); AL

Antibiotics - TopicalBACIGUENT OINT (UseBacitracin (Topical)) NF QL(30 gm per

fill retail)

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

bacitracin zinc oint F QL(30 gm perfill retail)

bacitracin-polymyxin b oint F


39

Drug Name DrugTier

Requirements/Limits

BACTROBAN CREA (UseMupirocin Calcium(Topical))


BACTROBAN OINT (UseMupirocin) NF QL(30 gm per

fill retail)

CENTANY OINT F QL(30 gm perfill retail)

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

fill retail)GENTAMICIN SULFATEOINT 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)

neomycin-bacitracin-polymyxin oint F QL(30 gm per

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

fill retail)NEOSPORIN ORIGINALOINT (Use Neomycin-Bacitracin-Polymyxin)


NEOSPORIN PLUS PAINRELIEF MAXIMUMSTRENGTH CREA (UseNeomycin-Polymyxin w/Pramoxine)

NF

QL(30 gm perfill retail)

POLYSPORIN OINT (UseBacitracin-Polymyxin B) NF

Antifungals - Topical

clotrimazole (topical) crea FQL(30 gm perfill retail);RX/OTC

clotrimazole (topical) soln FQL(30 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(30 gm perfill retail)

ketoconazole (topical) crea F

Limit 1package perclaim;QL(60gm per fillretail)

Drug Name DrugTier

Requirements/Limits

ketoconazole (topical)sham F QL(120 ml per

fill retail)LAMISIL AT CREA (UseTerbinafine HCl (Topical)) NF QL(30 gm per

fill retail)LAMISIL AT JOCK ITCHCREA (Use TerbinafineHCl (Topical))


LOTRIMIN AF CREA (UseClotrimazole (Topical)) NF

QL(30 gm perfill retail);RX/OTC

LOTRIMIN AF FOR HERCREA (Use Clotrimazole(Topical))

NFQL(30 gm perfill retail);RX/OTC

LOTRIMIN AF JOCK ITCHCREA (Use Clotrimazole(Topical))


LOTRISONE CREA (UseClotrimazole w/Betamethasone)


MICATIN CREA (UseMiconazole Nitrate(Topical))


miconazole nitrate (topical)crea F QL(45 ml per

fill retail)NIZORAL SHAM (UseKetoconazole (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(30 gm perfill retail)

nystatin-triamcinolone oint F QL(30 gm perfill retail)

terbinafine hcl (topical) crea F QL(30 gm perfill retail)

TINACTIN CREA (UseTolnaftate) NF QL(30 gm per

fill retail)TINACTIN JOCK ITCHCREA (Use Tolnaftate) NF QL(30 gm per

fill retail)

tolnaftate crea F QL(30 gm perfill retail)

Antihistamines-Topical


40

Drug Name DrugTier

Requirements/Limits

diphenhydramine hcl(topical) crea F

Antineoplastic or Premalignant Lesion Agents -

CARAC CREA F QL(30 gm perfill retail)

EFUDEX CREA (UseFluorouracil (Topical)) NF QL(40 gm per

fill retail)

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

fluorouracil (topical) soln F QL(10 ml perfill retail)

FLUOROURACIL CREA F QL(30 gm perfill retail)

Antipruritics - Topical

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

SARNA LOTN (UseCamphor & 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 (UseCalcipotriene) NF QL(60 gm per

fill retail)

tazarotene crea FPA; QL(60 gmper fill retail);AL

TAZORAC CREA 0.05 % FPA; QL(60 gmper fill retail);AL

TAZORAC CREA 0.1 %(Use Tazarotene) NF

PA; QL(60 gmper fill retail);AL

TAZORAC GEL FPA; QL(60 gmper fill retail);AL

Antiseborrheic ProductsOVACE PLUS WASH LIQD(Use SulfacetamideSodium)


OVACE WASH LIQD (UseSulfacetamide Sodium) NF QL(360 ml per

fill retail)

selenium sulfide lotn 1 % F QL(240 ml perfill retail)

Drug Name DrugTier

Requirements/Limits

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

selenium sulfide sham F QL(240 ml perfill retail)

SELSUN BLUE DAILYLOTN (Use SeleniumSulfide)


SELSUN BLUE LOTN (UseSelenium Sulfide) NF QL(240 ml per

fill retail)SELSUN BLUEMEDICATED LOTN (UseSelenium Sulfide)


SELSUN BLUEMOISTURIZING LOTN(Use Selenium Sulfide)


sulfacetamide sodium liqd F QL(360 ml perfill retail)

Antivirals - Topical

acyclovir topical oint FLimit 1 packageper month;QL(1gm daily)

ZOVIRAX CREA F QL(5 gm per fillretail)

ZOVIRAX OINT (UseAcyclovir Topical) NF

Limit 1 packageper month;QL(1gm daily)

Burn ProductsSILVADENE CREA (UseSilver Sulfadiazine) NF QL(50 gm per

fill retail)

silver sulfadiazine crea F QL(50 gm perfill retail)

Corticosteroids - Topical

APEXICON E CREA F QL(60 gm perfill retail)

betamethasonedipropionate augmentedcrea


betamethasone valeratecrea F QL(45 gm per

fill retail)betamethasone valeratelotn F QL(60 ml per

fill retail)betamethasone valerateoint F QL(45 gm per

fill retail)

clobetasol propionate crea F QL(45 gm perfill retail)


41

Drug Name DrugTier

Requirements/Limits

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(25 ml perfill retail)

CUTIVATE CREA (UseFluticasone Propionate) NF

Limit 1package permonth;QL(2 gmdaily)

DERMATOP CREA (UsePrednicarbate) NF QL(60 gm per

fill retail)DERMATOP OINT (UsePrednicarbate) NF QL(60 gm per

fill retail)

desoximetasone crea F QL(60 gm perfill retail)

DIFLORASONEDIACETATE CREA F QL(60 gm per

fill retail)DIFLORASONEDIACETATE OINT F QL(60 gm per

fill retail)DIPROLENE AF CREA(Use BetamethasoneDipropionate Augmented)


ELOCON CREA (UseMometasone Furoate) NF QL(45 gm per

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

fill retail)

EPIFOAM FOAM F

fluocinonide crea F QL(60 gm perfill retail)

fluocinonide emulsifiedbase crea F QL(60 gm per

fill retail)

fluocinonide gel F QL(60 gm perfill retail)

fluocinonide oint F QL(60 gm perfill retail)

fluocinonide soln F QL(60 ml perfill retail)

fluticasone propionate crea F

Limit 1package permonth;QL(2 gmdaily)

Drug Name DrugTier

Requirements/Limits

fluticasone propionate oint F QL(60 gm perfill retail)

hydrocortisone (topical)crea 1%, 1 % F


hydrocortisone (topical)crea 2.5 %, 0.5 % F QL(30 gm per

fill retail)

hydrocortisone (topical) lotn F QL(60 ml perfill retail)

hydrocortisone (topical) oint0.5 % F

hydrocortisone (topical) oint1 % F

Limit 1 packageper month;QL(2gm daily);RX/OTC

hydrocortisone (topical) oint2.5 % F

Limit 1 packageper month;QL(1gm daily)

hydrocortisone butyratesoln F QL(60 ml per

fill retail)hydrocortisone-aloe veracrea F QL(60 gm per

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

fill retail)

mometasone furoate crea F QL(45 gm perfill retail)

mometasone furoate oint F QL(45 gm perfill retail)

mometasone furoate soln F QL(60 ml perfill retail)

MONISTAT SOOTHINGCARE ITCH RELIEF CREA(Use Hydrocortisone(Topical))

NF


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 (UseClobetasol Propionate) NF QL(45 gm per

fill retail)TEMOVATE E CREA (UseClobetasol PropionateEmollient Base)


TEMOVATE GEL (UseClobetasol Propionate) NF QL(60 gm per

fill retail)


42

Drug Name DrugTier

Requirements/Limits

TEMOVATE OINT (UseClobetasol Propionate) NF QL(60 gm per

fill retail)TEMOVATE SOLN (UseClobetasol Propionate) NF QL(25 ml per

fill retail)TOPICORT CREA (UseDesoximetasone) NF QL(60 gm per

fill retail)triamcinolone acetonide(topical) crea 0.025 % F QL(454 gm per



fill retail)triamcinolone acetonide(topical) lotn F QL(60 ml per

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


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

fill retail)Diaper Rash Productsdiaper rash products oint F

Emollient/Keratolytic Agents

urea crea F QL(210 gm perfill retail)

urea lotn F QL(240 ml perfill retail)

EmollientsAQUAPHILIC OINT F AQUAPHOR ADVANCEDTHERAPY OINT F

AQUAPHOR OINT F

AVEENO ACTIVENATURALS SKIN RELIEFHEALING OINT

F

BOUDREAUXS BABYBUTT SMOOTH DRY SKINOINT

F

DAILY CONDITIONINGTREATMENT OINT F

emollient oint F

GOLD BOND ULTIMATEHEALING OINT F

Drug Name DrugTier

Requirements/Limits

LAC-HYDRIN CREA (UseLactic Acid (AmmoniumLactate))


LAC-HYDRIN LOTN (UseLactic Acid (AmmoniumLactate))

NF

Limit 1 packagepermonth;QL(13.34 ml daily);RX/OTC

LAC-HYDRIN TWELVELOTN (Use Lactic Acid(Ammonium Lactate))

NF


lactic acid (ammoniumlactate) crea F


lactic acid (ammoniumlactate) lotn F


LANAPHILIC OINT F

OINTMENT BASE OINT F

Immunomodulating Agents - TopicalALDARA CREA (UseImiquimod) NF QL(48 ea per

180 days retail)

imiquimod crea F QL(48 ea per180 days retail)

Immunosuppressive Agents - Topical

ELIDEL CREA F

PA; Limit 1package permonth;QL(1 gmdaily)

PROTOPIC OINT (UseTacrolimus (Topical)) NF


tacrolimus (topical) oint F


Keratolytic/Antimitotic AgentsCONDYLOX SOLN (UsePodofilox) NF QL(4 ml per fill

retail)


43

Drug Name DrugTier

Requirements/Limits

KERALYT GEL (UseSalicylic Acid) NF QL(40 gm per

fill retail)

podofilox soln F QL(4 ml per fillretail)

salicylic acid gel F QL(40 gm perfill retail)

Local Anesthetics - TopicalARTHRITIS PAINRELIEVING 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(42.5 gm perfill retail)

CAPZASIN-HP CREA (UseCapsaicin) NF QL(42.5 gm per

fill retail)

dibucaine oint F QL(30 gm perfill retail)

EMLA CREA (UseLidocaine-Prilocaine) NF QL(30 gm per

fill retail)

lidocaine crea F QL(30 gm perfill retail)

lidocaine hcl crea F QL(30 gm perfill retail)

lidocaine hcl gel FQL(30 ml perfill retail);RX/OTC

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

LMX 4 CREA (UseLidocaine) NF QL(30 gm per

fill retail)

NEUROMED7 CREA F QL(65 ml perfill retail)

PREDATOR CREA F QL(65 ml perfill retail)

RA ARTHRITIS PAINRELIEF CREA F QL(60 gm per

fill retail)

RA PAIN RELIEF CREA F QL(65 ml perfill retail)

XOLIDO XP CREA F QL(65 ml perfill retail)

ZOSTRIX ARTHRITISPAIN RELIEF CREA (UseCapsaicin)

NF

Drug Name DrugTier

Requirements/Limits

ZOSTRIX DIABETIC FOOTPAIN CREA (UseCapsaicin)


Misc. Topical4-N-1 CREA F

COOL BOTTOMS CREA F

DRYSOL SOLN F QL(60 ml perfill retail)

NEUTRAPHOR CREA F NEUTRAPHORUS REXCREA F

PROSHIELD PLUS SKINPROTECTANT CREA F

REMEDY NUTRASHIELDCREA F

zinc oxide (topical) oint F QL(60 gm perfill retail)

Rosacea AgentsMETROCREAM CREA(Use Metronidazole(Topical))


METROLOTION LOTN(Use Metronidazole(Topical))

NF

metronidazole (topical)crea F QL(45 gm per

fill retail)

metronidazole (topical) gel F QL(45 gm perfill retail)

metronidazole (topical) lotn F

Scabicides & PediculicidesELIMITE CREA (UsePermethrin) NF QL(60 gm per

fill retail)

EURAX CREA F QL(60 gm perfill retail)

EURAX LOTN F QL(60 gm perfill retail)

malathion lotn F QL(59 ml perfill retail)

NATROBA SUSP F QL(120 ml perfill retail); AL

NIX CREME RINSE LIQD(Use Permethrin) NF


44

Drug Name DrugTier

Requirements/Limits

OVIDE LOTN (UseMalathion) NF QL(59 ml per

fill retail)

permethrin crea F QL(60 gm perfill retail)

permethrin liqd F

permethrin lotn F QL(120 ml perfill retail)

pyrethrins-piperonylbutoxide liqd F QL(60 ml per

fill retail)pyrethrins-piperonylbutoxide sham 0.3%-0.33%-4%, 0.33%-4%

F

pyrethrins-piperonylbutoxide sham 0.33%-4% F QL(60 ml per

fill retail)pyrethrins-piperonylbutoxide-permethrin-nitremover kit

F

RID COMPLETE LICEELIMINATION KIT (UsePyrethrins-PiperonylButoxide-Permethrin-NitRemover)

NF

RID LIQD (Use Pyrethrins-Piperonyl Butoxide) NF QL(60 ml per

fill retail)

SPINOSAD SUSP F QL(120 ml perfill retail); AL

SunscreensANTHELIOS 60 MELT-INSUNSCREEN LOTN F AVEENO ACTIVENATURALSPROTECT+HYDRATE/SPF 30 LOTN

F

AVEENO BABYCONTINUOUSPROTECTIONSUNBLOCK SPF55 LOTN

F

AVEENO BABY NATURALPROTECTION SPF 50LOTN

F

AVEENO NATURALPROTECTIONSPF 50LOTN

F

Drug Name DrugTier

Requirements/Limits

AVEENO POSITIVELYAGELESSLIFTING &FIRMING MOISTURIZERSPF30 LOTN

F

AVEENO POSITIVELYAGELESSSUNBLOCKSPF70 LOTN

F

AVEENO POSITIVELYRADIANTDAILYMOISTURIZER SPF15LOTN

F

AVEENO POSITIVELYRADIANTDAILYMOISTURIZER SPF30LOTN

F

AVEENO POSITIVELYRADIANTTINTEDMOISTURIZER SPF30FAIR/LIGHT LOTN

F

AVEENO POSITIVELYRADIANTTINTEDMOISTURIZER SPF30MEDIUM LOTN

F

AVEENO PROTECT +HYDRATESPF 50 LOTN F

AVEENO PROTECT +HYDRATESPF 70 LOTN F AVEENO SMARTESSENTIALS DAILYNOURISHINGMOISTURIZER SPF30LOTN

F

AVEENO ULTRA-CALMING DAILYMOISTURIZER SPF15LOTN

F

BULL FROGSUPERBLOCK SPF50LOTN

F

BULL FROG ULTIMATESHEERPROTECTIONFACE SUNBLOCK SPF 30LOTN

F

BULL FROG ULTIMATESHEERPROTECTIONSUNBLOCK SPF 30 LOTN

F


45

Drug Name DrugTier

Requirements/Limits

BULL FROG WATERARMOR SPORT FACESPF 30 LOTN

F

CERAVE SUNSCREENFACE/SPF50 LOTN F

CERAVESUNSCREEN/BODYLOTN

F

CERAVESUNSCREEN/FACE LOTN F

CHANTAL SUN SCREENSPF 30 LOTN F

COTZ LOTN F DIABETIDERMSUNSCREEN SPF15LOTN

F

ELTA BLOCK SPF 32LOTN F

FACE COTZ LOTN F

HUGGIES LITTLESWIMMERS SPF50 LOTN F

KERI AGE DEFY &PROTECT LOTN F LUBRIDERM DAILYMOISTURE/SUNSCREENSPF 15 LOTN

F

NEUTROGENA AGESHIELD FACESUNBLOCK WITHHELIOPLEX SPF110LOTN

F

NEUTROGENA AGESHIELD FACESUNBLOCK WITHHELIOPLEX SPF70 LOTN

F

NEUTROGENA COOLDRYSPORTWITH HELIOPLEXSPF 30 LOTN

F

NEUTROGENA HEALTHYDEFENSE DAILYMOISTURIZERPURESCREEN LOTN

F

NEUTROGENA MEN SPF20 LOTN F

Drug Name DrugTier

Requirements/Limits

NEUTROGENAMOISTURESPF15UNTINTED LOTN

F

NEUTROGENA SPORTFACE SUNBLOCK WITHHELIOPLEX SPF70 LOTN

F

NEUTROGENA ULTRASHEER DRY-TOUCH SPF45 LOTN

F

NEUTROGENA ULTRASHEER DRY-TOUCHWITH HELIOPLEX SPF100 LOTN

F

NEUTROGENA ULTRASHEER DRY-TOUCHWITH HELIOPLEX SPF 55LOTN

F

NEUTROGENA ULTRASHEER DRY-TOUCHWITH HELIOPLEX SPF 70LOTN

F

NIVEA HAND THERAPYLOTN F NIVEA VISAGE UV CAREDAILY FACIAL LOTN F

OIL OF BEAUTYCOMPLETE MOISTURESPF 15 LOTN

F

PRE SUN KIDS LOTN F

PURE & FREE BABYSUNSCREEN BROADSPECTRUM SPF 60+LOTN

F

RA RX SUNCAREADVANCEDPROTECTION SPF50LOTN

F

ROC MULTI CORREXION5 IN1 DAILYMOISTURIZER SPF 30LOTN

F

ROC MULTI CORREXIONLIFTANTI-GRAVITY DAYMOISTURIZER SPF30LOTN

F


46

Drug Name DrugTier

Requirements/Limits

ROC RETINOLCORREXION SPF30LOTN

F

SHADE SUNBLOCK SPF45 LOTN (UseSunscreens)

NF

SHADE UVAGUARD SPF15 LOTN (UseSunscreens)

NF

SOLBAR AVO LOTN F

SOLBAR PF SPF15 LOTN F

sunscreens lotn F TOTAL BLOCK SPF 60COVERUP LOTN F

TOTAL BLOCK SPF 65CLEAR LOTN F

WATER BABIES SPF 30LOTN (Use Sunscreens) NF

Tar Productscoal tar extract sham F

DHS TAR GEL SHAM (UseCoal Tar Extract) NF

DHS TAR SHAM (Use CoalTar Extract) NF

NEUTROGENA T/GELSHAM (Use Coal TarExtract)

NF

NEUTROGENA T/GELSTUBBORN ITCHCONTROL SHAM (UseCoal Tar Extract)

NF

DIAGNOSTIC PRODUCTS

Diagnostic TestsCHEK-STIX COMBO PAKURINALYSIS CONTROLSTRP

F

CHEK-STIX CONTROLSTRP F

CHEMSTRIP-K STRP F

KETOCARE STRP F

Drug Name DrugTier

Requirements/Limits

KETONE TEST STRIPSSTRP F

KETOSTIX STRP F

NOVA MAX PLUSKETONE TESTSTRIPSSTRP

FQL(1 ea daily)

PRECISION XTRA STRP F QL(1 ea daily)

PTS PANELS KETONETEST STRP F QL(1 ea daily)

RELION KETONE STRP F

RELION KETONE TESTSTRIPS STRP F

TRUE METRIX BLOODGLUCOSETEST STRIPSSTRP

FQL(5 ea daily);RX/OTC

TRUE METRIX SELFMONITORING BLOODGLUCOSE STRIPS STRP


TRUETEST BLOODGLUCOSE TEST STRIPSSTRP


TRUETEST BLOODGLUCOSE TEST STRP F QL(5 ea daily);

RX/OTC

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

TRUETRACK BLOODGLUCOSE TEST STRP F QL(5 ea daily);

RX/OTC

TRUETRACK TEST STRP F QL(5 ea daily);RX/OTC

DIETARY PRODUCTS/DIETARY MANAGEMENTPRODUCTSDietary Management ProductsDEPLIN 15 CAPS F

DEPLIN 7.5 CAPS F

ELFOLATE TABS F

L-METHYLFOLATECALCIUM TABS F

L-METHYLFOLATEFORMULA 15 CAPS F

L-METHYLFOLATEFORMULA 7.5 CAPS F


47

Drug Name DrugTier

Requirements/Limits

L-METHYLFOLATEFORTE CAPS F

L-METHYLFOLATE TABS F

LEVOMEFOLATECALCIUM/ALGALPOWDER CAPS

F

DIGESTIVE AIDS - Drugs to Treat Low DigestiveEnzymesDigestive EnzymesCREON CPEP F

PANCREAZE CPEP F

PANCRELIPASE CPEP F

ZENPEP CPEP F

DIURETICS - Drugs to Treat Heart, CirculationConditions and Blood PressureCarbonic Anhydrase Inhibitorsacetazolamide cp12 F

acetazolamide tabs F DIAMOX CP12 (UseAcetazolamide) NF

methazolamide tabs F

NEPTAZANE TABS (UseMethazolamide) NF

Diuretic CombinationsALDACTAZIDE TABS (UseSpironolactone &Hydrochlorothiazide)

NF

amiloride &hydrochlorothiazide tabs F QL(1 ea daily)

DYAZIDE CAPS (UseTriamterene &Hydrochlorothiazide)

NFQL(1 ea daily)

MAXZIDE TABS (UseTriamterene &Hydrochlorothiazide)

NFQL(1 ea daily)

MAXZIDE-25 TABS (UseTriamterene &Hydrochlorothiazide)

NFQL(1 ea daily)

Drug Name DrugTier

Requirements/Limits

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 Diureticsbumetanide tabs F

BUMEX TABS (UseBumetanide) NF

DEMADEX TABS (UseTorsemide) NF QL(1 ea daily)

furosemide soln ij 10 mg/ml F

furosemide soln or 10mg/ml F

FUROSEMIDE SOLN OR 8MG/ML F

furosemide tabs F

LASIX TABS (UseFurosemide) NF

torsemide tabs F QL(1 ea daily)

Potassium Sparing DiureticsALDACTONE TABS (UseSpironolactone) NF

amiloride hcl tabs F QL(4 ea daily)

spironolactone tabs F

Thiazides and Thiazide-Like DiureticsCHLOROTHIAZIDE TABS250 MG F QL(2 ea daily)

chlorothiazide tabs 500 mg F QL(4 ea daily)

chlorthalidone tabs F

hydrochlorothiazide caps F

hydrochlorothiazide tabs F

indapamide tabs F


48

Drug Name DrugTier

Requirements/Limits

metolazone tabs F

MICROZIDE CAPS (UseHydrochlorothiazide) NF

ENDOCRINE AND METABOLIC AGENTS -MISC. - Drugs to Treat Bone Disease andRegulate HormonesBone Density Regulators

ACTONEL TABS 35 MG(Use Risedronate Sodium) NF

PA; Limit 4 permonth;QL(0.134 ea daily)

ACTONEL TABS 5 MG, 30MG (Use RisedronateSodium)

NFPA; QL(1 eadaily)

ALENDRONATE SODIUMSOLN F PA; QL(10.8 ml

daily)alendronate sodium tabs10 mg, 5 mg F PA; QL(1 ea

daily)

alendronate sodium tabs35 mg, 70 mg F


ALENDRONATE SODIUMTABS 40 MG F PA; QL(1 ea

daily)ATELVIA TBEC (UseRisedronate Sodium) NF PA; QL(0.15 ea

daily)

calcitonin (salmon) soln F QL(0.143 mldaily)

FORTICAL SOLN F QL(0.143 mldaily)

FOSAMAX TABS (UseAlendronate Sodium) NF


MIACALCIN SOLN IJ 200UNIT/ML F

Limit 1package permonth;QL(0.067 ml daily,2 mlper fill retail)

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

NFQL(0.143 mldaily)

risedronate sodium tabs 35mg F


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

daily)

risedronate sodium tbec F PA; QL(0.15 eadaily)

Drug Name DrugTier

Requirements/Limits

Growth HormonesNORDITROPIN FLEXPROSOLN F PA

NORDITROPINNORDIFLEX PEN SOLN F PA

SAIZEN CLICK.EASYSOLR F PA

SAIZEN SOLR F PA

SAIZENPREPRECONSTITUTIONKITSOLR

FPA

SEROSTIM SOLR F PA

ZORBTIVE SOLR F PA

Hormone Receptor ModulatorsEVISTA TABS (UseRaloxifene HCl) NF QL(1 ea daily)

raloxifene hcl tabs F QL(1 ea daily)

LHRH/GnRH Agonist Analog PituitarySYNAREL SOLN F PA

Metabolic Modifierscalcitriol caps F

CARNITOR SF SOLN (UseLevocarnitine (MetabolicModifiers))

NFQL(30 ml daily)

CARNITOR SOLN (UseLevocarnitine (MetabolicModifiers))

NFQL(30 ml daily)

CARNITOR TABS (UseLevocarnitine (MetabolicModifiers))

NFQL(3 ea daily);RX/OTC

FABRAZYME SOLR F PA

levocarnitine (metabolicmodifiers) soln F QL(30 ml daily)

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

RX/OTCROCALTROL CAPS (UseCalcitriol) NF

Posterior Pituitary Hormones


49

Drug Name DrugTier

Requirements/Limits

DDAVP SOLN IJ 4MCG/ML (UseDesmopressin Acetate)

NFPA

DDAVP SOLN NA 0.01 %(Use DesmopressinAcetate Refrigerated)

NFQL(5 ml per fillretail)

DDAVP SOLN NA 0.01 %(Use DesmopressinAcetate Spray)

NFPA; QL(5 mlper fill retail)

DDAVP TABS (UseDesmopressin Acetate) NF QL(3 ea daily)

desmopressin acetaterefrigerated soln F QL(5 ml per fill

retail)

desmopressin acetate soln F PA

desmopressin acetatespray refrigerated soln F QL(5 ml per fill

retail)desmopressin acetatespray soln F PA; QL(5 ml

per fill retail)

desmopressin acetate tabs F QL(3 ea daily)

ESTROGENS - Hormone Replacement/ModifyingDrugsEstrogen CombinationsACTIVELLA TABS (UseEstradiol & NorethindroneAcetate)

NFQL(1 ea daily)

COMBIPATCH PTTW F


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

estradiol & norethindroneacetate tabs F QL(1 ea daily)

PREMPHASE TABS F QL(1 ea daily)

PREMPRO TABS F QL(1 ea daily)

Estrogens

ALORA PTTW F


Drug Name DrugTier

Requirements/Limits

CLIMARA PTWK (UseEstradiol) NF

Limit 4 patchespermonth;QL(0.143 ea daily)

ESTRACE TABS (UseEstradiol) NF

estradiol pttw 0.0375mg/24hr F QL(0.29 ea

daily)estradiol pttw 0.05mg/24hr, 0.075 mg/24hr,0.025 mg/24hr, 0.1mg/24hr

F


estradiol ptwk F

Limit 4 patchespermonth;QL(0.143 ea daily)

estradiol tabs F

estropipate tabs 0.75 mg,1.5 mg F QL(1 ea daily)

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

ESTROPIPATE TABS 3MG F QL(2 ea daily)

MINIVELLE PTTW 0.0375MG/24HR F QL(0.29 ea

daily)MINIVELLE PTTW 0.05MG/24HR, 0.1 MG/24HR,0.025 MG/24HR, 0.075MG/24HR

F


PREMARIN TABS F QL(1 ea daily)

VIVELLE-DOT PTTW0.025 MG/24HR, 0.1MG/24HR, 0.075MG/24HR, 0.05 MG/24HR(Use Estradiol)

NF


VIVELLE-DOT PTTW0.0375 MG/24HR (UseEstradiol)

NFQL(0.29 eadaily)

FLUOROQUINOLONES - Drugs to Treat BacterialInfectionsFluoroquinolonesCIPRO TABS (UseCiprofloxacin HCl) NF

CIPROFLOXACIN HCLTABS 100 MG F QL(6 ea per fill

retail)


50

Drug Name DrugTier

Requirements/Limits

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

LEVAQUIN TABS (UseLevofloxacin) NF

QL(1 eadaily,14 ea perfill retail)

levofloxacin tabs FQL(1 eadaily,14 ea perfill retail)

OFLOXACIN TABS 300MG F QL(56 ea per

fill retail)

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

GASTROINTESTINAL AGENTS - MISC. -Miscellaneous Gastrointestinal DrugsAntiflatulentsGAS-X CHEW (UseSimethicone) NF

MYLICON INFANTS GASRELIEF SUSP (UseSimethicone)


MYLICON SUSP (UseSimethicone) NF QL(30 ml per

fill retail)

simethicone chew F

simethicone susp F QL(30 ml perfill retail)

Bile Acid Synthesis Disorder AgentsCHOLBAM CAPS F PA

Gallstone Solubilizing AgentsACTIGALL CAPS (UseUrsodiol) NF QL(3 ea daily)

URSO 250 TABS (UseUrsodiol) NF QL(7 ea daily)

ursodiol caps F QL(3 ea daily)

ursodiol tabs F QL(7 ea daily)

Gastrointestinal Stimulantsmetoclopramide hcl soln F

metoclopramide hcl tabs F REGLAN TABS (UseMetoclopramide HCl) NF

Drug Name DrugTier

Requirements/Limits

Inflammatory Bowel Agents

ASACOL HD TBEC F ST; QL(3 eadaily)

AZULFIDINE EN-TABSTBEC (Use Sulfasalazine) NF

AZULFIDINE TABS (UseSulfasalazine) NF

balsalazide disodium caps F QL(9 ea daily)

COLAZAL CAPS (UseBalsalazide Disodium) NF QL(9 ea daily)

DELZICOL CPDR F PA; QL(6 eadaily)

MESALAMINE DR TBEC F ST; QL(3 eadaily)

mesalamine enem F QL(60 ml daily)

SFROWASA ENEM F

sulfasalazine tabs F

sulfasalazine tbec F

Intestinal Acidifierslactulose (encephalopathy)soln F

Phosphate Binder Agentscalcium acetate (phosphatebinder) caps F

PHOSLO CAPS (UseCalcium Acetate(Phosphate Binder))

NF

GENITOURINARY AGENTS - MISCELLANEOUS- Miscellaneous Drugs to Treat ReproductiveOrgans and Urinary SystemAlkalinizerspotassium citrate(alkalinizer) tbcr F

potassium citrate-citric acidpack F

SHOHLS SOLUTIONMODIFIED SOLN (UseSodium Citrate & CitricAcid)

NF



51

Drug Name DrugTier

Requirements/Limits

sodium citrate & citric acidsoln F

Limit 1package permonth;QL(16.67 ml daily);RX/OTC

UROCIT-K 10 TBCR (UsePotassium Citrate(Alkalinizer))

NF

UROCIT-K 5 TBCR (UsePotassium Citrate(Alkalinizer))

NF

Genitourinary Irrigantssodium chloride (guirrigant) soln F

Interstitial Cystitis AgentsELMIRON CAPS F QL(3 ea daily)

Prostatic Hypertrophy Agentsfinasteride tabs F QL(1 ea daily)

FLOMAX CAPS (UseTamsulosin HCl) NF QL(2 ea daily)

PROSCAR TABS (UseFinasteride) NF QL(1 ea daily)

tamsulosin hcl caps F QL(2 ea daily)

Urinary Analgesicsphenazopyridine hcl tabs F PYRIDIUM TABS (UsePhenazopyridine HCl) NF

GOUT AGENTS - Drugs to Treat Gout

Gout Agent Combinationscolchicine w/ probenecidtabs F

Gout Agentsallopurinol tabs F

COLCHICINE TABS FPA; Limit 6 perclaim;QL(6 eaper fill retail)

COLCRYS TABS FPA; Limit 6 perclaim;QL(6 eaper fill retail)

Drug Name DrugTier

Requirements/Limits

ZYLOPRIM TABS (UseAllopurinol) NF

Uricosuricsprobenecid tabs F

HEMATOLOGICAL AGENTS - MISC. - Drugs toTreat Blood DisordersAntihemophilic ProductsADVATE SOLR F

ADYNOVATE SOLR 2000UNIT, 500 UNIT, 250 UNIT,1000 UNIT

F

ALPHANATE/VONWILLEBRANDFACTORCOMPLEX/HUMAN SOLR

F

ALPHANINE SD SOLR F

ALPROLIX SOLR 2000UNIT, 250 UNIT, 3000UNIT, 500 UNIT, 1000UNIT

F

BEBULIN SOLR F

BENEFIX KIT F

CORIFACT KIT F

ELOCTATE SOLR F

FEIBA NF SOLR F

FEIBA SOLR F

HELIXATE FS KIT F

HEMOFIL M SOLR F

HUMATE-P SOLR F

IDELVION SOLR F

IXINITY SOLR F

KOATE SOLR F

KOATE-DVI SOLR F


52

Drug Name DrugTier

Requirements/Limits

KOGENATE FS BIO-SETKIT F

KOGENATE FS KIT F

KOVALTRY SOLR F

MONOCLATE-P KIT F

MONONINE SOLR F

NOVOEIGHT SOLR F

NOVOSEVEN RT SOLR F

OBIZUR SOLR F

PROFILNINE SD SOLR F

PROFILNINE SOLR F

RECOMBINATE SOLR F

RIASTAP SOLR F

RIXUBIS SOLR F

TRETTEN SOLR F

WILATE KIT F

WILATE SOLR F

XYNTHA KIT F

XYNTHA SOLOFUSE KIT F

Hematorheologic Agentspentoxifylline tbcr F

Platelet Aggregation InhibitorsAGRYLIN CAPS (UseAnagrelide HCl) NF

anagrelide hcl caps F

BRILINTA TABS F QL(2 ea daily)

cilostazol tabs F QL(2 ea daily)

Drug Name DrugTier

Requirements/Limits

clopidogrel bisulfate tabs F QL(1 ea daily)

dipyridamole tabs F

EFFIENT TABS F QL(1 ea daily)

PERSANTINE TABS (UseDipyridamole) NF

PLAVIX TABS (UseClopidogrel Bisulfate) NF QL(1 ea daily)

PLETAL TABS (UseCilostazol) NF QL(2 ea daily)

HEMATOPOIETIC AGENTS - Drugs to TreatBlood DisordersAgents for Gaucher DiseaseCERDELGA CAPS F PA

CEREZYME SOLR F PA

VPRIV SOLR F PA

ZAVESCA CAPS F PA

Agents for Sickle Cell AnemiaDROXIA CAPS F

Cobalaminscyanocobalamin soln F

Folic Acid/Folatesfolic acid tabs 1 mg F RX/OTC

folic acid tabs 800 mcg,400 mcg F QL(1 ea daily)

Hematopoietic Growth FactorsARANESP ALBUMINFREE SOLN F PA

ARANESP ALBUMINFREE SOSY F PA

EPOGEN SOLN F PA

MIRCERA SOSY 100MCG/0.3ML, 75MCG/0.3ML, 50MCG/0.3ML, 200MCG/0.3ML

F

PA


53

Drug Name DrugTier

Requirements/Limits

NEUMEGA SOLR F PA

NPLATE SOLR F PA

PROCRIT SOLN 40000UNIT/ML, 2000 UNIT/ML,10000 UNIT/ML, 3000UNIT/ML, 4000 UNIT/ML,20000 UNIT/ML

F

PA

PROMACTA TABS F PA

ZARXIO SOSY F PA

Hematopoietic Mixturesferrous fumarate-fa-bcomplex-c-zn-mg-mn-cutabs

FQL(1 ea daily)

Iron

FER-IN-SOL SOLN (UseFerrous Sulfate) NF

100 / 30days;QL(3.4 mldaily); AL

FERGON TABS (UseFerrous Gluconate) NF

FERRETTS TABS F QL(2 ea daily)

ferrous fumarate tabs F

ferrous gluconate tabs 27mg, 240 mg F

FERROUS GLUCONATETABS 324 MG F AL

ferrous sulfate dried tbcr F

ferrous sulfate elix F QL(16 mldaily); AL

FERROUS SULFATE LIQD F

ferrous sulfate soln F100 / 30days;QL(3.4 mldaily); AL

ferrous sulfate tabs F AL

FERROUS SULFATETBEC 324 MG F AL

ferrous sulfate tbec 325 mg F AL

Drug Name DrugTier

Requirements/Limits

HEMOCYTE TABS (UseFerrous Fumarate) NF

IRON CHEWS PEDIATRICCHEW F

polysaccharide ironcomplex caps F QL(1 ea daily)

Stem Cell MobilizersMOZOBIL SOLN F PA

HEMOSTATICS - Drugs to Stop Bleeding/TreatBlood DisordersHemostatics - Systemic

AMICAR TABS F QL(24 ea perfill retail)

aminocaproic acid syrp F QL(60 ml perfill retail)

aminocaproic acid tabs F QL(24 ea perfill retail)

LYSTEDA TABS (UseTranexamic Acid) NF QL(30 ea per 5

days retail); AL

tranexamic acid tabs F QL(30 ea per 5days retail); AL

HYPNOTICS/SEDATIVES/SLEEP DISORDERAGENTSAntihistamine Hypnoticsdiphenhydramine hcl(sleep) caps F

diphenhydramine hcl(sleep) liqd F

diphenhydramine hcl(sleep) tabs 25 mg F QL(1 ea daily)

diphenhydramine hcl(sleep) tabs 50 mg F

doxylamine succinate(sleep) tabs F

NYTOL MAXIMUMSTRENGTH TABS (UseDiphenhydramine HCl(Sleep))

NF

UNISOM SLEEPGELSCAPS (UseDiphenhydramine HCl(Sleep))

NF


54

Drug Name DrugTier

Requirements/Limits

UNISOM TABS (UseDoxylamine Succinate(Sleep))

NF

ZZZQUIL CAPS (UseDiphenhydramine HCl(Sleep))

NF

ZZZQUIL LIQD (UseDiphenhydramine HCl(Sleep))

NF

Barbiturate HypnoticsAMYTAL SODIUM SOLR F

BUTISOL SODIUM TABS F

phenobarbital elix F PHENOBARBITALSODIUM SOLN F

phenobarbital soln F

PHENOBARBITAL TABS15 MG, 60 MG, 100 MG,30 MG

F

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

F

SECONAL CAPS F

SECONAL SODIUM CAPS F

Hypnotics - Tricyclic Agents

SILENOR TABS FST; Try 2preferredhypnotics first

Non-Barbiturate HypnoticsAMBIEN TABS (UseZolpidem Tartrate) NF QL(1 ea daily)

estazolam tabs F

eszopiclone tabs FST; Try 2preferredhypnotics first

FLURAZEPAM HCL CAPS F QL(1 ea daily)

HALCION TABS (UseTriazolam) NF QL(1 ea daily)

Drug Name DrugTier

Requirements/Limits

LUNESTA TABS (UseEszopiclone) NF

ST; Try 2preferredhypnotics first

midazolam hcl soln F

midazolam hcl syrp F

RESTORIL CAPS 15 MG(Use Temazepam) NF QL(1 ea daily);

ALRESTORIL CAPS 30 MG(Use Temazepam) NF QL(2 ea daily);

ALRESTORIL CAPS 7.5 MG,22.5 MG (UseTemazepam)

NFST; Try 2preferredhypnotics first

SONATA CAPS (UseZaleplon) NF QL(1 ea daily);

AL

temazepam caps 15 mg F QL(1 ea daily);AL

temazepam caps 30 mg F QL(2 ea daily);AL

temazepam caps 7.5 mg,22.5 mg F

ST; Try 2preferredhypnotics first

TRIAZOLAM TABS 0.125MG F QL(1 ea daily)

triazolam tabs 0.25 mg F QL(1 ea daily)

zaleplon caps F QL(1 ea daily);AL

zolpidem tartrate tabs F QL(1 ea daily)

LAXATIVES - Bowel Treatment Drugs

Bulk Laxativescalcium polycarbophil tabs F QL(10 ea daily)

EVAC POWD (UsePsyllium) NF

FIBERCON TABS (UseCalcium Polycarbophil) NF QL(10 ea daily)

KONSYL PACK F

KONSYL POWD (UsePsyllium) NF

METAMUCIL CAPS (UsePsyllium) NF


55

Drug Name DrugTier

Requirements/Limits

METAMUCIL ORIGINALTEXTURE POWD (UsePsyllium)

NF

METAMUCIL POWD (UsePsyllium) NF

psyllium caps F

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

F

Laxative CombinationsCOLYTE-FLAVOR PACKSSOLR (Use PEG 3350-KCl-Sod Bicarb-SodChloride-Sod Sulfate)

NF


GOLYTELY SOLR (UsePEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod Sulfate)


NULYTELY/FLAVORPACKS SOLR (Use PEG3350-Potassium Chloride-Sod Bicarbonate-SodChloride)

NF


peg 3350-kcl-sod bicarb-sod chloride-sod sulfatesolr


peg 3350-potassiumchloride-sod bicarbonate-sod chloride solr


sennosides-docusatesodium tabs F QL(4 ea daily)

SENOKOT S TABS (UseSennosides-DocusateSodium)

NFQL(4 ea daily)

Laxatives - Miscellaneousglycerin (laxative) supp 2.1gm, 2 gm, 1.2 gm F

GLYCERIN ADULT SUPP(Use Glycerin (Laxative)) NF

lactulose soln F MIRALAX PACK (UsePolyethylene Glycol 3350) NF RX/OTC

MIRALAX POWD (UsePolyethylene Glycol 3350) NF QL(34 gm

daily); RX/OTC

PEDIA-LAX SUPP 2.8 GM F

Drug Name DrugTier

Requirements/Limits

polyethylene glycol 3350pack F RX/OTC

polyethylene glycol 3350powd F QL(34 gm

daily); RX/OTC

SORBITOL SOLN F

Saline LaxativesFLEET ENEMA ENEM(Use Sodium Phosphates) NF

FLEET ENEMA SIX PACKENEM (Use SodiumPhosphates)

NF

FLEET PEDIATRIC ENEM(Use Sodium Phosphates) NF

magnesium citrate soln F

magnesium hydroxide susp F QL(33 ml daily)

MILK OF MAGNESIACONCENTRATE SUSP F

sodium phosphates enem F

Stimulant Laxatives

bisacodyl supp F QL(12 ea perfill retail)

bisacodyl tbec F QL(1 ea daily)

DULCOLAX SUPP (UseBisacodyl) NF QL(12 ea per

fill retail)DULCOLAX TBEC (UseBisacodyl) NF QL(1 ea daily)

EX-LAX TABS (UseSennosides) NF

SENNA SYRP F

sennosides liqd F

sennosides syrp F

sennosides tabs F

SENOKOT TABS (UseSennosides) NF

SENOKOT XTRA TABS(Use Sennosides) NF

Surfactant Laxatives


56

Drug Name DrugTier

Requirements/Limits

COLACE CAPS (UseDocusate Sodium) NF QL(3 ea daily)

docusate calcium caps F

docusate sodium caps 250mg, 100 mg F QL(3 ea daily)

docusate sodium liqd F

docusate sodium syrp F

docusate sodium tabs F

MACROLIDES - Drugs to Treat BacterialInfectionsAzithromycin

AZITHROMYCIN PACK F QL(2 ea per fillretail)

azithromycin susr 100mg/5ml F

Limit 1package perclaim;QL(15 mlper fill retail)

azithromycin susr 200mg/5ml F


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

azithromycin tabs 500 mg F QL(4 ea daily)

azithromycin tabs 600 mg FLimit 8 per 28days;QL(0.286ea daily)

ZITHROMAX PACK F QL(2 ea per fillretail)

ZITHROMAX SUSR 100MG/5ML (UseAzithromycin)

NF


ZITHROMAX SUSR 200MG/5ML (UseAzithromycin)

NF


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

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

Drug Name DrugTier

Requirements/Limits

ZITHROMAX TABS 600MG (Use Azithromycin) NF

Limit 8 per 28days;QL(0.286ea daily)

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

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

retail)ClarithromycinBIAXIN SUSR (UseClarithromycin) NF

BIAXIN TABS (UseClarithromycin) NF QL(28 ea per

fill retail)

clarithromycin susr 125mg/5ml F


clarithromycin susr 250mg/5ml F

clarithromycin tabs F QL(28 ea perfill retail)

clarithromycin tb24 F QL(14 ea perfill retail)

ErythromycinsE.E.S. 400 TABS F

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

NF

ERY-TAB TBEC F

ERYPED 200 SUSR (UseErythromycinEthylsuccinate)

NF

ERYPED 400 SUSR F

ERYTHROCIN STEARATETABS F

erythromycin base cpep F

ERYTHROMYCIN BASETABS F

erythromycinethylsuccinate susr F

ERYTHROMYCINETHYLSUCCINATE TABS F


57

Drug Name DrugTier

Requirements/Limits

PCE TBEC F

MEDICAL DEVICES AND SUPPLIES

Bandages-Dressings-TapeALLEVYN PLUS CAVITYPADS F RX/OTC

ALLEVYN THIN PADS F RX/OTC

AMD FOAM DRESSING4"X4" PADS F RX/OTC

AMD FOAMDRESSING/TOPSHEET4"X4" PADS

FRX/OTC

BAND-AID GAUZE PADSLARGE4" X 4" PADS F RX/OTC

BAND-AID GAUZE PADSMEDIUM 3" X 3" PADS F BAND-AID GAUZE PADSSMALL2" X 2" PADS F RX/OTC

BAND-AID MIRASORBGAUZE SPONGESLARGE 4" X 4" PADS

FRX/OTC

BIATAIN ADHESIVEFOAM DRESSING 4"X4"PADS

FRX/OTC

BIATAIN FOAMDRESSING 4"X4" PADS F RX/OTC

BIOGUARD GAUZESPONGE 2"X2" 8 PLYPADS

FRX/OTC

BIOGUARD GAUZESPONGES 4"X4" 12 PLYPADS

FRX/OTC

BORDERED GAUZEPADS F RX/OTC

CARRASMART FOAMPADS F RX/OTC

CARRASMART PADS F RX/OTC

COPA ISLANDBORDERED FOAMDRESSING 4"X4" PADS

FRX/OTC

COPA PLUSHYDROPHILIC FOAMDRESSING 4"X4" PADS

FRX/OTC

Drug Name DrugTier

Requirements/Limits

COVRSITE COVERDRESSING PADS F RX/OTC

COVRSITE PLUSCOMPOSITE DRESSINGPADS

FRX/OTC

CUREX ALL-PURPOSESPONGES 4"X4" 4 PLYPADS

FRX/OTC

CURITY ALL PURPOSESPONGES 2"X2" 4PLYPADS

FRX/OTC

CURITY ALL PURPOSESPONGES 2"X2" PADS F RX/OTC


F

CURITY ALL PURPOSESPONGES 4 PLY PADS F RX/OTC


FRX/OTC

CURITY ALL PURPOSESPONGES 4"X4"4PLY/SOFT POUCH PADS

FRX/OTC

CURITY ALL PURPOSESPONGES 4"X4" PADS F RX/OTC

CURITY AMDANTIMICROBIALGAUZESPONGES 2"X2" 8 PLYPADS

F

RX/OTC

CURITY AMDANTIMICROBIALGAUZESPONGES 4"X4" 12 PLYPADS

F

RX/OTC

CURITY COVER SPONGE4"X4" PADS F RX/OTC

CURITY COVERSPONGES 3"X3" PADS F

CURITY COVERSPONGES 4"X4" PADS F RX/OTC

CURITY DRESSINGSPONGES 4"X4" 6 PLYPADS

FRX/OTC

CURITY GAUZE PADS2"X2" 12 PLY PADS F RX/OTC

CURITY GAUZE PADS2"X2" PADS F RX/OTC


58

Drug Name DrugTier

Requirements/Limits

CURITY GAUZE PADS3"X3" PADS F

CURITY GAUZE PADS4"X4" 12 PLY PADS F RX/OTC

CURITY GAUZE SPONGE2"X2" 8 PLY PADS F RX/OTC

CURITY GAUZE SPONGE2"X2"12 PLY PADS F RX/OTC

CURITY GAUZE SPONGE3"X3" 12 PLY PADS F




CURITY GAUZE SPONGE4"X4"16 PLY PADS F RX/OTC

CURITY GAUZESPONGES 4"X4" 12 PLYPADS

FRX/OTC

CURITY GAUZESPONGES 4"X4" 8 PLYPADS

FRX/OTC

CURITY NON-ADHERENTSTRIPS 3"X3" PADS F

CURITYSPONGES/CELLULOSEFILLED/2"X2" PADS

FRX/OTC

CURITYSPONGES/CELLULOSEFILLED/4"X4" PADS

FRX/OTC

CVS GAUZE PADS 2"X2"12-PLY PADS F RX/OTC

CVS GAUZE PADS 4"X4"12-PLY PADS F RX/OTC

DERMACEA DRAINSPONGES 4"X4" PADS F RX/OTC

DERMACEA GAUZESPONGE 2"X2" 12 PLYPADS

FRX/OTC


FRX/OTC


F

Drug Name DrugTier

Requirements/Limits


F


FRX/OTC


FRX/OTC


FRX/OTC

DERMACEA I.V. DRAINSPONGES 2"X2" PADS F RX/OTC

DERMACEA I.V. DRAINSPONGES 4"X4" PADS F RX/OTC

DERMACEA I.V.SPONGES 2"X2" PADS F RX/OTC

DERMACEA NON-WOVENSPONGES 2"X2" 4 PLYPADS

FRX/OTC


F


FRX/OTC


FRX/OTC

DERMACEA TYPE VIIGAUZE 2"X2" 12 PLYPADS

FRX/OTC

DERMACEA TYPE VIIGAUZE 2"X2" 8 PLY PADS F RX/OTC


F

DERMACEA TYPE VIIGAUZE 3"X3" 12PLYPADS

F


FRX/OTC


FRX/OTC


59

Drug Name DrugTier

Requirements/Limits

DERMACEA TYPE VIIGAUZE 4"X4" 8 PLY PADS F RX/OTC

DERMACEA X-RAYSPONGES 4"X4" 16 PLYPADS

FRX/OTC

DERMALEVIN ADHESIVEFOAMDRESSING 4"X4"PADS

FRX/OTC

DRESSING SPONGES4"X4" PADS F RX/OTC

DRYMAX EXTRA PADS F RX/OTC

EQL GAUZE PADS2"X2"/SMALL PADS F RX/OTC

EQL GAUZE PADS4"X4"/LARGE PADS F RX/OTC

EQL GAUZE PADSSTERILE 3"X3"/MEDIUMPADS

F

EQL GAUZE STERILEPADS 3"X3" PADS F

EXCILON AMDANTIMICROBIALDRAINSPONGES 4"X4" 6 PLYPADS

F

RX/OTC

EXCILON AMDANTIMICROBIALNON-WOVEN SPONGES 4"X4"6 PLY PADS

F

RX/OTC

EXCILON DRAINSPONGE 4"X4" PADS F RX/OTC

EXCILON DRAINSPONGES 4"X4" 6 PLYPADS

FRX/OTC

EXCILON I.V. SPONGES2"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" 12PLY PADS F RX/OTC

Drug Name DrugTier

Requirements/Limits

GAUZE PADS 4"X4" PADS F RX/OTC

GAUZE SPONGE TYPEVII MEDI-PAK 2"X2" 8PLYPADS

FRX/OTC

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

GAUZE SPONGES 4"X4"PADS F RX/OTC

GNP STERILE PADS3"X3" PADS F

HM STERILE PADS PADS F RX/OTC

HYDROCELL ADHESIVEDRESSING 4"X4" PADS F RX/OTC

HYDROCELL DRESSING4"X4" PADS F RX/OTC

ISLAND GARD-GRX PADS F RX/OTC

J & J GAUZE 2"X2" 8 PLYPADS F RX/OTC



J & J GAUZE SPONGES12-PLY 4" X 4" MISC F RX/OTC

J & J GAUZE SPONGES16-PLY 4" X 4" MISC F RX/OTC

J & J GAUZE SPONGES8-PLY4" X 4" MISC F RX/OTC

KENDALL HYDROPHILICFOAMDRESSING 2"X2"PADS

FRX/OTC


F


FRX/OTC

KENDALL HYDROPHILICFOAMPLUS DRESSING2"X2" PADS

FRX/OTC

KENDALL HYDROPHILICFOAMPLUS DRESSING3"X3" PADS

F


60

Drug Name DrugTier

Requirements/Limits

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" 4PLY MISC

FRX/OTC

OPTIFOAM PADS F RX/OTC

POLYMEM DRESSING/3"X 3" PADS F

POLYMEM DRESSING/4"X 4" PADS F RX/OTC

QC ALL PURPOSEDRESSINGS4"X4" PADS F RX/OTC

QC BORDER ISLANDGAUZE PAD 2"X2" PADS F RX/OTC

QC STERILE PADS PADS F

QC STERILE PADS PADS F RX/OTC

RA ALL PURPOSEDRESSINGS4"X4" PADS F RX/OTC

RA DRESSING SPONGES4"X4" PADS F RX/OTC

RA GAUZE SPONGES4"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-RAYDETECTABLESPONGES4" X 4" 16 PLY MISC

FRX/OTC

RESTORE CONTACTLAYER/NON-ADHERENT2"X2" PADS

FRX/OTC

Drug Name DrugTier

Requirements/Limits

RESTORE FOAMDRESSING BORDERED4"X4" PADS

FRX/OTC

RESTORE FOAMDRESSING NON-BORDERED 4"X4" PADS

FRX/OTC

RESTORE ODORABSORBING DRESSING4"X4" PADS

FRX/OTC

RESTORE TRIOABSORBENT DRESSING3"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 PADS2"X2" PADS F RX/OTC

STERILE GAUZE PADS3"X3" PADS F

STERILE PADS 2"X2"PADS F RX/OTC

STERILE PADS 3"X3"PADS F

STERILE PADS 4"X4"PADS F RX/OTC

TEGADERM FOAMDRESSING 2"X2" PADS F RX/OTC

TEGADERM FOAMDRESSING 4"X4" PADS F RX/OTC

THERAGAUZE PADS F RX/OTC

TOPPER DRESSINGSPONGES 4"X4" MISC F RX/OTC

VERSIVA XC 3" X 3"FOAMDRESSING/HYDROFIBERTECHNOLOGY PADS

F


61

Drug Name DrugTier

Requirements/Limits

VERSIVA XC 4" X 4"FOAMDRESSING/HYDROFIBERTECHNOLOGY PADS

F

RX/OTC

VISTEC X-RAYDETECTABLE SPONGES4"X4" 16 PLY PADS

FRX/OTC

ContraceptivesAIMSCO LUBRICATEDMISC F QL(36 ea per

fill retail)ATLAS COLOREDLUBRICATEDCONDOMDEVI

FQL(36 ea perfill retail)

ATLAS LUBRICATEDCONDOM DEVI F QL(36 ea per

fill retail)ATLAS LUBRICATEDCONDOM/SPERMICIDEDEVI


CLASS ACT LUBRICATEDMISC F QL(36 ea per

fill retail)DUREX EXTRASENSITIVE DEVI F QL(36 ea per

fill retail)ELEXA NATURAL FEELMISC F QL(36 ea per

fill retail)ELEXA STIMULATINGMISC F QL(36 ea per

fill retail)ELEXA ULTRA SENSITIVEMISC F QL(36 ea per

fill retail)EXTRA SENSITIVESPERMICIDAL DEVI F QL(36 ea per

fill retail)FANTASY LUBRICATEDMISC F QL(36 ea per

fill retail)FANTASYLUBRICATED/SPERMICIDE MISC


HIGH SENSATIONSPERMICIDAL DEVI F QL(36 ea per

fill retail)INTENSE SENSATIONDEVI F QL(36 ea per

fill retail)KAMELEON LUBRICATEDMISC F QL(36 ea per

fill retail)

KIMONO COLORS DEVI F QL(36 ea perfill retail)

KIMONO LUBRICATEDMISC F QL(36 ea per

fill retail)

Drug Name DrugTier

Requirements/Limits

KIMONO MICRO THINPLUS SPERMICIDELUBRICATED MISC


KIMONO PLUSSPERMICIDELUBRICATED MISC


KIMONO PLUSSPERMICIDE/LUBRICATED MISC


KIMONO PS LUBRICATEDMISC F QL(36 ea per

fill retail)KIMONO PS PLUSSPERMICIDE/LUBRICATED MISC


KIMONO SENSATIONLUBRICATED MISC F QL(36 ea per

fill retail)KIMONO SENSATIONPLUS SPERMICIDELUBRICATED MISC


KIMONO SPECIAL DEVI F QL(36 ea perfill retail)

MAXX LUBRICATED MISC F QL(36 ea perfill retail)

MAXX PLUS SPERMICIDELUBRICATED MISC F QL(36 ea per

fill retail)PREMIUM CONDOMSLUBRICATED MISC F QL(36 ea per

fill retail)REALITY LATEXCONDOMS/LUBRICATEDMISC


REALITY LATEX/ULTRATEXTURED DEVI F QL(36 ea per

fill retail)REALITY LATEX/ULTRATHIN DEVI F QL(36 ea per

fill retail)TROJAN EXTENDEDPLEASURE/LUBRICATEDDEVI


TROJAN MAGNUM MISC F QL(36 ea perfill retail)

TROJAN MAGNUM WARMSENSATIONS DEVI F QL(36 ea per

fill retail)TROJAN MAGNUM XLLUBRICATED DEVI F QL(36 ea per

fill retail)TROJAN PLEASUREMESH/SPERMICIDALDEVI



62

Drug Name DrugTier

Requirements/Limits

TROJAN RIBBEDW/SPERMICIDAL MISC F QL(36 ea per

fill retail)TROJAN SHAREDSENSATION/LUBRICATED DEVI


TROJAN SUPRASSPERMICIDAL DEVI F QL(36 ea per

fill retail)TROJAN TWISTEDPLEASURE DEVI F QL(36 ea per

fill retail)TROJAN ULTRAPLEASURE/LUBRICATEDDEVI


TROJAN VERYSENSITIVE LUBRICATEDMISC


TROJAN VERYSENSITIVE SPERMICIDALLUBRICANT MISC


TROJAN VERY THINLUBRICATED MISC F QL(36 ea per

fill retail)TROJAN VERY THINSPERMICIDALLUBRICANT MISC


TROJAN-ENZ LUBRICANTMISC F QL(36 ea per

fill retail)TROJAN-ENZLUBRICATED MISC F QL(36 ea per

fill retail)TROJAN-ENZW/SPERMICIDAL MISC F QL(36 ea per

fill retail)TRUSTEX COLORCONDOMS + LUBE MISC F QL(36 ea per

fill retail)TRUSTEX LUBRICATEDEXTRALARGE MISC F QL(36 ea per

fill retail)TRUSTEX LUBRICATEDEXTRASTRENGTH MISC F QL(36 ea per

fill retail)TRUSTEX LUBRICATEDMISC F QL(36 ea per

fill retail)TRUSTEXLUBRICATED/RIBBED/STUDDED MISC


TRUSTEXLUBRICATED/SPERMICIDE EXTRA LARGE MISC


TRUSTEXLUBRICATED/SPERMICIDE EXTRA STRENGTHMISC

F

QL(36 ea perfill retail)

Drug Name DrugTier

Requirements/Limits

TRUSTEXLUBRICATED/SPERMICIDE MISC


TRUSTEX NATURALCONDOMS+LUBE/LUBRICATEDMISC

F


TRUSTEX WITHNONOXYNOL-9/RIBBED/STUDDEDMISC

F


TRUSTEX/RIALUBRICATED MISC F QL(36 ea per

fill retail)TRUSTEX/RIALUBRICATEDSPERMICIDE MISC


TRUSTEX/RIALUBRICATED/SPERMICIDE MISC


ULTIMATE FEELING DEVI F QL(36 ea perfill retail)

Diabetic SuppliesACCU-CHEK FASTCLIXLANCETS MISC F QL(5 ea daily)

ACCU-CHEK SOFTCLIXLANCETS MISC F QL(5 ea daily)

ACTI-LANCE LANCETS28G MISC F QL(5 ea daily)

ACTI-LANCE LITESAFETY LANCETS 28GMISC

FQL(5 ea daily)

ACTI-LANCE SPECIALSAFETY LANCETS 17GMISC

FQL(5 ea daily)

ACTI-LANCE UNIVERSALSAFETY LANCETS 23GMISC

FQL(5 ea daily)

ADJUSTABLE LANCINGDEVICE MISC F QL(1 ea per

180 days retail)ADVOCATE LANCINGDEVICE MISC F QL(1 ea per

180 days retail)ADVOCATE RAPID-SAFELANCING DEVICE MISC F QL(1 ea per

180 days retail)ALTERNATE SITELANCING DEVICE MISC F QL(1 ea per

180 days retail)


63

Drug Name DrugTier

Requirements/Limits

AQUA LANCEADJUSTABLE LANCINGDEVICE DEVI


ASSURE COMFORTLANCETS ULTRA THIN28G MISC

FQL(5 ea daily)

ASSURE HAEMOLANCEPLUS HIGH FLOW 18GMISC

FQL(5 ea daily)

ASSURE HAEMOLANCEPLUS LOW FLOW 25GMISC

FQL(5 ea daily)

ASSURE HAEMOLANCEPLUS MICRO FLOW 28GMISC

FQL(5 ea daily)

ASSURE HAEMOLANCEPLUS NORMAL FLOW21G MISC

FQL(5 ea daily)

ASSURE HAEMOLANCEPLUS PEDIATRIC BLADEMISC

FQL(5 ea daily)

ASSURE LANCELANCETS 21G MISC F QL(5 ea daily)

ASSURE LANCELANCETS MISC F QL(5 ea daily)

ASSURE LANCE PLUSSAFETYLANCETS 25GMISC

FQL(5 ea daily)

ASSURE LANCE PLUSSAFETYLANCETS 30GMISC

FQL(5 ea daily)

AT LAST LANCETS MISC F QL(5 ea daily)

AURORA LANCET SUPERTHIN30G MISC F QL(5 ea daily)

AURORA LANCET THIN23G MISC F QL(5 ea daily)

AUTO-LANCET MINI MISC F QL(1 ea per180 days retail)

AUTO-LANCET MISC F QL(1 ea per180 days retail)

AUTOLET IMPRESSIONLANCING DEVICE MISC F QL(1 ea per

180 days retail)AUTOLET LANCINGDEVICE MISC F QL(1 ea per

180 days retail)

AUTOLET MINI MISC F QL(1 ea per180 days retail)

Drug Name DrugTier

Requirements/Limits

AUTOLET PLUS MISC F QL(1 ea per180 days retail)

BAYER MICROLET 2LANCING DEVICE MISC F QL(1 ea per

180 days retail)BAYER MICROLETLANCETS MISC F QL(5 ea daily)

BD LANCET DEVICEMISC F QL(1 ea per

180 days retail)BD LANCET ULTRAFINE30G MISC F QL(5 ea daily)

BD MICROTAINERLANCETS MISC F QL(5 ea daily)

BULLSEYE MINI SAFETYLANCETS MISC F QL(5 ea daily)

BULLSEYE SAFETYLANCETS MISC F QL(5 ea daily)

CARDIOCOM LANCINGDEVICE MISC F QL(1 ea per

180 days retail)CAREONE ADVANCEDLANCINGDEVICE MISC F QL(1 ea per

180 days retail)CAREONE LANCET THINMISC F QL(5 ea daily)

CAREONE LANCETULTRA THIN MISC F QL(5 ea daily)

CARETOUCH LANCINGDEVICEWITH EJECTORMISC


CARETOUCH TWISTLANCETS 30G MISC F QL(5 ea daily)

CLEANLET LANCETS 28GMISC F QL(5 ea daily)

CLOSERCARE MISC F QL(1 ea per180 days retail)

COMFORT ASSUREDLANCETS MICRO THIN33G MISC

FQL(5 ea daily)

COMFORT ASSUREDLANCETS SUPER THIN28G MISC

FQL(5 ea daily)

COMFORT LANCETSMISC F QL(5 ea daily)

CVS LANCETS 21G MISC F QL(5 ea daily)

CVS LANCETS MICROTHIN 33G MISC F QL(5 ea daily)


64

Drug Name DrugTier

Requirements/Limits

CVS LANCETS MICRO-THIN 33G MISC F QL(5 ea daily)

CVS LANCETS THIN 26GMISC F QL(5 ea daily)

CVS LANCETS ULTRATHIN 30G MISC F QL(5 ea daily)

CVS LANCETS ULTRA-THIN 30G MISC F QL(5 ea daily)

CVS LANCING DEVICEMISC F QL(1 ea per

180 days retail)DIASTAR EASY TEST IILANCETS 30G MISC F QL(5 ea daily)

DIASTAR EASY TESTLANCETS30G MISC F QL(5 ea daily)

DROPLET LANCETSULTRA THIN 30G MISC F QL(5 ea daily)

DROPLET LANCINGDEVICE MISC F QL(1 ea per

180 days retail)DRUG MARTADJUSTABLE LANCINGDEVICE MISC


DRUG MART LANCETSTHIN MISC F QL(5 ea daily)

DRUG MART ON-THE-GOLANCETS GENTLE 30GMISC

FQL(5 ea daily)

DRUG MART UNILETLANCETSSUPER THIN30G MISC

FQL(5 ea daily)

DRUG MART UNILETLANCETSULTRA THIN28G MISC

FQL(5 ea daily)

DUANE READE LANCETALTERNATE SITE 26GMISC

FQL(5 ea daily)

DUANE READE LANCETSUPERTHIN 30G MISC F QL(5 ea daily)

DUANE READE LANCETULTRATHIN 28G MISC F QL(5 ea daily)

E-Z JECT LANCETS 21GMISC F QL(5 ea daily)

E-Z JECT LANCETSCOLOR MISC F QL(5 ea daily)

E-Z JECT LANCETS MISC F QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits

E-Z JECT LANCETSSUPER THIN 30G MISC F QL(5 ea daily)

E-Z JECT LANCETS THIN26G MISC F QL(5 ea daily)

E-ZJECT LANCETSMICRO-THIN 33G MISC F QL(5 ea daily)

EASY MINI EJECTLANCING DEVICE MISC F QL(1 ea per

180 days retail)EASY MINI LANCINGDEVICE MISC F QL(1 ea per

180 days retail)EASY TOUCH LANCETS28G/PULL-TOP MISC F QL(5 ea daily)

EASY TOUCH LANCETS30G/BUTTON-ACTIVATEDMISC

FQL(5 ea daily)

EASY TOUCH LANCETS30G/PULL-TOP MISC F QL(5 ea daily)

EASY TOUCH LANCETS30G/TWIST MISC F QL(5 ea daily)

EASY TOUCH LANCETS32G/PRESSUREACTIVATED MISC

FQL(5 ea daily)

EASY TOUCH LANCINGDEVICE/EJECTOR MISC F QL(1 ea per

180 days retail)EASY TOUCH SAFETYLANCETS21G/PRESSUREACTIVATED MISC

FQL(5 ea daily)

EASY TOUCH SAFETYLANCETS28G/BUTTONACTIVATED MISC

FQL(5 ea daily)

EASY TWIST & CAPLANCETS MISC F QL(5 ea daily)

EASYTEST LANCETSMISC F QL(5 ea daily)

EQL COLOR LANCETS21G MISC F QL(5 ea daily)

EQL COLOR LANCETSMICRO THIN 33G MISC F QL(5 ea daily)

EQL SUPER THINLANCETS 30G MISC F QL(5 ea daily)

EQL THIN LANCETS 26GMISC F QL(5 ea daily)

EZ-LETS LANCETS 21GMISC F QL(5 ea daily)



65

Drug Name DrugTier

Requirements/Limits

EZ-LETS LANCETS 28GULTRA-SOFT MISC F QL(5 ea daily)


FIFTY50 LANCINGDEVICE MISC F QL(1 ea per

180 days retail)FIFTY50 SAFETY SEALLANCETS 32G MISC F QL(5 ea daily)

FIFTY50 UNILETLANCETS 33G MISC F QL(5 ea daily)

FINE 30 MISC F QL(5 ea daily)

FINGERSTIX LANCETSMISC F QL(5 ea daily)

FORA LANCETS MISC F QL(5 ea daily)

FORA LANCING DEVICEMISC F QL(1 ea per

180 days retail)FORA LANCINGDEVICE/CLEARCAP MISC F QL(1 ea per

180 days retail)FREDS PHARMACYAUTOLET LANCINGDEVICE MISC


FREDS PHARMACYUNILET LANCETS SUPERTHIN 30G MISC

FQL(5 ea daily)

FREDS PHARMACYUNILET LANCETS ULTRATHIN 28G MISC

FQL(5 ea daily)

GENTLE-LET GPLANCETS MISC F QL(5 ea daily)

GENTLE-LET LANCETSGENERAL PURPOSESTYLE/MEDIUM POINTMISC

F

QL(5 ea daily)

GENTLE-LET LANCETSSAFETY STYLE/FINEPOINT MISC

FQL(5 ea daily)

GENTLE-LET LANCETSSAFETY STYLE/MEDIUMPOINT MISC

FQL(5 ea daily)

GLOBAL LANCINGDEVICE MISC F QL(1 ea per

180 days retail)GLUCOCOM LANCETS33G MISC F QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits

GLUCOLET 2AUTOMATIC LANCINGDEVICE MISC


GLUCOSOURCE LANCETDEVICE MISC F QL(1 ea per

180 days retail)GMATE LANCING DEVICEMISC F QL(1 ea per

180 days retail)

GNP LANCETS 21G MISC F QL(5 ea daily)

GNP LANCETS MICROTHIN 33G MISC F QL(5 ea daily)

GNP LANCETS MISC F QL(5 ea daily)

GNP LANCETS SUPERTHIN 30G MISC F QL(5 ea daily)

GNP LANCETS THIN 26GMISC F QL(5 ea daily)

GNP LANCETS THINMISC F QL(5 ea daily)

GNP MICRO THINLANCETS 33G MISC F QL(5 ea daily)

GNP SUPER THINLANCETS/30G MISC F QL(5 ea daily)

GOODSENSE LANCINGDEVICE MISC F QL(1 ea per

180 days retail)H-E-B INCONTROLADVANCEDLANCINGDEVICE MISC


H-E-B INCONTROLLANCETS MICRO THIN33G MISC

FQL(5 ea daily)

H-E-B INCONTROLLANCETS SUPER THIN30G MISC

FQL(5 ea daily)

H-E-B INCONTROLLANCETS ULTRA THIN28G MISC

FQL(5 ea daily)

HAEMOLANCE LOWFLOW LANCETS MISC F QL(5 ea daily)

HAEMOLANCE MISC F QL(5 ea daily)

HAEMOLANCE PLUSLOW FLOW MISC F QL(5 ea daily)

HAEMOLANCE PLUSMISC F QL(5 ea daily)

HEALTH CARE LANCINGDEVICE MISC F QL(1 ea per

180 days retail)


66

Drug Name DrugTier

Requirements/Limits

HEALTHWISE LANCINGPEN MISC F QL(1 ea per

180 days retail)HEALTHY ACCENTSAUTOLET IMPRESSIONLANCING DEVICE MISC


HY-VEE LANCETS MISC F QL(5 ea daily)

HY-VEE THIN LANCETSMISC F QL(5 ea daily)

IN TOUCH LANCINGDEVICE MISC F QL(1 ea per

180 days retail)

KINNEY LANCETS MISC F QL(5 ea daily)

KINNEY THIN LANCETSMISC F QL(5 ea daily)

KROGER LANCETS 21GMISC F QL(5 ea daily)

KROGER LANCETSMICRO THIN33G MISC F QL(5 ea daily)

KROGER LANCETS MISC F QL(5 ea daily)

KROGER LANCETSSUPER THIN MISC F QL(5 ea daily)

KROGER LANCETS THIN26G MISC F QL(5 ea daily)

KROGER LANCETS THINMISC F QL(5 ea daily)

KROGER LANCETSULTRATHIN30G MISC F QL(5 ea daily)

KROGER LANCINGDEVICE MISC F QL(1 ea per

180 days retail)LANCET DEVICEADJUSTABLE MISC F QL(1 ea per

180 days retail)LANCET DEVICE WITHEJECTOR MISC F QL(1 ea per

180 days retail)LANCETS 26G TWISTTOP MISC F QL(5 ea daily)

LANCETS 28G MISC F QL(5 ea daily)

LANCETS 30G MISC F QL(5 ea daily)

LANCETS 31G TWISTTOP MISC F QL(5 ea daily)

LANCETS MICRO THIN33G MISC F QL(5 ea daily)

LANCETS MISC F QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits

LANCETS SAFETY SEAL21G MISC F QL(5 ea daily)



LANCETS SUPER THIN28G MISC F QL(5 ea daily)

LANCETS THIN MISC F QL(5 ea daily)

LANCETS ULTRA FINEMISC F QL(5 ea daily)

LANCETS ULTRA THIN30G MISC F QL(5 ea daily)

LANCETS ULTRA THINMISC F QL(5 ea daily)

LANCETSBULLSEYESAFETY MISC F QL(5 ea daily)

LANCING DEVICEADJUSTABLE MISC F QL(1 ea per

180 days retail)

LANCING DEVICE MISC F QL(1 ea per180 days retail)

LANZO MISC F QL(1 ea per180 days retail)

LEADER ADVANCEDLANCING DEVICE MISC F QL(1 ea per

180 days retail)LIBERTY MEDICALLANCETS 30G MISC F QL(5 ea daily)

LIBERTY MINI LANCINGDEVICE MISC F QL(1 ea per

180 days retail)LIFESCAN UNISTIK 2DEEP PENETRATIONMISC

FQL(5 ea daily)

LIFESCAN UNISTIK IILANCETS MISC F QL(5 ea daily)

LITE TOUCH LANCETSMISC F QL(5 ea daily)

LITE TOUCH LANCINGDEVICE MISC F QL(1 ea per

180 days retail)LITE TOUCH LANCINGPEN MISC F QL(1 ea per

180 days retail)LITETOUCH LANCETSMICRO THIN 33G MISC F QL(5 ea daily)

LIVE BETTER ADVANCEDLANCING DEVICE MISC F QL(1 ea per

180 days retail)


67

Drug Name DrugTier

Requirements/Limits

LIVE BETTER LANCETSUPERTHIN 30G MISC F QL(5 ea daily)

LIVE BETTER LANCETULTRATHIN 28G MISC F QL(5 ea daily)

LONGS LANCETSSTANDARD MISC F QL(5 ea daily)

LONGS LANCETS THINMISC F QL(5 ea daily)

LONGS LANCETS ULTRATHIN MISC F QL(5 ea daily)

MEDICHOICE PRE-SETSAFETY LANCET DUALUSE MISC

FQL(5 ea daily)

MEDICHOICE PRE-SETSAFETY LANCET LOWFLOW MISC

FQL(5 ea daily)

MEDICHOICE PRE-SETSAFETY LANCETMEDIUM FLOW MISC

FQL(5 ea daily)

MEDICHOICE PRE-SETSAFETY LANCETMODERATE FLOW MISC

FQL(5 ea daily)

MEDICHOICE SAFETYLANCETEXTRA MISC F QL(5 ea daily)

MEDICHOICE SAFETYLANCETNORMAL MISC F QL(5 ea daily)

MEDLANCE PLUS EXTRALANCETS 21G MISC F QL(5 ea daily)

MEDLANCE PLUSLANCETS LITE 25G MISC F QL(5 ea daily)

MEDLANCE PLUSLANCETS MISC F QL(5 ea daily)

MEDLANCE PLUS LITELANCETS 25G MISC F QL(5 ea daily)

MEDLANCE PLUSSPECIAL LANCETS0.8MM MISC

FQL(5 ea daily)

MEDLANCE PLUSSUPERLITE30G/COMFORT MAXMISC

F

QL(5 ea daily)

MEDLANCE PLUSUNIVERSAL LANCETS21G MISC

FQL(5 ea daily)

MEDLANCE/EXTRA MISC F QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits

MEDLANCE/LITE MISC F QL(5 ea daily)

MEDLANCE/UNIVERSALMISC F QL(5 ea daily)

MEIJER COLORLANCETS UNIVERSAL33G MISC

FQL(5 ea daily)

MEIJER LANCETS MISC F QL(5 ea daily)

MEIJER LANCETS THINMISC F QL(5 ea daily)

MEIJER LANCETSUNIVERSAL21G MISC F QL(5 ea daily)



MEIJER SUPER THINLANCETS MISC F QL(5 ea daily)

MICROLET LANCETSMISC F QL(5 ea daily)

MICROLET NEXT MISC F QL(1 ea per180 days retail)

MINI LANCING DEVICEMISC F QL(1 ea per

180 days retail)MONOLET OPD LANCETSMISC F QL(5 ea daily)

MONOLETTOR SAFETYLANCETS MISC F QL(5 ea daily)

MULTI-LANCET DEVICEMISC F QL(1 ea per

180 days retail)NOVA SUREFLEXLANCING DEVICE MISC F QL(1 ea per

180 days retail)ON CALL LANCINGDEVICE MISC F QL(1 ea per

180 days retail)ON CALL PLUS LANCINGDEVICE MISC F QL(1 ea per

180 days retail)ONETOUCH CLUBLANCETS FINE POINTMISC

FQL(5 ea daily)

ONETOUCH COMBOPACK MISC F QL(5 ea daily)

ONETOUCH DELICALANCETS EXTRA FINE33G MISC

FQL(5 ea daily)


68

Drug Name DrugTier

Requirements/Limits

ONETOUCH DELICALANCETS FINE 30G MISC F QL(5 ea daily)

ONETOUCH DELICALANCING DEVICE MISC F QL(1 ea per

180 days retail)ONETOUCH ULTRASOFTLANCETS MISC F QL(5 ea daily)

PC LANCETS SUPERTHIN 30G MISC F QL(5 ea daily)

PHARMACY COUNTERLANCETS MISC F QL(5 ea daily)

PRECISION THINLANCETS MISC F QL(5 ea daily)

PRECISION THINS GPLANCET MISC F QL(5 ea daily)

PRECISION ULTRALANCET MISC F QL(5 ea daily)

PREFERRED PLUSLANCETS COLORED 21GMISC

FQL(5 ea daily)

PREFERRED PLUSLANCETS THIN 26G MISC F QL(5 ea daily)

PRESSURE ACTIVATEDSAFETYLANCET 21GMISC

FQL(5 ea daily)

PRODIGY LANCINGDEVICE MISC F QL(1 ea per

180 days retail)PSS SELECT GPLANCETS MISC F QL(5 ea daily)

PSS SELECT SAFETYLANCETS MISC F QL(5 ea daily)

PUSH BUTTON SAFETYLANCETS 21G MISC F QL(5 ea daily)

PUSH BUTTON SAFETYLANCETS 28G MISC F QL(5 ea daily)

PX ADVANCED LANCINGDEVICE MISC F QL(1 ea per

180 days retail)PX LANCET AUTOINJECTOR MISC F QL(1 ea per

180 days retail)PX LANCETS ULTRATHIN MISC F QL(5 ea daily)

QC ADVANCED LANCINGDEVICE MISC F QL(1 ea per

180 days retail)QC LANCETS ULTRATHIN MISC F QL(5 ea daily)

QC UNILET LANCETS28G/ULTRA THIN MISC F QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits

QC UNILET LANCETS33G/MICRO THIN MISC F QL(5 ea daily)

RA E-ZJECT LANCETS28G MISC F QL(5 ea daily)

RA E-ZJECT LANCETSTHIN 26G MISC F QL(5 ea daily)

RA E-ZJECT LANCETSULTRATHIN 30G MISC F QL(5 ea daily)

RA LANCING DEVICEMISC F QL(1 ea per

180 days retail)

REALITY LANCETS MISC F QL(5 ea daily)

RELION 2-IN-1 LANCINGDEVICE 25G MISC F QL(1 ea per

180 days retail)RELION 2-IN-1 LANCINGDEVICE 30G MISC F QL(1 ea per

180 days retail)RELION LANCETSMICRO-THIN33G MISC F QL(5 ea daily)

RELION LANCETSSTANDARD 21G MISC F QL(5 ea daily)

RELION LANCETS THIN26G MISC F QL(5 ea daily)

RELION LANCETSULTRA-THIN30G MISC F QL(5 ea daily)

RELION LANCINGDEVICE MISC F QL(1 ea per

180 days retail)RELION ULTRA THINLANCETS30G MISC F QL(5 ea daily)

RELION ULTRA THINPLUS LANCETS 32GMISC

FQL(5 ea daily)

RELION ULTRA THINPLUS LANCETS 33GMISC

FQL(5 ea daily)

REXALL LANCETS ULTRATHIN MISC F QL(5 ea daily)

RIGHTEST GD500LANCING DEVICE MISC F QL(1 ea per

180 days retail)RIGHTEST GL300LANCETS MISC F QL(5 ea daily)

SAFE-T-LANCE LOWFLOW 25G MISC F QL(5 ea daily)

SAFE-T-LANCE NORMALFLOW21G MISC F QL(5 ea daily)


69

Drug Name DrugTier

Requirements/Limits

SAFE-T-LANCE PLUSSAFETYLANCET LOWFLOW MISC

FQL(5 ea daily)

SAFE-T-LANCE PLUSSAFETYLANCETNORMAL FLOW MISC

FQL(5 ea daily)

SAFETY LANCETS 28GMISC F QL(5 ea daily)

SAFETY LET LANCETSMISC F QL(5 ea daily)

SAFETY SEAL LANCETS28G MISC F QL(5 ea daily)

SAFETY SEAL LANCETS30G MISC F QL(5 ea daily)

SB LANCETS THIN MISC F QL(5 ea daily)

SELECT-LITE LANCINGDEVICE MISC F QL(1 ea per

180 days retail)SHOPKO AUTOLETLANCING DEVICE MISC F QL(1 ea per

180 days retail)SHOPKO ON-THE-GOCOMFORTLANCETS 30GMISC

FQL(5 ea daily)

SHOPKO UNILETLANCETS SUPER THIN30G MISC

FQL(5 ea daily)

SHOPKO UNILETLANCETS ULTRA THIN28G MISC

FQL(5 ea daily)

SIDE BUTTON SAFETYLANCET21G MISC F QL(5 ea daily)

SIMPLE DIAGNOSTICSLANCING DEVICE MISC F QL(1 ea per

180 days retail)

SINGLE-LET MISC F QL(5 ea daily)

SMART DIABETESVANTAGE LANCINGDEVICE MISC


SMART SENSE COLORLANCETS UNIVERSAL33G MISC

FQL(5 ea daily)

SMART SENSESTANDARD LANCETSUNIVERSAL 21G MISC

FQL(5 ea daily)

SMART SENSE SUPERTHIN LANCETSUNIVERSAL 30G MISC

FQL(5 ea daily)

Drug Name DrugTier

Requirements/Limits

SMART SENSE THINLANCETSUNIVERSAL26G MISC

FQL(5 ea daily)

SMARTEST LANCETS28G MISC F QL(5 ea daily)

SOLUS V2 LANCINGDEVICE MISC F QL(1 ea per

180 days retail)SURE COMFORTLANCING PEN MISC F QL(1 ea per

180 days retail)SURE-LANCE THINLANCETS 28G MISC F QL(5 ea daily)

SURE-LANCE ULTRATHIN LANCETS MISC F QL(5 ea daily)

SURE-PEN MISC F QL(1 ea per180 days retail)

SURE-TOUCH LANCETSUNIVERSAL MISC F QL(5 ea daily)

SURELITE LANCETSMISC F QL(5 ea daily)

TECHLITE AST LANCETSMISC F QL(5 ea daily)

TECHLITE LANCETS 30GMISC F QL(5 ea daily)

TECHLITE LANCETSMISC F QL(5 ea daily)

TGT ADVANCEDLANCING DEVICE MISC F QL(1 ea per

180 days retail)TGT LANCETALTERNATE SITE MISC F QL(5 ea daily)

TGT LANCET MICROTHIN 33G MISC F QL(5 ea daily)

TGT LANCET SUPERTHIN 30G MISC F QL(5 ea daily)

TGT LANCET THIN 23GMISC F QL(5 ea daily)

TGT LANCET THIN 26GMISC F QL(5 ea daily)

TGT LANCET ULTRATHIN 28G MISC F QL(5 ea daily)

TGT LANCET ULTRATHIN 30G MISC F QL(5 ea daily)

TGT LANCING DEVICEMISC F QL(1 ea per

180 days retail)THINLETS GP LANCETSMISC F QL(5 ea daily)


70

Drug Name DrugTier

Requirements/Limits

THINLETS LANCET MISC F QL(5 ea daily)

TODAYS HEALTHADVANCED LANCINGDEVICE MISC


TODAYS HEALTH ULTRATHINLANCETS 28G MISC F QL(5 ea daily)

TRAVEL LANCETS 30GMISC F QL(5 ea daily)

TRUECONTROLGLUCOSE CONTROLLEVEL 0 LIQD

F

TRUECONTROLGLUCOSE CONTROLLEVEL 1 LIQD

F

TRUEDRAW LANCINGDEVICE MISC F QL(1 ea per

180 days retail)TRUEPLUS LANCETS26G MISC F QL(5 ea daily)

TRUEPLUS LANCETS28G MISC F QL(5 ea daily)

TRUEPLUS LANCETS28G SUPER THIN MISC F QL(5 ea daily)

TRUEPLUS LANCETS30G ULTRA THIN MISC F QL(5 ea daily)

TRUEPLUS SAFETYLANCETS 28G MISC F QL(5 ea daily)

TRUETEST GLUCOSECONTROLLEVEL 1 LIQD F



ULTI-LANCE AUTOMATIC/CLEAR TIP MISC F QL(1 ea per

180 days retail)ULTICARE THINLANCETS 30G MISC F QL(5 ea daily)

ULTILET CLASSICLANCETS MISC F QL(5 ea daily)

ULTILET LANCETS 33GMISC F QL(5 ea daily)

ULTILET LANCETS MISC F QL(5 ea daily)

ULTRA THIN LANCETS28G MISC F QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits

ULTRA THIN LANCETS30G MISC F QL(5 ea daily)

UNILET COMFORTOUCHLANCET MISC F QL(5 ea daily)

UNILET EXCELITE II MISC F QL(5 ea daily)

UNILET EXCELITE MISC F QL(5 ea daily)

UNILET G.P. LANCETMISC F QL(5 ea daily)

UNILET G.P. SUPERLITELANCET MISC F QL(5 ea daily)

UNILET GP 28 ULTRATHIN MISC F QL(5 ea daily)

UNILET LANCET MISC F QL(5 ea daily)

UNILET LANCETSMICRO-THIN33G MISC F QL(5 ea daily)

UNILET LANCETSSUPER-THIN30G MISC F QL(5 ea daily)

UNILET LANCETSULTRA-THIN 28G MISC F QL(5 ea daily)

UNILET SUPERLITELANCET MISC F QL(5 ea daily)

UNISTIK TOUCH SAFETYLANCETS 23G MISC F QL(5 ea daily)

UNIVERSAL 1 LANCETSTHIN26G MISC F QL(5 ea daily)

UNIVERSAL 1 LANCETSULTRA THIN 30G MISC F QL(5 ea daily)

UNIVERSAL 1LANCETS/33G/MICRO-THIN MISC

FQL(5 ea daily)

VALUE PLUS LANCETSSTANDARD 21G MISC F QL(5 ea daily)

VALUE PLUS LANCETSSUPERTHIN 30G MISC F QL(5 ea daily)

VALUE PLUS LANCETSTHIN 26G MISC F QL(5 ea daily)

VALUE PLUS LANCINGDEVICE MISC F QL(1 ea per

180 days retail)VALUMARK LANCETSUPER THIN 30G MISC F QL(5 ea daily)

VALUMARK LANCETULTRA THIN 28G MISC F QL(5 ea daily)


71

Drug Name DrugTier

Requirements/Limits

VIDA MIA AUTOLETLANCINGDEVICE MISC F QL(1 ea per

180 days retail)VIDA MIA UNILETLANCETS ULTRA THIN28G MISC

FQL(5 ea daily)

VITALET PRO PLUSLANCETS MISC F QL(5 ea daily)

W&F LANCETS 26G MISC F QL(5 ea daily)

WALGREENS COMFORTASSUREDLANCETSMICRO THIN/33G MISC

FQL(5 ea daily)

WALGREENS COMFORTASSUREDLANCETSSUPER THIN/28G MISC

FQL(5 ea daily)

WALGREENS LANCETSMISC F QL(5 ea daily)

WALGREENS THINLANCETS MISC F QL(5 ea daily)

WALGREENS ULTRATHIN LANCETS MISC F QL(5 ea daily)

Misc. Devices

ALCOHOL PREP PADSPADS F

QL(400 ea perfill retail);RX/OTC

ALCOHOL PREPS PADS FQL(400 ea perfill retail);RX/OTC

ALCOHOL SWABS PADS FQL(400 ea perfill retail);RX/OTC

ALCOHOL SWABSTICKPADS F


ALCOHOL WIPES PADS FQL(400 ea perfill retail);RX/OTC

BD SWABS SINGLE USEPADS F


CURITY ALCOHOLPREPS/MEDIUM 2 PLYPADS

FQL(400 ea perfill retail);RX/OTC

CURITY ALCOHOLSWABS PADS F


Drug Name DrugTier

Requirements/Limits

CVS ALCOHOL PREPSWABS PADS F


CVS ALCOHOL SWABSPADS F


CVS PREP PADS PADS FQL(400 ea perfill retail);RX/OTC

EASY TOUCH ALCOHOLPREP PADS/MEDIUMPADS


EQL ALCOHOL SWABSPADS F


FIFTY50 ALCOHOL PREPPADS PADS F


GNP ALCOHOL SWABSPADS F


H-E-B INCONTROLALCOHOL PADS PADS F


PRO COMFORTALCOHOL PADS PADS F


QC ALCOHOL SWABSPADS F


RA ALCOHOL SWABSPADS F


REALITY SWABS PADS FQL(400 ea perfill retail);RX/OTC

RELION ALCOHOLSWABS PADS F


SB ALCOHOL PREPPADS PADS F


SHOPKO ALCOHOLSWABS PADS F


SM ALCOHOL PREPPADS PADS F



72

Drug Name DrugTier

Requirements/Limits

TGT ALCOHOL SWABSPADS F


WEBCOL ALCOHOLPREP LARGE 1 PLYPADS


WEBCOL ALCOHOLPREP LARGE 2 PLYPADS


WEBCOL ALCOHOLPREP MEDIUM 2 PLYPADS


Parenteral Therapy Supplies1ST TIER UNIFINEPENTIPS/MINI/31GX5MMMISC

FQL(5 ea daily)

1ST TIER UNIFINEPENTIPS29GX12MMMISC

FQL(5 ea daily)

1ST TIER UNIFINEPENTIPS31GX6MM MISC F QL(5 ea daily)

1ST TIER UNIFINEPENTIPS31GX8MM MISC F QL(5 ea daily);

RX/OTC1ST TIER UNIFINEPENTIPS32GX4MM MISC F QL(5 ea daily);

RX/OTC1ST TIER UNIFINEPENTIPSPLUS 31GX8MMMISC


1ST TIER UNIFINEPENTIPSPLUS 32GX4MMMISC


1ST TIER UNIFINEPENTIPSPLUS/MINI/31GX5MM MISC

FQL(5 ea daily)

1ST TIER UNIFINEPENTIPSPLUS/ORIGINAL/29GX12MM MISC

FQL(5 ea daily)

1ST TIER UNIFINEPENTIPSPLUS/ULTRASHORT/31GX6MM MISC

FQL(5 ea daily)

ADVOCATE INSULIN PENNEEDLES 29GX12.7MMMISC

FQL(5 ea daily)

ADVOCATE INSULIN PENNEEDLES 31GX5MMMISC

FQL(5 ea daily)

Drug Name DrugTier

Requirements/Limits

ADVOCATE INSULIN PENNEEDLES 31GX8MMMISC


ADVOCATE INSULINSYRINGE/U-100/0.3ML/29GX1/2" MISC


ADVOCATE INSULINSYRINGE/U-100/0.3ML/30GX5/16"MISC

F

QL(5 ea daily);RX/OTC


F

QL(5 ea daily)

ADVOCATE INSULINSYRINGE/U-100/0.5ML/29GX1/2" MISC



F



F

QL(5 ea daily)

ADVOCATE INSULINSYRINGE/U-100/1ML/29GX1/2" MISC





FQL(5 ea daily)

ANTI-STICK INSULINSYRINGE/U-100/0.5ML/28G X 1/2"MISC

F


ANTI-STICK INSULINSYRINGE/U-100/0.5ML/29G X 1/2"MISC

F


ANTI-STICK INSULINSYRINGE/U-100/1ML/29GX 1/2" MISC



73

Drug Name DrugTier

Requirements/Limits

ASSURE ID INSULINSAFETYSYRINGE/U-100/0.5ML/29G X 1/2"MISC

F


ASSURE ID INSULINSAFETYSYRINGE/U-100/1ML/29G X 1/2" MISC


AURORA PEN NEEDLES29GX12MM MISC F QL(5 ea daily)

AURORA PEN NEEDLES31G X6MM MISC F QL(5 ea daily)

AURORA PEN NEEDLES31G X8MM MISC F QL(5 ea daily);

RX/OTCAURORA UNIFINEPENTIPS/32GX5/32" MISC F QL(5 ea daily);

RX/OTCAURORA UNIFINEPENTIPS/MINI/31GX3/16"MISC

FQL(5 ea daily)

AUTOPEN DEVI FQL(1 ea per180 daysretail); RX/OTC

B-D INSULIN SYRINGEULTRAFINE II/0.3ML/31GX 5/16" MISC

FQL(5 ea daily)

B-D INSULIN SYRINGEULTRAFINE II/0.5ML/31GX 5/16" MISC

FQL(5 ea daily)

B-D INSULIN SYRINGEULTRAFINE II/1ML/31G X5/16" MISC

FQL(5 ea daily)

B-D INSULIN SYRINGEULTRAFINE/0.3ML/30G X1/2" MISC

FQL(5 ea daily)

B-D INSULIN SYRINGEULTRAFINE/0.5ML/30G X1/2" MISC

FQL(5 ea daily)

B-D INSULIN SYRINGEULTRAFINE/1ML/30G X1/2" MISC

FQL(5 ea daily)

BD LO-DOSE INSULINSYRINGE MICROFINEIV/0.5ML/28G X 1/2" MISC


BD AUTOSHIELD 29G X5/16" MISC F QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits

BD INSULIN SYRINGEMICROFINE IV/U-100/0.3ML/28G X 1/2"MISC

F

QL(5 ea daily)

BD INSULIN SYRINGEMICROFINE IV/U-100/0.5ML/28G X 1/2"MISC

F


BD INSULIN SYRINGEMICROFINE IV/U-100/1ML/27G X 5/8" MISC

FQL(5 ea daily)

BD INSULIN SYRINGEMICROFINE IV/U-100/1ML/28G X 1/2" MISC


BD INSULIN SYRINGEMICROFINE/U-100/0.3ML/28G X 1/2"MISC

F

QL(5 ea daily)

BD INSULIN SYRINGEMICROFINE/U-100/0.5ML/28G X 1/2"MISC

F


BD INSULIN SYRINGEMICROFINE/U-100/1ML/27G X 5/8" MISC

FQL(5 ea daily)

BD INSULIN SYRINGEMICROFINE/U-100/1ML/28G X 1/2" MISC


BD INSULIN SYRINGESAFETYGLIDE/0.5ML/29GX 1/2" MISC


BD INSULIN SYRINGESAFETYGLIDE/1ML/29G X1/2" MISC


BD INSULIN SYRINGESAFETYGLIDE/U-100/0.3ML/31G X 5/16"MISC

F

QL(5 ea daily)

BD INSULIN SYRINGEULTRAFINE HALF-UNIT/0.3ML/31G X 5/16"MISC

F

QL(5 ea daily)

BD INSULIN SYRINGEULTRAFINEII/SHORT/0.5ML/31G X5/16" MISC

F

QL(5 ea daily)


74

Drug Name DrugTier

Requirements/Limits

BD INSULIN SYRINGEULTRAFINEII/SHORT/1ML/31G X 5/16"MISC

F

QL(5 ea daily)

BD INSULIN SYRINGEULTRAFINE/0.3ML/30G X1/2" MISC

FQL(5 ea daily)


FQL(5 ea daily)


FQL(5 ea daily)


FQL(5 ea daily)

BD INSULIN SYRINGEULTRAFINE/1ML/30G X1/2" MISC

FQL(5 ea daily)

BD INSULIN SYRINGEULTRAFINE/1ML/31G X5/16" MISC

FQL(5 ea daily)

BD INSULIN SYRINGEULTRAFINE/U-100/0.3ML/29G X 1/2"MISC

F



F

QL(5 ea daily)


F

QL(5 ea daily)


F



F

QL(5 ea daily)


F

QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits

BD INSULIN SYRINGEULTRAFINE/U-100/1ML/29G X 1/2" MISC


BD INSULIN SYRINGEULTRAFINE/U-100/1ML/30G X 1/2" MISC

FQL(5 ea daily)

BD INSULIN SYRINGEULTRAFINE/U-100/1ML/31G X 15/64"MISC

F

QL(5 ea daily)

BD INSULIN SYRINGEULTRAFINE/U-100/1ML/31G X 5/16"MISC

F

QL(5 ea daily)

BD INSULINSYRINGE/DETACHABLENEEDLE/U-100/1ML/25GX 1" MISC

F

QL(5 ea daily)

BD INSULINSYRINGE/DETACHABLENEEDLE/U-100/1ML/25GX 5/8" MISC

F

QL(5 ea daily)

BD INSULINSYRINGE/DETACHABLENEEDLE/U-100/1ML/26GX 1/2" MISC

F

QL(5 ea daily)

BD INSULIN SYRINGE/U-100/0.5ML/30G X 1/2"MISC

FQL(5 ea daily)

BD INSULIN SYRINGE/U-100/1ML/27G X 1/2" MISC F QL(5 ea daily);

RX/OTCBD INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC F QL(5 ea daily);

RX/OTCBD INTEGRA INSULINSYRINGE/U-100/1ML/29GX 1/2" MISC


BD INTEGRASYRINGE/RETRACTINGNEEDLE/1ML/25G X 1"MISC

F

QL(5 ea daily)

BD PEN MINI MISC FQL(1 ea per180 daysretail); RX/OTC

BD PEN MISC FQL(1 ea per180 daysretail); RX/OTC


75

Drug Name DrugTier

Requirements/Limits

BD PENNEEDLE/MINI/ULTRAFINE/31G X 3/16" MISC

FQL(5 ea daily)

BD PENNEEDLE/NANO/ULTRAFINE/32G X 4MM MISC


BD PENNEEDLE/SHORT/ULTRAFINE/31G X 5/16" MISC


BD PENNEEDLE/ULTRAFINE/29GX 12.7MM MISC

FQL(5 ea daily)

BD PENNEEDLE/ULTRAFINE/29GX1/2" 12.7MM MISC

FQL(5 ea daily)

BD PEN NEEDLESSHORT/ULTRAFINE/31GX 5/16" MISC


BD SAFETY-GLIDEINSULINSYRINGE/0.5ML/29G X1/2" MISC

F


BD SAFETY-LOK INSULINSYRINGE/PERMNEEDLE/UF/1ML/29G X1/2" MISC

F


BD SAFETYGLIDEINSULINSYSYRINGE/0.5ML/30G X5/16" MISC

F


CAREFINE PEN NEEDLE32GX4MM MISC F QL(5 ea daily);

RX/OTCCAREFINE PENNEEDLES 29GX1/2" MISC F QL(5 ea daily)

CAREFINE PENNEEDLES 30GX5/16"MISC


CAREFINE PENNEEDLES 31GX6MMMISC

FQL(5 ea daily)





Drug Name DrugTier

Requirements/Limits


FQL(5 ea daily)

CAREONE INSULINSYRINGES/0.3ML/30G X1/2" MISC

FQL(5 ea daily)


FQL(5 ea daily)


FQL(5 ea daily)


FQL(5 ea daily)

CAREONE INSULINSYRINGES/1ML/30G X1/2" MISC

FQL(5 ea daily)

CAREONE INSULINSYRINGES/1ML/31GX5/16" MISC

FQL(5 ea daily)

CAREONE UNIFINEPENTIPS 29GX12MMMISC

FQL(5 ea daily)

CAREONE UNIFINEPENTIPS 31GX5MM MISC F QL(5 ea daily)

CAREONE UNIFINEPENTIPS 31GX6MM MISC F QL(5 ea daily)

CAREONE UNIFINEPENTIPS 31GX8MM MISC F QL(5 ea daily);

RX/OTCCAREONE UNIFINEPENTIPS PEN NEEDLES32GX4MM MISC


CAREONE UNIFINEPENTIPS PLUS PENNEEDLES 29GX12MMMISC

F

QL(5 ea daily)


F

QL(5 ea daily)


F

QL(5 ea daily)


76

Drug Name DrugTier

Requirements/Limits


F



F


CARETOUCH PENNEEDLES 31G X 6 MMMISC

FQL(5 ea daily)

CARETOUCH PENNEEDLES 31GX 5MMMISC

FQL(5 ea daily)







CLEVER CHOICECOMFORT EZINSULINPEN NEEDLES 31GX8MMMISC

F


CLEVER CHOICECOMFORT EZINSULINSYRINGE/0.3ML/29G X1/2" MISC

F



F

QL(5 ea daily)


F



F

QL(5 ea daily)


F


Drug Name DrugTier

Requirements/Limits


F



F

QL(5 ea daily)


F



F

QL(5 ea daily)


F

QL(5 ea daily)

CLEVER CHOICECOMFORT EZINSULINSYRINGE/1ML/28G X 1/2"MISC

F


CLEVER CHOICECOMFORT EZINSULINSYRINGE/1ML/29G X 1/2"MISC

F


CLEVER CHOICECOMFORT EZINSULINSYRINGE/1ML/30G X5/16" MISC

F


CLEVER CHOICECOMFORT EZINSULINSYRINGE/U-100/1ML/31GX5/16" MISC

F

QL(5 ea daily)

CLEVER CHOICECOMFORT EZPENNEEDLES 29GX12MMMISC

F

QL(5 ea daily)


F

QL(5 ea daily)


F

QL(5 ea daily)


77

Drug Name DrugTier

Requirements/Limits


F



F



F



F

QL(5 ea daily)

CLICKFINE PEN NEEDLE32GX5/32" MISC F QL(5 ea daily);

RX/OTCCLICKFINE PEN NEEDLEUNIVERSAL/31GX1/4"MISC

FQL(5 ea daily)

CLICKFINE PEN NEEDLEUNIVERSAL/31GX5/16"MISC


CLICKFINE PENNEEDLES/31GX1/4" MISC F QL(5 ea daily)

CLICKFINE PENNEEDLES/31GX5/16"MISC


CLICKFINE UNIVERSALPEN NEEDLES 31GX5/16"MISC


COMFORT ASSISTINSULIN SYRINGE0.3ML/29G X 1/2" MISC


COMFORT ASSISTINSULINSYRINGE/0.3ML/30G X5/16" MISC

F



F

QL(5 ea daily)


F


Drug Name DrugTier

Requirements/Limits


F



F

QL(5 ea daily)

COMFORT ASSISTINSULINSYRINGE/1ML/29G X 1/2"MISC

F


COMFORT ASSISTINSULINSYRINGE/1ML/30G X5/16" MISC

F


COMFORT ASSISTINSULINSYRINGE/1ML/31G X5/16" MISC

F

QL(5 ea daily)

DROPLET PEN NEEDLES29GX12MM MISC F QL(5 ea daily)



DROPLET PEN NEEDLES31GX8MM MISC F QL(5 ea daily);

RX/OTCDROPLET PEN NEEDLES32GX4MM MISC F QL(5 ea daily);

RX/OTCDROPLET PEN NEEDLES32GX5MM MISC F QL(5 ea daily);

RX/OTCDROPLET PEN NEEDLES32GX6MM MISC F QL(5 ea daily)

DRUG MART UNIFINEPENTIPS 31GX5MM MISC F QL(5 ea daily)

DRUG MART UNIFINEPENTIPS29G X 12MMMISC

FQL(5 ea daily)

DRUG MART UNIFINEPENTIPS31GX6MM MISC F QL(5 ea daily)

DRUG MART UNIFINEPENTIPS31GX8MM MISC F QL(5 ea daily);

RX/OTCDRUG MART UNIFINEPENTIPS32GX4MM MISC F QL(5 ea daily);

RX/OTC


78

Drug Name DrugTier

Requirements/Limits

DRUG MART UNIFINEPENTIPSPLUS 32GX4MMMISC


DUANE READE UNIFINEPENTIPS 29G X 12MMMISC

FQL(5 ea daily)

DUANE READE UNIFINEPENTIPS 31G X 6MMULTRA SHORT MISC

FQL(5 ea daily)

DUANE READE UNIFINEPENTIPS 31G X 8MMSHORT MISC


EASY COMFORT INSULINSYRINGE/0.3ML/30G X5/16" MISC





FQL(5 ea daily)

EASY COMFORT INSULINSYRINGE/1ML/30G X5/16" MISC


EASY COMFORT INSULINSYRINGE/1ML/31G X5/16" MISC

FQL(5 ea daily)

EASY COMFORT INSULINSYRINGE/U-100/0.5ML/30G X 1/2"MISC

F

QL(5 ea daily)

EASY COMFORT INSULINSYRINGE/U-100/1ML/30GX 1/2" MISC

FQL(5 ea daily)

EASY COMFORT PENNEEDLES31GX1/4" MISC F QL(5 ea daily)

EASY COMFORT PENNEEDLES31GX3/16"MISC

FQL(5 ea daily)





EASY TOUCH 32GX5MMMISC F QL(5 ea daily);

RX/OTC

Drug Name DrugTier

Requirements/Limits

EASY TOUCH 32GX6MMMISC F QL(5 ea daily)

EASY TOUCH FLIPLOCKSAFETY INSULINSYRINGE 1ML/29GX1/2"MISC

F



F

QL(5 ea daily)


F



F

QL(5 ea daily)

EASY TOUCH INSULINSYRINGE/0.3ML/30G X5/16" MISC



FQL(5 ea daily)





EASY TOUCH INSULINSYRINGE/1ML/30G X5/16" MISC


EASY TOUCH INSULINSYRINGE/SAFETY/U-100/0.5ML/29G X 1/2"MISC

F


EASY TOUCH INSULINSYRINGE/SAFETY/U-100/0.5ML/30G X 5/16"MISC

F


EASY TOUCH INSULINSYRINGE/SAFETY/U-100/1ML/29G X 1/2" MISC


EASY TOUCH INSULINSYRINGE/SAFETY/U-100/1ML/30G X 1/2" MISC

FQL(5 ea daily)


79

Drug Name DrugTier

Requirements/Limits

EASY TOUCH INSULINSYRINGE/U-100/0.3ML/30G X 1/2"MISC

F

QL(5 ea daily)


F

QL(5 ea daily)


F



F

QL(5 ea daily)


F

QL(5 ea daily)

EASY TOUCH INSULINSYRINGE/U-100/1ML/27GX 1/2" MISC







FQL(5 ea daily)


FQL(5 ea daily)

EASY TOUCH PENNEEDLES 29GX1/2" MISC F QL(5 ea daily)


EASY TOUCH PENNEEDLES 31GX5/16"MISC





Drug Name DrugTier

Requirements/Limits



EASY TOUCH PENNEEDLES/31G X 3/16"MISC

FQL(5 ea daily)

EASY TOUCHSHEATHLOCK SAFETYINSULIN SYRINGE1ML/29GX1/2" MISC

F



F



F

QL(5 ea daily)

EASY TOUCHSHEATHLOCK SAFETYSYRINGE 1ML/30GX1/2"MISC

F

QL(5 ea daily)

ELITE-THIN INSULINSYRINGE/0.3ML/31G X5/16" MISC

FQL(5 ea daily)





ELITE-THIN INSULINSYRINGE/1ML/30G X5/16" MISC


ELITE-THIN INSULINSYRINGE/U-100/0.5ML/28G X 1/2"MISC

F


ELITE-THIN INSULINSYRINGE/U-100/0.5ML/31G X 5/16"MISC

F

QL(5 ea daily)

ELITE-THIN INSULINSYRINGE/U-100/1ML/28GX 1/2" MISC





80

Drug Name DrugTier

Requirements/Limits


FQL(5 ea daily)

EQL INSULINSYRINGE/0.3ML/29G X1/2" MISC





FQL(5 ea daily)






FQL(5 ea daily)

EQL INSULINSYRINGE/1ML/29G X 1/2"MISC


EQL INSULINSYRINGE/1ML/30G X5/16" MISC


EQL INSULINSYRINGE/1ML/31G X5/16" MISC

FQL(5 ea daily)

EQL INSULINSYRINGE/U-100/0.3ML/29G X 1/2"MISC

F


EQL INSULINSYRINGE/U-100/0.5ML/29G X 1/2"MISC

F


EQL INSULINSYRINGE/U-100/1ML/29GX 1/2" MISC


EQL SHORT PENNEEDLES 31G X 8MMMISC


EQL ULTRA COMFORTINSULINSYRINGE/0.3ML/31G X 5/16" MISC

FQL(5 ea daily)

Drug Name DrugTier

Requirements/Limits

EQL ULTRA COMFORTINSULINSYRINGE/1ML/30G X 5/16" MISC


EQL ULTRA SHORT PENNEEDLES 31G X 6MMMISC

FQL(5 ea daily)

EXEL COMFORT POINTINSULIN PEN NEEDLES29G X 12MM MISC

FQL(5 ea daily)


FQL(5 ea daily)



EXEL COMFORT POINTINSULINSYRINGE/0.3ML/29G X1/2" MISC

F



F



F



F



F


EXEL COMFORT POINTINSULINSYRINGE/1ML/28G X 1/2"MISC

F


EXEL COMFORT POINTINSULINSYRINGE/1ML/29G X 1/2"MISC

F


EXEL COMFORT POINTINSULINSYRINGE/1ML/30G X5/16" MISC

F



81

Drug Name DrugTier

Requirements/Limits

FIFTY50 PEN NEEDLES31G X3/16" (5MM) MISC F QL(5 ea daily)

FIFTY50 PEN NEEDLES31G X5/16" (8MM) MISC F QL(5 ea daily);

RX/OTCFIFTY50 PEN NEEDLES31GX5MM MISC F QL(5 ea daily)

FIFTY50 PENNEEDLES/31GX8MMMISC





FQL(5 ea daily)

FIFTY50 SUPERIORCOMFORTINSULINSYRINGE/0.3ML/31G X5/16" MISC

F

QL(5 ea daily)

FIFTY50 SUPERIORCOMFORTINSULINSYRINGE/0.5ML/31G X5/16" MISC

F

QL(5 ea daily)

FIFTY50 SUPERIORCOMFORTINSULINSYRINGE/1ML/31G X5/16" MISC

F

QL(5 ea daily)

FREDS PHARMACYUNIFINE PENTIPS PENNEEDLES 32GX4MMMISC

F


FREDS PHARMACYUNIFINE PENTIPS PLUS31GX5MM MISC

FQL(5 ea daily)

FREDS PHARMACYUNIFINE PENTIPS PLUS31GX8MM MISC


FREESTYLE PRECISIONINSULIN SYRINGE/U-100/0.5ML/30G X 5/16"MISC

F


FREESTYLE PRECISIONINSULIN SYRINGE/U-100/0.5ML/31G X 5/16"MISC

F

QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits

FREESTYLE PRECISIONINSULIN SYRINGE/U-100/1ML/31G X 5/16"MISC

F

QL(5 ea daily)

FREESTYLE PRECISIONINSULIN SYRINGES/U-100/1ML/30G X 5/16"MISC

F


GLOBAL EASE INJECTPEN NEEDLES29GX12MM MISC

FQL(5 ea daily)

GLOBAL EASE INJECTPEN NEEDLES 31GX8MMMISC


GLOBAL EASE INJECTPEN NEEDLES 32GX4MMMISC


GLOBAL EASE INJECTPEN NEEEDLES31GX5MM MISC

FQL(5 ea daily)

GLOBAL EASY GLIDEINSULINSYRINGE/U-100/0.3ML/31G X 5/16"MISC

F

QL(5 ea daily)

GLOBAL EASY GLIDEPEN NEEDLES 32GX4MMMISC


GLOBAL INJECT EASEINSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC

F



F

QL(5 ea daily)


F



F

QL(5 ea daily)


F



82

Drug Name DrugTier

Requirements/Limits


F



F

QL(5 ea daily)


F



F

QL(5 ea daily)

GLOBAL INJECT EASEINSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC





FQL(5 ea daily)

GLOBAL INJECT EASEINSULIN SYRINGE/U-100/1ML/30G X 5/16"MISC

F


GLOBAL INJECT EASEINSULIN SYRINGE/U-100/1ML/31G X 5/16"MISC

F

QL(5 ea daily)

GLOBAL INSULINSYRINGE/U-100/0.3ML/30G X 1/2"MISC

F

QL(5 ea daily)

GLOBAL INSULINSYRINGES/U-100/0.3ML/30GX5/16"MISC

F


GLUCOPRO INSULINSYRINGE/U-100/0.3ML/30G X 1/2"MISC

F

QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits


F



F

QL(5 ea daily)


F

QL(5 ea daily)


F



F

QL(5 ea daily)

GLUCOPRO INSULINSYRINGE/U-100/1ML/30GX 1/2" MISC

FQL(5 ea daily)




FQL(5 ea daily)

GNP CLICKFINE PENNEEDLEUNIVERSAL/31GX5/16" MISC


GNP CLICKFINEUNIVERSAL PENNEEDLES 31GX1/4" MISC

FQL(5 ea daily)

GNP CLICKFINEUNIVERSAL PENNEEDLES 31GX5/16"MISC

F


GNP INSULINSYRINGE/0.3ML/29G X1/2" MISC





FQL(5 ea daily)


83

Drug Name DrugTier

Requirements/Limits








FQL(5 ea daily)

GNP INSULINSYRINGE/1ML/28G X 1/2"MISC


GNP INSULINSYRINGE/1ML/29G X 1/2"MISC


GNP INSULINSYRINGE/1ML/30G X5/16" MISC


GNP INSULINSYRINGE/1ML/31G X5/16" MISC

FQL(5 ea daily)

GNP ULTRA COMFORTINSULINSYRINGE/0.3ML/29G X1/2" MISC

F


GNP ULTRA COMFORTINSULINSYRINGE/0.3ML/30G X5/16" SHORT MISC

F



F

QL(5 ea daily)


F



F



F


Drug Name DrugTier

Requirements/Limits


F

QL(5 ea daily)

GNP ULTRA COMFORTINSULINSYRINGE/1ML/28G X 1/2"MISC

F


GNP ULTRA COMFORTINSULINSYRINGE/1ML/29G X 1/2"MISC

F


GNP ULTRA COMFORTINSULINSYRINGE/1ML/30G X5/16" SHORT MISC

F


GNP ULTRA COMFORTINSULINSYRINGE/1ML/31G X5/16" SHORT MISC

F

QL(5 ea daily)

H-E-B IN CONTROL PENNEEDLES 31GX5MMMISC

FQL(5 ea daily)


FQL(5 ea daily)



H-E-B IN CONTROL PENNEEDLES/NANO/32GX4MM MISC


H-E-B IN CONTROLUNIFINEPENTIPS PLUS31GX5MM MISC

FQL(5 ea daily)

H-E-B IN CONTROLUNIFINEPENTIPS PLUS32GX4MM MISC


H-E-B INCONTROL PENNEEDLES 29GX12MMMISC

FQL(5 ea daily)

HEALTHWISE MINI PENNEEDLES 31GX6MMMISC

FQL(5 ea daily)

HEALTHWISE PENNEEDLES 29GX12MMMISC

FQL(5 ea daily)


84

Drug Name DrugTier

Requirements/Limits

HEALTHWISE SHORTPEN NEEDLES 31GX8MMMISC


HEALTHWISE UNIFINEPENTIPS PEN NEEDLES32GX4MM MISC


HEALTHY ACCENTSUNIFINE PENTIPS PENNEEDLES 29GX12MMMISC

F

QL(5 ea daily)


F

QL(5 ea daily)


F

QL(5 ea daily)


F



F


HUMAPEN LUXURA HDDEVI F

QL(1 ea per180 daysretail); RX/OTC

INSULINSYRINGE/0.3ML/29G X 1"MISC

FQL(5 ea daily)

INSULINSYRINGE/0.3ML/29G X1/2" MISC





FQL(5 ea daily)


FQL(5 ea daily)



Drug Name DrugTier

Requirements/Limits




FQL(5 ea daily)




FQL(5 ea daily)

INSULINSYRINGE/1ML/28G X 1/2"MISC


INSULINSYRINGE/1ML/29G X 1/2"MISC


INSULINSYRINGE/1ML/30G X5/16" MISC


INSULINSYRINGE/1ML/31G X5/16" MISC

FQL(5 ea daily)

INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC






INSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC F QL(5 ea daily);

RX/OTCINSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC F QL(5 ea daily);

RX/OTCINSULIN SYRINGE/U-100/1ML/30G X 5/16"MISC


INSULIN SYRINGE/U-100/1ML/31G X 5/16"MISC

FQL(5 ea daily)

INSULINSYRINGES/0.5ML/27GX1/2" MISC

FQL(5 ea daily)


85

Drug Name DrugTier

Requirements/Limits








FQL(5 ea daily)


FQL(5 ea daily)

INSULINSYRINGES/1ML/27GX/1/2"MISC


INSULINSYRINGES/1ML/27GX1/2"MISC







FQL(5 ea daily)

INSULINSYRINGES/1ML/31GX5/16" MISC

FQL(5 ea daily)

INSUPEN PEN NEEDLES32G X4MM MISC F QL(5 ea daily);

RX/OTCINSUPEN SENSITIVE32GX6MM MISC F QL(5 ea daily)

INSUPEN ULTRAFIN29GX12MM MISC F QL(5 ea daily)

INSUPEN ULTRAFIN30GX8MM MISC F QL(5 ea daily);

RX/OTCINSUPEN ULTRAFIN31GX6MM MISC F QL(5 ea daily)

INSUPEN ULTRAFIN31GX8MM MISC F QL(5 ea daily);

RX/OTC

Drug Name DrugTier

Requirements/Limits

KINRAY INSULINSYRINGE PREFERREDPLUS/0.3ML/31G X 5/16"MISC

F

QL(5 ea daily)

KINRAY INSULINSYRINGE PREFERREDPLUS/0.5ML/31G X 5/16"MISC

F

QL(5 ea daily)

KINRAY INSULINSYRINGE PREFERREDPLUS/1ML/31G X 5/16"MISC

F

QL(5 ea daily)

KINRAY INSULINSYRINGE/0.5ML/29G X1/2" MISC


KROGER INSULINSYRINGE/0.3ML/29G X1/2" MISC





FQL(5 ea daily)






FQL(5 ea daily)

KROGER INSULINSYRINGE/1ML/29G X 1/2"MISC


KROGER INSULINSYRINGE/1ML/30G X5/16" MISC


KROGER INSULINSYRINGE/1ML/31G X5/16" MISC

FQL(5 ea daily)

KROGER PEN NEEDLES29G X12MM MISC F QL(5 ea daily)

KROGER PEN NEEDLES31G X8MM MISC F QL(5 ea daily);

RX/OTCKROGER PEN NEEDLES31GX1/4" MISC F QL(5 ea daily)


86

Drug Name DrugTier

Requirements/Limits

LEADER INSULINSYRINGE/0.3ML/29G X1/2" MISC





FQL(5 ea daily)








FQL(5 ea daily)

LEADER INSULINSYRINGE/1ML/28G X 1/2"MISC


LEADER INSULINSYRINGE/1ML/29G X 1/2"MISC


LEADER INSULINSYRINGE/1ML/30G X5/16" MISC


LEADER INSULINSYRINGE/1ML/31G X5/16" MISC

FQL(5 ea daily)

LEADER UNIFINEPENTIPSPLUS/MINI/31GX3/16"MISC

F

QL(5 ea daily)

LEADER UNIFINEPENTIPSPLUS/SHORT/31GX5/16"MISC

F


LEADER UNIFINEPENTIPS/MINI/31GX3/16"MISC

FQL(5 ea daily)

LEADER UNIFINEPENTIPS/NANO/32GX5/32" MISC


Drug Name DrugTier

Requirements/Limits

LEADER UNIFINEPENTIPS/PLUS/32GX5/32"MISC


LITE TOUCH PENNEEDLES/31G X 3/16"MISC

FQL(5 ea daily)

LITETOUCH INSULINSYRINGE/0.3ML/29G X1/2" MISC





FQL(5 ea daily)




FQL(5 ea daily)

LITETOUCH INSULINSYRINGE/1ML/30G X5/16" MISC


LITETOUCH INSULINSYRINGE/U-100/0.5ML/28G X 1/2"MISC

F


LITETOUCH INSULINSYRINGE/U-100/0.5ML/29G X 1/2"MISC

F


LITETOUCH INSULINSYRINGE/U-100/1ML/28GX 1/2" MISC





FQL(5 ea daily)

LITETOUCH PENNEEDLES 29GX12.7MMMISC

FQL(5 ea daily)

LITETOUCH PENNEEDLES 31G X 6MMMISC

FQL(5 ea daily)


87

Drug Name DrugTier

Requirements/Limits

LITETOUCH PENNEEDLES 31GX8MMSHORT MISC


LIVE BETTER PENNEEDLES 29G X 12MMMISC

FQL(5 ea daily)




FQL(5 ea daily)

LONGS INSULINSYRINGE/0.5ML/31G X5/16" MISC

FQL(5 ea daily)

MAGELLAN INSULINSAFETY SYRINGE/U-100/0.3ML/29G X 1/2"MISC

F



F



F



F


MAGELLAN INSULINSAFETY SYRINGE/U-100/1ML/29G X 1/2" MISC


MAGELLAN INSULINSAFETY SYRINGE/U-100/1ML/30G X 5/16"MISC

F


MAXI-COMFORT INSULINSYRINGE/U-100/0.5ML/28GX1/2" MISC


MAXI-COMFORT INSULINSYRINGE/U-100/1ML/28GX1/2" MISC


MEDIC INSULINSYRINGE/0.3ML/30G X5/16" MISC


Drug Name DrugTier

Requirements/Limits

MEDIC INSULINSYRINGE/0.5ML/30G X5/16" MISC


MEDICINE SHOPPE PENNEEDLES 29G X 12MMMISC

FQL(5 ea daily)


FQL(5 ea daily)



MEIJER PEN NEEDLES29G X12MM MISC F QL(5 ea daily)

MEIJER PEN NEEDLES31G X6MM MISC F QL(5 ea daily)

MEIJER PEN NEEDLES31G X8MM MISC F QL(5 ea daily);

RX/OTCMONOJECT INSULINSYRINGE/1ML/31G X5/16" MISC

FQL(5 ea daily)

MONOJECT INSULINSYRINGE/DETACHNEEDLE/1ML/25G X 5/8"MISC

F

QL(5 ea daily)

MONOJECT INSULINSYRINGE/DETACHNEEDLE/1ML/27G X 1/2"MISC

F


MONOJECT INSULINSYRINGE/PERMNEEDLE/1ML/28G X 1/2"MISC

F


MONOJECT INSULINSYRINGE/PERMNEEDLE/U-100/0.5ML/28GX 1/2" MISC

F


MONOJECT INSULINSYRINGE/SAFETY/PERMNEEDLE/0.3ML/29G X 1/2"MISC

F


MONOJECT INSULINSYRINGE/SAFETY/PERMNEEDLE/0.3ML/29GX1/2"MISC

F



88

Drug Name DrugTier

Requirements/Limits

MONOJECT INSULINSYRINGE/SAFETY/PERMNEEDLE/0.5ML/29G X 1/2"MISC

F


MONOJECT INSULINSYRINGE/SAFETY/PERMNEEDLE/1ML/29G X 1/2"MISC

F


MONOJECT INSULINSYRINGE/SOFTPACK/1ML/27G X 1/2" MISC


MONOJECT INSULINSYRINGE/SOFTPACK/U-100/0.5ML/28G X 1/2"MISC

F


MONOJECT INSULINSYRINGE/U-100/0.3ML/30G X 5/16"MISC

F



F



F


MONOJECT INSULINSYRINGE/U-100/1ML/28GX 1/2" MISC


MONOJECT INSULINSYRINGE/U-100/1ML/30GX 5/16" MISC


MONOJECT ULTRACOMFORT INSULINSYRINGE/0.3ML/29G X1/2" MISC

F



F



F

QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits


F



F



F



F

QL(5 ea daily)

MONOJECT ULTRACOMFORT INSULINSYRINGE/1ML/28G X 1/2"MISC

F


MONOJECT ULTRACOMFORT INSULINSYRINGE/1ML/29G X 1/2"MISC

F


MONOJECT ULTRACOMFORT INSULINSYRINGE/1ML/30G X5/16" MISC

F


MOORE MED MONOJECTINSULIN SYRINGE/U-100/0.5ML/28G X 1/2"MISC

F


MOORE MED MONOJECTINSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC

QL(5 ea daily);RX/OTCF

MOORE MED MONOJECTINSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC


MOORE MED MONOJECTINSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC


MS INSULINSYRINGE/0.3ML/31G X5/16" MISC

FQL(5 ea daily)

MS INSULINSYRINGE/0.5ML/31G X5/16" MISC

FQL(5 ea daily)


89

Drug Name DrugTier

Requirements/Limits

MS INSULINSYRINGE/1ML/31G X5/16" MISC

FQL(5 ea daily)

NOVOFINE 30GX8MMMISC F QL(5 ea daily);

RX/OTCNOVOFINE 32GX6MMMISC F QL(5 ea daily)

NOVOFINE AUTOCOVER30GX8MM MISC F QL(5 ea daily);

RX/OTCNOVOFINE PLUS32GX4MM MISC F QL(5 ea daily);

RX/OTC

NOVOPEN ECHO DEVI FQL(1 ea per180 daysretail); RX/OTC

NOVOTWIST 30GX8MMMISC F QL(5 ea daily);

RX/OTCNOVOTWIST 32GX5MMMISC F QL(5 ea daily);

RX/OTCPC UNIFINE PENTIPS29G X1/2" MISC F QL(5 ea daily)

PC UNIFINE PENTIPS31G X5MM MINI MISC F QL(5 ea daily)

PC UNIFINE PENTIPS31G X6MM ULTRASHORT MISC

FQL(5 ea daily)

PC UNIFINE PENTIPS31G X8MM SHORT MISC F QL(5 ea daily);

RX/OTCPEN NEEDLES 29G X12MM MISC F QL(5 ea daily)

PEN NEEDLES 29GX1/2"MISC F QL(5 ea daily)

PEN NEEDLES 30GX5/16"MISC F QL(5 ea daily);

RX/OTCPEN NEEDLES 30GX8MMMISC F QL(5 ea daily);

RX/OTCPEN NEEDLES 31G X 1/4"SHORT MISC F QL(5 ea daily)

PEN NEEDLES 31G X3/16" MISC F QL(5 ea daily)

PEN NEEDLES 31G X5MM MISC F QL(5 ea daily)

PEN NEEDLES 31G X6MM MISC F QL(5 ea daily)

PEN NEEDLES 31GX5/16"MISC F QL(5 ea daily);

RX/OTC

Drug Name DrugTier

Requirements/Limits

PEN NEEDLES 31GX6MM(1/4") MISC F QL(5 ea daily)

PEN NEEDLES 31GX8MM(5/16") MISC F QL(5 ea daily);



RX/OTCPENTIPS 29GX12MMMISC F QL(5 ea daily)

PENTIPS 31GX5MM MISC F QL(5 ea daily)

PENTIPS 31GX6MM MISC F QL(5 ea daily)

PENTIPS 31GX8MM MISC F QL(5 ea daily);RX/OTC

PENTIPS 32GX4MM MISC F QL(5 ea daily);RX/OTC

PRECISION SURE-DOSEINSULINSYRINGE/0.3ML/30G X5/16" MISC

F



F



F



F

QL(5 ea daily)

PRECISION SURE-DOSEINSULINSYRINGE/1ML/28G X 1/2"MISC

F


PRECISION SURE-DOSEPLUSINSULINSYRINGE/0.3ML/29G X1/2" MISC

F


PRECISION SURE-DOSEPLUSINSULINSYRINGE/1ML/29G X 1/2"MISC

F



90

Drug Name DrugTier

Requirements/Limits

PREFERRED PLUSINSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC

F



F



F



F



F


PREFERRED PLUSINSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC


PREFERRED PLUSINSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC


PREFERRED PLUSINSULIN SYRINGE/U-100/1ML/30G X 5/16"MISC

F


PREFERRED PLUSUNIFINE PENTIPS 29G X12MM MISC

FQL(5 ea daily)

PREFERRED PLUSUNIFINE PENTIPS 31G X6MM ULTRA SHORTMISC

F

QL(5 ea daily)

PREFERRED PLUSUNIFINE PENTIPS 31G X8MM SHORT MISC


PREFERRED PLUSUNIFINE PENTIPS32GX4MM MISC


PREFERRED PLUSUNIFINEPENTIPS/MINI/31GX5MMMISC

F

QL(5 ea daily)

Drug Name DrugTier

Requirements/Limits

PRO COMFORT PENNEEDLES/31G X 8MMMISC







FQL(5 ea daily)

PRODIGY INSULINSYRING/U-100/0.3ML/31GX 5/16" MISC

FQL(5 ea daily)

PRODIGY INSULINSYRINGE/1/2ML/31G X5/16" MISC

FQL(5 ea daily)

PRODIGY INSULINSYRINGE/1ML/28G X 1/2"MISC


PX EXTRA SHORT PENNEEDLES 31GX6MMMISC

FQL(5 ea daily)

PX INSULIN SYRINGE/U-100/0.3ML/30G X 1/2"MISC

FQL(5 ea daily)


FQL(5 ea daily)


FQL(5 ea daily)


FQL(5 ea daily)

PX INSULIN SYRINGE/U-100/1ML/30G X 1/2" MISC F QL(5 ea daily)

PX INSULIN SYRINGE/U-100/1ML/31G X 5/16"MISC

FQL(5 ea daily)

PX MINI PEN NEEDLES31GX5MM MISC F QL(5 ea daily)

PX PEN NEEDLE29GX12MM MISC F QL(5 ea daily)

PX PEN NEEDLE31GX8MM MISC F QL(5 ea daily);

RX/OTC


91

Drug Name DrugTier

Requirements/Limits

PX SHORTLENGTH PENNEEDLES/31GX8MMMISC


QC PEN NEEDLES 29G X12MM MISC F QL(5 ea daily)

QC PEN NEEDLES 31G X6MM MISC F QL(5 ea daily)

QC PEN NEEDLES 31G X8MM MISC F QL(5 ea daily);

RX/OTCQC UNIFINE PENTIPS32GX4MM MISC F QL(5 ea daily);

RX/OTCRA INSULINSYRINGE/0.5ML/29G X1/2" MISC


RA INSULINSYRINGE/1ML/29G X 1/2"MISC


RA INSULIN SYRINGE/U-100/0.5ML/30G X 5/16"MISC


RA INSULIN SYRINGE/U-100/1 ML/30G X 5/16"MISC


RA PEN NEEDLES 31G X5MM3/16" MISC F QL(5 ea daily)

RA PEN NEEDLES 31G X8MM5/16" MISC F QL(5 ea daily);

RX/OTCREALITY INSULINSYRINGE/U-100/0.5ML/28G X 1/2"MISC

F


REALITY INSULINSYRINGE/U-100/0.5ML/29G X 1/2"MISC

F


REALITY INSULINSYRINGE/U-100/1ML/28GX 1/2" MISC


REALITY INSULINSYRINGE/U-100/1ML/29GX 1/2" MISC


RELION INSULINSYRINGE1ML/31GX15/64" MISC

FQL(5 ea daily)

RELION INSULINSYRINGE/U-00/1ML/29GX 1/2" MISC


Drug Name DrugTier

Requirements/Limits

RELION INSULINSYRINGE/U-100/0.3ML/29G X 1/2"MISC

F



F



F

QL(5 ea daily)


F



F



F

QL(5 ea daily)




FQL(5 ea daily)

RELION MINI PENNEEDLES 31GX6MMMISC

FQL(5 ea daily)

RELION PEN NEEDLES29GX12MM MISC F QL(5 ea daily)

RELION PEN NEEDLES31GX6MM MISC F QL(5 ea daily)

RELION PEN NEEDLES31GX8MM MISC F QL(5 ea daily);

RX/OTCRELION PEN NEEDLES32GX4MM MISC F QL(5 ea daily);

RX/OTCRELION SHORT PENNEEDLES31GX8MM MISC F QL(5 ea daily);

RX/OTCSAFESNAP INSULINSYRINGE/0.3ML/30G X5/16" MISC



92

Drug Name DrugTier

Requirements/Limits

SAFESNAP INSULINSYRINGE/0.5ML/29G X1/2" MISC


SAFESNAP INSULINSYRINGE/0.5ML/30G X5/16" MISC


SAFESNAP INSULINSYRINGE/1ML/28G X 1/2"MISC


SAFESNAP INSULINSYRINGE/1ML/29G X 1/2"MISC


SAFETY INSULINSYRINGES0.5ML/29GX1/2" MISC


SAFETY INSULINSYRINGES0.5ML/30GX5/16" MISC


SAFETY INSULINSYRINGES 1ML/27GX1/2"MISC





FQL(5 ea daily)

SAFETY-GLIDE INSULINSYRINGE/0.3ML/29G X1/2" MISC


SB INSULIN SYRINGE/U-100/0.5ML/29G X 1/2"MISC


SB INSULIN SYRINGE/U-100/0.5ML/30G X 5/16"MISC


SB INSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC F QL(5 ea daily);

RX/OTCSB INSULIN SYRINGE/U-100/1ML/30G X 5/16"MISC


SB INSULIN SYRINGE/U-100/1ML/31G X 5/16"MISC

FQL(5 ea daily)

SCHNUCKS INSULINSYRINGEULTI-FINE/U-100/0.5ML/29G X 1/2"MISC

F


Drug Name DrugTier

Requirements/Limits

SCHNUCKS INSULINSYRINGEULTI-FINE/U-100/0.5ML/30G X 5/16"MISC

F


SHOPKO UNIFINEPENTIPS PENNEEDLES/MICRO/32GX4MM MISC

F


SHOPKO UNIFINEPENTIPS PENNEEDLES/MINI/31GX5MMMISC

F

QL(5 ea daily)

SHOPKO UNIFINEPENTIPS PENNEEDLES/ORIGINAL/29GX12MM MISC

F

QL(5 ea daily)

SHOPKO UNIFINEPENTIPS PENNEEDLES/SHORT/31GX8MM MISC

F


SHOPKO UNIFINEPENTIPS PLUS PENNEEDLES/MICRO/REMOVR/32GX4MM MISC

F


SHOPKO UNIFINEPENTIPS PLUS PENNEEDLES/MINI/REMOVER/31GX5MM MISC

F

QL(5 ea daily)

SHOPKO UNIFINEPENTIPS PLUS PENNEEDLES/REMOVER/29GX12MM MISC

F

QL(5 ea daily)

SHOPKO UNIFINEPENTIPS PLUS PENNEEDLES/SHORT/REMOVR/31GX8MM MISC

F


SM INSULINSYRINGE/1ML/31G X5/16" MISC

FQL(5 ea daily)

SURE COMFORTINSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC

F



F

QL(5 ea daily)


93

Drug Name DrugTier

Requirements/Limits


F


SURE COMFORTINSULIN SYRINGE/U-100/0.3ML/31G X 5/16MISC

F

QL(5 ea daily)


F

QL(5 ea daily)


F



F



F

QL(5 ea daily)


F


SURE COMFORTINSULIN SYRINGE/U-100/0.5ML/31G X 5/16MISC

F

QL(5 ea daily)

SURE COMFORTINSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC





FQL(5 ea daily)

SURE COMFORTINSULIN SYRINGE/U-100/1ML/30G X 5/16"MISC

F


Drug Name DrugTier

Requirements/Limits

SURE COMFORTINSULIN SYRINGE/U-100/1ML/31G X 5/16"MISC

F

QL(5 ea daily)

SURE COMFORT PENNEEDLES29GX1/2"12.7MM MISC

FQL(5 ea daily)

SURE COMFORT PENNEEDLES30GX5/16"SHORT MISC


SURE COMFORT PENNEEDLES31GX3/16"(5MM) MISC

FQL(5 ea daily)

SURE COMFORT PENNEEDLES31GX5/16"(8MM) MISC


SURE COMFORT PENNEEDLES32GX5/32" MISC F QL(5 ea daily);

RX/OTCSURE COMFORT PENNEEDLES32GX6MM MISC F QL(5 ea daily)

SURE-FINE PENNEEDLES 29GX1/2"12.7MM MISC

FQL(5 ea daily)

SURE-FINE PENNEEDLES 31GX3/16" 5MMMISC

FQL(5 ea daily)

SURE-FINE PENNEEDLES 31GX5/16" 8MMMISC


SURE-JECT INSULINSYRINGE/U-100/0.3ML/29G X 1/2"MISC

F



F



F

QL(5 ea daily)


F



94

Drug Name DrugTier

Requirements/Limits


F



F



F

QL(5 ea daily)

SURE-JECT INSULINSYRINGE/U-100/1ML/28GX 1/2" MISC







FQL(5 ea daily)

TECHLITE PENNEEDLES/31GX 5MMMISC

FQL(5 ea daily)

TECHLITE PENNEEDLES/31GX 6 MMMISC

FQL(5 ea daily)






FQL(5 ea daily)

TODAYS HEALTH MINIPEN NEEDLES 31G X 1/4"MISC

FQL(5 ea daily)

TODAYS HEALTHORIGINAL PEN NEEDLES29G X 1/2" MISC

FQL(5 ea daily)

TODAYS HEALTH SHORTPEN NEEDLES 31G X5/16" MISC


Drug Name DrugTier

Requirements/Limits

TOPCARE CLICKFINEUNIVERSAL PEN EEDLES31GX1/4" MISC

FQL(5 ea daily)

TOPCARE CLICKFINEUNIVERSAL PEN EEDLES31GX5/16" MISC


TOPCARE ULTRACOMFORT INSULINSYRINGE/0.3ML/30G X5/16" MISC

F



F

QL(5 ea daily)


F



F

QL(5 ea daily)

TOPCARE ULTRACOMFORT INSULINSYRINGE/1ML/30G X5/16" MISC

F


TOPCARE ULTRACOMFORT INSULINSYRINGE/1ML/31G X5/16" MISC

F

QL(5 ea daily)

TOPCARE ULTRACOMFORT INSULINSYRINGE/U-100/0.3ML/29G X 1/2"MISC

F


TOPCARE ULTRACOMFORT INSULINSYRINGE/U-100/0.5ML/29G X 1/2"MISC

F


TOPCARE ULTRACOMFORT INSULINSYRINGE/U-100/1ML/29GX 1/2" MISC

F


TOPCO INSULINSYRINGE/U-100/0.3ML/29G X 1/2"MISC

F



95

Drug Name DrugTier

Requirements/Limits


F



F


TOPCO INSULINSYRINGE/U-100/1ML/28GX 1/2" MISC


TOPCO INSULINSYRINGE/U-100/1ML/29GX 1/2" MISC


TRUEPLUS INSULINSYRINGE/U-100/0.3ML/29G X 1/2"MISC

F



F



F

QL(5 ea daily)


F



F



F



F

QL(5 ea daily)

TRUEPLUS INSULINSYRINGE/U-100/1ML/28GX 1/2" MISC




Drug Name DrugTier

Requirements/Limits




FQL(5 ea daily)

TRUEPLUS PENNEEDLES 29GX12MMMISC

FQL(5 ea daily)


FQL(5 ea daily)


FQL(5 ea daily)





ULTICARE INSULINSAFETYSYRINGE/0.5ML/29G X1/2" MISC

F


ULTICARE INSULINSAFETYSYRINGE/1ML/29G X 1/2"MISC

F


ULTICARE INSULINSYRINGE/0.3ML/29G X1/2" MISC



FQL(5 ea daily)








FQL(5 ea daily)


96

Drug Name DrugTier

Requirements/Limits



ULTICARE INSULINSYRINGE/1ML/28G X 1/2"MISC





FQL(5 ea daily)

ULTICARE INSULINSYRINGE/1ML/30G X5/16" MISC


ULTICARE INSULINSYRINGE/SHORT/0.3ML/30G X 5/16" MISC



FQL(5 ea daily)




FQL(5 ea daily)

ULTICARE INSULINSYRINGE/SHORT/1ML/30G X 5/16" MISC


ULTICARE INSULINSYRINGE/SHORT/1ML/31G X 5/16" MISC

FQL(5 ea daily)

ULTICARE INSULINSYRINGE/U-100/0.3ML/29G X 1/2"MISC

F



F

QL(5 ea daily)


F


Drug Name DrugTier

Requirements/Limits


F

QL(5 ea daily)


F



F

QL(5 ea daily)


F



F

QL(5 ea daily)

ULTICARE INSULINSYRINGE/U-100/1ML/29GX 1/2" MISC



FQL(5 ea daily)




FQL(5 ea daily)

ULTICARE INSULINSYRINGEULTRAFINE U-100/0.3ML/31G X 5/16"MISC

F

QL(5 ea daily)

ULTICARE INSULINSYRINGEULTRAFINE U-100/0.5ML/31G X 5/16"MISC

F

QL(5 ea daily)

ULTICARE INSULINSYRINGEULTRAFINE U-100/1ML/31G X 5/16"MISC

F

QL(5 ea daily)

ULTICARE MICRO PENNEEDLES 31G X 8MMMISC



97

Drug Name DrugTier

Requirements/Limits

ULTICARE MICRO PENNEEDLES 32G X 4MMMISC


ULTICARE MICRO PENNEEDLES/32G X 4MMMISC


ULTICARE MINI PENNEEDLES 31GX6MMMISC

FQL(5 ea daily)

ULTICARE MINI PENNEEDLES ULTI-FINE IVMISC

FQL(5 ea daily)

ULTICARE MINI PENNEEDLES/31G X 6MMMISC

FQL(5 ea daily)

ULTICARE MINI PENNEEDLES31GX6MM MISC F QL(5 ea daily)

ULTICARE ORIGINALPEN NEEDLES ULTI-FINEMISC

FQL(5 ea daily)

ULTICARE PENNEEDLES/29GX 12.7MMMISC

FQL(5 ea daily)

ULTICARE SHORT PENNEEDLES 31GX8MMMISC


ULTICARE SHORT PENNEEDLES ULTI-FINE IVMISC


ULTICARE SHORT PENNEEDLES/31G X 8MMMISC


ULTILET INSULINSYRINGE/SHORT/0.3ML/30G X 5/16" MISC



FQL(5 ea daily)




FQL(5 ea daily)

ULTILET INSULINSYRINGE/SHORT/1ML/30G X 5/16" MISC


Drug Name DrugTier

Requirements/Limits

ULTILET INSULINSYRINGE/SHORT/1ML/31G X 5/16" MISC

FQL(5 ea daily)

ULTILET PEN NEEDLE32GX4MM/SHORT MISC F QL(5 ea daily);

RX/OTCULTILET SHORT PENNEEDLES 31GX5/16"MISC


ULTILET SHORT PENNEEDLES31GX3/16" MISC F QL(5 ea daily)

ULTRA COMFORTINSULIN SYRINGE/U-100/0.3ML/30G X 5/16"MISC

F


ULTRA COMFORTINSULIN SYRINGE/U-100/0.5ML/28G X 1/2"MISC

F


ULTRA-COMFORTINSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC

F



F



F

QL(5 ea daily)


F



F



F



F

QL(5 ea daily)


98

Drug Name DrugTier

Requirements/Limits

ULTRA-COMFORTINSULIN SYRINGE/U-100/1ML/28G X 1/2" MISC


ULTRA-COMFORTINSULIN SYRINGE/U-100/1ML/29G X 1/2" MISC


ULTRA-COMFORTINSULIN SYRINGE/U-100/1ML/30G X 5/16"MISC

F


ULTRA-COMFORTINSULIN SYRINGE/U-100/1ML/31G X 5/16"MISC

F

QL(5 ea daily)

ULTRA-THIN II INSULINSYRINGE SHORT/U-100/0.3ML/30GX5/16"MISC

F



F

QL(5 ea daily)


F



F

QL(5 ea daily)

ULTRA-THIN II INSULINSYRINGE SHORT/U-100/1ML/30GX5/16" MISC


ULTRA-THIN II INSULINSYRINGE SHORT/U-100/1ML/31GX5/16" MISC

FQL(5 ea daily)

ULTRA-THIN II INSULINSYRINGE/U-100/0.3ML/29GX1/2" MISC


ULTRA-THIN II INSULINSYRINGE/U-100/0.5ML/29GX1/2" MISC


ULTRA-THIN II INSULINSYRINGE/U-100/1ML/29GX1/2" MISC


ULTRA-THIN II MINI PENNEEEDLES/31GX3/16"MISC

FQL(5 ea daily)

Drug Name DrugTier

Requirements/Limits

ULTRA-THIN II PENNEEDLES 29GX1/2" MISC F QL(5 ea daily)

ULTRA-THIN II PENNEEDLES/SHORT/31GX5/16" MISC


UNIFINE PENTIPS29GX12MM MISC F QL(5 ea daily)

UNIFINE PENTIPS 31G X3/16" MISC F QL(5 ea daily)



UNIFINE PENTIPS31GX8MM MISC F QL(5 ea daily);

RX/OTCUNIFINE PENTIPS32GX4MM MISC F QL(5 ea daily);

RX/OTCUNIFINE PENTIPS PLUS29GX12MM MISC F QL(5 ea daily)

UNIFINE PENTIPS PLUS31GX5MM MISC F QL(5 ea daily)

UNIFINE PENTIPS PLUS31GX6MM MISC F QL(5 ea daily)

UNIFINE PENTIPS PLUS31GX8MM MISC F QL(5 ea daily);

RX/OTCUNIFINE PENTIPS PLUS32GX4MM MISC F QL(5 ea daily);

RX/OTCV-R MONOJECT INSULINSYRINGE/U-100/0.3ML/29G X 1/2"MISC

F


V-R MONOJECT INSULINSYRINGE/U-100/0.5ML/28G X 1/2"MISC

F


V-R MONOJECT INSULINSYRINGE/U-100/0.5ML/29G X 1/2"MISC

F


V-R MONOJECT INSULINSYRINGE/U-100/1ML/28GX 1/2" MISC


V-R MONOJECT INSULINSYRINGE/U-100/1ML/29GX 1/2" MISC



99

Drug Name DrugTier

Requirements/Limits

VALUE HEALTH INSULINSYRINGE/U-100/0.5ML/29G X 1/2"MISC

F


VALUE HEALTH INSULINSYRINGE/U-100/1ML/29GX 1/2" MISC


VALUMARK PENNEEDLES 29GX12MMMISC

FQL(5 ea daily)

VALUMARK PENNEEDLES 31GX 6MMMISC

FQL(5 ea daily)

VALUMARK PENNEEDLES 31GX 8MMMISC


VANISHPOINT INSULINSYRINGE/0.5ML/30G X1/2" MISC

FQL(5 ea daily)

VANISHPOINT INSULINSYRINGE/0.5ML/30G X5/16" MISC


VANISHPOINT INSULINSYRINGE/1ML/29G X 1/2"MISC


VANISHPOINT INSULINSYRINGE/1ML/30G X5/16" MISC


VIDA MIA UNIFINEPENTIPS32GX4MM MISC F QL(5 ea daily);

RX/OTCVIDA MIA UNIFINEPENTIPSMINI 31GX6MMMISC

FQL(5 ea daily)

VIDA MIA UNIFINEPENTIPSORIGINAL29GX12MM MISC

FQL(5 ea daily)

VIDA MIA UNIPFINEPENTIPSSHORT31GX8MM MISC


VP INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"MISC


WEGMANS UNIFINEPENTIPS PLUS 32GX4MMMISC


Drug Name DrugTier

Requirements/Limits

WEGMANS UNIFINEPENTIPSPLUS/MINI/31GX5MMMISC

F

QL(5 ea daily)

WEGMANS UNIFINEPENTIPSPLUS/SHORT/31GX8MMMISC

F


WEGMANS UNIFINEPENTIPS PLUS/ULTRASHORT/31GX6MM MISC

FQL(5 ea daily)

Respiratory Therapy SuppliesAEROCHAMBER MINIAEROSOLCHAMBERDEVI

FQL(2 ea per360 daysretail); RX/OTC

AEROCHAMBER MVMISC F


AEROCHAMBER PLUSFLOW VU MISC F


AEROCHAMBER PLUSFLOW-VU MISC F


AEROCHAMBER PLUSFLOW-VU/LARGE MASKMISC


AEROCHAMBER PLUSFLOW-VU/MASK MISC F


AEROCHAMBER PLUSFLOW-VU/MEDIUM MASKMISC


AEROCHAMBER PLUSFLOW-VU/SMALL MASKMISC


AEROCHAMBER Z-STATPLUS VALVED HOLDINGCHAMBER W/FLOW VUMISC

F


AEROCHAMBER Z-STATPLUS/FLOWSIGNAL MISC F


AEROCHAMBER Z-STATPLUS/LARGE MASK MISC F



100

Drug Name DrugTier

Requirements/Limits

AEROCHAMBER Z-STATPLUS/MEDIUM MASKMISC


AEROCHAMBER Z-STATPLUS/SMALL MASK MISC F


AEROCHAMBER/FLOWSIGNAL MISC F


AEROVENT PLUSHOLDINGCHAMBER/COLLAPSIBLEDEVI

F


ARIAL CHAMBER DEVI FQL(2 ea per360 daysretail); RX/OTC

BREATHERITECOLLAPSIBLEADULTSPACER W/MASK MISC


BREATHERITECOLLAPSIBLECHILDSPACER W/MASK MISC


BREATHERITECOLLAPSIBLEINFANTSPACER W/MASK MISC


BREATHERITECOLLAPSIBLESMALLCHILD SPACER W/MASKMISC

F


BREATHERITECOLLAPSIBLESPACERW/ NEONATE MASK MISC


BREATHERITE MISC FQL(2 ea per360 daysretail); RX/OTC

BREATHERITE RIGIDSPACERW/MASK MISC F


BREATHERITE W/LARGEMASK MISC F


BREATHERITEW/MEDIUM MASK MISC F


BREATHERITE W/SMALLMASK MISC F


Drug Name DrugTier

Requirements/Limits

CLEVER CHOICE ANTI-STATICVALVEDHOLDINGCHAMBER/ADULT LARGEDEVI

F


CLEVER CHOICE ANTI-STATICVALVEDHOLDINGCHAMBER/MEDIUM DEVI

F


CLEVER CHOICE ANTI-STATICVALVEDHOLDINGCHAMBER/SMALL DEVI

F


COMPACT SPACECHAMBER/ANTI-STATICDEVI


COMPACT SPACECHAMBER/ANTI-STATIC/LARGE MASKDEVI

F


COMPACT SPACECHAMBER/ANTI-STATIC/MEDIUM MASKDEVI

F


COMPACT SPACECHAMBER/ANTI-STATIC/SMALL MASKDEVI

F


E-Z SPACER DEVI FQL(2 ea per360 daysretail); RX/OTC

E-Z SPACER THE BODYGUARDS PACK DEVI F


EASIVENT MISC FQL(2 ea per360 daysretail); RX/OTC

EASIVENT/MASK-LARGEMISC F


EASIVENT/MASK-MEDIUM MISC F


EASIVENT/MASK-SMALLMISC F



101

Drug Name DrugTier

Requirements/Limits

FLEXICHAMBER DEVI FQL(2 ea per360 daysretail); RX/OTC

INSPIRACHAMBER/ANTI-STATICVALVED/MOUTHPIECEDEVI

F


INSPIRACHAMBER/LARGE DEVI F


INSPIRACHAMBER/SOOTHERMASK/INSPIRAMASK/MEDIUM DEVI


INSPIRACHAMBER/SOOTHERMASK/INSPIRAMASK/SMALL DEVI


INSPIREASE BAGS MISC F QL(3 ea per180 days retail)

INSPIREASE DRUGDELIVERYSYSTEM MISC F


INSPIREASEMOUTHPIECE MISC F QL(3 ea per

180 days retail)INSPIREASE RESERVOIRBAGS MISC F QL(3 ea per

180 days retail)

LITEAIRE DEVI FQL(2 ea per360 daysretail); RX/OTC

MICROCHAMBER MISC FQL(2 ea per360 daysretail); RX/OTC

MICROSPACER MISC FQL(2 ea per360 daysretail); RX/OTC

OPTICHAMBERADVANTAGE MISC F


OPTICHAMBERADVANTAGE/LARGEMASK MISC


OPTICHAMBERADVANTAGE/MEDIUMFACE MASK MISC


OPTICHAMBERADVANTAGE/SMALLFACE MASK MISC


Drug Name DrugTier

Requirements/Limits

OPTICHAMBERDIAMOND DEVI F


OPTICHAMBERDIAMOND MISC F


OPTICHAMBERDIAMOND/LARGEFACEMASK DEVI


OPTICHAMBERDIAMOND/MEDIUM FACEMASK MISC


OPTICHAMBERDIAMOND/SMALLFACEMASK MISC


OPTICHAMBER FACEMASK/LARGE MISC F


OPTICHAMBER FACEMASK/MEDIUM MISC F


OPTICHAMBER FACEMASK/SMALL MISC F


OPTIHALER MDI DRUGDELIVERY SYSTEM DEVI F


OPTIHALER MISC FQL(2 ea per360 daysretail); RX/OTC

POCKET CHAMBER DEVI FQL(2 ea per360 daysretail); RX/OTC

POCKET SPACER DEVI FQL(2 ea per360 daysretail); RX/OTC

RITEFLO DEVI FQL(2 ea per360 daysretail); RX/OTC

VALVED HOLDINGCHAMBER DEVI F


VORTEX VALVEDHOLDING CHAMBERDEVI


WATCHHALER DEVI FQL(2 ea per360 daysretail); RX/OTC


102

Drug Name DrugTier

Requirements/Limits

MIGRAINE PRODUCTS - Drugs to Treat MigraineHeadachesMigraine ProductsD.H.E. 45 SOLN (UseDihydroergotamineMesylate)

NFAL

dihydroergotaminemesylate soln ij 1 mg/ml F AL

DIHYDROERGOTAMINEMESYLATE SOLN NA 4MG/ML

FAL

MIGRANAL SOLN F AL

Serotonin Agonists

AMERGE TABS (UseNaratriptan HCl) NF

Limit 9 permonth;QL(0.3ea daily); AL

IMITREX SOLN NA 5MG/ACT, 20 MG/ACT (UseSumatriptan)

NFLimit 6 permonth;QL(0.2ea daily); AL

IMITREX SOLN SC 6MG/0.5ML (UseSumatriptan Succinate)

NFLimit 2 permonth;QL(0.067 ml daily); AL

IMITREX STATDOSEREFILL SOCT (UseSumatriptan Succinate)

NFLimit 2 permonth;QL(0.067 ml daily); AL

IMITREX STATDOSESYSTEM SOAJ (UseSumatriptan Succinate)

NF

Limit 2 syringespermonth;QL(0.067 ml daily); AL

IMITREX TABS (UseSumatriptan Succinate) NF


MAXALT TABS (UseRizatriptan Benzoate) NF


naratriptan hcl tabs FLimit 9 permonth;QL(0.3ea daily); AL

RELPAX TABS FLimit 6 permonth;QL(0.2ea daily); AL

rizatriptan benzoate tabs FLimit 12 permonth;QL(0.4ea daily); AL

Drug Name DrugTier

Requirements/Limits

sumatriptan soln FLimit 6 permonth;QL(0.2ea daily); AL

sumatriptan succinate soaj F


sumatriptan succinate soct FLimit 2 permonth;QL(0.067 ml daily); AL

sumatriptan succinate soln FLimit 2 permonth;QL(0.067 ml daily); AL

SUMATRIPTANSUCCINATE SOSY F


sumatriptan succinate tabs FLimit 9 permonth;QL(0.3ea daily); AL

zolmitriptan tabs FLimit 6 permonth;QL(0.2ea daily); AL

zolmitriptan tbdp FLimit 6 permonth;QL(0.2ea daily); AL

ZOMIG SOLN FLimit 6 permonth;QL(0.2ea daily); AL

ZOMIG TABS (UseZolmitriptan) NF


ZOMIG ZMT TBDP (UseZolmitriptan) NF


MINERALS & ELECTROLYTES

CalciumCALCI-CHEW CHEW F

calcium carbonate susp F QL(16.67 mldaily)

calcium carbonate tabs F

calcium carbonate-cholecalciferol chew F


103

Drug Name DrugTier

Requirements/Limits

calcium carbonate-cholecalciferol tabs F

calcium carbonate-vitamind tabs 500mg-500mg-200unit-200unit, 125unit-500mg, 200unit-500mg,125unit-250mg, 250mg-125unit, 500mg-200unit,500mg-125unit

F

calcium carbonate-vitamind tabs 600mg-200unit,400unit-600mg, 200unit-600mg, 600mg-400unit

F

QL(2 ea daily)

calcium citrate tabs F

CALCIUM TABS 600MG-200UNIT F

calcium w/ vitamin d tabs F

CALTRATE 600+D TABS(Use Calcium Carbonate-Cholecalciferol)

NF

oyster shell tabs F

PARVA-CAL TABS F

Electrolyte MixturesCERALYTE 70 SOLN F

CERASPORT EX1 SOLN F

CERASPORT SOLN F

ENFAMIL ENFALYTESOLN F

oral electrolytes soln F

PEDIALYTE FREEZERPOPS SOLN (Use OralElectrolytes)

NF

PEDIALYTE SOLN20MEQ/L-45MEQ/L-35MEQ/L-5GM/L-20GM/L,20MEQ/L-45MEQ/L-35MEQ/L-30MEQ/L-25GM/L (Use OralElectrolytes)

NF

Fluoride

Drug Name DrugTier

Requirements/Limits

LURIDE SOLN (UseSodium Fluoride) NF AL

sodium fluoride chew F AL

sodium fluoride soln F AL

Iodine ProductsSSKI SOLN F

MagnesiumMAG64 TBCR F

magnesium oxide (mgsupplement) tabs F MAGOX 400 TABS (UseMagnesium Oxide (MgSupplement))

NF

PhosphateK-PHOS NEUTRAL TABS(Use Pot PhosphateMonobasic w/ SodPhosphate Dibasic &Monobasic)

NF

QL(8 ea daily)

pot phosphate monobasicw/ sod phosphate dibasic &monobasic tabs

FQL(8 ea daily)

PotassiumK-TAB TBCR 10 MEQ (UsePotassium Chloride) NF

K-TAB TBCR 8 MEQ F

KLOR-CON M15 TBCR F MICRO-K CPCR 10 MEQ(Use Potassium Chloride) NF

MICRO-K CPCR 8 MEQ(Use Potassium Chloride) NF QL(1 ea daily)

potassium bicarbonate tbef F

potassium chloride cpcr 10meq F

potassium chloride cpcr 8meq F QL(1 ea daily)

POTASSIUM CHLORIDEER TBCR F


104

Drug Name DrugTier

Requirements/Limits

potassium chloridemicroencapsulated crystalscr tbcr

F

potassium chloride pack F

potassium chloride soln 10%, 20 % F

POTASSIUM CHLORIDESOLN 20 % F

potassium chloride tbcr F

Sodiumsodium chloride soln F

Zinczinc sulfate caps F

MISCELLANEOUS THERAPEUTIC CLASSES

Chelating AgentsDEPEN TITRATABS TABS F

Immunosuppressive AgentsAZASAN TABS F QL(3 ea daily)

azathioprine tabs F

CELLCEPT CAPS (UseMycophenolate Mofetil) NF QL(2 ea daily)

CELLCEPTINTRAVENOUS SOLR(Use MycophenolateMofetil HCl)

NF

CELLCEPT SUSR (UseMycophenolate Mofetil) NF QL(15 ml daily)

CELLCEPT TABS (UseMycophenolate Mofetil) NF QL(4 ea daily)

cyclosporine caps F QL(4 ea daily)

cyclosporine modified (formicroemulsion) caps F QL(4 ea daily)

cyclosporine modified (formicroemulsion) soln F QL(8 ml daily)

CYCLOSPORINEMODIFIED CAPS (UseCyclosporine Modified (ForMicroemulsion))

NF

QL(4 ea daily)

Drug Name DrugTier

Requirements/Limits

IMURAN TABS (UseAzathioprine) NF

mycophenolate mofetilcaps F QL(2 ea daily)

mycophenolate mofetil hclsolr F

mycophenolate mofetil susr F QL(15 ml daily)

mycophenolate mofetil tabs F QL(4 ea daily)

mycophenolate sodiumtbec 180 mg F QL(2 ea daily)

mycophenolate sodiumtbec 360 mg F QL(4 ea daily)

MYFORTIC TBEC 180 MG(Use MycophenolateSodium)

NFQL(2 ea daily)

MYFORTIC TBEC 360 MG(Use MycophenolateSodium)

NFQL(4 ea daily)

NEORAL CAPS (UseCyclosporine Modified (ForMicroemulsion))

NFQL(4 ea daily)

NEORAL SOLN (UseCyclosporine Modified (ForMicroemulsion))

NFQL(8 ml daily)

PROGRAF CAPS (UseTacrolimus) NF QL(3 ea daily)

PROGRAF SOLN F

RAPAMUNE SOLN F

RAPAMUNE TABS (UseSirolimus) NF

SANDIMMUNE CAPS (UseCyclosporine) NF QL(4 ea daily)

SANDIMMUNE SOLN OR100 MG/ML F QL(8 ml daily)

sirolimus tabs F

tacrolimus caps F QL(3 ea daily)

Potassium Removing AgentsKAYEXALATE POWD (UseSodium PolystyreneSulfonate)



105

Drug Name DrugTier

Requirements/Limits

sodium polystyrenesulfonate powd F QL(454 gm per

fill retail)sodium polystyrenesulfonate susp F

MOUTH/THROAT/DENTAL AGENTS

Anesthetics Topical Orallidocaine hcl (mouth-throat)soln F QL(100 ml per

fill retail)Anti-infectives - Throatnystatin (mouth-throat)susp F QL(120 ml per

fill retail)Antiseptics - Mouth/Throatchlorhexidine gluconate(mouth-throat) soln F

PERIDEX SOLN (UseChlorhexidine Gluconate(Mouth-Throat))

NF

Dental ProductsPREVIDENT 5000 DRYMOUTH GEL (Use SodiumFluoride (Dental))


PREVIDENT 5000 PLUSCREA (Use SodiumFluoride (Dental))


PREVIDENT FLUORIDEGEL (Use Sodium Fluoride(Dental))


PREVIDENT SOLN (UseSodium Fluoride (Dental)) NF RX/OTC

sodium fluoride (dental)crea F QL(60 gm per

fill retail)

sodium fluoride (dental) gel F QL(60 ml perfill retail)

sodium fluoride (dental)soln F RX/OTC

THERA-FLUR-N GEL (UseSodium Fluoride (Dental)) NF QL(60 ml per

fill retail)Steroids - Mouth/Throattriamcinolone acetonide(mouth) pste F QL(5 gm per fill

retail)Throat Products - Misc.

AQUORAL SOLN FQL(900 ml perfill retail);RX/OTC

Drug Name DrugTier

Requirements/Limits

BIOTENE DRY MOUTHMOISTURIZING SPRAYSOLN

FQL(900 ml perfill retail);RX/OTC

CAPHOSOL SOLN FQL(900 ml perfill retail);RX/OTC

CVS DRY MOUTH SPRAYSOLN F

QL(900 ml perfill retail);RX/OTC

DRY MOUTH SPRAYSOLN F


EQL DRY MOUTH ORALRINSE SOLN F


MOI-STIR SOLN FQL(900 ml perfill retail);RX/OTC

MOUTHKOTE SOLN FQL(900 ml perfill retail);RX/OTC

NUMOISYN LIQD FQL(900 ml perfill retail);RX/OTC

ORAL RELIEF SPRAYFOR DRYMOUTH &DISCOMFORT SOLN

FQL(900 ml perfill retail);RX/OTC

pilocarpine hcl (oral) tabs F QL(6 ea daily)

RA DRY MOUTH SOLN FQL(900 ml perfill retail);RX/OTC

SALAGEN TABS (UsePilocarpine HCl (Oral)) NF QL(6 ea daily)

MULTIVITAMINS

B-Complex Vitaminsb-complex vitamins caps F QL(1 ea daily)

b-complex vitamins tabs F QL(1 ea daily)

B-Complex w/ Folic Acidb-complex w/ c & folic acidcaps F QL(1 ea daily)

NEPHROCAPS CAPS(Use B-Complex w/ C &Folic Acid)

NFQL(1 ea daily)


106

Drug Name DrugTier

Requirements/Limits

Multiple Vitamins w/ MineralsAIRBORNE LOZG F

ANTIOXIDANT FORMULASG CPCR F

BIOVOL SYRP F

C-BUFF POWD F

CENTRUMMULTIVITAMIN FLAVORBURST DRINK PACK

F

CONCEPTIONXRMOTILITY SUPPORTFORMULA MISC

F

CORVITE TABS (UseMultiple Vitamins w/Minerals & Folic Acid)

NF

CVS DIABETES HEALTHSUPPORT MISC F

DAILY HEART HEALTHSUPPORT MISC F

DAILY PAK MAXIMUMMULTIVITAMIN/ASIANGINSENG EXTRACTMISC

F

DIABETES HEALTH PACKMISC F

DIABETES SUPPORTPACK MISC F

ELDERTONIC ELIX F

ELLIS TONIC ELIX F

EMERGEN-C BLUE PACK F

EMERGEN-C FIVE PACK F

EMERGEN-C HEARTHEALTH PACK F

EMERGEN-C IMMUNEPACK F

EMERGEN-C IMMUNEPLUS PACK F

EMERGEN-C IMMUNE+WARMERS PACK F

Drug Name DrugTier

Requirements/Limits

EMERGEN-C JOINTHEALTH PACK F

EMERGEN-C KIDZ PACK F

EMERGEN-C MSM LITEPACK F

EMERGEN-C PINK PACK F

EMERGEN-C SUPERFRUIT PACK F

EMERGEN-C VITAMIN CLITE PACK F

EMERGEN-C VITAMIN CPACK F

EMERGEN-C VITAMIN D& CALCIUM PACK F

END FATIGUE DAILYENERGYENFUSIONPOWD

F

ENERGY BOOSTERPACK F

EQL SUPER ENERGYBOOSTER PACK F

IMMUNE SUPPORTVITAMIN C PACK F KP WOMENS DAILYPACK MISC F

LIFE PACK MENS MISC F

LIFE PACK WOMENSMISC F

MAXIMIN PACK PACK F

MEGA MULTIVITAMINPOWD F

MENS PACK MISC F

MH MACULAR HEALTHMISC F

MULTI FOR HER PACK F

MULTI FOR HIM PACK F

multiple vitamins w/minerals & folic acid tabs F

PA MENS 50 PLUSVITAPAK MISC F


107

Drug Name DrugTier

Requirements/Limits

PA MENS VITAPAK MISC F

PA WOMENS 50 PLUSVITAPAK MISC F

PA WOMENS VITAPAKMISC F

PHLEXY-VITS POWD F

PREMIUM PACKETSMISC F

PRESCRIPTIVEFORMULAS OPTIMALVITAMIN PACKS MENSMISC

F

PRESCRIPTIVEFORMULAS OPTIMALVITAMIN PACKSWOMENS MISC

F

RA ESSENCE-C PACK F SKIN BEAUTY &WELLNESS PACK F

STROVITE FORTE SYRP F

SUPER NU-THERA POWD F

SUPERVITE EC TBEC F

SYNAGEX CAPS F

SYNATEK CAPS F

THERANATALLACTATION COMPLETEMISC

F

THERANATALLACTATION SUPPORTMISC

F

ULTRA MENS PACK MISC F

ULTRA WOMENS PACKMISC F

VITAMENT PACK F VITAMIN CEFFERVESCENT BLENDPACK

F

Drug Name DrugTier

Requirements/Limits

VITAMINC/ELECTROLYTES PACK F

VITAMINS TO GOMAXIMUM MISC F

VITAMINS TO GO MENMISC F

VITAMINS TO GOWOMEN MISC F

WOMENS PACK MISC F

ZINC LOZG F

Ped MV w/ Fluoridepediatric vitamins acd w/fluoride soln F QL(50 ml per

fill retail); ALPed Multi Vitamins w/Fl & FEped multivitamins w/fl &iron soln F QL(50 ml per

fill retail); ALTRI-VIT/FLUORIDE/IRONSOLN F QL(50 ml per

fill retail); ALPediatric Multiple Vitaminspediatric multiple vitaminsliqd F

Pediatric Vitamins

pediatric vitamins adc soln F QL(50 ml perfill retail)

Prenatal VitaminsCLASSIC PRENATALTABS F QL(1 ea daily);

ALCVS PRENATALGUMMY/DHA/FOLIC ACIDCHEW

F

CVS PRENATAL TABS F QL(1 ea daily);AL

EQL PRENATALFORMULA TABS F QL(1 ea daily);

AL

GNP PRENATAL TABS F QL(1 ea daily);AL

GOODSENSE PRENATALVITAMINS TABS F QL(1 ea daily);

AL

HM PRENATAL TABS F QL(1 ea daily);AL

KP PRENATALMULTIVITAMINS TABS F QL(1 ea daily);

AL


108

Drug Name DrugTier

Requirements/Limits

KPN PRENATAL TABS F QL(1 ea daily);AL

M-VIT TABS F QL(1 ea daily);AL; RX/OTC

MULTI PRENATAL TABS F QL(1 ea daily);AL

MYNATAL CAPS F QL(1 ea daily);AL

NAT-RUL PRENATALVITAMINS TABS F QL(1 ea daily);

AL

NIVA-PLUS TABS F QL(1 ea daily);AL; RX/OTC

O-CAL FA TABS F QL(1 ea daily);AL; RX/OTC

PNV FOLIC ACID + IRONMULTIVITAMIN TABS F QL(1 ea daily);

AL; RX/OTCPNV PRENATAL PLUSMULTIVITAMIN TABS F QL(1 ea daily);

AL; RX/OTCPRE-NATAL FORMULATABS F QL(1 ea daily);

ALPRENATAL AND IRONTABS F QL(1 ea daily);

ALPRENATAL FORMULACAPS F

PRENATAL FORMULATABS F QL(1 ea daily);

AL

PRENATAL FORTE TABS F QL(1 ea daily);AL

PRENATAL LOW IRONTABS F QL(1 ea daily);

ALPRENATALMULTIVITAMIN TABS F QL(1 ea daily);

ALPRENATAL ONE DAILYTABS F QL(1 ea daily);

AL

PRENATAL PLUS TABS F QL(1 ea daily);AL; RX/OTC

Drug Name DrugTier

Requirements/Limits

PRENATAL TABS 160MG-11UNIT-200MG-25MG-1.84MG-27MG-4000UNIT-18MG-1.7MG-4MCG-400UNIT-800MCG-2.6MG-100MG, 30UNIT-4000UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-8MCG-400UNIT-0.8MG-2.6MG-120MG,4000UNIT-30UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-8MCG-400UNIT-800MCG-2.6MG-120MG, 11UNIT-263MG-25MG-1.5MG-27MG-4000UNIT-18MG-1.7MG-4MCG-400UNIT-0.8MG-2.6MG-100MG, 4000UNIT-30UNIT-200MG-25MG-1.8MG-28MG-20MG-1.7MG-8MCG-400UNIT-800MCG-2.6MG-120MG,30UNIT-4000UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-8MCG-400UNIT-800MCG-2.6MG-120MG, 30UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-4000UNIT-8MCG-400UNIT-800MCG-2.6MG-120MG

F

QL(1 ea daily);AL

PRENATAL TABS 22MG-2MG-25MG-1.84MG-200MG-27MG-4000UNIT-20MG-3MG-12MCG-400UNIT-1MG-10MG-120MG

F

QL(1 ea daily);AL; RX/OTC

PRENATAL TABS4000UNIT-200MG-11UNIT-27MG-25MG-1.84MG-18MG-1.7MG-4MCG-400UNIT-0.8MG-2.6MG-100MG

F

QL(1 ea daily);AL

PRENATAL VITAMINTABS F QL(1 ea daily);

ALPRENATALVITAMIN/IRON TABS F QL(1 ea daily);

ALPRENATAL VITAMINSPLUS LOW IRON TABS F QL(1 ea daily);

AL; RX/OTC


109

Drug Name DrugTier

Requirements/Limits

PRENATAL VITAMINSTABS F QL(1 ea daily);

AL

PREPLUS TABS F QL(1 ea daily);AL; RX/OTC

PX PRENATALMULTIVITAMINS TABS F QL(1 ea daily);

AL

QC PRENATAL TABS F QL(1 ea daily);AL

RA PRENATALFORMULA/FOLICACIDTABS

FQL(1 ea daily);AL

RA PRENATAL TABS F QL(1 ea daily);AL

RIGHT STEP PRENATALTABS F QL(1 ea daily);

ALSM PRENATAL VITAMINSTABS F QL(1 ea daily);

ALTH PRENATAL VITAMINSTABS F QL(1 ea daily);

ALTHERANATAL CORENUTRITION TABS F QL(1 ea daily);

AL; RX/OTC

TRICARE TABS F QL(1 ea daily);AL; RX/OTC

VOL-PLUS TABS F QL(1 ea daily);AL; RX/OTC

Vitamins w/ Lipotropicsvitamins w/ lipotropics caps F QL(1 ea daily)

MUSCULOSKELETAL THERAPY AGENTS -Drugs to Treat SpasmsCentral Muscle Relaxantsbaclofen tabs F

chlorzoxazone tabs F

cyclobenzaprine hcl tabs F QL(3 ea daily)

methocarbamol tabs F

PARAFON FORTE DSCTABS (UseChlorzoxazone)

NF

ROBAXIN TABS (UseMethocarbamol) NF

ROBAXIN-750 TABS (UseMethocarbamol) NF

Drug Name DrugTier

Requirements/Limits

tizanidine hcl tabs F

ZANAFLEX TABS (UseTizanidine HCl) NF

NASAL AGENTS - SYSTEMIC AND TOPICAL -Drugs to treat the Nose or SinusNasal Agents - Misc.OCEAN NASAL SPRAYSOLN (Use Saline) NF QL(90 ml per

fill retail)

saline soln F QL(90 ml perfill retail)

Nasal Anti-infectivesBACTROBAN NASALOINT F

Nasal Antiallergy

ASTEPRO SOLN (UseAzelastine HCl) NF

Limit 1 packageper month;QL(1ml daily)

azelastine hcl soln FLimit 1 packageper month;QL(1ml daily)

cromolyn sodium (nasal)aers F QL(26 ml per

fill retail)NASALCROM AERS (UseCromolyn Sodium (Nasal)) NF QL(26 ml per

fill retail)Nasal Anticholinergics

ATROVENT SOLN 0.03 %(Use Ipratropium Bromide(Nasal))

NF

Limit 1 packagepermonth;QL(1.2ml daily)

ATROVENT SOLN 0.06 %(Use Ipratropium Bromide(Nasal))

NF


ipratropium bromide (nasal)soln 0.03 % F


ipratropium bromide (nasal)soln 0.06 % F


Nasal Steroids


110

Drug Name DrugTier

Requirements/Limits

FLONASE ALLERGYRELIEF CHILDRENSSUSP (Use FluticasonePropionate (Nasal))

NF


FLONASE ALLERGYRELIEF SUSP (UseFluticasone Propionate(Nasal))

NF


flunisolide (nasal) soln F QL(25 ml perfill retail)

fluticasone propionate(nasal) susp F


mometasone furoate(nasal) susp F QL(17 gm per

fill retail); AL

NASACORT ALLERGY24HR AERO F

QL(17 ml perfill retail);RX/OTC; MO

NASACORT ALLERGY24HR AERO (UseTriamcinolone Acetonide(Nasal))

F


NASACORT ALLERGY24HR CHILDRENS AERO(Use TriamcinoloneAcetonide (Nasal))

F


NASONEX SUSP (UseMometasone Furoate(Nasal))

NFQL(17 gm perfill retail); AL

triamcinolone acetonide(nasal) aero F


Sympathomimetic DecongestantsADRENALIN SOLN F

NASAL DECONGESTANTLIQD F

NASAL DECONGESTANTSYRP F

phenylephrine hcl (oral)tabs F QL(24 ea per

fill retail)

pseudoephedrine hcl liqd F

pseudoephedrine hcl tabs F

pseudoephedrine hcl tb12 F QL(2 ea daily)

Drug Name DrugTier

Requirements/Limits

SUDAFED CHILDRENSLIQD (UsePseudoephedrine HCl)

NF

SUDAFED CONGESTIONTABS (UsePseudoephedrine HCl)

NF

SUDAFED NASALDECONGESTANTMAXIMUM STRENGTHTABS (UsePseudoephedrine HCl)

NF

SUDAFED PECONGESTION TABS (UsePhenylephrine HCl (Oral))


SUDAFED TABS (UsePseudoephedrine HCl) NF

NUTRIENTS

Misc. Nutritional Substancesomega-3 fatty acids caps F QL(6 ea daily)

Proteinsarginine tabs 500 mg F

L-TRYPTOPHAN TABS F

OPHTHALMIC AGENTS - Drugs to Treat the Eye

Artificial Tears and Lubricants

artificial tear ointment oint F QL(4 gm per fillretail)

artificial tear solution soln F

ARTIFICIAL TEARS SOLN F QL(15 ml perfill retail)

GENTEAL TEARSMODERATEPF SOLN F

hypromellose (ophth) soln0.4 % F QL(15 ml per

fill retail)

polyvinyl alcohol soln F QL(15 ml perfill retail)

TEARS NATURALE PMOINT (Use WhitePetrolatum-Mineral Oil)

NFQL(4 gm per fillretail)

white petrolatum-mineral oiloint F QL(4 gm per fill

retail)


111

Drug Name DrugTier

Requirements/Limits

Beta-blockers - OphthalmicBETAGAN SOLN (UseLevobunolol HCl) NF QL(10 ml per

fill retail)

betaxolol hcl (ophth) soln F QL(10 ml perfill retail)

carteolol hcl (ophth) soln F


COSOPT SOLN (UseDorzolamide HCl-TimololMaleate)


dorzolamide hcl-timololmaleate soln F QL(10 ml per

fill retail)

levobunolol hcl soln F QL(10 ml perfill retail)

METIPRANOLOL SOLN F

timolol maleate (ophth)solg F QL(5 ml per fill

retail)timolol maleate (ophth)soln 0.25 % F QL(10 ml per

fill retail)timolol maleate (ophth)soln 0.5 % F QL(15 ml per

fill retail)TIMOPTIC OCUDOSESOLN F QL(60 ea per

fill retail)TIMOPTIC SOLN 0.25 %(Use Timolol Maleate(Ophth))


TIMOPTIC SOLN 0.5 %(Use Timolol Maleate(Ophth))


TIMOPTIC-XE SOLG (UseTimolol Maleate (Ophth)) NF QL(5 ml per fill

retail)Cycloplegic Mydriaticsatropine sulfate(ophthalmic) soln F QL(15 ml per

fill retail)ATROPINE SULFATEOINT F QL(4 gm per fill

retail)ATROPINE SULFATESOLN F QL(15 ml per

fill retail)CYCLOGYL SOLN 0.5 %,1 % (Use CyclopentolateHCl)


CYCLOGYL SOLN 2 %(Use Cyclopentolate HCl) NF

Drug Name DrugTier

Requirements/Limits

cyclopentolate hcl soln 1%, 0.5 % F QL(15 ml per

fill retail)

cyclopentolate hcl soln 2 % F

ISOPTO ATROPINE SOLN(Use Atropine Sulfate(Ophthalmic))


MYDRIACYL SOLN (UseTropicamide) NF QL(15 ml per

fill retail)

tropicamide soln F QL(15 ml perfill retail)

MioticsISOPTO CARPINE SOLN(Use Pilocarpine HCl) NF

pilocarpine hcl soln F

Ophthalmic Adrenergic Agentsapraclonidine hcl soln F

brimonidine tartrate soln F QL(15 ml perfill retail)

IOPIDINE SOLN 0.5 %(Use Apraclonidine HCl) NF

IOPIDINE SOLN 1 % F

Ophthalmic Anti-infectivesbacitracin-polymyxin b(ophth) oint F QL(4 gm per fill

retail)BLEPH-10 SOLN (UseSulfacetamide Sodium(Ophth))


erythromycin (ophth) oint F QL(4 gm per fillretail)

gentamicin sulfate (ophth)oint F QL(4 gm per fill

retail)gentamicin sulfate (ophth)soln F QL(15 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 (UseNeomycin-Polymyxin-Gramicidin)


OCUFLOX SOLN (UseOfloxacin (Ophth)) NF QL(10 ml per

fill retail)


112

Drug Name DrugTier

Requirements/Limits

ofloxacin (ophth) soln F QL(10 ml perfill retail)

polymyxin b-trimethoprimsoln F QL(10 ml per

fill retail)POLYTRIM SOLN (UsePolymyxin B-Trimethoprim) NF QL(10 ml per

fill retail)sulfacetamide sodium(ophth) soln F QL(15 ml per

fill retail)SULFACETAMIDESODIUM OINT F

tobramycin (ophth) soln F QL(5 ml per fillretail)

TOBREX OINT F QL(4 gm per fillretail)

TOBREX SOLN (UseTobramycin (Ophth)) NF QL(5 ml per fill

retail)

trifluridine soln F QL(8 ml per fillretail)

VIGAMOX SOLN F QL(3 ml per fillretail)

VIROPTIC SOLN (UseTrifluridine) NF QL(8 ml per fill

retail)Ophthalmic DecongestantsNAPHAZOLINE HCLSOLN F QL(16 ml per

fill retail)phenylephrine hcl (ophth)soln F QL(15 ml per

fill retail)

tetrahydrozoline hcl (ophth)soln F


VISINE EXTRA SOLN (UseTetrahydrozoline HCl(Ophth))

NF


VISINE SOLN (UseTetrahydrozoline HCl(Ophth))

NF


Ophthalmic SteroidsBLEPHAMIDE S.O.P.OINT F QL(4 gm per fill

retail)

BLEPHAMIDE SUSP F QL(10 ml perfill retail)

Drug Name DrugTier

Requirements/Limits

DEXAMETHASONESODIUM PHOSPHATESOLN 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 (UseNeomycin-Polymy-Dexameth)

NFQL(4 gm per fillretail)

MAXITROL SUSP (UseNeomycin-Polymy-Dexameth)

NFQL(5 ml per fillretail)

neomycin-polymy-dexameth oint F QL(4 gm per fill

retail)neomycin-polymy-dexameth susp F QL(5 ml per fill

retail)NEOMYCIN/POLYMYXIN/HYDROCORTISONESUSP


OMNIPRED SUSP (UsePrednisolone Acetate(Ophth))


PRED FORTE SUSP (UsePrednisolone 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 SODIUMPHOSPHATE SOLN OP 1%

F


sulfacetamide sod-prednisolone soln F QL(10 ml per

fill retail)

TOBRADEX OINT F QL(4 gm per fillretail)

TOBRADEX SUSP (UseTobramycin-Dexamethasone)



113

Drug Name DrugTier

Requirements/Limits

tobramycin-dexamethasone susp F QL(10 ml per

fill retail)

VEXOL SUSP F QL(10 ml perfill retail)

Ophthalmics - Misc.ACULAR LS SOLN (UseKetorolac Tromethamine(Ophth))

NF

ACULAR SOLN (UseKetorolac Tromethamine(Ophth))


ALOCRIL SOLN F

ST; Tryketotifen ophth.first;QL(5 mlper fill retail)

ALOMIDE SOLN F


azelastine hcl (ophth) soln F


AZOPT SUSP F QL(15 ml perfill retail)

cromolyn sodium (ophth)soln F QL(10 ml per

fill retail)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)

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(10 ml per

fill retail)

NEVANAC SUSP F QL(3 ml per fillretail)

OCUFEN SOLN (UseFlurbiprofen Sodium) NF QL(3 ml per fill

retail)TRUSOPT SOLN (UseDorzolamide HCl) NF QL(10 ml per

fill retail)

Drug Name DrugTier

Requirements/Limits

ZADITOR SOLN (UseKetotifen Fumarate(Ophth))


Prostaglandins - Ophthalmic

latanoprost soln F QL(3 ml per fillretail)

XALATAN SOLN (UseLatanoprost) 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 (UseCarbamide Peroxide (Otic)) NF


Otic Anti-infectivesFLOXIN OTIC SOLN (UseOfloxacin (Otic)) NF QL(10 ml per

fill retail)

ofloxacin (otic) soln F QL(10 ml perfill retail)

Otic Combinations

antipyrine-benzocaine soln F QL(10 ml perfill retail)

CORTANE-B-OTIC SOLN(Use Pramoxine-HC-Chloroxylenol)

NF


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 (UsePramoxine-HC-Chloroxylenol)

NF


PRAMOTIC LIQD F


114

Drug Name DrugTier

Requirements/Limits

pramoxine-hc-chloroxylenolsoln F


Otic Steroids

DERMOTIC OIL (UseFluocinolone Acetonide(Otic))

NF


fluocinolone acetonide(otic) oil F


hydrocortisone w/aceticacid soln F QL(10 ml per

fill retail)OXYTOCICS - Drugs to Prevent/Control UterineBleedingOxytocicsMETHERGINE TABS F

methylergonovine maleatetabs F

PASSIVE IMMUNIZING AGENTS - AntibodyDrugs to Treat Low Immune SystemMonoclonal AntibodiesSYNAGIS SOLN F PA

PENICILLINS - Drugs to Treat Bacterial Infections

Aminopenicillinsamoxicillin caps F

AMOXICILLIN CHEW F

amoxicillin susr F

amoxicillin tabs F

ampicillin caps F

AMPICILLIN SUSR F

Natural Penicillinspenicillin v potassium solr F

Drug Name DrugTier

Requirements/Limits

penicillin v potassium tabs F

Penicillin Combinations

amoxicillin & potclavulanate susr200mg/5ml-28.5mg/5ml

F



F


amoxicillin & potclavulanate susr400mg/5ml-57mg/5ml

F


F

Limit 2packages perclaim;QL(400ml per fill retail)

amoxicillin & potclavulanate tabs 250mg-125mg


amoxicillin & potclavulanate tabs 875mg-125mg, 500mg-125mg


amoxicillin & potclavulanate tb12 F

Limit 40 per 30days;QL(1.34ea daily)

AMOXICILLIN/CLAVULANATE POTASSIUM CHEW F QL(20 ea per

fill retail)

AUGMENTIN ES-600SUSR (Use Amoxicillin &Pot Clavulanate)

NF

Limit 2packages perclaim;QL(400ml per fill retail)

AUGMENTIN SUSR125MG/5ML-31.25MG/5ML F

AUGMENTIN SUSR250MG/5ML-62.5MG/5ML(Use Amoxicillin & PotClavulanate)

NF


AUGMENTIN TABS (UseAmoxicillin & PotClavulanate)


AUGMENTIN XR TB12(Use Amoxicillin & PotClavulanate)

NFLimit 40 per 30days;QL(1.34ea daily)

Penicillinase-Resistant Penicillins


115

Drug Name DrugTier

Requirements/Limits

dicloxacillin sodium caps F

PROGESTINS - Hormone Replacement/ModifyingDrugsProgestinsAYGESTIN TABS (UseNorethindrone Acetate) NF

MAKENA OIL F PA

medroxyprogesteroneacetate tabs F

norethindrone acetate tabs F

progesterone micronizedcaps 100 mg F QL(1 ea daily)

progesterone micronizedcaps 200 mg F


PROMETRIUM CAPS 100MG (Use ProgesteroneMicronized)

NFQL(1 ea daily)

PROMETRIUM CAPS 200MG (Use ProgesteroneMicronized)

NFLimit 20 permonth;QL(0.67ea daily)

PROVERA TABS (UseMedroxyprogesteroneAcetate)

NF

PSYCHOTHERAPEUTIC AND NEUROLOGICALAGENTS - MISC. - Drugs to Treat Mental andEmotional ConditionsAgents for Chemical DependencyANTABUSE TABS (UseDisulfiram) NF

disulfiram tabs F

Antidementia AgentsARICEPT TABS (UseDonepezil Hydrochloride) NF QL(1 ea daily)

donepezil hydrochloridetabs F QL(1 ea daily)

EXELON CAPS (UseRivastigmine Tartrate) NF PA; QL(2 ea

daily)EXELON PT24 (UseRivastigmine) NF PA; QL(1 ea

daily)galantamine hydrobromidecp24 F QL(1 ea daily)

Drug Name DrugTier

Requirements/Limits

GALANTAMINEHYDROBROMIDE SOLN F QL(6 ml daily)

galantamine hydrobromidetabs F QL(2 ea daily)

memantine hcl soln F QL(10 ml daily)

memantine hcl tabs F

Limit 1 packageper 28days;QL(1.75ea daily)

memantine hcl tabs 5 mg,10 mg F QL(2 ea daily)

NAMENDA TABS (UseMemantine HCl) NF QL(2 ea daily)

NAMENDA TITRATIONPAK TABS (UseMemantine HCl)

NF

Limit 1 packageper 28days;QL(1.75ea daily)

RAZADYNE ER CP24 (UseGalantamineHydrobromide)

NFQL(1 ea daily)

RAZADYNE TABS (UseGalantamineHydrobromide)

NFQL(2 ea daily)

rivastigmine pt24 F PA; QL(1 eadaily)

rivastigmine tartrate caps F PA; QL(2 eadaily)

Combination PsychotherapeuticsPERPHENAZINE/AMITRIPTYLINE TABS F QL(4 ea daily)

Fibromyalgia Agents

SAVELLA TABS F PA; QL(2 eadaily)

SAVELLA TITRATIONPACK MISC F

PA; QL(55 eaper 365 daysretail)

Multiple Sclerosis AgentsAMPYRA TB12 F PA

AUBAGIO TABS F PA

AVONEX KIT F PA

AVONEX PEN AJKT F PA


116

Drug Name DrugTier

Requirements/Limits

AVONEX PSKT F PA

BETASERON KIT F PA

COPAXONE SOSY 20MG/ML (Use GlatiramerAcetate)

NFPA

COPAXONE SOSY 40MG/ML F PA

GILENYA CAPS F PA

glatiramer acetate sosy F PA

LEMTRADA SOLN F PA

PLEGRIDY SOPN F PA

PLEGRIDY SOSY F PA

PLEGRIDY STARTERPACK SOPN F PA

PLEGRIDY STARTERPACK SOSY F PA

REBIF REBIDOSE SOAJ F PA

REBIF REBIDOSETITRATIONPACK SOAJ F PA

REBIF SOSY F PA

REBIF TITRATION PACKSOSY F PA

TECFIDERA CPDR F PA

TECFIDERA STARTERPACK MISC F PA

TYSABRI CONC F PA

ZINBRYTA SOSY F PA

Premenstrual Dysphoric Disorder (PMDD) AgentsFLUOXETINE CAPS F

Psychotherapeutic and Neurological Agents -ergoloid mesylates tabs F

ERGOLOID MESYLATESTABS F

Drug Name DrugTier

Requirements/Limits

Smoking Deterrentsbupropion hcl (smokingdeterrent) tb12 F QL(2 ea daily)

CHANTIX CONTINUINGMONTHPAK TABS F

CHANTIX STARTINGMONTH PAK TABS F

CHANTIX TABS F NICODERM CQ PT24 (UseNicotine) NF

NICORETTE GUM (UseNicotine Polacrilex) NF

NICORETTE LOZG (UseNicotine Polacrilex) NF

NICORETTE MINI LOZG(Use Nicotine Polacrilex) NF

NICORETTE STARTERKIT GUM (Use NicotinePolacrilex)

NF

nicotine polacrilex gum F

nicotine polacrilex lozg F

nicotine pt24 F

NICOTINETRANSDERMAL SYSTEMKIT

F

NICOTROL INHALERINHA F

NICOTROL NS SOLN F

ZYBAN TB12 (UseBupropion HCl (SmokingDeterrent))

NFQL(2 ea daily)

RESPIRATORY AGENTS - MISC. - Drugs toTreat Lung ConditionsCystic Fibrosis AgentsKALYDECO PACK F PA

KALYDECO TABS F PA

ORKAMBI TABS F PA

PULMOZYME SOLN F PA


117

Drug Name DrugTier

Requirements/Limits

TETRACYCLINES - Drugs to Treat BacterialInfectionsTetracyclinesdoxycycline hyclate caps F

doxycycline hyclate tabs F

MINOCIN CAPS (UseMinocycline HCl) NF

minocycline hcl caps F

VIBRAMYCIN CAPS (UseDoxycycline Hyclate) NF

THYROID AGENTS - Drugs to Regulate ThyroidHormonesAntithyroid Agentsmethimazole tabs F

propylthiouracil tabs F

TAPAZOLE TABS (UseMethimazole) NF

Thyroid HormonesARMOUR THYROID TABS180 MG, 300 MG, 240 MG F

ARMOUR THYROID TABS90 MG, 30 MG, 15 MG,120 MG, 60 MG (UseThyroid)

NF

CYTOMEL TABS (UseLiothyronine Sodium) NF

levothyroxine sodium tabs F

liothyronine sodium tabs F

SYNTHROID TABS (UseLevothyroxine Sodium) NF

thyroid tabs F

THYROLAR-1 TABS F

THYROLAR-1/2 TABS F

THYROLAR-1/4 TABS F

THYROLAR-2 TABS F

Drug Name DrugTier

Requirements/Limits

THYROLAR-3 TABS F

TOXOIDS

Toxoid Combinations

ADACEL SUSP FQL(0.5 ml per9999 daysretail); AL

BOOSTRIX SUSP FQL(0.5 ml per9999 daysretail); AL

TENIVAC INJ FQL(0.5 ml per9999 daysretail); AL

TETANUS/DIPHTHERIATOXOIDS-ADSORBEDADULT SUSP

FQL(0.5 ml per9999 daysretail); AL

TETANUS/DIPHTHERIATOXOIDS-ADSORBEDSUSP

FQL(0.5 ml per9999 daysretail); AL

ULCER DRUGS - Drugs to Treat Bowel, Intestineand Stomach ConditionsAntispasmodicsANASPAZ TBDP (UseHyoscyamine Sulfate) NF

BENTYL CAPS (UseDicyclomine HCl) NF

BENTYL TABS (UseDicyclomine HCl) NF

dicyclomine hcl caps F

dicyclomine hcl soln F QL(40 ml daily)

dicyclomine hcl tabs F

DONNATAL TABS (UsePhenobarbital-Hyoscyamine-Atropine-Scopolamine)

NF

glycopyrrolate tabs F QL(4 ea daily)

hyoscyamine sulfate elix F

hyoscyamine sulfate soln F

hyoscyamine sulfate subl F


118

Drug Name DrugTier

Requirements/Limits

hyoscyamine sulfate tabs F

hyoscyamine sulfate tb12 F QL(4 ea daily)

hyoscyamine sulfate tbdp F

LEVBID TB12 (UseHyoscyamine Sulfate) NF QL(4 ea daily)

LEVSIN TABS (UseHyoscyamine Sulfate) NF

LEVSIN/SL SUBL (UseHyoscyamine Sulfate) NF

phenobarbital-hyoscyamine-atropine-scopolamine tabs

F

ROBINUL FORTE TABS(Use Glycopyrrolate) NF QL(4 ea daily)

ROBINUL TABS (UseGlycopyrrolate) NF QL(4 ea daily)

H-2 Antagonistscimetidine hcl soln F QL(27 ml daily)

cimetidine tabs 200 mg F RX/OTC

cimetidine tabs 400 mg,800 mg, 300 mg F

famotidine tabs 20 mg F RX/OTC

famotidine tabs 40 mg, 10mg F

PEPCID AC MAXIMUMSTRENGTH TABS (UseFamotidine)

NFRX/OTC

PEPCID AC TABS (UseFamotidine) NF

PEPCID TABS 20 MG (UseFamotidine) NF RX/OTC

PEPCID TABS 40 MG (UseFamotidine) NF

ranitidine hcl caps 150 mg F QL(2 ea daily)

ranitidine hcl caps 300 mg F QL(1 ea daily)

ranitidine hcl syrp F QL(20 mldaily); AL

ranitidine hcl tabs 150 mg F QL(2 ea daily);RX/OTC

Drug Name DrugTier

Requirements/Limits

ranitidine hcl tabs 300 mg,75 mg F QL(2 ea daily)

TAGAMET HB TABS (UseCimetidine) NF RX/OTC

ZANTAC 150 MAXIMUMSTRENGTH TABS (UseRanitidine HCl)

NFQL(2 ea daily);RX/OTC

ZANTAC 75 TABS (UseRanitidine HCl) NF QL(2 ea daily)

ZANTAC TABS 150 MG(Use Ranitidine HCl) NF QL(2 ea daily);

RX/OTCZANTAC TABS 300 MG(Use Ranitidine HCl) NF QL(2 ea daily)

Misc. Anti-Ulcer

CARAFATE SUSP F QL(420 ml perfill retail); AL

CARAFATE TABS (UseSucralfate) NF QL(4 ea daily)

sucralfate tabs F QL(4 ea daily)

Proton Pump InhibitorsCVS 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 40 mg F

GNP OMEPRAZOLETBEC 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(4 ea daily);RX/OTC

lansoprazole cpdr 30 mg F NEXIUM CPDR 40 MG(Use EsomeprazoleMagnesium)

NF

omeprazole cpdr 10 mg F

omeprazole cpdr 40 mg, 20mg F QL(1 ea daily)


119

Drug Name DrugTier

Requirements/Limits

OMEPRAZOLE TBEC F QL(1 ea daily)

pantoprazole sodium tbec20 mg F QL(1 ea daily)

pantoprazole sodium tbec40 mg F QL(2 ea daily)

PREVACID 24HR CPDR(Use Lansoprazole) NF QL(4 ea daily);

RX/OTCPREVACID CPDR 15 MG(Use Lansoprazole) NF QL(4 ea daily);

RX/OTCPREVACID CPDR 30 MG(Use Lansoprazole) NF

PREVACID SOLUTABTBDP F

PRILOSEC CPDR 10 MG(Use Omeprazole) NF

PRILOSEC CPDR 40 MG,20 MG (Use Omeprazole) NF QL(1 ea daily)

PROTONIX TBEC 20 MG(Use PantoprazoleSodium)

NFQL(1 ea daily)

PROTONIX TBEC 40 MG(Use PantoprazoleSodium)

NFQL(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 - ProstaglandinsCYTOTEC TABS (UseMisoprostol) NF

misoprostol tabs F

URINARY ANTI-INFECTIVES - Drugs to TreatBladder/Kidney InfectionsUrinary Anti-infective Combinationsmethenamine-hyosc-methylene blue-sod phos-phenyl sal tabs

F

Drug Name DrugTier

Requirements/Limits

Urinary Anti-infectivesFURADANTIN SUSP (UseNitrofurantoin) NF QL(40 ml

daily); ALMACROBID CAPS (UseNitrofurantoin MonohydMacro)

NF

MACRODANTIN CAPS(Use NitrofurantoinMacrocrystal)

NF

METHENAMINEMANDELATE TABS 0.5GM

F

methenamine mandelatetabs 1 gm F

nitrofurantoin macrocrystalcaps F

nitrofurantoin monohydmacro caps F

nitrofurantoin susp F QL(40 mldaily); AL

URINARY ANTISPASMODICS - Drugs to TreatMiscellaneous Bladder SpasmsUrinary Antispasmodic - AntimuscarinicsDETROL LA CP24 (UseTolterodine Tartrate) NF QL(1 ea daily)

DETROL TABS (UseTolterodine Tartrate) NF QL(2 ea daily)

DITROPAN XL TB24 (UseOxybutynin Chloride) NF QL(2 ea daily)

oxybutynin chloride syrp F QL(16 ml daily)

oxybutynin chloride tabs F QL(3 ea daily)

oxybutynin chloride tb24 F QL(2 ea daily)

tolterodine tartrate cp24 F QL(1 ea daily)

tolterodine tartrate tabs F QL(2 ea daily)

trospium chloride tabs F QL(2 ea daily)

Urinary Antispasmodics - Cholinergic Agonistsbethanechol chloride tabs F

URECHOLINE TABS (UseBethanechol Chloride) NF


120

Drug Name DrugTier

Requirements/Limits

Urinary Antispasmodics - Direct Muscle Relaxantsflavoxate hcl tabs F

VACCINES

Bacterial Vaccines

PNEUMOVAX 23 INJ F

One perlifetime;QL(0.5ml per 9999days retail); AL

PNEUMOVAX 23/1 DOSEINJ F


PREVNAR 13 SUSP F


Mixed Vaccine CombinationsCOMVAX SUSP F AL

Viral Vaccines

AFLURIA 2014-2015SUSP F

QL(1 ml per180 daysretail); AL





AFLURIA PF 2014-2015SUSY F






AFLURIA QUADRIVALENT2016-2017 SUSY F


CERVARIX SUSP FQL(1.5 ml per9999 daysretail); AL

Drug Name DrugTier

Requirements/Limits

ENGERIX-B INJ F AL

ENGERIX-B SUSP F AL

FLUAD 2016-2017 SUSY FQL(1 ml per180 daysretail); AL

FLUARIX 2014-2015 SUSY FQL(1 ml per180 daysretail); AL

FLUARIX QUADRIVALENT2014-2015 SUSY F






FLUBLOK 2014-2015SOLN F






FLUCELVAX 2014-2015SUSY F


FLUCELVAX 2015-2016SUSY F


FLUCELVAXQUADRIVALENT 2016-2017 SUSY

FQL(1 ml per180 daysretail); AL

FLULAVAL 2014-2015SUSP F


FLULAVALQUADRIVALENT 2014-2015 SUSP


FLULAVALQUADRIVALENT 2014-2015 SUSY



121

Drug Name DrugTier

Requirements/Limits





FLULAVALQUADRIVALENT 2016-2017 SUSY


FLUVIRIN 2014-2015SUSP F




FLUVIRIN 2015-2016SUSY F




FLUVIRIN 2016-2017SUSY F


FLUVIRIN PF 2014-2015SUSY F


FLUZONE HIGH-DOSE PF2014-2015 SUSY F






FLUZONE INTRADERMALQUADRIVALENT 2015-2016 SUPN


FLUZONE INTRADERMALQUADRIVALENT 2016-2017 SUPN


FLUZONE PF 2014-2015SUSY F


FLUZONEQUADRIVALENT 2014-2015 SUSP


Drug Name DrugTier

Requirements/Limits

FLUZONEQUADRIVALENT 2014-2015 SUSY










FLUZONE SPLIT 2014-2015 SUSP F


FLUZONE SPLIT 2015-2016 SUSP F


GARDASIL 9 SUSP FQL(1.5 ml per9999 daysretail); AL

GARDASIL 9 SUSY FQL(1.5 ml per9999 daysretail); AL

GARDASIL SUSP FQL(1.5 ml per9999 daysretail); AL

HAVRIX SUSP F AL

MEDICAL PROVIDER EZFLU SHOT 2014-2015PSKT

FQL(1 ea per180 daysretail); AL

MEDICAL PROVIDER EZFLU SHOT 2015-2016PSKT


MEDICAL PROVIDERSINGLE USE EZ FLUSHOT PSKT


RECOMBIVAX HB SUSP F AL

TWINRIX SUSP F AL

VAQTA SUSP F AL


122

Drug Name DrugTier

Requirements/Limits

ZOSTAVAX SUSR F AL

VAGINAL PRODUCTS - Drugs to Treat VaginalInfections and Low HormonesVaginal Anti-infectivesCLEOCIN CREA (UseClindamycin PhosphateVaginal)


clindamycin phosphatevaginal crea F QL(40 gm per

fill retail)clotrimazole vaginal crea 1% F QL(45 gm per

fill retail)clotrimazole vaginal crea 2% F QL(20 gm per

fill retail)

GYNAZOLE-1 CREA F

GYNE-LOTRIMIN 3 CREA(Use Clotrimazole Vaginal) NF QL(20 gm per

fill retail)GYNE-LOTRIMIN CREA(Use Clotrimazole Vaginal) NF QL(45 gm per

fill retail)METROGEL-VAGINALGEL (Use MetronidazoleVaginal)


metronidazole vaginal gel F QL(70 gm perfill retail)

MICONAZOLE 3 SUPP F QL(3 ea per fillretail)

miconazole nitrate vaginalcrea 2 % F QL(45 gm per

fill retail)

miconazole nitrate vaginalcrea 4 % F


miconazole nitrate vaginalkit F QL(1 gm per fill

retail)miconazole nitrate vaginalkit F

miconazole nitrate vaginalsupp F QL(7 ea per fill

retail)MONISTAT 1 COMBOPACK KIT (UseMiconazole Nitrate Vaginal)

NF

MONISTAT 1 DAY ORNIGHT COMBO PACK KIT(Use Miconazole NitrateVaginal)

NF

Drug Name DrugTier

Requirements/Limits

MONISTAT 3COMBINATION PACK KIT(Use Miconazole NitrateVaginal)

NF

QL(1 gm per fillretail)

MONISTAT 3 CREA (UseMiconazole Nitrate Vaginal) NF


MONISTAT 7 SIMPLYCURE CREA (UseMiconazole Nitrate Vaginal)


TERAZOL 3 CREA (UseTerconazole Vaginal) NF QL(20 gm per

fill retail)TERAZOL 7 CREA (UseTerconazole Vaginal) NF QL(45 gm per

fill 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 supp F QL(3 ea per fillretail)

tioconazole vaginal oint F QL(5 gm per fillretail)

VAGISTAT-1 OINT (UseTioconazole Vaginal) NF QL(5 gm per fill

retail)Vaginal Estrogens

ESTRACE CREA F


PREMARIN CREA F


VASOPRESSORS - Drugs to Treat Heart andCirculation ConditionsAnaphylaxis Therapy Agents

epinephrine soaj 0.15mg/0.3ml F

QL(4 ea per365 daysretail); MO

epinephrine soaj 0.3mg/0.3ml F QL(4 ea per

365 days retail)Vasopressorsmidodrine hcl tabs F


123

Drug Name DrugTier

Requirements/Limits

VITAMINS

Oil Soluble Vitaminscholecalciferol caps 1000unit, 2000 unit F

cholecalciferol caps 5000unit F QL(2 ea daily)

cholecalciferol caps 50000unit F


cholecalciferol chew 400unit F

cholecalciferol liqd 400unit/ml F

cholecalciferol tabs 1000unit, 400 unit F

D-VI-SOL LIQD (UseCholecalciferol) NF DRISDOL CAPS (UseErgocalciferol) NF

DRISDOL SOLN (UseErgocalciferol) NF

ergocalciferol caps F

ergocalciferol soln F

MEPHYTON TABS F

vitamin a caps F

vitamin a tabs F

vitamin e caps F QL(2 ea daily)

vitamin e soln F

Water Soluble VitaminsASCOCID POWD F

ascorbic acid chew F

ASCORBIC ACID POWD F

ascorbic acid tabs F

100 / 30days;QL(100ea per 34 daysretail)

Drug Name DrugTier

Requirements/Limits

biotin caps F

niacin cpcr F

niacin tabs 50 mg, 100 mg,500 mg F

niacin tbcr F

NIACIN TR TBCR F

pyridoxine hcl tabs 50 mg,250 mg, 100 mg, 25 mg F

riboflavin tabs 50 mg, 100mg F


SLO-NIACIN TBCR (UseNiacin) NF

thiamine hcl tabs F


thiamine mononitrate tabs F


VITAMIN C POWD F

VITAMIN C SYRP F


124

Index

1ST TIER UNIFINEPENTIPS/MINI/31GX5MM 731ST TIER UNIFINEPENTIPS29GX12MM 731ST TIER UNIFINEPENTIPS31GX6MM 731ST TIER UNIFINEPENTIPS31GX8MM 731ST TIER UNIFINEPENTIPS32GX4MM 731ST TIER UNIFINEPENTIPSPLUS 31GX8MM 731ST TIER UNIFINEPENTIPSPLUS 32GX4MM 731ST TIER UNIFINEPENTIPSPLUS/MINI/31GX5MM

731ST TIER UNIFINEPENTIPSPLUS/ORIGINAL/29GX12MM 731ST TIER UNIFINEPENTIPSPLUS/ULTRASHORT/31GX6MM

73

4-N-1 44abacavir sulfate 29abacavir sulfate-lamivudine 29abacavir sulfate-lamivudine-zidovudine 29ABILIFY 28ABILIFY DISCMELT 28ABILIFY MAINTENA 28ACCU-CHEK FASTCLIXLANCETS 63ACCU-CHEK SOFTCLIXLANCETS 63ACCUPRIL 21acebutolol hcl 32acetaminophen 3acetaminophen w/ codeine 5acetaminophen w/ dm 37acetazolamide 48acetic acid (otic) 114acetylcysteine 39ACNE MEDICATION 10 39ACNE MEDICATION 5 39ACTI-LANCE LANCETS28G 63ACTI-LANCE LITE SAFETYLANCETS 28G 63ACTI-LANCE SPECIAL SAFETYLANCETS 17G 63ACTI-LANCE UNIVERSALSAFETY LANCETS 23G 63ACTIGALL 51

ACTIVELLA 50ACTONEL 35 MG 49ACTONEL 5 MG, 30 MG 49ACTOPLUS MET 15ACTOS 16ACULAR 114ACULAR LS 114acyclovir 31acyclovir 400 mg 31acyclovir 800 mg 31acyclovir topical 41ADACEL 118ADALAT CC 30 MG, 90MG 32ADALAT CC 60 MG 32ADDERALL 1ADDERALL XR 1adefovir dipivoxil 31ADJUSTABLE LANCINGDEVICE 63ADRENALIN 111ADVATE 52ADVIL 2ADVIL COLD & SINUS 37ADVOCATE INSULIN PENNEEDLES 29GX12.7MM 73ADVOCATE INSULIN PENNEEDLES 31GX5MM 73ADVOCATE INSULIN PENNEEDLES 31GX8MM 73ADVOCATE INSULINSYRINGE/U-100/0.3ML/29GX1/2" 73ADVOCATE INSULINSYRINGE/U-100/0.3ML/30GX5/16" 73ADVOCATE INSULINSYRINGE/U-100/0.3ML/31GX5/16" 73ADVOCATE INSULINSYRINGE/U-100/0.5ML/29GX1/2" 73ADVOCATE INSULINSYRINGE/U-100/0.5ML/30GX5/16" 73ADVOCATE INSULINSYRINGE/U-100/0.5ML/31GX5/16" 73ADVOCATE INSULINSYRINGE/U-100/1ML/29GX1/2" 73

ADVOCATE INSULINSYRINGE/U-100/1ML/30GX5/16"

73ADVOCATE INSULINSYRINGE/U-100/1ML/31GX5/16"

73ADVOCATE LANCINGDEVICE 63ADVOCATE RAPID-SAFELANCING DEVICE 63ADYNOVATE 2000 UNIT, 500UNIT, 250 UNIT, 1000 UNIT 52AEROCHAMBER MINIAEROSOLCHAMBER 100AEROCHAMBER MV 100AEROCHAMBER PLUS FLOWVU 100AEROCHAMBER PLUS FLOW-VU 100AEROCHAMBER PLUS FLOW-VU/LARGE MASK 100AEROCHAMBER PLUS FLOW-VU/MASK 100AEROCHAMBER PLUS FLOW-VU/MEDIUM MASK 100AEROCHAMBER PLUS FLOW-VU/SMALL MASK 100AEROCHAMBER Z-STAT PLUSVALVED HOLDING CHAMBERW/FLOW VU 100AEROCHAMBER Z-STATPLUS/FLOWSIGNAL 100AEROCHAMBER Z-STATPLUS/LARGE MASK 100AEROCHAMBER Z-STATPLUS/MEDIUM MASK 101AEROCHAMBER Z-STATPLUS/SMALL MASK 101AEROCHAMBER/FLOWSIGNAL

101AEROSPAN 9AEROVENT PLUS HOLDINGCHAMBER/COLLAPSIBLE 101AFINITOR 24AFINITOR DISPERZ 24AFLURIA 2014-2015 121AFLURIA 2015-2016 121AFLURIA 2016-2017 121AFLURIA PF 2014-2015 121AFLURIA PF 2015-2016 121AFLURIA PF 2016-2017 121AFLURIA QUADRIVALENT2016-2017 121AGRYLIN 53AIMSCO LUBRICATED 62AIRBORNE 107

Index 1

albuterol sulfate 9albuterol sulfate 0.5 % 9albuterol sulfate 0.63 mg/3ml,0.083 %, 1.25 mg/3ml 9ALCOHOL PREP PADS 72ALCOHOL PREPS 72ALCOHOL SWABS 72ALCOHOL SWABSTICK 72ALCOHOL WIPES 72ALDACTAZIDE 48ALDACTONE 48ALDARA 43ALENDRONATE SODIUM 49alendronate sodium 10 mg, 5mg 49alendronate sodium 35 mg, 70mg 49ALENDRONATE SODIUM 40MG 49ALEVE 2ALEVE ARTHRITIS 2ALKERAN 23ALLEGRA ALLERGY 180MG 19ALLEGRA ALLERGY 60 MG19ALLEVYN PLUS CAVITY 58ALLEVYN THIN 58allopurinol 52ALOCRIL 114alogliptin benzoate 15alogliptin-metformin hcl 15alogliptin-pioglitazone 15ALOMIDE 114ALORA 50ALPHANATE/VONWILLEBRANDFACTORCOMPLEX/HUMAN 52ALPHANINE SD 52alprazolam 8ALPROLIX 2000 UNIT, 250UNIT, 3000 UNIT, 500 UNIT,1000 UNIT 52ALTACE 21ALTERNATE SITE LANCINGDEVICE 63alum & mag hydrox-simethicone 6

alum & mag hydrox-simethicone 200mg/5ml-200mg/5ml-20mg/5ml-20mg/5ml-200mg/5ml-200mg/5ml, 200mg/5ml-20mg/5ml-200mg/5ml 6alum & mag hydrox-simethicone 200mg/5ml-20mg/5ml-200mg/5ml 6alum & mag hydrox-simethicone 400mg/5ml-40mg/5ml-400mg/5ml 6alum & mag hydrox-simethicone 400mg/5ml-40mg/5ml-400mg/5ml,400mg/5ml-400mg/5ml-40mg/5ml-40mg/5ml-400mg/5ml-400mg/5ml 6ALUMINUM HYDROXIDE 6amantadine hcl 26AMARYL 1 MG, 2 MG 17AMARYL 4 MG 17AMBIEN 55AMD FOAM DRESSING4"X4" 58AMD FOAMDRESSING/TOPSHEET4"X4" 58AMERGE 103AMICAR 54amiloride &hydrochlorothiazide 48amiloride hcl 48aminocaproic acid 54amiodarone hcl 8amitriptyline hcl 14amlodipine besylate 32amlodipine besylate-benazeprilhcl 22AMOXAPINE 14amoxicillin 115AMOXICILLIN 115amoxicillin & potclavulanate 115amoxicillin & pot clavulanate200mg/5ml-28.5mg/5ml 115amoxicillin & pot clavulanate250mg-125mg 115amoxicillin & pot clavulanate250mg/5ml-62.5mg/5ml 115amoxicillin & pot clavulanate400mg/5ml-57mg/5ml 115amoxicillin & pot clavulanate600mg/5ml-42.9mg/5ml 115

amoxicillin & pot clavulanate875mg-125mg, 500mg-125mg 115AMOXICILLIN/CLAVULANATEPOTASSIUM 115amphetamine-dextroamphetamine 1ampicillin 115AMPICILLIN 115AMPYRA 116AMYTAL SODIUM 55ANAFRANIL 14anagrelide hcl 53ANAPROX DS 2ANASPAZ 118anastrozole 24ANDRODERM 5ANDROXY 5ANORO ELLIPTA 9ANTABUSE 116ANTHELIOS 60 MELT-INSUNSCREEN 45ANTI-STICK INSULINSYRINGE/U-100/0.5ML/28G X1/2" 73ANTI-STICK INSULINSYRINGE/U-100/0.5ML/29G X1/2" 73ANTI-STICK INSULINSYRINGE/U-100/1ML/29G X1/2" 73ANTIOXIDANT FORMULASG 107antipyrine-benzocaine 114ANUSOL-HC 6APEXICON E 41APIDRA 16

16APIDRA SOLOSTARAPLENZIN 12apraclonidine hcl 112APTIVUS 29AQUA LANCE ADJUSTABLELANCING DEVICE 64AQUAPHILIC 43AQUAPHOR 43AQUAPHOR ADVANCEDTHERAPY 43AQUORAL 106ARANESP ALBUMIN FREE 53arginine 500 mg 111ARIAL CHAMBER 101

Index 2

ARICEPT 116ARIMIDEX 24aripiprazole 28ARISTADA 441 MG/1.6ML 28ARISTADA 662 MG/2.4ML 28ARISTADA 882 MG/3.2ML 28armodafinil 1ARMOUR THYROID 180 MG,300 MG, 240 MG 118ARMOUR THYROID 90 MG, 30MG, 15 MG, 120 MG, 60MG 118AROMASIN 24ARTHRITIS PAINRELIEVING 44artificial tear ointment 111artificial tear solution 111ARTIFICIAL TEARS 111ASACOL HD 51ASCOCID 124ascorbic acid 124ASCORBIC ACID 124aspirin 4ASPIRIN 200 MG, 120 MG 4aspirin 324 mg, 81 mg, 325mg 4aspirin 600 mg, 300 mg 4aspirin buffered (cal carb-magcarb-mag oxide) 4ASSURE COMFORT LANCETSULTRA THIN 28G 64ASSURE HAEMOLANCE PLUSHIGH FLOW 18G 64ASSURE HAEMOLANCE PLUSLOW FLOW 25G 64ASSURE HAEMOLANCE PLUSMICRO FLOW 28G 64ASSURE HAEMOLANCE PLUSNORMAL FLOW 21G 64ASSURE HAEMOLANCE PLUSPEDIATRIC BLADE 64ASSURE ID INSULINSAFETYSYRINGE/U-100/0.5ML/29G X 1/2" 74ASSURE ID INSULINSAFETYSYRINGE/U-100/1ML/29G X 1/2" 74ASSURE LANCE LANCETS 64ASSURE LANCE LANCETS21G 64ASSURE LANCE PLUSSAFETYLANCETS 25G 64ASSURE LANCE PLUSSAFETYLANCETS 30G 64

ASTEPRO 110AT LAST LANCETS 64ATELVIA 49atenolol 32atenolol & chlorthalidone 22ATIVAN 8ATIVAN 0.5 MG, 2 MG 8ATIVAN 1 MG 8ATLAS COLOREDLUBRICATEDCONDOM 62ATLAS LUBRICATEDCONDOM 62ATLAS LUBRICATEDCONDOM/SPERMICIDE 62atorvastatin calcium 20ATRIPLA 29ATROPINE SULFATE 112atropine sulfate(ophthalmic) 112ATROVENT 0.03 % 110ATROVENT 0.06 % 110ATROVENT HFA 9AUBAGIO 116AUGMENTIN 115AUGMENTIN 125MG/5ML-31.25MG/5ML 115AUGMENTIN 250MG/5ML-62.5MG/5ML 115AUGMENTIN ES-600 115AUGMENTIN XR 115AURORA LANCET SUPERTHIN30G 64AURORA LANCET THIN23G 64AURORA PEN NEEDLES29GX12MM 74AURORA PEN NEEDLES 31GX6MM 74AURORA PEN NEEDLES 31GX8MM 74AURORA UNIFINEPENTIPS/32GX5/32" 74AURORA UNIFINEPENTIPS/MINI/31GX3/16"

74AUTO-LANCET 64AUTO-LANCET MINI 64AUTOLET IMPRESSIONLANCING DEVICE 64AUTOLET LANCINGDEVICE 64AUTOLET MINI 64AUTOLET PLUS 64

AUTOPEN 74AVALIDE 22AVANDIA 16AVAPRO 21AVEENO ACTIVE NATURALSPROTECT+HYDRATE/SPF30 45AVEENO ACTIVE NATURALSSKIN RELIEF HEALING 43AVEENO BABY CONTINUOUSPROTECTION SUNBLOCKSPF55 45AVEENO BABY NATURALPROTECTION SPF 50 45AVEENO NATURALPROTECTIONSPF 50 45AVEENO POSITIVELYAGELESSLIFTING & FIRMINGMOISTURIZER SPF30 45AVEENO POSITIVELYAGELESSSUNBLOCKSPF70 45AVEENO POSITIVELYRADIANTDAILY MOISTURIZERSPF15 45AVEENO POSITIVELYRADIANTDAILY MOISTURIZERSPF30 45AVEENO POSITIVELYRADIANTTINTEDMOISTURIZER SPF30FAIR/LIGHT 45AVEENO POSITIVELYRADIANTTINTEDMOISTURIZER SPF30MEDIUM 45AVEENO PROTECT +HYDRATESPF 50 45AVEENO PROTECT +HYDRATESPF 70 45AVEENO SMART ESSENTIALSDAILY NOURISHINGMOISTURIZER SPF30 45AVEENO ULTRA-CALMINGDAILY MOISTURIZERSPF15 45AVONEX 116AVONEX PEN 116AYGESTIN 116AZASAN 105azathioprine 105azelastine hcl 110azelastine hcl (ophth) 114AZITHROMYCIN 57azithromycin 100 mg/5ml 57

Index 3

azithromycin 200 mg/5ml 57azithromycin 250 mg 57azithromycin 500 mg 57azithromycin 600 mg 57AZOPT 114AZULFIDINE 51AZULFIDINE EN-TABS 51b-complex vitamins 106b-complex w/ c & folic acid 106B-D INSULIN SYRINGEULTRAFINE II/0.3ML/31G X5/16" 74B-D INSULIN SYRINGEULTRAFINE II/0.5ML/31G X5/16" 74B-D INSULIN SYRINGEULTRAFINE II/1ML/31G X5/16" 74B-D INSULIN SYRINGEULTRAFINE/0.3ML/30G X1/2" 74B-D INSULIN SYRINGEULTRAFINE/0.5ML/30G X1/2" 74B-D INSULIN SYRINGEULTRAFINE/1ML/30G X1/2" 74BACIGUENT 39bacitracin (topical) 39bacitracin zinc 39bacitracin-polymyxin b 39bacitracin-polymyxin b(ophth) 112baclofen 110BACTRIM 7BACTRIM DS 7BACTROBAN 40BACTROBAN NASAL 110balsalazide disodium 51BAND-AID GAUZE PADSLARGE4" X 4" 58BAND-AID GAUZE PADSMEDIUM 3" X 3" 58BAND-AID GAUZE PADSSMALL2" X 2" 58BAND-AID MIRASORB GAUZESPONGES LARGE 4" X 4" 58BARACLUDE 31BASAGLAR KWIKPEN 16BAYER MICROLET 2 LANCINGDEVICE 64BAYER MICROLETLANCETS 64

BD LO-DOSE INSULINSYRINGE MICROFINEIV/0.5ML/28G X 1/2" 74BD AUTOSHIELD 29G X5/16" 74BD INSULIN SYRINGEMICROFINE IV/U-100/0.3ML/28G X 1/2" 74BD INSULIN SYRINGEMICROFINE IV/U-100/0.5ML/28G X 1/2" 74BD INSULIN SYRINGEMICROFINE IV/U-100/1ML/27G X 5/8" 74BD INSULIN SYRINGEMICROFINE IV/U-100/1ML/28G X 1/2" 74BD INSULIN SYRINGEMICROFINE/U-100/0.3ML/28GX 1/2" 74BD INSULIN SYRINGEMICROFINE/U-100/0.5ML/28GX 1/2" 74BD INSULIN SYRINGEMICROFINE/U-100/1ML/27G X5/8" 74BD INSULIN SYRINGEMICROFINE/U-100/1ML/28G X1/2" 74BD INSULIN SYRINGESAFETYGLIDE/0.5ML/29G X1/2" 74BD INSULIN SYRINGESAFETYGLIDE/1ML/29G X1/2" 74BD INSULIN SYRINGESAFETYGLIDE/U-100/0.3ML/31G X 5/16" 74BD INSULIN SYRINGEULTRAFINE HALF-UNIT/0.3ML/31G X 5/16" 74BD INSULIN SYRINGEULTRAFINEII/SHORT/0.5ML/31G X5/16" 74BD INSULIN SYRINGEULTRAFINEII/SHORT/1ML/31G X5/16" 75BD INSULIN SYRINGEULTRAFINE/0.3ML/30G X1/2" 75BD INSULIN SYRINGEULTRAFINE/0.3ML/31G X5/16" 75BD INSULIN SYRINGEULTRAFINE/0.5ML/30G X1/2" 75

BD INSULIN SYRINGEULTRAFINE/0.5ML/31G X5/16" 75BD INSULIN SYRINGEULTRAFINE/1ML/30G X1/2" 75BD INSULIN SYRINGEULTRAFINE/1ML/31G X5/16" 75BD INSULIN SYRINGEULTRAFINE/U-100/0.3ML/29G X1/2" 75BD INSULIN SYRINGEULTRAFINE/U-100/0.3ML/30G X1/2" 75BD INSULIN SYRINGEULTRAFINE/U-100/0.3ML/31G X5/16" 75BD INSULIN SYRINGEULTRAFINE/U-100/0.5ML/29G X1/2" 75BD INSULIN SYRINGEULTRAFINE/U-100/0.5ML/30G X1/2" 75BD INSULIN SYRINGEULTRAFINE/U-100/0.5ML/31G X5/16" 75BD INSULIN SYRINGEULTRAFINE/U-100/1ML/29G X1/2" 75BD INSULIN SYRINGEULTRAFINE/U-100/1ML/30G X1/2" 75BD INSULIN SYRINGEULTRAFINE/U-100/1ML/31G X15/64" 75BD INSULIN SYRINGEULTRAFINE/U-100/1ML/31G X5/16" 75BD INSULINSYRINGE/DETACHABLENEEDLE/U-100/1ML/25G X1" 75BD INSULINSYRINGE/DETACHABLENEEDLE/U-100/1ML/25G X5/8" 75BD INSULINSYRINGE/DETACHABLENEEDLE/U-100/1ML/26G X1/2" 75BD INSULIN SYRINGE/U-100/0.5ML/30G X 1/2" 75BD INSULIN SYRINGE/U-100/1ML/27G X 1/2" 75BD INSULIN SYRINGE/U-100/1ML/28G X 1/2" 75

Index 4

BD INTEGRA INSULINSYRINGE/U-100/1ML/29G X1/2" 75BD INTEGRASYRINGE/RETRACTINGNEEDLE/1ML/25G X 1" 75BD LANCET DEVICE 64BD LANCET ULTRAFINE30G 64BD MICROTAINERLANCETS 64BD PEN 75BD PEN MINI 75BD PENNEEDLE/MINI/ULTRAFINE/31GX 3/16" 76BD PENNEEDLE/NANO/ULTRAFINE/32G X 4MM 76BD PENNEEDLE/SHORT/ULTRAFINE/31G X 5/16" 76BD PENNEEDLE/ULTRAFINE/29G X12.7MM 76BD PENNEEDLE/ULTRAFINE/29GX1/2"12.7MM 76BD PEN NEEDLESSHORT/ULTRAFINE/31G X5/16" 76BD SAFETY-GLIDE INSULINSYRINGE/0.5ML/29G X 1/2" 76BD SAFETY-LOK INSULINSYRINGE/PERMNEEDLE/UF/1ML/29G X1/2" 76BD SAFETYGLIDE INSULINSYSYRINGE/0.5ML/30G X5/16" 76BD SWABS SINGLE USE 72BEBULIN 52BENADRYL ALLERGY 19BENADRYL ALLERGYCHILDRENS 19BENADRYL DYE-FREEALLERGYLIQUID-GELS 19benazepril &hydrochlorothiazide 22benazepril hcl 40 mg 21benazepril hcl 5 mg, 20 mg, 10mg 21BENEFIX 52BENTYL 118BENZAC AC WASH 39benzonatate 100 mg 37

benzonatate 200 mg 37benzoyl peroxide 39benzoyl peroxide 10 % 39BENZOYL PEROXIDE 2.5% 39benzoyl peroxide 5 % 39benztropine mesylate 25BETADINE 29BETAGAN 112betamethasone dipropionateaugmented 41betamethasone valerate 41BETAPACE 32BETAPACE AF 32BETASERON 117betaxolol hcl (ophth) 112bethanechol chloride 120BETHKIS 1bexarotene 25BIATAIN ADHESIVE FOAMDRESSING 4"X4" 58BIATAIN FOAM DRESSING4"X4" 58BIAXIN 57bicalutamide 24BIOGUARD GAUZE SPONGE2"X2" 8 PLY 58BIOGUARD GAUZESPONGES 4"X4" 12 PLY 58BIOTENE DRY MOUTHMOISTURIZING SPRAY 106biotin 124BIOVOL 107bisacodyl 56bismuth subsalicylate 17bisoprolol &hydrochlorothiazide 22bisoprolol fumarate 32BLEPH-10 112BLEPHAMIDE 113BLEPHAMIDE S.O.P. 113BOOSTRIX 118BORDERED GAUZE 58BOSULIF 24BOUDREAUXS BABY BUTTSMOOTH DRY SKIN 43BREATHERITE 101BREATHERITECOLLAPSIBLEADULTSPACER W/MASK 101

BREATHERITECOLLAPSIBLECHILD SPACERW/MASK 101BREATHERITECOLLAPSIBLEINFANT SPACERW/MASK 101BREATHERITECOLLAPSIBLESMALL CHILDSPACER W/MASK 101BREATHERITECOLLAPSIBLESPACER W/NEONATE MASK 101BREATHERITE RIGIDSPACERW/MASK 101BREATHERITE W/LARGEMASK 101BREATHERITE W/MEDIUMMASK 101BREATHERITE W/SMALLMASK 101BREVICON-28 34BRILINTA 53brimonidine tartrate 112BRINTELLIX 13bromocriptine mesylate 26brompheniramine &phenyleph 37brompheniramine &pseudoeph 37BROTAPP DM 37budesonide (inhalation) 9BUFFERIN 4BULL FROG SUPERBLOCKSPF50 45BULL FROG ULTIMATESHEERPROTECTION FACESUNBLOCK SPF 30 45BULL FROG ULTIMATESHEERPROTECTIONSUNBLOCK SPF 30 45BULL FROG WATER ARMORSPORT FACE SPF 30 46BULLSEYE MINI SAFETYLANCETS 64BULLSEYE SAFETYLANCETS 64bumetanide 48BUMEX 48buprenorphine hcl 5buprenorphine hcl-naloxone hcldihydrate 5bupropion hcl 12bupropion hcl (smokingdeterrent) 117buspirone hcl 8

Index 5

butalbital-acetaminophen 3butalbital-acetaminophen-caffeine 3butalbital-acetaminophen-caffeine w/ codeine 5butalbital-aspirin-caffeine 3butalbital-aspirin-caffeinew/cod 5BUTISOL SODIUM 55BYDUREON 16BYDUREON PEN 16BYETTA 10 MCG/0.04ML 16BYETTA 5 MCG/0.02ML 16C-BUFF 107caffeine citrate 1CALAN 33CALAN SR 32CALCI-CHEW 103calcipotriene 41calcitonin (salmon) 49calcitriol 49CALCIUM 600MG-200UNIT 104calcium acetate (phosphatebinder) 51calcium carbonate 103calcium carbonate (antacid) 6calcium carbonate-cholecalciferol 103calcium carbonate-vitamin d500mg-500mg-200unit-200unit,125unit-500mg, 200unit-500mg,125unit-250mg, 250mg-125unit,500mg-200unit, 500mg-125unit 104calcium carbonate-vitamin d600mg-200unit, 400unit-600mg,200unit-600mg, 600mg-400unit 104calcium citrate 104calcium polycarbophil 55calcium w/ vitamin d 104CALTRATE 600+D 104camphor & menthol 41capecitabine 23CAPHOSOL 106capsaicin 0.025 % 44capsaicin 0.075 % 44capsaicin 0.1 % 44captopril 21

CAPTOPRIL/HYDROCHLOROTHIAZIDE 22CAPZASIN-HP 44CARAC 41CARAFATE 119carbamazepine 11carbamide peroxide (otic) 114CARBATROL 11carbidopa 25carbidopa-levodopa 26CARDIOCOM LANCINGDEVICE 64CARDIZEM 33CARDIZEM CD 180 MG, 120MG, 300 MG 33CARDIZEM CD 240 MG 33CARDURA 21CAREFINE PEN NEEDLE32GX4MM 76CAREFINE PEN NEEDLES29GX1/2" 76CAREFINE PEN NEEDLES30GX5/16" 76CAREFINE PEN NEEDLES31GX6MM 76CAREFINE PEN NEEDLES31GX8MM 76CAREFINE PEN NEEDLES32GX5MM 76CAREFINE PEN NEEDLES32GX6MM 76CAREONE ADVANCEDLANCINGDEVICE 64CAREONE INSULINSYRINGES/0.3ML/30G X1/2" 76CAREONE INSULINSYRINGES/0.3ML/31G X5/16" 76CAREONE INSULINSYRINGES/0.5ML/30G X1/2" 76CAREONE INSULINSYRINGES/0.5ML/31G X5/16" 76CAREONE INSULINSYRINGES/1ML/30G X1/2" 76CAREONE INSULINSYRINGES/1ML/31GX5/16"

76CAREONE LANCET THIN 64CAREONE LANCET ULTRATHIN 64CAREONE UNIFINE PENTIPS29GX12MM 76

CAREONE UNIFINE PENTIPS31GX5MM 76CAREONE UNIFINE PENTIPS31GX6MM 76CAREONE UNIFINE PENTIPS31GX8MM 76CAREONE UNIFINE PENTIPSPEN NEEDLES 32GX4MM 76CAREONE UNIFINE PENTIPSPLUS PEN NEEDLES29GX12MM 76CAREONE UNIFINE PENTIPSPLUS PEN NEEDLES31GX5MM 76CAREONE UNIFINE PENTIPSPLUS PEN NEEDLES31GX6MM 76CAREONE UNIFINE PENTIPSPLUS PEN NEEDLES31GX8MM 77CAREONE UNIFINE PENTIPSPLUS PEN NEEDLES32GX4MM 77CARETOUCH LANCINGDEVICEWITH EJECTOR 64CARETOUCH PEN NEEDLES31G X 6 MM 77CARETOUCH PEN NEEDLES31GX 5MM 77CARETOUCH PEN NEEDLES31GX 8MM 77CARETOUCH PEN NEEDLES32GX 4MM 77CARETOUCH PEN NEEDLES32GX 5MM 77CARETOUCH TWIST LANCETS30G 64CARNITOR 49CARNITOR SF 49CARRASMART 58CARRASMART FOAM 58carteolol hcl (ophth) 112carvedilol 12.5 mg, 6.25 mg,3.125 mg 32carvedilol 25 mg 32CASODEX 24CATAPRES 21CATAPRES-TTS-1 21CATAPRES-TTS-2 21CATAPRES-TTS-3 21cefaclor 34CEFACLOR 34cefadroxil 34cefdinir 34cefprozil 34

Index 6

CEFTIN 34ceftriaxone sodium 34cefuroxime axetil 34CELEBREX 100 MG, 200 MG, 50MG 2CELEBREX 400 MG 2celecoxib 400 mg 2celecoxib 50 mg, 100 mg, 200mg 2CELEXA 10 MG, 20 MG 13CELEXA 40 MG 13CELLCEPT 105CELLCEPTINTRAVENOUS 105CENTANY 40CENTRUM MULTIVITAMINFLAVOR BURST DRINK 107cephalexin 34CERALYTE 70 104CERASPORT 104CERASPORT EX1 104CERAVE SUNSCREENFACE/SPF50 46CERAVESUNSCREEN/BODY 46CERAVESUNSCREEN/FACE 46CERDELGA 53CEREZYME 53CERVARIX 121cetirizine hcl 19cetirizine-pseudoephedrine 37CHANTAL SUN SCREEN SPF30 46CHANTIX 117CHANTIX CONTINUINGMONTHPAK 117CHANTIX STARTING MONTHPAK 117CHEK-STIX COMBO PAKURINALYSIS CONTROL 47CHEK-STIX CONTROL 47CHEMET 17CHEMSTRIP-K 47CHERACOL PLUS 37CHERACOL-D COUGH 37CHILDRENS ADVIL 2CHILDRENS MOTRIN 2CHLOR-TRIMETON 19chlordiazepoxide hcl 8chlorhexidine gluconate 29

chlorhexidine gluconate(mouth-throat) 106CHLOROQUINE PHOSPHATE250 MG 23chloroquine phosphate 250mg 23chloroquine phosphate 500mg 23CHLOROTHIAZIDE 250MG 48chlorothiazide 500 mg 48chlorpheniramine maleate 19CHLORPROMAZINE HCL 28chlorpromazine hcl 10 mg 28chlorpromazine hcl 50 mg, 200mg, 25 mg, 100 mg 28chlorthalidone 48chlorzoxazone 110CHOLBAM 51cholecalciferol 1000 unit, 2000unit 124cholecalciferol 1000 unit, 400unit 124cholecalciferol 400 unit 124cholecalciferol 400unit/ml 124cholecalciferol 5000 unit 124cholecalciferol 50000 unit 124cholestyramine 20cholestyramine light 20choline & mag salicylate 4cilostazol 53cimetidine 200 mg 119cimetidine 400 mg, 800 mg,300 mg 119cimetidine hcl 119CIPRO 50CIPROFLOXACIN HCL 100MG 50ciprofloxacin hcl 250 mg, 500mg, 750 mg 51citalopram hydrobromide 13citalopram hydrobromide 10mg, 20 mg 13citalopram hydrobromide 40mg 13clarithromycin 57clarithromycin 125 mg/5ml 57clarithromycin 250 mg/5ml 57CLARITIN 19CLARITIN REDITABS 19CLARITIN-D 12 HOUR 37

CLARITIN-D 24 HOUR 37CLASS ACT LUBRICATED 62CLASSIC PRENATAL 108CLEAN & CLEAR ADVANTAGE3-IN-1 EXFOLIATINGCLEANSER 39CLEANLET LANCETS 28G 64CLEAR COUGH PM MULTI-SYMPTOM 37clemastine fumarate 19CLEOCIN 7CLEOCIN PEDIATRICGRANULES 7CLEOCIN-T 39CLEVER CHOICE ANTI-STATICVALVED HOLDINGCHAMBER/ADULT LARGE101CLEVER CHOICE ANTI-STATICVALVED HOLDINGCHAMBER/MEDIUM 101CLEVER CHOICE ANTI-STATICVALVED HOLDINGCHAMBER/SMALL 101CLEVER CHOICE COMFORTEZINSULIN PEN NEEDLES31GX8MM 77CLEVER CHOICE COMFORTEZINSULINSYRINGE/0.3ML/29G X 1/2" 77CLEVER CHOICE COMFORTEZINSULINSYRINGE/0.3ML/30G X 1/2" 77CLEVER CHOICE COMFORTEZINSULINSYRINGE/0.3ML/30G X5/16" 77CLEVER CHOICE COMFORTEZINSULINSYRINGE/0.3ML/31G X5/16" 77CLEVER CHOICE COMFORTEZINSULINSYRINGE/0.5ML/28G X 1/2" 77CLEVER CHOICE COMFORTEZINSULINSYRINGE/0.5ML/29G X 1/2" 77CLEVER CHOICE COMFORTEZINSULINSYRINGE/0.5ML/30G X 1/2" 77CLEVER CHOICE COMFORTEZINSULINSYRINGE/0.5ML/30G X5/16" 77CLEVER CHOICE COMFORTEZINSULINSYRINGE/0.5ML/31G X5/16" 77

Index 7

CLEVER CHOICE COMFORTEZINSULINSYRINGE/1.0ML/30G X 1/2" 77CLEVER CHOICE COMFORTEZINSULIN SYRINGE/1ML/28GX 1/2" 77CLEVER CHOICE COMFORTEZINSULIN SYRINGE/1ML/29GX 1/2" 77CLEVER CHOICE COMFORTEZINSULIN SYRINGE/1ML/30GX 5/16" 77CLEVER CHOICE COMFORTEZINSULIN SYRINGE/U-100/1ML/31GX5/16" 77CLEVER CHOICE COMFORTEZPEN NEEDLES29GX12MM 77CLEVER CHOICE COMFORTEZPEN NEEDLES31GX5MM 77CLEVER CHOICE COMFORTEZPEN NEEDLES31GX6MM 77CLEVER CHOICE COMFORTEZPEN NEEDLES31GX8MM 78CLEVER CHOICE COMFORTEZPEN NEEDLES32GX4MM 78CLEVER CHOICE COMFORTEZPEN NEEDLES32GX5MM 78CLEVER CHOICE COMFORTEZPEN NEEDLES32GX6MM 78CLICKFINE PEN NEEDLE32GX5/32" 78CLICKFINE PEN NEEDLEUNIVERSAL/31GX1/4" 78CLICKFINE PEN NEEDLEUNIVERSAL/31GX5/16" 78CLICKFINE PENNEEDLES/31GX1/4" 78CLICKFINE PENNEEDLES/31GX5/16" 78CLICKFINE UNIVERSAL PENNEEDLES 31GX5/16" 78CLIMARA 50clindamycin hcl 7clindamycin palmitatehydrochloride 7clindamycin phosphate(topical) 39clindamycin phosphatevaginal 123clobetasol propionate 41

clobetasol propionate emollientbase 42clomipramine hcl 14clonazepam 10clonidine hcl 21clopidogrel bisulfate 53clorazepate dipotassium 8CLOSERCARE 64clotrimazole (topical) 40clotrimazole vaginal 1 % 123clotrimazole vaginal 2 % 123clotrimazole w/betamethasone 40clozapine 100 mg 27clozapine 25 mg 27clozapine 50 mg, 200 mg, 25mg 27CLOZAPINE ODT 27CLOZARIL 100 MG 27CLOZARIL 25 MG 27coal tar extract 47COARTEM 23codeine sulfate 15 mg, 60 mg,30 mg 4CODEINE SULFATE 60 MG,15 MG, 30 MG 4COGENTIN 25COLACE 57COLAZAL 51COLCHICINE 52colchicine w/ probenecid 52COLCRYS 52COLESTID 20COLESTID FLAVORED 20colestipol hcl 20COLYTE-FLAVOR PACKS56COMBIPATCH 50COMBIVENT RESPIMAT 9COMBIVIR 29COMFORT ASSIST INSULINSYRINGE 0.3ML/29G X1/2" 78COMFORT ASSIST INSULINSYRINGE/0.3ML/30G X5/16" 78COMFORT ASSIST INSULINSYRINGE/0.3ML/31G X5/16" 78COMFORT ASSIST INSULINSYRINGE/0.5ML/29G X1/2" 78

COMFORT ASSIST INSULINSYRINGE/0.5ML/30G X5/16" 78COMFORT ASSIST INSULINSYRINGE/0.5ML/31G X5/16" 78COMFORT ASSIST INSULINSYRINGE/1ML/29G X 1/2" 78COMFORT ASSIST INSULINSYRINGE/1ML/30G X 5/16" 78COMFORT ASSIST INSULINSYRINGE/1ML/31G X 5/16" 78COMFORT ASSUREDLANCETS MICRO THIN33G 64COMFORT ASSUREDLANCETS SUPER THIN28G 64COMFORT LANCETS 64COMPACT SPACECHAMBER/ANTI-STATIC 101COMPACT SPACECHAMBER/ANTI-STATIC/LARGE MASK 101COMPACT SPACECHAMBER/ANTI-STATIC/MEDIUM MASK 101COMPACT SPACECHAMBER/ANTI-STATIC/SMALLMASK 101COMPLERA 29COMVAX 121CONCEPTIONXR MOTILITYSUPPORT FORMULA 107CONCERTA 36 MG 1CONCERTA 54 MG, 27 MG, 18MG 1CONDYLOX 43COOL BOTTOMS 44COPA ISLAND BORDEREDFOAM DRESSING 4"X4" 58COPA PLUS HYDROPHILICFOAM DRESSING 4"X4" 58COPAXONE 20 MG/ML 117COPAXONE 40 MG/ML 117CORDARONE 8COREG 25 MG 32COREG 6.25 MG, 12.5 MG,3.125 MG 32COREG CR 32CORGARD 32CORIFACT 52CORTANE-B-OTIC 114CORTEF 36CORTENEMA 6

Index 8

CORTISONE ACETATE 36CORVITE 107COSOPT 112COTELLIC 24COTZ 46COUMADIN 10COVRSITE COVERDRESSING 58COVRSITE PLUS COMPOSITEDRESSING 58COZAAR 21CREON 48CRIXIVAN 200 MG 29CRIXIVAN 400 MG 29CROMOLYN SODIUM 9cromolyn sodium (nasal) 110cromolyn sodium (ophth) 114CUREX ALL-PURPOSESPONGES 4"X4" 4 PLY 58CURITY ALCOHOLPREPS/MEDIUM 2 PLY 72CURITY ALCOHOL SWABS 72CURITY ALL PURPOSESPONGES 2"X2" 58CURITY ALL PURPOSESPONGES 2"X2" 4PLY 58CURITY ALL PURPOSESPONGES 3"X3" 4PLY 58CURITY ALL PURPOSESPONGES 4 PLY 58CURITY ALL PURPOSESPONGES 4"X4" 58CURITY ALL PURPOSESPONGES 4"X4" 4PLY 58CURITY ALL PURPOSESPONGES 4"X4" 4PLY/SOFTPOUCH 58CURITY AMDANTIMICROBIALGAUZESPONGES 2"X2" 8 PLY 58CURITY AMDANTIMICROBIALGAUZESPONGES 4"X4" 12 PLY 58CURITY COVER SPONGE4"X4" 58CURITY COVER SPONGES3"X3" 58CURITY COVER SPONGES4"X4" 58CURITY DRESSING SPONGES4"X4" 6 PLY 58CURITY GAUZE PADS2"X2" 58CURITY GAUZE PADS 2"X2" 12PLY 58

CURITY GAUZE PADS3"X3" 59CURITY GAUZE PADS 4"X4"12 PLY 59CURITY GAUZE SPONGE2"X2" 8 PLY 59CURITY GAUZE SPONGE2"X2"12 PLY 59CURITY GAUZE SPONGE3"X3" 12 PLY 59CURITY GAUZE SPONGE4"X4" 12 PLY 59CURITY GAUZE SPONGE4"X4" 16 PLY 59CURITY GAUZE SPONGE4"X4" 8 PLY 59CURITY GAUZE SPONGE4"X4"16 PLY 59CURITY GAUZE SPONGES4"X4" 12 PLY 59CURITY GAUZE SPONGES4"X4" 8 PLY 59CURITY NON-ADHERENTSTRIPS 3"X3" 59CURITYSPONGES/CELLULOSEFILLED/2"X2" 59CURITYSPONGES/CELLULOSEFILLED/4"X4" 59CUTIVATE 42CVS ALCOHOL PREPSWABS 72CVS ALCOHOL SWABS 72CVS DIABETES HEALTHSUPPORT 107CVS DRY MOUTHSPRAY 106CVS GAUZE PADS 2"X2" 12-PLY 59CVS GAUZE PADS 4"X4" 12-PLY 59CVS GLUCOSE 15CVS LANCETS 21G 64CVS LANCETS MICRO THIN33G 64CVS LANCETS MICRO-THIN33G 65CVS LANCETS THIN 26G 65CVS LANCETS ULTRA THIN30G 65CVS LANCETS ULTRA-THIN30G 65CVS LANCING DEVICE 65CVS OMEPRAZOLE 119CVS PRENATAL 108

CVS PRENATALGUMMY/DHA/FOLIC ACID 108CVS PREP PADS 72cyanocobalamin 53CYCLESSA 34cyclobenzaprine hcl 110CYCLOGYL 0.5 %, 1 % 112CYCLOGYL 2 % 112cyclopentolate hcl 1 %, 0.5% 112cyclopentolate hcl 2 % 112CYCLOPHOSPHAMIDE 23cyclosporine 105CYCLOSPORINEMODIFIED 105cyclosporine modified (formicroemulsion) 105CYMBALTA 14cyproheptadine hcl 20CYTOMEL 118CYTOTEC 120D-VI-SOL 124D.H.E. 45 103DAILY CONDITIONINGTREATMENT 43DAILY HEART HEALTHSUPPORT 107DAILY PAK MAXIMUMMULTIVITAMIN/ASIANGINSENG EXTRACT 107dakin's solution 29DAKINS SOLUTION QUARTERSTRENGTH 29DALIRESP 9dapsone 7DAY TIME MULTI-SYMPTOMCOLD/FLU RELIEF 37DAYPRO 2DDAVP 50DDAVP 0.01 % 50DDAVP 4 MCG/ML 50DEBROX 114DELSYM 37DELSYM COUGHCHILDRENS 37DELZICOL 51DEMADEX 48DEMEROL 4DEPACON 12DEPAKENE 12DEPAKOTE 12

Index 9

DEPAKOTE ER 12DEPAKOTE SPRINKLES 12DEPEN TITRATABS 105DEPLIN 15 47DEPLIN 7.5 47DEPO-PROVERACONTRACEPTIVE 36DEPO-SUBQ PROVERA104 36DEPO-TESTOSTERONE 5DERMACEA DRAIN SPONGES4"X4" 59DERMACEA GAUZE SPONGE2"X2" 12 PLY 59DERMACEA GAUZE SPONGE2"X2" 8 PLY 59DERMACEA GAUZE SPONGE3"X3" 12 PLY 59DERMACEA GAUZE SPONGE3"X3" 8 PLY 59DERMACEA GAUZE SPONGE4"X4" 12 PLY 59DERMACEA GAUZE SPONGE4"X4" 16 PLY 59DERMACEA GAUZE SPONGE4"X4" 8 PLY 59DERMACEA I.V. DRAINSPONGES 2"X2" 59DERMACEA I.V. DRAINSPONGES 4"X4" 59DERMACEA I.V. SPONGES2"X2" 59DERMACEA NON-WOVENSPONGES 2"X2" 4 PLY 59DERMACEA NON-WOVENSPONGES 3"X3" 4 PLY 59DERMACEA NON-WOVENSPONGES 4"X4" 4 PLY 59DERMACEA NON-WOVENSPONGES 4"X4" 6 PLY 59DERMACEA TYPE VII GAUZE2"X2" 12 PLY 59DERMACEA TYPE VII GAUZE2"X2" 8 PLY 59DERMACEA TYPE VII GAUZE3"X3" 12 PLY 59DERMACEA TYPE VII GAUZE3"X3" 12PLY 59DERMACEA TYPE VII GAUZE4"X4" 12 PLY 59DERMACEA TYPE VII GAUZE4"X4" 16 PLY 59DERMACEA TYPE VII GAUZE4"X4" 8 PLY 60DERMACEA X-RAY SPONGES4"X4" 16 PLY 60DERMALEVIN ADHESIVEFOAMDRESSING 4"X4" 60

DERMATOP 42DERMOTIC 115DESCOVY 29desipramine hcl 25 mg 14desipramine hcl 50 mg, 100mg, 10 mg, 150 mg, 75 mg14desmopressin acetate 50desmopressin acetaterefrigerated 50desmopressin acetatespray 50desmopressin acetate sprayrefrigerated 50DESOGEN 34desogestrel & ethinylestradiol 34desogestrel-ethinyl estradiol(biphasic) 34desogestrel-ethinyl estradiol(triphasic) 34desoximetasone 42DESQUAM-X WASH 39DESVENLAFAXINE ER 50 MG,100 MG 14desvenlafaxine succinate 14DETROL 120DETROL LA 120DEX4 QUICK DISSOLVEGLUCOSE 15dexamethasone 36DEXAMETHASONE 36dexamethasone 0.5 mg, 1.5mg, 6 mg, 0.75 mg, 4 mg 36DEXAMETHASONE 1 MG, 2MG 36DEXAMETHASONEINTENSOL 36DEXAMETHASONE SODIUMPHOSPHATE 0.1 % 113dexamethasone sodiumphosphate 120 mg/30ml, 20mg/5ml, 4 mg/ml 36DEXEDRINE 15 MG, 10MG 1DEXEDRINE 5 MG 1dexmethylphenidate hcl 1dextroamphetamine sulfate 1dextroamphetamine sulfate 15mg, 10 mg 1dextroamphetamine sulfate 5mg 1dextromethorphanpolistirex 37dextromethorphan-doxylamine-acetaminophen 37

dextromethorphan-guaifenesin37

dextromethorphan-phenylephrine-acetaminophen

37dextrose (diabetic use) 15DHS TAR 47DHS TAR GEL 47DIABETA 17DIABETES HEALTH PACK 107DIABETES SUPPORTPACK 107DIABETIDERM SUNSCREENSPF15 46DIAMOX 48diaper rash products 43DIASTAR EASY TEST IILANCETS 30G 65DIASTAR EASY TESTLANCETS30G 65DIASTAT ACUDIAL 10DIASTAT PEDIATRIC 10diazepam 8DIAZEPAM 10DIAZEPAM 1 MG/ML 8DIAZEPAM 5 MG/ML 8dibucaine 44diclofenac potassium 2diclofenac sodium 2diclofenac sodium (ophth) 114dicloxacillin sodium 116dicyclomine hcl 118didanosine 29DIFLORASONEDIACETATE 42DIFLUCAN 18DIFLUCAN 100 MG 18DIFLUCAN 150 MG 18DIFLUCAN 200 MG 18DIFLUCAN 50 MG 18diflunisal 4DIGOXIN 33digoxin 33dihydroergotamine mesylate 1mg/ml 103DIHYDROERGOTAMINEMESYLATE 4 MG/ML 103DILANTIN 100 MG 12DILANTIN 30 MG 12DILANTIN INFATABS 12

Index 10

DILANTIN-125 12DILAUDID 4diltiazem hcl 33diltiazem hcl 180 mg, 120mg 33diltiazem hcl 240 mg 33diltiazem hcl coated beads 180mg, 300 mg, 120 mg 33diltiazem hcl coated beads 240mg 33diltiazem hcl extended releasebeads 33dimenhydrinate 18DIMETAPP COLD &ALLERGY 37DIOVAN 21DIOVAN HCT 22diphenhydramine hcl 19diphenhydramine hcl (sleep) 54diphenhydramine hcl (sleep) 25mg 54diphenhydramine hcl (sleep) 50mg 54diphenhydramine hcl(topical) 41diphenhydramine hcl 25 mg 19diphenhydramine hcl 50 mg 19diphenoxylate w/ atropine 17DIPHENOXYLATE/ATROPINE

17DIPROLENE AF 42dipyridamole 53DISALCID 4disopyramide phosphate 8disulfiram 116DITROPAN XL 120divalproex sodium 12docusate calcium 57docusate sodium 57docusate sodium 250 mg, 100mg 57dofetilide 8DOLOPHINE 10 MG 4DOLOPHINE 5 MG 4donepezil hydrochloride 116DONNATAL 118dorzolamide hcl 114dorzolamide hcl-timololmaleate 112DOVONEX 41doxazosin mesylate 21

doxepin hcl 14doxepin hcl 100 mg, 50 mg, 10mg, 150 mg, 25 mg 14DOXEPIN HCL 75 MG 14doxycycline hyclate 118doxylamine succinate(sleep) 54DRAMAMINE 18DRESSING SPONGES4"X4" 60DRISDOL 124droperidol 8DROPLET LANCETS ULTRATHIN 30G 65DROPLET LANCINGDEVICE 65DROPLET PEN NEEDLES29GX12MM 78DROPLET PEN NEEDLES31GX5MM 78DROPLET PEN NEEDLES31GX6MM 78DROPLET PEN NEEDLES31GX8MM 78DROPLET PEN NEEDLES32GX4MM 78DROPLET PEN NEEDLES32GX5MM 78DROPLET PEN NEEDLES32GX6MM 78drospirenone-ethinylestradiol 34DROXIA 53DRUG MART ADJUSTABLELANCING DEVICE 65DRUG MART LANCETSTHIN 65DRUG MART ON-THE-GOLANCETS GENTLE 30G 65DRUG MART UNIFINEPENTIPS 31GX5MM 78DRUG MART UNIFINEPENTIPS29G X 12MM 78DRUG MART UNIFINEPENTIPS31GX6MM 78DRUG MART UNIFINEPENTIPS31GX8MM 78DRUG MART UNIFINEPENTIPS32GX4MM 78DRUG MART UNIFINEPENTIPSPLUS 32GX4MM79DRUG MART UNILETLANCETSSUPER THIN30G 65DRUG MART UNILETLANCETSULTRA THIN28G 65

DRY MOUTH SPRAY 106DRYMAX EXTRA 60DRYSOL 44DUANE READE LANCETALTERNATE SITE 26G 65DUANE READE LANCETSUPERTHIN 30G 65DUANE READE LANCETULTRATHIN 28G 65DUANE READE UNIFINEPENTIPS 29G X 12MM 79DUANE READE UNIFINEPENTIPS 31G X 6MM ULTRASHORT 79DUANE READE UNIFINEPENTIPS 31G X 8MMSHORT 79DULCOLAX 56DULERA 9DULOXETINE HCL 40 MG 14duloxetine hcl 60 mg, 20 mg, 30mg 14DURAGESIC 4DUREX EXTRA SENSITIVE 62DUTOPROL 22DYAZIDE 48E-Z JECT LANCETS 65E-Z JECT LANCETS 21G 65E-Z JECT LANCETSCOLOR 65E-Z JECT LANCETS SUPERTHIN 30G 65E-Z JECT LANCETS THIN26G 65E-Z SPACER 101E-Z SPACER THE BODYGUARDS PACK 101E-ZJECT LANCETS MICRO-THIN 33G 65E.E.S. 400 57E.E.S. GRANULES 57EASIVENT 101EASIVENT/MASK-LARGE 101EASIVENT/MASK-MEDIUM

101EASIVENT/MASK-SMALL 101EASY COMFORT INSULINSYRINGE/0.3ML/30G X5/16" 79EASY COMFORT INSULINSYRINGE/0.5ML/30G X5/16" 79

Index 11

EASY COMFORT INSULINSYRINGE/0.5ML/31G X5/16" 79EASY COMFORT INSULINSYRINGE/1ML/30G X 5/16" 79EASY COMFORT INSULINSYRINGE/1ML/31G X 5/16" 79EASY COMFORT INSULINSYRINGE/U-100/0.5ML/30G X1/2" 79EASY COMFORT INSULINSYRINGE/U-100/1ML/30G X1/2" 79EASY COMFORT PENNEEDLES31GX1/4" 79EASY COMFORT PENNEEDLES31GX3/16" 79EASY COMFORT PENNEEDLES31GX5/16" 79EASY COMFORT PENNEEDLES32GX5/32" 79EASY MINI EJECT LANCINGDEVICE 65EASY MINI LANCINGDEVICE 65EASY TOUCH 32GX5MM 79EASY TOUCH 32GX6MM 79EASY TOUCH ALCOHOL PREPPADS/MEDIUM 72EASY TOUCH FLIPLOCKSAFETY INSULIN SYRINGE1ML/29GX1/2" 79EASY TOUCH FLIPLOCKSAFETY INSULIN SYRINGE1ML/30GX1/2" 79EASY TOUCH FLIPLOCKSAFETY INSULIN SYRINGE1ML/30GX5/16" 79EASY TOUCH FLIPLOCKSAFETY INSULIN SYRINGE1ML/31GX5/16" 79EASY TOUCH INSULINSYRINGE/0.3ML/30G X5/16" 79EASY TOUCH INSULINSYRINGE/0.3ML/31G X5/16" 79EASY TOUCH INSULINSYRINGE/0.5ML/29G X 1/2" 79EASY TOUCH INSULINSYRINGE/0.5ML/30G X5/16" 79EASY TOUCH INSULINSYRINGE/1ML/30G X 5/16" 79EASY TOUCH INSULINSYRINGE/SAFETY/U-100/0.5ML/29G X 1/2" 79

EASY TOUCH INSULINSYRINGE/SAFETY/U-100/0.5ML/30G X 5/16" 79EASY TOUCH INSULINSYRINGE/SAFETY/U-100/1ML/29G X 1/2" 79EASY TOUCH INSULINSYRINGE/SAFETY/U-100/1ML/30G X 1/2" 79EASY TOUCH INSULINSYRINGE/U-100/0.3ML/30G X1/2" 80EASY TOUCH INSULINSYRINGE/U-100/0.5ML/27G X1/2" 80EASY TOUCH INSULINSYRINGE/U-100/0.5ML/28G X1/2" 80EASY TOUCH INSULINSYRINGE/U-100/0.5ML/30G X1/2" 80EASY TOUCH INSULINSYRINGE/U-100/0.5ML/31G X5/16" 80EASY TOUCH INSULINSYRINGE/U-100/1ML/27G X1/2" 80EASY TOUCH INSULINSYRINGE/U-100/1ML/28G X1/2" 80EASY TOUCH INSULINSYRINGE/U-100/1ML/29G X1/2" 80EASY TOUCH INSULINSYRINGE/U-100/1ML/30G X1/2" 80EASY TOUCH INSULINSYRINGE/U-100/1ML/31G X5/16" 80EASY TOUCH LANCETS28G/PULL-TOP 65EASY TOUCH LANCETS30G/BUTTON-ACTIVATED

65EASY TOUCH LANCETS30G/PULL-TOP 65EASY TOUCH LANCETS30G/TWIST 65EASY TOUCH LANCETS32G/PRESSUREACTIVATED 65EASY TOUCH LANCINGDEVICE/EJECTOR 65EASY TOUCH PEN NEEDLES29GX1/2" 80EASY TOUCH PEN NEEDLES31GX1/4" 80EASY TOUCH PEN NEEDLES31GX5/16" 80

EASY TOUCH PEN NEEDLES32GX1/4" 80EASY TOUCH PEN NEEDLES32GX3/16" 80EASY TOUCH PEN NEEDLES32GX5/32" 80EASY TOUCH PENNEEDLES/31G X 3/16" 80EASY TOUCH SAFETYLANCETS21G/PRESSUREACTIVATED 65EASY TOUCH SAFETYLANCETS28G/BUTTONACTIVATED 65EASY TOUCH SHEATHLOCKSAFETY INSULIN SYRINGE1ML/29GX1/2" 80EASY TOUCH SHEATHLOCKSAFETY INSULIN SYRINGE1ML/30GX5/16" 80EASY TOUCH SHEATHLOCKSAFETY INSULIN SYRINGE1ML/31GX5/16" 80EASY TOUCH SHEATHLOCKSAFETY SYRINGE1ML/30GX1/2" 80EASY TWIST & CAPLANCETS 65EASYTEST LANCETS 65EC-NAPROSYN 2econazole nitrate 40ECOTRIN REGULARSTRENGTH 4ED BRON GP 37EDURANT 29EFFEXOR XR 14EFFIENT 53EFUDEX 41ELAVIL 14ELDEPRYL 26ELDERTONIC 107ELEXA NATURAL FEEL 62ELEXA STIMULATING 62ELEXA ULTRA SENSITIVE 62ELFOLATE 47ELIDEL 43ELIGARD 24ELIMITE 44ELIQUIS 10ELITE-THIN INSULINSYRINGE/0.3ML/31G X5/16" 80ELITE-THIN INSULINSYRINGE/0.5ML/29G X 1/2" 80

Index 12

ELITE-THIN INSULINSYRINGE/0.5ML/30G X5/16" 80ELITE-THIN INSULINSYRINGE/1ML/30G X 5/16" 80ELITE-THIN INSULINSYRINGE/U-100/0.5ML/28G X1/2" 80ELITE-THIN INSULINSYRINGE/U-100/0.5ML/31G X5/16" 80ELITE-THIN INSULINSYRINGE/U-100/1ML/28G X1/2" 80ELITE-THIN INSULINSYRINGE/U-100/1ML/29G X1/2" 80ELITE-THIN INSULINSYRINGE/U-100/1ML/31G X5/16" 81ELIXOPHYLLIN 10ELLA 35ELLIS TONIC 107ELMIRON 52ELOCON 42ELOCTATE 52ELTA BLOCK SPF 32 46EMBEDA 4EMCYT 24EMERGEN-C BLUE 107EMERGEN-C FIVE 107EMERGEN-C HEARTHEALTH 107EMERGEN-C IMMUNE 107EMERGEN-C IMMUNEPLUS 107EMERGEN-C IMMUNE+WARMERS 107EMERGEN-C JOINTHEALTH 107EMERGEN-C KIDZ 107EMERGEN-C MSM LITE 107EMERGEN-C PINK 107EMERGEN-C SUPERFRUIT 107EMERGEN-C VITAMIN C 107EMERGEN-C VITAMIN CLITE 107EMERGEN-C VITAMIN D &CALCIUM 107EMLA 44emollient 43EMSAM 13

EMTRIVA 29enalapril maleate 21enalapril maleate &hydrochlorothiazide 22ENBREL 3ENBREL SURECLICK 3END FATIGUE DAILYENERGYENFUSION 107ENERGY BOOSTER 107ENFAMIL ENFALYTE 104ENGERIX-B 121enoxaparin sodium 120mg/0.8ml, 80 mg/0.8ml 10enoxaparin sodium 150 mg/ml,100 mg/ml 10enoxaparin sodium 30mg/0.3ml 10enoxaparin sodium 300mg/3ml 10enoxaparin sodium 40mg/0.4ml 10enoxaparin sodium 60mg/0.6ml 10entecavir 31EPANED 21EPCLUSA 31EPIFOAM 42epinephrine 0.15mg/0.3ml 123epinephrine 0.3 mg/0.3ml 123EPIVIR 29EPIVIR 150 MG 29EPIVIR 300 MG 29EPOGEN 53EPZICOM 29EQ OMEPRAZOLE 119EQL ALCOHOL SWABS 72EQL COLOR LANCETS21G 65EQL COLOR LANCETSMICRO THIN 33G 65EQL DRY MOUTH ORALRINSE 106EQL GAUZE PADS2"X2"/SMALL 60EQL GAUZE PADS4"X4"/LARGE 60EQL GAUZE PADS STERILE3"X3"/MEDIUM 60EQL GAUZE STERILE PADS3"X3" 60EQL INSULINSYRINGE/0.3ML/29G X1/2" 81

EQL INSULINSYRINGE/0.3ML/30G X5/16" 81EQL INSULINSYRINGE/0.3ML/31G X5/16" 81EQL INSULINSYRINGE/0.5ML/29G X 1/2" 81EQL INSULINSYRINGE/0.5ML/30G X5/16" 81EQL INSULINSYRINGE/0.5ML/31G X5/16" 81EQL INSULINSYRINGE/1ML/29G X 1/2" 81EQL INSULINSYRINGE/1ML/30G X 5/16" 81EQL INSULINSYRINGE/1ML/31G X 5/16" 81EQL INSULIN SYRINGE/U-100/0.3ML/29G X 1/2" 81EQL INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" 81EQL INSULIN SYRINGE/U-100/1ML/29G X 1/2" 81EQL OMEPRAZOLE 119EQL PRENATALFORMULA 108EQL SHORT PEN NEEDLES31G X 8MM 81EQL SUPER ENERGYBOOSTER 107EQL SUPER THIN LANCETS30G 65EQL THIN LANCETS 26G 65EQL ULTRA COMFORTINSULINSYRINGE/0.3ML/31G X5/16" 81EQL ULTRA COMFORTINSULINSYRINGE/1ML/30G X5/16" 81EQL ULTRA SHORT PENNEEDLES 31G X 6MM 81EQUETRO 26ergocalciferol 124ergoloid mesylates 117ERGOLOID MESYLATES 117ERIVEDGE 24ERY-TAB 57ERYGEL 39ERYPED 200 57ERYPED 400 57ERYTHROCIN STEARATE 57erythromycin (acne aid) 39

Index 13

erythromycin (ophth) 112erythromycin base 57ERYTHROMYCIN BASE 57erythromycin ethylsuccinate 57ERYTHROMYCINETHYLSUCCINATE 57escitalopram oxalate 13ESGIC 3esomeprazole magnesium 40mg 119estazolam 55esterified estrogens &methyltestosterone 50ESTRACE 50estradiol 50estradiol & norethindroneacetate 50estradiol 0.0375 mg/24hr 50estradiol 0.05 mg/24hr, 0.075mg/24hr, 0.025 mg/24hr, 0.1mg/24hr 50estropipate 0.75 mg, 1.5 mg 50ESTROPIPATE 1.5 MG, 0.75MG 50ESTROPIPATE 3 MG 50eszopiclone 55ethambutol hcl 23ethosuximide 12ethynodiol diacet & ethestrad 34etodolac 2ETOPOSIDE 25EURAX 44EVAC 55EVISTA 49EVOTAZ 29EX-LAX 56EXCILON AMDANTIMICROBIALDRAINSPONGES 4"X4" 6 PLY 60EXCILON AMDANTIMICROBIALNON-WOVENSPONGES 4"X4" 6 PLY 60EXCILON DRAIN SPONGE4"X4" 60EXCILON DRAIN SPONGES4"X4" 6 PLY 60EXCILON I.V. SPONGES 2"X2" 6PLY 60EXEL COMFORT POINTINSULIN PEN NEEDLES 29G X12MM 81

EXEL COMFORT POINTINSULIN PEN NEEDLES 31GX 6MM 81EXEL COMFORT POINTINSULIN PEN NEEDLES 31GX 8MM 81EXEL COMFORT POINTINSULIN SYRINGE/0.3ML/29GX 1/2" 81EXEL COMFORT POINTINSULIN SYRINGE/0.3ML/30GX 5/16" 81EXEL COMFORT POINTINSULIN SYRINGE/0.5ML/28GX 1/2" 81EXEL COMFORT POINTINSULIN SYRINGE/0.5ML/29GX 1/2" 81EXEL COMFORT POINTINSULIN SYRINGE/0.5ML/30GX 5/16" 81EXEL COMFORT POINTINSULIN SYRINGE/1ML/28G X1/2" 81EXEL COMFORT POINTINSULIN SYRINGE/1ML/29G X1/2" 81EXEL COMFORT POINTINSULIN SYRINGE/1ML/30G X5/16" 81EXELON 116exemestane 24EXTRA SENSITIVESPERMICIDAL 62EZ-LETS LANCETS 21G 65EZ-LETS LANCETS 23G 65EZ-LETS LANCETS 28GULTRA-SOFT 66EZ-LETS LANCETS 30G 66ezetimibe 21ezetimibe-simvastatin 20FABRAZYME 49FACE COTZ 46famotidine 20 mg 119famotidine 40 mg, 10 mg 119FANAPT 26FANAPT TITRATIONPACK 26FANTASY LUBRICATED 62FANTASYLUBRICATED/SPERMICIDE

62FARESTON 24FARXIGA 17

FARYDAK 24FAZACLO 100 MG 27FAZACLO 150 MG, 200 MG,12.5 MG 27FAZACLO 25 MG 27FEIBA 52FEIBA NF 52felbamate 11FELBATOL 12FELDENE 2felodipine 33FEMARA 24fenofibrate 160 mg 20fenofibrate 54 mg 20fenofibrate micronized 200 mg,134 mg 20fenofibrate micronized 67mg 20fentanyl 4FER-IN-SOL 54FERGON 54FERRETTS 54ferrous fumarate 54ferrous fumarate-fa-b complex-c-zn-mg-mn-cu 54ferrous gluconate 27 mg, 240mg 54FERROUS GLUCONATE 324MG 54ferrous sulfate 54FERROUS SULFATE 54FERROUS SULFATE 324MG 54ferrous sulfate 325 mg 54ferrous sulfate dried 54FETZIMA 14FETZIMA TITRATION PACK14FEVERALL INFANTS 3fexofenadine hcl 180 mg 19fexofenadine hcl 60 mg 19FIBERCON 55FIFTY50 ALCOHOL PREPPADS 72FIFTY50 LANCING DEVICE 66FIFTY50 PEN NEEDLES 31GX3/16" (5MM) 82FIFTY50 PEN NEEDLES 31GX5/16" (8MM) 82FIFTY50 PEN NEEDLES31GX5MM 82

Index 14

FIFTY50 PENNEEDLES/31GX8MM 82FIFTY50 PENNEEDLES/32GX4MM 82FIFTY50 PENNEEDLES/32GX6MM 82FIFTY50 SAFETY SEALLANCETS 32G 66FIFTY50 SUPERIORCOMFORTINSULINSYRINGE/0.3ML/31G X5/16" 82FIFTY50 SUPERIORCOMFORTINSULINSYRINGE/0.5ML/31G X5/16" 82FIFTY50 SUPERIORCOMFORTINSULINSYRINGE/1ML/31G X 5/16" 82FIFTY50 UNILET LANCETS33G 66finasteride 52FINE 30 66FINGERSTIX LANCETS 66FIORINAL 3FIORINAL/CODEINE #3 5FIRMAGON 24FLAGYL 7flavoxate hcl 121flecainide acetate 8FLEET ENEMA 56FLEET ENEMA SIX PACK 56FLEET PEDIATRIC 56FLEXICHAMBER 102FLEXZAN 4 X 4 60FLOMAX 52FLONASE ALLERGYRELIEF 111FLONASE ALLERGY RELIEFCHILDRENS 111FLOVENT DISKUS 9FLOVENT HFA 220 MCG/ACT,110 MCG/ACT 9FLOVENT HFA 44 MCG/ACT 9FLOXIN OTIC 114FLUAD 2016-2017 121FLUARIX 2014-2015 121FLUARIX QUADRIVALENT2014-2015 121FLUARIX QUADRIVALENT2015-2016 121FLUARIX QUADRIVALENT2016-2017 121

FLUBLOK 2014-2015 121FLUBLOK 2015-2016 121FLUBLOK 2016-2017 121FLUCELVAX 2014-2015 121FLUCELVAX 2015-2016 121FLUCELVAX QUADRIVALENT2016-2017 121fluconazole 18fluconazole 100 mg 18fluconazole 150 mg 18fluconazole 200 mg 18fluconazole 50 mg 18fludrocortisone acetate 37FLULAVAL 2014-2015 121FLULAVAL QUADRIVALENT2014-2015 121FLULAVAL QUADRIVALENT2015-2016 122FLULAVAL QUADRIVALENT2016-2017 122flunisolide (nasal) 111fluocinolone acetonide(otic) 115fluocinonide 42fluocinonide emulsifiedbase 42fluorometholone (ophth) 113FLUOROURACIL 41fluorouracil (topical) 41FLUOXETINE 117FLUOXETINE DR 13fluoxetine hcl 13fluoxetine hcl 10 mg 13fluoxetine hcl 10 mg, 20mg 13fluoxetine hcl 20 mg 13fluoxetine hcl 40 mg 13FLUOXETINE HCL 60 MG 13fluphenazine decanoate 28FLUPHENAZINE HCL 28fluphenazine hcl 28FLURAZEPAM HCL 55flurbiprofen 2flurbiprofen sodium 114flutamide 24fluticasone propionate 42fluticasone propionate(nasal) 111FLUVIRIN 2014-2015 122FLUVIRIN 2015-2016 122

FLUVIRIN 2016-2017 122FLUVIRIN PF 2014-2015 122fluvoxamine maleate 13fluvoxamine maleate 100 mg13fluvoxamine maleate 25 mg, 50mg 13FLUZONE HIGH-DOSE PF 2014-2015 122FLUZONE HIGH-DOSE PF 2015-2016 122FLUZONE HIGH-DOSE PF 2016-2017 122FLUZONE INTRADERMALQUADRIVALENT 2015-2016 122FLUZONE INTRADERMALQUADRIVALENT 2016-2017 122FLUZONE PF 2014-2015 122FLUZONE QUADRIVALENT2014-2015 122FLUZONE QUADRIVALENT2015-2016 122FLUZONE QUADRIVALENT2016-2017 122FLUZONE SPLIT 2014-2015 122FLUZONE SPLIT 2015-2016 122FML 113FML LIQUIFILM 113FOCALIN 1folic acid 1 mg 53folic acid 800 mcg, 400 mcg 53FORA LANCETS 66FORA LANCING DEVICE 66FORA LANCINGDEVICE/CLEARCAP 66FORFIVO XL 12formaldehyde 29FORTICAL 49FOSAMAX 49fosinopril sodium 21fosinopril sodium &hydrochlorothiazide 22FREDS PHARMACY AUTOLETLANCING DEVICE 66FREDS PHARMACY UNIFINEPENTIPS PEN NEEDLES32GX4MM 82FREDS PHARMACY UNIFINEPENTIPS PLUS 31GX5MM 82FREDS PHARMACY UNIFINEPENTIPS PLUS 31GX8MM 82

Index 15

FREDS PHARMACY UNILETLANCETS SUPER THIN30G 66FREDS PHARMACY UNILETLANCETS ULTRA THIN28G 66FREESTYLE PRECISIONINSULIN SYRINGE/U-100/0.5ML/30G X 5/16" 82FREESTYLE PRECISIONINSULIN SYRINGE/U-100/0.5ML/31G X 5/16" 82FREESTYLE PRECISIONINSULIN SYRINGE/U-100/1ML/31G X 5/16" 82FREESTYLE PRECISIONINSULIN SYRINGES/U-100/1ML/30G X 5/16" 82FURADANTIN 120furosemide 48furosemide 10 mg/ml 48FUROSEMIDE 8 MG/ML 48FUZEON 29gabapentin 11GABITRIL 12 MG, 16 MG 12GABITRIL 2 MG, 4 MG 12galantamine hydrobromide 116GALANTAMINEHYDROBROMIDE 116GARDASIL 122GARDASIL 9 122GAS-X 51GAUZE DRESSING 4"X4" 60GAUZE PADS 2"X2" 60GAUZE PADS 3"X3" 60GAUZE PADS 4"X4" 60GAUZE PADS 4"X4" 12 PLY60GAUZE SPONGE TYPE VIIMEDI-PAK 2"X2" 8PLY 60GAUZE SPONGES 4"X4" 60GAUZE SPONGES 4"X4" 12PLY 60GELUSIL 200MG-25MG-200MG 6gemfibrozil 20GENTAMICIN SULFATE 40gentamicin sulfate (ophth) 112gentamicin sulfate (topical) 40GENTEAL TEARSMODERATEPF 111GENTLE-LET GP LANCETS66

GENTLE-LET LANCETSGENERAL PURPOSESTYLE/MEDIUM POINT 66GENTLE-LET LANCETSSAFETY STYLE/FINEPOINT 66GENTLE-LET LANCETSSAFETY STYLE/MEDIUMPOINT 66GENVOYA 29GEODON 26GILENYA 117GILOTRIF 24glatiramer acetate 117GLEEVEC 100 MG, 400MG 25GLEEVEC 400 MG 25glimepiride 1 mg, 2 mg 17glimepiride 4 mg 17glipizide 17glipizide-metformin hcl 15GLOBAL EASE INJECT PENNEEDLES 29GX12MM 82GLOBAL EASE INJECT PENNEEDLES 31GX8MM 82GLOBAL EASE INJECT PENNEEDLES 32GX4MM 82GLOBAL EASE INJECT PENNEEEDLES 31GX5MM 82GLOBAL EASY GLIDEINSULINSYRINGE/U-100/0.3ML/31G X 5/16" 82GLOBAL EASY GLIDE PENNEEDLES 32GX4MM 82GLOBAL INJECT EASEINSULIN SYRINGE/U-100/0.3ML/29G X 1/2" 82GLOBAL INJECT EASEINSULIN SYRINGE/U-100/0.3ML/30G X 1/2" 82GLOBAL INJECT EASEINSULIN SYRINGE/U-100/0.3ML/30G X 5/16" 82GLOBAL INJECT EASEINSULIN SYRINGE/U-100/0.3ML/31G X 5/16" 82GLOBAL INJECT EASEINSULIN SYRINGE/U-100/0.5ML/28G X 1/2" 82GLOBAL INJECT EASEINSULIN SYRINGE/U-100/0.5ML/29G X 1/2" 83GLOBAL INJECT EASEINSULIN SYRINGE/U-100/0.5ML/30G X 1/2" 83

GLOBAL INJECT EASE INSULINSYRINGE/U-100/0.5ML/30G X5/16" 83GLOBAL INJECT EASE INSULINSYRINGE/U-100/0.5ML/31G X5/16" 83GLOBAL INJECT EASE INSULINSYRINGE/U-100/1ML/28G X1/2" 83GLOBAL INJECT EASE INSULINSYRINGE/U-100/1ML/29G X1/2" 83GLOBAL INJECT EASE INSULINSYRINGE/U-100/1ML/30G X1/2" 83GLOBAL INJECT EASE INSULINSYRINGE/U-100/1ML/30G X5/16" 83GLOBAL INJECT EASE INSULINSYRINGE/U-100/1ML/31G X5/16" 83GLOBAL INSULIN SYRINGE/U-100/0.3ML/30G X 1/2" 83GLOBAL INSULIN SYRINGES/U-100/0.3ML/30GX5/16" 83GLOBAL LANCING DEVICE 66GLUCAGEN HYPOKIT 15GLUCAGON EMERGENCYKIT 15GLUCOCOM LANCETS33G 66GLUCOLET 2 AUTOMATICLANCING DEVICE 66GLUCOPHAGE 1000 MG 15GLUCOPHAGE 500 MG 15GLUCOPHAGE 850 MG 15GLUCOPHAGE XR 500 MG 15GLUCOPHAGE XR 750 MG 15GLUCOPRO INSULINSYRINGE/U-100/0.3ML/30G X1/2" 83GLUCOPRO INSULINSYRINGE/U-100/0.3ML/30G X5/16" 83GLUCOPRO INSULINSYRINGE/U-100/0.3ML/31G X5/16" 83GLUCOPRO INSULINSYRINGE/U-100/0.5ML/30G X1/2" 83GLUCOPRO INSULINSYRINGE/U-100/0.5ML/30G X5/16" 83GLUCOPRO INSULINSYRINGE/U-100/0.5ML/31G X5/16" 83

Index 16

GLUCOPRO INSULINSYRINGE/U-100/1ML/30G X1/2" 83GLUCOPRO INSULINSYRINGE/U-100/1ML/30G X5/16" 83GLUCOPRO INSULINSYRINGE/U-100/1ML/31G X5/16" 83GLUCOSE 15GLUCOSOURCE LANCETDEVICE 66GLUCOTROL 17GLUCOTROL XL 17GLUCOVANCE 15glyburide 17glyburide micronized 17glyburide-metformin 15glycerin (laxative) 2.1 gm, 2 gm,1.2 gm 56GLYCERIN ADULT 56glycopyrrolate 118GLYNASE 17GMATE LANCING DEVICE 66GNP ALCOHOL SWABS 72GNP CLICKFINE PENNEEDLEUNIVERSAL/31GX5/16"

83GNP CLICKFINE UNIVERSALPEN NEEDLES 31GX1/4" 83GNP CLICKFINE UNIVERSALPEN NEEDLES 31GX5/16" 83GNP GLUCOSE 15GNP INSULINSYRINGE/0.3ML/29G X 1/2" 83GNP INSULINSYRINGE/0.3ML/30G X5/16" 83GNP INSULINSYRINGE/0.3ML/31G X5/16" 83GNP INSULINSYRINGE/0.5ML/28G X 1/2" 84GNP INSULINSYRINGE/0.5ML/29G X 1/2" 84GNP INSULINSYRINGE/0.5ML/30G X5/16" 84GNP INSULINSYRINGE/0.5ML/31G X5/16" 84GNP INSULINSYRINGE/1ML/28G X 1/2" 84GNP INSULINSYRINGE/1ML/29G X 1/2" 84

GNP INSULINSYRINGE/1ML/30G X5/16" 84GNP INSULINSYRINGE/1ML/31G X5/16" 84GNP LANCETS 66GNP LANCETS 21G 66GNP LANCETS MICRO THIN33G 66GNP LANCETS SUPER THIN30G 66GNP LANCETS THIN 66GNP LANCETS THIN 26G 66GNP MICRO THIN LANCETS33G 66GNP OMEPRAZOLE 119GNP PRENATAL 108GNP QUICK DISSOLVEGLUCOSE 15GNP STERILE PADS3"X3" 60GNP SUPER THINLANCETS/30G 66GNP ULTRA COMFORTINSULIN SYRINGE/0.3ML/29GX 1/2" 84GNP ULTRA COMFORTINSULIN SYRINGE/0.3ML/30GX 5/16" SHORT 84GNP ULTRA COMFORTINSULIN SYRINGE/0.3ML/31GX 5/16" SHORT 84GNP ULTRA COMFORTINSULIN SYRINGE/0.5ML/28GX 1/2" 84GNP ULTRA COMFORTINSULIN SYRINGE/0.5ML/29GX 1/2" 84GNP ULTRA COMFORTINSULIN SYRINGE/0.5ML/30GX 5/16" SHORT 84GNP ULTRA COMFORTINSULIN SYRINGE/0.5ML/31GX 5/16" SHORT 84GNP ULTRA COMFORTINSULIN SYRINGE/1ML/28G X1/2" 84GNP ULTRA COMFORTINSULIN SYRINGE/1ML/29G X1/2" 84GNP ULTRA COMFORTINSULIN SYRINGE/1ML/30G X5/16" SHORT 84GNP ULTRA COMFORTINSULIN SYRINGE/1ML/31G X5/16" SHORT 84

GOLD BOND ULTIMATEHEALING 43GOLYTELY 56GOODSENSE LANCINGDEVICE 66GOODSENSE PRENATALVITAMINS 108GRASTEK 1GRIFULVIN V 18GRIS-PEG 18griseofulvin microsize 18griseofulvin ultramicrosize 18guaifenesin 38guaifenesin-codeine 38guanfacine hcl 21GYNAZOLE-1 123GYNE-LOTRIMIN 123GYNE-LOTRIMIN 3 123H-E-B IN CONTROL PENNEEDLES 31GX5MM 84H-E-B IN CONTROL PENNEEDLES 31GX6MM 84H-E-B IN CONTROL PENNEEDLES 31GX8MM 84H-E-B IN CONTROL PENNEEDLES/NANO/32GX4MM

84H-E-B IN CONTROLUNIFINEPENTIPS PLUS31GX5MM 84H-E-B IN CONTROLUNIFINEPENTIPS PLUS32GX4MM 84H-E-B INCONTROLADVANCEDLANCINGDEVICE 66H-E-B INCONTROL ALCOHOLPADS 72H-E-B INCONTROL LANCETSMICRO THIN 33G 66H-E-B INCONTROL LANCETSSUPER THIN 30G 66H-E-B INCONTROL LANCETSULTRA THIN 28G 66H-E-B INCONTROL PENNEEDLES 29GX12MM 84HAEMOLANCE 66HAEMOLANCE LOW FLOWLANCETS 66HAEMOLANCE PLUS 66HAEMOLANCE PLUS LOWFLOW 66HALCION 55HALDOL 27

Index 17

HALDOL DECANOATE 100 27HALDOL DECANOATE 50 27haloperidol 1 mg, 0.5 mg, 10mg 27haloperidol 5 mg, 2 mg, 20mg 27haloperidol decanoate 27haloperidol lactate 27HAVRIX 122HEALTH CARE LANCINGDEVICE 66HEALTHWISE LANCINGPEN 67HEALTHWISE MINI PENNEEDLES 31GX6MM 84HEALTHWISE PEN NEEDLES29GX12MM 84HEALTHWISE SHORT PENNEEDLES 31GX8MM 85HEALTHWISE UNIFINEPENTIPS PEN NEEDLES32GX4MM 85HEALTHY ACCENTS AUTOLETIMPRESSION LANCINGDEVICE 67HEALTHY ACCENTS UNIFINEPENTIPS PEN NEEDLES29GX12MM 85HEALTHY ACCENTS UNIFINEPENTIPS PEN NEEDLES31GX5MM 85HEALTHY ACCENTS UNIFINEPENTIPS PEN NEEDLES31GX6MM 85HEALTHY ACCENTS UNIFINEPENTIPS PEN NEEDLES31GX8MM 85HEALTHY ACCENTS UNIFINEPENTIPS PEN NEEDLES32GX4MM 85HELIXATE FS 52HEMANGEOL 32HEMOCYTE 54HEMOFIL M 52heparin sodium (porcine) 10HEPSERA 31HIBICLENS 29HIGH SENSATIONSPERMICIDAL 62HM OMEPRAZOLE 119HM PRENATAL 108HM STERILE PADS 60HUGGIES LITTLE SWIMMERSSPF50 46HUMALOG 16

HUMALOG KWIKPEN 16HUMALOG MIX 50/50 16HUMALOG MIX 50/50KWIKPEN 16HUMALOG MIX 75/25 16HUMALOG MIX 75/25KWIKPEN 16HUMAPEN LUXURA HD 85HUMATE-P 52HUMIRA 2HUMIRA PEDIATRIC CROHNSDISEASE STARTER PACK 2HUMIRA PEN 2HUMIRA PEN-CROHNSDISEASESTARTER 2HUMIRA PEN-PSORIASISSTARTER 2HUMULIN 70/30 16HUMULIN 70/30KWIKPEN 16HUMULIN N 16HUMULIN N KWIKPEN 16HUMULIN R 16HY-VEE LANCETS 67HY-VEE THIN LANCETS 67HYCAMTIN 25HYCET 5hydralazine hcl 23HYDREA 25HYDROCELL ADHESIVEDRESSING 4"X4" 60HYDROCELL DRESSING4"X4" 60hydrochlorothiazide 48hydrocodone w/homatropine 37hydrocodone-acetaminophen 5hydrocodone-acetaminophen10mg-325mg 5hydrocodone-acetaminophen5mg-325mg 5hydrocodone-acetaminophen7.5mg-325mg 5hydrocortisone 36hydrocortisone (intrarectal) 6hydrocortisone (rectal) 6hydrocortisone (topical) 42hydrocortisone (topical) 0.5% 42hydrocortisone (topical) 1% 42

hydrocortisone (topical) 1%, 1% 42hydrocortisone (topical) 2.5% 42hydrocortisone (topical) 2.5 %,0.5 % 42hydrocortisone butyrate 42hydrocortisone w/aceticacid 115hydrocortisone-aloe vera 42HYDROMORPHONE HCL 4hydromorphone hcl 4hydroxychloroquine sulfate 23HYDROXYPROGESTERONECAPROATE 24hydroxyurea 25hydroxyzine hcl 8HYDROXYZINE HCL 25MG/ML 8hydroxyzine hcl 50 mg/ml 8HYDROXYZINE PAMOATE 100MG 8hydroxyzine pamoate 25 mg, 50mg 8hyoscyamine sulfate 118hypromellose (ophth) 0.4 %111HYSINGLA ER 4HYVEE ADVANCED ANTACIDMAXIMUM STRENGTH 6HYZAAR 22IBRANCE 25ibuprofen 2ibuprofen 100 mg/5ml 2ibuprofen 40 mg/ml, 50mg/1.25ml 2ICLUSIG 25IDELVION 52imatinib mesylate 25imipramine hcl 14imipramine pamoate 14imiquimod 43IMITREX 103IMITREX 5 MG/ACT, 20MG/ACT 103IMITREX 6 MG/0.5ML 103IMITREX STATDOSEREFILL 103IMITREX STATDOSESYSTEM 103IMMUNE SUPPORT VITAMINC 107IMODIUM A-D 17

Index 18

IMURAN 105IN TOUCH LANCINGDEVICE 67INCRUSE ELLIPTA 9indapamide 48INDERAL LA 32indomethacin 2INFANTS ADVIL 3INFANTS SILAPAP 4INLYTA 25INSPIRACHAMBER/ANTI-STATICVALVED/MOUTHPIECE 102INSPIRACHAMBER/LARGE

102INSPIRACHAMBER/SOOTHERMASK/INSPIRAMASK/MEDIUM

102INSPIRACHAMBER/SOOTHERMASK/INSPIRAMASK/SMALL

102INSPIREASE BAGS 102INSPIREASE DRUGDELIVERYSYSTEM 102INSPIREASEMOUTHPIECE 102INSPIREASE RESERVOIRBAGS 102INSULIN SYRINGE/0.3ML/29G X1" 85INSULIN SYRINGE/0.3ML/29G X1/2" 85INSULIN SYRINGE/0.3ML/30G X5/16" 85INSULIN SYRINGE/0.3ML/31G X5/16" 85INSULIN SYRINGE/0.5ML/27G X1/2" 85INSULIN SYRINGE/0.5ML/28G X1/2" 85INSULIN SYRINGE/0.5ML/29G X1/2" 85INSULIN SYRINGE/0.5ML/30G X1/2" 85INSULIN SYRINGE/0.5ML/30G X5/16" 85INSULIN SYRINGE/0.5ML/31G X5/16" 85INSULIN SYRINGE/1ML/28G X1/2" 85INSULIN SYRINGE/1ML/29G X1/2" 85INSULIN SYRINGE/1ML/30G X5/16" 85INSULIN SYRINGE/1ML/31G X5/16" 85

INSULIN SYRINGE/U-100/0.3ML/29G X 1/2" 85INSULIN SYRINGE/U-100/0.5ML/28G X 1/2" 85INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" 85INSULIN SYRINGE/U-100/1ML/28G X 1/2" 85INSULIN SYRINGE/U-100/1ML/29G X 1/2" 85INSULIN SYRINGE/U-100/1ML/30G X 5/16" 85INSULIN SYRINGE/U-100/1ML/31G X 5/16" 85INSULINSYRINGES/0.5ML/27GX1/2"

85INSULINSYRINGES/0.5ML/28GX1/2"



86INSULINSYRINGES/0.5ML/31GX5/16" 86INSULINSYRINGES/0.5ML/31GX5/16"

86INSULINSYRINGES/1ML/27GX/1/2"

86INSULINSYRINGES/1ML/27GX1/2"





86INSUPEN PEN NEEDLES 32GX4MM 86INSUPEN SENSITIVE32GX6MM 86INSUPEN ULTRAFIN29GX12MM 86INSUPEN ULTRAFIN30GX8MM 86

INSUPEN ULTRAFIN31GX6MM 86INSUPEN ULTRAFIN31GX8MM 86INTELENCE 100 MG, 25MG 29INTELENCE 200 MG 29INTENSE SENSATION 62INVEGA 27INVEGA SUSTENNA 117MG/0.75ML 26INVEGA SUSTENNA 156MG/ML 26INVEGA SUSTENNA 234MG/1.5ML 26INVEGA SUSTENNA 39MG/0.25ML 27INVEGA SUSTENNA 78MG/0.5ML 27INVEGA TRINZA 273MG/0.875ML 27INVEGA TRINZA 410MG/1.315ML 27INVEGA TRINZA 546MG/1.75ML 27INVEGA TRINZA 819MG/2.625ML 27INVIRASE 29INVOKANA 17IOPIDINE 0.5 % 112IOPIDINE 1 % 112ipratropium bromide 9ipratropium bromide (nasal) 0.03% 110ipratropium bromide (nasal) 0.06% 110ipratropium-albuterol 9irbesartan 21irbesartan-hydrochlorothiazide

22IRON CHEWS PEDIATRIC 54ISENTRESS 29ISENTRESS 100 MG 29ISENTRESS 25 MG 29ISLAND GARD-GRX 60ISONIAZID 23isoniazid 23ISOPTO ATROPINE 112ISOPTO CARPINE 112ISORDIL TITRADOSE 7isosorbide dinitrate 7ISOSORBIDE DINITRATE ER7isosorbide mononitrate 7

Index 19

isotretinoin 39isoxsuprine hcl 33ISTODAX 25ISTODAX (OVERFILL) 25itraconazole 18IXINITY 52J & J GAUZE 2"X2" 8 PLY 60J & J GAUZE 4"X4" 12 PLY 60J & J GAUZE 4"X4" 8 PLY 60J & J GAUZE SPONGES 12-PLY4" X 4" 60J & J GAUZE SPONGES 16-PLY4" X 4" 60J & J GAUZE SPONGES 8-PLY4" X 4" 60JADENU 18JAKAFI 25JENTADUETO 15K-PHOS NEUTRAL 104K-TAB 10 MEQ 104K-TAB 8 MEQ 104KALETRA 29KALETRA 100MG-25MG 29KALETRA 200MG-50MG 30KALYDECO 117KAMELEON LUBRICATED 62KAYEXALATE 105KAZANO 15KEFLEX 34KENDALL HYDROPHILICFOAMDRESSING 2"X2" 60KENDALL HYDROPHILICFOAMDRESSING 3"X3" 60KENDALL HYDROPHILICFOAMDRESSING 4"X4" 60KENDALL HYDROPHILICFOAMPLUS DRESSING2"X2" 60KENDALL HYDROPHILICFOAMPLUS DRESSING3"X3" 60KEPPRA 100 MG/ML 11KEPPRA 1000 MG 11KEPPRA 500 MG, 250 MG, 750MG 11KEPPRA 500 MG/5ML 11KEPPRA XR 11KERALYT 44KERI AGE DEFY &PROTECT 46

KERLIX SPONGES 4" X 4" 12PLY 61KERLIX SPONGES 4" X 4" 16PLY 61KETOCARE 47ketoconazole (topical) 40KETONE TEST STRIPS 47ketoprofen 3KETOPROFEN ER 3ketorolac tromethamine 3ketorolac tromethamine (ophth)0.4 % 114ketorolac tromethamine (ophth)0.5 % 114KETOSTIX 47ketotifen fumarate (ophth)114KHEDEZLA 14KIMONO COLORS 62KIMONO LUBRICATED 62KIMONO MICRO THIN PLUSSPERMICIDELUBRICATED 62KIMONO PLUS SPERMICIDELUBRICATED 62KIMONO PLUSSPERMICIDE/LUBRICATED

62KIMONO PSLUBRICATED 62KIMONO PS PLUSSPERMICIDE/LUBRICATED

62KIMONO SENSATIONLUBRICATED 62KIMONO SENSATION PLUSSPERMICIDELUBRICATED 62KIMONO SPECIAL 62KINERET 2KINNEY LANCETS 67KINNEY THIN LANCETS 67KINRAY INSULIN SYRINGEPREFERREDPLUS/0.3ML/31G X 5/16" 86KINRAY INSULIN SYRINGEPREFERREDPLUS/0.5ML/31G X 5/16" 86KINRAY INSULIN SYRINGEPREFERRED PLUS/1ML/31GX 5/16" 86KINRAY INSULINSYRINGE/0.5ML/29G X1/2" 86KITABIS PAK 1

KLARON 39KLONOPIN 10KLOR-CON M15 104KLS OMEPRAZOLE 119KOATE 52KOATE-DVI 52KOGENATE FS 53KOGENATE FS BIO-SET 53KONSYL 55KOVALTRY 53KP PRENATALMULTIVITAMINS 108KP WOMENS DAILYPACK 107KPN PRENATAL 109KROGER INSULINSYRINGE/0.3ML/29G X 1/2" 86KROGER INSULINSYRINGE/0.3ML/30G X5/16" 86KROGER INSULINSYRINGE/0.3ML/31G X5/16" 86KROGER INSULINSYRINGE/0.5ML/29G X 1/2" 86KROGER INSULINSYRINGE/0.5ML/30G X5/16" 86KROGER INSULINSYRINGE/0.5ML/31G X5/16" 86KROGER INSULINSYRINGE/1ML/29G X 1/2" 86KROGER INSULINSYRINGE/1ML/30G X 5/16" 86KROGER INSULINSYRINGE/1ML/31G X 5/16" 86KROGER LANCETS 67KROGER LANCETS 21G 67KROGER LANCETS MICROTHIN33G 67KROGER LANCETS SUPERTHIN 67KROGER LANCETS THIN 67KROGER LANCETS THIN26G 67KROGER LANCETSULTRATHIN30G 67KROGER LANCINGDEVICE 67KROGER PEN NEEDLES 29GX12MM 86KROGER PEN NEEDLES 31GX8MM 86

Index 20

KROGER PEN NEEDLES31GX1/4" 86L-METHYLFOLATE 48L-METHYLFOLATECALCIUM 47L-METHYLFOLATE FORMULA15 47L-METHYLFOLATE FORMULA7.5 47L-METHYLFOLATE FORTE 48L-TRYPTOPHAN 111labetalol hcl 100 mg 32labetalol hcl 200 mg 32labetalol hcl 300 mg 32LAC-HYDRIN 43LAC-HYDRIN TWELVE 43lactic acid (ammoniumlactate) 43lactulose 56lactulose (encephalopathy) 51LAMICTAL 11LAMICTAL CHEWABLEDISPERSIBLE 11LAMISIL 18LAMISIL AT 40LAMISIL AT JOCK ITCH 40lamivudine 30lamivudine 150 mg 30lamivudine 300 mg 30lamivudine-zidovudine 30lamotrigine 11LANAPHILIC 43LANCET DEVICEADJUSTABLE 67LANCET DEVICE WITHEJECTOR 67LANCETS 67LANCETS 26G TWIST TOP 67LANCETS 28G 67LANCETS 30G 67LANCETS 31G TWIST TOP 67LANCETS MICRO THIN33G 67LANCETS SAFETY SEAL21G 67LANCETS SAFETY SEAL26G 67LANCETS SAFETY SEAL30G 67LANCETS SUPER THIN28G 67LANCETS THIN 67

LANCETS ULTRA FINE 67LANCETS ULTRA THIN 67LANCETS ULTRA THIN30G 67LANCETSBULLSEYESAFETY 67LANCING DEVICE 67LANCING DEVICEADJUSTABLE 67LANOXIN 33lansoprazole 15 mg 119lansoprazole 30 mg 119LANTUS 16LANZO 67LASIX 48latanoprost 114LATUDA 26LEADER ADVANCEDLANCING DEVICE 67LEADER INSULINSYRINGE/0.3ML/29G X1/2" 87LEADER INSULINSYRINGE/0.3ML/30G X5/16" 87LEADER INSULINSYRINGE/0.3ML/31G X5/16" 87LEADER INSULINSYRINGE/0.5ML/28G X1/2" 87LEADER INSULINSYRINGE/0.5ML/29G X1/2" 87LEADER INSULINSYRINGE/0.5ML/30G X5/16" 87LEADER INSULINSYRINGE/0.5ML/31G X5/16" 87LEADER INSULINSYRINGE/1ML/28G X 1/2" 87LEADER INSULINSYRINGE/1ML/29G X 1/2" 87LEADER INSULINSYRINGE/1ML/30G X5/16" 87LEADER INSULINSYRINGE/1ML/31G X5/16" 87LEADER QUICK DISSOLVEGLUCOSE 15LEADER UNIFINE PENTIPSPLUS/MINI/31GX3/16" 87LEADER UNIFINE PENTIPSPLUS/SHORT/31GX5/16" 87

LEADER UNIFINEPENTIPS/MINI/31GX3/16" 87LEADER UNIFINEPENTIPS/NANO/32GX5/32" 87LEADER UNIFINEPENTIPS/PLUS/32GX5/32" 87LEMTRADA 117LETAIRIS 33letrozole 24LEUCOVORIN CALCIUM 10 MG,15 MG 25leucovorin calcium 5 mg, 25mg 25LEUKERAN 23leuprolide acetate 24LEVAQUIN 51LEVBID 119levetiracetam 11levetiracetam 100 mg/ml, 500mg/5ml 11levetiracetam 1000 mg 11levetiracetam 250 mg, 750 mg,500 mg 11levetiracetam 500 mg/5ml 11levobunolol hcl 112levocarnitine (metabolicmodifiers) 49levofloxacin 51LEVOMEFOLATECALCIUM/ALGAL POWDER48levonorgestrel & ethestradiol 34levonorgestrel (emergencyoc) 35levonorgestrel-eth estradiol(triphasic) 34levonorgestrel-ethinyl estradiol(91-day) 34levothyroxine sodium 118LEVSIN 119LEVSIN/SL 119LEXAPRO 13LEXIVA 30LIBERTY MEDICAL LANCETS30G 67LIBERTY MINI LANCINGDEVICE 67lidocaine 44lidocaine hcl 44lidocaine hcl (mouth-throat) 106lidocaine-prilocaine 44LIFE PACK MENS 107LIFE PACK WOMENS 107

Index 21

LIFESCAN UNISTIK 2 DEEPPENETRATION 67LIFESCAN UNISTIK IILANCETS 67liothyronine sodium 118LIPITOR 20lisinopril & hydrochlorothiazide10mg-12.5mg, 20mg-12.5mg 22lisinopril & hydrochlorothiazide20mg-25mg 22lisinopril 2.5 mg 21lisinopril 5 mg, 20 mg, 30 mg, 40mg, 10 mg 21LITE TOUCH LANCETS 67LITE TOUCH LANCINGDEVICE 67LITE TOUCH LANCINGPEN 67LITE TOUCH PENNEEDLES/31G X 3/16" 87LITEAIRE 102LITETOUCH INSULINSYRINGE/0.3ML/29G X 1/2" 87LITETOUCH INSULINSYRINGE/0.3ML/30G X5/16" 87LITETOUCH INSULINSYRINGE/0.3ML/31G X5/16" 87LITETOUCH INSULINSYRINGE/0.5ML/30G X5/16" 87LITETOUCH INSULINSYRINGE/0.5ML/31G X5/16" 87LITETOUCH INSULINSYRINGE/1ML/30G X 5/16" 87LITETOUCH INSULINSYRINGE/U-100/0.5ML/28G X1/2" 87LITETOUCH INSULINSYRINGE/U-100/0.5ML/29G X1/2" 87LITETOUCH INSULINSYRINGE/U-100/1ML/28G X1/2" 87LITETOUCH INSULINSYRINGE/U-100/1ML/29G X1/2" 87LITETOUCH INSULINSYRINGE/U-100/1ML/31G X5/16" 87LITETOUCH LANCETS MICROTHIN 33G 67LITETOUCH PEN NEEDLES29GX12.7MM 87

LITETOUCH PEN NEEDLES31G X 6MM 87LITETOUCH PEN NEEDLES31GX8MM SHORT 88LITHIUM 26lithium carbonate 26lithium carbonate 300 mg, 150mg, 600 mg 26LITHIUM CARBONATE 600MG, 150 MG 26LITHOBID 26LIVE BETTER ADVANCEDLANCING DEVICE 67LIVE BETTER LANCETSUPERTHIN 30G 68LIVE BETTER LANCETULTRATHIN 28G 68LIVE BETTER PEN NEEDLES29G X 12MM 88LIVE BETTER PEN NEEDLES31G X 12MM 88LIVE BETTER PEN NEEDLES31G X 6MM 88LMX 4 44LOCOID 42LODINE 3LODOSYN 25LOESTRIN 1.5/30-21 34LOESTRIN 1/20-21 34LOESTRIN FE 1.5/30 35LOESTRIN FE 1/20 35LOFIBRA 160 MG 20LOFIBRA 200 MG, 134MG 20LOFIBRA 54 MG 20LOFIBRA 67 MG 20LOHIST-D 38LOMOTIL 17LONGS INSULINSYRINGE/0.5ML/31G X5/16" 88LONGS LANCETSSTANDARD 68LONGS LANCETS THIN 68LONGS LANCETS ULTRATHIN 68loperamide hcl 17LOPID 20lopinavir-ritonavir 30LOPRESSOR 100 MG 32LOPRESSOR 50 MG 32LOPRESSOR HCT 22

loratadine 19loratadine &pseudoephedrine 38lorazepam 8lorazepam 0.5 mg, 2 mg 8lorazepam 1 mg 8losartan potassium 21losartan potassium &hydrochlorothiazide 22LOTENSIN 20 MG 21LOTENSIN 40 MG 21LOTENSIN HCT 22LOTREL 22LOTRIMIN AF 40LOTRIMIN AF FOR HER 40LOTRIMIN AF JOCK ITCH 40LOTRISONE 40lovastatin 20 mg, 10 mg 20lovastatin 40 mg 20LOVENOX 150 MG/ML, 100MG/ML 10LOVENOX 30 MG/0.3ML 10LOVENOX 300 MG/3ML 10LOVENOX 40 MG/0.4ML 10LOVENOX 60 MG/0.6ML 10LOVENOX 80 MG/0.8ML, 120MG/0.8ML 10loxapine succinate 27LUBRIDERM DAILYMOISTURE/SUNSCREEN SPF15 46LUNESTA 55LUPRON DEPOT (1-MONTH) 24LUPRON DEPOT (3-MONTH) 24LUPRON DEPOT (4-MONTH) 24LUPRON DEPOT (6-MONTH) 24LURIDE 104LYSODREN 24LYSTEDA 54M-VIT 109MACROBID 120MACRODANTIN 120MAG64 104MAGELLAN INSULIN SAFETYSYRINGE/U-100/0.3ML/29G X1/2" 88

Index 22

MAGELLAN INSULIN SAFETYSYRINGE/U-100/0.3ML/30G X5/16" 88MAGELLAN INSULIN SAFETYSYRINGE/U-100/0.5ML/29G X1/2" 88MAGELLAN INSULIN SAFETYSYRINGE/U-100/0.5ML/30G X5/16" 88MAGELLAN INSULIN SAFETYSYRINGE/U-100/1ML/29G X1/2" 88MAGELLAN INSULIN SAFETYSYRINGE/U-100/1ML/30G X5/16" 88magnesium citrate 56magnesium hydroxide 56magnesium oxide 7magnesium oxide (mgsupplement) 104MAGOX 400 104MAKENA 116malathion 44MAPROTILINE HCL 12MARPLAN 13MATULANE 25MAVIK 1 MG, 2 MG 21MAVIK 4 MG 21MAXALT 103MAXI-COMFORT INSULINSYRINGE/U-100/0.5ML/28GX1/2" 88MAXI-COMFORT INSULINSYRINGE/U-100/1ML/28GX1/2"

88MAXIMIN PACK 107MAXITROL 113MAXX LUBRICATED 62MAXX PLUS SPERMICIDELUBRICATED 62MAXZIDE 48MAXZIDE-25 48meclizine hcl 18MEDIC INSULINSYRINGE/0.3ML/30G X5/16" 88MEDIC INSULINSYRINGE/0.5ML/30G X5/16" 88MEDICAL PROVIDER EZ FLUSHOT 2014-2015 122MEDICAL PROVIDER EZ FLUSHOT 2015-2016 122

MEDICAL PROVIDER SINGLEUSE EZ FLU SHOT 122MEDICHOICE PRE-SETSAFETY LANCET DUALUSE 68MEDICHOICE PRE-SETSAFETY LANCET LOWFLOW 68MEDICHOICE PRE-SETSAFETY LANCET MEDIUMFLOW 68MEDICHOICE PRE-SETSAFETY LANCET MODERATEFLOW 68MEDICHOICE SAFETYLANCETEXTRA 68MEDICHOICE SAFETYLANCETNORMAL 68MEDICINE SHOPPE PENNEEDLES 29G X 12MM 88MEDICINE SHOPPE PENNEEDLES 31G X 6MM 88MEDICINE SHOPPE PENNEEDLES 31G X 8MM 88MEDLANCE PLUS EXTRALANCETS 21G 68MEDLANCE PLUSLANCETS 68MEDLANCE PLUS LANCETSLITE 25G 68MEDLANCE PLUS LITELANCETS 25G 68MEDLANCE PLUS SPECIALLANCETS 0.8MM 68MEDLANCE PLUSSUPERLITE 30G/COMFORTMAX 68MEDLANCE PLUSUNIVERSAL LANCETS21G 68MEDLANCE/EXTRA 68MEDLANCE/LITE 68MEDLANCE/UNIVERSAL 68MEDROL 36MEDROL DOSEPAK 36medroxyprogesteroneacetate 116medroxyprogesterone acetate(contraceptive) 36mefloquine hcl 23MEGA MULTIVITAMIN 107MEGACE ORAL 24megestrol acetate 24MEIJER COLOR LANCETSUNIVERSAL 33G 68MEIJER LANCETS 68

MEIJER LANCETS THIN 68MEIJER LANCETSUNIVERSAL21G 68MEIJER LANCETSUNIVERSAL30G 68MEIJER LANCETSUNIVERSAL33G 68MEIJER PEN NEEDLES 29GX12MM 88MEIJER PEN NEEDLES 31GX6MM 88MEIJER PEN NEEDLES 31GX8MM 88MEIJER SUPER THINLANCETS 68MEKINIST 25melatonin 1meloxicam 3memantine hcl 116memantine hcl 5 mg, 10 mg116MENS PACK 107MEPERIDINE HCL 4meperidine hcl 4MEPHYTON 124meprobamate 8mercaptopurine 23mesalamine 51MESALAMINE DR 51MESNEX 25MESTINON 23MESTINON TIMESPAN 23METADATE CD 1METAMUCIL 55METAMUCIL ORIGINALTEXTURE 56METAPROTERENOLSULFATE 9metformin hcl 1000 mg 15metformin hcl 500 mg 15metformin hcl 750 mg 15metformin hcl 850 mg 15methadone hcl 10 mg 4methadone hcl 5 mg 4methazolamide 48METHENAMINE MANDELATE0.5 GM 120methenamine mandelate 1gm 120methenamine-hyosc-methyleneblue-sod phos-phenyl sal 120METHERGINE 115

Index 23

methimazole 118METHITEST 5methocarbamol 110methotrexate sodium 23methotrexate sodium 200mg/8ml, 100 mg/4ml, 1 gm/40ml,250 mg/10ml, 50 mg/2ml 23METHOTREXATE SODIUM 250MG/10ML 23methyldopa 21methylergonovine maleate 115methylphenidate hcl 1methylphenidate hcl 10 mg, 36mg 1methylphenidate hcl 54 mg, 18mg, 20 mg, 27 mg 1METHYLPHENIDATE HCLER 1methylprednisolone 36METIPRANOLOL 112metoclopramide hcl 51metolazone 49metoprolol &hydrochlorothiazide 22metoprolol succinate 200 mg32metoprolol succinate 50 mg, 25mg, 100 mg 32METOPROLOL SUCCINATEER/HYDROCHLOROTHIAZIDE

22metoprolol tartrate 25 mg, 100mg 32metoprolol tartrate 50 mg 32METOPROLOL/HYDROCHLOROTHIAZIDE 22METROCREAM 44METROGEL-VAGINAL 123METROLOTION 44metronidazole 7metronidazole (topical) 44metronidazole vaginal 123MEVACOR 20mexiletine hcl 8MH MACULAR HEALTH 107MIACALCIN 200 UNIT/ACT 49MIACALCIN 200 UNIT/ML 49MICATIN 40MICONAZOLE 3 123miconazole nitrate (topical) 40miconazole nitrate vaginal 123

miconazole nitrate vaginal 2% 123miconazole nitrate vaginal 4% 123MICRO-K 10 MEQ 104MICRO-K 8 MEQ 104MICROCHAMBER 102MICROLET LANCETS 68MICROLET NEXT 68MICROSPACER 102MICROZIDE 49midazolam hcl 55midodrine hcl 123MIGRANAL 103MILK OF MAGNESIACONCENTRATE 56MILLIPRED 36MINI LANCING DEVICE 68MINIPRESS 22MINIVELLE 0.0375MG/24HR 50MINIVELLE 0.05 MG/24HR, 0.1MG/24HR, 0.025 MG/24HR,0.075 MG/24HR 50MINOCIN 118minocycline hcl 118minoxidil 23MIRALAX 56MIRAPEX 26MIRASORB SPONGES 2" X2" 61MIRASORB SPONGES 4" X4" 61MIRCERA 100 MCG/0.3ML, 75MCG/0.3ML, 50 MCG/0.3ML,200 MCG/0.3ML 53MIRCETTE 35mirtazapine 12misoprostol 120MOBIC 3MODICON 35MOI-STIR 106MOLINDONEHYDROCHLORIDE 28mometasone furoate 42mometasone furoate(nasal) 111MONISTAT 1 COMBOPACK 123MONISTAT 1 DAY OR NIGHTCOMBO PACK 123MONISTAT 3 123

MONISTAT 3 COMBINATIONPACK 123MONISTAT 7 SIMPLYCURE 123MONISTAT SOOTHING CAREITCH RELIEF 42MONOCLATE-P 53MONOJECT INSULINSYRINGE/1ML/31G X 5/16" 88MONOJECT INSULINSYRINGE/DETACHNEEDLE/1ML/25G X 5/8" 88MONOJECT INSULINSYRINGE/DETACHNEEDLE/1ML/27G X 1/2" 88MONOJECT INSULINSYRINGE/PERMNEEDLE/1ML/28G X 1/2" 88MONOJECT INSULINSYRINGE/PERM NEEDLE/U-100/0.5ML/28G X 1/2" 88MONOJECT INSULINSYRINGE/SAFETY/PERMNEEDLE/0.3ML/29G X 1/2" 88MONOJECT INSULINSYRINGE/SAFETY/PERMNEEDLE/0.3ML/29GX1/2" 88MONOJECT INSULINSYRINGE/SAFETY/PERMNEEDLE/0.5ML/29G X 1/2" 89MONOJECT INSULINSYRINGE/SAFETY/PERMNEEDLE/1ML/29G X 1/2" 89MONOJECT INSULINSYRINGE/SOFTPACK/1ML/27GX 1/2" 89MONOJECT INSULINSYRINGE/SOFTPACK/U-100/0.5ML/28G X 1/2" 89MONOJECT INSULINSYRINGE/U-100/0.3ML/30G X5/16" 89MONOJECT INSULINSYRINGE/U-100/0.5ML/28G X1/2" 89MONOJECT INSULINSYRINGE/U-100/0.5ML/30G X5/16" 89MONOJECT INSULINSYRINGE/U-100/1ML/28G X1/2" 89MONOJECT INSULINSYRINGE/U-100/1ML/30G X5/16" 89MONOJECT ULTRA COMFORTINSULIN SYRINGE/0.3ML/29G X1/2" 89

Index 24

MONOJECT ULTRA COMFORTINSULIN SYRINGE/0.3ML/30G X5/16" 89MONOJECT ULTRA COMFORTINSULIN SYRINGE/0.3ML/31G X5/16" 89MONOJECT ULTRA COMFORTINSULIN SYRINGE/0.5ML/28G X1/2" 89MONOJECT ULTRA COMFORTINSULIN SYRINGE/0.5ML/29G X1/2" 89MONOJECT ULTRA COMFORTINSULIN SYRINGE/0.5ML/30G X5/16" 89MONOJECT ULTRA COMFORTINSULIN SYRINGE/0.5ML/31G X5/16" 89MONOJECT ULTRA COMFORTINSULIN SYRINGE/1ML/28G X1/2" 89MONOJECT ULTRA COMFORTINSULIN SYRINGE/1ML/29G X1/2" 89MONOJECT ULTRA COMFORTINSULIN SYRINGE/1ML/30G X5/16" 89MONOLET OPD LANCETS 68MONOLETTOR SAFETYLANCETS 68MONONINE 53montelukast sodium 9MOORE MED MONOJECTINSULIN SYRINGE/U-100/0.5ML/28G X 1/2" 89MOORE MED MONOJECTINSULIN SYRINGE/U-100/0.5ML/29G X 1/2" 89MOORE MED MONOJECTINSULIN SYRINGE/U-100/1ML/28G X 1/2" 89MOORE MED MONOJECTINSULIN SYRINGE/U-100/1ML/29G X 1/2" 89MORPHINE SULFATE 4morphine sulfate 4morphine sulfate 100 mg/5ml, 20mg/ml 4morphine sulfate 20 mg/5ml, 10mg/5ml 4MOTRIN INFANTS DROPS 3MOUTHKOTE 106MOZOBIL 54MS CONTIN 5

MS INSULINSYRINGE/0.3ML/31G X5/16" 89MS INSULINSYRINGE/0.5ML/31G X5/16" 89MS INSULINSYRINGE/1ML/31G X5/16" 90MUCINEX 38MUCINEX D 38MUCINEX D MAXIMUMSTRENGTH 38MUCINEX DM 38MUCINEX MAXIMUMSTRENGTH 38MULTI FOR HER 107MULTI FOR HIM 107MULTI PRENATAL 109MULTI-LANCET DEVICE 68multiple vitamins w/ minerals &folic acid 107mupirocin 40mupirocin calcium (topical) 40MYAMBUTOL 23mycophenolate mofetil 105mycophenolate mofetilhcl 105mycophenolate sodium 180mg 105mycophenolate sodium 360mg 105MYDRIACYL 112MYFORTIC 180 MG 105MYFORTIC 360 MG 105MYLERAN 23MYLICON 51MYLICON INFANTS GASRELIEF 51MYNATAL 109MYSOLINE 11nabumetone 3nadolol 32naloxone hcl 18naltrexone hcl 18NAMENDA 116NAMENDA TITRATIONPAK 116NAPHAZOLINE HCL 113NAPROSYN 3naproxen 3NAPROXEN 3

naproxen sodium 220 mg 3naproxen sodium 275 mg, 550mg 3naratriptan hcl 103NARCAN 18NARDIL 13NASACORT ALLERGY24HR 111NASACORT ALLERGY 24HRCHILDRENS 111NASAL DECONGESTANT 111NASALCROM 110NASONEX 111NAT-RUL PRENATALVITAMINS 109nateglinide 17NATROBA 44NECON 1/50-28 35NECON 10/11-28 35NEFAZODONE HCL 100 MG,200 MG, 150 MG 13nefazodone hcl 50 mg, 250mg 13neomycin sulfate 1neomycin-bacitracin zn-polymyxin 112neomycin-bacitracin-polymyxin

40neomycin-polymy-dexameth 113neomycin-polymyxin w/pramoxine 40neomycin-polymyxin-gramicidin

112neomycin-polymyxin-hc(otic) 114NEOMYCIN/POLYMYXIN/HYDROCORTISONE 113NEORAL 105NEOSPORIN 112NEOSPORIN ORIGINAL 40NEOSPORIN PLUS PAINRELIEF MAXIMUMSTRENGTH 40NEPHROCAPS 106NEPTAZANE 48NESINA 15NEUMEGA 54NEUROMED7 44NEURONTIN 11NEUTRAPHOR 44NEUTRAPHORUS REX 44

Index 25

NEUTROGENA AGE SHIELDFACE SUNBLOCK WITHHELIOPLEX SPF110 46NEUTROGENA AGE SHIELDFACE SUNBLOCK WITHHELIOPLEX SPF70 46NEUTROGENA COOLDRYSPORTWITH HELIOPLEX SPF30 46NEUTROGENA HEALTHYDEFENSE DAILYMOISTURIZERPURESCREEN 46NEUTROGENA MEN SPF20 46NEUTROGENA MOISTURESPF15UNTINTED 46NEUTROGENA SPORT FACESUNBLOCK WITH HELIOPLEXSPF70 46NEUTROGENA T/GEL 47NEUTROGENA T/GELSTUBBORN ITCHCONTROL 47NEUTROGENA ULTRA SHEERDRY-TOUCH SPF 45 46NEUTROGENA ULTRA SHEERDRY-TOUCH WITH HELIOPLEXSPF 100 46NEUTROGENA ULTRA SHEERDRY-TOUCH WITH HELIOPLEXSPF 55 46NEUTROGENA ULTRA SHEERDRY-TOUCH WITH HELIOPLEXSPF 70 46NEVANAC 114NEVIRAPINE 30nevirapine 30nevirapine 100 mg 30nevirapine 400 mg 30NEXAVAR 25NEXIUM 40 MG 119NEXPLANON 36niacin 124niacin 50 mg, 100 mg, 500mg 124NIACIN TR 124NIACOR 21nicardipine hcl 33NICODERM CQ 117NICORETTE 117NICORETTE MINI 117NICORETTE STARTERKIT 117

nicotine 117nicotine polacrilex 117NICOTINE TRANSDERMALSYSTEM 117NICOTROL INHALER 117NICOTROL NS 117nifedipine 33nifedipine 30 mg, 90 mg 33nifedipine 60 mg 33NINLARO 25NITRO-BID 7NITRO-DUR 7nitrofurantoin 120nitrofurantoinmacrocrystal 120nitrofurantoin monohydmacro 120nitroglycerin 7NITROSTAT 7NIVA-PLUS 109NIVEA HAND THERAPY 46NIVEA VISAGE UV CAREDAILY FACIAL 46NIX CREME RINSE 44NIZORAL 40NOR-QD 36NORCO 10MG-325MG 5NORCO 5MG-325MG 5NORCO 7.5MG-325MG 5NORDITROPIN FLEXPRO49NORDITROPIN NORDIFLEXPEN 49norethin acet & estrad-fe 75mg-20mcg-1mg 35norethin acet & estrad-fe 75mg-20mcg-1mg, 75mg-30mcg-1.5mg 35norethindrone & ethestradiol 35norethindrone(contraceptive) 36norethindrone acet & ethestra 35norethindrone acetate 116norethindrone-eth estradiol(triphasic) 35norgestimate-ethinylestradiol 35norgestimate-ethinyl estradiol(triphasic) 35norgestrel & ethinylestradiol 35

NORINYL 1+35 35NORINYL 1+50 35NORPACE 8NORPACE CR 8NORPRAMIN 150 MG, 50 MG,10 MG, 75 MG, 100 MG 14NORPRAMIN 25 MG 14nortriptyline hcl 14NORTRIPTYLINE HCL 14NORVASC 33NORVIR 30NOVA MAX PLUS KETONETESTSTRIPS 47NOVA SUREFLEX LANCINGDEVICE 68NOVOEIGHT 53NOVOFINE 30GX8MM 90NOVOFINE 32GX6MM 90NOVOFINE AUTOCOVER30GX8MM 90NOVOFINE PLUS32GX4MM 90NOVOLIN 70/30 16NOVOLIN 70/30 RELION 16NOVOLIN N 16NOVOLIN N RELION 16NOVOLIN R 16NOVOLIN R RELION 16NOVOLOG 17NOVOLOG FLEXPEN 16NOVOLOG MIX 70/30 17NOVOLOG MIX 70/30PREFILLED FLEXPEN 16NOVOLOG PENFILL 17NOVOPEN ECHO 90NOVOSEVEN RT 53NOVOTWIST 30GX8MM 90NOVOTWIST 32GX5MM 90NPLATE 54NU GAUZE 4PLY 4"X4" 61NU GAUZE GENERAL-USESPONGES 4"X4" 4 PLY 61NULYTELY/FLAVORPACKS 56NUMOISYN 106NUPLAZID 26NUVARING 35NUVIGIL 1nystatin 18nystatin (mouth-throat) 106

Index 26

nystatin (topical) 40nystatin-triamcinolone 40NYTOL MAXIMUMSTRENGTH 54O-CAL FA 109OBIZUR 53OCEAN NASAL SPRAY 110OCUFEN 114OCUFLOX 112ODOMZO 24ofloxacin (ophth) 113ofloxacin (otic) 114OFLOXACIN 300 MG 51ofloxacin 400 mg 51OGESTREL 35OIL OF BEAUTY COMPLETEMOISTURE SPF 15 46OINTMENT BASE 43olanzapine 27OLEPTRO 13omega-3 fatty acids 111OMEPRAZOLE 120omeprazole 10 mg 119omeprazole 40 mg, 20 mg 119OMNIPRED 113ON CALL LANCINGDEVICE 68ON CALL PLUS LANCINGDEVICE 68ondansetron 18ondansetron hcl 24 mg 18ondansetron hcl 4 mg/2ml, 40mg/20ml 18ondansetron hcl 4 mg/5ml 18ondansetron hcl 8 mg, 4 mg 18ONETOUCH CLUB LANCETSFINE POINT 68ONETOUCH COMBO PACK68ONETOUCH DELICA LANCETSEXTRA FINE 33G 68ONETOUCH DELICA LANCETSFINE 30G 69ONETOUCH DELICA LANCINGDEVICE 69ONETOUCH ULTRASOFTLANCETS 69OPTICHAMBERADVANTAGE 102OPTICHAMBERADVANTAGE/LARGEMASK 102

OPTICHAMBERADVANTAGE/MEDIUM FACEMASK 102OPTICHAMBERADVANTAGE/SMALL FACEMASK 102OPTICHAMBERDIAMOND 102OPTICHAMBERDIAMOND/LARGEFACEMASK 102OPTICHAMBERDIAMOND/MEDIUM FACEMASK 102OPTICHAMBERDIAMOND/SMALLFACEMASK 102OPTICHAMBER FACEMASK/LARGE 102OPTICHAMBER FACEMASK/MEDIUM 102OPTICHAMBER FACEMASK/SMALL 102OPTIFOAM 61OPTIHALER 102OPTIHALER MDI DRUGDELIVERY SYSTEM 102oral electrolytes 104ORAL RELIEF SPRAY FORDRYMOUTH &DISCOMFORT 106ORALAIR 1ORALAIR ADULT SAMPLEKIT 1ORALAIR ADULT STARTERPACK 1ORALAIRCHILDREN/ADOLESCENTSSTARTER PACK 1ORKAMBI 117ORTHO MICRONOR 36ORTHO TRI-CYCLEN 35ORTHO TRI-CYCLEN LO 35ORTHO-CEPT 35ORTHO-CYCLEN 35ORTHO-NOVUM 1/35 35ORTHO-NOVUM 7/7/7 35OSENI 15OTICIN HC NR 114OTREXUP 2OVACE PLUS WASH 41OVACE WASH 41OVCON-35 35OVIDE 45

oxaprozin 3oxazepam 8oxcarbazepine 11oxybutynin chloride 120oxycodone hcl 5oxycodone w/ acetaminophen 5oxycodone-aspirin 5OXYCODONE/ACETAMINOPHEN 5oyster shell 104PA MENS 50 PLUSVITAPAK 107PA MENS VITAPAK 108PA WOMENS 50 PLUSVITAPAK 108PA WOMENS VITAPAK 108paliperidone 27PAMELOR 14PANCREAZE 48PANCRELIPASE 48pantoprazole sodium 20mg 120pantoprazole sodium 40mg 120PARAFON FORTE DSC 110PARLODEL 26PARNATE 13paroxetine hcl 13PARVA-CAL 104PAXIL 13PAXIL CR 13PC LANCETS SUPER THIN30G 69PC UNIFINE PENTIPS 29GX1/2" 90PC UNIFINE PENTIPS 31GX5MM MINI 90PC UNIFINE PENTIPS 31GX6MM ULTRA SHORT 90PC UNIFINE PENTIPS 31GX8MM SHORT 90PCE 58ped multivitamins w/fl &iron 108PEDIA-LAX 2.8 GM 56PEDIALYTE 20MEQ/L-45MEQ/L-35MEQ/L-5GM/L-20GM/L,20MEQ/L-45MEQ/L-35MEQ/L-30MEQ/L-25GM/L 104PEDIALYTE FREEZERPOPS 104PEDIAPRED 36

Index 27

pediatric multiple vitamins 108pediatric vitamins acd w/fluoride 108pediatric vitamins adc 108peg 3350-kcl-sod bicarb-sodchloride-sod sulfate 56peg 3350-potassium chloride-sodbicarbonate-sod chloride 56PEN NEEDLES 29G X12MM 90PEN NEEDLES 29GX1/2" 90PEN NEEDLES 30GX5/16" 90PEN NEEDLES 30GX8MM 90PEN NEEDLES 31G X 1/4"SHORT 90PEN NEEDLES 31G X 3/16" 90PEN NEEDLES 31G X 5MM 90PEN NEEDLES 31G X 6MM 90PEN NEEDLES 31GX5/16" 90PEN NEEDLES 31GX6MM(1/4") 90PEN NEEDLES 31GX8MM 90PEN NEEDLES 31GX8MM(5/16") 90PEN NEEDLES 32GX4MM 90penicillin v potassium 115PENTIPS 29GX12MM 90PENTIPS 31GX5MM 90PENTIPS 31GX6MM 90PENTIPS 31GX8MM 90PENTIPS 32GX4MM 90pentoxifylline 53PEPCID 20 MG 119PEPCID 40 MG 119PEPCID AC 119PEPCID AC MAXIMUMSTRENGTH 119PEPTO BISMOL 17PEPTO-BISMOL 17PEPTO-BISMOL 262MG/15ML 17PEPTO-BISMOLINSTACOOL 17PEPTO-BISMOL MAXSTRENGTH 17PEPTO-BISMOL TO-GO 17PERCOCET 5PERIDEX 106permethrin 45perphenazine 28

PERPHENAZINE/AMITRIPTYLINE 116PERSANTINE 53PEXEVA 13PHARMACY COUNTERLANCETS 69phenazopyridine hcl 52phenelzine sulfate 13phenobarbital 55PHENOBARBITAL 15 MG, 60MG, 100 MG, 30 MG 55phenobarbital 64.8 mg, 16.2mg, 32.4 mg, 97.2 mg 55PHENOBARBITALSODIUM 55phenobarbital-hyoscyamine-atropine-scopolamine 119phenylephrine hcl (ophth) 113phenylephrine hcl (oral) 111phenylephrine-chlorphen-dm

38phenylephrine-dm 38phenylephrine-guaifenesin 38phenylephrine-shark liver oil-cocoa butter 6phenylephrine-shark liver oil-mineral oil-petrolatum 6phenytoin 12phenytoin sodiumextended 12PHLEXY-VITS 108PHOSLO 51pilocarpine hcl 112pilocarpine hcl (oral) 106pindolol 32pioglitazone hcl 16pioglitazone hcl-metforminhcl 15piroxicam 3PLAN B ONE-STEP 36PLAQUENIL 23PLAVIX 53PLEGRIDY 117PLEGRIDY STARTERPACK 117PLETAL 53PNEUMOVAX 23 121PNEUMOVAX 23/1DOSE 121PNV FOLIC ACID + IRONMULTIVITAMIN 109PNV PRENATAL PLUSMULTIVITAMIN 109

POCKET CHAMBER 102POCKET SPACER 102podofilox 44polyethylene glycol 3350 56POLYMEM DRESSING/3" X3" 61POLYMEM DRESSING/4" X4" 61polymyxin b-trimethoprim 113polysaccharide iron complex 54POLYSPORIN 40POLYTRIM 113polyvinyl alcohol 111POMALYST 24pot phosphate monobasic w/ sodphosphate dibasic &monobasic 104potassium bicarbonate 104potassium chloride 105potassium chloride 10 %, 20% 105potassium chloride 10 meq 104POTASSIUM CHLORIDE 20% 105potassium chloride 8 meq 104POTASSIUM CHLORIDEER 104potassium chloridemicroencapsulated crystalscr 105potassium citrate(alkalinizer) 51potassium citrate-citric acid 51povidone-iodine 29pramipexole dihydrochloride 26PRAMOTIC 114pramoxine hcl (rectal) 6pramoxine-hc-chloroxylenol

115PRAVACHOL 20pravastatin sodium 20prazosin hcl 22PRE SUN KIDS 46PRE-NATAL FORMULA 109PRECISION SURE-DOSEINSULIN SYRINGE/0.3ML/30G X5/16" 90PRECISION SURE-DOSEINSULIN SYRINGE/0.5ML/28G X1/2" 90

Index 28

PRECISION SURE-DOSEINSULIN SYRINGE/0.5ML/29G X1/2" 90PRECISION SURE-DOSEINSULIN SYRINGE/0.5ML/30G X3/8" 90PRECISION SURE-DOSEINSULIN SYRINGE/1ML/28G X1/2" 90PRECISION SURE-DOSEPLUSINSULINSYRINGE/0.3ML/29G X 1/2" 90PRECISION SURE-DOSEPLUSINSULINSYRINGE/1ML/29G X 1/2" 90PRECISION THINLANCETS 69PRECISION THINS GPLANCET 69PRECISION ULTRALANCET 69PRECISION XTRA 47PRED FORTE 113PRED MILD 113PRED-G 113PREDATOR 44prednicarbate 42prednisolone 36prednisolone acetate(ophth) 113PREDNISOLONE SODIUMPHOSPHATE 1 % 113prednisolone sodium phosphate15 mg/5ml 36prednisolone sodium phosphate20 mg/5ml 36prednisolone sodium phosphate5 mg/5ml, 6.7 mg/5ml 36PREDNISONE 36prednisone 10 mg, 1 mg, 5 mg,2.5 mg, 20 mg 36PREDNISONE 50 MG 37PREDNISONE INTENSOL 36PREFERRED PLUS INSULINSYRINGE/U-100/0.3ML/29G X1/2" 91PREFERRED PLUS INSULINSYRINGE/U-100/0.3ML/30G X5/16" 91PREFERRED PLUS INSULINSYRINGE/U-100/0.5ML/28G X

911/2"PREFERRED PLUS INSULINSYRINGE/U-100/0.5ML/29G X1/2" 91

PREFERRED PLUS INSULINSYRINGE/U-100/0.5ML/30G X5/16" 91PREFERRED PLUS INSULINSYRINGE/U-100/1ML/28G X1/2" 91PREFERRED PLUS INSULINSYRINGE/U-100/1ML/29G X1/2" 91PREFERRED PLUS INSULINSYRINGE/U-100/1ML/30G X5/16" 91PREFERRED PLUS LANCETSCOLORED 21G 69PREFERRED PLUS LANCETSTHIN 26G 69PREFERRED PLUS UNIFINEPENTIPS 29G X 12MM 91PREFERRED PLUS UNIFINEPENTIPS 31G X 6MM ULTRASHORT 91PREFERRED PLUS UNIFINEPENTIPS 31G X 8MMSHORT 91PREFERRED PLUS UNIFINEPENTIPS 32GX4MM 91PREFERRED PLUS UNIFINEPENTIPS/MINI/31GX5MM 91PREMARIN 50PREMIUM CONDOMSLUBRICATED 62PREMIUM PACKETS 108PREMPHASE 50PREMPRO 50

PRENATAL 160MG-11UNIT-200MG-25MG-1.84MG-27MG-4000UNIT-18MG-1.7MG-4MCG-400UNIT-800MCG-2.6MG-100MG, 30UNIT-4000UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-8MCG-400UNIT-0.8MG-2.6MG-120MG,4000UNIT-30UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-8MCG-400UNIT-800MCG-2.6MG-120MG,11UNIT-263MG-25MG-1.5MG-27MG-4000UNIT-18MG-1.7MG-4MCG-400UNIT-0.8MG-2.6MG-100MG, 4000UNIT-30UNIT-200MG-25MG-1.8MG-28MG-20MG-1.7MG-8MCG-400UNIT-800MCG-2.6MG-120MG,30UNIT-4000UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-8MCG-400UNIT-800MCG-2.6MG-120MG,30UNIT-25MG-1.8MG-200MG-28MG-20MG-1.7MG-4000UNIT-8MCG-400UNIT-800MCG-2.6MG-120MG 109PRENATAL 22MG-2MG-25MG-1.84MG-200MG-27MG-4000UNIT-20MG-3MG-12MCG-400UNIT-1MG-10MG-120MG

109PRENATAL 4000UNIT-200MG-11UNIT-27MG-25MG-1.84MG-18MG-1.7MG-4MCG-400UNIT-0.8MG-2.6MG-100MG 109PRENATAL AND IRON 109PRENATAL FORMULA 109PRENATAL FORTE 109PRENATAL LOW IRON 109PRENATALMULTIVITAMIN 109PRENATAL ONE DAILY 109PRENATAL PLUS 109PRENATAL VITAMIN 109PRENATALVITAMIN/IRON 109PRENATAL VITAMINS 110PRENATAL VITAMINS PLUSLOW IRON 109PREPLUS 110PRESCRIPTIVE FORMULASOPTIMAL VITAMIN PACKSMENS 108

Index 29

PRESCRIPTIVE FORMULASOPTIMAL VITAMIN PACKSWOMENS 108PRESSURE ACTIVATEDSAFETYLANCET 21G 69PREVACID 15 MG 120PREVACID 24HR 120PREVACID 30 MG 120PREVACID SOLUTAB 120PREVIDENT 106PREVIDENT 5000 DRYMOUTH 106PREVIDENT 5000 PLUS 106PREVIDENT FLUORIDE 106PREVNAR 13 121PREZCOBIX 30PREZISTA 30PREZISTA 150 MG 30PREZISTA 75 MG, 600 MG 30PREZISTA 800 MG 30PRILOSEC 10 MG 120PRILOSEC 40 MG, 20 MG 120PRIMAQUINE PHOSPHATE23primidone 11PRINIVIL 21PRISTIQ 14PRO COMFORT ALCOHOLPADS 72PRO COMFORT PENNEEDLES/31G X 8MM 91PRO COMFORT PENNEEDLES/32G X 4MM 91PRO COMFORT PENNEEDLES/32G X 5MM 91PRO COMFORT PENNEEDLES/32G X 6MM 91probenecid 52PROCARDIA 33PROCARDIA XL 30 MG, 90MG 33PROCARDIA XL 60 MG 33prochlorperazine 28prochlorperazine edisylate 28prochlorperazine maleate 28PROCRIT 40000 UNIT/ML, 2000UNIT/ML, 10000 UNIT/ML, 3000UNIT/ML, 4000 UNIT/ML, 20000UNIT/ML 54PROCTOFOAM 6PRODIGY INSULIN SYRING/U-100/0.3ML/31G X 5/16" 91

PRODIGY INSULINSYRINGE/1/2ML/31G X5/16" 91PRODIGY INSULINSYRINGE/1ML/28G X 1/2" 91PRODIGY LANCINGDEVICE 69PROFILNINE 53PROFILNINE SD 53progesterone micronized 100mg 116progesterone micronized 200mg 116PROGRAF 105PROMACTA 54promethazine &phenylephrine 38promethazine hcl 20promethazine w/codeine 38promethazine-dm 38promethazine-phenylephrine-codeine 38PROMETHAZINE/PHENYLEPHRINE 38PROMETRIUM 100 MG 116PROMETRIUM 200 MG 116propafenone hcl 8propranolol hcl 32PROPRANOLOL HCL 32PROPRANOLOL/HYDROCHLOROTHIAZIDE 22propylthiouracil 118PROSCAR 52PROSHIELD PLUS SKINPROTECTANT 44PROTONIX 20 MG 120PROTONIX 40 MG 120PROTOPIC 43protriptyline hcl 14PROVERA 116PROZAC 10 MG, 20 MG 13PROZAC 40 MG 13pseudoephed-bromphen-dm 38pseudoephedrine hcl 111pseudoephedrine w/ codeine-gg 38pseudoephedrine-chlorphen-dm 38pseudoephedrine-guaifenesin

38pseudoephedrine-ibuprofen 38

PSORCON 42PSS SELECT GP LANCETS69PSS SELECT SAFETYLANCETS 69psyllium 56psyllium 30.9 %, 58.6 %, 33 %,28.3 %, , 48.57 %, 30 %, 100% 56PTS PANELS KETONETEST 47PULMICORT 9PULMICORT FLEXHALER 9PULMOZYME 117PURE & FREE BABYSUNSCREEN BROADSPECTRUM SPF 60+ 46PURIXAN 23PUSH BUTTON SAFETYLANCETS 21G 69PUSH BUTTON SAFETYLANCETS 28G 69PX ADVANCED LANCINGDEVICE 69PX EXTRA SHORT PENNEEDLES 31GX6MM 91PX INSULIN SYRINGE/U-100/0.3ML/30G X 1/2" 91PX INSULIN SYRINGE/U-100/0.3ML/31G X 5/16" 91PX INSULIN SYRINGE/U-100/0.5ML/30G X 1/2" 91PX INSULIN SYRINGE/U-100/0.5ML/31G X 5/16" 91PX INSULIN SYRINGE/U-100/1ML/30G X 1/2" 91PX INSULIN SYRINGE/U-100/1ML/31G X 5/16" 91PX LANCET AUTOINJECTOR 69PX LANCETS ULTRA THIN 69PX MINI PEN NEEDLES31GX5MM 91PX OMEPRAZOLE 120PX PEN NEEDLE29GX12MM 91PX PEN NEEDLE31GX8MM 91PX PRENATALMULTIVITAMINS 110PX SHORTLENGTH PENNEEDLES/31GX8MM 92pyrazinamide 23pyrethrins-piperonyl butoxide45pyrethrins-piperonyl butoxide0.3%-0.33%-4%, 0.33%-4% 45

Index 30

pyrethrins-piperonyl butoxide0.33%-4% 45pyrethrins-piperonyl butoxide-permethrin-nit remover 45PYRIDIUM 52pyridostigmine bromide 23pyridoxine hcl 50 mg, 250 mg,100 mg, 25 mg 124QC ADVANCED LANCINGDEVICE 69QC ALCOHOL SWABS 72QC ALL PURPOSEDRESSINGS4"X4" 61QC BORDER ISLAND GAUZEPAD 2"X2" 61QC LANCETS ULTRA THIN 69QC PEN NEEDLES 29G X12MM 92QC PEN NEEDLES 31G X6MM 92QC PEN NEEDLES 31G X8MM 92QC PRENATAL 110QC STERILE PADS 61QC UNIFINE PENTIPS32GX4MM 92QC UNILET LANCETS28G/ULTRA THIN 69QC UNILET LANCETS33G/MICRO THIN 69QUESTRAN 20QUESTRAN LIGHT 20quetiapine fumarate 28quinapril hcl 21quinidine gluconate 8quinidine sulfate 300 mg 8QUINIDINE SULFATE 300 MG,200 MG 8QUINIDINE SULFATE ER 8RA ALCOHOL SWABS 72RA ALL PURPOSEDRESSINGS4"X4" 61RA ARTHRITIS PAINRELIEF 44RA DRESSING SPONGES4"X4" 61RA DRY MOUTH 106RA E-ZJECT LANCETS 28G69RA E-ZJECT LANCETS THIN26G 69RA E-ZJECT LANCETSULTRATHIN 30G 69RA ESSENCE-C 108RA GAUZE SPONGES4"X4" 61

RA INSULINSYRINGE/0.5ML/29G X1/2" 92RA INSULINSYRINGE/1ML/29G X 1/2" 92RA INSULIN SYRINGE/U-100/0.5ML/30G X 5/16" 92RA INSULIN SYRINGE/U-100/1 ML/30G X 5/16" 92RA LANCING DEVICE 69RA OMEPRAZOLE 120RA PAIN RELIEF 44RA PEN NEEDLES 31G X5MM3/16" 92RA PEN NEEDLES 31G X8MM5/16" 92RA PRENATAL 110RA PRENATALFORMULA/FOLICACID 110RA RX SUNCARE ADVANCEDPROTECTION SPF50 46RA STERILE PADS 2"X2" 61RA STERILE PADS 3"X3" 61RA STERILE PADS 4"X4" 61RAGWITEK 1raloxifene hcl 49ramipril 21ranitidine hcl 119ranitidine hcl 150 mg 119ranitidine hcl 300 mg 119ranitidine hcl 300 mg, 75mg 119RAPAMUNE 105RASUVO 2RAY-TEC X-RAYDETECTABLESPONGES 4" X4" 16 PLY 61RAZADYNE 116RAZADYNE ER 116REALITY INSULINSYRINGE/U-100/0.5ML/28G X1/2" 92REALITY INSULINSYRINGE/U-100/0.5ML/29G X1/2" 92REALITY INSULINSYRINGE/U-100/1ML/28G X1/2" 92REALITY INSULINSYRINGE/U-100/1ML/29G X1/2" 92REALITY LANCETS 69REALITY LATEXCONDOMS/LUBRICATED 62

REALITY LATEX/ULTRATEXTURED 62REALITY LATEX/ULTRATHIN 62REALITY SWABS 72REBIF 117REBIF REBIDOSE 117REBIF REBIDOSETITRATIONPACK 117REBIF TITRATION PACK 117RECOMBINATE 53RECOMBIVAX HB 122REGLAN 51RELENZA DISKHALER 31RELION 2-IN-1 LANCINGDEVICE 25G 69RELION 2-IN-1 LANCINGDEVICE 30G 69RELION ALCOHOL SWABS 72RELION INSULIN SYRINGE1ML/31GX15/64" 92RELION INSULIN SYRINGE/U-00/1ML/29G X 1/2" 92RELION INSULIN SYRINGE/U-100/0.3ML/29G X 1/2" 92RELION INSULIN SYRINGE/U-100/0.3ML/30G X 5/16" 92RELION INSULIN SYRINGE/U-100/0.3ML/31G X 5/16" 92RELION INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" 92RELION INSULIN SYRINGE/U-100/0.5ML/30G X 5/16" 92RELION INSULIN SYRINGE/U-100/0.5ML/31G X 5/16" 92RELION INSULIN SYRINGE/U-100/1ML/30G X 5/16" 92RELION INSULIN SYRINGE/U-100/1ML/31G X 5/16" 92RELION KETONE 47RELION KETONE TESTSTRIPS 47RELION LANCETS MICRO-THIN33G 69RELION LANCETS STANDARD21G 69RELION LANCETS THIN26G 69RELION LANCETS ULTRA-THIN30G 69RELION LANCING DEVICE 69RELION MINI PEN NEEDLES31GX6MM 92RELION PEN NEEDLES29GX12MM 92

Index 31

RELION PEN NEEDLES31GX6MM 92RELION PEN NEEDLES31GX8MM 92RELION PEN NEEDLES32GX4MM 92RELION SHORT PENNEEDLES31GX8MM 92RELION ULTRA THINLANCETS30G 69RELION ULTRA THIN PLUSLANCETS 32G 69RELION ULTRA THIN PLUSLANCETS 33G 69RELPAX 103REMEDY NUTRASHIELD 44REMERON 12REMERON SOLTAB 12REQUIP 4 MG, 3 MG, 0.25MG 26REQUIP 5 MG, 2 MG, 1 MG, 0.5MG 26RESCON-GG 38RESCRIPTOR 100 MG 30RESCRIPTOR 200 MG 30RESERPINE 22RESTORE CONTACTLAYER/NON-ADHERENT2"X2" 61RESTORE FOAM DRESSINGBORDERED 4"X4" 61RESTORE FOAM DRESSINGNON-BORDERED 4"X4" 61RESTORE ODOR ABSORBINGDRESSING 4"X4" 61RESTORE TRIO ABSORBENTDRESSING 3"X3" 61RESTORIL 15 MG 55RESTORIL 30 MG 55RESTORIL 7.5 MG, 22.5MG 55RETIN-A 39RETIN-A 0.01 % 39RETIN-A 0.025 % 39RETROVIR 30RETROVIR IV INFUSION 30REVATIO 33REVIA 18REXALL LANCETS ULTRATHIN 69REXULTI 28REYATAZ 30RHEUMATREX 2

RIASTAP 53riboflavin 50 mg, 100 mg 124RID 45RID COMPLETE LICEELIMINATION 45RIFADIN 23rifampin 23RIGHT STEPPRENATAL 110RIGHTEST GD500 LANCINGDEVICE 69RIGHTEST GL300LANCETS 69risedronate sodium 49risedronate sodium 35 mg 49risedronate sodium 5 mg, 30mg 49RISPERDAL 27RISPERDAL CONSTA 27RISPERDAL M-TAB 27risperidone 27risperidone 0.25 mg 27risperidone 3 mg, 1 mg, 4 mg, 2mg, 0.5 mg 27RITALIN 1RITEFLO 102rivastigmine 116rivastigmine tartrate 116RIXUBIS 53rizatriptan benzoate 103ROBAXIN 110ROBAXIN-750 110ROBINUL 119ROBINUL FORTE 119ROBITUSSIN DM 38ROBITUSSIN PEAK COLDCOUGH+ CHESTCONGESTION DM MAXSTRENGTH 38ROBITUSSIN PEAK COLDDM 38ROC MULTI CORREXION 5IN1 DAILY MOISTURIZER SPF30 46ROC MULTI CORREXIONLIFTANTI-GRAVITY DAYMOISTURIZER SPF30 46ROC RETINOL CORREXIONSPF30 47ROCALTROL 49ropinirole hydrochloride 4 mg, 3mg, 0.25 mg 26

ropinirole hydrochloride 5 mg, 0.5mg, 2 mg, 1 mg 26ROXICODONE 5RYTHMOL 8SAFE-T-LANCE LOW FLOW25G 69SAFE-T-LANCE NORMALFLOW21G 69SAFE-T-LANCE PLUSSAFETYLANCET LOWFLOW 70SAFE-T-LANCE PLUSSAFETYLANCET NORMALFLOW 70SAFESNAP INSULINSYRINGE/0.3ML/30G X5/16" 92SAFESNAP INSULINSYRINGE/0.5ML/29G X 1/2" 93SAFESNAP INSULINSYRINGE/0.5ML/30G X5/16" 93SAFESNAP INSULINSYRINGE/1ML/28G X 1/2" 93SAFESNAP INSULINSYRINGE/1ML/29G X 1/2" 93SAFETY INSULIN SYRINGES0.5ML/29GX1/2" 93SAFETY INSULIN SYRINGES0.5ML/30GX5/16" 93SAFETY INSULIN SYRINGES1ML/27GX1/2" 93SAFETY INSULIN SYRINGES1ML/29GX1/2" 93SAFETY INSULIN SYRINGES1ML/30GX1/2" 93SAFETY LANCETS 28G 70SAFETY LET LANCETS 70SAFETY SEAL LANCETS28G 70SAFETY SEAL LANCETS30G 70SAFETY-GLIDE INSULINSYRINGE/0.3ML/29G X 1/2" 93SAIZEN 49SAIZEN CLICK.EASY 49SAIZENPREPRECONSTITUTIONKIT 49SALAGEN 106salicylic acid 44saline 110salsalate 4SANDIMMUNE 105SANDIMMUNE 100 MG/ML105SAPHRIS 28

Index 32

SARNA 41SAVELLA 116SAVELLA TITRATIONPACK 116SB ALCOHOL PREP PADS 72SB INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" 93SB INSULIN SYRINGE/U-100/0.5ML/30G X 5/16" 93SB INSULIN SYRINGE/U-100/1ML/29G X 1/2" 93SB INSULIN SYRINGE/U-100/1ML/30G X 5/16" 93SB INSULIN SYRINGE/U-100/1ML/31G X 5/16" 93SB LANCETS THIN 70SB OMEPRAZOLE 120SCHNUCKS INSULINSYRINGEULTI-FINE/U-100/0.5ML/29G X 1/2" 93SCHNUCKS INSULINSYRINGEULTI-FINE/U-100/0.5ML/30G X 5/16" 93SEASONIQUE 35SECONAL 55SECONAL SODIUM 55SECTRAL 32SELECT-LITE LANCINGDEVICE 70selegiline hcl 26selenium sulfide 41selenium sulfide 1 % 41selenium sulfide 2.5 % 41SELSUN BLUE 41SELSUN BLUE DAILY 41SELSUN BLUEMEDICATED 41SELSUN BLUEMOISTURIZING 41SELZENTRY 150 MG 30SELZENTRY 300 MG 30SELZENTRY 75 MG, 25 MG 30SENNA 56sennosides 56sennosides-docusatesodium 56SENOKOT 56SENOKOT S 56SENOKOT XTRA 56SEREVENT DISKUS 9SEROQUEL 28SEROQUEL XR 28

SEROSTIM 49sertraline hcl 13sertraline hcl 100 mg 13sertraline hcl 50 mg, 25 mg13SFROWASA 51SHADE SUNBLOCK SPF45 47SHADE UVAGUARD SPF15 47SHOHLS SOLUTIONMODIFIED 51SHOPKO ALCOHOLSWABS 72SHOPKO AUTOLET LANCINGDEVICE 70SHOPKO ON-THE-GOCOMFORTLANCETS 30G 70SHOPKO UNIFINE PENTIPSPENNEEDLES/MICRO/32GX4MM

93SHOPKO UNIFINE PENTIPSPENNEEDLES/MINI/31GX5MM

93SHOPKO UNIFINE PENTIPSPENNEEDLES/ORIGINAL/29GX12MM 93SHOPKO UNIFINE PENTIPSPENNEEDLES/SHORT/31GX8MM

93SHOPKO UNIFINE PENTIPSPLUS PENNEEDLES/MICRO/REMOVR/32GX4MM 93SHOPKO UNIFINE PENTIPSPLUS PENNEEDLES/MINI/REMOVER/31GX5MM 93SHOPKO UNIFINE PENTIPSPLUS PENNEEDLES/REMOVER/29GX12MM 93SHOPKO UNIFINE PENTIPSPLUS PENNEEDLES/SHORT/REMOVR/31GX8MM 93SHOPKO UNILET LANCETSSUPER THIN 30G 70SHOPKO UNILET LANCETSULTRA THIN 28G 70SIDE BUTTON SAFETYLANCET21G 70sildenafil citrate (pulmonaryhypertension) 34

SILENOR 55SILPHEN COUGH 19SILVADENE 41silver sulfadiazine 41simethicone 51SIMPLE DIAGNOSTICSLANCING DEVICE 70simvastatin 20 mg, 10 mg, 5 mg,40 mg 20simvastatin 80 mg 20SINEMET 26SINEMET CR 26SINGLE-LET 70SINGULAIR 9sirolimus 105SIVEXTRO 7SKIN BEAUTY &WELLNESS 108SKYLA 36SLO-NIACIN 124SM ALCOHOL PREP PADS 72SM GAUZE PADS 2"X2" 61SM GAUZE PADS 3"X3" 61SM GAUZE PADS 4"X4" 61SM GLUCOSE 15SM INSULIN SYRINGE/1ML/31GX 5/16" 93SM IPECAC SYRUP 18SM OMEPRAZOLE 120SM PRENATAL VITAMINS 110SM STERILE PADS 61SM STERILE PADS 2"X2" 61SMART DIABETES VANTAGELANCING DEVICE 70SMART SENSE COLORLANCETS UNIVERSAL 33G 70SMART SENSE STANDARDLANCETS UNIVERSAL 21G 70SMART SENSE SUPER THINLANCETS UNIVERSAL 30G 70SMART SENSE THINLANCETSUNIVERSAL 26G 70SMARTEST LANCETS 28G 70sodium bicarbonate (antacid) 6sodium chloride 105sodium chloride (gu irrigant) 52sodium chloride (inhalant) 39sodium citrate & citric acid 52sodium fluoride 104sodium fluoride (dental) 106

Index 33

sodium phosphates 56sodium polystyrenesulfonate 106SODIUMSULFACETAMIDE/SULFUR

39SOF-WICK 4"X4" 61SOLBAR AVO 47SOLBAR PF SPF15 47SOLUS V2 LANCINGDEVICE 70SONATA 55SORBITOL 56sotalol hcl (afib/afl) 32sotalol hcl 240 mg 32sotalol hcl 80 mg, 120 mg, 160mg 32SPINOSAD 45spironolactone 48spironolactone &hydrochlorothiazide 48SPORANOX 19SPORANOX PULSEPAK 19SPRYCEL 25SSKI 104STARLIX 17stavudine 30STERILE GAUZE PADS2"X2" 61STERILE GAUZE PADS3"X3" 61STERILE PADS 2"X2" 61STERILE PADS 3"X3" 61STERILE PADS 4"X4" 61STIOLTO RESPIMAT 9STIVARGA 25STRIBILD 30STROVITE FORTE 108SUBOXONE 2MG-0.5MG, 4MG-1MG 5SUBOXONE 8MG-2MG, 12MG-3MG 5sucralfate 119SUDAFED 111SUDAFED CHILDRENS 111SUDAFED CONGESTION 111SUDAFED NASALDECONGESTANT MAXIMUMSTRENGTH 111SUDAFED PECONGESTION 111

sulfacetamide sod-prednisolone 113sulfacetamide sodium 41SULFACETAMIDESODIUM 113sulfacetamide sodium(acne) 39sulfacetamide sodium(ophth) 113sulfacetamide sodium w/sulfur 39sulfamethoxazole-trimethoprim 7sulfasalazine 51sulindac 3sumatriptan 103sumatriptan succinate 103SUMATRIPTANSUCCINATE 103sunscreens 47SUPER NU-THERA 108SUPERVITE EC 108SURE COMFORT INSULINSYRINGE/U-100/0.3ML/29G X1/2" 93SURE COMFORT INSULINSYRINGE/U-100/0.3ML/30G X1/2" 93SURE COMFORT INSULINSYRINGE/U-100/0.3ML/30G X5/16" 94SURE COMFORT INSULINSYRINGE/U-100/0.3ML/31G X5/16 94SURE COMFORT INSULINSYRINGE/U-100/0.3ML/31G X5/16" 94SURE COMFORT INSULINSYRINGE/U-100/0.5ML/28G X1/2" 94SURE COMFORT INSULINSYRINGE/U-100/0.5ML/29G X1/2" 94SURE COMFORT INSULINSYRINGE/U-100/0.5ML/30G X1/2" 94SURE COMFORT INSULINSYRINGE/U-100/0.5ML/30G X5/16" 94SURE COMFORT INSULINSYRINGE/U-100/0.5ML/31G X5/16 94SURE COMFORT INSULINSYRINGE/U-100/1ML/28G X1/2" 94

SURE COMFORT INSULINSYRINGE/U-100/1ML/29G X1/2" 94SURE COMFORT INSULINSYRINGE/U-100/1ML/30G X1/2" 94SURE COMFORT INSULINSYRINGE/U-100/1ML/30G X5/16" 94SURE COMFORT INSULINSYRINGE/U-100/1ML/31G X5/16" 94SURE COMFORT LANCINGPEN 70SURE COMFORT PENNEEDLES29GX1/2" 12.7MM94SURE COMFORT PENNEEDLES30GX5/16"SHORT 94SURE COMFORT PENNEEDLES31GX3/16" (5MM) 94SURE COMFORT PENNEEDLES31GX5/16" (8MM) 94SURE COMFORT PENNEEDLES32GX5/32" 94SURE COMFORT PENNEEDLES32GX6MM 94SURE-FINE PEN NEEDLES29GX1/2" 12.7MM 94SURE-FINE PEN NEEDLES31GX3/16" 5MM 94SURE-FINE PEN NEEDLES31GX5/16" 8MM 94SURE-JECT INSULINSYRINGE/U-100/0.3ML/29G X1/2" 94SURE-JECT INSULINSYRINGE/U-100/0.3ML/30G X5/16" 94SURE-JECT INSULINSYRINGE/U-100/0.3ML/31G X5/16" 94SURE-JECT INSULINSYRINGE/U-100/0.5ML/28G X1/2" 94SURE-JECT INSULINSYRINGE/U-100/0.5ML/29G X1/2" 95SURE-JECT INSULINSYRINGE/U-100/0.5ML/30G X5/16" 95SURE-JECT INSULINSYRINGE/U-100/0.5ML/31G X5/16" 95SURE-JECT INSULINSYRINGE/U-100/1ML/28G X1/2" 95

Index 34

SURE-JECT INSULINSYRINGE/U-100/1ML/29G X1/2" 95SURE-JECT INSULINSYRINGE/U-100/1ML/30G X5/16" 95SURE-JECT INSULINSYRINGE/U-100/1ML/31G X5/16" 95SURE-LANCE THIN LANCETS28G 70SURE-LANCE ULTRA THINLANCETS 70SURE-PEN 70SURE-TOUCH LANCETSUNIVERSAL 70SURELITE LANCETS 70SURMONTIL 14SUSTIVA 30SUSTIVA 200 MG 30SUSTIVA 50 MG 30SUTENT 25SW OMEPRAZOLE 120SYMBICORT 10SYMLINPEN 120 15SYMLINPEN 60 15SYNAGEX 108SYNAGIS 115SYNAREL 49SYNATEK 108SYNTHROID 118tacrolimus 105tacrolimus (topical) 43TAFINLAR 25TAGAMET HB 119TAMIFLU 31TAMIFLU 30 MG 31TAMIFLU 75 MG, 45 MG 31tamoxifen citrate 24tamsulosin hcl 52TAPAZOLE 118TARCEVA 25TARGRETIN 25TASIGNA 25TAVIST ALLERGY 19tazarotene 41TAZORAC 41TAZORAC 0.05 % 41TAZORAC 0.1 % 41

TEARS NATURALE PM 111TECFIDERA 117TECFIDERA STARTERPACK 117TECHLITE AST LANCETS70TECHLITE LANCETS 70TECHLITE LANCETS 30G 70TECHLITE PENNEEDLES/31GX 5MM 95TECHLITE PENNEEDLES/31GX 6 MM 95TECHLITE PENNEEDLES/31GX 8MM 95TECHLITE PENNEEDLES/32GX 4MM 95TECHLITE PENNEEDLES/32GX 6MM 95TEGADERM FOAMDRESSING 2"X2" 61TEGADERM FOAMDRESSING 4"X4" 61TEGRETOL 11TEGRETOL-XR 11TEKTURNA 22TEKTURNA HCT 22temazepam 15 mg 55temazepam 30 mg 55temazepam 7.5 mg, 22.5mg 55TEMODAR 23TEMOVATE 42TEMOVATE E 42temozolomide 23TENCON 3TENEX 22TENIVAC 118TENORETIC 100 22TENORETIC 50 22TENORMIN 32TERAZOL 3 123TERAZOL 7 123terazosin hcl 22terbinafine hcl 18terbinafine hcl (topical) 40terbutaline sulfate 10terconazole vaginal 123terconazole vaginal 0.4 %123terconazole vaginal 0.8 %123TESSALON PERLES 37testosterone cypionate 6

TETANUS/DIPHTHERIATOXOIDS-ADSORBED 118TETANUS/DIPHTHERIATOXOIDS-ADSORBEDADULT 118tetrahydrozoline hcl (ophth) 113TGT ADVANCED LANCINGDEVICE 70TGT ALCOHOL SWABS 73TGT LANCET ALTERNATESITE 70TGT LANCET MICRO THIN33G 70TGT LANCET SUPER THIN30G 70TGT LANCET THIN 23G 70TGT LANCET THIN 26G 70TGT LANCET ULTRA THIN28G 70TGT LANCET ULTRA THIN30G 70TGT LANCING DEVICE 70TGT OMEPRAZOLE 120TH PRENATAL VITAMINS 110THEO-24 10theophylline 10THERA-FLUR-N 106THERAGAUZE 61THERANATAL CORENUTRITION 110THERANATAL LACTATIONCOMPLETE 108THERANATAL LACTATIONSUPPORT 108thiamine hcl 124thiamine mononitrate 124THINLETS GP LANCETS 70THINLETS LANCET 71thioridazine hcl 28thiothixene 29thyroid 118THYROLAR-1 118THYROLAR-1/2 118THYROLAR-1/4 118THYROLAR-2 118THYROLAR-3 118tiagabine hcl 12TIAZAC 33TIKOSYN 8TIMOLOL MALEATE 32timolol maleate (ophth) 112

Index 35

timolol maleate (ophth) 0.25% 112timolol maleate (ophth) 0.5% 112TIMOPTIC 0.25 % 112TIMOPTIC 0.5 % 112TIMOPTIC OCUDOSE 112TIMOPTIC-XE 112TINACTIN 40TINACTIN JOCK ITCH 40tioconazole vaginal 123TIVICAY 30tizanidine hcl 110TOBI 2TOBI PODHALER 2TOBRADEX 113tobramycin 2TOBRAMYCIN 2tobramycin (ophth) 113tobramycin sulfate 2tobramycin sulfate 10 mg/ml, 1.2gm/30ml, 80 mg/2ml, 40mg/ml 2TOBRAMYCIN SULFATE 10MG/ML, 40 MG/ML 2tobramycin-dexamethasone 114TOBREX 113TODAYS HEALTH ADVANCEDLANCING DEVICE 71TODAYS HEALTH MINI PENNEEDLES 31G X 1/4" 95TODAYS HEALTH ORIGINALPEN NEEDLES 29G X 1/2" 95TODAYS HEALTH SHORT PENNEEDLES 31G X 5/16" 95TODAYS HEALTH ULTRATHINLANCETS 28G 71TOFRANIL 14TOFRANIL-PM 14TOLMETIN SODIUM 3tolmetin sodium 3tolnaftate 40tolterodine tartrate 120TOPAMAX 11TOPAMAX SPRINKLE 15MG 11TOPAMAX SPRINKLE 25MG 11TOPCARE CLICKFINEUNIVERSAL PEN EEDLES31GX1/4" 95

TOPCARE CLICKFINEUNIVERSAL PEN EEDLES31GX5/16" 95TOPCARE ULTRA COMFORTINSULIN SYRINGE/0.3ML/30GX 5/16" 95TOPCARE ULTRA COMFORTINSULIN SYRINGE/0.3ML/31GX 5/16" 95TOPCARE ULTRA COMFORTINSULIN SYRINGE/0.5ML/30GX 5/16" 95TOPCARE ULTRA COMFORTINSULIN SYRINGE/0.5ML/31GX 5/16" 95TOPCARE ULTRA COMFORTINSULIN SYRINGE/1ML/30G X5/16" 95TOPCARE ULTRA COMFORTINSULIN SYRINGE/1ML/31G X5/16" 95TOPCARE ULTRA COMFORTINSULIN SYRINGE/U-100/0.3ML/29G X 1/2" 95TOPCARE ULTRA COMFORTINSULIN SYRINGE/U-100/0.5ML/29G X 1/2" 95TOPCARE ULTRA COMFORTINSULIN SYRINGE/U-100/1ML/29G X 1/2" 95TOPCO INSULIN SYRINGE/U-100/0.3ML/29G X 1/2" 95TOPCO INSULIN SYRINGE/U-100/0.5ML/28G X 1/2" 96TOPCO INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" 96TOPCO INSULIN SYRINGE/U-100/1ML/28G X 1/2" 96TOPCO INSULIN SYRINGE/U-100/1ML/29G X 1/2" 96TOPICORT 43topiramate 11topiramate 15 mg 11topiramate 25 mg 11TOPPER DRESSINGSPONGES 4"X4" 61TOPROL XL 200 MG 32TOPROL XL 50 MG, 25 MG,100 MG 32torsemide 48TOTAL BLOCK SPF 60COVERUP 47TOTAL BLOCK SPF 65CLEAR 47TRACLEER 33TRADJENTA 16tramadol hcl 5

tramadol-acetaminophen 5trandolapril 2 mg, 1 mg 21trandolapril 4 mg 21tranexamic acid 54TRANXENE T 8tranylcypromine sulfate 13TRAVEL LANCETS 30G 71trazodone hcl 100 mg, 150 mg,50 mg 13trazodone hcl 300 mg 14TRECATOR 23TRELSTAR 24TRELSTAR MIXJECT 24tretinoin 39tretinoin (chemotherapy) 25tretinoin 0.01 % 39tretinoin 0.025 % 39TRETTEN 53TREXALL 24TRI-NORINYL 28 35TRI-VIT/FLUORIDE/IRON 108triamcinolone acetonide(mouth) 106triamcinolone acetonide(nasal) 111triamcinolone acetonide(topical) 43triamcinolone acetonide (topical)0.025 % 43triamcinolone acetonide (topical)0.1 % 43triamcinolone acetonide (topical)0.1 %, 0.025 % 43triamcinolone acetonide (topical)0.5 % 43TRIAMINIC COLD & COUGHDAY TIME CHILDRENS 38triamterene &hydrochlorothiazide 48TRIAMTERENE/HYDROCHLOROTHIAZIDE 48TRIAZOLAM 0.125 MG 55triazolam 0.25 mg 55TRICARE 110trifluoperazine hcl 28trifluridine 113TRIGLIDE 20trihexyphenidyl hcl 25TRILEPTAL 11trimethoprim 7trimipramine maleate 14

Index 36

TRINTELLIX 14TRIUMEQ 30TRIZIVIR 30TROJAN EXTENDEDPLEASURE/LUBRICATED 62TROJAN MAGNUM 62TROJAN MAGNUM WARMSENSATIONS 62TROJAN MAGNUM XLLUBRICATED 62TROJAN PLEASUREMESH/SPERMICIDAL 62TROJAN RIBBEDW/SPERMICIDAL 63TROJAN SHAREDSENSATION/LUBRICATED 63TROJAN SUPRASSPERMICIDAL 63TROJAN TWISTEDPLEASURE 63TROJAN ULTRAPLEASURE/LUBRICATED 63TROJAN VERY SENSITIVELUBRICATED 63TROJAN VERY SENSITIVESPERMICIDAL LUBRICANT 63TROJAN VERY THINLUBRICATED 63TROJAN VERY THINSPERMICIDAL LUBRICANT 63TROJAN-ENZ LUBRICANT 63TROJAN-ENZLUBRICATED 63TROJAN-ENZW/SPERMICIDAL 63tropicamide 112trospium chloride 120TRUE METRIX BLOODGLUCOSETEST STRIPS 47TRUE METRIX SELFMONITORING BLOODGLUCOSE STRIPS 47TRUECONTROL GLUCOSECONTROL LEVEL 0 71TRUECONTROL GLUCOSECONTROL LEVEL 1 71TRUEDRAW LANCINGDEVICE 71TRUEPLUS INSULINSYRINGE/U-100/0.3ML/29G X1/2" 96TRUEPLUS INSULINSYRINGE/U-100/0.3ML/30G X5/16" 96TRUEPLUS INSULINSYRINGE/U-100/0.3ML/31G X5/16" 96

TRUEPLUS INSULINSYRINGE/U-100/0.5ML/28G X1/2" 96TRUEPLUS INSULINSYRINGE/U-100/0.5ML/29G X1/2" 96TRUEPLUS INSULINSYRINGE/U-100/0.5ML/30G X5/16" 96TRUEPLUS INSULINSYRINGE/U-100/0.5ML/31G X5/16" 96TRUEPLUS INSULINSYRINGE/U-100/1ML/28G X1/2" 96TRUEPLUS INSULINSYRINGE/U-100/1ML/29G X1/2" 96TRUEPLUS INSULINSYRINGE/U-100/1ML/30G X5/16" 96TRUEPLUS INSULINSYRINGE/U-100/1ML/31G X5/16" 96TRUEPLUS LANCETS26G 71TRUEPLUS LANCETS28G 71TRUEPLUS LANCETS 28GSUPER THIN 71TRUEPLUS LANCETS 30GULTRA THIN 71TRUEPLUS PEN NEEDLES29GX12MM 96TRUEPLUS PEN NEEDLES31GX5MM 96TRUEPLUS PEN NEEDLES31GX6MM 96TRUEPLUS PEN NEEDLES31GX8MM 96TRUEPLUS PEN NEEDLES32GX4MM 96TRUEPLUS SAFETYLANCETS 28G 71TRUETEST BLOODGLUCOSE TEST 47TRUETEST BLOODGLUCOSE TEST STRIPS 47TRUETEST GLUCOSECONTROLLEVEL 1 71TRUETEST GLUCOSECONTROLLEVEL 2 71TRUETEST GLUCOSECONTROLLEVEL 3 71TRUETEST STRIPS 47TRUETRACK BLOODGLUCOSE TEST 47TRUETRACK TEST 47

TRUSOPT 114TRUSTEX COLOR CONDOMS +LUBE 63TRUSTEX LUBRICATED 63TRUSTEX LUBRICATEDEXTRALARGE 63TRUSTEX LUBRICATEDEXTRASTRENGTH 63TRUSTEXLUBRICATED/RIBBED/STUDDED 63TRUSTEXLUBRICATED/SPERMICIDE

63TRUSTEXLUBRICATED/SPERMICIDEEXTRA LARGE 63TRUSTEXLUBRICATED/SPERMICIDEEXTRA STRENGTH 63TRUSTEX NATURALCONDOMS+LUBE/LUBRICATED 63TRUSTEX WITH NONOXYNOL-9/RIBBED/STUDDED 63TRUSTEX/RIALUBRICATED 63TRUSTEX/RIA LUBRICATEDSPERMICIDE 63TRUSTEX/RIALUBRICATED/SPERMICIDE

63TRUVADA 30TUDORZA PRESSAIR 9TUMS 6TUMS CHEWY BITES 6TUMS E-X 750 6TUMS KIDS 6TUMS LASTING EFFECTS 6TUMS SMOOTHIES 7TUMS ULTRA 1000 7TWINRIX 122TYBOST 30TYKERB 25TYLENOL 4TYLENOL CHILDRENS 4TYLENOL EXTRASTRENGTH 4TYLENOL INFANTS 4TYLENOL INFANTSPAIN+FEVER 4TYLENOL/CODEINE #3 5TYLENOL/CODEINE #4 5

Index 37

TYSABRI 117TYVASO 33TYVASO REFILL 33TYVASO STARTER 33ULTI-LANCE AUTOMATIC/CLEAR TIP 71ULTICARE INSULIN SAFETYSYRINGE/0.5ML/29G X 1/2" 96ULTICARE INSULIN SAFETYSYRINGE/1ML/29G X 1/2" 96ULTICARE INSULINSYRINGE/0.3ML/29G X 1/2" 96ULTICARE INSULINSYRINGE/0.3ML/30G X 1/2" 96ULTICARE INSULINSYRINGE/0.3ML/30G X5/16" 96ULTICARE INSULINSYRINGE/0.5ML/28G X 1/2" 96ULTICARE INSULINSYRINGE/0.5ML/29G X 1/2" 96ULTICARE INSULINSYRINGE/0.5ML/30G X 1/2" 96ULTICARE INSULINSYRINGE/0.5ML/30G X5/16" 97ULTICARE INSULINSYRINGE/1ML/28G X 1/2" 97ULTICARE INSULINSYRINGE/1ML/29G X 1/2" 97ULTICARE INSULINSYRINGE/1ML/30G X 1/2" 97ULTICARE INSULINSYRINGE/1ML/30G X 5/16" 97ULTICARE INSULINSYRINGE/SHORT/0.3ML/30G X5/16" 97ULTICARE INSULINSYRINGE/SHORT/0.3ML/31G X5/16" 97ULTICARE INSULINSYRINGE/SHORT/0.5ML/30G X5/16" 97ULTICARE INSULINSYRINGE/SHORT/0.5ML/31G X5/16" 97ULTICARE INSULINSYRINGE/SHORT/1ML/30G X5/16" 97ULTICARE INSULINSYRINGE/SHORT/1ML/31G X5/16" 97ULTICARE INSULINSYRINGE/U-100/0.3ML/29G X1/2" 97ULTICARE INSULINSYRINGE/U-100/0.3ML/30G X1/2" 97

ULTICARE INSULINSYRINGE/U-100/0.3ML/30G X5/16" 97ULTICARE INSULINSYRINGE/U-100/0.3ML/31G X5/16" 97ULTICARE INSULINSYRINGE/U-100/0.5ML/29G 1/2" 97

X

ULTICARE INSULINSYRINGE/U-100/0.5ML/30G X1/2" 97ULTICARE INSULINSYRINGE/U-100/0.5ML/30G X5/16" 97ULTICARE INSULINSYRINGE/U-100/0.5ML/31G X5/16" 97ULTICARE INSULINSYRINGE/U-100/1ML/29G X1/2" 97ULTICARE INSULINSYRINGE/U-100/1ML/30G X1/2" 97ULTICARE INSULINSYRINGE/U-100/1ML/30G X5/16" 97ULTICARE INSULINSYRINGE/U-100/1ML/31G X5/16" 97ULTICARE INSULINSYRINGEULTRAFINE U-100/0.3ML/31G X 5/16" 97ULTICARE INSULINSYRINGEULTRAFINE U-100/0.5ML/31G X 5/16" 97ULTICARE INSULINSYRINGEULTRAFINE U-100/1ML/31G X 5/16" 97ULTICARE MICRO PENNEEDLES 31G X 8MM 97ULTICARE MICRO PENNEEDLES 32G X 4MM 98ULTICARE MICRO PENNEEDLES/32G X 4MM 98ULTICARE MINI PENNEEDLES 31GX6MM 98ULTICARE MINI PENNEEDLES ULTI-FINE IV 98ULTICARE MINI PENNEEDLES/31G X 6MM 98ULTICARE MINI PENNEEDLES31GX6MM 98ULTICARE ORIGINAL PENNEEDLES ULTI-FINE 98ULTICARE PENNEEDLES/29GX 12.7MM 98ULTICARE SHORT PENNEEDLES 31GX8MM 98

ULTICARE SHORT PENNEEDLES ULTI-FINE IV 98ULTICARE SHORT PENNEEDLES/31G X 8MM 98ULTICARE THIN LANCETS30G 71ULTILET CLASSICLANCETS 71ULTILET INSULINSYRINGE/SHORT/0.3ML/30G X5/16" 98ULTILET INSULINSYRINGE/SHORT/0.3ML/31G X5/16" 98ULTILET INSULINSYRINGE/SHORT/0.5ML/30G X5/16" 98ULTILET INSULINSYRINGE/SHORT/0.5ML/31G X5/16" 98ULTILET INSULINSYRINGE/SHORT/1ML/30G X5/16" 98ULTILET INSULINSYRINGE/SHORT/1ML/31G X5/16" 98ULTILET LANCETS 71ULTILET LANCETS 33G 71ULTILET PEN NEEDLE32GX4MM/SHORT 98ULTILET SHORT PENNEEDLES 31GX5/16" 98ULTILET SHORT PENNEEDLES31GX3/16" 98ULTIMATE FEELING 63ULTRA COMFORT INSULINSYRINGE/U-100/0.3ML/30G X5/16" 98ULTRA COMFORT INSULINSYRINGE/U-100/0.5ML/28G X1/2" 98ULTRA MENS PACK 108ULTRA THIN LANCETS28G 71ULTRA THIN LANCETS30G 71ULTRA WOMENS PACK 108ULTRA-COMFORT INSULINSYRINGE/U-100/0.3ML/29G X1/2" 98ULTRA-COMFORT INSULINSYRINGE/U-100/0.3ML/30G X5/16" 98ULTRA-COMFORT INSULINSYRINGE/U-100/0.3ML/31G X5/16" 98

Index 38

ULTRA-COMFORT INSULINSYRINGE/U-100/0.5ML/28G X1/2" 98ULTRA-COMFORT INSULINSYRINGE/U-100/0.5ML/29G X1/2" 98ULTRA-COMFORT INSULINSYRINGE/U-100/0.5ML/30G X5/16" 98ULTRA-COMFORT INSULINSYRINGE/U-100/0.5ML/31G X5/16" 98ULTRA-COMFORT INSULINSYRINGE/U-100/1ML/28G X1/2" 99ULTRA-COMFORT INSULINSYRINGE/U-100/1ML/29G X1/2" 99ULTRA-COMFORT INSULINSYRINGE/U-100/1ML/30G X5/16" 99ULTRA-COMFORT INSULINSYRINGE/U-100/1ML/31G X5/16" 99ULTRA-THIN II INSULINSYRINGE SHORT/U-100/0.3ML/30GX5/16" 99ULTRA-THIN II INSULINSYRINGE SHORT/U-100/0.3ML/31GX5/16" 99ULTRA-THIN II INSULINSYRINGE SHORT/U-100/0.5ML/30GX5/16" 99ULTRA-THIN II INSULINSYRINGE SHORT/U-100/0.5ML/31GX5/16" 99ULTRA-THIN II INSULINSYRINGE SHORT/U-100/1ML/30GX5/16" 99ULTRA-THIN II INSULINSYRINGE SHORT/U-100/1ML/31GX5/16" 99ULTRA-THIN II INSULINSYRINGE/U-100/0.3ML/29GX1/2" 99ULTRA-THIN II INSULINSYRINGE/U-100/0.5ML/29GX1/2" 99ULTRA-THIN II INSULINSYRINGE/U-100/1ML/29GX1/2"

99ULTRA-THIN II MINI PENNEEEDLES/31GX3/16" 99ULTRA-THIN II PEN NEEDLES29GX1/2" 99ULTRA-THIN II PENNEEDLES/SHORT/31GX5/16"

99ULTRACET 5

ULTRAM 5UNIFINE PENTIPS29GX12MM 99UNIFINE PENTIPS 31G X3/16" 99UNIFINE PENTIPS31GX5MM 99UNIFINE PENTIPS31GX6MM 99UNIFINE PENTIPS31GX8MM 99UNIFINE PENTIPS32GX4MM 99UNIFINE PENTIPS PLUS29GX12MM 99UNIFINE PENTIPS PLUS31GX5MM 99UNIFINE PENTIPS PLUS31GX6MM 99UNIFINE PENTIPS PLUS31GX8MM 99UNIFINE PENTIPS PLUS32GX4MM 99UNILET COMFORTOUCHLANCET 71UNILET EXCELITE 71UNILET EXCELITE II 71UNILET G.P. LANCET 71UNILET G.P. SUPERLITELANCET 71UNILET GP 28 ULTRATHIN 71UNILET LANCET 71UNILET LANCETS MICRO-THIN33G 71UNILET LANCETS SUPER-THIN30G 71UNILET LANCETS ULTRA-THIN 28G 71UNILET SUPERLITELANCET 71UNISOM 55UNISOM SLEEPGELS 54UNISTIK TOUCH SAFETYLANCETS 23G 71UNIVERSAL 1 LANCETSTHIN26G 71UNIVERSAL 1 LANCETSULTRA THIN 30G 71UNIVERSAL 1LANCETS/33G/MICRO-THIN

71urea 43URECHOLINE 120UROCIT-K 10 52UROCIT-K 5 52

URSO 250 51ursodiol 51V-R MONOJECT INSULINSYRINGE/U-100/0.3ML/29G X1/2" 99V-R MONOJECT INSULINSYRINGE/U-100/0.5ML/28G X1/2" 99V-R MONOJECT INSULINSYRINGE/U-100/0.5ML/29G X1/2" 99V-R MONOJECT INSULINSYRINGE/U-100/1ML/28G X1/2" 99V-R MONOJECT INSULINSYRINGE/U-100/1ML/29G X1/2" 99VAGISTAT-1 123valacyclovir hcl 1000 mg, 1gm 31valacyclovir hcl 500 mg 31VALCYTE 31valganciclovir hcl 31VALIUM 8valproate sodium 12valproic acid 12valsartan 21valsartan-hydrochlorothiazide

22VALTREX 1 GM 31VALTREX 500 MG 31VALUE HEALTH INSULINSYRINGE/U-100/0.5ML/29G X1/2" 100VALUE HEALTH INSULINSYRINGE/U-100/1ML/29G X1/2" 100VALUE PLUS LANCETSSTANDARD 21G 71VALUE PLUS LANCETSSUPERTHIN 30G 71VALUE PLUS LANCETS THIN26G 71VALUE PLUS LANCINGDEVICE 71VALUMARK LANCET SUPERTHIN 30G 71VALUMARK LANCET ULTRATHIN 28G 71VALUMARK PEN NEEDLES29GX12MM 100VALUMARK PEN NEEDLES31GX 6MM 100VALUMARK PEN NEEDLES31GX 8MM 100

Index 39

VALVED HOLDINGCHAMBER 102VANCOCIN HCL 125 MG 7VANCOCIN HCL 250 MG 7vancomycin hcl 1000 mg 7vancomycin hcl 125 mg 7vancomycin hcl 250 mg 7vancomycin hcl 500 mg 7VANISHPOINT INSULINSYRINGE/0.5ML/30G X1/2" 100VANISHPOINT INSULINSYRINGE/0.5ML/30G X5/16" 100VANISHPOINT INSULINSYRINGE/1ML/29G X 1/2" 100VANISHPOINT INSULINSYRINGE/1ML/30G X5/16" 100VANTAS 24VAQTA 122VASERETIC 22VASOTEC 21venlafaxine hcl 14VENLAFAXINE HCL ER 225MG 14VENLAFAXINE HCL ER 37.5MG, 150 MG, 75 MG 14VENTAVIS 33VENTOLIN HFA 10verapamil hcl 33verapamil hcl 120 mg, 180 mg,240 mg 33verapamil hcl 360 mg 33VERELAN 180 MG, 120 MG, 240MG 33VERELAN 360 MG 33VERIPRED 20 37VERSACLOZ 28VERSIVA XC 3" X 3" FOAMDRESSING/HYDROFIBERTECHNOLOGY 61VERSIVA XC 4" X 4" FOAMDRESSING/HYDROFIBERTECHNOLOGY 62VEXOL 114VIBRAMYCIN 118VICTOZA 16VIDA MIA AUTOLETLANCINGDEVICE 72VIDA MIA UNIFINEPENTIPS32GX4MM 100

VIDA MIA UNIFINEPENTIPSMINI 31GX6MM100VIDA MIA UNIFINEPENTIPSORIGINAL29GX12MM 100VIDA MIA UNILET LANCETSULTRA THIN 28G 72VIDA MIA UNIPFINEPENTIPSSHORT31GX8MM 100VIDEX EC 30VIDEXPEDIATRIC 30VIGAMOX 113VIIBRYD 14VIIBRYD STARTER PACK14VIRACEPT 250 MG 30VIRACEPT 625 MG 30VIRAMUNE 30VIRAMUNE XR 100 MG 31VIRAMUNE XR 400 MG 31VIREAD 31VIROPTIC 113VISINE 113VISINE EXTRA 113VISTARIL 8VISTEC X-RAY DETECTABLESPONGES 4"X4" 16 PLY 62VITALET PRO PLUSLANCETS 72VITAMENT 108vitamin a 124VITAMIN C 124VITAMIN C EFFERVESCENTBLEND 108VITAMINC/ELECTROLYTES 108vitamin e 124VITAMINS TO GOMAXIMUM 108VITAMINS TO GO MEN 108VITAMINS TO GOWOMEN 108vitamins w/ lipotropics 110VITEKTA 31VIVELLE-DOT 0.025MG/24HR, 0.1 MG/24HR, 0.075MG/24HR, 0.05 MG/24HR 50VIVELLE-DOT 0.0375MG/24HR 50VIVITROL 18VOL-PLUS 110VOLTAREN-XR 3

VORTEX VALVED HOLDINGCHAMBER 102VOSPIRE ER 10VOTRIENT 25VP INSULIN SYRINGE/U-100/0.3ML/29G X 1/2" 100VPRIV 53VRAYLAR 26VYTORIN 20VYVANSE 1W&F LANCETS 26G 72WALGREENS COMFORTASSUREDLANCETS MICROTHIN/33G 72WALGREENS COMFORTASSUREDLANCETS SUPERTHIN/28G 72WALGREENS GLUCOSE 15WALGREENS LANCETS 72WALGREENS THINLANCETS 72WALGREENS ULTRA THINLANCETS 72warfarin sodium 10WATCHHALER 102WATER BABIES SPF 30 47WEBCOL ALCOHOL PREPLARGE 1 PLY 73WEBCOL ALCOHOL PREPLARGE 2 PLY 73WEBCOL ALCOHOL PREPMEDIUM 2 PLY 73WEGMANS UNIFINE PENTIPSPLUS 32GX4MM 100WEGMANS UNIFINE PENTIPSPLUS/MINI/31GX5MM 100WEGMANS UNIFINE PENTIPSPLUS/SHORT/31GX8MM 100WEGMANS UNIFINE PENTIPSPLUS/ULTRASHORT/31GX6MM 100WELLBUTRIN 12WELLBUTRIN SR 12WELLBUTRIN XL 12white petrolatum-mineral oil111WILATE 53WOMENS PACK 108XALATAN 114XALKORI 25XANAX 8XARELTO 10 MG 10XARELTO 15 MG 10

Index 40

XARELTO 20 MG 10XELODA 24XOLIDO XP 44XTANDI 24XULANE 35XYNTHA 53XYNTHA SOLOFUSE 53YASMIN 28 35YAZ 35ZADITOR 114zaleplon 55ZANAFLEX 110ZANTAC 150 MAXIMUMSTRENGTH 119ZANTAC 150 MG 119ZANTAC 300 MG 119ZANTAC 75 119ZARONTIN 12ZARXIO 54ZAVESCA 53ZEBETA 32ZELBORAF 25ZENPEP 48ZEPATIER 31ZERIT 31ZESTORETIC 20MG-12.5MG,10MG-12.5MG 22ZESTORETIC 20MG-25MG 22ZESTRIL 10 MG, 30 MG, 20 MG,40 MG, 5 MG 21ZESTRIL 2.5 MG 21ZETIA 21ZIAC 22ZIAGEN 31zidovudine 31ZINBRYTA 117ZINC 108zinc oxide (topical) 44zinc sulfate 105ziprasidone hcl 26ZITHROMAX 57ZITHROMAX 100 MG/5ML 57ZITHROMAX 200 MG/5ML 57ZITHROMAX 250 MG 57ZITHROMAX 500 MG 57ZITHROMAX 600 MG 57ZITHROMAX TRI-PAK 57

ZITHROMAX Z-PAK 57ZOCOR 40 MG, 10 MG, 5 MG,20 MG 20ZOCOR 80 MG 21ZOFRAN 18ZOFRAN ODT 18ZOLADEX 24ZOLINZA 25zolmitriptan 103ZOLOFT 13ZOLOFT 100 MG 13ZOLOFT 50 MG, 25 MG 13zolpidem tartrate 55ZOMIG 103ZOMIG ZMT 103ZONEGRAN 11zonisamide 11ZORBTIVE 49ZOSTAVAX 123ZOSTRIX ARTHRITIS PAINRELIEF 44ZOSTRIX DIABETIC FOOTPAIN 44ZOVIRAX 31ZOVIRAX 400 MG 31ZOVIRAX 800 MG 31ZYBAN 117ZYKADIA 25ZYLOPRIM 52ZYPREXA 28ZYPREXA RELPREVV 28ZYPREXA ZYDIS 28ZYRTEC ALLERGY 19ZYRTEC CHILDRENSALLERGY 19ZYRTEC-DALLERGY/CONGESTION 38ZYTIGA 24ZZZQUIL 55

Index 41

preferred drug list - silversummit healthplan · 2020-04-30 · preferred drug list the...

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