Qualified Health Plan Drug Formulary

Transcription

QUALIFIED HEALTH PLAN FORMULARY
Effective October 2015
Provided by EnvisionRxOptions
Introduction
The Total Health Care (THC) Qualified Health Plan Formulary was developed to serve as a guide for
physicians, pharmacists, health care professionals and members in the selection of cost-effective drug
therapy. Total Health Care recognizes that drug therapy is an integral part of effective health management.
Total Health Care continually reviews new and existing medications to ensure the Formulary remains
responsive to the needs of our members and health professionals. Criteria used to evaluate drug selection for
the formulary includes, but is not limited to: safety, efficacy and cost-effectiveness data, as well as
comparison of relevant benefits of similar prescription or over-the counter (OTC) agents while minimizing
potential duplications.
Notice
The information contained in this formulary is provided by THC & EnvisionRxOptions, solely for the
convenience of medical providers and members. THC does not warrant or assure accuracy of this
information, nor is it intended to be comprehensive in nature.
This formulary is not intended to be a substitute for the knowledge, expertise, skill or judgment of the
medical provider in their choice of prescription drugs. Total Health Care assumes no responsibility for the
actions or omissions of any medical provider based upon reliance, in whole or in part, on the information
contained herein. The medical provider should consult the drug manufacturer’s product literature or standard
references for more detailed information.
How to Read the Formulary
All formulary drugs are listed either by their generic names (in lowercase) or by their brand names (in
uppercase). Drugs are grouped together by their therapeutic drug category. Specific drug listings may be
accessed by using the index, using the covered generic name or the covered brand name of the drug. Any
drug not found in this Formulary listing shall be considered a non-formulary drug.
i
Tier Guidelines
Generic
Tier 1
Preferred Brand
Tier 2
Non-Preferred Brand
Non- Preferred
Generic
Specialty
Tier 3
Preventive
Tier 5
$0 co-pay at in-network pharmacies
Tier 4
The Certificate of Coverage provided upon enrollment has specific information regarding co-payments, coinsurance, annual deductible requirements and maximum out of pocket limits associated with the
corresponding pharmacy benefit.
Prescribing Guidelines
Prescribing guidelines may apply to select drugs on the THC formulary. Prescribing guidelines may vary by
benefit design but may include:
Prior Authorization
Required (PA)
Drug requires prior authorization through a specific physician request
process.
Over the Counter
Drugs (OTC)
Drug coverage is available for drugs that are available OTC with an
authorized prescription from your provider.
Specialty Drugs (SP)
Drug requires processing through THC’s contracted specialty pharmacy,
Diplomat Specialty Pharmacy.
Quantity Limit (QL)
Drug coverage may be limited to specific quantities per prescription
and/or time period.
Age Limit (AL)
Drug coverage may depend on patient age.
Gender Restriction
(GR)
Step Therapy
Required (ST)
Drug coverage may depend on patient gender.
Custom (C)
Drug coverage has unique restrictions.
Drug coverage requires that an alternative or trial of another drug be used
before the medication is covered.
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Saving on Out-Of-Pocket Costs
Total Health Care has designed its prescription drug plan to encourage the use of generic and preferred brand
name drugs. Choosing non-preferred drugs may mean paying higher out-of-pocket expenses (such as
coinsurance and co-payments) or not receiving coverage at all. Members may also pay less for generic drugs
or they may be asked to pay the cost difference between brand name drugs and their generic alternatives,
which are preferred by the plan.
Benefit Coverage and Limitations
This formulary does not define benefit coverage and limitations. Many members have specific benefit
inclusions, exclusions, copayments, coinsurance or a lack of coverage, which are not reflected in the THC
Qualified Health Plan Formulary. Members should contact Total Health Care at 1-800-826-2862 if they
have questions regarding their coverage. Please note that the formulary process is evolutionary and changes
can occur throughout the year.
Preventive Medications
Total Health Care covers certain preventive services for $0 co-pay when delivered by in-network
pharmacies. These drugs are indicated on the THC Qualified Health Plan Formulary under Drug Tier 5.
Examples of preventive medications include aspirin, contraceptives, iron supplementations, smoking
cessation products and Vitamin D drugs. These drugs are available with standard drug coverage
recommendations and are only available for certain populations.
Prior Authorization (PA)
Drugs indicated with a “PA” require Prior Authorization for coverage. A prescriber may complete a Prior
Authorization form that can be found on the Total Health Care website at www.THCmi.com. You may also
request a form by calling Total Health Care at 1-844-222-5584. Completed prior authorization forms should
be faxed to 1-877-503-7231. Prior Authorization review of prescribing guidelines will be evaluated utilizing
the established drug review criteria approved by Total Health Care. If the request does not meet the
approved criteria, the request will not be approved and alternative therapy may be recommended along with
the proper course of alternative action. The requesting provider will be provided written notification of Total
Health Care review decisions. THC’s website has a contact link where members can contact THC’s
Pharmacy Department to ask for an exception request.
Non-Formulary Agents
Drugs not located on the Total Health Care Qualified Health Plan Formulary, or any updates published by
Total Health Care, shall be considered a non-formulary drug. Requests for coverage of non-formulary agents
may be requested by the health professional depending on specific coverage parameters. Review for nonformulary drug requests will require a Prior Authorization request with documentation of medical necessity.
Generally, the following basic medical necessity guidelines are used in conducting a review:
 The patient has failed an appropriate trial of formulary or preferred agents.
 The use of preferred or formulary agent is contraindicated in the patient.
 The formulary drug or preferred agents are not suited for the present patient care need, and the drug
selected is required for patient safety.
If the request does not meet the established guidelines request, it will not be approved and alternative therapy
may be recommended along with the proper course of alternative action.
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Common Drug Exclusions
The member’s plan design may exclude certain drug classes. Prior authorization is generally not available
for drugs that are specifically excluded by benefit design. Common excluded coverages may include, but are
not limited to:
 OTC medications or their equivalents unless otherwise specified in the Formulary listing.
 Drug products used for cosmetic purposes.
 Experimental drug products, or any drug product used in an experimental manner.
 Foreign drugs or drugs not approved by the United States Food & Drug Administration (FDA).
Mandated Generic Substitution
Total Health Care advocates the use of cost-effective generic drugs where FDA-approved generic equivalent
drugs are available. Generic products are listed in the Formulary and noted in lowercase lettering wherever
an FDA-approved generic drug product is available. If a member or physician requests a brand name product
in lieu of an approved generic, the member, based upon their coverage, will be required to pay the difference
in cost between the brand/non-preferred brand and the generic drug, plus the brand/non-preferred brand
copay.
Total Health Care Pharmacy and Therapeutics (P&T) Committee
Total Health Care’s Pharmacy & Therapeutic Committee meets quarterly to review and recommend
medications for formulary consideration. The Committee considers clinical information on drugs that are
new to the market and drugs that are typically included in an outpatient pharmacy benefit. This assures that
the formulary remains responsive to patient and physician needs. The Committee is composed of physicians,
pharmacists, and health care professionals. The Committee also uses reference materials from our Pharmacy
Benefits Manager's Pharmacy and Therapeutics Advisory Panel.
Product Selection Criteria
The primary goal of the THC Pharmacy & Therapeutic Committee is to maintain and update the formulary
based upon an objective analysis of the safety, efficacy, approved indications, adverse effects,
contraindications, patient administration/compliance considerations and cost effectiveness of available drugs.
When a drug is considered for formulary inclusion, it will be reviewed relative to similar drugs including
those currently in the THC Formulary. Physicians may request a copy of THC’s drug criteria by calling the
Pharmacy Department at 1-800-826-2862.
Diabetic Testing Supplies
Total Health Care works with J&B Medical Supply to provide diabetic testing supplies to our members.
Covered diabetic testing supplies include Glucocard Vital glucometer, Glucocard Expression glucometer,
and SD Biosensor GlucoNavii glucometer, Glucocard Vital test strips, Glucocard Expression test strips, SD
Biosensor GlucoNavii test strips, lancets, insulin syringes, alcohol swabs and ketone strips. These supplies
are to be filled through J&B Medical Supply. If you have any questions about our diabetic supply program,
please contact J&B Medical Supply at 1-844-236-7933.
Specialty Bio-Pharmaceutical Pharmacy Program
Total Health Care works with Diplomat Specialty Pharmacy to provide Specialty Bio-Pharmaceutical
Pharmacy products to our members. These medications are to be filled exclusively through Diplomat
Specialty Pharmacy.
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A Specialty Drug Prior Authorization Request form must be completed and faxed to EnvisionRxOptions at
1-877-503-7231 with supporting documentation and the prescription. A prescriber may obtain a Specialty
Drug Prior Authorization Request form found on the Total Health Care website at www.THCmi.com.
Once the order is received, EnvisionRxOptions obtains authorization from Total Health Care. If the specialty
prior authorization is approved, Total Health Care notifies Diplomat Specialty Pharmacy. Then the Diplomat
Specialty Pharmacy staff ships the medication directly to the physician's office or the patient’s home. All
packages are individually marked for each patient and refrigerated items are shipped in insulated containers.
Where appropriate, each shipment includes needles, syringes and alcohol swabs. If you have any questions
about our Specialty Bio-Pharmaceutical Pharmacy program, please contact EnvisionRxOptions at 1-844222-5584 or Diplomat Specialty Pharmacy at 1-877-977-9118.
Contact Information
The Total Health Care Qualified Health Plan Formulary is designed to assist physicians, members and other
health care professionals in the selection of cost-effective agents. Total Health Care encourages your input
and feedback on how we can assist in improving this document and the formulary management process.
You may contact THC at 1-800-826-2862.
Medication Limitations
Quantity Limitations
Quantity Limitations are on medications throughout the formulary and are indicated with a "QL" notation.
These are medications that have a daily dose restriction, quantity/days’ supply limitation, and/or a limitation
on the duration of therapy.
Age Limitations
Age Limitations are on medications throughout the formulary and are indicated with an "AL" notation.
Coverage for a medication is indicated by the age limitation. This could be a minimum age, maximum age,
and/or the combination of a minimum and maximum age edit.
Gender Restrictions
Gender restrictionss are indicated with a “GR” on the formulary and require the member to be a specific
gender for coverage.
Step Therapy Criteria
Step Therapy medications are indicated with a “ST” on the formulary and require that an alternative, first
line medication be tried and failed before the requested medication can be covered. The online claims
adjudication system will automatically allow for the requested medication to be filled based on electronic
claims history indicating that the first line medication was filled.
Therapy Class
First Line
Acetylcholinesterase
Inhibitors
Aricept
ImmediateRelease,
Galantamine
Immediate-
Second Line
Galantamine
ExtendedRelease
v
Third Line
Fourth
Line
Prior use of Aricept
Immediate-Release or
Galantamine
Immediate-Release in
the last 90 days.
Release
Aminosalicylic Acid
Derivative Agents
Apriso, Delzicol Pentasa,
Asacol HD
Analgesic
Combination Agents
Norco,
Ibuprofen
Angiotensin Receptor Losartan /
Blocker
Losartan-HCTZ
(Cozaar)
AngiotensinTrandolapril,
Converting Enzyme Verapamil
and Calcium Channel
Blocker
Antianginal Agents
Nitro-Bid
Antidiabetic Agents
Januvia
Antiemetic Agents
Ondansetron
Antiglaucoma Agents Latanoprost
Reprexain,
HydrocodoneIbuprofen
CandesaBenicar,
HCTZ,
BenicarMicardis,
HCT
MicardisHCT,
Ibesartan,
IbesartanHCTZ
Tarka
Rectiv
Ointment
Tradjenta,
Onglyza
Anzemet
Lumigan,
Travatan-Z,
Zioptan
Cortifoam
Antihemorrhoidal
Agents
Anusol HC
Cream,
Hydrocortisone
Suppositories
Antimigraine
Sumatriptan
(Imitrex)
Rizatriptan
(Maxalt)
Anti-Parkinson's
Agents
Selegiline tablets Emsam
Anti-Parkinson's
Agents
Ropinirole
Immediate-
Naratriptan
Ropinirole
Extendedvi
Axert,
Frova,
Relpax
Prior use of Apriso or
Delzicol in the last 90
days.
Prior use of Norco
and Ibuprofen in the
last 90 days.
Second Line: Prior
use of losartan in the
last 90 days.
Third Line: Prior use
of Candesa-HCTZ,
Micardis, MicardisHCTZ, Ibesartan or
Ibesartan-HCTZ in
the last 90 days.
Prior use of
Trandolapril and
Verapamil in the last
90 days.
Prior use of Nitro-Bid
in the last 90 days.
Prior use of Januvia
Prior use of
Ondansetron in the
last 90 days.
Prior use of
Latanoprost in the last
90 days.
Prior use of Anusol
HC Cream or
Hydrocortisone
Suppositories in the
last 90 days.
Second Line: Prior
use of sumatriptan or
rizatriptan in the last
90 days
of Naratriptan in the
last 90 days.
Prior use of Selegiline
tablets in the last 90
days.
Prior use of
Ropinirole
Release
Antiprotozoal
Antibiotic
Release
Flagyl
Immediate
Release
Antipsychotic Agents Quetiapine
ImmediateRelease
Flagyl
Extended
Release
Ziprasidone,
Olanzapine
Antiviral Agents
Valacyclovir
Famciclovir
Benign Prostatic
Hyperplasia agents
Doxazosin
ImmediateRelease,
Finasteride,
Tamsulosin,
Terazosin
Avodart
Angiotensin Receptor Amlodipine,
Blocker and Calcium Losartan
Channel Blocker
Azor,
Exforge
Beta2 Agonist
Albuterol
Nebulizer
Levalbuterol
Nebulizer
Beta2 Agonist
Ventolin HFA,
Proair HFA
Xopenex HFA
Beta Blocker
Coreg
ImmediateRelease
Coreg
ControlledRelease,
Bystolic
Glucocorticoid
Inhaler
Qvar,
Dulera
Symbicort
vii
Seroquel
XR
Advair
Diskus,
Advair HFA
Saphris
the last 90 days.
Prior use of Flagyl
Immediate Release in
the last 90 days.
Second Line: Prior
use of Quetiapine
within the last 90
days.
of Ziprasidone or
Olanzapine in the last
90 days.
Fourth Line: Prior
use of Seroquel XR in
the last 90 days.
Prior use of
Valacyclovir in the
last 90 days.
Prior use of
Doxazosin
Immediate-Release,
Finasteride,
Tamsulosin or
Terazosin in the last
90 days (Member
must have paid claims
for two first line
drugs).
Prior use of
Amlodipine and
Losartan in the last 90
days.
Prior use of Albuterol
Nebulizer in the last
90 days.
Prior use of Ventolin
HFA or Proair HFA
Prior use of Coreg
the last 90 days.
Second Line: Prior
use of Qvar or Dulera
within the last 90
days.
of Symbicort in the
last 90 days.
Beta Blocker
Propranolol
ImmediateRelease
Propranolol
ExtendedRelease
HMG-CoA Reductase Atorvastatin,
Inhibitor
Simvastatin
Crestor,
Livalo,
Vytorin
Insulin Combination
Novolog Mix
70/30
Humalog Mix
75/25
Macrolide Antibiotics Clindamycin
Erythromycin
250mg BS,
Erythromycin
500mg BS
Rozerem
Melatonin Receptor
Agonists
Temazepam,
Zaleplon,
Zolpidem
ImmediateRelease,
Nasal Corticosteriods Flunisolide,
Fluticasone,
Nasacort OTC
Osteoporosis
Alendronate
(Fosamax)
Pleuromutilin
Antibiotic
Mupirocin
Rapid-Acting Insulin Apidra vials
Astepro,
Azelastine,
Beconase AQ,
Nasonex,
Patanase,
QNASL,
Rhinocort,
Veramyst
Actonel,
Miacalcin
Altelvia,
Ibandronate
Altabax
Humalog vials
viii
Prior use of
Propranolol
the last 90 days.
Prior use of
Atorvastatin and
Simvastatin in the last
90 days.
Prior use of Humalog
Mix in the last 90
days.
Prior use of
Clindamycin in the
last 90 days.
Prior use of
Temazepam,
Zaleplon or Zolpidem
the last 90 days
(Member must have
paid claims for two
first line drugs).
Prior use of
Flunisolide,
fluticasone or
Nasacort OTC in the
last 180 days
(Member must have
paid claims for two
first line drugs).
Second Line: Prior
use of alendronate
within the last 90
days.
of Actonel, Altevia or
Ibandronate in the last
90 days (Member
for two first line
drugs).
Prior use of
Mupirocin in the last
90 days.
Prior use of Apidra
vials in the last 90
days.
Retinoic Acid
Derivatives
Tretinoin
Atralin Gel,
0.025%,
Tretinoin
Tretinoin 0.05%, 0.04% Gel
Tretinoin 0.1%
Scabicidal Agent
Permethrin 5%
Natroba 0.9%
Selective Serotonin
Reuptake Inhibitors
Citalopram
Escitalopram
Short-Acting Insulin
Novolin N,
Novolin R
Doxycycline
Hyclate,
Doxycycline
Monohydrate,
Doxycycline
Suspension
Humulin N,
Humulin R
Minocycline
Tablets,
Minocycline
Capsules
Topical
Corticosteroids
Ketoconazole
2% Shampoo
Capex
Shampoo
Topical
Corticosteroids
Clobetasol,
Desonide,
Betamethasone,
Flucinolone,
Flucinonide,
Hydrocortisone,
Triamcinolone
Taclonex
Suspension,
Taclonex
Ointment
Urinary
Antispasmodics
Oxybutynin,
Oxybutynin-ER,
Oxytrol OTC,
Oxytrol Syrup
Tolterodine,
Tolterodine
ExtendedRelease,
Trospium
Tetracycline
Antibiotics
ix
Doxycycline
75mg,
Doxycycline
150mg
Enablex,
Toviaz,
Vesicare,
Trospium
ER
Prior use of Tretinoin
0.025%, Tretinoin
0.05% or Tretinoin
0.1% in the last 90
days.
Prior use of
Permethrin 5% in the
last 90 days.
Prior use of
Citalopram in the last
90 days.
Prior use of Novolin
Second Line: Prior
use of Doxycycline
Hyclate, Doxycycline
Monohydrate or
Doxycycline
Suspension in the last
90 days.
of Minocycline
tablets or capsules in
the last 90 days.
Prior use of
Ketoconazole 2%
Shampoo in the last
90 days.
Prior use of
Clobetasol, Desonide,
Betamethasone,
Flucinolone,
Flucinonide,
Hydrocortisone or
Triamcinolone in the
last 90 days (Member
for two first line
drugs).
Second Line: Prior
use of Oxytrol OTC,
Oxybutynin,
oxybutynin-ER or
Oxybutynin Syrup in
the last 90 days.
of Tolterodine,
Tolterodine ER or
Trospium in the last
90 days.
*Formulary Disclaimer: Coverage for some drugs may be limited to specific dosage forms and/or strengths. The
benefit design determines what is covered and the applicable co-payment. The medications listed on this
formulary are subject to change pursuant to the formulary management activities of EnvisionRxOptions. The
presence of a medication on this formulary list does not guarantee coverage.
x
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
Anti-infective Agents
ALBENZA TAB 200 MG
albendazole
2
hyophen tab 81.6 mg
1
methenamine hippurate tab 1 gm
1
METHENAMINE MANDELATE TAB 0.5 GM
methenamine mandelate
1
MONUROL PACKET 3 GM
fosfomycin tromethamine
3
nitrofurantoin macrocrystal cap 100 mg
1
nitrofurantoin macrocrystal cap 50 mg
1
nitrofurantoin suspension 25 mg/5ml
3
phosphasal tab 81.6 mg
1
sulfamethoxazole-trimethoprim suspension 200-40 mg/5ml
1
1
sulfamethoxazole-trimethoprim tab 400-80 mg
1
1
sulfatrim pediatric suspension 200-40 mg/5ml
1
trimethoprim tab 100 mg
1
uretron d/s tab
1
URETRON D/S TAB
methenamine-hyosc-methylene blue-sod phos-phenyl sal
1
ustell cap 120 mg
1
utira-c tab 81.6 mg
1
Antibacterials
amoxicillin cap 250 mg
1
1
AMOXICILLIN CHEW TAB 125 MG
amoxicillin
1
amoxicillin
1
amoxicillin recon susp 125 mg/5ml
1
PAGE 11
LAST UPDATED 09/2015
PRODUCT DESCRIPTION
TIER
1
1
1
amoxicillin tab 500 mg
1
1
amoxicillin-pot clavulanate chew tab 200-28.5 mg
1
amoxicillin-pot clavulanate chew tab 400-57 mg
1
amoxicillin-pot clavulanate er tab er 12h 1000-62.5 mg
3
amoxicillin-pot clavulanate recon susp 200-28.5 mg/5ml
1
amoxicillin-pot clavulanate recon susp 400-57 mg/5ml
1
amoxicillin-pot clavulanate tab 250-125 mg
1
QL
28 / 14 days
1
QL
28 / 14 days
1
QL
28 / 14 days
ampicillin cap 250 mg
1
ampicillin cap 500 mg
1
AMPICILLIN RECON SUSP 125 MG/5ML
ampicillin
1
AMPICILLIN RECON SUSP 250 MG/5ML
ampicillin
1
AUGMENTIN RECON SUSP 125-31.25 MG/5ML
amoxicillin & pot clavulanate
2
AVELOX ABC PACK TAB 400 MG
moxifloxacin hcl
3
AVELOX TAB 400 MG
moxifloxacin hcl
3
AVIDOXY DK KIT 100 MG
doxycycline w/ suncreen & salicylic acid
1
avidoxy tab 100 mg
1
AZITHROMYCIN PACKET 1 GM
azithromycin
1
QL
30 / 30 days
azithromycin recon soln 500 mg
1
azithromycin recon susp 100 mg/5ml
1
azithromycin recon susp 200 mg/5ml
1
PAGE 12
PRODUCT DESCRIPTION
TIER
azithromycin tab 600 mg
1
BICILLIN L-A SUSPENSION 1200000 UNIT/2ML
penicillin g benzathine
2
BICILLIN L-A SUSPENSION 600000 UNIT/ML
penicillin g benzathine
4
cefaclor cap 250 mg
1
cefaclor cap 500 mg
1
CEFACLOR ER TAB ER 12H 500 MG
cefaclor monohydrate
1
CEFACLOR RECON SUSP 125 MG/5ML
cefaclor
1
cefaclor
1
cefaclor
1
cefadroxil cap 500 mg
1
cefadroxil recon susp 250 mg/5ml
1
cefadroxil recon susp 500 mg/5ml
1
cefadroxil tab 1 gm
1
cefdinir cap 300 mg
1
cefdinir recon susp 125 mg/5ml
1
AL1
Up to 11 yrs old
cefdinir recon susp 250 mg/5ml
1
AL1
Up to 11 yrs old
cefpodoxime proxetil recon susp 100 mg/5ml
1
cefpodoxime proxetil recon susp 50 mg/5ml
1
cefpodoxime proxetil tab 100 mg
1
cefpodoxime proxetil tab 200 mg
1
cefprozil recon susp 125 mg/5ml
1
cefprozil recon susp 250 mg/5ml
1
cefprozil tab 250 mg
1
cefprozil tab 500 mg
1
ceftriaxone sodium recon soln 10 gm
1
1
1
PAGE 13
QL
60 / 30 days
PA
PRODUCT DESCRIPTION
TIER
ceftriaxone sodium recon soln 250 mg
1
cefuroxime axetil tab 250 mg
1
cefuroxime axetil tab 500 mg
1
cephalexin cap 250 mg
1
1
3
cephalexin recon susp 125 mg/5ml
1
cephalexin recon susp 250 mg/5ml
1
CEPHALEXIN TAB 250 MG
cephalexin
1
CEPHALEXIN TAB 500 MG
cephalexin
1
CIPRO RECON SUSP 250 MG/5ML (5%)
ciprofloxacin
3
ciprofloxacin
3
ciprofloxacin hcl tab 100 mg
1
CIPROFLOXACIN HCL TAB 100 MG
ciprofloxacin hcl
1
1
1
1
ciprofloxacin recon susp 250 mg/5ml (5%)
3
3
ciprofloxacin-ciproflox hcl er tab er 24h 1000 mg
1
1
clarithromycin er tab er 24h 500 mg
1
clarithromycin recon susp 125 mg/5ml
1
1
clarithromycin tab 250 mg
1
1
clindamycin hcl cap 150 mg
1
1
PAGE 14
PA
PRODUCT DESCRIPTION
TIER
1
clindamycin palmitate hcl recon soln 75 mg/5ml
1
demeclocycline hcl tab 150 mg
3
demeclocycline hcl tab 300 mg
3
dicloxacillin sodium cap 250 mg
1
dicloxacillin sodium cap 500 mg
1
DIFICID TAB 200 MG
fidaxomicin
3
doxycycline hyclate cap 100 mg
1
1
doxycycline hyclate tab 100 mg
1
1
doxycycline hyclate tab dr 150 mg
3
3
doxycycline monohydrate cap 150 mg
3
ST
3
ST
doxycycline monohydrate recon susp 25 mg/5ml
1
doxycycline monohydrate tab 150 mg
3
1
1
E.E.S. 400 TAB 400 MG
erythromycin ethylsuccinate
1
ERY-TAB TAB DR 333 MG
erythromycin base
3
ERYTHROCIN STEARATE TAB 250 MG
erythromycin stearate
1
erythromycin base cp dr part 250 mg
1
ERYTHROMYCIN BASE TAB 250 MG
erythromycin base
1
ERYTHROMYCIN BASE TAB 500 MG
erythromycin base
1
ERYTHROMYCIN ETHYLSUCCINATE TAB 400 MG
erythromycin ethylsuccinate
1
FACTIVE TAB 320 MG
gemifloxacin mesylate
3
PAGE 15
PA
PRODUCT DESCRIPTION
TIER
KEFLEX CAP 750 MG
cephalexin
3
PA
KETEK TAB 400 MG
telithromycin
3
PA
levofloxacin tab 250 mg
1
QL
14 / 30 days
1
QL
14 / 30 days
1
QL
14 / 30 days
minocycline hcl cap 100 mg
1
ST
1
1
minocycline hcl er tab er 24h 135 mg
4
ST
PA
ST
PA
4
ST
PA
3
ST
minocycline hcl tab 100 mg
1
ST
1
ST
1
ST
morgidox cap 100 mg
1
moxifloxacin hcl tab 400 mg
3
MYCOBUTIN CAP 150 MG
rifabutin
2
neomycin sulfate tab 500 mg
1
ofloxacin tab 400 mg
1
OFLOXACIN TAB 400 MG
ofloxacin
1
penicillin v potassium recon soln 125 mg/5ml
1
penicillin v potassium recon soln 250 mg/5ml
1
penicillin v potassium tab 250 mg
1
penicillin v potassium tab 500 mg
1
PAGE 16
PA
PRODUCT DESCRIPTION
TIER
rifabutin cap 150 mg
2
rifampin cap 150 mg
1
rifampin cap 300 mg
1
SULFADIAZINE TAB 500 MG
sulfadiazine
3
1
1
1
1
sulfasalazine tab 500 mg
1
sulfasalazine tab dr 500 mg
1
1
sulfazine ec tab dr 500 mg
1
sulfazine tab 500 mg
1
SUPRAX RECON SUSP 500 MG/5ML
cefixime
3
tetracycline hcl cap 250 mg
1
TETRACYCLINE HCL CAP 250 MG
tetracycline hcl
1
1
tetracycline hcl
1
vancomycin hcl recon soln 10 gm
3
vancomycin hcl recon soln 1000 mg
1
vancomycin hcl recon soln 500 mg
1
VANCOMYCIN HCL RECON SOLN 750 MG
vancomycin hcl
1
ZITHROMAX PACKET 1 GM
azithromycin
3
ZYVOX RECON SUSP 100 MG/5ML
linezolid
3
PA
ZYVOX SOLUTION 2 MG/ML
linezolid
3
PA
ZYVOX TAB 600 MG
linezolid
3
PA
PAGE 17
PA
PRODUCT DESCRIPTION
TIER
Antifungals
fluconazole recon susp 10 mg/ml
1
QL
105 / 30 days
fluconazole recon susp 40 mg/ml
1
QL
105 / 30 days
fluconazole tab 100 mg
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
griseofulvin microsize suspension 125 mg/5ml
1
griseofulvin microsize tab 500 mg
1
griseofulvin ultramicrosize tab 125 mg
1
griseofulvin ultramicrosize tab 250 mg
1
ketoconazole tab 200 mg
1
nystatin suspension 100000 unit/ml
1
nystatin tab 500000 unit
1
terbinafine hcl tab 250 mg
1
Antimycobacterials
AVELOX ABC PACK TAB 400 MG
moxifloxacin hcl
3
AVELOX TAB 400 MG
moxifloxacin hcl
3
ciprofloxacin
3
ciprofloxacin
3
1
CIPROFLOXACIN HCL TAB 100 MG
ciprofloxacin hcl
1
1
1
1
3
3
PAGE 18
PRODUCT DESCRIPTION
TIER
1
1
1
1
1
1
1
DAPSONE TAB 100 MG
dapsone
1
DAPSONE TAB 25 MG
dapsone
1
ethambutol hcl tab 100 mg
1
ethambutol hcl tab 400 mg
1
ISONIAZID SYRUP 50 MG/5ML
isoniazid
1
isoniazid tab 100 mg
1
isoniazid tab 300 mg
1
1
QL
14 / 30 days
1
QL
14 / 30 days
1
QL
14 / 30 days
moxifloxacin hcl tab 400 mg
3
MYCOBUTIN CAP 150 MG
rifabutin
2
pyrazinamide tab 500 mg
3
rifabutin cap 150 mg
2
RIFAMATE CAP 150-300 MG
isoniazid & rifampin
3
rifampin cap 150 mg
1
rifampin cap 300 mg
1
RIFATER TAB 50-120-300 MG
isoniazid-rifampin w/ pyrazinamide
3
PAGE 19
PA
PA
PRODUCT DESCRIPTION
TIER
Antiprotozoals
ALINIA RECON SUSP 100 MG/5ML
nitazoxanide
4
PA
ALINIA TAB 500 MG
nitazoxanide
4
PA
atovaquone suspension 750 mg/5ml
2
QL
210 / 18 days
atovaquone-proguanil hcl tab 250-100 mg
1
QL
30 / 30 days
atovaquone-proguanil hcl tab 62.5-25 mg
1
QL
30 / 30 days
avidoxy tab 100 mg
1
chloroquine phosphate tab 250 mg
1
chloroquine phosphate tab 500 mg
1
DAPSONE TAB 100 MG
dapsone
1
DAPSONE TAB 25 MG
dapsone
1
DARAPRIM TAB 25 MG
pyrimethamine
2
1
1
1
3
3
3
ST
3
ST
doxycycline monohydrate recon susp 25 mg/5ml
1
3
1
1
FLAGYL ER TAB ER 24H 750 MG
metronidazole
3
hydroxychloroquine sulfate tab 200 mg
1
mefloquine hcl tab 250 mg
1
MEPRON SUSPENSION 750 MG/5ML
atovaquone
2
PAGE 20
ST
QL
210 / 18 days
PRODUCT DESCRIPTION
TIER
metronidazole cap 375 mg
1
metronidazole gel 0.75 %
1
metronidazole tab 250 mg
1
1
1
1
1
ST
1
ST
1
ST
1
ST
morgidox cap 100 mg
1
PRIMAQUINE PHOSPHATE TAB 26.3 MG
primaquine phosphate
1
QUALAQUIN CAP 324 MG
quinine sulfate
1
quinidine gluconate er tab er 324 mg
1
QUINIDINE SULFATE ER TAB ER 300 MG
quinidine sulfate
1
quinidine sulfate tab 200 mg
1
QUINIDINE SULFATE TAB 200 MG
quinidine sulfate
1
1
quinine sulfate cap 324 mg
1
1
1
1
1
1
1
tetracycline hcl
1
1
PAGE 21
ST
PRODUCT DESCRIPTION
TIER
tetracycline hcl
1
tinidazole tab 250 mg
3
tinidazole tab 500 mg
3
vandazole gel 0.75 %
1
Antivirals
abacavir sulfate tab 300 mg
3
QL
60 / 30 days
abacavir-lamivudine-zidovudine tab 300-150-300 mg
2
QL
60 / 30 days
acyclovir cap 200 mg
1
acyclovir suspension 200 mg/5ml
1
AL1
Up to 12 yrs old
acyclovir tab 400 mg
1
acyclovir tab 800 mg
1
adefovir dipivoxil tab 10 mg
4
amantadine hcl cap 100 mg
1
amantadine hcl syrup 50 mg/5ml
1
AMANTADINE HCL TAB 100 MG
amantadine hcl
1
APTIVUS CAP 250 MG
tipranavir
3
QL
120 / 30 days
APTIVUS SOLUTION 100 MG/ML
tipranavir
3
QL
300 / 30 days
ATRIPLA TAB 600-200-300 MG
efavirenz-emtricitabine-tenofovir disoproxil fumarate
2
QL
30 / 30 days
BARACLUDE SOLUTION 0.05 MG/ML
entecavir
4
PA
COMPLERA TAB 200-25-300 MG
emtricitabine-rilpivirine-tenofovir disoproxil fumarate
2
QL
30 / 30 days
CRIXIVAN CAP 200 MG
indinavir sulfate
2
QL
360 / 30 days
CRIXIVAN CAP 400 MG
indinavir sulfate
2
QL
180 / 30 days
didanosine cap dr 125 mg
3
QL
60 / 30 days
3
QL
60 / 30 days
3
QL
30 / 30 days
PAGE 22
PA
PRODUCT DESCRIPTION
TIER
3
QL
30 / 30 days
EDURANT TAB 25 MG
rilpivirine hcl
2
QL
30 / 30 days
EMTRIVA CAP 200 MG
emtricitabine
2
QL
30 / 30 days
EMTRIVA SOLUTION 10 MG/ML
emtricitabine
2
EPIVIR HBV SOLUTION 5 MG/ML
lamivudine (hbv)
3
QL
1800 / 30 days
EPIVIR HBV TAB 100 MG
lamivudine (hbv)
2
QL
90 / 30 days
EPIVIR SOLUTION 10 MG/ML
lamivudine
3
QL
900 / 30 days
EPZICOM TAB 600-300 MG
abacavir sulfate-lamivudine
2
QL
30 / 30 days
QL
famciclovir tab 125 mg
90 / 30 days
3
ST
QL
90 / 30 days
3
ST
QL
90 / 30 days
3
ST
HEPSERA TAB 10 MG
adefovir dipivoxil
4
PA
INCIVEK TAB 375 MG
telaprevir
4
PA
INFERGEN INJECTABLE 15 MCG/0.5ML
interferon alfacon-1
4
PA
INTELENCE TAB 100 MG
etravirine
3
QL
120 / 30 days
INTELENCE TAB 200 MG
etravirine
3
QL
60 / 30 days
INTELENCE TAB 25 MG
etravirine
3
QL
480 / 30 days
INTRON A RECON SOLN 10000000 UNIT
interferon alfa-2b
4
PA
interferon alfa-2b
4
PA
PAGE 23
PRODUCT DESCRIPTION
TIER
interferon alfa-2b
4
PA
INTRON A SOLUTION 6000000 UNIT/ML
interferon alfa-2b
4
PA
INVIRASE CAP 200 MG
saquinavir mesylate
2
QL
300 / 30 days
INVIRASE TAB 500 MG
saquinavir mesylate
2
QL
120 / 30 days
ISENTRESS CHEW TAB 100 MG
raltegravir potassium
3
QL
60 / 30 days
ISENTRESS CHEW TAB 25 MG
3
QL
60 / 30 days
ISENTRESS TAB 400 MG
2
QL
60 / 30 days
KALETRA SOLUTION 400-100 MG/5ML
lopinavir-ritonavir
2
QL
450 / 23 days
KALETRA TAB 100-25 MG
lopinavir-ritonavir
2
QL
360 / 30 days
KALETRA TAB 200-50 MG
lopinavir-ritonavir
2
QL
180 / 30 days
lamivudine tab 100 mg
2
QL
90 / 30 days
3
QL
60 / 30 days
3
QL
30 / 30 days
lamivudine-zidovudine tab 150-300 mg
3
QL
60 / 30 days
LEXIVA SUSPENSION 50 MG/ML
fosamprenavir calcium
2
QL
180 / 30 days
LEXIVA TAB 700 MG
fosamprenavir calcium
2
QL
120 / 30 days
MODERIBA 800 DOSE PACK TAB 400 MG
ribavirin (hepatitis c)
4
PA
nevirapine er tab er 24h 400 mg
2
QL
NEVIRAPINE SUSPENSION 50 MG/5ML
nevirapine
1
PA
nevirapine tab 200 mg
1
QL
60 / 30 days
NORVIR CAP 100 MG
ritonavir
2
QL
360 / 30 days
PAGE 24
30 / 30 days
PRODUCT DESCRIPTION
TIER
NORVIR SOLUTION 80 MG/ML
ritonavir
2
QL
450 / 23 days
NORVIR TAB 100 MG
ritonavir
2
QL
360 / 30 days
PEG-INTRON KIT 120 MCG/0.5ML
peginterferon alfa-2b
4
PA
4
PA
4
PA
4
PA
PEG-INTRON REDIPEN KIT 120 MCG/0.5ML
4
PA
4
PA
4
PA
4
PA
PEG-INTRON REDIPEN PAK 4 KIT 120 MCG/0.5ML
4
PA
4
PA
4
PA
4
PA
PEGASYS KIT 180 MCG/0.5ML
peginterferon alfa-2a
4
PA
PEGASYS PROCLICK SOLUTION 135 MCG/0.5ML
4
PA
PEGASYS SOLUTION 180 MCG/ML
4
PA
PREZISTA SUSPENSION 100 MG/ML
darunavir ethanolate
3
QL
480 / 30 days
PREZISTA TAB 150 MG
2
QL
240 / 30 days
PREZISTA TAB 600 MG
2
QL
60 / 30 days
PAGE 25
PRODUCT DESCRIPTION
TIER
PREZISTA TAB 75 MG
2
QL
480 / 30 days
PREZISTA TAB 800 MG
3
QL
60 / 30 days
REBETOL SOLUTION 40 MG/ML
4
PA
RELENZA DISKHALER AER POW BA 5 MG/BLISTER
zanamivir
2
RESCRIPTOR TAB 100 MG
delavirdine mesylate
2
QL
360 / 30 days
RESCRIPTOR TAB 200 MG
delavirdine mesylate
2
QL
180 / 30 days
REYATAZ CAP 150 MG
atazanavir sulfate
2
QL
60 / 30 days
REYATAZ CAP 200 MG
atazanavir sulfate
2
QL
60 / 30 days
REYATAZ CAP 300 MG
atazanavir sulfate
2
QL
30 / 30 days
ribasphere cap 200 mg
4
PA
RIBASPHERE RIBAPAK TAB 400 & 600 MG
4
PA
RIBASPHERE RIBAPAK TAB 400 MG
4
PA
ribasphere tab 200 mg
4
PA
RIBASPHERE TAB 400 MG
4
PA
RIBASPHERE TAB 600 MG
4
PA
RIBATAB MISC 400 & 600 MG
4
PA
RIBATAB TAB 400 MG
4
PA
RIBATAB TAB 600 MG
4
PA
ribavirin cap 200 mg
4
PA
ribavirin tab 200 mg
4
PA
PAGE 26
QL
20 / 5 days
PA
PRODUCT DESCRIPTION
TIER
rimantadine hcl tab 100 mg
1
SELZENTRY TAB 150 MG
maraviroc
3
QL
120 / 30 days
SELZENTRY TAB 300 MG
maraviroc
3
QL
120 / 30 days
stavudine cap 15 mg
1
QL
60 / 30 days
stavudine cap 20 mg
1
QL
60 / 30 days
stavudine cap 30 mg
1
QL
60 / 30 days
stavudine cap 40 mg
1
QL
60 / 30 days
stavudine recon soln 1 mg/ml
1
QL
1200 / 30 days
STRIBILD TAB 150-150-200-300 MG
elvitegravir-cobicistat-emtricitabine-tenofovir
2
QL
30 / 30 days
SUSTIVA CAP 200 MG
efavirenz
2
QL
90 / 30 days
SUSTIVA CAP 50 MG
efavirenz
2
QL
360 / 30 days
SUSTIVA TAB 600 MG
efavirenz
2
QL
30 / 30 days
SYLATRON KIT 200 MCG
peginterferon alfa-2b (antineoplastic)
4
PA
4
PA
SYLATRON KIT 4 X 200 MCG
4
PA
4
PA
4
PA
SYNAGIS SOLUTION 100 MG/ML
palivizumab
4
PA
TAMIFLU CAP 30 MG
oseltamivir phosphate
2
QL
10 / 5 days
TAMIFLU CAP 45 MG
2
QL
10 / 5 days
TAMIFLU CAP 75 MG
2
QL
10 / 5 days
PAGE 27
PRODUCT DESCRIPTION
TIER
QL
120 / 10 days
AL1
Up to 6 yrs old
2
QL
60 / 30 days
TRUVADA TAB 200-300 MG
emtricitabine-tenofovir disoproxil fumarate
2
QL
30 / 30 days
TYZEKA TAB 600 MG
telbivudine
4
PA
valacyclovir hcl tab 1 gm
1
valacyclovir hcl tab 500 mg
1
VALCYTE RECON SOLN 50 MG/ML
valganciclovir hcl
4
PA
VICTRELIS CAP 200 MG
boceprevir
4
PA
VIDEX RECON SOLN 2 GM
didanosine
2
QL
603 / 30 days
VIRACEPT TAB 250 MG
nelfinavir mesylate
2
QL
300 / 30 days
VIRACEPT TAB 625 MG
nelfinavir mesylate
2
QL
120 / 30 days
VIRAMUNE SUSPENSION 50 MG/5ML
nevirapine
2
QL
1200 / 30 days
VIRAMUNE XR TAB ER 24H 400 MG
nevirapine
2
QL
30 / 30 days
VIREAD TAB 150 MG
tenofovir disoproxil fumarate
2
QL
30 / 30 days
VIREAD TAB 200 MG
2
QL
30 / 30 days
VIREAD TAB 250 MG
2
QL
30 / 30 days
VIREAD TAB 300 MG
2
QL
30 / 30 days
ZIAGEN SOLUTION 20 MG/ML
abacavir sulfate
2
QL
900 / 30 days
zidovudine cap 100 mg
1
QL
180 / 30 days
zidovudine syrup 50 mg/5ml
1
QL
1800 / 30 days
zidovudine tab 300 mg
1
QL
60 / 30 days
TAMIFLU RECON SUSP 6 MG/ML
2
TRIZIVIR TAB 300-150-300 MG
abacavir sulfate-lamivudine-zidovudine
PAGE 28
PRODUCT DESCRIPTION
TIER
Autonomic Drugs
Anticholinergic Agents
altaryl syrup 12.5 mg/5ml
1
AL1
Up to 64 yrs old
ATROVENT HFA AERO SOLN 17 MCG/ACT
ipratropium bromide hfa
2
QL
26 / 25 days
BELLADONNA ALKALOIDS-OPIUM SUPPOS 16.2-60 MG
belladonna alkaloids & opium
1
AL1
Up to 64 yrs old
BELLADONNA-OPIUM SUPPOS 16.2-30 MG
1
AL1
Up to 64 yrs old
benztropine mesylate solution 1 mg/ml
3
benztropine mesylate tab 0.5 mg
1
AL1
Up to 64 yrs old
benztropine mesylate tab 1 mg
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
chlordiazepoxide-clidinium cap 5-2.5 mg
1
COMBIVENT RESPIMAT AERO SOLN 20-100 MCG/ACT
ipratropium-albuterol
3
QL
4 / 25 days
dicyclomine hcl cap 10 mg
1
AL1
Up to 64 yrs old
dicyclomine hcl solution 10 mg/5ml
1
AL1
Up to 64 yrs old
dicyclomine hcl tab 20 mg
1
AL1
Up to 64 yrs old
diphenhydramine hcl cap 50 mg
1
AL1
Up to 64 yrs old
diphenhydramine hcl elixir 12.5 mg/5ml
1
AL1
Up to 64 yrs old
diphenhydramine hcl solution 50 mg/ml
1
AL1
Up to 64 yrs old
DIPHENOXYLATE-ATROPINE LIQUID 2.5-0.025 MG/5ML
diphenoxylate w/ atropine
1
diphenoxylate-atropine tab 2.5-0.025 mg
1
ed-spaz tab disp 0.125 mg
1
AL1
Up to 64 yrs old
eq allergy relief childrens elixir 12.5 mg/5ml
1
AL1
Up to 64 yrs old
glycopyrrolate tab 1 mg
1
glycopyrrolate tab 2 mg
1
hydrocodone-homatropine syrup 5-1.5 mg/5ml
1
hydrocodone-homatropine tab 5-1.5 mg
1
PAGE 29
PRODUCT DESCRIPTION
TIER
hydromet syrup 5-1.5 mg/5ml
1
hyomax-sl sl tab 0.125 mg
1
hyophen tab 81.6 mg
1
hyoscyamine sulfate elixir 0.125 mg/5ml
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
hyoscyamine sulfate er tab er 12h 0.375 mg
1
AL1
Up to 64 yrs old
hyoscyamine sulfate sl tab 0.125 mg
1
AL1
Up to 64 yrs old
hyoscyamine sulfate solution 0.125 mg/ml
1
AL1
Up to 64 yrs old
hyoscyamine sulfate tab 0.125 mg
1
AL1
Up to 64 yrs old
hyoscyamine sulfate tab disp 0.125 mg
1
AL1
Up to 64 yrs old
hyosyne elixir 0.125 mg/5ml
1
AL1
Up to 64 yrs old
hyosyne solution 0.125 mg/ml
1
AL1
Up to 64 yrs old
INCRUSE ELLIPTA AER POW BA 62.5 MCG/INH
umeclidinium bromide
2
QL
30 / 30 days
ipratropium bromide solution 0.02 %
1
1
QL
30 / 25 days
1
QL
15 / 25 days
ipratropium-albuterol solution 0.5-2.5 (3) mg/3ml
1
lonox tab 2.5-0.025 mg
1
medi-phedryl elixir 12.5 mg/5ml
1
AL1
Up to 64 yrs old
methscopolamine bromide tab 2.5 mg
3
AL1
Up to 64 yrs old
methscopolamine bromide tab 5 mg
3
AL1
Up to 64 yrs old
nulev tab disp 0.125 mg
1
AL1
Up to 64 yrs old
oscimin sr tab er 12h 0.375 mg
1
AL1
Up to 64 yrs old
oscimin tab 0.125 mg
1
AL1
Up to 64 yrs old
oscimin tab disp 0.125 mg
1
AL1
Up to 64 yrs old
1
PROPANTHELINE BROMIDE TAB 15 MG
propantheline bromide
1
quenalin syrup 12.5 mg/5ml
1
AL1
Up to 64 yrs old
PAGE 30
PRODUCT DESCRIPTION
TIER
silphen cough syrup 12.5 mg/5ml
1
AL1
Up to 64 yrs old
SPIRIVA HANDIHALER CAP 18 MCG
tiotropium bromide monohydrate
2
QL
30 / 30 days
symax fastabs tab disp 0.125 mg
1
AL1
Up to 64 yrs old
symax-sl sl tab 0.125 mg
1
AL1
Up to 64 yrs old
symax-sr tab er 12h 0.375 mg
1
AL1
Up to 64 yrs old
TUDORZA PRESSAIR AER POW BA 400 MCG/ACT
aclidinium bromide
2
QL
60 / 30 days
tussigon tab 5-1.5 mg
1
uretron d/s tab
1
URETRON D/S TAB
1
ustell cap 120 mg
1
utira-c tab 81.6 mg
1
bethanechol chloride tab 10 mg
1
1
1
1
CHANTIX CONTINUING MONTH PAK TAB 1 MG
varenicline tartrate
5
QL
180 / 365 days
CHANTIX STARTING MONTH PAK TAB 0.5 MG X 11 & 1 MG
X 42
5
QL
180 / 90 days
CHANTIX TAB 0.5 MG
5
QL
180 / 365 days
CHANTIX TAB 1 MG
5
QL
180 / 365 days
cvs nicotine patch 24hr 14 mg/24hr
5
QL
90 / 365 days
cvs nicotine patch 24hr 7 mg/24hr
5
QL
90 / 365 days
cvs nts step 1 patch 24hr 21 mg/24hr
5
QL
90 / 365 days
donepezil hcl tab 10 mg
1
3
1
PAGE 31
PRODUCT DESCRIPTION
TIER
donepezil hcl tab disp 10 mg
1
donepezil hcl tab disp 5 mg
3
eq nicotine patch 24hr 14 mg/24hr
5
QL
90 / 365 days
5
QL
90 / 365 days
5
QL
90 / 365 days
eq nicotine step 3 patch 24hr 7 mg/24hr
5
QL
90 / 365 days
eql nicotine patch 24hr 14 mg/24hr
5
QL
90 / 365 days
5
QL
90 / 365 days
5
QL
90 / 365 days
EXELON PATCH 24HR 13.3 MG/24HR
rivastigmine
3
PA
rivastigmine
3
PA
rivastigmine
3
PA
galantamine hydrobromide er cap er 24h 16 mg
1
ST
1
ST
1
ST
galantamine hydrobromide tab 12 mg
1
1
1
hm nicotine patch 24hr 14 mg/24hr
5
QL
90 / 365 days
5
QL
90 / 365 days
5
QL
90 / 365 days
MESTINON SYRUP 60 MG/5ML
pyridostigmine bromide
2
PA
MESTINON TAB ER 180 MG
pyridostigmine bromide
2
PA
nicorelief gum 2 mg
5
QL
810 / 365 days
nicorelief gum 4 mg
5
QL
810 / 365 days
PAGE 32
PA
PRODUCT DESCRIPTION
TIER
nicotine patch 24hr 14 mg/24hr
5
QL
90 / 365 days
5
QL
90 / 365 days
5
QL
90 / 365 days
nicotine polacrilex gum 2 mg
5
QL
810 / 365 days
nicotine polacrilex gum 4 mg
5
QL
810 / 365 days
nicotine step 1 patch 24hr 21 mg/24hr
5
QL
90 / 365 days
5
QL
90 / 365 days
5
QL
90 / 365 days
NICOTROL INHALER 10 MG
nicotine
5
NICOTROL NS SOLUTION 10 MG/ML
nicotine
5
PHYSOSTIGMINE SALICYLATE SOLUTION 1 MG/ML
physostigmine salicylate
1
pilocarpine hcl tab 5 mg
1
pilocarpine hcl tab 7.5 mg
1
pyridostigmine bromide tab 60 mg
1
ra nicotine patch 24hr 14 mg/24hr
5
QL
90 / 365 days
5
QL
90 / 365 days
5
QL
90 / 365 days
rivastigmine tartrate cap 1.5 mg
3
rivastigmine tartrate cap 3 mg
3
rivastigmine tartrate cap 4.5 mg
3
rivastigmine tartrate cap 6 mg
3
PA
sm nicotine patch 24hr 14 mg/24hr
5
QL
90 / 365 days
5
QL
90 / 365 days
5
QL
90 / 365 days
tgt nicotine step one patch 24hr 21 mg/24hr
5
QL
90 / 365 days
tgt nicotine step three patch 24hr 7 mg/24hr
5
QL
90 / 365 days
PAGE 33
PRODUCT DESCRIPTION
TIER
tgt nicotine step two patch 24hr 14 mg/24hr
5
QL
90 / 365 days
thrive gum 2 mg
5
QL
810 / 90 days
thrive gum 4 mg
5
QL
810 / 90 days
Skeletal Muscle Relaxants
baclofen tab 10 mg
1
baclofen tab 20 mg
1
chlorzoxazone tab 500 mg
1
AL1
Up to 64 yrs old
cyclobenzaprine hcl tab 10 mg
1
AL1
Up to 64 yrs old
cyclobenzaprine hcl tab 5 mg
1
AL1
Up to 64 yrs old
DYSPORT RECON SOLN 500 UNIT
abobotulinumtoxina
4
PA
LORZONE TAB 375 MG
chlorzoxazone
3
metaxalone tab 800 mg
3
PA
AL1
Up to 64 yrs old
methocarbamol tab 500 mg
1
AL1
Up to 64 yrs old
methocarbamol tab 750 mg
1
AL1
Up to 64 yrs old
orphenadrine citrate er tab er 12h 100 mg
1
AL1
Up to 64 yrs old
orphenadrine-aspirin-caffeine tab 25-385-30 mg
1
AL1
Up to 64 yrs old
tizanidine hcl cap 2 mg
3
QL
90 / 30 days
3
QL
90 / 30 days
3
QL
90 / 30 days
tizanidine hcl tab 2 mg
1
QL
90 / 30 days
tizanidine hcl tab 4 mg
1
QL
90 / 30 days
Sympatholytic (Adrenergic Blocking) Agents
acebutolol hcl cap 200 mg
1
1
alfuzosin hcl er tab er 24h 10 mg
3
atenolol tab 100 mg
1
PAGE 34
PRODUCT DESCRIPTION
TIER
atenolol tab 25 mg
1
atenolol tab 50 mg
1
betaxolol hcl tab 10 mg
1
1
bisoprolol fumarate tab 10 mg
1
1
BYSTOLIC TAB 10 MG
nebivolol hcl
3
ST
BYSTOLIC TAB 2.5 MG
nebivolol hcl
3
ST
BYSTOLIC TAB 20 MG
nebivolol hcl
3
ST
BYSTOLIC TAB 5 MG
nebivolol hcl
3
ST
CAFERGOT TAB 1-100 MG
ergotamine w/ caffeine
2
CARDURA XL TAB ER 24H 4 MG
doxazosin mesylate (bph)
3
carvedilol tab 12.5 mg
1
carvedilol tab 25 mg
1
1
1
COREG CR CAP ER 24H 10 MG
carvedilol phosphate
3
ST
3
ST
3
ST
3
ST
DIBENZYLINE CAP 10 MG
phenoxybenzamine hcl
3
PA
DIHYDROERGOTAMINE MESYLATE SOLUTION 4 MG/ML
dihydroergotamine mesylate
3
doxazosin mesylate tab 1 mg
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
PAGE 35
PRODUCT DESCRIPTION
TIER
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
ergoloid mesylates tab 1 mg
3
PA
labetalol hcl tab 100 mg
1
1
1
metoprolol succinate er tab er 24h 100 mg
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
metoprolol tartrate tab 100 mg
1
1
1
nadolol tab 20 mg
1
nadolol tab 40 mg
1
nadolol tab 80 mg
1
pindolol tab 10 mg
1
pindolol tab 5 mg
1
prazosin hcl cap 1 mg
1
1
1
propranolol hcl er cap er 24h 120 mg
1
ST
1
ST
1
ST
1
ST
PROPRANOLOL HCL SOLUTION 20 MG/5ML
propranolol hcl
1
propranolol hcl
1
propranolol hcl tab 10 mg
1
PAGE 36
PRODUCT DESCRIPTION
TIER
1
1
1
1
RAPAFLO CAP 4 MG
silodosin
3
PA
RAPAFLO CAP 8 MG
silodosin
3
PA
sorine tab 120 mg
1
sorine tab 160 mg
1
sorine tab 240 mg
1
sorine tab 80 mg
1
sotalol hcl tab 120 mg
1
1
1
1
tamsulosin hcl cap 0.4 mg
1
QL
60 / 30 days
terazosin hcl cap 1 mg
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
TIMOLOL MALEATE TAB 10 MG
timolol maleate
1
timolol maleate
1
timolol maleate
1
60 / 30 days
Sympathomimetic (Adrenergic) Agents
ADRENACLICK SOLN A-INJ 0.15 MG/0.15ML
epinephrine
3
ADVAIR DISKUS AER POW BA 100-50 MCG/DOSE
fluticasone-salmeterol
2
QL
3
ST
PAGE 37
PRODUCT DESCRIPTION
TIER
3
ST
ADVAIR HFA AEROSOL 115-21 MCG/ACT
3
ST
3
ST
3
ST
albuterol sulfate er tab er 12h 4 mg
1
1
albuterol sulfate nebu soln (2.5 mg/3ml) 0.083%
1
albuterol sulfate nebu soln (5 mg/ml) 0.5%
1
albuterol sulfate nebu soln 0.63 mg/3ml
1
1
albuterol sulfate syrup 2 mg/5ml
1
ARCAPTA NEOHALER CAP 75 MCG
indacaterol maleate
3
AUVI-Q SOLN A-INJ 0.15 MG/0.15ML
epinephrine
3
bromfed dm syrup 30-2-10 mg/5ml
1
BROVANA NEBU SOLN 15 MCG/2ML
arformoterol tartrate
3
clonidine hcl patch wk 0.1 mg/24hr
3
3
3
clonidine hcl tab 0.1 mg
1
1
1
3
QL
4 / 25 days
DULERA AEROSOL 100-5 MCG/ACT
mometasone furoate-formoterol fumarate dihydrate
2
QL
13 / 25 days
2
QL
13 / 25 days
epinephrine hcl soln prsyr 0.1 mg/ml
1
PAGE 38
QL
30 / 30 days
PA
PA
PRODUCT DESCRIPTION
TIER
epinephrine hcl solution 1 mg/ml
1
EPINEPHRINE SOLN A-INJ 0.15 MG/0.15ML
epinephrine
1
epinephrine
1
EPIPEN 2-PAK SOLN A-INJ 0.3 MG/0.3ML
epinephrine
2
EPIPEN JR 2-PAK SOLN A-INJ 0.15 MG/0.3ML
epinephrine
QL
2 / 90 days
2
QL
2 / 90 days
FORADIL AEROLIZER CAP 12 MCG
formoterol fumarate
2
QL
60 / 30 days
1
levalbuterol hcl nebu soln 0.31 mg/3ml
1
ST
1
ST
levalbuterol hcl nebu soln 1.25 mg/0.5ml
1
ST
metaproterenol sulfate syrup 10 mg/5ml
1
METAPROTERENOL SULFATE SYRUP 10 MG/5ML
metaproterenol sulfate
1
METAPROTERENOL SULFATE TAB 10 MG
1
1
methyldopa tab 250 mg
1
1
midodrine hcl tab 10 mg
1
midodrine hcl tab 2.5 mg
1
midodrine hcl tab 5 mg
1
PERFOROMIST NEBU SOLN 20 MCG/2ML
formoterol fumarate
3
PROAIR HFA AERO SOLN 108 (90 BASE) MCG/ACT
albuterol sulfate
3
promethazine vc plain syrup 6.25-5 mg/5ml
1
promethazine vc/codeine syrup 6.25-5-10 mg/5ml
1
PROVENTIL HFA AERO SOLN 108 (90 BASE) MCG/ACT
albuterol sulfate
3
PAGE 39
PA
QL
6.7 / 30 days
PRODUCT DESCRIPTION
TIER
SEREVENT DISKUS AER POW BA 50 MCG/DOSE
salmeterol xinafoate
2
SYMBICORT AEROSOL 160-4.5 MCG/ACT
budesonide-formoterol fumarate dihydrate
2
2
terbutaline sulfate solution 1 mg/ml
1
terbutaline sulfate tab 2.5 mg
1
terbutaline sulfate tab 5 mg
1
TGQ 15DM/5PEH/2CPM SYRUP 15-5-2 MG/5ML
phenylephrine-chlorphen-dm
1
TGQ 30PSE/150GFN/15DM SYRUP 30-150-15 MG/5ML
pseudoephedrine w/ dm-gg
1
VENTOLIN HFA AERO SOLN 108 (90 BASE) MCG/ACT
albuterol sulfate
2
XOPENEX HFA AEROSOL 45 MCG/ACT
levalbuterol tartrate
3
PA
QL
10.2 / 25 days
ST
QL
10.2 / 25 days
ST
QL
60 / 30 days
ST
Blood Formation,Coagulation & Thrombosis
Antihemorrhagic Agents
AMINOCAPROIC ACID TAB 1000 MG
aminocaproic acid
3
aminocaproic acid tab 500 mg
3
desmopressin ace rhinal tube solution 0.01 %
1
desmopressin ace spray refrig solution 0.01 %
3
desmopressin acetate solution 4 mcg/ml
4
desmopressin acetate spray solution 0.01 %
1
desmopressin acetate tab 0.1 mg
1
1
STIMATE SOLUTION 1.5 MG/ML
desmopressin acetate
4
PA
PA
Antithrombotic Agents
adult aspirin ec low strength tab dr 81 mg
PAGE 40
QL
60 / 30 days
AL1
40 to 79 yrs old
5
PRODUCT DESCRIPTION
TIER
AGGRENOX CAP ER 12H 25-200 MG
aspirin-dipyridamole
3
anagrelide hcl cap 0.5 mg
1
anagrelide hcl cap 1 mg
1
aspir-low tab dr 81 mg
5
aspirin adult low strength chew tab 81 mg
aspirin adult low strength tab dr 81 mg
aspirin chew tab 81 mg
aspirin ec lo-dose tab dr 81 mg
aspirin ec low dose tab dr 81 mg
aspirin ec low strength tab dr 81 mg
aspirin ec tab dr 325 mg
aspirin low dose tab dr 81 mg
aspirin low strength chew tab 81 mg
aspirin tab 325 mg
aspirin tab dr 81 mg
PAGE 41
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
30 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
30 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
5
5
5
5
5
5
5
5
5
5
5
5
PRODUCT DESCRIPTION
bayer aspirin ec low dose tab dr 81 mg
bayer aspirin tab 325 mg
bayer aspirin tab dr 325 mg
bayer low dose chew tab 81 mg
bayer low dose tab dr 81 mg
TIER
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
30 / 30 days
AL1
40 to 79 yrs old
QL
30 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
30 / 30 days
AL1
40 to 79 yrs old
5
5
5
5
5
BRILINTA TAB 90 MG
ticagrelor
3
PA
CEPROTIN RECON SOLN 500 UNIT
protein c concentrate (human)
4
PA
cilostazol tab 100 mg
1
1
clopidogrel bisulfate tab 300 mg
1
QL
30 / 30 days
clopidogrel bisulfate tab 75 mg
1
QL
30 / 30 days
QL
cvs aspirin adult low strength tab dr 81 mg
60 / 30 days
5
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
30 / 30 days
AL1
40 to 79 yrs old
dipyridamole tab 25 mg
1
1
1
ec-81 aspirin tab dr 81 mg
5
ecotrin low strength tab dr 81 mg
ecpirin tab dr 325 mg
5
5
enoxaparin sodium solution 100 mg/ml
4
PA
enoxaparin sodium solution 120 mg/0.8ml
4
PA
PAGE 42
PRODUCT DESCRIPTION
TIER
enoxaparin sodium solution 150 mg/ml
4
PA
4
PA
enoxaparin sodium solution 300 mg/3ml
4
PA
4
PA
4
PA
4
PA
eq adult aspirin low strength tab dr 81 mg
5
eq aspirin adult low dose tab dr 81 mg
eql adult aspirin low strength tab dr 81 mg
eql aspirin low dose tab dr 81 mg
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
5
5
5
fondaparinux sodium solution 10 mg/0.8ml
4
PA
fondaparinux sodium solution 2.5 mg/0.5ml
4
PA
fondaparinux sodium solution 5 mg/0.4ml
4
PA
fondaparinux sodium solution 7.5 mg/0.6ml
4
PA
FRAGMIN SOLUTION 10000 UNIT/ML
dalteparin sodium
4
PA
FRAGMIN SOLUTION 12500 UNIT/0.5ML
dalteparin sodium
4
PA
dalteparin sodium
4
PA
FRAGMIN SOLUTION 18000 UNT/0.72ML
dalteparin sodium
4
PA
dalteparin sodium
4
PA
dalteparin sodium
4
PA
dalteparin sodium
4
PA
PAGE 43
PRODUCT DESCRIPTION
gnp adult aspirin low strength tab dr 81 mg
gnp aspirin low dose tab dr 81 mg
goodsense aspirin low dose tab dr 81 mg
TIER
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
30 / 30 days
AL1
40 to 79 yrs old
5
5
1
HEPARIN LOCK FLUSH SOLUTION 1 UNIT/ML
heparin sodium (porcine) lock flush
1
heparin lock flush solution 10 unit/ml
1
1
HEPARIN LOCK FLUSH SOLUTION 2 UNIT/ML
heparin sodium (porcine) lock flush
1
heparin sodium (porcine) pf solution 5000 unit/0.5ml
1
heparin sodium (porcine) solution 1000 unit/ml
1
1
1
1
heparin sodium lock flush solution 10 unit/ml
1
heparin sodium lock flush solution 100 unit/ml
1
hm aspirin ec low dose tab dr 81 mg
5
5
jantoven tab 1 mg
1
jantoven tab 10 mg
1
jantoven tab 2 mg
1
jantoven tab 2.5 mg
1
jantoven tab 3 mg
1
jantoven tab 4 mg
1
jantoven tab 5 mg
1
jantoven tab 6 mg
1
PAGE 44
QL
5
hm aspirin ec tab dr 325 mg
PRODUCT DESCRIPTION
TIER
jantoven tab 7.5 mg
1
monoject flush syr/hep lock solution 10 unit/ml
1
monoject flush syr/hep lock solution 100 unit/ml
1
PRADAXA CAP 150 MG
dabigatran etexilate mesylate
3
PA
PRADAXA CAP 75 MG
dabigatran etexilate mesylate
3
PA
qc aspirin low dose tab dr 81 mg
5
sb aspirin tab dr 81 mg
sb low dose asa ec tab dr 81 mg
st joseph aspirin tab dr 81 mg
tgt aspirin ec tab dr 325 mg
tgt aspirin low dose tab dr 81 mg
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
30 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
5
5
5
5
5
ticlopidine hcl tab 250 mg
1
TICLOPIDINE HCL TAB 250 MG
ticlopidine hcl
1
warfarin sodium tab 1 mg
1
1
1
warfarin sodium tab 2.5 mg
1
1
1
1
1
warfarin sodium tab 7.5 mg
1
XARELTO TAB 10 MG
rivaroxaban
3
PAGE 45
QL
PA
PRODUCT DESCRIPTION
TIER
XARELTO TAB 15 MG
rivaroxaban
3
PA
XARELTO TAB 20 MG
rivaroxaban
3
PA
ARANESP (ALBUMIN FREE) SOLUTION 100 MCG/0.5ML
darbepoetin alfa-polysorbate 80
4
PA
ARANESP (ALBUMIN FREE) SOLUTION 100 MCG/ML
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
4
PA
cvs iron tab 240 (27 fe) mg
5
cvs iron tab 325 (65 fe) mg
5
cyanocobalamin solution 1000 mcg/ml
1
dexferrum solution 50 mg/ml
1
PAGE 46
PA
PRODUCT DESCRIPTION
TIER
EPOGEN SOLUTION 10000 UNIT/ML
epoetin alfa
4
PA
epoetin alfa
4
PA
epoetin alfa
4
PA
epoetin alfa
4
PA
epoetin alfa
4
PA
eql iron supplement therapy tab 325 mg
5
fe tabs tab dr 325 (65 fe) mg
5
ferate tab 240 (27 fe) mg
5
ferosul elixir 220 (44 fe) mg/5ml
5
FERRAPLUS 90 TAB 90-1 MG
iron-folic acid-vitamin b12-vitamin c-docusate sodium
1
ferrogels forte cap 460-60-0.01-1 mg
1
ferrotabs tab 240 mg
5
ferrous gluconate tab 240 (27 fe) mg
5
ferrous sulfate elixir 220 (44 fe) mg/5ml
5
ferrous sulfate tab 325 (65 fe) mg
5
ferrous sulfate tab dr 325 (65 fe) mg
5
ferrousul tab 325 (65 fe) mg
5
gnp b-12 sl tab 2500 mcg
5
hematinic/folic acid tab 324-1 mg
1
HEMATOGEN FA CAP 200-250-0.01-1 MG
fe fumarate-vitamin c-vitamin b12-folic acid
1
hematogen forte cap 460-60-0.01-1 mg
1
hemocyte-f tab 324-1 mg
1
HYDROXOCOBALAMIN SOLUTION 1000 MCG/ML
hydroxocobalamin
1
iferex 150 forte cap 150-25-1 mg-mcg-mg
1
INFED SOLUTION 50 MG/ML
iron dextran
4
iron supplement tab 325 (65 fe) mg
5
PAGE 47
PA
PRODUCT DESCRIPTION
TIER
iron tab 240 (27 fe) mg
5
iron tab 325 (65 fe) mg
5
kp ferrous sulfate tab 325 (65 fe) mg
5
LEUKINE RECON SOLN 250 MCG
sargramostim
4
meijer ferrous sulfate tab 325 (65 fe) mg
5
MULTI PRENATAL TAB 27-0.8 MG
prenatal vit w/ ferrous fumarate-folic acid
5
NEUMEGA RECON SOLN 5 MG
oprelvekin
4
PA
NEUPOGEN SOLUTION 300 MCG/0.5ML
filgrastim
4
PA
NEUPOGEN SOLUTION 300 MCG/ML
filgrastim
4
PA
NEUPOGEN SOLUTION 480 MCG/0.8ML
filgrastim
4
PA
OMONTYS SOLUTION 10 MG/ML
peginesatide acetate
4
PA
pentoxifylline er tab er 400 mg
1
QL
PNV FE FUM/DOCUSATE/FOLIC ACID TAB 29-1 MG
prenatal vit w/ docusate-fe fumarate-folic acid
1
poly-iron 150 forte cap 150-25-1 mg-mcg-mg
1
PRENATAL 19 TAB
1
PRENATAL 19 TAB 29-1 MG
1
PRENATAL LOW IRON TAB 27-0.8 MG
5
PRENATAL ONE DAILY TAB 27-0.8 MG
5
PRENATAL TAB 27-0.8 MG
5
PROCRIT SOLUTION 10000 UNIT/ML
epoetin alfa
4
PA
epoetin alfa
4
PA
epoetin alfa
4
PA
PAGE 48
PA
90 / 30 days
PRODUCT DESCRIPTION
TIER
epoetin alfa
4
PA
epoetin alfa
4
PA
epoetin alfa
4
PA
qc ferrous sulfate tab 325 (65 fe) mg
5
ra iron tab 325 (65 fe) mg
5
RIGHT STEP PRENATAL TAB 27-0.8 MG
5
SE-NATAL 19 TAB 29-1 MG
1
sm iron tab 325 (65 fe) mg
5
TARON-PREX CAP 30-1.2-265 MG
prenatal w/o vit a w/ fe fumarate-dss-fa-dha
1
th iron tab 325 (65 fe) mg
5
Cardiovascular Drugs
Antilipemic Agents
atorvastatin calcium tab 10 mg
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
cholestyramine light packet 4 gm
1
cholestyramine light powder 4 gm/dose
1
colestipol hcl granules 5 gm
1
colestipol hcl packet 5 gm
1
colestipol hcl tab 1 gm
1
CRESTOR TAB 10 MG
rosuvastatin calcium
QL
30 / 30 days
3
CRESTOR TAB 20 MG
3
CRESTOR TAB 40 MG
3
PAGE 49
ST
QL
30 / 30 days
ST
QL
30 / 30 days
ST
PRODUCT DESCRIPTION
TIER
QL
CRESTOR TAB 5 MG
3
fenofibrate micronized cap 130 mg
1
1
1
1
1
fenofibrate tab 145 mg
1
1
1
1
fenofibric acid cap dr 135 mg
3
PA
fenofibric acid cap dr 45 mg
3
PA
FENOFIBRIC ACID TAB 105 MG
fenofibric acid
1
FENOFIBRIC ACID TAB 35 MG
fenofibric acid
1
fluvastatin sodium cap 20 mg
3
fluvastatin sodium cap 40 mg
3
gemfibrozil tab 600 mg
1
LIPOFEN CAP 150 MG
fenofibrate
3
PA
LIPOFEN CAP 50 MG
fenofibrate
3
PA
LIVALO TAB 1 MG
pitavastatin calcium
3
ST
LIVALO TAB 2 MG
3
ST
LIVALO TAB 4 MG
3
ST
lovastatin tab 10 mg
1
1
1
PAGE 50
30 / 30 days
ST
PA
PA
PRODUCT DESCRIPTION
TIER
LOVAZA CAP 1 GM
omega-3-acid ethyl esters
3
micronized colestipol hcl tab 1 gm
1
niacin er (antihyperlipidemic) tab er 1000 mg
3
3
3
NIASPAN TAB ER 1000 MG
niacin (antihyperlipidemic)
3
3
3
pravastatin sodium tab 10 mg
1
1
1
1
prevalite packet 4 gm
1
prevalite powder 4 gm/dose
1
simvastatin tab 10 mg
1
1
1
1
1
PA
TRIGLIDE TAB 160 MG
fenofibrate
3
PA
TRILIPIX CAP DR 135 MG
choline fenofibrate
3
PA
TRILIPIX CAP DR 45 MG
choline fenofibrate
3
PA
VYTORIN TAB 10-10 MG
ezetimibe-simvastatin
3
ST
3
ST
3
ST
PAGE 51
PA
PRODUCT DESCRIPTION
TIER
3
ST
WELCHOL PACKET 3.75 GM
colesevelam hcl
3
PA
WELCHOL TAB 625 MG
colesevelam hcl
3
PA
ZETIA TAB 10 MG
ezetimibe
3
PA
afeditab cr tab er 24h 30 mg
1
QL
30 / 30 days
1
QL
30 / 30 days
amlodipine besy-benazepril hcl cap 10-20 mg
1
1
amlodipine besy-benazepril hcl cap 2.5-10 mg
1
1
1
1
amlodipine besylate tab 10 mg
1
QL
30 / 30 days
amlodipine besylate tab 2.5 mg
1
QL
30 / 30 days
1
QL
30 / 30 days
amlodipine besylate-valsartan tab 10-160 mg
3
ST
3
ST
3
ST
3
ST
AZOR TAB 10-20 MG
amlodipine besylate-olmesartan medoxomil
3
ST
AZOR TAB 10-40 MG
3
ST
AZOR TAB 5-20 MG
3
ST
AZOR TAB 5-40 MG
3
ST
cartia xt cap er 24h 120 mg
1
QL
Calcium-Channel Blocking Agents
PAGE 52
30 / 30 days
PRODUCT DESCRIPTION
TIER
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
dilt-xr cap er 24h 120 mg
1
QL
30 / 30 days
diltiazem cd cap er 24h 120 mg
1
QL
60 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
diltiazem hcl er beads cap er 24h 360 mg
1
QL
30 / 30 days
1
QL
30 / 30 days
diltiazem hcl er cap er 12h 120 mg
1
QL
60 / 30 days
1
QL
60 / 30 days
1
QL
60 / 30 days
1
1
QL
30 / 30 days
1
QL
30 / 30 days
diltiazem hcl er coated beads cap er 24h 120 mg
1
QL
60 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
diltiazem hcl tab 120 mg
1
1
1
1
felodipine er tab er 24h 10 mg
1
QL
30 / 30 days
felodipine er tab er 24h 2.5 mg
1
QL
30 / 30 days
1
QL
30 / 30 days
isradipine cap 2.5 mg
1
PAGE 53
PRODUCT DESCRIPTION
TIER
isradipine cap 5 mg
1
nicardipine hcl cap 20 mg
1
1
nifediac cc tab er 24h 30 mg
1
QL
30 / 30 days
1
QL
30 / 30 days
nifedical xl tab er 24h 30 mg
1
QL
30 / 30 days
1
QL
30 / 30 days
nifedipine cap 10 mg
1
1
nifedipine er osmotic tab er 24h 30 mg
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
nifedipine er tab er 24h 30 mg
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
nimodipine cap 30 mg
1
nisoldipine er tab er 24h 17 mg
1
NISOLDIPINE ER TAB ER 24H 20 MG
nisoldipine
1
nisoldipine er tab er 24h 25.5 mg
1
NISOLDIPINE ER TAB ER 24H 25.5 MG
nisoldipine
1
nisoldipine
1
1
nisoldipine
1
1
TARKA TAB ER 1-240 MG
trandolapril-verapamil hcl
3
ST
3
ST
PAGE 54
PRODUCT DESCRIPTION
TIER
3
ST
3
ST
taztia xt cap er 24h 120 mg
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
verapamil hcl er cap er 24h 100 mg
1
1
1
1
1
1
1
verapamil hcl er tab er 120 mg
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
verapamil hcl tab 120 mg
1
VERAPAMIL HCL TAB 40 MG
verapamil hcl
1
1
Cardiac Drugs
1
1
amiodarone hcl tab 200 mg
1
amiodarone hcl tab 400 mg
1
atenolol tab 100 mg
1
atenolol tab 25 mg
1
atenolol tab 50 mg
1
PAGE 55
PRODUCT DESCRIPTION
TIER
1
1
1
1
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
1
1
1
3
ST
3
ST
3
ST
3
ST
digitek tab 250 mcg
1
digox tab 250 mcg
1
DIGOXIN SOLUTION 0.05 MG/ML
digoxin
1
digoxin tab 125 mcg
1
digoxin tab 250 mcg
1
DILANTIN CAP 100 MG
phenytoin sodium extended
2
DILANTIN CAP 30 MG
2
1
QL
30 / 30 days
1
QL
60 / 30 days
1
QL
30 / 30 days
PAGE 56
PRODUCT DESCRIPTION
TIER
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
60 / 30 days
1
QL
60 / 30 days
1
QL
60 / 30 days
1
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
60 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
1
1
1
disopyramide phosphate cap 100 mg
1
disopyramide phosphate cap 150 mg
1
flecainide acetate tab 100 mg
1
1
1
1
1
1
LANOXIN TAB 250 MCG
digoxin
1
1
QL
30 / 30 days
1
QL
30 / 30 days
PAGE 57
PRODUCT DESCRIPTION
TIER
1
QL
30 / 30 days
1
QL
30 / 30 days
1
1
1
mexiletine hcl cap 150 mg
1
1
1
MULTAQ TAB 400 MG
dronedarone hcl
3
NORPACE CR CAP ER 12H 100 MG
disopyramide phosphate
3
pacerone tab 100 mg
3
pacerone tab 200 mg
1
phenytoin chew tab 50 mg
1
phenytoin infatabs chew tab 50 mg
1
phenytoin sodium extended cap 100 mg
1
1
1
phenytoin sodium solution 50 mg/ml
1
phenytoin suspension 125 mg/5ml
1
pindolol tab 10 mg
1
pindolol tab 5 mg
1
propafenone hcl er cap er 12h 225 mg
3
3
3
propafenone hcl tab 150 mg
1
1
1
1
ST
1
ST
PAGE 58
PA
PA
PRODUCT DESCRIPTION
TIER
1
ST
1
ST
propranolol hcl
1
propranolol hcl
1
1
1
1
1
1
quinidine gluconate er tab er 324 mg
1
QUINIDINE SULFATE ER TAB ER 300 MG
quinidine sulfate
1
1
QUINIDINE SULFATE TAB 200 MG
quinidine sulfate
1
1
RANEXA TAB ER 12H 1000 MG
ranolazine
3
PA
RANEXA TAB ER 12H 500 MG
ranolazine
3
PA
sorine tab 120 mg
1
sorine tab 160 mg
1
sorine tab 240 mg
1
sorine tab 80 mg
1
1
1
1
1
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
PAGE 59
PRODUCT DESCRIPTION
TIER
1
QL
30 / 30 days
1
QL
30 / 30 days
timolol maleate
1
timolol maleate
1
timolol maleate
1
1
1
1
1
1
1
1
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
verapamil hcl
1
1
1
1
atenolol tab 100 mg
1
atenolol tab 25 mg
1
atenolol tab 50 mg
1
atenolol-chlorthalidone tab 100-25 mg
1
1
1
1
1
PAGE 60
PRODUCT DESCRIPTION
TIER
1
bisoprolol-hydrochlorothiazide tab 10-6.25 mg
1
bisoprolol-hydrochlorothiazide tab 2.5-6.25 mg
1
1
BYSTOLIC TAB 10 MG
nebivolol hcl
3
ST
BYSTOLIC TAB 2.5 MG
nebivolol hcl
3
ST
BYSTOLIC TAB 20 MG
nebivolol hcl
3
ST
BYSTOLIC TAB 5 MG
nebivolol hcl
3
ST
3
1
1
1
1
3
ST
3
ST
3
ST
3
ST
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
1
1
LEVATOL TAB 20 MG
penbutolol sulfate
3
PAGE 61
PA
PRODUCT DESCRIPTION
TIER
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
1
1
metoprolol-hydrochlorothiazide tab 100-25 mg
1
1
1
nadolol tab 20 mg
1
nadolol tab 40 mg
1
nadolol tab 80 mg
1
nadolol-bendroflumethiazide tab 40-5 mg
1
1
pindolol tab 10 mg
1
pindolol tab 5 mg
1
1
1
1
1
ST
1
ST
1
ST
1
ST
propranolol hcl
1
propranolol hcl
1
1
1
1
PAGE 62
PRODUCT DESCRIPTION
TIER
1
1
PROPRANOLOL-HCTZ TAB 40-25 MG
propranolol & hydrochlorothiazide
1
1
sorine tab 120 mg
1
sorine tab 160 mg
1
sorine tab 240 mg
1
sorine tab 80 mg
1
1
1
1
1
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
timolol maleate
1
timolol maleate
1
timolol maleate
1
Hypotensive Agents
1
1
acetazolamide er cap er 12h 500 mg
1
ACETAZOLAMIDE TAB 125 MG
acetazolamide
1
acetazolamide tab 250 mg
1
1
QL
30 / 30 days
1
QL
30 / 30 days
PAGE 63
PRODUCT DESCRIPTION
TIER
amiloride hcl tab 5 mg
1
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
atenolol tab 100 mg
1
atenolol tab 25 mg
1
atenolol tab 50 mg
1
benazepril hcl tab 10 mg
1
1
1
1
BENICAR TAB 20 MG
olmesartan medoxomil
3
BENICAR TAB 40 MG
3
BENICAR TAB 5 MG
3
1
1
1
1
bumetanide solution 0.25 mg/ml
1
bumetanide tab 0.5 mg
1
bumetanide tab 1 mg
1
bumetanide tab 2 mg
1
captopril tab 100 mg
1
captopril tab 12.5 mg
1
captopril tab 25 mg
1
captopril tab 50 mg
1
3
1
QL
30 / 30 days
PAGE 64
PRODUCT DESCRIPTION
TIER
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
1
1
1
chlorothiazide tab 250 mg
1
CHLOROTHIAZIDE TAB 250 MG
chlorothiazide
1
1
CHLORTHALIDONE TAB 25 MG
chlorthalidone
1
chlorthalidone
1
3
3
3
1
1
1
3
ST
3
ST
3
ST
3
ST
DIBENZYLINE CAP 10 MG
phenoxybenzamine hcl
3
PA
1
QL
30 / 30 days
1
QL
60 / 30 days
1
QL
30 / 30 days
PAGE 65
PRODUCT DESCRIPTION
TIER
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
60 / 30 days
1
QL
60 / 30 days
1
QL
60 / 30 days
1
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
60 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
1
1
1
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
DYRENIUM CAP 100 MG
triamterene
3
EDARBI TAB 40 MG
azilsartan medoxomil
3
PA
EDARBI TAB 80 MG
3
PA
EDECRIN TAB 25 MG
ethacrynic acid
3
ELIXOPHYLLIN ELIXIR 80 MG/15ML
theophylline
2
PAGE 66
PRODUCT DESCRIPTION
TIER
enalapril maleate tab 10 mg
1
enalapril maleate tab 2.5 mg
1
1
1
eplerenone tab 25 mg
3
3
EPROSARTAN MESYLATE TAB 600 MG
eprosartan mesylate
1
PA
1
QL
30 / 30 days
felodipine er tab er 24h 2.5 mg
1
QL
30 / 30 days
1
QL
30 / 30 days
fosinopril sodium tab 10 mg
1
1
1
furosemide solution 10 mg/ml
1
1
FUROSEMIDE SOLUTION 8 MG/ML
furosemide
1
furosemide tab 20 mg
1
1
1
guanfacine hcl tab 1 mg
1
1
hydralazine hcl tab 10 mg
1
1
1
1
hydrochlorothiazide cap 12.5 mg
1
hydrochlorothiazide tab 12.5 mg
1
hydrochlorothiazide tab 25 mg
1
1
indapamide tab 1.25 mg
1
PAGE 67
PRODUCT DESCRIPTION
TIER
1
irbesartan tab 150 mg
3
QL
30 / 30 days
3
QL
30 / 30 days
3
QL
30 / 30 days
isradipine cap 2.5 mg
1
isradipine cap 5 mg
1
1
1
1
lisinopril tab 10 mg
1
lisinopril tab 2.5 mg
1
1
1
1
lisinopril tab 5 mg
1
losartan potassium tab 100 mg
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
METHYCLOTHIAZIDE TAB 5 MG
methyclothiazide
1
1
1
metolazone tab 10 mg
1
metolazone tab 2.5 mg
1
metolazone tab 5 mg
1
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
PAGE 68
PRODUCT DESCRIPTION
TIER
1
1
MICARDIS TAB 20 MG
telmisartan
3
MICARDIS TAB 40 MG
telmisartan
3
MICARDIS TAB 80 MG
telmisartan
3
minoxidil tab 10 mg
1
minoxidil tab 2.5 mg
1
moexipril hcl tab 15 mg
1
moexipril hcl tab 7.5 mg
1
nadolol tab 20 mg
1
nadolol tab 40 mg
1
nadolol tab 80 mg
1
1
1
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
1
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
1
PAGE 69
PRODUCT DESCRIPTION
TIER
nisoldipine
1
1
NISOLDIPINE ER TAB ER 24H 25.5 MG
nisoldipine
1
nisoldipine
1
1
nisoldipine
1
1
perindopril erbumine tab 2 mg
1
1
1
pindolol tab 10 mg
1
pindolol tab 5 mg
1
1
1
1
1
ST
1
ST
1
ST
1
ST
propranolol hcl
1
propranolol hcl
1
1
1
1
1
1
quinapril hcl tab 10 mg
1
PAGE 70
PRODUCT DESCRIPTION
TIER
1
1
1
ramipril cap 1.25 mg
1
ramipril cap 10 mg
1
ramipril cap 2.5 mg
1
ramipril cap 5 mg
1
RESERPINE TAB 0.1 MG
reserpine
1
RESERPINE TAB 0.25 MG
reserpine
1
sorine tab 120 mg
1
sorine tab 160 mg
1
sorine tab 240 mg
1
sorine tab 80 mg
1
1
1
1
1
spironolactone tab 100 mg
1
1
1
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
PAGE 71
PRODUCT DESCRIPTION
TIER
theochron tab er 12h 100 mg
1
1
1
theophylline er tab er 12h 100 mg
1
1
1
1
1
1
theophylline solution 80 mg/15ml
1
timolol maleate
1
timolol maleate
1
timolol maleate
1
torsemide tab 10 mg
1
torsemide tab 100 mg
1
torsemide tab 20 mg
1
torsemide tab 5 mg
1
trandolapril tab 1 mg
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
valsartan tab 160 mg
1
1
valsartan tab 40 mg
1
valsartan tab 80 mg
1
1
1
1
1
1
PAGE 72
PRODUCT DESCRIPTION
TIER
1
1
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
verapamil hcl
1
1
Renin-Angiotensin-Aldosterone Sys Inhib
1
1
amlodipine besy-benazepril hcl cap 2.5-10 mg
1
1
1
1
3
ST
3
ST
3
ST
3
ST
AZOR TAB 10-20 MG
3
ST
AZOR TAB 10-40 MG
3
ST
AZOR TAB 5-20 MG
3
ST
AZOR TAB 5-40 MG
3
ST
1
1
1
1
PAGE 73
PRODUCT DESCRIPTION
TIER
benazepril-hydrochlorothiazide tab 10-12.5 mg
1
1
benazepril-hydrochlorothiazide tab 20-25 mg
1
1
BENICAR HCT TAB 20-12.5 MG
olmesartan medoxomil-hydrochlorothiazide
3
ST
3
ST
BENICAR HCT TAB 40-25 MG
3
ST
BENICAR TAB 20 MG
3
BENICAR TAB 40 MG
3
BENICAR TAB 5 MG
3
candesartan cilexetil-hctz tab 16-12.5 mg
1
1
candesartan cilexetil-hctz tab 32-25 mg
1
captopril tab 100 mg
1
captopril tab 12.5 mg
1
captopril tab 25 mg
1
captopril tab 50 mg
1
CAPTOPRIL-HYDROCHLOROTHIAZIDE TAB 25-15 MG
captopril & hydrochlorothiazide
1
1
1
1
EDARBI TAB 40 MG
3
PA
EDARBI TAB 80 MG
3
PA
1
PAGE 74
PRODUCT DESCRIPTION
TIER
enalapril maleate tab 2.5 mg
1
1
1
enalapril-hydrochlorothiazide tab 10-25 mg
1
enalapril-hydrochlorothiazide tab 5-12.5 mg
1
3
3
EPROSARTAN MESYLATE TAB 600 MG
eprosartan mesylate
1
1
1
1
fosinopril sodium-hctz tab 10-12.5 mg
1
1
3
QL
30 / 30 days
3
QL
30 / 30 days
3
QL
30 / 30 days
irbesartan-hydrochlorothiazide tab 150-12.5 mg
1
1
1
lisinopril tab 2.5 mg
1
1
1
1
lisinopril tab 5 mg
1
lisinopril-hydrochlorothiazide tab 10-12.5 mg
1
1
lisinopril-hydrochlorothiazide tab 20-25 mg
1
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
PAGE 75
PA
PRODUCT DESCRIPTION
TIER
losartan potassium-hctz tab 100-12.5 mg
1
QL
30 / 30 days
losartan potassium-hctz tab 100-25 mg
1
QL
30 / 30 days
1
QL
30 / 30 days
MICARDIS HCT TAB 40-12.5 MG
telmisartan-hydrochlorothiazide
3
ST
3
ST
MICARDIS HCT TAB 80-25 MG
3
ST
MICARDIS TAB 20 MG
telmisartan
3
MICARDIS TAB 40 MG
telmisartan
3
MICARDIS TAB 80 MG
telmisartan
3
moexipril hcl tab 15 mg
1
moexipril hcl tab 7.5 mg
1
moexipril-hydrochlorothiazide tab 15-12.5 mg
1
moexipril-hydrochlorothiazide tab 15-25 mg
1
moexipril-hydrochlorothiazide tab 7.5-12.5 mg
1
1
1
1
1
1
1
1
quinapril-hydrochlorothiazide tab 10-12.5 mg
1
1
quinapril-hydrochlorothiazide tab 20-25 mg
1
ramipril cap 1.25 mg
1
ramipril cap 10 mg
1
ramipril cap 2.5 mg
1
PAGE 76
PRODUCT DESCRIPTION
TIER
ramipril cap 5 mg
1
1
1
1
spironolactone-hctz tab 25-25 mg
1
3
ST
3
ST
3
ST
3
ST
TEKTURNA HCT TAB 150-12.5 MG
aliskiren-hydrochlorothiazide
3
TEKTURNA HCT TAB 150-25 MG
3
3
3
TEKTURNA TAB 150 MG
aliskiren fumarate
3
TEKTURNA TAB 300 MG
aliskiren fumarate
3
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
1
valsartan tab 40 mg
1
valsartan tab 80 mg
1
valsartan-hydrochlorothiazide tab 160-12.5 mg
1
valsartan-hydrochlorothiazide tab 160-25 mg
1
1
PAGE 77
PRODUCT DESCRIPTION
TIER
1
1
Vasodilating Agents
ADCIRCA TAB 20 MG
tadalafil (pulmonary hypertension)
4
PA
1
QL
30 / 30 days
1
QL
30 / 30 days
alprostadil solution 500 mcg/ml
1
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
CAVERJECT IMPULSE KIT 10 MCG
alprostadil (vasodilator)
3
PA
CAVERJECT IMPULSE KIT 20 MCG
3
PA
CAVERJECT RECON SOLN 20 MCG
3
PA
CAVERJECT RECON SOLN 40 MCG
3
PA
CIALIS TAB 20 MG
tadalafil
3
PA
CIALIS TAB 5 MG
tadalafil
3
PA
1
1
DILATRATE-SR CAP ER 40 MG
isosorbide dinitrate
3
1
PAGE 78
QL
30 / 30 days
PRODUCT DESCRIPTION
TIER
1
QL
60 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
60 / 30 days
1
QL
60 / 30 days
1
QL
60 / 30 days
1
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
60 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
1
1
1
1
1
1
EDEX KIT 10 MCG
3
PA
EDEX KIT 20 MCG
3
PA
isoditrate er tab er 40 mg
1
isosorbide dinitrate er tab er 40 mg
1
ISOSORBIDE DINITRATE ER TAB ER 40 MG
1
PAGE 79
PRODUCT DESCRIPTION
TIER
isosorbide dinitrate tab 10 mg
1
1
1
ISOSORBIDE DINITRATE TAB 30 MG
1
1
isosorbide mononitrate er tab er 24h 120 mg
1
1
1
isosorbide mononitrate tab 10 mg
1
isosorbide mononitrate tab 20 mg
1
isoxsuprine hcl tab 10 mg
1
ISOXSUPRINE HCL TAB 10 MG
isoxsuprine hcl
1
minitran patch 24hr 0.1 mg/hr
1
1
1
1
MUSE PELLET 1000 MCG
3
PA
MUSE PELLET 125 MCG
3
PA
MUSE PELLET 250 MCG
3
PA
MUSE PELLET 500 MCG
3
PA
1
1
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
PAGE 80
PRODUCT DESCRIPTION
TIER
1
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
NITRO-BID OINTMENT 2 %
nitroglycerin
3
NITRO-DUR PATCH 24HR 0.3 MG/HR
nitroglycerin
3
NITRO-DUR PATCH 24HR 0.8 MG/HR
nitroglycerin
3
nitro-time cap er 2.5 mg
1
nitro-time cap er 6.5 mg
1
nitro-time cap er 9 mg
1
NITROGLYCERIN AERO SOLN 400 MCG/SPRAY
nitroglycerin
3
nitroglycerin er cap er 2.5 mg
1
nitroglycerin er cap er 6.5 mg
1
nitroglycerin er cap er 9 mg
1
nitroglycerin patch 24hr 0.1 mg/hr
1
1
1
1
nitroglycerin solution 0.4 mg/spray
3
NITROLINGUAL SOLUTION 0.4 MG/SPRAY
nitroglycerin
3
NITROSTAT SL TAB 0.3 MG
nitroglycerin
2
nitroglycerin
2
PAGE 81
PRODUCT DESCRIPTION
TIER
nitroglycerin
2
papaverine hcl solution 30 mg/ml
1
PA
sildenafil citrate tab 20 mg
4
PA
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
1
1
1
1
1
1
1
QL
30 / 30 days
1
QL
30 / 30 days
1
QL
30 / 30 days
1
verapamil hcl
1
1
Central Nervous System Agents
Analgesics and Antipyretics
acetaminophen extra strength tab 500 mg
1
acetaminophen-codeine #2 tab 300-15 mg
1
QL
390 / 30 days
1
QL
390 / 30 days
1
QL
390 / 30 days
PAGE 82
PRODUCT DESCRIPTION
TIER
acetaminophen-codeine solution 120-12 mg/5ml
1
acetaminophen-codeine tab 300-15 mg
1
QL
390 / 30 days
1
QL
390 / 30 days
1
QL
390 / 30 days
QL
60 / 30 days
5
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
30 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
AGGRENOX CAP ER 12H 25-200 MG
aspirin-dipyridamole
3
analgesic creme/aloe cream 10 %
1
ascomp-codeine cap 50-325-40-30 mg
1
5
PAGE 83
5
5
5
5
5
5
5
5
5
PRODUCT DESCRIPTION
aspirin tab 325 mg
TIER
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
30 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
5
5
5
astramorph solution 0.5 mg/ml
3
PA
astramorph solution 1 mg/ml
3
PA
5
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
30 / 30 days
AL1
40 to 79 yrs old
QL
30 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
30 / 30 days
AL1
40 to 79 yrs old
5
5
5
5
BELLADONNA ALKALOIDS-OPIUM SUPPOS 16.2-60 MG
1
AL1
Up to 64 yrs old
BELLADONNA-OPIUM SUPPOS 16.2-30 MG
1
AL1
Up to 64 yrs old
buprenorphine hcl sl tab 2 mg
3
PA
buprenorphine hcl sl tab 8 mg
3
PA
buprenorphine hcl solution 0.3 mg/ml
3
PA
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg
3
QL
90 / 30 days
PA
QL
buprenorphine hcl-naloxone hcl sl tab 8-2 mg
90 / 30 days
3
PA
butalbital-acetaminophen tab 50-325 mg
PAGE 84
1
PRODUCT DESCRIPTION
TIER
butalbital-apap-caff-cod cap 50-300-40-30 mg
1
1
butalbital-apap-caffeine cap 50-300-40 mg
1
1
butalbital-apap-caffeine tab 50-325-40 mg
1
butalbital-asa-caff-codeine cap 50-325-40-30 mg
1
butalbital-aspirin-caffeine cap 50-325-40 mg
1
butorphanol tartrate solution 1 mg/ml
3
3
3
BUTRANS PATCH WK 10 MCG/HR
buprenorphine
3
PA
buprenorphine
3
PA
buprenorphine
3
PA
capacet cap 50-325-40 mg
1
celecoxib cap 100 mg
3
QL
30 / 30 days
celecoxib cap 200 mg
3
QL
30 / 30 days
childrens ibuprofen 100 suspension 100 mg/5ml
1
childrens ibuprofen suspension 100 mg/5ml
1
childrens medi-profen suspension 100 mg/5ml
1
childs ibuprofen suspension 100 mg/5ml
1
choline-mag trisalicylate liquid 500 mg/5ml
1
CODEINE SULFATE SOLUTION 30 MG/5ML
codeine sulfate
1
codeine sulfate tab 15 mg
1
CODEINE SULFATE TAB 15 MG
codeine sulfate
1
1
codeine sulfate
1
QL
60 / 30 days
5
AL1
40 to 79 yrs old
PAGE 85
PRODUCT DESCRIPTION
TIER
cvs childrens ibuprofen suspension 100 mg/5ml
1
cvs ibuprofen infants suspension 50 mg/1.25ml
5
diclofenac potassium tab 50 mg
1
diclofenac sodium er tab er 24h 100 mg
1
diclofenac sodium tab dr 25 mg
1
1
1
diclofenac-misoprostol tab dr 50-0.2 mg
3
3
diflunisal tab 500 mg
1
duramorph solution 0.5 mg/ml
3
PA
duramorph solution 1 mg/ml
3
PA
5
QL
60 / 30 days
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
30 / 30 days
AL1
40 to 79 yrs old
5
5
endocet tab 10-325 mg
1
QL
180 / 30 days
endocet tab 5-325 mg
1
QL
360 / 30 days
endocet tab 7.5-325 mg
1
QL
180 / 30 days
endodan tab 4.8355-325 mg
1
QL
60 / 30 days
5
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
5
eq childrens ibuprofen suspension 100 mg/5ml
1
5
PAGE 86
PRODUCT DESCRIPTION
TIER
eql childrens ibuprofen suspension 100 mg/5ml
1
etodolac cap 200 mg
1
etodolac cap 300 mg
1
etodolac er tab er 24h 400 mg
1
1
1
etodolac tab 400 mg
1
etodolac tab 500 mg
1
fentanyl patch 72hr 100 mcg/hr
1
QL
10 / 30 days
PA
QL
10 / 30 days
1
PA
QL
10 / 30 days
1
PA
QL
10 / 30 days
1
PA
QL
10 / 30 days
1
PA
flurbiprofen tab 100 mg
1
flurbiprofen tab 50 mg
1
gabapentin cap 100 mg
1
1
1
gabapentin solution 250 mg/5ml
1
gabapentin tab 600 mg
1
1
5
gnp childrens ibuprofen suspension 100 mg/5ml
PAGE 87
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
5
1
PRODUCT DESCRIPTION
TIER
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
30 / 30 days
AL1
40 to 79 yrs old
5
5
5
hm ibuprofen childrens suspension 100 mg/5ml
1
HYDROCODONE-ACETAMINOPHEN SOLUTION 10-325
MG/15ML
hydrocodone-acetaminophen
1
hydrocodone-acetaminophen solution 2.5-108 mg/5ml
1
hydrocodone-acetaminophen solution 5-217 mg/10ml
1
hydrocodone-acetaminophen solution 7.5-325 mg/15ml
1
hydrocodone-acetaminophen tab 10-300 mg
3
QL
180 / 30 days
1
QL
180 / 30 days
hydrocodone-acetaminophen tab 2.5-325 mg
1
3
1
QL
360 / 30 days
3
QL
180 / 30 days
1
QL
180 / 30 days
hydrocodone-ibuprofen tab 10-200 mg
1
ST
hydrocodone-ibuprofen tab 2.5-200 mg
1
hydrocodone-ibuprofen tab 5-200 mg
1
hydrocodone-ibuprofen tab 7.5-200 mg
1
hydromorphone hcl liquid 1 mg/ml
3
HYDROMORPHONE HCL SUPPOS 3 MG
hydromorphone hcl
3
hydromorphone hcl tab 2 mg
1
QL
240 / 30 days
1
QL
240 / 30 days
1
QL
240 / 30 days
PAGE 88
PRODUCT DESCRIPTION
TIER
hyophen tab 81.6 mg
1
ibudone tab 5-200 mg
1
ibuprofen childrens suspension 100 mg/5ml
1
ibuprofen suspension 100 mg/5ml
1
ibuprofen tab 400 mg
1
1
1
indomethacin cap 25 mg
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
indomethacin er cap er 75 mg
1
AL1
Up to 64 yrs old
isometheptene-caffeine-apap tab 65-20-325 mg
1
ketoprofen cap 50 mg
1
QL
180 / 30 days
1
QL
120 / 30 days
KETOPROFEN ER CAP ER 24H 200 MG
ketoprofen
1
QL
30 / 30 days
LEVORPHANOL TARTRATE TAB 2 MG
levorphanol tartrate
1
lorcet plus tab 7.5-325 mg
1
QL
180 / 30 days
lortab tab 7.5-325 mg
1
QL
180 / 30 days
margesic cap 50-325-40 mg
1
marten-tab tab 50-325 mg
1
MECLOFENAMATE SODIUM CAP 100 MG
meclofenamate sodium
3
MECLOFENAMATE SODIUM CAP 50 MG
meclofenamate sodium
3
MELOXICAM SUSPENSION 7.5 MG/5ML
meloxicam
3
meloxicam tab 15 mg
1
meloxicam tab 7.5 mg
1
MEPERIDINE HCL SOLUTION 10 MG/ML
meperidine hcl
3
meperidine hcl solution 100 mg/ml
3
PAGE 89
PRODUCT DESCRIPTION
TIER
3
MEPERIDINE HCL SOLUTION 50 MG/5ML
meperidine hcl
1
3
meperidine hcl tab 100 mg
1
meperidine hcl tab 50 mg
1
meperitab tab 100 mg
1
meperitab tab 50 mg
1
methadone hcl conc 10 mg/ml
1
methadone hcl intensol conc 10 mg/ml
1
methadone hcl solution 10 mg/5ml
1
METHADONE HCL SOLUTION 10 MG/5ML
methadone hcl
1
METHADONE HCL SOLUTION 10 MG/ML
methadone hcl
3
methadone hcl solution 5 mg/5ml
1
METHADONE HCL SOLUTION 5 MG/5ML
methadone hcl
1
methadone hcl tab 10 mg
1
methadone hcl tab 5 mg
1
methadone hcl tab sol 40 mg
1
METHADOSE CONC 10 MG/ML
methadone hcl
1
methadose tab 10 mg
1
methadose tab sol 40 mg
1
morphine sulfate (concentrate) solution 100 mg/5ml
1
morphine sulfate (concentrate) solution 20 mg/ml
1
morphine sulfate (pf) solution 0.5 mg/ml
3
morphine sulfate (pf) solution 1 mg/ml
3
MORPHINE SULFATE (PF) SOLUTION 10 MG/ML
morphine sulfate
3
morphine sulfate
3
morphine sulfate
3
PAGE 90
QL
240 / 30 days
QL
240 / 30 days
PRODUCT DESCRIPTION
TIER
morphine sulfate
3
morphine sulfate
3
MORPHINE SULFATE DEVICE 10 MG/0.7ML
morphine sulfate
3
morphine sulfate er tab er 100 mg
1
QL
90 / 30 days
1
QL
90 / 30 days
1
QL
90 / 30 days
1
QL
90 / 30 days
morphine sulfate solution 1 mg/ml
3
morphine sulfate solution 10 mg/5ml
1
3
3
MORPHINE SULFATE SOLUTION 150 MG/30ML
morphine sulfate
3
MORPHINE SULFATE SOLUTION 2 MG/ML
morphine sulfate
3
morphine sulfate solution 20 mg/5ml
1
morphine sulfate
3
morphine sulfate
3
morphine sulfate
3
3
MORPHINE SULFATE SUPPOS 10 MG
morphine sulfate
3
morphine sulfate
3
morphine sulfate
3
morphine sulfate
3
MORPHINE SULFATE TAB 15 MG
morphine sulfate
3
QL
180 / 30 days
PAGE 91
PRODUCT DESCRIPTION
TIER
MORPHINE SULFATE TAB 30 MG
morphine sulfate
3
QL
180 / 30 days
nabumetone tab 500 mg
1
QL
120 / 30 days
nabumetone tab 750 mg
1
QL
60 / 30 days
nalbuphine hcl solution 10 mg/ml
3
nalbuphine hcl solution 20 mg/ml
3
naproxen dr tab dr 375 mg
1
1
naproxen sodium tab 275 mg
1
1
naproxen suspension 125 mg/5ml
1
NAPROXEN SUSPENSION 125 MG/5ML
naproxen
1
naproxen tab 250 mg
1
naproxen tab 375 mg
1
naproxen tab 500 mg
1
NORCO TAB 7.5-325 MG
hydrocodone-acetaminophen
1
NUCYNTA ER TAB ER 12H 100 MG
tapentadol hcl
3
PA
tapentadol hcl
3
PA
tapentadol hcl
3
PA
tapentadol hcl
3
PA
tapentadol hcl
3
PA
OPANA ER TB12 DETER 10 MG
oxymorphone hcl
3
PA
oxymorphone hcl
3
PA
oxymorphone hcl
3
PA
oxymorphone hcl
3
PA
PAGE 92
PRODUCT DESCRIPTION
TIER
oxymorphone hcl
3
PA
oxymorphone hcl
3
PA
OPANA ER TB12 DETER 7.5 MG
oxymorphone hcl
3
PA
1
AL1
Up to 64 yrs old
oxaprozin tab 600 mg
3
oxycodone hcl cap 5 mg
1
QL
180 / 30 days
oxycodone hcl conc 100 mg/5ml
3
OXYCODONE HCL CONC 100 MG/5ML
oxycodone hcl
3
oxycodone hcl solution 5 mg/5ml
1
OXYCODONE HCL SOLUTION 5 MG/5ML
oxycodone hcl
1
oxycodone hcl tab 10 mg
1
QL
180 / 30 days
1
QL
180 / 30 days
1
QL
180 / 30 days
1
QL
180 / 30 days
1
QL
180 / 30 days
oxycodone-acetaminophen tab 10-325 mg
1
QL
180 / 30 days
oxycodone-acetaminophen tab 2.5-325 mg
1
oxycodone-acetaminophen tab 5-325 mg
1
QL
360 / 30 days
oxycodone-acetaminophen tab 7.5-325 mg
1
QL
180 / 30 days
oxycodone-aspirin tab 4.8355-325 mg
1
oxycodone-ibuprofen tab 5-400 mg
1
QL
240 / 30 days
QL
oxymorphone hcl er tab er 12h 10 mg
90 / 30 days
3
PA
3
PA
3
PA
3
PA
PAGE 93
PRODUCT DESCRIPTION
TIER
3
3
oxymorphone hcl er tab er 12h 7.5 mg
3
pentazocine-naloxone hcl tab 50-0.5 mg
1
1
piroxicam cap 10 mg
1
piroxicam cap 20 mg
1
px childrens profen ib suspension 100 mg/5ml
1
5
PA
PA
QL
60 / 30 days
AL1
40 to 79 yrs old
qc childrens ibuprofen suspension 100 mg/5ml
1
ra ibuprofen childrens suspension 100 mg/5ml
1
ra ibuprofen suspension 100 mg/5ml
1
reprexain tab 10-200 mg
1
ST
roxicet tab 5-325 mg
1
QL
360 / 30 days
salsalate tab 500 mg
1
salsalate tab 750 mg
1
QL
60 / 30 days
5
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
30 / 30 days
sb childrens ibuprofen suspension 100 mg/5ml
1
5
sm childrens ibuprofen suspension 100 mg/5ml
1
5
SUBOXONE FILM 12-3 MG
buprenorphine hcl-naloxone hcl dihydrate
3
SUBOXONE FILM 2-0.5 MG
3
3
PAGE 94
PA
QL
90 / 30 days
PA
QL
90 / 30 days
PA
PRODUCT DESCRIPTION
TIER
QL
3
sulindac tab 150 mg
1
sulindac tab 200 mg
1
5
60 / 30 days
PA
QL
30 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
240 / 30 days
QL
180 / 30 days
5
tgt childrens ibuprofen suspension 100 mg/5ml
1
tgt ibuprofen childrens suspension 100 mg/5ml
1
tolmetin sodium cap 400 mg
1
TOLMETIN SODIUM TAB 200 MG
tolmetin sodium
3
TOLMETIN SODIUM TAB 600 MG
tolmetin sodium
3
tramadol hcl er (biphasic) tab er 24h 100 mg
3
3
3
TRAMADOL HCL ER CAP ER 24H 150 MG
tramadol hcl
3
tramadol hcl er tab er 24h 100 mg
3
3
3
tramadol hcl tab 50 mg
1
tramadol-acetaminophen tab 37.5-325 mg
1
uretron d/s tab
1
URETRON D/S TAB
1
ustell cap 120 mg
1
utira-c tab 81.6 mg
1
vicodin es tab 7.5-300 mg
3
vicodin tab 5-300 mg
3
PAGE 95
PRODUCT DESCRIPTION
wal-profen tab 200 mg
TIER
1
Anorexigenic Agents and Respiratory and CNS Stimulants
amphetamine-dextroamphet er cap er 24h 10 mg
QL
30 / 30 days
AL1
6 to 17 yrs old
QL
30 / 30 days
AL1
6 to 17 yrs old
QL
30 / 30 days
AL1
6 to 17 yrs old
QL
30 / 30 days
AL1
6 to 17 yrs old
QL
30 / 30 days
AL1
6 to 17 yrs old
QL
30 / 30 days
AL1
6 to 17 yrs old
3
3
3
3
3
3
amphetamine-dextroamphetamine tab 10 mg
1
AL1
6 to 17 yrs old
amphetamine-dextroamphetamine tab 12.5 mg
1
AL1
6 to 17 yrs old
1
AL1
6 to 17 yrs old
1
AL1
6 to 17 yrs old
1
AL1
6 to 17 yrs old
1
AL1
6 to 17 yrs old
amphetamine-dextroamphetamine tab 7.5 mg
1
AL1
6 to 17 yrs old
1
1
1
1
1
1
1
1
PAGE 96
PRODUCT DESCRIPTION
TIER
2
caffeine citrate solution 20 mg/ml
1
caffeine citrate solution 60 mg/3ml
1
1
CAFFEINE-SODIUM BENZOATE SOLUTION 125-125 MG/ML
caffeine & sodium benzoate
1
1
QL
DAYTRANA PATCH 10 MG/9HR
methylphenidate
methylphenidate
methylphenidate
methylphenidate
dexmethylphenidate hcl er cap er 24h 15 mg
3
3
3
3
3
3
3
30 / 30 days
PA
AL1
6 to 17 yrs old
QL
30 / 30 days
PA
AL1
6 to 17 yrs old
QL
30 / 30 days
PA
AL1
6 to 17 yrs old
QL
30 / 30 days
PA
AL1
6 to 17 yrs old
QL
30 / 30 days
PA
AL1
6 to 17 yrs old
QL
30 / 30 days
PA
AL1
6 to 17 yrs old
QL
30 / 30 days
PA
AL1
6 to 17 yrs old
dexmethylphenidate hcl tab 10 mg
1
AL1
6 to 17 yrs old
dexmethylphenidate hcl tab 2.5 mg
1
AL1
6 to 17 yrs old
dexmethylphenidate hcl tab 5 mg
1
AL1
6 to 17 yrs old
PAGE 97
PRODUCT DESCRIPTION
TIER
dextroamphetamine sulfate er cap er 24h 10 mg
1
AL1
6 to 17 yrs old
1
AL1
6 to 17 yrs old
1
AL1
6 to 17 yrs old
dextroamphetamine sulfate tab 10 mg
1
AL1
6 to 17 yrs old
dextroamphetamine sulfate tab 5 mg
1
AL1
6 to 17 yrs old
diethylpropion hcl er tab er 24h 75 mg
1
diethylpropion hcl tab 25 mg
1
DIETHYLPROPION HCL TAB 25 MG
diethylpropion hcl
1
doxapram hcl solution 20 mg/ml
1
theophylline
2
QL
30 / 30 days
FOCALIN XR CAP ER 24H 10 MG
dexmethylphenidate hcl
3
3
3
3
3
3
PA
AL1
6 to 17 yrs old
QL
30 / 30 days
PA
AL1
6 to 17 yrs old
QL
30 / 30 days
PA
AL1
6 to 17 yrs old
QL
30 / 30 days
PA
AL1
6 to 17 yrs old
QL
30 / 30 days
PA
AL1
6 to 17 yrs old
QL
30 / 30 days
PA
AL1
PAGE 98
6 to 17 yrs old
PRODUCT DESCRIPTION
TIER
1
1
metadate er tab er 20 mg
1
methamphetamine hcl tab 5 mg
1
methylphenidate hcl er (cd) cap er 10 mg
1
methylphenidate hcl er tab er 10 mg
QL
30 / 30 days
AL1
6 to 17 yrs old
AL1
6 to 17 yrs old
QL
30 / 30 days
AL1
6 to 17 yrs old
QL
30 / 30 days
AL1
6 to 17 yrs old
QL
30 / 30 days
AL1
6 to 17 yrs old
QL
30 / 30 days
AL1
6 to 17 yrs old
QL
30 / 30 days
AL1
6 to 17 yrs old
QL
30 / 30 days
AL1
6 to 17 yrs old
QL
30 / 30 days
AL1
6 to 17 yrs old
QL
30 / 30 days
AL1
6 to 17 yrs old
QL
30 / 30 days
AL1
6 to 17 yrs old
QL
30 / 30 days
AL1
6 to 17 yrs old
QL
30 / 30 days
AL1
6 to 17 yrs old
QL
30 / 30 days
AL1
6 to 17 yrs old
1
1
1
1
1
1
METHYLPHENIDATE HCL ER TAB ER 18 MG
methylphenidate hcl
3
methylphenidate hcl er tab er 20 mg
1
methylphenidate hcl
3
methylphenidate hcl
3
methylphenidate hcl
3
methylphenidate hcl solution 10 mg/5ml
1
PA
AL1
PAGE 99
6 to 17 yrs old
PRODUCT DESCRIPTION
TIER
PA
methylphenidate hcl solution 5 mg/5ml
1
AL1
6 to 17 yrs old
methylphenidate hcl tab 10 mg
1
AL1
6 to 17 yrs old
1
AL1
6 to 17 yrs old
1
AL1
6 to 17 yrs old
modafinil tab 100 mg
4
PA
modafinil tab 200 mg
4
PA
NUVIGIL TAB 150 MG
armodafinil
4
PA
1
AL1
PHENDIMETRAZINE TARTRATE ER CAP ER 24H 105 MG
phendimetrazine tartrate
1
phendimetrazine tartrate tab 35 mg
1
phentermine hcl cap 15 mg
1
phentermine hcl cap 30 mg
1
phentermine hcl cap 37.5 mg
1
phentermine hcl tab 37.5 mg
1
1
1
1
1
1
1
1
1
1
1
Up to 64 yrs old
Anticonvulsants
1
acetazolamide
1
PAGE 100
PRODUCT DESCRIPTION
TIER
1
BANZEL SUSPENSION 40 MG/ML
rufinamide
3
carbamazepine chew tab 100 mg
1
carbamazepine er cap er 12h 100 mg
1
1
1
carbamazepine er tab er 12h 200 mg
1
1
carbamazepine suspension 100 mg/5ml
1
carbamazepine tab 200 mg
1
CELONTIN CAP 300 MG
methsuximide
2
clonazepam tab 0.5 mg
1
clonazepam tab 1 mg
1
clonazepam tab 2 mg
1
clonazepam tab disp 0.125 mg
1
1
1
clonazepam tab disp 1 mg
1
1
clorazepate dipotassium tab 15 mg
1
AL1
Up to 64 yrs old
clorazepate dipotassium tab 3.75 mg
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
DIAZEPAM SOLUTION 1 MG/ML
diazepam
1
AL1
Up to 64 yrs old
diazepam
1
AL1
Up to 64 yrs old
diazepam tab 10 mg
1
AL1
Up to 64 yrs old
diazepam tab 2 mg
1
AL1
Up to 64 yrs old
diazepam tab 5 mg
1
AL1
Up to 64 yrs old
DILANTIN CAP 100 MG
2
PAGE 101
PRODUCT DESCRIPTION
TIER
DILANTIN CAP 30 MG
2
divalproex sodium cap sprink 125 mg
1
divalproex sodium er tab er 24h 250 mg
1
1
divalproex sodium tab dr 125 mg
1
1
1
epitol tab 200 mg
1
ethosuximide cap 250 mg
1
ethosuximide solution 250 mg/5ml
3
felbamate suspension 600 mg/5ml
4
felbamate tab 400 mg
3
felbamate tab 600 mg
3
1
1
1
gabapentin solution 250 mg/5ml
1
1
1
GABITRIL TAB 12 MG
tiagabine hcl
3
GABITRIL TAB 16 MG
tiagabine hcl
3
LAMICTAL ODT KIT 25 & 50 & 100 MG
lamotrigine
3
LAMICTAL ODT KIT 25 (21)-50 (7) MG
lamotrigine
3
LAMICTAL ODT KIT 50 (42)-100(14) MG
lamotrigine
3
lamotrigine chew tab 25 mg
1
1
lamotrigine er tab er 24h 100 mg
3
3
PAGE 102
PRODUCT DESCRIPTION
TIER
3
3
3
3
lamotrigine tab 100 mg
1
1
1
1
levetiracetam er tab er 24h 500 mg
3
levetiracetam er tab er 24h 750 mg
3
levetiracetam solution 100 mg/ml
1
levetiracetam solution 500 mg/5ml
1
levetiracetam tab 1000 mg
1
QL
90 / 30 days
1
QL
360 / 30 days
1
QL
180 / 30 days
1
QL
120 / 30 days
lorazepam conc 2 mg/ml
1
AL1
Up to 64 yrs old
lorazepam intensol conc 2 mg/ml
1
AL1
Up to 64 yrs old
lorazepam solution 2 mg/ml
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
lorazepam tab 0.5 mg
1
AL1
Up to 64 yrs old
lorazepam tab 1 mg
1
AL1
Up to 64 yrs old
lorazepam tab 2 mg
1
AL1
Up to 64 yrs old
LYRICA CAP 100 MG
pregabalin
3
PA
LYRICA CAP 150 MG
pregabalin
3
PA
LYRICA CAP 200 MG
pregabalin
3
PA
LYRICA CAP 225 MG
pregabalin
3
PA
PAGE 103
PRODUCT DESCRIPTION
TIER
LYRICA CAP 25 MG
pregabalin
3
PA
LYRICA CAP 300 MG
pregabalin
3
PA
LYRICA CAP 50 MG
pregabalin
3
PA
LYRICA CAP 75 MG
pregabalin
3
PA
LYRICA SOLUTION 20 MG/ML
pregabalin
3
PA
oxcarbazepine suspension 300 mg/5ml
1
oxcarbazepine tab 150 mg
1
1
1
PEGANONE TAB 250 MG
ethotoin
3
phenobarbital elixir 20 mg/5ml
1
phenobarbital solution 20 mg/5ml
1
PHENOBARBITAL TAB 100 MG
phenobarbital
1
phenobarbital
1
phenobarbital tab 16.2 mg
1
phenobarbital
1
1
phenobarbital
1
1
1
phenytoin chew tab 50 mg
1
phenytoin infatabs chew tab 50 mg
1
1
1
1
PAGE 104
PRODUCT DESCRIPTION
TIER
phenytoin sodium solution 50 mg/ml
1
phenytoin suspension 125 mg/5ml
1
POTIGA TAB 200 MG
ezogabine
3
POTIGA TAB 300 MG
ezogabine
3
POTIGA TAB 400 MG
ezogabine
3
POTIGA TAB 50 MG
ezogabine
3
primidone tab 250 mg
1
primidone tab 50 mg
1
SABRIL PACKET 500 MG
vigabatrin
4
PA
STAVZOR CAP DR 125 MG
valproic acid
3
PA
TEGRETOL-XR TAB ER 12H 100 MG
carbamazepine
2
tiagabine hcl tab 2 mg
3
tiagabine hcl tab 4 mg
3
topiragen tab 100 mg
1
1
topiragen tab 25 mg
1
topiragen tab 50 mg
1
topiramate cap sprink 15 mg
1
1
topiramate tab 100 mg
1
1
1
1
valproic acid cap 250 mg
1
valproic acid solution 250 mg/5ml
1
valproic acid syrup 250 mg/5ml
1
zonisamide cap 100 mg
1
PAGE 105
QL
180 / 30 days
PRODUCT DESCRIPTION
TIER
1
QL
360 / 30 days
1
QL
360 / 30 days
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
30 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
30 / 30 days
AL1
40 to 79 yrs old
Antimigraine Agents
acetaminophen extra strength tab 500 mg
1
5
aspirin tab 325 mg
PAGE 106
5
5
5
5
5
5
5
5
5
5
5
5
PRODUCT DESCRIPTION
TIER
3
AXERT TAB 6.25 MG
almotriptan malate
3
5
60 / 30 days
AL1
40 to 79 yrs old
QL
9 / 23 days
ST
QL
9 / 23 days
ST
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
30 / 30 days
AL1
40 to 79 yrs old
QL
30 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
30 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
5
5
5
5
3
3
3
2
caffeine citrate solution 20 mg/ml
1
1
1
CAFFEINE-SODIUM BENZOATE SOLUTION 125-125 MG/ML
caffeine & sodium benzoate
1
childrens ibuprofen 100 suspension 100 mg/5ml
1
childrens ibuprofen suspension 100 mg/5ml
1
childrens medi-profen suspension 100 mg/5ml
1
childs ibuprofen suspension 100 mg/5ml
1
5
PAGE 107
QL
5
AXERT TAB 12.5 MG
almotriptan malate
PRODUCT DESCRIPTION
TIER
cvs childrens ibuprofen suspension 100 mg/5ml
1
cvs ibuprofen infants suspension 50 mg/1.25ml
5
DIHYDROERGOTAMINE MESYLATE SOLUTION 4 MG/ML
dihydroergotamine mesylate
3
1
1
1
1
1
1
5
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
30 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
9 / 23 days
5
5
5
5
eql childrens ibuprofen suspension 100 mg/5ml
1
FROVA TAB 2.5 MG
frovatriptan succinate
3
5
PAGE 108
60 / 30 days
5
1
QL
5
eq childrens ibuprofen suspension 100 mg/5ml
eql aspirin low dose tab dr 81 mg
ST
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
5
PRODUCT DESCRIPTION
TIER
gnp childrens ibuprofen suspension 100 mg/5ml
1
5
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
30 / 30 days
AL1
40 to 79 yrs old
5
5
hm ibuprofen childrens suspension 100 mg/5ml
1
ibuprofen childrens suspension 100 mg/5ml
1
ibuprofen suspension 100 mg/5ml
1
1
1
1
1
1
QL
180 / 30 days
1
QL
120 / 30 days
KETOPROFEN ER CAP ER 24H 200 MG
ketoprofen
1
QL
30 / 30 days
1
1
1
1
1
naproxen
1
naproxen tab 250 mg
1
naproxen tab 375 mg
1
naproxen tab 500 mg
1
QL
naratriptan hcl tab 1 mg
9 / 23 days
1
ST
QL
naratriptan hcl tab 2.5 mg
9 / 23 days
1
ST
PAGE 109
PRODUCT DESCRIPTION
TIER
1
ST
1
ST
1
ST
1
ST
propranolol hcl
1
propranolol hcl
1
1
1
1
1
1
px childrens profen ib suspension 100 mg/5ml
1
5
qc childrens ibuprofen suspension 100 mg/5ml
1
ra ibuprofen childrens suspension 100 mg/5ml
1
ra ibuprofen suspension 100 mg/5ml
1
RELPAX TAB 20 MG
eletriptan hydrobromide
3
RELPAX TAB 40 MG
eletriptan hydrobromide
3
rizatriptan benzoate tab 10 mg
1
rizatriptan benzoate tab 5 mg
1
5
AL1
40 to 79 yrs old
QL
9 / 23 days
QL
9 / 23 days
ST
1
5
PAGE 110
60 / 30 days
ST
sb childrens ibuprofen suspension 100 mg/5ml
sm childrens ibuprofen suspension 100 mg/5ml
QL
QL
60 / 30 days
AL1
40 to 79 yrs old
QL
60 / 30 days
AL1
40 to 79 yrs old
1
PRODUCT DESCRIPTION
TIER
QL
60 / 30 days
AL1
40 to 79 yrs old
5
valproic acid
3
SUMATRIPTAN SOLUTION 20 MG/ACT
sumatriptan
3
SUMATRIPTAN SOLUTION 5 MG/ACT
sumatriptan
3
sumatriptan succinate refill soln cart 4 mg/0.5ml
3
PA
QL
10 / 23 days
PA
QL
sumatriptan succinate refill soln cart 6 mg/0.5ml
10 / 23 days
3
PA
QL
sumatriptan succinate soln a-inj 4 mg/0.5ml
10 / 23 days
3
PA
QL
sumatriptan succinate soln a-inj 6 mg/0.5ml
10 / 23 days
3
PA
QL
sumatriptan succinate soln prsyr 6 mg/0.5ml
10 / 23 days
3
PA
QL
SUMATRIPTAN SUCCINATE SOLN PRSYR 6 MG/0.5ML
sumatriptan succinate
3
sumatriptan succinate solution 4 mg/0.5ml
3
10 / 23 days
PA
QL
10 / 23 days
PA
QL
SUMATRIPTAN SUCCINATE SOLUTION 4 MG/0.5ML
sumatriptan succinate
3
sumatriptan succinate solution 6 mg/0.5ml
3
10 / 23 days
PA
QL
10 / 23 days
PA
sumatriptan succinate tab 100 mg
1
QL
9 / 23 days
1
QL
9 / 23 days
1
QL
9 / 23 days
QL
30 / 30 days
5
AL1
40 to 79 yrs old
PAGE 111
PRODUCT DESCRIPTION
TIER
QL
60 / 30 days
AL1
40 to 79 yrs old
AL1
Up to 64 yrs old
5
tgt childrens ibuprofen suspension 100 mg/5ml
1
tgt ibuprofen childrens suspension 100 mg/5ml
1
timolol maleate
1
timolol maleate
1
timolol maleate
1
1
1
topiragen tab 25 mg
1
topiragen tab 50 mg
1
1
1
1
1
1
1
1
1
1
wal-profen tab 200 mg
1
Antiparkinsonian Agents
1
amantadine hcl cap 100 mg
1
amantadine hcl syrup 50 mg/5ml
1
AMANTADINE HCL TAB 100 MG
amantadine hcl
1
AZILECT TAB 0.5 MG
rasagiline mesylate
3
AZILECT TAB 1 MG
rasagiline mesylate
3
PAGE 112
PRODUCT DESCRIPTION
TIER
benztropine mesylate solution 1 mg/ml
3
benztropine mesylate tab 0.5 mg
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
bromocriptine mesylate cap 5 mg
3
bromocriptine mesylate tab 2.5 mg
1
cabergoline tab 0.5 mg
1
carbidopa tab 25 mg
3
carbidopa-levodopa er tab er 25-100 mg
1
carbidopa-levodopa er tab er 50-200 mg
1
carbidopa-levodopa tab 10-100 mg
1
1
1
carbidopa-levodopa tab disp 10-100 mg
1
1
1
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
EMSAM PATCH 24HR 12 MG/24HR
selegiline
3
ST
selegiline
3
ST
selegiline
3
ST
entacapone tab 200 mg
3
1
LODOSYN TAB 25 MG
carbidopa
3
MIRAPEX ER TAB ER 24H 0.375 MG
pramipexole dihydrochloride
PAGE 113
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
3
PA
PRODUCT DESCRIPTION
TIER
3
PA
3
PA
3
PA
MIRAPEX ER TAB ER 24H 3 MG
3
PA
3
PA
3
PA
NEUPRO PATCH 24HR 1 MG/24HR
rotigotine
3
PA
rotigotine
3
PA
rotigotine
3
PA
rotigotine
3
PA
rotigotine
3
PA
rotigotine
3
PA
orphenadrine citrate er tab er 12h 100 mg
1
AL1
Up to 64 yrs old
pramipexole dihydrochloride tab 0.125 mg
1
1
1
1
pramipexole dihydrochloride tab 1 mg
1
1
1
AL1
Up to 64 yrs old
ropinirole hcl er tab er 24h 12 mg
1
ST
1
ST
1
ST
PAGE 114
PRODUCT DESCRIPTION
TIER
1
ST
1
ST
ropinirole hcl tab 0.25 mg
1
ropinirole hcl tab 0.5 mg
1
ropinirole hcl tab 1 mg
1
1
1
1
1
selegiline hcl cap 5 mg
1
selegiline hcl tab 5 mg
1
1
AL1
TASMAR TAB 100 MG
tolcapone
4
PA
alprazolam er tab er 24h 0.5 mg
3
AL1
Up to 64 yrs old
alprazolam er tab er 24h 1 mg
3
AL1
Up to 64 yrs old
3
AL1
Up to 64 yrs old
3
AL1
Up to 64 yrs old
alprazolam tab 0.25 mg
1
AL1
Up to 64 yrs old
alprazolam tab 0.5 mg
1
AL1
Up to 64 yrs old
alprazolam tab 1 mg
1
AL1
Up to 64 yrs old
alprazolam tab 2 mg
1
AL1
Up to 64 yrs old
alprazolam tab disp 0.25 mg
3
AL1
Up to 64 yrs old
alprazolam tab disp 0.5 mg
3
AL1
Up to 64 yrs old
alprazolam tab disp 1 mg
3
AL1
Up to 64 yrs old
alprazolam tab disp 2 mg
3
AL1
Up to 64 yrs old
alprazolam xr tab er 24h 0.5 mg
3
AL1
Up to 64 yrs old
Up to 64 yrs old
Anxiolytics, Sedatives, and Hypnotics
PAGE 115
PRODUCT DESCRIPTION
TIER
alprazolam xr tab er 24h 1 mg
3
AL1
Up to 64 yrs old
3
AL1
Up to 64 yrs old
3
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
buspirone hcl tab 10 mg
1
1
1
1
buspirone hcl tab 7.5 mg
1
butalbital-acetaminophen tab 50-325 mg
1
1
1
1
1
1
1
1
1
chlordiazepoxide hcl cap 10 mg
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
CHLORDIAZEPOXIDE-AMITRIPTYLINE TAB 10-25 MG
chlordiazepoxide-amitriptyline
1
CHLORDIAZEPOXIDE-AMITRIPTYLINE TAB 5-12.5 MG
1
chlordiazepoxide-clidinium cap 5-2.5 mg
1
clonazepam tab 0.5 mg
1
clonazepam tab 1 mg
1
clonazepam tab 2 mg
1
1
PAGE 116
PRODUCT DESCRIPTION
TIER
1
1
1
1
clorazepate dipotassium tab 15 mg
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
diazepam
1
AL1
Up to 64 yrs old
diazepam
1
AL1
Up to 64 yrs old
diazepam tab 10 mg
1
AL1
Up to 64 yrs old
diazepam tab 2 mg
1
AL1
Up to 64 yrs old
diazepam tab 5 mg
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
droperidol solution 2.5 mg/ml
1
1
AL1
Up to 64 yrs old
estazolam tab 1 mg
1
estazolam tab 2 mg
1
flurazepam hcl cap 15 mg
1
AL1
Up to 64 yrs old
FLURAZEPAM HCL CAP 15 MG
flurazepam hcl
1
AL1
Up to 64 yrs old
flurazepam hcl cap 30 mg
1
AL1
Up to 64 yrs old
FLURAZEPAM HCL CAP 30 MG
flurazepam hcl
1
AL1
Up to 64 yrs old
hydroxyzine hcl solution 10 mg/5ml
1
AL1
Up to 64 yrs old
HYDROXYZINE HCL SOLUTION 25 MG/ML
hydroxyzine hcl
1
AL1
Up to 64 yrs old
hydroxyzine hcl solution 50 mg/ml
1
AL1
Up to 64 yrs old
PAGE 117
PRODUCT DESCRIPTION
TIER
hydroxyzine hcl syrup 10 mg/5ml
1
AL1
Up to 64 yrs old
hydroxyzine hcl tab 10 mg
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
HYDROXYZINE PAMOATE CAP 100 MG
hydroxyzine pamoate
1
AL1
Up to 64 yrs old
hydroxyzine pamoate cap 25 mg
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
lorazepam conc 2 mg/ml
1
AL1
Up to 64 yrs old
lorazepam intensol conc 2 mg/ml
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
lorazepam tab 0.5 mg
1
AL1
Up to 64 yrs old
lorazepam tab 1 mg
1
AL1
Up to 64 yrs old
lorazepam tab 2 mg
1
AL1
Up to 64 yrs old
LUNESTA TAB 1 MG
eszopiclone
3
LUNESTA TAB 2 MG
eszopiclone
3
LUNESTA TAB 3 MG
eszopiclone
3
1
marten-tab tab 50-325 mg
1
PA
AL1
Up to 64 yrs old
PA
AL1
Up to 64 yrs old
PA
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
meprobamate tab 200 mg
1
AL1
Up to 64 yrs old
meprobamate tab 400 mg
1
AL1
Up to 64 yrs old
oxazepam cap 10 mg
1
AL1
Up to 64 yrs old
oxazepam cap 15 mg
1
AL1
Up to 64 yrs old
PAGE 118
PRODUCT DESCRIPTION
TIER
oxazepam cap 30 mg
1
AL1
Up to 64 yrs old
phenadoz suppos 12.5 mg
1
AL1
Up to 64 yrs old
phenadoz suppos 25 mg
1
AL1
Up to 64 yrs old
phenergan suppos 50 mg
1
AL1
Up to 64 yrs old
phenobarbital elixir 20 mg/5ml
1
phenobarbital solution 20 mg/5ml
1
phenobarbital
1
phenobarbital
1
1
phenobarbital
1
1
phenobarbital
1
1
1
promethazine hcl solution 25 mg/ml
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
promethazine hcl solution 6.25 mg/5ml
1
AL1
Up to 64 yrs old
promethazine hcl suppos 12.5 mg
1
AL1
Up to 64 yrs old
promethazine hcl suppos 25 mg
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
promethazine hcl syrup 6.25 mg/5ml
1
AL1
Up to 64 yrs old
promethazine hcl tab 12.5 mg
1
AL1
Up to 64 yrs old
promethazine hcl tab 25 mg
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
promethegan suppos 12.5 mg
1
AL1
Up to 64 yrs old
promethegan suppos 25 mg
1
AL1
Up to 64 yrs old
PAGE 119
PRODUCT DESCRIPTION
TIER
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
ROZEREM TAB 8 MG
ramelteon
QL
30 / 30 days
3
1
AL1
Up to 64 yrs old
temazepam cap 15 mg
1
AL1
Up to 64 yrs old
temazepam cap 22.5 mg
3
AL1
Up to 64 yrs old
temazepam cap 30 mg
1
AL1
Up to 64 yrs old
temazepam cap 7.5 mg
3
AL1
Up to 64 yrs old
triazolam tab 0.125 mg
1
AL1
Up to 64 yrs old
triazolam tab 0.25 mg
1
AL1
Up to 64 yrs old
zaleplon cap 10 mg
1
AL1
Up to 64 yrs old
zaleplon cap 5 mg
1
AL1
Up to 64 yrs old
QL
zolpidem tartrate er tab er 12.5 mg
30 / 30 days
3
AL1
Up to 64 yrs old
QL
30 / 30 days
AL1
Up to 64 yrs old
zolpidem tartrate er tab er 6.25 mg
ST
3
zolpidem tartrate tab 10 mg
1
QL
30 / 30 days
zolpidem tartrate tab 5 mg
1
QL
30 / 30 days
ABILIFY DISCMELT TAB DISP 10 MG
aripiprazole
4
PA
aripiprazole
4
PA
ABILIFY MAINTENA RECON SUSP 300 MG
aripiprazole
4
PA
ABILIFY SOLUTION 1 MG/ML
aripiprazole
4
PA
ABILIFY SOLUTION 9.75 MG/1.3ML
aripiprazole
4
PA
ABILIFY TAB 10 MG
aripiprazole
4
PA
PAGE 120
PRODUCT DESCRIPTION
TIER
ABILIFY TAB 15 MG
aripiprazole
4
PA
ABILIFY TAB 2 MG
aripiprazole
4
PA
ABILIFY TAB 20 MG
aripiprazole
4
PA
ABILIFY TAB 30 MG
aripiprazole
4
PA
ABILIFY TAB 5 MG
aripiprazole
4
PA
acamprosate calcium tab dr 333 mg
3
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg
3
QL
90 / 30 days
PA
QL
buprenorphine hcl-naloxone hcl sl tab 8-2 mg
90 / 30 days
3
PA
carbamazepine chew tab 100 mg
1
1
1
1
1
1
carbamazepine suspension 100 mg/5ml
1
carbamazepine tab 200 mg
1
CYMBALTA CP DR PART 20 MG
duloxetine hcl
3
PA
duloxetine hcl
3
PA
duloxetine hcl
3
PA
1
1
1
1
1
PAGE 121
PRODUCT DESCRIPTION
TIER
1
duloxetine hcl cp dr part 20 mg
3
QL
30 / 30 days
3
QL
30 / 30 days
3
QL
30 / 30 days
epitol tab 200 mg
1
1
1
LAMICTAL ODT KIT 25 & 50 & 100 MG
lamotrigine
3
LAMICTAL ODT KIT 25 (21)-50 (7) MG
lamotrigine
3
LAMICTAL ODT KIT 50 (42)-100(14) MG
lamotrigine
3
1
1
3
3
3
3
3
3
1
1
1
1
lithium carbonate cap 150 mg
1
LITHIUM CARBONATE CAP 150 MG
lithium carbonate
1
1
1
LITHIUM CARBONATE CAP 600 MG
lithium carbonate
1
lithium carbonate er tab er 300 mg
1
PAGE 122
PRODUCT DESCRIPTION
TIER
lithium carbonate er tab er 450 mg
1
lithium carbonate tab 300 mg
1
LITHIUM SOLUTION 8 MEQ/5ML
lithium
1
LYRICA CAP 100 MG
pregabalin
3
PA
LYRICA CAP 150 MG
pregabalin
3
PA
LYRICA CAP 200 MG
pregabalin
3
PA
LYRICA CAP 225 MG
pregabalin
3
PA
LYRICA CAP 25 MG
pregabalin
3
PA
LYRICA CAP 300 MG
pregabalin
3
PA
LYRICA CAP 50 MG
pregabalin
3
PA
LYRICA CAP 75 MG
pregabalin
3
PA
LYRICA SOLUTION 20 MG/ML
pregabalin
3
PA
naloxone hcl solution 0.4 mg/ml
1
QL
2 / 90 days
NALOXONE HCL SOLUTION 1 MG/ML
naloxone hcl
2
QL
2 / 90 days
naltrexone hcl tab 50 mg
1
NAMENDA SOLUTION 10 MG/5ML
memantine hcl
3
PA
NAMENDA TAB 10 MG
memantine hcl
3
PA
NAMENDA TAB 5 MG
memantine hcl
3
PA
NAMENDA TITRATION PAK TAB 5 (28)-10 (21) MG
memantine hcl
3
PA
NUEDEXTA CAP 20-10 MG
dextromethorphan hbr-quinidine sulfate
4
PA
olanzapine recon soln 10 mg
3
PA
PAGE 123
PRODUCT DESCRIPTION
TIER
olanzapine tab 10 mg
3
ST
3
ST
olanzapine tab 2.5 mg
3
ST
3
ST
olanzapine tab 5 mg
3
ST
3
ST
olanzapine tab disp 10 mg
3
PA
3
PA
3
PA
3
PA
pentazocine-naloxone hcl tab 50-0.5 mg
1
quetiapine fumarate tab 100 mg
1
1
1
1
1
1
RILUTEK TAB 50 MG
riluzole
4
riluzole tab 50 mg
4
risperidone m-tab tab disp 0.5 mg
3
risperidone m-tab tab disp 1 mg
3
3
3
3
risperidone solution 1 mg/ml
3
risperidone tab 0.25 mg
1
1
risperidone tab 1 mg
1
1
PAGE 124
PRODUCT DESCRIPTION
TIER
1
1
risperidone tab disp 0.25 mg
3
3
risperidone tab disp 1 mg
3
3
3
3
SAPHRIS SL TAB 10 MG
asenapine maleate
3
ST
SAPHRIS SL TAB 5 MG
asenapine maleate
3
ST
SAVELLA TAB 100 MG
milnacipran hcl
3
PA
SAVELLA TAB 12.5 MG
milnacipran hcl
3
PA
SAVELLA TAB 25 MG
milnacipran hcl
3
PA
SAVELLA TAB 50 MG
milnacipran hcl
3
PA
SEROQUEL XR TAB ER 24H 150 MG
quetiapine fumarate
3
ST
quetiapine fumarate
3
ST
quetiapine fumarate
3
ST
quetiapine fumarate
3
ST
quetiapine fumarate
3
ST
valproic acid
3
PA
STRATTERA CAP 10 MG
atomoxetine hcl
3
STRATTERA CAP 100 MG
atomoxetine hcl
3
PAGE 125
PA
AL1
6 to 17 yrs old
PA
AL1
6 to 17 yrs old
PRODUCT DESCRIPTION
TIER
PA
STRATTERA CAP 18 MG
atomoxetine hcl
3
STRATTERA CAP 25 MG
atomoxetine hcl
3
STRATTERA CAP 40 MG
atomoxetine hcl
3
STRATTERA CAP 60 MG
atomoxetine hcl
3
STRATTERA CAP 80 MG
atomoxetine hcl
3
3
SUBOXONE FILM 2-0.5 MG
3
3
3
TEGRETOL-XR TAB ER 12H 100 MG
carbamazepine
2
1
1
1
VIVITROL RECON SUSP 380 MG
naltrexone
4
PA
XENAZINE TAB 12.5 MG
tetrabenazine
4
PA
XENAZINE TAB 25 MG
tetrabenazine
4
PA
XYREM SOLUTION 500 MG/ML
sodium oxybate
4
PA
ziprasidone hcl cap 20 mg
3
ST
PAGE 126
AL1
6 to 17 yrs old
PA
AL1
6 to 17 yrs old
PA
AL1
6 to 17 yrs old
PA
AL1
6 to 17 yrs old
PA
AL1
6 to 17 yrs old
QL
30 / 30 days
PA
QL
90 / 30 days
PA
QL
90 / 30 days
PA
QL
60 / 30 days
PA
PRODUCT DESCRIPTION
TIER
3
ST
3
ST
3
ST
aripiprazole
4
PA
aripiprazole
4
PA
ABILIFY MAINTENA RECON SUSP 300 MG
aripiprazole
4
PA
ABILIFY SOLUTION 1 MG/ML
aripiprazole
4
PA
ABILIFY SOLUTION 9.75 MG/1.3ML
aripiprazole
4
PA
ABILIFY TAB 10 MG
aripiprazole
4
PA
ABILIFY TAB 15 MG
aripiprazole
4
PA
ABILIFY TAB 2 MG
aripiprazole
4
PA
ABILIFY TAB 20 MG
aripiprazole
4
PA
ABILIFY TAB 30 MG
aripiprazole
4
PA
ABILIFY TAB 5 MG
aripiprazole
4
PA
amitriptyline hcl tab 10 mg
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
AMOXAPINE TAB 100 MG
amoxapine
1
AL1
Up to 64 yrs old
Psychotherapeutic Agents
PAGE 127
PRODUCT DESCRIPTION
TIER
AMOXAPINE TAB 150 MG
amoxapine
1
AL1
Up to 64 yrs old
AMOXAPINE TAB 25 MG
amoxapine
1
AL1
Up to 64 yrs old
AMOXAPINE TAB 50 MG
amoxapine
1
AL1
Up to 64 yrs old
AZILECT TAB 0.5 MG
rasagiline mesylate
3
AZILECT TAB 1 MG
rasagiline mesylate
3
budeprion sr tab er 12h 150 mg
1
buproban tab er 12h 150 mg
5
bupropion hcl er (sr) tab er 12h 100 mg
1
1
1
bupropion hcl er (xl) tab er 24h 150 mg
1
bupropion hcl er (xl) tab er 24h 300 mg
1
bupropion hcl tab 100 mg
1
bupropion hcl tab 75 mg
1
CHLORDIAZEPOXIDE-AMITRIPTYLINE TAB 10-25 MG
1
CHLORDIAZEPOXIDE-AMITRIPTYLINE TAB 5-12.5 MG
1
chlorpromazine hcl tab 10 mg
1
1
1
1
1
citalopram hydrobromide solution 10 mg/5ml
1
citalopram hydrobromide tab 10 mg
1
QL
51 / 30 days
1
QL
51 / 30 days
1
QL
51 / 30 days
clomipramine hcl cap 25 mg
1
AL1
Up to 64 yrs old
PAGE 128
PRODUCT DESCRIPTION
TIER
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
clozapine tab 100 mg
1
clozapine tab 200 mg
1
clozapine tab 25 mg
1
clozapine tab 50 mg
1
CLOZAPINE TAB DISP 100 MG
clozapine
3
CLOZAPINE TAB DISP 12.5 MG
clozapine
3
CLOZAPINE TAB DISP 25 MG
clozapine
3
compro suppos 25 mg
1
duloxetine hcl
3
PA
duloxetine hcl
3
PA
duloxetine hcl
3
PA
desipramine hcl tab 10 mg
1
QL
60 / 30 days
1
QL
60 / 30 days
1
QL
60 / 30 days
1
QL
60 / 30 days
1
QL
60 / 30 days
1
QL
60 / 30 days
DESVENLAFAXINE ER TAB ER 24H 100 MG
desvenlafaxine
1
DESVENLAFAXINE ER TAB ER 24H 50 MG
desvenlafaxine
1
DESVENLAFAXINE FUMARATE ER TAB ER 24H 100 MG
desvenlafaxine fumarate
1
DESVENLAFAXINE FUMARATE ER TAB ER 24H 50 MG
desvenlafaxine fumarate
1
doxepin hcl cap 10 mg
1
AL1
Up to 64 yrs old
PAGE 129
PRODUCT DESCRIPTION
TIER
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
DOXEPIN HCL CAP 75 MG
doxepin hcl
1
AL1
Up to 64 yrs old
doxepin hcl conc 10 mg/ml
1
AL1
Up to 64 yrs old
3
QL
30 / 30 days
3
QL
30 / 30 days
3
QL
30 / 30 days
selegiline
3
ST
selegiline
3
ST
selegiline
3
ST
escitalopram oxalate solution 5 mg/5ml
1
ST
escitalopram oxalate tab 10 mg
1
QL
45 / 30 days
1
QL
30 / 30 days
1
QL
45 / 30 days
FANAPT TAB 1 MG
iloperidone
4
PA
FANAPT TAB 10 MG
iloperidone
4
PA
FANAPT TAB 12 MG
iloperidone
4
PA
FANAPT TAB 2 MG
iloperidone
4
PA
FANAPT TAB 4 MG
iloperidone
4
PA
FANAPT TAB 6 MG
iloperidone
4
PA
FANAPT TAB 8 MG
iloperidone
4
PA
PAGE 130
PRODUCT DESCRIPTION
TIER
fluoxetine hcl (pmdd) cap 10 mg
1
fluoxetine hcl (pmdd) cap 20 mg
1
fluoxetine hcl cap 10 mg
1
1
1
fluoxetine hcl cap dr 90 mg
1
fluoxetine hcl solution 20 mg/5ml
1
fluoxetine hcl tab 10 mg
1
fluoxetine hcl tab 20 mg
1
fluphenazine decanoate solution 25 mg/ml
3
FLUPHENAZINE HCL CONC 5 MG/ML
fluphenazine hcl
3
FLUPHENAZINE HCL ELIXIR 2.5 MG/5ML
fluphenazine hcl
1
FLUPHENAZINE HCL SOLUTION 2.5 MG/ML
fluphenazine hcl
3
fluphenazine hcl tab 1 mg
1
1
fluphenazine hcl tab 2.5 mg
1
1
fluvoxamine maleate tab 100 mg
1
1
1
haloperidol decanoate solution 100 mg/ml
3
haloperidol decanoate solution 50 mg/ml
3
haloperidol lactate conc 2 mg/ml
1
haloperidol lactate solution 5 mg/ml
3
haloperidol tab 0.5 mg
1
haloperidol tab 1 mg
1
1
1
1
PAGE 131
QL
4 / 28 days
PRODUCT DESCRIPTION
TIER
1
imipramine hcl tab 10 mg
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
imipramine pamoate cap 100 mg
3
AL1
Up to 64 yrs old
3
AL1
Up to 64 yrs old
3
AL1
Up to 64 yrs old
3
AL1
Up to 64 yrs old
INVEGA SUSTENNA SUSPENSION 117 MG/0.75ML
paliperidone palmitate
4
PA
INVEGA SUSTENNA SUSPENSION 156 MG/ML
4
PA
4
PA
4
PA
4
PA
INVEGA TAB ER 24H 1.5 MG
paliperidone
4
PA
INVEGA TAB ER 24H 3 MG
paliperidone
4
PA
paliperidone
4
PA
paliperidone
4
PA
LATUDA TAB 120 MG
lurasidone hcl
3
PA
LATUDA TAB 20 MG
lurasidone hcl
3
PA
LATUDA TAB 40 MG
lurasidone hcl
3
PA
LATUDA TAB 80 MG
lurasidone hcl
3
PA
loxapine succinate cap 10 mg
1
PAGE 132
PRODUCT DESCRIPTION
TIER
1
1
1
MAPROTILINE HCL TAB 25 MG
maprotiline hcl
1
maprotiline hcl
1
maprotiline hcl
1
MARPLAN TAB 10 MG
isocarboxazid
3
mirtazapine tab 15 mg
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
mirtazapine tab 7.5 mg
1
AL1
Up to 64 yrs old
mirtazapine tab disp 15 mg
3
AL1
Up to 64 yrs old
3
AL1
Up to 64 yrs old
3
AL1
Up to 64 yrs old
NEFAZODONE HCL TAB 100 MG
nefazodone hcl
1
nefazodone hcl
1
nefazodone hcl
1
nefazodone hcl tab 250 mg
1
nefazodone hcl
1
nortriptyline hcl cap 10 mg
1
1
1
1
nortriptyline hcl solution 10 mg/5ml
1
NORTRIPTYLINE HCL SOLUTION 10 MG/5ML
nortriptyline hcl
1
PAGE 133
PRODUCT DESCRIPTION
TIER
olanzapine recon soln 10 mg
3
PA
3
ST
3
ST
3
ST
3
ST
olanzapine tab 5 mg
3
ST
3
ST
3
PA
3
PA
3
PA
3
PA
olanzapine-fluoxetine hcl cap 12-25 mg
3
3
3
3
3
ORAP TAB 1 MG
pimozide
3
PA
ORAP TAB 2 MG
pimozide
3
PA
paroxetine hcl er tab er 24h 12.5 mg
3
paroxetine hcl er tab er 24h 25 mg
3
paroxetine hcl er tab er 24h 37.5 mg
3
paroxetine hcl tab 10 mg
1
1
1
1
PAXIL SUSPENSION 10 MG/5ML
paroxetine hcl
2
perphenazine tab 16 mg
1
PAGE 134
PA
PRODUCT DESCRIPTION
TIER
1
1
1
PERPHENAZINE-AMITRIPTYLINE TAB 2-10 MG
perphenazine-amitriptyline
1
1
1
1
1
phenelzine sulfate tab 15 mg
1
PRISTIQ TAB ER 24H 100 MG
desvenlafaxine succinate
3
PA
PRISTIQ TAB ER 24H 50 MG
desvenlafaxine succinate
3
PA
prochlorperazine edisylate solution 5 mg/ml
3
prochlorperazine maleate tab 10 mg
1
1
prochlorperazine suppos 25 mg
1
1
1
1
1
1
1
risperidone m-tab tab disp 0.5 mg
3
3
3
3
3
risperidone solution 1 mg/ml
3
PAGE 135
PRODUCT DESCRIPTION
TIER
1
1
1
1
1
1
3
3
3
3
3
3
SAPHRIS SL TAB 10 MG
asenapine maleate
3
ST
SAPHRIS SL TAB 5 MG
asenapine maleate
3
ST
SAVELLA TAB 100 MG
milnacipran hcl
3
PA
SAVELLA TAB 12.5 MG
milnacipran hcl
3
PA
SAVELLA TAB 25 MG
milnacipran hcl
3
PA
SAVELLA TAB 50 MG
milnacipran hcl
3
PA
selegiline hcl cap 5 mg
1
selegiline hcl tab 5 mg
1
quetiapine fumarate
3
ST
quetiapine fumarate
3
ST
quetiapine fumarate
3
ST
quetiapine fumarate
3
ST
quetiapine fumarate
3
ST
PAGE 136
PRODUCT DESCRIPTION
TIER
sertraline hcl conc 20 mg/ml
1
sertraline hcl tab 100 mg
1
1
1
thiothixene cap 1 mg
1
1
1
1
tranylcypromine sulfate tab 10 mg
1
trazodone hcl tab 100 mg
1
1
1
1
trifluoperazine hcl tab 1 mg
1
1
1
1
trimipramine maleate cap 100 mg
3
3
3
venlafaxine hcl er cap er 24h 150 mg
1
venlafaxine hcl er cap er 24h 37.5 mg
1
venlafaxine hcl er cap er 24h 75 mg
1
venlafaxine hcl er tab er 24h 150 mg
3
VENLAFAXINE HCL ER TAB ER 24H 150 MG
venlafaxine hcl
3
venlafaxine hcl
3
venlafaxine hcl er tab er 24h 37.5 mg
3
VENLAFAXINE HCL ER TAB ER 24H 37.5 MG
venlafaxine hcl
3
venlafaxine hcl er tab er 24h 75 mg
3
PAGE 137
PA
PRODUCT DESCRIPTION
TIER
venlafaxine hcl
3
venlafaxine hcl tab 100 mg
1
1
venlafaxine hcl tab 37.5 mg
1
1
1
VIIBRYD KIT 10 & 20 & 40 MG
vilazodone hcl
3
PA
VIIBRYD TAB 10 MG
vilazodone hcl
3
PA
VIIBRYD TAB 20 MG
vilazodone hcl
3
PA
VIIBRYD TAB 40 MG
vilazodone hcl
3
PA
3
ST
3
ST
3
ST
3
ST
Electrolytic, Caloric, and Water Balance
Diuretics
1
acetazolamide
1
1
amiloride hcl tab 5 mg
1
amiloride-hydrochlorothiazide tab 5-50 mg
1
1
1
1
1
benazepril-hydrochlorothiazide tab 20-25 mg
1
1
PAGE 138
PRODUCT DESCRIPTION
TIER
3
ST
3
ST
BENICAR HCT TAB 40-25 MG
3
ST
1
bisoprolol-hydrochlorothiazide tab 2.5-6.25 mg
1
1
bumetanide solution 0.25 mg/ml
1
bumetanide tab 0.5 mg
1
bumetanide tab 1 mg
1
bumetanide tab 2 mg
1
1
1
candesartan cilexetil-hctz tab 32-25 mg
1
1
1
1
1
1
CHLOROTHIAZIDE TAB 250 MG
chlorothiazide
1
1
chlorthalidone
1
chlorthalidone
1
DYRENIUM CAP 100 MG
triamterene
3
EDECRIN TAB 25 MG
ethacrynic acid
3
PAGE 139
PRODUCT DESCRIPTION
TIER
theophylline
2
enalapril-hydrochlorothiazide tab 10-25 mg
1
enalapril-hydrochlorothiazide tab 5-12.5 mg
1
3
3
1
1
1
1
FUROSEMIDE SOLUTION 8 MG/ML
furosemide
1
1
1
1
hydrochlorothiazide cap 12.5 mg
1
hydrochlorothiazide tab 12.5 mg
1
1
1
1
1
1
1
1
1
lisinopril-hydrochlorothiazide tab 20-25 mg
1
1
QL
30 / 30 days
losartan potassium-hctz tab 100-25 mg
1
QL
30 / 30 days
1
QL
30 / 30 days
METHYCLOTHIAZIDE TAB 5 MG
methyclothiazide
1
metolazone tab 10 mg
1
PAGE 140
PRODUCT DESCRIPTION
TIER
metolazone tab 2.5 mg
1
metolazone tab 5 mg
1
1
1
1
3
ST
3
ST
MICARDIS HCT TAB 80-25 MG
3
ST
moexipril-hydrochlorothiazide tab 15-12.5 mg
1
moexipril-hydrochlorothiazide tab 15-25 mg
1
moexipril-hydrochlorothiazide tab 7.5-12.5 mg
1
1
1
1
1
1
1
quinapril-hydrochlorothiazide tab 20-25 mg
1
SAMSCA TAB 15 MG
tolvaptan
4
PA
SAMSCA TAB 30 MG
tolvaptan
4
PA
1
1
1
spironolactone-hctz tab 25-25 mg
1
3
3
PAGE 141
PRODUCT DESCRIPTION
TIER
3
3
1
1
1
1
1
1
1
1
1
1
torsemide tab 10 mg
1
torsemide tab 100 mg
1
torsemide tab 20 mg
1
torsemide tab 5 mg
1
triamterene-hctz cap 37.5-25 mg
1
triamterene-hctz tab 37.5-25 mg
1
triamterene-hctz tab 75-50 mg
1
1
1
1
1
1
acetic acid solution 0.25 %
1
aminoacetic acid solution 1.5 %
1
argyle sterile saline solution 0.9 %
1
AVORIA CAL+D PACKET 500-40-60-400
calcium-magnesium-vitamin c-vitamin d
5
AVORIA GC+ PACKET
glucosamine-chondroitin-calcium-magnesium-vit c-vit d
5
PAGE 142
PRODUCT DESCRIPTION
TIER
BP FOLINATAL PLUS B TAB 1 MG
prenatal w/ calcium carbonate-vit b6-vit b12-folic acid
1
calcium acetate (phos binder) tab 667 mg
1
calcium acetate cap 667 mg
1
citric acid-sodium citrate solution 334-500 mg/5ml
1
colchicine-probenecid tab 0.5-500 mg
1
constulose solution 10 gm/15ml
1
curity sterile saline solution 0.9 %
1
cytra-2 solution 500-334 mg/5ml
1
CYTRA-3 SYRUP 550-500-334 MG/5ML
pot & sod citrates w/citric ac
1
EFFER-K EFFER TAB 10 MEQ
potassium bicarbonate-citric acid
3
EFFER-K EFFER TAB 20 MEQ
potassium bicarbonate-citric acid
3
effer-k effer tab 25 meq
1
effervescent pot chloride effer tab 25 meq
1
enulose solution 10 gm/15ml
1
generlac solution 10 gm/15ml
1
glycine solution 1.5 %
1
glycine urologic solution 1.5 %
1
k-effervescent effer tab 25 meq
1
k-sol solution 20 meq/15ml (10%)
1
k-sol solution 40 meq/15ml (20%)
1
k-vescent effer tab 25 meq
1
k-vescent packet 20 meq
1
klor-con 10 tab er 10 meq
1
KLOR-CON M15 TAB ER 15 MEQ
potassium chloride microencapsulated crystals cr
3
klor-con m20 tab er 20 meq
1
klor-con packet 20 meq
1
klor-con tab er 8 meq
1
klor-con/ef effer tab 25 meq
1
PAGE 143
PA
PRODUCT DESCRIPTION
TIER
KRISTALOSE PACKET 10 GM
lactulose
3
PA
KRISTALOSE PACKET 20 GM
lactulose
3
PA
lactulose encephalopathy solution 10 gm/15ml
1
lactulose solution 10 gm/15ml
1
n-acetyl-l-cysteine cap 600 mg
1
nac 600 cap 600 mg
1
nac cap 600 mg
1
nf formulas nac cap 600 mg
1
normal saline flush solution 0.9 %
3
one daily mens tab
1
one daily womens tab
1
PHOSLYRA SOLUTION 667 MG/5ML
calcium acetate (phosphate binder)
3
phospha 250 neutral tab 155-852-130 mg
1
potassium bicarbonate effer tab 25 meq
1
potassium chloride crys er tab er 10 meq
1
potassium chloride crys er tab er 20 meq
1
potassium chloride er cap er 10 meq
1
potassium chloride er cap er 8 meq
1
potassium chloride er tab er 10 meq
1
potassium chloride er tab er 8 meq
1
POTASSIUM CHLORIDE ER TAB ER 8 MEQ
potassium chloride
1
potassium chloride liquid 20 meq/15ml (10%)
1
potassium chloride liquid 40 meq/15ml (20%)
1
potassium chloride packet 20 meq
1
potassium chloride solution 20 meq/15ml (10%)
1
potassium citrate er tab er 10 meq (1080 mg)
1
3
1
potassium citrate-citric acid solution 1100-334 mg/5ml
1
PAGE 144
PRODUCT DESCRIPTION
TIER
5
probenecid tab 500 mg
1
RX SUPPORT HB/REFLUX/ALOE TAB
folic acid-cyanocobalamin-vit b6-vit d-calcium-aloe
5
sodium chloride flush solution 0.9 %
1
sodium chloride solution 0.9 %
1
1
1
SORBITOL SOLUTION 3 %
sorbitol irrigation
1
SORBITOL SOLUTION 3.3 %
sorbitol irrigation
1
SORBITOL-MANNITOL SOLUTION 2.7-0.54 GM/100ML
sorbitol-mannitol
1
UROCIT-K 10 TAB ER 10 MEQ (1080 MG)
potassium citrate (alkalinizer)
2
3
2
zinc sulfate cap 220 mg
1
Ion-removing Agents
calcium acetate (phos binder) tab 667 mg
1
calcium acetate cap 667 mg
1
FOSRENOL CHEW TAB 1000 MG
lanthanum carbonate
3
PA
lanthanum carbonate
3
PA
lanthanum carbonate
3
PA
kionex suspension 15 gm/60ml
1
PHOSLYRA SOLUTION 667 MG/5ML
calcium acetate (phosphate binder)
3
RENAGEL TAB 400 MG
sevelamer hcl
3
PAGE 145
PA
PRODUCT DESCRIPTION
TIER
RENAGEL TAB 800 MG
sevelamer hcl
3
PA
RENVELA PACKET 0.8 GM
sevelamer carbonate
3
PA
sevelamer carbonate
3
PA
RENVELA TAB 800 MG
sevelamer carbonate
3
PA
sodium polystyrene sulfonate suspension 15 gm/60ml
1
1
1
Eye, Ear, Nose & Throat Preparations
Anti-infectives
ak-poly-bac ointment 500-10000 unit/gm
1
AZASITE SOLUTION 1 %
azithromycin (ophth)
3
bacitra-neomycin-polymyxin-hc ointment 1 %
1
BACITRACIN OINTMENT 500 UNIT/GM
bacitracin (ophthalmic)
1
BESIVANCE SUSPENSION 0.6 %
besifloxacin hcl
3
BLEPHAMIDE S.O.P. OINTMENT 10-0.2 %
sulfacetamide sod-prednisolone
2
chlorhexidine gluconate solution 0.12 %
1
CILOXAN OINTMENT 0.3 %
ciprofloxacin hcl (ophth)
3
CIPRO HC SUSPENSION 0.2-1 %
ciprofloxacin-hydrocortisone
3
CIPRODEX SUSPENSION 0.3-0.1 %
ciprofloxacin-dexamethasone
3
CIPROFLOXACIN HCL SOLUTION 0.2 %
ciprofloxacin hcl (otic)
1
ciprofloxacin hcl solution 0.3 %
1
COLY-MYCIN S SUSPENSION 3.3-3-10-0.5 MG/ML
neomycin-colistin-hc-thonzonium
3
CORTISPORIN-TC SUSPENSION 3.3-3-10-0.5 MG/ML
3
PAGE 146
PA
PA
PRODUCT DESCRIPTION
TIER
erythromycin ointment 5 mg/gm
1
gatifloxacin solution 0.5 %
3
gentak ointment 0.3 %
1
gentamicin sulfate ointment 0.3 %
1
gentamicin sulfate solution 0.3 %
1
levofloxacin solution 0.5 %
1
MOXEZA SOLUTION 0.5 %
moxifloxacin hcl (ophth)
3
NATACYN SUSPENSION 5 %
natamycin
3
neo-polycin hc ointment 1 %
1
neo-polycin ointment 3.5-400-10000
1
neomycin-bacitracin zn-polymyx ointment 5-400-10000
1
neomycin-polymyxin-dexameth ointment 3.5-10000-0.1
1
neomycin-polymyxin-dexameth suspension 3.5-10000-0.1
1
neomycin-polymyxin-gramicidin solution 1.75-10000-.025
1
neomycin-polymyxin-hc solution 1 %
1
neomycin-polymyxin-hc solution 3.5-10000-1
1
NEOMYCIN-POLYMYXIN-HC SUSPENSION 3.5-10000-1
neomycin-polymyxin-hc (ophth)
1
neomycin-polymyxin-hc suspension 3.5-10000-1
1
ofloxacin solution 0.3 %
1
ofloxacin solution 0.3 %
1
periogard solution 0.12 %
1
polymyxin b-trimethoprim solution 10000-0.1 unit/ml-%
1
romycin ointment 5 mg/gm
1
SILVER NITRATE OINTMENT 10 %
silver nitrate
1
SILVER NITRATE SOLUTION 0.5 %
silver nitrate
1
SILVER NITRATE SOLUTION 10 %
silver nitrate
1
silver nitrate
1
PAGE 147
PA
PA
PRODUCT DESCRIPTION
TIER
silver nitrate
1
sulfacetamide sodium solution 10 %
1
sulfacetamide-prednisolone solution 10-0.23 %
1
TOBRADEX OINTMENT 0.3-0.1 %
tobramycin-dexamethasone
3
QL
3.5 / 10 days
TOBRADEX ST SUSPENSION 0.3-0.05 %
2
QL
1 / 10 days
tobramycin solution 0.3 %
1
tobramycin-dexamethasone suspension 0.3-0.1 %
1
QL
5 / 10 days
TOBREX OINTMENT 0.3 %
tobramycin (ophth)
2
trifluridine solution 1 %
3
VIGAMOX SOLUTION 0.5 %
moxifloxacin hcl (ophth)
3
ZIRGAN GEL 0.15 %
ganciclovir ophthalmic
3
ZYMAXID SOLUTION 0.5 %
gatifloxacin (ophth)
3
Anti-inflammatory Agents
acetasol hc solution 2-1 %
3
ACUVAIL SOLUTION 0.45 %
ketorolac tromethamine (ophth)
3
antipyrine-benzocaine solution 5.4-1.4 %
1
antipyrine-benzocaine solution 54-14 mg/ml
1
bacitra-neomycin-polymyxin-hc ointment 1 %
1
BECONASE AQ SUSPENSION 42 MCG/SPRAY
beclomethasone diprop monohyd
3
BLEPHAMIDE S.O.P. OINTMENT 10-0.2 %
sulfacetamide sod-prednisolone
2
bromfenac sodium (once-daily) solution 0.09 %
3
bromfenac sodium solution 0.09 %
3
CIPRO HC SUSPENSION 0.2-1 %
ciprofloxacin-hydrocortisone
3
CIPRODEX SUSPENSION 0.3-0.1 %
ciprofloxacin-dexamethasone
3
PAGE 148
ST
PA
PRODUCT DESCRIPTION
TIER
COLY-MYCIN S SUSPENSION 3.3-3-10-0.5 MG/ML
3
CORTISPORIN-TC SUSPENSION 3.3-3-10-0.5 MG/ML
3
dexamethasone sodium phosphate solution 0.1 %
1
diclofenac sodium solution 0.1 %
1
DUREZOL EMULSION 0.05 %
difluprednate
3
FLAREX SUSPENSION 0.1 %
fluorometholone acetate
3
flunisolide solution 25 mcg/act (0.025%)
1
fluocinolone acetonide oil 0.01 %
3
fluorometholone suspension 0.1 %
1
flurbiprofen sodium solution 0.03 %
1
fluticasone propionate suspension 50 mcg/act
1
FML OINTMENT 0.1 %
fluorometholone (ophth)
2
hydrocortisone-acetic acid solution 1-2 %
3
ketorolac tromethamine solution 0.4 %
1
ketorolac tromethamine solution 0.5 %
1
LOTEMAX OINTMENT 0.5 %
loteprednol etabonate
3
LOTEMAX SUSPENSION 0.5 %
loteprednol etabonate
3
NASACORT ALLERGY 24HR AEROSOL 55 MCG/ACT
triamcinolone acetonide (nasal)
1
NASONEX SUSPENSION 50 MCG/ACT
mometasone furoate (nasal)
3
neo-polycin hc ointment 1 %
1
neomycin-polymyxin-dexameth ointment 3.5-10000-0.1
1
neomycin-polymyxin-dexameth suspension 3.5-10000-0.1
1
neomycin-polymyxin-hc solution 1 %
1
neomycin-polymyxin-hc solution 3.5-10000-1
1
NEOMYCIN-POLYMYXIN-HC SUSPENSION 3.5-10000-1
neomycin-polymyxin-hc (ophth)
1
PAGE 149
QL
50 / 25 days
QL
16 / 25 days
ST
PRODUCT DESCRIPTION
TIER
neomycin-polymyxin-hc suspension 3.5-10000-1
1
NEVANAC SUSPENSION 0.1 %
nepafenac
3
PRED MILD SUSPENSION 0.12 %
prednisolone acetate (ophth)
2
prednisolone acetate suspension 1 %
1
PREDNISOLONE SODIUM PHOSPHATE SOLUTION 1 %
prednisolone sodium phosphate (ophth)
1
QNASL AERO SOLN 80 MCG/ACT
beclomethasone dipropionate (nasal)
3
ST
RHINOCORT AQUA SUSPENSION 32 MCG/ACT
budesonide (nasal)
3
ST
sulfacetamide-prednisolone solution 10-0.23 %
1
TOBRADEX OINTMENT 0.3-0.1 %
3
QL
3.5 / 10 days
TOBRADEX ST SUSPENSION 0.3-0.05 %
2
QL
1 / 10 days
tobramycin-dexamethasone suspension 0.3-0.1 %
1
QL
5 / 10 days
VERAMYST SUSPENSION 27.5 MCG/SPRAY
fluticasone furoate
3
ST
VEXOL SUSPENSION 1 %
rimexolone
3
PA
Antiglaucoma Agents
1
acetazolamide
1
1
ALPHAGAN P SOLUTION 0.1 %
brimonidine tartrate
3
betaxolol hcl solution 0.5 %
1
BETOPTIC-S SUSPENSION 0.25 %
betaxolol hcl (ophth)
2
brimonidine tartrate solution 0.15 %
3
brimonidine tartrate solution 0.2 %
1
carteolol hcl solution 1 %
1
COMBIGAN SOLUTION 0.2-0.5 %
brimonidine tartrate-timolol maleate
3
PAGE 150
PA
PRODUCT DESCRIPTION
TIER
dorzolamide hcl solution 2 %
1
dorzolamide hcl-timolol mal solution 22.3-6.8 mg/ml
3
ISOPTO CARBACHOL SOLUTION 3 %
carbachol (ophth)
2
latanoprost solution 0.005 %
1
LEVOBUNOLOL HCL SOLUTION 0.25 %
levobunolol hcl
1
levobunolol hcl solution 0.5 %
1
LUMIGAN SOLUTION 0.01 %
bimatoprost
3
metipranolol solution 0.3 %
1
METIPRANOLOL SOLUTION 0.3 %
metipranolol
1
PHOSPHOLINE IODIDE RECON SOLN 0.125 %
echothiophate iodide
2
pilocarpine hcl solution 1 %
1
1
1
timolol maleate gel f soln 0.25 %
3
timolol maleate gel f soln 0.5 %
3
timolol maleate solution 0.25 %
1
timolol maleate solution 0.5 %
1
TRAVATAN Z SOLUTION 0.004 %
travoprost
3
ST
ZIOPTAN SOLUTION 0.0015 %
tafluprost
3
ST
acetasol hc solution 2-1 %
3
acetic acid solution 2 %
1
ALOCRIL SOLUTION 2 %
nedocromil sodium (ophth)
3
PA
ALOMIDE SOLUTION 0.1 %
lodoxamide tromethamine
3
PA
altacaine solution 0.5 %
1
antipyrine-benzocaine solution 5.4-1.4 %
1
antipyrine-benzocaine solution 54-14 mg/ml
1
PAGE 151
QL
5 / 23 days
ST
PA
PRODUCT DESCRIPTION
TIER
apraclonidine hcl solution 0.5 %
3
artificial tears solution 0.1-0.3 %
5
QL
ASTEPRO SOLUTION 0.15 %
azelastine hcl
3
ST
ATROPINE SULFATE OINTMENT 1 %
atropine sulfate (ophthalmic)
1
atropine sulfate solution 1 %
1
azelastine hcl solution 0.05 %
3
3
ST
azelastine hcl solution 137 mcg/spray
1
ST
balanced salt solution
1
BEPREVE SOLUTION 1.5 %
bepotastine besilate
3
bss solution
1
cromolyn sodium conc 100 mg/5ml
1
cromolyn sodium solution 4 %
1
cyclopentolate hcl solution 1 %
1
cyclopentolate hcl solution 2 %
1
CYSTARAN SOLUTION 0.44 %
cysteamine hcl
4
epinastine hcl solution 0.05 %
3
eye wash solution
1
homatropaire solution 5 %
1
homatropine hbr solution 5 %
1
hydrocortisone-acetic acid solution 1-2 %
3
IOPIDINE SOLUTION 1 %
apraclonidine hcl
3
LACRISERT INSERT 5 MG
artificial tear insert
3
PA
LASTACAFT SOLUTION 0.25 %
alcaftadine
3
PA
lidocaine hcl solution 4 %
1
QL
100 / 23 days
lidocaine viscous solution 2 %
1
QL
100 / 23 days
PAGE 152
30 / 30 days
PA
QL
50 / 30 days
PRODUCT DESCRIPTION
TIER
NAPHAZOLINE HCL SOLUTION 0.1 %
naphazoline hcl
1
olopatadine hcl solution 0.6 %
3
parcaine solution 0.5 %
1
PATADAY SOLUTION 0.2 %
olopatadine hcl
3
PA
PATANOL SOLUTION 0.1 %
olopatadine hcl
3
PA
proparacaine hcl solution 0.5 %
1
redness reliever eye drops solution 0.05 %
5
tetracaine hcl solution 0.5 %
1
tropicamide solution 0.5 %
1
tropicamide solution 1 %
1
ST
QL
30 / 30 days
Gastrointestinal Drugs
Antiemetics
ANZEMET TAB 100 MG
dolasetron mesylate
3
ST
ANZEMET TAB 50 MG
dolasetron mesylate
3
ST
CESAMET CAP 1 MG
nabilone
3
PA
compro suppos 25 mg
1
DIMENHYDRINATE SOLUTION 50 MG/ML
dimenhydrinate
3
dronabinol cap 10 mg
4
PA
dronabinol cap 2.5 mg
3
PA
dronabinol cap 5 mg
3
PA
granisetron hcl tab 1 mg
3
QL
10 / 23 days
meclizine hcl tab 12.5 mg
1
meclizine hcl tab 25 mg
1
ondansetron hcl solution 4 mg/5ml
1
ondansetron hcl tab 24 mg
1
QL
5 / 23 days
1
QL
15 / 23 days
PAGE 153
PRODUCT DESCRIPTION
TIER
1
QL
15 / 23 days
ondansetron tab disp 4 mg
1
QL
10 / 23 days
ondansetron tab disp 8 mg
1
QL
10 / 23 days
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
prochlorperazine edisylate solution 5 mg/ml
3
1
1
prochlorperazine suppos 25 mg
1
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
trimethobenzamide hcl cap 300 mg
1
acid control maximum strength tab 20 mg
1
acid controller max st tab 20 mg
1
acid reducer maximum strength tab 20 mg
1
acid relief tab 200 mg
1
PAGE 154
PRODUCT DESCRIPTION
TIER
AMITIZA CAP 24 MCG
lubiprostone
3
PA
AMITIZA CAP 8 MCG
lubiprostone
3
PA
1
1
amoxicillin
1
amoxicillin
1
1
1
1
1
1
1
anti-diarrheal cap 2 mg
1
anti-diarrheal liquid 1 mg/5ml
1
anti-diarrheal tab 2 mg
1
APRISO CAP ER 24H 0.375 GM
mesalamine
3
ASACOL HD TAB DR 800 MG
mesalamine
3
balsalazide disodium cap 750 mg
1
BIOGAIA CHEW TAB
lactobacillus reuteri
5
BIOGAIA PROBIOTIC MISC
lactobacillus reuteri
5
BIOGAIA PROTECTIS/VITAMIN D LIQUID
lactobacillus reuteri-vitamin d
5
CANASA SUPPOS 1000 MG
mesalamine
4
CARAFATE SUSPENSION 1 GM/10ML
sucralfate
3
cimetidine 200 tab 200 mg
1
cimetidine acid reducer tab 200 mg
1
PAGE 155
ST
PA
PRODUCT DESCRIPTION
TIER
cimetidine hcl solution 300 mg/5ml
1
cimetidine tab 200 mg
1
1
1
1
1
1
1
1
1
COLYTE WITH FLAVOR PACKS RECON SOLN 227.1 GM
peg 3350-kcl-sod bicarb-sod chloride-sod sulfate
3
CREON CP DR PART 12000 UNIT
pancrelipase (lipase-protease-amylase)
2
2
CREON CP DR PART 3000-9500 UNIT
2
2
cvs acid controller max st tab 20 mg
1
cvs anti-diarrheal cap 2 mg
1
cvs anti-diarrheal tab 2 mg
1
cvs heartburn relief tab 200 mg
1
cvs lansoprazole cap dr 15 mg
3
DELZICOL CAP DR 400 MG
mesalamine
2
diamode tab 2 mg
1
3
3
DIPENTUM CAP 250 MG
olsalazine sodium
3
DIPHENOXYLATE-ATROPINE LIQUID 2.5-0.025 MG/5ML
diphenoxylate w/ atropine
1
PAGE 156
QL
60 / 30 days
PA
PRODUCT DESCRIPTION
TIER
diphenoxylate-atropine tab 2.5-0.025 mg
1
eq acid reducer max st tab 20 mg
1
eq acid reducer tab 200 mg
1
eq anti-diarrheal cap 2 mg
1
eq anti-diarrheal liquid 1 mg/5ml
1
eq anti-diarrheal tab 2 mg
1
eq heartburn relief tab 200 mg
1
eq lansoprazole cap dr 15 mg
3
eql acid reducer tab 200 mg
1
eql anti-diarrheal liquid 1 mg/5ml
1
eql anti-diarrheal tab 2 mg
1
eql heartburn prevention tab 20 mg
1
famotidine recon susp 40 mg/5ml
1
famotidine tab 20 mg
1
1
1
FIRST-LANSOPRAZOLE SUSPENSION 3 MG/ML
lansoprazole
QL
60 / 30 days
3
QL
150 / 30 days
FLAGYL ER TAB ER 24H 750 MG
metronidazole
3
ST
gavilyte-c recon soln 240 gm
1
gavilyte-g recon soln 236 gm
1
gavilyte-n with flavor pack recon soln 420 gm
1
gnp acid reducer max st tab 20 mg
1
gnp anti-diarrheal cap 2 mg
1
gnp anti-diarrheal tab 2 mg
1
gnp heartburn relief tab 200 mg
1
gnp lansoprazole cap dr 15 mg
3
QL
60 / 30 days
heartburn relief 24 hour cap dr 15 mg
3
QL
60 / 30 days
heartburn relief max st tab 20 mg
1
heartburn relief tab 200 mg
1
PAGE 157
PRODUCT DESCRIPTION
TIER
heartburn treatment 24 hour cap dr 15 mg
3
hm anti-diarrheal tab 2 mg
1
hm famotidine tab 20 mg
1
hm lansoprazole cap dr 15 mg
3
hm loperamide hcl cap 2 mg
1
HUMIRA PEDIATRIC CROHNS START PREF SY KT 40
MG/0.8ML
adalimumab
4
PA
HUMIRA PEN-CROHNS STARTER PEN KIT 40 MG/0.8ML
adalimumab
4
PA
HUMIRA PREF SY KT 20 MG/0.4ML
adalimumab
4
PA
adalimumab
4
PA
kls acid controller max st tab 20 mg
1
kls anti-diarrheal tab 2 mg
1
kls lansoprazole cap dr 15 mg
3
QL
60 / 30 days
lansoprazole cap dr 15 mg
3
QL
60 / 30 days
lansoprazole cap dr 30 mg
3
QL
30 / 30 days
LINZESS CAP 145 MCG
linaclotide
3
PA
LINZESS CAP 290 MCG
linaclotide
3
PA
lonox tab 2.5-0.025 mg
1
loperamide hcl cap 2 mg
1
loperamide hcl liquid 1 mg/5ml
1
meijer anti-diarrheal tab 2 mg
1
mesalamine enema 4 gm
1
metoclopramide hcl solution 10 mg/10ml
1
metoclopramide hcl solution 5 mg/5ml
1
metoclopramide hcl tab 10 mg
1
metoclopramide hcl tab 5 mg
1
metronidazole cap 375 mg
1
PAGE 158
QL
60 / 30 days
QL
60 / 30 days
PRODUCT DESCRIPTION
TIER
1
1
misoprostol tab 100 mcg
1
misoprostol tab 200 mcg
1
NEXIUM 24HR CAP DR 20 MG
esomeprazole magnesium
1
nizatidine cap 150 mg
1
1
nizatidine solution 15 mg/ml
1
octreotide acetate solution 100 mcg/ml
4
PA
octreotide acetate solution 1000 mcg/5ml
4
PA
4
PA
4
PA
4
PA
4
PA
omeprazole cap dr 10 mg
1
QL
60 / 30 days
1
QL
60 / 30 days
1
QL
60 / 30 days
QL
omeprazole-sodium bicarbonate cap 20-1100 mg
30 / 30 days
3
QL
60 / 30 days
PA
QL
omeprazole-sodium bicarbonate cap 40-1100 mg
30 / 30 days
3
PA
OSMOPREP TAB 1.102-0.398 GM
sodium phosphate monobasic-sodium phosphate dibasic
3
pantoprazole sodium tab dr 20 mg
1
QL
60 / 30 days
pantoprazole sodium tab dr 40 mg
1
QL
60 / 30 days
peg 3350-kcl-na bicarb-nacl recon soln 420 gm
1
peg 3350/electrolytes recon soln 240 gm
1
peg-3350/electrolytes recon soln 236 gm
1
PENTASA CAP ER 250 MG
mesalamine
3
PAGE 159
ST
PRODUCT DESCRIPTION
TIER
PENTASA CAP ER 500 MG
mesalamine
3
1
polyethylene glycol 3350 packet
1
polyethylene glycol 3350 powder
1
POLYETHYLENE GLYCOL 3350 POWDER
polyethylene glycol 3350 (bulk)
1
PRENATAL 19 TAB
1
1
PREPOPIK PACKET 10-3.5-12 MG-GM-GM
sodium picosulfate-magnesium oxide-anhydrous citric acid
3
px acid reducer max st tab 20 mg
1
qc acid controller max st tab 20 mg
1
qc anti-diarrheal tab 2 mg
1
ra acid reducer max st tab 20 mg
1
ra acid reducer tab 200 mg
1
ra anti-diarrheal cap 2 mg
1
ra anti-diarrheal liquid 1 mg/5ml
1
ra anti-diarrheal tab 2 mg
1
ra lansoprazole cap dr 15 mg
3
ra omeprazole-sodium bicarb cap 20-1100 mg
3
ST
PA
QL
60 / 30 days
QL
30 / 30 days
PA
ranitidine hcl cap 150 mg
3
3
ranitidine hcl syrup 15 mg/ml
1
ranitidine hcl syrup 150 mg/10ml
1
1
ranitidine hcl tab 150 mg
1
1
SANDOSTATIN LAR DEPOT KIT 10 MG
octreotide acetate
4
PAGE 160
PA
PRODUCT DESCRIPTION
TIER
octreotide acetate
4
PA
octreotide acetate
4
PA
sb acid controller max st tab 20 mg
1
sb anti-diarrhea tab 2 mg
1
1
sm acid reducer max st tab 20 mg
1
sm acid reducer tab 200 mg
1
sm anti-diarrheal cap 2 mg
1
sm anti-diarrheal liquid 1 mg/5ml
1
sm anti-diarrheal tab 2 mg
1
sm lansoprazole cap dr 15 mg
3
sucralfate tab 1 gm
1
1
1
1
1
SUPREP BOWEL PREP SOLUTION
sodium sulfate-potassium sulfate-magnesium sulfate
3
1
1
tetracycline hcl
1
1
tetracycline hcl
1
tgt acid reducer tab 200 mg
1
tgt anti-diarrheal tab 2 mg
1
tgt loperamide hcl cap 2 mg
1
th anti-diarrheal tab 2 mg
1
trilyte recon soln 420 gm
1
PAGE 161
QL
60 / 30 days
PRODUCT DESCRIPTION
TIER
ursodiol cap 300 mg
1
ursodiol tab 250 mg
3
ursodiol tab 500 mg
3
ZENPEP CP DR PART 25000 UNIT
2
Hormones and Synthetic Substitutes
Antidiabetic Agents
acarbose tab 100 mg
1
acarbose tab 25 mg
1
acarbose tab 50 mg
1
APIDRA SOLOSTAR SOLN PEN 100 UNIT/ML
insulin glulisine
3
APIDRA SOLUTION 100 UNIT/ML
insulin glulisine
2
AVANDIA TAB 2 MG
rosiglitazone maleate
3
BYDUREON RECON SUSP 2 MG
exenatide
3
BYETTA 10 MCG PEN SOLN PEN 10 MCG/0.04ML
exenatide
3
BYETTA 5 MCG PEN SOLN PEN 5 MCG/0.02ML
exenatide
3
CHLORPROPAMIDE TAB 100 MG
chlorpropamide
1
CHLORPROPAMIDE TAB 250 MG
chlorpropamide
1
CYCLOSET TAB 0.8 MG
bromocriptine mesylate (diabetes)
3
glimepiride tab 1 mg
1
1
1
glipizide er tab er 24h 10 mg
1
QL
60 / 30 days
glipizide er tab er 24h 2.5 mg
1
QL
60 / 30 days
PAGE 162
PA
QL
4 / 30 days
PA
QL
2.4 / 30 days
PA
QL
1.2 / 30 days
PA
PRODUCT DESCRIPTION
TIER
glipizide er tab er 24h 5 mg
1
glipizide tab 10 mg
1
glipizide tab 5 mg
1
glipizide xl tab er 24h 10 mg
QL
60 / 30 days
1
QL
60 / 30 days
glipizide xl tab er 24h 2.5 mg
1
QL
60 / 30 days
glipizide xl tab er 24h 5 mg
1
QL
60 / 30 days
glipizide-metformin hcl tab 2.5-250 mg
1
glipizide-metformin hcl tab 2.5-500 mg
1
glipizide-metformin hcl tab 5-500 mg
1
GLUMETZA TAB ER 24H 500 MG
metformin hcl
3
glyburide micronized tab 1.5 mg
1
glyburide micronized tab 3 mg
1
glyburide micronized tab 6 mg
1
glyburide tab 1.25 mg
1
GLYBURIDE TAB 1.25 MG
glyburide
1
glyburide tab 2.5 mg
1
GLYBURIDE TAB 2.5 MG
glyburide
1
glyburide tab 5 mg
1
GLYBURIDE TAB 5 MG
glyburide
1
glyburide-metformin tab 1.25-250 mg
1
glyburide-metformin tab 2.5-500 mg
1
glyburide-metformin tab 5-500 mg
1
GLYSET TAB 25 MG
miglitol
3
HUMALOG MIX 50/50 KWIKPEN SUSP PEN (50-50) 100
UNIT/ML
insulin lispro protamine & lispro (human)
3
HUMALOG MIX 50/50 SUSPENSION (50-50) 100 UNIT/ML
3
HUMALOG MIX 75/25 KWIKPEN SUSP PEN (75-25) 100
UNIT/ML
3
PAGE 163
PA
PA
PRODUCT DESCRIPTION
TIER
HUMALOG MIX 75/25 SUSPENSION (75-25) 100 UNIT/ML
3
ST
HUMALOG SOLN CART 100 UNIT/ML
insulin lispro (human)
3
ST
HUMALOG SOLUTION 100 UNIT/ML
insulin lispro (human)
3
ST
HUMULIN N SUSPENSION 100 UNIT/ML
insulin isophane (human)
3
ST
HUMULIN R SOLUTION 100 UNIT/ML
insulin regular (human)
3
ST
HUMULIN R U-500 (CONCENTRATED) SOLUTION 500
UNIT/ML
4
PA
JANUMET XR TAB ER 24H 100-1000 MG
sitagliptin-metformin hcl
3
QL
30 / 30 days
3
QL
30 / 30 days
3
QL
30 / 30 days
JANUVIA TAB 100 MG
sitagliptin phosphate
3
QL
30 / 30 days
JANUVIA TAB 25 MG
3
QL
30 / 30 days
JANUVIA TAB 50 MG
3
QL
30 / 30 days
JENTADUETO TAB 2.5-1000 MG
linagliptin-metformin hcl
QL
60 / 30 days
3
3
3
LANTUS SOLOSTAR SOLN PEN 100 UNIT/ML
insulin glargine
3
LANTUS SOLUTION 100 UNIT/ML
insulin glargine
2
LEVEMIR FLEXPEN SOLN PEN 100 UNIT/ML
insulin detemir
3
PAGE 164
PA
QL
60 / 30 days
PA
QL
60 / 30 days
PA
PRODUCT DESCRIPTION
TIER
LEVEMIR FLEXTOUCH SOLN PEN 100 UNIT/ML
insulin detemir
3
LEVEMIR SOLUTION 100 UNIT/ML
insulin detemir
2
metformin hcl er (osm) tab er 24h 1000 mg
1
metformin hcl er (osm) tab er 24h 500 mg
1
metformin hcl er tab er 24h 500 mg
1
metformin hcl er tab er 24h 750 mg
1
metformin hcl tab 1000 mg
1
1
1
nateglinide tab 120 mg
1
nateglinide tab 60 mg
1
NOVOLIN 70/30 RELION SUSPENSION (70-30) 100 UNIT/ML
insulin isophane & reg (human)
2
NOVOLIN 70/30 SUSPENSION (70-30) 100 UNIT/ML
insulin isophane & reg (human)
2
NOVOLIN N RELION SUSPENSION 100 UNIT/ML
2
NOVOLIN N SUSPENSION 100 UNIT/ML
2
NOVOLIN R RELION SOLUTION 100 UNIT/ML
2
NOVOLIN R SOLUTION 100 UNIT/ML
2
NOVOLOG MIX 70/30 FLEXPEN SUSP PEN (70-30) 100
UNIT/ML
insulin aspart protamine & aspart (human)
3
NOVOLOG MIX 70/30 SUSPENSION (70-30) 100 UNIT/ML
insulin aspart protamine & aspart (human)
3
NOVOLOG PENFILL SOLN CART 100 UNIT/ML
insulin aspart
3
NOVOLOG SOLUTION 100 UNIT/ML
insulin aspart
3
ONGLYZA TAB 2.5 MG
saxagliptin hcl
3
PAGE 165
PA
QL
30 / 30 days
ST
PRODUCT DESCRIPTION
TIER
QL
30 / 30 days
ONGLYZA TAB 5 MG
saxagliptin hcl
3
pioglitazone hcl tab 15 mg
3
QL
30 / 30 days
3
QL
30 / 30 days
3
QL
30 / 30 days
pioglitazone hcl-glimepiride tab 30-2 mg
3
pioglitazone hcl-glimepiride tab 30-4 mg
3
pioglitazone hcl-metformin hcl tab 15-500 mg
3
pioglitazone hcl-metformin hcl tab 15-850 mg
3
PRANDIN TAB 0.5 MG
repaglinide
2
PRANDIN TAB 1 MG
repaglinide
2
PRANDIN TAB 2 MG
repaglinide
2
repaglinide tab 0.5 mg
2
repaglinide tab 1 mg
2
repaglinide tab 2 mg
2
SYMLINPEN 120 SOLN PEN 2700 MCG/2.7ML
pramlintide acetate
3
PA
SYMLINPEN 60 SOLN PEN 1500 MCG/1.5ML
pramlintide acetate
3
PA
TANZEUM PEN 30 MG
albiglutide
3
PA
TANZEUM PEN 50 MG
albiglutide
3
PA
tolazamide tab 250 mg
1
TOLAZAMIDE TAB 500 MG
tolazamide
1
TOLBUTAMIDE TAB 500 MG
tolbutamide
1
TRADJENTA TAB 5 MG
linagliptin
3
VICTOZA SOLN PEN 18 MG/3ML
liraglutide
3
PAGE 166
ST
QL
30 / 30 days
ST
QL
6 / 30 days
PA
PRODUCT DESCRIPTION
TIER
WELCHOL PACKET 3.75 GM
colesevelam hcl
3
PA
WELCHOL TAB 625 MG
colesevelam hcl
3
PA
GLUCAGEN DIAGNOSTIC RECON SOLN 1 MG
glucagon hcl rdna (diagnostic)
3
QL
2 / 30 days
GLUCAGEN HYPOKIT RECON SOLN 1 MG
glucagon hcl (rdna)
3
QL
2 / 30 days
GLUCAGON EMERGENCY KIT 1 MG
glucagon (rdna)
3
QL
2 / 30 days
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
Antihypoglycemic Agents
Estrogens and Antiestrogens
altavera tab 0.15-30 mg-mcg
alyacen 1/35 tab 1-35 mg-mcg
alyacen 7/7/7 tab 0.5/0.75/1-35 mg-mcg
apri tab 0.15-30 mg-mcg
aviane tab 0.1-20 mg-mcg
caziant tab 0.1/0.125/0.15 -0.025 mg
cesia tab 0.1/0.125/0.15 -0.025 mg
chateal tab 0.15-30 mg-mcg
5
5
5
5
5
5
5
5
COMBIPATCH PATCH TW 0.05-0.14 MG/DAY
estradiol & norethindrone acetate
3
3
covaryx hs tab 0.625-1.25 mg
1
PAGE 167
PRODUCT DESCRIPTION
TIER
covaryx tab 1.25-2.5 mg
1
cryselle-28 tab 0.3-30 mg-mcg
5
cyclafem 1/35 tab 1-35 mg-mcg
cyclafem 7/7/7 tab 0.5/0.75/1-35 mg-mcg
dasetta 1/35 tab 1-35 mg-mcg
dasetta 7/7/7 tab 0.5/0.75/1-35 mg-mcg
elinest tab 0.3-30 mg-mcg
emoquette tab 0.15-30 mg-mcg
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
5
5
5
5
5
5
ENJUVIA TAB 0.3 MG
estrogens, conjugated synthetic b
2
GL
Female
ENJUVIA TAB 0.45 MG
2
GL
Female
ENJUVIA TAB 0.625 MG
2
GL
Female
ENJUVIA TAB 0.9 MG
2
GL
Female
ENJUVIA TAB 1.25 MG
2
GL
Female
QL
enpresse-28 tab
28 / 28 days
5
GL
Female
QL
28 / 28 days
GL
Female
QL
8 / 28 days
GL
Female
estarylla tab 0.25-35 mg-mcg
5
ESTRACE CREAM 0.1 MG/GM
estradiol vaginal
2
estradiol patch tw 0.025 mg/24hr
2
PAGE 168
PRODUCT DESCRIPTION
estradiol patch wk 0.025 mg/24hr
TIER
QL
8 / 28 days
GL
Female
QL
8 / 28 days
GL
Female
QL
8 / 28 days
GL
Female
QL
8 / 28 days
GL
Female
QL
4 / 28 days
GL
Female
QL
4 / 28 days
GL
Female
QL
4 / 28 days
GL
Female
QL
4 / 28 days
GL
Female
QL
4 / 28 days
GL
Female
QL
4 / 28 days
GL
Female
2
2
2
2
1
1
1
1
1
1
estradiol tab 0.5 mg
1
GL
Female
estradiol tab 1 mg
1
GL
Female
estradiol tab 2 mg
1
GL
Female
estradiol valerate oil 20 mg/ml
1
GL
Female
1
GL
Female
estradiol-norethindrone acet tab 0.5-0.1 mg
1
estradiol-norethindrone acet tab 1-0.5 mg
1
ESTRING RING 2 MG
estradiol vaginal
3
ESTROGEL GEL 0.75 MG/1.25 GM (0.06%)
estradiol
3
GL
Female
PAGE 169
PRODUCT DESCRIPTION
TIER
estropipate tab 0.75 mg
1
GL
Female
1
GL
Female
ESTROPIPATE TAB 3 MG
estropipate
1
GL
Female
EVAMIST SOLUTION 1.53 MG/SPRAY
estradiol
3
GL
Female
EVISTA TAB 60 MG
raloxifene hcl
3
PA
falmina tab 0.1-20 mg-mcg
5
QL
28 / 28 days
GL
Female
FARESTON TAB 60 MG
toremifene citrate
4
PA
gildess 1.5/30 tab 1.5-30 mg-mcg
5
GL
Female
gildess 1/20 tab 1-20 mg-mcg
5
GL
Female
QL
gildess fe 1.5/30 tab 1.5-30 mg-mcg
28 / 28 days
5
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
gildess fe 1/20 tab 1-20 mg-mcg
jinteli tab 1-5 mg-mcg
junel 1.5/30 tab 1.5-30 mg-mcg
junel 1/20 tab 1-20 mg-mcg
junel fe 1.5/30 tab 1.5-30 mg-mcg
junel fe 1/20 tab 1-20 mg-mcg
kelnor 1/35 tab 1-35 mg-mcg
kurvelo tab 0.15-30 mg-mcg
PAGE 170
5
1
5
5
5
5
5
5
PRODUCT DESCRIPTION
TIER
larin fe 1/20 tab 1-20 mg-mcg
5
lessina tab 0.1-20 mg-mcg
5
levonest tab
levonorgest-eth estrad 91-day tab 0.1-0.02 & 0.01 mg
levonorgest-eth estrad 91-day tab 0.15-0.03 mg
levonorgestrel-ethinyl estrad tab 0.15-30 mg-mcg
levora 0.15/30 (28) tab 0.15-30 mg-mcg
low-ogestrel tab 0.3-30 mg-mcg
lutera tab 0.1-20 mg-mcg
marlissa tab 0.15-30 mg-mcg
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
5
5
5
5
5
5
5
5
MENEST TAB 0.3 MG
esterified estrogens
3
GL
Female
MENEST TAB 0.625 MG
3
GL
Female
MENEST TAB 1.25 MG
3
GL
Female
MENEST TAB 2.5 MG
3
GL
Female
microgestin fe 1/20 tab 1-20 mg-mcg
5
GL
Female
mimvey tab 1-0.5 mg
1
QL
mono-linyah tab 0.25-35 mg-mcg
28 / 28 days
5
GL
Female
QL
28 / 28 days
GL
Female
mononessa tab 0.25-35 mg-mcg
PAGE 171
5
PRODUCT DESCRIPTION
myzilra tab
necon 0.5/35 (28) tab 0.5-35 mg-mcg
necon 1/35 (28) tab 1-35 mg-mcg
necon 7/7/7 tab 0.5/0.75/1-35 mg-mcg
TIER
norgestim-eth estrad triphasic tab 0.18/0.215/0.25 mg-35 mcg
5
nortrel 7/7/7 tab 0.5/0.75/1-35 mg-mcg
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
5
5
5
5
5
orsythia tab 0.1-20 mg-mcg
5
ORTHO EVRA PATCH WK 150-35 MCG/24HR
norelgestromin-ethinyl estradiol
5
portia-28 tab 0.15-30 mg-mcg
5
PAGE 172
QL
5
NUVARING RING 0.12-0.015 MG/24HR
etonogestrel-ethinyl estradiol
PREMARIN TAB 0.3 MG
estrogens, conjugated
Female
5
5
nortrel 1/35 (28) tab 1-35 mg-mcg
GL
5
norethin ace-eth estrad-fe tab 1-20 mg-mcg(24)
28 / 28 days
5
5
nortrel 0.5/35 (28) tab 0.5-35 mg-mcg
QL
5
norethin ace-eth estrad-fe tab 1-20 mg-mcg
norgestimate-eth estradiol tab 0.25-35 mg-mcg
2
PA
QL
28 / 28 days
GL
Female
PA
QL
28 / 28 days
GL
Female
GL
Female
PRODUCT DESCRIPTION
TIER
PREMARIN TAB 0.45 MG
3
GL
Female
3
GL
Female
PREMARIN TAB 0.9 MG
3
GL
Female
3
GL
Female
PREMPHASE TAB 0.625-5 MG
conjugated estrogens-medroxyprogesterone acetate
2
PREMPRO TAB 0.3-1.5 MG
2
2
2
PREMPRO TAB 0.625-5 MG
2
QL
previfem tab 0.25-35 mg-mcg
28 / 28 days
5
GL
Female
raloxifene hcl tab 60 mg
3
reclipsen tab 0.15-30 mg-mcg
5
solia tab 0.15-30 mg-mcg
sprintec 28 tab 0.25-35 mg-mcg
sronyx tab 0.1-20 mg-mcg
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
5
5
5
tamoxifen citrate tab 10 mg
1
1
tarina fe 1/20 tab 1-20 mg-mcg
5
tri-estarylla tab 0.18/0.215/0.25 mg-35 mcg
5
PAGE 173
PA
PRODUCT DESCRIPTION
tri-linyah tab 0.18/0.215/0.25 mg-35 mcg
tri-previfem tab 0.18/0.215/0.25 mg-35 mcg
tri-sprintec tab 0.18/0.215/0.25 mg-35 mcg
trinessa (28) tab 0.18/0.215/0.25 mg-35 mcg
trivora (28) tab
TIER
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
5
5
5
5
5
VAGIFEM TAB 10 MCG
estradiol vaginal
3
velivet tab 0.1/0.125/0.15 -0.025 mg
5
wera tab 0.5-35 mg-mcg
5
xulane patch wk 150-35 mcg/24hr
5
zovia 1/35e (28) tab 1-35 mg-mcg
5
PA
QL
28 / 28 days
GL
Female
60 / 30 days
A-HYDROCORT RECON SOLN 100 MG
hydrocortisone sod succinate
1
2
QL
3
ST
3
ST
3
ST
3
ST
3
ST
AEROSPAN AERO SOLN 80 MCG/ACT
flunisolide hfa
2
QL
PAGE 174
8.9 / 30 days
PRODUCT DESCRIPTION
altavera tab 0.15-30 mg-mcg
alyacen 1/35 tab 1-35 mg-mcg
alyacen 7/7/7 tab 0.5/0.75/1-35 mg-mcg
TIER
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
5
5
5
ANDRODERM PATCH 24HR 2 MG/24HR
testosterone
3
PA
ANDRODERM PATCH 24HR 4 MG/24HR
testosterone
3
PA
ANDROGEL GEL 20.25 MG/1.25GM (1.62%)
testosterone
3
PA
ANDROGEL GEL 25 MG/2.5GM (1%)
testosterone
3
PA
ANDROGEL GEL 40.5 MG/2.5GM (1.62%)
testosterone
3
PA
ANDROGEL PUMP GEL 20.25 MG/ACT (1.62%)
testosterone
3
PA
ANDROXY TAB 10 MG
fluoxymesterone
3
PA
apri tab 0.15-30 mg-mcg
5
QL
28 / 28 days
GL
Female
ASMANEX 120 METERED DOSES AER POW BA 220
MCG/INH
mometasone furoate (inhalation)
3
QL
2 / 30 days
MCG/INH
3
QL
2 / 30 days
MCG/INH
3
QL
2 / 30 days
MCG/INH
3
QL
2 / 30 days
MCG/INH
3
QL
2 / 30 days
ASMANEX 7 METERED DOSES AER POW BA 110 MCG/INH
3
QL
2 / 30 days
PAGE 175
PRODUCT DESCRIPTION
aviane tab 0.1-20 mg-mcg
TIER
3
baycadron elixir 0.5 mg/5ml
1
betamethasone sod phos & acet suspension 6 (3-3) mg/ml
1
budesonide er cap er 24h 3 mg
4
budesonide suspension 0.25 mg/2ml
1
1
camila tab 0.35 mg
5
cesia tab 0.1/0.125/0.15 -0.025 mg
chateal tab 0.15-30 mg-mcg
28 / 28 days
GL
Female
PA
QL
120 / 30 days
AL1
Up to 8 yrs old
QL
120 / 30 days
AL1
Up to 8 yrs old
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
1
calcitonin (salmon) solution 200 unit/act
caziant tab 0.1/0.125/0.15 -0.025 mg
QL
5
AXIRON SOLUTION 30 MG/ACT
testosterone
5
5
5
chorionic gonadotropin recon soln 10000 unit
4
3
3
CORTISONE ACETATE TAB 25 MG
cortisone acetate
1
covaryx hs tab 0.625-1.25 mg
1
covaryx tab 1.25-2.5 mg
1
CRINONE GEL 4 %
progesterone (vaginal)
4
PA
CRINONE GEL 8 %
4
PA
PAGE 176
PA
PRODUCT DESCRIPTION
cryselle-28 tab 0.3-30 mg-mcg
cyclafem 1/35 tab 1-35 mg-mcg
cyclafem 7/7/7 tab 0.5/0.75/1-35 mg-mcg
dasetta 1/35 tab 1-35 mg-mcg
dasetta 7/7/7 tab 0.5/0.75/1-35 mg-mcg
TIER
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
1 / 90 days
GL
Female
5
5
5
5
5
DEPO-MEDROL SUSPENSION 20 MG/ML
methylprednisolone acetate
3
DEPO-PROVERA SUSPENSION 400 MG/ML
medroxyprogesterone acetate (antineoplastic)
3
DEPO-SUBQ PROVERA 104 SUSPENSION 104 MG/0.65ML
medroxyprogesterone acetate (contraceptive)
3
desmopressin ace rhinal tube solution 0.01 %
1
desmopressin ace spray refrig solution 0.01 %
3
desmopressin acetate solution 4 mcg/ml
4
desmopressin acetate spray solution 0.01 %
1
1
1
DEXAMETHASONE INTENSOL CONC 1 MG/ML
dexamethasone
3
DEXAMETHASONE SOD PHOSPHATE PF SOLUTION 10
MG/ML
dexamethasone sodium phosphate
1
DEXAMETHASONE SODIUM PHOSPHATE SOLUTION 10
MG/ML
dexamethasone sodium phosphate
1
dexamethasone sodium phosphate solution 100 mg/10ml
1
1
1
PAGE 177
PA
PRODUCT DESCRIPTION
TIER
dexamethasone sodium phosphate solution 4 mg/ml
1
DEXAMETHASONE SOLUTION 0.5 MG/5ML
dexamethasone
1
dexamethasone tab 0.5 mg
1
1
DEXAMETHASONE TAB 1 MG
dexamethasone
1
1
DEXAMETHASONE TAB 2 MG
dexamethasone
1
dexamethasone tab 4 mg
1
dexamethasone tab 6 mg
1
DEXPAK 10 DAY TAB 1.5 MG
dexamethasone
3
dexamethasone
3
dexamethasone
3
2
QL
13 / 25 days
2
QL
13 / 25 days
ELIGARD KIT 22.5 MG
leuprolide acetate (3 month)
4
PA
ELIGARD KIT 30 MG
4
PA
ELIGARD KIT 45 MG
4
PA
ELIGARD KIT 7.5 MG
leuprolide acetate
4
PA
elinest tab 0.3-30 mg-mcg
5
ELLA TAB 30 MG
ulipristal acetate
3
emoquette tab 0.15-30 mg-mcg
5
PAGE 178
QL
28 / 28 days
GL
Female
GL
Female
QL
28 / 28 days
GL
Female
PRODUCT DESCRIPTION
TIER
ENDOMETRIN INSERT 100 MG
3
enpresse-28 tab
5
errin tab 0.35 mg
estarylla tab 0.25-35 mg-mcg
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
60 / 30 days
5
5
estradiol-norethindrone acet tab 0.5-0.1 mg
1
estradiol-norethindrone acet tab 1-0.5 mg
1
falmina tab 0.1-20 mg-mcg
5
FLOVENT DISKUS AER POW BA 100 MCG/BLIST
fluticasone propionate (inhalation)
3
fludrocortisone acetate tab 0.1 mg
1
1
QL
50 / 25 days
1
QL
16 / 25 days
FORTEO SOLUTION 600 MCG/2.4ML
teriparatide (recombinant)
4
PA
GENOTROPIN MINIQUICK RECON SOLN 0.2 MG
somatropin
4
PA
somatropin
4
PA
somatropin
4
PA
somatropin
4
PA
GENOTROPIN MINIQUICK RECON SOLN 1 MG
somatropin
4
PA
somatropin
4
PA
somatropin
4
PA
somatropin
4
PA
PAGE 179
PRODUCT DESCRIPTION
TIER
somatropin
4
PA
somatropin
4
PA
GENOTROPIN RECON SOLN 12 MG
somatropin
4
PA
somatropin
4
PA
gildess 1.5/30 tab 1.5-30 mg-mcg
5
GL
Female
gildess 1/20 tab 1-20 mg-mcg
5
GL
Female
QL
gildess fe 1.5/30 tab 1.5-30 mg-mcg
28 / 28 days
5
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
gildess fe 1/20 tab 1-20 mg-mcg
heather tab 0.35 mg
5
5
hydrocortisone tab 10 mg
1
1
1
HYDROXYPROGESTERONE CAPROATE POWDER
hydroxyprogesterone caproate (bulk)
1
jinteli tab 1-5 mg-mcg
1
jolivette tab 0.35 mg
junel 1.5/30 tab 1.5-30 mg-mcg
junel 1/20 tab 1-20 mg-mcg
junel fe 1.5/30 tab 1.5-30 mg-mcg
junel fe 1/20 tab 1-20 mg-mcg
PAGE 180
5
5
5
5
5
PRODUCT DESCRIPTION
kelnor 1/35 tab 1-35 mg-mcg
kurvelo tab 0.15-30 mg-mcg
TIER
lessina tab 0.1-20 mg-mcg
5
leuprolide acetate kit 1 mg/0.2ml
4
levonest tab
5
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
PA
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
2 / 30 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
5
5
levonorgestrel-ethinyl estrad tab 0.15-30 mg-mcg
5
low-ogestrel tab 0.3-30 mg-mcg
GL
5
LEVONORGESTREL TAB 0.75 MG
levonorgestrel (emergency oc)
levora 0.15/30 (28) tab 0.15-30 mg-mcg
28 / 28 days
5
5
levonorgest-eth estrad 91-day tab 0.15-0.03 mg
QL
5
larin fe 1/20 tab 1-20 mg-mcg
levonorgest-eth estrad 91-day tab 0.1-0.02 & 0.01 mg
5
5
LUPRON DEPOT KIT 11.25 MG
4
PA
4
PA
leuprolide acetate
4
PA
LUPRON DEPOT KIT 30 MG
4
PA
4
PA
PAGE 181
PRODUCT DESCRIPTION
lutera tab 0.1-20 mg-mcg
marlissa tab 0.15-30 mg-mcg
medroxyprogesterone acetate suspension 150 mg/ml
TIER
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
1 / 90 days
GL
Female
5
5
5
medroxyprogesterone acetate tab 10 mg
1
medroxyprogesterone acetate tab 2.5 mg
1
medroxyprogesterone acetate tab 5 mg
1
megestrol acetate suspension 40 mg/ml
1
megestrol acetate suspension 400 mg/10ml
1
megestrol acetate tab 20 mg
1
1
METHITEST TAB 10 MG
methyltestosterone
3
methylprednisolone (pak) tab 4 mg
1
methylprednisolone tab 16 mg
1
1
1
1
MIACALCIN SOLUTION 200 UNIT/ML
calcitonin (salmon)
3
ST
microgestin fe 1/20 tab 1-20 mg-mcg
5
GL
Female
MILLIPRED TAB 5 MG
prednisolone
3
mimvey tab 1-0.5 mg
1
QL
mono-linyah tab 0.25-35 mg-mcg
28 / 28 days
5
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
mononessa tab 0.25-35 mg-mcg
myzilra tab
PAGE 182
5
5
PRODUCT DESCRIPTION
TIER
3
necon 0.5/35 (28) tab 0.5-35 mg-mcg
5
necon 1/35 (28) tab 1-35 mg-mcg
necon 7/7/7 tab 0.5/0.75/1-35 mg-mcg
nora-be tab 0.35 mg
ST
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
5
5
5
NORDITROPIN FLEXPRO SOLUTION 10 MG/1.5ML
somatropin
4
PA
somatropin
4
PA
somatropin
4
PA
NORDITROPIN NORDIFLEX PEN SOLUTION 30 MG/3ML
somatropin
4
PA
norethin ace-eth estrad-fe tab 1-20 mg-mcg
5
norethin ace-eth estrad-fe tab 1-20 mg-mcg(24)
5
norethindrone acetate tab 5 mg
1
norethindrone tab 0.35 mg
5
norgestim-eth estrad triphasic tab 0.18/0.215/0.25 mg-35 mcg
norgestimate-eth estradiol tab 0.25-35 mg-mcg
nortrel 0.5/35 (28) tab 0.5-35 mg-mcg
PAGE 183
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
5
5
5
5
5
PRODUCT DESCRIPTION
nortrel 7/7/7 tab 0.5/0.75/1-35 mg-mcg
TIER
QL
28 / 28 days
GL
Female
5
NUTROPIN AQ NUSPIN 10 SOLUTION 10 MG/2ML
somatropin
4
PA
somatropin
4
PA
somatropin
4
PA
NUTROPIN AQ PEN SOLUTION 10 MG/2ML
somatropin
4
PA
somatropin
4
PA
NUVARING RING 0.12-0.015 MG/24HR
etonogestrel-ethinyl estradiol
5
PA
orsythia tab 0.1-20 mg-mcg
5
ORTHO EVRA PATCH WK 150-35 MCG/24HR
norelgestromin-ethinyl estradiol
5
portia-28 tab 0.15-30 mg-mcg
5
prednisolone sodium phosphate solution 15 mg/5ml
1
PREDNISOLONE SODIUM PHOSPHATE SOLUTION 25
MG/5ML
prednisolone sodium phosphate
1
prednisolone sodium phosphate solution 6.7 (5 base) mg/5ml
1
prednisolone solution 15 mg/5ml
1
prednisolone syrup 15 mg/5ml
1
prednisone (pak) tab 10 mg
1
PREDNISONE (PAK) TAB 10 MG
prednisone
1
prednisone (pak) tab 5 mg
1
PREDNISONE (PAK) TAB 5 MG
prednisone
1
PREDNISONE INTENSOL CONC 5 MG/ML
prednisone
3
PREDNISONE SOLUTION 5 MG/5ML
prednisone
1
PAGE 184
QL
28 / 28 days
GL
Female
PA
QL
28 / 28 days
GL
Female
PRODUCT DESCRIPTION
TIER
prednisone tab 1 mg
1
prednisone tab 10 mg
1
prednisone tab 2.5 mg
1
prednisone tab 20 mg
1
prednisone tab 5 mg
1
PREDNISONE TAB 50 MG
prednisone
1
PREMPHASE TAB 0.625-5 MG
2
2
2
2
PREMPRO TAB 0.625-5 MG
2
previfem tab 0.25-35 mg-mcg
5
QL
28 / 28 days
GL
Female
PULMICORT FLEXHALER AER POW BA 180 MCG/ACT
budesonide (inhalation)
3
QL
1 / 30 days
3
QL
1 / 30 days
PULMICORT SUSPENSION 1 MG/2ML
QL
120 / 30 days
4
AL1
Up to 8 yrs old
QVAR AERO SOLN 40 MCG/ACT
beclomethasone dipropionate
2
QL
8.7 / 30 days
2
QL
reclipsen tab 0.15-30 mg-mcg
28 / 28 days
5
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
solia tab 0.15-30 mg-mcg
sprintec 28 tab 0.25-35 mg-mcg
PAGE 185
5
5
PRODUCT DESCRIPTION
sronyx tab 0.1-20 mg-mcg
TIER
QL
28 / 28 days
GL
Female
5
STIMATE SOLUTION 1.5 MG/ML
desmopressin acetate
4
2
2
tarina fe 1/20 tab 1-20 mg-mcg
5
TESTOSTERONE GEL 25 MG/2.5GM (1%)
testosterone
3
PA
TEV-TROPIN RECON SOLN 5 MG
somatropin
4
PA
tri-estarylla tab 0.18/0.215/0.25 mg-35 mcg
5
tri-linyah tab 0.18/0.215/0.25 mg-35 mcg
tri-previfem tab 0.18/0.215/0.25 mg-35 mcg
tri-sprintec tab 0.18/0.215/0.25 mg-35 mcg
trinessa (28) tab 0.18/0.215/0.25 mg-35 mcg
trivora (28) tab
velivet tab 0.1/0.125/0.15 -0.025 mg
QL
QL
10.2 / 25 days
ST
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
QL
28 / 28 days
GL
Female
5
5
5
5
5
5
3
wera tab 0.5-35 mg-mcg
5
PAGE 186
10.2 / 25 days
ST
fluticasone furoate
xulane patch wk 150-35 mcg/24hr
PA
5
ST
QL
28 / 28 days
GL
Female
PA
PRODUCT DESCRIPTION
TIER
ZOLADEX IMPLANT 10.8 MG
goserelin acetate
3
PA
goserelin acetate
3
PA
zovia 1/35e (28) tab 1-35 mg-mcg
5
QL
28 / 28 days
GL
Female
Somatostatin Agonists and Antagonists
4
PA
octreotide acetate solution 1000 mcg/5ml
4
PA
4
PA
4
PA
4
PA
4
PA
octreotide acetate
4
PA
octreotide acetate
4
PA
octreotide acetate
4
PA
SOMATULINE DEPOT SOLUTION 120 MG/0.5ML
lanreotide acetate
4
PA
lanreotide acetate
4
PA
lanreotide acetate
4
PA
somatropin
4
PA
somatropin
4
PA
somatropin
4
PA
somatropin
4
PA
somatropin
4
PA
Somatotropin Agonists and Antagonists
PAGE 187
PRODUCT DESCRIPTION
TIER
somatropin
4
PA
somatropin
4
PA
somatropin
4
PA
somatropin
4
PA
somatropin
4
PA
somatropin
4
PA
somatropin
4
PA
INCRELEX SOLUTION 40 MG/4ML
mecasermin
4
PA
somatropin
4
PA
somatropin
4
PA
somatropin
4
PA
NORDITROPIN NORDIFLEX PEN SOLUTION 30 MG/3ML
somatropin
4
PA
somatropin
4
PA
somatropin
4
PA
somatropin
4
PA
somatropin
4
PA
somatropin
4
PA
SOMAVERT RECON SOLN 10 MG
pegvisomant
4
PA
pegvisomant
4
PA
pegvisomant
4
PA
PAGE 188
PRODUCT DESCRIPTION
TEV-TROPIN RECON SOLN 5 MG
somatropin
TIER
4
PA
Thyroid and Antithyroid Agents
levothyroxine sodium tab 100 mcg
1
1
1
1
1
1
1
1
1
1
1
1
levoxyl tab 100 mcg
1
levoxyl tab 112 mcg
1
levoxyl tab 125 mcg
1
levoxyl tab 137 mcg
1
levoxyl tab 150 mcg
1
levoxyl tab 175 mcg
1
levoxyl tab 200 mcg
1
levoxyl tab 25 mcg
1
levoxyl tab 50 mcg
1
levoxyl tab 75 mcg
1
levoxyl tab 88 mcg
1
liothyronine sodium tab 25 mcg
1
1
1
methimazole tab 10 mg
1
methimazole tab 5 mg
1
NATURE-THROID TAB 130 MG
thyroid
1
PAGE 189
PRODUCT DESCRIPTION
TIER
NATURE-THROID TAB 16.25 MG
thyroid
1
thyroid
1
NATURE-THROID TAB 32.5 MG
thyroid
1
thyroid
1
propylthiouracil tab 50 mg
1
SYNTHROID TAB 100 MCG
levothyroxine sodium
2
2
2
2
2
2
2
2
2
2
2
2
THYROLAR-1 TAB 60 (12.5-50) MG (MCG)
liotrix (t3-t4)
3
THYROLAR-1/2 TAB 30 (6.25-25) MG (MCG)
liotrix (t3-t4)
3
THYROLAR-1/4 TAB 15 (3.1-12.5) MG (MCG)
liotrix (t3-t4)
3
PAGE 190
PRODUCT DESCRIPTION
TIER
THYROLAR-2 TAB 120 (25-100) MG (MCG)
liotrix (t3-t4)
3
THYROLAR-3 TAB 180 (37.5-150) MG (MCG)
liotrix (t3-t4)
3
unithroid tab 100 mcg
1
1
1
1
1
1
1
1
1
1
1
WESTHROID TAB 130 MG
thyroid
1
WESTHROID TAB 32.5 MG
thyroid
1
WESTHROID TAB 65 MG
thyroid
1
Miscellaneous Therapeutic Agents
acetylcysteine solution 10 %
1
1
acetylcysteine solution 200 mg/ml
1
ACTEMRA SOLN PRSYR 162 MG/0.9ML
tocilizumab
4
PA
ACTIMMUNE SOLUTION 2000000 UNIT/0.5ML
interferon gamma-1b
4
PA
ACTONEL TAB 150 MG
risedronate sodium
2
ACTONEL TAB 30 MG
risedronate sodium
2
ACTONEL TAB 35 MG
risedronate sodium
2
PAGE 191
QL
1 / 30 days
ST
QL
30 / 30 days
ST
ST
PRODUCT DESCRIPTION
TIER
QL
30 / 30 days
ACTONEL TAB 5 MG
risedronate sodium
2
alendronate sodium tab 10 mg
1
QL
4 / 28 days
1
QL
4 / 28 days
ALENDRONATE SODIUM TAB 40 MG
alendronate sodium
QL
4 / 28 days
1
1
QL
4 / 28 days
1
QL
4 / 28 days
allopurinol tab 100 mg
1
allopurinol tab 300 mg
1
alpha-lipoic acid tab 200 mg
5
AMPYRA TAB ER 12H 10 MG
dalfampridine
4
PA
ARCALYST RECON SOLN 220 MG
rilonacept
4
PA
ATELVIA TAB DR 35 MG
risedronate sodium
3
AVODART CAP 0.5 MG
dutasteride
3
ST
AVONEX KIT 30 MCG
interferon beta-1a
4
PA
AVONEX PEN KIT 30 MCG/0.5ML
interferon beta-1a
4
PA
AVONEX PREFILLED KIT 30 MCG/0.5ML
interferon beta-1a
4
PA
AVORIA GC+ PACKET
5
AZASAN TAB 100 MG
azathioprine
3
PA
AZASAN TAB 75 MG
azathioprine
3
PA
azathioprine tab 50 mg
1
BERINERT KIT 500 UNIT
c1 esterase inhibitor (human)
4
PAGE 192
ST
PA
QL
4 / 30 days
ST
PA
PRODUCT DESCRIPTION
TIER
BETASERON KIT 0.3 MG
interferon beta-1b
4
calcitonin (salmon) solution 200 unit/act
1
CELLCEPT RECON SUSP 200 MG/ML
mycophenolate mofetil
4
CHEMET CAP 100 MG
succimer
3
clinpro 5000 paste 1.1 %
1
COENZYME Q10 TAB 100 MG
coenzyme q10 (ubidecarenone)
5
COLCHICINE TAB 0.6 MG
colchicine
3
colchicine-probenecid tab 0.5-500 mg
1
cranberry tab 400 mg
5
cyclosporine cap 100 mg
3
cyclosporine cap 25 mg
3
cyclosporine modified cap 100 mg
3
cyclosporine modified cap 25 mg
1
CYCLOSPORINE MODIFIED CAP 50 MG
cyclosporine modified (for microemulsion)
1
cyclosporine modified solution 100 mg/ml
3
CYSTADANE POWDER
betaine
4
deferoxamine mesylate recon soln 500 mg
1
denta 5000 plus cream 1.1 %
1
dentagel gel 1.1 %
1
DEPEN TITRATABS TAB 250 MG
penicillamine
4
disulfiram tab 250 mg
1
disulfiram tab 500 mg
1
DYSPORT RECON SOLN 500 UNIT
abobotulinumtoxina
4
PA
ELIDEL CREAM 1 %
pimecrolimus
3
QL
ELMIRON CAP 100 MG
pentosan polysulfate sodium
4
PA
PAGE 193
PA
QL
20 / 30 days
PA
100 / 30 days
PRODUCT DESCRIPTION
TIER
ENBREL KIT 25 MG
etanercept
4
PA
ENJUVIA TAB 0.3 MG
2
GL
Female
ENJUVIA TAB 0.45 MG
2
GL
Female
ENJUVIA TAB 0.625 MG
2
GL
Female
ENJUVIA TAB 0.9 MG
2
GL
Female
ENJUVIA TAB 1.25 MG
2
GL
Female
ESTRACE CREAM 0.1 MG/GM
estradiol vaginal
2
QL
8 / 28 days
2
GL
Female
QL
8 / 28 days
GL
Female
QL
8 / 28 days
GL
Female
QL
8 / 28 days
GL
Female
QL
8 / 28 days
GL
Female
QL
4 / 28 days
GL
Female
QL
4 / 28 days
GL
Female
QL
4 / 28 days
GL
Female
QL
4 / 28 days
GL
Female
QL
4 / 28 days
GL
Female
PAGE 194
2
2
2
2
1
1
1
1
1
PRODUCT DESCRIPTION
TIER
QL
4 / 28 days
GL
Female
1
estradiol tab 0.5 mg
1
GL
Female
estradiol tab 1 mg
1
GL
Female
estradiol tab 2 mg
1
GL
Female
1
GL
Female
1
GL
Female
ESTRING RING 2 MG
estradiol vaginal
3
ESTROGEL GEL 0.75 MG/1.25 GM (0.06%)
estradiol
3
GL
Female
1
GL
Female
1
GL
Female
ESTROPIPATE TAB 3 MG
estropipate
1
GL
Female
ETIDRONATE DISODIUM TAB 200 MG
etidronate disodium
3
ETIDRONATE DISODIUM TAB 400 MG
etidronate disodium
3
EVAMIST SOLUTION 1.53 MG/SPRAY
estradiol
3
GL
Female
EVISTA TAB 60 MG
raloxifene hcl
3
PA
EXTAVIA KIT 0.3 MG
interferon beta-1b
4
PA
finasteride tab 1 mg
1
1
FIRAZYR SOLUTION 30 MG/3ML
icatibant acetate
4
fluoridex sensitivity relief paste 1.1-5 %
1
fluoritab chew tab 1.1 (0.5 f) mg
5
fluoritab chew tab 2.2 (1 f) mg
5
fomepizole solution 1 gm/ml
1
PAGE 195
PA
PRODUCT DESCRIPTION
TIER
fomepizole solution 1.5 gm/1.5ml
1
FOSAMAX PLUS D TAB 70-2800 MG-UNIT
alendronate sodium-cholecalciferol
3
PA
3
PA
lanthanum carbonate
3
PA
lanthanum carbonate
3
PA
lanthanum carbonate
3
PA
GANIRELIX ACETATE SOLUTION 250 MCG/0.5ML
ganirelix acetate
4
PA
gengraf cap 100 mg
3
gengraf cap 25 mg
1
gengraf solution 100 mg/ml
3
GILENYA CAP 0.5 MG
fingolimod hcl
4
PA
glatopa soln prsyr 20 mg/ml
4
PA
GLUCAGEN DIAGNOSTIC RECON SOLN 1 MG
glucagon hcl rdna (diagnostic)
3
QL
2 / 30 days
GLUCAGEN HYPOKIT RECON SOLN 1 MG
glucagon hcl (rdna)
3
QL
2 / 30 days
GLUCAGON EMERGENCY KIT 1 MG
glucagon (rdna)
3
QL
2 / 30 days
GLUCOSAMINE HCL TAB 500 MG
glucosamine hydrochloride
5
hecoria cap 0.5 mg
1
hecoria cap 1 mg
1
hecoria cap 5 mg
3
HUMIRA PEDIATRIC CROHNS START PREF SY KT 40
MG/0.8ML
adalimumab
4
PA
HUMIRA PEN-CROHNS STARTER PEN KIT 40 MG/0.8ML
adalimumab
4
PA
adalimumab
4
PA
PAGE 196
PRODUCT DESCRIPTION
TIER
adalimumab
4
hydroxychloroquine sulfate tab 200 mg
1
ibandronate sodium tab 150 mg
3
ST
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
indomethacin er cap er 75 mg
1
AL1
Up to 64 yrs old
interferon alfa-2b
4
PA
interferon alfa-2b
4
PA
interferon alfa-2b
4
PA
interferon alfa-2b
4
PA
KALBITOR SOLUTION 10 MG/ML
ecallantide
4
PA
KINERET SOLN PRSYR 100 MG/0.67ML
anakinra
4
PA
kionex suspension 15 gm/60ml
1
leflunomide tab 10 mg
1
leflunomide tab 20 mg
1
LEUCOVORIN CALCIUM TAB 10 MG
leucovorin calcium
4
PA
leucovorin calcium
4
PA
leucovorin calcium tab 25 mg
4
PA
4
PA
levocarnitine solution 1 gm/10ml
3
levocarnitine tab 330 mg
3
ludent chew tab 1.1 (0.5 f) mg
5
ludent chew tab 2.2 (1 f) mg
5
MENEST TAB 0.3 MG
3
PAGE 197
PA
GL
Female
PRODUCT DESCRIPTION
TIER
MENEST TAB 0.625 MG
3
GL
Female
MENEST TAB 1.25 MG
3
GL
Female
MENEST TAB 2.5 MG
3
GL
Female
MEPHYTON TAB 5 MG
phytonadione
2
PA
mercaptopurine tab 50 mg
1
MESNEX TAB 400 MG
mesna
4
methotrexate sodium (pf) solution 1 gm/40ml
1
methotrexate sodium (pf) solution 100 mg/4ml
1
methotrexate sodium (pf) solution 25 mg/ml
1
1
1
methotrexate sodium recon soln 1 gm
1
methotrexate tab 2.5 mg
1
MIACALCIN SOLUTION 200 UNIT/ML
calcitonin (salmon)
3
multi-vit/fluoride solution 0.25 mg/ml
1
multi-vitamin/fluoride solution 0.25 mg/ml
1
mycophenolate mofetil cap 250 mg
1
mycophenolate mofetil recon susp 200 mg/ml
4
mycophenolate mofetil tab 500 mg
1
mycophenolic acid tab dr 180 mg
3
PA
mycophenolic acid tab dr 360 mg
3
PA
MYFORTIC TAB DR 180 MG
mycophenolate sodium
3
PA
MYFORTIC TAB DR 360 MG
mycophenolate sodium
3
PA
naloxone hcl solution 0.4 mg/ml
1
QL
2 / 90 days
NALOXONE HCL SOLUTION 1 MG/ML
naloxone hcl
2
QL
2 / 90 days
PAGE 198
PA
ST
PRODUCT DESCRIPTION
TIER
naltrexone hcl tab 50 mg
1
1
1
1
1
1
naproxen
1
naproxen tab 250 mg
1
naproxen tab 375 mg
1
naproxen tab 500 mg
1
OMEGA-3-6-9 CAP
omega 3 fatty acids-omega 6 fatty acids-omega 9 fatty acids
5
ORFADIN CAP 10 MG
nitisinone
4
PA
ORFADIN CAP 2 MG
nitisinone
4
PA
ORFADIN CAP 5 MG
nitisinone
4
PA
perio med conc 0.63 %
1
periomed conc 0.63 %
1
1
PHYSOSTIGMINE SALICYLATE SOLUTION 1 MG/ML
physostigmine salicylate
1
POMALYST CAP 1 MG
pomalidomide
4
PA
POMALYST CAP 2 MG
pomalidomide
4
PA
POMALYST CAP 3 MG
pomalidomide
4
PA
POMALYST CAP 4 MG
pomalidomide
4
PA
PREMARIN TAB 0.3 MG
2
GL
Female
3
GL
Female
PAGE 199
PRODUCT DESCRIPTION
TIER
3
GL
Female
PREMARIN TAB 0.9 MG
3
GL
Female
3
GL
Female
probenecid tab 500 mg
1
PROLIA SOLUTION 60 MG/ML
denosumab
4
PA
raloxifene hcl tab 60 mg
3
PA
RAPAMUNE SOLUTION 1 MG/ML
sirolimus
4
PA
RAPAMUNE TAB 0.5 MG
sirolimus
4
PA
REBIF REBIDOSE SOLUTION 22 MCG/0.5ML
interferon beta-1a
4
PA
REBIF REBIDOSE SOLUTION 44 MCG/0.5ML
interferon beta-1a
4
PA
REBIF REBIDOSE TITRATION PACK SOLUTION 6X8.8 &
6X22 MCG
interferon beta-1a
4
PA
REBIF SOLUTION 22 MCG/0.5ML
interferon beta-1a
4
PA
REBIF SOLUTION 44 MCG/0.5ML
interferon beta-1a
4
PA
REBIF TITRATION PACK SOLUTION 6X8.8 & 6X22 MCG
interferon beta-1a
4
PA
RENAGEL TAB 400 MG
sevelamer hcl
3
PA
RENAGEL TAB 800 MG
sevelamer hcl
3
PA
sevelamer carbonate
3
PA
sevelamer carbonate
3
PA
RENVELA TAB 800 MG
sevelamer carbonate
3
PA
REVLIMID CAP 10 MG
lenalidomide
4
PA
PAGE 200
PRODUCT DESCRIPTION
TIER
REVLIMID CAP 15 MG
lenalidomide
4
PA
REVLIMID CAP 2.5 MG
lenalidomide
4
PA
REVLIMID CAP 25 MG
lenalidomide
4
PA
REVLIMID CAP 5 MG
lenalidomide
4
PA
RIDAURA CAP 3 MG
auranofin
4
PA
risedronate sodium tab 150 mg
2
QL
1 / 30 days
ST
5
SANDIMMUNE SOLUTION 100 MG/ML
cyclosporine
4
PA
SENSIPAR TAB 30 MG
cinacalcet hcl
4
PA
SENSIPAR TAB 60 MG
cinacalcet hcl
4
PA
SENSIPAR TAB 90 MG
cinacalcet hcl
4
PA
sf gel 1.1 %
1
sirolimus tab 0.5 mg
4
sodium fluoride chew tab 2.2 (1 f) mg
5
sodium fluoride solution 1.1 (0.5 f) mg/ml
5
1
1
1
SODIUM SULFACETAMIDE WASH LIQUID 10 %
sulfacetamide sodium in bakuchiol vehicle
3
stannous fluoride conc 0.63 %
1
STRIBILD TAB 150-150-200-300 MG
elvitegravir-cobicistat-emtricitabine-tenofovir
2
1
1
PAGE 201
PA
QL
30 / 30 days
PRODUCT DESCRIPTION
TIER
1
1
4
PA
4
PA
4
PA
4
PA
4
PA
tacrolimus cap 0.5 mg
1
tacrolimus cap 1 mg
1
tacrolimus cap 5 mg
3
1
tart cherry advanced cap
5
THALOMID CAP 100 MG
thalidomide
4
PA
THALOMID CAP 150 MG
thalidomide
4
PA
THALOMID CAP 200 MG
thalidomide
4
PA
THALOMID CAP 50 MG
thalidomide
4
PA
TREXALL TAB 10 MG
methotrexate sodium
3
PA
TREXALL TAB 15 MG
methotrexate sodium
3
PA
TREXALL TAB 5 MG
methotrexate sodium
3
PA
TREXALL TAB 7.5 MG
methotrexate sodium
3
PA
tri-vit/fluoride solution 0.25 mg/ml
1
1
tri-vitamin/fluoride solution 0.25 mg/ml
1
PAGE 202
PRODUCT DESCRIPTION
TIER
1
triple-vitamin/fluoride solution 0.25 mg/ml
1
uretron d/s tab
1
URETRON D/S TAB
1
ustell cap 120 mg
1
utira-c tab 81.6 mg
1
VAGIFEM TAB 10 MCG
estradiol vaginal
3
vitamins acd-fluoride solution 0.25 mg/ml
1
VIVITROL RECON SUSP 380 MG
naltrexone
4
PA
ZORTRESS TAB 0.25 MG
everolimus (immunosuppressant)
4
PA
ZORTRESS TAB 0.5 MG
4
PA
ZORTRESS TAB 0.75 MG
4
PA
AEROSPAN AERO SOLN 80 MCG/ACT
flunisolide hfa
2
QL
ALOCRIL SOLUTION 2 %
nedocromil sodium (ophth)
3
PA
BECONASE AQ SUSPENSION 42 MCG/SPRAY
beclomethasone diprop monohyd
3
ST
1
Respiratory Tract Agents
Anti-inflammatory Agents
8.9 / 30 days
QL
120 / 30 days
AL1
Up to 8 yrs old
QL
120 / 30 days
AL1
Up to 8 yrs old
1
cromolyn sodium conc 100 mg/5ml
1
cromolyn sodium solution 4 %
1
FLOVENT DISKUS AER POW BA 100 MCG/BLIST
fluticasone propionate (inhalation)
3
QL
60 / 30 days
1
QL
50 / 25 days
PAGE 203
PRODUCT DESCRIPTION
TIER
1
montelukast sodium chew tab 4 mg
1
montelukast sodium chew tab 5 mg
1
montelukast sodium packet 4 mg
1
montelukast sodium tab 10 mg
1
NASACORT ALLERGY 24HR AEROSOL 55 MCG/ACT
triamcinolone acetonide (nasal)
1
3
ST
3
QL
1 / 30 days
3
QL
1 / 30 days
PULMICORT SUSPENSION 1 MG/2ML
QL
120 / 30 days
4
AL1
Up to 8 yrs old
QNASL AERO SOLN 80 MCG/ACT
beclomethasone dipropionate (nasal)
3
ST
2
QL
2
RHINOCORT AQUA SUSPENSION 32 MCG/ACT
budesonide (nasal)
3
ST
fluticasone furoate
3
ST
zafirlukast tab 10 mg
3
zafirlukast tab 20 mg
3
ZYFLO TAB 600 MG
zileuton
4
PA
ALLEGRA ALLERGY CHILDRENS TAB 30 MG
fexofenadine hcl
1
QL
50 / 30 days
1
AL1
Up to 64 yrs old
arbinoxa tab 4 mg
1
AL1
Up to 64 yrs old
ASTEPRO SOLUTION 0.15 %
azelastine hcl
3
ST
QL
16 / 25 days
8.7 / 30 days
Antihistamines
PAGE 204
PRODUCT DESCRIPTION
TIER
3
3
ST
azelastine hcl solution 137 mcg/spray
1
ST
carbinoxamine maleate tab 4 mg
1
AL1
Up to 64 yrs old
cetirizine hcl childrens alrgy syrup 1 mg/ml
1
QL
50 / 30 days
cetirizine hcl solution 1 mg/ml
1
QL
50 / 30 days
cetirizine hcl syrup 1 mg/ml
1
QL
50 / 30 days
cetirizine hcl syrup 5 mg/5ml
1
cetirizine hcl tab 10 mg
1
QL
50 / 30 days
1
QL
50 / 30 days
childrens loratadine syrup 5 mg/5ml
1
QL
50 / 30 days
CLARITIN REDITABS TAB DISP 10 MG
loratadine
1
QL
50 / 30 days
clemastine fumarate syrup 0.67 mg/5ml
1
AL1
Up to 64 yrs old
CLEMASTINE FUMARATE SYRUP 0.67 MG/5ML
clemastine fumarate
1
AL1
Up to 64 yrs old
clemastine fumarate tab 2.68 mg
1
AL1
Up to 64 yrs old
cvs allergy relief tab 10 mg
1
QL
50 / 30 days
cvs loratadine tab 10 mg
1
QL
50 / 30 days
cyproheptadine hcl syrup 2 mg/5ml
1
AL1
Up to 64 yrs old
cyproheptadine hcl tab 4 mg
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
eq loratadine tab 10 mg
1
QL
50 / 30 days
eql childrens loratadine syrup 5 mg/5ml
1
QL
50 / 30 days
fexofenadine hcl tab 180 mg
1
QL
50 / 30 days
PAGE 205
PRODUCT DESCRIPTION
TIER
1
QL
50 / 30 days
gnp loratadine childrens syrup 5 mg/5ml
1
QL
50 / 30 days
gnp loratadine syrup 5 mg/5ml
1
QL
50 / 30 days
gnp loratadine tab 10 mg
1
QL
50 / 30 days
hm fexofenadine hcl tab 180 mg
1
QL
50 / 30 days
1
QL
50 / 30 days
hm loratadine childrens syrup 5 mg/5ml
1
QL
50 / 30 days
kp cetirizine hcl tab 10 mg
1
QL
50 / 30 days
1
QL
50 / 30 days
kp fexofenadine hcl tab 180 mg
1
QL
50 / 30 days
loratadine allergy relief tab disp 10 mg
1
QL
50 / 30 days
loratadine tab 10 mg
1
QL
50 / 30 days
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
PAGE 206
PRODUCT DESCRIPTION
TIER
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
qc loratadine allergy relief tab 10 mg
1
QL
50 / 30 days
1
AL1
Up to 64 yrs old
sb loratadine tab 10 mg
1
QL
50 / 30 days
1
AL1
Up to 64 yrs old
sm childrens loratadine syrup 5 mg/5ml
1
QL
50 / 30 days
sm fexofenadine hcl tab 180 mg
1
QL
50 / 30 days
1
QL
50 / 30 days
sm loratadine allergy relief tab disp 10 mg
1
QL
50 / 30 days
sm loratadine syrup 5 mg/5ml
1
QL
50 / 30 days
sm loratadine tab 10 mg
1
QL
50 / 30 days
sm loratadine tab disp 10 mg
1
QL
50 / 30 days
tgt loratadine childrens syrup 5 mg/5ml
1
QL
50 / 30 days
wal-itin tab 10 mg
1
QL
30 / 30 days
Bronchodilators
ADRENACLICK SOLN A-INJ 0.15 MG/0.15ML
epinephrine
3
1
1
albuterol sulfate nebu soln (2.5 mg/3ml) 0.083%
1
albuterol sulfate nebu soln (5 mg/ml) 0.5%
1
1
1
albuterol sulfate syrup 2 mg/5ml
1
ARCAPTA NEOHALER CAP 75 MCG
indacaterol maleate
3
ATROVENT HFA AERO SOLN 17 MCG/ACT
ipratropium bromide hfa
2
PAGE 207
PA
QL
26 / 25 days
PRODUCT DESCRIPTION
TIER
AUVI-Q SOLN A-INJ 0.15 MG/0.15ML
epinephrine
3
3
theophylline
2
epinephrine hcl soln prsyr 0.1 mg/ml
1
epinephrine hcl solution 1 mg/ml
1
epinephrine
1
epinephrine
1
EPIPEN 2-PAK SOLN A-INJ 0.3 MG/0.3ML
epinephrine
2
EPIPEN JR 2-PAK SOLN A-INJ 0.15 MG/0.3ML
epinephrine
QL
4 / 25 days
QL
2 / 90 days
2
QL
2 / 90 days
FORADIL AEROLIZER CAP 12 MCG
formoterol fumarate
2
QL
60 / 30 days
1
1
QL
30 / 25 days
1
QL
15 / 25 days
1
1
ST
1
ST
levalbuterol hcl nebu soln 1.25 mg/0.5ml
1
ST
metaproterenol sulfate syrup 10 mg/5ml
1
METAPROTERENOL SULFATE SYRUP 10 MG/5ML
1
1
1
PERFOROMIST NEBU SOLN 20 MCG/2ML
formoterol fumarate
3
PROAIR HFA AERO SOLN 108 (90 BASE) MCG/ACT
albuterol sulfate
3
PAGE 208
PA
PRODUCT DESCRIPTION
TIER
PROVENTIL HFA AERO SOLN 108 (90 BASE) MCG/ACT
albuterol sulfate
3
QL
SEREVENT DISKUS AER POW BA 50 MCG/DOSE
salmeterol xinafoate
2
PA
SPIRIVA HANDIHALER CAP 18 MCG
tiotropium bromide monohydrate
2
QL
30 / 30 days
terbutaline sulfate solution 1 mg/ml
1
terbutaline sulfate tab 2.5 mg
1
terbutaline sulfate tab 5 mg
1
1
1
1
1
1
1
1
1
1
1
VENTOLIN HFA AERO SOLN 108 (90 BASE) MCG/ACT
albuterol sulfate
2
XOPENEX HFA AEROSOL 45 MCG/ACT
levalbuterol tartrate
QL
60 / 30 days
3
6.7 / 30 days
ST
Cystic Fibrosis Transmembrane Conductance Regulator Modulators
KALYDECO TAB 150 MG
ivacaftor
4
1
1
1
benzonatate cap 100 mg
1
benzonatate cap 200 mg
1
1
CODEINE SULFATE SOLUTION 30 MG/5ML
codeine sulfate
1
PAGE 209
PA
AL1
Up to 64 yrs old
PRODUCT DESCRIPTION
TIER
1
codeine sulfate
1
1
codeine sulfate
1
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
hydrocod polst-cpm polst er liquid er 10-8 mg/5ml
1
hydrocodone-homatropine syrup 5-1.5 mg/5ml
1
hydrocodone-homatropine tab 5-1.5 mg
1
hydromet syrup 5-1.5 mg/5ml
1
IODINE STRONG (LUGOL'S) SOLUTION
iodine strong (lugol's) (bulk)
1
IODINE STRONG SOLUTION 5 %
iodine strong (lugol's)
1
LETAIRIS TAB 10 MG
ambrisentan
4
PA
LETAIRIS TAB 5 MG
ambrisentan
4
PA
1
AL1
Up to 64 yrs old
1
promethazine-codeine syrup 6.25-10 mg/5ml
1
promethazine-dm syrup 6.25-15 mg/5ml
1
PULMOZYME SOLUTION 1 MG/ML
dornase alfa
QL
60 / 30 days
4
1
AL1
4
PA
1
AL1
sodium chloride nebu soln 0.9 %
1
PAGE 210
PA
Up to 64 yrs old
Up to 64 yrs old
PRODUCT DESCRIPTION
TIER
sodium chloride nebu soln 10 %
1
1
1
1
TGQ 30PSE/150GFN/15DM SYRUP 30-150-15 MG/5ML
pseudoephedrine w/ dm-gg
1
tussigon tab 5-1.5 mg
1
TYVASO REFILL SOLUTION 0.6 MG/ML
treprostinil
4
PA
TYVASO SOLUTION 0.6 MG/ML
treprostinil
4
PA
TYVASO STARTER SOLUTION 0.6 MG/ML
treprostinil
4
PA
VENTAVIS SOLUTION 10 MCG/ML
iloprost
4
PA
VENTAVIS SOLUTION 20 MCG/ML
iloprost
4
PA
XOLAIR RECON SOLN 150 MG
omalizumab
4
PA
Serums, Toxoids and Vaccines
AFLURIA PRESERVATIVE FREE SUSP PRSYR 0.5 ML
influenza virus vaccine split preservative free
5
AFLURIA SUSPENSION
influenza virus vaccine split
5
FLUARIX QUADRIVALENT SUSP PRSYR 0.5 ML
influenza virus vaccine split quadrivalent
5
FLUARIX SUSP PRSYR 0.5 ML
5
FLUCELVAX SUSP PRSYR 0.5 ML
influenza virus vaccine tissue-cultured subunit
5
FLULAVAL QUADRIVALENT SUSP PRSYR 0.5 ML
5
FLULAVAL SUSPENSION
5
FLUVIRIN PRESERVATIVE FREE SUSP PRSYR 0.5 ML
influenza virus vaccine types a & b preservative free
5
FLUVIRIN SUSPENSION
influenza virus vaccine types a & b surface antigen
5
PAGE 211
PRODUCT DESCRIPTION
TIER
FLUZONE PRESERVATIVE FREE SUSP PRSYR 0.5 ML
5
FLUZONE PRESERVATIVE FREE SUSPENSION
5
FLUZONE QUADRIVALENT SUSP PRSYR 0.5 ML
5
FLUZONE QUADRIVALENT SUSPENSION 0.5 ML
5
FLUZONE SUSP PEN 9 MCG/STRAIN
5
FLUZONE SUSPENSION
5
ZOSTAVAX RECON SOLN 19400 UNT/0.65ML
zoster vaccine live
5
Skin and Mucous Membrane Preparations
Anti-infectives
acticin cream 5 %
1
QL
acyclovir ointment 5 %
4
PA
ALTABAX OINTMENT 1 %
retapamulin
3
ST
antifungal cream 2 %
1
BACTROBAN NASAL OINTMENT 2 %
mupirocin calcium
3
baza antifungal cream 2 %
1
benzepro foam 5.3 %
3
benzepro short contact foam 9.8 %
3
benzoyl peroxide cleanser lotion 6 %
1
benzoyl peroxide foam 5.3 %
3
benzoyl peroxide gel 10 %
1
benzoyl peroxide gel 5 %
1
benzoyl peroxide wash kit 4 & 5 %
1
benzoyl peroxide wash kit 8 & 5 %
1
benzoyl peroxide-erythromycin gel 5-3 %
1
bp wash liquid 7 %
3
PAGE 212
120 / 30 days
PRODUCT DESCRIPTION
TIER
bpo creamy wash kit 4 & 5 %
1
BPO CREAMY WASH KIT 8 & 5 %
benzoyl peroxide
1
carrington antifungal cream 2 %
1
chlorhexidine gluconate solution 0.12 %
1
CHLORHEXIDINE GLUCONATE SOLUTION 20 %
chlorhexidine gluconate
3
CLEOCIN SUPPOS 100 MG
clindamycin phosphate vaginal
3
clindacin-p swab 1 %
1
clindamax gel 1 %
3
clindamax lotion 1 %
1
clindamycin phos-benzoyl perox gel 1-5 %
3
clindamycin phosphate cream 2 %
1
clindamycin phosphate foam 1 %
3
clindamycin phosphate gel 1 %
3
clindamycin phosphate lotion 1 %
1
clindamycin phosphate solution 1 %
1
clindamycin phosphate swab 1 %
1
clotrimazole af cream 1 %
1
QL
50 / 30 days
clotrimazole anti-fungal cream 1 %
1
QL
50 / 30 days
clotrimazole cream 1 %
1
QL
50 / 30 days
clotrimazole cream 1 %
1
QL
50 / 30 days
clotrimazole lozenge 10 mg
1
clotrimazole solution 1 %
1
clotrimazole troche 10 mg
1
clotrimazole-7 cream 1 %
1
QL
50 / 30 days
clotrimazole-betamethasone cream 1-0.05 %
1
QL
90 / 23 days
clotrimazole-betamethasone lotion 1-0.05 %
3
QL
60 / 23 days
CORTISPORIN CREAM 0.5-0.5-10000
neomycin-polymyxin-hc
1
CORTISPORIN OINTMENT 1 %
bacitracin-polymyxin-neomycin hc
3
PAGE 213
PRODUCT DESCRIPTION
TIER
DENAVIR CREAM 1 %
penciclovir
3
econazole nitrate cream 1 %
1
EPIDUO GEL 0.1-2.5 %
adapalene-benzoyl peroxide
3
eql miconazole 3 kit 200-2 mg-% (9gm)
1
ERTACZO CREAM 2 %
sertaconazole nitrate
3
ery pad 2 %
1
erythromycin gel 2 %
1
erythromycin pad 2 %
1
erythromycin solution 2 %
1
EURAX CREAM 10 %
crotamiton
2
PA
EURAX LOTION 10 %
crotamiton
2
PA
EXODERM LOTION 25-1 %
sodium thiosulfate-salicylic acid
1
fungicure intensive/nailguard solution 1 %
1
gentamicin sulfate cream 0.1 %
1
GENTAMICIN SULFATE CREAM 0.1 %
gentamicin sulfate (topical)
1
gentamicin sulfate ointment 0.1 %
1
GENTAMICIN SULFATE OINTMENT 0.1 %
gentamicin sulfate (topical)
1
gnp miconazole 3 kit
1
gnp miconazole 3 kit 200-2 mg-% (9gm)
1
GYNAZOLE-1 CREAM 2 %
butoconazole nitrate (one dose)
3
IODINE TINCTURE TINCTURE
iodine (topical)
1
ketoconazole cream 2 %
1
ketoconazole shampoo 2 %
1
ketodan foam 2 %
3
kp benzoyl peroxide gel 10 %
1
PAGE 214
QL
85 / 23 days
PRODUCT DESCRIPTION
TIER
kp benzoyl peroxide gel 5 %
1
kp clotrimazole cream 1 %
1
kp miconazole nitrate cream 2 %
1
lindane lotion 1 %
3
lindane shampoo 1 %
3
LUGOLS SOLUTION
iodine (topical)
1
mafenide acetate packet 5 %
3
malathion lotion 0.5 %
2
MENTAX CREAM 1 %
butenafine hcl
3
metronidazole cream 0.75 %
3
3
1
metronidazole lotion 0.75 %
1
miconazole 3 combo pack kit 200-2 mg-% (9gm)
1
miconazole nitrate cream 2 %
1
miconazole nitrate cream 2 %
1
mupirocin calcium cream 2 %
3
mupirocin ointment 2 %
1
NATROBA SUSPENSION 0.9 %
spinosad
3
neomycin-polymyxin b gu solution 40-200000
1
nyamyc powder 100000 unit/gm
1
nystatin cream 100000 unit/gm
1
nystatin ointment 100000 unit/gm
1
nystatin powder 100000 unit/gm
1
nystatin-triamcinolone cream 100000-0.1 unit/gm-%
3
nystatin-triamcinolone ointment 100000-0.1 unit/gm-%
1
nystop powder 100000 unit/gm
1
OXISTAT CREAM 1 %
oxiconazole nitrate
3
periogard solution 0.12 %
1
PAGE 215
QL
50 / 30 days
ST
PRODUCT DESCRIPTION
TIER
permethrin cream 5 %
1
podactin cream 2 %
1
qc clotrimazole cream 1 %
QL
120 / 30 days
1
QL
50 / 30 days
ra clotrimazole 7 cream 1 %
1
QL
50 / 30 days
remedy antifungal cream 2 %
1
rosadan cream 0.75 %
3
rosadan gel 0.75 %
3
seb-prev wash liquid 10 %
3
secura antifungal cream 2 %
1
secura antifungal extra thick cream 2 %
1
selenium sulf-pyrithione-urea shampoo 2.25 %
3
selenium sulfide lotion 2.5 %
1
SKLICE LOTION 0.5 %
ivermectin (pediculicide)
3
PA
sm antifungal clotrimazole cream 1 %
1
QL
50 / 30 days
sm antifungal miconazole cream 2 %
1
sm clotrimazole vaginal cream 1 %
1
QL
50 / 30 days
sm miconazole 3 kit 200-2 mg-% (9gm)
1
SODIUM SULFACETAMIDE WASH LIQUID 10 %
sulfacetamide sodium in bakuchiol vehicle
3
soothe & cool inzo antifungal cream 2 %
1
sulfacetamide sodium (acne) lotion 10 %
3
sulfacetamide sodium liquid 10 %
3
sulfacetamide sodium suspension 10 %
3
sulfacetamide sodium-sulfur lotion 10-5 %
3
terconazole cream 0.4 %
1
terconazole cream 0.8 %
1
terconazole suppos 80 mg
3
tgt clotrimazole cream 1 %
1
QL
50 / 30 days
tgt miconazole 3 combo pack kit 200-2 mg-% (9gm)
1
triple antibiotic ointment 3.5-400-5000
1
QL
50 / 30 days
PAGE 216
PRODUCT DESCRIPTION
TIER
urea emulsion 50 %
3
urea in zn undecyl-lactic acid emulsion 50 %
3
vandazole gel 0.75 %
1
VELTIN GEL 1.2-0.025 %
clindamycin phosphate-tretinoin
3
zazole cream 0.4 %
1
zazole cream 0.8 %
1
ZIANA GEL 1.2-0.025 %
3
ZOVIRAX CREAM 5 %
acyclovir topical
3
PA
Depigmenting and Pigmenting Agents
alphaquin hp cream 4 %
1
hydroquinone time release cream 4 %
1
melpaque hp cream 4 %
1
MELQUIN 3 SOLUTION 3 %
hydroquinone
1
melquin hp cream 4 %
1
methoxsalen rapid cap 10 mg
3
OXSORALEN LOTION 1 %
methoxsalen (topical)
4
OXSORALEN ULTRA CAP 10 MG
methoxsalen rapid
3
PA
acitretin cap 10 mg
4
PA
acitretin cap 17.5 mg
4
PA
acitretin cap 25 mg
4
PA
ala cort cream 1 %
1
alclometasone dipropionate cream 0.05 %
1
alclometasone dipropionate ointment 0.05 %
1
amcinonide cream 0.1 %
3
AMCINONIDE CREAM 0.1 %
amcinonide
3
AMCINONIDE LOTION 0.1 %
amcinonide
3
PAGE 217
PA
PRODUCT DESCRIPTION
TIER
AMCINONIDE OINTMENT 0.1 %
amcinonide
3
ammonium lactate cream 12 %
1
PA
ammonium lactate lotion 12 %
1
PA
ANALPRAM-HC LOTION 1-2.5 %
hydrocortisone acetate w/ pramoxine
3
anti-itch intensive healing lotion 1 %
1
QL
240 / 23 days
anti-itch maximum strength cream 1 %
1
QL
120 / 23 days
anucort-hc suppos 25 mg
1
aquanil hc lotion 1 %
1
QL
240 / 23 days
QL
45 / 23 days
ATRALIN GEL 0.05 %
tretinoin
3
aveeno anti-itch max st cream 1 %
1
AVIDOXY DK KIT 100 MG
doxycycline w/ suncreen & salicylic acid
1
avita cream 0.025 %
1
ST
AL1
Up to 28 yrs old
QL
120 / 23 days
QL
45 / 23 days
AL1
Up to 28 yrs old
AL1
Up to 28 yrs old
avita gel 0.025 %
1
BENZYL ALCOHOL LIQUID
benzyl alcohol
1
beta hc lotion 1 %
1
QL
240 / 23 days
betamethasone dipropionate aug cream 0.05 %
1
QL
100 / 23 days
betamethasone dipropionate aug gel 0.05 %
1
QL
100 / 23 days
betamethasone dipropionate aug lotion 0.05 %
1
QL
120 / 23 days
betamethasone dipropionate aug ointment 0.05 %
1
QL
100 / 23 days
betamethasone dipropionate cream 0.05 %
1
QL
90 / 23 days
betamethasone dipropionate lotion 0.05 %
1
QL
120 / 23 days
betamethasone dipropionate ointment 0.05 %
1
QL
90 / 23 days
betamethasone valerate cream 0.1 %
1
QL
90 / 23 days
PAGE 218
PRODUCT DESCRIPTION
TIER
betamethasone valerate foam 0.12 %
3
betamethasone valerate lotion 0.1 %
1
QL
120 / 23 days
betamethasone valerate ointment 0.1 %
1
QL
90 / 23 days
calahist clear lotion 1-0.1 %
1
calcipotriene cream 0.005 %
3
calcipotriene ointment 0.005 %
3
calcipotriene solution 0.005 %
3
calcipotriene-betameth diprop ointment 0.005-0.064 %
3
ST
CALCITRIOL OINTMENT 3 MCG/GM
calcitriol (topical)
3
PA
CAPEX SHAMPOO 0.01 %
fluocinolone acetonide
3
capsaicin cream 0.025 %
1
capsaicin cream 0.1 %
1
capsaicin hp cream 0.1 %
1
CEM-UREA SOLUTION 45 %
urea
3
clobetasol propionate cream 0.05 %
1
clobetasol propionate emulsion foam 0.05 %
3
clobetasol propionate foam 0.05 %
3
clobetasol propionate gel 0.05 %
1
clobetasol propionate lotion 0.05 %
3
clobetasol propionate ointment 0.05 %
1
clobetasol propionate shampoo 0.05 %
3
clobetasol propionate solution 0.05 %
1
CLODERM CREAM 0.1 %
clocortolone pivalate
3
CLODERM PUMP CREAM 0.1 %
clocortolone pivalate
3
clotrimazole-betamethasone cream 1-0.05 %
clotrimazole-betamethasone lotion 1-0.05 %
PAGE 219
QL
120 / 23 days
ST
QL
120 / 23 days
QL
120 / 23 days
QL
120 / 23 days
1
QL
90 / 23 days
3
QL
60 / 23 days
PRODUCT DESCRIPTION
TIER
COAL TAR EXTRACT SOLUTION 20 %
coal tar (crude)
1
COAL TAR SOLUTION
coal tar (crude)
1
COAL TAR SOLUTION 20 %
coal tar (crude)
1
COAL TAR SOLUTION 20 %
coal tar extract
1
colocort enema 100 mg/60ml
1
CONDYLOX GEL 0.5 %
podofilox
3
PA
CORDRAN CREAM 0.05 %
flurandrenolide
3
PA
CORDRAN LOTION 0.05 %
flurandrenolide
3
PA
CORDRAN TAPE 4 MCG/SQCM
flurandrenolide
3
cormax scalp application solution 0.05 %
1
QL
100 / 23 days
cortaid advanced 12 hour cream 1 %
1
QL
120 / 23 days
cortaid maximum strength cream 1 %
1
QL
120 / 23 days
CORTIFOAM FOAM 90 MG
hydrocortisone acetate (intrarectal)
3
ST
CORTISPORIN CREAM 0.5-0.5-10000
neomycin-polymyxin-hc
1
CORTISPORIN OINTMENT 1 %
bacitracin-polymyxin-neomycin hc
3
cortizone-10 eczema lotion 1 %
1
QL
240 / 23 days
cortizone-10 hydratensive lotion 1 %
1
QL
240 / 23 days
cortizone-10 ointment 1 %
1
QL
90 / 23 days
COTTONSEED OIL OIL
cottonseed oil (bulk)
1
cvs anti-itch maximum strength cream 1 %
1
QL
120 / 23 days
cvs capsaicin hp cream 0.1 %
1
cvs cortisone intense healing cream 1 %
1
QL
120 / 23 days
PAGE 220
QL
1 / 23 days
PA
PRODUCT DESCRIPTION
TIER
cvs cortisone long-lasting lotion 1 %
1
QL
240 / 23 days
cvs cortisone maximum strength cream 1 %
1
QL
120 / 23 days
cvs cortisone maximum strength ointment 1 %
1
QL
90 / 23 days
cvs eczema anti-itch cream 1 %
1
QL
120 / 23 days
cvs hydrocortisone anti-itch cream 1 %
1
QL
120 / 23 days
cvs hydrocortisone max st cream 1 %
1
QL
120 / 23 days
desonide cream 0.05 %
3
QL
120 / 23 days
desonide lotion 0.05 %
3
desonide ointment 0.05 %
1
QL
120 / 23 days
DESOXIMETASONE CREAM 0.05 %
desoximetasone
1
QL
200 / 23 days
desoximetasone cream 0.25 %
1
QL
200 / 23 days
desoximetasone gel 0.05 %
1
QL
120 / 23 days
DESOXIMETASONE OINTMENT 0.05 %
desoximetasone
3
QL
120 / 23 days
desoximetasone ointment 0.25 %
1
QL
200 / 23 days
DIFLORASONE DIACETATE CREAM 0.05 %
diflorasone diacetate
1
QL
120 / 23 days
diflorasone diacetate ointment 0.05 %
1
QL
120 / 23 days
DIFLORASONE DIACETATE OINTMENT 0.05 %
diflorasone diacetate
1
QL
120 / 23 days
DRITHO-CREME HP CREAM 1 %
anthralin
3
ELIDEL CREAM 1 %
pimecrolimus
3
QL
100 / 30 days
EPIDUO GEL 0.1-2.5 %
adapalene-benzoyl peroxide
3
eq anti-itch max strength cream 1 %
1
QL
120 / 23 days
eq hydrocortisone max st cream 1 %
1
QL
120 / 23 days
eq hydrocortisone plus cream 1 %
1
QL
120 / 23 days
eql anti-itch intensive heal cream 1 %
1
QL
120 / 23 days
PAGE 221
PRODUCT DESCRIPTION
TIER
eql anti-itch maximum strength cream 1 %
1
QL
120 / 23 days
eql anti-itch maximum strength ointment 1 %
1
QL
90 / 23 days
ETHYL CHLORIDE AEROSOL
ethyl chloride
1
EXODERM LOTION 25-1 %
sodium thiosulfate-salicylic acid
1
1
fluocinolone acetonide cream 0.01 %
1
QL
120 / 23 days
fluocinolone acetonide cream 0.025 %
1
QL
120 / 23 days
fluocinolone acetonide ointment 0.025 %
1
QL
120 / 23 days
fluocinolone acetonide solution 0.01 %
3
QL
120 / 23 days
fluocinonide cream 0.05 %
1
QL
120 / 23 days
fluocinonide gel 0.05 %
1
QL
120 / 23 days
fluocinonide ointment 0.05 %
1
QL
120 / 23 days
fluocinonide solution 0.05 %
1
QL
120 / 23 days
fluorouracil cream 5 %
3
fluorouracil solution 2 %
1
fluorouracil solution 5 %
1
fluticasone propionate cream 0.05 %
1
QL
120 / 23 days
fluticasone propionate lotion 0.05 %
3
fluticasone propionate ointment 0.005 %
1
QL
120 / 23 days
geri-hydrolac 12 cream 12 %
1
PA
glydo gel 2 %
1
QL
90 / 23 days
gnp capsaicin cream 0.1 %
1
gnp hydro-lotion lotion 1 %
1
QL
240 / 23 days
gnp hydrocortisone max st ointment 1 %
1
QL
90 / 23 days
gnp hydrocortisone plus cream 1 %
1
QL
120 / 23 days
halobetasol propionate cream 0.05 %
1
QL
100 / 23 days
halobetasol propionate ointment 0.05 %
1
QL
100 / 23 days
PAGE 222
PRODUCT DESCRIPTION
TIER
HALOG CREAM 0.1 %
halcinonide
3
QL
100 / 23 days
HALOG OINTMENT 0.1 %
halcinonide
3
QL
100 / 23 days
halonate pac kit 0.05 & 12 %
3
hydro skin maximum strength lotion 1 %
1
QL
240 / 23 days
hydrocortisone ace-pramoxine cream 1-1 %
3
hydrocortisone ace-pramoxine cream 2.5-1 %
3
hydrocortisone ace-pramoxine cream 2.5-1 %
1
QL
60 / 23 days
hydrocortisone ace-pramoxine kit 2.5-1 & 1 %
1
hydrocortisone acetate suppos 25 mg
1
hydrocortisone acetate suppos 30 mg
1
hydrocortisone butyr lipo base cream 0.1 %
1
hydrocortisone butyrate cream 0.1 %
1
hydrocortisone butyrate ointment 0.1 %
1
hydrocortisone butyrate solution 0.1 %
1
hydrocortisone cream 1 %
1
QL
120 / 23 days
hydrocortisone cream 2.5 %
3
QL
90 / 23 days
hydrocortisone enema 100 mg/60ml
1
hydrocortisone intensive heal cream 1 %
1
QL
120 / 23 days
hydrocortisone lotion 1 %
1
hydrocortisone lotion 2.5 %
1
QL
120 / 23 days
hydrocortisone max st cream 1 %
1
QL
120 / 23 days
hydrocortisone max st/12 moist cream 1 %
1
hydrocortisone ointment 0.5 %
1
hydrocortisone ointment 1 %
1
QL
90 / 23 days
hydrocortisone ointment 2.5 %
1
QL
90 / 23 days
hydrocortisone plus cream 1 %
1
QL
120 / 23 days
hydrocortisone valerate cream 0.2 %
1
QL
120 / 23 days
hydrocortisone valerate ointment 0.2 %
1
QL
120 / 23 days
PAGE 223
PRODUCT DESCRIPTION
TIER
hydroskin cream 1 %
1
hygienic cleansing pad 50 %
1
hypercare solution 20 %
1
ice blue gel 2 %
1
imiquimod cream 5 %
QL
120 / 23 days
4
QL
60 / 30 days
KENALOG AERO SOLN
triamcinolone acetonide (topical)
3
PA
kericort 10 cream 1 %
1
QL
120 / 23 days
kp hydrocortisone cream 1 %
1
kp hydrocortisone max st ointment 1 %
1
QL
90 / 23 days
laclotion lotion 12 %
1
PA
lactic acid e cream 10-3500 %-unt/30gm
1
PA
lactic acid lotion 10 %
1
PA
latrix suspension 50 %
1
lidocaine hcl cream 3 %
1
lidocaine hcl gel 2 %
1
LIDOCAINE HCL LOTION 3 %
lidocaine hcl
QL
85 / 30 days
1
QL
100 / 23 days
1
QL
100 / 23 days
lidocaine ointment 5 %
1
QL
70.8 / 23 days
lidocaine patch 5 %
3
PA
lidocaine-hydrocortisone ace cream 3-0.5 %
1
LIDOCAINE-HYDROCORTISONE ACE GEL 2.8-0.55 %
lidocaine-hydrocortisone acetate (rectal)
3
lidocaine-hydrocortisone ace kit 2-2 %
3
lidocaine-hydrocortisone ace kit 3-1 %
1
lidocaine-hydrocortisone ace kit 3-2.5 %
1
lidocaine-prilocaine cream 2.5-2.5 %
1
AL1
LIDODERM PATCH 5 %
lidocaine
3
PA
PAGE 224
PA
Up to 15 yrs old
PRODUCT DESCRIPTION
TIER
lidopin cream 3 %
1
QL
lokara lotion 0.05 %
1
PA
lubricating jelly gel
1
4
85 / 30 days
PA
ST
PA
4
ST
PA
3
ST
mometasone furoate cream 0.1 %
1
mometasone furoate ointment 0.1 %
1
mometasone furoate solution 0.1 %
1
muscle relief cream 0.075 %
1
neosporin eczema essent max st cream 1 %
1
QL
120 / 23 days
noble formula hc cream 1 %
1
QL
120 / 23 days
nystatin-triamcinolone cream 100000-0.1 unit/gm-%
3
nystatin-triamcinolone ointment 100000-0.1 unit/gm-%
1
oralone paste 0.1 %
3
PETROLEUM JELLY GEL
white petrolatum
1
phenazo tab 200 mg
1
phenazopyridine hcl tab 100 mg
1
phenazopyridine hcl tab 200 mg
1
PODOCON SOLUTION 25 %
podophyllum resin
3
podofilox solution 0.5 %
1
pramcort cream 1-1 %
1
QL
60 / 23 days
prednicarbate cream 0.1 %
1
QL
120 / 23 days
prednicarbate ointment 0.1 %
1
QL
120 / 23 days
preparation h hydrocortisone cream 1 %
1
QL
120 / 23 days
PAGE 225
PRODUCT DESCRIPTION
TIER
PROCTOFOAM HC FOAM 1-1 %
hydrocortisone acetate w/ pramoxine
3
proctosol hc cream 2.5 %
1
proctozone-hc cream 2.5 %
1
PRUDOXIN CREAM 5 %
doxepin hcl (antipruritic)
3
px hydrocream cream 1 %
1
PYROGALLIC ACID OINTMENT 25-2 %
pyrogallol-chlorobutanol
1
qc hydrocortisone cream 1 %
QL
120 / 23 days
1
QL
120 / 23 days
qc hydrocortisone max st cream 1 %
1
QL
120 / 23 days
ra anti-itch maximum strength cream 1 %
1
QL
120 / 23 days
ra anti-itch maximum strength ointment 1 %
1
QL
90 / 23 days
ra hydrocortisone max st cream 1 %
1
QL
120 / 23 days
ra hydrocortisone plus 12 cream 1 %
1
QL
120 / 23 days
rea lo 39 cream 39 %
3
recort plus cream 1 %
1
QL
120 / 23 days
RECTIV OINTMENT 0.4 %
nitroglycerin (intra-anal)
3
ST
regenecare ha gel 2 %
1
QL
remeven cream 50 %
1
revina ointment
1
salacyn cream 6 %
1
salacyn lotion 6 %
1
salicylic acid cream 6 %
3
salicylic acid foam 6 %
3
salicylic acid gel 6 %
1
SALICYLIC ACID LIQUID 26 %
salicylic acid
1
salicylic acid liquid 27.5 %
1
salicylic acid lotion 6 %
3
salicylic acid shampoo 6 %
1
PAGE 226
90 / 23 days
PRODUCT DESCRIPTION
TIER
salicylic acid wart remover liquid 27.5 %
1
SALVAX FOAM 6 %
salicylic acid
3
SANTYL OINTMENT 250 UNIT/GM
collagenase
3
sarnol-hc lotion 1 %
1
QL
240 / 23 days
sb hydrocortisone cream 1 %
1
QL
120 / 23 days
sb hydrocortisone max st ointment 1 %
1
QL
90 / 23 days
scalacort lotion 2 %
3
QL
120 / 23 days
selenium sulf-pyrithione-urea shampoo 2.25 %
3
sm hydrocortisone cream 1 %
1
QL
120 / 23 days
sm hydrocortisone max st ointment 1 %
1
QL
90 / 23 days
SORIATANE CAP 10 MG
acitretin
4
PA
SORIATANE CAP 17.5 MG
acitretin
4
PA
SORIATANE CAP 25 MG
acitretin
4
PA
STELARA SOLN PRSYR 45 MG/0.5ML
ustekinumab
4
PA
sulfacetamide sodium-sulfur lotion 10-5 %
3
SYNALAR CREAM 0.025 %
3
SYNALAR OINTMENT 0.025 %
3
TACLONEX OINTMENT 0.005-0.064 %
calcipotriene-betamethasone dipropionate
3
ST
TACLONEX SUSPENSION 0.005-0.064 %
calcipotriene-betamethasone dipropionate
3
ST
TAZORAC CREAM 0.05 %
tazarotene
4
PA
TAZORAC CREAM 0.1 %
tazarotene
4
PA
TAZORAC GEL 0.05 %
tazarotene
4
PA
PAGE 227
PRODUCT DESCRIPTION
TIER
TAZORAC GEL 0.1 %
tazarotene
4
PA
tgt anti-itch maximum strength cream 1 %
1
QL
120 / 23 days
tgt anti-itch maximum strength ointment 1 %
1
QL
90 / 23 days
tgt anti-itch plus oatmeal cream 1 %
1
QL
120 / 23 days
tgt anti-itch/aloe/vit e cream 1 %
1
QL
120 / 23 days
th hydrocortisone cream 1 %
1
QL
120 / 23 days
theracort lotion 1 %
1
QL
240 / 23 days
QL
tretinoin cream 0.025 %
45 / 23 days
1
AL1
Up to 28 yrs old
QL
45 / 23 days
AL1
Up to 28 yrs old
QL
45 / 23 days
AL1
Up to 28 yrs old
QL
45 / 23 days
AL1
Up to 28 yrs old
Up to 28 yrs old
tretinoin gel 0.01 %
1
1
1
tretinoin gel 0.025 %
1
AL1
tretinoin microsphere gel 0.04 %
3
ST
tretinoin microsphere pump gel 0.04 %
3
ST
triamcinolone acetonide cream 0.025 %
1
QL
160 / 23 days
1
QL
160 / 23 days
1
QL
60 / 23 days
triamcinolone acetonide lotion 0.025 %
1
QL
120 / 23 days
triamcinolone acetonide lotion 0.1 %
1
QL
120 / 23 days
triamcinolone acetonide ointment 0.025 %
1
QL
160 / 23 days
triamcinolone acetonide ointment 0.1 %
1
QL
160 / 23 days
TRIAMCINOLONE ACETONIDE OINTMENT 0.5 %
1
QL
60 / 23 days
triamcinolone acetonide paste 0.1 %
3
PAGE 228
PRODUCT DESCRIPTION
TIER
TRIANEX OINTMENT 0.05 %
3
QL
60 / 23 days
triderm cream 0.1 %
1
QL
160 / 23 days
trixaicin hp cream 0.075 %
1
umecta mousse foam 40 %
3
URAMAXIN FOAM 20 %
urea in ammonium lactate vehicle
3
urea cream 39 %
3
urea cream 40 %
1
urea cream 45 %
3
urea cream 50 %
3
urea emulsion 50 %
3
urea gel 40 %
3
urea in zn undecyl-lactic acid emulsion 50 %
3
urea lotion 40 %
1
urea lotion 45 %
3
urea nail film suspension 40 %
3
urea nail gel 45 %
3
UREA NAIL KIT 40 & 0.2 %
urea & hyaluronate sodium
3
vasolex ointment
1
VELTIN GEL 1.2-0.025 %
3
VEREGEN OINTMENT 15 %
sinecatechins
3
PA
VOLTAREN GEL 1 %
diclofenac sodium (topical)
3
QL
wal-dryl anti-itch liquid 2-0.1 %
1
x-viate cream 40 %
1
x-viate gel 40 %
1
ZIANA GEL 1.2-0.025 %
3
PAGE 229
200 / 30 days
PRODUCT DESCRIPTION
TIER
Smooth Muscle Relaxants
Genitourinary Smooth Muscle Relaxants
DETROL LA CAP ER 24H 2 MG
tolterodine tartrate
2
DETROL LA CAP ER 24H 4 MG
tolterodine tartrate
2
ENABLEX TAB ER 24H 15 MG
darifenacin hydrobromide
2
ST
ENABLEX TAB ER 24H 7.5 MG
darifenacin hydrobromide
2
ST
flavoxate hcl tab 100 mg
1
GELNIQUE GEL 3 (28) % (MG/ACT)
oxybutynin
3
oxybutynin chloride er tab er 24h 10 mg
1
1
1
oxybutynin chloride syrup 5 mg/5ml
1
oxybutynin chloride tab 5 mg
1
OXYTROL PATCH TW 3.9 MG/24HR
oxybutynin
3
tolterodine tartrate er cap er 24h 2 mg
2
tolterodine tartrate er cap er 24h 4 mg
2
tolterodine tartrate tab 1 mg
1
ST
tolterodine tartrate tab 2 mg
1
ST
TOVIAZ TAB ER 24H 4 MG
fesoterodine fumarate
2
ST
TOVIAZ TAB ER 24H 8 MG
fesoterodine fumarate
2
ST
trospium chloride er cap er 24h 60 mg
1
ST
trospium chloride tab 20 mg
1
ST
VESICARE TAB 10 MG
solifenacin succinate
3
ST
VESICARE TAB 5 MG
solifenacin succinate
3
ST
PAGE 230
PRODUCT DESCRIPTION
TIER
aminophylline solution 25 mg/ml
1
theophylline
2
4
1
1
1
1
1
1
1
1
1
1
PA
UNCATEGORIZED
1ST CHOICE LANCETS SUPER THIN MISC
lancets
1
1ST CHOICE LANCETS THIN MISC
lancets
1
1ST CHOICE LANCETS ULTRA THIN MISC
lancets
1
1ST TIER UNIFINE PENTIPS MISC 29G X 12MM
insulin pen needle
1
QL
200 / 30 days
1ST TIER UNIFINE PENTIPS MISC 31G X 5 MM
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
1ST TIER UNIFINE PENTIPS PLUS MISC 29G X 12MM
insulin pen needle
1
QL
200 / 30 days
1ST TIER UNIFINE PENTIPS PLUS MISC 31G X 5 MM
insulin pen needle
1
QL
200 / 30 days
PAGE 231
PRODUCT DESCRIPTION
TIER
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
1ST TIER UNILET COMFORTOUCH MISC
lancets
1
ACCU-CHEK ACTIVE GLUCOSE CONT LIQUID
blood glucose calibration
1
ACCU-CHEK ACTIVE STRIP
glucose blood
1
ACCU-CHEK AVIVA PLUS KIT W/DEVICE
blood glucose monitoring supplies
1
ACCU-CHEK AVIVA PLUS STRIP
glucose blood
1
ACCU-CHEK AVIVA SOLUTION
1
ACCU-CHEK AVIVA STRIP
glucose blood
1
ACCU-CHEK COMFORT CURVE LINEAR SOLUTION
1
ACCU-CHEK COMFORT CURVE SOLUTION
1
ACCU-CHEK COMFORT CURVE STRIP
glucose blood
1
ACCU-CHEK COMPACT BLUE CONTROL LIQUID
1
ACCU-CHEK COMPACT PLUS CONTROL SOLUTION
1
ACCU-CHEK COMPACT PLUS STRIP
glucose blood
1
ACCU-CHEK COMPACT TEST DRUM STRIP
glucose blood
1
ACCU-CHEK FASTCLIX LANCETS MISC
lancets
1
ACCU-CHEK MULTICLIX LANCETS MISC
lancets
1
ACCU-CHEK NANO SMARTVIEW KIT W/DEVICE
1
PAGE 232
PRODUCT DESCRIPTION
TIER
ACCU-CHEK SAFE-T PRO LANCETS MISC
lancets
1
ACCU-CHEK SMARTVIEW CONTROL LIQUID
1
ACCU-CHEK SMARTVIEW STRIP
glucose blood
1
ACCU-CHEK SOFT TOUCH LANCETS MISC
lancets
1
ACCU-CHEK SOFTCLIX LANCET DEV MISC
lancet devices
1
ACCU-CHEK SOFTCLIX LANCETS MISC
lancets
1
ACCU-CHEK VOICEMATE KIT
1
ACCUTREND GLUCOSE CONTROL SOLUTION
1
ACCUTREND GLUCOSE STRIP
glucose blood
1
acid control maximum strength tab 20 mg
1
acid controller max st tab 20 mg
1
acid reducer maximum strength tab 20 mg
1
acid relief tab 200 mg
1
ACTI-LANCE 28G MISC
lancets
1
ACTI-LANCE LITE LANCETS 28G MISC
lancets
1
ACTI-LANCE SPECIAL LANCETS 17G MISC
lancets
1
ACTI-LANCE UNIVERSAL 23G MISC
lancets
1
ACURA BLOOD GLUCOSE METER KIT W/DEVICE
1
ACURA BLOOD GLUCOSE STARTER KIT W/DEVICE
1
ACURA BLOOD GLUCOSE TEST STRIP
glucose blood
1
ACURA CONTROL SOLUTION NORMAL
1
PAGE 233
PRODUCT DESCRIPTION
TIER
ACURA PLUS BLOOD GLUCOSE SYS KIT W/DEVICE
1
ADJUSTABLE LANCING DEVICE MISC
lancet devices
1
ADVOCATE BLOOD GLUCOSE SYSTEM KIT W/DEVICE
1
ADVOCATE INSULIN PEN NEEDLES MISC 31G X 5 MM
insulin pen needle
1
QL
200 / 30 days
ADVOCATE INSULIN PEN NEEDLES MISC 31G X 8 MM
insulin pen needle
1
QL
200 / 30 days
ADVOCATE INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML
insulin syringe/needle u-100
1
QL
200 / 30 days
1
ADVOCATE INSULIN SYRINGE MISC 29G X 1/2" 1 ML
1
1
1
1
1
1
1
ADVOCATE LANCETS MISC
lancets
1
ADVOCATE LANCING DEVICE MISC
lancet devices
1
ADVOCATE REDI-CODE KIT W/DEVICE
1
ADVOCATE REDI-CODE STRIP
glucose blood
1
ADVOCATE REDI-CODE+ TALKING KIT W/DEVICE
1
ADVOCATE SAFETY LANCETS MISC
lancets
1
PAGE 234
PRODUCT DESCRIPTION
TIER
ADVOCATE TEST STRIP
glucose blood
1
AFINITOR TAB 10 MG
everolimus
4
PA
AFINITOR TAB 2.5 MG
everolimus
4
PA
AFINITOR TAB 5 MG
everolimus
4
PA
AFINITOR TAB 7.5 MG
everolimus
4
PA
AGAMATRIX AMP TEST STRIP
glucose blood
1
AGAMATRIX CONTROL SOLUTION
1
AGAMATRIX CONTROL SOLUTION NORMAL
1
AGAMATRIX JAZZ KIT W/DEVICE
1
AGAMATRIX JAZZ TEST STRIP
glucose blood
1
AGAMATRIX KEYNOTE TEST STRIP
glucose blood
1
AGAMATRIX PRESTO KIT W/DEVICE
1
AGAMATRIX PRESTO TEST STRIP
glucose blood
1
AGAMATRIX ULTRA-THIN LANCETS MISC
lancets
1
ALLEGRA ALLERGY CHILDRENS TAB 30 MG
fexofenadine hcl
1
QL
ALOMIDE SOLUTION 0.1 %
lodoxamide tromethamine
3
PA
1
AL1
ALTERNATE SITE LANCING DEVICE MISC
lancet devices
1
anastrozole tab 1 mg
1
ANTI-STICK INSULIN SYRINGE MISC 29G X 1/2" 1 ML
1
PAGE 235
50 / 30 days
Up to 64 yrs old
PRODUCT DESCRIPTION
TIER
AQUA LANCE ADJUSTABLE LANCING DEVICE
lancet devices
1
arbinoxa tab 4 mg
1
ASSURE 4 CONTROL LEVEL 1 & 2 LIQUID
1
ASSURE 4 TEST STRIP
glucose blood
1
ASSURE COMFORT LANCETS 28G MISC
lancets
1
ASSURE COMFORT LANCETS 30G MISC
lancets
1
ASSURE DOSE CONTROL SOLUTION NORMAL
1
ASSURE DOSE NORM/HIGH CONTROL SOLUTION
1
ASSURE HAEMOLANCE PLUS HIGH MISC
lancets
1
ASSURE HAEMOLANCE PLUS LOW MISC
lancets
1
ASSURE HAEMOLANCE PLUS MICRO MISC
lancets
1
ASSURE HAEMOLANCE PLUS NORMAL MISC
lancets
1
ASSURE HAEMOLANCE PLUS PED MISC
lancets
1
ASSURE ID INSULIN SAFETY SYR MISC 29G X 1/2" 0.5 ML
1
ASSURE ID INSULIN SAFETY SYR MISC 29G X 1/2" 1 ML
1
ASSURE II CHECK STRIP
glucose blood
1
ASSURE LANCE LANCETS MISC
lancets
1
ASSURE PLATINUM STRIP
glucose blood
1
ASSURE PRISM CONTROL LEVEL 1&2 SOLUTION
1
ASSURE PRISM MULTI TEST STRIP
glucose blood
1
PAGE 236
AL1
Up to 64 yrs old
PRODUCT DESCRIPTION
TIER
ASSURE PRO TEST STRIP
glucose blood
1
AURORA LANCET SUPER THIN 30G MISC
lancets
1
AURORA PEN NEEDLES MISC 29G X 12MM
insulin pen needle
1
QL
200 / 30 days
AURORA PEN NEEDLES MISC 31G X 6 MM
insulin pen needle
1
QL
200 / 30 days
AURORA PEN NEEDLES MISC 31G X 8 MM
insulin pen needle
1
QL
200 / 30 days
AURORA UNIFINE PENTIPS MISC 31G X 5 MM
insulin pen needle
1
QL
200 / 30 days
AURORA UNIFINE PENTIPS MISC 32G X 4 MM
insulin pen needle
1
QL
200 / 30 days
AUTO-LANCET MINI MISC
lancet devices
1
AUTO-LANCET MISC
lancet devices
1
AUTOLET IMPRESSION MISC
lancet devices
1
AUTOLET LANCING DEVICE MISC
lancet devices
1
BAYER BREEZE 2 CONTROL LIQUID NORMAL
1
BAYER BREEZE 2 SYSTEM KIT W/DEVICE
1
BAYER CONTOUR LINK MONITOR KIT W/DEVICE
1
BAYER CONTOUR LIQUID NORMAL
1
BAYER CONTOUR MONITOR KIT W/DEVICE
1
BAYER CONTOUR NEXT CONTROL SOLUTION NORMAL
1
BAYER CONTOUR NEXT EZ KIT W/DEVICE
1
BAYER CONTOUR NEXT LINK KIT W/DEVICE
1
BAYER CONTOUR NEXT MONITOR KIT W/DEVICE
1
PAGE 237
PRODUCT DESCRIPTION
TIER
BAYER CONTOUR NEXT TEST STRIP
glucose blood
1
BAYER CONTOUR NEXT USB MONITOR KIT W/DEVICE
1
BAYER CONTOUR TEST STRIP
glucose blood
1
BAYER MICROLET 2 LANCING DEVIC MISC
lancet devices
1
BAYER MICROLET LANCETS MISC
lancets
1
BD AUTOSHIELD MISC 29G X 12MM
insulin pen needle
1
BD INSULIN SYR ULTRAFINE II MISC 31G X 5/16" 0.5 ML
1
BD INSULIN SYR ULTRAFINE II MISC 31G X 5/16" 1 ML
1
BD INSULIN SYRINGE HALF-UNIT MISC 31G X 5/16" 0.3 ML
1
BD INSULIN SYRINGE MICROFINE MISC 28G X 1/2" 0.5 ML
QL
200 / 30 days
1
QL
200 / 30 days
BD INSULIN SYRINGE MICROFINE MISC 28G X 1/2" 1 ML
1
QL
200 / 30 days
BD INSULIN SYRINGE MISC 28G X 1/2" 1 ML
1
QL
200 / 30 days
BD INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML
1
BD INSULIN SYRINGE MISC 29G X 1/2" 1 ML
1
1
QL
200 / 30 days
1
BD INSULIN SYRINGE ULTRAFINE MISC 29G X 1/2" 0.3 ML
1
QL
200 / 30 days
1
BD INSULIN SYRINGE ULTRAFINE MISC 29G X 1/2" 1 ML
1
1
QL
200 / 30 days
PAGE 238
PRODUCT DESCRIPTION
TIER
1
QL
200 / 30 days
1
QL
200 / 30 days
1
1
1
BD INTEGRA INSULIN SYRINGE MISC 29G X 1/2" 1 ML
1
BD LANCET DEVICE MISC
lancet devices
1
BD LANCET ULTRAFINE 30G MISC
lancets
1
BD LANCET ULTRAFINE 33G MISC
lancets
1
BD MICROTAINER LANCETS MISC
lancets
1
BD PEN NEEDLE MINI U/F MISC 31G X 5 MM
insulin pen needle
1
QL
200 / 30 days
BD PEN NEEDLE NANO U/F MISC 32G X 4 MM
insulin pen needle
1
QL
200 / 30 days
BD PEN NEEDLE SHORT U/F MISC 31G X 8 MM
insulin pen needle
1
QL
200 / 30 days
BD PEN NEEDLE ULTRAFINE MISC 29G X 12.7MM
insulin pen needle
1
QL
200 / 30 days
BD SAFETY-LOK INSULIN SYRINGE MISC 29G X 1/2" 1 ML
1
BD SAFETYGLIDE INSULIN SYRINGE MISC 30G X 5/16" 0.5
ML
1
BG STAR TEST STRIP
glucose blood
1
bicalutamide tab 50 mg
1
BLOOD GLUCOSE MONITOR SYSTEM KIT W/DEVICE
1
BLOOD GLUCOSE SYSTEM PAK KIT
1
PAGE 239
PRODUCT DESCRIPTION
TIER
BLOOD GLUCOSE TEST STRIP
glucose blood
1
BOSULIF TAB 100 MG
bosutinib
4
PA
BOSULIF TAB 500 MG
bosutinib
4
PA
1
BULLSEYE MINI SAFETY LANCETS MISC
lancets
1
BULLSEYE SAFETY LANCETS MISC
lancets
1
capecitabine tab 150 mg
4
PA
CAPRELSA TAB 100 MG
vandetanib
4
PA
CAPRELSA TAB 300 MG
vandetanib
4
PA
carbinoxamine maleate tab 4 mg
1
AL1
Up to 64 yrs old
CARDIOCOM LANCING DEVICE MISC
lancet devices
1
CAREFINE PEN NEEDLES MISC 29G X 12MM
insulin pen needle
1
QL
200 / 30 days
CAREFINE PEN NEEDLES MISC 31G X 6 MM
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
CAREONE ADVANCED LANCING DEV MISC
lancet devices
1
CAREONE BLOOD GLUCOSE SYSTEM KIT W/DEVICE
1
CAREONE BLOOD GLUCOSE TEST STRIP
glucose blood
1
CAREONE INSULIN SYRINGE MISC 30G X 1/2" 0.3 ML
1
QL
200 / 30 days
1
QL
200 / 30 days
CAREONE INSULIN SYRINGE MISC 30G X 1/2" 1 ML
1
QL
200 / 30 days
PAGE 240
PRODUCT DESCRIPTION
TIER
1
1
CAREONE INSULIN SYRINGE MISC 31G X 5/16" 1 ML
1
CAREONE LANCET THIN 23G MISC
lancets
1
CAREONE LANCET ULTRA THIN 28G MISC
lancets
1
CAREONE UNIFINE PENTIPS MISC 29G X 12MM
insulin pen needle
1
QL
200 / 30 days
CAREONE UNIFINE PENTIPS MISC 31G X 5 MM
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
CAREONE UNIFINE PENTIPS PLUS MISC 29G X 12MM
insulin pen needle
1
QL
200 / 30 days
CAREONE UNIFINE PENTIPS PLUS MISC 31G X 5 MM
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
CARESENS CONTROL A SOLUTION
1
CARESENS N GLUCOSE TEST STRIP
glucose blood
1
cetirizine hcl childrens alrgy syrup 1 mg/ml
1
QL
50 / 30 days
cetirizine hcl solution 1 mg/ml
1
QL
50 / 30 days
cetirizine hcl syrup 1 mg/ml
1
QL
50 / 30 days
cetirizine hcl syrup 5 mg/5ml
1
PAGE 241
PRODUCT DESCRIPTION
TIER
1
QL
50 / 30 days
1
QL
50 / 30 days
CHEK-STIX CONTROL STRIP
acetone (urine) test
1
CHEMET CAP 100 MG
succimer
3
CHEMSTRIP K STRIP
1
CHERRY CONCENTRATE SYRUP
cherry syrup
2
CHERRY SYRUP
cherry syrup
2
childrens loratadine syrup 5 mg/5ml
1
QL
50 / 30 days
cimetidine 200 tab 200 mg
1
cimetidine acid reducer tab 200 mg
1
cimetidine hcl solution 300 mg/5ml
1
1
1
1
1
CLARITIN REDITABS TAB DISP 10 MG
loratadine
1
QL
50 / 30 days
CLEANLET LANCETS 28G MISC
lancets
1
clemastine fumarate syrup 0.67 mg/5ml
1
AL1
Up to 64 yrs old
CLEMASTINE FUMARATE SYRUP 0.67 MG/5ML
clemastine fumarate
1
AL1
Up to 64 yrs old
clemastine fumarate tab 2.68 mg
1
AL1
Up to 64 yrs old
CLEVER CHEK AUTO-CODE TEST STRIP
glucose blood
1
CLEVER CHEK AUTO-CODE VOICE STRIP
glucose blood
1
CLEVER CHEK LANCETS MISC
lancets
1
CLEVER CHEK SYSTEM KIT W/DEVICE
1
PAGE 242
PRODUCT DESCRIPTION
TIER
CLEVER CHEK TEST STRIP
glucose blood
1
CLEVER CHOICE AUTO-CODE TEST STRIP
glucose blood
1
CLEVER CHOICE MICRO SYSTEM KIT W/DEVICE
1
CLEVER CHOICE MICRO TEST STRIP
glucose blood
1
CLICKFINE PEN NEEDLES MISC 31G X 6 MM
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
COAGUCHEK LANCETS MISC
lancets
1
COMETRIQ (100 MG DAILY DOSE) KIT 1 X 80 & 1 X 20 MG
cabozantinib s-malate
4
PA
COMETRIQ (140 MG DAILY DOSE) KIT 1 X 80 & 3 X 20 MG
4
PA
COMETRIQ (60 MG DAILY DOSE) KIT 20 MG
4
PA
COMFORT ASSIST INSULIN SYRINGE MISC 29G X 1/2" 0.3
ML
1
QL
200 / 30 days
COMFORT ASSURED LANCETS 28G MISC
lancets
1
COMFORT ASSURED LANCETS 33G MISC
lancets
1
COMFORT EZ INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML
1
QL
200 / 30 days
COMFORT EZ INSULIN SYRINGE MISC 28G X 1/2" 1 ML
1
QL
200 / 30 days
1
QL
200 / 30 days
1
1
PAGE 243
PRODUCT DESCRIPTION
TIER
1
QL
200 / 30 days
1
QL
200 / 30 days
1
QL
200 / 30 days
1
1
1
1
1
1
COMFORT EZ PEN NEEDLES MISC 31G X 5 MM
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
COMFORT LANCETS MISC
lancets
1
CONTROL AST STRIP
glucose blood
1
CONTROL BLOOD GLUCOSE SYSTEM KIT W/DEVICE
1
CONTROL SOLUTION NORMAL
1
CONTROL TEST STRIP
glucose blood
1
2
2
PAGE 244
PRODUCT DESCRIPTION
TIER
CREON CP DR PART 3000-9500 UNIT
2
2
cvs acid controller max st tab 20 mg
1
CVS ADVANCED GLUCOSE TEST STRIP
glucose blood
1
cvs allergy relief tab 10 mg
1
CVS BLOOD GLUCOSE METER KIT W/DEVICE
1
cvs heartburn relief tab 200 mg
1
CVS INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML
QL
50 / 30 days
1
QL
200 / 30 days
1
QL
200 / 30 days
1
QL
200 / 30 days
CVS LANCETS 21G MISC
lancets
1
CVS LANCETS MICRO THIN 33G MISC
lancets
1
CVS LANCETS THIN 26G MISC
lancets
1
CVS LANCETS ULTRA THIN 30G MISC
lancets
1
CVS LANCING DEVICE MISC
lancet devices
1
cvs loratadine tab 10 mg
1
QL
50 / 30 days
CVS ULTRA THIN LANCETS MISC
lancets
1
cyproheptadine hcl syrup 2 mg/5ml
1
AL1
Up to 64 yrs old
cyproheptadine hcl tab 4 mg
1
AL1
Up to 64 yrs old
deferoxamine mesylate recon soln 500 mg
1
DEPEN TITRATABS TAB 250 MG
penicillamine
4
DEXCHLORPHENIRAMINE MALEATE SYRUP 2 MG/5ML
dexchlorpheniramine maleate
1
AL1
Up to 64 yrs old
PAGE 245
PRODUCT DESCRIPTION
TIER
DIASTAR EASY TEST II LANCETS MISC
lancets
1
DIASTAR EASY TEST LANCETS MISC
lancets
1
DIATRUE CONTROL LEVEL 2 SOLUTION NORMAL
1
DIATRUE PLUS TEST STRIP
glucose blood
1
DIMENHYDRINATE SOLUTION 50 MG/ML
dimenhydrinate
3
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
DROPLET LANCETS ULTRA THIN 30G MISC
lancets
1
DROPLET LANCING DEVICE MISC
lancet devices
1
DROXIA CAP 200 MG
hydroxyurea (sickle cell anemia)
2
DROXIA CAP 300 MG
2
DROXIA CAP 400 MG
2
DRUG MART LANCETS THIN 26G MISC
lancets
1
DRUG MART LANCING DEVICE MISC
lancet devices
1
DRUG MART ON-THE-GO LANCET 30G MISC
lancets
1
DRUG MART ULTRA COMFORT SYR MISC 29G X 1/2" 0.3
ML
1
QL
200 / 30 days
DRUG MART UNIFINE PENTIPS MISC 29G X 12MM
insulin pen needle
1
QL
200 / 30 days
DRUG MART UNIFINE PENTIPS MISC 31G X 5 MM
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
PAGE 246
PRODUCT DESCRIPTION
TIER
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
DRUG MART UNIFINE PENTIPS PLUS MISC 32G X 4 MM
insulin pen needle
1
QL
200 / 30 days
DRUG MART UNILET LANCETS 28G MISC
lancets
1
DRUG MART UNILET LANCETS 30G MISC
lancets
1
DUANE READE LANCET ALTERN SITE MISC
lancets
1
DUANE READE LANCET SUPER THIN MISC
lancets
1
DUANE READE LANCET ULTRA THIN MISC
lancets
1
DUANE READE UNIFINE PENTIPS MISC 29G X 12MM
insulin pen needle
1
QL
200 / 30 days
DUANE READE UNIFINE PENTIPS MISC 31G X 6 MM
insulin pen needle
1
QL
200 / 30 days
DUANE READE UNIFINE PENTIPS MISC 31G X 8 MM
insulin pen needle
1
QL
200 / 30 days
E-Z JECT LANCET MICRO-THIN 33G MISC
lancets
1
E-Z JECT LANCET SUPER THIN 30G MISC
lancets
1
E-Z JECT LANCETS 21G MISC
lancets
1
E-Z JECT LANCETS MISC
lancets
1
E-Z JECT LANCETS THIN 26G MISC
lancets
1
EASIVENT MASK LARGE MISC
spacer/aerosol-holding chambers
2
QL
2 / 365 days
EASIVENT MASK MEDIUM MISC
2
QL
2 / 365 days
EASIVENT MASK SMALL MISC
2
QL
2 / 365 days
EASIVENT MISC
2
QL
2 / 365 days
PAGE 247
PRODUCT DESCRIPTION
TIER
EASY COMFORT INSULIN SYRINGE MISC 30G X 1/2" 0.5 ML
1
QL
200 / 30 days
EASY COMFORT INSULIN SYRINGE MISC 30G X 1/2" 1 ML
1
QL
200 / 30 days
EASY COMFORT INSULIN SYRINGE MISC 30G X 5/16" 0.3
ML
1
EASY COMFORT INSULIN SYRINGE MISC 30G X 5/16" 0.5
ML
1
EASY COMFORT INSULIN SYRINGE MISC 30G X 5/16" 1 ML
1
EASY COMFORT LANCETS MISC
lancets
1
EASY COMFORT PEN NEEDLES MISC 31G X 5 MM
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
EASY MINI LANCING DEVICE MISC
lancet devices
1
EASY PLUS BLOOD GLUCOSE SYSTEM KIT W/DEVICE
1
EASY PLUS BLOOD GLUCOSE TEST STRIP
glucose blood
1
EASY PLUS II GLUCOSE TEST STRIP
glucose blood
1
EASY STEP CONTROL SOLUTION NORMAL
1
EASY STEP GLUCOSE MONITOR KIT W/DEVICE
1
EASY STEP TEST STRIP
glucose blood
1
EASY TALK BLOOD GLUCOSE SYSTEM KIT W/DEVICE
1
EASY TALK BLOOD GLUCOSE TEST STRIP
glucose blood
1
PAGE 248
PRODUCT DESCRIPTION
TIER
EASY TALK CONTROL SOLUTION NORMAL
1
EASY TOUCH CONTROL HIGH & LOW SOLUTION
1
EASY TOUCH GLUCOSE SYSTEM KIT W/DEVICE
1
EASY TOUCH HEALTHPRO CONTROL SOLUTION
1
EASY TOUCH HEALTHPRO SYSTEM KIT W/DEVICE
1
EASY TOUCH HEALTHPRO TEST STRIP
glucose blood
1
EASY TOUCH INSULIN SAFETY SYR MISC 29G X 1/2" 0.5
ML
1
EASY TOUCH INSULIN SAFETY SYR MISC 29G X 1/2" 1 ML
1
EASY TOUCH INSULIN SAFETY SYR MISC 30G X 1/2" 1 ML
1
EASY TOUCH INSULIN SAFETY SYR MISC 30G X 5/16" 0.5
ML
1
EASY TOUCH INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML
QL
200 / 30 days
1
QL
200 / 30 days
EASY TOUCH INSULIN SYRINGE MISC 28G X 1/2" 1 ML
1
QL
200 / 30 days
1
1
1
QL
200 / 30 days
1
QL
200 / 30 days
1
QL
200 / 30 days
1
1
PAGE 249
PRODUCT DESCRIPTION
TIER
1
1
1
1
EASY TOUCH LANCETS 21G MISC
lancets
1
lancets
1
lancets
1
lancets
1
EASY TOUCH LANCETS 28G/TWIST MISC
lancets
1
lancets
1
lancets
1
lancets
1
lancets
1
lancets
1
EASY TOUCH LANCING DEVICE MISC
lancet devices
1
EASY TOUCH PEN NEEDLES MISC 29G X 12MM
insulin pen needle
1
QL
200 / 30 days
EASY TOUCH PEN NEEDLES MISC 31G X 5 MM
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
PAGE 250
PRODUCT DESCRIPTION
TIER
EASY TOUCH SAFETY LANCETS 21G MISC
lancets
1
lancets
1
lancets
1
lancets
1
EASY TOUCH TEST STRIP
glucose blood
1
EASY TRAK BLOOD GLUCOSE SYSTEM KIT W/DEVICE
1
EASY TRAK BLOOD GLUCOSE TEST STRIP
glucose blood
1
EASY TRAK CONTROL SOLUTION NORMAL
1
EASY TWIST & CAP LANCETS MISC
lancets
1
EASYGLUCO CONTROL SOLUTION NORMAL
1
EASYGLUCO STRIP
glucose blood
1
EASYMAX 15 LEVEL 1 CONTROL SOLUTION
1
EASYMAX 15 LEVEL 2 CONTROL SOLUTION
1
EASYMAX 15 TEST STRIP
glucose blood
1
EASYMAX CONTROL SOLUTION NORMAL
1
EASYMAX NG BLOOD GLUCOSE KIT W/DEVICE
1
EASYMAX TEST STRIP
glucose blood
1
EASYMAX V BLOOD GLUCOSE KIT W/DEVICE
1
EASYMAX V2 BLOOD GLUCOSE KIT W/DEVICE
1
ELEMENT AUTOCODE SYSTEM KIT W/DEVICE
1
PAGE 251
PRODUCT DESCRIPTION
TIER
ELEMENT COMPACT CONTROL 2 SOLUTION
1
ELEMENT COMPACT CONTROL 3 SOLUTION
1
ELEMENT COMPACT TEST STRIP
glucose blood
1
ELEMENT CONTROL LIQUID NORMAL
1
ELEMENT TEST STRIP
glucose blood
1
ELIGARD KIT 22.5 MG
4
PA
ELIGARD KIT 30 MG
4
PA
ELIGARD KIT 45 MG
4
PA
ELIGARD KIT 7.5 MG
leuprolide acetate
4
PA
EMBRACE BLOOD GLUCOSE TEST STRIP
glucose blood
1
EMBRACE EVO BLOOD GLUCOSE TEST STRIP
glucose blood
1
EMBRACE EVO CONTROL LEVEL 2 LIQUID NORMAL
1
EMBRACE EVO GLUCOSE MONITORING KIT W/DEVICE
1
EMBRACE LANCETS ULTRA THIN 30G MISC
lancets
1
EMBRACE PRO GLUCOSE CONTROL LIQUID
1
EMBRACE PRO GLUCOSE TEST STRIP
glucose blood
1
EMCYT CAP 140 MG
estramustine phosphate sodium
3
eq acid reducer max st tab 20 mg
1
eq acid reducer tab 200 mg
1
1
eq heartburn relief tab 200 mg
1
PAGE 252
AL1
Up to 64 yrs old
PRODUCT DESCRIPTION
TIER
eq loratadine tab 10 mg
1
eql acid reducer tab 200 mg
1
eql childrens loratadine syrup 5 mg/5ml
1
EQL COLOR LANCETS 21G MISC
lancets
1
EQL COLOR LANCETS MICRO 33G MISC
lancets
1
eql heartburn prevention tab 20 mg
1
EQL INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML
1
1
EQL INSULIN SYRINGE MISC 29G X 1/2" 1 ML
1
1
1
1
1
1
1
EQL SHORT PEN NEEDLE MISC 31G X 8 MM
insulin pen needle
1
EQL SUPER THIN LANCETS 30G MISC
lancets
1
EQL THIN LANCETS 26G MISC
lancets
1
EQL TRUE2GO BLOOD GLUCOSE KIT W/DEVICE
1
EQL TRUETEST TEST STRIP
glucose blood
1
EQL ULTRA SHORT PEN NEEDLE MISC 31G X 6 MM
insulin pen needle
1
PAGE 253
QL
50 / 30 days
QL
50 / 30 days
QL
200 / 30 days
QL
200 / 30 days
QL
200 / 30 days
PRODUCT DESCRIPTION
TIER
EVENCARE + BLOOD GLUCOSE TEST STRIP
glucose blood
1
EVENCARE BLOOD GLUCOSE TEST STRIP
glucose blood
1
EVENCARE CONTROL LOW/HIGH LIQUID
1
EVENCARE G2 LOW/HIGH CONTROL SOLUTION
1
EVENCARE G2 TEST STRIP
glucose blood
1
EVENCARE G3 LOW/HIGH CONTROL SOLUTION
1
EVENCARE G3 TEST STRIP
glucose blood
1
EVOLUTION AUTOCODE STRIP
glucose blood
1
EVOLUTION CONTROL SOLUTION NORMAL
1
EXCEL COMFORT POINT PEN NEEDLE MISC 29G X 12MM
insulin pen needle
1
QL
200 / 30 days
EXCEL COMFORT POINT PEN NEEDLE MISC 31G X 6 MM
insulin pen needle
1
QL
200 / 30 days
EXCEL COMFORT POINT PEN NEEDLE MISC 31G X 8 MM
insulin pen needle
1
QL
200 / 30 days
EXEL COMFORT POINT INSULIN SYR MISC 28G X 1/2" 0.5
ML
1
QL
200 / 30 days
EXEL COMFORT POINT INSULIN SYR MISC 28G X 1/2" 1 ML
1
QL
200 / 30 days
ML
1
QL
200 / 30 days
ML
1
EXEL COMFORT POINT INSULIN SYR MISC 29G X 1/2" 1 ML
1
ML
1
PAGE 254
PRODUCT DESCRIPTION
TIER
ML
1
EXEL COMFORT POINT INSULIN SYR MISC 30G X 5/16" 1
ML
1
exemestane tab 25 mg
1
EZ SMART BLOOD GLUCOSE LANCETS MISC
lancets
1
EZ SMART BLOOD GLUCOSE TEST STRIP
glucose blood
1
EZ SMART PLUS GLUCOSE TEST STRIP
glucose blood
1
EZ-LETS LANCETS 21G MISC
lancets
1
lancets
1
lancets
1
lancets
1
famotidine recon susp 40 mg/5ml
1
1
1
FARESTON TAB 60 MG
toremifene citrate
4
PA
FASLODEX SOLUTION 250 MG/5ML
fulvestrant
4
PA
FERRIPROX TAB 500 MG
deferiprone
4
PA
1
QL
50 / 30 days
1
QL
50 / 30 days
FIFTY50 CONTROL 2.0 SOLUTION
1
FIFTY50 GLUCOSE METER 2.0 KIT W/DEVICE
1
FIFTY50 GLUCOSE TEST 2.0 STRIP
glucose blood
1
PAGE 255
PRODUCT DESCRIPTION
TIER
FIFTY50 LANCING DEVICE MISC
lancet devices
1
FIFTY50 PEN NEEDLES MISC 31G X 5 MM
insulin pen needle
1
QL
200 / 30 days
FIFTY50 PEN NEEDLES MISC 31G X 8 MM
insulin pen needle
1
QL
200 / 30 days
FIFTY50 SAFETY SEAL LANCETS MISC
lancets
1
FIFTY50 SUPERIOR COMFORT SYR MISC 31G X 5/16" 0.3
ML
1
FIFTY50 SUPERIOR COMFORT SYR MISC 31G X 5/16" 0.5
ML
1
FIFTY50 SUPERIOR COMFORT SYR MISC 31G X 5/16" 1 ML
1
FINE 30 MISC
lancets
1
FINGERSTIX LANCETS MISC
lancets
1
FIRMAGON RECON SOLN 120 MG
degarelix acetate
4
PA
FIRMAGON RECON SOLN 80 MG
degarelix acetate
4
PA
flucaine solution 0.25-0.5 %
1
fluoridex sensitivity relief paste 1.1-5 %
1
flutamide cap 125 mg
3
FORA CONTROL SOLUTION NORMAL
1
FORA D10 BLOOD GLUCOSE TEST STRIP
glucose blood
1
FORA D15G BLOOD GLUCOSE TEST STRIP
glucose blood
1
FORA D20 BLOOD GLUCOSE TEST STRIP
glucose blood
1
FORA G20 BLOOD GLUCOSE SYSTEM KIT W/DEVICE
1
FORA G20 BLOOD GLUCOSE TEST STRIP
glucose blood
1
PAGE 256
PRODUCT DESCRIPTION
TIER
FORA G30A BLOOD GLUCOSE TEST STRIP
glucose blood
1
FORA GD20 TEST STRIP
glucose blood
1
FORA GD50 BLOOD GLUCOSE TEST STRIP
glucose blood
1
FORA LANCETS MISC
lancets
1
FORA LANCING DEVICE MISC
lancet devices
1
FORA V10 BLOOD GLUCOSE TEST STRIP
glucose blood
1
glucose blood
1
glucose blood
1
FORA V30A BLOOD GLUCOSE SYSTEM KIT W/DEVICE
1
FORA V30A BLOOD GLUCOSE TEST STRIP
glucose blood
1
FORACARE GD40 TEST STRIP
glucose blood
1
FORACARE GDH CONTROL SOLUTION NORMAL
1
FORACARE PREMIUM V10 TEST STRIP
glucose blood
1
FORACARE TEST N GO TEST STRIP
glucose blood
1
FORTISCARE CONTROL SOLUTION NORMAL
1
FORTISCARE GLUCOSE SYSTEM KIT W/DEVICE
1
FREDS PHARMACY AUTOLET LANCING MISC
lancet devices
1
FREDS PHARMACY UNIFINE PENTIP+ MISC 31G X 5 MM
insulin pen needle
1
QL
200 / 30 days
FREDS PHARMACY UNIFINE PENTIP+ MISC 31G X 8 MM
insulin pen needle
1
QL
200 / 30 days
FREDS PHARMACY UNIFINE PENTIPS MISC 32G X 4 MM
insulin pen needle
1
QL
200 / 30 days
PAGE 257
PRODUCT DESCRIPTION
TIER
FREDS PHARMACY UNILET LANC 28G MISC
lancets
1
FREDS PHARMACY UNILET LANC 30G MISC
lancets
1
FREESTYLE CONTROL SOLUTION LIQUID
1
FREESTYLE FREEDOM KIT
1
FREESTYLE FREEDOM LITE KIT W/DEVICE
1
FREESTYLE INSULINX SYSTEM KIT W/DEVICE
1
FREESTYLE INSULINX TEST STRIP
glucose blood
1
FREESTYLE LANCETS MISC
lancets
1
FREESTYLE LITE TEST STRIP
glucose blood
1
FREESTYLE PRECISION INS SYR MISC 30G X 5/16" 0.5 ML
1
FREESTYLE PRECISION INS SYR MISC 30G X 5/16" 1 ML
1
FREESTYLE PRECISION INS SYR MISC 31G X 5/16" 0.5 ML
1
FREESTYLE PRECISION INS SYR MISC 31G X 5/16" 1 ML
1
FREESTYLE SIDEKICK II KIT
1
FREESTYLE TEST STRIP
glucose blood
1
FREESTYLE UNISTICK II LANCETS MISC
lancets
1
GE100 BLOOD GLUCOSE SYSTEM KIT W/DEVICE
1
GE100 BLOOD GLUCOSE TEST STRIP
glucose blood
1
GE100 CONTROL SOLUTION NORMAL
1
GHT BLOOD GLUCOSE MONITOR KIT W/DEVICE
1
PAGE 258
PRODUCT DESCRIPTION
TIER
GHT TEST STRIP
glucose blood
1
GLEEVEC TAB 100 MG
imatinib mesylate
4
PA
GLEEVEC TAB 400 MG
imatinib mesylate
4
PA
GLOBAL EASE INJECT PEN NEEDLES MISC 29G X 12MM
insulin pen needle
1
QL
200 / 30 days
GLOBAL EASE INJECT PEN NEEDLES MISC 31G X 5 MM
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
GLOBAL INJECT EASE INSULIN SYR MISC 28G X 1/2" 0.5
ML
1
QL
200 / 30 days
GLOBAL INJECT EASE INSULIN SYR MISC 28G X 1/2" 1 ML
1
QL
200 / 30 days
ML
1
QL
200 / 30 days
ML
1
1
ML
1
QL
200 / 30 days
ML
1
QL
200 / 30 days
1
QL
200 / 30 days
ML
1
ML
1
PAGE 259
PRODUCT DESCRIPTION
TIER
1
ML
1
ML
1
1
GLOBAL INJECT EASE LANCETS 28G MISC
lancets
1
GLOBAL INJECT EASE LANCETS 30G MISC
lancets
1
GLOBAL LANCING DEVICE MISC
lancet devices
1
GLUCO PERFECT 3 TEST STRIP
glucose blood
1
GLUCOCARD 01 BLOOD GLUCOSE KIT W/DEVICE
1
GLUCOCARD 01 CONTROL LIQUID
1
GLUCOCARD 01 CONTROL SOLUTION NORMAL
1
GLUCOCARD 01 SENSOR PLUS STRIP
glucose blood
1
GLUCOCARD 01 SENSOR STRIP
glucose blood
1
GLUCOCARD 01-MINI GLUCOSE KIT W/DEVICE
1
GLUCOCARD EXPRESSION CONTROL SOLUTION
1
GLUCOCARD EXPRESSION MONITOR KIT W/DEVICE
1
GLUCOCARD EXPRESSION TEST STRIP
glucose blood
1
GLUCOCARD SHINE CONTROL SOLUTION
1
GLUCOCARD SHINE KIT W/DEVICE
1
PAGE 260
PRODUCT DESCRIPTION
TIER
GLUCOCARD SHINE TEST STRIP
glucose blood
1
GLUCOCARD VITAL MONITOR KIT W/DEVICE
1
GLUCOCARD VITAL TEST STRIP
glucose blood
1
GLUCOCOM CONTROL LIQUID NORMAL
1
GLUCOCOM LANCETS 28G MISC
lancets
1
lancets
1
lancets
1
GLUCOCOM MONITOR KIT W/DEVICE
1
GLUCOCOM TEST STRIP
glucose blood
1
GLUCOLET 2 AUTOMATIC LANCING MISC
lancet devices
1
GLUCONAVII BLOOD GLUCOSE SYS KIT W/DEVICE
1
GLUCONAVII BLOOD GLUCOSE TEST STRIP
glucose blood
1
GLUCOPRO INSULIN SYRINGE MISC 30G X 1/2" 0.3 ML
1
QL
200 / 30 days
1
QL
200 / 30 days
GLUCOPRO INSULIN SYRINGE MISC 30G X 1/2" 1 ML
1
QL
200 / 30 days
1
1
1
1
1
PAGE 261
PRODUCT DESCRIPTION
TIER
1
GLUCOSE CONTROL SOLUTION
1
GLUCOSE CONTROL SOLUTION NORMAL
1
GLUCOSOURCE LANCET DEVICE MISC
lancet devices
1
GLUCOSOURCE LANCETS MISC
lancets
1
GMATE BLOOD GLUCOSE TEST STRIP
glucose blood
1
GMATE CONTROL LEVEL 2 SOLUTION
1
GMATE SMART STARTER KIT W/DEVICE
1
gnp acid reducer max st tab 20 mg
1
GNP CLICKFINE PEN NEEDLES MISC 31G X 6 MM
insulin pen needle
1
QL
200 / 30 days
GNP CLICKFINE PEN NEEDLES MISC 31G X 8 MM
insulin pen needle
1
QL
200 / 30 days
gnp heartburn relief tab 200 mg
1
GNP INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML
1
QL
200 / 30 days
GNP INSULIN SYRINGE MISC 28G X 1/2" 1 ML
1
QL
200 / 30 days
1
QL
200 / 30 days
1
1
1
1
1
1
PAGE 262
PRODUCT DESCRIPTION
TIER
1
1
GNP LANCETS 21G MISC
lancets
1
GNP LANCETS MICRO THIN 33G MISC
lancets
1
GNP LANCETS MISC
lancets
1
GNP LANCETS SUPER THIN 30G MISC
lancets
1
GNP LANCETS THIN 26G MISC
lancets
1
GNP LANCETS THIN MISC
lancets
1
gnp loratadine childrens syrup 5 mg/5ml
1
QL
50 / 30 days
gnp loratadine syrup 5 mg/5ml
1
QL
50 / 30 days
gnp loratadine tab 10 mg
1
QL
50 / 30 days
GNP MICRO THIN LANCETS 33G MISC
lancets
1
GNP SUPER THIN LANCETS 30G MISC
lancets
1
GNP ULTRA COM INSULIN SYRINGE MISC 28G X 1/2" 0.5
ML
1
QL
200 / 30 days
GNP ULTRA COM INSULIN SYRINGE MISC 28G X 1/2" 1 ML
1
QL
200 / 30 days
ML
1
QL
200 / 30 days
ML
1
1
ML
1
PAGE 263
PRODUCT DESCRIPTION
TIER
ML
1
1
ML
1
ML
1
1
H-E-B INCONTROL ADV LANCING MISC
lancet devices
1
H-E-B INCONTROL LANCETS 28G MISC
lancets
1
H-E-B INCONTROL LANCETS 30G MISC
lancets
1
H-E-B INCONTROL PEN NEEDLES MISC 29G X 12MM
insulin pen needle
1
QL
200 / 30 days
H-E-B INCONTROL PEN NEEDLES MISC 31G X 5 MM
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
HEALTH CARE LANCING DEVICE MISC
lancet devices
1
HEALTHWISE LANCETS 30G MISC
lancets
1
HEALTHWISE LANCING PEN MISC
lancet devices
1
HEALTHWISE MINI PEN NEEDLES MISC 31G X 6 MM
insulin pen needle
1
QL
200 / 30 days
HEALTHWISE PEN NEEDLES MISC 29G X 12MM
insulin pen needle
1
QL
200 / 30 days
HEALTHWISE SHORT PEN NEEDLES MISC 31G X 8 MM
insulin pen needle
1
QL
200 / 30 days
PAGE 264
PRODUCT DESCRIPTION
TIER
HEALTHWISE UNIFINE PENTIPS MISC 32G X 4 MM
insulin pen needle
1
HEALTHY ACCENTS LANCING DEVICE MISC
lancet devices
1
HEALTHY ACCENTS UNIFINE PENTIP MISC 29G X 12MM
insulin pen needle
QL
200 / 30 days
1
QL
200 / 30 days
HEALTHY ACCENTS UNIFINE PENTIP MISC 31G X 5 MM
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
HEALTHY ACCENTS UNILET LANCETS MISC
lancets
1
heartburn relief max st tab 20 mg
1
heartburn relief tab 200 mg
1
hm famotidine tab 20 mg
1
1
QL
50 / 30 days
1
QL
50 / 30 days
hm loratadine childrens syrup 5 mg/5ml
1
QL
50 / 30 days
hydrocod polst-cpm polst er liquid er 10-8 mg/5ml
1
hydroxyurea cap 500 mg
1
hydroxyzine hcl solution 10 mg/5ml
1
AL1
Up to 64 yrs old
HYDROXYZINE HCL SOLUTION 25 MG/ML
hydroxyzine hcl
1
AL1
Up to 64 yrs old
hydroxyzine hcl solution 50 mg/ml
1
AL1
Up to 64 yrs old
hydroxyzine hcl syrup 10 mg/5ml
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
HYDROXYZINE PAMOATE CAP 100 MG
hydroxyzine pamoate
1
AL1
Up to 64 yrs old
PAGE 265
PRODUCT DESCRIPTION
TIER
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
IBG STAR BLOOD GLUCOSE SYSTEM KIT W/DEVICE
1
INFINITY BLOOD GLUCOSE SYSTEM KIT W/DEVICE
1
INFINITY BLOOD GLUCOSE TEST STRIP
glucose blood
1
INFINITY CONTROL SOLUTION NORMAL
1
INLYTA TAB 1 MG
axitinib
4
PA
INLYTA TAB 5 MG
axitinib
4
PA
INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML
1
QL
200 / 30 days
INSULIN SYRINGE MISC 28G X 1/2" 1 ML
1
QL
200 / 30 days
1
QL
200 / 30 days
1
1
1
QL
200 / 30 days
1
1
1
1
1
INSULIN SYRINGE/NEEDLE MISC 28G X 1/2" 0.5 ML
1
QL
200 / 30 days
PAGE 266
PRODUCT DESCRIPTION
TIER
INSULIN SYRINGE/NEEDLE MISC 28G X 1/2" 1 ML
1
QL
200 / 30 days
INSUPEN PEN NEEDLES MISC 32G X 4 MM
insulin pen needle
1
QL
200 / 30 days
INSUPEN ULTRAFIN MISC 29G X 12MM
insulin pen needle
1
QL
200 / 30 days
INSUPEN ULTRAFIN MISC 31G X 6 MM
insulin pen needle
1
QL
200 / 30 days
INSUPEN ULTRAFIN MISC 31G X 8 MM
insulin pen needle
1
QL
200 / 30 days
interferon alfa-2b
4
PA
interferon alfa-2b
4
PA
interferon alfa-2b
4
PA
interferon alfa-2b
4
PA
JAKAFI TAB 10 MG
ruxolitinib phosphate
4
PA
JAKAFI TAB 15 MG
4
PA
JAKAFI TAB 20 MG
4
PA
JAKAFI TAB 25 MG
4
PA
JAKAFI TAB 5 MG
4
PA
KETOCARE STRIP
1
KETONE TEST STRIP
1
KETOSTIX STRIP
1
KINNEY LANCETS MISC
lancets
1
KINNEY THIN LANCETS MISC
lancets
1
KINRAY INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML
1
PAGE 267
PRODUCT DESCRIPTION
TIER
1
1
KINRAY INSULIN SYRINGE MISC 31G X 5/16" 1 ML
1
kls acid controller max st tab 20 mg
1
1
QL
50 / 30 days
1
QL
50 / 30 days
kp fexofenadine hcl tab 180 mg
1
QL
50 / 30 days
KROGER BLOOD GLUCOSE KIT W/DEVICE
1
KROGER BLOOD GLUCOSE TEST STRIP
glucose blood
1
KROGER INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML
1
QL
200 / 30 days
1
KROGER INSULIN SYRINGE MISC 29G X 1/2" 1 ML
1
1
1
1
1
1
1
KROGER LANCETS 21G MISC
lancets
1
KROGER LANCETS MICRO THIN 33G MISC
lancets
1
KROGER LANCETS SUPER THIN MISC
lancets
1
PAGE 268
PRODUCT DESCRIPTION
TIER
KROGER LANCETS THIN 26G MISC
lancets
1
KROGER LANCETS ULTRATHIN 30G MISC
lancets
1
KROGER LANCING DEVICE MISC
lancet devices
1
KROGER PEN NEEDLES MISC 29G X 12MM
insulin pen needle
1
QL
200 / 30 days
KROGER PEN NEEDLES MISC 31G X 6 MM
insulin pen needle
1
QL
200 / 30 days
KROGER PEN NEEDLES MISC 31G X 8 MM
insulin pen needle
1
QL
200 / 30 days
KROGER PREMIUM BLOOD GLUCOSE KIT W/DEVICE
1
KROGER PREMIUM GLUCOSE TEST STRIP
glucose blood
1
KROGER TEST STRIP
glucose blood
1
KYPROLIS RECON SOLN 60 MG
carfilzomib
4
LANCETS 28G MISC
lancets
1
LANCETS 30G MISC
lancets
1
LANCETS MICRO THIN 33G MISC
lancets
1
LANCETS MISC
lancets
1
LANCETS SUPER THIN 28G MISC
lancets
1
LANCETS THIN MISC
lancets
1
LANCETS ULTRA FINE MISC
lancets
1
LANCETS ULTRA THIN 30G MISC
lancets
1
LANCETS ULTRA THIN MISC
lancets
1
LANCING DEVICE MISC
lancet devices
1
PAGE 269
PA
PRODUCT DESCRIPTION
TIER
LASTACAFT SOLUTION 0.25 %
alcaftadine
3
LEADER ADVANCED LANCING DEVICE MISC
lancet devices
1
LEADER INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML
1
QL
200 / 30 days
LEADER INSULIN SYRINGE MISC 28G X 1/2" 1 ML
1
QL
200 / 30 days
1
QL
200 / 30 days
1
1
1
1
1
1
1
1
LEADER UNIFINE PENTIPS MISC 31G X 5 MM
insulin pen needle
1
QL
200 / 30 days
LEADER UNIFINE PENTIPS MISC 32G X 4 MM
insulin pen needle
1
QL
200 / 30 days
LEADER UNIFINE PENTIPS PLUS MISC 31G X 5 MM
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
QL
30 / 30 days
GL
Female
AL1
At least 18 yrs old
letrozole tab 2.5 mg
PAGE 270
1
PA
PRODUCT DESCRIPTION
TIER
LEUKERAN TAB 2 MG
chlorambucil
4
PA
leuprolide acetate kit 1 mg/0.2ml
4
PA
LIBERTY GLUCOSE CONTROL LIQUID NORMAL
1
LIBERTY GLUCOSE CONTROL SOLUTION
1
LIBERTY TEST STRIP
glucose blood
1
1
LITE TOUCH LANCETS MISC
lancets
1
LITE TOUCH LANCING DEVICE MISC
lancet devices
1
LITE TOUCH LANCING PEN MISC
lancet devices
1
LITE TOUCH PEN NEEDLES MISC 31G X 5 MM
insulin pen needle
QL
100 / 23 days
1
QL
200 / 30 days
LITETOUCH INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML
1
QL
200 / 30 days
LITETOUCH INSULIN SYRINGE MISC 28G X 1/2" 1 ML
1
QL
200 / 30 days
1
QL
200 / 30 days
1
1
1
1
1
1
1
PAGE 271
PRODUCT DESCRIPTION
TIER
1
LITETOUCH LANCETS MISC
lancets
1
LITETOUCH PEN NEEDLES MISC 29G X 12.7MM
insulin pen needle
1
QL
200 / 30 days
LITETOUCH PEN NEEDLES MISC 31G X 6 MM
insulin pen needle
1
QL
200 / 30 days
LITETOUCH PEN NEEDLES MISC 31G X 8 MM
insulin pen needle
1
QL
200 / 30 days
LIVE BETTER ADV LANCING DEVICE MISC
lancet devices
1
LIVE BETTER LANCET SUPER THIN MISC
lancets
1
LIVE BETTER LANCET ULTRA THIN MISC
lancets
1
LIVE BETTER PEN NEEDLES MISC 29G X 12MM
insulin pen needle
1
QL
200 / 30 days
LIVE BETTER PEN NEEDLES MISC 31G X 6 MM
insulin pen needle
1
QL
200 / 30 days
LIVE BETTER PEN NEEDLES MISC 31G X 8 MM
insulin pen needle
1
QL
200 / 30 days
LONGS INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML
1
LONGS LANCETS STANDARD MISC
lancets
1
LONGS LANCETS THIN MISC
lancets
1
LONGS LANCETS ULTRA THIN MISC
lancets
1
loratadine allergy relief tab disp 10 mg
1
QL
50 / 30 days
loratadine tab 10 mg
1
QL
50 / 30 days
4
PA
4
PA
leuprolide acetate
4
PA
PAGE 272
PRODUCT DESCRIPTION
TIER
4
PA
4
PA
LYSODREN TAB 500 MG
mitotane
2
PA
MAGELLAN INSULIN SAFETY SYR MISC 29G X 1/2" 0.3 ML
1
QL
1
MAGELLAN INSULIN SAFETY SYR MISC 29G X 1/2" 1 ML
1
1
1
MAGELLAN INSULIN SAFETY SYR MISC 30G X 5/16" 1 ML
1
MATULANE CAP 50 MG
procarbazine hcl
4
PA
MAXI-COMFORT INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML
1
QL
200 / 30 days
MAXI-COMFORT INSULIN SYRINGE MISC 28G X 1/2" 1 ML
1
QL
200 / 30 days
MAXIMA BLOOD GLUCOSE SYSTEM KIT W/DEVICE
1
MAXIMA BLOOD GLUCOSE TEST STRIP
glucose blood
1
MAXIMA CONTROL SOLUTION
1
MAXIMA CONTROL SOLUTION NORMAL
1
MAXIMA METER KIT W/DEVICE
1
MAXIMA STARTER KIT W/DEVICE
1
meclizine hcl tab 12.5 mg
1
meclizine hcl tab 25 mg
1
1
AL1
Up to 64 yrs old
PAGE 273
200 / 30 days
PRODUCT DESCRIPTION
TIER
MEDIC INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML
1
MEDIC INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML
1
MEDICHOICE SAFETY LANCET EXTRA MISC
lancets
1
MEDICHOICE SAFETY LANCET MISC
lancets
1
MEDICHOICE SAFETY LANCET NORM MISC
lancets
1
MEDICINE SHOPPE PEN NEEDLES MISC 29G X 12MM
insulin pen needle
1
QL
200 / 30 days
MEDICINE SHOPPE PEN NEEDLES MISC 31G X 6 MM
insulin pen needle
1
QL
200 / 30 days
MEDICINE SHOPPE PEN NEEDLES MISC 31G X 8 MM
insulin pen needle
1
QL
200 / 30 days
MEDISENSE GLUCOSE KETONE CONTR LIQUID
1
MEDISENSE HI/MID/LOW CONTROL LIQUID
1
MEDISENSE HIGH/LOW CONTROL LIQUID
1
MEDISENSE MID CONTROL LIQUID
1
MEDISENSE THIN LANCETS MISC
lancets
1
MEDLANCE LITE 25G MISC
lancets
1
MEDLANCE PLUS EXTRA 21G MISC
lancets
1
MEDLANCE PLUS LANCETS MISC
lancets
1
MEDLANCE PLUS LITE 25G MISC
lancets
1
MEDLANCE PLUS SPECIAL 0.8MM MISC
lancets
1
MEDLANCE PLUS SUPERLITE 30G MISC
lancets
1
MEDLANCE PLUS UNIVERSAL 21G MISC
lancets
1
PAGE 274
PRODUCT DESCRIPTION
TIER
MEDLANCE UNIVERSAL 21G MISC
lancets
1
megestrol acetate suspension 40 mg/ml
1
megestrol acetate suspension 400 mg/10ml
1
1
1
MEIJER BLOOD GLUCOSE KIT W/DEVICE
1
MEIJER BLOOD GLUCOSE TEST STRIP
glucose blood
1
MEIJER LANCETS MISC
lancets
1
MEIJER LANCETS THIN MISC
lancets
1
MEIJER LANCETS UNIVERSAL 30G MISC
lancets
1
MEIJER LANCETS UNIVERSAL 33G MISC
lancets
1
MEIJER PEN NEEDLES MISC 29G X 12MM
insulin pen needle
1
QL
200 / 30 days
MEIJER PEN NEEDLES MISC 31G X 6 MM
insulin pen needle
1
QL
200 / 30 days
MEIJER PEN NEEDLES MISC 31G X 8 MM
insulin pen needle
1
QL
200 / 30 days
MEIJER PREMIUM BLOOD GLUCOSE KIT W/DEVICE
1
MEIJER PREMIUM GLUCOSE TEST STRIP
glucose blood
1
MEIJER SUPER THIN LANCETS MISC
lancets
1
MEIJER TRUE2GO BLOOD GLUCOSE KIT W/DEVICE
1
MEIJER TRUERESULT GLUCOSE SYS KIT W/DEVICE
1
MEIJER TRUETEST TEST STRIP
glucose blood
1
MEIJER TRUETRACK GLUCOSE SYS KIT W/DEVICE
1
PAGE 275
PRODUCT DESCRIPTION
TIER
MEIJER TRUETRACK TEST STRIP
glucose blood
1
mercaptopurine tab 50 mg
1
methotrexate sodium (pf) solution 1 gm/40ml
1
1
methotrexate sodium (pf) solution 25 mg/ml
1
1
1
methotrexate sodium recon soln 1 gm
1
methotrexate tab 2.5 mg
1
methylergonovine maleate tab 0.2 mg
1
MICRODOT BLOOD GLUCOSE SYSTEM KIT W/DEVICE
1
MICRODOT CONTROL HIGH/LOW SOLUTION
1
MICRODOT TEST STRIP
glucose blood
1
MICROLET LANCETS MISC
lancets
1
MICROTAINER SAFETY FLOW LANCET MISC
lancets
1
MINI LANCING DEVICE MISC
lancet devices
1
MONOJECT INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML
1
QL
200 / 30 days
MONOJECT INSULIN SYRINGE MISC 28G X 1/2" 1 ML
1
QL
200 / 30 days
1
QL
200 / 30 days
1
1
1
1
PAGE 276
PRODUCT DESCRIPTION
TIER
1
1
MONOJECT ULTRA COMFORT SYRINGE MISC 28G X 1/2"
0.5 ML
1
QL
200 / 30 days
MONOJECT ULTRA COMFORT SYRINGE MISC 28G X 1/2" 1
ML
1
QL
200 / 30 days
0.3 ML
1
QL
200 / 30 days
0.5 ML
1
MONOJECT ULTRA COMFORT SYRINGE MISC 29G X 1/2" 1
ML
1
0.3 ML
1
0.5 ML
1
0.3 ML
1
0.5 ML
1
MONOLET LANCETS MISC
lancets
1
MONOLET OPD LANCETS MISC
lancets
1
MONOLETTOR SAFETY LANCETS MISC
lancets
1
MOORE MONO INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML
1
QL
200 / 30 days
MOORE MONO INSULIN SYRINGE MISC 28G X 1/2" 1 ML
1
QL
200 / 30 days
PAGE 277
PRODUCT DESCRIPTION
TIER
MOORE MONO INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML
1
MOORE MONO INSULIN SYRINGE MISC 29G X 1/2" 1 ML
1
MS INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML
1
1
1
MS INSULIN SYRINGE MISC 31G X 5/16" 1 ML
1
MULTI-LANCET DEVICE MISC
lancet devices
1
MYGLUCOHEALTH BLOOD GLUCOSE KIT W/DEVICE
1
MYGLUCOHEALTH CONTROL SOLUTION
1
MYGLUCOHEALTH LANCETS 30G MISC
lancets
1
MYGLUCOHEALTH TEST STRIP
glucose blood
1
MYLERAN TAB 2 MG
busulfan
4
NEUTEK 2TEK CONTROL SOLUTION
1
NEUTEK 2TEK TEST STRIP
glucose blood
1
NEXAVAR TAB 200 MG
sorafenib tosylate
4
1
1
nizatidine solution 15 mg/ml
1
NOVA MAX BLOOD GLUCOSE SYSTEM KIT W/DEVICE
1
NOVA MAX GLUCOSE TEST STRIP
glucose blood
1
NOVA MAX PLUS GLU/KET CONTROL LIQUID
1
PAGE 278
QL
200 / 30 days
PA
PA
PRODUCT DESCRIPTION
TIER
NOVA MAX PLUS KETONE TEST STRIP
ketone blood test
1
NOVA SAFETY LANCETS 23G MISC
lancets
1
NOVA SAFETY LANCETS 28G MISC
lancets
1
NOVA SUREFLEX LANCETS MISC
lancets
1
NOVA SUREFLEX LANCING DEVICE MISC
lancet devices
1
NOVOFINE PLUS MISC 32G X 4 MM
insulin pen needle
QL
10 / 30 days
1
QL
200 / 30 days
olopatadine hcl solution 0.6 %
3
ST
ON CALL EXPRESS BLOOD GLUCOSE STRIP
glucose blood
1
ON CALL EXPRESS GLUCOSE CONTR SOLUTION
1
ON CALL EXPRESS MONITORING SYS KIT W/DEVICE
1
ON CALL LANCETS MISC
lancets
1
ON CALL LANCING DEVICE MISC
lancet devices
1
ON CALL PLUS BLOOD GLUCOSE STRIP
glucose blood
1
ON CALL PLUS GLUCOSE CONTROL SOLUTION
1
ON CALL PLUS LANCETS MISC
lancets
1
ON CALL PLUS LANCING DEVICE MISC
lancet devices
1
ON CALL PLUS METER KIT W/DEVICE
1
ON CALL PLUS MONITORING SYSTEM KIT W/DEVICE
1
ON CALL VIVID BLOOD GLUCOSE STRIP
glucose blood
1
ON CALL VIVID GLUCOSE CONTROL SOLUTION
1
PAGE 279
PRODUCT DESCRIPTION
TIER
ON CALL VIVID METER KIT W/DEVICE
1
ON CALL VIVID MONITORING KIT W/DEVICE
1
ON CALL VIVID PAL METER KIT W/DEVICE
1
ONETOUCH DELICA LANCETS 33G MISC
lancets
1
ONETOUCH DELICA LANCETS FINE MISC
lancets
1
ONETOUCH DELICA LANCING DEV MISC
lancet devices
1
ONETOUCH FINEPOINT LANCETS MISC
lancets
1
ONETOUCH ULTRA 2 KIT W/DEVICE
1
ONETOUCH ULTRA BLUE STRIP
glucose blood
1
ONETOUCH ULTRA CONTROL SOLUTION
1
ONETOUCH ULTRA MINI KIT W/DEVICE
1
ONETOUCH ULTRA SYSTEM KIT W/DEVICE
1
ONETOUCH ULTRALINK KIT W/DEVICE
1
ONETOUCH ULTRASOFT LANCETS MISC
lancets
1
ONETOUCH VERIO IQ SYSTEM KIT W/DEVICE
1
ONETOUCH VERIO KIT W/DEVICE
1
ONETOUCH VERIO SOLUTION
1
ONETOUCH VERIO STRIP
glucose blood
1
ONETOUCH VERIO SYNC SYSTEM KIT W/DEVICE
1
OPTIUM TEST STRIP
glucose blood
1
PAGE 280
PRODUCT DESCRIPTION
TIER
OPTIUMEZ TEST STRIP
glucose blood
1
OPTUMRX BLOOD GLUCOSE METER KIT W/DEVICE
1
OPTUMRX BLOOD GLUCOSE SYSTEM KIT W/DEVICE
1
OPTUMRX BLOOD GLUCOSE TEST STRIP
glucose blood
1
OPTUMRX GLUCOSE CONTROL SOLUTION
1
PARADIGM LINK GLUCOSE MONITOR KIT W/DEVICE
1
PATADAY SOLUTION 0.2 %
olopatadine hcl
3
PA
PATANOL SOLUTION 0.1 %
olopatadine hcl
3
PA
PC LANCETS SUPER THIN 30G MISC
lancets
1
PC UNIFINE PENTIPS MISC 29G X 12MM
insulin pen needle
1
QL
200 / 30 days
PC UNIFINE PENTIPS MISC 31G X 5 MM
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
PEN NEEDLES 1/2" MISC 29G X 12MM
insulin pen needle
1
QL
200 / 30 days
PEN NEEDLES 3/16" MISC 31G X 5 MM
insulin pen needle
1
QL
200 / 30 days
PEN NEEDLES 5/16" MISC 31G X 8 MM
insulin pen needle
1
QL
200 / 30 days
PEN NEEDLES MISC 29G X 12MM
insulin pen needle
1
QL
200 / 30 days
PEN NEEDLES MISC 31G X 6 MM
insulin pen needle
1
QL
200 / 30 days
PENTETATE CALCIUM TRISODIUM SOLUTION 200 MG/ML
pentetate calcium trisodium
1
PENTETATE ZINC TRISODIUM SOLUTION 200 MG/ML
pentetate zinc trisodium
1
PAGE 281
PRODUCT DESCRIPTION
TIER
PERFECT LANCETS 28G MISC
lancets
1
PERFECT LANCETS 30G MISC
lancets
1
PHARMACIST CHOICE AUTOCODE STRIP
glucose blood
1
PHARMACIST CHOICE AUTOCODE SYS KIT W/DEVICE
1
PHARMACIST CHOICE LANCETS MISC
lancets
1
PHARMACY COUNTER LANCETS MISC
lancets
1
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
POMALYST CAP 1 MG
pomalidomide
4
PA
POMALYST CAP 2 MG
pomalidomide
4
PA
POMALYST CAP 3 MG
pomalidomide
4
PA
POMALYST CAP 4 MG
pomalidomide
4
PA
PRECISION GLUCOSE KETONE CONTR LIQUID
1
PRECISION PCX PLUS TEST STRIP
glucose blood
1
PRECISION PCX STRIP
glucose blood
1
PRECISION POINT OF CARE TEST STRIP
glucose blood
1
PRECISION QID TEST STRIP
glucose blood
1
PRECISION SURE-DOSE SYRINGE MISC 28G X 1/2" 0.5 ML
1
QL
200 / 30 days
PRECISION SURE-DOSE SYRINGE MISC 28G X 1/2" 1 ML
1
QL
200 / 30 days
PRECISION SURE-DOSE SYRINGE MISC 29G X 1/2" 0.5 ML
1
PAGE 282
PRODUCT DESCRIPTION
TIER
PRECISION SUREDOSE PLUS SYR MISC 29G X 1/2" 0.3 ML
1
PRECISION SUREDOSE PLUS SYR MISC 29G X 1/2" 1 ML
1
PRECISION XTRA BLOOD GLUCOSE STRIP
glucose blood
1
PRECISION XTRA KETONE STRIP
ketone blood test
QL
200 / 30 days
1
QL
10 / 30 days
PREFERRED PLUS INSULIN SYRINGE MISC 28G X 1/2" 0.5
ML
1
QL
200 / 30 days
PREFERRED PLUS INSULIN SYRINGE MISC 28G X 1/2" 1
ML
1
QL
200 / 30 days
ML
1
QL
200 / 30 days
ML
1
ML
1
ML
1
ML
1
ML
1
PREFERRED PLUS LANCETS COLORED MISC
lancets
1
PREFERRED PLUS LANCETS THIN MISC
lancets
1
PREFERRED PLUS UNIFINE PENTIPS MISC 29G X 12MM
insulin pen needle
1
QL
200 / 30 days
PREFERRED PLUS UNIFINE PENTIPS MISC 31G X 5 MM
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
PAGE 283
PRODUCT DESCRIPTION
TIER
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
PRODIGY AUTOCODE BLOOD GLUCOSE KIT W/DEVICE
1
PRODIGY INSULIN SYRINGE MISC 28G X 1/2" 1 ML
1
QL
200 / 30 days
PRODIGY INSULIN SYRINGE MISC 31G X 5/16" 0.3 ML
1
PRODIGY INSULIN SYRINGE MISC 31G X 5/16" 0.5 ML
1
PRODIGY LANCETS 28G MISC
lancets
1
PRODIGY LANCING DEVICE MISC
lancet devices
1
PRODIGY NO CODING BLOOD GLUC STRIP
glucose blood
1
PRODIGY POCKET BLOOD GLUCOSE KIT W/DEVICE
1
PRODIGY TWIST TOP LANCETS 28G MISC
lancets
1
PRODIGY VOICE BLOOD GLUCOSE KIT W/DEVICE
1
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
PAGE 284
PRODUCT DESCRIPTION
TIER
promethazine vc plain syrup 6.25-5 mg/5ml
1
1
promethazine-codeine syrup 6.25-10 mg/5ml
1
promethazine-dm syrup 6.25-15 mg/5ml
1
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
1
AL1
Up to 64 yrs old
PTS PANELS KETONE TEST STRIP
ketone blood test
1
QL
10 / 30 days
PULMOZYME SOLUTION 1 MG/ML
dornase alfa
QL
60 / 30 days
4
px acid reducer max st tab 20 mg
1
PX ADVANCED LANCING DEVICE MISC
lancet devices
1
PX EXTRA SHORT PEN NEEDLES MISC 31G X 6 MM
insulin pen needle
1
QL
200 / 30 days
PX INSULIN SYRINGE MISC 30G X 1/2" 0.3 ML
1
QL
200 / 30 days
1
QL
200 / 30 days
PX INSULIN SYRINGE MISC 30G X 1/2" 1 ML
1
QL
200 / 30 days
1
1
PX INSULIN SYRINGE MISC 31G X 5/16" 1 ML
1
PX LANCET AUTO INJECTOR MISC
lancet devices
1
PX LANCETS ULTRA THIN MISC
lancets
1
PX MINI PEN NEEDLES MISC 31G X 5 MM
insulin pen needle
1
QL
200 / 30 days
PX PEN NEEDLE MISC 29G X 12MM
insulin pen needle
1
QL
200 / 30 days
PAGE 285
PA
PRODUCT DESCRIPTION
TIER
PX PEN NEEDLE MISC 31G X 8 MM
insulin pen needle
1
PYROGALLIC ACID OINTMENT 25-2 %
pyrogallol-chlorobutanol
1
qc acid controller max st tab 20 mg
1
QC LANCETS SUPER THIN 30G MISC
lancets
1
qc loratadine allergy relief tab 10 mg
QL
200 / 30 days
1
QL
50 / 30 days
QC PEN NEEDLES MISC 29G X 12MM
insulin pen needle
1
QL
200 / 30 days
QC PEN NEEDLES MISC 31G X 6 MM
insulin pen needle
1
QL
200 / 30 days
QC PEN NEEDLES MISC 31G X 8 MM
insulin pen needle
1
QL
200 / 30 days
QC UNIFINE PENTIPS MISC 32G X 4 MM
insulin pen needle
1
QL
200 / 30 days
1
AL1
Up to 64 yrs old
ra acid reducer max st tab 20 mg
1
ra acid reducer tab 200 mg
1
RA E-ZJECT COLOR LANCETS 33G MISC
lancets
1
RA E-ZJECT LANCETS 28G MISC
lancets
1
RA E-ZJECT LANCETS THIN 26G MISC
lancets
1
RA E-ZJECT LANCETS THIN 28G MISC
lancets
1
RA E-ZJECT LANCETS ULTRA THIN MISC
lancets
1
RA INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML
1
RA INSULIN SYRINGE MISC 29G X 1/2" 1 ML
1
RA INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML
1
RA INSULIN SYRINGE MISC 30G X 5/16" 1 ML
1
PAGE 286
PRODUCT DESCRIPTION
TIER
RA LANCING DEVICE MISC
lancet devices
1
RA PEN NEEDLES MISC 31G X 5 MM
insulin pen needle
1
QL
200 / 30 days
RA PEN NEEDLES MISC 31G X 8 MM
insulin pen needle
1
QL
200 / 30 days
RA TRUERESULT BLOOD GLUCOSE KIT W/DEVICE
1
RA TRUETEST TEST STRIP
glucose blood
1
3
3
ranitidine hcl syrup 15 mg/ml
1
1
1
1
1
REFUAH PLUS BLOOD GLUCOSE TEST STRIP
glucose blood
1
REFUAH PLUS GLUCOSE CONTROL SOLUTION
1
REFUAH PLUS MONITORING SYSTEM KIT W/DEVICE
1
RELI-ON INSULIN SYRINGE MISC 29G X 1/2" 1 ML
1
RELION BLOOD GLUCOSE TEST STRIP
glucose blood
1
RELION CONFIRM GLUCOSE MONITOR KIT W/DEVICE
1
RELION CONFIRM/MICRO TEST STRIP
glucose blood
1
RELION INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML
1
QL
200 / 30 days
1
RELION INSULIN SYRINGE MISC 29G X 1/2" 1 ML
1
PAGE 287
PRODUCT DESCRIPTION
TIER
1
1
1
1
1
1
RELION KETONE STRIP
1
RELION LANCETS MICRO-THIN 33G MISC
lancets
1
RELION LANCETS THIN 26G MISC
lancets
1
RELION LANCETS ULTRA-THIN 30G MISC
lancets
1
RELION LANCING DEVICE MISC
lancet devices
1
RELION MICRO KIT W/DEVICE
1
RELION MINI PEN NEEDLES MISC 31G X 6 MM
insulin pen needle
1
QL
200 / 30 days
RELION PEN NEEDLES MISC 29G X 12MM
insulin pen needle
1
QL
200 / 30 days
RELION PEN NEEDLES MISC 31G X 8 MM
insulin pen needle
1
QL
200 / 30 days
RELION PEN NEEDLES MISC 32G X 4 MM
insulin pen needle
1
QL
200 / 30 days
RELION PRIME TEST STRIP
glucose blood
1
RELION SHORT PEN NEEDLES MISC 31G X 8 MM
insulin pen needle
1
QL
200 / 30 days
RELION ULTIMA GLUCOSE SYSTEM KIT W/DEVICE
1
RELION ULTIMA TEST STRIP
glucose blood
1
PAGE 288
PRODUCT DESCRIPTION
TIER
RELION ULTRA THIN LANCETS 30G MISC
lancets
1
RELION ULTRA THIN PLUS LANCETS MISC
lancets
1
REVEAL BLOOD GLUCOSE MONITOR KIT W/DEVICE
1
REVEAL BLOOD GLUCOSE TEST STRIP
glucose blood
1
REVLIMID CAP 10 MG
lenalidomide
4
PA
REVLIMID CAP 15 MG
lenalidomide
4
PA
REVLIMID CAP 2.5 MG
lenalidomide
4
PA
REVLIMID CAP 25 MG
lenalidomide
4
PA
REVLIMID CAP 5 MG
lenalidomide
4
PA
REXALL BLOOD GLUCOSE SYSTEM KIT W/DEVICE
1
REXALL BLOOD GLUCOSE TEST STRIP
glucose blood
1
REXALL LANCETS ULTRA THIN 30G MISC
lancets
1
RIDAURA CAP 3 MG
auranofin
4
RIGHTEST GC300 CONTROL LIQUID NORMAL
1
RIGHTEST GD500 LANCING DEVICE MISC
lancet devices
1
RIGHTEST GL300 LANCETS MISC
lancets
1
RIGHTEST GM100 BLOOD GLUCOSE KIT W/DEVICE
1
1
1
RIGHTEST GS100 BLOOD GLUCOSE STRIP
glucose blood
1
PAGE 289
PA
PRODUCT DESCRIPTION
TIER
glucose blood
1
glucose blood
1
SAFESNAP INSULIN SYRINGE MISC 28G X 1/2" 1 ML
1
SAFESNAP INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML
1
SAFESNAP INSULIN SYRINGE MISC 29G X 1/2" 1 ML
1
1
1
SAFETY LANCET 21G/PRESSURE ACT MISC
lancets
1
SAFETY LANCET 28G/PRESSURE ACT MISC
lancets
1
SAFETY LANCETS 21G MISC
lancets
1
SAFETY LANCETS 28G MISC
lancets
1
SAFETY LANCETS MISC
lancets
1
SAFETY LET LANCETS MISC
lancets
1
SAFETY SEAL LANCETS MISC
lancets
1
SAFETY-GLIDE SYRINGE MISC 29G X 1/2" 0.3 ML
1
SANTYL OINTMENT 250 UNIT/GM
collagenase
3
SAPSCARE TWIST TOP LANCETS MISC
lancets
1
sb acid controller max st tab 20 mg
1
SB INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML
1
SB INSULIN SYRINGE MISC 29G X 1/2" 1 ML
1
PAGE 290
QL
200 / 30 days
QL
200 / 30 days
PRODUCT DESCRIPTION
TIER
SB INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML
1
1
1
SB LANCETS THIN MISC
lancets
1
SB LANCETS ULTRA THIN MISC
lancets
1
sb loratadine tab 10 mg
1
SCHNUCKS INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML
1
SCHNUCKS INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML
1
SHOPKO AUTOLET LANCING DEVICE MISC
lancet devices
1
SHOPKO ON-THE-GO LANCETS 30G MISC
lancets
1
SHOPKO UNIFINE PENTIPS MISC 29G X 12MM
insulin pen needle
QL
50 / 30 days
1
QL
200 / 30 days
SHOPKO UNIFINE PENTIPS MISC 31G X 5 MM
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
SHOPKO UNILET LANCETS 28G MISC
lancets
1
SHOPKO UNILET LANCETS 30G MISC
lancets
1
1
AL1
Up to 64 yrs old
SIMPLE DIAGNOSTICS LANCING DEV MISC
lancet devices
1
sm acid reducer max st tab 20 mg
1
sm acid reducer tab 200 mg
1
sm childrens loratadine syrup 5 mg/5ml
1
QL
50 / 30 days
PAGE 291
PRODUCT DESCRIPTION
TIER
1
QL
50 / 30 days
1
QL
50 / 30 days
SM INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML
1
QL
200 / 30 days
SM INSULIN SYRINGE MISC 28G X 1/2" 1 ML
1
QL
200 / 30 days
SM INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML
1
QL
200 / 30 days
SM INSULIN SYRINGE MISC 31G X 5/16" 1 ML
1
SM LANCETS 33G MISC
lancets
1
sm loratadine allergy relief tab disp 10 mg
1
QL
50 / 30 days
sm loratadine syrup 5 mg/5ml
1
QL
50 / 30 days
sm loratadine tab 10 mg
1
QL
50 / 30 days
sm loratadine tab disp 10 mg
1
QL
50 / 30 days
SMART DIABETES VANTAGE LANCETS MISC
lancets
1
SMART DIABETES VANTAGE LANCING MISC
lancet devices
1
SMART DIABETES XPRES SYSTEM KIT W/DEVICE
1
SMART DIABETES XPRES TEST STRIP
glucose blood
1
SMART SENSE COLOR LANCETS 33G MISC
lancets
1
SMART SENSE PREMIUM SYSTEM KIT W/DEVICE
1
SMART SENSE PREMIUM TEST STRIP
glucose blood
1
SMART SENSE STANDARD LANCETS MISC
lancets
1
SMART SENSE SUPER THIN LANCETS MISC
lancets
1
SMART SENSE THIN LANCETS 26G MISC
lancets
1
PAGE 292
PRODUCT DESCRIPTION
TIER
SMART SENSE VALUE GLUCOSE SYS KIT W/DEVICE
1
SMART SENSE VALUE TEST STRIP
glucose blood
1
SMARTEST BLOOD GLUCOSE TEST STRIP
glucose blood
1
SMARTEST CONTROL MEDIUM SOLUTION
1
SMARTEST EJECT STARTER KIT W/DEVICE
1
SMARTEST LANCETS 28G MISC
lancets
1
SMARTEST PERSONA STARTER KIT W/DEVICE
1
SMARTEST PRONTO STARTER KIT W/DEVICE
1
SMARTEST PROTEGE STARTER KIT W/DEVICE
1
SOLARTEK GLUCOSE CONTROL LIQUID
1
SOLUS V2 BLOOD GLUCOSE SYSTEM KIT W/DEVICE
1
SOLUS V2 LANCETS 28G MISC
lancets
1
SOLUS V2 LANCING DEVICE MISC
lancet devices
1
SOLUS V2 TEST STRIP
glucose blood
1
SOLUS V2 TWIST LANCETS 30G MISC
lancets
1
SPRYCEL TAB 100 MG
dasatinib
4
PA
SPRYCEL TAB 140 MG
dasatinib
4
PA
SPRYCEL TAB 20 MG
dasatinib
4
PA
SPRYCEL TAB 50 MG
dasatinib
4
PA
SPRYCEL TAB 70 MG
dasatinib
4
PA
PAGE 293
PRODUCT DESCRIPTION
TIER
SPRYCEL TAB 80 MG
dasatinib
4
STERILANCE TL MISC
lancets
1
STIVARGA TAB 40 MG
regorafenib
4
PA
SURE COMFORT INSULIN SYRINGE MISC 28G X 1/2" 0.5
ML
1
QL
200 / 30 days
SURE COMFORT INSULIN SYRINGE MISC 28G X 1/2" 1 ML
1
QL
200 / 30 days
ML
1
QL
200 / 30 days
ML
1
1
ML
1
QL
200 / 30 days
ML
1
QL
200 / 30 days
1
QL
200 / 30 days
ML
1
1
ML
1
ML
1
1
SURE COMFORT LANCETS 28G MISC
lancets
1
PAGE 294
PA
PRODUCT DESCRIPTION
TIER
SURE COMFORT LANCETS 30G MISC
lancets
1
SURE COMFORT LANCING PEN MISC
lancet devices
1
SURE COMFORT PEN NEEDLES MISC 29G X 12.7MM
insulin pen needle
1
QL
200 / 30 days
SURE COMFORT PEN NEEDLES MISC 31G X 5 MM
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
SURE EDGE TEST STRIP
glucose blood
1
SURE-FINE PEN NEEDLES MISC 29G X 12.7MM
insulin pen needle
1
QL
200 / 30 days
SURE-FINE PEN NEEDLES MISC 31G X 5 MM
insulin pen needle
1
QL
200 / 30 days
SURE-FINE PEN NEEDLES MISC 31G X 8 MM
insulin pen needle
1
QL
200 / 30 days
SURE-JECT INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML
1
QL
200 / 30 days
SURE-JECT INSULIN SYRINGE MISC 28G X 1/2" 1 ML
1
QL
200 / 30 days
1
QL
200 / 30 days
1
1
1
1
1
1
1
PAGE 295
PRODUCT DESCRIPTION
TIER
1
SURE-LANCE FLAT LANCETS MISC
lancets
1
SURE-LANCE LANCETS 26G MISC
lancets
1
SURE-LANCE THIN LANCETS 28G MISC
lancets
1
SURE-LANCE ULTRA THIN LANCETS MISC
lancets
1
SURE-PEN MISC
lancet devices
1
SURE-TEST EASYPLUS MINI TEST STRIP
glucose blood
1
SURE-TOUCH LANCETS UNIVERSAL MISC
lancets
1
SURECHEK BLOOD GLUCOSE TEST STRIP
glucose blood
1
SURELITE LANCETS MISC
lancets
1
SURESTEP GLUCOSE CONTROL SOLUTION
1
SURESTEP PRO NORMAL GLUCOSE LIQUID
1
SURESTEP PRO TEST STRIP
glucose blood
1
SUTENT CAP 12.5 MG
sunitinib malate
4
PA
SUTENT CAP 25 MG
sunitinib malate
4
PA
SUTENT CAP 50 MG
sunitinib malate
4
PA
4
PA
4
PA
4
PA
4
PA
PAGE 296
PRODUCT DESCRIPTION
TIER
4
SYPRINE CAP 250 MG
trientine hcl
4
TABLOID TAB 40 MG
thioguanine
4
TAI DOC CONTROL SOLUTION NORMAL
1
1
1
TARCEVA TAB 100 MG
erlotinib hcl
4
PA
TARCEVA TAB 150 MG
erlotinib hcl
4
PA
TARCEVA TAB 25 MG
erlotinib hcl
4
PA
TARGRETIN CAP 75 MG
bexarotene
4
PA
TASIGNA CAP 150 MG
nilotinib hcl
4
PA
TASIGNA CAP 200 MG
nilotinib hcl
4
PA
TECHLITE LANCETS 30G MISC
lancets
1
TELCARE BLOOD GLUCOSE SYSTEM KIT W/DEVICE
1
TELCARE BLOOD GLUCOSE TEST STRIP
glucose blood
1
TELCARE GLUCOSE CONTROL SOLUTION
1
TERUMO INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML
1
QL
200 / 30 days
TERUMO INSULIN SYRINGE MISC 28G X 1/2" 1 ML
1
QL
200 / 30 days
1
QL
200 / 30 days
1
TERUMO INSULIN SYRINGE MISC 29G X 1/2" 1 ML
1
PAGE 297
PA
PA
PRODUCT DESCRIPTION
TIER
TERUMO SURGUARD INSULIN SYR MISC 28G X 1/2" 0.5 ML
1
QL
200 / 30 days
TERUMO SURGUARD INSULIN SYR MISC 28G X 1/2" 1 ML
1
QL
200 / 30 days
1
QL
200 / 30 days
1
TERUMO SURGUARD INSULIN SYR MISC 29G X 1/2" 1 ML
1
1
tgt acid reducer tab 200 mg
1
TGT ADVANCED LANCING DEVICE MISC
lancet devices
1
TGT BLOOD GLUCOSE MONITORING KIT W/DEVICE
1
TGT BLOOD GLUCOSE TEST STRIP
glucose blood
1
TGT LANCET ALTERNATE SITE MISC
lancets
1
TGT LANCET MICRO THIN 33G MISC
lancets
1
TGT LANCET SUPER THIN 30G MISC
lancets
1
TGT LANCET THIN 23G MISC
lancets
1
TGT LANCET THIN 26G MISC
lancets
1
TGT LANCET ULTRA THIN 28G MISC
lancets
1
TGT LANCET ULTRA THIN 30G MISC
lancets
1
TGT LANCING DEVICE MISC
lancet devices
1
tgt loratadine childrens syrup 5 mg/5ml
1
QL
50 / 30 days
THINPRO INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML
1
QL
200 / 30 days
PAGE 298
PRODUCT DESCRIPTION
TIER
THINPRO INSULIN SYRINGE MISC 28G X 1/2" 1 ML
1
QL
200 / 30 days
1
QL
200 / 30 days
1
THINPRO INSULIN SYRINGE MISC 29G X 1/2" 1 ML
1
THYROGEN RECON SOLN 1.1 MG
thyrotropin alfa
4
TODAYS HEALTH LANCING DEVICE MISC
lancet devices
1
TODAYS HEALTH MINI PEN NEEDLES MISC 31G X 6 MM
insulin pen needle
1
QL
200 / 30 days
TODAYS HEALTH PEN NEEDLES MISC 29G X 12MM
insulin pen needle
1
QL
200 / 30 days
TODAYS HEALTH SHORT PEN NEEDLE MISC 31G X 8 MM
insulin pen needle
1
QL
200 / 30 days
TODAYS HEALTH THIN LANCETS 28G MISC
lancets
1
TODAYS HEALTH THIN LANCETS 30G MISC
lancets
1
TOLBUTAMIDE TAB 500 MG
tolbutamide
1
TOPCARE CLICKFINE PEN NEEDLES MISC 31G X 6 MM
insulin pen needle
1
QL
200 / 30 days
TOPCARE CLICKFINE PEN NEEDLES MISC 31G X 8 MM
insulin pen needle
1
QL
200 / 30 days
TOPCARE ULTRA COMFORT INS SYR MISC 29G X 1/2" 0.3
ML
1
QL
200 / 30 days
ML
1
TOPCARE ULTRA COMFORT INS SYR MISC 29G X 1/2" 1
ML
1
ML
1
PAGE 299
PA
PRODUCT DESCRIPTION
TIER
ML
1
ML
1
ML
1
ML
1
ML
1
TRELSTAR DEPOT MIXJECT RECON SUSP 3.75 MG
triptorelin pamoate
4
PA
TRELSTAR LA MIXJECT RECON SUSP 11.25 MG
triptorelin pamoate
4
PA
TRELSTAR MIXJECT RECON SUSP 22.5 MG
triptorelin pamoate
4
PA
TRELSTAR RECON SUSP 11.25 MG
triptorelin pamoate
4
PA
TRELSTAR RECON SUSP 3.75 MG
triptorelin pamoate
4
PA
tretinoin cap 10 mg
4
PA
TREXALL TAB 10 MG
methotrexate sodium
3
PA
TREXALL TAB 15 MG
methotrexate sodium
3
PA
TREXALL TAB 5 MG
methotrexate sodium
3
PA
TREXALL TAB 7.5 MG
methotrexate sodium
3
PA
TRUE METRIX BLOOD GLUCOSE TEST STRIP
glucose blood
1
TRUE METRIX LEVEL 2 SOLUTION NORMAL
1
TRUE METRIX METER KIT W/DEVICE
1
PAGE 300
PRODUCT DESCRIPTION
TIER
TRUE2GO BLOOD GLUCOSE MONITOR KIT W/DEVICE
1
TRUECONTROL GLUCOSE CONT LEV 0 LIQUID
1
TRUECONTROL GLUCOSE CONT LEV 1 LIQUID
1
TRUEDRAW LANCING DEVICE MISC
lancet devices
1
TRUEPLUS INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML
1
QL
200 / 30 days
TRUEPLUS INSULIN SYRINGE MISC 28G X 1/2" 1 ML
1
QL
200 / 30 days
1
QL
200 / 30 days
1
1
1
1
1
1
1
1
TRUEPLUS LANCETS 26G MISC
lancets
1
lancets
1
lancets
1
lancets
1
TRUEPLUS SAFETY LANCETS 28G MISC
lancets
1
PAGE 301
PRODUCT DESCRIPTION
TIER
TRUERESULT BLOOD GLUCOSE KIT W/DEVICE
1
TRUETEST CONTROL LEVEL 1 LIQUID
1
1
1
TRUETEST TEST STRIP
glucose blood
1
TRUETRACK BLOOD GLUCOSE KIT W/DEVICE
1
TRUETRACK SMART SYSTEM KIT
1
TRUETRACK TEST STRIP
glucose blood
1
TYKERB TAB 250 MG
lapatinib ditosylate
4
ULTI-LANCE AUTOMATIC MISC
lancet devices
1
ULTICARE INSULIN SAFETY SYR MISC 29G X 1/2" 0.5 ML
1
ULTICARE INSULIN SAFETY SYR MISC 29G X 1/2" 1 ML
1
ULTICARE INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML
1
QL
200 / 30 days
ULTICARE INSULIN SYRINGE MISC 28G X 1/2" 1 ML
1
QL
200 / 30 days
1
QL
200 / 30 days
1
1
1
QL
200 / 30 days
1
QL
200 / 30 days
1
QL
200 / 30 days
PAGE 302
PA
PRODUCT DESCRIPTION
TIER
1
1
1
1
1
1
ULTICARE MICRO PEN NEEDLES MISC 32G X 4 MM
insulin pen needle
1
QL
200 / 30 days
ULTICARE MINI PEN NEEDLES MISC 31G X 6 MM
insulin pen needle
1
QL
200 / 30 days
ULTICARE PEN NEEDLES MISC 29G X 12.7MM
insulin pen needle
1
QL
200 / 30 days
ULTICARE PEN NEEDLES MISC 29G X 12MM
insulin pen needle
1
QL
200 / 30 days
ULTICARE SHORT PEN NEEDLES MISC 31G X 8 MM
insulin pen needle
1
QL
200 / 30 days
ULTILET CLASSIC LANCETS MISC
lancets
1
ULTILET INSULIN SYRINGE SHORT MISC 30G X 5/16" 0.3
ML
1
ML
1
ULTILET INSULIN SYRINGE SHORT MISC 30G X 5/16" 1 ML
1
ML
1
ML
1
ULTILET INSULIN SYRINGE SHORT MISC 31G X 5/16" 1 ML
1
PAGE 303
PRODUCT DESCRIPTION
TIER
ULTILET LANCETS MISC
lancets
1
ULTILET PEN NEEDLE MISC 31G X 8 MM
insulin pen needle
1
ULTILET SAFETY LANCETS 23G MISC
lancets
1
ULTIMA TEST STRIP
glucose blood
1
ULTRA COMFORT INSULIN SYRINGE MISC 30G X 5/16" 0.3
ML
1
ULTRA THIN LANCETS 28G MISC
lancets
1
ULTRA THIN LANCETS 30G MISC
lancets
1
ULTRA TRAK PRO BLOOD GLUCOSE KIT W/DEVICE
1
ULTRA-COMFORT INSULIN SYRINGE MISC 28G X 1/2" 0.5
ML
QL
200 / 30 days
1
QL
200 / 30 days
ULTRA-COMFORT INSULIN SYRINGE MISC 28G X 1/2" 1 ML
1
QL
200 / 30 days
ML
1
QL
200 / 30 days
ML
1
ULTRA-COMFORT INSULIN SYRINGE MISC 29G X 1/2" 1 ML
1
ML
1
ML
1
ULTRA-COMFORT INSULIN SYRINGE MISC 30G X 5/16" 1
ML
1
ML
1
PAGE 304
PRODUCT DESCRIPTION
TIER
ML
1
ULTRA-COMFORT INSULIN SYRINGE MISC 31G X 5/16" 1
ML
1
ULTRA-THIN II AUTO LANCET MISC
lancets
1
ULTRA-THIN II INS SYR SHORT MISC 31G X 5/16" 1 ML
1
ULTRA-THIN II INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML
1
QL
200 / 30 days
ULTRA-THIN II PEN NEEDLES MISC 29G X 12.7MM
insulin pen needle
1
QL
200 / 30 days
ULTRATRAK PRO CONTROL SOLUTION
1
ULTRATRAK PRO CONTROL SOLUTION NORMAL
1
ULTRATRAK PRO TEST STRIP
glucose blood
1
ULTRATRAK ULTIMATE CONTROL SOLUTION
1
ULTRATRAK ULTIMATE TEST STRIP
glucose blood
1
UNIFINE PENTIPS MISC 29G X 12MM
insulin pen needle
1
QL
200 / 30 days
UNIFINE PENTIPS MISC 31G X 5 MM
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
UNIFINE PENTIPS PLUS MISC 29G X 12MM
insulin pen needle
1
QL
200 / 30 days
UNIFINE PENTIPS PLUS MISC 31G X 5 MM
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
PAGE 305
PRODUCT DESCRIPTION
TIER
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
UNILET COMFORTOUCH LANCET MISC
lancets
1
UNILET EXCELITE II MISC
lancets
1
UNILET EXCELITE MISC
lancets
1
UNILET G.P. SUPERLITE LANCET MISC
lancets
1
UNILET GP 28 ULTRA THIN MISC
lancets
1
UNISTIK 3 GENTLE MISC
lancets
1
UNISTRIP1 GENERIC STRIP
glucose blood
1
UNIVERSAL 1 LANCETS THIN 26G MISC
lancets
1
UNIVERSAL 1 LANCETS ULTRA THIN MISC
lancets
1
V-R MONO INSULIN SYRINGE MISC 28G X 1/2" 0.5 ML
1
QL
200 / 30 days
V-R MONO INSULIN SYRINGE MISC 28G X 1/2" 1 ML
1
QL
200 / 30 days
1
QL
200 / 30 days
1
V-R MONO INSULIN SYRINGE MISC 29G X 1/2" 1 ML
1
VALSTAR SOLUTION 40 MG/ML
valrubicin
4
VALUE HEALTH INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML
1
VALUE HEALTH INSULIN SYRINGE MISC 29G X 1/2" 1 ML
1
VALUE PLUS LANCET STANDARD 21G MISC
lancets
1
PAGE 306
PA
PRODUCT DESCRIPTION
TIER
VALUE PLUS LANCETS SUPER THIN MISC
lancets
1
VALUE PLUS LANCETS THIN 26G MISC
lancets
1
VALUE PLUS LANCING DEVICE MISC
lancet devices
1
VALUMARK LANCET SUPER THIN 30G MISC
lancets
1
VALUMARK LANCET ULTRA THIN 28G MISC
lancets
1
VALUMARK PEN NEEDLES MISC 29G X 12MM
insulin pen needle
1
QL
200 / 30 days
VALUMARK PEN NEEDLES MISC 31G X 6 MM
insulin pen needle
1
QL
200 / 30 days
VALUMARK PEN NEEDLES MISC 31G X 8 MM
insulin pen needle
1
QL
200 / 30 days
VANISHPOINT INSULIN SYRINGE MISC 29G X 1/2" 1 ML
1
VANISHPOINT INSULIN SYRINGE MISC 30G X 1/2" 0.5 ML
1
QL
200 / 30 days
VANTAS KIT 50 MG
histrelin acetate
4
PA
VICTORY AGM-4000 TEST STRIP
glucose blood
1
VICTORY CONTROL LEVEL 1/2 SOLUTION
1
VIDA MIA AUTOLET LANCING DEV MISC
lancet devices
1
VIDA MIA UNIFINE PENTIPS MISC 29G X 12MM
insulin pen needle
1
QL
200 / 30 days
VIDA MIA UNIFINE PENTIPS MISC 31G X 6 MM
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
VIDA MIA UNILET LANCETS 28G MISC
lancets
1
VIDA MIA UNILET LANCETS 30G MISC
lancets
1
PAGE 307
PRODUCT DESCRIPTION
TIER
VOCAL POINT BLOOD GLUCOSE TEST STRIP
glucose blood
1
VOTRIENT TAB 200 MG
pazopanib hcl
4
PA
VP INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML
1
QL
200 / 30 days
wal-itin tab 10 mg
1
WALGREENS ADV TRAVEL LANCETS MISC
lancets
1
WALGREENS LANCETS MICRO THIN MISC
lancets
1
WALGREENS LANCETS MISC
lancets
1
WALGREENS LANCETS SUPER THIN MISC
lancets
1
WALGREENS THIN LANCETS MISC
lancets
1
WALGREENS ULTRA THIN LANCETS MISC
lancets
1
WAVESENSE AMP KIT W/DEVICE
1
WAVESENSE KEYNOTE KIT W/DEVICE
1
WAVESENSE PRESTO STRIP
glucose blood
1
WEGMANS UNIFINE PENTIPS PLUS MISC 31G X 5 MM
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
insulin pen needle
1
QL
200 / 30 days
XALKORI CAP 200 MG
crizotinib
4
PA
XALKORI CAP 250 MG
crizotinib
4
PA
XELODA TAB 150 MG
capecitabine
4
PA
PAGE 308
PRODUCT DESCRIPTION
TIER
XELODA TAB 500 MG
capecitabine
4
XPRES CONTROL SOLUTION NORMAL
1
ZENPEP CP DR PART 25000 UNIT
2
goserelin acetate
3
PA
goserelin acetate
3
PA
ZYTIGA TAB 250 MG
abiraterone acetate
4
PA
PA
Vitamins
aqueous vitamin d liquid 400 unit/ml
5
ascorbic acid solution 500 mg/ml
1
AVORIA CAL+D PACKET 500-40-60-400
calcium-magnesium-vitamin c-vitamin d
5
AVORIA GC+ PACKET
5
B-6 FOLIC ACID CAP 400-1000-50 MCG-MCG-MG
cobalamine combinations
1
B-NATAL LOZ HANDLE 25 MG
pyridoxine hcl
5
B-NATAL LOZENGE 25 MG
pyridoxine hcl
5
BIOGAIA PROTECTIS/VITAMIN D LIQUID
lactobacillus reuteri-vitamin d
5
BP FOLINATAL PLUS B TAB 1 MG
prenatal w/ calcium carbonate-vit b6-vit b12-folic acid
1
bprotected pedia d-vite liquid 400 unit/ml
5
calcitriol cap 0.25 mcg
1
calcitriol cap 0.5 mcg
1
calcitriol solution 1 mcg/ml
3
calcitriol solution 1 mcg/ml
3
cvs folic acid tab 800 mcg
5
QL
30 / 30 days
cvs vit d 5000 high-potency cap 5000 unit
5
QL
60 / 30 days
PAGE 309
PRODUCT DESCRIPTION
TIER
cvs vitamin d cap 2000 unit
5
cvs vitamin d infants liquid 400 unit/ml
5
cvs vitamin d3 cap 1000 unit
QL
60 / 30 days
5
QL
60 / 30 days
cvs vitamin d3 cap 400 unit
5
QL
60 / 30 days
cyanocobalamin solution 1000 mcg/ml
1
d 1000 cap 1000 unit
5
QL
60 / 30 days
d 1000 chew tab 1000 unit
5
d 1000 tab 1000 unit
5
d 400 chew tab 400 unit
5
d 400 tab 400 unit
5
d 5000 cap 5000 unit
5
QL
60 / 30 days
d 5000 tab 5000 unit
5
d-1000 extra strength tab 1000 unit
5
d-1000 tab 1000 unit
5
d-3-5 cap 5000 unit
5
QL
60 / 30 days
d-400 tab 400 unit
5
d-5000 maximum strength cap 5000 unit
5
QL
60 / 30 days
d-5000 tab 5000 unit
5
d-vita liquid 400 unit/ml
5
d2000 ultra strength cap 2000 unit
5
QL
60 / 30 days
d3 adult chew tab 1000 unit
5
d3 high potency cap 1000 unit
5
QL
60 / 30 days
d3 maximum strength cap 5000 unit
5
QL
60 / 30 days
d3 maximum strength liquid 5000 unit/ml
5
d3 super strength cap 2000 unit
5
QL
60 / 30 days
d3-1000 cap 1000 unit
5
QL
60 / 30 days
d3-1000 tab 1000 unit
5
d3-50 cap 50000 unit
5
QL
60 / 30 days
delta d3 tab 400 unit
5
PAGE 310
PRODUCT DESCRIPTION
TIER
DIALYVITE VITAMIN D3 MAX TAB 50000 UNIT
cholecalciferol
5
doxercalciferol cap 0.5 mcg
3
PA
doxercalciferol cap 1 mcg
3
PA
doxercalciferol cap 2.5 mcg
3
PA
eql folic acid tab 400 mcg
5
QL
30 / 30 days
eql vitamin d-3 tab 400 unit
5
eql vitamin d3 tab 1000 unit
5
ergocalciferol cap 50000 unit
1
fa-vitamin b-6-vitamin b-12 tab 2.2-25-0.5 mg
1
1
ferrogels forte cap 460-60-0.01-1 mg
1
FOLIC ACID SOLUTION 5 MG/ML
folic acid
1
folic acid tab 1 mg
5
QL
30 / 30 days
folic acid tab 400 mcg
5
QL
30 / 30 days
folic acid tab 800 mcg
5
QL
30 / 30 days
folplex 2.2 tab 2.2-25-0.5 mg
1
3
PA
3
PA
gnp b-12 sl tab 2500 mcg
5
gnp folic acid tab 400 mcg
5
gnp vitamin d chew tab 400 unit
5
gnp vitamin d super strength tab 5000 unit
5
gnp vitamin d tab 1000 unit
5
gnp vitamin d3 extra strength tab 1000 unit
5
HECTOROL CAP 0.5 MCG
doxercalciferol
3
PA
HECTOROL CAP 1 MCG
doxercalciferol
3
PA
PAGE 311
QL
30 / 30 days
PRODUCT DESCRIPTION
TIER
HECTOROL CAP 2.5 MCG
doxercalciferol
3
hematinic/folic acid tab 324-1 mg
1
HEMATOGEN FA CAP 200-250-0.01-1 MG
fe fumarate-vitamin c-vitamin b12-folic acid
1
hematogen forte cap 460-60-0.01-1 mg
1
hemocyte-f tab 324-1 mg
1
hm folic acid tab 400 mcg
5
hm vitamin d tab 1000 unit
5
hm vitamin d tab 400 unit
5
hm vitamin d3 cap 2000 unit
5
HYDROXOCOBALAMIN SOLUTION 1000 MCG/ML
hydroxocobalamin
1
iferex 150 forte cap 150-25-1 mg-mcg-mg
1
just d liquid 400 unit/ml
5
kp folic acid tab 800 mcg
PA
QL
30 / 30 days
QL
60 / 30 days
5
QL
30 / 30 days
kp vitamin d cap 1000 unit
5
QL
60 / 30 days
kp vitamin d cap 2000 unit
5
QL
60 / 30 days
leucovorin calcium
4
PA
leucovorin calcium
4
PA
4
PA
4
PA
maximum d3 cap 10000 unit
5
QL
MEPHYTON TAB 5 MG
phytonadione
2
PA
MULTI PRENATAL TAB 27-0.8 MG
5
multi-vit/fluoride solution 0.25 mg/ml
1
multi-vitamin/fluoride solution 0.25 mg/ml
1
nat-rul vitamin d tab 1000 unit
5
nat-rul vitamin d tab 5000 unit
5
PAGE 312
60 / 30 days
PRODUCT DESCRIPTION
TIER
NIACIN ER TAB ER 1000 MG
niacin
1
niacin tab 500 mg
1
NIACOR TAB 500 MG
1
one daily mens tab
1
one daily womens tab
1
pa vitamin d-3 cap 2000 unit
5
QL
60 / 30 days
pa vitamin d-3 cap 5000 unit
5
QL
60 / 30 days
pa vitamin d-3 tab 1000 unit
5
paricalcitol cap 1 mcg
3
PA
3
PA
3
PA
1
poly-iron 150 forte cap 150-25-1 mg-mcg-mg
1
POTABA CAP 500 MG
potassium aminobenzoate
3
PRENATAL 19 TAB
1
1
PRENATAL LOW IRON TAB 27-0.8 MG
5
PRENATAL ONE DAILY TAB 27-0.8 MG
5
5
pronutrients vitamin d3 cap 1000 unit
5
QL
60 / 30 days
px folic acid tab 400 mcg
5
QL
30 / 30 days
PYRIDOXINE HCL SOLUTION 100 MG/ML
pyridoxine hcl
3
ra folic acid tab 400 mcg
5
QL
30 / 30 days
ra folic acid tab 800 mcg
5
QL
30 / 30 days
PAGE 313
PRODUCT DESCRIPTION
TIER
ra niacin tab 500 mg
1
ra no flush niacin tab 500 mg
1
ra vitamin d-3 cap 2000 unit
5
QL
60 / 30 days
ra vitamin d-3 cap 5000 unit
5
QL
60 / 30 days
ra vitamin d-3 tab 1000 unit
5
REPLESTA CHILDRENS WAFER 14000 UNIT
cholecalciferol
5
REPLESTA NX WAFER 14000 UNIT
cholecalciferol
5
REPLESTA WAFER 50000 UNIT
cholecalciferol
5
RIGHT STEP PRENATAL TAB 27-0.8 MG
5
5
1
sm folic acid tab 400 mcg
5
QL
30 / 30 days
sm vitamin d tab 400 unit
5
sm vitamin d3 cap 2000 unit
5
QL
60 / 30 days
sm vitamin d3 tab 1000 unit
5
1
th folic acid tab 400 mcg
5
QL
30 / 30 days
th vitamin d3 cap 1000 unit
5
QL
60 / 30 days
th vitamin d3 cap 2000 unit
5
QL
60 / 30 days
thera-d 2000 tab 2000 unit
5
THERA-D 4000 TAB 4000 UNIT
cholecalciferol
5
tl gard rx tab 2.2-25-1 mg
1
1
1
1
PAGE 314
PRODUCT DESCRIPTION
TIER
1
triple-vitamin/fluoride solution 0.25 mg/ml
1
vitamin d (cholecalciferol) chew tab 400 unit
5
vitamin d (cholecalciferol) tab 1000 unit
5
vitamin d (ergocalciferol) cap 50000 unit
1
vitamin d cap 1000 unit
5
QL
60 / 30 days
5
QL
60 / 30 days
5
QL
60 / 30 days
vitamin d liquid 400 unit/ml
5
vitamin d tab 1000 unit
5
5
5
vitamin d-1000 max st tab 1000 unit
5
vitamin d-3 cap 1000 unit
5
QL
60 / 30 days
vitamin d-3 tab 5000 unit
5
vitamin d-400 tab 400 unit
5
vitamin d3 adult gummies chew tab 1000 unit
5
vitamin d3 cap 1000 unit
5
QL
60 / 30 days
5
QL
60 / 30 days
5
QL
60 / 30 days
5
QL
60 / 30 days
5
QL
60 / 30 days
vitamin d3 chew tab 1000 unit
5
vitamin d3 high potency cap 1000 unit
5
QL
60 / 30 days
vitamin d3 liquid 400 unit/ml
5
vitamin d3 liquid 5000 unit/ml
5
vitamin d3 maximum strength cap 5000 unit
5
QL
60 / 30 days
vitamin d3 tab 1000 unit
5
VITAMIN D3 TAB 3000 UNIT
cholecalciferol
5
PAGE 315
PRODUCT DESCRIPTION
TIER
5
5
vitamins acd-fluoride solution 0.25 mg/ml
1
ZEMPLAR CAP 1 MCG
paricalcitol
3
PA
ZEMPLAR CAP 2 MCG
paricalcitol
3
PA
ZEMPLAR CAP 4 MCG
paricalcitol
3
PA
PAGE 316
Index of covered drugs
1
Accutrend Glucose
233
Accutrend Glucose Control
233
1st Choice Lancets Super Thin
231
Acebutolol HCl
1st Choice Lancets Thin
231
Acetaminophen
1st Choice Lancets Ultra Thin
231
Acetaminophen w/ Codeine
1st Tier Unifine Pentips
231
Acetazolamide
1st Tier Unifine Pentips Plus
231,232
1st Tier Unilet ComforTouch
232
A
A-Hydrocort
Abacavir Sulfate
Abacavir Sulfate-Lamivudine
Abacavir Sulfate-Lamivudine-Zidovudine
Abilify
AcetaZOLAMIDE
82,106
82,83
63,100,101,138,150
63,100,138,150
Acetic Acid
142
Acetic Acid (Otic)
151
Acetone (Urine) Test
174
34,55,60,63
Acetylcysteine
242,267,288
191,209
22,28
Acetylcysteine (Antidote)
191
23
Acetylcysteine (Nutrient)
144
22,28
120,121,127
Acitretin
Aclidinium Bromide
217,227
31
Abilify Discmelt
120,127
Actemra
191
Abilify Maintena
120,127
Acti-Lance 28G
233
Acti-Lance Lite Lancets 28G
233
Acti-Lance Special Lancets 17G
233
Abiraterone Acetate
309
AbobotulinumtoxinA
34,193
Acamprosate Calcium
121
Acti-Lance Universal 23G
233
Acarbose
162
Actimmune
191
Accu-Chek Active
232
Actonel
Accu-Chek Active Glucose Cont
232
Acura Blood Glucose Meter
233
Accu-Chek Aviva
232
Acura Blood Glucose Starter
233
Accu-Chek Aviva Plus
232
Acura Blood Glucose Test
233
Accu-Chek Comfort Curve
232
Acura Control
233
Accu-Chek Comfort Curve Linear
232
Acura Plus Blood Glucose Sys
234
Accu-Chek Compact Blue Control
232
Acuvail
148
Accu-Chek Compact Plus
232
Acyclovir
Accu-Chek Compact Plus Control
232
Acyclovir Topical
Accu-Chek Compact Test Drum
232
Adalimumab
Accu-Chek FastClix Lancets
232
Adapalene-Benzoyl Peroxide
Accu-Chek Multiclix Lancets
232
Adcirca
Accu-Chek Nano SmartView
232
Adefovir Dipivoxil
Accu-Chek Safe-T Pro Lancets
233
Adjustable Lancing Device
Accu-Chek SmartView
233
Adrenaclick
Accu-Chek SmartView Control
233
Advair Diskus
Accu-Chek Soft Touch Lancets
233
Advair HFA
Accu-Chek Softclix Lancet Dev
233
Advocate Blood Glucose System
234
Accu-Chek Softclix Lancets
233
Advocate Insulin Pen Needles
234
Accu-Chek Voicemate
233
Advocate Insulin Syringe
234
191,192
22
212,217
158,196,197
214,221
78
22,23
234
37,207
37,38,174
38,174
Advocate Lancets
234
Altabax
212
Advocate Lancing Device
234
Alternate Site Lancing Device
235
Advocate Redi-Code
234
Aluminum Chloride
224
Advocate Redi-Code+ Talking
234
Amantadine HCl
Advocate Safety Lancets
234
Ambrisentan
Advocate Test
235
Amcinonide
Aerospan
174,203
Amiloride & Hydrochlorothiazide
22,112
210
217,218
138
Afinitor
235
Amiloride HCl
Afluria
211
Aminocaproic Acid
Afluria Preservative Free
211
Aminophylline
AgaMatrix AMP Test
235
Amiodarone HCl
AgaMatrix Control
235
Amitiza
155
AgaMatrix Jazz
235
Amitriptyline HCl
127
AgaMatrix Jazz Test
235
Amlodipine Besylate
AgaMatrix KeyNote Test
235
Amlodipine Besylate-Benazepril HCl
52,73
AgaMatrix Presto
235
Amlodipine Besylate-Olmesartan Medoxomil
52,73
AgaMatrix Presto Test
235
Amlodipine Besylate-Valsartan
52,73
AgaMatrix Ultra-Thin Lancets
235
Amoxapine
127,128
41,83
Amoxicillin
11,12,155
Aggrenox
64,138
40
231
55,58
52,64,78
Albendazole
11
Amoxicillin & Pot Clavulanate
12
Albenza
11
Amphetamine-Dextroamphetamine
96
Ampicillin
12
Albiglutide
Albuterol Sulfate
166
38,39,40,207,208,209
Alcaftadine
152,270
Ampyra
Anagrelide HCl
192
41
Alclometasone Dipropionate
217
Anakinra
197
Alendronate Sodium
192
Analpram-HC
218
Anastrozole
235
Alendronate Sodium-Cholecalciferol
196,311
Alfuzosin HCl
34
Androderm
175
Alinia
20
AndroGel
175
Aliskiren Fumarate
77
AndroGel Pump
175
77,141,142
Androxy
175
204,235
Anthralin
221
235
Aliskiren-Hydrochlorothiazide
Allegra Allergy Childrens
Allopurinol
192
Anti-Stick Insulin Syringe
Almotriptan Malate
107
Antipyrine-Benzocaine
148,151
Alocril
151,203
Anzemet
153
Alomide
151,235
Apidra
162
Alpha-Lipoic Acid (Thioctic Acid)
192
Apidra SoloStar
162
Alphagan P
150
Apraclonidine HCl
152
Alprazolam
115,116
Apriso
155
Aptivus
22
Alprostadil
Alprostadil (Vasodilator)
78
78,79,80
Aqua Lance Adjustable Lancing
236
Aranesp (Albumin Free)
Arcalyst
Arcapta Neohaler
Arformoterol Tartrate
46
192
38,207
38
Atenolol & Chlorthalidone
Atomoxetine HCl
60,138
125,126
Atorvastatin Calcium
49
Atovaquone
20
Atovaquone-Proguanil HCl
20
Aripiprazole
120,121,127
Armodafinil
100
Atralin
218
Artificial Tear Insert
152
Atripla
22
Artificial Tear Solution
152
Atropine Sulfate
152
Asacol HD
155
Atropine Sulfate (Ophthalmic)
152
Ascorbic Acid
309
Atrovent HFA
Asenapine Maleate
125,136
Augmentin
29,207
12
Asmanex 120 Metered Doses
175
Auranofin
175
Aurora Lancet Super Thin 30G
237
175
Aurora Pen Needles
237
175
Aurora Unifine Pentips
237
175
Auto-Lancet
237
Aspirin40,41,42,43,44,45,83,84,85,86,87,88,94,95,106,
Auto-Lancet Mini
237
107,108,109,110,111,112
Autolet Impression
237
Autolet Lancing Device
237
Aspirin-Dipyridamole
41,83
201,289
Assure 4 Control Level 1 & 2
236
Auvi-Q
Assure 4 Test
236
Avandia
Assure Comfort Lancets 28G
236
Avelox
12,18
Assure Comfort Lancets 30G
236
Avelox ABC Pack
12,18
Assure Dose Control
236
Avidoxy DK
Assure Dose Norm/High Control
236
Avodart
192
Assure Haemolance Plus High
236
Avonex
192
Assure Haemolance Plus Low
236
Avonex Pen
192
Assure Haemolance Plus Micro
236
Avonex Prefilled
192
Assure Haemolance Plus Normal
236
Avoria Cal+D
Assure Haemolance Plus Ped
236
Avoria GC+
Assure ID Insulin Safety Syr
236
Axert
107
Assure II Check
236
Axiron
176
Assure Lance Lancets
236
Axitinib
266
Assure Platinum
236
Azasan
192
Assure Prism Control Level 1&2
236
AzaSite
146
Assure Prism multi Test
236
Azathioprine
192
Assure Pro Test
237
Azelastine HCl
Astepro
Atazanavir Sulfate
Atelvia
Atenolol
152,204
26
192
34,35,55,60,64
38,208
162
12,218
142,309
142,192,309
152,204,205
Azelastine HCl (Ophth)
152,205
Azilect
112,128
Azilsartan Medoxomil
Azithromycin
66,74
12,13,17
Azithromycin (Ophth)
Azor
146
52,73
B
BD Pen Needle Mini U/F
239
BD Pen Needle Nano U/F
239
BD Pen Needle Short U/F
239
BD Pen Needle Ultrafine
239
B-6 Folic Acid
309
BD Safety-Lok Insulin Syringe
239
B-natal
309
BD SafetyGlide Insulin Syringe
239
Bacitracin
146
Beclomethasone Diprop Monohyd
148,203
Bacitracin (Ophthalmic)
146
Beclomethasone Dipropionate
185,204
Beclomethasone Dipropionate (Nasal)
150,204
Beconase AQ
148,203
Bacitracin-Poly-Neomycin-HC
Bacitracin-Polymyxin B (Ophth)
Bacitracin-Polymyxin-Neomycin HC
Baclofen
146,147,148,149
146
213,220
34
Belladonna Alkaloids & Opium
29,84
Belladonna Alkaloids-Opium
29,84
29,84
Bactroban Nasal
212
Belladonna-Opium
Balsalazide Disodium
155
Benazepril & Hydrochlorothiazide
Banzel
101
Benazepril HCl
64,73
Benicar
64,74
Baraclude
22
74,138
Bayer Breeze 2 Control
237
Benicar HCT
74,139
Bayer Breeze 2 System
237
Benzonatate
209
Bayer Contour
237
Benzoyl Peroxide
Bayer Contour Link Monitor
237
Benzoyl Peroxide-Erythromycin
Bayer Contour Monitor
237
Benztropine Mesylate
Bayer Contour Next Control
237
Benzyl Alcohol
218
Bayer Contour Next EZ
237
Bepotastine Besilate
152
Bayer Contour next Link
237
Bepreve
152
Bayer Contour Next Monitor
237
Berinert
192
Bayer Contour Next Test
238
Besifloxacin HCl
146
Bayer Contour Next USB Monitor
238
Besivance
146
Bayer Contour Test
238
Betaine
193
Bayer Microlet 2 Lancing Devic
238
Betamethasone Dipropionate (Topical)
218
Bayer Microlet Lancets
238
Betamethasone Dipropionate Augmented
218
BD AutoShield
238
Betamethasone Sod Phosphate & Acetate
176
BD Insulin Syr Ultrafine II
238
Betamethasone Valerate
BD Insulin Syringe
238
Betaseron
BD Insulin Syringe Half-Unit
238
Betaxolol HCl
BD Insulin Syringe MicroFine
238
Betaxolol HCl (Ophth)
150
238,239
Bethanechol Chloride
31
BD Insulin Syringe Ultrafine
212,213,214,215
212
29,113
218,219
193
35,56,60,64
BD Integra Insulin Syringe
239
Betoptic-S
150
BD Lancet Device
239
Bexarotene
297
BD Lancet Ultrafine 30G
239
BG Star Test
239
BD Lancet Ultrafine 33G
239
Bicalutamide
239
BD Microtainer Lancets
239
Bicillin L-A
13
Bimatoprost
151
Buprenorphine HCl-Naloxone HCl
BioGaia
155
Dihydrate
BioGaia Probiotic
155
Bupropion HCl
128
Bupropion HCl (Smoking Deterrent)
128
Buspirone HCl
116
Busulfan
278
BioGaia ProTectis/Vitamin D
155,309
Bisoprolol & Hydrochlorothiazide
Bisoprolol Fumarate
61,139
35,56,60,61,64
Blephamide S.O.P.
146,148
84,94,95,121,126
Butalbital-Acetaminophen
84,89,116,118
Blood Glucose
Butalbital-Acetaminophen-
Calibration 232,233,235,236,237,241,244,246,248,249,
Caffeine
251,252,254,255,256,257,258,260,261,262,266,271,27
Butalbital-Acetaminophen-Caffeine w/
3,274,276,278,279,280,281,282,287,289,293,296,297,
Codeine
85,96,116
300,301,302,305,307,309
Butalbital-Aspirin-Caffeine
85,96,116
Blood Glucose Monitor System
239
85,89,96,97,99,116,118
Butalbital-Aspirin-Caffeine w/Cod
83,85,96,116
Blood Glucose Monitoring
Butenafine HCl
215
Supplies232,233,234,235,237,238,239,240,242,243,24
Butoconazole Nitrate (One Dose)
214
4,245,248,249,251,252,253,255,256,257,258,260,261,
Butorphanol Tartrate
262,266,268,269,273,275,276,278,279,280,281,282,28
Butrans
4,287,288,289,292,293,297,298,300,301,302,304,308
Bydureon
162
Blood Glucose System Pak
239
Byetta 10 MCG Pen
162
Blood Glucose Test
240
Byetta 5 MCG Pen
162
Boceprevir
28
Bosulif
240
Bosutinib
240
BP FoliNatal Plus B
143,309
BPO Creamy Wash
213
Brilinta
42
85,107
85
Bystolic
35,61
C
C1 Esterase Inhibitor (Human)
192
Cabergoline
113
Cabozantinib S-Malate
243
Brimonidine Tartrate
150
Cafergot
Brimonidine Tartrate-Timolol Maleate
150
Caffeine & Sodium Benzoate
97,107
Bromfenac Sodium (Ophth)
148
Caffeine Citrate
97,107
Bromocriptine Mesylate
113
Caffeine-Sodium Benzoate
97,107
Bromocriptine Mesylate (Diabetes)
162
Calcipotriene
Brovana
38
Budesonide
Budesonide (Inhalation)
176
176,185,203,204
Budesonide (Nasal)
Budesonide-Formoterol Fumarate Dihydrate
150,204
40,186
35,97,107
219
Calcipotriene-Betamethasone Dipropionate
Calcitonin (Salmon)
176,182,193,198
Calcitriol
Calcitriol (Topical)
Calcium Acetate (Phosphate Binder)
Bullseye Mini Safety Lancets
240
Calcium-Magnesium-Vitamin C-Vitamin D
Bullseye Safety Lancets
240
Canasa
Bumetanide
64,139
Candesartan Cilexetil-Hydrochlorothiazide
Buprenorphine
85
Capecitabine
Buprenorphine HCl
84
Capex
219,227
219,309
219
143,144,145
142,309
155
74,139
240,308,309
219
Caprelsa
240
CellCept
193
219,220,222,225,229
Celontin
101
64,74
CEM-Urea
219
Captopril & Hydrochlorothiazide
74,139
Cephalexin
14,16
Captopril-Hydrochlorothiazide
74,139
Ceprotin
42
Carafate
155
Cesamet
153
Carbachol (Ophth)
151
Cetirizine HCl
Capsaicin
Captopril
Carbamazepine
101,102,105,121,122,126
205,206,241,242,268
Chantix
31
Carbidopa
113
Chantix Continuing Month Pak
31
Carbidopa-Levodopa
113
Chantix Starting Month Pak
31
Carbinoxamine Maleate
CardioCom Lancing Device
Cardura XL
204,205,236,240
240
35,61,64
Chek-Stix Control
242
Chemet
193,242
Chemstrip K
242
CareFine Pen Needles
240
Cherry
242
CareOne Advanced Lancing Dev
240
Cherry Concentrate
242
CareOne Blood Glucose System
240
Cherry Syrup
242
CareOne Blood Glucose Test
240
Chlorambucil
271
Chlordiazepoxide HCl
116
CareOne Insulin Syringe
240,241
CareOne Lancet Thin 23G
241
Chlordiazepoxide HCl-Clidinium Bromide
29,116
CareOne Lancet Ultra Thin 28G
241
Chlordiazepoxide-Amitriptyline
CareOne Unifine Pentips
241
Chlorhexidine Gluconate
CareOne Unifine Pentips Plus
241
Chlorhexidine Gluconate (Mouth-
CareSens Control A
241
Throat)
CareSens N Glucose Test
241
Chloroquine Phosphate
Carfilzomib
269
Chlorothiazide
Carteolol HCl (Ophth)
150
Chlorpromazine HCl
128
116,128
213
146,147,213,215
20
65,139
Carvedilol
35,56,61,65
Chlorpropamide
162
Carvedilol Phosphate
35,56,61,65
ChlorproPAMIDE
162
Caverject
78
Chlorthalidone
65,139
Caverject Impulse
78
Chlorzoxazone
34
Cefaclor
13
Cholecalciferol
309,310,311,312,313,314,315,316
Cefaclor ER
13
Cholestyramine Light
Cefaclor Monohydrate
13
Choline & Mag Salicylate
Cefadroxil
13
Choline Fenofibrate
Cefdinir
13
Chorionic Gonadotropin
Cefixime
17
Cialis
Cefpodoxime Proxetil
13
Cilostazol
Cefprozil
13
Ciloxan
Ceftriaxone Sodium
13,14
49,51
85
50,51
176
78
42,78
146
Cimetidine 154,155,156,157,160,161,233,242,245,252,
Cefuroxime Axetil
14
253,262,265,286,291,298
Celecoxib
85
Cimetidine HCl
156,242
Cinacalcet HCl
Cipro
201
14,18
Clorazepate Dipotassium
101,117
Clotrimazole
213
Cipro HC
146,148
Clotrimazole (Topical)
Ciprodex
146,148
Clotrimazole Vaginal
213,216
Clotrimazole w/ Betamethasone
213,219
Ciprofloxacin
Ciprofloxacin HCl
14,18
14,18,146
213,214,215,216
Clozapine
129
Ciprofloxacin HCl (Ophth)
146
CloZAPine
129
Ciprofloxacin HCl (Otic)
146
CoaguChek Lancets
243
Coal Tar
220
Ciprofloxacin-Ciprofloxacin HCl
14,19
Ciprofloxacin-Dexamethasone
146,148
Coal Tar (Crude)
220
Ciprofloxacin-Hydrocortisone
146,148
Coal Tar Extract
220
Cobalamine Combinations
309
Citalopram Hydrobromide
Clarithromycin
Claritin Reditabs
128
14,19,156
Codeine Sulfate
85,209,210
205,242
Coenzyme Q10
193
Coenzyme Q10 (Ubidecarenone)
193
Colchicine
193
Cleanlet Lancets 28G
242
Clemastine Fumarate
205,242
Cleocin
213
Colchicine w/ Probenecid
Clever Chek Auto-Code Test
242
Colesevelam HCl
Clever Chek Auto-Code Voice
242
Colestipol HCl
Clever Chek Lancets
242
Collagenase
227,290
Clever Chek System
242
Coly-Mycin S
146,149
Clever Chek Test
243
Colyte with Flavor Packs
156
Clever Choice Auto-Code Test
243
Combigan
150
Clever Choice Micro System
243
CombiPatch
Clever Choice Micro Test
243
Combivent Respimat
Clickfine Pen Needles
243
Cometriq (100 mg Daily Dose)
243
14,15
243
15
243
Clindamycin Phosphate (Topical)
213
Comfort Assist Insulin Syringe
243
Clindamycin Phosphate Vaginal
213
Comfort Assured Lancets 28G
243
Clindamycin Phosphate-Benzoyl Peroxide
213
Comfort Assured Lancets 33G
243
Clindamycin HCl
Clindamycin Palmitate Hydrochloride
143,193
52,167
49,51
167,176
29,38,208
Clindamycin Phosphate-Tretinoin
217,229
Comfort EZ Insulin Syringe
243,244
Clobetasol Propionate
219,220
Comfort EZ Pen Needles
244
244
Clobetasol Propionate Emulsion
219
Comfort Lancets
Clocortolone Pivalate
219
Complera
22
Cloderm
219
Condylox
220
Cloderm Pump
219
Conjugated Estrogens-Medroxyprogesterone
Clomipramine HCl
Clonazepam
Clonidine HCl
Clopidogrel Bisulfate
128,129
Acetate
173,185
101,116,117
Control
244
Control AST
244
Control Blood Glucose System
244
38,65
42
Control Test
244
Cordran
220
D
Coreg CR
35,56,61,65
Dabigatran Etexilate Mesylate
Cortifoam
220
Dalfampridine
Cortisone Acetate
176
Dalteparin Sodium
45
192
43
Cortisporin
213,220
Dapsone
19,20
Cortisporin-TC
146,149
Daraprim
20
Cottonseed Oil
220
Darbepoetin Alfa-Polysorbate 80
46
Cottonseed Oil (Bulk)
220
Darifenacin Hydrobromide
Cranberry (Vaccinium macrocarpon)
193
Darunavir Ethanolate
Creon
230
25,26
156,244,245
Dasatinib
293,294
Crestor
49,50
Daytrana
97
Crinone
176
Crixivan
22
Crizotinib
308
Deferiprone
255
Deferoxamine Mesylate
193,245
Degarelix Acetate
Cromolyn Sodium (Mastocytosis)
152,203
Delavirdine Mesylate
Cromolyn Sodium (Ophth)
152,203
Delzicol
256
26
156
Crotamiton
214
Demeclocycline HCl
CVS Advanced Glucose Test
245
Denavir
214
CVS Blood Glucose Meter
245
Denosumab
200
CVS Insulin Syringe
245
Depen Titratabs
CVS Lancets 21G
245
Depo-Medrol
177
CVS Lancets Micro Thin 33G
245
Depo-Provera
177
CVS Lancets Thin 26G
245
Depo-SubQ Provera 104
177
CVS Lancets Ultra Thin 30G
245
Desipramine HCl
129
CVS Lancing Device
245
Desmopressin Acetate
CVS Ultra Thin Lancets
245
Desmopressin Acetate Refrigerated
40,177
Desmopressin Acetate Spray
40,177
Desmopressin Acetate Spray Refrigerated
40,177
Cyanocobalamin
46,47,310,311
Cyclobenzaprine HCl
34
Cyclopentolate HCl
152
Desogestrel & Ethinyl
Cycloset
162
Estradiol
Cyclosporine
CycloSPORINE Modified
193,201
193
15
193,245
40,177,186
167,168,173,175,178,185
Desogestrel-Ethinyl Estradiol
(Triphasic)
167,174,176,186
Cyclosporine Modified (For Microemulsion)
193,196
Desonide
221,225
Cymbalta
121,129
Desoximetasone
221
Cyproheptadine HCl
205,245
Desvenlafaxine
129
Cystadane
193
Desvenlafaxine ER
129
Cystaran
152
Desvenlafaxine Fumarate
129
Cysteamine HCl
152
Desvenlafaxine Fumarate ER
129
Cytra-3
143
Desvenlafaxine Succinate
135
Detrol LA
230
Dexamethasone
176,177,178
Dimenhydrinate
153,246
153,246
Dexamethasone Intensol
177
DimenhyDRINATE
Dexamethasone Sod Phosphate PF
177
Dipentum
Dexamethasone Sodium Phosphate
177,178
156
Diphenhydramine
Dexamethasone Sodium Phosphate (Ophth)
149
HCl29,30,31,112,113,114,115,116,117,118,120,204,20
Dexchlorpheniramine Maleate
245
5,206,207,209,210,235,246,252,273,286,291
Dexmethylphenidate HCl
97,98
Diphenhydramine-Zinc Acetate
229
DexPak 10 Day
178
Diphenoxylate w/ Atropine
DexPak 13 Day
178
Diphenoxylate-Atropine
DexPak 6 Day
178
Dipyridamole
42,79
Disopyramide Phosphate
57,58
Dextroamphetamine Sulfate
98
29,30,156,157,158
29,156
Dextromethorphan HBr-Quinidine Sulfate
123
Disulfiram
Dialyvite Vitamin D3 Max
311
Divalproex Sodium
Diastar Easy Test II Lancets
246
Dolasetron Mesylate
Diastar Easy Test Lancets
246
Donepezil Hydrochloride
DiaTrue Control Level 2
246
Dornase Alfa
DiaTrue Plus Test
246
Dorzolamide HCl
151
Dorzolamide HCl-Timolol Maleate
151
Diazepam
101,117
Dibenzyline
35,65
193
102,108,121,122
Doxapram HCl
153
31,32
210,285
98
Diclofenac Potassium
86
Doxazosin Mesylate
Diclofenac Sodium
86
Doxazosin Mesylate (BPH)
35,61,64
129,130
Diclofenac Sodium (Ophth)
149
Doxepin HCl
Diclofenac Sodium (Topical)
229
Doxepin HCl (Antipruritic)
Diclofenac w/ Misoprostol
86,156
311,312
12,15,20
15
Doxycycline (Monohydrate)
Dicyclomine HCl
29
Doxycycline Hyclate
22,23,28
226
Doxercalciferol
Dicloxacillin Sodium
Didanosine
35,36,61,66
Doxycycline w/ Suncreen & Salicylic Acid
15,16,20,21
12,218
Diethylpropion HCl
98
Dritho-Creme HP
221
Dificid
15
Dronabinol
153
Diflorasone Diacetate
221
Diflunisal
86
Difluprednate
149
Digoxin
56,57
Dihydroergotamine Mesylate
Dilantin
35,108
56,101,102
Dilatrate-SR
78
Diltiazem HCl
53,56,57,65,66,78,79
Diltiazem HCl Coated
Beads
52,53,56,57,64,65,66,78,79
Dronedarone HCl
58
Droperidol
117
Droplet Lancets Ultra Thin 30G
246
Droplet Lancing Device
246
Droxia
246
Drug Mart Lancets Thin 26G
246
Drug Mart Lancing Device
246
Drug Mart On-The-Go Lancet 30G
246
Drug Mart Ultra Comfort Syr
246
Drug Mart Unifine Pentips
246,247
Diltiazem HCl Extended Release
Drug Mart Unifine Pentips Plus
247
Beads
Drug Mart Unilet Lancets 28G
247
53,55,57,59,60,66,71,79,82
Drug Mart Unilet Lancets 30G
247
Easy Touch Insulin Safety Syr
Duane Reade Lancet Altern Site
247
Easy Touch Insulin Syringe
Duane Reade Lancet Super Thin
247
Easy Touch Lancets 21G
250
Duane Reade Lancet Ultra Thin
247
250
Duane Reade Unifine Pentips
247
250
38,178
250
Easy Touch Lancets 28G/Twist
250
Dulera
Duloxetine HCl
121,122,129,130
249
249,250
Durezol
149
250
Dutasteride
192
250
Dyrenium
66,139
250
Dysport
34,193
250
250
Easy Touch Lancing Device
250
E
E-Z Ject Lancet Micro-Thin 33G
247
Easy Touch Pen Needles
250
E-Z Ject Lancet Super Thin 30G
247
Easy Touch Safety Lancets 21G
251
E-Z Ject Lancets
247
251
E-Z Ject Lancets 21G
247
251
E-Z Ject Lancets Thin 26G
247
251
Easy Touch Test
251
E.E.S. 400
15
EasiVent
247
Easy Trak Blood Glucose System
251
EasiVent Mask Large
247
Easy Trak Blood Glucose Test
251
EasiVent Mask Medium
247
Easy Trak Control
251
EasiVent Mask Small
247
Easy Twist & Cap Lancets
251
Easy Comfort Insulin Syringe
248
EasyGluco
251
Easy Comfort Lancets
248
EasyGluco Control
251
Easy Comfort Pen Needles
248
EasyMax 15 Level 1 Control
251
Easy Mini Lancing Device
248
EasyMax 15 Level 2 Control
251
Easy Plus Blood Glucose System
248
EasyMax 15 Test
251
Easy Plus Blood Glucose Test
248
EasyMax Control
251
Easy Plus II Glucose Test
248
EasyMax NG Blood Glucose
251
Easy Step Control
248
EasyMax Test
251
Easy Step Glucose Monitor
248
EasyMax V Blood Glucose
251
Easy Step Test
248
EasyMax V2 Blood Glucose
251
Easy Talk Blood Glucose System
248
Ecallantide
197
Easy Talk Blood Glucose Test
248
Echothiophate Iodide
151
Easy Talk Control
249
Econazole Nitrate
214
Easy Touch Control High & Low
249
Edarbi
66,74
Easy Touch Glucose System
249
Edecrin
66,139
Easy Touch HealthPro Control
249
Edex
79
Easy Touch HealthPro System
249
Edurant
23
Easy Touch HealthPro Test
249
Efavirenz
27
Efavirenz-Emtricitabine-Tenofovir Disoproxil
Fumarate
Epinephrine
22
EPINEPHrine
37,38,39,207,208
39,208
Effer-K
143
Epinephrine HCl
Element Autocode System
251
EpiPen 2-Pak
39,208
Element Compact Control 2
252
EpiPen Jr 2-Pak
39,208
Element Compact Control 3
252
Epivir
23
Element Compact Test
252
Epivir HBV
23
Element Control
252
Eplerenone
67,75,140
Element Test
252
Epoetin Alfa
47,48,49
Eletriptan Hydrobromide
110
Epogen
Elidel
193,221
Eprosartan Mesylate
Eligard
178,252
Epzicom
Elixophyllin
66,98,140,208,231
38,39,208
47
67,75
23
EQL Color Lancets 21G
253
Ella
178
EQL Color Lancets Micro 33G
253
Elmiron
193
EQL Insulin Syringe
253
EQL Short Pen Needle
253
Elvitegravir-Cobicistat-Emtricitabine-Tenofovir
27,201
Embrace Blood Glucose Test
252
EQL Super Thin Lancets 30G
253
Embrace Evo Blood Glucose Test
252
EQL Thin Lancets 26G
253
Embrace Evo Control Level 2
252
EQL TRUE2go Blood Glucose
253
Embrace Evo Glucose Monitoring
252
EQL TRUEtest Test
253
Embrace Lancets Ultra Thin 30G
252
EQL Ultra Short Pen Needle
253
Embrace Pro Glucose Control
252
Ergocalciferol
Embrace Pro Glucose Test
252
Ergoloid Mesylates
Emcyt
252
Ergotamine w/ Caffeine
Emsam
Emtricitabine
113,130
23
Emtricitabine-Rilpivirine-Tenofovir Disoproxil
311,315
36
35,97,107
Erlotinib HCl
297
Ertaczo
214
Ery-Tab
15
15
Fumarate
22
Erythrocin Stearate
Emtricitabine-Tenofovir Disoproxil Fumarate
28
Erythromycin (Acne Aid)
214
Emtriva
23
Erythromycin (Ophth)
147
Enablex
230
Enalapril Maleate
Enalapril Maleate & Hydrochlorothiazide
67,74,75
75,140
Erythromycin Base
15
Erythromycin Ethylsuccinate
15
Erythromycin Stearate
15
Enbrel
194
Escitalopram Oxalate
130
Endometrin
179
Esomeprazole Magnesium
159
Estazolam
117
Enjuvia
Enoxaparin Sodium
Entacapone
Entecavir
Epiduo
Epinastine HCl (Ophth)
168,194
42,43
113
22
214,221
152
Esterified Estrogens
171,197,198
Esterified Estrogens & Methyltestosterone 167,168,176
Estrace
Estradiol
168,194
168,169,170,194,195
Estradiol & Norethindrone
Exoderm
214,222
Acetate
167,169,171,176,179,182
Extavia
195
Estradiol Vaginal
168,169,174,194,195,203
Ez Smart Blood Glucose Lancets
255
Ez Smart Blood Glucose Test
255
Ez Smart Plus Glucose Test
255
Estradiol Valerate
Estramustine Phosphate Sodium
169,195
252
Estring
169,195
EZ-Lets Lancets 21G
255
Estrogel
169,195
EZ-Lets Lancets 26G
255
172,173,199,200
EZ-Lets Lancets 28G
255
Estrogens, Conjugated Synthetic B
168,194
EZ-Lets Lancets 30G
255
Estropipate
170,195
Ezetimibe
Estrogens, Conjugated
52
Eszopiclone
118
Ezetimibe-Simvastatin
Etanercept
194
Ezogabine
Ethacrynic Acid
66,139
Ethambutol HCl
19
51,52
105
F
Ethosuximide
102
Factive
15
Ethotoin
104
Famciclovir
23
Ethyl Chloride
222
Famotidine154,156,157,158,160,161,233,245,252,253,
Ethynodiol Diacet & Eth Estrad
Etidronate Disodium
Etodolac
Etonogestrel-Ethinyl Estradiol
Etravirine
Eurax
Evamist
170,174,181,187
195
255,262,265,268,285,286,290,291
Fanapt
130
87
Fareston
170,255
172,184
Faslodex
255
23
214
Fe Fumarate-Vitamin C-Vitamin B12-Folic
Acid
47,311,312
170,195
Felbamate
102
EvenCare + Blood Glucose Test
254
Felodipine
53,67
EvenCare Blood Glucose Test
254
Fenofibrate
50,51
EvenCare Control Low/High
254
Fenofibrate Micronized
50
EvenCare G2 Low/High Control
254
Fenofibric Acid
50
EvenCare G2 Test
254
Fentanyl
87
EvenCare G3 Low/High Control
254
FerraPlus 90
EvenCare G3 Test
254
Ferriprox
Everolimus
235
Ferrous Fumarate-Folic Acid
Everolimus (Immunosuppressant)
203
Ferrous Gluconate
Evista
170,195
47,157,311
255
Ferrous Sulfate
254
Fesoterodine Fumarate
Evolution Control
254
Fexofenadine
Excel Comfort Point Pen Needle
254
HCl
Exelon
254,255
32
46,47,48
46,47,48,49
Evolution Autocode
Exel Comfort Point Insulin Syr
47,312
230
204,205,206,207,235,255,265,268,292
Fidaxomicin
15
Fifty50 Control 2.0
255
Exemestane
255
Fifty50 Glucose Meter 2.0
255
Exenatide
162
Fifty50 Glucose Test 2.0
255
Fifty50 Lancing Device
256
Flurazepam HCl
Fifty50 Pen Needles
256
Flurbiprofen
Fifty50 Safety Seal Lancets
256
Flurbiprofen Sodium
149
Fifty50 Superior Comfort Syr
256
Flutamide
256
Filgrastim
Finasteride
Finasteride (Alopecia)
48
195
195,222
117
87
Fluticasone Furoate
150,186,204
Fluticasone Propionate
222
Fluticasone Propionate (Inhalation)
179,203
Fine 30
256
Fluticasone Propionate (Nasal)
Fingerstix Lancets
256
Fluticasone-Salmeterol
Fingolimod HCl
196
Fluvastatin Sodium
Firazyr
195
Fluvirin
211
Firmagon
256
Fluvirin Preservative Free
211
First-Lansoprazole
157
Fluvoxamine Maleate
131
Fluzone
212
Flagyl ER
20,157
149,179,204
37,38,174
50
Flarex
149
Fluzone Preservative Free
212
Flavoxate HCl
230
Fluzone Quadrivalent
212
FML
149
Flecainide Acetate
Flovent Diskus
57
179,203
Focalin XR
98
Fluarix
211
Folic Acid
Fluarix Quadrivalent
211
Folic Acid-Cyanocobalamin-Vit B6-Vit D-Calcium-
Flucelvax
211
Aloe
Fluconazole
18
309,311,312,313,314
145,201,314
Folic Acid-Vitamin B6-Vitamin B12
311,314
195,196
Fludrocortisone Acetate
179
Fomepizole
Flulaval
211
Fondaparinux Sodium
Flulaval Quadrivalent
211
FORA Control
256
FORA D10 Blood Glucose Test
256
FORA D15g Blood Glucose Test
256
FORA D20 Blood Glucose Test
256
Flunisolide (Nasal)
Flunisolide HFA
Fluocinolone Acetonide
149,179,203
174,203
219,222,227
43
Fluocinolone Acetonide (Otic)
149
FORA G20 Blood Glucose System
256
Fluocinonide
222
FORA G20 Blood Glucose Test
256
Fluorescein w/ Proparacaine
256
FORA G30a Blood Glucose Test
257
Fluorometholone (Ophth)
149
Fora GD20 Test
257
Fluorometholone Acetate
149
FORA GD50 Blood Glucose Test
257
Fluorouracil (Topical)
222
FORA Lancets
257
Fluoxetine HCl
131
FORA Lancing Device
257
Fluoxetine HCl (PMDD)
131
FORA V10 Blood Glucose Test
257
Fluoxymesterone
175
257
Fluphenazine Decanoate
131
257
Fluphenazine HCl
131
FORA V30a Blood Glucose System
257
FluPHENAZine HCl
131
FORA V30a Blood Glucose Test
257
Flurandrenolide
220
ForaCare GD40 Test
257
ForaCare GDH Control
257
Ganirelix Acetate
196
ForaCare premium V10 Test
257
Gatifloxacin (Ophth)
ForaCare Test N Go Test
257
GE100 Blood Glucose System
258
147,148
Foradil Aerolizer
39,208
GE100 Blood Glucose Test
258
Formoterol Fumarate
39,208
GE100 Control
258
230
Forteo
179
Gelnique
FortisCare Control
257
Gemfibrozil
50
FortisCare Glucose System
257
Gemifloxacin Mesylate
15
Fosamax Plus D
196,311
Genotropin
180,188
Fosamprenavir Calcium
24
Genotropin MiniQuick
Fosfomycin Tromethamine
11
Gentamicin Sulfate
214
67,75
Gentamicin Sulfate (Ophth)
147
75,140
Gentamicin Sulfate (Topical)
214
Fosrenol
145,196
GHT Blood Glucose Monitor
258
Fragmin
43
GHT Test
259
Fosinopril Sodium
Fosinopril Sodium & Hydrochlorothiazide
179,180,187,188
Freds Pharmacy Autolet Lancing
257
Gilenya
196
Freds Pharmacy Unifine Pentip+
257
Glatiramer Acetate
196
Freds Pharmacy Unifine Pentips
257
Gleevec
259
Freds Pharmacy Unilet Lanc 28G
258
Glimepiride
162
Freds Pharmacy Unilet Lanc 30G
258
Glipizide
FreeStyle Control Solution
258
Glipizide-Metformin HCl
163
FreeStyle Freedom
258
Global Ease Inject Pen Needles
259
FreeStyle Freedom Lite
258
Global Inject Ease Insulin Syr
FreeStyle InsuLinx System
258
Global Inject Ease Lancets 28G
260
FreeStyle InsuLinx Test
258
Global Inject Ease Lancets 30G
260
FreeStyle Lancets
258
Global Lancing Device
260
FreeStyle Lite Test
258
GlucaGen Diagnostic
167,196
FreeStyle Precision Ins Syr
258
GlucaGen HypoKit
167,196
FreeStyle Sidekick II
258
Glucagon (rDNA)
167,196
FreeStyle Test
258
Glucagon Emergency
167,196
FreeStyle Unistick II Lancets
258
Glucagon HCl (rDNA)
167,196
Frova
108
Glucagon HCl rDNA (Diagnostic)
167,196
Frovatriptan Succinate
108
Gluco Perfect 3 Test
260
Fulvestrant
255
Glucocard 01 Blood Glucose
260
Glucocard 01 Control
260
Glucocard 01 Sensor
260
Glucocard 01 Sensor Plus
260
Glucocard 01-mini Glucose
260
102
Glucocard Expression Control
260
32
Glucocard Expression Monitor
260
Glucocard Expression Test
260
Furosemide
67,140
G
Gabapentin
Gabitril
Galantamine Hydrobromide
Ganciclovir Ophthalmic
87,102
148
162,163
259,260
Glucocard Shine
260
GNP Lancets
263
Glucocard Shine Control
260
GNP Lancets 21G
263
Glucocard Shine Test
261
GNP Lancets Micro Thin 33G
263
Glucocard Vital Monitor
261
GNP Lancets Super Thin 30G
263
Glucocard Vital Test
261
GNP Lancets Thin
263
GlucoCom Control
261
GNP Lancets Thin 26G
263
GlucoCom Lancets 28G
261
GNP Micro Thin Lancets 33G
263
261
GNP Super Thin Lancets 30G
263
261
GNP Ultra Com Insulin Syringe
263,264
GlucoCom Monitor
261
Goserelin Acetate
187,309
GlucoCom Test
261
Granisetron HCl
Glucolet 2 Automatic Lancing
261
Griseofulvin Microsize
18
GlucoNavii Blood Glucose Sys
261
Griseofulvin Ultramicrosize
18
GlucoNavii Blood Glucose Test
261
Guanfacine HCl
GlucoPro Insulin Syringe
261,262
Glucosamine HCl
196
Glucosamine Hydrochloride
196
Gynazole-1
153
67,122
214
H
Glucosamine-Chondroitin-Calcium-Magnesium-Vit C-
H-E-B inControl Adv Lancing
264
Vit D
H-E-B inControl Lancets 28G
264
Glucose
H-E-B inControl Lancets 30G
264
Blood 232,233,234,235,236,237,238,239,240,241,242,
H-E-B inControl Pen Needles
264
243,244,245,246,248,249,251,252,253,254,255,256,25
Halcinonide
223
7,258,259,260,261,262,266,268,269,271,273,275,276,
Halobetasol Propionate
222
278,279,280,281,282,283,284,287,288,289,290,292,29
Halobetasol Propionate & Ammonium Lactate
223
3,295,296,297,298,300,302,304,305,306,307,308
Halog
223
142,192,309
Glucose Control
262
Haloperidol
Glucosource Lancet Device
262
Haloperidol Decanoate
131
Glucosource Lancets
262
Haloperidol Lactate
131
Glumetza
163
Health Care Lancing Device
264
Glyburide
163
HealthWise Lancets 30G
264
GlyBURIDE
163
HealthWise Lancing Pen
264
Glyburide Micronized
163
HealthWise Mini Pen Needles
264
Glyburide-Metformin
163
HealthWise Pen Needles
264
Glycine (GU Irrigant)
142,143
HealthWise Short Pen Needles
264
HealthWise Unifine Pentips
265
Glycopyrrolate
29
131,132
Glyset
163
Healthy Accents Lancing Device
265
Gmate Blood Glucose Test
262
Healthy Accents Unifine Pentip
265
Gmate Control Level 2
262
Healthy Accents Unilet Lancets
265
Gmate Smart Starter
262
Hectorol
GNP Clickfine Pen Needles
262
Hematogen FA
GNP Insulin Syringe
262,263
Heparin Lock Flush
311,312
47,312
44
Heparin Sodium (Porcine)
44
Heparin Sodium (Porcine) Lock Flush
44,45
Hepsera
23
Hydroquinone w/ Sunscreens
217
Hydroxocobalamin
47,312
Hydroxychloroquine Sulfate
20,197
Histrelin Acetate
307
Hydroxyprogesterone Caproate
180
Homatropine HBr
152
Hydroxyprogesterone Caproate (Bulk)
180
HumaLOG
164
Hydroxyurea
265
HumaLOG Mix 50/50
163
Hydroxyurea (Sickle Cell Anemia)
246
HumaLOG Mix 50/50 KwikPen
163
Hydroxyzine HCl
HumaLOG Mix 75/25
164
HydrOXYzine HCl
HumaLOG Mix 75/25 KwikPen
163
Hydroxyzine Pamoate
Humira
158,196,197
Humira Pediatric Crohns Start
158,196
Humira Pen-Crohns Starter
158,196
117,118,265
117,265
118,265,266
HydrOXYzine Pamoate
118,265
Hyoscyamine Sulfate
29,30,31
HumuLIN N
164
I
HumuLIN R
164
Ibandronate Sodium
197
HumuLIN R U-500 (CONCENTRATED)
164
IBG STAR Blood Glucose System
266
Hydralazine HCl
67
Hydrochlorothiazide
67,140
Hydrocodone Polistirex-Chlorpheniramine
Polistirex
210,265
Hydrocodone w/ Homatropine
29,30,31,210,211
Hydrocodone-Acetaminophen
88,89,92,95
Hydrocodone-Ibuprofen
88,89,94
Hydrocortisone
180
Hydrocortisone (Intrarectal)
220,223
Hydrocortisone (Rectal)
226
Ibuprofen 85,86,87,88,89,94,95,96,107,108,109,110,11
2
Icatibant Acetate
195
Iloperidone
130
Iloprost
211
Imatinib Mesylate
259
Imipramine HCl
132
Imipramine Pamoate
132
Imiquimod
224
Incivek
23
Hydrocortisone
Increlex
188
(Topical)217,218,220,221,222,223,224,225,226,227,22
Incruse Ellipta
8
Indacaterol Maleate
Hydrocortisone Acetate (Intrarectal)
220
Hydrocortisone Acetate (Rectal)
218,223
Indapamide
30
38,207
67,68,140
Indinavir Sulfate
22
Hydrocortisone Acetate w/ Pramoxine 218,223,225,226
Indomethacin
Hydrocortisone Butyrate
223
Infed
47
Hydrocortisone Butyrate Hydrophilic Lipo Base
223
Infergen
23
Hydrocortisone Sod Succinate
174
Infinity Blood Glucose System
266
Hydrocortisone Valerate
223
Infinity Blood Glucose Test
266
Infinity Control
266
Hydrocortisone w/Acetic Acid
148,149,151,152
89,197
Hydromorphone HCl
88
Influenza Virus Vaccine Split
211,212
HYDROmorphone HCl
88
Influenza Virus Vaccine Split Preservative Free211,212
Hydroquinone
217
Influenza Virus Vaccine Split Quadrivalent
211,212
Hydroquinone Microspheres
217
Influenza Virus Vaccine Tissue-Cultured Subunit
211
Influenza Virus Vaccine Types A & B Preservative
Free
211
Influenza Virus Vaccine Types A & B Surface
Iodine Strong
210
Iodine Strong (Lugol's)
210
Iodine Strong (Lugol's) (Bulk)
210
Antigen
211
Iodine Tincture
214
Inlyta
266
Iopidine
152
Insulin Aspart
165
Ipratropium Bromide
30,208
Insulin Aspart Protamine & Aspart (Human)
165
Ipratropium Bromide (Nasal)
30,208
Ipratropium Bromide HFA
29,207
Insulin Detemir
164,165
Insulin Glargine
164
Ipratropium-Albuterol
Insulin Glulisine
162
Irbesartan
Insulin Isophane & Reg (Human)
165
Irbesartan-Hydrochlorothiazide
Insulin Isophane (Human)
164,165
Insulin Lispro (Human)
164
Insulin Lispro Protamine & Lispro (Human)
163,164
29,30,38,39,208
68,75
75,140
Iron Dextran
46,47
Iron Polysaccharide Complex-Vit B12-Folic
Acid
47,48,312,313
Insulin Pen
Iron-Folic Acid-Vitamin B12-Vitamin C-Docusate
Needle 231,232,234,237,238,239,240,241,243,244,246
Sodium
,247,248,250,253,254,256,257,259,262,264,265,267,2
Isentress
69,270,271,272,274,275,279,281,283,284,285,286,287
Isocarboxazid
,288,291,295,299,303,304,305,306,307,308
Isometheptene-Caffeine-Acetaminophen
Insulin Regular (Human)
Insulin Syringe
Insulin Syringe/Needle
164,165
266
266,267
47,157,311
24
133
89,99,109
Isoniazid
19
Isoniazid & Rifampin
19
Isoniazid-Rifampin w/ Pyrazinamide
19
Insulin Syringe/Needle U-
Isopto Carbachol
100 234,235,236,238,239,240,241,243,244,245,246,24
Isosorbide Dinitrate
8,249,250,253,254,255,256,258,259,260,261,262,263,
Isosorbide Dinitrate ER
79
264,266,267,268,270,271,272,273,274,276,277,278,28
Isosorbide Mononitrate
80
2,283,284,285,286,287,288,290,291,292,294,295,296,
Isoxsuprine HCl
80
297,298,299,300,301,302,303,304,305,306,307,308
Isradipine
Insupen Pen Needles
267
Ivacaftor
209
Insupen Ultrafin
267
Ivermectin (Pediculicide)
216
Intelence
Interferon Alfa-2B
Interferon alfacon-1
23
23,24,197,267
23
151
78,79,80
53,54,68
J
Jakafi
267
Interferon Beta-1a
192,200
Janumet XR
164
Interferon Beta-1b
193,195
Januvia
164
Jentadueto
164
Interferon Gamma-1B
Intron A
191
23,24,197,267
Invega
132
K
Invega Sustenna
132
Kalbitor
197
24
Kaletra
24
Invirase
Iodine (Topical)
214,215
Kalydeco
209
Keflex
Kenalog
Ketek
KetoCare
Ketoconazole
Ketoconazole (Topical)
Ketone Blood Test
Ketone Test
16
224
16
267
18
214
279,283,285
267
Lactulose (Encephalopathy)
143,144
LaMICtal ODT
102,122
Lamivudine
23,24
Lamivudine (HBV)
23,24
Lamivudine-Zidovudine
24
Lamotrigine
102,103,122
Lancet
Devices 233,234,235,236,237,238,239,240,245,246,24
Ketoprofen
89,109
8,250,256,257,260,261,262,264,265,269,270,271,272,
Ketoprofen ER
89,109
276,278,279,280,284,285,287,288,289,291,292,293,29
Ketorolac Tromethamine (Ophth)
148,149
5,296,298,299,301,302,307
Ketostix
267
Lancets 231,232,233,234,235,236,237,238,239,240,24
Kineret
197
1,242,243,244,245,246,247,248,250,251,252,253,255,
Kinney Lancets
267
256,257,258,260,261,262,263,264,265,267,268,269,27
Kinney Thin Lancets
267
1,272,274,275,276,277,278,279,280,281,282,283,284,
267,268
285,286,288,289,290,291,292,293,294,295,296,297,29
Kinray Insulin Syringe
Klor-Con M15
143
8,299,301,303,304,305,306,307,308
Kristalose
144
Lancets 28G
269
Kroger Blood Glucose
268
Lancets 30G
269
Kroger Blood Glucose Test
268
Lancets Micro Thin 33G
269
Kroger Insulin Syringe
268
Lancets Super Thin 28G
269
Kroger Lancets 21G
268
Lancets Thin
269
Kroger Lancets Micro Thin 33G
268
Lancets Ultra Fine
269
Kroger Lancets Super Thin
268
Lancets Ultra Thin
269
Kroger Lancets Thin 26G
269
Lancets Ultra Thin 30G
269
Kroger Lancets UltraThin 30G
269
Lancing Device
269
Kroger Lancing Device
269
Lanoxin
Kroger Pen Needles
269
Lanreotide Acetate
Kroger Premium Blood Glucose
269
Lansoprazole
Kroger Premium Glucose Test
269
Lanthanum Carbonate
Kroger Test
269
Lantus
164
Kyprolis
269
Lantus SoloStar
164
Lapatinib Ditosylate
302
L
Labetalol HCl
Lacrisert
Lactic Acid (Ammonium Lactate)
Lastacaft
36,57,61,68
152
218,222,224
57
187
156,157,158,160,161
145,196
152,270
Latanoprost
151
Latuda
132
Leader Advanced Lancing Device
270
Lactic Acid w/ Vitamin E
224
Leader Insulin Syringe
270
Lactobacillus Reuteri
155
Leader Unifine Pentips
270
Lactobacillus Reuteri-Vitamin D
155,309
Leader Unifine Pentips Plus
270
Lactulose
143,144
Leflunomide
197
Lenalidomide
200,201,289
Lidoderm
224
Letairis
210
Linaclotide
158
Letrozole
270
Linagliptin
166
Linagliptin-Metformin HCl
164
271
Lindane
215
48
Linezolid
17
Linzess
158
189
Leucovorin Calcium
197,312
Leukeran
Leukine
Leuprolide Acetate
178,181,252,271,272
Leuprolide Acetate (3 Month)
178,181,252,272
Liothyronine Sodium
178,181,252,273
Liotrix (T3-T4)
178,181,252,273
Lipofen
Levalbuterol HCl
39,208
Liraglutide
Levalbuterol Tartrate
40,209
Lisinopril
190,191
50
166
68,75
Levatol
61
Levemir
165
Lite Touch Lancets
271
Levemir FlexPen
164
Lite Touch Lancing Device
271
Levemir FlexTouch
165
Lite Touch Lancing Pen
271
Levetiracetam
103
Lite Touch Pen Needles
271
Levobunolol HCl
151
Litetouch Insulin Syringe
271,272
Levocarnitine (Metabolic Modifiers)
197
Litetouch Lancets
272
Litetouch Pen Needles
272
123
Levofloxacin
16,19
Lisinopril & Hydrochlorothiazide
Levofloxacin (Ophth)
147
Lithium
Levonorgestrel
181
Lithium Carbonate
75,140
122,123
Levonorgestrel & Eth
Livalo
Estradiol167,170,171,172,173,175,176,179,181,182,18
Live Better Adv Lancing Device
272
4,186
Live Better Lancet Super Thin
272
Live Better Lancet Ultra Thin
272
Levonorgestrel-Eth Estradiol
Live Better Pen Needles
272
(Triphasic)
Lodosyn
113
Levonorgestrel (Emergency OC)
181
168,171,172,174,179,181,182,186
Levonorgestrel-Ethinyl Estradiol (91-Day)
Levorphanol Tartrate
171,181
89
Levothyroxine Sodium
189,190,191
Lexiva
24
Lodoxamide Tromethamine
272
Longs Lancets Standard
272
Longs Lancets Thin
272
272
271
Longs Lancets Ultra Thin
Liberty Test
271
Loperamide HCl
Lidocaine
224
Lopinavir-Ritonavir
222,224,225,226
151,235
Longs Insulin Syringe
Liberty Glucose Control
Lidocaine HCl
50
155,156,157,158,160,161
24
Loratadine 205,206,207,242,245,253,263,265,272,286,
Lidocaine HCl (Local Anesth.)
271
291,292,298,308
Lidocaine HCl (Mouth-Throat)
152
Lorazepam
Lidocaine-Hydrocortisone Ace
224
Lorzone
Lidocaine-Hydrocortisone Acetate (Rectal)
224
Losartan Potassium
Lidocaine-Prilocaine
224
Losartan Potassium & Hydrochlorothiazide
103,118
34
68,75
76,140
Lotemax
149
MediSense Thin Lancets
274
Loteprednol Etabonate
149
Medlance Lite 25G
274
Lovastatin
50
Medlance Plus Extra 21G
274
Lovaza
51
Medlance Plus Lancets
274
132,133
Medlance Plus Lite 25G
274
Loxapine Succinate
Lubiprostone
155
Medlance Plus Special 0.8mm
274
Lubricants
225
Medlance Plus SuperLite 30G
274
Lugols
215
Medlance Plus Universal 21G
274
Lumigan
151
Medlance Universal 21G
275
Lunesta
118
Medroxyprogesterone Acetate
182
Medroxyprogesterone Acetate (Antineoplastic)
177
Lupron Depot
Lurasidone HCl
Lyrica
Lysodren
181,272,273
132
103,104,123
273
M
Medroxyprogesterone Acetate (Contraceptive) 177,182
Mefloquine HCl
Megestrol Acetate
20
182,275
Meijer Blood Glucose
275
Meijer Blood Glucose Test
275
Mafenide Acetate
215
Meijer Lancets
275
Magellan Insulin Safety Syr
273
Meijer Lancets Thin
275
Malathion
215
Meijer Lancets Universal 30G
275
Maprotiline HCl
133
Meijer Lancets Universal 33G
275
Meijer Pen Needles
275
Maraviroc
27
Marplan
133
Meijer Premium Blood Glucose
275
Matulane
273
Meijer Premium Glucose Test
275
Maxi-Comfort Insulin Syringe
273
Meijer Super Thin Lancets
275
Maxima Blood Glucose System
273
Meijer TRUE2go Blood Glucose
275
Maxima Blood Glucose Test
273
Meijer TRUEresult Glucose Sys
275
Maxima Control
273
Meijer TRUEtest Test
275
Maxima Meter
273
Meijer TRUEtrack Glucose Sys
275
Maxima Starter
273
Meijer TRUEtrack Test
276
Mecasermin
188
Meloxicam
89
Melquin 3
217
Memantine HCl
123
Meclizine HCl
Meclofenamate Sodium
153,273
89
Medic Insulin Syringe
274
Menest
171,197,198
MediChoice Safety Lancet
274
Mentax
215
MediChoice Safety Lancet Extra
274
Menthol (Topical Analgesic)
224
MediChoice Safety Lancet Norm
274
Meperidine HCl
Medicine Shoppe Pen Needles
274
Mephyton
MediSense Glucose Ketone Contr
274
Meprobamate
Medisense Hi/Mid/Low Control
274
Mepron
Medisense High/Low Control
274
Mercaptopurine
Medisense Mid Control
274
Mesalamine
89,90
198,312
118
20
198,276
155,156,158,159,160
Mesna
198
Mexiletine HCl
Mesnex
198
Miacalcin
Mestinon
32
Micardis
Metaproterenol Sulfate
39,208
Metaxalone
34
Metformin HCl
163,165
58
182,198
69,76
Micardis HCT
Miconazole Nitrate (Topical)
Miconazole Nitrate Vaginal
76,141
212,213,215,216
214,215,216
Methadone HCl
90
Microdot Blood Glucose System
276
Methadose
90
Microdot Control High/Low
276
Methamphetamine HCl
99
Microdot Test
276
Methenamine Hippurate
11
Microlet Lancets
276
Methenamine Mandelate
11
Microtainer Safety Flow Lancet
276
Methenamine-Hyosc-Methylene Blue-Benzoic Acid-
Midodrine HCl
Phenyl Sal
Miglitol
163
Methenamine-Hyosc-Methylene Blue-Sod Phos-Phenyl
Millipred
182
Sal
Milnacipran HCl
11,30,89
11,30,31,94,95,199,203
Methimazole
189
Mini Lancing Device
Methitest
182
Minocycline HCl
Methocarbamol
Methotrexate Sodium
34
39
125,136
276
16,21,225
Minoxidil
69
198,202,276,300
Mirapex ER
113,114
Methoxsalen (Topical)
217
Mirtazapine
133
Methoxsalen Rapid
217
Misc Natural Products
202
Misoprostol
159
101
Mitotane
273
68,140
Modafinil
100
Methscopolamine Bromide
Methsuximide
Methyclothiazide
Methyldopa
Methylergonovine Maleate
Methylphenidate
Methylphenidate HCl
Methylphenidate HCl ER
30
39,68
276
97
99,100
99
Moderiba 800 Dose Pack
24
Moexipril HCl
69,76
Moexipril-Hydrochlorothiazide
76,141
Mometasone Furoate
225
Mometasone Furoate (Inhalation)
175
Methylprednisolone
182
Mometasone Furoate (Nasal)
Methylprednisolone Acetate
177
Mometasone Furoate-Formoterol Fumarate
Methyltestosterone
182
Dihydrate
Metipranolol
151
Monoject Insulin Syringe
Metoclopramide HCl
158
Monoject Ultra Comfort Syringe
277
Monolet Lancets
277
Monolet OPD Lancets
277
Metolazone
Metoprolol & Hydrochlorothiazide
68,140,141
62,141
149,183,204
38,178
276,277
Metoprolol Succinate
36,57,58,62,68
Monolettor Safety Lancets
277
Metoprolol Tartrate
36,58,62,68,69
Montelukast Sodium
204
Metronidazole
Metronidazole (Topical)
Metronidazole Vaginal
20,21,157,158,159
215,216
21,22,215,217
Monurol
Moore Mono Insulin Syringe
Morphine Sulfate
11
277,278
84,86,90,91,92
Morphine Sulfate (PF)
Moxeza
Moxifloxacin HCl
Moxifloxacin HCl (Ophth)
MS Insulin Syringe
Multaq
Multi Prenatal
Multi-Lancet Device
Multiple Vitamins w/ Minerals
90,91
Natamycin
147
147
Nateglinide
165
Natroba
215
12,16,18,19
147,148
Nature-Throid
189,190
278
Nebivolol HCl
35,61
58
48,312
278
144,313
Nedocromil Sodium (Ophth)
151,203
Nefazodone HCl
133
Nelfinavir Mesylate
28
Neomycin Sulfate
16
Mupirocin
215
Neomycin-Bacitracin Zn-Polymyxin
147
Mupirocin Calcium
212
Neomycin-Bacitracin-Polymyxin
216
Mupirocin Calcium (Topical)
215
Neomycin-Colistin-HC-Thonzonium
146,149
Neomycin-Polymy-Dexameth
147,149
Muse
Mycobutin
Mycophenolate Mofetil
80
16,19
193,198
Neomycin-Polymyxin-Gramicidin
Neomycin-Polymyxin-HC
147
147,149,213,220
Mycophenolate Sodium
198
Neomycin-Polymyxin-HC (Ophth)
Myfortic
198
Neomycin-Polymyxin-HC (Otic)
MyGlucoHealth Blood Glucose
278
Neomycin/Polymyxin B GU
215
MyGlucoHealth Control
278
Nepafenac
150
MyGlucoHealth Lancets 30G
278
Neumega
48
MyGlucoHealth Test
278
Neupogen
48
Myleran
278
Neupro
114
Neutek 2Tek Control
278
Neutek 2Tek Test
278
Nevanac
150
N
Nabilone
Nabumetone
Nadolol
Nadolol & Bendroflumethiazide
Nalbuphine HCl
153
147,149
147,149,150
92
Nevirapine
24,28
36,62,69
NexAVAR
278
Nexium 24HR
159
62,141
92
Niacin
313,314
Naloxone HCl
123,198
Niacin (Antihyperlipidemic)
Naltrexone
126,203
Niacin ER
313
Naltrexone HCl
123,199
Niacor
313
Namenda
123
Niaspan
Namenda Titration Pak
123
Nicardipine HCl
Naphazoline HCl
153
Nicotine
51,313
51
54,69,80
31,32,33,34
Naproxen
92,109,199
Nicotine Polacrilex
Naproxen Sodium
92,109,199
Nicotrol
33
Nicotrol NS
33
Naratriptan HCl
Nasacort Allergy 24HR
109
149,204
Nasonex
149,183,204
Natacyn
147
Nifedipine
Nilotinib HCl
Nimodipine
32,33,34
52,54,63,69,78,80,81
297
54,69,81
Nisoldipine
54,69,70
Nova Sureflex Lancets
279
Nova Sureflex Lancing Device
279
20
NovoFine Plus
279
Nitisinone
199
NovoLIN 70/30
165
Nitro-Bid
81
NovoLIN 70/30 ReliOn
165
Nitro-Dur
81
NovoLIN N
165
Nitrofurantoin
11
NovoLIN N ReliOn
165
Nitrofurantoin Macrocrystal
11
NovoLIN R
165
NovoLIN R ReliOn
165
NovoLOG
165
NovoLOG Mix 70/30
165
NovoLOG Mix 70/30 FlexPen
165
NovoLOG PenFill
165
Nisoldipine ER
54,70
Nitazoxanide
Nitroglycerin
80,81,82
Nitroglycerin (Intra-Anal)
226
Nitrolingual
81
Nitrostat
81,82
Nizatidine
159,278
Norco
92
Nucynta ER
92
Norditropin FlexPro
183,188
Nuedexta
Norditropin NordiFlex Pen
183,188
Nutropin AQ NuSpin 10
184,188
172,174,184,186
184,188
Norethin Acet & Estrad-
184,188
Fe
Nutropin AQ Pen
184,188
NuvaRing
172,184
Norelgestromin-Ethinyl Estradiol
170,171,172,173,180,181,182,183,186
Norethindrone & Eth
Estradiol
167,168,172,174,175,177,183,186
Norethindrone (Contraceptive)
176,179,180,183
Norethindrone Acet & Eth Estra
170,180
Norethindrone Acetate
183
Norethindrone Acetate-Ethinyl Estradiol
170,180
Norethindrone-Eth Estradiol
(Triphasic)
167,168,172,175,177,183,184
Nuvigil
18
Nystatin (Mouth-Throat)
18
Nystatin (Topical)
Ofloxacin
147
Ofloxacin (Otic)
Norgestrel & Ethinyl Estradiol
168,171,177,178,181
Olanzapine
Norvir
133
24,25
16
147
172,173,174,183,186
Nortriptyline HCl
159,160,161,187
Ofloxacin (Ophth)
(Triphasic)
58
215,225
O
Estradiol
Norpace CR
215
Nystatin-Triamcinolone
Octreotide Acetate
Norgestimate-Ethinyl Estradiol
100
Nystatin
Norgestimate-Ethinyl
168,171,172,173,179,182,183,185
123
123,124,134
Olanzapine-Fluoxetine HCl
Olmesartan Medoxomil
Olmesartan Medoxomil-Hydrochlorothiazide
134
64,74
74,139
Nova Max Blood Glucose System
278
Olopatadine HCl
153,281
Nova Max Glucose Test
278
Olopatadine HCl (Nasal)
153,279
Nova Max Plus Glu/Ket Control
278
Olsalazine Sodium
156
Nova Max Plus Ketone Test
279
Omalizumab
211
Nova Safety Lancets 23G
279
Omega 3 Fatty Acids-Omega 6 Fatty Acids-Omega 9
Nova Safety Lancets 28G
279
Fatty Acids
199
Omega-3-6-9
Omega-3-acid Ethyl Esters
Omeprazole
Omeprazole-Sodium Bicarbonate
Omontys
199
51
159
159,160
48
Oprelvekin
48
Optium Test
280
OptiumEZ Test
281
OptumRx Blood Glucose Meter
281
OptumRx Blood Glucose System
281
On Call Express Blood Glucose
279
OptumRx Blood Glucose Test
281
On Call Express Glucose Contr
279
OptumRx Glucose Control
281
On Call Express Monitoring Sys
279
Orap
134
On Call Lancets
279
Orfadin
199
On Call Lancing Device
279
Orphenadrine Citrate
On Call Plus Blood Glucose
279
Orphenadrine w/ Aspirin & Caff
On Call Plus Glucose Control
279
Ortho Evra
On Call Plus Lancets
279
Oseltamivir Phosphate
On Call Plus Lancing Device
279
OsmoPrep
159
On Call Plus Meter
279
Oxaprozin
93
On Call Plus Monitoring System
279
Oxazepam
118,119
On Call Vivid Blood Glucose
279
Oxcarbazepine
104
On Call Vivid Glucose Control
279
Oxiconazole Nitrate
215
On Call Vivid Meter
280
Oxistat
215
On Call Vivid Monitoring
280
Oxsoralen
217
On Call Vivid Pal Meter
280
Oxsoralen Ultra
217
Ondansetron
154
Oxybutynin
230
Oxybutynin Chloride
230
Ondansetron HCl
153,154
34,114
34,93,100
172,184
27,28
OneTouch Delica Lancets 33G
280
Oxycodone HCl
93
OneTouch Delica Lancets Fine
280
OxyCODONE HCl
93
OneTouch Delica Lancing Dev
280
Oxycodone w/ Acetaminophen
OneTouch FinePoint Lancets
280
Oxycodone-Aspirin
OneTouch Ultra 2
280
Oxycodone-Ibuprofen
OneTouch Ultra Blue
280
Oxymorphone HCl
OneTouch Ultra Control
280
Oxytrol
OneTouch Ultra Mini
280
OneTouch Ultra System
280
P
OneTouch UltraLink
280
Paliperidone
132
OneTouch UltraSoft Lancets
280
Paliperidone Palmitate
132
OneTouch Verio
280
Palivizumab
OneTouch Verio IQ System
280
Pancrelipase (Lipase-Protease-
OneTouch Verio Sync System
280
Amylase)
Onglyza
Opana ER
165,166
92,93
Pantoprazole Sodium
Papaverine HCl
Ophthalmic Irrigation Solution
152
Paradigm Link Glucose Monitor
Ophthalmic Irrigation Solution - Intraocular
152
Paricalcitol
86,93,94
86,93
93
92,93,94
230
27
156,162,244,245,309
159
82
281
313,316
Paroxetine HCl
134
Perfect Lancets 30G
Pataday
153,281
Perforomist
Patanol
153,281
Perindopril Erbumine
282
39,208
70,76
Paxil
134
Permethrin
212,216
Pazopanib HCl
308
Perphenazine
134,135
PC Lancets Super Thin 30G
281
Perphenazine-Amitriptyline
135
PC Unifine Pentips
281
Petroleum Jelly
225
Pharmacist Choice Autocode
282
Pharmacist Choice Autocode Sys
282
Pharmacist Choice Lancets
282
PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod
Pharmacy Counter Lancets
282
Sulfate
Phenazopyridine HCl
225
PEG 3350-Potassium Chloride-Sod Bicarbonate-Sod
Phendimetrazine Tartrate
100
Chloride
Phendimetrazine Tartrate ER
100
135
Pediatric Multivitamins w/Fl
198,312
Pediatric Vitamins ACD w/
Fluoride
202,203,314,315,316
156,157,159
157,159,161
Peg-Intron
25
Phenelzine Sulfate
Peg-Intron Redipen
25
Phenobarbital
104,119
Peg-Intron Redipen Pak 4
25
PHENobarbital
104,119
Peganone
104
Phenoxybenzamine HCl
35,65
Pegasys
25
Phentermine HCl
Pegasys ProClick
25
Phenyleph-Promethazine w/ Cod
39,210,285
Peginesatide Acetate
48
Phenylephrine-Chlorphen-DM
40,211,298
Peginterferon alfa-2a
25
Phenytoin
58,104,105
Peginterferon alfa-2b
25
Phenytoin Sodium
Peginterferon alfa-2b (Antineoplastic)
27,202,296,297
Phenytoin Sodium Extended
Pegvisomant
188
Phoslyra
Pen Needles
281
Phospholine Iodide
Pen Needles 1/2"
281
Physostigmine Salicylate
Pen Needles 3/16"
281
Phytonadione
Pen Needles 5/16"
281
Pilocarpine HCl
Penbutolol Sulfate
61
Penciclovir
Penicillamine
214
193,245
Pilocarpine HCl (Oral)
Pimecrolimus
Pimozide
100
58,105
56,58,101,102,104
144,145
151
33,199
198,312
151
33
193,221
134
Penicillin G Benzathine
13
Pindolol
Penicillin V Potassium
16
Pioglitazone HCl
166
Pioglitazone HCl-Glimepiride
166
Pioglitazone HCl-Metformin HCl
166
Pentasa
Pentazocine w/ Naloxone
159,160
94,124
36,58,62,70
Pentetate Calcium Trisodium
281
Piroxicam
94
Pentetate Zinc Trisodium
281
Pitavastatin Calcium
50
Pentosan Polysulfate Sodium
193
PNV Fe Fum/Docusate/Folic Acid
Pentoxifylline
Perfect Lancets 28G
48,160,313
48
Podocon
225
282
Podofilox
220,225
Podophyllum Resin
225
Prednisolone Acetate (Ophth)
150
Polyethylene Glycol 3350
160
PrednisoLONE Sodium Phosphate
Polyethylene Glycol 3350 (Bulk)
160
Prednisolone Sodium Phosphate
184
Polymyxin B-Trimethoprim
147
Prednisolone Sodium Phosphate (Ophth)
150
150,184
Pomalidomide
199,282
Prednisone
184,185
Pomalyst
199,282
PredniSONE
184,185
Pot & Sod Citrates w/Citric Ac
PredniSONE (Pak)
184
Pot Phosphate Monobasic w/ Sod Phosphate Dibasic
PredniSONE Intensol
184
& Monobasic
144
Preferred Plus Insulin Syringe
283
Potaba
313
Preferred Plus Lancets Colored
283
Potassium Aminobenzoate
313
Preferred Plus Lancets Thin
283
Potassium Bicarb & Chloride
143
Preferred Plus Unifine Pentips
Potassium Bicarbonate
143
143,144
Potassium Bicarbonate-Citric Acid
Potassium Chloride
143
143,144
283,284
Pregabalin
Premarin
103,104,123
172,173,199,200
Premphase
173,185
Prempro
173,185
Potassium Chloride Microencapsulated Crystals
Prenatal
48,145,313
CR
143,144
Prenatal 19
48,160,313
Potassium Citrate (Alkalinizer)
144,145
Prenatal Low Iron
48,313
48,313
Potassium Chloride ER
144
Potassium Citrate-Citric Acid
144
Prenatal One Daily
Potiga
105
Prenatal Vit w/ Docusate-Fe Fumarate-Folic
Pradaxa
Pramipexole Dihydrochloride
45
113,114
Acid
48,49,160,161,313,314
Prenatal Vit w/ Ferrous Fumarate-Folic
Pramlintide Acetate
166
Acid
Pramoxine-Camphor-Zinc Acetate
219
Prenatal w/ Calcium Carbonate-Vit B6-Vit B12-Folic
Pramoxine-HC
223
Acid
Prandin
166
Prenatal w/o Vit A w/ Fe Fumarate-DSS-FA-
Pravastatin Sodium
Prazosin HCl
51
36,62,70
DHA
Prepopik
48,49,145,312,313,314
143,309
49,161,202,314
160
Precision Glucose Ketone Contr
282
Prezista
Precision PCx
282
Primaquine Phosphate
Precision PCX Plus Test
282
Primidone
105
Precision Point of Care Test
282
Pristiq
135
Precision QID Test
282
ProAir HFA
39,208
Precision Sure-Dose Syringe
282
Probenecid
145,200
Precision SureDose Plus Syr
283
Procarbazine HCl
273
Precision Xtra Blood Glucose
283
Prochlorperazine
129,135,153,154
Precision Xtra Ketone
283
Prochlorperazine Edisylate
135,154
Pred Mild
150
Prochlorperazine Maleate
135,154
Prednicarbate
225
Procrit
Prednisolone
182,184
Proctofoam HC
25,26
21
48,49
226
Prodigy AutoCode Blood Glucose
284
Pyrogallic Acid
226,286
Prodigy Insulin Syringe
284
Pyrogallol-Chlorobutanol
226,286
Prodigy Lancets 28G
284
Prodigy Lancing Device
284
Q
Prodigy No Coding Blood Gluc
284
QC Lancets Super Thin 30G
286
Prodigy Pocket Blood Glucose
284
QC Pen Needles
286
Prodigy Twist Top Lancets 28G
284
QC Unifine Pentips
286
Prodigy Voice Blood Glucose
284
Qnasl
Progesterone (Vaginal)
176,179
Prolia
200
Promethazine & Phenylephrine
Promethazine HCl
39,285
119,120,154,206,207,282,284,285
Qualaquin
Quetiapine Fumarate
Quinapril HCl
Quinapril-Hydrochlorothiazide
150,204
21
124,125,135,136
70,71,76
76,141
Promethazine w/Codeine
210,285
Quinidine Gluconate
21,59
Promethazine-DM
210,285
Quinidine Sulfate
21,59
Propafenone HCl
58
QuiNIDine Sulfate
21,59
Propantheline Bromide
30
QuiNIDine Sulfate ER
21,59
Proparacaine HCl
153
Propranolol & Hydrochlorothiazide
Propranolol HCl
63,141
36,37,58,59,62,63,70,110
Propranolol-HCTZ
Propylthiouracil
63,141
Qvar
21
185,204
R
RA E-Zject Color Lancets 33G
286
RA E-Zject Lancets 28G
286
39,209
RA E-Zject Lancets Thin 26G
286
226
RA E-Zject Lancets Thin 28G
286
Pseudoephed-Bromphen-DM
38,209,240
RA E-Zject Lancets Ultra Thin
286
Pseudoephedrine w/ DM-GG
40,211
RA Insulin Syringe
286
285
RA Lancing Device
287
Protein C Concentrate (Human)
Proventil HFA
Prudoxin
PTS Panels Ketone Test
190
Quinine Sulfate
42
Pulmicort
185,204
RA Pen Needles
287
Pulmicort Flexhaler
185,204
RA TRUEresult Blood Glucose
287
Pulmozyme
210,285
RA TRUEtest Test
287
PX Advanced Lancing Device
285
Raloxifene HCl
PX Extra Short Pen Needles
285
Raltegravir Potassium
PX Insulin Syringe
285
Ramelteon
PX Lancet Auto Injector
285
Ramipril
71,76,77
PX Lancets Ultra Thin
285
Ranexa
59
PX Mini Pen Needles
285
Ranitidine HCl
PX Pen Needle
Pyrazinamide
Pyridostigmine Bromide
285,286
19
32,33
Pyridoxine HCl
309,313
Pyrimethamine
20
170,173,195,200
24
120
160,287
Ranolazine
59
Rapaflo
37
Rapamune
Rasagiline Mesylate
Rebetol
200
112,128
26
Rebif
200
Revlimid
Rebif Rebidose
200
Rexall Blood Glucose System
289
Rebif Rebidose Titration Pack
200
Rexall Blood Glucose Test
289
Rebif Titration Pack
200
Rexall Lancets Ultra Thin 30G
289
Rectiv
226
Reyataz
RefuAH Plus Blood Glucose Test
287
Rhinocort Aqua
RefuAH Plus Glucose Control
287
Ribasphere
26
RefuAH Plus Monitoring System
287
Ribasphere RibaPak
26
Regorafenib
294
RibaTab
26
Relenza Diskhaler
26
Ribavirin (Hepatitis C)
200,201,289
26
150,204
24,26
Reli-On Insulin Syringe
287
Ridaura
201,289
ReliOn Blood Glucose Test
287
Rifabutin
16,17,19
ReliOn Confirm Glucose Monitor
287
Rifamate
19
ReliOn Confirm/micro Test
287
Rifampin
17,19
ReliOn Insulin Syringe
287,288
Rifater
19
ReliOn Ketone
288
Right Step Prenatal
ReliOn Lancets Micro-Thin 33G
288
Rightest GC300 Control
289
ReliOn Lancets Thin 26G
288
Rightest GD500 Lancing Device
289
ReliOn Lancets Ultra-Thin 30G
288
Rightest GL300 Lancets
289
ReliOn Lancing Device
288
Rightest GM100 Blood Glucose
289
ReliOn Micro
288
289
ReliOn Mini Pen Needles
288
289
ReliOn Pen Needles
288
Rightest GS100 Blood Glucose
289
ReliOn Prime Test
288
290
ReliOn Short Pen Needles
288
290
ReliOn Ultima Glucose System
288
Rilonacept
192
ReliOn Ultima Test
288
Rilpivirine HCl
ReliOn Ultra Thin Lancets 30G
289
Rilutek
124
ReliOn Ultra Thin Plus Lancets
289
Riluzole
124
Relpax
110
Rimantadine Hydrochloride
Renagel
145,146,200
Renvela
146,200
Rimexolone
Risedronate Sodium
49,314
23
27
150
191,192,201
Repaglinide
166
Risperidone
124,125,135,136
Replesta
314
Ritonavir
24,25
Replesta Childrens
314
Rivaroxaban
45,46
Replesta NX
314
Rivastigmine
32
Rescriptor
26
Rivastigmine Tartrate
33
Reserpine
71
Rizatriptan Benzoate
110
Retapamulin
212
Ropinirole Hydrochloride
114,115
Reveal Blood Glucose Monitor
289
Rosiglitazone Maleate
162
Reveal Blood Glucose Test
289
Rosuvastatin Calcium
49,50
Rotigotine
114
Selzentry
27
Rozerem
120
Sensipar
201
Rufinamide
101
Serevent Diskus
Ruxolitinib Phosphate
267
SEROquel XR
Rx Support HB/Reflux/Aloe
145,201,314
S
40,209
125,136
Sertaconazole Nitrate
214
Sertraline HCl
137
Sevelamer Carbonate
146,200
Sabril
105
Sevelamer HCl
SafeSnap Insulin Syringe
290
Shopko Autolet Lancing Device
291
Safety Lancet 21G/Pressure Act
290
Shopko On-the-Go Lancets 30G
291
Safety Lancet 28G/Pressure Act
290
Shopko Unifine Pentips
291
Safety Lancets
290
Shopko Unilet Lancets 28G
291
Safety Lancets 21G
290
Shopko Unilet Lancets 30G
291
Safety Lancets 28G
290
Sildenafil Citrate (Pulmonary Hypertension) 82,210,231
Safety Let Lancets
290
Silodosin
Safety Seal Lancets
290
Silver Nitrate
Safety-Glide Syringe
290
Simple Diagnostics Lancing Dev
Salicylic Acid
Salmeterol Xinafoate
Salsalate
226,227
40,209
94
Simvastatin
Sinecatechins
Sirolimus
145,146,200
37
147,148
291
51
229
200,201
Salvax
227
Sitagliptin Phosphate
164
Samsca
141
Sitagliptin-Metformin HCl
164
SandIMMUNE
201
Sklice
216
SM Insulin Syringe
292
SandoSTATIN LAR Depot
160,161,187
Santyl
227,290
SM Lancets 33G
292
Saphris
125,136
Smart Diabetes Vantage Lancets
292
290
Smart Diabetes Vantage Lancing
292
SAPScare Twist Top Lancets
Saquinavir Mesylate
24
Smart Diabetes Xpres System
292
Sargramostim
48
Smart Diabetes Xpres Test
292
Savella
125,136
Smart Sense Color Lancets 33G
292
Saxagliptin HCl
165,166
Smart Sense Premium System
292
SB Insulin Syringe
290,291
Smart Sense Premium Test
292
SB Lancets Thin
291
Smart Sense Standard Lancets
292
SB Lancets Ultra Thin
291
Smart Sense Super Thin Lancets
292
Schnucks Insulin Syringe
291
Smart Sense Thin Lancets 26G
292
Smart Sense Value Glucose Sys
293
Se-Natal 19
49,161,314
Selegiline
113,130
Smart Sense Value Test
293
Selegiline HCl
115,136
Smartest Blood Glucose Test
293
Smartest Control Medium
293
Smartest Eject Starter
293
Smartest Lancets 28G
293
Selenium Sulfide
216
Selenium Sulfide-Pyrithione Zinc in Urea
Vehicle
216,227
Smartest Persona Starter
293
Spironolactone & Hydrochlorothiazide
Smartest Pronto Starter
293
Sprycel
293,294
Smartest Protege Starter
293
Stannous Fluoride
199,201
Sodium Chloride
145
Stavudine
Sodium Chloride (GU Irrigant)
77,141
27
142,143,145
Stavzor
105,111,125
Sodium Chloride (Inhalant)
210,211
Stelara
227
Sodium Chloride Flush
144,145
SteriLance TL
294
Sodium Citrate & Citric Acid
143
Stimate
40,186
195,197,201
Stivarga
294
Sodium Fluoride (Dental)
193,201
Strattera
125,126
Sodium Fluoride-Potassium Nitrate
195,256
Stribild
Sodium Fluoride
Sodium Oxybate
126
Sodium Phosphate Monobasic-Sodium Phosphate
Dibasic
159
Sodium Picosulfate-Magnesium Oxide-Anhydrous
Citric Acid
Sodium Polystyrene Sulfonate
145,146,197,201
Sodium Sulfacetamide Wash
201,216
Sodium Sulfate-Potassium Sulfate-Magnesium
Sulfate
161
Sodium Thiosulfate-Salicylic Acid
Suboxone
214,222
94,95,126
Succimer
193,242
Sucralfate
155,161
Sulfacetamide Sod-Prednisolone
160
27,201
146,148,150
Sulfacetamide Sodium
216
Sulfacetamide Sodium (Acne)
216
Sulfacetamide Sodium (Ophth)
148
Sulfacetamide Sodium in Bakuchiol Vehicle
201,216
Sulfacetamide Sodium w/ Sulfur
216,227
Sulfadiazine
17
17
Solartek Glucose Control
293
SulfADIAZINE
Solifenacin Succinate
230
Sulfamethoxazole-Trimethoprim
Solus V2 Blood Glucose System
293
Sulfasalazine
Solus V2 Lancets 28G
293
Sulindac
Solus V2 Lancing Device
293
Sumatriptan
111
Solus V2 Test
293
SUMAtriptan
111
Solus V2 Twist Lancets 30G
293
Sumatriptan Succinate
111
179,180,183,184,186,187,188,189
SUMAtriptan Succinate
111
296
Somatropin
11,17,21
17,161,201,202
95
Somatuline Depot
187
Sunitinib Malate
Somavert
188
Suprax
Sorafenib Tosylate
278
Suprep Bowel Prep
161
Sorbitol
145
Sure Comfort Insulin Syringe
294
Sorbitol Irrigation
145
Sure Comfort Lancets 28G
294
Sorbitol-Mannitol
145
Sure Comfort Lancets 30G
295
Soriatane
227
Sure Comfort Lancing Pen
295
37,59,63,71
Sure Comfort Pen Needles
295
Sotalol HCl
17
Spacer/Aerosol-Holding Chambers
247
Sure Edge Test
295
Spinosad
215
Sure-Fine Pen Needles
295
Spiriva HandiHaler
Spironolactone
31,209
Sure-Ject Insulin Syringe
295,296
71,77,141
Sure-Lance Flat Lancets
296
Sure-Lance Lancets 26G
296
Tazarotene
227,228
Sure-Lance Thin Lancets 28G
296
Tazorac
227,228
Sure-Lance Ultra Thin Lancets
296
TechLite Lancets 30G
Sure-Pen
296
TEGretol-XR
Sure-Test EasyPlus Mini Test
296
Tekturna
Sure-Touch Lancets Universal
296
Tekturna HCT
SureChek Blood Glucose Test
296
Telaprevir
23
Surelite Lancets
296
Telbivudine
28
SureStep Glucose Control
296
Telcare Blood Glucose System
297
SureStep Pro Normal Glucose
296
Telcare Blood Glucose Test
297
SureStep Pro Test
296
Telcare Glucose Control
297
Sustiva
27
Sutent
296
Sylatron
Symbicort
27,202,296,297
40,186
Telithromycin
Telmisartan
Telmisartan-Hydrochlorothiazide
Temazepam
SymlinPen 120
166
Tenofovir Disoproxil Fumarate
SymlinPen 60
166
Terazosin HCl
105,126
77
77,141,142
16
69,76
76,141
120
28
37,63,71
Synagis
27
Synalar
227
Terbutaline Sulfate
Synthroid
190
Terconazole Vaginal
Syprine
297
Teriparatide (Recombinant)
179
Terumo Insulin Syringe
297
Terumo SurGuard Insulin Syr
298
T
Terbinafine HCl
297
Tabloid
297
Testosterone
Taclonex
227
Tetrabenazine
Tacrolimus
196,202
Tetracaine HCl (Ophth)
Tadalafil
78
Tetracycline HCl
Tadalafil (Pulmonary Hypertension)
78
Tetrahydrozoline HCl (Ophth)
Tafluprost
151
Tev-Tropin
Tai Doc Control
297
TGQ 15DM/5PEH/2CPM
Tamiflu
Tamoxifen Citrate
Tamsulosin HCl
Tanzeum
Tapentadol HCl
27,28
TGQ 30PSE/150GFN/15DM
18
40,209
216,217
175,176,186
126
151,153
17,21,22,161
153
186,189
40,211,298
40,211
173,297
TGT Advanced Lancing Device
298
37
TGT Blood Glucose Monitoring
298
166
TGT Blood Glucose Test
298
92
TGT Lancet Alternate Site
298
Tarceva
297
TGT Lancet Micro Thin 33G
298
Targretin
297
TGT Lancet Super Thin 30G
298
54,55,77
TGT Lancet Thin 23G
298
49,161,202,314
TGT Lancet Thin 26G
298
Tarka
Taron-Prex
Tasigna
297
TGT Lancet Ultra Thin 28G
298
Tasmar
115
TGT Lancet Ultra Thin 30G
298
TGT Lancing Device
298
Tolcapone
Thalidomide
202
Tolmetin Sodium
Thalomid
202
Tolterodine Tartrate
230
Tolvaptan
141
TopCare Clickfine Pen Needles
299
Theophylline
66,72,98,100,140,142,208,209,231
Thera-D 4000
Thinpro Insulin Syringe
314
298,299
115
95
TopCare Ultra Comfort Ins Syr
299,300
Thioguanine
297
Topiramate
105,112
Thiothixene
137
Toremifene Citrate
170,255
Thyrogen
299
Torsemide
Thyroid
189,190,191
72,142
Toviaz
230
166
Thyrolar-1
190
Tradjenta
Thyrolar-1/2
190
Tramadol HCl
95
Thyrolar-1/4
190
TraMADol HCl ER
95
Thyrolar-2
191
Tramadol-Acetaminophen
95
Thyrolar-3
191
Trandolapril
Thyrotropin Alfa
299
Trandolapril-Verapamil HCl
Tiagabine HCl
102,105
72,77
54,55,77
Tranylcypromine Sulfate
137
Ticagrelor
42
Travatan Z
151
Ticlopidine HCl
45
Travoprost
151
Trazodone HCl
137
Trelstar
300
Trelstar Depot Mixject
300
Trelstar LA Mixject
300
Timolol Maleate
Timolol Maleate (Ophth)
Tinidazole
Tiotropium Bromide Monohydrate
37,60,63,72,112
151
22
31,209
Tipranavir
22
Trelstar Mixject
300
Tizanidine HCl
34
Treprostinil
211
TobraDex
148,150
Tretinoin
TobraDex ST
148,150
Tretinoin (Chemotherapy)
300
Tretinoin Microsphere
228
Tobramycin (Ophth)
Tobramycin-Dexamethasone
148
148,150
Trexall
218,228
202,300
Tobrex
148
Triamcinolone Acetonide
Tocilizumab
191
Triamcinolone Acetonide (Mouth)
225,228
Todays Health Lancing Device
299
Triamcinolone Acetonide (Nasal)
149,204
Todays Health Mini Pen Needles
299
Triamcinolone Acetonide (Topical)
Todays Health Pen Needles
299
Triamterene
Todays Health Short Pen Needle
299
Triamterene & Hydrochlorothiazide
142
Todays Health Thin Lancets 28G
299
Trianex
229
Todays Health Thin Lancets 30G
299
Triazolam
120
Tolazamide
166
Trientine HCl
297
TOLAZamide
166
Trifluoperazine HCl
137
148
Tolbutamide
166,299
Trifluridine
TOLBUTamide
166,299
Triglide
228
224,228,229
66,139
51
Trilipix
Trimethobenzamide HCl
Trimethoprim
51
154
11
Ulti-Lance Automatic
302
UltiCare Insulin Safety Syr
302
UltiCare Insulin Syringe
302,303
Trimipramine Maleate
137
UltiCare Micro Pen Needles
303
Triptorelin Pamoate
300
UltiCare Mini Pen Needles
303
Trizivir
28
UltiCare Pen Needles
303
Trolamine Salicylate
83
UltiCare Short Pen Needles
303
Tropicamide
153
Ultilet Classic Lancets
303
Trospium Chloride
230
Ultilet Insulin Syringe Short
303
True Metrix Blood Glucose Test
300
Ultilet Lancets
304
True Metrix Level 2
300
Ultilet Pen Needle
304
True Metrix Meter
300
Ultilet Safety Lancets 23G
304
TRUE2go Blood Glucose Monitor
301
Ultima Test
304
TrueControl Glucose Cont Lev 0
301
Ultra Comfort Insulin Syringe
304
TrueControl Glucose Cont Lev 1
301
Ultra Thin Lancets 28G
304
TRUEdraw Lancing Device
301
Ultra Thin Lancets 30G
304
TRUEplus Insulin Syringe
301
Ultra Trak Pro Blood Glucose
304
TRUEplus Lancets 26G
301
Ultra-Comfort Insulin Syringe
304,305
301
Ultra-Thin II Auto Lancet
305
301
Ultra-Thin II Ins Syr Short
305
301
Ultra-Thin II Insulin Syringe
305
TRUEplus Safety Lancets 28G
301
Ultra-Thin II Pen Needles
305
TRUEresult Blood Glucose
302
UltraTRAK PRO Control
305
TRUEtest Control Level 1
302
UltraTRAK PRO Test
305
302
UltraTRAK Ultimate Control
305
302
UltraTRAK Ultimate Test
305
TRUEtest Test
302
Umeclidinium Bromide
TrueTrack Blood Glucose
302
Unifine Pentips
TrueTrack Smart System
302
Unifine Pentips Plus
TrueTrack Test
302
Unilet ComforTouch Lancet
306
Unilet ExceLite
306
Unilet ExceLite II
306
Unilet G.P. Superlite Lancet
306
Truvada
Trypsin w/ Castor Oil & Peruvian Balsam
Tudorza Pressair
28
226,229
31
30
305
305,306
Tykerb
302
Unilet GP 28 Ultra Thin
306
Tyvaso
211
Unistik 3 Gentle
306
Tyvaso Refill
211
Unistrip1 Generic
306
Tyvaso Starter
211
Universal 1 Lancets Thin 26G
306
28
Universal 1 Lancets Ultra Thin
306
Uramaxin
229
Tyzeka
U
Ulipristal Acetate
Urea
178
Urea & Hyaluronate Sodium
219,226,229
229
Urea in Ammonium Lactate Vehicle
229
Veramyst
Urea in Lactic Acid-Salicylic Acid Vehicle
224
Verapamil HCl
150,186,204
55,60,72,73,82
Urea in Zinc Undecylenate-Lactic Acid Vehicle 217,229
Veregen
229
Urea Nail
VESIcare
230
Vexol
150
229
Uretron D/S
11,31,95,203
Urocit-K 10
145
Victory AGM-4000 Test
307
Urocit-K 15
145
Victory Control Level 1/2
307
Urocit-K 5
145
Victoza
166
Ursodiol
162
Victrelis
28
Ustekinumab
227
Vida Mia Autolet Lancing Dev
307
Vida Mia Unifine Pentips
307
Vida Mia Unilet Lancets 28G
307
Vida Mia Unilet Lancets 30G
307
V
V-R Mono Insulin Syringe
Vagifem
306
174,203
Videx
28
Valacyclovir HCl
28
Vigabatrin
105
Valcyte
28
Vigamox
148
Valganciclovir HCl
28
Viibryd
138
Valproate Sodium
105,112,126
Vilazodone HCl
138
Valproic Acid
105,111,112,125,126
Valrubicin
306
Valsartan
72,77
Valsartan-Hydrochlorothiazide
77,78,142
Viracept
28
Viramune
28
Viramune XR
28
Viread
28
Valstar
306
Vitamin D3
Value Health Insulin Syringe
306
Vivitrol
Value Plus Lancet Standard 21G
306
Vocal Point Blood Glucose Test
308
Value Plus Lancets Super Thin
307
Voltaren
229
Value Plus Lancets Thin 26G
307
Votrient
308
Value Plus Lancing Device
307
VP Insulin Syringe
308
ValuMark Lancet Super Thin 30G
307
Vytorin
ValuMark Lancet Ultra Thin 28G
307
ValuMark Pen Needles
307
Vancomycin HCl
17
315
126,203
51,52
W
Walgreens Adv Travel Lancets
308
Vandetanib
240
Walgreens Lancets
308
VanishPoint Insulin Syringe
307
Walgreens Lancets Micro Thin
308
Vantas
307
Walgreens Lancets Super Thin
308
Walgreens Thin Lancets
308
308
Varenicline Tartrate
31
Veltin
217,229
Walgreens Ultra Thin Lancets
Venlafaxine HCl
137,138
Warfarin Sodium
Venlafaxine HCl ER
137,138
WaveSense AMP
308
WaveSense KeyNote
308
WaveSense Presto
308
Ventavis
Ventolin HFA
211
40,209
44,45
Wegmans Unifine Pentips Plus
Welchol
308
Zytiga
309
52,167
Zyvox
17
Westhroid
191
White Petrolatum
225
Witch Hazel-Glycerin
224
X
Xalkori
308
Xarelto
45,46
Xeloda
308,309
Xenazine
126
Xolair
211
Xopenex HFA
40,209
Xpres Control
309
Xyrem
126
Z
Zafirlukast
204
Zaleplon
120
Zanamivir
26
Zemplar
316
Zenpep
162,309
Zetia
52
Ziagen
28
Ziana
Zidovudine
217,229
28
Zileuton
204
Zinc Sulfate
145
Zioptan
151
Ziprasidone HCl
Zirgan
Zithromax
Zoladex
Zolpidem Tartrate
Zonisamide
126,127,138
148
17
187,309
120
105,106
Zortress
203
Zostavax
212
Zoster Vaccine Live
212
Zovirax
217
Zyflo
204
Zymaxid
148

Qualified Health Plan Drug Formulary

Transcription

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