Hoosier Care Connect

Transcription

Comprehensive
PREFERRED DRUG LIST
MHS Indiana Effective 12/1/2016
PAGE 1
LAST UPDATED 10/2016
Pharmacy Program
Managed health Services (MHS) is committed to providing appropriate, high-quality,
and cost-effective drug therapy to all MHS members. MHS works with providers and
pharmacists to ensure that medications used to treat a variety of conditions and
diseases are covered. MHS covers prescription medications and certain over-thecounter (OTC) medications when ordered by an Indiana Medicaid enrolled MHS
practitioner. The pharmacy program does not cover all medications. Some medications
require prior authorization (PA) or have limitations on age, dosage, and maximum
quantities.
For the most current information about the MHS Pharmacy Program you may call
Member Services at 1-877-647-4848 (TTY/TTD 1-800-743-3333) or visit the MHS
website at mhsindiana.com.
Preferred Drug List
The MHS Preferred Drug List (PDL) is the list of covered drugs. The PDL applies to
drugs that members can receive at retail pharmacies. The MHS PDL is continually
evaluated by the MHS Pharmacy and Therapeutics (P&T) Committee to promote the
appropriate and cost-effective use of medications. The Committee is composed of the
MHS Medical Director, MHS Pharmacy Director, and several Indiana physicians,
pharmacists, and specialists.
Pharmacy Benefit Manager
US Script is our Pharmacy Benefit Manager. MHS works with US Script to process all
pharmacy claims for prescribed drugs. Some drugs on the MHS PDL require PA, and
US Script is responsible for administering this process.
Specialty Drugs
Certain medications are only covered when supplied by MHS’ specialty pharmacy provider.
AcariaHealth is our specialty pharmacy provider. A medical provider can obtain specialty
medications through Acaria Health. Acaria Health will ship these medications to the medical
provider’s office. Some selected medications are also available through the medical benefit
upon administration within the medical provider’s office for providers who choose to
inventory these medications for office administration. Billing instructions for this situation can
be found in the provider handbook.
The MHS Pharmacy Director and MHS Medical Director oversee the clinical review of these
medications and AcariaHealth provides members with the following services:


Deliver drugs to the member’s home or provider’s office
Provide staff pharmacists who can help 24 hours a day, seven days a week to
answer member questions and offer help with drugs

Give information, materials, and ongoing support to help members take the drug(s) to
appropriately manage their health condition(s)
These drugs are not usually available at retail pharmacies. Additional information about the
drugs that AcariaHealth provides is in the Biopharmaceutical Pharmacy Program document
located on the MHS website at mhsindiana.com.
Mental Health Drugs
In accordance with Indiana law, all antianxiety, antidepressant, antipsychotic drugs are
considered as being preferred and do not require prior authorizations. If such a mental
health drug is not listed on the PDL it is still considered preferred. Although considered
preferred and no prior authorization is required, mental health drugs may be subject to
utilizations edits such as quantity and age limits, duplicate therapy edits and other
authorization requirements.
Dispensing Limits
Drugs may be dispensed up to a maximum of 30 days supply for each new prescription
or refill. A total of 80% of the days supply or 25 days must have elapsed before the
prescription can be refilled for 30 days supply, non-controlled-substance PDL drugs. A
total of 88% of the days supply must have elapsed before the prescription can be
refilled for controlled substances and narcotic PDL drugs.
Appropriate Use and Safety Edits
Member health and safety is a priority for MHS. One of the ways we address member
safety is through point-of sale (POS) edits at the time a prescription is processed at the
pharmacy. These edits are based on the Food and Drug Administration (FDA)
recommendations and promote safe and effective medication utilization. A primary
example of these recommendations would be limiting the number of fills each month to
one medication in the same therapy classes.
Additional information about the drugs that are part of the these edits can be found in
the Appropriate Use and Safety Edits document located on the MHS website at
mhsindiana.com.
Prior Authorizations
Some medications listed on the MHS PDL may require PA. The information should be
submitted by the practitioner or pharmacist to US Script on the Medication Prior
Authorization Form. This document is located on the MHS website at
mhsindiana.com. The completed form and all clinicals to support the request should be
faxed to US Script at 1-866-399-0929.
MHS will cover the medication if it is determined that:
1. There is a medical reason the member needs the specific medication.
2. Depending on the medication, other medications on the PDL have not worked.
All reviews are performed by a licensed clinical pharmacist using the criteria established
by the MHS P&T Committee. If the request is approved, US Script notifies the
practitioner by fax. If the clinical information provided does not meet the coverage
criteria for the requested medication, MHS will notify the member and their practitioner
of alternatives and provide information regarding the appeal process.
Step Therapy
Some medications listed on the MHS PDL may require specific medications to be used
before the member can receive the step therapy medication. If MHS has a record that
the required medication was tried first, the step therapy medications are automatically
covered. If MHS does not have a record that the required medication was tried, the
member’s practitioner may be required to provide additional information. If MHS does
not grant PA we will notify the member and their practitioner and provide information
regarding the appeal process.
Quantity Limits
MHS may limit how much of a medication a member can get at one time. If the
practitioner feels the member has a medical reason for getting a larger amount, a PA
may be requested. If MHS does not grant PA we will notify the member and their
practitioner and provide information regarding the appeal process.
Age Limits
Some medications on the MHS PDL may have age limits. These are set for certain
drugs based on FDA approved labeling and for safety concerns and quality standards of
care. Age limits align with current FDA alerts for the appropriate use of pharmaceuticals.
Gender Limits
Some medications on the MHS PDL may be limited to one gender. These limits are set
for certain drugs based on FDA-approved labeling and for safety concerns and quality
standards of care. Gender limits align with current FDA alerts for the appropriate use of
pharmaceuticals.
Medical Necessity Requests
If the member requires a medication that does not appear on the PDL, the member’s
practitioner can make a medical necessity (MN) request for the medication. It is
anticipated that such exceptions will be rare and that PDL medications will be
appropriate to treat the vast majority of medical conditions. MHS requires:

Documentation of failure of at least two PDL agents within the same therapeutic
class (provided two agents exist in the therapeutic category with comparable
labeled indications) for the same diagnosis (e.g. migraine, neuropathic pain,
etc.); or

Documented intolerance or contraindication to at least two PDL agents within the
same therapeutic class (provided two agents exist in the therapeutic category
with comparable labeled indications); or

Documented clinical history or presentation where the patient is not a candidate
for any of the PDL agents for the indication.
All reviews are performed by a licensed clinical pharmacist or physician using the
criteria established by the MHS P&T Committee. If the clinical information provided
does not meet the coverage criteria for the requested medication, MHS will notify the
member and their practitioner of alternatives and provide information regarding the
appeal process.
72 Hour Emergency Supply Policy
State and Federal law require that a pharmacy dispense a 72 hour (3 day) supply of
medication to any member awaiting PA determination. The purpose is to avoid
interruption of current therapy or delay in the initiation of therapy. All participating
pharmacies are authorized to provide a 72 hour supply of medication and will be
reimbursed for the ingredient cost and dispensing fee of the 72 hour supply of
medication, whether or not the PA request is ultimately approved or denied. The
pharmacy must call US Script at 1-855-772-7125 for a prescription override to submit
the 72 hour medication supply for payment.
Exclusions
The following drug categories are not part of the MHS PDL and are not covered by the
72 hour emergency supply policy:

Drugs that are considered experimental

Drug Efficacy Study and Implementation (DESI) drugs

Drugs prescribed for weight loss (with the exception of Orlistat)

Drugs prescribed for infertility

Drugs prescribed for erectile dysfunction

Drugs prescribed for cosmetic purposes or hair growth

Cough and cold preparations, minus those covered by OTC program

Infusion therapy and supplies

Immunizations and vaccines (except flu vaccine)

Physician administered drugs that are not listed in the PDL, Specialty Drug
Benefit, or the Physician Administered Drug Prior Authorization List

Hepatitis C Agents*
Effective September 1, 2016 all drugs used in the treatment of Hepatitis C will be
provided by the Office of Medicaid Policy and Planning (OMPP) through the FFS
pharmacy benefit. Any member of MHS who is presently treated with a Hepatitis
C agent prior to September 1, 2016 will continue to get their medication with no
interruption. Any MHS member requesting a Hepatitis C agent after September
1, 2016 will need to have their physician send the prior authorization (PA)
request to:
o Optum Clinical Call Center
o Phone: 855-577-6317
o Fax: 855-577-6384
Newly Approved Products
MHS reviews new drugs for safety and effectiveness before adding them to the PDL.
During this period, access to these medications will be considered through the PA
review process. If MHS does not grant PA, we will notify the member and their
practitioner and provide information regarding the appeal process.
Over-the-Counter Medications
The MHS OTC list covers a variety of medications. A list of covered OTC medications
can be found in the Over-the-Counter Medications program document. These OTCs
are covered when the member has a prescription from a licensed practitioner that meets
all the legal requirements for a prescription.
A list of covered OTC medications in the Over-the-Counter Pharmacy Program is also
located on the MHS website at mhsindiana.com.
Tobacco Cessation Medications
The following types of tobacco cessation medications will be covered by MHS: generic
nicotine replacement products (gum, lozenges, and patches), Bupropion SR 150mg
(Zyban), and Chantix. A prescription will be required for all tobacco cessation
medications.
MHS authorizes benefits for tobacco cessation medications for the purpose of
supporting members who are trying to quit tobacco use with the temporary assistance of
nicotine replacement therapy. It is expected that utilization of these products will be in
accordance with medical standards of practice, FDA guidelines, and manufacturers’
recommendations
Generic Drugs
When generic drugs are available, the brand-name drug will not be covered without
prior MHS authorization. Generic drugs have the same active ingredient, work the same
as brand-name drugs, and have lower copayments. If the member or their practitioner
feels a brand-name drug is medically necessary, the practitioner can request the drug
using the PA process. We will cover the brand-name drug according to our clinical
guidelines if there is a medical reason the member needs the particular brand-name
drug. If MHS does not grant PA, we will notify the member and their practitioner and
provide information regarding the appeal process.
Drug Efficacy Study and Implementation Drugs
Drug Efficacy Study and Implementation (DESI) products and known related drug
products are defined as less than effective by the Food and Drug Administration
because there is a lack of substantial evidence of effectiveness for all labeling
indications and because a compelling justification for their medical need has not been
established. DESI products are not covered by MHS.
Filling a Prescription
A member can have prescriptions filled at an MHS network pharmacy. If the member
decides to have a prescription filled at a network pharmacy they can locate a pharmacy
near them by contacting MHS Member Services or by visiting mhsindiana.com. At the
pharmacy the member will need to provide the pharmacist with the prescription and
their MHS ID card.
Ordering, Prescribing and Referring (OPR) Provider Requirements
To ensure compliance with Indiana Medicaid and the Center for Medicaid and Medicare
Services (CMS) regulations, MHS and US Script edit pharmacy claims for the presence
of a participating Medicaid provider or an enrolled ordering, prescribing, or referring
(OPR) provider. All pharmacy claims must contain the NPI of the prescribing provider.
All prescriptions written by a non-registered or non-OPR prescriber will result in a claim
denial.
Pharmacies will be notified through claim transactions if the submitted prescribing
provider is not enrolled with the Department of Community Health (DCH) as a
participating provider or an ordering, prescribing or rendering provider. Pharmacies will
also receive a claims message if their own store NPI is not enrolled in Indiana Medicaid.
Copayments (Copays)
The table below lists the copayment for the drugs according to the actual cost of the
prescription. Copayments are not required for members under the age of 18 years,
pregnant women, family planning supplies, and Native Americans.
Plan Type
Generic
/Preferred Drug
Copay
Brand-Name Drug
Copay
Non-Preferred
Drug
Hoosier Care
Connect
3$
3$
3$
Contact Information
MHS Member & Provider Services
Phone: 1-877-647-4848
Fax: 1-866-714-7993
TTY/TDD: 1-800-743-3333
US Script Prior Authorizations
Phone: 1-855-772-7125
Fax: 1-866-399-0929
Specialty Medication Prior Authorization Fax
Fax: 1-855-678-6976
US Script Pharmacy Help Desk
Phone: 1-855-772-7121
AcariaHealth Specialty Medication Shipping
Questions
Phone: 1-855-535-1815
PAGE 8
LEGEND
TYPE
DESCRIPTION
QL
Quantity Limit
There is a limit on the amount of drug covered per prescription, or
within a specific time frame.
PA
Prior Authorization
Prior Authorization required before prescription can be filled.
ST
Step Therapy
Requires trial and failure of one or more preferred products prior to
coverage.
GL
Gender Limit
Drug is limited to specific gender.
AL
Age Limit
Drug is limited to specific age.
MDD
Max Daily Dose
A limit on the number of times the drug can be taken per day.
MPL
Max Package Limit
A limit on the amount of drug covered per prescription.
MFL
Max Fill Limit
There is a limit on the number of times this drug can be refilled.
MDS
Max Days Supply
There is a limit on the amount of this drug that is covered.
Custom
This drug has unique restrictions.
Specialty Drug
Specialty drugs are high-cost drugs used to treat complex or rare
conditions, such as multiple sclerosis, rheumatoid arthritis, hepatitis
C, and hemophilia.
C
S
PAGE 9
LIST OF COVERED OVER-THE-COUNTER MEDICATIONS
The MHS Indiana Effective 10/1/2016 pharmacy program covers a variety of OTC products. The products listed
below are covered when the member has a prescription from a licensed clinician that meets all the legal
requirements for a prescription and has it filled at a MHS Indiana Effective 10/1/2016 network pharmacy. Covered
products are available in quantities up to a thirty (30) days supply. All other OTC drugs except insulins require PA.
Please note that generic products must be prescribed when available.
BRAND NAME
DRUG DESCRIPTION (OTC)
COVERAGE
LIMITS & RESTRICTIONS
ANALGESICS
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
St Joseph Aspirin
Aspirin (CHEW TAB 81 MG,
TAB DELAYED RELEASE 81
MG)
generic
Aspirin
Aspirin (SUPPOS 300 MG,
SUPPOS 600 MG)
generic
Tri-Buffered Aspirin
aspirin buffered (ca carb-mg
carb-mg ox) tab 325 mg
generic
Aspirin
aspirin tab 325 mg
generic
Aspirin EC
aspirin tab delayed release 325
mg
generic
Ibuprofen Junior
Strength
ibuprofen chew tab 100 mg
Childrens Ibuprofen
ibuprofen susp 100 mg/5ml
generic
Infants Ibuprofen
ibuprofen susp 40 mg/ml
generic
Motrin IB
ibuprofen tab 200 mg
generic
All Day Pain Relief
naproxen sodium tab 220 mg
generic
QL
12 / 31 days
QL
62 / 31 days
generic
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
SMOKING CESSATION AGENTS
Nicotine
Nicotine
Thrive
PAGE 10
Nicotine (PATCH 24HR 21
MG/24HR, PATCH 24HR 14
MG/24HR)
generic
NICOTINE KIT 21-14-7
MG/24HR
nicotine
BRAND
Nicotine Polacrilex (GUM 2
MG, GUM 4 MG)
MDD
1 per day
MDS
180 / 365 days
MPL
2 / 365 days
MDS
180 / 365 days
MDD
24 per day
MDS
180 / 365 days
generic
BRAND NAME
Nicotine Polacrilex
EQ Nicotine
Nicotine Polacrilex (LOZENGE
2 MG, LOZENGE 4 MG)
nicotine td patch 24hr 7
mg/24hr
COVERAGE
MDD
20 per day
MDS
180 / 365 days
MDD
1 per day
MDS
180 / 365 days
generic
generic
ANTIEMETICS
ANTIEMETICS, OTHER
Motion Sickness
dimenhydrinate tab 50 mg
Motion Sickness
Relief
meclizine hcl chew tab 25 mg
Meclizine HCl
meclizine hcl tab 12.5 mg
Dramamine Less
Drowsy
meclizine hcl tab 25 mg
generic
QL
24 / claim
generic
generic
generic
ANTIFUNGALS
Desenex
clotrimazole cream 1%
generic
MPL
1 / 31 days
Clotrimazole
clotrimazole soln 1%
generic
MPL
1 / claim
Clotrimazole
clotrimazole vaginal cream 1%
generic
QL
45 / 31 days
RA Clotrimazole 3
clotrimazole vaginal cream 2%
generic
QL
31 / 31 days
Anti-Fungal
miconazole nitrate cream 2%
generic
QL
45 / 31 days
Miconazole 7
miconazole nitrate vaginal
cream 2%
generic
QL
45 / 31 days
Miconazole 3
cream 4% (200 mg/5gm)
generic
QL
45 / 31 days
Miconazole 1
supp 1200 mg & 2% cream kit
generic
Vagistat-3
supp 200 mg & 2% cream 9
gm kit
generic
MPL
Miconazole 7
suppos 100 mg
generic
QL
Tioconazole-1
tioconazole vaginal oint 6.5%
generic
PAGE 11
1 / claim
7 / 31 days
BRAND NAME
COVERAGE
BLOOD GLUCOSE REGULATORS
GLYCEMIC AGENTS
Glucose
glucose chew tab 4 gm
generic
Glutose 15
glucose gel 40%
generic
QL
50 / 30 days
CARDIOVASCULAR AGENTS
DYSLIPIDEMICS, OTHER
Sea-Omega 50
*omega-3 fatty acids cap 1000
mg**
generic
MDD
6 per day
KP Fish Oil
*omega-3 fatty acids cap 1200
mg**
generic
MDD
6 per day
Niacin ER
Niacin (TAB 500 MG, TAB 750
MG, TAB 1000 MG)
generic
Slo-Niacin
niacin tab cr 250 mg
generic
QL
30 / claim
QL
31 / 31 days
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM, OTHER
APAP Drops
acetaminophen soln 100 mg/ml
generic
Acetaminophen
acetaminophen soln 160
mg/5ml
generic
DERMATOLOGICAL AGENTS
Double Antibiotic
*bacitracin-polymyxin b oint***
generic
A+D Prevent
*diaper rash products ointment**
generic
RA Moisturizing
Therapy
*emollient - cream**
DML
*emollient - lotion**
generic
Hydrolatum
*emollient - ointment**
generic
Triple Antibiotic
*neomycin-bacitracinpolymyxin oint***
generic
Carrington Moisture
Barrier
*SKIN PROTECTANTS MISC CREAM***
skin protectants, misc.
BRAND
Hydrocerin
BRAND
PAGE 12
generic
BRAND NAME
Sensi-Care
Moisturizing
Minerin
generic
Carrington Moist
Barrier/Zinc
BRAND
Basis Facial
Moisturizer
BRAND
Basis Overnight
BRAND
BRAND
BRAND
Proshield Protective
Hand
BRAND
SM Skin Cleanser
Gentle
*soap & cleansers - lotion***
Tropical Gold Baby
Sunblock
*sunscreen lotion**
Sween 24
*VITAMINS A & D CREAM**
vitamins a & d (topical)
BRAND
Sween
*VITAMINS A & D CREAM**
vitamins a & d (topical)
BRAND
Vitamins A & D
*vitamins a & d oint**
generic
Abreva
ABREVA CREAM 10 %
docosanol
BRAND
Acne Medication 5
ACNE MEDICATION 5
LOTION 5 %
benzoyl peroxide
BRAND
Aloe Vesta Skin
Conditioner
ALOE VESTA SKIN
CONDITIONER LOTION 3 %
dimethicone (topical)
BRAND
Bacitracin
bacitracin oint 500 unit/gm
generic
Bacitracin Zinc
bacitracin zinc oint 500 unit/gm
Dermagran BC
Sorbidon Hydrate
COVERAGE
BRAND
generic
generic
MPL
QL
generic
MPL
PAGE 13
1 / claim
30 / claim
1 / claim
BRAND NAME
Baza Cleanse &
Protect
BAZA CLEANSE & PROTECT
LOTION 2 %
COVERAGE
Clean & Clear
Continuous
benzoyl peroxide cream 10%
PanOxyl Aqua
benzoyl peroxide gel 10%
generic
Benzoyl Peroxide
benzoyl peroxide gel 2.5%
generic
KP Benzoyl Peroxide
generic
PanOxyl Wash
benzoyl peroxide liq 10%
generic
KP Benzoyl Peroxide
Wash
Acne 10
benzoyl peroxide lotion 10%
generic
Anti-Itch
camphor & menthol lotion 0.50.5%
generic
Capsaicin
capsaicin cream 0.025%
BRAND
generic
generic
MPL
QL
generic
1 / claim
62 / 31 days
MPL
1 / claim
Trixaicin HP
generic
MPL
1 / claim
Capsaicin HP
generic
MPL
1 / claim
Cavilon Emollient
CAVILON EMOLLIENT
CREAM
glycerin-dimethicone-stearyl
alcohol
BRAND
Clean & Clear
Advantage 3-in-1
CLEAN & CLEAR
ADVANTAGE 3-IN-1 LOTION
5%
benzoyl peroxide
BRAND
Therapeutic
coal tar shampoo 0.5%
generic
Johnsons Baby
Cornstarch
corn starch topical powder
Dibucaine
dibucaine oint 1%
generic
QL
generic
MPL
Dibucaine
dibucaine rectal ointment 1%
QL
generic
MPL
Proshield Plus Skin
Protectant
DIMETHICONE CREAM 1%
BRAND
Remedy Nutrashield
BRAND
PAGE 14
31 / 31 days
1 / claim
31 / 31 days
1 / claim
BRAND NAME
NeutrapHorus Rex
Pacquin Plus
Hand/Body
BRAND
4-N-1
BRAND
NeutrapHor
BRAND
Cool Bottoms
BRAND
Aveeno Intense Relief
DIMETHICONE CREAM 1.3%
BRAND
Cavilon Durable
Barrier
DIMETHICONE CREAM 1.3%
BRAND
Scholls For Her
Cracked Skin
dimethicone cream 1.5%
Chapstick Ultra
Renewal
dimethicone cream 2%
Remedy Moisture
Barrier
BRAND
Moisture Barrier
BRAND
Moisture Guard
BRAND
Secura Dimethicone
Protectant
BRAND
RA Advanced Healing
dimethicone lotion 1%
generic
RA Renewal Daily
Moisturizing
dimethicone lotion 1.3%
Moisturizing
dimethicone lotion 1.5%
generic
Anti-Itch Maximum
Strength
diphenhydramine hcl cream
2%
generic
Glycerin
glycerin topical liquid
generic
Lanacort 10
hydrocortisone acetate cream
1%
generic
Hydrocortisone
hydrocortisone cream 0.5%
generic
MPL
1 / claim
Anti-Itch Maximum
Strength
hydrocortisone cream 1%
generic
MPL
1 / claim
Aquanil HC
hydrocortisone lotion 1%
generic
MPL
1 / claim
PAGE 15
COVERAGE
BRAND
generic
generic
generic
BRAND NAME
Hydrocortisone
hydrocortisone oint 0.5%
Hydrocortisone
hydrocortisone oint 1%
COVERAGE
generic
QL
generic
60 / 30 days
MPL
1 / 30 days
Hydrocortisone-Aloe
hydrocortisone-aloe vera
cream 1%
generic
MPL
1 / claim
AmLactin
Lactic Acid (Ammonium
Lactate) (CREAM, LOTION)
generic
MPL
1 / 31 days
Mineral Oil-Hydrophil
Petrolat
MINERAL OIL-HYDROPHIL
PETROLAT OINTMENT
mineral oil-hydrophilic
petrolatum
BRAND
Double Antibiotic +
Pain Rlf
neomycin-polymyxin w/
pramoxine cream 1%
QL
generic
MPL
Normlshield
NORMLSHIELD CREAM 4.5 %
Permethrin
permethrin lotion 1%
15 / 31 days
1 / claim
BRAND
QL
generic
124 / 31 days
Pkg Size 60: 2/claim
C
Pkg Size 120: 1/claim
Hemorrhoidal
phenyleph-shark liver oil-cocoa
butter suppos 0.25-3-85.5%
generic
Hemorrhoidal
phenylephrine in hard fat rectal
suppos 0.25%
generic
Preparation H
phenylephrine-cocoa butter
suppos 0.25-88.44%
generic
Hemorrhoidal
phenylephrine-shark liver oilmo-pet oint 0.25-3-14-71.9%
generic
Complete Lice
Treatment
pyreth-piperonyl butox shampermeth aero-nit remover gel
kit
generic
Pronto Plus-Lice
Killing
pyrethrins-piperonyl butoxide
liq 0.33-4%
generic
Lice Killing Maximum
Strength
pyrethrins-piperonyl butoxide
shampoo 0.33-4%
generic
RA Oatmeal
Moisturizing
RA OATMEAL
MOISTURIZING LOTION 1.6
%
BRAND
Remedy Skin Repair
REMEDY SKIN REPAIR
CREAM 1.5 %
BRAND
PAGE 16
QL
12 / 31 days
QL
31 / 31 days
BRAND NAME
Anti-Dandruff
selenium sulfide lotion 1%
COVERAGE
Sween 24 Skin
Protectant
SWEEN 24 SKIN
PROTECTANT CREAM 6 %
KP Terbinafine
Hydrochloride
terbinafine hcl cream 1%
Tolnaftate
tolnaftate cream 1%
generic
QL
Zinc Oxide
zinc oxide oint 20%
generic
MPL
generic
MPL
1 / claim
BRAND
generic
30 / claim
1 / claim
GASTROINTESTINAL AGENTS
GASTROINTESTINAL AGENTS, OTHER
Mintox Plus
alum & mag hydroxidesimethicone chew tab 200-20025 mg
generic
Maalox Regular
Strength
alum & mag hydroxidesimethicone susp 200-200-20
mg/5ml
generic
Maalox Max
alum & mag hydroxidesimethicone susp 400-400-40
mg/5ml
generic
Aluminum Hydroxide
Gel
aluminum hydroxide gel susp
320 mg/5ml
generic
Soothe
Bismuth Subsalicylate (CHEW
TAB 262 MG, TAB 262 MG)
generic
Stomach Relief
bismuth subsalicylate susp 262
mg/15ml
generic
Calcium Antacid Ultra
Max St
calcium carbonate (antacid)
chew tab 1000 mg
generic
Calcium Antacid
chew tab 500 mg
generic
Calcium Antacid Extra
Strength
chew tab 750 mg
generic
Calcium Rich
Supreme Antacid
calcium carbonate-mag
hydroxide susp 400-135
mg/5ml
generic
Anti-Diarrheal
Loperamide HCl (CAP 2 MG,
LIQ 1 MG/5ML (0.2 MG/ML))
generic
Anti-Diarrheal
loperamide hcl tab 2 mg
generic
Magnesium Oxide
magnesium oxide tab 400 mg
generic
PAGE 17
QL
MDD
720 / 30 days
2 per day
BRAND NAME
Simethicone
simethicone chew tab 80 mg
COVERAGE
Infants Simethicone
simethicone susp 40 mg/0.6ml
generic
QL
31 / 31 days
Sodium Bicarbonate
Sodium Bicarbonate (Antacid)
(TAB 325 MG, TAB 650 MG)
generic
QL
100 / 31 days
generic
HISTAMINE2 (H2) RECEPTOR ANTAGONISTS
Heartburn Relief
cimetidine tab 200 mg
generic
Acid Reducer
famotidine tab 10 mg
generic
Acid Reducer
Maximum Strength
famotidine tab 20 mg
KLS Acid Reducer
Max St
ranitidine hcl tab 150 mg
KLS Acid Reducer
ranitidine hcl tab 75 mg
generic
Enema
*sodium phosphates enema***
generic
Gentle Laxative
bisacodyl suppos 10 mg
Ex-Lax Ultra
generic
generic
MDD
2 per day
generic
QL
12 / claim
bisacodyl tab delayed release
5 mg
generic
MDD
1 per day
Fiber Laxative
calcium polycarbophil tab 625
mg
generic
MDD
10 per day
CVS Natural Fiber
Supplement
CVS NATURAL FIBER
SUPPLEMENT PACKET 58.6
%
psyllium
BRAND
Docusate Calcium
docusate calcium cap 240 mg
generic
Stool Softener
docusate sodium cap 100 mg
generic
MDD
3 per day
D.O.S.
docusate sodium cap 250 mg
generic
MDD
3 per day
Docusate Sodium
docusate sodium liquid 150
mg/15ml
generic
Diocto
docusate sodium syrup 60
mg/15ml
generic
DOK
docusate sodium tab 100 mg
generic
Glycerin (Infants &
Children)
glycerin suppos 1 gm
Sani-Supp Pediatric
glycerin suppos 1.2 gm
LAXATIVES
PAGE 18
generic
generic
BRAND NAME
Sani-Supp Adult
glycerin suppos 2 gm
COVERAGE
Glycerin (Adult)
glycerin suppos 2.1 gm
generic
Magnesium Citrate
magnesium citrate soln
generic
Milk of Magnesia
magnesium hydroxide susp
400 mg/5ml
generic
Metamucil MultiHealth
Fiber
METAMUCIL MULTIHEALTH
FIBER PACKET 58.12 %
psyllium
BRAND
Milk of Magnesia
Concentrate
MILK OF MAGNESIA
CONCENTRATE
SUSPENSION 2400 MG/10ML
magnesium hydroxide
BRAND
Pedia-Lax
PEDIA-LAX SUPPOS 2.8 GM
glycerin (laxative)
BRAND
Smooth LAX
polyethylene glycol 3350 oral
powder
generic
Konsyl
Psyllium (KONSYL PACKET
100 %, PSYLLIUM CAP 0.52
GM, PSYLLIUM POWDER
28.3%, PSYLLIUM POWDER
30.9%)
generic
Wal-Mucil
Psyllium (POWDER 48.57%,
POWDER 100%)
generic
SB Fib Lax Orange
psyllium powder 33%
generic
Genfiber
psyllium powder 50%
generic
Natural Fiber
psyllium powder 58.6%
generic
Senna
senna syrup 176 mg/5ml
generic
Senexon
sennosides syrup 8.8 mg/5ml
generic
Perdiem Overnight
Relief
sennosides tab 15 mg
RA Laxative Extra
Strength
sennosides tab 17.2 mg
Senna-Gen
sennosides tab 8.6 mg
generic
Senna S
sennosides-docusate sodium
tab 8.6-50 mg
generic
Sorbitol
sorbitol oral solution 70%
generic
generic
QL
992 / 31 days
MDD
34 per day
MDD
4 per day
MDD
4 per day
generic
generic
PROTON PUMP INHIBITORS
Lansoprazole
lansoprazole cap delayed
release 15 mg
generic
C
PAGE 19
OTC Covered Only
BRAND NAME
NexIUM 24HR
NEXIUM 24HR CAP DR 20
MG
esomeprazole magnesium
COVERAGE
MDD
BRAND
C
2 per day
OTC Covered Only
Omeprazole
omeprazole delayed release
tab 20 mg
generic
Prevacid 24HR
PREVACID 24HR CAP DR 15
MG
lansoprazole
BRAND
PRILOSEC OTC TAB DR 20
MG
omeprazole magnesium
BRAND
MDD
4 per day
MPL
1 / claim
MPL
1 / claim
PriLOSEC OTC
MDD
4 per day
MDD
4 per day
C
OTC Covered Only
GENITOURINARY AGENTS
GENITOURINARY AGENTS, OTHER
Gynol II
GYNOL II GEL 2 %
nonoxynol-9
BRAND
Urinary Pain Relief
phenazopyridine hcl tab 95 mg
generic
Shur-Seal
Contraceptive
SHUR-SEAL
CONTRACEPTIVE GEL 2 %
nonoxynol-9
BRAND
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)
PROGESTINS
My Way
levonorgestrel tab 1.5 mg
QL
generic
MFL
1 / 21 days
4 / 365 days
METABOLIC BONE DISEASE AGENTS
D3-50
cholecalciferol cap 50000 unit
generic
QL
8 / 30 days
MISCELLANEOUS THERAPEUTIC AGENTS
Restore Contact
Layer
*GAUZE PADS & DRESSINGS
- PADS 2" X 2"***
gauze pads & dressings
BRAND
Dermacea IV
Sponges
- PADS 2" X 2"***
BRAND
Band-Aid Gauze
Small
- PADS 2" X 2"***
BRAND
TheraGauze
- PADS 2" X 2"***
BRAND
PAGE 20
BRAND NAME
Curity AMD
Antimicrobial Spnge
- PADS 2" X 2"***
Excilon IV Sponges
- PADS 2" X 2"***
BRAND
- PADS 3" X 3"***
BRAND
Band-Aid Gauze
Medium
- PADS 3" X 3"***
BRAND
Curity Non-Adherent
Strips
- PADS 3" X 3"***
BRAND
Restore Trio
Absorbent Dress
- PADS 3" X 3"***
BRAND
GNP Sterile Pads
- PADS 3" X 3"***
BRAND
Hospital Grade
Gauze
- PADS 3" X 3"***
generic
J & J Non-Stick
Dressing
- PADS 3" X 3"***
BRAND
Dermacea Drain
Sponges
- PADS 4" X 4"***
BRAND
Biatain Adhesive
Foam Dressing
- PADS 4" X 4"***
BRAND
Copa Plus Hydrophilic
Foam
- PADS 4" X 4"***
BRAND
CarraSmart
- PADS 4" X 4"***
BRAND
- PADS 4" X 4"***
BRAND
- PADS 4" X 4"***
BRAND
EQL Gauze Sterile
CarraSmart Foam
Optifoam
PAGE 21
COVERAGE
BRAND
BRAND NAME
DermaLevin Adhesive
Kerlix Sponges
- PADS 4" X 4"***
COVERAGE
BRAND
- PADS 4" X 4"***
BRAND
J & J Gauze Sponges
16-Ply
- PADS 4" X 4"***
BRAND
Restore Foam
Dressing
- PADS 4" X 4"***
BRAND
Curity Dressing
Sponges
- PADS 4" X 4"***
BRAND
Hydrocell Dressing
- PADS 4" X 4"***
BRAND
- PADS 4" X 4"***
BRAND
- PADS 4" X 4"***
BRAND
J & J Gauze Sponges
8-Ply
- PADS 4" X 4"***
BRAND
Biatain Foam
Dressing
- PADS 4" X 4"***
BRAND
Copa Island Bordered
Foam
- PADS 4" X 4"***
BRAND
Sof-Wick
- PADS 4" X 4"***
BRAND
- PADS 4" X 4"***
BRAND
- PADS 4" X 4"***
BRAND
- PADS 4" X 4"***
BRAND
Bordered Gauze
Nu Gauze 4ply
Flexzan
CVS Gauze
Curex All-Purpose
Sponges
PAGE 22
BRAND NAME
Hydrocell Adhesive
Dressing
- PADS 4" X 4"***
Dermacea X-Ray
Sponges
- PADS 4" X 4"***
BRAND
Hydrocell Thin
Adhesive
- PADS 4" X 4"***
BRAND
RA Gauze Sponges
- PADS 4" X 4"***
BRAND
- PADS 4" X 4"***
BRAND
- PADS 4" X 4"***
BRAND
Band-Aid Gauze
Large
- PADS 4" X 4"***
BRAND
Covrsite Cover
Dressing
- PADS 4" X 4"***
BRAND
Gauze Pads
- PADS 4" X 4"***
BRAND
J & J Gauze Sponges
12-Ply
- PADS 4" X 4"***
BRAND
Nu Gauze GeneralUse Sponges
- PADS 4" X 4"***
BRAND
J & J Ulcer Dressing
- PADS 4" X 4"***
BRAND
Restore Odor
Absorbing Dress
- PADS 4" X 4"***
BRAND
Ray-Tec X-Ray
Detectable Spnge
- PADS 4" X 4"***
BRAND
RA All Purpose
Dressings
- PADS 4" X 4"***
BRAND
Allevyn Plus Cavity
Gauze Sponge
PAGE 23
COVERAGE
BRAND
BRAND NAME
Vistec X-Ray
Detectable Sponge
- PADS 4" X 4"***
Allevyn Thin
- PADS 4" X 4"***
BRAND
Topper Dressing
Sponges
- PADS 4" X 4"***
BRAND
Dressing Sponges
- PADS 4" X 4"***
BRAND
- PADS 4" X 4"***
BRAND
Band-Aid Mirasorb
Gauze Sponge
- PADS 4" X 4"***
BRAND
Excilon Drain
Sponges
- PADS 4" X 4"***
BRAND
RA Dressing Sponges
- PADS 4" X 4"***
BRAND
Covrsite Plus
Composite Dress
- PADS 4" X 4"***
BRAND
Ora-Blend SF
*ORAL VEHICLES - SUSP***
oral vehicles
BRAND
MX-Sol Blend
oral vehicles
BRAND
MX-Sol Blend SF
oral vehicles
BRAND
Ora-Blend
oral vehicles
BRAND
MX-Sol Suspend
oral vehicles
BRAND
Bubble Gum
*oral vehicles - syrup***
generic
Feverall
Acetaminophen (SUPPOS 120
MG, SUPPOS 325 MG)
generic
Acetaminophen
acetaminophen cap 500 mg
generic
Non-Aspirin Jr
Strength
acetaminophen chew tab 160
mg
generic
DryMax Extra
PAGE 24
COVERAGE
BRAND
QL
12 / 31 days
BRAND NAME
Childrens Non-Aspirin
acetaminophen chew tab 80
mg
Ed-APAP
acetaminophen liquid 160
mg/5ml
generic
Acetaminophen
acetaminophen suppos 650 mg
generic
QL
12 / 31 days
Pain Relief Childrens
acetaminophen susp 160
mg/5ml
generic
QL
240 / claim
Infants Pain Reliever
acetaminophen susp 80
mg/0.8ml
generic
Genebs
acetaminophen tab 325 mg
generic
Pain Relief Extra
Strength
acetaminophen tab 500 mg
Acetyl L-Carnitine
acetylcarnitine hcl cap 500 mg
generic
L-Arginine
Arginine (ARGININE
POWDER, L-ARGININE
POWDER )
arginine
BRAND
Arginine HCl
arginine hcl (bulk) powder
generic
Chlorhexidine
Gluconate
chlorhexidine gluconate liquid
4%
generic
Trustex Ria
Lub/Spermicide
CONDOMS LATEX
LUBRICATED
condoms latex lubricated male
BRAND
QL
36 / 30 days
Trustex
Lub/Spermicide XL
CONDOMS LATEX
LUBRICATED
BRAND
QL
36 / 30 days
Trustex Color
Condoms + Lube
CONDOMS LATEX
LUBRICATED
BRAND
QL
36 / 30 days
Trustex Natural
Condoms + Lube
CONDOMS LATEX
LUBRICATED
BRAND
QL
36 / 30 days
Premium Condoms
Lubricated
CONDOMS LATEX
LUBRICATED
BRAND
QL
36 / 30 days
Trustex Lubricated Ex
Large
CONDOMS LATEX
LUBRICATED
BRAND
QL
36 / 30 days
PAGE 25
COVERAGE
generic
generic
BRAND NAME
Kimono PS
CONDOMS LATEX
LUBRICATED
COVERAGE
BRAND
QL
36 / 30 days
Trojan Supras
Spermicidal
CONDOMS LATEX
LUBRICATED
BRAND
QL
36 / 30 days
Kimono Plus
CONDOMS LATEX
LUBRICATED
BRAND
QL
36 / 30 days
Trojan Twisted
Pleasure
CONDOMS LATEX
LUBRICATED
BRAND
QL
36 / 30 days
Reality Latex/Ultra
Thin
CONDOMS LATEX
LUBRICATED
BRAND
QL
36 / 30 days
Kimono
CONDOMS LATEX
LUBRICATED
BRAND
QL
36 / 30 days
CONDOMS LATEX
LUBRICATED
BRAND
QL
36 / 30 days
CONDOMS LATEX
LUBRICATED
BRAND
QL
36 / 30 days
Trojan Magnum
Warm Sensations
CONDOMS LATEX
LUBRICATED
BRAND
QL
36 / 30 days
Kimono PS Plus
CONDOMS LATEX
LUBRICATED
BRAND
QL
36 / 30 days
Trustex
Lubricated/Spermicid
e
CONDOMS LATEX
LUBRICATED
BRAND
QL
36 / 30 days
Trustex-Nonoxynol9/Rib/Stud
CONDOMS LATEX
LUBRICATED
BRAND
QL
36 / 30 days
Kameleon Lubricated
Durex Extra Sensitive
PAGE 26
BRAND NAME
Reality Latex/Ultra
Textured
CONDOMS LATEX
LUBRICATED
Trustex Lubricated
COVERAGE
BRAND
QL
36 / 30 days
CONDOMS LATEX
LUBRICATED
BRAND
QL
36 / 30 days
CONDOMS LATEX
LUBRICATED
BRAND
QL
36 / 30 days
Trustex
Lub/Ribbed/Studded
CONDOMS LATEX
LUBRICATED
BRAND
QL
36 / 30 days
Kimono Sensation
CONDOMS LATEX
LUBRICATED
BRAND
QL
36 / 30 days
Fantasy
Lubricated/Spermicid
e
CONDOMS LATEX
LUBRICATED
BRAND
QL
36 / 30 days
Kimono Micro Thin
Plus
CONDOMS LATEX
LUBRICATED
BRAND
QL
36 / 30 days
Trustex Ria
Lubricated
CONDOMS LATEX
LUBRICATED
BRAND
QL
36 / 30 days
Trustex Lubricated
Extra St
CONDOMS LATEX
LUBRICATED
BRAND
QL
36 / 30 days
Elexa Ultra Sensitive
CONDOMS LATEX
LUBRICATED
BRAND
QL
36 / 30 days
Kimono Sensation
Plus
CONDOMS LATEX
LUBRICATED
BRAND
QL
36 / 30 days
Maxx
CONDOMS LATEX
LUBRICATED
BRAND
QL
36 / 30 days
Elexa Stimulating
PAGE 27
BRAND NAME
Trustex
Lub/Spermicide Ex St
CONDOMS LATEX
LUBRICATED
Aimsco Lubricated
COVERAGE
BRAND
QL
36 / 30 days
CONDOMS LATEX
LUBRICATED
BRAND
QL
36 / 30 days
CONDOMS LATEX
LUBRICATED
BRAND
QL
36 / 30 days
CONDOMS LATEX
LUBRICATED
BRAND
QL
36 / 30 days
CONDOMS LATEX
LUBRICATED
BRAND
QL
36 / 30 days
Cromolyn Sodium
cromolyn sodium nasal aerosol
soln 5.2 mg/act (4%)
generic
QL
26 / 30 days
Dakins (1/4 strength)
dakin's solution 0.125%
(quarter strength)
generic
Dakins (1/2 strength)
dakin's solution 0.25% (half
strength)
generic
Dakins
dakin's solution 0.5%
generic
FeverAll Infants
FEVERALL INFANTS
SUPPOS 80 MG
acetaminophen
BRAND
Feverall
FEVERALL SUPPOS 80 MG
acetaminophen
BRAND
Kendall Hydrophilic
Foam Plus
Gauze Pads & Dressings
(PADS PADS 2" 2"***, PADS
PADS 3" 3"***)
BRAND
Curity All Purpose
Sponges
PADS 3" 3"***, PADS PADS 4"
4"***)
BRAND
4"***)
BRAND
Maxx Plus
Fantasy Lubricated
Elexa Natural Feel
Dermacea NonWoven Sponges
PAGE 28
BRAND NAME
Dermacea Gauze
Sponge
Kendall Hydrophilic
Foam Dress
RA Sterile
Curity Gauze
Sterile
Dermacea Type VII
Gauze
Curity Gauze Sponge
SM Gauze
Mirasorb Sponges
Steri-Pad Sterile
PAGE 29
4"***)
COVERAGE
BRAND
4"***)
BRAND
4"***)
BRAND
4"***)
BRAND
4"***)
BRAND
4"***)
BRAND
4"***)
BRAND
4"***)
BRAND
PADS 4" 4"***)
BRAND
PADS 4" 4"***)
BRAND
BRAND NAME
J & J Gauze
EQL Gauze
PADS 4" 4"***)
COVERAGE
BRAND
PADS 4" 4"***)
BRAND
PADS 4" 4"***)
BRAND
Dermacea IV Drain
Sponges
PADS 4" 4"***)
BRAND
Tegaderm Foam
PADS 4" 4"***)
BRAND
PADS 4" 4"***)
BRAND
PADS 4" 4"***)
BRAND
PADS 4" 4"***)
BRAND
PADS 4" 4"***)
BRAND
PADS 4" 4"***)
BRAND
KP Melatonin
melatonin tab 3 mg
generic
MDD
1 per day
Melatonin
melatonin tab 5 mg
generic
MDD
1 per day
MX-Sol SF
MX-SOL SF SYRUP
oral vehicles
BRAND
SM Sterile
Island Gard-GRX
Curity Sponges
Versiva XC
Polymem Dressing
Curity Cover Sponge
PAGE 30
BRAND NAME
MX-Sol
MX-SOL SYRUP
oral vehicles
COVERAGE
Ora-Sweet SF
ORA-SWEET SF SYRUP
oral vehicles
BRAND
Ora-Sweet
ORA-SWEET SYRUP
oral vehicles
BRAND
Lice Treatment
permethrin creme rinse 1%
generic
Nasal Decongestant
PE Max St
phenylephrine hcl tab 10 mg
Povidone-Iodine
povidone-iodine soln 10%
generic
Nasal Decongestant
Pseudoephedrine HCl (LIQUID
30, SYRUP 30)
pseudoephedrine hcl
BRAND
GNP Suphedrin
pseudoephedrine hcl liq 15
mg/5ml
generic
Pseudoephedrine HCl
pseudoephedrine hcl tab 30
mg
generic
KP Pseudoephedrine
HCl
pseudoephedrine hcl tab 60
mg
generic
Sudafed 12 Hour
pseudoephedrine hcl tab sr
12hr 120 mg
Afrin Saline Nasal
Mist
saline nasal spray 0.65%
Sorbitol
Sorbitol (SOLUTION (BULK),
SOLUTION 70 %)
sorbitol
BRAND
Thick Now
starch-maltodextrin oral
thickening powder
generic
Suspendol-S
SUSPENDOL-S LIQUID
vehicle s
BRAND
Syrpalta
SYRPALTA SYRUP
oral vehicles
BRAND
Tylenol Extra
Strength
TYLENOL EXTRA STRENGTH
TAB 500 MG
acetaminophen
BRAND
BRAND
generic
QL
24 / claim
generic
QL
62 / 31 days
generic
MPL
1 / claim
QL
4 / claim
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS, OTHER
Refresh P.M.
*artificial tear ophth ointment***
generic
Systane Contacts
*artificial tear ophth solution***
generic
PAGE 31
BRAND NAME
Systane Nighttime
*white petrolatum-mineral oil
ophth ointment***
Artificial Tears
COVERAGE
generic
MPL
1 / claim
ARTIFICIAL TEARS
SOLUTION 0.4 %
hypromellose (ophth)
BRAND
QL
15 / claim
Lubricating Plus Eye
Drops
carboxymethylcellulose sodium
ophth soln 0.5%
generic
Pure & Gentle
Lubricant
hypromellose ophth soln 0.3%
Natures Tears
hypromellose ophth soln 0.4%
generic
QL
15 / claim
Refresh Eye Itch
Relief
ketotifen fumarate ophth soln
0.025% (base equiv)
generic
MPL
Artificial Tears
polyvinyl alcohol ophth soln
1.4%
generic
QL
TGT Lubricant Eye
Drops
propylene glycol-glycerin ophth
soln 1-0.3%
generic
Tetrahydrozoline HCl
tetrahydrozoline hcl ophth soln
0.05%
generic
Theratears
THERATEARS SOLUTION
0.25 %
carboxymethylcellulose sodium
(ophth)
BRAND
carbamide peroxide 6.5% otic
soln
generic
QL
15 / 31 days
9 / 30 days
generic
MPL
1 / 31 days
31 / 31 days
1 / 30 days
OTIC AGENTS
E-R-O Ear Drops
RESPIRATORY TRACT/PULMONARY AGENTS
ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS
Rhinocort Allergy
budesonide nasal susp 32
mcg/act
generic
QL
Flonase Allergy Relief
FLONASE ALLERGY RELIEF
SUSPENSION 50 MCG/ACT
fluticasone propionate (nasal)
BRAND
MPL
1 / claim
fluticasone propionate nasal
susp 50 mcg/act
generic
MPL
1 / claim
Cetirizine HCl
Cetirizine HCl (CHEW TAB 10
MG, TAB 5 MG)
generic
MDD
1 per day
Wal-Zyr Childrens
cetirizine hcl chew tab 5 mg
generic
MDD
1 per day
Fluticasone
Propionate
ANTIHISTAMINES
PAGE 32
BRAND NAME
All Day Allergy
Childrens
cetirizine hcl oral soln 1 mg/ml
(5 mg/5ml)
COVERAGE
QL
240 / claim
AL
Up to 12 yrs old
generic
KLS Aller-Tec
cetirizine hcl tab 10 mg
generic
Ed Chlorped Jr
chlorpheniramine maleate
syrup 2 mg/5ml
generic
Allergy 4 Hour
chlorpheniramine maleate tab
4 mg
generic
QL
Dayhist Allergy 12
Hour Relief
clemastine fumarate tab 1.34
mg (1 mg base equiv)
generic
MDD
2 per day
Allergy Relief
Diphenhydramine HCl (CAP 25
MG, TAB 25 MG)
generic
MDD
4 per day
KP
DiphenhydrAMINE
HCl
diphenhydramine hcl cap 50
mg
generic
MDD
4 per day
Allergy Relief
Childrens
diphenhydramine hcl liquid
12.5 mg/5ml
generic
QL
240 / claim
Quenalin
diphenhydramine hcl syrup
12.5 mg/5ml
generic
QL
240 / claim
KP Fexofenadine HCl
fexofenadine hcl tab 180 mg
generic
MDD
1 per day
Aller-Ease
fexofenadine hcl tab 60 mg
generic
MDD
2 per day
Triaminic Allerchews
loratadine rapidly-disintegrating
tab 10 mg
generic
MDD
1 per day
Wal-itin
loratadine syrup 5 mg/5ml
generic
QL
Loratadine
loratadine tab 10 mg
generic
MDD
MDD
1 per day
120 / claim
240 / claim
1 per day
RESPIRATORY TRACT AGENTS, OTHER
Triaminic Cough/Sore
Throat
acetaminophen w/ dm liq 160-5
mg/5ml
generic
Childrens Cold &
Allergy
brompheniramine &
phenylephrine elixir 1-2.5
mg/5ml
generic
brompheniramine &
pseudoephedrine elixir 1-15
mg/5ml
generic
All Day Allergy-D
cetirizine-pseudoephedrine tab
sr 12hr 5-120 mg
Trigofen
chlorpheniramine &
phenylephrine liquid 1-2 mg/ml
Wal-tap Cold/Allergy
PAGE 33
QL
120 / claim
MFL
1 / 30 days
QL
120 / claim
MFL
1 / 30 days
generic
MDD
2 per day
generic
MDD
1 per day
BRAND NAME
Cardec
Cough DM
chlorpheniramine &
phenylephrine liquid 1-3.5
mg/ml
COVERAGE
generic
QL
30 / claim
dextromethorphan polistirex
extended release susp 30
mg/5ml
generic
Nighttime Cold/Flu
Relief
dextromethorphan-doxylamineapap liquid 30-12.5-1000
mg/30ml
generic
Alka-Seltzer Plus
Mucus & Cong
dextromethorphan-guaifenesin
cap 10-200 mg
generic
Robitussin To Go
Cgh/Chest DM
liquid 10-100 mg/5ml
generic
QL
240 / claim
Wal-Tussin
Cough/Chest DM Max
liquid 10-200 mg/5ml
generic
QL
240 / claim
Mucus Relief Cough
Childrens
liquid 5-100 mg/5ml
generic
Tussin DM
syrup 10-100 mg/5ml
generic
QL
240 / claim
Mucus Relief DM
Cough
tab 20-400 mg
generic
Mucus-DM
tab sr 12hr 30-600 mg
QL
generic
210 / claim
MDD
Robitussin Cold+Flu
Daytime
dextromethorphanphenylephrine-apap cap 10-5325 mg
generic
ED Bron GP
ED BRON GP LIQUID 5-100
MG/5ML
phenylephrine-guaifenesin
BRAND
G-ZYNCOF SYRUP 20-400
MG/5ML
BRAND
G-Zyncof
Robitussin
Mucus+Chest
Congest
guaifenesin liquid 100 mg/5ml
Tussin Mucus+Chest
Congestion
guaifenesin syrup 100 mg/5ml
GuaiFENesin ER
guaifenesin tab sr 12hr 1200
mg
Mucus Relief ER
guaifenesin tab sr 12hr 600 mg
QL
240 / 6 days
generic
QL
240 / 6 days
generic
QL
240 / 6 days
QL
40 / claim
MDD
2 per day
MFL
1 / 30 days
generic
generic
PAGE 34
2 per day
BRAND NAME
Guaifenesin-Codeine
guaifenesin-codeine soln 10010 mg/5ml
COVERAGE
LoHist-D
LOHIST-D LIQUID 2-30
MG/5ML
chlorpheniramine & pseudoeph
BRAND
QL
Wal-itin D
loratadine & pseudoephedrine
generic
MDD
2 per day
Allergy/Congestion
Relief
loratadine & pseudoephedrine
generic
MDD
1 per day
ZoDen DM
phenylephrine-chlorphen-dm
liquid 1.5-1-3 mg/ml
generic
QL
60 / 6 days
Tri-Dex PE
liquid 10-2-15 mg/5ml
generic
QL
240 / claim
Ed-A-Hist DM
generic
QL
240 / claim
Cardec DM
liquid 3.5-1-3 mg/ml
QL
generic
30 / 6 days
MPL
2 / 31 days
generic
240 / claim
PE-Hist DM
syrup 5-2-15 mg/5ml
generic
QL
240 / claim
Triaminic Cold/Cough
Day Time
Phenylephrine-DM
(SOLUTION, SYRUP)
phenylephrine-dm
BRAND
QL
240 / claim
Sudafed PE Cold &
Cough Child
phenylephrine-dm soln 2.5-5
mg/5ml
generic
QL
240 / claim
Despec
phenylephrine-guaifenesin liqd
5-100 mg/5ml
generic
QL
240 / 6 days
Wal-Tap DM
Cold/Cough
pseudoephed-bromphen-dm
elixir 15-1-5 mg/5ml
generic
QL
240 / claim
Dimetane DX
syrup 30-2-10 mg/5ml
generic
QL
240 / claim
Kidkare Cough/Cold
pseudoephed-chlorphen-dm liq
15-1-5 mg/5ml
generic
QL
240 / claim
GNP Day Time D
Cold/Flu
pseudoephedrine w/ apap-dm
cap 30-325-15 mg
generic
Cheratussin DAC
pseudoephedrine w/ cod-gg
soln 30-10-100 mg/5ml
generic
QL
240 / 6 days
SB Cough Control PE
pseudoephedrine-guaifenesin
syrup 30-100 mg/5ml
generic
Mucus D
tab sr 12hr 120-1200 mg
generic
PseudoephedrineGuaifenesin ER
generic
QL
210 / claim
PAGE 35
BRAND NAME
RA Ibuprofen Cold
Childrens
pseudoephedrine-ibuprofen
susp 15-100 mg/5ml
COVERAGE
Wal-Profen Cold &
Sinus
pseudoephedrine-ibuprofen tab
30-200 mg
generic
PX Daytime MultiSymptom
PX DAYTIME MULTISYMPTOM CAP 30-325-15
MG
pseudoephedrineacetaminophendextromethorphan
BRAND
Vicks Formula 44
Chesty Cough
VICKS FORMULA 44 CHESTY
COUGH SYRUP 20-200
MG/15ML
BRAND
Zyncof
ZYNCOF SYRUP 20-400
MG/5ML
BRAND
generic
SLEEP DISORDER AGENTS
SLEEP DISORDERS, OTHER
Wal-Sleep Z
Diphenhydramine HCl (Sleep)
(CAP 25 MG, LIQUID 50
MG/30ML)
generic
Wal-Som Maximum
Strength
diphenhydramine hcl (sleep)
cap 50 mg
generic
Simply Sleep
tab 25 mg
generic
Sominex Maximum
Strength
tab 50 mg
generic
Wal-Som
tab disp 25 mg
generic
Sleep Aid
doxylamine succinate (sleep)
tab 25 mg
generic
MDD
1 per day
THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES
ELECTROLYTE/MINERAL REPLACEMENT
Rehydralyte
*oral electrolyte solution***
generic
Calci-Chew
CALCI-CHEW CHEW TAB
1250 (500 CA) MG
calcium carbonate
BRAND
calcium carbonate chew tab
1250 mg (500 mg elemental
ca)
generic
Os-Cal
PAGE 36
BRAND NAME
Calcium
calcium carbonate chew tab
500 mg
COVERAGE
Calcium Carbonate
calcium carbonate susp 1250
mg/5ml (500 mg/5ml elemental
ca)
generic
Calcium Carbonate
calcium carbonate tab 1250 mg
(500 mg elemental ca)
generic
Calcium
calcium carbonatecholecalciferol chew tab 500
mg-100 unit
generic
calcium carbonatecholecalciferol chew tab 500
mg-400 unit
generic
calcium carbonatecholecalciferol tab 500 mg-200
unit
generic
unit
generic
unit
Pronutrients
Calcium+D3
generic
QL
500 / 30 days
generic
QL
62 / 31 days
unit
generic
QL
62 / 31 days
Oyst-Cal-D 500
calcium carbonate-vitamin d
tab 500 mg-200 unit
generic
RA Calcium Plus
Vitamin D
tab 600 mg-200 unit
generic
QL
62 / 31 days
Calcarb 600/D
tab 600 mg-400 unit
generic
QL
62 / 31 days
Calcium Citrate
calcium citrate tab 950 mg (200
mg elemental ca)
generic
RA Calcium Hi-Cal
calcium tab 500 mg
generic
Calcium-Vitamin D
calcium w/ vitamin d tab 600
mg-200 unit
generic
Ferretts
FERRETTS TAB 325 (106 FE)
MG
ferrous fumarate
BRAND
Ferrocite
ferrous fumarate tab 324 mg
(106 mg elemental fe)
generic
Ferrous Gluconate
ferrous gluconate tab 324 mg
(38 mg elemental iron)
generic
Calcium 500/D
Os-Cal Calcium + D3
Calcium-Vitamin D3
KP Calcium 600+D
PAGE 37
MDD
2 per day
QL
100 / 31 days
AL
Up to 50 yrs old
BRAND NAME
Ferrous Gluconate
ferrous gluconate tab 325 mg
COVERAGE
QL
100 / 30 days
AL
Up to 50 yrs old
AL
Up to 50 yrs old
generic
Ferrous Sulfate
Ferrous Sulfate
Ferrous Sulfate
Fer-Iron
Ferrous Sulfate (ELIXIR 220
MG/5ML (44 MG/5ML
ELEMENTAL FE), TAB EC 324
MG (65 MG FE
EQUIVALENT), TAB EC 325
MG (65 MG FE
EQUIVALENT))
generic
ferrous sulfate liquid 220
mg/5ml (44 mg/5ml elemental
fe)
generic
ferrous sulfate soln 75
mg/0.6ml (15 mg/0.6ml
elemental fe)
generic
ferrous sulfate soln 75 mg/ml
(15 mg/ml elemental fe)
MDD
AL
generic
MDD
KP Ferrous Sulfate
ferrous sulfate tab 325 mg (65
mg elemental fe)
generic
Iron Chews Pediatric
IRON CHEWS PEDIATRIC
CHEW TAB 15 MG
carbonyl iron
BRAND
Mag-Delay
magnesium chloride tab cr 535
mg (64 mg elemental mg)
generic
Magnesium Oxide
Magnesium Oxide (Mg
Supplement) (TAB 400 MG
(241.3 MG, TAB 400 MG (240
MG)
generic
NOVAFERRUM 125 LIQUID
125-100 MG-UNT/5ML
polysaccharide iron complexcholecalciferol (vit d3)
BRAND
Oyst-Cal
oyster shell calcium tab 500
mg
generic
Parva-Cal
PARVA-CAL TAB 500-200
MG-UNIT
calcium-ergocalciferol
BRAND
RA Oyster Shell
Calcium/D
RA OYSTER SHELL
CALCIUM/D TAB 500-200 MGUNIT
BRAND
Zinc
zinc gluconate lozenge 13.3
mg (zinc)
generic
NovaFerrum 125
PAGE 38
AL
3.4 per day
Up to 18 yrs old
3.4 per day
Up to 50 yrs old
BRAND NAME
Orazinc
zinc sulfate cap 220 mg (50 mg
elemental zn)
COVERAGE
Ascorbic Acid
*ascorbic acid oral powder***
generic
One-Tablet-Daily
*multiple vitamin tab**
Stress/Zinc
generic
QL
100 / 30 days
generic
QL
31 / 31 days
*multiple vitamins w/ iron tab**
generic
QL
31 / 31 days
ICaps
*multiple vitamins w/ minerals
cap**
generic
RA One Daily Gummy
Vites
chew tab**
generic
Certagen
liquid**
generic
Vitamin C-Electrolytes
pack**
generic
Ultra-Mega
tab cr**
generic
ICaps MV
tab**
generic
QL
31 / 31 days
Multi-Delyn
*pediatric multiple vitamin liq**
generic
Chewable Vite
Childrens
*pediatric multiple vitamin w/ c
& fa chew tab**
generic
MDD
1 per day
Baby Vitamin
*pediatric multiple vitamin w/ c
soln 35 mg/ml**
generic
QL
50 / claim
Centrum Kids
Complete
*pediatric multiple vitamin w/
minerals & c chew tab 60 mg**
generic
Multivitamins
Pediatric
minerals & c drops 45 mg/ml**
generic
AL
Up to 18 yrs old
Fruity Chews/Iron
*pediatric multiple vitamins w/
iron chew tab 15 mg**
generic
Baby Vitamin/Iron
iron drops 10 mg/ml**
generic
QL
60 / claim
Tri-Vitamin
*pediatric vitamins adc drops
1500 unit-400 unit-35 mg/ml***
generic
QL
50 / claim
Prenatal Vitamin
*prenatal vit w/ fe fumarate-fa
tab 27-0.8 mg***
generic
Prenatal Vitamins
*prenatal vit w/ fe fumarate-fa
tab 28-0.8 mg***
GL
generic
Female
AL
Up to 50 yrs old
QL
31 / 31 days
Vita-Plus G
*vitamins w/ lipotropics cap**
generic
L-Arginine
arginine cap 500 mg
generic
PAGE 39
BRAND NAME
RA L-Arginine
arginine tab 1000 mg
COVERAGE
Arginine
arginine tab 500 mg
generic
Ascocid
ASCOCID POWDER
ascorbic acid
BRAND
Vitamin C
Ascorbic Acid (CHEW TAB 500
MG, TAB 250 MG, TAB 500
MG, TAB 1000 MG)
generic
Vitamin C
ascorbic acid syrup 500
mg/5ml
generic
C-1500/Rose Hips SR
ascorbic acid tab cr 1500 mg
generic
B Complex
B-Complex Vitamins (CAP**,
TAB**)
generic
Meribin
biotin cap 5 mg
generic
Vitamin D3
Cholecalciferol (CAP 400
UNIT, ORAL LIQUID 400
UNIT/ML, TAB 400 UNIT)
generic
generic
QL
100 / 31 days
QL
31 / 31 days
generic
QL
100 / claim
100 / claim
Pronutrients Vitamin
D3
Vitamin D3
generic
QL
Vitamin D3
generic
MDD
2 per day
D 1000
cholecalciferol chew tab 1000
unit
generic
KP Vitamin D
cholecalciferol chew tab 400
unit
generic
Vitamin D
cholecalciferol tab 1000 unit
generic
Calciferol
ergocalciferol soln 8000 unit/ml
generic
Folic Acid
folic acid tab 400 mcg
generic
MDD
1 per day
KP Folic Acid
folic acid tab 800 mcg
generic
MDD
1 per day
Inositol
Inositol (TAB 500 MG, TAB
650 MG)
generic
PA
Niacin ER
Niacin (CAP 250 MG, CAP 500
MG)
generic
Niacin
Niacin (TAB 50 MG, TAB 100
MG)
generic
NOVAFERRUM PEDIATRIC
DROPS LIQUID 15 MG/ML
polysaccharide iron complex
BRAND
NovaFerrum Pediatric
Drops
PAGE 40
BRAND NAME
Nu-Iron
polysaccharide iron complex
cap 150 mg (iron equivalent)
COVERAGE
Prenatal Formula
PRENATAL FORMULA CAP
28-0.8-235 MG
prenatal vit w/ ferrous
fumarate-fa-omega 3 fatty
acids
BRAND
ProRenal + D
PRORENAL + D TAB
multiple vitamins w/ minerals
BRAND
ProRenal + D w/
Omega-3
PRORENAL + D W/ OMEGA-3
CAP
BRAND
Pure L-Citrulline
PURE L-CITRULLINE CAP
600 MG
arginine
BRAND
Vitamin B-6
Pyridoxine HCl (TAB 25 MG,
generic
Neuro-K-250 Vitamin
B6
pyridoxine hcl tab 250 mg
Neuro-K-500
pyridoxine hcl tab 500 mg
generic
B-2
Riboflavin (TAB 50 MG, TAB
100 MG)
generic
Riboflavin
riboflavin cap 50 mg
generic
Vitamin B-1
Thiamine HCl (TAB 50 MG,
SM Vitamin B1
generic
MDD
1 per day
QL
31 / 31 days
QL
100 / 31 days
generic
QL
100 / 31 days
thiamine mononitrate tab 100
mg
generic
QL
100 / 31 days
L-Tryptophan
Tryptophan (CAP 500 MG,
TAB 500 MG)
generic
Vitamin A
Vitamin A (CP 10000, TB
10000)
generic
KP Vitamin E
vitamin e cap 100 unit
generic
QL
62 / 31 days
Vitamin E
generic
QL
62 / 31 days
Vita-Plus E
generic
QL
62 / 31 days
Liqui-E
vitamin e liquid 400 unit/15ml
(26.6 unit/ml)
generic
Vitamin E
vitamin e soln 15 unit/0.3ml (50
unit/ml)
generic
PAGE 41
generic
LIST OF COVERED PRESCRIPTION MEDICATIONS
BRAND NAME
DRUG DESCRIPTION (RX)
COVERAGE
ANALGESICS
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
Butalbital-AspirinCaffeine
butalbital-aspirin-caffeine tab
50-325-40 mg
generic
Celecoxib
Celecoxib (CAP 50 MG, CAP
100 MG, CAP 200 MG, CAP
400 MG)
generic
Diclofenac Potassium
diclofenac potassium tab 50
mg
generic
Diclofenac Sodium
Diclofenac Sodium (TAB 25
MG, TAB 50 MG, TAB 75 MG)
generic
Diclofenac Sodium
ER
diclofenac sodium tab sr 24hr
100 mg
generic
Diflunisal
diflunisal tab 500 mg
generic
Etodolac
Etodolac (CAP 200 MG, CAP
300 MG, TAB 400 MG, TAB
500 MG)
generic
Etodolac (TAB 24HR 600 MG,
TAB 24HR 400 MG, TAB 24HR
500 MG)
generic
Flurbiprofen
Flurbiprofen (TAB 50 MG, TAB
100 MG)
generic
Ibuprofen
Ibuprofen (SUSP 100 MG/5ML,
generic
IBU
ibuprofen tab 800 mg
generic
Indomethacin
Indomethacin (CAP 25 MG,
CAP 50 MG)
generic
Indomethacin ER
indomethacin cap cr 75 mg
generic
Ketoprofen
Ketoprofen (CAP 50 MG, CAP
75 MG)
generic
Ketoprofen ER
ketoprofen cap sr 24hr 200 mg
generic
Ketorolac
Tromethamine
ketorolac tromethamine tab 10
mg
generic
Etodolac ER
Meloxicam
PAGE 42
Meloxicam (TAB 7.5 MG, TAB
15 MG)
MDD
QL
4 per day
62 / 31 days
PA
QL
20 / 30 days
AL
At least 17 yrs old
generic
BRAND NAME
Nabumetone
Nabumetone (TAB 500 MG,
TAB 750 MG)
COVERAGE
Naproxen
Naproxen (SUSP 125
MG/5ML, TAB 250 MG, TAB
375 MG, TAB 500 MG)
generic
Naproxen DR
Naproxen (TAB EC 375 MG,
TAB EC 500 MG)
generic
Naproxen Sodium
Naproxen Sodium (TAB 275
MG, TAB 550 MG)
generic
Oxaprozin
oxaprozin tab 600 mg
generic
Piroxicam
Piroxicam (CAP 10 MG, CAP
20 MG)
generic
Salsalate
Salsalate (TAB 500 MG, TAB
750 MG)
generic
Sulindac
Sulindac (TAB 150 MG, TAB
200 MG)
generic
generic
MDD
2 per day
OPIOID ANALGESICS, LONG-ACTING
FentaNYL
Fentanyl (PATCH 72HR 25,
PATCH 72HR 12, PATCH
72HR 100, PATCH 72HR 75,
PATCH 72HR 50)
generic
MDD
0.33 per day
Methadone HCl
methadone hcl tab 10 mg
generic
MDD
10 per day
Methadone HCl
methadone hcl tab 5 mg
generic
QL
Morphine Sulfate ER
Morphine Sulfate (TAB 15 MG,
TAB 30 MG, TAB 60 MG, TAB
100 MG, TAB 200 MG)
generic
MDD
3 per day
30 per day
124 / 31 days
OPIOID ANALGESICS, SHORT-ACTING
AcetaminophenCodeine
acetaminophen w/ codeine
soln 120-12 mg/5ml
generic
MDD
AcetaminophenCodeine #2
acetaminophen w/ codeine tab
300-15 mg
generic
QL
186 / 31 days
300-30 mg
generic
QL
186 / 31 days
300-60 mg
generic
QL
186 / 31 days
Butalbital-APAP-CaffCod
butalbital-acetaminophen-caff
w/ cod cap 50-325-40-30 mg
generic
QL
124 / 31 days
Butalbital-ASA-CaffCodeine
butalbital-aspirin-caff w/
codeine cap 50-325-40-30 mg
generic
QL
124 / 31 days
PAGE 43
BRAND NAME
Codeine Sulfate
Codeine Sulfate (TAB 15 MG,
HydrocodoneAcetaminophen
Hydrocodone-Acetaminophen
(TAB 5-325 MG, TAB 7.5-650
MG, TAB 10-325 MG)
generic
MDD
6 per day
(TAB 7.5-325 MG, TAB 7.5500 MG)
generic
MDD
8 per day
hydrocodone-acetaminophen
soln 7.5-325 mg/15ml
generic
MDD
180 per day
Co-Gesic
tab 5-500 mg
generic
MDD
8 per day
tab 7.5-750 mg
generic
MDD
5 per day
HYDROmorphone
HCl
hydromorphone hcl suppos 3
mg
generic
QL
HYDROmorphone
HCl
hydromorphone hcl tab 2 mg
generic
MDD
8 per day
HYDROmorphone
HCl
HYDROmorphone
HCl
generic
MDD
4 per day
Meperidine HCl
Meperidine HCl (TAB 50 MG,
TAB 100 MG)
generic
MDD
6 per day
Meperidine HCl
meperidine hcl oral soln 50
mg/5ml
generic
Morphine Sulfate
Morphine Sulfate (SOLN 10,
SOLN 20)
generic
QL
500 / 31 days
Morphine Sulfate
Morphine Sulfate (SUPPOS 5
MG, SUPPOS 10 MG,
SUPPOS 20 MG, SUPPOS 30
MG)
generic
QL
24 / 31 days
Morphine Sulfate
Morphine Sulfate (TAB 15 MG,
TAB 30 MG)
generic
MDD
Morphine Sulfate
(Concentrate)
morphine sulfate oral soln 100
mg/5ml (20 mg/ml)
generic
QL
OxyCODONE HCl
Oxycodone HCl (CAP 5 MG,
20 MG, TAB 30 MG)
generic
MDD
OxyCODONE HCl
oxycodone hcl conc 100
mg/5ml (20 mg/ml)
generic
QL
120 / claim
OxyCODONE HCl
oxycodone hcl soln 5 mg/5ml
generic
MDD
30 per day
PAGE 44
COVERAGE
generic
62 / 31 days
generic
6 per day
240 / claim
6 per day
BRAND NAME
OxyCODONE HCl
oxycodone hcl tab 5 mg
OxycodoneAcetaminophen
COVERAGE
generic
QL
186 / 31 days
Oxycodone w/ Acetaminophen
(CAP 5-500 MG, TAB 7.5-325
MG, TAB 7.5-500 MG, TAB 10650 MG, TAB 10-325 MG)
generic
QL
186 / 31 days
Roxicet
oxycodone w/ acetaminophen
tab 5-325 mg
generic
QL
186 / 31 days
Oxycodone-Aspirin
oxycodone-aspirin tab 4.8355325 mg
generic
QL
186 / 31 days
Roxicet
ROXICET SOLUTION 5-325
MG/5ML
oxycodone w/ acetaminophen
BRAND
QL
500 / 31 days
TraMADol HCl
tramadol hcl tab 50 mg
generic
MDD
TramadolAcetaminophen
tramadol-acetaminophen tab
37.5-325 mg
generic
QL
124 / 31 days
Lidocaine Viscous
lidocaine hcl viscous soln 2%
generic
QL
100 / claim
Lidocaine-Prilocaine
lidocaine-prilocaine cream 2.52.5%
QL
generic
30 / claim
8 per day
ANESTHETICS
LOCAL ANESTHETICS
MPL
1 / claim
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
ALCOHOL DETERRENTS/ANTI-CRAVING
Disulfiram
disulfiram tab 250 mg
generic
Naltrexone HCl
naltrexone hcl tab 50 mg
generic
Vivitrol
VIVITROL RECON SUSP 380
MG
naltrexone
BRAND
OPIOID DEPENDENCE TREATMENTS
Suboxone
Suboxone
PAGE 45
Buprenorphine HCl-Naloxone
HCl Dihydrate (FILM 2-0.5 MG,
FILM 4-1 MG)
buprenorphine hcl-naloxone hcl
dihydrate
BRAND
Buprenorphine HCl-Naloxone
HCl Dihydrate (FILM 8-2 MG,
FILM 12-3 MG)
buprenorphine hcl-naloxone hcl
dihydrate
BRAND
PA
MDD
1 per day
PA
MDD
2 per day
BRAND NAME
COVERAGE
OPIOID REVERSAL AGENTS
Naloxone HCl
Naloxone HCl (INJ 0.4 MG/ML,
INJ 1 MG/ML)
generic
QL
2 / 90 days
Narcan
NALOXONE HCL NASAL
SPRAY 4 MG/0.1ML
naloxone hcl
BRAND
MPL
1 / 90 days
MDD
2 per day
MDS
180 / 365 days
MDD
2 per day
MDS
180 / 365 days
MPL
2 / 365 days
MDS
180 / 365 days
SMOKING CESSATION AGENTS
Buproban
Chantix Continuing
Month Pak
Chantix Starting
Month Pak
Nicotrol
bupropion hcl (smoking
deterrent) tab sr 12hr 150 mg
generic
CHANTIX CONTINUING
MONTH PAK TAB 1 MG
varenicline tartrate
BRAND
CHANTIX STARTING MONTH
PAK TAB 0.5 MG X 11 & 1 MG
X 42
BRAND
NICOTROL INHALER 10 MG
nicotine
QL
BRAND
MDS
Nicotrol NS
Chantix
NICOTROL NS SOLUTION 10
MG/ML
nicotine
BRAND
Varenicline Tartrate (TAB 0.5
MG, TAB 1 MG)
BRAND
QL
504 / 30 days
180 / 365 days
120 / 30 days
MDS
180 / 365 days
MDD
2 per day
MDS
180 / 365 days
ANTIBACTERIALS
AMINOGLYCOSIDES
Gentamicin Sulfate
gentamicin sulfate cream 0.1%
QL
generic
C
Gentamicin Sulfate
gentamicin sulfate oint 0.1%
QL
generic
C
Gentak
PAGE 46
gentamicin sulfate ophth oint
0.3%
generic
QL
31 / 31 days
Pkg Size 15: Package
Limit=2/claim | Pkg
Size 30: Package
Limit=1/claim |
31 / 31 days
Limit=1/claim | Pkg
Size 15: Package
Limit=2/claim |
4 / 31 days
BRAND NAME
Gentamicin Sulfate
gentamicin sulfate ophth soln
0.3%
COVERAGE
Neomycin Sulfate
neomycin sulfate tab 500 mg
generic
TobraDex
TOBRADEX OINTMENT 0.30.1 %
tobramycin-dexamethasone
BRAND
QL
4 / 31 days
Tobramycin
tobramycin ophth soln 0.3%
generic
QL
5 / 31 days
Tobramycin Sulfate
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), INJ 80 MG/2ML (40
MG/ML))
generic
PA
Tobramycin Sulfate in
Saline
TOBRAMYCIN SULFATE IN
SALINE SOLUTION 1.2-0.9
MG/ML-%
tobramycin sulfate in saline
BRAND
PA
Tobrex
TOBREX OINTMENT 0.3 %
tobramycin (ophth)
BRAND
generic
MPL
2 / claim
ANTIBACTERIALS, OTHER
Phosphasal
*methenamine-hyos-meth bluesod phos-phen sal tab 81.6
mg***
generic
Bacitracin
bacitracin ophth oint 500
unit/gm
generic
Clindamycin HCl
Clindamycin HCl (CAP 150
MG, CAP 300 MG)
generic
Clindamycin
Palmitate HCl
clindamycin palmitate hcl for
soln 75 mg/5ml (base equiv)
generic
Clindamycin
Phosphate
Clindamycin Phosphate
(Topical) (LOTION, SOLN)
generic
Clindamycin
Phosphate
clindamycin phosphate gel 1%
Clindamycin
Phosphate
clindamycin phosphate vaginal
cream 2%
generic
Methenamine
Mandelate
Methenamine Mandelate (TAB
0.5 GM, TAB 1 GM)
generic
MetroNIDAZOLE
Metronidazole (TAB 250 MG,
TAB 500 MG)
generic
PAGE 47
generic
QL
4 / 31 days
QL
300 / claim
MPL
1 / claim
BRAND NAME
MetroNIDAZOLE
Metronidazole (Topical)
(CREAM, GEL)
COVERAGE
MetroNIDAZOLE
metronidazole lotion 0.75%
generic
Vandazole
metronidazole vaginal gel
0.75%
generic
generic
QL
45 / 30 days
QL
45 / 30 days
MPL
1 / claim
Mupirocin Calcium
mupirocin calcium cream 2%
generic
MPL
1 / 31 days
Mupirocin
mupirocin oint 2%
generic
MPL
1 / 31 days
Nitrofurantoin
Macrocrystal
Nitrofurantoin Macrocrystal
(CAP 50 MG, CAP 100 MG)
generic
Nitrofurantoin
Monohyd Macro
nitrofurantoin monohydrate
macrocrystalline cap 100 mg
generic
Nitrofurantoin
nitrofurantoin susp 25 mg/5ml
AL
generic
MDD
Sivextro
SIVEXTRO TAB 200 MG
tedizolid phosphate
QL
BRAND
Up to 6 yrs old
40 per day
6 / claim
PA
Trimethoprim
trimethoprim tab 100 mg
generic
Vancomycin HCl
vancomycin hcl cap 125 mg
generic
MDD
4 per day
Vancomycin HCl
vancomycin hcl cap 250 mg
generic
MDD
8 per day
Vancomycin HCl
vancomycin hcl for inj 1000 mg
generic
QL
14 / claim
Vancomycin HCl
vancomycin hcl for inj 500 mg
generic
QL
14 / 30 days
BETA-LACTAM, CEPHALOSPORINS
Cefaclor
Cefaclor (CAP 250 MG, CAP
500 MG, FOR SUSP 125
MG/5ML, FOR SUSP 250
MG/5ML)
generic
Cefadroxil (CAP 500 MG, FOR
SUSP 250 MG/5ML, FOR
SUSP 500 MG/5ML, TAB 1
GM)
generic
Cefdinir
Cefdinir (SUSP 125, SUSP
250)
generic
MPL
Cefdinir
cefdinir cap 300 mg
generic
QL
20 / claim
Cefprozil
Cefprozil (TAB 250 MG, TAB
500 MG)
generic
QL
20 / claim
Cefadroxil
PAGE 48
1 / claim
BRAND NAME
Cefprozil
cefprozil for susp 125 mg/5ml
COVERAGE
AL
generic
MPL
Cefprozil
cefprozil for susp 250 mg/5ml
AL
generic
MPL
Ceftin
CEFTIN RECON SUSP 250
MG/5ML
cefuroxime axetil
BRAND
Ceftriaxone Sodium (INJ 1 GM,
INJ 250 MG, INJ 500 MG, IV
SOLN 1 GM)
generic
Cefuroxime Axetil
Cefuroxime Axetil (TAB 250
MG, TAB 500 MG)
generic
Cefuroxime Axetil
cefuroxime axetil for susp 125
mg/5ml
generic
CefTRIAXone Sodium
AL
Cephalexin (CAP 250 MG,
CAP 500 MG, FOR SUSP 125
MG/5ML)
2 / claim
Up to 12 yrs old
1 / claim
Up to 12 yrs old
MPL
1 / claim
QL
3 / claim
MFL
1 / 30 days
QL
20 / claim
AL
Up to 12 yrs old
MPL
Cephalexin
Up to 12 yrs old
1 / claim
generic
BETA-LACTAM, PENICILLINS
Amoxicillin-Pot
Clavulanate ER
amoxicillin & k clavulanate tab
sr 12hr 1000-62.5 mg
generic
QL
40 / 30 days
Amoxicillin-Pot
Clavulanate
Amoxicillin & Pot Clavulanate
(CHEW TAB 200-28.5 MG,
CHEW TAB 400-57 MG, TAB
875-125 MG)
generic
QL
20 / claim
Amoxicillin-Pot
Clavulanate
(SUSP 200-28.5, SUSP 25062.5)
generic
MPL
1 / claim
Amoxicillin-Pot
Clavulanate
(SUSP 400-57, SUSP 60042.9)
generic
MPL
2 / claim
Amoxicillin-Pot
Clavulanate
(TAB 250-125 MG, TAB 500125 MG)
generic
QL
Amoxicillin
Amoxicillin (CAP 250 MG, CAP
500 MG, CHEW TAB 125 MG,
CHEW TAB 250 MG, FOR
SUSP 400 MG/5ML, TAB 875
MG)
generic
PAGE 49
30 / claim
BRAND NAME
Ampicillin
Augmentin
Ampicillin (CAP 250 MG, CAP
500 MG, RECON SUSP 125
MG/5ML, RECON SUSP 250
MG/5ML)
ampicillin
COVERAGE
BRAND
AUGMENTIN RECON SUSP
125-31.25 MG/5ML
amoxicillin & pot clavulanate
BRAND
Dicloxacillin Sodium
Dicloxacillin Sodium (CAP 250
MG, CAP 500 MG)
generic
Penicillin V Potassium
Penicillin V Potassium (FOR
SOLN 125 MG/5ML, FOR
SOLN 250 MG/5ML, TAB 250
MG, TAB 500 MG)
generic
Azithromycin
azithromycin for susp 100
mg/5ml
generic
Azithromycin
azithromycin for susp 200
mg/5ml
MPL
1 / claim
MPL
1 / claim
MACROLIDES
generic
C
Limit=1/claim | Pkg
Size 22.5: Package
Limit=2/claim | Pkg
Size 30: Package
Limit=2/claim |
Azithromycin
azithromycin tab 250 mg
generic
QL
6 / claim
Azithromycin
generic
MDD
4 per day
Azithromycin
generic
QL
8 / 28 days
Clarithromycin
Clarithromycin (TAB 250 MG,
TAB 500 MG)
generic
QL
28 / claim
Clarithromycin
clarithromycin for susp 125
mg/5ml
generic
MPL
1 / claim
Clarithromycin
clarithromycin for susp 250
mg/5ml
generic
MPL
2 / claim
Clarithromycin ER
clarithromycin tab sr 24hr 500
mg
generic
QL
E.E.S. Granules
E.E.S. GRANULES RECON
SUSP 200 MG/5ML
erythromycin ethylsuccinate
BRAND
ERYPED 200 RECON SUSP
200 MG/5ML
BRAND
ERYPED 400 RECON SUSP
400 MG/5ML
BRAND
EryPed 200
EryPed 400
PAGE 50
14 / claim
BRAND NAME
PCE
Ery-Tab
Erythromycin Base (Coated)
(TAB DR 333 MG, TAB DR
500 MG)
erythromycin base (coated)
COVERAGE
BRAND
Erythromycin Base (TAB DR
250 MG, TAB DR 333 MG,
TAB DR 500 MG)
erythromycin base
BRAND
Erythromycin
erythromycin gel 2%
generic
Erythromycin
erythromycin ophth oint 5
mg/gm
generic
Erythromycin
erythromycin soln 2%
generic
Erythromycin Base
erythromycin w/ delayed
release particles cap 250 mg
generic
E.S.P.
erythromycin-sulfisoxazole for
susp 200-600 mg/5ml
generic
Ciloxan
CILOXAN OINTMENT 0.3 %
ciprofloxacin hcl (ophth)
BRAND
Ciprofloxacin HCl
Ciprofloxacin HCl (TAB 250
MG)
generic
Ciprofloxacin HCl
ciprofloxacin hcl ophth soln
0.3%
Ciprofloxacin HCl
LevoFLOXacin
MPL
1 / claim
MPL
1 / claim
generic
MPL
1 / claim
ciprofloxacin hcl tab 100 mg
(base equiv)
generic
QL
6 / claim
Levofloxacin (TAB 250 MG,
QL
generic
14 / claim
MDD
1 per day
QUINOLONES
Ofloxacin
Ofloxacin (TAB 200 MG, TAB
300 MG, TAB 400 MG)
generic
QL
56 / claim
Ofloxacin
ofloxacin ophth soln 0.3%
generic
QL
10 / 31 days
Ofloxacin
ofloxacin otic soln 0.3%
QL
10 / 31 days
generic
Vigamox
VIGAMOX SOLUTION 0.5 %
moxifloxacin hcl (ophth)
BRAND
silver sulfadiazine cream 1%
generic
MPL
1 / claim
QL
3 / claim
SULFONAMIDES
Silver Sulfadiazine
PAGE 51
BRAND NAME
Sulfacetamide
Sodium
sulfacetamide sodium ophth
oint 10%
Sulfacetamide
Sodium
COVERAGE
generic
QL
4 / 31 days
sulfacetamide sodium ophth
soln 10%
generic
QL
15 / 31 days
SulfamethoxazoleTrimethoprim
SulfamethoxazoleTrimethoprim (SUSP 200-40
MG/5ML, TAB 400-80 MG)
generic
SulfamethoxazoleTMP DS
sulfamethoxazole-trimethoprim
tab 800-160 mg
generic
Doxycycline Hyclate (CAP 50
MG, CAP 100 MG, TAB 100
MG)
generic
Minocycline HCl (CAP 50 MG,
CAP 75 MG, CAP 100 MG)
generic
TETRACYCLINES
Doxycycline Hyclate
Minocycline HCl
ANTICONVULSANTS
ANTICONVULSANTS, OTHER
Potiga
Ezogabine (TAB 200 MG, TAB
300 MG, TAB 400 MG)
ezogabine
BRAND
Levetiracetam (INJ 500
MG/5ML (100 MG/ML), ORAL
SOLN 100 MG/ML, TAB 250
MG, TAB 1000 MG)
generic
LevETIRAcetam ER
Levetiracetam (TAB 24HR 750
MG, TAB 24HR 500 MG)
generic
LevETIRAcetam in
NaCl
Levetiracetam in Sodium
Chloride (SOLUTION 500,
SOLUTION 1000, SOLUTION
1500)
levetiracetam in sodium
chloride
BRAND
POTIGA TAB 50 MG
ezogabine
BRAND
LevETIRAcetam
Potiga
MDD
3 per day
CALCIUM CHANNEL MODIFYING AGENTS
Celontin
CELONTIN CAP 300 MG
methsuximide
BRAND
Ethosuximide
Ethosuximide (CAP 250 MG,
SOLN 250 MG/5ML)
generic
PAGE 52
BRAND NAME
Zonisamide
Zonisamide (CAP 25 MG, CAP
50 MG, CAP 100 MG)
COVERAGE
generic
GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS
DiazePAM
Diazepam (Anticonvulsant)
(GEL 2.5 MG, GEL 10 MG,
GEL 20 MG)
generic
Divalproex Sodium
divalproex sodium cap delayed
release sprinkle 125 mg
generic
Divalproex Sodium
divalproex sodium tab delayed
release 125 mg
generic
MDD
2 per day
Divalproex Sodium
release 250 mg
generic
MDD
3 per day
Divalproex Sodium
release 500 mg
generic
MDD
7 per day
Divalproex Sodium
ER
divalproex sodium tab sr 24 hr
250 mg
generic
QL
Divalproex Sodium
ER
divalproex sodium tab sr 24 hr
500 mg
generic
MDD
7 per day
Gabapentin
Gabapentin (CAP 100 MG,
CAP 300 MG, CAP 400 MG,
ORAL SOLN 250 MG/5ML,
TAB 600 MG)
generic
Gabapentin
gabapentin tab 800 mg
generic
MDD
4 per day
Nembutal
NEMBUTAL SOLUTION 50
MG/ML
pentobarbital sodium
BRAND
ONFI SUSPENSION 2.5
MG/ML
clobazam
BRAND
MDD
32 per day
Onfi
ONFI TAB 10 MG
clobazam
BRAND
MDD
8 per day
Onfi
ONFI TAB 20 MG
clobazam
BRAND
MDD
4 per day
PHENobarbital
Phenobarbital (ELIXIR 20
16.2 MG, TAB 30 MG, TAB
32.4 MG, TAB 60 MG, TAB
64.8 MG, TAB 97.2 MG, TAB
100 MG)
generic
Phenobarbital Sodium (INJ 65
MG/ML, INJ 130 MG/ML)
generic
Onfi
PHENobarbital
Sodium
PAGE 53
QL
1 / claim
AL
Up to 21 yrs old
93 / 31 days
BRAND NAME
Primidone
Primidone (TAB 50 MG, TAB
250 MG)
Therapentin-60
THERAPENTIN-60 MISC 300
MG
gabapentin-dietary
management product
BRAND
THERAPENTIN-90 MISC 300
MG
gabapentin-dietary
management product
BRAND
Tiagabine HCl (TAB 12 MG,
TAB 16 MG)
tiagabine hcl
BRAND
TiaGABine HCl
Tiagabine HCl (TAB 2 MG,
TAB 4 MG)
generic
Valproate Sodium
valproate sodium inj 100 mg/ml
generic
Valproic Acid
valproate sodium syrup 250
mg/5ml (base equiv)
generic
Stavzor
Valproic Acid (CAP DR 125
MG, CAP DR 250 MG, CAP
DR 500 MG)
valproic acid
BRAND
valproic acid cap 250 mg
generic
Therapentin-90
Gabitril
Valproic Acid
COVERAGE
generic
GLUTAMATE REDUCING AGENTS
Felbamate
Felbamate (SUSP 600
600 MG)
generic
LaMICtal
LAMICTAL CHEW TAB 2 MG
lamotrigine
BRAND
LaMICtal XR
Lamotrigine (KIT 25 (21)-50 (7)
MG, KIT 25 50 100 MG, KIT 50
100 200 MG)
lamotrigine
BRAND
Lamotrigine (KIT 25 (84)100(14) MG, KIT 25 (35) MG,
KIT 25 (42)-100 (7) MG)
lamotrigine
BRAND
LaMICtal Starter
PAGE 54
BRAND NAME
LamoTRIgine
LamoTRIgine ER
Trokendi XR
Topiramate ER
Qudexy XR
Topiramate
Lamotrigine (ORALLY
DISINTEGRATING TAB 25
MG, ORALLY
MG, ORALLY
MG, ORALLY
MG, TAB CHEWABLE
DISPERSIBLE 5 MG, TAB
CHEWABLE DISPERSIBLE 25
MG, TAB DISP 25 MG (21) &
50 MG (7) TITRATION KIT,
TAB DISP 25 (14) & 50 MG
(14) & 100 MG (7) KIT, TAB
DISP 50 MG (42) & 100 MG
(14) TITRATION KIT)
COVERAGE
generic
Lamotrigine (TAB 24HR 50
MG, TAB 24HR 25 MG, TAB
24HR 100 MG, TAB 24HR 200
24HR 300 MG)
generic
Topiramate (CAP ER 24H 50
MG, CAP ER 24H 25 MG, CAP
ER 24H 100 MG, CAP ER 24H
200 MG)
topiramate
BRAND
MDD
2 per day
Topiramate (CAP ER 24HR
150 MG, CAP ER 24HR 50
MG, CAP ER 24HR 25 MG,
CAP ER 24HR 100 MG)
generic
MDD
2 per day
Topiramate (CP24 SPRNK 50
MG, CP24 SPRNK 100 MG,
CP24 SPRNK 150 MG, CP24
SPRNK 25 MG)
topiramate
BRAND
MDD
2 per day
Topiramate (SPRINKLE CAP
15 MG, SPRINKLE CAP 25
MG, TAB 25 MG, TAB 50 MG,
generic
SODIUM CHANNEL AGENTS
Aptiom
APTIOM TAB 400 MG
eslicarbazepine acetate
BRAND
MDD
3 per day
Aptiom
APTIOM TAB 800 MG
BRAND
MDD
1 per day
PAGE 55
BRAND NAME
CarBAMazepine ER
Carbamazepine (CAP 100 MG,
CAP 200 MG, CAP 300 MG,
TAB 100 MG, TAB 200 MG,
TAB 400 MG)
COVERAGE
generic
CarBAMazepine
Carbamazepine (CHEW TAB
100 MG, SUSP 100 MG/5ML)
generic
Epitol
carbamazepine tab 200 mg
generic
Dilantin
DILANTIN CAP 30 MG
phenytoin sodium extended
BRAND
Aptiom
Eslicarbazepine Acetate (TAB
200 MG, TAB 600 MG)
BRAND
Lacosamide (SOLUTION 10
MG/ML, SOLUTION 200
200 MG)
lacosamide
BRAND
Oxcarbazepine (SUSP 300
MG/5ML (60 MG/ML), TAB 150
MG)
generic
Oxcarbazepine (TAB ER 24H
600 MG, TAB ER 24H 300 MG,
TAB ER 24H 150 MG)
oxcarbazepine
BRAND
Peganone
PEGANONE TAB 250 MG
ethotoin
BRAND
Phenytoin
Phenytoin (CHEW TAB 50 MG,
SUSP 125 MG/5ML)
generic
Phenytoin Sodium
Extended
phenytoin sodium extended
cap 100 mg
generic
Banzel
Rufinamide (SUSPENSION 40
MG/ML, TAB 200 MG, TAB
400 MG)
rufinamide
BRAND
Vimpat
OXcarbazepine
Oxtellar XR
MDD
2 per day
MDD
3 per day
ANTIDEMENTIA AGENTS
ANTIDEMENTIA AGENTS, OTHER
Ergoloid Mesylates
ergoloid mesylates tab 1 mg
generic
Isoxsuprine HCl
isoxsuprine hcl tab 10 mg
generic
PAGE 56
BRAND NAME
COVERAGE
CHOLINESTERASE INHIBITORS
Donepezil HCl
Donepezil Hydrochloride
(ORALLY DISINTEGRATING
TAB 5 MG, ORALLY
TAB 23 MG)
generic
MDD
1 per day
Exelon
EXELON SOLUTION 2 MG/ML
rivastigmine tartrate
BRAND
MDD
6 per day
Galantamine
Hydrobromide ER
Galantamine Hydrobromide
(CAP 24HR 8 MG, CAP 24HR
24 MG, CAP 24HR 16 MG)
generic
MDD
1 per day
Galantamine
Hydrobromide
(TAB 4 MG, TAB 8 MG, TAB
12 MG)
generic
MDD
2 per day
Galantamine
Hydrobromide
galantamine hydrobromide oral
soln 4 mg/ml
generic
MDD
6 per day
Namzaric
Memantine HCl-Donepezil HCl
(CAP ER 24H 14-10 MG, CAP
ER 24H 28-10 MG)
memantine hcl-donepezil hcl
BRAND
MDD
1 per day
Rivastigmine (PATCH 24HR
13.3 MG/24HR, PATCH 24HR
4.6 MG/24HR, PATCH 24HR
9.5 MG/24HR)
generic
MDD
1 per day
Rivastigmine Tartrate (CAP 1.5
MG, CAP 3 MG, CAP 4.5 MG,
CAP 6 MG)
generic
MDD
2 per day
Rivastigmine
Rivastigmine Tartrate
N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST
Memantine HCl
Memantine HCl
Memantine HCl (TAB 5 MG,
TAB 5 MG (28) & 10 MG (21)
TITRATION PAK, TAB 10 MG)
generic
MDD
2 per day
memantine hcl oral solution 2
mg/ml
generic
MDD
10 per day
MDD
2 per day
ANTIDEPRESSANTS
ANTIDEPRESSANTS, OTHER
Appbutamone
Budeprion SR
PAGE 57
APPBUTAMONE MISC 75 MG
bupropion hcl-dietary
management product
BRAND
Bupropion HCl (TAB 100 MG,
TAB 150 MG)
generic
BRAND NAME
Budeprion XL
Bupropion HCl (TAB 24HR 150
BuPROPion HCl
COVERAGE
generic
MDD
1 per day
Bupropion HCl (TAB 75 MG,
TAB 100 MG)
generic
MDD
4 per day
BuPROPion HCl ER
(SR)
bupropion hcl tab sr 12hr 200
mg
generic
MDD
2 per day
Aplenzin
Bupropion Hydrobromide (TAB
ER 24H 348 MG, TAB ER 24H
174 MG, TAB ER 24H 522
MG)
bupropion hydrobromide
BRAND
MDD
1 per day
ChlordiazepoxideAmitriptyline
Chlordiazepoxide-Amitriptyline
(TAB 5-12.5 MG, TAB 10-25
MG)
generic
Forfivo XL
FORFIVO XL TAB ER 24H 450
MG
bupropion hcl
BRAND
MDD
1 per day
Mirtazapine (TAB 7.5 MG, TAB
15 MG, TAB 30 MG, TAB 45
MG, TAB ODT 15 MG, TAB
ODT 30 MG, TAB ODT 45 MG)
generic
MDD
1 per day
Olanzapine-Fluoxetine HCl
(CAP 3-25 MG, CAP 6-25 MG,
CAP 6-50 MG, CAP 12-50 MG,
CAP 12-25 MG)
generic
Perphenazine-Amitriptyline
(TAB 2-10 MG, TAB 2-25 MG,
TAB 4-10 MG, TAB 4-25 MG,
TAB 4-50 MG)
generic
Mirtazapine
OLANZapineFLUoxetine HCl
PerphenazineAmitriptyline
AL
At least 18 yrs old
MDD
1 per day
MONOAMINE OXIDASE INHIBITORS
Marplan
MARPLAN TAB 10 MG
isocarboxazid
BRAND
MDD
3 per day
Phenelzine Sulfate
phenelzine sulfate tab 15 mg
generic
MDD
6 per day
Emsam
Selegiline (9 MG/24HR,
PATCH 24HR 6 MG/24HR,
PATCH 24HR 9 MG/24HR,
PATCH 24HR 12 MG/24HR)
selegiline
BRAND
MDD
1 per day
tranylcypromine sulfate tab 10
mg
generic
MDD
6 per day
Tranylcypromine
Sulfate
PAGE 58
BRAND NAME
COVERAGE
SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITORS/SEROTONIN AND NOREPINEPHRINE
REUPTAKE INHIBITOR
Citalopram
Hydrobromide
Citalopram Hydrobromide (TAB
MG)
generic
MDD
1 per day
Citalopram
Hydrobromide
citalopram hydrobromide oral
soln 10 mg/5ml
generic
MDD
20 per day
Desvenlafaxine
Fumarate ER
DESVENLAFAXINE
FUMARATE ER TAB ER 24H
100 MG
desvenlafaxine fumarate
BRAND
MDD
2 per day
Desvenlafaxine
Fumarate ER
DESVENLAFAXINE
FUMARATE ER TAB ER 24H
50 MG
desvenlafaxine fumarate
BRAND
MDD
1 per day
Pristiq
Desvenlafaxine Succinate
(TAB ER 24H 25 MG, TAB ER
24H 50 MG)
desvenlafaxine succinate
BRAND
MDD
1 per day
Desvenlafaxine ER
desvenlafaxine tab sr 24hr 100
mg
generic
MDD
2 per day
Desvenlafaxine ER
desvenlafaxine tab sr 24hr 50
mg
generic
MDD
1 per day
Escitalopram Oxalate
Escitalopram Oxalate (TAB 5
MG, TAB 10 MG)
generic
MDD
1 per day
escitalopram oxalate soln 5
mg/5ml (base equiv)
generic
MDD
20 per day
escitalopram oxalate tab 20 mg
(base equiv)
generic
MDD
2 per day
Fetzima Titration
FETZIMA TITRATION CP24
THPK 20 & 40 MG
levomilnacipran hcl
BRAND
MDD
1 per day
FLUoxetine HCl
Fluoxetine HCl (CAP 10 MG,
TAB 60 MG)
generic
MDD
1 per day
FLUoxetine HCl
Fluoxetine HCl (CAP 20 MG,
TAB 20 MG)
generic
MDD
4 per day
Selfemra
fluoxetine hcl (pmdd) cap 10
mg
generic
MDD
1 per day
Selfemra
fluoxetine hcl (pmdd) cap 20
mg
generic
MDD
4 per day
FLUoxetine HCl
fluoxetine hcl cap 40 mg
AL
generic
MDD
PAGE 59
At least 7 yrs old
2 per day
BRAND NAME
FLUoxetine HCl
fluoxetine hcl cap delayed
release 90 mg
FLUoxetine HCl
fluoxetine hcl solution 20
mg/5ml
COVERAGE
generic
QL
4 / 28 days
AL
Up to 6 yrs old
generic
MDD
FLUoxetine HCl
fluoxetine hcl tab 10 mg
AL
generic
20 per day
Up to 12 yrs old
MDD
1.5 per day
FluvoxaMINE Maleate
ER
Fluvoxamine Maleate (CAP
24HR 100 MG, CAP 24HR 150
MG)
generic
MDD
2 per day
FluvoxaMINE Maleate
Fluvoxamine Maleate (TAB 25
MG, TAB 50 MG)
generic
MDD
1 per day
FluvoxaMINE Maleate
fluvoxamine maleate tab 100
mg
generic
MDD
3 per day
Gaboxetine
GABOXETINE MISC 10 MG
fluoxetine hcl-dietary
management product
BRAND
Levomilnacipran HCl (CAP ER
24H 40 MG, CAP ER 24H 80
ER 24H 120 MG)
levomilnacipran hcl
BRAND
MDD
1 per day
Maprotiline HCl
Maprotiline HCl (TAB 25 MG,
generic
MDD
3 per day
Nefazodone HCl
Nefazodone HCl (TAB 50 MG,
TAB 100 MG, TAB 150 MG,
generic
MDD
2 per day
OLEPTRO TAB ER 24H 150
MG
trazodone hcl
BRAND
MDD
1.5 per day
OLEPTRO TAB ER 24H 300
MG
trazodone hcl
BRAND
MDD
1 per day
Fetzima
Oleptro
Oleptro
PARoxetine HCl
Paroxetine HCl (TAB 10 MG,
TAB 20 MG)
AL
generic
MDD
PARoxetine HCl ER
PARoxetine HCl
Paroxetine HCl (TAB 24HR
37.5 MG, TAB 24HR 25 MG,
TAB 24HR 12.5 MG)
Paroxetine HCl (TAB 30 MG,
TAB 40 MG)
AL
generic
MDD
AL
generic
MDD
PARoxetine HCl
paroxetine hcl oral susp 10
mg/5ml (base equiv)
AL
generic
MDD
PAGE 60
At least 18 yrs old
1 per day
At least 18 yrs old
1 per day
At least 18 yrs old
2 per day
At least 18 yrs old
40 per day
BRAND NAME
Pexeva
Paxil
Paroxetine Mesylate (TAB 10
TAB 40 MG)
paroxetine mesylate
COVERAGE
AL
BRAND
MDD
PAXIL SUSPENSION 10
MG/5ML
paroxetine hcl
BRAND
Pristiq
PRISTIQ TAB ER 24H 100 MG
desvenlafaxine succinate
Sarafem
AL
At least 18 yrs old
1 per day
At least 18 yrs old
MDD
40 per day
BRAND
MDD
2 per day
SARAFEM TAB 10 MG
fluoxetine hcl (pmdd)
BRAND
MDD
1.5 per day
Sarafem
SARAFEM TAB 20 MG
fluoxetine hcl (pmdd)
BRAND
MDD
4 per day
Sentraflox AM-10
SENTRAFLOX AM-10 MISC
10 MG
management product
BRAND
SENTRALOPRAM AM-10
MISC 10 MG
citalopram & dietary
management product
BRAND
SENTROXATINE MISC 10 MG
management product
BRAND
Sertraline HCl
Sertraline HCl (TAB 25 MG,
TAB 50 MG)
generic
MDD
2 per day
Sertraline HCl
sertraline hcl oral conc 20
mg/ml
generic
MDD
10 per day
Sertraline HCl
sertraline hcl tab 100 mg
generic
MDD
3 per day
Trazamine
TRAZAMINE MISC 50 MG
trazodone hcl-dietary
management product
BRAND
TraZODone HCl
Trazodone HCl (TAB 100 MG,
TAB 150 MG)
generic
MDD
3 per day
TraZODone HCl
Trazodone HCl (TAB 50 MG,
TAB 300 MG)
generic
MDD
2 per day
Venlafaxine HCl ER
Venlafaxine HCl (CAP 24HR
150 MG, TAB 24HR 150 MG)
generic
MDD
2 per day
Venlafaxine HCl ER
Venlafaxine HCl (CAP 24HR
75 MG, TAB 24HR 75 MG)
generic
MDD
3 per day
Sentralopram AM-10
Sentroxatine
PAGE 61
BRAND NAME
Venlafaxine HCl
Venlafaxine HCl (TAB 25 MG,
TAB 37.5 MG, TAB 50 MG,
COVERAGE
generic
MDD
QL
3 per day
Viibryd
VIIBRYD KIT 10 & 20 & 40 MG
vilazodone hcl
BRAND
Viibryd Starter Pack
VIIBRYD STARTER PACK KIT
10 & 20 MG
vilazodone hcl
BRAND
Vilazodone HCl (TAB 10 MG,
vilazodone hcl
BRAND
MDD
1 per day
Vortioxetine HBr (TAB 5 MG,
vortioxetine hbr
BRAND
MDD
1 per day
Vortioxetine HBr (TAB 5 MG,
vortioxetine hbr
BRAND
MDD
1 per day
Amitriptyline HCl (TAB 10 MG,
75 MG, TAB 100 MG, TAB 150
MG)
generic
MDD
3 per day
Amoxapine
Amoxapine (TAB 25 MG, TAB
150 MG)
generic
MDD
2 per day
Amoxapine
Amoxapine (TAB 50 MG, TAB
100 MG)
generic
MDD
4 per day
ClomiPRAMINE HCl
clomipramine hcl cap 25 mg
generic
MDD
2 per day
ClomiPRAMINE HCl
generic
MDD
5 per day
ClomiPRAMINE HCl
generic
MDD
3 per day
Desipramine HCl
Desipramine HCl (TAB 25 MG,
150 MG)
generic
MDD
2 per day
Desipramine HCl
desipramine hcl tab 10 mg
generic
MDD
4 per day
Desipramine HCl
desipramine hcl tab 100 mg
generic
MDD
3 per day
Doxepin HCl
Doxepin HCl (CAP 25 MG,
CAP 50 MG, CAP 75 MG, CAP
100 MG, CAP 150 MG)
generic
MDD
2 per day
doxepin hcl cap 10 mg
generic
MDD
4 per day
Viibryd
Trintellix
Brintellix
1 / 30 days
TRICYCLICS
Amitriptyline HCl
Doxepin HCl
PAGE 62
BRAND NAME
Doxepin HCl
doxepin hcl conc 10 mg/ml
COVERAGE
generic
MDD
30 per day
Imipramine HCl
imipramine hcl tab 10 mg
generic
MDD
2 per day
Imipramine HCl
generic
MDD
1 per day
Imipramine HCl
generic
MDD
6 per day
Imipramine Pamoate
Imipramine Pamoate (CAP 125
MG, CAP 150 MG)
generic
MDD
2 per day
Imipramine Pamoate
imipramine pamoate cap 100
mg
generic
MDD
3 per day
Imipramine Pamoate
imipramine pamoate cap 75
mg
generic
MDD
1 per day
Nortriptyline HCl
Nortriptyline HCl (CAP 10 MG,
CAP 25 MG)
generic
MDD
4 per day
Nortriptyline HCl
nortriptyline hcl cap 50 mg
generic
MDD
3 per day
Nortriptyline HCl
nortriptyline hcl cap 75 mg
generic
MDD
2 per day
Nortriptyline HCl
nortriptyline hcl soln 10 mg/5ml
generic
MDD
20 per day
Protriptyline HCl
Protriptyline HCl (TAB 5 MG,
TAB 10 MG)
generic
MDD
4 per day
Sentravil PM-25
SENTRAVIL PM-25 MISC 25
MG
amitriptyline hcl & dietary
management product
BRAND
Trimipramine Maleate
Trimipramine Maleate (CAP 25
MG, CAP 50 MG)
generic
MDD
1 per day
trimipramine maleate cap 100
mg
generic
MDD
3 per day
Meclizine HCl
Meclizine HCl (TAB 12.5 MG,
TAB 25 MG)
generic
Metoclopramide HCl
Metoclopramide HCl (SOLN 5
MG/5ML (10 MG/10ML), TAB 5
MG, TAB 10 MG)
generic
ANTIEMETICS
ANTIEMETICS, OTHER
Perphenazine
Perphenazine (TAB 2 MG, TAB
4 MG, TAB 8 MG, TAB 16 MG)
AL
generic
MDD
Prochlorperazine
Edisylate
PAGE 63
prochlorperazine edisylate inj 5
mg/ml
At least 18 yrs old
4 per day
generic
BRAND NAME
Prochlorperazine
Maleate
Prochlorperazine Maleate (TAB
5 MG, TAB 10 MG)
Compro
prochlorperazine suppos 25
mg
COVERAGE
generic
generic
EMETOGENIC THERAPY ADJUNCTS
Ondansetron HCl
Ondansetron HCl (INJ 4
MG/2ML, INJ 40 MG/20ML)
generic
Ondansetron HCl
Ondansetron HCl (TAB 4 MG,
TAB 8 MG)
generic
MDD
Ondansetron HCl
ondansetron hcl oral soln 4
mg/5ml
generic
QL
50 / 31 days
Ondansetron HCl
ondansetron hcl tab 24 mg
generic
QL
1 / 14 days
Ondansetron
ondansetron odt (tab 4 mg, tab
8 mg)
generic
MDD
2 per day
Nystop
*nystatin topical powder**
generic
MPL
1 / 31 days
Clotrimazole
clotrimazole cream 1%
generic
MPL
1 / 31 days
Clotrimazole
clotrimazole soln 1%
generic
MPL
1 / claim
Econazole Nitrate
econazole nitrate cream 1%
generic
QL
30 / claim
Fluconazole
Fluconazole (SUSP 10 MG/ML,
SUSP 40 MG/ML)
generic
QL
70 / claim
Fluconazole
Fluconazole (TAB 100 MG,
TAB 200 MG)
generic
Fluconazole
fluconazole tab 150 mg
generic
QL
2 / claim
Fluconazole
fluconazole tab 50 mg
generic
QL
3 / 14 days
Griseofulvin Microsize
Griseofulvin Microsize (SUSP
125 MG/5ML, TAB 500 MG)
generic
Griseofulvin
Ultramicrosize
Griseofulvin Ultramicrosize
(TAB 125 MG, TAB 250 MG)
generic
Gynazole-1
GYNAZOLE-1 CREAM 2 %
butoconazole nitrate (one
dose)
BRAND
2 per day
ANTIFUNGALS
Itraconazole
itraconazole cap 100 mg
PA
generic
Ketoconazole
PAGE 64
ketoconazole cream 2%
generic
MDD
1 per day
MPL
1 / 31 days
BRAND NAME
Ketoconazole
ketoconazole shampoo 2%
COVERAGE
Miconazole 3
MICONAZOLE 3 SUPPOS 200
MG
BRAND
Nystatin
nystatin cream 100000 unit/gm
generic
MPL
1 / 31 days
Nystatin
nystatin oint 100000 unit/gm
generic
MPL
1 / claim
Nystatin
nystatin susp 100000 unit/ml
generic
MPL
2 / claim
Nystatin
nystatin tab 500000 unit
generic
MDD
6 per day
NystatinTriamcinolone
Nystatin-Triamcinolone
(CREAM, OINT)
generic
MPL
1 / claim
Terbinafine HCl
terbinafine hcl tab 250 mg
generic
QL
QL
generic
Zazole
Terconazole Vaginal (CREAM
0.8%, SUPPOS 80 MG)
generic
Terconazole
terconazole vaginal cream
0.4%
generic
Allopurinol
Allopurinol (TAB 100 MG, TAB
300 MG)
generic
Colchicine
colchicine tab 0.6 mg
124 / 31 days
90 / 120 days
MDD
1 per day
QL
6 / claim
ANTIGOUT AGENTS
generic
ColchicineProbenecid
colchicine w/ probenecid tab
0.5-500 mg
generic
Probenecid
probenecid tab 500 mg
generic
Dihydroergotamine Mesylate
(INJ 1 MG/ML, NASAL SPRAY
4 MG/ML)
generic
MFL
1 / 30 days
QL
6 / 30 days
ANTIMIGRAINE AGENTS
ERGOT ALKALOIDS
Dihydroergotamine
Mesylate
SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS
Relpax
PAGE 65
Eletriptan Hydrobromide (TAB
20 MG, TAB 40 MG)
eletriptan hydrobromide
BRAND
BRAND NAME
Naratriptan HCl
Rizatriptan Benzoate
SUMAtriptan
Naratriptan HCl (TAB 1 MG,
TAB 2.5 MG)
Rizatriptan Benzoate (TAB 5
MG, TAB 10 MG)
COVERAGE
QL
9 / 30 days
AL
At least 18 yrs old
QL
12 / 30 days
AL
At least 6 yrs old
QL
6 / 30 days
AL
At least 12 yrs old
QL
2 / 30 days
AL
At least 12 yrs old
QL
9 / 30 days
AL
At least 12 yrs old
generic
generic
Sumatriptan (5, 20)
generic
SUMAtriptan
Succinate
SUMAtriptan
Succinate
ZOLMitriptan
Zomig
Sumatriptan Succinate (INJ 6,
SOLUTION AUTO-INJECTOR
6, SOLUTION PREFILLED
SYRINGE 6)
generic
Sumatriptan Succinate (TAB
MG)
generic
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
zolmitriptan
BRAND
QL
6 / 30 days
ANTIMYASTHENIC AGENTS
PARASYMPATHOMIMETICS
Pyridostigmine
Bromide
pyridostigmine bromide tab 60
mg
generic
Pyridostigmine
Bromide ER
pyridostigmine bromide tab cr
180 mg
generic
ANTIMYCOBACTERIALS
ANTIMYCOBACTERIALS, OTHER
Dapsone
Dapsone (TAB 25 MG, TAB
100 MG)
generic
Ethambutol HCl
Ethambutol HCl (TAB 100 MG,
TAB 400 MG)
generic
Isoniazid
Isoniazid (SYRUP 50 MG/5ML,
generic
Pyrazinamide
pyrazinamide tab 500 mg
generic
ANTITUBERCULARS
PAGE 66
BRAND NAME
RifAMPin
Rifampin (CAP 150 MG, CAP
300 MG)
COVERAGE
Trecator
TRECATOR TAB 250 MG
ethionamide
BRAND
Alkeran
ALKERAN TAB 2 MG
melphalan
BRAND
Cyclophosphamide
Cyclophosphamide (TAB 25
MG, TAB 50 MG)
generic
Leukeran
LEUKERAN TAB 2 MG
chlorambucil
BRAND
Myleran
MYLERAN TAB 2 MG
busulfan
BRAND
Bicalutamide
bicalutamide tab 50 mg
generic
Flutamide
flutamide cap 125 mg
generic
generic
ANTINEOPLASTICS
ALKYLATING AGENTS
ANTIANDROGENS
MDD
1 per day
ANTIESTROGENS/MODIFIERS
Fareston
FARESTON TAB 60 MG
toremifene citrate
BRAND
Tamoxifen Citrate
Tamoxifen Citrate (TAB 10
MG, TAB 20 MG)
generic
Hydroxyurea (Sickle Cell
Anemia) (CAP 200 MG, CAP
300 MG, CAP 400 MG)
hydroxyurea (sickle cell
anemia)
BRAND
Hydroxyurea
hydroxyurea cap 500 mg
generic
Mercaptopurine
mercaptopurine tab 50 mg
generic
Purixan
PURIXAN SUSPENSION 2000
MG/100ML
mercaptopurine
BRAND
AL
BRAND
PA
PA
ANTIMETABOLITES
Droxia
Up to 8 yrs old
ANTINEOPLASTICS, OTHER
Hemangeol
PAGE 67
HEMANGEOL SOLUTION
4.28 MG/ML
propranolol hcl
BRAND NAME
Leucovorin Calcium
Leucovorin Calcium (TAB 5
TAB 25 MG)
COVERAGE
generic
AROMATASE INHIBITORS, 3RD GENERATION
Anastrozole
anastrozole tab 1 mg
generic
Exemestane
exemestane tab 25 mg
generic
Letrozole
letrozole tab 2.5 mg
generic
Chloroquine
Phosphate
chloroquine phosphate tab 250
mg
generic
Chloroquine
Phosphate
chloroquine phosphate tab 500
mg
generic
MDD
1 per day
Coartem
COARTEM TAB 20-120 MG
artemether-lumefantrine
BRAND
QL
24 / claim
Hydroxychloroquine
Sulfate
hydroxychloroquine sulfate tab
200 mg
generic
Mefloquine HCl
mefloquine hcl tab 250 mg
generic
Primaquine
Phosphate
Primaquine Phosphate (TAB
26.3 MG (15 MG BASE), TAB
26.3 MG)
generic
62 / 31 days
ANTIPARASITICS
ANTIPROTOZOALS
PEDICULICIDES/SCABICIDES
Eurax
EURAX CREAM 10 %
crotamiton
BRAND
QL
Eurax
EURAX LOTION 10 %
crotamiton
BRAND
MPL
Malathion
malathion lotion 0.5%
QL
generic
MFL
Natroba
Acticin
NATROBA SUSPENSION 0.9
%
spinosad
permethrin cream 5%
QL
C
PAGE 68
SPINOSAD SUSPENSION 0.9
%
spinosad
59 / claim
2 / 30 days
BRAND
generic
Spinosad
1 / claim
62 / 31 days
Limit=1/claim | Pkg
Size 10: Package
Limit=6/claim |
BRAND
BRAND NAME
COVERAGE
ANTIPARKINSON AGENTS
ANTICHOLINERGICS
Benztropine Mesylate
Benztropine Mesylate (INJ 1
MG/ML, TAB 0.5 MG, TAB 1
MG, TAB 2 MG)
generic
Trihexyphenidyl HCl
Trihexyphenidyl HCl (TAB 2
MG, TAB 5 MG)
generic
Trihexyphenidyl HCl
trihexyphenidyl hcl elixir 0.4
mg/ml
generic
QL
500 / 31 days
ANTIPARKINSON AGENTS, OTHER
Amantadine HCl
Amantadine HCl (CAP 100
MG, SYRUP 50 MG/5ML)
generic
Nuplazid
NUPLAZID TAB 17 MG
pimavanserin tartrate
BRAND
Bromocriptine
Mesylate
Bromocriptine Mesylate (CAP 5
MG, TAB 2.5 MG)
generic
Pramipexole
Dihydrochloride
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
MG, TAB 5 MG)
MDD
2 per day
DOPAMINE AGONISTS
ROPINIRole HCl
ROPINIRole HCl
AL
At least 18 yrs old
MDD
3 per day
generic
MDD
6 per day
generic
MDD
3 per day
DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS
Carbidopa
carbidopa tab 25 mg
generic
Carbidopa-Levodopa
Carbidopa-Levodopa (TAB 10100 MG, TAB 25-100 MG, TAB
25-250 MG)
generic
Carbidopa-Levodopa (TAB 25100 MG, TAB 50-200 MG)
generic
Carbidopa-Levodopa
ER
MONOAMINE OXIDASE B (MAO-B) INHIBITORS
Selegiline HCl
PAGE 69
Selegiline HCl (CAP 5 MG,
TAB 5 MG)
generic
BRAND NAME
COVERAGE
ANTIPSYCHOTICS
1ST GENERATION/TYPICAL
ChlorproMAZINE HCl
Chlorpromazine HCl (TAB 10
generic
ChlorproMAZINE HCl
chlorpromazine hcl inj 25
mg/ml
generic
Droperidol
droperidol inj 2.5 mg/ml
generic
FluPHENAZine
Decanoate
fluphenazine decanoate inj 25
mg/ml
generic
AL
At least 18 yrs old
FluPHENAZine HCl
Fluphenazine HCl (ELIXIR 2.5
MG/5ML, INJ 2.5 MG/ML,
ORAL CONC 5 MG/ML)
generic
AL
At least 18 yrs old
Fluphenazine HCl (TAB 1 MG,
TAB 2.5 MG, TAB 5 MG, TAB
10 MG)
AL
generic
At least 18 yrs old
Haloperidol (TAB 0.5 MG, TAB
1 MG, TAB 2 MG, TAB 5 MG,
Haloperidol
Decanoate
Haloperidol Lactate
FluPHENAZine HCl
MDD
4 per day
MDD
4 per day
generic
MDD
3 per day
Haloperidol Decanoate (SOLN
50 MG/ML, SOLN 100 MG/ML)
generic
AL
At least 18 yrs old
Haloperidol Lactate (INJ 5
MG/ML, ORAL CONC 2
MG/ML)
generic
Loxapine Succinate (CAP 5
MG, CAP 10 MG, CAP 25 MG,
CAP 50 MG)
AL
generic
At least 18 yrs old
Pimozide
pimozide tab 1 mg
Pimozide
Thioridazine HCl
Haloperidol
Loxapine Succinate
MDD
4 per day
generic
MDD
10 per day
pimozide tab 2 mg
generic
MDD
5 per day
Thioridazine HCl (TAB 10 MG,
100 MG)
generic
MDD
4 per day
Thiothixene (CAP 1 MG, CAP
2 MG, CAP 5 MG, CAP 10
MG)
generic
MDD
3 per day
Trifluoperazine HCl
Trifluoperazine HCl (TAB 1
generic
MDD
2 per day
Trifluoperazine HCl
trifluoperazine hcl tab 10 mg
generic
MDD
4 per day
Thiothixene
PAGE 70
BRAND NAME
COVERAGE
2ND GENERATION/ATYPICAL
Abilify
ABILIFY SOLUTION 1 MG/ML
aripiprazole
BRAND
Abilify
ABILIFY SOLUTION 9.75
MG/1.3ML
aripiprazole
BRAND
Aripiprazole (ORALLY
MG, ORALLY
MG, TAB 20 MG)
generic
Aripiprazole (RECON SUSP
300 MG, RECON SUSP 400
MG)
aripiprazole
BRAND
Aripiprazole (TAB 2 MG, TAB
MG)
generic
MDD
1 per day
Aripiprazole (TAB DISP 10
MG, TAB DISP 15 MG)
aripiprazole
BRAND
MDD
2 per day
Aripiprazole Lauroxil (PRSYR
441 MG/1.6ML, PRSYR 662
MG/2.4ML, PRSYR 882
MG/3.2ML)
aripiprazole lauroxil
BRAND
ARIPiprazole
aripiprazole oral solution 1
mg/ml
generic
MDD
30 per day
ARIPiprazole
aripiprazole tab 5 mg
generic
MDD
1.5 per day
Saphris
Asenapine Maleate (SL TAB
2.5 MG, SL TAB 5 MG, SL
TAB 10 MG)
asenapine maleate
BRAND
MDD
2 per day
Brexpiprazole (TAB 0.25 MG,
brexpiprazole
BRAND
Cariprazine HCl (CAP 3 MG,
CAP 4.5 MG, CAP 6 MG)
cariprazine hcl
BRAND
FANAPT TITRATION PACK
TAB 1 & 2 & 4 & 6 MG
iloperidone
BRAND
ARIPiprazole
Abilify Maintena
ARIPiprazole
Abilify Discmelt
Aristada
Rexulti
Vraylar
Fanapt Titration Pack
PAGE 71
MDD
30 per day
MDD
2 per day
QL
1 / 28 days
AL
At least 18 yrs old
QL
1 / 28 days
AL
At least 18 yrs old
AL
MDD
AL
MDD
AL
MDD
At least 18 yrs old
1 per day
At least 18 yrs old
1 per day
At least 18 yrs old
2 per day
BRAND NAME
Geodon
Fanapt
Latuda
GEODON RECON SOLN 20
MG
ziprasidone mesylate
Iloperidone (TAB 1 MG, TAB 2
12 MG)
iloperidone
LATUDA TAB 80 MG
lurasidone hcl
COVERAGE
BRAND
AL
At least 18 yrs old
AL
At least 18 yrs old
BRAND
MDD
AL
BRAND
MDD
Latuda
Lurasidone HCl (TAB 20 MG,
lurasidone hcl
BRAND
Olanzapine (ORALLY
MG, ORALLY
AL
2 per day
At least 18 yrs old
2 per day
At least 18 yrs old
MDD
1 per day
generic
MDD
2 per day
Olanzapine (ORALLY
MG, TAB 20 MG)
generic
MDD
3 per day
Olanzapine (ORALLY
7.5 MG)
generic
MDD
1 per day
OLANZapine
olanzapine for im inj 10 mg
generic
ZyPREXA Relprevv
Olanzapine Pamoate (RECON
SUSP 210 MG, RECON SUSP
300 MG)
olanzapine pamoate
BRAND
Paliperidone (TAB 24HR 9 MG,
1.5 MG)
generic
Paliperidone Palmitate
(SUSPENSION 273
MG/0.875ML, SUSPENSION
410 MG/1.315ML,
SUSPENSION 546
819 MG/2.625ML)
paliperidone palmitate
BRAND
OLANZapine
OLANZapine
OLANZapine
Paliperidone ER
Invega Trinza
PAGE 72
QL
2 / 28 days
AL
At least 18 yrs old
MDD
1 per day
QL
1 / 84 days
AL
At least 18 yrs old
BRAND NAME
Invega Sustenna
(SUSPENSION 39
MG/0.25ML, SUSPENSION 78
MG/0.5ML, SUSPENSION 117
156 MG/ML, SUSPENSION
234 MG/1.5ML)
paliperidone palmitate
COVERAGE
Paliperidone ER
paliperidone tab sr 24hr 6 mg
generic
MDD
2 per day
QUEtiapine Fumarate
Quetiapine Fumarate (TAB 25
MG, TAB 200 MG)
generic
MDD
3 per day
QUEtiapine Fumarate
Quetiapine Fumarate (TAB 300
MG, TAB 400 MG)
generic
MDD
4 per day
SEROquel XR
Quetiapine Fumarate (TAB ER
24H 200 MG, TAB ER 24H 150
MG)
quetiapine fumarate
BRAND
MDD
1 per day
Risperidone (ORALLY
MG, ORALLY
MG, ORALLY
ORALLY DISINTEGRATING
TAB 2 MG, ORALLY
TAB 4 MG, TAB 0.25 MG, TAB
generic
MDD
2 per day
Risperidone Microspheres
(RECON SUSP 12.5 MG,
RECON SUSP 25 MG,
RECON SUSP 37.5 MG,
RECON SUSP 50 MG)
risperidone microspheres
BRAND
RisperiDONE
risperidone soln 1 mg/ml
generic
MDD
8 per day
SEROquel XR
SEROQUEL XR TAB ER 24H
300 MG
quetiapine fumarate
BRAND
MDD
3 per day
400 MG
quetiapine fumarate
BRAND
MDD
4 per day
50 MG
quetiapine fumarate
BRAND
MDD
2 per day
RisperiDONE
RisperDAL Consta
SEROquel XR
SEROquel XR
PAGE 73
QL
1 / 28 days
AL
At least 18 yrs old
BRAND
QL
2 / 28 days
AL
At least 18 yrs old
BRAND NAME
Vraylar
VRAYLAR CAP 1.5 MG
cariprazine hcl
COVERAGE
AL
BRAND
MDD
Ziprasidone HCl
Ziprasidone HCl (CAP 20 MG,
CAP 40 MG)
AL
generic
MDD
Ziprasidone HCl
Ziprasidone HCl (CAP 60 MG,
CAP 80 MG)
AL
generic
MDD
ZyPREXA Relprevv
ZYPREXA RELPREVV
RECON SUSP 405 MG
olanzapine pamoate
At least 18 yrs old
2 per day
At least 18 yrs old
2 per day
At least 18 yrs old
3 per day
QL
1 / 28 days
AL
At least 18 yrs old
AL
At least 18 yrs old
BRAND
TREATMENT-RESISTANT
CloZAPine
CloZAPine
Versacloz
Clozapine (ORALLY
MG, TAB 100 MG)
generic
Clozapine (ORALLY
MG, ORALLY
MG, ORALLY
MG, ORALLY
TAB 200 MG)
generic
VERSACLOZ SUSPENSION
50 MG/ML
clozapine
BRAND
MDD
AL
MDD
AL
6 per day
At least 18 yrs old
3 per day
At least 18 yrs old
MDD
12 per day
MDD
2 per day
ANTIVIRALS
ANTI-CYTOMEGALOVIRUS (CMV) AGENTS
ValGANciclovir HCl
valganciclovir hcl tab 450 mg
(base equivalent)
generic
ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)
Vitekta
Genvoya
PAGE 74
Elvitegravir (TAB 85 MG, TAB
150 MG)
elvitegravir
BRAND
GENVOYA TAB 150-150-20010 MG
elvitegravir-cobicistatemtricitabine-tenofovir
alafenamide
BRAND
AL
At least 18 yrs old
MDD
1 per day
MDD
1 per day
BRAND NAME
Isentress
Isentress
Isentress
Stribild
Tivicay
ISENTRESS CHEW TAB 100
MG
raltegravir potassium
COVERAGE
BRAND
MDD
6 per day
ISENTRESS CHEW TAB 25
MG
BRAND
MDD
12 per day
Raltegravir Potassium
(PACKET 100 MG, TAB 400
MG)
BRAND
MDD
2 per day
STRIBILD TAB 150-150-200300 MG
elvitegravir-cobicistatemtricitabine-tenofovir df
BRAND
MDD
1 per day
TIVICAY TAB 50 MG
dolutegravir sodium
BRAND
MDD
2 per day
ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)
Atripla
ATRIPLA TAB 600-200-300
MG
efavirenz-emtricitabinetenofovir disoproxil fumarate
BRAND
MDD
1 per day
COMPLERA TAB 200-25-300
MG
emtricitabine-rilpivirinetenofovir disoproxil fumarate
BRAND
MDD
1 per day
Edurant
EDURANT TAB 25 MG
rilpivirine hcl
BRAND
MDD
1 per day
Sustiva
Efavirenz (CAP 200 MG, TAB
600 MG)
efavirenz
BRAND
MDD
1 per day
Etravirine (TAB 25 MG, TAB
100 MG)
etravirine
BRAND
MDD
4 per day
Intelence
INTELENCE TAB 200 MG
etravirine
BRAND
MDD
2 per day
Nevirapine ER
Nevirapine (TAB 24HR 400
generic
MDD
1 per day
Nevirapine
nevirapine susp 50 mg/5ml
generic
MDD
40 per day
Nevirapine
nevirapine tab 200 mg
generic
MDD
2 per day
Rescriptor
RESCRIPTOR TAB 100 MG
delavirdine mesylate
BRAND
MDD
12 per day
Complera
Intelence
PAGE 75
BRAND NAME
Rescriptor
RESCRIPTOR TAB 200 MG
delavirdine mesylate
Sustiva
SUSTIVA CAP 50 MG
efavirenz
COVERAGE
BRAND
MDD
6 per day
BRAND
MDD
2 per day
ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)
Abacavir Sulfate
abacavir sulfate tab 300 mg
(base equiv)
generic
MDD
2 per day
Descovy
DESCOVY TAB 200-25 MG
emtricitabine-tenofovir
alafenamide fumarate
BRAND
MDD
1 per day
Didanosine (CAPSULE 125
MG, CAPSULE 200 MG,
CAPSULE 250 MG, CAPSULE
400 MG)
generic
MDD
1 per day
Didanosine (RECON SOLN 2
GM, RECON SOLN 4 GM)
didanosine
BRAND
MDD
20 per day
Emtriva
EMTRIVA CAP 200 MG
emtricitabine
BRAND
MDD
1 per day
Emtriva
EMTRIVA SOLUTION 10
MG/ML
emtricitabine
BRAND
MDD
24 per day
Epzicom
EPZICOM TAB 600-300 MG
abacavir sulfate-lamivudine
BRAND
MDD
1 per day
LamiVUDine
lamivudine oral soln 10 mg/ml
generic
MDD
30 per day
LamiVUDine
lamivudine tab 150 mg
generic
MDD
2 per day
LamiVUDine
lamivudine tab 300 mg
generic
MDD
1 per day
Stavudine
Stavudine (CAP 15 MG, CAP
MG)
generic
MDD
2 per day
Stavudine
stavudine for oral soln 1 mg/ml
generic
MDD
80 per day
Viread
Tenofovir Disoproxil Fumarate
(TAB 150 MG, TAB 200 MG,
tenofovir disoproxil fumarate
BRAND
MDD
1 per day
TRUVADA TAB 200-300 MG
emtricitabine-tenofovir
disoproxil fumarate
BRAND
MDD
1 per day
VIREAD POWDER 40 MG/GM
tenofovir disoproxil fumarate
BRAND
QL
Didanosine
Videx
Truvada
Viread
PAGE 76
240 / 30 days
BRAND NAME
Ziagen
ZIAGEN SOLUTION 20
MG/ML
abacavir sulfate
COVERAGE
BRAND
MDD
30 per day
Zidovudine
zidovudine cap 100 mg
generic
MDD
6 per day
Zidovudine
zidovudine syrup 10 mg/ml
generic
MDD
60 per day
Zidovudine
zidovudine tab 300 mg
generic
MDD
2 per day
ANTI-HIV AGENTS, OTHER
Selzentry
SELZENTRY TAB 150 MG
maraviroc
BRAND
MDD
2 per day
Selzentry
SELZENTRY TAB 300 MG
maraviroc
BRAND
MDD
4 per day
Triumeq
TRIUMEQ TAB 600-50-300
MG
abacavir-dolutegravirlamivudine
BRAND
Tybost
TYBOST TAB 150 MG
cobicistat
AL
MDD
AL
BRAND
At least 18 yrs old
1 per day
At least 18 yrs old
MDD
1 per day
ANTI-HIV AGENTS, PROTEASE INHIBITORS
Aptivus
APTIVUS CAP 250 MG
tipranavir
BRAND
MDD
4 per day
Aptivus
APTIVUS SOLUTION 100
MG/ML
tipranavir
BRAND
MDD
10 per day
Atazanavir Sulfate (CAP 150
MG, CAP 200 MG)
atazanavir sulfate
BRAND
MDD
2 per day
Crixivan
CRIXIVAN CAP 200 MG
indinavir sulfate
BRAND
MDD
9 per day
Crixivan
CRIXIVAN CAP 400 MG
indinavir sulfate
BRAND
MDD
6 per day
Prezista
Darunavir Ethanolate (TAB 75
MG, TAB 600 MG)
darunavir ethanolate
BRAND
MDD
2 per day
Evotaz
EVOTAZ TAB 300-150 MG
atazanavir sulfate-cobicistat
BRAND
MDD
1 per day
Invirase
INVIRASE CAP 200 MG
saquinavir mesylate
BRAND
MDD
10 per day
Invirase
INVIRASE TAB 500 MG
saquinavir mesylate
BRAND
MDD
4 per day
Reyataz
PAGE 77
BRAND NAME
Kaletra
KALETRA SOLUTION 400-100
MG/5ML
lopinavir-ritonavir
COVERAGE
BRAND
QL
480 / 30 days
Kaletra
KALETRA TAB 100-25 MG
lopinavir-ritonavir
BRAND
MDD
4 per day
Kaletra
KALETRA TAB 200-50 MG
lopinavir-ritonavir
BRAND
MDD
6 per day
Lexiva
LEXIVA SUSPENSION 50
MG/ML
fosamprenavir calcium
BRAND
MDD
56 per day
Lexiva
LEXIVA TAB 700 MG
fosamprenavir calcium
BRAND
MDD
4 per day
Norvir
NORVIR SOLUTION 80
MG/ML
ritonavir
BRAND
MDD
15 per day
PREZISTA SUSPENSION 100
MG/ML
BRAND
MDD
12 per day
Prezista
PREZISTA TAB 150 MG
BRAND
MDD
3 per day
Prezista
PREZISTA TAB 800 MG
BRAND
MDD
1 per day
Reyataz
REYATAZ CAP 300 MG
atazanavir sulfate
BRAND
Reyataz
REYATAZ PACKET 50 MG
atazanavir sulfate
BRAND
MDD
6 per day
Norvir
Ritonavir (CAP 100 MG, TAB
100 MG)
ritonavir
BRAND
MDD
12 per day
Viracept
VIRACEPT TAB 250 MG
nelfinavir mesylate
BRAND
MDD
9 per day
Viracept
VIRACEPT TAB 625 MG
nelfinavir mesylate
BRAND
MDD
4 per day
Prezista
ANTI-INFLUENZA AGENTS
Tamiflu
Relenza Diskhaler
Tamiflu
PAGE 78
Oseltamivir Phosphate (CAP
45 MG, CAP 75 MG)
oseltamivir phosphate
BRAND
RELENZA DISKHALER AER
POW BA 5 MG/BLISTER
zanamivir
BRAND
TAMIFLU CAP 30 MG
QL
10 / 30 days
MFL
1 / 180 days
AL
MPL
At least 6 yrs old
1 / 30 days
QL
20 / 30 days
MFL
1 / 180 days
BRAND
BRAND NAME
Tamiflu
TAMIFLU RECON SUSP 6
MG/ML
COVERAGE
QL
BRAND
120 / 30 days
MFL
1 / 180 days
QL
50 / 30 days
QL
30 / 30 days
ANTIHERPETIC AGENTS
Acyclovir
Acyclovir (CAP 200 MG, TAB
800 MG)
Acyclovir
acyclovir oint 5%
generic
generic
MPL
1 / claim
Acyclovir
acyclovir susp 200 mg/5ml
generic
QL
Acyclovir
acyclovir tab 400 mg
generic
MDD
Trifluridine
trifluridine ophth soln 1%
generic
QL
8 / 31 days
ValACYclovir HCl
valacyclovir hcl tab 1 gm
generic
QL
21 / 31 days
ValACYclovir HCl
valacyclovir hcl tab 500 mg
generic
QL
60 / 30 days
Zovirax
ZOVIRAX CREAM 5 %
acyclovir topical
BRAND
MPL
1 / 31 days
Buspirone HCl (TAB 5 MG,
15 MG)
generic
MDD
3 per day
BusPIRone HCl
buspirone hcl tab 30 mg
generic
MDD
2 per day
Meprobamate
Meprobamate (TAB 200 MG,
TAB 400 MG)
generic
MDD
4 per day
Midazolam HCl
Midazolam HCl (INJ 2
MG/2ML, INJ 5 MG/ML, INJ 5
MG/5ML, INJ 10 MG/2ML, INJ
10 MG/10ML, INJ 25 MG/5ML,
INJ 50 MG/10ML, SYRUP 2
MG/ML)
generic
400 / 30 days
3 per day
ANXIOLYTICS
ANXIOLYTICS, OTHER
BusPIRone HCl
BENZODIAZEPINES
PAGE 79
ALPRAZolam
BRAND NAME
ALPRAZolam ER
Alprazolam (ORALLY
MG, ORALLY
MG, ORALLY
MG)
Alprazolam (TAB 24HR 2 MG,
TAB 24HR 1 MG, TAB 24HR 3
MG, TAB 24HR 0.5 MG)
generic
COVERAGE
MDD
4 per day
generic
MDD
1 per day
ALPRAZOLAM INTENSOL
CONC 1 MG/ML
alprazolam
BRAND
MDD
4 per day
ChlordiazePOXIDE
HCl
Chlordiazepoxide HCl (CAP 5
MG, CAP 10 MG, CAP 25 MG)
generic
MDD
4 per day
ClonazePAM
Clonazepam (ORALLY
MG, ORALLY
MG, ORALLY
MG, ORALLY
1 MG, TAB 2 MG)
generic
MDD
3 per day
Clorazepate
Dipotassium
Clorazepate Dipotassium (TAB
3.75 MG, TAB 7.5 MG, TAB 15
MG)
generic
MDD
4 per day
DiazePAM
Diazepam (ORAL SOLN 1
MG/ML, SOLUTION 5 MG/ML)
diazepam
BRAND
DiazePAM
Diazepam (TAB 2 MG, TAB 5
MG, TAB 10 MG)
generic
MDD
4 per day
DiazePAM Intensol
diazepam conc 5 mg/ml
generic
MDD
8 per day
Gabavale-5
GABAVALE-5 MISC 5 MG
diazepam-dietary management
product
BRAND
GABAZOLAMINE MISC 0.25
MG
alprazolam-dietary
management product
BRAND
ALPRAZolam Intensol
Gabazolamine
PAGE 80
BRAND NAME
Gabazolamine-0.5
GABAZOLAMINE-0.5 MISC
0.5 MG
alprazolam-dietary
management product
COVERAGE
BRAND
LORazepam
Lorazepam (INJ 2 MG/ML, INJ
4 MG/ML)
generic
LORazepam
Lorazepam (TAB 0.5 MG, TAB
1 MG, TAB 2 MG)
generic
QL
MDD
LORazepam Intensol
lorazepam conc 2 mg/ml
generic
Oxazepam
Oxazepam (CAP 10 MG, CAP
15 MG, CAP 30 MG)
generic
Sentrazolam AM 0.25
QL
120 / 30 days
4 per day
120 / 30 days
MDD
4 per day
SENTRAZOLAM AM 0.25
MISC 0.25 MG
alprazolam-dietary
management product
BRAND
EQUETRO CAP ER 12H 100
MG
carbamazepine (antipsychotic)
BRAND
MDD
4 per day
MG
BRAND
MDD
8 per day
MG
BRAND
MDD
5 per day
Lithium Carbonate (CAP 150
MG, CAP 300 MG, CAP 600
MG, TAB 300 MG)
generic
Lithium Carbonate ER
Lithium Carbonate (TAB 300
MG, TAB 450 MG)
generic
Lithium
lithium oral solution 8 meq/5ml
generic
BIPOLAR AGENTS
MOOD STABILIZERS
Equetro
Equetro
Equetro
Lithium Carbonate
QL
310 / 31 days
BLOOD GLUCOSE REGULATORS
ANTIDIABETIC AGENTS
Bydureon
PAGE 81
BYDUREON 2 MG
exenatide
BRAND
BRAND NAME
Byetta 10 MCG Pen
Byetta 5 MCG Pen
BYETTA 10 MCG PEN SOLN
PEN 10 MCG/0.04ML
exenatide
BYETTA 5 MCG PEN SOLN
PEN 5 MCG/0.02ML
exenatide
COVERAGE
QL
BRAND
BRAND
ST
AL
At least 18 yrs old
QL
1.2 / 30 days
ST
AL
Farxiga
Dapagliflozin Propanediol (TAB
5 MG, TAB 10 MG)
dapagliflozin propanediol
2.4 / 30 days
At least 18 yrs old
ST
BRAND
AL
At least 18 yrs old
MDD
1 per day
Glimepiride
Glimepiride (TAB 1 MG, TAB 2
MG)
generic
MDD
1 per day
Glimepiride
glimepiride tab 4 mg
generic
MDD
2 per day
GlipiZIDE ER
Glipizide (TAB 24HR 2.5 MG,
10 MG)
generic
GlipiZIDE
Glipizide (TAB 5 MG, TAB 10
MG)
generic
GlipiZIDEMetFORMIN HCl
Glipizide-Metformin HCl (TAB
2.5-500 MG, TAB 2.5-250 MG,
TAB 5-500 MG)
generic
GlyBURIDE
Glyburide (TAB 1.25 MG, TAB
2.5 MG, TAB 5 MG)
generic
GlyBURIDE
Micronized
Glyburide Micronized (TAB 1.5
generic
GlyBURIDEMetFORMIN
Glyburide-Metformin (TAB
1.25-250 MG, TAB 2.5-500
MG, TAB 5-500 MG)
generic
Kombiglyze XR
KOMBIGLYZE XR TAB ER
24H 2.5-1000 MG
saxagliptin-metformin hcl
BRAND
Linagliptin-Metformin HCl (TAB
2.5-1000 MG, TAB 2.5-850
MG, TAB 2.5-500 MG)
linagliptin-metformin hcl
BRAND
MetFORMIN HCl
Metformin HCl (TAB 850 MG,
TAB 1000 MG)
generic
MetFORMIN HCl
metformin hcl tab 500 mg
MetFORMIN HCl ER
metformin hcl tab sr 24hr 500
mg
Jentadueto
PAGE 82
AL
MDD
AL
At least 18 yrs old
2 per day
At least 18 yrs old
MDD
2 per day
generic
MDD
5 per day
generic
MDD
4 per day
BRAND NAME
MetFORMIN HCl ER
metformin hcl tab sr 24hr 750
mg
Nateglinide
COVERAGE
generic
MDD
3 per day
Nateglinide (TAB 60 MG, TAB
120 MG)
generic
MDD
3 per day
Pioglitazone HCl
Pioglitazone HCl (TAB 15 MG,
generic
MDD
1 per day
Pioglitazone HClMetformin HCl
Pioglitazone HCl-Metformin
HCl (-METFORMIN TAB 15500 MG, -METFORMIN TAB
15-850 MG)
generic
MDD
2 per day
Onglyza
Saxagliptin HCl (TAB 2.5 MG,
TAB 5 MG)
saxagliptin hcl
BRAND
AL
At least 18 yrs old
Saxagliptin-Metformin HCl
(TAB ER 24H 5-500 MG, TAB
ER 24H 5-1000 MG)
saxagliptin-metformin hcl
AL
BRAND
At least 18 yrs old
SYMLINPEN 120 SOLN PEN
2700 MCG/2.7ML
pramlintide acetate
BRAND
SYMLINPEN 60 SOLN PEN
1500 MCG/1.5ML
pramlintide acetate
BRAND
Kombiglyze XR
SymlinPen 120
SymlinPen 60
Tradjenta
TRADJENTA TAB 5 MG
linagliptin
MDD
QL
1 per day
10.8 / 30 days
ST
QL
6 / 30 days
ST
AL
BRAND
At least 18 yrs old
MDD
1 per day
MPL
1 / claim
MFL
1 / 30 days
MPL
1 / claim
MFL
1 / 30 days
MPL
1 / claim
MFL
4 / 365 days
GLYCEMIC AGENTS
GlucaGen Diagnostic
GlucaGen HypoKit
Glucagon Emergency
GLUCAGEN DIAGNOSTIC
RECON SOLN 1 MG
glucagon hcl rdna (diagnostic)
BRAND
GLUCAGEN HYPOKIT
RECON SOLN 1 MG
glucagon hcl (rdna)
BRAND
GLUCAGON EMERGENCY
KIT 1 MG
glucagon (rdna)
BRAND
APIDRA SOLOSTAR SOLN
PEN 100 UNIT/ML
insulin glulisine
BRAND
QL
30 / 30 days
APIDRA SOLUTION 100
UNIT/ML
insulin glulisine
BRAND
QL
40 / 30 days
INSULINS
Apidra SoloStar
Apidra
PAGE 83
BRAND NAME
HumaLOG KwikPen
HumaLOG Mix 50/50
KwikPen
HumaLOG Mix 50/50
Pen
HumaLOG Mix 50/50
HumaLOG Mix 75/25
KwikPen
HumaLOG Mix 75/25
Pen
HumaLOG Mix 75/25
HumaLOG Pen
HumuLIN 70/30
KwikPen
HumuLIN 70/30 Pen
PAGE 84
HUMALOG KWIKPEN SOLN
PEN 100 UNIT/ML
insulin lispro (human)
COVERAGE
BRAND
QL
30 / 30 days
HUMALOG MIX 50/50
KWIKPEN SUSP PEN (50-50)
100 UNIT/ML
insulin lispro protamine & lispro
(human)
BRAND
QL
30 / 30 days
HUMALOG MIX 50/50 PEN
SUSP PEN (50-50) 100
UNIT/ML
(human)
BRAND
QL
30 / 30 days
HUMALOG MIX 50/50
SUSPENSION (50-50) 100
UNIT/ML
(human)
BRAND
QL
40 / 30 days
HUMALOG MIX 75/25
KWIKPEN SUSP PEN (75-25)
100 UNIT/ML
(human)
BRAND
QL
30 / 30 days
HUMALOG MIX 75/25 PEN
SUSP PEN (75-25) 100
UNIT/ML
(human)
BRAND
QL
30 / 30 days
HUMALOG MIX 75/25
UNIT/ML
(human)
BRAND
QL
40 / 30 days
HUMALOG PEN SOLN PEN
100 UNIT/ML
BRAND
QL
30 / 30 days
HUMULIN 70/30 KWIKPEN
SUSP PEN (70-30) 100
UNIT/ML
insulin nph isophane & reg
(human)
BRAND
QL
30 / 30 days
HUMULIN 70/30 PEN SUSP
PEN (70-30) 100 UNIT/ML
(human)
BRAND
QL
30 / 30 days
BRAND NAME
HumuLIN N KwikPen
HumuLIN N Pen
HumuLIN N
HumuLIN R
HumaLOG
Lantus SoloStar
Lantus
NovoLIN 70/30
ReliOn
NovoLIN 70/30
NovoLIN N ReliOn
NovoLIN N
NovoLIN R ReliOn
NovoLIN R
NovoLOG FlexPen
PAGE 85
HUMULIN N KWIKPEN SUSP
PEN 100 UNIT/ML
insulin nph (human) (isophane)
COVERAGE
BRAND
QL
30 / 30 days
HUMULIN N PEN SUSP PEN
100 UNIT/ML
BRAND
QL
30 / 30 days
HUMULIN N SUSPENSION
100 UNIT/ML
BRAND
QL
40 / 30 days
HUMULIN R SOLUTION 100
UNIT/ML
insulin regular (human)
BRAND
QL
40 / 30 days
Insulin Lispro (Human) (SOLN
CART 100, SOLUTION 100)
BRAND
QL
30 / 30 days
LANTUS SOLOSTAR SOLN
PEN 100 UNIT/ML
insulin glargine
BRAND
QL
30 / 30 days
LANTUS SOLUTION 100
UNIT/ML
insulin glargine
BRAND
QL
30 / 30 days
NOVOLIN 70/30 RELION
UNIT/ML
(human)
BRAND
QL
40 / 30 days
NOVOLIN 70/30
UNIT/ML
(human)
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
insulin aspart
BRAND
QL
30 / 30 days
BRAND NAME
NovoLOG Mix 70/30
FlexPen
NovoLOG Mix 70/30
NovoLOG PenFill
NovoLOG
ReliOn 70/30
ReliOn N
ReliOn R
NOVOLOG MIX 70/30
FLEXPEN SUSP PEN (70-30)
100 UNIT/ML
insulin aspart protamine &
aspart (human)
COVERAGE
BRAND
QL
30 / 30 days
NOVOLOG MIX 70/30
UNIT/ML
insulin aspart protamine &
aspart (human)
BRAND
QL
40 / 30 days
NOVOLOG PENFILL SOLN
CART 100 UNIT/ML
insulin aspart
BRAND
QL
30 / 30 days
NOVOLOG SOLUTION 100
UNIT/ML
insulin aspart
BRAND
QL
40 / 30 days
RELION 70/30 SUSPENSION
(70-30) 100 UNIT/ML
insulin isophane & reg (human)
BRAND
QL
40 / 30 days
RELION N SUSPENSION 100
UNIT/ML
insulin isophane (human)
BRAND
QL
40 / 30 days
RELION R SOLUTION 100
UNIT/ML
BRAND
QL
40 / 30 days
BRAND
MDD
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS
ANTICOAGULANTS
Eliquis
Enoxaparin Sodium
Apixaban (TAB 2.5 MG, TAB 5
MG)
apixaban
Enoxaparin Sodium (INJ 100
MG/ML, INJ 150 MG/ML)
QL
generic
MFL
Enoxaparin Sodium
Enoxaparin Sodium (INJ 80,
INJ 120)
QL
generic
MFL
Enoxaparin Sodium
enoxaparin sodium inj 30
mg/0.3ml
QL
generic
MFL
Enoxaparin Sodium
mg/3ml
QL
generic
MFL
Enoxaparin Sodium
mg/0.4ml
QL
generic
MFL
PAGE 86
4 per day
14 / 7 days
1 / 180 days
12 / 7 days
1 / 180 days
5 / 7 days
1 / 180 days
42 / 7 days
1 / 180 days
6 / 7 days
1 / 180 days
BRAND NAME
Enoxaparin Sodium
mg/0.6ml
COVERAGE
QL
generic
MFL
Heparin Sodium
(Porcine)
Heparin Sodium (Porcine) (INJ
1000, INJ 5000, INJ 10000, INJ
20000)
generic
Heparin Sodium
(Porcine) PF
heparin sodium (porcine) pf inj
5000 unit/0.5ml
generic
Warfarin Sodium
Warfarin Sodium (TAB 1 MG,
3 MG, TAB 4 MG, TAB 5 MG,
10 MG)
generic
Xarelto
XARELTO TAB 10 MG
rivaroxaban
QL
BRAND
9 / 7 days
1 / 180 days
35 / 180 days
MDD
1 per day
Xarelto
XARELTO TAB 15 MG
rivaroxaban
BRAND
MDD
2 per day
Xarelto
XARELTO TAB 20 MG
rivaroxaban
BRAND
MDD
1 per day
BLOOD FORMATION MODIFIERS
Agrylin
AGRYLIN CAP 0.5 MG
anagrelide hcl
BRAND
Anagrelide HCl
Anagrelide HCl (CAP 0.5 MG,
CAP 1 MG)
generic
Aminocaproic Acid
aminocaproic acid syrup 25%
generic
QL
60 / claim
Aminocaproic Acid
aminocaproic acid tab 500 mg
generic
QL
24 / claim
Tranexamic Acid
tranexamic acid tab 650 mg
QL
30 / 5 days
GL
Female
AL
12 to 49 yrs old
COAGULANTS
generic
MFL
1 / month
PLATELET MODIFYING AGENTS
Cilostazol
Cilostazol (TAB 50 MG, TAB
100 MG)
generic
MDD
2 per day
Clopidogrel Bisulfate
clopidogrel bisulfate tab 75 mg
(base equiv)
generic
MDD
1 per day
PAGE 87
BRAND NAME
Dipyridamole
Dipyridamole (TAB 25 MG,
Effient
Prasugrel HCl (TAB 5 MG,
TAB 10 MG)
prasugrel hcl
BRAND
MDD
1 per day
Ticagrelor (TAB 60 MG, TAB
90 MG)
ticagrelor
BRAND
MDD
2 per day
Brilinta
COVERAGE
generic
CARDIOVASCULAR AGENTS
ALPHA-ADRENERGIC AGONISTS
Nexiclon XR
Clonidine HCl (LIQUID ER 0.09
MG/ML, TAB ER 24H 0.17
MG)
clonidine hcl
BRAND
Clonidine HCl (PATCH 0.1
MG/24HR, PATCH 0.2
MG/24HR, PATCH 0.3
MG/24HR)
generic
CloNIDine HCl
Clonidine HCl (TAB 0.1 MG,
TAB 0.2 MG)
generic
MDD
10 per day
CloNIDine HCl
clonidine hcl tab 0.3 mg
generic
MDD
8 per day
Guanabenz Acetate
Guanabenz Acetate (TAB 4
MG, TAB 8 MG)
generic
GuanFACINE HCl
Guanfacine HCl (TAB 1 MG,
TAB 2 MG)
generic
Methyldopa
Methyldopa (TAB 250 MG,
TAB 500 MG)
generic
Midodrine HCl
Midodrine HCl (TAB 2.5 MG,
generic
CloNIDine HCl
ALPHA-ADRENERGIC BLOCKING AGENTS
Doxazosin Mesylate
Prazosin HCl
Doxazosin Mesylate (TAB 1
TAB 8 MG)
generic
Prazosin HCl (CAP 1 MG, CAP
2 MG, CAP 5 MG)
generic
ANGIOTENSIN II RECEPTOR ANTAGONISTS
Irbesartan
Irbesartan (TAB 75 MG, TAB
150 MG, TAB 300 MG)
generic
MDD
1 per day
Losartan Potassium
Losartan Potassium (TAB 25
MG)
generic
MDD
1 per day
PAGE 88
BRAND NAME
Valsartan
Valsartan (TAB 40 MG, TAB 80
MG)
COVERAGE
generic
MDD
1 per day
ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS
Benazepril HCl
Benazepril HCl (TAB 5 MG,
generic
MDD
1 per day
Benazepril HCl
benazepril hcl tab 40 mg
generic
MDD
2 per day
Captopril
Captopril (TAB 12.5 MG, TAB
MG)
generic
MDD
3 per day
Enalapril Maleate (TAB 2.5
TAB 20 MG)
generic
MDD
2 per day
EPANED RECON SOLN 1
MG/ML
enalapril maleate
BRAND
AL
Fosinopril Sodium
Fosinopril Sodium (TAB 10
generic
MDD
1 per day
Lisinopril
Lisinopril (TAB 2.5 MG, TAB 5
generic
MDD
2 per day
Quinapril HCl (TAB 5 MG, TAB
MG)
generic
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
1 per day
Amiodarone HCl
amiodarone hcl tab 200 mg
generic
Disopyramide
Phosphate
Disopyramide Phosphate (CAP
100 MG, CAP 150 MG)
generic
Dofetilide
Dofetilide (CAP 125 MCG
(0.125, CAP 250 MCG (0.25,
CAP 500 MCG (0.5)
generic
Flecainide Acetate (TAB 50
MG)
generic
Mexiletine HCl (CAP 150 MG,
generic
Enalapril Maleate
Epaned
Quinapril HCl
Ramipril
Trandolapril
Up to 8 yrs old
ANTIARRHYTHMICS
Flecainide Acetate
Mexiletine HCl
PAGE 89
BRAND NAME
Norpace CR
Propafenone HCl
NORPACE CR CAP ER 12H
150 MG
disopyramide phosphate
COVERAGE
BRAND
Propafenone HCl (TAB 150
MG)
generic
QuiNIDine Gluconate
ER
quinidine gluconate tab cr 324
mg
generic
QuiNIDine Sulfate
Quinidine Sulfate (TAB 200
MG, TAB 300 MG)
generic
QuiNIDine Sulfate ER
quinidine sulfate tab cr 300 mg
generic
Sotalol HCl (AF)
Sotalol HCl (AFIB/AFL) (TAB
80 MG, TAB 120 MG, TAB 160
MG)
generic
Sotalol HCl (TAB 80 MG, TAB
240 MG)
generic
Sotalol HCl
MDD
2 per day
BETA-ADRENERGIC BLOCKING AGENTS
Acebutolol HCl
Acebutolol HCl (CAP 200 MG,
CAP 400 MG)
generic
Atenolol
Atenolol (TAB 25 MG, TAB 50
MG, TAB 100 MG)
generic
MDD
2 per day
Bisoprolol Fumarate
Bisoprolol Fumarate (TAB 5
MG, TAB 10 MG)
generic
MDD
1 per day
Carvedilol
Carvedilol (TAB 3.125 MG,
TAB 6.25 MG, TAB 12.5 MG)
generic
MDD
2 per day
Coreg CR
Carvedilol Phosphate (CAP ER
24H 20 MG, CAP ER 24H 40
ER 24H 80 MG)
carvedilol phosphate
BRAND
MDD
1 per day
Carvedilol
carvedilol tab 25 mg
generic
MDD
4 per day
Labetalol HCl
labetalol hcl tab 100 mg
generic
MDD
3 per day
Labetalol HCl
generic
MDD
6 per day
Labetalol HCl
generic
MDD
8 per day
Metoprolol Succinate
ER
Metoprolol Succinate (TAB
24HR 100 MG, TAB 24HR 50
MG (TARTRATE EQUIV), TAB
24HR 100 MG (TARTRATE
EQUIV), TAB 24HR 25 MG
(TARTRATE EQUIV), TAB
24HR 25 MG)
generic
MDD
1 per day
PAGE 90
BRAND NAME
ER
Metoprolol Succinate (TAB
24HR 200 MG, TAB 24HR 200
MG (TARTRATE EQUIV))
Metoprolol Tartrate
COVERAGE
generic
MDD
2 per day
Metoprolol Tartrate (TAB 25
MG, TAB 100 MG)
generic
MDD
2 per day
Metoprolol Tartrate
metoprolol tartrate tab 50 mg
generic
MDD
3 per day
Nadolol
Nadolol (TAB 20 MG, TAB 40
MG, TAB 80 MG)
generic
MDD
2 per day
Pindolol
Pindolol (TAB 5 MG, TAB 10
MG)
generic
Propranolol HCl ER
Propranolol HCl (CAP 24HR 80
MG, CAP 24HR 60 MG, CAP
24HR 120 MG, CAP 24HR 160
MG)
generic
Propranolol HCl (INJ 1 MG/ML,
ORAL SOLN 20 MG/5ML,
ORAL SOLN 40 MG/5ML, TAB
generic
Propranolol HCl SustainedRelease Beads (CAP ER 24H
120 MG, CAP ER 24H 80 MG)
propranolol hcl sustainedrelease beads
BRAND
Propranolol HCl SustainedRelease Beads (CAP ER 24H
80 MG, CAP ER 24H 120 MG)
propranolol hcl sustainedrelease beads
BRAND
Timolol Maleate (TAB 5 MG,
generic
Propranolol HCl
InnoPran XL
Inderal XL
Timolol Maleate
CALCIUM CHANNEL BLOCKING AGENTS
AmLODIPine
Besylate
Amlodipine Besylate (TAB 2.5
generic
MDD
1 per day
DiltiaZEM HCl ER
Diltiazem HCl (CAP 12HR 90
12HR 60 MG, CAP 24HR 240
MG)
generic
MDD
2 per day
DiltiaZEM HCl ER
Diltiazem HCl (CAP 24HR 120
MG, CAP 24HR 180 MG)
generic
MDD
1 per day
DiltiaZEM HCl
Diltiazem HCl (TAB 30 MG,
120 MG)
generic
MDD
3 per day
PAGE 91
BRAND NAME
DiltiaZEM HCl ER
Coated Beads
Diltiazem HCl Coated Beads
(BEADS CAP 24HR 300 MG,
BEADS CAP 24HR 180 MG,
BEADS CAP 24HR 120 MG)
DiltiaZEM HCl ER
Coated Beads
DiltiaZEM HCl ER
Beads
COVERAGE
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 420 MG)
generic
MDD
1 per day
DiltiaZEM HCl ER
Beads
diltiazem hcl extended release
beads cap sr 24hr 240 mg
generic
MDD
2 per day
Felodipine ER
Felodipine (TAB 24HR 10 MG,
2.5 MG)
generic
MDD
1 per day
NiCARdipine HCl
Nicardipine HCl (CAP 20 MG,
CAP 30 MG)
generic
NIFEdipine
Nifedipine (CAP 10 MG, CAP
20 MG)
generic
MDD
4 per day
NIFEdipine ER
nifedipine tab sr 24hr 30 mg
generic
MDD
1 per day
Nifediac CC
generic
MDD
2 per day
Nifediac CC
generic
MDD
1 per day
Nifedical XL
nifedipine tab sr 24hr osmotic
release 30 mg
generic
MDD
1 per day
Nifedical XL
release 60 mg
generic
MDD
2 per day
NIFEdipine ER
Osmotic Release
release 90 mg
generic
MDD
1 per day
Verapamil HCl ER
Verapamil HCl (CAP 24HR 120
24HR 360 MG, CAP 24HR 240
MG)
generic
MDD
1 per day
Verapamil HCl ER
Verapamil HCl (TAB 120 MG,
generic
MDD
2 per day
Verapamil HCl
Verapamil HCl (TAB 40 MG,
generic
MDD
3 per day
PAGE 92
BRAND NAME
COVERAGE
CARDIOVASCULAR AGENTS, OTHER
AMILorideHydroCHLOROthiazid
e
amiloride & hydrochlorothiazide
tab 5-50 mg
Amlodipine BesyBenazepril HCl
generic
MDD
1 per day
Amlodipine BesylateBenazepril HCl (CAP 2.5-10
MG, CAP 5-10 MG, CAP 5-20
MG, CAP 10-20 MG)
generic
MDD
1 per day
AtenololChlorthalidone
Atenolol & Chlorthalidone (TAB
50-25 MG, TAB 100-25 MG)
generic
MDD
2 per day
BenazeprilHydrochlorothiazide
Benazepril &
Hydrochlorothiazide (TAB 56.25 MG, TAB 10-12.5 MG,
TAB 20-12.5 MG, TAB 20-25
MG)
generic
MDD
1 per day
BisoprololHydrochlorothiazide
Bisoprolol &
Hydrochlorothiazide (TAB 56.25 MG, TAB 10-6.25 MG)
generic
MDD
1 per day
CaptoprilHydrochlorothiazide
Captopril &
Hydrochlorothiazide (TAB 2525 MG, TAB 25-15 MG, TAB
50-15 MG)
generic
MDD
2 per day
CaptoprilHydrochlorothiazide
captopril & hydrochlorothiazide
tab 50-25 mg
generic
MDD
3 per day
Digoxin
Digoxin (ORAL SOLN 0.05
MG/ML, TAB 125 MCG (0.125
MG), TAB 250 MCG (0.25
MG))
generic
EnalaprilHydrochlorothiazide
Enalapril Maleate &
Hydrochlorothiazide (TAB 512.5 MG, TAB 10-25 MG)
generic
MDD
2 per day
Fosinopril SodiumHCTZ
Fosinopril Sodium &
generic
MDD
1 per day
IrbesartanHydrochlorothiazide
Irbesartan-Hydrochlorothiazide
(TAB 150-12.5 MG, TAB 30012.5 MG)
generic
MDD
1 per day
LisinoprilHydrochlorothiazide
Lisinopril &
generic
MDD
2 per day
LisinoprilHydrochlorothiazide
lisinopril & hydrochlorothiazide
tab 20-25 mg
generic
MDD
1 per day
Losartan PotassiumHCTZ
Losartan Potassium &
Hydrochlorothiazide (TAB 5012.5 MG, TAB 100-25 MG,
TAB 100-12.5 MG)
generic
MDD
1 per day
PAGE 93
BRAND NAME
MetoprololHydrochlorothiazide
Metoprolol &
Hydrochlorothiazide (TAB 5025 MG, TAB 100-25 MG)
Dutoprol
COVERAGE
generic
MDD
2 per day
Metoprolol &
Hydrochlorothiazide (TAB ER
24H 50-12.5 MG, TAB ER 24H
100-12.5 MG, TAB ER 24H 2512.5 MG)
metoprolol &
hydrochlorothiazide
BRAND
MDD
1 per day
MetoprololHydrochlorothiazide
metoprolol &
hydrochlorothiazide tab 100-50
mg
generic
MDD
1 per day
Pentoxifylline ER
pentoxifylline tab cr 400 mg
generic
Propranolol-HCTZ
Propranolol &
Hydrochlorothiazide (TAB 4025 MG, TAB 80-25 MG)
generic
Reserpine
Reserpine (TAB 0.1 MG, TAB
0.25 MG)
generic
Spironolactone-HCTZ
spironolactone &
hydrochlorothiazide tab 25-25
mg
generic
Triamterene &
Hydrochlorothiazide (CAP
37.5-25 MG, CAP 50-25 MG,
TAB 75-50 MG)
generic
triamterene &
hydrochlorothiazide tab 37.525 mg
generic
MDD
2 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
Triamterene-HCTZ
Triamterene-HCTZ
ValsartanHydrochlorothiazide
DIURETICS, CARBONIC ANHYDRASE INHIBITORS
AcetaZOLAMIDE
Acetazolamide (TAB 125 MG,
TAB 250 MG)
generic
AcetaZOLAMIDE ER
acetazolamide cap sr 12hr 500
mg
generic
Bumetanide
Bumetanide (TAB 0.5 MG, TAB
1 MG, TAB 2 MG)
generic
Furosemide
Furosemide (INJ 10 MG/ML,
ORAL SOLN 8 MG/ML, ORAL
SOLN 10 MG/ML, TAB 20 MG,
generic
DIURETICS, LOOP
PAGE 94
BRAND NAME
Torsemide
Torsemide (TAB 5 MG, TAB 10
MG)
COVERAGE
generic
MDD
1 per day
MDD
4 per day
DIURETICS, POTASSIUM-SPARING
AMILoride HCl
amiloride hcl tab 5 mg
generic
Spironolactone
Spironolactone (TAB 25 MG,
generic
Chlorothiazide
chlorothiazide tab 250 mg
generic
MDD
2 per day
Chlorothiazide
chlorothiazide tab 500 mg
generic
MDD
4 per day
Chlorthalidone
Chlorthalidone (TAB 25 MG,
TAB 50 MG)
chlorthalidone
BRAND
HydroCHLOROthiazid
e
Hydrochlorothiazide (CAP 12.5
MG, TAB 12.5 MG, TAB 25
MG, TAB 50 MG)
generic
Indapamide
Indapamide (TAB 1.25 MG,
TAB 2.5 MG)
generic
MetOLazone
Metolazone (TAB 2.5 MG, TAB
5 MG, TAB 10 MG)
generic
DIURETICS, THIAZIDE
DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES
Fenofibrate
Micronized
Fenofibrate Micronized (CAP
134 MG, CAP 200 MG)
generic
MDD
1 per day
Fenofibrate
Micronized
fenofibrate micronized cap 67
mg
generic
MDD
2 per day
Fenofibrate
fenofibrate tab 160 mg
generic
MDD
1 per day
Fenofibrate
fenofibrate tab 54 mg
generic
MDD
3 per day
Gemfibrozil
gemfibrozil tab 600 mg
generic
MDD
2 per day
Atorvastatin Calcium (TAB 10
TAB 80 MG)
generic
MDD
1 per day
Lovastatin
Lovastatin (TAB 10 MG, TAB
20 MG)
generic
MDD
1 per day
Lovastatin
lovastatin tab 40 mg
generic
MDD
2 per day
DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS
Atorvastatin Calcium
PAGE 95
BRAND NAME
Pravastatin Sodium
Pravastatin Sodium (TAB 10
TAB 80 MG)
COVERAGE
generic
MDD
1 per day
Simvastatin (TAB 5 MG, TAB
MG, TAB 80 MG)
generic
MDD
1 per day
Cholestyramine (POWDER 4
GM/DOSE, POWDER
PACKETS 4 GM)
generic
Cholestyramine Light
(POWDER 4 GM/DOSE,
POWDER PACKETS 4 GM)
generic
Colestipol HCl
Colestipol HCl (GRANULES 5
GM, TAB 1 GM)
generic
Vytorin
Ezetimibe-Simvastatin (TAB
10-40 MG, TAB 10-20 MG,
TAB 10-80 MG, TAB 10-10
MG)
ezetimibe-simvastatin
BRAND
Niacor
NIACOR TAB 500 MG
niacin (antihyperlipidemic)
BRAND
Omega-3-acid Ethyl
Esters
omega-3-acid ethyl esters cap
1 gm
generic
Simvastatin
DYSLIPIDEMICS, OTHER
Cholestyramine
PA
MDD
1 per day
VASODILATORS, DIRECT-ACTING ARTERIAL
HydrALAZINE HCl
Hydralazine HCl (TAB 10 MG,
100 MG)
generic
Minoxidil
minoxidil tab 10 mg
generic
MDD
10 per day
Minoxidil
minoxidil tab 2.5 mg
generic
MDD
3 per day
MDD
2 per day
VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS
Isosorbide Dinitrate
Isosorbide Dinitrate (SL TAB
2.5 MG, SL TAB 5 MG, TAB 5
TAB 30 MG)
generic
Isochron
isosorbide dinitrate tab cr 40
mg
generic
Isosorbide
Mononitrate
Isosorbide Mononitrate (TAB
10 MG, TAB 20 MG)
generic
PAGE 96
BRAND NAME
Isosorbide
Mononitrate ER
Isosorbide Mononitrate (TAB
24HR 120 MG, TAB 24HR 60
MG, TAB 24HR 30 MG)
COVERAGE
Nitro-Bid
NITRO-BID OINTMENT 2 %
nitroglycerin
BRAND
Nitroglycerin ER
Nitroglycerin (CAP 2.5 MG,
CAP 6.5 MG, CAP 9 MG)
generic
Nitroglycerin
Nitroglycerin (SL TAB 0.3 MG,
SL TAB 0.4 MG, SL TAB 0.6
MG, TD PATCH 24HR 0.4
MG/HR, TD PATCH 24HR 0.2
MG/HR)
generic
generic
MDD
1 per day
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES
Adzenys XR-ODT
Amphetamine (TAB ER DISP
3.1 MG, TAB ER DISP 6.3 MG,
TAB ER DISP 9.4 MG, TAB ER
DISP 12.5 MG, TAB ER DISP
15.7 MG, TAB ER DISP 18.8
MG)
amphetamine
BRAND
MDD
1 per day
AmphetamineDextroamphet ER
AmphetamineDextroamphetamine (CAP
24HR 15 MG, CAP 24HR 5
MG, CAP 24HR 10 MG)
generic
MDD
1 per day
AmphetamineDextroamphet ER
AmphetamineDextroamphetamine (CAP
24HR 30 MG, CAP 24HR 20
MG, CAP 24HR 25 MG)
generic
MDD
2 per day
AmphetamineDextroamphetamine
AmphetamineDextroamphetamine (TAB 5
MG, TAB 7.5 MG, TAB 10 MG,
TAB 12.5 MG, TAB 15 MG,
TAB 20 MG)
generic
MDD
3 per day
AmphetamineDextroamphetamine
amphetaminedextroamphetamine tab 30 mg
generic
MDD
1 per day
Dextroamphetamine
Sulfate ER
Dextroamphetamine Sulfate
(CAP 24HR 15 MG, CAP 24HR
10 MG, CAP 24HR 5 MG)
generic
MDD
2 per day
Zenzedi
(TAB 2.5 MG, TAB 15 MG)
dextroamphetamine sulfate
BRAND
MDD
1 per day
PAGE 97
BRAND NAME
Zenzedi
(TAB 7.5 MG, TAB 20 MG,
TAB 30 MG)
COVERAGE
BRAND
MDD
2 per day
Dextroamphetamine
Sulfate
oral solution 5 mg/5ml
generic
MDD
40 per day
Dextroamphetamine
Sulfate
dextroamphetamine sulfate tab
10 mg
generic
MDD
4 per day
Dextroamphetamine
Sulfate
dextroamphetamine sulfate tab
5 mg
generic
MDD
1 per day
Evekeo
EVEKEO TAB 10 MG
amphetamine sulfate
BRAND
MDD
6 per day
Evekeo
EVEKEO TAB 5 MG
amphetamine sulfate
BRAND
MDD
1 per day
Vyvanse
Lisdexamfetamine Dimesylate
(CAP 10 MG, CAP 20 MG,
MG)
lisdexamfetamine dimesylate
BRAND
methamphetamine hcl tab 5
mg
generic
Methamphetamine
HCl
PA
MDD
1 per day
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES
Strattera
Atomoxetine HCl (CAP 10 MG,
atomoxetine hcl
BRAND
MDD
2 per day
Atomoxetine HCl (CAP 40 MG,
100 MG)
atomoxetine hcl
BRAND
MDD
1 per day
CloNIDine HCl ER
clonidine hcl tab sr 12hr 0.1 mg
generic
MDD
4 per day
Dexmethylphenidate
HCl ER
Dexmethylphenidate HCl (CAP
24 HR 40 MG, CAP 24 HR 20
MG, CAP 24 HR 5 MG, CAP
24 HR 10 MG, CAP 24 HR 30
MG, CAP 24 HR 15 MG)
generic
MDD
1 per day
Dexmethylphenidate HCl (CAP
35 MG)
dexmethylphenidate hcl
BRAND
MDD
1 per day
Dexmethylphenidate HCl (TAB
MG)
generic
Strattera
Focalin XR
Dexmethylphenidate
HCl
PAGE 98
AL
MDD
At least 6 yrs old
2 per day
BRAND NAME
GuanFACINE HCl ER
Guanfacine HCl (ADHD) (TAB
24HR 3 MG, TAB 24HR 2 MG,
TAB 24HR 1 MG)
COVERAGE
generic
MDD
1 per day
GuanFACINE HCl ER
guanfacine hcl tab sr 24hr 4
mg (base equiv)
generic
MDD
2 per day
Daytrana
Methylphenidate (PATCH 10,
PATCH 15, PATCH 20,
PATCH 30)
methylphenidate
BRAND
MDD
1 per day
Methylphenidate HCl
ER (CD)
Methylphenidate HCl (CAP 10
MG, CAP 20 MG, CAP 30 MG,
60 MG)
generic
MDD
1 per day
Methylphenidate HCl
ER (LA)
Methylphenidate HCl (CAP
24HR 20 MG, CAP 24HR 40
MG)
generic
MDD
1 per day
Ritalin LA
Methylphenidate HCl (CAP ER
24H 10 MG, CAP ER 24H 60
MG)
methylphenidate hcl
BRAND
MDD
1 per day
Methylphenidate HCl (CAP ER
24H 50 MG, CAP ER 24H 30
60 MG, CAP ER 24H 15 MG,
CAP ER 24H 20 MG)
methylphenidate hcl
BRAND
MDD
1 per day
Methylphenidate HCl (CHEW
TAB 2.5 MG, CHEW TAB 5
MG, CHEW TAB 10 MG)
generic
MDD
3 per day
Methylphenidate HCl (ER 20
MG, ER 30 MG, ER 40 MG)
methylphenidate hcl
BRAND
Methylin ER
Methylphenidate HCl (TAB 10
MG, TAB 20 MG)
generic
MDD
3 per day
Methylin
MG, TAB 20 MG)
generic
MDD
3 per day
Methylphenidate HCl
ER
MG, TAB 27 MG)
generic
MDD
1 per day
Methylphenidate HCl
ER
MG, TAB 54 MG)
generic
MDD
2 per day
Methylphenidate HCl
ER (LA)
methylphenidate hcl cap sr
24hr 30 mg (la)
generic
MDD
2 per day
Methylphenidate HCl
methylphenidate hcl soln 10
mg/5ml
generic
MDD
30 per day
Aptensio XR
Methylphenidate HCl
QuilliChew ER
PAGE 99
BRAND NAME
Methylphenidate HCl
methylphenidate hcl soln 5
mg/5ml
Methylin
methylphenidate hcl tab 5 mg
COVERAGE
generic
MDD
AL
generic
Quillivant XR
QUILLIVANT XR RECON
SUSP 25 MG/5ML
methylphenidate hcl
BRAND
60 per day
3 to 21 yrs old
MDD
3 per day
MDD
12 per day
CENTRAL NERVOUS SYSTEM, OTHER
ButalbitalAcetaminophen
butalbital-acetaminophen tab
50-325 mg
generic
Promacet
butalbital-acetaminophen tab
50-650 mg
generic
QL
124 / 31 days
Margesic
butalbital-acetaminophencaffeine cap 50-325-40 mg
generic
QL
124 / 31 days
Butalbital-APAPCaffeine
butalbital-acetaminophencaffeine tab 50-325-40 mg
generic
MDD
Butalbital-APAPCaffeine
butalbital-acetaminophencaffeine tab 50-500-40 mg
generic
QL
124 / 31 days
Butalbital-AspirinCaffeine
butalbital-aspirin-caffeine cap
50-325-40 mg
generic
QL
124 / 31 days
Phrenilin Forte
PHRENILIN FORTE CAP 50650 MG
butalbital-acetaminophen
BRAND
TENCON TAB 50-325 MG
butalbital-acetaminophen
BRAND
Tencon
4 per day
FIBROMYALGIA AGENTS
Cymbalta
CYMBALTA CP DR PART 60
MG
duloxetine hcl
BRAND
MDD
2 per day
Duloxetine HCl (CAP 20 MG,
60 MG)
generic
MDD
2 per day
Irenka
IRENKA CP DR PART 40 MG
duloxetine hcl
BRAND
MDD
2 per day
Savella
Milnacipran HCl (TAB 12.5
TAB 100 MG)
milnacipran hcl
BRAND
DULoxetine HCl
PAGE 100
BRAND NAME
Savella Titration Pack
SAVELLA TITRATION PACK
MISC 12.5 & 25 & 50 MG
milnacipran hcl
COVERAGE
BRAND
DENTAL AND ORAL AGENTS
Chlorhexidine
Gluconate
chlorhexidine gluconate soln
0.12%
generic
Pilocarpine HCl
pilocarpine hcl tab 5 mg
generic
MDD
ControlRx
sodium fluoride cream 1.1%
generic
QL
60 / month
Phos-Flur
sodium fluoride gel 1.1% (0.5%
f)
generic
QL
60 / month
QL
62 / 31 days
6 per day
DERMATOLOGICAL AGENTS
Ceramax
generic
Clearplex X
generic
Benzoyl Peroxide
generic
Benzoyl Peroxide
Wash
Calcipotriene
Calcipotriene (CREAM, SOLN
(50 MCG/ML))
generic
generic
MPL
1 / claim
1 / 30 days
Clindamycin PhosBenzoyl Perox
clindamycin phosphate-benzoyl
peroxide gel 1-5%
generic
MPL
ClotrimazoleBetamethasone
clotrimazole w/ betamethasone
cream 1-0.05%
generic
QL
45 / 31 days
ClotrimazoleBetamethasone
clotrimazole w/ betamethasone
lotion 1-0.05%
generic
QL
31 / 31 days
Elidel
ELIDEL CREAM 1 %
pimecrolimus
QL
30 / 30 days
BRAND
PA
AL
At least 2 yrs old
QL
10 / 31 days
40 / 31 days
Epifoam
EPIFOAM FOAM 1-1 %
pramoxine-hc
BRAND
Fluorouracil
Fluorouracil (Topical) (SOLN
2%, SOLN 5%)
generic
Fluorouracil
fluorouracil cream 0.5%
generic
Fluorouracil
fluorouracil cream 5%
generic
QL
Hydrocortisone
Hydrocortisone (Topical)
(CREAM 1%, LOTION 2.5%)
generic
MPL
PAGE 101
1 / claim
BRAND NAME
Hydrocortisone
hydrocortisone cream 2.5%
COVERAGE
generic
Hydrocortisone
hydrocortisone oint 1%
C
QL
generic
MPL
Hydrocortisone
hydrocortisone oint 2.5%
generic
Imiquimod
imiquimod cream 5%
generic
Amnesteem
Isotretinoin (CAP 10 MG, CAP
20 MG, CAP 40 MG)
QL
Pkg JAR: Max
Qty=120/30 days |
Pkg TUBE: Package
Limit=1/claim |
60 / 30 days
1 / 30 days
48 / 180 days
PA
generic
AL
Up to 21 yrs old
MDD
2 per day
Ammonium Lactate
lactic acid (ammonium lactate)
cream 12%
generic
MPL
1 / 31 days
LAClotion
lactic acid (ammonium lactate)
lotion 12%
generic
MPL
1 / 31 days
Lidocaine HCl
lidocaine hcl cream 3%
generic
MPL
1 / claim
Lidocaine
lidocaine oint 5%
generic
MPL
1 / claim
Podofilox
podofilox soln 0.5%
generic
Selenium Sulfide
selenium sulfide lotion 2.5%
QL
generic
MPL
Sulfacetamide
Sodium
sulfacetamide sodium liquid
10%
Sulfacetamide
Sodium
sulfacetamide sodium lotion
10% (acne)
QL
C
Sulfacetamide
Sodium-Sulfur
sulfacetamide sodium w/ sulfur
lotion 10-5%
generic
Sulfacetamide
Sodium-Sulfur
sulfacetamide sodium w/ sulfur
susp 10-5%
generic
MPL
QL
MPL
tacrolimus oint 0.03%
QL
generic
Tacrolimus
tacrolimus oint 0.1%
generic
124 / 31 days
Limit=1/claim | Pkg
Size 59: Package
Limit=2/claim |
1 / 31 days
31 / 31 days
1 / claim
30 / 30 days
PA
AL
At least 2 yrs old
QL
30 / 30 days
PA
AL
PAGE 102
1 / claim
generic
generic
Tacrolimus
124 / 31 days
At least 16 yrs old
BRAND NAME
Tazorac
Tazorac
Tazarotene (GEL 0.05 %, GEL
0.1 %)
tazarotene
COVERAGE
QL
BRAND
C
TAZORAC CREAM 0.05 %
tazarotene
QL
BRAND
C
Tazorac
TAZORAC CREAM 0.1 %
tazarotene
QL
BRAND
C
Tretinoin
Avita
Tretinoin (CREAM 0.05%,
CREAM 0.1%)
tretinoin gel 0.01%
tretinoin gel 0.025%
generic
Urea
Urea (CREAM, LOTION)
generic
Limit=1/claim | Pkg
Size 15: Package
Limit=4/claim | Pkg
Size 30: Package
Limit=2/claim |
62 / 31 days
Limit=1/claim | Pkg
Size 30: Package
Limit=2/claim |
AL
Up to 21 yrs old
QL
20 / claim
AL
Up to 21 yrs old
QL
15 / claim
AL
Up to 21 yrs old
AL
Up to 21 yrs old
generic
Avita
62 / 31 days
20 / claim
generic
Tretinoin
Limit=2/claim |
QL
generic
tretinoin cream 0.025%
62 / 31 days
ENZYME REPLACEMENT/MODIFIERS
Pancrelipase (LipProt-Amyl)
pancrelipase (lip-prot-amyl) dr
cap 5000-17000-27000 unit
generic
Zenpep
Pancrelipase (LipaseProtease-Amylase) (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)
pancrelipase (lipase-proteaseamylase)
BRAND
10500, CP DR PART 16800,
CP DR PART 21000)
BRAND
Pancreaze
PAGE 103
BRAND NAME
Creon
12000, CP DR PART 24000)
COVERAGE
BRAND
ANTISPASMODICS, GASTROINTESTINAL
Dicyclomine HCl
Dicyclomine HCl (CAP 10 MG,
TAB 20 MG)
generic
Dicyclomine HCl
dicyclomine hcl oral soln 10
mg/5ml
generic
QL
Glycopyrrolate
Glycopyrrolate (TAB 1 MG,
TAB 2 MG)
generic
MDD
4 per day
Hyoscyamine Sulfate
Hyoscyamine Sulfate (ELIXIR
0.125 MG/5ML, SOLN 0.125
MG/ML, TAB 0.125 MG, TAB
SL 0.125 MG)
generic
Ed-Spaz
hyoscyamine sulfate tab disp
0.125 mg
generic
Hyoscyamine Sulfate
ER
hyoscyamine sulfate tab sr
12hr 0.375 mg
generic
MDD
4 per day
Phenohytro
pb-hyoscy-atrop-scopol tab
16.2-0.1037-0.0194-0.0065 mg
generic
MDD
7 per day
496 / 31 days
DiphenoxylateAtropine
Diphenoxylate w/ Atropine (LIQ
MG/5ML, TAB MG)
generic
Loperamide HCl
loperamide hcl cap 2 mg
generic
Ursodiol
ursodiol cap 300 mg
generic
Ursodiol
ursodiol tab 250 mg
generic
HISTAMINE2 (H2) RECEPTOR ANTAGONISTS
Cimetidine
Cimetidine (TAB 200 MG, TAB
800 MG)
generic
Cimetidine HCl
cimetidine hcl soln 300 mg/5ml
generic
Famotidine
Famotidine (TAB 20 MG, TAB
40 MG)
generic
RaNITidine HCl
Ranitidine HCl (TAB 150 MG,
TAB 300 MG)
generic
PAGE 104
BRAND NAME
RaNITidine HCl
ranitidine hcl cap 150 mg
COVERAGE
generic
MDD
2 per day
RaNITidine HCl
ranitidine hcl cap 300 mg
generic
MDD
1 per day
RaNITidine HCl
ranitidine hcl syrup 15 mg/ml
(75 mg/5ml)
generic
AL
Up to 6 yrs old
MDD
20 per day
LAXATIVES
Enulose
lactulose (encephalopathy)
solution 10 gm/15ml
generic
Lactulose
lactulose solution 10 gm/15ml
generic
PEG3350/Electrolytes
peg 3350-kcl-na bicarb-nacl-na
sulfate for soln 236 gm
generic
MPL
1 / claim
GaviLyte-C
peg 3350-kcl-na bicarb-nacl-na
sulfate for soln 240 gm
generic
MPL
1 / claim
PEG 3350-KCl-Na
Bicarb-NaCl
peg 3350-kcl-sod bicarb-nacl
for soln 420 gm
generic
MPL
1 / claim
Polyethylene Glycol
3350
polyethylene glycol 3350 oral
powder
generic
MDD
34 per day
CARAFATE SUSPENSION 1
GM/10ML
sucralfate
QL
BRAND
420 / claim
AL
Up to 6 yrs old
Misoprostol
Misoprostol (TAB 100 MCG,
TAB 200 MCG)
generic
Sucralfate
sucralfate tab 1 gm
generic
PROTECTANTS
Carafate
MDD
4 per day
MDD
4 per day
PROTON PUMP INHIBITORS
Lansoprazole
lansoprazole cap delayed
release 15 mg
generic
C
OTC Covered Only
Omeprazole
Omeprazole (CAP 20 MG,
CAP 40 MG)
generic
MDD
1 per day
Pantoprazole Sodium
pantoprazole sodium ec tab 20
mg (base equiv)
generic
MDD
1 per day
Pantoprazole Sodium
pantoprazole sodium ec tab 40
mg (base equiv)
generic
MDD
2 per day
PAGE 105
BRAND NAME
COVERAGE
GENITOURINARY AGENTS
ANTISPASMODICS, URINARY
FlavoxATE HCl
flavoxate hcl tab 100 mg
generic
Oxybutynin Chloride
ER
Oxybutynin Chloride (TAB
24HR 15 MG, TAB 24HR 10
MG, TAB 24HR 5 MG)
generic
QL
62 / 31 days
Oxybutynin Chloride
oxybutynin chloride syrup 5
mg/5ml
generic
QL
496 / 31 days
Oxybutynin Chloride
oxybutynin chloride tab 5 mg
generic
QL
93 / 31 days
Tolterodine Tartrate
Tolterodine Tartrate (TAB 1
MG, TAB 2 MG)
generic
QL
62 / 31 days
ER
tolterodine tartrate cap sr 24hr
2 mg
generic
MDD
ER
tolterodine tartrate cap sr 24hr
4 mg
generic
QL
Trospium Chloride
trospium chloride tab 20 mg
generic
MDD
2 per day
1 per day
31 / 31 days
BENIGN PROSTATIC HYPERTROPHY AGENTS
Finasteride
finasteride tab 5 mg
generic
MDD
1 per day
Tamsulosin HCl
tamsulosin hcl cap 0.4 mg
generic
MDD
2 per day
Terazosin HCl
Terazosin HCl (CAP 1 MG,
10 MG)
generic
MDD
3 per day
MDD
8 per day
GENITOURINARY AGENTS, OTHER
Bethanechol Chloride
Bethanechol Chloride (TAB 5
TAB 50 MG)
generic
Cuprimine
CUPRIMINE CAP 250 MG
penicillamine
BRAND
Elmiron
ELMIRON CAP 100 MG
pentosan polysulfate sodium
BRAND
Phenazopyridine HCl
Phenazopyridine HCl (TAB 100
MG, TAB 200 MG)
generic
Phospha 250 Neutral
pot phos monobasic w/sod
phos di & monobas tab 155852-130mg
generic
Potassium Citrate (Alkalinizer)
(TAB 5 (540, TAB 10 (1080)
generic
Potassium Citrate ER
PAGE 106
BRAND NAME
Sodium Chloride
sodium chloride irrigation soln
0.9%
COVERAGE
Citric Acid-Sodium
Citrate
sodium citrate & citric acid soln
500-334 mg/5ml
generic
calcium acetate (phosphate
binder) cap 667 mg (169 mg
ca)
generic
generic
QL
500 / 30 days
PHOSPHATE BINDERS
Calcium Acetate
(Phos Binder)
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)
Betamethasone
Dipropionate Aug
betamethasone dipropionate
augmented cream 0.05%
generic
Beta-Val
Betamethasone Valerate
(CREAM, LOTION)
generic
Betamethasone
Valerate
betamethasone valerate oint
0.1%
generic
Clobetasol Propionate
(CREAM, GEL, OINT)
E
MPL
1 / claim
generic
MPL
1 / claim
clobetasol propionate emollient
base cream 0.05%
generic
MPL
1 / claim
Cormax Scalp
Application
clobetasol propionate soln
0.05%
generic
MPL
1 / claim
Cortisone Acetate
cortisone acetate tab 25 mg
generic
Dexamethasone
Dexamethasone (ELIXIR 0.5
MG/5ML, SOLN 0.5 MG/5ML,
TAB 0.5 MG, TAB 0.75 MG,
generic
Dexamethasone
Sodium Phosphate
Dexamethasone Sodium
Phosphate (INJ 4 MG/ML, INJ
20 MG/5ML, INJ 120
MG/30ML)
generic
Fludrocortisone
Acetate
fludrocortisone acetate tab 0.1
mg
generic
Fluocinonide
Fluocinonide (CREAM, GEL,
OINT, SOLN)
generic
MPL
1 / claim
Fluocinonide-E
fluocinonide emulsified base
cream 0.05%
generic
MPL
1 / claim
Fluticasone
Propionate
fluticasone propionate cream
0.05%
generic
MPL
1 / 30 days
Fluticasone
Propionate
fluticasone propionate oint
0.005%
generic
MPL
1 / claim
PAGE 107
QL
150 / 30 days
BRAND NAME
Hydrocortisone
Hydrocortisone (TAB 5 MG,
Hydrocortisone
Butyrate
hydrocortisone butyrate soln
0.1%
generic
MethylPREDNISolone
Methylprednisolone (TAB 4
MG, TAB 8 MG, TAB
THERAPY PACK 4 MG (21))
generic
MethylPREDNISolone
(Pak)
methylprednisolone tab 4 mg
dose pack
generic
Millipred
MILLIPRED TAB 5 MG
prednisolone
BRAND
Mometasone Furoate
Mometasone Furoate
(CREAM, OINT, SOLUTION
(LOTION))
generic
PrednisoLONE
Sodium Phosphate
prednisolone sod phosph oral
soln 6.7 mg/5ml (5 mg/5ml
base)
generic
PrednisoLONE
Sodium Phosphate
prednisolone sod phosphate
oral soln 15 mg/5ml (base
equiv)
generic
PrednisoLONE
prednisolone syrup 15 mg/5ml
(usp solution equivalent)
generic
PredniSONE
Prednisone (ORAL SOLN 5
MG/5ML, TAB 1 MG, TAB 2.5
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
prednisone
BRAND
Sterapred
prednisone tab 5 mg dose pack
generic
Triamcinolone
Acetonide
Triamcinolone Acetonide
(Topical) (CREAM 0.5%,
LOTION 0.025%, LOTION
0.1%, OINT 0.025%, OINT
0.5%)
generic
Triamcinolone
Acetonide
Triamcinolone Acetonide
(Topical) (CREAM, OINT)
generic
Triamcinolone
Acetonide
triamcinolone acetonide cream
0.025%
generic
PredniSONE Intensol
PAGE 108
COVERAGE
generic
MPL
QL
MPL
C
1 / claim
240 / claim
1 / claim
Pkg JAR: Max
Qty=120/30 days |
Pkg TUBE: Package
Limit=1/claim |
BRAND NAME
Triamcinolone
Acetonide
triamcinolone acetonide dental
paste 0.1%
Veripred 20
VERIPRED 20 SOLUTION 20
MG/5ML
prednisolone sodium
phosphate
COVERAGE
generic
MPL
1 / claim
BRAND
QL
150 / claim
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)
Desmopressin Ace
Rhinal Tube
desmopressin acetate nasal
soln 0.01% (refrigerated)
generic
QL
5 / claim
Desmopressin
Acetate Spray
spray soln 0.01%
generic
QL
5 / claim
Desmopressin Ace
Spray Refrig
spray soln 0.01% (refrigerated)
generic
QL
5 / claim
Desmopressin
Acetate
desmopressin acetate tab 0.1
mg
generic
MDD
1 per day
Desmopressin
Acetate
desmopressin acetate tab 0.2
mg
generic
MDD
3 per day
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)
ANDROGENS
Androxy
ANDROXY TAB 10 MG
fluoxymesterone
BRAND
Methitest
METHITEST TAB 10 MG
methyltestosterone
BRAND
Androderm
Testosterone (PATCH 24HR 4
MG/24HR, PATCH 24HR 2
MG/24HR)
testosterone
BRAND
MDD
testosterone cypionate im inj in
oil 200 mg/ml
generic
QL
4 / 30 days
Conjugated EstrogensMedroxyprogesterone Acetate
(TAB 0.45-1.5 MG, TAB 0.6255 MG, TAB 0.625-2.5 MG)
conjugated estrogensmedroxyprogesterone acetate
BRAND
desogest-eth estrad & eth
estrad tab 0.15-0.02/0.01
mg(21/5)
generic
GL
Female
desogest-ethin est tab 0.10.025/0.125-0.025/0.150.025mg-mg
generic
GL
Female
Testosterone
Cypionate
1 per day
ESTROGENS
Prempro
Kariva
Velivet
PAGE 109
BRAND NAME
Apri
desogestrel & ethinyl estradiol
tab 0.15 mg-30 mcg
Gianvi
COVERAGE
generic
GL
Female
drospirenone-ethinyl estradiol
tab 3-0.02 mg
generic
GL
Female
Ocella
drospirenone-ethinyl estradiol
tab 3-0.03 mg
generic
GL
Female
Methyltest-Est
Estrogens HS
esterified estrogens &
methyltestosterone tab 0.6251.25 mg
generic
MDD
1 per day
Methyltest-Est
Estrogens
esterified estrogens &
methyltestosterone tab 1.252.5 mg
generic
MDD
1 per day
Estrace
ESTRACE CREAM 0.1
MG/GM
estradiol vaginal
BRAND
QL
43 / 31 days
Estradiol & Norethindrone
Acetate (PATCH TW 0.050.14, PATCH TW 0.05-0.25)
estradiol & norethindrone
acetate
BRAND
QL
8 / 28 days
EstradiolNorethindrone Acet
acetate tab 0.5-0.1 mg
generic
MDD
1 per day
Mimvey
acetate tab 1-0.5 mg
generic
MDD
1 per day
Estradiol
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 TW 0.025
MG/24HR, PATCH TW 0.05
MG/24HR)
estradiol
BRAND
MG/24HR)
estradiol
BRAND
MG/24HR)
estradiol
BRAND
CombiPatch
Minivelle
Alora
Estraderm
PAGE 110
QL
4 / 28 days
GL
Female
QL
8 / 28 days
GL
Female
QL
8 / 28 days
GL
Female
QL
8 / 28 days
GL
Female
BRAND NAME
Estradiol
Estradiol (TAB 0.5 MG, TAB 1
MG, TAB 2 MG)
Premarin
Estrogens, Conjugated (TAB
1.25 MG)
estrogens, conjugated
Estropipate
Estropipate (TAB 0.75 MG,
TAB 1.5 MG)
COVERAGE
generic
GL
Female
GL
Female
BRAND
MDD
GL
generic
MDD
Estropipate
estropipate tab 3 mg
GL
generic
MDD
Kelnor 1/35
ethynodiol diacetate & ethinyl
estradiol tab 1 mg-35 mcg
generic
Camrese
levonorg-eth est tab 0.150.03mg(84) & eth est tab
0.01mg(7)
generic
levonorgestrel & ethinyl
estradiol (91-day) tab 0.15-0.03
mg
generic
Lessina
estradiol tab 0.1 mg-20 mcg
LevonorgestrelEthinyl Estrad
Enpresse-28
1 per day
Female
1 per day
Female
2 per day
GL
Female
QL
91 / claim
GL
Female
QL
91 / claim
GL
Female
generic
GL
Female
generic
GL
Female
levonorgestrel-eth estra tab
0.05-30/0.075-40/0.125-30mgmcg
generic
LOESTRIN 24 FE TAB 1-20
MG-MCG
norethin acet & estrad-fe
BRAND
MINIVELLE PATCH TW
0.0375 MG/24HR
estradiol
BRAND
NECON 1/50 (28) TAB 1-50
MG-MCG
norethindrone & mestranol
BRAND
GL
Female
NECON 10/11 (28) TAB 35
MCG
norethindrone-eth estradiol
(biphasic)
BRAND
GL
Female
Balziva
norethindrone & ethinyl
generic
GL
Female
Nortrel 0.5/35 (28)
generic
GL
Female
Jolessa
Loestrin 24 Fe
Minivelle
Necon 1/50 (28)
Necon 10/11 (28)
PAGE 111
BRAND NAME
Nortrel 1/35 (21)
Junel 1/20
COVERAGE
generic
GL
Female
norethindrone ace & ethinyl
generic
GL
Female
Junel 1.5/30
generic
GL
Female
Junel FE 1/20
estradiol-fe tab 1 mg-20 mcg
generic
GL
Female
Junel FE 1.5/30
estradiol-fe tab 1.5 mg-30 mcg
generic
GL
Female
Lomedia 24 FE
norethindrone ace-ethinyl
estradiol-fe tab 1 mg-20 mcg
(24)
generic
Nortrel 7/7/7
norethindrone-eth estradiol tab
0.5-35/0.75-35/1-35 mg-mcg
generic
Aranelle
norethindrone-eth estradiol tab
0.5-35/1-35/0.5-35 mg-mcg
generic
Sprintec 28
norgestimate & ethinyl estradiol
tab 0.25 mg-35 mcg
generic
GL
Female
Tri-Lo-Sprintec
norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25 mgmcg
generic
norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mgmcg
generic
GL
Female
Tri-Sprintec
Cryselle-28
norgestrel & ethinyl estradiol
tab 0.3 mg-30 mcg
generic
MDD
Norinyl 1+50 (28)
NuvaRing
Ogestrel
Ortho Evra
Premarin
NORINYL 1+50 (28) TAB 1-50
MG-MCG
norethindrone & mestranol
BRAND
NUVARING RING 0.12-0.015
MG/24HR
etonogestrel-ethinyl estradiol
BRAND
OGESTREL TAB 0.5-50 MGMCG
norgestrel & ethinyl estradiol
ORTHO EVRA PATCH WK
150-35 MCG/24HR
norelgestromin-ethinyl estradiol
PREMARIN CREAM 0.625
MG/GM
estrogens, conjugated vaginal
GL
Female
QL
1 / claim
GL
Female
BRAND
GL
Female
BRAND
MPL
GL
BRAND
C
PAGE 112
2 per day
1 / 28 days
Female
From age 40 and older:
Max Qty=43/30 days |
From age 0 through
40: Max Qty=43/365
days |
BRAND NAME
Prempro
PREMPRO TAB 0.3-1.5 MG
conjugated estrogensmedroxyprogesterone acetate
COVERAGE
BRAND
GL
XULANE PATCH WK 150-35
MCG/24HR
norelgestromin-ethinyl estradiol
BRAND
MPL
ZOVIA 1/50E (28) TAB 1-50
MG-MCG
ethynodiol diacet & eth estrad
BRAND
GL
Female
ELLA TAB 30 MG
ulipristal acetate
BRAND
QL
4 / 365 days
Depo-SubQ Provera
104
DEPO-SUBQ PROVERA 104
SUSP PRSYR 104 MG/0.65ML
medroxyprogesterone acetate
(contraceptive)
BRAND
QL
1 / claim
Levonorgestrel
GL
Female
Xulane
Zovia 1/50E (28)
Female
1 / 28 days
PROGESTERONE AGONISTS/ANTAGONISTS
Ella
PROGESTINS
generic
MFL
My Way
QL
generic
MFL
Makena
MAKENA OIL 250 MG/ML
hydroxyprogesterone caproate
BRAND
MedroxyPROGESTE
Rone Acetate
Medroxyprogesterone Acetate
(TAB 2.5 MG, TAB 5 MG, TAB
10 MG)
generic
MedroxyPROGESTE
Rone Acetate
im susp 150 mg/ml
im susp prefilled syr 150 mg/ml
generic
Megestrol Acetate
Megestrol Acetate (SUSP 40
MG/ML, TAB 20 MG, TAB 40
MG)
generic
Norethindrone
Acetate
norethindrone acetate tab 5 mg
Norethindrone
norethindrone tab 0.35 mg
generic
Progesterone
Micronized
progesterone micronized cap
100 mg
generic
PAGE 113
1 / 21 days
4 / 365 days
PA
QL
1 / claim
GL
Female
QL
1 / claim
QL
30 / 30 days
generic
MedroxyPROGESTE
Rone Acetate
4 / 365 days
generic
BRAND NAME
Progesterone
Micronized
progesterone micronized cap
200 mg
COVERAGE
generic
QL
generic
MDD
20 / 30 days
SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS
Raloxifene HCl
raloxifene hcl tab 60 mg
1 per day
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)
Levothyroxine
Sodium
Levothyroxine Sodium (TAB 25
MCG, TAB 50 MCG, TAB 75
MCG, TAB 300 MCG)
generic
Liothyronine Sodium (TAB 5
MCG)
generic
Thyroid (TAB 15 MG, TAB 120
MG, TAB 300 MG)
thyroid
BRAND
NP Thyroid
Thyroid (TAB 30 MG, TAB 60
MG, TAB 90 MG)
generic
Thyrolar-1
THYROLAR-1 TAB 60 (12.550) MG (MCG)
liotrix (t3-t4)
BRAND
THYROLAR-1/2 TAB 30 (6.2525) MG (MCG)
liotrix (t3-t4)
BRAND
THYROLAR-1/4 TAB 15 (3.112.5) MG (MCG)
liotrix (t3-t4)
BRAND
THYROLAR-2 TAB 120 (25100) MG (MCG)
liotrix (t3-t4)
BRAND
THYROLAR-3 TAB 180 (37.5150) MG (MCG)
liotrix (t3-t4)
BRAND
Liothyronine Sodium
Armour Thyroid
Thyrolar-1/2
Thyrolar-1/4
Thyrolar-2
Thyrolar-3
HORMONAL AGENTS, SUPPRESSANT (THYROID)
ANTITHYROID AGENTS
MethIMAzole
PAGE 114
Methimazole (TAB 5 MG, TAB
10 MG)
generic
BRAND NAME
Propylthiouracil
propylthiouracil tab 50 mg
SSKI
SSKI SOLUTION 1 GM/ML
potassium iodide
COVERAGE
generic
BRAND
IMMUNOLOGICAL AGENTS
ANGIOEDEMA (HAE) AGENTS
Kalbitor
KALBITOR SOLUTION 10
MG/ML
ecallantide
BRAND
PA
IMMUNE SUPPRESSANTS
Azasan
Azathioprine (TAB 75 MG, TAB
100 MG)
azathioprine
BRAND
AzaTHIOprine
azathioprine tab 50 mg
generic
CycloSPORINE
Cyclosporine (CAP 25 MG,
CAP 100 MG)
generic
Gengraf
Cyclosporine Modified (For
Microemulsion) (CAP 25 MG,
CAP 100 MG, ORAL SOLN
100 MG/ML)
generic
CycloSPORINE
Modified
cyclosporine modified cap 50
mg
generic
Enbrel
ENBREL RECON SOLN 25
MG
etanercept
BRAND
Methotrexate Sodium (INJ 25
MG/ML, INJ 50 MG/2ML (25
MG/ML), INJ 100 MG/4ML (25
MG/ML), INJ 200 MG/8ML (25
MG/ML), INJ 250 MG/10ML
(25 MG/ML), INJ 1000
MG/40ML (25 MG/ML))
generic
Methotrexate Sodium (INJ 25
MG/ML, INJ 50 MG/2ML (25
MG/ML), INJ 250 MG/10ML
(25 MG/ML))
generic
Methotrexate Sodium (TAB 5
MG, TAB 7.5 MG, TAB 10 MG,
TAB 15 MG)
methotrexate sodium
BRAND
methotrexate sodium tab 2.5
mg (base equiv)
generic
Methotrexate Sodium
(PF)
Methotrexate Sodium
Trexall
Methotrexate
PAGE 115
BRAND NAME
Mycophenolate
Mofetil
Mycophenolate Mofetil (CAP
250 MG, FOR ORAL SUSP
200 MG/ML, TAB 500 MG)
Mycophenolate
Sodium
Mycophenolate Sodium (TAB
DR 180 MG, TAB DR 360 MG)
generic
Rapamune
RAPAMUNE SOLUTION 1
MG/ML
sirolimus
BRAND
RHEUMATREX TAB 2.5 MG
methotrexate sodium
(antirheumatic)
BRAND
Sirolimus
Sirolimus (TAB 0.5 MG, TAB 1
MG, TAB 2 MG)
generic
Hecoria
Tacrolimus (CAP 0.5 MG, CAP
1 MG, CAP 5 MG)
generic
Rheumatrex
COVERAGE
generic
IMMUNIZING AGENTS, PASSIVE
HyperRHO S/D
RhoGAM UltraFiltered Plus
HYPERRHO S/D SOLN
PRSYR 1500 UNIT
rho d immune globulin (human)
BRAND
RHOGAM ULTRA-FILTERED
PLUS SOLN PRSYR 1500
UNIT
rho d immune globulin (human)
BRAND
Leflunomide (TAB 10 MG, TAB
20 MG)
generic
MDD
1 per day
IMMUNOMODULATORS
Leflunomide
INFLAMMATORY BOWEL DISEASE AGENTS
AMINOSALICYLATES
Asacol
ASACOL TAB DR 400 MG
mesalamine
BRAND
MDD
12 per day
Balsalazide Disodium
balsalazide disodium cap 750
mg
generic
MDD
9 per day
Delzicol
DELZICOL CAP DR 400 MG
mesalamine
BRAND
MDD
6 per day
Pentasa
Mesalamine (CAP ER 250 MG,
CAP ER 500 MG)
mesalamine
BRAND
MDD
8 per day
Mesalamine
mesalamine enema 4 gm
generic
MDD
60 per day
SfRowasa
SFROWASA ENEMA 4
GM/60ML
mesalamine
BRAND
PAGE 116
BRAND NAME
COVERAGE
Hydrocortisone
hydrocortisone enema 100
mg/60ml
generic
Proctocream HC
hydrocortisone rectal cream
2.5%
generic
Sulfasalazine (TAB 500 MG,
TAB DELAYED RELEASE 500
MG)
generic
GLUCOCORTICOIDS
SULFONAMIDES
SulfaSALAzine
METABOLIC BONE DISEASE AGENTS
Alendronate Sodium
Alendronate Sodium (TAB 35
MG, TAB 70 MG)
generic
MDD
0.15 per day
Alendronate Sodium
Alendronate Sodium (TAB 5
generic
MDD
1 per day
Alendronate Sodium
alendronate sodium oral soln
70 mg/75ml
generic
MDD
10.8 per day
Calcitonin (Salmon)
calcitonin (salmon) nasal soln
200 unit/act
generic
MPL
1 / claim
Calcitriol
Calcitriol (CAP 0.25 MCG, CAP
0.5 MCG)
generic
Etidronate Disodium
Etidronate Disodium (TAB 200
MG, TAB 400 MG)
generic
Miacalcin
MIACALCIN SOLUTION 200
UNIT/ML
calcitonin (salmon)
BRAND
QL
2 / claim
Risedronate Sodium (TAB 35
MG, TAB DELAYED RELEASE
35 MG)
QL
generic
4 / 28 days
Risedronate Sodium
Risedronate Sodium
Risedronate Sodium (TAB 5
MG, TAB 30 MG)
PA
PA
generic
MDD
1 per day
MISCELLANEOUS THERAPEUTIC AGENTS
Curity AMD
Antimicrobial Spnge
- PADS 4" X 4"***
BRAND
AMD Foam Dressing
Topsheet
- PADS 4" X 4"***
BRAND
Excilon AMD Drain
Sponges
- PADS 4" X 4"***
BRAND
PAGE 117
BRAND NAME
Ora-Blend SF
oral vehicles
Flavor Blend
oral vehicles
BRAND
Suspension Vehicle
generic
PCCA-Plus
oral vehicles
BRAND
Ora-Blend
oral vehicles
BRAND
Syrup Vehicle SF
*oral vehicles - syrup***
generic
AeroChamber Mini
Chamber
AEROCHAMBER MINI
CHAMBER DEVICE
spacer/aerosol-holding
chambers
BRAND
QL
2 / 360 days
AeroChamber MV
AEROCHAMBER MV MISC
chambers
BRAND
QL
2 / 360 days
AeroChamber Plus
Flo-Vu Large
AEROCHAMBER PLUS FLOVU LARGE MISC
chambers
BRAND
QL
2 / 360 days
AeroChamber Plus
Flo-Vu Medium
AEROCHAMBER PLUS FLOVU MEDIUM MISC
chambers
BRAND
QL
2 / 360 days
AeroChamber Plus
Flo-Vu
AEROCHAMBER PLUS FLOVU MISC
chambers
BRAND
QL
2 / 360 days
AeroChamber Plus
Flo-Vu Small
AEROCHAMBER PLUS FLOVU SMALL MISC
chambers
BRAND
QL
2 / 360 days
AeroChamber Plus
Flo-Vu w/Mask
AEROCHAMBER PLUS FLOVU W/MASK MISC
chambers
BRAND
QL
2 / 360 days
AeroChamber Plus
Flow VU
AEROCHAMBER PLUS FLOW
VU MISC
chambers
BRAND
QL
2 / 360 days
AeroChamber
w/FLOWSIGnal
AEROCHAMBER
W/FLOWSIGNAL MISC
chambers
BRAND
QL
2 / 360 days
PAGE 118
COVERAGE
BRAND
BRAND NAME
AeroChamber Z-Stat
Plus Chambr
AEROCHAMBER Z-STAT
PLUS CHAMBR MISC
chambers
AeroChamber Z-Stat
Plus
COVERAGE
BRAND
QL
2 / 360 days
AEROCHAMBER Z-STAT
PLUS MISC
chambers
BRAND
QL
2 / 360 days
AeroChamber Z-Stat
Plus/Large
AEROCHAMBER Z-STAT
PLUS/LARGE MISC
chambers
BRAND
QL
2 / 360 days
AeroChamber Z-Stat
Plus/Medium
AEROCHAMBER Z-STAT
PLUS/MEDIUM MISC
chambers
BRAND
QL
2 / 360 days
AeroChamber Z-Stat
Plus/Small
AEROCHAMBER Z-STAT
PLUS/SMALL MISC
chambers
BRAND
QL
2 / 360 days
ALPRAZolam
alprazolam (bulk) powder
generic
Arginine HCl
arginine hcl (bulk) powder
generic
L-Arginine
arginine powder
generic
benztropine mesylate powder
generic
BuPROPion HCl
Bupropion HCl (Bulk) ((BULK)
POWDER, POWDER)
bupropion hcl (bulk)
BRAND
BusPIRone HCl
buspirone hcl powder
generic
CarBAMazepine
Carbamazepine (POWDER,
POWDER)
carbamazepine
BRAND
Chloral Hydrate
chloral hydrate crystals
generic
ChlorproMAZINE HCl
chlorpromazine hcl powder
generic
CloNIDine HCl
Clonidine HCl (POWDER,
POWDER)
clonidine hcl
BRAND
Cyproheptadine HCl
cyproheptadine hcl (bulk)
powder
generic
Desipramine HCl
desipramine hcl powder
generic
Dexmedetomidine
HCl
dexmedetomidine hcl inj 200
mcg/2ml (for iv infusion)
generic
PAGE 119
BRAND NAME
Ortho Diaphragm AllFlex
Diaphragm Arc-Spring
(DIAPHRAGM DIAPHRAGM
65, DIAPHRAGM
DIAPHRAGM 70,
DIAPHRAGM DIAPHRAGM
75, DIAPHRAGM
DIAPHRAGM 80)
diaphragm arc-spring
COVERAGE
DiazePAM
diazepam (bulk) powder
generic
Doxepin HCl
doxepin hcl powder
generic
Droperidol
droperidol powder
generic
EasiVent Mask Large
EASIVENT MASK LARGE
MISC
chambers
EasiVent Mask
Medium
EasiVent Mask Small
QL
1 / 365 days
BRAND
QL
2 / 360 days
EASIVENT MASK MEDIUM
MISC
chambers
BRAND
QL
2 / 360 days
EASIVENT MASK SMALL
MISC
chambers
BRAND
QL
2 / 360 days
EASIVENT MISC
chambers
BRAND
QL
2 / 360 days
Flavor Sweet
FLAVOR SWEET SYRUP
oral vehicles
BRAND
Flexichamber
FLEXICHAMBER DEVICE
chambers
BRAND
QL
2 / 360 days
FLUoxetine HCl
fluoxetine hcl (bulk) powder
generic
Formadon
formaldehyde solution 10%
generic
QL
90 / claim
Bioguard Gauze
Sponges
PADS 4" 4"***)
BRAND
AMD Foam Dressing
PADS 4" 4"***)
BRAND
hydroxyzine hcl (bulk) powder
generic
EasiVent
HydrOXYzine HCl
PAGE 120
BRAND
BRAND NAME
HydrOXYzine
Pamoate
hydroxyzine pamoate powder
COVERAGE
Imipramine HCl
imipramine hcl powder
generic
InspiraChamber/Larg
e
INSPIRACHAMBER/LARGE
DEVICE
chambers
BRAND
QL
2 / 360 days
InspiraChamber/Medi
um
INSPIRACHAMBER/MEDIUM
DEVICE
chambers
BRAND
QL
2 / 360 days
InspiraChamber/Mout
hpiece
INSPIRACHAMBER/MOUTHPI
ECE DEVICE
chambers
BRAND
QL
2 / 360 days
InspiraChamber/Smal
l
INSPIRACHAMBER/SMALL
DEVICE
chambers
BRAND
QL
2 / 360 days
Inspirease Bags
INSPIREASE BAGS MISC
chamber supplies - bags
BRAND
QL
3 / 180 days
INSPIREASE MISC
chambers
BRAND
QL
2 / 360 days
Inspirease Reservoir
Bags
INSPIREASE RESERVOIR
BAGS MISC
chamber supplies - bags
BRAND
QL
3 / 180 days
L-Arginine HCl
L-ARGININE HCL POWDER
arginine hcl (bulk)
BRAND
LiteAire
LITEAIRE DEVICE
chambers
BRAND
QL
2 / 360 days
Lithium Carbonate
lithium carbonate powder
generic
LORazepam
lorazepam (bulk) powder
generic
Methylergonovine
Maleate
methylergonovine maleate tab
0.2 mg
generic
Microchamber
MICROCHAMBER MISC
chambers
BRAND
QL
2 / 360 days
Nortriptyline HCl (POWDER,
POWDER)
nortriptyline hcl
BRAND
Inspirease
Nortriptyline HCl
PAGE 121
generic
BRAND NAME
Ora-Sweet SF
ORA-SWEET SF SYRUP
oral vehicles
COVERAGE
Ora-Sweet
ORA-SWEET SYRUP
oral vehicles
BRAND
PCCA Sweet-SF
PCCA SWEET-SF SYRUP
oral vehicles
BRAND
PCCA Syrup Vehicle
PCCA SYRUP VEHICLE
SYRUP
oral vehicles
BRAND
BRAND
PENTobarbital
Sodium
pentobarbital sodium powder
Phenelzine Sulfate
phenelzine sulfate (bulk)
powder
generic
PHENobarbital
phenobarbital powder
generic
Pocket Chamber
POCKET CHAMBER DEVICE
chambers
BRAND
Prochlorperazine
Maleate
prochlorperazine maleate
powder
generic
Propranolol HCl
Propranolol HCl (POWDER,
POWDER)
propranolol hcl
BRAND
RITEFLO DEVICE
chambers
BRAND
Selegiline HCl
selegiline hcl powder
generic
Sertraline HCl
Sertraline HCl (Bulk) ((BULK)
POWDER, POWDER)
sertraline hcl (bulk)
BRAND
Sorbitol
sorbitol solution (bulk)
generic
OptiHaler
Spacer/Aerosol-Holding
Chambers (DEVICE, MISC)
chambers
BRAND
Syrpalta (Red)
SYRPALTA (RED) SYRUP
oral vehicles
BRAND
Syrpalta
SYRPALTA SYRUP
oral vehicles
BRAND
TraZODone HCl
trazodone hcl powder
generic
trimipramine maleate powder
generic
Tryptophan
tryptophan powder
generic
RiteFlo
PAGE 122
generic
QL
2 / 360 days
QL
2 / 360 days
QL
2 / 360 days
BRAND NAME
Sodium Valproate
Valproate Sodium (Bulk)
((BULK) POWDER, POWDER)
COVERAGE
Valved Holding
Chamber
VALVED HOLDING
CHAMBER DEVICE
chambers
BRAND
VersaFree
VERSAFREE SYRUP
oral vehicles
BRAND
VersaPlus
VERSAPLUS SYRUP
oral vehicles
BRAND
Vistogard
VISTOGARD PACKET 10 GM
uridine triacetate (emergency
treatment)
BRAND
Vortex Valved
Holding Chamber
VORTEX VALVED HOLDING
CHAMBER DEVICE
chambers
Watchhaler
WATCHHALER DEVICE
chambers
generic
QL
2 / 360 days
BRAND
QL
2 / 360 days
BRAND
QL
2 / 360 days
QL
4 / 31 days
MPL
1 / 31 days
1 / 31 days
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS, OTHER
Atropine Sulfate
atropine sulfate ophth soln 1%
generic
AK-Poly-Bac
bacitracin-polymyxin b ophth
oint
generic
Blephamide S.O.P.
BLEPHAMIDE S.O.P.
OINTMENT 10-0.2 %
sulfacetamide sodprednisolone
BRAND
BLEPHAMIDE SUSPENSION
10-0.2 %
sulfacetamide sodprednisolone
BRAND
Cyclopentolate HCl
Cyclopentolate HCl (SOLN
0.5%, SOLN 1%)
generic
Cyclopentolate HCl
cyclopentolate hcl ophth soln
2%
generic
MPL
Isopto Homatropine
ISOPTO HOMATROPINE
SOLUTION 2 %
homatropine hbr
BRAND
QL
naphazoline hcl ophth soln
0.1%
generic
Blephamide
Naphazoline HCl
PAGE 123
15 / 31 days
BRAND NAME
Neomycin-Bacitracin
Zn-Polymyx
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op
oin
Neomycin-PolymyxinGramicidin
COVERAGE
generic
QL
neomycin-polymy-gramicid op
sol 1.75-10000-0.025mg-untmg/ml
generic
MPL
Neomycin-PolymyxinDexameth
neomycin-polymyxindexamethasone ophth oint
0.1%
generic
QL
4 / 31 days
Neomycin-PolymyxinDexameth
neomycin-polymyxindexamethasone ophth susp
0.1%
generic
QL
10 / 31 days
Neomycin-PolymyxinHC
neomycin-polymyxin-hc ophth
susp
generic
QL
15 / 31 days
Phenylephrine HCl
phenylephrine hcl ophth soln
2.5%
generic
QL
5 / 31 days
Polymyxin BTrimethoprim
polymyxin b-trimethoprim ophth
soln 10000 unit/ml-0.1%
QL
generic
10 / 31 days
Pred-G
4 / 31 days
1 / claim
MPL
1 / claim
1 / claim
PRED-G SUSPENSION 0.3-1
%
gentamicin-prednisolone
acetate
BRAND
MPL
SulfacetamidePrednisolone
sulfacetamide sodiumprednisolone ophth soln 100.23(0.25)%
generic
QL
TobramycinDexamethasone
tobramycin-dexamethasone
ophth susp 0.3-0.1%
generic
MPL
1 / 31 days
Tropicamide
Tropicamide (SOLN 0.5%,
SOLN 1%)
generic
QL
5 / 31 days
10 / 31 days
OPHTHALMIC ANTI-ALLERGY AGENTS
Alocril
ALOCRIL SOLUTION 2 %
nedocromil sodium (ophth)
BRAND
ST
Alomide
ALOMIDE SOLUTION 0.1 %
lodoxamide tromethamine
QL
BRAND
10 / 31 days
ST
Azelastine HCl
azelastine hcl ophth soln
0.05%
generic
Cromolyn Sodium
cromolyn sodium ophth soln
4%
generic
QL
6 / 31 days
QL
10 / 31 days
MPL
PAGE 124
1 / claim
BRAND NAME
COVERAGE
OPHTHALMIC ANTI-INFLAMMATORIES
Dexamethasone
Sodium Phosphate
dexamethasone sodium
phosphate ophth soln 0.1%
generic
Diclofenac Sodium
diclofenac sodium ophth soln
0.1%
generic
QL
3 / 31 days
Fluorometholone
fluorometholone ophth susp
0.1%
generic
MPL
1 / 31 days
Flurbiprofen Sodium
flurbiprofen sodium ophth soln
0.03%
generic
QL
5 / 31 days
FML
FML OINTMENT 0.1 %
fluorometholone (ophth)
BRAND
QL
4 / 31 days
Ketorolac
Tromethamine
ketorolac tromethamine ophth
soln 0.4%
generic
MFL
1 / 30 days
Ketorolac
Tromethamine
ketorolac tromethamine ophth
soln 0.5%
generic
MPL
1 / 31 days
Nevanac
NEVANAC SUSPENSION 0.1
%
nepafenac
BRAND
PRED MILD SUSPENSION
0.12 %
prednisolone acetate (ophth)
BRAND
QL
PrednisoLONE
Acetate
prednisolone acetate ophth
susp 1%
generic
MPL
1 / 31 days
PrednisoLONE
Sodium Phosphate
PREDNISOLONE SODIUM
PHOSPHATE SOLUTION 1 %
prednisolone sodium
phosphate (ophth)
BRAND
MPL
1 / 31 days
Vexol
VEXOL SUSPENSION 1 %
rimexolone
BRAND
Pred Mild
QL
3 / claim
PA
10 / 31 days
OPHTHALMIC ANTIGLAUCOMA AGENTS
Apraclonidine HCl
apraclonidine hcl ophth soln
0.5% (base equivalent)
generic
Azopt
AZOPT SUSPENSION 1 %
brinzolamide
BRAND
MPL
1 / 31 days
Betaxolol HCl
betaxolol hcl ophth soln 0.5%
generic
MPL
1 / 31 days
Brimonidine Tartrate
brimonidine tartrate ophth soln
0.2%
generic
MPL
1 / 31 days
Isopto Carbachol
Carbachol (Ophth) (SOLUTION
1.5 %, SOLUTION 3 %)
carbachol (ophth)
BRAND
PAGE 125
BRAND NAME
Carteolol HCl
carteolol hcl ophth soln 1%
COVERAGE
generic
MFL
Dorzolamide HCl
dorzolamide hcl ophth soln 2%
generic
QL
10 / 31 days
Dorzolamide HClTimolol Mal
dorzolamide hcl-timolol
maleate ophth soln 22.3-6.8
mg/ml
generic
QL
10 / 31 days
Iopidine
IOPIDINE SOLUTION 1 %
apraclonidine hcl
BRAND
Levobunolol HCl
levobunolol hcl ophth soln
0.25%
generic
MPL
Levobunolol HCl
levobunolol hcl ophth soln
0.5%
generic
QL
15 / 31 days
Methazolamide
Methazolamide (TAB 25 MG,
TAB 50 MG)
generic
Pilocarpine HCl
Pilocarpine HCl (SOLN 1%,
SOLN 2%, SOLN 4%)
generic
Timolol Maleate
Timolol Maleate (Ophth)
(SOLN 0.25%, SOLN 0.5%)
generic
QL
15 / 31 days
Timoptic Ocudose
(SOLUTION 0.25 %,
SOLUTION 0.5 %)
timolol maleate (ophth)
BRAND
QL
15 / 31 days
1 / 30 days
1 / claim
OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS
Latanoprost
latanoprost ophth soln 0.005%
generic
QL
5 / 31 days
Acetic Acid
acetic acid otic soln 2%
generic
QL
15 / 31 days
Aurodex
antipyrine-benzocaine otic soln
54-14 mg/ml (5.4-1.4%)
generic
MPL
1 / 30 days
Ciprodex
CIPRODEX SUSPENSION
0.3-0.1 %
ciprofloxacin-dexamethasone
QL
BRAND
8 / 31 days
Fluocinolone
Acetonide
fluocinolone acetonide (otic) oil
0.01%
Acetasol HC
OTIC AGENTS
MPL
1 / claim
generic
MPL
1 / 30 days
hydrocortisone w/ acetic acid
otic soln 1-2%
generic
QL
20 / 31 days
neomycin-polymyxin-hc otic
soln 1%
generic
QL
10 / claim
neomycin-polymyxin-hc otic
susp 3.5 mg/ml-10000 unit/ml1%
generic
MPL
PAGE 126
1 / claim
BRAND NAME
Cortic-ND
pramoxine-hc-chloroxylenol
otic soln 10-10-1 mg/ml
COVERAGE
generic
MPL
AEROSPAN AERO SOLN 80
MCG/ACT
flunisolide hfa
BRAND
QL
Budesonide (Inhalation) (AER
POW BA 90, AER POW BA
180)
budesonide (inhalation)
BRAND
MPL
1 / 30 days
ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS
Aerospan
Pulmicort Flexhaler
Budesonide
Budesonide
Budesonide (Inhalation) (SUSP
0.25, SUSP 0.5)
budesonide inhalation susp 1
mg/2ml
8.9 / 30 days
1 / claim
QL
120 / claim
AL
Up to 6 yrs old
QL
60 / 30 days
AL
Up to 6 yrs old
generic
generic
Budesonide
budesonide nasal susp 32
mcg/act
generic
QL
9 / 30 days
Flovent HFA
FLOVENT HFA AEROSOL 44
MCG/ACT
fluticasone propionate hfa
BRAND
QL
11 / 25 days
Flunisolide
flunisolide nasal soln 25
mcg/act (0.025%)
generic
QL
25 / 30 days
Flunisolide
flunisolide nasal soln 29
mcg/act (0.025%)
generic
Flovent Diskus
Fluticasone Propionate
(Inhalation) (AER POW BA 50,
AER POW BA 100, AER POW
BA 250)
fluticasone propionate
(inhalation)
BRAND
MDD
Fluticasone Propionate HFA
(AEROSOL 110, AEROSOL
220)
fluticasone propionate hfa
BRAND
QL
fluticasone propionate nasal
susp 50 mcg/act
generic
MPL
1 / claim
Azelastine HCl (0.1% (137,
0.15% (205.5)
generic
MPL
1 / 30 days
Flovent HFA
Fluticasone
Propionate
2 per day
12 / 25 days
ANTIHISTAMINES
Azelastine HCl
PAGE 127
BRAND NAME
Cetirizine HCl
cetirizine hcl oral soln 1 mg/ml
(5 mg/5ml)
COVERAGE
QL
240 / claim
AL
Up to 12 yrs old
generic
Cyproheptadine HCl
Cyproheptadine HCl (SYRUP 2
MG/5ML, TAB 4 MG)
generic
Dexchlorpheniramine
Maleate
DEXCHLORPHENIRAMINE
MALEATE SYRUP 2 MG/5ML
dexchlorpheniramine maleate
BRAND
DiphenhydrAMINE
HCl
diphenhydramine hcl cap 50
mg
generic
HydrOXYzine HCl
Hydroxyzine HCl (SOLN 25
MG/ML, SOLN 50 MG/ML)
generic
HydrOXYzine HCl
Hydroxyzine HCl (TAB 10 MG,
TAB 25 MG)
HydrOXYzine HCl
MDD
4 per day
generic
MDD
4 per day
hydroxyzine hcl syrup 10
mg/5ml
generic
MDD
100 per day
HydrOXYzine HCl
hydroxyzine hcl tab 50 mg
generic
MDD
8 per day
HydrOXYzine
Pamoate
Hydroxyzine Pamoate (CAP 25
MG, CAP 50 MG, CAP 100
MG)
generic
MDD
4 per day
Phenadoz
Promethazine HCl (SUPPOS
12.5 MG, SUPPOS 25 MG)
QL
12 / claim
AL
At least 2 yrs old
At least 2 yrs old
Promethazine HCl
generic
Promethazine HCl (SYRUP
6.25 MG/5ML, TAB 12.5 MG,
generic
AL
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
ipratropium bromide hfa
BRAND
MPL
2 / month
INCRUSE ELLIPTA AER POW
BA 62.5 MCG/INH
umeclidinium bromide
BRAND
MPL
1 / 30 days
Ipratropium Bromide
ipratropium bromide inhal soln
0.02%
generic
QL
375 / 25 days
Ipratropium Bromide
ipratropium bromide nasal soln
0.03% (21 mcg/spray)
generic
QL
31 / 30 days
ANTILEUKOTRIENES
Montelukast Sodium
BRONCHODILATORS, ANTICHOLINERGIC
Atrovent HFA
Incruse Ellipta
PAGE 128
BRAND NAME
Ipratropium Bromide
ipratropium bromide nasal soln
0.06% (42 mcg/spray)
Spiriva HandiHaler
Tudorza Pressair
COVERAGE
generic
QL
15 / 30 days
SPIRIVA HANDIHALER CAP
18 MCG
tiotropium bromide
monohydrate
BRAND
MPL
1 / claim
TUDORZA PRESSAIR AER
POW BA 400 MCG/ACT
aclidinium bromide
BRAND
MPL
1 / month
BRONCHODILATORS, SYMPATHOMIMETIC
Adrenaclick
ADRENACLICK SOLN A-INJ
0.3 MG/0.3ML
epinephrine
BRAND
Albuterol Sulfate (SOLN NEBU
0.5% (5 MG/ML), SYRUP 2
MG/5ML, TAB 2 MG, TAB 4
MG)
generic
Albuterol Sulfate
Albuterol Sulfate (SOLN NEBU
0.63, SOLN NEBU 1.25)
generic
Albuterol Sulfate ER
Albuterol Sulfate (TAB 4 MG,
TAB 8 MG)
generic
Albuterol Sulfate
albuterol sulfate soln nebu
0.083% (2.5 mg/3ml)
generic
Auvi-Q
AUVI-Q SOLN A-INJ 0.3
MG/0.3ML
epinephrine
BRAND
EPINEPHRINE SOLN A-INJ
0.3 MG/0.3ML
epinephrine
BRAND
EPIPEN 2-PAK SOLN A-INJ
0.3 MG/0.3ML
epinephrine
BRAND
EPIPEN JR 2-PAK SOLN AINJ 0.15 MG/0.3ML
epinephrine
BRAND
EPIPEN JR SOLN A-INJ 0.15
MG/0.3ML
epinephrine
BRAND
EPIPEN SOLN A-INJ 0.3
MG/0.3ML
epinephrine
BRAND
FORADIL AEROLIZER CAP
12 MCG
formoterol fumarate
BRAND
Albuterol Sulfate
EPINEPHrine
EpiPen 2-Pak
EpiPen Jr 2-Pak
EpiPen Jr
EpiPen
Foradil Aerolizer
PAGE 129
QL
MFL
2 / 30 days
2 / 365 days
QL
375 / 30 days
MDD
12.5 per day
QL
MFL
QL
MFL
QL
MFL
QL
MFL
QL
MFL
QL
2 / 30 days
2 / 365 days
2 / 30 days
2 / 365 days
2 / 30 days
2 / 365 days
2 / 30 days
2 / 365 days
2 / 30 days
2 / 365 days
2 / 30 days
MFL
2 / 365 days
MPL
1 / claim
BRAND NAME
Metaproterenol
Sulfate
Metaproterenol Sulfate (TAB
10 MG, TAB 20 MG)
Metaproterenol
Sulfate
metaproterenol sulfate syrup
10 mg/5ml
generic
MDD
30 per day
ProAir HFA
PROAIR HFA AERO SOLN
108 (90 BASE) MCG/ACT
albuterol sulfate
BRAND
MPL
2 / month
PROVENTIL HFA AERO
SOLN 108 (90 BASE)
MCG/ACT
albuterol sulfate
BRAND
MPL
2 / month
SEREVENT DISKUS AER
POW BA 50 MCG/DOSE
salmeterol xinafoate
BRAND
MPL
1 / claim
Terbutaline Sulfate
Terbutaline Sulfate (TAB 2.5
MG, TAB 5 MG)
generic
Twinject
TWINJECT SOLN A-INJ 0.3
MG/0.3ML
epinephrine
BRAND
VENTOLIN HFA AERO SOLN
108 (90 BASE) MCG/ACT
albuterol sulfate
BRAND
Proventil HFA
Serevent Diskus
Ventolin HFA
COVERAGE
generic
QL
2 / 30 days
MFL
2 / 365 days
MPL
2 / month
QL
45 / claim
MFL
2 / lifetime
PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE
Aminophylline
Aminophylline (TAB 100 MG,
TAB 200 MG)
generic
Caffeine Citrate
Caffeine Citrate (INJ 60
MG/ML, ORAL SOLN 60
MG/ML)
generic
ELIXOPHYLLIN ELIXIR 80
MG/15ML
theophylline
BRAND
Lufyllin
LUFYLLIN TAB 400 MG
dyphylline
BRAND
Theo-24
Theophylline (CAP ER 24H
400 MG, CAP ER 24H 100
MG, CAP ER 24H 200 MG,
CAP ER 24H 300 MG)
theophylline
BRAND
Theochron
Theophylline (TAB 100 MG,
generic
Theophylline ER
Theophylline (TAB 12HR 450
24HR 400 MG)
generic
Elixophyllin
PAGE 130
BRAND NAME
Theophylline
theophylline soln 80 mg/15ml
COVERAGE
generic
QL
475 / claim
AL
At least 10 yrs old
QL
30 / 30 days
AL
At least 10 yrs old
RESPIRATORY TRACT AGENTS, OTHER
Acetylcysteine
Acetylcysteine (SOLN 10%,
SOLN 20%)
generic
Benzonatate
benzonatate cap 100 mg
generic
Benzonatate
benzonatate cap 200 mg
generic
MFL
Symbicort
1 / 30 days
Budesonide-Formoterol
Fumarate Dihydrate
(AEROSOL 80-4.5, AEROSOL
160-4.5)
budesonide-formoterol
fumarate dihydrate
BRAND
QL
11 / claim
COMBIVENT AEROSOL 18103 MCG/ACT
ipratropium-albuterol
BRAND
MDD
1 per day
COMBIVENT RESPIMAT
AERO SOLN 20-100
MCG/ACT
ipratropium-albuterol
BRAND
QL
Cromolyn Sodium
cromolyn sodium soln nebu 20
mg/2ml
generic
MDD
Doxapram HCl
doxapram hcl inj 20 mg/ml
generic
Grastek
GRASTEK SL TAB 2800 BAU
timothy grass pollen allergen
extract
Combivent
Combivent Respimat
4 / 30 days
8 per day
ST
BRAND
AL
5 to 65 yrs old
MDD
1 per day
HydrocodoneHomatropine
hydrocodone w/ homatropine
syrup 5-1.5 mg/5ml
generic
Ipratropium-Albuterol
ipratropium-albuterol nebu soln
0.5-2.5(3) mg/3ml
generic
MDD
12 per day
Dulera
Mometasone FuroateFormoterol Fumarate Dihydrate
(AEROSOL 100-5, AEROSOL
200-5)
mometasone furoateformoterol fumarate dihydrate
BRAND
QL
13 / claim
Oralair Adult Sample
Kit
PAGE 131
ORALAIR ADULT SAMPLE
KIT SL TAB 300 IR
grass mixed pollens allergen
extract
ST
BRAND
AL
MDD
10 to 65 yrs old
1 per day
BRAND NAME
Oralair Adult Starter
Pack
Oralair Childrens
Starter Pack
Oralair
ORALAIR ADULT STARTER
PACK SL TAB 300 IR
extract
ORALAIR CHILDRENS
STARTER PACK SL TAB 100
IR
extract
ORALAIR SL TAB 300 IR
extract
COVERAGE
ST
BRAND
AL
MDD
10 to 65 yrs old
1 per day
ST
BRAND
AL
MDD
10 to 65 yrs old
3 per day
ST
BRAND
AL
MDD
10 to 65 yrs old
1 per day
Qual-Tussin
phenyleph-chlorphen w/ dm-gg
syrup 10-2-7.5-100 mg/5ml
generic
QL
248 / 31 days
PhenylephrineChlorphen-DM
generic
QL
240 / claim
Promethazine VC
promethazine & phenylephrine
syrup 6.25-5 mg/5ml
QL
generic
240 / 6 days
AL
At least 2 yrs old
QL
240 / claim
AL
At least 2 yrs old
QL
240 / claim
AL
At least 2 yrs old
PromethazineCodeine
Promethazine-DM
promethazine w/ codeine syrup
6.25-10 mg/5ml
promethazine-dm syrup 6.2515 mg/5ml
generic
generic
Bromfed DM
generic
QL
240 / claim
Carbofed DM
generic
QL
240 / claim
Novagest
Expectorant/Codeine
pseudoephedrine w/ cod-gg
soln 30-10-100 mg/5ml
generic
QL
240 / 6 days
Ragwitek
RAGWITEK SL TAB 12 AMB A
1-U
short ragweed pollen allergen
extract
BRAND
Sodium Chloride (Inhalant)
(SOLN NEBU 0.9%, SOLN
NEBU 3%, SOLN NEBU 10%)
generic
Sodium Chloride
ST
AL
MDD
18 to 65 yrs old
1 per day
SKELETAL MUSCLE RELAXANTS
Chlorzoxazone
PAGE 132
chlorzoxazone tab 500 mg
generic
BRAND NAME
Cyclobenzaprine HCl
cyclobenzaprine hcl tab 10 mg
COVERAGE
QL
generic
MDD
Cyclobenzaprine HCl
cyclobenzaprine hcl tab 5 mg
generic
Methocarbamol
Methocarbamol (TAB 500 MG,
TAB 750 MG)
generic
QL
93 / 31 days
3 per day
93 / 31 days
SLEEP DISORDER AGENTS
GABA RECEPTOR MODULATORS
Estazolam
Estazolam (TAB 1 MG, TAB 2
MG)
generic
MDD
1 per day
Eszopiclone
Eszopiclone (TAB 1 MG, TAB
2 MG, TAB 3 MG)
generic
MDD
1 per day
Quazepam
quazepam tab 15 mg
generic
MDD
1 per day
Temazepam
Temazepam (CAP 7.5 MG,
CAP 15 MG, CAP 22.5 MG,
CAP 30 MG)
generic
MDD
1 per day
Triazolam
Triazolam (TAB 0.125 MG,
TAB 0.25 MG)
generic
MDD
1 per day
Zaleplon
Zaleplon (CAP 5 MG, CAP 10
MG)
generic
MDD
2 per day
Zolpidem Tartrate
Zolpidem Tartrate (SL TAB
1.75 MG, SL TAB 3.5 MG, TAB
5 MG, TAB 10 MG)
generic
MDD
1 per day
Zolpidem Tartrate (SL TAB 5
MG, SL TAB 10 MG)
zolpidem tartrate
BRAND
MDD
1 per day
Zolpidem Tartrate ER
Zolpidem Tartrate (TAB 6.25
MG, TAB 12.5 MG)
generic
MDD
1 per day
Zolpimist
ZOLPIMIST SOLUTION 5
MG/ACT
zolpidem tartrate
BRAND
MDD
2 per day
Edluar
SLEEP DISORDERS, OTHER
Amytal Sodium
AMYTAL SODIUM RECON
SOLN 500 MG
amobarbital sodium
BRAND
Armodafinil
Armodafinil (TAB 150 MG, TAB
200 MG, TAB 250 MG)
generic
MDD
1 per day
Armodafinil
armodafinil tab 50 mg
generic
MDD
2 per day
PAGE 133
BRAND NAME
Butisol Sodium
BUTISOL SODIUM ELIXIR 30
MG/5ML
butabarbital sodium
COVERAGE
BRAND
MDD
15 per day
BUTISOL SODIUM TAB 30
MG
butabarbital sodium
BRAND
MDD
3 per day
BUTISOL SODIUM TAB 50
MG
butabarbital sodium
BRAND
MDD
2 per day
Doxepin HCl (Sleep) (TAB 3
MG, TAB 6 MG)
doxepin hcl (sleep)
BRAND
MDD
1 per day
Flurazepam HCl
Flurazepam HCl (CAP 15 MG,
CAP 30 MG)
generic
MDD
1 per day
Hetlioz
HETLIOZ CAP 20 MG
tasimelteon
BRAND
MDD
1 per day
Modafinil
modafinil tab 100 mg
generic
MDD
1 per day
Modafinil
modafinil tab 200 mg
generic
MDD
2 per day
Rozerem
ROZEREM TAB 8 MG
ramelteon
BRAND
MDD
1 per day
Seconal
SECONAL CAP 100 MG
secobarbital sodium
BRAND
Sentramodafin AM100
SENTRAMODAFIN AM-100
MISC 100 MG
modafinil & dietary
management product
BRAND
Belsomra
Suvorexant (TAB 5 MG, TAB
MG)
suvorexant
BRAND
MDD
1 per day
XYREM SOLUTION 500
MG/ML
sodium oxybate
BRAND
MDD
18 per day
Butisol Sodium
Butisol Sodium
Silenor
Xyrem
THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES
ELECTROLYTE/MINERAL MODIFIERS
Kionex
*sodium polystyrene sulfonate
powder**
generic
Chemet
CHEMET CAP 100 MG
succimer
BRAND
Jadenu
Deferasirox (TAB 90 MG, TAB
180 MG, TAB 360 MG)
deferasirox
BRAND
PAGE 134
PA
BRAND NAME
Sodium Polystyrene
Sulfonate
sodium polystyrene sulfonate
oral susp 15 gm/60ml
COVERAGE
generic
ELECTROLYTE/MINERAL REPLACEMENT
Ferrocite Plus
*ferrous fumarate-fa-b
complex-c-zn-mg-mn-cu tab
106-1 mg***
generic
KLOR-CON M15 TAB ER 15
MEQ
potassium chloride
microencapsulated crystals cr
BRAND
Klor-Con/EF
potassium bicarbonate effer
tab 25 meq
generic
Klor-Con
Potassium Chloride (POWDER
PACKET 20, TAB CR 8 (600
MG))
generic
Potassium Chloride
Potassium Chloride (SOLN
10% (20, SOLN 20% (40)
generic
Potassium Chloride
ER
potassium chloride cap cr 10
meq
generic
Potassium Chloride
ER
potassium chloride cap cr 8
meq
generic
Potassium Chloride
Crys ER
Potassium Chloride
Microencapsulated Crystals
CR (MIOENCAPSULATED YS
TAB 10, MIOENCAPSULATED
YS TAB 20)
generic
Klor-Con 10
potassium chloride tab cr 10
meq
generic
Sodium Chloride
Sodium Chloride (INJ, IV
SOLN)
generic
Fluoritab
Sodium Fluoride (CHEW TAB
0.25 MG F 0.55 MG, CHEW
TAB 0.5 MG F 1.1 MG, CHEW
TAB 1 MG F 2.2 MG)
generic
AL
Up to 15 yrs old
Karidium
sodium fluoride soln 0.125
mg/drop f (0.275 mg/drop naf)
generic
AL
Up to 15 yrs old
Sodium Fluoride
sodium fluoride soln 0.5 mg/ml
f (from 1.1 mg/ml naf)
generic
AL
Up to 15 yrs old
Zinc Sulfate
zinc sulfate cap 220 mg (50 mg
elemental zn)
generic
QL
100 / 30 days
Triphrocaps
*b-complex w/ c & folic acid
cap 1 mg***
generic
MDD
Klor-Con M15
PAGE 135
MDD
1 per day
MDD
1 per day
1 per day
BRAND NAME
V-C Forte
cap**
Strovite Plus
tab**
generic
QL
31 / 31 days
Vitamax Pediatric
minerals & c drops 45 mg/ml**
generic
AL
Up to 18 yrs old
Multi-Vit/Fluoride/Iron
fl-fe drops 0.25-10 mg/ml**
QL
generic
50 / claim
AL
Up to 21 yrs old
AL
Up to 21 yrs old
Multi-Vitamin/Fluoride
fluoride chew tab 0.5 mg***
COVERAGE
generic
generic
MDD
1 per day
TriVitamin/Iron/Fluoride
*pediatric vitamins acd fluoride
& fe drops 0.25-10 mg/ml***
generic
Cyanocobalamin
cyanocobalamin inj 1000
mcg/ml
generic
Vitamin D
(Ergocalciferol)
ergocalciferol cap 50000 unit
LevOCARNitine
levocarnitine oral soln 1
gm/10ml (10%)
generic
MDD
30 per day
LevOCARNitine
levocarnitine tab 330 mg
generic
MDD
3 per day
Multi-Vitamin/Fluoride
Pediatric Multivitamins w/Fl
(CHEW TAB 0.25, CHEW TAB
1)
generic
QL
50 / claim
AL
Up to 21 yrs old
QL
50 / claim
AL
Up to 21 yrs old
QL
31 / 31 days
Multi-Vit/Fluoride
Tri-Vit/Fluoride
(SOLN 0.25, SOLN 0.5)
QL
10 / 270 days
generic
generic
Pediatric Vitamins ACD w/
Fluoride (SOLN 0.25, SOLN
0.5)
generic
Tryptophan
tryptophan cap 500 mg
generic
Vitaroca Plus
VITAROCA PLUS TAB
BRAND
ANTISPASTICITY AGENTS
Baclofen
Baclofen (TAB 10 MG, TAB 20
MG)
generic
TiZANidine HCl
Tizanidine HCl (TAB 2 MG
(BASE EQUIVALENT), TAB 2
MG, TAB 4 MG (BASE
EQUIVALENT), TAB 4 MG)
generic
PAGE 136
LIST OF COVERED SPECIALTY MEDICATIONS
BRAND NAME
COVERAGE
ANTINEOPLASTICS
MOLECULAR TARGET INHIBITORS
Cotellic
COTELLIC TAB 20 MG
cobimetinib fumarate
PA
BRAND
S
Ninlaro
Ixazomib Citrate (CAP 2.3 MG,
CAP 3 MG, CAP 4 MG)
ixazomib citrate
Specialty Drug
PA
BRAND
S
Specialty Drug
MULTIPLE SCLEROSIS AGENTS
Avonex
AVONEX KIT 30 MCG
interferon beta-1a
PA
BRAND
S
Avonex Pen
Avonex Prefilled
Copaxone
Gilenya
AVONEX PEN AUT-IJ KIT 30
MCG/0.5ML
interferon beta-1a
BRAND
AVONEX PREFILLED PREF
SY KT 30 MCG/0.5ML
interferon beta-1a
BRAND
COPAXONE SOLN PRSYR 40
MG/ML
glatiramer acetate
BRAND
GILENYA CAP 0.5 MG
fingolimod hcl
PA
S
glatiramer acetate soln prefilled
syringe 20 mg/ml
S
Plegridy Starter
Pack
PAGE 137
Specialty Drug
PA
S
Specialty Drug
PA
BRAND
Specialty Drug
PA
generic
S
Plegridy
Specialty Drug
PA
S
Glatopa
Specialty Drug
Peginterferon Beta-1a (SOLN
PEN 125, SOLN PRSYR 125)
peginterferon beta-1a
BRAND
Peginterferon Beta-1a (PACK
SOLN PEN 63 94, PACK
SOLN PRSYR 63 94)
peginterferon beta-1a
BRAND
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
BRAND NAME
Tecfidera
Dimethyl Fumarate (CAP DR
120 MG, CAP DR 240 MG,
MISC 120 & 240 MG)
dimethyl fumarate
COVERAGE
PA
BRAND
S
Specialty Drug
Cholbam
Cholic Acid (CAP 50 MG, CAP
250 MG)
cholic acid
PA
BRAND
MDD
S
5 per day
Specialty Drug
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)
Norditropin
Norditropin FlexPro
Norditropin
NordiFlex Pen
Omnitrope
Somatropin (SOLUTION 5,
SOLUTION 15)
somatropin
BRAND
Somatropin (SOLUTION 5
MG/1.5ML, SOLUTION 10
MG/3ML)
somatropin
BRAND
Somatropin (PEN SOLUTION
5 MG/1.5ML, PEN SOLUTION
10 MG/1.5ML, PEN
SOLUTION 15 MG/1.5ML,
PEN SOLUTION 30 MG/3ML)
somatropin
BRAND
Somatropin (SOLUTION 5,
SOLUTION 10)
somatropin
BRAND
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
IMMUNOLOGICAL AGENTS
IMMUNE SUPPRESSANTS
Enbrel
Enbrel SureClick
PAGE 138
Etanercept (SOLN PRSYR 25
MG/0.5ML, SOLN PRSYR 50
MG/ML)
etanercept
BRAND
ENBREL SURECLICK SOLN
A-INJ 50 MG/ML
etanercept
BRAND
PA
S
Specialty Drug
PA
S
Specialty Drug
BRAND NAME
Humira
Humira Pediatric
Crohns Start
Humira Pen
Humira Pen-Crohns
Starter
Humira PenPsoriasis Starter
Adalimumab (PREF SY KT 10
MG/0.2ML, PREF SY KT 20
MG/0.4ML, PREF SY KT 40
MG/0.8ML)
adalimumab
COVERAGE
PA
BRAND
S
HUMIRA PEDIATRIC
CROHNS START PREF SY
KT 40 MG/0.8ML
adalimumab
BRAND
HUMIRA PEN PEN KIT 40
MG/0.8ML
adalimumab
BRAND
HUMIRA PEN-CROHNS
STARTER PEN KIT 40
MG/0.8ML
adalimumab
BRAND
HUMIRA PEN-PSORIASIS
STARTER PEN KIT 40
MG/0.8ML
adalimumab
BRAND
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
PA
S
Specialty Drug
CYSTIC FIBROSIS AGENTS
Kalydeco
Orkambi
Ivacaftor (PACKET 50 MG,
PACKET 75 MG, TAB 150 MG)
ivacaftor
ORKAMBI TAB 200-125 MG
lumacaftor-ivacaftor
PA
BRAND
S
PA
BRAND
S
Tobramycin
tobramycin nebu soln 300
mg/5ml
Specialty Drug
PA
generic
S
PAGE 139
Specialty Drug
Specialty Drug
Index of covered drugs
Aerospan
4
4-N-1
15
Agrylin
87
Aimsco Lubricated
28
Albuterol Sulfate
A
Abacavir Sulfate
127
129,130
Alendronate Sodium
76,77
117
Alkeran
67
Abacavir Sulfate-Lamivudine
76
Allevyn Plus Cavity
23
Abacavir-Dolutegravir-Lamivudine
77
Allevyn Thin
24
Abilify
71
Allopurinol
65
Abilify Discmelt
71
Alocril
Abilify Maintena
71
Aloe Vesta Skin Conditioner
Abreva
13
Alomide
124
Acebutolol HCl
90
Alora
110
Acetaminophen
12,24,25,28,31
124
Alprazolam
79,80
Acetaminophen w/ Codeine
43
Alprazolam (Bulk)
Acetaminophen w/ DM
33
ALPRAZolam Intensol
Acetazolamide
94
Alprazolam-Dietary Management Product
Acetic Acid (Otic)
Acetylcarnitine HCl
126
25
13
119
80
80,81
Alum & Mag Hydrox-Simethicone
17
Aluminum Hydroxide Gel
17
69
Acetylcysteine
131
Amantadine HCl
Aclidinium Bromide
129
AMD Foam Dressing
120
Acne Medication 5
13
AMD Foam Dressing Topsheet
117
Acyclovir
79
Amiloride & Hydrochlorothiazide
93
Acyclovir Topical
79
Amiloride HCl
95
87
Adalimumab
139
Aminocaproic Acid
Adrenaclick
129
Aminophylline
Adzenys XR-ODT
130
97
Amiodarone HCl
89
AeroChamber Mini Chamber
118
Amitriptyline HCl
62
AeroChamber MV
118
Amitriptyline HCl & Dietary Management Product
63
AeroChamber Plus Flo-Vu
118
Amlodipine Besylate
91
AeroChamber Plus Flo-Vu Large
118
Amlodipine Besylate-Benazepril HCl
93
AeroChamber Plus Flo-Vu Medium
118
Amobarbital Sodium
AeroChamber Plus Flo-Vu Small
118
Amoxapine
62
AeroChamber Plus Flo-Vu w/Mask
118
Amoxicillin
49
AeroChamber Plus Flow VU
118
AeroChamber w/FLOWSIGnal
118
Amphetamine
97
AeroChamber Z-Stat Plus
119
Amphetamine Sulfate
98
AeroChamber Z-Stat Plus Chambr
119
Amphetamine-Dextroamphetamine
97
AeroChamber Z-Stat Plus/Large
119
Ampicillin
50
AeroChamber Z-Stat Plus/Medium
119
Amytal Sodium
133
AeroChamber Z-Stat Plus/Small
119
Anagrelide HCl
87
PAGE 140
133
49,50
Anastrozole
68
Aveeno Intense Relief
15
Androderm
109
Avonex
137
Androxy
109
Avonex Pen
137
Antipyrine-Benzocaine
126
Avonex Prefilled
137
Apidra
83
Azasan
115
Apidra SoloStar
83
Azathioprine
115
Apixaban
86
Azelastine HCl
127
Aplenzin
58
Azelastine HCl (Ophth)
124
Appbutamone
57
Azithromycin
Apraclonidine HCl
125,126
Aptensio XR
99
Aptiom
55,56
Aptivus
77
Arginine
Arginine HCl (Bulk)
25,39,40,41,119
25,119,121
50
Azopt
125
B
B-Complex Vitamins
40
B-Complex w/ C & Folic Acid
135
Bacitracin (Ophthalmic)
47
Aripiprazole
71
Bacitracin (Topical)
13
Aripiprazole Lauroxil
71
Bacitracin Zinc
13
Aristada
71
Bacitracin-Polymyxin B
12
Armodafinil
133
Bacitracin-Polymyxin B (Ophth)
123
Armour Thyroid
114
Baclofen
136
116
Artemether-Lumefantrine
68
Balsalazide Disodium
Artificial Tear Ointment
31
Band-Aid Gauze Large
23
Artificial Tear Solution
31
Band-Aid Gauze Medium
21
Artificial Tears
32
Band-Aid Gauze Small
20
Band-Aid Mirasorb Gauze Sponge
24
Banzel
56
Basis Facial Moisturizer
13
Asacol
116
Ascocid
40
Ascorbic Acid
39,40
Asenapine Maleate
71
Basis Overnight
13
Aspirin
10
Baza Cleanse & Protect
14
Aspirin Buffered (Cal Carb-Mag Carb-Mag Oxide)
10
Belsomra
Atazanavir Sulfate
77,78
134
Benazepril & Hydrochlorothiazide
93
89
Atazanavir Sulfate-Cobicistat
77
Benazepril HCl
Atenolol
90
Benzonatate
Atenolol & Chlorthalidone
93
Benzoyl Peroxide
Atomoxetine HCl
98
Atorvastatin Calcium
95
Betamethasone Dipropionate Augmented
107
Atripla
75
Betamethasone Valerate
107
131
13,14,101
69,119
Atropine Sulfate (Ophthalmic)
123
Betaxolol HCl (Ophth)
125
Atrovent HFA
128
Bethanechol Chloride
106
Augmentin
Auvi-Q
PAGE 141
50
129
Biatain Adhesive Foam Dressing
21
Biatain Foam Dressing
22
Bicalutamide
Bioguard Gauze Sponges
67
Byetta 10 MCG Pen
82
120
Byetta 5 MCG Pen
82
Biotin
40
Bisacodyl
18
C
Bismuth Subsalicylate
17
Caffeine Citrate
Bisoprolol & Hydrochlorothiazide
93
Calci-Chew
Bisoprolol Fumarate
90
Calcipotriene
101
130
36
Blephamide
123
Calcitonin (Salmon)
117
Blephamide S.O.P.
123
Calcitriol
117
Bordered Gauze
22
Calcium
37
Brexpiprazole
71
Calcium Acetate (Phosphate Binder)
Brilinta
88
Calcium Carbonate
Brimonidine Tartrate
Brintellix
Brinzolamide
125
62
125
107
36,37
Calcium Carbonate (Antacid)
17
Calcium Carbonate-Cholecalciferol
37
Calcium Carbonate-Mag Hydrox
17
Bromocriptine Mesylate
69
Calcium Carbonate-Vitamin D
Brompheniramine & Phenyleph
33
Calcium Citrate
37
Brompheniramine & Pseudoeph
33
Calcium Polycarbophil
18
127
Calcium w/ Vitamin D
37
Calcium-Ergocalciferol
38
Camphor & Menthol
14
Budesonide (Inhalation)
Budesonide (Nasal)
Budesonide-Formoterol Fumarate Dihydrate
32,127
131
37,38
Bumetanide
94
Capsaicin
14
Buprenorphine HCl-Naloxone HCl Dihydrate
45
Captopril
89
Captopril & Hydrochlorothiazide
93
Bupropion HCl
57,58
BuPROPion HCl
119
Carafate
105
Bupropion HCl (Bulk)
119
Carbachol (Ophth)
125
Bupropion HCl (Smoking Deterrent)
46
Carbamazepine
56,119
Bupropion HCl-Dietary Management Product
57
CarBAMazepine
119
Bupropion Hydrobromide
58
Carbamazepine (Antipsychotic)
81
Buspirone HCl
79
Carbamide Peroxide (Otic)
32
Carbidopa
69
Carbidopa-Levodopa
69
Buspirone HCl (Bulk)
Busulfan
119
67
Butabarbital Sodium
134
Carbonyl Iron
38
Butalbital-Acetaminophen
100
Carboxymethylcellulose Sodium (Ophth)
32
Butalbital-Acetaminophen-Caffeine
100
Cariprazine HCl
Butalbital-Acetaminophen-Caffeine w/ Codeine
Butalbital-Aspirin-Caffeine
Butalbital-Aspirin-Caffeine w/Cod
Butisol Sodium
43
42,100
43
134
CarraSmart
21
CarraSmart Foam
21
Carrington Moist Barrier/Zinc
13
Carrington Moisture Barrier
12
Butoconazole Nitrate (One Dose)
64
Carteolol HCl (Ophth)
Bydureon
81
Carvedilol
PAGE 142
71,74
126
90
Carvedilol Phosphate
90
Cimetidine HCl
104
Cavilon Durable Barrier
15
Ciprodex
126
Cavilon Emollient
14
Ciprofloxacin HCl
51
Cefaclor
48
Ciprofloxacin HCl (Ophth)
51
Cefadroxil
48
Ciprofloxacin-Dexamethasone
Cefdinir
48
Citalopram & Dietary Management Product
61
Citalopram Hydrobromide
59
Cefprozil
48,49
126
Ceftin
49
Clarithromycin
50
Ceftriaxone Sodium
49
Clean & Clear Advantage 3-in-1
14
Cefuroxime Axetil
49
Clemastine Fumarate
33
Celecoxib
42
Clindamycin HCl
47
Celontin
52
Clindamycin Palmitate Hydrochloride
47
Cephalexin
49
Clindamycin Phosphate (Topical)
47
Clindamycin Phosphate Vaginal
47
Cetirizine HCl
32,33,128
Cetirizine-Pseudoephedrine
33
Clindamycin Phosphate-Benzoyl Peroxide
101
Chantix
46
Clobazam
Chantix Continuing Month Pak
46
107
Chantix Starting Month Pak
46
Clobetasol Propionate Emollient Base
107
53
Chemet
134
Clomipramine HCl
62
Chloral Hydrate
119
Clonazepam
80
Chlorambucil
67
Clonidine HCl
Chlordiazepoxide HCl
80
CloNIDine HCl
Chlordiazepoxide-Amitriptyline
58
Clonidine HCl (ADHD)
98
Chlorhexidine Gluconate
25
Clopidogrel Bisulfate
87
Clorazepate Dipotassium
80
Chlorhexidine Gluconate (Mouth-Throat)
101
Chloroquine Phosphate
68
Clotrimazole (Topical)
Chlorothiazide
95
Clotrimazole Vaginal
Chlorpheniramine & Phenylephrine
33,34
88,119
119
11,64
11
Clotrimazole w/ Betamethasone
101
Chlorpheniramine & Pseudoeph
35
Clozapine
74
Chlorpheniramine Maleate
33
Coal Tar Extract
14
Coartem
68
Cobicistat
77
Chlorpromazine HCl
70,119
Chlorthalidone
95
Chlorzoxazone
132
Cobimetinib Fumarate
Cholbam
138
Codeine Sulfate
44
Colchicine
65
Cholecalciferol
20,40
137
Cholestyramine
96
Colchicine w/ Probenecid
65
96
Colestipol HCl
96
Cholic Acid
138
CombiPatch
110
Cilostazol
87
Combivent
131
Ciloxan
51
Combivent Respimat
131
Cimetidine
PAGE 143
18,104
Complera
75
Condoms Latex Lubricated - Male
25,26,27,28
Conjugated Estrogens-Medroxyprogesterone
Acetate
109,113
D
Dakin's Solution
28
Cool Bottoms
15
Dapagliflozin Propanediol
82
Copa Island Bordered Foam
22
Dapsone
66
Copa Plus Hydrophilic Foam
21
Darunavir Ethanolate
Copaxone
137
Coreg CR
90
Deferasirox
Corn Starch
14
Delavirdine Mesylate
77,78
Daytrana
99
134
75,76
Cortisone Acetate
107
Delzicol
116
Cotellic
137
Depo-SubQ Provera 104
113
Covrsite Cover Dressing
23
Dermacea Drain Sponges
21
Covrsite Plus Composite Dress
24
Dermacea Gauze Sponge
29
Dermacea IV Drain Sponges
30
Dermacea IV Sponges
20
Dermacea Non-Woven Sponges
28
Creon
Crixivan
Cromolyn Sodium
104
77
131
Cromolyn Sodium (Nasal)
28
Dermacea Type VII Gauze
29
Cromolyn Sodium (Ophth)
124
Dermacea X-Ray Sponges
23
Dermagran BC
13
DermaLevin Adhesive
22
76
Crotamiton
68
Cuprimine
106
Curex All-Purpose Sponges
22
Descovy
Curity All Purpose Sponges
28
Desipramine HCl
Curity AMD Antimicrobial Spnge
21,117
62,119
Desmopressin Acetate
109
Curity Cover Sponge
30
Desmopressin Acetate Refrigerated
109
Curity Dressing Sponges
22
Desmopressin Acetate Spray
109
Curity Gauze
29
Desmopressin Acetate Spray Refrigerated
109
Curity Gauze Sponge
29
Desogestrel & Ethinyl Estradiol
110
Curity Non-Adherent Strips
21
Desogestrel-Ethinyl Estradiol (Biphasic)
109
Curity Sponges
30
Desogestrel-Ethinyl Estradiol (Triphasic)
109
CVS Gauze
22
Desvenlafaxine
59
CVS Natural Fiber Supplement
18
Desvenlafaxine Fumarate
59
59
Cyanocobalamin
136
Desvenlafaxine Fumarate ER
Cyclobenzaprine HCl
133
Desvenlafaxine Succinate
Cyclopentolate HCl
123
Dexamethasone
107
Cyclophosphamide
67
Dexamethasone Sodium Phosphate
107
59,61
Cyclosporine
115
Dexamethasone Sodium Phosphate (Ophth)
125
Cyclosporine Modified (For Microemulsion)
115
Dexchlorpheniramine Maleate
128
Cymbalta
100
Dexmedetomidine HCl
119
Cyproheptadine HCl
128
Dexmethylphenidate HCl
Cyproheptadine HCl (Bulk)
119
97,98
Dextromethorphan Polistirex
34
PAGE 144
98
Dextromethorphan-Doxylamine-Acetaminophen
Dextromethorphan-Guaifenesin
34
34,36
Dolutegravir Sodium
75
Donepezil Hydrochloride
57
Dextromethorphan-Phenylephrine-Acetaminophen
34
Dorzolamide HCl
126
Dextrose (Diabetic Use)
12
Dorzolamide HCl-Timolol Maleate
126
Diaper Rash Products
12
Doxapram HCl
131
Diaphragm Arc-Spring
120
Doxazosin Mesylate
88
Diazepam
80
Doxepin HCl
DiazePAM
80
Doxepin HCl (Sleep)
134
Diazepam (Anticonvulsant)
53
Doxycycline Hyclate
52
Doxylamine Succinate (Sleep)
36
24
Diazepam (Bulk)
120
62,63,120
Diazepam-Dietary Management Product
80
Dressing Sponges
Dibucaine
14
Droperidol
Dibucaine (Rectal)
14
Drospirenone-Ethinyl Estradiol
Diclofenac Potassium
42
Droxia
67
Diclofenac Sodium
42
DryMax Extra
24
Diclofenac Sodium (Ophth)
Dicloxacillin Sodium
Dicyclomine HCl
125
50
104
70,120
110
Dulera
131
Duloxetine HCl
100
Durex Extra Sensitive
26
94
Didanosine
76
Dutoprol
Diflunisal
42
Dyphylline
Digoxin
93
Dihydroergotamine Mesylate
65
E
Dilantin
56
E.E.S. Granules
Diltiazem HCl
91
EasiVent
120
Diltiazem HCl Coated Beads
92
EasiVent Mask Large
120
Diltiazem HCl Extended Release Beads
92
EasiVent Mask Medium
120
Dimenhydrinate
11
EasiVent Mask Small
120
Ecallantide
115
Dimethicone (Topical)
Dimethyl Fumarate
Diphenhydramine HCl
13,14,15,16,17
138
33,128
64
ED Bron GP
34
36
Edluar
Diphenhydramine HCl (Topical)
15
Edurant
Dipyridamole
Disopyramide Phosphate
104
88
89,90
50
Econazole Nitrate
Diphenhydramine HCl (Sleep)
Diphenoxylate w/ Atropine
130
133
75
Efavirenz
75,76
Efavirenz-Emtricitabine-Tenofovir Disoproxil
Fumarate
75
Disulfiram
45
Effient
88
Divalproex Sodium
53
Eletriptan Hydrobromide
65
Docosanol
13
Elexa Natural Feel
28
Docusate Calcium
18
Elexa Stimulating
27
Docusate Sodium
18
Elexa Ultra Sensitive
27
Dofetilide
89
Elidel
PAGE 145
101
Eliquis
86
Erythromycin Base (Coated)
51
Elixophyllin
130
Erythromycin Ethylsuccinate
50
Ella
113
Erythromycin-Sulfisoxazole
51
Elmiron
106
59
Elvitegravir
74
Elvitegravir-Cobicistat-Emtricitabine-Tenofovir
Eslicarbazepine Acetate
Esomeprazole Magnesium
55,56
20
Alafenamide
74
Estazolam
133
Elvitegravir-Cobicistat-Emtricitabine-Tenofovir DF
75
Esterified Estrogens & Methyltestosterone
110
Emollient
12
Estrace
110
Emsam
58
Estraderm
110
Emtricitabine
76
Estradiol
Emtricitabine-Rilpivirine-Tenofovir Disoproxil
110,111
Estradiol & Norethindrone Acetate
110
Fumarate
75
Estradiol Vaginal
110
Emtricitabine-Tenofovir Alafenamide Fumarate
76
Estrogens, Conjugated
111
Emtricitabine-Tenofovir Disoproxil Fumarate
76
Estrogens, Conjugated Vaginal
112
Emtriva
76
Estropipate
111
Enalapril Maleate
89
Eszopiclone
133
Enalapril Maleate & Hydrochlorothiazide
93
Etanercept
Enbrel
Enbrel SureClick
Enoxaparin Sodium
115,138
138
86,87
Epaned
89
Epifoam
101
Epinephrine
129,130
115,138
Ethambutol HCl
66
Ethionamide
67
Ethosuximide
52
Ethotoin
56
Ethynodiol Diacet & Eth Estrad
Etidronate Disodium
111,113
117
EPINEPHrine
129
Etodolac
EpiPen
129
Etonogestrel-Ethinyl Estradiol
EpiPen 2-Pak
129
Etravirine
75
EpiPen Jr
129
Eurax
68
EpiPen Jr 2-Pak
129
Evekeo
98
Epzicom
76
Evotaz
77
EQL Gauze
30
Excilon AMD Drain Sponges
EQL Gauze Sterile
21
Excilon Drain Sponges
24
Equetro
81
Excilon IV Sponges
21
Exelon
57
68
Ergocalciferol
40,136
42
112
117
Ergoloid Mesylates
56
Exemestane
Ery-Tab
51
Exenatide
EryPed 200
50
Ezetimibe-Simvastatin
96
EryPed 400
50
Ezogabine
52
Erythromycin (Acne Aid)
51
Erythromycin (Ophth)
51
F
Erythromycin Base
51
Famotidine
PAGE 146
81,82
18,104
Fanapt
72
Fluoxetine HCl
59,60
Fanapt Titration Pack
71
Fluoxetine HCl (Bulk)
Fantasy Lubricated
28
Fluoxetine HCl (PMDD)
59,61
Fantasy Lubricated/Spermicide
27
Fluoxetine HCl-Dietary Management Product
60,61
Fareston
67
Fluoxymesterone
Farxiga
82
Fluphenazine Decanoate
70
Felbamate
54
Fluphenazine HCl
70
Felodipine
92
Flurazepam HCl
Fenofibrate
95
Flurbiprofen
Fenofibrate Micronized
95
Flurbiprofen Sodium
Fentanyl
43
Flutamide
Ferretts
37
Fluticasone Propionate
107
Ferrous Fumarate
37
Fluticasone Propionate (Inhalation)
127
120
109
134
42
125
67
Ferrous Fumarate-FA-B Complex-C-Zn-Mg-Mn-Cu 135
Fluticasone Propionate (Nasal)
Ferrous Gluconate
Fluticasone Propionate HFA
37,38
32,127
127
Ferrous Sulfate
38
Fluvoxamine Maleate
60
Fetzima
60
FML
Fetzima Titration
59
Focalin XR
98
Feverall
28
Folic Acid
40
FeverAll Infants
28
Foradil Aerolizer
Fexofenadine HCl
33
Forfivo XL
125
129
58
Finasteride
106
Formaldehyde
120
Fingolimod HCl
137
Formoterol Fumarate
129
Flavor Blend
118
Fosamprenavir Calcium
78
Flavor Sweet
120
Fosinopril Sodium
89
Flavoxate HCl
106
Fosinopril Sodium & Hydrochlorothiazide
93
Furosemide
94
Flecainide Acetate
Flexichamber
89
120
Flexzan
22
G
Flonase Allergy Relief
32
G-Zyncof
34
Flovent Diskus
127
Gabapentin
53
Flovent HFA
127
Gabapentin-Dietary Management Product
54
Fluconazole
64
Gabavale-5
80
Fludrocortisone Acetate
107
Gabazolamine
80
Flunisolide (Nasal)
127
Gabazolamine-0.5
81
Flunisolide HFA
127
Gabitril
54
Fluocinolone Acetonide (Otic)
126
Gaboxetine
60
Fluocinonide
107
57
Fluocinonide Emulsified Base
107
Gauze Pads
23
Fluorometholone (Ophth)
125
Gauze Pads &
Fluorouracil (Topical)
101
Dressings
PAGE 147
20,21,22,23,24,28,29,30,117,120
Gauze Sponge
23
Haloperidol Lactate
70
Gemfibrozil
95
Hemangeol
67
Heparin Sodium (Porcine)
87
Gentamicin Sulfate (Ophth)
Gentamicin Sulfate (Topical)
Gentamicin-Prednisolone Acetate
46,47
46
124
Hetlioz
134
Homatropine HBr
123
Genvoya
74
HumaLOG
85
Geodon
72
HumaLOG KwikPen
84
Gilenya
137
HumaLOG Mix 50/50
84
Glatiramer Acetate
137
HumaLOG Mix 50/50 KwikPen
84
Glimepiride
82
HumaLOG Mix 50/50 Pen
84
Glipizide
82
HumaLOG Mix 75/25
84
Glipizide-Metformin HCl
82
HumaLOG Mix 75/25 KwikPen
84
GlucaGen Diagnostic
83
HumaLOG Mix 75/25 Pen
84
GlucaGen HypoKit
83
HumaLOG Pen
84
Glucagon (rDNA)
83
Humira
139
Glucagon Emergency
83
Humira Pediatric Crohns Start
139
Glucagon HCl (rDNA)
83
Humira Pen
139
Glucagon HCl rDNA (Diagnostic)
83
Humira Pen-Crohns Starter
139
Glyburide
82
Humira Pen-Psoriasis Starter
139
Glyburide Micronized
82
HumuLIN 70/30
84
Glyburide-Metformin
82
HumuLIN 70/30 KwikPen
84
HumuLIN 70/30 Pen
84
Glycerin (Laxative)
18,19
Glycerin (Topical)
15
HumuLIN N
85
Glycerin-Dimethicone-Stearyl Alcohol
14
HumuLIN N KwikPen
85
HumuLIN N Pen
85
HumuLIN R
85
Hydralazine HCl
96
Hydrocell Adhesive Dressing
23
Glycopyrrolate
GNP Sterile Pads
Grass Mixed Pollens Allergen Extract
Grastek
104
21
131,132
131
Griseofulvin Microsize
64
Hydrocell Dressing
22
Griseofulvin Ultramicrosize
64
Hydrocell Thin Adhesive
23
Guaifenesin
34
Hydrocerin
12
Guaifenesin-Codeine
35
Hydrochlorothiazide
95
Guanabenz Acetate
88
Hydrocodone w/ Homatropine
131
Guanfacine HCl
88
44
Guanfacine HCl (ADHD)
99
Hydrocortisone
108
Gynazole-1
64
Hydrocortisone (Intrarectal)
117
Gynol II
20
Hydrocortisone (Rectal)
117
Hydrocortisone (Topical)
H
Hydrocortisone Acetate (Topical)
15,16,101,102
15
Haloperidol
70
Hydrocortisone Butyrate
108
Haloperidol Decanoate
70
Hydrocortisone w/Acetic Acid
126
PAGE 148
Hydrocortisone-Aloe Vera
16
Insulin NPH (Human) (Isophane)
Hydromorphone HCl
44
Insulin NPH Isophane & Reg (Human)
84,85
Hydroxychloroquine Sulfate
68
Insulin Regular (Human)
85,86
Hydroxyprogesterone Caproate
113
Intelence
85
75
Hydroxyurea
67
Interferon Beta-1a
137
Hydroxyurea (Sickle Cell Anemia)
67
Invega Sustenna
73
Hydroxyzine HCl
128
Invega Trinza
72
Hydroxyzine HCl (Bulk)
120
Invirase
77
121,128
Iopidine
126
128
Hydroxyzine Pamoate
Hyoscyamine Sulfate
104
Ipratropium Bromide
HyperRHO S/D
116
Ipratropium Bromide (Nasal)
Hypromellose (Ophth)
32
I
Ipratropium Bromide HFA
128
Ipratropium-Albuterol
131
Irbesartan
88
93
Ibuprofen
10,42
Irbesartan-Hydrochlorothiazide
Iloperidone
71,72
Irenka
Imipramine HCl
Imipramine Pamoate
63,121
63
128,129
100
Iron Chews Pediatric
38
Isentress
75
Imiquimod
102
Island Gard-GRX
30
Incruse Ellipta
128
Isocarboxazid
58
66
Indapamide
95
Isoniazid
Inderal XL
91
Isopto Carbachol
125
Indinavir Sulfate
77
Isopto Homatropine
123
Indomethacin
42
Isosorbide Dinitrate
96
InnoPran XL
91
Isosorbide Mononitrate
Inositol
40
Isotretinoin
96,97
102
InspiraChamber/Large
121
Isoxsuprine HCl
56
InspiraChamber/Medium
121
Itraconazole
64
InspiraChamber/Mouthpiece
121
Ivacaftor
139
InspiraChamber/Small
121
Ixazomib Citrate
137
Inspirease
121
Inspirease Bags
121
J
Inspirease Reservoir Bags
121
J & J Gauze
30
85,86
J & J Gauze Sponges 12-Ply
23
Insulin Aspart Protamine & Aspart (Human)
86
22
Insulin Glargine
85
22
Insulin Glulisine
83
J & J Non-Stick Dressing
21
Insulin Isophane & Reg (Human)
86
J & J Ulcer Dressing
23
Insulin Isophane (Human)
86
Jadenu
Insulin Aspart
Insulin Lispro (Human)
Insulin Lispro Protamine & Lispro (Human)
PAGE 149
84,85
Jentadueto
134
82
84
Latuda
K
Leflunomide
Kalbitor
115
Kaletra
78
Kalydeco
72
139
116
Letrozole
68
Leucovorin Calcium
68
Leukeran
67
Kameleon Lubricated
26
Levetiracetam
52
Kendall Hydrophilic Foam Dress
29
LevETIRAcetam in NaCl
52
Kendall Hydrophilic Foam Plus
28
Levetiracetam in Sodium Chloride
52
Kerlix Sponges
22
Levobunolol HCl
126
Levocarnitine (Metabolic Modifiers)
136
Ketoconazole (Topical)
64,65
Ketoprofen
42
Levofloxacin
Ketorolac Tromethamine
42
Levomilnacipran HCl
Ketorolac Tromethamine (Ophth)
125
51
59,60
Levonorgestrel & Eth Estradiol
111
Ketotifen Fumarate (Ophth)
32
Levonorgestrel (Emergency OC)
Kimono
26
Levonorgestrel-Eth Estradiol (Triphasic)
111
Kimono Micro Thin Plus
27
Levonorgestrel-Ethinyl Estradiol (91-Day)
111
Kimono Plus
26
Levothyroxine Sodium
114
Kimono PS
26
Lexiva
Kimono PS Plus
26
Lidocaine
102
Kimono Sensation
27
Lidocaine HCl
102
Kimono Sensation Plus
27
Lidocaine HCl (Mouth-Throat)
45
Lidocaine-Prilocaine
45
Linagliptin
83
Linagliptin-Metformin HCl
82
Klor-Con M15
Kombiglyze XR
135
82,83
L
L-Arginine
25
L-Arginine HCl
121
Labetalol HCl
Lacosamide
Lactic Acid (Ammonium Lactate)
20,113
78
Liothyronine Sodium
114
Liotrix (T3-T4)
114
Lisdexamfetamine Dimesylate
98
90
Lisinopril
89
56
Lisinopril & Hydrochlorothiazide
93
16,102
LiteAire
121
Lactulose
105
Lithium
81
Lactulose (Encephalopathy)
105
Lithium Carbonate
81,121
LaMICtal
54
Lodoxamide Tromethamine
124
LaMICtal Starter
54
Loestrin 24 Fe
111
LaMICtal XR
54
LoHist-D
Lamivudine
76
Loperamide HCl
Lamotrigine
54,55
Lansoprazole
19,20,105
35
17,104
Lopinavir-Ritonavir
78
Loratadine
33
Lantus
85
Loratadine & Pseudoephedrine
35
Lantus SoloStar
85
Lorazepam
81
Latanoprost
PAGE 150
126
Lorazepam (Bulk)
121
Losartan Potassium
88
Methazolamide
126
Losartan Potassium & Hydrochlorothiazide
93
Methenamine Mandelate
Lovastatin
95
Methenamine-Hyosc-Methylene Blue-Sod Phos-Phenyl
Loxapine Succinate
70
Sal
47
47
Lufyllin
130
Methimazole
114
Lumacaftor-Ivacaftor
139
Methitest
109
Methocarbamol
133
Methotrexate Sodium
115
Methotrexate Sodium (Antirheumatic)
116
Lurasidone HCl
Lyrica
72
100
M
Methsuximide
52
88
Magnesium Chloride
38
Methyldopa
Magnesium Citrate
19
Methylergonovine Maleate
Magnesium Hydroxide
19
Methylphenidate
Magnesium Oxide
17
Methylphenidate HCl
Magnesium Oxide (Mg Supplement)
38
Methylprednisolone
108
113
Methyltestosterone
109
Makena
121
99
99,100
Malathion
68
Metoclopramide HCl
63
Maprotiline HCl
60
Metolazone
95
Maraviroc
77
Metoprolol & Hydrochlorothiazide
94
Marplan
58
Maxx
27
Metoprolol Tartrate
91
Maxx Plus
28
Metronidazole
47
Metronidazole (Topical)
48
Meclizine HCl
11,63
90,91
Medroxyprogesterone Acetate
113
Metronidazole Vaginal
48
Medroxyprogesterone Acetate (Contraceptive)
113
Mexiletine HCl
89
Mefloquine HCl
Megestrol Acetate
68
113
Miacalcin
117
Miconazole 3
65
11
Melatonin
30
Miconazole Nitrate (Topical)
Meloxicam
42
Miconazole Nitrate Vaginal
Melphalan
67
Microchamber
121
Memantine HCl
57
Midazolam HCl
79
Memantine HCl-Donepezil HCl
57
Midodrine HCl
88
Meperidine HCl
44
Milk of Magnesia Concentrate
19
Meprobamate
79
Millipred
Mercaptopurine
67
Milnacipran HCl
Mesalamine
Metamucil MultiHealth Fiber
Metaproterenol Sulfate
Metformin HCl
116
19
130
82,83
11,65
108
100,101
Mineral Oil-Hydrophil Petrolat
16
Mineral Oil-Hydrophilic Petrolatum
16
Minivelle
110,111
Minocycline HCl
52
Methadone HCl
43
Minoxidil
96
Methamphetamine HCl
98
Mirasorb Sponges
29
PAGE 151
Mirtazapine
58
Necon 1/50 (28)
111
Misoprostol
105
Necon 10/11 (28)
111
Modafinil
134
Nedocromil Sodium (Ophth)
124
Modafinil & Dietary Management Product
134
Nefazodone HCl
60
Moisture Barrier
15
Nelfinavir Mesylate
78
Moisture Guard
15
Nembutal
53
Neomycin Sulfate
47
Mometasone Furoate
108
Mometasone Furoate-Formoterol Fumarate
Neomycin-Bacitracin Zn-Polymyxin
Dihydrate
131
Neomycin-Bacitracin-Polymyxin
Montelukast Sodium
128
Neomycin-Polymy-Dexameth
Morphine Sulfate
43,44
Neomycin-Polymyxin w/ Pramoxine
124
12
124
16
Moxifloxacin HCl (Ophth)
51
Neomycin-Polymyxin-Gramicidin
124
Multiple Vitamin
39
Neomycin-Polymyxin-HC (Ophth)
124
Multiple Vitamins w/ Iron
39
Neomycin-Polymyxin-HC (Otic)
126
Nepafenac
125
Multiple Vitamins w/ Minerals
39,41,136
Mupirocin
48
NeutrapHor
15
Mupirocin Calcium (Topical)
48
NeutrapHorus Rex
15
MX-Sol
31
Nevanac
MX-Sol Blend
24
Nevirapine
75
MX-Sol Blend SF
24
Nexiclon XR
88
MX-Sol SF
30
NexIUM 24HR
20
MX-Sol Suspend
24
Niacin
125
12,40
Mycophenolate Mofetil
116
Niacin (Antihyperlipidemic)
96
Mycophenolate Sodium
116
Niacor
96
Nicardipine HCl
92
Myleran
67
Nicotine
N
10,11,46
Nicotine Polacrilex
10,11
Nabumetone
43
Nicotrol
46
Nadolol
91
Nicotrol NS
46
Naloxone HCl
46
Nifedipine
92
Naltrexone
45
Ninlaro
Naltrexone HCl
45
Nitro-Bid
97
Namzaric
57
Nitrofurantoin
48
Nitrofurantoin Macrocrystal
48
Nitrofurantoin Monohyd Macro
48
10,43
Nitroglycerin
97
Naratriptan HCl
66
Nonoxynol-9
20
Narcan
46
Norditropin
138
Nasal Decongestant
31
Norditropin FlexPro
138
Nateglinide
83
Norditropin NordiFlex Pen
138
Natroba
68
Norelgestromin-Ethinyl Estradiol
Naphazoline HCl
Naproxen
Naproxen Sodium
PAGE 152
123
43
137
112,113
Norethin Acet & Estrad-Fe
111,112
Ofloxacin (Otic)
Norethindrone & Eth Estradiol
111,112
Ogestrel
Norethindrone & Mestranol
111,112
Olanzapine
51
112
72
Norethindrone (Contraceptive)
113
Olanzapine Pamoate
72,74
Norethindrone Acet & Eth Estra
112
Olanzapine-Fluoxetine HCl
58
Norethindrone Acetate
113
Oleptro
60
Norethindrone-Eth Estradiol (Biphasic)
111
Omega-3 Fatty Acids
12
Norethindrone-Eth Estradiol (Triphasic)
112
Omega-3-acid Ethyl Esters
96
Norgestimate-Ethinyl Estradiol
112
Omeprazole
Norgestimate-Ethinyl Estradiol (Triphasic)
112
Omeprazole Magnesium
Norgestrel & Ethinyl Estradiol
112
Omnitrope
Norinyl 1+50 (28)
112
Ondansetron
64
20,105
20
138
Normlshield
16
Ondansetron HCl
64
Norpace CR
90
Onfi
53
Onglyza
83
Nortriptyline HCl
63,121
Norvir
78
Optifoam
21
NovaFerrum 125
38
OptiHaler
122
NovaFerrum Pediatric Drops
40
Ora-Blend
24,118
NovoLIN 70/30
85
Ora-Blend SF
24,118
NovoLIN 70/30 ReliOn
85
Ora-Sweet
31,122
NovoLIN N
85
Ora-Sweet SF
31,122
NovoLIN N ReliOn
85
Oral Electrolytes
NovoLIN R
85
Oral Vehicles
NovoLIN R ReliOn
85
Oralair
132
NovoLOG
86
Oralair Adult Sample Kit
131
NovoLOG FlexPen
85
Oralair Adult Starter Pack
132
NovoLOG Mix 70/30
86
Oralair Childrens Starter Pack
132
NovoLOG Mix 70/30 FlexPen
86
Orkambi
139
NovoLOG PenFill
86
Ortho Diaphragm All-Flex
120
Nu Gauze 4ply
22
Ortho Evra
112
Nu Gauze General-Use Sponges
23
Oseltamivir Phosphate
Nuplazid
69
Oxaprozin
43
NuvaRing
112
Oxazepam
81
36
24,30,31,118,120,122,123
78,79
Nystatin
65
Oxcarbazepine
56
Nystatin (Mouth-Throat)
65
Oxtellar XR
56
Nystatin (Topical)
Nystatin-Triamcinolone
64,65
65
O
Ofloxacin
51
Ofloxacin (Ophth)
51
PAGE 153
Oxybutynin Chloride
106
Oxycodone HCl
44,45
Oxycodone w/ Acetaminophen
45
Oxycodone-Aspirin
45
Oyster Shell
38
P
Pacquin Plus Hand/Body
15
Perphenazine-Amitriptyline
58
Pexeva
61
Phenazopyridine HCl
20,106
Paliperidone
72,73
Phenelzine Sulfate
72,73
Phenelzine Sulfate (Bulk)
Pancreaze
Pancrelipase (Lipase-Protease-Amylase)
Pantoprazole Sodium
Paroxetine HCl
103
103,104
105
60,61
58
Phenobarbital
122
53,122
Phenobarbital Sodium
53
Phenobarbital-Hyoscyamine-Atropine-Scopolamine 104
Phenylephrine HCl (Ophth)
124
Paroxetine Mesylate
61
Phenylephrine HCl (Oral)
31
Parva-Cal
38
Phenylephrine in Hard Fat
16
Paxil
61
Phenylephrine-Chlorphen-DM
35,132
PCCA Sweet-SF
122
Phenylephrine-Chlorpheniramine w/ DM-GG
PCCA Syrup Vehicle
122
Phenylephrine-Cocoa Butter
16
PCCA-Plus
118
Phenylephrine-DM
35
PCE
Ped Multivitamins w/Fl & Iron
51
136
132
Phenylephrine-Guaifenesin
34,35
Phenylephrine-Shark Liver Oil-Cocoa Butter
16
Pedia-Lax
19
Phenylephrine-Shark Liver Oil-Mineral Oil-
Pediatric Multiple Vitamin w/ C
39
Petrolatum
16
Pediatric Multiple Vitamin w/ C & FA
39
Phenytoin
56
Phenytoin Sodium Extended
56
Pediatric Multiple Vitamin w/ Minerals & C
39,136
Pediatric Multiple Vitamins
39
Phrenilin Forte
100
Pediatric Multiple Vitamins w/ Iron
39
Pilocarpine HCl
126
136
Pilocarpine HCl (Oral)
101
Pediatric Vitamins ACD Fluoride & Iron
136
Pimavanserin Tartrate
69
Pediatric Vitamins ACD w/ Fluoride
136
Pimecrolimus
Pediatric Vitamins ADC
39
101
Pimozide
70
Pindolol
91
Pioglitazone HCl
83
PEG 3350-Potassium Chloride-Sod Bicarbonate-Sod
Pioglitazone HCl-Metformin HCl
83
Chloride
Piroxicam
43
PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod
Sulfate
Peganone
105
105
56
Plegridy
137
Peginterferon Beta-1a
137
Plegridy Starter Pack
137
Penicillamine
106
Pocket Chamber
122
Podofilox
102
Penicillin V Potassium
Pentasa
Pentobarbital Sodium
Pentosan Polysulfate Sodium
Pentoxifylline
Permethrin
Perphenazine
PAGE 154
50
116
53,122
106
94
16,31,68
63
Polyethylene Glycol 3350
19,105
Polymem Dressing
30
Polymyxin B-Trimethoprim
Polysaccharide Iron Complex
124
40,41
Polysaccharide Iron Complex-Cholecalciferol (Vit
D3)
38
Polyvinyl Alcohol
32
ProAir HFA
130
Pot Phosphate Monobasic w/ Sod Phosphate Dibasic
Probenecid
65
& Monobasic
106
Prochlorperazine
64
Potassium Bicarbonate
135
Prochlorperazine Edisylate
63
Potassium Chloride
135
Prochlorperazine Maleate
64,122
Progesterone Micronized
113,114
Potassium Chloride Microencapsulated Crystals
CR
135
Promethazine & Phenylephrine
132
Potassium Citrate (Alkalinizer)
106
Promethazine HCl
128
Potassium Iodide
115
Promethazine w/Codeine
132
Potiga
52
Promethazine-DM
132
Povidone-Iodine
31
Propafenone HCl
90
Pramipexole Dihydrochloride
69
Propranolol & Hydrochlorothiazide
94
Pramlintide Acetate
83
Propranolol HCl
67,91,122
Pramoxine-HC
101
Propranolol HCl Sustained-Release Beads
91
Pramoxine-HC-Chloroxylenol
127
Propylene Glycol-Glycerin
32
Prasugrel HCl
88
Propylthiouracil
115
Pravastatin Sodium
96
ProRenal + D
41
Prazosin HCl
88
ProRenal + D w/ Omega-3
41
Pred Mild
125
Proshield Plus Skin Protectant
14
Pred-G
124
Proshield Protective Hand
13
Prednisolone
108
Protriptyline HCl
63
Prednisolone Acetate (Ophth)
125
Proventil HFA
Prednisolone Sodium Phosphate
108,109
130
Pseudoephed-Bromphen-DM
35,132
PrednisoLONE Sodium Phosphate
125
Pseudoephedrine HCl
Prednisolone Sodium Phosphate (Ophth)
125
Pseudoephedrine w/ Codeine-GG
Prednisone
108
Pseudoephedrine-Acetaminophen-
PredniSONE Intensol
108
Dextromethorphan
Pregabalin
100
Pseudoephedrine-Chlorphen-DM
35
Pseudoephedrine-Guaifenesin
35
Pseudoephedrine-Ibuprofen
36
Premarin
111,112
Premium Condoms Lubricated
Prempro
25
109,113
Prenatal Formula
41
Prenatal Vit w/ Ferrous Fumarate-FA-Omega 3 Fatty
31
35,132
35,36
Psyllium
18,19
Pulmicort Flexhaler
127
Pure L-Citrulline
41
Acids
41
Purixan
67
Prenatal Vit w/ Ferrous Fumarate-Folic Acid
39
PX Daytime Multi-Symptom
36
Prevacid 24HR
20
Pyrazinamide
66
Pyrethrins-Piperonyl Butoxide
16
Prezista
77,78
PriLOSEC OTC
20
Pyrethrins-Piperonyl Butoxide-Permethrin-Nit
Primaquine Phosphate
68
Remover
16
Primidone
54
Pyridostigmine Bromide
66
Pyridoxine HCl
41
Pristiq
PAGE 155
59,61
Q
Restore Trio Absorbent Dress
21
Rexulti
71
Quazepam
133
Reyataz
77,78
Qudexy XR
55
Rheumatrex
116
Quetiapine Fumarate
73
Rho D Immune Globulin (Human)
116
QuilliChew ER
99
RhoGAM Ultra-Filtered Plus
116
Quillivant XR
100
Riboflavin
41
Quinapril HCl
89
Rifampin
67
Quinidine Gluconate
90
Rilpivirine HCl
75
Quinidine Sulfate
90
Rimexolone
125
Risedronate Sodium
117
R
RisperDAL Consta
73
RA All Purpose Dressings
23
Risperidone
73
RA Dressing Sponges
24
Risperidone Microspheres
73
RA Gauze Sponges
23
Ritalin LA
99
RA Oatmeal Moisturizing
16
RiteFlo
RA Oyster Shell Calcium/D
38
Ritonavir
78
RA Sterile
29
Rivaroxaban
87
Ragwitek
132
Rivastigmine
57
Raloxifene HCl
114
Rivastigmine Tartrate
57
75
Rizatriptan Benzoate
66
Ropinirole Hydrochloride
69
Roxicet
45
Raltegravir Potassium
Ramelteon
Ramipril
Ranitidine HCl
Rapamune
134
89
18,104,105
116
122
Rozerem
134
Rufinamide
56
Ray-Tec X-Ray Detectable Spnge
23
Reality Latex/Ultra Textured
27
S
Reality Latex/Ultra Thin
26
Saline
Relenza Diskhaler
78
Salmeterol Xinafoate
ReliOn 70/30
86
Salsalate
43
ReliOn N
86
Saphris
71
ReliOn R
86
Saquinavir Mesylate
77
Relpax
65
Sarafem
61
Remedy Moisture Barrier
15
Savella
100
Remedy Nutrashield
14
Savella Titration Pack
101
Remedy Skin Repair
16
Saxagliptin HCl
31
130
83
Rescriptor
75,76
Reserpine
94
Secobarbital Sodium
134
Restore Contact Layer
20
Seconal
134
Restore Foam Dressing
22
Secura Dimethicone Protectant
15
Restore Odor Absorbing Dress
23
Selegiline
58
PAGE 156
Saxagliptin-Metformin HCl
82,83
Selegiline HCl
69,122
Somatropin
Selenium Sulfide
17,102
Sorbidon Hydrate
138
13
Selzentry
77
Sorbitol
Senna
19
Sorbitol (Laxative)
19
Sennosides
19
Sotalol HCl
90
Sennosides-Docusate Sodium
19
Sotalol HCl (AFIB/AFL)
90
Sensi-Care Moisturizing
13
Spacer/Aerosol-Holding Chamber Supplies - Bags 121
Sentraflox AM-10
61
Spacer/Aerosol-Holding
Sentralopram AM-10
61
Chambers
134
Spinosad
Sentramodafin AM-100
31,122
118,119,120,121,122,123
68
Sentravil PM-25
63
Spiriva HandiHaler
Sentrazolam AM 0.25
81
Spironolactone
95
Sentroxatine
61
Spironolactone & Hydrochlorothiazide
94
Serevent Diskus
130
SEROquel XR
73
Sertraline HCl
61,122
129
SSKI
115
Starch-Maltodextrin (Thickening)
31
Stavudine
76
Sertraline HCl (Bulk)
122
Stavzor
54
SfRowasa
116
Steri-Pad Sterile
29
Short Ragweed Pollen Allergen Extract
132
Sterile
29
Strattera
98
Stribild
75
Shur-Seal Contraceptive
Silenor
20
134
Silver Sulfadiazine
51
Suboxone
45
Simethicone
18
Succimer
134
Simvastatin
96
Sucralfate
105
Sirolimus
116
Sivextro
48
Skin Protectants, Misc.
12,13,101
Sulfacetamide Sod-Prednisolone
123,124
Sulfacetamide Sodium
102
Sulfacetamide Sodium (Acne)
102
SM Gauze
29
Sulfacetamide Sodium (Ophth)
52
SM Sterile
30
Sulfacetamide Sodium w/ Sulfur
102
Soap & Cleansers
13
Sulfamethoxazole-Trimethoprim
52
Sodium Bicarbonate (Antacid)
18
Sulfasalazine
117
Sodium Chloride
135
Sulindac
43
Sodium Chloride (GU Irrigant)
107
Sumatriptan
66
Sodium Chloride (Inhalant)
132
Sumatriptan Succinate
66
Sodium Citrate & Citric Acid
107
Sunscreens
13
Sodium Fluoride
135
Suspendol-S
31
Sodium Fluoride (Dental)
101
Sustiva
Sodium Oxybate
134
Suvorexant
Sodium Phosphates
Sodium Polystyrene Sulfonate
Sof-Wick
PAGE 157
18
134,135
22
75,76
134
Sween
13
Sween 24
13
Sween 24 Skin Protectant
17
Symbicort
131
Thyrolar-1/2
114
SymlinPen 120
83
Thyrolar-1/4
114
SymlinPen 60
83
Thyrolar-2
114
31,122
Thyrolar-3
114
Syrpalta
Syrpalta (Red)
122
T
Tiagabine HCl
54
Ticagrelor
88
Timolol Maleate
91
Tacrolimus
116
126
Tacrolimus (Topical)
102
Timoptic Ocudose
126
Timothy Grass Pollen Allergen Extract
131
Tamiflu
Tamoxifen Citrate
78,79
67
Tioconazole Vaginal
11
Tamsulosin HCl
106
Tiotropium Bromide Monohydrate
129
Tasimelteon
134
Tipranavir
77
Tazarotene
103
Tivicay
75
Tazorac
103
Tizanidine HCl
Tecfidera
138
TobraDex
136
47
Tedizolid Phosphate
48
Tobramycin
Tegaderm Foam
30
Tobramycin (Ophth)
47
Temazepam
133
Tobramycin Sulfate
47
Tencon
100
Tobramycin Sulfate in Saline
47
76
Tobramycin-Dexamethasone
47,124
Tenofovir Disoproxil Fumarate
Terazosin HCl
106
Tobrex
47
17
Terbinafine HCl
65
Tolnaftate
Terbinafine HCl (Topical)
17
Terbutaline Sulfate
Terconazole Vaginal
130
65
139
106
Topiramate
55
Topper Dressing Sponges
24
Testosterone
109
Toremifene Citrate
67
Testosterone Cypionate
109
Torsemide
95
32
Tradjenta
83
Tramadol HCl
45
Tramadol-Acetaminophen
45
Tetrahydrozoline HCl (Ophth)
Theo-24
130
Theophylline
130,131
TheraGauze
20
Trandolapril
89
Therapentin-60
54
Tranexamic Acid
87
Therapentin-90
54
Tranylcypromine Sulfate
58
Theratears
32
Trazamine
61
Thiamine HCl
41
Trazodone HCl
Thiamine Mononitrate
41
Trazodone HCl-Dietary Management Product
61
Thioridazine HCl
70
Trecator
67
Thiothixene
70
Tretinoin
103
60,61,122
Thyroid
114
Trexall
115
Thyrolar-1
114
Triamcinolone Acetonide (Mouth)
109
PAGE 158
Triamcinolone Acetonide (Topical)
108
Triaminic Cold/Cough Day Time
35
Triamterene & Hydrochlorothiazide
94
Triazolam
133
Ursodiol
104
V
Valacyclovir HCl
79
Trifluoperazine HCl
70
Valganciclovir HCl
74
Trifluridine
79
Valproate Sodium
54
Trihexyphenidyl HCl
69
Valproate Sodium (Bulk)
Trimethoprim
48
Valproic Acid
54
Valsartan
89
94
63,122
123
Trintellix
62
Valsartan-Hydrochlorothiazide
Triumeq
77
Valved Holding Chamber
Trojan Magnum Warm Sensations
26
Vancomycin HCl
48
Trojan Supras Spermicidal
26
Varenicline Tartrate
46
Trojan Twisted Pleasure
26
Vehicle S
31
Trokendi XR
55
Venlafaxine HCl
Tropicamide
124
Ventolin HFA
130
Trospium Chloride
106
Verapamil HCl
92
123
61,62
Trustex Color Condoms + Lube
25
Veripred 20
Trustex Lub/Ribbed/Studded
27
Versacloz
74
Trustex Lub/Spermicide Ex St
28
VersaFree
123
Trustex Lub/Spermicide XL
25
VersaPlus
123
Trustex Lubricated
27
Versiva XC
30
Trustex Lubricated Ex Large
25
Vexol
Trustex Lubricated Extra St
27
Vicks Formula 44 Chesty Cough
36
Trustex Lubricated/Spermicide
26
Videx
76
Trustex Natural Condoms + Lube
25
Vigamox
51
Trustex Ria Lub/Spermicide
25
Viibryd
62
Trustex Ria Lubricated
27
Viibryd Starter Pack
62
Trustex-Nonoxynol-9/Rib/Stud
26
Vilazodone HCl
62
Truvada
76
Vimpat
56
Viracept
78
Tryptophan
41,122,136
109
125
Tudorza Pressair
129
Viread
76
Twinject
130
Vistec X-Ray Detectable Sponge
24
Tybost
77
Vistogard
123
Tylenol Extra Strength
31
Vitamin A
41
Vitamin E
41
Vitamins A & D (Topical)
13
39
U
Ulipristal Acetate
113
Vitamins w/ Lipotropics
Umeclidinium Bromide
128
Vitaroca Plus
Urea
103
Vitekta
74
Uridine Triacetate (Emergency Treatment)
123
Vivitrol
45
PAGE 159
136
Vortex Valved Holding Chamber
Vortioxetine HBr
123
62
Vraylar
71,74
Vytorin
96
Vyvanse
98
W
Warfarin Sodium
Watchhaler
White Petrolatum-Mineral Oil
87
123
32
X
Xarelto
87
Xulane
113
Xyrem
134
Z
Zaleplon
133
Zanamivir
78
Zenpep
103
Zenzedi
97,98
Ziagen
77
Zidovudine
77
Zinc Gluconate
38
Zinc Oxide (Topical)
17
Zinc Sulfate
39,135
Ziprasidone HCl
74
Ziprasidone Mesylate
72
Zolmitriptan
66
Zolpidem Tartrate
133
Zolpimist
133
Zomig
66
Zonisamide
53
Zovia 1/50E (28)
113
Zovirax
79
Zyncof
36
ZyPREXA Relprevv
PAGE 160
72,74

Hoosier Care Connect

Transcription

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