CeltiCare Health

Transcription

CeltiCare Health

Comprehensive
PREFERRED DRUG LIST
CeltiCare Health
PAGE 1
LAST UPDATED 09/2016
Pharmacy Program
CeltiCare Health Plan of Massachusetts (CeltiCare Health) is committed to providing appropriate, high
quality, and cost effective drug therapy to all CeltiCare Health members. CeltiCare Health works with
providers and pharmacists to ensure that medications used to treat a variety of conditions and diseases are
covered. CeltiCare Health covers prescription medications and certain over-the-counter (OTC)
medications when ordered by a Massachusetts Medicaid enrolled, CeltiCare Health practitioner. The
pharmacy program does not cover all medications. Some medications require prior authorization (PA) or
have limitations on age, dosage, and maximum quantities.
Preferred Drug List
The CeltiCare Health Preferred Drug List (PDL) is the list of covered drugs. The PDL applies to drugs
members can receive at retail pharmacies. The CeltiCare Health PDL is continually evaluated by the
CeltiCare Health Pharmacy and Therapeutics (P&T) Committee to promote the appropriate and costeffective use of medications. The Committee is composed of the CeltiCare Health Medical Director,
CeltiCare Health Pharmacy Director, and several Massachusetts physicians, pharmacists, and other
healthcare professionals.
Pharmacy Benefit Manager
CeltiCare Health works with US Script to process pharmacy claims for prescribed drugs. Some drugs on
the CeltiCare Health PDL may require PA; US Script is responsible for administering this process. US
Script is our Pharmacy Benefit Manager.
Specialty Drugs
CeltiCare Health contracts with a number of specialty pharmacies to ensure members have adequate access to
the specialty drugs they require. All specialty drugs, such as biopharmaceuticals and injectables, require PA to be
approved for payment by CeltiCare Health. PA requirements are programmed specific to the drug. A list of
preferred specialty products can be found on the last page of the PDL.
Dispensing Limits
Drugs may be dispensed up to a maximum of thirty (30) days supply for each new prescription or refill. A
total of 80% of the days supply must have elapsed before the prescription can be refilled for noncontrolled-substance PDL drugs. A total of 90% of the days supply must have elapsed before the
prescription can be refilled for controlled substances PDL drugs. There are no refills for narcotic PDL
drugs; each fill requires a new prescription. A total of 90% of the days supply of the previous prescription
must have elapsed before the new prescription can be filled.
Appropriate Use and Safety Edits
The health and safety of our members is a priority for CeltiCare Health. One of the ways we address
member 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.
PAGE 2
Prior Authorizations
Some medications listed on the CeltiCare Health PDL may require PA. Necessary information should be
submitted by the practitioner or pharmacist to US Script on the Medication Prior Authorization Form.
This form should be faxed to US Script at 1-866-399-0929. This document can be found on the
CeltiCare Health website.
CeltiCare Health will cover the medication if it is determined that:
1. There is a medical reason the member needs the specific medication.
2. Other medications on the PDL, including preferred agents have not worked.
Authorization requests are reviewed by a licensed clinical pharmacist using the criteria established by the
CeltiCare Health P&T Committee. If the request is approved, US Script notifies the practitioner by fax. If
the clinical information provided does not meet the coverage criteria for the requested medication,
CeltiCare Health will notify the member and their practitioner of covered medication alternatives and
provide information regarding the appeal process.
Step Therapy
Some medications listed on the CeltiCare Health PDL may require specific medications to be used before
the member can receive the step therapy medication. If CeltiCare Health has a record that the required
medication was tried first the step therapy medications are automatically covered. If CeltiCare Health does
not have a record that the required medication was tried, the member’s practitioner may be required to
provide additional information. If authorization is not granted, CeltiCare Health will notify the member
and their practitioner of covered medication alternatives and provide information regarding the appeal
process.
Quantity Limits
CeltiCare Health may limit how much of a certain medication a member can get at one time. If the
practitioner feels the member has a medical reason for getting a greater amount, a PA may be requested. If
CeltiCare Health does not grant PA we will notify the member and their practitioner of covered
medication alternatives and provide information regarding the appeal process.
Age Limits
Some medications on the CeltiCare Health PDL may have age limits. These are set for certain drugs based
on FDA approved labeling and for safety concerns and quality standards of care. Age limits align with
current FDA alerts for the appropriate use of pharmaceuticals.
Gender Limits
Some medications on the CeltiCare Health PDL may be limited to one gender. These limits are set for
certain drugs based on FDA approved labeling and for safety concerns and quality standards of care.
Gender limits align with current FDA alerts for the appropriate use of pharmaceuticals.
PAGE 3
Medical Necessity Requests
If the member requires a medication that does not appear on the PDL, the member’s practitioner can
make a medical necessity (MN) request for the medication. It is anticipated that such exceptions will be
rare as the PDL medications are appropriate to treat the vast majority of medical conditions.
For a MN request CeltiCare Health requires:

Documentation of failure of at least two PDL agents within the same therapeutic class (provided
two agents exist in the therapeutic category with comparable labeled indications) for the same
diagnosis (e.g. migraine, neuropathic pain, etc.); or

Documented intolerance or contraindication to at least two PDL agents within the same
therapeutic class (provided two agents exist in the therapeutic category with comparable labeled
indications); or

Documented clinical history or presentation where the patient is not a candidate for any of the
PDL agents for the indication.
These requests are reviewed by a licensed clinical pharmacist using the criteria established by the CeltiCare
Health P&T Committee. If the request is approved, US Script notifies the practitioner by fax. If the
clinical information provided does not meet the coverage criteria for the requested medication, CeltiCare
Health will notify the member and their practitioner of alternatives and provide information regarding the
appeal process.
72 Hour Emergency Supply Policy
State and Federal law require that a pharmacy dispense a 72 hour (3 day) supply of medication to any
member awaiting PA determination. The purpose is to avoid interruption of current therapy or delay in the
initiation of therapy. A provision of a 72 hour supply does not guarantee that the medication will be
approved after a PA review. All participating pharmacies are authorized to provide a 72 hour supply of
medication and will be reimbursed for the ingredient cost and dispensing fee of the 72 hour supply of
medication, whether or not the PA request is ultimately approved or denied. The pharmacy must call US
Script at 1-888-929-3790 for a prescription override to submit the 72 hour medication supply for
payment.
Exclusions
The following drug categories are not part of the CeltiCare Health PDL and are not covered by the 72
hour emergency supply policy:

Drugs that are not approved by the FDA

Drugs classified as less-than-effective (LTE) by the FDA

Drugs that are experimental, medically unproven, or investigational in nature

Drugs prescribed for weight loss

Drugs used to promote fertility

Drugs prescribed for the treatment of sexual dysfunction

Drugs prescribed for cosmetic purposes or hair growth

Drugs used for the symptomatic relief of coughs and colds
PAGE 4
Newly Approved Products
CeltiCare Health reviews new drugs for safety and effectiveness before adding them to the PDL. During
this period, access to these medications will be considered through the PA review process. If CeltiCare
Health does not grant PA we will notify the member and their practitioner of covered medication
alternatives and provide information regarding the appeal process.
Over-the-Counter Medications
CeltiCare Health covers a variety of OTC medications. These medications can be found throughout the
CeltiCare Health PDL. CeltiCare Health covers OTC products listed in the PDL if the member has a
prescription from a licensed practitioner that meets all the legal requirements for a prescription.
Generic Drugs
When generic drugs are available, the brand name drug will not be covered without CeltiCare Health
authorization. Generic drugs have the same active ingredient and work the same as brand name drugs. If
the member or their practitioner feels a brand name drug is medically necessary, the practitioner request
the drug using the PA process. We will cover the brand-name drug according to our clinical guidelines if
there is a medical reason the member needs the particular brand-name drug. If CeltiCare Health does not
grant authorization, we will notify the member and their practitioner of covered medication alternatives
and provide information regarding the appeal process.
The provision is waived for the following products due to their narrow therapeutic index (NTI) as
recognized by current medical and pharmaceutical literature: Aminophylline, Carbamazepine,
Cyclosporine, Digoxin, Disopyramide, Ethosuximide, Flecainide, L-Thyroxine, Lithium, Phenytoin,
Theophylline, Thyroid, Valproic Acid, and Warfarin.
Drug Efficacy Study Implementation Drugs
Drug Efficacy Study Implementation (DESI) products and known related drug products are defined as
less than effective by the Food and Drug Administration because there is a lack of substantial evidence of
effectiveness for all labeling indications and because a compelling justification for their medical need has
not been established. DESI products are not covered by CeltiCare Health.
Filling a Prescription
A member can have prescriptions filled at a CeltiCare Health network pharmacy. If the member decides
to have a prescription filled at a network pharmacy they can locate a pharmacy near them by contacting
CeltiCare Health Member Services. At the pharmacy the member will need to provide the pharmacist with
the prescription and their CeltiCare Health ID card.
PAGE 5
Copayments
The table below lists the member copayment amounts according drug type. Copayments are not required
for pregnant women, members on hospice, American Indians, or Alaska natives.
Drug Type
Member Copayment
Generic Antihyperglycemics, Antihypertensives and Antilipidemics
$1.00
All Other Generics and Brand Name Drugs
$3.65
Abbreviations
The following notations and abbreviations may be found throughout the drug listing in the limitations and
restrictions column.
DS/DU:
Days Supply per Dosage Unit
Max Days Sply:
Maximum Days Supply
Max Fills:
Maximum Fills (per a designated time period)
Max Qty:
Maximum Quantity (per claim or designated time period)
Min DS:
Minimum Days Supply
PA:
Prior Authorization
Pkg Size:
Package Size
Contact Information
CeltiCare Health
US Script
PAGE 6
Phone:
1-855-678-6975
TDD/TTY:
1-866-614-1949
Fax:
1-855-565-7655
Website:
www.CeltiCareHealthPlan.com
PA Phone:
1-855-688-6592
PA Fax:
1-866-399-0929
Help Desk:
1- 855-688-6591
LEGEND
TYPE
DESCRIPTION
QL
Quantity Limit
There is a limit on the amount of drug covered per prescription, or
within a specific time frame.
PA
Prior Authorization
Prior Authorization required before prescription can be filled.
ST
Step Therapy
Requires trial and failure of one or more preferred products prior to
coverage.
GL
Gender Limit
Drug is limited to specific gender.
AL
Age Limit
Drug is limited to specific age.
MDD
Max Daily Dose
A limit on the number of times the drug can be taken per day.
MPL
Max Package Limit
A limit on the amount of drug covered per prescription.
MFL
Max Fill Limit
There is a limit on the number of times this drug can be refilled.
Custom
This drug has unique restrictions.
C
PAGE 7
LIST OF COVERED OVER-THE-COUNTER MEDICATIONS
PRODUCT DESCRIPTION
BRAND/GEN
LIMITS & RESTRICTIONS
ANALGESICS
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
aspirin (chew tab 81 mg, tab 81 mg, tab 325 mg, tab
delayed release 81 mg, tab delayed release 325 mg)
generic
aspirin (suppos 300 mg, suppos 600 mg)
generic
aspirin buffered (ca carb-mg carb-mg ox) tab 325 mg
generic
aspirin buffered tab 325 mg
generic
aspirin tab chew 81 mg
generic
ibuprofen (chew tab 100 mg, susp 40 mg/ml, susp 100
mg/5ml, tab 200 mg)
generic
ibuprofen tab 200 mg
generic
naproxen sodium tab 220 mg
generic
ST JOSEPH ADULT CHEW TAB 75 MG
BRAND
ST JOSEPH ADULT LOW DOSE CHEW TAB 75 MG
BRAND
QL
12 / claim
MDD
2 per day
MPL
1 / claim
ANESTHETICS
LOCAL ANESTHETICS
lidocaine hcl gel 2%
generic
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
SMOKING CESSATION AGENTS
AL
nicotine (patch 24hr 7 mg/24hr, patch 24hr 21 mg/24hr,
patch 24hr 14 mg/24hr)
generic
NICOTINE KIT 21-14-7 MG/24HR
BRAND
nicotine polacrilex (gum 2 mg, gum 4 mg)
generic
MDD
1 per day
MPL
2 / years
AL
MDD
nicotine polacrilex (lozenge 2 mg, lozenge 4 mg)
AL
generic
MDD
PAGE 8
At least 18 yrs old
At least 18 yrs old
24 per day
At least 18 yrs old
20 per day
PRODUCT DESCRIPTION
BRAND/GEN
ANTIEMETICS
ANTIEMETICS, OTHER
meclizine hcl (chew tab 25 mg, tab 12.5 mg, tab 25 mg)
generic
ANTIFUNGALS
clotrimazole (topical) (cream, soln)
generic
MPL
clotrimazole vaginal cream 1%
generic
QL
clotrimazole vaginal cream 2%
generic
MPL
1 / claim
miconazole nitrate cream 2%
generic
MPL
1 / claim
miconazole nitrate vaginal app 200 mg & 2% cream 9 gm
kit
generic
miconazole nitrate vaginal cream 2%
generic
QL
45 / claim
miconazole nitrate vaginal cream 4% (200 mg/5gm)
generic
QL
45 / 30 days
miconazole nitrate vaginal supp 200 mg & 2% cream 9 gm
kit
generic
MPL
1 / claim
miconazole nitrate vaginal suppos 100 mg
generic
QL
7 / claim
NIZORAL A-D SHAMPOO 1 %
BRAND
MPL
1 / claim
tioconazole vaginal oint 6.5%
generic
QL
5 / claim
QL
4 / claim
1 / claim
45 / claim
ANTIPARASITICS
ANTIHELMINTHICS
PIN-X CHEW TAB 720.5 MG
BRAND
MFL
pyrantel pamoate susp 144 mg/ml (50 mg/ml base equiv)
QL
generic
MFL
PAGE 9
1 / 30 days
60 / claim
1 / 30 days
PRODUCT DESCRIPTION
BRAND/GEN
BLOOD GLUCOSE REGULATORS
GLYCEMIC AGENTS
BD GLUCOSE CHEW TAB 5 GM
BRAND
QL
50 / 30 days
CVS GLUCOSE CHEW TAB 4 GM
BRAND
QL
50 / 30 days
DEX4 QUICK DISSOLVE GLUCOSE CHEW TAB 4 GM
BRAND
QL
50 / 30 days
glucose chew tab 4 gm
generic
QL
50 / 30 days
GNP GLUCOSE CHEW TAB 4 GM
BRAND
QL
50 / 30 days
GNP QUICK DISSOLVE GLUCOSE CHEW TAB 4 GM
BRAND
QL
50 / 30 days
LEADER QUICK DISSOLVE GLUCOSE CHEW TAB 4 GM
BRAND
QL
50 / 30 days
MS QUICK DISSOLVE GLUCOSE CHEW TAB 4 GM
BRAND
QL
50 / 30 days
SM GLUCOSE CHEW TAB 4 GM
BRAND
QL
50 / 30 days
ULTILET GLUCOSE CHEW TAB 4 GM
BRAND
QL
50 / 30 days
WALGREENS GLUCOSE CHEW TAB 4 GM
BRAND
QL
50 / 30 days
CARDIOVASCULAR AGENTS
DYSLIPIDEMICS, OTHER
niacin (tab 250 mg, tab 500 mg, tab 750 mg, tab 1000 mg)
generic
omega-3 fatty acids (cap 1000, cap 1200)
generic
MDD
6 per day
acetaminophen soln 100 mg/ml
generic
QL
30 / claim
acetaminophen soln 160 mg/5ml
generic
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM, OTHER
DENTAL AND ORAL AGENTS
BIOTENE MOISTURIZING MOUTH SOLUTION
BRAND
QL
900 / claim
BIOTENE ORALBALANCE DRY MOUTH LIQUID
BRAND
QL
900 / claim
PAGE 10
PRODUCT DESCRIPTION
BRAND/GEN
CVS DRY MOUTH SOLUTION
BRAND
QL
900 / claim
DRY MOUTH SPRAY SOLUTION
BRAND
QL
900 / claim
MOI-STIR SOLUTION
BRAND
QL
900 / claim
MOUTH KOTE SOLUTION
BRAND
QL
900 / claim
ORAL RELIEF SPRAY SOLUTION
BRAND
QL
900 / claim
RA DRY MOUTH SOLUTION
BRAND
QL
900 / claim
sodium fluoride rinse 0.2%
generic
stannous fluoride conc 0.63%
generic
zinc lozenge 15 mg
generic
DERMATOLOGICAL AGENTS
*emollient - lotion**
generic
*lanolin cream***
generic
*neomycin-bacitracin-polymyxin oint***
generic
*soap & cleansers - lotion***
generic
A-200 GEL 0.33-4 %
BRAND
ACNE MEDICATION 5 LOTION 5 %
BRAND
bacitracin oint 500 unit/gm
MPL
1 / claim
generic
MPL
1 / claim
bacitracin zinc oint 500 unit/gm
generic
MPL
1 / claim
benzoyl peroxide (gel 2.5%, gel 5%, gel 10%, liq 5%, liq
10%, lotion 10%)
generic
camphor & menthol lotion 0.5-0.5%
generic
MPL
1 / claim
capsaicin (cream 0.075%, cream 0.1%)
generic
MPL
1 / claim
capsaicin cream 0.025%
generic
CAPZASIN-P CREAM 0.035 %
BRAND
MPL
1 / claim
CASTIVA WARMING LOTION 0.035 %
BRAND
MPL
1 / claim
CLEAN & CLEAR ADVANTAGE 3-IN-1 LOTION 5 %
BRAND
PAGE 11
PRODUCT DESCRIPTION
BRAND/GEN
coal tar shampoo 0.5%
generic
dibucaine oint 1%
generic
MPL
1 / claim
dibucaine rectal ointment 1%
generic
MPL
1 / claim
diphenhydramine hcl cream 2%
generic
hydrocortisone (topical) (cream, lotion)
generic
MPL
1 / claim
hydrocortisone cream 0.5%
generic
QL
30 / claim
hydrocortisone oint 1%
QL
generic
60 / 30 days
MPL
1 / 30 days
hydrocortisone-aloe vera cream 1%
generic
MPL
1 / claim
lactic acid (ammonium lactate) cream 12%
generic
MPL
1 / claim
lactic acid (ammonium lactate) lotion 12%
generic
MPL
1 / 30 days
LICEMD GEL 0.33-4 %
BRAND
LICIDE TREATMENT KIT
BRAND
neomycin-polymyxin w/ pramoxine cream 1%
generic
MPL
1 / claim
permethrin lotion 1%
generic
MPL
1 / claim
permethrin spray & pyrethins-piperonyl butoxide shamp kit
generic
phenyleph-shark liver oil-cocoa butter suppos 0.25-385.5%
generic
phenylephrine-cocoa butter suppos 0.25-88.44%
generic
phenylephrine-mineral oil-petrolatum oint 0.25-14-74.9%
generic
phenylephrine-shark liver oil-mo-pet oint 0.25-3-14-71.9%
generic
POLYSPORIN POWDER 500-10000 UNIT/GM
BRAND
pramoxine hcl rectal foam 1%
generic
pyreth-piperonyl butox sham-permeth aero-nit remover gel
kit
generic
pyrethrins-piperonyl butoxide (liq 0.3-3%, shampoo 0.334%)
generic
pyrethrins-piperonyl butoxide liq 0.33-4%
generic
PAGE 12
QL
MPL
QL
MPL
12 / claim
1 / claim
15 / claim
1 / claim
PRODUCT DESCRIPTION
BRAND/GEN
SCHOOLTIME SHAMPOO SHAMPOO
BRAND
selenium sulfide lotion 1%
generic
QL
terbinafine hcl cream 1%
generic
MPL
1 / claim
tolnaftate cream 1%
generic
MPL
1 / claim
zinc oxide oint 20%
generic
MPL
1 / claim
alum & mag hydroxide-simethicone susp 200-200-20
mg/5ml
generic
QL
aluminum hydroxide gel susp 320 mg/5ml
generic
bismuth subsalicylate (chew tab 262 mg, susp 262
mg/15ml)
generic
calcium carbonate (antacid) chew tab 500 mg
generic
loperamide hcl (cap 2 mg, liq 1 mg/5ml (0.2 mg/ml))
generic
loperamide hcl tab 2 mg
generic
magnesium oxide tab 400 mg
generic
simethicone chew tab 80 mg
generic
simethicone susp 40 mg/0.6ml
sodium bicarbonate (antacid) (tab 325 mg, tab 650 mg)
240 / claim
GASTROINTESTINAL AGENTS
GASTROINTESTINAL AGENTS, OTHER
496 / 30 days
MDD
2 per day
generic
MPL
1 / claim
generic
QL
496 / 30 days
HISTAMINE2 (H2) RECEPTOR ANTAGONISTS
AXID AR TAB 75 MG
BRAND
cimetidine tab 200 mg
generic
famotidine (tab 10 mg, tab 20 mg)
generic
ranitidine hcl (tab 75 mg, tab 150 mg)
generic
MDD
2 per day
generic
MDD
1 per day
LAXATIVES
bisacodyl ec tab dr 5 mg
PAGE 13
PRODUCT DESCRIPTION
BRAND/GEN
bisacodyl laxative suppos 10 mg
generic
QL
12 / claim
calcium polycarbophil tab 625 mg
generic
MDD
10 per day
complete ready-to-use enema enema 7-19 gm/118ml
generic
docusate sodium (cap 50 mg, liquid 150 mg/15ml, syrup 60
mg/15ml, tab 100 mg)
generic
docusate sodium cap 100 mg
generic
MDD
3 per day
generic
MDD
3 per day
fiber cap 0.52 gm
generic
glycerin suppos 2 gm
generic
magnesium citrate solution 1.745 gm/30ml
generic
milk of magnesia suspension 400 mg/5ml
generic
polyethylene glycol 3350 oral packet
generic
polyethylene glycol 3350 oral powder
generic
psyllium (powder 28.3%, powder 30%, powder 30.9%,
powder 33%, powder 48.57%, powder 50%, powder
58.6%, powder 68%, powder 100%)
generic
senna tab 8.6 mg
generic
senna-docusate sodium tab 8.6-50 mg
generic
sorbitol (laxative) (oral solution, rectal solution)
generic
QL
990 / 30 days
MDD
34 per day
MDD
4 per day
4 per day
PROTON PUMP INHIBITORS
lansoprazole cap delayed release 15 mg
generic
MDD
NEXIUM 24HR CAP DR 20 MG
BRAND
C
omeprazole delayed release tab 20 mg
generic
MDD
4 per day
PRILOSEC OTC TAB DR 20 MG
BRAND
MDD
4 per day
PAGE 14
OTC Covered Only
PRODUCT DESCRIPTION
BRAND/GEN
GENITOURINARY AGENTS
GENITOURINARY AGENTS, OTHER
CONCEPTROL INSERTS INSERT 150 MG
BRAND
QL
10 / claim
ENCARE SUPPOS 100 MG
BRAND
MPL
1 / claim
GYNOL II GEL 2 %
BRAND
MPL
1 / claim
OPTIONS GYNOL II CONTRACEPTIVE GEL 3 %
BRAND
QL
VCF VAGINAL CONTRACEPTIVE FILM 28 %
BRAND
MPL
86 / claim
1 / claim
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)
PROGESTINS
levonorgestrel tab 1.5 mg
QL
generic
MFL
1 / 21 days
4 / 365 days
METABOLIC BONE DISEASE AGENTS
cholecalciferol cap 50000 unit
generic
QL
8 / 30 days
*alcohol swabs***
generic
QL
400 / claim
*respiratory therapy supplies - misc**
generic
QL
1 / 360 days
acetaminophen (chew tab 80 mg, chew tab 160 mg, elixir
160 mg/5ml, liquid 160 mg/5ml, susp 80 mg/0.8ml, susp
160 mg/5ml, tab 325 mg, tab 500 mg)
generic
acetaminophen (suppos 120 mg, suppos 325 mg, suppos
650 mg)
generic
QL
12 / claim
ADULT AEROSOL MASK MISC
BRAND
QL
1 / 360 days
AIMSCO LUBRICATED MISC
BRAND
QL
36 / claim
AIRS PEDIATRIC AEROSOL MASK MISC
BRAND
QL
1 / 360 days
ALCOHOL PREP PAD 70 %
BRAND
QL
400 / claim
MISCELLANEOUS THERAPEUTIC AGENTS
PAGE 15
PRODUCT DESCRIPTION
BRAND/GEN
ALCOHOL SWABS PAD 70 %
BRAND
ALLEVYN PLUS CAVITY PAD 4"X4"
BRAND
ALLEVYN THIN PAD 4"X4"
BRAND
ARIAL CHAMBER DEVICE
QL
400 / claim
BRAND
QL
2 / 360 days
BD SWAB SINGLE USE REGULAR PAD
BRAND
QL
400 / claim
BIATAIN ADHESIVE FOAM DRESSING PAD 4"X4"
BRAND
BIATAIN FOAM DRESSING PAD 4"X4"
BRAND
BORDERED GAUZE PAD 4"X4"
BRAND
BUBBLES THE FISH II PEDI MASK MISC
BRAND
QL
1 / 360 days
CARRASMART FOAM PAD 4"X4"
BRAND
CARRASMART PAD 4"X4"
BRAND
CONE MASK MISC
BRAND
QL
1 / 360 days
COPA ISLAND BORDERED FOAM PAD 4"X4"
BRAND
COPA PLUS HYDROPHILIC FOAM PAD 4"X4"
BRAND
COVRSITE COVER DRESSING PAD 4"X4"
BRAND
COVRSITE PLUS COMPOSITE DRESS PAD 4"X4"
BRAND
cromolyn sodium nasal aerosol soln 5.2 mg/act (4%)
generic
QL
26 / claim
CUREX ALL-PURPOSE SPONGES PAD 4"X4"
BRAND
CURITY ALCOHOL PREPS PAD 70 %
BRAND
QL
400 / claim
CURITY ALCOHOL SWABS PAD
BRAND
QL
400 / claim
CURITY ALL PURPOSE SPONGES (PAD 2"X2", PAD
3"X3", PAD 4"X4")
BRAND
CURITY AMD ANTIMICROBIAL SPNGE PAD 2"X2"
BRAND
CURITY COVER SPONGE (PAD 3"X3", PAD 4"X4")
BRAND
CURITY DRESSING SPONGES PAD 4"X4"
BRAND
CURITY GAUZE (PAD 2"X2", PAD 3"X3", PAD 4"X4")
BRAND
CURITY GAUZE SPONGE (PAD 2"X2", PAD 3"X3", PAD
4"X4")
BRAND
PAGE 16
PRODUCT DESCRIPTION
BRAND/GEN
CURITY NON-ADHERENT STRIPS PAD 3"X3"
BRAND
CURITY SPONGES (PAD 2"X2", PAD 4"X4")
BRAND
CVS ADHESIVE DRESSINGS 4"X4" PAD 4"X4"
BRAND
CVS ALCOHOL PREP SWABS PAD 70 %
BRAND
QL
400 / claim
CVS ALCOHOL SWABS PAD
BRAND
QL
400 / claim
CVS GAUZE PAD 4"X4"
BRAND
CVS GAUZE PAD STERILE PAD 3"X3"
BRAND
CVS GAUZE STERILE PAD 2"X2"
BRAND
CVS NON-ADHESIVE (PAD 2"X2", PAD 3"X3", PAD
4"X4")
BRAND
CVS PREP PAD 70 %
BRAND
QL
400 / claim
CVS STERILE PADS PAD 4"X4"
BRAND
DERMACEA DRAIN SPONGES PAD 4"X4"
BRAND
DERMACEA GAUZE SPONGE (PAD 2"X2", PAD 3"X3",
PAD 4"X4")
BRAND
DERMACEA IV DRAIN SPONGES (PAD 2"X2", PAD
4"X4")
BRAND
DERMACEA IV SPONGES PAD 2"X2"
BRAND
DERMACEA NON-WOVEN SPONGES (PAD 2"X2", PAD
3"X3", PAD 4"X4")
BRAND
DERMACEA TYPE VII GAUZE (PAD 2"X2", PAD 3"X3",
PAD 4"X4")
BRAND
DERMACEA X-RAY SPONGES PAD 4"X4"
BRAND
DERMALEVIN ADHESIVE PAD 4"X4"
BRAND
DRESSING SPONGES PAD 4"X4"
BRAND
EARLOOP MASK MISC
BRAND
QL
1 / 360 days
EASY TOUCH ALCOHOL PREP MEDIUM PAD 70 %
BRAND
QL
400 / claim
ELEXA NATURAL FEEL MISC
BRAND
QL
36 / claim
ELEXA STIMULATING MISC
BRAND
QL
36 / claim
PAGE 17
PRODUCT DESCRIPTION
BRAND/GEN
ELEXA ULTRA SENSITIVE MISC
BRAND
EQL GAUZE (PAD 2"X2", PAD 4"X4")
BRAND
EQL GAUZE STERILE PAD 3"X3"
BRAND
EXCILON DRAIN SPONGES PAD 4"X4"
BRAND
EXCILON IV SPONGES PAD 2"X2"
BRAND
FANTASY LUBRICATED MISC
QL
36 / claim
BRAND
QL
36 / claim
FANTASY LUBRICATED/SPERMICIDE MISC
BRAND
QL
36 / claim
FIFTY50 ALCOHOL PREP PAD 70 %
BRAND
QL
400 / claim
FLEXZAN PAD 4"X4"
BRAND
gauze pads & dressings (pads pads 2" 2"***, pads pads 3"
3"***, pads pads 4" 4"***)
generic
GAUZE SPONGE PAD 4"X4"
BRAND
ginger (zingiber officinalis) cap 250 mg
generic
MDD
GNP ALCOHOL SWABS (PAD, PAD 70 %)
BRAND
QL
400 / claim
GNP STERILE PADS PAD 3"X3"
BRAND
HEALTHY LIVING FILTERS MISC
BRAND
QL
1 / 360 days
HEALTHY LIVING MASKS MISC
BRAND
QL
1 / 360 days
HEALTHY LIVING REPLACEMENT KIT MISC
BRAND
QL
1 / 360 days
INHALER COMPANIONS MISC
BRAND
QL
1 / 360 days
ISLAND GARD-GRX (PAD 2"X2", PAD 4"X4")
BRAND
J & J GAUZE (PAD 2"X2", PAD 4"X4")
BRAND
J & J GAUZE SPONGES 12-PLY MISC 4"X4"
BRAND
BRAND
BRAND
J & J NON-STICK DRESSING PAD 3"X3"
BRAND
J & J ULCER DRESSING PAD 4"X4"
BRAND
KAMELEON LUBRICATED MISC
BRAND
QL
36 / claim
PAGE 18
4 per day
PRODUCT DESCRIPTION
BRAND/GEN
KENDALL HYDROPHILIC FOAM DRESS (FOAM PAD
2"X2", FOAM PAD 3"X3", FOAM PAD 4"X4")
BRAND
KENDALL HYDROPHILIC FOAM PLUS (FOAM PAD
2"X2", FOAM PAD 3"X3")
BRAND
KERLIX SPONGES PAD 4"X4"
BRAND
KIMONO MICRO THIN MISC
BRAND
QL
36 / claim
KIMONO MICRO THIN PLUS MISC
BRAND
QL
36 / claim
KIMONO MISC
BRAND
QL
36 / claim
KIMONO PLUS MISC
BRAND
QL
36 / claim
KIMONO PS MISC
BRAND
QL
36 / claim
KIMONO PS PLUS MISC
BRAND
QL
36 / claim
KIMONO SENSATION MISC
BRAND
QL
36 / claim
KIMONO SENSATION PLUS MISC
BRAND
QL
36 / claim
lanolin
generic
MAXX MISC
BRAND
QL
36 / claim
MAXX PLUS MISC
BRAND
QL
36 / claim
MEIJER ALCOHOL SWABS PAD 70 %
BRAND
QL
400 / claim
melatonin (tab 3 mg, tab 5 mg)
generic
MDD
MICROELITE BATTERY MISC
BRAND
QL
1 / 360 days
MICROELITE FILTER REPLACEMENTS MISC
BRAND
QL
1 / 360 days
MINIELITE FILTER REPLACEMENTS MISC
BRAND
QL
1 / 360 days
MIRASORB SPONGES (MISC 2"X2", MISC 4"X4")
BRAND
nasal moisturizing spray solution 0.65 %
generic
MPL
NESSI SPACER WITH MASK LARGE DEVICE
BRAND
QL
2 / 360 days
NESSI SPACER WITH MASK SM/MED DEVICE
BRAND
QL
2 / 360 days
NESSI SPACER WITH MOUTHPIECE DEVICE
BRAND
QL
2 / 360 days
PAGE 19
1 per day
1 / claim
PRODUCT DESCRIPTION
BRAND/GEN
NOVA MAX PLUS KETONE TEST STRIP
BRAND
NU GAUZE 4PLY PAD 4"X4"
BRAND
NU GAUZE GENERAL-USE SPONGES MISC 4"X4"
BRAND
OPTICHAMBER FACE MASK-LARGE MISC
QL
30 / 30 days
BRAND
QL
2 / 360 days
OPTICHAMBER FACE MASK-MEDIUM MISC
BRAND
QL
2 / 360 days
OPTICHAMBER FACE MASK-SMALL MISC
BRAND
QL
2 / 360 days
OPTIFOAM PAD 4"X4"
BRAND
PEDIATRIC AEROSOL MASK MISC
BRAND
QL
1 / 360 days
PEDIATRIC MOUTHPIECE MISC
BRAND
QL
1 / 360 days
permethrin (aerosol 0.5%, creme rinse 1%)
generic
phenylephrine hcl tab 10 mg
generic
QL
24 / claim
polyethylene glycol 3350 powder
generic
MDD
34 per day
POLYMEM DRESSING (PAD 3"X3", PAD 4"X4")
BRAND
PRECISION XTRA KETONE STRIP
BRAND
QL
30 / 30 days
PREMIUM CONDOMS LUBRICATED MISC
BRAND
QL
36 / claim
pseudoephedrine hcl (liq 15 mg/5ml, tab 60 mg)
generic
pseudoephedrine hcl er tab er 12h 120 mg
generic
MDD
2 per day
pseudoephedrine hcl tab 30 mg
generic
PTS PANELS KETONE TEST STRIP
BRAND
QL
30 / 30 days
QC ALCOHOL SWABS PAD 70 %
BRAND
QL
400 / claim
RA ALCOHOL SWABS PAD 70 %
BRAND
QL
400 / claim
RA ALL PURPOSE DRESSINGS PAD 4"X4"
BRAND
RA DRESSING SPONGES PAD 4"X4"
BRAND
RA GAUZE SPONGES PAD 4"X4"
BRAND
RA STERILE (PAD 2"X2", PAD 3"X3", PAD 4"X4")
BRAND
RAY-TEC X-RAY DETECTABLE SPNGE MISC 4"X4"
BRAND
PAGE 20
PRODUCT DESCRIPTION
BRAND/GEN
REALITY LATEX/ULTRA TEXTURED DEVICE
BRAND
QL
36 / claim
REALITY LATEX/ULTRA THIN DEVICE
BRAND
QL
36 / claim
RELION ALCOHOL SWABS (PAD, PAD 70 %)
BRAND
QL
400 / claim
REPLACEMENT FILTERS MISC
BRAND
QL
1 / 360 days
RESTORE CONTACT LAYER PAD 2"X2"
BRAND
RESTORE FOAM DRESSING PAD 4"X4"
BRAND
RESTORE ODOR ABSORBING DRESS PAD 4"X4"
BRAND
RESTORE TRIO ABSORBENT DRESS PAD 3"X3"
BRAND
SAMI THE SEAL FILTERS MISC
BRAND
QL
1 / 360 days
SB ALCOHOL PREP PAD 70 %
BRAND
QL
400 / claim
SHOPKO ALCOHOL SWABS PAD 70 %
BRAND
QL
400 / claim
SIDESTREAM ADULT FACE MASK MISC
BRAND
QL
1 / 360 days
SIDESTREAM PEDIATRIC FACE MASK MISC
BRAND
QL
1 / 360 days
SIDESTREAM PLS ADULT FACE MASK MISC
BRAND
QL
1 / 360 days
simethicone liquid 40 mg/0.6ml
generic
MPL
SIMPLYTHICK GEL
BRAND
QL
1816 / claim
SM ALCOHOL PREP (PAD, PAD 70 %)
BRAND
QL
400 / claim
SM GAUZE (PAD 2"X2", PAD 3"X3", PAD 4"X4")
BRAND
SM STERILE PAD 2"X2"
BRAND
SOF-WICK PAD 4"X4"
BRAND
sorbitol solution (bulk)
generic
SORBITOL SOLUTION 70 %
BRAND
STERI-PAD STERILE PAD 4"X4"
BRAND
STERILE (PAD 2"X2", PAD 3"X3", PAD 4"X4")
BRAND
SUDAFED PE CHILDRENS SOLUTION 2.5 MG/5ML
BRAND
QL
120 / claim
TEGADERM FOAM (FOAM PAD 2"X2", FOAM PAD
4"X4")
BRAND
PAGE 21
1 / claim
PRODUCT DESCRIPTION
BRAND/GEN
TGT ALCOHOL SWABS PAD 70 %
BRAND
THERAGAUZE PAD 2"X2"
BRAND
TOPPER DRESSING SPONGES MISC 4"X4"
BRAND
TROJAN MAGNUM WARM SENSATIONS DEVICE
QL
400 / claim
BRAND
QL
36 / claim
TROJAN SUPRAS SPERMICIDAL DEVICE
BRAND
QL
36 / claim
TROJAN TWISTED PLEASURE DEVICE
BRAND
QL
36 / claim
TRUSTEX COLOR CONDOMS + LUBE MISC
BRAND
QL
36 / claim
TRUSTEX LUB/RIBBED/STUDDED MISC
BRAND
QL
36 / claim
TRUSTEX LUB/SPERMICIDE EX ST MISC
BRAND
QL
36 / claim
TRUSTEX LUB/SPERMICIDE XL MISC
BRAND
QL
36 / claim
TRUSTEX LUBRICATED EX LARGE MISC
BRAND
QL
36 / claim
TRUSTEX LUBRICATED EXTRA ST MISC
BRAND
QL
36 / claim
TRUSTEX LUBRICATED MISC
BRAND
QL
36 / claim
TRUSTEX LUBRICATED/SPERMICIDE MISC
BRAND
QL
36 / claim
TRUSTEX NATURAL CONDOMS + LUBE MISC
BRAND
QL
36 / claim
TRUSTEX NON-LUBRICATED MISC
BRAND
QL
36 / claim
TRUSTEX RIA LUB/SPERMICIDE MISC
BRAND
QL
36 / claim
TRUSTEX RIA LUBRICATED MISC
BRAND
QL
36 / claim
TRUSTEX RIA NON-LUBRICATED MISC
BRAND
QL
36 / claim
TRUSTEX-NONOXYNOL-9/RIB/STUD MISC
BRAND
QL
36 / claim
TUBING/WING TIP MISC
BRAND
QL
1 / 360 days
ULTILET ALCOHOL SWAB PAD
BRAND
QL
400 / claim
ULTILET ALCOHOL SWABS PAD
BRAND
QL
400 / claim
VERSIVA XC (PAD 3"X3", PAD 4"X4")
BRAND
VISTEC X-RAY DETECTABLE SPONGE PAD 4"X4"
BRAND
PAGE 22
PRODUCT DESCRIPTION
BRAND/GEN
WEBCOL ALCOHOL PREP LARGE PAD 70 %
BRAND
QL
400 / claim
WEBCOL ALCOHOL PREP MEDIUM PAD 70 %
BRAND
QL
400 / claim
*artificial tear ophth ointment***
generic
QL
4 / claim
*white petrolatum-mineral oil ophth ointment***
generic
MPL
1 / claim
ARTIFICIAL TEARS SOLUTION 0.4 %
BRAND
HYPOTEARS SOLUTION 1-1 %
BRAND
MPL
1 / claim
hypromellose ophth soln 0.4%
generic
QL
ketotifen fumarate ophth soln 0.025% (base equiv)
generic
MPL
1 / claim
naphazoline w/ pheniramine ophth soln 0.025-0.3%
generic
MFL
1 / 30 days
naphazoline w/ pheniramine ophth soln 0.027-0.315%
generic
QL
15 / 30 days
polyvinyl alcohol ophth soln 1.4%
generic
QL
15 / claim
tetrahydrozoline hcl ophth soln 0.05%
generic
MPL
generic
QL
FLONASE ALLERGY RELIEF SUSPENSION 50
MCG/ACT
BRAND
C
fluticasone propionate nasal susp 50 mcg/act
generic
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS, OTHER
15 / claim
1 / 30 days
OTIC AGENTS
carbamide peroxide 6.5% otic soln
15 / 30 days
RESPIRATORY TRACT/PULMONARY AGENTS
ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS
QL
C
triamcinolone acetonide nasal aerosol suspension 55
mcg/act
PAGE 23
generic
OTC Covered Only
16 / claim
OTC Covered Only
QL
17 / claim
AL
At least 2 yrs old
C
From 4 and older =
Step Therapy
OTC Covered Only
PRODUCT DESCRIPTION
BRAND/GEN
ANTIHISTAMINES
ALER-DRYL TAB 50 MG
BRAND
cetirizine hcl allergy child solution 5 mg/5ml
generic
MDD
4 per day
QL
240 / claim
AL
Up to 12 yrs old
cetirizine hcl chew tab 10 mg
generic
MDD
1 per day
generic
MDD
1 per day
cetirizine hcl tab 10 mg
generic
MDD
1 per day
generic
MDD
1 per day
childrens loratadine syrup 5 mg/5ml
generic
QL
240 / claim
chlorpheniramine maleate syrup 2 mg/5ml
generic
MDD
60 per day
chlorpheniramine maleate tab 4 mg
generic
QL
120 / claim
generic
QL
120 / claim
clemastine fumarate tab 1.34 mg
generic
MDD
2 per day
diphenhydramine hcl cap 25 mg
generic
MDD
4 per day
generic
MDD
4 per day
diphenhydramine hcl elixir 12.5 mg/5ml
generic
QL
240 / claim
diphenhydramine hcl liquid 12.5 mg/5ml
generic
QL
240 / claim
diphenhydramine hcl syrup 12.5 mg/5ml
generic
QL
240 / claim
diphenhydramine hcl tab 25 mg
generic
MDD
fexofenadine hcl tab 180 mg
generic
ST
MDD
1 per day
ST
generic
MDD
loratadine allergy relief tab disp 10 mg
generic
loratadine tab 10 mg
generic
PAGE 24
4 per day
2 per day
PRODUCT DESCRIPTION
BRAND/GEN
RESPIRATORY TRACT AGENTS, OTHER
dextromethorphan-guaifenesin liquid 10-100 mg/5ml
generic
sodium chloride aero soln 0.9%
generic
QL
240 / claim
SLEEP DISORDER AGENTS
SLEEP DISORDERS, OTHER
diphenhydramine hcl (sleep) (cap 50 mg, tab 50 mg)
generic
diphenhydramine hcl (sleep) tab 25 mg
generic
doxylamine succinate (sleep) tab 25 mg
generic
MDD
1 per day
THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES
ELECTROLYTE/MINERAL REPLACEMENT
*oral electrolyte solution***
generic
calcium carbonate susp 1250 mg/5ml (500 mg/5ml
elemental ca)
generic
QL
calcium carbonate-cholecalciferol (tab 600 mg-800, tab
600 mg-400, tab 600 mg-200)
generic
MDD
2 per day
calcium carbonate-cholecalciferol tab 500 mg-200 unit
generic
calcium carbonate-vitamin d (tab 250 mg-125, tab 500 mg125, tab 500 mg-200)
generic
calcium carbonate-vitamin d (tab 600 mg-400, tab 600 mg200)
generic
MDD
2 per day
FERRETTS TAB 325 (106 FE) MG
BRAND
ferrous fumarate tab 324 mg (106 mg elemental fe)
generic
ferrous gluconate (tab 240 mg (27 mg elemental fe), tab
324 mg (38 mg elemental iron), tab 325 mg)
generic
FERROUS GLUCONATE TAB 225 (27 FE) MG
BRAND
ferrous sulfate (soln 75 mg/ml mg/ml, soln 75 mg/0.6ml
mg/0.6ml)
generic
MDD
3.4 per day
PAGE 25
500 / 30 days
PRODUCT DESCRIPTION
BRAND/GEN
ferrous sulfate (tab 28 mg (elemental fe), tab 325 mg (65
mg elemental fe), tab ec 324 mg (65 mg fe equivalent), tab
ec 325 mg (65 mg fe equivalent))
generic
ferrous sulfate dried tab cr 160 mg (50 mg fe equivalent)
generic
ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe)
generic
IRON CHEWS PEDIATRIC CHEW TAB 15 MG
BRAND
oyster shell calcium tab 500 mg
generic
RA OYSTER SHELL CALCIUM/D TAB 500-200 MG-UNIT
BRAND
zinc sulfate cap 220 mg (50 mg elemental zn)
generic
*b-complex w/ c cap**
MDD
16 per day
generic
MDD
1 per day
*multiple vitamin tab**
generic
MDD
1 per day
*multiple vitamins w/ iron tab**
generic
MDD
1 per day
*multiple vitamins w/ minerals tab**
generic
MDD
1 per day
*pediatric multiple vitamin w/ c & fa chew tab**
generic
MDD
1 per day
*pediatric multiple vitamin w/ c soln 35 mg/ml**
generic
QL
50 / claim
*pediatric multiple vitamins w/ iron drops 10 mg/ml**
generic
QL
60 / claim
*pediatric vitamins adc drops 1500 unit-400 unit-35
mg/ml***
generic
QL
50 / claim
GL
Female
AL
Up to 45 yrs old
*prenatal multivitamins & minerals w/iron & fa tab 0.8 mg***
generic
MDD
1 per day
1 per day
*vitamins w/ lipotropics cap**
generic
MDD
ascorbic acid (tab 250 mg, tab 500 mg, tab 1000 mg)
generic
QL
b-complex vitamins (cap**, tab**)
generic
MDD
1 per day
cholecalciferol (cap 1000, cap 2000)
generic
cholecalciferol cap 5000 unit
generic
MDD
2 per day
CLASSIC PRENATAL TAB 28-0.8 MG
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
PAGE 26
100 / 34 days
1 per day
PRODUCT DESCRIPTION
CVS PRENATAL TAB 28-0.8 MG
BRAND/GEN
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
EQL PRENATAL FORMULA TAB 28-0.8 MG
BRAND
folic acid (tab 400 mcg, tab 800 mcg)
generic
folic acid tab 1 mg
generic
GNP PRENATAL TAB 28-0.8 MG
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
1 per day
MDD
1 per day
GL
Female
AL
Up to 45 yrs old
MDD
GNP PRENATAL VITAMINS TAB 28-0.8 MG
BRAND
KEY-E CHEW TAB 400 UNIT
KP PRENATAL MULTIVITAMINS TAB 28-0.8 MG
BRAND
BRAND
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
MDD
1 per day
MDD
2 per day
GL
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
PAGE 27
1 per day
GL
Female
AL
Up to 45 yrs old
MDD
niacin (cap cr 250 mg, cap cr 500 mg, tab 500 mg)
1 per day
GL
MDD
MISSION PRENATAL TAB
1 per day
GL
MDD
KPN PRENATAL TAB 0.1 MG
1 per day
GL
MDD
HM PRENATAL TAB 28-0.8 MG
1 per day
1 per day
generic
PRODUCT DESCRIPTION
NUTRICION PORVIDA TAB 0.25 MG
BRAND/GEN
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
PERRY PRENATAL CAP 13.5-0.4 MG
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
PNV PRENATAL PLUS MULTIVITAMIN TAB 27-1 MG
BRAND
1 per day
1 per day
GL
Female
AL
Up to 45 yrs old
MDD
1 per day
POLYCOSE (LIQUID, POWDER)
BRAND
MPL
1 / 30 days
polysaccharide iron complex cap 150 mg (iron equivalent)
generic
MDD
1 per day
PRENATAL FORMULA TAB 28-0.8 MG
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
PRENATAL TAB 28-0.8 MG
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
prenatal vit w/ ferrous fumarate-folic acid (w/ tab 27-0.8, w/
tab 28-0.8)
generic
PX PRENATAL MULTIVITAMINS TAB 28-0.8 MG
Female
AL
Up to 45 yrs old
QC PRENATAL TAB 28-0.8 MG
BRAND
GL
Female
AL
Up to 45 yrs old
1 per day
generic
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
PAGE 28
1 per day
BRAND
MDD
pyridoxine hcl (tab 25 mg, tab 50 mg, tab 100 mg)
1 per day
GL
MDD
PRORENAL + D TAB
1 per day
1 per day
PRODUCT DESCRIPTION
RA PRENATAL FORMULA TAB 28-0.8 MG
BRAND/GEN
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
RA PRENATAL TAB 28-0.8 MG
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
riboflavin (tab 25 mg, tab 50 mg, tab 100 mg)
SM PRENATAL VITAMINS TAB 28-0.8 MG
generic
BRAND
BRAND
100 / 34 days
GL
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
BRAND
1 per day
GL
Female
AL
Up to 45 yrs old
MDD
THERANATAL CORE NUTRITION TAB 27-1 MG
1 per day
GL
MDD
TH PRENATAL VITAMINS TAB 28-0.8 MG
1 per day
QL
MDD
STUART PRENATAL TAB 28-0.8 MG
1 per day
1 per day
GL
Female
AL
Up to 45 yrs old
MDD
1 per day
thiamine hcl (tab 50 mg, tab 100 mg, tab 250 mg, tab 500
mg)
generic
QL
100 / 34 days
thiamine mononitrate tab 100 mg
generic
QL
100 / 34 days
QL
TRI-VI-SOL/IRON SOLUTION 10 MG/ML
BRAND
50 / claim
AL
Up to 13 yrs old
vitamin e (cap 100, cap 200, cap 400, chw tab 400)
PAGE 29
generic
MDD
2 per day
LIST OF COVERED PRESCRIPTION MEDICATIONS
PRODUCT DESCRIPTION
BRAND/GEN
ANALGESICS
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
butalbital-aspirin-caffeine tab 50-325-40 mg
generic
celecoxib (cap 50 mg, cap 100 mg, cap 200 mg, cap 400
mg)
generic
choline & mag salicylate (liq 500 mg/5ml, tab 1000 mg)
generic
diclofenac potassium tab 50 mg
generic
diclofenac sodium (tab delayed release 25 mg, tab delayed
release 50 mg, tab delayed release 75 mg, tab sr 24hr 100
mg)
generic
diflunisal tab 500 mg
generic
etodolac (cap 200 mg, cap 300 mg, tab 400 mg, tab 500
mg, tab sr 24hr 600 mg, tab sr 24hr 400 mg, tab sr 24hr
500 mg)
generic
flurbiprofen (tab 50 mg, tab 100 mg)
generic
ibuprofen (tab 400 mg, tab 600 mg, tab 800 mg)
generic
indomethacin (cap 25 mg, cap 50 mg, cap cr 75 mg)
generic
ketoprofen (cap 50 mg, cap 75 mg, cap sr 24hr 200 mg)
generic
ketorolac tromethamine tab 10 mg
generic
4 per day
PA
MDD
meloxicam (tab 7.5 mg, tab 15 mg)
generic
nabumetone (tab 500 mg, tab 750 mg)
generic
naproxen (susp 125 mg/5ml, tab 250 mg, tab 375 mg, tab
500 mg)
generic
naproxen (tab ec 375 mg, tab ec 500 mg)
generic
naproxen sodium (tab 275 mg, tab 550 mg)
generic
oxaprozin tab 600 mg
generic
piroxicam (cap 10 mg, cap 20 mg)
generic
PAGE 30
MDD
2 per day
QL
20 / 30 days
AL
At least 17 yrs old
MDD
2 per day
PRODUCT DESCRIPTION
BRAND/GEN
salsalate (tab 500 mg, tab 750 mg)
generic
sulindac (tab 150 mg, tab 200 mg)
generic
tolmetin sodium (cap 400 mg, tab 200 mg, tab 600 mg)
generic
OPIOID ANALGESICS, LONG-ACTING
EMBEDA (CAP ER 20-0.8 MG, CAP ER 30-1.2 MG, CAP
ER 50-2 MG, CAP ER 60-2.4 MG, CAP ER 80-3.2 MG,
CAP ER 100-4 MG)
BRAND
fentanyl (patch 72hr 25 mcg/hr, patch 72hr 12 mcg/hr,
patch 72hr 100 mcg/hr, patch 72hr 75 mcg/hr, patch 72hr
50 mcg/hr)
generic
HYSINGLA ER (ER TB24 DETER 60 MG, ER TB24
DETER 30 MG, ER TB24 DETER 80 MG, ER TB24
DETER 100 MG, ER TB24 DETER 20 MG, ER TB24
DETER 120 MG, ER TB24 DETER 40 MG)
BRAND
methadone hcl tab 10 mg
MDD
0.33 per day
generic
MDD
10 per day
methadone hcl tab 5 mg
generic
MDD
4 per day
morphine sulfate (tab 15 mg, tab 30 mg, tab 60 mg, tab
100 mg, tab 200 mg)
generic
MDD
3 per day
oxycodone hcl (tab er deter 10 mg, tab er deter 20 mg, tab
er deter 40 mg, tab er deter 80 mg)
generic
OXYCONTIN (TB12 DETER 60 MG, TB12 DETER 30 MG,
TB12 DETER 15 MG)
BRAND
PA
MDD
2 per day
OPIOID ANALGESICS, SHORT-ACTING
acetaminophen w/ codeine (w/ tab 300-60 mg, w/ tab 30030 mg, w/ tab 300-15 mg)
generic
MDD
6 per day
acetaminophen w/ codeine soln 120-12 mg/5ml
generic
MDD
30 per day
butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg
generic
MDD
4 per day
butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg
generic
MDD
4 per day
codeine sulfate (tab 15 mg, tab 30 mg, tab 60 mg)
generic
MDD
2 per day
hydrocodone-acetaminophen (tab 5-500 mg, tab 7.5-325
mg)
generic
MDD
8 per day
PAGE 31
PRODUCT DESCRIPTION
BRAND/GEN
hydrocodone-acetaminophen (tab 7.5-650 mg, tab 7.5-500
mg, tab 10-500 mg, tab 10-660 mg, tab 10-650 mg, tab 10325 mg)
generic
MDD
6 per day
hydrocodone-acetaminophen soln 7.5-325 mg/15ml
generic
MDD
180 per day
hydrocodone-acetaminophen soln 7.5-500 mg/15ml
generic
MDD
120 per day
hydrocodone-acetaminophen tab 5-325 mg
generic
MDD
12 per day
hydrocodone-acetaminophen tab 7.5-750 mg
generic
MDD
5 per day
hydromorphone hcl (tab 2 mg, tab 4 mg, tab 8 mg)
generic
MDD
8 per day
hydromorphone hcl suppos 3 mg
generic
QL
12 / claim
meperidine hcl (tab 50 mg, tab 100 mg)
generic
MDD
6 per day
meperidine hcl oral soln 50 mg/5ml
generic
QL
500 / claim
morphine sulfate (soln 10 mg/5ml, soln 20 mg/5ml)
generic
QL
500 / 30 days
morphine sulfate (suppos 5 mg, suppos 10 mg, suppos 20
mg, suppos 30 mg)
generic
QL
24 / claim
morphine sulfate (tab 15 mg, tab 30 mg)
generic
MDD
6 per day
morphine sulfate oral soln 100 mg/5ml (20 mg/ml)
generic
QL
oxycodone hcl (cap 5 mg, conc 100 mg/5ml (20 mg/ml),
tab 5 mg, tab 15 mg, tab 30 mg)
generic
MDD
oxycodone hcl (soln 5 mg/5ml, tab 20 mg)
generic
oxycodone hcl tab 10 mg
generic
PA
oxycodone w/ acetaminophen (w/ cap 5-500 mg, w/ tab 5325 mg, w/ tab 7.5-325 mg, w/ tab 7.5-500 mg, w/ tab 10650 mg, w/ tab 10-325 mg)
generic
MDD
6 per day
oxycodone-aspirin tab 4.8355-325 mg
generic
MDD
6 per day
tramadol hcl tab 50 mg
generic
MDD
8 per day
tramadol-acetaminophen tab 37.5-325 mg
generic
MDD
4 per day
PAGE 32
240 / claim
6 per day
PRODUCT DESCRIPTION
BRAND/GEN
ANESTHETICS
LOCAL ANESTHETICS
lidocaine hcl viscous soln 2%
generic
QL
lidocaine-prilocaine cream 2.5-2.5%
generic
MPL
100 / claim
1 / claim
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
ALCOHOL DETERRENTS/ANTI-CRAVING
disulfiram tab 250 mg
generic
naltrexone hcl tab 50 mg
generic
VIVITROL RECON SUSP 380 MG
BRAND
OPIOID DEPENDENCE TREATMENTS
buprenorphine hcl (sl tab 2 mg, sl tab 8 mg)
generic
SUBOXONE (FILM 2-0.5 MG, FILM 4-1 MG, FILM 8-2 MG)
BRAND
QL
90 / month
SUBOXONE FILM 12-3 MG
BRAND
QL
60 / month
naloxone hcl (inj 0.4 mg/ml, inj 1 mg/ml)
generic
QL
2 / 30 days
NARCAN LIQUID 4 MG/0.1ML
BRAND
QL
2 / 30 days
AL
At least 18 yrs old
OPIOID REVERSAL AGENTS
SMOKING CESSATION AGENTS
bupropion hcl (smoking deterrent) tab sr 12hr 150 mg
generic
MDD
2 per day
CHANTIX (TAB 0.5 MG, TAB 1 MG)
BRAND
MDD
2 per day
CHANTIX CONTINUING MONTH PAK TAB 1 MG
BRAND
MDD
2 per day
CHANTIX STARTING MONTH PAK TAB 0.5 MG X 11 & 1
MG X 42
BRAND
MPL
2 / years
NICOTROL INHALER 10 MG
BRAND
QL
504 / 30 days
NICOTROL NS SOLUTION 10 MG/ML
BRAND
QL
120 / 30 days
PAGE 33
PRODUCT DESCRIPTION
BRAND/GEN
ANTIBACTERIALS
AMINOGLYCOSIDES
gentamicin sulfate (topical) (cream, oint)
generic
MPL
1 / claim
gentamicin sulfate ophth oint 0.3%
generic
QL
4 / claim
gentamicin sulfate ophth soln 0.3%
generic
MPL
1 / claim
neomycin sulfate tab 500 mg
generic
TOBRADEX OINTMENT 0.3-0.1 %
BRAND
QL
4 / claim
tobramycin ophth soln 0.3%
generic
QL
5 / claim
tobramycin sulfate (for inj 1.2 gm, inj 1.2 gm/30ml (40
mg/ml) (base equiv), inj 2 gm/50ml (40 mg/ml) (base
equiv), inj 10 mg/ml (base equivalent), inj 80 mg/2ml (40
mg/ml) (base equiv), inj 80 mg/2ml (40 mg/ml))
generic
PA
TOBRAMYCIN SULFATE IN SALINE SOLUTION 1.2-0.9
MG/ML-%
BRAND
PA
TOBREX OINTMENT 0.3 %
BRAND
QL
4 / claim
ANTIBACTERIALS, OTHER
*methenamine-hyos-meth blue-sod phos-phen sal tab 81.6
mg***
generic
BACTROBAN NASAL OINTMENT 2 %
BRAND
clindamycin hcl (cap 150 mg, cap 300 mg)
generic
clindamycin palmitate hcl for soln 75 mg/5ml (base equiv)
generic
MPL
1 / claim
clindamycin phosphate (topical) (gel, lotion)
generic
MPL
1 / claim
clindamycin phosphate soln 1%
generic
clindamycin phosphate vaginal cream 2%
generic
FIRST-VANCOMYCIN 25 SOLUTION 25 MG/ML
BRAND
FIRST-VANCOMYCIN 50 SOLUTION 50 MG/ML
BRAND
methenamine mandelate (tab 0.5 gm, tab 1 gm)
generic
metronidazole (tab 250 mg, tab 500 mg)
generic
PAGE 34
QL
40 / claim
PRODUCT DESCRIPTION
BRAND/GEN
metronidazole cream 0.75 %
generic
QL
45 / claim
metronidazole gel 0.75 %
generic
QL
45 / claim
metronidazole lotion 0.75%
generic
metronidazole vaginal gel 0.75%
generic
QL
70 / claim
mupirocin calcium cream 2%
generic
MPL
1 / claim
mupirocin oint 2%
generic
MPL
1 / claim
nitrofurantoin macrocrystal (cap 50 mg, cap 100 mg)
generic
nitrofurantoin monohydrate macrocrystalline cap 100 mg
generic
nitrofurantoin susp 25 mg/5ml
generic
AL
Up to 6 yrs old
MDD
40 per day
SIVEXTRO TAB 200 MG
BRAND
trimethoprim tab 100 mg
generic
vancomycin hcl cap 125 mg
generic
MDD
4 per day
vancomycin hcl cap 250 mg
generic
MDD
8 per day
vancomycin hcl for inj 1000 mg
generic
QL
14 / claim
vancomycin hcl for inj 500 mg
generic
QL
14 / 30 days
BETA-LACTAM, CEPHALOSPORINS
cefaclor (cap 250 mg, cap 500 mg, for susp 125 mg/5ml,
for susp 250 mg/5ml, for susp 375 mg/5ml)
generic
cefadroxil (cap 500 mg, for susp 250 mg/5ml, for susp 500
mg/5ml, tab 1 gm)
generic
cefdinir (susp 125 mg/5ml, susp 250 mg/5ml)
generic
MPL
cefdinir cap 300 mg
generic
QL
20 / claim
cefprozil (tab 250 mg, tab 500 mg)
generic
QL
20 / claim
cefprozil for susp 125 mg/5ml
AL
generic
Up to 12 yrs old
cefprozil for susp 250 mg/5ml
PAGE 35
generic
1 / claim
MPL
1 / claim
MPL
1 / claim
PRODUCT DESCRIPTION
BRAND/GEN
CEFTIN RECON SUSP 250 MG/5ML
BRAND
ceftriaxone sodium (inj 1 gm, inj 250 mg, inj 500 mg)
QL
100 / claim
AL
Up to 12 yrs old
QL
3 / claim
generic
MFL
cefuroxime axetil (tab 250 mg, tab 500 mg)
generic
cefuroxime axetil for susp 125 mg/5ml
generic
cephalexin (cap 250 mg, cap 500 mg, for susp 125
mg/5ml, for susp 250 mg/5ml)
1 / 30 days
QL
20 / claim
QL
100 / claim
AL
Up to 12 yrs old
Pkg Size 100: Package
Limit=2/claim; Pkg Size
50: Package
75: Package
Limit=2/claim
generic
BETA-LACTAM, PENICILLINS
amoxicillin & k clavulanate for susp 400-57 mg/5ml
generic
C
amoxicillin & k clavulanate for susp 600-42.9 mg/5ml
generic
MPL
amoxicillin & k clavulanate tab 250-125 mg
generic
QL
30 / claim
amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg
generic
QL
40 / 30 days
amoxicillin & pot clavulanate (chew tab 200-28.5 mg, chew
tab 400-57 mg, tab 500-125 mg, tab 875-125 mg)
generic
QL
20 / claim
amoxicillin & pot clavulanate (susp 200-28.5 mg/5ml, susp
250-62.5 mg/5ml)
generic
MPL
amoxicillin (cap 250 mg, cap 500 mg, chew tab 125 mg,
chew tab 250 mg, for susp 125 mg/5ml, for susp 200
mg/5ml, for susp 250 mg/5ml, for susp 400 mg/5ml, tab
875 mg)
generic
ampicillin (cap 250 mg, cap 500 mg)
generic
dicloxacillin sodium (cap 250 mg, cap 500 mg)
generic
penicillin v potassium (for soln 125 mg/5ml, for soln 250
mg/5ml, tab 250 mg, tab 500 mg)
generic
PAGE 36
2 / claim
1 / claim
PRODUCT DESCRIPTION
BRAND/GEN
MACROLIDES
azithromycin for susp 100 mg/5ml
generic
QL
azithromycin for susp 200 mg/5ml
generic
MPL
1 / claim
azithromycin tab 250 mg
generic
QL
6 / claim
generic
MDD
4 per day
generic
QL
8 / 28 days
clarithromycin (tab 250 mg, tab 500 mg)
generic
QL
28 / claim
clarithromycin for susp 125 mg/5ml
generic
MPL
clarithromycin for susp 250 mg/5ml
generic
C
clarithromycin tab sr 24hr 500 mg
generic
QL
ERY-TAB (TAB DR 250 MG, TAB DR 333 MG, TAB DR
500 MG)
BRAND
ERYPED 400 RECON SUSP 400 MG/5ML
BRAND
ERYTHROCIN STEARATE TAB 250 MG
BRAND
erythromycin ethylsuccinate for susp 200 mg/5ml
generic
erythromycin gel 2%
generic
MPL
1 / claim
erythromycin ophth oint 5 mg/gm
generic
QL
4 / claim
erythromycin soln 2%
generic
erythromycin w/ delayed release particles cap 250 mg
generic
erythromycin-sulfisoxazole for susp 200-600 mg/5ml
generic
PCE (TAB DR 333 MG, TAB DR 500 MG)
BRAND
QL
4 / claim
MPL
1 / claim
15 / claim
1 / claim
50: Package
Limit=1/claim
14 / claim
QUINOLONES
CILOXAN OINTMENT 0.3 %
BRAND
ciprofloxacin hcl (tab 250 mg, tab 500 mg, tab 750 mg)
generic
ciprofloxacin hcl ophth soln 0.3%
generic
PAGE 37
PRODUCT DESCRIPTION
BRAND/GEN
ciprofloxacin hcl tab 100 mg (base equiv)
generic
levofloxacin (tab 250 mg, tab 500 mg, tab 750 mg)
generic
QL
6 / claim
QL
14 / claim
MDD
1 per day
56 / claim
ofloxacin (tab 200 mg, tab 300 mg, tab 400 mg)
generic
QL
ofloxacin ophth soln 0.3%
generic
MPL
1 / claim
ofloxacin otic soln 0.3%
generic
MPL
1 / claim
VIGAMOX SOLUTION 0.5 %
BRAND
QL
3 / claim
silver sulfadiazine cream 1%
generic
MPL
1 / claim
sulfacetamide sodium ophth soln 10%
generic
QL
15 / claim
sulfamethoxazole-trimethoprim (susp 200-40 mg/5ml, tab
400-80 mg, tab 800-160 mg)
generic
SULFONAMIDES
TETRACYCLINES
doxycycline hyclate (cap 50 mg, cap 100 mg, tab 100 mg)
generic
minocycline hcl (cap 50 mg, cap 75 mg, cap 100 mg)
generic
ANTICONVULSANTS
ANTICONVULSANTS, OTHER
levetiracetam (tab 250 mg, tab 500 mg, tab 750 mg)
generic
MDD
4 per day
levetiracetam oral soln 100 mg/ml
generic
MDD
30 per day
CALCIUM CHANNEL MODIFYING AGENTS
ethosuximide (cap 250 mg, soln 250 mg/5ml)
generic
zonisamide (cap 25 mg, cap 50 mg, cap 100 mg)
generic
GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS
diazepam (anticonvulsant) (gel 2.5 mg, gel 10 mg, gel 20
mg)
PAGE 38
generic
QL
1 / claim
PRODUCT DESCRIPTION
BRAND/GEN
divalproex sodium (cap delayed release sprinkle 125 mg,
tab delayed release 125 mg, tab delayed release 250 mg,
tab delayed release 500 mg, tab sr 24 hr 500 mg, tab sr 24
hr 250 mg)
generic
gabapentin (cap 100 mg, cap 300 mg, cap 400 mg, tab 600
mg, tab 800 mg)
generic
gabapentin oral soln 250 mg/5ml
generic
GABITRIL (TAB 12 MG, TAB 16 MG)
BRAND
phenobarbital (elixir 20 mg/5ml, tab 15 mg, tab 16.2 mg,
tab 30 mg, tab 32.4 mg, tab 60 mg, tab 64.8 mg, tab 97.2
mg, tab 100 mg)
generic
primidone (tab 50 mg, tab 250 mg)
generic
tiagabine hcl (tab 2 mg, tab 4 mg)
generic
valproate sodium syrup 250 mg/5ml (base equiv)
generic
valproic acid cap 250 mg
generic
MDD
4 per day
GLUTAMATE REDUCING AGENTS
felbamate (susp 600 mg/5ml, tab 400 mg, tab 600 mg)
generic
lamotrigine (tab 25 mg, tab 100 mg, tab 150 mg, tab 200
mg, tab chewable dispersible 5 mg, tab chewable
dispersible 25 mg)
generic
topiramate (tab 25 mg, tab 50 mg, tab 100 mg, tab 200 mg)
generic
MDD
3 per day
topiramate sprinkle cap 15 mg
generic
MDD
6 per day
topiramate sprinkle cap 25 mg
generic
MDD
8 per day
SODIUM CHANNEL AGENTS
carbamazepine (chew tab 100 mg, susp 100 mg/5ml, tab
200 mg, tab sr 12hr 100 mg, tab sr 12hr 200 mg, tab sr
12hr 400 mg)
generic
DILANTIN CAP 30 MG
BRAND
oxcarbazepine (susp 300 mg/5ml (60 mg/ml), tab 150 mg,
tab 300 mg, tab 600 mg)
generic
phenytoin (chew tab 50 mg, susp 125 mg/5ml)
generic
phenytoin sodium extended cap 100 mg
generic
PAGE 39
PRODUCT DESCRIPTION
BRAND/GEN
ANTIDEMENTIA AGENTS
ANTIDEMENTIA AGENTS, OTHER
ergoloid mesylates tab 1 mg
generic
CHOLINESTERASE INHIBITORS
donepezil hydrochloride (tab 5 mg, tab 10 mg)
generic
EXELON SOLUTION 2 MG/ML
BRAND
MDD
1 per day
PA
MDD
6 per day
galantamine hydrobromide (cap 24hr 8 mg, cap 24hr 24
mg, cap 24hr 16 mg)
generic
MDD
1 per day
galantamine hydrobromide (tab 4 mg, tab 8 mg, tab 12 mg)
generic
MDD
2 per day
galantamine hydrobromide oral soln 4 mg/ml
generic
MDD
6 per day
rivastigmine (patch 24hr 4.6 mg/24hr, patch 24hr 9.5
mg/24hr)
generic
rivastigmine tartrate (cap 1.5 mg, cap 3 mg, cap 4.5 mg,
cap 6 mg)
generic
PA
MDD
1 per day
PA
MDD
2 per day
N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST
memantine hcl (tab 5 mg, tab 10 mg)
PA
generic
MDD
memantine hcl oral solution 2 mg/ml
generic
memantine hcl tab 5 mg (28) & 10 mg (21) titration pak
generic
2 per day
PA
MPL
1 / 28 days
ANTIDEPRESSANTS
ANTIDEPRESSANTS, OTHER
bupropion hcl (tab 24hr 150 mg, tab 24hr 300 mg)
generic
MDD
1 per day
bupropion hcl (tab 75 mg, tab 100 mg)
generic
MDD
3 per day
bupropion hcl er (sr) tab er 12h 100 mg
generic
MDD
2 per day
PAGE 40
PRODUCT DESCRIPTION
BRAND/GEN
generic
MDD
2 per day
bupropion hcl tab sr 12hr 200 mg
generic
MDD
2 per day
mirtazapine (orally disintegrating tab 15 mg, orally
disintegrating tab 30 mg, orally disintegrating tab 45 mg,
tab 7.5 mg, tab 15 mg, tab 30 mg, tab 45 mg)
generic
MDD
1 per day
perphenazine-amitriptyline (tab 2-10 mg, tab 2-25 mg, tab
4-10 mg, tab 4-25 mg, tab 4-50 mg)
generic
MDD
4 per day
MONOAMINE OXIDASE INHIBITORS
phenelzine sulfate tab 15 mg
generic
tranylcypromine sulfate tab 10 mg
generic
SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITORS/SEROTONIN AND NOREPINEPHRINE
REUPTAKE INHIBITOR
citalopram hydrobromide (tab 10 mg, tab 20 mg)
generic
MDD
citalopram hydrobromide oral soln 10 mg/5ml
generic
QL
citalopram hydrobromide tab 40 mg (base equiv)
generic
MDD
1 per day
escitalopram oxalate (tab 5 mg, tab 10 mg, tab 20 mg)
generic
MDD
1 per day
fluoxetine hcl (cap 10 mg, cap 20 mg)
generic
MDD
4 per day
fluoxetine hcl solution 20 mg/5ml
generic
fluoxetine hcl tab 10 mg
1.5 per day
240 / 30 days
QL
120 / 30 days
AL
Up to 7 yrs old
AL
At least 13 yrs old
generic
MDD
1 per day
fluvoxamine maleate (tab 25 mg, tab 50 mg)
generic
MDD
2 per day
fluvoxamine maleate tab 100 mg
generic
MDD
3 per day
maprotiline hcl (tab 25 mg, tab 50 mg, tab 75 mg)
generic
nefazodone hcl (tab 50 mg, tab 100 mg, tab 150 mg, tab
200 mg, tab 250 mg)
generic
paroxetine hcl (tab 10 mg, tab 20 mg, tab 30 mg, tab 40
mg)
generic
MDD
2 per day
PAGE 41
PRODUCT DESCRIPTION
BRAND/GEN
paroxetine hcl oral susp 10 mg/5ml (base equiv)
generic
MDD
40 per day
sertraline hcl (tab 25 mg, tab 50 mg)
generic
MDD
1.5 per day
sertraline hcl oral conc 20 mg/ml
generic
MDD
10 per day
sertraline hcl tab 100 mg
generic
MDD
2 per day
trazodone hcl (tab 50 mg, tab 100 mg, tab 150 mg)
generic
trazodone hcl tab 300 mg
generic
MDD
2 per day
venlafaxine hcl (cap 24hr 150 mg, cap 24hr 37.5 mg, cap
24hr 75 mg, tab 24hr 150 mg, tab 24hr 75 mg, tab 24hr
37.5 mg)
generic
MDD
1 per day
venlafaxine hcl (tab 25 mg, tab 37.5 mg, tab 50 mg, tab 75
mg, tab 100 mg)
generic
VENLAFAXINE HCL ER TAB ER 24H 225 MG
BRAND
MDD
1 per day
VIIBRYD (TAB 10 MG, TAB 20 MG, TAB 40 MG)
BRAND
PA
MDD
QL
VIIBRYD KIT 10 & 20 & 40 MG
BRAND
1 per day
30 / 365 days
PA
TRICYCLICS
amitriptyline hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab 75
mg, tab 100 mg, tab 150 mg)
generic
amoxapine (tab 25 mg, tab 50 mg, tab 100 mg, tab 150
mg)
generic
clomipramine hcl cap 75 mg
generic
desipramine hcl (tab 10 mg, tab 50 mg, tab 75 mg, tab 100
mg, tab 150 mg)
generic
desipramine hcl tab 25 mg
generic
doxepin hcl (cap 10 mg, cap 25 mg, cap 50 mg, cap 75
mg, cap 100 mg, cap 150 mg, conc 10 mg/ml)
generic
imipramine hcl (tab 10 mg, tab 25 mg, tab 50 mg)
generic
nortriptyline hcl (cap 10 mg, cap 25 mg, cap 50 mg, cap 75
mg)
generic
PAGE 42
MDD
2 per day
PRODUCT DESCRIPTION
BRAND/GEN
nortriptyline hcl soln 10 mg/5ml
generic
MDD
20 per day
MDD
4 per day
ANTIEMETICS
ANTIEMETICS, OTHER
metoclopramide hcl (soln 5 mg/5ml (10 mg/10ml), tab 5
mg, tab 10 mg)
generic
perphenazine (tab 2 mg, tab 4 mg, tab 8 mg, tab 16 mg)
generic
prochlorperazine maleate (tab 5 mg, tab 10 mg)
generic
prochlorperazine suppos 25 mg
generic
EMETOGENIC THERAPY ADJUNCTS
ondansetron hcl (tab 4 mg, tab 8 mg)
generic
MDD
2 per day
ondansetron hcl oral soln 4 mg/5ml
generic
QL
50 / claim
ondansetron orally disintegrating tab 4 mg
generic
MDD
2 per day
generic
MDD
2 per day
*nystatin oral powder*
generic
MPL
1 / claim
econazole nitrate cream 1%
generic
MPL
1 / claim
fluconazole (susp 10 mg/ml, susp 40 mg/ml)
generic
QL
70 / claim
fluconazole tab 100 mg
generic
MDD
1 per day
generic
QL
2 / claim
generic
MDD
2 per day
generic
QL
7 / claim
griseofulvin microsize (susp 125 mg/5ml, tab 500 mg)
generic
griseofulvin ultramicrosize (tab 125 mg, tab 250 mg)
generic
GYNAZOLE-1 CREAM 2 %
BRAND
itraconazole cap 100 mg
generic
ANTIFUNGALS
PA
MDD
PAGE 43
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
ketoconazole cream 2%
generic
ketoconazole shampoo 2%
generic
QL
ketoconazole tab 200 mg
generic
MDD
2 per day
MICONAZOLE 3 SUPPOS 200 MG
BRAND
QL
3 / claim
nystatin (topical) (*nystatin topical powder**, nystatin
cream 100000 unit/gm, nystatin oint 100000 unit/gm)
generic
MPL
1 / claim
nystatin susp 100000 unit/ml
generic
QL
nystatin tab 500000 unit
generic
MDD
6 per day
nystatin-triamcinolone (cream unit/gm-%, oint unit/gm-%)
generic
MPL
1 / claim
terbinafine hcl tab 250 mg
generic
QL
120 / claim
120 / claim
90 / 120 days
MDD
1 per day
terconazole vaginal cream 0.4%
generic
QL
45 / claim
terconazole vaginal cream 0.8%
generic
QL
20 / claim
terconazole vaginal suppos 80 mg
generic
QL
3 / claim
QL
6 / claim(s)
MFL
1 / 30 days
ANTIGOUT AGENTS
allopurinol (tab 100 mg, tab 300 mg)
generic
colchicine tab 0.6 mg
generic
colchicine w/ probenecid tab 0.5-500 mg
generic
probenecid tab 500 mg
generic
ANTIMIGRAINE AGENTS
ERGOT ALKALOIDS
CAFERGOT TAB 1-100 MG
BRAND
AL
At least 18 yrs old
dihydroergotamine mesylate (inj 1 mg/ml, nasal spray 4
mg/ml)
generic
AL
At least 18 yrs old
PAGE 44
PRODUCT DESCRIPTION
BRAND/GEN
SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS
almotriptan malate tab 6.25 mg
QL
6 / 30 days
AL
At least 12 yrs old
QL
6 / 30 days
AL
At least 18 yrs old
QL
6 / 30 days
AL
At least 12 yrs old
QL
2 / 30 days
AL
At least 12 yrs old
QL
9 / 30 days
AL
At least 12 yrs old
QL
6 / 30 days
AL
At least 18 yrs old
QL
6 / 30 days
AL
At least 18 yrs old
generic
naratriptan hcl (tab 1 mg, tab 2.5 mg)
generic
RELPAX (TAB 20 MG, TAB 40 MG)
BRAND
rizatriptan benzoate (tab 5 mg, tab 10 mg)
generic
sumatriptan nasal spray (5 mg/act, 20 mg/act)
generic
sumatriptan succinate (inj 6 mg/0.5ml, solution autoinjector 6 mg/0.5ml, solution prefilled syringe 6 mg/0.5ml)
generic
sumatriptan succinate (tab 25 mg, tab 50 mg, tab 100 mg)
generic
sumatriptan succinate solution cartridge 4 mg/0.5ml
generic
zolmitriptan (orally disintegrating tab 2.5 mg, orally
disintegrating tab 5 mg, tab 2.5 mg, tab 5 mg)
generic
ZOMIG SOLUTION 5 MG
BRAND
ANTIMYASTHENIC AGENTS
PARASYMPATHOMIMETICS
pyridostigmine bromide (tab 60 mg, tab cr 180 mg)
generic
ANTIMYCOBACTERIALS
ANTIMYCOBACTERIALS, OTHER
dapsone (tab 25 mg, tab 100 mg)
generic
ANTITUBERCULARS
ethambutol hcl (tab 100 mg, tab 400 mg)
PAGE 45
generic
PRODUCT DESCRIPTION
BRAND/GEN
isoniazid (tab 100 mg, tab 300 mg)
generic
ISONIAZID SYRUP 50 MG/5ML
BRAND
pyrazinamide tab 500 mg
generic
rifampin (cap 150 mg, cap 300 mg)
generic
TRECATOR TAB 250 MG
BRAND
ANTINEOPLASTICS
ALKYLATING AGENTS
ALKERAN TAB 2 MG
BRAND
cyclophosphamide (tab 25 mg, tab 50 mg)
generic
LEUKERAN TAB 2 MG
BRAND
MYLERAN TAB 2 MG
BRAND
ANTIANDROGENS
bicalutamide tab 50 mg
generic
flutamide cap 125 mg
generic
MDD
1 per day
ANTIESTROGENS/MODIFIERS
FARESTON TAB 60 MG
BRAND
tamoxifen citrate (tab 10 mg, tab 20 mg)
generic
PA
ANTIMETABOLITES
DROXIA (CAP 200 MG, CAP 300 MG, CAP 400 MG)
BRAND
hydroxyurea cap 500 mg
generic
mercaptopurine tab 50 mg
generic
PURIXAN SUSPENSION 2000 MG/100ML
BRAND
AL
HEMANGEOL SOLUTION 4.28 MG/ML
BRAND
PA
leucovorin calcium (tab 5 mg, tab 10 mg, tab 15 mg, tab 25
mg)
generic
Up to 8 yrs old
ANTINEOPLASTICS, OTHER
PAGE 46
PRODUCT DESCRIPTION
BRAND/GEN
AROMATASE INHIBITORS, 3RD GENERATION
anastrozole tab 1 mg
generic
exemestane tab 25 mg
generic
ST
letrozole tab 2.5 mg
generic
ST
COTELLIC TAB 20 MG
BRAND
PA
NINLARO (CAP 2.3 MG, CAP 3 MG, CAP 4 MG)
BRAND
PA
chloroquine phosphate tab 250 mg
generic
QL
60 / 30 days
chloroquine phosphate tab 500 mg
generic
QL
8 / 56 days
COARTEM TAB 20-120 MG
BRAND
QL
24 / claim
hydroxychloroquine sulfate tab 200 mg
generic
mefloquine hcl tab 250 mg
generic
60 / claim
MOLECULAR TARGET INHIBITORS
ANTIPARASITICS
ANTIPROTOZOALS
PEDICULICIDES/SCABICIDES
EURAX CREAM 10 %
BRAND
QL
EURAX LOTION 10 %
BRAND
MPL
malathion lotion 0.5%
generic
QL
permethrin cream 5%
generic
MPL
SPINOSAD SUSPENSION 0.9 %
BRAND
1 / claim
59 / claim
1 / claim
QL
120 / claim
AL
At least 4 yrs old
ANTIPARKINSON AGENTS
ANTICHOLINERGICS
benztropine mesylate (tab 0.5 mg, tab 1 mg, tab 2 mg)
PAGE 47
generic
PRODUCT DESCRIPTION
BRAND/GEN
trihexyphenidyl hcl (tab 2 mg, tab 5 mg)
generic
trihexyphenidyl hcl elixir 0.4 mg/ml
generic
QL
500 / 31 days
ANTIPARKINSON AGENTS, OTHER
amantadine hcl (cap 100 mg, syrup 50 mg/5ml)
generic
DOPAMINE AGONISTS
bromocriptine mesylate (cap 5 mg, tab 2.5 mg)
generic
pramipexole dihydrochloride (tab 0.125 mg, tab 0.25 mg,
tab 0.5 mg, tab 0.75 mg, tab 1 mg, tab 1.5 mg)
generic
ropinirole hydrochloride (tab 0.25 mg, tab 3 mg, tab 4 mg)
generic
MDD
6 per day
ropinirole hydrochloride (tab 0.5 mg, tab 1 mg, tab 2 mg,
tab 5 mg)
generic
MDD
3 per day
DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS
carbidopa tab 25 mg
generic
carbidopa-levodopa (tab 10-100 mg, tab 25-100 mg, tab
25-250 mg, tab cr 25-100 mg, tab cr 50-200 mg)
generic
MONOAMINE OXIDASE B (MAO-B) INHIBITORS
selegiline hcl (cap 5 mg, tab 5 mg)
generic
ANTIPSYCHOTICS
1ST GENERATION/TYPICAL
chlorpromazine hcl (tab 25 mg, tab 50 mg, tab 100 mg, tab
200 mg)
generic
MDD
3 per day
chlorpromazine hcl tab 10 mg
generic
MDD
10 per day
fluphenazine decanoate inj 25 mg/ml
generic
fluphenazine hcl (tab 1 mg, tab 2.5 mg, tab 5 mg, tab 10
mg)
generic
haloperidol (tab 0.5 mg, tab 1 mg, tab 10 mg)
generic
MDD
3 per day
haloperidol (tab 2 mg, tab 5 mg, tab 20 mg)
generic
haloperidol decanoate (soln 50 mg/ml, soln 100 mg/ml)
generic
PAGE 48
PRODUCT DESCRIPTION
BRAND/GEN
haloperidol lactate oral conc 2 mg/ml
generic
loxapine succinate (cap 5 mg, cap 10 mg, cap 25 mg, cap
50 mg)
generic
MDD
4 per day
thioridazine hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab 100
mg)
generic
MDD
3 per day
thiothixene (cap 1 mg, cap 2 mg, cap 5 mg, cap 10 mg)
generic
MDD
3 per day
trifluoperazine hcl (tab 1 mg, tab 2 mg, tab 5 mg, tab 10
mg)
generic
MDD
3 per day
2ND GENERATION/ATYPICAL
aripiprazole (orally disintegrating tab 10 mg, orally
disintegrating tab 15 mg, tab 2 mg, tab 5 mg, tab 10 mg,
tab 15 mg, tab 20 mg, tab 30 mg)
PA
generic
AL
MDD
QL
aripiprazole oral solution 1 mg/ml
generic
olanzapine (tab 2.5 mg, tab 5 mg, tab 7.5 mg, tab 10 mg,
tab 15 mg, tab 20 mg)
generic
quetiapine fumarate (tab 100 mg, tab 200 mg, tab 300 mg,
tab 400 mg)
generic
quetiapine fumarate (tab 25 mg, tab 50 mg)
generic
risperidone (tab 0.25 mg, tab 0.5 mg, tab 1 mg, tab 2 mg,
tab 3 mg, tab 4 mg)
generic
risperidone odt (tab 3 mg, tab 4 mg)
generic
At least 6 yrs old
AL
At least 13 yrs old
MDD
1 per day
MDD
2 per day
MDD
2 per day
C
From age 18 through
64: Max Fills=1/year
AL
At least 5 yrs old
MDD
AL
AL
generic
AL
generic
MDD
PAGE 49
750 / 30 days
AL
MDD
risperidone orally disintegrating tab 0.5 mg
1 per day
PA
MDD
At least 6 yrs old
2 per day
At least 5 yrs old
2 per day
At least 5 yrs old
1 per day
At least 5 yrs old
2 per day
PRODUCT DESCRIPTION
BRAND/GEN
risperidone orally disintegrating tab 1 mg
generic
AL
MDD
AL
generic
MDD
risperidone soln 1 mg/ml
AL
generic
SEROQUEL XR (TAB ER 24H 200 MG, TAB ER 24H 400
MG, TAB ER 24H 300 MG)
BRAND
ziprasidone hcl (cap 20 mg, cap 40 mg, cap 60 mg, cap 80
mg)
generic
At least 5 yrs old
2 per day
At least 5 yrs old
2 per day
At least 5 yrs old
MDD
4 per day
MDD
1 per day
AL
MDD
At least 18 yrs old
2 per day
TREATMENT-RESISTANT
clozapine (tab 25 mg, tab 50 mg, tab 200 mg)
AL
generic
MDD
clozapine tab 100 mg
AL
generic
At least 18 yrs old
3 per day
At least 18 yrs old
MDD
9 per day
generic
MDD
2 per day
DAKLINZA (TAB 30 MG, TAB 60 MG, TAB 90 MG)
BRAND
PA
EPCLUSA TAB 400-100 MG
BRAND
PA
HARVONI TAB 90-400 MG
BRAND
PA
SOVALDI TAB 400 MG
BRAND
PA
ZEPATIER TAB 50-100 MG
BRAND
ANTIVIRALS
ANTI-CYTOMEGALOVIRUS (CMV) AGENTS
valganciclovir hcl tab 450 mg (base equivalent)
ANTI-HEPATITIS C (HCV) AGENTS
PA
MDD
PAGE 50
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)
GENVOYA TAB 150-150-200-10 MG
BRAND
MDD
1 per day
ISENTRESS (PACKET 100 MG, TAB 400 MG)
BRAND
MDD
2 per day
ISENTRESS CHEW TAB 100 MG
BRAND
MDD
6 per day
ISENTRESS CHEW TAB 25 MG
BRAND
MDD
12 per day
STRIBILD TAB 150-150-200-300 MG
BRAND
ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)
ATRIPLA TAB 600-200-300 MG
BRAND
MDD
1 per day
COMPLERA TAB 200-25-300 MG
BRAND
MDD
1 per day
EDURANT TAB 25 MG
BRAND
MDD
1 per day
INTELENCE (TAB 25 MG, TAB 100 MG)
BRAND
MDD
4 per day
INTELENCE TAB 200 MG
BRAND
MDD
2 per day
nevirapine (tab 24hr 400 mg, tab 24hr 100 mg)
generic
MDD
1 per day
nevirapine susp 50 mg/5ml
generic
MDD
40 per day
nevirapine tab 200 mg
generic
MDD
2 per day
RESCRIPTOR TAB 100 MG
BRAND
MDD
12 per day
RESCRIPTOR TAB 200 MG
BRAND
MDD
6 per day
SUSTIVA (CAP 200 MG, TAB 600 MG)
BRAND
MDD
1 per day
SUSTIVA CAP 50 MG
BRAND
MDD
2 per day
ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)
abacavir sulfate tab 300 mg (base equiv)
generic
MDD
2 per day
abacavir sulfate-lamivudine-zidovudine tab 300-150-300
mg
generic
MDD
2 per day
DESCOVY TAB 200-25 MG
BRAND
MDD
1 per day
didanosine (capsule 125 mg, capsule 200 mg, capsule 250
mg, capsule 400 mg)
generic
MDD
1 per day
PAGE 51
PRODUCT DESCRIPTION
BRAND/GEN
EMTRIVA CAP 200 MG
BRAND
MDD
1 per day
EMTRIVA SOLUTION 10 MG/ML
BRAND
MDD
24 per day
EPZICOM TAB 600-300 MG
BRAND
MDD
1 per day
lamivudine oral soln 10 mg/ml
generic
MDD
30 per day
lamivudine tab 150 mg
generic
MDD
2 per day
lamivudine tab 300 mg
generic
MDD
1 per day
lamivudine-zidovudine tab 150-300 mg
generic
MDD
2 per day
stavudine (cap 15 mg, cap 20 mg, cap 30 mg, cap 40 mg)
generic
MDD
2 per day
stavudine for oral soln 1 mg/ml
generic
MDD
80 per day
TRUVADA TAB 200-300 MG
BRAND
MDD
1 per day
VIDEX (RECON SOLN 2 GM, RECON SOLN 4 GM)
BRAND
MDD
20 per day
VIREAD (TAB 150 MG, TAB 200 MG, TAB 250 MG, TAB
300 MG)
BRAND
MDD
1 per day
VIREAD POWDER 40 MG/GM
BRAND
QL
ZIAGEN SOLUTION 20 MG/ML
BRAND
MDD
30 per day
zidovudine cap 100 mg
generic
MDD
6 per day
zidovudine syrup 10 mg/ml
generic
MDD
60 per day
zidovudine tab 300 mg
generic
MDD
2 per day
SELZENTRY TAB 150 MG
BRAND
MDD
2 per day
SELZENTRY TAB 300 MG
BRAND
MDD
4 per day
TYBOST TAB 150 MG
BRAND
MDD
1 per day
APTIVUS CAP 250 MG
BRAND
MDD
4 per day
APTIVUS SOLUTION 100 MG/ML
BRAND
MDD
10 per day
240 / 30 days
ANTI-HIV AGENTS, OTHER
ANTI-HIV AGENTS, PROTEASE INHIBITORS
PAGE 52
PRODUCT DESCRIPTION
BRAND/GEN
CRIXIVAN CAP 200 MG
BRAND
MDD
9 per day
CRIXIVAN CAP 400 MG
BRAND
MDD
6 per day
EVOTAZ TAB 300-150 MG
BRAND
MDD
1 per day
INVIRASE CAP 200 MG
BRAND
MDD
10 per day
INVIRASE TAB 500 MG
BRAND
MDD
4 per day
KALETRA SOLUTION 400-100 MG/5ML
BRAND
MPL
1 / claim
KALETRA TAB 100-25 MG
BRAND
MDD
4 per day
KALETRA TAB 200-50 MG
BRAND
MDD
6 per day
LEXIVA SUSPENSION 50 MG/ML
BRAND
MDD
56 per day
LEXIVA TAB 700 MG
BRAND
MDD
4 per day
NORVIR (CAP 100 MG, TAB 100 MG)
BRAND
MDD
12 per day
NORVIR SOLUTION 80 MG/ML
BRAND
MDD
15 per day
PREZISTA (TAB 75 MG, TAB 600 MG)
BRAND
MDD
2 per day
PREZISTA SUSPENSION 100 MG/ML
BRAND
MDD
12 per day
PREZISTA TAB 150 MG
BRAND
MDD
3 per day
PREZISTA TAB 800 MG
BRAND
MDD
1 per day
REYATAZ (CAP 150 MG, CAP 200 MG, CAP 300 MG)
BRAND
MDD
2 per day
REYATAZ PACKET 50 MG
BRAND
MDD
6 per day
VIRACEPT TAB 250 MG
BRAND
MDD
9 per day
VIRACEPT TAB 625 MG
BRAND
MDD
4 per day
ANTI-INFLUENZA AGENTS
AL
RELENZA DISKHALER AER POW BA 5 MG/BLISTER
BRAND
MPL
QL
TAMIFLU (CAP 45 MG, CAP 75 MG)
BRAND
C
PAGE 53
At least 5 yrs old
1 / 30 days
10 / 30 days
PA required for ages 364
PRODUCT DESCRIPTION
BRAND/GEN
TAMIFLU CAP 30 MG
BRAND
QL
C
QL
TAMIFLU RECON SUSP 6 MG/ML
BRAND
C
20 / 30 days
120 / 30 days
ANTIHERPETIC AGENTS
acyclovir (cap 200 mg, tab 800 mg)
generic
QL
50 / 30 days
acyclovir oint 5%
generic
QL
30 / 30 days
acyclovir susp 200 mg/5ml
generic
QL
400 / 30 days
acyclovir tab 400 mg
generic
MDD
3 per day
trifluridine ophth soln 1%
generic
QL
8 / claim
valacyclovir hcl tab 1 gm
generic
QL
21 / 21 days
valacyclovir hcl tab 500 mg
generic
QL
60 / 30 days
ZOVIRAX CREAM 5 %
BRAND
MPL
1 / claim
buspirone hcl (tab 5 mg, tab 7.5 mg, tab 10 mg, tab 15 mg,
tab 30 mg)
generic
MDD
3 per day
meprobamate (tab 200 mg, tab 400 mg)
generic
midazolam hcl (inj 2 mg/2ml, inj 5 mg/ml, inj 5 mg/5ml, inj
10 mg/2ml, inj 10 mg/10ml, inj 25 mg/5ml, inj 50 mg/10ml)
generic
ANXIOLYTICS
ANXIOLYTICS, OTHER
BENZODIAZEPINES
alprazolam (tab 0.25 mg, tab 0.5 mg, tab 1 mg, tab 2 mg)
generic
MDD
4 per day
chlordiazepoxide hcl (cap 5 mg, cap 10 mg, cap 25 mg)
generic
MDD
4 per day
clonazepam (tab 0.5 mg, tab 1 mg, tab 2 mg)
generic
MDD
4 per day
clorazepate dipotassium (tab 3.75 mg, tab 7.5 mg, tab 15
mg)
generic
MDD
3 per day
PAGE 54
PRODUCT DESCRIPTION
BRAND/GEN
diazepam (tab 2 mg, tab 5 mg, tab 10 mg)
generic
MDD
diazepam oral soln 1 mg/ml
generic
QL
lorazepam (tab 0.5 mg, tab 2 mg)
generic
MDD
3 per day
lorazepam tab 1 mg
generic
MDD
4 per day
oxazepam (cap 10 mg, cap 15 mg, cap 30 mg)
generic
MDD
4 per day
4 per day
500 / claim
BIPOLAR AGENTS
MOOD STABILIZERS
lithium carbonate (cap 150 mg, cap 300 mg, cap 600 mg,
tab 300 mg, tab cr 300 mg, tab cr 450 mg)
generic
lithium oral solution 8 meq/5ml
generic
BLOOD GLUCOSE REGULATORS
ANTIDIABETIC AGENTS
AVANDAMET (TAB 2-1000 MG, TAB 2-500 MG, TAB 4500 MG, TAB 4-1000 MG)
BRAND
MDD
2 per day
AVANDARYL (TAB 4-4 MG, TAB 4-2 MG, TAB 4-1 MG,
TAB 8-4 MG, TAB 8-2 MG)
BRAND
MDD
1 per day
AVANDIA (TAB 2 MG, TAB 4 MG, TAB 8 MG)
BRAND
MDD
1 per day
BYDUREON (PEN 2 MG, 2 MG)
BRAND
BYETTA 10 MCG PEN SOLN PEN 10 MCG/0.04ML
BRAND
BYETTA 5 MCG PEN SOLN PEN 5 MCG/0.02ML
BRAND
glimepiride (tab 1 mg, tab 2 mg)
generic
MDD
1 per day
glimepiride tab 4 mg
generic
MDD
2 per day
glipizide (tab 5 mg, tab 10 mg, tab sr 24hr 2.5 mg, tab sr
24hr 5 mg, tab sr 24hr 10 mg)
generic
glipizide-metformin hcl (tab 2.5-500 mg, tab 2.5-250 mg,
tab 5-500 mg)
generic
glyburide (tab 1.25 mg, tab 2.5 mg, tab 5 mg)
generic
glyburide micronized (tab 1.5 mg, tab 3 mg, tab 6 mg)
generic
PAGE 55
PRODUCT DESCRIPTION
BRAND/GEN
glyburide-metformin (tab 1.25-250 mg, tab 2.5-500 mg, tab
5-500 mg)
generic
JENTADUETO (TAB 2.5-1000 MG, TAB 2.5-850 MG, TAB
2.5-500 MG)
BRAND
MDD
2 per day
KOMBIGLYZE XR (TAB ER 24H 5-500 MG, TAB ER 24H
5-1000 MG)
BRAND
MDD
1 per day
KOMBIGLYZE XR TAB ER 24H 2.5-1000 MG
BRAND
MDD
2 per day
metformin hcl (tab 1000 mg, tab sr 24hr 750 mg)
generic
MDD
2 per day
metformin hcl tab 500 mg
generic
MDD
5 per day
metformin hcl tab 850 mg
generic
MDD
3 per day
metformin hcl tab sr 24hr 500 mg
generic
MDD
4 per day
nateglinide (tab 60 mg, tab 120 mg)
generic
MDD
3 per day
ONGLYZA (TAB 2.5 MG, TAB 5 MG)
BRAND
pioglitazone hcl (tab 15 mg, tab 30 mg, tab 45 mg)
generic
MDD
1 per day
pioglitazone hcl-metformin hcl (-metformin tab 15-500 mg, metformin tab 15-850 mg)
generic
MDD
2 per day
SYMLINPEN 120 SOLN PEN 2700 MCG/2.7ML
BRAND
SYMLINPEN 60 SOLN PEN 1500 MCG/1.5ML
BRAND
TRADJENTA TAB 5 MG
BRAND
AL
At least 18 yrs old
MDD
1 per day
GLYCEMIC AGENTS
GLUCAGEN HYPOKIT RECON SOLN 1 MG
BRAND
GLUCAGON EMERGENCY KIT 1 MG
BRAND
QL
1 / claim
APIDRA SOLOSTAR SOLN PEN 100 UNIT/ML
BRAND
QL
30 / 30 days
APIDRA SOLUTION 100 UNIT/ML
BRAND
HUMALOG KWIKPEN SOLN PEN 100 UNIT/ML
BRAND
QL
30 / 30 days
HUMALOG MIX 50/50 KWIKPEN SUSP PEN (50-50) 100
UNIT/ML
BRAND
QL
30 / 30 days
INSULINS
PAGE 56
PRODUCT DESCRIPTION
BRAND/GEN
HUMALOG MIX 50/50 PEN SUSP PEN (50-50) 100
UNIT/ML
BRAND
QL
30 / 30 days
HUMALOG MIX 50/50 SUSPENSION (50-50) 100
UNIT/ML
BRAND
QL
40 / 30 days
HUMALOG MIX 75/25 KWIKPEN SUSP PEN (75-25) 100
UNIT/ML
BRAND
QL
30 / 30 days
HUMALOG MIX 75/25 PEN SUSP PEN (75-25) 100
UNIT/ML
BRAND
QL
30 / 30 days
HUMALOG MIX 75/25 SUSPENSION (75-25) 100
UNIT/ML
BRAND
QL
40 / 30 days
HUMALOG PEN SOLN PEN 100 UNIT/ML
BRAND
QL
30 / 30 days
HUMALOG SOLUTION 100 UNIT/ML
BRAND
QL
40 / 30 days
HUMULIN 70/30 KWIKPEN SUSP PEN (70-30) 100
UNIT/ML
BRAND
QL
30 / 30 days
HUMULIN 70/30 PEN SUSP PEN (70-30) 100 UNIT/ML
BRAND
QL
30 / 30 days
HUMULIN 70/30 SUSPENSION (70-30) 100 UNIT/ML
BRAND
QL
40 / 30 days
HUMULIN N KWIKPEN SUSP PEN 100 UNIT/ML
BRAND
QL
30 / 30 days
HUMULIN N PEN SUSP PEN 100 UNIT/ML
BRAND
QL
30 / 30 days
HUMULIN N SUSPENSION 100 UNIT/ML
BRAND
QL
40 / 30 days
HUMULIN R SOLUTION 100 UNIT/ML
BRAND
QL
40 / 30 days
LANTUS SOLOSTAR SOLN PEN 100 UNIT/ML
BRAND
QL
30 / 30 days
LANTUS SOLUTION 100 UNIT/ML
BRAND
QL
30 / 30 days
NOVOLIN 70/30 RELION SUSPENSION (70-30) 100
UNIT/ML
BRAND
QL
40 / 30 days
NOVOLIN 70/30 SUSPENSION (70-30) 100 UNIT/ML
BRAND
QL
40 / 30 days
NOVOLIN N RELION SUSPENSION 100 UNIT/ML
BRAND
QL
40 / 30 days
NOVOLIN N SUSPENSION 100 UNIT/ML
BRAND
QL
40 / 30 days
NOVOLIN R RELION SOLUTION 100 UNIT/ML
BRAND
QL
40 / 30 days
NOVOLIN R SOLUTION 100 UNIT/ML
BRAND
QL
40 / 30 days
PAGE 57
PRODUCT DESCRIPTION
BRAND/GEN
NOVOLOG FLEXPEN SOLN PEN 100 UNIT/ML
BRAND
QL
30 / 30 days
NOVOLOG MIX 70/30 FLEXPEN SUSP PEN (70-30) 100
UNIT/ML
BRAND
QL
30 / 30 days
NOVOLOG MIX 70/30 SUSPENSION (70-30) 100
UNIT/ML
BRAND
QL
40 / 30 days
NOVOLOG PENFILL SOLN CART 100 UNIT/ML
BRAND
NOVOLOG SOLUTION 100 UNIT/ML
BRAND
QL
30 / 30 days
RELION 70/30 SUSPENSION (70-30) 100 UNIT/ML
BRAND
QL
40 / 30 days
RELION N SUSPENSION 100 UNIT/ML
BRAND
QL
40 / 30 days
RELION R SOLUTION 100 UNIT/ML
BRAND
QL
40 / 30 days
ELIQUIS (TAB 2.5 MG, TAB 5 MG)
BRAND
MDD
enoxaparin sodium (inj 100 mg/ml, inj 150 mg/ml)
generic
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS
ANTICOAGULANTS
QL
MFL
enoxaparin sodium (inj 80 mg/0.8ml, inj 120 mg/0.8ml)
QL
generic
MFL
enoxaparin sodium inj 30 mg/0.3ml
QL
generic
MFL
enoxaparin sodium inj 300 mg/3ml
QL
generic
MFL
QL
generic
MFL
QL
generic
MFL
heparin sodium (porcine) (inj 1000 unit/ml, inj 5000 unit/ml,
inj 10000 unit/ml, inj 20000 unit/ml, pf inj 5000 unit/0.5ml)
PAGE 58
4 per day
14 / 7 days
3 / 180 days
12 / 7 days
3 / 180 days
5 / 7 days
3 / 180 days
42 / 7 days
3 / 180 days
6 / 7 days
3 / 180 days
9 / 7 days
3 / 180 days
generic
PRODUCT DESCRIPTION
BRAND/GEN
warfarin sodium (tab 1 mg, tab 2 mg, tab 2.5 mg, tab 3 mg,
tab 4 mg, tab 5 mg, tab 6 mg, tab 7.5 mg, tab 10 mg)
generic
XARELTO (TAB 15 MG, TAB 20 MG)
BRAND
XARELTO TAB 10 MG
BRAND
QL
35 / 180 days
MDD
1 per day
COAGULANTS
aminocaproic acid syrup 25%
generic
QL
60 / claim
aminocaproic acid tab 500 mg
generic
QL
24 / claim
QL
30 / 5 days
GL
Female
AL
12 to 49 yrs old
tranexamic acid tab 650 mg
generic
MFL
1 / month
PLATELET MODIFYING AGENTS
BRILINTA (TAB 60 MG, TAB 90 MG)
BRAND
MDD
2 per day
cilostazol (tab 50 mg, tab 100 mg)
generic
MDD
2 per day
clopidogrel bisulfate tab 75 mg (base equiv)
generic
MDD
1 per day
dipyridamole (tab 25 mg, tab 50 mg, tab 75 mg)
generic
EFFIENT (TAB 5 MG, TAB 10 MG)
BRAND
MDD
1 per day
CARDIOVASCULAR AGENTS
ALPHA-ADRENERGIC AGONISTS
clonidine hcl (tab 0.1 mg, tab 0.2 mg, tab 0.3 mg)
generic
guanabenz acetate tab 4 mg
generic
guanfacine hcl (tab 1 mg, tab 2 mg)
generic
methyldopa (tab 250 mg, tab 500 mg)
generic
midodrine hcl (tab 2.5 mg, tab 5 mg, tab 10 mg)
generic
PAGE 59
PRODUCT DESCRIPTION
BRAND/GEN
ALPHA-ADRENERGIC BLOCKING AGENTS
doxazosin mesylate (tab 1 mg, tab 2 mg, tab 4 mg, tab 8
mg)
generic
prazosin hcl (cap 1 mg, cap 2 mg, cap 5 mg)
generic
ANGIOTENSIN II RECEPTOR ANTAGONISTS
irbesartan (tab 75 mg, tab 150 mg, tab 300 mg)
generic
MDD
1 per day
losartan potassium (tab 25 mg, tab 50 mg, tab 100 mg)
generic
MDD
1 per day
valsartan (tab 40 mg, tab 80 mg, tab 160 mg, tab 320 mg)
generic
MDD
1 per day
benazepril hcl (tab 5 mg, tab 10 mg, tab 20 mg)
generic
MDD
1 per day
benazepril hcl tab 40 mg
generic
MDD
2 per day
captopril (tab 12.5 mg, tab 25 mg, tab 50 mg, tab 100 mg)
generic
MDD
3 per day
enalapril maleate (tab 2.5 mg, tab 5 mg, tab 10 mg, tab 20
mg)
generic
MDD
2 per day
EPANED RECON SOLN 1 MG/ML
BRAND
AL
fosinopril sodium (tab 10 mg, tab 20 mg, tab 40 mg)
generic
MDD
1 per day
lisinopril (tab 5 mg, tab 10 mg, tab 20 mg, tab 30 mg, tab
40 mg)
generic
MDD
2 per day
lisinopril tab 2.5 mg
generic
MDD
1 per day
quinapril hcl (tab 5 mg, tab 10 mg, tab 20 mg, tab 40 mg)
generic
MDD
1 per day
ramipril (cap 1.25 mg, cap 2.5 mg, cap 5 mg, cap 10 mg)
generic
MDD
2 per day
trandolapril (tab 1 mg, tab 2 mg, tab 4 mg)
generic
MDD
4 per day
ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS
Up to 8 yrs old
ANTIARRHYTHMICS
amiodarone hcl tab 200 mg
generic
disopyramide phosphate (cap 100 mg, cap 150 mg)
generic
dofetilide (cap 125 mcg (0.125, cap 250 mcg (0.25, cap
500 mcg (0.5)
generic
PAGE 60
PRODUCT DESCRIPTION
BRAND/GEN
flecainide acetate (tab 50 mg, tab 100 mg, tab 150 mg)
generic
mexiletine hcl (cap 150 mg, cap 200 mg, cap 250 mg)
generic
propafenone hcl (tab 150 mg, tab 225 mg, tab 300 mg)
generic
quinidine gluconate tab cr 324 mg
generic
quinidine sulfate (tab 200 mg, tab 300 mg, tab cr 300 mg)
generic
sotalol hcl (afib/afl) ((afib/afl) tab 80 mg, (afib/afl) tab 120
mg, (afib/afl) tab 160 mg)
generic
MDD
2 per day
sotalol hcl (tab 80 mg, tab 120 mg, tab 160 mg)
generic
MDD
2 per day
sotalol hcl tab 240 mg
generic
BETA-ADRENERGIC BLOCKING AGENTS
acebutolol hcl (cap 200 mg, cap 400 mg)
generic
atenolol (tab 25 mg, tab 50 mg, tab 100 mg)
generic
MDD
2 per day
bisoprolol fumarate (tab 5 mg, tab 10 mg)
generic
MDD
1 per day
carvedilol (tab 3.125 mg, tab 6.25 mg, tab 12.5 mg)
generic
MDD
3 per day
carvedilol tab 25 mg
generic
MDD
4 per day
COREG CR (CAP ER 24H 20 MG, CAP ER 24H 40 MG,
CAP ER 24H 10 MG, CAP ER 24H 80 MG)
BRAND
MDD
1 per day
labetalol hcl tab 100 mg
generic
MDD
3 per day
generic
MDD
6 per day
generic
MDD
8 per day
metoprolol succinate (tab 24hr 100 mg, tab 24hr 50 mg
(tartrate equiv), tab 24hr 100 mg (tartrate equiv), tab 24hr
25 mg (tartrate equiv), tab 24hr 25 mg)
generic
MDD
1 per day
metoprolol succinate (tab 24hr 200 mg, tab 24hr 200 mg
(tartrate equiv))
generic
MDD
2 per day
metoprolol tartrate (tab 25 mg, tab 100 mg)
generic
MDD
2 per day
metoprolol tartrate tab 50 mg
generic
MDD
3 per day
nadolol (tab 20 mg, tab 40 mg, tab 80 mg)
generic
MDD
2 per day
PAGE 61
PRODUCT DESCRIPTION
BRAND/GEN
pindolol (tab 5 mg, tab 10 mg)
generic
propranolol hcl (cap 24hr 80 mg, cap 24hr 60 mg, cap 24hr
120 mg, cap 24hr 160 mg)
generic
propranolol hcl (oral soln 20 mg/5ml, oral soln 40 mg/5ml,
tab 10 mg, tab 20 mg, tab 40 mg, tab 60 mg, tab 80 mg)
generic
timolol maleate (tab 5 mg, tab 10 mg, tab 20 mg)
generic
MDD
2 per day
CALCIUM CHANNEL BLOCKING AGENTS
amlodipine besylate (tab 2.5 mg, tab 5 mg, tab 10 mg)
generic
MDD
1 per day
diltiazem hcl (cap 12hr 90 mg, cap 12hr 120 mg, cap 12hr
60 mg, cap 24hr 240 mg)
generic
MDD
2 per day
diltiazem hcl (cap 24hr 120 mg, cap 24hr 180 mg)
generic
MDD
1 per day
diltiazem hcl (tab 30 mg, tab 60 mg, tab 90 mg, tab 120
mg)
generic
MDD
3 per day
diltiazem hcl coated beads (beads cap 24hr 300 mg, beads
cap 24hr 180 mg, beads cap 24hr 120 mg)
generic
MDD
1 per day
diltiazem hcl coated beads cap sr 24hr 240 mg
generic
MDD
2 per day
diltiazem hcl extended release beads (beads cap 24hr 360
mg, beads cap 24hr 180 mg, beads cap 24hr 300 mg,
beads cap 24hr 240 mg, beads cap 24hr 120 mg, beads
cap 24hr 420 mg)
generic
MDD
1 per day
felodipine (tab 24hr 10 mg, tab 24hr 5 mg, tab 24hr 2.5 mg)
generic
MDD
1 per day
nicardipine hcl (cap 20 mg, cap 30 mg)
generic
nifedipine (cap 10 mg, cap 20 mg)
generic
MDD
4 per day
nifedipine (tab 24hr 60 mg, tab 24hr osmotic release 60
mg)
generic
MDD
2 per day
nifedipine (tab 24hr osmotic release 30 mg, tab 24hr
osmotic release 90 mg, tab 24hr 30 mg, tab 24hr 90 mg)
generic
MDD
1 per day
verapamil hcl (cap sr 24hr 120 mg, cap sr 24hr 180 mg,
cap sr 24hr 240 mg, tab cr 120 mg, tab cr 180 mg, tab cr
240 mg)
generic
MDD
2 per day
verapamil hcl (tab 40 mg, tab 80 mg, tab 120 mg)
generic
MDD
3 per day
verapamil hcl cap sr 24hr 360 mg
generic
MDD
1 per day
PAGE 62
PRODUCT DESCRIPTION
BRAND/GEN
CARDIOVASCULAR AGENTS, OTHER
amiloride & hydrochlorothiazide tab 5-50 mg
generic
MDD
1 per day
amlodipine besylate-benazepril hcl (cap 2.5-10 mg, cap 510 mg, cap 5-20 mg, cap 10-20 mg)
generic
MDD
1 per day
atenolol & chlorthalidone (tab 50-25 mg, tab 100-25 mg)
generic
MDD
1 per day
benazepril & hydrochlorothiazide (tab 5-6.25 mg, tab 1012.5 mg, tab 20-12.5 mg, tab 20-25 mg)
generic
MDD
1 per day
bisoprolol & hydrochlorothiazide (tab 5-6.25 mg, tab 106.25 mg)
generic
MDD
1 per day
captopril & hydrochlorothiazide (tab 25-25 mg, tab 25-15
mg, tab 50-25 mg, tab 50-15 mg)
generic
MDD
2 per day
digoxin (oral soln 0.05 mg/ml, tab 125 mcg (0.125 mg), tab
250 mcg (0.25 mg))
generic
DUTOPROL (TAB ER 24H 50-12.5 MG, TAB ER 24H 10012.5 MG, TAB ER 24H 25-12.5 MG)
BRAND
MDD
1 per day
enalapril maleate & hydrochlorothiazide (tab 5-12.5 mg, tab
10-25 mg)
generic
MDD
2 per day
fosinopril sodium & hydrochlorothiazide (tab 10-12.5 mg,
tab 20-12.5 mg)
generic
MDD
1 per day
irbesartan-hydrochlorothiazide (tab 150-12.5 mg, tab 30012.5 mg)
generic
MDD
1 per day
lisinopril & hydrochlorothiazide (tab 10-12.5 mg, tab 2012.5 mg)
generic
MDD
2 per day
lisinopril & hydrochlorothiazide tab 20-25 mg
generic
MDD
1 per day
losartan potassium & hydrochlorothiazide (tab 50-12.5 mg,
tab 100-25 mg, tab 100-12.5 mg)
generic
MDD
1 per day
metoprolol & hydrochlorothiazide (tab 50-25 mg, tab 10025 mg, tab 100-50 mg)
generic
MDD
2 per day
pentoxifylline tab cr 400 mg
generic
propranolol & hydrochlorothiazide (tab 40-25 mg, tab 80-25
mg)
generic
reserpine (tab 0.1 mg, tab 0.25 mg)
generic
spironolactone & hydrochlorothiazide tab 25-25 mg
generic
PAGE 63
PRODUCT DESCRIPTION
BRAND/GEN
triamterene & hydrochlorothiazide (cap 37.5-25 mg, cap
50-25 mg, tab 37.5-25 mg, tab 75-50 mg)
generic
MDD
1 per day
valsartan-hydrochlorothiazide (tab 80-12.5 mg, tab 160-25
mg, tab 160-12.5 mg, tab 320-25 mg, tab 320-12.5 mg)
generic
MDD
1 per day
DIURETICS, CARBONIC ANHYDRASE INHIBITORS
acetazolamide (cap sr 12hr 500 mg, tab 125 mg, tab 250
mg)
generic
DIURETICS, LOOP
bumetanide (tab 0.5 mg, tab 1 mg, tab 2 mg)
generic
furosemide (oral soln 8 mg/ml, oral soln 10 mg/ml, tab 20
mg, tab 40 mg, tab 80 mg)
generic
torsemide (tab 5 mg, tab 10 mg, tab 20 mg, tab 100 mg)
generic
MDD
1 per day
amiloride hcl tab 5 mg
generic
MDD
4 per day
spironolactone (tab 25 mg, tab 50 mg, tab 100 mg)
generic
DIURETICS, POTASSIUM-SPARING
DIURETICS, THIAZIDE
chlorothiazide tab 250 mg
generic
MDD
2 per day
chlorothiazide tab 500 mg
generic
MDD
4 per day
chlorthalidone (tab 25 mg, tab 50 mg)
generic
hydrochlorothiazide (cap 12.5 mg, tab 25 mg, tab 50 mg)
generic
indapamide (tab 1.25 mg, tab 2.5 mg)
generic
metolazone (tab 2.5 mg, tab 5 mg, tab 10 mg)
generic
DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES
fenofibrate micronized (cap 134 mg, cap 200 mg)
generic
MDD
1 per day
fenofibrate micronized cap 67 mg
generic
MDD
2 per day
fenofibrate tab 160 mg
generic
MDD
1 per day
fenofibrate tab 54 mg
generic
MDD
3 per day
PAGE 64
PRODUCT DESCRIPTION
BRAND/GEN
gemfibrozil tab 600 mg
generic
MDD
2 per day
DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS
atorvastatin calcium (tab 10 mg, tab 20 mg)
ST
generic
MDD
1 per day
atorvastatin calcium (tab 40 mg, tab 80 mg)
generic
MDD
1 per day
lovastatin (tab 10 mg, tab 20 mg)
generic
MDD
1 per day
lovastatin tab 40 mg
generic
MDD
2 per day
pravastatin sodium (tab 10 mg, tab 20 mg, tab 40 mg, tab
80 mg)
generic
MDD
1 per day
simvastatin (tab 5 mg, tab 10 mg, tab 20 mg, tab 40 mg)
generic
MDD
1 per day
MDD
2 per day
DYSLIPIDEMICS, OTHER
cholestyramine (powder 4 gm/dose, powder packets 4 gm)
generic
cholestyramine light (powder 4 gm/dose, powder packets 4
gm)
generic
colestipol hcl granules 5 gm
generic
colestipol hcl tab 1 gm
generic
NIACOR TAB 500 MG
BRAND
VASODILATORS, DIRECT-ACTING ARTERIAL
hydralazine hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab 100
mg)
generic
minoxidil (tab 2.5 mg, tab 10 mg)
generic
VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS
isosorbide dinitrate (sl tab 2.5 mg, sl tab 5 mg, tab 5 mg,
tab 10 mg, tab 20 mg, tab 30 mg, tab cr 40 mg)
generic
isosorbide mononitrate (tab 10 mg, tab 20 mg)
generic
MDD
2 per day
isosorbide mononitrate (tab 24hr 120 mg, tab 24hr 60 mg,
tab 24hr 30 mg)
generic
MDD
1 per day
NITRO-BID OINTMENT 2 %
BRAND
PAGE 65
PRODUCT DESCRIPTION
BRAND/GEN
nitroglycerin (cap cr 2.5 mg, cap cr 6.5 mg, cap cr 9 mg, sl
tab 0.3 mg, sl tab 0.4 mg, sl tab 0.6 mg, td patch 24hr 0.4
mg/hr, td patch 24hr 0.2 mg/hr, td patch 24hr 0.1 mg/hr, td
patch 24hr 0.6 mg/hr)
generic
CENTRAL NERVOUS SYSTEM AGENTS
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES
amphetamine-dextroamphetamine (cap 24hr 30 mg, cap
24hr 20 mg, cap 24hr 15 mg, cap 24hr 5 mg, cap 24hr 25
mg, cap 24hr 10 mg)
generic
amphetamine-dextroamphetamine (tab 5 mg, tab 7.5 mg,
tab 10 mg, tab 12.5 mg, tab 15 mg, tab 20 mg, tab 30 mg)
generic
dextroamphetamine sulfate (cap 24hr 15 mg, cap 24hr 10
mg)
generic
dextroamphetamine sulfate (tab 5 mg, tab 10 mg)
generic
AL
MDD
AL
MDD
AL
MDD
AL
MDD
dextroamphetamine sulfate cap sr 24hr 5 mg
AL
generic
MDD
VYVANSE (CAP 10 MG, CAP 20 MG, CAP 30 MG, CAP
40 MG, CAP 50 MG, CAP 60 MG, CAP 70 MG)
6 to 18 yrs old
1 per day
3 to 18 yrs old
2 per day
6 to 18 yrs old
2 per day
3 to 18 yrs old
3 per day
6 to 18 yrs old
1 per day
PA
BRAND
MDD
1 per day
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES
dexmethylphenidate hcl (tab 2.5 mg, tab 5 mg, tab 10 mg)
AL
generic
MDD
methylphenidate hcl (cap cr 10 mg (cd), cap cr 20 mg (cd),
cap cr 30 mg (cd), cap cr 40 mg (cd), cap cr 50 mg (cd),
cap cr 60 mg (cd), tab cr 20 mg, tab sa osm 18 mg, tab sa
osm 27 mg, tab sa osm 54 mg, tab sr 24hr 54 mg, tab sr
24hr 27 mg, tab sr 24hr 18 mg)
generic
methylphenidate hcl (tab 5 mg, tab 10 mg, tab 20 mg)
generic
AL
MDD
AL
MDD
methylphenidate hcl (tab cr 10 mg, tab sa osm 36 mg, tab
sr 24hr 36 mg)
PAGE 66
AL
generic
MDD
6 to 18 yrs old
2 per day
6 to 18 yrs old
1 per day
3 to 18 yrs old
3 per day
6 to 18 yrs old
2 per day
PRODUCT DESCRIPTION
BRAND/GEN
CENTRAL NERVOUS SYSTEM, OTHER
butalbital-acetaminophen tab 50-325 mg
generic
butalbital-acetaminophen tab 50-650 mg
generic
MDD
6 per day
butalbital-acetaminophen-caffeine (cap 50-325-40 mg, tab
50-500-40 mg, tab 50-325-40 mg)
generic
MDD
4 per day
butalbital-aspirin-caffeine cap 50-325-40 mg
generic
MDD
4 per day
PHRENILIN FORTE CAP 50-650 MG
BRAND
SOMNOTE CAP 500 MG
BRAND
TENCON TAB 50-325 MG
BRAND
QL
45 / 25 days
FIBROMYALGIA AGENTS
ST
duloxetine hcl (cap 20 mg, cap 30 mg, cap 60 mg)
generic
AL
MDD
At least 18 yrs old
1 per day
PA
SAVELLA (TAB 12.5 MG, TAB 25 MG, TAB 50 MG, TAB
100 MG)
BRAND
SAVELLA TITRATION PACK MISC 12.5 & 25 & 50 MG
BRAND
MDD
QL
2 per day
55 / 365 days
PA
MULTIPLE SCLEROSIS AGENTS
AVONEX KIT 30 MCG
BRAND
PA
AVONEX PEN AUT-IJ KIT 30 MCG/0.5ML
BRAND
PA
AVONEX PREFILLED PREF SY KT 30 MCG/0.5ML
BRAND
PA
COPAXONE SOLN PRSYR 40 MG/ML
BRAND
PA
GILENYA CAP 0.5 MG
BRAND
PA
glatiramer acetate soln prefilled syringe 20 mg/ml
generic
PA
PLEGRIDY (SOLN PEN 125 MCG/0.5ML, SOLN PRSYR
125 MCG/0.5ML)
BRAND
PA
PLEGRIDY STARTER PACK (PACK SOLN PEN 63 94
MCG/0.5ML, PACK SOLN PRSYR 63 94 MCG/0.5ML)
BRAND
PA
PAGE 67
PRODUCT DESCRIPTION
BRAND/GEN
TECFIDERA (CAP DR 120 MG, CAP DR 240 MG, MISC
120 & 240 MG)
BRAND
PA
DENTAL AND ORAL AGENTS
chlorhexidine gluconate soln 0.12%
generic
pilocarpine hcl tab 5 mg
generic
MDD
6 per day
sodium fluoride (dental) (cream, gel (0.5% f))
generic
MPL
1 / claim
aluminum chloride soln 20%
generic
MPL
1 / claim
calcipotriene (cream, soln (50 mcg/ml))
generic
QL
clindamycin phosphate-benzoyl peroxide gel 1-5%
generic
MPL
1 / claim
clotrimazole w/ betamethasone (w/ cream, w/ lotion)
generic
MPL
1 / claim
DERMATOLOGICAL AGENTS
QL
ELIDEL CREAM 1 %
BRAND
60 / claim
30 / 30 days
PA
AL
At least 2 yrs old
10 / claim
EPIFOAM FOAM 1-1 %
BRAND
fluorouracil (topical) (soln 2%, soln 5%)
generic
QL
fluorouracil cream 0.5%
generic
MPL
fluorouracil cream 5%
generic
QL
hydrocortisone (topical) (cream, lotion)
generic
MPL
1 / claim
hydrocortisone oint 2.5%
generic
MPL
1 / 31 days
imiquimod cream 5%
generic
QL
1 / claim
40 / claim
48 / 180 days
ST
isotretinoin (cap 10 mg, cap 20 mg, cap 40 mg)
generic
AL
12 to 22 yrs old
MDD
2 per day
lidocaine hcl cream 3%
generic
MPL
1 / claim
lidocaine oint 5%
generic
MPL
1 / claim
PAGE 68
PRODUCT DESCRIPTION
BRAND/GEN
lidocaine-prilocaine cream kit 2.5-2.5%
generic
MPL
1 / claim
podofilox soln 0.5%
generic
QL
4 / claim
selenium sulfide lotion 2.5%
generic
QL
120 / claim
sulfacetamide sodium liquid 10%
generic
MPL
sulfacetamide sodium lotion 10% (acne)
generic
QL
sulfacetamide sodium w/ sulfur (w/ lotion, w/ susp)
generic
MPL
QL
tacrolimus oint 0.03%
generic
1 / claim
120 / claim
1 / claim
30 / 30 days
PA
AL
At least 2 yrs old
TAZORAC (CREAM 0.05 %, CREAM 0.1 %, GEL 0.05 %,
GEL 0.1 %)
BRAND
MPL
1 / claim
tretinoin (cream 0.025%, cream 0.05%, cream 0.1%, gel
0.01%, gel 0.025%)
generic
MPL
1 / claim
urea (cream, lotion)
generic
MPL
1 / claim
ENZYME REPLACEMENT/MODIFIERS
CREON (CP DR PART 6000, CP DR PART 12000, CP DR
PART 24000)
BRAND
PANCREAZE (CP DR PART 4200, CP DR PART 10500,
CP DR PART 16800, CP DR PART 21000)
BRAND
pancrelipase (lip-prot-amyl) dr cap 5000-17000-27000 unit
generic
ZENPEP (CP DR PART 3000-10000, CP DR PART 5000,
CP DR PART 10000, CP DR PART 15000, CP DR PART
20000, CP DR PART 25000)
BRAND
GASTROINTESTINAL AGENTS
ANTISPASMODICS, GASTROINTESTINAL
dicyclomine hcl (cap 10 mg, tab 20 mg)
generic
dicyclomine hcl oral soln 10 mg/5ml
generic
MDD
40 per day
glycopyrrolate (tab 1 mg, tab 2 mg)
generic
MDD
4 per day
PAGE 69
PRODUCT DESCRIPTION
BRAND/GEN
hyoscyamine sulfate (elixir 0.125 mg/5ml, soln 0.125
mg/ml, tab 0.125 mg, tab disp 0.125 mg, tab sl 0.125 mg)
generic
hyoscyamine sulfate tab sr 12hr 0.375 mg
generic
SYMAX DUOTAB TAB ER 0.375 MG
BRAND
MDD
4 per day
GASTROINTESTINAL AGENTS, OTHER
PA
CHOLBAM (CAP 50 MG, CAP 250 MG)
BRAND
MDD
5 per day
diphenoxylate w/ atropine (w/ liq mg/5ml, w/ tab mg)
generic
paregoric tincture 2 mg/5ml
generic
ursodiol cap 300 mg
generic
MDD
3 per day
ursodiol tab 250 mg
generic
MDD
7 per day
MDD
27 per day
MPL
1 / claim
HISTAMINE2 (H2) RECEPTOR ANTAGONISTS
cimetidine (tab 300 mg, tab 400 mg, tab 800 mg)
generic
cimetidine hcl soln 300 mg/5ml
generic
famotidine tab 40 mg
generic
ranitidine hcl (cap 150 mg, tab 300 mg)
generic
MDD
2 per day
ranitidine hcl cap 300 mg
generic
MDD
1 per day
ranitidine hcl syrup 15 mg/ml (75 mg/5ml)
generic
AL
Up to 6 yrs old
MDD
20 per day
LAXATIVES
lactulose (encephalopathy) solution 10 gm/15ml
generic
lactulose solution 10 gm/15ml
generic
peg 3350-kcl-sod bicarb-nacl for soln 420 gm
generic
MPL
1 / claim
peg 3350-kcl-sod bicarb-sod chloride-sod sulfate (soln 236
gm, soln 240 gm)
generic
MPL
1 / claim
senna powder
generic
PAGE 70
PRODUCT DESCRIPTION
BRAND/GEN
PROTECTANTS
CARAFATE SUSPENSION 1 GM/10ML
QL
420 / claim
AL
Up to 6 yrs old
BRAND
misoprostol (tab 100 mcg, tab 200 mcg)
generic
sucralfate tab 1 gm
generic
MDD
FIRST-OMEPRAZOLE SUSPENSION 2 MG/ML
BRAND
QL
omeprazole (cap 20 mg, cap 40 mg)
generic
MDD
OMEPRAZOLE+SYRSPEND SF ALKA SUSPENSION 2
MG/ML
BRAND
QL
pantoprazole sodium (ec tab 20 mg, ec tab 40 mg)
generic
PA
4 per day
PROTON PUMP INHIBITORS
300 / claim
1 per day
300 / claim
GENITOURINARY AGENTS
ANTISPASMODICS, URINARY
flavoxate hcl tab 100 mg
generic
oxybutynin chloride (tab 24hr 15 mg, tab 24hr 10 mg, tab
24hr 5 mg)
generic
MDD
oxybutynin chloride syrup 5 mg/5ml
generic
QL
oxybutynin chloride tab 5 mg
generic
MDD
3 per day
tolterodine tartrate (cap 24hr 4 mg, cap 24hr 2 mg)
generic
MDD
1 per day
tolterodine tartrate (tab 1 mg, tab 2 mg)
generic
MDD
2 per day
trospium chloride tab 20 mg
generic
MDD
2 per day
finasteride tab 5 mg
generic
MDD
1 per day
tamsulosin hcl cap 0.4 mg
generic
MDD
2 per day
terazosin hcl (cap 1 mg, cap 2 mg, cap 5 mg, cap 10 mg)
generic
2 per day
480 / 30 days
BENIGN PROSTATIC HYPERTROPHY AGENTS
PAGE 71
PRODUCT DESCRIPTION
BRAND/GEN
GENITOURINARY AGENTS, OTHER
bethanechol chloride (tab 5 mg, tab 10 mg, tab 25 mg, tab
50 mg)
generic
CUPRIMINE CAP 250 MG
BRAND
ELMIRON CAP 100 MG
BRAND
phenazopyridine hcl (tab 100 mg, tab 200 mg)
generic
pot phos monobasic w/sod phos di & monobas tab 155852-130mg
generic
potassium citrate & citric acid powder pack 3300-1002 mg
generic
potassium citrate (alkalinizer) (tab 5 (540, tab 10 (1080)
generic
sodium chloride irrigation soln 0.9%
generic
sodium citrate & citric acid soln 500-334 mg/5ml
generic
MDD
3 per day
MDD
8 per day
QL
500 / 30 days
PHOSPHATE BINDERS
calcium acetate (phosphate binder) cap 667 mg (169 mg
ca)
generic
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)
APEXICON E CREAM 0.05 %
BRAND
MPL
1 / claim
betamethasone dipropionate augmented cream 0.05%
generic
MPL
1 / claim
betamethasone valerate (cream, oint)
generic
MPL
1 / claim
betamethasone valerate lotion 0.1%
generic
QL
clobetasol propionate (cream, gel, oint, soln)
generic
MPL
1 / claim
clobetasol propionate emollient base cream 0.05%
generic
MPL
1 / claim
cortisone acetate tab 25 mg
generic
dexamethasone (elixir 0.5 mg/5ml, soln 0.5 mg/5ml, tab 0.5
mg, tab 0.75 mg, tab 1 mg, tab 1.5 mg, tab 2 mg, tab 4 mg,
tab 6 mg)
generic
DEXAMETHASONE INTENSOL CONC 1 MG/ML
BRAND
diflorasone diacetate (cream, oint)
generic
MPL
1 / claim
PAGE 72
60 / claim
PRODUCT DESCRIPTION
BRAND/GEN
fludrocortisone acetate tab 0.1 mg
generic
fluocinonide (cream, gel, oint, soln)
generic
MPL
1 / claim
fluocinonide emulsified base cream 0.05%
generic
MPL
1 / claim
fluticasone propionate cream 0.05%
generic
MPL
1 / 30 days
fluticasone propionate oint 0.005%
generic
MPL
1 / claim
hydrocortisone (tab 5 mg, tab 10 mg, tab 20 mg)
generic
hydrocortisone butyrate soln 0.1%
generic
MPL
1 / claim
methylprednisolone (tab 4 mg, tab 4 mg dose pack, tab 8
mg, tab therapy pack 4 mg (21))
generic
mometasone furoate (cream, oint, solution (lotion))
generic
MPL
1 / claim
prednicarbate (cream, oint)
generic
MPL
1 / claim
prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml
base)
generic
prednisolone sod phosphate oral soln 15 mg/5ml (base
equiv)
generic
prednisolone syrup 15 mg/5ml (usp solution equivalent)
generic
prednisone (oral soln 5 mg/5ml, tab 1 mg, tab 2.5 mg, tab 5
mg, tab 5 mg dose pack, tab 10 mg, tab 20 mg, tab 50 mg,
tab therapy pack 5 mg (21), tab therapy pack 5 mg (48),
tab therapy pack 10 mg (21), tab therapy pack 10 mg (48))
generic
PREDNISONE INTENSOL CONC 5 MG/ML
BRAND
PSORCON CREAM 0.05 %
BRAND
MPL
1 / claim
triamcinolone acetonide (topical) (cream 0.1%, oint
0.025%, oint 0.1%)
generic
MPL
1 / claim
triamcinolone acetonide (topical) (lotion 0.025%, lotion
0.1%)
generic
QL
QL
triamcinolone acetonide cream 0.025%
generic
C
triamcinolone acetonide cream 0.5%
generic
QL
PAGE 73
240 / claim
60 / claim
15: Package
454: Package
Limit=1/claim
15 / claim
PRODUCT DESCRIPTION
BRAND/GEN
triamcinolone acetonide dental paste 0.1%
generic
QL
5 / claim
VERIPRED 20 SOLUTION 20 MG/5ML
BRAND
QL
150 / claim
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)
desmopressin acetate (tab 0.1 mg, tab 0.2 mg)
generic
MDD
3 per day
desmopressin acetate nasal soln 0.01% (refrigerated)
generic
QL
5 / claim
desmopressin acetate nasal spray soln 0.01%
generic
QL
5 / claim
desmopressin acetate nasal spray soln 0.01%
(refrigerated)
generic
QL
5 / claim
NORDITROPIN (SOLUTION 5 MG/1.5ML, SOLUTION 15
MG/1.5ML)
BRAND
PA
NORDITROPIN FLEXPRO (SOLUTION 5 MG/1.5ML,
SOLUTION 10 MG/1.5ML, SOLUTION 15 MG/1.5ML,
SOLUTION 30 MG/3ML)
BRAND
PA
NORDITROPIN NORDIFLEX PEN (PEN SOLUTION 5
MG/1.5ML, PEN SOLUTION 10 MG/1.5ML, PEN
SOLUTION 15 MG/1.5ML, PEN SOLUTION 30 MG/3ML)
BRAND
PA
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)
ANDROGENS
ANDRODERM (PATCH 24HR 4 MG/24HR, PATCH 24HR
2 MG/24HR)
BRAND
ANDROXY TAB 10 MG
BRAND
METHITEST TAB 10 MG
BRAND
testosterone cypionate im inj in oil 200 mg/ml
generic
QL
4 / 30 days
COMBIPATCH (PATCH TW 0.05-0.14 MG/DAY, PATCH
TW 0.05-0.25 MG/DAY)
BRAND
QL
8 / 28 days
desogest-ethin est tab 0.1-0.025/0.125-0.025/0.150.025mg-mg
generic
MDD
1 per day
DESOGESTREL-ETHINYL ESTRADIOL TAB 0.150.02/0.01 MG (AZURETTE, KARIVA, PIMTREA,
VIORELE, CAZIANT, CESIA, VELIVET)
BRAND
MDD
1 per day
MDD
1 per day
ESTROGENS
PAGE 74
PRODUCT DESCRIPTION
BRAND/GEN
DESOGESTREL-ETHINYL ESTRADIOL TAB 0.15-30 MGMCG (APRI, EMOQUETTE, ENSKYCE, RECLIPSEN,
SOLIA)
BRAND
MDD
1 per day
drospirenone-ethinyl estradiol tab 3-0.03 mg
generic
MDD
1 per day
DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG
(GIANVI, LORYNA, NIKKI, VESTURA, OCELLA, SYEDA,
ZARAH)
BRAND
esterified estrogens & methyltestosterone (tab 0.625-1.25
mg, tab 1.25-2.5 mg)
generic
MDD
1 per day
ESTRACE CREAM 0.1 MG/GM
BRAND
QL
estradiol & norethindrone acetate (tab 0.5-0.1 mg, tab 10.5 mg)
generic
MDD
estradiol (patch 0.025 mg/24hr, patch 0.0375 mg/24hr
(37.5 mcg/24hr), patch 0.05 mg/24hr, patch 0.06 mg/24hr,
patch 0.075 mg/24hr, patch 0.1 mg/24hr)
generic
QL
estradiol (patch 0.025 mg/24hr, patch 0.0375 mg/24hr,
patch 0.05 mg/24hr, patch 0.075 mg/24hr, patch 0.1
mg/24hr)
generic
MDD
0.29 per day
estradiol (tab 0.5 mg, tab 1 mg, tab 2 mg)
generic
estropipate (tab 0.75 mg, tab 1.5 mg)
generic
MDD
1 per day
estropipate tab 3 mg
generic
MDD
2 per day
ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB
1 MG-35 MCG (KELNOR, ZOVIA)
BRAND
MDD
1 per day
LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST
TAB 0.01MG(7) (AMETHIA, CAMRESE, DAYSEE)
QL
BRAND
91 / claim
MDD
1 per day
LEVONORGEST-ETH ESTRAD 91-DAY TAB 0.15-0.03
MG (INTROVALE, JOLESSA, QUASENSE)
BRAND
QL
91 / claim
LEVONORGESTREL-ETH ESTRA TAB 0.05-30/0.07540/0.125-30MG (ENPRESSE, LEVONEST, MYZILRA,
TRIVORA)
BRAND
MDD
1 per day
LEVONORGESTREL-ETHINYL ESTRAD TAB 0.1-20 MG
(AUBRA, AVIANE, DELYLA, FALMINA, LESSINA,
LUTERA, ORSYTHIA, SRONYX)
BRAND
MDD
1 per day
LEVONORGESTREL-ETHINYL ESTRAD TAB 0.15-30 MG
(ALTAVERA, CHATEAL, KURVELO, LEVORA,
MARLISSA, PORTIA)
BRAND
MDD
1 per day
PAGE 75
43 / 30 days
1 per day
4 / 28 days
PRODUCT DESCRIPTION
BRAND/GEN
NECON 1/50 (28) TAB 1-50 MG-MCG
BRAND
MDD
1 per day
NECON 10/11 (28) TAB 35 MCG
BRAND
MDD
1 per day
NORELGESTROMIN-ETHINYL ESTRADIOL TD PTWK
150-35 MCG/24HR (XULANE)
BRAND
MPL
1 / 28 days
NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.4
MG-35 MCG (BALZIVA, BRIELLYN, GILDAGIA, PHILITH,
VYFEMLA, ZENCHENT)
BRAND
MDD
1 per day
NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.5
MG-35 MCG (NECON, NORTREL, WERA)
BRAND
MDD
1 per day
NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG35 MCG (ALYACEN, CYCLAFEM, DASETTA, NECON,
NORTREL, PIRMELLA)
BRAND
MDD
1 per day
NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1
MG-20 MCG (GILDESS, JUNEL, LARIN, MICROGESTIN)
BRAND
MDD
1 per day
NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB
1.5 MG-30 MCG (GILDESS, JUNEL, LARIN,
MICROGESTIN)
BRAND
MDD
1 per day
NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE
TAB 1 MG-20 MCG (GILDESS, JUNEL, LARIN,
MICROGESTIN)
BRAND
MDD
1 per day
NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE
TAB 1.5 MG-30 MCG (GILDESS, JUNEL, LARIN,
MICROGESTIN)
BRAND
MDD
1 per day
NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.7535/1-35 MG (ALYACEN, CYCLAFEM, DASETTA, NECON,
NORTREL, PIRMELLA)
BRAND
MDD
1 per day
NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/135/0.5-35 MG (ARANELLE, LEENA)
BRAND
MDD
1 per day
NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG35 MCG (ESTARYLLA, MONO-LINYAH, MONONESSA,
PREVIFEM, SPRINTEC)
BRAND
MDD
1 per day
NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.21535/0.25-35 MG (TRI-ESTARYLLA, TRI-LINYAH, TRIPREVIFEM, TRI-SPRINTEC, TRINESSA)
BRAND
MDD
1 per day
NORGESTREL & ETHINYL ESTRADIOL TAB 0.3 MG-30
MCG (CRYSELLE, ELINEST, LOW-OGESTREL)
BRAND
MDD
2 per day
NORINYL 1+50 (28) TAB 1-50 MG-MCG
BRAND
MDD
1 per day
PAGE 76
PRODUCT DESCRIPTION
BRAND/GEN
NUVARING RING 0.12-0.015 MG/24HR
BRAND
QL
1 / claim
OGESTREL TAB 0.5-50 MG-MCG
BRAND
MDD
1 per day
PREMARIN (TAB 0.3 MG, TAB 0.45 MG, TAB 0.625 MG,
TAB 0.9 MG, TAB 1.25 MG)
BRAND
MDD
1 per day
PREMARIN CREAM 0.625 MG/GM
BRAND
QL
43 / 30 days
GL
Female
28 / 28 days
PREMPHASE TAB 0.625-5 MG
BRAND
QL
PREMPRO (TAB 0.3-1.5 MG, TAB 0.45-1.5 MG, TAB
0.625-5 MG, TAB 0.625-2.5 MG)
BRAND
MDD
ZOVIA 1/50E (28) TAB 1-50 MG-MCG
BRAND
1 per day
PROGESTERONE AGONISTS/ANTAGONISTS
ELLA TAB 30 MG
BRAND
QL
4 / 365 days
DEPO-SUBQ PROVERA 104 SUSPENSION 104
MG/0.65ML
BRAND
QL
1 / claim
levonorgestrel tab 0.75 mg
generic
MFL
MAKENA OIL 250 MG/ML
BRAND
PA
medroxyprogesterone acetate (tab 2.5 mg, tab 5 mg, tab
10 mg)
generic
medroxyprogesterone acetate im susp 150 mg/ml
generic
megestrol acetate (susp 40 mg/ml, tab 20 mg, tab 40 mg)
generic
norethindrone acetate tab 5 mg
generic
NORETHINDRONE TAB 0.35 MG (CAMILA, DEBLITANE,
ERRIN, HEATHER, JENCYCLA, JOLIVETTE, LYZA,
NORA-BE, NORLYROC, SHAROBEL)
PROGESTINS
4 / 365 days
QL
1 / claim
BRAND
MDD
1 per day
progesterone micronized cap 100 mg
generic
QL
30 / 30 days
progesterone micronized cap 200 mg
generic
QL
20 / 30 days
PAGE 77
PRODUCT DESCRIPTION
BRAND/GEN
SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS
raloxifene hcl tab 60 mg
generic
MDD
1 per day
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)
ARMOUR THYROID (TAB 15 MG, TAB 120 MG, TAB 180
MG, TAB 240 MG, TAB 300 MG)
BRAND
levothyroxine sodium (tab 25 mcg, tab 50 mcg, tab 75 mcg,
tab 88 mcg, tab 100 mcg, tab 112 mcg, tab 125 mcg, tab
137 mcg, tab 150 mcg, tab 175 mcg, tab 200 mcg, tab 300
mcg)
generic
liothyronine sodium (tab 5 mcg, tab 25 mcg, tab 50 mcg)
generic
NATURE-THROID (TAB 65 MG, TAB 130 MG)
BRAND
thyroid (tab 30 mg (1/2, tab 60 mg (1, tab 90 mg (1 1/2)
generic
THYROLAR-1 TAB 60 (12.5-50) MG (MCG)
BRAND
THYROLAR-1/2 TAB 30 (6.25-25) MG (MCG)
BRAND
THYROLAR-1/4 TAB 15 (3.1-12.5) MG (MCG)
BRAND
THYROLAR-2 TAB 120 (25-100) MG (MCG)
BRAND
THYROLAR-3 TAB 180 (37.5-150) MG (MCG)
BRAND
WESTHROID (TAB 65 MG, TAB 130 MG)
BRAND
WESTHROID-P (TAB 65 MG, TAB 130 MG)
BRAND
WP THYROID (TAB 65 MG, TAB 130 MG)
BRAND
HORMONAL AGENTS, SUPPRESSANT (PITUITARY)
EGRIFTA (RECON SOLN 1 MG, RECON SOLN 2 MG)
BRAND
PA
HORMONAL AGENTS, SUPPRESSANT (THYROID)
ANTITHYROID AGENTS
methimazole (tab 5 mg, tab 10 mg)
generic
propylthiouracil tab 50 mg
generic
SSKI SOLUTION 1 GM/ML
BRAND
PAGE 78
PRODUCT DESCRIPTION
BRAND/GEN
IMMUNOLOGICAL AGENTS
IMMUNE SUPPRESSANTS
AZASAN (TAB 75 MG, TAB 100 MG)
BRAND
MDD
3 per day
azathioprine tab 50 mg
generic
cyclosporine (cap 25 mg, cap 100 mg)
generic
MDD
4 per day
cyclosporine modified (for microemulsion) (cap 25 mg, cap
50 mg, cap 100 mg)
generic
MDD
4 per day
cyclosporine modified oral soln 100 mg/ml
generic
MDD
8 per day
ENBREL (SOLN PRSYR 25 MG/0.5ML, SOLN PRSYR 50
MG/ML)
BRAND
PA
ENBREL RECON SOLN 25 MG
BRAND
ENBREL SURECLICK SOLN A-INJ 50 MG/ML
BRAND
PA
HUMIRA (PREF SY KT 10 MG/0.2ML, PREF SY KT 20
MG/0.4ML, PREF SY KT 40 MG/0.8ML)
BRAND
PA
HUMIRA PEDIATRIC CROHNS START PREF SY KT 40
MG/0.8ML
BRAND
PA
HUMIRA PEN PEN KIT 40 MG/0.8ML
BRAND
PA
HUMIRA PEN-CROHNS STARTER PEN KIT 40
MG/0.8ML
BRAND
PA
HUMIRA PEN-PSORIASIS STARTER PEN KIT 40
MG/0.8ML
BRAND
PA
methotrexate sodium (inj 25 mg/ml, inj 50 mg/2ml (25
mg/ml), inj 250 mg/10ml (25 mg/ml), inj pf 25 mg/ml, inj pf
50 mg/2ml (25 mg/ml), inj pf 100 mg/4ml (25 mg/ml), inj pf
200 mg/8ml (25 mg/ml), inj pf 250 mg/10ml (25 mg/ml), inj
pf 1000 mg/40ml (25 mg/ml), tab 2.5 mg (base equiv))
generic
mycophenolate mofetil cap 250 mg
generic
MDD
2 per day
mycophenolate mofetil for oral susp 200 mg/ml
generic
MDD
15 per day
mycophenolate mofetil tab 500 mg
generic
MDD
4 per day
mycophenolate sodium tab dr 180 mg (mycophenolic acid
equiv)
generic
MDD
2 per day
PAGE 79
PRODUCT DESCRIPTION
BRAND/GEN
mycophenolate sodium tab dr 360 mg (mycophenolic acid
equiv)
generic
MDD
4 per day
RAPAMUNE SOLUTION 1 MG/ML
BRAND
MDD
4 per day
RHEUMATREX TAB 2.5 MG
BRAND
SANDIMMUNE SOLUTION 100 MG/ML
BRAND
MDD
8 per day
sirolimus tab 0.5 mg
generic
sirolimus tab 1 mg
generic
MDD
6 per day
sirolimus tab 2 mg
generic
MDD
2 per day
tacrolimus (cap 0.5 mg, cap 1 mg, cap 5 mg)
generic
MDD
3 per day
TREXALL (TAB 5 MG, TAB 7.5 MG, TAB 10 MG, TAB 15
MG)
BRAND
generic
MDD
1 per day
ASACOL TAB DR 400 MG
BRAND
MDD
12 per day
balsalazide disodium cap 750 mg
generic
MDD
9 per day
DELZICOL CAP DR 400 MG
BRAND
MDD
6 per day
mesalamine enema 4 gm
generic
MDD
60 per day
PENTASA (CAP ER 250 MG, CAP ER 500 MG)
BRAND
MDD
8 per day
SFROWASA ENEMA 4 GM/60ML
BRAND
IMMUNIZING AGENTS, PASSIVE
HYPERRHO S/D SOLN PRSYR 1500 UNIT
BRAND
RHOGAM ULTRA-FILTERED PLUS SOLN PRSYR 1500
UNIT
BRAND
IMMUNOMODULATORS
leflunomide (tab 10 mg, tab 20 mg)
INFLAMMATORY BOWEL DISEASE AGENTS
AMINOSALICYLATES
PAGE 80
PRODUCT DESCRIPTION
BRAND/GEN
GLUCOCORTICOIDS
hydrocortisone enema 100 mg/60ml
generic
QL
hydrocortisone rectal cream 2.5%
generic
MPL
1 / claim
420 / claim
SULFONAMIDES
sulfasalazine (tab 500 mg, tab delayed release 500 mg)
generic
METABOLIC BONE DISEASE AGENTS
alendronate sodium (tab 35 mg, tab 70 mg)
generic
MDD
0.15 per day
alendronate sodium (tab 5 mg, tab 10 mg, tab 40 mg)
generic
MDD
1 per day
alendronate sodium oral soln 70 mg/75ml
generic
MDD
10.8 per day
calcitonin (salmon) nasal soln 200 unit/act
generic
QL
4 / 30 days
calcitriol (cap 0.25 mcg, cap 0.5 mcg)
generic
MIACALCIN SOLUTION 200 UNIT/ML
BRAND
QL
2 / 30 days
risedronate sodium (tab 5 mg, tab 30 mg)
generic
PA
MDD
risedronate sodium tab 35 mg
QL
generic
1 per day
4 / 28 days
PA
MISCELLANEOUS THERAPEUTIC AGENTS
*lancet devices***
generic
QL
1 / 180 days
*lancets***
generic
QL
200 / 30 days
1ST CHOICE LANCETS SUPER THIN MISC
BRAND
QL
200 / 30 days
1ST CHOICE LANCETS THIN MISC
BRAND
QL
200 / 30 days
1ST CHOICE LANCETS ULTRA THIN MISC
BRAND
QL
200 / 30 days
1ST TIER UNILET COMFORTOUCH MISC
BRAND
QL
200 / 30 days
ACCU-CHEK SOFT TOUCH LANCETS MISC
BRAND
QL
200 / 30 days
PAGE 81
PRODUCT DESCRIPTION
BRAND/GEN
ACCU-CHEK SOFTCLIX LANCET DEV MISC
BRAND
acetone (urine) test strip
generic
QL
1 / 180 days
QL
1 / 30 days
MPL
1 / 30 days
ADJUSTABLE LANCING DEVICE MISC
BRAND
QL
ADVOCATE INSULIN SYRINGE MISC 31G X 5/16" 1 ML
BRAND
MDD
ADVOCATE LANCING DEVICE MISC
BRAND
QL
1 / 180 days
ADVOCATE RAPID-SAFE LANCING MISC
BRAND
QL
1 / 180 days
AF LANCETS SUPER THIN MISC
BRAND
QL
200 / 30 days
AGAMATRIX ULTRA-THIN LANCETS MISC
BRAND
QL
200 / 30 days
ALTERNATE SITE LANCING DEVICE MISC
BRAND
QL
1 / 180 days
AQUA LANCE ADJUSTABLE LANCING DEVICE
BRAND
QL
1 / 180 days
AURORA LANCET SUPER THIN 30G MISC
BRAND
QL
200 / 30 days
AURORA LANCET THIN 23G MISC
BRAND
QL
200 / 30 days
AUTO-LANCET MINI MISC
BRAND
QL
1 / 180 days
AUTO-LANCET MISC
BRAND
QL
1 / 180 days
AUTOLET IMPRESSION MISC
BRAND
QL
1 / 180 days
AUTOLET LANCING DEVICE MISC
BRAND
QL
1 / 180 days
AUTOLET MINI MISC
BRAND
QL
1 / 180 days
BAYER MICROLET 2 LANCING DEVIC MISC
BRAND
QL
1 / 180 days
BD AUTOSHIELD MISC 29G X 8MM
BRAND
MDD
5 per day
BD INSULIN SYR ULTRAFINE II MISC 31G X 5/16" 1 ML
BRAND
MDD
5 per day
BD INSULIN SYRINGE MICROFINE (MISC 27G 5/8" 1
ML, MISC 28G 1/2" 0.3 ML)
BRAND
MDD
5 per day
BD INSULIN SYRINGE MISC 26G X 1/2" 1 ML
BRAND
MDD
5 per day
BD INSULIN SYRINGE ULTRAFINE MISC 31G X 15/64" 1
ML
BRAND
PAGE 82
QL
MDD
1 / 180 days
5 per day
150 / 30 days
5 per day
PRODUCT DESCRIPTION
BRAND/GEN
BD INSULIN SYRINGE ULTRAFINE MISC 31G X 5/16" 1
ML
BRAND
MDD
BD LANCET DEVICE MISC
BRAND
QL
1 / 180 days
BD LANCET ULTRAFINE 30G MISC
BRAND
QL
200 / 30 days
CARDIOCOM LANCING DEVICE MISC
BRAND
QL
1 / 180 days
CAREONE ADVANCED LANCING DEV MISC
BRAND
QL
1 / 180 days
CAREONE LANCET THIN 23G MISC
BRAND
QL
200 / 30 days
CAREONE LANCET ULTRA THIN 28G MISC
BRAND
QL
200 / 30 days
CHEK-STIX CONTROL STRIP
BRAND
QL
1 / 30 days
CHEMSTRIP K STRIP
BRAND
QL
1 / 30 days
CLEANLET LANCETS 28G MISC
BRAND
QL
200 / 30 days
CLOSERCARE MISC
BRAND
QL
1 / 180 days
COMFORT ASSURED LANCETS 28G MISC
BRAND
QL
200 / 30 days
COMFORT ASSURED LANCETS 33G MISC
BRAND
QL
200 / 30 days
COMFORT EZ INSULIN SYRINGE MISC 31G X 5/16" 1
ML
BRAND
MDD
COMFORT LANCETS MISC
BRAND
QL
200 / 30 days
CVS LANCETS 21G MISC
BRAND
QL
200 / 30 days
CVS LANCETS MICRO THIN 33G MISC
BRAND
QL
200 / 30 days
CVS LANCETS ORIGINAL MISC
BRAND
QL
200 / 30 days
CVS LANCETS THIN 26G MISC
BRAND
QL
200 / 30 days
CVS LANCETS THIN MISC
BRAND
QL
200 / 30 days
CVS LANCETS ULTRA THIN 30G MISC
BRAND
QL
200 / 30 days
CVS LANCING DEVICE MISC
BRAND
QL
1 / 180 days
CVS ULTRA THIN LANCETS MISC
BRAND
QL
200 / 30 days
PAGE 83
5 per day
5 per day
PRODUCT DESCRIPTION
BRAND/GEN
DIASTAR EASY TEST II LANCETS MISC
BRAND
QL
200 / 30 days
DIASTAR EASY TEST LANCETS MISC
BRAND
QL
200 / 30 days
DROPLET LANCETS ULTRA THIN 30G MISC
BRAND
QL
200 / 30 days
DROPLET LANCING DEVICE MISC
BRAND
QL
1 / 180 days
DRUG MART LANCETS THIN 26G MISC
BRAND
QL
200 / 30 days
DRUG MART LANCETS ULTRA THIN MISC
BRAND
QL
200 / 30 days
DRUG MART LANCING DEVICE MISC
BRAND
QL
1 / 180 days
DRUG MART UNILET LANCETS 28G MISC
BRAND
QL
200 / 30 days
DRUG MART UNILET LANCETS 30G MISC
BRAND
QL
200 / 30 days
DUANE READE LANCET ALTERN SITE MISC
BRAND
QL
200 / 30 days
DUANE READE LANCET SUPER THIN MISC
BRAND
QL
200 / 30 days
DUANE READE LANCET ULTRA THIN MISC
BRAND
QL
200 / 30 days
E-Z JECT LANCET MICRO-THIN 33G MISC
BRAND
QL
200 / 30 days
E-Z JECT LANCET SUPER THIN 30G MISC
BRAND
QL
200 / 30 days
E-Z JECT LANCETS 21G MISC
BRAND
QL
200 / 30 days
E-Z JECT LANCETS MISC
BRAND
QL
200 / 30 days
E-Z JECT LANCETS THIN 26G MISC
BRAND
QL
200 / 30 days
EASY MINI LANCING DEVICE MISC
BRAND
QL
1 / 180 days
EASY TOUCH INSULIN SYRINGE MISC 31G X 5/16" 1
ML
BRAND
MDD
EASY TOUCH LANCETS 26G MISC
BRAND
QL
200 / 30 days
EASY TOUCH LANCETS 26G/TWIST MISC
BRAND
QL
200 / 30 days
BRAND
QL
200 / 30 days
BRAND
QL
200 / 30 days
BRAND
QL
200 / 30 days
PAGE 84
5 per day
PRODUCT DESCRIPTION
BRAND/GEN
BRAND
QL
200 / 30 days
BRAND
QL
200 / 30 days
BRAND
QL
200 / 30 days
BRAND
QL
200 / 30 days
EASY TOUCH LANCING DEVICE MISC
BRAND
QL
1 / 180 days
EQL COLOR LANCETS 21G MISC
BRAND
QL
200 / 30 days
EQL COLOR LANCETS MICRO 33G MISC
BRAND
QL
200 / 30 days
EQL INSULIN SYRINGE MISC 31G X 5/16" 1 ML
BRAND
MDD
EQL SUPER THIN LANCETS 30G MISC
BRAND
QL
200 / 30 days
EQL THIN LANCETS 26G MISC
BRAND
QL
200 / 30 days
EZ SMART BLOOD GLUCOSE LANCETS MISC
BRAND
QL
200 / 30 days
EZ-LETS LANCETS 21G MISC
BRAND
QL
200 / 30 days
BRAND
QL
200 / 30 days
BRAND
QL
200 / 30 days
BRAND
QL
200 / 30 days
BRAND
QL
200 / 30 days
FIFTY50 LANCING DEVICE MISC
BRAND
QL
1 / 180 days
FIFTY50 SUPERIOR COMFORT SYR MISC 31G X 5/16"
1 ML
BRAND
MDD
FORA LANCETS MISC
BRAND
QL
200 / 30 days
FORA LANCING DEVICE MISC
BRAND
QL
1 / 180 days
formaldehyde solution 10%
generic
QL
90 / claim
FREDS PHARMACY AUTOLET LANCING MISC
BRAND
QL
1 / 180 days
FREDS PHARMACY UNILET LANC 28G MISC
BRAND
QL
200 / 30 days
FREDS PHARMACY UNILET LANC 30G MISC
BRAND
QL
200 / 30 days
PAGE 85
5 per day
5 per day
PRODUCT DESCRIPTION
BRAND/GEN
FREESTYLE PRECISION INS SYR MISC 31G X 5/16" 1
ML
BRAND
MDD
5 per day
GLOBAL INJECT EASE INSULIN SYR MISC 31G X 5/16"
1 ML
BRAND
MDD
5 per day
GLOBAL LANCING DEVICE MISC
BRAND
QL
1 / 180 days
GLUCOCOM LANCETS 28G MISC
BRAND
QL
200 / 30 days
GLUCOCOM LANCETS 30G MISC
BRAND
QL
200 / 30 days
GLUCOLET 2 AUTOMATIC LANCING MISC
BRAND
QL
1 / 180 days
GLUCOPRO INSULIN SYRINGE MISC 31G X 5/16" 1 ML
BRAND
MDD
GLUCOSOURCE LANCET DEVICE MISC
BRAND
QL
1 / 180 days
GLUCOSOURCE LANCETS MISC
BRAND
QL
200 / 30 days
GNP INSULIN SYRINGE MISC 31G X 5/16" 1 ML
BRAND
MDD
GNP LANCETS 21G MISC
BRAND
QL
200 / 30 days
GNP LANCETS MICRO THIN 33G MISC
BRAND
QL
200 / 30 days
GNP LANCETS MISC
BRAND
QL
200 / 30 days
GNP LANCETS SUPER THIN 30G MISC
BRAND
QL
200 / 30 days
GNP LANCETS THIN 26G MISC
BRAND
QL
200 / 30 days
GNP LANCETS THIN MISC
BRAND
QL
200 / 30 days
GNP MICRO THIN LANCETS 33G MISC
BRAND
QL
200 / 30 days
GNP SUPER THIN LANCETS 30G MISC
BRAND
QL
200 / 30 days
GNP ULTRA COM INSULIN SYRINGE MISC 31G X 5/16"
1 ML
BRAND
MDD
H&H THINLET LANCETS 26G MISC
BRAND
QL
200 / 30 days
H&H THINLET LANCETS 30G MISC
BRAND
QL
200 / 30 days
H-E-B INCONTROL ADV LANCING MISC
BRAND
QL
1 / 180 days
H-E-B INCONTROL LANCETS 28G MISC
BRAND
QL
200 / 30 days
PAGE 86
5 per day
5 per day
5 per day
PRODUCT DESCRIPTION
BRAND/GEN
BRAND
QL
200 / 30 days
BRAND
QL
200 / 30 days
HEALTH CARE LANCING DEVICE MISC
BRAND
QL
1 / 180 days
HEALTHWISE LANCING PEN MISC
BRAND
QL
1 / 180 days
HEALTHY ACCENTS LANCING DEVICE MISC
BRAND
QL
1 / 180 days
HEALTHY ACCENTS UNILET LANCETS MISC
BRAND
QL
200 / 30 days
HM LANCETS MICRO THIN 33G MISC
BRAND
QL
200 / 30 days
HM LANCETS ULTRA THIN 30G MISC
BRAND
QL
200 / 30 days
HY-VEE LANCETS MISC
BRAND
QL
200 / 30 days
HY-VEE THIN LANCETS MISC
BRAND
QL
200 / 30 days
INSPIREASE BAGS MISC
BRAND
QL
3 / 180 days
INSPIREASE MOUTHPIECE MISC
BRAND
QL
1 / 180 days
INSPIREASE RESERVOIR BAGS MISC
BRAND
QL
3 / 180 days
insulin pen needle 29 g x 12 mm (1/2")
generic
MDD
5 per day
insulin pen needle 29 g x 12.7 mm
generic
MDD
5 per day
insulin pen needle 30 g x 8 mm (1/3" or 5/16")
generic
MDD
5 per day
generic
MDD
5 per day
generic
MDD
5 per day
generic
MDD
5 per day
generic
MDD
5 per day
generic
MDD
5 per day
generic
MDD
5 per day
insulin syringe (disp) u-100 1 ml
generic
MDD
5 per day
INSULIN SYRINGE (MISC 29G 1" 0.3 ML, MISC 31G
5/16" 1 ML)
BRAND
MDD
5 per day
PAGE 87
PRODUCT DESCRIPTION
BRAND/GEN
insulin syringe/needle u-100 (syringe/needle 0.3 ml 29 1/2",
syringe/needle 0.3 ml 30 5/16", syringe/needle 1/2 ml 28
1/2", syringe/needle 1 ml 28 1/2", syringe/needle 1/2 ml 29
1/2", syringe/needle 1/2 ml 30 5/16", syringe/needle 1 ml
29 1/2", syringe/needle 1 ml 31 5/16")
generic
MDD
5 per day
insulin syringe/needle u-100 0.3 ml 30 x 1/2"
generic
MDD
5 per day
generic
MDD
5 per day
generic
MDD
5 per day
insulin syringe/needle u-100 1 ml 25 x 1"
generic
MDD
5 per day
insulin syringe/needle u-100 1 ml 25 x 5/8"
generic
MDD
5 per day
generic
MDD
5 per day
generic
MDD
5 per day
generic
MDD
5 per day
insulin syringe/needle u-100 1/2 ml 27 x 1/2"
generic
MDD
5 per day
generic
MDD
5 per day
generic
MDD
5 per day
generic
MDD
5 per day
KETOCARE STRIP
BRAND
QL
1 / 30 days
KETOSTIX STRIP
BRAND
QL
1 / 30 days
KINNEY LANCETS MISC
BRAND
QL
200 / 30 days
KINNEY THIN LANCETS MISC
BRAND
QL
200 / 30 days
KINRAY INSULIN SYRINGE MISC 31G X 5/16" 1 ML
BRAND
MDD
5 per day
KROGER INSULIN SYRINGE MISC 31G X 5/16" 1 ML
BRAND
MDD
5 per day
KROGER LANCETS 21G MISC
BRAND
QL
200 / 30 days
KROGER LANCETS MICRO THIN 33G MISC
BRAND
QL
200 / 30 days
KROGER LANCETS MISC
BRAND
QL
200 / 30 days
PAGE 88
PRODUCT DESCRIPTION
BRAND/GEN
KROGER LANCETS SUPER THIN MISC
BRAND
QL
200 / 30 days
KROGER LANCETS THIN 26G MISC
BRAND
QL
200 / 30 days
KROGER LANCETS THIN MISC
BRAND
QL
200 / 30 days
KROGER LANCETS ULTRATHIN 30G MISC
BRAND
QL
200 / 30 days
KROGER LANCING DEVICE MISC
BRAND
QL
1 / 180 days
LADY LITE LANCETS MISC
BRAND
QL
200 / 30 days
LANCET DEVICE MISC
BRAND
QL
1 / 180 days
LANCETS 28G MISC
BRAND
QL
200 / 30 days
LANCETS 30G MISC
BRAND
QL
200 / 30 days
LANCETS MISC
BRAND
QL
200 / 30 days
LANCETS THIN MISC
BRAND
QL
200 / 30 days
LANCETS ULTRA THIN MISC
BRAND
QL
200 / 30 days
LANCING DEVICE MISC
BRAND
QL
1 / 180 days
LEADER ADVANCED LANCING DEVICE MISC
BRAND
QL
1 / 180 days
LEADER INSULIN SYRINGE MISC 31G X 5/16" 1 ML
BRAND
MDD
LIBERTY MINI LANCING DEVICE MISC
BRAND
QL
1 / 180 days
LITE TOUCH LANCING DEVICE MISC
BRAND
QL
1 / 180 days
LITE TOUCH LANCING PEN MISC
BRAND
QL
1 / 180 days
LITETOUCH INSULIN SYRINGE MISC 31G X 5/16" 1 ML
BRAND
MDD
LIVE BETTER ADV LANCING DEVICE MISC
BRAND
QL
1 / 180 days
LIVE BETTER LANCET SUPER THIN MISC
BRAND
QL
200 / 30 days
LIVE BETTER LANCET ULTRA THIN MISC
BRAND
QL
200 / 30 days
LONGS LANCETS STANDARD MISC
BRAND
QL
200 / 30 days
LONGS LANCETS THIN MISC
BRAND
QL
200 / 30 days
PAGE 89
5 per day
5 per day
PRODUCT DESCRIPTION
BRAND/GEN
MAJOR COMFORT LANCETS MISC
BRAND
QL
200 / 30 days
MEDI-LANCE LANCETS MISC
BRAND
QL
200 / 30 days
MEDICINE SHOPPE LANCETS MISC
BRAND
QL
200 / 30 days
MEDICINE SHOPPE LANCETS THIN MISC
BRAND
QL
200 / 30 days
MEDISENSE THIN LANCETS MISC
BRAND
QL
200 / 30 days
MEIJER LANCETS MISC
BRAND
QL
200 / 30 days
MEIJER LANCETS THIN MISC
BRAND
QL
200 / 30 days
MEIJER LANCETS UNIVERSAL 30G MISC
BRAND
QL
200 / 30 days
MEIJER LANCETS UNIVERSAL 33G MISC
BRAND
QL
200 / 30 days
MEIJER SUPER THIN LANCETS MISC
BRAND
QL
200 / 30 days
methylergonovine maleate tab 0.2 mg
generic
MINI LANCING DEVICE MISC
BRAND
QL
1 / 180 days
MONOJECT INSULIN SYRINGE MISC 31G X 5/16" 1 ML
BRAND
MDD
MONOLET LANCETS MISC
BRAND
QL
200 / 30 days
MONOLET OPD LANCETS MISC
BRAND
QL
200 / 30 days
MS INSULIN SYRINGE MISC 31G X 5/16" 1 ML
BRAND
MDD
NOVA SUREFLEX LANCETS MISC
BRAND
QL
200 / 30 days
NOVA SUREFLEX LANCING DEVICE MISC
BRAND
QL
1 / 180 days
nystatin (bulk) powder
generic
MPL
ON CALL LANCING DEVICE MISC
BRAND
QL
1 / 180 days
ON CALL PLUS LANCING DEVICE MISC
BRAND
QL
1 / 180 days
ONETOUCH DELICA LANCING DEV MISC
BRAND
QL
1 / 180 days
ONETOUCH LANCETS MISC
BRAND
QL
200 / 30 days
ORTHO DIAPHRAGM ALL-FLEX (DIAPHRAGM
DIAPHRAGM 65, DIAPHRAGM DIAPHRAGM 70,
DIAPHRAGM DIAPHRAGM 75, DIAPHRAGM
DIAPHRAGM 80)
BRAND
PAGE 90
5 per day
5 per day
1 / claim
PRODUCT DESCRIPTION
BRAND/GEN
ORTHO DIAPHRAGM COIL (DIAPHRAGM KIT 100,
DIAPHRAGM KIT 105)
BRAND
QL
1 / 180 days
ORTHO DIAPHRAGM COIL KIT 50 MM
BRAND
QL
1 / 365 days
ORTHO DIAPHRAGM FLAT (DIAPHRAGM KIT 55,
DIAPHRAGM KIT 60, DIAPHRAGM KIT 65, DIAPHRAGM
KIT 70, DIAPHRAGM KIT 75, DIAPHRAGM KIT 80,
DIAPHRAGM KIT 85, DIAPHRAGM KIT 90, DIAPHRAGM
KIT 95)
BRAND
QL
1 / 180 days
PC LANCETS SUPER THIN 30G MISC
BRAND
QL
200 / 30 days
PERFECT LANCETS 30G MISC
BRAND
QL
200 / 30 days
PHARMACY COUNTER LANCETS MISC
BRAND
QL
200 / 30 days
PREFERRED PLUS LANCETS COLORED MISC
BRAND
QL
200 / 30 days
PREFERRED PLUS LANCETS THIN MISC
BRAND
QL
200 / 30 days
PRODIGY LANCING DEVICE MISC
BRAND
QL
1 / 180 days
PRODIGY TWIST TOP LANCETS 28G MISC
BRAND
QL
200 / 30 days
PX ADVANCED LANCING DEVICE MISC
BRAND
QL
1 / 180 days
PX INSULIN SYRINGE MISC 31G X 5/16" 1 ML
BRAND
MDD
PX LANCET AUTO INJECTOR MISC
BRAND
QL
1 / 180 days
PX LANCETS MISC
BRAND
QL
200 / 30 days
PX LANCETS ULTRA THIN MISC
BRAND
QL
200 / 30 days
QC ADVANCED LANCING DEVICE MISC
BRAND
QL
1 / 180 days
QC INSULIN SYRINGE MISC 31G X 5/16" 1 ML
BRAND
MDD
QC LANCETS SUPER THIN 30G MISC
BRAND
QL
200 / 30 days
QC LANCETS ULTRA THIN MISC
BRAND
QL
200 / 30 days
QC UNILET LANCETS MICRO THIN MISC
BRAND
QL
200 / 30 days
RA E-ZJECT COLOR LANCETS 33G MISC
BRAND
QL
200 / 30 days
RA E-ZJECT LANCETS 28G MISC
BRAND
QL
200 / 30 days
PAGE 91
5 per day
5 per day
PRODUCT DESCRIPTION
BRAND/GEN
RA E-ZJECT LANCETS THIN 26G MISC
BRAND
QL
200 / 30 days
RA E-ZJECT LANCETS THIN 28G MISC
BRAND
QL
200 / 30 days
RA E-ZJECT LANCETS ULTRA THIN MISC
BRAND
QL
200 / 30 days
RA LANCING DEVICE MISC
BRAND
QL
1 / 180 days
RELION INSULIN SYRINGE MISC 31G X 5/16" 1 ML
BRAND
MDD
RELION LANCETS MICRO-THIN 33G MISC
BRAND
QL
200 / 30 days
RELION LANCETS STANDARD 21G MISC
BRAND
QL
200 / 30 days
RELION LANCETS THIN 26G MISC
BRAND
QL
200 / 30 days
RELION LANCETS ULTRA-THIN 30G MISC
BRAND
QL
200 / 30 days
RELION LANCING DEVICE MISC
BRAND
QL
1 / 180 days
RELION ULTRA THIN LANCETS 30G MISC
BRAND
QL
200 / 30 days
RELION ULTRA THIN PLUS LANCETS MISC
BRAND
QL
200 / 30 days
RENEW ADVANCED LANCING DEVICE MISC
BRAND
QL
1 / 180 days
REXALL LANCETS ULTRA THIN 30G MISC
BRAND
QL
200 / 30 days
RIGHTEST GD500 LANCING DEVICE MISC
BRAND
QL
1 / 180 days
RIGHTEST GL300 LANCETS MISC
BRAND
QL
200 / 30 days
SAFETY SEAL LANCETS MISC
BRAND
QL
200 / 30 days
SB INSULIN SYRINGE MISC 31G X 5/16" 1 ML
BRAND
MDD
SB LANCETS THIN MISC
BRAND
QL
200 / 30 days
SB LANCETS ULTRA THIN MISC
BRAND
QL
200 / 30 days
SELECT-LITE LANCING DEVICE MISC
BRAND
QL
1 / 180 days
SHOPKO AUTOLET LANCING DEVICE MISC
BRAND
QL
1 / 180 days
SHOPKO UNILET LANCETS 28G MISC
BRAND
QL
200 / 30 days
SHOPKO UNILET LANCETS 30G MISC
BRAND
QL
200 / 30 days
PAGE 92
5 per day
5 per day
PRODUCT DESCRIPTION
BRAND/GEN
SIMPLE DIAGNOSTICS LANCING DEV MISC
BRAND
QL
SM INSULIN SYRINGE MISC 31G X 5/16" 1 ML
BRAND
MDD
SM LANCETS 21G MISC
BRAND
QL
200 / 30 days
SM LANCETS 33G MISC
BRAND
QL
200 / 30 days
SM SUPER THIN LANCETS 30G MISC
BRAND
QL
200 / 30 days
SM THIN LANCETS 26G MISC
BRAND
QL
200 / 30 days
SMART DIABETES VANTAGE LANCING MISC
BRAND
QL
1 / 180 days
SMART SENSE COLOR LANCETS 33G MISC
BRAND
QL
200 / 30 days
SMART SENSE STANDARD LANCETS MISC
BRAND
QL
200 / 30 days
SMART SENSE SUPER THIN LANCETS MISC
BRAND
QL
200 / 30 days
SMART SENSE THIN LANCETS 26G MISC
BRAND
QL
200 / 30 days
sodium polystyrene sulfonate (bulk) powder
generic
QL
454 / claim
SOLUS V2 LANCING DEVICE MISC
BRAND
QL
1 / 180 days
STERILANCE TL MISC
BRAND
QL
200 / 30 days
SUPER THIN LANCETS MISC
BRAND
QL
200 / 30 days
SURE COMFORT INSULIN SYRINGE MISC 31G X 5/16"
1 ML
BRAND
MDD
SURE COMFORT LANCING PEN MISC
BRAND
QL
SURE-JECT INSULIN SYRINGE MISC 31G X 5/16" 1 ML
BRAND
MDD
SURE-PEN MISC
BRAND
QL
1 / 180 days
SURELITE LANCETS MISC
BRAND
QL
200 / 30 days
TECHLITE AST LANCETS MISC
BRAND
QL
200 / 30 days
TECHLITE LANCETS 30G MISC
BRAND
QL
200 / 30 days
TECHLITE LANCETS MISC
BRAND
QL
200 / 30 days
TGT ADVANCED LANCING DEVICE MISC
BRAND
QL
1 / 180 days
PAGE 93
1 / 180 days
5 per day
5 per day
1 / 180 days
5 per day
PRODUCT DESCRIPTION
BRAND/GEN
TGT LANCET ALTERNATE SITE MISC
BRAND
QL
200 / 30 days
TGT LANCET MICRO THIN 33G MISC
BRAND
QL
200 / 30 days
TGT LANCET SUPER THIN 30G MISC
BRAND
QL
200 / 30 days
TGT LANCET THIN 23G MISC
BRAND
QL
200 / 30 days
TGT LANCET THIN 26G MISC
BRAND
QL
200 / 30 days
TGT LANCET ULTRA THIN 28G MISC
BRAND
QL
200 / 30 days
TGT LANCET ULTRA THIN 30G MISC
BRAND
QL
200 / 30 days
TGT LANCING DEVICE MISC
BRAND
QL
1 / 180 days
TODAYS HEALTH LANCING DEVICE MISC
BRAND
QL
1 / 180 days
TODAYS HEALTH THIN LANCETS 28G MISC
BRAND
QL
200 / 30 days
TODAYS HEALTH THIN LANCETS 30G MISC
BRAND
QL
200 / 30 days
TOPCARE ULTRA COMFORT INS SYR MISC 31G X
5/16" 1 ML
BRAND
MDD
5 per day
TRUE METRIX AIR GLUCOSE METER KIT W/DEVICE
BRAND
TRUE METRIX BLOOD GLUCOSE TEST STRIP
BRAND
MDD
5 per day
TRUE METRIX LEVEL 1 SOLUTION LOW
BRAND
QL
1 / 90 days
TRUE METRIX LEVEL 2 SOLUTION NORMAL
BRAND
QL
1 / 90 days
TRUE METRIX LEVEL 3 SOLUTION HIGH
BRAND
QL
1 / 90 days
TRUE METRIX METER KIT W/DEVICE
BRAND
TRUEPLUS LANCETS 26G MISC
BRAND
QL
200 / 30 days
BRAND
QL
200 / 30 days
BRAND
QL
200 / 30 days
BRAND
QL
200 / 30 days
TRUERESULT BLOOD GLUCOSE KIT W/DEVICE
BRAND
TRUETEST CONTROL LEVEL 1 LIQUID
BRAND
QL
1 / 90 days
PAGE 94
PRODUCT DESCRIPTION
BRAND/GEN
BRAND
QL
1 / 90 days
BRAND
QL
1 / 90 days
TRUETEST TEST STRIP
BRAND
MDD
TRUETRACK GLUCOSE CONTROL (LIQUID, LIQUID
LOW)
BRAND
QL
TRUETRACK TEST STRIP
BRAND
MDD
ULTI-LANCE AUTO-ADJUST DEVICE MISC
BRAND
QL
1 / 180 days
ULTI-LANCE AUTOMATIC MISC
BRAND
QL
1 / 180 days
ULTI-LANCE MINI ADJUSTABLE MISC
BRAND
QL
1 / 180 days
ULTICARE INSULIN SYRINGE MISC 31G X 5/16" 1 ML
BRAND
MDD
ULTILET BASIC LANCETS 30G MISC
BRAND
QL
200 / 30 days
ULTILET CLASSIC LANCETS MISC
BRAND
QL
200 / 30 days
ULTILET INSULIN SYRINGE (MISC 7/16" 0.5 ML, MISC
7/16" 0.3 ML, MISC 7/16" 1 ML)
BRAND
MDD
5 per day
ULTILET INSULIN SYRINGE SHORT MISC 31G X 5/16" 1
ML
BRAND
MDD
5 per day
ULTILET LANCETS MISC
BRAND
QL
ULTRA COMFORT INSULIN SYRINGE MISC 31G X 5/16"
1 ML
BRAND
MDD
ULTRA THIN LANCETS 28G MISC
BRAND
QL
200 / 30 days
ULTRA THIN LANCETS 30G MISC
BRAND
QL
200 / 30 days
ULTRA-COMFORT INSULIN SYRINGE MISC 31G X 5/16"
1 ML
BRAND
MDD
5 per day
ULTRA-THIN II INS SYR SHORT MISC 31G X 5/16" 1 ML
BRAND
MDD
5 per day
UNILET COMFORTOUCH LANCET MISC
BRAND
QL
200 / 30 days
UNILET EXCELITE II MISC
BRAND
QL
200 / 30 days
UNILET EXCELITE MISC
BRAND
QL
200 / 30 days
PAGE 95
5 per day
1 / 90 days
5 per day
5 per day
200 / 30 days
5 per day
PRODUCT DESCRIPTION
BRAND/GEN
UNILET G.P. LANCET MISC
BRAND
QL
200 / 30 days
UNILET G.P. SUPERLITE LANCET MISC
BRAND
QL
200 / 30 days
UNILET GP 28 ULTRA THIN MISC
BRAND
QL
200 / 30 days
UNILET LANCET MISC
BRAND
QL
200 / 30 days
UNILET MICRO-THIN 33G MISC
BRAND
QL
200 / 30 days
UNILET SUPER-THIN 30G MISC
BRAND
QL
200 / 30 days
UNILET SUPERLITE LANCET MISC
BRAND
QL
200 / 30 days
UNILET ULTRA-THIN 28G MISC
BRAND
QL
200 / 30 days
UNIVERSAL 1 LANCETS THIN 26G MISC
BRAND
QL
200 / 30 days
UNIVERSAL 1 LANCETS ULTRA THIN MISC
BRAND
QL
200 / 30 days
VALUE PLUS LANCET STANDARD 21G MISC
BRAND
QL
200 / 30 days
VALUE PLUS LANCETS SUPER THIN MISC
BRAND
QL
200 / 30 days
VALUE PLUS LANCETS THIN 26G MISC
BRAND
QL
200 / 30 days
VALUE PLUS LANCING DEVICE MISC
BRAND
QL
1 / 180 days
VALUMARK LANCET SUPER THIN 30G MISC
BRAND
QL
200 / 30 days
VALUMARK LANCET ULTRA THIN 28G MISC
BRAND
QL
200 / 30 days
VIDA MIA AUTOLET LANCING DEV MISC
BRAND
QL
1 / 180 days
VIDA MIA UNILET LANCETS 28G MISC
BRAND
QL
200 / 30 days
VIDA MIA UNILET LANCETS 30G MISC
BRAND
QL
200 / 30 days
VISTOGARD PACKET 10 GM
BRAND
W&F LANCETS 26G MISC
BRAND
QL
200 / 30 days
W&F LANCETS COLORED 21G MISC
BRAND
QL
200 / 30 days
WALGREENS LANCETS MICRO THIN MISC
BRAND
QL
200 / 30 days
WALGREENS LANCETS MISC
BRAND
QL
200 / 30 days
PAGE 96
PRODUCT DESCRIPTION
BRAND/GEN
WALGREENS LANCETS SUPER THIN MISC
BRAND
QL
200 / 30 days
WALGREENS LANCING DEVICE MISC
BRAND
QL
1 / 180 days
WALGREENS THIN LANCETS MISC
BRAND
QL
200 / 30 days
WALGREENS ULTRA THIN LANCETS MISC
BRAND
QL
200 / 30 days
atropine sulfate ophth soln 1%
generic
MPL
1 / claim
bacitracin-polymyxin b ophth oint
generic
QL
4 / claim
BLEPHAMIDE S.O.P. OINTMENT 10-0.2 %
BRAND
QL
4 / claim
BLEPHAMIDE SUSPENSION 10-0.2 %
BRAND
MPL
1 / claim
cyclopentolate hcl ophth soln 0.5%
generic
cyclopentolate hcl ophth soln 1%
generic
MPL
1 / claim
ISOPTO HOMATROPINE SOLUTION 2 %
BRAND
QL
5 / claim
naphazoline hcl ophth soln 0.1%
generic
QL
15 / claim
neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt
op oin
generic
QL
4 / claim
neomycin-polymy-gramicid op sol 1.75-10000-0.025mgunt-mg/ml
generic
QL
10 / claim
neomycin-polymyxin-dexamethasone ophth oint 0.1%
generic
QL
4 / claim
neomycin-polymyxin-dexamethasone ophth susp 0.1%
generic
QL
5 / claim
neomycin-polymyxin-hc ophth susp
generic
QL
8 / claim
phenylephrine hcl ophth soln 2.5%
generic
MPL
1 / claim
polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%
generic
QL
PRED-G SUSPENSION 0.3-1 %
BRAND
MPL
1 / claim
sulfacetamide sodium-prednisolone ophth soln 100.23(0.25)%
generic
MPL
1 / claim
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS, OTHER
PAGE 97
10 / claim
PRODUCT DESCRIPTION
BRAND/GEN
tobramycin-dexamethasone ophth susp 0.3-0.1%
generic
MPL
tropicamide ophth soln 0.5%
generic
QL
tropicamide ophth soln 1%
generic
MPL
1 / claim
QL
5 / claim
1 / claim
15 / claim
OPHTHALMIC ANTI-ALLERGY AGENTS
ALOCRIL SOLUTION 2 %
BRAND
ST
QL
ALOMIDE SOLUTION 0.1 %
BRAND
10 / claim
ST
azelastine hcl ophth soln 0.05%
QL
generic
6 / claim
ST
cromolyn sodium ophth soln 4%
generic
QL
10 / claim
dexamethasone sodium phosphate ophth soln 0.1%
generic
QL
5 / claim
diclofenac sodium ophth soln 0.1%
generic
MPL
1 / claim
fluorometholone ophth susp 0.1%
generic
MPL
1 / claim
flurbiprofen sodium ophth soln 0.03%
generic
QL
3 / claim
FML OINTMENT 0.1 %
BRAND
QL
4 / claim
ketorolac tromethamine ophth soln 0.4%
generic
MFL
1 / 30 days
ketorolac tromethamine ophth soln 0.5%
generic
MPL
1 / claim
NEVANAC SUSPENSION 0.1 %
BRAND
QL
3 / claim
PRED MILD SUSPENSION 0.12 %
BRAND
QL
10 / claim
prednisolone acetate ophth susp 1%
generic
MPL
1 / claim
VEXOL SUSPENSION 1 %
BRAND
MPL
1 / claim
OPHTHALMIC ANTI-INFLAMMATORIES
PAGE 98
PRODUCT DESCRIPTION
BRAND/GEN
OPHTHALMIC ANTIGLAUCOMA AGENTS
apraclonidine hcl ophth soln 0.5% (base equivalent)
generic
AZOPT SUSPENSION 1 %
BRAND
MPL
1 / claim
betaxolol hcl ophth soln 0.5%
generic
MPL
1 / claim
BETOPTIC-S SUSPENSION 0.25 %
BRAND
MPL
1 / claim
brimonidine tartrate ophth soln 0.2%
generic
MPL
1 / claim
carteolol hcl ophth soln 1%
generic
MFL
1 / 30 days
dorzolamide hcl ophth soln 2%
generic
QL
10 / claim
dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml
generic
QL
10 / claim
IOPIDINE SOLUTION 1 %
BRAND
ISOPTO CARBACHOL (SOLUTION 1.5 %, SOLUTION 3
%)
BRAND
levobunolol hcl (soln 0.25%, soln 0.5%)
generic
methazolamide (tab 25 mg, tab 50 mg)
generic
metipranolol ophth soln 0.3%
generic
pilocarpine hcl (soln 1%, soln 2%, soln 4%)
generic
timolol maleate (ophth) (gel forming soln 0.5%, soln 0.25%,
soln 0.5%)
TIMOPTIC OCUDOSE (SOLUTION 0.25 %, SOLUTION
0.5 %)
MPL
1 / claim
generic
MPL
1 / claim
BRAND
MPL
1 / claim
generic
QL
3 / claim
acetic acid otic soln 2%
generic
QL
15 / claim
antipyrine-benzocaine otic soln 54-14 mg/ml (5.4-1.4%)
generic
MPL
1 / claim
CIPRODEX SUSPENSION 0.3-0.1 %
BRAND
QL
8 / claim
fluocinolone acetonide (otic) oil 0.01%
generic
MPL
OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS
latanoprost ophth soln 0.005%
OTIC AGENTS
PAGE 99
1 / 30 days
PRODUCT DESCRIPTION
BRAND/GEN
hydrocortisone w/ acetic acid otic soln 1-2%
generic
QL
10 / claim
neomycin-polymyxin-hc otic soln 1%
generic
QL
10 / claim
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml1%
generic
MPL
1 / claim
pramoxine-chloroxylenol otic liquid 1-0.1%
generic
MFL
1 / 30 days
pramoxine-hc-chloroxylenol otic soln 10-10-1 mg/ml
generic
MPL
1 / 30 days
AEROSPAN AERO SOLN 80 MCG/ACT
BRAND
QL
8.9 / 30 days
budesonide (inhalation) (susp 0.25 mg/2ml, susp 0.5
mg/2ml)
QL
generic
120 / 30 days
AL
Up to 6 yrs old
budesonide inhalation susp 1 mg/2ml
QL
generic
60 / 30 days
AL
Up to 6 yrs old
OTC Covered Only
RESPIRATORY TRACT/PULMONARY AGENTS
ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS
FLONASE SUSPENSION 50 MCG/ACT
BRAND
C
FLOVENT DISKUS (AER POW BA 100 MCG/BLIST, AER
POW BA 250 MCG/BLIST)
BRAND
MDD
FLOVENT DISKUS AER POW BA 50 MCG/BLIST
BRAND
QL
60 / 25 days
FLOVENT HFA (AEROSOL 110 MCG/ACT, AEROSOL
220 MCG/ACT)
BRAND
QL
12 / 25 days
FLOVENT HFA AEROSOL 44 MCG/ACT
BRAND
QL
11 / 25 days
flunisolide nasal soln 25 mcg/act (0.025%)
generic
QL
25 / claim
flunisolide nasal soln 29 mcg/act (0.025%)
generic
PULMICORT FLEXHALER (AER POW BA 90 MCG/ACT,
AER POW BA 180 MCG/ACT)
BRAND
QL
1 / 25 days
QVAR (AERO SOLN 40 MCG/ACT, AERO SOLN 80
MCG/ACT)
BRAND
QL
15 / 30 days
2 per day
ANTIHISTAMINES
azelastine hcl (0.1% (137 mcg/), 0.15% (205.5 mcg/))
PAGE 100
generic
PRODUCT DESCRIPTION
BRAND/GEN
cyproheptadine hcl (syrup 2 mg/5ml, tab 4 mg)
generic
DEXCHLORPHENIRAMINE MALEATE SYRUP 2 MG/5ML
BRAND
hydroxyzine hcl (syrup 10 mg/5ml, tab 10 mg, tab 25 mg,
tab 50 mg)
generic
hydroxyzine pamoate (cap 25 mg, cap 50 mg, cap 100 mg)
generic
promethazine hcl (tab 12.5 mg, tab 25 mg, tab 50 mg)
generic
promethazine hcl suppos 12.5 mg
generic
promethazine hcl suppos 25 mg
promethazine hcl syrup 6.25 mg/5ml
AL
At least 2 yrs old
QL
12 / claim
AL
At least 2 yrs old
QL
12 / claim
AL
At least 2 yrs old
QL
12 / claim
AL
At least 2 yrs old
QL
240 / claim
AL
At least 2 yrs old
generic
generic
generic
ANTILEUKOTRIENES
montelukast sodium (chew tab 4 mg, chew tab 5 mg, oral
granules packet 4 mg, tab 10 mg)
generic
MDD
1 per day
ATROVENT HFA AERO SOLN 17 MCG/ACT
BRAND
QL
INCRUSE ELLIPTA AER POW BA 62.5 MCG/INH
BRAND
MPL
ipratropium bromide inhal soln 0.02%
generic
QL
375 / 25 days
ipratropium bromide nasal soln 0.03% (21 mcg/spray)
generic
QL
30 / 25 days
ipratropium bromide nasal soln 0.06% (42 mcg/spray)
generic
QL
15 / 30 days
TUDORZA PRESSAIR AER POW BA 400 MCG/ACT
BRAND
QL
1 / 30 days
ADRENACLICK SOLN A-INJ 0.3 MG/0.3ML
BRAND
QL
4 / year
ADRENALIN SOLUTION 0.1 %
BRAND
BRONCHODILATORS, ANTICHOLINERGIC
26 / 30 days
1 / 30 days
BRONCHODILATORS, SYMPATHOMIMETIC
PAGE 101
PRODUCT DESCRIPTION
BRAND/GEN
albuterol sulfate (soln nebu 0.63 mg/3ml, soln nebu 1.25
mg/3ml)
generic
albuterol sulfate (syrup 2 mg/5ml, tab 2 mg, tab 4 mg, tab
sr 12hr 4 mg, tab sr 12hr 8 mg)
generic
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)
QL
375 / 30 days
generic
QL
375 / 25 days
albuterol sulfate soln nebu 0.5% (5 mg/ml)
generic
MDD
EPINEPHRINE SOLN A-INJ 0.3 MG/0.3ML
BRAND
QL
4 / year
EPIPEN 2-PAK SOLN A-INJ 0.3 MG/0.3ML
BRAND
QL
4 / year
EPIPEN JR 2-PAK SOLN A-INJ 0.15 MG/0.3ML
BRAND
QL
4 / year
EPIPEN JR SOLN A-INJ 0.15 MG/0.3ML
BRAND
QL
4 / year
EPIPEN SOLN A-INJ 0.3 MG/0.3ML
BRAND
QL
4 / year
FORADIL AEROLIZER CAP 12 MCG
BRAND
MDD
2 per day
metaproterenol sulfate (tab 10 mg, tab 20 mg)
generic
metaproterenol sulfate syrup 10 mg/5ml
generic
MDD
30 per day
SEREVENT DISKUS AER POW BA 50 MCG/DOSE
BRAND
MDD
2 per day
terbutaline sulfate (tab 2.5 mg, tab 5 mg)
generic
TWINJECT SOLN A-INJ 0.3 MG/0.3ML
BRAND
QL
4 / year
VENTOLIN HFA AERO SOLN 108 (90 BASE) MCG/ACT
BRAND
QL
2 / 30 days
KALYDECO (PACKET 50 MG, PACKET 75 MG, TAB 150
MG)
BRAND
PA
ORKAMBI TAB 200-125 MG
BRAND
PA
tobramycin nebu soln 300 mg/5ml
generic
PA
2 per day
CYSTIC FIBROSIS AGENTS
PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE
aminophylline (tab 100 mg, tab 200 mg)
generic
caffeine citrate (inj 60 mg/3ml mg/ml, oral soln 60 mg/3ml
mg/ml)
generic
PAGE 102
QL
45 / claim
MFL
2 / lifetime
PRODUCT DESCRIPTION
BRAND/GEN
ELIXOPHYLLIN ELIXIR 80 MG/15ML
BRAND
LUFYLLIN TAB 400 MG
BRAND
THEO-24 (CAP ER 24H 400 MG, CAP ER 24H 100 MG,
CAP ER 24H 200 MG, CAP ER 24H 300 MG)
BRAND
theophylline (tab 12hr 200 mg, tab 12hr 450 mg, tab 12hr
300 mg, tab 12hr 100 mg, tab 24hr 600 mg, tab 24hr 400
mg)
generic
theophylline soln 80 mg/15ml
generic
QL
475 / claim
RESPIRATORY TRACT AGENTS, OTHER
acetylcysteine (soln 10%, soln 20%)
generic
COMBIVENT AEROSOL 18-103 MCG/ACT
BRAND
MDD
COMBIVENT RESPIMAT AERO SOLN 20-100 MCG/ACT
BRAND
QL
4 / 30 days
cromolyn sodium soln nebu 20 mg/2ml
generic
QL
240 / 30 days
DULERA (AEROSOL 100-5 MCG/ACT, AEROSOL 200-5
MCG/ACT)
BRAND
QL
13 / 30 days
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml
generic
MDD
sodium chloride soln nebu 0.9%
generic
SYMBICORT (AEROSOL 80-4.5 MCG/ACT, AEROSOL
160-4.5 MCG/ACT)
BRAND
QL
1 per day
12 per day
11 / 30 days
SKELETAL MUSCLE RELAXANTS
chlorzoxazone tab 500 mg
generic
cyclobenzaprine hcl (tab 5 mg, tab 10 mg)
generic
methocarbamol (tab 500 mg, tab 750 mg)
generic
MDD
3 per day
SLEEP DISORDER AGENTS
GABA RECEPTOR MODULATORS
temazepam (cap 15 mg, cap 30 mg)
generic
MDD
1 per day
triazolam (tab 0.125 mg, tab 0.25 mg)
generic
MDD
1 per day
ST
zaleplon (cap 5 mg, cap 10 mg)
generic
AL
MDD
PAGE 103
At least 18 yrs old
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
zolpidem tartrate (tab 5 mg, tab 10 mg)
generic
MDD
1 per day
generic
MDD
1 per day
*sodium polystyrene sulfonate powder**
generic
QL
CHEMET CAP 100 MG
BRAND
JADENU (TAB 90 MG, TAB 180 MG, TAB 360 MG)
BRAND
sodium polystyrene sulfonate oral susp 15 gm/60ml
generic
SLEEP DISORDERS, OTHER
flurazepam hcl (cap 15 mg, cap 30 mg)
THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES
ELECTROLYTE/MINERAL MODIFIERS
454 / claim
PA
ELECTROLYTE/MINERAL REPLACEMENT
*ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab 106-1
mg***
generic
FLURA-DROPS SOLUTION 0.55 (0.25 F) MG/DROP
BRAND
KLOR-CON M15 TAB ER 15 MEQ
BRAND
potassium bicarbonate effer tab 25 meq
generic
potassium chloride (cap cr 10 meq, oral soln 10% (20
meq/15ml), oral soln 20% (40 meq/15ml), powder packet
20 meq, tab cr 8 meq (600 mg), tab cr 10 meq)
generic
potassium chloride cap cr 8 meq
generic
potassium chloride microencapsulated crystals cr
(mioencapsulated ys tab 10, mioencapsulated ys tab 20)
generic
sodium chloride iv soln 0.9%
generic
sodium fluoride (chew tab 0.25 mg f (from 0.55 mg, chew
tab 0.5 mg f (from 1.1 mg, chew tab 1 mg f (from 2.2 mg,
soln 0.125 mg/drop f (0.275 mg/drop, soln 0.5 mg/ml f
(from 1.1 mg/ml)
generic
*pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/ml**
generic
*pediatric multiple vitamins w/ fluoride chew tab 1 mg***
PAGE 104
MDD
1 per day
MDD
1 per day
QL
50 / claim
AL
Up to 13 yrs old
QL
30 / 30 days
AL
Up to 13 yrs old
generic
PRODUCT DESCRIPTION
BRAND/GEN
*pediatric vitamins acd fluoride & fe drops 0.25-10 mg/ml***
generic
b-complex w/ c & folic acid (w/ ap 1, w/ tab 1)
CAVAN-FOLATE OB TAB 65-1 MG
generic
BRAND
QL
50 / claim
AL
Up to 13 yrs old
MDD
GL
Female
AL
Up to 45 yrs old
MDD
CO-NATAL FA TAB
BRAND
BRAND
Female
AL
Up to 45 yrs old
generic
ergocalciferol cap 50000 unit
generic
INATAL ADVANCE TAB
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
BRAND
1 per day
GL
Female
AL
Up to 45 yrs old
MDD
LACTOCAL-F TAB
1 per day
GL
MDD
INATAL ULTRA TAB
1 per day
GL
MDD
INATAL GT TAB
1 per day
GL
MDD
cyanocobalamin inj 1000 mcg/ml
1 per day
GL
MDD
COMPLETENATE CHEW TAB 29-1 MG
1 per day
1 per day
GL
Female
AL
Up to 45 yrs old
MDD
1 per day
levocarnitine oral soln 1 gm/10ml (10%)
generic
MDD
30 per day
levocarnitine tab 330 mg
generic
MDD
3 per day
PAGE 105
PRODUCT DESCRIPTION
MARNATAL-F PLUS DUO PACK MISC 60-1-250 & 250
MG
BRAND/GEN
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
MEPHYTON TAB 5 MG
MYNATAL (CAP, TAB 90-1 MG)
BRAND
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
MYNATAL ADVANCE TAB
BRAND
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
1 per day
GL
Female
AL
Up to 45 yrs old
MDD
PAGE 106
1 per day
GL
MDD
O-CAL PRENATAL TAB
1 per day
GL
MDD
NATALVIT TAB
1 per day
GL
MDD
NATAL-V RX TAB 29-1 MG
1 per day
GL
MDD
NATACHEW CHEW TAB 29-1 MG
1 per day
GL
MDD
MYNATE 90 PLUS TAB ER
1 per day
GL
MDD
MYNATAL-Z TAB
1 per day
GL
MDD
MYNATAL PLUS TAB
1 per day
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
pediatric multivitamins w/fl (w/ chew tab 0.25, w/ chew tab
0.5)
generic
pediatric multivitamins w/fl (w/ soln 0.25 mg/ml***, w/ soln
0.5 mg/ml***)
generic
pediatric vitamins acd w/ fluoride (w/ soln 0.25 mg/ml***, w/
soln 0.5 mg/ml***)
generic
PNV FE FUM/DOCUSATE/FOLIC ACID TAB 29-1 MG
AL
BRAND
MDD
1 per day
QL
50 / claim
AL
Up to 13 yrs old
QL
50 / claim
AL
Up to 13 yrs old
GL
Female
AL
Up to 45 yrs old
MDD
PNV TABS 29-1 TAB 29-1 MG
POLY-VITAMIN/FLUORIDE/IRON SOLUTION 0.5-10
MG/ML
PRENACARE TAB 90-1 MG
BRAND
Female
AL
Up to 45 yrs old
MDD
1 per day
QL
50 / claim
AL
Up to 13 yrs old
GL
Female
AL
Up to 45 yrs old
MDD
PRENATABS FA TAB
BRAND
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
1 per day
GL
Female
AL
Up to 45 yrs old
MDD
PAGE 107
1 per day
GL
MDD
PRENATAL AD TAB
1 per day
GL
MDD
PRENATAL 19 (19 CHEW TAB, 19 CHEW TAB 29-1 MG,
19 TAB 29-1 MG, 19 TAB)
1 per day
GL
MDD
PRENATABS RX TAB 29-1 MG
1 per day
GL
BRAND
BRAND
Up to 13 yrs old
1 per day
PRODUCT DESCRIPTION
PRENATAL PLUS IRON TAB 29-1 MG
BRAND/GEN
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
PRETAB TAB 29-1 MG
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
RE PRENATAL MULTIVITAMIN/IRON CHEW TAB 29-1
MG
BRAND
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
1 per day
GL
Female
AL
Up to 45 yrs old
MDD
PAGE 108
1 per day
GL
MDD
TRINATAL RX 1 TAB 60-1 MG
1 per day
GL
MDD
TRINATAL GT TAB 90-1 MG
1 per day
GL
MDD
TRIADVANCE TAB 90-1 MG
1 per day
GL
MDD
SE-NATAL ONE TAB 60-1 MG
1 per day
GL
MDD
SE-NATAL 90 TAB ER 90-1 MG
1 per day
GL
MDD
SE-NATAL 19 (19 TAB MG, 19 CHEW TAB MG)
1 per day
GL
MDD
RE-NATA 29 OB TAB 29-1 MG
1 per day
1 per day
PRODUCT DESCRIPTION
TRINATAL ULTRA TAB 90-1 MG
BRAND/GEN
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
VENATAL-FA TAB 29-1 MG
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
VINATE CALCIUM TAB 27-1 MG
BRAND
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
1 per day
GL
Female
AL
Up to 45 yrs old
MDD
PAGE 109
1 per day
GL
MDD
VITAFOL-OB TAB
1 per day
GL
MDD
VIRT-VITE GT TAB 90-1 MG
1 per day
GL
MDD
VIRT-ADVANCE TAB 90-1 MG
1 per day
GL
MDD
VINATE ULTRA TAB
1 per day
GL
MDD
VINATE ONE TAB 60-1 MG
1 per day
GL
MDD
VINATE M TAB 27-1 MG
1 per day
GL
MDD
VINATE GT TAB 90-1 MG
1 per day
1 per day
PRODUCT DESCRIPTION
VITAFOL-PN TAB
BRAND/GEN
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
VITASPIRE TAB 29-1 MG
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
VOL-TAB RX TAB 29-1 MG
BRAND
1 per day
1 per day
GL
Female
AL
Up to 45 yrs old
MDD
1 per day
ANTISPASTICITY AGENTS
baclofen (tab 10 mg, tab 20 mg)
generic
tizanidine hcl (tab 2 mg (base equivalent), tab 2 mg, tab 4
mg (base equivalent), tab 4 mg)
generic
PAGE 110
Index of covered drugs
1
ALKERAN
46
ALLEVYN PLUS CAVITY
16
1ST CHOICE LANCETS SUPER THIN
81
ALLEVYN THIN
16
1ST CHOICE LANCETS THIN
81
allopurinol
44
1ST CHOICE LANCETS ULTRA THIN
81
almotriptan malate
45
1ST TIER UNILET COMFORTOUCH
81
ALOCRIL
98
ALOMIDE
98
alprazolam
54
A
A-200
11
ALTERNATE SITE LANCING DEVICE
82
abacavir sulfate
51
alum & mag hydrox-simethicone
13
abacavir sulfate-lamivudine-zidovudine
51
aluminum chloride
68
ACCU-CHEK SOFT TOUCH LANCETS
81
aluminum hydroxide gel
13
ACCU-CHEK SOFTCLIX LANCET DEV
82
amantadine hcl
48
acebutolol hcl
61
amiloride & hydrochlorothiazide
63
amiloride hcl
64
59
acetaminophen
10,15
acetaminophen w/ codeine
31
aminocaproic acid
acetazolamide
64
aminophylline
acetic acid (otic)
99
amiodarone hcl
60
acetone (urine) test
82
amitriptyline hcl
42
amlodipine besylate
62
acetylcysteine
103
102
ACNE MEDICATION 5
11
amlodipine besylate-benazepril hcl
63
acyclovir
54
amoxapine
42
acyclovir topical
54
amoxicillin
36
ADJUSTABLE LANCING DEVICE
82
amoxicillin & pot clavulanate
36
ADRENACLICK
101
amphetamine-dextroamphetamine
66
ADRENALIN
101
ampicillin
36
ADULT AEROSOL MASK
15
anastrozole
47
ADVOCATE INSULIN SYRINGE
82
ANDRODERM
74
ADVOCATE LANCING DEVICE
82
ANDROXY
74
ADVOCATE RAPID-SAFE LANCING
82
antipyrine-benzocaine
99
APEXICON E
72
AEROSPAN
100
AF LANCETS SUPER THIN
82
APIDRA
56
AGAMATRIX ULTRA-THIN LANCETS
82
APIDRA SOLOSTAR
56
AIMSCO LUBRICATED
15
apraclonidine hcl
99
AIRS PEDIATRIC AEROSOL MASK
15
APTIVUS
52
AQUA LANCE ADJUSTABLE LANCING
82
albuterol sulfate
102
ALCOHOL PREP
15
ARIAL CHAMBER
16
alcohol swabs
15
aripiprazole
49
ALCOHOL SWABS
16
ARMOUR THYROID
78
alendronate sodium
81
artificial tear ointment
23
ALER-DRYL
24
ARTIFICIAL TEARS
23
PAGE 111
ASACOL
80
BACTROBAN NASAL
34
ascorbic acid
26
balsalazide disodium
80
aspirin
8
BAYER MICROLET 2 LANCING DEVIC
82
aspirin buffered
8
BD AUTOSHIELD
82
aspirin buffered (cal carb-mag carb-mag oxide)
8
BD GLUCOSE
10
aspirin tab chew 81 mg
8
BD INSULIN SYR ULTRAFINE II
82
atenolol
61
BD INSULIN SYRINGE
82
atenolol & chlorthalidone
63
BD INSULIN SYRINGE MICROFINE
82
atorvastatin calcium
65
BD INSULIN SYRINGE ULTRAFINE
82,83
ATRIPLA
51
BD LANCET DEVICE
83
atropine sulfate (ophthalmic)
97
BD LANCET ULTRAFINE 30G
83
BD SWAB SINGLE USE REGULAR
16
ATROVENT HFA
101
AURORA LANCET SUPER THIN 30G
82
benazepril & hydrochlorothiazide
63
AURORA LANCET THIN 23G
82
benazepril hcl
60
AUTO-LANCET
82
benzoyl peroxide
11
AUTO-LANCET MINI
82
benztropine mesylate
47
AUTOLET IMPRESSION
82
betamethasone dipropionate augmented
72
AUTOLET LANCING DEVICE
82
betamethasone valerate
72
AUTOLET MINI
82
betaxolol hcl (ophth)
99
AVANDAMET
55
bethanechol chloride
72
AVANDARYL
55
BETOPTIC-S
99
AVANDIA
55
BIATAIN ADHESIVE FOAM DRESSING
16
AVONEX
67
BIATAIN FOAM DRESSING
16
AVONEX PEN
67
bicalutamide
46
AVONEX PREFILLED
67
BIOTENE MOISTURIZING MOUTH
10
AXID AR
13
BIOTENE ORALBALANCE DRY MOUTH
10
AZASAN
79
bisacodyl ec tab dr 5 mg
13
azathioprine
79
bisacodyl laxative suppos 10 mg
14
bismuth subsalicylate
13
azelastine hcl
100
azelastine hcl (ophth)
98
bisoprolol & hydrochlorothiazide
63
azithromycin
37
bisoprolol fumarate
61
AZOPT
99
BLEPHAMIDE
97
BLEPHAMIDE S.O.P.
97
BORDERED GAUZE
16
B
b complex w/ c
26
BRILINTA
59
b-complex vitamins
26
brimonidine tartrate
99
bromocriptine mesylate
48
16
b-complex w/ c & folic acid
105
bacitracin (topical)
11
BUBBLES THE FISH II PEDI MASK
bacitracin zinc
11
budesonide (inhalation)
bacitracin-polymyxin b (ophth)
97
bumetanide
64
buprenorphine hcl
33
baclofen
PAGE 112
110
100
bupropion hcl
40,41
CARRASMART FOAM
16
bupropion hcl (smoking deterrent)
33
carteolol hcl (ophth)
99
40
carvedilol
61
41
CASTIVA WARMING
11
buspirone hcl
54
CAVAN-FOLATE OB
105
butalbital-acetaminophen
67
cefaclor
35
butalbital-acetaminophen-caffeine
67
cefadroxil
35
butalbital-acetaminophen-caffeine w/ codeine
31
cefdinir
35
30,67
cefprozil
35
butalbital-aspirin-caffeine w/cod
31
CEFTIN
36
BYDUREON
55
ceftriaxone sodium
36
BYETTA 10 MCG PEN
55
cefuroxime axetil
36
BYETTA 5 MCG PEN
55
celecoxib
30
cephalexin
36
cetirizine hcl
24
cetirizine hcl allergy child solution 5 mg/5ml
24
102
24
calcipotriene
68
24
calcitonin (salmon)
81
24
calcitriol
81
CHANTIX
33
calcium acetate (phosphate binder)
72
CHANTIX CONTINUING MONTH PAK
33
calcium carbonate
25
CHANTIX STARTING MONTH PAK
33
calcium carbonate (antacid)
13
CHEK-STIX CONTROL
83
calcium carbonate-cholecalciferol
25
CHEMET
calcium carbonate-vitamin d
25
CHEMSTRIP K
83
calcium polycarbophil
14
childrens loratadine syrup 5 mg/5ml
24
camphor & menthol
11
chlordiazepoxide hcl
54
capsaicin
11
chlorhexidine gluconate (mouth-throat)
68
captopril
60
chloroquine phosphate
47
captopril & hydrochlorothiazide
63
chlorothiazide
64
CAPZASIN-P
11
chlorpheniramine maleate
24
CARAFATE
71
24
carbamazepine
39
chlorpromazine hcl
48
carbamide peroxide (otic)
23
chlorthalidone
64
carbidopa
48
chlorzoxazone
103
carbidopa-levodopa
48
CHOLBAM
CARDIOCOM LANCING DEVICE
83
cholecalciferol
CAREONE ADVANCED LANCING DEV
83
cholestyramine
65
CAREONE LANCET THIN 23G
83
cholestyramine light
65
CAREONE LANCET ULTRA THIN 28G
83
choline & mag salicylate
30
CARRASMART
16
cilostazol
59
butalbital-aspirin-caffeine
C
CAFERGOT
caffeine citrate
PAGE 113
44
104
70
15,26
CILOXAN
37
cimetidine
13,70
COMFORT EZ INSULIN SYRINGE
83
COMFORT LANCETS
83
51
cimetidine hcl
70
COMPLERA
CIPRODEX
99
complete ready-to-use enema enema 7-19
ciprofloxacin hcl
37,38
gm/118ml
14
ciprofloxacin hcl (ophth)
37
COMPLETENATE
105
citalopram hydrobromide
41
CONCEPTROL INSERTS
15
clarithromycin
37
CONE MASK
16
CLASSIC PRENATAL
26
COPA ISLAND BORDERED FOAM
16
CLEAN & CLEAR ADVANTAGE 3-IN-1
11
COPA PLUS HYDROPHILIC FOAM
16
CLEANLET LANCETS 28G
83
COPAXONE
67
clemastine fumarate tab 1.34 mg
24
COREG CR
61
clindamycin hcl
34
cortisone acetate
72
clindamycin palmitate hydrochloride
34
COTELLIC
47
clindamycin phosphate (topical)
34
COVRSITE COVER DRESSING
16
clindamycin phosphate vaginal
34
COVRSITE PLUS COMPOSITE DRESS
16
clindamycin phosphate-benzoyl peroxide
68
CREON
69
clobetasol propionate
72
CRIXIVAN
53
clobetasol propionate emollient base
72
cromolyn sodium
clomipramine hcl
42
cromolyn sodium (nasal)
16
clonazepam
54
cromolyn sodium (ophth)
98
clonidine hcl
59
CUPRIMINE
72
clopidogrel bisulfate
59
CUREX ALL-PURPOSE SPONGES
16
clorazepate dipotassium
54
CURITY ALCOHOL PREPS
16
CLOSERCARE
83
CURITY ALCOHOL SWABS
16
103
clotrimazole (topical)
9
CURITY ALL PURPOSE SPONGES
16
clotrimazole vaginal
9
CURITY AMD ANTIMICROBIAL SPNGE
16
clotrimazole w/ betamethasone
68
CURITY COVER SPONGE
16
clozapine
50
CURITY DRESSING SPONGES
16
CURITY GAUZE
16
CO-NATAL FA
105
coal tar extract
12
CURITY GAUZE SPONGE
16
COARTEM
47
CURITY NON-ADHERENT STRIPS
17
codeine sulfate
31
CURITY SPONGES
17
colchicine
44
CVS ADHESIVE DRESSINGS 4"X4"
17
colchicine w/ probenecid
44
CVS ALCOHOL PREP SWABS
17
colestipol hcl
65
CVS ALCOHOL SWABS
17
COMBIPATCH
74
CVS DRY MOUTH
11
COMBIVENT
103
CVS GAUZE
17
COMBIVENT RESPIMAT
103
CVS GAUZE PAD STERILE
17
COMFORT ASSURED LANCETS 28G
83
CVS GAUZE STERILE
17
COMFORT ASSURED LANCETS 33G
83
CVS GLUCOSE
10
PAGE 114
CVS LANCETS 21G
83
Desogestrel-Ethinyl Estradiol TAB 0.15-0.02/0.01 MG
CVS LANCETS MICRO THIN 33G
83
(Azurette, Kariva, Pimtrea, Viorele, Caziant, Cesia,
CVS LANCETS ORIGINAL
83
Velivet)
CVS LANCETS THIN
83
Desogestrel-Ethinyl Estradiol TAB 0.15-30 MG-MCG
CVS LANCETS THIN 26G
83
(Apri, Emoquette, Enskyce, Reclipsen, Solia)
75
CVS LANCETS ULTRA THIN 30G
83
DEX4 QUICK DISSOLVE GLUCOSE
10
CVS LANCING DEVICE
83
dexamethasone
72
CVS NON-ADHESIVE
17
DEXAMETHASONE INTENSOL
72
CVS PRENATAL
27
dexamethasone sodium phosphate (ophth)
98
CVS PREP
17
DEXCHLORPHENIRAMINE MALEATE
CVS STERILE PADS
17
dexmethylphenidate hcl
66
CVS ULTRA THIN LANCETS
83
dextroamphetamine sulfate
66
74
101
cyanocobalamin
105
dextromethorphan-guaifenesin
25
cyclobenzaprine hcl
103
dextrose (diabetic use)
10
cyclopentolate hcl
97
DIASTAR EASY TEST II LANCETS
84
cyclophosphamide
46
DIASTAR EASY TEST LANCETS
84
cyclosporine
79
diazepam
55
cyclosporine modified (for microemulsion)
79
diazepam (anticonvulsant)
38
dibucaine
12
dibucaine (rectal)
12
diclofenac potassium
30
cyproheptadine hcl
101
D
DAKLINZA
50
diclofenac sodium
30
dapsone
45
diclofenac sodium (ophth)
98
DELZICOL
80
dicloxacillin sodium
36
DEPO-SUBQ PROVERA 104
77
dicyclomine hcl
69
DERMACEA DRAIN SPONGES
17
didanosine
51
DERMACEA GAUZE SPONGE
17
diflorasone diacetate
72
DERMACEA IV DRAIN SPONGES
17
diflunisal
30
DERMACEA IV SPONGES
17
digoxin
63
DERMACEA NON-WOVEN SPONGES
17
dihydroergotamine mesylate
44
DERMACEA TYPE VII GAUZE
17
DILANTIN
39
DERMACEA X-RAY SPONGES
17
diltiazem hcl
62
DERMALEVIN ADHESIVE
17
diltiazem hcl coated beads
62
DESCOVY
51
diltiazem hcl extended release beads
62
desipramine hcl
42
diphenhydramine hcl
24
desmopressin acetate
74
diphenhydramine hcl (sleep)
25
desmopressin acetate refrigerated
74
diphenhydramine hcl (topical)
12
desmopressin acetate spray
74
24
desmopressin acetate spray refrigerated
74
24
desogestrel-ethinyl estradiol (triphasic)
74
diphenhydramine hcl elixir 12.5 mg/5ml
24
diphenhydramine hcl liquid 12.5 mg/5ml
24
PAGE 115
diphenoxylate w/ atropine
70
EARLOOP MASK
17
dipyridamole
59
EASY MINI LANCING DEVICE
84
disopyramide phosphate
60
EASY TOUCH ALCOHOL PREP MEDIUM
17
disulfiram
33
EASY TOUCH INSULIN SYRINGE
84
divalproex sodium
39
EASY TOUCH LANCETS 26G
84
docusate sodium
14
EASY TOUCH LANCETS 26G/TWIST
84
14
84
dofetilide
60
84
donepezil hydrochloride
40
84
dorzolamide hcl
99
85
dorzolamide hcl-timolol maleate
99
85
doxazosin mesylate
60
85
doxepin hcl
42
85
doxycycline hyclate
38
EASY TOUCH LANCING DEVICE
85
doxylamine succinate (sleep)
25
econazole nitrate
43
DRESSING SPONGES
17
EDURANT
51
DROPLET LANCETS ULTRA THIN 30G
84
EFFIENT
59
DROPLET LANCING DEVICE
84
EGRIFTA
78
drospirenone-ethinyl estradiol
75
ELEXA NATURAL FEEL
17
Drospirenone-Ethinyl Estradiol TAB 3-0.03 MG (Gianvi,
ELEXA STIMULATING
17
Loryna, Nikki, Vestura, Ocella, Syeda, Zarah)
75
ELEXA ULTRA SENSITIVE
18
DROXIA
46
ELIDEL
68
DRUG MART LANCETS THIN 26G
84
ELIQUIS
58
DRUG MART LANCETS ULTRA THIN
84
ELIXOPHYLLIN
DRUG MART LANCING DEVICE
84
ELLA
77
DRUG MART UNILET LANCETS 28G
84
ELMIRON
72
DRUG MART UNILET LANCETS 30G
84
EMBEDA
31
DRY MOUTH SPRAY
11
emollient
11
DUANE READE LANCET ALTERN SITE
84
EMTRIVA
52
DUANE READE LANCET SUPER THIN
84
enalapril maleate
60
DUANE READE LANCET ULTRA THIN
84
enalapril maleate & hydrochlorothiazide
63
ENBREL
79
DULERA
103
103
duloxetine hcl
67
ENBREL SURECLICK
79
DUTOPROL
63
ENCARE
15
enoxaparin sodium
58
EPANED
60
E
E-Z JECT LANCET MICRO-THIN 33G
84
EPCLUSA
50
E-Z JECT LANCET SUPER THIN 30G
84
EPIFOAM
68
E-Z JECT LANCETS
84
EPINEPHRINE
102
E-Z JECT LANCETS 21G
84
EPIPEN
102
E-Z JECT LANCETS THIN 26G
84
EPIPEN 2-PAK
102
PAGE 116
EPIPEN JR
102
EZ-LETS LANCETS 26G
85
EPIPEN JR 2-PAK
102
EZ-LETS LANCETS 28G
85
EPZICOM
52
EZ-LETS LANCETS 30G
85
EQL COLOR LANCETS 21G
85
EQL COLOR LANCETS MICRO 33G
85
F
EQL GAUZE
18
famotidine
EQL GAUZE STERILE
18
FANTASY LUBRICATED
18
EQL INSULIN SYRINGE
85
FANTASY LUBRICATED/SPERMICIDE
18
EQL PRENATAL FORMULA
27
FARESTON
46
EQL SUPER THIN LANCETS 30G
85
felbamate
39
EQL THIN LANCETS 26G
85
felodipine
62
105
fenofibrate
64
ergocalciferol
13,70
ergoloid mesylates
40
fenofibrate micronized
64
ERY-TAB
37
fentanyl
31
ERYPED 400
37
FERRETTS
25
ERYTHROCIN STEARATE
37
ferrous fumarate
25
erythromycin (acne aid)
37
ferrous fumarate-fa-b complex-c-zn-mg-mn-cu
erythromycin (ophth)
37
ferrous gluconate
25
erythromycin base
37
FERROUS GLUCONATE
25
erythromycin ethylsuccinate
37
ferrous sulfate
erythromycin-sulfisoxazole
37
ferrous sulfate dried
26
escitalopram oxalate
41
24
esterified estrogens & methyltestosterone
75
24
ESTRACE
75
fiber cap 0.52 gm
14
estradiol
75
FIFTY50 ALCOHOL PREP
18
estradiol & norethindrone acetate
75
FIFTY50 LANCING DEVICE
85
estropipate
75
FIFTY50 SUPERIOR COMFORT SYR
85
ethambutol hcl
45
finasteride
71
ethosuximide
38
FIRST-OMEPRAZOLE
71
Ethynodiol Diacetate & Ethinyl Estradiol Tab 1 MG-35
FIRST-VANCOMYCIN 25
34
MCG (Kelnor, Zovia)
75
FIRST-VANCOMYCIN 50
34
etodolac
30
flavoxate hcl
71
EURAX
47
flecainide acetate
61
EVOTAZ
53
FLEXZAN
18
EXCILON DRAIN SPONGES
18
FLONASE
100
EXCILON IV SPONGES
18
FLONASE ALLERGY RELIEF
EXELON
40
FLOVENT DISKUS
100
exemestane
47
FLOVENT HFA
100
EZ SMART BLOOD GLUCOSE LANCETS
85
fluconazole
43
EZ-LETS LANCETS 21G
85
fludrocortisone acetate
73
EZ-LETS LANCETS 23G
85
flunisolide (nasal)
PAGE 117
104
25,26
23
100
fluocinolone acetonide (otic)
99
ginger (zingiber officinalis)
18
fluocinonide
73
glatiramer acetate
67
fluocinonide emulsified base
73
glimepiride
55
fluorometholone (ophth)
98
glipizide
55
fluorouracil (topical)
68
glipizide-metformin hcl
55
fluoxetine hcl
41
GLOBAL INJECT EASE INSULIN SYR
86
fluphenazine decanoate
48
GLOBAL LANCING DEVICE
86
fluphenazine hcl
48
GLUCAGEN HYPOKIT
56
FLURA-DROPS
104
GLUCAGON EMERGENCY
56
flurazepam hcl
104
GLUCOCOM LANCETS 28G
86
flurbiprofen
30
GLUCOCOM LANCETS 30G
86
flurbiprofen sodium
98
GLUCOLET 2 AUTOMATIC LANCING
86
flutamide
46
GLUCOPRO INSULIN SYRINGE
86
fluticasone propionate
73
GLUCOSOURCE LANCET DEVICE
86
fluticasone propionate (nasal)
23
GLUCOSOURCE LANCETS
86
fluvoxamine maleate
41
glyburide
55
FML
98
glyburide micronized
55
folic acid
27
glyburide-metformin
56
FORA LANCETS
85
glycerin (laxative)
14
FORA LANCING DEVICE
85
glycopyrrolate
69
GNP ALCOHOL SWABS
18
FORADIL AEROLIZER
102
formaldehyde
85
GNP GLUCOSE
10
fosinopril sodium
60
GNP INSULIN SYRINGE
86
fosinopril sodium & hydrochlorothiazide
63
GNP LANCETS
86
FREDS PHARMACY AUTOLET LANCING
85
GNP LANCETS 21G
86
FREDS PHARMACY UNILET LANC 28G
85
GNP LANCETS MICRO THIN 33G
86
FREDS PHARMACY UNILET LANC 30G
85
GNP LANCETS SUPER THIN 30G
86
FREESTYLE PRECISION INS SYR
86
GNP LANCETS THIN
86
furosemide
64
GNP LANCETS THIN 26G
86
GNP MICRO THIN LANCETS 33G
86
GNP PRENATAL
27
G
gabapentin
39
GNP PRENATAL VITAMINS
27
GABITRIL
39
GNP QUICK DISSOLVE GLUCOSE
10
galantamine hydrobromide
40
GNP STERILE PADS
18
gauze pads & dressings
18
GNP SUPER THIN LANCETS 30G
86
GAUZE SPONGE
18
GNP ULTRA COM INSULIN SYRINGE
86
gemfibrozil
65
griseofulvin microsize
43
gentamicin sulfate (ophth)
34
griseofulvin ultramicrosize
43
gentamicin sulfate (topical)
34
guanabenz acetate
59
GENVOYA
51
guanfacine hcl
59
GILENYA
67
GYNAZOLE-1
43
PAGE 118
GYNOL II
15
H
HUMULIN 70/30 PEN
57
HUMULIN N
57
HUMULIN N KWIKPEN
57
H&H THINLET LANCETS 26G
86
HUMULIN N PEN
57
H&H THINLET LANCETS 30G
86
HUMULIN R
57
H-E-B INCONTROL ADV LANCING
86
HY-VEE LANCETS
87
H-E-B INCONTROL LANCETS 28G
86
HY-VEE THIN LANCETS
87
87
hydralazine hcl
65
87
hydrochlorothiazide
64
haloperidol
48
hydrocodone-acetaminophen
haloperidol decanoate
48
hydrocortisone
73
haloperidol lactate
49
hydrocortisone (intrarectal)
81
HARVONI
50
hydrocortisone (rectal)
81
HEALTH CARE LANCING DEVICE
87
hydrocortisone (topical)
12,68
HEALTHWISE LANCING PEN
87
hydrocortisone butyrate
73
HEALTHY ACCENTS LANCING DEVICE
87
hydrocortisone w/acetic acid
HEALTHY ACCENTS UNILET LANCETS
87
hydrocortisone-aloe vera
12
HEALTHY LIVING FILTERS
18
hydromorphone hcl
32
HEALTHY LIVING MASKS
18
hydroxychloroquine sulfate
47
HEALTHY LIVING REPLACEMENT KIT
18
hydroxyurea
46
HEMANGEOL
46
hydroxyzine hcl
101
heparin sodium (porcine)
58
hydroxyzine pamoate
101
HM LANCETS MICRO THIN 33G
87
hyoscyamine sulfate
70
HM LANCETS ULTRA THIN 30G
87
HYPERRHO S/D
80
HM PRENATAL
27
HYPOTEARS
23
HUMALOG
57
hypromellose (ophth)
23
HUMALOG KWIKPEN
56
HYSINGLA ER
31
HUMALOG MIX 50/50
57
HUMALOG MIX 50/50 KWIKPEN
56
I
HUMALOG MIX 50/50 PEN
57
ibuprofen
HUMALOG MIX 75/25
57
ibuprofen tab 200 mg
HUMALOG MIX 75/25 KWIKPEN
57
imipramine hcl
42
HUMALOG MIX 75/25 PEN
57
imiquimod
68
HUMALOG PEN
57
INATAL ADVANCE
105
HUMIRA
79
INATAL GT
105
HUMIRA PEDIATRIC CROHNS START
79
INATAL ULTRA
105
HUMIRA PEN
79
INCRUSE ELLIPTA
101
HUMIRA PEN-CROHNS STARTER
79
indapamide
64
HUMIRA PEN-PSORIASIS STARTER
79
indomethacin
30
HUMULIN 70/30
57
INHALER COMPANIONS
18
HUMULIN 70/30 KWIKPEN
57
INSPIREASE BAGS
87
PAGE 119
31,32
100
8,30
8
INSPIREASE MOUTHPIECE
87
isosorbide dinitrate
65
INSPIREASE RESERVOIR BAGS
87
isosorbide mononitrate
65
87
isotretinoin
68
insulin pen needle 29 g x 12.7 mm
87
itraconazole
43
87
87
J
87
J & J GAUZE
18
87
J & J GAUZE SPONGES 12-PLY
18
87
18
87
18
87
J & J NON-STICK DRESSING
18
INSULIN SYRINGE
87
J & J ULCER DRESSING
18
insulin syringe (disp) u-100 1 ml
87
JADENU
insulin syringe/needle u-100
88
JENTADUETO
88
88
K
88
KALETRA
insulin syringe/needle u-100 1 ml 25 x 1"
88
KALYDECO
88
KAMELEON LUBRICATED
18
88
KENDALL HYDROPHILIC FOAM DRESS
19
88
KENDALL HYDROPHILIC FOAM PLUS
19
88
KERLIX SPONGES
19
88
KETOCARE
88
88
ketoconazole
44
88
ketoconazole (topical)
44
88
ketoprofen
30
INTELENCE
51
ketorolac tromethamine
30
INVIRASE
53
ketorolac tromethamine (ophth)
98
IOPIDINE
99
KETOSTIX
88
104
56
53
102
ipratropium bromide
101
ketotifen fumarate (ophth)
23
ipratropium bromide (nasal)
101
KEY-E
27
ipratropium-albuterol
103
KIMONO
19
irbesartan
60
KIMONO MICRO THIN
19
irbesartan-hydrochlorothiazide
63
KIMONO MICRO THIN PLUS
19
IRON CHEWS PEDIATRIC
26
KIMONO PLUS
19
ISENTRESS
51
KIMONO PS
19
ISLAND GARD-GRX
18
KIMONO PS PLUS
19
isoniazid
46
KIMONO SENSATION
19
ISONIAZID
46
KIMONO SENSATION PLUS
19
ISOPTO CARBACHOL
99
KINNEY LANCETS
88
ISOPTO HOMATROPINE
97
KINNEY THIN LANCETS
88
PAGE 120
KINRAY INSULIN SYRINGE
KLOR-CON M15
88
104
LEADER INSULIN SYRINGE
89
LEADER QUICK DISSOLVE GLUCOSE
10
KOMBIGLYZE XR
56
leflunomide
80
KP PRENATAL MULTIVITAMINS
27
letrozole
47
KPN PRENATAL
27
leucovorin calcium
46
KROGER INSULIN SYRINGE
88
LEUKERAN
46
KROGER LANCETS
88
levetiracetam
38
KROGER LANCETS 21G
88
levobunolol hcl
99
KROGER LANCETS MICRO THIN 33G
88
levocarnitine (metabolic modifiers)
KROGER LANCETS SUPER THIN
89
levofloxacin
KROGER LANCETS THIN
89
Levonorg-Eth Est Tab 0.15-0.03MG(84) & Eth Est Tab
KROGER LANCETS THIN 26G
89
0.01MG(7) (Amethia, Camrese, Daysee)
KROGER LANCETS ULTRATHIN 30G
89
Levonorgest-Eth Estrad 91-Day TAB 0.15-0.03 MG
KROGER LANCING DEVICE
89
(Introvale, Jolessa, Quasense)
75
levonorgestrel (emergency oc)
15,77
L
105
38
75
Levonorgestrel-Eth Estra Tab 0.05-30/0.075-40/0.125-
labetalol hcl
61
30MG (Enpresse, Levonest, Myzilra, Trivora)
lactic acid (ammonium lactate)
12
Levonorgestrel-Ethinyl Estrad TAB 0.1-20 MG (Aubra,
LACTOCAL-F
105
75
Aviane, Delyla, Falmina, Lessina, Lutera, Orsythia,
lactulose
70
Sronyx)
lactulose (encephalopathy)
70
Levonorgestrel-Ethinyl Estrad TAB 0.15-30 MG
LADY LITE LANCETS
89
(Altavera, Chateal, Kurvelo, Levora, Marlissa, Portia)75
lamivudine
52
levothyroxine sodium
78
lamivudine-zidovudine
52
LEXIVA
53
lamotrigine
39
LIBERTY MINI LANCING DEVICE
89
LANCET DEVICE
89
LICEMD
12
lancet devices
81
LICIDE TREATMENT
12
lancets
81
lidocaine
68
LANCETS
89
lidocaine hcl
LANCETS 28G
89
lidocaine hcl (mouth-throat)
LANCETS 30G
89
lidocaine-prilocaine
33,69
LANCETS THIN
89
liothyronine sodium
78
LANCETS ULTRA THIN
89
lisinopril
60
LANCING DEVICE
89
lisinopril & hydrochlorothiazide
63
lanolin
19
LITE TOUCH LANCING DEVICE
89
lanolin (topical)
11
LITE TOUCH LANCING PEN
89
lansoprazole
14
LITETOUCH INSULIN SYRINGE
89
LANTUS
57
lithium
55
LANTUS SOLOSTAR
57
lithium carbonate
55
latanoprost
99
LIVE BETTER ADV LANCING DEVICE
89
LEADER ADVANCED LANCING DEVICE
89
LIVE BETTER LANCET SUPER THIN
89
PAGE 121
75
8,68
33
LIVE BETTER LANCET ULTRA THIN
89
memantine hcl
40
LONGS LANCETS STANDARD
89
meperidine hcl
32
LONGS LANCETS THIN
89
MEPHYTON
106
loperamide hcl
13
meprobamate
54
loperamide hcl tab 2 mg
13
mercaptopurine
46
loratadine allergy relief tab disp 10 mg
24
mesalamine
80
loratadine tab 10 mg
24
metaproterenol sulfate
lorazepam
55
metformin hcl
56
losartan potassium
60
methadone hcl
31
losartan potassium & hydrochlorothiazide
63
methazolamide
99
lovastatin
65
methenamine mandelate
34
loxapine succinate
49
methenamine-hyosc-methylene blue-sod phos-phenyl
LUFYLLIN
103
M
102
sal
34
methimazole
78
METHITEST
74
magnesium citrate solution 1.745 gm/30ml
14
methocarbamol
magnesium oxide
13
methotrexate sodium
79
MAJOR COMFORT LANCETS
90
methyldopa
59
MAKENA
77
methylergonovine maleate
90
malathion
47
methylphenidate hcl
66
maprotiline hcl
41
methylprednisolone
73
metipranolol
99
MARNATAL-F PLUS DUO PACK
106
103
MAXX
19
metoclopramide hcl
43
MAXX PLUS
19
metolazone
64
meclizine hcl
9
metoprolol & hydrochlorothiazide
63
MEDI-LANCE LANCETS
90
metoprolol succinate
61
MEDICINE SHOPPE LANCETS
90
metoprolol tartrate
61
MEDICINE SHOPPE LANCETS THIN
90
metronidazole
34
MEDISENSE THIN LANCETS
90
metronidazole (topical)
35
medroxyprogesterone acetate
77
metronidazole cream 0.75 %
35
medroxyprogesterone acetate (contraceptive)
77
metronidazole gel 0.75 %
35
mefloquine hcl
47
metronidazole vaginal
35
megestrol acetate
77
mexiletine hcl
61
MEIJER ALCOHOL SWABS
19
MIACALCIN
81
MEIJER LANCETS
90
MICONAZOLE 3
44
MEIJER LANCETS THIN
90
miconazole nitrate (topical)
9
MEIJER LANCETS UNIVERSAL 30G
90
miconazole nitrate vaginal
9
MEIJER LANCETS UNIVERSAL 33G
90
MICROELITE BATTERY
19
MEIJER SUPER THIN LANCETS
90
MICROELITE FILTER REPLACEMENTS
19
melatonin
19
midazolam hcl
54
meloxicam
30
midodrine hcl
59
PAGE 122
milk of magnesia suspension 400 mg/5ml
14
naproxen sodium
MINI LANCING DEVICE
90
naproxen sodium tab 220 mg
MINIELITE FILTER REPLACEMENTS
19
naratriptan hcl
45
minocycline hcl
38
NARCAN
33
minoxidil
65
nasal moisturizing spray solution 0.65 %
19
MIRASORB SPONGES
19
NATACHEW
106
mirtazapine
41
NATAL-V RX
106
misoprostol
71
NATALVIT
106
MISSION PRENATAL
27
nateglinide
56
MOI-STIR
11
NATURE-THROID
78
mometasone furoate
73
NECON 1/50 (28)
76
MONOJECT INSULIN SYRINGE
90
NECON 10/11 (28)
76
MONOLET LANCETS
90
nefazodone hcl
41
MONOLET OPD LANCETS
90
neomycin sulfate
34
neomycin-bacitracin zn-polymyxin
97
neomycin-bacitracin-polymyxin
11
montelukast sodium
morphine sulfate
101
31,32
30
8
MOUTH KOTE
11
neomycin-polymy-dexameth
97
MS INSULIN SYRINGE
90
neomycin-polymyxin w/ pramoxine
12
MS QUICK DISSOLVE GLUCOSE
10
neomycin-polymyxin-gramicidin
97
multiple vitamin
26
neomycin-polymyxin-hc (ophth)
97
multiple vitamins w/ iron
26
neomycin-polymyxin-hc (otic)
multiple vitamins w/ minerals
26
NESSI SPACER WITH MASK LARGE
19
mupirocin
35
NESSI SPACER WITH MASK SM/MED
19
mupirocin calcium (topical)
35
NESSI SPACER WITH MOUTHPIECE
19
mycophenolate mofetil
79
NEVANAC
98
mycophenolate sodium
79,80
nevirapine
51
NEXIUM 24HR
14
100
MYLERAN
46
MYNATAL
106
niacin
MYNATAL ADVANCE
106
NIACOR
65
MYNATAL PLUS
106
nicardipine hcl
62
MYNATAL-Z
106
nicotine
8
MYNATE 90 PLUS
106
NICOTINE
8
nicotine polacrilex
8
N
10,27
NICOTROL
33
nabumetone
30
NICOTROL NS
33
nadolol
61
nifedipine
62
naloxone hcl
33
NINLARO
47
naltrexone hcl
33
NITRO-BID
65
naphazoline hcl
97
nitrofurantoin
35
naphazoline w/ pheniramine
23
nitrofurantoin macrocrystal
35
naproxen
30
nitrofurantoin monohyd macro
35
PAGE 123
nitroglycerin
66
NIZORAL A-D
9
nortriptyline hcl
42,43
NORVIR
53
NORDITROPIN
74
NOVA MAX PLUS KETONE TEST
20
NORDITROPIN FLEXPRO
74
NOVA SUREFLEX LANCETS
90
NORDITROPIN NORDIFLEX PEN
74
NOVA SUREFLEX LANCING DEVICE
90
NOVOLIN 70/30
57
NOVOLIN 70/30 RELION
57
Norethindrone & Ethinyl Estradiol Tab 0.4 MG-35 MCG
NOVOLIN N
57
(Balziva, Briellyn, Gildagia, Philith, Vyfemla,
NOVOLIN N RELION
57
NOVOLIN R
57
Norethindrone & Ethinyl Estradiol Tab 0.5 MG-35 MCG
NOVOLIN R RELION
57
(Necon, Nortrel, Wera)
NOVOLOG
58
Norethindrone & Ethinyl Estradiol Tab 1 MG-35 MCG
NOVOLOG FLEXPEN
58
(Alyacen, Cyclafem, Dasetta, Necon, Nortrel,
NOVOLOG MIX 70/30
58
NOVOLOG MIX 70/30 FLEXPEN
58
NOVOLOG PENFILL
58
NU GAUZE 4PLY
20
Norethindrone Ace & Ethinyl Estradiol Tab 1.5 MG-30
NU GAUZE GENERAL-USE SPONGES
20
MCG (Gildess, Junel, Larin, Microgestin)
NUTRICION PORVIDA
28
Norethindrone Ace & Ethinyl Estradiol-FE Tab 1 MG-20
NUVARING
77
nystatin
Norelgestromin-Ethinyl Estradiol TD PTWK 150-35
MCG/24HR (Xulane)
Zenchent)
Pirmella)
76
76
76
76
Norethindrone Ace & Ethinyl Estradiol Tab 1 MG-20
76
76
76
Norethindrone Ace & Ethinyl Estradiol-FE Tab 1.5 MG-
nystatin (mouth-throat)
30 MCG (Gildess, Junel, Larin, Microgestin)
76
nystatin (topical)
norethindrone acetate
77
nystatin-triamcinolone
Norethindrone Tab 0.35 MG (Camila, Deblitane, Errin,
Heather, Jencycla, Jolivette, Lyza, Nora-BE, Norlyroc,
O
Sharobel)
O-CAL PRENATAL
77
43,44
44
44,90
44
106
Norethindrone-Eth Estradiol Tab 0.5-35/0.75-35/1-35
ofloxacin
38
MG (Alyacen, Cyclafem, Dasetta, Necon, Nortrel,
ofloxacin (ophth)
38
ofloxacin (otic)
38
OGESTREL
77
olanzapine
49
Norgestimate & Ethinyl Estradiol Tab 0.25 MG-35 MCG
omega-3 fatty acids
10
(Estarylla, Mono-Linyah, MonoNessa, Previfem,
omeprazole
71
76
omeprazole delayed release tab 20 mg
14
Norgestimate-Eth Estrad Tab 0.18-35/0.215-35/0.25-35
OMEPRAZOLE+SYRSPEND SF ALKA
71
MG (Tri-Estarylla, Tri-Linyah, Tri-Previfem, Tri-
ON CALL LANCING DEVICE
90
ON CALL PLUS LANCING DEVICE
90
ondansetron hcl
43
Pirmella)
76
Norethindrone-Eth Estradiol Tab 0.5-35/1-35/0.5-35
MG (Aranelle, Leena)
Sprintec)
Sprintec, Trinessa)
76
76
Norgestrel & Ethinyl Estradiol Tab 0.3 MG-30 MCG
(Cryselle, Elinest, Low-Ogestrel)
76
43
NORINYL 1+50 (28)
76
43
PAGE 124
ONETOUCH DELICA LANCING DEV
90
pediatric vitamins adc
26
ONETOUCH LANCETS
90
peg 3350-kcl-sod bicarb-sod chloride-sod sulfate
70
ONGLYZA
56
peg 3350-potassium chloride-sod bicarbonate-sod
OPTICHAMBER FACE MASK-LARGE
20
chloride
70
OPTICHAMBER FACE MASK-MEDIUM
20
penicillin v potassium
36
OPTICHAMBER FACE MASK-SMALL
20
PENTASA
80
OPTIFOAM
20
pentoxifylline
63
OPTIONS GYNOL II CONTRACEPTIVE
15
PERFECT LANCETS 30G
91
oral electrolytes
25
permethrin
ORAL RELIEF SPRAY
11
permethrin & pyrethrins-piperonyl butoxide
12
perphenazine
43
ORKAMBI
102
12,20,47
ORTHO DIAPHRAGM ALL-FLEX
90
perphenazine-amitriptyline
41
ORTHO DIAPHRAGM COIL
91
PERRY PRENATAL
28
ORTHO DIAPHRAGM FLAT
91
PHARMACY COUNTER LANCETS
91
oxaprozin
30
phenazopyridine hcl
72
oxazepam
55
phenelzine sulfate
41
oxcarbazepine
39
phenobarbital
39
oxybutynin chloride
71
phenylephrine hcl (ophth)
97
phenylephrine hcl tab 10 mg
20
oxycodone hcl
31,32
oxycodone w/ acetaminophen
32
phenylephrine-cocoa butter
12
oxycodone-aspirin
32
phenylephrine-mineral oil-petrolatum
12
OXYCONTIN
31
phenylephrine-shark liver oil-cocoa butter
12
oyster shell
26
phenylephrine-shark liver oil-mineral oil-petrolatum 12
P
phenytoin
39
phenytoin sodium extended
39
PANCREAZE
69
PHRENILIN FORTE
67
pancrelipase (lipase-protease-amylase)
69
pilocarpine hcl
99
pantoprazole sodium
71
pilocarpine hcl (oral)
68
paregoric
70
PIN-X
paroxetine hcl
41,42
9
pindolol
62
PC LANCETS SUPER THIN 30G
91
pioglitazone hcl
56
PCE
37
pioglitazone hcl-metformin hcl
56
piroxicam
30
ped multivitamins w/fl & iron
104
PEDIATRIC AEROSOL MASK
20
PLEGRIDY
67
PEDIATRIC MOUTHPIECE
20
PLEGRIDY STARTER PACK
67
pediatric multiple vitamin w/ c
26
PNV FE FUM/DOCUSATE/FOLIC ACID
107
pediatric multiple vitamin w/ c & fa
26
PNV PRENATAL PLUS MULTIVITAMIN
28
pediatric multiple vitamins w/ iron
26
PNV TABS 29-1
pediatric multivitamins w/fl
104,107
107
podofilox
69
pediatric vitamins acd fluoride & iron
105
POLY-VITAMIN/FLUORIDE/IRON
pediatric vitamins acd w/ fluoride
107
POLYCOSE
PAGE 125
107
28
polyethylene glycol 3350
14
PRENATAL FORMULA
28
polyethylene glycol 3350 (bulk)
20
prenatal multivit-min w/fe-fa
26
POLYMEM DRESSING
20
PRENATAL PLUS IRON
polymyxin b-trimethoprim
97
prenatal vit w/ ferrous fumarate-folic acid
polysaccharide iron complex
28
PRETAB
POLYSPORIN
12
PREZISTA
53
polyvinyl alcohol
23
PRILOSEC OTC
14
pot phosphate monobasic w/ sod phosphate dibasic &
primidone
39
monobasic
probenecid
44
72
108
28
108
potassium bicarbonate
104
prochlorperazine
43
potassium chloride
104
prochlorperazine maleate
43
potassium chloride microencapsulated crystals cr
104
PRODIGY LANCING DEVICE
91
potassium citrate (alkalinizer)
72
PRODIGY TWIST TOP LANCETS 28G
91
potassium citrate-citric acid
72
progesterone micronized
77
pramipexole dihydrochloride
48
promethazine hcl
101
pramoxine hcl (rectal)
12
101
pramoxine-chloroxylenol
100
101
pramoxine-hc-chloroxylenol
100
propafenone hcl
61
pravastatin sodium
65
propranolol & hydrochlorothiazide
63
prazosin hcl
60
propranolol hcl
62
PRECISION XTRA KETONE
20
propylthiouracil
78
PRED MILD
98
PRORENAL + D
28
PRED-G
97
pseudoephedrine hcl
20
prednicarbate
73
pseudoephedrine hcl er tab er 12h 120 mg
20
prednisolone
73
pseudoephedrine hcl tab 30 mg
20
prednisolone acetate (ophth)
98
PSORCON
73
prednisolone sodium phosphate
73
psyllium
14
prednisone
73
PTS PANELS KETONE TEST
20
PREDNISONE INTENSOL
73
PULMICORT FLEXHALER
PREFERRED PLUS LANCETS COLORED
91
PURIXAN
46
PREFERRED PLUS LANCETS THIN
91
PX ADVANCED LANCING DEVICE
91
PREMARIN
77
PX INSULIN SYRINGE
91
PREMIUM CONDOMS LUBRICATED
20
PX LANCET AUTO INJECTOR
91
PREMPHASE
77
PX LANCETS
91
PREMPRO
77
PX LANCETS ULTRA THIN
91
28
100
PRENACARE
107
PX PRENATAL MULTIVITAMINS
PRENATABS FA
107
pyrantel pamoate
PRENATABS RX
107
pyrazinamide
46
pyrethrins-piperonyl butoxide
12
PRENATAL
28
9
PRENATAL 19
107
pyrethrins-piperonyl butoxide-permethrin-nit remover 12
PRENATAL AD
107
pyridostigmine bromide
PAGE 126
45
pyridoxine hcl
28
Q
RELENZA DISKHALER
53
RELION 70/30
58
RELION ALCOHOL SWABS
21
QC ADVANCED LANCING DEVICE
91
RELION INSULIN SYRINGE
92
QC ALCOHOL SWABS
20
RELION LANCETS MICRO-THIN 33G
92
QC INSULIN SYRINGE
91
RELION LANCETS STANDARD 21G
92
QC LANCETS SUPER THIN 30G
91
RELION LANCETS THIN 26G
92
QC LANCETS ULTRA THIN
91
RELION LANCETS ULTRA-THIN 30G
92
QC PRENATAL
28
RELION LANCING DEVICE
92
QC UNILET LANCETS MICRO THIN
91
RELION N
58
quetiapine fumarate
49
RELION R
58
quinapril hcl
60
RELION ULTRA THIN LANCETS 30G
92
quinidine gluconate
61
RELION ULTRA THIN PLUS LANCETS
92
quinidine sulfate
61
RELPAX
45
RENEW ADVANCED LANCING DEVICE
92
REPLACEMENT FILTERS
21
RESCRIPTOR
51
QVAR
100
R
RA ALCOHOL SWABS
20
reserpine
63
RA ALL PURPOSE DRESSINGS
20
respiratory therapy supplies
15
RA DRESSING SPONGES
20
RESTORE CONTACT LAYER
21
RA DRY MOUTH
11
RESTORE FOAM DRESSING
21
RA E-ZJECT COLOR LANCETS 33G
91
RESTORE ODOR ABSORBING DRESS
21
RA E-ZJECT LANCETS 28G
91
RESTORE TRIO ABSORBENT DRESS
21
RA E-ZJECT LANCETS THIN 26G
92
REXALL LANCETS ULTRA THIN 30G
92
RA E-ZJECT LANCETS THIN 28G
92
REYATAZ
53
RA E-ZJECT LANCETS ULTRA THIN
92
RHEUMATREX
80
RA GAUZE SPONGES
20
RHOGAM ULTRA-FILTERED PLUS
80
RA LANCING DEVICE
92
riboflavin
29
RA OYSTER SHELL CALCIUM/D
26
rifampin
46
RA PRENATAL
29
RIGHTEST GD500 LANCING DEVICE
92
RA PRENATAL FORMULA
29
RIGHTEST GL300 LANCETS
92
RA STERILE
20
risedronate sodium
81
raloxifene hcl
78
risperidone
ramipril
60
risperidone odt (tab 3 mg, tab 4 mg)
49
49
49,50
ranitidine hcl
13,70
RAPAMUNE
80
49
RAY-TEC X-RAY DETECTABLE SPNGE
20
50
RE PRENATAL MULTIVITAMIN/IRON
108
50
RE-NATA 29 OB
108
rivastigmine
40
REALITY LATEX/ULTRA TEXTURED
21
rivastigmine tartrate
40
REALITY LATEX/ULTRA THIN
21
rizatriptan benzoate
45
PAGE 127
ropinirole hydrochloride
48
S
SIVEXTRO
35
SM ALCOHOL PREP
21
SM GAUZE
21
SAFETY SEAL LANCETS
92
SM GLUCOSE
10
salsalate
31
SM INSULIN SYRINGE
93
SAMI THE SEAL FILTERS
21
SM LANCETS 21G
93
SANDIMMUNE
80
SM LANCETS 33G
93
SAVELLA
67
SM PRENATAL VITAMINS
29
SAVELLA TITRATION PACK
67
SM STERILE
21
SB ALCOHOL PREP
21
SM SUPER THIN LANCETS 30G
93
SB INSULIN SYRINGE
92
SM THIN LANCETS 26G
93
SB LANCETS THIN
92
SMART DIABETES VANTAGE LANCING
93
SB LANCETS ULTRA THIN
92
SMART SENSE COLOR LANCETS 33G
93
SCHOOLTIME SHAMPOO
13
SMART SENSE STANDARD LANCETS
93
SE-NATAL 19
108
SMART SENSE SUPER THIN LANCETS
93
SE-NATAL 90
108
SMART SENSE THIN LANCETS 26G
93
SE-NATAL ONE
108
soap & cleansers
11
13
SELECT-LITE LANCING DEVICE
92
sodium bicarbonate (antacid)
selegiline hcl
48
sodium chloride
selenium sulfide
13,69
104
sodium chloride (gu irrigant)
72
SELZENTRY
52
sodium chloride (inhalant)
25,103
senna
70
sodium citrate & citric acid
72
senna tab 8.6 mg
14
sodium fluoride
senna-docusate sodium tab 8.6-50 mg
14
sodium fluoride (dental)
SEREVENT DISKUS
102
104
11,68
sodium polystyrene sulfonate
104
SEROQUEL XR
50
sodium polystyrene sulfonate (bulk)
93
sertraline hcl
42
SOF-WICK
21
SFROWASA
80
SOLUS V2 LANCING DEVICE
93
SHOPKO ALCOHOL SWABS
21
SOMNOTE
67
SHOPKO AUTOLET LANCING DEVICE
92
sorbitol
21
SHOPKO UNILET LANCETS 28G
92
SORBITOL
21
SHOPKO UNILET LANCETS 30G
92
sorbitol (laxative)
14
SIDESTREAM ADULT FACE MASK
21
sotalol hcl
61
SIDESTREAM PEDIATRIC FACE MASK
21
sotalol hcl (afib/afl)
61
SIDESTREAM PLS ADULT FACE MASK
21
SOVALDI
50
silver sulfadiazine
38
SPINOSAD
47
spironolactone
64
simethicone
13,21
SIMPLE DIAGNOSTICS LANCING DEV
93
spironolactone & hydrochlorothiazide
63
SIMPLYTHICK
21
SSKI
78
simvastatin
65
ST JOSEPH ADULT
8
sirolimus
80
ST JOSEPH ADULT LOW DOSE
8
PAGE 128
stannous fluoride
11
TECHLITE LANCETS
93
stavudine
52
TECHLITE LANCETS 30G
93
STERI-PAD STERILE
21
TEGADERM FOAM
21
STERILANCE TL
93
temazepam
STERILE
21
TENCON
67
STRIBILD
51
terazosin hcl
71
STUART PRENATAL
29
terbinafine hcl
44
SUBOXONE
33
terbinafine hcl (topical)
13
sucralfate
71
terbutaline sulfate
SUDAFED PE CHILDRENS
21
terconazole vaginal
44
sulfacetamide sod-prednisolone
97
testosterone cypionate
74
sulfacetamide sodium
69
tetrahydrozoline hcl (ophth)
23
sulfacetamide sodium (acne)
69
TGT ADVANCED LANCING DEVICE
93
sulfacetamide sodium (ophth)
38
TGT ALCOHOL SWABS
22
sulfacetamide sodium w/ sulfur
69
TGT LANCET ALTERNATE SITE
94
sulfamethoxazole-trimethoprim
38
TGT LANCET MICRO THIN 33G
94
sulfasalazine
81
TGT LANCET SUPER THIN 30G
94
sulindac
31
TGT LANCET THIN 23G
94
sumatriptan nasal spray (5 mg/act, 20 mg/act)
45
TGT LANCET THIN 26G
94
sumatriptan succinate
45
TGT LANCET ULTRA THIN 28G
94
SUPER THIN LANCETS
93
TGT LANCET ULTRA THIN 30G
94
SURE COMFORT INSULIN SYRINGE
93
TGT LANCING DEVICE
94
SURE COMFORT LANCING PEN
93
TH PRENATAL VITAMINS
29
SURE-JECT INSULIN SYRINGE
93
THEO-24
103
SURE-PEN
93
theophylline
103
SURELITE LANCETS
93
THERAGAUZE
22
SUSTIVA
51
THERANATAL CORE NUTRITION
29
SYMAX DUOTAB
70
thiamine hcl
29
thiamine mononitrate
29
SYMBICORT
103
103
102
SYMLINPEN 120
56
thioridazine hcl
49
SYMLINPEN 60
56
thiothixene
49
thyroid
78
THYROLAR-1
78
T
tacrolimus
80
THYROLAR-1/2
78
tacrolimus (topical)
69
THYROLAR-1/4
78
53,54
THYROLAR-2
78
tamoxifen citrate
46
THYROLAR-3
78
tamsulosin hcl
71
tiagabine hcl
39
TAZORAC
69
timolol maleate
62
TECFIDERA
68
timolol maleate (ophth)
99
TECHLITE AST LANCETS
93
TIMOPTIC OCUDOSE
99
TAMIFLU
PAGE 129
tioconazole vaginal
9
tizanidine hcl
110
TOBRADEX
34
tobramycin
102
TRINATAL RX 1
108
TRINATAL ULTRA
109
TROJAN MAGNUM WARM SENSATIONS
22
TROJAN SUPRAS SPERMICIDAL
22
tobramycin (ophth)
34
TROJAN TWISTED PLEASURE
22
tobramycin sulfate
34
tropicamide
98
TOBRAMYCIN SULFATE IN SALINE
34
trospium chloride
71
tobramycin-dexamethasone
98
TRUE METRIX AIR GLUCOSE METER
94
TOBREX
34
TRUE METRIX BLOOD GLUCOSE TEST
94
TODAYS HEALTH LANCING DEVICE
94
TRUE METRIX LEVEL 1
94
TODAYS HEALTH THIN LANCETS 28G
94
TRUE METRIX LEVEL 2
94
TODAYS HEALTH THIN LANCETS 30G
94
TRUE METRIX LEVEL 3
94
tolmetin sodium
31
TRUE METRIX METER
94
tolnaftate
13
TRUEPLUS LANCETS 26G
94
tolterodine tartrate
71
94
TOPCARE ULTRA COMFORT INS SYR
94
94
topiramate
39
94
TOPPER DRESSING SPONGES
22
TRUERESULT BLOOD GLUCOSE
94
torsemide
64
TRUETEST CONTROL LEVEL 1
94
TRADJENTA
56
95
tramadol hcl
32
95
tramadol-acetaminophen
32
TRUETEST TEST
95
trandolapril
60
TRUETRACK GLUCOSE CONTROL
95
tranexamic acid
59
TRUETRACK TEST
95
tranylcypromine sulfate
41
TRUSTEX COLOR CONDOMS + LUBE
22
trazodone hcl
42
TRUSTEX LUB/RIBBED/STUDDED
22
TRECATOR
46
TRUSTEX LUB/SPERMICIDE EX ST
22
tretinoin
69
TRUSTEX LUB/SPERMICIDE XL
22
TREXALL
80
TRUSTEX LUBRICATED
22
TRI-VI-SOL/IRON
29
TRUSTEX LUBRICATED EX LARGE
22
108
TRUSTEX LUBRICATED EXTRA ST
22
TRIADVANCE
triamcinolone acetonide (mouth)
74
TRUSTEX LUBRICATED/SPERMICIDE
22
triamcinolone acetonide (nasal)
23
TRUSTEX NATURAL CONDOMS + LUBE
22
triamcinolone acetonide (topical)
73
TRUSTEX NON-LUBRICATED
22
triamterene & hydrochlorothiazide
64
TRUSTEX RIA LUB/SPERMICIDE
22
TRUSTEX RIA LUBRICATED
22
triazolam
103
trifluoperazine hcl
49
TRUSTEX RIA NON-LUBRICATED
22
trifluridine
54
TRUSTEX-NONOXYNOL-9/RIB/STUD
22
trihexyphenidyl hcl
48
TRUVADA
52
trimethoprim
35
TUBING/WING TIP
22
TRINATAL GT
PAGE 130
108
TUDORZA PRESSAIR
101
TWINJECT
TYBOST
102
52
U
valproic acid
39
valsartan
60
valsartan-hydrochlorothiazide
64
VALUE PLUS LANCET STANDARD 21G
96
ULTI-LANCE AUTO-ADJUST DEVICE
95
VALUE PLUS LANCETS SUPER THIN
96
ULTI-LANCE AUTOMATIC
95
VALUE PLUS LANCETS THIN 26G
96
ULTI-LANCE MINI ADJUSTABLE
95
VALUE PLUS LANCING DEVICE
96
ULTICARE INSULIN SYRINGE
95
VALUMARK LANCET SUPER THIN 30G
96
ULTILET ALCOHOL SWAB
22
VALUMARK LANCET ULTRA THIN 28G
96
ULTILET ALCOHOL SWABS
22
vancomycin hcl
35
ULTILET BASIC LANCETS 30G
95
VCF VAGINAL CONTRACEPTIVE
15
ULTILET CLASSIC LANCETS
95
VENATAL-FA
109
ULTILET GLUCOSE
10
venlafaxine hcl
42
ULTILET INSULIN SYRINGE
95
VENLAFAXINE HCL ER
42
ULTILET INSULIN SYRINGE SHORT
95
VENTOLIN HFA
ULTILET LANCETS
95
verapamil hcl
62
ULTRA COMFORT INSULIN SYRINGE
95
VERIPRED 20
74
ULTRA THIN LANCETS 28G
95
VERSIVA XC
22
ULTRA THIN LANCETS 30G
95
VEXOL
98
ULTRA-COMFORT INSULIN SYRINGE
95
VIDA MIA AUTOLET LANCING DEV
96
ULTRA-THIN II INS SYR SHORT
95
VIDA MIA UNILET LANCETS 28G
96
UNILET COMFORTOUCH LANCET
95
VIDA MIA UNILET LANCETS 30G
96
UNILET EXCELITE
95
VIDEX
52
UNILET EXCELITE II
95
VIGAMOX
38
UNILET G.P. LANCET
96
VIIBRYD
42
UNILET G.P. SUPERLITE LANCET
96
VINATE CALCIUM
109
UNILET GP 28 ULTRA THIN
96
VINATE GT
109
UNILET LANCET
96
VINATE M
109
UNILET MICRO-THIN 33G
96
VINATE ONE
109
UNILET SUPER-THIN 30G
96
VINATE ULTRA
109
UNILET SUPERLITE LANCET
96
VIRACEPT
53
UNILET ULTRA-THIN 28G
96
VIREAD
52
UNIVERSAL 1 LANCETS THIN 26G
96
VIRT-ADVANCE
109
UNIVERSAL 1 LANCETS ULTRA THIN
96
VIRT-VITE GT
109
urea
69
VISTEC X-RAY DETECTABLE SPONGE
22
ursodiol
70
VISTOGARD
96
VITAFOL-OB
109
VITAFOL-PN
110
V
102
valacyclovir hcl
54
vitamin e
29
valganciclovir hcl
50
vitamins w/ lipotropics
26
valproate sodium
39
VITASPIRE
PAGE 131
110
VIVITROL
VOL-TAB RX
VYVANSE
33
110
66
W
W&F LANCETS 26G
96
W&F LANCETS COLORED 21G
96
WALGREENS GLUCOSE
10
WALGREENS LANCETS
96
WALGREENS LANCETS MICRO THIN
96
WALGREENS LANCETS SUPER THIN
97
WALGREENS LANCING DEVICE
97
WALGREENS THIN LANCETS
97
WALGREENS ULTRA THIN LANCETS
97
warfarin sodium
59
WEBCOL ALCOHOL PREP LARGE
23
WEBCOL ALCOHOL PREP MEDIUM
23
WESTHROID
78
WESTHROID-P
78
white petrolatum-mineral oil
23
WP THYROID
78
X
XARELTO
59
Z
zaleplon
103
ZENPEP
69
ZEPATIER
50
ZIAGEN
52
zidovudine
52
zinc (mouth-throat)
11
zinc oxide (topical)
13
zinc sulfate
26
ziprasidone hcl
50
zolmitriptan
45
zolpidem tartrate
104
ZOMIG
45
zonisamide
38
ZOVIA 1/50E (28)
77
ZOVIRAX
54
PAGE 132

CeltiCare Health

Transcription

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