HIP State Plus

Transcription

HIP State Plus

Comprehensive
PREFERRED DRUG LIST
MHS Indiana
PAGE 1
LAST UPDATED 10/2016
Pharmacy Program
MHS Health Plan (MHS) is committed to providing appropriate, high-quality, and costeffective drug therapy to all MHS members. MHS works with providers and pharmacists
to ensure that medications used to treat a variety of conditions and diseases are
covered. MHS covers prescription medications and certain over-the-counter (OTC)
medications when ordered by an Indiana Medicaid enrolled MHS practitioner. The
pharmacy program does not cover all medications. Some medications require prior
authorization (PA) or have limitations on age, dosage, and maximum quantities.
For the most current information about the MHS Pharmacy Program you may call
Member Services at (877) 647-4848 (TTY/TTD (800) 743-3333) or visit the MHS
website www.mhsindiana.com.
Preferred Drug List
The MHS Preferred Drug List (PDL) is the list of covered drugs. The PDL applies to
drugs that members can receive at retail pharmacies. The MHS PDL is continually
evaluated by the MHS Pharmacy and Therapeutics (P&T) Committee to promote the
appropriate and cost-effective use of medications. The Committee is composed of the
MHS Medical Director, MHS Pharmacy Director, and several Indiana physicians,
pharmacists, and specialists.
Pharmacy Benefit Manager
US Script is our Pharmacy Benefit Manager. MHS works with US Script to process all
pharmacy claims for prescribed drugs. Some drugs on the MHS PDL require PA, and
US Script is responsible for administering this process.
Specialty Drugs
Certain medications are only covered when supplied by MHS’ specialty pharmacy provider.
AcariaHealth is our specialty pharmacy provider. A medical provider can obtain specialty
medications through Acaria Health. Acaria Health will ship these medications to the medical
provider’s office. Some selected medications are also available through the medical benefit
upon administration within the medical provider’s office for providers who choose to
inventory these medications for office administration. Billing instructions for this situation can
be found in the provider handbook.
The MHS Pharmacy Director and MHS Medical Director oversee the clinical review of these
medications and AcariaHealth provides members with the following services:



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Deliver drugs to the member’s home or provider’s office
Provide staff pharmacists who can help 24 hours a day, seven days a week to
answer member questions and offer help with drugs
Give information, materials, and ongoing support to help members take the drug(s) to
appropriately manage their health condition(s)
These drugs are not usually available at retail pharmacies. Additional information about the
drugs that AcariaHealth provides is in the Biopharmaceutical Pharmacy Program document
located on the MHS website at www.mhsindiana.com.
Mental Health Drugs
In accordance with Indiana law, all antianxiety, antidepressant, antipsychotic drugs are
considered as being preferred and do not require prior authorizations. If such a mental
health drug is not listed on the PDL it is still considered preferred. Although considered
preferred and no prior authorization is required, mental health drugs may be subject to
utilizations edits such as quantity and age limits, duplicate therapy edits and other
authorization requirements.
Dispensing Limits
Drugs may be dispensed up to a maximum of 30 days supply for each new prescription
or refill. A total of 80% of the days supply or 25 days must have elapsed before the
prescription can be refilled for 30 days supply, non-controlled-substance PDL drugs. A
total of 88% of the days supply must have elapsed before the prescription can be
refilled for controlled substances and narcotic PDL drugs.
Appropriate Use and Safety Edits
Member health and safety is a priority for MHS. One of the ways we address member
safety is through point-of sale (POS) edits at the time a prescription is processed at the
pharmacy. These edits are based on the Food and Drug Administration (FDA)
recommendations and promote safe and effective medication utilization. A primary
example of these recommendations would be limiting the number of fills each month to
one medication in the same therapy classes.
Additional information about the drugs that are part of the these edits can be found in
the Appropriate Use and Safety Edits document located on the MHS website at
www.mhsindiana.com.
Prior Authorizations
Some medications listed on the MHS PDL may require PA. The information should be
submitted by the practitioner or pharmacist to US Script on the Medication Prior
Authorization Form. This document is located on the MHS website at
www.mhsindiana.com. The completed form and all clinicals to support the request
should be faxed to US Script at (866) 399-0929.
MHS will cover the medication if it is determined that:
1. There is a medical reason the member needs the specific medication.
2. Depending on the medication, other medications on the PDL have not worked.
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All reviews are performed by a licensed clinical pharmacist using the criteria established
by the MHS P&T Committee. If the request is approved, US Script notifies the
practitioner by fax. If the clinical information provided does not meet the coverage
criteria for the requested medication, MHS will notify the member and their practitioner
of alternatives and provide information regarding the appeal process.
Step Therapy
Some medications listed on the MHS PDL may require specific medications to be used
before the member can receive the step therapy medication. If MHS has a record that
the required medication was tried first, the step therapy medications are automatically
covered. If MHS does not have a record that the required medication was tried, the
member’s practitioner may be required to provide additional information. If MHS does
not grant PA we will notify the member and their practitioner and provide information
regarding the appeal process.
Quantity Limits
MHS may limit how much of a medication a member can get at one time. If the
practitioner feels the member has a medical reason for getting a larger amount, a PA
may be requested. If MHS does not grant PA we will notify the member and their
practitioner and provide information regarding the appeal process.
Age Limits
Some medications on the MHS PDL may have age limits. These are set for certain
drugs based on FDA approved labeling and for safety concerns and quality standards of
care. Age limits align with current FDA alerts for the appropriate use of
pharmaceuticals.
Gender Limits
Some medications on the MHS PDL may be limited to one gender. These limits are set
for certain drugs based on FDA-approved labeling and for safety concerns and quality
standards of care. Gender limits align with current FDA alerts for the appropriate use of
pharmaceuticals.
Medical Necessity Requests
If the member requires a medication that does not appear on the PDL, the member’s
practitioner can make a medical necessity (MN) request for the medication. It is
anticipated that such exceptions will be rare and that PDL medications will be
appropriate to treat the vast majority of medical conditions. MHS requires:
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Documentation of failure of at least two PDL agents within the same therapeutic
class (provided two agents exist in the therapeutic category with comparable
labeled indications) for the same diagnosis (e.g. migraine, neuropathic pain,
etc.); or

Documented intolerance or contraindication to at least two PDL agents within the
same therapeutic class (provided two agents exist in the therapeutic category
with comparable labeled indications); or

Documented clinical history or presentation where the patient is not a candidate
for any of the PDL agents for the indication.
All reviews are performed by a licensed clinical pharmacist or physician using the
criteria established by the MHS P&T Committee. If the clinical information provided
does not meet the coverage criteria for the requested medication, MHS will notify the
member and their practitioner of alternatives and provide information regarding the
appeal process.
72 Hour Emergency Supply Policy
State and Federal law require that a pharmacy dispense a 72 hour (3 day) supply of
medication to any member awaiting PA determination. The purpose is to avoid
interruption of current therapy or delay in the initiation of therapy. All participating
pharmacies are authorized to provide a 72 hour supply of medication and will be
reimbursed for the ingredient cost and dispensing fee of the 72 hour supply of
medication, whether or not the PA request is ultimately approved or denied. The
pharmacy must call US Script at (855) 772-7125 for a prescription override to submit
the 72 hour medication supply for payment.
Exclusions
The following drug categories are not part of the MHS PDL and are not covered by the
72 hour emergency supply policy:

Drugs that are considered experimental

Drug Efficacy Study and Implementation (DESI) drugs

Drugs prescribed for weight loss (with the exception of Orlistat)

Drugs prescribed for infertility

Drugs prescribed for erectile dysfunction

Drugs prescribed for cosmetic purposes or hair growth

Cough and cold preparations, minus those covered by OTC program

Infusion therapy and supplies

Immunizations and vaccines (except flu vaccine)

Physician administered drugs that are not listed in the PDL, Specialty Drug
Benefit, or the Physician Administered Drug Prior Authorization List

Hepatitis C Agents*
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Effective September 1, 2016 all drugs used in the treatment of Hepatitis C will be
provided by the Office of Medicaid Policy and Planning (OMPP) through the FFS
pharmacy benefit. Any member of MHS who is presently treated with a Hepatitis
C agent prior to September 1, 2016 will continue to get their medication with no
interruption. Any MHS member requesting a Hepatitis C agent after September
1, 2016 will need to have their physician send the prior authorization (PA)
request to:
o Optum Clinical Call Center
o Phone: 855-577-6317
o Fax: 855-577-6384
Newly Approved Products
MHS reviews new drugs for safety and effectiveness before adding them to the PDL.
During this period, access to these medications will be considered through the PA
review process. If MHS does not grant PA, we will notify the member and their
practitioner and provide information regarding the appeal process.
Over-the-Counter Medications
The MHS OTC list covers a variety of medications. A list of covered OTC medications
can be found in the Over-the-Counter Medications program document. These OTCs
are covered when the member has a prescription from a licensed practitioner that meets
all the legal requirements for a prescription.
A list of covered OTC medications in the Over-the-Counter Pharmacy Program is also
located on the MHS website at www.mhsindiana.com.
Tobacco Cessation Medications
The following types of tobacco cessation medications will be covered by MHS: generic
nicotine replacement products (gum, lozenges, and patches), Bupropion SR 150mg
(Zyban), and Chantix. A prescription will be required for all tobacco cessation
medications.
MHS authorizes benefits for tobacco cessation medications for the purpose of
supporting members who are trying to quit tobacco use with the temporary assistance of
nicotine replacement therapy. It is expected that utilization of these products will be in
accordance with medical standards of practice, FDA guidelines, and manufacturers’
recommendations.
Generic Drugs
When generic drugs are available, the brand-name drug will not be covered without
prior MHS authorization. Generic drugs have the same active ingredient, work the same
as brand-name drugs, and have lower copayments. If the member or their practitioner
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feels a brand-name drug is medically necessary, the practitioner can request the drug
using the PA process. We will cover the brand-name drug according to our clinical
guidelines if there is a medical reason the member needs the particular brand-name
drug. If MHS does not grant PA, we will notify the member and their practitioner and
provide information regarding the appeal process.
Drug Efficacy Study and Implementation Drugs
Drug Efficacy Study and Implementation (DESI) products and known related drug
products are defined as less than effective by the Food and Drug Administration
because there is a lack of substantial evidence of effectiveness for all labeling
indications and because a compelling justification for their medical need has not been
established. DESI products are not covered by MHS.
Filling a Prescription
A member can have prescriptions filled at an MHS network pharmacy. If the member
decides to have a prescription filled at a network pharmacy they can locate a pharmacy
near them by contacting MHS Member Services or by visiting www.mhsindiana.com. At
the pharmacy the member will need to provide the pharmacist with the prescription and
their MHS ID card.
Ordering, Prescribing and Referring (OPR) Provider Requirements
To ensure compliance with Indiana Medicaid and the Center for Medicaid and Medicare
Services (CMS) regulations, MHS and US Script edit pharmacy claims for the presence
of a participating Medicaid provider or an enrolled ordering, prescribing, or referring
(OPR) provider. All pharmacy claims must contain the NPI of the prescribing provider.
All prescriptions written by a non-registered or non-OPR prescriber will result in a claim
denial.
Pharmacies will be notified through claim transactions if the submitted prescribing
provider is not enrolled with the Department of Community Health (DCH) as a
participating provider or an ordering, prescribing or rendering provider. Pharmacies will
also receive a claims message if their own store NPI is not enrolled in Indiana Medicaid.
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Copayments (Copays)
The table below lists the copayment for the drugs according to the actual cost of the
prescription. Copayments are not required for pregnant women, family planning
supplies, members in the hospital or a nursing home, Native Americans.
Plan Type
Generic
/Preferred Drug
Copay
Brand-Name Drug
Copay
Non-Preferred
Drug
HIP State Basic
$4.00
$8.00
$8.00
HIP Basic
$4.00
$8.00
$8.00
HIP Plus and
State Plus
No Cost
No Cost
No Cost
Contact Information
MHS Member & Provider Services
Phone: (877) 647-4848
Fax: (866) 714-7993
TTY/TDD: (800) 743-3333
US Script Prior Authorizations
Phone: (855) 772-7125
Fax: (866) 399-0929
Specialty Medication Prior Authorization Fax
Fax: (855) 678-6976
US Script Pharmacy Help Desk
Phone: (855) 772-7121
AcariaHealth Specialty Medication Shipping
Questions
Phone: (855) 535-1815
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LEGEND
TYPE
DESCRIPTION
QL
Quantity Limit
There is a limit on the amount of drug covered per prescription, or
within a specific time frame.
PA
Prior Authorization
Prior Authorization required before prescription can be filled.
ST
Step Therapy
Requires trial and failure of one or more preferred products prior to
coverage.
GL
Gender Limit
Drug is limited to specific gender.
AL
Age Limit
Drug is limited to specific age.
MDD
Max Daily Dose
A limit on the number of times the drug can be taken per day.
MPL
Max Package Limit
A limit on the amount of drug covered per prescription.
MFL
Max Fill Limit
There is a limit on the number of times this drug can be refilled.
MDS
Max Days Supply
There is a limit on the amount of this drug that is covered.
Custom
This drug has unique restrictions.
Specialty Drug
Specialty drugs are high-cost drugs used to treat complex or rare
conditions, such as multiple sclerosis, rheumatoid arthritis, hepatitis
C, and hemophilia.
C
S
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LIST OF COVERED OVER-THE-COUNTER MEDICATIONS
PRODUCT DESCRIPTION
BRAND/GEN
LIMITS & RESTRICTIONS
ANALGESICS
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
aspirin (chew tab 81 mg, suppos 300 mg, suppos 600 mg,
tab 325 mg, tab delayed release 81 mg, tab delayed
release 325 mg)
generic
ASPIRIN LOW DOSE TAB 81 MG
BRAND
aspirin tab chew 81 mg
generic
ibuprofen (chew tab 100 mg, susp 40 mg/ml, susp 100
mg/5ml, tab 200 mg)
generic
ibuprofen cap 200 mg
generic
ibuprofen tab 200 mg
generic
naproxen sodium (cap 220 mg, tab 220 mg)
generic
MDD
2 per day
naproxen sodium tab 220 mg
generic
MDD
2 per day
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
SMOKING CESSATION AGENTS
nicotine (patch 24hr 7 mg/24hr, patch 24hr 21 mg/24hr,
patch 24hr 14 mg/24hr)
NICOTINE KIT 21-14-7 MG/24HR
QL
180 / 365 days
AL
At least 18 yrs old
generic
MDD
1 per day
MDS
180 / 365 DAYS
QL
56 / claim
AL
At least 18 yrs old
BRAND
MFL
2 / 365 days
MDS
180 / 365 DAYS
AL
nicotine polacrilex (gum 2 mg, gum 4 mg)
generic
MDD
24 per day
MDS
180 / 365 DAYS
AL
nicotine polacrilex (lozenge 2 mg, lozenge 4 mg)
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generic
At least 18 yrs old
At least 18 yrs old
MDD
20 per day
MDS
180 / 365 DAYS
PRODUCT DESCRIPTION
BRAND/GEN
ANTIEMETICS
ANTIEMETICS, OTHER
dimenhydrinate tab 50 mg
generic
meclizine hcl (chew tab 25 mg, tab 12.5 mg, tab 25 mg)
generic
ANTIFUNGALS
ALEVAZOL OINTMENT 1 %
BRAND
MPL
1 / claim
clotrimazole (topical) (cream, soln)
generic
MPL
1 / claim
clotrimazole vaginal cream 1%
generic
clotrimazole vaginal cream 2%
generic
MPL
1 / claim
miconazole nitrate vaginal (app 200 mg & 2% cream 9 gm
kit, cream 2%, cream 4% (200 mg/5gm), supp 1200 mg &
2% cream kit, suppos 100 mg)
generic
QL
45 / claim
miconazole nitrate vaginal supp 200 mg & 2% cream 9 gm
kit
QL
generic
45 / claim
tioconazole vaginal oint 6.5%
MPL
1 / claim
generic
QL
5 / claim
dextrose (diabetic use) (chew tab 4 gm, gel 40%)
generic
QL
50 / 30 days
glucose oral liquid 15 gm/59ml
generic
GNP GLUCOSE CHEW TAB 4 GM
BRAND
QL
50 / 30 days
INSTA-GLUCOSE GEL 77.4 %
BRAND
SM GLUCOSE CHEW TAB 4 GM
BRAND
QL
50 / 30 days
BLOOD GLUCOSE REGULATORS
GLYCEMIC AGENTS
CARDIOVASCULAR AGENTS
DYSLIPIDEMICS, OTHER
DIALYVITE OMEGA-3 CONCENTRATE CAP 600 MG
BRAND
GNP FISH OIL CAP DR 840 MG
BRAND
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PRODUCT DESCRIPTION
BRAND/GEN
HM FISH OIL CAP 554 MG
BRAND
niacin (tab 250 mg, tab 500 mg, tab 750 mg, tab 1000 mg)
generic
OCEAN BLUE MINICAPS OMEGA-3 CAP 350 MG
BRAND
OMEGA POWER CAP 1050 MG
BRAND
OMEGA-3 2100 CAP 1050 MG
BRAND
omega-3 fatty acids (cap 1000, cap 1200)
generic
omega-3 fatty acids (cap 435, cap 500, cap 1400, cap
delayed release 1000, cap delayed release 1200)
generic
OMEGA-3 IQ CHEW TAB 240 MG
BRAND
SM FISH OIL CAP 554 MG
BRAND
SYSTANE OMEGA-3 HEALTHY TEARS CAP DR 500 MG
BRAND
MDD
6 per day
QL
90 / claim
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM, OTHER
acetaminophen soln 100 mg/ml
generic
acetaminophen soln 160 mg/5ml
generic
DENTAL AND ORAL AGENTS
CREST COMPLETE PASTE 0.243 %
BRAND
sodium fluoride (dental) (0.0221% (0.01% f), 0.05%, 0.2%)
generic
stannous fluoride gel 0.4%
generic
DERMATOLOGICAL AGENTS
*bacitracin-polymyxin b oint***
generic
*colloidal oatmeal packet**
generic
*neomycin-bacitracin-polymyxin oint***
generic
*soap & cleansers - lotion***
generic
A + D PERSONAL CARE LOTION LOTION
BRAND
ABREVA CREAM 10 %
BRAND
ACNE MEDICATION 10 LOTION 10 %
BRAND
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MPL
1 / claim
PRODUCT DESCRIPTION
BRAND/GEN
ACNE MEDICATION 5 LOTION 5 %
BRAND
ACNE MEDICATION LOTION 10 %
BRAND
AMLACTIN CERAPEUTIC LOTION
BRAND
AMLACTIN ULTRA CREAM
BRAND
AQUA GLYCOLIC FACE CREAM
BRAND
AQUA GLYCOLIC HAND/BODY LOTION
BRAND
AQUA LACTEN LOTION
BRAND
AQUAMED LOTION
BRAND
AQUAPHOR ADVANCED THERAPY OINTMENT
BRAND
benzoyl peroxide (bar 10%, cleanser 4.25%, cream 10%,
creamy wash 4% &bar 5% kit, creamy wash 8% &bar 5%
kit, gel 2.5%, gel 5%, gel 10%, liq 4%, liq 5%, liq 10%,
lotion 6%)
generic
BENZOYL PEROXIDE CLEANSER (LOTION 3 %,
LOTION 9 %)
BRAND
CAM LOTION
BRAND
camphor & menthol lotion 0.5-0.5%
generic
MPL
1 / claim
capsaicin (cream 0.025%, cream 0.075%, cream 0.1%)
generic
MPL
1 / claim
CAPSAICIN ARTHRITIS RELIEF LIQUID 0.15 %
BRAND
CERAVE (CREAM, LOTION)
BRAND
CERAVE AM SPF 30 LOTION
BRAND
CERAVE PM LOTION
BRAND
CERAVE SA RENEWING (CREAM, LOTION)
BRAND
CETAPHIL CREAM
BRAND
CETAPHIL DAILY ADVANCE LOTION
BRAND
CETAPHIL DAILY FACIAL MOIST LOTION
BRAND
CETAPHIL DERMACONTROL/SPF 30 LOTION
BRAND
CETAPHIL MOISTURIZING LOTION
BRAND
CETAPHIL RESTORADERM LOTION
BRAND
CETAPHIL THERAPEUTIC HAND CREAM
BRAND
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PRODUCT DESCRIPTION
BRAND/GEN
CVS DAILY ULTRA MOISTURE LOTION
BRAND
DERMABASE CREAM
BRAND
dibucaine rectal ointment 1%
generic
diphenhydramine hcl soln 2%
generic
DML FORTE CREAM
BRAND
ELON SKIN REPAIR SYSTEM CREAM
BRAND
emollient (lotion**, ointment**)
generic
FORMULA 405 A.H.A FACIAL NIGHT CREAM
BRAND
FORMULA 405 BODY SMOOTHING LOTION
BRAND
FORMULA 405 ENRICHED EYE CREAM
BRAND
FORMULA 405 FACE CREAM
BRAND
FORMULA 405 LE PONT NAIL OIL
BRAND
FORMULA 405 LIGHT MOISTURIZER CREAM
BRAND
FORMULA 405 MOISTURIZING LOTION
BRAND
GNP ADVANCED RECOVERY LOTION
BRAND
GNP CAPSAICIN LIQUID 0.15 %
BRAND
HYDRISINOL CREAM 0.1 %
BRAND
hydrocortisone (topical) (cream, lotion)
generic
hydrocortisone (topical) (cream, oint)
generic
hydrocortisone oint 1%
generic
ITCH-X FOAM 1 %
BRAND
KERADAN CREAM
BRAND
KERI ADVANCED MOISTURE THERAPY LOTION
BRAND
KERI BASIC ESSENTIALS LOTION
BRAND
KERI LONG LASTING CREAM
BRAND
KERI NOURISHING SHEA BUTTER LOTION
BRAND
KERI ORIGINAL LOTION
BRAND
KERI OVERNIGHT LOTION
BRAND
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MPL
1 / claim
MPL
1 / 30 days
PRODUCT DESCRIPTION
BRAND/GEN
KERI RENEWAL MILK BODY LOTION
BRAND
KERI RENEWAL SERUM LIQUID
BRAND
KERI RENEWAL SKIN FIRMING LOTION
BRAND
KERI RENEWAL STRETCH MARK LOTION
BRAND
KERI SENSITIVE SKIN LOTION
BRAND
lactic acid (ammonium lactate) (cream 12%, lotion 5%)
generic
MPL
1 / claim
lactic acid (ammonium lactate) lotion 12%
generic
MPL
1 / 30 days
LACTINOL HX CREAM
BRAND
LAMISIL ADVANCED GEL 1 %
BRAND
LAMISILK REPAIR COMPLEX SERUM LIQUID
BRAND
LICEMD COMPLETE KIT 0.33-4 %
BRAND
LICEMD GEL 0.33-4 %
BRAND
MPL
1 / claim
lidocaine (aerosol 0.5%, cream 4%)
generic
lidocaine hcl gel 0.5%
generic
LUBRISOFT LOTION
BRAND
MEDERMA STRETCH MARKS THERAPY CREAM
BRAND
MOISTUREL LOTION
BRAND
NEUTROGENA CLEAR PORE LIQUID 3.5 %
BRAND
NIVEA LOTION
BRAND
NUTRADERM ADVANCED FORMULA LOTION
BRAND
NUTRADERM LOTION
BRAND
NUTRADERM-30 LOTION
BRAND
OSTIDERM LIQUID
BRAND
PANOXYL GEL 3 %
BRAND
PEN-KERA CREAM
BRAND
PENTRAVAN PLUS CREAM
BRAND
MPL
1 / claim
permethrin lotion 1%
generic
Pkg Size 60: 2/claim
C
Pkg Size 120: 1/claim
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PRODUCT DESCRIPTION
BRAND/GEN
phenyleph-shark liver oil-cocoa butter suppos 0.25-385.5%
generic
phenylephrine in hard fat rectal suppos 0.25%
generic
phenylephrine-cocoa butter suppos 0.25-88.44%
generic
phenylephrine-mineral oil-petrolatum (oint 0.25-14-71.9%,
oint 0.25-14-74.9%)
generic
phenylephrine-shark liver oil-mo-pet oint 0.25-3-14-71.9%
generic
phenylephrine-witch hazel rectal gel 0.25-50%
generic
pramox-pe-glycerin-petrolatum rectal cream 1-0.25-14.415%
generic
PRETTY FEET/HANDS CREAM
BRAND
PRO:12 MOUSSE AL12 FOAM 12 %
QL
12 / claim
MPL
1 / claim
BRAND
MPL
1 / claim
pyrethrins-piperonyl butoxide (liq, shampoo)
generic
MPL
1 / claim
RISABAL-PH CREAM
BRAND
selenium sulfide lotion 1%
generic
SOOTHE & COOL MOISTURIZING LOTION
BRAND
SOOTHE & COOL SKIN CREAM
BRAND
SPECIAL CARE CREAM
BRAND
terbinafine hcl cream 1%
generic
UDDERLY SMOOTH CREAM
BRAND
UDDERLY SMOOTH EXTRA CARE 20 CREAM
BRAND
VANICREAM CREAM
BRAND
VANICREAM LITE LOTION
BRAND
VELVACHOL CREAM
BRAND
vitamin e (topical) (cram**, lotion**, oil**)
generic
VOPAC 5 CREAM 5 %
BRAND
WIBI LOTION
BRAND
PAGE 16
QL
240 / claim
PRODUCT DESCRIPTION
BRAND/GEN
GASTROINTESTINAL AGENTS
GASTROINTESTINAL AGENTS, OTHER
*probiotic product - chew tab**
generic
4X PROBIOTIC TAB
BRAND
ALIGN (CAP, CAP 4 MG)
BRAND
alum & mag hydrox-simethicone (chew tab 200-200-25 mg,
susp 200-200-20 mg/5ml, susp 400-400-40 mg/5ml)
generic
aluminum hydroxide gel susp 320 mg/5ml
generic
aluminum hydroxide-mag carb (chew tab 160-105 mg,
susp 95-358 mg/15ml)
generic
betaine hcl tab 300 mg
generic
bismuth subsalicylate (chew tab 262 mg, susp 262
mg/15ml, susp 525 mg/15ml, tab 262 mg)
generic
calcium carbonate (antacid) (chew tab 400 mg, chew tab
500 mg, chew tab 750 mg, chew tab 1000 mg, tab 648 mg)
generic
CULTURELLE IMMUNE DEFENSE CAP
BRAND
CVS DIGESTIVE PROBIOTIC CAP
BRAND
CVS PROBIOTIC CAP
BRAND
DIFF-STAT CAP
BRAND
GAS-X CHILDRENS STRIP 40 MG
BRAND
MPL
1 / claim
GAS-X EXTRA STRENGTH STRIP 62.5 MG
BRAND
MPL
1 / claim
GAVISCON EXTRA RELIEF FORMULA SUSPENSION
508-475 MG/10ML
BRAND
GAVISCON EXTRA STRENGTH SUSPENSION 254-237.5
MG/5ML
BRAND
GNP 4X PROBIOTIC TAB
BRAND
GNP ACIDOPHILUS HIGH POTENCY CAP
BRAND
GNP PROBIOTIC COLON SUPPORT CAP
BRAND
HM 4X PROBIOTIC TAB
BRAND
HM ACIDOPHILUS CAP
BRAND
PAGE 17
QL
496 / 30 days
PRODUCT DESCRIPTION
BRAND/GEN
LACTO-PECTIN CAP
BRAND
lactobacillus (- packet**, cap**, tab**)
generic
loperamide hcl cap 2 mg
generic
MDD
8 per day
loperamide hcl liq 1 mg/5ml (0.2 mg/ml)
generic
MDD
10 per day
loperamide hcl liq 1 mg/7.5ml
generic
loperamide hcl tab 2 mg
generic
MDD
8 per day
MAG-AL LIQUID 200-200 MG/5ML
BRAND
QL
magnesium oxide (tab 250 mg, tab 400 mg, tab 420 mg)
generic
META BIOTIC/BIO-ACTIVE 12 CAP
BRAND
PHAZYME MAXIMUM STRENGTH CAP 250 MG
BRAND
PROBIOTIC ADVANCED CAP
BRAND
PROBIOTIC FORMULA CAP
BRAND
PROBIOTIC PEARLS CAP
BRAND
PROVELLA TAB
BRAND
RE:IIMMUNE PACKET
BRAND
RESTORA CAP
BRAND
RISA-BID PROBIOTIC TAB
BRAND
RISAQUAD CAP
BRAND
RISAQUAD-2 CAP
BRAND
simethicone (cap 125 mg, cap 180 mg, chew tab 80 mg,
chew tab 125 mg, susp 40 mg/0.6ml)
generic
SM 4X PROBIOTIC TAB
BRAND
SM ACIDOPHILUS CAP
BRAND
sodium bicarbonate (antacid) (tab 325 mg, tab 650 mg)
generic
TUMS CHEWY DELIGHTS CHEW TAB 1177 MG
BRAND
URO-MAG CAP 140 MG
BRAND
VISBIOME PROBIOTIC HIGH POT (CAP, PACKET)
BRAND
PAGE 18
496 / 30 days
MPL
1 / claim
MPL
1 / claim
QL
496 / 30 days
PRODUCT DESCRIPTION
BRAND/GEN
HISTAMINE2 (H2) RECEPTOR ANTAGONISTS
cimetidine tab 200 mg
generic
MDD
4 per day
famotidine tab 10 mg
generic
MDD
2 per day
famotidine tab 20 mg
generic
ranitidine hcl tab 150 mg
generic
ranitidine hcl tab 75 mg
generic
MDD
2 per day
MDD
1 per day
QL
12 / claim
MDD
1 per day
LAXATIVES
*sodium phosphates - enema***
generic
bisacodyl ec tab dr 5 mg
generic
bisacodyl laxative suppos 10 mg
generic
bisacodyl tab delayed release 5 mg
generic
MDD
1 per day
calcium polycarbophil tab 625 mg
generic
MDD
10 per day
complete ready-to-use enema enema 7-19 gm/118ml
generic
docusate calcium cap 240 mg
generic
docusate sodium (cap 50 mg, cap 100 mg, cap 250 mg,
enema 100 mg/5ml, liquid 150 mg/15ml, syrup 60
mg/15ml, tab 100 mg)
generic
docusate sodium cap 100 mg
generic
DOCUSOL MINI ENEMA 283 MG
BRAND
ENEMEEZ MINI ENEMA 283 MG
BRAND
fiber cap 0.52 gm
generic
FLEET BISACODYL ENEMA 10 MG/30ML
BRAND
FLEET LIQUID GLYCERIN SUPP ENEMA 5.4 GM/DOSE
BRAND
glycerin (laxative) (suppos 1.2 gm, suppos 2.1 gm)
generic
glycerin suppos 2 gm
generic
QL
12 / claim
KONSYL (PACKET 28.3 %, PACKET 60.3 %, PACKET
100 %, POWDER 60.3 %, POWDER 71.67 %)
BRAND
PAGE 19
PRODUCT DESCRIPTION
BRAND/GEN
KONSYL-D POWDER 52.3 %
BRAND
magnesium citrate solution 1.745 gm/30ml
generic
magnesium hydroxide (chew tab 311 mg, susp 400
mg/5ml)
generic
METAMUCIL MULTIHEALTH FIBER (PACKET 58.12 %,
POWDER 55.46 %, POWDER 63 %)
BRAND
METAMUCIL SMOOTH TEXTURE PACKET 28 %
BRAND
METAMUCIL WAFER
BRAND
MILK OF MAGNESIA CONCENTRATE SUSPENSION
2400 MG/10ML
QL
990 / 30 days
BRAND
QL
990 / 30 days
milk of magnesia suspension 400 mg/5ml
generic
QL
990 / 30 days
PEDIA-LAX (LIQUID 50 MG/15ML, SUPPOS 2.8 GM)
BRAND
PEDIA-LAX CHEW TAB 400 MG
BRAND
QL
990 / 30 days
polyethylene glycol 3350 (3350 powder, 3350 packet)
generic
psyllium (cap 0.52 gm, powder 28.3%, powder 30.9%,
powder 33%, powder 48.57%, powder 49%, powder
58.6%, powder 95%, powder 100%)
generic
senna (*senna leaves**, senna syrup 176 mg/5ml)
generic
senna tab 8.6 mg
generic
senna-docusate sodium tab 8.6-50 mg
generic
sennosides (syrup 8.8 mg/5ml, tab 8.6 mg)
generic
sennosides-docusate sodium tab 8.6-50 mg
generic
sorbitol oral solution 70%
generic
PROTON PUMP INHIBITORS
PA
lansoprazole cap delayed release 15 mg
generic
MDD
C
MDD
NEXIUM 24HR CAP DR 20 MG
BRAND
C
omeprazole delayed release tab 20 mg
PAGE 20
4 per day
OTC Covered Only
2 per day
OTC Covered Only
generic
PRODUCT DESCRIPTION
BRAND/GEN
PREVACID 24HR CAP DR 15 MG
BRAND
MDD
C
4 per day
OTC Covered Only
GENITOURINARY AGENTS
GENITOURINARY AGENTS, OTHER
nonoxynol-9 gel 4%
generic
phenazopyridine hcl (tab 95 mg, tab 97.5 mg)
generic
PHOSPHATE BINDERS
calcium acetate (phosphate binder) tab 667 mg
generic
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)
PROGESTINS
levonorgestrel tab 1.5 mg
GL
generic
Female
MFL
4 / lifetime
METABOLIC BONE DISEASE AGENTS
cholecalciferol cap 50000 unit
generic
DECARA CAP 25000 UNIT
BRAND
MISCELLANEOUS THERAPEUTIC AGENTS
acetaminophen (cap 500 mg, chew tab 80 mg, chew tab
160 mg, dispersible tab 80 mg, dispersible tab 160 mg,
liquid 160 mg/5ml, liquid 167 mg/5ml, suppos 120 mg,
suppos 325 mg, suppos 650 mg, susp 80 mg/0.8ml, susp
160 mg/5ml, tab 325 mg, tab 500 mg, tab cr 650 mg)
generic
ALLEVYN NON-ADHESIVE PAD 8"X8"
BRAND
AYR NASAL MIST ALLERGY/SINUS SOLUTION 2.65 %
BRAND
MPL
1 / claim
AYR SALINE NASAL DROPS SOLUTION 0.65 %
BRAND
MPL
1 / claim
BANDAGE NEW GENERATION LARGE PAD
BRAND
BIATAIN ADHESIVE FOAM DRESSING (FOAM PAD
4"X4", FOAM PAD 5"X5", FOAM PAD 7"X7")
BRAND
BIATAIN FOAM DRESSING (FOAM PAD, FOAM PAD
4"X4", FOAM PAD 6"X6", FOAM PAD 8"X8")
BRAND
PAGE 21
PRODUCT DESCRIPTION
BRAND/GEN
BIATAIN HEEL ADH FOAM DRESSING PAD
19CMX20CM
BRAND
BIATAIN SACRAL FOAM DRESSING PAD 9"X9"
BRAND
BIOGUARD BARRIER DRESSING MISC
BRAND
BORDERED GAUZE (PAD 4"X4", PAD 6"X6")
BRAND
calcium carbonate oral powder 800 mg/2gm (elemental ca)
generic
CARRASMART (PAD 4"X4", PAD 6"X6")
BRAND
CARRASMART FOAM (FOAM PAD 2"X3", FOAM PAD
4"X4", FOAM PAD 6"X8")
BRAND
chlorhexidine gluconate liquid 4%
generic
COMBINE ABD PAD 5"X9"
BRAND
cromolyn sodium nasal aerosol soln 5.2 mg/act (4%)
generic
CVS HYDROCOLLOID PADS PAD
BRAND
CVS NON-STICK PADS PAD 3"X8"
BRAND
DERMADRESS WATERPROOF DRESSING MISC
BRAND
DERMALEVIN ADHESIVE (PAD 4"X4", PAD 6"X6")
BRAND
DRYMAX EXTRA (PAD 4"X4", PAD 4"X8", PAD 8"X8")
BRAND
DUREX EXTRA SENSITIVE DEVICE
BRAND
EPSOM SALT GRANULES
BRAND
FEVERALL INFANTS SUPPOS 80 MG
BRAND
FLEXZAN (PAD 2"X3", PAD 4"X8", PAD 4"X4", PAD
8"X8")
BRAND
FOAM DRESSING PAD
BRAND
gauze pads & dressings (pads misc***, pads pads 2" x
2"***, pads pads 2" x 3"***, pads pads 3" x 4"***, pads pads
3" x 3"***, pads pads 4" x 4"***)
generic
GNP STERILE PADS PAD 3"X3"
BRAND
HM NON-STICK 3"X4" PAD 3"X4"
BRAND
ISLAND GARD-GRX KIT
BRAND
magnesium sulfate oral granules
generic
PAGE 22
QL
26 / claim
QL
36 / claim
QL
12 / claim
PRODUCT DESCRIPTION
BRAND/GEN
melatonin (cap 10 mg, chew tab 2.5 mg, liquid 1 mg/4ml
(2.5 mg/10ml), tab 1 mg, tab 3 mg, tab 5 mg, tab 10 mg,
tablet dispersible 3 mg)
generic
melatonin cap 5 mg
generic
NASAL DECONGESTANT (LIQUID 30 MG/5ML, SYRUP
30 MG/5ML)
BRAND
nasal moisturizing spray solution 0.65 %
MDD
1 per day
generic
MPL
1 / claim
NESSI SPACER WITH MASK LARGE DEVICE
BRAND
QL
2 / claim
NESSI SPACER WITH MASK SM/MED DEVICE
BRAND
QL
2 / claim
NESSI SPACER WITH MOUTHPIECE DEVICE
BRAND
QL
2 / claim
OPTIFOAM (PAD 4"X4", PAD 6"X6")
BRAND
permethrin (aerosol 0.5%, creme rinse 1%)
generic
MPL
1 / claim
phenylephrine hcl tab 10 mg
generic
QL
24 / claim
generic
QL
24 / claim
pseudoephedrine hcl (liq 15 mg/5ml, tab 60 mg, tab sr 12hr
120 mg)
generic
pseudoephedrine hcl er tab er 12h 120 mg
generic
pseudoephedrine hcl tab 30 mg
generic
RHINARIS (GEL 0.2 %, SOLUTION 0.2 %)
BRAND
MPL
1 / claim
saline (*saline gel**, saline spray 0.65%)
generic
MPL
1 / claim
simethicone liquid 40 mg/0.6ml
generic
MPL
1 / claim
SM BANDAGE ROLL MISC
BRAND
SM GAUZE (PAD 2"X2", PAD 3"X3", PAD 4"X4")
BRAND
SM ROLLED GAUZE 2"X4.1YD MISC
BRAND
SM ROLLED GAUZE 3"X4.1YD MISC
BRAND
SM STERILE (PAD 2"X2", PAD 4"X4")
BRAND
TRIAMINIC FEVER REDUCER SYRUP 160 MG/5ML
BRAND
PAGE 23
PRODUCT DESCRIPTION
BRAND/GEN
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS, OTHER
*artificial tear ophth ointment***
generic
*artificial tear ophth solution***
generic
*white petrolatum-mineral oil ophth ointment***
QL
4 / claim
generic
MPL
1 / claim
GENTEAL SEVERE GEL 0.3 %
BRAND
QL
15 / claim
hypromellose ophth soln 0.4%
generic
QL
15 / claim
ISOPTO TEARS SOLUTION 0.5 %
BRAND
QL
15 / claim
ketotifen fumarate ophth soln 0.025% (base equiv)
generic
MPL
naphazoline w/ pheniramine ophth soln 0.025-0.3%
generic
C
polyvinyl alcohol ophth soln 1.4%
generic
QL
15 / claim
SYSTANE OVERNIGHT THERAPY GEL 0.3 %
BRAND
QL
15 / claim
tetrahydrozoline hcl ophth soln 0.05%
generic
MPL
generic
QL
15 / claim
FLONASE ALLERGY RELIEF SUSPENSION 50
MCG/ACT
BRAND
QL
16 / 30 days
fluticasone propionate nasal susp 50 mcg/act
generic
QL
16 / 30 days
triamcinolone acetonide nasal aerosol suspension 55
mcg/act
generic
1 / claim
Pkg Size 15: Package
Limit=1/30 days |
1 / 30 days
OTIC AGENTS
carbamide peroxide 6.5% otic soln
RESPIRATORY TRACT/PULMONARY AGENTS
ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS
ANTIHISTAMINES
ALLEGRA ALLERGY CHILDRENS TAB DISP 30 MG
BRAND
cetirizine hcl (tab 5 mg, tab 10 mg)
generic
PAGE 24
MDD
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
cetirizine hcl allergy child solution 5 mg/5ml
generic
QL
cetirizine hcl chew tab 10 mg
generic
MDD
1 per day
generic
MDD
1 per day
cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)
generic
QL
cetirizine hcl tab 10 mg
generic
MDD
childrens loratadine syrup 5 mg/5ml
generic
chlorpheniramine maleate er tab er 12 mg
generic
chlorpheniramine maleate syrup 2 mg/5ml
generic
240 / claim
240 / claim
1 per day
QL
120 / claim
MDD
60 per day
chlorpheniramine maleate tab 4 mg
generic
QL
120 / claim
generic
QL
120 / claim
clemastine fumarate tab 1.34 mg
generic
diphenhydramine hcl (cap 25 mg, chew tab 12.5 mg, tab
25 mg, tab disp 12.5 mg)
generic
MDD
4 per day
diphenhydramine hcl cap 25 mg
generic
MDD
4 per day
generic
MDD
4 per day
diphenhydramine hcl liquid 12.5 mg/5ml
generic
QL
240 / claim
generic
QL
240 / claim
diphenhydramine hcl syrup 12.5 mg/5ml
generic
MDD
5 per day
ED CHLORPED LIQUID 2 MG/ML
BRAND
fexofenadine hcl (susp 30 mg/5ml (6 mg/ml), tab 60 mg)
generic
fexofenadine hcl tab 180 mg
generic
MDD
2 per day
generic
MDD
2 per day
generic
J-TAN PD LIQUID 1 MG/ML
BRAND
loratadine (syrup 5 mg/5ml, tab 10 mg)
generic
PAGE 25
PRODUCT DESCRIPTION
BRAND/GEN
loratadine allergy relief tab disp 10 mg
generic
loratadine tab 10 mg
generic
ZYRTEC ALLERGY TAB DISP 10 MG
BRAND
RESPIRATORY TRACT AGENTS, OTHER
ALDEX GS TAB 30-190 MG
BRAND
AMBIFED TAB 30-400 MG
BRAND
AMBIFED-G TAB 20-400 MG
BRAND
BROHIST D TAB 4-10 MG
BRAND
brompheniramine & phenyleph (elixir 1-2.5 mg/5ml, liqd 410 mg/5ml, susp 6-10 mg/5ml)
generic
brompheniramine & pseudoephedrine elixir 1-15 mg/5ml
generic
cetirizine-pseudoephedrine tab sr 12hr 5-120 mg
generic
CHLO TUSS (LIQUID 5-1-12.5 MG/5ML, LIQUID 30-1-12.5
MG/5ML)
BRAND
chlorpheniramine & phenylephrine (liquid 1-3.5 mg/ml,
liquid 4-10 mg/5ml, tab 4-10 mg)
generic
CODITUSS DM SYRUP 5-8.33-10 MG/5ML
BRAND
DALLERGY LIQUID 1-2.5 MG/ML
BRAND
dextromethorphan-guaifenesin (liquid 5-100 mg/5ml, liquid
10-200 mg/5ml, liquid 10-100 mg/5ml, syrup 10-100
mg/5ml, tab 20-400 mg, tab sr 12hr 60-1200 mg, tab sr
12hr 30-600 mg)
generic
DRYMAX AF TAB 15-4-25 MG
BRAND
ED A-HIST DM TAB 10-4-10 MG
BRAND
ED CHLORPED D LIQUID 2-5 MG/ML
MDD
2 per day
QL
30 / claim
QL
30 / claim
BRAND
QL
30 / claim
ED-A-HIST TAB 3-10 MG
BRAND
QL
30 / claim
ESOCOR P SUSPENSION 30-4-30 MG/5ML
BRAND
guaifenesin (liquid 100 mg/5ml, liquid 200 mg/5ml, syrup
100 mg/5ml, tab 200 mg, tab 400 mg, tab sr 12hr 600 mg,
tab sr 12hr 1200 mg)
generic
PAGE 26
PRODUCT DESCRIPTION
BRAND/GEN
guaifenesin-codeine (liquid 200-8 mg/5ml, liquid 225-7.5
mg/5ml, soln 100-10 mg/5ml, soln 100-6.3 mg/5ml)
generic
HISTEX-DM SYRUP 10-2.5-20 MG/5ML
BRAND
J-TAN D PD LIQUID 1-7.5 MG/ML
BRAND
LODRANE D CAP 4-60 MG
BRAND
loratadine & pseudoephedrine (tab 12hr 5-120 mg, tab
24hr 10-240 mg)
generic
LORTUSS DM LIQUID 30-6.25-15 MG/5ML
BRAND
LORTUSS EX LIQUID 30-10-100 MG/5ML
BRAND
M-END DMX LIQUID 20-0.667-10 MG/5ML
BRAND
MUCINEX COUGH FOR KIDS PACKET 5-100 MG
BRAND
MUCINEX FOR KIDS PACKET 100 MG
BRAND
NOREL CS LIQUID 10-4-12.5 MG/5ML
BRAND
pe-dm & pe-diphenhydramine syrup day/night therapy pack
generic
PECGEN DMX LIQUID 10-187 MG/5ML
BRAND
phenylephrine-brompheniramine-dm (elixir 2.5-1-5 mg/5ml,
liquid 2.5-1-5 mg/5ml, liquid 7.5-4-15 mg/5ml, liquid 10-420 mg/5ml, syrup 5-2-10 mg/5ml)
generic
phenylephrine-chlorphen-dm (liquid 3.5-1-3 mg/ml, liquid 52-10 mg/5ml, liquid 10-4-15 mg/5ml)
generic
phenylephrine-dm soln 2.5-5 mg/5ml
generic
POLY-HIST DM LIQUID 5-25-10 MG/5ML
BRAND
POLY-VENT IR TAB 60-380 MG
BRAND
PRO-CHLO LIQUID 5-12.5-12.5 MG/5ML
BRAND
pseudoephed-bromphen-dm (elixir 15-1-5 mg/5ml, syrup
30-2-10 mg/5ml)
generic
pseudoephedrine-chlorphen-dm (15-1-5 mg/5ml, 15-2-15
mg/5ml)
generic
pseudoephedrine-dexchlorpheniramine-chlophedianol (liq
15-0.5-6.25 mg/ml, liqd 60-2-25 mg/5ml)
generic
PAGE 27
MDD
2 per day
QL
240 / claim
MFL
1 / 30 days
QL
240 / claim
PRODUCT DESCRIPTION
BRAND/GEN
pseudoephedrine-guaifenesin (tab 40-400 mg, tab 60-400
mg, tab sr 12hr 60-600 mg, tab sr 12hr 120-1200 mg)
generic
pseudoephedrine-ibuprofen tab 30-200 mg
generic
PYRIL DM SUSPENSION 5-16-15 MG/5ML
BRAND
RELHIST BP TAB 4-10 MG
BRAND
RESCON DM SYRUP 30-2-10 MG/5ML
BRAND
RESPAIRE-30 CAP 30-150 MG
BRAND
RU-HIST D TAB 4-10 MG
BRAND
RYDEX G TAB 38.5-398 MG
BRAND
SCOT-TUSSIN SENIOR LIQUID 15-200 MG/5ML
BRAND
THERAFLU COLD & COUGH PACKET 10-20-20 MG
BRAND
THERAFLU COLD/COUGH DAYTIME STRIP 10-20 MG
BRAND
QL
240 / claim
TRIAMINIC COLD/COUGH DAY TIME SYRUP 2.5-5
MG/5ML
BRAND
QL
240 / claim
TRIAMINIC-D SYRUP 15-1-7.5 MG/5ML
BRAND
QL
TUSNEL C SYRUP 30-10-100 MG/5ML
BRAND
240 / claim
MFL
1 / 30 days
TUSNEL PEDIATRIC LIQUID 7.5-50 MG/ML
BRAND
SLEEP DISORDER AGENTS
SLEEP DISORDERS, OTHER
diphenhydramine hcl (sleep) (cap 25 mg, cap 50 mg, liquid
50 mg/30ml, tab 25 mg)
generic
doxylamine succinate (sleep) tab 25 mg
generic
THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES
ELECTROLYTE/MINERAL REPLACEMENT
*cobalamine combination tab***
generic
CAL-MINT CHEW TAB 260 MG
BRAND
CALCI-CHEW CHEW TAB 1250 (500 CA) MG
BRAND
PAGE 28
QL
500 / 30 days
PRODUCT DESCRIPTION
BRAND/GEN
CALCI-MIX CAP 1250 (500 CA) MG
BRAND
calcium carbonate (chew tab 260 mg (elemental ca), tab
600 mg, tab 1250 mg (500 mg elemental ca), tab 1500 mg
(600 mg elemental ca))
generic
calcium carbonate susp 1250 mg/5ml (500 mg/5ml
elemental ca)
generic
CALCIUM CARBONATE WAFER 500 (200 CA) MG
BRAND
calcium carbonate-cholecalciferol (tab 600 mg-800, tab
600 mg-400)
generic
calcium carbonate-vitamin d (tab 500 mg-200, tab 500 mg400, tab 600 mg-400, tab 600 mg-200)
generic
calcium citrate (oral granules 760 mg/3.5gm (elemental
ca), tab 250 mg, tab 950 mg (200 mg elemental ca))
generic
calcium gluconate (tab 50 mg (elemental ca), tab 500 mg,
tab 648 mg (60 mg elemental ca))
generic
carbonyl iron susp 15 mg/1.25ml (elemental iron)
generic
CERALYTE 50 POTASSIUM FREE PACKET
BRAND
CERALYTE 70 POTASSIUM FREE PACKET
BRAND
CVS SLOW RELEASE IRON TAB ER 143 (45 FE) MG
BRAND
DRIPDROP HYDRATION PACKET
BRAND
DRIPDROP PACKET
BRAND
EMERGEN-C ELECTRO MIX PACKET
BRAND
ENFALYTE SOLUTION
BRAND
ENFAMIL ENFALYTE SOLUTION
BRAND
FERRETTS CHEWABLE IRON CHEW TAB 18 MG
BRAND
FERRETTS TAB 325 (106 FE) MG
BRAND
FERRIMIN 150 TAB 150 MG
BRAND
ferrous fumarate tab 29 mg (fe equivalent)
generic
ferrous fumarate tab 324 mg (106 mg elemental fe)
generic
FERROUS FUMARATE TAB 90 MG
BRAND
ferrous gluconate (tab 240 mg (27 mg fe), tab 324 mg
(37.5 mg iron), tab 324 mg (38 mg iron))
generic
PAGE 29
QL
500 / 30 days
MDD
2 per day
MDD
2 per day
MDD
2 per day
PRODUCT DESCRIPTION
BRAND/GEN
ferrous sulfate (elixir 220 mg/5ml (44 mg/5ml elemental fe),
liquid 220 mg/5ml (44 mg/5ml elemental fe), soln 75 mg/ml
(15 mg/ml elemental fe), tab 325 mg (65 mg elemental fe),
tab ec 325 mg (65 mg fe equivalent))
generic
ferrous sulfate (syrup 300 mg/5ml (60 mg/5ml elemental
fe), tab 134 mg (27 mg elemental fe), tab cr 47.5 mg
(elemental fe), tab cr 140 mg (45 mg fe equivalent), tab cr
142 mg (45 mg fe equivalent), tab ec 324 mg (65 mg fe
equivalent))
generic
ferrous sulfate dried (tab 200 mg (65 mg elemental fe), tab
cr 45 mg (fe equivalent))
generic
IRON CHEWS PEDIATRIC CHEW TAB 15 MG
BRAND
magnesium (tab 100 mg, tab 250 mg)
generic
magnesium gluconate (tab 27.5 mg (elemental, tab 500 mg
(27 mg elemental)
generic
magnesium oxide (mg supplement) (tab 250 mg (mg
supplement), tab 400 mg (241.3 mg elemental mg), tab
400 mg (240 mg elemental mg), tab 500 mg (mg
supplement))
generic
MAGONATE LIQUID 1000 (54 MG) MG/5ML
BRAND
NORMALYTE PACKET
BRAND
oral electrolytes (solution***, tab***)
generic
PEDIALYTE PACKET
BRAND
PHOS-NAK PACKET 280-160-250 MG
BRAND
potassium gluconate (tab 80 mg (elemental ), tab 595 mg
(99 mg equiv k))
generic
SLOW RELEASE IRON (TAB ER 50 MG, TAB ER 140 (45
FE) MG)
BRAND
SM SLOW RELEASE IRON TAB ER 143 (45 FE) MG
BRAND
zinc sulfate (cap 220 mg mg elemental zn), tab 220 mg mg
equivalent))
generic
*b-complex vitamin cap**
generic
*b-complex w/ c tab**
generic
*multiple vitamins w/ iron tab**
generic
PAGE 30
MDD
16 per day
MDD
1 per day
MDD
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
*multiple vitamins w/ minerals chew tab**
generic
*pediatric multiple vitamin w/ c & fa chew tab**
generic
MDD
1 per day
*pediatric multiple vitamin w/ c soln 35 mg/ml**
generic
QL
50 / claim
*pediatric vitamins adc drops 1500 unit-400 unit-35
mg/ml***
generic
QL
50 / claim
*prenatal vit w/ fe fumarate-fa tab 27-0.8 mg***
GL
generic
Female
MDD
1 per day
AIRBORNE LOZENGE
BRAND
ANTIOXIDANT ULTRA FORMULA CAP
BRAND
MDD
1 per day
AQUADEKS CAP
BRAND
MDD
1 per day
AQUADEKS CHEW TAB
BRAND
ascorbic acid (cap cr 500 mg, chew tab 100 mg, chew tab
250 mg, chew tab 500 mg, lozenge 60 mg, tab 100 mg, tab
cr 500 mg, tab cr 1000 mg)
generic
ascorbic acid (tab 250 mg, tab 500 mg, tab 1000 mg)
generic
QL
100 / 34 days
ascorbic acid syrup 500 mg/5ml
generic
QL
100 / 30 days
b-complex vitamins (tab cr**, tab**)
generic
b-complex w/ c & folic acid (w/ tab 0.8 mg***, w/ tab***)
generic
biotin (cap 5 mg, cap 10 mg, tab 2.5 mg, tab 5 mg, tab 10
mg, tab 300 mcg)
generic
BIOTIN MAXIMUM STRENGTH TAB 10000 MCG
BRAND
CERTAVITE SENIOR/ANTIOXIDANT TAB
BRAND
cholecalciferol (cap 400 unit, cap 1000 unit, cap 2000 unit,
cap 5000 unit, cap 10000 unit, chew tab 400 unit, chew tab
1000 unit, oral liquid 400 unit/ml, tab 400 unit, tab 1000
unit, tab 2000 unit, tab 3000 unit, tab 5000 unit, tab 50000
unit)
generic
COMPLETE FORMULATION D5000 CAP
BRAND
CVS AIRSHIELD IMMUNITY SUPPORT CHEW TAB
BRAND
PAGE 31
MDD
1 per day
MDD
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
cyanocobalamin (chew tab 2500 mcg, lozenge 50 mcg,
lozenge 100 mcg, lozenge 250 mcg, lozenge 500 mcg, tab
100 mcg, tab 250 mcg, tab 500 mcg, tab 1000 mcg, tab cr
1000 mcg, tab cr 2000 mcg, tab sl 2500 mcg)
generic
DEKAS ESSENTIAL CAP
BRAND
MDD
1 per day
DEKAS PLUS CAP
BRAND
MDD
1 per day
DERMAVITE TAB
BRAND
MDD
1 per day
docosahexaenoic acid cap 200 mg
generic
ELDERTONIC ELIXIR
BRAND
ELLIS TONIC ELIXIR
BRAND
EMERGEN-C BLUE PACKET
BRAND
EMERGEN-C FIVE PACKET
BRAND
EMERGEN-C HEART HEALTH PACKET
BRAND
EMERGEN-C IMMUNE PACKET
BRAND
EMERGEN-C IMMUNE PLUS PACKET
BRAND
EMERGEN-C IMMUNE+WARMERS PACKET
BRAND
EMERGEN-C JOINT HEALTH PACKET
BRAND
EMERGEN-C KIDZ PACKET
BRAND
EMERGEN-C MSM LITE PACKET
BRAND
EMERGEN-C PINK PACKET
BRAND
EMERGEN-C VITAMIN C LITE PACKET
BRAND
EMERGEN-C VITAMIN C PACKET
BRAND
EMERGEN-C VITAMIN D/CALCIUM PACKET
BRAND
ergocalciferol (soln 8000 unit/ml, tab 400 unit, tab 2000
unit)
generic
folic acid (tab 400 mcg, tab 800 mcg)
generic
MDD
1 per day
FREEDAVITE TAB
BRAND
MDD
1 per day
GERI-FREEDA SENIOR FORMULA TAB
BRAND
MDD
1 per day
GNP PRENATAL TAB 28-0.8 MG
BRAND
GL
MDD
PAGE 32
Female
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
GOODSENSE PRENATAL VITAMINS TAB 28-0.8 MG
BRAND
GL
Female
MDD
1 per day
HM COMPLETE 50+ MENS ULTIMATE TAB
BRAND
MDD
1 per day
HM COMPLETE 50+ WOMEN ULTIMATE TAB
BRAND
MDD
1 per day
HM COMPLETE TAB
BRAND
MDD
1 per day
HM HAIR/SKIN/NAILS TAB
BRAND
MDD
1 per day
HM ONE DAILY MENS TAB
BRAND
MDD
1 per day
HM ONE DAILY WOMENS TAB
BRAND
MDD
1 per day
HM PRENATAL TAB 28-0.8 MG
BRAND
GL
HM VITAMIN D3 CAP 4000 UNIT
BRAND
ICAPS AREDS FORMULA TAB
BRAND
ICAPS LUTEIN & ZEAXANTHIN TAB DR
BRAND
ICAPS PLUS TAB
BRAND
KPN PRENATAL TAB 0.1 MG
BRAND
Female
MDD
1 per day
MDD
1 per day
MDD
1 per day
GL
Female
MDD
1 per day
MEGA MULTIVITAMIN FOR MEN TAB
BRAND
MDD
1 per day
MEGA MULTIVITAMIN FOR WOMEN TAB
BRAND
MDD
1 per day
MULTI-BETIC TAB
BRAND
MDD
1 per day
MULTI-DELYN/IRON LIQUID
BRAND
MULTI-VITAMIN MONOCAPS TAB
BRAND
MDD
1 per day
multiple vitamin (liquid**, tab**)
generic
MDD
1 per day
multiple vitamins w/ minerals (w/ cap**, w/ liquid**, w/ tab
cr**, w/ tab**)
generic
MDD
1 per day
MULTIVITAMIN ADULT TAB
BRAND
MDD
1 per day
MULTIVITAMIN MEN TAB
BRAND
MDD
1 per day
PAGE 33
PRODUCT DESCRIPTION
BRAND/GEN
MYKIDZ IRON SUSPENSION 10 MG/2ML
BRAND
NATURAL VITAMIN E TAB 200 UNIT
BRAND
NEPHRONEX LIQUID
BRAND
niacin (cap cr 250 mg, cap cr 500 mg, tab 50 mg, tab 100
mg, tab 250 mg, tab 500 mg)
generic
OCUVITE ADULT 50+ CAP
QL
60 / claim
BRAND
MDD
1 per day
OCUVITE-LUTEIN CAP
BRAND
MDD
1 per day
ONCOVITE TAB
BRAND
MDD
1 per day
ONE DAILY PLUS IRON TAB
BRAND
MDD
1 per day
PARVLEX TAB
BRAND
MDD
1 per day
pediatric multiple vitamins w/ iron (w/ chew tab 15 mg**, w/
drops 10 mg/ml**)
generic
PNV PRENATAL PLUS MULTIVITAMIN TAB 27-1 MG
BRAND
QL
100 / 100 days
GL
Female
MDD
polysaccharide iron complex (cap 150 mg (equivalent), cap
434.8 mg (200 mg elem fe))
generic
PRENATAL (TAB 27-0.8 MG, TAB 28-0.8 MG)
BRAND
GL
MDD
GL
PRENATAL LOW IRON TAB 27-0.8 MG
BRAND
MDD
GL
PRENATAL ONE DAILY TAB 27-0.8 MG
BRAND
MDD
1 per day
Female
1 per day
Female
1 per day
Female
1 per day
PRENATAL TAB 6.75-0.2 MG
BRAND
GL
PRESERVISION AREDS (CAP, TAB)
BRAND
MDD
1 per day
PRESERVISION AREDS 2 CAP
BRAND
MDD
1 per day
PRESERVISION/LUTEIN CAP
BRAND
MDD
1 per day
PROFE CAP 391.3 (180 FE) MG
BRAND
PAGE 34
Female
PRODUCT DESCRIPTION
BRAND/GEN
PRORENAL + D TAB
BRAND
MDD
1 per day
PRORENAL + D W/ OMEGA-3 CAP
BRAND
MDD
1 per day
pyridoxine hcl (tab 25 mg, tab 50 mg, tab 100 mg, tab 250
mg)
generic
QUIN B STRONG TAB
BRAND
MDD
1 per day
QUINTABS TAB
BRAND
MDD
1 per day
QUINTABS-M TAB
BRAND
MDD
1 per day
RENAPLEX-D TAB
BRAND
MDD
1 per day
riboflavin tab 100 mg
generic
riboflavin tab 50 mg
generic
SM B-COMPLEX/VITAMIN C TAB
BRAND
SM ONE DAILY MENS TAB
BRAND
MDD
1 per day
SM ONE DAILY WOMENS TAB
BRAND
MDD
1 per day
SM PRENATAL VITAMINS TAB 28-0.8 MG
BRAND
QL
GL
100 / 34 days
Female
MDD
1 per day
MDD
1 per day
SM VITAMIN D3 CAP 4000 UNIT
BRAND
SOURCECF CAP
BRAND
SOURCECF CHEW TAB
BRAND
T-VITES TAB
BRAND
MDD
1 per day
THERA M PLUS TAB
BRAND
MDD
1 per day
THERA-M TAB
BRAND
MDD
1 per day
THERA/BETA-CAROTENE TAB
BRAND
MDD
1 per day
THEREMS-H TAB
BRAND
MDD
1 per day
THEREMS-M TAB
BRAND
MDD
1 per day
thiamine hcl (tab 50 mg, tab 100 mg, tab 250 mg)
generic
QL
100 / 34 days
thiamine mononitrate tab 100 mg
generic
QL
100 / 34 days
PAGE 35
PRODUCT DESCRIPTION
BRAND/GEN
TRI-VI-SOL SOLUTION 750-400-35 UNIT-MG/ML
BRAND
TRI-VI-SOL/IRON SOLUTION 10 MG/ML
BRAND
tryptophan tab 500 mg
generic
UNICOMPLEX-M TAB
BRAND
VITA-C CRYSTALS
BRAND
vitamin a (cp 10000, tb 10000)
generic
vitamin e (cap 100 unit, cap 200 unit, cap 400 unit, liquid
400 unit/15ml (26.6 unit/ml))
generic
vitamin e (cap 1000 unit, oral oil 100 unit/0.25ml, soln 15
unit/0.3ml (50 unit/ml), tab 100 unit, tab 200 unit, tab 400
unit)
generic
vitamins w/ lipotropics (w/ cap**, w/ tab**)
QL
50 / claim
MDD
1 per day
MDD
2 per day
generic
MDD
1 per day
YELETS TEENAGE FORMULA TAB
BRAND
MDD
1 per day
ZINC LOZENGE
BRAND
PAGE 36
LIST OF COVERED PRESCRIPTION MEDICATIONS
PRODUCT DESCRIPTION
BRAND/GEN
ANALGESICS
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
butalbital-aspirin-caffeine tab 50-325-40 mg
generic
celecoxib (cap 50 mg, cap 100 mg, cap 200 mg, cap 400
mg)
generic
choline & magnesium salicylates liq 500 mg/5ml
generic
diclofenac potassium tab 50 mg
generic
diclofenac sodium (tab delayed release 25 mg, tab delayed
release 50 mg, tab delayed release 75 mg, tab sr 24hr 100
mg)
generic
diclofenac sodium soln 1.5%
generic
diflunisal tab 500 mg
generic
etodolac (cap 200 mg, cap 300 mg, tab 400 mg, tab 500
mg, tab sr 24hr 600 mg, tab sr 24hr 400 mg, tab sr 24hr
500 mg)
generic
fenoprofen calcium (cap 400 mg, tab 600 mg)
generic
flurbiprofen (tab 50 mg, tab 100 mg)
generic
ibuprofen (susp 100 mg/5ml, tab 400 mg, tab 600 mg, tab
800 mg)
generic
indomethacin (cap 25 mg, cap 50 mg)
generic
ketoprofen (cap 50 mg, cap 75 mg, cap sr 24hr 200 mg)
generic
ketorolac tromethamine tab 10 mg
generic
PA
MDD
meclofenamate sodium (cap 50 mg, cap 100 mg)
generic
meloxicam (tab 7.5 mg, tab 15 mg)
generic
nabumetone (tab 500 mg, tab 750 mg)
generic
NALFON (CAP 200 MG, CAP 400 MG)
BRAND
naproxen (susp 125 mg/5ml, tab 250 mg, tab 375 mg, tab
500 mg, tab ec 375 mg, tab ec 500 mg)
generic
PAGE 37
2 per day
QL
20 / 30 days
AL
At least 17 yrs old
MDD
1 per day
MDD
2 per day
PRODUCT DESCRIPTION
BRAND/GEN
naproxen sodium (tab 275 mg, tab 550 mg)
generic
oxaprozin tab 600 mg
generic
piroxicam (cap 10 mg, cap 20 mg)
generic
salsalate (tab 500 mg, tab 750 mg)
generic
SPRIX SOLUTION 15.75 MG/SPRAY
BRAND
sulindac (tab 150 mg, tab 200 mg)
MDD
2 per day
QL
20 / 30 days
AL
At least 18 yrs old
generic
OPIOID ANALGESICS, LONG-ACTING
fentanyl (patch 72hr 25 mcg/hr, patch 72hr 12 mcg/hr,
patch 72hr 100 mcg/hr, patch 72hr 75 mcg/hr, patch 72hr
50 mcg/hr)
generic
KADIAN CAP ER 24H 40 MG
BRAND
methadone hcl (conc 10 mg/ml, tab 10 mg)
MDD
0.33 per day
generic
MDD
6 per day
methadone hcl soln 10 mg/5ml
generic
MDD
30 per day
methadone hcl soln 5 mg/5ml
generic
MDD
60 per day
methadone hcl tab 5 mg
generic
MDD
12 per day
methadone hcl tab for oral susp 40 mg
generic
MDD
1.5 per day
morphine sulfate (tab 15 mg, tab 30 mg, tab 60 mg, tab
100 mg, tab 200 mg)
generic
MDD
3 per day
OPANA ER (ER TB12 DETER 5 MG, ER TB12 DETER 15
MG, ER TB12 DETER 30 MG, ER TB12 DETER 7.5 MG,
ER TB12 DETER 20 MG, ER TB12 DETER 10 MG)
BRAND
oxycodone hcl (tab er deter 10 mg, tab er deter 20 mg, tab
er deter 40 mg, tab er deter 80 mg)
generic
OXYCONTIN (TB12 DETER 60 MG, TB12 DETER 40 MG,
TB12 DETER 30 MG, TB12 DETER 80 MG, TB12 DETER
20 MG, TB12 DETER 10 MG, TB12 DETER 15 MG)
BRAND
tramadol hcl (tab 24hr biphasic release 300 mg, tab 24hr
300 mg, tab 24hr biphasic release 200 mg, tab 24hr
biphasic release 100 mg)
generic
TRAMADOL HCL ER CAP ER 24H 150 MG
BRAND
PAGE 38
PA
MDD
2 per day
PA
MDD
2 per day
MDD
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
OPIOID ANALGESICS, SHORT-ACTING
acetaminophen w/ codeine (w/ tab 300-60 mg, w/ tab 30030 mg, w/ tab 300-15 mg)
generic
MDD
13 per day
acetaminophen w/ codeine soln 120-12 mg/5ml
generic
MDD
30 per day
butalbital-acetaminophen-caff w/ cod cap 50-300-40-30 mg
generic
butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg
generic
MDD
4 per day
butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg
generic
MDD
4 per day
CAPITAL/CODEINE SUSPENSION 120-12 MG/5ML
BRAND
MDD
13 per day
codeine sulfate (tab 15 mg, tab 30 mg, tab 60 mg)
generic
MDD
2 per day
hydrocodone-acetaminophen (soln 7.5-325 mg/15ml, soln
10-325 mg/15ml)
generic
MDD
180 per day
hydrocodone-acetaminophen (tab 2.5-325 mg, tab 5-325
mg, tab 7.5-325 mg, tab 10-325 mg)
generic
MDD
12 per day
hydrocodone-acetaminophen (tab 5-300 mg, tab 7.5-300
mg, tab 10-300 mg)
generic
MDD
13 per day
hydrocodone-ibuprofen (tab 2.5-200 mg, tab 5-200 mg, tab
7.5-200 mg, tab 10-200 mg)
generic
hydromorphone hcl (tab 2 mg, tab 4 mg, tab 8 mg)
generic
MDD
8 per day
hydromorphone hcl liqd 1 mg/ml
generic
MDD
80 per day
hydromorphone hcl suppos 3 mg
generic
QL
12 / claim
meperidine hcl (tab 50 mg, tab 100 mg)
generic
MDD
6 per day
meperidine hcl oral soln 50 mg/5ml
generic
morphine sulfate (suppos 5 mg, suppos 10 mg, suppos 20
mg, suppos 30 mg)
generic
QL
24 / claim
morphine sulfate (tab 15 mg, tab 30 mg)
generic
MDD
6 per day
morphine sulfate oral soln 10 mg/5ml
generic
MDD
100 per day
morphine sulfate oral soln 100 mg/5ml (20 mg/ml)
QL
generic
240 / claim
MDD
10 per day
MDD
50 per day
morphine sulfate oral soln 20 mg/5ml
PAGE 39
generic
PRODUCT DESCRIPTION
BRAND/GEN
OXAYDO (TAB DETER 5 MG, TAB DETER 7.5 MG)
BRAND
oxycodone hcl (cap 5 mg, conc 100 mg/5ml (20 mg/ml),
tab 5 mg, tab 10 mg, tab 15 mg, tab 20 mg, tab 30 mg)
generic
MDD
6 per day
oxycodone hcl soln 5 mg/5ml
generic
MDD
30 per day
oxycodone w/ acetaminophen (w/ tab 2.5-325 mg, w/ tab 5325 mg, w/ tab 7.5-325 mg, w/ tab 10-325 mg)
generic
MDD
8 per day
oxycodone-aspirin tab 4.8355-325 mg
generic
MDD
6 per day
oxycodone-ibuprofen tab 5-400 mg
generic
MDD
4 per day
tramadol hcl tab 50 mg
generic
MDD
8 per day
tramadol-acetaminophen tab 37.5-325 mg
generic
MDD
8 per day
lidocaine hcl (mouth-throat) (laryngotracheal soln 4%,
viscous soln 2%)
generic
QL
lidocaine hcl gel 2%
generic
C
lidocaine-prilocaine cream 2.5-2.5%
generic
MPL
ANESTHETICS
LOCAL ANESTHETICS
100 / claim
Limit=1/claim | Pkg
Size 15: Package
Limit=2/claim |
1 / claim
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
ALCOHOL DETERRENTS/ANTI-CRAVING
acamprosate calcium tab delayed release 333 mg
generic
disulfiram (tab 250 mg, tab 500 mg)
generic
naltrexone hcl tab 50 mg
generic
VIVITROL RECON SUSP 380 MG
BRAND
OPIOID DEPENDENCE TREATMENTS
PA
SUBOXONE (FILM 2-0.5 MG, FILM 4-1 MG)
BRAND
AL
MDD
PAGE 40
At least 16 yrs old
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
PA
SUBOXONE (FILM 8-2 MG, FILM 12-3 MG)
BRAND
AL
MDD
At least 16 yrs old
2 per day
OPIOID REVERSAL AGENTS
QL
EVZIO SOLN A-INJ 0.4 MG/0.4ML
BRAND
2 / 365 days
PA
MPL
2 / 365 days
naloxone hcl (inj 0.4 mg/ml, inj 1 mg/ml)
generic
QL
2 / 90 days
NARCAN LIQUID 4 MG/0.1ML
BRAND
MPL
1 / 90 days
SMOKING CESSATION AGENTS
AL
bupropion hcl (smoking deterrent) tab sr 12hr 150 mg
generic
MDD
2 per day
MDS
180 / 365 DAYS
AL
CHANTIX (TAB 0.5 MG, TAB 1 MG)
BRAND
CHANTIX STARTING MONTH PAK TAB 0.5 MG X 11 & 1
MG X 42
NICOTROL INHALER 10 MG
BRAND
2 per day
MDS
180 / 365 DAYS
2 per day
MDS
180 / 365 DAYS
QL
53 / claim
AL
At least 18 yrs old
MFL
2 / 365 days
MDS
180 / 365 DAYS
QL
504 / 30 days
AL
At least 18 yrs old
MDS
NICOTROL NS SOLUTION 10 MG/ML
BRAND
180 / 365 DAYS
QL
120 / 30 days
AL
At least 18 yrs old
MDS
PAGE 41
At least 18 yrs old
MDD
BRAND
BRAND
At least 18 yrs old
MDD
AL
CHANTIX CONTINUING MONTH PAK TAB 1 MG
At least 18 yrs old
180 ML / 365 DAYS
PRODUCT DESCRIPTION
BRAND/GEN
ANTIBACTERIALS
AMINOGLYCOSIDES
gentamicin sulfate (ophth) (oint, soln)
generic
gentamicin sulfate cream 0.1%
generic
C
Limit=2/claim | Pkg
Size 30: Package
Limit=1/claim |
gentamicin sulfate oint 0.1%
generic
C
Limit=1/claim | Pkg
Size 15: Package
Limit=2/claim |
neomycin sulfate tab 500 mg
generic
TOBRADEX OINTMENT 0.3-0.1 %
BRAND
MPL
tobramycin ophth soln 0.3%
generic
QL
tobramycin sulfate (for inj 1.2 gm, inj 1.2 gm/30ml (40
mg/ml) (base equiv), inj 2 gm/50ml (40 mg/ml) (base
equiv), inj 10 mg/ml (base equivalent), inj 80 mg/2ml (40
mg/ml) (base equiv))
generic
PA
TOBREX OINTMENT 0.3 %
BRAND
QL
1 / claim
5 / 30 days
5 / 30 days
ANTIBACTERIALS, OTHER
*methenamine-hyosc-meth blue-sod phos-phen sal tab 81
mg***
generic
ALTABAX OINTMENT 1 %
BRAND
bacitracin ophth oint 500 unit/gm
generic
CENTANY OINTMENT 2 %
BRAND
CLINDAGEL GEL 1 %
BRAND
clindamycin hcl (cap 75 mg, cap 150 mg, cap 300 mg)
generic
clindamycin palmitate hcl for soln 75 mg/5ml (base equiv)
MPL
1 / claim
generic
MPL
1 / claim
clindamycin phosphate (topical) (gel, lotion, soln)
generic
MPL
1 / claim
clindamycin phosphate vaginal cream 2%
generic
CLINDESSE CREAM 2 %
BRAND
PAGE 42
PRODUCT DESCRIPTION
BRAND/GEN
linezolid (for susp 100 mg/5ml, tab 600 mg)
generic
mafenide acetate packet for topical soln 5% (50 gm)
generic
methenamine mandelate (tab 0.5 gm, tab 1 gm)
generic
metronidazole (cap 375 mg, tab 250 mg, tab 500 mg)
generic
metronidazole cream 0.75 %
generic
QL
MPL
metronidazole gel 0.75 %
QL
generic
metronidazole lotion 0.75%
generic
metronidazole vaginal gel 0.75%
generic
mupirocin calcium cream 2%
generic
mupirocin oint 2%
generic
nitrofurantoin macrocrystal (cap 25 mg, cap 50 mg, cap
100 mg)
generic
nitrofurantoin monohydrate macrocrystalline cap 100 mg
generic
nitrofurantoin susp 25 mg/5ml
generic
SIVEXTRO TAB 200 MG
BRAND
45 / claim
1 / claim
45 / claim
MPL
1 / claim
MPL
1 / claim
QL
6 / claim
PA
SULFAMYLON CREAM 85 MG/GM
BRAND
tinidazole tab 500 mg
generic
trimethoprim tab 100 mg
generic
vancomycin hcl cap 125 mg
generic
MDD
4 per day
vancomycin hcl cap 250 mg
generic
MDD
8 per day
XIFAXAN (TAB 200 MG, TAB 550 MG)
BRAND
PA
BETA-LACTAM, CEPHALOSPORINS
cefadroxil (cap 500 mg, for susp 250 mg/5ml, for susp 500
mg/5ml, tab 1 gm)
generic
cefdinir (susp 125 mg/5ml, susp 250 mg/5ml)
generic
PAGE 43
MPL
1 / claim
PRODUCT DESCRIPTION
BRAND/GEN
cefdinir cap 300 mg
generic
cefixime (susp 100 mg/5ml, susp 200 mg/5ml)
generic
cefprozil (susp 125 mg/5ml, susp 250 mg/5ml)
generic
cefprozil (tab 250 mg, tab 500 mg)
generic
CEFTIN (RECON SUSP 125 MG/5ML, RECON SUSP 250
MG/5ML)
BRAND
cefuroxime axetil (tab 250 mg, tab 500 mg)
generic
cephalexin (cap 250 mg, cap 500 mg, cap 750 mg, for
susp 125 mg/5ml, for susp 250 mg/5ml, tab 250 mg, tab
500 mg)
generic
SUPRAX (CAP 400 MG, CHEW TAB 100 MG, CHEW TAB
200 MG, RECON SUSP 500 MG/5ML, TAB 400 MG)
BRAND
QL
30 / claim
MPL
1 / claim
BETA-LACTAM, PENICILLINS
amoxicillin & pot clavulanate (chew tab 200-28.5 mg, chew
tab 400-57 mg, tab 250-125 mg, tab 500-125 mg, tab 875125 mg, tab sr 12hr 1000-62.5 mg)
generic
amoxicillin & pot clavulanate (susp 200-28.5 mg/5ml, susp
250-62.5 mg/5ml)
generic
MPL
1 / claim
amoxicillin & pot clavulanate (susp 400-57 mg/5ml, susp
600-42.9 mg/5ml)
generic
MPL
2 / claim
amoxicillin (cap 250 mg, cap 500 mg, chew tab 125 mg,
chew tab 250 mg, for susp 125 mg/5ml, for susp 200
mg/5ml, for susp 250 mg/5ml, for susp 400 mg/5ml, tab
500 mg, tab 875 mg)
generic
ampicillin (cap 250 mg, cap 500 mg)
generic
AMPICILLIN (RECON SUSP 125 MG/5ML, RECON SUSP
250 MG/5ML)
BRAND
dicloxacillin sodium (cap 250 mg, cap 500 mg)
generic
penicillin v potassium (for soln 125 mg/5ml, for soln 250
mg/5ml, tab 250 mg, tab 500 mg)
generic
MACROLIDES
azithromycin (powd pack for susp 1 gm, tab 250 mg, tab
500 mg, tab 600 mg)
PAGE 44
generic
PRODUCT DESCRIPTION
BRAND/GEN
azithromycin for susp 100 mg/5ml
generic
azithromycin for susp 200 mg/5ml
MPL
1 / claim
MPL
2 / claim
generic
C
Limit=1/claim | Pkg
Size 22.5: Package
Limit=2/claim | Pkg
Size 30: Package
Limit=2/claim |
clarithromycin (tab 250 mg, tab 500 mg, tab sr 24hr 500
mg)
generic
clarithromycin for susp 125 mg/5ml
generic
MPL
1 / claim
clarithromycin for susp 250 mg/5ml
generic
MPL
2 / claim
E.E.S. 400 TAB 400 MG
BRAND
E.E.S. GRANULES RECON SUSP 200 MG/5ML
BRAND
ERY-TAB (TAB DR 250 MG, TAB DR 333 MG, TAB DR
500 MG)
BRAND
ERYPED 200 RECON SUSP 200 MG/5ML
BRAND
ERYPED 400 RECON SUSP 400 MG/5ML
BRAND
ERYTHROMYCIN BASE (TAB 250 MG, TAB 500 MG)
BRAND
ERYTHROMYCIN ETHYLSUCCINATE TAB 400 MG
BRAND
erythromycin gel 2%
generic
MPL
1 / claim
erythromycin ophth oint 5 mg/gm
generic
erythromycin soln 2%
generic
erythromycin w/ delayed release particles cap 250 mg
generic
MPL
1 / claim
MPL
1 / claim
QUINOLONES
CILOXAN OINTMENT 0.3 %
BRAND
ciprofloxacin (susp 250 mg/5ml (5%) (5 gm/100ml), susp
500 mg/5ml (10%) (10 gm/100ml))
generic
ciprofloxacin hcl (tab 100 mg, tab 250 mg, tab 500 mg, tab
750 mg)
generic
ciprofloxacin hcl ophth soln 0.3%
generic
PAGE 45
PRODUCT DESCRIPTION
BRAND/GEN
levofloxacin (tab 250 mg, tab 500 mg, tab 750 mg)
generic
levofloxacin oral soln 25 mg/ml
generic
ofloxacin ophth soln 0.3%
generic
ofloxacin otic soln 0.3%
MDD
1 per day
generic
MPL
1 / claim
ofloxacin tab 400 mg
generic
QL
56 / claim
VIGAMOX SOLUTION 0.5 %
BRAND
QL
3 / claim
SULFONAMIDES
silver sulfadiazine cream 1%
generic
sulfacetamide sodium (ophth) (oint, soln)
generic
sulfamethoxazole-trimethoprim (susp 200-40 mg/5ml, tab
400-80 mg, tab 800-160 mg)
generic
TETRACYCLINES
doxycycline (monohydrate) (cap 50 mg, cap 75 mg, cap
100 mg, cap 150 mg, for susp 25 mg/5ml, tab 50 mg, tab
75 mg, tab 100 mg, tab 150 mg)
generic
doxycycline hyclate (cap 50 mg, cap 100 mg, tab 20 mg,
tab 100 mg)
generic
minocycline hcl (cap 50 mg, cap 75 mg, cap 100 mg, tab
50 mg, tab 100 mg, tab sr 24hr 45 mg, tab sr 24hr 135 mg,
tab sr 24hr 90 mg)
generic
SOLODYN (TAB ER 24H 55 MG, TAB ER 24H 115 MG,
TAB ER 24H 80 MG, TAB ER 24H 65 MG, TAB ER 24H
105 MG)
BRAND
ANTICONVULSANTS
ANTICONVULSANTS, OTHER
levetiracetam (inj 500 mg/5ml (100 mg/ml), oral soln 100
mg/ml, tab 250 mg, tab 500 mg, tab 750 mg, tab 1000 mg,
tab sr 24hr 750 mg, tab sr 24hr 500 mg)
generic
LEVETIRACETAM IN NACL (SOLUTION 500 MG/100ML,
SOLUTION 1000 MG/100ML, SOLUTION 1500
MG/100ML)
BRAND
PAGE 46
PRODUCT DESCRIPTION
BRAND/GEN
POTIGA (TAB 200 MG, TAB 300 MG, TAB 400 MG)
BRAND
POTIGA TAB 50 MG
BRAND
MDD
3 per day
CALCIUM CHANNEL MODIFYING AGENTS
CELONTIN CAP 300 MG
BRAND
ethosuximide (cap 250 mg, soln 250 mg/5ml)
generic
zonisamide (cap 25 mg, cap 50 mg, cap 100 mg)
generic
GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS
diazepam (anticonvulsant) (gel 2.5 mg, gel 10 mg, gel 20
mg)
generic
divalproex sodium (cap delayed release sprinkle 125 mg,
tab delayed release 125 mg, tab delayed release 250 mg,
tab delayed release 500 mg, tab sr 24 hr 500 mg, tab sr 24
hr 250 mg)
generic
gabapentin (cap 100 mg, cap 300 mg, cap 400 mg, oral
soln 250 mg/5ml, tab 600 mg, tab 800 mg)
generic
GABITRIL (TAB 12 MG, TAB 16 MG)
BRAND
NEMBUTAL SOLUTION 50 MG/ML
BRAND
ONFI SUSPENSION 2.5 MG/ML
BRAND
MDD
32 per day
ONFI TAB 10 MG
BRAND
MDD
8 per day
ONFI TAB 20 MG
BRAND
MDD
4 per day
phenobarbital (elixir 20 mg/5ml, tab 15 mg, tab 16.2 mg,
tab 30 mg, tab 32.4 mg, tab 60 mg, tab 64.8 mg, tab 97.2
mg, tab 100 mg)
generic
phenobarbital sodium (inj 65 mg/ml, inj 130 mg/ml)
generic
primidone (tab 50 mg, tab 250 mg)
generic
SABRIL (PACKET 500 MG, TAB 500 MG)
BRAND
THERAPENTIN-90 MISC 300 MG
BRAND
tiagabine hcl (tab 2 mg, tab 4 mg)
generic
valproate sodium (inj 100 mg/ml, syrup 250 mg/5ml (base
equiv))
generic
PAGE 47
S
Specialty Drug
PRODUCT DESCRIPTION
BRAND/GEN
valproic acid cap 250 mg
generic
GLUTAMATE REDUCING AGENTS
felbamate susp 600 mg/5ml
generic
MDD
120 per day
felbamate tab 400 mg
generic
MDD
9 per day
felbamate tab 600 mg
generic
MDD
6 per day
LAMICTAL CHEW TAB 2 MG
BRAND
LAMICTAL STARTER (KIT 25 (84)-100(14) MG, KIT 25
(35) MG, KIT 25 (42)-100 (7) MG)
BRAND
LAMICTAL XR (KIT 25 (21)-50 (7) MG, KIT 25 50 100 MG,
KIT 50 100 200 MG)
BRAND
lamotrigine (orally disintegrating tab 25 mg, orally
disintegrating tab 50 mg, orally disintegrating tab 100 mg,
orally disintegrating tab 200 mg, tab 25 mg, tab 100 mg,
tab 150 mg, tab 200 mg, tab chewable dispersible 5 mg,
tab chewable dispersible 25 mg, tab disp 25 mg (21) & 50
mg (7) titration kit, tab disp 25 (14) & 50 mg (14) & 100 mg
(7) kit, tab disp 50 mg (42) & 100 mg (14) titration kit, tab sr
24hr 50 mg, tab sr 24hr 25 mg, tab sr 24hr 100 mg, tab sr
24hr 250 mg, tab sr 24hr 300 mg, tab sr 24hr 200 mg)
generic
topiramate (cap er 24hr 150 mg, cap er 24hr 50 mg, cap er
24hr 25 mg, cap er 24hr 200 mg, cap er 24hr 100 mg)
generic
MDD
1 per day
topiramate (sprinkle cap 15 mg, sprinkle cap 25 mg, tab 25
mg, tab 50 mg, tab 100 mg, tab 200 mg)
generic
TROKENDI XR (CAP ER 24H 50 MG, CAP ER 24H 25
MG, CAP ER 24H 100 MG, CAP ER 24H 200 MG)
BRAND
MDD
2 per day
APTIOM (TAB 200 MG, TAB 600 MG)
BRAND
MDD
2 per day
APTIOM TAB 400 MG
BRAND
MDD
3 per day
APTIOM TAB 800 MG
BRAND
MDD
1 per day
BANZEL (SUSPENSION 40 MG/ML, TAB 200 MG, TAB
400 MG)
BRAND
SODIUM CHANNEL AGENTS
PAGE 48
PRODUCT DESCRIPTION
BRAND/GEN
carbamazepine (cap sr 12hr 200 mg, cap sr 12hr 300 mg,
cap sr 12hr 100 mg, chew tab 100 mg, susp 100 mg/5ml,
tab 200 mg, tab sr 12hr 100 mg, tab sr 12hr 200 mg, tab sr
12hr 400 mg)
generic
DILANTIN CAP 30 MG
BRAND
oxcarbazepine (susp 300 mg/5ml (60 mg/ml), tab 150 mg,
tab 300 mg, tab 600 mg)
generic
OXTELLAR XR (TAB ER 24H 600 MG, TAB ER 24H 300
MG, TAB ER 24H 150 MG)
BRAND
PEGANONE TAB 250 MG
BRAND
phenytoin (chew tab 50 mg, susp 125 mg/5ml)
generic
phenytoin sodium extended (cap 100 mg, cap 200 mg, cap
300 mg)
generic
VIMPAT (SOLUTION 10 MG/ML, SOLUTION 200
MG/20ML, TAB 50 MG, TAB 100 MG, TAB 150 MG, TAB
200 MG)
BRAND
ANTIDEMENTIA AGENTS
ANTIDEMENTIA AGENTS, OTHER
ergoloid mesylates tab 1 mg
generic
isoxsuprine hcl tab 10 mg
generic
MDD
3 per day
CHOLINESTERASE INHIBITORS
donepezil hydrochloride (orally disintegrating tab 5 mg,
orally disintegrating tab 10 mg, tab 5 mg, tab 10 mg, tab 23
mg)
generic
MDD
1 per day
galantamine hydrobromide (cap 24hr 8 mg, cap 24hr 24
mg, cap 24hr 16 mg)
generic
MDD
1 per day
galantamine hydrobromide (tab 4 mg, tab 8 mg, tab 12 mg)
generic
MDD
2 per day
galantamine hydrobromide oral soln 4 mg/ml
generic
MDD
6 per day
NAMZARIC (CAP ER 24H 14-10 MG, CAP ER 24H 28-10
MG)
BRAND
MDD
1 per day
rivastigmine (patch 24hr 13.3 mg/24hr, patch 24hr 4.6
mg/24hr, patch 24hr 9.5 mg/24hr)
generic
MDD
1 per day
PAGE 49
PRODUCT DESCRIPTION
BRAND/GEN
rivastigmine tartrate (cap 1.5 mg, cap 3 mg, cap 4.5 mg,
cap 6 mg)
generic
MDD
2 per day
N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST
memantine hcl (tab 5 mg, tab 5 mg (28) & 10 mg (21)
titration pak, tab 10 mg)
generic
MDD
2 per day
memantine hcl oral solution 2 mg/ml
generic
MDD
10 per day
NAMENDA XR (CAP ER 24H 7 MG, CAP ER 24H 21 MG,
CAP ER 24H 28 MG, CAP ER 24H 14 MG)
BRAND
MDD
1 per day
NAMENDA XR TITRATION PACK CAP ER 24H 7 & 14 &
21 &28 MG
BRAND
MPL
1 / 28 days
APLENZIN (TAB ER 24H 348 MG, TAB ER 24H 174 MG,
TAB ER 24H 522 MG)
BRAND
MDD
1 per day
APPBUTAMONE MISC 75 MG
BRAND
bupropion hcl (tab 100 mg, tab 150 mg, tab 200 mg)
generic
MDD
2 per day
bupropion hcl (tab 24hr 150 mg, tab 24hr 300 mg)
generic
MDD
1 per day
bupropion hcl (tab 75 mg, tab 100 mg)
generic
MDD
4 per day
bupropion hcl er (sr) tab er 12h 100 mg
generic
MDD
2 per day
generic
MDD
2 per day
chlordiazepoxide-amitriptyline (tab 5-12.5 mg, tab 10-25
mg)
generic
FORFIVO XL TAB ER 24H 450 MG
BRAND
MDD
1 per day
mirtazapine (orally disintegrating tab 15 mg, orally
tab 7.5 mg, tab 15 mg, tab 30 mg, tab 45 mg)
generic
MDD
1 per day
olanzapine-fluoxetine hcl (cap 3-25 mg, cap 6-25 mg, cap
6-50 mg, cap 12-50 mg, cap 12-25 mg)
generic
perphenazine-amitriptyline (tab 2-10 mg, tab 2-25 mg, tab
4-10 mg, tab 4-25 mg, tab 4-50 mg)
generic
ANTIDEPRESSANTS
ANTIDEPRESSANTS, OTHER
PAGE 50
AL
MDD
At least 18 yrs old
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
MONOAMINE OXIDASE INHIBITORS
EMSAM (PATCH 24HR 6 MG/24HR, PATCH 24HR 9
MG/24HR, PATCH 24HR 12 MG/24HR)
BRAND
MDD
1 per day
MARPLAN TAB 10 MG
BRAND
MDD
3 per day
phenelzine sulfate tab 15 mg
generic
MDD
6 per day
tranylcypromine sulfate tab 10 mg
generic
MDD
6 per day
SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITORS/SEROTONIN AND NOREPINEPHRINE
REUPTAKE INHIBITOR
BRINTELLIX (TAB 5 MG, TAB 10 MG, TAB 20 MG)
BRAND
MDD
1 per day
citalopram hydrobromide (tab 10 mg, tab 20 mg, tab 40
mg)
generic
MDD
1 per day
citalopram hydrobromide oral soln 10 mg/5ml
generic
MDD
20 per day
DESVENLAFAXINE FUMARATE ER TAB ER 24H 100 MG
BRAND
MDD
2 per day
DESVENLAFAXINE FUMARATE ER TAB ER 24H 50 MG
BRAND
MDD
1 per day
desvenlafaxine tab sr 24hr 100 mg
generic
MDD
2 per day
desvenlafaxine tab sr 24hr 50 mg
generic
MDD
1 per day
escitalopram oxalate (tab 5 mg, tab 10 mg)
generic
MDD
1 per day
escitalopram oxalate soln 5 mg/5ml (base equiv)
generic
MDD
20 per day
escitalopram oxalate tab 20 mg (base equiv)
generic
MDD
1.5 per day
FETZIMA (CAP ER 24H 40 MG, CAP ER 24H 80 MG, CAP
ER 24H 20 MG, CAP ER 24H 120 MG)
BRAND
MDD
1 per day
FETZIMA TITRATION CP24 THPK 20 & 40 MG
BRAND
MDD
1 per day
fluoxetine hcl (cap 10 mg, tab 60 mg)
generic
MDD
1 per day
fluoxetine hcl (cap 20 mg, tab 20 mg)
generic
MDD
4 per day
fluoxetine hcl (pmdd) cap 10 mg
generic
MDD
1 per day
fluoxetine hcl (pmdd) cap 20 mg
generic
MDD
4 per day
PAGE 51
PRODUCT DESCRIPTION
BRAND/GEN
fluoxetine hcl cap 40 mg
generic
MDD
2 per day
fluoxetine hcl cap delayed release 90 mg
generic
MPL
4 / 28 days
fluoxetine hcl solution 20 mg/5ml
generic
MDD
20 per day
fluoxetine hcl tab 10 mg
generic
MDD
1.5 per day
fluvoxamine maleate (cap 24hr 100 mg, cap 24hr 150 mg)
generic
MDD
2 per day
fluvoxamine maleate (tab 25 mg, tab 50 mg)
generic
MDD
1 per day
fluvoxamine maleate tab 100 mg
generic
MDD
3 per day
GABOXETINE MISC 10 MG
BRAND
maprotiline hcl (tab 25 mg, tab 50 mg)
generic
MDD
3 per day
maprotiline hcl tab 75 mg
generic
MDD
4 per day
nefazodone hcl (tab 50 mg, tab 100 mg, tab 150 mg, tab
200 mg, tab 250 mg)
generic
MDD
2 per day
OLEPTRO TAB ER 24H 150 MG
BRAND
MDD
1.5 per day
OLEPTRO TAB ER 24H 300 MG
BRAND
MDD
1 per day
paroxetine hcl (tab 10 mg, tab 20 mg, tab sr 24hr 37.5 mg,
tab sr 24hr 25 mg, tab sr 24hr 12.5 mg)
generic
paroxetine hcl (tab 30 mg, tab 40 mg)
generic
AL
MDD
AL
MDD
AL
PAXIL SUSPENSION 10 MG/5ML
BRAND
MDD
AL
PEXEVA (TAB 10 MG, TAB 20 MG, TAB 30 MG, TAB 40
MG)
BRAND
PRISTIQ (TAB ER 24H 25 MG, TAB ER 24H 50 MG)
At least 18 yrs old
1 per day
At least 18 yrs old
2 per day
At least 18 yrs old
40 per day
At least 18 yrs old
MDD
1 per day
BRAND
MDD
1 per day
PRISTIQ TAB ER 24H 100 MG
BRAND
MDD
2 per day
SARAFEM TAB 10 MG
BRAND
MDD
1.5 per day
SARAFEM TAB 20 MG
BRAND
MDD
4 per day
PAGE 52
PRODUCT DESCRIPTION
BRAND/GEN
SENTRAFLOX AM-10 MISC 10 MG
BRAND
SENTRALOPRAM AM-10 MISC 10 MG
BRAND
SENTROXATINE MISC 10 MG
BRAND
sertraline hcl (tab 25 mg, tab 50 mg)
generic
MDD
2 per day
sertraline hcl oral conc 20 mg/ml
generic
MDD
10 per day
sertraline hcl tab 100 mg
generic
MDD
3 per day
TRAZAMINE MISC 50 MG
BRAND
trazodone hcl (tab 100 mg, tab 150 mg)
generic
MDD
3 per day
trazodone hcl (tab 50 mg, tab 300 mg)
generic
MDD
2 per day
TRINTELLIX (TAB 5 MG, TAB 10 MG, TAB 20 MG)
BRAND
MDD
1 per day
venlafaxine hcl (cap 24hr 150 mg, tab 24hr 150 mg)
generic
MDD
2 per day
venlafaxine hcl (cap 24hr 37.5 mg, tab 24hr 37.5 mg)
generic
MDD
1 per day
venlafaxine hcl (cap sr 24hr 75 mg (base equivalent), tab
25 mg, tab 37.5 mg, tab 50 mg, tab 75 mg, tab 100 mg, tab
sr 24hr 75 mg (base equivalent))
generic
MDD
3 per day
VENLAFAXINE HCL ER TAB ER 24H 225 MG
BRAND
MDD
1 per day
VIIBRYD (TAB 10 MG, TAB 20 MG, TAB 40 MG)
BRAND
MDD
1 per day
VIIBRYD KIT 10 & 20 & 40 MG
BRAND
MPL
1 / 30 days
VIIBRYD STARTER PACK KIT 10 & 20 MG
BRAND
TRICYCLICS
amitriptyline hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab 75
generic
MDD
3 per day
amoxapine (tab 25 mg, tab 150 mg)
generic
MDD
2 per day
amoxapine (tab 50 mg, tab 100 mg)
generic
MDD
4 per day
clomipramine hcl cap 25 mg
generic
MDD
2 per day
generic
MDD
5 per day
generic
MDD
3 per day
PAGE 53
PRODUCT DESCRIPTION
BRAND/GEN
desipramine hcl (tab 25 mg, tab 50 mg, tab 75 mg, tab 150
mg)
generic
MDD
2 per day
desipramine hcl tab 10 mg
generic
MDD
4 per day
desipramine hcl tab 100 mg
generic
MDD
3 per day
doxepin hcl (cap 25 mg, cap 50 mg, cap 75 mg, cap 100
mg, cap 150 mg)
generic
MDD
2 per day
doxepin hcl cap 10 mg
generic
MDD
4 per day
doxepin hcl conc 10 mg/ml
generic
MDD
30 per day
imipramine hcl tab 10 mg
generic
MDD
2 per day
generic
MDD
1 per day
generic
MDD
6 per day
imipramine pamoate (cap 125 mg, cap 150 mg)
generic
MDD
2 per day
imipramine pamoate cap 100 mg
generic
MDD
3 per day
imipramine pamoate cap 75 mg
generic
MDD
1 per day
nortriptyline hcl (cap 25 mg, cap 50 mg)
generic
MDD
3 per day
nortriptyline hcl cap 10 mg
generic
MDD
4 per day
nortriptyline hcl cap 75 mg
generic
MDD
2 per day
nortriptyline hcl soln 10 mg/5ml
generic
MDD
20 per day
protriptyline hcl (tab 5 mg, tab 10 mg)
generic
MDD
4 per day
SENTRAVIL PM-25 MISC 25 MG
BRAND
trimipramine maleate cap 100 mg
generic
MDD
3 per day
trimipramine maleate cap 50 mg
generic
MDD
1 per day
ANTIEMETICS
ANTIEMETICS, OTHER
ANTIVERT TAB 50 MG
BRAND
dimenhydrinate inj 50 mg/ml
generic
PAGE 54
PRODUCT DESCRIPTION
BRAND/GEN
meclizine hcl (tab 12.5 mg, tab 25 mg)
generic
metoclopramide hcl (inj 5 mg/ml, soln 5 mg/5ml (10
mg/10ml), tab 5 mg, tab 10 mg)
generic
METOCLOPRAMIDE HCL TAB DISP 10 MG
BRAND
perphenazine (tab 2 mg, tab 4 mg, tab 8 mg, tab 16 mg)
generic
AL
prochlorperazine edisylate inj 5 mg/ml
generic
prochlorperazine maleate (tab 5 mg, tab 10 mg)
generic
prochlorperazine suppos 25 mg
generic
At least 18 yrs old
MDD
4 per day
MDD
2 per day
EMETOGENIC THERAPY ADJUNCTS
dronabinol (cap 2.5 mg, cap 5 mg, cap 10 mg)
generic
ondansetron hcl (tab 4 mg, tab 8 mg)
generic
ondansetron hcl inj 4 mg/2ml (2 mg/ml)
generic
ondansetron hcl oral soln 4 mg/5ml
generic
QL
50 / 31 days
ondansetron hcl tab 24 mg
generic
QL
1 / 14 days
ondansetron orally disintegrating tab 4 mg
generic
MDD
2 per day
generic
MDD
2 per day
ANTIFUNGALS
ciclopirox olamine (cream, susp)
generic
ciclopirox solution 8%
generic
MPL
1 / claim
clotrimazole (topical) (cream, soln)
generic
MPL
1 / claim
econazole nitrate cream 1%
generic
MPL
1 / claim
EXELDERM (CREAM 1 %, SOLUTION 1 %)
BRAND
fluconazole (for susp 10 mg/ml, for susp 40 mg/ml, tab 50
mg, tab 150 mg)
generic
fluconazole tab 100 mg
generic
MDD
1 per day
fluconazole tab 200 mg
generic
MDD
2 per day
PAGE 55
PRODUCT DESCRIPTION
BRAND/GEN
griseofulvin microsize (susp 125 mg/5ml, tab 500 mg)
generic
griseofulvin ultramicrosize (tab 125 mg, tab 250 mg)
generic
GYNAZOLE-1 CREAM 2 %
BRAND
itraconazole cap 100 mg
generic
PA
ketoconazole (topical) (cream, foam, shampoo)
generic
MPL
ketoconazole tab 200 mg
generic
MICONAZOLE 3 SUPPOS 200 MG
BRAND
NAFTIFINE HCL CREAM 1 %
BRAND
naftifine hcl cream 2%
generic
NAFTIN (GEL 1 %, GEL 2 %)
BRAND
nystatin (*nystatin oral powder*, nystatin tab 500000 unit)
generic
nystatin (topical) (*nystatin topical powder**, nystatin
cream 100000 unit/gm, nystatin oint 100000 unit/gm)
generic
nystatin susp 100000 unit/ml
1 / claim
QL
45 / claim
generic
QL
12 / claim
nystatin-triamcinolone (cream unit/gm-%, oint unit/gm-%)
generic
MPL
oxiconazole nitrate cream 1%
generic
OXISTAT LOTION 1 %
BRAND
PEDIADERM AF COMPLETE KIT 100000 UNIT/GM
BRAND
SPORANOX SOLUTION 10 MG/ML
BRAND
terbinafine hcl tab 250 mg
generic
terconazole vaginal (cream 0.4%, cream 0.8%, suppos 80
mg)
QL
generic
1 / claim
90 / 120 days
MDD
1 per day
QL
45 / claim
QL
6 / 30 days
QL
6 / 30 days
ANTIGOUT AGENTS
allopurinol (tab 100 mg, tab 300 mg)
generic
ALOPRIM RECON SOLN 500 MG
BRAND
colchicine cap 0.6 mg
generic
COLCHICINE TAB 0.6 MG
BRAND
PA
MFL
PAGE 56
1 / 30 days
PRODUCT DESCRIPTION
BRAND/GEN
colchicine w/ probenecid tab 0.5-500 mg
generic
QL
COLCRYS TAB 0.6 MG
BRAND
PA
MFL
probenecid tab 500 mg
6 / 30 days
1 / 30 days
generic
ANTIMIGRAINE AGENTS
ERGOT ALKALOIDS
CAFERGOT TAB 1-100 MG
BRAND
dihydroergotamine mesylate nasal spray 4 mg/ml
generic
MIGERGOT SUPPOS 2-100 MG
BRAND
QL
8 / claim
QL
6 / 30 days
SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS
almotriptan malate (tab 6.25 mg, tab 12.5 mg)
generic
PA
ALSUMA SOLN A-INJ 6 MG/0.5ML
BRAND
naratriptan hcl (tab 1 mg, tab 2.5 mg)
generic
QL
2 / 30 days
QL
9 / 30 days
AL
At least 18 yrs old
rizatriptan benzoate (oral disintegrating tab 5 mg eq), oral
disintegrating tab 10 mg eq), tab 5 mg equivalent), tab 10
mg equivalent))
generic
QL
12 / 30 days
sumatriptan nasal spray (5 mg/act, 20 mg/act)
generic
QL
6 / 30 days
generic
QL
6 / claim
sumatriptan succinate (inj 6 mg/0.5ml, solution autoinjector 6 mg/0.5ml, solution cartridge 6 mg/0.5ml)
generic
QL
2 / 30 days
sumatriptan succinate (solution auto-injector 4 mg/0.5ml,
solution cartridge 4 mg/0.5ml)
generic
sumatriptan succinate (tab 25 mg, tab 50 mg, tab 100 mg)
generic
QL
9 / 30 days
SUMATRIPTAN SUCCINATE SOLN PRSYR 6 MG/0.5ML
BRAND
QL
2 / 30 days
SUMAVEL DOSEPRO SOLN J-INJ 4 MG/0.5ML
BRAND
PAGE 57
PRODUCT DESCRIPTION
BRAND/GEN
zolmitriptan (orally disintegrating tab 2.5 mg, orally
disintegrating tab 5 mg, tab 2.5 mg, tab 5 mg)
generic
QL
6 / 30 days
ZOMIG (SOLUTION 2.5 MG, SOLUTION 5 MG)
BRAND
QL
6 / 30 days
ANTIMYASTHENIC AGENTS
PARASYMPATHOMIMETICS
guanidine hcl tab 125 mg
generic
MESTINON SYRUP 60 MG/5ML
BRAND
pyridostigmine bromide (tab 60 mg, tab cr 180 mg)
generic
ANTIMYCOBACTERIALS
ANTIMYCOBACTERIALS, OTHER
dapsone (tab 25 mg, tab 100 mg)
generic
ANTITUBERCULARS
CAPASTAT SULFATE RECON SOLN 1 GM
BRAND
ethambutol hcl (tab 100 mg, tab 400 mg)
generic
isoniazid (tab 100 mg, tab 300 mg)
generic
ISONIAZID SYRUP 50 MG/5ML
BRAND
pyrazinamide tab 500 mg
generic
rifampin (cap 150 mg, cap 300 mg)
generic
TRECATOR TAB 250 MG
BRAND
ANTINEOPLASTICS
ALKYLATING AGENTS
ALKERAN TAB 2 MG
BRAND
cyclophosphamide (cap 25 mg, cap 50 mg)
generic
GLEOSTINE (CAP 10 MG, CAP 40 MG, CAP 100 MG)
BRAND
LEUKERAN TAB 2 MG
BRAND
lomustine (cap 40 mg, cap 100 mg)
generic
MATULANE CAP 50 MG
BRAND
PAGE 58
PRODUCT DESCRIPTION
BRAND/GEN
MYLERAN TAB 2 MG
BRAND
ANTIANDROGENS
bicalutamide tab 50 mg
generic
flutamide cap 125 mg
generic
MDD
1 per day
ANTIANGIOGENIC AGENTS
REVLIMID (CAP 2.5 MG, CAP 5 MG, CAP 10 MG, CAP 15
MG, CAP 20 MG, CAP 25 MG)
BRAND
S
Specialty Drug
THALOMID (CAP 50 MG, CAP 100 MG, CAP 150 MG,
CAP 200 MG)
BRAND
S
Specialty Drug
S
Specialty Drug
ANTIESTROGENS/MODIFIERS
FARESTON TAB 60 MG
BRAND
SOLTAMOX SOLUTION 10 MG/5ML
BRAND
tamoxifen citrate (tab 10 mg, tab 20 mg)
generic
ANTIMETABOLITES
hydroxyurea cap 500 mg
generic
mercaptopurine tab 50 mg
generic
PURIXAN SUSPENSION 2000 MG/100ML
BRAND
TABLOID TAB 40 MG
BRAND
ANTINEOPLASTICS, OTHER
leucovorin calcium (tab 5 mg, tab 10 mg, tab 15 mg, tab 25
mg)
generic
SYLATRON (KIT 4 X 600 MCG, KIT 200 MCG, KIT 300
MCG, KIT 600 MCG)
BRAND
AROMATASE INHIBITORS, 3RD GENERATION
anastrozole tab 1 mg
generic
exemestane tab 25 mg
generic
letrozole tab 2.5 mg
generic
PAGE 59
PRODUCT DESCRIPTION
BRAND/GEN
ENZYME INHIBITORS
etoposide cap 50 mg
generic
S
Specialty Drug
HYCAMTIN (CAP 0.25 MG, CAP 1 MG)
BRAND
S
Specialty Drug
MOLECULAR TARGET INHIBITORS
CAPRELSA (TAB 100 MG, TAB 300 MG)
BRAND
COTELLIC TAB 20 MG
BRAND
PA
GLEEVEC TAB 400 MG
BRAND
S
Specialty Drug
imatinib mesylate (tab 100 mg, tab 400 mg)
generic
INLYTA (TAB 1 MG, TAB 5 MG)
BRAND
S
Specialty Drug
NEXAVAR TAB 200 MG
BRAND
S
Specialty Drug
NINLARO (CAP 2.3 MG, CAP 3 MG, CAP 4 MG)
BRAND
PA
SPRYCEL (TAB 20 MG, TAB 50 MG, TAB 70 MG, TAB 80
MG, TAB 100 MG, TAB 140 MG)
BRAND
S
Specialty Drug
SUTENT (CAP 12.5 MG, CAP 25 MG, CAP 37.5 MG, CAP
50 MG)
BRAND
S
Specialty Drug
TARCEVA (TAB 25 MG, TAB 100 MG, TAB 150 MG)
BRAND
S
Specialty Drug
TASIGNA (CAP 150 MG, CAP 200 MG)
BRAND
S
Specialty Drug
TYKERB TAB 250 MG
BRAND
S
Specialty Drug
VOTRIENT TAB 200 MG
BRAND
S
Specialty Drug
XALKORI (CAP 200 MG, CAP 250 MG)
BRAND
S
Specialty Drug
ZELBORAF TAB 240 MG
BRAND
S
Specialty Drug
generic
S
Specialty Drug
RETINOIDS
bexarotene cap 75 mg
PAGE 60
PRODUCT DESCRIPTION
BRAND/GEN
ANTIPARASITICS
ANTIHELMINTHICS
EMVERM CHEW TAB 100 MG
BRAND
ivermectin tab 3 mg
generic
ANTIPROTOZOALS
atovaquone susp 750 mg/5ml
generic
atovaquone-proguanil hcl (tab 62.5-25 mg, tab 250-100
mg)
generic
chloroquine phosphate (tab 250 mg, tab 500 mg)
generic
QL
60 / 30 days
COARTEM TAB 20-120 MG
BRAND
QL
24 / claim
hydroxychloroquine sulfate tab 200 mg
generic
mefloquine hcl tab 250 mg
generic
NEBUPENT RECON SOLN 300 MG
BRAND
PENTAM RECON SOLN 300 MG
BRAND
primaquine phosphate tab 26.3 mg (15 mg base)
generic
QL
60 / claim
QL
60 / claim
PEDICULICIDES/SCABICIDES
EURAX CREAM 10 %
BRAND
EURAX LOTION 10 %
BRAND
MPL
malathion lotion 0.5%
permethrin cream 5%
QL
generic
PAGE 61
59 / claim
MFL
2 / 30 days
MPL
1 / claim
generic
C
SPINOSAD SUSPENSION 0.9 %
1 / claim
Limit=1/claim | Pkg
Size 10: Package
Limit=6/claim |
BRAND
PRODUCT DESCRIPTION
BRAND/GEN
ANTIPARKINSON AGENTS
ANTICHOLINERGICS
benztropine mesylate (inj 1 mg/ml, tab 0.5 mg, tab 1 mg,
tab 2 mg)
generic
trihexyphenidyl hcl (elixir 0.4 mg/ml, tab 2 mg, tab 5 mg)
generic
QL
amantadine hcl cap 100 mg
generic
MDD
4 per day
amantadine hcl syrup 50 mg/5ml
generic
MDD
40 per day
carbidopa-levodopa-entacapone (tabs 12.5-50-200 mg,
tabs 18.75-75-200 mg, tabs 25-100-200 mg, tabs 31.25125-200 mg, tabs 37.5-150-200 mg, tabs 50-200-200 mg)
generic
entacapone tab 200 mg
generic
NUPLAZID TAB 17 MG
BRAND
MDD
2 per day
tolcapone tab 100 mg
generic
500 / 30 days
ANTIPARKINSON AGENTS, OTHER
DOPAMINE AGONISTS
MIRAPEX ER TAB ER 24H 3.75 MG
BRAND
pramipexole dihydrochloride (tab 0.125 mg, tab 0.25 mg,
tab 0.5 mg, tab 0.75 mg, tab 1 mg, tab 1.5 mg, tab sr 24hr
3 mg, tab sr 24hr 1.5 mg, tab sr 24hr 4.5 mg, tab sr 24hr
0.375 mg, tab sr 24hr 2.25 mg, tab sr 24hr 0.75 mg)
generic
ropinirole hydrochloride (tab 0.25 mg, tab 0.5 mg, tab 1 mg,
tab 2 mg, tab 3 mg, tab 4 mg, tab 5 mg, tab sr 24hr 2 mg
(base equivalent), tab sr 24hr 12 mg (base equivalent), tab
sr 24hr 8 mg (base equivalent), tab sr 24hr 6 mg (base
equivalent), tab sr 24hr 4 mg (base equivalent))
generic
DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS
carbidopa & levodopa odt 10-100 mg
generic
generic
generic
carbidopa tab 25 mg
generic
PAGE 62
PRODUCT DESCRIPTION
BRAND/GEN
carbidopa-levodopa (orally disintegrating tab 25-250 mg,
tab 10-100 mg, tab 25-100 mg, tab 25-250 mg, tab cr 25100 mg, tab cr 50-200 mg)
generic
DUOPA SUSPENSION 4.63-20 MG/ML
BRAND
RYTARY (CAP ER 23.75-95 MG, CAP ER 36.25-145 MG,
CAP ER 48.75-195 MG, CAP ER 61.25-245 MG)
BRAND
MONOAMINE OXIDASE B (MAO-B) INHIBITORS
selegiline hcl (cap 5 mg, tab 5 mg)
generic
ANTIPSYCHOTICS
1ST GENERATION/TYPICAL
chlorpromazine hcl (inj 25 mg/ml, inj 50 mg/2ml)
generic
chlorpromazine hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab
100 mg, tab 200 mg)
generic
droperidol inj 2.5 mg/ml
generic
fluphenazine decanoate inj 25 mg/ml
generic
AL
At least 18 yrs old
fluphenazine hcl (elixir 2.5 mg/5ml, inj 2.5 mg/ml, oral conc
5 mg/ml)
generic
AL
At least 18 yrs old
fluphenazine hcl (tab 1 mg, tab 2.5 mg, tab 5 mg, tab 10
mg)
AL
generic
At least 18 yrs old
haloperidol (tab 0.5 mg, tab 1 mg, tab 2 mg, tab 5 mg, tab
10 mg, tab 20 mg)
MDD
4 per day
MDD
4 per day
generic
MDD
3 per day
haloperidol decanoate (soln 50 mg/ml, soln 100 mg/ml)
generic
AL
At least 18 yrs old
haloperidol lactate (inj 5 mg/ml, oral conc 2 mg/ml)
generic
loxapine succinate (cap 5 mg, cap 10 mg, cap 25 mg, cap
50 mg)
AL
generic
At least 18 yrs old
MOLINDONE HCL (TAB 5 MG, TAB 10 MG)
MDD
4 per day
BRAND
MDD
4 per day
MOLINDONE HCL TAB 25 MG
BRAND
MDD
9 per day
pimozide tab 1 mg
generic
MDD
10 per day
pimozide tab 2 mg
generic
MDD
5 per day
PAGE 63
PRODUCT DESCRIPTION
BRAND/GEN
thioridazine hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab 100
mg)
generic
MDD
4 per day
thiothixene (cap 1 mg, cap 2 mg, cap 5 mg, cap 10 mg)
generic
MDD
3 per day
trifluoperazine hcl (tab 1 mg, tab 2 mg, tab 5 mg, tab 10
mg)
generic
MDD
2 per day
ABILIFY DISCMELT (TAB DISP 10 MG, TAB DISP 15 MG)
BRAND
MDD
2 per day
ABILIFY MAINTENA RECON SUSP 300 MG
BRAND
2ND GENERATION/ATYPICAL
ABILIFY MAINTENA RECON SUSP 400 MG
QL
1 / 28 days
AL
At least 18 yrs old
AL
At least 18 yrs old
BRAND
MFL
1 / 28 days
MDD
30 per day
ABILIFY SOLUTION 1 MG/ML
BRAND
ABILIFY SOLUTION 9.75 MG/1.3ML
BRAND
aripiprazole (orally disintegrating tab 10 mg, orally
disintegrating tab 15 mg, tab 20 mg)
generic
MDD
2 per day
aripiprazole (tab 2 mg, tab 10 mg, tab 15 mg, tab 30 mg)
generic
MDD
1 per day
aripiprazole oral solution 1 mg/ml
generic
MDD
30 per day
aripiprazole tab 5 mg
generic
MDD
1.5 per day
ARISTADA (PRSYR 441 MG/1.6ML, PRSYR 662
MG/2.4ML, PRSYR 882 MG/3.2ML)
QL
BRAND
1 / 28 days
AL
At least 18 yrs old
FANAPT (TAB 1 MG, TAB 2 MG, TAB 4 MG, TAB 6 MG,
TAB 8 MG, TAB 10 MG, TAB 12 MG)
AL
BRAND
At least 18 yrs old
FANAPT TITRATION PACK TAB 1 & 2 & 4 & 6 MG
BRAND
MDD
AL
MDD
GEODON RECON SOLN 20 MG
BRAND
INVEGA SUSTENNA (SUSPENSION 39 MG/0.25ML,
SUSPENSION 78 MG/0.5ML, SUSPENSION 117
MG/0.75ML, SUSPENSION 156 MG/ML, SUSPENSION
234 MG/1.5ML)
BRAND
PAGE 64
2 per day
At least 18 yrs old
2 per day
AL
At least 18 yrs old
AL
At least 18 yrs old
MPL
1 / 28 days
PRODUCT DESCRIPTION
BRAND/GEN
INVEGA TRINZA (SUSPENSION 273 MG/0.875ML,
SUSPENSION 410 MG/1.315ML, SUSPENSION 546
MG/1.75ML)
BRAND
INVEGA TRINZA SUSPENSION 819 MG/2.625ML
BRAND
QL
1 / 84 days
AL
At least 18 yrs old
AL
At least 18 yrs old
MFL
AL
LATUDA (TAB 20 MG, TAB 40 MG, TAB 60 MG, TAB 120
MG)
BRAND
LATUDA TAB 80 MG
BRAND
MDD
AL
1 / 84 days
At least 18 yrs old
1 per day
At least 18 yrs old
MDD
2 per day
olanzapine (orally disintegrating tab 10 mg, orally
disintegrating tab 15 mg, tab 10 mg, tab 15 mg)
generic
MDD
2 per day
olanzapine (orally disintegrating tab 20 mg, tab 20 mg)
generic
MDD
3 per day
olanzapine (orally disintegrating tab 5 mg, tab 2.5 mg, tab
5 mg, tab 7.5 mg)
generic
MDD
1 per day
olanzapine for im inj 10 mg
generic
paliperidone (tab 24hr 9 mg, tab 24hr 3 mg, tab 24hr 1.5
mg)
generic
MDD
1 per day
paliperidone tab sr 24hr 6 mg
generic
MDD
2 per day
quetiapine fumarate (tab 25 mg, tab 50 mg, tab 100 mg,
tab 200 mg)
generic
MDD
3 per day
quetiapine fumarate (tab 300 mg, tab 400 mg)
generic
MDD
4 per day
REXULTI (TAB 0.25 MG, TAB 0.5 MG, TAB 1 MG, TAB 2
BRAND
RISPERDAL CONSTA (RECON SUSP 12.5 MG, RECON
SUSP 25 MG, RECON SUSP 37.5 MG, RECON SUSP 50
MG)
BRAND
risperidone (tab 0.25 mg, tab 0.5 mg, tab 1 mg, tab 2 mg,
tab 3 mg, tab 4 mg)
AL
MDD
AL
At least 18 yrs old
1 per day
At least 18 yrs old
MPL
2 / 28 days
generic
MDD
2 per day
risperidone odt (tab 3 mg, tab 4 mg)
generic
MDD
2 per day
risperidone orally disintegrating tab 0.25 mg
generic
MDD
2 per day
generic
MDD
2 per day
PAGE 65
PRODUCT DESCRIPTION
BRAND/GEN
risperidone orally disintegrating tab 1 mg
generic
MDD
2 per day
generic
MDD
2 per day
risperidone soln 1 mg/ml
generic
MDD
8 per day
SAPHRIS (SL TAB 2.5 MG, SL TAB 5 MG, SL TAB 10
MG)
BRAND
MDD
2 per day
SEROQUEL XR (TAB ER 24H 200 MG, TAB ER 24H 150
MG)
BRAND
MDD
1 per day
SEROQUEL XR TAB ER 24H 300 MG
BRAND
MDD
3 per day
BRAND
MDD
4 per day
BRAND
MDD
2 per day
VRAYLAR (CAP 3 MG, CAP 4.5 MG, CAP 6 MG)
BRAND
AL
MDD
AL
VRAYLAR CAP 1.5 MG
BRAND
MDD
AL
VRAYLAR CAP THPK 1.5 & 3 MG
BRAND
MPL
ziprasidone hcl (cap 20 mg, cap 40 mg)
AL
generic
MDD
ziprasidone hcl (cap 60 mg, cap 80 mg)
AL
generic
MDD
ZYPREXA RELPREVV (RECON SUSP 210 MG, RECON
SUSP 300 MG)
BRAND
ZYPREXA RELPREVV RECON SUSP 405 MG
BRAND
At least 18 yrs old
1 per day
At least 18 yrs old
2 per day
At least 18 yrs old
1 / 28 days
At least 18 yrs old
2 per day
At least 18 yrs old
3 per day
QL
2 / 28 days
AL
At least 18 yrs old
QL
1 / 28 days
AL
At least 18 yrs old
AL
At least 18 yrs old
TREATMENT-RESISTANT
clozapine (orally disintegrating tab 100 mg, tab 100 mg)
generic
MDD
PAGE 66
6 per day
PRODUCT DESCRIPTION
BRAND/GEN
clozapine (orally disintegrating tab 25 mg, orally
tab 25 mg, tab 50 mg, tab 200 mg)
generic
clozapine odt 100 mg
generic
AL
MDD
AL
MDD
clozapine odt 12.5 mg
AL
generic
MDD
clozapine odt 25 mg
AL
generic
MDD
AL
VERSACLOZ SUSPENSION 50 MG/ML
BRAND
At least 18 yrs old
3 per day
At least 18 yrs old
6 per day
At least 18 yrs old
3 per day
At least 18 yrs old
3 per day
At least 18 yrs old
MDD
12 per day
ANTIVIRALS
ANTI-CYTOMEGALOVIRUS (CMV) AGENTS
VALCYTE RECON SOLN 50 MG/ML
BRAND
MDD
4 per day
valganciclovir hcl tab 450 mg (base equivalent)
generic
MDD
4 per day
MDD
1 per day
ANTI-HEPATITIS B (HBV) AGENTS
adefovir dipivoxil tab 10 mg
generic
S
BARACLUDE SOLUTION 0.05 MG/ML
BRAND
entecavir (tab 0.5 mg, tab 1 mg)
generic
MDD
1 per day
MDD
1 per day
S
EPIVIR HBV SOLUTION 5 MG/ML
BRAND
lamivudine tab 100 mg (hbv)
generic
TYZEKA TAB 600 MG
BRAND
Specialty Drug
MDD
Specialty Drug
1 per day
ANTI-HEPATITIS C (HCV) AGENTS
INFERGEN (INJECTABLE 9 MCG/0.3ML, INJECTABLE
15 MCG/0.5ML)
PAGE 67
PA
BRAND
S
Specialty Drug
PRODUCT DESCRIPTION
BRAND/GEN
ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)
GENVOYA TAB 150-150-200-10 MG
BRAND
MDD
1 per day
ISENTRESS CHEW TAB 100 MG
BRAND
MDD
6 per day
ISENTRESS CHEW TAB 25 MG
BRAND
MDD
12 per day
ISENTRESS PACKET 100 MG
BRAND
MDD
2 per day
ISENTRESS TAB 400 MG
BRAND
STRIBILD TAB 150-150-200-300 MG
BRAND
MDD
1 per day
TIVICAY TAB 50 MG
BRAND
MDD
2 per day
VITEKTA (TAB 85 MG, TAB 150 MG)
BRAND
AL
MDD
At least 18 yrs old
1 per day
ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)
ATRIPLA TAB 600-200-300 MG
BRAND
MDD
1 per day
COMPLERA TAB 200-25-300 MG
BRAND
MDD
1 per day
EDURANT TAB 25 MG
BRAND
MDD
1 per day
INTELENCE (TAB 25 MG, TAB 100 MG, TAB 200 MG)
BRAND
MDD
8 per day
nevirapine (susp 50 mg/5ml, tab 200 mg, tab sr 24hr 400
mg)
generic
nevirapine tab sr 24hr 100 mg
generic
MDD
1 per day
RESCRIPTOR (TAB 100 MG, TAB 200 MG)
BRAND
MDD
12 per day
SUSTIVA (CAP 50 MG, CAP 200 MG, TAB 600 MG)
BRAND
MDD
3 per day
ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)
abacavir sulfate tab 300 mg (base equiv)
generic
MDD
2 per day
abacavir sulfate-lamivudine-zidovudine tab 300-150-300
mg
generic
MDD
2 per day
DESCOVY TAB 200-25 MG
BRAND
MDD
1 per day
PAGE 68
PRODUCT DESCRIPTION
BRAND/GEN
didanosine (capsule 125 mg, capsule 200 mg, capsule 250
mg, capsule 400 mg)
generic
EMTRIVA (CAP 200 MG, SOLUTION 10 MG/ML)
BRAND
MDD
1 per day
EPZICOM TAB 600-300 MG
BRAND
MDD
1 per day
lamivudine (oral soln 10 mg/ml, tab 150 mg, tab 300 mg)
generic
MDD
3 per day
lamivudine-zidovudine tab 150-300 mg
generic
MDD
2 per day
stavudine (cap 15 mg, cap 20 mg, cap 30 mg, cap 40 mg,
for oral soln 1 mg/ml)
generic
MDD
2 per day
TRUVADA TAB 200-300 MG
BRAND
MDD
1 per day
VIDEX (RECON SOLN 2 GM, RECON SOLN 4 GM)
BRAND
VIREAD (POWDER 40 MG/GM, TAB 150 MG, TAB 200
BRAND
MDD
1 per day
ZIAGEN SOLUTION 20 MG/ML
BRAND
MDD
2 per day
zidovudine (cap 100 mg, syrup 10 mg/ml, tab 300 mg)
generic
MDD
6 per day
SELZENTRY TAB 150 MG
BRAND
MDD
2 per day
SELZENTRY TAB 300 MG
BRAND
MDD
4 per day
TRIUMEQ TAB 600-50-300 MG
BRAND
ANTI-HIV AGENTS, OTHER
AL
MDD
AL
TYBOST TAB 150 MG
BRAND
At least 18 yrs old
1 per day
At least 18 yrs old
MDD
1 per day
ANTI-HIV AGENTS, PROTEASE INHIBITORS
APTIVUS (CAP 250 MG, SOLUTION 100 MG/ML)
BRAND
MDD
4 per day
CRIXIVAN (CAP 200 MG, CAP 400 MG)
BRAND
MDD
6 per day
EVOTAZ TAB 300-150 MG
BRAND
AL
INVIRASE TAB 500 MG
PAGE 69
BRAND
At least 18 yrs old
MDD
1 per day
MDD
10 per day
PRODUCT DESCRIPTION
BRAND/GEN
KALETRA (SOLUTION 400-100 MG/5ML, TAB 100-25
MG, TAB 200-50 MG)
BRAND
MDD
4 per day
LEXIVA (SUSPENSION 50 MG/ML, TAB 700 MG)
BRAND
MDD
4 per day
NORVIR (CAP 100 MG, SOLUTION 80 MG/ML, TAB 100
MG)
BRAND
PREZISTA (TAB 75 MG, TAB 150 MG, TAB 600 MG, TAB
800 MG)
BRAND
MDD
2 per day
PREZISTA SUSPENSION 100 MG/ML
BRAND
MDD
12 per day
REYATAZ (CAP 150 MG, CAP 200 MG, CAP 300 MG)
BRAND
MDD
4 per day
REYATAZ PACKET 50 MG
BRAND
MDD
6 per day
VIRACEPT (TAB 250 MG, TAB 625 MG)
BRAND
MDD
10 per day
RELENZA DISKHALER AER POW BA 5 MG/BLISTER
BRAND
QL
20 / 30 days
rimantadine hydrochloride tab 100 mg
generic
TAMIFLU (CAP 45 MG, CAP 75 MG)
BRAND
QL
10 / 30 days
TAMIFLU CAP 30 MG
BRAND
QL
20 / 30 days
TAMIFLU RECON SUSP 6 MG/ML
BRAND
QL
120 / 30 days
ANTI-INFLUENZA AGENTS
ANTIHERPETIC AGENTS
acyclovir (cap 200 mg, susp 200 mg/5ml, tab 800 mg)
generic
acyclovir oint 5%
generic
MPL
1 / claim
acyclovir tab 400 mg
generic
MDD
3 per day
SITAVIG TAB 50 MG
BRAND
trifluridine ophth soln 1%
generic
QL
8 / claim
valacyclovir hcl tab 1 gm
generic
MDD
3 per day
valacyclovir hcl tab 500 mg
generic
QL
ZOVIRAX CREAM 5 %
BRAND
MPL
PAGE 70
60 / 30 days
1 / claim
PRODUCT DESCRIPTION
BRAND/GEN
ANXIOLYTICS
ANXIOLYTICS, OTHER
buspirone hcl (tab 5 mg, tab 7.5 mg, tab 10 mg, tab 15 mg)
generic
MDD
3 per day
buspirone hcl tab 30 mg
generic
MDD
2 per day
meprobamate (tab 200 mg, tab 400 mg)
generic
MDD
4 per day
midazolam hcl (inj 2 mg/2ml, inj 5 mg/ml, inj 5 mg/5ml, inj
10 mg/2ml, inj 10 mg/10ml, inj 25 mg/5ml, inj 50 mg/10ml,
syrup 2 mg/ml)
generic
BENZODIAZEPINES
alprazolam (orally disintegrating tab 0.25 mg, orally
disintegrating tab 0.5 mg, orally disintegrating tab 1 mg,
orally disintegrating tab 2 mg, tab 0.25 mg, tab 0.5 mg, tab
1 mg, tab 2 mg)
generic
MDD
4 per day
alprazolam (tab 24hr 2 mg, tab 24hr 1 mg, tab 24hr 3 mg,
tab 24hr 0.5 mg)
generic
MDD
1 per day
ALPRAZOLAM INTENSOL CONC 1 MG/ML
BRAND
MDD
4 per day
chlordiazepoxide hcl (cap 5 mg, cap 10 mg, cap 25 mg)
generic
MDD
4 per day
clonazepam (orally disintegrating tab 0.125 mg, orally
disintegrating tab 0.25 mg, orally disintegrating tab 0.5 mg,
orally disintegrating tab 1 mg, orally disintegrating tab 2
mg, tab 0.5 mg, tab 1 mg, tab 2 mg)
generic
MDD
3 per day
clorazepate dipotassium (tab 3.75 mg, tab 7.5 mg, tab 15
mg)
generic
MDD
4 per day
diazepam (tab 2 mg, tab 5 mg, tab 10 mg)
generic
MDD
4 per day
diazepam conc 5 mg/ml
generic
MDD
8 per day
diazepam oral soln 1 mg/ml
generic
DIAZEPAM SOLUTION 5 MG/ML
BRAND
GABAVALE-5 MISC 5 MG
BRAND
GABAZOLAMINE MISC 0.25 MG
BRAND
GABAZOLAMINE-0.5 MISC 0.5 MG
BRAND
PAGE 71
PRODUCT DESCRIPTION
BRAND/GEN
lorazepam (conc 2 mg/ml, inj 2 mg/ml, inj 4 mg/ml)
generic
lorazepam (tab 0.5 mg, tab 1 mg, tab 2 mg)
generic
QL
MDD
oxazepam (cap 10 mg, cap 15 mg, cap 30 mg)
SENTRAZOLAM AM 0.25 MISC 0.25 MG
QL
generic
120 / claim
4 per day
120 / claim
MDD
4 per day
BRAND
BIPOLAR AGENTS
MOOD STABILIZERS
EQUETRO CAP ER 12H 100 MG
BRAND
MDD
4 per day
BRAND
MDD
8 per day
BRAND
MDD
5 per day
lithium carbonate (cap 150 mg, cap 300 mg, cap 600 mg,
tab 300 mg, tab cr 300 mg, tab cr 450 mg)
generic
MDD
3 per day
BLOOD GLUCOSE REGULATORS
ANTIDIABETIC AGENTS
acarbose (tab 25 mg, tab 50 mg, tab 100 mg)
generic
QL
BYDUREON PEN 2 MG
BRAND
4 / 28 days
PA
ST
QL
BYETTA 10 MCG PEN SOLN PEN 10 MCG/0.04ML
BRAND
2.4 / 30 days
PA
ST
QL
BYETTA 5 MCG PEN SOLN PEN 5 MCG/0.02ML
BRAND
1.2 / 30 days
PA
ST
chlorpropamide (tab 100 mg, tab 250 mg)
generic
FARXIGA (TAB 5 MG, TAB 10 MG)
BRAND
PA
ST
PAGE 72
PRODUCT DESCRIPTION
BRAND/GEN
glimepiride (tab 1 mg, tab 2 mg, tab 4 mg)
generic
glipizide (tab 5 mg, tab 10 mg, tab sr 24hr 2.5 mg, tab sr
24hr 5 mg, tab sr 24hr 10 mg)
generic
glipizide-metformin hcl (tab 2.5-500 mg, tab 2.5-250 mg,
tab 5-500 mg)
generic
glyburide (tab 1.25 mg, tab 2.5 mg, tab 5 mg)
generic
glyburide micronized (tab 1.5 mg, tab 3 mg, tab 6 mg)
generic
GLYBURIDE TAB 5 MG
BRAND
glyburide-metformin (tab 1.25-250 mg, tab 2.5-500 mg, tab
5-500 mg)
generic
MDD
2 per day
MDD
2 per day
PA
INVOKANA (TAB 100 MG, TAB 300 MG)
BRAND
ST
MDD
1 per day
JENTADUETO (TAB 2.5-1000 MG, TAB 2.5-850 MG, TAB
2.5-500 MG)
BRAND
MDD
2 per day
KOMBIGLYZE XR (TAB ER 24H 5-500 MG, TAB ER 24H
5-1000 MG)
BRAND
MDD
1 per day
KOMBIGLYZE XR TAB ER 24H 2.5-1000 MG
BRAND
MDD
2 per day
metformin hcl (tab 1000 mg, tab sr 24hr 750 mg)
generic
MDD
2 per day
metformin hcl (tab 24hr 1000 mg, tab 24hr 500 mg)
generic
metformin hcl tab 500 mg
generic
MDD
5 per day
metformin hcl tab 850 mg
generic
MDD
3 per day
metformin hcl tab sr 24hr 500 mg
generic
MDD
4 per day
nateglinide (tab 60 mg, tab 120 mg)
generic
MDD
3 per day
ONGLYZA (TAB 2.5 MG, TAB 5 MG)
BRAND
AL
pioglitazone hcl (tab 15 mg, tab 30 mg, tab 45 mg)
generic
MDD
1 per day
pioglitazone hcl-metformin hcl (-metformin tab 15-500 mg, metformin tab 15-850 mg)
generic
MDD
2 per day
repaglinide (tab 0.5 mg, tab 1 mg, tab 2 mg)
generic
MDD
4 per day
PAGE 73
At least 18 yrs old
PRODUCT DESCRIPTION
BRAND/GEN
SYMLINPEN 120 SOLN PEN 2700 MCG/2.7ML
BRAND
QL
10.8 / 30 days
PA
QL
SYMLINPEN 60 SOLN PEN 1500 MCG/1.5ML
BRAND
6 / 30 days
PA
tolazamide (tab 250 mg, tab 500 mg)
generic
tolbutamide tab 500 mg
generic
TRADJENTA TAB 5 MG
BRAND
GLYCEMIC AGENTS
GLUCAGEN HYPOKIT RECON SOLN 1 MG
BRAND
GLUCAGON EMERGENCY KIT 1 MG
BRAND
PROGLYCEM SUSPENSION 50 MG/ML
MPL
1 / claim
MFL
1 / 30 days
BRAND
INSULINS
AFREZZA (POWDER 4 (60) & 8 (30), POWDER 4 (30) & 8
(60), POWDER 4)
BRAND
QL
50 / 30 days
APIDRA SOLOSTAR SOLN PEN 100 UNIT/ML
BRAND
QL
30 / 30 days
APIDRA SOLUTION 100 UNIT/ML
BRAND
QL
40 / 30 days
HUMALOG (SOLN CART 100 UNIT/ML, SOLUTION 100
UNIT/ML)
BRAND
QL
30 / 30 days
HUMALOG KWIKPEN SOLN PEN 100 UNIT/ML
BRAND
QL
30 / 30 days
HUMALOG MIX 50/50 KWIKPEN SUSP PEN (50-50) 100
UNIT/ML
BRAND
QL
30 / 30 days
HUMALOG MIX 50/50 SUSPENSION (50-50) 100
UNIT/ML
BRAND
QL
40 / 30 days
HUMALOG MIX 75/25 KWIKPEN SUSP PEN (75-25) 100
UNIT/ML
BRAND
QL
30 / 30 days
HUMALOG MIX 75/25 SUSPENSION (75-25) 100
UNIT/ML
BRAND
QL
40 / 30 days
HUMULIN 70/30 KWIKPEN SUSP PEN (70-30) 100
UNIT/ML
BRAND
QL
30 / 30 days
PAGE 74
PRODUCT DESCRIPTION
BRAND/GEN
HUMULIN 70/30 SUSPENSION (70-30) 100 UNIT/ML
BRAND
QL
40 / 30 days
HUMULIN N KWIKPEN SUSP PEN 100 UNIT/ML
BRAND
QL
30 / 30 days
HUMULIN N SUSPENSION 100 UNIT/ML
BRAND
QL
30 / 30 days
HUMULIN R SOLUTION 100 UNIT/ML
BRAND
QL
50 / 30 days
LANTUS SOLOSTAR SOLN PEN 100 UNIT/ML
BRAND
QL
30 / 30 days
LANTUS SOLUTION 100 UNIT/ML
BRAND
QL
30 / 30 days
NOVOLIN 70/30 RELION SUSPENSION (70-30) 100
UNIT/ML
BRAND
QL
40 / 30 days
NOVOLIN 70/30 SUSPENSION (70-30) 100 UNIT/ML
BRAND
QL
40 / 30 days
NOVOLIN N RELION SUSPENSION 100 UNIT/ML
BRAND
QL
30 / 30 days
NOVOLIN N SUSPENSION 100 UNIT/ML
BRAND
QL
30 / 30 days
NOVOLIN R RELION SOLUTION 100 UNIT/ML
BRAND
QL
50 / 30 days
NOVOLIN R SOLUTION 100 UNIT/ML
BRAND
QL
50 / 30 days
NOVOLOG FLEXPEN SOLN PEN 100 UNIT/ML
BRAND
QL
30 / 30 days
NOVOLOG MIX 70/30 FLEXPEN SUSP PEN (70-30) 100
UNIT/ML
BRAND
QL
30 / 30 days
NOVOLOG MIX 70/30 SUSPENSION (70-30) 100
UNIT/ML
BRAND
QL
40 / 30 days
NOVOLOG PENFILL SOLN CART 100 UNIT/ML
BRAND
QL
30 / 30 days
NOVOLOG SOLUTION 100 UNIT/ML
BRAND
QL
40 / 30 days
ELIQUIS (TAB 2.5 MG, TAB 5 MG)
BRAND
MDD
enoxaparin sodium (inj 100 mg/ml, inj 150 mg/ml)
generic
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS
ANTICOAGULANTS
QL
MFL
enoxaparin sodium (inj 80 mg/0.8ml, inj 120 mg/0.8ml)
QL
generic
MFL
PAGE 75
4 per day
14 / 7 days
1 / 180 days
12 / 7 days
1 / 180 days
PRODUCT DESCRIPTION
BRAND/GEN
enoxaparin sodium inj 30 mg/0.3ml
generic
QL
MFL
enoxaparin sodium inj 300 mg/3ml
QL
generic
MFL
QL
generic
MFL
QL
generic
MFL
5 / 7 days
1 / 180 days
42 / 7 days
1 / 180 days
6 / 7 days
1 / 180 days
9 / 7 days
1 / 180 days
PA
FRAGMIN SOLUTION 10000 UNIT/ML
BRAND
MFL
S
1 / 180 days
Specialty Drug
heparin sodium (porcine) (inj 1000 unit/ml, inj 5000 unit/ml,
inj 10000 unit/ml, inj 20000 unit/ml, pf inj 5000 unit/0.5ml)
generic
heparin sodium (porcine) 2 unit/ml in sodium chloride 0.9%
generic
heparin sodium (porcine) lock flush (soln 1 unit/ml, soln 10
unit/ml, soln 100 unit/ml)
generic
warfarin sodium (tab 1 mg, tab 2 mg, tab 2.5 mg, tab 3 mg,
tab 4 mg, tab 5 mg, tab 6 mg, tab 7.5 mg, tab 10 mg)
generic
XARELTO (TAB 10 MG, TAB 20 MG)
BRAND
MDD
1 per day
XARELTO STARTER PACK TAB THPK 15 & 20 MG
BRAND
MPL
1 / 30 days
XARELTO TAB 15 MG
BRAND
MDD
2 per day
BLOOD FORMATION MODIFIERS
AGRYLIN CAP 0.5 MG
BRAND
anagrelide hcl (cap 0.5 mg, cap 1 mg)
generic
PROMACTA (TAB 12.5 MG, TAB 25 MG, TAB 50 MG,
TAB 75 MG)
BRAND
S
AMICAR SYRUP 25 %
BRAND
QL
AMICAR TAB 1000 MG
BRAND
Specialty Drug
COAGULANTS
PAGE 76
60 / claim
PRODUCT DESCRIPTION
BRAND/GEN
AMICAR TAB 500 MG
BRAND
QL
24 / claim
aminocaproic acid syrup 25%
generic
QL
60 / claim
aminocaproic acid tab 1000 mg
generic
aminocaproic acid tab 500 mg
generic
QL
24 / claim
QL
30 / 5 days
AL
At least 12 yrs old
tranexamic acid tab 650 mg
generic
MFL
1 / 30 days
PLATELET MODIFYING AGENTS
BRILINTA (TAB 60 MG, TAB 90 MG)
BRAND
MDD
2 per day
cilostazol (tab 50 mg, tab 100 mg)
generic
MDD
2 per day
clopidogrel bisulfate (tab 75 mg, tab 300 mg)
generic
MDD
1 per day
dipyridamole (tab 25 mg, tab 50 mg, tab 75 mg)
generic
EFFIENT (TAB 5 MG, TAB 10 MG)
BRAND
MDD
1 per day
ticlopidine hcl tab 250 mg
generic
CARDIOVASCULAR AGENTS
ALPHA-ADRENERGIC AGONISTS
clonidine hcl (patch 0.1 mg/24hr, patch 0.2 mg/24hr, patch
0.3 mg/24hr)
generic
clonidine hcl (tab 0.1 mg, tab 0.2 mg)
generic
MDD
10 per day
clonidine hcl tab 0.3 mg
generic
MDD
8 per day
guanfacine hcl (tab 1 mg, tab 2 mg)
generic
methyldopa (tab 250 mg, tab 500 mg)
generic
methyldopate hcl inj 250 mg/5ml
generic
midodrine hcl (tab 2.5 mg, tab 5 mg, tab 10 mg)
generic
ALPHA-ADRENERGIC BLOCKING AGENTS
doxazosin mesylate (tab 1 mg, tab 2 mg, tab 4 mg, tab 8
mg)
PAGE 77
generic
PRODUCT DESCRIPTION
BRAND/GEN
phenoxybenzamine hcl cap 10 mg
generic
prazosin hcl (cap 1 mg, cap 2 mg, cap 5 mg)
generic
ANGIOTENSIN II RECEPTOR ANTAGONISTS
candesartan cilexetil (tab 4 mg, tab 8 mg, tab 16 mg, tab
32 mg)
generic
irbesartan (tab 75 mg, tab 150 mg, tab 300 mg)
generic
losartan potassium (tab 25 mg, tab 50 mg, tab 100 mg)
generic
telmisartan (tab 20 mg, tab 40 mg, tab 80 mg)
generic
valsartan (tab 40 mg, tab 80 mg, tab 160 mg, tab 320 mg)
generic
ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS
benazepril hcl (tab 5 mg, tab 10 mg, tab 20 mg, tab 40 mg)
generic
captopril (tab 12.5 mg, tab 25 mg, tab 50 mg, tab 100 mg)
generic
enalapril maleate (tab 2.5 mg, tab 5 mg, tab 10 mg, tab 20
mg)
generic
EPANED RECON SOLN 1 MG/ML
BRAND
fosinopril sodium (tab 10 mg, tab 20 mg, tab 40 mg)
generic
lisinopril (tab 2.5 mg, tab 5 mg, tab 10 mg, tab 20 mg, tab
30 mg, tab 40 mg)
generic
moexipril hcl (tab 7.5 mg, tab 15 mg)
generic
perindopril erbumine (tab 2 mg, tab 4 mg, tab 8 mg)
generic
quinapril hcl (tab 5 mg, tab 10 mg, tab 20 mg, tab 40 mg)
generic
ramipril (cap 1.25 mg, cap 2.5 mg, cap 5 mg, cap 10 mg)
generic
trandolapril (tab 1 mg, tab 2 mg, tab 4 mg)
generic
ANTIARRHYTHMICS
amiodarone hcl tab 200 mg
generic
disopyramide phosphate (cap 100 mg, cap 150 mg)
generic
dofetilide (cap 125 mcg (0.125, cap 250 mcg (0.25, cap
500 mcg (0.5)
generic
flecainide acetate (tab 50 mg, tab 100 mg, tab 150 mg)
generic
PAGE 78
PA
MDD
2 per day
PRODUCT DESCRIPTION
BRAND/GEN
mexiletine hcl (cap 150 mg, cap 200 mg, cap 250 mg)
generic
propafenone hcl (tab 150 mg, tab 225 mg, tab 300 mg)
generic
quinidine gluconate tab cr 324 mg
generic
quinidine sulfate (tab 200 mg, tab 300 mg)
generic
sotalol hcl (tab 80 mg, tab 120 mg, tab 160 mg, tab 240
mg)
generic
BETA-ADRENERGIC BLOCKING AGENTS
acebutolol hcl (cap 200 mg, cap 400 mg)
generic
atenolol (tab 25 mg, tab 50 mg, tab 100 mg)
generic
betaxolol hcl (tab 10 mg, tab 20 mg)
generic
bisoprolol fumarate (tab 5 mg, tab 10 mg)
generic
carvedilol (tab 3.125 mg, tab 6.25 mg, tab 12.5 mg)
generic
MDD
3 per day
carvedilol tab 25 mg
generic
MDD
4 per day
COREG CR (CAP ER 24H 20 MG, CAP ER 24H 40 MG,
BRAND
MDD
1 per day
labetalol hcl (tab 100 mg, tab 200 mg, tab 300 mg)
generic
metoprolol succinate (tab 24hr 50 mg, tab 24hr 100 mg,
tab 24hr 25 mg, tab 24hr 200 mg)
generic
metoprolol tartrate (tab 25 mg, tab 100 mg)
generic
MDD
2 per day
metoprolol tartrate tab 50 mg
generic
MDD
3 per day
nadolol (tab 20 mg, tab 40 mg, tab 80 mg)
generic
propranolol hcl (cap sr 24hr 80 mg, cap sr 24hr 60 mg, cap
sr 24hr 120 mg, cap sr 24hr 160 mg, inj 1 mg/ml, oral soln
20 mg/5ml, oral soln 40 mg/5ml, tab 10 mg, tab 20 mg, tab
40 mg, tab 60 mg, tab 80 mg)
generic
timolol maleate (tab 5 mg, tab 10 mg, tab 20 mg)
generic
MDD
2 per day
CALCIUM CHANNEL BLOCKING AGENTS
amlodipine besylate (tab 2.5 mg, tab 5 mg, tab 10 mg)
generic
CARDIZEM LA TAB ER 24H 120 MG
BRAND
diltiazem hcl (cap 12hr 90 mg, cap 12hr 120 mg, cap 12hr
60 mg, cap 24hr 240 mg)
generic
PAGE 79
PRODUCT DESCRIPTION
BRAND/GEN
diltiazem hcl (cap 24hr 120 mg, cap 24hr 180 mg)
generic
MDD
1 per day
diltiazem hcl (tab 30 mg, tab 60 mg, tab 90 mg, tab 120
mg)
generic
MDD
3 per day
diltiazem hcl coated beads (beads cap 24hr 300 mg, beads
cap 24hr 180 mg, beads cap 24hr 120 mg, beads tab 24hr
300 mg, beads tab 24hr 180 mg)
generic
MDD
1 per day
diltiazem hcl coated beads (beads cap 24hr 360 mg, beads
cap 24hr 240 mg, beads tab 24hr 360 mg, beads tab 24hr
420 mg)
generic
diltiazem hcl coated beads tab sr 24hr 240 mg
generic
MDD
2 per day
diltiazem hcl extended release beads (beads cap 24hr 360
mg, beads cap 24hr 180 mg, beads cap 24hr 300 mg,
beads cap 24hr 120 mg, beads cap 24hr 420 mg)
generic
MDD
1 per day
diltiazem hcl extended release beads cap sr 24hr 240 mg
generic
MDD
2 per day
felodipine (tab 24hr 10 mg, tab 24hr 5 mg, tab 24hr 2.5 mg)
generic
nicardipine hcl (cap 20 mg, cap 30 mg)
generic
nifedipine (cap 10 mg, cap 20 mg, tab sr 24hr 60 mg, tab sr
24hr osmotic release 60 mg, tab sr 24hr osmotic release
30 mg, tab sr 24hr osmotic release 90 mg, tab sr 24hr 30
mg, tab sr 24hr 90 mg)
generic
NYMALIZE SOLUTION 60 MG/20ML
BRAND
verapamil hcl (cap sr 24hr 120 mg, cap sr 24hr 180 mg,
cap sr 24hr 360 mg, cap sr 24hr 240 mg, tab 40 mg, tab 80
mg, tab 120 mg, tab cr 120 mg, tab cr 180 mg, tab cr 240
mg)
generic
MDD
1 per day
CARDIOVASCULAR AGENTS, OTHER
amiloride & hydrochlorothiazide tab 5-50 mg
generic
amlodipine besylate-benazepril hcl (cap 2.5-10 mg, cap 510 mg, cap 5-20 mg, cap 10-20 mg)
generic
amlodipine besylate-benazepril hcl (cap 5-40 mg, cap 1040 mg)
generic
amlodipine besylate-valsartan (tab 5-160 mg, tab 5-320
mg, tab 10-160 mg, tab 10-320 mg)
generic
PAGE 80
PRODUCT DESCRIPTION
BRAND/GEN
amlodipine-valsartan-hydrochlorothiazide (tab 5-160-12.5
mg, tab 5-160-25 mg, tab 10-320-25 mg, tab 10-160-12.5
mg, tab 10-160-25 mg)
generic
atenolol & chlorthalidone (tab 50-25 mg, tab 100-25 mg)
generic
MDD
1 per day
benazepril & hydrochlorothiazide (tab 5-6.25 mg, tab 1012.5 mg, tab 20-12.5 mg, tab 20-25 mg)
generic
MDD
1 per day
bisoprolol & hydrochlorothiazide (tab 2.5-6.25 mg, tab 56.25 mg)
generic
MDD
1 per day
bisoprolol & hydrochlorothiazide tab 10-6.25 mg
generic
MDD
2 per day
candesartan cilexetil-hydrochlorothiazide (tab 16-12.5 mg,
tab 32-25 mg, tab 32-12.5 mg)
generic
captopril & hydrochlorothiazide (tab 25-25 mg, tab 25-15
mg, tab 50-25 mg, tab 50-15 mg)
generic
digoxin (inj 0.25 mg/ml, oral soln 0.05 mg/ml, tab 125 mcg
(0.125 mg), tab 250 mcg (0.25 mg))
generic
DUTOPROL (TAB ER 24H 50-12.5 MG, TAB ER 24H 10012.5 MG, TAB ER 24H 25-12.5 MG)
BRAND
MDD
1 per day
enalapril maleate & hydrochlorothiazide (tab 5-12.5 mg, tab
10-25 mg)
generic
MDD
2 per day
fosinopril sodium & hydrochlorothiazide (tab 10-12.5 mg,
tab 20-12.5 mg)
generic
MDD
1 per day
irbesartan-hydrochlorothiazide (tab 150-12.5 mg, tab 30012.5 mg)
generic
MDD
1 per day
LANOXIN (TAB 62.5 MCG, TAB 187.5 MCG)
BRAND
LANOXIN PEDIATRIC SOLUTION 0.1 MG/ML
BRAND
lisinopril & hydrochlorothiazide (tab 10-12.5 mg, tab 20-25
mg, tab 20-12.5 mg)
generic
MDD
2 per day
losartan potassium & hydrochlorothiazide (tab 50-12.5 mg,
tab 100-25 mg, tab 100-12.5 mg)
generic
MDD
1 per day
metoprolol & hydrochlorothiazide (tab 50-25 mg, tab 10025 mg, tab 100-50 mg)
generic
MDD
2 per day
pentoxifylline tab cr 400 mg
generic
propranolol & hydrochlorothiazide (tab 40-25 mg, tab 80-25
mg)
generic
PAGE 81
PRODUCT DESCRIPTION
BRAND/GEN
quinapril-hydrochlorothiazide (tab 10-12.5 mg, tab 20-25
mg, tab 20-12.5 mg)
generic
reserpine (tab 0.1 mg, tab 0.25 mg)
generic
spironolactone & hydrochlorothiazide tab 25-25 mg
generic
telmisartan-hydrochlorothiazide (tab 40-12.5 mg, tab 8012.5 mg, tab 80-25 mg)
generic
triamterene & hydrochlorothiazide (cap 37.5-25 mg, cap
50-25 mg, tab 37.5-25 mg, tab 75-50 mg)
generic
TRIBENZOR (TAB 20-5-12.5 MG, TAB 40-5-12.5 MG, TAB
40-10-12.5 MG, TAB 40-10-25 MG, TAB 40-5-25 MG)
BRAND
valsartan-hydrochlorothiazide (tab 80-12.5 mg, tab 160-25
mg, tab 160-12.5 mg, tab 320-25 mg, tab 320-12.5 mg)
generic
MDD
1 per day
MDD
1 per day
DIURETICS, CARBONIC ANHYDRASE INHIBITORS
acetazolamide (cap sr 12hr 500 mg, tab 125 mg, tab 250
mg)
generic
DIURETICS, LOOP
bumetanide (tab 0.5 mg, tab 1 mg, tab 2 mg)
generic
furosemide (oral soln 8 mg/ml, oral soln 10 mg/ml, tab 20
generic
torsemide (tab 5 mg, tab 10 mg, tab 20 mg, tab 100 mg)
generic
DIURETICS, POTASSIUM-SPARING
amiloride hcl tab 5 mg
generic
eplerenone (tab 25 mg, tab 50 mg)
generic
spironolactone (tab 25 mg, tab 50 mg, tab 100 mg)
generic
DIURETICS, THIAZIDE
chlorothiazide (tab 250 mg, tab 500 mg)
generic
chlorthalidone (tab 25 mg, tab 50 mg)
generic
CHLORTHALIDONE TAB 50 MG
BRAND
hydrochlorothiazide (cap 12.5 mg, tab 12.5 mg, tab 25 mg,
tab 50 mg)
generic
indapamide (tab 1.25 mg, tab 2.5 mg)
generic
PAGE 82
PRODUCT DESCRIPTION
BRAND/GEN
methyclothiazide tab 5 mg
generic
metolazone (tab 2.5 mg, tab 5 mg, tab 10 mg)
generic
DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES
choline fenofibrate (cap dr 45 mg, cap dr 135 mg)
generic
fenofibrate (cap 50 mg, cap 150 mg, tab 48 mg, tab 54 mg,
generic
fenofibrate micronized (cap 43 mg, cap 67 mg, cap 130
mg, cap 134 mg, cap 200 mg)
generic
fenofibric acid (tab 35 mg, tab 105 mg)
generic
FENOFIBRIC ACID TAB 105 MG
BRAND
gemfibrozil tab 600 mg
generic
TRIGLIDE TAB 160 MG
BRAND
DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS
atorvastatin calcium (tab 10 mg, tab 20 mg, tab 40 mg, tab
80 mg)
generic
MDD
1 per day
lovastatin (tab 10 mg, tab 20 mg)
generic
MDD
1 per day
lovastatin tab 40 mg
generic
MDD
2 per day
pravastatin sodium (tab 10 mg, tab 20 mg, tab 40 mg, tab
80 mg)
generic
MDD
1 per day
simvastatin (tab 5 mg, tab 10 mg, tab 20 mg, tab 40 mg,
tab 80 mg)
generic
MDD
1 per day
cholestyramine (powder 4 gm/dose, powder packets 4 gm)
generic
MPL
1 / claim
cholestyramine light powder packets 4 gm
generic
colestipol hcl (granule packets 5 gm, granules 5 gm, tab 1
gm)
generic
niacin (antihyperlipidemic) (tab 750 mg, tab 1000 mg)
generic
MDD
2 per day
niacin tab cr 500 mg (antihyperlipidemic)
generic
MDD
1 per day
NIACOR TAB 500 MG
BRAND
DYSLIPIDEMICS, OTHER
PAGE 83
PRODUCT DESCRIPTION
BRAND/GEN
omega-3-acid ethyl esters cap 1 gm
generic
VASODILATORS, DIRECT-ACTING ARTERIAL
hydralazine hcl (inj 20 mg/ml, tab 10 mg, tab 25 mg, tab 50
mg, tab 100 mg)
generic
minoxidil (tab 2.5 mg, tab 10 mg)
generic
VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS
ISORDIL TITRADOSE TAB 40 MG
BRAND
isosorbide dinitrate (sl tab 2.5 mg, sl tab 5 mg, tab 5 mg,
tab 10 mg, tab 20 mg, tab 30 mg)
generic
isosorbide mononitrate (tab 10 mg, tab 20 mg)
generic
MDD
2 per day
isosorbide mononitrate (tab 24hr 120 mg, tab 24hr 60 mg,
tab 24hr 30 mg)
generic
MDD
1 per day
NITRO-BID OINTMENT 2 %
BRAND
nitroglycerin (cap cr 2.5 mg, cap cr 6.5 mg, cap cr 9 mg, iv
soln 5 mg/ml, lingual aerosol 400 mcg/spray, sl tab 0.3 mg,
sl tab 0.4 mg, sl tab 0.6 mg, td patch 24hr 0.4 mg/hr, td
patch 24hr 0.2 mg/hr, td patch 24hr 0.1 mg/hr, td patch
24hr 0.6 mg/hr, tl soln 0.4 mg/spray (400 mcg/spray))
generic
CENTRAL NERVOUS SYSTEM AGENTS
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES
ADZENYS XR-ODT (TAB ER DISP 3.1 MG, TAB ER DISP
6.3 MG, TAB ER DISP 9.4 MG, TAB ER DISP 12.5 MG,
TAB ER DISP 15.7 MG, TAB ER DISP 18.8 MG)
BRAND
MDD
1 per day
amphetamine-dextroamphetamine (cap 24hr 15 mg, cap
24hr 5 mg, cap 24hr 10 mg)
generic
MDD
1 per day
amphetamine-dextroamphetamine (cap 24hr 30 mg, cap
24hr 20 mg, cap 24hr 25 mg)
generic
MDD
2 per day
amphetamine-dextroamphetamine (tab 5 mg, tab 7.5 mg,
tab 10 mg, tab 12.5 mg, tab 15 mg, tab 20 mg, tab 30 mg)
generic
MDD
3 per day
dextroamphetamine sulfate (cap 24hr 15 mg, cap 24hr 10
mg, cap 24hr 5 mg)
generic
MDD
2 per day
dextroamphetamine sulfate oral solution 5 mg/5ml
generic
MDD
40 per day
PAGE 84
PRODUCT DESCRIPTION
BRAND/GEN
dextroamphetamine sulfate tab 10 mg
generic
MDD
4 per day
dextroamphetamine sulfate tab 5 mg
generic
MDD
1 per day
DYANAVEL XR SUSP 2.5 MG/ML
BRAND
MDD
8 per day
EVEKEO TAB 10 MG
BRAND
MDD
6 per day
EVEKEO TAB 5 MG
BRAND
MDD
1 per day
methamphetamine hcl tab 5 mg
generic
VYVANSE (CAP 10 MG, CAP 20 MG, CAP 30 MG, CAP
40 MG, CAP 50 MG, CAP 60 MG, CAP 70 MG)
BRAND
ZENZEDI (TAB 2.5 MG, TAB 15 MG)
ZENZEDI (TAB 7.5 MG, TAB 20 MG, TAB 30 MG)
PA
MDD
1 per day
BRAND
MDD
1 per day
BRAND
MDD
2 per day
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES
APTENSIO XR (CAP ER 24H 50 MG, CAP ER 24H 30
MG, CAP ER 24H 40 MG, CAP ER 24H 10 MG, CAP ER
24H 60 MG, CAP ER 24H 15 MG, CAP ER 24H 20 MG)
BRAND
MDD
1 per day
clonidine hcl tab sr 12hr 0.1 mg
generic
MDD
4 per day
DAYTRANA (PATCH 10 MG/9HR, PATCH 15 MG/9HR,
PATCH 20 MG/9HR, PATCH 30 MG/9HR)
BRAND
MDD
1 per day
dexmethylphenidate hcl (cap 24 hr 40 mg, cap 24 hr 20
mg, cap 24 hr 5 mg, cap 24 hr 10 mg, cap 24 hr 30 mg,
cap 24 hr 15 mg)
generic
MDD
1 per day
dexmethylphenidate hcl (tab 2.5 mg, tab 5 mg, tab 10 mg)
generic
AL
At least 6 yrs old
MDD
2 per day
FOCALIN XR (CAP ER 24H 25 MG, CAP ER 24H 35 MG)
BRAND
MDD
1 per day
guanfacine hcl (adhd) (tab 24hr 3 mg, tab 24hr 2 mg, tab
24hr 1 mg, tab 24hr 4 mg)
generic
MDD
1 per day
methylphenidate hcl (cap 10 mg, cap 20 mg, cap 30 mg,
cap 40 mg, cap 50 mg, cap 60 mg)
generic
methylphenidate hcl (cap sr 24hr 20 mg (la), cap sr 24hr 40
mg (la), tab sa osm 18 mg, tab sa osm 27 mg)
generic
MDD
1 per day
methylphenidate hcl (cap sr 24hr 30 mg (la), tab sa osm 36
mg, tab sa osm 54 mg)
generic
MDD
2 per day
PAGE 85
PRODUCT DESCRIPTION
BRAND/GEN
methylphenidate hcl (chew tab 2.5 mg, chew tab 5 mg,
chew tab 10 mg, tab cr 10 mg, tab cr 20 mg)
generic
MDD
methylphenidate hcl (tab 5 mg, tab 10 mg, tab 20 mg)
generic
AL
At least 3 yrs old
METHYLPHENIDATE HCL ER (ER TAB ER 24H 27 MG,
ER TAB ER 24H 18 MG, ER TAB ER 24H 36 MG)
BRAND
AL
At least 6 yrs old
AL
METHYLPHENIDATE HCL ER TAB ER 24H 54 MG
BRAND
At least 6 yrs old
3 per day
MDD
2 per day
methylphenidate hcl soln 10 mg/5ml
generic
MDD
30 per day
methylphenidate hcl soln 5 mg/5ml
generic
MDD
60 per day
QUILLICHEW ER (ER 20 MG, ER 40 MG)
BRAND
MDD
1 per day
QUILLICHEW ER 30 MG
BRAND
MDD
2 per day
QUILLIVANT XR RECON SUSP 25 MG/5ML
BRAND
MDD
12 per day
RITALIN LA (CAP ER 24H 10 MG, CAP ER 24H 60 MG)
BRAND
MDD
1 per day
STRATTERA (CAP 10 MG, CAP 18 MG, CAP 25 MG, CAP
40 MG)
BRAND
MDD
2 per day
STRATTERA (CAP 60 MG, CAP 80 MG, CAP 100 MG)
BRAND
MDD
1 per day
CENTRAL NERVOUS SYSTEM, OTHER
BUPAP TAB 50-300 MG
BRAND
butalbital-acetaminophen (tab 50-650 mg, tab 50-325 mg)
generic
butalbital-acetaminophen-caffeine (cap 50-325-40 mg, cap
50-500-40 mg, cap 50-300-40 mg, soln 50-325-40
mg/15ml, tab 50-500-40 mg, tab 50-325-40 mg)
generic
butalbital-aspirin-caffeine cap 50-325-40 mg
generic
NUEDEXTA CAP 20-10 MG
BRAND
PHRENILIN FORTE CAP 50-650 MG
BRAND
riluzole tab 50 mg
generic
tetrabenazine (tab 12.5 mg, tab 25 mg)
generic
VANATOL LQ SOLUTION 50-325-40 MG/15ML
BRAND
PAGE 86
S
Specialty Drug
PRODUCT DESCRIPTION
BRAND/GEN
FIBROMYALGIA AGENTS
duloxetine hcl (cap 20 mg, cap 30 mg, cap 40 mg, cap 60
mg)
generic
MDD
2 per day
IRENKA CP DR PART 40 MG
BRAND
MDD
2 per day
LYRICA (CAP 225 MG, CAP 300 MG)
BRAND
MDD
2 per day
LYRICA (CAP 25 MG, CAP 50 MG, CAP 75 MG, CAP 100
MG, CAP 150 MG, CAP 200 MG)
BRAND
MDD
3 per day
LYRICA SOLUTION 20 MG/ML
BRAND
SAVELLA (TAB 12.5 MG, TAB 25 MG, TAB 50 MG, TAB
100 MG)
BRAND
SAVELLA TITRATION PACK MISC 12.5 & 25 & 50 MG
BRAND
MULTIPLE SCLEROSIS AGENTS
AMPYRA TAB ER 12H 10 MG
BRAND
AVONEX KIT 30 MCG
BRAND
S
Specialty Drug
PA
S
Specialty Drug
PA
AVONEX PEN AUT-IJ KIT 30 MCG/0.5ML
BRAND
S
Specialty Drug
PA
AVONEX PREFILLED PREF SY KT 30 MCG/0.5ML
BRAND
S
Specialty Drug
PA
COPAXONE SOLN PRSYR 40 MG/ML
BRAND
GILENYA CAP 0.5 MG
BRAND
glatiramer acetate soln prefilled syringe 20 mg/ml
generic
S
Specialty Drug
S
Specialty Drug
PA
S
PA
PLEGRIDY (SOLN PEN 125 MCG/0.5ML, SOLN PRSYR
125 MCG/0.5ML)
BRAND
PLEGRIDY STARTER PACK (PACK SOLN PEN 63 94
MCG/0.5ML, PACK SOLN PRSYR 63 94 MCG/0.5ML)
BRAND
PAGE 87
Specialty Drug
S
Specialty Drug
PA
S
Specialty Drug
PRODUCT DESCRIPTION
BRAND/GEN
TECFIDERA (CAP DR 120 MG, CAP DR 240 MG, MISC
120 & 240 MG)
BRAND
PA
S
Specialty Drug
DENTAL AND ORAL AGENTS
AQUORAL AERO SOLN
BRAND
CAPHOSOL SOLUTION
BRAND
QL
900 / claim
QL
900 / claim
MPL
cevimeline hcl cap 30 mg
generic
chlorhexidine gluconate soln 0.12%
generic
NEUTRASAL PACKET
BRAND
pilocarpine hcl (oral) (tab 5 mg, tab 7.5 mg)
generic
SALIVAMAX PACKET
1 / claim
QL
900 / claim
BRAND
QL
900 / claim
SALIVATE RX PACKET
BRAND
QL
900 / claim
sodium fluoride (dental) (cream, gel (0.5% f))
generic
MPL
sodium fluoride rinse 0.2%
generic
stannous fluoride gel 0.4%
generic
1 / claim
DERMATOLOGICAL AGENTS
*sulfacetamide sod-sulfur wash 9-4.5% & skin cleanser
kit***
generic
*sulfacetamide sod-sulfur wash 9-4.5% & sunscreen kit***
generic
ABSORICA (CAP 10 MG, CAP 20 MG, CAP 25 MG, CAP
30 MG, CAP 35 MG, CAP 40 MG)
BRAND
acitretin (cap 10 mg, cap 17.5 mg, cap 25 mg)
generic
adapalene gel 0.3%
generic
ANALPRAM ADVANCED KIT 2.5-1 %
BRAND
ANALPRAM-HC (LOTION 1-2.5 %, LOTION 2.5-1 %)
BRAND
PA
ST
QL
MPL
AVAR LS PAD 10-2 %
PAGE 88
60 / 30 days
1 / claim
BRAND
PRODUCT DESCRIPTION
BRAND/GEN
AVAR PAD 9.5-5 %
BRAND
benzoyl peroxide (cleanser 4.25%, cloth 3%, cloth 6%,
cloth 9%, liq 7%, liq 10%)
generic
BP CLEANSING WASH EMULSION 10-4 %
BRAND
BPO (GEL 4 %, GEL 8 %)
BRAND
BPO FOAMING CLOTHS (MISC 3 %, MISC 9 %)
BRAND
calcipotriene (cream, oint, soln (50 mcg/ml))
generic
capsaicin-menthol topical patch 0.05-5%
generic
CAPTRACIN PATCH 0.0375-5 %
BRAND
clindamycin phosphate swab 1%
generic
MPL
1 / claim
clindamycin phosphate-benzoyl peroxide gel 1-5%
generic
MPL
1 / claim
clotrimazole w/ betamethasone (w/ cream, w/ lotion)
generic
MPL
1 / claim
CONDYLOX GEL 0.5 %
BRAND
COPASIL GEL
BRAND
CORTISPORIN CREAM 3.5-10000-0.5
BRAND
DOXEPIN HCL CREAM 5 %
BRAND
fluorouracil (topical) (cream 0.5%, cream 5%, soln 2%, soln
5%)
generic
HPR FOAM
BRAND
HPR PLUS FOAM
BRAND
hydrocortisone (topical) (cream 1%, lotion 2.5%, oint 2.5%)
generic
MPL
1 / claim
MPL
1 / claim
hydrocortisone cream 2.5%
QL
generic
C
hydrocortisone oint 1%
generic
MPL
imiquimod cream 5%
generic
QL
isotretinoin (cap 10 mg, cap 20 mg, cap 30 mg, cap 40 mg)
generic
60 / claim
Pkg JAR: Max
Qty=120/30 days |
Pkg TUBE: Package
Limit=1/claim |
1 / 30 days
56 / 180 days
PA
ST
PAGE 89
PRODUCT DESCRIPTION
BRAND/GEN
lactic acid (ammonium lactate) cream 12%
generic
MPL
1 / claim
lactic acid (ammonium lactate) lotion 12%
generic
MPL
1 / 30 days
LIDO-K LOTION 3 %
BRAND
lidocaine hcl (cream 3%, lotion 3%, soln 4%)
generic
lidocaine oint 5%
generic
MPL
1 / claim
lidocaine patch 5%
generic
MDD
3 per day
LIDOCAINE-HYDROCORTISONE ACE GEL 2.8-0.55 %
BRAND
lidocaine-hydrocortisone acetate rectal gel kit 3-2.5%
generic
lidocaine-prilocaine cream kit 2.5-2.5%
generic
MPL
1 / claim
LIDOCIN GEL 3 %
BRAND
LIDOPROFEN CREAM 5-5-2 %
BRAND
LIDORX GEL 3 %
BRAND
ONEXTON GEL 1.2-3.75 %
BRAND
MPL
1 / claim
OVACE PLUS (CREAM 10 %, LOTION 9.8 %)
BRAND
PLEXION CLEANSING CLOTH PAD 9.8-4.8 %
BRAND
podofilox soln 0.5%
generic
PROCORT CREAM 1.85-1.15 %
BRAND
QL
MPL
QL
PROCTOFOAM HC FOAM 1-1 %
BRAND
MPL
RECTIV OINTMENT 0.4 %
BRAND
SANTYL OINTMENT 250 UNIT/GM
BRAND
selenium sulfide lotion 2.5%
generic
SINELEE PATCH 0.0375-5 %
BRAND
SORILUX FOAM 0.005 %
BRAND
SSS 10-4 FOAM 10-4 %
BRAND
SSS 10-5 FOAM 10-5 %
BRAND
PAGE 90
60 / 30 days
1 / claim
60 / 30 days
1 / claim
QL
240 / claim
QL
60 / claim
PRODUCT DESCRIPTION
BRAND/GEN
sulfacetamide sodium (cleansing gel, shampoo)
generic
sulfacetamide sodium lotion 10% (acne)
generic
sulfacetamide sodium w/ sulfur (w/ cleansing pad 10-4%,
w/ cream 10-2%, w/ cream 10-5%, w/ emulsion 10-5%, w/
emulsion 10-1%, w/ lotion 10-5%, w/ susp 10-5%, w/ wash
9-4.5%)
generic
SULFACETAMIDE-SULFUR IN UREA EMULSION 10-5 %
BRAND
tacrolimus (topical) (oint 0.03%, oint 0.1%)
generic
C
QL
Limit=1/claim | Pkg
Size 59: Package
Limit=2/claim |
30 / 30 days
PA
MPL
TAZORAC CREAM 0.05 %
BRAND
C
MPL
TAZORAC CREAM 0.1 %
BRAND
C
1 / claim
Limit=1/claim | Pkg
Size 15: Package
Limit=4/claim | Pkg
Size 30: Package
Limit=2/claim |
1 / claim
Limit=1/claim | Pkg
Size 30: Package
Limit=2/claim |
TRETIN-X CREAM 0.0375 %
BRAND
MPL
1 / claim
tretinoin (cream 0.05%, cream 0.1%, gel 0.01%)
generic
MPL
1 / claim
TROPAZONE LOTION
BRAND
urea (cream, lotion)
generic
VEREGEN OINTMENT 15 %
BRAND
VOPAC CREAM 10-2 %
BRAND
VOPAC GB CREAM 5-2-5 %
BRAND
VOPAC KT CREAM 5-5-2 %
BRAND
ZYCLARA CREAM 3.75 %
BRAND
QL
56 / 180 days
ZYCLARA PUMP (PUMP CREAM 2.5 %, PUMP CREAM
3.75 %)
BRAND
QL
56 / 180 days
PAGE 91
PRODUCT DESCRIPTION
BRAND/GEN
ENZYME REPLACEMENT/MODIFIERS
BUPHENYL TAB 500 MG
BRAND
CARBAGLU TAB 200 MG
BRAND
CREON (CP DR PART 3000-9500, CP DR PART 6000,
CP DR PART 12000, CP DR PART 24000, CP DR PART
36000)
BRAND
CYSTADANE POWDER
BRAND
KUVAN (PACKET 100 MG, TAB SOL 100 MG)
BRAND
ORFADIN (CAP 2 MG, CAP 5 MG, CAP 10 MG)
BRAND
PANCREAZE (CP DR PART 4200, CP DR PART 10500,
CP DR PART 16800, CP DR PART 21000)
BRAND
pancrelipase (lip-prot-amyl) dr cap 5000-17000-27000 unit
generic
PERTZYE (CP DR PART 8000, CP DR PART 16000)
BRAND
PROCYSBI (CAP DR 25 MG, CAP DR 75 MG)
BRAND
sodium phenylbutyrate oral powder 3 gm/teaspoonful
generic
ULTRESA (CP DR PART 13800, CP DR PART 20700, CP
DR PART 23000)
BRAND
VIOKACE (TAB 10440, TAB 20880)
BRAND
ZENPEP (CP DR PART 3000-10000, CP DR PART 5000,
CP DR PART 10000, CP DR PART 15000, CP DR PART
20000, CP DR PART 25000, CP DR PART 40000)
BRAND
S
Specialty Drug
S
Specialty Drug
GASTROINTESTINAL AGENTS
ANTISPASMODICS, GASTROINTESTINAL
CUVPOSA SOLUTION 1 MG/5ML
BRAND
dicyclomine hcl (cap 10 mg, oral soln 10 mg/5ml, tab 20
mg)
generic
glycopyrrolate (tab 1 mg, tab 2 mg)
generic
hyoscyamine sulfate (tab 0.125 mg, tab sl 0.125 mg)
generic
hyoscyamine sulfate tab sr 12hr 0.375 mg
generic
methscopolamine bromide (tab 2.5 mg, tab 5 mg)
generic
PAGE 92
MDD
4 per day
PRODUCT DESCRIPTION
BRAND/GEN
GASTROINTESTINAL AGENTS, OTHER
PA
CHOLBAM (CAP 50 MG, CAP 250 MG)
BRAND
diphenoxylate w/ atropine (w/ liq mg/5ml, w/ tab mg)
generic
ENTEREG CAP 12 MG
BRAND
loperamide hcl cap 2 mg
generic
REZYST IM CHEW TAB
BRAND
ursodiol (cap 300 mg, tab 250 mg, tab 500 mg)
generic
VSL#3 DS PACKET
BRAND
MDD
5 per day
MDD
8 per day
MDD
4 per day
MDD
2 per day
MPL
1 / claim
HISTAMINE2 (H2) RECEPTOR ANTAGONISTS
cimetidine (tab 200 mg, tab 400 mg)
generic
cimetidine (tab 300 mg, tab 800 mg)
generic
famotidine (for susp 40 mg/5ml, tab 20 mg, tab 40 mg)
generic
nizatidine (cap 150 mg, cap 300 mg, oral soln 15 mg/ml)
generic
ranitidine hcl (cap 150 mg, syrup 15 mg/ml (75 mg/5ml),
generic
ranitidine hcl cap 300 mg
generic
IRRITABLE BOWEL SYNDROME AGENTS
alosetron hcl (tab 0.5 mg, tab 1 mg)
generic
LAXATIVES
COLYTE WITH FLAVOR PACKS RECON SOLN 227.1
GM
BRAND
GOLYTELY RECON SOLN 227.1 GM
BRAND
lactulose (encephalopathy) solution 10 gm/15ml
generic
lactulose solution 10 gm/15ml
generic
MOVIPREP RECON SOLN 100 GM
BRAND
OSMOPREP TAB 1.102-0.398 GM
BRAND
peg 3350-kcl-sod bicarb-nacl for soln 420 gm
generic
PAGE 93
PRODUCT DESCRIPTION
BRAND/GEN
peg 3350-kcl-sod bicarb-sod chloride-sod sulfate (soln 236
gm, soln 240 gm)
generic
polyethylene glycol 3350 (3350 powder, 3350 packet)
generic
PREPOPIK PACKET 10-3.5-12 MG-GM-GM
BRAND
SUPREP BOWEL PREP SOLUTION
BRAND
MPL
1 / claim
MDD
40 per day
MDD
4 per day
MDD
1 per day
PROTECTANTS
CARAFATE SUSPENSION 1 GM/10ML
BRAND
misoprostol (tab 100 mcg, tab 200 mcg)
generic
sucralfate tab 1 gm
generic
PROTON PUMP INHIBITORS
lansoprazole cap delayed release 30 mg
generic
omeprazole (cap 20 mg, cap 40 mg)
generic
omeprazole cap delayed release 10 mg
generic
OMEPRAZOLE+SYRSPEND SF ALKA SUSPENSION 2
MG/ML
BRAND
pantoprazole sodium (ec tab 20 mg, ec tab 40 mg)
generic
PREVACID SOLUTAB (TAB DISP 15 MG, TAB DISP 30
MG)
BRAND
rabeprazole sodium ec tab 20 mg
generic
GENITOURINARY AGENTS
ANTISPASMODICS, URINARY
flavoxate hcl tab 100 mg
generic
oxybutynin chloride (syrup 5 mg/5ml, tab 5 mg, tab sr 24hr
15 mg, tab sr 24hr 10 mg, tab sr 24hr 5 mg)
generic
tolterodine tartrate (cap sr 24hr 4 mg, cap sr 24hr 2 mg, tab
1 mg, tab 2 mg)
generic
trospium chloride tab 20 mg
generic
PAGE 94
PRODUCT DESCRIPTION
BRAND/GEN
BENIGN PROSTATIC HYPERTROPHY AGENTS
alfuzosin hcl tab sr 24hr 10 mg
GL
generic
MDD
Male
1 per day
CIALIS (TAB 2.5 MG, TAB 5 MG)
BRAND
PA
dutasteride cap 0.5 mg
generic
GL
finasteride tab 5 mg
generic
MDD
1 per day
tamsulosin hcl cap 0.4 mg
generic
MDD
2 per day
terazosin hcl (cap 1 mg, cap 2 mg, cap 5 mg, cap 10 mg)
generic
Male
GENITOURINARY AGENTS, OTHER
bethanechol chloride (tab 5 mg, tab 10 mg, tab 25 mg, tab
50 mg)
generic
CIALIS (TAB 10 MG, TAB 20 MG)
BRAND
CUPRIMINE CAP 250 MG
BRAND
CYSTAGON (CAP 50 MG, CAP 150 MG)
BRAND
ELMIRON CAP 100 MG
BRAND
ORACIT SOLUTION 490-640 MG/5ML
BRAND
phenazopyridine hcl (tab 100 mg, tab 200 mg)
generic
pot phos monobasic w/sod phos di & monobas tab 155852-130mg
generic
potassium citrate (alkalinizer) (tab 5 (540, tab 10 (1080, tab
15 (1620)
generic
sodium citrate & citric acid soln 500-334 mg/5ml
generic
PA
S
QL
MDD
QL
Specialty Drug
500 / 30 days
8 per day
500 / 30 days
PHOSPHATE BINDERS
calcium acetate (phosphate binder) (cap 667 mg (169 mg
ca), tab 667 mg)
generic
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)
betamethasone dipropionate augmented cream 0.05%
PAGE 95
generic
MPL
1 / claim
PRODUCT DESCRIPTION
BRAND/GEN
betamethasone valerate (cream, lotion, oint)
generic
MPL
1 / claim
clobetasol propionate (cream, gel, oint, shampoo, soln)
generic
MPL
1 / claim
clobetasol propionate emulsion foam 0.05%
generic
cortisone acetate tab 25 mg
generic
desonide (cream, lotion)
generic
MPL
1 / claim
dexamethasone (elixir 0.5 mg/5ml, soln 0.5 mg/5ml, tab 0.5
mg, tab 0.75 mg, tab 1 mg, tab 1.5 mg, tab 2 mg, tab 4 mg,
tab 6 mg)
generic
DEXAMETHASONE INTENSOL CONC 1 MG/ML
BRAND
DEXPAK 10 DAY TAB THPK 1.5 MG (35)
BRAND
BRAND
BRAND
diflorasone diacetate (cream, oint)
generic
MPL
1 / claim
fludrocortisone acetate tab 0.1 mg
generic
fluocinonide gel 0.05%
generic
MPL
1 / claim
fluticasone propionate cream 0.05%
generic
MPL
1 / 30 days
fluticasone propionate oint 0.005%
generic
MPL
1 / claim
hydrocortisone (tab 5 mg, tab 10 mg, tab 20 mg)
generic
hydrocortisone acetate suppos 25 mg
generic
MDD
2 per day
hydrocortisone butyrate (cream, oint, soln)
generic
MEDROL TAB 2 MG
BRAND
methylprednisolone (tab 4 mg, tab 8 mg, tab 16 mg, tab 32
mg, tab therapy pack 4 mg (21))
generic
MILLIPRED DP (TAB THPK 5 MG (48), TAB THPK 5 MG
(21))
BRAND
MILLIPRED SOLUTION 10 MG/5ML
BRAND
MILLIPRED TAB 5 MG
BRAND
mometasone furoate (cream, oint)
generic
PAGE 96
QL
MPL
240 / claim
1 / claim
PRODUCT DESCRIPTION
BRAND/GEN
prednicarbate (cream, oint)
generic
MPL
prednisolone sodium phosphate (phos orally disintegr tab
10 mg (base eq), phos orally disintegr tab 15 mg (base eq),
phos orally disintegr tab 30 mg (base eq), phosph oral soln
6.7 mg/5ml (5 mg/5ml base), phosphate oral soln 15
mg/5ml (base equiv))
generic
QL
240 / claim
PREDNISOLONE SODIUM PHOSPHATE SOLUTION 25
MG/5ML
BRAND
QL
240 / claim
prednisolone syrup 15 mg/5ml (usp solution equivalent)
generic
prednisone (oral soln 5 mg/5ml, tab 1 mg, tab 2.5 mg, tab 5
mg, tab 10 mg, tab 20 mg, tab 50 mg, tab therapy pack 5
mg (21), tab therapy pack 5 mg (48), tab therapy pack 10
mg (21), tab therapy pack 10 mg (48))
generic
PREDNISONE INTENSOL CONC 5 MG/ML
BRAND
PSORCON CREAM 0.05 %
BRAND
RAYOS (TAB DR 1 MG, TAB DR 2 MG, TAB DR 5 MG)
BRAND
triamcinolone acetonide (topical) (cream 0.1%, cream
0.5%, lotion 0.025%, lotion 0.1%, oint 0.025%, oint 0.1%,
oint 0.5%)
generic
triamcinolone acetonide cream 0.025%
generic
C
triamcinolone acetonide dental paste 0.1%
generic
QL
5 / claim
TRIANEX OINTMENT 0.05 %
BRAND
VERIPRED 20 SOLUTION 20 MG/5ML
BRAND
QL
240 / claim
MPL
1 / claim
1 / claim
Pkg JAR: Max
Qty=120/30 days |
Pkg TUBE: Package
Limit=1/claim |
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)
desmopressin acetate (inj 4 mcg/ml, tab 0.1 mg, tab 0.2
mg)
generic
desmopressin acetate nasal soln 0.01% (refrigerated)
generic
MDD
5 per day
desmopressin acetate nasal spray soln 0.01%
generic
MDD
5 per day
desmopressin acetate nasal spray soln 0.01%
(refrigerated)
generic
MDD
5 per day
PAGE 97
PRODUCT DESCRIPTION
BRAND/GEN
GENOTROPIN MINIQUICK (RECON SOLN 0.2 MG,
RECON SOLN 0.4 MG, RECON SOLN 0.6 MG, RECON
SOLN 0.8 MG, RECON SOLN 1 MG, RECON SOLN 1.2
MG, RECON SOLN 1.4 MG, RECON SOLN 1.6 MG,
RECON SOLN 1.8 MG, RECON SOLN 2 MG)
BRAND
S
Specialty Drug
HUMATROPE (RECON SOLN 5 MG, RECON SOLN 6
MG, RECON SOLN 12 MG, RECON SOLN 24 MG)
BRAND
S
Specialty Drug
INCRELEX SOLUTION 40 MG/4ML
BRAND
S
Specialty Drug
NORDITROPIN FLEXPRO (SOLUTION 5 MG/1.5ML,
SOLUTION 10 MG/1.5ML, SOLUTION 15 MG/1.5ML,
SOLUTION 30 MG/3ML)
BRAND
S
Specialty Drug
NORDITROPIN NORDIFLEX PEN SOLUTION 30 MG/3ML
BRAND
S
Specialty Drug
NUTROPIN AQ NUSPIN 10 SOLUTION 10 MG/2ML
BRAND
S
Specialty Drug
BRAND
S
Specialty Drug
BRAND
S
Specialty Drug
NUTROPIN AQ PEN (PEN SOLUTION 10 MG/2ML, PEN
SOLUTION 20 MG/2ML)
BRAND
S
Specialty Drug
OMNITROPE (RECON SOLN 5.8 MG, SOLUTION 5
MG/1.5ML, SOLUTION 10 MG/1.5ML)
BRAND
S
Specialty Drug
STIMATE SOLUTION 1.5 MG/ML
BRAND
MDD
5 per day
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)
ANDROGENS
ANDRODERM (PATCH 24HR 4 MG/24HR, PATCH 24HR
2 MG/24HR)
BRAND
ANDROGEL (GEL 20.25 MG/1.25GM, GEL 40.5
MG/2.5GM)
BRAND
ANDROGEL PUMP GEL 20.25 MG/ACT (1.62%)
BRAND
ANDROXY TAB 10 MG
BRAND
AVEED SOLUTION 750 MG/3ML
BRAND
AXIRON SOLUTION 30 MG/ACT
BRAND
danazol (cap 50 mg, cap 100 mg, cap 200 mg)
generic
PAGE 98
MDD
1 per day
QL
150 / 30 days
QL
180 / 30 days
PRODUCT DESCRIPTION
BRAND/GEN
METHITEST TAB 10 MG
BRAND
methyltestosterone cap 10 mg
generic
STRIANT MISC 30 MG
BRAND
TESTOPEL PELLET 75 MG
BRAND
testosterone (gel 10mg/act (2%), gel 12.5 mg/act (1%))
generic
QL
150 / 30 days
testosterone (gel 25 mg/2.5gm, gel 50 mg/5gm)
generic
QL
300 / 30 days
testosterone cypionate im inj in oil 100 mg/ml
generic
testosterone cypionate im inj in oil 200 mg/ml
generic
QL
4 / 30 days
testosterone enanthate im inj in oil 200 mg/ml
generic
TESTOSTERONE GEL 50 MG/5GM (1%)
BRAND
QL
300 / 30 days
ALORA (PATCH TW 0.025 MG/24HR, PATCH TW 0.05
MG/24HR, PATCH TW 0.075 MG/24HR, PATCH TW 0.1
MG/24HR)
BRAND
MDD
0.29 per day
BEYAZ TAB 3-0.02-0.451 MG
BRAND
COMBIPATCH (PATCH TW 0.05-0.14 MG/DAY, PATCH
TW 0.05-0.25 MG/DAY)
BRAND
desogest-eth estrad & eth estrad tab 0.15-0.02/0.01
mg(21/5)
generic
desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg
generic
DESOGESTREL-ETHINYL ESTRADIOL TAB 0.150.02/0.01 MG (AZURETTE, KARIVA, PIMTREA,
VIORELE, CAZIANT, CESIA, VELIVET)
BRAND
DESOGESTREL-ETHINYL ESTRADIOL TAB 0.15-30 MGMCG (APRI, EMOQUETTE, ENSKYCE, RECLIPSEN,
SOLIA)
BRAND
ESTRACE CREAM 0.1 MG/GM
estradiol (patch 0.025 mg/24hr, patch 0.0375 mg/24hr,
patch 0.05 mg/24hr, patch 0.075 mg/24hr, patch 0.1
mg/24hr)
MDD
2 per day
ESTROGENS
PAGE 99
GL
Female
BRAND
QL
43 / 30 days
generic
MDD
0.29 per day
PRODUCT DESCRIPTION
BRAND/GEN
estradiol (tab 0.5 mg, tab 1 mg, tab 2 mg, td patch weekly
0.025 mg/24hr, td patch weekly 0.0375 mg/24hr (37.5
mcg/24hr), td patch weekly 0.05 mg/24hr, td patch weekly
0.06 mg/24hr, td patch weekly 0.075 mg/24hr, td patch
weekly 0.1 mg/24hr)
generic
LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST
TAB 0.01MG(7) (AMETHIA, CAMRESE, DAYSEE)
BRAND
QL
91 / claim
LEVONORGEST-ETH ESTRAD 91-DAY TAB 0.1-0.02 &
0.01 MG (AMETHIA LO, CAMRESE LO,
BRAND
QL
91 / claim
LEVONORGEST-ETH ESTRAD 91-DAY TAB 0.15-0.03
MG (INTROVALE, JOLESSA, QUASENSE)
BRAND
QL
91 / claim
levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg
generic
MDD
1 per day
LEVONORGESTREL-ETH ESTRA TAB 0.05-30/0.07540/0.125-30MG (ENPRESSE, LEVONEST, MYZILRA,
TRIVORA)
BRAND
levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mgmcg
generic
LEVONORGESTREL-ETHINYL ESTRAD TAB 0.1-20 MG
(AUBRA, AVIANE, DELYLA, FALMINA, LESSINA,
LUTERA, ORSYTHIA, SRONYX)
BRAND
MDD
1 per day
LEVONORGESTREL-ETHINYL ESTRAD TAB 0.15-30 MG
(ALTAVERA, CHATEAL, KURVELO, LEVORA,
MARLISSA, PORTIA)
BRAND
MDD
1 per day
LEVONORGESTREL-ETHINYL ESTRADIOL
(CONTINUOUS) TAB 90-20 MCG (AMETHYST)
BRAND
LO LOESTRIN FE TAB 1 MG-10 MCG / 10 MCG
BRAND
LO MINASTRIN FE THER PACK 1 MG-10 MCG / 10 MCG
BRAND
MINASTRIN 24 FE CHEW TAB 1-20 MG-MCG(24)
BRAND
MINIVELLE (PATCH TW 0.025 MG/24HR, PATCH TW
0.0375 MG/24HR, PATCH TW 0.05 MG/24HR, PATCH TW
0.075 MG/24HR, PATCH TW 0.1 MG/24HR)
BRAND
MDD
0.29 per day
NECON 10/11 (28) TAB 35 MCG
BRAND
NORELGESTROMIN-ETHINYL ESTRADIOL TD PTWK
150-35 MCG/24HR (XULANE)
BRAND
MPL
1 / 28 days
norethin acet & estrad-fe (ace & ethinyl tab 1 mg-20 mcg,
ace & ethinyl tab 1.5 mg-30 mcg, ace-ethinyl tab 1 mg-20
mcg (24))
generic
PAGE 100
PRODUCT DESCRIPTION
BRAND/GEN
NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.4
MG-35 MCG (BALZIVA, BRIELLYN, GILDAGIA, PHILITH,
VYFEMLA, ZENCHENT)
BRAND
NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.5
MG-35 MCG (NECON, NORTREL, WERA)
BRAND
NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG35 MCG (ALYACEN, CYCLAFEM, DASETTA, NECON,
NORTREL, PIRMELLA)
BRAND
NORETHINDRONE AC-ETHINYL ESTRAD-FE TAB 120/1-30/1-35 MG-MCG (TILIA, TRI-LEGEST)
BRAND
NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1
MG-20 MCG (GILDESS, JUNEL, LARIN, MICROGESTIN)
BRAND
NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB
1.5 MG-30 MCG (GILDESS, JUNEL, LARIN,
MICROGESTIN)
BRAND
NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE
TAB 1 MG-20 MCG (GILDESS, JUNEL, LARIN,
MICROGESTIN)
BRAND
NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE
TAB 1.5 MG-30 MCG (GILDESS, JUNEL, LARIN,
MICROGESTIN)
BRAND
NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE TAB
1 MG-20 MCG (LOMEDIA)
BRAND
norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg
generic
NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.7535/1-35 MG (ALYACEN, CYCLAFEM, DASETTA, NECON,
NORTREL, PIRMELLA)
BRAND
NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/135/0.5-35 MG (ARANELLE, LEENA)
BRAND
NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG35 MCG (ESTARYLLA, MONO-LINYAH, MONONESSA,
PREVIFEM, SPRINTEC)
BRAND
norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mgmcg
generic
MDD
1 per day
NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.21535/0.25-35 MG (TRI-ESTARYLLA, TRI-LINYAH, TRIPREVIFEM, TRI-SPRINTEC, TRINESSA)
BRAND
MDD
1 per day
PAGE 101
GL
Female
PRODUCT DESCRIPTION
BRAND/GEN
NUVARING RING 0.12-0.015 MG/24HR
BRAND
PREMARIN (TAB 0.3 MG, TAB 0.45 MG, TAB 0.625 MG,
TAB 0.9 MG, TAB 1.25 MG)
BRAND
QL
PREMARIN CREAM 0.625 MG/GM
BRAND
C
43 / 30 days
From age 40 and older:
Max Qty=43/30 days |
From age 0 through
40: Max Qty=43/365
days |
PREMPHASE TAB 0.625-5 MG
BRAND
GL
Female
PREMPRO (TAB 0.3-1.5 MG, TAB 0.45-1.5 MG, TAB
0.625-5 MG, TAB 0.625-2.5 MG)
BRAND
GL
Female
QUARTETTE TAB 42-21-21-7 DAYS
BRAND
QL
91 / claim
SAFYRAL TAB 3-0.03-0.451 MG
BRAND
QL
4 / 365 days
GL
Female
PROGESTERONE AGONISTS/ANTAGONISTS
ELLA TAB 30 MG
BRAND
PROGESTINS
DEPO-SUBQ PROVERA 104 SUSP PRSYR 104
MG/0.65ML
BRAND
ENDOMETRIN INSERT 100 MG
BRAND
levonorgestrel tab 1.5 mg
generic
MFL
4 / lifetime
PA
MAKENA OIL 250 MG/ML
BRAND
S
medroxyprogesterone acetate (tab 2.5 mg, tab 5 mg, tab
10 mg)
generic
medroxyprogesterone acetate im susp 150 mg/ml
generic
QL
MFL
medroxyprogesterone acetate im susp prefilled syr 150
mg/ml
generic
megestrol acetate (susp 40 mg/ml, tab 20 mg, tab 40 mg)
generic
PAGE 102
Specialty Drug
84 / claim
1 / 84 days
PRODUCT DESCRIPTION
BRAND/GEN
MIRENA (52 MG) IUD 20 MCG/24HR
BRAND
NEXPLANON IMPLANT 68 MG
BRAND
norethindrone acetate tab 5 mg
generic
NORETHINDRONE TAB 0.35 MG (CAMILA, DEBLITANE,
ERRIN, HEATHER, JENCYCLA, JOLIVETTE, LYZA,
NORA-BE, NORLYROC, SHAROBEL)
BRAND
MDD
1 per day
progesterone micronized cap 100 mg
generic
MDD
1 per day
progesterone micronized cap 200 mg
generic
SKYLA IUD 13.5 MG
BRAND
SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS
raloxifene hcl tab 60 mg
generic
ANABOLIC STEROIDS
ANADROL-50 TAB 50 MG
BRAND
oxandrolone (tab 2.5 mg, tab 10 mg)
generic
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)
ARMOUR THYROID (TAB 15 MG, TAB 120 MG, TAB 180
BRAND
levothyroxine sodium (tab 25 mcg, tab 50 mcg, tab 75 mcg,
tab 88 mcg, tab 100 mcg, tab 112 mcg, tab 125 mcg, tab
137 mcg, tab 150 mcg, tab 175 mcg, tab 200 mcg, tab 300
mcg)
generic
liothyronine sodium (tab 5 mcg, tab 25 mcg, tab 50 mcg)
generic
thyroid (tab 30 mg (1/2, tab 60 mg (1, tab 90 mg (1 1/2)
generic
THYROLAR-1 TAB 60 (12.5-50) MG (MCG)
BRAND
THYROLAR-1/2 TAB 30 (6.25-25) MG (MCG)
BRAND
THYROLAR-1/4 TAB 15 (3.1-12.5) MG (MCG)
BRAND
THYROLAR-2 TAB 120 (25-100) MG (MCG)
BRAND
THYROLAR-3 TAB 180 (37.5-150) MG (MCG)
BRAND
PAGE 103
PRODUCT DESCRIPTION
BRAND/GEN
HORMONAL AGENTS, SUPPRESSANT (PARATHYROID)
SENSIPAR (TAB 30 MG, TAB 60 MG, TAB 90 MG)
BRAND
S
Specialty Drug
HORMONAL AGENTS, SUPPRESSANT (PITUITARY)
cabergoline tab 0.5 mg
generic
ELIGARD KIT 7.5 MG
BRAND
S
Specialty Drug
leuprolide acetate inj kit 5 mg/ml
generic
S
Specialty Drug
LUPRON DEPOT (KIT 3.75 MG, KIT 7.5 MG)
BRAND
S
Specialty Drug
LUPRON DEPOT-PED (KIT 7.5 MG, KIT 11.25 MG, KIT 15
MG)
BRAND
S
Specialty Drug
octreotide acetate (inj 50 mcg/ml (0.05 mg/ml), inj 100
mcg/ml (0.1 mg/ml), inj 200 mcg/ml (0.2 mg/ml), inj 500
mcg/ml (0.5 mg/ml), inj 1000 mcg/ml (1 mg/ml))
generic
S
Specialty Drug
SANDOSTATIN LAR DEPOT (KIT 10 MG, KIT 20 MG, KIT
30 MG)
BRAND
S
Specialty Drug
SOMATULINE DEPOT (SOLUTION 60 MG/0.2ML,
SOLUTION 90 MG/0.3ML, SOLUTION 120 MG/0.5ML)
BRAND
S
Specialty Drug
SOMAVERT (RECON SOLN 10 MG, RECON SOLN 15
MG, RECON SOLN 20 MG, RECON SOLN 25 MG,
RECON SOLN 30 MG)
BRAND
S
Specialty Drug
SYNAREL SOLUTION 2 MG/ML
BRAND
HORMONAL AGENTS, SUPPRESSANT (THYROID)
ANTITHYROID AGENTS
methimazole (tab 5 mg, tab 10 mg)
generic
propylthiouracil tab 50 mg
generic
SSKI SOLUTION 1 GM/ML
BRAND
IMMUNOLOGICAL AGENTS
IMMUNE SUPPRESSANTS
ASTAGRAF XL (CAP ER 24H 1 MG, CAP ER 24H 0.5 MG,
CAP ER 24H 5 MG)
PAGE 104
BRAND
PRODUCT DESCRIPTION
BRAND/GEN
AZASAN (TAB 75 MG, TAB 100 MG)
BRAND
azathioprine tab 50 mg
generic
cyclosporine (cap 25 mg, cap 100 mg)
MDD
3 per day
generic
MDD
4 per day
cyclosporine modified (for microemulsion) (cap 25 mg, cap
50 mg, cap 100 mg)
generic
MDD
4 per day
cyclosporine modified oral soln 100 mg/ml
generic
MDD
8 per day
ENBREL (RECON SOLN 25 MG, SOLN PRSYR 25
MG/0.5ML, SOLN PRSYR 50 MG/ML)
BRAND
S
Specialty Drug
ENBREL SURECLICK SOLN A-INJ 50 MG/ML
BRAND
S
Specialty Drug
HUMIRA (PREF SY KT 10 MG/0.2ML, PREF SY KT 20
MG/0.4ML, PREF SY KT 40 MG/0.8ML)
BRAND
S
Specialty Drug
HUMIRA PEDIATRIC CROHNS START PREF SY KT 40
MG/0.8ML
BRAND
S
Specialty Drug
HUMIRA PEN PEN KIT 40 MG/0.8ML
BRAND
S
Specialty Drug
HUMIRA PEN-CROHNS STARTER PEN KIT 40
MG/0.8ML
BRAND
S
Specialty Drug
HUMIRA PEN-PSORIASIS STARTER PEN KIT 40
MG/0.8ML
BRAND
S
Specialty Drug
methotrexate sodium tab 2.5 mg (base equiv)
generic
mycophenolate mofetil cap 250 mg
generic
MDD
2 per day
mycophenolate mofetil for oral susp 200 mg/ml
generic
MDD
15 per day
mycophenolate mofetil tab 500 mg
generic
MDD
4 per day
mycophenolate sodium tab dr 180 mg (mycophenolic acid
equiv)
generic
MDD
2 per day
mycophenolate sodium tab dr 360 mg (mycophenolic acid
equiv)
generic
MDD
4 per day
OTREXUP (SOLN A-INJ 10 MG/0.4ML, SOLN A-INJ 15
MG/0.4ML, SOLN A-INJ 20 MG/0.4ML, SOLN A-INJ 25
MG/0.4ML)
BRAND
RAPAMUNE SOLUTION 1 MG/ML
BRAND
MDD
4 per day
PAGE 105
PRODUCT DESCRIPTION
BRAND/GEN
RASUVO (SOLN A-INJ 7.5 MG/0.15ML, SOLN A-INJ 10
MG/0.2ML, SOLN A-INJ 12.5 MG/0.25ML, SOLN A-INJ 15
MG/0.6ML)
BRAND
RHEUMATREX TAB 2.5 MG
BRAND
SANDIMMUNE SOLUTION 100 MG/ML
BRAND
sirolimus tab 0.5 mg
generic
sirolimus tab 1 mg
MDD
8 per day
generic
MDD
6 per day
sirolimus tab 2 mg
generic
MDD
2 per day
tacrolimus (cap 0.5 mg, cap 1 mg, cap 5 mg)
generic
MDD
3 per day
TREXALL (TAB 5 MG, TAB 7.5 MG, TAB 10 MG, TAB 15
MG)
BRAND
IMMUNOMODULATORS
ARCALYST RECON SOLN 220 MG
BRAND
RIDAURA CAP 3 MG
BRAND
S
Specialty Drug
INFLAMMATORY BOWEL DISEASE AGENTS
AMINOSALICYLATES
*mesalamine rectal enema 4 gm & cleanser wipe kit**
generic
balsalazide disodium cap 750 mg
generic
MDD
9 per day
DELZICOL CAP DR 400 MG
BRAND
MDD
8 per day
mesalamine enema 4 gm
generic
MDD
8 per day
PENTASA (CAP ER 250 MG, CAP ER 500 MG)
BRAND
MDD
8 per day
SFROWASA ENEMA 4 GM/60ML
BRAND
MDD
8 per day
MPL
1 / claim
GLUCOCORTICOIDS
budesonide delayed release particles cap 3 mg
generic
hydrocortisone (rectal) (cream 1%, cream 2.5%)
generic
PAGE 106
PRODUCT DESCRIPTION
BRAND/GEN
hydrocortisone enema 100 mg/60ml
generic
UCERIS TAB ER 24H 9 MG
BRAND
QL
420 / claim
SULFONAMIDES
sulfasalazine (tab 500 mg, tab delayed release 500 mg)
generic
METABOLIC BONE DISEASE AGENTS
alendronate sodium (oral soln 70 mg/75ml, tab 5 mg, tab
10 mg, tab 35 mg, tab 40 mg, tab 70 mg)
generic
calcitonin (salmon) nasal soln 200 unit/act
generic
calcitriol (cap 0.25 mcg, cap 0.5 mcg, oral soln 1 mcg/ml)
generic
doxercalciferol (cap 0.5 mcg, cap 1 mcg, cap 2.5 mcg, inj 4
mcg/2ml (2 mcg/ml))
generic
MDD
QL
FORTEO SOLUTION 600 MCG/2.4ML
BRAND
MPL
S
FORTICAL SOLUTION 200 UNIT/ACT
BRAND
HECTOROL SOLUTION 2 MCG/ML
BRAND
MIACALCIN SOLUTION 200 UNIT/ML
BRAND
paricalcitol (cap 1 mcg, cap 2 mcg, cap 4 mcg)
generic
risedronate sodium (tab 35 mg, tab delayed release 35 mg)
generic
risedronate sodium (tab 5 mg, tab 30 mg)
generic
1 per day
2.4 / 28 days
1 / 28 days
Specialty Drug
MDD
1 per day
MISCELLANEOUS THERAPEUTIC AGENTS
ACE AEROSOL CLOUD ENHANCER MISC
BRAND
MPL
1 / claim
AEROCHAMBER PLUS FLO-VU LARGE MISC
BRAND
QL
2 / claim
AEROCHAMBER PLUS FLO-VU MISC
BRAND
QL
2 / claim
AEROCHAMBER PLUS FLO-VU SMALL MISC
BRAND
QL
2 / claim
AEROCHAMBER PLUS FLO-VU W/MASK MISC
BRAND
QL
2 / claim
AIRS DISPOSABLE NEBULIZER KIT
BRAND
MPL
1 / claim
PAGE 107
PRODUCT DESCRIPTION
BRAND/GEN
chloral hydrate crystals
generic
dexmedetomidine hcl inj 200 mcg/2ml (for iv infusion)
generic
E-Z SPACER DEVICE
BRAND
QL
2 / claim
E-Z SPACER THE BODY GUARDS PK DEVICE
BRAND
QL
2 / claim
EASIVENT MASK LARGE MISC
BRAND
QL
2 / claim
EASIVENT MASK MEDIUM MISC
BRAND
QL
2 / claim
EASIVENT MASK SMALL MISC
BRAND
QL
2 / claim
EASIVENT MISC
BRAND
QL
2 / claim
EBASE CONTROLLER KIT MISC
BRAND
MPL
1 / claim
FLEXICHAMBER DEVICE
BRAND
QL
2 / claim
FLUTTER DEVICE
BRAND
MPL
1 / claim
formaldehyde solution 10%
generic
QL
90 / claim
INSPIRACHAMBER/LARGE DEVICE
BRAND
QL
2 / claim
INSPIRACHAMBER/MEDIUM DEVICE
BRAND
QL
2 / claim
INSPIRACHAMBER/MOUTHPIECE DEVICE
BRAND
QL
2 / claim
INSPIRACHAMBER/SMALL DEVICE
BRAND
QL
2 / claim
INSPIREASE BAGS MISC
BRAND
QL
3 / 180 days
INSPIREASE MISC
BRAND
QL
2 / claim
INSPIREASE MOUTHPIECE MISC
BRAND
QL
1 / 180 days
INSPIREASE RESERVOIR BAGS MISC
BRAND
QL
3 / 180 days
MISTASSIST DEVICE
BRAND
MPL
ORTHO DIAPHRAGM ALL-FLEX (DIAPHRAGM
DIAPHRAGM 65, DIAPHRAGM DIAPHRAGM 70,
DIAPHRAGM DIAPHRAGM 75, DIAPHRAGM
DIAPHRAGM 80)
BRAND
ORTHO DIAPHRAGM COIL (DIAPHRAGM KIT 100,
DIAPHRAGM KIT 105)
BRAND
PAGE 108
QL
1 / claim
1 / 180 days
PRODUCT DESCRIPTION
BRAND/GEN
ORTHO DIAPHRAGM COIL KIT 50 MM
BRAND
ORTHO DIAPHRAGM FLAT (DIAPHRAGM KIT 55,
DIAPHRAGM KIT 60, DIAPHRAGM KIT 65, DIAPHRAGM
KIT 70, DIAPHRAGM KIT 75, DIAPHRAGM KIT 80,
DIAPHRAGM KIT 85, DIAPHRAGM KIT 90, DIAPHRAGM
KIT 95)
BRAND
PEDIATRIC COMPRESSOR/NEBULIZER KIT
MPL
1 / claim
BRAND
MPL
1 / claim
PULMONEB LT DEVICE
BRAND
MPL
1 / claim
RELION KETONE TEST STRIP
BRAND
VALVED HOLDING CHAMBER DEVICE
BRAND
QL
2 / claim
VISTOGARD PACKET 10 GM
BRAND
WATCHHALER DEVICE
BRAND
QL
2 / claim
water for injection, sterile (, iv)
generic
QL
4 / claim
QL
15 / claim
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS, OTHER
atropine sulfate (ophthalmic) (oint, soln)
generic
bacitracin-polymyxin b ophth oint
generic
bacitracin-polymyxin-neomycin-hc ophth oint 1%
generic
BLEPHAMIDE SUSPENSION 10-0.2 %
BRAND
LACRISERT INSERT 5 MG
BRAND
naphazoline hcl ophth soln 0.1%
generic
neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt
op oin
generic
neomycin-polymy-dexameth (oint, susp)
generic
QL
5 / claim
neomycin-polymyxin-hc ophth susp
generic
QL
8 / claim
phenylephrine hcl ophth soln 2.5%
generic
QL
5 / 30 days
polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%
generic
QL
10 / claim
proparacaine hcl ophth soln 0.5%
generic
PAGE 109
PRODUCT DESCRIPTION
BRAND/GEN
RESTASIS EMULSION 0.05 %
BRAND
sulfacetamide sodium-prednisolone ophth soln 100.23(0.25)%
generic
tetracaine hcl ophth soln 0.5%
generic
tobramycin-dexamethasone ophth susp 0.3-0.1%
generic
MPL
tropicamide ophth soln 0.5%
generic
QL
15 / claim
tropicamide ophth soln 1%
QL
generic
15 / claim
QL
10 / 30 days
1 / claim
MPL
1 / claim
QL
5 / claim
OPHTHALMIC ANTI-ALLERGY AGENTS
ALOCRIL SOLUTION 2 %
BRAND
PA
ST
QL
ALOMIDE SOLUTION 0.1 %
BRAND
10 / claim
PA
ST
azelastine hcl ophth soln 0.05%
PA
generic
ST
cromolyn sodium ophth soln 4%
generic
olopatadine hcl ophth soln 0.1% (base equivalent)
generic
OPHTHALMIC ANTI-INFLAMMATORIES
dexamethasone sodium phosphate ophth soln 0.1%
generic
diclofenac sodium ophth soln 0.1%
generic
MPL
1 / claim
fluorometholone ophth susp 0.1%
generic
MPL
1 / claim
flurbiprofen sodium ophth soln 0.03%
generic
QL
5 / 31 days
ketorolac tromethamine ophth soln 0.4%
generic
MPL
1 / 30 days
ketorolac tromethamine ophth soln 0.5%
generic
PRED MILD SUSPENSION 0.12 %
BRAND
PAGE 110
QL
10 / 30 days
PRODUCT DESCRIPTION
BRAND/GEN
prednisolone acetate ophth susp 1%
generic
PREDNISOLONE SODIUM PHOSPHATE SOLUTION 1 %
BRAND
MPL
1 / 30 days
VEXOL SUSPENSION 1 %
BRAND
MPL
1 / claim
MPL
1 / claim
MPL
1 / claim
OPHTHALMIC ANTIGLAUCOMA AGENTS
apraclonidine hcl ophth soln 0.5% (base equivalent)
generic
AZOPT SUSPENSION 1 %
BRAND
betaxolol hcl ophth soln 0.5%
generic
BETIMOL (SOLUTION 0.25 %, SOLUTION 0.5 %)
BRAND
brimonidine tartrate ophth soln 0.2%
generic
carteolol hcl ophth soln 1%
generic
COSOPT PF SOLUTION 22.3-6.8 MG/ML
BRAND
QL
10 / claim
dorzolamide hcl ophth soln 2%
generic
QL
10 / claim
dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml
generic
QL
10 / claim
IOPIDINE SOLUTION 1 %
BRAND
ISTALOL SOLUTION 0.5 %
BRAND
levobunolol hcl (soln 0.25%, soln 0.5%)
generic
methazolamide (tab 25 mg, tab 50 mg)
generic
pilocarpine hcl (soln 1%, soln 2%, soln 4%)
generic
timolol maleate (ophth) (gel forming soln 0.25%, gel
forming soln 0.5%, soln 0.25%, soln 0.5%)
generic
TIMOPTIC OCUDOSE (SOLUTION 0.25 %, SOLUTION
0.5 %)
BRAND
MPL
1 / claim
QL
3 / claim
QL
15 / claim
OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS
latanoprost ophth soln 0.005%
generic
travoprost ophth soln 0.004%
generic
OTIC AGENTS
acetic acid otic soln 2%
PAGE 111
generic
PRODUCT DESCRIPTION
BRAND/GEN
antipyrine-benzocaine otic soln 54-14 mg/ml (5.4-1.4%)
generic
antipyrine-benzocaine otic soln 55-14 mg/ml (5.5-1.4%)
generic
ANTIPYRINE-BENZOCAINE SOLUTION 5.5-1.4 %
BRAND
CIPRODEX SUSPENSION 0.3-0.1 %
MPL
1 / claim
BRAND
QL
8 / claim
hydrocortisone w/ acetic acid otic soln 1-2%
generic
QL
10 / claim
neomycin-polymyxin-hc (otic) (soln 1%, susp 3.5 mg/ml10000 unit/ml-1%)
generic
QL
8.9 / 30 days
MPL
2 / 365 days
RESPIRATORY TRACT/PULMONARY AGENTS
ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS
AEROSPAN AERO SOLN 80 MCG/ACT
BRAND
budesonide (inhalation) (susp 0.25 mg/2ml, susp 0.5
mg/2ml)
generic
QL
120 / claim
budesonide inhalation susp 1 mg/2ml
generic
QL
60 / 30 days
FLOVENT DISKUS (AER POW BA 50 MCG/BLIST, AER
POW BA 100 MCG/BLIST, AER POW BA 250
MCG/BLIST)
BRAND
MDD
FLOVENT HFA (AEROSOL 44 MCG/ACT, AEROSOL 110
MCG/ACT, AEROSOL 220 MCG/ACT)
BRAND
QL
12 / 25 days
flunisolide (nasal) (soln 25 mcg/act, soln 29 mcg/act)
generic
QL
25 / 30 days
fluticasone propionate nasal susp 50 mcg/act
generic
QL
16 / 30 days
mometasone furoate nasal susp 50 mcg/act
QL
generic
34 / 30 days
AL
At least 2 yrs old
PULMICORT FLEXHALER (AER POW BA 90 MCG/ACT,
AER POW BA 180 MCG/ACT)
BRAND
triamcinolone acetonide nasal aerosol suspension 55
mcg/act
generic
2 per day
MPL
1 / 30 days
MPL
1 / 30 days
ANTIHISTAMINES
azelastine hcl (0.1% (137 mcg/), 0.15% (205.5 mcg/))
PAGE 112
generic
PRODUCT DESCRIPTION
BRAND/GEN
carbinoxamine maleate (soln 4 mg/5ml, tab 4 mg)
generic
generic
generic
cyproheptadine hcl (syrup 2 mg/5ml, tab 4 mg)
generic
generic
MDD
4 per day
diphenhydramine hcl elixir 12.5 mg/5ml
generic
MDD
5 per day
diphenhydramine hcl inj 50 mg/ml
generic
MDD
1 per day
hydroxyzine hcl (soln 25 mg/ml, soln 50 mg/ml)
generic
hydroxyzine hcl (tab 10 mg, tab 25 mg)
generic
MDD
4 per day
hydroxyzine hcl syrup 10 mg/5ml
generic
MDD
100 per day
hydroxyzine hcl tab 50 mg
generic
MDD
8 per day
hydroxyzine pamoate (cap 25 mg, cap 50 mg, cap 100 mg)
generic
MDD
4 per day
KARBINAL ER SUSP 4 MG/5ML
BRAND
olopatadine hcl nasal soln 0.6%
generic
promethazine hcl (syrup 6.25 mg/5ml, tab 12.5 mg, tab 25
mg, tab 50 mg)
generic
promethazine hcl suppos 12.5 mg
generic
QL
12 / claim
promethazine hcl suppos 25 mg
generic
QL
12 / claim
generic
QL
12 / claim
montelukast sodium (chew tab 4 mg, chew tab 5 mg, oral
granules packet 4 mg, tab 10 mg)
generic
MDD
1 per day
zafirlukast (tab 10 mg, tab 20 mg)
generic
QL
240 / claim
ANTILEUKOTRIENES
BRONCHODILATORS, ANTICHOLINERGIC
ATROVENT HFA AERO SOLN 17 MCG/ACT
BRAND
MPL
2 / 30 days
INCRUSE ELLIPTA AER POW BA 62.5 MCG/INH
BRAND
MPL
1 / 30 days
PAGE 113
PRODUCT DESCRIPTION
BRAND/GEN
ipratropium bromide (nasal) (soln 0.03% (21 mcg/spray),
soln 0.06% (42 mcg/spray))
generic
QL
30 / 25 days
ipratropium bromide inhal soln 0.02%
generic
QL
375 / 30 days
SPIRIVA HANDIHALER CAP 18 MCG
BRAND
MPL
TUDORZA PRESSAIR AER POW BA 400 MCG/ACT
BRAND
QL
1 / 30 days
QL
2 / 30 days
QL
1 / claim
1 / claim
BRONCHODILATORS, SYMPATHOMIMETIC
ADRENALIN SOLUTION 0.1 %
BRAND
albuterol sulfate (soln nebu 0.083% (2.5 mg/3ml), soln
nebu 0.5% (5 mg/ml), soln nebu 0.63 mg/3ml (base equiv),
soln nebu 1.25 mg/3ml (base equiv), syrup 2 mg/5ml, tab 2
mg, tab 4 mg, tab sr 12hr 4 mg, tab sr 12hr 8 mg)
generic
EPIPEN JR 2-PAK SOLN A-INJ 0.15 MG/0.3ML
BRAND
levalbuterol hcl (soln nebu 0.31 mg/3ml, soln nebu 0.63
mg/3ml, soln nebu 1.25 mg/3ml, soln nebu conc 1.25
mg/0.5ml)
generic
metaproterenol sulfate (syrup 10 mg/5ml, tab 10 mg, tab 20
mg)
generic
SEREVENT DISKUS AER POW BA 50 MCG/DOSE
BRAND
terbutaline sulfate (tab 2.5 mg, tab 5 mg)
generic
VENTOLIN HFA AERO SOLN 108 (90 BASE) MCG/ACT
BRAND
XOPENEX HFA AEROSOL 45 MCG/ACT
BRAND
CYSTIC FIBROSIS AGENTS
PA
KALYDECO (PACKET 50 MG, PACKET 75 MG, TAB 150
MG)
BRAND
KITABIS PAK NEBU SOLN 300 MG/5ML
BRAND
ORKAMBI TAB 200-125 MG
BRAND
S
Specialty Drug
PA
PA
S
tobramycin nebu soln 300 mg/5ml
PAGE 114
generic
Specialty Drug
PA
PRODUCT DESCRIPTION
BRAND/GEN
PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE
caffeine citrate (inj 60 mg/3ml mg/ml, oral soln 60 mg/3ml
mg/ml)
generic
ELIXOPHYLLIN ELIXIR 80 MG/15ML
BRAND
THEO-24 (CAP ER 24H 400 MG, CAP ER 24H 100 MG,
BRAND
theophylline (soln 80 mg/15ml, tab sr 12hr 200 mg, tab sr
12hr 450 mg, tab sr 12hr 300 mg, tab sr 12hr 100 mg, tab
sr 24hr 600 mg, tab sr 24hr 400 mg)
generic
PULMONARY ANTIHYPERTENSIVES
LETAIRIS (TAB 5 MG, TAB 10 MG)
BRAND
S
Specialty Drug
REMODULIN (SOLUTION 1 MG/ML, SOLUTION 2.5
MG/ML, SOLUTION 5 MG/ML, SOLUTION 10 MG/ML)
BRAND
REVATIO RECON SUSP 10 MG/ML
BRAND
S
Specialty Drug
sildenafil citrate tab 20 mg
generic
S
Specialty Drug
TRACLEER (TAB 62.5 MG, TAB 125 MG)
BRAND
S
Specialty Drug
VENTAVIS (SOLUTION 10 MCG/ML, SOLUTION 20
MCG/ML)
BRAND
S
Specialty Drug
RESPIRATORY TRACT AGENTS, OTHER
acetylcysteine (soln 10%, soln 20%)
generic
ALLFEN CD TAB 400-10 MG
BRAND
ALLFEN CDX (LIQUID 200-20 MG/5ML, TAB 400-20 MG)
BRAND
AMBIFED CD TAB 30-10-400 MG
BRAND
AMBIFED CDX TAB 30-20-400 MG
AMBIFED-G CD TAB 20-10-400 MG
AMBIFED-G CDX TAB 20-20-400 MG
PAGE 115
QL
240 / claim
MFL
1 / 30 days
QL
240 / claim
MFL
1 / 30 days
QL
240 / claim
MFL
1 / 30 days
QL
240 / claim
MFL
1 / 30 days
BRAND
BRAND
BRAND
PRODUCT DESCRIPTION
BRAND/GEN
benzonatate (cap 100 mg, cap 150 mg, cap 200 mg)
generic
BREO ELLIPTA AER POW BA 200-25 MCG/INH
BRAND
AL
At least 10 yrs old
AL
At least 18 yrs old
MPL
1 / claim
COMBIVENT RESPIMAT AERO SOLN 20-100 MCG/ACT
BRAND
QL
4 / 30 days
cromolyn sodium soln nebu 20 mg/2ml
generic
QL
240 / 30 days
doxapram hcl inj 20 mg/ml
generic
DULERA (AEROSOL 100-5 MCG/ACT, AEROSOL 200-5
MCG/ACT)
BRAND
QL
13 / claim
FLOWTUSS SOLUTION 2.5-200 MG/5ML
BRAND
QL
240 / claim
hydrocod polst-chlorphen polst er susp 10-8 mg/5ml
generic
hydrocodone w/ homatropine (w/ syrup mg/5ml, w/ tab mg)
generic
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml
generic
MDD
12 per day
QL
MAXIFED CD TAB 60-10-400 MG
BRAND
240 / claim
MFL
1 / 30 days
QL
240 / claim
MFL
1 / 30 days
QL
240 / claim
MFL
1 / 30 days
QL
240 / claim
MFL
1 / 30 days
QL
240 / claim
AL
At least 2 yrs old
QL
240 / claim
AL
At least 2 yrs old
QL
240 / claim
AL
At least 2 yrs old
MAXIFED CDX TAB 60-20-400 MG
MAXIFED-G CD TAB 40-10-400 MG
MAXIFED-G CDX TAB 40-20-400 MG
BRAND
BRAND
BRAND
PEDIATEX TDM SUSPENSION 10-0.938-4 MG/ML
BRAND
phenylephrine-chlorphen-dm liquid 1.75-0.75-2.75 mg/ml
generic
phenylephrine-promethazine w/ codeine syrup 5-6.25-10
mg/5ml
generic
promethazine & phenylephrine syrup 6.25-5 mg/5ml
generic
promethazine w/ codeine syrup 6.25-10 mg/5ml
PAGE 116
generic
PRODUCT DESCRIPTION
BRAND/GEN
promethazine-dm syrup 6.25-15 mg/5ml
generic
pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml
generic
sodium chloride (inhalant) (soln nebu 0.9%, soln nebu 3%,
soln nebu 7%, soln nebu 10%)
generic
SYMBICORT (AEROSOL 80-4.5 MCG/ACT, AEROSOL
160-4.5 MCG/ACT)
BRAND
TYZINE (SOLUTION 0.05 %, SOLUTION 0.1 %)
BRAND
XOLAIR RECON SOLN 150 MG
BRAND
S
carisoprodol (tab 250 mg, tab 350 mg)
generic
MDD
3 per day
chlorzoxazone tab 500 mg
generic
cyclobenzaprine hcl (tab 5 mg, tab 7.5 mg, tab 10 mg)
generic
LORZONE (TAB 375 MG, TAB 750 MG)
BRAND
metaxalone tab 800 mg
generic
MDD
4 per day
methocarbamol (tab 500 mg, tab 750 mg)
generic
orphenadrine citrate tab sr 12hr 100 mg
generic
MDD
2 per day
EDLUAR (SL TAB 5 MG, SL TAB 10 MG)
BRAND
MDD
1 per day
estazolam (tab 1 mg, tab 2 mg)
generic
MDD
1 per day
eszopiclone (tab 1 mg, tab 2 mg, tab 3 mg)
generic
MDD
1 per day
temazepam (cap 7.5 mg, cap 15 mg, cap 22.5 mg, cap 30
mg)
generic
MDD
1 per day
triazolam tab 0.125 mg
generic
MDD
1 per day
triazolam tab 0.25 mg
generic
MDD
2 per day
zaleplon (cap 5 mg, cap 10 mg)
generic
MDD
2 per day
zolpidem tartrate (sl tab 1.75 mg, sl tab 3.5 mg, tab 5 mg,
tab 10 mg, tab cr 6.25 mg, tab cr 12.5 mg)
generic
MDD
1 per day
QL
11 / claim
Specialty Drug
SKELETAL MUSCLE RELAXANTS
SLEEP DISORDER AGENTS
GABA RECEPTOR MODULATORS
PAGE 117
PRODUCT DESCRIPTION
BRAND/GEN
ZOLPIMIST SOLUTION 5 MG/ACT
BRAND
MDD
0.25 per day
SLEEP DISORDERS, OTHER
AMYTAL SODIUM RECON SOLN 500 MG
BRAND
armodafinil (tab 150 mg, tab 200 mg, tab 250 mg)
generic
MDD
1 per day
armodafinil tab 50 mg
generic
MDD
2 per day
BELSOMRA (TAB 5 MG, TAB 10 MG, TAB 15 MG, TAB 20
MG)
BRAND
MDD
1 per day
flurazepam hcl (cap 15 mg, cap 30 mg)
generic
MDD
1 per day
HETLIOZ CAP 20 MG
BRAND
MDD
1 per day
modafinil tab 100 mg
generic
MDD
1 per day
modafinil tab 200 mg
generic
MDD
2 per day
ROZEREM TAB 8 MG
BRAND
MDD
1 per day
SECONAL CAP 100 MG
BRAND
SENTRAMODAFIN AM-100 MISC 100 MG
BRAND
SILENOR (TAB 3 MG, TAB 6 MG)
BRAND
MDD
1 per day
XYREM SOLUTION 500 MG/ML
BRAND
MDD
18 per day
THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES
ELECTROLYTE/MINERAL MODIFIERS
CHEMET CAP 100 MG
BRAND
EXJADE (TAB SOL 125 MG, TAB SOL 250 MG, TAB SOL
500 MG)
BRAND
FERRIPROX TAB 500 MG
BRAND
JADENU (TAB 90 MG, TAB 180 MG, TAB 360 MG)
BRAND
S
Specialty Drug
PA
SAMSCA (TAB 15 MG, TAB 30 MG)
PAGE 118
BRAND
S
Specialty Drug
S
Specialty Drug
PRODUCT DESCRIPTION
BRAND/GEN
sodium polystyrene sulfonate (*sodium powder**, sodium
oral susp 15 gm/60ml, sodium rectal susp 30 gm/120ml)
generic
SYPRINE CAP 250 MG
BRAND
QL
454 / claim
ELECTROLYTE/MINERAL REPLACEMENT
*ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab 106-1
mg***
generic
*parenteral electrolyte conc***
generic
EFFER-K (EFFER TAB 10, EFFER TAB 20)
BRAND
FOLTRATE TAB 500-1 MCG-MG
BRAND
HYPERLYTE-CR SOLUTION
BRAND
ISOLYTE-S PH 7.4 SOLUTION
BRAND
ISOLYTE-S SOLUTION
BRAND
KLOR-CON M15 TAB ER 15 MEQ
BRAND
KLOR-CON PACKET 25 MEQ
BRAND
NORMOSOL-R PH 7.4 SOLUTION
BRAND
NORMOSOL-R SOLUTION
BRAND
pot bicarbonate & chloride effer tab 25 meq
generic
potassium bicarbonate effer tab 25 meq
generic
potassium chloride (cap cr 8 meq, cap cr 10 meq, oral soln
10% (20 meq/15ml), oral soln 20% (40 meq/15ml), powder
packet 20 meq, tab cr 8 meq (600 mg), tab cr 10 meq, tab
cr 20 meq (1500 mg))
generic
POTASSIUM CHLORIDE ER (ER TAB ER 8, ER TAB ER
20)
BRAND
potassium chloride microencapsulated crystals cr
(mioencapsulated ys tab 10, mioencapsulated ys tab 20)
generic
sodium acetate (inj 2 meq/ml, inj 4 meq/ml)
generic
sodium fluoride (chew tab 0.25 mg f (from 0.55 mg, chew
tab 0.5 mg f (from 1.1 mg, chew tab 1 mg f (from 2.2 mg,
soln 0.125 mg/drop f (0.275 mg/drop, soln 0.5 mg/ml f
(from 1.1 mg/ml)
generic
zinc sulfate (cap 220 mg (50 mg elemental zn), inj 1 mg/ml,
inj 5 mg/ml)
generic
PAGE 119
MDD
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
*b-complex vitamin inj**
generic
*b-complex w/ c & folic acid tab 5 mg***
generic
*l-methylfolate-algae-vit b12-b6 cap 3-90.314-2-35 mg***
generic
*pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/ml**
generic
QL
50 / claim
*pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml***
generic
QL
30 / 30 days
*pediatric vitamins acd w/ fluoride soln 0.25 mg/ml***
generic
MDD
1 per day
*pediatric vitamins acd w/ fluoride soln 0.5 mg/ml***
generic
QL
50 / claim
AP-ZEL TAB
BRAND
MDD
1 per day
AQUASOL A SOLUTION 50000 UNIT/ML
BRAND
ascorbic acid inj 500 mg/ml
generic
B-12 COMPLIANCE INJECTION KIT 1000 MCG/ML
BRAND
B-12 KIT 1000 MCG/ML
BRAND
b-complex w/ c & folic acid (w/ ap 1, w/ tab 1)
generic
MDD
1 per day
BACMIN TAB
BRAND
MDD
1 per day
CENTRATEX CAP 106-1 MG
BRAND
MDD
1 per day
CHOICE-OB+DHA MISC 29-1 & 250 MG
BRAND
GL
Female
QL
100 / 100 days
GL
Female
COMPLETENATE CHEW TAB 29-1 MG
BRAND
MDD
cyanocobalamin inj 1000 mcg/ml
generic
DEXTROSE THERMOJECT SYSTEM SOLUTION 5 %
BRAND
ELITE-OB TAB 50-1.25 MG
BRAND
ergocalciferol cap 50000 unit
generic
ESCAVITE CHEW TAB 0.25-7.5 MG
BRAND
ESCAVITE D CHEW TAB 0.25-6 MG
BRAND
ESCAVITE LQ LIQUID 0.25-6 MG/ML
BRAND
folic acid tab 1 mg
generic
PAGE 120
GL
1 per day
Female
PRODUCT DESCRIPTION
BRAND/GEN
FOLTANX RF CAP 3-90.314-2-35 MG
BRAND
HEMOCYTE PLUS CAP 106-1 MG
BRAND
INATAL ADVANCE TAB
BRAND
MDD
QL
100 / 100 days
GL
Female
MDD
INATAL GT TAB
BRAND
BRAND
1 per day
QL
100 / 100 days
GL
Female
MDD
INATAL ULTRA TAB
1 per day
1 per day
QL
100 / 100 days
GL
Female
MDD
1 per day
INFUVITE ADULT INJECTABLE
BRAND
MDD
1 per day
INFUVITE INJECTABLE
BRAND
MDD
1 per day
INFUVITE PEDIATRIC SOLUTION
BRAND
L-METHYLFOLATE-ALGAE-B12-B6 CAP 3-90.314-2-35
MG
BRAND
levocarnitine inj 200 mg/ml
generic
levocarnitine oral soln 1 gm/10ml (10%)
generic
MDD
30 per day
levocarnitine tab 330 mg
generic
MDD
3 per day
M-VIT TAB
BRAND
M.V.I. ADULT INJECTABLE
BRAND
M.V.I. PEDIATRIC RECON SOLN
BRAND
M.V.I.-12 (WITHOUT VITAMIN K) INJECTABLE
BRAND
MEPHYTON TAB 5 MG
BRAND
multiple vitamins w/ minerals (w/ cap**, w/ tab**)
generic
MYKIDZ IRON FL SUSPENSION 0.25-10 MG/2ML
BRAND
PAGE 121
QL
100 / 100 days
GL
Female
MDD
1 per day
MDD
1 per day
MDD
1 per day
MDD
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
NASCOBAL SOLUTION 500 MCG/0.1ML
BRAND
NATAL-V RX TAB 29-1 MG
BRAND
GL
MDD
GL
NATALVIT TAB
NICADAN TAB
NIVA-PLUS TAB 27-1 MG
NUTRICAP TAB
O-CAL FA TAB 27-1 MG
BRAND
BRAND
BRAND
BRAND
BRAND
MDD
1 per day
QL
100 / 100 days
GL
Female
MDD
1 per day
MDD
1 per day
QL
100 / 100 days
GL
Female
BRAND
MDD
OB COMPLETE TAB 50-1.25 MG
BRAND
GL
pediatric multivitamins w/fl (w/ chew tab 0.25, w/ chew tab
0.5)
generic
MDD
pediatric multivitamins w/fl (w/ chew tab 1 mg***, w/ soln
0.25 mg/ml***)
generic
phytonadione inj 1 mg/0.5ml (2 mg/ml)
generic
PNV FE FUM/DOCUSATE/FOLIC ACID TAB 29-1 MG
BRAND
GL
MDD
BRAND
BRAND
Female
1 per day
Female
1 per day
Female
1 per day
100 / 100 days
GL
Female
1 per day
QL
100 / 100 days
GL
Female
MDD
PAGE 122
1 per day
QL
MDD
PNV PRENATAL PLUS MULTIVITAMIN TAB 27-1 MG
Female
1 per day
GL
PNV FOLIC ACID + IRON TAB 27-1 MG
1 per day
MDD
MDD
O-CAL PRENATAL TAB
Female
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
PNV TABS 29-1 TAB 29-1 MG
BRAND
GL
MDD
Female
1 per day
PNV-DHA CAP 27-0.6-0.4-300 MG
BRAND
GL
Female
PNV-FIRST CAP 29-1-200 MG
BRAND
GL
Female
POLY-VI-FLOR (CHEW TAB 0.25 MG, CHEW TAB 0.5
MG, CHEW TAB 1 MG)
BRAND
POLY-VI-FLOR FS STRIP 1 MG
BRAND
POLY-VI-FLOR SUSPENSION 0.25 MG/ML
BRAND
QL
50 / claim
POLY-VI-FLOR/IRON (POLY-VI-FLOR/IRON CHEW TAB
0.5-10 MG, POLY-VI-FLOR/IRON SUSPENSION 0.25-7
MG/ML)
BRAND
QL
100 / 100 days
GL
Female
PRENAPLUS TAB 27-1 MG
BRAND
MDD
GL
PRENATABS FA TAB
BRAND
MDD
GL
PRENATABS RX TAB 29-1 MG
BRAND
MDD
GL
PRENATAL 19 (19 TAB 29-1 MG, 19 TAB)
BRAND
MDD
PRENATAL 19 CHEW TAB
BRAND
BRAND
BRAND
Female
1 per day
Female
1 per day
GL
Female
1 per day
QL
100 / 100 days
GL
Female
1 per day
QL
100 / 100 days
GL
Female
MDD
PAGE 123
1 per day
100 / 100 days
MDD
PRENATAL PLUS TAB 27-1 MG
Female
QL
MDD
PRENATAL AD TAB
1 per day
1 per day
PRODUCT DESCRIPTION
PRENATAL VITAMIN PLUS LOW IRON TAB 27-1 MG
BRAND/GEN
BRAND
QL
100 / 100 days
GL
Female
MDD
PRENATAL VITAMINS PLUS TAB 27-1 MG
BRAND
QL
100 / 100 days
GL
Female
MDD
PREPLUS TAB 27-1 MG
BRAND
1 per day
QL
100 / 100 days
GL
Female
MDD
GL
PRETAB TAB 29-1 MG
1 per day
BRAND
1 per day
Female
MDD
1 per day
MDD
1 per day
MDD
1 per day
PUREFE PLUS CAP 106-1 MG
BRAND
pyridoxine hcl inj 100 mg/ml
generic
QUFLORA PEDIATRIC (CHEW TAB 0.25 MG, CHEW TAB
0.5 MG)
BRAND
QUFLORA PEDIATRIC (CHEW TAB 1 MG, SOLUTION
0.25 MG/ML)
BRAND
QUFLORA PEDIATRIC SOLUTION 0.5 MG/ML
BRAND
QL
30 / 30 days
REAPHIRM CAP 29-1-200 MG
BRAND
GL
Female
REQ 49+ TAB
BRAND
MDD
RULAVITE DHA CAP 27-0.6-0.4-300 MG
BRAND
GL
Female
QL
100 / 100 days
GL
Female
SE-NATAL 19 CHEW TAB 29-1 MG
BRAND
MDD
GL
SE-NATAL 19 TAB 29-1 MG
BRAND
MDD
SELECT-OB+DHA MISC 29-1 & 250 MG
BRAND
GL
STROVITE ONE TAB
BRAND
MDD
PAGE 124
1 per day
1 per day
Female
1 per day
Female
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
thiamine hcl inj 100 mg/ml
generic
THRIVITE 19 TAB 29-1 MG
BRAND
GL
MDD
GL
THRIVITE RX TAB 29-1 MG
BRAND
MDD
Female
1 per day
Female
1 per day
TL-ASSURE ONE CAP 29-1-200 MG
BRAND
GL
Female
TL-ASSURE+DHA MISC 29-1 & 250 MG
BRAND
GL
Female
TRI-VIT/FLUORIDE/IRON SOLUTION 0.25-10 MG/ML
BRAND
QL
100 / 100 days
GL
Female
TRICARE TAB
BRAND
MDD
TRINATAL GT TAB 90-1 MG
BRAND
QL
100 / 100 days
GL
Female
MDD
TRINATAL RX 1 TAB 60-1 MG
BRAND
BRAND
VENATAL-FA TAB 29-1 MG
BRAND
100 / 100 days
GL
Female
Female
GL
Female
GL
BRAND
MDD
VINATE ONE TAB 60-1 MG
BRAND
BRAND
Female
1 per day
100 / 100 days
GL
Female
1 per day
QL
100 / 100 days
GL
Female
MDD
PAGE 125
1 per day
QL
MDD
VINATE ULTRA TAB
1 per day
GL
MDD
VINATE M TAB 27-1 MG
1 per day
QL
MDD
TRINATE TAB
1 per day
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
VIRT NATE TAB 28-1 MG
BRAND
VIRT-ADVANCE TAB 90-1 MG
BRAND
GL
Female
QL
100 / 100 days
GL
Female
MDD
VIRT-PN DHA CAP 27-0.6-0.4-300 MG
VIRT-VITE GT TAB 90-1 MG
BRAND
BRAND
GL
Female
QL
100 / 100 days
GL
Female
MDD
VITAFOL ULTRA CAP 29-0.6-0.4-200 MG
BRAND
VITAFOL-OB TAB
BRAND
1 per day
1 per day
GL
Female
GL
Female
MDD
1 per day
VITAFOL-ONE CAP 29-1-200 MG
BRAND
GL
Female
VITAFOL-PLUS CAP 27-1-200 MG
BRAND
GL
Female
GL
VITAFOL-PN TAB
BRAND
Female
MDD
VITAMIN K1 SOLUTION 10 MG/ML
BRAND
VOL-NATE TAB 28-1 MG
BRAND
VOL-PLUS TAB 27-1 MG
BRAND
GL
Female
QL
100 / 100 days
GL
Female
MDD
GL
VOL-TAB RX TAB 29-1 MG
1 per day
BRAND
1 per day
Female
MDD
1 per day
1 per day
VP-ZEL TAB
BRAND
MDD
ZATEAN-PN DHA CAP 27-0.6-0.4-300 MG
BRAND
GL
Female
ANTISPASTICITY AGENTS
baclofen (tab 10 mg, tab 20 mg)
generic
tizanidine hcl (tab 2 mg (base equivalent), tab 2 mg, tab 4
mg (base equivalent), tab 4 mg)
generic
PAGE 126
MDD
9 per day
Index of covered drugs
albuterol sulfate
4
4X PROBIOTIC
114
ALDEX GS
17
A
26
alendronate sodium
107
ALEVAZOL
11
alfuzosin hcl
95
A + D PERSONAL CARE LOTION
12
ALIGN
17
abacavir sulfate
68
ALKERAN
58
abacavir sulfate-lamivudine-zidovudine
68
ALLEGRA ALLERGY CHILDRENS
24
ABILIFY
64
ALLEVYN NON-ADHESIVE
21
ABILIFY DISCMELT
64
ALLFEN CD
115
ABILIFY MAINTENA
64
ALLFEN CDX
115
ABREVA
12
allopurinol
56
ABSORICA
88
almotriptan malate
57
acamprosate calcium
40
ALOCRIL
110
acarbose
72
ALOMIDE
110
107
ALOPRIM
56
ALORA
99
alosetron hcl
93
ACE AEROSOL CLOUD ENHANCER
acebutolol hcl
acetaminophen
79
12,21
acetaminophen w/ codeine
39
alprazolam
71
acetazolamide
82
ALPRAZOLAM INTENSOL
71
acetic acid (otic)
111
ALSUMA
57
acetylcysteine
115
ALTABAX
42
acitretin
88
alum & mag hydrox-simethicone
17
ACNE MEDICATION
13
aluminum hydroxide gel
17
ACNE MEDICATION 10
12
aluminum hydroxide-mag carb
17
ACNE MEDICATION 5
13
amantadine hcl
62
acyclovir
70
AMBIFED
26
acyclovir topical
70
AMBIFED CD
115
adapalene
88
AMBIFED CDX
115
adefovir dipivoxil
67
AMBIFED-G
ADRENALIN
ADZENYS XR-ODT
114
84
26
AMBIFED-G CD
115
AMBIFED-G CDX
115
AEROCHAMBER PLUS FLO-VU
107
AMICAR
AEROCHAMBER PLUS FLO-VU LARGE
107
amiloride & hydrochlorothiazide
80
AEROCHAMBER PLUS FLO-VU SMALL
107
amiloride hcl
82
AEROCHAMBER PLUS FLO-VU W/MASK
107
aminocaproic acid
77
AEROSPAN
112
amiodarone hcl
78
AFREZZA
74
amitriptyline hcl
53
AGRYLIN
76
AMLACTIN CERAPEUTIC
13
AIRBORNE
31
AMLACTIN ULTRA
13
107
amlodipine besylate
79
AIRS DISPOSABLE NEBULIZER
PAGE 127
76,77
amlodipine besylate-benazepril hcl
80
ARCALYST
106
amlodipine besylate-valsartan
80
aripiprazole
64
amlodipine-valsartan-hydrochlorothiazide
81
ARISTADA
64
amoxapine
53
armodafinil
118
amoxicillin
44
ARMOUR THYROID
103
amoxicillin & pot clavulanate
44
artificial tear ointment
24
amphetamine-dextroamphetamine
84
artificial tear solution
24
ampicillin
44
ascorbic acid
AMPICILLIN
44
aspirin
10
AMPYRA
87
ASPIRIN LOW DOSE
10
10
31,120
AMYTAL SODIUM
118
aspirin tab chew 81 mg
ANADROL-50
103
ASTAGRAF XL
anagrelide hcl
76
atenolol
79
ANALPRAM ADVANCED
88
atenolol & chlorthalidone
81
ANALPRAM-HC
88
atorvastatin calcium
83
anastrozole
59
atovaquone
61
ANDRODERM
98
atovaquone-proguanil hcl
61
ANDROGEL
98
ATRIPLA
68
ANDROGEL PUMP
98
atropine sulfate (ophthalmic)
109
ANDROXY
98
ATROVENT HFA
113
ANTIOXIDANT ULTRA FORMULA
31
AVAR
89
104
antipyrine-benzocaine
112
AVAR LS
88
ANTIPYRINE-BENZOCAINE
112
AVEED
98
AVONEX
87
AVONEX PEN
87
ANTIVERT
54
AP-ZEL
120
APIDRA
74
AVONEX PREFILLED
87
APIDRA SOLOSTAR
74
AXIRON
98
APLENZIN
50
AYR NASAL MIST ALLERGY/SINUS
21
APPBUTAMONE
50
AYR SALINE NASAL DROPS
21
apraclonidine hcl
111
AZASAN
105
APTENSIO XR
85
azathioprine
105
APTIOM
48
azelastine hcl
112
APTIVUS
69
azelastine hcl (ophth)
110
AQUA GLYCOLIC FACE
13
azithromycin
AQUA GLYCOLIC HAND/BODY
13
AZOPT
AQUA LACTEN
13
AQUADEKS
31
B
AQUAMED
13
b complex w/ c
AQUAPHOR ADVANCED THERAPY
13
B-12
120
B-12 COMPLIANCE INJECTION
120
AQUASOL A
AQUORAL
PAGE 128
120
88
b-complex vitamins
44,45
111
30
30,31,120
b-complex w/ c & folic acid
bacitracin (ophthalmic)
bacitracin-poly-neomycin-hc
bacitracin-polymyxin b
31,120
42
109
12
BLEPHAMIDE
109
BORDERED GAUZE
22
BP CLEANSING WASH
89
BPO
89
89
bacitracin-polymyxin b (ophth)
109
BPO FOAMING CLOTHS
baclofen
126
BREO ELLIPTA
BACMIN
120
BRILINTA
balsalazide disodium
106
brimonidine tartrate
116
77
111
BANDAGE NEW GENERATION LARGE
21
BRINTELLIX
51
BANZEL
48
BROHIST D
26
BARACLUDE
67
brompheniramine & phenyleph
26
BELSOMRA
118
brompheniramine & pseudoeph
26
benazepril & hydrochlorothiazide
81
budesonide
106
benazepril hcl
78
budesonide (inhalation)
112
benzonatate
benzoyl peroxide
116
13,89
bumetanide
82
BUPAP
86
BENZOYL PEROXIDE CLEANSER
13
BUPHENYL
92
benztropine mesylate
62
bupropion hcl
50
betaine hcl (digestive aid)
17
bupropion hcl (smoking deterrent)
41
betamethasone dipropionate augmented
95
50
betamethasone valerate
96
50
betaxolol hcl
79
buspirone hcl
71
butalbital-acetaminophen
86
butalbital-acetaminophen-caffeine
86
butalbital-acetaminophen-caffeine w/ codeine
39
betaxolol hcl (ophth)
111
bethanechol chloride
95
BETIMOL
111
bexarotene
60
butalbital-aspirin-caffeine
BEYAZ
99
butalbital-aspirin-caffeine w/cod
39
BIATAIN ADHESIVE FOAM DRESSING
21
BYDUREON
72
BIATAIN FOAM DRESSING
21
BYETTA 10 MCG PEN
72
BIATAIN HEEL ADH FOAM DRESSING
22
BYETTA 5 MCG PEN
72
BIATAIN SACRAL FOAM DRESSING
22
bicalutamide
59
C
BIOGUARD BARRIER DRESSING
22
cabergoline
104
biotin
31
CAFERGOT
57
BIOTIN MAXIMUM STRENGTH
31
caffeine citrate
bisacodyl
19
CAL-MINT
28
bisacodyl ec tab dr 5 mg
19
CALCI-CHEW
28
bisacodyl laxative suppos 10 mg
19
CALCI-MIX
29
bismuth subsalicylate
17
calcipotriene
89
bisoprolol & hydrochlorothiazide
81
calcitonin (salmon)
107
bisoprolol fumarate
79
calcitriol
107
PAGE 129
37,86
115
calcium acetate (phosphate binder)
21,95
cefadroxil
calcium carbonate
22,29
cefdinir
43
43,44
CALCIUM CARBONATE
29
cefixime
44
calcium carbonate (antacid)
17
cefprozil
44
calcium carbonate-cholecalciferol
29
CEFTIN
44
calcium carbonate-vitamin d
29
cefuroxime axetil
44
calcium citrate
29
celecoxib
37
calcium gluconate
29
CELONTIN
47
calcium polycarbophil
19
CENTANY
42
CAM
13
CENTRATEX
camphor & menthol
13
cephalexin
44
candesartan cilexetil
78
CERALYTE 50 POTASSIUM FREE
29
candesartan cilexetil-hydrochlorothiazide
81
CERALYTE 70 POTASSIUM FREE
29
CAPASTAT SULFATE
58
CERAVE
13
CAPHOSOL
88
CERAVE AM SPF 30
13
CAPITAL/CODEINE
39
CERAVE PM
13
CAPRELSA
60
CERAVE SA RENEWING
13
capsaicin
13
CERTAVITE SENIOR/ANTIOXIDANT
31
CAPSAICIN ARTHRITIS RELIEF
13
CETAPHIL
13
capsaicin-menthol
89
CETAPHIL DAILY ADVANCE
13
captopril
78
CETAPHIL DAILY FACIAL MOIST
13
captopril & hydrochlorothiazide
81
CETAPHIL DERMACONTROL/SPF 30
13
CAPTRACIN
89
CETAPHIL MOISTURIZING
13
CARAFATE
94
CETAPHIL RESTORADERM
13
CARBAGLU
92
CETAPHIL THERAPEUTIC HAND
13
carbamazepine
49
cetirizine hcl
carbamide peroxide (otic)
24
carbidopa
62
25
62
25
62
cetirizine hcl tab 10 mg
25
62
cetirizine-pseudoephedrine
26
carbidopa-levodopa
63
cevimeline hcl
88
carbidopa-levodopa-entacapone
62
CHANTIX
41
CHANTIX CONTINUING MONTH PAK
41
41
carbinoxamine maleate
113
120
24,25
carbonyl iron
29
CHANTIX STARTING MONTH PAK
CARDIZEM LA
79
CHEMET
carisoprodol
117
25
26
22
CHLO TUSS
CARRASMART FOAM
22
chloral hydrate
carvedilol
PAGE 130
111
79
118
childrens loratadine syrup 5 mg/5ml
CARRASMART
carteolol hcl (ophth)
25,113
108
chlordiazepoxide hcl
71
chlordiazepoxide-amitriptyline
50
chlorhexidine gluconate
22
clobetasol propionate
96
chlorhexidine gluconate (mouth-throat)
88
clobetasol propionate emulsion
96
chloroquine phosphate
61
clomipramine hcl
53
chlorothiazide
82
clonazepam
71
chlorpheniramine & phenylephrine
26
clonidine hcl
77
chlorpheniramine maleate
25
clonidine hcl (adhd)
85
chlorpheniramine maleate er tab er 12 mg
25
clopidogrel bisulfate
77
25
clorazepate dipotassium
71
chlorpromazine hcl
63
clotrimazole (topical)
chlorpropamide
72
clotrimazole vaginal
11
chlorthalidone
82
clotrimazole w/ betamethasone
89
CHLORTHALIDONE
82
clozapine
11,55
66,67
chlorzoxazone
117
clozapine odt 100 mg
67
CHOICE-OB+DHA
120
clozapine odt 12.5 mg
67
clozapine odt 25 mg
67
COARTEM
61
CHOLBAM
cholecalciferol
93
21,31
cholestyramine
83
cobalamine combinations
28
cholestyramine light
83
codeine sulfate
39
choline & mag salicylate
37
CODITUSS DM
26
choline fenofibrate
83
colchicine
56
CIALIS
95
COLCHICINE
56
ciclopirox
55
colchicine w/ probenecid
57
ciclopirox olamine
55
COLCRYS
57
cilostazol
77
colestipol hcl
83
CILOXAN
45
colloidal oatmeal
12
cimetidine
19,93
COLYTE WITH FLAVOR PACKS
93
CIPRODEX
112
COMBINE ABD
22
ciprofloxacin
45
COMBIPATCH
99
ciprofloxacin hcl
45
COMBIVENT RESPIMAT
ciprofloxacin hcl (ophth)
45
COMPLERA
68
citalopram hydrobromide
51
COMPLETE FORMULATION D5000
31
clarithromycin
45
complete ready-to-use enema enema 7-19
clemastine fumarate
113
gm/118ml
116
19
25
COMPLETENATE
CLINDAGEL
42
CONDYLOX
89
clindamycin hcl
42
COPASIL
89
clindamycin palmitate hydrochloride
42
COPAXONE
87
42,89
COREG CR
79
clindamycin phosphate (topical)
120
clindamycin phosphate vaginal
42
cortisone acetate
96
clindamycin phosphate-benzoyl peroxide
89
CORTISPORIN
89
CLINDESSE
42
COSOPT PF
PAGE 131
111
COTELLIC
60
desipramine hcl
54
CREON
92
desmopressin acetate
97
CREST COMPLETE
12
desmopressin acetate refrigerated
97
CRIXIVAN
69
desmopressin acetate spray
97
desmopressin acetate spray refrigerated
97
desogestrel & ethinyl estradiol
99
desogestrel-ethinyl estradiol (biphasic)
99
cromolyn sodium
116
cromolyn sodium (nasal)
22
cromolyn sodium (ophth)
110
CULTURELLE IMMUNE DEFENSE
17
Desogestrel-Ethinyl Estradiol TAB 0.15-0.02/0.01 MG
CUPRIMINE
95
(Azurette, Kariva, Pimtrea, Viorele, Caziant, Cesia,
CUVPOSA
92
Velivet)
CVS AIRSHIELD IMMUNITY SUPPORT
31
Desogestrel-Ethinyl Estradiol TAB 0.15-30 MG-MCG
CVS DAILY ULTRA MOISTURE
14
(Apri, Emoquette, Enskyce, Reclipsen, Solia)
99
CVS DIGESTIVE PROBIOTIC
17
desonide
96
CVS HYDROCOLLOID PADS
22
desvenlafaxine
51
CVS NON-STICK PADS
22
DESVENLAFAXINE FUMARATE ER
51
CVS PROBIOTIC
17
dexamethasone
96
CVS SLOW RELEASE IRON
29
DEXAMETHASONE INTENSOL
96
cyanocobalamin
32,120
cyclobenzaprine hcl
117
cyclophosphamide
58
99
dexamethasone sodium phosphate (ophth)
110
dexmedetomidine hcl
108
dexmethylphenidate hcl
85
cyclosporine
105
DEXPAK 10 DAY
96
cyclosporine modified (for microemulsion)
105
DEXPAK 13 DAY
96
cyproheptadine hcl
113
DEXPAK 6 DAY
96
CYSTADANE
92
dextroamphetamine sulfate
CYSTAGON
95
dextromethorphan-guaifenesin
26
dextrose (diabetic use)
11
D
DEXTROSE THERMOJECT SYSTEM
84,85
120
DALLERGY
26
DIALYVITE OMEGA-3 CONCENTRATE
11
danazol
98
diazepam
71
dapsone
58
DIAZEPAM
71
DAYTRANA
85
diazepam (anticonvulsant)
47
DECARA
21
dibucaine (rectal)
14
DEKAS ESSENTIAL
32
diclofenac potassium
37
DEKAS PLUS
32
diclofenac sodium
37
DELZICOL
106
diclofenac sodium (ophth)
110
DEPO-SUBQ PROVERA 104
102
diclofenac sodium (topical)
37
DERMABASE
14
dicloxacillin sodium
44
DERMADRESS WATERPROOF DRESSING
22
dicyclomine hcl
92
DERMALEVIN ADHESIVE
22
didanosine
69
DERMAVITE
32
DIFF-STAT
17
DESCOVY
68
diflorasone diacetate
96
PAGE 132
diflunisal
37
droperidol
63
digoxin
81
DRYMAX AF
26
dihydroergotamine mesylate
57
DRYMAX EXTRA
22
DILANTIN
49
DULERA
diltiazem hcl
79,80
116
duloxetine hcl
87
diltiazem hcl coated beads
80
DUOPA
63
diltiazem hcl extended release beads
80
DUREX EXTRA SENSITIVE
22
dutasteride
95
DUTOPROL
81
DYANAVEL XR
85
dimenhydrinate
diphenhydramine hcl
11,54
25,113
diphenhydramine hcl (sleep)
28
diphenhydramine hcl (topical)
14
25
25,113
E
E-Z SPACER
108
E-Z SPACER THE BODY GUARDS PK
108
diphenhydramine hcl elixir 12.5 mg/5ml
113
25
E.E.S. 400
45
diphenoxylate w/ atropine
93
E.E.S. GRANULES
45
dipyridamole
77
EASIVENT
108
disopyramide phosphate
78
EASIVENT MASK LARGE
108
disulfiram
40
EASIVENT MASK MEDIUM
108
divalproex sodium
47
EASIVENT MASK SMALL
108
DML FORTE
14
EBASE CONTROLLER KIT
108
docosahexaenoic acid
32
econazole nitrate
55
docusate calcium
19
ED A-HIST DM
26
docusate sodium
19
ED CHLORPED
25
docusate sodium cap 100 mg
19
ED CHLORPED D
26
DOCUSOL MINI
19
ED-A-HIST
26
dofetilide
78
EDLUAR
donepezil hydrochloride
49
EDURANT
68
dorzolamide hcl
111
EFFER-K
119
dorzolamide hcl-timolol maleate
111
EFFIENT
77
doxapram hcl
116
ELDERTONIC
32
117
doxazosin mesylate
77
ELIGARD
104
doxepin hcl
54
ELIQUIS
75
DOXEPIN HCL
89
ELITE-OB
120
doxercalciferol
107
ELIXOPHYLLIN
115
102
doxycycline (monohydrate)
46
ELLA
doxycycline hyclate
46
ELLIS TONIC
32
doxylamine succinate (sleep)
28
ELMIRON
95
DRIPDROP
29
ELON SKIN REPAIR SYSTEM
14
DRIPDROP HYDRATION
29
EMERGEN-C BLUE
32
dronabinol
55
EMERGEN-C ELECTRO MIX
29
PAGE 133
EMERGEN-C FIVE
32
erythromycin (ophth)
45
EMERGEN-C HEART HEALTH
32
ERYTHROMYCIN BASE
45
EMERGEN-C IMMUNE
32
erythromycin base
45
EMERGEN-C IMMUNE PLUS
32
ERYTHROMYCIN ETHYLSUCCINATE
45
EMERGEN-C IMMUNE+WARMERS
32
ESCAVITE
120
EMERGEN-C JOINT HEALTH
32
ESCAVITE D
120
EMERGEN-C KIDZ
32
ESCAVITE LQ
120
EMERGEN-C MSM LITE
32
escitalopram oxalate
51
EMERGEN-C PINK
32
ESOCOR P
26
EMERGEN-C VITAMIN C
32
estazolam
117
EMERGEN-C VITAMIN C LITE
32
ESTRACE
99
EMERGEN-C VITAMIN D/CALCIUM
32
estradiol
emollient
14
eszopiclone
EMSAM
51
ethambutol hcl
58
EMTRIVA
69
ethosuximide
47
EMVERM
61
etodolac
37
enalapril maleate
78
etoposide
60
enalapril maleate & hydrochlorothiazide
81
EURAX
61
99,100
117
ENBREL
105
EVEKEO
85
ENBREL SURECLICK
105
EVOTAZ
69
ENDOMETRIN
102
EVZIO
41
ENEMEEZ MINI
19
EXELDERM
55
ENFALYTE
29
exemestane
59
ENFAMIL ENFALYTE
29
EXJADE
enoxaparin sodium
75,76
118
entacapone
62
F
entecavir
67
famotidine
ENTEREG
93
FANAPT
64
EPANED
78
FANAPT TITRATION PACK
64
FARESTON
59
EPIPEN JR 2-PAK
114
19,93
EPIVIR HBV
67
FARXIGA
72
eplerenone
82
felbamate
48
EPSOM SALT
22
felodipine
80
EPZICOM
69
fenofibrate
83
EQUETRO
72
fenofibrate micronized
83
fenofibric acid
83
ergocalciferol
32,120
ergoloid mesylates
49
FENOFIBRIC ACID
83
ERY-TAB
45
fenoprofen calcium
37
ERYPED 200
45
fentanyl
38
ERYPED 400
45
FERRETTS
29
erythromycin (acne aid)
45
FERRETTS CHEWABLE IRON
29
PAGE 134
FERRIMIN 150
FERRIPROX
29
118
fluticasone propionate (nasal)
FLUTTER
24,112
108
ferrous fumarate
29
fluvoxamine maleate
52
FERROUS FUMARATE
29
FOAM DRESSING
22
FOCALIN XR
85
ferrous fumarate-fa-b complex-c-zn-mg-mn-cu
119
ferrous gluconate
29
folic acid
ferrous sulfate
30
FOLTANX RF
121
ferrous sulfate dried
30
FOLTRATE
119
FETZIMA
51
FORFIVO XL
50
FETZIMA TITRATION
51
formaldehyde
108
FEVERALL INFANTS
22
FORMULA 405 A.H.A FACIAL NIGHT
14
fexofenadine hcl
25
FORMULA 405 BODY SMOOTHING
14
25
FORMULA 405 ENRICHED EYE
14
25
FORMULA 405 FACE
14
fiber cap 0.52 gm
19
FORMULA 405 LE PONT NAIL
14
finasteride
95
FORMULA 405 LIGHT MOISTURIZER
14
flavoxate hcl
94
FORMULA 405 MOISTURIZING
14
flecainide acetate
78
FORTEO
107
FLEET BISACODYL
19
FORTICAL
107
FLEET LIQUID GLYCERIN SUPP
19
fosinopril sodium
78
fosinopril sodium & hydrochlorothiazide
81
FLEXICHAMBER
108
32,120
FLEXZAN
22
FRAGMIN
76
FLONASE ALLERGY RELIEF
24
FREEDAVITE
32
furosemide
82
FLOVENT DISKUS
112
FLOVENT HFA
112
FLOWTUSS
116
fluconazole
55
gabapentin
47
fludrocortisone acetate
96
GABAVALE-5
71
GABAZOLAMINE
71
GABAZOLAMINE-0.5
71
GABITRIL
47
GABOXETINE
52
galantamine hydrobromide
49
flunisolide (nasal)
fluocinonide
fluorometholone (ophth)
fluorouracil (topical)
fluoxetine hcl
112
96
110
89
51,52
G
fluoxetine hcl (pmdd)
51
GAS-X CHILDRENS
17
fluphenazine decanoate
63
GAS-X EXTRA STRENGTH
17
fluphenazine hcl
63
gauze pads & dressings
22
GAVISCON EXTRA RELIEF FORMULA
17
GAVISCON EXTRA STRENGTH
17
gemfibrozil
83
flurazepam hcl
flurbiprofen
flurbiprofen sodium
118
37
110
flutamide
59
GENOTROPIN MINIQUICK
98
fluticasone propionate
96
gentamicin sulfate (ophth)
42
PAGE 135
gentamicin sulfate (topical)
42
GENTEAL SEVERE
24
H
GENVOYA
68
haloperidol
63
GEODON
64
haloperidol decanoate
63
GERI-FREEDA SENIOR FORMULA
32
haloperidol lactate
63
GILENYA
87
HECTOROL
107
glatiramer acetate
87
HEMOCYTE PLUS
121
GLEEVEC
60
heparin (porcine) in sodium chloride
76
GLEOSTINE
58
heparin sodium (porcine)
76
glimepiride
73
heparin sodium (porcine) lock flush
76
glipizide
73
HETLIOZ
glipizide-metformin hcl
73
HISTEX-DM
27
GLUCAGEN HYPOKIT
74
HM 4X PROBIOTIC
17
GLUCAGON EMERGENCY
74
HM ACIDOPHILUS
17
glyburide
73
HM COMPLETE
33
GLYBURIDE
73
HM COMPLETE 50+ MENS ULTIMATE
33
glyburide micronized
73
HM COMPLETE 50+ WOMEN ULTIMATE
33
glyburide-metformin
73
HM FISH OIL
12
glycerin (laxative)
19
HM HAIR/SKIN/NAILS
33
glycopyrrolate
92
HM NON-STICK 3"X4"
22
GNP 4X PROBIOTIC
17
HM ONE DAILY MENS
33
GNP ACIDOPHILUS HIGH POTENCY
17
HM ONE DAILY WOMENS
33
GNP ADVANCED RECOVERY
14
HM PRENATAL
33
GNP CAPSAICIN
14
HM VITAMIN D3
33
GNP FISH OIL
11
HPR
89
GNP GLUCOSE
11
HPR PLUS
89
GNP PRENATAL
32
HUMALOG
74
GNP PROBIOTIC COLON SUPPORT
17
HUMALOG KWIKPEN
74
GNP STERILE PADS
22
HUMALOG MIX 50/50
74
GOLYTELY
93
HUMALOG MIX 50/50 KWIKPEN
74
GOODSENSE PRENATAL VITAMINS
33
HUMALOG MIX 75/25
74
griseofulvin microsize
56
HUMALOG MIX 75/25 KWIKPEN
74
griseofulvin ultramicrosize
56
HUMATROPE
98
guaifenesin
26
HUMIRA
105
guaifenesin-codeine
27
HUMIRA PEDIATRIC CROHNS START
105
guanfacine hcl
77
HUMIRA PEN
105
guanfacine hcl (adhd)
85
HUMIRA PEN-CROHNS STARTER
105
guanidine hcl
58
HUMIRA PEN-PSORIASIS STARTER
105
GYNAZOLE-1
56
HUMULIN 70/30
75
HUMULIN 70/30 KWIKPEN
74
HUMULIN N
75
PAGE 136
118
HUMULIN N KWIKPEN
75
INCRUSE ELLIPTA
113
HUMULIN R
75
indapamide
82
HYCAMTIN
60
indomethacin
37
hydralazine hcl
84
INFERGEN
67
HYDRISINOL
14
INFUVITE
121
hydrochlorothiazide
82
INFUVITE ADULT
121
hydrocodone polistirex-chlorpheniramine polistirex 116
INFUVITE PEDIATRIC
121
hydrocodone w/ homatropine
116
INLYTA
hydrocodone-acetaminophen
39
INSPIRACHAMBER/LARGE
108
hydrocodone-ibuprofen
39
INSPIRACHAMBER/MEDIUM
108
hydrocortisone
96
INSPIRACHAMBER/MOUTHPIECE
108
60
hydrocortisone (intrarectal)
107
INSPIRACHAMBER/SMALL
108
hydrocortisone (rectal)
106
INSPIREASE
108
INSPIREASE BAGS
108
hydrocortisone (topical)
14,89
hydrocortisone acetate (rectal)
96
INSPIREASE MOUTHPIECE
108
hydrocortisone butyrate
96
INSPIREASE RESERVOIR BAGS
108
hydrocortisone w/acetic acid
112
INSTA-GLUCOSE
11
hydromorphone hcl
39
INTELENCE
68
hydroxychloroquine sulfate
61
INVEGA SUSTENNA
64
hydroxyurea
59
INVEGA TRINZA
65
hydroxyzine hcl
113
INVIRASE
69
hydroxyzine pamoate
113
INVOKANA
73
hyoscyamine sulfate
92
HYPERLYTE-CR
hypromellose (ophth)
119
24
I
ibuprofen
10,37
IOPIDINE
111
ipratropium bromide
114
ipratropium bromide (nasal)
114
ipratropium-albuterol
116
irbesartan
78
irbesartan-hydrochlorothiazide
81
ibuprofen cap 200 mg
10
IRENKA
87
ibuprofen tab 200 mg
10
IRON CHEWS PEDIATRIC
30
ICAPS AREDS FORMULA
33
ISENTRESS
68
ICAPS LUTEIN & ZEAXANTHIN
33
ISLAND GARD-GRX
22
ICAPS PLUS
33
ISOLYTE-S
119
imatinib mesylate
60
ISOLYTE-S PH 7.4
119
imipramine hcl
54
isoniazid
58
imipramine pamoate
54
ISONIAZID
58
imiquimod
89
ISOPTO TEARS
24
INATAL ADVANCE
121
ISORDIL TITRADOSE
84
INATAL GT
121
isosorbide dinitrate
84
INATAL ULTRA
121
isosorbide mononitrate
84
isotretinoin
89
INCRELEX
PAGE 137
98
isoxsuprine hcl
ISTALOL
49
111
KPN PRENATAL
33
KUVAN
92
ITCH-X
14
itraconazole
56
L
ivermectin
61
l-methylfolate w/ algae-vitamin b12-vitamin b6
120
L-METHYLFOLATE-ALGAE-B12-B6
121
J
labetalol hcl
79
109
J-TAN D PD
27
LACRISERT
J-TAN PD
25
lactic acid (ammonium lactate)
JADENU
118
JENTADUETO
73
K
15,90
LACTINOL HX
15
LACTO-PECTIN
18
lactobacillus
18
lactulose
93
KADIAN
38
lactulose (encephalopathy)
93
KALETRA
70
LAMICTAL
48
KALYDECO
114
LAMICTAL STARTER
48
KARBINAL ER
113
LAMICTAL XR
48
KERADAN
14
LAMISIL ADVANCED
15
KERI ADVANCED MOISTURE THERAPY
14
LAMISILK REPAIR COMPLEX SERUM
15
KERI BASIC ESSENTIALS
14
lamivudine
69
KERI LONG LASTING
14
lamivudine (hbv)
67
KERI NOURISHING SHEA BUTTER
14
lamivudine-zidovudine
69
KERI ORIGINAL
14
lamotrigine
48
KERI OVERNIGHT
14
LANOXIN
81
KERI RENEWAL MILK BODY
15
LANOXIN PEDIATRIC
81
KERI RENEWAL SERUM
15
lansoprazole
KERI RENEWAL SKIN FIRMING
15
LANTUS
75
KERI RENEWAL STRETCH MARK
15
LANTUS SOLOSTAR
75
KERI SENSITIVE SKIN
15
latanoprost
ketoconazole
56
LATUDA
65
ketoconazole (topical)
56
LETAIRIS
115
ketoprofen
37
letrozole
59
ketorolac tromethamine
37
leucovorin calcium
59
LEUKERAN
58
ketorolac tromethamine (ophth)
ketotifen fumarate (ophth)
110
24
20,94
111
leuprolide acetate
104
114
KITABIS PAK
114
levalbuterol hcl
KLOR-CON
119
levetiracetam
46
KLOR-CON M15
119
LEVETIRACETAM IN NACL
46
KOMBIGLYZE XR
73
levobunolol hcl
111
KONSYL
19
levocarnitine (metabolic modifiers)
121
KONSYL-D
20
levofloxacin
PAGE 138
46
Levonorg-Eth Est Tab 0.15-0.03MG(84) & Eth Est Tab
lomustine
0.01MG(7) (Amethia, Camrese, Daysee)
loperamide hcl
100
58
18,93
Levonorgest-Eth Estrad 91-Day TAB 0.1-0.02 & 0.01
loperamide hcl tab 2 mg
18
MG (Amethia Lo, Camrese Lo,
loratadine
25
loratadine & pseudoephedrine
27
100
Levonorgest-Eth Estrad 91-Day TAB 0.15-0.03 MG
(Introvale, Jolessa, Quasense)
100
loratadine allergy relief tab disp 10 mg
26
levonorgestrel & eth estradiol
100
loratadine tab 10 mg
26
lorazepam
72
Levonorgestrel-Eth Estra Tab 0.05-30/0.075-40/0.125-
LORTUSS DM
27
30MG (Enpresse, Levonest, Myzilra, Trivora)
100
LORTUSS EX
27
levonorgestrel-eth estradiol (triphasic)
100
LORZONE
levonorgestrel (emergency oc)
21,102
117
Levonorgestrel-Ethinyl Estrad TAB 0.1-20 MG (Aubra,
losartan potassium
78
Aviane, Delyla, Falmina, Lessina, Lutera, Orsythia,
losartan potassium & hydrochlorothiazide
81
lovastatin
83
Levonorgestrel-Ethinyl Estrad TAB 0.15-30 MG
loxapine succinate
63
(Altavera, Chateal, Kurvelo, Levora, Marlissa,
LUBRISOFT
15
Sronyx)
Portia)
100
100
LUPRON DEPOT
104
Levonorgestrel-Ethinyl Estradiol (Continuous) Tab 90-
LUPRON DEPOT-PED
104
20 MCG (Amethyst)
100
LYRICA
levothyroxine sodium
103
87
LEXIVA
70
M
LICEMD
15
M-END DMX
LICEMD COMPLETE
15
M-VIT
121
LIDO-K
90
M.V.I. ADULT
121
M.V.I. PEDIATRIC
121
M.V.I.-12 (WITHOUT VITAMIN K)
121
lidocaine
lidocaine hcl
15,90
15,40,90
27
lidocaine hcl (mouth-throat)
40
mafenide acetate
43
LIDOCAINE-HYDROCORTISONE ACE
90
MAG-AL
18
lidocaine-hydrocortisone acetate (rectal)
90
magnesium
30
magnesium citrate solution 1.745 gm/30ml
20
lidocaine-prilocaine
40,90
LIDOCIN
90
magnesium gluconate
30
LIDOPROFEN
90
magnesium hydroxide
20
LIDORX
90
magnesium oxide
18
linezolid
43
magnesium oxide (mg supplement)
30
magnesium sulfate (laxative)
22
30
liothyronine sodium
103
lisinopril
78
MAGONATE
lisinopril & hydrochlorothiazide
81
MAKENA
102
lithium carbonate
72
malathion
61
LO LOESTRIN FE
100
maprotiline hcl
52
LO MINASTRIN FE
100
MARPLAN
51
MATULANE
58
LODRANE D
PAGE 139
27
MAXIFED CD
116
methscopolamine bromide
92
MAXIFED CDX
116
methyclothiazide
83
MAXIFED-G CD
116
methyldopa
77
MAXIFED-G CDX
116
methyldopate hcl
77
meclizine hcl
11,55
methylphenidate hcl
85,86
meclofenamate sodium
37
METHYLPHENIDATE HCL ER
86
MEDERMA STRETCH MARKS THERAPY
15
methylprednisolone
96
MEDROL
96
methyltestosterone
99
medroxyprogesterone acetate
102
metoclopramide hcl
55
medroxyprogesterone acetate (contraceptive)
102
METOCLOPRAMIDE HCL
55
mefloquine hcl
61
metolazone
83
MEGA MULTIVITAMIN FOR MEN
33
metoprolol & hydrochlorothiazide
81
MEGA MULTIVITAMIN FOR WOMEN
33
metoprolol succinate
79
metoprolol tartrate
79
megestrol acetate
102
melatonin
23
metronidazole
43
meloxicam
37
metronidazole (topical)
43
memantine hcl
50
metronidazole cream 0.75 %
43
meperidine hcl
39
metronidazole gel 0.75 %
43
metronidazole vaginal
43
79
MEPHYTON
121
meprobamate
71
mexiletine hcl
mercaptopurine
59
MIACALCIN
107
mesalamine
106
MICONAZOLE 3
56
mesalamine w/ cleanser
106
miconazole nitrate vaginal
11
MESTINON
58
midazolam hcl
71
META BIOTIC/BIO-ACTIVE 12
18
midodrine hcl
77
METAMUCIL
20
MIGERGOT
57
METAMUCIL MULTIHEALTH FIBER
20
MILK OF MAGNESIA CONCENTRATE
20
METAMUCIL SMOOTH TEXTURE
20
milk of magnesia suspension 400 mg/5ml
20
metaproterenol sulfate
114
MILLIPRED
96
metaxalone
117
MILLIPRED DP
96
metformin hcl
73
MINASTRIN 24 FE
100
methadone hcl
38
MINIVELLE
100
methamphetamine hcl
85
minocycline hcl
46
minoxidil
84
MIRAPEX ER
62
methazolamide
methenamine mandelate
111
43
methenamine-hyosc-methylene blue-sod phos-phenyl
MIRENA (52 MG)
sal
42
mirtazapine
50
methimazole
104
misoprostol
94
METHITEST
99
MISTASSIST
108
118
methocarbamol
117
modafinil
methotrexate sodium
105
moexipril hcl
PAGE 140
103
78
MOISTUREL
15
naproxen sodium tab 220 mg
10
MOLINDONE HCL
63
naratriptan hcl
57
mometasone furoate
96
NARCAN
41
mometasone furoate (nasal)
112
NASAL DECONGESTANT
23
montelukast sodium
113
nasal moisturizing spray solution 0.65 %
23
morphine sulfate
38,39
NASCOBAL
122
MOVIPREP
93
NATAL-V RX
122
MUCINEX COUGH FOR KIDS
27
NATALVIT
122
MUCINEX FOR KIDS
27
nateglinide
73
MULTI-BETIC
33
NATURAL VITAMIN E
34
MULTI-DELYN/IRON
33
NEBUPENT
61
MULTI-VITAMIN MONOCAPS
33
NECON 10/11 (28)
multiple vitamin
33
nefazodone hcl
52
multiple vitamins w/ iron
30
NEMBUTAL
47
neomycin sulfate
42
multiple vitamins w/ minerals
31,33,121
100
MULTIVITAMIN ADULT
33
neomycin-bacitracin zn-polymyxin
109
MULTIVITAMIN MEN
33
neomycin-bacitracin-polymyxin
mupirocin
43
neomycin-polymy-dexameth
109
mupirocin calcium (topical)
43
neomycin-polymyxin-hc (ophth)
109
112
12
mycophenolate mofetil
105
neomycin-polymyxin-hc (otic)
mycophenolate sodium
105
NEPHRONEX
34
NESSI SPACER WITH MASK LARGE
23
121
NESSI SPACER WITH MASK SM/MED
23
59
NESSI SPACER WITH MOUTHPIECE
23
NEUTRASAL
88
NEUTROGENA CLEAR PORE
15
MYKIDZ IRON
MYKIDZ IRON FL
MYLERAN
34
N
nabumetone
37
nevirapine
68
nadolol
79
NEXAVAR
60
NAFTIFINE HCL
56
NEXIUM 24HR
20
naftifine hcl
56
NEXPLANON
103
NAFTIN
56
niacin
NALFON
37
niacin (antihyperlipidemic)
83
naloxone hcl
41
NIACOR
83
naltrexone hcl
40
NICADAN
NAMENDA XR
50
nicardipine hcl
80
NAMENDA XR TITRATION PACK
50
nicotine
10
NAMZARIC
49
NICOTINE
10
nicotine polacrilex
10
naphazoline hcl
109
12,34
122
naphazoline w/ pheniramine
24
NICOTROL
41
naproxen
37
NICOTROL NS
41
nifedipine
80
naproxen sodium
PAGE 141
10,38
NINLARO
60
Norethindrone-Eth Estradiol Tab 0.5-35/0.75-35/1-35
NITRO-BID
84
MG (Alyacen, Cyclafem, Dasetta, Necon, Nortrel,
nitrofurantoin
43
Pirmella)
nitrofurantoin macrocrystal
43
Norethindrone-Eth Estradiol Tab 0.5-35/1-35/0.5-35
nitrofurantoin monohyd macro
43
MG (Aranelle, Leena)
nitroglycerin
84
Norgestimate & Ethinyl Estradiol Tab 0.25 MG-35 MCG
NIVA-PLUS
122
101
101
(Estarylla, Mono-Linyah, MonoNessa, Previfem,
NIVEA
15
Sprintec)
nizatidine
93
Norgestimate-Eth Estrad Tab 0.18-35/0.215-35/0.25-35
nonoxynol-9
21
MG (Tri-Estarylla, Tri-Linyah, Tri-Previfem, Tri-
NORDITROPIN FLEXPRO
98
Sprintec, Trinessa)
101
NORDITROPIN NORDIFLEX PEN
98
norgestimate-ethinyl estradiol (triphasic)
101
NOREL CS
27
NORMALYTE
Norelgestromin-Ethinyl Estradiol TD PTWK 150-35
101
30
NORMOSOL-R
119
119
MCG/24HR (Xulane)
100
NORMOSOL-R PH 7.4
norethin acet & estrad-fe
100
nortriptyline hcl
54
Norethindrone & Ethinyl Estradiol Tab 0.4 MG-35 MCG
NORVIR
70
(Balziva, Briellyn, Gildagia, Philith, Vyfemla,
NOVOLIN 70/30
75
NOVOLIN 70/30 RELION
75
Norethindrone & Ethinyl Estradiol Tab 0.5 MG-35 MCG
NOVOLIN N
75
(Necon, Nortrel, Wera)
NOVOLIN N RELION
75
Norethindrone & Ethinyl Estradiol Tab 1 MG-35 MCG
NOVOLIN R
75
(Alyacen, Cyclafem, Dasetta, Necon, Nortrel,
NOVOLIN R RELION
75
NOVOLOG
75
Norethindrone Ac-Ethinyl Estrad-Fe Tab 1-20/1-30/1-
NOVOLOG FLEXPEN
75
35 MG-MCG (Tilia, Tri-Legest)
NOVOLOG MIX 70/30
75
Norethindrone Ace & Ethinyl Estradiol Tab 1 MG-20
NOVOLOG MIX 70/30 FLEXPEN
75
MCG (Gildess, Junel, Larin, Microgestin)
NOVOLOG PENFILL
75
Norethindrone Ace & Ethinyl Estradiol Tab 1.5 MG-30
NUEDEXTA
86
NUPLAZID
62
Norethindrone Ace & Ethinyl Estradiol-FE Tab 1 MG-20
NUTRADERM
15
NUTRADERM ADVANCED FORMULA
15
Norethindrone Ace & Ethinyl Estradiol-FE Tab 1.5 MG-
NUTRADERM-30
15
30 MCG (Gildess, Junel, Larin, Microgestin)
NUTRICAP
Zenchent)
Pirmella)
101
101
101
101
101
101
101
101
122
Norethindrone Ace-Ethinyl Estradiol-FE Tab 1 MG-20
NUTROPIN AQ NUSPIN 10
98
MCG (Lomedia)
101
98
norethindrone acetate
103
98
norethindrone acetate-ethinyl estradiol
101
NUTROPIN AQ PEN
98
Norethindrone Tab 0.35 MG (Camila, Deblitane, Errin,
NUVARING
102
Heather, Jencycla, Jolivette, Lyza, Nora-BE, Norlyroc,
NYMALIZE
80
Sharobel)
nystatin
56
PAGE 142
103
nystatin (mouth-throat)
56
ORFADIN
92
nystatin (topical)
56
ORKAMBI
114
nystatin-triamcinolone
56
orphenadrine citrate
117
ORTHO DIAPHRAGM ALL-FLEX
108
O
ORTHO DIAPHRAGM COIL
108,109
109
O-CAL FA
122
ORTHO DIAPHRAGM FLAT
O-CAL PRENATAL
122
OSMOPREP
93
OB COMPLETE
122
OSTIDERM
15
12
OTREXUP
105
OCEAN BLUE MINICAPS OMEGA-3
octreotide acetate
104
OVACE PLUS
90
OCUVITE ADULT 50+
34
oxandrolone
OCUVITE-LUTEIN
34
oxaprozin
38
ofloxacin
46
OXAYDO
40
ofloxacin (ophth)
46
oxazepam
72
ofloxacin (otic)
46
oxcarbazepine
49
olanzapine
65
oxiconazole nitrate
56
olanzapine-fluoxetine hcl
50
OXISTAT
56
OLEPTRO
52
OXTELLAR XR
49
94
olopatadine hcl
110
oxybutynin chloride
olopatadine hcl (nasal)
113
oxycodone hcl
103
38,40
OMEGA POWER
12
oxycodone w/ acetaminophen
40
OMEGA-3 2100
12
oxycodone-aspirin
40
omega-3 fatty acids
12
oxycodone-ibuprofen
40
OMEGA-3 IQ
12
OXYCONTIN
38
omega-3-acid ethyl esters
84
omeprazole
94
P
omeprazole delayed release tab 20 mg
20
paliperidone
65
OMEPRAZOLE+SYRSPEND SF ALKA
94
PANCREAZE
92
OMNITROPE
98
pancrelipase (lipase-protease-amylase)
92
ONCOVITE
34
PANOXYL
15
ondansetron hcl
55
pantoprazole sodium
94
55
parenteral electrolytes
119
55
paricalcitol
107
ONE DAILY PLUS IRON
34
paroxetine hcl
52
ONEXTON
90
PARVLEX
34
ONFI
47
PAXIL
52
ONGLYZA
73
PECGEN DMX
27
OPANA ER
38
ped multivitamins w/fl & iron
OPTIFOAM
23
PEDIA-LAX
20
ORACIT
95
PEDIADERM AF COMPLETE
56
oral electrolytes
30
PEDIALYTE
30
PAGE 143
120
PEDIATEX TDM
116
phenylephrine-shark liver oil-cocoa butter
16
PEDIATRIC COMPRESSOR/NEBULIZER
109
phenylephrine-shark liver oil-mineral oil-petrolatum 16
pediatric multiple vitamin w/ c
31
phenylephrine-witch hazel
16
pediatric multiple vitamin w/ c & fa
31
phenytoin
49
pediatric multiple vitamins w/ iron
34
phenytoin sodium extended
49
PHOS-NAK
30
PHRENILIN FORTE
86
pediatric multivitamins w/fl
120,122
pediatric vitamins acd w/ fluoride
120
pediatric vitamins adc
31
phytonadione
122
peg 3350-kcl-sod bicarb-sod chloride-sod sulfate
94
pilocarpine hcl
111
peg 3350-potassium chloride-sod bicarbonate-sod
pilocarpine hcl (oral)
88
chloride
93
pimozide
63
PEGANONE
49
pioglitazone hcl
73
PEN-KERA
15
pioglitazone hcl-metformin hcl
73
penicillin v potassium
44
piroxicam
38
PENTAM
61
PLEGRIDY
87
PENTASA
106
PLEGRIDY STARTER PACK
87
90
pentoxifylline
81
PLEXION CLEANSING CLOTH
PENTRAVAN PLUS
15
PNV FE FUM/DOCUSATE/FOLIC ACID
122
perindopril erbumine
78
PNV FOLIC ACID + IRON
122
permethrin
15,23,61
PNV PRENATAL PLUS MULTIVITAMIN
34,122
perphenazine
55
PNV TABS 29-1
123
perphenazine-amitriptyline
50
PNV-DHA
123
PERTZYE
92
PNV-FIRST
123
PEXEVA
52
podofilox
90
PHAZYME MAXIMUM STRENGTH
18
POLY-HIST DM
27
21,95
POLY-VENT IR
27
phenelzine sulfate
51
POLY-VI-FLOR
123
phenobarbital
47
POLY-VI-FLOR FS
123
phenobarbital sodium
47
POLY-VI-FLOR/IRON
123
phenoxybenzamine hcl
78
polyethylene glycol 3350
20,94
phenyleph-promethazine w/ cod
116
polymyxin b-trimethoprim
109
phenylephrine hcl (ophth)
109
polysaccharide iron complex
34
24
phenazopyridine hcl
phenylephrine hcl (oral)
23
polyvinyl alcohol
23
pot phosphate monobasic w/ sod phosphate dibasic &
phenylephrine in hard fat
16
monobasic
phenylephrine-brompheniramine-dm
27
potassium bicarb & chloride
119
potassium bicarbonate
119
potassium chloride
119
phenylephrine-diphenhydramine-dextromethorphan 27
POTASSIUM CHLORIDE ER
119
phenylephrine-dm
27
potassium chloride microencapsulated crystals cr
119
phenylephrine-mineral oil-petrolatum
16
potassium citrate (alkalinizer)
phenylephrine-chlorphen-dm
phenylephrine-cocoa butter
PAGE 144
27,116
16
95
95
potassium gluconate
30
PRISTIQ
52
POTIGA
47
PRO-CHLO
27
pramipexole dihydrochloride
62
PRO:12 MOUSSE AL12
16
pramoxine-phenylephrine-glycerin-petrolatum
16
probenecid
57
pravastatin sodium
83
PROBIOTIC ADVANCED
18
prazosin hcl
78
PROBIOTIC FORMULA
18
PRED MILD
110
PROBIOTIC PEARLS
18
prednicarbate
97
probiotic product
17
prednisolone
97
prochlorperazine
55
111
prochlorperazine edisylate
55
97
prochlorperazine maleate
55
PROCORT
90
prednisolone acetate (ophth)
prednisolone sodium phosphate
PREDNISOLONE SODIUM PHOSPHATE
97,111
prednisone
97
PROCTOFOAM HC
90
PREDNISONE INTENSOL
97
PROCYSBI
92
34
PREMARIN
102
PROFE
PREMPHASE
102
progesterone micronized
PREMPRO
102
PROGLYCEM
74
PRENAPLUS
123
PROMACTA
76
PRENATABS FA
123
promethazine & phenylephrine
116
PRENATABS RX
123
promethazine hcl
113
34
113
PRENATAL 19
123
113
PRENATAL AD
123
promethazine w/codeine
116
117
PRENATAL
103
PRENATAL LOW IRON
34
promethazine-dm
PRENATAL ONE DAILY
34
propafenone hcl
79
123
proparacaine hcl
109
PRENATAL PLUS
prenatal vit w/ ferrous fumarate-folic acid
31
propranolol & hydrochlorothiazide
81
PRENATAL VITAMIN PLUS LOW IRON
124
propranolol hcl
79
PRENATAL VITAMINS PLUS
124
propylthiouracil
104
PREPLUS
124
PRORENAL + D
35
PREPOPIK
94
PRORENAL + D W/ OMEGA-3
35
PRESERVISION AREDS
34
protriptyline hcl
54
PRESERVISION AREDS 2
34
PROVELLA
18
PRESERVISION/LUTEIN
34
pseudoephed-bromphen-dm
PRETAB
124
27,117
pseudoephedrine hcl
23
PRETTY FEET/HANDS
16
pseudoephedrine hcl er tab er 12h 120 mg
23
PREVACID 24HR
21
pseudoephedrine hcl tab 30 mg
23
PREVACID SOLUTAB
94
pseudoephedrine-chlorphen-dm
27
PREZISTA
70
pseudoephedrine-dexchlorpheniramine-
primaquine phosphate
61
chlophedianol
27
primidone
47
pseudoephedrine-guaifenesin
28
PAGE 145
pseudoephedrine-ibuprofen
28
REMODULIN
115
PSORCON
97
RENAPLEX-D
35
psyllium
20
repaglinide
73
PULMICORT FLEXHALER
112
REQ 49+
124
PULMONEB LT
109
RESCON DM
28
PUREFE PLUS
124
RESCRIPTOR
68
PURIXAN
59
reserpine
82
pyrazinamide
58
RESPAIRE-30
28
pyrethrins-piperonyl butoxide
16
RESTASIS
110
pyridostigmine bromide
58
RESTORA
18
REVATIO
115
REVLIMID
59
REXULTI
65
REYATAZ
70
REZYST IM
93
pyridoxine hcl
PYRIL DM
35,124
28
Q
QUARTETTE
quetiapine fumarate
QUFLORA PEDIATRIC
102
65
124
RHEUMATREX
106
RHINARIS
23
QUILLICHEW ER
86
riboflavin
35
QUILLIVANT XR
86
RIDAURA
106
QUIN B STRONG
35
rifampin
58
quinapril hcl
78
riluzole
86
quinapril-hydrochlorothiazide
82
rimantadine hydrochloride
70
quinidine gluconate
79
RISA-BID PROBIOTIC
18
quinidine sulfate
79
RISABAL-PH
16
QUINTABS
35
RISAQUAD
18
QUINTABS-M
35
RISAQUAD-2
18
risedronate sodium
R
rabeprazole sodium
raloxifene hcl
ramipril
107
RISPERDAL CONSTA
94
103
78
65
risperidone
65,66
risperidone odt (tab 3 mg, tab 4 mg)
65
65
65
ranitidine hcl
19,93
RAPAMUNE
105
66
RASUVO
106
66
RAYOS
97
RITALIN LA
86
RE:IIMMUNE
18
rivastigmine
49
124
rivastigmine tartrate
50
RECTIV
90
rizatriptan benzoate
57
RELENZA DISKHALER
70
ropinirole hydrochloride
62
RELHIST BP
28
ROZEREM
118
109
RU-HIST D
28
REAPHIRM
RELION KETONE TEST
PAGE 146
RULAVITE DHA
124
SFROWASA
106
RYDEX G
28
sildenafil citrate (pulmonary hypertension)
115
RYTARY
63
SILENOR
118
silver sulfadiazine
S
SABRIL
46
simethicone
simvastatin
83
102
SINELEE
90
saline
23
sirolimus
106
SALIVAMAX
88
SITAVIG
70
SALIVATE RX
88
SIVEXTRO
43
salsalate
38
SKYLA
SAMSCA
118
SLOW RELEASE IRON
30
SANDIMMUNE
106
SM 4X PROBIOTIC
18
SANDOSTATIN LAR DEPOT
104
SM ACIDOPHILUS
18
SAFYRAL
47
18,23
103
SANTYL
90
SM B-COMPLEX/VITAMIN C
35
SAPHRIS
66
SM BANDAGE ROLL
23
SARAFEM
52
SM FISH OIL
12
SAVELLA
87
SM GAUZE
23
SAVELLA TITRATION PACK
87
SM GLUCOSE
11
SCOT-TUSSIN SENIOR
28
SM ONE DAILY MENS
35
SE-NATAL 19
124
SM ONE DAILY WOMENS
35
SECONAL
118
SM PRENATAL VITAMINS
35
SELECT-OB+DHA
124
SM ROLLED GAUZE 2"X4.1YD
23
63
SM ROLLED GAUZE 3"X4.1YD
23
SM SLOW RELEASE IRON
30
selegiline hcl
selenium sulfide
16,90
SELZENTRY
69
SM STERILE
23
senna
20
SM VITAMIN D3
35
senna tab 8.6 mg
20
soap & cleansers
12
senna-docusate sodium tab 8.6-50 mg
20
sodium acetate
sennosides
20
sodium bicarbonate (antacid)
sennosides-docusate sodium
20
sodium chloride (inhalant)
117
104
sodium citrate & citric acid
95
SENSIPAR
119
18
SENTRAFLOX AM-10
53
sodium fluoride
SENTRALOPRAM AM-10
53
sodium fluoride (dental)
118
sodium phenylbutyrate
92
19
SENTRAMODAFIN AM-100
119
12,88
SENTRAVIL PM-25
54
sodium phosphates
SENTRAZOLAM AM 0.25
72
sodium polystyrene sulfonate
SENTROXATINE
53
SOLODYN
46
SOLTAMOX
59
SEREVENT DISKUS
114
119
SEROQUEL XR
66
SOMATULINE DEPOT
104
sertraline hcl
53
SOMAVERT
104
PAGE 147
SOOTHE & COOL MOISTURIZING
16
SUMAVEL DOSEPRO
57
SOOTHE & COOL SKIN
16
SUPRAX
44
sorbitol (laxative)
20
SUPREP BOWEL PREP
94
SORILUX
90
SUSTIVA
68
sotalol hcl
79
SUTENT
60
SOURCECF
35
SYLATRON
59
SPECIAL CARE
16
SYMBICORT
117
SPINOSAD
61
SYMLINPEN 120
74
114
SYMLINPEN 60
74
SPIRIVA HANDIHALER
spironolactone
82
SYNAREL
104
spironolactone & hydrochlorothiazide
82
SYPRINE
119
SPORANOX
56
SYSTANE OMEGA-3 HEALTHY TEARS
12
SPRIX
38
SYSTANE OVERNIGHT THERAPY
24
SPRYCEL
60
SSKI
104
T
SSS 10-4
90
T-VITES
35
SSS 10-5
90
TABLOID
59
12,88
tacrolimus
106
stannous fluoride
stavudine
69
tacrolimus (topical)
91
STIMATE
98
TAMIFLU
70
STRATTERA
86
tamoxifen citrate
59
STRIANT
99
tamsulosin hcl
95
STRIBILD
68
TARCEVA
60
124
TASIGNA
60
TAZORAC
91
TECFIDERA
88
telmisartan
78
82
STROVITE ONE
SUBOXONE
sucralfate
sulfacetamide sod-prednisolone
40,41
94
110
sulfacetamide sodium
91
telmisartan-hydrochlorothiazide
sulfacetamide sodium (acne)
91
temazepam
117
sulfacetamide sodium (ophth)
46
terazosin hcl
95
sulfacetamide sodium w/ sulfur
91
terbinafine hcl
56
sulfacetamide sodium-sulfur w/ skin cleanser
88
terbinafine hcl (topical)
16
sulfacetamide sodium-sulfur-sunscreen
88
terbutaline sulfate
SULFACETAMIDE-SULFUR IN UREA
91
terconazole vaginal
56
sulfamethoxazole-trimethoprim
46
TESTOPEL
99
SULFAMYLON
43
testosterone
99
TESTOSTERONE
99
sulfasalazine
107
114
sulindac
38
testosterone cypionate
99
57
testosterone enanthate
99
sumatriptan succinate
57
tetrabenazine
86
SUMATRIPTAN SUCCINATE
57
tetracaine hcl (ophth)
PAGE 148
110
tetrahydrozoline hcl (ophth)
24
tolazamide
74
THALOMID
59
tolbutamide
74
THEO-24
115
tolcapone
62
theophylline
115
tolterodine tartrate
94
THERA M PLUS
35
topiramate
48
THERA-M
35
torsemide
82
THERA/BETA-CAROTENE
35
TRACLEER
115
THERAFLU COLD & COUGH
28
TRADJENTA
74
THERAFLU COLD/COUGH DAYTIME
28
tramadol hcl
THERAPENTIN-90
47
TRAMADOL HCL ER
38
THEREMS-H
35
tramadol-acetaminophen
40
THEREMS-M
35
trandolapril
78
tranexamic acid
77
51
thiamine hcl
35,125
38,40
thiamine mononitrate
35
tranylcypromine sulfate
thioridazine hcl
64
travoprost
thiothixene
64
TRAZAMINE
53
THRIVITE 19
125
trazodone hcl
53
THRIVITE RX
125
TRECATOR
58
thyroid
103
TRETIN-X
91
THYROLAR-1
103
tretinoin
91
THYROLAR-1/2
103
TREXALL
THYROLAR-1/4
103
TRI-VI-SOL
36
THYROLAR-2
103
TRI-VI-SOL/IRON
36
THYROLAR-3
103
TRI-VIT/FLUORIDE/IRON
111
106
125
tiagabine hcl
47
triamcinolone acetonide (mouth)
97
ticlopidine hcl
77
triamcinolone acetonide (nasal)
timolol maleate
79
triamcinolone acetonide (topical)
97
24,112
timolol maleate (ophth)
111
TRIAMINIC COLD/COUGH DAY TIME
28
TIMOPTIC OCUDOSE
111
TRIAMINIC FEVER REDUCER
23
tinidazole
43
TRIAMINIC-D
28
tioconazole vaginal
11
triamterene & hydrochlorothiazide
82
TIVICAY
68
TRIANEX
97
tizanidine hcl
126
triazolam
117
TL-ASSURE ONE
125
TRIBENZOR
TL-ASSURE+DHA
125
TRICARE
TOBRADEX
125
trifluoperazine hcl
64
114
trifluridine
70
tobramycin (ophth)
42
TRIGLIDE
83
tobramycin sulfate
42
trihexyphenidyl hcl
62
trimethoprim
43
trimipramine maleate
54
tobramycin
tobramycin-dexamethasone
TOBREX
PAGE 149
42
82
110
42
TRINATAL GT
125
VANICREAM
16
TRINATAL RX 1
125
VANICREAM LITE
16
TRINATE
125
VELVACHOL
16
TRINTELLIX
53
VENATAL-FA
125
TRIUMEQ
69
venlafaxine hcl
53
TROKENDI XR
48
VENLAFAXINE HCL ER
53
TROPAZONE
91
VENTAVIS
115
VENTOLIN HFA
114
tropicamide
110
trospium chloride
94
verapamil hcl
80
TRUVADA
69
VEREGEN
91
tryptophan
36
VERIPRED 20
97
114
VERSACLOZ
67
TUDORZA PRESSAIR
TUMS CHEWY DELIGHTS
18
VEXOL
111
TUSNEL C
28
VIDEX
69
TUSNEL PEDIATRIC
28
VIGAMOX
46
TYBOST
69
VIIBRYD
53
TYKERB
60
VIIBRYD STARTER PACK
53
TYZEKA
67
VIMPAT
49
TYZINE
117
U
UCERIS
VINATE M
125
VINATE ONE
125
VINATE ULTRA
125
107
VIOKACE
92
UDDERLY SMOOTH
16
VIRACEPT
70
UDDERLY SMOOTH EXTRA CARE 20
16
VIREAD
69
ULTRESA
92
VIRT NATE
126
UNICOMPLEX-M
36
VIRT-ADVANCE
126
urea
91
VIRT-PN DHA
126
URO-MAG
18
VIRT-VITE GT
126
ursodiol
93
VISBIOME PROBIOTIC HIGH POT
VISTOGARD
V
VITA-C
18
109
36
valacyclovir hcl
70
VITAFOL ULTRA
126
VALCYTE
67
VITAFOL-OB
126
valganciclovir hcl
67
VITAFOL-ONE
126
valproate sodium
47
VITAFOL-PLUS
126
valproic acid
48
VITAFOL-PN
126
valsartan
78
vitamin a
36
valsartan-hydrochlorothiazide
82
vitamin e
36
vitamin e (topical)
16
VALVED HOLDING CHAMBER
109
VANATOL LQ
86
VITAMIN K1
vancomycin hcl
43
vitamins w/ lipotropics
PAGE 150
126
36
VITEKTA
68
ZIAGEN
69
VIVITROL
40
zidovudine
69
VOL-NATE
126
ZINC
36
VOL-PLUS
126
zinc sulfate
VOL-TAB RX
126
ziprasidone hcl
66
58
30,119
VOPAC
91
zolmitriptan
VOPAC 5
16
zolpidem tartrate
117
VOPAC GB
91
ZOLPIMIST
118
VOPAC KT
91
ZOMIG
58
VOTRIENT
60
zonisamide
47
126
ZOVIRAX
70
VRAYLAR
66
ZYCLARA
91
VSL#3 DS
93
ZYCLARA PUMP
91
VYVANSE
85
ZYPREXA RELPREVV
66
ZYRTEC ALLERGY
26
VP-ZEL
W
warfarin sodium
76
WATCHHALER
109
water for injection, sterile
109
white petrolatum-mineral oil
24
WIBI
16
X
XALKORI
60
XARELTO
76
XARELTO STARTER PACK
76
XIFAXAN
43
XOLAIR
117
XOPENEX HFA
114
XYREM
118
Y
YELETS TEENAGE FORMULA
36
Z
zafirlukast
113
zaleplon
117
ZATEAN-PN DHA
126
ZELBORAF
60
ZENPEP
92
ZENZEDI
85
PAGE 151

HIP State Plus

Transcription

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