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MCD-KY STAT 2 - WellCare of Kentucky
2015 Comprehensive Dual Eligible Preferred Drug List (List of Covered Drugs) WellCare of Kentucky 00 9 Please read: This document contains information about the drugs we cover in this plan. Last updated (1/01/2015) Kentucky Dual Eligible Cough & Cold Drug List Non-Preferred Drugs Preferred Drugs ANTITUSSIVES,NON-NARCOTIC Benzonatate TESSALON 200 MG CAPSULE BENZONATATE 100 MG CAPSULE BENZONATATE 200 MG CAPSULE Dextromethorphan Polistirex DELSYM 30 MG/5 ML EXTENDED-RELEASE SUSPENSION Dextromethorphan HBr ROBITUSSIN PEDIATRIC COUGH SYP Dextromethorphan HBr/Menthol DELSYM COUGH RELIEF PLUS LOZENGE NON-NARC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGEST Brompheniramine/Dextromethorphan HBr/Pseudoephedrine HCl ALLANHIST PDX DROPS BROMFED DM SYRUP BROMHIST PDX DROPS ENDACOF-PD DROPS BROTAPP DM LIQUID Q-TAPP DM ELIXIR Brophenaramine/Dextromethorphan HBr/Phenylephrine HCl COLD/COUGH CHILDRENS ELIXIR RYNEX DM DIMAPHEN DM ELIXIR Chlorpheniramine/Dextromethorphan HBr/Phenylephrine HCl C-PHEN DM PD-COF SYRUP RONDEX-DM SYRUP SILDEC PE-DM SYRUP DE-CHLOR DM LIQUID CORFEN DM NOHIST-DM TRI-DEX PE Chlorpheniramine/Dextromethorphan HBr/Pseudoephedrine HCl PEDIATRIC COUGH-COLD LIQUID KIDKARE COUGH/COLD MESEHIST DM Dexchlorpheniramine/Pseudoephedrine HCl/Chlophedianol HCl VANACOF LIQUID Chlorpheniramine/Dextromethorphan HBr DIMETAPP LONG-ACTING COUGH LIQ ROBITUSSIN LONG ACTING LIQUID Promethazine HCl/Dextromethorphan HBr PROMETHAZINE-DM SYRUP NON-NARC ANTITUSS-1ST GEN. ANTIHIST-ANALGESIC COMBINATION Dextromethorphan HBr/Acetaminophen/Doxylamine DELSYM NIGHTTIME MULTI-SYMPTOM EXPECTORANTS DECONGESTANT-EXPECTORANT COMBINATIONS Guaifenesin/Phenylephrine HCl DONATUSSIN DROPS PE-GUAI DROPS DESPEC LIQUID Last updated 07/31/14 RESCON-GG LIQUID Page 1 of 2 Kentucky Dual Eligible Cough & Cold Drug List Non-Preferred Drugs Preferred Drugs NON-NARCOTIC DECONGESTANT-EXPECTORANT-ANTITUSSIVE Guaifenesin/Dextromethorphan HBr/Phenylephreine ROBAFEN CF SYRUP NON-NARCOTIC ANTITUSSIVE AND EXPECTORANT COMB. Dextromethorphan HBr/Guaifenesin DURATUSS DM ELIXIR SIMUC-DM ELIXIR SU-TUSS DM ELIXIR MUCUS RELIEF COUGH LIQUID DIABETIC TUSSIN DM LIQUID GUAIFENESIN DM SYRUP Q-TUSSIN-DM SYRUP EXTRA ACTION COUGH SILTUSSIN DM COUGH SYRUP REFENESEN DM SILTUSSIN DM DAS COUGH SYRUP MUCOSA DM ROBITUSSIN COUGH CHEST CONGESTION DM LIQUID NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE Chlorpheniramine/Hydrocodone Polistirex TUSSIONEX PENNKINETIC SUSP TUSSICAPS (min. age 6 years old) HYDROCODONE-CHLORPHENIRAMINE SUSPENSION (min. age 6 years old) Codeine Phosphate/Promethazine HCl PROMETHAZINE-CODEINE SYRUP (min. age 6 years old) NARCOTIC ANTITUSSIVE-1ST GEN. ANTIHISTAMINE-DECONGESTANT Dexbrompheniramine/Hydrocodone Bit/Phenylephrine HCl CYTUSS-HC NR SYRUP HC 2.5-PE 5-DBROM 1 MG SYRUP HC/PE/DBROM SYRUP Codeine/Phenylephrine HCl/Promethazine PROMETH VC W/COD SYRUP PROMETHAZINE VC/COD SYRUP Pseudoephedrine HCl/Codeine/Chlorpheniramine PHENYLHISTINE DH NARCOTIC ANTITUSSIVE-ANTICHOLINERGIC COMBINATION Hydrocodone Bit/Homatropine HYDROCODONE-HOMATROPINE HYDROMET SYRUP NARCOTIC ANTITUSSIVE-EXPECTORANT COMBINATION Guaifenesin/Hydrocodone Bit HYDROCODONE-GUAIFENESIN SYRUP NARCOF SYRUP Codeine Phosphate/Guaifenesin TUSSICLEAR DH SYRUP CHERATUSSIN AC SYRUP GUAIFENESIN-CODEINE SYRUP IOPHEN C-NR NARCOTIC ANTITUSSIVE-DECONGESTANT-EXPECTORANT COMBINATIONS Codeine Phosphate/Guaifenesin/Pseudoephedrine HCl CHERATUSSIN DAC SYRUP Last updated 07/31/14 Page 2 of 2 This plan has a limit of 248 dosage units, unless otherwise specified through a quantity limit. Drug Name Preference Details Coverage Details *Alternative Medicines* *Alternative Medicine - M's**-*Alternative Medicine - Me's*** P OTC childrens ibuprofen oral suspension 40 mg/ml P OTC ibuprofen oral suspension 100 mg/5ml P OTC ibuprofen oral tablet 200 mg *Analgesics - Nonnarcotic* P OTC acetaminophen oral solution 160 mg/5ml P OTC acetaminophen oral tablet 325 mg P OTC; QL (279 EA per 31 days) acetaminophen oral tablet 500 mg P OTC; QL (186 EA per 31 days) apap oral tablet 325 mg P OTC; QL (279 EA per 31 days) apap extra strength oral tablet 500 mg P OTC; QL (186 EA per 31 days) childrens non-asa pain relief oral tablet chewable 80 mg P OTC childrens non-aspirin oral tablet chewable 80 mg P OTC childrens pain reliever oral tablet chewable 80 mg P OTC childrens silapap oral liquid† 160 mg/5ml P OTC childrens tactinal oral tablet chewable 80 mg P OTC ed-apap oral liquid† 160 mg/5ml P OTC infants silapap oral solution 100 mg/ml P OTC mapap oral capsule 500 mg P OTC; QL (186 EA per 31 days) mapap oral tablet 325 mg P OTC; QL (279 EA per 31 days) melatonin maximum strength oral tablet 5 mg *Analgesics - Anti-Inflammatory* *Nonsteroidal Anti-Inflammatory Agents (Nsaids)**-*Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** *Analgesics Other**-*Analgesics Other*** P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 1 Drug Name Preference Details Coverage Details mapap oral tablet 500 mg P OTC; QL (186 EA per 31 days) mapap oral tablet chewable 80 mg P OTC mapap arthritis pain oral tablet extendedrelease* 650 mg P OTC; QL (93 EA per 31 days) MAPAP CHILDRENS ORAL SUSPENSION 160 MG/5ML P OTC maxapap maximum strength oral tablet 500 mg P OTC; QL (186 EA per 31 days) maxapap regular strength oral tablet 325 mg P OTC; QL (279 EA per 31 days) non-aspirin oral tablet 325 mg P OTC; QL (279 EA per 31 days) non-aspirin extra strength oral tablet 500 mg P OTC; QL (186 EA per 31 days) non-aspirin pain relief oral tablet 325 mg P OTC; QL (279 EA per 31 days) nortemp infants oral suspension 80 mg/0.8ml P OTC pain & fever childrens oral solution 160 mg/5ml P OTC pain relief oral tablet 500 mg P OTC; QL (186 EA per 31 days) pain relief extra strength oral tablet 500 mg P OTC; QL (186 EA per 31 days) PHARBETOL ORAL TABLET 325 MG P OTC; QL (279 EA per 31 days) PHARBETOL EXTRA STRENGTH ORAL TABLET 500 MG P OTC; QL (186 EA per 31 days) q-pap oral tablet 325 mg P OTC; QL (279 EA per 31 days) tactinal oral tablet 325 mg P OTC; QL (279 EA per 31 days) tactinal extra strength oral tablet 500 mg *Salicylates**-*Salicylate Combinations*** P OTC; QL (186 EA per 31 days) tri-buffered aspirin oral tablet 325 mg *Salicylates**-*Salicylates*** P OTC aspirin oral tablet 325 mg, 81 mg P OTC aspirin oral tablet chewable 81 mg P OTC aspirin oral tablet delayed release 81 mg P OTC aspirin suppository 300 mg, 600 mg P OTC aspirin adult low strength oral tablet delayed release 81 mg P OTC aspirin childrens oral tablet chewable 81 mg P OTC aspirin ec oral tablet delayed release 325 mg, 81 mg P OTC aspirin ec low dose oral tablet delayed release 81 mg P OTC aspirin low dose oral tablet 81 mg P OTC P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 2 Drug Name ECPIRIN ORAL TABLET DELAYED RELEASE 325 MG *Antacids* Preference Details Coverage Details P OTC alamag plus oral tablet chewable 200-200-25 mg P OTC ALMACONE ORAL SUSPENSION 200-200-20 MG/5ML P OTC antacid oral suspension 200-200-20 mg/5ml P OTC antacid anti-gas oral suspension 200-200-20 mg/5ml P OTC antacid anti-gas max strength oral suspension 400-400-40 mg/5ml P OTC antacid extra strength oral suspension 400-400-40 mg/5ml P OTC antacid i oral suspension 200-200-20 mg/5ml P OTC antacid iii oral suspension 400-400-40 mg/5ml P OTC geri-lanta oral suspension 200-200-20 mg/5ml P OTC MAALOX ADVANCED ORAL SUSPENSION 200-200-20 MG/5ML P OTC MAALOX ADVANCED MAX ST ORAL SUSPENSION 400-400-40 MG/5ML P OTC MAALOX MAX ORAL SUSPENSION 400-400-40 MG/5ML P OTC MAALOX MULTI SYMPTOM MAX ST ORAL SUSPENSION 400-400-40 MG/5ML P OTC MAALOX REGULAR STRENGTH ORAL SUSPENSION 200-200-20 MG/5ML P OTC milantex oral suspension 200-200-20 mg/5ml P OTC milantex extra strength oral suspension 400-400-40 mg/5ml P OTC P OTC P OTC *Antacid Combinations**-*Antacid & Simethicone*** MINTOX PLUS ORAL TABLET CHEWABLE 200-200-25 MG *Antacid Combinations**-*Antacid Combinations*** ACID GONE ORAL TABLET CHEWABLE 160-105 MG P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 3 Drug Name gnp foaming antacid oral tablet chewable 80-20 mg Preference Details Coverage Details P OTC P OTC P OTC sodium bicarbonate oral tablet 325 mg, 650 mg *Antacids - Calcium Salts**-*Antacids Calcium Salts*** P OTC alcalak oral tablet chewable 420 mg P OTC antacid oral tablet chewable 420 mg, 500 mg P OTC CAL-GEST ANTACID ORAL TABLET CHEWABLE 500 MG P OTC calcium antacid oral tablet chewable 500 mg P OTC calcium antacid extra strength oral tablet chewable 750 mg P OTC calcium carbonate antacid oral tablet 648 mg P OTC calcium carbonate antacid oral tablet chewable 500 mg P OTC MAALOX ORAL TABLET CHEWABLE 600 MG P OTC P OTC P OTC P OTC MI-ACID ORAL TABLET CHEWABLE 700-300 MG *Antacids - Aluminum Salts**-*Antacids Aluminum Salts*** aluminum hydroxide gel oral suspension 320 mg/5ml *Antacids - Bicarbonate**-*Antacids Bicarbonate*** TITRALAC ORAL TABLET CHEWABLE 420 MG *Antacids - Magnesium Salts**-*Antacids Magnesium Salts*** magnesium oxide oral tablet 250 mg, 400 mg, 420 mg *Anthelmintics* *Anthelmintics**-*Anthelmintics*** reeses pinworm medicine oral suspension 144 mg/ml P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 4 Drug Name Preference Details Coverage Details *Antidiabetics* *Diabetic Other**-*Diabetic Other*** BD GLUCOSE ORAL TABLET CHEWABLE 5 GM P OTC P OTC bismatrol oral suspension 262 mg/15ml P OTC bismatrol oral tablet chewable 262 mg P OTC bismuth oral tablet chewable 262 mg P OTC diotame oral tablet chewable 262 mg P OTC kao-tin oral suspension 262 mg/15ml P OTC KAOPECTATE ORAL SUSPENSION 262 MG/15ML P OTC KAOPECTATE EXTRA STRENGTH ORAL SUSPENSION 525 MG/15ML P OTC pink bismuth oral suspension 262 mg/15ml P OTC pink bismuth oral tablet chewable 262 mg P OTC stomach relief oral suspension 262 mg/15ml, 527 mg/30ml P OTC stomach relief oral tablet chewable 262 mg P OTC stomach relief plus oral suspension 525 mg/15ml *Antiperistaltic Agents**-*Antiperistaltic Agents*** P OTC anti-diarrheal oral liquid† 1 mg/5ml P OTC LOPERAMIDE A-D ORAL TABLET 2 MG P OTC loperamide hcl oral liquid† 1 mg/5ml *Antidotes* P OTC P OTC meclizine hcl oral tablet 12.5 mg, 25 mg P OTC travel sickness oral tablet chewable 25 mg P OTC glucose oral tablet chewable 4 gm *Antidiarrheals* *Antidiarrheal Agents - Misc.**-*Antidiarrheal Agents - Misc.*** *Antidotes**-*Antidotes*** ipecac oral syrup *Antiemetics* *Antiemetics - Anticholinergic**-*Antiemetics Anticholinergic*** P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 5 Drug Name Preference Details Coverage Details *Antihistamines* *Antihistamines Alkylamines**-*Antihistamines Alkylamines*** aller-chlor oral syrup 2 mg/5ml P OTC aller-chlor oral tablet 4 mg P OTC allergy oral tablet 4 mg P OTC allergy relief oral tablet 4 mg P OTC chlorhist oral tablet 4 mg P OTC chlorphen oral tablet 4 mg P OTC P OTC aler-cap oral capsule 25 mg P OTC aler-dryl oral tablet 50 mg P OTC alertab oral tablet 25 mg P OTC allergy relief childrens oral liquid† 12.5 mg/5ml P OTC altaryl oral elixir 12.5 mg/5ml P OTC altaryl oral syrup 12.5 mg/5ml P OTC anti-hist allergy oral tablet 25 mg P OTC BANOPHEN ORAL CAPSULE 25 MG P OTC BANOPHEN ORAL LIQUID† 12.5 MG/5ML P OTC BANOPHEN ORAL TABLET 25 MG P OTC BENADRYL ALLERGY CHILDRENS ORAL LIQUID† 12.5 MG/5ML P OTC complete allergy medication oral tablet 25 mg P OTC complete allergy relief oral tablet 25 mg P OTC diphenhist oral capsule 25 mg P OTC diphenhist oral liquid† 12.5 mg/5ml P OTC diphenhist oral tablet 25 mg P OTC diphenhydramine hcl oral capsule 25 mg, 50 mg P OTC diphenhydramine hcl oral tablet 25 mg P OTC DORMIN ORAL CAPSULE 25 MG P OTC DIABETIC TUSSIN ALLERGY ORAL SYRUP 2 MG/5ML *Antihistamines Ethanolamines**-*Antihistamines Ethanolamines*** P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 6 Drug Name Preference Details Coverage Details genahist oral capsule 25 mg P OTC pharbedryl oral capsule 25 mg, 50 mg P OTC q-dryl oral capsule 25 mg P OTC q-dryl oral liquid† 12.5 mg/5ml P OTC quenalin oral syrup 12.5 mg/5ml P OTC SCOT-TUSSIN ALLERGY RELIEF ORAL LIQUID† 12.5 MG/5ML P OTC siladryl allergy oral liquid† 12.5 mg/5ml P OTC silphen cough oral syrup 12.5 mg/5ml P OTC SIMPLY ALLERGY ORAL TABLET 25 MG P OTC total allergy oral tablet 25 mg P OTC P OTC ALLEGRA ALLERGY CHILDRENS ORAL TABLET 30 MG P OTC allergy oral tablet dispersible 10 mg P OTC cetirizine hcl oral tablet 10 mg, 5 mg P OTC cetirizine hcl childrens oral solution 1 mg/ml P OTC cetirizine hcl childrens alrgy oral syrup 1 mg/ml P OTC childrens loratadine oral syrup 5 mg/5ml P OTC; QL (310 ML per 31 days) fexofenadine hcl oral tablet 180 mg, 60 mg P OTC loratadine oral tablet 10 mg P OTC loratadine hives relief oral solution 5 mg/5ml *Antiseptics & Disinfectants* P OTC; QL (300 ML per 31 days) P OTC; QL (480 ML per 31 days) OPERAND POVIDONE-IODINE EXTERNAL SOLUTION 10 % P OTC povidone-iodine external solution 10 % P OTC TOTAL ALLERGY MEDICINE ORAL LIQUID† 12.5 MG/5ML *Antihistamines Non-Sedating**-*Antihistamines Non-Sedating*** *Chlorine Antiseptics**-*Chlorine Antiseptics*** chlorhexidine gluconate external liquid† 4 % *Iodine Antiseptics**-*Iodine Antiseptics*** P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 7 Drug Name Preference Details Coverage Details *Cough/Cold/Allergy* *Cough/Cold/Allergy Combinations**-*Decongestant & Antihistamine*** ALAVERT ALLERGY/SINUS ORAL TABLET EXTENDED RELEASE 12 HR* 5-120 MG P OTC ALLEGRA-D ALLERGY & CONGESTION ORAL TABLET EXTENDED RELEASE 12 HR* 60-120 MG P OTC allergy relief/nasal decongest oral tablet extended release 24 hr* 10-240 mg P OTC BROTAPP ORAL LIQUID† 1-15 MG/5ML P OTC cetirizine-pseudoephedrine er oral tablet extended release 12 hr* 5-120 mg P OTC fexofenadine-pseudoephed er oral tablet extended release 24 hr* 180-240 mg P OTC Q-TAPP ORAL ELIXIR 1-15 MG/5ML P OTC triprolidine-pse oral tablet 2.5-60 mg *Expectorants**-*Expectorants*** P OTC mucus relief oral tablet 400 mg P OTC refenesen oral tablet 200 mg P OTC refenesen 400 oral tablet 400 mg P OTC robafen oral syrup 100 mg/5ml *Misc. Respiratory Inhalants**-*Misc. Respiratory Inhalants*** P OTC P OTC P OTC acne medication 5 external lotion 5 % P OTC benzoyl peroxide external 10 %, 5 % *Antibiotics - Topical**-*Antibiotic Mixtures Topical*** P OTC P OTC BRONCHO SALINE INHALATION AEROSOL, SOLUTION 0.9 % sodium chloride inhalation nebulization solution 0.9 % *Dermatologicals* *Acne Products**-*Acne Products*** bacitracin-neomycin-polymyxin external ointment 400-5-5000 P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 8 Drug Name double antibiotic external ointment 500-10000 unit/gm Preference Details Coverage Details P OTC P OTC bacitracin external ointment 500 unit/gm P OTC bacitracin zinc external ointment 500 unit/gm *Antifungals - Topical**-*Antifungals Topical*** P OTC terbinafine hcl external cream 1 % *Antifungals - Topical**-*Imidazole-Related Antifungals - Topical*** P OTC clotrimazole external cream 1 % P OTC clotrimazole external solution 1 % *Antihistamines-Topical**-*Antihistamines Topical*** P OTC anti-itch maximum strength external cream 2 % P OTC BENADRYL ITCH STOPPING EXTERNAL 2 % P OTC P OTC AVEENO ANTI-ITCH MAX ST EXTERNAL CREAM 1 % P OTC hydrocortisone external cream 0.5 %, 1 % P OTC hydrocortisone external lotion 1 % P OTC hydrocortisone external ointment 0.5 %, 1 % P OTC hydrocortisone max st external cream 1 % P OTC hydrocortisone max st/12 moist external cream 1 % P OTC HYDROSKIN EXTERNAL CREAM 1 % P OTC kp hydrocortisone external cream 1 % P OTC PREPARATION H HYDROCORTISONE EXTERNAL CREAM 1 % P OTC tgt anti-itch/aloe/vit e external cream 1 % P OTC triple antibiotic external ointment 3.5-400-5000 , 5-400-5000 *Antibiotics - Topical**-*Antibiotics Topical*** itch relief external cream 2 % *Corticosteroids - Topical**-*Corticosteroids Topical*** P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 9 Drug Name Preference Details Coverage Details *Corticosteroids - Topical**-*Topical Steroid Combinations*** hydrocortisone-aloe external cream 1 % P OTC sm hydrocortisone plus external cream 1 % *Emollients**-*Emollients*** P OTC AMLACTIN EXTERNAL LOTION 12 % P OTC; QL (400 GM per 31 days) ammonium lactate external cream 12 % P OTC; QL (400 GM per 31 days) ammonium lactate external lotion 12 % *Keratolytic/Antimitotic Agents**-*Keratolytic/Antimitotic Agents*** P OTC; QL (400 GM per 31 days) CLEAR AWAY 1-STEP WART REMOVER EXTERNAL PAD 40 % P OTC COMPOUND W EXTERNAL LIQUID† 17 % P OTC COMPOUND W MAXIMUM STRENGTH EXTERNAL 17 % P OTC FREEZONE EXTERNAL LIQUID† 17.6 % P OTC P OTC capsaicin external cream 0.025 % *Scabicides & Pediculicides**-*Scabicides & Pediculicides*** P OTC permethrin external lotion 1 % *Gastrointestinal Agents - Misc.* P OTC; QL (60 ML per 31 days) mi-acid gas relief oral tablet chewable 80 mg P OTC mytab gas oral tablet chewable 80 mg P OTC simethicone oral suspension 40 mg/0.6ml P OTC simethicone oral tablet chewable 80 mg *Genitourinary Agents - Miscellaneous* P OTC SALACTIC FILM EXTERNAL SOLUTION 17 % *Local Anesthetics - Topical**-*Local Anesthetics - Topical*** *Antiflatulents**-*Antiflatulents*** *Urinary Analgesics**-*Urinary Analgesics*** phenazopyridine hcl oral tablet 100 mg, 200 mg *Hematopoietic Agents* P *Cobalamins**-*Cobalamins*** cyanocobalamin injection solution 1000 mcg/ml P P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 10 Drug Name Preference Details Coverage Details vitamin b-12 oral tablet 1000 mcg, 500 mcg P OTC vitamin b-12 sublingual tablet sublingual 1000 mcg P OTC P OTC folic acid oral tablet 1 mg, 400 mcg, 800 mcg *Iron**-*Iron*** P OTC ferro-bob oral tablet 325 (65 fe) mg P OTC ferrous sulfate oral elixir 220 (44 fe) mg/5ml P OTC ferrous sulfate oral tablet 325 (65 fe) mg P OTC ferrous sulfate oral tablet delayed release 324 (65 fe) mg, 325 (65 fe) mg P OTC ferrousul oral tablet 325 (65 fe) mg P OTC iron oral tablet 325 (65 fe) mg, 90 (18 fe) mg P OTC POLY-IRON 150 ORAL CAPSULE 150 MG P OTC P OTC acetaminophen pm oral tablet 500-25 mg P OTC; QL (62 EA per 31 Days) headache pm oral tablet 25-500 mg P OTC; QL (62 EA per 31 days) mapap pm oral tablet 500-25 mg P OTC; QL (62 EA per 31 days) pain relief pm extra strength oral tablet 500-25 mg P OTC; QL (62 EA per 31 days) pain reliever pm oral tablet 500-25 mg *Antihistamine Hypnotics**-*Antihistamine Hypnotics*** P OTC; QL (62 EA per 31 days) compoz oral capsule 50 mg P OTC compoz oral tablet 50 mg P OTC NYTOL ORAL TABLET 25 MG P OTC SIMPLY SLEEP ORAL TABLET 25 MG P OTC sleep tabs oral tablet 25 mg P OTC sleep-tabs oral tablet 25 mg P OTC SOMINEX ORAL TABLET 25 MG P OTC vitamin b-12 er oral tablet extendedrelease* 1000 mcg *Folic Acid/Folates**-*Folic Acid/Folates*** slow release iron oral tablet extendedrelease* 160 (50 fe) mg *Hypnotics* *Antihistamine Hypnotics**-*Antihistamine Hypnotic Combinations*** P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 11 Drug Name SOMINEX MAXIMUM STRENGTH ORAL TABLET 50 MG Preference Details Coverage Details P OTC P OTC fiber oral tablet 625 mg P OTC fiber laxative oral tablet 625 mg P OTC fiber therapy oral powder 58.6 % P OTC fiber-lax oral tablet 625 mg P OTC FIBERGEN ORAL TABLET 625 MG P OTC KONSYL ORAL PACKET 100 % P OTC KONSYL FIBER ORAL TABLET 625 MG P OTC METAMUCIL ORAL POWDER 30.9 % P OTC METAMUCIL ORAL WAFER P OTC METAMUCIL MULTIHEALTH FIBER ORAL POWDER 58.6 % P OTC METAMUCIL SMOOTH TEXTURE ORAL PACKET 28 % P OTC METAMUCIL SMOOTH TEXTURE ORAL POWDER 28.3 %, 58.6 % P OTC natural fiber therapy oral powder 30.9 %, 48.57 % P OTC natural vegetable fiber oral powder 48.57 % P OTC REGULOID ORAL CAPSULE 0.52 GM *Laxative Combinations**-*Laxatives & Dss*** P OTC DOC-Q-LAX ORAL TABLET 8.6-50 MG P OTC PERI-COLACE ORAL TABLET 8.6-50 MG P OTC senna plus oral tablet 8.6-50 mg P OTC senna s oral tablet 8.6-50 mg P OTC senna-docusate sodium oral tablet 8.6-50 mg P OTC senna-s oral tablet 8.6-50 mg P OTC senna-time s oral tablet 8.6-50 mg P OTC SENNALAX-S ORAL TABLET 8.6-50 MG P OTC sennosides-docusate sodium oral tablet 8.6-50 mg P OTC tetra-formula nighttime sleep oral tablet 50 mg *Laxatives* *Bulk Laxatives**-*Bulk Laxatives*** P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 12 Drug Name Preference Details Coverage Details *Laxatives - Miscellaneous**-*Laxatives Miscellaneous*** sorbitol oral solution 70 % *Saline Laxatives**-*Saline Laxative Mixtures*** P OTC enema enema 7-19 gm/118ml P OTC P OTC citrate of magnesia oral solution 1.745 gm/30ml P OTC CITROMA ORAL SOLUTION 1.745 GM/30ML P OTC DULCOLAX MILK OF MAGNESIA ORAL SUSPENSION 400 MG/5ML P OTC magnesium citrate oral solution 1.745 gm/30ml P OTC P OTC BISAC-EVAC SUPPOSITORY 10 MG P OTC biscolax suppository 10 mg P OTC CARTERS LITTLE PILLS ORAL TABLET DELAYED RELEASE 5 MG P OTC correct oral tablet delayed release 5 mg P OTC CORRECTOL ORAL TABLET DELAYED RELEASE 5 MG P OTC ducodyl oral tablet delayed release 5 mg P OTC EX-LAX ORAL TABLET CHEWABLE 15 MG P OTC EX-LAX ULTRA ORAL TABLET DELAYED RELEASE 5 MG P OTC FEENAMINT ORAL TABLET DELAYED RELEASE 5 MG P OTC FLEET LAXATIVE ORAL TABLET DELAYED RELEASE 5 MG P OTC gentle laxative oral tablet delayed release 5 mg P OTC laxative suppository 10 mg P OTC natural senna laxative oral tablet 64.8-324 mg P OTC sm oral saline laxative oral solution 2.7-7.2 gm/5ml *Saline Laxatives**-*Saline Laxatives*** milk of magnesia oral suspension 400 mg/5ml, 7.75 % *Stimulant Laxatives**-*Stimulant Laxatives*** P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 13 Drug Name Preference Details Coverage Details senexon oral liquid† 8.8 mg/5ml P OTC senexon oral tablet 8.6 mg P OTC senna oral syrup 8.8 mg/5ml P OTC senna oral tablet 15 mg, 8.6 mg P OTC senna lax oral tablet 8.6 mg P OTC senna laxative oral tablet 8.6 mg P OTC senna maximum strength oral tablet 25 mg P OTC SENNA SMOOTH ORAL TABLET 15 MG P OTC senna-lax oral tablet 8.6 mg P OTC senna-tabs oral tablet 8.6 mg P OTC senna-time oral tablet 8.6 mg P OTC SENNACON ORAL TABLET 8.6 MG P OTC SENNO ORAL TABLET 8.6 MG P OTC stimulant laxative oral tablet delayed release 5 mg P OTC P OTC CORRECTOL EXTRA GENTLE ORAL CAPSULE 100 MG P OTC d.o.s. oral capsule 250 mg P OTC diocto oral liquid† 50 mg/5ml P OTC diocto oral syrup 60 mg/15ml P OTC docqlace oral capsule 100 mg P OTC docu soft oral capsule 100 mg P OTC docusate sodium oral tablet 100 mg P OTC DOCUSIL ORAL CAPSULE 100 MG P OTC dok oral capsule 100 mg, 250 mg P OTC dok oral tablet 100 mg P OTC dss oral capsule 100 mg, 250 mg P OTC DULCOLAX STOOL SOFTENER ORAL CAPSULE 100 MG P OTC kao-tin oral capsule 240 mg P OTC laxa basic oral capsule 100 mg P OTC silace oral liquid† 150 mg/15ml P OTC womens laxative oral tablet delayed release 5 mg *Surfactant Laxatives**-*Surfactant Laxatives*** silace oral syrup 60 mg/15ml P OTC P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 14 Drug Name Preference Details Coverage Details SOF-LAX ORAL CAPSULE 100 MG P OTC stool softener oral capsule 100 mg, 250 mg P OTC stool softener laxative dc oral capsule 240 mg P OTC sur-q-lax oral capsule 240 mg P OTC SURFAK ORAL CAPSULE 240 MG *Medical Devices* P OTC ACE AEROSOL CLOUD ENHANCER P QL (2 EA per 365 days) IN-CHECK DIAL FLOW TRAINER DEVICE P QL (2 EA per 365 days) PFLEX P QL (2 EA per 365 days) THRESHOLD IMT P QL (2 EA per 365 days) THRESHOLD PEP DEVICE P QL (2 EA per 365 days) WINDMILL TRAINER *Respiratory Therapy Supplies**-*Spacer/Aerosol-Holding Chambers & Supplies*** P QL (2 EA per 365 days) AEROCHAMBER MV P QL (2 EA per 365 days) AEROCHAMBER PLUS FLO-VU P QL (2 EA per 365 days) AEROCHAMBER PLUS FLO-VU LARGE P QL (2 EA per 365 days) AEROCHAMBER PLUS FLO-VU SMALL P QL (2 EA per 365 days) AEROCHAMBER PLUS FLO-VU W/MASK P QL (2 EA per 365 days) AEROCHAMBER W/FLOWSIGNAL P QL (2 EA per 365 days) AEROCHAMBER Z-STAT PLUS P QL (2 EA per 365 days) AEROCHAMBER Z-STAT PLUS CHAMBR P QL (2 EA per 365 days) EASIVENT P QL (2 EA per 365 days) MICROCHAMBER P QL (2 EA per 365 days) MICROSPACER P QL (2 EA per 365 days) OPTICHAMBER ADVANTAGE P QL (2 EA per 365 days) OPTIHALER P QL (2 EA per 365 days) OPTIHALER DEVICE P QL (2 EA per 365 days) POCKET CHAMBER DEVICE P QL (2 EA per 365 days) POCKET SPACER DEVICE P QL (2 EA per 365 days) *Respiratory Therapy Supplies**-*Respiratory Therapy Supplies*** P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 15 Drug Name WATCHHALER DEVICE *Minerals & Electrolytes* Preference Details Coverage Details P QL (2 EA per 365 days) calcium oral tablet 500-125 mg-unit P OTC calcium + d3 oral tablet 600-200 mg-unit P OTC calcium 600-d oral tablet 600-400 mg-unit P OTC calcium carbonate-vitamin d oral tablet 500-400 mg-unit, 600-400 mg-unit P OTC calcium high potency/vitamin d oral tablet 600-200 mg-unit P OTC calcium-carb 600 + d oral tablet 600-125 mg-unit P OTC calcium-vitamin d oral tablet 500-125 mg-unit, 600-125 mg-unit, 600-200 mg-unit P OTC CALTRATE 600+D ORAL TABLET 600-800 MG-UNIT P OTC liquid calcium/vitamin d oral capsule 600-200 mg-unit P OTC OYSCO 500+D ORAL TABLET 500-200 MG-UNIT P OTC OYSCO D ORAL TABLET 250-125 MG-UNIT P OTC oyst-cal d oral tablet 250-125 mg-unit P OTC oyster calcium + d oral tablet 250-125 mg-unit P OTC oyster shell calcium + d oral tablet 500-400 mg-unit P OTC oyster shell calcium 500 + d oral tablet 500-125 mg-unit P OTC oyster shell calcium/d oral tablet 250-125 mg-unit, 500-200 mg-unit P OTC oyster shell calcium/vitamin d oral tablet 500-200 mg-unit P OTC P OTC CAL-CARB FORTE ORAL TABLET 1250 MG P OTC cal-lac oral capsule 500 mg P OTC *Calcium**-*Calcium Combinations*** oyster shell/vitamin d oral tablet 600-125 mg-unit *Calcium**-*Calcium*** P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 16 Drug Name Preference Details Coverage Details calcarb 600 oral tablet 1500 mg P OTC CALCI-CHEW ORAL TABLET CHEWABLE 1250 MG P OTC calcium oral tablet 600 mg P OTC calcium 600 oral tablet 600 mg P OTC calcium carbonate oral suspension 1250 mg/5ml P OTC calcium carbonate oral tablet 1250 mg, 600 mg P OTC calcium high potency oral tablet 600 mg P OTC calcium lactate oral tablet 648 mg P OTC calcium oyster shell oral tablet 1250 mg P OTC calcium-carb 600 oral tablet 600 mg P OTC CALTRATE 600 ORAL TABLET 1500 MG P OTC OYSCO 500 ORAL TABLET 500 MG P OTC OYSTERCAL ORAL TABLET 500 MG *Electrolyte Mixtures**-*Electrolytes Oral*** P OTC ORALYTE ORAL SOLUTION *Magnesium**-*Magnesium*** P OTC; QL (4000 ML per 31 days) mag-delay oral tablet extendedrelease* 535 (64 mg) mg P OTC mag-sr oral tablet extendedrelease* 535 (64 mg) mg P OTC MAG-TAB SR ORAL TABLET EXTENDEDRELEASE* 84 MG (7MEQ) P OTC MAG64 ORAL TABLET EXTENDEDRELEASE* 535 (64 MG) MG P OTC magnacaps oral capsule 100 mg P OTC magnesium oral tablet 250 mg P OTC magnesium oxide oral tablet 400 (240 mg) mg P OTC P OTC ORAZINC ORAL CAPSULE 220 MG P OTC zinc sulfate oral capsule 220 mg P OTC zinc sulfate oral tablet 220 (50 zn) mg P OTC zinc-220 oral capsule 220 mg P OTC MAGNESIUM-OXIDE ORAL TABLET 400 (241.3 MG) MG *Zinc**-*Zinc*** P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 17 Drug Name Preference Details Coverage Details *Multivitamins* *B-Complex W/ C**-*B-Complex W/ C*** vitamin b complex-c oral capsule *B-Complex W/ Folic Acid**-*B-Complex W/ C & Folic Acid*** P OTC NEPHRONEX ORAL TABLET P rena-vite rx oral tablet 1 mg P RENAL ORAL CAPSULE 1 MG P reno caps oral capsule 1 mg *Multiple Vitamins W/ Minerals**-*Multiple Vitamins W/ Minerals*** P centamin oral liquid† P OTC centavite oral liquid† P OTC centavite a-z complete-mineral oral tablet P OTC CEROVITE ADVANCED FORMULA ORAL TABLET P OTC CERTAVITE/ANTIOXIDANTS ORAL LIQUID† P OTC formula twenty-one oral tablet P OTC gerivite complete oral tablet P OTC golden age vitamin/minerals oral liquid† P OTC multivitamin & mineral oral liquid† P OTC SUPER NU-THERA ORAL TABLET P OTC thera vital m oral tablet P OTC therabasic-m oral tablet P OTC therapeutic liquid oral solution P OTC therapeutic-m oral tablet P OTC TOTAL FORMULA 3 ORAL TABLET *Multivitamins**-*Multivitamins*** P OTC daily multiple vitamins oral tablet P OTC daily vite oral tablet P OTC daily vites oral tablet P OTC multi-day oral tablet P OTC multi-vitamin oral tablet P OTC multi-vitamins oral tablet P OTC once daily oral tablet P OTC P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 18 Drug Name Preference Details Coverage Details one-daily multi vitamins oral tablet P OTC THERA ORAL TABLET P OTC thera-tabs oral tablet P OTC THERA/BETA-CAROTENE ORAL TABLET P OTC P OTC therapeutic oral tablet *Ped Mv W/ Fluoride**-*Ped Mv W/ Fluoride*** multi-vit/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml P multi-vitamin/fluoride oral tablet chewable 0.5 mg P multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg P multivitamins/fluoride oral tablet chewable 0.25 mg *Ped Mv W/ Iron**-*Ped Mv W/ Iron*** P polyvitamin/iron oral solution 10 mg/ml *Pediatric Multiple Vitamins**-*Pediatric Multiple Vitamins W/ C*** P OTC poly-vitamin oral solution 35 mg/ml *Pediatric Vitamins**-*Pediatric Vitamins A & D W/ C*** P OTC tri-vitamin oral solution 1500-400-35 *Prenatal Vitamins**-*Prenatal Mv & Min W/Fe-Fa*** P OTC prenatal low iron oral tablet 27-0.8 mg *Specialty Vitamins Products**-*Specialty Vitamins Products*** P OTC vitamins for hair oral tablet *Nasal Agents - Systemic And Topical* P OTC altamist spray nasal solution 0.65 % P OTC AYR NASAL SOLUTION 0.65 % P OTC deep sea nasal spray nasal solution 0.65 % P OTC HUMIST NASAL SOLUTION 0.65 % P OTC *Nasal Agents - Misc.**-*Nasal Agents Misc.*** P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 19 Drug Name Preference Details Coverage Details LITTLE NOSES SALINE NASAL SOLUTION 0.65 % P OTC na-zone nasal solution 0.65 % P OTC NASAL MOIST NASAL SOLUTION 0.65 % P OTC OCEAN FOR KIDS NASAL SOLUTION 0.65 % P OTC saline mist spray nasal solution 0.65 % P OTC saline nasal spray nasal solution 0.65 % P OTC sea soft nasal mist nasal solution 0.65 % *Nasal Antiallergy**-*Nasal Mast Cell Stabilizers*** P OTC P OTC P OTC P OTC P OTC P OTC P OTC tears again ophthalmic solution *Artificial Tears And Lubricants**-*Artificial Tears And Lubricants*** P OTC artificial tears ophthalmic solution 1.4 % P OTC; QL (15 ML per 31 days) liquitears ophthalmic solution 1.4 % P OTC; QL (15 ML per 31 Days) polyvinyl alcohol ophthalmic solution 1.4 % P OTC; QL (15 ML per 31 Days) cromolyn sodium nasal aerosol, solution 5.2 mg/act *Sympathomimetic Decongestants**-*Systemic Decongestants*** pseudoephedrine hcl oral tablet 30 mg, 60 mg *Ophthalmic Agents* *Artificial Tears And Lubricants**-*Artificial Tear And Lubricant Combinations*** artificial tears ophthalmic ointment 83-15 % HYPOTEARS OPHTHALMIC SOLUTION 1-1 % *Artificial Tears And Lubricants**-*Artificial Tear Ointments*** tears again ophthalmic ointment ULTRA FRESH PM OPHTHALMIC OINTMENT *Artificial Tears And Lubricants**-*Artificial Tear Solutions*** P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 20 Drug Name Preference Details Coverage Details *Ophthalmics - Misc.**-*Ophthalmic Antiallergic*** ALAWAY OPHTHALMIC SOLUTION 0.025 % P OTC P OTC auraphene-b otic solution 6.5 % P OTC AURO EARDROPS OTIC SOLUTION 6.5 % P OTC E-R-O EAR DROPS OTIC SOLUTION 6.5 % P OTC E-R-O EAR WAX REMOVAL SYSTEM OTIC SOLUTION 6.5 % P OTC ear drops earwax aid otic solution 6.5 % P OTC earwax treatment drops otic solution 6.5 % P OTC MURINE EAR OTIC SOLUTION 6.5 % P OTC MURINE EAR WAX REMOVAL SYSTEM OTIC SOLUTION 6.5 % P OTC OTIX OTIC SOLUTION 6.5 % P OTC thera-ear otic solution 6.5 % *Psychotherapeutic And Neurological Agents Misc.* P OTC nicotine transdermal patch 24 hr 14 mg/24hr, 21 mg/24hr, 7 mg/24hr P OTC; QL (70 EA per 365 days) nicotine polacrilex mouth/throat gum 2 mg, 4 mg P OTC; QL (4032 EA per 365 days) acid reducer oral tablet 75 mg P OTC cimetidine oral tablet 200 mg P OTC famotidine oral tablet 10 mg P OTC ketotifen fumarate ophthalmic solution 0.025 % *Otic Agents* *Otic Agents - Miscellaneous**-*Otic Agents Miscellaneous*** *Smoking Deterrents**-*Smoking Deterrents*** *Ulcer Drugs* *H-2 Antagonists**-*H-2 Antagonists*** P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 21 Drug Name Preference Details Coverage Details *Proton Pump Inhibitors**-*Proton Pump Inhibitors*** P OTC GYNE-LOTRIMIN 3 VAGINAL CREAM 2 % P OTC miconazole 3 combo pack vaginal kit 200-2 mg-% (9gm) P OTC miconazole nitrate vaginal cream 2 % P OTC miconazole nitrate vaginal suppository 100 mg P OTC MONISTAT 3 VAGINAL CREAM 4 % *Vitamins* P OTC P OTC CALCIFEROL ORAL SOLUTION 8000 UNIT/ML P OTC vitamin d oral capsule 1000 unit, 400 unit P OTC vitamin d oral tablet 400 unit P OTC vitamin d (ergocalciferol) oral capsule 50000 unit P QL (4 EA per 28 days) vitamin d-400 oral tablet 400 unit P OTC vitamin d3 oral capsule 2000 unit P OTC vitamin d3 oral tablet 1000 unit, 400 unit P OTC vitamin d3 oral tablet chewable 400 unit *Oil Soluble Vitamins**-*Vitamin E*** P OTC vitamin e oral capsule 400 unit P OTC vitamin e oral tablet chewable 400 unit *Oil Soluble Vitamins**-*Vitamin K*** P OTC vitamin k (phytonadione) oral tablet 100 mcg *Water Soluble Vitamins**-*Vitamin B-1*** P OTC vitamin b-1 oral tablet 100 mg, 250 mg, 50 mg *Water Soluble Vitamins**-*Vitamin B-2*** P OTC vitamin b-2 oral tablet 100 mg P OTC omeprazole oral tablet delayed release 20 mg *Vaginal Products* *Vaginal Anti-Infectives**-*Imidazole-Related Antifungals*** *Oil Soluble Vitamins**-*Vitamin A*** vitamin a oral capsule 10000 unit, 8000 unit *Oil Soluble Vitamins**-*Vitamin D*** P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 22 Drug Name Preference Details Coverage Details *Water Soluble Vitamins**-*Vitamin B-3*** niacin oral tablet 100 mg, 250 mg, 50 mg, 500 mg P OTC niacin er oral capsule extended release* 250 mg P OTC niacin er oral tablet extendedrelease* 250 mg *Water Soluble Vitamins**-*Vitamin B-6*** P OTC P OTC P OTC ascorbic acid oral tablet 1000 mg, 250 mg, 500 mg P OTC ascorbic acid oral tablet chewable 250 mg P OTC c-500 oral tablet chewable 500 mg P OTC vitamin c oral syrup 500 mg/5ml P OTC vitamin c oral tablet 100 mg, 1000 mg, 250 mg, 500 mg P OTC vitamin c oral tablet chewable 100 mg, 250 mg P OTC vitamin b-6 oral tablet 100 mg, 25 mg, 250 mg, 50 mg, 500 mg vitamin b-6 er oral tablet extendedrelease* 200 mg *Water Soluble Vitamins**-*Vitamin C*** P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 23 P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 24 Index ACE AEROSOL CLOUD ENHANCER ............................................................................................... acetaminophen allergy relief ................................................................................................... 15 ................................................................................................... ................................................................................................... acetaminophen pm ............................................................................................... ACID GONE allergy relief childrens 1 allergy relief/nasal decongest ................................................................................................... 11 ................................................................................................... 3 acid reducer ......................................................... 21 acne medication 5 ................................................................................................... 8 AEROCHAMBER MV ............................................................................................... 15 AEROCHAMBER PLUS FLO-VU ................................................................. 15 AEROCHAMBER PLUS FLO-VU LARGE ............................................................................................... 15 AEROCHAMBER PLUS FLO-VU SMALL ............................................................................................... 15 AEROCHAMBER PLUS FLO-VU W/MASK ............................................................................................... 15 AEROCHAMBER W/FLOWSIGNAL ............................................................................................... 15 AEROCHAMBER Z-STAT PLUS ........................................................................... 15 AEROCHAMBER Z-STAT PLUS CHAMBR ............................................................................................... 15 alamag plus ............................................................. 3 ALAVERT ALLERGY/SINUS ................................................................................................... 8 ALAWAY ........................................................... 21 alcalak ............................................................................ 4 aler-cap ......................................................................... 6 aler-dryl ........................................................................ 6 alertab ............................................................................ 6 ALLEGRA ALLERGY CHILDRENS ................................................................................................... 7 ALLEGRA-D ALLERGY & CONGESTION ................................................................................................... 8 aller-chlor .................................................................. 6 allergy ............................................................................. 6 ALMACONE ................................................................................................... altamist spray 6 6 8 3 ............................................................................................... 19 altaryl .............................................................................. 6 aluminum hydroxide gel ................................................................................................... 4 AMLACTIN ............................................................................................... 10 ammonium lactate ............................................................................................... 10 antacid ............................................................................ 3 antacid anti-gas ................................................................................................... 3 antacid anti-gas max strength ................................................................................................... 3 antacid extra strength ................................................................................................... 3 antacid i ........................................................................ 3 antacid iii .................................................................... 3 anti-diarrheal ................................................................................................... 5 anti-hist allergy ................................................................................................... 6 anti-itch maximum strength ................................................................................................... 9 apap ................................................................................... 1 apap extra strength ................................................................................................... 1 artificial tears ............................................................................................... 20 ascorbic acid ............................................................................................... 23 aspirin ............................................................................. 2 aspirin adult low strength ................................................................................................... 2 aspirin childrens ................................................................................................... 2 aspirin ec ..................................................................... 2 aspirin ec low dose ................................................................................................... 2 aspirin low dose ................................................................................................... 2 auraphene-b ......................................................... 21 AURO EARDROPS 21 AVEENO ANTI-ITCH MAX ST ......................................................................................... 9 AYR ............................................................................. 19 bacitracin ................................................................... 9 bacitracin zinc ................................................................................................... 9 bacitracin-neomycin-polymyxin ................................................................................................... 8 BANOPHEN ................................................................................................... 6 BD GLUCOSE ................................................................................................... 5 BENADRYL ALLERGY CHILDRENS ................................................................................................... 6 BENADRYL ITCH STOPPING ........................................................... 9 benzoyl peroxide ................................................................................................... 8 BISAC-EVAC ............................................................................................... 13 biscolax ..................................................................... 13 bismatrol ..................................................................... 5 bismuth .......................................................................... 5 BRONCHO SALINE ................................................................................................... 8 BROTAPP .............................................................. 8 c-500 .............................................................................. 23 calcarb 600 ........................................................... 17 CAL-CARB FORTE ............................................................................................... 16 CALCI-CHEW ............................................................................................... 17 CALCIFEROL ............................................................................................... 22 calcium ....................................................................... 16 calcium + d3 ............................................................................................... 16 calcium 600 .......................................................... 17 calcium 600-d ............................................................................................... 16 calcium antacid ................................................................................................... 4 calcium antacid extra strength ................................................................................................... 4 calcium carbonate ............................................................................................... 17 ............................................................................................... P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 25 calcium carbonate antacid ................................................................................................... calcium carbonate-vitamin d ............................................................................................... calcium high potency ............................................................................................... calcium high potency/vitamin d ............................................................................................... calcium lactate ............................................................................................... calcium oyster shell ............................................................................................... calcium-carb 600 ............................................................................................... calcium-carb 600 + d ............................................................................................... calcium-vitamin d ............................................................................................... CAL-GEST ANTACID 4 16 17 16 17 17 17 16 16 ................................................................................................... 4 cal-lac .......................................................................... 16 CALTRATE 600 ............................................................................................... 17 CALTRATE 600+D ............................................................................................... 16 capsaicin .................................................................. 10 CARTERS LITTLE PILLS ............................................................................................... 13 centamin ................................................................... 18 centavite ................................................................... 18 centavite a-z complete-mineral ............................................................................................... 18 CEROVITE ADVANCED FORMULA ............................................................................................... 18 CERTAVITE/ANTIOXIDANT S .......................................................................................... 18 cetirizine hcl ................................................................................................... 7 cetirizine hcl childrens ................................................................................................... 7 cetirizine hcl childrens alrgy ................................................................................................... 7 cetirizine-pseudoephedrine er ................................................................................................... 8 childrens ibuprofen ................................................................................................... 1 childrens loratadine ................................................................................................... 7 childrens non-asa pain relief ................................................................................................... 1 childrens non-aspirin ................................................................................................... childrens pain reliever ................................................................................................... childrens silapap ................................................................................................... childrens tactinal ................................................................................................... chlorhexidine gluconate 1 1 1 1 ................................................................................................... 7 chlorhist ........................................................................ 6 chlorphen .................................................................... 6 cimetidine ............................................................... 21 citrate of magnesia ............................................................................................... 13 CITROMA ......................................................... 13 CLEAR AWAY 1-STEP WART REMOVER ............................................................................................... 10 clotrimazole ............................................................ 9 complete allergy medication ................................................................................................... 6 complete allergy relief ................................................................................................... 6 COMPOUND W ............................................................................................... 10 COMPOUND W MAXIMUM STRENGTH ............................................................................................... 10 compoz ....................................................................... 11 correct ......................................................................... 13 CORRECTOL ............................................................................................... 13 CORRECTOL EXTRA GENTLE .............................................................. 14 cromolyn sodium ............................................................................................... 20 cyanocobalamin ............................................................................................... 10 d.o.s. .............................................................................. 14 daily multiple vitamins ............................................................................................... 18 daily vite .................................................................. 18 daily vites ................................................................ 18 deep sea nasal spray ............................................................................................... 19 DIABETIC TUSSIN ALLERGY ............................................................ 6 diocto ............................................................................ 14 diotame .......................................................................... 5 diphenhist ................................................................... 6 diphenhydramine hcl 6 docqlace .................................................................... 14 DOC-Q-LAX ............................................................................................... 12 docu soft ................................................................... 14 docusate sodium ............................................................................................... 14 DOCUSIL ........................................................... 14 dok ................................................................................... 14 DORMIN ................................................................ 6 double antibiotic ................................................................................................... 9 dss ..................................................................................... 14 ducodyl ....................................................................... 13 DULCOLAX MILK OF MAGNESIA ............................................................................................... 13 DULCOLAX STOOL SOFTENER ............................................................................................... 14 ear drops earwax aid ............................................................................................... 21 earwax treatment drops ............................................................................................... 21 EASIVENT ............................................................................................... 15 ECPIRIN .................................................................. 3 ed-apap .......................................................................... 1 enema ........................................................................... 13 E-R-O EAR DROPS ............................................................................................... 21 E-R-O EAR WAX REMOVAL SYSTEM ............................................................... 21 EX-LAX ................................................................. 13 EX-LAX ULTRA ............................................................................................... 13 famotidine .............................................................. 21 FEENAMINT ............................................................................................... 13 ferro-bob .................................................................. 11 ferrous sulfate ............................................................................................... 11 ferrousul ................................................................... 11 fexofenadine hcl ................................................................................................... 7 fexofenadine-pseudoephed er ................................................................................................... 8 fiber ................................................................................ 12 fiber laxative ............................................................................................... 12 ................................................................................................... P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 26 fiber therapy ............................................................................................... FIBERGEN 12 ............................................................................................... 12 fiber-lax .................................................................... 12 FLEET LAXATIVE ............................................................................................... 13 folic acid .................................................................. 11 formula twenty-one ............................................................................................... 18 FREEZONE ............................................................................................... 10 genahist ......................................................................... 7 gentle laxative ............................................................................................... 13 geri-lanta .................................................................... 3 gerivite complete ............................................................................................... 18 glucose ............................................................................ 5 gnp foaming antacid ................................................................................................... 4 golden age vitamin/minerals ............................................................................................... 18 GYNE-LOTRIMIN 3 ............................................................................................... 22 headache pm ............................................................................................... 11 HUMIST ............................................................... 19 hydrocortisone ................................................................................................... 9 hydrocortisone max st ................................................................................................... 9 hydrocortisone max st/12 moist ................................................................................................... 9 hydrocortisone-aloe ............................................................................................... 10 HYDROSKIN ................................................................................................... 9 HYPOTEARS ............................................................................................... 20 ibuprofen ..................................................................... 1 IN-CHECK DIAL FLOW TRAINER .......................................................... 15 infants silapap ................................................................................................... 1 ipecac ............................................................................... 5 iron .................................................................................. 11 itch relief ..................................................................... 9 KAOPECTATE ................................................................................................... 5 KAOPECTATE EXTRA STRENGTH 5 kao-tin ............................................................................ 5 ketotifen fumarate ............................................................................................... 21 KONSYL .............................................................. 12 KONSYL FIBER ............................................................................................... 12 kp hydrocortisone ................................................................................................... 9 laxa basic ................................................................ 14 laxative ...................................................................... 13 liquid calcium/vitamin d ............................................................................................... 16 liquitears .................................................................. 20 LITTLE NOSES SALINE ............................................................................................... 20 LOPERAMIDE A-D ................................................................................................... 5 loperamide hcl ................................................................................................... 5 loratadine ................................................................... 7 loratadine hives relief ................................................................................................... 7 MAALOX ............................................................... 4 MAALOX ADVANCED ................................................................................................... 3 MAALOX ADVANCED MAX ST ......................................................................................... 3 MAALOX MAX ................................................................................................... 3 MAALOX MULTI SYMPTOM MAX ST .................................................................... 3 MAALOX REGULAR STRENGTH ................................................................................................... 3 MAG64 .................................................................... 17 mag-delay .............................................................. 17 magnacaps ............................................................ 17 magnesium ............................................................ 17 magnesium citrate ............................................................................................... 13 magnesium oxide ................................................................................................... 4 MAGNESIUM-OXIDE ............................................................................................... 17 mag-sr ......................................................................... 17 MAG-TAB SR ............................................................................................... 17 mapap ...................................................................... 1, 2 ................................................................................................... mapap arthritis pain ................................................................................................... MAPAP CHILDRENS 2 ................................................................................................... 2 mapap pm ............................................................... 11 maxapap maximum strength ................................................................................................... 2 maxapap regular strength ................................................................................................... 2 meclizine hcl ................................................................................................... 5 melatonin maximum strength ................................................................................................... 1 METAMUCIL ............................................................................................... 12 METAMUCIL MULTIHEALTH FIBER ............................................................................................... 12 METAMUCIL SMOOTH TEXTURE ......................................................... 12 MI-ACID ................................................................. 4 mi-acid gas relief ............................................................................................... 10 miconazole 3 combo pack ............................................................................................... 22 miconazole nitrate ............................................................................................... 22 MICROCHAMBER ............................................................................................... 15 MICROSPACER ............................................................................................... 15 milantex ....................................................................... 3 milantex extra strength ................................................................................................... 3 milk of magnesia ............................................................................................... 13 MINTOX PLUS ................................................................................................... 3 MONISTAT 3 ............................................................................................... 22 mucus relief ............................................................. 8 multi-day ................................................................. 18 multi-vit/fluoride ............................................................................................... 19 multi-vitamin ............................................................................................... 18 multivitamin & mineral ............................................................................................... 18 multivitamin/fluoride ............................................................................................... 19 multi-vitamin/fluoride ............................................................................................... 19 P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 27 multi-vitamins ............................................................................................... multivitamins/fluoride ............................................................................................... MURINE EAR ............................................................................................... MURINE EAR WAX REMOVAL SYSTEM 18 19 21 21 mytab gas ............................................................... 10 NASAL MOIST ............................................................................................... 20 natural fiber therapy ............................................................................................... 12 natural senna laxative ............................................................................................... 13 natural vegetable fiber ............................................................................................... 12 na-zone ....................................................................... 20 NEPHRONEX ............................................................................................... 18 niacin ............................................................................ 23 niacin er .................................................................... 23 nicotine ...................................................................... 21 nicotine polacrilex ............................................................................................... 21 non-aspirin ................................................................ 2 non-aspirin extra strength ................................................................................................... 2 non-aspirin pain relief ................................................................................................... 2 nortemp infants ................................................................................................... 2 NYTOL ................................................................... 11 OCEAN FOR KIDS ............................................................................................... 20 omeprazole ........................................................... 22 once daily ................................................................ 18 one-daily multi vitamins ............................................................................................... 19 OPERAND POVIDONE-IODINE ................................................................................................... 7 OPTICHAMBER ADVANTAGE ............................................................................................... 15 OPTIHALER ............................................................................................... 15 ORALYTE ......................................................... 17 ORAZINC .......................................................... 17 OTIX ........................................................................... 21 ............................................................................................... OYSCO 500 ............................................................................................... OYSCO 500+D 17 ............................................................................................... 16 OYSCO D ............................................................ 16 oyst-cal d ................................................................. 16 oyster calcium + d ............................................................................................... 16 oyster shell calcium + d ............................................................................................... 16 oyster shell calcium 500 + d ............................................................................................... 16 oyster shell calcium/d ............................................................................................... 16 oyster shell calcium/vitamin d ............................................................................................... 16 oyster shell/vitamin d ............................................................................................... 16 OYSTERCAL ............................................................................................... 17 pain & fever childrens ................................................................................................... 2 pain relief ................................................................... 2 pain relief extra strength ................................................................................................... 2 pain relief pm extra strength ............................................................................................... 11 pain reliever pm ............................................................................................... 11 PERI-COLACE ............................................................................................... 12 permethrin ............................................................. 10 PFLEX ..................................................................... 15 pharbedryl ................................................................. 7 PHARBETOL ................................................................................................... 2 PHARBETOL EXTRA STRENGTH ................................................................................................... 2 phenazopyridine hcl ............................................................................................... 10 pink bismuth ................................................................................................... 5 POCKET CHAMBER ............................................................................................... 15 POCKET SPACER ............................................................................................... 15 POLY-IRON 150 ............................................................................................... 11 polyvinyl alcohol ............................................................................................... 20 poly-vitamin ........................................................ 19 polyvitamin/iron ............................................................................................... povidone-iodine 19 ................................................................................................... prenatal low iron ............................................................................................... PREPARATION H HYDROCORTISONE 19 ................................................................................................... pseudoephedrine hcl 7 9 ............................................................................................... 20 q-dryl ................................................................................ 7 q-pap ................................................................................. 2 Q-TAPP ...................................................................... 8 quenalin ........................................................................ 7 reeses pinworm medicine ................................................................................................... 4 refenesen ...................................................................... 8 refenesen 400 ................................................................................................... 8 REGULOID ............................................................................................... 12 RENAL ................................................................... 18 rena-vite rx ........................................................... 18 reno caps .................................................................. 18 robafen ........................................................................... 8 SALACTIC FILM ............................................................................................... 10 saline mist spray ............................................................................................... 20 saline nasal spray ............................................................................................... 20 SCOT-TUSSIN ALLERGY RELIEF ...................................................................... 7 sea soft nasal mist ............................................................................................... 20 senexon ...................................................................... 14 senna ............................................................................. 14 senna lax .................................................................. 14 senna laxative ............................................................................................... 14 senna maximum strength ............................................................................................... 14 senna plus ............................................................... 12 senna s ........................................................................ 12 SENNA SMOOTH ............................................................................................... 14 SENNACON ............................................................................................... 14 senna-docusate sodium ............................................................................................... 12 senna-lax ................................................................. 14 P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 28 SENNALAX-S ............................................................................................... 12 senna-s ........................................................................ 12 senna-tabs .............................................................. 14 senna-time ............................................................. 14 senna-time s ......................................................... 12 SENNO ................................................................... 14 sennosides-docusate sodium ............................................................................................... 12 silace ............................................................................. 14 siladryl allergy ................................................................................................... 7 silphen cough ................................................................................................... 7 simethicone ........................................................... 10 SIMPLY ALLERGY ................................................................................................... 7 SIMPLY SLEEP ............................................................................................... 11 sleep tabs ................................................................. 11 sleep-tabs ................................................................ 11 slow release iron ............................................................................................... 11 sm hydrocortisone plus ............................................................................................... 10 sm oral saline laxative ............................................................................................... 13 sodium bicarbonate ................................................................................................... 4 sodium chloride ................................................................................................... 8 SOF-LAX ............................................................. 15 SOMINEX .......................................................... 11 SOMINEX MAXIMUM STRENGTH ............................................................................................... 12 sorbitol ....................................................................... 13 stimulant laxative ............................................................................................... 14 stomach relief ................................................................................................... 5 stomach relief plus ................................................................................................... 5 stool softener ............................................................................................... 15 stool softener laxative dc ............................................................................................... 15 SUPER NU-THERA ............................................................................................... 18 SURFAK .............................................................. 15 sur-q-lax ................................................................... 15 tactinal ........................................................................... 2 tactinal extra strength ................................................................................................... 2 tears again ............................................................. 20 terbinafine hcl ................................................................................................... 9 tetra-formula nighttime sleep ............................................................................................... 12 tgt anti-itch/aloe/vit e ................................................................................................... 9 THERA ................................................................... 19 thera vital m ............................................................................................... 18 THERA/BETA-CAROTENE ............................................................................................... 19 therabasic-m ............................................................................................... 18 thera-ear .................................................................. 21 therapeutic ............................................................ 19 therapeutic liquid ............................................................................................... 18 therapeutic-m ............................................................................................... 18 thera-tabs ............................................................... 19 THRESHOLD IMT ............................................................................................... 15 THRESHOLD PEP ............................................................................................... 15 TITRALAC ................................................................................................... 4 total allergy ............................................................. 7 TOTAL ALLERGY MEDICINE ................................................................................................... 7 TOTAL FORMULA 3 ............................................................................................... 18 travel sickness ................................................................................................... 5 tri-buffered aspirin ................................................................................................... 2 triple antibiotic ................................................................................................... 9 triprolidine-pse ................................................................................................... 8 tri-vitamin .............................................................. 19 ULTRA FRESH PM ............................................................................................... 20 vitamin a .................................................................. 22 vitamin b complex-c ............................................................................................... 18 vitamin b-1 ............................................................ 22 vitamin b-12 ........................................................ 11 vitamin b-12 er ............................................................................................... 11 vitamin b-2 ............................................................ 22 vitamin b-6 ............................................................ 23 vitamin b-6 er ............................................................................................... 23 vitamin c .................................................................. 23 vitamin d .................................................................. 22 vitamin d (ergocalciferol) ............................................................................................... 22 vitamin d3 .............................................................. 22 vitamin d-400 ............................................................................................... 22 vitamin e .................................................................. 22 vitamin k (phytonadione) ............................................................................................... 22 vitamins for hair ............................................................................................... 19 WATCHHALER ............................................................................................... 16 WINDMILL TRAINER ............................................................................................... 15 womens laxative ............................................................................................... 14 zinc sulfate ............................................................ 17 zinc-220 ..................................................................... 17 P=Preferred, Dagger=N/A, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 29
