New Hampshire Healthy Families

Transcription

Comprehensive
PREFERRED DRUG LIST
New Hampshire Healthy Families
PAGE 1
LAST UPDATED 10/2016
LEGEND
TYPE
DESCRIPTION
QL
Quantity Limit
There is a limit on the amount of drug covered per prescription, or
within a specific time frame.
PA
Prior Authorization
Prior Authorization required before prescription can be filled.
ST
Step Therapy
Requires trial and failure of one or more preferred products prior to
coverage.
GL
Gender Limit
Drug is limited to specific gender.
AL
Age Limit
Drug is limited to specific age.
MDD
Max Daily Dose
A limit on the number of times the drug can be taken per day.
MPL
Max Package Limit
A limit on the amount of drug covered per prescription.
MFL
Max Fill Limit
There is a limit on the number of times this drug can be refilled.
PAGE 2
LIST OF COVERED OVER-THE-COUNTER MEDICATIONS
PRODUCT DESCRIPTION
BRAND/GEN
LIMITS & RESTRICTIONS
ANALGESICS
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
aspirin (chew tab 81 mg, tab 325 mg, tab delayed release
81 mg, tab delayed release 325 mg)
generic
aspirin (suppos 300 mg, suppos 600 mg)
generic
aspirin buffered (ca carb-mg carb-mg ox) tab 325 mg
generic
ASPIRIN LOW DOSE TAB 81 MG
BRAND
aspirin tab chew 81 mg
generic
ibuprofen (chew tab 100 mg, susp 40 mg/ml, susp 100
mg/5ml, tab 200 mg)
generic
ibuprofen tab 200 mg
generic
naproxen sodium tab 220 mg
generic
MDD
2 per day
generic
MDD
2 per day
QL
12 / 1 claim
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
SMOKING CESSATION AGENTS
AL
nicotine (patch 24hr 7 mg/24hr, patch 24hr 21 mg/24hr,
patch 24hr 14 mg/24hr)
generic
NICOTINE KIT 21-14-7 MG/24HR
BRAND
MDD
AL
MPL
nicotine polacrilex (gum 2 mg, gum 4 mg)
AL
generic
MDD
nicotine polacrilex (lozenge 2 mg, lozenge 4 mg)
AL
generic
MDD
PAGE 3
At least 18 yrs old
1 per day
At least 18 yrs old
2 / years
At least 18 yrs old
24 per day
At least 18 yrs old
20 per day
PRODUCT DESCRIPTION
BRAND/GEN
ANTIEMETICS
ANTIEMETICS, OTHER
meclizine hcl (chew tab 25 mg, tab 12.5 mg, tab 25 mg)
generic
ANTIFUNGALS
clotrimazole (topical) (cream, soln)
generic
MPL
clotrimazole vaginal cream 1%
generic
QL
clotrimazole vaginal cream 2%
generic
MPL
1 / 1 claim
miconazole nitrate cream 2%
generic
MPL
1 / 1 claim
miconazole nitrate vaginal cream 2%
generic
QL
45 / 1 claim
miconazole nitrate vaginal cream 4% (200 mg/5gm)
generic
QL
45 / 30 days
miconazole nitrate vaginal supp 200 mg & 2% cream 9 gm
kit
generic
MPL
1 / 1 claim
miconazole nitrate vaginal suppos 100 mg
generic
QL
7 / 1 claim
tioconazole vaginal oint 6.5%
generic
QL
5 / 1 claim
glucose chew tab 4 gm
generic
QL
50 / 30 days
GNP GLUCOSE CHEW TAB 4 GM
BRAND
QL
50 / 30 days
SM GLUCOSE CHEW TAB 4 GM
BRAND
QL
50 / 30 days
1 / 1 claim
45 / 1 claim
BLOOD GLUCOSE REGULATORS
GLYCEMIC AGENTS
CARDIOVASCULAR AGENTS
DYSLIPIDEMICS, OTHER
niacin (tab 250 mg, tab 500 mg, tab 750 mg, tab 1000 mg)
generic
omega-3 fatty acids (cap 1000, cap 1200)
generic
PAGE 4
MDD
6 per day
PRODUCT DESCRIPTION
BRAND/GEN
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM, OTHER
acetaminophen soln 100 mg/ml
generic
acetaminophen soln 160 mg/5ml
generic
QL
30 / 1 claim
DENTAL AND ORAL AGENTS
sodium fluoride rinse 0.2%
generic
DERMATOLOGICAL AGENTS
*emollient - lotion**
generic
*neomycin-bacitracin-polymyxin oint***
generic
*soap & cleansers - lotion***
generic
A + D PERSONAL CARE LOTION LOTION
BRAND
ACNE MEDICATION 10 LOTION 10 %
BRAND
ACNE MEDICATION 5 LOTION 5 %
BRAND
ACNE MEDICATION LOTION 10 %
BRAND
AMLACTIN CERAPEUTIC LOTION
BRAND
AQUA GLYCOLIC HAND/BODY LOTION
BRAND
AQUA LACTEN LOTION
BRAND
AQUAMED LOTION
BRAND
bacitracin oint 500 unit/gm
MPL
1 / 1 claim
generic
MPL
1 / 1 claim
bacitracin zinc oint 500 unit/gm
generic
MPL
1 / 1 claim
benzoyl peroxide (gel 2.5%, gel 5%, gel 10%, liq 5%, liq
10%)
generic
CAM LOTION
BRAND
camphor & menthol lotion 0.5-0.5%
generic
MPL
1 / 1 claim
capsaicin (cream 0.075%, cream 0.1%)
generic
MPL
1 / 1 claim
capsaicin cream 0.025%
generic
CERAVE AM SPF 30 LOTION
BRAND
PAGE 5
PRODUCT DESCRIPTION
BRAND/GEN
CERAVE LOTION
BRAND
CERAVE PM LOTION
BRAND
CERAVE SA RENEWING LOTION
BRAND
CETAPHIL DAILY ADVANCE LOTION
BRAND
CETAPHIL DAILY FACIAL MOIST LOTION
BRAND
CETAPHIL DERMACONTROL/SPF 30 LOTION
BRAND
CETAPHIL MOISTURIZING LOTION
BRAND
CETAPHIL RESTORADERM LOTION
BRAND
coal tar shampoo 0.5%
generic
CVS DAILY ULTRA MOISTURE LOTION
BRAND
dibucaine oint 1%
generic
FORMULA 405 BODY SMOOTHING LOTION
BRAND
FORMULA 405 MOISTURIZING LOTION
BRAND
GNP ADVANCED RECOVERY LOTION
BRAND
hydrocortisone (topical) (cream, lotion)
MPL
1 / 1 claim
generic
MPL
1 / 1 claim
hydrocortisone cream 0.5%
generic
QL
30 / 1 claim
hydrocortisone oint 1%
QL
generic
60 / 30 days
hydrocortisone-aloe vera cream 1%
generic
KERI ADVANCED MOISTURE THERAPY LOTION
BRAND
KERI BASIC ESSENTIALS LOTION
BRAND
KERI NOURISHING SHEA BUTTER LOTION
BRAND
KERI ORIGINAL LOTION
BRAND
KERI OVERNIGHT LOTION
BRAND
KERI RENEWAL MILK BODY LOTION
BRAND
KERI RENEWAL SKIN FIRMING LOTION
BRAND
KERI RENEWAL STRETCH MARK LOTION
BRAND
KERI SENSITIVE SKIN LOTION
BRAND
PAGE 6
MPL
1 / 30 days
MPL
1 / 1 claim
PRODUCT DESCRIPTION
BRAND/GEN
lactic acid (ammonium lactate) cream 12%
generic
MPL
1 / 1 claim
lactic acid (ammonium lactate) lotion 12%
generic
MPL
1 / 30 days
LICEMD GEL 0.33-4 %
BRAND
LUBRISOFT LOTION
BRAND
MOISTUREL LOTION
BRAND
neomycin-polymyxin w/ pramoxine cream 1%
generic
MPL
1 / 1 claim
NUTRADERM ADVANCED FORMULA LOTION
BRAND
NUTRADERM LOTION
BRAND
NUTRADERM-30 LOTION
BRAND
permethrin lotion 1%
generic
MPL
1 / 1 claim
phenyleph-shark liver oil-cocoa butter suppos 0.25-385.5%
generic
QL
12 / 1 claim
phenylephrine-cocoa butter suppos 0.25-88.44%
generic
QL
12 / 1 claim
phenylephrine-shark liver oil-mo-pet oint 0.25-3-14-71.9%
generic
MPL
pramoxine hcl rectal foam 1%
generic
QL
pyreth-piperonyl butox sham-permeth aero-nit remover gel
kit
generic
pyrethrins-piperonyl butoxide liq 0.33-4%
generic
pyrethrins-piperonyl butoxide shampoo 0.33-4%
generic
REPEL SPORTSMEN MAX LOTION 40 %
BRAND
SAWYER INSECT REPELLENT LOTION 20 %
BRAND
selenium sulfide lotion 1%
generic
SOOTHE & COOL MOISTURIZING LOTION
BRAND
terbinafine hcl cream 1%
generic
MPL
1 / 1 claim
tolnaftate cream 1%
generic
MPL
1 / 1 claim
ULTRATHON INSECT REPELLENT LOTION 34.34 %
BRAND
WIBI LOTION
BRAND
PAGE 7
MPL
QL
1 / 1 claim
15 / 1 claim
1 / 1 claim
240 / 1 claim
PRODUCT DESCRIPTION
BRAND/GEN
zinc oxide oint 20%
generic
MPL
alum & mag hydroxide-simethicone susp 200-200-20
mg/5ml
generic
QL
aluminum hydroxide gel susp 320 mg/5ml
generic
bismuth subsalicylate (chew tab 262 mg, susp 262
mg/15ml)
generic
calcium carbonate (antacid) chew tab 500 mg
generic
loperamide hcl (cap 2 mg, liq 1 mg/5ml (0.2 mg/ml))
generic
loperamide hcl tab 2 mg
generic
magnesium oxide tab 400 mg
generic
simethicone chew tab 80 mg
generic
simethicone susp 40 mg/0.6ml
sodium bicarbonate (antacid) (tab 325 mg, tab 650 mg)
1 / 1 claim
GASTROINTESTINAL AGENTS
GASTROINTESTINAL AGENTS, OTHER
496 / 30 days
MDD
2 per day
generic
MPL
1 / 1 claim
generic
QL
496 / 30 days
HISTAMINE2 (H2) RECEPTOR ANTAGONISTS
cimetidine tab 200 mg
generic
famotidine (tab 10 mg, tab 20 mg)
generic
ranitidine hcl (tab 75 mg, tab 150 mg)
generic
MDD
2 per day
1 per day
LAXATIVES
*sodium phosphates - enema***
generic
bisacodyl ec tab dr 5 mg
generic
MDD
bisacodyl laxative suppos 10 mg
generic
QL
bisacodyl tab delayed release 5 mg
generic
MDD
1 per day
calcium polycarbophil tab 625 mg
generic
MDD
10 per day
complete ready-to-use enema enema 7-19 gm/118ml
generic
PAGE 8
12 / 1 claim
PRODUCT DESCRIPTION
BRAND/GEN
docusate sodium (liquid 150 mg/15ml, syrup 60 mg/15ml,
tab 100 mg)
generic
docusate sodium cap 100 mg
generic
MDD
3 per day
generic
MDD
3 per day
fiber cap 0.52 gm
generic
glycerin suppos 2 gm
generic
magnesium citrate solution 1.745 gm/30ml
generic
milk of magnesia suspension 400 mg/5ml
generic
polyethylene glycol 3350 oral packet
generic
polyethylene glycol 3350 oral powder
generic
psyllium (cap 0.52 gm, powder 28.3%, powder 30.9%,
powder 33%, powder 48.57%, powder 58.6%, powder
100%)
generic
senna tab 8.6 mg
generic
senna-docusate sodium tab 8.6-50 mg
generic
sennosides tab 8.6 mg
generic
sorbitol oral solution 70%
generic
QL
990 / 30 days
MDD
34 per day
MDD
4 per day
PROTON PUMP INHIBITORS
lansoprazole cap delayed release 15 mg
PA
generic
MDD
4 per day
omeprazole delayed release tab 20 mg
generic
MDD
4 per day
PRILOSEC OTC TAB DR 20 MG
BRAND
MDD
4 per day
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)
PROGESTINS
levonorgestrel tab 1.5 mg
generic
GL
Female
generic
QL
8 / 30 days
METABOLIC BONE DISEASE AGENTS
cholecalciferol cap 50000 unit
PAGE 9
PRODUCT DESCRIPTION
BRAND/GEN
MISCELLANEOUS THERAPEUTIC AGENTS
*alcohol swabs***
generic
acetaminophen (chew tab 80 mg, chew tab 160 mg, liquid
160 mg/5ml, susp 80 mg/0.8ml, tab 325 mg, tab 500 mg)
generic
acetaminophen (suppos 120 mg, suppos 325 mg, suppos
650 mg)
generic
acetaminophen susp 160 mg/5ml
generic
QL
400 / 1 claim
QL
12 / 1 claim
QL
240 / 1 claim
MFL
1 / 30 days
ALCOHOL PREP PAD 70 %
BRAND
QL
400 / 1 claim
ALCOHOL SWABS PAD 70 %
BRAND
QL
400 / 1 claim
BD SWAB SINGLE USE REGULAR PAD
BRAND
QL
400 / 1 claim
BIATAIN ADHESIVE FOAM DRESSING PAD 4"X4"
BRAND
BIATAIN FOAM DRESSING PAD 4"X4"
BRAND
BORDERED GAUZE PAD 4"X4"
BRAND
CARRASMART FOAM PAD 4"X4"
BRAND
CARRASMART PAD 4"X4"
BRAND
COLEMAN 100 MAX CONTINUOUS SPR AEROSOL
98.11 %
BRAND
COLEMAN INSECT REPEL HIGH&DRY AEROSOL 25 %
BRAND
COLEMAN INSECT REPEL SPORTSMEN AEROSOL 40
%
BRAND
cromolyn sodium nasal aerosol soln 5.2 mg/act (4%)
generic
QL
26 / 1 claim
CURITY ALCOHOL PREPS PAD 70 %
BRAND
QL
400 / 1 claim
CURITY ALCOHOL SWABS PAD
BRAND
QL
400 / 1 claim
CUTTER AEROSOL 10 %
BRAND
CUTTER ALL FAMILY AEROSOL 7 %
BRAND
CUTTER BACKWOODS AEROSOL
BRAND
CUTTER BACKWOODS DRY AEROSOL
BRAND
CUTTER DRY AEROSOL 10 %
BRAND
PAGE 10
PRODUCT DESCRIPTION
BRAND/GEN
CUTTER SKINSATIONS AEROSOL 7 %
BRAND
CUTTER SPORT AEROSOL 15 %
BRAND
CVS ALCOHOL PREP SWABS PAD 70 %
BRAND
QL
400 / 1 claim
CVS ALCOHOL SWABS PAD
BRAND
QL
400 / 1 claim
CVS INSECT REPELLENT AEROSOL 15 %
BRAND
CVS PREP PAD 70 %
BRAND
QL
400 / 1 claim
CVS TOTAL HOME INSECT REPEL AEROSOL 30 %
BRAND
DERMALEVIN ADHESIVE PAD 4"X4"
BRAND
EASY TOUCH ALCOHOL PREP MEDIUM PAD 70 %
BRAND
QL
400 / 1 claim
FIFTY50 ALCOHOL PREP PAD 70 %
BRAND
QL
400 / 1 claim
FLEXZAN PAD 4"X4"
BRAND
gauze pads & dressings (pads pads 2" 2"***, pads pads 3"
3"***, pads pads 4" 4"***)
generic
GNP ALCOHOL SWABS (PAD, PAD 70 %)
BRAND
QL
400 / 1 claim
GNP STERILE PADS PAD 3"X3"
BRAND
MEIJER ALCOHOL SWABS PAD 70 %
BRAND
QL
400 / 1 claim
melatonin (tab 3 mg, tab 5 mg)
generic
MDD
1 per day
NASAL DECONGESTANT (LIQUID 30 MG/5ML, SYRUP
30 MG/5ML)
BRAND
nasal moisturizing spray solution 0.65 %
generic
MPL
1 / 1 claim
NESSI SPACER WITH MASK LARGE DEVICE
BRAND
QL
2 / 360 days
NESSI SPACER WITH MASK SM/MED DEVICE
BRAND
QL
2 / 360 days
NESSI SPACER WITH MOUTHPIECE DEVICE
BRAND
QL
2 / 360 days
NOVA MAX PLUS KETONE TEST STRIP
BRAND
QL
30 / 30 days
OFF ACTIVE AEROSOL 15 %
BRAND
OFF DEEP WOODS AEROSOL
BRAND
OFF DEEP WOODS DRY AEROSOL
BRAND
PAGE 11
PRODUCT DESCRIPTION
BRAND/GEN
OFF DEEP WOODS SPORTSMEN AEROSOL 30 %
BRAND
OFF SMOOTH & DRY AEROSOL 15 %
BRAND
OPTIFOAM PAD 4"X4"
BRAND
permethrin (aerosol 0.5%, creme rinse 1%)
generic
phenylephrine hcl tab 10 mg
generic
QL
24 / 1 claim
PRECISION XTRA KETONE STRIP
BRAND
QL
30 / 30 days
pseudoephedrine hcl (liq 15 mg/5ml, tab 60 mg)
generic
pseudoephedrine hcl er tab er 12h 120 mg
generic
pseudoephedrine hcl tab 30 mg
generic
PTS PANELS KETONE TEST STRIP
BRAND
QL
30 / 30 days
QC ALCOHOL SWABS PAD 70 %
BRAND
QL
400 / 1 claim
RA ALCOHOL SWABS PAD 70 %
BRAND
QL
400 / 1 claim
RELION ALCOHOL SWABS (PAD, PAD 70 %)
BRAND
QL
400 / 1 claim
REPEL FAMILY AEROSOL 15 %
BRAND
REPEL FAMILY DRY AEROSOL 10 %
BRAND
REPEL HUNTERS FORMULA AEROSOL
BRAND
REPEL SPORTSMEN AEROSOL
BRAND
REPEL SPORTSMEN DRY AEROSOL
BRAND
REPEL SPORTSMEN MAX AEROSOL 40 %
BRAND
SAWYER INSECT REPELLENT AEROSOL 30 %
BRAND
SB ALCOHOL PREP PAD 70 %
BRAND
QL
400 / 1 claim
SHOPKO ALCOHOL SWABS PAD 70 %
BRAND
QL
400 / 1 claim
simethicone liquid 40 mg/0.6ml
generic
MPL
SM ALCOHOL PREP (PAD, PAD 70 %)
BRAND
QL
400 / 1 claim
SM GAUZE (PAD 2"X2", PAD 3"X3", PAD 4"X4")
BRAND
SM STERILE (PAD 2"X2", PAD 4"X4")
BRAND
TGT ALCOHOL SWABS PAD 70 %
BRAND
QL
400 / 1 claim
PAGE 12
MDD
2 per day
1 / 1 claim
PRODUCT DESCRIPTION
BRAND/GEN
ULTILET ALCOHOL SWAB PAD
BRAND
QL
400 / 1 claim
ULTILET ALCOHOL SWABS PAD
BRAND
QL
400 / 1 claim
ULTRATHON INSECT REPELLENT 8 AEROSOL 25 %
BRAND
WEBCOL ALCOHOL PREP LARGE PAD 70 %
BRAND
QL
400 / 1 claim
WEBCOL ALCOHOL PREP MEDIUM PAD 70 %
BRAND
QL
400 / 1 claim
*artificial tear ophth ointment***
generic
QL
4 / 1 claim
*white petrolatum-mineral oil ophth ointment***
generic
MPL
1 / 1 claim
hypromellose ophth soln 0.4%
generic
QL
ketotifen fumarate ophth soln 0.025% (base equiv)
generic
MPL
polyvinyl alcohol ophth soln 1.4%
generic
QL
15 / 1 claim
tetrahydrozoline hcl ophth soln 0.05%
generic
MPL
1 / 30 days
generic
QL
15 / 30 days
QL
240 / 1 claim
AL
Up to 12 yrs old
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS, OTHER
15 / 1 claim
1 / 1 claim
OTIC AGENTS
carbamide peroxide 6.5% otic soln
RESPIRATORY TRACT/PULMONARY AGENTS
ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS
FLONASE ALLERGY RELIEF SUSPENSION 50
MCG/ACT
BRAND
ANTIHISTAMINES
cetirizine hcl allergy child solution 5 mg/5ml
generic
cetirizine hcl chew tab 10 mg
generic
MDD
1 per day
generic
MDD
1 per day
PAGE 13
PRODUCT DESCRIPTION
BRAND/GEN
cetirizine hcl tab 10 mg
generic
MDD
1 per day
generic
MDD
1 per day
childrens loratadine syrup 5 mg/5ml
generic
QL
chlorpheniramine maleate syrup 2 mg/5ml
generic
MDD
chlorpheniramine maleate tab 4 mg
generic
QL
120 / 1 claim
generic
QL
120 / 1 claim
clemastine fumarate tab 1.34 mg
generic
MDD
2 per day
diphenhydramine hcl cap 25 mg
generic
MDD
4 per day
generic
MDD
4 per day
diphenhydramine hcl liquid 12.5 mg/5ml
generic
QL
240 / 1 claim
diphenhydramine hcl syrup 12.5 mg/5ml
generic
QL
240 / 1 claim
diphenhydramine hcl tab 25 mg
generic
MDD
4 per day
fexofenadine hcl tab 180 mg
generic
MDD
1 per day
generic
MDD
2 per day
loratadine allergy relief tab disp 10 mg
generic
loratadine tab 10 mg
generic
generic
240 / 1 claim
60 per day
RESPIRATORY TRACT AGENTS, OTHER
brompheniramine & phenylephrine elixir 1-2.5 mg/5ml
QL
generic
MFL
brompheniramine & pseudoephedrine elixir 1-15 mg/5ml
QL
generic
1 / 30 days
120 / 1 claim
MFL
1 / 30 days
2 per day
cetirizine-pseudoephedrine tab sr 12hr 5-120 mg
generic
MDD
chlorpheniramine & phenylephrine liquid 1-3.5 mg/ml
generic
QL
dextromethorphan-guaifenesin liquid 10-100 mg/5ml
generic
PAGE 14
120 / 1 claim
30 / 1 claim
PRODUCT DESCRIPTION
BRAND/GEN
guaifenesin-codeine soln 100-10 mg/5ml
generic
QL
240 / 1 claim
MFL
1 / 30 days
loratadine & pseudoephedrine tab sr 12hr 5-120 mg
generic
MDD
2 per day
loratadine & pseudoephedrine tab sr 24hr 10-240 mg
generic
MDD
1 per day
phenylephrine-dm soln 2.5-5 mg/5ml
generic
QL
240 / 1 claim
pseudoephedrine w/ cod-gg soln 30-10-100 mg/5ml
QL
generic
240 / 1 claim
pseudoephedrine-ibuprofen tab 30-200 mg
MFL
1 / 30 days
MDD
1 per day
generic
SLEEP DISORDER AGENTS
SLEEP DISORDERS, OTHER
diphenhydramine hcl (sleep) cap 50 mg
generic
diphenhydramine hcl (sleep) tab 25 mg
generic
doxylamine succinate (sleep) tab 25 mg
generic
THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES
ELECTROLYTE/MINERAL REPLACEMENT
*oral electrolyte solution***
generic
calcium carbonate susp 1250 mg/5ml (500 mg/5ml
elemental ca)
generic
calcium carbonate-cholecalciferol tab 500 mg-200 unit
generic
calcium carbonate-cholecalciferol tab 600 mg-400 unit
generic
MDD
2 per day
calcium carbonate-vitamin d (tab 600 mg-400, tab 600 mg200)
generic
MDD
2 per day
calcium carbonate-vitamin d tab 500 mg-200 unit
generic
ENFALYTE SOLUTION
BRAND
ENFAMIL ENFALYTE SOLUTION
BRAND
FERRETTS TAB 325 (106 FE) MG
BRAND
ferrous fumarate tab 324 mg (106 mg elemental fe)
generic
PAGE 15
QL
500 / 30 days
PRODUCT DESCRIPTION
BRAND/GEN
ferrous gluconate (tab 240 mg (27 mg fe), tab 324 mg (38
mg iron))
generic
ferrous sulfate (tab 325 mg mg elemental fe), tab ec 324
mg mg fe equivalent), tab ec 325 mg mg fe equivalent))
generic
ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe)
generic
MDD
16 per day
ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe)
generic
MDD
3.4 per day
IRON CHEWS PEDIATRIC CHEW TAB 15 MG
BRAND
oyster shell calcium tab 500 mg
generic
zinc sulfate cap 220 mg (50 mg elemental zn)
generic
*b-complex w/ c & folic acid tab***
generic
*multiple vitamin tab**
generic
MDD
1 per day
*multiple vitamins w/ iron tab**
generic
MDD
1 per day
*multiple vitamins w/ minerals tab**
generic
MDD
1 per day
*pediatric multiple vitamin w/ c & fa chew tab**
generic
MDD
1 per day
*pediatric multiple vitamin w/ c soln 35 mg/ml**
generic
QL
50 / 1 claim
*pediatric multiple vitamins w/ iron drops 10 mg/ml**
generic
QL
60 / 1 claim
*pediatric vitamins adc drops 1500 unit-400 unit-35
mg/ml***
generic
QL
50 / 1 claim
*vitamins w/ lipotropics cap**
generic
MDD
ascorbic acid (tab 250 mg, tab 500 mg, tab 1000 mg)
generic
QL
b-complex vitamins (cap**, tab**)
generic
MDD
1 per day
CERTAVITE SENIOR/ANTIOXIDANT TAB
BRAND
MDD
1 per day
cholecalciferol (cap 1000, cap 2000)
generic
cholecalciferol cap 5000 unit
generic
MDD
2 per day
DERMAVITE TAB
BRAND
MDD
1 per day
folic acid (tab 400 mcg, tab 800 mcg)
generic
MDD
1 per day
GNP PRENATAL TAB 28-0.8 MG
BRAND
100 / 34 days
GL
Female
AL
Up to 45 yrs old
MDD
PAGE 16
1 per day
1 per day
PRODUCT DESCRIPTION
GOODSENSE PRENATAL VITAMINS TAB 28-0.8 MG
BRAND/GEN
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
1 per day
HM COMPLETE 50+ MENS ULTIMATE TAB
BRAND
MDD
1 per day
HM COMPLETE 50+ WOMEN ULTIMATE TAB
BRAND
MDD
1 per day
HM COMPLETE TAB
BRAND
MDD
1 per day
HM HAIR/SKIN/NAILS TAB
BRAND
MDD
1 per day
HM ONE DAILY MENS TAB
BRAND
MDD
1 per day
HM ONE DAILY WOMENS TAB
BRAND
MDD
1 per day
HM PRENATAL TAB 28-0.8 MG
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
1 per day
ICAPS AREDS FORMULA TAB
BRAND
MDD
1 per day
ICAPS PLUS TAB
BRAND
MDD
1 per day
MEGA MULTIVITAMIN FOR MEN TAB
BRAND
MDD
1 per day
MEGA MULTIVITAMIN FOR WOMEN TAB
BRAND
MDD
1 per day
niacin (cap cr 250 mg, cap cr 500 mg, tab 500 mg)
generic
ONCOVITE TAB
BRAND
MDD
1 per day
PNV PRENATAL PLUS MULTIVITAMIN TAB 27-1 MG
polysaccharide iron complex cap 150 mg (iron equivalent)
PRENATAL (TAB 27-0.8 MG, TAB 28-0.8 MG)
BRAND
generic
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
1 per day
MDD
1 per day
GL
Female
AL
Up to 45 yrs old
MDD
PRENATAL LOW IRON TAB 27-0.8 MG
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
PAGE 17
1 per day
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
PRESERVISION AREDS TAB
BRAND
MDD
1 per day
PRORENAL + D TAB
BRAND
MDD
1 per day
pyridoxine hcl (tab 25 mg, tab 50 mg, tab 100 mg)
generic
RENAPLEX-D TAB
BRAND
MDD
1 per day
SM ONE DAILY MENS TAB
BRAND
MDD
1 per day
SM ONE DAILY WOMENS TAB
BRAND
MDD
1 per day
SM PRENATAL VITAMINS TAB 28-0.8 MG
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
1 per day
THERA M PLUS TAB
BRAND
MDD
1 per day
THERA-M TAB
BRAND
MDD
1 per day
THERA/BETA-CAROTENE TAB
BRAND
MDD
1 per day
THEREMS-H TAB
BRAND
MDD
1 per day
THEREMS-M TAB
BRAND
MDD
1 per day
thiamine hcl (tab 50 mg, tab 100 mg, tab 250 mg)
generic
QL
100 / 34 days
thiamine mononitrate tab 100 mg
generic
QL
100 / 34 days
TRI-VI-SOL/IRON SOLUTION 10 MG/ML
BRAND
QL
50 / 1 claim
UNICOMPLEX-M TAB
BRAND
MDD
1 per day
vitamin e (cap 100, cap 200, cap 400)
generic
MDD
2 per day
PAGE 18
LIST OF COVERED PRESCRIPTION MEDICATIONS
PRODUCT DESCRIPTION
BRAND/GEN
ANALGESICS
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
butalbital-aspirin-caffeine tab 50-325-40 mg
generic
celecoxib (cap 50 mg, cap 100 mg, cap 200 mg, cap 400
mg)
generic
choline & magnesium salicylates liq 500 mg/5ml
generic
diclofenac potassium tab 50 mg
generic
diclofenac sodium (tab delayed release 25 mg, tab delayed
release 50 mg, tab delayed release 75 mg, tab sr 24hr 100
mg)
generic
diflunisal tab 500 mg
generic
etodolac (cap 200 mg, cap 300 mg, tab 400 mg, tab 500
mg, tab sr 24hr 600 mg, tab sr 24hr 400 mg, tab sr 24hr
500 mg)
generic
flurbiprofen (tab 50 mg, tab 100 mg)
generic
ibuprofen (susp 100 mg/5ml, tab 400 mg, tab 600 mg, tab
800 mg)
generic
indomethacin (cap 25 mg, cap 50 mg, cap cr 75 mg)
generic
ketoprofen (cap 50 mg, cap 75 mg, cap sr 24hr 200 mg)
generic
ketorolac tromethamine tab 10 mg
generic
4 per day
PA
MDD
meloxicam (tab 7.5 mg, tab 15 mg)
generic
nabumetone (tab 500 mg, tab 750 mg)
generic
naproxen (susp 125 mg/5ml, tab 250 mg, tab 375 mg, tab
500 mg)
generic
naproxen (tab ec 375 mg, tab ec 500 mg)
generic
naproxen sodium (tab 275 mg, tab 550 mg)
generic
oxaprozin tab 600 mg
generic
PAGE 19
MDD
2 Per Day
QL
20 / 30 days
AL
At least 17 yrs old
MDD
2 per day
PRODUCT DESCRIPTION
BRAND/GEN
piroxicam (cap 10 mg, cap 20 mg)
generic
salsalate (tab 500 mg, tab 750 mg)
generic
sulindac (tab 150 mg, tab 200 mg)
generic
tolmetin sodium (cap 400 mg, tab 200 mg, tab 600 mg)
generic
OPIOID ANALGESICS, LONG-ACTING
fentanyl (patch 72hr 25 mcg/hr, patch 72hr 12 mcg/hr,
patch 72hr 100 mcg/hr, patch 72hr 75 mcg/hr, patch 72hr
50 mcg/hr)
generic
MDD
0.33 per day
methadone hcl tab 10 mg
generic
MDD
10 per day
methadone hcl tab 5 mg
generic
MDD
4 per day
morphine sulfate (tab 15 mg, tab 30 mg, tab 60 mg, tab
100 mg, tab 200 mg)
generic
MDD
3 per day
oxycodone hcl (tab er deter 10 mg, tab er deter 20 mg, tab
er deter 40 mg, tab er deter 80 mg)
generic
PA
MDD
2 per day
OPIOID ANALGESICS, SHORT-ACTING
acetaminophen w/ codeine (w/ tab 300-60 mg, w/ tab 30030 mg, w/ tab 300-15 mg)
generic
MDD
6 per day
acetaminophen w/ codeine soln 120-12 mg/5ml
generic
MDD
30 per day
butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg
generic
MDD
4 per day
butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg
generic
MDD
4 per day
codeine sulfate (tab 15 mg, tab 30 mg, tab 60 mg)
generic
MDD
2 per day
hydrocodone-acetaminophen (tab 5-500 mg, tab 7.5-325
mg)
generic
MDD
8 per day
hydrocodone-acetaminophen (tab 7.5-650 mg, tab 7.5-500
mg, tab 10-500 mg, tab 10-660 mg, tab 10-650 mg, tab 10325 mg)
generic
MDD
6 per day
hydrocodone-acetaminophen soln 7.5-325 mg/15ml
generic
MDD
180 per day
hydrocodone-acetaminophen soln 7.5-500 mg/15ml
generic
MDD
120 per day
hydrocodone-acetaminophen tab 5-325 mg
generic
MDD
12 per day
PAGE 20
PRODUCT DESCRIPTION
BRAND/GEN
hydrocodone-acetaminophen tab 7.5-750 mg
generic
MDD
5 per day
hydromorphone hcl (tab 2 mg, tab 4 mg, tab 8 mg)
generic
MDD
8 per day
hydromorphone hcl suppos 3 mg
generic
QL
meperidine hcl (tab 50 mg, tab 100 mg)
generic
MDD
meperidine hcl oral soln 50 mg/5ml
generic
QL
500 / 1 claim
morphine sulfate (soln 10 mg/5ml, soln 20 mg/5ml)
generic
QL
500 / 30 days
morphine sulfate (suppos 5 mg, suppos 10 mg, suppos 20
mg, suppos 30 mg)
generic
QL
24 / 1 claim
morphine sulfate (tab 15 mg, tab 30 mg)
generic
MDD
morphine sulfate oral soln 100 mg/5ml (20 mg/ml)
generic
QL
oxycodone hcl (cap 5 mg, conc 100 mg/5ml (20 mg/ml),
tab 5 mg, tab 10 mg, tab 15 mg, tab 20 mg, tab 30 mg)
generic
MDD
6 per day
oxycodone hcl soln 5 mg/5ml
generic
oxycodone w/ acetaminophen (w/ cap 5-500 mg, w/ tab 5325 mg, w/ tab 7.5-325 mg, w/ tab 10-325 mg)
generic
MDD
6 per day
oxycodone-aspirin tab 4.8355-325 mg
generic
MDD
6 per day
tramadol hcl tab 50 mg
generic
MDD
8 per day
tramadol-acetaminophen tab 37.5-325 mg
generic
MDD
4 per day
lidocaine hcl gel 2%
generic
MPL
1 / 1 claim
lidocaine hcl viscous soln 2%
generic
QL
lidocaine-prilocaine cream 2.5-2.5%
generic
MPL
12 / 1 claim
6 per day
6 per day
240 / 1 claim
ANESTHETICS
LOCAL ANESTHETICS
100 / 1 claim
1 / 1 claim
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
ALCOHOL DETERRENTS/ANTI-CRAVING
disulfiram tab 250 mg
PAGE 21
generic
PRODUCT DESCRIPTION
BRAND/GEN
naltrexone hcl tab 50 mg
generic
VIVITROL RECON SUSP 380 MG
BRAND
OPIOID DEPENDENCE TREATMENTS
SUBOXONE FILM 12-3 MG
BRAND
MDD
1.33 per day
SUBOXONE FILM 2-0.5 MG
BRAND
MDD
8 per day
BRAND
MDD
4 per day
BRAND
MDD
2 per day
naloxone hcl (inj 0.4 mg/ml, inj 1 mg/ml, inj 4 mg/10ml)
generic
QL
2 / 90 days
NARCAN LIQUID 4 MG/0.1ML
BRAND
QL
2 / 90 days
AL
At least 18 yrs old
OPIOID REVERSAL AGENTS
SMOKING CESSATION AGENTS
bupropion hcl (smoking deterrent) tab sr 12hr 150 mg
generic
MDD
AL
CHANTIX (TAB 0.5 MG, TAB 1 MG)
BRAND
MDD
AL
CHANTIX CONTINUING MONTH PAK TAB 1 MG
BRAND
MDD
AL
CHANTIX STARTING MONTH PAK TAB 0.5 MG X 11 & 1
MG X 42
BRAND
NICOTROL INHALER 10 MG
BRAND
NICOTROL NS SOLUTION 10 MG/ML
PAGE 22
MPL
2 per day
At least 18 yrs old
2 per day
At least 18 yrs old
2 per day
At least 18 yrs old
2 / years
QL
504 / 30 days
AL
At least 18 yrs old
QL
120 / 30 days
AL
At least 18 yrs old
BRAND
PRODUCT DESCRIPTION
BRAND/GEN
ANTIBACTERIALS
AMINOGLYCOSIDES
gentamicin sulfate (topical) (cream, oint)
generic
MPL
1 / 1 claim
gentamicin sulfate ophth oint 0.3%
generic
QL
4 / 1 claim
gentamicin sulfate ophth soln 0.3%
generic
MPL
1 / 1 claim
neomycin sulfate tab 500 mg
generic
TOBRADEX OINTMENT 0.3-0.1 %
BRAND
QL
4 / 1 claim
tobramycin ophth soln 0.3%
generic
QL
5 / 1 claim
tobramycin sulfate (for inj 1.2 gm, inj 1.2 gm/30ml (40
mg/ml) (base equiv), inj 2 gm/50ml (40 mg/ml) (base
equiv), inj 10 mg/ml (base equivalent), inj 80 mg/2ml (40
mg/ml) (base equiv))
generic
PA
TOBREX OINTMENT 0.3 %
BRAND
QL
4 / 1 claim
ANTIBACTERIALS, OTHER
*methenamine-hyos-meth blue-sod phos-phen sal tab 81.6
mg***
generic
BACTROBAN NASAL OINTMENT 2 %
BRAND
CENTANY OINTMENT 2 %
BRAND
MPL
1 / 1 claim
CLINDAGEL GEL 1 %
BRAND
MPL
1 / 1 claim
clindamycin hcl (cap 150 mg, cap 300 mg)
generic
clindamycin palmitate hcl for soln 75 mg/5ml (base equiv)
generic
MPL
1 / 1 claim
clindamycin phosphate (topical) (gel, lotion)
generic
MPL
1 / 1 claim
clindamycin phosphate soln 1%
generic
clindamycin phosphate vaginal cream 2%
generic
methenamine mandelate (tab 0.5 gm, tab 1 gm)
generic
metronidazole (tab 250 mg, tab 500 mg)
generic
metronidazole cream 0.75 %
generic
PAGE 23
QL
40 / 1 claim
QL
45 / 1 claim
PRODUCT DESCRIPTION
BRAND/GEN
metronidazole gel 0.75 %
generic
metronidazole lotion 0.75%
generic
metronidazole vaginal gel 0.75%
QL
45 / 1 claim
generic
QL
70 / 1 claim
mupirocin calcium cream 2%
generic
MPL
1 / 1 claim
mupirocin oint 2%
generic
MPL
1 / 1 claim
nitrofurantoin macrocrystal (cap 50 mg, cap 100 mg)
generic
nitrofurantoin monohydrate macrocrystalline cap 100 mg
generic
nitrofurantoin susp 25 mg/5ml
generic
SIVEXTRO TAB 200 MG
AL
Up to 6 yrs old
MDD
40 per day
QL
6 / 1 claim
BRAND
PA
trimethoprim tab 100 mg
generic
vancomycin hcl cap 125 mg
generic
MDD
4 per day
vancomycin hcl cap 250 mg
generic
MDD
8 per day
vancomycin hcl for inj 1000 mg
generic
QL
14 / 1 claim
vancomycin hcl for inj 500 mg
generic
QL
14 / 30 days
BETA-LACTAM, CEPHALOSPORINS
cefaclor (cap 250 mg, cap 500 mg, for susp 125 mg/5ml,
for susp 250 mg/5ml, for susp 375 mg/5ml)
generic
CEFACLOR (RECON SUSP 250 MG/5ML, RECON SUSP
375 MG/5ML)
BRAND
cefadroxil (cap 500 mg, for susp 250 mg/5ml, for susp 500
mg/5ml, tab 1 gm)
generic
cefdinir (susp 125 mg/5ml, susp 250 mg/5ml)
generic
MPL
cefdinir cap 300 mg
generic
QL
20 / 1 claim
cefprozil (susp 125 mg/5ml, susp 250 mg/5ml)
AL
generic
Up to 12 yrs old
MPL
PAGE 24
1 / 1 claim
1 / 1 claim
PRODUCT DESCRIPTION
BRAND/GEN
cefprozil (tab 250 mg, tab 500 mg)
generic
CEFTIN (RECON SUSP 125 MG/5ML, RECON SUSP 250
MG/5ML)
BRAND
ceftriaxone sodium (inj 1 gm, inj 250 mg, inj 500 mg)
generic
cefuroxime axetil (tab 250 mg, tab 500 mg)
generic
cephalexin (cap 250 mg, cap 500 mg, for susp 125
mg/5ml, for susp 250 mg/5ml)
generic
QL
20 / 1 claim
QL
100 / 1 claim
AL
Up to 12 yrs old
QL
3 / 1 claim
MFL
1 / 30 days
QL
20 / 1 claim
BETA-LACTAM, PENICILLINS
amoxicillin & k clavulanate for susp 600-42.9 mg/5ml
generic
MPL
amoxicillin & k clavulanate tab 250-125 mg
generic
QL
30 / 1 claim
amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg
generic
QL
40 / 30 days
amoxicillin & pot clavulanate (chew tab 200-28.5 mg, chew
tab 400-57 mg, tab 500-125 mg, tab 875-125 mg)
generic
QL
20 / 1 claim
amoxicillin & pot clavulanate (susp 200-28.5 mg/5ml, susp
250-62.5 mg/5ml, susp 400-57 mg/5ml)
generic
MPL
amoxicillin (cap 250 mg, cap 500 mg, chew tab 125 mg,
chew tab 250 mg, for susp 125 mg/5ml, for susp 200
mg/5ml, for susp 250 mg/5ml, for susp 400 mg/5ml, tab
875 mg)
generic
ampicillin (cap 250 mg, cap 500 mg)
generic
dicloxacillin sodium (cap 250 mg, cap 500 mg)
generic
penicillin v potassium (for soln 125 mg/5ml, for soln 250
mg/5ml, tab 250 mg, tab 500 mg)
generic
2 / 1 claim
1 / 1 claim
MACROLIDES
azithromycin for susp 100 mg/5ml
generic
QL
azithromycin for susp 200 mg/5ml
generic
MPL
1 / 1 claim
azithromycin powd pack for susp 1 gm
generic
QL
2 / 1 claim
azithromycin tab 250 mg
generic
QL
6 / 1 claim
PAGE 25
15 / 1 claim
PRODUCT DESCRIPTION
BRAND/GEN
generic
MDD
generic
QL
8 / 28 days
clarithromycin (susp 125 mg/5ml, susp 250 mg/5ml)
generic
MPL
1 / 1 claim
clarithromycin (tab 250 mg, tab 500 mg)
generic
QL
28 / 1 claim
clarithromycin tab sr 24hr 500 mg
generic
QL
14 / 1 claim
E.E.S. 400 TAB 400 MG
BRAND
E.E.S. GRANULES RECON SUSP 200 MG/5ML
BRAND
ERY-TAB (TAB DR 250 MG, TAB DR 333 MG, TAB DR
500 MG)
BRAND
ERYPED 200 RECON SUSP 200 MG/5ML
BRAND
ERYPED 400 RECON SUSP 400 MG/5ML
BRAND
ERYTHROCIN STEARATE TAB 250 MG
BRAND
ERYTHROMYCIN BASE (TAB 250 MG, TAB 500 MG)
BRAND
ERYTHROMYCIN ETHYLSUCCINATE TAB 400 MG
BRAND
erythromycin gel 2%
generic
MPL
1 / 1 claim
erythromycin ophth oint 5 mg/gm
generic
QL
4 / 1 claim
erythromycin soln 2%
generic
erythromycin w/ delayed release particles cap 250 mg
generic
PCE (TAB DR 333 MG, TAB DR 500 MG)
BRAND
QL
4 / 1 claim
4 per day
QUINOLONES
CILOXAN OINTMENT 0.3 %
BRAND
ciprofloxacin hcl (tab 250 mg, tab 500 mg, tab 750 mg)
generic
ciprofloxacin hcl ophth soln 0.3%
generic
MPL
1 / 1 claim
ciprofloxacin hcl tab 100 mg (base equiv)
generic
QL
6 / 1 claim
levofloxacin (tab 250 mg, tab 500 mg, tab 750 mg)
QL
generic
14 / 1 claim
ofloxacin ophth soln 0.3%
PAGE 26
generic
MDD
1 per day
MPL
1 / 1 claim
PRODUCT DESCRIPTION
BRAND/GEN
ofloxacin otic soln 0.3%
generic
MPL
ofloxacin tab 400 mg
generic
QL
56 / 1 claim
VIGAMOX SOLUTION 0.5 %
BRAND
QL
3 / 1 claim
silver sulfadiazine cream 1%
generic
MPL
1 / 1 claim
sulfacetamide sodium ophth soln 10%
generic
QL
15 / 1 claim
sulfamethoxazole-trimethoprim (susp 200-40 mg/5ml, tab
400-80 mg, tab 800-160 mg)
generic
AL
Up to 21 yrs old
1 / 1 claim
SULFONAMIDES
TETRACYCLINES
doxycycline hyclate (cap 50 mg, cap 100 mg, tab 100 mg)
generic
minocycline hcl (cap 50 mg, cap 75 mg, cap 100 mg)
generic
ANTICONVULSANTS
ANTICONVULSANTS, OTHER
levetiracetam (oral soln 100 mg/ml, tab 250 mg, tab 500
mg, tab 750 mg)
generic
CALCIUM CHANNEL MODIFYING AGENTS
ethosuximide (cap 250 mg, soln 250 mg/5ml)
generic
zonisamide (cap 25 mg, cap 50 mg, cap 100 mg)
generic
GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS
diazepam (anticonvulsant) (gel 2.5 mg, gel 10 mg, gel 20
mg)
generic
divalproex sodium (cap delayed release sprinkle 125 mg,
tab delayed release 125 mg, tab delayed release 250 mg,
tab delayed release 500 mg, tab sr 24 hr 500 mg, tab sr 24
hr 250 mg)
generic
gabapentin (cap 100 mg, cap 300 mg, cap 400 mg, oral
soln 250 mg/5ml, tab 600 mg, tab 800 mg)
generic
GABITRIL (TAB 12 MG, TAB 16 MG)
BRAND
PAGE 27
PRODUCT DESCRIPTION
BRAND/GEN
phenobarbital (elixir 20 mg/5ml, tab 15 mg, tab 16.2 mg,
tab 30 mg, tab 32.4 mg, tab 60 mg, tab 64.8 mg, tab 97.2
mg, tab 100 mg)
generic
primidone (tab 50 mg, tab 250 mg)
generic
tiagabine hcl (tab 2 mg, tab 4 mg)
generic
valproate sodium syrup 250 mg/5ml (base equiv)
generic
valproic acid cap 250 mg
generic
GLUTAMATE REDUCING AGENTS
felbamate (susp 600 mg/5ml, tab 400 mg, tab 600 mg)
generic
lamotrigine (tab 25 mg, tab 100 mg, tab 150 mg, tab 200
mg, tab chewable dispersible 5 mg, tab chewable
dispersible 25 mg)
generic
topiramate (sprinkle cap 15 mg, sprinkle cap 25 mg, tab 25
mg, tab 50 mg, tab 100 mg, tab 200 mg)
generic
SODIUM CHANNEL AGENTS
carbamazepine (chew tab 100 mg, susp 100 mg/5ml, tab
200 mg, tab sr 12hr 100 mg, tab sr 12hr 200 mg, tab sr
12hr 400 mg)
generic
DILANTIN CAP 30 MG
BRAND
oxcarbazepine (susp 300 mg/5ml (60 mg/ml), tab 150 mg,
tab 300 mg, tab 600 mg)
generic
phenytoin (chew tab 50 mg, susp 125 mg/5ml)
generic
phenytoin sodium extended cap 100 mg
generic
ANTIDEMENTIA AGENTS
ANTIDEMENTIA AGENTS, OTHER
ergoloid mesylates tab 1 mg
generic
CHOLINESTERASE INHIBITORS
donepezil hydrochloride (tab 5 mg, tab 10 mg)
generic
MDD
1 per day
galantamine hydrobromide (cap 24hr 8 mg, cap 24hr 24
mg, cap 24hr 16 mg)
generic
MDD
1 per day
PAGE 28
PRODUCT DESCRIPTION
BRAND/GEN
galantamine hydrobromide (tab 4 mg, tab 8 mg, tab 12 mg)
generic
MDD
2 per day
galantamine hydrobromide oral soln 4 mg/ml
generic
MDD
6 per day
rivastigmine (patch 24hr 4.6 mg/24hr, patch 24hr 9.5
mg/24hr)
generic
rivastigmine tartrate (cap 1.5 mg, cap 3 mg, cap 4.5 mg,
cap 6 mg)
generic
PA
MDD
2 per day
MDD
2 per day
N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST
memantine hcl (tab 5 mg, tab 10 mg)
generic
memantine hcl oral solution 2 mg/ml
generic
memantine hcl tab 5 mg (28) & 10 mg (21) titration pak
generic
MPL
1 / 28 days
bupropion hcl (tab 24hr 150 mg, tab 24hr 300 mg)
generic
MDD
1 per day
bupropion hcl (tab 75 mg, tab 100 mg)
generic
MDD
3 per day
bupropion hcl er (sr) tab er 12h 100 mg
generic
MDD
2 per day
generic
MDD
2 per day
bupropion hcl tab sr 12hr 200 mg
generic
MDD
2 per day
mirtazapine (orally disintegrating tab 15 mg, orally
disintegrating tab 30 mg, orally disintegrating tab 45 mg,
tab 7.5 mg, tab 15 mg, tab 30 mg, tab 45 mg)
generic
perphenazine-amitriptyline (tab 2-10 mg, tab 2-25 mg, tab
4-10 mg, tab 4-25 mg, tab 4-50 mg)
generic
MDD
4 per day
ANTIDEPRESSANTS
ANTIDEPRESSANTS, OTHER
MONOAMINE OXIDASE INHIBITORS
phenelzine sulfate tab 15 mg
generic
tranylcypromine sulfate tab 10 mg
generic
PAGE 29
PRODUCT DESCRIPTION
BRAND/GEN
SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITORS/SEROTONIN AND NOREPINEPHRINE
REUPTAKE INHIBITOR
citalopram hydrobromide (oral soln 10 mg/5ml, tab 10 mg
(base equiv), tab 20 mg (base equiv), tab 40 mg (base
equiv))
generic
escitalopram oxalate (tab 5 mg, tab 10 mg, tab 20 mg)
generic
fluoxetine hcl (cap 10 mg, cap 20 mg, cap 40 mg)
generic
fluoxetine hcl solution 20 mg/5ml
generic
AL
At least 7 yrs old
fluoxetine hcl tab 10 mg
generic
AL
At least 13 yrs old
fluvoxamine maleate (tab 25 mg, tab 50 mg, tab 100 mg)
generic
maprotiline hcl (tab 25 mg, tab 50 mg, tab 75 mg)
generic
nefazodone hcl (tab 50 mg, tab 100 mg, tab 150 mg, tab
200 mg, tab 250 mg)
generic
paroxetine hcl (tab 10 mg, tab 20 mg, tab 30 mg, tab 40
mg)
generic
PAXIL SUSPENSION 10 MG/5ML
BRAND
sertraline hcl (oral conc 20 mg/ml, tab 25 mg, tab 50 mg,
tab 100 mg)
generic
trazodone hcl (tab 50 mg, tab 100 mg, tab 150 mg)
generic
trazodone hcl tab 300 mg
generic
MDD
2 per day
venlafaxine hcl (cap 24hr 150 mg, cap 24hr 37.5 mg, cap
24hr 75 mg)
generic
MDD
1 Per Day
venlafaxine hcl (tab 24hr 150 mg, tab 24hr 75 mg, tab 24hr
37.5 mg)
generic
MDD
1 per day
venlafaxine hcl (tab 25 mg, tab 37.5 mg, tab 50 mg, tab 75
mg, tab 100 mg)
generic
VIIBRYD (KIT 10 & 20 & 40 MG, TAB 10 MG, TAB 20 MG,
TAB 40 MG)
BRAND
PA
TRICYCLICS
amitriptyline hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab 75
mg, tab 100 mg, tab 150 mg)
generic
amoxapine (tab 25 mg, tab 50 mg, tab 100 mg, tab 150
mg)
generic
PAGE 30
PRODUCT DESCRIPTION
BRAND/GEN
clomipramine hcl cap 75 mg
generic
desipramine hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab 75
generic
doxepin hcl (cap 10 mg, cap 25 mg, cap 50 mg, cap 75
mg, cap 100 mg, cap 150 mg, conc 10 mg/ml)
generic
imipramine hcl (tab 10 mg, tab 25 mg, tab 50 mg)
generic
nortriptyline hcl (cap 10 mg, cap 25 mg, cap 50 mg, cap 75
mg, soln 10 mg/5ml)
generic
ANTIEMETICS
ANTIEMETICS, OTHER
meclizine hcl (tab 12.5 mg, tab 25 mg)
generic
metoclopramide hcl (soln 5 mg/5ml (10 mg/10ml), tab 5
mg, tab 10 mg)
generic
perphenazine (tab 2 mg, tab 4 mg, tab 8 mg, tab 16 mg)
generic
prochlorperazine maleate (tab 5 mg, tab 10 mg)
generic
prochlorperazine suppos 25 mg
generic
EMETOGENIC THERAPY ADJUNCTS
ondansetron hcl (tab 4 mg, tab 8 mg)
generic
MDD
ondansetron hcl oral soln 4 mg/5ml
generic
QL
ondansetron orally disintegrating tab 4 mg
generic
MDD
2 per day
generic
MDD
2 per day
clotrimazole (topical) (cream, soln)
generic
MPL
1 / 1 claim
econazole nitrate cream 1%
generic
MPL
1 / 1 claim
fluconazole (susp 10 mg/ml, susp 40 mg/ml)
generic
QL
fluconazole tab 100 mg
generic
MDD
1 per day
generic
QL
2 / 1 claim
2 per day
50 / 1 claim
ANTIFUNGALS
PAGE 31
70 / 1 claim
PRODUCT DESCRIPTION
BRAND/GEN
generic
MDD
2 per day
generic
QL
7 / 1 claim
griseofulvin microsize (susp 125 mg/5ml, tab 500 mg)
generic
griseofulvin ultramicrosize (tab 125 mg, tab 250 mg)
generic
GYNAZOLE-1 CREAM 2 %
BRAND
itraconazole cap 100 mg
generic
PA
MDD
1 per day
1 / 1 claim
ketoconazole cream 2%
generic
MPL
ketoconazole shampoo 2%
generic
QL
120 / 1 claim
MICONAZOLE 3 SUPPOS 200 MG
BRAND
QL
3 / 1 claim
nystatin (topical) (*nystatin topical powder**, nystatin
cream 100000 unit/gm, nystatin oint 100000 unit/gm)
generic
MPL
1 / 1 claim
nystatin susp 100000 unit/ml
generic
QL
nystatin tab 500000 unit
generic
MDD
6 per day
nystatin-triamcinolone (cream unit/gm-%, oint unit/gm-%)
generic
MPL
1 / 1 claim
terbinafine hcl tab 250 mg
generic
QL
MDD
120 / 1 claim
90 / 120 days
1 per day
terconazole vaginal cream 0.4%
generic
QL
45 / 1 claim
terconazole vaginal cream 0.8%
generic
QL
20 / 1 claim
terconazole vaginal suppos 80 mg
generic
QL
3 / 1 claim
ANTIGOUT AGENTS
allopurinol (tab 100 mg, tab 300 mg)
generic
colchicine w/ probenecid tab 0.5-500 mg
generic
probenecid tab 500 mg
generic
PAGE 32
PRODUCT DESCRIPTION
BRAND/GEN
ANTIMIGRAINE AGENTS
ERGOT ALKALOIDS
CAFERGOT TAB 1-100 MG
BRAND
dihydroergotamine mesylate (inj 1 mg/ml, nasal spray 4
mg/ml)
generic
SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS
ALSUMA SOLN A-INJ 6 MG/0.5ML
BRAND
naratriptan hcl (tab 1 mg, tab 2.5 mg)
generic
QL
9 / 30 days
RELPAX (TAB 20 MG, TAB 40 MG)
BRAND
QL
6 / 30 days
rizatriptan benzoate (tab 5 mg, tab 10 mg)
generic
QL
12 / 30 days
sumatriptan nasal spray (5 mg/act, 20 mg/act)
generic
QL
6 / 30 days
sumatriptan succinate (solution auto-injector 6 mg/0.5ml,
solution cartridge 6 mg/0.5ml)
generic
sumatriptan succinate (tab 25 mg, tab 50 mg, tab 100 mg)
generic
QL
9 / 30 days
sumatriptan succinate inj 6 mg/0.5ml
generic
QL
2 / 30 days
SUMATRIPTAN SUCCINATE SOLN PRSYR 6 MG/0.5ML
BRAND
zolmitriptan (orally disintegrating tab 2.5 mg, orally
disintegrating tab 5 mg, tab 2.5 mg, tab 5 mg)
generic
QL
6 / 30 days
ZOMIG SOLUTION 5 MG
BRAND
QL
6 / 30 days
ANTIMYASTHENIC AGENTS
PARASYMPATHOMIMETICS
pyridostigmine bromide (tab 60 mg, tab cr 180 mg)
generic
ANTIMYCOBACTERIALS
ANTIMYCOBACTERIALS, OTHER
dapsone (tab 25 mg, tab 100 mg)
PAGE 33
generic
PRODUCT DESCRIPTION
BRAND/GEN
ANTITUBERCULARS
ethambutol hcl (tab 100 mg, tab 400 mg)
generic
isoniazid (tab 100 mg, tab 300 mg)
generic
ISONIAZID SYRUP 50 MG/5ML
BRAND
pyrazinamide tab 500 mg
generic
rifampin (cap 150 mg, cap 300 mg)
generic
TRECATOR TAB 250 MG
BRAND
ANTINEOPLASTICS
ALKYLATING AGENTS
ALKERAN TAB 2 MG
BRAND
cyclophosphamide (cap 25 mg, cap 50 mg)
generic
LEUKERAN TAB 2 MG
BRAND
MYLERAN TAB 2 MG
BRAND
ANTIANDROGENS
bicalutamide tab 50 mg
generic
flutamide cap 125 mg
generic
MDD
1 per day
ANTIESTROGENS/MODIFIERS
FARESTON TAB 60 MG
BRAND
tamoxifen citrate (tab 10 mg, tab 20 mg)
generic
PA
ANTIMETABOLITES
DROXIA (CAP 200 MG, CAP 300 MG, CAP 400 MG)
BRAND
hydroxyurea cap 500 mg
generic
mercaptopurine tab 50 mg
generic
PURIXAN SUSPENSION 2000 MG/100ML
BRAND
AL
BRAND
PA
Up to 8 yrs old
ANTINEOPLASTICS, OTHER
HEMANGEOL SOLUTION 4.28 MG/ML
PAGE 34
PRODUCT DESCRIPTION
BRAND/GEN
leucovorin calcium (tab 5 mg, tab 10 mg, tab 15 mg, tab 25
mg)
generic
AROMATASE INHIBITORS, 3RD GENERATION
anastrozole tab 1 mg
generic
exemestane tab 25 mg
generic
PA
ST
letrozole tab 2.5 mg
PA
generic
ST
MOLECULAR TARGET INHIBITORS
COTELLIC TAB 20 MG
BRAND
PA
NINLARO (CAP 2.3 MG, CAP 3 MG, CAP 4 MG)
BRAND
PA
chloroquine phosphate tab 250 mg
generic
QL
60 / 30 days
chloroquine phosphate tab 500 mg
generic
QL
8 / 56 days
COARTEM TAB 20-120 MG
BRAND
QL
24 / 1 claim
hydroxychloroquine sulfate tab 200 mg
generic
mefloquine hcl tab 250 mg
generic
60 / 1 claim
ANTIPARASITICS
ANTIPROTOZOALS
PEDICULICIDES/SCABICIDES
EURAX CREAM 10 %
BRAND
QL
EURAX LOTION 10 %
BRAND
MPL
malathion lotion 0.5%
generic
permethrin cream 5%
PAGE 35
generic
1 / 1 claim
QL
59 / 1 claim
MFL
2 / 30 days
MPL
1 / 1 claim
PRODUCT DESCRIPTION
BRAND/GEN
ANTIPARKINSON AGENTS
ANTICHOLINERGICS
benztropine mesylate (tab 0.5 mg, tab 1 mg, tab 2 mg)
generic
trihexyphenidyl hcl (tab 2 mg, tab 5 mg)
generic
trihexyphenidyl hcl elixir 0.4 mg/ml
generic
QL
500 / 31 days
AL
At least 18 yrs old
ANTIPARKINSON AGENTS, OTHER
amantadine hcl (cap 100 mg, syrup 50 mg/5ml)
generic
DOPAMINE AGONISTS
bromocriptine mesylate (cap 5 mg, tab 2.5 mg)
generic
pramipexole dihydrochloride (tab 0.125 mg, tab 0.25 mg,
tab 0.5 mg, tab 0.75 mg, tab 1 mg, tab 1.5 mg)
generic
ropinirole hydrochloride (tab 0.25 mg, tab 3 mg, tab 4 mg)
ropinirole hydrochloride (tab 0.5 mg, tab 1 mg, tab 2 mg,
tab 5 mg)
MDD
3 per day
generic
MDD
6 per day
generic
MDD
3 per day
DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS
carbidopa tab 25 mg
generic
carbidopa-levodopa (tab 10-100 mg, tab 25-100 mg, tab
25-250 mg, tab cr 25-100 mg, tab cr 50-200 mg)
generic
MONOAMINE OXIDASE B (MAO-B) INHIBITORS
selegiline hcl (cap 5 mg, tab 5 mg)
generic
ANTIPSYCHOTICS
1ST GENERATION/TYPICAL
chlorpromazine hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab
100 mg, tab 200 mg)
generic
fluphenazine decanoate inj 25 mg/ml
generic
fluphenazine hcl (tab 1 mg, tab 2.5 mg, tab 5 mg, tab 10
mg)
generic
PAGE 36
PRODUCT DESCRIPTION
BRAND/GEN
haloperidol (tab 0.5 mg, tab 1 mg, tab 2 mg, tab 5 mg, tab
10 mg, tab 20 mg)
generic
haloperidol decanoate (soln 50 mg/ml, soln 100 mg/ml)
generic
haloperidol lactate oral conc 2 mg/ml
generic
loxapine succinate (cap 5 mg, cap 10 mg, cap 25 mg, cap
50 mg)
generic
thioridazine hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab 100
mg)
generic
thiothixene (cap 1 mg, cap 2 mg, cap 5 mg, cap 10 mg)
generic
trifluoperazine hcl (tab 1 mg, tab 2 mg, tab 5 mg, tab 10
mg)
generic
2ND GENERATION/ATYPICAL
aripiprazole (oral solution 1 mg/ml, orally disintegrating tab
10 mg, orally disintegrating tab 15 mg, tab 2 mg, tab 5 mg,
tab 10 mg, tab 15 mg, tab 20 mg, tab 30 mg)
generic
olanzapine (tab 2.5 mg, tab 5 mg, tab 7.5 mg, tab 10 mg,
tab 15 mg, tab 20 mg)
generic
quetiapine fumarate (tab 25 mg, tab 50 mg, tab 100 mg,
tab 200 mg, tab 300 mg, tab 400 mg)
generic
risperidone (soln 1 mg/ml, tab 0.25 mg, tab 0.5 mg, tab 1
mg, tab 2 mg, tab 3 mg, tab 4 mg)
generic
risperidone odt (tab 3 mg, tab 4 mg)
generic
risperidone orally disintegrating tab 0.25 mg
generic
generic
risperidone orally disintegrating tab 1 mg
generic
generic
ziprasidone hcl (cap 20 mg, cap 40 mg, cap 60 mg, cap 80
mg)
generic
PA
TREATMENT-RESISTANT
clozapine (tab 25 mg, tab 50 mg, tab 100 mg, tab 200 mg)
PAGE 37
generic
PRODUCT DESCRIPTION
BRAND/GEN
ANTIVIRALS
ANTI-CYTOMEGALOVIRUS (CMV) AGENTS
valganciclovir hcl tab 450 mg (base equivalent)
generic
MDD
2 per day
GENVOYA TAB 150-150-200-10 MG
BRAND
MDD
1 per day
ISENTRESS CHEW TAB 100 MG
BRAND
MDD
6 Per Day
ISENTRESS CHEW TAB 25 MG
BRAND
MDD
12 Per Day
ISENTRESS PACKET 100 MG
BRAND
MDD
2 Per Day
ISENTRESS TAB 400 MG
BRAND
MDD
2 per day
STRIBILD TAB 150-150-200-300 MG
BRAND
TIVICAY TAB 50 MG
BRAND
VITEKTA (TAB 85 MG, TAB 150 MG)
BRAND
ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)
ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)
ATRIPLA TAB 600-200-300 MG
BRAND
MDD
1 per day
COMPLERA TAB 200-25-300 MG
BRAND
MDD
1 per day
EDURANT TAB 25 MG
BRAND
MDD
1 per day
INTELENCE (TAB 25 MG, TAB 100 MG)
BRAND
MDD
4 per day
INTELENCE TAB 200 MG
BRAND
MDD
2 per day
nevirapine susp 50 mg/5ml
generic
MDD
40 per day
nevirapine tab 200 mg
generic
MDD
2 per day
nevirapine tab sr 24hr 100 mg
generic
MDD
1 Per Day
nevirapine tab sr 24hr 400 mg
generic
MDD
1 per day
RESCRIPTOR TAB 100 MG
BRAND
MDD
12 per day
RESCRIPTOR TAB 200 MG
BRAND
MDD
6 per day
PAGE 38
PRODUCT DESCRIPTION
BRAND/GEN
SUSTIVA (CAP 200 MG, TAB 600 MG)
BRAND
MDD
1 per day
SUSTIVA CAP 50 MG
BRAND
MDD
2 per day
ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)
abacavir sulfate tab 300 mg (base equiv)
generic
MDD
2 per day
abacavir sulfate-lamivudine-zidovudine tab 300-150-300
mg
generic
MDD
2 per day
DESCOVY TAB 200-25 MG
BRAND
MDD
1 Per Day
didanosine (capsule 125 mg, capsule 200 mg, capsule 250
mg, capsule 400 mg)
generic
MDD
1 per day
EMTRIVA CAP 200 MG
BRAND
MDD
1 per day
EMTRIVA SOLUTION 10 MG/ML
BRAND
MDD
24 per day
EPZICOM TAB 600-300 MG
BRAND
MDD
1 per day
lamivudine oral soln 10 mg/ml
generic
MDD
30 per day
lamivudine tab 150 mg
generic
MDD
2 per day
lamivudine tab 300 mg
generic
MDD
1 per day
lamivudine-zidovudine tab 150-300 mg
generic
MDD
2 per day
stavudine (cap 15 mg, cap 20 mg, cap 30 mg, cap 40 mg)
generic
MDD
2 per day
stavudine for oral soln 1 mg/ml
generic
MDD
80 per day
TRUVADA TAB 200-300 MG
BRAND
MDD
1 per day
VIDEX (RECON SOLN 2 GM, RECON SOLN 4 GM)
BRAND
MDD
20 per day
VIREAD (TAB 150 MG, TAB 200 MG, TAB 250 MG, TAB
300 MG)
BRAND
MDD
1 per day
VIREAD POWDER 40 MG/GM
BRAND
QL
ZIAGEN SOLUTION 20 MG/ML
BRAND
MDD
30 per day
zidovudine cap 100 mg
generic
MDD
6 per day
zidovudine syrup 10 mg/ml
generic
MDD
60 per day
PAGE 39
240 / 30 days
PRODUCT DESCRIPTION
BRAND/GEN
zidovudine tab 300 mg
generic
MDD
2 per day
SELZENTRY TAB 150 MG
BRAND
MDD
2 per day
SELZENTRY TAB 300 MG
BRAND
MDD
4 per day
TRIUMEQ TAB 600-50-300 MG
BRAND
TYBOST TAB 150 MG
BRAND
MDD
1 Per Day
APTIVUS CAP 250 MG
BRAND
MDD
4 per day
APTIVUS SOLUTION 100 MG/ML
BRAND
MDD
10 per day
CRIXIVAN CAP 200 MG
BRAND
MDD
9 per day
CRIXIVAN CAP 400 MG
BRAND
MDD
6 per day
EVOTAZ TAB 300-150 MG
BRAND
MDD
1 Per Day
INVIRASE CAP 200 MG
BRAND
MDD
10 per day
INVIRASE TAB 500 MG
BRAND
MDD
4 per day
KALETRA SOLUTION 400-100 MG/5ML
BRAND
MPL
1 / 1 claim
KALETRA TAB 100-25 MG
BRAND
MDD
4 per day
KALETRA TAB 200-50 MG
BRAND
MDD
6 per day
LEXIVA SUSPENSION 50 MG/ML
BRAND
MDD
56 per day
LEXIVA TAB 700 MG
BRAND
MDD
4 per day
NORVIR (CAP 100 MG, TAB 100 MG)
BRAND
MDD
12 per day
NORVIR SOLUTION 80 MG/ML
BRAND
MDD
15 per day
PREZISTA (TAB 75 MG, TAB 600 MG)
BRAND
MDD
2 per day
PREZISTA SUSPENSION 100 MG/ML
BRAND
MDD
12 Per Day
PREZISTA TAB 150 MG
BRAND
MDD
3 per day
ANTI-HIV AGENTS, OTHER
ANTI-HIV AGENTS, PROTEASE INHIBITORS
PAGE 40
PRODUCT DESCRIPTION
BRAND/GEN
PREZISTA TAB 800 MG
BRAND
MDD
1 per day
REYATAZ (CAP 150 MG, CAP 200 MG, CAP 300 MG)
BRAND
MDD
2 per day
REYATAZ PACKET 50 MG
BRAND
MDD
6 Per Day
VIRACEPT TAB 250 MG
BRAND
MDD
9 per day
VIRACEPT TAB 625 MG
BRAND
MDD
4 per day
ANTI-INFLUENZA AGENTS
AL
RELENZA DISKHALER AER POW BA 5 MG/BLISTER
BRAND
MPL
At least 5 yrs old
1 / 30 days
TAMIFLU (CAP 45 MG, CAP 75 MG)
BRAND
QL
10 / 30 days
TAMIFLU CAP 30 MG
BRAND
QL
20 / 30 days
TAMIFLU RECON SUSP 6 MG/ML
BRAND
QL
120 / 30 days
acyclovir (cap 200 mg, tab 800 mg)
generic
QL
50 / 30 days
acyclovir oint 5%
generic
QL
30 / 30 days
acyclovir susp 200 mg/5ml
generic
QL
400 / 30 days
acyclovir tab 400 mg
generic
MDD
3 Per Day
trifluridine ophth soln 1%
generic
QL
8 / 1 claim
valacyclovir hcl tab 1 gm
generic
QL
21 / 21 days
valacyclovir hcl tab 500 mg
generic
QL
60 / 30 day(s)
ZOVIRAX CREAM 5 %
BRAND
MPL
1 / 1 claim
buspirone hcl (tab 5 mg, tab 7.5 mg, tab 10 mg, tab 15 mg,
tab 30 mg)
generic
MDD
3 per day
meprobamate (tab 200 mg, tab 400 mg)
generic
ANTIHERPETIC AGENTS
ANXIOLYTICS
ANXIOLYTICS, OTHER
PAGE 41
PRODUCT DESCRIPTION
BRAND/GEN
midazolam hcl (inj 2 mg/2ml, inj 5 mg/ml, inj 5 mg/5ml, inj
10 mg/2ml, inj 10 mg/10ml, inj 25 mg/5ml, inj 50 mg/10ml)
generic
BENZODIAZEPINES
alprazolam (tab 0.25 mg, tab 0.5 mg, tab 1 mg, tab 2 mg)
generic
MDD
4 per day
chlordiazepoxide hcl (cap 5 mg, cap 10 mg, cap 25 mg)
generic
MDD
4 per day
clonazepam (tab 0.5 mg, tab 1 mg, tab 2 mg)
generic
clorazepate dipotassium (tab 3.75 mg, tab 7.5 mg, tab 15
mg)
generic
MDD
3 per day
diazepam (tab 2 mg, tab 5 mg, tab 10 mg)
generic
MDD
4 per day
diazepam oral soln 1 mg/ml
generic
QL
lorazepam (tab 0.5 mg, tab 2 mg)
generic
MDD
3 per day
lorazepam tab 1 mg
generic
MDD
4 per day
oxazepam (cap 10 mg, cap 15 mg, cap 30 mg)
generic
MDD
4 per day
MDD
1 per day
500 / 1 claim
BIPOLAR AGENTS
MOOD STABILIZERS
lithium carbonate (cap 150 mg, cap 300 mg, cap 600 mg,
tab 300 mg, tab cr 300 mg, tab cr 450 mg)
generic
lithium oral solution 8 meq/5ml
generic
BLOOD GLUCOSE REGULATORS
ANTIDIABETIC AGENTS
AVANDIA (TAB 2 MG, TAB 4 MG, TAB 8 MG)
BRAND
BYDUREON 2 MG
BRAND
QL
4 / 28 days
PA
BYDUREON PEN 2 MG
BRAND
ST
AL
At least 18 yrs old
QL
2.4 / 30 days
PA
BYETTA 10 MCG PEN SOLN PEN 10 MCG/0.04ML
BRAND
ST
AL
PAGE 42
At least 18 yrs old
PRODUCT DESCRIPTION
BRAND/GEN
QL
1.2 / 30 days
PA
BYETTA 5 MCG PEN SOLN PEN 5 MCG/0.02ML
BRAND
ST
AL
At least 18 yrs old
glimepiride (tab 1 mg, tab 2 mg)
generic
MDD
1 per day
glimepiride tab 4 mg
generic
MDD
2 per day
glipizide (tab 5 mg, tab 10 mg, tab sr 24hr 2.5 mg, tab sr
24hr 5 mg, tab sr 24hr 10 mg)
generic
glipizide-metformin hcl (tab 2.5-500 mg, tab 2.5-250 mg,
tab 5-500 mg)
generic
glyburide (tab 1.25 mg, tab 2.5 mg, tab 5 mg)
generic
glyburide micronized (tab 1.5 mg, tab 3 mg, tab 6 mg)
generic
glyburide-metformin (tab 1.25-250 mg, tab 2.5-500 mg, tab
5-500 mg)
generic
JENTADUETO (TAB 2.5-1000 MG, TAB 2.5-850 MG, TAB
2.5-500 MG)
BRAND
KOMBIGLYZE XR (TAB ER 24H 5-500 MG, TAB ER 24H
5-1000 MG)
BRAND
KOMBIGLYZE XR TAB ER 24H 2.5-1000 MG
BRAND
AL
MDD
AL
MDD
AL
At least 18 yrs old
2 per day
At least 18 yrs old
1 per day
At least 18 yrs old
MDD
2 per day
metformin hcl (tab 1000 mg, tab sr 24hr 750 mg)
generic
MDD
2 per day
metformin hcl tab 500 mg
generic
MDD
5 per day
metformin hcl tab 850 mg
generic
MDD
3 per day
metformin hcl tab sr 24hr 500 mg
generic
MDD
4 per day
nateglinide (tab 60 mg, tab 120 mg)
generic
MDD
3 per day
ONGLYZA (TAB 2.5 MG, TAB 5 MG)
BRAND
AL
pioglitazone hcl (tab 15 mg, tab 30 mg, tab 45 mg)
PAGE 43
generic
At least 18 yrs old
MDD
1 per day
MDD
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
pioglitazone hcl-metformin hcl (-metformin tab 15-500 mg, metformin tab 15-850 mg)
generic
SYMLINPEN 120 SOLN PEN 2700 MCG/2.7ML
BRAND
MDD
QL
2 per day
10.8 / 30 days
PA
QL
SYMLINPEN 60 SOLN PEN 1500 MCG/1.5ML
BRAND
6 / 30 days
PA
AL
TRADJENTA TAB 5 MG
BRAND
At least 18 yrs old
MDD
1 per day
GLYCEMIC AGENTS
GLUCAGEN HYPOKIT RECON SOLN 1 MG
BRAND
GLUCAGON EMERGENCY KIT 1 MG
BRAND
QL
1 / 1 claim
APIDRA SOLOSTAR SOLN PEN 100 UNIT/ML
BRAND
QL
30 / 30 days
APIDRA SOLUTION 100 UNIT/ML
BRAND
HUMALOG KWIKPEN SOLN PEN 100 UNIT/ML
BRAND
QL
30 / 30 days
HUMALOG MIX 50/50 KWIKPEN SUSP PEN (50-50) 100
UNIT/ML
BRAND
QL
30 / 30 days
HUMALOG MIX 50/50 SUSPENSION (50-50) 100
UNIT/ML
BRAND
QL
40 / 30 days
HUMALOG MIX 75/25 KWIKPEN SUSP PEN (75-25) 100
UNIT/ML
BRAND
QL
30 / 30 days
HUMALOG MIX 75/25 SUSPENSION (75-25) 100
UNIT/ML
BRAND
QL
40 / 30 days
HUMALOG SOLN CART 100 UNIT/ML
BRAND
HUMALOG SOLUTION 100 UNIT/ML
BRAND
QL
40 / 30 days
HUMULIN 70/30 KWIKPEN SUSP PEN (70-30) 100
UNIT/ML
BRAND
QL
30 / 30 days
HUMULIN 70/30 SUSPENSION (70-30) 100 UNIT/ML
BRAND
QL
40 / 30 days
HUMULIN N KWIKPEN SUSP PEN 100 UNIT/ML
BRAND
QL
30 / 30 days
INSULINS
PAGE 44
PRODUCT DESCRIPTION
BRAND/GEN
HUMULIN N SUSPENSION 100 UNIT/ML
BRAND
QL
40 / 30 days
HUMULIN R SOLUTION 100 UNIT/ML
BRAND
QL
40 / 30 days
LANTUS SOLOSTAR SOLN PEN 100 UNIT/ML
BRAND
QL
30 / 30 days
LANTUS SOLUTION 100 UNIT/ML
BRAND
QL
30 / 30 days
LEVEMIR FLEXPEN SOLN PEN 100 UNIT/ML
BRAND
QL
30 / 30 days
LEVEMIR FLEXTOUCH SOLN PEN 100 UNIT/ML
BRAND
QL
30 / 30 days
LEVEMIR SOLUTION 100 UNIT/ML
BRAND
QL
30 / 30 days
NOVOLIN 70/30 RELION SUSPENSION (70-30) 100
UNIT/ML
BRAND
QL
40 / 30 days
NOVOLIN 70/30 SUSPENSION (70-30) 100 UNIT/ML
BRAND
QL
40 / 30 days
NOVOLIN N RELION SUSPENSION 100 UNIT/ML
BRAND
QL
40 / 30 days
NOVOLIN N SUSPENSION 100 UNIT/ML
BRAND
QL
40 / 30 days
NOVOLIN R RELION SOLUTION 100 UNIT/ML
BRAND
QL
40 / 30 days
NOVOLIN R SOLUTION 100 UNIT/ML
BRAND
QL
40 / 30 days
NOVOLOG FLEXPEN SOLN PEN 100 UNIT/ML
BRAND
QL
30 / 30 days
NOVOLOG MIX 70/30 FLEXPEN SUSP PEN (70-30) 100
UNIT/ML
BRAND
QL
30 / 30 days
NOVOLOG MIX 70/30 SUSPENSION (70-30) 100
UNIT/ML
BRAND
QL
40 / 30 days
NOVOLOG PENFILL SOLN CART 100 UNIT/ML
BRAND
NOVOLOG SOLUTION 100 UNIT/ML
BRAND
QL
30 / 30 days
ELIQUIS (TAB 2.5 MG, TAB 5 MG)
BRAND
MDD
enoxaparin sodium (inj 100 mg/ml, inj 150 mg/ml)
generic
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS
ANTICOAGULANTS
QL
MFL
PAGE 45
4 per day
14 / 7 days
3 / 180 days
PRODUCT DESCRIPTION
BRAND/GEN
enoxaparin sodium (inj 80 mg/0.8ml, inj 120 mg/0.8ml)
generic
QL
MFL
enoxaparin sodium inj 30 mg/0.3ml
QL
generic
MFL
enoxaparin sodium inj 300 mg/3ml
QL
generic
MFL
QL
generic
MFL
QL
generic
MFL
heparin sodium (porcine) (inj 1000 unit/ml, inj 5000 unit/ml,
inj 10000 unit/ml, inj 20000 unit/ml, pf inj 5000 unit/0.5ml)
generic
warfarin sodium (tab 1 mg, tab 2 mg, tab 2.5 mg, tab 3 mg,
tab 4 mg, tab 5 mg, tab 6 mg, tab 7.5 mg, tab 10 mg)
generic
XARELTO TAB 10 MG
BRAND
QL
12 / 7 days
3 / 180 days
5 / 7 days
3 / 180 days
42 / 7 days
3 / 180 days
6 / 7 days
3 / 180 days
9 / 7 days
3 / 180 days
35 / 180 days
MDD
1 per day
XARELTO TAB 15 MG
BRAND
MDD
2 per day
XARELTO TAB 20 MG
BRAND
MDD
1 per day
aminocaproic acid syrup 25%
generic
QL
60 / 1 claim
aminocaproic acid tab 500 mg
generic
QL
24 / 1 claim
QL
30 / 5 days
GL
Female
AL
12 to 49 yrs old
COAGULANTS
tranexamic acid tab 650 mg
generic
MFL
1 / 1 month
MDD
2 per day
PLATELET MODIFYING AGENTS
BRILINTA (TAB 60 MG, TAB 90 MG)
PAGE 46
BRAND
PRODUCT DESCRIPTION
BRAND/GEN
cilostazol (tab 50 mg, tab 100 mg)
generic
MDD
2 per day
clopidogrel bisulfate tab 75 mg (base equiv)
generic
MDD
1 per day
dipyridamole (tab 25 mg, tab 50 mg, tab 75 mg)
generic
EFFIENT (TAB 5 MG, TAB 10 MG)
BRAND
MDD
1 per day
CARDIOVASCULAR AGENTS
ALPHA-ADRENERGIC AGONISTS
clonidine hcl (tab 0.1 mg, tab 0.2 mg, tab 0.3 mg)
generic
guanfacine hcl (tab 1 mg, tab 2 mg)
generic
methyldopa (tab 250 mg, tab 500 mg)
generic
midodrine hcl (tab 2.5 mg, tab 5 mg, tab 10 mg)
generic
ALPHA-ADRENERGIC BLOCKING AGENTS
doxazosin mesylate (tab 1 mg, tab 2 mg, tab 4 mg, tab 8
mg)
generic
prazosin hcl (cap 1 mg, cap 2 mg, cap 5 mg)
generic
ANGIOTENSIN II RECEPTOR ANTAGONISTS
irbesartan (tab 75 mg, tab 150 mg, tab 300 mg)
generic
MDD
1 per day
losartan potassium (tab 25 mg, tab 50 mg, tab 100 mg)
generic
MDD
1 per day
valsartan (tab 40 mg, tab 80 mg, tab 160 mg, tab 320 mg)
generic
MDD
1 per day
benazepril hcl (tab 5 mg, tab 10 mg, tab 20 mg)
generic
MDD
1 per day
benazepril hcl tab 40 mg
generic
MDD
2 per day
captopril (tab 12.5 mg, tab 25 mg, tab 50 mg, tab 100 mg)
generic
MDD
3 per day
enalapril maleate (tab 2.5 mg, tab 5 mg, tab 10 mg, tab 20
mg)
generic
MDD
2 per day
EPANED RECON SOLN 1 MG/ML
BRAND
AL
fosinopril sodium (tab 10 mg, tab 20 mg, tab 40 mg)
generic
MDD
ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS
PAGE 47
Up to 8 yrs old
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
lisinopril (tab 5 mg, tab 10 mg, tab 20 mg, tab 30 mg, tab
40 mg)
generic
MDD
2 per day
lisinopril tab 2.5 mg
generic
MDD
1 per day
quinapril hcl (tab 5 mg, tab 10 mg, tab 20 mg, tab 40 mg)
generic
MDD
1 per day
ramipril (cap 1.25 mg, cap 2.5 mg, cap 5 mg, cap 10 mg)
generic
MDD
2 per day
trandolapril (tab 1 mg, tab 2 mg, tab 4 mg)
generic
MDD
4 per day
ANTIARRHYTHMICS
amiodarone hcl tab 200 mg
generic
disopyramide phosphate (cap 100 mg, cap 150 mg)
generic
flecainide acetate (tab 50 mg, tab 100 mg, tab 150 mg)
generic
mexiletine hcl (cap 150 mg, cap 200 mg, cap 250 mg)
generic
propafenone hcl (tab 150 mg, tab 225 mg, tab 300 mg)
generic
quinidine gluconate tab cr 324 mg
generic
quinidine sulfate (tab 200 mg, tab 300 mg)
generic
sotalol hcl (afib/afl) ((afib/afl) tab 80 mg, (afib/afl) tab 120
mg, (afib/afl) tab 160 mg)
generic
MDD
2 per day
sotalol hcl (tab 80 mg, tab 120 mg, tab 160 mg)
generic
MDD
2 per day
sotalol hcl tab 240 mg
generic
TIKOSYN (CAP 125 MCG, CAP 250 MCG, CAP 500 MCG)
BRAND
BETA-ADRENERGIC BLOCKING AGENTS
acebutolol hcl (cap 200 mg, cap 400 mg)
generic
atenolol (tab 25 mg, tab 50 mg, tab 100 mg)
generic
MDD
2 per day
bisoprolol fumarate (tab 5 mg, tab 10 mg)
generic
MDD
1 per day
carvedilol (tab 3.125 mg, tab 6.25 mg, tab 12.5 mg)
generic
MDD
3 per day
carvedilol tab 25 mg
generic
MDD
4 per day
COREG CR (CAP ER 24H 20 MG, CAP ER 24H 40 MG,
CAP ER 24H 10 MG, CAP ER 24H 80 MG)
BRAND
MDD
1 per day
labetalol hcl tab 100 mg
generic
MDD
3 per day
PAGE 48
PRODUCT DESCRIPTION
BRAND/GEN
generic
MDD
6 per day
generic
MDD
8 per day
metoprolol succinate (tab 24hr 50 mg, tab 24hr 100 mg,
tab 24hr 25 mg)
generic
MDD
1 per day
metoprolol succinate tab sr 24hr 200 mg (tartrate equiv)
generic
MDD
2 per day
metoprolol tartrate (tab 25 mg, tab 100 mg)
generic
MDD
2 per day
metoprolol tartrate tab 50 mg
generic
MDD
3 per day
nadolol (tab 20 mg, tab 40 mg, tab 80 mg)
generic
MDD
2 per day
pindolol (tab 5 mg, tab 10 mg)
generic
propranolol hcl (cap 24hr 80 mg, cap 24hr 60 mg, cap 24hr
120 mg, cap 24hr 160 mg)
generic
MDD
2 per day
propranolol hcl (oral soln 20 mg/5ml, oral soln 40 mg/5ml,
tab 10 mg, tab 20 mg, tab 40 mg, tab 60 mg, tab 80 mg)
generic
timolol maleate (tab 5 mg, tab 10 mg, tab 20 mg)
generic
CALCIUM CHANNEL BLOCKING AGENTS
amlodipine besylate (tab 2.5 mg, tab 5 mg, tab 10 mg)
generic
MDD
1 per day
diltiazem hcl (cap 12hr 90 mg, cap 12hr 120 mg, cap 12hr
60 mg, cap 24hr 240 mg)
generic
MDD
2 per day
diltiazem hcl (cap 24hr 120 mg, cap 24hr 180 mg)
generic
MDD
1 per day
diltiazem hcl (tab 30 mg, tab 60 mg, tab 90 mg, tab 120
mg)
generic
MDD
3 per day
diltiazem hcl coated beads (beads cap 24hr 300 mg, beads
cap 24hr 180 mg, beads cap 24hr 120 mg)
generic
MDD
1 per day
diltiazem hcl coated beads cap sr 24hr 240 mg
generic
MDD
2 per day
diltiazem hcl extended release beads (beads cap 24hr 360
mg, beads cap 24hr 180 mg, beads cap 24hr 300 mg,
beads cap 24hr 240 mg, beads cap 24hr 120 mg, beads
cap 24hr 420 mg)
generic
MDD
1 per day
felodipine (tab 24hr 10 mg, tab 24hr 5 mg, tab 24hr 2.5 mg)
generic
MDD
1 per day
nicardipine hcl (cap 20 mg, cap 30 mg)
generic
PAGE 49
PRODUCT DESCRIPTION
BRAND/GEN
nifedipine (cap 10 mg, cap 20 mg)
generic
MDD
4 per day
nifedipine (tab 24hr 60 mg, tab 24hr osmotic release 60
mg)
generic
MDD
2 per day
nifedipine (tab 24hr osmotic release 30 mg, tab 24hr
osmotic release 90 mg, tab 24hr 30 mg, tab 24hr 90 mg)
generic
MDD
1 per day
verapamil hcl (cap sr 24hr 120 mg, cap sr 24hr 180 mg,
cap sr 24hr 240 mg, tab cr 120 mg, tab cr 180 mg, tab cr
240 mg)
generic
MDD
2 per day
verapamil hcl (tab 40 mg, tab 80 mg, tab 120 mg)
generic
MDD
3 per day
verapamil hcl cap sr 24hr 360 mg
generic
MDD
1 per day
amiloride & hydrochlorothiazide tab 5-50 mg
generic
MDD
1 per day
amlodipine besylate-benazepril hcl (cap 2.5-10 mg, cap 510 mg, cap 5-20 mg, cap 10-20 mg)
generic
MDD
1 per day
atenolol & chlorthalidone (tab 50-25 mg, tab 100-25 mg)
generic
MDD
1 per day
benazepril & hydrochlorothiazide (tab 5-6.25 mg, tab 1012.5 mg, tab 20-12.5 mg, tab 20-25 mg)
generic
MDD
1 per day
bisoprolol & hydrochlorothiazide (tab 5-6.25 mg, tab 106.25 mg)
generic
MDD
1 per day
captopril & hydrochlorothiazide (tab 25-25 mg, tab 25-15
mg, tab 50-25 mg, tab 50-15 mg)
generic
MDD
2 per day
digoxin (oral soln 0.05 mg/ml, tab 125 mcg (0.125 mg), tab
250 mcg (0.25 mg))
generic
DUTOPROL (TAB ER 24H 50-12.5 MG, TAB ER 24H 10012.5 MG, TAB ER 24H 25-12.5 MG)
BRAND
MDD
1 per day
enalapril maleate & hydrochlorothiazide (tab 5-12.5 mg, tab
10-25 mg)
generic
MDD
2 per day
fosinopril sodium & hydrochlorothiazide (tab 10-12.5 mg,
tab 20-12.5 mg)
generic
MDD
1 per day
irbesartan-hydrochlorothiazide (tab 150-12.5 mg, tab 30012.5 mg)
generic
MDD
1 per day
lisinopril & hydrochlorothiazide (tab 10-12.5 mg, tab 2012.5 mg)
generic
MDD
2 per day
CARDIOVASCULAR AGENTS, OTHER
PAGE 50
PRODUCT DESCRIPTION
BRAND/GEN
lisinopril & hydrochlorothiazide tab 20-25 mg
generic
MDD
1 per day
losartan potassium & hydrochlorothiazide (tab 50-12.5 mg,
tab 100-25 mg, tab 100-12.5 mg)
generic
MDD
1 per day
metoprolol & hydrochlorothiazide (tab 50-25 mg, tab 10025 mg, tab 100-50 mg)
generic
MDD
2 per day
pentoxifylline tab cr 400 mg
generic
propranolol & hydrochlorothiazide (tab 40-25 mg, tab 80-25
mg)
generic
reserpine (tab 0.1 mg, tab 0.25 mg)
generic
spironolactone & hydrochlorothiazide tab 25-25 mg
generic
triamterene & hydrochlorothiazide (cap 37.5-25 mg, cap
50-25 mg, tab 37.5-25 mg, tab 75-50 mg)
generic
MDD
1 per day
valsartan-hydrochlorothiazide (tab 80-12.5 mg, tab 160-25
mg, tab 160-12.5 mg, tab 320-25 mg, tab 320-12.5 mg)
generic
MDD
1 per day
DIURETICS, CARBONIC ANHYDRASE INHIBITORS
acetazolamide (cap sr 12hr 500 mg, tab 125 mg, tab 250
mg)
generic
DIURETICS, LOOP
bumetanide (tab 0.5 mg, tab 1 mg, tab 2 mg)
generic
furosemide (oral soln 8 mg/ml, oral soln 10 mg/ml, tab 20
generic
torsemide (tab 5 mg, tab 10 mg, tab 20 mg, tab 100 mg)
generic
MDD
1 per day
amiloride hcl tab 5 mg
generic
MDD
4 per day
spironolactone (tab 25 mg, tab 50 mg, tab 100 mg)
generic
DIURETICS, POTASSIUM-SPARING
DIURETICS, THIAZIDE
chlorothiazide tab 250 mg
generic
MDD
2 per day
chlorothiazide tab 500 mg
generic
MDD
4 per day
chlorthalidone (tab 25 mg, tab 50 mg)
generic
PAGE 51
PRODUCT DESCRIPTION
BRAND/GEN
hydrochlorothiazide (cap 12.5 mg, tab 25 mg, tab 50 mg)
generic
indapamide (tab 1.25 mg, tab 2.5 mg)
generic
metolazone (tab 2.5 mg, tab 5 mg, tab 10 mg)
generic
DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES
fenofibrate micronized (cap 134 mg, cap 200 mg)
generic
MDD
1 per day
fenofibrate micronized cap 67 mg
generic
MDD
2 per day
fenofibrate tab 160 mg
generic
MDD
1 per day
fenofibrate tab 54 mg
generic
MDD
3 per day
gemfibrozil tab 600 mg
generic
MDD
2 per day
TRIGLIDE TAB 160 MG
BRAND
MDD
1 per day
atorvastatin calcium (tab 10 mg, tab 20 mg, tab 40 mg, tab
80 mg)
generic
MDD
1 per day
lovastatin (tab 10 mg, tab 20 mg)
generic
MDD
1 per day
lovastatin tab 40 mg
generic
MDD
2 per day
pravastatin sodium (tab 10 mg, tab 20 mg, tab 40 mg, tab
80 mg)
generic
MDD
1 per day
simvastatin (tab 5 mg, tab 10 mg, tab 20 mg, tab 40 mg)
generic
MDD
1 per day
MDD
2 per day
DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS
DYSLIPIDEMICS, OTHER
cholestyramine (powder 4 gm/dose, powder packets 4 gm)
generic
cholestyramine light (powder 4 gm/dose, powder packets 4
gm)
generic
colestipol hcl granules 5 gm
generic
colestipol hcl tab 1 gm
generic
NIACOR TAB 500 MG
BRAND
PAGE 52
PRODUCT DESCRIPTION
BRAND/GEN
VASODILATORS, DIRECT-ACTING ARTERIAL
hydralazine hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab 100
mg)
generic
minoxidil (tab 2.5 mg, tab 10 mg)
generic
VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS
isosorbide dinitrate (sl tab 2.5 mg, sl tab 5 mg, tab 5 mg,
tab 10 mg, tab 20 mg, tab 30 mg, tab cr 40 mg)
generic
isosorbide mononitrate (tab 10 mg, tab 20 mg)
generic
MDD
2 per day
isosorbide mononitrate (tab 24hr 120 mg, tab 24hr 60 mg,
tab 24hr 30 mg)
generic
MDD
1 per day
NITRO-BID OINTMENT 2 %
BRAND
nitroglycerin (cap cr 2.5 mg, cap cr 6.5 mg, cap cr 9 mg, td
patch 24hr 0.4 mg/hr, td patch 24hr 0.2 mg/hr, td patch
24hr 0.1 mg/hr, td patch 24hr 0.6 mg/hr)
generic
NITROSTAT (SL TAB 0.3 MG, SL TAB 0.4 MG, SL TAB
0.6 MG)
BRAND
MDD
1 per day
CENTRAL NERVOUS SYSTEM AGENTS
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES
amphetamine-dextroamphetamine (cap 24hr 30 mg, cap
24hr 15 mg, cap 24hr 5 mg, cap 24hr 25 mg, cap 24hr 10
mg)
generic
amphetamine-dextroamphetamine (tab 5 mg, tab 7.5 mg,
tab 10 mg, tab 12.5 mg, tab 15 mg, tab 20 mg, tab 30 mg)
generic
amphetamine-dextroamphetamine cap sr 24hr 20 mg
generic
MDD
1 Per Day
dextroamphetamine sulfate (cap 24hr 15 mg, cap 24hr 10
mg)
generic
MDD
2 per day
dextroamphetamine sulfate (tab 5 mg, tab 10 mg)
generic
dextroamphetamine sulfate cap sr 24hr 5 mg
generic
MDD
1 per day
VYVANSE (CAP 10 MG, CAP 20 MG, CAP 30 MG, CAP
40 MG, CAP 50 MG, CAP 60 MG, CAP 70 MG)
BRAND
PAGE 53
PA
MDD
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES
dexmethylphenidate hcl (tab 2.5 mg, tab 5 mg, tab 10 mg)
AL
generic
6 to 18 yrs old
MDD
2 per day
MDD
1 per day
MDD
2 per day
methylphenidate hcl (cap cr 10 mg (cd), cap cr 20 mg (cd),
cap cr 30 mg (cd), cap cr 40 mg (cd), cap cr 50 mg (cd),
cap cr 60 mg (cd), tab cr 20 mg, tab sa osm 18 mg, tab sa
osm 27 mg)
generic
methylphenidate hcl (tab 5 mg, tab 10 mg, tab 20 mg, tab
sa osm 54 mg)
generic
methylphenidate hcl (tab cr 10 mg, tab sa osm 36 mg)
generic
METHYLPHENIDATE HCL ER (ER TAB ER 24H 54 MG,
ER TAB ER 24H 18 MG)
BRAND
METHYLPHENIDATE HCL ER TAB ER 24H 27 MG
BRAND
MDD
1 per day
METHYLPHENIDATE HCL ER TAB ER 24H 36 MG
BRAND
MDD
2 per day
CENTRAL NERVOUS SYSTEM, OTHER
butalbital-acetaminophen tab 50-325 mg
generic
butalbital-acetaminophen tab 50-650 mg
generic
MDD
6 per day
butalbital-acetaminophen-caffeine (cap 50-325-40 mg, tab
50-500-40 mg, tab 50-325-40 mg)
generic
MDD
4 per day
butalbital-aspirin-caffeine cap 50-325-40 mg
generic
MDD
4 per day
PHRENILIN FORTE CAP 50-650 MG
BRAND
FIBROMYALGIA AGENTS
duloxetine hcl (cap 20 mg, cap 30 mg, cap 60 mg)
AL
generic
MDD
At least 7 yrs old
1 per day
PA
SAVELLA (TAB 12.5 MG, TAB 25 MG, TAB 50 MG, TAB
100 MG)
BRAND
SAVELLA TITRATION PACK MISC 12.5 & 25 & 50 MG
BRAND
MDD
QL
2 per day
55 / 365 days
PA
PAGE 54
PRODUCT DESCRIPTION
BRAND/GEN
MULTIPLE SCLEROSIS AGENTS
AVONEX KIT 30 MCG
BRAND
AVONEX PEN AUT-IJ KIT 30 MCG/0.5ML
BRAND
PA
AVONEX PREFILLED PREF SY KT 30 MCG/0.5ML
BRAND
PA
COPAXONE SOLN PRSYR 40 MG/ML
BRAND
PA
GILENYA CAP 0.5 MG
BRAND
PA
PLEGRIDY SOLN PEN 125 MCG/0.5ML
BRAND
PA
PLEGRIDY SOLN PRSYR 125 MCG/0.5ML
BRAND
PLEGRIDY STARTER PACK SOLN PEN 63 & 94
MCG/0.5ML
BRAND
PLEGRIDY STARTER PACK SOLN PRSYR 63 & 94
MCG/0.5ML
BRAND
TECFIDERA (CAP DR 120 MG, CAP DR 240 MG, MISC
120 & 240 MG)
BRAND
PA
CAPHOSOL SOLUTION
BRAND
QL
chlorhexidine gluconate soln 0.12%
generic
pilocarpine hcl tab 5 mg
generic
MDD
6 per day
sodium fluoride (dental) (cream, gel (0.5% f))
generic
MPL
1 / 1 claim
sodium fluoride rinse 0.2%
generic
PA
DENTAL AND ORAL AGENTS
900 / 1 claim
DERMATOLOGICAL AGENTS
PA
ST
ABSORICA (CAP 10 MG, CAP 20 MG, CAP 40 MG)
BRAND
AL
MDD
benzoyl peroxide liq 10%
generic
calcipotriene (cream, soln (50 mcg/ml))
generic
PAGE 55
QL
12 to 22 yrs old
2 per day
60 / 1 claim
PRODUCT DESCRIPTION
BRAND/GEN
clindamycin phosphate-benzoyl peroxide gel 1-5%
generic
MPL
1 / 1 claim
clotrimazole w/ betamethasone (w/ cream, w/ lotion)
generic
MPL
1 / 1 claim
DRYSOL SOLUTION 20 %
BRAND
MPL
1 / 1 claim
QL
ELIDEL CREAM 1 %
BRAND
30 / 30 days
PA
AL
At least 2 yrs old
10 / 1 claim
EPIFOAM FOAM 1-1 %
BRAND
fluorouracil (topical) (soln 2%, soln 5%)
generic
QL
fluorouracil cream 0.5%
generic
MPL
fluorouracil cream 5%
generic
QL
hydrocortisone (topical) (cream 1%, cream 2.5%, lotion
2.5%)
generic
MPL
hydrocortisone oint 1%
generic
QL
1 / 1 claim
40 / 1 claim
1 / 1 claim
60 / 30 days
MPL
1 / 30 days
1 / 31 days
hydrocortisone oint 2.5%
generic
MPL
imiquimod cream 5%
generic
QL
48 / 180 days
PA
isotretinoin (cap 10 mg, cap 20 mg, cap 40 mg)
ST
generic
AL
12 to 22 yrs old
MDD
2 per day
lactic acid (ammonium lactate) cream 12%
generic
MPL
1 / 1 claim
lactic acid (ammonium lactate) lotion 12%
generic
MPL
1 / 30 days
lidocaine hcl cream 3%
generic
MPL
1 / 1 claim
lidocaine oint 5%
generic
MPL
1 / 1 claim
podofilox soln 0.5%
generic
QL
4 / 1 claim
salicylic acid gel 6%
generic
MPL
1 / 1 claim
PAGE 56
PRODUCT DESCRIPTION
BRAND/GEN
selenium sulfide lotion 2.5%
generic
QL
sulfacetamide sodium liquid 10%
generic
MPL
sulfacetamide sodium lotion 10% (acne)
generic
QL
sulfacetamide sodium w/ sulfur (w/ lotion, w/ susp)
generic
MPL
QL
tacrolimus oint 0.03%
generic
BRAND
tretinoin (cream 0.025%, cream 0.05%, cream 0.1%, gel
0.01%, gel 0.025%)
generic
TROPAZONE LOTION
BRAND
urea (cream, lotion)
generic
1 / 1 claim
120 / 1 claim
1 / 1 claim
30 / 30 days
PA
AL
TAZORAC (CREAM 0.05 %, CREAM 0.1 %, GEL 0.05 %,
GEL 0.1 %)
120 / 1 claim
MPL
AL
At least 2 yrs old
1 / 1 claim
Up to 21 yrs old
MPL
1 / 1 claim
MPL
1 / 1 claim
MDD
40 per day
MDD
4 per day
ENZYME REPLACEMENT/MODIFIERS
CREON (CP DR PART 3000-9500, CP DR PART 6000,
CP DR PART 12000, CP DR PART 24000, CP DR PART
36000)
BRAND
PANCREAZE (CP DR PART 4200, CP DR PART 10500,
CP DR PART 16800, CP DR PART 21000)
BRAND
pancrelipase (lip-prot-amyl) dr cap 5000-17000-27000 unit
generic
ZENPEP (CP DR PART 3000-10000, CP DR PART 5000,
CP DR PART 10000, CP DR PART 15000, CP DR PART
20000, CP DR PART 25000)
BRAND
GASTROINTESTINAL AGENTS
ANTISPASMODICS, GASTROINTESTINAL
dicyclomine hcl (cap 10 mg, tab 20 mg)
generic
dicyclomine hcl oral soln 10 mg/5ml
generic
DONNATAL ELIXIR 16.2 MG/5ML
BRAND
glycopyrrolate (tab 1 mg, tab 2 mg)
generic
PAGE 57
PRODUCT DESCRIPTION
BRAND/GEN
hyoscyamine sulfate (elixir 0.125 mg/5ml, soln 0.125
mg/ml, tab 0.125 mg, tab disp 0.125 mg, tab sl 0.125 mg)
generic
hyoscyamine sulfate tab sr 12hr 0.375 mg
generic
pb-hyoscy-atrop-scopol tab 16.2-0.1037-0.0194-0.0065 mg
generic
MDD
4 per day
GASTROINTESTINAL AGENTS, OTHER
PA
CHOLBAM (CAP 50 MG, CAP 250 MG)
BRAND
MDD
5 per day
diphenoxylate w/ atropine (w/ liq mg/5ml, w/ tab mg)
generic
loperamide hcl cap 2 mg
generic
paregoric tincture 2 mg/5ml
generic
ursodiol cap 300 mg
generic
MDD
3 per day
ursodiol tab 250 mg
generic
MDD
7 per day
MDD
27 per day
MPL
1 / 1 claim
HISTAMINE2 (H2) RECEPTOR ANTAGONISTS
cimetidine (tab 200 mg, tab 300 mg, tab 400 mg, tab 800
mg)
generic
cimetidine hcl soln 300 mg/5ml
generic
famotidine (tab 20 mg, tab 40 mg)
generic
ranitidine hcl (cap 150 mg, tab 150 mg, tab 300 mg)
generic
MDD
2 per day
ranitidine hcl cap 300 mg
generic
MDD
1 per day
ranitidine hcl syrup 15 mg/ml (75 mg/5ml)
generic
AL
Up to 6 yrs old
MDD
20 per day
LAXATIVES
lactulose (encephalopathy) solution 10 gm/15ml
generic
lactulose solution 10 gm/15ml
generic
peg 3350-kcl-sod bicarb-nacl for soln 420 gm
generic
MPL
1 / 1 claim
peg 3350-kcl-sod bicarb-sod chloride-sod sulfate (soln 236
gm, soln 240 gm)
generic
MPL
1 / 1 claim
PAGE 58
PRODUCT DESCRIPTION
BRAND/GEN
polyethylene glycol 3350 oral packet
generic
polyethylene glycol 3350 oral powder
generic
MDD
34 per day
PROTECTANTS
CARAFATE SUSPENSION 1 GM/10ML
QL
420 / 1 claim
AL
Up to 6 yrs old
BRAND
misoprostol (tab 100 mcg, tab 200 mcg)
generic
sucralfate tab 1 gm
generic
MDD
4 per day
PROTON PUMP INHIBITORS
PA
esomeprazole magnesium cap delayed release 20 mg
(base eq)
generic
FIRST-OMEPRAZOLE SUSPENSION 2 MG/ML
BRAND
lansoprazole cap delayed release 15 mg
generic
MDD
QL
2 per day
300 / claim(s)
PA
MDD
4 per day
PA
NEXIUM CAP DR 20 MG
BRAND
MDD
2 per day
1 Per Day
omeprazole (cap 20 mg, cap 40 mg)
generic
MDD
OMEPRAZOLE+SYRSPEND SF ALKA SUSPENSION 2
MG/ML
BRAND
QL
pantoprazole sodium ec tab 20 mg (base equiv)
generic
MDD
1 per day
pantoprazole sodium ec tab 40 mg (base equiv)
generic
MDD
2 per day
2 per day
300 / claim(s)
GENITOURINARY AGENTS
ANTISPASMODICS, URINARY
flavoxate hcl tab 100 mg
generic
oxybutynin chloride (tab 24hr 15 mg, tab 24hr 10 mg, tab
24hr 5 mg)
generic
MDD
oxybutynin chloride syrup 5 mg/5ml
generic
QL
PAGE 59
480 / 30 days
PRODUCT DESCRIPTION
BRAND/GEN
oxybutynin chloride tab 5 mg
generic
MDD
3 per day
tolterodine tartrate (cap 24hr 4 mg, cap 24hr 2 mg)
generic
MDD
1 per day
tolterodine tartrate (tab 1 mg, tab 2 mg)
generic
MDD
2 per day
trospium chloride tab 20 mg
generic
MDD
2 per day
finasteride tab 5 mg
generic
MDD
1 per day
tamsulosin hcl cap 0.4 mg
generic
MDD
2 per day
terazosin hcl (cap 1 mg, cap 2 mg, cap 5 mg, cap 10 mg)
generic
MDD
3 per day
MDD
8 per day
BENIGN PROSTATIC HYPERTROPHY AGENTS
GENITOURINARY AGENTS, OTHER
bethanechol chloride (tab 5 mg, tab 10 mg, tab 25 mg, tab
50 mg)
generic
CUPRIMINE CAP 250 MG
BRAND
ELMIRON CAP 100 MG
BRAND
phenazopyridine hcl (tab 100 mg, tab 200 mg)
generic
pot phos monobasic w/sod phos di & monobas tab 155852-130mg
generic
potassium citrate & citric acid powder pack 3300-1002 mg
generic
potassium citrate (alkalinizer) (tab 5 (540, tab 10 (1080)
generic
sodium chloride irrigation soln 0.9%
generic
sodium citrate & citric acid soln 500-334 mg/5ml
generic
QL
500 / 30 days
PHOSPHATE BINDERS
calcium acetate (phosphate binder) cap 667 mg (169 mg
ca)
generic
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)
APEXICON E CREAM 0.05 %
BRAND
MPL
1 / 1 claim
betamethasone dipropionate augmented cream 0.05%
generic
MPL
1 / 1 claim
betamethasone valerate (cream, oint)
generic
MPL
1 / 1 claim
PAGE 60
PRODUCT DESCRIPTION
BRAND/GEN
betamethasone valerate lotion 0.1%
generic
QL
clobetasol propionate (cream, gel, oint, soln)
generic
MPL
1 / 1 claim
clobetasol propionate emollient base cream 0.05%
generic
MPL
1 / 1 claim
cortisone acetate tab 25 mg
generic
DESOXIMETASONE CREAM 0.05 %
BRAND
MPL
1 / 1 claim
dexamethasone (elixir 0.5 mg/5ml, soln 0.5 mg/5ml, tab 0.5
mg, tab 0.75 mg, tab 1 mg, tab 1.5 mg, tab 2 mg, tab 4 mg,
tab 6 mg)
generic
DEXAMETHASONE INTENSOL CONC 1 MG/ML
BRAND
dexamethasone sodium phosphate (inj 4 mg/ml, inj 20
mg/5ml, inj 120 mg/30ml)
generic
QL
diflorasone diacetate (cream, oint)
generic
MPL
1 / 1 claim
fludrocortisone acetate tab 0.1 mg
generic
fluocinonide (cream, gel, oint, soln)
generic
MPL
1 / 1 claim
fluocinonide emulsified base cream 0.05%
generic
MPL
1 / 1 claim
fluticasone propionate cream 0.05%
generic
MPL
1 / 30 days
fluticasone propionate oint 0.005%
generic
MPL
1 / 1 claim
hydrocortisone (tab 5 mg, tab 10 mg, tab 20 mg)
generic
hydrocortisone butyrate soln 0.1%
generic
MPL
1 / 1 claim
methylprednisolone (tab 4 mg, tab 8 mg, tab therapy pack
4 mg (21))
generic
mometasone furoate (cream, oint, solution (lotion))
generic
MPL
1 / 1 claim
prednicarbate (cream, oint)
generic
MPL
1 / 1 claim
prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml
base)
generic
prednisolone sod phosphate oral soln 15 mg/5ml (base
equiv)
generic
prednisolone syrup 15 mg/5ml (usp solution equivalent)
generic
PAGE 61
QL
60 / 1 claim
150 / 30 days
240 / 1 claim
PRODUCT DESCRIPTION
BRAND/GEN
prednisone (oral soln 5 mg/5ml, tab 1 mg, tab 2.5 mg, tab 5
mg, tab 10 mg, tab 20 mg, tab 50 mg, tab therapy pack 5
mg (21), tab therapy pack 5 mg (48), tab therapy pack 10
mg (21), tab therapy pack 10 mg (48))
generic
PREDNISONE INTENSOL CONC 5 MG/ML
BRAND
PSORCON CREAM 0.05 %
BRAND
MPL
1 / 1 claim
TOPICORT CREAM 0.05 %
BRAND
MPL
1 / 1 claim
triamcinolone acetonide (topical) (cream 0.025%, cream
0.1%, oint 0.025%, oint 0.1%)
generic
MPL
1 / 1 claim
triamcinolone acetonide (topical) (cream, oint)
generic
QL
15 / 1 claim
triamcinolone acetonide (topical) (lotion 0.025%, lotion
0.1%)
generic
QL
60 / 1 claim
triamcinolone acetonide dental paste 0.1%
generic
QL
5 / 1 claim
VERIPRED 20 SOLUTION 20 MG/5ML
BRAND
QL
150 / 1 claim
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)
desmopressin acetate (tab 0.1 mg, tab 0.2 mg)
generic
MDD
3 per day
desmopressin acetate nasal soln 0.01% (refrigerated)
generic
QL
5 / 1 claim
desmopressin acetate nasal spray soln 0.01%
generic
QL
5 / 1 claim
desmopressin acetate nasal spray soln 0.01%
(refrigerated)
generic
QL
5 / 1 claim
NORDITROPIN FLEXPRO (SOLUTION 5 MG/1.5ML,
SOLUTION 10 MG/1.5ML, SOLUTION 15 MG/1.5ML,
SOLUTION 30 MG/3ML)
BRAND
PA
NORDITROPIN NORDIFLEX PEN SOLUTION 30 MG/3ML
BRAND
PA
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)
ANDROGENS
ANDRODERM (PATCH 24HR 4 MG/24HR, PATCH 24HR
2 MG/24HR)
BRAND
ANDROXY TAB 10 MG
BRAND
METHITEST TAB 10 MG
BRAND
PAGE 62
MDD
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
testosterone cypionate im inj in oil 200 mg/ml
generic
QL
ALORA (PATCH TW 0.025 MG/24HR, PATCH TW 0.05
MG/24HR, PATCH TW 0.075 MG/24HR, PATCH TW 0.1
MG/24HR)
BRAND
MDD
COMBIPATCH (PATCH TW 0.05-0.14 MG/DAY, PATCH
TW 0.05-0.25 MG/DAY)
BRAND
desogest-ethin est tab 0.1-0.025/0.125-0.025/0.150.025mg-mg
4 / 30 days
ESTROGENS
0.29 per day
QL
8 / 28 days
GL
Female
generic
GL
Female
desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg
generic
GL
Female
DESOGESTREL-ETHINYL ESTRADIOL TAB 0.150.02/0.01 MG (AZURETTE, KARIVA, PIMTREA,
VIORELE, CAZIANT, CESIA, VELIVET)
BRAND
GL
Female
DESOGESTREL-ETHINYL ESTRADIOL TAB 0.15-30 MGMCG (APRI, EMOQUETTE, ENSKYCE, RECLIPSEN,
SOLIA)
BRAND
GL
Female
drospirenone-ethinyl estradiol tab 3-0.03 mg
generic
GL
Female
DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG
(GIANVI, LORYNA, NIKKI, VESTURA, OCELLA, SYEDA,
ZARAH)
BRAND
GL
Female
ESTRACE CREAM 0.1 MG/GM
BRAND
QL
43 / 30 days
estradiol & norethindrone acetate (tab 0.5-0.1 mg, tab 10.5 mg)
generic
MDD
estradiol (patch 0.025 mg/24hr, patch 0.0375 mg/24hr
(37.5 mcg/24hr), patch 0.05 mg/24hr, patch 0.06 mg/24hr,
patch 0.075 mg/24hr, patch 0.1 mg/24hr)
generic
estradiol (patch 0.025 mg/24hr, patch 0.0375 mg/24hr,
patch 0.05 mg/24hr, patch 0.075 mg/24hr, patch 0.1
mg/24hr)
generic
MDD
estradiol (tab 0.5 mg, tab 1 mg, tab 2 mg)
generic
GL
Female
estropipate (tab 0.75 mg, tab 1.5 mg)
GL
generic
Female
QL
4 / 28 days
GL
Female
MDD
estropipate tab 3 mg
GL
generic
MDD
PAGE 63
1 per day
0.29 per day
1 per day
Female
2 per day
PRODUCT DESCRIPTION
BRAND/GEN
ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB
1 MG-35 MCG (KELNOR, ZOVIA)
BRAND
GL
Female
LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST
TAB 0.01MG(7) (AMETHIA, CAMRESE, DAYSEE)
BRAND
GL
Female
LEVONORGEST-ETH ESTRAD 91-DAY TAB 0.15-0.03
MG (INTROVALE, JOLESSA, QUASENSE)
BRAND
GL
Female
LEVONORGESTREL-ETH ESTRA TAB 0.05-30/0.07540/0.125-30MG (ENPRESSE, LEVONEST, MYZILRA,
TRIVORA)
BRAND
GL
Female
LEVONORGESTREL-ETHINYL ESTRAD TAB 0.1-20 MG
(AUBRA, AVIANE, DELYLA, FALMINA, LESSINA,
LUTERA, ORSYTHIA, SRONYX)
BRAND
GL
Female
LEVONORGESTREL-ETHINYL ESTRAD TAB 0.15-30 MG
(ALTAVERA, CHATEAL, KURVELO, LEVORA,
MARLISSA, PORTIA)
BRAND
GL
Female
MINIVELLE (PATCH TW 0.025 MG/24HR, PATCH TW
0.0375 MG/24HR, PATCH TW 0.05 MG/24HR, PATCH TW
0.075 MG/24HR, PATCH TW 0.1 MG/24HR)
BRAND
MDD
NECON 1/50 (28) TAB 1-50 MG-MCG
BRAND
GL
Female
NECON 10/11 (28) TAB 35 MCG
BRAND
GL
Female
NORELGESTROMIN-ETHINYL ESTRADIOL TD PTWK
150-35 MCG/24HR (XULANE)
GL
BRAND
Female
NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.4
MG-35 MCG (BALZIVA, BRIELLYN, GILDAGIA, PHILITH,
VYFEMLA, ZENCHENT)
BRAND
GL
Female
NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.5
MG-35 MCG (NECON, NORTREL, WERA)
BRAND
GL
Female
NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG35 MCG (ALYACEN, CYCLAFEM, DASETTA, NECON,
NORTREL, PIRMELLA)
BRAND
GL
Female
NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1
MG-20 MCG (GILDESS, JUNEL, LARIN, MICROGESTIN)
BRAND
GL
Female
NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB
1.5 MG-30 MCG (GILDESS, JUNEL, LARIN,
MICROGESTIN)
BRAND
GL
Female
NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE
TAB 1 MG-20 MCG (GILDESS, JUNEL, LARIN,
MICROGESTIN)
BRAND
GL
Female
PAGE 64
MPL
0.29 per day
1 / 28 day(s)
PRODUCT DESCRIPTION
BRAND/GEN
NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE
TAB 1.5 MG-30 MCG (GILDESS, JUNEL, LARIN,
MICROGESTIN)
BRAND
GL
Female
NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.7535/1-35 MG (ALYACEN, CYCLAFEM, DASETTA, NECON,
NORTREL, PIRMELLA)
BRAND
GL
Female
NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/135/0.5-35 MG (ARANELLE, LEENA)
BRAND
GL
Female
NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG35 MCG (ESTARYLLA, MONO-LINYAH, MONONESSA,
PREVIFEM, SPRINTEC)
BRAND
GL
Female
NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.21535/0.25-35 MG (TRI-ESTARYLLA, TRI-LINYAH, TRIPREVIFEM, TRI-SPRINTEC, TRINESSA)
BRAND
GL
Female
NORGESTREL & ETHINYL ESTRADIOL TAB 0.3 MG-30
MCG (CRYSELLE, ELINEST, LOW-OGESTREL)
BRAND
GL
Female
NORINYL 1+50 (28) TAB 1-50 MG-MCG
BRAND
GL
Female
QL
NUVARING RING 0.12-0.015 MG/24HR
BRAND
1 / 1 claim
GL
Female
GL
Female
GL
Female
OGESTREL TAB 0.5-50 MG-MCG
BRAND
PREMARIN (TAB 0.3 MG, TAB 0.45 MG, TAB 0.625 MG,
TAB 0.9 MG, TAB 1.25 MG)
BRAND
PREMARIN CREAM 0.625 MG/GM
BRAND
PREMPHASE TAB 0.625-5 MG
MDD
QL
43 / 30 days
GL
Female
QL
28 / 28 days
GL
Female
GL
Female
BRAND
PREMPRO (TAB 0.3-1.5 MG, TAB 0.45-1.5 MG, TAB
0.625-5 MG, TAB 0.625-2.5 MG)
BRAND
ZOVIA 1/50E (28) TAB 1-50 MG-MCG
BRAND
1 per day
MDD
1 per day
PROGESTERONE AGONISTS/ANTAGONISTS
ELLA TAB 30 MG
PAGE 65
BRAND
PRODUCT DESCRIPTION
BRAND/GEN
PROGESTINS
CRINONE (GEL 4 %, GEL 8 %)
GL
Female
AL
At least 15 yrs old
GL
Female
AL
At least 15 yrs old
Female
BRAND
DEPO-SUBQ PROVERA 104 SUSP PRSYR 104
MG/0.65ML
BRAND
ENDOMETRIN INSERT 100 MG
BRAND
levonorgestrel tab 1.5 mg
generic
GL
MAKENA OIL 250 MG/ML
BRAND
PA
medroxyprogesterone acetate (tab 2.5 mg, tab 5 mg, tab
10 mg)
generic
medroxyprogesterone acetate im susp 150 mg/ml
generic
QL
1 / 1 claim
GL
Female
medroxyprogesterone acetate im susp prefilled syr 150
mg/ml
generic
megestrol acetate (susp 40 mg/ml, tab 20 mg, tab 40 mg)
generic
norethindrone acetate tab 5 mg
generic
NORETHINDRONE TAB 0.35 MG (CAMILA, DEBLITANE,
ERRIN, HEATHER, JENCYCLA, JOLIVETTE, LYZA,
NORA-BE, NORLYROC, SHAROBEL)
BRAND
GL
Female
progesterone micronized cap 100 mg
generic
QL
30 / 30 days
progesterone micronized cap 200 mg
generic
QL
20 / 30 days
generic
MDD
SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS
raloxifene hcl tab 60 mg
1 per day
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)
ARMOUR THYROID (TAB 15 MG, TAB 30 MG, TAB 60
MG, TAB 90 MG, TAB 120 MG, TAB 180 MG, TAB 240
MG, TAB 300 MG)
PAGE 66
BRAND
PRODUCT DESCRIPTION
BRAND/GEN
levothyroxine sodium (tab 25 mcg, tab 50 mcg, tab 75 mcg,
tab 88 mcg, tab 100 mcg, tab 112 mcg, tab 125 mcg, tab
137 mcg, tab 150 mcg, tab 175 mcg, tab 200 mcg, tab 300
mcg)
generic
liothyronine sodium (tab 5 mcg, tab 25 mcg, tab 50 mcg)
generic
thyroid (tab 30 mg (1/2, tab 60 mg (1, tab 90 mg (1 1/2)
generic
THYROLAR-1 TAB 60 (12.5-50) MG (MCG)
BRAND
THYROLAR-1/2 TAB 30 (6.25-25) MG (MCG)
BRAND
THYROLAR-1/4 TAB 15 (3.1-12.5) MG (MCG)
BRAND
THYROLAR-2 TAB 120 (25-100) MG (MCG)
BRAND
THYROLAR-3 TAB 180 (37.5-150) MG (MCG)
BRAND
HORMONAL AGENTS, SUPPRESSANT (THYROID)
ANTITHYROID AGENTS
methimazole (tab 5 mg, tab 10 mg)
generic
propylthiouracil tab 50 mg
generic
SSKI SOLUTION 1 GM/ML
BRAND
IMMUNOLOGICAL AGENTS
IMMUNE SUPPRESSANTS
AZASAN (TAB 75 MG, TAB 100 MG)
BRAND
MDD
3 per day
azathioprine tab 50 mg
generic
cyclosporine (cap 25 mg, cap 100 mg)
generic
MDD
4 per day
cyclosporine modified (for microemulsion) (cap 25 mg, cap
50 mg, cap 100 mg)
generic
MDD
4 per day
cyclosporine modified oral soln 100 mg/ml
generic
MDD
8 per day
ENBREL (SOLN PRSYR 25 MG/0.5ML, SOLN PRSYR 50
MG/ML)
BRAND
PA
ENBREL RECON SOLN 25 MG
BRAND
ENBREL SURECLICK SOLN A-INJ 50 MG/ML
BRAND
PA
HUMIRA (PREF SY KT 20 MG/0.4ML, PREF SY KT 40
MG/0.8ML)
BRAND
PA
PAGE 67
PRODUCT DESCRIPTION
BRAND/GEN
HUMIRA PEDIATRIC CROHNS START PREF SY KT 40
MG/0.8ML
BRAND
PA
HUMIRA PEN PEN KIT 40 MG/0.8ML
BRAND
PA
HUMIRA PEN-CROHNS STARTER PEN KIT 40
MG/0.8ML
BRAND
PA
HUMIRA PEN-PSORIASIS STARTER PEN KIT 40
MG/0.8ML
BRAND
PA
methotrexate sodium (inj 50 mg/2ml (25 mg/ml), inj 250
mg/10ml (25 mg/ml), inj pf 50 mg/2ml (25 mg/ml), inj pf 100
mg/4ml (25 mg/ml), inj pf 200 mg/8ml (25 mg/ml), inj pf 250
mg/10ml (25 mg/ml), inj pf 1000 mg/40ml (25 mg/ml), tab
2.5 mg (base equiv))
generic
mycophenolate mofetil cap 250 mg
generic
MDD
2 per day
mycophenolate mofetil for oral susp 200 mg/ml
generic
MDD
15 per day
mycophenolate mofetil tab 500 mg
generic
MDD
4 per day
mycophenolate sodium tab dr 180 mg (mycophenolic acid
equiv)
generic
MDD
2 per day
mycophenolate sodium tab dr 360 mg (mycophenolic acid
equiv)
generic
MDD
4 per day
RAPAMUNE SOLUTION 1 MG/ML
BRAND
MDD
4 per day
RHEUMATREX TAB 2.5 MG
BRAND
SANDIMMUNE SOLUTION 100 MG/ML
BRAND
MDD
8 per day
sirolimus tab 0.5 mg
generic
sirolimus tab 1 mg
generic
MDD
6 per day
sirolimus tab 2 mg
generic
MDD
2 per day
tacrolimus (cap 0.5 mg, cap 1 mg, cap 5 mg)
generic
MDD
3 per day
TREXALL (TAB 5 MG, TAB 7.5 MG, TAB 10 MG, TAB 15
MG)
BRAND
IMMUNIZING AGENTS, PASSIVE
HYPERRHO S/D SOLN PRSYR 1500 UNIT
BRAND
RHOGAM ULTRA-FILTERED PLUS SOLN PRSYR 1500
UNIT
BRAND
PAGE 68
PRODUCT DESCRIPTION
BRAND/GEN
IMMUNOMODULATORS
leflunomide (tab 10 mg, tab 20 mg)
generic
MDD
1 per day
balsalazide disodium cap 750 mg
generic
MDD
9 per day
DELZICOL CAP DR 400 MG
BRAND
MDD
6 per day
mesalamine enema 4 gm
generic
MDD
60 per day
PENTASA (CAP ER 250 MG, CAP ER 500 MG)
BRAND
MDD
8 per day
SFROWASA ENEMA 4 GM/60ML
BRAND
INFLAMMATORY BOWEL DISEASE AGENTS
AMINOSALICYLATES
GLUCOCORTICOIDS
hydrocortisone enema 100 mg/60ml
generic
QL
hydrocortisone rectal cream 2.5%
generic
MPL
1 / 1 claim
420 / 1 claim
SULFONAMIDES
sulfasalazine (tab 500 mg, tab delayed release 500 mg)
generic
METABOLIC BONE DISEASE AGENTS
alendronate sodium (tab 35 mg, tab 70 mg)
generic
MDD
0.15 per day
alendronate sodium (tab 5 mg, tab 10 mg, tab 40 mg)
generic
MDD
1 per day
alendronate sodium oral soln 70 mg/75ml
generic
MDD
10.8 per day
calcitonin (salmon) nasal soln 200 unit/act
generic
QL
4 / 30 days
calcitriol (cap 0.25 mcg, cap 0.5 mcg)
generic
FORTICAL SOLUTION 200 UNIT/ACT
BRAND
QL
4 / 30 days
MIACALCIN SOLUTION 200 UNIT/ML
BRAND
QL
2 / 30 days
risedronate sodium (tab 5 mg, tab 30 mg)
generic
PA
MDD
PAGE 69
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
risedronate sodium tab 35 mg
generic
QL
4 / 28 days
PA
MISCELLANEOUS THERAPEUTIC AGENTS
*lancet devices***
generic
QL
1 / 180 days
*lancets***
generic
QL
200 / 30 days
1ST CHOICE LANCETS SUPER THIN MISC
BRAND
QL
200 / 30 days
1ST CHOICE LANCETS THIN MISC
BRAND
QL
200 / 30 days
1ST CHOICE LANCETS ULTRA THIN MISC
BRAND
QL
200 / 30 days
1ST TIER UNILET COMFORTOUCH MISC
BRAND
QL
200 / 30 days
ACCU-CHEK SOFT TOUCH LANCETS MISC
BRAND
QL
200 / 30 days
ACCU-CHEK SOFTCLIX LANCET DEV MISC
BRAND
QL
1 / 180 days
ACE AEROSOL CLOUD ENHANCER MISC
BRAND
QL
1 / 360 days
ADJUSTABLE LANCING DEVICE MISC
BRAND
QL
1 / 180 days
ADVOCATE INSULIN SYRINGE (MISC 29G 1/2" 0.3 ML,
MISC 29G 1/2" 1 ML, MISC 30G 5/16" 0.5 ML)
BRAND
MDD
ADVOCATE INSULIN SYRINGE (MISC 29G 1/2" 0.5 ML,
MISC 30G 5/16" 0.3 ML, MISC 31G 5/16" 1 ML)
BRAND
ADVOCATE LANCING DEVICE MISC
BRAND
QL
1 / 180 days
ADVOCATE RAPID-SAFE LANCING MISC
BRAND
QL
1 / 180 days
AEROCHAMBER PLUS FLO-VU LARGE MISC
BRAND
QL
2 / 360 days
AEROCHAMBER PLUS FLO-VU MISC
BRAND
QL
2 / 360 days
AEROCHAMBER PLUS FLO-VU SMALL MISC
BRAND
QL
2 / 360 days
AEROCHAMBER PLUS FLO-VU W/MASK MISC
BRAND
QL
2 / 360 days
AF LANCETS SUPER THIN MISC
BRAND
QL
200 / 30 days
AGAMATRIX ULTRA-THIN LANCETS MISC
BRAND
QL
200 / 30 days
ALTERNATE SITE LANCING DEVICE MISC
BRAND
QL
1 / 180 days
PAGE 70
5 per day
PRODUCT DESCRIPTION
BRAND/GEN
ANTI-STICK INSULIN SYRINGE MISC 29G X 1/2" 1 ML
BRAND
MDD
AQUA LANCE ADJUSTABLE LANCING DEVICE
BRAND
QL
ASSURE ID INSULIN SAFETY SYR MISC 29G X 1/2" 0.5
ML
BRAND
ASSURE ID INSULIN SAFETY SYR MISC 29G X 1/2" 1
ML
BRAND
MDD
AURORA LANCET SUPER THIN 30G MISC
BRAND
QL
200 / 30 days
AURORA LANCET THIN 23G MISC
BRAND
QL
200 / 30 days
AUTO-LANCET MINI MISC
BRAND
QL
1 / 180 days
AUTO-LANCET MISC
BRAND
QL
1 / 180 days
AUTOLET IMPRESSION MISC
BRAND
QL
1 / 180 days
AUTOLET LANCING DEVICE MISC
BRAND
QL
1 / 180 days
AUTOLET MINI MISC
BRAND
QL
1 / 180 days
BAYER MICROLET 2 LANCING DEVIC MISC
BRAND
QL
1 / 180 days
BD AUTOSHIELD MISC 29G X 8MM
BRAND
MDD
5 per day
BD INSULIN SYR ULTRAFINE II MISC 31G X 5/16" 1 ML
BRAND
BD INSULIN SYRINGE (MISC 26G 1/2" 1 ML, MISC 29G
1/2" 0.5 ML)
BRAND
BD INSULIN SYRINGE (MISC 28G 1/2" 1 ML, MISC 29G
1/2" 1 ML)
BRAND
MDD
5 per day
BD INSULIN SYRINGE MICROFINE (MISC 1/2" 1 ML,
MISC 1/2" 0.3 ML, MISC 1/2" 0.5 ML)
BRAND
MDD
5 per day
BD INSULIN SYRINGE MICROFINE MISC 27G X 5/8" 1
ML
BRAND
BD INSULIN SYRINGE ULTRAFINE (MISC 1/2" 0.3 ML,
MISC 1/2" 1 ML)
BRAND
MDD
5 per day
BD INSULIN SYRINGE ULTRAFINE (MISC 29G 1/2" 0.5
ML, MISC 31G 15/64" 1 ML, MISC 31G 5/16" 1 ML)
BRAND
BD INTEGRA INSULIN SYRINGE MISC 29G X 1/2" 1 ML
BRAND
MDD
5 per day
BD LANCET DEVICE MISC
BRAND
QL
PAGE 71
5 per day
1 / 180 days
5 per day
1 / 180 days
PRODUCT DESCRIPTION
BRAND/GEN
BD LANCET ULTRAFINE 30G MISC
BRAND
QL
BD SAFETY-LOK INSULIN SYRINGE MISC 29G X 1/2" 1
ML
BRAND
MDD
5 per day
BD SAFETYGLIDE INSULIN SYRINGE MISC 29G X 1/2"
0.5 ML
BRAND
BD SAFETYGLIDE INSULIN SYRINGE MISC 30G X 5/16"
0.5 ML
BRAND
MDD
5 per day
CARDIOCOM LANCING DEVICE MISC
BRAND
QL
1 / 180 days
CAREONE ADVANCED LANCING DEV MISC
BRAND
QL
1 / 180 days
CAREONE INSULIN SYRINGE MISC 31G X 5/16" 1 ML
BRAND
CAREONE LANCET THIN 23G MISC
BRAND
QL
200 / 30 days
CAREONE LANCET ULTRA THIN 28G MISC
BRAND
QL
200 / 30 days
CAREONE ULTIGUARD INSULIN SYR (MISC 29G 1/2"
0.5 ML, MISC 30G 5/16" 0.3 ML)
BRAND
CAREONE ULTIGUARD INSULIN SYR (MISC 29G 1/2" 1
ML, MISC 29G 1/2" 0.3 ML, MISC 30G 5/16" 0.5 ML)
BRAND
MDD
CHEK-STIX CONTROL STRIP
BRAND
QL
1 / 30 days
CHEMSTRIP K STRIP
BRAND
QL
1 / 30 days
CLEANLET LANCETS 28G MISC
BRAND
QL
200 / 30 days
CLOSERCARE MISC
BRAND
QL
1 / 180 days
COMFORT ASSIST INSULIN SYRINGE (MISC 29G 1/2"
0.5 ML, MISC 30G 5/16" 0.3 ML, MISC 31G 5/16" 1 ML)
BRAND
COMFORT ASSIST INSULIN SYRINGE (MISC 29G 1/2" 1
ML, MISC 29G 1/2" 0.3 ML, MISC 30G 5/16" 0.5 ML)
BRAND
MDD
COMFORT ASSURED LANCETS 28G MISC
BRAND
QL
200 / 30 days
COMFORT ASSURED LANCETS 33G MISC
BRAND
QL
200 / 30 days
COMFORT EZ INSULIN SYRINGE (MISC 28G 1/2" 1 ML,
MISC 28G 1/2" 0.5 ML, MISC 29G 1/2" 1 ML, MISC 29G
1/2" 0.3 ML, MISC 30G 5/16" 0.5 ML)
BRAND
MDD
COMFORT EZ INSULIN SYRINGE (MISC 29G 1/2" 0.5
ML, MISC 30G 5/16" 0.3 ML, MISC 31G 5/16" 1 ML)
BRAND
PAGE 72
200 / 30 days
5 per day
5 per day
5 per day
PRODUCT DESCRIPTION
BRAND/GEN
COMFORT LANCETS MISC
BRAND
QL
CVS INSULIN SYRINGE (MISC 1/2" 1 ML, MISC 1/2" 0.3
ML)
BRAND
MDD
CVS INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML
BRAND
CVS LANCETS 21G MISC
BRAND
QL
200 / 30 days
CVS LANCETS MICRO THIN 33G MISC
BRAND
QL
200 / 30 days
CVS LANCETS ORIGINAL MISC
BRAND
QL
200 / 30 days
CVS LANCETS THIN 26G MISC
BRAND
QL
200 / 30 days
CVS LANCETS THIN MISC
BRAND
QL
200 / 30 days
CVS LANCETS ULTRA THIN 30G MISC
BRAND
QL
200 / 30 days
CVS LANCING DEVICE MISC
BRAND
QL
1 / 180 days
CVS ULTRA THIN LANCETS MISC
BRAND
QL
200 / 30 days
DIASTAR EASY TEST II LANCETS MISC
BRAND
QL
200 / 30 days
DIASTAR EASY TEST LANCETS MISC
BRAND
QL
200 / 30 days
DROPLET LANCETS ULTRA THIN 30G MISC
BRAND
QL
200 / 30 days
DROPLET LANCING DEVICE MISC
BRAND
QL
1 / 180 days
DRUG MART LANCETS THIN 26G MISC
BRAND
QL
200 / 30 days
DRUG MART LANCETS ULTRA THIN MISC
BRAND
QL
200 / 30 days
DRUG MART LANCING DEVICE MISC
BRAND
QL
1 / 180 days
DRUG MART ULTRA COMFORT SYR (MISC 29G 1/2" 0.3
ML, MISC 29G 1/2" 1 ML, MISC 30G 5/16" 0.5 ML)
BRAND
MDD
DRUG MART ULTRA COMFORT SYR MISC 30G X 5/16"
0.3 ML
BRAND
DRUG MART UNILET LANCETS 28G MISC
BRAND
QL
200 / 30 days
DRUG MART UNILET LANCETS 30G MISC
BRAND
QL
200 / 30 days
DUANE READE LANCET ALTERN SITE MISC
BRAND
QL
200 / 30 days
PAGE 73
200 / 30 days
5 per day
5 per day
PRODUCT DESCRIPTION
BRAND/GEN
DUANE READE LANCET SUPER THIN MISC
BRAND
QL
200 / 30 days
DUANE READE LANCET ULTRA THIN MISC
BRAND
QL
200 / 30 days
E-Z JECT LANCET MICRO-THIN 33G MISC
BRAND
QL
200 / 30 days
E-Z JECT LANCET SUPER THIN 30G MISC
BRAND
QL
200 / 30 days
E-Z JECT LANCETS 21G MISC
BRAND
QL
200 / 30 days
E-Z JECT LANCETS MISC
BRAND
QL
200 / 30 days
E-Z JECT LANCETS THIN 26G MISC
BRAND
QL
200 / 30 days
E-Z SPACER DEVICE
BRAND
QL
2 / 360 days
E-Z SPACER THE BODY GUARDS PK DEVICE
BRAND
QL
2 / 360 days
EASIVENT MASK LARGE MISC
BRAND
QL
2 / 360 days
EASIVENT MASK MEDIUM MISC
BRAND
QL
2 / 360 days
EASIVENT MASK SMALL MISC
BRAND
QL
2 / 360 days
EASIVENT MISC
BRAND
QL
2 / 360 days
EASY COMFORT INSULIN SYRINGE MISC 30G X 5/16"
0.3 ML
BRAND
EASY COMFORT INSULIN SYRINGE MISC 30G X 5/16"
0.5 ML
BRAND
MDD
EASY MINI LANCING DEVICE MISC
BRAND
QL
EASY TOUCH INSULIN SAFETY SYR (MISC 29G 1/2" 1
ML, MISC 30G 5/16" 0.5 ML)
BRAND
MDD
5 per day
EASY TOUCH INSULIN SAFETY SYR MISC 29G X 1/2"
0.5 ML
BRAND
EASY TOUCH INSULIN SYRINGE (MISC 28G 1/2" 0.5
ML, MISC 28G 1/2" 1 ML, MISC 29G 1/2" 1 ML, MISC 30G
5/16" 0.5 ML)
BRAND
MDD
5 per day
EASY TOUCH INSULIN SYRINGE (MISC 29G 1/2" 0.5
BRAND
EASY TOUCH LANCETS 26G MISC
BRAND
QL
200 / 30 days
EASY TOUCH LANCETS 26G/TWIST MISC
BRAND
QL
200 / 30 days
PAGE 74
5 per day
1 / 180 days
PRODUCT DESCRIPTION
BRAND/GEN
BRAND
QL
200 / 30 days
BRAND
QL
200 / 30 days
BRAND
QL
200 / 30 days
BRAND
QL
200 / 30 days
BRAND
QL
200 / 30 days
BRAND
QL
200 / 30 days
BRAND
QL
200 / 30 days
EASY TOUCH LANCING DEVICE MISC
BRAND
QL
1 / 180 days
EQL COLOR LANCETS 21G MISC
BRAND
QL
200 / 30 days
EQL COLOR LANCETS MICRO 33G MISC
BRAND
QL
200 / 30 days
EQL INSULIN SYRINGE (MISC 29G 1/2" 0.3 ML, MISC
29G 1/2" 1 ML, MISC 30G 5/16" 0.5 ML)
BRAND
MDD
EQL INSULIN SYRINGE (MISC 29G 1/2" 0.5 ML, MISC
30G 5/16" 0.3 ML, MISC 31G 5/16" 1 ML)
BRAND
EQL SUPER THIN LANCETS 30G MISC
BRAND
QL
200 / 30 days
EQL THIN LANCETS 26G MISC
BRAND
QL
200 / 30 days
EXEL COMFORT POINT INSULIN SYR (EEL MISC 28G
1/2" 1 ML, EEL MISC 28G 1/2" 0.5 ML, EEL MISC 29G
1/2" 1 ML, EEL MISC 29G 1/2" 0.3 ML, EEL MISC 30G
5/16" 0.5 ML)
BRAND
MDD
EXEL COMFORT POINT INSULIN SYR (EEL MISC 29G
1/2" 0.5 ML, EEL MISC 30G 5/16" 0.3 ML)
BRAND
EZ SMART BLOOD GLUCOSE LANCETS MISC
BRAND
QL
200 / 30 days
EZ-LETS LANCETS 21G MISC
BRAND
QL
200 / 30 days
BRAND
QL
200 / 30 days
BRAND
QL
200 / 30 days
BRAND
QL
200 / 30 days
BRAND
QL
200 / 30 days
PAGE 75
5 per day
5 per day
PRODUCT DESCRIPTION
BRAND/GEN
FIFTY50 LANCING DEVICE MISC
BRAND
FIFTY50 SUPERIOR COMFORT SYR MISC 31G X 5/16"
1 ML
BRAND
FLEXICHAMBER DEVICE
QL
1 / 180 days
BRAND
QL
2 / 360 days
FORA LANCETS MISC
BRAND
QL
200 / 30 days
FORA LANCING DEVICE MISC
BRAND
QL
1 / 180 days
FORA TN'G VOICE KIT W/DEVICE
BRAND
formaldehyde solution 10%
generic
QL
90 / 1 claim
FREDS PHARMACY AUTOLET LANCING MISC
BRAND
QL
1 / 180 days
FREDS PHARMACY UNILET LANC 28G MISC
BRAND
QL
200 / 30 days
FREDS PHARMACY UNILET LANC 30G MISC
BRAND
QL
200 / 30 days
FREESTYLE PRECISION INS SYR MISC 30G X 5/16" 0.5
ML
BRAND
MDD
5 per day
FREESTYLE PRECISION INS SYR MISC 31G X 5/16" 1
ML
BRAND
GLOBAL INJECT EASE INSULIN SYR (MISC 28G 1/2" 1
ML, MISC 28G 1/2" 0.5 ML, MISC 29G 1/2" 0.3 ML, MISC
29G 1/2" 1 ML, MISC 30G 5/16" 0.5 ML)
BRAND
MDD
5 per day
GLOBAL INJECT EASE INSULIN SYR (MISC 29G 1/2" 0.5
BRAND
GLOBAL LANCING DEVICE MISC
BRAND
QL
1 / 180 days
GLUCOCOM LANCETS 28G MISC
BRAND
QL
200 / 30 days
GLUCOCOM LANCETS 30G MISC
BRAND
QL
200 / 30 days
GLUCOLET 2 AUTOMATIC LANCING MISC
BRAND
QL
1 / 180 days
GLUCOPRO INSULIN SYRINGE (MISC 30G 5/16" 0.3 ML,
MISC 31G 5/16" 1 ML)
BRAND
GLUCOPRO INSULIN SYRINGE MISC 30G X 5/16" 0.5
ML
BRAND
MDD
GLUCOSOURCE LANCET DEVICE MISC
BRAND
QL
PAGE 76
5 per day
1 / 180 days
PRODUCT DESCRIPTION
BRAND/GEN
GLUCOSOURCE LANCETS MISC
BRAND
QL
GNP INSULIN SYRINGE (MISC 28G 1/2" 1 ML, MISC 28G
1/2" 0.5 ML, MISC 29G 1/2" 1 ML, MISC 29G 1/2" 0.3 ML,
MISC 30G 5/16" 0.5 ML)
BRAND
MDD
GNP INSULIN SYRINGE (MISC 29G 1/2" 0.5 ML, MISC
30G 5/16" 0.3 ML, MISC 31G 5/16" 1 ML)
BRAND
GNP LANCETS 21G MISC
BRAND
QL
200 / 30 days
GNP LANCETS MICRO THIN 33G MISC
BRAND
QL
200 / 30 days
GNP LANCETS MISC
BRAND
QL
200 / 30 days
GNP LANCETS SUPER THIN 30G MISC
BRAND
QL
200 / 30 days
GNP LANCETS THIN 26G MISC
BRAND
QL
200 / 30 days
GNP LANCETS THIN MISC
BRAND
QL
200 / 30 days
GNP MICRO THIN LANCETS 33G MISC
BRAND
QL
200 / 30 days
GNP SUPER THIN LANCETS 30G MISC
BRAND
QL
200 / 30 days
GNP ULTRA COM INSULIN SYRINGE (MISC 28G 1/2" 1
29G 1/2" 1 ML, MISC 30G 5/16" 0.5 ML)
BRAND
MDD
GNP ULTRA COM INSULIN SYRINGE (MISC 29G 1/2"
BRAND
H&H THINLET LANCETS 26G MISC
BRAND
QL
200 / 30 days
H&H THINLET LANCETS 30G MISC
BRAND
QL
200 / 30 days
H-E-B INCONTROL ADV LANCING MISC
BRAND
QL
1 / 180 days
H-E-B INCONTROL LANCETS 28G MISC
BRAND
QL
200 / 30 days
BRAND
QL
200 / 30 days
BRAND
QL
200 / 30 days
HEALTH CARE LANCING DEVICE MISC
BRAND
QL
1 / 180 days
HEALTHWISE LANCING PEN MISC
BRAND
QL
1 / 180 days
HEALTHY ACCENTS LANCING DEVICE MISC
BRAND
QL
1 / 180 days
PAGE 77
200 / 30 days
5 per day
5 per day
PRODUCT DESCRIPTION
BRAND/GEN
HEALTHY ACCENTS UNILET LANCETS MISC
BRAND
QL
200 / 30 days
HM LANCETS MICRO THIN 33G MISC
BRAND
QL
200 / 30 days
HM LANCETS ULTRA THIN 30G MISC
BRAND
QL
200 / 30 days
HY-VEE LANCETS MISC
BRAND
QL
200 / 30 days
HY-VEE THIN LANCETS MISC
BRAND
QL
200 / 30 days
IN TOUCH LANCING DEVICE MISC
BRAND
QL
1 / 180 days
INSPIRACHAMBER/MEDIUM DEVICE
BRAND
QL
2 / 360 days
INSPIRACHAMBER/MOUTHPIECE DEVICE
BRAND
QL
2 / 360 days
INSPIRACHAMBER/SMALL DEVICE
BRAND
QL
2 / 360 days
INSPIREASE BAGS MISC
BRAND
QL
3 / 180 days
INSPIREASE MISC
BRAND
QL
2 / 360 days
INSPIREASE MOUTHPIECE MISC
BRAND
QL
1 / 180 days
INSPIREASE RESERVOIR BAGS MISC
BRAND
QL
3 / 180 days
insulin pen needle 29 g x 12 mm (1/2")
generic
MDD
5 per day
insulin pen needle 29 g x 12.7 mm
generic
MDD
5 per day
insulin pen needle 30 g x 8 mm (1/3" or 5/16")
generic
MDD
5 per day
generic
MDD
5 per day
generic
MDD
5 per day
generic
MDD
5 per day
generic
MDD
5 per day
generic
MDD
5 per day
generic
insulin syringe (disp) u-100 1 ml
generic
MDD
5 per day
INSULIN SYRINGE (MISC 28G 1/2" 0.5 ML, MISC 28G
1/2" 1 ML, MISC 29G 1/2" 1 ML, MISC 29G 1/2" 0.3 ML,
MISC 30G 5/16" 0.5 ML)
BRAND
MDD
5 per day
PAGE 78
PRODUCT DESCRIPTION
BRAND/GEN
INSULIN SYRINGE (MISC 29G 1" 0.3 ML, MISC 29G 1/2"
0.5 ML, MISC 31G 5/16" 1 ML)
BRAND
INSULIN SYRINGE/NEEDLE (SYRINGE/NEEDLE MISC
1/2" 1 ML, SYRINGE/NEEDLE MISC 1/2" 0.5 ML)
BRAND
MDD
5 per day
insulin syringe/needle u-100 (syringe/needle 0.3 ml 29 1/2",
syringe/needle 1/2 ml 28 1/2", syringe/needle 1 ml 28 1/2",
syringe/needle 1/2 ml 30 5/16", syringe/needle 1 ml 29
1/2")
generic
MDD
5 per day
insulin syringe/needle u-100 (syringe/needle 0.3 ml 30
5/16", syringe/needle 1/2 ml 29 1/2", syringe/needle 1 ml
31 5/16")
generic
insulin syringe/needle u-100 0.3 ml 30 x 1/2"
generic
MDD
5 per day
generic
generic
MDD
5 per day
insulin syringe/needle u-100 1 ml 25 x 1"
generic
MDD
5 per day
insulin syringe/needle u-100 1 ml 25 x 5/8"
generic
MDD
5 per day
generic
MDD
5 per day
generic
MDD
5 per day
generic
MDD
5 per day
insulin syringe/needle u-100 1/2 ml 27 x 1/2"
generic
MDD
5 per day
generic
MDD
5 per day
generic
MDD
5 per day
generic
KETOCARE STRIP
BRAND
QL
1 / 30 days
KETOSTIX STRIP
BRAND
QL
1 / 30 days
KINNEY LANCETS MISC
BRAND
QL
200 / 30 days
KINNEY THIN LANCETS MISC
BRAND
QL
200 / 30 days
KINRAY INSULIN SYRINGE (MISC 29G 1/2" 0.5 ML,
MISC 31G 5/16" 1 ML)
BRAND
PAGE 79
PRODUCT DESCRIPTION
BRAND/GEN
KROGER INSULIN SYRINGE (MISC 29G 1/2" 0.5 ML,
MISC 30G 5/16" 0.3 ML, MISC 31G 5/16" 1 ML)
BRAND
KROGER INSULIN SYRINGE (MISC 29G 1/2" 1 ML, MISC
29G 1/2" 0.3 ML, MISC 30G 5/16" 0.5 ML)
BRAND
MDD
KROGER LANCETS 21G MISC
BRAND
QL
200 / 30 days
KROGER LANCETS MICRO THIN 33G MISC
BRAND
QL
200 / 30 days
KROGER LANCETS MISC
BRAND
QL
200 / 30 days
KROGER LANCETS SUPER THIN MISC
BRAND
QL
200 / 30 days
KROGER LANCETS THIN 26G MISC
BRAND
QL
200 / 30 days
KROGER LANCETS THIN MISC
BRAND
QL
200 / 30 days
KROGER LANCETS ULTRATHIN 30G MISC
BRAND
QL
200 / 30 days
KROGER LANCING DEVICE MISC
BRAND
QL
1 / 180 days
LADY LITE LANCETS MISC
BRAND
QL
200 / 30 days
LANCET DEVICE MISC
BRAND
QL
1 / 180 days
LANCET DEVICE WITH EJECTOR MISC
BRAND
QL
1 / 180 days
LANCETS 28G MISC
BRAND
QL
200 / 30 days
LANCETS 30G MISC
BRAND
QL
200 / 30 days
LANCETS MISC
BRAND
QL
200 / 30 days
LANCETS THIN MISC
BRAND
QL
200 / 30 days
LANCETS ULTRA THIN MISC
BRAND
QL
200 / 30 days
LANCING DEVICE MISC
BRAND
QL
1 / 180 days
LANZO MISC
BRAND
QL
1 / 180 days
LEADER ADVANCED LANCING DEVICE MISC
BRAND
QL
1 / 180 days
LEADER INSULIN SYRINGE (MISC 28G 1/2" 1 ML, MISC
28G 1/2" 0.5 ML, MISC 29G 1/2" 0.3 ML, MISC 29G 1/2" 1
ML, MISC 30G 5/16" 0.5 ML)
BRAND
MDD
LEADER INSULIN SYRINGE (MISC 29G 1/2" 0.5 ML,
MISC 30G 5/16" 0.3 ML, MISC 31G 5/16" 1 ML)
BRAND
PAGE 80
5 per day
5 per day
PRODUCT DESCRIPTION
BRAND/GEN
LIBERTY MINI LANCING DEVICE MISC
BRAND
QL
1 / 180 days
LITE TOUCH LANCING DEVICE MISC
BRAND
QL
1 / 180 days
LITE TOUCH LANCING PEN MISC
BRAND
QL
1 / 180 days
LITETOUCH INSULIN SYRINGE (MISC 28G 1/2" 0.5 ML,
MISC 28G 1/2" 1 ML, MISC 29G 1/2" 1 ML, MISC 29G 1/2"
0.3 ML, MISC 30G 5/16" 0.5 ML)
BRAND
MDD
LITETOUCH INSULIN SYRINGE (MISC 29G 1/2" 0.5 ML,
MISC 30G 5/16" 0.3 ML, MISC 31G 5/16" 1 ML)
BRAND
LIVE BETTER ADV LANCING DEVICE MISC
BRAND
QL
1 / 180 days
LIVE BETTER LANCET SUPER THIN MISC
BRAND
QL
200 / 30 days
LIVE BETTER LANCET ULTRA THIN MISC
BRAND
QL
200 / 30 days
LONGS LANCETS STANDARD MISC
BRAND
QL
200 / 30 days
LONGS LANCETS THIN MISC
BRAND
QL
200 / 30 days
MAGELLAN INSULIN SAFETY SYR (MISC 29G 1/2" 0.3
ML, MISC 29G 1/2" 1 ML, MISC 30G 5/16" 0.5 ML)
BRAND
MDD
MAGELLAN INSULIN SAFETY SYR (MISC 29G 1/2" 0.5
ML, MISC 30G 5/16" 0.3 ML)
BRAND
MAJOR COMFORT LANCETS MISC
BRAND
QL
MAXI-COMFORT INSULIN SYRINGE (MAI-COMFORT
MISC 1/2" 0.5 ML, MAI-COMFORT MISC 1/2" 1 ML)
BRAND
MDD
MEDI-LANCE LANCETS MISC
BRAND
QL
MEDIC INSULIN SYRINGE MISC 30G X 5/16" 0.3 ML
BRAND
MEDIC INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML
BRAND
MDD
MEDICINE SHOPPE LANCETS MISC
BRAND
QL
200 / 30 days
MEDICINE SHOPPE LANCETS THIN MISC
BRAND
QL
200 / 30 days
MEDISENSE THIN LANCETS MISC
BRAND
QL
200 / 30 days
MEIJER LANCETS MISC
BRAND
QL
200 / 30 days
MEIJER LANCETS THIN MISC
BRAND
QL
200 / 30 days
PAGE 81
5 per day
5 per day
200 / 30 days
5 per day
200 / 30 days
5 per day
PRODUCT DESCRIPTION
BRAND/GEN
MEIJER LANCETS UNIVERSAL 30G MISC
BRAND
QL
200 / 30 days
MEIJER LANCETS UNIVERSAL 33G MISC
BRAND
QL
200 / 30 days
MEIJER SUPER THIN LANCETS MISC
BRAND
QL
200 / 30 days
methylergonovine maleate tab 0.2 mg
generic
MINI LANCING DEVICE MISC
BRAND
QL
1 / 180 days
MONOJECT INSULIN SYRINGE (MISC 28G 1/2" 0.5 ML,
0.3 ML, MISC 30G 5/16" 0.5 ML)
BRAND
MDD
5 per day
MONOJECT INSULIN SYRINGE (MISC 29G 1/2" 0.5 ML,
MISC 30G 5/16" 0.3 ML, MISC 31G 5/16" 1 ML)
BRAND
MONOJECT ULTRA COMFORT SYRINGE (MISC 28G
1/2" 0.5 ML, MISC 28G 1/2" 1 ML, MISC 29G 1/2" 0.3 ML,
MISC 29G 1/2" 1 ML, MISC 30G 5/16" 0.5 ML)
BRAND
MDD
5 per day
MONOJECT ULTRA COMFORT SYRINGE (MISC 29G
1/2" 0.5 ML, MISC 30G 5/16" 0.3 ML)
BRAND
MONOLET LANCETS MISC
BRAND
QL
200 / 30 days
MONOLET OPD LANCETS MISC
BRAND
QL
200 / 30 days
MOORE MONO INSULIN SYRINGE (MISC 28G 1/2" 1 ML,
MISC 28G 1/2" 0.5 ML, MISC 29G 1/2" 1 ML)
BRAND
MDD
5 per day
MOORE MONO INSULIN SYRINGE MISC 29G X 1/2" 0.5
ML
BRAND
MS INSULIN SYRINGE (MISC 29G 1/2" 0.3 ML, MISC
29G 1/2" 1 ML, MISC 30G 5/16" 0.5 ML)
BRAND
MDD
5 per day
MS INSULIN SYRINGE (MISC 29G 1/2" 0.5 ML, MISC
30G 5/16" 0.3 ML, MISC 31G 5/16" 1 ML)
BRAND
NOVA SUREFLEX LANCETS MISC
BRAND
QL
200 / 30 days
NOVA SUREFLEX LANCING DEVICE MISC
BRAND
QL
1 / 180 days
ON CALL LANCING DEVICE MISC
BRAND
QL
1 / 180 days
ON CALL PLUS LANCING DEVICE MISC
BRAND
QL
1 / 180 days
ONETOUCH DELICA LANCING DEV MISC
BRAND
QL
1 / 180 days
ONETOUCH LANCETS MISC
BRAND
QL
200 / 30 days
PAGE 82
PRODUCT DESCRIPTION
BRAND/GEN
ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE
BRAND
ORSINI INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML
BRAND
ORSINI INSULIN SYRINGE MISC 30G X 5/16" 0.5 ML
BRAND
ORTHO DIAPHRAGM ALL-FLEX (DIAPHRAGM
DIAPHRAGM 65, DIAPHRAGM DIAPHRAGM 70,
DIAPHRAGM DIAPHRAGM 75, DIAPHRAGM
DIAPHRAGM 80)
BRAND
ORTHO DIAPHRAGM COIL (DIAPHRAGM KIT 100,
DIAPHRAGM KIT 105)
BRAND
QL
1 / 180 days
ORTHO DIAPHRAGM COIL KIT 50 MM
BRAND
QL
1 / 365 days
ORTHO DIAPHRAGM FLAT (DIAPHRAGM KIT 55,
DIAPHRAGM KIT 60, DIAPHRAGM KIT 65, DIAPHRAGM
KIT 70, DIAPHRAGM KIT 75, DIAPHRAGM KIT 80,
DIAPHRAGM KIT 85, DIAPHRAGM KIT 90, DIAPHRAGM
KIT 95)
BRAND
QL
1 / 180 days
PC LANCETS SUPER THIN 30G MISC
BRAND
QL
200 / 30 days
PERFECT LANCETS 30G MISC
BRAND
QL
200 / 30 days
PHARMACY COUNTER LANCETS MISC
BRAND
QL
200 / 30 days
PRECISION SURE-DOSE SYRINGE (MISC 1/2" 0.5 ML,
MISC 1/2" 1 ML)
BRAND
MDD
5 per day
PRECISION SURE-DOSE SYRINGE (MISC 29G 1/2" 0.5
ML, MISC 30G 5/16" 0.3 ML)
BRAND
PRECISION SUREDOSE PLUS SYR (MISC 1/2" 0.3 ML,
MISC 1/2" 1 ML)
BRAND
MDD
5 per day
PREFERRED PLUS INSULIN SYRINGE (MISC 28G 1/2" 1
ML, MISC 28G 1/2" 0.5 ML, MISC 29G 1/2" 1 ML, MISC
29G 1/2" 0.3 ML, MISC 30G 5/16" 0.5 ML)
BRAND
MDD
5 per day
PREFERRED PLUS INSULIN SYRINGE (MISC 29G 1/2"
0.5 ML, MISC 30G 5/16" 0.3 ML)
BRAND
PREFERRED PLUS LANCETS COLORED MISC
BRAND
QL
200 / 30 days
PREFERRED PLUS LANCETS THIN MISC
BRAND
QL
200 / 30 days
PRODIGY INSULIN SYRINGE MISC 28G X 1/2" 1 ML
BRAND
MDD
PRODIGY LANCING DEVICE MISC
BRAND
QL
PAGE 83
MDD
5 per day
5 per day
1 / 180 days
PRODUCT DESCRIPTION
BRAND/GEN
PRODIGY TWIST TOP LANCETS 28G MISC
BRAND
QL
200 / 30 days
PX ADVANCED LANCING DEVICE MISC
BRAND
QL
1 / 180 days
PX INSULIN SYRINGE MISC 31G X 5/16" 1 ML
BRAND
PX LANCET AUTO INJECTOR MISC
BRAND
QL
1 / 180 days
PX LANCETS MISC
BRAND
QL
200 / 30 days
PX LANCETS ULTRA THIN MISC
BRAND
QL
200 / 30 days
QC ADVANCED LANCING DEVICE MISC
BRAND
QL
1 / 180 days
QC INSULIN SYRINGE (MISC 1/2" 1 ML, MISC 1/2" 0.3
ML)
BRAND
MDD
QC INSULIN SYRINGE (MISC 29G 1/2" 0.5 ML, MISC
31G 5/16" 1 ML)
BRAND
QC LANCETS SUPER THIN 30G MISC
BRAND
QL
200 / 30 days
QC LANCETS ULTRA THIN MISC
BRAND
QL
200 / 30 days
QC UNILET LANCETS MICRO THIN MISC
BRAND
QL
200 / 30 days
RA E-ZJECT COLOR LANCETS 33G MISC
BRAND
QL
200 / 30 days
RA E-ZJECT LANCETS 28G MISC
BRAND
QL
200 / 30 days
RA E-ZJECT LANCETS THIN 26G MISC
BRAND
QL
200 / 30 days
RA E-ZJECT LANCETS THIN 28G MISC
BRAND
QL
200 / 30 days
RA E-ZJECT LANCETS ULTRA THIN MISC
BRAND
QL
200 / 30 days
RA INSULIN SYRINGE (MISC 29G 1/2" 1 ML, MISC 30G
5/16" 0.5 ML)
BRAND
MDD
RA INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML
BRAND
RA LANCING DEVICE MISC
BRAND
QL
RELI-ON INSULIN SYRINGE MISC 29G X 1/2" 1 ML
BRAND
MDD
5 per day
RELION INSULIN SYRINGE (MISC 29G 1/2" 0.3 ML,
MISC 29G 1/2" 1 ML, MISC 30G 5/16" 0.5 ML)
BRAND
MDD
5 per day
RELION INSULIN SYRINGE (MISC 29G 1/2" 0.5 ML,
MISC 30G 5/16" 0.3 ML, MISC 31G 5/16" 1 ML)
BRAND
PAGE 84
5 per day
5 per day
1 / 180 days
PRODUCT DESCRIPTION
BRAND/GEN
RELION LANCETS MICRO-THIN 33G MISC
BRAND
QL
200 / 30 days
RELION LANCETS STANDARD 21G MISC
BRAND
QL
200 / 30 days
RELION LANCETS THIN 26G MISC
BRAND
QL
200 / 30 days
RELION LANCETS ULTRA-THIN 30G MISC
BRAND
QL
200 / 30 days
RELION LANCING DEVICE MISC
BRAND
QL
1 / 180 days
RELION ULTRA THIN LANCETS 30G MISC
BRAND
QL
200 / 30 days
RELION ULTRA THIN PLUS LANCETS MISC
BRAND
QL
200 / 30 days
RENEW ADVANCED LANCING DEVICE MISC
BRAND
QL
1 / 180 days
REXALL LANCETS ULTRA THIN 30G MISC
BRAND
QL
200 / 30 days
RIGHTEST GD500 LANCING DEVICE MISC
BRAND
QL
1 / 180 days
RIGHTEST GL300 LANCETS MISC
BRAND
QL
200 / 30 days
SAFESNAP INSULIN SYRINGE (MISC 28G 1/2" 1 ML,
MISC 29G 1/2" 1 ML, MISC 30G 5/16" 0.5 ML)
BRAND
MDD
SAFESNAP INSULIN SYRINGE (MISC 29G 1/2" 0.5 ML,
MISC 30G 5/16" 0.3 ML)
BRAND
SAFETY SEAL LANCETS MISC
BRAND
QL
SAFETY-GLIDE SYRINGE MISC 29G X 1/2" 0.3 ML
BRAND
MDD
5 per day
SB INSULIN SYRINGE (MISC 29G 1/2" 0.5 ML, MISC 31G
5/16" 1 ML)
BRAND
SB INSULIN SYRINGE (MISC 29G 1/2" 1 ML, MISC 30G
5/16" 0.5 ML)
BRAND
MDD
5 per day
SB LANCETS THIN MISC
BRAND
QL
200 / 30 days
SB LANCETS ULTRA THIN MISC
BRAND
QL
200 / 30 days
SCHNUCKS INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML
BRAND
SCHNUCKS INSULIN SYRINGE MISC 30G X 5/16" 0.5
ML
BRAND
MDD
SELECT-LITE LANCING DEVICE MISC
BRAND
QL
1 / 180 days
SHOPKO AUTOLET LANCING DEVICE MISC
BRAND
QL
1 / 180 days
PAGE 85
5 per day
200 / 30 days
5 per day
PRODUCT DESCRIPTION
BRAND/GEN
SHOPKO UNILET LANCETS 28G MISC
BRAND
QL
200 / 30 days
SHOPKO UNILET LANCETS 30G MISC
BRAND
QL
200 / 30 days
SIMPLE DIAGNOSTICS LANCING DEV MISC
BRAND
QL
1 / 180 days
SM INSULIN SYRINGE (MISC 28G 1/2" 1 ML, MISC 28G
1/2" 0.5 ML, MISC 29G 1/2" 0.3 ML, MISC 29G 1/2" 1 ML,
MISC 30G 5/16" 0.5 ML)
BRAND
MDD
SM INSULIN SYRINGE (MISC 29G 1/2" 0.5 ML, MISC
30G 5/16" 0.3 ML, MISC 31G 5/16" 1 ML)
BRAND
SM LANCETS 21G MISC
BRAND
QL
200 / 30 days
SM LANCETS 33G MISC
BRAND
QL
200 / 30 days
SM SUPER THIN LANCETS 30G MISC
BRAND
QL
200 / 30 days
SM THIN LANCETS 26G MISC
BRAND
QL
200 / 30 days
SMART DIABETES VANTAGE LANCING MISC
BRAND
QL
1 / 180 days
SMART SENSE COLOR LANCETS 33G MISC
BRAND
QL
200 / 30 days
SMART SENSE STANDARD LANCETS MISC
BRAND
QL
200 / 30 days
SMART SENSE SUPER THIN LANCETS MISC
BRAND
QL
200 / 30 days
SMART SENSE THIN LANCETS 26G MISC
BRAND
QL
200 / 30 days
SOLUS V2 LANCING DEVICE MISC
BRAND
QL
1 / 180 days
STERILANCE TL MISC
BRAND
QL
200 / 30 days
SUPER THIN LANCETS MISC
BRAND
QL
200 / 30 days
SURE COMFORT INSULIN SYRINGE (MISC 28G 1/2" 1
29G 1/2" 1 ML, MISC 30G 5/16" 0.5 ML)
BRAND
MDD
SURE COMFORT INSULIN SYRINGE (MISC 29G 1/2" 0.5
BRAND
SURE COMFORT LANCING PEN MISC
BRAND
QL
SURE-JECT INSULIN SYRINGE (MISC 28G 1/2" 1 ML,
1/2" 0.3 ML, MISC 30G 5/16" 0.5 ML)
BRAND
MDD
PAGE 86
5 per day
5 per day
1 / 180 days
5 per day
PRODUCT DESCRIPTION
BRAND/GEN
SURE-JECT INSULIN SYRINGE (MISC 29G 1/2" 0.5 ML,
MISC 30G 5/16" 0.3 ML, MISC 31G 5/16" 1 ML)
BRAND
SURE-PEN MISC
BRAND
QL
1 / 180 days
SURELITE LANCETS MISC
BRAND
QL
200 / 30 days
TECHLITE AST LANCETS MISC
BRAND
QL
200 / 30 days
TECHLITE LANCETS 30G MISC
BRAND
QL
200 / 30 days
TECHLITE LANCETS MISC
BRAND
QL
200 / 30 days
TERUMO INSULIN SYRINGE (MISC 28G 1/2" 0.5 ML,
MISC 28G 1/2" 1 ML, MISC 29G 1/2" 0.3 ML, MISC 29G
1/2" 1 ML)
BRAND
MDD
5 per day
TERUMO INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML
BRAND
TERUMO SURGUARD INSULIN SYR (MISC 28G 1/2" 0.5
ML, MISC 28G 1/2" 1 ML, MISC 29G 1/2" 1 ML, MISC 29G
1/2" 0.3 ML)
BRAND
MDD
5 per day
TERUMO SURGUARD INSULIN SYR MISC 29G X 1/2"
0.5 ML
BRAND
TGT ADVANCED LANCING DEVICE MISC
BRAND
TGT BLOOD GLUCOSE MONITORING KIT W/DEVICE
BRAND
TGT LANCET ALTERNATE SITE MISC
QL
1 / 180 days
BRAND
QL
200 / 30 days
TGT LANCET MICRO THIN 33G MISC
BRAND
QL
200 / 30 days
TGT LANCET SUPER THIN 30G MISC
BRAND
QL
200 / 30 days
TGT LANCET THIN 23G MISC
BRAND
QL
200 / 30 days
TGT LANCET THIN 26G MISC
BRAND
QL
200 / 30 days
TGT LANCET ULTRA THIN 28G MISC
BRAND
QL
200 / 30 days
TGT LANCET ULTRA THIN 30G MISC
BRAND
QL
200 / 30 days
TGT LANCING DEVICE MISC
BRAND
QL
1 / 180 days
THINPRO INSULIN SYRINGE (MISC 28G 1/2" 0.5 ML,
0.3 ML)
BRAND
MDD
PAGE 87
5 per day
PRODUCT DESCRIPTION
BRAND/GEN
THINPRO INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML
BRAND
TODAYS HEALTH LANCING DEVICE MISC
BRAND
QL
1 / 180 days
TODAYS HEALTH THIN LANCETS 28G MISC
BRAND
QL
200 / 30 days
TODAYS HEALTH THIN LANCETS 30G MISC
BRAND
QL
200 / 30 days
TOPCARE ULTRA COMFORT INS SYR (MISC 29G 1/2"
0.3 ML, MISC 29G 1/2" 1 ML, MISC 30G 5/16" 0.5 ML)
BRAND
MDD
5 per day
TOPCARE ULTRA COMFORT INS SYR (MISC 29G 1/2"
BRAND
TRUE METRIX AIR GLUCOSE METER KIT W/DEVICE
BRAND
TRUE METRIX BLOOD GLUCOSE TEST STRIP
BRAND
MDD
5 per day
TRUE METRIX LEVEL 1 SOLUTION LOW
BRAND
QL
1 / 90 days
TRUE METRIX LEVEL 2 SOLUTION NORMAL
BRAND
QL
1 / 90 days
TRUE METRIX LEVEL 3 SOLUTION HIGH
BRAND
QL
1 / 90 days
TRUE METRIX METER KIT W/DEVICE
BRAND
TRUECONTROL GLUCOSE CONT LEV 0 LIQUID
BRAND
QL
1 / 90 days
TRUECONTROL GLUCOSE CONT LEV 1 LIQUID
BRAND
QL
1 / 90 days
TRUEDRAW LANCING DEVICE MISC
BRAND
QL
1 / 180 days
TRUEPLUS INSULIN SYRINGE (MISC 28G 1/2" 0.5 ML,
0.3 ML, MISC 30G 5/16" 0.5 ML)
BRAND
MDD
TRUEPLUS INSULIN SYRINGE (MISC 29G 1/2" 0.5 ML,
MISC 30G 5/16" 0.3 ML, MISC 31G 5/16" 1 ML)
BRAND
TRUEPLUS LANCETS 26G MISC
BRAND
QL
200 / 30 days
BRAND
QL
200 / 30 days
BRAND
QL
200 / 30 days
BRAND
QL
200 / 30 days
TRUERESULT BLOOD GLUCOSE KIT W/DEVICE
BRAND
TRUETEST CONTROL LEVEL 1 LIQUID
BRAND
QL
1 / 90 days
PAGE 88
5 per day
PRODUCT DESCRIPTION
BRAND/GEN
BRAND
QL
1 / 90 days
BRAND
QL
1 / 90 days
TRUETEST TEST STRIP
BRAND
MDD
TRUETRACK GLUCOSE CONTROL (LIQUID, LIQUID
LOW)
BRAND
QL
TRUETRACK TEST STRIP
BRAND
MDD
ULTI-LANCE AUTO-ADJUST DEVICE MISC
BRAND
QL
1 / 180 days
ULTI-LANCE AUTOMATIC MISC
BRAND
QL
1 / 180 days
ULTI-LANCE MINI ADJUSTABLE MISC
BRAND
QL
1 / 180 days
ULTICARE INSULIN SAFETY SYR MISC 29G X 1/2" 0.5
ML
BRAND
ULTICARE INSULIN SAFETY SYR MISC 29G X 1/2" 1 ML
BRAND
MDD
5 per day
ULTICARE INSULIN SYRINGE (MISC 28G 1/2" 1 ML,
1/2" 0.3 ML, MISC 30G 5/16" 0.5 ML)
BRAND
MDD
5 per day
ULTICARE INSULIN SYRINGE (MISC 29G 1/2" 0.5 ML,
MISC 30G 5/16" 0.3 ML, MISC 31G 5/16" 1 ML)
BRAND
ULTILET BASIC LANCETS 30G MISC
BRAND
QL
200 / 30 days
ULTILET CLASSIC LANCETS MISC
BRAND
QL
200 / 30 days
ULTILET INSULIN SYRINGE (MISC 7/16" 0.5 ML, MISC
7/16" 1 ML)
BRAND
MDD
5 per day
ULTILET INSULIN SYRINGE MISC 29G X 7/16" 0.3 ML
BRAND
ULTILET INSULIN SYRINGE SHORT (MISC 30G 5/16"
0.3 ML, MISC 31G 5/16" 1 ML)
BRAND
ULTILET INSULIN SYRINGE SHORT MISC 30G X 5/16"
0.5 ML
BRAND
MDD
5 per day
ULTILET LANCETS MISC
BRAND
QL
ULTRA COMFORT INSULIN SYRINGE (MISC 29G 1/2"
BRAND
ULTRA COMFORT INSULIN SYRINGE MISC 29G X 1/2"
1 ML
BRAND
PAGE 89
MDD
5 per day
1 / 90 days
5 per day
200 / 30 days
5 per day
PRODUCT DESCRIPTION
BRAND/GEN
ULTRA THIN LANCETS 28G MISC
BRAND
QL
200 / 30 days
ULTRA THIN LANCETS 30G MISC
BRAND
QL
200 / 30 days
ULTRA-COMFORT INSULIN SYRINGE (MISC 28G 1/2" 1
29G 1/2" 1 ML, MISC 30G 5/16" 0.5 ML)
BRAND
MDD
5 per day
ULTRA-COMFORT INSULIN SYRINGE (MISC 29G 1/2"
BRAND
ULTRA-THIN II INS SYR SHORT (MISC 30G 5/16" 0.3
ML, MISC 31G 5/16" 1 ML)
BRAND
ULTRA-THIN II INS SYR SHORT MISC 30G X 5/16" 0.5
ML
BRAND
MDD
5 per day
ULTRA-THIN II INSULIN SYRINGE (MISC 1/2" 1 ML,
MISC 1/2" 0.3 ML)
BRAND
MDD
5 per day
ULTRA-THIN II INSULIN SYRINGE MISC 29G X 1/2" 0.5
ML
BRAND
UNILET COMFORTOUCH LANCET MISC
BRAND
QL
200 / 30 days
UNILET EXCELITE II MISC
BRAND
QL
200 / 30 days
UNILET EXCELITE MISC
BRAND
QL
200 / 30 days
UNILET G.P. LANCET MISC
BRAND
QL
200 / 30 days
UNILET G.P. SUPERLITE LANCET MISC
BRAND
QL
200 / 30 days
UNILET GP 28 ULTRA THIN MISC
BRAND
QL
200 / 30 days
UNILET LANCET MISC
BRAND
QL
200 / 30 days
UNILET MICRO-THIN 33G MISC
BRAND
QL
200 / 30 days
UNILET SUPER-THIN 30G MISC
BRAND
QL
200 / 30 days
UNILET SUPERLITE LANCET MISC
BRAND
QL
200 / 30 days
UNILET ULTRA-THIN 28G MISC
BRAND
QL
200 / 30 days
UNIVERSAL 1 LANCETS THIN 26G MISC
BRAND
QL
200 / 30 days
UNIVERSAL 1 LANCETS ULTRA THIN MISC
BRAND
QL
200 / 30 days
PAGE 90
PRODUCT DESCRIPTION
BRAND/GEN
V-R MONO INSULIN SYRINGE (MISC 28G 1/2" 1 ML,
1/2" 0.3 ML)
BRAND
V-R MONO INSULIN SYRINGE MISC 29G X 1/2" 0.5 ML
BRAND
VALUE HEALTH INSULIN SYRINGE MISC 29G X 1/2" 0.5
ML
BRAND
VALUE HEALTH INSULIN SYRINGE MISC 29G X 1/2" 1
ML
MDD
5 per day
BRAND
MDD
5 per day
VALUE PLUS LANCET STANDARD 21G MISC
BRAND
QL
200 / 30 days
VALUE PLUS LANCETS SUPER THIN MISC
BRAND
QL
200 / 30 days
VALUE PLUS LANCETS THIN 26G MISC
BRAND
QL
200 / 30 days
VALUE PLUS LANCING DEVICE MISC
BRAND
QL
1 / 180 days
VALUMARK LANCET SUPER THIN 30G MISC
BRAND
QL
200 / 30 days
VALUMARK LANCET ULTRA THIN 28G MISC
BRAND
QL
200 / 30 days
VANISHPOINT INSULIN SYRINGE MISC 29G X 1/2" 1 ML
BRAND
MDD
VIDA MIA AUTOLET LANCING DEV MISC
BRAND
QL
1 / 180 days
VIDA MIA UNILET LANCETS 28G MISC
BRAND
QL
200 / 30 days
VIDA MIA UNILET LANCETS 30G MISC
BRAND
QL
200 / 30 days
VISTOGARD PACKET 10 GM
BRAND
VP INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML
BRAND
MDD
W&F LANCETS 26G MISC
BRAND
QL
200 / 30 days
W&F LANCETS COLORED 21G MISC
BRAND
QL
200 / 30 days
WALGREENS LANCETS MICRO THIN MISC
BRAND
QL
200 / 30 days
WALGREENS LANCETS MISC
BRAND
QL
200 / 30 days
WALGREENS LANCETS SUPER THIN MISC
BRAND
QL
200 / 30 days
WALGREENS LANCING DEVICE MISC
BRAND
QL
1 / 180 days
WALGREENS THIN LANCETS MISC
BRAND
QL
200 / 30 days
PAGE 91
5 per day
5 per day
PRODUCT DESCRIPTION
BRAND/GEN
WALGREENS ULTRA THIN LANCETS MISC
BRAND
QL
200 / 30 days
WATCHHALER DEVICE
BRAND
QL
2 / 360 days
WD MEDIC INSULIN SYRINGE (MISC 29G 1/2" 0.5 ML,
MISC 30G 5/16" 0.3 ML)
BRAND
WD MEDIC INSULIN SYRINGE (MISC 29G 1/2" 1 ML,
MISC 29G 1/2" 0.3 ML, MISC 30G 5/16" 0.5 ML)
BRAND
MDD
5 per day
atropine sulfate ophth oint 1%
generic
QL
4 / 1 claim
atropine sulfate ophth soln 1%
generic
MPL
1 / 1 claim
bacitracin-polymyxin b ophth oint
generic
QL
4 / 1 claim
BLEPHAMIDE S.O.P. OINTMENT 10-0.2 %
BRAND
QL
4 / 1 claim
BLEPHAMIDE SUSPENSION 10-0.2 %
BRAND
MPL
1 / 1 claim
cyclopentolate hcl ophth soln 0.5%
generic
cyclopentolate hcl ophth soln 1%
generic
MPL
1 / 1 claim
naphazoline hcl ophth soln 0.1%
generic
QL
15 / 1 claim
neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt
op oin
generic
QL
4 / 1 claim
neomycin-polymy-gramicid op sol 1.75-10000-0.025mgunt-mg/ml
generic
QL
10 / 1 claim
neomycin-polymyxin-dexamethasone ophth oint 0.1%
generic
QL
4 / 1 claim
neomycin-polymyxin-dexamethasone ophth susp 0.1%
generic
QL
5 / 1 claim
neomycin-polymyxin-hc ophth susp
generic
QL
8 / 1 claim
phenylephrine hcl ophth soln 2.5%
generic
MPL
1 / 1 claim
polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%
generic
QL
PRED-G SUSPENSION 0.3-1 %
BRAND
MPL
1 / 1 claim
sulfacetamide sodium-prednisolone ophth soln 100.23(0.25)%
generic
MPL
1 / 1 claim
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS, OTHER
PAGE 92
10 / 1 claim
PRODUCT DESCRIPTION
BRAND/GEN
tobramycin-dexamethasone ophth susp 0.3-0.1%
generic
MPL
tropicamide ophth soln 0.5%
generic
QL
tropicamide ophth soln 1%
generic
MPL
1 / 1 claim
QL
5 / 1 claim
1 / 1 claim
15 / 1 claim
OPHTHALMIC ANTI-ALLERGY AGENTS
ALOCRIL SOLUTION 2 %
BRAND
PA
ST
QL
ALOMIDE SOLUTION 0.1 %
BRAND
10 / 1 claim
PA
ST
azelastine hcl ophth soln 0.05%
generic
QL
6 / 1 claim
cromolyn sodium ophth soln 4%
generic
QL
10 / 1 claim
dexamethasone sodium phosphate ophth soln 0.1%
generic
QL
5 / 1 claim
diclofenac sodium ophth soln 0.1%
generic
MPL
1 / 1 claim
fluorometholone ophth susp 0.1%
generic
MPL
1 / 1 claim
flurbiprofen sodium ophth soln 0.03%
generic
QL
3 / 1 claim
FML OINTMENT 0.1 %
BRAND
QL
4 / 1 claim
ketorolac tromethamine ophth soln 0.4%
generic
MFL
1 / 30 days
ketorolac tromethamine ophth soln 0.5%
generic
MPL
1 / 1 claim
NEVANAC SUSPENSION 0.1 %
BRAND
QL
3 / 1 claim
PRED MILD SUSPENSION 0.12 %
BRAND
QL
10 / 1 claim
prednisolone acetate ophth susp 1%
generic
MPL
1 / 1 claim
PREDNISOLONE SODIUM PHOSPHATE SOLUTION 1 %
BRAND
MPL
1 / 30 days
VEXOL SUSPENSION 1 %
BRAND
MPL
1 / 1 claim
OPHTHALMIC ANTI-INFLAMMATORIES
PAGE 93
PRODUCT DESCRIPTION
BRAND/GEN
OPHTHALMIC ANTIGLAUCOMA AGENTS
apraclonidine hcl ophth soln 0.5% (base equivalent)
generic
AZOPT SUSPENSION 1 %
BRAND
MPL
1 / 1 claim
betaxolol hcl ophth soln 0.5%
generic
MPL
1 / 1 claim
BETOPTIC-S SUSPENSION 0.25 %
BRAND
MPL
1 / 1 claim
brimonidine tartrate ophth soln 0.2%
generic
MPL
1 / 1 claim
carteolol hcl ophth soln 1%
generic
MFL
1 / 30 days
dorzolamide hcl ophth soln 2%
generic
QL
10 / 1 claim
dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml
generic
QL
10 / 1 claim
IOPIDINE SOLUTION 1 %
BRAND
levobunolol hcl (soln 0.25%, soln 0.5%)
generic
methazolamide (tab 25 mg, tab 50 mg)
generic
pilocarpine hcl (soln 1%, soln 2%, soln 4%)
generic
timolol maleate (ophth) (gel forming soln 0.5%, soln 0.25%,
soln 0.5%)
TIMOPTIC OCUDOSE (SOLUTION 0.25 %, SOLUTION
0.5 %)
MPL
1 / 1 claim
generic
MPL
1 / 1 claim
BRAND
MPL
1 / 1 claim
generic
QL
3 / 1 claim
acetic acid otic soln 2%
generic
QL
15 / 1 claim
antipyrine-benzocaine otic soln 54-14 mg/ml (5.4-1.4%)
generic
MPL
1 / 1 claim
CIPRODEX SUSPENSION 0.3-0.1 %
BRAND
QL
8 / 1 claim
fluocinolone acetonide (otic) oil 0.01%
generic
MPL
1 / 30 days
hydrocortisone w/ acetic acid otic soln 1-2%
generic
QL
10 / 1 claim
neomycin-polymyxin-hc otic soln 1%
generic
QL
10 / 1 claim
OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS
latanoprost ophth soln 0.005%
OTIC AGENTS
PAGE 94
PRODUCT DESCRIPTION
BRAND/GEN
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml1%
generic
MPL
AEROSPAN AERO SOLN 80 MCG/ACT
BRAND
QL
8.9 / 30 days
budesonide (inhalation) (susp 0.25 mg/2ml, susp 0.5
mg/2ml, susp 1 mg/2ml)
QL
generic
120 / 30 days
AL
Up to 6 yrs old
FLOVENT DISKUS (AER POW BA 100 MCG/BLIST, AER
POW BA 250 MCG/BLIST)
BRAND
MDD
FLOVENT DISKUS AER POW BA 50 MCG/BLIST
BRAND
QL
60 / 25 days
FLOVENT HFA (AEROSOL 110 MCG/ACT, AEROSOL
220 MCG/ACT)
BRAND
QL
12 / 25 days
FLOVENT HFA AEROSOL 44 MCG/ACT
BRAND
QL
11 / 25 days
flunisolide nasal soln 25 mcg/act (0.025%)
generic
QL
25 / 1 claim
flunisolide nasal soln 29 mcg/act (0.025%)
generic
fluticasone propionate nasal susp 50 mcg/act
generic
QL
16 / 1 claim
mometasone furoate nasal susp 50 mcg/act
generic
PULMICORT FLEXHALER (AER POW BA 90 MCG/ACT,
AER POW BA 180 MCG/ACT)
BRAND
QL
1 / 25 days
QL
17 / claim
1 / 1 claim
RESPIRATORY TRACT/PULMONARY AGENTS
ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS
triamcinolone acetonide nasal aerosol suspension 55
mcg/act
generic
2 per day
PA
AL
At least 2 yrs old
ANTIHISTAMINES
azelastine hcl (0.1% (137 mcg/), 0.15% (205.5 mcg/))
generic
generic
cyproheptadine hcl (syrup 2 mg/5ml, tab 4 mg)
generic
generic
PAGE 95
MPL
1 / 30 days
QL
240 / 1 claim
AL
Up to 12 yrs old
MDD
4 per day
PRODUCT DESCRIPTION
BRAND/GEN
diphenhydramine hcl elixir 12.5 mg/5ml
generic
hydroxyzine hcl (syrup 10 mg/5ml, tab 10 mg, tab 25 mg,
tab 50 mg)
generic
hydroxyzine pamoate (cap 25 mg, cap 50 mg, cap 100 mg)
generic
promethazine hcl (tab 12.5 mg, tab 25 mg, tab 50 mg)
generic
promethazine hcl suppos 12.5 mg
generic
promethazine hcl suppos 25 mg
promethazine hcl syrup 6.25 mg/5ml
QL
240 / 1 claim
AL
At least 2 yrs old
QL
12 / 1 claim
AL
At least 2 yrs old
QL
12 / 1 claim
AL
At least 2 yrs old
QL
12 / 1 claim
AL
At least 2 yrs old
QL
240 / 1 claim
AL
At least 2 yrs old
generic
generic
generic
ANTILEUKOTRIENES
montelukast sodium (chew tab 4 mg, chew tab 5 mg, oral
granules packet 4 mg, tab 10 mg)
generic
MDD
1 per day
ATROVENT HFA AERO SOLN 17 MCG/ACT
BRAND
QL
INCRUSE ELLIPTA AER POW BA 62.5 MCG/INH
BRAND
MPL
ipratropium bromide inhal soln 0.02%
generic
QL
375 / 25 days
ipratropium bromide nasal soln 0.03% (21 mcg/spray)
generic
QL
30 / 25 days
ipratropium bromide nasal soln 0.06% (42 mcg/spray)
generic
QL
15 / 30 days
TUDORZA PRESSAIR AER POW BA 400 MCG/ACT
BRAND
QL
1 / 30 days
ADRENACLICK (SOLN A-INJ 0.15 MG/0.15ML, SOLN AINJ 0.3 MG/0.3ML)
BRAND
QL
4 year(s)
ADRENALIN SOLUTION 0.1 %
BRAND
BRONCHODILATORS, ANTICHOLINERGIC
26 / 30 days
1 / 30 days
BRONCHODILATORS, SYMPATHOMIMETIC
PAGE 96
PRODUCT DESCRIPTION
BRAND/GEN
albuterol sulfate (soln nebu 0.63 mg/3ml, soln nebu 1.25
mg/3ml)
generic
albuterol sulfate (syrup 2 mg/5ml, tab 2 mg, tab 4 mg, tab
sr 12hr 4 mg, tab sr 12hr 8 mg)
generic
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)
QL
375 / 30 days
generic
QL
375 / 25 days
albuterol sulfate soln nebu 0.5% (5 mg/ml)
generic
MDD
2 per day
EPINEPHRINE (SOLN A-INJ 0.15 MG/0.15ML, SOLN AINJ 0.3 MG/0.3ML)
BRAND
QL
4 year(s)
EPIPEN 2-PAK SOLN A-INJ 0.3 MG/0.3ML
BRAND
QL
4 year(s)
EPIPEN JR 2-PAK SOLN A-INJ 0.15 MG/0.3ML
BRAND
QL
4 year(s)
EPIPEN JR SOLN A-INJ 0.15 MG/0.3ML
BRAND
QL
4 year(s)
EPIPEN SOLN A-INJ 0.3 MG/0.3ML
BRAND
QL
4 year(s)
FORADIL AEROLIZER CAP 12 MCG
BRAND
MDD
2 per day
metaproterenol sulfate (tab 10 mg, tab 20 mg)
generic
metaproterenol sulfate syrup 10 mg/5ml
generic
MDD
30 per day
SEREVENT DISKUS AER POW BA 50 MCG/DOSE
BRAND
MDD
2 per day
terbutaline sulfate (tab 2.5 mg, tab 5 mg)
generic
TWINJECT SOLN A-INJ 0.3 MG/0.3ML
BRAND
QL
4 year(s)
VENTOLIN HFA AERO SOLN 108 (90 BASE) MCG/ACT
BRAND
MPL
KALYDECO (PACKET 50 MG, PACKET 75 MG, TAB 150
MG)
BRAND
PA
ORKAMBI TAB 200-125 MG
BRAND
PA
tobramycin nebu soln 300 mg/5ml
generic
PA
2 / 30 days
CYSTIC FIBROSIS AGENTS
PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE
caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv)
QL
generic
MFL
PAGE 97
45 / 1 claim
2 / lifetime
PRODUCT DESCRIPTION
BRAND/GEN
ELIXOPHYLLIN ELIXIR 80 MG/15ML
BRAND
THEO-24 (CAP ER 24H 400 MG, CAP ER 24H 100 MG,
CAP ER 24H 200 MG, CAP ER 24H 300 MG)
BRAND
theophylline (tab 12hr 200 mg, tab 12hr 450 mg, tab 12hr
300 mg, tab 12hr 100 mg, tab 24hr 600 mg, tab 24hr 400
mg)
generic
theophylline soln 80 mg/15ml
generic
QL
475 / 1 claim
RESPIRATORY TRACT AGENTS, OTHER
acetylcysteine (soln 10%, soln 20%)
generic
ADVAIR DISKUS (AER POW BA 100-50 MCG/DOSE,
AER POW BA 250-50 MCG/DOSE, AER POW BA 500-50
MCG/DOSE)
BRAND
QL
60 / 30 days
ADVAIR HFA (AEROSOL 45-21 MCG/ACT, AEROSOL
115-21 MCG/ACT, AEROSOL 230-21 MCG/ACT)
BRAND
QL
12 / 30 days
benzonatate cap 100 mg
generic
AL
At least 10 yrs old
QL
30 / 30 days
AL
At least 10 yrs old
benzonatate cap 200 mg
generic
MFL
AL
BREO ELLIPTA (AER POW BA 100-25 MCG/INH, AER
POW BA 200-25 MCG/INH)
BRAND
COMBIVENT RESPIMAT AERO SOLN 20-100 MCG/ACT
1 / 30 days
At least 18 yrs old
MPL
1 / 30 days
BRAND
QL
4 / 30 days
cromolyn sodium soln nebu 20 mg/2ml
generic
QL
240 / 30 days
DULERA (AEROSOL 100-5 MCG/ACT, AEROSOL 200-5
MCG/ACT)
BRAND
QL
13 / 30 days
hydrocodone w/ homatropine syrup 5-1.5 mg/5ml
generic
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml
generic
phenylephrine-promethazine w/ codeine syrup 5-6.25-10
mg/5ml
generic
promethazine & phenylephrine syrup 6.25-5 mg/5ml
generic
PAGE 98
MDD
12 per day
QL
240 / 1 claim
AL
At least 2 yrs old
QL
240 / 1 claim
AL
At least 2 yrs old
PRODUCT DESCRIPTION
BRAND/GEN
promethazine w/ codeine syrup 6.25-10 mg/5ml
generic
sodium chloride soln nebu 0.9%
generic
SYMBICORT (AEROSOL 80-4.5 MCG/ACT, AEROSOL
160-4.5 MCG/ACT)
BRAND
QL
240 / 1 claim
AL
At least 2 yrs old
QL
11 / 30 days
SKELETAL MUSCLE RELAXANTS
chlorzoxazone tab 500 mg
generic
cyclobenzaprine hcl (tab 5 mg, tab 10 mg)
generic
methocarbamol (tab 500 mg, tab 750 mg)
generic
MDD
3 per day
SLEEP DISORDER AGENTS
GABA RECEPTOR MODULATORS
temazepam (cap 15 mg, cap 30 mg)
generic
MDD
1 per day
triazolam (tab 0.125 mg, tab 0.25 mg)
generic
MDD
1 per day
zaleplon (cap 5 mg, cap 10 mg)
generic
MDD
1 per day
zolpidem tartrate (tab 5 mg, tab 10 mg)
generic
MDD
1 per day
generic
MDD
1 per day
*sodium polystyrene sulfonate powder**
generic
QL
CHEMET CAP 100 MG
BRAND
JADENU (TAB 90 MG, TAB 180 MG, TAB 360 MG)
BRAND
sodium polystyrene sulfonate oral susp 15 gm/60ml
generic
SLEEP DISORDERS, OTHER
flurazepam hcl (cap 15 mg, cap 30 mg)
THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES
ELECTROLYTE/MINERAL MODIFIERS
454 / 1 claim
PA
ELECTROLYTE/MINERAL REPLACEMENT
*ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab 106-1
mg***
PAGE 99
generic
MDD
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
KLOR-CON M15 TAB ER 15 MEQ
BRAND
KLOR-CON PACKET 25 MEQ
BRAND
potassium bicarbonate effer tab 25 meq
generic
potassium chloride (cap cr 10 meq, oral soln 10% (20
meq/15ml), oral soln 20% (40 meq/15ml), powder packet
20 meq, tab cr 8 meq (600 mg), tab cr 10 meq)
generic
potassium chloride cap cr 8 meq
generic
potassium chloride microencapsulated crystals cr
(mioencapsulated ys tab 10, mioencapsulated ys tab 20)
generic
sodium fluoride (chew tab 0.25 mg f (from 0.55 mg, chew
tab 0.5 mg f (from 1.1 mg, chew tab 1 mg f (from 2.2 mg,
soln 0.125 mg/drop f (0.275 mg/drop, soln 0.5 mg/ml f
(from 1.1 mg/ml)
generic
zinc sulfate cap 220 mg (50 mg elemental zn)
generic
*multiple vitamins w/ minerals tab**
generic
*pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/ml**
generic
*pediatric multiple vitamins w/ fluoride chew tab 1 mg***
MDD
1 per day
MDD
1 per day
QL
50 / 1 claim
AL
Up to 13 yrs old
QL
30 / 30 days
AL
Up to 13 yrs old
generic
AP-ZEL TAB
BRAND
MDD
1 per day
b-complex w/ c & folic acid (w/ ap 1, w/ tab 1)
generic
MDD
1 per day
BACMIN TAB
BRAND
MDD
1 per day
COMPLETENATE CHEW TAB 29-1 MG
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
cyanocobalamin inj 1000 mcg/ml
generic
ergocalciferol cap 50000 unit
generic
folic acid tab 1 mg
generic
INATAL ADVANCE TAB
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
PAGE 100
1 per day
1 per day
PRODUCT DESCRIPTION
INATAL GT TAB
BRAND/GEN
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
INATAL ULTRA TAB
BRAND
1 per day
GL
Female
AL
Up to 45 yrs old
MDD
1 per day
levocarnitine oral soln 1 gm/10ml (10%)
generic
MDD
30 per day
levocarnitine tab 330 mg
generic
MDD
3 per day
M-VIT TAB
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
MEPHYTON TAB 5 MG
NATAL-V RX TAB 29-1 MG
BRAND
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
NATALVIT TAB
NICADAN TAB
NIVA-PLUS TAB 27-1 MG
NUTRICAP TAB
O-CAL FA TAB 27-1 MG
BRAND
BRAND
BRAND
BRAND
BRAND
BRAND
Female
AL
Up to 45 yrs old
MDD
1 per day
MDD
1 per day
GL
Female
AL
Up to 45 yrs old
MDD
1 per day
MDD
1 per day
GL
Female
AL
Up to 45 yrs old
1 per day
GL
Female
AL
Up to 45 yrs old
MDD
PAGE 101
1 per day
GL
MDD
O-CAL PRENATAL TAB
1 per day
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
pediatric multivitamins w/fl (w/ chew tab 0.25, w/ chew tab
0.5)
generic
pediatric multivitamins w/fl (w/ soln 0.25 mg/ml***, w/ soln
0.5 mg/ml***)
generic
pediatric vitamins acd w/ fluoride (w/ soln 0.25 mg/ml***, w/
soln 0.5 mg/ml***)
generic
PNV FE FUM/DOCUSATE/FOLIC ACID TAB 29-1 MG
AL
MDD
BRAND
BRAND
50 / 1 claim
AL
Up to 13 yrs old
QL
50 / 1 claim
AL
Up to 13 yrs old
GL
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
1 per day
GL
Female
AL
Up to 45 yrs old
MDD
PAGE 102
1 per day
GL
MDD
PRETAB TAB 29-1 MG
1 per day
GL
MDD
PREPLUS TAB 27-1 MG
1 per day
GL
MDD
PRENATAL VITAMINS PLUS TAB 27-1 MG
1 per day
GL
MDD
PRENATAL PLUS TAB 27-1 MG
1 per day
GL
MDD
PNV TABS 29-1 TAB 29-1 MG
1 per day
GL
MDD
PNV PRENATAL PLUS MULTIVITAMIN TAB 27-1 MG
1 per day
QL
MDD
PNV FOLIC ACID + IRON TAB 27-1 MG
Up to 13 yrs old
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
QUFLORA PEDIATRIC (CHEW TAB 0.25 MG, CHEW TAB
0.5 MG)
BRAND
QUFLORA PEDIATRIC (SOLUTION 0.25 MG/ML,
SOLUTION 0.5 MG/ML)
BRAND
QUFLORA PEDIATRIC CHEW TAB 1 MG
BRAND
REQ 49+ TAB
SE-NATAL 19 (19 TAB MG, 19 CHEW TAB MG)
STROVITE ONE TAB
THRIVITE 19 TAB 29-1 MG
AL
MDD
BRAND
BRAND
BRAND
BRAND
BRAND
50 / 1 claim
AL
Up to 13 yrs old
QL
30 / 30 days
AL
Up to 13 yrs old
MDD
TRICARE TAB
Female
AL
Up to 45 yrs old
MDD
1 per day
MDD
1 per day
GL
Female
AL
Up to 45 yrs old
Female
AL
Up to 45 yrs old
BRAND
50 / 1 claim
AL
Up to 13 yrs old
GL
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
1 per day
GL
Female
AL
Up to 45 yrs old
MDD
PAGE 103
1 per day
GL
MDD
TRINATAL RX 1 TAB 60-1 MG
1 per day
QL
MDD
TRINATAL GT TAB 90-1 MG
1 per day
GL
BRAND
BRAND
1 per day
GL
MDD
TRI-VIT/FLUORIDE/IRON SOLUTION 0.25-10 MG/ML
1 per day
QL
MDD
THRIVITE RX TAB 29-1 MG
Up to 13 yrs old
1 per day
PRODUCT DESCRIPTION
VENATAL-FA TAB 29-1 MG
BRAND/GEN
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
VINATE M TAB 27-1 MG
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
VINATE ONE TAB 60-1 MG
BRAND
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
1 per day
GL
Female
AL
Up to 45 yrs old
MDD
PAGE 104
1 per day
GL
MDD
VOL-TAB RX TAB 29-1 MG
1 per day
GL
MDD
VOL-PLUS TAB 27-1 MG
1 per day
GL
MDD
VITAFOL-PN TAB
1 per day
GL
MDD
VITAFOL-OB TAB
1 per day
GL
MDD
VIRT-VITE GT TAB 90-1 MG
1 per day
GL
MDD
VIRT-ADVANCE TAB 90-1 MG
1 per day
GL
MDD
VINATE ULTRA TAB
1 per day
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
VP-ZEL TAB
BRAND
MDD
1 per day
ANTISPASTICITY AGENTS
baclofen (tab 10 mg, tab 20 mg)
generic
tizanidine hcl (tab 2 mg (base equivalent), tab 2 mg, tab 4
mg (base equivalent), tab 4 mg)
generic
PAGE 105
Index of covered drugs
1
albuterol sulfate
97
ALCOHOL PREP
10
1ST CHOICE LANCETS SUPER THIN
70
alcohol swabs
10
1ST CHOICE LANCETS THIN
70
ALCOHOL SWABS
10
1ST CHOICE LANCETS ULTRA THIN
70
alendronate sodium
69
1ST TIER UNILET COMFORTOUCH
70
ALKERAN
34
allopurinol
32
ALOCRIL
93
ALOMIDE
93
A
A + D PERSONAL CARE LOTION
5
abacavir sulfate
39
ALORA
63
abacavir sulfate-lamivudine-zidovudine
39
alprazolam
42
ABSORICA
55
ALSUMA
33
ACCU-CHEK SOFT TOUCH LANCETS
70
ALTERNATE SITE LANCING DEVICE
70
ACCU-CHEK SOFTCLIX LANCET DEV
70
alum & mag hydrox-simethicone
8
ACE AEROSOL CLOUD ENHANCER
70
aluminum hydroxide gel
8
acebutolol hcl
48
amantadine hcl
36
amiloride & hydrochlorothiazide
50
acetaminophen
5,10
acetaminophen w/ codeine
20
amiloride hcl
51
acetazolamide
51
aminocaproic acid
46
acetic acid (otic)
94
amiodarone hcl
48
acetylcysteine
98
amitriptyline hcl
30
ACNE MEDICATION
5
AMLACTIN CERAPEUTIC
5
ACNE MEDICATION 10
5
amlodipine besylate
49
ACNE MEDICATION 5
5
amlodipine besylate-benazepril hcl
50
acyclovir
41
amoxapine
30
acyclovir topical
41
amoxicillin
25
ADJUSTABLE LANCING DEVICE
70
amoxicillin & pot clavulanate
25
ADRENACLICK
96
amphetamine-dextroamphetamine
53
ADRENALIN
96
ampicillin
25
ADVAIR DISKUS
98
anastrozole
35
ADVAIR HFA
98
ANDRODERM
62
ADVOCATE INSULIN SYRINGE
70
ANDROXY
62
ADVOCATE LANCING DEVICE
70
ANTI-STICK INSULIN SYRINGE
71
ADVOCATE RAPID-SAFE LANCING
70
antipyrine-benzocaine
94
AEROCHAMBER PLUS FLO-VU
70
AP-ZEL
AEROCHAMBER PLUS FLO-VU LARGE
70
APEXICON E
60
AEROCHAMBER PLUS FLO-VU SMALL
70
APIDRA
44
AEROCHAMBER PLUS FLO-VU W/MASK
70
APIDRA SOLOSTAR
44
AEROSPAN
95
apraclonidine hcl
94
AF LANCETS SUPER THIN
70
APTIVUS
40
AGAMATRIX ULTRA-THIN LANCETS
70
AQUA GLYCOLIC HAND/BODY
PAGE 106
100
5
AQUA LACTEN
AQUA LANCE ADJUSTABLE LANCING
5
bacitracin-polymyxin b (ophth)
92
71
baclofen
105
AQUAMED
5
BACMIN
100
aripiprazole
37
BACTROBAN NASAL
23
ARMOUR THYROID
66
balsalazide disodium
69
artificial tear ointment
13
BAYER MICROLET 2 LANCING DEVIC
71
ascorbic acid
16
BD AUTOSHIELD
71
aspirin
3
BD INSULIN SYR ULTRAFINE II
71
aspirin buffered (cal carb-mag carb-mag oxide)
3
BD INSULIN SYRINGE
71
ASPIRIN LOW DOSE
3
BD INSULIN SYRINGE MICROFINE
71
aspirin tab chew 81 mg
3
BD INSULIN SYRINGE ULTRAFINE
71
ASSURE ID INSULIN SAFETY SYR
71
BD INTEGRA INSULIN SYRINGE
71
atenolol
48
BD LANCET DEVICE
71
atenolol & chlorthalidone
50
BD LANCET ULTRAFINE 30G
72
atorvastatin calcium
52
BD SAFETY-LOK INSULIN SYRINGE
72
ATRIPLA
38
BD SAFETYGLIDE INSULIN SYRINGE
72
atropine sulfate (ophthalmic)
92
BD SWAB SINGLE USE REGULAR
10
ATROVENT HFA
96
benazepril & hydrochlorothiazide
50
AURORA LANCET SUPER THIN 30G
71
benazepril hcl
47
AURORA LANCET THIN 23G
71
benzonatate
98
AUTO-LANCET
71
benzoyl peroxide
AUTO-LANCET MINI
71
benztropine mesylate
36
AUTOLET IMPRESSION
71
betamethasone dipropionate augmented
60
AUTOLET LANCING DEVICE
71
betamethasone valerate
AUTOLET MINI
71
betaxolol hcl (ophth)
94
AVANDIA
42
bethanechol chloride
60
AVONEX
55
BETOPTIC-S
94
AVONEX PEN
55
BIATAIN ADHESIVE FOAM DRESSING
10
AVONEX PREFILLED
55
BIATAIN FOAM DRESSING
10
AZASAN
67
bicalutamide
34
azathioprine
67
bisacodyl
8
azelastine hcl
95
bisacodyl ec tab dr 5 mg
8
azelastine hcl (ophth)
93
bisacodyl laxative suppos 10 mg
8
bismuth subsalicylate
8
azithromycin
AZOPT
25,26
94
b-complex w/ c & folic acid
60,61
bisoprolol & hydrochlorothiazide
50
bisoprolol fumarate
48
BLEPHAMIDE
92
16
BLEPHAMIDE S.O.P.
92
16,100
BORDERED GAUZE
10
B
b-complex vitamins
5,55
bacitracin (topical)
5
BREO ELLIPTA
98
bacitracin zinc
5
BRILINTA
46
PAGE 107
brimonidine tartrate
94
carbidopa
36
bromocriptine mesylate
36
carbidopa-levodopa
36
brompheniramine & phenyleph
14
CARDIOCOM LANCING DEVICE
72
brompheniramine & pseudoeph
14
CAREONE ADVANCED LANCING DEV
72
budesonide (inhalation)
95
CAREONE INSULIN SYRINGE
72
bumetanide
51
CAREONE LANCET THIN 23G
72
bupropion hcl
29
CAREONE LANCET ULTRA THIN 28G
72
bupropion hcl (smoking deterrent)
22
CAREONE ULTIGUARD INSULIN SYR
72
29
CARRASMART
10
29
CARRASMART FOAM
10
buspirone hcl
41
carteolol hcl (ophth)
94
butalbital-acetaminophen
54
carvedilol
48
butalbital-acetaminophen-caffeine
54
cefaclor
24
butalbital-acetaminophen-caffeine w/ codeine
20
CEFACLOR
24
cefadroxil
24
24
butalbital-aspirin-caffeine
19,54
butalbital-aspirin-caffeine w/cod
20
cefdinir
BYDUREON
42
cefprozil
24,25
BYETTA 10 MCG PEN
42
CEFTIN
25
BYETTA 5 MCG PEN
43
ceftriaxone sodium
25
cefuroxime axetil
25
celecoxib
19
C
CAFERGOT
33
CENTANY
23
caffeine citrate
97
cephalexin
25
calcipotriene
55
CERAVE
6
calcitonin (salmon)
69
CERAVE AM SPF 30
5
calcitriol
69
CERAVE PM
6
calcium acetate (phosphate binder)
60
CERAVE SA RENEWING
6
calcium carbonate
15
CERTAVITE SENIOR/ANTIOXIDANT
calcium carbonate (antacid)
8
16
CETAPHIL DAILY ADVANCE
6
calcium carbonate-cholecalciferol
15
CETAPHIL DAILY FACIAL MOIST
6
calcium carbonate-vitamin d
15
CETAPHIL DERMACONTROL/SPF 30
6
calcium polycarbophil
8
CETAPHIL MOISTURIZING
6
CAM
5
CETAPHIL RESTORADERM
6
camphor & menthol
5
cetirizine hcl
CAPHOSOL
55
14
13,95
capsaicin
5
13
captopril
47
13
captopril & hydrochlorothiazide
50
14
CARAFATE
59
cetirizine-pseudoephedrine
14
carbamazepine
28
CHANTIX
22
carbamide peroxide (otic)
13
CHANTIX CONTINUING MONTH PAK
22
PAGE 108
CHANTIX STARTING MONTH PAK
22
clonidine hcl
47
CHEK-STIX CONTROL
72
clopidogrel bisulfate
47
CHEMET
99
clorazepate dipotassium
42
CHEMSTRIP K
72
CLOSERCARE
72
childrens loratadine syrup 5 mg/5ml
14
clotrimazole (topical)
chlordiazepoxide hcl
42
clotrimazole vaginal
chlorhexidine gluconate (mouth-throat)
55
clotrimazole w/ betamethasone
56
chloroquine phosphate
35
clozapine
37
chlorothiazide
51
coal tar extract
chlorpheniramine & phenylephrine
14
COARTEM
35
chlorpheniramine maleate
14
codeine sulfate
20
14
colchicine w/ probenecid
32
chlorpromazine hcl
36
COLEMAN 100 MAX CONTINUOUS SPR
10
chlorthalidone
51
COLEMAN INSECT REPEL HIGH&DRY
10
chlorzoxazone
99
COLEMAN INSECT REPEL SPORTSMEN
10
CHOLBAM
58
colestipol hcl
52
COMBIPATCH
63
cholecalciferol
9,16
4,31
4
6
cholestyramine
52
COMBIVENT RESPIMAT
98
cholestyramine light
52
COMFORT ASSIST INSULIN SYRINGE
72
choline & mag salicylate
19
COMFORT ASSURED LANCETS 28G
72
cilostazol
47
COMFORT ASSURED LANCETS 33G
72
CILOXAN
26
COMFORT EZ INSULIN SYRINGE
72
cimetidine
8,58
COMFORT LANCETS
73
38
cimetidine hcl
58
COMPLERA
CIPRODEX
94
complete ready-to-use enema enema 7-19 gm/118ml 8
ciprofloxacin hcl
26
COMPLETENATE
ciprofloxacin hcl (ophth)
26
COPAXONE
55
citalopram hydrobromide
30
COREG CR
48
clarithromycin
26
cortisone acetate
61
CLEANLET LANCETS 28G
72
COTELLIC
35
clemastine fumarate tab 1.34 mg
14
CREON
57
CLINDAGEL
23
CRINONE
66
clindamycin hcl
23
CRIXIVAN
40
clindamycin palmitate hydrochloride
23
cromolyn sodium
98
clindamycin phosphate (topical)
23
cromolyn sodium (nasal)
10
clindamycin phosphate vaginal
23
cromolyn sodium (ophth)
93
clindamycin phosphate-benzoyl peroxide
56
CUPRIMINE
60
clobetasol propionate
61
CURITY ALCOHOL PREPS
10
clobetasol propionate emollient base
61
CURITY ALCOHOL SWABS
10
clomipramine hcl
31
CUTTER
10
clonazepam
42
CUTTER ALL FAMILY
10
PAGE 109
100
CUTTER BACKWOODS
10
desogestrel-ethinyl estradiol (triphasic)
CUTTER BACKWOODS DRY
10
Desogestrel-Ethinyl Estradiol TAB 0.15-0.02/0.01 MG
CUTTER DRY
10
(Azurette, Kariva, Pimtrea, Viorele, Caziant, Cesia,
CUTTER SKINSATIONS
11
Velivet)
CUTTER SPORT
11
Desogestrel-Ethinyl Estradiol TAB 0.15-30 MG-MCG
CVS ALCOHOL PREP SWABS
11
(Apri, Emoquette, Enskyce, Reclipsen, Solia)
63
CVS ALCOHOL SWABS
11
DESOXIMETASONE
61
dexamethasone
61
CVS DAILY ULTRA MOISTURE
6
63
63
CVS INSECT REPELLENT
11
DEXAMETHASONE INTENSOL
61
CVS INSULIN SYRINGE
73
dexamethasone sodium phosphate
61
CVS LANCETS 21G
73
dexamethasone sodium phosphate (ophth)
93
CVS LANCETS MICRO THIN 33G
73
dexmethylphenidate hcl
54
CVS LANCETS ORIGINAL
73
dextroamphetamine sulfate
53
CVS LANCETS THIN
73
dextromethorphan-guaifenesin
14
CVS LANCETS THIN 26G
73
dextrose (diabetic use)
CVS LANCETS ULTRA THIN 30G
73
DIASTAR EASY TEST II LANCETS
73
CVS LANCING DEVICE
73
DIASTAR EASY TEST LANCETS
73
CVS PREP
11
diazepam
42
CVS TOTAL HOME INSECT REPEL
11
diazepam (anticonvulsant)
27
CVS ULTRA THIN LANCETS
73
dibucaine
cyanocobalamin
100
4
6
diclofenac potassium
19
cyclobenzaprine hcl
99
diclofenac sodium
19
cyclopentolate hcl
92
diclofenac sodium (ophth)
93
cyclophosphamide
34
dicloxacillin sodium
25
cyclosporine
67
dicyclomine hcl
57
cyclosporine modified (for microemulsion)
67
didanosine
39
cyproheptadine hcl
95
diflorasone diacetate
61
diflunisal
19
digoxin
50
D
dapsone
33
dihydroergotamine mesylate
33
DELZICOL
69
DILANTIN
28
DEPO-SUBQ PROVERA 104
66
diltiazem hcl
49
DERMALEVIN ADHESIVE
11
diltiazem hcl coated beads
49
DERMAVITE
16
diltiazem hcl extended release beads
49
DESCOVY
39
diphenhydramine hcl
14
desipramine hcl
31
diphenhydramine hcl (sleep)
15
desmopressin acetate
62
14
desmopressin acetate refrigerated
62
14,95
desmopressin acetate spray
62
diphenhydramine hcl elixir 12.5 mg/5ml
96
desmopressin acetate spray refrigerated
62
diphenhydramine hcl liquid 12.5 mg/5ml
14
desogestrel & ethinyl estradiol
63
diphenoxylate w/ atropine
58
PAGE 110
dipyridamole
47
E-Z SPACER THE BODY GUARDS PK
74
disopyramide phosphate
48
E.E.S. 400
26
disulfiram
21
E.E.S. GRANULES
26
divalproex sodium
27
EASIVENT
74
docusate sodium
9
EASIVENT MASK LARGE
74
9
EASIVENT MASK MEDIUM
74
donepezil hydrochloride
28
EASIVENT MASK SMALL
74
DONNATAL
57
EASY COMFORT INSULIN SYRINGE
74
dorzolamide hcl
94
EASY MINI LANCING DEVICE
74
dorzolamide hcl-timolol maleate
94
EASY TOUCH ALCOHOL PREP MEDIUM
11
doxazosin mesylate
47
EASY TOUCH INSULIN SAFETY SYR
74
doxepin hcl
31
EASY TOUCH INSULIN SYRINGE
74
doxycycline hyclate
27
EASY TOUCH LANCETS 26G
74
doxylamine succinate (sleep)
15
EASY TOUCH LANCETS 26G/TWIST
74
DROPLET LANCETS ULTRA THIN 30G
73
75
DROPLET LANCING DEVICE
73
75
drospirenone-ethinyl estradiol
63
75
Drospirenone-Ethinyl Estradiol TAB 3-0.03 MG (Gianvi,
75
Loryna, Nikki, Vestura, Ocella, Syeda, Zarah)
63
75
DROXIA
34
75
DRUG MART LANCETS THIN 26G
73
75
DRUG MART LANCETS ULTRA THIN
73
EASY TOUCH LANCING DEVICE
75
DRUG MART LANCING DEVICE
73
econazole nitrate
31
DRUG MART ULTRA COMFORT SYR
73
EDURANT
38
DRUG MART UNILET LANCETS 28G
73
EFFIENT
47
DRUG MART UNILET LANCETS 30G
73
ELIDEL
56
DRYSOL
56
ELIQUIS
45
DUANE READE LANCET ALTERN SITE
73
ELIXOPHYLLIN
98
DUANE READE LANCET SUPER THIN
74
ELLA
65
DUANE READE LANCET ULTRA THIN
74
ELMIRON
60
DULERA
98
emollient
5
duloxetine hcl
54
EMTRIVA
39
DUTOPROL
50
enalapril maleate
47
enalapril maleate & hydrochlorothiazide
50
ENBREL
67
E
E-Z JECT LANCET MICRO-THIN 33G
74
ENBREL SURECLICK
67
E-Z JECT LANCET SUPER THIN 30G
74
ENDOMETRIN
66
E-Z JECT LANCETS
74
ENFALYTE
15
E-Z JECT LANCETS 21G
74
ENFAMIL ENFALYTE
15
E-Z JECT LANCETS THIN 26G
74
enoxaparin sodium
E-Z SPACER
74
EPANED
PAGE 111
45,46
47
EPIFOAM
56
EZ-LETS LANCETS 26G
75
EPINEPHRINE
97
EZ-LETS LANCETS 28G
75
EPIPEN
97
EZ-LETS LANCETS 30G
75
EPIPEN 2-PAK
97
EPIPEN JR
97
F
EPIPEN JR 2-PAK
97
famotidine
EPZICOM
39
FARESTON
34
EQL COLOR LANCETS 21G
75
felbamate
28
EQL COLOR LANCETS MICRO 33G
75
felodipine
49
EQL INSULIN SYRINGE
75
fenofibrate
52
EQL SUPER THIN LANCETS 30G
75
fenofibrate micronized
52
EQL THIN LANCETS 26G
75
fentanyl
20
FERRETTS
15
ergocalciferol
100
8,58
ergoloid mesylates
28
ferrous fumarate
15
ERY-TAB
26
ferrous fumarate-fa-b complex-c-zn-mg-mn-cu
99
ERYPED 200
26
ferrous gluconate
16
ERYPED 400
26
ferrous sulfate
16
ERYTHROCIN STEARATE
26
14
erythromycin (acne aid)
26
14
erythromycin (ophth)
26
fiber cap 0.52 gm
ERYTHROMYCIN BASE
26
FIFTY50 ALCOHOL PREP
11
erythromycin base
26
FIFTY50 LANCING DEVICE
76
ERYTHROMYCIN ETHYLSUCCINATE
26
FIFTY50 SUPERIOR COMFORT SYR
76
escitalopram oxalate
30
finasteride
60
esomeprazole magnesium
59
FIRST-OMEPRAZOLE
59
ESTRACE
63
flavoxate hcl
59
estradiol
63
flecainide acetate
48
estradiol & norethindrone acetate
63
FLEXICHAMBER
76
estropipate
63
FLEXZAN
11
ethambutol hcl
34
FLONASE ALLERGY RELIEF
13
ethosuximide
27
FLOVENT DISKUS
95
Ethynodiol Diacetate & Ethinyl Estradiol Tab 1 MG-35
FLOVENT HFA
95
MCG (Kelnor, Zovia)
64
fluconazole
etodolac
19
fludrocortisone acetate
61
EURAX
35
flunisolide (nasal)
95
EVOTAZ
40
fluocinolone acetonide (otic)
94
EXEL COMFORT POINT INSULIN SYR
75
fluocinonide
61
exemestane
35
fluocinonide emulsified base
61
EZ SMART BLOOD GLUCOSE LANCETS
75
fluorometholone (ophth)
93
EZ-LETS LANCETS 21G
75
fluorouracil (topical)
56
EZ-LETS LANCETS 23G
75
fluoxetine hcl
30
PAGE 112
9
31,32
fluphenazine decanoate
36
GLOBAL LANCING DEVICE
76
fluphenazine hcl
36
GLUCAGEN HYPOKIT
44
flurazepam hcl
99
GLUCAGON EMERGENCY
44
flurbiprofen
19
GLUCOCOM LANCETS 28G
76
flurbiprofen sodium
93
GLUCOCOM LANCETS 30G
76
flutamide
34
GLUCOLET 2 AUTOMATIC LANCING
76
fluticasone propionate
61
GLUCOPRO INSULIN SYRINGE
76
fluticasone propionate (nasal)
95
GLUCOSOURCE LANCET DEVICE
76
fluvoxamine maleate
30
GLUCOSOURCE LANCETS
77
FML
93
glyburide
43
glyburide micronized
43
43
folic acid
16,100
FORA LANCETS
76
glyburide-metformin
FORA LANCING DEVICE
76
glycerin (laxative)
FORA TN'G VOICE
76
glycopyrrolate
FORADIL AEROLIZER
97
GNP ADVANCED RECOVERY
formaldehyde
76
GNP ALCOHOL SWABS
9
57
6
11
FORMULA 405 BODY SMOOTHING
6
GNP GLUCOSE
4
FORMULA 405 MOISTURIZING
6
GNP INSULIN SYRINGE
77
FORTICAL
69
GNP LANCETS
77
fosinopril sodium
47
GNP LANCETS 21G
77
fosinopril sodium & hydrochlorothiazide
50
GNP LANCETS MICRO THIN 33G
77
FREDS PHARMACY AUTOLET LANCING
76
GNP LANCETS SUPER THIN 30G
77
FREDS PHARMACY UNILET LANC 28G
76
GNP LANCETS THIN
77
FREDS PHARMACY UNILET LANC 30G
76
GNP LANCETS THIN 26G
77
FREESTYLE PRECISION INS SYR
76
GNP MICRO THIN LANCETS 33G
77
furosemide
51
GNP PRENATAL
16
GNP STERILE PADS
11
GNP SUPER THIN LANCETS 30G
77
G
gabapentin
27
GNP ULTRA COM INSULIN SYRINGE
77
GABITRIL
27
GOODSENSE PRENATAL VITAMINS
17
griseofulvin microsize
32
galantamine hydrobromide
28,29
gauze pads & dressings
11
griseofulvin ultramicrosize
32
gemfibrozil
52
guaifenesin-codeine
15
gentamicin sulfate (ophth)
23
guanfacine hcl
47
gentamicin sulfate (topical)
23
GYNAZOLE-1
32
GENVOYA
38
GILENYA
55
H
glimepiride
43
H&H THINLET LANCETS 26G
77
glipizide
43
H&H THINLET LANCETS 30G
77
glipizide-metformin hcl
43
H-E-B INCONTROL ADV LANCING
77
GLOBAL INJECT EASE INSULIN SYR
76
H-E-B INCONTROL LANCETS 28G
77
PAGE 113
77
hydrocodone-acetaminophen
77
hydrocortisone
61
haloperidol
37
hydrocortisone (intrarectal)
69
haloperidol decanoate
37
hydrocortisone (rectal)
69
haloperidol lactate
37
hydrocortisone (topical)
6,56
HEALTH CARE LANCING DEVICE
77
hydrocortisone butyrate
61
HEALTHWISE LANCING PEN
77
hydrocortisone w/acetic acid
94
HEALTHY ACCENTS LANCING DEVICE
77
hydrocortisone-aloe vera
HEALTHY ACCENTS UNILET LANCETS
78
hydromorphone hcl
21
HEMANGEOL
34
hydroxychloroquine sulfate
35
heparin sodium (porcine)
46
hydroxyurea
34
HM COMPLETE
17
hydroxyzine hcl
96
HM COMPLETE 50+ MENS ULTIMATE
17
hydroxyzine pamoate
96
HM COMPLETE 50+ WOMEN ULTIMATE
17
hyoscyamine sulfate
58
HM HAIR/SKIN/NAILS
17
HYPERRHO S/D
68
HM LANCETS MICRO THIN 33G
78
hypromellose (ophth)
13
HM LANCETS ULTRA THIN 30G
78
HM ONE DAILY MENS
17
I
HM ONE DAILY WOMENS
17
ibuprofen
HM PRENATAL
17
ibuprofen tab 200 mg
HUMALOG
44
ICAPS AREDS FORMULA
17
HUMALOG KWIKPEN
44
ICAPS PLUS
17
HUMALOG MIX 50/50
44
imipramine hcl
31
HUMALOG MIX 50/50 KWIKPEN
44
imiquimod
56
HUMALOG MIX 75/25
44
IN TOUCH LANCING DEVICE
78
HUMALOG MIX 75/25 KWIKPEN
44
INATAL ADVANCE
100
HUMIRA
67
INATAL GT
101
HUMIRA PEDIATRIC CROHNS START
68
INATAL ULTRA
101
HUMIRA PEN
68
INCRUSE ELLIPTA
96
HUMIRA PEN-CROHNS STARTER
68
indapamide
52
HUMIRA PEN-PSORIASIS STARTER
68
indomethacin
19
HUMULIN 70/30
44
INSPIRACHAMBER/MEDIUM
78
HUMULIN 70/30 KWIKPEN
44
INSPIRACHAMBER/MOUTHPIECE
78
HUMULIN N
45
INSPIRACHAMBER/SMALL
78
HUMULIN N KWIKPEN
44
INSPIREASE
78
HUMULIN R
45
INSPIREASE BAGS
78
HY-VEE LANCETS
78
INSPIREASE MOUTHPIECE
78
HY-VEE THIN LANCETS
78
INSPIREASE RESERVOIR BAGS
78
hydralazine hcl
53
78
hydrochlorothiazide
52
insulin pen needle 29 g x 12.7 mm
78
hydrocodone w/ homatropine
98
78
PAGE 114
20,21
6
3,19
3
78
78
78
K
78
KALETRA
40
78
KALYDECO
97
78
KERI ADVANCED MOISTURE THERAPY
6
KERI BASIC ESSENTIALS
6
INSULIN SYRINGE
78,79
JENTADUETO
43
insulin syringe (disp) u-100 1 ml
78
KERI NOURISHING SHEA BUTTER
6
INSULIN SYRINGE/NEEDLE
79
KERI ORIGINAL
6
insulin syringe/needle u-100
79
KERI OVERNIGHT
6
79
KERI RENEWAL MILK BODY
6
79
KERI RENEWAL SKIN FIRMING
6
79
KERI RENEWAL STRETCH MARK
6
insulin syringe/needle u-100 1 ml 25 x 1"
79
KERI SENSITIVE SKIN
6
79
KETOCARE
79
79
ketoconazole (topical)
32
79
ketoprofen
19
79
ketorolac tromethamine
19
79
ketorolac tromethamine (ophth)
93
79
KETOSTIX
79
79
ketotifen fumarate (ophth)
13
79
KINNEY LANCETS
79
INTELENCE
38
KINNEY THIN LANCETS
79
INVIRASE
40
KINRAY INSULIN SYRINGE
79
IOPIDINE
94
KLOR-CON
100
ipratropium bromide
96
KLOR-CON M15
100
ipratropium bromide (nasal)
96
KOMBIGLYZE XR
43
ipratropium-albuterol
98
KROGER INSULIN SYRINGE
80
irbesartan
47
KROGER LANCETS
80
irbesartan-hydrochlorothiazide
50
KROGER LANCETS 21G
80
IRON CHEWS PEDIATRIC
16
KROGER LANCETS MICRO THIN 33G
80
ISENTRESS
38
KROGER LANCETS SUPER THIN
80
isoniazid
34
KROGER LANCETS THIN
80
ISONIAZID
34
KROGER LANCETS THIN 26G
80
isosorbide dinitrate
53
KROGER LANCETS ULTRATHIN 30G
80
isosorbide mononitrate
53
KROGER LANCING DEVICE
80
isotretinoin
56
itraconazole
32
labetalol hcl
J
JADENU
PAGE 115
L
48,49
lactic acid (ammonium lactate)
99
lactulose
7,56
58
lactulose (encephalopathy)
58
Levonorgestrel-Ethinyl Estrad TAB 0.1-20 MG (Aubra,
LADY LITE LANCETS
80
Aviane, Delyla, Falmina, Lessina, Lutera, Orsythia,
lamivudine
39
Sronyx)
lamivudine-zidovudine
39
Levonorgestrel-Ethinyl Estrad TAB 0.15-30 MG
lamotrigine
28
(Altavera, Chateal, Kurvelo, Levora, Marlissa, Portia)64
LANCET DEVICE
80
levothyroxine sodium
67
LANCET DEVICE WITH EJECTOR
80
LEXIVA
40
lancet devices
70
LIBERTY MINI LANCING DEVICE
81
lancets
70
LICEMD
7
LANCETS
80
lidocaine
56
LANCETS 28G
80
lidocaine hcl
LANCETS 30G
80
lidocaine hcl (mouth-throat)
21
LANCETS THIN
80
lidocaine-prilocaine
21
LANCETS ULTRA THIN
80
liothyronine sodium
67
LANCING DEVICE
80
lisinopril
48
lansoprazole
9,59
64
21,56
lisinopril & hydrochlorothiazide
50,51
LANTUS
45
LITE TOUCH LANCING DEVICE
81
LANTUS SOLOSTAR
45
LITE TOUCH LANCING PEN
81
LANZO
80
LITETOUCH INSULIN SYRINGE
81
latanoprost
94
lithium
42
LEADER ADVANCED LANCING DEVICE
80
lithium carbonate
42
LEADER INSULIN SYRINGE
80
LIVE BETTER ADV LANCING DEVICE
81
leflunomide
69
LIVE BETTER LANCET SUPER THIN
81
letrozole
35
LIVE BETTER LANCET ULTRA THIN
81
leucovorin calcium
35
LONGS LANCETS STANDARD
81
LEUKERAN
34
LONGS LANCETS THIN
81
LEVEMIR
45
loperamide hcl
LEVEMIR FLEXPEN
45
loperamide hcl tab 2 mg
LEVEMIR FLEXTOUCH
45
loratadine
14
levetiracetam
27
loratadine & pseudoephedrine
15
levobunolol hcl
94
loratadine allergy relief tab disp 10 mg
14
14
lorazepam
42
Levonorg-Eth Est Tab 0.15-0.03MG(84) & Eth Est Tab
losartan potassium
47
0.01MG(7) (Amethia, Camrese, Daysee)
losartan potassium & hydrochlorothiazide
51
lovastatin
52
loxapine succinate
37
levocarnitine (metabolic modifiers)
101
levofloxacin
26
64
Levonorgest-Eth Estrad 91-Day TAB 0.15-0.03 MG
(Introvale, Jolessa, Quasense)
64
levonorgestrel (emergency oc)
9,66
Levonorgestrel-Eth Estra Tab 0.05-30/0.075-40/0.12530MG (Enpresse, Levonest, Myzilra, Trivora)
64
LUBRISOFT
8
7
M
M-VIT
PAGE 116
8,58
101
MAGELLAN INSULIN SAFETY SYR
81
methimazole
67
magnesium citrate solution 1.745 gm/30ml
9
METHITEST
62
magnesium oxide
8
methocarbamol
99
MAJOR COMFORT LANCETS
81
methotrexate sodium
68
MAKENA
66
methyldopa
47
malathion
35
methylergonovine maleate
82
maprotiline hcl
30
methylphenidate hcl
54
MAXI-COMFORT INSULIN SYRINGE
81
METHYLPHENIDATE HCL ER
54
4,31
methylprednisolone
61
MEDI-LANCE LANCETS
81
metoclopramide hcl
31
MEDIC INSULIN SYRINGE
81
metolazone
52
MEDICINE SHOPPE LANCETS
81
metoprolol & hydrochlorothiazide
51
MEDICINE SHOPPE LANCETS THIN
81
metoprolol succinate
49
MEDISENSE THIN LANCETS
81
metoprolol tartrate
49
medroxyprogesterone acetate
66
metronidazole
23
medroxyprogesterone acetate (contraceptive)
66
metronidazole (topical)
24
mefloquine hcl
35
metronidazole cream 0.75 %
23
MEGA MULTIVITAMIN FOR MEN
17
metronidazole gel 0.75 %
24
MEGA MULTIVITAMIN FOR WOMEN
17
metronidazole vaginal
24
megestrol acetate
66
mexiletine hcl
48
MEIJER ALCOHOL SWABS
11
MIACALCIN
69
MEIJER LANCETS
81
MICONAZOLE 3
32
MEIJER LANCETS THIN
81
miconazole nitrate (topical)
4
MEIJER LANCETS UNIVERSAL 30G
82
miconazole nitrate vaginal
4
MEIJER LANCETS UNIVERSAL 33G
82
midazolam hcl
42
MEIJER SUPER THIN LANCETS
82
midodrine hcl
47
melatonin
11
milk of magnesia suspension 400 mg/5ml
meloxicam
19
MINI LANCING DEVICE
82
memantine hcl
29
MINIVELLE
64
meperidine hcl
21
minocycline hcl
27
minoxidil
53
meclizine hcl
9
MEPHYTON
101
meprobamate
41
mirtazapine
29
mercaptopurine
34
misoprostol
59
mesalamine
69
MOISTUREL
metaproterenol sulfate
97
mometasone furoate
61
metformin hcl
43
mometasone furoate (nasal)
95
methadone hcl
20
MONOJECT INSULIN SYRINGE
82
methazolamide
94
MONOJECT ULTRA COMFORT SYRINGE
82
methenamine mandelate
23
MONOLET LANCETS
82
methenamine-hyosc-methylene blue-sod phos-phenyl
MONOLET OPD LANCETS
82
sal
montelukast sodium
96
PAGE 117
23
7
MOORE MONO INSULIN SYRINGE
NESSI SPACER WITH MOUTHPIECE
11
20,21
NEVANAC
93
MS INSULIN SYRINGE
82
nevirapine
38
multiple vitamin
16
NEXIUM
59
multiple vitamins w/ iron
16
niacin
morphine sulfate
multiple vitamins w/ minerals
82
16,100
4,17
NIACOR
52
mupirocin
24
NICADAN
mupirocin calcium (topical)
24
nicardipine hcl
mycophenolate mofetil
68
nicotine
3
mycophenolate sodium
68
NICOTINE
3
MYLERAN
34
nicotine polacrilex
3
N
101
49
NICOTROL
22
NICOTROL NS
22
nabumetone
19
nifedipine
50
nadolol
49
NINLARO
35
naloxone hcl
22
NITRO-BID
53
naltrexone hcl
22
nitrofurantoin
24
naphazoline hcl
92
nitrofurantoin macrocrystal
24
naproxen
19
nitrofurantoin monohyd macro
24
3,19
nitroglycerin
53
3
NITROSTAT
53
naratriptan hcl
33
NIVA-PLUS
101
NARCAN
22
NORDITROPIN FLEXPRO
62
NASAL DECONGESTANT
11
NORDITROPIN NORDIFLEX PEN
62
nasal moisturizing spray solution 0.65 %
11
Norelgestromin-Ethinyl Estradiol TD PTWK 150-35
naproxen sodium
NATAL-V RX
101
MCG/24HR (Xulane)
NATALVIT
101
Norethindrone & Ethinyl Estradiol Tab 0.4 MG-35 MCG
nateglinide
43
(Balziva, Briellyn, Gildagia, Philith, Vyfemla,
NECON 1/50 (28)
64
Zenchent)
NECON 10/11 (28)
64
Norethindrone & Ethinyl Estradiol Tab 0.5 MG-35 MCG
nefazodone hcl
30
(Necon, Nortrel, Wera)
neomycin sulfate
23
Norethindrone & Ethinyl Estradiol Tab 1 MG-35 MCG
neomycin-bacitracin zn-polymyxin
92
(Alyacen, Cyclafem, Dasetta, Necon, Nortrel,
neomycin-bacitracin-polymyxin
neomycin-polymy-dexameth
neomycin-polymyxin w/ pramoxine
5
92
7
64
64
64
Pirmella)
64
Norethindrone Ace & Ethinyl Estradiol Tab 1 MG-20
MCG (Gildess, Junel, Larin, Microgestin)
64
neomycin-polymyxin-gramicidin
92
Norethindrone Ace & Ethinyl Estradiol Tab 1.5 MG-30
neomycin-polymyxin-hc (ophth)
92
neomycin-polymyxin-hc (otic)
94,95
NESSI SPACER WITH MASK LARGE
11
NESSI SPACER WITH MASK SM/MED
11
PAGE 118
64
Norethindrone Ace & Ethinyl Estradiol-FE Tab 1 MG-20
64
Norethindrone Ace & Ethinyl Estradiol-FE Tab 1.5 MG-
nystatin
32
30 MCG (Gildess, Junel, Larin, Microgestin)
65
nystatin (mouth-throat)
32
norethindrone acetate
66
nystatin (topical)
32
nystatin-triamcinolone
32
Norethindrone Tab 0.35 MG (Camila, Deblitane, Errin,
Heather, Jencycla, Jolivette, Lyza, Nora-BE, Norlyroc,
Sharobel)
66
O
Norethindrone-Eth Estradiol Tab 0.5-35/0.75-35/1-35
O-CAL FA
101
MG (Alyacen, Cyclafem, Dasetta, Necon, Nortrel,
O-CAL PRENATAL
101
Pirmella)
65
OFF ACTIVE
11
OFF DEEP WOODS
11
OFF DEEP WOODS DRY
11
Norgestimate & Ethinyl Estradiol Tab 0.25 MG-35 MCG
OFF DEEP WOODS SPORTSMEN
12
(Estarylla, Mono-Linyah, MonoNessa, Previfem,
OFF SMOOTH & DRY
12
ofloxacin
27
Norgestimate-Eth Estrad Tab 0.18-35/0.215-35/0.25-35
ofloxacin (ophth)
26
MG (Tri-Estarylla, Tri-Linyah, Tri-Previfem, Tri-
ofloxacin (otic)
27
OGESTREL
65
olanzapine
37
Norethindrone-Eth Estradiol Tab 0.5-35/1-35/0.5-35
MG (Aranelle, Leena)
Sprintec)
Sprintec, Trinessa)
65
65
65
Norgestrel & Ethinyl Estradiol Tab 0.3 MG-30 MCG
(Cryselle, Elinest, Low-Ogestrel)
65
omega-3 fatty acids
4
NORINYL 1+50 (28)
65
omeprazole
nortriptyline hcl
31
omeprazole delayed release tab 20 mg
9
NORVIR
40
OMEPRAZOLE+SYRSPEND SF ALKA
59
NOVA MAX PLUS KETONE TEST
11
ON CALL LANCING DEVICE
82
NOVA SUREFLEX LANCETS
82
ON CALL PLUS LANCING DEVICE
82
NOVA SUREFLEX LANCING DEVICE
82
ONCOVITE
17
NOVOLIN 70/30
45
ondansetron hcl
31
NOVOLIN 70/30 RELION
45
31
NOVOLIN N
45
31
NOVOLIN N RELION
45
ONETOUCH DELICA LANCING DEV
82
NOVOLIN R
45
ONETOUCH LANCETS
82
NOVOLIN R RELION
45
ONETOUCH VERIO FLEX SYSTEM
83
NOVOLOG
45
ONGLYZA
43
NOVOLOG FLEXPEN
45
OPTIFOAM
12
NOVOLOG MIX 70/30
45
oral electrolytes
15
NOVOLOG MIX 70/30 FLEXPEN
45
ORKAMBI
97
NOVOLOG PENFILL
45
ORSINI INSULIN SYRINGE
83
59
NUTRADERM
7
ORTHO DIAPHRAGM ALL-FLEX
83
NUTRADERM ADVANCED FORMULA
7
ORTHO DIAPHRAGM COIL
83
NUTRADERM-30
7
ORTHO DIAPHRAGM FLAT
83
NUTRICAP
101
oxaprozin
19
NUVARING
65
oxazepam
42
PAGE 119
oxcarbazepine
28
phenylephrine-cocoa butter
7
oxybutynin chloride
59,60
phenylephrine-dm
15
oxycodone hcl
20,21
phenylephrine-shark liver oil-cocoa butter
7
7
oxycodone w/ acetaminophen
21
phenylephrine-shark liver oil-mineral oil-petrolatum
oxycodone-aspirin
21
phenytoin
28
oyster shell
16
phenytoin sodium extended
28
PHRENILIN FORTE
54
pilocarpine hcl
94
P
PANCREAZE
57
pilocarpine hcl (oral)
55
pancrelipase (lipase-protease-amylase)
57
pindolol
49
pantoprazole sodium
59
pioglitazone hcl
43
paregoric
58
pioglitazone hcl-metformin hcl
44
paroxetine hcl
30
piroxicam
20
PAXIL
30
PLEGRIDY
55
PC LANCETS SUPER THIN 30G
83
PLEGRIDY STARTER PACK
55
PCE
26
PNV FE FUM/DOCUSATE/FOLIC ACID
102
PNV FOLIC ACID + IRON
102
ped multivitamins w/fl & iron
100
pediatric multiple vitamin w/ c
16
PNV PRENATAL PLUS MULTIVITAMIN
pediatric multiple vitamin w/ c & fa
16
PNV TABS 29-1
pediatric multiple vitamins w/ iron
16
podofilox
pediatric multivitamins w/fl
17,102
102
56
100,102
polyethylene glycol 3350
9,59
102
polymyxin b-trimethoprim
92
pediatric vitamins acd w/ fluoride
pediatric vitamins adc
16
polysaccharide iron complex
17
peg 3350-kcl-sod bicarb-sod chloride-sod sulfate
58
polyvinyl alcohol
13
peg 3350-potassium chloride-sod bicarbonate-sod
pot phosphate monobasic w/ sod phosphate dibasic &
chloride
58
monobasic
penicillin v potassium
25
potassium bicarbonate
100
PENTASA
69
potassium chloride
100
pentoxifylline
51
potassium chloride microencapsulated crystals cr
100
PERFECT LANCETS 30G
83
potassium citrate (alkalinizer)
60
potassium citrate-citric acid
60
36
permethrin
7,12,35
60
perphenazine
31
pramipexole dihydrochloride
perphenazine-amitriptyline
29
pramoxine hcl (rectal)
PHARMACY COUNTER LANCETS
83
pravastatin sodium
52
phenazopyridine hcl
60
prazosin hcl
47
phenelzine sulfate
29
PRECISION SURE-DOSE SYRINGE
83
phenobarbital
28
PRECISION SUREDOSE PLUS SYR
83
phenobarbital-hyoscyamine-atropine-scopolamine
58
PRECISION XTRA KETONE
12
phenyleph-promethazine w/ cod
98
PRED MILD
93
phenylephrine hcl (ophth)
92
PRED-G
92
phenylephrine hcl tab 10 mg
12
prednicarbate
61
PAGE 120
7
prednisolone
61
pseudoephedrine hcl tab 30 mg
12
prednisolone acetate (ophth)
93
pseudoephedrine w/ codeine-gg
15
prednisolone sodium phosphate
61
pseudoephedrine-ibuprofen
15
PREDNISOLONE SODIUM PHOSPHATE
93
PSORCON
62
prednisone
62
psyllium
PREDNISONE INTENSOL
62
PTS PANELS KETONE TEST
12
PREFERRED PLUS INSULIN SYRINGE
83
PULMICORT FLEXHALER
95
PREFERRED PLUS LANCETS COLORED
83
PURIXAN
34
PREFERRED PLUS LANCETS THIN
83
PX ADVANCED LANCING DEVICE
84
PREMARIN
65
PX INSULIN SYRINGE
84
PREMPHASE
65
PX LANCET AUTO INJECTOR
84
PREMPRO
65
PX LANCETS
84
PRENATAL
17
PX LANCETS ULTRA THIN
84
PRENATAL LOW IRON
17
pyrazinamide
34
9
PRENATAL PLUS
102
pyrethrins-piperonyl butoxide
PRENATAL VITAMINS PLUS
102
pyrethrins-piperonyl butoxide-permethrin-nit remover 7
PREPLUS
102
pyridostigmine bromide
33
pyridoxine hcl
18
PRESERVISION AREDS
PRETAB
PREZISTA
PRILOSEC OTC
18
102
40,41
9
7
Q
QC ADVANCED LANCING DEVICE
84
primidone
28
QC ALCOHOL SWABS
12
probenecid
32
QC INSULIN SYRINGE
84
prochlorperazine
31
QC LANCETS SUPER THIN 30G
84
prochlorperazine maleate
31
QC LANCETS ULTRA THIN
84
PRODIGY INSULIN SYRINGE
83
QC UNILET LANCETS MICRO THIN
84
PRODIGY LANCING DEVICE
83
quetiapine fumarate
37
PRODIGY TWIST TOP LANCETS 28G
84
QUFLORA PEDIATRIC
progesterone micronized
66
quinapril hcl
48
promethazine & phenylephrine
98
quinidine gluconate
48
promethazine hcl
96
quinidine sulfate
48
96
96
R
promethazine w/codeine
99
RA ALCOHOL SWABS
12
propafenone hcl
48
RA E-ZJECT COLOR LANCETS 33G
84
propranolol & hydrochlorothiazide
51
RA E-ZJECT LANCETS 28G
84
propranolol hcl
49
RA E-ZJECT LANCETS THIN 26G
84
propylthiouracil
67
RA E-ZJECT LANCETS THIN 28G
84
PRORENAL + D
18
RA E-ZJECT LANCETS ULTRA THIN
84
pseudoephedrine hcl
12
RA INSULIN SYRINGE
84
pseudoephedrine hcl er tab er 12h 120 mg
12
RA LANCING DEVICE
84
PAGE 121
103
raloxifene hcl
66
rivastigmine
29
ramipril
48
rivastigmine tartrate
29
ranitidine hcl
8,58
rizatriptan benzoate
33
RAPAMUNE
68
ropinirole hydrochloride
36
RELENZA DISKHALER
41
RELI-ON INSULIN SYRINGE
84
S
RELION ALCOHOL SWABS
12
SAFESNAP INSULIN SYRINGE
85
RELION INSULIN SYRINGE
84
SAFETY SEAL LANCETS
85
RELION LANCETS MICRO-THIN 33G
85
SAFETY-GLIDE SYRINGE
85
RELION LANCETS STANDARD 21G
85
salicylic acid
56
RELION LANCETS THIN 26G
85
salsalate
20
RELION LANCETS ULTRA-THIN 30G
85
SANDIMMUNE
68
RELION LANCING DEVICE
85
SAVELLA
54
RELION ULTRA THIN LANCETS 30G
85
SAVELLA TITRATION PACK
54
RELION ULTRA THIN PLUS LANCETS
85
SAWYER INSECT REPELLENT
RELPAX
33
SB ALCOHOL PREP
12
RENAPLEX-D
18
SB INSULIN SYRINGE
85
RENEW ADVANCED LANCING DEVICE
85
SB LANCETS THIN
85
REPEL FAMILY
12
SB LANCETS ULTRA THIN
85
REPEL FAMILY DRY
12
SCHNUCKS INSULIN SYRINGE
85
REPEL HUNTERS FORMULA
12
SE-NATAL 19
REPEL SPORTSMEN
12
SELECT-LITE LANCING DEVICE
85
REPEL SPORTSMEN DRY
12
selegiline hcl
36
REPEL SPORTSMEN MAX
7,12
selenium sulfide
REQ 49+
103
SELZENTRY
7,12
103
7,57
40
RESCRIPTOR
38
senna tab 8.6 mg
9
reserpine
51
senna-docusate sodium tab 8.6-50 mg
9
REXALL LANCETS ULTRA THIN 30G
85
sennosides
9
REYATAZ
41
SEREVENT DISKUS
97
RHEUMATREX
68
sertraline hcl
30
RHOGAM ULTRA-FILTERED PLUS
68
SFROWASA
69
rifampin
34
SHOPKO ALCOHOL SWABS
12
RIGHTEST GD500 LANCING DEVICE
85
SHOPKO AUTOLET LANCING DEVICE
85
RIGHTEST GL300 LANCETS
85
SHOPKO UNILET LANCETS 28G
86
69,70
SHOPKO UNILET LANCETS 30G
86
27
risedronate sodium
risperidone
37
silver sulfadiazine
risperidone odt (tab 3 mg, tab 4 mg)
37
simethicone
37
SIMPLE DIAGNOSTICS LANCING DEV
86
37
simvastatin
52
37
sirolimus
68
37
SIVEXTRO
24
PAGE 122
8,12
SM ALCOHOL PREP
12
sulfacetamide sodium
57
SM GAUZE
12
sulfacetamide sodium (acne)
57
4
sulfacetamide sodium (ophth)
27
SM INSULIN SYRINGE
86
sulfacetamide sodium w/ sulfur
57
SM LANCETS 21G
86
sulfamethoxazole-trimethoprim
27
SM LANCETS 33G
86
sulfasalazine
69
SM ONE DAILY MENS
18
sulindac
20
SM ONE DAILY WOMENS
18
sumatriptan nasal spray (5 mg/act, 20 mg/act)
33
SM PRENATAL VITAMINS
18
sumatriptan succinate
33
SM STERILE
12
SUMATRIPTAN SUCCINATE
33
SM SUPER THIN LANCETS 30G
86
SUPER THIN LANCETS
86
SM THIN LANCETS 26G
86
SURE COMFORT INSULIN SYRINGE
86
SMART DIABETES VANTAGE LANCING
86
SURE COMFORT LANCING PEN
86
SMART SENSE COLOR LANCETS 33G
86
SURE-JECT INSULIN SYRINGE
SMART SENSE STANDARD LANCETS
86
SURE-PEN
87
SMART SENSE SUPER THIN LANCETS
86
SURELITE LANCETS
87
SMART SENSE THIN LANCETS 26G
86
SUSTIVA
39
SM GLUCOSE
86,87
soap & cleansers
5
SYMBICORT
99
sodium bicarbonate (antacid)
8
SYMLINPEN 120
44
sodium chloride (gu irrigant)
60
SYMLINPEN 60
44
sodium chloride (inhalant)
99
sodium citrate & citric acid
60
T
sodium fluoride
100
tacrolimus
68
sodium fluoride (dental)
5,55
tacrolimus (topical)
57
TAMIFLU
41
sodium phosphates
8
sodium polystyrene sulfonate
99
tamoxifen citrate
34
SOLUS V2 LANCING DEVICE
86
tamsulosin hcl
60
SOOTHE & COOL MOISTURIZING
7
TAZORAC
57
sorbitol (laxative)
9
TECFIDERA
55
sotalol hcl
48
TECHLITE AST LANCETS
87
sotalol hcl (afib/afl)
48
TECHLITE LANCETS
87
spironolactone
51
TECHLITE LANCETS 30G
87
spironolactone & hydrochlorothiazide
51
temazepam
99
SSKI
67
terazosin hcl
60
stavudine
39
terbinafine hcl
32
STERILANCE TL
86
terbinafine hcl (topical)
STRIBILD
38
terbutaline sulfate
97
terconazole vaginal
32
STROVITE ONE
103
7
SUBOXONE
22
TERUMO INSULIN SYRINGE
87
sucralfate
59
TERUMO SURGUARD INSULIN SYR
87
sulfacetamide sod-prednisolone
92
testosterone cypionate
63
PAGE 123
tetrahydrozoline hcl (ophth)
13
tobramycin
97
TGT ADVANCED LANCING DEVICE
87
tobramycin (ophth)
23
TGT ALCOHOL SWABS
12
tobramycin sulfate
23
TGT BLOOD GLUCOSE MONITORING
87
tobramycin-dexamethasone
93
TGT LANCET ALTERNATE SITE
87
TOBREX
23
TGT LANCET MICRO THIN 33G
87
TODAYS HEALTH LANCING DEVICE
88
TGT LANCET SUPER THIN 30G
87
TODAYS HEALTH THIN LANCETS 28G
88
TGT LANCET THIN 23G
87
TODAYS HEALTH THIN LANCETS 30G
88
TGT LANCET THIN 26G
87
tolmetin sodium
20
TGT LANCET ULTRA THIN 28G
87
tolnaftate
TGT LANCET ULTRA THIN 30G
87
tolterodine tartrate
60
TGT LANCING DEVICE
87
TOPCARE ULTRA COMFORT INS SYR
88
THEO-24
98
TOPICORT
62
theophylline
98
topiramate
28
THERA M PLUS
18
torsemide
51
THERA-M
18
TRADJENTA
44
THERA/BETA-CAROTENE
18
tramadol hcl
21
THEREMS-H
18
tramadol-acetaminophen
21
THEREMS-M
18
trandolapril
48
thiamine hcl
18
tranexamic acid
46
thiamine mononitrate
18
tranylcypromine sulfate
29
trazodone hcl
30
THINPRO INSULIN SYRINGE
87,88
7
thioridazine hcl
37
TRECATOR
34
thiothixene
37
tretinoin
57
THRIVITE 19
103
TREXALL
68
THRIVITE RX
103
TRI-VI-SOL/IRON
18
thyroid
67
TRI-VIT/FLUORIDE/IRON
THYROLAR-1
67
triamcinolone acetonide (mouth)
62
THYROLAR-1/2
67
triamcinolone acetonide (nasal)
95
THYROLAR-1/4
67
triamcinolone acetonide (topical)
62
THYROLAR-2
67
triamterene & hydrochlorothiazide
51
THYROLAR-3
67
triazolam
99
tiagabine hcl
28
TRICARE
103
TIKOSYN
48
trifluoperazine hcl
37
timolol maleate
49
trifluridine
41
timolol maleate (ophth)
94
TRIGLIDE
52
TIMOPTIC OCUDOSE
94
trihexyphenidyl hcl
36
trimethoprim
24
tioconazole vaginal
TIVICAY
4
38
tizanidine hcl
105
TOBRADEX
23
PAGE 124
103
TRINATAL GT
103
TRINATAL RX 1
103
TRIUMEQ
40
TROPAZONE
57
ULTILET LANCETS
89
tropicamide
93
ULTRA COMFORT INSULIN SYRINGE
89
trospium chloride
60
ULTRA THIN LANCETS 28G
90
TRUE METRIX AIR GLUCOSE METER
88
ULTRA THIN LANCETS 30G
90
TRUE METRIX BLOOD GLUCOSE TEST
88
ULTRA-COMFORT INSULIN SYRINGE
90
TRUE METRIX LEVEL 1
88
ULTRA-THIN II INS SYR SHORT
90
TRUE METRIX LEVEL 2
88
ULTRA-THIN II INSULIN SYRINGE
90
TRUE METRIX LEVEL 3
88
ULTRATHON INSECT REPELLENT
7
TRUE METRIX METER
88
ULTRATHON INSECT REPELLENT 8
13
TRUECONTROL GLUCOSE CONT LEV 0
88
UNICOMPLEX-M
18
TRUECONTROL GLUCOSE CONT LEV 1
88
UNILET COMFORTOUCH LANCET
90
TRUEDRAW LANCING DEVICE
88
UNILET EXCELITE
90
TRUEPLUS INSULIN SYRINGE
88
UNILET EXCELITE II
90
TRUEPLUS LANCETS 26G
88
UNILET G.P. LANCET
90
88
UNILET G.P. SUPERLITE LANCET
90
88
UNILET GP 28 ULTRA THIN
90
88
UNILET LANCET
90
TRUERESULT BLOOD GLUCOSE
88
UNILET MICRO-THIN 33G
90
TRUETEST CONTROL LEVEL 1
88
UNILET SUPER-THIN 30G
90
89
UNILET SUPERLITE LANCET
90
89
UNILET ULTRA-THIN 28G
90
TRUETEST TEST
89
UNIVERSAL 1 LANCETS THIN 26G
90
TRUETRACK GLUCOSE CONTROL
89
UNIVERSAL 1 LANCETS ULTRA THIN
90
TRUETRACK TEST
89
urea
57
TRUVADA
39
ursodiol
58
TUDORZA PRESSAIR
96
TWINJECT
97
V
TYBOST
40
V-R MONO INSULIN SYRINGE
91
valacyclovir hcl
41
valganciclovir hcl
38
U
ULTI-LANCE AUTO-ADJUST DEVICE
89
valproate sodium
28
ULTI-LANCE AUTOMATIC
89
valproic acid
28
ULTI-LANCE MINI ADJUSTABLE
89
valsartan
47
ULTICARE INSULIN SAFETY SYR
89
valsartan-hydrochlorothiazide
51
ULTICARE INSULIN SYRINGE
89
VALUE HEALTH INSULIN SYRINGE
91
ULTILET ALCOHOL SWAB
13
VALUE PLUS LANCET STANDARD 21G
91
ULTILET ALCOHOL SWABS
13
VALUE PLUS LANCETS SUPER THIN
91
ULTILET BASIC LANCETS 30G
89
VALUE PLUS LANCETS THIN 26G
91
ULTILET CLASSIC LANCETS
89
VALUE PLUS LANCING DEVICE
91
ULTILET INSULIN SYRINGE
89
VALUMARK LANCET SUPER THIN 30G
91
ULTILET INSULIN SYRINGE SHORT
89
VALUMARK LANCET ULTRA THIN 28G
91
PAGE 125
vancomycin hcl
24
WALGREENS THIN LANCETS
91
VANISHPOINT INSULIN SYRINGE
91
WALGREENS ULTRA THIN LANCETS
92
VENATAL-FA
104
warfarin sodium
46
venlafaxine hcl
30
WATCHHALER
92
VENTOLIN HFA
97
WD MEDIC INSULIN SYRINGE
92
verapamil hcl
50
WEBCOL ALCOHOL PREP LARGE
13
VERIPRED 20
62
WEBCOL ALCOHOL PREP MEDIUM
13
VEXOL
93
white petrolatum-mineral oil
13
VIDA MIA AUTOLET LANCING DEV
91
WIBI
VIDA MIA UNILET LANCETS 28G
91
VIDA MIA UNILET LANCETS 30G
91
X
VIDEX
39
XARELTO
VIGAMOX
27
VIIBRYD
30
7
46
Z
VINATE M
104
zaleplon
99
VINATE ONE
104
ZENPEP
57
VINATE ULTRA
104
ZIAGEN
39
VIRACEPT
41
zidovudine
VIREAD
39
zinc oxide (topical)
39,40
8
VIRT-ADVANCE
104
zinc sulfate
16,100
VIRT-VITE GT
104
ziprasidone hcl
37
zolmitriptan
33
VISTOGARD
91
VITAFOL-OB
104
zolpidem tartrate
99
VITAFOL-PN
104
ZOMIG
33
vitamin e
18
zonisamide
27
vitamins w/ lipotropics
16
ZOVIA 1/50E (28)
65
VITEKTA
38
ZOVIRAX
41
VIVITROL
22
VOL-PLUS
104
VOL-TAB RX
104
VP INSULIN SYRINGE
VP-ZEL
VYVANSE
91
105
53
W
W&F LANCETS 26G
91
W&F LANCETS COLORED 21G
91
WALGREENS LANCETS
91
WALGREENS LANCETS MICRO THIN
91
WALGREENS LANCETS SUPER THIN
91
WALGREENS LANCING DEVICE
91
PAGE 126

New Hampshire Healthy Families

Transcription

Similar documents

Preferred Drug List

CeltiCare Health

HIP State Plus

Aetna`s Pharmacy Tier Listing

Buckeye Health Plan

preferred drug list

Qualified Health Plan Drug Formulary

3-Tier Formulary - Total Health Care

Formulary

Page 1 NY026466_HIX_FOR_CHI ©WellCare 2014 NY_06_14

Rx Formulary - Millenium Medical Solutions Corp

Peach State Health Plan Preferred Drug List