preferred drug list

Transcription

preferred drug list

Comprehensive
PREFERRED DRUG LIST
CountyCare
PAGE 1
LAST UPDATED 02/2016
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.
MDS
Max Days Supply
There is a limit on the amount of this drug that is covered.
Custom
This drug has unique restrictions.
C
PAGE 2
LIST OF COVERED OVER-THE-COUNTER MEDICATIONS
PRODUCT DESCRIPTION
BRAND/GEN
LIMITS & RESTRICTIONS
ANTI-INFECTIVE AGENTS
ANTHELMINTICS
QL
PIN-X CHEW TAB 720.5 MG
BRAND
MFL
pyrantel pamoate susp 144 mg/ml (50 mg/ml base equiv)
QL
generic
MFL
QL
REESES PINWORM MEDICINE TAB 180 MG
BRAND
4 / claim
1 / 30 days
60 / claim
1 / 30 days
16 / claim
MFL
1 / 30 days
QL
1 / 21 Days
GL
Female
ENDOCRINE AND METABOLIC DRUGS
CONTRACEPTIVES
levonorgestrel tab 1.5 mg
generic
MFL
4 / 365 days
ANTIDIABETICS
BD GLUCOSE CHEW TAB 5 GM
BRAND
QL
50 / 30 days
glucose chew tab 4 gm
generic
QL
50 / 30 days
ALER-DRYL TAB 50 MG
BRAND
MDD
4 per day
ALLEGRA ALLERGY CHILDRENS TAB DISP 30 MG
BRAND
MDD
2 per day
cetirizine hcl (cap 10 mg, tab 5 mg)
generic
MDD
1 per day
cetirizine hcl allergy child solution 5 mg/5ml
generic
RESPIRATORY AGENTS
ANTIHISTAMINES
PAGE 3
QL
240 / claim
AL
Up to 12 yrs old
PRODUCT DESCRIPTION
BRAND/GEN
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
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
4 per day
fexofenadine hcl tab 180 mg
generic
MDD
1 per day
generic
MDD
2 per day
loratadine allergy relief tab disp 10 mg
generic
loratadine tab 10 mg
generic
NASAL AGENTS - SYSTEMIC AND TOPICAL
cromolyn sodium nasal aerosol soln 5.2 mg/act (4%)
generic
QL
26 / claim
CVS NASAL MIST AERO SOLN 0.9 %
BRAND
QL
240 / claim
nasal moisturizing spray solution 0.65 %
generic
MPL
phenylephrine hcl tab 10 mg
generic
QL
pseudoephedrine hcl (liq 15 mg/5ml, liq 30 mg/5ml, syrup
30 mg/5ml, tab 60 mg)
generic
PAGE 4
1 / claim
24 / claim
PRODUCT DESCRIPTION
BRAND/GEN
pseudoephedrine hcl er tab er 12h 120 mg
generic
pseudoephedrine hcl tab 30 mg
generic
SUDAFED PE CHILDRENS SOLUTION 2.5 MG/5ML
BRAND
triamcinolone acetonide nasal aerosol suspension 55
mcg/act
generic
QL
62 / 31 days
QL
120 / claim
QL
17 / claim
AL
At least 2 yrs old
C
OTC Covered Only
COUGH/COLD/ALLERGY
acetaminophen w/ dm liq 160-5 mg/5ml
generic
BIOSPEC DMX LIQUID 15-25 MG/5ML
BRAND
brompheniramine & phenylephrine elixir 1-2.5 mg/5ml
generic
brompheniramine & pseudoephedrine elixir 1-15 mg/5ml
QL
120 / claim
MFL
1 / 30 days
QL
120 / claim
MFL
1 / 30 days
MDD
2 per day
generic
cetirizine-pseudoephedrine tab sr 12hr 5-120 mg
generic
chlorphen-pseudoephedrine w/ apap cap 2-30-325 mg
generic
chlorpheniramine & phenylephrine liquid 1-3.5 mg/ml
generic
QL
30 / claim
chlorpheniramine-dm liquid 2-15 mg/5ml
generic
QL
240 / claim
DECON-A LIQUID 2-5 MG/ML
BRAND
dextromethorphan polistirex er liquid er 30 mg/5ml
generic
QL
240 / 6 days
dextromethorphan-doxylamine-apap liquid 30-12.5-1000
mg/30ml
generic
dextromethorphan-guaifenesin (liquid 10-200 mg/5ml,
liquid 10-100 mg/5ml, syrup 10-100 mg/5ml)
generic
QL
240 / claim
dextromethorphan-guaifenesin (liquid 5-100 mg/5ml, liquid
30-200 mg/5ml)
generic
dextromethorphan-guaifenesin tab sr 12hr 30-600 mg
generic
dextromethorphan-phenylephrine-apap cap 10-5-325 mg
generic
DIMETAPP LONG ACT COUGH/COLD SYRUP 1-7.5
MG/5ML
BRAND
PAGE 5
MDD
QL
2 per day
240 / claim
PRODUCT DESCRIPTION
BRAND/GEN
guaifenesin liquid 100 mg/5ml
generic
QL
MFL
guaifenesin syrup 100 mg/5ml
generic
guaifenesin tab sr 12hr 1200 mg
generic
guaifenesin tab sr 12hr 600 mg
generic
guaifenesin-codeine soln 100-10 mg/5ml
generic
LITTLE REMEDIES FOR COLDS LIQUID 2.5-1.25-80
MG/ML
BRAND
LOHIST-D LIQUID 2-30 MG/5ML
BRAND
loratadine & pseudoephedrine tab sr 12hr 5-120 mg
generic
240 / 6 days
1 / 30 days
QL
240 / 6 days
QL
40 / claim
MFL
1 / 30 days
QL
240 / claim
QL
62 / 31 days
MDD
2 per day
1 per day
loratadine & pseudoephedrine tab sr 24hr 10-240 mg
generic
MDD
MEDI-GRAINE TAB 500-75-5 MG
BRAND
QL
120 / 30 days
phenylephrine-dm soln 2.5-5 mg/5ml
generic
QL
240 / claim
phenylephrine-guaifenesin liqd 5-100 mg/5ml
generic
QL
240 / 6 days
pseudoephed-bromphen-dm (elixir 15-1-5 mg/5ml, syrup
30-2-10 mg/5ml)
generic
QL
240 / claim
pseudoephed-chlorphen-dm liq 15-1-5 mg/5ml
generic
QL
240 / claim
pseudoephed-doxyl-dm w/apap (w/ apap cap 30-6.25-15325 mg, w/apap liq 60-12.5-30-1000 mg/30ml)
generic
pseudoephedrine w/ apap-dm cap 30-325-15 mg
generic
pseudoephedrine w/ cod-gg soln 30-10-100 mg/5ml
generic
QL
240 / 6 days
pseudoephedrine w/ dm-gg liquid 30-10-100 mg/5ml
generic
QL
240 / 6 days
pseudoephedrine-guaifenesin syrup 30-100 mg/5ml
generic
QL
240 / claim
pseudoephedrine-guaifenesin tab sr 12hr 60-600 mg
generic
pseudoephedrine-ibuprofen (susp 15-100 mg/5ml, tab 30200 mg)
generic
PAGE 6
PRODUCT DESCRIPTION
BRAND/GEN
SCOT-TUSSIN SENIOR LIQUID 15-200 MG/5ML
BRAND
sodium chloride aero soln 0.9%
generic
QL
240 / claim
TRIAMINIC COLD/COUGH DAY TIME (COLD/COUGH
SOLUTION MG/5ML, COLD/COUGH SYRUP MG/5ML)
BRAND
QL
240 / claim
bisacodyl ec tab dr 5 mg
generic
MDD
1 per day
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 250 mg, tab 100 mg)
generic
MDD
3 per day
docusate sodium (cap 50 mg, liquid 150 mg/15ml, syrup 60
mg/15ml)
generic
docusate sodium cap 100 mg
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
sennosides cap 8.6 mg
generic
sorbitol (laxative) (oral solution, rectal solution)
generic
GASTROINTESTINAL AGENTS
LAXATIVES
PAGE 7
QL
992 / 31 days
MDD
34 per day
MDD
4 per day
PRODUCT DESCRIPTION
BRAND/GEN
ANTIDIARRHEALS
bismuth subsalicylate (chew tab 262 mg, susp 262
mg/15ml, tab 262 mg)
generic
loperamide hcl (cap 2 mg, liq 1 mg/5ml (0.2 mg/ml))
generic
loperamide hcl tab 2 mg
generic
MDD
alum & mag hydroxide-simethicone susp 200-200-20
mg/5ml
generic
QL
496 / 31 days
aluminum hydroxide gel susp 320 mg/5ml
generic
calcium carbonate (antacid) chew tab 500 mg
generic
magnesium oxide tab 400 mg
generic
sodium bicarbonate (antacid) (tab 325 mg, tab 650 mg)
generic
QL
496 / 31 days
2 per day
ANTACIDS
ULCER DRUGS
AXID AR TAB 75 MG
BRAND
cimetidine tab 200 mg
generic
famotidine (tab 10 mg, tab 20 mg)
generic
lansoprazole cap delayed release 15 mg
generic
MDD
4 per day
NEXIUM 24HR CAP DR 20 MG
BRAND
MDD
2 per day
omeprazole delayed release tab 20 mg
generic
MDD
4 per day
PRILOSEC OTC TAB DR 20 MG
BRAND
MDD
4 per day
ranitidine hcl (tab 75 mg, tab 150 mg)
generic
MDD
2 per day
dimenhydrinate tab 50 mg
generic
QL
24 / claim
DRAMAMINE CHEW TAB 50 MG
BRAND
QL
24 / claim
meclizine hcl (chew tab 25 mg, tab 12.5 mg, tab 25 mg)
generic
ANTIEMETICS
PAGE 8
PRODUCT DESCRIPTION
BRAND/GEN
GASTROINTESTINAL AGENTS - MISC.
simethicone (chew tab 80 mg, liquid 40 mg/0.6ml, susp 40
mg/0.6ml)
generic
GENITOURINARY PRODUCTS
VAGINAL PRODUCTS
clotrimazole vaginal (cream 1%, cream 2%)
generic
CONCEPTROL INSERTS INSERT 150 MG
BRAND
ENCARE SUPPOS 100 MG
BRAND
MPL
1 / claim
GYNOL II GEL 2 %
BRAND
MPL
1 / claim
miconazole nitrate vaginal (cream 2%, cream 4% (200
mg/5gm), suppos 100 mg)
generic
miconazole nitrate vaginal supp 200 mg & 2% cream 9 gm
kit
generic
MPL
1 / claim
OPTIONS GYNOL II CONTRACEPTIVE GEL 3 %
BRAND
tioconazole vaginal oint 6.5%
generic
VCF VAGINAL CONTRACEPTIVE (FILM 28 %, FOAM
12.5 %)
BRAND
MPL
1 / claim
CENTRAL NERVOUS SYSTEM DRUGS
HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS
diphenhydramine hcl (sleep) (cap 50 mg, tab 50 mg, tab
disp 25 mg)
generic
diphenhydramine hcl (sleep) tab 25 mg
generic
MDD
1 per day
diphenhydramine-acetaminophen tab 25-500 mg (sleep)
generic
MDD
1 per day
doxylamine succinate (sleep) tab 25 mg
generic
MDD
1 per day
MDS
180 / 365 DAYS
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISCELLANEOUS
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.
nicotine (patch 24hr 7 mg/24hr, patch 24hr 21 mg/24hr,
patch 24hr 14 mg/24hr)
PAGE 9
generic
PRODUCT DESCRIPTION
BRAND/GEN
NICOTINE KIT 21-14-7 MG/24HR
BRAND
QL
nicotine polacrilex (gum 2 mg, gum 4 mg)
nicotine polacrilex (lozenge 2 mg, lozenge 4 mg)
2 / 365 days
MDS
180 / 365 DAYS
MDD
24 per day
MDS
180 / 365 DAYS
MDD
20 per day
MDS
180 / 365 DAYS
generic
generic
ANALGESICS AND ANESTHETICS
ANALGESICS - NONNARCOTIC
acetaminophen (cap 500 mg, chew tab 80 mg, chew tab
160 mg, dispersible tab 80 mg, elixir 160 mg/5ml, liquid
160 mg/5ml, soln 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 / 31 days
acetaminophen soln 100 mg/ml
generic
QL
30 / 30 days
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
QL
12 / 31 days
aspirin buffered (ca carb-mg carb-mg ox) tab 325 mg
generic
aspirin buffered tab 325 mg
generic
aspirin tab chew 81 mg
generic
ANALGESICS - ANTI-INFLAMMATORY
ibuprofen (chew tab 100 mg, susp 40 mg/ml, susp 100
generic
ibuprofen cap 200 mg
generic
ibuprofen tab 200 mg
generic
naproxen sodium cap 220 mg
generic
QL
62 / 31 days
naproxen sodium tab 220 mg
generic
QL
62 / 31 days
PAGE 10
PRODUCT DESCRIPTION
BRAND/GEN
NUTRITIONAL PRODUCTS
VITAMINS
ascorbic acid (chew tab 250 mg, chew tab 500 mg, tab 250
mg, tab 500 mg, tab 1000 mg, tab cr 500 mg, tab cr 1000
mg)
generic
QL
100 / 31 days
cholecalciferol (cap 1000, cap 2000, chew tab 1000, chew
tab 2000, tab 1000, tab 2000)
generic
QL
100 / claim
cholecalciferol (cap 5000, chew tab 5000, tab 5000)
generic
MDD
cholecalciferol cap 50000 unit
generic
QL
8 / 30 days
cholecalciferol tab 50000 unit
generic
niacin (cap cr 250 mg, cap cr 500 mg, tab 500 mg, tab cr
250 mg, tab cr 500 mg, tab cr 750 mg, tab cr 1000 mg)
generic
pyridoxine hcl (tab 25 mg, tab 50 mg, tab 100 mg)
generic
riboflavin (tab 25 mg, tab 50 mg, tab 100 mg)
generic
QL
100 / 31 days
thiamine hcl (tab 50 mg, tab 100 mg, tab 250 mg, tab 500
mg)
generic
QL
100 / 31 days
thiamine mononitrate tab 100 mg
generic
QL
100 / 31 days
vitamin e (cap 100, cap 200, cap 400, chw tab 400, tab
400)
generic
QL
62 / 31 days
*multiple vitamin tab**
generic
MDD
1 per day
*multiple vitamins w/ iron 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
2 per day
MULTIVITAMINS
*prenatal vit w/ fe fumarate-fa tab 28-0.8 mg***
generic
MDD
PAGE 11
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
b complex w/ c (w/ ap**, w/ tab**)
generic
MDD
1 per day
b-complex vitamins (cap**, sublingual liquid**, tab**)
generic
MDD
1 per day
KPN PRENATAL TAB 0.1 MG
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
MISSION PRENATAL FA TAB
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
MISSION PRENATAL HP TAB
BRAND
multiple vitamins w/ minerals (w/ cap**, w/ chew tab**, w/
liquid**, w/ tab**)
NUTRICION PORVIDA 0.25 MG
BRAND
generic
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
MDD
1 per day
MDD
1 per day
GL
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
TRI-VI-SOL/IRON SOLUTION 10 MG/ML
PAGE 12
BRAND
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
PNV PRENATAL PLUS MULTIVITAMIN TAB 27-1 MG
1 per day
GL
MDD
PERRY PRENATAL CAP 13.5-0.4 MG
1 per day
GL
MDD
MISSION PRENATAL TAB
1 per day
1 per day
GL
Female
AL
Up to 45 yrs old
MDD
1 per day
QL
50 / claim
PRODUCT DESCRIPTION
BRAND/GEN
vitamins w/ lipotropics (w/ cap**, w/ tab**)
generic
MDD
1 per day
MINERALS & ELECTROLYTES
*oral electrolyte solution***
generic
calcium carbonate susp 1250 mg/5ml (500 mg/5ml
elemental ca)
generic
calcium carbonate-cholecalciferol (chew tab 500 mg-100,
tab 500 mg-200)
generic
calcium carbonate-cholecalciferol (tab 600 mg-800, tab
600 mg-400, tab 600 mg-200)
QL
500 / 30 days
generic
QL
62 / 31 days
calcium carbonate-vitamin d (cap 600 mg-200, chew tab
600 mg-400, tab 600 mg-400, tab 600 mg-200)
generic
QL
62 / 31 days
calcium carbonate-vitamin d (tab 250 mg-125, tab 500 mg125, tab 500 mg-200)
generic
magnesium oxide (mg supplement) (cap 400 mg
(elemental (mg supplement), tab 400 mg (241.3 mg
elemental, tab 400 mg (240 mg elemental)
generic
oyster shell calcium tab 500 mg
generic
PARVA-CAL TAB 500-200 MG-UNIT
BRAND
RA CALCIUM HI-CAL/VITAMIN D TAB 500-200 MG-UNIT
BRAND
zinc sulfate cap 220 mg (50 mg elemental zn)
generic
NUTRIENTS
omega-3 fatty acids (cap 500, cap 1000, cap 1200, cap
delayed release 1000, cap delayed release 1200)
generic
MDD
6 per day
POLYCOSE (, LIQUID, POWDER)
BRAND
MPL
1 / 30 days
ferrous fumarate tab 325 mg (106 mg elemental fe)
generic
MDD
2 per day
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
HEMATOLOGICAL AGENTS
HEMATOPOIETIC AGENTS
PAGE 13
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
MDD
16 per day
ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe)
generic
MDD
3.4 per day
folic acid (tab 400 mcg, tab 800 mcg)
generic
MDD
1 per day
folic acid tab 1 mg
generic
IRON CHEWS PEDIATRIC CHEW TAB 15 MG
BRAND
IRON TAB 246 (28 FE) MG
BRAND
polysaccharide iron complex cap 150 mg (iron equivalent)
generic
MDD
1 per day
*artificial tear ophth ointment***
generic
QL
4 / claim
*artificial tear ophth solution***
generic
QL
4 / claim
*white petrolatum-mineral oil ophth ointment***
generic
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
TOPICAL PRODUCTS
OPHTHALMIC AGENTS
15 / claim
1 / 30 days
OTIC AGENTS
carbamide peroxide 6.5% otic soln
PAGE 14
15 / 31 days
PRODUCT DESCRIPTION
BRAND/GEN
MOUTH/THROAT/DENTAL AGENTS
BIOTENE MOISTURIZING MOUTH SOLUTION
BRAND
QL
900 / claim
BIOTENE ORALBALANCE DRY MOUTH LIQUID
BRAND
QL
900 / claim
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
ANORECTAL AGENTS
dibucaine rectal ointment 1%
generic
QL
30 / claim
phenyleph-shark liver oil-cocoa butter suppos 0.25-385.5%
generic
QL
12 / 31 days
phenylephrine-shark liver oil-mo-pet oint 0.25-3-14-71.9%
generic
QL
31 / 31 days
pramoxine hcl rectal foam 1%
generic
QL
15 / claim
DERMATOLOGICALS
*dermatological products misc - cream**
generic
*lanolin cream***
generic
*neomycin-bacitracin-polymyxin oint***
generic
*skin protectants misc - cream***
generic
A-200 GEL 0.33-4 %
BRAND
ACNE MEDICATION 5 LOTION 5 %
BRAND
bacitracin oint 500 unit/gm
PAGE 15
generic
MPL
C
1 / claim
Pkg Size 30: Package
Limit=1/claim; Pkg Size
15: Package
28: Package
Limit=1/claim
PRODUCT DESCRIPTION
BRAND/GEN
QL
bacitracin zinc oint 500 unit/gm
generic
C
30 / claim
15: Package
28: Package
Limit=1/claim
benzoyl peroxide (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
clotrimazole cream 1%
generic
clotrimazole soln 1%
generic
MPL
1 / claim
coal tar shampoo 0.5%
generic
dibucaine oint 1%
generic
diphenhydramine hcl cream 2%
generic
emollient (cream**, lotion**)
generic
hydrocortisone (topical) (cream, lotion, soln)
generic
MPL
hydrocortisone (topical) (cream, oint)
generic
QL
30 / claim
hydrocortisone (topical) (gel, oint)
QL
generic
60 / 30 days
QL
MPL
30 / claim
1 / claim
1 / 30 days
hydrocortisone-aloe vera cream 1%
generic
QL
30 / claim
KERALYT GEL 3 %
BRAND
QL
30 / claim
lactic acid (ammonium lactate) cream 12%
generic
MPL
1 / claim
lactic acid (ammonium lactate) lotion 12%
generic
MPL
1 / 31 days
PAGE 16
PRODUCT DESCRIPTION
BRAND/GEN
LICIDE TREATMENT KIT
BRAND
lidocaine hcl gel 2%
generic
QL
miconazole nitrate (topical) (aerosol, cream, powder)
generic
MPL
1 / claim
miconazole nitrate aerosol pow 2%
generic
neomycin-polymyxin w/ pramoxine cream 1%
generic
MPL
1 / claim
NIX LICE CONTROL LIQUID 0.25 %
BRAND
NIZORAL A-D SHAMPOO 1 %
BRAND
MPL
1 / claim
permethrin (aerosol 0.5%, creme rinse 1%)
generic
permethrin lotion 1%
generic
MPL
1 / claim
permethrin spray & pyrethins-piperonyl butoxide shamp kit
generic
POLYSPORIN POWDER 500-10000 UNIT/GM
BRAND
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
MPL
1 / claim
pyrithione zinc shampoo 1%
generic
QL
240 / claim
RID ESSENTIAL LICE ELIMINATION KIT 0.33-4 %
BRAND
SCHOOLTIME SHAMPOO SHAMPOO
BRAND
selenium sulfide lotion 1%
generic
QL
240 / claim
soap & cleansers (liquid***, lotion***)
generic
terbinafine hcl cream 1%
generic
tolnaftate (aerosol, aerosol pow)
generic
MPL
QL
MPL
tolnaftate (cream, powder, soln)
generic
QL
zinc oxide oint 20%
generic
MPL
PAGE 17
30 / claim
1 / claim
30 / claim
1 / claim
30 / claim
1 / claim
PRODUCT DESCRIPTION
BRAND/GEN
MISCELLANEOUS PRODUCTS
ANTISEPTICS & DISINFECTANTS
chlorhexidine gluconate liquid 4%
generic
DIAGNOSTIC PRODUCTS
NOVA MAX PLUS KETONE TEST STRIP
BRAND
QL
30 / 30 days
PRECISION XTRA KETONE STRIP
BRAND
QL
30 / 30 days
PTS PANELS KETONE TEST STRIP
BRAND
QL
30 / 30 days
ginger (zingiber officinalis) cap 250 mg
generic
MDD
4 per day
melatonin (cap 3 mg, cap 5 mg, tab 3 mg, tab 5 mg, tablet
dispersible 5 mg)
generic
MDD
1 per day
*alcohol swabs***
generic
QL
400 / claim
*respiratory therapy supplies - misc**
generic
QL
1 / 360 Days
AIMSCO LUBRICATED MISC
BRAND
QL
36 / claim
ARIAL CHAMBER DEVICE
BRAND
QL
2 / 360 days
ELEXA NATURAL FEEL MISC
BRAND
QL
36 / claim
ELEXA STIMULATING MISC
BRAND
QL
36 / claim
ELEXA ULTRA SENSITIVE MISC
BRAND
QL
36 / claim
FANTASY LUBRICATED MISC
BRAND
QL
36 / claim
FANTASY LUBRICATED/SPERMICIDE MISC
BRAND
QL
36 / claim
gauze pads & dressings (pads pads 2" 2"***, pads pads 3"
3"***, pads pads 4" 4"***)
generic
KAMELEON LUBRICATED MISC
BRAND
QL
36 / claim
KIMONO MICRO THIN MISC
BRAND
QL
36 / claim
ALTERNATIVE MEDICINES
MEDICAL DEVICES AND SUPPLIES
PAGE 18
PRODUCT DESCRIPTION
BRAND/GEN
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
MAXX MISC
BRAND
QL
36 / claim
MAXX PLUS MISC
BRAND
QL
36 / claim
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
OPTICHAMBER FACE MASK-LARGE MISC
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
PREMIUM CONDOMS LUBRICATED MISC
BRAND
QL
36 / claim
REALITY LATEX/ULTRA TEXTURED DEVICE
BRAND
QL
36 / claim
REALITY LATEX/ULTRA THIN DEVICE
BRAND
QL
36 / claim
TROJAN MAGNUM WARM SENSATIONS DEVICE
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
PAGE 19
PRODUCT DESCRIPTION
BRAND/GEN
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
MDD
34 per day
PHARMACEUTICAL ADJUVANTS
lanolin
generic
polyethylene glycol 3350 powder
generic
SIMPLYTHICK GEL
BRAND
sorbitol solution (bulk)
PAGE 20
QL
1816 / claim
AL
At least 1 yrs old
generic
LIST OF COVERED PRESCRIPTION MEDICATIONS
PRODUCT DESCRIPTION
BRAND/GEN
ANTI-INFECTIVE AGENTS
PENICILLINS
75: Package
100: Package
Limit=2/claim
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
AMPICILLIN (RECON SUSP 125 MG/5ML, RECON SUSP
250 MG/5ML)
BRAND
dicloxacillin sodium (cap 250 mg, cap 500 mg)
generic
penicillin v potassium (for soln 125 mg/5ml, for soln 250
generic
2 / claim
1 / claim
CEPHALOSPORINS
cefaclor (cap 250 mg, cap 500 mg)
generic
CEFACLOR (RECON SUSP 125 MG/5ML, RECON SUSP
250 MG/5ML, RECON SUSP 375 MG/5ML)
BRAND
cefadroxil (cap 500 mg, for susp 250 mg/5ml, for susp 500
mg/5ml, tab 1 gm)
generic
PAGE 21
PRODUCT DESCRIPTION
BRAND/GEN
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
MPL
cefprozil for susp 250 mg/5ml
AL
generic
MPL
QL
CEFTIN RECON SUSP 250 MG/5ML
BRAND
ceftriaxone sodium (inj 1 gm, inj 250 mg, inj 500 mg, iv soln
1 gm)
generic
cefuroxime axetil (tab 250 mg, tab 500 mg)
generic
cefuroxime axetil for susp 125 mg/5ml
Up to 12 yrs old
1 / claim
100 / claim
AL
Up to 12 yrs old
QL
3 / claim
1 / 30 days
QL
20 / claim
QL
100 / claim
ST
AL
cephalexin (cap 250 mg, cap 500 mg, for susp 125
mg/5ml, for susp 250 mg/5ml)
2 / claim
ST
MFL
generic
1 / claim
Up to 12 yrs old
generic
MACROLIDES
azithromycin (iv for soln 500 mg, tab 500 mg)
generic
MDD
4 per day
azithromycin for susp 100 mg/5ml
generic
QL
15 / claim
30: Package
22.5: Package
Limit=2/claim
azithromycin for susp 200 mg/5ml
generic
C
azithromycin tab 250 mg
generic
QL
6 / claim
azithromycin tab 600 mg
generic
QL
8 / 28 days
PAGE 22
PRODUCT DESCRIPTION
BRAND/GEN
clarithromycin (tab 250 mg, tab 500 mg)
generic
QL
clarithromycin for susp 125 mg/5ml
generic
MPL
clarithromycin for susp 250 mg/5ml
generic
C
clarithromycin tab sr 24hr 500 mg
generic
QL
14 / claim
E.E.S. GRANULES RECON SUSP 200 MG/5ML
BRAND
QL
6 / claim
ERY-TAB (TAB DR 250 MG, TAB DR 333 MG, TAB DR
500 MG)
BRAND
ERYPED 200 RECON SUSP 200 MG/5ML
BRAND
QL
6 / claim
ERYPED 400 RECON SUSP 400 MG/5ML
BRAND
MDD
4 per day
ERYTHROCIN STEARATE TAB 250 MG
BRAND
erythromycin w/ delayed release particles cap 250 mg
generic
PCE (TAB DR 333 MG, TAB DR 500 MG)
BRAND
QL
6 / claim
QL
14 / claim
MDD
1 per day
QL
56 / claim
28 / claim
1 / claim
100: Package
Limit=2/claim
TETRACYCLINES
doxycycline hyclate (cap 50 mg, cap 100 mg, for inj 100
mg, tab 100 mg, tab delayed release 100 mg)
generic
minocycline hcl (cap 50 mg, cap 75 mg, cap 100 mg)
generic
FLUOROQUINOLONES
ciprofloxacin hcl (tab 250 mg, tab 500 mg, tab 750 mg)
generic
ciprofloxacin hcl tab 100 mg (base equiv)
generic
levofloxacin (tab 250 mg, tab 500 mg, tab 750 mg)
generic
ofloxacin (tab 200 mg, tab 300 mg, tab 400 mg)
generic
AMINOGLYCOSIDES
neomycin sulfate tab 500 mg
generic
tobramycin nebu soln 300 mg/5ml
generic
PAGE 23
PA
PRODUCT DESCRIPTION
BRAND/GEN
tobramycin sulfate (for inj 1.2 gm, inj 1.2 gm/30ml (40
mg/ml), inj 2 gm/50ml (40 mg/ml), inj 10 mg/ml, inj 80
mg/2ml (40 mg/ml))
generic
PA
TOBRAMYCIN SULFATE IN SALINE SOLUTION 1.2-0.9
MG/ML-%
BRAND
PA
ANTIMYCOBACTERIAL AGENTS
ethambutol hcl (tab 100 mg, tab 400 mg)
generic
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
ANTIFUNGALS
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
itraconazole cap 100 mg
generic
PA
nystatin tab 500000 unit
generic
terbinafine hcl tab 250 mg
generic
MDD
1 per day
MDD
6 per day
QL
90 / 120 days
MDD
1 per day
MDD
2 per day
ANTIVIRALS
abacavir sulfate tab 300 mg (base equiv)
PAGE 24
generic
PRODUCT DESCRIPTION
BRAND/GEN
abacavir sulfate-lamivudine-zidovudine tab 300-150-300
mg
generic
MDD
acyclovir (cap 200 mg, tab 800 mg)
generic
QL
50 / 30 days
acyclovir susp 200 mg/5ml
generic
QL
400 / 30 days
acyclovir tab 400 mg
generic
MDD
2 per day
APTIVUS CAP 250 MG
BRAND
MDD
4 per day
APTIVUS SOLUTION 100 MG/ML
BRAND
MDD
10 per day
ATRIPLA TAB 600-200-300 MG
BRAND
MDD
1 per day
COMPLERA TAB 200-25-300 MG
BRAND
MDD
1 per day
CRIXIVAN CAP 200 MG
BRAND
MDD
9 per day
CRIXIVAN CAP 400 MG
BRAND
MDD
6 per day
didanosine (capsule 125 mg, capsule 200 mg, capsule 250
mg, capsule 400 mg)
generic
MDD
1 per day
EDURANT TAB 25 MG
BRAND
MDD
1 per day
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
HARVONI TAB 90-400 MG
BRAND
PA
INTELENCE (TAB 25 MG, TAB 100 MG)
BRAND
MDD
4 per day
INTELENCE TAB 200 MG
BRAND
MDD
2 per day
INVIRASE CAP 200 MG
BRAND
MDD
10 per day
INVIRASE TAB 500 MG
BRAND
MDD
4 per day
ISENTRESS TAB 400 MG
BRAND
MDD
2 per day
KALETRA SOLUTION 400-100 MG/5ML
BRAND
QL
KALETRA TAB 100-25 MG
BRAND
MDD
PAGE 25
2 per day
320 / 32 days
4 per day
PRODUCT DESCRIPTION
BRAND/GEN
KALETRA TAB 200-50 MG
BRAND
MDD
6 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
LEXIVA SUSPENSION 50 MG/ML
BRAND
MDD
56 per day
LEXIVA TAB 700 MG
BRAND
MDD
4 per day
nevirapine susp 50 mg/5ml
generic
MDD
40 per day
nevirapine tab 200 mg
generic
MDD
2 per day
nevirapine tab sr 24hr 400 mg
generic
MDD
1 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 400 MG, TAB 600 MG)
BRAND
MDD
2 per day
PREZISTA TAB 150 MG
BRAND
MDD
3 per day
PREZISTA TAB 800 MG
BRAND
MDD
1 per day
RELENZA DISKHALER AER POW BA 5 MG/BLISTER
BRAND
AL
At least 5 yrs old
MPL
1 / 30 days
RESCRIPTOR TAB 100 MG
BRAND
MDD
12 per day
RESCRIPTOR TAB 200 MG
BRAND
MDD
6 per day
REYATAZ (CAP 100 MG, CAP 150 MG, CAP 200 MG,
CAP 300 MG)
BRAND
MDD
2 per day
SELZENTRY TAB 150 MG
BRAND
MDD
2 per day
SELZENTRY TAB 300 MG
BRAND
MDD
4 per day
SOVALDI TAB 400 MG
BRAND
PA
stavudine (cap 15 mg, cap 20 mg, cap 30 mg, cap 40 mg)
generic
MDD
PAGE 26
2 per day
PRODUCT DESCRIPTION
BRAND/GEN
stavudine for oral soln 1 mg/ml
generic
MDD
80 per day
STRIBILD TAB 150-150-200-300 MG
BRAND
MDD
1 per day
SUSTIVA (CAP 200 MG, TAB 600 MG)
BRAND
MDD
1 per day
SUSTIVA CAP 50 MG
BRAND
MDD
2 per day
TAMIFLU (CAP 45 MG, CAP 75 MG)
BRAND
QL
MFL
QL
TAMIFLU CAP 30 MG
BRAND
MFL
QL
TAMIFLU RECON SUSP 6 MG/ML
BRAND
10 / 30 days
1 / 80 days
20 / 30 days
1 / 80 days
120 / 30 days
MFL
1 / 80 days
1 per day
TRUVADA TAB 200-300 MG
BRAND
MDD
valacyclovir hcl tab 1 gm
generic
QL
21 / 21 Days
valacyclovir hcl tab 500 mg
generic
QL
42 / 21 days
valganciclovir hcl tab 450 mg
generic
MDD
2 per day
VIDEX (RECON SOLN 2 GM, RECON SOLN 4 GM)
BRAND
MDD
20 per day
VIRACEPT TAB 250 MG
BRAND
MDD
9 per day
VIRACEPT TAB 625 MG
BRAND
MDD
4 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
PAGE 27
240 / 30 days
PRODUCT DESCRIPTION
BRAND/GEN
ANTIMALARIALS
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
primaquine phosphate tab 26.3 mg (15 mg base)
generic
QL
300 / claim
QL
6 / claim
ANTI-INFECTIVE AGENTS - MISC.
clindamycin hcl (cap 150 mg, cap 300 mg)
generic
clindamycin palmitate hcl for soln 75 mg/5ml (base equiv)
generic
dapsone (tab 25 mg, tab 100 mg)
generic
erythromycin-sulfisoxazole for susp 200-600 mg/5ml
generic
FIRST-VANCOMYCIN 25 SOLUTION 25 MG/ML
BRAND
FIRST-VANCOMYCIN 50 SOLUTION 50 MG/ML
BRAND
metronidazole (tab 250 mg, tab 500 mg)
generic
SIVEXTRO TAB 200 MG
BRAND
PA
sulfamethoxazole-trimethoprim (susp 200-40 mg/5ml, tab
400-80 mg, tab 800-160 mg)
generic
trimethoprim tab 100 mg
generic
vancomycin hcl for inj 1000 mg
generic
QL
14 / claim
vancomycin hcl for inj 500 mg
generic
QL
14 / 30 days
BIOLOGICALS
PASSIVE IMMUNIZING AGENTS
HYPERRHO S/D SOLN PRSYR 1500 UNIT
BRAND
RHOGAM ULTRA-FILTERED PLUS SOLN PRSYR 1500
UNIT
BRAND
PAGE 28
PRODUCT DESCRIPTION
BRAND/GEN
ANTINEOPLASTIC AGENTS
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES
ALKERAN TAB 2 MG
BRAND
anastrozole tab 1 mg
generic
bicalutamide tab 50 mg
generic
cyclophosphamide (cap 25 mg, cap 50 mg, tab 25 mg, tab
50 mg)
generic
exemestane tab 25 mg
generic
FARESTON TAB 60 MG
BRAND
flutamide cap 125 mg
generic
hydroxyurea cap 500 mg
generic
letrozole tab 2.5 mg
generic
leucovorin calcium (tab 5 mg, tab 10 mg, tab 15 mg, tab 25
mg)
generic
LEUKERAN TAB 2 MG
BRAND
megestrol acetate (susp 40 mg/ml, tab 20 mg, tab 40 mg)
generic
mercaptopurine tab 50 mg
generic
methotrexate sodium (inj 25 mg/ml, inj pf 25 mg/ml, tab 2.5
mg (base equiv))
generic
MYLERAN TAB 2 MG
BRAND
PURIXAN 20 MG/ML ORAL SUSP
BRAND
tamoxifen citrate (tab 10 mg, tab 20 mg)
generic
temozolomide (cap 180 mg, cap 250 mg)
generic
TREXALL (TAB 5 MG, TAB 7.5 MG, TAB 10 MG, TAB 15
MG)
BRAND
MDD
1 per day
ST
ST
AL
MDD
Up to 8 yrs old
2 per day
ENDOCRINE AND METABOLIC DRUGS
CORTICOSTEROIDS
cortisone acetate tab 25 mg
PAGE 29
generic
PRODUCT DESCRIPTION
BRAND/GEN
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
dexamethasone sodium phosphate (inj 4 mg/ml, inj 20
mg/5ml, inj 120 mg/30ml)
generic
fludrocortisone acetate tab 0.1 mg
generic
hydrocortisone (tab 5 mg, tab 10 mg, tab 20 mg)
generic
methylprednisolone (tab 4 mg, tab 4 mg dose pack, tab 8
mg)
generic
MILLIPRED TAB 5 MG
BRAND
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 10 mg dose pack,
tab 20 mg, tab 50 mg)
generic
PREDNISONE INTENSOL CONC 5 MG/ML
BRAND
VERIPRED 20 SOLUTION 20 MG/5ML
QL
150 / 30 days
QL
240 / claim
BRAND
QL
150 / claim
ANDRODERM (PATCH 24HR 4 MG/24HR, PATCH 24HR
2 MG/24HR)
BRAND
MDD
ANDROXY TAB 10 MG
BRAND
METHITEST TAB 10 MG
BRAND
testosterone cypionate im inj in oil 200 mg/ml
generic
QL
ALORA (PATCH TW 0.025 MG/24HR, PATCH TW 0.05
MG/24HR, PATCH TW 0.075 MG/24HR, PATCH TW 0.1
MG/24HR)
BRAND
MDD
COMBIPATCH (PATCH TW 0.05-0.14 MG/DAY, PATCH
TW 0.05-0.25 MG/DAY)
BRAND
ANDROGENS-ANABOLIC
1 per day
4 / 30 days
ESTROGENS
PAGE 30
0.29 per day
QL
8 / 28 days
GL
Female
PRODUCT DESCRIPTION
BRAND/GEN
esterified estrogens & methyltestosterone (tab 0.625-1.25
mg, tab 1.25-2.5 mg)
generic
MDD
1 per day
ESTRADERM (PATCH TW 0.05 MG/24HR, PATCH TW
0.1 MG/24HR)
BRAND
MDD
0.29 per day
estradiol & norethindrone acetate (tab 0.5-0.1 mg, tab 10.5 mg)
generic
MDD
1 per day
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
estradiol (tab 0.5 mg, tab 1 mg, tab 2 mg)
generic
estropipate (tab 0.75 mg, tab 1.5 mg)
generic
QL
4 / 28 days
GL
Female
GL
Female
GL
Female
MDD
estropipate tab 3 mg
GL
generic
MINIVELLE (PATCH TW 0.0375 MG/24HR, PATCH TW
0.05 MG/24HR, PATCH TW 0.075 MG/24HR, PATCH TW
0.1 MG/24HR)
BRAND
PREMARIN (TAB 0.3 MG, TAB 0.45 MG, TAB 0.625 MG,
TAB 0.9 MG, TAB 1.25 MG)
BRAND
PREMPHASE TAB 0.625-5 MG
BRAND
PREMPRO (TAB 0.3-1.5 MG, TAB 0.45-1.5 MG, TAB
0.625-5 MG, TAB 0.625-2.5 MG)
1 per day
Female
MDD
2 per day
MDD
0.29 per day
GL
MDD
Female
1 per day
QL
28 / 28 days
GL
Female
GL
Female
BRAND
MDD
1 per day
QL
1 / claim
GL
Female
GL
Female
CONTRACEPTIVES
DEPO-SUBQ PROVERA 104 SUSPENSION 104
MG/0.65ML
BRAND
desogest-ethin est tab 0.1-0.025/0.125-0.025/0.150.025mg-mg
generic
DESOGESTREL-ETHINYL ESTRADIOL TAB 0.150.02/0.01 MG (AZURETTE, KARIVA, PIMTREA,
VIORELE, CAZIANT, CESIA, VELIVET)
BRAND
PAGE 31
MDD
GL
MDD
1 per day
Female
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
DESOGESTREL-ETHINYL ESTRADIOL TAB 0.15-30 MGMCG (APRI, EMOQUETTE, ENSKYCE, RECLIPSEN,
SOLIA)
BRAND
drospirenone-ethinyl estradiol tab 3-0.03 mg
generic
GL
MDD
GL
MDD
Female
1 per day
Female
1 per day
DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG
(GIANVI, LORYNA, NIKKI, VESTURA, OCELLA, SYEDA,
ZARAH)
BRAND
GL
Female
ELLA TAB 30 MG
BRAND
QL
4 / 365 days
ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB
1 MG-35 MCG (KELNOR, ZOVIA)
GL
BRAND
Female
LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST
TAB 0.01MG(7) (AMETHIA, CAMRESE, DAYSEE)
BRAND
LEVONORGEST-ETH ESTRAD 91-DAY TAB 0.15-0.03
MG (INTROVALE, JOLESSA, QUASENSE)
BRAND
levonorgestrel tab 0.75 mg
generic
MDD
GL
BRAND
LEVONORGESTREL-ETHINYL ESTRAD TAB 0.1-20 MG
(AUBRA, AVIANE, DELYLA, FALMINA, LESSINA,
LUTERA, ORSYTHIA, SRONYX)
BRAND
LEVONORGESTREL-ETHINYL ESTRAD TAB 0.15-30 MG
(ALTAVERA, CHATEAL, KURVELO, LEVORA,
MARLISSA, PORTIA)
BRAND
medroxyprogesterone acetate im susp 150 mg/ml
generic
NECON 1/50 (28) TAB 1-50 MG-MCG
1 per day
QL
91 / claim
GL
Female
GL
Female
GL
MDD
GL
MDD
GL
Female
1 per day
Female
1 per day
Female
1 per day
QL
1 / claim
GL
Female
GL
Female
BRAND
GL
BRAND
MDD
PAGE 32
4 / 365 days
MDD
MDD
NECON 10/11 (28) TAB 35 MCG
Female
MDD
MFL
LEVONORGESTREL-ETH ESTRA TAB 0.05-30/0.07540/0.125-30MG (ENPRESSE, LEVONEST, MYZILRA,
TRIVORA)
1 per day
1 per day
Female
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
NORELGESTROMIN-ETHINYL ESTRADIOL TD PTWK
150-35 MCG/24HR (XULANE)
BRAND
NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.4
MG-35 MCG (BALZIVA, BRIELLYN, GILDAGIA, PHILITH,
VYFEMLA, ZENCHENT)
BRAND
NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.5
MG-35 MCG (NECON, NORTREL, WERA)
BRAND
NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG35 MCG (ALYACEN, CYCLAFEM, DASETTA, NECON,
NORTREL, PIRMELLA)
BRAND
NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1
MG-20 MCG (GILDESS, JUNEL, LARIN, MICROGESTIN)
BRAND
NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB
1.5 MG-30 MCG (GILDESS, JUNEL, LARIN,
MICROGESTIN)
BRAND
NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE
TAB 1 MG-20 MCG (GILDESS, JUNEL, LARIN,
MICROGESTIN)
BRAND
NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE
TAB 1.5 MG-30 MCG (GILDESS, JUNEL, LARIN,
MICROGESTIN)
BRAND
NORETHINDRONE TAB 0.35 MG (CAMILA, DEBLITANE,
ERRIN, HEATHER, JENCYCLA, JOLIVETTE, LYZA,
NORA-BE, NORLYROC, SHAROBEL)
BRAND
NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.7535/1-35 MG (ALYACEN, CYCLAFEM, DASETTA, NECON,
NORTREL, PIRMELLA)
BRAND
NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/135/0.5-35 MG (ARANELLE, LEENA)
BRAND
NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG35 MCG (ESTARYLLA, MONO-LINYAH, MONONESSA,
PREVIFEM, SPRINTEC)
BRAND
NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.21535/0.25-35 MG (TRI-ESTARYLLA, TRI-LINYAH, TRIPREVIFEM, TRI-SPRINTEC, TRINESSA)
BRAND
NORGESTREL & ETHINYL ESTRADIOL TAB 0.3 MG-30
MCG (CRYSELLE, ELINEST, LOW-OGESTREL)
BRAND
PAGE 33
QL
3 / claim
GL
Female
GL
Female
MDD
GL
MDD
GL
MDD
GL
MDD
GL
MDD
GL
MDD
GL
MDD
GL
MDD
GL
MDD
GL
MDD
GL
MDD
GL
MDD
GL
MDD
1 per day
Female
1 per day
Female
2 per day
Female
1 per day
Female
1 per day
Female
1 per day
Female
1 per day
Female
1 per day
Female
1 per day
Female
1 per day
Female
1 per day
Female
1 per day
Female
2 per day
PRODUCT DESCRIPTION
BRAND/GEN
NORINYL 1+50 (28) TAB 1-50 MG-MCG
BRAND
GL
NUVARING RING 0.12-0.015 MG/24HR
OGESTREL TAB 0.5-50 MG-MCG
MDD
1 per day
QL
1 / claim
GL
Female
GL
Female
BRAND
BRAND
MDD
GL
ZOVIA 1/50E (28) TAB 1-50 MG-MCG
Female
BRAND
MDD
1 per day
Female
1 per day
PROGESTINS
medroxyprogesterone acetate (tab 2.5 mg, tab 5 mg, tab
10 mg)
generic
norethindrone acetate tab 5 mg
generic
progesterone micronized cap 100 mg
generic
QL
30 / 30 days
progesterone micronized cap 200 mg
generic
QL
20 / 30 days
APIDRA SOLOSTAR SOLN PEN 100 UNIT/ML
BRAND
QL
30 / 30 days
APIDRA SOLUTION 100 UNIT/ML
BRAND
QL
40 / 30 days
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
ANTIDIABETICS
QL
BYDUREON PEN 2 MG
BYDUREON RECON SUSP 2 MG
BRAND
BRAND
ST
AL
At least 18 yrs old
QL
4 / 28 days
PA
AL
PAGE 34
4 / 28 days
At least 18 yrs old
PRODUCT DESCRIPTION
BRAND/GEN
QL
BYETTA 10 MCG PEN SOLN PEN 10 MCG/0.04ML
BYETTA 5 MCG PEN SOLN PEN 5 MCG/0.02ML
BRAND
BRAND
2.4 / 30 days
ST
AL
At least 18 yrs old
QL
1.2 / 30 days
ST
AL
At least 18 yrs old
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
GLUCAGEN HYPOKIT RECON SOLN 1 MG
BRAND
GLUCAGON EMERGENCY KIT 1 MG
BRAND
QL
1 / claim
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
glyburide-metformin (tab 1.25-250 mg, tab 2.5-500 mg, tab
5-500 mg)
generic
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
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
PAGE 35
PRODUCT DESCRIPTION
BRAND/GEN
HUMALOG SOLN CART 100 UNIT/ML
BRAND
QL
30 / 30 days
HUMALOG SOLUTION 100 UNIT/ML
BRAND
QL
40 / 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
JENTADUETO (TAB 2.5-1000 MG, TAB 2.5-850 MG, TAB
2.5-500 MG)
AL
BRAND
At least 8 yrs old
KOMBIGLYZE XR (TAB ER 24H 5-500 MG, TAB ER 24H
5-1000 MG)
BRAND
KOMBIGLYZE XR TAB ER 24H 2.5-1000 MG
BRAND
MDD
AL
MDD
AL
MDD
2 per day
At least 8 yrs old
1 per day
At least 8 yrs old
2 per day
LANTUS SOLOSTAR SOLN PEN 100 UNIT/ML
BRAND
QL
30 / 30 days
LANTUS SOLUTION 100 UNIT/ML
BRAND
QL
30 / 30 days
LEVEMIR FLEXPEN SOLN PEN 100 UNIT/ML
BRAND
QL
30 / 30 days
LEVEMIR FLEXTOUCH SOLN PEN 100 UNIT/ML
BRAND
QL
30 / 30 days
LEVEMIR SOLUTION 100 UNIT/ML
BRAND
QL
30 / 30 days
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
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
PAGE 36
PRODUCT DESCRIPTION
BRAND/GEN
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
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
QL
30 / 30 days
NOVOLOG SOLUTION 100 UNIT/ML
BRAND
QL
40 / 30 days
AL
ONGLYZA TAB 2.5 MG
BRAND
At least 8 yrs old
MDD
AL
ONGLYZA TAB 5 MG
BRAND
2 per day
At least 8 yrs old
MDD
3 per day
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
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
QL
SYMLINPEN 120 SOLN PEN 2700 MCG/2.7ML
BRAND
10.8 / 30 days
PA
QL
SYMLINPEN 60 SOLN PEN 1500 MCG/1.5ML
BRAND
6 / 30 days
PA
AL
TRADJENTA TAB 5 MG
BRAND
MDD
PAGE 37
At least 8 yrs old
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
THYROID AGENTS
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
methimazole (tab 5 mg, tab 10 mg)
generic
NATURE-THROID (TAB 32.5 MG, TAB 130 MG, TAB 195
MG)
BRAND
propylthiouracil tab 50 mg
generic
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 32.5 MG, TAB 130 MG, TAB 195 MG)
BRAND
WESTHROID-P (TAB 32.5 MG, TAB 130 MG)
BRAND
WP THYROID (TAB 32.5 MG, TAB 130 MG)
BRAND
OXYTOCICS
methylergonovine maleate tab 0.2 mg
generic
ENDOCRINE AND METABOLIC AGENTS - MISC.
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
calcitriol (cap 0.25 mcg, cap 0.5 mcg)
generic
PAGE 38
4 / 30 days
PRODUCT DESCRIPTION
BRAND/GEN
desmopressin acetate (tab 0.1 mg, tab 0.2 mg)
generic
desmopressin acetate nasal soln 0.01% (refrigerated)
generic
MDD
3 per day
QL
5 / claim
PA
desmopressin acetate nasal spray soln 0.01%
QL
generic
5 / claim
PA
QL
5 / claim
desmopressin acetate nasal spray soln 0.01%
(refrigerated)
generic
levocarnitine oral soln 1 gm/10ml (10%)
generic
MDD
30 per day
levocarnitine tab 330 mg
generic
MDD
3 per day
MIACALCIN SOLUTION 200 UNIT/ML
BRAND
QL
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)
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
raloxifene hcl tab 60 mg
generic
MDD
risedronate sodium (tab 5 mg, tab 30 mg)
generic
PA
1 per day
PA
MDD
risedronate sodium tab 35 mg
2 / 30 days
QL
generic
1 per day
4 / 28 days
PA
CARDIOVASCULAR AGENTS
CARDIOTONICS
digoxin (oral soln 0.05 mg/ml, tab 125 mcg (0.125 mg), tab
250 mcg (0.25 mg))
PAGE 39
generic
PRODUCT DESCRIPTION
BRAND/GEN
ANTIANGINAL AGENTS
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
nitroglycerin (cap cr 2.5 mg, cap cr 6.5 mg, cap cr 9 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
BETA BLOCKERS
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
HEMANGEOL SOLUTION 4.28 MG/ML
BRAND
PA
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,
tab 24hr 25 mg)
generic
MDD
1 per day
metoprolol succinate tab sr 24hr 200 mg
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 40
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
sotalol hcl (afib/afl) ((afib/afl) tab 80 mg, (afib/afl) tab 120
mg, (afib/afl) tab 160 mg)
MDD
2 per day
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
timolol maleate (tab 5 mg, tab 10 mg, tab 20 mg)
generic
CALCIUM CHANNEL BLOCKERS
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 240 mg, beads
tab 24hr 240 mg)
generic
MDD
2 per day
diltiazem hcl coated beads (beads cap 24hr 300 mg, beads
cap 24hr 180 mg, beads cap 24hr 120 mg, beads tab 24hr
300 mg, beads tab 24hr 180 mg)
generic
MDD
1 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 120 mg, beads cap 24hr 420 mg)
generic
MDD
1 per day
diltiazem hcl extended release beads cap sr 24hr 240 mg
generic
MDD
2 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 60 mg)
generic
MDD
2 per day
nifedipine (tab 24hr osmotic 30 mg, tab 24hr osmotic 90
mg, tab 24hr 30 mg, tab 24hr 90 mg)
generic
MDD
1 per day
PAGE 41
PRODUCT DESCRIPTION
BRAND/GEN
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
ANTIARRHYTHMICS
amiodarone hcl tab 200 mg
generic
disopyramide phosphate (cap 100 mg, cap 150 mg)
generic
flecainide acetate (tab 50 mg, tab 100 mg, tab 150 mg)
generic
mexiletine hcl (cap 150 mg, cap 200 mg, cap 250 mg)
generic
NORPACE CR CAP ER 12H 150 MG
BRAND
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
TIKOSYN (CAP 125 MCG, CAP 250 MCG, CAP 500 MCG)
BRAND
ANTIHYPERTENSIVES
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
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
bisoprolol & hydrochlorothiazide (tab 5-6.25 mg, tab 106.25 mg)
generic
MDD
1 per day
captopril (tab 12.5 mg, tab 25 mg, tab 50 mg, tab 100 mg)
generic
MDD
3 per day
clonidine hcl (tab 0.1 mg, tab 0.2 mg, tab 0.3 mg)
generic
doxazosin mesylate (tab 1 mg, tab 2 mg, tab 4 mg, tab 8
mg)
generic
PAGE 42
PRODUCT DESCRIPTION
BRAND/GEN
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
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 & hydrochlorothiazide (tab 10-12.5 mg,
tab 20-12.5 mg)
generic
MDD
1 per day
fosinopril sodium (tab 10 mg, tab 20 mg, tab 40 mg)
generic
MDD
1 per day
guanabenz acetate (tab 4 mg, tab 8 mg)
generic
guanfacine hcl (tab 1 mg, tab 2 mg)
generic
hydralazine hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab 100
mg)
generic
irbesartan (tab 75 mg, tab 150 mg, tab 300 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
lisinopril (tab 2.5 mg, tab 5 mg, tab 10 mg, tab 20 mg, tab
30 mg, tab 40 mg)
generic
MDD
2 per day
losartan potassium & hydrochlorothiazide (tab 50-12.5 mg,
tab 100-25 mg, tab 100-12.5 mg)
generic
MDD
1 per day
losartan potassium (tab 25 mg, tab 50 mg, tab 100 mg)
generic
MDD
1 per day
methyldopa (tab 250 mg, tab 500 mg)
generic
metoprolol & hydrochlorothiazide (tab 50-25 mg, tab 10025 mg, tab 100-50 mg)
generic
MDD
2 per day
minoxidil (tab 2.5 mg, tab 10 mg)
generic
prazosin hcl (cap 1 mg, cap 2 mg, cap 5 mg)
generic
propranolol & hydrochlorothiazide (tab 40-25 mg, tab 80-25
mg)
generic
PAGE 43
Up to 8 yrs old
PRODUCT DESCRIPTION
BRAND/GEN
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
reserpine (tab 0.1 mg, tab 0.25 mg)
generic
terazosin hcl (cap 1 mg, cap 2 mg, cap 5 mg, cap 10 mg)
generic
trandolapril (tab 1 mg, tab 2 mg, tab 4 mg)
generic
MDD
4 per day
valsartan (tab 40 mg, tab 80 mg, tab 160 mg, tab 320 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
acetazolamide (cap sr 12hr 500 mg, tab 125 mg, tab 250
mg)
generic
amiloride & hydrochlorothiazide tab 5-50 mg
generic
MDD
1 per day
amiloride hcl tab 5 mg
generic
MDD
4 per day
bumetanide (tab 0.5 mg, tab 1 mg, tab 2 mg)
generic
chlorothiazide tab 250 mg
generic
MDD
2 per day
chlorothiazide tab 500 mg
generic
MDD
4 per day
chlorthalidone tab 50 mg
generic
furosemide (inj 10 mg/ml, oral soln 8 mg/ml, oral soln 10
mg/ml, tab 20 mg, tab 40 mg, tab 80 mg)
generic
hydrochlorothiazide (cap 12.5 mg, tab 12.5 mg, tab 25 mg,
tab 50 mg)
generic
indapamide (tab 1.25 mg, tab 2.5 mg)
generic
methazolamide (tab 25 mg, tab 50 mg)
generic
metolazone (tab 2.5 mg, tab 5 mg, tab 10 mg)
generic
spironolactone & hydrochlorothiazide tab 25-25 mg
generic
spironolactone (tab 25 mg, tab 50 mg, tab 100 mg)
generic
torsemide (tab 5 mg, tab 10 mg, tab 20 mg, tab 100 mg)
generic
MDD
1 per day
triamterene & hydrochlorothiazide (cap 37.5-25 mg, tab
37.5-25 mg, tab 75-50 mg)
generic
MDD
1 per day
PAGE 44
PRODUCT DESCRIPTION
BRAND/GEN
VASOPRESSORS
ADRENACLICK SOLN A-INJ 0.3 MG/0.3ML
BRAND
QL
2 / 30 days
EPINEPHRINE SOLN A-INJ 0.3 MG/0.3ML
BRAND
QL
2 / 30 days
EPIPEN 2-PAK SOLN A-INJ 0.3 MG/0.3ML
BRAND
QL
2 / 30 days
EPIPEN JR 2-PAK SOLN A-INJ 0.15 MG/0.3ML
BRAND
QL
2 / 30 days
EPIPEN JR SOLN A-INJ 0.15 MG/0.3ML
BRAND
QL
2 / 30 days
EPIPEN SOLN A-INJ 0.3 MG/0.3ML
BRAND
QL
2 / 30 days
midodrine hcl (tab 2.5 mg, tab 5 mg, tab 10 mg)
generic
TWINJECT SOLN A-INJ 0.3 MG/0.3ML
BRAND
QL
2 / 30 days
atorvastatin calcium (tab 10 mg, tab 20 mg, tab 40 mg, tab
80 mg)
generic
MDD
1 per day
cholestyramine (powder 4 gm/dose, powder packets 4 gm)
generic
cholestyramine light (powder 4 gm/dose, powder packets 4
gm)
generic
colestipol hcl (granule packets 5 gm, granules 5 gm)
generic
colestipol hcl tab 1 gm
generic
MDD
2 per day
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
gemfibrozil tab 600 mg
generic
MDD
2 per day
lovastatin (tab 10 mg, tab 20 mg)
generic
MDD
1 per day
lovastatin tab 40 mg
generic
MDD
2 per day
NIACOR TAB 500 MG
BRAND
pravastatin sodium (tab 10 mg, tab 20 mg, tab 40 mg, tab
80 mg)
generic
MDD
1 per day
ANTIHYPERLIPIDEMICS
PAGE 45
PRODUCT DESCRIPTION
BRAND/GEN
simvastatin (tab 5 mg, tab 10 mg, tab 20 mg, tab 40 mg)
generic
MDD
1 per day
4 per day
RESPIRATORY AGENTS
ANTIHISTAMINES
cyproheptadine hcl (syrup 2 mg/5ml, tab 4 mg)
generic
DEXCHLORPHENIRAMINE MALEATE SYRUP 2 MG/5ML
BRAND
generic
MDD
promethazine hcl (tab 12.5 mg, tab 25 mg, tab 50 mg)
generic
AL
At least 2 yrs old
promethazine hcl suppos 12.5 mg
QL
generic
12 / claim
AL
At least 2 yrs old
QL
12 / claim
AL
At least 2 yrs old
QL
2 / claim
AL
At least 2 yrs old
QL
240 / claim
AL
At least 2 yrs old
promethazine hcl suppos 25 mg
promethazine hcl syrup 6.25 mg/5ml
generic
generic
generic
NASAL AGENTS - SYSTEMIC AND TOPICAL
ADRENALIN SOLUTION 0.1 %
BRAND
azelastine hcl (0.1% (137 mcg/), 0.15% (205.5 mcg/), 137
mcg/(1 mg/ml))
generic
BACTROBAN NASAL OINTMENT 2 %
BRAND
flunisolide nasal soln 25 mcg/act (0.025%)
generic
flunisolide nasal soln 29 mcg/act (0.025%)
generic
fluticasone propionate nasal susp 50 mcg/act
MPL
1 / 30 days
QL
25 / claim
generic
QL
16 / claim
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
PAGE 46
PRODUCT DESCRIPTION
BRAND/GEN
COUGH/COLD/ALLERGY
acetylcysteine (soln 10%, soln 20%)
generic
benzonatate cap 100 mg
generic
benzonatate cap 200 mg
generic
AL
At least 10 yrs old
QL
30 / 30 days
AL
At least 10 yrs old
MFL
chlorpheniramine tan-phenylephrine tan susp 4.5-5 mg/5ml
BRAND
hydrocodone w/ homatropine syrup 5-1.5 mg/5ml
generic
phenyleph-chlorphen w/ dm-gg syrup 10-2-7.5-100 mg/5ml
generic
phenylephrine-promethazine w/ codeine syrup 5-6.25-10
mg/5ml
generic
promethazine & phenylephrine syrup 6.25-5 mg/5ml
generic
promethazine w/ codeine syrup 6.25-10 mg/5ml
promethazine-dm syrup 6.25-15 mg/5ml
AL
At least 3 yrs old
C
From age 6 and Older:
Daily Dosage=20;
From age 3 through 5:
Daily Dosage=10
generic
DECON-A ELIXIR 2-5 MG/5ML
QL
240 / claim
AL
At least 2 yrs old
QL
240 / claim
AL
At least 2 yrs old
QL
240 / claim
AL
At least 2 yrs old
QL
240 / claim
AL
At least 2 yrs old
QL
240 / claim
generic
generic
pseudoephed-bromphen-dm syrup 45-4-15 mg/5ml
generic
sodium chloride (inhalant) (soln nebu 0.9%, soln nebu 3%,
soln nebu 10%)
generic
1 / 30 days
ANTIASTHMATIC AND BRONCHODILATOR AGENTS
ADVAIR DISKUS (AER POW BA 100-50 MCG/DOSE,
AER POW BA 250-50 MCG/DOSE, AER POW BA 500-50
MCG/DOSE)
BRAND
QL
60 / 30 days
ADVAIR HFA (AEROSOL 45-21 MCG/ACT, AEROSOL
115-21 MCG/ACT, AEROSOL 230-21 MCG/ACT)
BRAND
QL
12 / 30 days
PAGE 47
PRODUCT DESCRIPTION
BRAND/GEN
AEROSPAN AERO SOLN 80 MCG/ACT
BRAND
QL
8.9 / 30 days
albuterol sulfate (soln nebu 0.63 mg/3ml, soln nebu 1.25
mg/3ml)
generic
QL
375 / 30 days
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)
generic
QL
375 / 25 days
albuterol sulfate soln nebu 0.5% (5 mg/ml)
generic
MDD
aminophylline (tab 100 mg, tab 200 mg)
generic
ATROVENT HFA AERO SOLN 17 MCG/ACT
BRAND
QL
26 / 30 days
BREO ELLIPTA AER POW BA 100-25 MCG/INH
BRAND
AL
At least 18 yrs old
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
2 per day
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 / claim
ELIXOPHYLLIN ELIXIR 80 MG/15ML
BRAND
FLOVENT DISKUS (AER POW BA 100 MCG/BLIST, AER
POW BA 250 MCG/BLIST)
BRAND
MDD
2 per day
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
FORADIL AEROLIZER CAP 12 MCG
BRAND
MDD
ipratropium bromide inhal soln 0.02%
generic
QL
PAGE 48
1 per day
2 per day
375 / 25 days
PRODUCT DESCRIPTION
BRAND/GEN
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml
generic
LUFYLLIN (TAB 200 MG, TAB 400 MG)
BRAND
metaproterenol sulfate (tab 10 mg, tab 20 mg)
generic
metaproterenol sulfate syrup 10 mg/5ml
MDD
12 per day
generic
MDD
30 per day
montelukast sodium (chew tab 4 mg, chew tab 5 mg, oral
granules packet 4 mg, tab 10 mg)
generic
MDD
1 per day
PROAIR HFA AERO SOLN 108 (90 BASE) MCG/ACT
BRAND
MPL
2 / 30 days
PROVENTIL HFA AERO SOLN 108 (90 BASE) MCG/ACT
BRAND
MPL
2 / 30 days
PULMICORT FLEXHALER (AER POW BA 90 MCG/ACT,
AER POW BA 180 MCG/ACT)
BRAND
QL
1 / 25 Days
SEREVENT DISKUS AER POW BA 50 MCG/DOSE
BRAND
MDD
2 per day
SYMBICORT (AEROSOL 80-4.5 MCG/ACT, AEROSOL
160-4.5 MCG/ACT)
BRAND
QL
11 / claim
terbutaline sulfate (tab 2.5 mg, tab 5 mg)
generic
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
TUDORZA PRESSAIR AER POW BA 400 MCG/ACT
BRAND
MPL
1 / month
VENTOLIN HFA AERO SOLN 108 (90 BASE) MCG/ACT
BRAND
MPL
2 / 30 days
BRAND
PA
RESPIRATORY AGENTS - MISC.
ORKAMBI TAB 200-125 MG
GASTROINTESTINAL AGENTS
LAXATIVES
lactulose solution 10 gm/15ml
generic
peg 3350-kcl-sod bicarb-nacl for soln 420 gm
generic
PAGE 49
MPL
1 / claim
PRODUCT DESCRIPTION
BRAND/GEN
peg 3350-kcl-sod bicarb-sod chloride-sod sulfate
(soln236gm, soln240gm)
generic
MPL
1 / claim
ANTIDIARRHEALS
diphenoxylate w/ atropine (w/ liq mg/5ml, w/ tab mg)
generic
ULCER DRUGS
CARAFATE SUSPENSION 1 GM/10ML
QL
420 / claim
AL
Up to 6 yrs old
BRAND
cimetidine (tab 300 mg, tab 400 mg, tab 800 mg)
generic
cimetidine hcl soln 300 mg/5ml
generic
dicyclomine hcl (cap 10 mg, tab 20 mg)
generic
dicyclomine hcl oral soln 10 mg/5ml
generic
famotidine tab 40 mg
generic
FIRST-OMEPRAZOLE SUSPENSION 2 MG/ML
BRAND
QL
glycopyrrolate (tab 1 mg, tab 2 mg)
generic
MDD
4 per day
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
MDD
4 per day
lansoprazole cap delayed release 15 mg
generic
MDD
4 per day
misoprostol (tab 100 mcg, tab 200 mcg)
generic
omeprazole cap delayed release 20 mg
generic
MDD
4 per day
omeprazole cap delayed release 40 mg
generic
MDD
2 per day
OMEPRAZOLE+SYRSPEND SF ALKA SUSPENSION 2
MG/ML
BRAND
QL
pantoprazole sodium ec tab 20 mg (base equiv)
generic
MDD
1 per day
pantoprazole sodium ec tab 40 mg (base equiv)
generic
MDD
2 per day
phenobarbital-hyoscyamine-atropine-scopolamine (elix
mg/5ml, tab mg)
generic
ranitidine hcl (cap 150 mg, tab 150 mg, tab 300 mg)
generic
MDD
2 per day
PAGE 50
MDD
27 per day
MDD
40 per day
300 / 30 days
300 / 30 days
PRODUCT DESCRIPTION
BRAND/GEN
ranitidine hcl cap 300 mg
generic
ranitidine hcl syrup 15 mg/ml (75 mg/5ml)
generic
sucralfate tab 1 gm
MDD
AL
generic
1 per day
Up to 6 yrs old
MDD
20 per day
MDD
4 per day
MDD
2 per day
MDS
90 / 365 DAYS
MDD
2 per day
MDS
90 / 365 DAYS
MDS
90 / 365 DAYS
ANTIEMETICS
ondansetron hcl (oral soln 4 mg/5ml, tab 24 mg)
generic
ondansetron hcl (tab 4 mg, tab 8 mg)
generic
ondansetron orally disintegrating tab 4 mg
generic
generic
DIGESTIVE AIDS
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 10000,
CP DR PART 15000, CP DR PART 20000, CP DR PART
25000)
BRAND
GASTROINTESTINAL AGENTS - MISC.
ASACOL TAB DR 400 MG
BRAND
MDD
12 per day
balsalazide disodium cap 750 mg
generic
MDD
9 per day
calcium acetate (phosphate binder) cap 667 mg (169 mg
ca)
generic
CHOLBAM (CAP 50 MG, CAP 250 MG)
BRAND
PA
DELZICOL CAP DR 400 MG
PAGE 51
BRAND
MDD
5 per day
MDD
6 per day
PRODUCT DESCRIPTION
BRAND/GEN
lactulose (encephalopathy) solution 10 gm/15ml
generic
mesalamine enema 4 gm
generic
metoclopramide hcl (soln 5 mg/5ml (10 mg/10ml), tab 5
mg, tab 10 mg)
generic
PENTASA (CAP ER 250 MG, CAP ER 500 MG)
BRAND
SFROWASA ENEMA 4 GM/60ML
BRAND
sulfasalazine (tab 500 mg, tab delayed release 500 mg)
generic
ursodiol cap 300 mg
ursodiol tab 250 mg
MDD
60 per day
MDD
8 per day
generic
MDD
3 per day
generic
MDD
7 per day
GENITOURINARY PRODUCTS
URINARY ANTI-INFECTIVES
*methenamine-hyos-meth blue-sod phos-phen sal tab 81.6
mg***
generic
methenamine mandelate (tab 0.5 gm, tab 1 gm)
generic
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
MDD
2 per day
URINARY ANTISPASMODICS
bethanechol chloride (tab 5 mg, tab 10 mg, tab 25 mg, tab
50 mg)
generic
flavoxate hcl tab 100 mg
generic
oxybutynin chloride (tab 24hr 15 mg, tab 24hr 10 mg, tab
24hr 5 mg)
generic
oxybutynin chloride syrup 5 mg/5ml
generic
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
PAGE 52
PRODUCT DESCRIPTION
BRAND/GEN
trospium chloride tab 20 mg
generic
MDD
2 per day
clindamycin phosphate vaginal cream 2%
generic
MPL
1 / claim
ESTRACE CREAM 0.1 MG/GM
BRAND
GYNAZOLE-1 CREAM 2 %
BRAND
metronidazole vaginal gel 0.75%
generic
QL
45 / claim
MICONAZOLE 3 SUPPOS 200 MG
BRAND
QL
3 / claim
PREMARIN CREAM 0.625 MG/GM
BRAND
GL
Female
terconazole vaginal (cream 0.4%, cream 0.8%, suppos 80
mg)
generic
VAGINAL PRODUCTS
GENITOURINARY AGENTS - MISCELLANEOUS
ELMIRON CAP 100 MG
BRAND
MDD
3 per day
finasteride tab 5 mg
generic
MDD
1 per day
phenazopyridine hcl (tab 100 mg, tab 200 mg)
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
tamsulosin hcl cap 0.4 mg
generic
MDD
2 per day
alprazolam (orally disintegrating tab 0.25 mg, orally
disintegrating tab 0.5 mg, orally disintegrating tab 1 mg,
orally disintegrating tab 2 mg, tab 0.25 mg, tab 0.5 mg, tab
1 mg, tab 2 mg)
generic
MDD
4 per day
buspirone hcl (tab 7.5 mg, tab 10 mg, tab 15 mg, tab 30
mg)
generic
MDD
3 per day
buspirone hcl tab 5 mg
generic
MDD
1 per day
CENTRAL NERVOUS SYSTEM DRUGS
ANTIANXIETY AGENTS
PAGE 53
PRODUCT DESCRIPTION
BRAND/GEN
chlordiazepoxide hcl (cap 5 mg, cap 10 mg, cap 25 mg)
generic
MDD
4 per day
clorazepate dipotassium (tab 3.75 mg, tab 7.5 mg, tab 15
mg)
generic
MDD
3 per day
diazepam (tab 2 mg, tab 5 mg, tab 10 mg)
generic
MDD
4 per day
diazepam soln 1 mg/ml
generic
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
lorazepam (conc 2 mg/ml, inj 2 mg/ml, tab 0.5 mg, tab 2
mg)
generic
MDD
3 per day
lorazepam tab 1 mg
generic
MDD
4 per day
meprobamate (tab 200 mg, tab 400 mg)
generic
oxazepam (cap 10 mg, cap 15 mg, cap 30 mg)
generic
MDD
4 per day
ANTIDEPRESSANTS
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
ST
BRINTELLIX (TAB 5 MG, TAB 10 MG, TAB 20 MG)
BRAND
AL
At least 18 yrs old
MDD
1 per day
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
generic
MDD
2 per day
bupropion hcl tab sr 12hr 200 mg
generic
MDD
2 per day
citalopram hydrobromide (tab 10 mg, tab 20 mg, tab 40
mg)
generic
MDD
1.5 per day
citalopram hydrobromide oral soln 10 mg/5ml
generic
PAGE 54
PRODUCT DESCRIPTION
BRAND/GEN
clomipramine hcl (cap 25 mg, cap 50 mg, 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
duloxetine hcl (cap 20 mg, cap 30 mg, cap 60 mg)
generic
MDD
AL
2 per day
At least 18 yrs old
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, tab 20 mg)
generic
MDD
4 per day
fluoxetine hcl cap 40 mg
generic
AL
MDD
fluoxetine hcl solution 20 mg/5ml
generic
fluoxetine hcl tab 10 mg
generic
At least 7 yrs old
2 per day
AL
Up to 6 yrs old
AL
Up to 12 yrs old
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
imipramine hcl (tab 10 mg, tab 25 mg, tab 50 mg)
generic
maprotiline hcl (tab 25 mg, tab 50 mg, tab 75 mg)
generic
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
nefazodone hcl (tab 50 mg, tab 100 mg, tab 150 mg, tab
200 mg, tab 250 mg)
generic
nortriptyline hcl (cap 10 mg, cap 25 mg, cap 50 mg, cap 75
mg)
generic
nortriptyline hcl soln 10 mg/5ml
generic
MDD
20 per day
paroxetine hcl (tab 10 mg, tab 20 mg, tab 30 mg, tab 40
mg)
MDD
generic
2 per day
MFL
1 / 30 days
PAGE 55
PRODUCT DESCRIPTION
BRAND/GEN
paroxetine hcl oral susp 10 mg/5ml (base equiv)
generic
phenelzine sulfate tab 15 mg
generic
sertraline hcl (tab 25 mg, tab 50 mg)
generic
sertraline hcl oral conc 20 mg/ml
sertraline hcl tab 100 mg
MDD
40 per day
MFL
1 / 30 days
MDD
1.5 per day
MFL
1 / 30 days
MDD
10 per day
MFL
1 / 30 days
MDD
2 per day
MFL
1 / 30 days
generic
generic
tranylcypromine sulfate tab 10 mg
generic
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)
generic
MDD
2 per day
venlafaxine hcl (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
VIIBRYD KIT 10 & 20 & 40 MG
BRAND
1 per day
PA
ANTIPSYCHOTICS/ANTIMANIC AGENTS
aripiprazole (oral solution 1 mg/ml, orally disintegrating tab
10 mg, orally disintegrating tab 15 mg)
generic
PA
aripiprazole (tab 2 mg, tab 5 mg, tab 10 mg, tab 15 mg, tab
20 mg, tab 30 mg)
chlorpromazine hcl (inj 25 mg/ml, inj 50 mg/2ml)
PAGE 56
generic
generic
AL
At least 6 yrs old
MDD
1 per day
MDD
12 per day
PRODUCT DESCRIPTION
BRAND/GEN
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
clozapine (tab 25 mg, tab 50 mg, tab 200 mg)
generic
AL
MDD
clozapine odt 100 mg
AL
generic
MDD
clozapine odt 25 mg
AL
generic
MDD
clozapine odt 50 mg
AL
generic
MDD
clozapine orally disintegrating tab 100 mg
AL
generic
MDD
AL
generic
MDD
clozapine tab 100 mg
AL
generic
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
haloperidol (tab 2 mg, tab 5 mg, tab 20 mg)
generic
haloperidol decanoate (soln 50 mg/ml, soln 100 mg/ml)
generic
haloperidol lactate inj 5 mg/ml
generic
haloperidol lactate oral conc 2 mg/ml
generic
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
loxapine succinate (cap 5 mg, cap 10 mg, cap 25 mg, cap
50 mg)
generic
PAGE 57
At least 18 yrs old
3 per day
At least 18 yrs old
9 per day
At least 18 yrs old
3 per day
At least 18 yrs old
3 per day
At least 18 yrs old
9 per day
At least 18 yrs old
3 per day
At least 18 yrs old
MDD
9 per day
MDD
3 per day
MDD
6 per day
MDD
4 per day
PRODUCT DESCRIPTION
BRAND/GEN
olanzapine (for im inj 10 mg, orally disintegrating tab 5 mg,
orally disintegrating tab 10 mg, orally disintegrating tab 15
mg, orally disintegrating tab 20 mg, tab 5 mg, tab 7.5 mg,
tab 10 mg, tab 15 mg, tab 20 mg)
generic
AL
MDD
AL
olanzapine tab 2.5 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
quetiapine fumarate (tab 100 mg, tab 200 mg, tab 300 mg,
tab 400 mg)
generic
MFL
1 / 30 days
MDD
4 per day
MDD
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
MDD
MDD
AL
AL
generic
AL
generic
AL
generic
AL
generic
MDD
risperidone soln 1 mg/ml
AL
generic
MDD
PAGE 58
2 per day
At least 5 yrs old
MDD
risperidone orally disintegrating tab 2 mg
At least 10 yrs old
AL
MDD
2 per day
From age 18 through
64: Max Fills=1/year
MDD
risperidone orally disintegrating tab 0.5 mg
At least 10 yrs old
C
MDD
At least 13 yrs old
1 per day
AL
generic
1 per day
MDD
AL
quetiapine fumarate (tab 25 mg, tab 50 mg)
At least 13 yrs old
2 per day
At least 5 yrs old
2 per day
At least 5 yrs old
2 per day
At least 5 yrs old
2 per day
At least 5 yrs old
2 per day
At least 5 yrs old
2 per day
At least 5 yrs old
4 per day
PRODUCT DESCRIPTION
BRAND/GEN
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
ziprasidone hcl (cap 20 mg, cap 40 mg, cap 60 mg, cap 80
mg)
generic
AL
At least 18 yrs old
MDD
2 per day
MDD
1 per day
HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS
flurazepam hcl (cap 15 mg, cap 30 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
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
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
zaleplon (cap 5 mg, cap 10 mg)
generic
zolpidem tartrate (tab 5 mg, tab 10 mg)
AL
generic
At least 18 yrs old
MDD
1 per day
MDD
1 per day
ADHD/ANTI-NARCOLEPSY /ANTI-OBESITY/ANOREXIANT AGENTS
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS
amphetamine-dextroamphetamine (cap 24hr 30 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
amphetamine-dextroamphetamine cap sr 24hr 20 mg
generic
caffeine citrate (inj 60 mg/3ml mg/ml, oral soln 60 mg/3ml
mg/ml)
PAGE 59
AL
MDD
AL
MDD
AL
generic
6 to 18 yrs old
1 per day
3 to 18 yrs old
2 per day
6 to 18 yrs old
MDD
2 per day
MFL
2 / lifetime
PRODUCT DESCRIPTION
BRAND/GEN
dextroamphetamine sulfate (cap 24hr 15 mg, cap 24hr 10
mg)
generic
dextroamphetamine sulfate (tab 5 mg, tab 10 mg)
generic
AL
MDD
AL
MDD
dextroamphetamine sulfate cap sr 24hr 5 mg
AL
generic
MDD
methylphenidate hcl (cap cr 10 mg, cap cr 20 mg, cap cr
30 mg, cap cr 40 mg, cap cr 50 mg, cap cr 60 mg, 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)
AL
generic
MDD
6 to 18 yrs old
2 per day
3 to 18 yrs old
3 per day
6 to 18 yrs old
1 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
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISCELLANEOUS
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.
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
bupropion hcl (smoking deterrent) tab sr 12hr 150 mg
generic
CHANTIX (TAB 0.5 MG, TAB 1 MG)
CHANTIX CONTINUING MONTH PAK TAB 1 MG
CHANTIX STARTING MONTH PAK TAB 0.5 MG X 11 & 1
MG X 42
PAGE 60
MDD
2 per day
MDS
180 / 365 DAYS
MDD
2 per day
MDS
180 / 365 DAYS
MDD
2 per day
MDS
180 / 365 DAYS
MFL
2 / 365 days
MDS
180 / 365 DAYS
BRAND
BRAND
BRAND
PRODUCT DESCRIPTION
BRAND/GEN
COPAXONE SOLN PRSYR 40 MG/ML
BRAND
disulfiram tab 250 mg
generic
donepezil hydrochloride (orally disintegrating tab 5 mg,
orally disintegrating tab 10 mg, tab 5 mg, tab 10 mg)
generic
ergoloid mesylates tab 1 mg
generic
EXELON SOLUTION 2 MG/ML
BRAND
PA
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
GILENYA CAP 0.5 MG
BRAND
PA
glatiramer acetate soln prefilled syringe 20 mg/ml
generic
PA
memantine hcl (tab 5 mg, tab 10 mg)
generic
MDD
2 per day
memantine hcl oral solution 2 mg/ml
generic
memantine hcl tab 5 mg (28) & 10 mg (21) titration pak
generic
MPL
1 / 28 days
NICOTROL INHALER 10 MG
BRAND
QL
MDS
QL
NICOTROL NS SOLUTION 10 MG/ML
BRAND
180 / 365 DAYS
120 / 30 days
MDS
180 ML / 365 DAYS
4 per day
perphenazine-amitriptyline (tab 2-10 mg, tab 2-25 mg, tab
4-10 mg, tab 4-25 mg)
generic
MDD
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
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
PAGE 61
504 / 30 days
PA
MDD
1 per day
PA
MDD
2 per day
PRODUCT DESCRIPTION
BRAND/GEN
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
PA
MDD
QL
2 per day
55 / 365 days
PA
TECFIDERA (CAP DR 120 MG, CAP DR 240 MG, MISC
120 & 240 MG)
BRAND
PA
ANALGESICS AND ANESTHETICS
ANALGESICS - NONNARCOTIC
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 mg, tab mg)
generic
MDD
4 per day
choline & mag salicylate (liq 500 mg/5ml, tab 500 mg, tab
750 mg, tab 1000 mg)
generic
diflunisal tab 500 mg
generic
PHRENILIN FORTE CAP 50-650 MG
BRAND
salsalate (tab 500 mg, tab 750 mg)
generic
ANALGESICS - OPIOID
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 60 mg)
generic
MDD
2 per day
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
MDD
0.33 per day
hydrocodone-acetaminophen (tab 5-500 mg, tab 7.5-325
mg)
generic
MDD
8 per day
PAGE 62
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
methadone hcl tab 10 mg
generic
MDD
10 per day
methadone hcl tab 5 mg
generic
MDD
4 per day
morphine sulfate ((concentrate) soln 20 mg/ml, soln 100
mg/5ml (20 mg/ml))
generic
QL
morphine sulfate (cap sr 24hr 30 mg, cap sr 24hr 60 mg,
cap sr 24hr 100 mg, tab cr 15 mg, tab cr 30 mg, tab cr 60
mg, tab cr 100 mg, tab cr 200 mg)
generic
MDD
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, tab 30 mg)
generic
QL
24 / claim
oxycodone hcl (cap 5 mg, tab 5 mg, tab 10 mg, tab 15 mg,
generic
MDD
6 per day
oxycodone hcl conc 100 mg/5ml (20 mg/ml)
generic
MDD
2 per day
oxycodone hcl tab er 12hr deter 40 mg
generic
240 / claim
3 per day
PA
MDD
2 per day
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
PAGE 63
PRODUCT DESCRIPTION
BRAND/GEN
OXYCONTIN (TB12 DETER 60 MG, TB12 DETER 30 MG,
TB12 DETER 80 MG, TB12 DETER 20 MG, TB12 DETER
10 MG, TB12 DETER 15 MG)
BRAND
ROXICET SOLUTION 5-325 MG/5ML
BRAND
SUBOXONE (FILM 2-0.5 MG, FILM 4-1 MG)
BRAND
PA
MDD
2 per day
MDD
30 per day
PA
MDD
1 per day
PA
SUBOXONE (FILM 8-2 MG, FILM 12-3 MG)
BRAND
MDD
2 per day
tramadol hcl tab 50 mg
generic
MDD
8 per day
tramadol-acetaminophen tab 37.5-325 mg
generic
MDD
4 per day
ANALGESICS - ANTI-INFLAMMATORY
QL
celecoxib (cap 100 mg, cap 200 mg)
generic
PA
MDD
celecoxib (cap 50 mg, cap 400 mg)
62 / 31 days
QL
generic
2 per day
62 / 31 days
PA
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
ENBREL (KIT 25 MG, SOLN PRSYR 25 MG/0.5ML, SOLN
PRSYR 50 MG/ML)
BRAND
PA
ENBREL SURECLICK SOLN A-INJ 50 MG/ML
BRAND
PA
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
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
PAGE 64
PRODUCT DESCRIPTION
BRAND/GEN
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
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
leflunomide (tab 10 mg, tab 20 mg)
generic
meloxicam tab 15 mg
generic
meloxicam tab 7.5 mg
generic
nabumetone tab 500 mg
generic
nabumetone tab 750 mg
generic
naproxen (susp 125 mg/5ml, tab 250 mg, tab 375 mg, tab
500 mg, 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
RHEUMATREX TAB 2.5 MG
BRAND
sulindac (tab 150 mg, tab 200 mg)
generic
tolmetin sodium (cap 400 mg, tab 200 mg, tab 600 mg)
generic
QL
20 / 30 days
AL
At least 17 yrs old
MDD
2 per day
MDD
2 per day
MIGRAINE PRODUCTS
dihydroergotamine mesylate (inj 1 mg/ml, nasal spray 4
mg/ml)
generic
naratriptan hcl (tab 1 mg, tab 2.5 mg)
generic
RELPAX (TAB 20 MG, TAB 40 MG)
PAGE 65
BRAND
QL
9 / 30 days
AL
At least 18 yrs old
QL
6 / 30 days
PRODUCT DESCRIPTION
BRAND/GEN
rizatriptan benzoate (tab 5 mg, tab 10 mg)
generic
sumatriptan nasal spray (5 mg/act, 20 mg/act)
QL
12 / 30 days
AL
At least 6 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 12 yrs old
QL
6 / 30 days
QL
6 / 30 days
AL
At least 12 yrs old
QL
6 / claim
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
zolmitriptan (tab 2.5 mg, tab 5 mg)
generic
zolmitriptan (tab 2.5 mg, tab 5 mg)
generic
ZOMIG SOLUTION 5 MG
BRAND
GOUT 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
MFL
1 / 30 days
MDD
4 per day
QL
1 / claim
AL
Up to 21 yrs old
NEUROMUSCULAR DRUGS
ANTICONVULSANTS
carbamazepine (cap sr 12hr 200 mg, chew tab 100 mg,
susp 100 mg/5ml, tab 200 mg, tab sr 12hr 200 mg, tab sr
12hr 400 mg)
generic
clonazepam (orally disintegrating tab 0.5 mg, orally
disintegrating tab 1 mg, orally disintegrating tab 2 mg, tab
0.5 mg, tab 1 mg, tab 2 mg)
generic
diazepam (anticonvulsant) (gel 2.5 mg, gel 10 mg, gel 20
mg)
generic
PAGE 66
PRODUCT DESCRIPTION
BRAND/GEN
DILANTIN CAP 30 MG
BRAND
divalproex sodium (cap 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
ethosuximide (cap 250 mg, soln 250 mg/5ml)
generic
felbamate (susp 600 mg/5ml, tab 400 mg, tab 600 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
lamotrigine (tab 25 mg, tab 100 mg, tab 150 mg, tab 200
mg, tab chewable dispersible 5 mg, tab chewable
dispersible 25 mg)
generic
levetiracetam (tab 250 mg, tab 500 mg, tab 750 mg)
MDD
4 per day
generic
MDD
4 per day
levetiracetam oral soln 100 mg/ml
generic
MDD
30 per day
oxcarbazepine (susp 300 mg/5ml (60 mg/ml), tab 150 mg,
generic
phenytoin (chew tab 50 mg, susp 125 mg/5ml)
generic
phenytoin sodium extended cap 100 mg
generic
primidone (tab 50 mg, tab 250 mg)
generic
TEGRETOL-XR TAB ER 12H 100 MG
BRAND
tiagabine hcl (tab 2 mg, tab 4 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
valproate sodium syrup 250 mg/5ml (base equiv)
generic
valproic acid cap 250 mg
generic
zonisamide (cap 25 mg, cap 50 mg, cap 100 mg)
generic
ANTIPARKINSON AGENTS
amantadine hcl (cap 100 mg, syrup 50 mg/5ml)
PAGE 67
generic
PRODUCT DESCRIPTION
BRAND/GEN
benztropine mesylate (tab 0.5 mg, tab 1 mg, tab 2 mg)
generic
bromocriptine mesylate (cap 5 mg, tab 2.5 mg)
generic
carbidopa & levodopa odt 10-100 mg
generic
generic
generic
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
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)
AL
At least 18 yrs old
MDD
3 per day
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
selegiline hcl (cap 5 mg, tab 5 mg)
generic
trihexyphenidyl hcl (tab 2 mg, tab 5 mg)
generic
trihexyphenidyl hcl elixir 0.4 mg/ml
generic
QL
500 / 31 days
MUSCULOSKELETAL THERAPY AGENTS
baclofen (tab 10 mg, tab 20 mg)
generic
chlorzoxazone tab 500 mg
generic
cyclobenzaprine hcl (tab 5 mg, tab 10 mg)
generic
methocarbamol (tab 500 mg, tab 750 mg)
generic
tizanidine hcl (tab 2 mg (base equivalent), tab 2 mg, tab 4
mg (base equivalent), tab 4 mg)
generic
MDD
3 per day
ANTIMYASTHENIC/CHOLINERGIC AGENTS
pyridostigmine bromide (tab 60 mg, tab cr 180 mg)
generic
NUTRITIONAL PRODUCTS
VITAMINS
ergocalciferol cap 50000 unit
PAGE 68
generic
PRODUCT DESCRIPTION
BRAND/GEN
MEPHYTON TAB 5 MG
BRAND
MULTIVITAMINS
*pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/ml**
*pediatric multiple vitamins w/ fluoride chew tab 1 mg***
*pediatric vitamins acd fluoride & fe drops 0.25-10 mg/ml***
b-complex w/ c & folic acid (w/ ap 1, w/ tab 1)
CAVAN PRENATAL/EC CALCIUM TAB DR 28-1 MG
QL
50 / claim
AL
Up to 13 yrs old
QL
30 / 30 days
AL
Up to 13 yrs old
QL
50 / claim
AL
Up to 13 yrs old
generic
generic
generic
generic
BRAND
MDD
GL
Female
AL
Up to 45 yrs old
MDD
CAVAN-FOLATE OB TAB 65-1 MG
BRAND
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
ESCAVITE LQ LIQUID 0.25-6 MG/ML
GESTICARE TAB DR 28-1 MG
BRAND
Female
AL
Up to 45 yrs old
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
PAGE 69
1 per day
GL
BRAND
BRAND
1 per day
GL
MDD
COMPLETENATE CHEW TAB 29-1 MG
1 per day
GL
MDD
COMPLETE-RF PRENATAL TAB 90-1 MG
1 per day
GL
MDD
CO-NATAL FA TAB
1 per day
1 per day
PRODUCT DESCRIPTION
LACTOCAL-F TAB
BRAND/GEN
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
MARNATAL-F PLUS DUO PACK MISC 60-1-250 & 250
MG
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
MYNATAL CAP
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 70
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
PRENAFIRST TAB 17-1 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
1 per day
GL
Female
AL
Up to 45 yrs old
MDD
PAGE 71
1 per day
GL
MDD
RE-NATA 29 OB TAB 29-1 MG
1 per day
GL
MDD
RE PRENATAL MULTIVITAMIN/IRON CHEW TAB 29-1
MG
1 per day
GL
MDD
PRENATAL PLUS IRON TAB 29-1 MG
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
MDD
PRENATABS FA TAB
Up to 13 yrs old
1 per day
PRODUCT DESCRIPTION
SE-NATAL 19 (19 TAB MG, 19 CHEW TAB MG)
BRAND/GEN
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
SE-NATAL 90 TAB ER 90-1 MG
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
SE-NATAL ONE TAB 60-1 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 72
1 per day
GL
MDD
VITAFOL-OB 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 CALCIUM TAB 27-1 MG
1 per day
GL
MDD
VENATAL-FA TAB 29-1 MG
1 per day
GL
MDD
TRINATAL RX 1 TAB 60-1 MG
1 per day
GL
MDD
TARON-EC CAL TAB DR 28-1 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
MDD
8 per day
MDD
1 per day
MINERALS & ELECTROLYTES
FLURA-DROPS SOLUTION 0.55 (0.25 F) MG/DROP
BRAND
KLOR-CON M15 TAB ER 15 MEQ
BRAND
pot phos monobasic w/sod phos di & monobas tab 155852-130mg
generic
potassium bicarbonate effer tab 25 meq
generic
potassium chloride (cap cr 10 meq, oral liq 10% (20
meq/15ml), 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 (inj 0.9%, inj 3%, iv soln 0.9%)
generic
sodium chloride flush 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
SSKI SOLUTION 1 GM/ML
BRAND
PAGE 73
PRODUCT DESCRIPTION
BRAND/GEN
HEMATOLOGICAL AGENTS
HEMATOPOIETIC AGENTS
*ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab 106-1
mg***
generic
cyanocobalamin inj 1000 mcg/ml
generic
DROXIA (CAP 200 MG, CAP 300 MG, CAP 400 MG)
BRAND
MDD
1 per day
ANTICOAGULANTS
QL
enoxaparin sodium (inj 100 mg/ml, inj 150 mg/ml)
generic
MFL
C
QL
enoxaparin sodium (inj 80 mg/0.8ml, inj 120 mg/0.8ml)
generic
MFL
C
QL
enoxaparin sodium inj 30 mg/0.3ml
generic
MFL
C
QL
enoxaparin sodium inj 300 mg/3ml
generic
MFL
C
QL
generic
MFL
C
QL
generic
MFL
C
PAGE 74
14 / 7 days
3 / 180 days
PA required if > 7 days
of therapy
12 / 7 days
3 / 180 days
of therapy
5 / 7 days
3 / 180 days
of therapy
42 / 7 days
3 / 180 days
of therapy
6 / 7 days
3 / 180 days
of therapy
9 / 7 days
3 / 180 days
of therapy
PRODUCT DESCRIPTION
BRAND/GEN
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)
generic
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 10 MG
BRAND
QL
MDD
QL
XARELTO TAB 15 MG
BRAND
35 / 180 days
1 per day
21 / 180 Days
MDD
2 per day
BRAND
MDD
1 per day
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
XARELTO TAB 20 MG
HEMOSTATICS
tranexamic acid tab 650 mg
generic
MFL
1 / month
HEMATOLOGICAL AGENTS - MISC.
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
pentoxifylline tab cr 400 mg
generic
QL
5 / claim
TOPICAL PRODUCTS
OPHTHALMIC AGENTS
ALOCRIL SOLUTION 2 %
BRAND
ST
QL
ALOMIDE SOLUTION 0.1 %
BRAND
10 / claim
ST
PAGE 75
PRODUCT DESCRIPTION
BRAND/GEN
apraclonidine hcl ophth soln 0.5% (base equivalent)
generic
atropine sulfate ophth soln 1%
generic
azelastine hcl ophth soln 0.05%
generic
MPL
1 / claim
QL
6 / claim
MPL
1 / 30 days
AZOPT SUSPENSION 1 %
BRAND
MPL
1 / claim
bacitracin ophth oint 500 unit/gm
generic
QL
4 / claim
bacitracin-polymyxin b ophth oint
generic
QL
4 / claim
betaxolol hcl ophth soln 0.5%
generic
MPL
1 / claim
BETOPTIC-S SUSPENSION 0.25 %
BRAND
MPL
1 / claim
BLEPHAMIDE S.O.P. OINTMENT 10-0.2 %
BRAND
QL
4 / claim
BLEPHAMIDE SUSPENSION 10-0.2 %
BRAND
MPL
1 / claim
brimonidine tartrate ophth soln 0.2%
generic
MPL
1 / claim
carteolol hcl ophth soln 1%
generic
MFL
1 / 30 days
CILOXAN OINTMENT 0.3 %
BRAND
QL
4 / claim
ciprofloxacin hcl ophth soln 0.3%
generic
cromolyn sodium ophth soln 4%
generic
QL
10 / claim
CYCLOGYL SOLUTION 0.5 %
BRAND
QL
15 / claim
cyclopentolate hcl (soln 1%, soln 2%)
generic
MPL
1 / claim
dexamethasone sodium phosphate ophth soln 0.1%
generic
QL
5 / claim
diclofenac sodium ophth soln 0.1%
generic
MPL
1 / claim
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
erythromycin ophth oint 5 mg/gm
generic
QL
4 / claim
fluorometholone ophth susp 0.1%
generic
MPL
1 / claim
flurbiprofen sodium ophth soln 0.03%
generic
QL
3 / claim
PAGE 76
PRODUCT DESCRIPTION
BRAND/GEN
FML OINTMENT 0.1 %
BRAND
QL
4 / claim
gentamicin sulfate ophth oint 0.3%
generic
QL
4 / claim
gentamicin sulfate ophth soln 0.3%
generic
MPL
1 / claim
homatropine hbr ophth soln 5%
generic
MPL
1 / claim
IOPIDINE SOLUTION 1 %
BRAND
ISOPTO CARBACHOL (SOLUTION 1.5 %, SOLUTION 3
%)
BRAND
ISOPTO HOMATROPINE SOLUTION 2 %
BRAND
QL
5 / claim
ketorolac tromethamine ophth soln 0.4%
generic
MFL
1 / 30 days
ketorolac tromethamine ophth soln 0.5%
generic
MPL
1 / claim
latanoprost ophth soln 0.005%
generic
QL
3 / claim
levobunolol hcl ophth soln 0.5%
generic
MPL
1 / claim
metipranolol ophth soln 0.3%
generic
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
QL
NEVANAC SUSPENSION 0.1 %
BRAND
3 / claim
PA
ofloxacin ophth soln 0.3%
generic
MPL
1 / claim
phenylephrine hcl ophth soln 2.5%
generic
MPL
1 / claim
pilocarpine hcl (soln 1%, soln 2%, soln 4%)
generic
polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%
generic
QL
10 / claim
PRED MILD SUSPENSION 0.12 %
BRAND
QL
10 / claim
PAGE 77
PRODUCT DESCRIPTION
BRAND/GEN
PRED-G SUSPENSION 0.3-1 %
BRAND
MPL
1 / claim
prednisolone acetate ophth susp 1%
generic
MPL
1 / 30 days
PREDNISOLONE SODIUM PHOSPHATE SOLUTION 1 %
BRAND
MPL
1 / 30 days
sulfacetamide sodium ophth oint 10%
generic
QL
4 / claim
sulfacetamide sodium ophth soln 10%
QL
generic
15 / claim
MPL
1 / claim
sulfacetamide sodium-prednisolone ophth soln 100.23(0.25)%
generic
MPL
1 / claim
timolol maleate (ophth) (gel forming soln 0.25%, gel
forming soln 0.5%, soln 0.25%, soln 0.5%)
generic
MPL
1 / claim
TIMOPTIC OCUDOSE (SOLUTION 0.25 %, SOLUTION
0.5 %)
BRAND
MPL
1 / claim
TOBRADEX OINTMENT 0.3-0.1 %
BRAND
QL
4 / claim
tobramycin ophth soln 0.3%
generic
QL
5 / claim
tobramycin-dexamethasone ophth susp 0.3-0.1%
generic
MPL
1 / claim
TOBREX OINTMENT 0.3 %
BRAND
QL
4 / claim
trifluridine ophth soln 1%
generic
QL
8 / claim
tropicamide ophth soln 0.5%
generic
QL
15 / claim
tropicamide ophth soln 1%
generic
MPL
1 / claim
VEXOL SUSPENSION 1 %
BRAND
MPL
1 / claim
VIGAMOX SOLUTION 0.5 %
BRAND
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
OTIC AGENTS
PAGE 78
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
ofloxacin otic soln 0.3%
generic
MPL
1 / claim
pramoxine-chloroxylenol otic liquid 1-0.1%
generic
MFL
1 / 30 days
pramoxine-hc-chloroxylenol aqueous otic soln 10-10-1
mg/ml
generic
MPL
1 / 30 days
pramoxine-hc-chloroxylenol otic soln 10-10-1 mg/ml
generic
MPL
1 / 30 days
MOUTH/THROAT/DENTAL AGENTS
chlorhexidine gluconate soln 0.12%
generic
lidocaine hcl viscous soln 2%
generic
QL
100 / claim
nystatin susp 100000 unit/ml
generic
QL
120 / claim
pilocarpine hcl tab 5 mg
generic
MDD
6 per day
sodium fluoride (dental) (cream, gel (0.5% f))
generic
MPL
1 / claim
sodium fluoride paste 1.1%
generic
QL
106 / claim
stannous fluoride conc 0.63%
generic
triamcinolone acetonide dental paste 0.1%
generic
QL
5 / claim
ANALPRAM-HC LOTION 1-2.5 %
BRAND
QL
60 / claim
hydrocortisone enema 100 mg/60ml
generic
QL
420 / claim
hydrocortisone rectal cream 2.5%
generic
MPL
acyclovir oint 5%
generic
QL
aluminum chloride soln 20%
generic
MPL
ANORECTAL AGENTS
1 / claim
DERMATOLOGICALS
PAGE 79
30 / 30 days
1 / claim
PRODUCT DESCRIPTION
BRAND/GEN
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
60 / claim
calcipotriene (cream, oint, soln (50 mcg/ml))
generic
QL
60 / claim
clindamycin phosphate (topical) (foam, gel, lotion, soln,
swab)
generic
MPL
1 / claim
clindamycin phosphate-benzoyl peroxide gel 1-5%
generic
MPL
1 / 30 days
clobetasol propionate (cream, foam, gel, lotion, oint,
shampoo, soln)
generic
MPL
1 / claim
clobetasol propionate emollient base cream 0.05%
generic
MPL
1 / claim
clotrimazole w/ betamethasone cream 1-0.05%
generic
MPL
1 / claim
clotrimazole w/ betamethasone lotion 1-0.05%
generic
QL
diflorasone diacetate (cream, oint)
generic
MPL
DRITHO-CREME HP CREAM 1 %
BRAND
econazole nitrate cream 1%
generic
ELIDEL CREAM 1 %
BRAND
30 / claim
1 / claim
QL
30 / claim
QL
30 / 30 days
PA
AL
At least 2 yrs old
EPIFOAM FOAM 1-1 %
BRAND
erythromycin (acne aid) (pads, soln)
generic
erythromycin gel 2%
generic
MPL
EURAX CREAM 10 %
BRAND
QL
EURAX LOTION 10 %
BRAND
MPL
1 / claim
fluocinonide (cream, gel, oint, soln)
generic
MPL
1 / claim
fluocinonide emulsified base cream 0.05%
generic
MPL
1 / claim
PAGE 80
1 / claim
60 / claim
PRODUCT DESCRIPTION
BRAND/GEN
fluorouracil (topical) (soln 2%, soln 5%)
generic
fluorouracil cream 0.5%
generic
fluorouracil cream 5%
QL
10 / claim
generic
QL
40 / claim
fluticasone propionate (cream, lotion)
generic
MPL
1 / 30 days
fluticasone propionate oint 0.005%
generic
MPL
1 / claim
gentamicin sulfate (topical) (cream, oint)
generic
MPL
1 / claim
hydrocortisone (topical) (lotion, oint)
generic
MPL
1 / claim
hydrocortisone butyrate soln 0.1%
generic
MPL
1 / claim
hydrocortisone cream 2.5%
generic
hydroquinone (cream, emulsion)
generic
MPL
1 / claim
imiquimod cream 5%
generic
QL
48 / 180 days
PA
isotretinoin (cap 10 mg, cap 20 mg, cap 40 mg)
generic
AL
12 to 22 yrs old
MDD
2 per day
1 / claim
ketoconazole (topical) (cream, foam)
generic
MPL
ketoconazole shampoo 2%
generic
QL
lidocaine hcl cream 3%
generic
MPL
1 / claim
lidocaine oint 5%
generic
MPL
1 / claim
lidocaine-prilocaine cream 2.5-2.5%
generic
MPL
1 / claim
malathion lotion 0.5%
generic
QL
MFL
120 / claim
59 / claim
2 / 30 days
metronidazole cream 0.75 %
generic
QL
45 / claim
metronidazole gel 0.75 %
generic
QL
45 / claim
metronidazole lotion 0.75%
generic
mometasone furoate (cream, oint, solution (lotion))
generic
PAGE 81
MPL
1 / claim
PRODUCT DESCRIPTION
BRAND/GEN
mupirocin calcium cream 2%
generic
MPL
mupirocin oint 2%
generic
C
nystatin (topical) (*nystatin topical powder**, nystatin
cream 100000 unit/gm, nystatin oint 100000 unit/gm)
generic
MPL
1 / claim
nystatin-triamcinolone (cream unit/gm-%, oint unit/gm-%)
generic
MPL
1 / claim
permethrin cream 5%
generic
MPL
1 / claim
podofilox soln 0.5%
generic
QL
4 / claim
pramoxine-hc cream 1-2.5%
generic
QL
30 / claim
prednicarbate (cream, oint)
generic
MPL
selenium sulfide lotion 2.5%
generic
QL
silver sulfadiazine cream 1%
generic
MPL
SPINOSAD SUSPENSION 0.9 %
BRAND
1 / claim
.9: Package
Limit=72/30 days
1 / claim
120 / claim
1 / claim
QL
120 / claim
MFL
2 / 30 days
1 / claim
sulfacetamide sodium liquid 10%
generic
MPL
sulfacetamide sodium lotion 10% (acne)
generic
QL
sulfacetamide sodium w/ sulfur (w/ cleansing cloth, w/
cream, w/ emulsion, w/ foam, w/ lotion)
generic
MPL
sulfacetamide sodium w/ sulfur susp 10-5%
generic
QL
30 / claim
QL
30 / 30 days
tacrolimus oint 0.03%
tacrolimus oint 0.1%
generic
generic
PAGE 82
BRAND
1 / claim
PA
AL
At least 2 yrs old
QL
30 / 30 days
PA
AL
TAZORAC (CREAM 0.05 %, CREAM 0.1 %, GEL 0.05 %,
GEL 0.1 %)
120 / claim
MPL
At least 16 yrs old
1 / claim
PRODUCT DESCRIPTION
BRAND/GEN
tretinoin (cream 0.05%, cream 0.1%)
generic
tretinoin cream 0.025%
tretinoin gel 0.01%
tretinoin gel 0.025%
QL
20 / 30 days
AL
Up to 21 yrs old
QL
20 / claim
AL
Up to 21 yrs old
QL
15 / 30 days
AL
Up to 21 yrs old
AL
Up to 21 yrs old
generic
generic
generic
triamcinolone acetonide (topical) (cream 0.1%, oint
0.025%, oint 0.1%)
generic
triamcinolone acetonide (topical) (lotion 0.025%, lotion
0.1%)
generic
MPL
1 / 30 days
MPL
1 / claim
QL
MPL
triamcinolone acetonide cream 0.025%
generic
triamcinolone acetonide cream 0.5%
generic
C
QL
60 / claim
1 / claim
454: Package
15: Package
Limit=2/claim
15 / claim
MPL
1 / claim
urea (cream, gel, lotion)
generic
MPL
1 / claim
ZOVIRAX CREAM 5 %
BRAND
MPL
1 / claim
generic
QL
MISCELLANEOUS PRODUCTS
ANTISEPTICS & DISINFECTANTS
formaldehyde solution 10%
90 / claim
ANTIDOTES
CHEMET CAP 100 MG
BRAND
JADENU (TAB 90 MG, TAB 180 MG, TAB 360 MG)
BRAND
naltrexone hcl tab 50 mg
generic
PAGE 83
PA
PRODUCT DESCRIPTION
BRAND/GEN
DIAGNOSTIC PRODUCTS
CHEK-STIX CONTROL STRIP
BRAND
CHEMSTRIP K STRIP
BRAND
GLUCAGEN DIAGNOSTIC RECON SOLN 1 MG
BRAND
KETOCARE (, STRIP)
BRAND
KETOSTIX STRIP
BRAND
ONETOUCH ULTRA BLUE STRIP
BRAND
MDD
5 per day
ONETOUCH VERIO STRIP
BRAND
MDD
5 per day
RELION KETONE STRIP
BRAND
CHEMICALS
AZELASTINE HCL POWDER
BRAND
MPL
1 / 30 days
sodium polystyrene sulfonate (bulk) powder
generic
QL
454 / claim
*lancet devices***
generic
QL
1 / 180 Days
*lancets***
generic
QL
200 / 30 days
BD AUTOSHIELD MISC 29G X 8MM
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
QL
150 / 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
MEDICAL DEVICES AND SUPPLIES
PAGE 84
PRODUCT DESCRIPTION
BRAND/GEN
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 X 1" 0.3 ML
BRAND
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
ONETOUCH ULTRA 2 KIT W/DEVICE
BRAND
QL
1 / 365 Days
ONETOUCH ULTRA MINI KIT W/DEVICE
BRAND
QL
1 / 365 Days
ONETOUCH ULTRA SYSTEM KIT W/DEVICE
BRAND
QL
1 / 365 Days
PAGE 85
PRODUCT DESCRIPTION
BRAND/GEN
ONETOUCH ULTRASMART KIT W/DEVICE
BRAND
ORTHO DIAPHRAGM ALL-FLEX (DIAPHRAGM
DIAPHRAGM 65, DIAPHRAGM DIAPHRAGM 70,
DIAPHRAGM DIAPHRAGM 75, DIAPHRAGM
DIAPHRAGM 80)
BRAND
ORTHO DIAPHRAGM COIL (DIAPHRAGM KIT 100,
DIAPHRAGM KIT 105)
QL
1 / 365 Days
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
ULTILET INSULIN SYRINGE (MISC 7/16" 0.5 ML, MISC
7/16" 0.3 ML, MISC 7/16" 1 ML)
BRAND
MDD
*sodium polystyrene sulfonate powder**
generic
QL
AZASAN (TAB 75 MG, TAB 100 MG)
BRAND
MDD
3 per day
azathioprine tab 50 mg
generic
CUPRIMINE CAP 250 MG
BRAND
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
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
mycophenolate sodium tab dr 360 mg (mycophenolic acid
equiv)
generic
MDD
4 per day
5 per day
ASSORTED CLASSES
PAGE 86
454 / claim
PRODUCT DESCRIPTION
BRAND/GEN
RAPAMUNE SOLUTION 1 MG/ML
BRAND
sirolimus tab 0.5 mg
generic
sirolimus tab 1 mg
MDD
4 per day
generic
MDD
6 per day
sirolimus tab 2 mg
generic
MDD
2 per day
sodium polystyrene sulfonate oral susp 15 gm/60ml
generic
tacrolimus (cap 0.5 mg, cap 1 mg, cap 5 mg)
generic
MDD
3 per day
PAGE 87
Index of covered drugs
A
amitriptyline hcl
54
amlodipine besylate
41
A-200
15
amlodipine besylate-benazepril hcl
42
abacavir sulfate
24
amoxapine
54
abacavir sulfate-lamivudine-zidovudine
25
amoxicillin
21
acebutolol hcl
40
amoxicillin & pot clavulanate
21
acetaminophen
10
amphetamine-dextroamphetamine
59
acetaminophen w/ codeine
62
ampicillin
21
AMPICILLIN
21
acetaminophen w/ dm
5
acetazolamide
44
ANALPRAM-HC
79
acetic acid (otic)
78
anastrozole
29
acetylcysteine
47
ANDRODERM
30
ACNE MEDICATION 5
15
ANDROXY
30
acyclovir
25
antipyrine-benzocaine
78
acyclovir topical
79
APEXICON E
80
ADRENACLICK
45
APIDRA
34
ADRENALIN
46
APIDRA SOLOSTAR
34
ADVAIR DISKUS
47
apraclonidine hcl
76
ADVAIR HFA
47
APTIVUS
25
AEROSPAN
48
ARIAL CHAMBER
18
AIMSCO LUBRICATED
18
aripiprazole
56
albuterol sulfate
48
ARMOUR THYROID
38
alcohol swabs
18
artificial tear ointment
14
alendronate sodium
38
artificial tear solution
14
ASACOL
51
ascorbic acid
11
aspirin
10
ALER-DRYL
ALKERAN
ALLEGRA ALLERGY CHILDRENS
3
29
3
allopurinol
66
aspirin buffered
10
ALOCRIL
75
aspirin buffered (cal carb-mag carb-mag oxide)
10
ALOMIDE
75
aspirin tab chew 81 mg
10
ALORA
30
atenolol
40
alprazolam
53
atenolol & chlorthalidone
42
atorvastatin calcium
45
ATRIPLA
25
atropine sulfate (ophthalmic)
76
alum & mag hydrox-simethicone
aluminum chloride
aluminum hydroxide gel
8
79
8
amantadine hcl
67
ATROVENT HFA
48
amiloride & hydrochlorothiazide
44
AVANDAMET
34
amiloride hcl
44
AVANDARYL
34
aminocaproic acid
75
AVANDIA
34
aminophylline
48
AVONEX
60
amiodarone hcl
42
AVONEX PEN
60
PAGE 88
AVONEX PREFILLED
60
bisacodyl laxative suppos 10 mg
7
bismuth subsalicylate
8
AXID AR
8
AZASAN
86
bisoprolol & hydrochlorothiazide
42
azathioprine
86
bisoprolol fumarate
40
azelastine hcl
46
BLEPHAMIDE
76
AZELASTINE HCL
84
BLEPHAMIDE S.O.P.
76
azelastine hcl (ophth)
76
BREO ELLIPTA
48
azithromycin
22
brimonidine tartrate
76
AZOPT
76
BRINTELLIX
54
bromocriptine mesylate
68
B
brompheniramine & phenyleph
5
5
b complex w/ c
12
brompheniramine & pseudoeph
b-complex vitamins
12
budesonide (inhalation)
48
b-complex w/ c & folic acid
69
bumetanide
44
bacitracin (ophthalmic)
76
bupropion hcl
54
bacitracin (topical)
15
bupropion hcl (smoking deterrent)
60
bacitracin zinc
16
54
bacitracin-polymyxin b (ophth)
76
54
baclofen
68
buspirone hcl
53
BACTROBAN NASAL
46
butalbital-acetaminophen
62
balsalazide disodium
51
butalbital-acetaminophen-caffeine
62
BD AUTOSHIELD
84
butalbital-acetaminophen-caffeine w/ codeine
62
butalbital-aspirin-caffeine
62
BD GLUCOSE
3
BD INSULIN SYRINGE
84
butalbital-aspirin-caffeine w/cod
62
BD INSULIN SYRINGE MICROFINE
84
BYDUREON
34
BD INSULIN SYRINGE ULTRAFINE
84
BYETTA 10 MCG PEN
35
benazepril & hydrochlorothiazide
42
BYETTA 5 MCG PEN
35
benazepril hcl
42
benzonatate
47
C
benzoyl peroxide
16
caffeine citrate
59
benztropine mesylate
68
calcipotriene
80
betamethasone dipropionate augmented
80
calcitonin (salmon)
38
betamethasone valerate
80
calcitriol
38
betaxolol hcl (ophth)
76
calcium acetate (phosphate binder)
51
bethanechol chloride
52
calcium carbonate
13
BETOPTIC-S
76
calcium carbonate (antacid)
bicalutamide
29
calcium carbonate-cholecalciferol
13
calcium carbonate-vitamin d
13
BIOSPEC DMX
5
8
BIOTENE MOISTURIZING MOUTH
15
calcium polycarbophil
BIOTENE ORALBALANCE DRY MOUTH
15
camphor & menthol
16
capsaicin
16
bisacodyl ec tab dr 5 mg
PAGE 89
7
7
captopril
42
chloroquine phosphate
28
CAPZASIN-P
16
chlorothiazide
44
CARAFATE
50
chlorpheniramine & phenylephrine
5
carbamazepine
66
chlorpheniramine maleate
4
carbamide peroxide (otic)
14
4
carbidopa
68
chlorpheniramine tannate-phenylephrine tannate
68
chlorpheniramine-dm
5
68
chlorpheniramine-pseudoephedrine-acetaminophen
5
68
chlorpromazine hcl
carbidopa-levodopa
68
chlorthalidone
44
carteolol hcl (ophth)
76
chlorzoxazone
68
carvedilol
40
CHOLBAM
51
CASTIVA WARMING
16
cholecalciferol
11
CAVAN PRENATAL/EC CALCIUM
69
cholestyramine
45
CAVAN-FOLATE OB
69
cholestyramine light
45
cefaclor
21
choline & mag salicylate
62
CEFACLOR
21
cilostazol
75
cefadroxil
21
CILOXAN
76
cefdinir
22
cimetidine
8,50
cefprozil
22
cimetidine hcl
50
CEFTIN
22
CIPRODEX
78
ceftriaxone sodium
22
ciprofloxacin hcl
23
cefuroxime axetil
22
ciprofloxacin hcl (ophth)
76
celecoxib
64
citalopram hydrobromide
54
cephalexin
22
clarithromycin
23
16
47
56,57
cetirizine hcl
3
CLEAN & CLEAR ADVANTAGE 3-IN-1
cetirizine hcl allergy child solution 5 mg/5ml
3
clemastine fumarate tab 1.34 mg
4
clindamycin hcl
28
4
clindamycin palmitate hydrochloride
28
cetirizine hcl tab 10 mg
4
clindamycin phosphate (topical)
80
cetirizine-pseudoephedrine
5
clindamycin phosphate vaginal
53
4
CHANTIX
60
clindamycin phosphate-benzoyl peroxide
80
CHANTIX CONTINUING MONTH PAK
60
clobetasol propionate
80
CHANTIX STARTING MONTH PAK
60
clobetasol propionate emollient base
80
CHEK-STIX CONTROL
84
clomipramine hcl
55
CHEMET
83
clonazepam
66
CHEMSTRIP K
84
clonidine hcl
42
clopidogrel bisulfate
75
childrens loratadine syrup 5 mg/5ml
4
chlordiazepoxide hcl
54
clorazepate dipotassium
54
chlorhexidine gluconate
18
clotrimazole (topical)
16
chlorhexidine gluconate (mouth-throat)
79
clotrimazole vaginal
9
PAGE 90
clotrimazole w/ betamethasone
80
clozapine
57
D
clozapine odt 100 mg
57
dapsone
clozapine odt 25 mg
57
DECON-A
5,47
clozapine odt 50 mg
57
DELZICOL
51
57
DEPO-SUBQ PROVERA 104
31
57
dermatological products, misc.
15
CO-NATAL FA
69
desipramine hcl
55
coal tar extract
16
desmopressin acetate
39
COARTEM
28
desmopressin acetate refrigerated
39
codeine sulfate
62
desmopressin acetate spray
39
colchicine
66
desmopressin acetate spray refrigerated
39
colchicine w/ probenecid
66
desogestrel-ethinyl estradiol (triphasic)
31
colestipol hcl
45
Desogestrel-Ethinyl Estradiol TAB 0.15-0.02/0.01 MG
COMBIPATCH
30
(Azurette, Kariva, Pimtrea, Viorele, Caziant, Cesia,
COMBIVENT
48
Velivet)
COMBIVENT RESPIMAT
48
Desogestrel-Ethinyl Estradiol TAB 0.15-30 MG-MCG
COMPLERA
25
(Apri, Emoquette, Enskyce, Reclipsen, Solia)
32
complete ready-to-use enema enema 7-19 gm/118ml 7
dexamethasone
30
COMPLETE-RF PRENATAL
69
DEXAMETHASONE INTENSOL
30
COMPLETENATE
69
dexamethasone sodium phosphate
30
dexamethasone sodium phosphate (ophth)
76
CONCEPTROL INSERTS
9
28
31
COPAXONE
61
DEXCHLORPHENIRAMINE MALEATE
46
COREG CR
40
dextroamphetamine sulfate
60
cortisone acetate
29
dextromethorphan polistirex er liquid er 30 mg/5ml
5
CREON
51
dextromethorphan-doxylamine-acetaminophen
5
CRIXIVAN
25
dextromethorphan-guaifenesin
5
cromolyn sodium
48
dextromethorphan-phenylephrine-acetaminophen
5
dextrose (diabetic use)
3
cromolyn sodium (nasal)
4
cromolyn sodium (ophth)
76
diazepam
54
CUPRIMINE
86
diazepam (anticonvulsant)
66
CVS DRY MOUTH
15
dibucaine
16
CVS NASAL MIST
4
dibucaine (rectal)
15
cyanocobalamin
74
diclofenac potassium
64
cyclobenzaprine hcl
68
diclofenac sodium
64
CYCLOGYL
76
diclofenac sodium (ophth)
76
cyclopentolate hcl
76
dicloxacillin sodium
21
cyclophosphamide
29
dicyclomine hcl
50
cyclosporine
86
didanosine
25
cyclosporine modified (for microemulsion)
86
diflorasone diacetate
80
cyproheptadine hcl
46
diflunisal
62
PAGE 91
digoxin
39
dihydroergotamine mesylate
65
E
DILANTIN
67
E.E.S. GRANULES
23
diltiazem hcl
41
econazole nitrate
80
diltiazem hcl coated beads
41
EDURANT
25
diltiazem hcl extended release beads
41
EFFIENT
75
dimenhydrinate
8
ELEXA NATURAL FEEL
18
DIMETAPP LONG ACT COUGH/COLD
5
ELEXA STIMULATING
18
diphenhydramine hcl
4
ELEXA ULTRA SENSITIVE
18
diphenhydramine hcl (sleep)
9
ELIDEL
80
diphenhydramine hcl (topical)
16
ELIXOPHYLLIN
48
ELLA
32
ELMIRON
53
4
4,46
diphenhydramine hcl elixir 12.5 mg/5ml
4
emollient
16
diphenhydramine hcl liquid 12.5 mg/5ml
4
EMTRIVA
25
diphenhydramine-acetaminophen (sleep)
9
enalapril maleate
43
diphenoxylate w/ atropine
50
enalapril maleate & hydrochlorothiazide
43
dipyridamole
75
ENBREL
64
disopyramide phosphate
42
ENBREL SURECLICK
64
disulfiram
61
ENCARE
divalproex sodium
67
enoxaparin sodium
74
docusate sodium
7
EPANED
43
docusate sodium cap 100 mg
7
EPIFOAM
80
9
donepezil hydrochloride
61
EPINEPHRINE
45
dorzolamide hcl
76
EPIPEN
45
dorzolamide hcl-timolol maleate
76
EPIPEN 2-PAK
45
doxazosin mesylate
42
EPIPEN JR
45
doxepin hcl
55
EPIPEN JR 2-PAK
45
doxycycline hyclate
23
EPZICOM
25
doxylamine succinate (sleep)
9
ergocalciferol
68
DRAMAMINE
8
ergoloid mesylates
61
DRITHO-CREME HP
80
ERY-TAB
23
drospirenone-ethinyl estradiol
32
ERYPED 200
23
Drospirenone-Ethinyl Estradiol TAB 3-0.03 MG (Gianvi,
ERYPED 400
23
Loryna, Nikki, Vestura, Ocella, Syeda, Zarah)
32
ERYTHROCIN STEARATE
23
DROXIA
74
erythromycin (acne aid)
80
DRY MOUTH SPRAY
15
erythromycin (ophth)
76
DULERA
48
erythromycin base
23
duloxetine hcl
55
erythromycin-sulfisoxazole
28
DUTOPROL
43
ESCAVITE LQ
69
escitalopram oxalate
55
PAGE 92
esterified estrogens & methyltestosterone
31
FLOVENT HFA
48
ESTRACE
53
fluconazole
24
ESTRADERM
31
fludrocortisone acetate
30
estradiol
31
flunisolide (nasal)
46
estradiol & norethindrone acetate
31
fluocinolone acetonide (otic)
78
estropipate
31
fluocinonide
80
ethambutol hcl
24
fluocinonide emulsified base
80
ethosuximide
67
fluorometholone (ophth)
76
Ethynodiol Diacetate & Ethinyl Estradiol Tab 1 MG-35
fluorouracil (topical)
81
MCG (Kelnor, Zovia)
32
fluoxetine hcl
55
etodolac
64
fluphenazine decanoate
57
EURAX
80
fluphenazine hcl
57
EXELON
61
FLURA-DROPS
73
exemestane
29
flurazepam hcl
59
flurbiprofen
64
flurbiprofen sodium
76
flutamide
29
F
famotidine
8,50
FANTASY LUBRICATED
18
fluticasone propionate
81
FANTASY LUBRICATED/SPERMICIDE
18
fluticasone propionate (nasal)
46
FARESTON
29
fluvoxamine maleate
55
felbamate
67
FML
77
felodipine
41
folic acid
14
fenofibrate
45
FORADIL AEROLIZER
48
fenofibrate micronized
45
formaldehyde
83
fentanyl
62
fosinopril sodium
43
ferrous fumarate
13
fosinopril sodium & hydrochlorothiazide
43
ferrous fumarate-fa-b complex-c-zn-mg-mn-cu
74
furosemide
44
ferrous gluconate
13
FERROUS GLUCONATE
13
G
ferrous sulfate
14
gabapentin
67
ferrous sulfate dried
14
GABITRIL
67
4
galantamine hydrobromide
61
4
gauze pads & dressings
18
fiber cap 0.52 gm
7
gemfibrozil
45
finasteride
53
gentamicin sulfate (ophth)
77
FIRST-OMEPRAZOLE
50
gentamicin sulfate (topical)
81
FIRST-VANCOMYCIN 25
28
GESTICARE
69
FIRST-VANCOMYCIN 50
28
GILENYA
61
flavoxate hcl
52
ginger (zingiber officinalis)
18
flecainide acetate
42
glatiramer acetate
61
FLOVENT DISKUS
48
glimepiride
35
PAGE 93
glipizide
35
HUMULIN 70/30
36
glipizide-metformin hcl
35
HUMULIN N
36
GLUCAGEN DIAGNOSTIC
84
HUMULIN N KWIKPEN
36
GLUCAGEN HYPOKIT
35
HUMULIN N PEN
36
GLUCAGON EMERGENCY
35
HUMULIN R
36
glyburide
35
hydralazine hcl
43
glyburide micronized
35
hydrochlorothiazide
44
glyburide-metformin
35
hydrocodone w/ homatropine
47
7
hydrocodone-acetaminophen
62,63
glycerin (laxative)
glycopyrrolate
50
hydrocortisone
30
griseofulvin microsize
24
hydrocortisone (intrarectal)
79
griseofulvin ultramicrosize
24
hydrocortisone (rectal)
79
guaifenesin
6
hydrocortisone (topical)
16,81
guaifenesin-codeine
6
hydrocortisone butyrate
81
guanabenz acetate
43
hydrocortisone w/acetic acid
79
guanfacine hcl
43
hydrocortisone-aloe vera
16
GYNAZOLE-1
53
hydromorphone hcl
63
hydroquinone
81
hydroxychloroquine sulfate
28
hydroxyurea
29
GYNOL II
9
H
haloperidol
57
hydroxyzine hcl
54
haloperidol decanoate
57
hydroxyzine pamoate
54
haloperidol lactate
57
hyoscyamine sulfate
50
HARVONI
25
HYPERRHO S/D
28
HEMANGEOL
40
hypromellose (ophth)
14
heparin sodium (porcine)
75
homatropine hbr
77
I
HUMALOG
36
ibuprofen
HUMALOG KWIKPEN
35
ibuprofen cap 200 mg
10
HUMALOG MIX 50/50
35
ibuprofen tab 200 mg
10
HUMALOG MIX 50/50 KWIKPEN
35
imipramine hcl
55
HUMALOG MIX 50/50 PEN
35
imiquimod
81
HUMALOG MIX 75/25
35
indapamide
44
HUMALOG MIX 75/25 KWIKPEN
35
indomethacin
65
HUMALOG MIX 75/25 PEN
35
INSPIREASE BAGS
84
HUMALOG PEN
35
INSPIREASE MOUTHPIECE
84
HUMIRA
64
INSPIREASE RESERVOIR BAGS
84
HUMIRA PEDIATRIC CROHNS START
64
84
HUMIRA PEN
65
insulin pen needle 29 g x 12.7 mm
84
HUMIRA PEN-CROHNS STARTER
65
85
HUMIRA PEN-PSORIASIS STARTER
65
85
PAGE 94
10,65
85
85
85
K
85
KALETRA
85
KAMELEON LUBRICATED
18
INSULIN SYRINGE
85
KERALYT
16
insulin syringe (disp) u-100 1 ml
85
KETOCARE
84
insulin syringe/needle u-100
85
ketoconazole (topical)
81
85
ketoprofen
65
85
ketorolac tromethamine
65
85
ketorolac tromethamine (ophth)
77
insulin syringe/needle u-100 1 ml 25 x 1"
85
KETOSTIX
84
85
ketotifen fumarate (ophth)
14
85
KIMONO
19
85
KIMONO MICRO THIN
18
85
KIMONO MICRO THIN PLUS
19
85
KIMONO PLUS
19
85
KIMONO PS
19
85
KIMONO PS PLUS
19
INTELENCE
25
KIMONO SENSATION
19
INVIRASE
25
KIMONO SENSATION PLUS
19
IOPIDINE
77
KLOR-CON M15
73
ipratropium bromide
48
KOMBIGLYZE XR
36
ipratropium bromide (nasal)
46
KPN PRENATAL
12
ipratropium-albuterol
49
irbesartan
43
L
irbesartan-hydrochlorothiazide
43
labetalol hcl
40
IRON
14
lactic acid (ammonium lactate)
16
IRON CHEWS PEDIATRIC
14
LACTOCAL-F
70
ISENTRESS
25
lactulose
49
isoniazid
24
lactulose (encephalopathy)
52
ISONIAZID
24
lamivudine
26
ISOPTO CARBACHOL
77
lamivudine-zidovudine
26
ISOPTO HOMATROPINE
77
lamotrigine
67
isosorbide dinitrate
40
lancet devices
84
isosorbide mononitrate
40
lancets
84
isotretinoin
81
lanolin
20
itraconazole
24
lanolin (topical)
15
lansoprazole
J
JADENU
PAGE 95
JENTADUETO
83
36
25,26
8,50
LANTUS
36
LANTUS SOLOSTAR
36
latanoprost
77
loratadine allergy relief tab disp 10 mg
4
leflunomide
65
loratadine tab 10 mg
4
letrozole
29
lorazepam
54
leucovorin calcium
29
losartan potassium
43
LEUKERAN
29
losartan potassium & hydrochlorothiazide
43
LEVEMIR
36
lovastatin
45
LEVEMIR FLEXPEN
36
loxapine succinate
57
LEVEMIR FLEXTOUCH
36
LUFYLLIN
49
levetiracetam
67
levobunolol hcl
77
M
levocarnitine (metabolic modifiers)
39
magnesium citrate solution 1.745 gm/30ml
7
levofloxacin
23
magnesium oxide
8
Levonorg-Eth Est Tab 0.15-0.03MG(84) & Eth Est Tab
magnesium oxide (mg supplement)
13
0.01MG(7) (Amethia, Camrese, Daysee)
malathion
81
maprotiline hcl
55
MARNATAL-F PLUS DUO PACK
70
MAXX
19
Levonorgestrel-Eth Estra Tab 0.05-30/0.075-40/0.125-
MAXX PLUS
19
30MG (Enpresse, Levonest, Myzilra, Trivora)
meclizine hcl
8
Levonorgestrel-Ethinyl Estrad TAB 0.1-20 MG (Aubra,
MEDI-GRAINE
6
Aviane, Delyla, Falmina, Lessina, Lutera, Orsythia,
medroxyprogesterone acetate
34
medroxyprogesterone acetate (contraceptive)
32
Levonorgestrel-Ethinyl Estrad TAB 0.15-30 MG
mefloquine hcl
28
(Altavera, Chateal, Kurvelo, Levora, Marlissa, Portia)32
megestrol acetate
29
levothyroxine sodium
38
melatonin
18
LEXIVA
26
meloxicam
65
LICIDE TREATMENT
17
memantine hcl
61
lidocaine
81
meperidine hcl
63
MEPHYTON
69
32
Levonorgest-Eth Estrad 91-Day TAB 0.15-0.03 MG
(Introvale, Jolessa, Quasense)
32
levonorgestrel (emergency oc)
3,32
Sronyx)
lidocaine hcl
32
32
17,81
lidocaine hcl (mouth-throat)
79
meprobamate
54
lidocaine-prilocaine
81
mercaptopurine
29
liothyronine sodium
38
mesalamine
52
lisinopril
43
metaproterenol sulfate
49
lisinopril & hydrochlorothiazide
43
metformin hcl
36
lithium
57
methadone hcl
63
lithium carbonate
57
methazolamide
44
52
LITTLE REMEDIES FOR COLDS
6
methenamine mandelate
LOHIST-D
6
methenamine-hyosc-methylene blue-sod phos-phenyl
loperamide hcl
8
sal
52
loperamide hcl tab 2 mg
8
methimazole
38
loratadine & pseudoephedrine
6
METHITEST
30
PAGE 96
methocarbamol
68
multiple vitamins w/ minerals
12
methotrexate sodium
29
mupirocin
82
methyldopa
43
mupirocin calcium (topical)
82
methylergonovine maleate
38
mycophenolate mofetil
86
methylphenidate hcl
60
mycophenolate sodium
86
methylprednisolone
30
MYLERAN
29
metipranolol
77
MYNATAL
70
metoclopramide hcl
52
MYNATAL PLUS
70
metolazone
44
MYNATAL-Z
70
metoprolol & hydrochlorothiazide
43
MYNATE 90 PLUS
70
metoprolol succinate
40
metoprolol tartrate
40
N
metronidazole
28
nabumetone
65
metronidazole (topical)
81
nadolol
40
metronidazole cream 0.75 %
81
naltrexone hcl
83
metronidazole gel 0.75 %
81
naphazoline w/ pheniramine
14
metronidazole vaginal
53
naproxen
65
mexiletine hcl
42
naproxen sodium
MIACALCIN
39
naproxen sodium tab 220 mg
10
MICONAZOLE 3
53
naratriptan hcl
65
miconazole nitrate (topical)
17
nasal moisturizing spray solution 0.65 %
miconazole nitrate vaginal
9
NATACHEW
70
midazolam hcl
59
NATAL-V RX
70
midodrine hcl
45
NATALVIT
70
7
nateglinide
36
milk of magnesia suspension 400 mg/5ml
10,65
4
MILLIPRED
30
NATURE-THROID
38
MINIVELLE
31
NECON 1/50 (28)
32
minocycline hcl
23
NECON 10/11 (28)
32
minoxidil
43
nefazodone hcl
55
mirtazapine
55
neomycin sulfate
23
misoprostol
50
neomycin-bacitracin zn-polymyxin
77
MISSION PRENATAL
12
neomycin-bacitracin-polymyxin
15
MISSION PRENATAL FA
12
neomycin-polymy-dexameth
77
MISSION PRENATAL HP
12
neomycin-polymyxin w/ pramoxine
17
MOI-STIR
15
neomycin-polymyxin-gramicidin
77
mometasone furoate
81
neomycin-polymyxin-hc (ophth)
77
montelukast sodium
49
neomycin-polymyxin-hc (otic)
79
morphine sulfate
63
NESSI SPACER WITH MASK LARGE
19
MOUTH KOTE
15
NESSI SPACER WITH MASK SM/MED
19
multiple vitamin
11
NESSI SPACER WITH MOUTHPIECE
19
multiple vitamins w/ iron
11
NEVANAC
77
PAGE 97
nevirapine
26
Norethindrone Tab 0.35 MG (Camila, Deblitane, Errin,
8
Heather, Jencycla, Jolivette, Lyza, Nora-BE, Norlyroc,
NEXIUM 24HR
niacin
11
Sharobel)
NIACOR
45
Norethindrone-Eth Estradiol Tab 0.5-35/0.75-35/1-35
nicardipine hcl
41
MG (Alyacen, Cyclafem, Dasetta, Necon, Nortrel,
nicotine
9
33
Pirmella)
33
NICOTINE
10
Norethindrone-Eth Estradiol Tab 0.5-35/1-35/0.5-35
nicotine polacrilex
10
MG (Aranelle, Leena)
NICOTROL
61
Norgestimate & Ethinyl Estradiol Tab 0.25 MG-35 MCG
NICOTROL NS
61
(Estarylla, Mono-Linyah, MonoNessa, Previfem,
nifedipine
41
Sprintec)
NITRO-BID
40
Norgestimate-Eth Estrad Tab 0.18-35/0.215-35/0.25-35
nitrofurantoin
52
MG (Tri-Estarylla, Tri-Linyah, Tri-Previfem, Tri-
nitrofurantoin macrocrystal
52
Sprintec, Trinessa)
nitrofurantoin monohyd macro
52
Norgestrel & Ethinyl Estradiol Tab 0.3 MG-30 MCG
nitroglycerin
40
(Cryselle, Elinest, Low-Ogestrel)
33
NIX LICE CONTROL
17
NORINYL 1+50 (28)
34
NIZORAL A-D
17
NORPACE CR
42
NORDITROPIN
39
nortriptyline hcl
55
NORDITROPIN FLEXPRO
39
NORVIR
26
NORDITROPIN NORDIFLEX PEN
39
NOVA MAX PLUS KETONE TEST
18
NOVOLIN 70/30
36
NOVOLIN 70/30 RELION
36
Norethindrone & Ethinyl Estradiol Tab 0.4 MG-35 MCG
NOVOLIN N
37
(Balziva, Briellyn, Gildagia, Philith, Vyfemla,
NOVOLIN N RELION
37
NOVOLIN R
37
Norethindrone & Ethinyl Estradiol Tab 0.5 MG-35 MCG
NOVOLIN R RELION
37
(Necon, Nortrel, Wera)
NOVOLOG
37
Norethindrone & Ethinyl Estradiol Tab 1 MG-35 MCG
NOVOLOG FLEXPEN
37
(Alyacen, Cyclafem, Dasetta, Necon, Nortrel,
NOVOLOG MIX 70/30
37
NOVOLOG MIX 70/30 FLEXPEN
37
NOVOLOG PENFILL
37
NUTRICION PORVIDA
12
Norethindrone Ace & Ethinyl Estradiol Tab 1.5 MG-30
NUVARING
34
MCG (Gildess, Junel, Larin, Microgestin)
nystatin
24
Norethindrone Ace & Ethinyl Estradiol-FE Tab 1 MG-20
nystatin (mouth-throat)
79
nystatin (topical)
82
nystatin-triamcinolone
82
Norelgestromin-Ethinyl Estradiol TD PTWK 150-35
MCG/24HR (Xulane)
Zenchent)
Pirmella)
33
33
33
33
Norethindrone Ace & Ethinyl Estradiol Tab 1 MG-20
33
33
33
Norethindrone Ace & Ethinyl Estradiol-FE Tab 1.5 MG30 MCG (Gildess, Junel, Larin, Microgestin)
33
norethindrone acetate
34
33
33
O
O-CAL PRENATAL
PAGE 98
33
70
ofloxacin
23
pancrelipase (lipase-protease-amylase)
51
ofloxacin (ophth)
77
pantoprazole sodium
50
ofloxacin (otic)
79
paroxetine hcl
OGESTREL
34
PARVA-CAL
13
olanzapine
58
PCE
23
omega-3 fatty acids
13
ped multivitamins w/fl & iron
69
omeprazole
50
pediatric multiple vitamin w/ c
11
55,56
omeprazole delayed release tab 20 mg
8
pediatric multiple vitamin w/ c & fa
11
OMEPRAZOLE+SYRSPEND SF ALKA
50
pediatric multiple vitamins w/ iron
11
ondansetron hcl
51
pediatric multivitamins w/fl
51
pediatric vitamins acd fluoride & iron
69
51
pediatric vitamins acd w/ fluoride
71
ONETOUCH ULTRA 2
85
pediatric vitamins adc
11
ONETOUCH ULTRA BLUE
84
peg 3350-kcl-sod bicarb-sod chloride-sod sulfate
50
ONETOUCH ULTRA MINI
85
peg 3350-potassium chloride-sod bicarbonate-sod
ONETOUCH ULTRA SYSTEM
85
chloride
49
ONETOUCH ULTRASMART
86
penicillin v potassium
21
ONETOUCH VERIO
84
PENTASA
52
ONGLYZA
37
pentoxifylline
75
OPTICHAMBER FACE MASK-LARGE
19
permethrin
OPTICHAMBER FACE MASK-MEDIUM
19
permethrin & pyrethrins-piperonyl butoxide
17
OPTICHAMBER FACE MASK-SMALL
19
perphenazine
58
perphenazine-amitriptyline
61
OPTIONS GYNOL II CONTRACEPTIVE
9
69,71
17,82
oral electrolytes
13
PERRY PRENATAL
12
ORAL RELIEF SPRAY
15
phenazopyridine hcl
53
ORKAMBI
49
phenelzine sulfate
56
ORTHO DIAPHRAGM ALL-FLEX
86
phenobarbital
59
ORTHO DIAPHRAGM COIL
86
phenobarbital-hyoscyamine-atropine-scopolamine
50
ORTHO DIAPHRAGM FLAT
86
phenyleph-promethazine w/ cod
47
oxaprozin
65
phenylephrine hcl (ophth)
77
oxazepam
54
phenylephrine hcl tab 10 mg
oxcarbazepine
67
phenylephrine-chlorpheniramine w/ dm-gg
oxybutynin chloride
52
phenylephrine-dm
6
oxycodone hcl
63
phenylephrine-guaifenesin
6
oxycodone w/ acetaminophen
63
phenylephrine-shark liver oil-cocoa butter
oxycodone-aspirin
63
phenylephrine-shark liver oil-mineral oil-petrolatum 15
OXYCONTIN
64
phenytoin
67
oyster shell
13
phenytoin sodium extended
67
PHRENILIN FORTE
62
pilocarpine hcl
77
pilocarpine hcl (oral)
79
P
PANCREAZE
PAGE 99
51
4
47
15
PIN-X
3
PREDNISONE INTENSOL
30
pindolol
41
PREMARIN
pioglitazone hcl
37
PREMIUM CONDOMS LUBRICATED
19
pioglitazone hcl-metformin hcl
37
PREMPHASE
31
piroxicam
65
PREMPRO
31
PLEGRIDY
61
PRENAFIRST
71
PLEGRIDY STARTER PACK
61
PRENATABS FA
71
PNV FE FUM/DOCUSATE/FOLIC ACID
71
PRENATABS RX
71
PNV PRENATAL PLUS MULTIVITAMIN
12
PRENATAL 19
71
podofilox
82
PRENATAL PLUS IRON
71
POLYCOSE
13
prenatal vit w/ ferrous fumarate-folic acid
11
PREZISTA
26
polyethylene glycol 3350
7
31,53
polyethylene glycol 3350 (bulk)
20
PRILOSEC OTC
polymyxin b-trimethoprim
77
primaquine phosphate
28
polysaccharide iron complex
14
primidone
67
POLYSPORIN
17
PROAIR HFA
49
polyvinyl alcohol
14
probenecid
66
pot phosphate monobasic w/ sod phosphate dibasic &
prochlorperazine
58
monobasic
73
prochlorperazine maleate
58
potassium bicarbonate
73
progesterone micronized
34
potassium chloride
73
promethazine & phenylephrine
47
potassium chloride microencapsulated crystals cr
73
promethazine hcl
46
potassium citrate (alkalinizer)
53
46
potassium citrate-citric acid
53
46
pramipexole dihydrochloride
68
promethazine w/codeine
47
pramoxine hcl (rectal)
15
promethazine-dm
47
pramoxine-chloroxylenol
79
propafenone hcl
42
pramoxine-hc
82
propranolol & hydrochlorothiazide
43
pramoxine-hc-chloroxylenol
79
propranolol hcl
41
pramoxine-hc-chloroxylenol aqueous
79
propylthiouracil
38
pravastatin sodium
45
PROVENTIL HFA
49
prazosin hcl
43
pseudoephed-bromphen-dm
PRECISION XTRA KETONE
18
pseudoephed-doxyl-dm w/apap
6
PRED MILD
77
pseudoephedrine hcl
4
PRED-G
78
pseudoephedrine hcl er tab er 12h 120 mg
5
prednicarbate
82
pseudoephedrine hcl tab 30 mg
5
prednisolone
30
pseudoephedrine w/ codeine-gg
6
prednisolone acetate (ophth)
78
pseudoephedrine w/ dm-gg
6
prednisolone sodium phosphate
30
pseudoephedrine-acetaminophen-dextromethorphan 6
PREDNISOLONE SODIUM PHOSPHATE
78
pseudoephedrine-chlorphen-dm
6
prednisone
30
pseudoephedrine-guaifenesin
6
PAGE 100
8
6,47
pseudoephedrine-ibuprofen
6
RHEUMATREX
65
psyllium
7
RHOGAM ULTRA-FILTERED PLUS
28
PTS PANELS KETONE TEST
18
riboflavin
11
PULMICORT FLEXHALER
49
RID ESSENTIAL LICE ELIMINATION
17
PURIXAN
29
rifampin
24
risedronate sodium
39
pyrantel pamoate
3
pyrazinamide
24
risperidone
58
pyrethrins-piperonyl butoxide
17
risperidone odt (tab 3 mg, tab 4 mg)
58
pyrethrins-piperonyl butoxide-permethrin-nit remover 17
58
pyridostigmine bromide
68
58
pyridoxine hcl
11
58
pyrithione zinc
17
58
rivastigmine
61
rivastigmine tartrate
61
Q
quetiapine fumarate
58
rizatriptan benzoate
66
quinapril hcl
44
ropinirole hydrochloride
68
quinidine gluconate
42
ROXICET
64
quinidine sulfate
42
R
S
salsalate
62
RA CALCIUM HI-CAL/VITAMIN D
13
SAVELLA
62
RA DRY MOUTH
15
SAVELLA TITRATION PACK
62
raloxifene hcl
39
SCHOOLTIME SHAMPOO
17
ramipril
44
SCOT-TUSSIN SENIOR
7
ranitidine hcl
8,50,51
SE-NATAL 19
72
RAPAMUNE
87
SE-NATAL 90
72
RE PRENATAL MULTIVITAMIN/IRON
71
SE-NATAL ONE
72
RE-NATA 29 OB
71
selegiline hcl
68
REALITY LATEX/ULTRA TEXTURED
19
selenium sulfide
REALITY LATEX/ULTRA THIN
19
SELZENTRY
REESES PINWORM MEDICINE
3
17,82
26
senna tab 8.6 mg
7
RELENZA DISKHALER
26
senna-docusate sodium tab 8.6-50 mg
7
RELION 70/30
37
sennosides
7
RELION KETONE
84
SEREVENT DISKUS
49
RELION N
37
sertraline hcl
56
RELION R
37
SFROWASA
52
RELPAX
65
silver sulfadiazine
82
RESCRIPTOR
26
simethicone
reserpine
44
SIMPLYTHICK
20
respiratory therapy supplies
18
simvastatin
46
REYATAZ
26
sirolimus
87
PAGE 101
9
SIVEXTRO
28
skin protectants, misc.
15
soap & cleansers
17
sodium bicarbonate (antacid)
8
SYMLINPEN 60
37
T
tacrolimus
87
sodium chloride
73
tacrolimus (topical)
82
sodium chloride (gu irrigant)
53
TAMIFLU
27
tamoxifen citrate
29
sodium chloride (inhalant)
7,47
sodium chloride flush
73
tamsulosin hcl
53
sodium citrate & citric acid
53
TARON-EC CAL
72
sodium fluoride
73
TAZORAC
82
sodium fluoride (dental)
15,79
TECFIDERA
62
sodium polystyrene sulfonate
86,87
TEGRETOL-XR
67
sodium polystyrene sulfonate (bulk)
84
temazepam
59
sorbitol
20
temozolomide
29
terazosin hcl
44
sorbitol (laxative)
7
sotalol hcl
41
terbinafine hcl
24
sotalol hcl (afib/afl)
41
terbinafine hcl (topical)
17
SOVALDI
26
terbutaline sulfate
49
SPINOSAD
82
terconazole vaginal
53
spironolactone
44
testosterone cypionate
30
spironolactone & hydrochlorothiazide
44
tetrahydrozoline hcl (ophth)
14
SSKI
73
THEO-24
49
stannous fluoride
15,79
theophylline
49
stavudine
26,27
THERANATAL CORE NUTRITION
12
STRIBILD
27
thiamine hcl
11
SUBOXONE
64
thiamine mononitrate
11
sucralfate
51
thioridazine hcl
59
thiothixene
59
SUDAFED PE CHILDRENS
5
sulfacetamide sod-prednisolone
78
thyroid
38
sulfacetamide sodium
82
THYROLAR-1
38
sulfacetamide sodium (acne)
82
THYROLAR-1/2
38
sulfacetamide sodium (ophth)
78
THYROLAR-1/4
38
sulfacetamide sodium w/ sulfur
82
THYROLAR-2
38
sulfamethoxazole-trimethoprim
28
THYROLAR-3
38
sulfasalazine
52
tiagabine hcl
67
sulindac
65
TIKOSYN
42
sumatriptan nasal spray (5 mg/act, 20 mg/act)
66
timolol maleate
41
sumatriptan succinate
66
timolol maleate (ophth)
78
SUSTIVA
27
TIMOPTIC OCUDOSE
78
SYMBICORT
49
tioconazole vaginal
SYMLINPEN 120
37
tizanidine hcl
PAGE 102
9
68
TOBRADEX
78
TRUSTEX LUB/SPERMICIDE EX ST
19
tobramycin
23
TRUSTEX LUB/SPERMICIDE XL
20
tobramycin (ophth)
78
TRUSTEX LUBRICATED
20
tobramycin sulfate
24
TRUSTEX LUBRICATED EX LARGE
20
TOBRAMYCIN SULFATE IN SALINE
24
TRUSTEX LUBRICATED EXTRA ST
20
tobramycin-dexamethasone
78
TRUSTEX LUBRICATED/SPERMICIDE
20
TOBREX
78
TRUSTEX NATURAL CONDOMS + LUBE
20
tolmetin sodium
65
TRUSTEX NON-LUBRICATED
20
tolnaftate
17
TRUSTEX RIA LUB/SPERMICIDE
20
tolterodine tartrate
52
TRUSTEX RIA LUBRICATED
20
topiramate
67
TRUSTEX RIA NON-LUBRICATED
20
torsemide
44
TRUSTEX-NONOXYNOL-9/RIB/STUD
20
TRADJENTA
37
TRUVADA
27
tramadol hcl
64
TUDORZA PRESSAIR
49
tramadol-acetaminophen
64
TWINJECT
45
trandolapril
44
tranexamic acid
75
U
tranylcypromine sulfate
56
ULTILET INSULIN SYRINGE
86
trazodone hcl
56
urea
83
TRECATOR
24
ursodiol
52
tretinoin
83
TREXALL
29
V
TRI-VI-SOL/IRON
12
valacyclovir hcl
27
triamcinolone acetonide (mouth)
79
valganciclovir hcl
27
triamcinolone acetonide (nasal)
5
valproate sodium
67
triamcinolone acetonide (topical)
83
valproic acid
67
valsartan
44
TRIAMINIC COLD/COUGH DAY TIME
7
triamterene & hydrochlorothiazide
44
valsartan-hydrochlorothiazide
44
triazolam
59
vancomycin hcl
28
trifluoperazine hcl
59
VCF VAGINAL CONTRACEPTIVE
trifluridine
78
VENATAL-FA
72
trihexyphenidyl hcl
68
venlafaxine hcl
56
trimethoprim
28
VENLAFAXINE HCL ER
56
TRINATAL RX 1
72
VENTOLIN HFA
49
TROJAN MAGNUM WARM SENSATIONS
19
verapamil hcl
42
TROJAN SUPRAS SPERMICIDAL
19
VERIPRED 20
30
TROJAN TWISTED PLEASURE
19
VEXOL
78
tropicamide
78
VIDEX
27
trospium chloride
53
VIGAMOX
78
TRUSTEX COLOR CONDOMS + LUBE
19
VIIBRYD
56
TRUSTEX LUB/RIBBED/STUDDED
19
VINATE CALCIUM
72
PAGE 103
9
VINATE M
72
VINATE ONE
72
VIRACEPT
27
VIREAD
27
VITAFOL-OB
72
VITAFOL-PN
73
vitamin e
11
vitamins w/ lipotropics
13
VITASPIRE
73
VOL-TAB RX
73
W
warfarin sodium
75
WESTHROID
38
WESTHROID-P
38
white petrolatum-mineral oil
14
WP THYROID
38
X
XARELTO
75
Z
zaleplon
59
ZENPEP
51
ZIAGEN
27
zidovudine
27
zinc (mouth-throat)
15
zinc oxide (topical)
17
zinc sulfate
13
ziprasidone hcl
59
zolmitriptan
66
zolpidem tartrate
59
ZOMIG
66
zonisamide
67
ZOVIA 1/50E (28)
34
ZOVIRAX
83
PAGE 104

preferred drug list

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