Health Share of Oregon/Providence (Medicaid)

Transcription

To help find a drug see the back of the document for an alphabetical listing
Drug Name
Status*
Requirements/Limits
Analgesics
8 HOUR
OTC
8 HOUR PAIN RELIEF
OTC
8 HOUR PAIN RELIEVER
OTC
ACEPHEN (325 MG, 650 MG)
OTC
ACETADRYL
OTC
ACETAMINOPHEN (80MG/0.8ML
DROPS SUSP, 80 MG TAB CHEW, 120
MG SUPP.RECT, 160 MG/5ML ORAL
SUSP, 160 MG/5ML SOLUTION, 160
MG/5ML ELIXIR, 160 MG/5ML LIQUID,
325/10.15 SOLUTION, 325 MG TABLET,
500 MG TABLET, 500 MG/5ML LIQUID,
650MG/20.3 SOLUTION, 650 MG
TABLET ER, 650 MG SUPP.RECT)
OTC
ACETAMINOPHEN PM
OTC
ACETAMINOPHEN PM XTRA STRENGTH
OTC
ACETAMINOPHEN/DIPHENHYDRAMINE
HCL
OTC
ARTHRITIS PAIN
OTC
ARTHRITIS PAIN RELIEF (ARTHRITIS ER
650 MG CAPLT, ARTHRITIS RELF ER 650
MG, ARTHRITIS RLF ER 650 MG, CVS
ARTHRITIS ER 650 MG, EQL ARTHRIT
RLF ER 650 MG, GNP ARTHRIT RLF ER
650 MG, HM ARTHRITIS ER 650 MG,
KRO ARTHRIT RLF ER 650 MG, PUB
ARTHRITIS ER 650 MG, PV ARTHRITIS ER
650 MG, QC ARTHRITIS ER 650 MG, RA
ARTHRITIS ER 650 MG, SB ARTHRITIS ER
650 MG, SM ARTHRITIS ER 650 MG, SM
ARTHRITIS RELF ER 650)
OTC
ARTHRITIS PAIN RELIEVER
OTC
ASPIRIN (500 MG TABLET DR, 600 MG
SUPP.RECT, 650 MG TABLET DR)
OTC
ATHENOL
OTC
*Specialty medications are only available through the Providence specialty network. See introduction.
PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access
1
LAST UPDATE 10/2016
Drug Name
Status*
BETATEMP
OTC
butalbital/acetaminophen
Generic
butalbital/acetaminophen/caffeine (50325-40 tablet, 50-325-40 capsule)
Generic
butalbital/aspirin/caffeine
Generic
capacet
Generic
CHILD PAIN REL-FEVER REDUCER
OTC
CHILDREN'S FEVER REDUCER
OTC
CHILDREN'S FEVER REDUCING
OTC
CHILDREN'S MEDI-TABS
OTC
CHILDREN'S NON-ASPIRIN (CHILD NONASPIRIN 160 MG/5 ML, CVS CHILD NONASA 80 MG TB CHW, NON-ASA
CHILDREN'S TAB CHEW, NON-ASA PAIN
RELIEF TB CHEW, NON-ASPIRIN 160
MG/5 ML SUSP, NON-ASPIRIN CHILD 80
MG TAB, NON-ASPIRIN CHILD 120 MG
SUP, NON-ASPIRIN CHILD'S DROPS, PV
CHILD NON-ASA 80 MG TB CHEW, PV
CHILD NON-ASPIRIN 160 MG/5, PV
CHILDREN'S NON-ASA LIQ, RA NONASPIRIN 160 MG/5 ML)
OTC
CHILDREN'S PAIN & FEVER
OTC
CHILDREN'S PAIN RELIEF
OTC
CHILDREN'S PAIN RELIEVER (CHILD'S
SUSP, EQ CHILD'S SUSP, EQL CHILD'S
SUSP, SB CHILD'S SUSP, SM 80 MG TAB,
SM CHEW TAB, SM CHILD'S SUSP)
OTC
CHILDREN'S PAIN-FEVER
OTC
CHILDREN'S Q-PAP
OTC
CHILDREN'S SILAPAP
OTC
CHILDREN'S TACTINAL
OTC
EAZZZE THE PAIN
OTC
ED-APAP
OTC
Requirements/Limits
2
LAST UPDATE 10/2016
Drug Name
Status*
EXTRA STRENGTH NON-ASPIRIN
OTC
FEVER REDUCER-PAIN RELIEVER
OTC
FEVERALL (120 MG, 325 MG, 650 MG)
OTC
HEADACHE PM
OTC
HEADACHE PM FORMULA
OTC
INFANT FEVER-PAIN RELIEVER
OTC
INFANT PAIN RELIEF
OTC
INFANT PAIN-FEVER
OTC
INFANT'S NON-ASPIRIN
OTC
INFANT'S PAIN RELIEF
OTC
INFANT'S PAIN RELIEVER
OTC
INFANTS' PAIN RELIEF
OTC
INFANTS' PAIN RELIEVER
OTC
INFANTS' PAIN-FEVER
OTC
LITTLE REMEDIES FEVER-PAIN
OTC
MAPAP (80 MG TABLET CHEW, 160
MG/5 ML ELIXIR, 160 MG/5 ML
SUSPENSION, 325 MG TABLET, 500 MG
TABLET, 500 MG/15 ML LIQUID, 500
MG CAPLET, 500 MG GELCAP, 500 MG
CAPSULE)
OTC
MAPAP ARTHRITIS PAIN
OTC
MAPAP PM
OTC
MASOPHEN
OTC
MEDI-TABS
OTC
MEDI-TABS EXTRA STRENGTH
OTC
MEDI-TABS PM
OTC
NIGHT TIME PAIN MEDICINE
OTC
Requirements/Limits
3
LAST UPDATE 10/2016
Drug Name
Status*
NON-ASPIRIN (CVS NON-ASA 80 MG
TABLET CHW, MEDI-FIRST NON-ASPIRIN
325 MG, NON-ASPIRIN 80 MG TAB
CHEW, NON-ASPIRIN 160 MG/5 ML
ELIX, NON-ASPIRIN 325 MG TABLET, PV
NON-ASPIRIN 325 MG TABLET, SB NONASPIRIN 80 MG TAB CHW, SB NONASPIRIN 325 MG TABLET, V-R NONASPIRIN INFANT DRPS)
OTC
NON-ASPIRIN 8 HOUR
OTC
NON-ASPIRIN EXTRA STRENGTH (CVS
NON-ASPIRIN 500 MG GELTAB, CVS
NON-ASPIRIN 500 MG CAPLET, CVS
NON-ASPIRIN 500 MG TABLET, NON
ASPIRIN 500 MG CAPLET, NON-ASPIRIN
500 MG GELTAB, NON-ASPIRIN 500 MG
GELCAP, NON-ASPIRIN 500 MG
SOFTGEL, NON-ASPIRIN 500 MG
TABLET, NON-ASPIRIN 500 MG CAPLET,
NON-ASPIRIN X-STR 167 MG/5 ML, PV
NON-ASPIRIN 500 MG SOFTGEL, RA
NON-ASPIRIN 500 MG CAPLET, SB NONASPIRIN 500 MG CAPLET, SM NONASPIRIN 500 MG CAPLET)
OTC
NON-ASPIRIN JR STRENGTH
OTC
NON-ASPIRIN PAIN RELIEF
OTC
NON-ASPIRIN PM
OTC
NON-ASPIRIN PM EX-STRENGTH
OTC
NORTEMP
OTC
PAIN & FEVER (& 500 MG CAPLET, &
500 MG TABLET)
OTC
PAIN & SLEEP
OTC
Requirements/Limits
4
LAST UPDATE 10/2016
Drug Name
Status*
PAIN RELIEF (160 MG/5 ML LIQUID, 325
MG TABLET, CVS 500 MG GELCAP, EQL
500 MG TABLET, EQL 500 MG CAPLET,
GNP 500 MG GELCAP, HM 500 MG
CAPLET, 500 MG GELTAB, 500 MG
CAPLET, EQL 500 MG GELTAB, HM 500
MG TABLET, PUB 500 MG TABLET, 500
MG CAPSULE, 500 MG GELCAP, 500 MG
TABLET, ER 650 MG CAPLET, GNP ER
650 MG CPLT, PUB 500 MG GELTAB,
PUB 500 MG CAPLET, PV 500 MG
TABLET, SM 500 MG GELCAP)
OTC
PAIN RELIEF ADULT
OTC
PAIN RELIEF EXTRA STRENGTH (CVS 500
MG CAPLET, CVS 500 MG EZ-TAB, GNP
500 MG CAPLET, PV 500 MG CAPLET)
OTC
PAIN RELIEF PM
OTC
PAIN RELIEVER (CVS 500 MG CPLT, ER
650 MG CAPLET, GNP 325 MG TAB,
GNP 500 MG TAB, GNP 500 MG CAPLT,
HM 325 MG TABLET, HM 500 MG
TABLET, PV 325 MG TABLET, PV 500 MG
TABLET, PV 500 MG CAPLET, SM 325
MG TABLET, 325 MG TABLET, SM 500
MG GELTAB, 500 MG CAPLET, SB 500
MG CAPLET, SB 500 MG GELCAP, SM
500 MG GELCAP, 500 MG GELCAP, 500
MG TABLET, SM 500 MG TABLET, SM
500 MG CAPLET)
OTC
PAIN RELIEVER JUNIOR STRENGTH
OTC
PAIN RELIEVER PM
OTC
PAIN RELIEVER-FEVER REDUCER
OTC
PEDIACARE FEVER REDUCER
OTC
PHARBETOL
OTC
Q-PAP (80 MG/0.8 ML DROPS, 160
MG/5 ML LIQUID, 160 MG/5 ML
SOLUTION, 325 MG TABLET)
OTC
Q-PAP EXTRA STRENGTH
OTC
SHAKE THAT ACHE
OTC
Requirements/Limits
5
LAST UPDATE 10/2016
Drug Name
Status*
TACTINAL
OTC
tencon 50-325 mg tablet
Generic
TENSION HEADACHE RELIEVER
OTC
TYLENOL PM EXTRA STRENGTH
OTC
TYLOPHEN
OTC
WAL-NADOL PM
OTC
Requirements/Limits
Nonsteroidal Anti-inflammatory Drugs
ADULT LOW DOSE ASPIRIN EC
OTC
ADVIL JR STR 100 MG TAB CHEW
OTC
ALL DAY PAIN RELIEF (CVS PAIN RLF 220
MG TB, EQL RLF 220 MG CAPLET, GNP
PAIN RLF 220 MG TB, PAIN RELIEF 220
MG TAB, PAIN RLF 220 MG CAPLET, SM
RELIEF 220 MG CAPLT, SM RELIEF 220
MG TAB)
OTC
ALL DAY RELIEF
OTC
ASPIR 81
OTC
ASPIR-LOW
OTC
ASPIR-TRIN
OTC
ASPIRIN (81 MG TAB CHEW, 81 MG
TABLET DR, 300 MG SUPP.RECT, 325
MG TABLET, BAYER 325 MG CAPLET,
BAYER 325 MG TABLET, 325 MG TABLET
DR)
OTC
celecoxib (50 mg capsule, 100 mg
capsule, 200 mg capsule)
Generic
QL (2 PER DAY)
celecoxib 400 mg capsule
Generic
QL (1 PER DAY)
CHILDREN'S ADVIL
OTC
CHILDREN'S IBUPROFEN
OTC
CHILDREN'S MEDI-PROFEN
OTC
CHILDREN'S PROFEN IB
OTC
CHILDREN'S PROFENIB
OTC
6
LAST UPDATE 10/2016
Drug Name
Status*
choline sal/mag salicylate 500 mg/5ml
liquid
Generic
diclofenac potassium
Generic
diclofenac sodium (25 mg tablet dr, 50
mg tablet dr, 75 mg tablet dr, 100 mg
tab er 24h)
Generic
diflunisal
Generic
ECOTRIN EC 81 MG TABLET
OTC
ECPIRIN
OTC
etodolac
Generic
fenoprofen calcium 600 mg tablet
Generic
FLANAX 220 MG TABLET
OTC
flurbiprofen (50 mg tablet, 100 mg
tablet)
Generic
I-PRIN
OTC
IBU-DROPS
OTC
ibuprofen (400 mg tablet, 600 mg
tablet, 800 mg tablet)
Generic
IBUPROFEN (50 MG/1.25 DROPS SUSP,
100 MG/5ML ORAL SUSP, 100 MG TAB
CHEW, 200 MG CAPSULE, 200 MG
TABLET)
OTC
INDOCIN (25 MG/5 ML SUSPENSION, 50
MG SUPPOSITORY)
Brand
indomethacin (25 mg capsule, 50 mg
capsule, 75 mg capsule er)
Generic
INFANTS IBU-DROPS
OTC
INFANTS MEDI-PROFEN
OTC
INFANTS PROFENIB
OTC
ketoprofen (50 mg capsule, 75 mg
capsule, 200 mg cap24h pel)
Generic
ketorolac tromethamine 10 mg tablet
Generic
meclofenamate sodium (50 mg capsule,
100 mg capsule)
Generic
Requirements/Limits
7
LAST UPDATE 10/2016
Drug Name
Status*
MEDI-PROFEN
OTC
MEDIPROXEN
OTC
meloxicam (7.5 mg tablet, 15 mg
tablet)
Generic
MOTRIN IB
OTC
nabumetone (500 mg tablet, 750 mg
tablet)
Generic
naproxen (125 mg/5ml oral susp, 250
mg tablet, 375 mg tablet, 375 mg tablet
dr, 500 mg tablet dr, 500 mg tablet)
Generic
naproxen sodium (275 mg tablet, 550
mg tablet)
Generic
NAPROXEN SODIUM 220 MG TABLET
OTC
oxaprozin
Generic
piroxicam (10 mg capsule, 20 mg
capsule)
Generic
PROVIL
OTC
ST. JOSEPH ASPIRIN
OTC
sulindac (150 mg tablet, 200 mg tablet)
Generic
tolmetin sodium
Generic
WAL-PROFEN (200 MG CAPLET, 200 MG
SOFTGEL, 200 MG CAPSULE, 200 MG
TABLET)
OTC
WAL-PROXEN
OTC
Requirements/Limits
Opioid Analgesics, Long-acting
fentanyl (12 patch td72, 25 patch td72)
Generic
QL (15 PER 30 DAYS)
fentanyl (50mcg/hr patch td72,
75mcg/hr patch td72, 100 mcg/hr patch
td72)
Generic
QL (10 PER 30 DAYS)
methadone hcl (10 mg/ml oral conc, 10
mg tablet)
Generic
QL (4 PER DAY)
methadone hcl 10 mg/5 ml solution
Generic
QL (20 ML PER DAY)
methadone hcl 40 mg tablet sol
Generic
QL (1 PER DAY)
8
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
methadone hcl 5 mg tablet
Generic
QL (8 PER DAY)
methadone hcl 5 mg/5 ml solution
Generic
QL (40 ML PER DAY)
methadone intensol
Generic
QL (4 ML PER DAY)
methadose 40 mg tablet dispr
Generic
QL (1 PER DAY)
morphine sulfate (100 mg tablet er, 200
mg tablet er)
Generic
QL (1 PER DAY)
morphine sulfate (15 mg tablet er, 30
mg tablet er)
Generic
QL (3 PER DAY)
morphine sulfate 60 mg tablet er
Generic
QL (2 PER DAY)
OXYCODONE HCL (10 MG TAB ER 12H,
15 MG TAB ER 12H, 20 MG TAB ER 12H)
Brand
PA, QL (3 PER DAY)
40 MG TAB ER 12H)
Brand
PA, QL (2 PER DAY)
80 MG TAB ER 12H)
Brand
PA, QL (1 PER DAY)
OXYCONTIN (10 MG TABLET, 15 MG
TABLET, 20 MG TABLET)
Brand
PA, QL (3 PER DAY)
TABLET)
Brand
PA, QL (2 PER DAY)
TABLET)
Brand
PA, QL (1 PER DAY)
tramadol hcl (100 mg tbmp 24hr, 100
mg tab er 24h, 200 mg tbmp 24hr, 200
mg tab er 24h, 300 mg tab er 24h, 300
mg tbmp 24hr)
Generic
PA, QL (1 PER DAY)
acetaminophen with codeine phosphate
(120-12mg/5 solution, 300mg/12.5
solution, 300mg-30mg tablet, 300mg60mg tablet, 300mg-15mg tablet)
Generic
PA (PA for ages 5 and under)
ascomp with codeine
Generic
butalbit/acetamin/caff/codeine 50-32530 capsule
Generic
butorphanol tartrate (1 mg/ml vial, 2
mg/ml vial)
Generic
PA
Opioid Analgesics, Short-acting
9
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
butorphanol tartrate 10 mg/ml spray
Generic
QL (2.5 ML PER 30 DAYS)
carisoprodol/aspirin/codeine phosphate
Generic
co-gesic
Generic
codeine
phosphate/butalbital/aspirin/caffeine
Generic
codeine sulfate (15 mg tablet, 30 mg
Generic
endocet (2.5-325 mg tablet, 5-325
tablet, 7.5-325 mg tablet)
Generic
endocet 10-325 mg tablet
Generic
endodan
Generic
hydrocodone bitartrate/acetaminophen
(2.5-167/5 solution, 5 mg-325mg tablet,
7.5-325/15 solution, 7.5-750 mg tablet,
7.5-325 mg tablet, 7.5-650 mg tablet,
10mg-325mg tablet, 10mg-650mg
tablet, 10mg-660mg tablet, 10mg500mg tablet)
Generic
hydrocodone/ibuprofen
Generic
hydromorphone hcl (1 mg/ml liquid, 2
mg tablet)
Generic
hydromorphone hcl 3 mg supp.rect
Generic
hydromorphone hcl 4 mg tablet
Generic
QL (8 PER DAY)
hydromorphone hcl 8 mg tablet
Generic
QL (4 PER DAY)
ibudone 5-200 mg tablet
Generic
lorcet
Generic
lorcet hd
Generic
lorcet plus 7.5-325 mg tablet
Generic
lortab (5-325 mg tablet, 5-500 tablet,
7.5-325 mg tablet, 10-325 mg tablet)
Generic
LORTAB 7.5-500 TABLET
Brand
meperidine hcl (50 mg tablet, 50 mg/5
ml solution, 100 mg tablet)
Generic
QL (8 PER DAY)
QL (10 ML PER DAY)
10
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
morphine sulfate (5 mg supp.rect, 10
mg supp.rect, 20 mg supp.rect, 30 mg
supp.rect)
Generic
morphine sulfate 10 mg/5 ml solution
Generic
QL (60 ML PER DAY)
morphine sulfate 100 mg/5ml solution
Generic
QL (5 ML PER DAY)
morphine sulfate 15 mg tablet
Generic
QL (8 PER DAY)
morphine sulfate 20 mg/5 ml solution
Generic
QL (30 ML PER DAY)
morphine sulfate 30 mg tablet
Generic
QL (4 PER DAY)
oxycodone hcl (20 mg/ml oral conc, 20
mg tablet)
Generic
QL (4 ML PER DAY)
oxycodone hcl (5 mg capsule, 5 mg
tablet)
Generic
QL (10 PER DAY)
oxycodone hcl 10 mg tablet
Generic
QL (8 PER DAY)
Generic
QL (5 PER DAY)
Generic
QL (2 PER DAY)
oxycodone hcl 5 mg/5 ml solution
Generic
QL (80 ML PER DAY)
oxycodone hcl/acetaminophen (10mg650mg tablet, 10mg-325mg tablet)
Generic
QL (8 PER DAY)
oxycodone hcl/acetaminophen (2.5-325
mg tablet, 5 mg-500mg capsule, 5 mg325mg tablet, 7.5-325 mg tablet, 7.5500 mg tablet)
Generic
oxycodone hcl/aspirin
Generic
oxymorphone hcl 10 mg tablet
Generic
PA, QL (4 PER DAY)
oxymorphone hcl 5 mg tablet
Generic
PA, QL (8 PER DAY)
pentazocine hcl/acetaminophen
Generic
pentazocine hcl/naloxone hcl
Generic
reprexain 10-200 mg tablet
Generic
ROXICET 5-325 ORAL SOLUTION
Brand
roxicet 5-325 tablet
Generic
stagesic
Generic
tramadol hcl 50 mg tablet
Generic
PA, QL (8 PER DAY)
11
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
tramadol hcl/acetaminophen
Generic
PA, QL (10 PER DAY)
xylon 10
Generic
Anesthetics
Local Anesthetics
dermacinrx prizopak
Generic
lidocaine 5 % adh. patch
Generic
lidocaine 5 % oint. (g)
Generic
lidocaine hcl (2 % solution, 2 % jel (ml),
4 % solution, 40 mg/ml solution)
Generic
lidocaine/prilocaine (2.5 %-2.5% cream
(g), 2.5 %-2.5% kit)
Generic
lidopril
Generic
lidopril xr
Generic
medolor pak
Generic
relador pak
Generic
relador pak plus
Generic
PA, QL (3 PER DAY)
Anti-Addiction/Substance Abuse Treatment Agents
Alcohol Deterrents/Anti-craving
acamprosate calcium
Generic
disulfiram (250 mg tablet, 500 mg
tablet)
Generic
naltrexone hcl 50 mg tablet
Generic
revia
Generic
Opioid Antagonists
buprenorphine hcl (2 mg tab subl, 8 mg
tab subl)
Generic
QL (3 PER DAY)
buprenorphine hcl/naloxone hcl
Generic
QL (3 PER DAY)
naloxone hcl (0.4 mg/ml vial, 0.4 mg/ml
syringe, 1 mg/ml syringe)
Generic
12
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
NARCAN
Brand
PA, QL (2 PER 1 YEARS)
Smoking Cessation Agents
buproban
Generic
bupropion hcl 150 mg tablet er
Generic
CHANTIX
Brand
NICOTINE 14 MG/24 HR PATCH
OTC
NICOTINE 2 MG CHEWING GUM
OTC
NICOTINE 2 MG LOZENGE
OTC
OTC
NICOTINE 21-14-7 MG TRANSDERMAL
SYSTEM
OTC
OTC
OTC
OTC
OTC
NICOTROL
Brand
NICOTROL NS
Brand
Anti-inflammatory Agents
Glucocorticoids
alclometasone dipropionate
Generic
amcinonide 0.1 % cream (g)
Generic
ANTI-ITCH (1% LOTION, 1% CREAM, CVS
1% CREAM, EQL 1% CREAM, RA 1%
CREAM)
OTC
anusol-hc 2.5% cream
Generic
apexicon e
Generic
AQUANIL HC
OTC
BETA HC
OTC
13
LAST UPDATE 10/2016
Drug Name
Status*
betamethasone dipropionate (0.05 %
lotion, 0.05 % gel (gram), 0.05 % cream
(g), 0.05 % oint. (g))
Generic
betamethasone dipropionate/propylene
glycol (0.05 % cream (g), 0.05 % oint.
(g), 0.05 % lotion)
Generic
betamethasone valerate (0.1 % cream
(g), 0.1 % lotion, 0.1 % oint. (g))
Generic
clobetasol propionate (0.05 % solution,
0.05 % shampoo, 0.05 % cream (g), 0.05
% oint. (g), 0.05 % gel (gram))
Generic
clobetasol propionate/emoll 0.05 %
cream (g)
Generic
clodan 0.05% shampoo
Generic
cormax
Generic
CORTISONE
OTC
CORTIZONE-10 (CORTIZONE-10 1%
LOTION, CORTIZONE-10 1% CREME)
OTC
CORTIZONE-10 PLUS
OTC
DERMAREST ECZEMA
OTC
desonide (0.05 % lotion, 0.05 % cream
(g), 0.05 % oint. (g))
Generic
desoximetasone
Generic
ECZEMA ANTI-ITCH
OTC
fludrocortisone acetate 0.1 mg tablet
Generic
fluocinolone acetonide (0.01 % cream
(g), 0.01 % oil, 0.01 % solution, 0.025 %
oint. (g), 0.025 % cream (g))
Generic
fluocinonide (0.05 % gel (gram), 0.05 %
solution, 0.05 % cream (g), 0.05 % oint.
(g))
Generic
fluocinonide/emollient base
Generic
fluticasone propionate (0.05 % lotion,
0.05 % cream (g))
Generic
Requirements/Limits
14
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
halobetasol propionate
Generic
HYDRO SKIN
OTC
hydrocortisone (1 % cream (g), 1 %
crm/pe app, 2.5 % lotion, 2.5 % cream
(g), 2.5 % oint. (g), 2.5 % crm/pe app)
Generic
HYDROCORTISONE 1 % LOTION
OTC
HYDROCORTISONE ACETATE 1 %
CREAM (G)
OTC
hydrocortisone butyrate 0.1 % cream
(g)
Generic
HYDROCORTISONE PLUS 12
OTC
HYDROCORTISONE/ALOE VERA 1 %
CREAM (G)
OTC
HYDROCREAM
OTC
HYDROSKIN
OTC
methylprednisolone
Generic
millipred 5 mg tablet
Generic
PA
millipred dp
Generic
PA
neomycin sulfate/polymyxin b
sulfate/hydrocortisone (3.5-10k-1
solution, 3.5-10k-1 drops susp)
Generic
NEOSPORIN 1% ANTI-ITCH CREAM
OTC
NOBLE FORMULA HC 1% CREAM
OTC
nystatin/triamcinolone acetonide
Generic
oralone
Generic
prednisolone 15 mg/5 ml solution
Generic
prednisolone sod phosphate (5 mg/5 ml
solution, 10 mg tab rapdis, 15 mg tab
rapdis, 15 mg/5 ml solution, 30 mg tab
rapdis)
Generic
prednisone (1 mg tablet, 2.5 mg tablet,
5 mg tablet, 5 mg/5 ml solution, 5 mg
tab ds pk, 10 mg tab ds pk, 10 mg
tablet, 20 mg tablet, 50 mg tablet)
Generic
PA
15
LAST UPDATE 10/2016
Drug Name
Status*
prednisone intensol
Generic
PREPARATION H HC 1% CREAM
OTC
procto-med hc
Generic
proctocream-hc
Generic
RECORT PLUS
OTC
SOOTHING CARE
OTC
triamcinolone acetonide (0.025 %
cream (g), 0.025 % oint. (g), 0.025 %
lotion, 0.1 % lotion, 0.1 % oint. (g), 0.1
% cream (g), 0.1 % paste (g), 0.5 % oint.
(g), 0.5 % cream (g))
Generic
triderm
Generic
Requirements/Limits
Antibacterials
Aminoglycosides
garamycin
Generic
gentak
Generic
gentamicin sulfate (0.1 % oint. (g), 0.1
% cream (g), 0.3 % oint. (g), 0.3 %
drops)
Generic
neomycin sulfate 500 mg tablet
Generic
TOBI PODHALER
Specialty
TOBRADEX EYE OINTMENT
Brand
tobramycin 0.3 % drops
Generic
TOBRAMYCIN IN 0.225 % SODIUM
CHLORIDE
Specialty
LA
Antibacterials, Other
acetic acid 2 % solution
Generic
ANTIBIOTIC
OTC
ANTIBIOTIC + PAIN RELIEF (RA RLF
OINT, RELIEF OINT)
OTC
16
LAST UPDATE 10/2016
Drug Name
Status*
BACITRACIN (500 OINT. (G), 500
PACKET)
OTC
BACITRACIN ZINC (500 PACKET, 500
OINT. (G))
OTC
BACITRACIN/POLYMYXIN B SULFATE
(500-10K/G OINT. (G), PACKET)
OTC
BACITRAYCIN PLUS 500 UNIT/GM
OTC
chlorhexidine gluconate 0.12 %
mouthwash
Generic
clindacin etz 1% pledget
Generic
clindacin p
Generic
clindamycin hcl (75 mg capsule, 150 mg
Generic
clindamycin palmitate hcl
Generic
clindamycin phosphate (1 % foam, 1 %
lotion, 1 % med. swab, 1 % gel (gram), 1
% solution, 2 % cream/appl)
Generic
cycloserine 250 mg capsule
Generic
EQL FIRST AID ANTIBIOTIC OINT
OTC
FIRST AID ANTIBIOTIC-PAIN RLF
OTC
FLAGYL ER
Brand
linezolid (100 mg/5ml susp recon, 600
mg tablet)
Generic
methenamine hippurate
Generic
metronidazole (0.75 % gel (gram), 0.75
% gel w/appl, 0.75 % lotion, 250 mg
tablet, 375 mg capsule, 500 mg tablet)
Generic
MONUROL
Brand
mupirocin 2% ointment
Generic
nitrofurantoin 25 mg/5 ml oral susp
Generic
nitrofurantoin macrocrystal (50 mg
Generic
nitrofurantoin
monohydrate/macrocrystals
Generic
Requirements/Limits
17
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
paroex
Generic
periogard
Generic
rosadan 0.75% gel
Generic
SIVEXTRO 200 MG TABLET
Specialty
tinidazole (250 mg tablet, 500 mg
tablet)
Generic
TRI-BIOZENE
OTC
trimethoprim 100 mg tablet
Generic
TRIPLE ANTIBIOTIC (, CVS, EQ, GNP, HM,
KRO, PUB, PV, RA, SB, SM)
OTC
TRIPLE ANTIBIOTIC EXTRA
OTC
TRIPLE ANTIBIOTIC PLUS
OTC
TRIPLE ANTIBIOTIC-PAIN RELIEF
OTC
vancomycin hcl (125 mg capsule, 250
mg capsule)
Generic
vandazole
Generic
XIFAXAN 200 MG TABLET
Brand
PA, QL (3 PER DAY)
XIFAXAN 550 MG TABLET
Brand
PA, QL (2 PER DAY)
PA
Beta-lactam, Cephalosporins
CEDAX 90 MG/5 ML SUSPENSION
Brand
cefaclor (125 mg/5ml susp recon, 250
mg/5ml susp recon, 250 mg capsule,
375 mg/5ml susp recon, 500 mg tab er
12h, 500 mg capsule)
Generic
cefadroxil (1 g tablet, 250 mg/5ml susp
recon, 500 mg capsule)
Generic
cefdinir (125 mg/5ml susp recon, 250
mg/5ml susp recon, 300 mg capsule)
Generic
cefpodoxime proxetil (100 mg tablet,
100 mg/5ml susp recon, 200 mg tablet)
Generic
cefprozil (125 mg/5ml susp recon, 250
mg tablet, 250 mg/5ml susp recon, 500
mg tablet)
Generic
18
LAST UPDATE 10/2016
Drug Name
Status*
ceftibuten (180 mg/5ml susp recon, 400
mg capsule)
Generic
CEFTIN (125 MG/5 ML ORAL SUSP, 250
MG/5 ML ORAL SUSP)
Brand
cefuroxime axetil
Generic
cephalexin (125 mg/5ml susp recon,
250 mg tablet, 250 mg capsule, 250
mg/5ml susp recon, 500 mg tablet, 500
mg capsule)
Generic
Requirements/Limits
Beta-lactam, Penicillins
amoxicillin (125 mg tab chew, 125
mg/5ml susp recon, 200 mg/5ml susp
recon, 250 mg capsule, 250 mg tab
chew, 250 mg/5ml susp recon, 400
mg/5ml susp recon, 500 mg tablet, 500
mg capsule, 875 mg tablet)
Generic
amoxicillin/potassium clavulanate (20028.5mg tab chew, 200-28.5/5 susp
recon, 250-125 mg tablet, 250-62.5/5
susp recon, 400-57mg tab chew, 40057mg/5 susp recon, 500-125 mg tablet,
600-42.9/5 susp recon, 875-125 mg
tablet, 1000-62.5 tab er 12h)
Generic
ampicillin trihydrate (125 mg/5ml susp
recon, 250 mg capsule, 250 mg/5ml
susp recon, 500 mg capsule)
Generic
AUGMENTIN 125-31.25 MG/5 ML
Brand
dicloxacillin sodium
Generic
penicillin v potassium (125 mg/5ml soln
recon, 250 mg tablet, 250 mg/5ml soln
recon, 500 mg tablet)
Generic
Macrolides
AKNE-MYCIN
Brand
azithromycin (100 mg/5ml susp recon,
200 mg/5ml susp recon, 250 mg tablet,
500 mg tablet, 600 mg tablet)
Generic
19
LAST UPDATE 10/2016
Drug Name
Status*
clarithromycin (125 mg/5ml susp recon,
250 mg/5ml susp recon, 250 mg tablet,
500 mg tab er 24h, 500 mg tablet)
Generic
DIFICID
Specialty
ery
Generic
ERY-TAB
Brand
erygel
Generic
ERYPED 400
Brand
ERYTHROCIN STEARATE
Brand
erythromycin base (5 mg/g oint. (g),
250 mg tablet, 250 mg capsule dr, 500
mg tablet)
Generic
erythromycin base/ethyl alcohol (2 %
med. swab, 2 % solution, 2 % gel
(gram))
Generic
erythromycin ethylsuccinate (200
mg/5ml susp recon, 400 mg tablet)
Generic
Requirements/Limits
PA
Quinolones
ciprofloxacin
Generic
ciprofloxacin hcl (0.3 % drops, 100 mg
tablet, 250 mg tablet, 500 mg tablet,
750 mg tablet)
Generic
ciprofloxacin/ciprofloxacin hcl
Generic
gatifloxacin
Generic
levofloxacin (0.5 % drops, 250mg/10ml
solution, 250 mg tablet, 500 mg tablet,
750 mg tablet)
Generic
moxifloxacin hcl 400 mg tablet
Generic
ofloxacin (0.3 % drops, 400 mg tablet)
Generic
Sulfonamides
bleph-10
Generic
silver sulfadiazine 1 % cream (g)
Generic
20
LAST UPDATE 10/2016
Drug Name
Status*
sulfacetamide sodium 10 % drops
Generic
sulfamethoxazole/trimethoprim (20040mg/5 oral susp, 400mg-80mg tablet,
800-160/20 oral susp, 800-160 mg
tablet)
Generic
sulfamide
Generic
Requirements/Limits
Tetracyclines
avidoxy
Generic
demeclocycline hcl
Generic
doxycycline hyclate (50 mg capsule, 100
mg capsule, 100 mg tablet)
Generic
doxycycline monohydrate (25 mg/5 ml
susp recon, 50 mg capsule, 50 mg
tablet, 75 mg tablet, 100 mg tablet, 100
mg capsule)
Generic
dynacin (50 mg tablet, 100 mg tablet)
Generic
minocycline hcl (50 mg tablet, 50 mg
capsule, 75 mg capsule, 75 mg tablet,
100 mg capsule, 100 mg tablet)
Generic
mondoxyne nl (nl 50 mg capsule, nl 100
mg capsule)
Generic
morgidox (50 mg capsule, 100 mg
capsule)
Generic
tetracycline hcl (250 mg capsule, 500
mg capsule)
Generic
VIBRAMYCIN 50 MG/5 ML SYRUP
Brand
Anticonvulsants
Anticonvulsants, Other
acetazolamide (125 mg tablet, 250 mg
tablet)
Generic
levetiracetam (100 mg/ml solution, 250
mg tablet, 500 mg tab er 24h, 500
mg/5ml solution, 500 mg tablet, 750
mg tab er 24h, 750 mg tablet, 1000 mg
tablet)
Generic
(ELIGIBLE FOR 90 DAY SUPPLY)
21
LAST UPDATE 10/2016
Drug Name
Status*
primidone (50 mg tablet, 250 mg tablet)
Generic
roweepra
Generic
Requirements/Limits
Calcium Channel Modifying Agents
CELONTIN
Brand
ethosuximide (250 mg/5ml solution,
250 mg capsule)
Generic
LYRICA (20 MG/ML ORAL SOLUTION, 25
MG CAPSULE, 50 MG CAPSULE, 75 MG
CAPSULE, 100 MG CAPSULE, 150 MG
CAPSULE, 200 MG CAPSULE, 225 MG
CAPSULE, 300 MG CAPSULE)
Brand
zonisamide (25 mg capsule, 50 mg
Generic
PA
Gamma-aminobutyric Acid (GABA) Augmenting Agents
DIASTAT
Brand
diazepam (5-7.5-10mg kit, 12.5-15-20
kit)
Generic
DIAZEPAM 2.5 MG KIT
Brand
gabapentin (100 mg capsule, 250
mg/5ml solution, 300 mg capsule, 400
mg capsule, 600 mg tablet, 800 mg
tablet)
Generic
GABITRIL (12 MG TABLET, 16 MG
TABLET)
Brand
ONFI (5 MG TABLET, 10 MG TABLET, 20
MG TABLET)
Brand
PA, QL (2 PER DAY)
ONFI 2.5 MG/ML SUSPENSION
Brand
PA
phenobarbital (15 mg tablet, 16.2 mg
tablet, 20 mg/5 ml elixir, 30 mg tablet,
32.4 mg tablet, 60 mg tablet, 64.8 mg
tablet, 97.2mg tablet, 100 mg tablet)
Generic
SABRIL
Specialty
tiagabine hcl
Generic
LA
22
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
Glutamate Reducing Agents
felbamate (400 mg tablet, 600 mg
tablet, 600 mg/5ml oral susp)
Generic
topiragen
Generic
topiramate (15 mg cap sprink, 25 mg
cap sprink, 25 mg tablet, 50 mg tablet,
Generic
topiramate (25 mg cap spr 24, 50 mg
cap spr 24, 100 mg cap spr 24, 150 mg
cap spr 24, 200 mg cap spr 24)
Generic
PA
Sodium Channel Agents
APTIOM
Brand
BANZEL (40 MG/ML SUSPENSION, 200
MG TABLET, 400 MG TABLET)
Brand
carbamazepine (100 mg tab er 12h, 100
mg cpmp 12hr, 100 mg tab chew, 100
mg/5ml oral susp, 200 mg tablet, 200
mg tab er 12h, 200 mg cpmp 12hr, 300
mg cpmp 12hr, 400 mg tab er 12h)
Generic
DILANTIN 30 MG CAPSULE
Brand
epitol
Generic
oxcarbazepine (150 mg tablet, 300 mg
tablet, 300 mg/5ml oral susp, 600 mg
tablet)
Generic
PEGANONE
Brand
phenytoin (50 mg tab chew, 100
mg/4ml oral susp, 125 mg/5ml oral
susp)
Generic
phenytoin sodium extended
Generic
VIMPAT (10 MG/ML SOLUTION, 50 MG
TABLET, 100 MG TABLET, 150 MG
Brand
23
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
Antidementia Agents
Cholinesterase Inhibitors
donepezil hcl (5 mg tab rapdis, 5 mg
tablet, 10 mg tablet, 10 mg tab rapdis)
Generic
galantamine hbr (4 mg tablet, 4 mg/ml
solution, 8 mg tablet, 12 mg tablet)
Generic
rivastigmine
Generic
rivastigmine tartrate
Generic
QL (2 PER DAY)
N-methyl-D-aspartate (NMDA) Receptor Antagonist
memantine hcl (5 mg tablet, 10 mg
tablet)
Generic
QL (2 PER DAY)
memantine hcl 2 mg/ml solution
Generic
QL (10 ML PER DAY)
memantine hcl 5 mg-10 mg tab ds pk
Generic
Antidepressants
Antidepressants, Other
budeprion sr 150 mg tablet
Generic
Antiemetics
Antiemetics, Other
AMBIZINE
OTC
compro
Generic
DICLEGIS
Brand
DRAMAMINE LESS DROWSY
OTC
hydroxyzine hcl (10 mg tablet, 10 mg/5
ml solution, 25 mg tablet, 50 mg tablet)
Generic
hydroxyzine pamoate (25 mg capsule,
50 mg capsule, 100 mg capsule)
Generic
meclizine hcl (12.5 mg tablet, 25 mg
tablet)
Generic
QL (2 PER DAY)
24
LAST UPDATE 10/2016
Drug Name
Status*
MECLIZINE HCL 25 MG TAB CHEW
OTC
MEDI-MECLIZINE
OTC
metoclopramide hcl (5 mg tablet, 5
mg/5 ml solution, 10 mg tablet, 10
mg/10ml solution)
Generic
MOTION RELIEF
OTC
MOTION SICKNESS (GNP SICKNES 25
MG TAB, SICKNESS 25 MG TABLET, SM
SICKNES 25 MG TABLET, SM SICKNESS
25 MG TAB)
OTC
MOTION SICKNESS II
OTC
MOTION SICKNESS RELIEF (CVS RELIEF
TAB, EQ 25 MG TAB, EQL 25 MG TAB,
RA RELIEF TAB, RA RLF TB CHEW, RELIEF
TB CHEW)
OTC
MOTION SICKNESS RELIEF II
OTC
MOTION-TIME
OTC
phenadoz
Generic
prochlorperazine
Generic
prochlorperazine maleate (5 mg tablet,
10 mg tablet)
Generic
promethazine hcl (6.25mg/5ml syrup,
12.5 mg supp.rect, 12.5 mg tablet, 25
mg tablet, 25 mg/ml vial, 25 mg
supp.rect, 50 mg supp.rect, 50 mg
tablet)
Generic
promethegan
Generic
trimethobenzamide hcl 300 mg capsule
Generic
VERTICALM
OTC
Requirements/Limits
Emetogenic Therapy Adjuncts
EMEND (125 MG POWDER PACKET, 125
MG CAPSULE)
Brand
QL (2 PER 30 DAYS)
EMEND 80 MG CAPSULE
Brand
QL (4 PER 30 DAYS)
EMEND TRIPACK
Brand
QL (6 PER 30 DAYS)
25
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
granisetron hcl 1 mg tablet
Generic
QL (8 PER 30 DAYS)
ondansetron 8 mg tab rapdis
Generic
ondansetron hcl (4 mg/5 ml solution, 4
mg tablet, 8 mg tablet, 24 mg tablet)
Generic
ondansetron odt
Generic
Antifungals
1-DAY
OTC
3 DAY VAGINAL
OTC
3-DAY VAGINAL CREAM (CVS 3-DAY
CREAM, SM 3-DAY CREAM, V-R 3-DAY
CREAM)
OTC
ANTI-FUNGAL CREAM
OTC
ANTIFUNGAL (1% CREAM, EQL 1%
CREAM, GNP 1% CREAM, SM 1%
CREAM)
OTC
ANTIFUNGAL CREAM
OTC
ATHLETE'S FOOT (EQ 1% CREAM, 2%
POWDER)
OTC
ATHLETE'S FOOT CREAM
OTC
ATHLETE'S FOOT SPRAY
OTC
ATHLETIC FOOT CREAM
OTC
BAZA ANTIFUNGAL
OTC
ciclodan 0.77% cream
Generic
ciclopirox (0.77 % gel (gram), 1 %
shampoo)
Generic
ciclopirox olamine (0.77 % cream (g),
0.77 % suspension)
Generic
clotrimazole (1 % cream (g), 1 %
solution, 10 mg troche)
Generic
CLOTRIMAZOLE (1 % CREAM/APPL, 2 %
CREAM/APPL, 100 MG TABLET)
OTC
CLOTRIMAZOLE AF
OTC
26
LAST UPDATE 10/2016
Drug Name
Status*
CVS ANTI-FUNGAL 2% POWDER
OTC
CVS ITCH RELIEF 1% CREAM
OTC
DESENEX (2% POWDER, 2% SPRAY
POWDER)
OTC
econazole nitrate 1 % cream (g)
Generic
fluconazole (10 mg/ml susp recon, 40
mg/ml susp recon, 50 mg tablet, 100
mg tablet, 150 mg tablet, 200 mg
tablet)
Generic
flucytosine (250 mg capsule, 500 mg
capsule)
Generic
FUNGOID-D
OTC
griseofulvin ultramicrosize
Generic
griseofulvin, microsize (125 mg/5ml oral
susp, 500 mg tablet)
Generic
GYNE-LOTRIMIN
OTC
GYNE-LOTRIMIN-7
OTC
INZO ANTIFUNGAL
OTC
itraconazole 100 mg capsule
Generic
JOCK ITCH (EQ 1% CREAM, 1% CREAM)
OTC
JOCK ITCH RELIEF
OTC
ketoconazole (2 % cream (g), 2 % foam,
2 % shampoo)
Generic
ketodan 2% foam
Generic
LOTRIMIN AF (1% CREAM, 2% SPRAY
POWDER, 2% POWDER)
OTC
MICATIN
OTC
MICONAZOLE NITRATE (2 % CREAM (G),
2 % CREAM/APPL, 2 % AERO POWD,
100 MG SUPP.VAG, 200 MG-2 % KIT,
200 MG-2 % CMB PF CRM, POWDER)
OTC
miconazole nitrate 200 mg supp.vag
Generic
MICONAZORB AF
OTC
Requirements/Limits
PA
27
LAST UPDATE 10/2016
Drug Name
Status*
MICRO-GUARD
OTC
MONISTAT 3 (3 4% CREAM, 3 COMBO
PACK)
OTC
NOXAFIL (40 MG/ML SUSPENSION, DR
100 MG TABLET)
Specialty
NUZOLE
OTC
nyamyc
Generic
nystatin (50mm unit powder(ea),
150mm unit powder(ea), 500mm unit
powder(ea), 500k unit tablet,
100000/ml oral susp, 100000/g powder,
100000/g cream (g), 100000/g oint. (g))
Generic
nystop
Generic
REMEDY ANTIFUNGAL (2% POWDER,
2% CREAM)
OTC
REMEDY PHYTOPLEX ANTIFUNGAL 2%
OTC
RINGWORM
OTC
SECURA ANTIFUNGAL
OTC
SPORANOX 10 MG/ML SOLUTION
Brand
terbinafine hcl 250 mg tablet
Generic
terconazole (0.4 % cream/appl, 0.8 %
cream/appl, 80 mg supp.vag)
Generic
TIOCONAZOLE
OTC
TIOCONAZOLE 1
OTC
TIOCONAZOLE-1
OTC
TOLNAFTATE 1 % CREAM (G)
OTC
VAGISTAT-3
OTC
voriconazole (50 mg tablet, 200 mg
tablet, 200 mg/5ml susp recon)
Generic
ZEASORB 2% POWDER
OTC
Requirements/Limits
PA
PA
PA
28
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
Antigout Agents
allopurinol (100 mg tablet, 300 mg
tablet)
Generic
COLCHICINE 0.6 MG TABLET
Brand
colchicine/probenecid
Generic
COLCRYS
Brand
probenecid
Generic
QL (2 PER DAY)
QL (2 PER DAY)
Antimigraine Agents
Ergot Alkaloids
cafergot
Generic
DIHYDROERGOTAMINE MESYLATE
0.5MG/SPRY SPRAY/PUMP
Brand
migergot
Generic
MIGRANAL
Brand
QL (8 ML PER 30 DAYS)
Serotonin (5-HT) 1b/1d Receptor Agonists
frovatriptan succinate
Generic
QL (9 PER 30 DAYS)
naratriptan hcl
Generic
ST, QL (9 PER 30 DAYS)
rizatriptan benzoate
Generic
QL (9 PER 30 DAYS)
sumatriptan (5 mg spray, 20 mg spray)
Generic
QL (6 PER 30 DAYS)
sumatriptan succinate (25 mg tablet, 50
mg tablet, 100 mg tablet)
Generic
QL (9 PER 30 DAYS)
sumatriptan succinate (4 mg/0.5ml
cartridge, 6 mg/0.5ml pen injctr, 6
mg/0.5ml syringe, 6 mg/0.5ml
cartridge, 6 mg/0.5ml vial)
Generic
sumatriptan succinate 4 mg/0.5ml pen
injctr
Generic
zolmitriptan (2.5 mg tab rapdis, 2.5 mg
tablet)
Generic
zolmitriptan (5 mg tab rapdis, 5 mg
tablet)
Generic
29
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
ZOMIG 2.5 MG NASAL SPRAY
Brand
QL (12 PER 30 DAYS)
ZOMIG 5 MG NASAL SPRAY
Brand
QL (6 PER 30 DAYS)
Antimyasthenic Agents
Parasympathomimetics
MESTINON 60 MG/5 ML SYRUP
Brand
pyridostigmine bromide (60 mg tablet,
180 mg tablet er)
Generic
Antimycobacterials
Antimycobacterials, Other
dapsone (25 mg tablet, 100 mg tablet)
Generic
rifabutin
Generic
Antituberculars
ethambutol hcl
Generic
isoniazid (50 mg/5 ml solution, 100 mg
Generic
pyrazinamide 500 mg tablet
Generic
RIFAMATE
Brand
rifampin (150 mg capsule, 300 mg
capsule)
Generic
SIRTURO
Specialty
LA
ALKERAN 2 MG TABLET
Brand
PA
CEENU
Brand
CYCLOPHOSPHAMIDE CAPSULES
Brand
GLEOSTINE
Brand
Antineoplastics
Alkylating Agents
30
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
LEUKERAN
Brand
LOMUSTINE
Brand
MATULANE
Specialty
MYLERAN
Brand
TEMOZOLOMIDE
Specialty
PA
VALCHLOR
Specialty
LA
POMALYST
Specialty
PA
REVLIMID
Specialty
PA, LA
THALOMID
Specialty
Antiangiogenic Agents
Antiestrogens/Modifiers
EMCYT
Specialty
FARESTON
Specialty
SOLTAMOX
Brand
tamoxifen citrate (10 mg tablet, 20 mg
tablet)
Generic
Antimetabolites
capecitabine
Generic
DROXIA
Brand
hydroxyurea 500 mg capsule
Generic
mercaptopurine 50 mg tablet
Generic
methotrexate sodium (2.5 mg tablet, 25
mg/ml vial)
Generic
methotrexate sodium/pf (1 g vial, 25
mg/ml vial)
Generic
PURIXAN
Brand
RHEUMATREX
Brand
TABLOID
Brand
TREXALL
Brand
31
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
FARYDAK
Specialty
PA, QL (6 PER 21 DAYS)
flutamide
Generic
HEXALEN
Specialty
imiquimod 5 % cream pack
Generic
INTRON A (10 MILLION UNITS VIL, 18
MILLION UNIT/3 ML, 18 MILLION UNITS
VIL, 25 MILLION UNIT/2.5ML, 50
MILLION UNITS VIL)
Specialty
IRESSA
Specialty
leucovorin calcium 5 mg tablet
Generic
LONSURF 15 MG-6.14 MG TABLET
Specialty
LONSURF 20 MG-8.19 MG TABLET
Specialty
SYLATRON
Specialty
PA
SYLATRON 4-PACK
Specialty
PA
SYNRIBO
Specialty
PA
Antineoplastics, Other
PA, QL (1 PER DAY)
Aromatase Inhibitors, 3rd Generation
anastrozole 1 mg tablet
Generic
exemestane
Generic
letrozole 2.5 mg tablet
Generic
Enzyme Inhibitors
BOSULIF
Specialty
PA
etoposide 50 mg capsule
Generic
GILOTRIF
Specialty
HYCAMTIN (0.25 MG CAPSULE, 1 MG
CAPSULE)
Specialty
IMBRUVICA
Specialty
PA
INLYTA
Specialty
PA, LA
JAKAFI
Specialty
PA, LA
PA
32
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
LYNPARZA
Specialty
PA, LA
MEKINIST
Specialty
PA
TAFINLAR
Specialty
PA
VOTRIENT
Specialty
PA
ZELBORAF
Specialty
PA
ZYTIGA
Specialty
PA
AFINITOR
Specialty
PA
AFINITOR DISPERZ
Specialty
PA
ALECENSA
Specialty
PA
CABOMETYX
Specialty
PA
CAPRELSA
Specialty
PA
COMETRIQ
Specialty
PA, LA
COTELLIC
Specialty
ERIVEDGE
Specialty
PA
IBRANCE
Specialty
PA
ICLUSIG
Specialty
PA
IMATINIB MESYLATE
Specialty
PA
LENVIMA
Specialty
PA, LA
NEXAVAR
Specialty
PA
NINLARO
Specialty
PA
ODOMZO
Specialty
PA
SPRYCEL
Specialty
PA
STIVARGA
Specialty
PA
SUTENT
Specialty
PA
TAGRISSO
Specialty
PA
TARCEVA
Specialty
PA
TASIGNA
Specialty
PA
Molecular Target Inhibitors
33
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
TYKERB
Specialty
PA
VANDETANIB
Specialty
PA
VENCLEXTA
Specialty
PA
VENCLEXTA STARTING PACK
Specialty
PA
XALKORI
Specialty
PA, LA
ZOLINZA
Specialty
PA
ZYDELIG
Specialty
PA, QL (2 PER DAY)
ZYKADIA
Specialty
PA
BEXAROTENE
Specialty
PA
TARGRETIN (1% GEL, 75 MG SOFTGEL,
75 MG CAPSULE)
Specialty
PA
TRETINOIN 10 MG CAPSULE
Specialty
PA
ALBENZA
Brand
PA
ivermectin 3 mg tablet
Generic
Retinoids
Antiparasitics
Anthelmintics
Antiprotozoals
ATOVAQUONE
Specialty
PA
chloroquine phosphate (250 mg tablet,
500 mg tablet)
Generic
PA
DARAPRIM
Brand
PA, LA
hydroxychloroquine sulfate 200 mg
tablet
Generic
mefloquine hcl
Generic
NEBUPENT
Brand
primaquine phosphate
Generic
PA
PA
34
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
Pediculicides/Scabicides
elimite
Generic
emverm
Generic
LICE CREAM RINSE
OTC
LICE KILLING (EQ SHAMPOO, KRO
SHAMPOO, SM SHAMPOO, V-R
SHAMPOO)
OTC
LICE TREATMENT (GNP 1% CRM RINS,
HM 1% CRM RINSE, HM 1% LOTION, PV
PERMETHRIN, RA 1% CRM RINSE, SM
1% CRM RINSE, 1% CREME RINSE, SM
PERMETHRIN)
OTC
lindane
Generic
PERMETHRIN 1 % LIQUID
OTC
permethrin 5 % cream (g)
Generic
ULESFIA
Brand
PA
Antiparkinson Agents
Anticholinergics
benztropine mesylate (0.5 mg tablet, 1
Generic
trihexyphenidyl hcl (2 mg/5 ml elixir, 2
Generic
Antiparkinson Agents, Other
amantadine hcl (50 mg/5 ml solution,
100 mg tablet, 100 mg capsule)
Generic
carbidopa/levodopa/entacapone
Generic
entacapone
Generic
Dopamine Agonists
bromocriptine mesylate (2.5 mg tablet,
5 mg capsule)
Generic
35
LAST UPDATE 10/2016
Drug Name
Status*
pramipexole di-hcl (0.125 mg tablet,
0.25 mg tablet, 0.5 mg tablet, 0.75 mg
tablet, 1 mg tablet, 1.5 mg tablet)
Generic
ropinirole hcl (0.25 mg tablet, 0.5 mg
tablet, 1 mg tablet, 2 mg tablet, 3 mg
Generic
Requirements/Limits
Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors
carbidopa 25 mg tablet
Generic
carbidopa/levodopa (10mg-100mg
tablet, 25mg-250mg tablet, 25mg100mg tablet er, 25mg-100mg tablet,
50mg-200mg tablet er)
Generic
Monoamine Oxidase B (MAO-B) Inhibitors
AZILECT
Brand
selegiline hcl (5 mg tablet, 5 mg
capsule)
Generic
Antispasticity Agents
baclofen (10 mg tablet, 20 mg tablet)
Generic
dantrolene sodium (25 mg capsule, 50
mg capsule, 100 mg capsule)
Generic
MYRBETRIQ
Brand
tizanidine hcl (2 mg tablet, 4 mg tablet)
Generic
PA
Antivirals
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors
EDURANT
Brand
INTELENCE
Brand
nevirapine (50 mg/5 ml oral susp, 100
mg tab er 24h, 200 mg tablet, 400 mg
tab er 24h)
Generic
ODEFSEY
Brand
RESCRIPTOR 100 MG TABLET
Brand
36
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
SUSTIVA
Brand
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors
abacavir sulfate
Generic
abacavir sulfate/lamivudine
Generic
abacavir sulfate/lamivudine/zidovudine
Generic
COMPLERA
Brand
DESCOVY
Brand
didanosine
Generic
EMTRIVA 200 MG CAPSULE
Brand
lamivudine (10 mg/ml solution, 150 mg
Generic
lamivudine/zidovudine
Generic
stavudine (1 mg/ml soln recon, 15 mg
capsule, 20 mg capsule, 30 mg capsule,
40 mg capsule)
Generic
TRUVADA
Brand
VIDEX
Brand
VIREAD (150 MG TABLET, 200 MG
TABLET, POWDER)
Brand
ZIAGEN 20 MG/ML SOLUTION
Brand
zidovudine (10 mg/ml syrup, 100 mg
capsule, 300 mg tablet)
Generic
ATRIPLA
Brand
FUZEON
Brand
GENVOYA
Brand
ISENTRESS (100 MG POWDER PACKET,
400 MG TABLET)
Brand
SELZENTRY
Brand
STRIBILD
Brand
Anti-HIV Agents, Other
37
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
TIVICAY
Brand
TRIUMEQ
Brand
TYBOST
Brand
VITEKTA
Brand
APTIVUS 250 MG CAPSULE
Brand
CRIXIVAN
Brand
EVOTAZ
Brand
INVIRASE
Brand
KALETRA (100-25 MG TABLET, 200-50
MG TABLET, 400-100/5 ML ORAL SOLU)
Brand
LEXIVA 700 MG TABLET
Brand
NORVIR (80 MG/ML SOLUTION, 100 MG
TABLET, 100 MG SOFTGEL CAP)
Brand
PREZCOBIX
Brand
PREZISTA (75 MG TABLET, 100 MG/ML
SUSPENSION, 150 MG TABLET, 400 MG
TABLET)
Brand
REYATAZ
Brand
VIRACEPT
Brand
VALGANCICLOVIR HCL 450 MG TABLET
Specialty
QL (2 PER DAY)
VALGANCICLOVIR HCL 50 MG/ML SOLN
RECON
Specialty
QL (18 ML PER DAY)
ZIRGAN
Brand
Anti-HIV Agents, Protease Inhibitors
Anti-cytomegalovirus (CMV) Agents
Anti-influenza Agents
RELENZA
Brand
rimantadine hcl
Generic
TAMIFLU (6 MG/ML SUSPENSION, 30
MG CAPSULE, 45 MG CAPSULE, 75 MG
CAPSULE)
Brand
38
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
ADEFOVIR DIPIVOXIL
Specialty
QL (1 PER DAY)
BARACLUDE 0.05 MG/ML SOLUTION
Specialty
DAKLINZA
Specialty
ENTECAVIR
Specialty
EPCLUSA
Specialty
EPIVIR HBV 25 MG/5 ML SOLN
Brand
HARVONI
Specialty
INCIVEK
Specialty
INFERGEN
Specialty
lamivudine 100 mg tablet
Generic
MODERIBA
Specialty
OLYSIO
Specialty
PEGASYS (180 MCG/ML VIAL, 180
MCG/0.5 ML SYRINGE)
Specialty
PEGASYS PROCLICK
Specialty
PEGINTRON
Specialty
PEGINTRON REDIPEN
Specialty
REBETOL 40 MG/ML SOLUTION
Specialty
RIBAPAK
Specialty
RIBASPHERE
Specialty
RIBASPHERE RIBAPAK
Specialty
RIBATAB
Specialty
RIBAVIRIN (200 MG CAPSULE, 200 MG
TABLET)
Specialty
SOVALDI
Specialty
PA, QL (1 PER DAY)
TYZEKA
Specialty
QL (1 PER DAY)
VIEKIRA PAK
Specialty
PA, QL (4 PER DAY)
Antihepatitis Agents
PA, QL (1 PER DAY)
PA, QL (1 PER DAY)
PA, QL (1 PER DAY)
PA, QL (1 PER DAY)
39
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
VIEKIRA XR
Specialty
PA, QL (3 PER DAY)
ZEPATIER
Specialty
PA, QL (1 PER DAY)
Antiherpetic Agents
acyclovir (200 mg capsule, 200 mg/5ml
oral susp, 400 mg tablet, 800 mg tablet)
Generic
DENAVIR
Brand
famciclovir
Generic
trifluridine 1 % drops
Generic
valacyclovir hcl (500 mg tablet, 1000
mg tablet)
Generic
PA
Anxiolytics
Anxiolytics, Other
clonazepam (0.125 mg tab rapdis, 0.25
mg tab rapdis, 0.5 mg tablet, 0.5 mg
tab rapdis, 1 mg tab rapdis, 1 mg
tablet, 2 mg tab rapdis, 2 mg tablet)
Generic
Blood Glucose Regulators
Antidiabetic Agents
acarbose
Generic
ACTOPLUS MET XR
Brand
ALOGLIPTIN BENZOATE
Brand
PA, QL (1 PER DAY), (ELIGIBLE FOR 90
DAY SUPPLY)
ALOGLIPTIN BENZOATE/METFORMIN
HCL
Brand
PA, (ELIGIBLE FOR 90 DAY SUPPLY)
ALOGLIPTIN BENZOATE/PIOGLITAZONE
HCL
Brand
DAY SUPPLY)
BYDUREON
Brand
ST, (ELIGIBLE FOR 90 DAY SUPPLY)
BYDUREON PEN
Brand
BYETTA
Brand
40
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
chlorpropamide
Generic
FARXIGA
Brand
glimepiride
Generic
glipizide (2.5 mg tab er 24, 5 mg tablet,
5 mg tab er 24, 10 mg tab er 24, 10 mg
tablet)
Generic
glipizide/metformin hcl
Generic
glyburide (1.25 mg tablet, 2.5 mg
Generic
glyburide,micronized
Generic
glyburide/metformin hcl
Generic
GLYXAMBI
Brand
INVOKAMET
Brand
INVOKAMET XR
Brand
PA
INVOKANA
Brand
JANUMET
Brand
JANUMET XR (50-500 MG TABLET, 1001,000 MG TABLET)
Brand
DAY SUPPLY)
JANUMET XR 50-1,000 MG TABLET
Brand
PA, QL (2 PER 2 DAYS), (ELIGIBLE FOR
90 DAY SUPPLY)
JANUVIA
Brand
DAY SUPPLY)
JARDIANCE
Brand
JENTADUETO
Brand
JENTADUETO XR
Brand
PA
KAZANO
Brand
KOMBIGLYZE XR (5-1,000 MG TAB, 5500 MG TABLET)
Brand
DAY SUPPLY)
KOMBIGLYZE XR 2.5-1,000 MG TAB
Brand
PA, QL (2 PER 2 DAYS), (ELIGIBLE FOR
90 DAY SUPPLY)
metformin hcl (500 mg tablet, 750 mg
tab er 24h, 850 mg tablet, 1000 mg
tablet)
Generic
41
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
metformin hcl 500 mg tab er 24h
(generic for glucophage xr)
Generic
NESINA
Brand
DAY SUPPLY)
ONGLYZA
Brand
DAY SUPPLY)
OSENI
Brand
DAY SUPPLY)
pioglitazone hcl
Generic
pioglitazone hcl/glimepiride
Generic
pioglitazone hcl/metformin hcl
Generic
RIOMET
Brand
SYMLINPEN 120
Brand
SYMLINPEN 60
Brand
SYNJARDY
Brand
tolazamide
Generic
TRADJENTA
Brand
DAY SUPPLY)
VICTOZA 2-PAK
Brand
ST, QL (9 ML PER 30 DAYS), (ELIGIBLE
FOR 90 DAY SUPPLY)
VICTOZA 3-PAK
Brand
ST, QL (9 ML PER 30 DAYS), (ELIGIBLE
FOR 90 DAY SUPPLY)
XIGDUO XR
Brand
GLUCAGEN 1MG HYPOKIT
Brand
GLUCAGON EMERGENCY KIT
Brand
HUMALOG
Brand
HUMALOG KWIKPEN U-100
Brand
Brand
HUMALOG MIX 50-50
Brand
Glycemic Agents
Insulins
42
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
HUMALOG MIX 50-50 KWIKPEN
Brand
HUMALOG MIX 75-25
Brand
Brand
HUMULIN 70-30
OTC
HUMULIN 70/30 KWIKPEN
OTC
HUMULIN N
OTC
HUMULIN N KWIKPEN
OTC
HUMULIN R
OTC
HUMULIN R U-500
Brand
HUMULIN R U-500 KWIKPEN
Brand
LANTUS
Brand
LANTUS SOLOSTAR
Brand
LEVEMIR
Brand
LEVEMIR FLEXTOUCH
Brand
TOUJEO SOLOSTAR
Brand
TRESIBA FLEXTOUCH U-100
Brand
Brand
Blood Products/Modifiers/Volume Expanders
Anticoagulants
ELIQUIS
Brand
enoxaparin sodium
Generic
fondaparinux sodium
Generic
FRAGMIN
Specialty
heparin 50 units/5 ml (10/ml)
Generic
heparin sodium,porcine (10 unit/ml vial,
10 unit/ml syringe, 100/ml (1) syringe,
100/ml vial, 500/5 ml syringe, 1000/ml
vial, 5000/ml vial, 10000/ml vial,
20000/ml vial)
Generic
43
LAST UPDATE 10/2016
Drug Name
Status*
heparin sodium,porcine/pf (10 unit/ml
syringe, 10 unit/ml vial, 100/ml (1) vial,
500/5 ml syringe, 1000/10 ml syringe,
1000/ml vial)
Generic
jantoven
Generic
monoject prefill advanced (30 units/3
ml (10/ml), 100 unit/10 ml (10/ml), 500
unit/5 ml (100/ml), 1,000 unit/10
(100/ml))
Generic
PRADAXA
Brand
SAVAYSA
Brand
warfarin sodium (1 mg tablet, 2 mg
tablet, 2.5 mg tablet, 3 mg tablet, 4 mg
tablet, 5 mg tablet, 6 mg tablet, 7.5 mg
Generic
XARELTO
Brand
Requirements/Limits
Blood Formation Modifiers
anagrelide hcl
Generic
ARANESP
Specialty
PA
EPOGEN
Specialty
PA
GRANIX
Brand
LEUKINE (250 MCG VIAL, 500 MCG/ML
VIAL)
Specialty
NEULASTA
Specialty
NEUMEGA
Specialty
NEUPOGEN
Specialty
PROCRIT
Specialty
PA
PROMACTA
Specialty
PA
Coagulants
tranexamic acid 650 mg tablet
Generic
44
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
Platelet Modifying Agents
AGGRENOX
Brand
ASPIRIN/DIPYRIDAMOLE
Brand
BRILINTA
Brand
cilostazol
Generic
clopidogrel bisulfate 75 mg tablet
Generic
dipyridamole (25 mg tablet, 50 mg
Generic
EFFIENT
Brand
ticlopidine hcl
Generic
Cardiovascular Agents
Alpha-adrenergic Agonists
clonidine
Generic
clonidine hcl (0.1 mg tablet, 0.2 mg
tablet, 0.3 mg tablet)
Generic
guanfacine hcl (1 mg tablet, 2 mg
tablet)
Generic
methyldopa
Generic
midodrine hcl (2.5 mg tablet, 5 mg
tablet)
Generic
Alpha-adrenergic Blocking Agents
doxazosin mesylate (1 mg tablet, 2 mg
Generic
PHENOXYBENZAMINE HCL 10 MG
CAPSULE
Specialty
prazosin hcl (1 mg capsule, 2 mg
Generic
reserpine (0.1 mg tablet, 0.25 mg
tablet)
Generic
terazosin hcl
Generic
45
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
candesartan cilexetil
Generic
eprosartan mesylate
Generic
irbesartan
Generic
losartan potassium
Generic
telmisartan (20 mg tablet, 40 mg
tablet)
Generic
QL (1 PER DAY), (ELIGIBLE FOR 90 DAY
SUPPLY)
telmisartan 80 mg tablet
Generic
valsartan
Generic
Angiotensin II Receptor Antagonists
Angiotensin-converting Enzyme (ACE) Inhibitors
benazepril hcl (5 mg tablet, 10 mg
Generic
captopril (12.5 mg tablet, 25 mg tablet,
Generic
enalapril maleate (2.5 mg tablet, 5 mg
Generic
EPANED
Brand
fosinopril sodium
Generic
lisinopril (2.5 mg tablet, 5 mg tablet, 10
mg tablet, 20 mg tablet, 30 mg tablet,
40 mg tablet)
Generic
moexipril hcl
Generic
perindopril erbumine
Generic
quinapril hcl
Generic
ramipril
Generic
trandolapril 1 mg tablet
Generic
amiodarone hcl (100 mg tablet, 200 mg
Generic
disopyramide phosphate
Generic
dofetilide
Generic
Antiarrhythmics
46
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
flecainide acetate
Generic
mexiletine hcl (150 mg capsule, 200 mg
Generic
MULTAQ
Brand
NORPACE CR
Brand
pacerone 200 mg tablet
Generic
propafenone hcl (150 mg tablet, 225
Generic
quinidine gluconate 324 mg tablet er
Generic
quinidine sulfate (200 mg tablet, 300
mg tablet er, 300 mg tablet)
Generic
sorine
Generic
sotalol hcl (80 mg tablet, 120 mg tablet,
Generic
verapamil hcl (40 mg tablet, 80 mg
Generic
acebutolol hcl (200 mg capsule, 400 mg
capsule)
Generic
atenolol (25 mg tablet, 50 mg tablet,
100 mg tablet)
Generic
betaxolol hcl (10 mg tablet, 20 mg
tablet)
Generic
bisoprolol fumarate
Generic
carvedilol
Generic
COREG CR
Brand
esmolol hcl 100mg/10ml vial
Generic
INDERAL XL
Brand
INNOPRAN XL
Brand
labetalol hcl (100 mg tablet, 200 mg
Generic
LEVATOL
Brand
Beta-adrenergic Blocking Agents
47
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
metoprolol succinate
Generic
metoprolol tartrate (25 mg tablet, 37.5
100 mg tablet)
Generic
nadolol (20 mg tablet, 40 mg tablet, 80
mg tablet)
Generic
pindolol
Generic
propranolol hcl (10 mg tablet, 20 mg/5
ml solution, 20 mg tablet, 40 mg tablet,
40mg/5ml solution, 60 mg cap sa 24h,
60 mg tablet, 80 mg tablet, 80 mg cap
sa 24h, 120 mg cap sa 24h, 160 mg cap
sa 24h)
Generic
timolol maleate (5 mg tablet, 10 mg
Generic
afeditab cr
Generic
amlodipine besylate (2.5 mg tablet, 5
Generic
CARDIZEM LA 120 MG TABLET
Brand
cartia xt
Generic
dilt-cd
Generic
dilt-xr
Generic
Calcium Channel Blocking Agents
48
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
diltiazem hcl (30 mg tablet, 60 mg cap
er 12h, 60 mg tablet, 90 mg cap er 12h,
90 mg tablet, 120 mg cap er 12h, 120
mg cap er 24h, 120 mg cap er deg, 120
mg capsule er, 120 mg tablet, 180 mg
cap er 24h, 180 mg capsule er, 180 mg
tab er 24h, 180 mg cap er deg, 240 mg
tab er 24h, 240 mg cap er deg, 240 mg
capsule er, 300 mg cap er 24h, 360 mg
tab er 24h, 420 mg tab er 24h, 420 mg
capsule er)
Generic
diltiazem hcl 300 mg tab er 24h
Generic
felodipine
Generic
matzim la (180 mg tablet, 240 mg
Generic
matzim la 300 mg tablet
Generic
nicardipine hcl (20 mg capsule, 30 mg
capsule)
Generic
nifediac cc
Generic
nifedical xl
Generic
nifedipine (10 mg capsule, 20 mg
capsule, 30 mg tab er 24, 30 mg tablet
er, 60 mg tablet er, 60 mg tab er 24, 90
mg tab er 24, 90 mg tablet er)
Generic
nimodipine 30 mg capsule
Generic
nisoldipine (8.5mg tab er 24h, 17 mg
tab er 24h, 25.5 mg tab er 24h, 34 mg
tab er 24h)
Generic
taztia xt
Generic
verapamil hcl (100 mg cap24h pct, 120
mg tablet er, 120 mg cap24h pel, 180
mg cap24h pel, 180 mg tablet er, 200
mg cap24h pct, 240 mg cap24h pel, 240
mg tablet er, 300 mg cap24h pct, 360
mg cap24h pel)
Generic
49
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
amiloride hcl/hydrochlorothiazide
Generic
amlodipine besylate/atorvastatin
calcium
Generic
amlodipine besylate/benazepril hcl (5
mg-40 mg capsule, 10 mg-40mg
capsule)
Generic
amlodipine besylate/valsartan
Generic
atenolol/chlorthalidone
Generic
benazepril hcl/hydrochlorothiazide
Generic
bisoprolol
fumarate/hydrochlorothiazide
Generic
captopril/hydrochlorothiazide
Generic
clorpres
Generic
CORLANOR
Brand
digitek
Generic
digox
Generic
digoxin (50 mcg/ml solution, 125 mcg
tablet, 250 mcg tablet)
Generic
enalapril maleate/hydrochlorothiazide
Generic
ENTRESTO
Brand
fosinopril sodium/hydrochlorothiazide
Generic
irbesartan/hydrochlorothiazide
Generic
lisinopril/hydrochlorothiazide
Generic
losartan potassium/hydrochlorothiazide
Generic
methyldopa/hydrochlorothiazide
Generic
metoprolol
tartrate/hydrochlorothiazide
Generic
pentoxifylline 400 mg tablet er
Generic
propranolol hcl/hydrochlorothiazide
Generic
quinapril hcl/hydrochlorothiazide
Generic
Cardiovascular Agents, Other
50
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
spironolactone/hydrochlorothiazide
Generic
telmisartan/hydrochlorothiazid 40-12.5
mg tablet
Generic
SUPPLY)
telmisartan/hydrochlorothiazide (8012.5mg tablet, 80 mg-25mg tablet)
Generic
triamterene/hydrochlorothiazide (37.525 mg capsule, 37.5-25 mg tablet, 75
mg-50mg tablet)
Generic
valsartan/hydrochlorothiazide
Generic
Diuretics, Carbonic Anhydrase Inhibitors
acetazolamide 500 mg capsule er
Generic
methazolamide (25 mg tablet, 50 mg
tablet)
Generic
bumetanide (0.5 mg tablet, 1 mg tablet,
2 mg tablet)
Generic
ethacrynate sodium
Generic
ethacrynic acid
Generic
furosemide (10 mg/ml solution, 20 mg
tablet, 40 mg tablet, 40mg/5ml
solution, 80 mg tablet)
Generic
torsemide (5 mg tablet, 10 mg tablet,
Generic
Diuretics, Loop
Diuretics, Potassium-sparing
amiloride hcl
Generic
eplerenone
Generic
spironolactone (25 mg tablet, 50 mg
Generic
Diuretics, Thiazide
chlorothiazide
Generic
chlorthalidone
Generic
51
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
indapamide
Generic
methyclothiazide
Generic
metolazone
Generic
fenofibrate (54 mg tablet, 160 mg
tablet)
Generic
fenofibrate nanocrystallized
Generic
fenofibrate,micronized (67 mg capsule,
134mg capsule, 200 mg capsule)
Generic
fenofibric acid
Generic
fenofibric acid (choline)
Generic
gemfibrozil 600 mg tablet
Generic
lofibra
Generic
Dyslipidemics, Fibric Acid Derivatives
Dyslipidemics, HMG CoA Reductase Inhibitors
atorvastatin calcium
Generic
fluvastatin sodium (20 mg capsule, 40
mg capsule)
Generic
lovastatin
Generic
pravastatin sodium
Generic
rosuvastatin calcium
Generic
SUPPLY)
simvastatin (5 mg tablet, 10 mg tablet,
20 mg tablet)
Generic
simvastatin 40 mg tablet
Generic
SUPPLY)
Dyslipidemics, Other
cholestyramine (with sugar) (sugar) 4 g
powder, sugar) 4 g powd pack)
Generic
cholestyramine/aspartame 4 g powd
pack
Generic
COLESTID FLAVORED GRANULES
Brand
52
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
colestid granules
Generic
colestipol hcl (1 g tablet, 5 g packet, 5 g
granules)
Generic
JUXTAPID
Specialty
PA, LA
KYNAMRO
Specialty
PA, LA
PRALUENT PEN
Specialty
PA
PRALUENT SYRINGE
Specialty
PA
prevalite packet
Generic
REPATHA PUSHTRONEX
Specialty
PA
REPATHA SURECLICK
Specialty
PA
REPATHA SYRINGE
Specialty
PA
ZETIA
Brand
hydralazine hcl (10 mg tablet, 25 mg
Generic
minoxidil (2.5 mg tablet, 10 mg tablet)
Generic
Vasodilators, Direct-acting Arterial
Vasodilators, Direct-acting Arterial/Venous
isochron
Generic
isosorbide dinitrate
Generic
isosorbide mononitrate
Generic
minitran
Generic
NITRO-BID
Brand
NITRO-DUR (0.3 PATCH, 0.8 PATCH)
Brand
nitro-time
Generic
nitroglycerin (0.1mg/hr patch td24,
0.2mg/hr patch td24, 0.3 mg tab subl,
0.4 mg tab subl, 0.4mg/hr patch td24,
0.6mg/hr patch td24, 0.6 mg tab subl,
2.5 mg capsule er, 6.5 mg capsule er, 9
mg capsule er)
Generic
53
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
Central Nervous System Agents
Attention Deficit Hyperactivity Disorder Agents, Amphetamines
dextroamphetamine sulfsaccharate/amphetamine sulfaspartate (5 mg cap er 24h, 10 mg cap
er 24h, 15 mg cap er 24h, 20 mg cap er
24h, 25 mg cap er 24h, 30 mg cap er
24h)
Generic
dextroamphetamine sulfsaccharate/amphetamine sulfaspartate (5 mg tablet, 7.5 mg tablet,
10 mg tablet, 12.5 mg tablet, 15 mg
Generic
dextroamphetamine sulfate (5 mg
tablet, 5 mg capsule er, 10 mg tablet,
10 mg capsule er, 15 mg capsule er)
Generic
VYVANSE
Brand
zenzedi (5 mg tablet, 10 mg tablet)
Generic
QL (1 PER DAY)
QL (1 PER DAY)
Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines
DAYTRANA
Brand
QL (1 PER DAY)
metadate er
Generic
QL (1 PER DAY)
methylphenidate hcl (10 mg tablet er,
10 mg cpbp 30-70, 18 mg tab er 24, 20
mg cpbp 30-70, 20 mg cpbp 50-50, 20
mg tablet er, 27 mg tab er 24, 30 mg
cpbp 50-50, 30 mg cpbp 30-70, 36 mg
tab er 24, 40 mg cpbp 50-50, 40 mg
cpbp 30-70, 50 mg cpbp 30-70, 54 mg
tab er 24, 60 mg cpbp 30-70)
Generic
QL (1 PER DAY)
methylphenidate hcl (2.5 mg tab chew,
5 mg tablet, 5 mg tab chew, 10 mg
tablet, 10 mg/5 ml solution, 10 mg tab
chew, 20 mg tablet)
Generic
RITALIN LA (10 MG CAPSULE, 60 MG
CAPSULE)
Brand
QL (1 PER DAY)
54
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
Central Nervous System Agents, Other
alagesic lq
Generic
BETASERON
Specialty
ESGIC PLUS CAPSULE
Brand
EXTAVIA
Specialty
GILENYA
Specialty
PA, QL (1 PER DAY)
NUEDEXTA
Brand
PA, QL (2 PER DAY)
riluzole
Generic
TETRABENAZINE
Specialty
vanatol lq
Generic
PA, LA
Multiple Sclerosis Agents
AMPYRA
Specialty
PA, LA, QL (2 PER DAY)
AUBAGIO
Specialty
AVONEX (30 MCG VIAL KIT, PREFILLED
SYR 30 MCG, PREFILLED SYR 30 MCG
KT)
Specialty
AVONEX PEN
Specialty
COPAXONE 20 MG/ML SYRINGE
Specialty
QL (1 ML PER DAY)
COPAXONE 40 MG/ML SYRINGE
Specialty
GLATOPA
Specialty
QL (1 ML PER DAY)
PLEGRIDY
Specialty
PLEGRIDY PEN
Specialty
REBIF (22 MCG/0.5 ML SYRINGE, 44
MCG/0.5 ML SYRINGE)
Specialty
REBIF REBIDOSE (22 MCG/0.5 ML, 44
MCG/0.5 ML)
Specialty
REBIF REBIDOSE TITRATION PACK
Specialty
REBIF TITRATION PACK
Specialty
TECFIDERA
Specialty
QL (2 PER DAY)
55
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
Dental and Oral Agents
denta 5000 plus
Generic
dentagel
Generic
FLUOR-A-DAY (0.25 MG TAB CHEW, 0.5
MG TAB CHEW, 1 MG TABLET CHEW)
Brand
fluoridex daily defense
Generic
fluoritab (0.125 mg/drp drops, 0.5 mg
tablet chew)
Generic
ludent fluoride
Generic
PHOS-FLUR
OTC
pilocarpine hcl (5 mg tablet, 7.5 mg
tablet)
Generic
prevident 1.1% gel
Generic
sf
Generic
sf 5000 plus
Generic
sodium fluoride (0.2 % solution,
0.25(0.55) tab chew, 0.5(1.1)mg tab
chew, 1mg(2.2mg) tab chew)
Generic
Dermatological Agents
ALLERGY CREAM
OTC
ALLERGY RELIEF SPRAY
OTC
ANTI-ITCH (2% SPRAY, CVS 2% CREAM,
2% CREAM, 2%-0.1% CREAM, EQ
CREAM, EQL 2%-0.1% CREAM, GNP 2%
CREAM, QC CREAM, RA SPRAY, SB 2%0.1% CREAM, SM 2% CREAM, SM
SPRAY)
OTC
BANOPHEN ANTI-ITCH
OTC
BENADRYL ITCH STOPPING CRM
OTC
DESITIN CLEAR
OTC
DIPHENHYDRAMINE HCL 2 % CREAM
(G)
OTC
56
LAST UPDATE 10/2016
Drug Name
Status*
DRY SKIN THERAPY
OTC
ITCH RELIEF (CREAM, CVS CREAM, CVS
SPRAY)
OTC
PV ALLERGY 2% CREAM
OTC
SELSUN BLUE 1% SHAMPOO
OTC
SKIN PROTECTANT A & D
OTC
VITAMIN A & D GRX
OTC
VITAMINS A AND D OINT. (G)
OTC
VITS A AND D/WHITE PET/LANOLIN
OINT. (G)
OTC
WAL-DRYL (2%-0.1% CREAM, ANTI-ITCH
SPRAY)
OTC
acitretin
Generic
ANTI-ITCH CREAM
OTC
calcipotriene (0.005 % cream (g), 0.005
% oint. (g), 0.005 % solution)
Generic
calcitrene
Generic
clotrimazole/betamethasone
dipropionate (1 %-0.05 % lotion, 1 %0.05 % cream (g))
Generic
CLOVERINE
OTC
CONDYLOX 0.5% GEL
Brand
cyclosporine, modified (25 mg capsule,
50 mg capsule, 100 mg/ml solution)
Generic
diclofenac sodium 1 % gel (gram)
Generic
DRITHOCREME HP
Brand
ELIDEL
Brand
gengraf (25 mg capsule, 50 mg capsule,
100 mg/ml solution, 100 mg capsule)
Generic
HYDROLATUM
OTC
LOBANA BATH OIL
OTC
MAPO
OTC
Requirements/Limits
PA
57
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
MINERAL OIL OIL
OTC
mometasone furoate (0.1 % cream (g),
0.1 % oint. (g), 0.1 % solution)
Generic
PETROLATUM,WHITE (JELLY (G), OINT
PACK, OINT. (G))
OTC
PETROLATUM,WHITE/LANOLIN
OTC
podofilox 0.5 % solution
Generic
PROTECTIVE OINTMENT
OTC
REGRANEX
Specialty
SECURA PROTECTIVE OINTMENT
OTC
selenium sulfide (2.25 % shampoo, 2.5
% lotion)
Generic
STELARA 45 MG/0.5 ML SYRINGE
Specialty
STELARA 90 MG/ML SYRINGE
Specialty
tacrolimus (0.03 % oint. (g), 0.1 % oint.
(g))
Generic
PA
trianex
Generic
vaseline white petroleum
Generic
PA
Enzyme Replacement/Modifiers
BUPHENYL 500 MG TABLET
Specialty
CARBAGLU
Brand
CERDELGA
Specialty
CREON
Brand
ELELYSO
Specialty
KUVAN
Specialty
ORFADIN (2 MG CAPSULE, 4 MG/ML
SUSPENSION, 5 MG CAPSULE, 10 MG
CAPSULE, 20 MG CAPSULE)
Specialty
pancrelipase 5,000
Generic
RAVICTI
Specialty
PA
PA, LA
LA
58
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
SODIUM PHENYLBUTYRATE 0.94 G/G
POWDER
Specialty
PA
STRENSIQ
Specialty
PA, LA
ZENPEP (DR 3,000 CAPSULE, DR 10,000
CAPSULE, DR 15,000 CAPSULE, DR
20,000 CAPSULE, DR 25,000 CAPSULE,
DR 40,000 CAPSULE)
Brand
Gastrointestinal Agents
Antispasmodics, Gastrointestinal
ANTI-DIARRHEA
OTC
ANTI-DIARRHEAL (ANTI-DIARRHEAL 1
MG/5 ML SOLN, ANTI-DIARRHEAL 1
MG/5 ML LIQ, ANTI-DIARRHEAL 2 MG
CAPLET, ANTI-DIARRHEAL 2 MG
TABLET, ANTI-DIARRHEAL 2 MG
SOFTGEL, CVS ANTI-DIARRHEAL 2 MG
SFTGEL, CVS ANTI-DIARRHEAL 2 MG
CAPLET, EQ ANTI-DIARRHEAL 2 MG
CAPLET, EQL ANTI-DIARRHEAL 1 MG/5
ML, EQL ANTI-DIARRHEAL 2 MG
CAPLET, GNP ANTI-DIARRHEAL 2 MG
CAPLET, HM ANTI-DIARRHEAL 2 MG
CAPLET, KRO ANTI-DIARRHEAL 2 MG
CAPLET, PV ANTI-DIARRHEAL 2 MG
CAPLET, QC ANTI-DIARRHEAL 2 MG
CAPLET, QC ANTI-DIARRHEAL 2 MG
SOFTGEL, RA ANTI DIARRHEAL 2 MG
CAPLET, RA ANTI-DIARRHEAL 1 MG/5
ML, RA ANTI-DIARRHEAL 2 MG CAPLET,
RA ANTI-DIARRHEAL 2 MG SOFTGEL,
SM ANTI-DIARRHEAL 1 MG/5 ML, SM
ANTI-DIARRHEAL 2 MG CAPLET, SM
ANTI-DIARRHEAL 2 MG SOFTGEL, V-R
ANTI-DIARRHEAL 2 MG CAPLET)
OTC
CUVPOSA
Brand
DIAMODE
OTC
dicyclomine hcl (10 mg capsule, 10
mg/5 ml solution, 20 mg tablet)
Generic
glycopyrrolate (1 mg tablet, 2 mg
tablet)
Generic
59
LAST UPDATE 10/2016
Drug Name
Status*
LO-PERAMIDE
OTC
LOPERAMIDE HCL (1 MG/5 ML LIQUID,
2 MG TABLET)
OTC
loperamide hcl 2 mg capsule
Generic
ULTRA A-D
OTC
Requirements/Limits
Gastrointestinal Agents, Other
ACID CONTROL (150 MG TABLET, GNP
150 MG TABLET)
OTC
ACID GONE
OTC
ACID GONE ANTACID
OTC
ACID REDUCER (CVS 150 MG TABLET,
EQ 75 MG TABLET, EQ 150 MG TABLET,
EQL 75 MG TABLET, EQL 150 MG
TABLET, GNP 75 MG TABLET, PUB 75
MG TABLET, 75 MG TABLET, HM 75 MG
TABLET, HM 150 MG TABLET, PV 75 MG
TABLET, PV 150 MG TABLET, RA 75 MG
TABLET, RA 150 MG TABLET, SB 75 MG
TABLET, SB 150 MG TABLET, SM 75 MG
TABLET, SM 150 MG TABLET, V-R 75
MG TABLET, 150 MG TABLET)
OTC
ACID REDUCER 150
OTC
ADVANCED ANTACID
OTC
ADVANCED ANTACID-ANTIGAS
OTC
ALMACONE LIQUID
OTC
ALMACONE-2
OTC
ALUMINUM HYDROXIDE (320 MG/5ML
ORAL SUSP, 600 MG/5ML ORAL SUSP)
OTC
ANALPRAM HC 2.5% LOTION
Brand
ANTACID & ANTIGAS
OTC
ANTACID & GAS RELIEF
OTC
60
LAST UPDATE 10/2016
Drug Name
Status*
ANTACID (675-135 MG TAB CHEW, CVS
750 MG CHEW TABLET, CVS LIQUID, EQ
500 MG CHEW TABLET, EQL 500 MG
CHEW TABLET, 500 MG CHEW TABLET,
500 MG CHEWABLE TABLET, 750 MG
CHEW TB, CVS KIDS 750 MG CHEW, EQ
EXTRA STR TAB CHEW, EQ LIQUID, EQL
CHEW TAB, EQL LIQUID, EQL
SUSPENSION, EX-STR 750 MG TAB
CHEW, EX-STR TABLET CHEW, GNP 500
MG CHEW TABLET, GNP 750 MG TAB
CHEW, GNP SUSPENSION, LIQUID, PUB
500 MG CHEW TABLET, PV 675-135 MG
TAB CHEW, PV SUSPENSION, QC 500
MG CHEW TABLET, QC SUSPENSION, RA
500 MG CHEW TABLET, SB 500 MG
CHEW TABLET, SB SUSPENSION, SM 500
MG CHEW TABLET, SM SUSPENSION,
SUSPENSION)
OTC
ANTACID ANTI-GAS DOUBLE STR
OTC
ANTACID EXTRA STRENGTH (CVS XTRA
STR CHEW TAB, EQ EX-STR CHEW
TABLET, EQ EXTRA STR CHEW TAB, EQL
XTRA STR CHEW TAB, EXTRA STRENGTH
CHW TAB, GNP EXT STRGTH CHW TAB,
GNP XTRA STR CHEW TAB, PV EXTRA
STRENGTH SUSP, QC XTRA STR CHEW
TAB, RA XTRA STR CHEW TAB, SB XTRA
STR CHEW TAB, SM EX-STR TAB CHEW,
SM XTRA STR CHEW TAB, V-R XTRA STR
CHEW TAB, VR X-S TAB CHEW, XTRA
STRENGTH CHEW TAB)
OTC
ANTACID II PLUS SIMETHICONE
OTC
ANTACID II WITH SIMETHICONE
OTC
ANTACID M
OTC
ANTACID MAXIMUM STRENGTH
OTC
ANTACID PLUS ANTI-GAS
OTC
ANTACID TABLET
OTC
ANTACID ULTRA STRENGTH (CVS TAB
CHEW, EQ STR TAB CHEW, RA TAB
CHEW, STR 1,000 MG CHW, STR TAB
CHEWABLE)
OTC
Requirements/Limits
61
LAST UPDATE 10/2016
Drug Name
Status*
ANTACID WITH SIMETHICONE
OTC
ANTACID-ANTIGAS (ANTACID ANTI-GAS
LIQUID, ANTACID-ANTIGAS LIQUID, CVS
ANTACID-ANTIGAS LIQUID, CVS
ANTACID-ANTIGAS MAX STR LQ, GNP
ANTACID ANTI-GAS LIQUID, HM
ANTACID ANTI-GAS SUSPENSION, HM
ANTACID-ANTIGAS SUSPENSION, KRO
ANTACID-ANTIGAS LIQUID, PUB
ANTACID-ANTI GAS SUSP, PV ANTACIDANTIGAS SUSPENSION, QC ANTACIDANTIGAS MAX STR, QC ANTACIDANTIGAS SUSPENSION, RA ANTACIDANTIGAS LIQUID, RA ANTACID-ANTIGAS
SUSPENSION, SB ANTACID-ANTIGAS
LIQUID, SM ANTACID ANTI-GAS LIQUID,
SM ANTACID-ANTIGAS LIQUID)
OTC
ANTI-GAS (CVS 180 MG, QC 180 MG,
ULTRA STR, V-R 166 MG)
OTC
APRISO
Brand
BAN-ACID
OTC
BISMATROL TABLET CHEW
OTC
BISMUTH SUBSALICYLATE 262 MG TAB
CHEW
OTC
CAL-GEST
OTC
CALCI-CHEW
OTC
Requirements/Limits
62
LAST UPDATE 10/2016
Drug Name
Status*
CALCIUM ANTACID (CALCIUM 500 MG
CHW TAB, CALCIUM 750 MG TB CHEW,
CALCIUM 1,000 MG TAB, CALCIUM E-S
TAB CHEW, CALCIUM EX-STR CHEW,
CALCIUM EX-STR TABLET, CALCIUM
ULTRA-STR CHEW, CVS CALCIUM 1,000
MG, EQL CALCIUM CHEW TAB, EQL
CALCIUM TABLET, HM CAL 500 MG
CHEW TAB, HM CAL 750 MG CHEW
TAB, PUB CALCIUM 750 MG, PV CAL
500 MG CHEW TAB, PV CALCIUM 1,000
MG TB, PV CALCIUM TABLET CHEW, SM
CAL 500 MG CHEW TAB, SM CAL 750
MG CHEW TAB)
OTC
CALCIUM CARBONATE (200(500)MG
TAB CHEW, 300MG(750) TAB CHEW,
400(1000) TAB CHEW, 500 MG/5ML
ORAL SUSP, 500(1250) TAB CHEW)
OTC
CANASA
Brand
CHENODAL
Specialty
CHILDREN'S PEPTO
OTC
CHILDREN'S SOOTHE
OTC
CHOLBAM
Specialty
CITROMA
OTC
COMFORT GEL
OTC
DELZICOL
Brand
DIGESTIVE RELIEF 262 MG CHW TB
OTC
DIOTAME
OTC
diphenoxylate hcl/atropine sulfate (2.5.025mg tablet, 2.5-.025/5 liquid)
Generic
FLANAX ANTACID LIQUID
OTC
FLAVOR CHEWS ANTACID
OTC
FOAMING ANTACID (GNP LIQUID,
LIQUID, PV CHEW TABLET, SM TABLET
CHEW)
OTC
FULYZAQ
Brand
Requirements/Limits
PA, LA
PA, LA
63
LAST UPDATE 10/2016
Drug Name
Status*
GAS FREE
OTC
Requirements/Limits
64
LAST UPDATE 10/2016
Drug Name
Status*
GAS RELIEF (CVS GAS RELIEF 80 MG TAB
CHEW, CVS GAS RELIEF 125 MG CHEW
TAB, CVS GAS RELIEF 125 MG SOFTGEL,
CVS GAS RELIEF EX-STR DROPS, EQ GAS
RELIEF 125 MG SOFTGEL, EQL GAS
RELIEF 125 MG CHEW TAB, EQL GAS
RELIEF DROPS, GAS RELIEF 20 MG/0.3
ML DROPS, GAS RELIEF 40 MG/0.6 ML
DROPS, GAS RELIEF 80 MG TABLET
CHEW, GAS RELIEF 125 MG SOFTGEL,
GAS RELIEF 125 MG CHEW TABLET, GAS
RELIEF 180 MG SOFTGEL, GAS RELIEF
DROPS, GNP GAS RELIEF 125 MG CHEW
TAB, GNP GAS RELIEF 125 MG SFTG,
GNP GAS RELIEF 125 MG SOFTGEL, GS
GAS RELIEF 125 MG SOFTGEL, HM GAS
RELIEF 80 MG TAB CHEW, HM GAS
RELIEF 125 MG SOFTGEL, KRO GAS
RELIEF 180 MG SOFTGEL, PUB GAS
RELIEF 125 MG SOFTGEL, PUB GAS
RELIEF 180 MG SOFTGEL, PV GAS RELIEF
125 MG CHEW TAB, PV GAS RELIEF 125
MG SOFTGEL, PV GAS RELIEF 180 MG
SOFTGEL, QC GAS RELIEF 80 MG TAB
CHEW, QC GAS RELIEF 125 MG TAB
CHEW, RA GAS RELIEF 40 MG/0.6 ML
DP, RA GAS RELIEF 80 MG TAB CHEW,
RA GAS RELIEF 125 MG TAB CHEW, RA
GAS RELIEF 125 MG SOFTGEL, SM GAS
REL ANTIFLATUENT 180 MG, SM GAS
RELIEF 80 MG TAB CHEW, SM GAS
RELIEF 125 MG SOFTGEL, V-R GAS
RELIEF 80 MG TAB CHEW)
OTC
GAS RELIEF 80
OTC
GAS-X EXTRA STRENGTH SOFTGEL
OTC
GAS-X ULTRA STRENGTH
OTC
GATTEX
Specialty
GAVISCON 80-14.2 MG TAB CHEW
OTC
GELUSIL ANTACID & ANTIGAS LIQ
OTC
GERI-LANTA
OTC
Requirements/Limits
PA
65
LAST UPDATE 10/2016
Drug Name
Status*
GERI-MOX
OTC
HEARTBURN ANTACID
OTC
HEARTBURN RELIEF (CVS RELIEF CHEW
TAB, EQL RELIEF 75 MG TAB, EQL RELIEF
150 MG TB, EQL RLF 150 MG TAB, KRO
RELIEF 150 MG TB, RELIEF 75 MG
TABLET, RELIEF 150 MG TABLET)
OTC
HEARTBURN RELIEF 150
OTC
INFANT GAS RELIEF
OTC
INFANTS' GAS RELIEF
OTC
IPECAC
OTC
lansoprazole/amoxicillin
trihydrate/clarithromycin
Generic
LIALDA
Brand
LIQUID ANTACID
OTC
MAALOX MAXIMUM STRENGTH
OTC
MAG-AL PLUS XS
OTC
MAGLOX
OTC
MAGNESIUM CITRATE SOLUTION
OTC
MASANTI
OTC
MEDI-BISMUTH
OTC
mesalamine (4 g/60 ml enema, 800 mg
tablet dr)
Generic
MI ACID
OTC
MI-ACID (MI ACID SUSPENSION, MIACID GAS 80 MG TAB CHEW)
OTC
MINTOX
OTC
MINTOX MAXIMUM STRENGTH
OTC
MYTAB GAS
OTC
MYTAB GAS MAXIMUM STRENGTH
OTC
MYTESI
Brand
Requirements/Limits
66
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
OCALIVA
Specialty
PA, QL (1 PER DAY)
PENTASA
Brand
PEP-T-MED
OTC
PEPTIC RELIEF 262 MG CHEW TAB
OTC
PINK BISMUTH (GNP TABLET CHEW, PV
TABLET CHEW, QC TABLET CHEW, RA
TABLET CHEW, TABLET CHEW)
OTC
PROCTOFOAM-HC
Brand
propantheline bromide 15 mg tablet
Generic
PYLERA
Brand
ranitidine hcl 150 mg tablet
Generic
RANITIDINE HCL 75 MG TABLET
OTC
RI-GEL
OTC
RI-GEL II
OTC
RI-MAG
OTC
RI-MOX
OTC
RI-MOX PLUS
OTC
RIGINIC
OTC
RULOX
OTC
SIMETHICONE (40MG/0.6ML DROPS
SUSP, 80 MG TAB CHEW, 125 MG TAB
CHEW, 125 MG CAPSULE, 180 MG
CAPSULE)
OTC
SMOOTH ANTACID
OTC
SMOOTH DISSOLVING ANTACID
OTC
SOOTHE 262 MG CHEWABLE TABLET
OTC
STOMACH RELIEF (CVS RLF 262 MG
CHEW TB, EQ RLF 262 MG CHEW TAB,
EQL RLF 262 MG CHEW TB, HM RLF 262
MG CHEW TAB, KRO RLF 262 MG CHEW
TB, PUB RLF 262 MG CHEW TB, RELIEF
262 MG CHEW TAB, SM RLF 262 MG
CHEW TAB)
OTC
67
LAST UPDATE 10/2016
Drug Name
Status*
sulfasalazine (500 mg tablet, 500 mg
tablet dr)
Generic
ULTRA STRENGTH ANTACID
OTC
ursodiol (250 mg tablet, 300 mg
capsule, 500 mg tablet)
Generic
WAL-ZAN 150
OTC
WAL-ZAN 75
OTC
ZANTAC 75
OTC
Requirements/Limits
Histamine2 (H2) Receptor Antagonists
ACID CONTROL 20 MG TABLET
OTC
ACID CONTROLLER
OTC
ACID REDUCER (EQ 10 MG TABLET, EQ
20 MG TABLET, KRO 200 MG TABLET,
PV 10 MG TABLET, 10 MG TABLET, EQ
200 MG TABLET, EQL 200 MG TABLET,
GNP 10 MG TABLET, GNP 20 MG
TABLET, PUB 10 MG TABLET, PUB 200
MG TABLET, PV 20 MG TABLET, RA 10
MG TABLET, RA 20 MG TABLET, SM 10
MG TABLET, SM 20 MG TABLET, SM 200
MG TABLET, V-R 10 MG TABLET, 20 MG
OTC
ACID RELIEF
OTC
cimetidine (300 mg tablet, 400 mg
Generic
CIMETIDINE 200 MG TABLET
OTC
cimetidine hcl
Generic
famotidine (20 mg tablet, 40 mg tablet)
Generic
FAMOTIDINE 10 MG TABLET
OTC
HEARTBURN PREVENTION
OTC
HEARTBURN RELIEF (RELIEF 10 MG
TABLET, RELIEF 20 MG TABLET, RELIEF
200 MG TABLET, SM RELIEF 200 MG
TAB, V-R RELF 200 MG TB)
OTC
nizatidine (150 mg capsule, 300 mg
capsule)
Generic
68
LAST UPDATE 10/2016
Drug Name
Status*
PEPCID AC 20 MG TABLET
OTC
ranitidine hcl (15 mg/ml syrup, 150 mg
capsule, 300 mg tablet, 300 mg
capsule)
Generic
Requirements/Limits
Irritable Bowel Syndrome Agents
alosetron hcl
Generic
PA
VIBERZI
Brand
PA, QL (2 PER DAY)
Laxatives
ADULT GLYCERIN
OTC
ALOPHEN PILLS
OTC
BISA-LAX
OTC
BISACODYL (5 MG TABLET DR, FLEET EC
5 MG TAB, 10 MG SUPP.RECT)
OTC
BISCOLAX
OTC
CALCIUM POLYCARBOPHIL
OTC
CASTOR OIL
OTC
CHILD SUPPOSITORY
OTC
CHOCOLATED LAXATIVE
OTC
CITRUCEL 500 MG CAPLET
OTC
CLEARLAX
OTC
COL-RITE
OTC
constulose
Generic
CURAD ENEMA
OTC
DIOCTYL
OTC
DOC-Q-LACE
OTC
DOC-Q-LAX
OTC
DOCU LIQUID
OTC
DOCU SOFT
OTC
DOCUPRENE
OTC
69
LAST UPDATE 10/2016
Drug Name
Status*
DOCUSATE CALCIUM
OTC
DOCUSATE SODIUM (50 MG/5 ML
LIQUID, 60 MG/15ML SYRUP, 100 MG
TABLET, 100 MG CAPSULE, 250 MG
CAPSULE)
OTC
DOCUSIL
OTC
DOK 100 MG TABLET
OTC
DOK PLUS
OTC
DSS
OTC
DUCODYL
OTC
DULCOLAX STOOL SOFTENER
OTC
ENEMA (ENEMA, ENEMA READY TO
USE, ENEMA READY-TO-USE, ENEMA
TWIN PACK, EQ ENEMA, EQL ENEMA
READY TO USE, GNP ENEMA READY TO
USE, HM ENEMA READY TO USE, HM
ENEMA READY TO USE TWIN PAK, PV
ENEMA, PV ENEMA READY TO USE, QC
READY TO USE ENEMA, RA ENEMA
TWIN PACK, SM ENEMA READY TO USE)
OTC
ENEMA DISPOSABLE
OTC
enulose
Generic
EQ DAILY FIBER LAXATIVE POWDER
OTC
EVAC-U-GEN
OTC
EX-LAX CHOCOLATE
OTC
FAST RELIEF LAXATIVE
OTC
FIBER (HM 500 MG CAPLET, 625 MG
TABLET, HM POWDER, PUB 625 MG
CAPLET, SM POWDER, TABLET)
OTC
FIBER LAX
OTC
FIBER LAXATIVE (EQL 625 MG CPLT, 625
MG TABLET, 625 MG CAPLET, CVS 625
MG CPLT, KRO 625 MG CPLT, PV 625
MG CAPLT, PV POWDER, RA POWDER,
SM 500 MG CPLT, SM 625 MG TAB)
OTC
Requirements/Limits
70
LAST UPDATE 10/2016
Drug Name
Status*
FIBER SMOOTH
OTC
FIBER TABS
OTC
FIBER THERAPY (500 MG CAPLET, 625
MG CAPLET, CAPLET, CVS 500 MG
CAPLT, EQ 625 MG CAPLET, EQ CAPLET,
EQ POWDER, EQL 500 MG CPLT, EQL
CAPLET, GNP 500 MG CAPLT, POWDER,
PV 500 MG CAPLET, PV POWDER)
OTC
FIBER-LAX
OTC
FIBER-TABS
OTC
FLEET PEDIA-LAX SUPPOSITORIES
OTC
GAVILAX
OTC
gavilyte-c
Generic
gavilyte-g
Generic
gavilyte-n
Generic
generlac
Generic
GENTLE LAXATIVE
OTC
GENTLELAX
OTC
GERI-KOT
OTC
GERI-MUCIL
OTC
GLYCERIN (ADULT SUPP.RECT,
PEDIATRIC SUPP.RECT)
OTC
GLYCOLAX
OTC
HEALTHYLAX
OTC
HYDROCIL INSTANT PACKET
OTC
KAO-TIN 240 MG SOFTGEL
OTC
KONSYL (ORIGINAL POWDER, PSYLLIUM
POWDER)
OTC
KONSYL EASY MIX
OTC
KONSYL FIBER
OTC
KONSYL FORMULA-D
OTC
Requirements/Limits
71
LAST UPDATE 10/2016
Drug Name
Status*
KRISTALOSE
Brand
lactulose
Generic
LAX STOOL SOFTENER WITH SENNA
OTC
LAXA CLEAR
OTC
LAXACIN
OTC
LAXATIVE (PUB EC 5 MG TABLET, 5 MG
TABLET, CVS 15 MG PILLS, EC 5 MG
TABLET, EQL EC 5 MG TABLET, GNP EC 5
MG TABLET, HM EC 5 MG TABLET, PV 5
MG TAB, PV EC 5 MG TABLET, SM
TABLET, V-R CHOCOLATE)
OTC
LAXATIVE DIETARY SUPPLEMENT
OTC
LAXATIVE FEMININE
OTC
LAXATIVE SUPPOSITORY
OTC
MAGIC BULLET
OTC
MAGNESIUM HYDROXIDE (400
MG/5ML ORAL SUSP, 2400 MG/10
ORAL SUSP)
OTC
MAGNESIUM OXIDE (250 MG TABLET,
500 MG TABLET)
OTC
MEDI-LAXX
OTC
MEDI-NATURAL
OTC
MEDI-NATURAL SENNA STOOL SOFT
OTC
METAMUCIL POWDER
OTC
METAMUCIL SUGAR FREE
OTC
MINERAL OIL (OIL ENEMA, OIL, HEAVY,
OIL LAXATIVE)
OTC
MINERAL OIL EXTRA HEAVY
OTC
MOVE IT ALONG
OTC
MOVIPREP
Brand
NATURAL DAILY FIBER
OTC
NATURAL FIBER (EQ LAXATIVE POWD,
GNP POWDER, LAX POWDER)
OTC
Requirements/Limits
72
LAST UPDATE 10/2016
Drug Name
Status*
NATURAL FIBER LAXATIVE
OTC
NATURAL FIBER POWDER
OTC
NATURAL FIBER SUPPLEMENT
OTC
NATURAL SENNA LAXATIVE
OTC
NATURAL VEGETABLE POWDER
OTC
nulytely with flavor packs
Generic
ORAL SALINE LAXATIVE
OTC
ORAL SALINE LAXATIVE KIT
OTC
P-COL RITE
OTC
PEDIA-LAX STOOL SOFTENER
OTC
peg 3350/sod sulf/sod bicarbonate/sod
chloride/potassium chl
Generic
PEG3350
OTC
PHILLIPS
OTC
PHILLIPS' LAXATIVE
OTC
PHOSPHATE ENEMA
OTC
PHOSPHATE LAXATIVE
OTC
polyethylene glycol 3350 (3350 17g
powd pack, 3350 17g/dose powder)
Generic
POWDERLAX
OTC
PROMOLAXIN
OTC
PSYLLIUM HUSK/ASPARTAME
OTC
PURE & GENTLE SALINE ENEMA
OTC
PURELAX (POWDER, POWDER PACKET)
OTC
QC NATURAL VEG LAXATIVE TABLET
OTC
READY TO USE ENEMA
OTC
REGULOID (LAXATIVE POWDER,
POWDER, POWDER ORANGE)
OTC
SALINE ENEMA
OTC
SEN-O-TAB
OTC
Requirements/Limits
73
LAST UPDATE 10/2016
Drug Name
Status*
SENEXON (8.8 MG/5 ML LIQUID,
TABLET)
OTC
SENEXON-S
OTC
SENNA (HM SENNA 8.6 MG TABLET, PV
SENNA 8.6 MG TABLET, QC SENNA
LAXATIVE 8.6 MG TAB, RA SENNA 8.6
MG TABLET, SENNA 8.6 MG TABLET,
SENNA LAXATIVE 8.6 MG TAB, SENNA
LAXATIVE 8.6 MG TABLET, SENNA-TIME
8.6 MG TABLET)
OTC
SENNA LAX
OTC
SENNA LAXATIVE (CVS 8.6 MG TAB, EQL
8.6 MG TAB, SM 8.6 MG TAB, TABLET)
OTC
SENNA PLUS
OTC
SENNA S
OTC
SENNA-S
OTC
SENNA-TIME S
OTC
SENNALAX-S
OTC
SENNO
OTC
SENNOSIDES
OTC
SENNOSIDES/DOCUSATE SODIUM
OTC
SILACE
OTC
SMOOTHLAX (POWDER, POWDER
PACKET)
OTC
sodium chloride/sodium
bicarbonate/potassium chloride/peg
Generic
SOF-LAX
OTC
SOLUBLE FIBER
OTC
SORBITOL SOLUTION 70 % SOLUTION
OTC
STIMULANT LAXATIVE PLUS
OTC
Requirements/Limits
74
LAST UPDATE 10/2016
Drug Name
Status*
STOOL SOFTENER (CVS SOFTENER 50
MG SFTGL, CVS SOFTENER 100 MG CAP,
CVS SOFTENER 100 MG SFTG, CVS
SOFTENER 250MG SFTGL, CVS
SOFTENER 250 MG SFGL, CVS
SOFTENER SOFTGEL, EQ SOFTENER 100
MG CAP, EQ SOFTENER 100 MG SFTGL,
EQL SOFTENER 100 MG SFGL, GNP
SOFTENER 50 MG/5 ML, GNP
SOFTENER 100 MG SFGL, GNP
SOFTENER 250 MG SFGL, GNP
SOFTENER SYRUP, HM SOFTENER 100
MG SFTGL, HM SOFTENER 250 MG
SFTGL, PV SOFTENER 100 MG CAP, PV
SOFTENER 100 MG SFTGL, QC
SOFTENER 100 MG CAP, QC SOFTENER
100 MG SFTGL, QC SOFTENER-LAX
TABLET, RA SOFTENER 100 MG SFTGL,
RA SOFTENER 100 MG CAP, SM NAT
LAX PLUS SOFTENER, SM SOFTENER 100
MG SFTGL, SM SOFTENER 240 MG
SFTGL, SM SOFTENER 250 MG SFTGL,
SM SOFTENER TABLET, SOFTENER 50
MG/5 ML LIQ, SOFTENER 100 MG
TABLET, SOFTENER 100 MG SOFTGEL,
SOFTENER 100 MG CAPSULE, SOFTENER
240 MG CAPS, SOFTENER 240 MG
SOFTGEL, SOFTENER 250 MG SOFTGEL,
SOFTENER SYRUP, SOFTENER TABLET,
V-R SOFTENER TABLET)
OTC
STOOL SOFTENER-LAXATIVE
OTC
STOOL SOFTENER-STIMULANT LAX
OTC
SUPPOSITORY
OTC
SUPREP
Brand
trilyte with flavor packets
Generic
VEGETABLE LAXATIVE
OTC
WAL-MUCIL 100% NATURAL FIBER
OTC
WAL-MUCIL NATURAL FIBER LAX
OTC
WOMAN'S LAXATIVE
OTC
WOMEN'S GENTLE LAXATIVE
OTC
Requirements/Limits
75
LAST UPDATE 10/2016
Drug Name
Status*
WOMEN'S LAXATIVE
OTC
WOMENS STOOL SOFTENER
OTC
Requirements/Limits
Protectants
CARAFATE 1 GM/10 ML SUSP
Brand
misoprostol (100 mcg tablet, 200 mcg
tablet)
Generic
sucralfate 1 g tablet
Generic
Proton Pump Inhibitors
esomeprazole magnesium 20 mg
capsule dr
Generic
PA, QL (1 PER DAY)
esomeprazole magnesium 40 mg
capsule dr
Generic
PA, QL (2 PER DAY)
HEARTBURN RELIEF 24 HOUR
OTC
HEARTBURN TREATMENT 24 HOUR
OTC
lansoprazole (15 mg capsule dr, 30 mg
capsule dr)
Generic
NEXIUM (DR 10 MG PACKET, DR 20 MG
PACKET)
Brand
PA, QL (1 PER DAY)
NEXIUM DR 40 MG PACKET
Brand
PA, QL (2 PER DAY)
omeprazole (10 mg capsule dr, 20 mg
capsule dr, 40 mg capsule dr)
Generic
OMEPRAZOLE 20 MG TABLET DR
OTC
OMEPRAZOLE MAGNESIUM
OTC
pantoprazole sodium (20 mg tablet dr,
40 mg tablet dr)
Generic
PREVACID 30 MG SOLUTAB
Brand
PRILOSEC OTC
OTC
PROTONIX 40 MG SUSPENSION
Brand
rabeprazole sodium
Generic
76
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
Genitourinary Agents
Antispasmodics, Urinary
flavoxate hcl
Generic
oxybutynin chloride (5 mg/5 ml syrup, 5
mg tablet, 5 mg tab er 24, 10 mg tab er
24, 15 mg tab er 24)
Generic
OXYTROL
Brand
tolterodine tartrate (er 2 mg cap, er 4
mg cap, 1 mg tab, 2 mg tab)
Generic
trospium chloride 20 mg tablet
Generic
Benign Prostatic Hypertrophy Agents
alfuzosin hcl
Generic
dutasteride
Generic
finasteride 5 mg tablet
Generic
tamsulosin hcl
Generic
Genitourinary Agents, Other
AZO-TABS
OTC
bethanechol chloride (5 mg tablet, 10
Generic
ELMIRON
Brand
methergine
Generic
methylergonovine maleate 0.2 mg
tablet
Generic
PROCYSBI
Brand
PV AZO DINE 95 MG TABLET
OTC
URINARY PAIN RELIEF (CVS RLF 95 MG
TAB, EQ RLF 95 MG TAB, KRO RLF 95
MG TAB, PV RLF 95 MG TAB, RELIEF 95
MG TAB, SM RLF 95 MG TAB, V-R RLF
95 MG TAB)
OTC
URINARY TRACT
OTC
QL (3 PER DAY)
PA, LA
77
LAST UPDATE 10/2016
Drug Name
Status*
URISTAT 95 MG TABLET
OTC
Requirements/Limits
Phosphate Binders
AURYXIA
Brand
calcium acetate 667 mg capsule
Generic
RENAGEL
Brand
RENVELA
Brand
SEVELAMER CARBONATE
Brand
PA
PA
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
Glucocorticoids/Mineralocorticoids
ANTI-ITCH (EQL 1%, RA 1%, 1%)
OTC
budesonide 3 mg capdr - er
Generic
CORTIZONE-10 1% OINTMENT
OTC
dexamethasone (0.5 mg tablet, 0.5
mg/5ml elixir, 0.5 mg/5ml solution, 0.75
mg tablet, 1 mg tablet, 1.5 mg tablet, 2
Generic
dexamethasone intensol
Generic
dexamethasone sod phosphate 0.1 %
drops
Generic
DEXPAK 13 DAY 1.5 MG TABLET
Brand
diclofenac sodium 0.1 % drops
Generic
EPIFOAM
Brand
FLOVENT DISKUS
Brand
FLOVENT HFA
Brand
fluorometholone
Generic
fluticasone propionate 50 mcg spray
susp
Generic
FML FORTE
Brand
FML S.O.P.
Brand
PA
78
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
HYDROCORTISONE (0.5 % CREAM (G),
0.5 % OINT. (G))
OTC
hydrocortisone (1 % oint. (g), 5 mg
Generic
HYDROCORTISONE ACETATE (0.5 %
CREAM (G), 1 % OINT. (G))
OTC
hydrocortisone butyrate (0.1 % oint. (g),
0.1 % solution)
Generic
hydrocortisone valerate
Generic
MEDROL 2 MG TABLET
Brand
NASAL ALLERGY
OTC
prednisolone acetate
Generic
TRIAMCINOLONE ACETONIDE 55 MCG
SPRAY
OTC
PA
XURIDEN
Specialty
PA
PA
Hormonal Agents, Stimulant/Replacement/Modifying (Other)
MYALEPT
Specialty
PA
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
desmopressin acetate (0.1 mg tablet,
0.1 mg/ml solution, 0.2 mg tablet,
10/spray spray/pump)
Generic
PA
desmopressin acetate (nonrefrigerated)
Generic
PA
EGRIFTA
Specialty
PA
INCRELEX
Specialty
PA, LA
OMNITROPE (5 MG/1.5 ML CRTG, 5.8
MG VIAL, 10 MG/1.5 ML CRTG)
Specialty
PA
STIMATE
Brand
79
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)
Androgens
ANDRODERM
Brand
PA
ANDROGEL (1.62%(1.25G) GEL PCKT,
1.62% GEL PUMP, 1.62%(2.5G) GEL
PCKT)
Brand
PA
testosterone (1.25 g(1%) gel md pmp,
25mg(1%) gel packet, 50 mg (1%) gel
(gram), 50 mg (1%) gel packet)
Generic
PA
testosterone cypionate (100 mg/ml vial,
200 mg/ml vial)
Generic
testosterone enanthate 200 mg/ml vial
Generic
Estrogens
AFTERA
OTC
altavera
Generic
alyacen
Generic
amabelz
Generic
amethia
Generic
amethia lo
Generic
amethyst
Generic
apri
Generic
aranelle
Generic
ashlyna
Generic
aubra
Generic
aviane
Generic
azurette
Generic
balziva
Generic
bekyree
Generic
blisovi 24 fe
Generic
80
LAST UPDATE 10/2016
Drug Name
Status*
blisovi fe
Generic
briellyn
Generic
camrese
Generic
camrese lo
Generic
caziant
Generic
chateal
Generic
cryselle
Generic
cyclafem
Generic
cyred
Generic
dasetta
Generic
daysee
Generic
delyla
Generic
desogestrel-ethinyl estradiol
Generic
desogestrel-ethinyl estradiol/ethinyl
estradiol
Generic
DUAVEE
Brand
ECONTRA EZ
OTC
elinest
Generic
emoquette
Generic
enpresse
Generic
enskyce
Generic
ESTRACE 0.01% CREAM
Brand
estradiol (.025mg/24h patch tdwk,
.025mg/24h patch tdsw, .0375mg/24
patch tdwk, .0375mg/24 patch tdsw,
0.05mg/24h patch tdsw, 0.05mg/24h
patch tdwk, 0.06mg/24h patch tdwk,
.075mg/24h patch tdwk, .075mg/24h
patch tdsw, 0.1mg/24hr patch tdwk,
0.1mg/24hr patch tdsw, 0.5 mg tablet,
Generic
estradiol/norethindrone acetate
Generic
Requirements/Limits
81
LAST UPDATE 10/2016
Drug Name
Status*
ESTRING
Brand
estropipate
Generic
ethinyl estradiol/drospirenone
Generic
FALLBACK SOLO
OTC
falmina
Generic
fyavolv
Generic
gianvi
Generic
gildagia
Generic
gildess
Generic
gildess 24 fe
Generic
gildess fe
Generic
introvale
Generic
jevantique lo
Generic
jinteli
Generic
jolessa
Generic
juleber
Generic
junel
Generic
junel fe
Generic
junel fe 24
Generic
kariva
Generic
kelnor 1-35
Generic
kimidess
Generic
kurvelo
Generic
larin
Generic
larin 24 fe
Generic
larin fe
Generic
larissia
Generic
leena
Generic
Requirements/Limits
82
LAST UPDATE 10/2016
Drug Name
Status*
lessina
Generic
levonest
Generic
levonorgestrel 1.5 mg tablet
Generic
levonorgestrel-ethinyl estradiol
Generic
levonorgestrel/ethinyl estradiol and
ethinyl estradiol
Generic
levora-28
Generic
lomedia 24 fe
Generic
lopreeza
Generic
loryna
Generic
low-ogestrel
Generic
lutera
Generic
marlissa
Generic
microgestin
Generic
microgestin fe
Generic
mimvey
Generic
mimvey lo
Generic
MY WAY
OTC
myzilra
Generic
necon (1-35-28 tablet, 1-50-28 tablet, 77-7-28 tablet, 10-11-28 tablet)
Generic
NEXT CHOICE ONE DOSE
OTC
nikki
Generic
norethindrone acetate-ethinyl estradiol
Generic
norethindrone acetate-ethinyl
estradiol/ferrous fumarate
Generic
norgestimate-ethinyl estradiol (7daysx3
28 tablet, 7daysx3 lo tablet)
Generic
nortrel (1-35 tablet, 7-7-7-28 tablet)
Generic
NUVARING
Brand
Requirements/Limits
83
LAST UPDATE 10/2016
Drug Name
Status*
ocella
Generic
ogestrel
Generic
OPCICON ONE-STEP
OTC
OPTION 2
OTC
orsythia
Generic
philith
Generic
pimtrea
Generic
pirmella
Generic
portia
Generic
PREFEST
Brand
PREMARIN (0.3 MG TABLET, 0.45 MG
TABLET, 0.625 MG TABLET, 0.9 MG
TABLET, 1.25 MG TABLET, VAGINAL
CREAM-APPL)
Brand
PREMPHASE
Brand
PREMPRO
Brand
quasense
Generic
REACT
OTC
reclipsen
Generic
setlakin
Generic
sronyx
Generic
syeda
Generic
tarina fe
Generic
tilia fe
Generic
tri-estarylla
Generic
tri-legest fe
Generic
tri-linyah
Generic
tri-lo-estarylla
Generic
tri-lo-marzia
Generic
tri-lo-sprintec
Generic
Requirements/Limits
84
LAST UPDATE 10/2016
Drug Name
Status*
tri-previfem
Generic
tri-sprintec
Generic
trinessa
Generic
trinessa lo
Generic
trivora-28
Generic
VAGIFEM
Brand
velivet
Generic
vestura
Generic
vienva
Generic
viorele
Generic
vyfemla
Generic
xulane
Generic
zarah
Generic
zenchent
Generic
zovia 1-35e
Generic
zovia 1-50e
Generic
Requirements/Limits
Progestins
camila
Generic
deblitane
Generic
DEPO-SUBQ PROVERA 104
Brand
errin
Generic
heather
Generic
jencycla
Generic
jolivette
Generic
levonorgestrel 0.75 mg tablet
Generic
lyza
Generic
medroxyprogesterone acetate (2.5 mg
Generic
megestrol acetate (20 mg tablet, 40 mg
tablet, 400mg/10ml oral susp)
Generic
85
LAST UPDATE 10/2016
Drug Name
Status*
nora-be
Generic
norethindrone 0.35 mg tablet
Generic
norethindrone acetate 5 mg tablet
Generic
norlyroc
Generic
progesterone,micronized (100 mg
Generic
sharobel
Generic
Requirements/Limits
Selective Estrogen Receptor Modifying Agents
raloxifene hcl
Generic
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
ARMOUR THYROID (15 MG TABLET, 120
MG TABLET, 180 MG TABLET, 240 MG
Brand
levothyroxine sodium (25 mcg tablet, 50
mcg tablet, 75 mcg tablet, 88 mcg
tablet, 100 mcg tablet, 112 mcg tablet,
125 mcg tablet, 137 mcg tablet, 150
mcg tablet, 175mcg tablet, 200 mcg
tablet, 300 mcg tablet)
Generic
levoxyl
Generic
liothyronine sodium (5 mcg tablet, 25
mcg tablet, 50 mcg tablet)
Generic
NATPARA
Specialty
np thyroid
Generic
THYROLAR-1
Brand
THYROLAR-1/2
Brand
THYROLAR-1/4
Brand
THYROLAR-2
Brand
THYROLAR-3
Brand
PA, LA, QL (2 PER 28 DAYS)
86
LAST UPDATE 10/2016
Drug Name
Status*
unithroid (25 mcg tablet, 50 mcg tablet,
75 mcg tablet, 88 mcg tablet, 100 mcg
tablet, 112 mcg tablet, 125 mcg tablet,
150 mcg tablet, 175 mcg tablet, 200
mcg tablet, 300 mcg tablet)
Generic
wp thyroid (32.5 mg tablet, 65 mg
Generic
Requirements/Limits
Hormonal Agents, Suppressant (Adrenal)
LYSODREN
Brand
SIGNIFOR
Specialty
PA, LA
Hormonal Agents, Suppressant (Parathyroid)
calcitriol (0.25 mcg capsule, 0.5 mcg
capsule, 1 mcg/ml solution)
Generic
paricalcitol (1 mcg capsule, 2 mcg
capsule, 4mcg capsule)
Generic
ST
SENSIPAR (30 MG TABLET, 60 MG
TABLET)
Specialty
QL (2 PER DAY)
SENSIPAR 90 MG TABLET
Specialty
QL (4 PER DAY)
Hormonal Agents, Suppressant (Pituitary)
ELIGARD
Brand
PA
GANIRELIX ACETATE
Brand
PA
leuprolide acetate 1 mg/0.2ml kit
Generic
PA
OCTREOTIDE ACETATE
Specialty
PA
SOMAVERT
Specialty
PA, LA
ZOLADEX 3.6 MG IMPLANT SYRN
Brand
PA
Hormonal Agents, Suppressant (Sex Hormones/Modifiers)
Antiandrogens
bicalutamide
Generic
87
LAST UPDATE 10/2016
Drug Name
Status*
NILUTAMIDE
Specialty
XTANDI
Specialty
Requirements/Limits
PA
Hormonal Agents, Suppressant (Thyroid)
Antithyroid Agents
methimazole (5 mg tablet, 10 mg
tablet)
Generic
propylthiouracil 50 mg tablet
Generic
Immunological Agents
Angioedema (HAE) Agents
BERINERT
Specialty
PA, LA, QL (3 PER 30 DAYS)
Immune Suppressants
ASTAGRAF XL
Brand
azathioprine 50 mg tablet
Generic
cyclosporine (25 mg capsule, 100 mg
capsule)
Generic
cyclosporine, modified 100 mg capsule
Generic
ENBREL (50 MG/ML SYRINGE, 50
MG/ML SURECLICK SYR)
Specialty
ENBREL 25 MG KIT
Specialty
QL (8 PER 28 DAYS)
ENBREL 25 MG/0.5 ML SYRINGE
Specialty
hecoria
Generic
HUMIRA (10 MG/0.2 ML SYRINGE, 20
MG/0.4 ML SYRINGE)
Specialty
QL (2 PER 28 DAYS)
HUMIRA 40 MG/0.8 ML SYRINGE
Specialty
QL (4 PER 28 DAYS)
HUMIRA PEDIATRIC CROHN'S
Specialty
QL (1 PER 28 DAYS)
HUMIRA PEN
Specialty
QL (2 PER 28 DAYS)
HUMIRA PEN CROHN-UC-HS STARTER
Specialty
QL (6 PER 28 DAYS)
HUMIRA PEN PSORIASIS-UVEITIS
Specialty
QL (4 PER 28 DAYS)
88
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
mycophenolate mofetil (200 mg/ml
susp recon, 250 mg capsule, 500 mg
tablet)
Generic
mycophenolate sodium
Generic
ORENCIA 125 MG/ML SYRINGE
Specialty
PA, QL (4 ML PER 28 DAYS)
ORENCIA CLICKJECT
Specialty
RAPAMUNE 1 MG/ML ORAL SOLN
Brand
RESTASIS
Brand
QL (2 PER DAY)
SIMPONI (100 MG/ML PEN INJECTOR,
100 MG/ML SYRINGE)
Specialty
SIMPONI (50 MG/0.5 ML SYRINGE, 50
MG/0.5 ML PEN INJEC)
Specialty
sirolimus (0.5 mg tablet, 1 mg tablet, 2
mg tablet)
Generic
tacrolimus (0.5 mg capsule, 1 mg
Generic
ZORTRESS
Specialty
Immunizing Agents, Passive
GAMMAKED
Specialty
PA
GAMUNEX-C
Specialty
PA
HIZENTRA
Specialty
PA
HYQVIA
Specialty
PA
ACTIMMUNE
Specialty
PA
FIRAZYR
Specialty
leflunomide
Generic
OTEZLA (28 DAY PACK, PACK)
Specialty
PA
OTEZLA 30 MG TABLET
Specialty
PA, QL (2 PER DAY)
XELJANZ
Specialty
PA, QL (2 PER DAY)
XELJANZ XR
Specialty
PA, QL (1 PER DAY)
Immunomodulators
89
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
Inflammatory Bowel Disease Agents
Aminosalicylates
balsalazide disodium
Generic
DIPENTUM
Brand
Glucocorticoids
colocort
Generic
hydrocortisone 100mg/60ml enema
Generic
proctosol-hc
Generic
proctozone-hc
Generic
UCERIS 9 MG ER TABLET
Brand
PA
ACCU CHEK (METERS & TEST STRIPS)
DME Benefit
QL (150 STRIPS PER 30 DAYS)
LIFESCAN (METERS & TEST STRIPS)
DME Benefit
QL (150 STRIPS PER 30 DAYS)
NOVOFINE NEEDLES
DME Benefit
QL
MISCELLANEOUS
Diabetes Testing Supplies
MISCELLANEOUS THERAPEUTIC AGENTS
ADENOSINE PHOSPHATE
OTC
ALTAMIST
OTC
ATHLETE'S FOOT 1% CREAM
OTC
CHILDREN'S SALINE NASAL SPRAY
OTC
CHOLECALCIFEROL (VITAMIN D3) 50000
UNIT CAPSULE
OTC
DEEP SEA
OTC
EPSOM SALT
OTC
LITTLE REMEDIES
OTC
LITTLE REMEDIES STUFFY NOSE
OTC
90
LAST UPDATE 10/2016
Drug Name
Status*
MAGNESIUM SULFATE 100 % CRYSTALS
OTC
NASAL MOISTURIZING
OTC
NASAL SPRAY (0.65% SPRAY, EQ 0.65%
SPRAY)
OTC
SEA SOFT
OTC
SODIUM CHLORIDE 0.65 % SPRAY
OTC
URINE ACETONE TEST,STRIPS STRIP
OTC
URINE ACETONE TEST,TABLET
OTC
URINE GLUCOSE-ACET TEST STRIP
OTC
VISTOGARD
Specialty
Requirements/Limits
PA
Metabolic Bone Disease Agents
alendronate sodium (5 mg tablet, 10
70 mg/75ml solution, 70 mg tablet)
Generic
calcitonin,salmon,synthetic
Generic
doxercalciferol (0.5 mcg capsule, 1 mcg
capsule, 2.5 mcg capsule)
Generic
etidronate disodium
Generic
fortical
Generic
ibandronate sodium 150 mg tablet
Generic
risedronate sodium (5 mg tablet, 30 mg
Generic
ST
Ophthalmic Agents
Ophthalmic Prostaglandin and Prostamide Analogs
bimatoprost
Generic
latanoprost 0.005 % drops
Generic
LUMIGAN
Brand
TRAVATAN Z
Brand
ST, QL (2.5 ML PER 30 DAYS)
ST, QL (2.5 ML PER 30 DAYS)
91
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
Ophthalmic Agents, Other
AKWA TEARS
OTC
ARTIFICIAL TEARS (, 1.4 % DROPS, CVS
DROPS, DROPS, EQ DROPS, RA DROPS)
OTC
BLEPHAMIDE
Brand
BLEPHAMIDE S.O.P.
Brand
CVS REDNESS RELIEF DROPS
OTC
CYSTARAN
Brand
GS LUBRICAT PLUS 0.5% EYE DRPS
OTC
LIQUITEARS
OTC
LUBRICANT EYE (CVS LUBRICANT
OINTMENT, GNP LUBRICANT 0.5%
DROPS, LUBRICANT 0.5% DROPS,
LUBRICANT DROPS, LUBRICANT
OINTMENT, PV LUBRICANT 1.4 %
DROPS, RA LUBRICANT DROPS)
OTC
LUBRICANT EYE DROPS (CVS
LUBRICANT 0.5% DROPS, CVS
LUBRICANT 0.6% DROPS, LUBRICANT
0.6% DROPS)
OTC
LUBRICANT PLUS
OTC
LUBRICANT PM
OTC
LUBRICATING RELIEF
OTC
LUBRICATING TEARS
OTC
LUBRIFRESH PM
OTC
MOISTURIZING LUBRICANT
OTC
naphazoline hcl
Generic
neo-polycin
Generic
neo-polycin hc
Generic
neomycin sulfate/bacitracin
zinc/polymyxin b/hydrocortisone
Generic
neomycin sulfate/bacitracin/polymyxin
b
Generic
PA, LA, QL (2 ML PER DAY)
92
LAST UPDATE 10/2016
Drug Name
Status*
sulfate/gramicidin d
Generic
neomycin/polymyxin b sulf/hc 3.5-10k10 drops susp
Generic
neomycin/polymyxin b
sulfate/dexamethasone (0.1 % drops
susp, 3.5-10k-.1 oint. (g))
Generic
neosporin eye drops
Generic
phenylephrine hcl (2.5 % drops, 10 %
drops)
Generic
polymyxin b sulfate/trimethoprim
Generic
POLYVINYL ALCOHOL 1.4 % DROPS
OTC
RA STERILE EYE DROPS
OTC
REDNESS LUBRICANT EYE DROPS
OTC
REDNESS RELIEVER EYE DROPS
OTC
REFRESH LACRI-LUBE
OTC
RESTORE TEARS
OTC
RETAINE CMC
OTC
sulfacetamide sodium 10 % oint. (g)
Generic
sulfacetamide sodium/prednisolone
sodium phosphate
Generic
TEARS AGAIN (1.4 % DROPS, EYE
OINTMENT)
OTC
TOBRADEX ST
Brand
tobramycin/dexamethasone
Generic
ULTRA FRESH
OTC
ULTRA FRESH PM
OTC
ULTRA LUBRICANT EYE DROPS
OTC
ZYLET
Brand
Requirements/Limits
Ophthalmic Anti-allergy Agents
ALOMIDE
Brand
93
LAST UPDATE 10/2016
Drug Name
Status*
azelastine hcl 0.05 % drops
Generic
Requirements/Limits
Ophthalmic Anti-inflammatories
flurbiprofen sodium
Generic
ketorolac tromethamine 0.4 % drops
Generic
LOTEMAX (0.5% EYE DROPS, 0.5%
OPHTHALMIC GEL, 0.5% EYE
OINTMENT)
Brand
PRED MILD
Brand
prednisolone sod phosphate 1 % drops
Generic
VEXOL
Brand
Ophthalmic Antiglaucoma Agents
AZOPT
Brand
betaxolol hcl 0.5 % drops
Generic
BETIMOL
Brand
BETOPTIC S
Brand
brimonidine tartrate (0.15 % drops, 0.2
% drops)
Generic
carteolol hcl
Generic
dorzolamide hcl
Generic
dorzolamide hcl/timolol maleate
Generic
levobunolol hcl
Generic
pilocarpine hcl (1 % drops, 2 % drops, 4
% drops)
Generic
timolol maleate (0.25 % drops, 0.25 %
sol-gel, 0.5 % sol-gel, 0.5 % drops)
Generic
Otic Agents
acetasol hc
Generic
acetic acid/hydrocortisone
Generic
AURAPHENE-B
OTC
94
LAST UPDATE 10/2016
Drug Name
Status*
CARBAMOXIDE
OTC
CIPRODEX
Brand
ciprofloxacin hcl 0.2 % droperette
Generic
COLY-MYCIN S
Brand
CORTISPORIN-TC
Brand
EAR DROPS (CVS DROPS 6.5%, DROPS
6.5%, EQL DROPS 6.5%, GNP DROPS
6.5%, RA DROPS 6.5%, SM DROPS 6.5%,
WAX DROPS 6.5%)
OTC
EAR HEALTH PLUS
OTC
EAR SYSTEM
OTC
EAR WAX REMOVAL
OTC
EARWAX TREATMENT
OTC
MURINE EAR WAX REMOVAL SYSTEM
OTC
Requirements/Limits
Respiratory Tract Agents
Anti-inflammatories, Inhaled Corticosteroids
24 HOUR ALLERGY RELIEF
OTC
PA
AEROSPAN
Brand
ALLER-FLO
OTC
PA
ALLERGY RELIEF (SM 50 MCG SPRAY, 50
MCG SPRAY)
OTC
PA
ALVESCO
Brand
ARNUITY ELLIPTA
Brand
ASMANEX
Brand
ASMANEX HFA
Brand
BREO ELLIPTA 100-25 MCG INH
Brand
budesonide (0.25mg/2ml ampul-neb,
0.5 mg/2ml ampul-neb, 1 mg/2 ml
ampul-neb)
Generic
CLARISPRAY
OTC
PA
95
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
flunisolide 29mcg spray
Generic
PA
PULMICORT FLEXHALER
Brand
QVAR
Brand
Antihistamines
24HOUR ALLERGY
OTC
PA
ALAVERT
OTC
PA
ALER-CAPS
OTC
ALER-TAB
OTC
ALKA-SELTZER PLUS ALLERGY
OTC
ALL DAY ALLERGY (1 MG/ML SYRUP,
EQL 10 MG TAB, GNP 10 MG TAB, HM
10 MG TAB, KRO 10 MG TAB, KRO 10
MG SFGL, SM 1 MG/ML SYR, 10 MG
CHEW TAB, PV 10 MG SFTGL, 10 MG
TABLET, QC 10 MG TAB, SM 10 MG
TAB)
OTC
PA
ALL DAY ALLERGY RELIEF
OTC
PA
ALLER-EASE
OTC
PA
ALLER-FEX
OTC
PA
ALLER-G-TIME
OTC
ALLER-TEC
OTC
PA
ALLERCLEAR
OTC
PA
ALLERCLEAR D-12HR
OTC
PA
96
LAST UPDATE 10/2016
Drug Name
Status*
ALLERGY (GNP 4 MG TABLET, KRO 4 MG
TABLET, 4 MG TABLET, CVS 12.5 MG/5
ML LIQ, EQL 4 MG TABLET, 25 MG
SOFTGEL, CVS 25 MG SOFTGEL, CVS 25
MG CAPSULE, CVS 25 MG TABLET, EQL
12.5 MG/5 ML LIQ, EQL 25 MG TABLET,
EQL 25 MG CAPSULE, GNP 25 MG
CAPSULE, GNP 25 MG TABLET, GNP 25
MG SOFTGEL, HM 25 MG TABLET, HM
25 MG CAPSULE, KRO 25 MG TABLET,
KRO 25 MG CAPSULE, PUB 12.5 MG/5
ML LIQ, PUB 25 MG CAPSULE, PUB 25
MG TABLET, RA 25 MG TABLET, 25 MG
TABLET, 25 MG CAPSULE)
OTC
ALLERGY (SB 10 MG TABLET, 10 MG
TABLET)
OTC
ALLERGY 4-HOUR
OTC
ALLERGY MEDICATION
OTC
ALLERGY MEDICINE (MEDICINE 25 MG
TABLET, PV MEDICINE 25 MG CAP, RA
MED 25 MG TABLET, SB 12.5 MG/5 ML
ELIXIR, SB MED 25 MG TABLET, SB
MEDICINE 25 MG CAP)
OTC
ALLERGY RELIEF (CVS 25 MG/10 ML LIQ,
CVS 50 MG/20 ML LIQ, CVS RELIEF 4
MG TABLET, EQ RELIEF 25 MG CAP, EQ
RELIEF 25 MG TABLET, EQL RELIEF 25
MG CAP, HM RELIEF 4 MG TABLET, HM
RELIEF 25 MG CAP, PV RELIEF 4 MG
TABLET, RA RELIEF 25 MG TABLET,
RELIEF 4 MG TABLET, RELIEF 25 MG
SOFTGEL, RELIEF 25 MG CAPSULE,
RELIEF 25 MG TABLET, SM RELIEF 1.34
MG TAB, SM RELIEF 12.5 MG/5 ML, SM
RELIEF 25 MG CAP, SM RELIEF 25 MG
SFTGEL, SM RELIEF 25 MG TABLET)
OTC
Requirements/Limits
PA
97
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
ALLERGY RELIEF (CVS RELIEF 5 MG/5
ML, CVS RELIEF 10 MG TAB, CVS RELIEF
10 MG SFTGL, CVS RELIEF 10 MG ODT,
CVS RELIEF 60 MG TAB, CVS RELIEF 180
MG TAB, EQ RELIEF 1 MG/ML SOLN, EQ
RELIEF 10 MG TABLET, EQ RELIEF 180
MG TAB, EQL RELIEF 10 MG TAB, EQL
RELIEF 10 MG ODT, GNP RELF 5 MG/5
ML SLN, GNP RELIEF 10 MG ODT, GNP
RELIEF 180 MG TAB, GS RELIEF 10 MG
TABLET, HM RELIEF 10 MG TABLET, HM
RELIEF 10 MG ODT, KRO RELIEF 10 MG
TAB, KRO RELIEF 60 MG TAB, KRO
RELIEF 180 MG TAB, PUB RELIEF 10 MG
TAB, PUB RELIEF 180 MG TAB, PV
RELIEF 10 MG TABLET, PV RELIEF 10 MG
ODT, PV RELIEF 180 MG TAB, QC RELIEF
10 MG ODT, RA RELIEF 10 MG TABLET,
RA RELIEF 180 MG TAB, RELIEF 5 MG/5
ML SOLN, RELIEF 10 MG TABLET, RELIEF
10 MG ODT, RELIEF 180 MG TABLET,
RELIEF SYRUP, SM RELIEF 10 MG ODT,
SW RELIEF 10 MG TAB)
OTC
PA
ALLERGY RELIEF D 12-HOUR TAB
OTC
PA
ALLERGY RELIEF D12
OTC
PA
ALLERGY RELIEF-D 12 HOUR TAB
OTC
PA
ALLERGY RELIEF-D12
OTC
PA
ALLERGY-CONGESTION
OTC
PA
ALLERGY-CONGESTION RELIEF (EQL 12H
TAB, KRO 12H TAB, RLF 12H TAB)
OTC
PA
ALLERGY-CONGESTION RLF-D 12HR
OTC
PA
ALLERGY-TIME
OTC
ALLERHIST-1
OTC
ANIMAL SHAPES PLUS IRON
OTC
ANTIHIST
OTC
ANTIHISTAMINE
OTC
BANOPHEN (ALLERGY 12.5 MG/5 ML,
12.5 MG/5 ML SOLUTION, 25 MG
CAPSULE, 25 MG TABLET, 50 MG
CAPSULE)
OTC
98
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
BENADRYL ALLERGY
OTC
CETIRIZINE HCL (1 MG/ML SOLUTION, 5
MG/5 ML SOLUTION, 5 MG TABLET, 5
MG TAB CHEW, 10 MG TAB CHEW, 10
MG TABLET)
OTC
CHEWABLE MULTIVITAMIN W-IRON
OTC
CHILD CHEW + IRON
OTC
CHILD'S VITAMIN WITH IRON
OTC
CHILD'S WAL-DRYL 12.5 MG/5 ML
OTC
CHILDREN'S ALL DAY ALLERGY
OTC
PA
CHILDREN'S ALLER-TEC
OTC
PA
CHILDREN'S ALLERGY (CHILD 12.5 MG/5
ML LIQ, CHILD'S 12.5 MG/5 ML, CVS
CHILD 12.5 MG/5 ML, EQL CHILD 12.5
MG/5 ML, GS CHILD 12.5 MG/5 ML, HM
CHILD 12.5 MG/5 ML, PV CHILD 12.5
MG/5 ML, QC CHILD 12.5 MG/5 ML,
12.5 MG/5 ML ELIXIR)
OTC
CHILDREN'S ALLERGY COMPLETE
OTC
CHILDREN'S ALLERGY RELIEF (CHILD REL
12.5 MG/5 ML, CHILD RLF 12.5 MG/5
ML, CHILD'S 12.5 MG/5ML, EQ CHILD
12.5 MG/5 ML, KRO CHILD 12.5 MG/5
ML, RA CHILD 12.5 MG/5 ML, SM CHILD
12.5 MG/5 ML)
OTC
CHILDREN'S ALLERGY RELIEF (CVS 10
MG CHW TB, CVS RELF 1 MG/ML, CVS
RELF 1MG/ML, CVS RLF 30 MG/5, EQ
RELF 1 MG/ML, EQ RELIEF SOLN, KRO
RELIEF SOLN, RA RELF 1 MG/ML, RELIEF
1 MG/ML)
OTC
CHILDREN'S MULTIVITAMIN-IRON
OTC
CHILDREN'S VITAMINS WITH IRON
OTC
CHILDREN'S WAL-FEX
OTC
PA
CHILDREN'S WAL-ZYR (CHILD 1 MG/ML
SOLUTION, CHILD'S 10 MG CHEW TAB)
OTC
PA
PA
PA
PA
99
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
CHILDREN'S ZYRTEC ALLERGY
OTC
PA
CHLD ALLEGRA ALLERGY 30 MG ODT
OTC
PA
CHLORHIST
OTC
CHLORPHENIRAMINE MALEATE 4 MG
TABLET
OTC
CHLORTABS
OTC
CLARITIN 10 MG LIQUI-GEL CAP
OTC
clemastine fumarate (0.67mg/5ml
syrup, 2.68 mg tablet)
Generic
CLEMASTINE FUMARATE 1.34 MG
TABLET
OTC
COMPLETE ALLERGY (COMPLETE 12.5
MG/5 ML, COMPLETE 25 MG TAB,
COMPLT MED 25 MG CP, PV COMPLETE
25 MG SFGL, PV COMPLETE 25 MG TAB,
QC COMPLETE 25 MG CAP, QC
COMPLETE 25 MG CPLT, RA COMPLETE
MED CPT, RA COMPLETE SOFTGEL)
OTC
COMPOZ
OTC
cyproheptadine hcl (2 mg/5 ml syrup, 4
mg tablet)
Generic
DAILYHIST-1
OTC
DAYHIST
OTC
DAYHIST ALLERGY
OTC
DIMENHYDRINATE 50 MG TABLET
OTC
DIPHEDRYL (12.5 MG/5 ML ELIXIR,
ALLERGY CAPSULE, GNP 12.5 MG/5 ML
ELX, GNP 25 MG TABLET, GNP ALLERGY
CAP, RA 12.5 MG/5 ML ELIX, 25 MG
TABLET)
OTC
DIPHEDRYL ALLERGY
OTC
DIPHEN
OTC
DIPHENHIST (12.5 MG/5 ML SOLN, 25
MG CAPTAB, 25 MG CAPLET, 50 MG
TABLET)
OTC
PA
100
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
DIPHENHYDRAMINE HCL (12.5MG/5ML
LIQUID, 12.5MG/5ML SYRUP, 25 MG
TABLET, 25 MG CAPSULE, 50 MG
CAPSULE, 50 MG TABLET)
OTC
diphenhydramine hcl 12.5mg/5ml elixir
Generic
DRIMINATE
OTC
ED CHLORPED JR
OTC
ED-CHLORTAN
OTC
FEXOFENADINE HCL (30 MG/5 ML ORAL
SUSP, 60 MG TABLET, 180 MG TABLET)
OTC
GERI-DRYL
OTC
levocetirizine dihydrochloride (2.5
mg/5ml solution, 5 mg tablet)
Generic
LITTLE ANIMALS WITH IRON
OTC
LORADAMED
OTC
PA
LORATADINE (5 MG/5 ML SOLUTION,
10 MG TABLET, 10 MG TAB RAPDIS)
OTC
PA
LORATADINE D
OTC
PA
LORATADINE-D (GNP 12 HOUR TAB, 12
HOUR TABLET)
OTC
PA
MEDI-PHEDRYL (12.5 MG/5 ML ELIX, 25
MG CAPSULE)
OTC
MOTION SICKNESS (50 MG TABLET, CVS
50 MG TAB, PV 50 MG TAB, SB 50 MG
TAB)
OTC
MOTION SICKNESS RELIEF (GNP 50 MG
TAB, HM 50 MG TAB, RA 50 MG TAB,
SM 50 MG TAB)
OTC
MUCINEX ALLERGY
OTC
NIGHTTIME ALLERGY RELIEF
OTC
PA
PA
PA
101
LAST UPDATE 10/2016
Drug Name
Status*
NIGHTTIME SLEEP AID (CVS NIGHTTIME
25 MG CPLT, EQ NIGHTTIME 25 MG
CPLT, EQL NIGHTTIME 25 MG CPLT,
GNP NIGHTTIME 25 MG CPLT, KRO
NIGHTTIME 25 MG CPLT, NIGHT TIME
25 MG CAPLET, NIGHTTIME AID 25 MG
CPLT, QC NIGHTTIME 25 MG TAB, RA
NIGHTTIME 25 MG TAB, RA NIGHTTIME
25 MG CPLT)
OTC
NON-DROWSY ALLERGY
OTC
NYT-TIME SLEEP
OTC
NYTOL QUICKCAPS
OTC
PHARBECHLOR
OTC
PHARBEDRYL
OTC
PUB CHILDREN'S ALLERGY 1 MG/ML
OTC
PV KID'S VIT + IRON TAB CHEW
OTC
Q-DRYL (12.5 MG/5 ML LIQUID, 25 MG
CAPSULE)
OTC
QUENALIN
OTC
REST SIMPLY
OTC
RESTFULLY SLEEP
OTC
SILADRYL
OTC
SILPHEN
OTC
SIMPLY SLEEP
OTC
SLEEP AID (CVS CAPLET, EQL 25 MG
CAPLET, PV 25 MG CAPLET, PV 25 MG
TABLET, 25 MG TABLET, CVS 25 MG
TABLET, PV TABLET, RA 25 MG CAPLET,
25 MG CAPLET, SM NIGHT TIME
CAPLET, TABLET)
OTC
SLEEP II
OTC
SLEEP TABLET
OTC
SLEEP TABS
OTC
TOTAL ALLERGY
OTC
Requirements/Limits
PA
PA
102
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
TRAVEL SICKNESS (50 MG TABLET, RA
50 MG TAB)
OTC
V-R PEDIA RELIEF INF DROPS
OTC
V-R VALUDRYL 12.5 MG/5 ML ELX
OTC
VALU-DRYL ALLERGY MEDICINE
OTC
VICKS QLEARQUIL ALLERGY
OTC
VICKS QLEARQUIL NIGHT 25 MG
OTC
VITALETS
OTC
WAL-DRAM
OTC
WAL-DRYL (25 MG MINITAB, 25 MG
CAPSULE, 25 MG SOFTGEL)
OTC
WAL-DRYL ALLERGY 12.5 MG/5 ML
OTC
WAL-FEX ALLERGY
OTC
PA
WAL-FEX D 24 HOUR
OTC
PA
WAL-FINATE
OTC
WAL-ITIN (CHILD 5 MG/5 ML SYRUP, 5
MG/5 ML SYRUP, 10 MG TABLET, 10
MG ODT)
OTC
PA
WAL-ITIN D 12 HOUR
OTC
PA
WAL-ZYR (10 MG SOFTGEL, 10 MG
TABLET, SOLUTION)
OTC
PA
ZYRTEC 10 MG ODT
OTC
PA
montelukast sodium (4 mg gran pack, 4
mg tab chew, 5 mg tab chew, 10 mg
tablet)
Generic
PA
zafirlukast
Generic
PA
Antileukotrienes
Bronchodilators, Anticholinergic
ATROVENT HFA
Brand
INCRUSE ELLIPTA
Brand
ipratropium bromide 0.2 mg/ml
solution
Generic
103
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
SPIRIVA
Brand
SPIRIVA RESPIMAT
Brand
Bronchodilators, Phosphodiesterase Inhibitors (Xanthines)
ELIXOPHYLLIN
Brand
THEO-24 ER 300 MG CAPSULE
Brand
theochron
Generic
theophylline anhydrous (80 mg/15ml
elixir, 80 mg/15ml solution, 100 mg tab
er 12h, 200 mg tab er 12h, 300 mg tab
er 12h, 450 mg tab er 12h)
Generic
Bronchodilators, Sympathomimetic
ADVAIR DISKUS
Brand
ADVAIR HFA
Brand
albuterol sulfate (0.63mg/3ml vial-neb,
1.25mg/3ml vial-neb, 2 mg/5 ml syrup,
2 mg tablet, 2.5 mg/3ml vial-neb, 4 mg
tab er 12h, 4 mg tablet, 5 mg/ml
solution, 8 mg tab er 12h)
Generic
ANORO ELLIPTA
Brand
BREO ELLIPTA 200-25 MCG INH
Brand
COMBIVENT RESPIMAT
Brand
QL (4 GM PER 30 DAYS), (ELIGIBLE
FOR 90 DAY SUPPLY)
epinephrine 0.15 mg auto-injct
Generic
epinephrine 0.3 mg auto-inject
Generic
EPIPEN 2-PAK
Brand
EPIPEN JR 2-PAK
Brand
FORADIL
Brand
ipratropium bromide/albuterol sulfate
Generic
levalbuterol tartrate
Generic
metaproterenol sulfate (10 mg tablet,
10 mg/5 ml syrup, 20 mg tablet)
Generic
proair hfa
Generic
QL (17 GM PER 30 DAYS)
104
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
proair respiclick
Generic
QL (2 PER 30 DAYS)
SEREVENT DISKUS
Brand
SYMBICORT
Brand
terbutaline sulfate (2.5 mg tablet, 5 mg
tablet)
Generic
ventolin hfa
Generic
QL (36 GM PER 30 DAYS)
Mast Cell Stabilizers
cromolyn sodium 20 mg/2 ml ampulneb
Generic
Pulmonary Antihypertensives
ADCIRCA
Specialty
PA, QL (2 PER DAY)
ADEMPAS
Specialty
PA
LETAIRIS
Specialty
PA
OPSUMIT
Specialty
PA, LA
ORENITRAM ER
Specialty
PA, LA
REVATIO 10 MG/ML ORAL SUSP
Specialty
PA
sildenafil citrate 20 mg tablet
Generic
PA, QL (3 PER DAY)
TRACLEER
Specialty
PA, LA
UPTRAVI
Specialty
PA, LA, (ELIGIBLE FOR 90 DAY SUPPLY)
VENTAVIS
Specialty
PA
Respiratory Tract Agents, Other
12 HOUR COLD RELIEF
OTC
12 HOUR DECONGESTANT
OTC
60PSE-400GFN
OTC
ACTIDOM DMX
OTC
ADLT WAL-TUSSIN COUGH-COLD CF
OTC
ADT ROBITUSSIN PEAK CLD DM MAX
OTC
ADULT COUGH FORMULA DM MAX
OTC
ADULT ROBITUSSIN PEAK COLD
OTC
105
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
ADULT ROBITUSSIN PEAK COLD M-S
OTC
ADULT TUSSIN CHEST CONGESTION
OTC
ADULT TUSSIN COUGH CONGEST DM
OTC
ADULT TUSSIN DM
OTC
ADULT TUSSIN MULTI-SYMP COLD
OTC
ADULT WAL-TUSSIN
OTC
ADULT WAL-TUSSIN DM
OTC
ADULT WAL-TUSSIN DM MAX
OTC
ALLERCLEAR D-24HR
OTC
PA
ALLERGY RELIEF D-24
OTC
PA
ALLERGY RELIEF-NASAL DECONGEST
OTC
PA
ALLERGY-CONGEST RLF-D 24HR TAB
OTC
PA
ALLERGY-CONGESTION RELIEF
(ALLERGY CONGESTION RELIEF TAB,
ALLERGY-CONGES RELF ER TABLET,
ALLERGY-CONGEST RELIEF ER TAB, EQL
ALLERGY-CONGEST RLF ER TAB, GNP
ALLERGY-CONGES RELF ER TAB, KRO
ALLERGY-CONGEST RLF ER TAB)
OTC
PA
AMBITUSSIN AC
OTC
ANTITUSSIVE DM
OTC
APRODINE
OTC
benzonatate
Generic
BIO-S-PRES DX
OTC
BIOCOTRON
OTC
BIOGIL
OTC
bromfed dm
Generic
brompheniramine/pseudoephed/dm 230-10/5 syrup
Generic
BRONTUSS SF
OTC
CHERATUSSIN AC
OTC
106
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
CHERATUSSIN DAC
OTC
CHEST CONGESTION RELIEF D
OTC
CHILD MUCINEX CHEST CONGESTION
OTC
CHILDREN'S CHEST CONGESTION
OTC
CHILDREN'S COLD & ALLERGY ELXR
OTC
CHILDREN'S MUCUS RELIEF
OTC
CLARITIN 5 MG REDITABS
OTC
CONGEST-EZE
OTC
CONGESTAC
OTC
COUGH
OTC
COUGH AND COLD MULTI-SYMPTOM
OTC
COUGH CONTROL CF
OTC
COUGH CONTROL DM
OTC
COUGH CONTROL DM MAX
OTC
COUGH FORMULA DM
OTC
COUGH SYRUP 100 MG/5 ML
OTC
COUGH SYRUP DM
OTC
COUGH-COLD
OTC
COUGH-HEAD CONGESTION RELIEF
OTC
COUGHTAB
OTC
CREO-TERPIN
OTC
DAY TIME LIQUID CAPSULE
OTC
DESGEN DM LIQUID
OTC
DESPEC DM
OTC
DESPEC DM-G
OTC
DESPEC EDA COUGH & COLD DROPS
OTC
DIABETIC SILTUSSIN DAS-NA
OTC
DIABETIC SILTUSSIN-DM
OTC
PA
107
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
DIABETIC SILTUSSIN-DM MAX STR
OTC
DIABETIC TUSSIN DM
OTC
DIABETIC TUSSIN EX
OTC
DIABETIC TUSSIN MAX-STRENGTH
OTC
DOMETUSS-DMX
OTC
ED A-HIST PSE
OTC
ESBRIET
Specialty
EXEFEN IR
OTC
EXPECTORANT (100 MG/5 ML SYRUP,
200 MG TABLET, RA COUGH SYRUP)
OTC
EXPECTORANT COUGH SYRUP
OTC
EXPECTORANT DM COUGH SYRUP
OTC
EXTRA ACTION COUGH
OTC
G-TRON LIQUID
OTC
GERI-TUSSIN
OTC
GERI-TUSSIN DM
OTC
GRASTEK
Brand
GUAIASORB DM
OTC
GUAIATUSSIN AC
OTC
GUAIFENESIN (100 MG/5ML LIQUID,
200 MG TABLET, 600 MG TAB ER 12H)
OTC
GUAIFENESIN AC
OTC
GUAIFENESIN DAC
OTC
GUAIFENESIN/CODEINE PHOSPHATE
OTC
GUAIFENESIN/DEXTROMETHORPHAN
HBR (100-10MG/5 SYRUP, 100-10MG/5
LIQUID)
OTC
GUAIFENESIN/PSEUDOEPHEDRINE HCL
OTC
hydrocodone bitartrate/homatropine
methylbromide (5 mg-1.5mg tablet, 51.5 mg/5 syrup)
Generic
PA, LA
PA
108
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
hydromet
Generic
HYPER-SAL 3.5% VIAL
Brand
INTENSE COUGH
OTC
INTENSE COUGH RELIEVER
OTC
IOPHEN DM-NR
OTC
IOPHEN NR
OTC
IOPHEN-C NR
OTC
KALYDECO
Specialty
LOHIST-D
OTC
LONG ACTING NASAL DECONGESTANT
OTC
LORATA-D
OTC
PA
LORATA-DINE D
OTC
PA
LORATADINE-D (24HR TABLET, CVS
24HR TABLET, GNP 24HR TABLET, QC
24HR TABLET)
OTC
PA
LORTUSS EX
OTC
MEDI-PHEDRINE
OTC
MEDI-TUSSIN
OTC
MEDI-TUSSIN DM
OTC
MEDI-TUSSIN DM DIABETIC
OTC
MEDIFIN EXPECTORANT MUCUS RLF
OTC
MUCINEX DM ER 600-30 MG TABLET
OTC
MUCUS D
OTC
MUCUS DM
OTC
MUCUS ER (CVS ER 600 MG TABLET, EQ
ER 600 MG TABLET, EQL ER 600 MG
TABLET, ER 600 MG TABLET, GNP ER
600 MG TABLET, HM ER 600 MG
TABLET, KRO ER 600 MG TABLET, SM ER
600 MG TABLET)
OTC
MUCUS RELIEF (ER 600 MG TABLET, RA
ER 600 MG TAB, SB 200 MG TABLET)
OTC
109
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
MUCUS RELIEF D (HM RLF ER 600-60
MG TB, RA RELIEF ER 600-60 MG, RA
RELIEF ER 1,200-120)
OTC
MUCUS-ER
OTC
NASAL & SINUS DECONGESTANT
OTC
NASAL DECONGEST-ANTIHISTAMINE
OTC
NASAL DECONGESTANT (CVS
DECONGEST 30 MG TAB,
DECONGESTANT 30 MG TAB, EQL
DECONGEST 30 MG TAB, GNP
DECONGEST 30 MG TAB, HM
DECONGEST 30 MG TAB, HM
DECONGEST ER 120 MG, KRO
DECONGEST 30 MG TAB, PUB
DECONGEST 30 MG TAB, PUB
DECONGEST ER 120 MG, PV
DECONGEST 30 MG TAB, SM
DECONGEST 30 MG TAB, SW
DECONGESTANT 30 MG TB)
OTC
NASAL DECONGESTANT-ANTIHIST
OTC
NON-DRYING SINUS
OTC
OFEV
Specialty
PA
ORALAIR
Brand
PA, LA
ORGAN-I NR
OTC
ORKAMBI 200 MG-125 MG TABLET
Specialty
PEDIA RELIEF INFANT
OTC
PEDIATRIC COUGH-COLD SYRUP
OTC
phenylephrine hcl/promethazine hcl
Generic
promethazine hcl/codeine
Generic
promethazine hcl/dextromethorphan
hbr
Generic
promethazine/phenylephrine
hcl/codeine
Generic
PSEUDOEPHEDRINE HCL (30 MG/5 ML
LIQUID, 30 MG TABLET, 60 MG TABLET,
120 MG TABLET ER)
OTC
110
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
PUB ALLERGY RELIEF D TABLET
OTC
PA
pulmosal
Generic
PULMOZYME
Specialty
PV COLD & COUGH SOFTGEL
OTC
PV SINUS & ALLERGY 120 MG CPLT
OTC
Q-TAPP
OTC
Q-TUSSIN
OTC
Q-TUSSIN DM
OTC
RAGWITEK
Brand
REFENESEN 200 MG TABLET
OTC
RI-TUSSIN
OTC
RI-TUSSIN DM
OTC
ROBAFEN
OTC
ROBAFEN CF
OTC
ROBAFEN DM COUGH
OTC
ROBAFEN DM COUGH-CHEST CONGEST
OTC
ROBAFEN-DM
OTC
ROBITUSSIN COUGH-CHEST DM LIQ
OTC
RYNEX PSE
OTC
SAFETUSSIN DM
OTC
SB COUGH CONTROL SYRUP
OTC
SILTUSSIN DM
OTC
SILTUSSIN DM DAS COUGH FORMULA
OTC
SILTUSSIN SA
OTC
SINUS 12 HOUR
OTC
SINUS 12-HOUR
OTC
SM COLD & ALLERGY TABLET
OTC
SM DAY TIME COLD-FLU REL SFTGL
OTC
PA
111
LAST UPDATE 10/2016
Drug Name
Status*
sodium chloride for inhalation 7 % vialneb
Generic
SORBUGEN NR
OTC
SUDOGEST
OTC
SUPHEDRIN (GNP 30 MG TABLET, 30
MG TABLET)
OTC
SUPHEDRIN 12-HOUR
OTC
SUPHEDRINE
OTC
SUPHEDRINE 12-HOUR
OTC
SUPHEDRINE SINUS CONGESTION
OTC
TRIACTING EXPECTORANT
OTC
TUSNEL C
OTC
TUSNEL DIABETIC
OTC
TUSNEL PEDIATRIC DROPS
OTC
tussigon
Generic
TUSSIN (CVS 100 MG/5 ML LIQUID, EQL
100 MG/5 ML LIQUID, GNP 100 MG/5
ML SYRUP, KRO 200 MG/10 ML SYRUP,
PUB 100 MG/5 ML SYRUP, PV 100
MG/5 ML LIQUID, SM 100 MG/5 ML
LIQUID, 100 MG/5 ML SYRUP, QC 100
MG/5 ML LIQUID, RA 100 MG/5 ML
SYRUP)
OTC
TUSSIN CF
OTC
TUSSIN CHEST CONGESTION
OTC
TUSSIN COLD SEVERE CONGESTION
OTC
TUSSIN COUGH (CVS LIQUID, RA
LIQUID)
OTC
TUSSIN COUGH DM
OTC
TUSSIN COUGH-CHEST CONGESTION
OTC
Requirements/Limits
112
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
TUSSIN DM (CLEAR LIQUID, COUGH &
CHEST SYRUP, COUGH SYRUP, CVS
LIQUID, EQ COUGH-CHEST SYR, EQL
COUGH-CHEST SYR, EQL SYRUP, GNP
SYRUP, KRO LIQUID, LIQUID, PUB
LIQUID, PV LIQUID, PV SYRUP, QC
SYRUP, RA SYRUP, SM SYRUP, SYRUP)
OTC
TUSSIN DM CLEAR
OTC
TUSSIN DM COUGH
OTC
TUSSIN DM COUGH & CHEST
OTC
TUSSIN DM COUGH-CHEST CONGEST
OTC
TUSSIN DM MAX
OTC
TUSSIN HONEY
OTC
TUSSIN MUCUS-CHEST CONGESTION
OTC
ULTRA DM FREE & CLEAR
OTC
ULTRA TUSS
OTC
V-R TUSSIN PE SYRUP
OTC
VALU-TAPP
OTC
VALU-TAPP DECONGESTANT
OTC
VIRTUSSIN AC
OTC
VIRTUSSIN DAC
OTC
WAL-ACT D COLD & ALLERGY
OTC
WAL-ITIN D
OTC
WAL-PHED 12 HOUR
OTC
WAL-PHED 30 MG TABLET
OTC
WAL-PHED D
OTC
WAL-TUSSIN COUGH-COLD CF
OTC
WAL-TUSSIN DM
OTC
WAL-TUSSIN SYRUP
OTC
PA
113
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
Skeletal Muscle Relaxants
carisoprodol (250 mg tablet, 350 mg
tablet)
Generic
carisoprodol/aspirin
Generic
chlorzoxazone
Generic
cyclobenzaprine hcl (5 mg tablet, 7.5
Generic
metaxall
Generic
metaxalone 800 mg tablet
Generic
methocarbamol (500 mg tablet, 750 mg
tablet)
Generic
orphenadrine citrate 100 mg tablet er
Generic
orphenadrine citrate/aspirin/caffeine
Generic
Sleep Disorder Agents
GABA Receptor Modulators
flurazepam hcl
Generic
temazepam (7.5 mg capsule, 15 mg
Generic
triazolam
Generic
Sleep Disorders, Other
CVS NIGHTTIME SLEEP 25 MG TAB
OTC
SLEEP AID (EQ 25 MG TABLET, EQL 25
MG TABLET, GS 25 MG TABLET, RA 25
MG TABLET)
OTC
WAL-SOM 25 MG TABLET
OTC
XYREM
Specialty
PA, LA, QL (18 ML PER DAY)
114
LAST UPDATE 10/2016
Drug Name
Status*
Requirements/Limits
Therapeutic Nutrients/Minerals/Electrolytes
Electrolyte/Mineral Modifiers
CARNITOR SF
Brand
EXJADE
Specialty
JADENU 180 MG TABLET
Specialty
kionex powder
Generic
levocarnitine (with sugar)
Generic
levocarnitine 330 mg tablet
Generic
sodium polystyrene sulfonate (50
g/200ml enema, powder)
Generic
Electrolyte/Mineral Replacement
A THRU Z ADVANCED FORMULA
OTC
A THRU Z ADVANCED FORMULA TAB
OTC
A THRU Z SELECT
OTC
A THRU Z SELECT 50+ FORMULA
OTC
A-G PRO
OTC
ABC PLUS
OTC
ADULTS 50+ MULTIVITAMIN
OTC
ADULTS' 50+ DAILY FORMULA
OTC
ADULTS' DAILY FORMULA
OTC
AMINO ACIDS CAPSULE
OTC
AMINO ACTION
OTC
ANIMAL CHEWS
OTC
ANIMAL SHAPES
OTC
ANIMAL SHAPES VITAMINS
OTC
ANTIOXIDANT FORM SOFTGEL CAP
OTC
ANTIOXIDANT SOFTGEL
OTC
ANTIOXIDANT VITAMIN
OTC
115
LAST UPDATE 10/2016
Drug Name
Status*
ANTIOXIDANT VITAMINS
OTC
AQUADEKS (CHEWABLE TABLET,
PEDIATRIC LIQUID)
OTC
ASCORBATE CALCIUM 500 MG TABLET
OTC
ASCORBIC ACID (250 MG TAB CHEW,
250 MG TABLET, 500 MG TAB CHEW,
500 MG TABLET, 500 MG TABLET ER,
500 MG WAFER, 1000 MG TAB CHEW)
OTC
ASCORBIC ACID/ASCORBATE SODIUM
500 MG WAFER
OTC
B COMPLETE
OTC
B COMPLEX WITH VITAMIN C TABLET
OTC
B-12 DOTS
OTC
BAL B-100
OTC
BAL B-50
OTC
BALANCE B-100
OTC
BALANCE B-50
OTC
BALANCED B-100 TABLET
OTC
BALANCED B-50 (B-50 TABLET, RA B-50
TABLET, SM B-50 TABLET, V-R B-50
TABLET)
OTC
BEE-ZEE
OTC
BIOPETIT
OTC
BIOTIN 5 MG CAPSULE
OTC
BIOVOL
OTC
C 500 MG TIMED RELEASED
OTC
C COMPLEX 500 MG TABLET SA
OTC
CA/D3/MAG OX/ZINC/COP/MANG/BOR
600 MG-800 TABLET
OTC
CALCIDOL
OTC
CALCITRATE
OTC
calcium acetate 667 mg tablet
Generic
Requirements/Limits
116
LAST UPDATE 10/2016
Drug Name
Status*
CALCIUM CARBONATE (500(1250)
OTC
CALCIUM
CARBONATE,CITRATE/MAGNESIUM
OXIDE,ASPARTATE/VIT D3
OTC
CALCIUM
CARBONATE/CHOLECALCIFEROL
(VITAMIN D3) (D3 250 MG-125 TABLET,
D3 600 MG-125 TABLET, D3 500 MG200 TABLET, D3 600 MG-200 TABLET,
D3 500 MG-100 TAB CHEW, D3 600
MG-400 TABLET, D3 600 MG-800
TABLET, D3 500 MG-400 TABLET, D3
500 MG-600 TABLET)
OTC
CALCIUM
CARBONATE/ERGOCALCIFEROL
(VITAMIN D2)
OTC
CALCIUM CITRATE 200(950)MG TABLET
OTC
CALCIUM CITRATE/ERGOCALCIFEROL
(VITAMIN D2)
OTC
CALPHRON
OTC
CENTAMIN
OTC
CENTRAL VITE
OTC
CENTRAL VITE FOR SENIORS
OTC
CENTRAL-VITE (EQL TABLET, RA TABLET)
OTC
CENTRAL-VITE SELECT
OTC
CENTRAL-VITE SENIOR
OTC
CENTRAL-VITE WOMEN'S UNDER 50
OTC
CENTRAM-CARE
OTC
CENTRAVITES 50 PLUS
OTC
CENTRUM COMPLETE
OTC
CENTRUM MULTIVIT-MINERAL LIQ
OTC
CENTRUM SILVER TABLET
OTC
CENTURY
OTC
Requirements/Limits
117
LAST UPDATE 10/2016
Drug Name
Status*
CENTURY ADVANCED FORMULA
OTC
CENTURY MATURE
OTC
CENTURY ULTIMATE MEN'S
OTC
CENTURY ULTIMATE WOMEN'S
OTC
CEROVITE JR
OTC
CERTAVITE-ANTIOXIDANT (LIQUID,
TABLET)
OTC
CHEWABLE MULTI VITAMIN
OTC
CHILD CHEW VITAMIN
OTC
CHILD VITAMIN WITH MINERALS
OTC
CHILDREN'S CHEW MULTIVIT-IRON
OTC
CHILDREN'S CHEWABLE VITAMIN
OTC
CHILDREN'S IRON
OTC
CHILDREN'S MULTIVIT W-EXTRA C
OTC
CHILDREN'S MULTIVIT-MINERALS
OTC
CHOLECALCIFEROL (VITAMIN D3) (D3)
400 UNIT TABLET, D3) 2000 UNIT
TABLET, D3) 1000 UNIT CAPSULE, D3)
5000 UNIT CAPSULE, D3) 5000 UNIT
TABLET, D3) 1000 UNIT TABLET, D3)
400/ML DROPS, D3) 2000 UNIT
CAPSULE, D3) 400 UNIT CAPSULE)
OTC
CLASSIC PRENATAL
OTC
COMPLETE (ADVANCED TABLET,
TABLET)
OTC
COMPLETE 50+
OTC
COMPLETE MULTI
OTC
COMPLETE MULTI 50+
OTC
COMPLETE MULTI-VIT-MINERAL
OTC
COMPLETE MULTIVITAMIN
OTC
COMPLETE PREMIUM VITAMIN
OTC
COMPLETE SENIOR
OTC
Requirements/Limits
118
LAST UPDATE 10/2016
Drug Name
Status*
COMPLETE WOMEN
OTC
completenate
Generic
CVS CALCIUM 600-D3 PLUS TABLET
OTC
CVS IRON 27 MG TABLET
OTC
CVS SPECTRAVITE ADULT 50+ TABS
OTC
CYANOCOBALAMIN (VITAMIN B-12) (B12) 1000 MCG TABLET, B-12) 500 MCG
TABLET, B-12) 100 MCG TABLET, B-12)
1000 MCG TAB SUBL, B-12) 1000 MCG
TABLET ER)
OTC
cyanocobalamin (vitamin b-12)
1000mcg/ml vial
Generic
D-VI-SOL
OTC
D-VITA
OTC
D3 DOTS
OTC
D3-2000
OTC
DAILY MULTIPLE (CVS DAILY TABLET,
DAILY TABLET)
OTC
DAILY MULTIPLE VITAMIN
OTC
DAILY MULTIVITAMIN WITH IRON
OTC
DAILY MULTIVITAMIN-IRON
OTC
DAILY VALUE
OTC
DAILY VITAMIN
OTC
DAILY VITAMIN + IRON
OTC
DAILY VITAMIN FORMULA
OTC
DAILY VITAMIN FORMULA + IRON
OTC
DAILY VITAMIN FORMULA-MINERALS
OTC
DAILY VITE TABLET
OTC
DECARA 50,000 UNIT SOFTGEL
OTC
DECUBI VITE
OTC
DELTA D3
OTC
Requirements/Limits
119
LAST UPDATE 10/2016
Drug Name
Status*
dialyvite
Generic
DIALYVITE 800
OTC
DIALYVITE VITAMIN D
OTC
DIALYVITE ZINC
Brand
DINO-LIFE
OTC
DINO-LIFE WITH EXTRA C
OTC
EAR CARE
OTC
EAR HEALTH FORMULA
OTC
ELDERCAPS
Brand
ELDERTONIC
OTC
eliphos
Generic
ELLIS TONIC
OTC
EQL CENTRAL-VITE PERFORMANCE
OTC
EQL ONE DAILY MEN'S TABLET
OTC
ERGOCALCIFEROL (VITAMIN D2) (D2)
8000/ML DROPS, D2) 400 UNIT TABLET)
OTC
ergocalciferol (vitamin d2) 50000 unit
capsule
Generic
ESCAVITE
Brand
ESSENTIA
OTC
EYE HEALTH PLUS LUTEIN
OTC
FEOSOL 65 MG TABLET
OTC
FER-IRON
OTC
FERATE
OTC
FERGON
OTC
FEROSUL 325 MG TABLET
OTC
FERREX 150
OTC
ferrex 150 forte plus
Generic
FERRIC X-150
OTC
Requirements/Limits
120
LAST UPDATE 10/2016
Drug Name
Status*
FERRO-TIME
OTC
FERROUS GLUCONATE (240(27)MG
TABLET, 324(38)MG TABLET,
324(36)MG TABLET, 324(37.5) TABLET)
OTC
FERROUS SULFATE (15 MG/ML DROPS,
47.5 IRON TABLET ER, 134MG TABLET,
142(45)MG TABLET ER, 143(45) MG
TABLET ER, 220 (44)/5 ELIXIR, 220
(44)/5 SOLUTION, 324(65)MG TABLET
DR, 325(65) MG TABLET DR, 325(65)
MG TABLET)
OTC
FERROUSUL
OTC
FLINTSTONES COMPLETE TABLET
OTC
FLINTSTONES EXTRA C TAB CHEW
OTC
FLINTSTONES PLUS CALCIUM
OTC
FLINTSTONES TABLET CHEWABLE
OTC
FLINTSTONES WITH IRON
OTC
fluoride/iron/vitamins a,c,and d
Generic
flura-drops
Generic
folbee plus
Generic
FOLIC ACID (0.4 MG TABLET, 0.8 MG
TABLET)
OTC
folic acid 1 mg tablet
Generic
FOLIC ACID/VIT BCOMP,C 400 MCG
TABLET
OTC
FOLIC ACID/VITAMIN B COMPLEX AND
C/RICE BRAN
OTC
FOSFREE
OTC
FRUIT C-500
OTC
FULL SPECTRUM B
OTC
GERAVIM
OTC
GERIATON
OTC
GERITOL COMPLETE
OTC
Requirements/Limits
121
LAST UPDATE 10/2016
Drug Name
Status*
GERITOL TONIC
OTC
GUMMI BEAR MULTIVITAMIN
OTC
HAIR VITAMIN
OTC
HAIR, SKIN AND NAILS (CVS SKIN CPLT,
CVS SKIN TAB, GNP SKIN TAB, HM SKIN
CAPLET, PV SKIN TABLET, SKIN CAPLET,
SM SKIN CAPLET)
OTC
HEALTHY EYES
OTC
HI B COMPLEX
OTC
HIGH POTENCY CALCIUM
OTC
HIGH POTENCY IRON
OTC
HIGH PROTEIN
OTC
HONEY BEARS
OTC
ICAPS PLUS
OTC
IFEREX 150
OTC
inatal advance
Generic
iron
asp,gly,ps/ascorb.calcium/b12/folic/cal
cium/succ.acid
Generic
k-sol 10% (20 meq/15 ml) liq
Generic
KENWOOD THERAPEUTIC
OTC
KID'S GUMMY BEAR VITAMINS
OTC
KID'S VITAMINS
OTC
KID'S VITAMINS + EXTRA C
OTC
KID'S VITAMINS COMPLETE
OTC
klor-con 8
Generic
klor-con m10
Generic
KLOR-CON M15
Brand
klor-con m20
Generic
klor-con sprinkle
Generic
Requirements/Limits
122
LAST UPDATE 10/2016
Drug Name
Status*
MACUVITE
OTC
MACUVITE EYE CARE
OTC
MAG64
OTC
MAGNESIUM 250 MG TABLET
OTC
MAGNESIUM OXIDE (400 MG TABLET,
500 MG CAPSULE)
OTC
MEGA MULTI W-CHELATED MINERALS
OTC
MEGA MULTIVITAMIN WITH MINERAL
OTC
MEN 50 PLUS MULTIVITAMIN
OTC
MEN'S DAILY MULTIVIT-MINERAL
OTC
MEN'S MULTI-VITAMIN
OTC
MEPHYTON
Brand
MG-PLUS-PROTEIN
OTC
MGO
OTC
MILLTRIUM SENIOR
OTC
MULTI COMPLETE-IRON
OTC
MULTI-DAY PLUS IRON
OTC
MULTI-DELYN LIQUID
OTC
MULTI-VITAMIN DAILY
OTC
MULTI-VITE
OTC
MULTI-VITE 50 & OVER
OTC
MULTIVIT WITH CALCIUM, IRON, AND
OTHER MINERALS
OTC
MULTIVITAL
OTC
MULTIVITAL PERFORMANCE
OTC
MULTIVITAL PLATINUM
OTC
MULTIVITAMIN
OTC
MULTIVITAMIN WITH IRON
OTC
MULTIVITAMIN WITH MINERALS
OTC
Requirements/Limits
123
LAST UPDATE 10/2016
Drug Name
Status*
MULTIVITAMIN WITH
MINERALS/FERROUS GLUCONATE
OTC
MULTIVITAMIN,THERAPEUTIC WITH
MINERALS
OTC
MY FAVORITE MULTIPLE
OTC
MYFERON 150
OTC
mynatal advance
Generic
mynephrocaps
Generic
mynephron
Generic
MYVITALIFE
OTC
NATURAL B-100
OTC
niva-plus
Generic
OCUTABS
OTC
OCUVITE WITH LUTEIN
OTC
ONCE DAILY
OTC
ONCOVITE
OTC
ONE DAILY (DAILY TABLET, GNP DAILY
TABLET, RA DAILY MULTI-VITAMIN TAB,
RA DAILY TABLET)
OTC
ONE DAILY 50 PLUS
OTC
ONE DAILY ESSENTIAL (DAILY TABLET,
EQL DAILY TABLET, GNP DAILY TABLET)
OTC
ONE DAILY FOR MEN
OTC
ONE DAILY FOR WOMEN
OTC
ONE DAILY FOR WOMEN 50+ ADV
OTC
ONE DAILY MAXIMUM (DAILY TABLET,
GNP DAILY TABLET, RA DAILY TABLET)
OTC
ONE DAILY MEN'S HEALTH
OTC
ONE DAILY MULTIVITAMIN (DAILY TAB,
DAILY TABLET)
OTC
ONE DAILY MULTIVITAMIN-IRON
OTC
Requirements/Limits
124
LAST UPDATE 10/2016
Drug Name
Status*
ONE DAILY PLUS IRON
OTC
ONE DAILY PLUS MINERALS
OTC
ONE DAILY WITH CALCIUM-IRON
OTC
ONE DAILY WITH IRON
OTC
ONE DAILY WOMEN'S
OTC
ONE DAILY WOMEN'S 50+ (DAILY 50+
TABLET, GNP DAILY 50+ TAB)
OTC
ONE DAILY WOMEN'S HEALTH
OTC
ONE-A-DAY ESSENTIAL
OTC
ONE-A-DAY MAXIMUM FORMULA
OTC
ONE-A-DAY TEEN ADVANTAGE
OTC
ONE-A-DAY WOMEN'S
OTC
OPTI-VITAMIN
OTC
OPTIMAL D3
OTC
ORALYTE
OTC
OS-CAL 500-VIT D3 200 CAPLET
OTC
OYSCO 500-VIT D3
OTC
OYSCO-500
OTC
OYSTERCAL-D
OTC
PARVA-CAL 500
OTC
PEDIATRIC ELECTROLYTE (CVS
PEDIATRIC POPS, CVS PEDIATRIC SOLN,
GNP PEDIATRIC SOLN, HEB PEDIATRIC
SOLN, HM PEDIATRIC SOLN, PEDI
FREEZER POP, PEDIATRIC SOLUTION, PV
PEDI FREEZE POP, PV PEDIATRIC SOLN,
RA PEDIATRIC SOLN, SB PEDIATRIC
SOLN, SM PEDIATRIC SOLN)
OTC
PEDIATRIC FREEZER POPS
OTC
PEDIATRIC MULTIVITAMIN A,C,AND D3
NO.21
OTC
pediatric multivitamin combination
no.2/sodium fluoride
Generic
Requirements/Limits
125
LAST UPDATE 10/2016
Drug Name
Status*
pediatric multivitamin combo
no.45/fluoride/ferrous sulfate
Generic
pediatric multivitamin combo
no.75/fluoride/ferrous sulfate
Generic
pediatric multivitamins a,c,& d3 no.21
with sodium fluoride
Generic
pediatric multivitamins no.16 with
sodium fluoride
Generic
sodium fluoride
Generic
sodium fluoride
Generic
PHARMACIST FAVORITE MULTI-VITE
OTC
pnv 29-1
Generic
pnv-vp-u
Generic
POLY-IRON
OTC
POLY-VI-SOL
OTC
POLY-VI-SOL WITH IRON
OTC
POLY-VITA
OTC
POLY-VITA WITH IRON
OTC
POLY-VITAMIN DROPS
OTC
POLYSACCHARIDE IRON
OTC
POLYVITAMIN WITH IRON (W-IRON
DROPS, WITH IRON TAB CHEW)
OTC
potassium chloride (8 meq capsule er, 8
meq tablet er, 10 meq tablet er, 10 meq
tab er prt, 10 meq capsule er,
20meq/15ml liquid, 20 meq tablet er,
20 meq tab er prt)
Generic
potassium chloride/potassium
bicarbonate/citric acid
Generic
potassium citrate (5 tablet er, 10 tablet
er, 15 tablet er)
Generic
PRE PROTEIN
OTC
Requirements/Limits
126
LAST UPDATE 10/2016
Drug Name
Status*
prenaplus
Generic
PRENATAL VIT CALC,IRON,FOLIC ACID
(LESS THAN 1 MG)
OTC
prenatal vitamin
no.15/iron,carbonyl/folic acid/docusate
sod
Generic
PRENATAL VITAMIN WITH CA
NO.124/FERROUS FUMARATE/FOLIC
ACID
OTC
ACID
OTC
ACID
OTC
ACID
OTC
prenatal vitamins comb no.115/iron
fumarate/folic acid
Generic
prenatal vitamins comb no.115/iron
fumarate/folic acid/dss
Generic
PRENATAL VITAMINS COMB
NO.119/IRON FUMARATE/FOLIC
ACID/DSS
OTC
prenatal vitamins combo no.60/ferrous
fumarate/folic acid
Generic
PRENATAL VITAMINS WITH
CALCIUM/FERROUS FUMARATE/FOLIC
ACID
OTC
prenatal vits with calcium #72/ferrous
fumarate/folic acid
Generic
prenatal vits with calcium
#72/iron,carbonyl/folic acid
Generic
prenatal vits with calcium #74/ferrous
fumarate/folic acid
Generic
PRENATAL VITS WITH CALCIUM
#95/FERROUS FUMARATE/FOLIC ACID
OTC
Requirements/Limits
127
LAST UPDATE 10/2016
Drug Name
Status*
PRENATAL VITS WITH CALCIUM
#96/FERROUS FUMARATE/FOLIC ACID
OTC
PRENATAL VITS WITH
CALCIUM#118/FERROUS
FUMARATE/FOLIC ACID
OTC
prenatal vits without calc no5/ferrous
fumarate/folic acid
Generic
preplus
Generic
PROSIGHT
OTC
PROTEIN
OTC
PROTEINEX TABLET
OTC
PV B-100 COMPLEX
OTC
PV B-50 COMPLEX
OTC
PV KIDS VITAMINS+IRON TAB CHEW
OTC
PYRIDOXINE HCL (50 MG TABLET, 100
MG TABLET)
OTC
QC CHILDREN'S CHEWABLE TABLET
OTC
QUFLORA (0.25 MG CHEW TAB, 0.25
MG/ML DROP, 0.5 MG/ML DROP, 0.5
MG CHEW TAB, 1 MG CHEW TAB)
Brand
RA HI-CAL PLUS VITAMIN D TAB
OTC
RA ONE DAILY ENERGY TABLET
OTC
RA ONE DAILY MEN'S 50+ TABLET
OTC
RENA-VITE
OTC
rena-vite rx
Generic
renal caps
Generic
RENAL VITAMIN
OTC
RENAL-VITE
OTC
reno caps
Generic
RIGHT STEP PRENATAL VITAMINS
OTC
RISANOID PLUS
OTC
Requirements/Limits
128
LAST UPDATE 10/2016
Drug Name
Status*
SCOOBY-DOO ONE A DAY TABLET
OTC
se-natal 19
Generic
SENIOR TABS
OTC
SENTRY
OTC
SENTRY SENIOR
OTC
sodium fluoride 0.5 mg/ml drops
Generic
SOOTHING PUREWAY-C
OTC
SPECTRAVITE ADVANCED FORMULA
OTC
SPECTRAVITE SENIOR
OTC
SPECTRAVITE ULTRA MEN 50+
OTC
SPECTRAVITE ULTRA MEN'S
OTC
SPECTRAVITE ULTRA WOMEN
OTC
STRESS 500
OTC
STRESS 500 PLUS ZINC
OTC
STRESS B
OTC
STRESS B WITH ZINC
OTC
STRESS FORMULA TABLET
OTC
STRESS FORMULA WITH ZINC
OTC
STRESS-C
OTC
SUPER AMINO ACIDS
OTC
SUPER B COMPLEX-VITAMIN C
OTC
SUPER B-50 COMPLEX
OTC
SUPER B-50 COMPLEX PLUS
OTC
SUPER CALCIUM
OTC
SUPER MULTIPLE VIT-MINERAL TAB
OTC
SUPER QUINTS B-50 TABLETS
OTC
SUPER THERAVITE-M
OTC
SUPERPLEX-T
OTC
Requirements/Limits
129
LAST UPDATE 10/2016
Drug Name
Status*
TAB-A-VITE
OTC
TAB-A-VITE WITH IRON
OTC
TAB-A-VITE-MINERALS
OTC
THERA
OTC
THERA-D (RAPID REPLETION TABLET,
SPORT 2,000 UNIT TAB, 2000 TABLET)
OTC
THERA-M CAPLET
OTC
THERA-TABS
OTC
THERADEX M
OTC
THERAMILL FORTE
OTC
THERAPEUTIC M (STABLET, TABLET)
OTC
THERAPEUTIC-M (, GNP)
OTC
THERATRUM COMPLETE
OTC
THERATRUM COMPLETE 50 PLUS
OTC
THEREMS
OTC
THEREMS-M
OTC
THIAMINE HCL 100 MG TABLET
OTC
THIAMINE MONONITRATE
OTC
thrivite 19
Generic
TL FOLATE
Brand
TOTAL B WITH C
OTC
TRI-VITA
OTC
triadvance
Generic
TRICARE
Brand
trinatal gt
Generic
trinatal rx 1
Generic
triphrocaps
Generic
ULTIMATE MEN'S COMPLETE 50+
OTC
ULTRA B-100 COMPLEX (B-100 TABLET,
B-100 TAB)
OTC
Requirements/Limits
130
LAST UPDATE 10/2016
Drug Name
Status*
v-c forte
Generic
vic-forte
Generic
vinate gt
Generic
vinate one
Generic
vinate pn care
Generic
vinate-m
Generic
virt nate
Generic
virt-advance
Generic
virt-caps
Generic
virt-nate
Generic
virt-vite gt
Generic
VISION
OTC
VISION FORMULA
OTC
VISION PLUS LUTEIN
OTC
VISION VITAMINS
OTC
VIT B COMPLEX/VIT C/FOLIC
ACID/FERROUS FUMARATE/VIT E ACET
OTC
VITAMIN A 10000 UNIT CAPSULE
OTC
VITAMIN A PALMITATE 10000 UNIT
CAPSULE
OTC
VITAMIN B COMPLEX (CAPSULE, TALET)
OTC
VITAMIN E (100 UNIT CAPSUL, 200 UNIT
CAPSUL, 400 UNIT CAPSUL)
OTC
VITAMIN E (DL-ALPHA TOCOPHERYL
ACETATE) ((DL,TOCOPHRYL ACT) 200
UNIT CAPSUL, (DL,TOCOPHRYL ACT) 400
UNIT CAPSUL)
OTC
VITAMIN E ACETATE (ACTAT200 UNIT
CAPSUL, ACTAT400 UNIT CAPSUL,
ACTAT600 UNIT CAPSUL)
OTC
VITAMIN E ACID SUCCINATE 200 UNIT
TABLET
OTC
Requirements/Limits
131
LAST UPDATE 10/2016
Drug Name
Status*
VITAMIN E MIXED (MIXD 200 UNIT
TABLT, MIXD 400 UNIT CAPSUL)
OTC
VITRUM SENIOR
OTC
vol-care rx
Generic
vol-nate
Generic
vol-plus
Generic
vol-tab rx
Generic
vp-vite rx
Generic
WOMEN'S DAILY FORMULA
OTC
WOMEN'S ONE DAILY
OTC
YELETS
OTC
ZOO CHEWS
OTC
Requirements/Limits
132
LAST UPDATE 10/2016
Alphabetical Listing
acetaminophen/diphenhydramine hcl
1
1-DAY
acetasol hc
26
acetazolamide
1
94
21,51
12 HOUR COLD RELIEF
105
acetic acid
16
12 HOUR DECONGESTANT
105
acetic acid/hydrocortisone
94
ACID CONTROL
2
60,68
ACID CONTROLLER
68
24 HOUR ALLERGY RELIEF
95
ACID GONE
60
24HOUR ALLERGY
96
ACID GONE ANTACID
60
ACID REDUCER
3
60,68
ACID REDUCER 150
60
3 DAY VAGINAL
26
ACID RELIEF
68
3-DAY VAGINAL CREAM
26
acitretin
57
ACTIDOM DMX
6
60PSE-400GFN
105
8
ACTIMMUNE
89
ACTOPLUS MET XR
40
acyclovir
40
ADCIRCA
8 HOUR
1
adefovir dipivoxil
8 HOUR PAIN RELIEF
1
ADEMPAS
8 HOUR PAIN RELIEVER
1
adenosine phosphate
A
105
105
39
105
90
ADLT WAL-TUSSIN COUGH-COLD CF
105
ADT ROBITUSSIN PEAK CLD DM MAX
105
105
A THRU Z
115
ADULT COUGH FORMULA DM MAX
A THRU Z ADVANCED FORMULA
115
ADULT GLYCERIN
A THRU Z SELECT
115
ADULT LOW DOSE ASPIRIN EC
A THRU Z SELECT 50+ FORMULA
115
ADULT ROBITUSSIN PEAK COLD
105
A-G PRO
115
ADULT ROBITUSSIN PEAK COLD M-S
106
abacavir sulfate
37
ADULT TUSSIN CHEST CONGESTION
106
abacavir sulfate/lamivudine
37
ADULT TUSSIN COUGH CONGEST DM
106
abacavir sulfate/lamivudine/zidovudine
37
ADULT TUSSIN DM
106
ADULT TUSSIN MULTI-SYMP COLD
106
ABC PLUS
115
69
6
acamprosate calcium
12
ADULT WAL-TUSSIN
106
acarbose
40
ADULT WAL-TUSSIN DM
106
acebutolol hcl
47
ADULT WAL-TUSSIN DM MAX
106
ACEPHEN
1
ADULTS 50+ MULTIVITAMIN
115
ACETADRYL
1
ADULTS' 50+ DAILY FORMULA
115
acetaminophen
1
ADULTS' DAILY FORMULA
115
ACETAMINOPHEN PM
1
ADVAIR DISKUS
104
ACETAMINOPHEN PM XTRA STRENGTH
1
ADVAIR HFA
104
acetaminophen with codeine phosphate
9
ADVANCED ANTACID
133
60
ADVANCED ANTACID-ANTIGAS
ADVIL
60
ALLERGY RELIEF D-24
106
6
ALLERGY RELIEF D12
98
AEROSPAN
95
ALLERGY RELIEF SPRAY
56
afeditab cr
48
ALLERGY RELIEF-D
98
AFINITOR
33
ALLERGY RELIEF-D12
98
AFINITOR DISPERZ
33
ALLERGY RELIEF-NASAL DECONGEST
AFTERA
80
ALLERGY-CONGESTION
AGGRENOX
45
ALLERGY-CONGESTION RELIEF
98,106
AKNE-MYCIN
19
ALLERGY-CONGESTION RELIEF-D
98,106
AKWA TEARS
92
ALLERGY-TIME
98
alagesic lq
55
ALLERHIST-1
98
ALAVERT
96
allopurinol
29
ALBENZA
34
ALMACONE
60
ALMACONE-2
60
albuterol sulfate
104
106
98
alclometasone dipropionate
13
alogliptin benzoate
40
ALECENSA
33
alogliptin benzoate/metformin hcl
40
alendronate sodium
91
alogliptin benzoate/pioglitazone hcl
40
ALER-CAPS
96
ALOMIDE
93
ALER-TAB
96
ALOPHEN PILLS
69
alfuzosin hcl
77
alosetron hcl
69
ALKA-SELTZER PLUS ALLERGY
96
ALTAMIST
90
ALKERAN
30
altavera
80
ALL DAY ALLERGY
96
aluminum hydroxide
60
ALL DAY ALLERGY RELIEF
96
ALVESCO
95
ALL DAY PAIN RELIEF
6
alyacen
80
ALL DAY RELIEF
6
amabelz
80
35
ALLER-EASE
96
amantadine hcl
ALLER-FEX
96
AMBITUSSIN AC
ALLER-FLO
95
AMBIZINE
24
ALLER-G-TIME
96
amcinonide
13
ALLER-TEC
96
amethia
80
ALLERCLEAR
96
amethia lo
80
ALLERCLEAR D-12HR
96
amethyst
80
ALLERCLEAR D-24HR
106
amiloride hcl
51
amiloride hcl/hydrochlorothiazide
50
ALLERGY
57,97
106
ALLERGY 4-HOUR
97
amino acids
115
ALLERGY CREAM
56
AMINO ACTION
115
ALLERGY MEDICATION
97
amiodarone hcl
46
ALLERGY MEDICINE
97
amlodipine besylate
48
amlodipine besylate/atorvastatin calcium
50
amlodipine besylate/benazepril hcl
50
ALLERGY RELIEF
ALLERGY RELIEF D
95,97,98
98,111
134
amlodipine besylate/valsartan
50
ANTIHISTAMINE
98
amoxicillin
19
ANTIOXIDANT
115
amoxicillin/potassium clavulanate
19
ANTIOXIDANT FORMULA
115
ampicillin trihydrate
19
ANTIOXIDANT VITAMIN
115
AMPYRA
55
ANTIOXIDANT VITAMINS
116
anagrelide hcl
44
ANTITUSSIVE DM
106
ANALPRAM HC
60
anusol-hc
13
anastrozole
32
apexicon e
13
ANDRODERM
80
apri
80
ANDROGEL
80
APRISO
62
ANIMAL CHEWS
115
APRODINE
ANIMAL SHAPES
115
APTIOM
23
98
APTIVUS
38
ANIMAL SHAPES PLUS IRON
106
ANIMAL SHAPES VITAMINS
115
AQUADEKS
116
ANORO ELLIPTA
104
AQUANIL HC
13
ANTACID
61
aranelle
80
ANTACID & ANTIGAS
60
ARANESP
44
ANTACID & GAS RELIEF
60
ARMOUR THYROID
86
ANTACID ANTI-GAS DOUBLE STR
61
ARNUITY ELLIPTA
95
ANTACID EXTRA STRENGTH
61
ARTHRITIS PAIN
1
ANTACID II PLUS SIMETHICONE
61
ARTHRITIS PAIN RELIEF
1
ANTACID II WITH SIMETHICONE
61
ARTHRITIS PAIN RELIEVER
1
ANTACID M
61
ARTIFICIAL TEARS
92
ANTACID MAXIMUM STRENGTH
61
ascomp with codeine
9
ANTACID PLUS ANTI-GAS
61
ascorbate calcium
116
ANTACID TABLET
61
ascorbic acid
116
ANTACID ULTRA STRENGTH
61
ascorbic acid/ascorbate sodium
116
ANTACID WITH SIMETHICONE
62
ashlyna
80
ANTACID-ANTIGAS
62
ASMANEX
95
ANTI-DIARRHEA
59
ASMANEX HFA
95
ANTI-DIARRHEAL
59
ASPIR 81
6
ANTI-FUNGAL
27
ASPIR-LOW
6
ANTI-FUNGAL CREAM
26
ASPIR-TRIN
6
ANTI-GAS
62
aspirin
1,6
ANTI-ITCH
13,56,78
aspirin/dipyridamole
45
ANTI-ITCH CREAM
57
ASTAGRAF XL
88
ANTIBIOTIC
16
atenolol
47
ANTIBIOTIC + PAIN RELIEF
16
atenolol/chlorthalidone
50
ANTIFUNGAL
26
ATHENOL
ANTIFUNGAL CREAM
26
ATHLETE'S FOOT
ANTIHIST
98
ATHLETE'S FOOT CREAM
135
1
26,90
26
ATHLETE'S FOOT SPRAY
26
balsalazide disodium
90
ATHLETIC FOOT CREAM
26
balziva
80
atorvastatin calcium
52
BAN-ACID
62
atovaquone
34
BANOPHEN
98
ATRIPLA
37
BANOPHEN ANTI-ITCH
56
BANZEL
23
ATROVENT HFA
103
AUBAGIO
55
BARACLUDE
39
aubra
80
BAZA ANTIFUNGAL
26
AUGMENTIN
19
BEE-ZEE
AURAPHENE-B
94
bekyree
80
AURYXIA
78
BENADRYL ALLERGY
99
aviane
80
BENADRYL ITCH STOPPING
56
avidoxy
21
benazepril hcl
46
AVONEX
55
benazepril hcl/hydrochlorothiazide
50
AVONEX PEN
55
benzonatate
azathioprine
88
benztropine mesylate
35
azelastine hcl
94
BERINERT
88
AZILECT
36
BETA HC
13
azithromycin
19
betamethasone dipropionate
14
AZO DINE
77
betamethasone dipropionate/propylene glycol
14
AZO-TABS
77
betamethasone valerate
14
AZOPT
94
BETASERON
55
azurette
80
BETATEMP
2
betaxolol hcl
47,94
B
116
106
bethanechol chloride
77
B COMPLETE
116
BETIMOL
94
b complex with vitamin c
116
BETOPTIC S
94
B-100 COMPLEX
128
bexarotene
34
B-12 DOTS
116
bicalutamide
87
B-50 COMPLEX
128
bimatoprost
91
bacitracin
17
BIO-S-PRES DX
106
bacitracin zinc
17
BIOCOTRON
106
bacitracin/polymyxin b sulfate
17
BIOGIL
106
BACITRAYCIN PLUS
17
BIOPETIT
116
baclofen
36
biotin
116
116
BAL B-100
116
BIOVOL
BAL B-50
116
BISA-LAX
69
BALANCE B-100
116
bisacodyl
69
BALANCE B-50
116
BISCOLAX
69
BALANCED B-100
116
BISMATROL
62
BALANCED B-50
116
bismuth subsalicylate
62
136
bisoprolol fumarate
47
CALCI-CHEW
bisoprolol fumarate/hydrochlorothiazide
50
CALCIDOL
bleph-10
20
calcipotriene
57
BLEPHAMIDE
92
calcitonin,salmon,synthetic
91
BLEPHAMIDE S.O.P.
92
CALCITRATE
blisovi 24 fe
80
calcitrene
57
blisovi fe
81
calcitriol
87
blood sugar diagnostic
90
CALCIUM 600-D3 PLUS
BOSULIF
32
calcium acetate
BREO ELLIPTA
95,104
CALCIUM ANTACID
62
116
116
119
78,116
63
briellyn
81
calcium carbonate
BRILINTA
45
calcium carbonate,citrate/magnesium
brimonidine tartrate
94
oxide,aspartate/vit d3
117
106
calcium carbonate/cholecalciferol (vitamin d3)
117
35
calcium carbonate/ergocalciferol (vitamin d2)
117
bromfed dm
bromocriptine mesylate
brompheniramine maleate/pseudoephedrine
63,117
calcium carbonate/vit d3/mag
hcl/dextromethorphan
106
ox/zinc/copper/manganese/boron
116
BRONTUSS SF
106
calcium citrate
117
calcium citrate/ergocalciferol (vitamin d2)
117
budeprion sr
24
budesonide
78,95
calcium polycarbophil
69
bumetanide
51
CALPHRON
BUPHENYL
58
camila
85
buprenorphine hcl
12
camrese
81
buprenorphine hcl/naloxone hcl
12
camrese lo
81
buproban
13
CANASA
63
bupropion hcl
13
candesartan cilexetil
46
117
butalbital/acetaminophen
2
capacet
butalbital/acetaminophen/caffeine
2
capecitabine
31
butalbital/acetaminophen/caffeine/codeine phosphate 9
CAPRELSA
33
butalbital/aspirin/caffeine
captopril
46
captopril/hydrochlorothiazide
50
butorphanol tartrate
2
9,10
2
BYDUREON
40
CARAFATE
76
BYDUREON PEN
40
CARBAGLU
58
BYETTA
40
carbamazepine
23
CARBAMOXIDE
95
carbidopa
36
C
C 500 MG TIMED RELEASED
116
carbidopa/levodopa
36
C COMPLEX
116
carbidopa/levodopa/entacapone
35
CABOMETYX
33
CARDIZEM LA
48
cafergot
29
carisoprodol
114
CAL-GEST
62
carisoprodol/aspirin
114
137
carisoprodol/aspirin/codeine phosphate
CARNITOR SF
10
115
cetirizine hcl
99
CHANTIX
13
carteolol hcl
94
chateal
81
cartia xt
48
CHENODAL
63
carvedilol
47
CHERATUSSIN AC
106
castor oil
69
CHERATUSSIN DAC
107
caziant
81
CHEST CONGESTION RELIEF D
107
CEDAX
18
CHEWABLE MULTI VITAMIN
118
CEENU
30
CHEWABLE MULTIVITAMIN W-IRON
99
cefaclor
18
CHILD CHEW + IRON
99
cefadroxil
18
CHILD CHEW VITAMIN
118
cefdinir
18
CHILD MUCINEX CHEST CONGESTION
107
cefpodoxime proxetil
18
CHILD PAIN REL-FEVER REDUCER
cefprozil
18
CHILD SUPPOSITORY
ceftibuten
19
CHILD VITAMIN WITH MINERALS
CEFTIN
19
CHILD'S VITAMIN WITH IRON
cefuroxime axetil
19
CHILDREN'S ADVIL
celecoxib
2
69
118
99
6
6
CHILDREN'S ALL DAY ALLERGY
99
CELONTIN
22
CHILDREN'S ALLEGRA ALLERGY
100
CENTAMIN
117
CHILDREN'S ALLER-TEC
CENTRAL VITE
117
CHILDREN'S ALLERGY
CENTRAL VITE FOR SENIORS
117
CHILDREN'S ALLERGY COMPLETE
99
CENTRAL-VITE
117
CHILDREN'S ALLERGY RELIEF
99
CENTRAL-VITE PERFORMANCE
120
CHILDREN'S CHEST CONGESTION
107
CENTRAL-VITE SELECT
117
CHILDREN'S CHEW MULTIVIT-IRON
118
CENTRAL-VITE SENIOR
117
CHILDREN'S CHEWABLE
128
CENTRAL-VITE WOMEN'S UNDER 50
117
CHILDREN'S CHEWABLE VITAMIN
118
CENTRAM-CARE
117
CHILDREN'S COLD & ALLERGY
107
CENTRAVITES 50 PLUS
117
CHILDREN'S FEVER REDUCER
2
CENTRUM
117
CHILDREN'S FEVER REDUCING
2
CENTRUM COMPLETE
117
CHILDREN'S IBUPROFEN
6
CENTRUM SILVER
117
CHILDREN'S IRON
CENTURY
117
CHILDREN'S MEDI-PROFEN
6
CENTURY ADVANCED FORMULA
118
CHILDREN'S MEDI-TABS
2
CENTURY MATURE
118
CHILDREN'S MUCUS RELIEF
107
CENTURY ULTIMATE MEN'S
118
CHILDREN'S MULTIVIT W-EXTRA C
118
CENTURY ULTIMATE WOMEN'S
118
CHILDREN'S MULTIVIT-MINERALS
118
cephalexin
19
CHILDREN'S MULTIVITAMIN-IRON
99
CERDELGA
58
CHILDREN'S NON-ASPIRIN
2
CEROVITE JR
118
CHILDREN'S PAIN & FEVER
2
CERTAVITE-ANTIOXIDANT
118
CHILDREN'S PAIN RELIEF
2
138
99
99,102
118
CHILDREN'S PAIN RELIEVER
2
CITRUCEL
69
CHILDREN'S PAIN-FEVER
2
CLARISPRAY
95
63
clarithromycin
20
CHILDREN'S PEPTO
CHILDREN'S PROFEN IB
6
CLARITIN
CHILDREN'S PROFENIB
6
CLASSIC PRENATAL
CHILDREN'S Q-PAP
2
CLEARLAX
CHILDREN'S SALINE NASAL SPRAY
90
CHILDREN'S SILAPAP
2
CHILDREN'S SOOTHE
63
CHILDREN'S TACTINAL
2
clemastine fumarate
100,107
118
69
100
clindacin etz
17
clindacin p
17
clindamycin hcl
17
CHILDREN'S VITAMINS WITH IRON
99
clindamycin palmitate hcl
17
CHILDREN'S WAL-DRYL ALLERGY
99
clindamycin phosphate
17
CHILDREN'S WAL-FEX
99
clobetasol propionate
14
CHILDREN'S WAL-ZYR
99
clobetasol propionate/emollient base
14
clodan
14
clonazepam
40
clonidine
45
CHILDREN'S ZYRTEC ALLERGY
chlorhexidine gluconate
CHLORHIST
100
17
100
chloroquine phosphate
34
clonidine hcl
45
chlorothiazide
51
clopidogrel bisulfate
45
clorpres
50
clotrimazole
26
CLOTRIMAZOLE AF
26
clotrimazole/betamethasone dipropionate
57
CLOVERINE
57
chlorpheniramine maleate
chlorpropamide
100
41
CHLORTABS
100
chlorthalidone
51
chlorzoxazone
114
CHOCOLATED LAXATIVE
69
co-gesic
10
CHOLBAM
63
codeine phosphate/butalbital/aspirin/caffeine
10
codeine sulfate
10
cholecalciferol (vitamin d3)
90,118
cholestyramine (with sugar)
52
COL-RITE
69
cholestyramine/aspartame
52
colchicine
29
colchicine/probenecid
29
29
choline salicylate/magnesium salicylate
7
ciclodan
26
COLCRYS
ciclopirox
26
COLD & ALLERGY
111
ciclopirox olamine
26
COLD & COUGH
111
cilostazol
45
COLESTID
52
cimetidine
68
colestid
53
cimetidine hcl
68
colestipol hcl
53
CIPRODEX
95
colocort
90
ciprofloxacin
20
COLY-MYCIN S
95
ciprofloxacin hcl
20,95
COMBIVENT RESPIMAT
104
ciprofloxacin/ciprofloxacin hcl
20
COMETRIQ
33
CITROMA
63
COMFORT GEL
63
139
COMPLERA
37
CRIXIVAN
38
COMPLETE
118
cromolyn sodium
COMPLETE 50+
118
cryselle
81
COMPLETE ALLERGY
100
CURAD ENEMA
69
COMPLETE MULTI
118
CUVPOSA
59
COMPLETE MULTI 50+
118
cyanocobalamin (vitamin b-12)
COMPLETE MULTI-VIT-MINERAL
118
cyclafem
COMPLETE MULTIVITAMIN
118
cyclobenzaprine hcl
COMPLETE PREMIUM VITAMIN
118
CYCLOPHOSPHAMIDE CAPSULES
30
COMPLETE SENIOR
118
cycloserine
17
COMPLETE WOMEN
119
cyclosporine
88
completenate
119
cyclosporine, modified
COMPOZ
100
cyproheptadine hcl
105
119
81
114
57,88
100
compro
24
cyred
81
CONDYLOX
57
CYSTARAN
92
CONGEST-EZE
107
CONGESTAC
107
D
constulose
69
D-VI-SOL
119
COPAXONE
55
D-VITA
119
COREG CR
47
D3 DOTS
119
CORLANOR
50
D3-2000
119
cormax
14
DAILY FIBER
CORTISONE
14
DAILY MULTIPLE
119
CORTISPORIN-TC
95
DAILY MULTIPLE VITAMIN
119
DAILY MULTIVITAMIN WITH IRON
119
CORTIZONE-10
14,78
70
CORTIZONE-10 PLUS
14
DAILY MULTIVITAMIN-IRON
119
COTELLIC
33
DAILY VALUE
119
COUGH
107
DAILY VITAMIN
119
COUGH AND COLD MULTI-SYMPTOM
107
DAILY VITAMIN + IRON
119
COUGH CONTROL
111
DAILY VITAMIN FORMULA
119
COUGH CONTROL CF
107
DAILY VITAMIN FORMULA + IRON
119
COUGH CONTROL DM
107
DAILY VITAMIN FORMULA-MINERALS
119
COUGH CONTROL DM MAX
107
DAILY VITE
119
COUGH FORMULA DM
107
DAILYHIST-1
100
COUGH SYRUP
107
DAKLINZA
39
COUGH SYRUP DM
107
dantrolene sodium
36
COUGH-COLD
107
dapsone
30
COUGH-HEAD CONGESTION RELIEF
107
DARAPRIM
34
COUGHTAB
107
dasetta
81
CREO-TERPIN
107
DAY TIME COLD-FLU RELIEF
111
DAYHIST
100
CREON
58
140
DAYHIST ALLERGY
daysee
DAYTIME
100
DIABETIC TUSSIN DM
108
81
DIABETIC TUSSIN EX
108
DIABETIC TUSSIN MAX-STRENGTH
108
107
DAYTRANA
54
dialyvite
120
deblitane
85
DIALYVITE 800
120
DECARA
119
DIALYVITE VITAMIN D
120
DECUBI VITE
119
DIALYVITE ZINC
120
DEEP SEA
90
DIAMODE
59
DELTA D3
119
DIASTAT
22
delyla
81
diazepam
22
DELZICOL
63
DICLEGIS
24
demeclocycline hcl
21
diclofenac potassium
DENAVIR
40
diclofenac sodium
denta 5000 plus
56
dicloxacillin sodium
19
dentagel
56
dicyclomine hcl
59
DEPO-SUBQ PROVERA 104
85
didanosine
37
dermacinrx prizopak
12
DIFICID
20
DERMAREST ECZEMA
14
diflunisal
7
DESCOVY
37
DIGESTIVE RELIEF
63
DESENEX
27
digitek
50
107
digox
50
DESGEN DM
7
7,57,78
DESITIN CLEAR
56
digoxin
50
desmopressin acetate
79
dihydroergotamine mesylate
29
desmopressin acetate (non-refrigerated)
79
DILANTIN
23
desogestrel-ethinyl estradiol
81
dilt-cd
48
desogestrel-ethinyl estradiol/ethinyl estradiol
81
dilt-xr
48
desonide
14
diltiazem hcl
49
desoximetasone
14
dimenhydrinate
100
DESPEC
107
DINO-LIFE
120
DESPEC DM
107
DINO-LIFE WITH EXTRA C
120
DESPEC DM-G
107
DIOCTYL
69
dexamethasone
78
DIOTAME
63
dexamethasone intensol
78
DIPENTUM
90
dexamethasone sod phosphate
78
DIPHEDRYL
100
DEXPAK
78
DIPHEDRYL ALLERGY
100
dextroamphetamine sulf-saccharate/amphetamine sulf-
DIPHEN
100
aspartate
54
DIPHENHIST
100
dextroamphetamine sulfate
54
diphenhydramine hcl
56,101
DIABETIC SILTUSSIN DAS-NA
107
diphenoxylate hcl/atropine sulfate
63
DIABETIC SILTUSSIN-DM
107
dipyridamole
45
DIABETIC SILTUSSIN-DM MAX STR
108
disopyramide phosphate
46
141
disulfiram
12
econazole nitrate
27
DOC-Q-LACE
69
ECONTRA EZ
81
DOC-Q-LAX
69
ECOTRIN
7
DOCU LIQUID
69
ECPIRIN
7
DOCU SOFT
69
ECZEMA ANTI-ITCH
DOCUPRENE
69
ED A-HIST PSE
108
docusate calcium
70
ED CHLORPED JR
101
docusate sodium
70
ED-APAP
DOCUSIL
70
ED-CHLORTAN
dofetilide
46
EDURANT
36
DOK
70
EFFIENT
45
DOK PLUS
70
EGRIFTA
79
DOMETUSS-DMX
14
2
101
108
ELDERCAPS
120
donepezil hcl
24
ELDERTONIC
120
dorzolamide hcl
94
ELELYSO
58
dorzolamide hcl/timolol maleate
94
ELIDEL
57
doxazosin mesylate
45
ELIGARD
87
doxercalciferol
91
elimite
35
doxycycline hyclate
21
elinest
81
doxycycline monohydrate
21
eliphos
120
DRAMAMINE LESS DROWSY
24
ELIQUIS
DRIMINATE
101
43
ELIXOPHYLLIN
104
120
DRITHOCREME HP
57
ELLIS TONIC
DROXIA
31
ELMIRON
77
DRY SKIN THERAPY
57
EMCYT
31
DSS
70
EMEND
25
DUAVEE
81
emoquette
81
DUCODYL
70
EMTRIVA
37
DULCOLAX STOOL SOFTENER
70
emverm
35
dutasteride
77
enalapril maleate
46
dynacin
21
enalapril maleate/hydrochlorothiazide
50
ENBREL
88
endocet
10
120
endodan
10
95
ENEMA
70
ENEMA DISPOSABLE
70
E
EAR CARE
EAR DROPS
EAR HEALTH FORMULA
120
EAR HEALTH PLUS
95
enoxaparin sodium
43
EAR SYSTEM
95
enpresse
81
EAR WAX REMOVAL
95
enskyce
81
EARWAX TREATMENT
95
entacapone
35
entecavir
39
EAZZZE THE PAIN
2
142
ENTRESTO
50
ethosuximide
22
enulose
70
etidronate disodium
91
EPANED
46
etodolac
7
EPCLUSA
39
etoposide
32
EPIFOAM
78
EVAC-U-GEN
70
epinephrine 0.15 mg auto-injct
104
EVOTAZ
38
epinephrine 0.3 mg auto-inject
104
EX-LAX
70
EPIPEN 2-PAK
104
EXEFEN IR
108
EPIPEN JR 2-PAK
104
exemestane
32
epitol
23
EXJADE
115
EPIVIR HBV
39
EXPECTORANT
108
eplerenone
51
EXPECTORANT COUGH SYRUP
108
EPOGEN
44
EXPECTORANT DM
108
eprosartan mesylate
46
EXTAVIA
EPSOM SALT
90
EXTRA ACTION COUGH
ergocalciferol (vitamin d2)
120
EXTRA STRENGTH NON-ASPIRIN
EYE HEALTH PLUS LUTEIN
55
108
3
ERIVEDGE
33
120
errin
85
ery
20
F
ERY-TAB
20
FALLBACK SOLO
82
erygel
20
falmina
82
ERYPED 400
20
famciclovir
40
ERYTHROCIN STEARATE
20
famotidine
68
erythromycin base
20
FARESTON
31
erythromycin base/ethyl alcohol
20
FARXIGA
41
erythromycin ethylsuccinate
20
FARYDAK
32
ESBRIET
108
FAST RELIEF LAXATIVE
70
ESCAVITE
120
felbamate
23
ESGIC-PLUS
55
felodipine
49
esmolol hcl
47
fenofibrate
52
esomeprazole magnesium
76
fenofibrate nanocrystallized
52
fenofibrate,micronized
52
ESSENTIA
120
ESTRACE
81
fenofibric acid
52
estradiol
81
fenofibric acid (choline)
52
estradiol/norethindrone acetate
81
fenoprofen calcium
7
ESTRING
82
fentanyl
8
estropipate
82
FEOSOL
120
ethacrynate sodium
51
FER-IRON
120
ethacrynic acid
51
FERATE
120
ethambutol hcl
30
FERGON
120
ethinyl estradiol/drospirenone
82
FEROSUL
120
143
FERREX 150
120
FLUOR-A-DAY
56
ferrex 150 forte plus
120
fluoride/iron/vitamins a,c,and d
FERRIC X-150
120
fluoridex daily defense
56
FERRO-TIME
121
fluoritab
56
ferrous gluconate
121
fluorometholone
78
ferrous sulfate
121
flura-drops
121
FERROUSUL
121
flurazepam hcl
114
121
FEVER REDUCER-PAIN RELIEVER
3
flurbiprofen
FEVERALL
3
flurbiprofen sodium
94
flutamide
32
fexofenadine hcl
101
7
FIBER
70
fluticasone propionate
FIBER LAX
70
fluvastatin sodium
52
FIBER LAXATIVE
70
FML FORTE
78
FIBER SMOOTH
71
FML S.O.P.
78
FIBER TABS
71
FOAMING ANTACID
63
FIBER THERAPY
71
folbee plus
121
FIBER-LAX
71
folic acid
121
FIBER-TABS
71
folic acid/vitamin b comp and c
121
finasteride
77
folic acid/vitamin b complex and c/rice bran
121
FIRAZYR
89
fondaparinux sodium
FIRST AID ANTIBIOTIC
17
FORADIL
FIRST AID ANTIBIOTIC-PAIN RLF
17
fortical
FLAGYL ER
17
FOSFREE
FLANAX
7,63
14,78
43
104
91
121
fosinopril sodium
46
FLAVOR CHEWS ANTACID
63
fosinopril sodium/hydrochlorothiazide
50
flavoxate hcl
77
FRAGMIN
43
flecainide acetate
47
frovatriptan succinate
29
FLINTSTONES
121
FRUIT C-500
121
FLINTSTONES COMPLETE
121
FULL SPECTRUM B
121
FLINTSTONES PLUS CALCIUM
121
FULYZAQ
63
FLINTSTONES WITH EXTRA C
121
FUNGOID-D
27
FLINTSTONES WITH IRON
121
furosemide
51
FLOVENT DISKUS
78
FUZEON
37
FLOVENT HFA
78
fyavolv
82
fluconazole
27
flucytosine
27
G
fludrocortisone acetate
14
G-TRON
flunisolide
96
gabapentin
22
fluocinolone acetonide
14
GABITRIL
22
fluocinonide
14
galantamine hbr
24
fluocinonide/emollient base
14
GAMMAKED
89
144
108
GAMUNEX-C
89
GILOTRIF
32
ganirelix acetate
87
GLATOPA
55
garamycin
16
GLEOSTINE
30
GAS FREE
64
glimepiride
41
GAS RELIEF
65
glipizide
41
GAS RELIEF 80
65
glipizide/metformin hcl
41
GAS-X
65
GLUCAGEN 1MG HYPOKIT
42
GAS-X ULTRA STRENGTH
65
GLUCAGON EMERGENCY KIT
42
gatifloxacin
20
glyburide
41
GATTEX
65
glyburide,micronized
41
GAVILAX
71
glyburide/metformin hcl
41
gavilyte-c
71
glycerin
71
gavilyte-g
71
GLYCOLAX
71
gavilyte-n
71
glycopyrrolate
59
GAVISCON
65
GLYXAMBI
41
GELUSIL
65
granisetron hcl
26
gemfibrozil
52
GRANIX
44
generlac
71
GRASTEK
gengraf
57
griseofulvin ultramicrosize
27
gentak
16
griseofulvin, microsize
27
gentamicin sulfate
16
GUAIASORB DM
108
GENTLE LAXATIVE
71
GUAIATUSSIN AC
108
GENTLELAX
71
guaifenesin
108
GENVOYA
37
GUAIFENESIN AC
108
GERAVIM
121
GUAIFENESIN DAC
108
GERI-DRYL
101
guaifenesin/codeine phosphate
108
108
GERI-KOT
71
guaifenesin/dextromethorphan hbr
108
GERI-LANTA
65
guaifenesin/pseudoephedrine hcl
108
GERI-MOX
66
guanfacine hcl
GERI-MUCIL
71
GUMMI BEAR MULTIVITAMIN
GERI-TUSSIN
108
GYNE-LOTRIMIN
27
GERI-TUSSIN DM
108
GYNE-LOTRIMIN-7
27
GERIATON
121
GERITOL COMPLETE
121
H
GERITOL TONIC
122
HAIR VITAMIN
122
122
45
122
gianvi
82
HAIR, SKIN AND NAILS
gildagia
82
halobetasol propionate
15
gildess
82
HARVONI
39
gildess 24 fe
82
HEADACHE PM
3
gildess fe
82
HEADACHE PM FORMULA
3
GILENYA
55
HEALTHY EYES
145
122
HEALTHYLAX
71
hydrochlorothiazide
52
HEARTBURN ANTACID
66
HYDROCIL INSTANT
71
HEARTBURN PREVENTION
68
hydrocodone bitartrate/acetaminophen
10
HEARTBURN RELIEF
66,68
hydrocodone bitartrate/homatropine methylbromide 108
HEARTBURN RELIEF 150
66
hydrocodone/ibuprofen
HEARTBURN RELIEF 24 HOUR
76
hydrocortisone
HEARTBURN TREATMENT 24 HOUR
76
hydrocortisone acetate
15,79
heather
85
hydrocortisone butyrate
15,79
hecoria
88
HYDROCORTISONE PLUS 12
15
heparin sodium,porcine
43
hydrocortisone valerate
79
heparin sodium,porcine/pf
44
hydrocortisone/aloe vera
15
HEXALEN
32
HYDROCREAM
15
HI B COMPLEX
122
HYDROLATUM
57
HI-CAL
128
hydromet
HIGH POTENCY CALCIUM
122
hydromorphone hcl
10
HIGH POTENCY IRON
122
HYDROSKIN
15
HIGH PROTEIN
122
hydroxychloroquine sulfate
34
hydroxyurea
31
hydroxyzine hcl
24
24
HIZENTRA
HONEY BEARS
89
122
10
15,79,90
109
HUMALOG
42
hydroxyzine pamoate
42
HYPER-SAL
42
HYQVIA
HUMALOG MIX 50-50
42
43
I
HUMALOG MIX 75-25
43
I-PRIN
43
ibandronate sodium
91
HUMIRA
88
IBRANCE
33
HUMIRA PEDIATRIC CROHN'S
88
IBU-DROPS
HUMIRA PEN
88
ibudone
HUMIRA PEN CROHN-UC-HS STARTER
88
ibuprofen
HUMIRA PEN PSORIASIS-UVEITIS
88
ICAPS PLUS
HUMULIN 70-30
43
ICLUSIG
HUMULIN 70/30 KWIKPEN
43
IFEREX 150
HUMULIN N
43
imatinib mesylate
33
HUMULIN N KWIKPEN
43
IMBRUVICA
32
HUMULIN R
43
imiquimod
32
HUMULIN R U-500
43
inatal advance
HUMULIN R U-500 KWIKPEN
43
INCIVEK
39
HYCAMTIN
32
INCRELEX
79
hydralazine hcl
53
INCRUSE ELLIPTA
HYDRO SKIN
15
indapamide
146
109
89
7
7
10
7
122
33
122
122
103
52
INDERAL XL
47
iron
INDOCIN
7
asp,gly,ps/ascorb.calcium/b12/folic/calcium/succ.acid 1
indomethacin
7
22
INFANT FEVER-PAIN RELIEVER
3
ISENTRESS
37
INFANT GAS RELIEF
66
isochron
53
INFANT PAIN RELIEF
3
isoniazid
30
INFANT PAIN-FEVER
3
isosorbide dinitrate
53
INFANT'S NON-ASPIRIN
3
isosorbide mononitrate
53
INFANT'S PAIN RELIEF
3
ITCH RELIEF
INFANT'S PAIN RELIEVER
3
itraconazole
27
INFANTS IBU-DROPS
7
ivermectin
34
INFANTS MEDI-PROFEN
7
INFANTS PROFENIB
7
27,57
J
INFANTS' GAS RELIEF
66
JADENU
115
INFANTS' PAIN RELIEF
3
JAKAFI
32
INFANTS' PAIN RELIEVER
3
jantoven
44
INFANTS' PAIN-FEVER
3
JANUMET
41
INFERGEN
39
JANUMET XR
41
INLYTA
32
JANUVIA
41
INNOPRAN XL
47
JARDIANCE
41
INTELENCE
36
jencycla
85
INTENSE COUGH
109
JENTADUETO
41
INTENSE COUGH RELIEVER
109
JENTADUETO XR
41
INTRON A
32
jevantique lo
82
introvale
82
jinteli
82
INVIRASE
38
JOCK ITCH
27
INVOKAMET
41
JOCK ITCH RELIEF
27
INVOKAMET XR
41
jolessa
82
INVOKANA
41
jolivette
85
INZO ANTIFUNGAL
27
juleber
82
IOPHEN DM-NR
109
junel
82
IOPHEN NR
109
junel fe
82
IOPHEN-C NR
109
junel fe 24
82
66
JUXTAPID
53
ipecac
ipratropium bromide
103
ipratropium bromide/albuterol sulfate
104
K
irbesartan
46
k-sol
irbesartan/hydrochlorothiazide
50
KALETRA
IRESSA
32
KALYDECO
IRON
119
147
122
38
109
KAO-TIN
71
kariva
82
KAZANO
41
larissia
82
kelnor 1-35
82
latanoprost
91
LAX STOOL SOFTENER WITH SENNA
72
KENWOOD THERAPEUTIC
122
ketoconazole
27
LAXA CLEAR
72
ketodan
27
LAXACIN
72
7
LAXATIVE
72
ketoprofen
ketorolac tromethamine
7,94
LAXATIVE DIETARY SUPPLEMENT
72
KID'S GUMMY BEAR VITAMINS
122
LAXATIVE FEMININE
72
KID'S VITAMINS
122
LAXATIVE SUPPOSITORY
72
KID'S VITAMINS + EXTRA C
122
leena
82
leflunomide
89
LENVIMA
33
lessina
83
KID'S VITAMINS + IRON
102,128
KID'S VITAMINS COMPLETE
kimidess
122
82
kionex
115
LETAIRIS
105
klor-con 8
122
letrozole
32
klor-con m10
122
leucovorin calcium
32
KLOR-CON M15
122
LEUKERAN
31
klor-con m20
122
LEUKINE
44
klor-con sprinkle
122
leuprolide acetate
87
KOMBIGLYZE XR
41
levalbuterol tartrate
KONSYL
71
LEVATOL
47
KONSYL EASY MIX
71
LEVEMIR
43
KONSYL FIBER
71
LEVEMIR FLEXTOUCH
43
KONSYL FORMULA-D
71
levetiracetam
21
KRISTALOSE
72
levobunolol hcl
94
kurvelo
82
levocarnitine
115
KUVAN
58
levocarnitine (with sugar)
115
KYNAMRO
53
levocetirizine dihydrochloride
101
L
levofloxacin
20
levonest
83
labetalol hcl
47
levonorgestrel
lactulose
72
levonorgestrel-ethinyl estradiol
lamivudine
37,39
104
83,85
83
levonorgestrel/ethinyl estradiol and ethinyl estradiol 83
lamivudine/zidovudine
37
levora-28
83
lansoprazole
76
levothyroxine sodium
86
lansoprazole/amoxicillin trihydrate/clarithromycin
66
levoxyl
86
LANTUS
43
LEXIVA
38
LANTUS SOLOSTAR
43
LIALDA
66
larin
82
LICE CREAM RINSE
35
larin 24 fe
82
LICE KILLING
35
larin fe
82
LICE TREATMENT
35
148
lidocaine
12
LOTEMAX
94
lidocaine hcl
12
LOTRIMIN AF
27
lidocaine/prilocaine
12
lovastatin
52
lidopril
12
low-ogestrel
83
lidopril xr
12
LUBRICANT EYE
92
lindane
35
LUBRICANT EYE DROPS
92
linezolid
17
LUBRICANT PLUS
92
liothyronine sodium
86
LUBRICANT PM
92
LIQUID ANTACID
66
LUBRICATING PLUS
92
LIQUITEARS
92
LUBRICATING RELIEF
92
lisinopril
46
LUBRICATING TEARS
92
lisinopril/hydrochlorothiazide
50
LUBRIFRESH PM
92
ludent fluoride
56
LUMIGAN
91
lutera
83
LITTLE ANIMALS WITH IRON
LITTLE REMEDIES
LITTLE REMEDIES FEVER-PAIN
101
90
3
LITTLE REMEDIES STUFFY NOSE
90
LYNPARZA
33
LO-PERAMIDE
60
LYRICA
22
LOBANA BATH OIL
57
LYSODREN
87
lofibra
52
lyza
85
LOHIST-D
109
lomedia 24 fe
83
M
lomustine
31
MAALOX MAXIMUM STRENGTH
LONG ACTING NASAL DECONGESTANT
109
66
MACUVITE
123
123
LONSURF
32
MACUVITE EYE CARE
loperamide hcl
60
MAG-AL PLUS XS
lopreeza
83
MAG64
66
123
LORADAMED
101
MAGIC BULLET
72
LORATA-D
109
MAGLOX
66
LORATA-DINE D
109
magnesium
loratadine
101
magnesium citrate
66
LORATADINE D
101
magnesium hydroxide
72
LORATADINE-D
101,109
magnesium oxide
123
72,123
lorcet
10
magnesium sulfate
lorcet hd
10
MAPAP
3
lorcet plus
10
MAPAP ARTHRITIS PAIN
3
lortab
10
MAPAP PM
3
LORTAB
10
MAPO
57
marlissa
83
66
LORTUSS EX
109
91
loryna
83
MASANTI
losartan potassium
46
MASOPHEN
3
losartan potassium/hydrochlorothiazide
50
MATULANE
31
149
matzim la
meclizine hcl
meclofenamate sodium
49
24,25
7
metaproterenol sulfate
104
metaxall
114
metaxalone
114
MEDI-BISMUTH
66
metformin hcl
41
MEDI-LAXX
72
metformin hcl 500 mg tab er 24h (generic for
MEDI-MECLIZINE
25
glucophage xr)
42
MEDI-NATURAL
72
methadone hcl
8,9
MEDI-NATURAL SENNA STOOL SOFT
72
methadone intensol
9
9
MEDI-PHEDRINE
109
methadose
MEDI-PHEDRYL
101
methazolamide
51
MEDI-PROFEN
8
methenamine hippurate
17
MEDI-TABS
3
methergine
77
MEDI-TABS EXTRA STRENGTH
3
methimazole
88
MEDI-TABS PM
3
methocarbamol
114
MEDI-TUSSIN
109
methotrexate sodium
31
MEDI-TUSSIN DM
109
methotrexate sodium/pf
31
MEDI-TUSSIN DM DIABETIC
109
methyclothiazide
52
MEDIFIN EXPECTORANT MUCUS RLF
109
methyldopa
45
methyldopa/hydrochlorothiazide
50
MEDIPROXEN
8
medolor pak
12
methylergonovine maleate
77
MEDROL
79
methylphenidate hcl
54
medroxyprogesterone acetate
85
methylprednisolone
15
mefloquine hcl
34
metoclopramide hcl
25
MEGA MULTI W-CHELATED MINERALS
123
metolazone
52
MEGA MULTIVITAMIN WITH MINERAL
123
metoprolol succinate
48
megestrol acetate
85
metoprolol tartrate
48
MEKINIST
33
metoprolol tartrate/hydrochlorothiazide
50
meloxicam
8
metronidazole
17
24
mexiletine hcl
47
memantine hcl
MEN 50 PLUS MULTIVITAMIN
123
MG-PLUS-PROTEIN
123
MEN'S DAILY MULTIVIT-MINERAL
123
MGO
123
MEN'S MULTI-VITAMIN
123
MI ACID
66
MEN'S ONE DAILY
120
MI-ACID
66
10
MICATIN
27
123
miconazole nitrate
27
mercaptopurine
31
MICONAZORB AF
27
mesalamine
66
MICRO-GUARD
28
MESTINON
30
microgestin
83
metadate er
54
microgestin fe
83
METAMUCIL
72
midodrine hcl
45
METAMUCIL SUGAR FREE
72
migergot
29
meperidine hcl
MEPHYTON
150
MIGRANAL
29
MUCUS ER
109
millipred
15
MUCUS RELIEF
109
millipred dp
15
MUCUS RELIEF D
110
MUCUS-ER
110
MILLTRIUM SENIOR
123
mimvey
83
MULTAQ
mimvey lo
83
MULTI COMPLETE-IRON
123
mineral oil
58
MULTI-DAY PLUS IRON
123
MINERAL OIL
72
MULTI-DELYN
123
MINERAL OIL EXTRA HEAVY
72
MULTI-VITAMIN DAILY
123
minitran
53
MULTI-VITE
123
minocycline hcl
21
MULTI-VITE 50 & OVER
123
minoxidil
53
multivit with calcium, iron, and other minerals
123
MINTOX
66
MULTIVITAL
123
MINTOX MAXIMUM STRENGTH
66
MULTIVITAL PERFORMANCE
123
misoprostol
76
MULTIVITAL PLATINUM
123
MODERIBA
39
multivitamin
123
moexipril hcl
46
multivitamin with iron
123
MOISTURIZING LUBRICANT
92
multivitamin with minerals
123
mometasone furoate
58
multivitamin with minerals/ferrous gluconate
124
mondoxyne nl
21
multivitamin,therapeutic with minerals
124
MONISTAT 3
28
mupirocin 2% ointment
17
monoject prefill
43
MURINE EAR WAX REMOVAL SYSTEM
95
monoject prefill advanced
44
MY FAVORITE MULTIPLE
montelukast sodium
103
47
124
MY WAY
83
MONUROL
17
MYALEPT
79
morgidox
21
mycophenolate mofetil
89
9,11
mycophenolate sodium
89
morphine sulfate
MOTION RELIEF
MOTION SICKNESS
MOTION SICKNESS II
MOTION SICKNESS RELIEF
25
25,101
25
25,101
MYFERON 150
MYLERAN
124
31
mynatal advance
124
mynephrocaps
124
124
MOTION SICKNESS RELIEF II
25
mynephron
MOTION-TIME
25
MYRBETRIQ
36
8
MYTAB GAS
66
MOTRIN IB
MOVE IT ALONG
72
MYTAB GAS MAXIMUM STRENGTH
66
MOVIPREP
72
MYTESI
66
moxifloxacin hcl
20
MYVITALIFE
MUCINEX ALLERGY
101
MUCINEX DM
109
MUCUS D
109
N
MUCUS DM
109
nabumetone
151
myzilra
124
83
8
nadolol
48
NEUMEGA
44
naloxone hcl
12
NEUPOGEN
44
naltrexone hcl
12
nevirapine
36
naphazoline hcl
92
NEXAVAR
33
naproxen
8
NEXIUM
76
naproxen sodium
8
NEXT CHOICE ONE DOSE
83
naratriptan hcl
29
nicardipine hcl
49
NARCAN
13
13
110
13
13
13
NASAL & SINUS DECONGESTANT
NASAL ALLERGY
79
NASAL DECONGEST-ANTIHISTAMINE
110
NASAL DECONGESTANT
110
NICOTINE 21-14-7 MG TRANSDERMAL SYSTEM 13
NASAL DECONGESTANT-ANTIHIST
110
13
NASAL MOISTURIZING
91
13
NASAL SPRAY
91
13
NATPARA
86
13
NICOTROL
13
NATURAL B-100
124
NATURAL DAILY FIBER
72
NICOTROL NS
13
NATURAL FIBER
72
nifediac cc
49
NATURAL FIBER LAXATIVE
73
nifedical xl
49
NATURAL FIBER POWDER
73
nifedipine
49
NATURAL FIBER SUPPLEMENT
73
NIGHT TIME PAIN MEDICINE
NATURAL SENNA LAXATIVE
73
NIGHTTIME ALLERGY RELIEF
101
NATURAL VEGETABLE LAXATIVE
73
NIGHTTIME SLEEP AID
102
NATURAL VEGETABLE POWDER
73
NIGHTTIME SLEEP-AID
114
NEBUPENT
34
nikki
83
necon
83
nilutamide
88
neo-polycin
92
nimodipine
49
neo-polycin hc
92
NINLARO
33
neomycin sulfate
16
nisoldipine
49
NITRO-BID
53
neomycin sulfate/bacitracin zinc/polymyxin
3
b/hydrocortisone
92
NITRO-DUR
53
neomycin sulfate/bacitracin/polymyxin b
92
nitro-time
53
neomycin sulfate/polymyxin b sulfate/gramicidin d
93
nitrofurantoin
17
nitrofurantoin macrocrystal
17
nitrofurantoin monohydrate/macrocrystals
17
53
sulfate/hydrocortisone
15,93
neomycin/polymyxin b sulfate/dexamethasone
93
nitroglycerin
NEOSPORIN
15
niva-plus
124
neosporin
93
nizatidine
68
NESINA
42
NOBLE FORMULA HC
15
NEULASTA
44
NON-ASPIRIN
152
4
NON-ASPIRIN 8 HOUR
4
OFEV
110
NON-ASPIRIN EXTRA STRENGTH
4
ofloxacin
20
NON-ASPIRIN JR STRENGTH
4
ogestrel
84
NON-ASPIRIN PAIN RELIEF
4
OLYSIO
39
NON-ASPIRIN PM
4
omeprazole
76
NON-ASPIRIN PM EX-STRENGTH
4
omeprazole magnesium
76
NON-DROWSY ALLERGY
102
OMNITROPE
79
NON-DRYING SINUS
110
ONCE DAILY
124
nora-be
86
ONCOVITE
124
norethindrone
86
ondansetron
26
norethindrone acetate
86
ondansetron hcl
26
norethindrone acetate-ethinyl estradiol
83
ondansetron odt
26
norethindrone acetate-ethinyl estradiol/ferrous
ONE DAILY
124
fumarate
83
ONE DAILY 50 PLUS
124
norgestimate-ethinyl estradiol
83
ONE DAILY ENERGY
128
norlyroc
86
ONE DAILY ESSENTIAL
124
NORPACE CR
47
ONE DAILY FOR MEN
124
ONE DAILY FOR WOMEN
124
NORTEMP
4
nortrel
83
ONE DAILY FOR WOMEN 50+ ADV
124
NORVIR
38
ONE DAILY MAXIMUM
124
NOXAFIL
28
ONE DAILY MEN'S 50+
128
np thyroid
86
ONE DAILY MEN'S HEALTH
124
NUEDEXTA
55
ONE DAILY MULTIVITAMIN
124
nulytely with flavor packs
73
ONE DAILY MULTIVITAMIN-IRON
124
NUVARING
83
ONE DAILY PLUS IRON
125
NUZOLE
28
ONE DAILY PLUS MINERALS
125
nyamyc
28
ONE DAILY WITH CALCIUM-IRON
125
nystatin
28
ONE DAILY WITH IRON
125
nystatin/triamcinolone acetonide
15
ONE DAILY WOMEN'S
125
nystop
28
ONE DAILY WOMEN'S 50+
125
NYT-TIME SLEEP
102
ONE DAILY WOMEN'S HEALTH
125
NYTOL QUICKCAPS
102
ONE-A-DAY ESSENTIAL
125
ONE-A-DAY MAXIMUM FORMULA
125
ONE-A-DAY TEEN ADVANTAGE
125
125
O
OCALIVA
67
ONE-A-DAY WOMEN'S
ocella
84
ONFI
22
octreotide acetate
87
ONGLYZA
42
84
OCUTABS
124
OPCICON ONE-STEP
OCUVITE WITH LUTEIN
124
OPSUMIT
105
ODEFSEY
36
OPTI-VITAMIN
125
ODOMZO
33
OPTIMAL D3
125
153
OPTION 2
84
PAIN RELIEVER JUNIOR STRENGTH
5
ORAL SALINE LAXATIVE
73
PAIN RELIEVER PM
5
ORAL SALINE LAXATIVE KIT
73
PAIN RELIEVER-FEVER REDUCER
5
ORALAIR
oralone
110
15
pancrelipase 5,000
58
pantoprazole sodium
76
paricalcitol
87
18
ORALYTE
125
ORENCIA
89
paroex
ORENCIA CLICKJECT
89
PARVA-CAL 500
125
PEDIA RELIEF
103
PEDIA RELIEF INFANT
110
ORENITRAM ER
ORFADIN
105
58
ORGAN-I NR
110
PEDIA-LAX
71
ORKAMBI
110
PEDIA-LAX STOOL SOFTENER
73
orphenadrine citrate
114
PEDIACARE FEVER REDUCER
5
orphenadrine citrate/aspirin/caffeine
114
PEDIATRIC COUGH-COLD
110
84
PEDIATRIC ELECTROLYTE
125
125
PEDIATRIC FREEZER POPS
125
125
orsythia
OS-CAL 500-VIT D3
OSENI
42
pediatric multivitamin a,c,and d3 no.21
OTEZLA
89
pediatric multivitamin combination no.2/sodium
oxaprozin
8
fluoride
oxcarbazepine
23
pediatric multivitamin combo no.45/fluoride/ferrous
oxybutynin chloride
77
sulfate
oxycodone hcl
9,11
11
sulfate
oxycodone hcl/aspirin
11
pediatric multivitamins a,c,& d3 no.21 with sodium
9
126
pediatric multivitamin combo no.75/fluoride/ferrous
oxycodone hcl/acetaminophen
OXYCONTIN
125
126
fluoride
126
oxymorphone hcl
11
pediatric multivitamins no.16 with sodium fluoride
126
OXYTROL
77
126
OYSCO 500-VIT D3
125
126
OYSCO-500
125
peg 3350/sod sulf/sod bicarbonate/sod
OYSTERCAL-D
125
chloride/potassium chl
73
PEG3350
73
PEGANONE
23
P
P-COL RITE
73
PEGASYS
39
pacerone
47
PEGASYS PROCLICK
39
PAIN & FEVER
4
PEGINTRON
39
PAIN & SLEEP
4
PEGINTRON REDIPEN
39
PAIN RELIEF
5
penicillin v potassium
19
PAIN RELIEF ADULT
5
PENTASA
67
PAIN RELIEF EXTRA STRENGTH
5
pentazocine hcl/acetaminophen
11
PAIN RELIEF PM
5
pentazocine hcl/naloxone hcl
11
PAIN RELIEVER
5
pentoxifylline
50
154
PEP-T-MED
67
POLY-VI-SOL WITH IRON
126
PEPCID AC
69
POLY-VITA
126
PEPTIC RELIEF
67
POLY-VITA WITH IRON
126
perindopril erbumine
46
POLY-VITAMIN
126
periogard
18
polyethylene glycol 3350
73
permethrin
35
polymyxin b sulfate/trimethoprim
93
petrolatum,white
58
POLYSACCHARIDE IRON
petrolatum,white/lanolin
58
polyvinyl alcohol
126
93
PHARBECHLOR
102
POLYVITAMIN WITH IRON
PHARBEDRYL
102
POMALYST
31
portia
84
PHARBETOL
PHARMACIST FAVORITE MULTI-VITE
5
126
potassium chloride
126
126
phenadoz
25
potassium chloride/potassium bicarbonate/citric
phenobarbital
22
acid
126
phenoxybenzamine hcl
45
potassium citrate
126
phenylephrine hcl
93
POWDERLAX
73
PRADAXA
44
phenylephrine hcl/promethazine hcl
110
phenytoin
23
PRALUENT PEN
53
phenytoin sodium extended
23
PRALUENT SYRINGE
53
philith
84
pramipexole di-hcl
36
PHILLIPS
73
pravastatin sodium
52
PHILLIPS' LAXATIVE
73
prazosin hcl
45
PHOS-FLUR
56
PRE PROTEIN
PHOSPHATE ENEMA
73
PRED MILD
94
PHOSPHATE LAXATIVE
73
prednisolone
15
prednisolone acetate
79
pilocarpine hcl
56,94
126
pimtrea
84
prednisolone sod phosphate
pindolol
48
prednisone
15
PINK BISMUTH
67
prednisone intensol
16
pioglitazone hcl
42
PREFEST
84
pioglitazone hcl/glimepiride
42
PREMARIN
84
pioglitazone hcl/metformin hcl
42
PREMPHASE
84
pirmella
84
PREMPRO
84
piroxicam
8
15,94
prenaplus
127
127
PLEGRIDY
55
prenatal vit calc,iron,folic acid (less than 1 mg)
PLEGRIDY PEN
55
prenatal vitamin no.15/iron,carbonyl/folic acid/docusate
pnv 29-1
126
sod
pnv-vp-u
126
prenatal vitamin with ca no.124/ferrous fumarate/folic
podofilox
58
acid
127
127
POLY-IRON
126
POLY-VI-SOL
126
acid
155
127
prochlorperazine
25
acid
prochlorperazine maleate
25
PROCRIT
44
acid
procto-med hc
16
proctocream-hc
16
PROCTOFOAM-HC
67
proctosol-hc
90
proctozone-hc
90
PROCYSBI
77
progesterone,micronized
86
prenatal vitamins combo no.60/ferrous fumarate/folic
PROMACTA
44
acid
promethazine hcl
25
127
127
prenatal vitamins comb no.115/iron fumarate/folic
acid
127
acid/dss
127
acid/dss
127
127
prenatal vitamins with calcium/ferrous fumarate/folic
promethazine hcl/codeine
110
acid
promethazine hcl/dextromethorphan hbr
110
promethazine/phenylephrine hcl/codeine
110
127
prenatal vits with calcium #72/ferrous fumarate/folic
acid
127
prenatal vits with calcium #72/iron,carbonyl/folic
acid
127
acid
127
acid
127
acid
promethegan
25
PROMOLAXIN
73
propafenone hcl
47
propantheline bromide
67
propranolol hcl
48
propranolol hcl/hydrochlorothiazide
50
propylthiouracil
88
PROSIGHT
128
PROTECTIVE OINTMENT
128
58
prenatal vits with calcium#118/ferrous fumarate/folic
PROTEIN
128
acid
PROTEINEX
128
PROTONIX
76
128
prenatal vits without calc no5/ferrous fumarate/folic
acid
PREPARATION H
preplus
128
16
128
PROVIL
pseudoephedrine hcl
8
110
psyllium husk/aspartame
73
96
PREVACID
76
PULMICORT FLEXHALER
prevalite
53
pulmosal
111
prevident
56
PULMOZYME
111
PREZCOBIX
38
PURE & GENTLE SALINE ENEMA
73
PREZISTA
38
PURELAX
73
PRILOSEC OTC
76
PURIXAN
31
primaquine phosphate
34
PYLERA
67
primidone
22
pyrazinamide
30
proair hfa
104
pyridostigmine bromide
30
proair respiclick
105
pyridoxine hcl
probenecid
29
156
128
Q
Q-DRYL
102
RELENZA
38
REMEDY ANTIFUNGAL
28
REMEDY PHYTOPLEX ANTIFUNGAL
28
Q-PAP
5
RENA-VITE
128
Q-PAP EXTRA STRENGTH
5
rena-vite rx
128
Q-TAPP
111
RENAGEL
78
Q-TUSSIN
111
renal caps
128
Q-TUSSIN DM
111
RENAL VITAMIN
128
RENAL-VITE
128
quasense
84
QUENALIN
102
reno caps
128
QUFLORA
128
RENVELA
78
quinapril hcl
46
REPATHA PUSHTRONEX
53
quinapril hcl/hydrochlorothiazide
50
REPATHA SURECLICK
53
quinidine gluconate
47
REPATHA SYRINGE
53
quinidine sulfate
47
reprexain
11
QVAR
96
RESCRIPTOR
36
reserpine
45
R
rabeprazole sodium
REST SIMPLY
76
RESTASIS
RESTFULLY SLEEP
102
89
RAGWITEK
111
raloxifene hcl
86
RESTORE TEARS
93
ramipril
46
RETAINE CMC
93
ranitidine hcl
67,69
RAPAMUNE
89
revia
12
RAVICTI
58
REVLIMID
31
REACT
84
REYATAZ
38
READY TO USE ENEMA
73
RHEUMATREX
31
REBETOL
39
RI-GEL
67
REBIF
55
RI-GEL II
67
REBIF REBIDOSE
55
RI-MAG
67
reclipsen
84
RI-MOX
67
RECORT PLUS
16
RI-MOX PLUS
67
REDNESS LUBRICANT EYE DROPS
93
RI-TUSSIN
111
REDNESS RELIEF
92
RI-TUSSIN DM
111
REDNESS RELIEVER EYE DROPS
93
RIBAPAK
39
RIBASPHERE
39
REFENESEN
111
REVATIO
102
105
REFRESH LACRI-LUBE
93
RIBASPHERE RIBAPAK
39
REGRANEX
58
RIBATAB
39
REGULOID
73
ribavirin
39
relador pak
12
rifabutin
30
relador pak plus
12
RIFAMATE
30
157
rifampin
30
SELZENTRY
37
128
SEN-O-TAB
73
RIGINIC
67
SENEXON
74
riluzole
55
SENEXON-S
74
rimantadine hcl
38
SENIOR TABS
RINGWORM
28
SENNA
74
RIOMET
42
SENNA LAX
74
SENNA LAXATIVE
74
RIGHT STEP PRENATAL VITAMINS
RISANOID PLUS
128
129
risedronate sodium
91
SENNA PLUS
74
RITALIN LA
54
SENNA S
74
rivastigmine
24
SENNA-S
74
rivastigmine tartrate
24
SENNA-TIME S
74
rizatriptan benzoate
29
SENNALAX-S
74
ROBAFEN
111
SENNO
74
ROBAFEN CF
111
sennosides
74
ROBAFEN DM COUGH
111
sennosides/docusate sodium
74
ROBAFEN DM COUGH-CHEST CONGEST
111
SENSIPAR
87
ROBAFEN-DM
111
SENTRY
129
ROBITUSSIN COUGH-CHEST-CONG DM
111
SENTRY SENIOR
129
105
ropinirole hcl
36
SEREVENT DISKUS
rosadan
18
setlakin
84
rosuvastatin calcium
52
sevelamer carbonate
78
roweepra
22
sf
56
ROXICET
11
sf 5000 plus
56
roxicet
11
SHAKE THAT ACHE
RULOX
67
sharobel
86
SIGNIFOR
87
SILACE
74
RYNEX PSE
111
S
SABRIL
SAFETUSSIN DM
22
111
5
SILADRYL
102
sildenafil citrate
105
SILPHEN
102
SALINE ENEMA
73
SILTUSSIN DM
111
SAVAYSA
44
SILTUSSIN DM DAS COUGH FORMULA
111
111
SCOOBY-DOO
129
SILTUSSIN SA
se-natal 19
129
silver sulfadiazine
20
SEA SOFT
91
simethicone
67
SECURA ANTIFUNGAL
28
SIMPLY SLEEP
SECURA PROTECTIVE
58
SIMPONI
89
selegiline hcl
36
simvastatin
52
selenium sulfide
58
SINUS & ALLERGY
111
SELSUN BLUE
57
SINUS 12 HOUR
111
158
102
SINUS 12-HOUR
111
SPORANOX
28
sirolimus
89
SPRYCEL
33
SIRTURO
30
sronyx
84
SIVEXTRO
18
ST. JOSEPH ASPIRIN
SKIN PROTECTANT A & D
57
stagesic
11
102,114
stavudine
37
SLEEP II
102
STELARA
58
SLEEP TABLET
102
STERILE EYE DROPS
93
SLEEP TABS
102
STIMATE
79
SLEEP AID
8
SMOOTH ANTACID
67
STIMULANT LAXATIVE PLUS
74
SMOOTH DISSOLVING ANTACID
67
STIVARGA
33
SMOOTHLAX
74
STOMACH RELIEF
67
sodium chloride
91
STOOL SOFTENER
75
STOOL SOFTENER-LAXATIVE
75
STOOL SOFTENER-STIMULANT LAX
75
STRENSIQ
59
sodium chloride for inhalation
112
sodium chloride/sodium bicarbonate/potassium
chloride/peg
sodium fluoride
sodium phenylbutyrate
sodium polystyrene sulfonate
74
56,129
59
115
STRESS 500
129
STRESS 500 PLUS ZINC
129
STRESS B
129
SOF-LAX
74
STRESS B WITH ZINC
129
SOLTAMOX
31
STRESS FORMULA
129
SOLUBLE FIBER
74
STRESS FORMULA WITH ZINC
129
SOMAVERT
87
STRESS-C
129
SOOTHE
67
STRIBILD
37
SOOTHING CARE
16
sucralfate
76
SOOTHING PUREWAY-C
129
sorbitol solution
74
SORBUGEN NR
112
SUDOGEST
sulfacetamide sodium
112
21,93
sulfacetamide sodium/prednisolone sodium
sorine
47
phosphate
93
sotalol hcl
47
sulfamethoxazole/trimethoprim
21
SOVALDI
39
sulfamide
21
68
SPECTRAVITE ADULT 50+
119
sulfasalazine
SPECTRAVITE ADVANCED FORMULA
129
sulindac
SPECTRAVITE SENIOR
129
sumatriptan
29
SPECTRAVITE ULTRA MEN 50+
129
sumatriptan succinate
29
SPECTRAVITE ULTRA MEN'S
129
SUPER AMINO ACIDS
129
SPECTRAVITE ULTRA WOMEN
129
SUPER B COMPLEX-VITAMIN C
129
SPIRIVA
104
SUPER B-50 COMPLEX
129
SPIRIVA RESPIMAT
104
SUPER B-50 COMPLEX PLUS
129
8
spironolactone
51
SUPER CALCIUM
129
spironolactone/hydrochlorothiazide
51
SUPER MULTIPLE
129
159
SUPER QUINTS
129
telmisartan/hydrochlorothiazide
51
SUPER THERAVITE-M
129
temazepam
SUPERPLEX-T
129
temozolomide
SUPHEDRIN
112
tencon
6
SUPHEDRIN 12-HOUR
112
TENSION HEADACHE RELIEVER
6
SUPHEDRINE
112
terazosin hcl
45
SUPHEDRINE 12-HOUR
112
terbinafine hcl
28
SUPHEDRINE SINUS CONGESTION
112
terbutaline sulfate
114
31
105
SUPPOSITORY
75
terconazole
28
SUPREP
75
testosterone
80
SUSTIVA
37
testosterone cypionate
80
SUTENT
33
testosterone enanthate
80
syeda
84
tetrabenazine
55
SYLATRON
32
tetracycline hcl
21
SYLATRON 4-PACK
32
THALOMID
31
SYMBICORT
105
THEO-24
104
SYMLINPEN 120
42
theochron
104
SYMLINPEN 60
42
theophylline anhydrous
104
SYNJARDY
42
THERA
130
SYNRIBO
32
THERA-D
130
THERA-M
130
THERA-TABS
130
T
TAB-A-VITE
130
THERADEX M
130
TAB-A-VITE WITH IRON
130
THERAMILL FORTE
130
TAB-A-VITE-MINERALS
130
THERAPEUTIC M
130
TABLOID
31
THERAPEUTIC-M
130
tacrolimus
58,89
THERATRUM COMPLETE
130
TACTINAL
6
THERATRUM COMPLETE 50 PLUS
130
TAFINLAR
33
THEREMS
130
TAGRISSO
33
THEREMS-M
130
TAMIFLU
38
thiamine hcl
130
tamoxifen citrate
31
thiamine mononitrate
130
tamsulosin hcl
77
thrivite 19
130
TARCEVA
33
THYROLAR-1
86
TARGRETIN
34
THYROLAR-1/2
86
tarina fe
84
THYROLAR-1/4
86
TASIGNA
33
THYROLAR-2
86
taztia xt
49
THYROLAR-3
86
TEARS AGAIN
93
tiagabine hcl
22
TECFIDERA
55
ticlopidine hcl
45
telmisartan
46
tilia fe
84
160
timolol maleate
48,94
tri-lo-estarylla
84
tinidazole
18
tri-lo-marzia
84
tioconazole
28
tri-lo-sprintec
84
TIOCONAZOLE 1
28
tri-previfem
85
TIOCONAZOLE-1
28
tri-sprintec
85
TIVICAY
38
TRI-VITA
130
tizanidine hcl
36
TRIACTING EXPECTORANT
112
TL FOLATE
130
triadvance
130
TOBI PODHALER
16
triamcinolone acetonide
TOBRADEX
16
triamterene/hydrochlorothiazide
51
TOBRADEX ST
93
trianex
58
tobramycin
16
triazolam
114
tobramycin in 0.225 % sodium chloride
16
TRICARE
130
tobramycin/dexamethasone
93
triderm
16
tolazamide
42
trifluridine
40
trihexyphenidyl hcl
35
trilyte with flavor packets
75
trimethobenzamide hcl
25
18
tolmetin sodium
8
tolnaftate
28
tolterodine tartrate (er 2 mg cap, er 4 mg cap, 1 mg
16,79
tab, 2 mg tab)
77
trimethoprim
topiragen
23
trinatal gt
130
topiramate
23
trinatal rx 1
130
torsemide
51
trinessa
85
TOTAL ALLERGY
102
trinessa lo
85
TOTAL B WITH C
130
triphrocaps
130
TOUJEO SOLOSTAR
43
TRACLEER
105
TRADJENTA
42
tramadol hcl
9,11
TRIPLE ANTIBIOTIC
18
TRIPLE ANTIBIOTIC EXTRA
18
TRIPLE ANTIBIOTIC PLUS
18
TRIPLE ANTIBIOTIC-PAIN RELIEF
18
tramadol hcl/acetaminophen
12
TRIUMEQ
38
trandolapril
46
trivora-28
85
tranexamic acid
44
trospium chloride
77
TRAVATAN Z
91
TRUVADA
37
103
TUSNEL C
112
TRAVEL SICKNESS
43
TUSNEL DIABETIC
112
43
TUSNEL PEDIATRIC
112
tretinoin
34
tussigon
112
TREXALL
31
TUSSIN
112
TRI-BIOZENE
18
TUSSIN CF
112
tri-estarylla
84
TUSSIN CHEST CONGESTION
112
tri-legest fe
84
TUSSIN COLD SEVERE CONGESTION
112
tri-linyah
84
TUSSIN COUGH
112
161
TUSSIN COUGH DM
112
VAGIFEM
85
TUSSIN COUGH-CHEST CONGESTION
112
VAGISTAT-3
28
TUSSIN DM
113
valacyclovir hcl
40
TUSSIN DM CLEAR
113
VALCHLOR
31
TUSSIN DM COUGH
113
valganciclovir hcl
38
TUSSIN DM COUGH & CHEST
113
valsartan
46
TUSSIN DM COUGH-CHEST CONGEST
113
valsartan/hydrochlorothiazide
51
TUSSIN DM MAX
113
VALU-DRYL
103
TUSSIN HONEY
113
VALU-DRYL ALLERGY MEDICINE
103
TUSSIN MUCUS-CHEST CONGESTION
113
VALU-TAPP
113
TUSSIN PE
113
VALU-TAPP DECONGESTANT
113
TYBOST
38
vanatol lq
55
TYKERB
34
vancomycin hcl
18
TYLENOL PM EXTRA STRENGTH
6
vandazole
18
TYLOPHEN
6
vandetanib
34
vaseline white petroleum
58
VEGETABLE LAXATIVE
75
velivet
85
TYZEKA
39
U
UCERIS
90
VENCLEXTA
34
ULESFIA
35
VENCLEXTA STARTING PACK
34
ULTIMATE MEN'S COMPLETE 50+
ULTRA A-D
130
VENTAVIS
105
60
ventolin hfa
105
ULTRA B-100 COMPLEX
130
verapamil hcl
47,49
ULTRA DM FREE & CLEAR
113
VERTICALM
25
ULTRA FRESH
93
vestura
85
ULTRA FRESH PM
93
VEXOL
94
ULTRA LUBRICANT EYE
93
VIBERZI
69
ULTRA STRENGTH ANTACID
68
VIBRAMYCIN
21
ULTRA TUSS
113
unithroid
87
UPTRAVI
105
vic-forte
131
VICKS QLEARQUIL ALLERGY
103
VICKS QLEARQUIL NIGHTTIME
103
URINARY PAIN RELIEF
77
VICTOZA 2-PAK
42
URINARY TRACT
77
VICTOZA 3-PAK
42
urine acetone test,strips
91
VIDEX
37
urine acetone test,tablet
91
VIEKIRA PAK
39
urine glucose-acet test strip
91
VIEKIRA XR
40
URISTAT
78
vienva
85
ursodiol
68
VIMPAT
23
vinate gt
131
vinate one
131
vinate pn care
131
V
v-c forte
131
162
vinate-m
131
viorele
85
W
VIRACEPT
38
WAL-ACT D COLD & ALLERGY
113
VIREAD
37
WAL-DRAM
103
virt nate
131
WAL-DRYL
57,103
virt-advance
131
WAL-DRYL ALLERGY
103
virt-caps
131
WAL-FEX ALLERGY
103
virt-nate
131
WAL-FEX D 24 HOUR
103
virt-vite gt
131
WAL-FINATE
103
VIRTUSSIN AC
113
WAL-ITIN
103
VIRTUSSIN DAC
113
WAL-ITIN D
113
VISION
131
WAL-ITIN D 12 HOUR
103
VISION FORMULA
131
WAL-MUCIL
75
VISION PLUS LUTEIN
131
WAL-MUCIL NATURAL FIBER LAX
75
VISION VITAMINS
131
WAL-NADOL PM
VISTOGARD
91
vit b complex/vit c/folic acid/ferrous fumarate/vit e
6
WAL-PHED
113
WAL-PHED 12 HOUR
113
113
acet
131
WAL-PHED D
VITALETS
103
WAL-PROFEN
8
vitamin a
131
WAL-PROXEN
8
VITAMIN A & D GRX
57
WAL-SOM
114
vitamin a palmitate
131
WAL-TUSSIN
113
vitamin b complex
131
WAL-TUSSIN COUGH-COLD CF
113
vitamin e
131
WAL-TUSSIN DM
113
vitamin e (dl-alpha tocopheryl acetate)
131
WAL-ZAN 150
68
vitamin e acetate
131
WAL-ZAN 75
68
vitamin e acid succinate
131
WAL-ZYR
vitamin e mixed
132
warfarin sodium
44
vitamins a and d
57
WOMAN'S LAXATIVE
75
vitamins a and d/white petrolatum/lanolin
57
WOMEN'S DAILY FORMULA
VITEKTA
38
WOMEN'S GENTLE LAXATIVE
75
103
132
VITRUM SENIOR
132
WOMEN'S LAXATIVE
76
vol-care rx
132
WOMEN'S ONE DAILY
132
vol-nate
132
WOMENS STOOL SOFTENER
76
vol-plus
132
wp thyroid
87
vol-tab rx
132
voriconazole
28
X
VOTRIENT
33
XALKORI
34
132
XARELTO
44
vyfemla
85
XELJANZ
89
VYVANSE
54
XELJANZ XR
89
vp-vite rx
163
XIFAXAN
18
XIGDUO XR
42
XTANDI
88
xulane
85
XURIDEN
79
xylon 10
12
XYREM
114
Y
YELETS
132
Z
zafirlukast
103
ZANTAC 75
68
zarah
85
ZEASORB
28
ZELBORAF
33
zenchent
85
ZENPEP
59
zenzedi
54
ZEPATIER
40
ZETIA
53
ZIAGEN
37
zidovudine
37
ZIRGAN
38
ZOLADEX
87
ZOLINZA
34
zolmitriptan
29
ZOMIG
30
zonisamide
22
ZOO CHEWS
132
ZORTRESS
89
zovia 1-35e
85
zovia 1-50e
85
ZYDELIG
34
ZYKADIA
34
ZYLET
93
ZYRTEC
103
ZYTIGA
33
164
Category Listing
Analgesics
Anesthetics
Anti-Addiction/Substance Abuse Treatment Agents
Anti-inflammatory Agents
Antibacterials
Anticonvulsants
Antidementia Agents
Antidepressants
Antiemetics
Antifungals
Antigout Agents
Antimigraine Agents
Antimyasthenic Agents
Antimycobacterials
Antineoplastics
Antiparasitics
Antiparkinson Agents
Antispasticity Agents
Antivirals
Anxiolytics
Blood Glucose Regulators
Blood Products/Modifiers/Volume Expanders
Cardiovascular Agents
Central Nervous System Agents
Dental and Oral Agents
Dermatological Agents
Enzyme Replacement/Modifiers
Gastrointestinal Agents
Genitourinary Agents
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
Hormonal Agents, Stimulant/Replacement/Modifying (Other)
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
Hormonal Agents, Suppressant (Adrenal)
Hormonal Agents, Suppressant (Parathyroid)
Hormonal Agents, Suppressant (Pituitary)
Hormonal Agents, Suppressant (Sex Hormones/Modifiers)
Hormonal Agents, Suppressant (Thyroid)
Immunological Agents
Inflammatory Bowel Disease Agents
Metabolic Bone Disease Agents
MISCELLANEOUS
MISCELLANEOUS THERAPEUTIC AGENTS
Ophthalmic Agents
165
1
12
12
13
16
21
24
24
24
26
29
29
30
30
30
34
35
36
36
40
40
43
45
54
56
56
58
59
77
78
79
79
80
86
87
87
87
87
88
88
90
91
90
90
91
Otic Agents
Respiratory Tract Agents
Skeletal Muscle Relaxants
Sleep Disorder Agents
Therapeutic Nutrients/Minerals/Electrolytes
94
95
114
114
115
166

Health Share of Oregon/Providence (Medicaid)

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