Buckeye Health Plan

Transcription

Buckeye Health Plan

Comprehensive
PREFERRED DRUG LIST
Buckeye Health Plan
PAGE 1
LAST UPDATED 09/2016
Buckeye Health Plan
Preferred Drug List
Approved October 09, 2014
Effective October 09, 2014
Preferred Drug List Medication Locator Instructions:
1. With the PDF open, click on the Edit menu, then click Find
2. In the Find box type the name of the medication you want to locate
3. Click the Next button until you find the medication(s) you are looking for
BCHP-MM-090711-01rev10.2014
PAGE 2
Buckeye Health Plan Pharmacy Program
Buckeye Health Plan, Inc. (Buckeye) is committed to providing appropriate, high quality, and cost effective
drug therapy to all Buckeye members. Buckeye works with providers and pharmacists to ensure that
medications used to treat a variety of conditions and diseases are covered. Buckeye covers prescription
medications and certain over- the-counter (OTC) medications when ordered by a physician/clinician. The
pharmacy program does not cover all medications. Some medications require prior authorization (PA) or
have limitations on age, dosage, and maximum quantities. This section provides an overview of the
Buckeye pharmacy program. For more detailed information, please visit our website at
www.bchpohio.com. The following program covers both the Covered Families & Children (CFC) and
Aged, Blind or Disabled (ABD) Ohio Medicaid consumers who are enrolled in Buckeye.
Plan Preferred Drug List and Prior Authorization List
The Buckeye Preferred Drug List (PDL) describes the circumstances under which contracted pharmacy
providers will be reimbursed for medications dispensed to members covered under the program. All
drugs covered under the Ohio Medicaid program are available for Buckeye members. The PDL includes
all drugs available without PA and those agents that have the restrictions of Step Therapy (ST). The PA
list includes those drugs that require PA for coverage. The PDL applies to drugs you receive at retail
pharmacies. The PDL is continually evaluated by the Buckeye Pharmacy and Therapeutics (P&T)
Committee to promote the appropriate and cost-effective use of medications. The Committee is
composed of the Buckeye Medical Director, Buckeye Pharmacy Director, and several Ohio primary care
physicians, pharmacists, and specialists. The PDL does not:
Require or prohibit the prescribing or dispensing of any medication
Substitute for the independent professional judgment of the physician/clinician or pharmacist, or
Relieve the physician/clinician or pharmacist of any obligation to the patient or others
US Script
With the exceptions of biopharmaceuticals and specialty drugs, Buckeye works with US Script to process
all pharmacy claims for prescribed drugs. Some drugs on the Buckeye PDL and PA list require a PA and
US Script is responsible for administering this process. US Script is our Pharmacy Benefit Manager.
Follow these guidelines for efficient processing of your authorization requests:
1. Complete the Buckeye Health Plan/US Script form: Medication Prior Authorization
Request Form.
2. Fax to US Script at 1-866-399-0929.
3. Once approved, US Script notifies the prescriber by fax.
4. If the clinical information provided does not explain the medical necessity for the requested PA
medication, US Script will deny the request and offer PDL alternatives to the prescriber by fax.
5. For urgent or after-hours requests, a pharmacy can provide up to a 72-hour emergency supply
of medication by calling 1-800-460-8988.
PAGE 3
Prior Authorization Process
The Buckeye PDL includes a broad spectrum of brand name and generic drugs. Clinicians are encouraged
to prescribe from the Buckeye PDL for their patients who are members of Buckeye. Some drugs will
require PA and are listed on the PA list. In addition, all name brand drugs not listed on either the PDL or
PA list will require prior authorization. If a request for authorization is needed the information should be
submitted by your physician/clinician to US Script on the Buckeye Health Plan/US Script form:
Medication Prior Authorization Request Form. This form should be faxed to US Script at 1-866-399-0929.
This document is located on the Buckeye website at www.bchpohio.com.
Buckeye will cover the medication if it is determined that:
1. There is a medical reason you need 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 Buckeye
P&T Committee. Once approved, US Script notifies the physician/clinician by fax. If the clinical
information provided does not meet the coverage criteria for the requested medication Buckeye we will
notify you and your physician/clinician of alternatives and provide information regarding the appeal
process.
The P&T committee has reviewed and approved, with input from its members and in consideration of
medical evidence, the list of drugs requiring prior authorization. This PDL attempts to provide appropriate
and cost-effective drug therapy to all members covered under the Buckeye pharmacy program. If a patient
requires a brand name medication that does not appear on the PDL, the physician/clinician can make a PA
request for the brand name 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.
A phone or fax-in process is available for PA requests.
US Script Contact Information: Prior Authorization Fax
1-866-399-0929
Prior Authorization Phone 1-866-399-0928
Mailing Address:
2425 W Shaw Ave, Fresno, CA 93711
When calling, please have patient information, including Medicaid number, complete diagnosis, medication
history and current medications readily available. US Script will provide a decision to the request by fax or
phone within 24 hours. When incomplete information is received to support medical necessity of a drug
requiring PA, the request will be denied. If the request is approved, information in the on-line pharmacy
claims processing system will be changed to allow the specific member to receive this specific drug. If the
request is denied, information about the denial will be provided to the clinician.
Clinicians are requested to utilize the PDL when prescribing medication for those patients covered by the
Buckeye pharmacy program. If a pharmacist receives a prescription for a drug that requires a PA, the
pharmacist should attempt to contact the clinician to request a change to a product included in the PDL.
Phone Numbers for Buckeye Health Plan Member Services
The phone and fax lines listed in the Prior Authorization Process section are dedicated to clinicians
requesting PA medication items only. Members can not be assisted if they call the PA toll-free number.
Buckeye Member Services may be reached at 1-866-246-4358 (TTY 1-800-750-0750).
PAGE 4
Transition Period
Buckeye members new to managed care will be able to receive their prescription drugs with no new PA
requirements than traditional Fee-for-Service (FFS) Medicaid for 30 days they are enrolled in our plan if
the prescription drug does not require PA by traditional FFS Medicaid. This means that if you needed a
PA under traditional FFS Medicaid to get your prescriptions you will most likely still need a PA to get the
same medication. If you have not needed PA under traditional FFS Medicaid to get your prescription you
will not need PA from Buckeye to get the same medication for the first 30 days you are enrolled. This will
allow you and your doctor time to consider other medications that do not require PA and to learn the
steps to getting PA. Buckeye’s PDL and PA List identify the drugs that will require PA once you have
been a managed care member for 30 days. If you are not sure when you will need to have your
medications prior authorized or you have other questions about continuing to get your medications, call
member services at 1-866-246-4358 (TTY 1-800-750-0750).
72-Hour Emergency Supply Policy
State and federal law require that a pharmacy dispense a 72-hour (3-day) supply of medication to any
patient awaiting a 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
the US Script Pharmacy Help Desk at 1-800-460-8988 for a prescription override to submit the 72-hour
medication supply for payment.
Step Therapy
Some medications listed on the Buckeye PDL may require specific medications to be used before you can
receive the step therapy medication. If Buckeye has a record that the required medication was tried first the
ST medications are automatically covered. If Buckeye does not have a record that the required medication
was tried, you or your physician/clinician may be required to provide additional information. If Buckeye
does not grant PA we will notify you and your physician/clinician and provide information regarding the
appeal process.
Dispensing Limits, Quantity Limits, and Age Limits
Drugs may be dispensed up to a maximum 31 day supply for each new or refill non-controlled substance.
A total of 80 percent (80%) of the days supplied must have elapsed before the prescription can be refilled.
A prescription can be filled after 26 days. Dispensing outside the quantity limit (QL) or age limits (AL)
requires PA. Buckeye may limit how much of a medication you can get at one time. If the
physician/clinician feels you have a medical reason for getting a larger amount, he or she can ask for PA.
If Buckeye does not grant PA we will notify you and your physician/clinician and provide information
regarding the appeal process. Some medications on the Buckeye PDL may have AL. These are set for
certain drugs based on Food and Drug Administration (FDA) approved labeling and for safety concerns
and quality standards of care. The AL aligns with current FDA alerts for the appropriate use of
pharmaceuticals.
PAGE 5
Gender Limits
Some medications on the Buckeye PDL may be limited to one gender. These medications have a GL after
them on the PDL. 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 you require a medication that does not appear on the PDL, you or your physician/clinician can make a
medical necessity 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. Buckeye 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 using the criteria established by the Buckeye
P&T Committee. If the clinical information provided does not meet the coverage criteria for the requested
medication Buckeye will notify you and your physician/clinician of alternatives and provide information
regarding the appeal process.
Appropriate Use and Safety Edits
Your health and safety is a priority for Buckeye. One of the ways we address your safety is through Pointof-Sale (POS) edits at the time a prescription is processed at the pharmacy. These edits are based on FDA
recommendations and promote safe and effective medication utilization. Additional information about the
drugs that are part of the Appropriate Use and Safety Edits can be found in the Appropriate Use and
Safety Edits document located on the Buckeye website at www.bchpohio.com.
DUR (Drug Utilization Review) Programs
Buckeye will monitor ongoing prescribing of medications for clinical appropriateness. Buckeye reviews
prescribing retrospectively to review for both safety and efficacy. Buckeye will work with US Script to
review for such things as disease management, fraud and abuse (i.e. Coordinated Services Program), and
prescriber profiling. Prescriber or member outreach may occur based on prescribing/dispensing patterns.
Buckeye will continue to monitor for issues going forward and take action as needed.
Mandatory Generic Substitution
When generic drugs are available, the brand name drug will not be covered without Buckeye PA. Generic
drugs have the same active ingredient and work the same as brand name drugs. If you or your
physician/clinician feels a brand name drug is medically necessary, the physician/clinician can ask for PA.
PAGE 6
We will cover the brand name drug according to our clinical guidelines if there is a medical reason you need
the particular brand name drug. If Buckeye does not grant PA we will notify you and your
physician/clinician and provide information regarding the appeal process. The provision is waived for the
following products due to their narrow therapeutic index (NTI) as recognized by current medical and
pharmaceutical literature: Aminophylline, Amiodarone, Carbamazepine, Clozapine, Cyclosporine, Digoxin,
Disopyramide, Ethosuximide, Flecainide, L-thyroxine, Lithium, Phenytoin, Procainamide, Propafenone,
Theophylline, Thyroid, Valproate Sodium, Valproic Acid, and Warfarin.
Over-The-Counter Medications
The pharmacy program covers a large selection of OTC medications. All covered OTC medications
appear in the PDL. All OTC medications must be written on a valid prescription by a licensed
physician/clinician in order to be reimbursed.
Filling a Prescription
You can have prescriptions filled at a Buckeye network pharmacy. If you decide to have a prescription
filled at a network pharmacy you can locate a pharmacy near you by contacting a Buckeye Member
Services Representative. At the pharmacy you will need to provide the pharmacist with your prescription
and your Buckeye ID card.
Please visit the Buckeye website at www.bchpohio.com to access the Buckeye PDL, Buckeye PA
lists, important forms, and provider/member information 24 hours a day, seven days a week.
Mail Order Program
Buckeye Health Plan offers a 90 day supply (3 month supply) of maintenance medications by mail. These
drugs are used to treat long-term conditions or illnesses. You can find a list of covered maintenance
medications in the Maintenance Drug Pharmacy Program document located on the Buckeye website at
www.bchpohio.com.
Please contact a Buckeye Member Service Representative if you have any questions. To transfer a current
prescription or to have you doctor phone a prescription directly to our mail order pharmacy they may call
RxDirect at 1-800-785-4197.
PAGE 7
Buckeye Health Plan Pharmacy Program - Additional Information
Working with Our Pharmacy Benefit Managers
Buckeye works with two Pharmacy Benefit Managers (PBMs). Acaria Health is the preferred provider of
biopharmaceuticals and injectables for Buckeye. US Script administers all other prescribed drugs. Certain
drugs require PA to be approved for payment by Buckeye. These include:
Some Buckeye drugs listed on the PA list
Most injectables including Procrit, Neulasta and Neupogen.
AcariaHealth – Biopharmaceuticals and Injectables
AcariaHealth is the provider of biopharmaceuticals and injectables for Buckeye. Most injectables require
PA to be approved for payment. Our Medical Director oversees the clinical review. Buckeye provides a
number of biopharmaceutical products through the Biopharmaceutical Program. Most biopharmaceuticals
and injectables require a PA to be approved for payment by Buckeye; however, PA requirements are
programmed specific to the drug as indicated in the list provided in the Biopharmaceutical Program
document located on the Buckeye website at www.bchpohio.com. Follow these guidelines for the most
efficient processing of your authorization requests.
Providers can request that AcariaHealth deliver the specialty drug to the office/member. If you want
AcariaHealth to deliver the specialty drug to the office/member:
1. Fax the AcariaHealth PA form to 1-855-217-0926 for PA.
2. If approved, AcariaHealth will contact the provider or member for delivery confirmation.
Pharmacy and Therapeutics Committee
The Buckeye Pharmacy and Therapeutics (P&T) Committee continually evaluates the therapeutic classes
included in the PDL. The Committee is composed of the Buckeye Medical Director, Buckeye Pharmacist,
and several community based primary care physicians and specialists. The primary purpose of the
Committee is to assist in developing and monitoring the Buckeye PDL and to establish programs and
procedures that promote the appropriate and cost-effective use of medications. The P&T Committee
schedules meetings at least twice yearly, and coordinates reviews with a national P&T Committee which
meets at least 4 times a year. Changes to the Buckeye PDL are done in conjunction with the approval of
the State of Ohio. Buckeye will meet with the State quarterly to review any proposed changes and update
the PDL and PA lists accordingly based on the results of both the Buckeye P&T Committee and the
requirements from the State of Ohio. Buckeye will follow all State policies regarding member notification
when changes are made to the PA list.
Unapproved Use of Preferred Medication
Medication coverage under this program is limited to non-experimental indications as approved by the
FDA. Other indications may also be covered if they are accepted as safe and effective using current
medical and pharmaceutical reference texts and evidence-based medicine. Reimbursement decisions for
PAGE 8
specific non-approved indications will be made by Buckeye. Experimental drugs and investigational drugs
are not eligible for coverage.
Benefit Exclusions
The following drug categories are not part of the Buckeye PDL and are not covered by the 72-hour
emergency supply policy:
- Fertility enhancing drugs
- Anorexia, weight loss, or weight gain drugs
- Immunizations and vaccines (except flu vaccine)
- Drug Efficacy Study Implementation (DESI) and Identical, Related and Similar (IRS) drugs that
are classified as ineffective
- Infusion therapy and supplies
- Drugs and other agents used for cosmetic purposes or for hair growth
- Erectile dysfunction drugs prescribed to treat impotence
DESI drugs products and known related drug products are defined as less than effective by the FDA
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. State programs may allow
coverage of certain DESI drugs. Any DESI drugs that are covered are listed in the PDL.
Newly Approved Products
We review new drugs for safety and effectiveness for the first 12 months before adding them to the
Buckeye PDL. During this period, access to these medications will be considered through the PA review
process. If Buckeye does not grant PA we will notify you and your physician/clinician and provide
information regarding the appeal process.
Medical Benefits
The following drugs and medical services are a part of the Buckeye medical benefit and are not available at
the retail pharmacy:
1.
Members will receive vaccines as a medical benefit under physician reimbursement if listed the
vaccine covered under the vaccine for children program.
2.
Cosmetic-botox is a medical benefit that is covered for non-cosmetic purposes only- it requires
a PA from Buckeye.
3.
Blood and blood products.
4.
Those specialty injectable drugs available as a medical benefit. Most injectables require PA from
Buckeye.
Prescribers who request medical prior authorizations at US Script will be redirected to contact Buckeye
Health Plan as applicable.
PAGE 9
DME/Home Health Benefits
The following medical services are a part of the Buckeye medical benefit and are not available at the retail
pharmacy:
1. Enteral products
2. Nebulizers
3. Medical supplies
Injectable Drugs
Injections that are self-administered by the member and/or a family member and appear on the PDL are
covered by the Buckeye pharmacy program. Insulin vials, Glucagon Kit, Epi-pen, Ana-Kit, Imitrex, and
Depo-Provera IM are covered by Buckeye and do not require a PA. Pre-filled insulin cartridges and
syringes require PA. All other injectables require PA.
Coordinated Services Program
Consumers eligible for Ohio Medicaid may be selected for enrollment in the Coordinated Services
Program, or CSP. CSP members may need to select one pharmacy to get medications filled, select one
doctor to write their scripts, or both depending on the CSP enrollment. While in CSP, the member will
still be able to get all medically necessary Medicaid-covered health care services. However, the member
must use the selected pharmacy or doctor for pharmacy services. Members enrolled in the CSP program
will also be enrolled in Care Management to help better coordinate the member’s needs. Care Managers
will work with the CSP members, to help make sure all their needs are met. Except in an emergency, the
member should contact their PCP before seeing other doctors. By knowing the complete medical history,
the PCP can take better care of the patient.
We help keep you informed
The Buckeye Pharmacy Director, a registered pharmacist, compiles current pharmacological policy and
information about important seasonal topics such as Respiratory Syncytial Virus (RSV) and influenza. The
information is consistent with published guidelines and is mailed to network providers as a service. The
most current Buckeye PDL and PA List can be downloaded from our website at www.bchpohio.com.
Contacts for Pharmacy Appeals/Grievances
Members: In the event that a member disagrees with the decision regarding coverage of a medication, the
member may file an appeal with Buckeye by calling Buckeye Member Services at 1-866-246-4358 (TTY 1800-750-0750).
Physicians / Clinicians: In the event that a clinician disagrees with the decision regarding coverage of a
medication, the clinician may request an appeal by submitting additional information to Buckeye in writing
to the Appeals Department at the following address:
PAGE 10
02/2015
Buckeye Health Plan
4349 Easton Way, Suite 200
Columbus, Ohio 43219
A decision will be rendered and the clinician will be notified with a mailed response. An expedited appeal
may be requested at any time the provider believes the adverse determination might seriously jeopardize
the life or health of a member by calling Buckeye at 1-866-246-4356 ext. 24084 (TTY 1-800-750-0750). A
response will be rendered the same day as receipt of complete information. In circumstances that require
research, a same day response may not be possible.
Abbreviations
The following notations and abbreviations may be found throughout the drug listing in the limitations and
restrictions column.
DS:
Days Supply
DS/DU:
Days Supply per Dosage Unit
Max Days:
Maximum Days Supply
Max Fills:
Maximum Fills (per a designated time period)
Max Qty:
Maximum Quantity (per claim or designated time period)
Min DS:
Minimum Days Supply
PA:
Prior Authorization
Pkg Size:
Package Size
QL:
Quantity Limit
PAGE 11
Over-the-Counter Pharmacy Program
T
he Buckeye Health Plan pharmacy program covers a variety of OTC products. The products listed
below are covered when a valid prescription from a licensed clinician that meets all the legal
requirements for a prescription is presented to be filled at a Buckeye network pharmacy. Covered
products are available in quantities up to a 30-day supply. Refer to the Buckeye Health Plan PDL
for a complete listing of available OTC items. Please note that generic products must be prescribed when
available.
ANALGESICS & ANTIPYRETICS
Acetaminophen – generic tablets, elixir,
drops, suppositories
Aspirin – generic tablets
ANTACIDS
Maalox – generic tablets, liquid
Mylanta DS – generic liquid
ANTHELMINTICS
Pin-X – Pyrantel pamoate tablets/chewable/suspension
ANTI-DIARRHEALS
Imodium A-D – generic (loperamide) capsules
Kaopectate – (attapulgite) suspension
Pepto-Bismol – generic (pink bismuth) chewable/liquid
ANTI-EMETIC
Triaminic – generic AM, Night, soft chewable tablets
DILUENTS
Sodium chloride – generic aerosol solution
DME PRODUCTS
Diabetic testing supplies (TRUEtest
preferred) Gauze pad – 2”x2”, 3”x3”, 4”x4”
Peak Flow Meters
Spacers
OTIC PREPARATIONS
Debrox drops – generic (carbamide peroxide 6.5%)
ELECTROLYTES
Electrolyte solutions – generic
H2-RECEPTOR ANTAGONISTS
Antivert – generic (meclizine)
ANTI-FLATULENTS
Gas-X chewables – generic simethicone 80mg
Mylicon drops** – generic simethicone 40 mg/0.6ml
ANTI-HISTAMINES
Benadryl – generic (diphenhydramine) capsules, liquid
Chlor-Trimeton – generic (chlorpheniramine) tablets,
liquid Claritin – generic (loratadine) tablets, syrup
Claritin-D – generic (loratadine/ pseudoephedrine) tablets
Zyrtec – generic (cetirizxine) tablets/chewables/liquid
CONTRACEPTIVES
Condoms lubricated
COUGH/EXPECTORANT/DECONGESTANT
Dallergy drops (chlorpheniramine & phenylephrine liquid)
1-2 mg/ml
Decon A drops (brompheniramine & phenylephrine liquid)
2-5 mg/ml
Delsym – DM Polistirex Liquid CR
Dimetapp – generic (brompheniramine & phenylephrine
elixir) 1-2.5 mg/5ml
Mucinex – generic (guaifenesin) tablets
Robitussin – generic (guaifenesin) syrup
Robitussin DM – generic (guaifenesin DM) syrup
Sudafed – generic (pseudoephedrine) tablets, liquid
PAGE 12
Pepcid – generic (famotidine) 10mg tablets
Tagamet – generic (cimetidine) 200mg tablets
Zantac – generic (ranitidine) 75mg tablets
IRON PREPERATIONS
Ferrous fumarate – generic tablets Ferrous
gluconate – generic tablets Ferrous sulfate –
generic tablets, elixir, drops Polysaccharide
Iron Complex – generic capsules 150mg
LAXATIVES
Citrate of magnesium – generic
Colace – generic (docusate sodium) capsules
Dulcolax – generic (bisacodyl) tablets, suppositories
Fleet enema – generic
Metamucil – generic (psyllium)
Milk Of Magnesium – generic MOM
Miralax OTC
Pediatric glycerin suppositories – generic
Senokot – generic (senna) tablets
Sorbitol oral solution 70%
MINERALS
Citracal – generic (calcium citrate) - tablets
Citracal+D – generic (calcium citrate+D)
tablets Magnesium oxide – generic
PAGE 13
Neutra-phos/K powder – generic
Oscal 500+Vit D – generic (calcium carbonate+D)
tablets Tums Chew Tabs – generic (calcium carbonate)
Zinc sulfate – generic capsules 220mg
NASAL
Nasalcrom spray – generic
Saline nasal spray/gel/solution
NSAIDS
Ibuprofen – generic tablets, chewable, liquid,
drops Naproxen – generic tablets
NUTRITIONAL SUPPLEMENTS
Omega-3 fatty acid capsules 1000mg, 1200mg
OPHTHALMIC PREPARATIONS
Alaway (ketotifen 0.025%)
Artificial tears – generic polyvinyl alcohol drops
Lacri-lube – generic (artificial tears) ointment
Naphcon-A – generic (naphazoline/pheniramine 0.025/0.3)
Zaditor-OTC (ketotifen 0.025%)
PEDICULICIDES
NIX – generic (permethrin)
RID – generic (pyrethrins/piperonyl butoxide)
PROTON PUMP INHIBITORS (PPIS)
Prevacid 24 HR capsules
Prilosec OTC tablets
SLEEPING AIDS
Nytol – generic (diphenhydramine sleep) tablets/capsules
Unisom – generic (doxylamine sleep) tablets
SMOKING DETERRENTS
Commit Lozenges
NicoDerm CQ transdermal patch – generic
Nicorette DS gum – generic
PAGE 14
Nicorette gum – generic
Nicotrol transdermal patch – generic
TOPICALS
AmLactin – generic
Bacitracin ointment – generic
Benzoyl peroxide – generic liquid/gel/lotion
Calamine – generic
Capsaicin cream/gel/lotion – generic
Clotrimazole – generic cream, vaginal cream/inserts
Hibiclens – generic (chlorhexidine gluconate liquid) 4%
Hydrocortisone – generic cream, lotion, ointment, solution
Miconazole – generic cream, vaginal cream/inserts
Polysporin – generic ointment
Nupercainal – generic (dibucaine rectal ointment) 1%
Selsun Blue – generic (selenium shampoo) 1%
Tolnaftate – generic cream
Triple antibiotic ointment
Vagistat – generic (tioconazole vaginal ointment) 6.5%
Xylocaine generic (lidocaine) gel 2%
Zinc oxide ointment – generic
VITAMINS
Folic acid – generic
Multi-vitamins with iron – generic tablets, liquid, chewable
Multi-vitamins – generic tablets, liquid, chewable
Niacin – generic
Prenatal vitamins – generic tablets
Pyridoxine – generic tablets
Slo-Niacin CR tablets
Thiamine – generic tablets
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.
C
PAGE 15
LIST OF COVERED OVER-THE-COUNTER MEDICATIONS
PRODUCT DESCRIPTION
BRAND/GEN
LIMITS & RESTRICTIONS
ANALGESICS
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
aspirin (chew tab 81 mg, tab 81 mg, tab 325 mg, tab
delayed release 81 mg, tab delayed release 325 mg)
generic
aspirin (suppos 300 mg, suppos 600 mg)
generic
aspirin buffered (ca carb-mg carb-mg ox) tab 325 mg
generic
aspirin buffered tab 325 mg
generic
aspirin tab chew 81 mg
generic
ibuprofen (chew tab 100 mg, susp 40 mg/ml, susp 100
mg/5ml, tab 100 mg, tab 200 mg)
generic
ibuprofen tab 200 mg
generic
naproxen sodium tab 220 mg
generic
QL
12 / 31 days
QL
62 / 31 days
ANESTHETICS
LOCAL ANESTHETICS
lidocaine hcl gel 2%
generic
C
Pkg Size 30: Package
Limit=1/claim; Pkg
Size 15: Package
Limit=2/claim
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
SMOKING CESSATION AGENTS
nicotine (patch 24hr 7 mg/24hr, patch 24hr 21 mg/24hr,
patch 24hr 14 mg/24hr)
MDD
1 per day
MDS
180 / 365 DAYS
generic
QL
NICOTINE KIT 21-14-7 MG/24HR
nicotine polacrilex (gum 2 mg, gum 4 mg)
PAGE 16
BRAND
56 / claim
MFL
2 / 365 days
MDS
180 / 365 DAYS
MDD
24 per day
MDS
180 / 365 DAYS
generic
PRODUCT DESCRIPTION
BRAND/GEN
nicotine polacrilex (lozenge 2 mg, lozenge 4 mg)
generic
MDD
20 per day
MDS
180 / 365 DAYS
ANTIEMETICS
ANTIEMETICS, OTHER
*fructose-dextrose-phosphoric acid oral soln***
generic
dimenhydrinate tab 50 mg
generic
QL
24 / claim
DRAMAMINE CHEW TAB 50 MG
BRAND
QL
24 / claim
meclizine hcl (chew tab 25 mg, tab 12.5 mg, tab 25 mg)
generic
ANTIFUNGALS
AZOLEN TINCTURE SOLUTION 2 %
BRAND
MPL
1 / claim
clotrimazole cream 1%
generic
MPL
1 / 31 days
clotrimazole soln 1%
generic
MPL
1 / claim
clotrimazole vaginal cream 1%
generic
QL
45 / 31 days
clotrimazole vaginal cream 2%
generic
QL
31 / 31 days
FUNGOID TINCTURE SOLUTION 2 %
BRAND
MPL
1 / claim
miconazole nitrate (topical) (ointment, powder)
generic
MPL
1 / claim
miconazole nitrate cream 2%
generic
miconazole nitrate vaginal (cream 2%, cream 4% (200
mg/5gm))
generic
QL
miconazole nitrate vaginal (supp 200 mg cream 9 gm kit,
supp 1200 mg cream kit)
generic
MPL
miconazole nitrate vaginal app 200 mg & 2% cream 9 gm
kit
generic
miconazole nitrate vaginal suppos 100 mg
generic
QL
MIRANEL AF SOLUTION 2 %
BRAND
MPL
tioconazole vaginal oint 6.5%
generic
PAGE 17
45 / 31 days
1 / claim
7 / 31 days
1 / claim
PRODUCT DESCRIPTION
BRAND/GEN
ANTIPARASITICS
ANTIHELMINTHICS
QL
PIN-X CHEW TAB 720.5 MG
BRAND
MFL
pyrantel pamoate susp 144 mg/ml (50 mg/ml base equiv)
QL
generic
MFL
4 / claim
1 / 30 days
60 / claim
1 / 30 days
BLOOD GLUCOSE REGULATORS
GLYCEMIC AGENTS
CVS GLUCOSE CHEW TAB 4 GM
BRAND
QL
50 / 30 days
DEX4 QUICK DISSOLVE GLUCOSE CHEW TAB 4 GM
BRAND
QL
50 / 30 days
glucose chew tab 4 gm
generic
QL
50 / 30 days
glucose gel 40%
generic
GNP GLUCOSE CHEW TAB 4 GM
BRAND
QL
50 / 30 days
GNP QUICK DISSOLVE GLUCOSE CHEW TAB 4 GM
BRAND
QL
50 / 30 days
INSTA-GLUCOSE GEL 77.4 %
BRAND
LEADER QUICK DISSOLVE GLUCOSE CHEW TAB 4 GM
BRAND
QL
50 / 30 days
MS QUICK DISSOLVE GLUCOSE CHEW TAB 4 GM
BRAND
QL
50 / 30 days
SM GLUCOSE CHEW TAB 4 GM
BRAND
QL
50 / 30 days
ULTILET GLUCOSE CHEW TAB 4 GM
BRAND
QL
50 / 30 days
WALGREENS GLUCOSE CHEW TAB 4 GM
BRAND
QL
50 / 30 days
CARDIOVASCULAR AGENTS
DYSLIPIDEMICS, OTHER
inositol niacinate cap 500 mg
generic
niacin (tab 250 mg, tab 500 mg, tab 750 mg, tab 1000 mg)
generic
PAGE 18
PRODUCT DESCRIPTION
BRAND/GEN
omega-3 fatty acids (cap 435, cap 500, cap 1000, cap
1200, cap delayed release 1000, cap delayed release
1200)
generic
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM, OTHER
acetaminophen soln 100 mg/ml
generic
acetaminophen soln 160 mg/5ml
generic
QL
30 / 30 days
DENTAL AND ORAL AGENTS
BIOTENE MOISTURIZING MOUTH SOLUTION
BRAND
QL
900 / claim
BIOTENE ORALBALANCE DRY MOUTH LIQUID
BRAND
QL
900 / claim
CVS DRY MOUTH SOLUTION
BRAND
QL
900 / claim
DRY MOUTH SPRAY SOLUTION
BRAND
QL
900 / claim
MOI-STIR SOLUTION
BRAND
QL
900 / claim
MOUTH KOTE SOLUTION
BRAND
QL
900 / claim
ORAL RELIEF SPRAY SOLUTION
BRAND
QL
900 / claim
RA DRY MOUTH SOLUTION
BRAND
QL
900 / claim
sodium fluoride rinse 0.2%
generic
stannous fluoride conc 0.63%
generic
DERMATOLOGICAL AGENTS
*bacitracin-polymyxin b oint***
generic
MPL
1 / claim
*dermatological products misc - liquid**
generic
MPL
1 / claim
*emollient - lotion**
generic
*emollient - ointment**
generic
MPL
1 / claim
*lanolin cream***
generic
*neomycin-bacitracin-polymyxin oint***
PAGE 19
generic
C
Limit=1/claim; Pkg
Size 14.2: Package
Limit=2/claim; Pkg
Size 15: Package
Limit=2/claim; Pkg
Size 28.35: Package
Limit=1/claim
PRODUCT DESCRIPTION
BRAND/GEN
*soap & cleansers - lotion***
generic
*wound cleansers - liquid**
generic
MPL
1 / claim
*wound dressings - gel***
generic
MPL
1 / claim
4-N-1 CREAM 1 %
BRAND
MPL
1 / claim
A-200 GEL 0.33-4 %
BRAND
ACNE MEDICATION 5 LOTION 5 %
BRAND
ALOE VESTA SKIN CONDITIONER LOTION 3 %
BRAND
MPL
1 / claim
aluminum hydroxide oint
generic
MPL
1 / claim
bacitracin oint 500 unit/gm
generic
C
QL
bacitracin zinc oint 500 unit/gm
generic
C
Limit=1/claim; Pkg
Size 15: Package
Limit=2/claim; Pkg
Size 28: Package
Limit=1/claim
30 / claim
Limit=1/claim; Pkg
Size 15: Package
Limit=2/claim; Pkg
Size 28: Package
Limit=1/claim
benzoyl peroxide (gel 2.5%, gel 5%, gel 10%, liq 5%, lotion
10%)
generic
benzoyl peroxide (liq 10%, lotion 6%)
generic
MPL
1 / claim
camphor & menthol lotion 0.5-0.5%
generic
MPL
1 / claim
capsaicin (cream 0.075%, cream 0.1%)
generic
MPL
1 / claim
capsaicin cream 0.025%
generic
CAPZASIN-P CREAM 0.035 %
BRAND
MPL
1 / claim
CASTIVA WARMING LOTION 0.035 %
BRAND
MPL
1 / claim
CLEAN & CLEAR ADVANTAGE 3-IN-1 LOTION 5 %
BRAND
coal tar extract (tar shampoo 1%, tar shampoo 2.5%)
generic
MPL
1 / claim
coal tar shampoo 0.5%
generic
PAGE 20
PRODUCT DESCRIPTION
BRAND/GEN
COMFEEL PASTE PASTE
BRAND
MPL
1 / claim
COOL BOTTOMS CREAM 1 %
BRAND
MPL
1 / claim
CVS SALINE WOUND WASH SOLUTION 0.9 %
BRAND
MPL
1 / claim
dibucaine oint 1%
generic
QL
MPL
dibucaine rectal ointment 1%
QL
generic
31 / 31 days
1 / claim
31 / 31 days
MPL
1 / claim
MPL
1 / claim
dimethicone cream 1.5%
generic
diphenhydramine hcl (topical) (cream, gel)
generic
diphenhydramine-zinc acetate cream 1-0.1%
generic
diphenhydramine-zinc acetate cream 2-0.1%
generic
MPL
1 / claim
GNP SALINE WOUND WASH SOLUTION 0.9 %
BRAND
MPL
1 / claim
hydrocortisone (topical) (cream 1%, lotion 1%, oint 0.5%)
generic
MPL
1 / claim
hydrocortisone acetate (topical) (cream, oint)
generic
hydrocortisone cream 0.5%
generic
hydrocortisone oint 1%
generic
QL
60 / 30 days
MPL
1 / 30 days
MPL
1 / claim
hydrocortisone-aloe vera cream 1%
generic
KERALYT GEL 3 %
BRAND
lactic acid (ammonium lactate) (cream, lotion)
generic
MPL
1 / 31 days
LAMISIL ADVANCED GEL 1 %
BRAND
MPL
1 / claim
LAMISIL AT SPRAY SOLUTION 1 %
BRAND
MPL
1 / claim
LICIDE TREATMENT KIT
BRAND
lidocaine cream 4%
generic
MPL
1 / claim
MINERAL OIL-HYDROPHIL PETROLAT OINTMENT
BRAND
MPL
1 / claim
neomycin-bacitracin-polymyxin-pramoxine oint 1%
generic
MPL
1 / claim
PAGE 21
PRODUCT DESCRIPTION
BRAND/GEN
neomycin-polymyxin w/ pramoxine cream 1%
generic
QL
15 / 31 days
MPL
1 / claim
NEUTRAPHOR CREAM 1 %
BRAND
MPL
1 / claim
NEUTRAPHORUS REX CREAM 1 %
BRAND
MPL
1 / claim
permethrin lotion 1%
generic
permethrin spray & pyrethins-piperonyl butoxide shamp kit
generic
phenyleph-shark liver oil-cocoa butter suppos 0.25-385.5%
generic
phenylephrine-cocoa butter suppos 0.25-88.44%
generic
phenylephrine-mineral oil-petrolatum oint 0.25-14-74.9%
generic
phenylephrine-shark liver oil-glyc-pet cream 0.25-3-12-18%
generic
MPL
phenylephrine-shark liver oil-mo-pet oint 0.25-3-14-71.9%
generic
QL
POLYSPORIN POWDER 500-10000 UNIT/GM
BRAND
pramox-pe-glycerin-petrolatum rectal cream 1-0.25-14.415%
generic
pramoxine hcl rectal foam 1%
generic
PROSHIELD PLUS SKIN PROTECTANT CREAM 1 %
BRAND
pyreth-piperonyl butox sham-permeth aero-nit remover gel
kit
generic
pyrethrins-piperonyl butoxide (liq, shampoo)
generic
RA SALINE WOUND WASH SOLUTION 0.9 %
C
QL
Limit=2/claim; Pkg
Size 120: Package
Limit=1/claim; Pkg
Size 118: Package
Limit=1/claim; Pkg
Size 60: Package
Limit=2/claim
12 / 31 days
1 / claim
31 / 31 days
MPL
1 / claim
BRAND
MPL
1 / claim
REMEDY NUTRASHIELD CREAM 1 %
BRAND
MPL
1 / claim
RID ESSENTIAL LICE ELIMINATION KIT 0.33-4 %
BRAND
SAFE WASH SOLUTION 0.9 %
BRAND
MPL
1 / claim
salicylic acid & sulfur shampoo 2-2%
generic
MPL
1 / claim
PAGE 22
PRODUCT DESCRIPTION
BRAND/GEN
salicylic acid (gel, soln)
generic
MPL
1 / claim
SALINE WOUND WASH SOLUTION 0.9 %
BRAND
MPL
1 / claim
SALJET RINSE SOLUTION 0.9 %
BRAND
MPL
1 / claim
SALJET SOLUTION 0.9 %
BRAND
MPL
1 / claim
SCHOOLTIME SHAMPOO SHAMPOO
BRAND
QL
selenium sulfide lotion 1%
generic
MPL
1 / claim
skin protectants, misc. (misc cream***, misc ointment***)
generic
MPL
1 / claim
terbinafine hcl cream 1%
generic
MPL
1 / claim
tolnaftate (aerosol pow, powder, soln)
generic
MPL
1 / claim
tolnaftate cream 1%
generic
QL
TRIAD HYDROPHILIC WOUND DRESS PASTE
BRAND
MPL
1 / claim
MPL
ULTRATHON INSECT REPELLENT LOTION 34.34 %
BRAND
1 / claim
MFL
2 / 30 days
1 / 14 days
30 / claim
urea (cream, lotion)
generic
MPL
1 / claim
WOUND WASH SALINE SOLUTION 0.9 %
BRAND
MPL
1 / claim
ZIKS ARTHRITIS PAIN RELIEF CREAM 0.025-1-12 %
BRAND
MPL
1 / claim
zinc oxide oint 20%
generic
MPL
1 / claim
GASTROINTESTINAL AGENTS
GASTROINTESTINAL AGENTS, OTHER
*lactobacillus tab**
generic
ACIDOPHILUS PLUS PECTIN TAB
BRAND
ACIDOPHILUS/CITRUS PECTIN TAB
BRAND
alum & mag hydroxide-simethicone susp 200-200-20
mg/5ml
generic
alum & mag hydroxide-simethicone susp 400-400-40
mg/5ml
generic
PAGE 23
QL
744 / 31 days
PRODUCT DESCRIPTION
BRAND/GEN
aluminum hydroxide gel susp 320 mg/5ml
generic
aluminum hydroxide-magnesium carbonate susp 95-358
mg/15ml
generic
aluminum hydroxide-magnesium trisilicate chew tab 80-20
mg
generic
bismuth subsalicylate (chew tab 262 mg, susp 262
mg/15ml, susp 525 mg/15ml)
generic
calcium carbonate (antacid) (chew tab 500 mg, tab 648
mg)
generic
KALA TAB
BRAND
LACTRASE CAP 250 MG
BRAND
loperamide hcl (cap 2 mg, liq 1 mg/5ml (0.2 mg/ml))
generic
loperamide hcl tab 2 mg
generic
magnesium oxide tab 400 mg
generic
simethicone (chew tab 80 mg, chew tab 125 mg)
generic
simethicone susp 40 mg/0.6ml
generic
QL
31 / 31 days
sodium bicarbonate (antacid) (tab 325 mg, tab 650 mg)
generic
QL
100 / 31 days
MDD
2 per day
HISTAMINE2 (H2) RECEPTOR ANTAGONISTS
AXID AR TAB 75 MG
BRAND
cimetidine tab 200 mg
generic
famotidine (tab 10 mg, tab 20 mg)
generic
ranitidine hcl tab 150 mg
generic
generic
MDD
2 per day
LAXATIVES
*sodium phosphates - soln***
generic
benzocaine-docusate sodium rectal enema 20-283 mg
generic
bisacodyl ec tab dr 5 mg
generic
MDD
1 per day
bisacodyl laxative suppos 10 mg
generic
QL
12 / claim
calcium polycarbophil tab 625 mg
generic
MDD
10 per day
PAGE 24
PRODUCT DESCRIPTION
BRAND/GEN
complete ready-to-use enema enema 7-19 gm/118ml
generic
docusate calcium cap 240 mg
generic
docusate sodium (cap 50 mg, enema 283 mg, liquid 150
mg/15ml, syrup 60 mg/15ml, tab 100 mg)
generic
docusate sodium cap 100 mg
generic
MDD
3 per day
generic
MDD
3 per day
DOCUSOL MINI ENEMA 283 MG
BRAND
DOCUSOL PLUS MINI-ENEMA ENEMA 20-283 MG
BRAND
ENEMEEZ MINI ENEMA 283 MG
BRAND
ENEMEEZ PLUS ENEMA 20-283 MG
BRAND
fiber cap 0.52 gm
generic
FLEET BISACODYL ENEMA 10 MG/30ML
BRAND
glycerin (laxative) (suppos 1.2 gm, suppos 2 gm)
generic
KONSYL (POWDER 60.3 %, POWDER 71.67 %)
BRAND
KONSYL-D POWDER 52.3 %
BRAND
magnesium citrate solution 1.745 gm/30ml
generic
methylcellulose tab 500 mg
generic
milk of magnesia suspension 400 mg/5ml
generic
mineral oil enema
generic
polyethylene glycol 3350 oral packet
generic
polyethylene glycol 3350 oral powder
generic
psyllium (powder 28.3%, powder 30.9%, powder 33%,
powder 48.57%, powder 50%, powder 58.6%, powder
68%, powder 100%)
generic
senna syrup 176 mg/5ml
generic
senna tab 8.6 mg
generic
senna-docusate sodium tab 8.6-50 mg
generic
sennosides syrup 8.8 mg/5ml
generic
sorbitol (laxative) (oral solution, rectal solution)
generic
PAGE 25
QL
992 / 31 days
MDD
34 per day
MDD
4 per day
PRODUCT DESCRIPTION
BRAND/GEN
PROTON PUMP INHIBITORS
lansoprazole cap delayed release 15 mg
generic
MDD
4 per day
NEXIUM 24HR CAP DR 20 MG
BRAND
MDD
2 per day
omeprazole delayed release tab 20 mg
generic
MDD
4 per day
omeprazole magnesium cap dr 20.6 mg (20 mg base
equiv)
generic
omeprazole-sodium bicarbonate cap 20-1100 mg
generic
MDD
2 per day
PRILOSEC OTC TAB DR 20 MG
BRAND
MDD
4 per day
ENCARE SUPPOS 100 MG
BRAND
MPL
1 / claim
GYNOL II GEL 2 %
BRAND
MPL
1 / claim
OPTIONS GYNOL II CONTRACEPTIVE GEL 3 %
BRAND
MPL
1 / claim
povidone-iodine douche soln 10%
generic
MPL
1 / claim
VCF VAGINAL CONTRACEPTIVE (FILM 28 %, FOAM
12.5 %)
BRAND
MPL
1 / claim
GENITOURINARY AGENTS
GENITOURINARY AGENTS, OTHER
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)
PROGESTINS
levonorgestrel tab 1.5 mg
QL
generic
MFL
1 / 21 days
4 / 365 days
METABOLIC BONE DISEASE AGENTS
cholecalciferol cap 50000 unit
generic
QL
*alcohol swabs***
generic
MDS
*oral vehicles - syrup***
generic
8 / 30 days
MISCELLANEOUS THERAPEUTIC AGENTS
PAGE 26
400 / 30 DAYS
PRODUCT DESCRIPTION
BRAND/GEN
*respiratory therapy supplies - misc**
generic
QL
1 / 360 days
*respiratory therapy supplies - mouthpieces**
generic
QL
1 / 180 days
*saline nasal gel**
generic
12 hour nasal relief spray solution 0.05 %
generic
acetaminophen (cap 500 mg, chew tab 80 mg, chew tab
160 mg, elixir 160 mg/5ml, liquid 160 mg/5ml, susp 80
mg/0.8ml, susp 160 mg/5ml, tab 325 mg, tab 500 mg, tab
cr 650 mg)
generic
acetaminophen (suppos 120 mg, suppos 325 mg, suppos
650 mg)
generic
QL
12 / 31 days
ADULT AEROSOL MASK MISC
BRAND
QL
1 / 360 days
AIMSCO LUBRICATED MISC
BRAND
QL
36 / 30 days
AIRS PEDIATRIC AEROSOL MASK MISC
BRAND
QL
1 / 360 days
AIRZONE PEAK FLOW METER (, DEVICE)
BRAND
QL
2 / 360 days
ALBUSTIX STRIP
BRAND
QL
100 / 30 days
ALCOHOL PREP PAD 70 %
BRAND
MDS
400 / 30 DAYS
ALCOHOL SWABS PAD 70 %
BRAND
MDS
400 / 30 DAYS
ALLEVYN PLUS CAVITY PAD 4"X4"
BRAND
ALLEVYN THIN PAD 4"X4"
BRAND
ARIAL CHAMBER DEVICE
BRAND
QL
2 / 360 days
ASSESS FULL RANGE PEAK METER DEVICE
BRAND
QL
2 / 360 days
ASSESS LOW RANGE PEAK METER DEVICE
BRAND
QL
2 / 360 days
ASSESS PEAK FLOW METER DEVICE
BRAND
QL
2 / 360 days
ASTHMA CHECK METER-ZONE SYSTEM DEVICE
BRAND
QL
2 / 360 days
ASTHMAMENTOR DEVICE
BRAND
QL
2 / 360 days
AYR SALINE NASAL DROPS SOLUTION 0.65 %
BRAND
BD SWAB SINGLE USE REGULAR PAD
BRAND
PAGE 27
MDS
400 / 30 DAYS
PRODUCT DESCRIPTION
BRAND/GEN
BIATAIN ADHESIVE FOAM DRESSING PAD 4"X4"
BRAND
BIATAIN FOAM DRESSING PAD 4"X4"
BRAND
BORDERED GAUZE PAD 4"X4"
BRAND
BUBBLES THE FISH II PEDI MASK MISC
BRAND
CARRASMART FOAM PAD 4"X4"
BRAND
CARRASMART PAD 4"X4"
BRAND
CHEMSTRIP 10 MD STRIP
QL
1 / 360 days
BRAND
QL
30 / 30 days
CHEMSTRIP 10/SG STRIP
BRAND
QL
30 / 30 days
CHEMSTRIP 2 GP STRIP
BRAND
QL
30 / 30 days
CHEMSTRIP 5 OB STRIP
BRAND
QL
30 / 30 days
CHEMSTRIP 7 STRIP
BRAND
QL
30 / 30 days
CHEMSTRIP 9 STRIP
BRAND
QL
30 / 30 days
CHEMSTRIP MICRAL STRIP
BRAND
QL
100 / 30 days
CHEMSTRIP UGK STRIP
BRAND
QL
100 / 30 days
CHEW Q CHEW TAB 100 MG
BRAND
chlorhexidine gluconate liquid 4%
generic
COMBISTIX STRIP
BRAND
QL
30 / 30 days
CONE MASK MISC
BRAND
QL
1 / 360 days
COPA ISLAND BORDERED FOAM PAD 4"X4"
BRAND
COPA PLUS HYDROPHILIC FOAM PAD 4"X4"
BRAND
COVRSITE COVER DRESSING PAD 4"X4"
BRAND
COVRSITE PLUS COMPOSITE DRESS PAD 4"X4"
BRAND
cromolyn sodium nasal aerosol soln 5.2 mg/act (4%)
generic
QL
26 / 30 days
CUREX ALL-PURPOSE SPONGES PAD 4"X4"
BRAND
CURITY ALCOHOL PREPS PAD 70 %
BRAND
CURITY ALL PURPOSE SPONGES (PAD 2"X2", PAD
3"X3", PAD 4"X4")
BRAND
PAGE 28
MDS
400 / 30 DAYS
PRODUCT DESCRIPTION
BRAND/GEN
CURITY AMD ANTIMICROBIAL SPNGE PAD 2"X2"
BRAND
CURITY COVER SPONGE (PAD 3"X3", PAD 4"X4")
BRAND
CURITY DRESSING SPONGES PAD 4"X4"
BRAND
CURITY GAUZE (PAD 2"X2", PAD 3"X3", PAD 4"X4")
BRAND
CURITY GAUZE SPONGE (PAD 2"X2", PAD 3"X3", PAD
4"X4")
BRAND
CURITY NON-ADHERENT STRIPS PAD 3"X3"
BRAND
CURITY SPONGES (PAD 2"X2", PAD 4"X4")
BRAND
CVS ADHESIVE DRESSINGS 4"X4" PAD 4"X4"
BRAND
CVS ALCOHOL PREP SWABS PAD 70 %
BRAND
MDS
400 / 30 DAYS
CVS ALCOHOL SWABS PAD
BRAND
MDS
400 / 30 DAYS
CVS GAUZE PAD 4"X4"
BRAND
CVS GAUZE PAD STERILE PAD 3"X3"
BRAND
CVS GAUZE STERILE PAD 2"X2"
BRAND
CVS KETONE CARE STRIP
BRAND
CVS NON-ADHESIVE (PAD 2"X2", PAD 3"X3", PAD
4"X4")
BRAND
CVS PREP PAD 70 %
BRAND
CVS STERILE PADS PAD 4"X4"
BRAND
CYTO-Q MAX LIQUID 100 MG/ML
BRAND
DELBASE COMPOUNDING OINTMENT
BRAND
DERMACEA DRAIN SPONGES PAD 4"X4"
BRAND
DERMACEA GAUZE SPONGE (PAD 2"X2", PAD 3"X3",
PAD 4"X4")
BRAND
DERMACEA IV DRAIN SPONGES (PAD 2"X2", PAD
4"X4")
BRAND
DERMACEA IV SPONGES PAD 2"X2"
BRAND
DERMACEA NON-WOVEN SPONGES (PAD 2"X2", PAD
3"X3", PAD 4"X4")
BRAND
DERMACEA TYPE VII GAUZE (PAD 2"X2", PAD 3"X3",
PAD 4"X4")
BRAND
PAGE 29
QL
MDS
100 / 30 days
400 / 30 DAYS
PRODUCT DESCRIPTION
BRAND/GEN
DERMACEA X-RAY SPONGES PAD 4"X4"
BRAND
DERMALEVIN ADHESIVE PAD 4"X4"
BRAND
DRESSING SPONGES PAD 4"X4"
BRAND
EARLOOP MASK MISC
BRAND
QL
EASY TOUCH ALCOHOL PREP MEDIUM PAD 70 %
BRAND
MDS
ELEXA NATURAL FEEL MISC
BRAND
QL
36 / 30 days
ELEXA STIMULATING MISC
BRAND
QL
36 / 30 days
ELEXA ULTRA SENSITIVE MISC
BRAND
QL
36 / 30 days
EQL GAUZE (PAD 2"X2", PAD 4"X4")
BRAND
EQL GAUZE STERILE PAD 3"X3"
BRAND
EXCILON DRAIN SPONGES PAD 4"X4"
BRAND
EXCILON IV SPONGES PAD 2"X2"
BRAND
FANTASY LUBRICATED MISC
BRAND
QL
36 / 30 days
FANTASY LUBRICATED/SPERMICIDE MISC
BRAND
QL
36 / 30 days
FC FEMALE CONDOM MISC
BRAND
QL
36 / 30 days
FC2 FEMALE CONDOM MISC
BRAND
QL
36 / 30 days
FIFTY50 ALCOHOL PREP PAD 70 %
BRAND
MDS
400 / 30 DAYS
FLEXZAN PAD 4"X4"
BRAND
gauze pads & dressings (pads pads 2" 2"***, pads pads 3"
3"***, pads pads 4" 4"***)
generic
GAUZE SPONGE PAD 4"X4"
BRAND
ginger (zingiber officinalis) cap 250 mg
generic
MDD
4 per day
GNP ALCOHOL SWABS (PAD, PAD 70 %)
BRAND
MDS
400 / 30 DAYS
GNP STERILE PADS PAD 3"X3"
BRAND
HEMA-COMBISTIX STRIP
BRAND
hydrophilic ointment
generic
HYDROPHILIC OINTMENT
BRAND
PAGE 30
QL
1 / 360 days
400 / 30 DAYS
30 / 30 days
PRODUCT DESCRIPTION
BRAND/GEN
ISLAND GARD-GRX (PAD 2"X2", PAD 4"X4")
BRAND
J & J GAUZE SPONGES 12-PLY MISC 4"X4"
BRAND
BRAND
BRAND
J & J NON-STICK DRESSING PAD 3"X3"
BRAND
KAMELEON LUBRICATED MISC
BRAND
KENDALL HYDROPHILIC FOAM DRESS (FOAM PAD
2"X2", FOAM PAD 3"X3", FOAM PAD 4"X4")
BRAND
KENDALL HYDROPHILIC FOAM PLUS (FOAM PAD
2"X2", FOAM PAD 3"X3")
BRAND
KERLIX SPONGES PAD 4"X4"
BRAND
KETO-DIASTIX STRIP
QL
36 / 30 days
BRAND
QL
100 / 30 days
KIMONO MICRO THIN MISC
BRAND
C
KIMONO MICRO THIN PLUS MISC
BRAND
QL
36 / 30 days
KIMONO MISC
BRAND
QL
36 / 30 days
KIMONO PLUS MISC
BRAND
QL
36 / 30 days
KIMONO PS MISC
BRAND
QL
36 / 30 days
KIMONO PS PLUS MISC
BRAND
QL
36 / 30 days
KIMONO SENSATION MISC
BRAND
QL
36 / 30 days
KIMONO SENSATION PLUS MISC
BRAND
QL
36 / 30 days
LABSTIX STRIP
BRAND
QL
30 / 30 days
lanolin
generic
lanolin anhydrous
generic
LIQ-10 SYRUP 50-15
BRAND
MAXX MISC
BRAND
QL
36 / 30 days
MAXX PLUS MISC
BRAND
QL
36 / 30 days
PAGE 31
Limit=1/30 days; Pkg
Size 3: Package
Limit=4/30 days
PRODUCT DESCRIPTION
BRAND/GEN
MEIJER ALCOHOL SWABS PAD 70 %
BRAND
MDS
400 / 30 DAYS
melatonin (tab 3 mg, tab 5 mg)
generic
MDD
1 per day
MICRO-BUMINTEST KIT
BRAND
QL
30 / 30 days
MICROELITE BATTERY MISC
BRAND
QL
1 / 360 days
MICROELITE FILTER REPLACEMENTS MISC
BRAND
QL
1 / 360 days
MICROLIFE DIGITAL PEAK FLOW DEVICE
BRAND
QL
2 / 360 days
MINI WRIGHT PEAK FLOW METER DEVICE
BRAND
QL
2 / 360 days
MINIELITE FILTER REPLACEMENTS MISC
BRAND
QL
1 / 360 days
MIRASORB SPONGES (MISC 2"X2", MISC 4"X4")
BRAND
MULTISTIX 10 SG STRIP
BRAND
QL
30 / 30 days
MULTISTIX 5 STRIP
BRAND
QL
30 / 30 days
MULTISTIX 7 STRIP
BRAND
QL
30 / 30 days
MULTISTIX 8 STRIP
BRAND
QL
30 / 30 days
MULTISTIX 9 SG STRIP
BRAND
QL
30 / 30 days
MULTISTIX 9 STRIP
BRAND
QL
30 / 30 days
MULTISTIX STRIP
BRAND
QL
30 / 30 days
nasal decongestant solution 1 %
generic
nasal moisturizing spray solution 0.65 %
generic
NEO-SYNEPHRINE SOLUTION 0.5 %
BRAND
NESSI SPACER WITH MASK LARGE DEVICE
BRAND
QL
2 / 360 days
NESSI SPACER WITH MASK SM/MED DEVICE
BRAND
QL
2 / 360 days
NESSI SPACER WITH MOUTHPIECE DEVICE
BRAND
QL
2 / 360 days
NOVA MAX PLUS KETONE TEST STRIP
BRAND
MDS
30 / 30 DAYS
NU GAUZE GENERAL-USE SPONGES MISC 4"X4"
BRAND
MPL
OFF DEEP WOODS AEROSOL
BRAND
1 / claim
MFL
2 / 30 days
PAGE 32
MPL
1 / claim
PRODUCT DESCRIPTION
BRAND/GEN
OFF DEEP WOODS DRY AEROSOL
BRAND
MPL
1 / claim
MFL
2 / 30 days
OPTICHAMBER FACE MASK-LARGE MISC
BRAND
QL
2 / 360 days
OPTICHAMBER FACE MASK-MEDIUM MISC
BRAND
QL
2 / 360 days
OPTICHAMBER FACE MASK-SMALL MISC
BRAND
QL
2 / 360 days
OPTIFOAM PAD 4"X4"
BRAND
PEAK AIR PEAK FLOW METER DEVICE
BRAND
QL
2 / 360 days
PEAK FLOW METER UNIVERSAL RANG DEVICE
BRAND
QL
2 / 360 days
PEDIATRIC AEROSOL MASK MISC
BRAND
QL
1 / 360 days
PEDIATRIC MOUTHPIECE MISC
BRAND
QL
1 / 360 days
permethrin (aerosol 0.5%, creme rinse 1%)
generic
PERSONAL BEST FULL RANGE DEVICE
BRAND
QL
2 / 360 days
PERSONAL BEST LOW RANGE DEVICE
BRAND
QL
2 / 360 days
petrolatum, hydrophilic ointment
generic
phenylephrine hcl tab 10 mg
generic
QL
24 / claim
PIKO 1 DEVICE
BRAND
QL
2 / 360 days
POCKET PEAK FLOW METER DEVICE
BRAND
QL
2 / 360 days
polyethylene glycol 3350 powder
generic
MDD
34 per day
POLYMEM DRESSING (PAD 3"X3", PAD 4"X4")
BRAND
povidone-iodine (oint 10%, soln 7.5%, soln 10%)
generic
MPL
1 / claim
POVIDONE-IODINE PAD 10 %
BRAND
MPL
1 / claim
PRECISION XTRA KETONE STRIP
BRAND
MDS
30 / 30 DAYS
PREMIUM CONDOMS LUBRICATED MISC
BRAND
QL
36 / 30 days
pseudoephedrine hcl (liq 15 mg/5ml, tab 60 mg)
generic
pseudoephedrine hcl er tab er 12h 120 mg
generic
QL
62 / 31 days
PAGE 33
PRODUCT DESCRIPTION
BRAND/GEN
pseudoephedrine hcl tab 30 mg
generic
PTS PANELS KETONE TEST STRIP
BRAND
MDS
30 / 30 DAYS
QC ALCOHOL SWABS PAD 70 %
BRAND
MDS
400 / 30 DAYS
QH LIQUID 100 MG/ML
BRAND
RA ALCOHOL SWABS PAD 70 %
BRAND
MDS
400 / 30 DAYS
RA ALL PURPOSE DRESSINGS PAD 4"X4"
BRAND
RA DRESSING SPONGES PAD 4"X4"
BRAND
RA GAUZE SPONGES PAD 4"X4"
BRAND
RA STERILE (PAD 2"X2", PAD 3"X3", PAD 4"X4")
BRAND
RAY-TEC X-RAY DETECTABLE SPNGE MISC 4"X4"
BRAND
REALITY LATEX/ULTRA TEXTURED DEVICE
BRAND
QL
36 / 30 days
REALITY LATEX/ULTRA THIN DEVICE
BRAND
QL
36 / 30 days
RELION ALCOHOL SWABS (PAD, PAD 70 %)
BRAND
MDS
REPLACEMENT FILTERS MISC
BRAND
QL
1 / 360 days
RESTORE CONTACT LAYER PAD 2"X2"
BRAND
RESTORE FOAM DRESSING PAD 4"X4"
BRAND
RESTORE ODOR ABSORBING DRESS PAD 4"X4"
BRAND
RESTORE TRIO ABSORBENT DRESS PAD 3"X3"
BRAND
SAMI THE SEAL FILTERS MISC
BRAND
QL
1 / 360 days
SB ALCOHOL PREP PAD 70 %
BRAND
MDS
400 / 30 DAYS
SHOPKO ALCOHOL SWABS PAD 70 %
BRAND
MDS
400 / 30 DAYS
SIDESTREAM ADULT FACE MASK MISC
BRAND
QL
1 / 360 days
SIDESTREAM PEDIATRIC FACE MASK MISC
BRAND
QL
1 / 360 days
SIDESTREAM PLS ADULT FACE MASK MISC
BRAND
QL
1 / 360 days
simethicone liquid 40 mg/0.6ml
generic
QL
31 / 31 days
SIMPLYTHICK GEL
BRAND
AL
At least 1 yrs old
PAGE 34
400 / 30 DAYS
PRODUCT DESCRIPTION
BRAND/GEN
SM ALCOHOL PREP (PAD, PAD 70 %)
BRAND
SM GAUZE (PAD 2"X2", PAD 3"X3", PAD 4"X4")
BRAND
SM STERILE PAD 2"X2"
BRAND
sorbitol solution (bulk)
generic
SORBITOL SOLUTION 70 %
BRAND
STERI-PAD STERILE PAD 4"X4"
BRAND
STERILE (PAD 2"X2", PAD 3"X3", PAD 4"X4")
BRAND
TEGADERM FOAM (FOAM PAD 2"X2", FOAM PAD
4"X4")
BRAND
TGT ALCOHOL SWABS PAD 70 %
BRAND
THERAGAUZE PAD 2"X2"
BRAND
TROJAN MAGNUM WARM SENSATIONS DEVICE
BRAND
QL
36 / 30 days
TROJAN SUPRAS SPERMICIDAL DEVICE
BRAND
QL
36 / 30 days
TROJAN TWISTED PLEASURE DEVICE
BRAND
QL
36 / 30 days
TRUSTEX COLOR CONDOMS + LUBE MISC
BRAND
QL
36 / 30 days
TRUSTEX LUB/RIBBED/STUDDED MISC
BRAND
QL
36 / 30 days
TRUSTEX LUB/SPERMICIDE EX ST MISC
BRAND
QL
36 / 30 days
TRUSTEX LUB/SPERMICIDE XL MISC
BRAND
QL
36 / 30 days
TRUSTEX LUBRICATED EX LARGE MISC
BRAND
QL
36 / 30 days
TRUSTEX LUBRICATED EXTRA ST MISC
BRAND
QL
36 / 30 days
TRUSTEX LUBRICATED MISC
BRAND
QL
36 / 30 days
TRUSTEX LUBRICATED/SPERMICIDE MISC
BRAND
QL
36 / 30 days
TRUSTEX NATURAL CONDOMS + LUBE MISC
BRAND
QL
36 / 30 days
TRUSTEX NON-LUBRICATED MISC
BRAND
C
TRUSTEX RIA LUB/SPERMICIDE MISC
BRAND
QL
PAGE 35
MDS
400 / 30 DAYS
MDS
400 / 30 DAYS
Size 3: Package
Limit=4/30 days
36 / 30 days
PRODUCT DESCRIPTION
BRAND/GEN
TRUSTEX RIA LUBRICATED MISC
BRAND
QL
TRUSTEX RIA NON-LUBRICATED MISC
BRAND
C
TRUSTEX-NONOXYNOL-9/RIB/STUD MISC
BRAND
QL
36 / 30 days
TUBING/WING TIP MISC
BRAND
QL
1 / 360 days
ULTILET ALCOHOL SWAB PAD
BRAND
MDS
400 / 30 DAYS
ULTILET ALCOHOL SWABS PAD
BRAND
MDS
400 / 30 DAYS
MPL
ULTRATHON INSECT REPELLENT 8 AEROSOL 25 %
BRAND
1 / claim
MFL
2 / 30 days
36 / 30 days
Size 3: Package
Limit=4/30 days
URISTIX 4 STRIP
BRAND
QL
30 / 30 days
URISTIX STRIP
BRAND
QL
30 / 30 days
UTI HOME TEST
BRAND
QL
30 / 30 days
VERSIVA XC (PAD 3"X3", PAD 4"X4")
BRAND
VISTEC X-RAY DETECTABLE SPONGE PAD 4"X4"
BRAND
WEBCOL ALCOHOL PREP LARGE PAD 70 %
BRAND
MDS
400 / 30 DAYS
WEBCOL ALCOHOL PREP MEDIUM PAD 70 %
BRAND
MDS
400 / 30 DAYS
white petrolatum gel
generic
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS, OTHER
*artificial tear ophth ointment***
generic
*artificial tear ophth solution***
generic
*white petrolatum-mineral oil ophth ointment***
generic
ARTIFICIAL TEARS SOLUTION 0.4 %
BRAND
carboxymethylcellulose sodium ophth soln 0.5%
generic
GENTEAL MILD SOLUTION 0.2 %
BRAND
PAGE 36
QL
4 / claim
MPL
1 / claim
PRODUCT DESCRIPTION
BRAND/GEN
GENTEAL SEVERE GEL 0.3 %
BRAND
hypromellose ophth soln 0.3%
generic
hypromellose ophth soln 0.4%
generic
ISOPTO TEARS SOLUTION 0.5 %
BRAND
ketotifen fumarate ophth soln 0.025% (base equiv)
generic
naphazoline w/ pheniramine ophth soln 0.025-0.3%
generic
naphazoline w/ pheniramine ophth soln 0.027-0.315%
generic
polyethylene glycol-propylene glycol ophth soln 0.4-0.3%
generic
polyvinyl alcohol ophth soln 1.4%
generic
propylene glycol ophth soln 0.6%
generic
REFRESH CELLUVISC SOLUTION 1 %
BRAND
REFRESH LIQUIGEL SOLUTION 1 %
BRAND
sodium chloride hypertonic (oint, soln)
generic
SYSTANE OVERNIGHT THERAPY GEL 0.3 %
BRAND
tetrahydrozoline hcl ophth soln 0.05%
QL
MPL
15 / claim
1 / 31 days
QL
15 / 30 days
QL
31 / 31 days
MPL
1 / 31 days
generic
MPL
1 / 30 days
generic
QL
15 / 31 days
QL
17 / 30 days
AL
At least 2 yrs old
OTIC AGENTS
carbamide peroxide 6.5% otic soln
RESPIRATORY TRACT/PULMONARY AGENTS
ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS
triamcinolone acetonide nasal aerosol suspension 55
mcg/act
generic
ANTIHISTAMINES
ALER-DRYL TAB 50 MG
BRAND
MDD
cetirizine hcl allergy child solution 5 mg/5ml
generic
QL
cetirizine hcl chew tab 10 mg
generic
MDD
PAGE 37
4 per day
240 / claim
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
generic
MDD
1 per day
cetirizine hcl tab 10 mg
generic
MDD
1 per day
generic
MDD
1 per day
childrens loratadine syrup 5 mg/5ml
generic
QL
240 / claim
chlorpheniramine maleate er tab er 12 mg
generic
chlorpheniramine maleate syrup 2 mg/5ml
generic
chlorpheniramine maleate tab 4 mg
generic
QL
120 / claim
generic
QL
120 / claim
CLARITIN CHEW TAB 5 MG
BRAND
clemastine fumarate tab 1.34 mg
generic
MDD
2 per day
diphenhydramine hcl cap 25 mg
generic
MDD
4 per day
generic
MDD
4 per day
diphenhydramine hcl elixir 12.5 mg/5ml
generic
QL
240 / claim
diphenhydramine hcl liquid 12.5 mg/5ml
generic
QL
240 / claim
diphenhydramine hcl syrup 12.5 mg/5ml
generic
QL
240 / claim
diphenhydramine hcl tab 25 mg
generic
MDD
4 per day
ED CHLORPED LIQUID 2 MG/ML
BRAND
fexofenadine hcl tab 180 mg
generic
MDD
1 per day
generic
MDD
2 per day
loratadine allergy relief tab disp 10 mg
generic
MDD
1 per day
loratadine tab 10 mg
generic
MDD
1 per day
BRONCHODILATORS, SYMPATHOMIMETIC
ephedrine sulfate cap 25 mg
generic
RESPIRATORY TRACT AGENTS, OTHER
acetaminophen w/ dm liq 160-5 mg/5ml
PAGE 38
generic
PRODUCT DESCRIPTION
BRAND/GEN
BIONEL LIQUID 30-15-200 MG/5ML
BRAND
BIONEL PEDIATRIC LIQUID 15-5-50 MG/5ML
BRAND
BIOSPEC DMX LIQUID 15-25 MG/5ML
BRAND
brompheniramine & phenylephrine elixir 1-2.5 mg/5ml
generic
QL
MFL
brompheniramine & phenylephrine liqd 4-10 mg/5ml
generic
brompheniramine & pseudoephedrine elixir 1-15 mg/5ml
generic
QL
120 / 30 days
1 / 30 days
120 / 30 days
MFL
1 / 30 days
MDD
2 per day
brompheniramine & pseudoephedrine liquid 4-20 mg/5ml
generic
CAPMIST DM TAB 30-30-400 MG
BRAND
cetirizine-pseudoephedrine tab sr 12hr 5-120 mg
generic
chlorphen-phenylephrine w/ apap tab 2-5-325 mg
generic
chlorphen-pseudoephedrine w/ apap cap 2-30-325 mg
generic
chlorpheniramine & phenylephrine (liquid 4-10 mg/5ml, tab
3-10 mg, tab 4-10 mg)
generic
chlorpheniramine & phenylephrine liquid 1-2 mg/ml
generic
MDD
1 per day
chlorpheniramine & phenylephrine liquid 1-3.5 mg/ml
generic
QL
30 / claim
chlorpheniramine & pseudoephedrine tab 4-60 mg
generic
chlorpheniramine-dm liquid 2-15 mg/5ml
generic
QL
240 / claim
COLD & FLU RELIEF NIGHTTIME D LIQUID 60-12.5-301000 MG/30ML
BRAND
DECON-A LIQUID 2-5 MG/ML
BRAND
dextromethorphan hbr (liquid 15 mg/5ml, liquid 15
mg/15ml, syrup 7.5 mg/5ml)
generic
dextromethorphan polistirex er liquid er 30 mg/5ml
generic
dextromethorphan-apap-chlorpheniramine susp 5-160-1
mg/5ml
generic
dextromethorphan-doxylamine-apap liquid 30-12.5-1000
mg/30ml
generic
PAGE 39
PRODUCT DESCRIPTION
BRAND/GEN
dextromethorphan-guaifenesin (cap 10-200 mg, liquid 5100 mg/5ml, liquid 10-200 mg/15ml, liquid 30-200 mg/5ml,
tab 20-400 mg, tab sr 12hr 60-1200 mg)
generic
dextromethorphan-guaifenesin (liquid 10-200 mg/5ml,
liquid 10-100 mg/5ml, syrup 10-100 mg/5ml)
generic
dextromethorphan-guaifenesin tab sr 12hr 30-600 mg
generic
QL
240 / claim
QL
210 / claim
MDD
dextromethorphan-phenylephrine-acetaminophen (cap mg,
liqd mg/15ml, tab mg)
generic
DIMETAPP LONG ACT COUGH/COLD SYRUP 1-7.5
MG/5ML
BRAND
diphenhydramine-phenylephrine (liq 6.25-2.5 mg/5ml, soln
12.5-5 mg/5ml)
generic
diphenhydramine-phenylephrine-acetaminophen (mg/10ml,
mg/15ml)
generic
diphenhydramine-phenylephrine-apap liq 6.25-2.5-160
mg/5ml
generic
doxylamine-dm liquid 6.25-15 mg/15ml
generic
ED BRON GP LIQUID 5-100 MG/5ML
BRAND
guaifenesin liquid 100 mg/5ml
generic
QL
MPL
QL
MFL
guaifenesin syrup 100 mg/5ml
generic
guaifenesin tab 400 mg
generic
guaifenesin tab sr 12hr 1200 mg
generic
guaifenesin tab sr 12hr 600 mg
generic
QL
MDD
QL
240 / claim
1 / claim
240 / 6 days
1 / 30 days
240 / 6 days
2 per day
40 / 30 days
MFL
1 / 30 days
240 / claim
guaifenesin-codeine soln 100-10 mg/5ml
generic
LITTLE REMEDIES FOR COLDS LIQUID 2.5-1.25-80
MG/ML
BRAND
LOHIST-D LIQUID 2-30 MG/5ML
BRAND
QL
loratadine & pseudoephedrine tab sr 12hr 5-120 mg
generic
MDD
PAGE 40
2 per day
2 per day
PRODUCT DESCRIPTION
BRAND/GEN
loratadine & pseudoephedrine tab sr 24hr 10-240 mg
generic
M-CLEAR CAP 200-9 MG
BRAND
phenylephrine w/ acetaminophen tab 5-325 mg
generic
phenylephrine w/ dm-gg (w/ liqd 2.5-5-100 mg/5ml, w/ liqd
5-10-100 mg/5ml)
generic
phenylephrine-apap-gg tab 10-650-400 mg
generic
phenylephrine-brompheniramine-dm liquid 2.5-1-5 mg/5ml
generic
phenylephrine-chlorpheniramine-dm w/ apap (w/apap susp
2.5-1-5-160 mg/5ml, w/apap tab 5-2-10-325 mg)
generic
phenylephrine-dm soln 2.5-5 mg/5ml
generic
phenylephrine-dm-gg w/ apap (w/ liq mg/15ml, w/ tab mg)
generic
phenylephrine-doxylamine-dm-apap liq 5-6.25-10-325
mg/15ml
generic
phenylephrine-guaifenesin liqd 2.5-100 mg/5ml
generic
phenylephrine-guaifenesin liqd 5-100 mg/5ml
generic
PHENYLHISTINE DH LIQUID 30-2-10 MG/5ML
BRAND
PRO-CLEAR AC SYRUP 9-8.33 MG/5ML
BRAND
PRO-RED AC SYRUP 5-8.33-9 MG/5ML
BRAND
pseudoephed-bromphen-dm (elixir 15-1-5 mg/5ml, syrup
30-2-10 mg/5ml)
MDD
1 per day
QL
240 / claim
QL
240 / 6 days
generic
QL
240 / claim
pseudoephed-chlorphen-dm liq 15-1-5 mg/5ml
generic
QL
240 / claim
pseudoephed-doxyl-dm w/apap (w/ apap cap 30-6.25-15325 mg, w/apap liq 60-12.5-30-1000 mg/30ml)
generic
pseudoephedrine w/ apap-dm cap 30-325-15 mg
generic
pseudoephedrine w/ cod-gg soln 30-10-100 mg/5ml
generic
QL
240 / 6 days
pseudoephedrine w/ dm-gg liquid 30-10-100 mg/5ml
generic
QL
240 / 6 days
pseudoephedrine-guaifenesin tab sr 12hr 120-1200 mg
generic
MDD
pseudoephedrine-guaifenesin tab sr 12hr 60-600 mg
generic
QL
pseudoephedrine-ibuprofen (susp 15-100 mg/5ml, tab 30200 mg)
generic
PAGE 41
2 per day
210 / claim(s)
PRODUCT DESCRIPTION
BRAND/GEN
PX DAYTIME MULTI-SYMPTOM CAP 30-325-15 MG
BRAND
PX NITETIME MULTI-SYMPTOM CAP 30-6.25-15-325 MG
BRAND
REFENESEN CHST CONG/PAIN PE TAB 10-650-400 MG
BRAND
RESCON DM SYRUP 30-2-10 MG/5ML
BRAND
RESPAIRE-30 CAP 30-150 MG
BRAND
SCOT-TUSSIN SENIOR LIQUID 15-200 MG/5ML
BRAND
sodium chloride aero soln 0.9%
generic
QL
240 / claim
TRIAMINIC COLD/COUGH DAY TIME (COLD/COUGH
SOLUTION MG/5ML, COLD/COUGH SYRUP MG/5ML)
BRAND
QL
240 / claim
TRIAMINIC FLU COUGH & FEVER SYRUP 7.5-160-1
MG/5ML
BRAND
TRIAMINIC MULTI-SYMPTOM FEVER SYRUP 7.5-160-1
MG/5ML
BRAND
triprolidine & pseudoephedrine tab 2.5-60 mg
generic
TUSNEL LIQUID 30-15-200 MG/5ML
BRAND
TUSNEL PEDIATRIC LIQUID 15-5-50 MG/5ML
BRAND
SLEEP DISORDER AGENTS
SLEEP DISORDERS, OTHER
diphenhydramine hcl (sleep) (cap 50 mg, tab 50 mg)
generic
diphenhydramine hcl (sleep) tab 25 mg
generic
doxylamine succinate (sleep) tab 25 mg
generic
MDD
1 per day
THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES
ELECTROLYTE/MINERAL REPLACEMENT
*oral electrolyte solution***
generic
BIFERA TAB 28 MG
BRAND
CALCI-MIX CAP 1250 MG
BRAND
CALCIONATE SYRUP 1.8 GM/5ML
BRAND
calcium & phosphorus w/ vitamin d tab 105 mg-81 mg-120
unit
generic
PAGE 42
PRODUCT DESCRIPTION
BRAND/GEN
calcium carbonate (tab 600 mg, tab 1250 mg (500 mg
elemental ca))
generic
calcium carbonate susp 1250 mg/5ml (500 mg/5ml
elemental ca)
generic
calcium carbonate-cholecalciferol (chew tab 500 mg-600,
chew tab 500 mg-100, tab 250 mg-125, tab 500 mg-200)
generic
calcium carbonate-cholecalciferol (tab 600 mg-800, tab
600 mg-400, tab 600 mg-200)
generic
calcium carbonate-vitamin d (tab 250 mg-125, tab 500 mg125, tab 500 mg-200, tab 500 mg-400)
generic
calcium carbonate-vitamin d (tab 600 mg-400, tab 600 mg200)
generic
calcium carbonate-vitamin d w/ minerals (w/ chew tab 600
mg-800, w/ chew tab 600 mg-400)
generic
calcium citrate tab 950 mg (200 mg elemental ca)
generic
calcium citrate-vitamin d tab 200 mg-250 unit (elemental
ca)
generic
calcium gluconate tab 648 mg (60 mg elemental ca)
generic
calcium lactate (tab 648 mg (84 mg elemental ca), tab 650
mg)
generic
DUOFER TAB 28 MG
BRAND
FEOSOL BIFERA TAB 28 MG
BRAND
FERRETTS TAB 325 (106 FE) MG
BRAND
FERREX 150 PLUS CAP 150-50-50 MG
BRAND
ferrous fumarate tab 324 mg (106 mg elemental fe)
generic
ferrous gluconate (tab 240 mg (27 mg elemental fe), tab
324 mg (37.5 mg elemental iron), tab 324 mg (38 mg
elemental iron), tab 325 mg (36 mg elemental fe), tab 325
mg)
generic
FERROUS GLUCONATE TAB 225 (27 FE) MG
BRAND
PAGE 43
QL
500 / 30 days
QL
62 / 31 days
QL
62 / 31 days
PRODUCT DESCRIPTION
BRAND/GEN
ferrous sulfate (elixir 220 mg/5ml (44 mg/5ml elemental fe),
liquid 220 mg/5ml (44 mg/5ml elemental fe), tab 28 mg
(elemental fe), tab 325 mg (65 mg elemental fe), tab cr
47.5 mg (elemental fe), tab cr 140 mg (45 mg fe
equivalent), tab ec 325 mg (65 mg fe equivalent))
generic
ferrous sulfate (soln 75 mg/ml mg/ml, soln 75 mg/0.6ml
mg/0.6ml)
generic
ferrous sulfate dried tab cr 160 mg (50 mg fe equivalent)
generic
IRON CHEWS PEDIATRIC CHEW TAB 15 MG
BRAND
iron polysacch complex-vit b12-fa cap 150-0.025-1 mg
generic
MAG-TAB SR TAB ER 84 MG (7MEQ)
BRAND
MAGNEBIND 300 TAB 250-300 MG
BRAND
magnesium chloride tab cr 535 mg (64 mg elemental mg)
generic
magnesium gluconate (tab 27.5 mg (elemental mg), tab
500 mg (27 mg elemental mg), tab 500 mg)
generic
magnesium oxide (mg supplement) (cap 400 mg
(elemental (mg supplement), tab 400 mg (241.3 mg
elemental)
generic
magnesium oxide tab 400 mg (240 mg elemental mg)
generic
MAGONATE LIQUID 1000 (54 MG) MG/5ML
BRAND
MYKIDZ IRON 10 SUSPENSION 15 MG/1.5ML
BRAND
oyster shell calcium tab 500 mg
generic
PHOS-NAK PACKET 280-160-250 MG
BRAND
RA OYSTER SHELL CALCIUM/D TAB 500-200 MG-UNIT
BRAND
RISACAL-D TAB 105-81-120 MG-MG-UNIT
BRAND
SLOW-MAG TAB DR 71.5-119 MG
BRAND
zinc sulfate cap 220 mg (50 mg elemental zn)
generic
zinc tab 50 mg
generic
*b-complex w/ c & folic acid tab 0.8 mg***
generic
*b-complex w/ c cap**
generic
*b-complex w/ minerals liq**
generic
*iron w/ vitamin tab**
generic
PAGE 44
MDD
3.4 per day
MDD
2 per day
MDD
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
*multiple vitamin liquid**
generic
*multiple vitamin tab**
generic
MDD
1 per day
*multiple vitamins w/ iron tab**
generic
MDD
1 per day
*multiple vitamins w/ minerals tab**
generic
MDD
1 per day
*pediatric multiple vitamin liq**
generic
*pediatric multiple vitamin w/ c & fa chew tab**
generic
MDD
1 per day
*pediatric multiple vitamin w/ c soln 35 mg/ml**
generic
QL
50 / claim
*pediatric multiple vitamin w/ extra c & fa chew tab**
generic
*pediatric multiple vitamins w/ iron chew tab 15 mg**
generic
*pediatric multiple vitamins w/ iron drops 10 mg/ml**
generic
QL
60 / claim
*pediatric vitamins adc drops 1500 unit-400 unit-35
mg/ml***
generic
QL
50 / claim
*prenatal multivitamins & minerals w/iron & fa tab 0.8 mg***
generic
*prenatal vit w/ fe fumarate-fa tab 28-0.8 mg***
GL
generic
Female
MDD
*vitamins w/ lipotropics cap**
generic
AQUA-E LIQUID 30-2 MG/ML
BRAND
arginine tab 500 mg
generic
ascorbic acid (chew tab 500 mg, tab 250 mg, tab 500 mg,
tab 1000 mg)
generic
QL
b-complex vitamins (cap**, tab**)
generic
MDD
cholecalciferol (cap 1000, cap 2000)
generic
QL
cholecalciferol (cap 10000 unit, drops 5000 unit/ml (1000
unit/0.2ml), oral liquid 400 unit/ml, tab 1000 unit, tab 2000
unit, tab 5000 unit, tab 50000 unit)
generic
cholecalciferol cap 5000 unit
generic
CLASSIC PRENATAL TAB 28-0.8 MG
BRAND
MDD
GL
MDD
PAGE 45
1 per day
100 / 31 days
1 per day
100 / claim
2 per day
Female
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
CVS PRENATAL TAB 28-0.8 MG
BRAND
GL
MDD
GL
EQL PRENATAL FORMULA TAB 28-0.8 MG
BRAND
ergocalciferol soln 8000 unit/ml
generic
folic acid (tab 400 mcg, tab 800 mcg)
generic
folic acid tab 1 mg
generic
FOLIC ACID TAB 200 MCG
BRAND
GNP DAILY PRENATAL MISC 28-0.8 & 440 MG
BRAND
GNP PRENATAL TAB 28-0.8 MG
BRAND
MDD
1 per day
GL
BRAND
MDD
BRAND
HM PRENATAL TAB 28-0.8 MG
BRAND
GL
MDD
KEY-E CHEW TAB 400 UNIT
BRAND
KP PRENATAL MULTIVITAMINS TAB 28-0.8 MG
BRAND
BRAND
MISSION PRENATAL FA TAB
BRAND
GL
MDD
GL
BRAND
MDD
BRAND
multiple vitamins w/ minerals (w/ cap**, w/ liquid**)
generic
PAGE 46
1 per day
Female
1 per day
Female
BRAND
MULTI-DELYN/IRON LIQUID
Female
GL
MDD
MISSION PRENATAL TAB
1 per day
62 / 31 days
GL
MISSION PRENATAL HP TAB
Female
QL
MDD
KPN PRENATAL TAB 0.1 MG
Female
1 per day
MDD
HM ONE DAILY PRENATAL MISC 28-0.8 & 440 MG
1 per day
MDD
GL
GNP PRENATAL VITAMINS TAB 28-0.8 MG
Female
1 per day
Female
1 per day
Female
1 per day
Female
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
MYKIDZ IRON SUSPENSION 10 MG/2ML
BRAND
niacin (cap cr 250 mg, cap cr 500 mg, tab 500 mg)
generic
NUTRICION PORVIDA 0.25 MG
BRAND
ONE-A-DAY WOMENS PRENATAL MISC 28-0.8 & 440
MG
BRAND
pediatric multiple vitamin w/ minerals & c (w/ drops 45
mg/ml**, w/ hew tab 30 mg**, w/ hew tab 60 mg**)
generic
PERRY PRENATAL CAP 13.5-0.4 MG
BRAND
PNV PRENATAL PLUS MULTIVITAMIN TAB 27-1 MG
BRAND
GL
POLYCOSE (, LIQUID, POWDER)
BRAND
polysaccharide iron complex cap 150 mg (iron equivalent)
generic
PRENATAL FORMULA TAB 28-0.8 MG
BRAND
MDD
1 per day
MDD
1 per day
GL
MDD
GL
PRENATAL TAB 28-0.8 MG
BRAND
PRESERVISION AREDS TAB
BRAND
PROFE CAP 391.3 (180 FE) MG
BRAND
PRORENAL + D TAB
BRAND
PRORENAL + D W/ OMEGA-3 CAP
BRAND
PX PRENATAL MULTIVITAMINS TAB 28-0.8 MG
BRAND
QC PRENATAL TAB 28-0.8 MG
BRAND
1 per day
MDD
1 per day
MDD
BRAND
RA PRENATAL FORMULA TAB 28-0.8 MG
BRAND
GL
MDD
PAGE 47
Female
MDD
GL
RA ONE DAILY MISC 28-0.8 & 440 MG
1 per day
1 per day
MDD
generic
Female
MDD
GL
pyridoxine hcl (tab 25 mg, tab 50 mg, tab 100 mg)
Female
Female
1 per day
Female
1 per day
Female
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
RA PRENATAL TAB 28-0.8 MG
BRAND
GL
MDD
riboflavin (tab 25 mg, tab 50 mg, tab 100 mg)
generic
SM ONE DAILY PRENATAL MISC 28-0.8 & 440 MG
BRAND
SM PRENATAL VITAMINS TAB 28-0.8 MG
BRAND
100 / 31 days
GL
Female
GL
BRAND
MDD
GL
TH PRENATAL VITAMINS TAB 28-0.8 MG
BRAND
MDD
GL
THERANATAL CORE NUTRITION TAB 27-1 MG
1 per day
QL
MDD
STUART PRENATAL TAB 28-0.8 MG
Female
BRAND
MDD
1 per day
Female
1 per day
Female
1 per day
Female
1 per day
thiamine hcl (tab 50 mg, tab 100 mg, tab 250 mg, tab 500
mg)
generic
QL
100 / 31 days
thiamine mononitrate tab 100 mg
generic
QL
100 / 31 days
TRI-VI-SOL/IRON SOLUTION 10 MG/ML
BRAND
vitamin e (cap 100, cap 200, cap 400)
generic
QL
62 / 31 days
vitamin e soln 15 unit/0.3ml (50 unit/ml)
generic
PAGE 48
LIST OF COVERED PRESCRIPTION MEDICATIONS
PRODUCT DESCRIPTION
BRAND/GEN
ANALGESICS
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
butalbital-aspirin-caffeine tab 50-325-40 mg
generic
celecoxib (cap 50 mg, cap 100 mg, cap 200 mg)
generic
MDD
PA
MDD
choline & magnesium salicylates tab 1000 mg
generic
diclofenac potassium tab 50 mg
generic
diclofenac sodium (tab delayed release 25 mg, tab delayed
release 50 mg, tab delayed release 75 mg, tab sr 24hr 100
mg)
generic
diflunisal tab 500 mg
generic
etodolac (cap 200 mg, cap 300 mg, tab 400 mg, tab 500
mg, tab sr 24hr 600 mg, tab sr 24hr 400 mg, tab sr 24hr
500 mg)
generic
fenoprofen calcium tab 600 mg
generic
flurbiprofen (tab 50 mg, tab 100 mg)
generic
ibuprofen (tab 400 mg, tab 600 mg, tab 800 mg)
generic
INDOCIN (SUPPOS 50 MG, SUSPENSION 25 MG/5ML)
BRAND
indomethacin (cap 25 mg, cap 50 mg, cap cr 75 mg)
generic
ketoprofen (cap 50 mg, cap 75 mg, cap sr 24hr 200 mg)
generic
ketorolac tromethamine tab 10 mg
generic
LEVACET TAB 500-250-150 MG
BRAND
meclofenamate sodium (cap 50 mg, cap 100 mg)
generic
meloxicam (susp 7.5 mg/5ml, tab 7.5 mg, tab 15 mg)
generic
nabumetone (tab 500 mg, tab 750 mg)
generic
naproxen (susp 125 mg/5ml, tab 250 mg, tab 375 mg, tab
500 mg)
generic
PAGE 49
4 per day
2 per day
QL
20 / 30 days
AL
At least 17 yrs old
PRODUCT DESCRIPTION
BRAND/GEN
naproxen (tab ec 375 mg, tab ec 500 mg)
generic
naproxen sodium (tab 275 mg, tab 550 mg)
generic
oxaprozin tab 600 mg
generic
piroxicam (cap 10 mg, cap 20 mg)
generic
salsalate (tab 500 mg, tab 750 mg)
generic
sulindac (tab 150 mg, tab 200 mg)
generic
MDD
2 per day
OPIOID ANALGESICS, LONG-ACTING
fentanyl (patch 72hr 25 mcg/hr, patch 72hr 12 mcg/hr,
patch 72hr 100 mcg/hr, patch 72hr 75 mcg/hr, patch 72hr
50 mcg/hr)
generic
MDD
0.33 per day
methadone hcl (conc 10 mg/ml, tab 10 mg)
generic
MDD
10 per day
methadone hcl soln 10 mg/5ml
generic
MDD
60 per day
methadone hcl soln 5 mg/5ml
generic
MDD
30 per day
methadone hcl tab 5 mg
generic
MDD
4 per day
morphine sulfate (tab 15 mg, tab 30 mg, tab 60 mg, tab
100 mg, tab 200 mg)
generic
MDD
3 per day
acetaminophen w/ codeine (w/ tab 300-60 mg, w/ tab 30030 mg, w/ tab 300-15 mg)
generic
MDD
6 per day
acetaminophen w/ codeine soln 120-12 mg/5ml
generic
MDD
30 per day
butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg
generic
MDD
4 per day
butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg
generic
MDD
4 per day
codeine sulfate (tab 15 mg, tab 30 mg, tab 60 mg)
generic
MDD
2 per day
hydrocodone-acetaminophen (tab 5-500 mg, tab 7.5-325
mg)
generic
MDD
8 per day
hydrocodone-acetaminophen (tab 7.5-650 mg, tab 7.5-500
mg, tab 10-500 mg, tab 10-660 mg, tab 10-650 mg, tab 10325 mg)
generic
MDD
6 per day
hydrocodone-acetaminophen soln 7.5-325 mg/15ml
generic
MDD
180 per day
OPIOID ANALGESICS, SHORT-ACTING
PAGE 50
PRODUCT DESCRIPTION
BRAND/GEN
hydrocodone-acetaminophen soln 7.5-500 mg/15ml
generic
hydrocodone-acetaminophen tab 2.5-500 mg
generic
hydrocodone-acetaminophen tab 5-325 mg
MDD
120 per day
generic
MDD
12 per day
hydrocodone-acetaminophen tab 7.5-750 mg
generic
MDD
5 per day
hydromorphone hcl (tab 2 mg, tab 4 mg, tab 8 mg)
generic
MDD
8 per day
hydromorphone hcl liqd 1 mg/ml
generic
MDD
80 per day
hydromorphone hcl suppos 3 mg
generic
meperidine hcl (tab 50 mg, tab 100 mg)
generic
MDD
6 per day
meperidine hcl oral soln 50 mg/5ml
generic
morphine sulfate ((concentrate) soln 20 mg/ml, soln 100
mg/5ml (20 mg/ml))
generic
QL
240 / claim
morphine sulfate (soln 10 mg/5ml, soln 20 mg/5ml)
generic
QL
500 / 31 days
morphine sulfate (suppos 5 mg, suppos 10 mg, suppos 20
mg, suppos 30 mg)
generic
QL
24 / claim
morphine sulfate (tab 15 mg, tab 30 mg)
generic
MDD
6 per day
oxycodone hcl (cap 5 mg, conc 100 mg/5ml (20 mg/ml),
tab 5 mg, tab 10 mg, tab 15 mg, tab 20 mg, tab 30 mg)
generic
MDD
6 per day
oxycodone hcl soln 5 mg/5ml
generic
oxycodone w/ acetaminophen (w/ cap 5-500 mg, w/ tab 5325 mg, w/ tab 7.5-325 mg, w/ tab 7.5-500 mg, w/ tab 10650 mg, w/ tab 10-325 mg)
generic
MDD
6 per day
oxycodone w/ acetaminophen tab 2.5-325 mg
generic
oxycodone-aspirin tab 4.8355-325 mg
generic
tramadol hcl tab 50 mg
generic
MDD
8 per day
ANESTHETICS
LOCAL ANESTHETICS
QL
lidocaine hcl viscous soln 2%
generic
C
PAGE 51
100 / claim
Compound: Max
Qty=120/claim
PRODUCT DESCRIPTION
BRAND/GEN
lidocaine-prilocaine cream 2.5-2.5%
generic
QL
30 / claim
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
ALCOHOL DETERRENTS/ANTI-CRAVING
disulfiram (tab 250 mg, tab 500 mg)
generic
naltrexone hcl tab 50 mg
generic
VIVITROL RECON SUSP 380 MG
BRAND
OPIOID DEPENDENCE TREATMENTS
PA
SUBOXONE (FILM 2-0.5 MG, FILM 4-1 MG)
BRAND
MDD
1 per day
PA
SUBOXONE (FILM 8-2 MG, FILM 12-3 MG)
BRAND
MDD
2 per day
OPIOID REVERSAL AGENTS
naloxone hcl (inj 0.4 mg/ml, inj 1 mg/ml)
generic
QL
2 / 90 days
NARCAN LIQUID 4 MG/0.1ML
BRAND
QL
1 / 90 days
SMOKING CESSATION AGENTS
bupropion hcl (smoking deterrent) tab sr 12hr 150 mg
CHANTIX (TAB 0.5 MG, TAB 1 MG)
CHANTIX CONTINUING MONTH PAK TAB 1 MG
MDD
2 per day
MDS
180 / 365 DAYS
MDD
2 per day
MFL
180 / 365 days
MDS
180 / 365 DAYS
MDD
2 per day
MFL
180 / 365 days
MDS
180 / 365 DAYS
MFL
2 / 365 days
MDS
180 / 365 DAYS
generic
BRAND
BRAND
CHANTIX STARTING MONTH PAK TAB 0.5 MG X 11 & 1
MG X 42
BRAND
NICOTROL INHALER 10 MG
BRAND
QL
MDS
PAGE 52
504 / 30 days
180 / 365 DAYS
PRODUCT DESCRIPTION
BRAND/GEN
NICOTROL NS SOLUTION 10 MG/ML
BRAND
QL
MDS
120 / 30 days
180 ML / 365 DAYS
ANTIBACTERIALS
AMINOGLYCOSIDES
gentamicin sulfate cream 0.1%
generic
C
Limit=2/claim; Pkg
Size 30: Package
Limit=1/claim
gentamicin sulfate oint 0.1%
generic
C
Limit=1/claim; Pkg
Size 15: Package
Limit=2/claim
gentamicin sulfate ophth oint 0.3%
generic
QL
gentamicin sulfate ophth soln 0.3%
generic
MPL
neomycin sulfate tab 500 mg
generic
TOBRADEX OINTMENT 0.3-0.1 %
BRAND
QL
4 / 31 days
tobramycin ophth soln 0.3%
generic
QL
5 / 31 days
tobramycin sulfate (for inj 1.2 gm, inj 1.2 gm/30ml (40
mg/ml), inj 2 gm/50ml (40 mg/ml), inj 10 mg/ml (base
equivalent), inj 80 mg/2ml (40 mg/ml))
generic
PA
TOBRAMYCIN SULFATE IN SALINE SOLUTION 1.2-0.9
MG/ML-%
BRAND
PA
TOBREX OINTMENT 0.3 %
BRAND
4 / 31 days
2 / claim
ANTIBACTERIALS, OTHER
bacitracin ophth oint 500 unit/gm
generic
BACTROBAN NASAL OINTMENT 2 %
BRAND
clindamycin hcl (cap 150 mg, cap 300 mg)
generic
clindamycin palmitate hcl for soln 75 mg/5ml (base equiv)
generic
clindamycin phosphate (topical) (gel, lotion, soln)
generic
clindamycin phosphate vaginal cream 2%
generic
CLINDESSE CREAM 2 %
BRAND
PAGE 53
QL
4 / 31 days
QL
300 / claim
PRODUCT DESCRIPTION
BRAND/GEN
FIRST-VANCOMYCIN 25 SOLUTION 25 MG/ML
BRAND
FIRST-VANCOMYCIN 50 SOLUTION 50 MG/ML
BRAND
methenamine mandelate (tab 0.5 gm, tab 1 gm)
generic
methenamine-hyosc-methylene blue-sod phos-phenyl sal
(*methenamine-hyos-meth tab 81.6, *methenamine-hyoscmeth tab 81)
generic
metronidazole (tab 250 mg, tab 500 mg)
generic
metronidazole cream 0.75 %
generic
metronidazole gel 0.75 %
generic
QL
45 / 30 days
QL
45 / 31 days
PA
metronidazole lotion 0.75%
generic
metronidazole vaginal gel 0.75%
generic
MPL
1 / 30 days
mupirocin calcium cream 2%
generic
MPL
1 / 31 days
mupirocin oint 2%
generic
MPL
1 / 31 days
nitrofurantoin macrocrystal (cap 25 mg, cap 50 mg, cap
100 mg)
generic
nitrofurantoin monohydrate macrocrystalline cap 100 mg
generic
nitrofurantoin susp 25 mg/5ml
generic
MDD
40 per day
SIVEXTRO TAB 200 MG
BRAND
QL
6 / claim
PA
SULFAMYLON CREAM 85 MG/GM
BRAND
trimethoprim tab 100 mg
generic
vancomycin hcl cap 125 mg
generic
MDD
4 per day
vancomycin hcl cap 250 mg
generic
MDD
8 per day
vancomycin hcl for inj 1000 mg
generic
QL
14 / claim
vancomycin hcl for inj 500 mg
generic
QL
14 / 30 days
BETA-LACTAM, CEPHALOSPORINS
cefaclor (cap 250 mg, cap 500 mg, for susp 125 mg/5ml,
for susp 250 mg/5ml, for susp 375 mg/5ml)
PAGE 54
generic
PRODUCT DESCRIPTION
BRAND/GEN
cefadroxil (susp 250 mg/5ml, susp 500 mg/5ml)
generic
MPL
cefadroxil cap 500 mg
generic
QL
20 / claim
cefadroxil tab 1 gm
generic
QL
10 / claim
cefdinir (susp 125 mg/5ml, susp 250 mg/5ml)
generic
MPL
cefdinir cap 300 mg
generic
QL
20 / claim
cefprozil (tab 250 mg, tab 500 mg)
generic
QL
20 / claim
cefprozil for susp 125 mg/5ml
generic
MPL
2 / claim
cefprozil for susp 250 mg/5ml
generic
MPL
1 / claim
CEFTIN RECON SUSP 250 MG/5ML
BRAND
MPL
1 / claim
ceftriaxone sodium (inj 1 gm, inj 250 mg, inj 500 mg, iv soln
1 gm)
QL
generic
3 / claim
cefuroxime axetil (tab 250 mg, tab 500 mg)
generic
QL
cefuroxime axetil for susp 125 mg/5ml
generic
MPL
cephalexin (cap 250 mg, cap 500 mg, for susp 125
mg/5ml, for susp 250 mg/5ml)
generic
MFL
1 / claim
1 / claim
1 / 30 days
20 / claim
1 / claim
BETA-LACTAM, PENICILLINS
amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg
generic
QL
40 / 30 days
amoxicillin & pot clavulanate (chew tab 200-28.5 mg, chew
tab 400-57 mg, tab 875-125 mg)
generic
QL
20 / claim
amoxicillin & pot clavulanate (susp 200-28.5 mg/5ml, susp
250-62.5 mg/5ml)
generic
MPL
1 / claim
amoxicillin & pot clavulanate (susp 400-57 mg/5ml, susp
600-42.9 mg/5ml)
generic
MPL
2 / claim
amoxicillin & pot clavulanate (tab 250-125 mg, tab 500-125
mg)
generic
QL
amoxicillin (cap 250 mg, cap 500 mg, chew tab 125 mg,
chew tab 250 mg, for susp 125 mg/5ml, for susp 200
mg/5ml, for susp 250 mg/5ml, for susp 400 mg/5ml, tab
875 mg)
generic
PAGE 55
30 / claim
PRODUCT DESCRIPTION
BRAND/GEN
ampicillin (cap 250 mg, cap 500 mg)
generic
AMPICILLIN (RECON SUSP 125 MG/5ML, RECON SUSP
250 MG/5ML)
BRAND
AUGMENTIN RECON SUSP 125-31.25 MG/5ML
BRAND
dicloxacillin sodium (cap 250 mg, cap 500 mg)
generic
penicillin v potassium (for soln 125 mg/5ml, for soln 250
mg/5ml, tab 250 mg, tab 500 mg)
generic
MPL
1 / claim
MPL
1 / claim
MACROLIDES
azithromycin for susp 100 mg/5ml
generic
Limit=1/claim; Pkg
Size 30: Package
Limit=2/claim; Pkg
Size 22.5: Package
Limit=2/claim
azithromycin for susp 200 mg/5ml
generic
C
azithromycin powd pack for susp 1 gm
generic
QL
2 / claim
azithromycin tab 250 mg
generic
QL
6 / claim
generic
MDD
4 per day
generic
QL
8 / 28 days
clarithromycin (tab 250 mg, tab 500 mg)
generic
QL
28 / claim
clarithromycin for susp 125 mg/5ml
generic
MPL
clarithromycin for susp 250 mg/5ml
generic
clarithromycin tab sr 24hr 500 mg
generic
E.E.S. GRANULES RECON SUSP 200 MG/5ML
BRAND
ERY-TAB (TAB DR 250 MG, TAB DR 333 MG, TAB DR
500 MG)
BRAND
ERYPED 200 RECON SUSP 200 MG/5ML
BRAND
ERYPED 400 RECON SUSP 400 MG/5ML
BRAND
erythromycin gel 2%
generic
erythromycin ophth oint 5 mg/gm
generic
PAGE 56
QL
MPL
1 / claim
14 / claim
1 / claim
PRODUCT DESCRIPTION
BRAND/GEN
erythromycin soln 2%
generic
erythromycin w/ delayed release particles cap 250 mg
generic
erythromycin-sulfisoxazole for susp 200-600 mg/5ml
generic
PCE (TAB DR 333 MG, TAB DR 500 MG)
BRAND
QUINOLONES
CILOXAN OINTMENT 0.3 %
BRAND
MPL
1 / claim
ciprofloxacin hcl (tab 250 mg, tab 500 mg, tab 750 mg)
generic
ciprofloxacin hcl ophth soln 0.3%
generic
MPL
1 / claim
ciprofloxacin hcl tab 100 mg (base equiv)
generic
QL
6 / claim
levofloxacin (tab 250 mg, tab 500 mg, tab 750 mg)
QL
generic
14 / claim
MDD
1 per day
ofloxacin (tab 200 mg, tab 300 mg, tab 400 mg)
generic
QL
56 / claim
ofloxacin ophth soln 0.3%
generic
QL
10 / 31 days
ofloxacin otic soln 0.3%
QL
generic
10 / 31 days
MPL
VIGAMOX SOLUTION 0.5 %
BRAND
1 / 31 days
QL
3 / claim
SULFONAMIDES
silver sulfadiazine cream 1%
generic
sulfacetamide sodium ophth oint 10%
generic
QL
4 / 31 days
sulfacetamide sodium ophth soln 10%
generic
QL
15 / 31 days
sulfamethoxazole-trimethoprim (susp 200-40 mg/5ml, tab
400-80 mg, tab 800-160 mg)
generic
TETRACYCLINES
doxycycline hyclate (cap 50 mg, cap 100 mg, tab 20 mg,
tab 100 mg)
generic
minocycline hcl (cap 50 mg, cap 75 mg, cap 100 mg)
generic
tetracycline hcl cap 250 mg
generic
PAGE 57
PRODUCT DESCRIPTION
BRAND/GEN
ANTICONVULSANTS
ANTICONVULSANTS, OTHER
levetiracetam (tab 250 mg, tab 500 mg, tab 750 mg, tab
1000 mg)
generic
MDD
4 per day
levetiracetam oral soln 100 mg/ml
generic
MDD
16 per day
CALCIUM CHANNEL MODIFYING AGENTS
ethosuximide (cap 250 mg, soln 250 mg/5ml)
generic
zonisamide (cap 25 mg, cap 50 mg, cap 100 mg)
generic
GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS
diazepam (anticonvulsant) (gel 2.5 mg, gel 10 mg, gel 20
mg)
generic
divalproex sodium (cap delayed release sprinkle 125 mg,
tab delayed release 125 mg, tab delayed release 250 mg,
tab delayed release 500 mg, tab sr 24 hr 500 mg, tab sr 24
hr 250 mg)
generic
gabapentin (cap 100 mg, cap 300 mg, cap 400 mg, tab 600
mg, tab 800 mg)
generic
gabapentin oral soln 250 mg/5ml
generic
GABITRIL (TAB 12 MG, TAB 16 MG)
BRAND
phenobarbital (elixir 20 mg/5ml, tab 15 mg, tab 16.2 mg,
tab 30 mg, tab 32.4 mg, tab 60 mg, tab 64.8 mg, tab 97.2
mg, tab 100 mg)
generic
primidone (tab 50 mg, tab 250 mg)
generic
tiagabine hcl (tab 2 mg, tab 4 mg)
generic
valproate sodium syrup 250 mg/5ml (base equiv)
generic
valproic acid cap 250 mg
generic
QL
1 / claim
MDD
4 per day
GLUTAMATE REDUCING AGENTS
felbamate (susp 600 mg/5ml, tab 400 mg, tab 600 mg)
generic
lamotrigine (tab 25 mg, tab 100 mg, tab 150 mg, tab 200
mg, tab chewable dispersible 5 mg, tab chewable
dispersible 25 mg)
generic
PAGE 58
PRODUCT DESCRIPTION
BRAND/GEN
topiramate (tab 25 mg, tab 50 mg, tab 100 mg, tab 200 mg)
generic
MDD
3 per day
topiramate sprinkle cap 15 mg
generic
MDD
6 per day
topiramate sprinkle cap 25 mg
generic
MDD
8 per day
SODIUM CHANNEL AGENTS
carbamazepine (cap sr 12hr 200 mg, cap sr 12hr 300 mg,
cap sr 12hr 100 mg, chew tab 100 mg, susp 100 mg/5ml,
tab 200 mg, tab sr 12hr 100 mg, tab sr 12hr 200 mg, tab sr
12hr 400 mg)
generic
DILANTIN CAP 30 MG
BRAND
oxcarbazepine (susp 300 mg/5ml (60 mg/ml), tab 150 mg,
tab 300 mg, tab 600 mg)
generic
phenytoin (chew tab 50 mg, susp 125 mg/5ml)
generic
phenytoin sodium extended (cap 100 mg, cap 200 mg, cap
300 mg)
generic
ANTIDEMENTIA AGENTS
CHOLINESTERASE INHIBITORS
donepezil hydrochloride (orally disintegrating tab 5 mg,
orally disintegrating tab 10 mg, tab 5 mg, tab 10 mg)
generic
QL
galantamine hydrobromide (cap 24hr 8 mg, cap 24hr 24
mg, cap 24hr 16 mg)
generic
MDD
1 per day
galantamine hydrobromide (tab 4 mg, tab 8 mg, tab 12 mg)
generic
MDD
2 per day
galantamine hydrobromide oral soln 4 mg/ml
generic
MDD
6 per day
rivastigmine tartrate (cap 1.5 mg, cap 3 mg, cap 4.5 mg,
cap 6 mg)
generic
MDD
2 per day
MDD
1 per day
31 / 31 days
N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST
memantine hcl (tab 5 mg, tab 10 mg)
generic
ANTIDEPRESSANTS
ANTIDEPRESSANTS, OTHER
bupropion hcl (tab 24hr 150 mg, tab 24hr 300 mg)
PAGE 59
generic
PRODUCT DESCRIPTION
BRAND/GEN
bupropion hcl (tab 75 mg, tab 100 mg)
generic
MDD
3 per day
bupropion hcl er (sr) tab er 12h 100 mg
generic
MDD
2 per day
generic
MDD
2 per day
bupropion hcl tab sr 12hr 200 mg
generic
MDD
2 per day
chlordiazepoxide-amitriptyline (tab 5-12.5 mg, tab 10-25
mg)
generic
mirtazapine (orally disintegrating tab 15 mg, orally
disintegrating tab 30 mg, orally disintegrating tab 45 mg,
tab 7.5 mg, tab 15 mg, tab 30 mg, tab 45 mg)
generic
MDD
1 per day
perphenazine-amitriptyline (tab 2-10 mg, tab 2-25 mg, tab
4-10 mg, tab 4-25 mg, tab 4-50 mg)
generic
MONOAMINE OXIDASE INHIBITORS
phenelzine sulfate tab 15 mg
generic
tranylcypromine sulfate tab 10 mg
generic
SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITORS/SEROTONIN AND NOREPINEPHRINE
REUPTAKE INHIBITOR
ST
BRINTELLIX (TAB 5 MG, TAB 10 MG, TAB 20 MG)
BRAND
AL
At least 18 yrs old
MDD
1 per day
MDD
1.5 per day
citalopram hydrobromide (tab 10 mg, tab 20 mg)
generic
citalopram hydrobromide oral soln 10 mg/5ml
generic
citalopram hydrobromide tab 40 mg (base equiv)
generic
MDD
1 per day
escitalopram oxalate (tab 5 mg, tab 10 mg, tab 20 mg)
generic
MDD
1 per day
fluoxetine hcl (cap 10 mg, cap 20 mg, tab 20 mg)
generic
MDD
4 per day
fluoxetine hcl (pmdd) (cap 10 mg, cap 20 mg)
generic
QL
124 / 31 days
fluoxetine hcl cap 40 mg
AL
generic
At least 7 yrs old
MDD
fluoxetine hcl solution 20 mg/5ml
PAGE 60
generic
QL
2 per day
120 / 30 days
PRODUCT DESCRIPTION
BRAND/GEN
fluoxetine hcl tab 10 mg
generic
MDD
1 per day
fluvoxamine maleate (tab 25 mg, tab 50 mg)
generic
MDD
2 per day
fluvoxamine maleate tab 100 mg
generic
MDD
3 per day
maprotiline hcl (tab 25 mg, tab 50 mg, tab 75 mg)
generic
MFL
2 / 30 days
nefazodone hcl (tab 50 mg, tab 100 mg, tab 150 mg, tab
200 mg, tab 250 mg)
generic
paroxetine hcl (tab 10 mg, tab 20 mg, tab 30 mg, tab 40
mg)
generic
MDD
2 per day
paroxetine hcl oral susp 10 mg/5ml (base equiv)
generic
MDD
40 per day
sertraline hcl (tab 25 mg, tab 50 mg)
generic
MDD
1.5 per day
sertraline hcl oral conc 20 mg/ml
generic
sertraline hcl tab 100 mg
generic
MDD
2 per day
trazodone hcl (tab 50 mg, tab 100 mg, tab 150 mg)
generic
trazodone hcl tab 300 mg
generic
MDD
2 per day
venlafaxine hcl (cap 24hr 150 mg, cap 24hr 37.5 mg, cap
24hr 75 mg, tab 24hr 75 mg, tab 24hr 37.5 mg)
generic
MDD
1 per day
venlafaxine hcl (tab 25 mg, tab 37.5 mg, tab 50 mg, tab 75
mg, tab 100 mg)
generic
VENLAFAXINE HCL ER TAB ER 24H 225 MG
BRAND
MDD
1 per day
venlafaxine hcl tab sr 24hr 150 mg (base equivalent)
generic
MDD
2 per day
VIIBRYD (TAB 10 MG, TAB 20 MG, TAB 40 MG)
BRAND
PA
MDD
QL
VIIBRYD KIT 10 & 20 & 40 MG
BRAND
1 per day
30 / 365 days
PA
TRICYCLICS
amitriptyline hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab 75
mg, tab 100 mg, tab 150 mg)
generic
amoxapine (tab 25 mg, tab 50 mg, tab 100 mg, tab 150
mg)
generic
PAGE 61
PRODUCT DESCRIPTION
BRAND/GEN
desipramine hcl (tab 10 mg, tab 50 mg, tab 75 mg, tab 100
mg, tab 150 mg)
generic
desipramine hcl tab 25 mg
generic
doxepin hcl (cap 10 mg, cap 25 mg, cap 50 mg, cap 75
mg, cap 100 mg, cap 150 mg, conc 10 mg/ml)
generic
imipramine hcl (tab 10 mg, tab 25 mg, tab 50 mg)
generic
imipramine pamoate (cap 75 mg, cap 100 mg, cap 125 mg)
generic
nortriptyline hcl (cap 10 mg, cap 25 mg, cap 50 mg, cap 75
mg)
generic
nortriptyline hcl soln 10 mg/5ml
generic
protriptyline hcl tab 10 mg
generic
MDD
2 per day
MDD
20 per day
MDD
4 per day
2 per day
ANTIEMETICS
ANTIEMETICS, OTHER
metoclopramide hcl (soln 5 mg/5ml (10 mg/10ml), tab 5
mg, tab 10 mg)
generic
perphenazine (tab 2 mg, tab 4 mg, tab 8 mg, tab 16 mg)
generic
prochlorperazine maleate (tab 5 mg, tab 10 mg)
generic
prochlorperazine suppos 25 mg
generic
trimethobenzamide hcl cap 300 mg
generic
EMETOGENIC THERAPY ADJUNCTS
dronabinol (cap 2.5 mg, cap 5 mg, cap 10 mg)
generic
ondansetron hcl (inj 4 mg/2ml mg/ml), inj 40 mg/20ml
mg/ml))
generic
ondansetron hcl (tab 4 mg, tab 8 mg)
generic
MDD
ondansetron hcl oral soln 4 mg/5ml
generic
QL
50 / 31 days
ondansetron hcl tab 24 mg
generic
QL
1 / 14 days
ondansetron orally disintegrating tab 4 mg
generic
MDD
2 per day
generic
MDD
2 per day
PAGE 62
PRODUCT DESCRIPTION
BRAND/GEN
ANTIFUNGALS
ciclopirox (gel 0.77%, solution 8%)
generic
MPL
1 / claim
ciclopirox olamine (cream, susp)
generic
MPL
1 / claim
clotrimazole troche 10 mg
generic
econazole nitrate cream 1%
generic
QL
30 / claim
fluconazole (susp 10 mg/ml, susp 40 mg/ml)
generic
QL
70 / claim
fluconazole (tab 100 mg, tab 200 mg)
generic
fluconazole tab 150 mg
generic
QL
2 / claim
fluconazole tab 50 mg
generic
QL
3 / 14 days
griseofulvin microsize (susp 125 mg/5ml, tab 500 mg)
generic
griseofulvin ultramicrosize (tab 125 mg, tab 250 mg)
generic
GYNAZOLE-1 CREAM 2 %
BRAND
ketoconazole (topical) (cream, shampoo)
generic
MPL
1 / claim
ketoconazole tab 200 mg
generic
MDD
1 per day
nystatin (topical) (*nystatin topical powder**, nystatin
cream 100000 unit/gm)
generic
MPL
1 / 31 days
nystatin oint 100000 unit/gm
generic
MPL
1 / claim
nystatin susp 100000 unit/ml
generic
NYSTATIN TAB 100000 UNIT
BRAND
nystatin tab 500000 unit
generic
MDD
6 per day
nystatin-triamcinolone (cream unit/gm-%, oint unit/gm-%)
generic
MPL
1 / claim
terbinafine hcl tab 250 mg
generic
QL
MDD
terconazole vaginal (cream 0.4%, cream 0.8%, suppos 80
mg)
PAGE 63
90 / 120 days
1 per day
generic
PRODUCT DESCRIPTION
BRAND/GEN
ANTIGOUT AGENTS
allopurinol (tab 100 mg, tab 300 mg)
generic
PA
colchicine tab 0.6 mg
generic
C
colchicine w/ probenecid tab 0.5-500 mg
generic
probenecid tab 500 mg
generic
From ages 16 and
older: Max Qty=
6/claim
ANTIMIGRAINE AGENTS
ERGOT ALKALOIDS
dihydroergotamine mesylate (inj 1 mg/ml, nasal spray 4
mg/ml)
generic
SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS
naratriptan hcl (tab 1 mg, tab 2.5 mg)
rizatriptan benzoate (tab 5 mg, tab 10 mg)
sumatriptan nasal spray (5 mg/act, 20 mg/act)
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
generic
sumatriptan succinate (inj 4 mg/0.5ml, inj 6 mg/0.5ml,
solution auto-injector 4 mg/0.5ml, solution auto-injector 6
mg/0.5ml, solution cartridge 4 mg/0.5ml, solution cartridge
6 mg/0.5ml, solution prefilled syringe 4 mg/0.5ml, solution
prefilled syringe 6 mg/0.5ml)
generic
sumatriptan succinate (tab 25 mg, tab 50 mg, tab 100 mg)
generic
ANTIMYASTHENIC AGENTS
PARASYMPATHOMIMETICS
MESTINON SYRUP 60 MG/5ML
PAGE 64
BRAND
PRODUCT DESCRIPTION
BRAND/GEN
pyridostigmine bromide (tab 60 mg, tab cr 180 mg)
generic
ANTIMYCOBACTERIALS
ANTIMYCOBACTERIALS, OTHER
dapsone (tab 25 mg, tab 100 mg)
generic
rifabutin cap 150 mg
generic
ANTITUBERCULARS
ethambutol hcl (tab 100 mg, tab 400 mg)
generic
isoniazid (tab 100 mg, tab 300 mg)
generic
ISONIAZID SYRUP 50 MG/5ML
BRAND
pyrazinamide tab 500 mg
generic
rifampin (cap 150 mg, cap 300 mg)
generic
TRECATOR TAB 250 MG
BRAND
ANTINEOPLASTICS
ALKYLATING AGENTS
ALKERAN TAB 2 MG
BRAND
cyclophosphamide (tab 25 mg, tab 50 mg)
generic
LEUKERAN TAB 2 MG
BRAND
lomustine (cap 10 mg, cap 40 mg, cap 100 mg)
generic
MYLERAN TAB 2 MG
BRAND
ANTIANDROGENS
bicalutamide tab 50 mg
generic
flutamide cap 125 mg
generic
MDD
1 per day
ANTIESTROGENS/MODIFIERS
tamoxifen citrate (tab 10 mg, tab 20 mg)
generic
ANTIMETABOLITES
DROXIA (CAP 200 MG, CAP 300 MG, CAP 400 MG)
PAGE 65
BRAND
PRODUCT DESCRIPTION
BRAND/GEN
hydroxyurea cap 500 mg
generic
mercaptopurine tab 50 mg
generic
PURIXAN 20 MG/ML ORAL SUSP
BRAND
AL
HEMANGEOL SOLUTION 4.28 MG/ML
BRAND
PA
leucovorin calcium (tab 5 mg, tab 10 mg, tab 15 mg, tab 25
mg)
generic
LYSODREN TAB 500 MG
BRAND
Up to 8 yrs old
ANTINEOPLASTICS, OTHER
AROMATASE INHIBITORS, 3RD GENERATION
anastrozole tab 1 mg
generic
exemestane tab 25 mg
generic
ST
letrozole tab 2.5 mg
generic
ST
ENZYME INHIBITORS
etoposide cap 50 mg
generic
MOLECULAR TARGET INHIBITORS
COTELLIC TAB 20 MG
BRAND
PA
NINLARO (CAP 2.3 MG, CAP 3 MG, CAP 4 MG)
BRAND
PA
ANTIPARASITICS
ANTIPROTOZOALS
atovaquone susp 750 mg/5ml
generic
chloroquine phosphate tab 250 mg
generic
chloroquine phosphate tab 500 mg
generic
MDD
1 per day
COARTEM TAB 20-120 MG
BRAND
QL
24 / claim
hydroxychloroquine sulfate tab 200 mg
generic
mefloquine hcl tab 250 mg
generic
PRIMAQUINE PHOSPHATE TAB 26.3 MG
BRAND
PAGE 66
PRODUCT DESCRIPTION
BRAND/GEN
primaquine phosphate tab 26.3 mg (15 mg base)
generic
quinine sulfate cap 324 mg
generic
PEDICULICIDES/SCABICIDES
EURAX (CREAM 10 %, LOTION 10 %)
BRAND
malathion lotion 0.5%
generic
MPL
QL
MFL
permethrin cream 5%
SPINOSAD SUSPENSION 0.9 %
generic
BRAND
C
1 / claim
59 / claim
2 / 30 days
Limit=1/claim; Pkg
Size 10: Package
Limit=6/claim
QL
120 / claim
AL
At least 4 yrs old
MFL
2 / 30 days
ANTIPARKINSON AGENTS
ANTICHOLINERGICS
benztropine mesylate (tab 0.5 mg, tab 1 mg, tab 2 mg)
generic
trihexyphenidyl hcl (tab 2 mg, tab 5 mg)
generic
trihexyphenidyl hcl elixir 0.4 mg/ml
generic
QL
500 / 31 days
AL
At least 18 yrs old
ANTIPARKINSON AGENTS, OTHER
amantadine hcl (cap 100 mg, syrup 50 mg/5ml)
generic
entacapone tab 200 mg
generic
DOPAMINE AGONISTS
bromocriptine mesylate (cap 5 mg, tab 2.5 mg)
generic
pramipexole dihydrochloride (tab 0.125 mg, tab 0.25 mg,
tab 0.5 mg, tab 0.75 mg, tab 1 mg, tab 1.5 mg)
generic
ropinirole hydrochloride (tab 0.25 mg, tab 3 mg, tab 4 mg)
ropinirole hydrochloride (tab 0.5 mg, tab 1 mg, tab 2 mg,
tab 5 mg)
PAGE 67
MDD
3 per day
generic
MDD
6 per day
generic
MDD
3 per day
PRODUCT DESCRIPTION
BRAND/GEN
DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS
carbidopa-levodopa (tab 10-100 mg, tab 25-100 mg, tab
25-250 mg, tab cr 25-100 mg, tab cr 50-200 mg)
generic
MONOAMINE OXIDASE B (MAO-B) INHIBITORS
selegiline hcl (cap 5 mg, tab 5 mg)
generic
ANTIPSYCHOTICS
1ST GENERATION/TYPICAL
chlorpromazine hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab
100 mg, tab 200 mg)
generic
fluphenazine decanoate inj 25 mg/ml
generic
fluphenazine hcl (elixir 2.5 mg/5ml, inj 2.5 mg/ml, oral conc
5 mg/ml, tab 1 mg, tab 2.5 mg, tab 5 mg, tab 10 mg)
generic
haloperidol (tab 0.5 mg, tab 1 mg, tab 10 mg)
generic
haloperidol (tab 2 mg, tab 5 mg, tab 20 mg)
generic
haloperidol decanoate (soln 50 mg/ml, soln 100 mg/ml)
generic
haloperidol lactate oral conc 2 mg/ml
generic
loxapine succinate (cap 10 mg, cap 25 mg, cap 50 mg)
generic
loxapine succinate cap 5 mg
generic
pimozide (tab 1 mg, tab 2 mg)
generic
thioridazine hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab 100
mg)
MDD
3 per day
MDD
3 per day
MDD
4 per day
generic
MDD
3 per day
thiothixene (cap 1 mg, cap 2 mg, cap 5 mg, cap 10 mg)
generic
MDD
3 per day
trifluoperazine hcl (tab 1 mg, tab 2 mg, tab 5 mg, tab 10
mg)
generic
MDD
3 per day
2ND GENERATION/ATYPICAL
QL
ABILIFY SOLUTION 1 MG/ML
BRAND
PA
AL
PAGE 68
750 / 30 days
At least 6 yrs old
PRODUCT DESCRIPTION
BRAND/GEN
PA
aripiprazole (tab 2 mg, tab 5 mg, tab 10 mg, tab 15 mg, tab
20 mg, tab 30 mg)
generic
AL
MDD
AL
olanzapine (tab 2.5 mg, tab 5 mg, tab 7.5 mg, tab 10 mg,
tab 15 mg, tab 20 mg)
generic
quetiapine fumarate (tab 25 mg, tab 50 mg, tab 100 mg,
tab 200 mg, tab 300 mg, tab 400 mg)
generic
risperidone (tab 0.25 mg, tab 0.5 mg, tab 1 mg, tab 2 mg,
tab 3 mg, tab 4 mg)
generic
risperidone odt (tab 3 mg, tab 4 mg)
generic
MDD
AL
MDD
AL
MDD
AL
MDD
risperidone orally disintegrating tab 0.25 mg
generic
generic
AL
MDD
risperidone orally disintegrating tab 1 mg
AL
generic
MDD
AL
generic
MDD
risperidone soln 1 mg/ml
AL
generic
MDD
ziprasidone hcl (cap 20 mg, cap 40 mg, cap 60 mg, cap 80
mg)
AL
generic
MDD
At least 6 yrs old
1 per day
At least 13 yrs old
1 per day
At least 10 yrs old
2 per day
At least 5 yrs old
2 per day
At least 5 yrs old
2 per day
At least 5 yrs old
2 per day
At least 5 yrs old
2 per day
At least 5 yrs old
2 per day
At least 5 yrs old
4 per day
At least 18 yrs old
2 per day
TREATMENT-RESISTANT
clozapine (tab 25 mg, tab 50 mg, tab 200 mg)
AL
generic
MDD
clozapine tab 100 mg
AL
generic
MDD
PAGE 69
At least 18 yrs old
3 per day
At least 18 yrs old
9 per day
PRODUCT DESCRIPTION
BRAND/GEN
ANTIVIRALS
ANTI-CYTOMEGALOVIRUS (CMV) AGENTS
valganciclovir hcl (tab 450 mg (base equivalent), tab 450
mg)
generic
MDD
HARVONI TAB 90-400 MG
BRAND
PA
SOVALDI TAB 400 MG
BRAND
PA
ZEPATIER TAB 50-100 MG
BRAND
2 per day
ANTI-HEPATITIS C (HCV) AGENTS
PA
MDD
1 per day
ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)
PA
GENVOYA TAB 150-150-200-10 MG
BRAND
MDD
1 per day
ISENTRESS (PACKET 100 MG, TAB 400 MG)
BRAND
MDD
2 per day
ISENTRESS CHEW TAB 100 MG
BRAND
MDD
6 per day
ISENTRESS CHEW TAB 25 MG
BRAND
MDD
12 per day
TIVICAY TAB 50 MG
BRAND
VITEKTA (TAB 85 MG, TAB 150 MG)
BRAND
AL
MDD
At least 18 yrs old
1 per day
ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)
ATRIPLA TAB 600-200-300 MG
BRAND
COMPLERA TAB 200-25-300 MG
BRAND
MDD
1 per day
EDURANT TAB 25 MG
BRAND
MDD
1 per day
INTELENCE (TAB 25 MG, TAB 100 MG)
BRAND
MDD
4 per day
INTELENCE TAB 200 MG
BRAND
MDD
2 per day
nevirapine (tab 24hr 400 mg, tab 24hr 100 mg)
generic
MDD
1 per day
PAGE 70
PRODUCT DESCRIPTION
BRAND/GEN
nevirapine susp 50 mg/5ml
generic
MDD
40 per day
nevirapine tab 200 mg
generic
MDD
2 per day
RESCRIPTOR TAB 100 MG
BRAND
MDD
12 per day
RESCRIPTOR TAB 200 MG
BRAND
MDD
6 per day
SUSTIVA (CAP 200 MG, TAB 600 MG)
BRAND
MDD
1 per day
SUSTIVA CAP 50 MG
BRAND
MDD
2 per day
ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)
abacavir sulfate tab 300 mg (base equiv)
generic
MDD
2 per day
abacavir sulfate-lamivudine-zidovudine tab 300-150-300
mg
generic
MDD
2 per day
DESCOVY TAB 200-25 MG
BRAND
PA
MDD
1 per day
didanosine (capsule 125 mg, capsule 200 mg, capsule 250
mg, capsule 400 mg)
generic
MDD
1 per day
EMTRIVA CAP 200 MG
BRAND
MDD
1 per day
EMTRIVA SOLUTION 10 MG/ML
BRAND
EPZICOM TAB 600-300 MG
BRAND
MDD
1 per day
lamivudine oral soln 10 mg/ml
generic
MDD
30 per day
lamivudine tab 150 mg
generic
MDD
2 per day
lamivudine tab 300 mg
generic
MDD
1 per day
lamivudine-zidovudine tab 150-300 mg
generic
MDD
2 per day
stavudine (cap 15 mg, cap 20 mg, cap 30 mg, cap 40 mg)
generic
MDD
2 per day
stavudine for oral soln 1 mg/ml
generic
MDD
80 per day
TRUVADA TAB 200-300 MG
BRAND
MDD
1 per day
VIDEX RECON SOLN 2 GM
BRAND
MDD
20 per day
VIDEX RECON SOLN 4 GM
BRAND
PAGE 71
PRODUCT DESCRIPTION
BRAND/GEN
VIREAD (TAB 150 MG, TAB 200 MG, TAB 250 MG, TAB
300 MG)
BRAND
MDD
VIREAD POWDER 40 MG/GM
BRAND
QL
ZIAGEN SOLUTION 20 MG/ML
BRAND
MDD
30 per day
zidovudine cap 100 mg
generic
MDD
6 per day
zidovudine syrup 10 mg/ml
generic
MDD
60 per day
zidovudine tab 300 mg
generic
MDD
2 per day
SELZENTRY TAB 150 MG
BRAND
MDD
2 per day
SELZENTRY TAB 300 MG
BRAND
MDD
4 per day
TRIUMEQ TAB 600-50-300 MG
BRAND
1 per day
240 / 30 days
ANTI-HIV AGENTS, OTHER
AL
MDD
AL
TYBOST TAB 150 MG
BRAND
At least 18 yrs old
1 per day
At least 18 yrs old
MDD
1 per day
ANTI-HIV AGENTS, PROTEASE INHIBITORS
APTIVUS CAP 250 MG
BRAND
MDD
4 per day
APTIVUS SOLUTION 100 MG/ML
BRAND
MDD
10 per day
CRIXIVAN CAP 200 MG
BRAND
MDD
9 per day
CRIXIVAN CAP 400 MG
BRAND
MDD
6 per day
EVOTAZ TAB 300-150 MG
BRAND
MDD
1 per day
INVIRASE CAP 200 MG
BRAND
MDD
10 per day
INVIRASE TAB 500 MG
BRAND
MDD
4 per day
KALETRA SOLUTION 400-100 MG/5ML
BRAND
QL
KALETRA TAB 100-25 MG
BRAND
MDD
4 per day
KALETRA TAB 200-50 MG
BRAND
MDD
6 per day
PAGE 72
480 / 30 days
PRODUCT DESCRIPTION
BRAND/GEN
LEXIVA SUSPENSION 50 MG/ML
BRAND
MDD
56 per day
LEXIVA TAB 700 MG
BRAND
MDD
4 per day
NORVIR (CAP 100 MG, TAB 100 MG)
BRAND
MDD
12 per day
NORVIR SOLUTION 80 MG/ML
BRAND
MDD
15 per day
PREZISTA (TAB 75 MG, TAB 600 MG)
BRAND
MDD
2 per day
PREZISTA SUSPENSION 100 MG/ML
BRAND
MDD
12 per day
PREZISTA TAB 150 MG
BRAND
MDD
3 per day
PREZISTA TAB 800 MG
BRAND
MDD
1 per day
REYATAZ (CAP 150 MG, CAP 200 MG, CAP 300 MG)
BRAND
MDD
2 per day
REYATAZ PACKET 50 MG
BRAND
MDD
6 per day
VIRACEPT TAB 250 MG
BRAND
MDD
9 per day
VIRACEPT TAB 625 MG
BRAND
MDD
4 per day
ANTI-INFLUENZA AGENTS
AL
RELENZA DISKHALER AER POW BA 5 MG/BLISTER
BRAND
MPL
rimantadine hydrochloride tab 100 mg
TAMIFLU (CAP 45 MG, CAP 75 MG)
generic
BRAND
20 / 10 days
QL
10 / 30 days
MFL
QL
BRAND
MFL
C
QL
TAMIFLU RECON SUSP 6 MG/ML
BRAND
MFL
C
PAGE 73
1 / 30 days
QL
C
TAMIFLU CAP 30 MG
At least 5 yrs old
1 / 80 days
PA Required for Ages
3-64
20 / 30 days
1 / 80 days
3-64
120 / 30 days
1 / 80 days
3-64
PRODUCT DESCRIPTION
BRAND/GEN
ANTIHERPETIC AGENTS
acyclovir (cap 200 mg, tab 800 mg)
generic
QL
50 / 30 days
acyclovir oint 5%
generic
QL
30 / 30 days
acyclovir susp 200 mg/5ml
generic
QL
400 / 30 days
acyclovir tab 400 mg
generic
MDD
trifluridine ophth soln 1%
generic
QL
8 / 31 days
valacyclovir hcl tab 1 gm
generic
QL
21 / 31 days
valacyclovir hcl tab 500 mg
generic
QL
60 / 30 days
ZOVIRAX CREAM 5 %
BRAND
MPL
1 / 31 days
buspirone hcl (tab 5 mg, tab 7.5 mg, tab 10 mg, tab 15 mg,
tab 30 mg)
generic
MDD
3 per day
meprobamate (tab 200 mg, tab 400 mg)
generic
midazolam hcl (inj 2 mg/2ml, inj 5 mg/ml, inj 5 mg/5ml, inj
10 mg/2ml, inj 10 mg/10ml, inj 25 mg/5ml, inj 50 mg/10ml)
generic
QL
alprazolam (tab 0.25 mg, tab 0.5 mg, tab 1 mg, tab 2 mg)
generic
MDD
4 per day
ALPRAZOLAM INTENSOL CONC 1 MG/ML
BRAND
chlordiazepoxide hcl (cap 5 mg, cap 10 mg, cap 25 mg)
generic
MDD
4 per day
clonazepam (tab 0.5 mg, tab 1 mg, tab 2 mg)
generic
MDD
4 per day
clorazepate dipotassium (tab 3.75 mg, tab 7.5 mg, tab 15
mg)
generic
MDD
3 per day
diazepam (conc 5 mg/ml, oral soln 1 mg/ml)
generic
diazepam (tab 2 mg, tab 5 mg, tab 10 mg)
generic
MDD
4 per day
lorazepam (tab 0.5 mg, tab 2 mg)
generic
MDD
3 per day
3 per day
ANXIOLYTICS
ANXIOLYTICS, OTHER
2 / 30 days
BENZODIAZEPINES
PAGE 74
PRODUCT DESCRIPTION
BRAND/GEN
lorazepam tab 1 mg
generic
MDD
4 per day
oxazepam (cap 10 mg, cap 15 mg, cap 30 mg)
generic
MDD
4 per day
MDD
3 per day
BIPOLAR AGENTS
MOOD STABILIZERS
lithium carbonate (cap 150 mg, cap 300 mg, cap 600 mg,
tab 300 mg, tab cr 300 mg, tab cr 450 mg)
generic
lithium oral solution 8 meq/5ml
generic
BLOOD GLUCOSE REGULATORS
ANTIDIABETIC AGENTS
acarbose (tab 25 mg, tab 50 mg, tab 100 mg)
generic
QL
BYDUREON PEN 2 MG
BYDUREON RECON SUSP 2 MG
BYETTA 10 MCG PEN SOLN PEN 10 MCG/0.04ML
BYETTA 5 MCG PEN SOLN PEN 5 MCG/0.02ML
BRAND
4 / 28 days
ST
AL
At least 18 yrs old
QL
2.4 / 30 days
BRAND
BRAND
BRAND
ST
AL
At least 18 yrs old
QL
1.2 / 30 days
ST
AL
At least 18 yrs old
chlorpropamide (tab 100 mg, tab 250 mg)
generic
glimepiride (tab 1 mg, tab 2 mg)
generic
MDD
1 per day
glimepiride tab 4 mg
generic
MDD
2 per day
glipizide (tab 5 mg, tab 10 mg, tab sr 24hr 2.5 mg, tab sr
24hr 5 mg, tab sr 24hr 10 mg)
generic
glipizide-metformin hcl (tab 2.5-500 mg, tab 2.5-250 mg,
tab 5-500 mg)
generic
glyburide (tab 1.25 mg, tab 2.5 mg, tab 5 mg)
generic
PAGE 75
PRODUCT DESCRIPTION
BRAND/GEN
glyburide micronized (tab 1.5 mg, tab 3 mg, tab 6 mg)
generic
glyburide-metformin (tab 1.25-250 mg, tab 2.5-500 mg, tab
5-500 mg)
generic
JENTADUETO (TAB 2.5-1000 MG, TAB 2.5-850 MG, TAB
2.5-500 MG)
BRAND
KOMBIGLYZE XR (TAB ER 24H 5-500 MG, TAB ER 24H
5-1000 MG)
BRAND
KOMBIGLYZE XR TAB ER 24H 2.5-1000 MG
BRAND
AL
MDD
AL
MDD
AL
At least 18 yrs old
2 per day
At least 18 yrs old
1 per day
At least 18 yrs old
MDD
2 per day
MDD
4 per day
metformin hcl (tab 500 mg, tab sr 24hr 500 mg)
generic
metformin hcl (tab 850 mg, tab 1000 mg)
generic
metformin hcl tab sr 24hr 750 mg
generic
MDD
3 per day
nateglinide (tab 60 mg, tab 120 mg)
generic
MDD
3 per day
ONGLYZA (TAB 2.5 MG, TAB 5 MG)
BRAND
AL
At least 18 yrs old
MDD
1 per day
pioglitazone hcl (tab 15 mg, tab 30 mg, tab 45 mg)
generic
MDD
1 per day
pioglitazone hcl-metformin hcl (-metformin tab 15-500 mg, metformin tab 15-850 mg)
generic
MDD
2 per day
SYMLINPEN 120 SOLN PEN 2700 MCG/2.7ML
BRAND
QL
10.8 / 30 days
PA
QL
SYMLINPEN 60 SOLN PEN 1500 MCG/1.5ML
BRAND
6 / 30 days
PA
tolazamide (tab 250 mg, tab 500 mg)
generic
tolbutamide tab 500 mg
generic
TRADJENTA TAB 5 MG
BRAND
AL
At least 18 yrs old
MDD
1 per day
MPL
1 / claim
MFL
1 / 30 days
GLYCEMIC AGENTS
GLUCAGEN DIAGNOSTIC RECON SOLN 1 MG
PAGE 76
BRAND
PRODUCT DESCRIPTION
BRAND/GEN
GLUCAGEN HYPOKIT RECON SOLN 1 MG
BRAND
GLUCAGON EMERGENCY KIT 1 MG
MPL
1 / claim
MFL
1 / 30 days
MPL
1 / claim
MFL
1 / 30 days
BRAND
INSULINS
APIDRA SOLOSTAR SOLN PEN 100 UNIT/ML
BRAND
QL
30 / 30 days
APIDRA SOLUTION 100 UNIT/ML
BRAND
QL
40 / 30 days
HUMALOG (SOLN CART 100 UNIT/ML, SOLUTION 100
UNIT/ML)
BRAND
QL
30 / 30 days
HUMALOG KWIKPEN SOLN PEN 100 UNIT/ML
BRAND
QL
30 / 30 days
HUMALOG MIX 50/50 KWIKPEN SUSP PEN (50-50) 100
UNIT/ML
BRAND
QL
30 / 30 days
HUMALOG MIX 50/50 PEN SUSP PEN (50-50) 100
UNIT/ML
BRAND
QL
30 / 30 days
HUMALOG MIX 50/50 SUSPENSION (50-50) 100
UNIT/ML
BRAND
QL
40 / 30 days
HUMALOG MIX 75/25 KWIKPEN SUSP PEN (75-25) 100
UNIT/ML
BRAND
QL
30 / 30 days
HUMALOG MIX 75/25 PEN SUSP PEN (75-25) 100
UNIT/ML
BRAND
QL
30 / 30 days
HUMALOG MIX 75/25 SUSPENSION (75-25) 100
UNIT/ML
BRAND
QL
40 / 30 days
HUMALOG PEN SOLN PEN 100 UNIT/ML
BRAND
QL
30 / 30 days
HUMULIN 70/30 KWIKPEN SUSP PEN (70-30) 100
UNIT/ML
BRAND
QL
30 / 30 days
HUMULIN 70/30 PEN SUSP PEN (70-30) 100 UNIT/ML
BRAND
QL
30 / 30 days
HUMULIN 70/30 SUSPENSION (70-30) 100 UNIT/ML
BRAND
QL
40 / 30 days
HUMULIN N KWIKPEN SUSP PEN 100 UNIT/ML
BRAND
QL
30 / 30 days
HUMULIN N PEN SUSP PEN 100 UNIT/ML
BRAND
QL
30 / 30 days
HUMULIN N SUSPENSION 100 UNIT/ML
BRAND
QL
40 / 30 days
PAGE 77
PRODUCT DESCRIPTION
BRAND/GEN
HUMULIN R SOLUTION 100 UNIT/ML
BRAND
HUMULIN R U-500 (CONCENTRATED) SOLUTION 500
UNIT/ML
BRAND
LANTUS SOLOSTAR SOLN PEN 100 UNIT/ML
QL
40 / 30 days
BRAND
QL
30 / 30 days
LANTUS SOLUTION 100 UNIT/ML
BRAND
QL
30 / 30 days
NOVOLIN 70/30 RELION SUSPENSION (70-30) 100
UNIT/ML
BRAND
QL
40 / 30 days
NOVOLIN 70/30 SUSPENSION (70-30) 100 UNIT/ML
BRAND
QL
40 / 30 days
NOVOLIN N RELION SUSPENSION 100 UNIT/ML
BRAND
QL
40 / 30 days
NOVOLIN N SUSPENSION 100 UNIT/ML
BRAND
QL
40 / 30 days
NOVOLIN R RELION SOLUTION 100 UNIT/ML
BRAND
QL
40 / 30 days
NOVOLIN R SOLUTION 100 UNIT/ML
BRAND
QL
40 / 30 days
NOVOLOG FLEXPEN SOLN PEN 100 UNIT/ML
BRAND
QL
30 / 30 days
NOVOLOG MIX 70/30 FLEXPEN SUSP PEN (70-30) 100
UNIT/ML
BRAND
QL
30 / 30 days
NOVOLOG MIX 70/30 SUSPENSION (70-30) 100
UNIT/ML
BRAND
QL
40 / 30 days
NOVOLOG PENFILL SOLN CART 100 UNIT/ML
BRAND
NOVOLOG SOLUTION 100 UNIT/ML
BRAND
QL
40 / 30 days
RELION 70/30 SUSPENSION (70-30) 100 UNIT/ML
BRAND
QL
40 / 30 days
RELION N SUSPENSION 100 UNIT/ML
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 (TAB 2.5 MG, TAB 5 MG)
enoxaparin sodium (inj 100 mg/ml, inj 150 mg/ml)
generic
QL
14 / 7 days
MFL
3 / 80 days
C
PAGE 78
4 per day
Biopharmacy benefit
via Acaria
PRODUCT DESCRIPTION
enoxaparin sodium (inj 80 mg/0.8ml, inj 120 mg/0.8ml)
BRAND/GEN
generic
QL
12 / 7 days
MFL
3 / 80 days
C
QL
enoxaparin sodium inj 30 mg/0.3ml
generic
MFL
C
enoxaparin sodium inj 300 mg/3ml
generic
3 / 80 days
MFL
QL
generic
MFL
C
heparin sodium (porcine) (inj 1000 unit/ml, inj 5000 unit/ml,
inj 10000 unit/ml, inj 20000 unit/ml, pf inj 5000 unit/0.5ml)
generic
warfarin sodium (tab 1 mg, tab 2 mg, tab 2.5 mg, tab 3 mg,
tab 4 mg, tab 5 mg, tab 6 mg, tab 7.5 mg, tab 10 mg)
generic
XARELTO TAB 10 MG
BRAND
Biopharmacy benefit
via Acaria
MFL
C
3 / 80 days
42 / 7 days
QL
generic
5 / 7 days
QL
C
Biopharmacy benefit
via Acaria
QL
Biopharmacy benefit
via Acaria
6 / 7 days
3 / 80 days
Biopharmacy benefit
via Acaria
9 / 7 days
3 / 80 days
Biopharmacy benefit
via Acaria
35 / 180 days
MDD
1 per day
XARELTO TAB 15 MG
BRAND
MDD
2 per day
XARELTO TAB 20 MG
BRAND
MDD
1 per day
QL
60 / claim
BLOOD FORMATION MODIFIERS
anagrelide hcl (cap 0.5 mg, cap 1 mg)
generic
COAGULANTS
aminocaproic acid syrup 25%
PAGE 79
generic
PRODUCT DESCRIPTION
BRAND/GEN
aminocaproic acid tab 500 mg
generic
QL
24 / claim
BRILINTA (TAB 60 MG, TAB 90 MG)
BRAND
MDD
2 per day
cilostazol (tab 50 mg, tab 100 mg)
generic
MDD
2 per day
clopidogrel bisulfate tab 75 mg (base equiv)
generic
dipyridamole (tab 25 mg, tab 50 mg, tab 75 mg)
generic
PLATELET MODIFYING AGENTS
CARDIOVASCULAR AGENTS
ALPHA-ADRENERGIC AGONISTS
clonidine hcl (tab 0.1 mg, tab 0.2 mg, tab 0.3 mg)
generic
guanabenz acetate (tab 4 mg, tab 8 mg)
generic
guanfacine hcl (tab 1 mg, tab 2 mg)
generic
methyldopa (tab 250 mg, tab 500 mg)
generic
midodrine hcl (tab 2.5 mg, tab 5 mg, tab 10 mg)
generic
ALPHA-ADRENERGIC BLOCKING AGENTS
doxazosin mesylate (tab 1 mg, tab 2 mg, tab 4 mg, tab 8
mg)
generic
prazosin hcl (cap 1 mg, cap 2 mg, cap 5 mg)
generic
ANGIOTENSIN II RECEPTOR ANTAGONISTS
irbesartan (tab 75 mg, tab 150 mg, tab 300 mg)
generic
MDD
1 per day
losartan potassium (tab 25 mg, tab 50 mg, tab 100 mg)
generic
MDD
1 per day
valsartan (tab 40 mg, tab 80 mg, tab 160 mg, tab 320 mg)
generic
MDD
1 per day
benazepril hcl (tab 5 mg, tab 10 mg, tab 20 mg)
generic
MDD
1 per day
benazepril hcl tab 40 mg
generic
MDD
2 per day
captopril (tab 12.5 mg, tab 25 mg, tab 50 mg, tab 100 mg)
generic
MDD
3 per day
ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS
PAGE 80
PRODUCT DESCRIPTION
BRAND/GEN
enalapril maleate (tab 2.5 mg, tab 5 mg, tab 10 mg, tab 20
mg)
generic
MDD
EPANED RECON SOLN 1 MG/ML
BRAND
AL
fosinopril sodium (tab 10 mg, tab 20 mg, tab 40 mg)
generic
MDD
1 per day
lisinopril (tab 5 mg, tab 10 mg, tab 20 mg, tab 30 mg, tab
40 mg)
generic
MDD
2 per day
lisinopril tab 2.5 mg
generic
MDD
1 per day
moexipril hcl (tab 7.5 mg, tab 15 mg)
generic
perindopril erbumine (tab 2 mg, tab 4 mg, tab 8 mg)
generic
quinapril hcl (tab 5 mg, tab 10 mg, tab 20 mg, tab 40 mg)
generic
ramipril (cap 1.25 mg, cap 2.5 mg, cap 5 mg, cap 10 mg)
generic
MDD
2 per day
trandolapril (tab 1 mg, tab 2 mg, tab 4 mg)
generic
MDD
1 per day
MDD
2 per day
2 per day
Up to 8 yrs old
ANTIARRHYTHMICS
amiodarone hcl (tab 200 mg, tab 400 mg)
generic
disopyramide phosphate (cap 100 mg, cap 150 mg)
generic
dofetilide (cap 125 mcg (0.125, cap 250 mcg (0.25, cap
500 mcg (0.5)
generic
flecainide acetate (tab 50 mg, tab 100 mg, tab 150 mg)
generic
mexiletine hcl (cap 150 mg, cap 200 mg, cap 250 mg)
generic
NORPACE CR (CAP ER 12H 100 MG, CAP ER 12H 150
MG)
BRAND
propafenone hcl (tab 150 mg, tab 225 mg, tab 300 mg)
generic
quinidine gluconate tab cr 324 mg
generic
quinidine sulfate (tab 200 mg, tab 300 mg, tab cr 300 mg)
generic
sotalol hcl (afib/afl) ((afib/afl) tab 80 mg, (afib/afl) tab 120
mg, (afib/afl) tab 160 mg)
generic
sotalol hcl (tab 80 mg, tab 120 mg, tab 160 mg, tab 240
mg)
generic
PAGE 81
PRODUCT DESCRIPTION
BRAND/GEN
BETA-ADRENERGIC BLOCKING AGENTS
acebutolol hcl (cap 200 mg, cap 400 mg)
generic
atenolol (tab 25 mg, tab 50 mg, tab 100 mg)
generic
MDD
2 per day
betaxolol hcl (tab 10 mg, tab 20 mg)
generic
MDD
1 per day
bisoprolol fumarate (tab 5 mg, tab 10 mg)
generic
MDD
1 per day
carvedilol (tab 3.125 mg, tab 6.25 mg, tab 12.5 mg)
generic
MDD
3 per day
carvedilol tab 25 mg
generic
MDD
4 per day
labetalol hcl tab 100 mg
generic
MDD
3 per day
generic
MDD
6 per day
generic
MDD
8 per day
metoprolol succinate (tab 24hr 100 mg, tab 24hr 50 mg,
tab 24hr 25 mg)
generic
MDD
1 per day
metoprolol succinate tab sr 24hr 200 mg
generic
MDD
2 per day
metoprolol tartrate (tab 25 mg, tab 100 mg)
generic
MDD
2 per day
metoprolol tartrate tab 50 mg
generic
MDD
3 per day
nadolol (tab 20 mg, tab 40 mg, tab 80 mg)
generic
MDD
2 per day
pindolol (tab 5 mg, tab 10 mg)
generic
propranolol hcl (cap 24hr 80 mg, cap 24hr 60 mg, cap 24hr
120 mg, cap 24hr 160 mg)
generic
MDD
2 per day
propranolol hcl (oral soln 20 mg/5ml, oral soln 40 mg/5ml,
tab 10 mg, tab 20 mg, tab 40 mg, tab 60 mg, tab 80 mg)
generic
timolol maleate (tab 5 mg, tab 10 mg, tab 20 mg)
generic
MDD
1 per day
MDD
2 per day
CALCIUM CHANNEL BLOCKING AGENTS
amlodipine besylate (tab 2.5 mg, tab 5 mg, tab 10 mg)
generic
CARDIZEM LA TAB ER 24H 120 MG
BRAND
diltiazem hcl (cap 12hr 90 mg, cap 12hr 120 mg, cap 12hr
60 mg, cap 24hr 240 mg)
generic
PAGE 82
PRODUCT DESCRIPTION
BRAND/GEN
diltiazem hcl (cap 24hr 120 mg, cap 24hr 180 mg)
generic
MDD
1 per day
diltiazem hcl (tab 30 mg, tab 60 mg, tab 90 mg, tab 120
mg)
generic
MDD
3 per day
diltiazem hcl coated beads (beads cap 24hr 300 mg, beads
cap 24hr 180 mg, beads cap 24hr 120 mg)
generic
MDD
1 per day
diltiazem hcl coated beads (beads cap 24hr 360 mg, beads
tab 24hr 360 mg, beads tab 24hr 420 mg, beads tab 24hr
300 mg, beads tab 24hr 180 mg, beads tab 24hr 240 mg)
generic
diltiazem hcl coated beads cap sr 24hr 240 mg
generic
MDD
2 per day
diltiazem hcl extended release beads (beads cap 24hr 360
mg, beads cap 24hr 180 mg, beads cap 24hr 300 mg,
beads cap 24hr 120 mg, beads cap 24hr 420 mg)
generic
MDD
1 per day
diltiazem hcl extended release beads cap sr 24hr 240 mg
generic
MDD
2 per day
felodipine (tab 24hr 10 mg, tab 24hr 5 mg, tab 24hr 2.5 mg)
generic
MDD
1 per day
nicardipine hcl (cap 20 mg, cap 30 mg)
generic
MDD
3 per day
nifedipine (cap 10 mg, cap 20 mg)
generic
MDD
4 per day
nifedipine (tab 24hr 60 mg, tab 24hr osmotic release 60
mg, tab 24hr osmotic 60 mg)
generic
MDD
2 per day
nifedipine (tab 24hr osmotic release 30 mg, tab 24hr
osmotic 30 mg, tab 24hr osmotic 90 mg, tab 24hr 30 mg,
tab 24hr 90 mg)
generic
MDD
1 per day
verapamil hcl (cap 24hr 120 mg, cap 24hr 180 mg, cap
24hr 360 mg, cap 24hr 240 mg)
generic
MDD
1 per day
verapamil hcl (tab 120 mg, tab 180 mg, tab 240 mg)
generic
MDD
2 per day
verapamil hcl (tab 40 mg, tab 80 mg, tab 120 mg)
generic
MDD
3 per day
amiloride & hydrochlorothiazide tab 5-50 mg
generic
MDD
1 per day
amlodipine besylate-benazepril hcl (cap 2.5-10 mg, cap 510 mg, cap 5-40 mg, cap 5-20 mg, cap 10-40 mg, cap 1020 mg)
generic
MDD
1 per day
atenolol & chlorthalidone (tab 50-25 mg, tab 100-25 mg)
generic
MDD
2 per day
CARDIOVASCULAR AGENTS, OTHER
PAGE 83
PRODUCT DESCRIPTION
BRAND/GEN
benazepril & hydrochlorothiazide (tab 5-6.25 mg, tab 1012.5 mg, tab 20-12.5 mg, tab 20-25 mg)
generic
MDD
1 per day
bisoprolol & hydrochlorothiazide (tab 5-6.25 mg, tab 106.25 mg)
generic
MDD
1 per day
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg
generic
captopril & hydrochlorothiazide (tab 25-25 mg, tab 25-15
mg, tab 50-15 mg)
generic
MDD
2 per day
captopril & hydrochlorothiazide tab 50-25 mg
generic
MDD
3 per day
digoxin (oral soln 0.05 mg/ml, tab 125 mcg (0.125 mg), tab
250 mcg (0.25 mg))
generic
DUTOPROL (TAB ER 24H 50-12.5 MG, TAB ER 24H 10012.5 MG, TAB ER 24H 25-12.5 MG)
BRAND
MDD
1 per day
enalapril maleate & hydrochlorothiazide (tab 5-12.5 mg, tab
10-25 mg)
generic
MDD
2 per day
fosinopril sodium & hydrochlorothiazide (tab 10-12.5 mg,
tab 20-12.5 mg)
generic
MDD
1 per day
irbesartan-hydrochlorothiazide (tab 150-12.5 mg, tab 30012.5 mg)
generic
MDD
1 per day
lisinopril & hydrochlorothiazide (tab 10-12.5 mg, tab 2012.5 mg)
generic
MDD
2 per day
lisinopril & hydrochlorothiazide tab 20-25 mg
generic
MDD
1 per day
losartan potassium & hydrochlorothiazide (tab 50-12.5 mg,
tab 100-25 mg, tab 100-12.5 mg)
generic
MDD
1 per day
methyldopa & hydrochlorothiazide (tab 250-25 mg, tab
250-15 mg)
generic
metoprolol & hydrochlorothiazide (tab 50-25 mg, tab 10025 mg)
generic
MDD
2 per day
metoprolol & hydrochlorothiazide tab 100-50 mg
generic
MDD
1 per day
moexipril-hydrochlorothiazide (tab 7.5-12.5 mg, tab 15-12.5
mg, tab 15-25 mg)
generic
MDD
2 per day
nadolol & bendroflumethiazide (tab 40-5 mg, tab 80-5 mg)
generic
pentoxifylline tab cr 400 mg
generic
propranolol & hydrochlorothiazide (tab 40-25 mg, tab 80-25
mg)
generic
PAGE 84
PRODUCT DESCRIPTION
BRAND/GEN
quinapril-hydrochlorothiazide (tab 10-12.5 mg, tab 20-25
mg, tab 20-12.5 mg)
generic
reserpine (tab 0.1 mg, tab 0.25 mg)
generic
spironolactone & hydrochlorothiazide tab 25-25 mg
generic
triamterene & hydrochlorothiazide (cap 37.5-25 mg, cap
50-25 mg, tab 37.5-25 mg, tab 75-50 mg)
generic
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
2 per day
MDD
1 per day
DIURETICS, CARBONIC ANHYDRASE INHIBITORS
acetazolamide (cap sr 12hr 500 mg, tab 125 mg, tab 250
mg)
generic
DIURETICS, LOOP
bumetanide (tab 0.5 mg, tab 1 mg, tab 2 mg)
generic
furosemide (inj 10 mg/ml, oral soln 8 mg/ml, oral soln 10
mg/ml, tab 20 mg, tab 40 mg, tab 80 mg)
generic
torsemide (tab 5 mg, tab 10 mg, tab 20 mg, tab 100 mg)
generic
MDD
1 per day
amiloride hcl tab 5 mg
generic
MDD
4 per day
eplerenone (tab 25 mg, tab 50 mg)
generic
spironolactone (tab 25 mg, tab 50 mg, tab 100 mg)
generic
DIURETICS, POTASSIUM-SPARING
DIURETICS, THIAZIDE
chlorothiazide tab 250 mg
generic
MDD
2 per day
chlorothiazide tab 500 mg
generic
MDD
4 per day
chlorthalidone (tab 25 mg, tab 50 mg)
generic
hydrochlorothiazide (cap 12.5 mg, tab 12.5 mg, tab 25 mg,
tab 50 mg)
generic
indapamide (tab 1.25 mg, tab 2.5 mg)
generic
metolazone (tab 2.5 mg, tab 5 mg, tab 10 mg)
generic
PAGE 85
PRODUCT DESCRIPTION
BRAND/GEN
DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES
fenofibrate micronized (cap 134 mg, cap 200 mg)
generic
MDD
1 per day
fenofibrate micronized cap 67 mg
generic
MDD
2 per day
fenofibrate tab 160 mg
generic
MDD
1 per day
fenofibrate tab 54 mg
generic
MDD
3 per day
gemfibrozil tab 600 mg
generic
MDD
2 per day
atorvastatin calcium (tab 10 mg, tab 20 mg, tab 40 mg, tab
80 mg)
generic
MDD
1 per day
lovastatin (tab 10 mg, tab 20 mg)
generic
MDD
1 per day
lovastatin tab 40 mg
generic
MDD
2 per day
pravastatin sodium (tab 10 mg, tab 20 mg, tab 40 mg, tab
80 mg)
generic
MDD
1 per day
simvastatin (tab 5 mg, tab 10 mg, tab 20 mg, tab 40 mg)
generic
MDD
1 per day
DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS
DYSLIPIDEMICS, OTHER
cholestyramine (powder 4 gm/dose, powder packets 4 gm)
generic
cholestyramine light (powder 4 gm/dose, powder packets 4
gm)
generic
colestipol hcl tab 1 gm
generic
NIACOR TAB 500 MG
BRAND
VASODILATORS, DIRECT-ACTING ARTERIAL
hydralazine hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab 100
mg)
generic
minoxidil tab 10 mg
generic
MDD
10 per day
minoxidil tab 2.5 mg
generic
MDD
3 per day
VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS
ISORDIL TITRADOSE TAB 40 MG
PAGE 86
BRAND
PRODUCT DESCRIPTION
BRAND/GEN
isosorbide dinitrate (sl tab 2.5 mg, sl tab 5 mg, tab 5 mg,
tab 10 mg, tab 20 mg, tab 30 mg, tab cr 40 mg)
generic
isosorbide mononitrate (tab 10 mg, tab 20 mg)
generic
MDD
2 per day
isosorbide mononitrate (tab 24hr 120 mg, tab 24hr 60 mg,
tab 24hr 30 mg)
generic
MDD
1 per day
NITRO-BID OINTMENT 2 %
BRAND
nitroglycerin (cap cr 2.5 mg, cap cr 6.5 mg, cap cr 9 mg, td
patch 24hr 0.4 mg/hr, td patch 24hr 0.2 mg/hr, td patch
24hr 0.1 mg/hr, td patch 24hr 0.6 mg/hr)
generic
NITROSTAT (SL TAB 0.3 MG, SL TAB 0.4 MG, SL TAB
0.6 MG)
BRAND
CENTRAL NERVOUS SYSTEM AGENTS
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES
amphetamine-dextroamphetamine (cap 24hr 30 mg, cap
24hr 20 mg, cap 24hr 15 mg, cap 24hr 5 mg, cap 24hr 25
mg, cap 24hr 10 mg)
generic
amphetamine-dextroamphetamine (tab 5 mg, tab 7.5 mg,
tab 10 mg, tab 12.5 mg, tab 15 mg, tab 20 mg, tab 30 mg)
generic
dextroamphetamine sulfate (cap 24hr 15 mg, cap 24hr 10
mg)
generic
dextroamphetamine sulfate (tab 5 mg, tab 10 mg)
generic
AL
MDD
AL
MDD
AL
MDD
AL
MDD
dextroamphetamine sulfate cap sr 24hr 5 mg
AL
generic
MDD
VYVANSE (CAP 10 MG, CAP 20 MG, CAP 30 MG, CAP
40 MG, CAP 50 MG, CAP 60 MG, CAP 70 MG)
At least 6 yrs old
1 per day
At least 3 yrs old
2 per day
At least 6 yrs old
2 per day
At least 3 yrs old
2 per day
At least 6 yrs old
1 per day
PA
BRAND
MDD
1 per day
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES
dexmethylphenidate hcl (tab 2.5 mg, tab 5 mg, tab 10 mg)
AL
generic
MDD
PAGE 87
At least 6 yrs old
2 per day
PRODUCT DESCRIPTION
BRAND/GEN
methylphenidate hcl (cap cr 10 mg, cap cr 20 mg, cap cr
30 mg, cap cr 40 mg, cap cr 50 mg, cap cr 60 mg, tab sa
osm 18 mg, tab sa osm 27 mg, tab sa osm 54 mg, tab sr
24hr 27 mg, tab sr 24hr 54 mg, tab sr 24hr 18 mg)
generic
methylphenidate hcl (soln 5 mg/5ml, soln 10 mg/5ml)
generic
methylphenidate hcl (tab 5 mg, tab 10 mg, tab 20 mg)
generic
AL
MDD
AL
MDD
AL
methylphenidate hcl (tab cr 10 mg, tab cr 20 mg, tab sa
osm 36 mg, tab sr 24hr 36 mg)
generic
METHYLPHENIDATE HCL ER (ER TAB ER 24H 54 MG,
ER TAB ER 24H 27 MG)
BRAND
METHYLPHENIDATE HCL ER TAB ER 24H 18 MG
BRAND
METHYLPHENIDATE HCL ER TAB ER 24H 36 MG
BRAND
MDD
AL
MDD
AL
At least 6 yrs old
1 per day
At least 6 yrs old
3 per day
At least 6 yrs old
2 per day
At least 6 yrs old
1 per day
At least 6 yrs old
MDD
2 per day
MDD
4 per day
MDD
4 per day
CENTRAL NERVOUS SYSTEM, OTHER
butalbital-acetaminophen (tab 50-650 mg, tab 50-325 mg)
generic
butalbital-acetaminophen-caffeine (cap 50-325-40 mg, tab
50-500-40 mg, tab 50-325-40 mg)
generic
butalbital-acetaminophen-caffeine cap 50-500-40 mg
generic
butalbital-aspirin-caffeine cap 50-325-40 mg
generic
PHRENILIN FORTE CAP 50-650 MG
BRAND
SOMNOTE CAP 500 MG
BRAND
QL
45 / 25 days
AL
At least 7 yrs old
FIBROMYALGIA AGENTS
duloxetine hcl (cap 20 mg, cap 30 mg, cap 60 mg)
generic
MDD
2 per day
PA
SAVELLA (TAB 12.5 MG, TAB 25 MG, TAB 50 MG, TAB
100 MG)
BRAND
SAVELLA TITRATION PACK MISC 12.5 & 25 & 50 MG
BRAND
MDD
QL
2 per day
55 / 365 days
PA
PAGE 88
PRODUCT DESCRIPTION
BRAND/GEN
MULTIPLE SCLEROSIS AGENTS
PA
AVONEX KIT 30 MCG
BRAND
C
Biopharmacy benefit
via Acaria
PA
AVONEX PEN AUT-IJ KIT 30 MCG/0.5ML
BRAND
C
Biopharmacy benefit
via Acaria
PA
AVONEX PREFILLED PREF SY KT 30 MCG/0.5ML
BRAND
C
Biopharmacy benefit
via Acaria
PA
COPAXONE SOLN PRSYR 40 MG/ML
BRAND
C
Biopharmacy benefit
via Acaria
PA
GILENYA CAP 0.5 MG
BRAND
C
Biopharmacy benefit
via Acaria
PA
glatiramer acetate soln prefilled syringe 20 mg/ml
generic
C
Biopharmacy benefit
via Acaria
PA
PLEGRIDY (SOLN PEN 125 MCG/0.5ML, SOLN PRSYR
125 MCG/0.5ML)
BRAND
PLEGRIDY STARTER PACK (PACK SOLN PEN 63 94
MCG/0.5ML, PACK SOLN PRSYR 63 94 MCG/0.5ML)
BRAND
TECFIDERA (CAP DR 120 MG, CAP DR 240 MG, MISC
120 & 240 MG)
BRAND
C
Biopharmacy benefit
via Acaria
PA
C
Biopharmacy benefit
via Acaria
PA
C
Biopharmacy benefit
via Acaria
DENTAL AND ORAL AGENTS
chlorhexidine gluconate soln 0.12%
generic
pilocarpine hcl tab 5 mg
generic
pilocarpine hcl tab 7.5 mg
generic
sodium fluoride (dental) (cream, paste)
generic
PAGE 89
MDD
6 per day
PRODUCT DESCRIPTION
BRAND/GEN
sodium fluoride gel 1.1% (0.5% f)
generic
QL
60 / 30 days
62 / 31 days
DERMATOLOGICAL AGENTS
aluminum chloride soln 20%
generic
ANALPRAM-HC LOTION 1-2.5 %
BRAND
QL
benzoyl peroxide lotion 9%
generic
MPL
1 / claim
benzoyl peroxide-erythromycin gel 5-3%
generic
MPL
1 / claim
BPO GEL 4 %
BRAND
calcipotriene (cream, soln (50 mcg/ml))
generic
MPL
1 / claim
calcipotriene oint 0.005%
generic
clotrimazole w/ betamethasone cream 1-0.05%
generic
QL
45 / 31 days
clotrimazole w/ betamethasone lotion 1-0.05%
generic
QL
31 / 31 days
DRITHO-CREME HP CREAM 1 %
BRAND
EPIFOAM FOAM 1-1 %
BRAND
fluorouracil (topical) (soln 2%, soln 5%)
generic
QL
10 / 31 days
fluorouracil cream 0.5%
generic
fluorouracil cream 5%
generic
QL
40 / 31 days
hydrocortisone cream 2.5%
generic
C
hydrocortisone lotion 2.5%
generic
MPL
hydrocortisone oint 2.5%
generic
Pkg JAR: Max
Qty=120/30 days; Pkg
TUBE: Package
Limit=1/claim
1 / claim
ST
isotretinoin (cap 10 mg, cap 20 mg, cap 40 mg)
generic
AL
Up to 21 yrs old
MDD
2 per day
lidocaine hcl cream 3%
generic
MPL
1 / claim
lidocaine oint 5%
generic
MPL
1 / claim
lidocaine-prilocaine kit 2.5-2.5%
generic
PAGE 90
PRODUCT DESCRIPTION
BRAND/GEN
podofilox soln 0.5%
generic
salicylic acid (cream, lotion, shampoo)
generic
selenium sulfide lotion 2.5%
generic
sulfacetamide sodium liquid 10%
generic
sulfacetamide sodium lotion 10% (acne)
generic
C
sulfacetamide sodium w/ sulfur emulsion 10-5%
generic
MPL
1 / claim
sulfacetamide sodium w/ sulfur lotion 10-5%
generic
MPL
1 / 31 days
sulfacetamide sodium w/ sulfur susp 10-5%
generic
C
MPL
QL
tacrolimus (topical) (oint 0.03%, oint 0.1%)
TAZORAC (GEL 0.05 %, GEL 0.1 %)
generic
1 / claim
Limit=1/claim; Pkg
Size 59: Package
Limit=2/claim
Limit=1/claim
30 / 30 days
PA
AL
At least 2 yrs old
BRAND
TAZORAC CREAM 0.05 %
BRAND
C
Limit=4/claim; Pkg
Size 30: Package
Limit=2/claim; Pkg
Size 60: Package
Limit=1/claim
TAZORAC CREAM 0.1 %
BRAND
C
Limit=1/claim; Pkg
Size 30: Package
Limit=2/claim
tretinoin (cream 0.025%, cream 0.05%, cream 0.1%)
generic
QL
20 / claim
tretinoin gel 0.01%
generic
QL
15 / claim
tretinoin gel 0.025%
generic
urea (cream, lotion)
generic
ENZYME REPLACEMENT/MODIFIERS
CREON (CP DR PART 3000-9500, CP DR PART 6000,
CP DR PART 12000, CP DR PART 24000)
BRAND
PANCREAZE (CP DR PART 4200, CP DR PART 10500,
CP DR PART 16800, CP DR PART 21000)
BRAND
PAGE 91
PRODUCT DESCRIPTION
BRAND/GEN
pancrelipase (lip-prot-amyl) dr cap 5000-17000-27000 unit
generic
ZENPEP (CP DR PART 3000-10000, CP DR PART 5000,
CP DR PART 10000, CP DR PART 15000, CP DR PART
20000, CP DR PART 25000)
BRAND
GASTROINTESTINAL AGENTS
ANTISPASMODICS, GASTROINTESTINAL
dicyclomine hcl (cap 10 mg, tab 20 mg)
generic
dicyclomine hcl oral soln 10 mg/5ml
generic
QL
glycopyrrolate (tab 1 mg, tab 2 mg)
generic
MDD
4 per day
hyoscyamine sulfate (elixir 0.125 mg/5ml, soln 0.125
mg/ml, tab 0.125 mg, tab disp 0.125 mg, tab sl 0.125 mg)
generic
hyoscyamine sulfate tab sr 12hr 0.375 mg
generic
MDD
4 per day
LEVSIN SOLUTION 0.5 MG/ML
BRAND
propantheline bromide tab 15 mg
generic
MDD
4 per day
496 / 31 days
GASTROINTESTINAL AGENTS, OTHER
PA
CHOLBAM (CAP 50 MG, CAP 250 MG)
BRAND
diphenoxylate w/ atropine (w/ liq mg/5ml, w/ tab mg)
generic
ursodiol (cap 300 mg, tab 500 mg)
generic
ursodiol tab 250 mg
generic
MDD
5 per day
MDD
7 per day
HISTAMINE2 (H2) RECEPTOR ANTAGONISTS
cimetidine (tab 300 mg, tab 400 mg, tab 800 mg)
generic
cimetidine hcl soln 300 mg/5ml
generic
famotidine (for susp 40 mg/5ml, tab 40 mg)
generic
ranitidine hcl cap 150 mg
generic
MDD
2 per day
ranitidine hcl cap 300 mg
generic
MDD
1 per day
ranitidine hcl syrup 15 mg/ml (75 mg/5ml)
generic
MDD
20 per day
PAGE 92
PRODUCT DESCRIPTION
BRAND/GEN
generic
LAXATIVES
COLYTE WITH FLAVOR PACKS RECON SOLN 227.1
GM
BRAND
GOLYTELY RECON SOLN 227.1 GM
BRAND
lactulose (encephalopathy) solution 10 gm/15ml
generic
lactulose solution 10 gm/15ml
generic
peg 3350-kcl-sod bicarb-nacl for soln 420 gm
generic
MPL
1 / claim
peg 3350-kcl-sod bicarb-sod chloride-sod sulfate (soln 236
gm, soln 236 gm, soln 240 gm)
generic
MPL
1 / claim
PROTECTANTS
CARAFATE SUSPENSION 1 GM/10ML
QL
420 / claim
AL
Up to 6 yrs old
300 / 30 days
BRAND
misoprostol (tab 100 mcg, tab 200 mcg)
generic
sucralfate tab 1 gm
generic
PROTON PUMP INHIBITORS
FIRST-OMEPRAZOLE SUSPENSION 2 MG/ML
BRAND
QL
generic
MDD
4 per day
generic
MDD
1 per day
omeprazole (cap 10 mg, cap 20 mg, cap 40 mg)
generic
MDD
1 per day
OMEPRAZOLE+SYRSPEND SF ALKA SUSPENSION 2
MG/ML
BRAND
QL
omeprazole-sodium bicarbonate (powd pack susp 20-1680
mg, powd pack susp 40-1680 mg)
generic
pantoprazole sodium ec tab 20 mg (base equiv)
generic
MDD
1 per day
pantoprazole sodium ec tab 40 mg (base equiv)
generic
MDD
2 per day
PAGE 93
300 / 30 days
PRODUCT DESCRIPTION
BRAND/GEN
GENITOURINARY AGENTS
ANTISPASMODICS, URINARY
flavoxate hcl tab 100 mg
generic
oxybutynin chloride (tab 24hr 15 mg, tab 24hr 10 mg, tab
24hr 5 mg)
generic
QL
62 / 31 days
oxybutynin chloride syrup 5 mg/5ml
generic
QL
496 / 31 days
oxybutynin chloride tab 5 mg
generic
QL
93 / 31 days
trospium chloride tab 20 mg
generic
MDD
2 per day
finasteride tab 5 mg
generic
MDD
1 per day
tamsulosin hcl cap 0.4 mg
generic
MDD
2 per day
terazosin hcl (cap 1 mg, cap 2 mg, cap 5 mg, cap 10 mg)
generic
MDD
8 per day
BENIGN PROSTATIC HYPERTROPHY AGENTS
GENITOURINARY AGENTS, OTHER
bethanechol chloride (tab 5 mg, tab 10 mg, tab 25 mg, tab
50 mg)
generic
CUPRIMINE CAP 250 MG
BRAND
phenazopyridine hcl (tab 100 mg, tab 200 mg)
generic
pot phos monobasic w/sod phos di & monobas tab 155852-130mg
generic
potassium citrate (alkalinizer) (tab 5 (540, tab 10 (1080)
generic
sodium chloride irrigation soln 0.9%
generic
sodium citrate & citric acid soln 500-334 mg/5ml
generic
QL
500 / 30 days
PHOSPHATE BINDERS
calcium acetate (phosphate binder) (cap 667 mg (169 mg
ca), tab 667 mg)
generic
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)
amcinonide cream 0.1%
PAGE 94
generic
MPL
1 / claim
PRODUCT DESCRIPTION
BRAND/GEN
betamethasone dipropionate (topical) (cream, oint)
generic
betamethasone dipropionate augmented (gel, oint)
generic
MPL
1 / claim
betamethasone dipropionate lotion 0.05%
generic
MPL
1 / claim
betamethasone valerate (cream, lotion, oint)
generic
clobetasol propionate (cream, gel, oint, soln)
generic
MPL
1 / claim
clobetasol propionate emollient base cream 0.05%
generic
MPL
1 / claim
cortisone acetate tab 25 mg
generic
dexamethasone (elixir 0.5 mg/5ml, soln 0.5 mg/5ml, tab 0.5
mg, tab 0.75 mg, tab 1 mg, tab 1.5 mg, tab 2 mg, tab 4 mg,
tab 6 mg)
generic
DEXAMETHASONE INTENSOL CONC 1 MG/ML
BRAND
dexamethasone sodium phosphate (inj 4 mg/ml, inj 20
mg/5ml, inj 120 mg/30ml)
generic
QL
diflorasone diacetate (cream, oint)
generic
MPL
1 / claim
fludrocortisone acetate tab 0.1 mg
generic
fluocinonide (cream, gel, oint, soln)
generic
MPL
1 / claim
fluocinonide emulsified base cream 0.05%
generic
MPL
1 / claim
fluticasone propionate cream 0.05%
generic
MPL
1 / 30 days
fluticasone propionate oint 0.005%
generic
MPL
1 / claim
hydrocortisone (tab 5 mg, tab 10 mg, tab 20 mg)
generic
hydrocortisone butyrate (cream, oint, soln)
generic
hydrocortisone valerate cream 0.2%
generic
MPL
1 / claim
methylprednisolone (tab 4 mg, tab 4 mg dose pack, tab 8
mg, tab 16 mg, tab 32 mg, tab therapy pack 4 mg (21))
generic
MILLIPRED TAB 5 MG
BRAND
mometasone furoate (cream, oint)
generic
MPL
1 / claim
prednisolone sodium phosphate (phosph soln 6.7 mg/5ml
(5 mg/5ml base), phosphate soln 15 mg/5ml (base equiv))
generic
prednisolone syrup 15 mg/5ml (usp solution equivalent)
generic
PAGE 95
150 / 30 days
PRODUCT DESCRIPTION
BRAND/GEN
prednisone (oral soln 5 mg/5ml, tab 1 mg, tab 2.5 mg, tab 5
mg, tab 5 mg dose pack, tab 10 mg, tab 20 mg, tab 50 mg,
tab therapy pack 5 mg (21), tab therapy pack 5 mg (48),
tab therapy pack 10 mg (21), tab therapy pack 10 mg (48))
generic
PREDNISONE INTENSOL CONC 5 MG/ML
BRAND
triamcinolone acetonide (topical) (cream 0.5%, lotion
0.025%, lotion 0.1%, oint 0.025%, oint 0.5%)
generic
triamcinolone acetonide (topical) (cream, oint)
generic
triamcinolone acetonide cream 0.025%
generic
C
triamcinolone acetonide dental paste 0.1%
generic
MPL
VERIPRED 20 SOLUTION 20 MG/5ML
BRAND
QL
150 / claim
MPL
1 / claim
Pkg JAR: Max
Qty=120/30 days; Pkg
TUBE: Package
Limit=1/claim
1 / claim
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)
desmopressin acetate nasal soln 0.01% (refrigerated)
generic
QL
5 / claim
desmopressin acetate nasal spray soln 0.01%
generic
QL
5 / claim
desmopressin acetate nasal spray soln 0.01%
(refrigerated)
generic
QL
5 / claim
desmopressin acetate tab 0.1 mg
generic
MDD
1 per day
desmopressin acetate tab 0.2 mg
generic
MDD
3 per day
NORDITROPIN (SOLUTION 5 MG/1.5ML, SOLUTION 15
MG/1.5ML)
BRAND
NORDITROPIN FLEXPRO (SOLUTION 5 MG/1.5ML,
SOLUTION 10 MG/1.5ML, SOLUTION 15 MG/1.5ML)
BRAND
NORDITROPIN NORDIFLEX PEN (PEN SOLUTION 5
MG/1.5ML, PEN SOLUTION 10 MG/1.5ML, PEN
SOLUTION 15 MG/1.5ML, PEN SOLUTION 30 MG/3ML)
BRAND
PAGE 96
PA
C
Biopharmacy benefit
via Acaria
PA
C
Biopharmacy benefit
via Acaria
PA
C
Biopharmacy benefit
via Acaria
PRODUCT DESCRIPTION
BRAND/GEN
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)
ANDROGENS
ANDRODERM (PATCH 24HR 4 MG/24HR, PATCH 24HR
2 MG/24HR)
BRAND
danazol (cap 50 mg, cap 100 mg, cap 200 mg)
generic
testosterone cypionate im inj in oil 200 mg/ml
generic
MDD
1 per day
QL
4 / 30 days
QL
8 / 28 days
GL
Female
ESTROGENS
ALORA (PATCH TW 0.025 MG/24HR, PATCH TW 0.05
MG/24HR, PATCH TW 0.075 MG/24HR, PATCH TW 0.1
MG/24HR)
BRAND
COMBIPATCH (PATCH TW 0.05-0.14 MG/DAY, PATCH
TW 0.05-0.25 MG/DAY)
BRAND
desogest-ethin est tab 0.1-0.025/0.125-0.025/0.150.025mg-mg
generic
GL
Female
DESOGESTREL-ETHINYL ESTRADIOL TAB 0.150.02/0.01 MG (AZURETTE, KARIVA, PIMTREA,
VIORELE, CAZIANT, CESIA, VELIVET)
BRAND
GL
Female
DESOGESTREL-ETHINYL ESTRADIOL TAB 0.15-30 MGMCG (APRI, EMOQUETTE, ENSKYCE, RECLIPSEN,
SOLIA)
BRAND
GL
Female
drospirenone-ethinyl estradiol tab 3-0.03 mg
generic
GL
Female
DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG
(GIANVI, LORYNA, NIKKI, VESTURA, OCELLA, SYEDA,
ZARAH)
BRAND
GL
Female
esterified estrogens & methyltestosterone (tab 0.625-1.25
mg, tab 1.25-2.5 mg)
generic
MDD
ESTRACE CREAM 0.1 MG/GM
BRAND
QL
estradiol & norethindrone acetate tab 0.5-0.1 mg
generic
PAGE 97
43 / 31 days
PA
MDD
estradiol & norethindrone acetate tab 1-0.5 mg
1 per day
generic
1 per day
PA
PRODUCT DESCRIPTION
BRAND/GEN
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 (tab 0.5 mg, tab 1 mg, tab 2 mg)
generic
estropipate (tab 0.75 mg, tab 1.5 mg)
generic
QL
8 / 28 days
GL
Female
GL
Female
GL
Female
MDD
estropipate tab 3 mg
GL
generic
MDD
ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB
1 MG-35 MCG (KELNOR, ZOVIA)
BRAND
LEVONORG-ETH EST TAB 0.15-0.03MG(84) & ETH EST
TAB 0.01MG(7) (AMETHIA, CAMRESE, DAYSEE)
BRAND
LEVONORGEST-ETH ESTRAD 91-DAY TAB 0.15-0.03
MG (INTROVALE, JOLESSA, QUASENSE)
BRAND
LEVONORGESTREL-ETH ESTRA TAB 0.05-30/0.07540/0.125-30MG (ENPRESSE, LEVONEST, MYZILRA,
TRIVORA)
BRAND
LEVONORGESTREL-ETHINYL ESTRAD TAB 0.1-20 MG
(AUBRA, AVIANE, DELYLA, FALMINA, LESSINA,
LUTERA, ORSYTHIA, SRONYX)
1 per day
Female
2 per day
GL
Female
QL
91 / claim
GL
Female
QL
91 / claim
GL
Female
BRAND
GL
Female
LEVONORGESTREL-ETHINYL ESTRAD TAB 0.15-30 MG
(ALTAVERA, CHATEAL, KURVELO, LEVORA,
MARLISSA, PORTIA)
BRAND
GL
Female
NECON 1/50 (28) TAB 1-50 MG-MCG
BRAND
GL
Female
NECON 10/11 (28) TAB 35 MCG
BRAND
GL
Female
NORELGESTROMIN-ETHINYL ESTRADIOL TD PTWK
150-35 MCG/24HR (XULANE)
QL
BRAND
1 / 28 days
GL
Female
NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.4
MG-35 MCG (BALZIVA, BRIELLYN, GILDAGIA, PHILITH,
VYFEMLA, ZENCHENT)
BRAND
GL
Female
NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.5
MG-35 MCG (NECON, NORTREL, WERA)
BRAND
GL
Female
NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG35 MCG (ALYACEN, CYCLAFEM, DASETTA, NECON,
NORTREL, PIRMELLA)
BRAND
GL
Female
PAGE 98
PRODUCT DESCRIPTION
BRAND/GEN
NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1
MG-20 MCG (GILDESS, JUNEL, LARIN, MICROGESTIN)
BRAND
GL
Female
NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB
1.5 MG-30 MCG (GILDESS, JUNEL, LARIN,
MICROGESTIN)
BRAND
GL
Female
NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE
TAB 1 MG-20 MCG (GILDESS, JUNEL, LARIN,
MICROGESTIN)
BRAND
GL
Female
NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE
TAB 1.5 MG-30 MCG (GILDESS, JUNEL, LARIN,
MICROGESTIN)
BRAND
GL
Female
NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE TAB
1 MG-20 MCG (LOMEDIA)
BRAND
NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/0.7535/1-35 MG (ALYACEN, CYCLAFEM, DASETTA, NECON,
NORTREL, PIRMELLA)
BRAND
NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/135/0.5-35 MG (ARANELLE, LEENA)
BRAND
NORGESTIMATE & ETHINYL ESTRADIOL TAB 0.25 MG35 MCG (ESTARYLLA, MONO-LINYAH, MONONESSA,
PREVIFEM, SPRINTEC)
BRAND
GL
Female
norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mgmcg
generic
NORGESTIMATE-ETH ESTRAD TAB 0.18-35/0.21535/0.25-35 MG (TRI-ESTARYLLA, TRI-LINYAH, TRIPREVIFEM, TRI-SPRINTEC, TRINESSA)
BRAND
NORGESTREL & ETHINYL ESTRADIOL TAB 0.3 MG-30
MCG (CRYSELLE, ELINEST, LOW-OGESTREL)
GL
BRAND
Female
NORINYL 1+50 (28) TAB 1-50 MG-MCG
BRAND
NUVARING RING 0.12-0.015 MG/24HR
BRAND
MDD
OGESTREL TAB 0.5-50 MG-MCG
BRAND
PREMARIN (TAB 0.3 MG, TAB 0.45 MG, TAB 0.625 MG,
TAB 0.9 MG, TAB 1.25 MG)
BRAND
PREMARIN CREAM 0.625 MG/GM
BRAND
PAGE 99
2 per day
GL
Female
QL
1 / claim
GL
Female
GL
Female
GL
Female
MDD
QL
1 per day
43 / 30 days
PRODUCT DESCRIPTION
BRAND/GEN
PREMPRO (TAB 0.45-1.5 MG, TAB 0.625-5 MG, TAB
0.625-2.5 MG)
BRAND
PREMPRO TAB 0.3-1.5 MG
BRAND
GL
Female
ZOVIA 1/50E (28) TAB 1-50 MG-MCG
BRAND
GL
Female
BRAND
QL
4 / 365 days
GL
Female
AL
At least 14 yrs old
QL
1 / claim
GL
Female
GL
Female
AL
At least 14 yrs old
GL
Female
AL
At least 14 yrs old
GL
Female
AL
At least 14 yrs old
GL
Female
AL
At least 14 yrs old
GL
Female
AL
At least 14 yrs old
GL
Female
AL
At least 14 yrs old
QL
4 / 365 days
GL
Female
PROGESTERONE AGONISTS/ANTAGONISTS
ELLA TAB 30 MG
PROGESTINS
CRINONE (GEL 4 %, GEL 8 %)
BRAND
DEPO-SUBQ PROVERA 104 SUSPENSION 104
MG/0.65ML
BRAND
ENDOMETRIN INSERT 100 MG
BRAND
FIRST-PROGESTERONE VGS 100 SUPPOS 100 MG
levonorgestrel tab 0.75 mg
BRAND
BRAND
BRAND
BRAND
BRAND
generic
MAKENA OIL 250 MG/ML
BRAND
medroxyprogesterone acetate (tab 2.5 mg, tab 5 mg, tab
10 mg)
generic
PAGE 100
PRODUCT DESCRIPTION
BRAND/GEN
medroxyprogesterone acetate im susp 150 mg/ml
generic
QL
1 / claim
GL
Female
30 / 30 days
megestrol acetate (susp 40 mg/ml, tab 20 mg, tab 40 mg)
generic
norethindrone acetate tab 5 mg
generic
NORETHINDRONE TAB 0.35 MG (CAMILA, DEBLITANE,
ERRIN, HEATHER, JENCYCLA, JOLIVETTE, LYZA,
NORA-BE, NORLYROC, SHAROBEL)
BRAND
progesterone micronized (cap 100 mg, cap 200 mg)
generic
QL
generic
MDD
SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS
raloxifene hcl tab 60 mg
1 per day
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)
ARMOUR THYROID (TAB 15 MG, TAB 120 MG, TAB 180
MG, TAB 240 MG, TAB 300 MG)
BRAND
levothyroxine sodium (tab 25 mcg, tab 50 mcg, tab 75 mcg,
tab 88 mcg, tab 100 mcg, tab 112 mcg, tab 125 mcg, tab
137 mcg, tab 150 mcg, tab 175 mcg, tab 200 mcg, tab 300
mcg)
generic
liothyronine sodium (tab 5 mcg, tab 25 mcg, tab 50 mcg)
generic
NATURE-THROID (TAB 32.5 MG, TAB 130 MG, TAB 195
MG)
BRAND
thyroid (tab 30 mg (1/2, tab 60 mg (1, tab 90 mg (1 1/2)
generic
THYROLAR-1 TAB 60 (12.5-50) MG (MCG)
BRAND
THYROLAR-1/2 TAB 30 (6.25-25) MG (MCG)
BRAND
THYROLAR-1/4 TAB 15 (3.1-12.5) MG (MCG)
BRAND
THYROLAR-2 TAB 120 (25-100) MG (MCG)
BRAND
THYROLAR-3 TAB 180 (37.5-150) MG (MCG)
BRAND
WESTHROID (TAB 32.5 MG, TAB 130 MG, TAB 195 MG)
BRAND
WESTHROID-P (TAB 32.5 MG, TAB 130 MG)
BRAND
WP THYROID (TAB 32.5 MG, TAB 130 MG)
BRAND
PAGE 101
PRODUCT DESCRIPTION
BRAND/GEN
HORMONAL AGENTS, SUPPRESSANT (THYROID)
ANTITHYROID AGENTS
methimazole (tab 5 mg, tab 10 mg)
generic
propylthiouracil tab 50 mg
generic
SSKI SOLUTION 1 GM/ML
BRAND
IMMUNOLOGICAL AGENTS
IMMUNE SUPPRESSANTS
PA
AZASAN (TAB 75 MG, TAB 100 MG)
BRAND
MDD
3 per day
azathioprine tab 50 mg
generic
MDD
3 per day
cyclosporine (cap 25 mg, cap 100 mg)
generic
MDD
4 per day
cyclosporine modified (for microemulsion) (cap 25 mg, cap
50 mg, cap 100 mg)
generic
MDD
4 per day
cyclosporine modified oral soln 100 mg/ml
generic
ENBREL (SOLN PRSYR 25 MG/0.5ML, SOLN PRSYR 50
MG/ML)
BRAND
ENBREL RECON SOLN 25 MG
BRAND
ENBREL SURECLICK SOLN A-INJ 50 MG/ML
BRAND
PA
C
Biopharmacy benefit
via Acaria
C
Biopharmacy benefit
via Acaria
PA
C
Biopharmacy benefit
via Acaria
PA
HUMIRA (PREF SY KT 20 MG/0.4ML, PREF SY KT 40
MG/0.8ML)
BRAND
HUMIRA PEN PEN KIT 40 MG/0.8ML
BRAND
C
Biopharmacy benefit
via Acaria
PA
C
PAGE 102
Biopharmacy benefit
via Acaria
PRODUCT DESCRIPTION
BRAND/GEN
methotrexate sodium (inj 25 mg/ml, inj 50 mg/2ml (25
mg/ml), inj 250 mg/10ml (25 mg/ml), inj pf 25 mg/ml, inj pf
50 mg/2ml (25 mg/ml), inj pf 100 mg/4ml (25 mg/ml), inj pf
200 mg/8ml (25 mg/ml), inj pf 250 mg/10ml (25 mg/ml), inj
pf 1000 mg/40ml (25 mg/ml), tab 2.5 mg (base equiv))
generic
mycophenolate mofetil (cap 250 mg, tab 500 mg)
generic
mycophenolate mofetil for oral susp 200 mg/ml
generic
mycophenolate sodium tab dr 180 mg (mycophenolic acid
equiv)
MDD
6 per day
generic
MDD
3 per day
mycophenolate sodium tab dr 360 mg (mycophenolic acid
equiv)
generic
MDD
4 per day
RAPAMUNE SOLUTION 1 MG/ML
BRAND
RHEUMATREX TAB 2.5 MG
BRAND
sirolimus tab 0.5 mg
generic
sirolimus tab 1 mg
generic
MDD
6 per day
sirolimus tab 2 mg
generic
MDD
2 per day
tacrolimus (cap 0.5 mg, cap 1 mg, cap 5 mg)
generic
MDD
3 per day
TREXALL (TAB 5 MG, TAB 7.5 MG, TAB 10 MG, TAB 15
MG)
BRAND
MDD
1 per day
IMMUNOMODULATORS
leflunomide (tab 10 mg, tab 20 mg)
generic
RIDAURA CAP 3 MG
BRAND
INFLAMMATORY BOWEL DISEASE AGENTS
AMINOSALICYLATES
ASACOL TAB DR 400 MG
BRAND
MDD
12 per day
balsalazide disodium cap 750 mg
generic
MDD
9 per day
DELZICOL CAP DR 400 MG
BRAND
MDD
6 per day
mesalamine enema 4 gm
generic
MDD
60 per day
PENTASA (CAP ER 250 MG, CAP ER 500 MG)
BRAND
MDD
8 per day
PAGE 103
PRODUCT DESCRIPTION
BRAND/GEN
SFROWASA ENEMA 4 GM/60ML
BRAND
GLUCOCORTICOIDS
hydrocortisone enema 100 mg/60ml
generic
hydrocortisone rectal cream 2.5%
generic
SULFONAMIDES
sulfasalazine (tab 500 mg, tab delayed release 500 mg)
generic
METABOLIC BONE DISEASE AGENTS
alendronate sodium (tab 35 mg, tab 70 mg)
generic
MDD
0.15 per day
alendronate sodium (tab 5 mg, tab 10 mg, tab 40 mg)
generic
MDD
1 per day
alendronate sodium oral soln 70 mg/75ml
generic
MDD
10.8 per day
calcitonin (salmon) nasal soln 200 unit/act
generic
MPL
1 / claim
calcitriol (cap 0.25 mcg, cap 0.5 mcg, inj 1 mcg/ml, oral
soln 1 mcg/ml)
generic
MIACALCIN SOLUTION 200 UNIT/ML
BRAND
QL
2 / claim
MISCELLANEOUS THERAPEUTIC AGENTS
MDS
*lancet devices***
generic
C
MDS
*lancets***
generic
C
1 / 180 DAYS
Select-Lite Lancing
Device MISC; MultiLancet Device MISC;
Lancing Device MISC
200 / 30 DAYS
ez-lets 23G misc; hyvee & hy-vee thin misc;
kroger & kroger thin
misc; lancet & lancet
thin misc; surelite
1ST CHOICE LANCETS SUPER THIN MISC
BRAND
MDS
200 / 30 DAYS
1ST CHOICE LANCETS THIN MISC
BRAND
MDS
200 / 30 DAYS
1ST CHOICE LANCETS ULTRA THIN MISC
BRAND
MDS
200 / 30 DAYS
1ST TIER UNILET COMFORTOUCH MISC
BRAND
MDS
200 / 30 DAYS
PAGE 104
PRODUCT DESCRIPTION
BRAND/GEN
ACCU-CHEK SOFT TOUCH LANCETS MISC
BRAND
MDS
200 / 30 DAYS
ACCU-CHEK SOFTCLIX LANCET DEV MISC
BRAND
MDS
1 / 180 DAYS
ACCUSURE INSULIN SYRINGE (29G 1/2" 1 ML, 29G 1/2"
0.5 ML, 30G 5/16" 0.5 ML)
BRAND
MDD
5 per day
ACETEST TAB
BRAND
ADJUSTABLE LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
ADVOCATE INSULIN SYRINGE (MISC 29G 1/2" 0.3 ML,
MISC 29G 1/2" 0.5 ML, MISC 29G 1/2" 1 ML, MISC 30G
5/16" 0.5 ML, MISC 30G 5/16" 0.3 ML, MISC 31G 5/16" 1
ML)
BRAND
MDD
5 per day
ADVOCATE LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
ADVOCATE RAPID-SAFE LANCING MISC
BRAND
MDS
1 / 180 DAYS
AF LANCETS SUPER THIN MISC
BRAND
MDS
200 / 30 DAYS
AGAMATRIX ULTRA-THIN LANCETS MISC
BRAND
MDS
200 / 30 DAYS
ALTERNATE SITE LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
ANTI-STICK INSULIN SYRINGE MISC 29G X 1/2" 1 ML
BRAND
MDD
5 per day
AQUA LANCE ADJUSTABLE LANCING DEVICE
BRAND
MDS
1 / 180 DAYS
ASSURE ID INSULIN SAFETY SYR (MISC 1/2" 1 ML,
MISC 1/2" 0.5 ML)
BRAND
MDD
5 per day
AURORA LANCET SUPER THIN 30G MISC
BRAND
MDS
200 / 30 DAYS
AURORA LANCET THIN 23G MISC
BRAND
MDS
200 / 30 DAYS
AUTO-LANCET MINI MISC
BRAND
MDS
1 / 180 DAYS
AUTO-LANCET MISC
BRAND
MDS
1 / 180 DAYS
AUTOLET IMPRESSION MISC
BRAND
MDS
1 / 180 DAYS
AUTOLET LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
AUTOLET MINI MISC
BRAND
MDS
1 / 180 DAYS
AUTOLET PLUS MISC
BRAND
MDS
1 / 180 DAYS
PAGE 105
PRODUCT DESCRIPTION
BRAND/GEN
BAYER MICROLET 2 LANCING DEVIC MISC
BRAND
MDS
1 / 180 DAYS
BD INSULIN SYR ULTRAFINE II MISC 31G X 5/16" 1 ML
BRAND
MDD
5 per day
BD INSULIN SYRINGE (MISC 26G 1/2" 1 ML, MISC 28G
1/2" 1 ML, MISC 29G 1/2" 0.5 ML, MISC 29G 1/2" 1 ML)
BRAND
MDD
5 per day
BD INSULIN SYRINGE MICROFINE (MISC 27G 5/8" 1
ML, MISC 28G 1/2" 1 ML, MISC 28G 1/2" 0.3 ML, MISC
28G 1/2" 0.5 ML)
BRAND
MDD
5 per day
BD INSULIN SYRINGE ULTRAFINE (MISC 29G 1/2" 0.5
ML, MISC 29G 1/2" 0.3 ML, MISC 29G 1/2" 1 ML, MISC
31G 15/64" 1 ML, MISC 31G 5/16" 1 ML)
BRAND
MDD
5 per day
BD INTEGRA INSULIN SYRINGE MISC 29G X 1/2" 1 ML
BRAND
MDD
5 per day
BD LANCET DEVICE MISC
BRAND
MDS
1 / 180 DAYS
BD LANCET ULTRAFINE 30G MISC
BRAND
MDS
200 / 30 DAYS
BD SAFETY-LOK INSULIN SYRINGE MISC 29G X 1/2" 1
ML
BRAND
MDD
5 per day
BD SAFETYGLIDE INSULIN SYRINGE (MISC 29G 1/2"
0.5 ML, MISC 30G 5/16" 0.5 ML)
BRAND
MDD
5 per day
CARDIOCOM LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
CAREONE ADVANCED LANCING DEV MISC
BRAND
MDS
1 / 180 DAYS
CAREONE INSULIN SYRINGE MISC 31G X 5/16" 1 ML
BRAND
MDD
5 per day
CAREONE LANCET THIN 23G MISC
BRAND
MDS
200 / 30 DAYS
CAREONE LANCET ULTRA THIN 28G MISC
BRAND
MDS
200 / 30 DAYS
CAREONE ULTIGUARD INSULIN SYR (MISC 29G 1/2" 1
ML, MISC 29G 1/2" 0.5 ML, MISC 29G 1/2" 0.3 ML, MISC
30G 5/16" 0.3 ML, MISC 30G 5/16" 0.5 ML)
BRAND
MDD
5 per day
CHEK-STIX CONTROL STRIP
BRAND
MPL
1 / 30 days
CHEMSTRIP K STRIP
BRAND
MPL
1 / 30 days
CLEANLET LANCETS 28G MISC
BRAND
MDS
200 / 30 DAYS
CLINISTIX STRIP
BRAND
QL
CLINITEST TAB
BRAND
PAGE 106
30 / 30 days
PRODUCT DESCRIPTION
BRAND/GEN
CLOSERCARE MISC
BRAND
MDS
1 / 180 DAYS
COMFORT ASSIST INSULIN SYRINGE (MISC 29G 1/2"
0.5 ML, MISC 29G 1/2" 1 ML, MISC 29G 1/2" 0.3 ML,
MISC 30G 5/16" 0.5 ML, MISC 30G 5/16" 0.3 ML, MISC
31G 5/16" 0.3 ML, MISC 31G 5/16" 1 ML)
BRAND
MDD
5 per day
COMFORT ASSURED LANCETS 28G MISC
BRAND
MDS
200 / 30 DAYS
COMFORT ASSURED LANCETS 33G MISC
BRAND
MDS
200 / 30 DAYS
COMFORT EZ INSULIN SYRINGE (MISC 28G 1/2" 1 ML,
MISC 28G 1/2" 0.5 ML, MISC 29G 1/2" 0.5 ML, MISC 29G
1/2" 1 ML, MISC 29G 1/2" 0.3 ML, MISC 30G 5/16" 0.3 ML,
MISC 30G 5/16" 0.5 ML, MISC 31G 5/16" 1 ML)
BRAND
MDD
5 per day
COMFORT LANCETS MISC
BRAND
MDS
200 / 30 DAYS
CVS INSULIN SYRINGE (MISC 1/2" 1 ML, MISC 1/2" 0.5
ML, MISC 1/2" 0.3 ML)
BRAND
MDD
5 per day
CVS LANCETS 21G MISC
BRAND
MDS
200 / 30 DAYS
CVS LANCETS MICRO THIN 33G MISC
BRAND
MDS
200 / 30 DAYS
CVS LANCETS ORIGINAL MISC
BRAND
MDS
200 / 30 DAYS
CVS LANCETS THIN 26G MISC
BRAND
MDS
200 / 30 DAYS
CVS LANCETS THIN MISC
BRAND
MDS
200 / 30 DAYS
CVS LANCETS ULTRA THIN 30G MISC
BRAND
MDS
200 / 30 DAYS
CVS LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
CVS ULTRA THIN LANCETS MISC
BRAND
MDS
200 / 30 DAYS
DIASTAR EASY TEST II LANCETS MISC
BRAND
MDS
200 / 30 DAYS
DIASTAR EASY TEST LANCETS MISC
BRAND
MDS
200 / 30 DAYS
DIASTIX STRIP
BRAND
QL
DROPLET LANCETS ULTRA THIN 30G MISC
BRAND
MDS
200 / 30 DAYS
DROPLET LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
DRUG MART LANCETS THIN 26G MISC
BRAND
MDS
200 / 30 DAYS
PAGE 107
30 / 30 days
PRODUCT DESCRIPTION
BRAND/GEN
DRUG MART LANCETS ULTRA THIN MISC
BRAND
MDS
200 / 30 DAYS
DRUG MART LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
DRUG MART ULTRA COMFORT SYR (MISC 29G 1/2" 0.3
30G 5/16" 0.5 ML)
BRAND
MDD
5 per day
DRUG MART UNILET LANCETS 28G MISC
BRAND
MDS
200 / 30 DAYS
DRUG MART UNILET LANCETS 30G MISC
BRAND
MDS
200 / 30 DAYS
DUANE READE LANCET ALTERN SITE MISC
BRAND
MDS
200 / 30 DAYS
DUANE READE LANCET SUPER THIN MISC
BRAND
MDS
200 / 30 DAYS
DUANE READE LANCET ULTRA THIN MISC
BRAND
MDS
200 / 30 DAYS
E-Z JECT LANCET MICRO-THIN 33G MISC
BRAND
MDS
200 / 30 DAYS
E-Z JECT LANCET SUPER THIN 30G MISC
BRAND
MDS
200 / 30 DAYS
E-Z JECT LANCETS 21G MISC
BRAND
MDS
200 / 30 DAYS
E-Z JECT LANCETS MISC
BRAND
MDS
200 / 30 DAYS
E-Z JECT LANCETS THIN 26G MISC
BRAND
MDS
200 / 30 DAYS
EASY COMFORT INSULIN SYRINGE (MISC 30G 5/16"
0.3 ML, MISC 30G 5/16" 0.5 ML, MISC 31G 5/16" 1 ML,
MISC 31G 5/16" 0.5 ML)
BRAND
MDD
5 per day
EASY MINI EJECT LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
EASY MINI LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
EASY TOUCH FLIPLOCK INSULIN SY (SY MISC 29G
1/2" 1 ML, SY MISC 30G 1/2" 1 ML, SY MISC 30G 5/16" 1
ML, SY MISC 31G 5/16" 1 ML)
BRAND
MDD
5 per day
EASY TOUCH INSULIN SAFETY SYR (MISC 29G 1/2" 1
ML, MISC 29G 1/2" 0.5 ML, MISC 30G 5/16" 0.5 ML)
BRAND
MDD
5 per day
EASY TOUCH INSULIN SYRINGE (MISC 28G 1/2" 0.5
ML, MISC 28G 1/2" 1 ML, MISC 29G 1/2" 1 ML, MISC 29G
1/2" 0.5 ML, MISC 30G 5/16" 0.5 ML, MISC 30G 5/16" 0.3
ML, MISC 31G 5/16" 1 ML)
BRAND
MDD
5 per day
EASY TOUCH LANCETS 26G MISC
BRAND
MDS
200 / 30 DAYS
PAGE 108
PRODUCT DESCRIPTION
BRAND/GEN
EASY TOUCH LANCETS 26G/TWIST MISC
BRAND
MDS
200 / 30 DAYS
BRAND
MDS
200 / 30 DAYS
BRAND
MDS
200 / 30 DAYS
BRAND
MDS
200 / 30 DAYS
BRAND
MDS
200 / 30 DAYS
BRAND
MDS
200 / 30 DAYS
BRAND
MDS
200 / 30 DAYS
BRAND
MDS
200 / 30 DAYS
EASY TOUCH LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
EASY TOUCH SHEATHLOCK SYRINGE (MISC 29G 1/2"
1 ML, MISC 30G 5/16" 1 ML, MISC 30G 1/2" 1 ML, MISC
31G 5/16" 1 ML)
BRAND
MDD
5 per day
EQL COLOR LANCETS 21G MISC
BRAND
MDS
200 / 30 DAYS
EQL COLOR LANCETS MICRO 33G MISC
BRAND
MDS
200 / 30 DAYS
EQL INSULIN SYRINGE (MISC 29G 1/2" 0.5 ML, MISC
29G 1/2" 0.3 ML, MISC 29G 1/2" 1 ML, MISC 30G 5/16"
0.3 ML, MISC 30G 5/16" 0.5 ML, MISC 31G 5/16" 1 ML)
BRAND
MDD
5 per day
EQL SUPER THIN LANCETS 30G MISC
BRAND
MDS
200 / 30 DAYS
EQL THIN LANCETS 26G MISC
BRAND
MDS
200 / 30 DAYS
EXEL COMFORT POINT INSULIN SYR (EEL MISC 28G
1/2" 1 ML, EEL MISC 28G 1/2" 0.5 ML, EEL MISC 29G
1/2" 1 ML, EEL MISC 29G 1/2" 0.5 ML, EEL MISC 29G
1/2" 0.3 ML, EEL MISC 30G 5/16" 0.3 ML, EEL MISC 30G
5/16" 0.5 ML)
BRAND
MDD
5 per day
EXEL COMFORT POINT PEN NEEDLE MISC 31G X 4
MM
BRAND
MDD
5 per day
EZ SMART BLOOD GLUCOSE LANCETS MISC
BRAND
MDS
200 / 30 DAYS
EZ-LETS LANCETS 21G MISC
BRAND
MDS
200 / 30 DAYS
BRAND
MDS
200 / 30 DAYS
PAGE 109
PRODUCT DESCRIPTION
BRAND/GEN
BRAND
MDS
200 / 30 DAYS
BRAND
MDS
200 / 30 DAYS
FIFTY50 LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
FIFTY50 SUPERIOR COMFORT SYR MISC 31G X 5/16"
1 ML
BRAND
MDD
5 per day
FORA LANCETS MISC
BRAND
MDS
200 / 30 DAYS
FORA LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
formaldehyde solution 10%
generic
QL
FREDS PHARMACY AUTOLET LANCING MISC
BRAND
MDS
1 / 180 DAYS
FREDS PHARMACY UNILET LANC 28G MISC
BRAND
MDS
200 / 30 DAYS
FREDS PHARMACY UNILET LANC 30G MISC
BRAND
MDS
200 / 30 DAYS
FREESTYLE PRECISION INS SYR (MISC 30G 5/16" 0.5
ML, MISC 31G 5/16" 1 ML)
BRAND
MDD
5 per day
GLOBAL INJECT EASE INSULIN SYR (MISC 28G 1/2" 1
29G 1/2" 1 ML, MISC 29G 1/2" 0.5 ML, MISC 30G 5/16"
BRAND
MDD
5 per day
GLOBAL LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
GLUCOCOM LANCETS 28G MISC
BRAND
MDS
200 / 30 DAYS
GLUCOCOM LANCETS 30G MISC
BRAND
MDS
200 / 30 DAYS
GLUCOLET 2 AUTOMATIC LANCING MISC
BRAND
MDS
1 / 180 DAYS
GLUCOPRO INSULIN SYRINGE (MISC 30G 5/16" 0.3 ML,
MISC 30G 5/16" 0.5 ML, MISC 31G 5/16" 1 ML)
BRAND
MDD
5 per day
GLUCOSOURCE LANCET DEVICE MISC
BRAND
MDS
1 / 180 DAYS
GLUCOSOURCE LANCETS MISC
BRAND
MDS
200 / 30 DAYS
GNP INSULIN SYRINGE (MISC 28G 1/2" 1 ML, MISC 28G
1/2" 0.5 ML, MISC 29G 1/2" 1 ML, MISC 29G 1/2" 0.3 ML,
30G 5/16" 0.5 ML, MISC 31G 5/16" 1 ML)
BRAND
MDD
5 per day
PAGE 110
90 / claim
PRODUCT DESCRIPTION
BRAND/GEN
GNP LANCETS 21G MISC
BRAND
MDS
200 / 30 DAYS
GNP LANCETS MICRO THIN 33G MISC
BRAND
MDS
200 / 30 DAYS
GNP LANCETS MISC
BRAND
MDS
200 / 30 DAYS
GNP LANCETS SUPER THIN 30G MISC
BRAND
MDS
200 / 30 DAYS
GNP LANCETS THIN 26G MISC
BRAND
MDS
200 / 30 DAYS
GNP LANCETS THIN MISC
BRAND
MDS
200 / 30 DAYS
GNP MICRO THIN LANCETS 33G MISC
BRAND
MDS
200 / 30 DAYS
GNP SUPER THIN LANCETS 30G MISC
BRAND
MDS
200 / 30 DAYS
GNP ULTRA COM INSULIN SYRINGE (MISC 28G 1/2" 1
BRAND
MDD
5 per day
H&H THINLET LANCETS 26G MISC
BRAND
MDS
200 / 30 DAYS
H&H THINLET LANCETS 30G MISC
BRAND
MDS
200 / 30 DAYS
H-E-B INCONTROL ADV LANCING MISC
BRAND
MDS
1 / 180 DAYS
H-E-B INCONTROL LANCETS 28G MISC
BRAND
MDS
200 / 30 DAYS
BRAND
MDS
200 / 30 DAYS
BRAND
MDS
200 / 30 DAYS
H-E-B INCONTROL PEN NEEDLES MISC 31G X 5 MM
BRAND
MDD
5 per day
HEALTH CARE LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
HEALTHWISE LANCING PEN MISC
BRAND
MDS
1 / 180 DAYS
HEALTHY ACCENTS LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
HEALTHY ACCENTS UNILET LANCETS MISC
BRAND
MDS
200 / 30 DAYS
HM LANCETS MICRO THIN 33G MISC
BRAND
MDS
200 / 30 DAYS
HM LANCETS ULTRA THIN 30G MISC
BRAND
MDS
200 / 30 DAYS
HY-VEE INSULIN SYRINGE (1/2" 1 ML, 1/2" 0.5 ML, 1/2"
0.3 ML)
BRAND
MDD
5 per day
PAGE 111
PRODUCT DESCRIPTION
BRAND/GEN
hyoscyamine sulfate powder
generic
IN TOUCH LANCING DEVICE MISC
BRAND
MDS
INSPIREASE BAGS MISC
BRAND
QL
3 / 180 days
INSPIREASE MOUTHPIECE MISC
BRAND
INSPIREASE RESERVOIR BAGS MISC
BRAND
QL
3 / 180 days
insulin pen needle 29 g x 12 mm (1/2")
generic
MDD
5 per day
insulin pen needle 29 g x 12.7 mm
generic
MDD
5 per day
insulin pen needle 30 g x 8 mm (1/3" or 5/16")
generic
MDD
5 per day
generic
MDD
5 per day
generic
MDD
5 per day
generic
MDD
5 per day
generic
MDD
5 per day
generic
MDD
5 per day
generic
MDD
5 per day
insulin syringe (disp) u-100 1 ml
generic
MDD
5 per day
INSULIN SYRINGE (MISC 28G 1/2" 0.5 ML, MISC 28G
1/2" 1 ML, MISC 29G 1/2" 1 ML, MISC 29G 1" 0.3 ML,
5/16" 0.5 ML, MISC 31G 5/16" 1 ML)
BRAND
MDD
5 per day
INSULIN SYRINGE/NEEDLE (SYRINGE/NEEDLE 1/2" 0.5
ML, SYRINGE/NEEDLE 1/2" 1 ML, SYRINGE/NEEDLE
MISC 1/2" 1 ML, SYRINGE/NEEDLE MISC 1/2" 0.5 ML)
BRAND
MDD
5 per day
insulin syringe/needle u-100 (syringe/needle 0.3 ml 29 1/2",
syringe/needle 0.3 ml 30 5/16", syringe/needle 1/2 ml 28
1/2", syringe/needle 1 ml 28 1/2", syringe/needle 1/2 ml 29
1/2", syringe/needle 1/2 ml 30 5/16", syringe/needle 1 ml
29 1/2", syringe/needle 1 ml 31 5/16")
generic
MDD
5 per day
insulin syringe/needle u-100 0.3 ml 30 x 1/2"
generic
MDD
5 per day
generic
MDD
5 per day
PAGE 112
1 / 180 DAYS
PRODUCT DESCRIPTION
BRAND/GEN
generic
MDD
5 per day
insulin syringe/needle u-100 1 ml 25 x 1"
generic
MDD
5 per day
insulin syringe/needle u-100 1 ml 25 x 5/8"
generic
MDD
5 per day
generic
MDD
5 per day
generic
MDD
5 per day
generic
MDD
5 per day
insulin syringe/needle u-100 1/2 ml 27 x 1/2"
generic
MDD
5 per day
generic
MDD
5 per day
generic
MDD
5 per day
generic
MDD
5 per day
INSUPEN PEN NEEDLES MISC 33G X 4 MM
BRAND
MDD
5 per day
INSUPEN SENSITIVE MISC 32G X 8 MM
BRAND
MDD
5 per day
KETOCARE (, STRIP)
BRAND
MPL
1 / 30 days
KETOSTIX STRIP
BRAND
MPL
1 / 30 days
KINNEY LANCETS MISC
BRAND
MDS
200 / 30 DAYS
KINNEY THIN LANCETS MISC
BRAND
MDS
200 / 30 DAYS
KINRAY INSULIN SYRINGE (MISC 29G 1/2" 0.5 ML,
MISC 31G 5/16" 1 ML)
BRAND
MDD
5 per day
KROGER INSULIN SYRINGE (MISC 29G 1/2" 1 ML, MISC
29G 1/2" 0.5 ML, MISC 29G 1/2" 0.3 ML, MISC 30G 5/16"
BRAND
MDD
5 per day
KROGER LANCETS 21G MISC
BRAND
MDS
200 / 30 DAYS
KROGER LANCETS MICRO THIN 33G MISC
BRAND
MDS
200 / 30 DAYS
KROGER LANCETS SUPER THIN MISC
BRAND
MDS
200 / 30 DAYS
KROGER LANCETS THIN 26G MISC
BRAND
MDS
200 / 30 DAYS
KROGER LANCETS ULTRATHIN 30G MISC
BRAND
MDS
200 / 30 DAYS
PAGE 113
PRODUCT DESCRIPTION
BRAND/GEN
KROGER LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
LADY LITE LANCETS MISC
BRAND
MDS
200 / 30 DAYS
LANCET DEVICE MISC
BRAND
MDS
1 / 180 DAYS
LANCET DEVICE WITH EJECTOR MISC
BRAND
MDS
1 / 180 DAYS
LANCETS 28G MISC
BRAND
MDS
200 / 30 DAYS
LANCETS 30G MISC
BRAND
MDS
200 / 30 DAYS
LANCETS MISC
BRAND
MDS
200 / 30 DAYS
LANCETS THIN MISC
BRAND
MDS
200 / 30 DAYS
LANCETS ULTRA THIN MISC
BRAND
MDS
200 / 30 DAYS
LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
LANZO MISC
BRAND
MDS
1 / 180 DAYS
LEADER ADVANCED LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
LEADER INSULIN SYRINGE (MISC 28G 1/2" 1 ML, MISC
0.3 ML, MISC 29G 1/2" 1 ML, MISC 30G 5/16" 0.5 ML,
MISC 30G 5/16" 0.3 ML, MISC 31G 5/16" 1 ML)
BRAND
MDD
5 per day
LIBERTY MINI LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
LITE TOUCH LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
LITE TOUCH LANCING PEN MISC
BRAND
MDS
1 / 180 DAYS
LITETOUCH INSULIN SYRINGE (MISC 28G 1/2" 0.5 ML,
MISC 28G 1/2" 1 ML, MISC 29G 1/2" 1 ML, MISC 29G 1/2"
0.3 ML, MISC 29G 1/2" 0.5 ML, MISC 30G 5/16" 0.5 ML,
MISC 30G 5/16" 0.3 ML, MISC 31G 5/16" 1 ML)
BRAND
MDD
5 per day
LIVE BETTER ADV LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
LIVE BETTER LANCET SUPER THIN MISC
BRAND
MDS
200 / 30 DAYS
LIVE BETTER LANCET ULTRA THIN MISC
BRAND
MDS
200 / 30 DAYS
LONGS LANCETS STANDARD MISC
BRAND
MDS
200 / 30 DAYS
PAGE 114
PRODUCT DESCRIPTION
BRAND/GEN
LONGS LANCETS THIN MISC
BRAND
MDS
200 / 30 DAYS
MAGELLAN INSULIN SAFETY SYR (MISC 29G 1/2" 0.3
30G 5/16" 0.5 ML, MISC 30G 5/16" 0.3 ML)
BRAND
MDD
5 per day
MAJOR COMFORT LANCETS MISC
BRAND
MDS
200 / 30 DAYS
MAXI-COMFORT INSULIN SYRINGE (MAI-COMFORT
MISC 1/2" 0.5 ML, MAI-COMFORT MISC 1/2" 1 ML)
BRAND
MDD
5 per day
MEDI-LANCE LANCETS MISC
BRAND
MDS
200 / 30 DAYS
MEDIC INSULIN SYRINGE (MISC 5/16" 0.3 ML, MISC
5/16" 0.5 ML)
BRAND
MDD
5 per day
MEDICINE SHOPPE LANCETS MISC
BRAND
MDS
200 / 30 DAYS
MEDICINE SHOPPE LANCETS THIN MISC
BRAND
MDS
200 / 30 DAYS
MEDISENSE THIN LANCETS MISC
BRAND
MDS
200 / 30 DAYS
MEIJER LANCETS MISC
BRAND
MDS
200 / 30 DAYS
MEIJER LANCETS THIN MISC
BRAND
MDS
200 / 30 DAYS
MEIJER LANCETS UNIVERSAL 30G MISC
BRAND
MDS
200 / 30 DAYS
MEIJER LANCETS UNIVERSAL 33G MISC
BRAND
MDS
200 / 30 DAYS
MEIJER SUPER THIN LANCETS MISC
BRAND
MDS
200 / 30 DAYS
methylergonovine maleate tab 0.2 mg
generic
MINI LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
MONOJECT INSULIN SYRINGE (MISC 28G 1/2" 0.5 ML,
0.3 ML, MISC 29G 1/2" 0.5 ML, MISC 30G 5/16" 0.3 ML,
MISC 30G 5/16" 0.5 ML, MISC 31G 5/16" 1 ML)
BRAND
MDD
5 per day
MONOJECT ULTRA COMFORT SYRINGE (MISC 28G
1/2" 0.5 ML, MISC 28G 1/2" 1 ML, MISC 29G 1/2" 0.3 ML,
5/16" 0.5 ML, MISC 30G 5/16" 0.3 ML)
BRAND
MDD
5 per day
MONOLET LANCETS MISC
BRAND
MDS
200 / 30 DAYS
MONOLET OPD LANCETS MISC
BRAND
MDS
200 / 30 DAYS
PAGE 115
PRODUCT DESCRIPTION
BRAND/GEN
MOORE MONO INSULIN SYRINGE (MISC 28G 1/2" 1 ML,
1/2" 1 ML)
BRAND
MDD
5 per day
MS INSULIN SYRINGE (MISC 29G 1/2" 0.5 ML, MISC
BRAND
MDD
5 per day
NOVA SUREFLEX LANCETS MISC
BRAND
MDS
200 / 30 DAYS
NOVA SUREFLEX LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
ON CALL LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
ON CALL PLUS LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
ONETOUCH DELICA LANCING DEV MISC
BRAND
MDS
1 / 180 DAYS
ONETOUCH LANCETS MISC
BRAND
MDS
200 / 30 DAYS
ORSINI INSULIN SYRINGE (MISC 29G 1/2" 0.5 ML, MISC
30G 5/16" 0.5 ML)
BRAND
MDD
5 per day
ORTHO DIAPHRAGM ALL-FLEX (DIAPHRAGM
DIAPHRAGM 65, DIAPHRAGM DIAPHRAGM 70,
DIAPHRAGM DIAPHRAGM 75, DIAPHRAGM
DIAPHRAGM 80)
BRAND
PC LANCETS SUPER THIN 30G MISC
BRAND
MDS
200 / 30 DAYS
PERFECT LANCETS 30G MISC
BRAND
MDS
200 / 30 DAYS
PHARMACY COUNTER LANCETS MISC
BRAND
MDS
200 / 30 DAYS
PRECISION SURE-DOSE SYRINGE (MISC 28G 1/2" 0.5
30G 5/16" 0.3 ML)
BRAND
MDD
5 per day
PRECISION SUREDOSE PLUS SYR (MISC 1/2" 0.3 ML,
MISC 1/2" 1 ML)
BRAND
MDD
5 per day
PREFERRED PLUS INSULIN SYRINGE (MISC 28G 1/2" 1
0.3 ML, MISC 30G 5/16" 0.5 ML)
BRAND
MDD
5 per day
PREFERRED PLUS LANCETS COLORED MISC
BRAND
MDS
200 / 30 DAYS
PREFERRED PLUS LANCETS THIN MISC
BRAND
MDS
200 / 30 DAYS
PAGE 116
PRODUCT DESCRIPTION
BRAND/GEN
PRODIGY INSULIN PEN NEEDLES MISC 29G X 13MM
BRAND
MDD
5 per day
PRODIGY INSULIN SYRINGE MISC 28G X 1/2" 1 ML
BRAND
MDD
5 per day
PRODIGY LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
PRODIGY TWIST TOP LANCETS 28G MISC
BRAND
MDS
200 / 30 DAYS
progesterone micronized powder
generic
PROGESTERONE MICRONIZED POWDER
BRAND
progesterone powder
generic
PROGESTERONE POWDER
BRAND
PROGESTERONE WETTABLE POWDER
BRAND
promethazine hcl (bulk) powder
generic
PX ADVANCED LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
PX INSULIN SYRINGE MISC 31G X 5/16" 1 ML
BRAND
MDD
5 per day
PX LANCET AUTO INJECTOR MISC
BRAND
MDS
1 / 180 DAYS
PX LANCETS MISC
BRAND
MDS
200 / 30 DAYS
PX LANCETS ULTRA THIN MISC
BRAND
MDS
200 / 30 DAYS
QC ADVANCED LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
QC INSULIN SYRINGE (MISC 29G 1/2" 0.5 ML, MISC
29G 1/2" 1 ML, MISC 29G 1/2" 0.3 ML, MISC 31G 5/16" 1
ML)
BRAND
MDD
5 per day
QC LANCETS SUPER THIN 30G MISC
BRAND
MDS
200 / 30 DAYS
QC LANCETS ULTRA THIN MISC
BRAND
MDS
200 / 30 DAYS
QC UNILET LANCETS MICRO THIN MISC
BRAND
MDS
200 / 30 DAYS
RA E-ZJECT COLOR LANCETS 33G MISC
BRAND
MDS
200 / 30 DAYS
RA E-ZJECT LANCETS 28G MISC
BRAND
MDS
200 / 30 DAYS
RA E-ZJECT LANCETS THIN 26G MISC
BRAND
MDS
200 / 30 DAYS
RA E-ZJECT LANCETS THIN 28G MISC
BRAND
MDS
200 / 30 DAYS
PAGE 117
PRODUCT DESCRIPTION
BRAND/GEN
RA E-ZJECT LANCETS ULTRA THIN MISC
BRAND
MDS
200 / 30 DAYS
RA INSULIN SYRINGE (MISC 29G 1/2" 0.5 ML, MISC 29G
1/2" 1 ML, MISC 30G 5/16" 0.5 ML)
BRAND
MDD
5 per day
RA LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
RELI-ON INSULIN SYRINGE MISC 29G X 1/2" 1 ML
BRAND
MDD
5 per day
RELION INSULIN SYRINGE (MISC 29G 1/2" 0.5 ML,
5/16" 0.5 ML, MISC 30G 5/16" 0.3 ML, MISC 31G 5/16" 1
ML)
BRAND
MDD
5 per day
RELION LANCETS MICRO-THIN 33G MISC
BRAND
MDS
200 / 30 DAYS
RELION LANCETS STANDARD 21G MISC
BRAND
MDS
200 / 30 DAYS
RELION LANCETS THIN 26G MISC
BRAND
MDS
200 / 30 DAYS
RELION LANCETS ULTRA-THIN 30G MISC
BRAND
MDS
200 / 30 DAYS
RELION LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
RELION ULTRA THIN LANCETS 30G MISC
BRAND
MDS
200 / 30 DAYS
RELION ULTRA THIN PLUS LANCETS MISC
BRAND
MDS
200 / 30 DAYS
RENEW ADVANCED LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
REXALL LANCETS ULTRA THIN 30G MISC
BRAND
MDS
200 / 30 DAYS
RIGHTEST GD500 LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
RIGHTEST GL300 LANCETS MISC
BRAND
MDS
200 / 30 DAYS
SAFESNAP INSULIN SYRINGE (MISC 28G 1/2" 1 ML,
MISC 29G 1/2" 1 ML, MISC 29G 1/2" 0.5 ML, MISC 30G
5/16" 0.5 ML, MISC 30G 5/16" 0.3 ML)
BRAND
MDD
5 per day
SAFETY SEAL LANCETS MISC
BRAND
MDS
200 / 30 DAYS
SAFETY-GLIDE SYRINGE MISC 29G X 1/2" 0.3 ML
BRAND
MDD
5 per day
SB INSULIN SYRINGE (MISC 29G 1/2" 1 ML, MISC 29G
1/2" 0.5 ML, MISC 30G 5/16" 0.5 ML, MISC 31G 5/16" 1
ML)
BRAND
MDD
5 per day
SB LANCETS THIN MISC
BRAND
MDS
200 / 30 DAYS
PAGE 118
PRODUCT DESCRIPTION
BRAND/GEN
SB LANCETS ULTRA THIN MISC
BRAND
MDS
200 / 30 DAYS
SCHNUCKS INSULIN SYRINGE (MISC 29G 1/2" 0.5 ML,
MISC 30G 5/16" 0.5 ML)
BRAND
MDD
5 per day
SHOPKO AUTOLET LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
SHOPKO UNILET LANCETS 28G MISC
BRAND
MDS
200 / 30 DAYS
SHOPKO UNILET LANCETS 30G MISC
BRAND
MDS
200 / 30 DAYS
SIMPLE DIAGNOSTICS LANCING DEV MISC
BRAND
MDS
1 / 180 DAYS
SM INSULIN SYRINGE (MISC 28G 1/2" 1 ML, MISC 28G
1/2" 0.5 ML, MISC 29G 1/2" 0.3 ML, MISC 29G 1/2" 0.5
30G 5/16" 0.3 ML, MISC 31G 5/16" 1 ML)
BRAND
MDD
5 per day
SM LANCETS 21G MISC
BRAND
MDS
200 / 30 DAYS
SM LANCETS 33G MISC
BRAND
MDS
200 / 30 DAYS
SM SUPER THIN LANCETS 30G MISC
BRAND
MDS
200 / 30 DAYS
SM THIN LANCETS 26G MISC
BRAND
MDS
200 / 30 DAYS
SMART DIABETES VANTAGE LANCING MISC
BRAND
MDS
1 / 180 DAYS
SMART SENSE COLOR LANCETS 33G MISC
BRAND
MDS
200 / 30 DAYS
SMART SENSE STANDARD LANCETS MISC
BRAND
MDS
200 / 30 DAYS
SMART SENSE SUPER THIN LANCETS MISC
BRAND
MDS
200 / 30 DAYS
SMART SENSE THIN LANCETS 26G MISC
BRAND
MDS
200 / 30 DAYS
sodium polystyrene sulfonate (bulk) powder
generic
QL
SOLUS V2 LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
STERILANCE TL MISC
BRAND
MDS
200 / 30 DAYS
SUPER THIN LANCETS MISC
BRAND
MDS
200 / 30 DAYS
PAGE 119
454 / claim
PRODUCT DESCRIPTION
BRAND/GEN
SURE COMFORT INSULIN SYRINGE (MISC 28G 1/2" 1
29G 1/2" 1 ML, MISC 29G 1/2" 0.5 ML, MISC 30G 5/16"
BRAND
MDD
5 per day
SURE COMFORT LANCING PEN MISC
BRAND
MDS
1 / 180 DAYS
SURE-JECT INSULIN SYRINGE (MISC 28G 1/2" 1 ML,
MISC 30G 5/16" 0.3 ML, MISC 31G 5/16" 1 ML)
BRAND
MDD
5 per day
SURE-PEN MISC
BRAND
MDS
1 / 180 DAYS
SURELITE LANCETS MISC
BRAND
MDS
200 / 30 DAYS
TECHLITE AST LANCETS MISC
BRAND
MDS
200 / 30 DAYS
TECHLITE LANCETS 30G MISC
BRAND
MDS
200 / 30 DAYS
TECHLITE LANCETS MISC
BRAND
MDS
200 / 30 DAYS
TERUMO INSULIN SYRINGE (MISC 28G 1/2" 0.5 ML,
1/2" 0.3 ML, MISC 29G 1/2" 1 ML)
BRAND
MDD
5 per day
TERUMO SURGUARD INSULIN SYR (MISC 28G 1/2" 0.5
29G 1/2" 1 ML, MISC 29G 1/2" 0.3 ML)
BRAND
MDD
5 per day
TGT ADVANCED LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
TGT LANCET ALTERNATE SITE MISC
BRAND
MDS
200 / 30 DAYS
TGT LANCET MICRO THIN 33G MISC
BRAND
MDS
200 / 30 DAYS
TGT LANCET SUPER THIN 30G MISC
BRAND
MDS
200 / 30 DAYS
TGT LANCET THIN 23G MISC
BRAND
MDS
200 / 30 DAYS
TGT LANCET THIN 26G MISC
BRAND
MDS
200 / 30 DAYS
TGT LANCET ULTRA THIN 28G MISC
BRAND
MDS
200 / 30 DAYS
TGT LANCET ULTRA THIN 30G MISC
BRAND
MDS
200 / 30 DAYS
TGT LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
PAGE 120
PRODUCT DESCRIPTION
BRAND/GEN
THINPRO INSULIN SYRINGE (MISC 28G 1/2" 0.5 ML,
0.3 ML, MISC 29G 1/2" 0.5 ML)
BRAND
MDD
5 per day
TODAYS HEALTH LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
TODAYS HEALTH THIN LANCETS 28G MISC
BRAND
MDS
200 / 30 DAYS
TODAYS HEALTH THIN LANCETS 30G MISC
BRAND
MDS
200 / 30 DAYS
TOPCARE ULTRA COMFORT INS SYR (MISC 29G 1/2"
0.3 ML, MISC 29G 1/2" 0.5 ML, MISC 29G 1/2" 1 ML,
31G 5/16" 1 ML)
BRAND
MDD
5 per day
TRUE METRIX AIR KIT W/DEVICE
BRAND
MDS
1 / 730 DAYS
TRUE METRIX BLOOD GLUCOSE TEST STRIP
BRAND
MDD
5 per day
TRUE METRIX LEVEL 1 SOLUTION LOW
BRAND
MDS
1 / 90 DAYS
TRUE METRIX LEVEL 2 SOLUTION NORMAL
BRAND
MDS
1 / 90 DAYS
TRUE METRIX LEVEL 3 SOLUTION HIGH
BRAND
MDS
1 / 90 DAYS
TRUE METRIX METER KIT W/DEVICE
BRAND
MDS
1 / 730 DAYS
TRUECONTROL GLUCOSE CONT LEV 0 LIQUID
BRAND
MDS
1 / 90 DAYS
TRUECONTROL GLUCOSE CONT LEV 1 LIQUID
BRAND
MDS
1 / 90 DAYS
TRUEDRAW LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
TRUEPLUS INSULIN SYRINGE (MISC 28G 1/2" 0.5 ML,
MISC 30G 5/16" 0.5 ML, MISC 31G 5/16" 1 ML)
BRAND
MDD
5 per day
TRUEPLUS LANCETS 26G MISC
BRAND
MDS
200 / 30 DAYS
BRAND
MDS
200 / 30 DAYS
BRAND
MDS
200 / 30 DAYS
BRAND
MDS
200 / 30 DAYS
TRUERESULT BLOOD GLUCOSE KIT W/DEVICE
BRAND
MDS
1 / 730 DAYS
TRUETEST CONTROL LEVEL 1 LIQUID
BRAND
MDS
1 / 90 DAYS
PAGE 121
PRODUCT DESCRIPTION
BRAND/GEN
BRAND
MDS
1 / 90 DAYS
BRAND
MDS
1 / 90 DAYS
TRUETEST TEST STRIP
BRAND
MDD
5 per day
TRUETRACK GLUCOSE CONTROL (LIQUID, LIQUID
LOW)
BRAND
MDS
1 / 90 DAYS
TRUETRACK TEST STRIP
BRAND
MDD
5 per day
ULTI-LANCE AUTO-ADJUST DEVICE MISC
BRAND
MDS
1 / 180 DAYS
ULTI-LANCE AUTOMATIC MISC
BRAND
MDS
1 / 180 DAYS
ULTI-LANCE MINI ADJUSTABLE MISC
BRAND
MDS
1 / 180 DAYS
ULTICARE INSULIN SAFETY SYR (MISC 1/2" 0.5 ML,
MISC 1/2" 1 ML)
BRAND
MDD
5 per day
ULTICARE INSULIN SYRINGE (MISC 28G 1/2" 1 ML,
1/2" 0.3 ML, MISC 29G 1/2" 0.5 ML, MISC 30G 5/16" 0.3
ML, MISC 30G 5/16" 0.5 ML, MISC 31G 5/16" 1 ML)
BRAND
MDD
5 per day
ULTILET BASIC LANCETS 30G MISC
BRAND
MDS
200 / 30 DAYS
ULTILET CLASSIC LANCETS MISC
BRAND
MDS
200 / 30 DAYS
ULTILET INSULIN SYRINGE (MISC 7/16" 0.5 ML, MISC
7/16" 0.3 ML, MISC 7/16" 1 ML)
BRAND
MDD
5 per day
ULTILET INSULIN SYRINGE SHORT (MISC 30G 5/16"
BRAND
MDD
5 per day
ULTILET LANCETS MISC
BRAND
MDS
200 / 30 DAYS
ULTRA COMFORT INSULIN SYRINGE (MISC 29G 1/2" 1
31G 5/16" 1 ML)
BRAND
MDD
5 per day
ULTRA THIN LANCETS 28G MISC
BRAND
MDS
200 / 30 DAYS
ULTRA THIN LANCETS 30G MISC
BRAND
MDS
200 / 30 DAYS
PAGE 122
PRODUCT DESCRIPTION
BRAND/GEN
ULTRA-COMFORT INSULIN SYRINGE (MISC 28G 1/2" 1
BRAND
MDD
5 per day
ULTRA-THIN II INS SYR SHORT (MISC 30G 5/16" 0.5
ML, MISC 30G 5/16" 0.3 ML, MISC 31G 5/16" 1 ML)
BRAND
MDD
5 per day
ULTRA-THIN II INSULIN SYRINGE (MISC 1/2" 1 ML,
MISC 1/2" 0.3 ML, MISC 1/2" 0.5 ML)
BRAND
MDD
5 per day
UNILET COMFORTOUCH LANCET MISC
BRAND
MDS
200 / 30 DAYS
UNILET EXCELITE II MISC
BRAND
MDS
200 / 30 DAYS
UNILET EXCELITE MISC
BRAND
MDS
200 / 30 DAYS
UNILET G.P. LANCET MISC
BRAND
MDS
200 / 30 DAYS
UNILET G.P. SUPERLITE LANCET MISC
BRAND
MDS
200 / 30 DAYS
UNILET GP 28 ULTRA THIN MISC
BRAND
MDS
200 / 30 DAYS
UNILET LANCET MISC
BRAND
MDS
200 / 30 DAYS
UNILET MICRO-THIN 33G MISC
BRAND
MDS
200 / 30 DAYS
UNILET SUPER-THIN 30G MISC
BRAND
MDS
200 / 30 DAYS
UNILET SUPERLITE LANCET MISC
BRAND
MDS
200 / 30 DAYS
UNILET ULTRA-THIN 28G MISC
BRAND
MDS
200 / 30 DAYS
UNIVERSAL 1 LANCETS THIN 26G MISC
BRAND
MDS
200 / 30 DAYS
UNIVERSAL 1 LANCETS ULTRA THIN MISC
BRAND
MDS
200 / 30 DAYS
V-R MONO INSULIN SYRINGE (MISC 28G 1/2" 1 ML,
1/2" 0.5 ML, MISC 29G 1/2" 0.3 ML)
BRAND
MDD
5 per day
VALUE HEALTH INSULIN SYRINGE (MISC 1/2" 0.5 ML,
MISC 1/2" 1 ML)
BRAND
MDD
5 per day
VALUE PLUS LANCET STANDARD 21G MISC
BRAND
MDS
200 / 30 DAYS
VALUE PLUS LANCETS SUPER THIN MISC
BRAND
MDS
200 / 30 DAYS
VALUE PLUS LANCETS THIN 26G MISC
BRAND
MDS
200 / 30 DAYS
PAGE 123
PRODUCT DESCRIPTION
BRAND/GEN
VALUE PLUS LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
VALUMARK LANCET SUPER THIN 30G MISC
BRAND
MDS
200 / 30 DAYS
VALUMARK LANCET ULTRA THIN 28G MISC
BRAND
MDS
200 / 30 DAYS
VANISHPOINT INSULIN SYRINGE MISC 29G X 1/2" 1 ML
BRAND
MDD
5 per day
VIDA MIA AUTOLET LANCING DEV MISC
BRAND
MDS
1 / 180 DAYS
VIDA MIA UNILET LANCETS 28G MISC
BRAND
MDS
200 / 30 DAYS
VIDA MIA UNILET LANCETS 30G MISC
BRAND
MDS
200 / 30 DAYS
VISTOGARD PACKET 10 GM
BRAND
VP INSULIN SYRINGE MISC 29G X 1/2" 0.3 ML
BRAND
MDD
5 per day
W&F LANCETS 26G MISC
BRAND
MDS
200 / 30 DAYS
W&F LANCETS COLORED 21G MISC
BRAND
MDS
200 / 30 DAYS
WALGREENS LANCETS MICRO THIN MISC
BRAND
MDS
200 / 30 DAYS
WALGREENS LANCETS MISC
BRAND
MDS
200 / 30 DAYS
WALGREENS LANCETS SUPER THIN MISC
BRAND
MDS
200 / 30 DAYS
WALGREENS LANCING DEVICE MISC
BRAND
MDS
1 / 180 DAYS
WALGREENS THIN LANCETS MISC
BRAND
MDS
200 / 30 DAYS
WALGREENS ULTRA THIN LANCETS MISC
BRAND
MDS
200 / 30 DAYS
water for irrigation, sterile irrigation soln
generic
WD MEDIC INSULIN SYRINGE (MISC 29G 1/2" 1 ML,
5/16" 0.3 ML, MISC 30G 5/16" 0.5 ML)
BRAND
MDD
5 per day
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS, OTHER
atropine sulfate ophth soln 1%
generic
bacitracin-polymyxin b ophth oint
generic
bacitracin-polymyxin-neomycin-hc ophth oint 1%
generic
PAGE 124
QL
4 / 31 days
PRODUCT DESCRIPTION
BRAND/GEN
BLEPHAMIDE S.O.P. OINTMENT 10-0.2 %
BRAND
BLEPHAMIDE SUSPENSION 10-0.2 %
BRAND
MPL
cyclopentolate hcl ophth soln 0.5%
generic
QL
cyclopentolate hcl ophth soln 1%
generic
cyclopentolate hcl ophth soln 2%
generic
homatropine hbr ophth soln 5%
generic
ISOPTO HOMATROPINE SOLUTION 2 %
BRAND
naphazoline hcl ophth soln 0.1%
generic
neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt
op oin
MPL
1 / 31 days
15 / 31 days
1 / 31 days
QL
15 / 31 days
generic
QL
4 / 31 days
neomycin-polymy-gramicid op sol 1.75-10000-0.025mgunt-mg/ml
generic
QL
10 / 31 days
neomycin-polymyxin-dexamethasone ophth oint 0.1%
generic
QL
4 / 31 days
neomycin-polymyxin-dexamethasone ophth susp 0.1%
generic
QL
10 / 31 days
neomycin-polymyxin-hc ophth susp
generic
QL
15 / 31 days
phenylephrine hcl ophth soln 2.5%
generic
QL
5 / 31 days
polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%
generic
MPL
1 / claim
PRED-G SUSPENSION 0.3-1 %
BRAND
MPL
1 / claim
sulfacetamide sodium-prednisolone ophth soln 100.23(0.25)%
generic
QL
tobramycin-dexamethasone ophth susp 0.3-0.1%
generic
MPL
1 / 31 days
tropicamide (soln 0.5%, soln 1%)
generic
QL
5 / 31 days
10 / 31 days
OPHTHALMIC ANTI-ALLERGY AGENTS
ALOCRIL SOLUTION 2 %
BRAND
ST
QL
ALOMIDE SOLUTION 0.1 %
BRAND
10 / 31 days
ST
PAGE 125
PRODUCT DESCRIPTION
BRAND/GEN
azelastine hcl ophth soln 0.05%
generic
QL
cromolyn sodium ophth soln 4%
generic
MPL
6 / 31 days
1 / claim
OPHTHALMIC ANTI-INFLAMMATORIES
dexamethasone sodium phosphate ophth soln 0.1%
generic
diclofenac sodium ophth soln 0.1%
generic
QL
3 / 31 days
fluorometholone ophth susp 0.1%
generic
MPL
1 / 31 days
flurbiprofen sodium ophth soln 0.03%
generic
QL
5 / 31 days
FML OINTMENT 0.1 %
BRAND
QL
4 / 31 days
ketorolac tromethamine ophth soln 0.4%
generic
MFL
1 / 30 days
ketorolac tromethamine ophth soln 0.5%
generic
MPL
1 / 31 days
NEVANAC SUSPENSION 0.1 %
BRAND
QL
3 / claim
PRED MILD SUSPENSION 0.12 %
BRAND
QL
10 / 31 days
prednisolone acetate ophth susp 1%
generic
MPL
1 / 31 days
PREDNISOLONE SODIUM PHOSPHATE SOLUTION 1 %
BRAND
MPL
1 / 31 days
VEXOL SUSPENSION 1 %
BRAND
OPHTHALMIC ANTIGLAUCOMA AGENTS
AZOPT SUSPENSION 1 %
BRAND
MPL
1 / 31 days
betaxolol hcl ophth soln 0.5%
generic
MPL
1 / 31 days
BETIMOL (SOLUTION 0.25 %, SOLUTION 0.5 %)
BRAND
QL
brimonidine tartrate ophth soln 0.2%
generic
MPL
1 / 31 days
carteolol hcl ophth soln 1%
generic
MFL
1 / 30 days
dorzolamide hcl ophth soln 2%
generic
QL
10 / 31 days
dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml
generic
QL
10 / 31 days
IOPIDINE SOLUTION 1 %
BRAND
PAGE 126
15 / 31 days
PRODUCT DESCRIPTION
BRAND/GEN
ISOPTO CARBACHOL (SOLUTION 1.5 %, SOLUTION 3
%)
BRAND
levobunolol hcl ophth soln 0.25%
generic
MPL
levobunolol hcl ophth soln 0.5%
generic
QL
methazolamide (tab 25 mg, tab 50 mg)
generic
pilocarpine hcl (soln 1%, soln 2%, soln 4%)
generic
timolol maleate (ophth) (gel forming soln 0.25%, gel
forming soln 0.5%, soln 0.25%, soln 0.5%)
generic
MPL
1 / claim
TIMOPTIC OCUDOSE (SOLUTION 0.25 %, SOLUTION
0.5 %)
BRAND
MPL
1 / claim
1 / claim
15 / 31 days
OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS
latanoprost ophth soln 0.005%
generic
QL
5 / 31 days
acetic acid otic soln 2%
generic
QL
15 / 31 days
antipyrine-benzocaine otic soln 54-14 mg/ml (5.4-1.4%)
generic
CIPRODEX SUSPENSION 0.3-0.1 %
BRAND
MPL
1 / claim
fluocinolone acetonide (otic) oil 0.01%
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
QL
20 / 31 days
pramoxine-chloroxylenol otic liquid 1-0.1%
generic
MFL
1 / 30 days
pramoxine-hc-chloroxylenol otic soln 10-10-1 mg/ml
generic
MPL
1 / 30 days
OTIC AGENTS
RESPIRATORY TRACT/PULMONARY AGENTS
ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS
QL
AEROSPAN AERO SOLN 80 MCG/ACT
BRAND
8.9 / 30 days
PA
PAGE 127
PRODUCT DESCRIPTION
BRAND/GEN
budesonide (inhalation) (susp 0.25 mg/2ml, susp 0.5
mg/2ml)
generic
QL
120 / claim
budesonide inhalation susp 1 mg/2ml
generic
QL
60 / 30 days
FLOVENT DISKUS (AER POW BA 100 MCG/BLIST, AER
POW BA 250 MCG/BLIST)
BRAND
MDD
2 per day
FLOVENT DISKUS AER POW BA 50 MCG/BLIST
BRAND
FLOVENT HFA (AEROSOL 44 MCG/ACT, AEROSOL 110
MCG/ACT, AEROSOL 220 MCG/ACT)
BRAND
MPL
1 / claim
flunisolide nasal soln 25 mcg/act (0.025%)
generic
QL
25 / 30 days
flunisolide nasal soln 29 mcg/act (0.025%)
generic
fluticasone propionate nasal susp 50 mcg/act
generic
QL
16 / 30 days
azelastine hcl (0.15% (205.5 mcg/), 137 mcg/(1 mg/ml))
generic
MPL
1 / 30 days
generic
cyproheptadine hcl (syrup 2 mg/5ml, tab 4 mg)
generic
DEXCHLORPHENIRAMINE MALEATE SYRUP 2 MG/5ML
BRAND
generic
MDD
4 per day
hydroxyzine hcl (syrup 10 mg/5ml, tab 10 mg, tab 25 mg,
tab 50 mg)
generic
hydroxyzine pamoate (cap 25 mg, cap 50 mg, cap 100 mg)
generic
promethazine hcl (syrup 6.25 mg/5ml, tab 12.5 mg, tab 25
mg, tab 50 mg)
generic
promethazine hcl suppos 12.5 mg
generic
ANTIHISTAMINES
promethazine hcl suppos 25 mg
PAGE 128
AL
At least 2 yrs old
QL
12 / claim
AL
At least 2 yrs old
QL
12 / claim
AL
At least 2 yrs old
QL
12 / claim
AL
At least 2 yrs old
generic
generic
PRODUCT DESCRIPTION
BRAND/GEN
ANTILEUKOTRIENES
montelukast sodium (chew tab 4 mg, chew tab 5 mg, oral
granules packet 4 mg, tab 10 mg)
generic
MDD
1 per day
ATROVENT HFA AERO SOLN 17 MCG/ACT
BRAND
MPL
2 / month
INCRUSE ELLIPTA AER POW BA 62.5 MCG/INH
BRAND
MPL
1 / 30 days
ipratropium bromide inhal soln 0.02%
generic
QL
375 / 25 days
ipratropium bromide nasal soln 0.03% (21 mcg/spray)
generic
QL
31 / 30 days
ipratropium bromide nasal soln 0.06% (42 mcg/spray)
generic
QL
15 / 30 days
SPIRIVA HANDIHALER CAP 18 MCG
BRAND
BRONCHODILATORS, ANTICHOLINERGIC
PA
MPL
1 / claim
BRAND
MPL
1 / 30 days
ADRENACLICK SOLN A-INJ 0.3 MG/0.3ML
BRAND
QL
2 / 30 days
albuterol sulfate (soln nebu 0.5% (5 mg/ml), syrup 2
mg/5ml, tab 2 mg, tab 4 mg, tab sr 12hr 4 mg, tab sr 12hr 8
mg)
generic
albuterol sulfate (soln nebu 0.63 mg/3ml, soln nebu 1.25
mg/3ml)
generic
QL
375 / 30 days
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)
generic
MDD
12.5 per day
EPINEPHRINE SOLN A-INJ 0.3 MG/0.3ML
BRAND
QL
2 / 30 days
EPIPEN 2-PAK SOLN A-INJ 0.3 MG/0.3ML
BRAND
QL
2 / 30 days
EPIPEN JR 2-PAK SOLN A-INJ 0.15 MG/0.3ML
BRAND
QL
2 / 30 days
EPIPEN JR SOLN A-INJ 0.15 MG/0.3ML
BRAND
QL
2 / 30 days
EPIPEN SOLN A-INJ 0.3 MG/0.3ML
BRAND
QL
2 / 30 days
FORADIL AEROLIZER CAP 12 MCG
BRAND
MPL
TUDORZA PRESSAIR AER POW BA 400 MCG/ACT
BRONCHODILATORS, SYMPATHOMIMETIC
PAGE 129
1 / claim
PRODUCT DESCRIPTION
BRAND/GEN
metaproterenol sulfate (tab 10 mg, tab 20 mg)
generic
metaproterenol sulfate syrup 10 mg/5ml
generic
MDD
30 per day
SEREVENT DISKUS AER POW BA 50 MCG/DOSE
BRAND
MPL
1 / claim
terbutaline sulfate (tab 2.5 mg, tab 5 mg)
generic
TWINJECT SOLN A-INJ 0.3 MG/0.3ML
BRAND
QL
VENTOLIN HFA AERO SOLN 108 (90 BASE) MCG/ACT
BRAND
MPL
KALYDECO (PACKET 50 MG, PACKET 75 MG, TAB 150
MG)
BRAND
PA
ORKAMBI TAB 200-125 MG
BRAND
PA
tobramycin nebu soln 300 mg/5ml
generic
PA
2 / 30 days
2 / month
CYSTIC FIBROSIS AGENTS
PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE
aminophylline (tab 100 mg, tab 200 mg)
generic
caffeine citrate (inj 60 mg/3ml mg/ml, oral soln 60 mg/3ml
mg/ml)
generic
ELIXOPHYLLIN ELIXIR 80 MG/15ML
BRAND
LUFYLLIN (TAB 200 MG, TAB 400 MG)
BRAND
THEO-24 (CAP ER 24H 400 MG, CAP ER 24H 100 MG,
CAP ER 24H 200 MG, CAP ER 24H 300 MG)
BRAND
theophylline (tab 12hr 200 mg, tab 12hr 450 mg, tab 12hr
300 mg, tab 12hr 100 mg, tab 24hr 600 mg, tab 24hr 400
mg)
generic
theophylline soln 80 mg/15ml
generic
QL
45 / claim
MFL
2 / lifetime
QL
475 / claim
QL
30 / 30 days
RESPIRATORY TRACT AGENTS, OTHER
acetylcysteine (soln 10%, soln 20%)
generic
benzonatate cap 100 mg
generic
benzonatate cap 200 mg
generic
MFL
PAGE 130
1 / 30 days
PRODUCT DESCRIPTION
chlorpheniramine tan-phenylephrine tan susp 4.5-5 mg/5ml
BRAND/GEN
AL
At least 3 yrs old
C
From age 6 and older:
Daily Dosage=20;
From age 3 through 5:
Daily Dosage=10
generic
COMBIVENT AEROSOL 18-103 MCG/ACT
BRAND
MDD
COMBIVENT RESPIMAT AERO SOLN 20-100 MCG/ACT
BRAND
QL
cromolyn sodium soln nebu 20 mg/2ml
generic
MDD
DECON-A ELIXIR 2-5 MG/5ML
BRAND
DULERA (AEROSOL 100-5 MCG/ACT, AEROSOL 200-5
MCG/ACT)
BRAND
hydrocodone w/ homatropine syrup 5-1.5 mg/5ml
generic
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml
generic
NORTUSS-EX LIQUID 20-200 MG/5ML
BRAND
phenyleph-chlorphen w/ dm-gg syrup 10-2-7.5-100 mg/5ml
generic
promethazine & phenylephrine syrup 6.25-5 mg/5ml
generic
promethazine w/ codeine syrup 6.25-10 mg/5ml
promethazine-dm syrup 6.25-15 mg/5ml
QL
MDD
sodium chloride (inhalant) (soln nebu 0.9%, soln nebu 3%,
soln nebu 10%)
generic
SYMBICORT (AEROSOL 80-4.5 MCG/ACT, AEROSOL
160-4.5 MCG/ACT)
BRAND
TGQ 30PSE/150GFN/15DM SYRUP 30-150-15 MG/5ML
BRAND
8 per day
13 / 30 days
12 per day
248 / 31 days
QL
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
QL
240 / claim
QL
11 / claim
generic
generic
4 / 30 days
QL
generic
pseudoephed-bromphen-dm syrup 45-4-15 mg/5ml
1 per day
SKELETAL MUSCLE RELAXANTS
carisoprodol w/ aspirin tab 200-325 mg
generic
chlorzoxazone tab 500 mg
generic
PAGE 131
PA
PRODUCT DESCRIPTION
BRAND/GEN
cyclobenzaprine hcl tab 10 mg
generic
MDD
cyclobenzaprine hcl tab 5 mg
generic
QL
methocarbamol (tab 500 mg, tab 750 mg)
generic
orphenadrine citrate tab sr 12hr 100 mg
generic
3 per day
93 / 31 days
MDD
2 per day
SLEEP DISORDER AGENTS
GABA RECEPTOR MODULATORS
estazolam (tab 1 mg, tab 2 mg)
generic
temazepam (cap 15 mg, cap 30 mg)
generic
MDD
1 per day
triazolam (tab 0.125 mg, tab 0.25 mg)
generic
MDD
1 per day
zaleplon cap 10 mg
generic
MDD
2 per day
zaleplon cap 5 mg
generic
MDD
1 per day
zolpidem tartrate (tab 5 mg, tab 10 mg)
generic
MDD
1 per day
generic
MDD
1 per day
*sodium polystyrene sulfonate powder**
generic
QL
CHEMET CAP 100 MG
BRAND
JADENU (TAB 90 MG, TAB 180 MG, TAB 360 MG)
BRAND
sodium polystyrene sulfonate oral susp 15 gm/60ml
generic
SLEEP DISORDERS, OTHER
flurazepam hcl (cap 15 mg, cap 30 mg)
THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES
ELECTROLYTE/MINERAL MODIFIERS
454 / claim
PA
ELECTROLYTE/MINERAL REPLACEMENT
*ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab 106-1
mg***
generic
FLURA-DROPS SOLUTION 0.55 (0.25 F) MG/DROP
BRAND
iron polysacch complex-vit b12-fa cap 150-0.025-1 mg
generic
PAGE 132
MDD
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
KLOR-CON M15 TAB ER 15 MEQ
BRAND
potassium bicarbonate effer tab 25 meq
generic
potassium chloride (cap cr 10 meq, oral liq 10% (20
meq/15ml), oral soln 10% (20 meq/15ml), oral soln 20%
(40 meq/15ml), powder packet 20 meq, tab cr 8 meq (600
mg), tab cr 10 meq)
generic
potassium chloride cap cr 8 meq
generic
potassium chloride microencapsulated crystals cr
(mioencapsulated ys tab 10, mioencapsulated ys tab 20)
generic
sodium chloride (inj, iv soln)
generic
sodium fluoride (chew tab 0.25 mg f (from 0.55 mg, chew
tab 0.5 mg f (from 1.1 mg, chew tab 1 mg f (from 2.2 mg,
soln 0.125 mg/drop f (0.275 mg/drop, soln 0.5 mg/ml f
(from 1.1 mg/ml, tab 1 mg f (from 2.2 mg)
generic
*b-complex w/ c & folic acid cap 1 mg***
MDD
1 per day
generic
MDD
1 per day
*pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/ml**
generic
QL
50 / claim
*pediatric multiple vitamins w/ fluoride chew tab 0.5 mg***
generic
MDD
1 per day
*pediatric vitamins acd fluoride & fe drops 0.25-10 mg/ml***
generic
CAVAN PRENATAL/EC CALCIUM TAB DR 28-1 MG
BRAND
GL
MDD
GL
CAVAN-FOLATE OB TAB 65-1 MG
BRAND
MDD
GL
CO-NATAL FA TAB
BRAND
MDD
GL
COMPLETE-RF PRENATAL TAB 90-1 MG
BRAND
MDD
GL
COMPLETENATE CHEW TAB 29-1 MG
BRAND
MDD
cyanocobalamin inj 1000 mcg/ml
generic
ergocalciferol cap 50000 unit
generic
PAGE 133
QL
Female
1 per day
Female
1 per day
Female
1 per day
Female
1 per day
Female
1 per day
10 / 270 days
PRODUCT DESCRIPTION
BRAND/GEN
ESCAVITE LQ LIQUID 0.25-6 MG/ML
BRAND
GESTICARE TAB DR 28-1 MG
BRAND
QL
50 / claim
GL
Female
MDD
INATAL ADVANCE TAB
BRAND
INATAL GT TAB
BRAND
INATAL ULTRA TAB
BRAND
LACTOCAL-F TAB
BRAND
GL
1 per day
Female
MDD
1 per day
levocarnitine oral soln 1 gm/10ml (10%)
generic
MDD
30 per day
levocarnitine tab 330 mg
generic
MDD
3 per day
M-VIT TAB
BRAND
GL
MDD
MEPHYTON TAB 5 MG
BRAND
MYNATAL (CAP, TAB 90-1 MG)
BRAND
MYNATAL ADVANCE TAB
BRAND
MYNATAL PLUS TAB
BRAND
GL
MDD
GL
MYNATAL-Z TAB
BRAND
MDD
GL
MYNATE 90 PLUS TAB ER
BRAND
MDD
GL
NATACHEW CHEW TAB 29-1 MG
BRAND
MDD
NATAL-V RX TAB 29-1 MG
BRAND
NATALVIT TAB
BRAND
GL
MDD
NATELLE-EZ TAB 25-0.8 MG
PAGE 134
Female
1 per day
Female
1 per day
Female
1 per day
Female
1 per day
Female
1 per day
Female
1 per day
BRAND
PRODUCT DESCRIPTION
BRAND/GEN
NIVA-PLUS TAB 27-1 MG
BRAND
GL
MDD
GL
O-CAL FA TAB 27-1 MG
BRAND
Female
1 per day
Female
MDD
1 per day
O-CAL PRENATAL TAB
BRAND
pediatric multivitamins w/fl (w/ chew tab 0.25, w/ chew tab
1)
generic
pediatric multivitamins w/fl (w/ soln 0.25 mg/ml***, w/ soln
0.5 mg/ml***)
generic
QL
50 / claim
pediatric vitamins acd w/ fluoride (w/ soln 0.25 mg/ml***, w/
soln 0.5 mg/ml***)
generic
QL
50 / claim
PNV FE FUM/DOCUSATE/FOLIC ACID TAB 29-1 MG
BRAND
GL
PNV FOLIC ACID + IRON TAB 27-1 MG
BRAND
Female
MDD
GL
PNV PRENATAL PLUS MULTIVITAMIN TAB 27-1 MG
BRAND
PNV TABS 29-1 TAB 29-1 MG
BRAND
POLY-VI-FLOR FS (STRIP 0.25 MG, STRIP 0.5 MG,
STRIP 1 MG)
BRAND
PRENAFIRST TAB 17-1 MG
BRAND
PRENAPLUS TAB 27-1 MG
BRAND
1 per day
MDD
1 per day
MDD
GL
BRAND
MDD
PRENATABS RX TAB 29-1 MG
BRAND
PRENATAL 19 (19 CHEW TAB, 19 CHEW TAB 29-1 MG)
BRAND
GL
MDD
PRENATAL 19 (19 TAB 29-1 MG, 19 TAB)
BRAND
PRENATAL AD TAB
BRAND
PRENATAL LOW IRON TAB 27-1 MG
BRAND
GL
MDD
PAGE 135
Female
MDD
GL
PRENATABS FA TAB
1 per day
Female
1 per day
Female
1 per day
Female
1 per day
Female
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
PRENATAL PLUS IRON TAB 29-1 MG
BRAND
PRENATAL PLUS TAB 27-1 MG
BRAND
GL
MDD
GL
PRENATAL TAB 27-1 MG
BRAND
MDD
GL
PRENATAL VITAMINS PLUS TAB 27-1 MG
BRAND
MDD
GL
PRENATAL-U CAP 106.5-1 MG
BRAND
MDD
GL
PREPLUS TAB 27-1 MG
BRAND
MDD
GL
PRETAB TAB 29-1 MG
BRAND
MDD
GL
RE PRENATAL MULTIVITAMIN/IRON CHEW TAB 29-1
MG
BRAND
RE-NATA 29 OB TAB 29-1 MG
BRAND
SE-NATAL 19 CHEW TAB 29-1 MG
BRAND
MDD
GL
MDD
SE-NATAL 19 TAB 29-1 MG
BRAND
SE-NATAL 90 TAB ER 90-1 MG
BRAND
GL
MDD
GL
SE-NATAL ONE TAB 60-1 MG
BRAND
MDD
TRIADVANCE TAB 90-1 MG
BRAND
TRICARE TAB
BRAND
GL
MDD
TRINATAL GT TAB 90-1 MG
BRAND
TRINATAL RX 1 TAB 60-1 MG
BRAND
GL
MDD
PAGE 136
Female
1 per day
Female
1 per day
Female
1 per day
Female
1 per day
Female
1 per day
Female
1 per day
Female
1 per day
Female
1 per day
Female
1 per day
Female
1 per day
Female
1 per day
Female
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
TRINATAL ULTRA TAB 90-1 MG
BRAND
TRIVEEN-U CAP 106.5-1 MG
BRAND
GL
MDD
GL
VENATAL-FA TAB 29-1 MG
BRAND
MDD
GL
VINATE CALCIUM TAB 27-1 MG
BRAND
MDD
VINATE GT TAB 90-1 MG
BRAND
VINATE M TAB 27-1 MG
BRAND
GL
MDD
GL
VINATE ONE TAB 60-1 MG
BRAND
MDD
VINATE ULTRA TAB
BRAND
VIRT-ADVANCE TAB 90-1 MG
BRAND
VIRT-VITE GT TAB 90-1 MG
BRAND
VITAFOL-OB TAB
BRAND
GL
MDD
GL
VITAFOL-PN TAB
BRAND
MDD
GL
VITASPIRE TAB 29-1 MG
BRAND
MDD
GL
VOL-PLUS TAB 27-1 MG
BRAND
MDD
VOL-TAB RX TAB 29-1 MG
Female
1 per day
Female
1 per day
Female
1 per day
Female
1 per day
Female
1 per day
Female
1 per day
Female
1 per day
Female
1 per day
Female
1 per day
BRAND
ANTISPASTICITY AGENTS
baclofen (tab 10 mg, tab 20 mg)
generic
dantrolene sodium (cap 25 mg, cap 50 mg, cap 100 mg)
generic
tizanidine hcl (tab 2 mg (base equivalent), tab 2 mg, tab 4
mg (base equivalent), tab 4 mg)
generic
PAGE 137
Index of covered drugs
AGAMATRIX ULTRA-THIN LANCETS
1
12 hour nasal relief spray solution 0.05 %
27
105
AIMSCO LUBRICATED
27
AIRS PEDIATRIC AEROSOL MASK
27
1ST CHOICE LANCETS SUPER THIN
104
AIRZONE PEAK FLOW METER
27
1ST CHOICE LANCETS THIN
104
ALBUSTIX
27
1ST CHOICE LANCETS ULTRA THIN
104
albuterol sulfate
1ST TIER UNILET COMFORTOUCH
104
ALCOHOL PREP
27
alcohol swabs
26
ALCOHOL SWABS
27
alendronate sodium
104
4
4-N-1
20
A
129
ALER-DRYL
37
ALKERAN
65
A-200
20
ALLEVYN PLUS CAVITY
27
abacavir sulfate
71
ALLEVYN THIN
27
abacavir sulfate-lamivudine-zidovudine
71
allopurinol
64
ABILIFY
68
ALOCRIL
125
acarbose
75
ALOE VESTA SKIN CONDITIONER
20
ACCU-CHEK SOFT TOUCH LANCETS
105
ALOMIDE
ACCU-CHEK SOFTCLIX LANCET DEV
105
ALORA
97
ACCUSURE INSULIN SYRINGE
105
alprazolam
74
ALPRAZOLAM INTENSOL
74
acebutolol hcl
acetaminophen
82
19,27
125
ALTERNATE SITE LANCING DEVICE
105
acetaminophen w/ codeine
50
alum & mag hydrox-simethicone
23
acetaminophen w/ dm
38
aluminum chloride
90
acetazolamide
85
aluminum hydroxide
20
ACETEST
105
aluminum hydroxide gel
24
acetic acid (otic)
127
aluminum hydroxide-mag carb
24
acetylcysteine
130
aluminum hydroxide-mag trisil
24
ACIDOPHILUS PLUS PECTIN
23
amantadine hcl
67
ACIDOPHILUS/CITRUS PECTIN
23
amcinonide
94
ACNE MEDICATION 5
20
amiloride & hydrochlorothiazide
83
acyclovir
74
amiloride hcl
85
acyclovir topical
74
aminocaproic acid
79,80
ADJUSTABLE LANCING DEVICE
105
aminophylline
ADRENACLICK
129
amiodarone hcl
81
27
amitriptyline hcl
61
ADULT AEROSOL MASK
130
ADVOCATE INSULIN SYRINGE
105
amlodipine besylate
82
ADVOCATE LANCING DEVICE
105
amlodipine besylate-benazepril hcl
83
ADVOCATE RAPID-SAFE LANCING
105
amoxapine
61
AEROSPAN
127
amoxicillin
55
AF LANCETS SUPER THIN
105
amoxicillin & pot clavulanate
55
PAGE 138
amphetamine-dextroamphetamine
87
AURORA LANCET SUPER THIN 30G
105
ampicillin
56
AURORA LANCET THIN 23G
105
AMPICILLIN
56
AUTO-LANCET
105
anagrelide hcl
79
AUTO-LANCET MINI
105
ANALPRAM-HC
90
AUTOLET IMPRESSION
105
anastrozole
66
AUTOLET LANCING DEVICE
105
ANDRODERM
97
AUTOLET MINI
105
ANTI-STICK INSULIN SYRINGE
105
AUTOLET PLUS
105
antipyrine-benzocaine
127
AVONEX
89
APIDRA
77
AVONEX PEN
89
APIDRA SOLOSTAR
77
AVONEX PREFILLED
89
APTIVUS
72
AXID AR
24
AYR SALINE NASAL DROPS
27
AQUA LANCE ADJUSTABLE LANCING
105
AQUA-E
45
AZASAN
102
arginine
45
azathioprine
102
ARIAL CHAMBER
27
azelastine hcl
128
aripiprazole
69
azelastine hcl (ophth)
126
ARMOUR THYROID
101
azithromycin
56
artificial tear ointment
36
AZOLEN TINCTURE
17
artificial tear solution
36
AZOPT
ARTIFICIAL TEARS
36
ASACOL
103
126
B
ascorbic acid
45
b complex w/ c
44
aspirin
16
b-complex vitamins
45
aspirin buffered
16
b-complex w/ c & folic acid
aspirin buffered (cal carb-mag carb-mag oxide)
16
b-complex w/ minerals
44
aspirin tab chew 81 mg
16
bacitracin (ophthalmic)
53
ASSESS FULL RANGE PEAK METER
27
bacitracin (topical)
20
ASSESS LOW RANGE PEAK METER
27
bacitracin zinc
20
ASSESS PEAK FLOW METER
27
bacitracin-poly-neomycin-hc
ASSURE ID INSULIN SAFETY SYR
105
bacitracin-polymyxin b
44,133
124
19
ASTHMA CHECK METER-ZONE SYSTEM
27
bacitracin-polymyxin b (ophth)
124
ASTHMAMENTOR
27
baclofen
137
atenolol
82
BACTROBAN NASAL
53
atenolol & chlorthalidone
83
balsalazide disodium
103
atorvastatin calcium
86
BAYER MICROLET 2 LANCING DEVIC
106
atovaquone
66
BD INSULIN SYR ULTRAFINE II
106
ATRIPLA
70
BD INSULIN SYRINGE
106
atropine sulfate (ophthalmic)
124
BD INSULIN SYRINGE MICROFINE
106
ATROVENT HFA
129
BD INSULIN SYRINGE ULTRAFINE
106
BD INTEGRA INSULIN SYRINGE
106
AUGMENTIN
PAGE 139
56
BD LANCET DEVICE
106
brompheniramine & phenyleph
39
BD LANCET ULTRAFINE 30G
106
brompheniramine & pseudoeph
39
BD SAFETY-LOK INSULIN SYRINGE
106
BUBBLES THE FISH II PEDI MASK
28
BD SAFETYGLIDE INSULIN SYRINGE
106
budesonide (inhalation)
128
BD SWAB SINGLE USE REGULAR
27
bumetanide
benazepril & hydrochlorothiazide
84
bupropion hcl
benazepril hcl
80
bupropion hcl (smoking deterrent)
52
benzocaine-docusate sodium
24
60
130
60
buspirone hcl
74
benzonatate
benzoyl peroxide
20,90
85
59,60
benzoyl peroxide-erythromycin
90
butalbital-acetaminophen
88
benztropine mesylate
67
butalbital-acetaminophen-caffeine
88
betamethasone dipropionate (topical)
95
butalbital-acetaminophen-caffeine w/ codeine
50
betamethasone dipropionate augmented
95
butalbital-aspirin-caffeine
betamethasone valerate
95
butalbital-aspirin-caffeine w/cod
50
betaxolol hcl
82
BYDUREON
75
49,88
betaxolol hcl (ophth)
126
BYETTA 10 MCG PEN
75
bethanechol chloride
94
BYETTA 5 MCG PEN
75
BETIMOL
126
BIATAIN ADHESIVE FOAM DRESSING
28
C
BIATAIN FOAM DRESSING
28
caffeine citrate
bicalutamide
65
CALCI-MIX
42
BIFERA
42
CALCIONATE
42
BIONEL
39
calcipotriene
90
BIONEL PEDIATRIC
39
calcitonin (salmon)
104
BIOSPEC DMX
39
calcitriol
104
BIOTENE MOISTURIZING MOUTH
19
calcium & phosphorus w/ vitamin d
42
BIOTENE ORALBALANCE DRY MOUTH
19
calcium acetate (phosphate binder)
94
bisacodyl ec tab dr 5 mg
24
calcium carbonate
43
bisacodyl laxative suppos 10 mg
24
calcium carbonate (antacid)
24
bismuth subsalicylate
24
calcium carbonate-cholecalciferol
43
bisoprolol & hydrochlorothiazide
84
calcium carbonate-vitamin d
43
bisoprolol fumarate
82
calcium carbonate-vitamin d w/ minerals
43
130
BLEPHAMIDE
125
calcium citrate
43
BLEPHAMIDE S.O.P.
125
calcium citrate-vitamin d
43
BORDERED GAUZE
28
calcium gluconate
43
BPO
90
calcium lactate
43
BRILINTA
80
calcium polycarbophil
24
camphor & menthol
20
brimonidine tartrate
126
BRINTELLIX
60
CAPMIST DM
39
bromocriptine mesylate
67
capsaicin
20
PAGE 140
captopril
80
CHEK-STIX CONTROL
106
captopril & hydrochlorothiazide
84
CHEMET
132
CAPZASIN-P
20
CHEMSTRIP 10 MD
28
CARAFATE
93
CHEMSTRIP 10/SG
28
carbamazepine
59
CHEMSTRIP 2 GP
28
carbamide peroxide (otic)
37
CHEMSTRIP 5 OB
28
carbidopa-levodopa
68
CHEMSTRIP 7
28
carboxymethylcellulose sodium (ophth)
36
CHEMSTRIP 9
28
106
CHEMSTRIP K
106
CARDIOCOM LANCING DEVICE
CARDIZEM LA
82
CHEMSTRIP MICRAL
28
CAREONE ADVANCED LANCING DEV
106
CHEMSTRIP UGK
28
CAREONE INSULIN SYRINGE
106
CHEW Q
28
CAREONE LANCET THIN 23G
106
childrens loratadine syrup 5 mg/5ml
38
CAREONE LANCET ULTRA THIN 28G
106
chlordiazepoxide hcl
74
CAREONE ULTIGUARD INSULIN SYR
106
chlordiazepoxide-amitriptyline
60
carisoprodol w/ aspirin
131
chlorhexidine gluconate
28
CARRASMART
28
chlorhexidine gluconate (mouth-throat)
89
CARRASMART FOAM
28
chloroquine phosphate
66
chlorothiazide
85
carteolol hcl (ophth)
126
carvedilol
82
chlorpheniramine & phenylephrine
39
CASTIVA WARMING
20
chlorpheniramine & pseudoeph
39
CAVAN PRENATAL/EC CALCIUM
133
chlorpheniramine maleate
38
CAVAN-FOLATE OB
133
chlorpheniramine maleate er tab er 12 mg
38
38
cefaclor
54
cefadroxil
55
chlorpheniramine tannate-phenylephrine tannate
cefdinir
55
chlorpheniramine-dm
39
cefprozil
55
chlorpheniramine-phenylephrine-acetaminophen
39
CEFTIN
55
chlorpheniramine-pseudoephedrine-acetaminophen 39
ceftriaxone sodium
55
chlorpromazine hcl
68
cefuroxime axetil
55
chlorpropamide
75
celecoxib
49
chlorthalidone
85
cephalexin
55
chlorzoxazone
131
cetirizine hcl
38
CHOLBAM
cetirizine hcl allergy child solution 5 mg/5ml
37
cholecalciferol
37
cholestyramine
86
38
cholestyramine light
86
38
choline & mag salicylate
49
cetirizine-pseudoephedrine
39
ciclopirox
63
CHANTIX
52
ciclopirox olamine
63
CHANTIX CONTINUING MONTH PAK
52
cilostazol
80
CHANTIX STARTING MONTH PAK
52
CILOXAN
57
PAGE 141
131
92
26,45
cimetidine
cimetidine hcl
CIPRODEX
24,92
COMBIPATCH
97
92
COMBISTIX
28
127
COMBIVENT
131
131
ciprofloxacin hcl
57
COMBIVENT RESPIMAT
ciprofloxacin hcl (ophth)
57
COMFEEL PASTE
citalopram hydrobromide
60
COMFORT ASSIST INSULIN SYRINGE
107
clarithromycin
56
COMFORT ASSURED LANCETS 28G
107
CLARITIN
38
COMFORT ASSURED LANCETS 33G
107
CLASSIC PRENATAL
45
COMFORT EZ INSULIN SYRINGE
107
CLEAN & CLEAR ADVANTAGE 3-IN-1
20
COMFORT LANCETS
107
21
CLEANLET LANCETS 28G
106
COMPLERA
70
clemastine fumarate
128
complete ready-to-use enema enema 7-19
38
gm/118ml
25
clindamycin hcl
53
COMPLETE-RF PRENATAL
133
clindamycin palmitate hydrochloride
53
COMPLETENATE
133
clindamycin phosphate (topical)
53
CONE MASK
28
clindamycin phosphate vaginal
53
COOL BOTTOMS
21
CLINDESSE
53
COPA ISLAND BORDERED FOAM
28
CLINISTIX
106
COPA PLUS HYDROPHILIC FOAM
28
CLINITEST
106
COPAXONE
89
clobetasol propionate
95
cortisone acetate
95
clobetasol propionate emollient base
95
COTELLIC
66
clonazepam
74
COVRSITE COVER DRESSING
28
clonidine hcl
80
COVRSITE PLUS COMPOSITE DRESS
28
clopidogrel bisulfate
80
CREON
91
clorazepate dipotassium
74
CRINONE
100
107
CRIXIVAN
72
CLOSERCARE
clotrimazole
63
cromolyn sodium
131
clotrimazole (topical)
17
cromolyn sodium (nasal)
28
clotrimazole vaginal
17
cromolyn sodium (ophth)
126
clotrimazole w/ betamethasone
90
CUPRIMINE
94
clozapine
69
CUREX ALL-PURPOSE SPONGES
28
CURITY ALCOHOL PREPS
28
CO-NATAL FA
133
coal tar extract
20
CURITY ALL PURPOSE SPONGES
28
COARTEM
66
CURITY AMD ANTIMICROBIAL SPNGE
29
codeine sulfate
50
CURITY COVER SPONGE
29
colchicine
64
CURITY DRESSING SPONGES
29
colchicine w/ probenecid
64
CURITY GAUZE
29
COLD & FLU RELIEF NIGHTTIME D
39
CURITY GAUZE SPONGE
29
colestipol hcl
86
CURITY NON-ADHERENT STRIPS
29
COLYTE WITH FLAVOR PACKS
93
CURITY SPONGES
29
PAGE 142
CVS ADHESIVE DRESSINGS 4"X4"
29
DERMACEA GAUZE SPONGE
29
CVS ALCOHOL PREP SWABS
29
DERMACEA IV DRAIN SPONGES
29
CVS ALCOHOL SWABS
29
DERMACEA IV SPONGES
29
CVS DRY MOUTH
19
DERMACEA NON-WOVEN SPONGES
29
CVS GAUZE
29
DERMACEA TYPE VII GAUZE
29
CVS GAUZE PAD STERILE
29
DERMACEA X-RAY SPONGES
30
CVS GAUZE STERILE
29
DERMALEVIN ADHESIVE
30
CVS GLUCOSE
18
dermatological products, misc.
19
DESCOVY
71
desipramine hcl
62
CVS INSULIN SYRINGE
107
CVS KETONE CARE
29
CVS LANCETS 21G
107
desmopressin acetate
96
CVS LANCETS MICRO THIN 33G
107
desmopressin acetate refrigerated
96
CVS LANCETS ORIGINAL
107
desmopressin acetate spray
96
CVS LANCETS THIN
107
desmopressin acetate spray refrigerated
96
CVS LANCETS THIN 26G
107
desogestrel-ethinyl estradiol (triphasic)
97
CVS LANCETS ULTRA THIN 30G
107
Desogestrel-Ethinyl Estradiol TAB 0.15-0.02/0.01 MG
CVS LANCING DEVICE
107
(Azurette, Kariva, Pimtrea, Viorele, Caziant, Cesia,
CVS NON-ADHESIVE
29
Velivet)
97
CVS PRENATAL
46
Desogestrel-Ethinyl Estradiol TAB 0.15-30 MG-MCG
CVS PREP
29
(Apri, Emoquette, Enskyce, Reclipsen, Solia)
97
CVS SALINE WOUND WASH
21
DEX4 QUICK DISSOLVE GLUCOSE
18
CVS STERILE PADS
29
dexamethasone
95
CVS ULTRA THIN LANCETS
107
DEXAMETHASONE INTENSOL
95
cyanocobalamin
133
dexamethasone sodium phosphate
95
cyclobenzaprine hcl
132
dexamethasone sodium phosphate (ophth)
126
cyclopentolate hcl
125
DEXCHLORPHENIRAMINE MALEATE
128
cyclophosphamide
65
dexmethylphenidate hcl
87
cyclosporine
102
dextroamphetamine sulfate
87
cyclosporine modified (for microemulsion)
102
dextromethorphan hbr
39
cyproheptadine hcl
128
dextromethorphan polistirex er liquid er 30 mg/5ml
39
CYTO-Q MAX
29
D
danazol
dantrolene sodium
dapsone
97
137
dextromethorphan-doxylamine-acetaminophen
39
dextromethorphan-guaifenesin
40
dextromethorphan-phenylephrine-acetaminophen
40
dextrose (diabetic use)
18
DIASTAR EASY TEST II LANCETS
107
DIASTAR EASY TEST LANCETS
107
29
DIASTIX
107
DELZICOL
103
diazepam
74
DEPO-SUBQ PROVERA 104
100
diazepam (anticonvulsant)
58
dibucaine
21
DECON-A
DELBASE COMPOUNDING
DERMACEA DRAIN SPONGES
PAGE 143
65
dextromethorphan-acetaminophen-chlorpheniramine 39
39,131
29
dibucaine (rectal)
21
dorzolamide hcl-timolol maleate
diclofenac potassium
49
doxazosin mesylate
80
diclofenac sodium
49
doxepin hcl
62
doxycycline hyclate
57
diclofenac sodium (ophth)
126
126
dicloxacillin sodium
56
doxylamine succinate (sleep)
42
dicyclomine hcl
92
doxylamine-dm
40
didanosine
71
DRAMAMINE
17
diflorasone diacetate
95
DRESSING SPONGES
30
diflunisal
49
DRITHO-CREME HP
90
digoxin
84
dronabinol
62
dihydroergotamine mesylate
64
DROPLET LANCETS ULTRA THIN 30G
107
DILANTIN
59
DROPLET LANCING DEVICE
107
drospirenone-ethinyl estradiol
97
diltiazem hcl
82,83
diltiazem hcl coated beads
83
Drospirenone-Ethinyl Estradiol TAB 3-0.03 MG (Gianvi,
diltiazem hcl extended release beads
83
Loryna, Nikki, Vestura, Ocella, Syeda, Zarah)
97
dimenhydrinate
17
DROXIA
65
DIMETAPP LONG ACT COUGH/COLD
40
DRUG MART LANCETS THIN 26G
107
dimethicone (topical)
21
DRUG MART LANCETS ULTRA THIN
108
diphenhydramine hcl
38
DRUG MART LANCING DEVICE
108
diphenhydramine hcl (sleep)
42
DRUG MART ULTRA COMFORT SYR
108
diphenhydramine hcl (topical)
21
DRUG MART UNILET LANCETS 28G
108
38
DRUG MART UNILET LANCETS 30G
108
38,128
DRY MOUTH SPRAY
19
diphenhydramine hcl elixir 12.5 mg/5ml
38
DUANE READE LANCET ALTERN SITE
108
diphenhydramine hcl liquid 12.5 mg/5ml
38
DUANE READE LANCET SUPER THIN
108
diphenhydramine-phenylephrine
40
DUANE READE LANCET ULTRA THIN
108
diphenhydramine-phenylephrine-acetaminophen
40
DULERA
131
diphenhydramine-zinc acetate
21
duloxetine hcl
88
diphenoxylate w/ atropine
92
DUOFER
43
dipyridamole
80
DUTOPROL
84
disopyramide phosphate
81
disulfiram
52
E
divalproex sodium
58
E-Z JECT LANCET MICRO-THIN 33G
108
docusate calcium
25
E-Z JECT LANCET SUPER THIN 30G
108
docusate sodium
25
E-Z JECT LANCETS
108
25
E-Z JECT LANCETS 21G
108
DOCUSOL MINI
25
E-Z JECT LANCETS THIN 26G
108
DOCUSOL PLUS MINI-ENEMA
25
E.E.S. GRANULES
56
dofetilide
81
EARLOOP MASK
30
donepezil hydrochloride
59
EASY COMFORT INSULIN SYRINGE
108
126
EASY MINI EJECT LANCING DEVICE
108
dorzolamide hcl
PAGE 144
EASY MINI LANCING DEVICE
EASY TOUCH ALCOHOL PREP MEDIUM
108
30
EPINEPHRINE
129
EPIPEN
129
EASY TOUCH FLIPLOCK INSULIN SY
108
EPIPEN 2-PAK
129
EASY TOUCH INSULIN SAFETY SYR
108
EPIPEN JR
129
EASY TOUCH INSULIN SYRINGE
108
EPIPEN JR 2-PAK
129
EASY TOUCH LANCETS 26G
108
eplerenone
85
EASY TOUCH LANCETS 26G/TWIST
109
EPZICOM
71
109
EQL COLOR LANCETS 21G
109
109
EQL COLOR LANCETS MICRO 33G
109
109
EQL GAUZE
30
109
EQL GAUZE STERILE
30
109
EQL INSULIN SYRINGE
109
EQL PRENATAL FORMULA
109
EQL SUPER THIN LANCETS 30G
109
EASY TOUCH LANCING DEVICE
109
EQL THIN LANCETS 26G
109
EASY TOUCH SHEATHLOCK SYRINGE
109
ergocalciferol
109
46
46,133
econazole nitrate
63
ERY-TAB
56
ED BRON GP
40
ERYPED 200
56
ED CHLORPED
38
ERYPED 400
56
EDURANT
70
erythromycin (acne aid)
ELEXA NATURAL FEEL
30
erythromycin (ophth)
56
ELEXA STIMULATING
30
erythromycin base
57
ELEXA ULTRA SENSITIVE
30
erythromycin-sulfisoxazole
57
ELIQUIS
78
ESCAVITE LQ
ELIXOPHYLLIN
130
escitalopram oxalate
ELLA
100
estazolam
56,57
134
60
132
emollient
19
esterified estrogens & methyltestosterone
97
EMTRIVA
71
ESTRACE
97
enalapril maleate
81
estradiol
98
enalapril maleate & hydrochlorothiazide
84
estradiol & norethindrone acetate
97
ENBREL
102
estropipate
98
ENBREL SURECLICK
102
ethambutol hcl
65
ethosuximide
58
ENCARE
26
ENDOMETRIN
100
ENEMEEZ MINI
25
MCG (Kelnor, Zovia)
98
ENEMEEZ PLUS
25
etodolac
49
etoposide
66
enoxaparin sodium
78,79
Ethynodiol Diacetate & Ethinyl Estradiol Tab 1 MG-35
entacapone
67
EURAX
67
EPANED
81
EVOTAZ
72
ephedrine sulfate
38
EXCILON DRAIN SPONGES
30
EPIFOAM
90
EXCILON IV SPONGES
30
PAGE 145
EXEL COMFORT POINT INSULIN SYR
109
FIRST-PROGESTERONE VGS 400
100
EXEL COMFORT POINT PEN NEEDLE
109
100
exemestane
66
FIRST-VANCOMYCIN 25
54
EZ SMART BLOOD GLUCOSE LANCETS
109
FIRST-VANCOMYCIN 50
54
EZ-LETS LANCETS 21G
109
flavoxate hcl
94
EZ-LETS LANCETS 26G
109
flecainide acetate
81
EZ-LETS LANCETS 28G
110
FLEET BISACODYL
25
EZ-LETS LANCETS 30G
110
FLEXZAN
30
F
famotidine
24,92
FLOVENT DISKUS
128
FLOVENT HFA
128
fluconazole
63
95
FANTASY LUBRICATED
30
fludrocortisone acetate
FANTASY LUBRICATED/SPERMICIDE
30
flunisolide (nasal)
128
FC FEMALE CONDOM
30
fluocinolone acetonide (otic)
127
FC2 FEMALE CONDOM
30
fluocinonide
95
felbamate
58
fluocinonide emulsified base
95
felodipine
83
fluorometholone (ophth)
fenofibrate
86
fluorouracil (topical)
fenofibrate micronized
86
fluoxetine hcl
fenoprofen calcium
49
fluoxetine hcl (pmdd)
60
fentanyl
50
fluphenazine decanoate
68
FEOSOL BIFERA
43
fluphenazine hcl
68
FERRETTS
43
FLURA-DROPS
132
FERREX 150 PLUS
43
flurazepam hcl
132
ferrous fumarate
43
flurbiprofen
ferrous fumarate-fa-b complex-c-zn-mg-mn-cu
132
126
90
60,61
49
flurbiprofen sodium
126
ferrous gluconate
43
flutamide
65
FERROUS GLUCONATE
43
fluticasone propionate
95
ferrous sulfate
44
fluticasone propionate (nasal)
ferrous sulfate dried
44
fluvoxamine maleate
38
FML
38
folic acid
46
fiber cap 0.52 gm
25
FOLIC ACID
46
FIFTY50 ALCOHOL PREP
30
FORA LANCETS
110
128
61
126
FIFTY50 LANCING DEVICE
110
FORA LANCING DEVICE
110
FIFTY50 SUPERIOR COMFORT SYR
110
FORADIL AEROLIZER
129
110
finasteride
94
formaldehyde
FIRST-OMEPRAZOLE
93
fosinopril sodium
81
84
100
fosinopril sodium & hydrochlorothiazide
100
FREDS PHARMACY AUTOLET LANCING
110
100
FREDS PHARMACY UNILET LANC 28G
110
PAGE 146
FREDS PHARMACY UNILET LANC 30G
110
GNP ALCOHOL SWABS
30
FREESTYLE PRECISION INS SYR
110
GNP DAILY PRENATAL
46
18
fructose-dextrose-phosphoric acid
17
GNP GLUCOSE
FUNGOID TINCTURE
17
GNP INSULIN SYRINGE
110
furosemide
85
GNP LANCETS
111
GNP LANCETS 21G
111
GNP LANCETS MICRO THIN 33G
111
G
gabapentin
58
GNP LANCETS SUPER THIN 30G
111
GABITRIL
58
GNP LANCETS THIN
111
galantamine hydrobromide
59
GNP LANCETS THIN 26G
111
gauze pads & dressings
30
GNP MICRO THIN LANCETS 33G
111
GAUZE SPONGE
30
GNP PRENATAL
46
gemfibrozil
86
GNP PRENATAL VITAMINS
46
gentamicin sulfate (ophth)
53
GNP QUICK DISSOLVE GLUCOSE
18
gentamicin sulfate (topical)
53
GNP SALINE WOUND WASH
21
GENTEAL MILD
36
GNP STERILE PADS
30
GENTEAL SEVERE
37
GNP SUPER THIN LANCETS 30G
111
GENVOYA
70
GNP ULTRA COM INSULIN SYRINGE
111
GESTICARE
134
GOLYTELY
93
GILENYA
89
griseofulvin microsize
63
ginger (zingiber officinalis)
30
griseofulvin ultramicrosize
63
glatiramer acetate
89
guaifenesin
40
glimepiride
75
guaifenesin-codeine
40
glipizide
75
guanabenz acetate
80
glipizide-metformin hcl
75
guanfacine hcl
80
GLOBAL INJECT EASE INSULIN SYR
110
GYNAZOLE-1
63
GLOBAL LANCING DEVICE
110
GYNOL II
26
GLUCAGEN DIAGNOSTIC
76
GLUCAGEN HYPOKIT
77
H
GLUCAGON EMERGENCY
77
H&H THINLET LANCETS 26G
111
GLUCOCOM LANCETS 28G
110
H&H THINLET LANCETS 30G
111
GLUCOCOM LANCETS 30G
110
H-E-B INCONTROL ADV LANCING
111
GLUCOLET 2 AUTOMATIC LANCING
110
H-E-B INCONTROL LANCETS 28G
111
GLUCOPRO INSULIN SYRINGE
110
111
GLUCOSOURCE LANCET DEVICE
110
111
GLUCOSOURCE LANCETS
110
H-E-B INCONTROL PEN NEEDLES
111
glyburide
75
haloperidol
68
glyburide micronized
76
haloperidol decanoate
68
glyburide-metformin
76
haloperidol lactate
68
glycerin (laxative)
25
HARVONI
70
glycopyrrolate
92
HEALTH CARE LANCING DEVICE
PAGE 147
111
HEALTHWISE LANCING PEN
111
hydrocortisone valerate
95
HEALTHY ACCENTS LANCING DEVICE
111
hydrocortisone w/acetic acid
HEALTHY ACCENTS UNILET LANCETS
111
hydrocortisone-aloe vera
21
127
HEMA-COMBISTIX
30
hydromorphone hcl
51
HEMANGEOL
66
HYDROPHILIC
30
heparin sodium (porcine)
79
hydrophilic ointment
30
HM LANCETS MICRO THIN 33G
111
hydroxychloroquine sulfate
66
HM LANCETS ULTRA THIN 30G
111
hydroxyurea
66
HM ONE DAILY PRENATAL
46
hydroxyzine hcl
128
HM PRENATAL
46
hydroxyzine pamoate
128
homatropine hbr
125
hyoscyamine sulfate
HUMALOG
77
hypromellose (ophth)
HUMALOG KWIKPEN
77
HUMALOG MIX 50/50
77
I
HUMALOG MIX 50/50 KWIKPEN
77
ibuprofen
HUMALOG MIX 50/50 PEN
77
ibuprofen tab 200 mg
16
HUMALOG MIX 75/25
77
imipramine hcl
62
HUMALOG MIX 75/25 KWIKPEN
77
imipramine pamoate
62
HUMALOG MIX 75/25 PEN
77
IN TOUCH LANCING DEVICE
112
HUMALOG PEN
77
INATAL ADVANCE
134
92,112
37
16,49
HUMIRA
102
INATAL GT
134
HUMIRA PEN
102
INATAL ULTRA
134
129
HUMULIN 70/30
77
INCRUSE ELLIPTA
HUMULIN 70/30 KWIKPEN
77
indapamide
85
HUMULIN 70/30 PEN
77
INDOCIN
49
HUMULIN N
77
indomethacin
49
HUMULIN N KWIKPEN
77
inositol niacinate
18
HUMULIN N PEN
77
INSPIREASE BAGS
112
HUMULIN R
78
INSPIREASE MOUTHPIECE
112
HUMULIN R U-500 (CONCENTRATED)
78
INSPIREASE RESERVOIR BAGS
112
HY-VEE INSULIN SYRINGE
111
INSTA-GLUCOSE
18
hydralazine hcl
86
112
hydrochlorothiazide
85
insulin pen needle 29 g x 12.7 mm
112
112
112
112
hydrocodone w/ homatropine
131
hydrocodone-acetaminophen
50,51
hydrocortisone
95
hydrocortisone (intrarectal)
104
112
hydrocortisone (rectal)
104
112
112
hydrocortisone (topical)
21,90
hydrocortisone acetate (topical)
21
112
hydrocortisone butyrate
95
INSULIN SYRINGE
112
PAGE 148
insulin syringe (disp) u-100 1 ml
112
INSULIN SYRINGE/NEEDLE
112
J
insulin syringe/needle u-100
112
J & J GAUZE SPONGES 12-PLY
31
112
31
112
31
113
J & J NON-STICK DRESSING
31
insulin syringe/needle u-100 1 ml 25 x 1"
113
JADENU
113
JENTADUETO
113
113
K
113
KALA
24
113
KALETRA
72
113
KALYDECO
113
KAMELEON LUBRICATED
31
113
KENDALL HYDROPHILIC FOAM DRESS
31
INSUPEN PEN NEEDLES
113
KENDALL HYDROPHILIC FOAM PLUS
31
INSUPEN SENSITIVE
113
KERALYT
21
132
76
130
INTELENCE
70
KERLIX SPONGES
31
INVIRASE
72
KETO-DIASTIX
31
IOPIDINE
126
KETOCARE
113
ipratropium bromide
129
ketoconazole
63
ipratropium bromide (nasal)
129
ketoconazole (topical)
63
ipratropium-albuterol
131
ketoprofen
49
49
irbesartan
80
ketorolac tromethamine
irbesartan-hydrochlorothiazide
84
ketorolac tromethamine (ophth)
126
IRON CHEWS PEDIATRIC
44
KETOSTIX
113
iron polysaccharide complex-vit b12-folic acid
44,132
ketotifen fumarate (ophth)
37
iron w/ vitamins
44
KEY-E
46
ISENTRESS
70
KIMONO
31
ISLAND GARD-GRX
31
KIMONO MICRO THIN
31
isoniazid
65
KIMONO MICRO THIN PLUS
31
ISONIAZID
65
KIMONO PLUS
31
ISOPTO CARBACHOL
127
KIMONO PS
31
ISOPTO HOMATROPINE
125
KIMONO PS PLUS
31
ISOPTO TEARS
37
KIMONO SENSATION
31
ISORDIL TITRADOSE
86
KIMONO SENSATION PLUS
31
isosorbide dinitrate
87
KINNEY LANCETS
113
isosorbide mononitrate
87
KINNEY THIN LANCETS
113
isotretinoin
90
KINRAY INSULIN SYRINGE
113
KLOR-CON M15
133
KOMBIGLYZE XR
PAGE 149
76
KONSYL
25
LANTUS
78
KONSYL-D
25
LANTUS SOLOSTAR
78
KP PRENATAL MULTIVITAMINS
46
LANZO
114
KPN PRENATAL
46
latanoprost
127
KROGER INSULIN SYRINGE
113
LEADER ADVANCED LANCING DEVICE
114
KROGER LANCETS 21G
113
LEADER INSULIN SYRINGE
114
KROGER LANCETS MICRO THIN 33G
113
LEADER QUICK DISSOLVE GLUCOSE
KROGER LANCETS SUPER THIN
113
leflunomide
KROGER LANCETS THIN 26G
113
letrozole
66
KROGER LANCETS ULTRATHIN 30G
113
leucovorin calcium
66
KROGER LANCING DEVICE
114
LEUKERAN
65
LEVACET
49
levetiracetam
58
L
18
103
labetalol hcl
82
levobunolol hcl
127
LABSTIX
31
levocarnitine (metabolic modifiers)
134
lactic acid (ammonium lactate)
21
levofloxacin
lactobacillus
23
Levonorg-Eth Est Tab 0.15-0.03MG(84) & Eth Est Tab
LACTOCAL-F
134
57
0.01MG(7) (Amethia, Camrese, Daysee)
98
LACTRASE
24
Levonorgest-Eth Estrad 91-Day TAB 0.15-0.03 MG
lactulose
93
(Introvale, Jolessa, Quasense)
98
lactulose (encephalopathy)
93
levonorgestrel (emergency oc)
26,100
LADY LITE LANCETS
114
Levonorgestrel-Eth Estra Tab 0.05-30/0.075-40/0.125-
LAMISIL ADVANCED
21
30MG (Enpresse, Levonest, Myzilra, Trivora)
LAMISIL AT SPRAY
21
Levonorgestrel-Ethinyl Estrad TAB 0.1-20 MG (Aubra,
lamivudine
71
Aviane, Delyla, Falmina, Lessina, Lutera, Orsythia,
lamivudine-zidovudine
71
Sronyx)
lamotrigine
58
Levonorgestrel-Ethinyl Estrad TAB 0.15-30 MG
98
98
LANCET DEVICE
114
(Altavera, Chateal, Kurvelo, Levora, Marlissa, Portia)98
LANCET DEVICE WITH EJECTOR
114
levothyroxine sodium
lancet devices
104
LEVSIN
92
lancets
104
LEXIVA
73
LANCETS
114
LIBERTY MINI LANCING DEVICE
LANCETS 28G
114
LICIDE TREATMENT
LANCETS 30G
114
lidocaine
21,90
LANCETS THIN
114
lidocaine hcl
16,90
LANCETS ULTRA THIN
114
lidocaine hcl (mouth-throat)
LANCING DEVICE
114
lidocaine-prilocaine
52,90
lanolin
31
liothyronine sodium
101
lanolin (topical)
19
LIQ-10
31
lanolin anhydrous
31
lisinopril
81
lisinopril & hydrochlorothiazide
84
lansoprazole
PAGE 150
26,93
101
114
21
51
LITE TOUCH LANCING DEVICE
114
maprotiline hcl
61
LITE TOUCH LANCING PEN
114
MAXI-COMFORT INSULIN SYRINGE
LITETOUCH INSULIN SYRINGE
114
MAXX
31
115
lithium
75
MAXX PLUS
31
lithium carbonate
75
meclizine hcl
17
LITTLE REMEDIES FOR COLDS
40
meclofenamate sodium
49
LIVE BETTER ADV LANCING DEVICE
114
MEDI-LANCE LANCETS
115
LIVE BETTER LANCET SUPER THIN
114
MEDIC INSULIN SYRINGE
115
LIVE BETTER LANCET ULTRA THIN
114
MEDICINE SHOPPE LANCETS
115
LOHIST-D
40
MEDICINE SHOPPE LANCETS THIN
115
lomustine
65
MEDISENSE THIN LANCETS
115
LONGS LANCETS STANDARD
114
medroxyprogesterone acetate
100
LONGS LANCETS THIN
115
medroxyprogesterone acetate (contraceptive)
101
loperamide hcl
24
mefloquine hcl
loperamide hcl tab 2 mg
24
megestrol acetate
loratadine & pseudoephedrine
40,41
66
101
MEIJER ALCOHOL SWABS
32
loratadine allergy relief tab disp 10 mg
38
MEIJER LANCETS
115
loratadine tab 10 mg
38
MEIJER LANCETS THIN
115
74,75
MEIJER LANCETS UNIVERSAL 30G
115
losartan potassium
80
MEIJER LANCETS UNIVERSAL 33G
115
losartan potassium & hydrochlorothiazide
84
MEIJER SUPER THIN LANCETS
115
lovastatin
86
melatonin
32
loxapine succinate
68
meloxicam
49
130
memantine hcl
59
66
meperidine hcl
51
lorazepam
LUFYLLIN
LYSODREN
M
M-CLEAR
M-VIT
MAG-TAB SR
MAGELLAN INSULIN SAFETY SYR
41
MEPHYTON
134
meprobamate
74
mercaptopurine
66
134
mesalamine
103
44
MESTINON
64
115
metaproterenol sulfate
130
MAGNEBIND 300
44
metformin hcl
76
magnesium chloride
44
methadone hcl
50
magnesium citrate solution 1.745 gm/30ml
25
methazolamide
127
magnesium gluconate
44
methenamine mandelate
magnesium oxide
24
methenamine-hyosc-methylene blue-sod phos-phenyl
magnesium oxide (mg supplement)
44
sal
MAGONATE
44
methimazole
102
54
54
MAJOR COMFORT LANCETS
115
methocarbamol
132
MAKENA
100
methotrexate sodium
103
malathion
67
PAGE 151
methylcellulose (laxative)
25
methyldopa
80
MISSION PRENATAL HP
46
methyldopa & hydrochlorothiazide
84
moexipril hcl
81
moexipril-hydrochlorothiazide
84
methylergonovine maleate
115
methylphenidate hcl
88
MOI-STIR
19
METHYLPHENIDATE HCL ER
88
mometasone furoate
95
methylprednisolone
95
MONOJECT INSULIN SYRINGE
115
metoclopramide hcl
62
MONOJECT ULTRA COMFORT SYRINGE
115
metolazone
85
MONOLET LANCETS
115
metoprolol & hydrochlorothiazide
84
MONOLET OPD LANCETS
115
metoprolol succinate
82
montelukast sodium
129
metoprolol tartrate
82
MOORE MONO INSULIN SYRINGE
116
metronidazole
54
morphine sulfate
metronidazole (topical)
54
MOUTH KOTE
metronidazole cream 0.75 %
54
MS INSULIN SYRINGE
metronidazole gel 0.75 %
54
MS QUICK DISSOLVE GLUCOSE
18
metronidazole vaginal
54
MULTI-DELYN/IRON
46
mexiletine hcl
81
multiple vitamin
45
multiple vitamins w/ iron
45
MIACALCIN
104
50,51
19
116
miconazole nitrate (topical)
17
multiple vitamins w/ minerals
miconazole nitrate vaginal
17
MULTISTIX
32
MICRO-BUMINTEST
32
MULTISTIX 10 SG
32
MICROELITE BATTERY
32
MULTISTIX 5
32
MICROELITE FILTER REPLACEMENTS
32
MULTISTIX 7
32
MICROLIFE DIGITAL PEAK FLOW
32
MULTISTIX 8
32
midazolam hcl
74
MULTISTIX 9
32
midodrine hcl
80
MULTISTIX 9 SG
32
milk of magnesia suspension 400 mg/5ml
25
mupirocin
54
MILLIPRED
95
mupirocin calcium (topical)
54
mineral oil
25
mycophenolate mofetil
103
MINERAL OIL-HYDROPHIL PETROLAT
21
mycophenolate sodium
103
MINI LANCING DEVICE
115
45,46
MYKIDZ IRON
47
MINI WRIGHT PEAK FLOW METER
32
MYKIDZ IRON 10
44
MINIELITE FILTER REPLACEMENTS
32
MYLERAN
65
minocycline hcl
57
MYNATAL
134
minoxidil
86
MYNATAL ADVANCE
134
MIRANEL AF
17
MYNATAL PLUS
134
MIRASORB SPONGES
32
MYNATAL-Z
134
mirtazapine
60
MYNATE 90 PLUS
134
misoprostol
93
MISSION PRENATAL
46
N
MISSION PRENATAL FA
46
nabumetone
PAGE 152
49
nadolol
82
NIACOR
86
nadolol & bendroflumethiazide
84
nicardipine hcl
83
naloxone hcl
52
nicotine
16
naltrexone hcl
52
NICOTINE
16
naphazoline hcl
naphazoline w/ pheniramine
naproxen
125
37
49,50
nicotine polacrilex
16,17
NICOTROL
52
NICOTROL NS
53
naproxen sodium
50
nifedipine
83
naproxen sodium tab 220 mg
16
NINLARO
66
naratriptan hcl
64
NITRO-BID
87
NARCAN
52
nitrofurantoin
54
nasal decongestant solution 1 %
32
nitrofurantoin macrocrystal
54
nasal moisturizing spray solution 0.65 %
32
nitrofurantoin monohyd macro
54
NATACHEW
134
nitroglycerin
87
NATAL-V RX
134
NITROSTAT
87
NATALVIT
134
NIVA-PLUS
135
nateglinide
76
NORDITROPIN
96
NATELLE-EZ
134
NORDITROPIN FLEXPRO
96
NATURE-THROID
101
NORDITROPIN NORDIFLEX PEN
96
NECON 1/50 (28)
98
Norelgestromin-Ethinyl Estradiol TD PTWK 150-35
NECON 10/11 (28)
98
MCG/24HR (Xulane)
nefazodone hcl
61
Norethindrone & Ethinyl Estradiol Tab 0.4 MG-35 MCG
NEO-SYNEPHRINE
32
(Balziva, Briellyn, Gildagia, Philith, Vyfemla,
neomycin sulfate
53
Zenchent)
neomycin-bacitracin zn-polymyxin
125
98
98
Norethindrone & Ethinyl Estradiol Tab 0.5 MG-35 MCG
neomycin-bacitracin-polymyxin
19
(Necon, Nortrel, Wera)
neomycin-bacitracin-polymyxin-pramoxine
21
Norethindrone & Ethinyl Estradiol Tab 1 MG-35 MCG
neomycin-polymy-dexameth
neomycin-polymyxin w/ pramoxine
125
22
98
(Alyacen, Cyclafem, Dasetta, Necon, Nortrel,
Pirmella)
98
neomycin-polymyxin-gramicidin
125
Norethindrone Ace & Ethinyl Estradiol Tab 1 MG-20
neomycin-polymyxin-hc (ophth)
125
MCG (Gildess, Junel, Larin, Microgestin)
neomycin-polymyxin-hc (otic)
127
Norethindrone Ace & Ethinyl Estradiol Tab 1.5 MG-30
99
NESSI SPACER WITH MASK LARGE
32
NESSI SPACER WITH MASK SM/MED
32
Norethindrone Ace & Ethinyl Estradiol-FE Tab 1 MG-20
NESSI SPACER WITH MOUTHPIECE
32
NEUTRAPHOR
22
Norethindrone Ace & Ethinyl Estradiol-FE Tab 1.5 MG-
NEUTRAPHORUS REX
22
30 MCG (Gildess, Junel, Larin, Microgestin)
NEVANAC
126
nevirapine
70,71
NEXIUM 24HR
niacin
PAGE 153
26
99
99
99
Norethindrone Ace-Ethinyl Estradiol-FE Tab 1 MG-20
MCG (Lomedia)
norethindrone acetate
99
101
18,47
Norethindrone Tab 0.35 MG (Camila, Deblitane, Errin,
nystatin (mouth-throat)
63
Heather, Jencycla, Jolivette, Lyza, Nora-BE, Norlyroc,
nystatin (topical)
63
Sharobel)
nystatin-triamcinolone
63
101
Norethindrone-Eth Estradiol Tab 0.5-35/0.75-35/1-35
O
MG (Alyacen, Cyclafem, Dasetta, Necon, Nortrel,
Pirmella)
99
O-CAL FA
135
O-CAL PRENATAL
135
OFF DEEP WOODS
32
Norgestimate & Ethinyl Estradiol Tab 0.25 MG-35 MCG
OFF DEEP WOODS DRY
33
(Estarylla, Mono-Linyah, MonoNessa, Previfem,
ofloxacin
57
ofloxacin (ophth)
57
Norgestimate-Eth Estrad Tab 0.18-35/0.215-35/0.25-35
ofloxacin (otic)
57
MG (Tri-Estarylla, Tri-Linyah, Tri-Previfem, Tri-
OGESTREL
99
Norethindrone-Eth Estradiol Tab 0.5-35/1-35/0.5-35
MG (Aranelle, Leena)
Sprintec)
99
99
Sprintec, Trinessa)
99
olanzapine
69
norgestimate-ethinyl estradiol (triphasic)
99
omega-3 fatty acids
19
omeprazole
93
Norgestrel & Ethinyl Estradiol Tab 0.3 MG-30 MCG
(Cryselle, Elinest, Low-Ogestrel)
99
omeprazole delayed release tab 20 mg
26
NORINYL 1+50 (28)
99
omeprazole magnesium
26
NORPACE CR
81
OMEPRAZOLE+SYRSPEND SF ALKA
93
nortriptyline hcl
62
omeprazole-sodium bicarbonate
NORTUSS-EX
131
26,93
ON CALL LANCING DEVICE
116
116
NORVIR
73
ON CALL PLUS LANCING DEVICE
NOVA MAX PLUS KETONE TEST
32
ondansetron hcl
62
NOVA SUREFLEX LANCETS
116
62
NOVA SUREFLEX LANCING DEVICE
116
62
47
NOVOLIN 70/30
78
ONE-A-DAY WOMENS PRENATAL
NOVOLIN 70/30 RELION
78
ONETOUCH DELICA LANCING DEV
116
NOVOLIN N
78
ONETOUCH LANCETS
116
NOVOLIN N RELION
78
ONGLYZA
76
NOVOLIN R
78
OPTICHAMBER FACE MASK-LARGE
33
NOVOLIN R RELION
78
OPTICHAMBER FACE MASK-MEDIUM
33
NOVOLOG
78
OPTICHAMBER FACE MASK-SMALL
33
NOVOLOG FLEXPEN
78
OPTIFOAM
33
NOVOLOG MIX 70/30
78
OPTIONS GYNOL II CONTRACEPTIVE
26
NOVOLOG MIX 70/30 FLEXPEN
78
oral electrolytes
42
NOVOLOG PENFILL
78
ORAL RELIEF SPRAY
19
NU GAUZE GENERAL-USE SPONGES
32
oral vehicles
26
NUTRICION PORVIDA
47
ORKAMBI
130
NUVARING
99
orphenadrine citrate
132
NYSTATIN
63
ORSINI INSULIN SYRINGE
116
nystatin
63
ORTHO DIAPHRAGM ALL-FLEX
116
PAGE 154
oxaprozin
50
perphenazine
62
oxazepam
75
perphenazine-amitriptyline
60
oxcarbazepine
59
PERRY PRENATAL
47
oxybutynin chloride
94
PERSONAL BEST FULL RANGE
33
oxycodone hcl
51
PERSONAL BEST LOW RANGE
33
oxycodone w/ acetaminophen
51
petrolatum, hydrophilic
33
oxycodone-aspirin
51
PHARMACY COUNTER LANCETS
oyster shell
44
phenazopyridine hcl
94
phenelzine sulfate
60
phenobarbital
58
P
116
PANCREAZE
91
phenylephrine hcl (ophth)
pancrelipase (lipase-protease-amylase)
92
phenylephrine hcl tab 10 mg
33
pantoprazole sodium
93
phenylephrine w/ acetaminophen
41
paroxetine hcl
61
phenylephrine w/ dm-gg
41
phenylephrine-acetaminophen-guaifenesin
41
41
PC LANCETS SUPER THIN 30G
116
125
PCE
57
phenylephrine-brompheniramine-dm
PEAK AIR PEAK FLOW METER
33
phenylephrine-chlorpheniramine w/ dm-gg
PEAK FLOW METER UNIVERSAL RANG
33
phenylephrine-chlorpheniramine-dm w/ apap
41
phenylephrine-cocoa butter
22
ped multivitamins w/fl & iron
133
131
PEDIATRIC AEROSOL MASK
33
phenylephrine-dm
41
PEDIATRIC MOUTHPIECE
33
phenylephrine-dm-gg w/ apap
41
pediatric multiple vitamin w/ c
45
phenylephrine-doxylamine-dextromethorphan-
pediatric multiple vitamin w/ c & fa
45
acetaminophen
41
pediatric multiple vitamin w/ extra c & fa
45
phenylephrine-guaifenesin
41
pediatric multiple vitamin w/ minerals & c
47
phenylephrine-mineral oil-petrolatum
22
pediatric multiple vitamins
45
phenylephrine-shark liver oil-cocoa butter
22
pediatric multiple vitamins w/ iron
45
phenylephrine-shark liver oil-glycerin-petrolatum
22
pediatric multivitamins w/fl
133,135
phenylephrine-shark liver oil-mineral oil-petrolatum 22
pediatric vitamins acd fluoride & iron
133
PHENYLHISTINE DH
41
pediatric vitamins acd w/ fluoride
135
phenytoin
59
pediatric vitamins adc
45
phenytoin sodium extended
59
peg 3350-kcl-sod bicarb-sod chloride-sod sulfate
93
PHOS-NAK
44
PHRENILIN FORTE
88
33
peg 3350-potassium chloride-sod bicarbonate-sod
chloride
93
PIKO 1
penicillin v potassium
56
pilocarpine hcl
PENTASA
pentoxifylline
PERFECT LANCETS 30G
perindopril erbumine
permethrin
permethrin & pyrethrins-piperonyl butoxide
PAGE 155
103
84
116
81
22,33,67
22
127
pilocarpine hcl (oral)
89
pimozide
68
PIN-X
18
pindolol
82
pioglitazone hcl
76
pioglitazone hcl-metformin hcl
76
piroxicam
50
prednisolone acetate (ophth)
PLEGRIDY
89
prednisolone sodium phosphate
PLEGRIDY STARTER PACK
89
PREDNISOLONE SODIUM PHOSPHATE
126
95
126
PNV FE FUM/DOCUSATE/FOLIC ACID
135
prednisone
96
PNV FOLIC ACID + IRON
135
PREDNISONE INTENSOL
96
PNV PRENATAL PLUS MULTIVITAMIN
47,135
PNV TABS 29-1
135
PREFERRED PLUS INSULIN SYRINGE
116
PREFERRED PLUS LANCETS COLORED
116
116
POCKET PEAK FLOW METER
33
PREFERRED PLUS LANCETS THIN
podofilox
91
PREMARIN
99
PREMIUM CONDOMS LUBRICATED
33
POLY-VI-FLOR FS
135
POLYCOSE
47
PREMPRO
100
polyethylene glycol 3350
25
PRENAFIRST
135
polyethylene glycol 3350 (bulk)
33
PRENAPLUS
135
polyethylene glycol-propylene glycol (ophth)
37
PRENATABS FA
135
POLYMEM DRESSING
33
PRENATABS RX
135
polymyxin b-trimethoprim
125
PRENATAL
47,136
polysaccharide iron complex
47
PRENATAL 19
135
POLYSPORIN
22
PRENATAL AD
135
polyvinyl alcohol
37
PRENATAL FORMULA
47
pot phosphate monobasic w/ sod phosphate dibasic &
PRENATAL LOW IRON
135
monobasic
prenatal multivit-min w/fe-fa
94
45
potassium bicarbonate
133
PRENATAL PLUS
136
potassium chloride
133
PRENATAL PLUS IRON
136
potassium chloride microencapsulated crystals cr
133
prenatal vit w/ ferrous fumarate-folic acid
45
potassium citrate (alkalinizer)
94
PRENATAL VITAMINS PLUS
136
povidone-iodine
33
PRENATAL-U
136
POVIDONE-IODINE
33
PREPLUS
136
povidone-iodine vaginal
26
PRESERVISION AREDS
pramipexole dihydrochloride
67
PRETAB
pramoxine hcl (rectal)
22
PREZISTA
73
47
136
pramoxine-chloroxylenol
127
PRILOSEC OTC
26
pramoxine-hc-chloroxylenol
127
PRIMAQUINE PHOSPHATE
66
pramoxine-phenylephrine-glycerin-petrolatum
22
primaquine phosphate
67
pravastatin sodium
86
primidone
58
prazosin hcl
80
PRO-CLEAR AC
41
PRECISION SURE-DOSE SYRINGE
116
PRO-RED AC
41
PRECISION SUREDOSE PLUS SYR
116
probenecid
64
prochlorperazine
62
62
PRECISION XTRA KETONE
33
PRED MILD
126
prochlorperazine maleate
PRED-G
125
PRODIGY INSULIN PEN NEEDLES
117
PRODIGY INSULIN SYRINGE
117
prednisolone
PAGE 156
95
PRODIGY LANCING DEVICE
117
PX INSULIN SYRINGE
117
PRODIGY TWIST TOP LANCETS 28G
117
PX LANCET AUTO INJECTOR
117
PX LANCETS
117
117
PROFE
47
progesterone
117
PX LANCETS ULTRA THIN
PROGESTERONE
117
PX NITETIME MULTI-SYMPTOM
42
101,117
PX PRENATAL MULTIVITAMINS
47
progesterone micronized
PROGESTERONE MICRONIZED
117
pyrantel pamoate
18
PROGESTERONE WETTABLE
117
pyrazinamide
65
promethazine & phenylephrine
131
pyrethrins-piperonyl butoxide
22
promethazine hcl
128
pyrethrins-piperonyl butoxide-permethrin-nit remover 22
promethazine hcl (bulk)
117
pyridostigmine bromide
65
128
pyridoxine hcl
47
128
promethazine w/codeine
131
Q
promethazine-dm
131
QC ADVANCED LANCING DEVICE
117
propafenone hcl
81
QC ALCOHOL SWABS
34
propantheline bromide
92
QC INSULIN SYRINGE
117
propranolol & hydrochlorothiazide
84
QC LANCETS SUPER THIN 30G
117
propranolol hcl
82
QC LANCETS ULTRA THIN
117
propylene glycol (ophth)
37
QC PRENATAL
propylthiouracil
102
47
QC UNILET LANCETS MICRO THIN
117
PRORENAL + D
47
QH
34
PRORENAL + D W/ OMEGA-3
47
quetiapine fumarate
69
PROSHIELD PLUS SKIN PROTECTANT
22
quinapril hcl
81
protriptyline hcl
62
quinapril-hydrochlorothiazide
85
quinidine gluconate
81
pseudoephed-bromphen-dm
41,131
pseudoephed-doxyl-dm w/apap
41
quinidine sulfate
81
pseudoephedrine hcl
33
quinine sulfate
67
pseudoephedrine hcl er tab er 12h 120 mg
33
pseudoephedrine hcl tab 30 mg
34
R
pseudoephedrine w/ codeine-gg
41
RA ALCOHOL SWABS
34
pseudoephedrine w/ dm-gg
41
RA ALL PURPOSE DRESSINGS
34
pseudoephedrine-acetaminophen-dextromethorphan41
RA DRESSING SPONGES
34
pseudoephedrine-chlorphen-dm
41
RA DRY MOUTH
19
pseudoephedrine-guaifenesin
41
RA E-ZJECT COLOR LANCETS 33G
117
pseudoephedrine-ibuprofen
41
RA E-ZJECT LANCETS 28G
117
psyllium
25
RA E-ZJECT LANCETS THIN 26G
117
PTS PANELS KETONE TEST
34
RA E-ZJECT LANCETS THIN 28G
117
PURIXAN
66
RA E-ZJECT LANCETS ULTRA THIN
118
PX ADVANCED LANCING DEVICE
PX DAYTIME MULTI-SYMPTOM
PAGE 157
117
RA GAUZE SPONGES
34
42
RA INSULIN SYRINGE
118
RA LANCING DEVICE
118
RESTORE CONTACT LAYER
34
RA ONE DAILY
47
RESTORE FOAM DRESSING
34
RA OYSTER SHELL CALCIUM/D
44
RESTORE ODOR ABSORBING DRESS
34
RA PRENATAL
48
RESTORE TRIO ABSORBENT DRESS
34
RA PRENATAL FORMULA
47
REXALL LANCETS ULTRA THIN 30G
RA SALINE WOUND WASH
22
REYATAZ
RA STERILE
34
RHEUMATREX
raloxifene hcl
101
ramipril
81
118
73
103
riboflavin
48
RID ESSENTIAL LICE ELIMINATION
22
ranitidine hcl
24,92,93
RAPAMUNE
103
rifabutin
65
34
rifampin
65
RAY-TEC X-RAY DETECTABLE SPNGE
RIDAURA
103
RE PRENATAL MULTIVITAMIN/IRON
136
RIGHTEST GD500 LANCING DEVICE
118
RE-NATA 29 OB
136
RIGHTEST GL300 LANCETS
118
REALITY LATEX/ULTRA TEXTURED
34
rimantadine hydrochloride
73
REALITY LATEX/ULTRA THIN
34
RISACAL-D
44
REFENESEN CHST CONG/PAIN PE
42
risperidone
69
REFRESH CELLUVISC
37
risperidone odt (tab 3 mg, tab 4 mg)
69
REFRESH LIQUIGEL
37
69
RELENZA DISKHALER
73
69
118
69
RELION 70/30
78
69
RELION ALCOHOL SWABS
34
rivastigmine tartrate
59
RELION INSULIN SYRINGE
118
rizatriptan benzoate
64
RELION LANCETS MICRO-THIN 33G
118
ropinirole hydrochloride
67
RELION LANCETS STANDARD 21G
118
RELION LANCETS THIN 26G
118
S
RELION LANCETS ULTRA-THIN 30G
118
SAFE WASH
RELION LANCING DEVICE
118
SAFESNAP INSULIN SYRINGE
118
RELI-ON INSULIN SYRINGE
22
RELION N
78
SAFETY SEAL LANCETS
118
RELION R
78
SAFETY-GLIDE SYRINGE
118
RELION ULTRA THIN LANCETS 30G
118
salicylic acid
RELION ULTRA THIN PLUS LANCETS
118
salicylic acid & sulfur
22
saline
27
SALINE WOUND WASH
23
REMEDY NUTRASHIELD
RENEW ADVANCED LANCING DEVICE
22
118
23,91
REPLACEMENT FILTERS
34
SALJET
23
RESCON DM
42
SALJET RINSE
23
RESCRIPTOR
71
salsalate
50
reserpine
85
SAMI THE SEAL FILTERS
34
RESPAIRE-30
42
SAVELLA
88
respiratory therapy supplies
27
SAVELLA TITRATION PACK
88
PAGE 158
SB ALCOHOL PREP
34
SM LANCETS 33G
119
SB INSULIN SYRINGE
118
SM ONE DAILY PRENATAL
48
SB LANCETS THIN
118
SM PRENATAL VITAMINS
48
SB LANCETS ULTRA THIN
119
SM STERILE
35
SCHNUCKS INSULIN SYRINGE
119
SM SUPER THIN LANCETS 30G
119
SCHOOLTIME SHAMPOO
23
SM THIN LANCETS 26G
119
SCOT-TUSSIN SENIOR
42
SMART DIABETES VANTAGE LANCING
119
SE-NATAL 19
136
SMART SENSE COLOR LANCETS 33G
119
SE-NATAL 90
136
SMART SENSE STANDARD LANCETS
119
SE-NATAL ONE
136
SMART SENSE SUPER THIN LANCETS
119
SMART SENSE THIN LANCETS 26G
119
selegiline hcl
selenium sulfide
68
23,91
soap & cleansers
20
24
SELZENTRY
72
sodium bicarbonate (antacid)
senna
25
sodium chloride
senna tab 8.6 mg
25
sodium chloride (gu irrigant)
senna-docusate sodium tab 8.6-50 mg
25
sodium chloride (inhalant)
sennosides
25
sodium chloride hypertonic
37
130
sodium citrate & citric acid
94
SEREVENT DISKUS
sertraline hcl
61
SFROWASA
104
SHOPKO ALCOHOL SWABS
34
133
sodium fluoride
94
42,131
133
sodium fluoride (dental)
19,89,90
sodium phosphates
24
SHOPKO AUTOLET LANCING DEVICE
119
sodium polystyrene sulfonate
132
SHOPKO UNILET LANCETS 28G
119
sodium polystyrene sulfonate (bulk)
119
SHOPKO UNILET LANCETS 30G
119
SOLUS V2 LANCING DEVICE
119
SIDESTREAM ADULT FACE MASK
34
SOMNOTE
88
SIDESTREAM PEDIATRIC FACE MASK
34
sorbitol
35
SIDESTREAM PLS ADULT FACE MASK
34
SORBITOL
35
silver sulfadiazine
57
sorbitol (laxative)
25
sotalol hcl
81
sotalol hcl (afib/afl)
81
simethicone
SIMPLE DIAGNOSTICS LANCING DEV
24,34
119
SIMPLYTHICK
34
SOVALDI
70
simvastatin
86
SPINOSAD
67
sirolimus
103
SPIRIVA HANDIHALER
129
SIVEXTRO
54
spironolactone
85
skin protectants, misc.
23
spironolactone & hydrochlorothiazide
85
SLOW-MAG
44
SSKI
SM ALCOHOL PREP
35
stannous fluoride
19
SM GAUZE
35
stavudine
71
SM GLUCOSE
18
STERI-PAD STERILE
35
SM INSULIN SYRINGE
119
STERILANCE TL
SM LANCETS 21G
119
STERILE
PAGE 159
102
119
35
STUART PRENATAL
48
terbinafine hcl (topical)
SUBOXONE
52
terbutaline sulfate
sucralfate
93
terconazole vaginal
sulfacetamide sod-prednisolone
125
23
130
63
TERUMO INSULIN SYRINGE
120
120
sulfacetamide sodium
91
TERUMO SURGUARD INSULIN SYR
sulfacetamide sodium (acne)
91
testosterone cypionate
97
sulfacetamide sodium (ophth)
57
tetracycline hcl
57
sulfacetamide sodium w/ sulfur
91
tetrahydrozoline hcl (ophth)
37
sulfamethoxazole-trimethoprim
57
TGQ 30PSE/150GFN/15DM
131
SULFAMYLON
54
TGT ADVANCED LANCING DEVICE
120
sulfasalazine
104
TGT ALCOHOL SWABS
35
sulindac
50
TGT LANCET ALTERNATE SITE
120
sumatriptan nasal spray (5 mg/act, 20 mg/act)
64
TGT LANCET MICRO THIN 33G
120
sumatriptan succinate
64
TGT LANCET SUPER THIN 30G
120
SUPER THIN LANCETS
119
TGT LANCET THIN 23G
120
SURE COMFORT INSULIN SYRINGE
120
TGT LANCET THIN 26G
120
SURE COMFORT LANCING PEN
120
TGT LANCET ULTRA THIN 28G
120
SURE-JECT INSULIN SYRINGE
120
TGT LANCET ULTRA THIN 30G
120
SURE-PEN
120
TGT LANCING DEVICE
120
SURELITE LANCETS
120
TH PRENATAL VITAMINS
SUSTIVA
SYMBICORT
71
131
48
THEO-24
130
theophylline
130
SYMLINPEN 120
76
THERAGAUZE
35
SYMLINPEN 60
76
THERANATAL CORE NUTRITION
48
SYSTANE OVERNIGHT THERAPY
37
thiamine hcl
48
thiamine mononitrate
48
T
tacrolimus
THINPRO INSULIN SYRINGE
103
121
thioridazine hcl
68
68
tacrolimus (topical)
91
thiothixene
TAMIFLU
73
thyroid
101
tamoxifen citrate
65
THYROLAR-1
101
tamsulosin hcl
94
THYROLAR-1/2
101
TAZORAC
91
THYROLAR-1/4
101
TECFIDERA
89
THYROLAR-2
101
TECHLITE AST LANCETS
120
THYROLAR-3
101
TECHLITE LANCETS
120
tiagabine hcl
58
TECHLITE LANCETS 30G
120
timolol maleate
82
TEGADERM FOAM
35
timolol maleate (ophth)
127
temazepam
132
TIMOPTIC OCUDOSE
127
terazosin hcl
94
tioconazole vaginal
17
terbinafine hcl
63
TIVICAY
70
PAGE 160
tizanidine hcl
137
TOBRADEX
53
tobramycin
130
trimethoprim
54
TRINATAL GT
136
TRINATAL RX 1
136
137
tobramycin (ophth)
53
TRINATAL ULTRA
tobramycin sulfate
53
triprolidine & pseudoephedrine
42
TOBRAMYCIN SULFATE IN SALINE
53
TRIUMEQ
72
tobramycin-dexamethasone
TOBREX
125
53
TRIVEEN-U
137
TROJAN MAGNUM WARM SENSATIONS
35
TODAYS HEALTH LANCING DEVICE
121
TROJAN SUPRAS SPERMICIDAL
35
TODAYS HEALTH THIN LANCETS 28G
121
TROJAN TWISTED PLEASURE
35
TODAYS HEALTH THIN LANCETS 30G
121
tropicamide
125
tolazamide
76
trospium chloride
tolbutamide
76
TRUE METRIX AIR
121
tolnaftate
23
TRUE METRIX BLOOD GLUCOSE TEST
121
121
TRUE METRIX LEVEL 1
121
topiramate
59
TRUE METRIX LEVEL 2
121
torsemide
85
TRUE METRIX LEVEL 3
121
TRADJENTA
76
TRUE METRIX METER
121
tramadol hcl
51
TRUECONTROL GLUCOSE CONT LEV 0
121
trandolapril
81
TRUECONTROL GLUCOSE CONT LEV 1
121
tranylcypromine sulfate
60
TRUEDRAW LANCING DEVICE
121
trazodone hcl
61
TRUEPLUS INSULIN SYRINGE
121
TRECATOR
65
TRUEPLUS LANCETS 26G
121
tretinoin
91
121
103
121
TRI-VI-SOL/IRON
48
121
TRIAD HYDROPHILIC WOUND DRESS
23
TRUERESULT BLOOD GLUCOSE
121
136
TRUETEST CONTROL LEVEL 1
121
triamcinolone acetonide (mouth)
96
122
triamcinolone acetonide (nasal)
37
122
triamcinolone acetonide (topical)
96
TRUETEST TEST
122
TRIAMINIC COLD/COUGH DAY TIME
42
TRUETRACK GLUCOSE CONTROL
122
TRIAMINIC FLU COUGH & FEVER
42
TRUETRACK TEST
122
TRIAMINIC MULTI-SYMPTOM FEVER
42
TRUSTEX COLOR CONDOMS + LUBE
35
triamterene & hydrochlorothiazide
85
TRUSTEX LUB/RIBBED/STUDDED
35
triazolam
132
TRUSTEX LUB/SPERMICIDE EX ST
35
TRICARE
136
TRUSTEX LUB/SPERMICIDE XL
35
TOPCARE ULTRA COMFORT INS SYR
TREXALL
TRIADVANCE
94
trifluoperazine hcl
68
TRUSTEX LUBRICATED
35
trifluridine
74
TRUSTEX LUBRICATED EX LARGE
35
trihexyphenidyl hcl
67
TRUSTEX LUBRICATED EXTRA ST
35
trimethobenzamide hcl
62
TRUSTEX LUBRICATED/SPERMICIDE
35
PAGE 161
TRUSTEX NATURAL CONDOMS + LUBE
35
UNILET GP 28 ULTRA THIN
123
TRUSTEX NON-LUBRICATED
35
UNILET LANCET
123
TRUSTEX RIA LUB/SPERMICIDE
35
UNILET MICRO-THIN 33G
123
TRUSTEX RIA LUBRICATED
36
UNILET SUPER-THIN 30G
123
TRUSTEX RIA NON-LUBRICATED
36
UNILET SUPERLITE LANCET
123
TRUSTEX-NONOXYNOL-9/RIB/STUD
36
UNILET ULTRA-THIN 28G
123
TRUVADA
71
UNIVERSAL 1 LANCETS THIN 26G
123
TUBING/WING TIP
36
UNIVERSAL 1 LANCETS ULTRA THIN
123
TUDORZA PRESSAIR
129
urea
23,91
TUSNEL
42
URISTIX
36
TUSNEL PEDIATRIC
42
URISTIX 4
36
ursodiol
92
UTI HOME
36
TWINJECT
TYBOST
130
72
U
V
ULTI-LANCE AUTO-ADJUST DEVICE
122
V-R MONO INSULIN SYRINGE
123
ULTI-LANCE AUTOMATIC
122
valacyclovir hcl
74
ULTI-LANCE MINI ADJUSTABLE
122
valganciclovir hcl
70
ULTICARE INSULIN SAFETY SYR
122
valproate sodium
58
ULTICARE INSULIN SYRINGE
122
valproic acid
58
ULTILET ALCOHOL SWAB
36
valsartan
80
ULTILET ALCOHOL SWABS
36
valsartan-hydrochlorothiazide
85
ULTILET BASIC LANCETS 30G
122
VALUE HEALTH INSULIN SYRINGE
123
ULTILET CLASSIC LANCETS
122
VALUE PLUS LANCET STANDARD 21G
123
VALUE PLUS LANCETS SUPER THIN
123
ULTILET GLUCOSE
18
ULTILET INSULIN SYRINGE
122
VALUE PLUS LANCETS THIN 26G
123
ULTILET INSULIN SYRINGE SHORT
122
VALUE PLUS LANCING DEVICE
124
ULTILET LANCETS
122
VALUMARK LANCET SUPER THIN 30G
124
ULTRA COMFORT INSULIN SYRINGE
122
VALUMARK LANCET ULTRA THIN 28G
124
ULTRA THIN LANCETS 28G
122
vancomycin hcl
ULTRA THIN LANCETS 30G
122
VANISHPOINT INSULIN SYRINGE
124
ULTRA-COMFORT INSULIN SYRINGE
123
VCF VAGINAL CONTRACEPTIVE
26
ULTRA-THIN II INS SYR SHORT
123
VENATAL-FA
137
ULTRA-THIN II INSULIN SYRINGE
123
venlafaxine hcl
61
ULTRATHON INSECT REPELLENT
23
VENLAFAXINE HCL ER
61
ULTRATHON INSECT REPELLENT 8
36
VENTOLIN HFA
54
130
UNILET COMFORTOUCH LANCET
123
verapamil hcl
83
UNILET EXCELITE
123
VERIPRED 20
96
UNILET EXCELITE II
123
VERSIVA XC
36
UNILET G.P. LANCET
123
VEXOL
126
UNILET G.P. SUPERLITE LANCET
123
VIDA MIA AUTOLET LANCING DEV
124
PAGE 162
VIDA MIA UNILET LANCETS 28G
124
WEBCOL ALCOHOL PREP LARGE
36
VIDA MIA UNILET LANCETS 30G
124
WEBCOL ALCOHOL PREP MEDIUM
36
VIDEX
71
WESTHROID
101
VIGAMOX
57
WESTHROID-P
101
VIIBRYD
61
white petrolatum
36
VINATE CALCIUM
137
white petrolatum-mineral oil
36
VINATE GT
137
wound cleansers
20
VINATE M
137
wound dressings
20
VINATE ONE
137
WOUND WASH SALINE
23
VINATE ULTRA
137
WP THYROID
VIRACEPT
73
VIREAD
72
VIRT-ADVANCE
137
VIRT-VITE GT
137
VISTEC X-RAY DETECTABLE SPONGE
36
101
X
XARELTO
79
Z
VISTOGARD
124
zaleplon
132
VITAFOL-OB
137
ZENPEP
92
VITAFOL-PN
137
ZEPATIER
70
vitamin e
48
ZIAGEN
72
vitamins w/ lipotropics
45
zidovudine
72
ZIKS ARTHRITIS PAIN RELIEF
23
VITASPIRE
137
VITEKTA
70
zinc
44
VIVITROL
52
zinc oxide (topical)
23
VOL-PLUS
137
zinc sulfate
44
VOL-TAB RX
137
ziprasidone hcl
69
VP INSULIN SYRINGE
124
zolpidem tartrate
VYVANSE
87
ZOVIA 1/50E (28)
W
ZOVIRAX
W&F LANCETS 26G
124
W&F LANCETS COLORED 21G
124
WALGREENS GLUCOSE
18
WALGREENS LANCETS
124
WALGREENS LANCETS MICRO THIN
124
WALGREENS LANCETS SUPER THIN
124
WALGREENS LANCING DEVICE
124
WALGREENS THIN LANCETS
124
WALGREENS ULTRA THIN LANCETS
124
warfarin sodium
58
100
74
79
water for irrigation, sterile
124
WD MEDIC INSULIN SYRINGE
124
PAGE 163
zonisamide
132

Buckeye Health Plan

Transcription

Similar documents

CeltiCare Health

OTC Drug List

New Hampshire Healthy Families

Preferred Drug List

Qualified Health Plan Drug Formulary

FL MMA Value-Added OTC

2016 MDWise HIEx Formulary

Aetna`s Pharmacy Tier Listing

English - UHCCommunityPlan.com

Formulary

3-Tier Formulary - Total Health Care

MDE-3807A The Advantage Series Pump and Dispenser

preferred drug list

Buckeye Community Health Plan Preferred Drug List

HIP State Plus

New Mexico - UHCCommunityPlan.com

Page 1 NY026466_HIX_FOR_CHI ©WellCare 2014 NY_06_14

Buckeye Community Health Plan Preferred Drug List

New York - WellCare

2015 Commercial Medication Formulary

Rx Formulary - Millenium Medical Solutions Corp

GENERIC “DRUGSTORE”!