Preferred Drug List

Transcription

Preferred Drug List

Comprehensive
PREFERRED DRUG LIST
Illinicare with CMS Labeler Effective 4/1/2016
PAGE 1
LAST UPDATED 09/2016
LEGEND
TYPE
DESCRIPTION
QL
Quantity Limit
There is a limit on the amount of drug covered per prescription, or
within a specific time frame.
PA
Prior Authorization
Prior Authorization required before prescription can be filled.
ST
Step Therapy
Requires trial and failure of one or more preferred products prior to
coverage.
GL
Gender Limit
Drug is limited to specific gender.
AL
Age Limit
Drug is limited to specific age.
MDD
Max Daily Dose
A limit on the number of times the drug can be taken per day.
MPL
Max Package Limit
A limit on the amount of drug covered per prescription.
MFL
Max Fill Limit
There is a limit on the number of times this drug can be refilled.
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 2
LIST OF COVERED OVER-THE-COUNTER MEDICATIONS
PRODUCT DESCRIPTION
BRAND/GEN
LIMITS & RESTRICTIONS
ANALGESICS
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
aspirin (chew tab 81 mg, tab 325 mg, tab delayed release
81 mg, tab delayed release 325 mg)
generic
aspirin (suppos 300 mg, suppos 600 mg)
generic
aspirin buffered (ca carb-mg carb-mg ox) tab 325 mg
generic
aspirin tab chew 81 mg
generic
ibuprofen (chew tab 100 mg, susp 40 mg/ml, susp 100
mg/5ml, tab 200 mg)
generic
ibuprofen tab 200 mg
generic
naproxen sodium tab 220 mg
QL
12 / 31 days
generic
QL
62 / 31 days
generic
QL
62 / 31 days
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)
generic
NICOTINE KIT 21-14-7 MG/24HR
BRAND
MDD
1 per day
MDS
180 / 365 DAYS
QL
nicotine polacrilex (gum 2 mg, gum 4 mg)
nicotine polacrilex (lozenge 2 mg, lozenge 4 mg)
PAGE 3
2 / 365 days
MDS
180 / 365 DAYS
MDD
24 per day
MDS
180 / 365 DAYS
MDD
20 per day
MDS
180 / 365 DAYS
generic
generic
PRODUCT DESCRIPTION
BRAND/GEN
ANTIEMETICS
ANTIEMETICS, OTHER
dimenhydrinate tab 50 mg
generic
meclizine hcl (chew tab 25 mg, tab 12.5 mg, tab 25 mg)
generic
QL
24 / claim
ANTIFUNGALS
clotrimazole cream 1%
generic
MPL
1 / claim(s)
clotrimazole soln 1%
generic
MPL
1 / claim
clotrimazole vaginal (cream 1%, cream 2%)
generic
miconazole nitrate cream 2%
generic
MPL
1 / claim
miconazole nitrate vaginal (cream 2%, cream 4% (200
mg/5gm), suppos 100 mg)
generic
miconazole nitrate vaginal supp 200 mg & 2% cream 9 gm
kit
generic
MPL
1 / claim
tioconazole vaginal oint 6.5%
generic
BLOOD GLUCOSE REGULATORS
GLYCEMIC AGENTS
BD GLUCOSE CHEW TAB 5 GM
BRAND
QL
50 / 30 days
glucose chew tab 4 gm
generic
QL
50 / 30 days
acetaminophen soln 100 mg/ml
generic
QL
30 / 30 days
acetaminophen soln 160 mg/5ml
generic
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM, OTHER
DERMATOLOGICAL AGENTS
*neomycin-bacitracin-polymyxin oint***
generic
ACNE MEDICATION 10 LOTION 10 %
BRAND
PAGE 4
MPL
1 / claim
PRODUCT DESCRIPTION
BRAND/GEN
ACNE MEDICATION 5 LOTION 5 %
BRAND
ACNE MEDICATION LOTION 10 %
BRAND
bacitracin oint 500 unit/gm
generic
C
Pkg Size 30: Package
Limit=1/claim; Pkg Size
15: Package
28: Package
Limit=1/claim
C
15: Package
28: Package
Limit=1/claim
bacitracin zinc oint 500 unit/gm
generic
benzoyl peroxide (gel 2.5%, gel 5%, gel 10%, liq 5%, liq
10%)
generic
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
coal tar shampoo 0.5%
generic
dibucaine oint 1%
generic
QL
hydrocortisone (topical) (cream, lotion)
generic
MPL
hydrocortisone cream 0.5%
generic
QL
30 / claim
hydrocortisone oint 1%
QL
generic
60 / 30 days
MPL
30 / claim
1 / claim
1 / 30 days
hydrocortisone-aloe vera cream 1%
generic
QL
lactic acid (ammonium lactate) cream 12%
generic
MPL
1 / claim
lactic acid (ammonium lactate) lotion 12%
generic
MPL
1 / 31 days
neomycin-polymyxin w/ pramoxine cream 1%
generic
MPL
1 / claim
permethrin lotion 1%
generic
MPL
1 / claim
phenyleph-shark liver oil-cocoa butter suppos 0.25-385.5%
generic
QL
phenylephrine-cocoa butter suppos 0.25-88.44%
generic
PAGE 5
30 / claim
12 / 31 days
PRODUCT DESCRIPTION
BRAND/GEN
phenylephrine-shark liver oil-mo-pet oint 0.25-3-14-71.9%
generic
QL
31 / 31 days
pramoxine hcl rectal foam 1%
generic
QL
15 / claim
pyreth-piperonyl butox sham-permeth aero-nit remover gel
kit
generic
pyrethrins-piperonyl butoxide liq 0.33-4%
generic
pyrethrins-piperonyl butoxide shampoo 0.33-4%
generic
selenium sulfide lotion 1%
generic
QL
terbinafine hcl cream 1%
generic
MPL
tolnaftate cream 1%
generic
QL
zinc oxide oint 20%
generic
MPL
alum & mag hydroxide-simethicone susp 200-200-20
mg/5ml
generic
QL
aluminum hydroxide gel susp 320 mg/5ml
generic
bismuth subsalicylate (chew tab 262 mg, susp 262
mg/15ml)
generic
calcium carbonate (antacid) chew tab 500 mg
generic
loperamide hcl (cap 2 mg, liq 1 mg/5ml (0.2 mg/ml))
generic
loperamide hcl tab 2 mg
generic
magnesium oxide tab 400 mg
generic
simethicone (chew tab 80 mg, susp 40 mg/0.6ml)
generic
sodium bicarbonate (antacid) (tab 325 mg, tab 650 mg)
generic
MPL
1 / claim
240 / claim
1 / claim
30 / claim
1 / claim
GASTROINTESTINAL AGENTS
GASTROINTESTINAL AGENTS, OTHER
MDD
QL
496 / 31 days
2 per day
496 / 31 days
HISTAMINE2 (H2) RECEPTOR ANTAGONISTS
cimetidine tab 200 mg
generic
famotidine (tab 10 mg, tab 20 mg)
generic
ranitidine hcl (tab 75 mg, tab 150 mg)
generic
PAGE 6
MDD
2 per day
PRODUCT DESCRIPTION
BRAND/GEN
LAXATIVES
*sodium phosphates - enema***
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
complete ready-to-use enema enema 7-19 gm/118ml
generic
docusate sodium (cap 100 mg, cap 250 mg, tab 100 mg)
generic
MDD
3 per day
docusate sodium (liquid 150 mg/15ml, syrup 60 mg/15ml)
generic
docusate sodium cap 100 mg
generic
MDD
3 per day
fiber cap 0.52 gm
generic
glycerin suppos 2 gm
generic
magnesium citrate solution 1.745 gm/30ml
generic
milk of magnesia suspension 400 mg/5ml
generic
polyethylene glycol 3350 oral packet
generic
polyethylene glycol 3350 oral powder
generic
psyllium (cap 0.52 gm, powder 28.3%, powder 30.9%,
powder 48.57%, powder 58.6%)
generic
senna tab 8.6 mg
generic
senna-docusate sodium tab 8.6-50 mg
generic
sennosides tab 8.6 mg
generic
QL
992 / 31 days
MDD
34 per day
MDD
4 per day
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
PRILOSEC OTC TAB DR 20 MG
BRAND
MDD
4 per day
PAGE 7
PRODUCT DESCRIPTION
BRAND/GEN
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)
PROGESTINS
levonorgestrel tab 1.5 mg
generic
QL
1 / 21 Days
GL
Female
MFL
4 / 365 days
MISCELLANEOUS THERAPEUTIC AGENTS
*alcohol swabs***
generic
QL
400 / claim
*respiratory therapy supplies - misc**
generic
QL
1 / 360 Days
acetaminophen (chew tab 80 mg, liquid 160 mg/5ml, susp
80 mg/0.8ml, susp 160 mg/5ml, tab 325 mg, tab 500 mg)
generic
acetaminophen (suppos 120 mg, suppos 325 mg, suppos
650 mg)
generic
QL
12 / 31 days
AIMSCO LUBRICATED MISC
BRAND
QL
36 / claim
ARIAL CHAMBER DEVICE
BRAND
QL
2 / 360 days
chlorhexidine gluconate liquid 4%
generic
cromolyn sodium nasal aerosol soln 5.2 mg/act (4%)
generic
QL
26 / claim
DUREX EXTRA SENSITIVE DEVICE
BRAND
QL
36 / claim
ELEXA NATURAL FEEL MISC
BRAND
QL
36 / claim
ELEXA STIMULATING MISC
BRAND
QL
36 / claim
ELEXA ULTRA SENSITIVE MISC
BRAND
QL
36 / claim
FANTASY LUBRICATED MISC
BRAND
QL
36 / claim
FANTASY LUBRICATED/SPERMICIDE MISC
BRAND
QL
36 / claim
gauze pads & dressings (pads pads 2" 2"***, pads pads 3"
3"***, pads pads 4" 4"***)
generic
KAMELEON LUBRICATED MISC
BRAND
QL
36 / claim
KIMONO MICRO THIN MISC
BRAND
QL
36 / claim
PAGE 8
PRODUCT DESCRIPTION
BRAND/GEN
KIMONO MICRO THIN PLUS MISC
BRAND
QL
36 / claim
KIMONO MISC
BRAND
QL
36 / claim
KIMONO PLUS MISC
BRAND
QL
36 / claim
KIMONO PS MISC
BRAND
QL
36 / claim
KIMONO PS PLUS MISC
BRAND
QL
36 / claim
KIMONO SENSATION MISC
BRAND
QL
36 / claim
KIMONO SENSATION PLUS MISC
BRAND
QL
36 / claim
MAXX MISC
BRAND
QL
36 / claim
MAXX PLUS MISC
BRAND
QL
36 / claim
NASAL DECONGESTANT (LIQUID 30 MG/5ML, SYRUP
30 MG/5ML)
BRAND
nasal moisturizing spray solution 0.65 %
AL
generic
Up to 4 yrs old
MPL
1 / claim
NESSI SPACER WITH MASK LARGE DEVICE
BRAND
QL
2 / 360 days
NESSI SPACER WITH MASK SM/MED DEVICE
BRAND
QL
2 / 360 days
NESSI SPACER WITH MOUTHPIECE DEVICE
BRAND
QL
2 / 360 days
NOVA MAX PLUS KETONE TEST STRIP
BRAND
QL
30 / 30 days
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
permethrin creme rinse 1%
generic
phenylephrine hcl tab 10 mg
generic
QL
24 / claim
PRECISION XTRA KETONE STRIP
BRAND
QL
30 / 30 days
PREMIUM CONDOMS LUBRICATED MISC
BRAND
QL
36 / claim
pseudoephedrine hcl (liq 15 mg/5ml, tab 60 mg)
generic
PAGE 9
PRODUCT DESCRIPTION
BRAND/GEN
pseudoephedrine hcl er tab er 12h 120 mg
generic
pseudoephedrine hcl tab 30 mg
generic
PTS PANELS KETONE TEST STRIP
QL
62 / 31 days
BRAND
QL
30 / 30 days
REALITY LATEX/ULTRA TEXTURED DEVICE
BRAND
QL
36 / claim
REALITY LATEX/ULTRA THIN DEVICE
BRAND
QL
36 / claim
saline nasal spray 0.65%
AL
generic
Up to 4 yrs old
MPL
1 / claim
simethicone liquid 40 mg/0.6ml
generic
AL
Up to 1 yrs old
TROJAN MAGNUM WARM SENSATIONS DEVICE
BRAND
QL
36 / claim
TROJAN SUPRAS SPERMICIDAL DEVICE
BRAND
QL
36 / claim
TROJAN TWISTED PLEASURE DEVICE
BRAND
QL
36 / claim
TRUSTEX COLOR CONDOMS + LUBE MISC
BRAND
QL
36 / claim
TRUSTEX LUB/RIBBED/STUDDED MISC
BRAND
QL
36 / claim
TRUSTEX LUB/SPERMICIDE EX ST MISC
BRAND
QL
36 / claim
TRUSTEX LUB/SPERMICIDE XL MISC
BRAND
QL
36 / claim
TRUSTEX LUBRICATED EX LARGE MISC
BRAND
QL
36 / claim
TRUSTEX LUBRICATED EXTRA ST MISC
BRAND
QL
36 / claim
TRUSTEX LUBRICATED MISC
BRAND
QL
36 / claim
TRUSTEX LUBRICATED/SPERMICIDE MISC
BRAND
QL
36 / claim
TRUSTEX NATURAL CONDOMS + LUBE MISC
BRAND
QL
36 / claim
TRUSTEX NON-LUBRICATED MISC
BRAND
QL
36 / claim
TRUSTEX RIA LUB/SPERMICIDE MISC
BRAND
QL
36 / claim
TRUSTEX RIA LUBRICATED MISC
BRAND
QL
36 / claim
TRUSTEX RIA NON-LUBRICATED MISC
BRAND
QL
36 / claim
TRUSTEX-NONOXYNOL-9/RIB/STUD MISC
BRAND
QL
36 / claim
PAGE 10
PRODUCT DESCRIPTION
BRAND/GEN
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS, OTHER
*artificial tear ophth ointment***
generic
QL
4 / claim
*white petrolatum-mineral oil ophth ointment***
generic
MPL
1 / claim
HYPOTEARS SOLUTION 1-1 %
BRAND
hypromellose ophth soln 0.4%
generic
QL
ketotifen fumarate ophth soln 0.025% (base equiv)
generic
MPL
polyvinyl alcohol ophth soln 1.4%
generic
QL
tetrahydrozoline hcl ophth soln 0.05%
generic
MPL
generic
QL
cetirizine hcl (tab 5 mg, tab 10 mg)
generic
MDD
cetirizine hcl allergy child solution 5 mg/5ml
generic
15 / claim
1 / claim
15 / claim
1 / 30 days
OTIC AGENTS
carbamide peroxide 6.5% otic soln
15 / 31 days
RESPIRATORY TRACT/PULMONARY AGENTS
ANTIHISTAMINES
1 per day
QL
240 / claim
AL
Up to 12 yrs old
cetirizine hcl chew tab 10 mg
generic
MDD
1 per day
generic
MDD
1 per day
cetirizine hcl tab 10 mg
generic
MDD
1 per day
childrens loratadine syrup 5 mg/5ml
generic
QL
240 / claim
chlorpheniramine maleate syrup 2 mg/5ml
generic
MDD
60 per day
chlorpheniramine maleate tab 4 mg
generic
QL
120 / claim
clemastine fumarate tab 1.34 mg
generic
MDD
2 per day
diphenhydramine hcl cap 25 mg
generic
MDD
4 per day
PAGE 11
PRODUCT DESCRIPTION
BRAND/GEN
generic
MDD
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
fexofenadine hcl tab 180 mg
generic
MDD
1 per day
generic
MDD
2 per day
loratadine allergy relief tab disp 10 mg
generic
loratadine tab 10 mg
generic
generic
4 per day
RESPIRATORY TRACT AGENTS, OTHER
brompheniramine & phenylephrine elixir 1-2.5 mg/5ml
brompheniramine & pseudoephedrine elixir 1-15 mg/5ml
QL
120 / claim
MFL
1 / 30 days
QL
120 / claim
MFL
1 / 30 days
generic
generic
cetirizine-pseudoephedrine tab sr 12hr 5-120 mg
generic
MDD
2 per day
chlorpheniramine & phenylephrine liquid 1-3.5 mg/ml
generic
QL
30 / claim
dextromethorphan polistirex er liquid er 30 mg/5ml
generic
dextromethorphan polistirex extended release susp 30
mg/5ml
generic
dextromethorphan-doxylamine-apap liquid 30-12.5-1000
mg/30ml
generic
dextromethorphan-guaifenesin (liquid 10-200 mg/5ml,
liquid 10-100 mg/5ml, syrup 10-100 mg/5ml)
generic
QL
240 / claim
dextromethorphan-guaifenesin liquid 5-100 mg/5ml
generic
dextromethorphan-phenylephrine-apap cap 10-5-325 mg
generic
DIMETAPP LONG ACT COUGH/COLD SYRUP 1-7.5
MG/5ML
BRAND
QL
240 / claim
ED BRON GP LIQUID 5-100 MG/5ML
BRAND
PAGE 12
PRODUCT DESCRIPTION
BRAND/GEN
guaifenesin liquid 100 mg/5ml
generic
guaifenesin syrup 100 mg/5ml
generic
guaifenesin tab sr 12hr 600 mg
generic
guaifenesin-codeine soln 100-10 mg/5ml
generic
LOHIST-D LIQUID 2-30 MG/5ML
BRAND
loratadine & pseudoephedrine tab sr 12hr 5-120 mg
generic
QL
240 / claim
MFL
1 / 30 days
QL
240 / 6 days
QL
40 / claim
MFL
1 / 30 days
QL
240 / claim
QL
62 / 31 days
MDD
2 per day
1 per day
loratadine & pseudoephedrine tab sr 24hr 10-240 mg
generic
MDD
phenylephrine-dm soln 2.5-5 mg/5ml
generic
QL
240 / claim
pseudoephed-bromphen-dm elixir 15-1-5 mg/5ml
generic
QL
240 / claim
pseudoephed-chlorphen-dm liq 15-1-5 mg/5ml
generic
QL
240 / claim
pseudoephedrine w/ cod-gg soln 30-10-100 mg/5ml
generic
QL
240 / 6 days
pseudoephedrine-ibuprofen tab 30-200 mg
generic
TRIAMINIC COLD/COUGH DAY TIME SYRUP 2.5-5
MG/5ML
BRAND
QL
240 / claim
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
AL
Up to 12 yrs old
calcium carbonate susp 1250 mg/5ml (500 mg/5ml
elemental ca)
generic
QL
500 / 30 days
PAGE 13
PRODUCT DESCRIPTION
BRAND/GEN
FERRETTS TAB 325 (106 FE) MG
BRAND
ferrous fumarate tab 324 mg (106 mg elemental fe)
generic
ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe)
generic
ferrous sulfate tab 325 mg (65 mg elemental fe)
generic
magnesium oxide tab 400 mg (241.3 mg elemental mg)
generic
*pediatric multiple vitamin w/ c & fa chew tab**
MDD
16 per day
generic
MDD
1 per day
*pediatric multiple vitamin w/ c soln 35 mg/ml**
generic
QL
50 / claim
*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
GL
Female
AL
Up to 45 yrs old
*prenatal multivitamins & minerals w/iron & fa tab 0.8 mg***
folic acid (tab 400 mcg, tab 800 mcg)
KPN PRENATAL TAB 0.1 MG
generic
generic
BRAND
MDD
1 per day
MDD
1 per day
GL
Female
AL
Up to 45 yrs old
MDD
MISSION PRENATAL FA TAB
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
MISSION PRENATAL HP TAB
BRAND
BRAND
Female
AL
Up to 45 yrs old
NUTRICION PORVIDA 0.25 MG
Female
AL
Up to 45 yrs old
1 per day
generic
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
PAGE 14
1 per day
GL
MDD
niacin (cap 250 mg, cap 500 mg)
1 per day
GL
MDD
MISSION PRENATAL TAB
1 per day
1 per day
PRODUCT DESCRIPTION
PERRY PRENATAL CAP 13.5-0.4 MG
BRAND/GEN
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
1 per day
POLYCOSE (, LIQUID, POWDER)
BRAND
MPL
1 / 30 days
polysaccharide iron complex cap 150 mg (iron equivalent)
generic
MDD
1 per day
prenatal vit w/ ferrous fumarate-folic acid (w/ tab 27-0.8, w/
tab 28-0.8)
TRI-VI-SOL/IRON SOLUTION 10 MG/ML
PAGE 15
generic
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
1 per day
QL
50 / claim
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
celecoxib cap 400 mg
4 per day
QL
generic
2 per day
62 / 31 days
PA
choline & magnesium salicylates liq 500 mg/5ml
generic
diclofenac potassium tab 50 mg
generic
diclofenac sodium (tab delayed release 25 mg, tab delayed
release 50 mg, tab delayed release 75 mg, tab sr 24hr 100
mg)
generic
diflunisal tab 500 mg
generic
etodolac (cap 200 mg, cap 300 mg, tab 400 mg, tab 500
mg, tab sr 24hr 600 mg, tab sr 24hr 400 mg, tab sr 24hr
500 mg)
generic
flurbiprofen (tab 50 mg, tab 100 mg)
generic
ibuprofen (susp 100 mg/5ml, tab 400 mg, tab 600 mg, tab
800 mg)
generic
indomethacin (cap 25 mg, cap 50 mg, cap cr 75 mg)
generic
ketoprofen (cap 50 mg, cap 75 mg, cap sr 24hr 200 mg)
generic
ketorolac tromethamine tab 10 mg
generic
meloxicam (tab 7.5 mg, tab 15 mg)
generic
nabumetone tab 500 mg
generic
nabumetone tab 750 mg
generic
naproxen (susp 125 mg/5ml, tab 250 mg, tab 375 mg, tab
500 mg, tab ec 375 mg, tab ec 500 mg)
generic
PAGE 16
QL
20 / 30 days
AL
At least 17 yrs old
MDD
2 per day
PRODUCT DESCRIPTION
BRAND/GEN
naproxen sodium (tab 275 mg, tab 550 mg)
generic
oxaprozin tab 600 mg
generic
piroxicam (cap 10 mg, cap 20 mg)
generic
salsalate (tab 500 mg, tab 750 mg)
generic
sulindac (tab 150 mg, tab 200 mg)
generic
tolmetin sodium (cap 400 mg, tab 200 mg, tab 600 mg)
generic
OPIOID ANALGESICS, LONG-ACTING
fentanyl (patch 72hr 25 mcg/hr, patch 72hr 12 mcg/hr,
patch 72hr 100 mcg/hr, patch 72hr 75 mcg/hr, patch 72hr
50 mcg/hr)
generic
MDD
0.33 per day
methadone hcl tab 10 mg
generic
MDD
10 per day
methadone hcl tab 5 mg
generic
MDD
4 per day
morphine sulfate (tab 15 mg, tab 30 mg, tab 60 mg, tab
100 mg, tab 200 mg)
generic
MDD
3 per day
oxycodone hcl (tab er deter 10 mg, tab er deter 20 mg, tab
er deter 40 mg, tab er deter 80 mg)
generic
OXYCONTIN (TB12 DETER 60 MG, TB12 DETER 30 MG,
TB12 DETER 15 MG)
BRAND
PA
MDD
2 per day
PA
MDD
2 per day
OPIOID ANALGESICS, SHORT-ACTING
acetaminophen w/ codeine (w/ tab 300-60 mg, w/ tab 30030 mg, w/ tab 300-15 mg)
generic
MDD
6 per day
acetaminophen w/ codeine soln 120-12 mg/5ml
generic
MDD
30 per day
butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg
generic
MDD
4 per day
butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg
generic
MDD
4 per day
codeine sulfate (tab 15 mg, tab 60 mg)
generic
MDD
2 per day
codeine sulfate tab 30 mg
generic
hydrocodone-acetaminophen (tab 5-500 mg, tab 7.5-325
mg)
generic
MDD
8 per day
PAGE 17
PRODUCT DESCRIPTION
BRAND/GEN
hydrocodone-acetaminophen (tab 7.5-650 mg, tab 7.5-500
mg, tab 10-500 mg, tab 10-660 mg, tab 10-650 mg, tab 10325 mg)
generic
MDD
6 per day
hydrocodone-acetaminophen soln 7.5-325 mg/15ml
generic
MDD
180 per day
hydrocodone-acetaminophen soln 7.5-500 mg/15ml
generic
MDD
120 per day
hydrocodone-acetaminophen tab 5-325 mg
generic
MDD
12 per day
hydrocodone-acetaminophen tab 7.5-750 mg
generic
MDD
5 per day
hydromorphone hcl (tab 2 mg, tab 4 mg, tab 8 mg)
generic
MDD
8 per day
hydromorphone hcl suppos 3 mg
generic
QL
12 / claim
meperidine hcl (tab 50 mg, tab 100 mg)
generic
MDD
6 per day
meperidine hcl oral soln 50 mg/5ml
generic
QL
500 / claim
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 / 30 days
morphine sulfate (suppos 5 mg, suppos 10 mg, suppos 20
mg, suppos 30 mg, tab 30 mg)
generic
QL
24 / claim
morphine sulfate tab 15 mg
generic
MDD
6 per day
oxycodone hcl (cap 5 mg, tab 5 mg, tab 10 mg, tab 15 mg,
tab 20 mg, tab 30 mg)
generic
MDD
6 per day
oxycodone hcl conc 100 mg/5ml (20 mg/ml)
generic
MDD
2 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-aspirin tab 4.8355-325 mg
generic
MDD
6 per day
ROXICET SOLUTION 5-325 MG/5ML
BRAND
tramadol hcl tab 50 mg
generic
MDD
8 per day
tramadol-acetaminophen tab 37.5-325 mg
generic
MDD
4 per day
PAGE 18
PRODUCT DESCRIPTION
BRAND/GEN
ANESTHETICS
LOCAL ANESTHETICS
lidocaine hcl gel 2%
generic
QL
30 / claim
lidocaine hcl viscous soln 2%
generic
QL
100 / claim
lidocaine-prilocaine cream 2.5-2.5%
generic
MPL
1 / claim
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
ALCOHOL DETERRENTS/ANTI-CRAVING
acamprosate calcium tab delayed release 333 mg
generic
disulfiram (tab 250 mg, tab 500 mg)
generic
naltrexone hcl tab 50 mg
generic
VIVITROL RECON SUSP 380 MG
BRAND
OPIOID DEPENDENCE TREATMENTS
BUNAVAIL (FILM 2.1-0.3 MG, FILM 4.2-0.7 MG, FILM 6.31 MG)
BRAND
buprenorphine hcl (sl tab 2 mg, sl tab 8 mg)
generic
buprenorphine hcl-naloxone hcl dihydrate (sl tab 2-0.5 mg,
sl tab 8-2 mg)
generic
SUBOXONE (FILM 2-0.5 MG, FILM 4-1 MG)
BRAND
MDD
1 per day
SUBOXONE (FILM 8-2 MG, FILM 12-3 MG)
BRAND
MDD
2 per day
ZUBSOLV (SL TAB 1.4-0.36 MG, SL TAB 2.9-0.71 MG, SL
TAB 5.7-1.4 MG, SL TAB 8.6-2.1 MG, SL TAB 11.4-2.9
MG)
BRAND
OPIOID REVERSAL AGENTS
EVZIO SOLN A-INJ 0.4 MG/0.4ML
BRAND
naloxone hcl (inj 0.4 mg/ml, inj 1 mg/ml)
generic
NARCAN LIQUID 4 MG/0.1ML
BRAND
PAGE 19
PRODUCT DESCRIPTION
BRAND/GEN
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
MDS
180 / 365 DAYS
MDD
2 per day
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
QL
NICOTROL NS SOLUTION 10 MG/ML
BRAND
504 / 30 days
180 / 365 DAYS
120 / 30 days
MDS
180 ML / 365 DAYS
ANTIBACTERIALS
AMINOGLYCOSIDES
gentamicin sulfate (topical) (cream, oint)
generic
MPL
1 / claim
gentamicin sulfate ophth oint 0.3%
generic
QL
4 / claim
gentamicin sulfate ophth soln 0.3%
generic
MPL
1 / claim
neomycin sulfate tab 500 mg
generic
TOBRADEX OINTMENT 0.3-0.1 %
BRAND
QL
4 / claim
tobramycin ophth soln 0.3%
generic
QL
5 / claim
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
TOBREX OINTMENT 0.3 %
BRAND
QL
PAGE 20
4 / claim
PRODUCT DESCRIPTION
BRAND/GEN
ANTIBACTERIALS, OTHER
*methenamine-hyos-meth blue-sod phos-phen sal tab 81.6
mg***
generic
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)
QL
4 / claim
generic
QL
300 / claim
clindamycin phosphate (topical) (gel, lotion, soln)
generic
MPL
1 / claim
clindamycin phosphate vaginal cream 2%
generic
MPL
1 / claim
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
metronidazole (tab 250 mg, tab 500 mg)
generic
metronidazole cream 0.75 %
generic
QL
45 / claim
metronidazole gel 0.75 %
generic
QL
45 / claim
metronidazole lotion 0.75%
generic
metronidazole vaginal gel 0.75%
generic
QL
45 / claim
mupirocin calcium cream 2%
generic
MPL
mupirocin oint 2%
generic
C
.9: Package
Limit=72/30 days
nitrofurantoin macrocrystal (cap 50 mg, cap 100 mg)
generic
nitrofurantoin monohydrate macrocrystalline cap 100 mg
generic
nitrofurantoin susp 25 mg/5ml
AL
generic
Up to 6 yrs old
MDD
QL
SIVEXTRO TAB 200 MG
BRAND
1 / claim
40 per day
6 / claim
PA
trimethoprim tab 100 mg
PAGE 21
generic
PRODUCT DESCRIPTION
BRAND/GEN
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)
generic
cefadroxil (cap 500 mg, for susp 250 mg/5ml, for susp 500
mg/5ml, tab 1 gm)
generic
cefdinir (susp 125 mg/5ml, susp 250 mg/5ml)
generic
MPL
cefdinir cap 300 mg
generic
QL
20 / claim
cefprozil (tab 250 mg, tab 500 mg)
generic
QL
20 / claim
cefprozil for susp 125 mg/5ml
AL
generic
Up to 12 yrs old
MPL
cefprozil for susp 250 mg/5ml
AL
generic
MPL
QL
CEFTIN RECON SUSP 125 MG/5ML
CEFTIN RECON SUSP 250 MG/5ML
ceftriaxone sodium (inj 1 gm, inj 250 mg, inj 500 mg)
BRAND
BRAND
cephalexin (cap 250 mg, cap 500 mg, for susp 125
mg/5ml, for susp 250 mg/5ml)
generic
PAGE 22
Up to 12 yrs old
1 / claim
100 / claim(s)
AL
Up to 12 yrs old
QL
100 / claim
ST
AL
Up to 12 yrs old
QL
3 / claim
MFL
generic
2 / claim
ST
generic
cefuroxime axetil (tab 250 mg, tab 500 mg)
1 / claim
QL
1 / 30 days
20 / claim
PRODUCT DESCRIPTION
BRAND/GEN
BETA-LACTAM, PENICILLINS
75: Package
100: Package
Limit=2/claim
amoxicillin & k clavulanate for susp 400-57 mg/5ml
generic
C
amoxicillin & k clavulanate for susp 600-42.9 mg/5ml
generic
MPL
amoxicillin & k clavulanate tab 250-125 mg
generic
QL
30 / claim
amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg
generic
QL
40 / 30 days
amoxicillin & pot clavulanate (chew tab 200-28.5 mg, chew
tab 400-57 mg, tab 500-125 mg, tab 875-125 mg)
generic
QL
20 / claim
amoxicillin & pot clavulanate (susp 200-28.5 mg/5ml, susp
250-62.5 mg/5ml)
generic
MPL
amoxicillin (cap 250 mg, cap 500 mg, chew tab 125 mg,
chew tab 250 mg, for susp 125 mg/5ml, for susp 200
mg/5ml, for susp 250 mg/5ml, for susp 400 mg/5ml, tab
875 mg)
generic
ampicillin (cap 250 mg, cap 500 mg)
generic
AMPICILLIN (RECON SUSP 125 MG/5ML, RECON SUSP
250 MG/5ML)
BRAND
dicloxacillin sodium (cap 250 mg, cap 500 mg)
generic
penicillin v potassium (for soln 125 mg/5ml, for soln 250
mg/5ml, tab 250 mg, tab 500 mg)
generic
2 / claim
1 / claim
MACROLIDES
azithromycin for susp 100 mg/5ml
generic
QL
15 / claim
30: Package
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
PAGE 23
PRODUCT DESCRIPTION
BRAND/GEN
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
C
clarithromycin tab sr 24hr 500 mg
generic
QL
14 / claim
E.E.S. 400 TAB 400 MG
BRAND
E.E.S. GRANULES RECON SUSP 200 MG/5ML
BRAND
QL
6 / claim
ERY-TAB (TAB DR 250 MG, TAB DR 333 MG, TAB DR
500 MG)
BRAND
ERYPED 200 RECON SUSP 200 MG/5ML
BRAND
QL
6 / claim
ERYPED 400 RECON SUSP 400 MG/5ML
BRAND
MDD
4 per day
ERYTHROCIN STEARATE TAB 250 MG
BRAND
ERYTHROMYCIN BASE TAB 500 MG
BRAND
ERYTHROMYCIN ETHYLSUCCINATE TAB 400 MG
BRAND
erythromycin gel 2%
generic
MPL
1 / claim
erythromycin ophth oint 5 mg/gm
generic
QL
4 / claim
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
QL
4 / claim
QL
6 / claim
1 / claim
100: Package
Limit=2/claim
QUINOLONES
CILOXAN OINTMENT 0.3 %
BRAND
ciprofloxacin hcl (tab 250 mg, tab 500 mg, tab 750 mg)
generic
ciprofloxacin hcl ophth soln 0.3%
generic
ciprofloxacin hcl tab 100 mg (base equiv)
generic
PAGE 24
PRODUCT DESCRIPTION
BRAND/GEN
levofloxacin (tab 250 mg, tab 500 mg, tab 750 mg)
generic
QL
14 / claim
MDD
1 per day
56 / claim
ofloxacin (tab 200 mg, tab 300 mg, tab 400 mg)
generic
QL
ofloxacin ophth soln 0.3%
generic
MPL
1 / claim
ofloxacin otic soln 0.3%
generic
MPL
1 / claim
VIGAMOX SOLUTION 0.5 %
BRAND
QL
3 / claim
silver sulfadiazine cream 1%
generic
MPL
1 / claim
sulfacetamide sodium ophth oint 10%
generic
QL
4 / claim
sulfacetamide sodium ophth soln 10%
QL
generic
15 / claim
SULFONAMIDES
sulfamethoxazole-trimethoprim (susp 200-40 mg/5ml, tab
400-80 mg, tab 800-160 mg)
MPL
1 / claim
generic
TETRACYCLINES
doxycycline hyclate (cap 50 mg, cap 100 mg, tab 100 mg)
generic
minocycline hcl (cap 50 mg, cap 75 mg, cap 100 mg)
generic
ANTICONVULSANTS
ANTICONVULSANTS, OTHER
levetiracetam (tab 250 mg, tab 500 mg, tab 750 mg)
generic
MDD
4 per day
levetiracetam oral soln 100 mg/ml
generic
MDD
30 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
DEPACON SOLUTION 100 MG/ML
PAGE 25
BRAND
PRODUCT DESCRIPTION
BRAND/GEN
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
AL
Up to 21 yrs old
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
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 (chew tab 100 mg, susp 100 mg/5ml, tab
200 mg, tab sr 12hr 200 mg, tab sr 12hr 400 mg)
generic
CARBATROL (CAP ER 12H 300 MG, CAP ER 12H 100
MG, CAP ER 12H 200 MG)
BRAND
CEREBYX (SOLUTION 100 MG PE/2ML, SOLUTION 500
MG PE/10ML)
BRAND
PAGE 26
PRODUCT DESCRIPTION
BRAND/GEN
DILANTIN CAP 30 MG
BRAND
oxcarbazepine (susp 300 mg/5ml (60 mg/ml), tab 150 mg,
tab 300 mg, tab 600 mg)
generic
PHENYTEK (CAP 200 MG, CAP 300 MG)
BRAND
phenytoin (chew tab 50 mg, susp 125 mg/5ml)
generic
phenytoin sodium extended cap 100 mg
generic
TEGRETOL-XR TAB ER 12H 100 MG
BRAND
ANTIDEMENTIA AGENTS
ANTIDEMENTIA AGENTS, OTHER
ergoloid mesylates tab 1 mg
generic
CHOLINESTERASE INHIBITORS
donepezil hydrochloride (tab 5 mg, tab 10 mg)
generic
MDD
1 per day
galantamine hydrobromide (cap 24hr 8 mg, cap 24hr 24
mg, cap 24hr 16 mg)
generic
MDD
1 per day
galantamine hydrobromide (tab 4 mg, tab 8 mg, tab 12 mg)
generic
MDD
2 per day
galantamine hydrobromide oral soln 4 mg/ml
generic
MDD
6 per day
rivastigmine (patch 24hr 4.6 mg/24hr, patch 24hr 9.5
mg/24hr)
generic
rivastigmine tartrate (cap 1.5 mg, cap 3 mg, cap 4.5 mg,
cap 6 mg)
generic
PA
MDD
1 per day
PA
MDD
2 per day
N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST
memantine hcl (tab 5 mg, tab 10 mg)
generic
MDD
2 per day
memantine hcl tab 5 mg (28) & 10 mg (21) titration pak
generic
MPL
1 / 28 days
generic
MDD
1 per day
ANTIDEPRESSANTS
ANTIDEPRESSANTS, OTHER
bupropion hcl (tab 24hr 150 mg, tab 24hr 300 mg)
PAGE 27
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
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)
generic
MDD
4 per day
perphenazine-amitriptyline 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
1.5 per day
citalopram hydrobromide (tab 10 mg, tab 20 mg, tab 40
mg)
generic
MDD
citalopram hydrobromide oral soln 10 mg/5ml
generic
QL
escitalopram oxalate (tab 5 mg, tab 10 mg, tab 20 mg)
generic
MDD
1 per day
fluoxetine hcl (cap 10 mg, cap 20 mg)
generic
MDD
4 per day
fluoxetine hcl cap 40 mg
generic
AL
MDD
fluoxetine hcl solution 20 mg/5ml
generic
fluoxetine hcl tab 10 mg
generic
At least 7 yrs old
2 per day
AL
Up to 6 yrs old
AL
Up to 12 yrs old
MDD
PAGE 28
240 / 30 days
4 per day
PRODUCT DESCRIPTION
BRAND/GEN
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
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)
MDD
generic
2 per day
MFL
1 / 30 days
paroxetine hcl oral susp 10 mg/5ml (base equiv)
MDD
generic
40 per day
MFL
1 / 30 days
MDD
1.5 per day
MFL
1 / 30 days
MDD
10 per day
MFL
1 / 30 days
MDD
2 per day
MFL
1 / 30 days
sertraline hcl (tab 25 mg, tab 50 mg)
sertraline hcl oral conc 20 mg/ml
sertraline hcl tab 100 mg
generic
generic
generic
trazodone hcl (tab 50 mg, tab 100 mg, tab 150 mg)
generic
trazodone hcl tab 300 mg
generic
MDD
2 per day
venlafaxine hcl (cap 24hr 150 mg, cap 24hr 37.5 mg, cap
24hr 75 mg, tab 24hr 37.5 mg)
generic
MDD
1 per day
venlafaxine hcl (tab 24hr 150 mg, tab 24hr 75 mg)
generic
MDD
2 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
VIIBRYD (TAB 10 MG, TAB 20 MG, TAB 40 MG)
BRAND
PA
MDD
VIIBRYD KIT 10 & 20 & 40 MG
BRAND
1 per day
PA
TRICYCLICS
amitriptyline hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab 75
mg, tab 100 mg, tab 150 mg)
PAGE 29
generic
PRODUCT DESCRIPTION
BRAND/GEN
amoxapine (tab 25 mg, tab 50 mg, tab 100 mg, tab 150
mg)
generic
clomipramine hcl (cap 50 mg, cap 75 mg)
generic
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
nortriptyline hcl (cap 10 mg, cap 25 mg, cap 50 mg, cap 75
mg)
generic
nortriptyline hcl soln 10 mg/5ml
generic
MDD
2 per day
MDD
20 per day
MDD
4 per day
2 per day
ANTIEMETICS
ANTIEMETICS, OTHER
meclizine hcl (tab 12.5 mg, tab 25 mg)
generic
metoclopramide hcl (soln 5 mg/5ml (10 mg/10ml), tab 5
mg, tab 10 mg)
generic
perphenazine (tab 2 mg, tab 4 mg, tab 8 mg, tab 16 mg)
generic
prochlorperazine maleate (tab 5 mg, tab 10 mg)
generic
prochlorperazine suppos 25 mg
generic
EMETOGENIC THERAPY ADJUNCTS
ondansetron hcl (tab 4 mg, tab 8 mg)
generic
MDD
ondansetron hcl oral soln 4 mg/5ml
generic
QL
ondansetron orally disintegrating tab 4 mg
generic
MDD
2 per day
generic
MDD
2 per day
clotrimazole cream 1%
generic
MPL
1 / claim(s)
clotrimazole soln 1%
generic
MPL
1 / claim
50 / claim(s)
ANTIFUNGALS
PAGE 30
PRODUCT DESCRIPTION
BRAND/GEN
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
generic
MDD
1 per day
generic
QL
2 / claim
generic
MDD
2 per day
generic
QL
7 / claim
griseofulvin microsize (susp 125 mg/5ml, tab 500 mg)
generic
griseofulvin ultramicrosize (tab 125 mg, tab 250 mg)
generic
GYNAZOLE-1 CREAM 2 %
BRAND
itraconazole cap 100 mg
generic
PA
MDD
1 per day
1 / claim
ketoconazole cream 2%
generic
MPL
ketoconazole shampoo 2%
generic
QL
120 / claim
MICONAZOLE 3 SUPPOS 200 MG
BRAND
QL
3 / claim
nystatin (topical) (*nystatin topical powder**, nystatin
cream 100000 unit/gm, nystatin oint 100000 unit/gm)
generic
MPL
1 / claim
nystatin susp 100000 unit/ml
generic
QL
nystatin tab 500000 unit
generic
MDD
6 per day
nystatin-triamcinolone (cream unit/gm-%, oint unit/gm-%)
generic
MPL
1 / claim
terbinafine hcl tab 250 mg
generic
QL
MDD
terconazole vaginal (cream 0.4%, cream 0.8%, suppos 80
mg)
120 / claim
90 / 120 days
1 per day
generic
ANTIGOUT AGENTS
allopurinol (tab 100 mg, tab 300 mg)
generic
COLCHICINE TAB 0.6 MG
BRAND
PAGE 31
QL
6 / claim(s)
MFL
1 / 30 days
PRODUCT DESCRIPTION
BRAND/GEN
colchicine w/ probenecid tab 0.5-500 mg
generic
COLCRYS TAB 0.6 MG
BRAND
probenecid tab 500 mg
QL
6 / claim(s)
MFL
1 / 30 days
QL
9 / 30 days
AL
At least 18 yrs old
QL
6 / 30 days
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
QL
2 / 30 days
AL
At least 12 yrs old
QL
6 / 30 days
AL
At least 12 yrs old
QL
6 / 30 days
QL
6 / 30 days
AL
At least 12 yrs old
generic
ANTIMIGRAINE AGENTS
ERGOT ALKALOIDS
CAFERGOT TAB 1-100 MG
BRAND
dihydroergotamine mesylate (inj 1 mg/ml, nasal spray 4
mg/ml)
generic
SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS
naratriptan hcl (tab 1 mg, tab 2.5 mg)
generic
RELPAX (TAB 20 MG, TAB 40 MG)
BRAND
rizatriptan benzoate (tab 5 mg, tab 10 mg)
generic
sumatriptan nasal spray (5 mg/act, 20 mg/act)
generic
sumatriptan succinate (inj 6 mg/0.5ml, solution autoinjector 6 mg/0.5ml, solution cartridge 6 mg/0.5ml)
generic
sumatriptan succinate (tab 25 mg, tab 50 mg, tab 100 mg)
generic
SUMATRIPTAN SUCCINATE SOLN PRSYR 6 MG/0.5ML
zolmitriptan (tab 2.5 mg, tab 5 mg)
BRAND
generic
zolmitriptan (tab 2.5 mg, tab 5 mg)
generic
ZOMIG SOLUTION 5 MG
BRAND
PAGE 32
PRODUCT DESCRIPTION
BRAND/GEN
ANTIMYASTHENIC AGENTS
PARASYMPATHOMIMETICS
pyridostigmine bromide (tab 60 mg, tab cr 180 mg)
generic
ANTIMYCOBACTERIALS
ANTIMYCOBACTERIALS, OTHER
dapsone (tab 25 mg, tab 100 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
MYLERAN TAB 2 MG
BRAND
temozolomide (cap 180 mg, cap 250 mg)
generic
MDD
2 per day
bicalutamide tab 50 mg
generic
MDD
1 per day
flutamide cap 125 mg
generic
ANTIANDROGENS
ANTIESTROGENS/MODIFIERS
FARESTON TAB 60 MG
PAGE 33
BRAND
PRODUCT DESCRIPTION
BRAND/GEN
tamoxifen citrate (tab 10 mg, tab 20 mg)
generic
ANTIMETABOLITES
DROXIA (CAP 200 MG, CAP 300 MG, CAP 400 MG)
BRAND
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
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
COTELLIC TAB 20 MG
BRAND
PA
NINLARO (CAP 2.3 MG, CAP 3 MG, CAP 4 MG)
BRAND
PA
chloroquine phosphate tab 250 mg
generic
QL
60 / 30 days
chloroquine phosphate tab 500 mg
generic
QL
8 / 56 days
COARTEM TAB 20-120 MG
BRAND
QL
24 / claim
hydroxychloroquine sulfate tab 200 mg
generic
mefloquine hcl tab 250 mg
generic
primaquine phosphate tab 26.3 mg (15 mg base)
generic
MOLECULAR TARGET INHIBITORS
ANTIPARASITICS
ANTIPROTOZOALS
PAGE 34
PRODUCT DESCRIPTION
BRAND/GEN
PEDICULICIDES/SCABICIDES
EURAX CREAM 10 %
BRAND
QL
EURAX LOTION 10 %
BRAND
MPL
malathion lotion 0.5%
generic
NATROBA SUSPENSION 0.9 %
QL
generic
SPINOSAD SUSPENSION 0.9 %
BRAND
1 / claim
59 / claim
MFL
2 / 30 days
QL
120 / claim
MFL
2 / 30 days
MPL
1 / claim
BRAND
permethrin cream 5%
60 / claim
QL
120 / claim
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
DOPAMINE AGONISTS
bromocriptine mesylate (cap 5 mg, tab 2.5 mg)
generic
pramipexole dihydrochloride (tab 0.125 mg, tab 0.25 mg,
tab 0.5 mg, tab 0.75 mg, tab 1 mg, tab 1.5 mg)
generic
ropinirole hydrochloride (tab 0.25 mg, tab 3 mg, tab 4 mg)
ropinirole hydrochloride (tab 0.5 mg, tab 1 mg, tab 2 mg,
tab 5 mg)
MDD
3 per day
generic
MDD
6 per day
generic
MDD
3 per day
DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS
carbidopa tab 25 mg
PAGE 35
generic
PRODUCT DESCRIPTION
BRAND/GEN
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 (inj 25 mg/ml, inj 50 mg/2ml)
generic
MDD
12 per day
chlorpromazine hcl (tab 25 mg, tab 50 mg, tab 100 mg, tab
200 mg)
generic
MDD
3 per day
chlorpromazine hcl tab 10 mg
generic
MDD
10 per day
fluphenazine decanoate inj 25 mg/ml
generic
fluphenazine hcl (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
MDD
3 per day
haloperidol (tab 2 mg, tab 5 mg, tab 20 mg)
generic
haloperidol decanoate (soln 50 mg/ml, soln 100 mg/ml)
generic
haloperidol lactate inj 5 mg/ml
generic
MDD
6 per day
haloperidol lactate oral conc 2 mg/ml
generic
loxapine succinate (cap 5 mg, cap 10 mg, cap 25 mg, cap
50 mg)
generic
MDD
4 per day
MOLINDONE HCL (TAB 5 MG, TAB 10 MG, TAB 25 MG)
BRAND
thioridazine hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab 100
mg)
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
PAGE 36
PRODUCT DESCRIPTION
BRAND/GEN
2ND GENERATION/ATYPICAL
aripiprazole (orally disintegrating tab 10 mg, orally
disintegrating tab 15 mg, tab 2 mg, tab 5 mg, tab 10 mg,
tab 15 mg, tab 20 mg, tab 30 mg)
PA
generic
AL
MDD
QL
aripiprazole oral solution 1 mg/ml
olanzapine (tab 5 mg, tab 7.5 mg, tab 10 mg, tab 15 mg,
tab 20 mg)
generic
quetiapine fumarate (tab 100 mg, tab 200 mg, tab 300 mg,
tab 400 mg)
At least 6 yrs old
AL
At least 13 yrs old
MDD
MFL
1 / 30 days
AL
MDD
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
2 per day
At least 5 yrs old
MDD
AL
AL
generic
AL
generic
AL
generic
MDD
PAGE 37
At least 10 yrs old
AL
MDD
risperidone orally disintegrating tab 1 mg
2 per day
From age 18 through
64: Max Fills=1/year
MDD
risperidone orally disintegrating tab 0.5 mg
At least 10 yrs old
C
MDD
At least 13 yrs old
1 per day
generic
generic
1 per day
MDD
AL
quetiapine fumarate (tab 25 mg, tab 50 mg)
750 / 30 days
AL
generic
generic
1 per day
PA
AL
olanzapine tab 2.5 mg
At least 6 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
PRODUCT DESCRIPTION
BRAND/GEN
generic
AL
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 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
At least 18 yrs old
3 per day
At least 18 yrs old
MDD
9 per day
generic
MDD
2 per day
HARVONI TAB 90-400 MG
BRAND
PA
SOVALDI TAB 400 MG
BRAND
PA
ZEPATIER TAB 50-100 MG
BRAND
ANTIVIRALS
ANTI-CYTOMEGALOVIRUS (CMV) AGENTS
valganciclovir hcl (tab 450 mg (base equivalent), tab 450
mg)
ANTI-HEPATITIS C (HCV) AGENTS
PA
MDD
1 per day
ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)
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
STRIBILD TAB 150-150-200-300 MG
BRAND
MDD
1 per day
PAGE 38
PRODUCT DESCRIPTION
BRAND/GEN
TIVICAY TAB 50 MG
BRAND
ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)
ATRIPLA TAB 600-200-300 MG
BRAND
MDD
1 per day
COMPLERA TAB 200-25-300 MG
BRAND
MDD
1 per day
EDURANT TAB 25 MG
BRAND
MDD
1 per day
INTELENCE (TAB 25 MG, TAB 100 MG)
BRAND
MDD
4 per day
INTELENCE TAB 200 MG
BRAND
MDD
2 per day
nevirapine (tab 24hr 400 mg, tab 24hr 100 mg)
generic
MDD
1 per day
nevirapine susp 50 mg/5ml
generic
MDD
40 per day
nevirapine tab 200 mg
generic
MDD
2 per day
ODEFSEY TAB 200-25-25 MG
BRAND
MDD
1 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
MDD
1 per day
didanosine (capsule 125 mg, capsule 200 mg, capsule 250
mg, capsule 400 mg)
generic
MDD
1 per day
EMTRIVA CAP 200 MG
BRAND
MDD
1 per day
EMTRIVA SOLUTION 10 MG/ML
BRAND
MDD
24 per day
EPZICOM TAB 600-300 MG
BRAND
MDD
1 per day
PAGE 39
PRODUCT DESCRIPTION
BRAND/GEN
lamivudine oral soln 10 mg/ml
generic
MDD
30 per day
lamivudine tab 150 mg
generic
MDD
2 per day
lamivudine tab 300 mg
generic
MDD
1 per day
lamivudine-zidovudine tab 150-300 mg
generic
MDD
2 per day
stavudine (cap 15 mg, cap 20 mg, cap 30 mg, cap 40 mg)
generic
MDD
2 per day
stavudine for oral soln 1 mg/ml
generic
MDD
80 per day
TRUVADA TAB 200-300 MG
BRAND
MDD
1 per day
VIDEX (RECON SOLN 2 GM, RECON SOLN 4 GM)
BRAND
MDD
20 per day
VIREAD (TAB 150 MG, TAB 200 MG, TAB 250 MG, TAB
300 MG)
BRAND
MDD
1 per day
VIREAD POWDER 40 MG/GM
BRAND
QL
ZIAGEN SOLUTION 20 MG/ML
BRAND
MDD
30 per day
zidovudine cap 100 mg
generic
MDD
6 per day
zidovudine syrup 10 mg/ml
generic
MDD
60 per day
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
TYBOST TAB 150 MG
BRAND
MDD
1 per day
APTIVUS CAP 250 MG
BRAND
MDD
4 per day
APTIVUS SOLUTION 100 MG/ML
BRAND
MDD
10 per day
CRIXIVAN CAP 200 MG
BRAND
MDD
9 per day
CRIXIVAN CAP 400 MG
BRAND
MDD
6 per day
EVOTAZ TAB 300-150 MG
BRAND
MDD
1 per day
240 / 30 days
ANTI-HIV AGENTS, OTHER
ANTI-HIV AGENTS, PROTEASE INHIBITORS
PAGE 40
PRODUCT DESCRIPTION
BRAND/GEN
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
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
320 / 32 days
ANTI-INFLUENZA AGENTS
AL
RELENZA DISKHALER AER POW BA 5 MG/BLISTER
BRAND
MPL
TAMIFLU (CAP 45 MG, CAP 75 MG)
TAMIFLU CAP 30 MG
10 / 30 days
MFL
1 / 180 days
QL
20 / 30 days
MFL
1 / 180 days
BRAND
BRAND
MFL
PAGE 41
1 / 30 days
QL
BRAND
QL
TAMIFLU RECON SUSP 6 MG/ML
At least 5 yrs old
120 / 30 days
1 / 180 days
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
3 per day
trifluridine ophth soln 1%
generic
QL
8 / claim
valacyclovir hcl tab 1 gm
generic
QL
21 / 21 Days
valacyclovir hcl tab 500 mg
generic
QL
60 / 30 days
ZOVIRAX CREAM 5 %
BRAND
MPL
1 / claim
buspirone hcl (tab 5 mg, tab 7.5 mg, tab 10 mg, tab 15 mg,
tab 30 mg)
generic
MDD
3 per day
meprobamate (tab 200 mg, tab 400 mg)
generic
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
ANXIOLYTICS
ANXIOLYTICS, OTHER
BENZODIAZEPINES
alprazolam (tab 0.25 mg, tab 0.5 mg, tab 1 mg, tab 2 mg)
generic
MDD
4 per day
chlordiazepoxide hcl (cap 5 mg, cap 10 mg, cap 25 mg)
generic
MDD
4 per day
clonazepam (tab 0.5 mg, tab 1 mg, tab 2 mg)
generic
MDD
4 per day
clorazepate dipotassium (tab 3.75 mg, tab 7.5 mg, tab 15
mg)
generic
MDD
3 per day
diazepam (tab 2 mg, tab 5 mg, tab 10 mg)
generic
MDD
4 per day
diazepam oral soln 1 mg/ml
generic
QL
lorazepam (inj 2 mg/ml, tab 0.5 mg, tab 2 mg)
generic
MDD
3 per day
lorazepam tab 1 mg
generic
MDD
4 per day
PAGE 42
500 / claim(s)
PRODUCT DESCRIPTION
BRAND/GEN
oxazepam (cap 10 mg, cap 15 mg, cap 30 mg)
generic
MDD
4 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
AVANDAMET (TAB 2-1000 MG, TAB 2-500 MG, TAB 4500 MG, TAB 4-1000 MG)
BRAND
MDD
2 per day
AVANDARYL (TAB 4-4 MG, TAB 4-2 MG, TAB 4-1 MG,
TAB 8-4 MG, TAB 8-2 MG)
BRAND
MDD
1 per day
AVANDIA (TAB 2 MG, TAB 4 MG, TAB 8 MG)
BRAND
MDD
1 per day
QL
BYDUREON (PEN 2 MG, 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
BRAND
BRAND
4 / 28 days
ST
AL
At least 18 yrs old
QL
2.4 / 30 days
ST
AL
At least 18 yrs old
QL
1.2 / 30 days
ST
AL
At least 18 yrs old
glimepiride (tab 1 mg, tab 2 mg)
generic
MDD
1 per day
glimepiride tab 4 mg
generic
MDD
2 per day
glipizide (tab 5 mg, tab 10 mg, tab sr 24hr 2.5 mg, tab sr
24hr 5 mg, tab sr 24hr 10 mg)
generic
glipizide-metformin hcl (tab 2.5-500 mg, tab 2.5-250 mg,
tab 5-500 mg)
generic
glyburide (tab 1.25 mg, tab 2.5 mg, tab 5 mg)
generic
PAGE 43
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 8 yrs old
2 per day
At least 8 yrs old
1 per day
At least 8 yrs old
MDD
2 per day
metformin hcl (tab 1000 mg, tab sr 24hr 750 mg)
generic
MDD
2 per day
metformin hcl tab 500 mg
generic
MDD
5 per day
metformin hcl tab 850 mg
generic
MDD
3 per day
metformin hcl tab sr 24hr 500 mg
generic
MDD
4 per day
nateglinide (tab 60 mg, tab 120 mg)
generic
MDD
3 per day
ONGLYZA TAB 2.5 MG
BRAND
AL
MDD
AL
ONGLYZA TAB 5 MG
BRAND
At least 8 yrs old
2 per day
At least 8 yrs old
MDD
3 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
AL
TRADJENTA TAB 5 MG
BRAND
MDD
PAGE 44
At least 8 yrs old
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
GLYCEMIC AGENTS
GLUCAGEN HYPOKIT RECON SOLN 1 MG
BRAND
GLUCAGON EMERGENCY KIT 1 MG
BRAND
QL
1 / claim
APIDRA SOLOSTAR SOLN PEN 100 UNIT/ML
BRAND
QL
30 / 30 days
APIDRA SOLUTION 100 UNIT/ML
BRAND
QL
40 / 30 days
HUMALOG KWIKPEN SOLN PEN 100 UNIT/ML
BRAND
QL
30 / 30 days
HUMALOG MIX 50/50 KWIKPEN SUSP PEN (50-50) 100
UNIT/ML
BRAND
QL
30 / 30 days
HUMALOG MIX 50/50 SUSPENSION (50-50) 100
UNIT/ML
BRAND
QL
40 / 30 days
HUMALOG MIX 75/25 KWIKPEN SUSP PEN (75-25) 100
UNIT/ML
BRAND
QL
30 / 30 days
HUMALOG MIX 75/25 SUSPENSION (75-25) 100
UNIT/ML
BRAND
QL
40 / 30 days
HUMALOG SOLN CART 100 UNIT/ML
BRAND
QL
30 / 30 days
HUMALOG SOLUTION 100 UNIT/ML
BRAND
QL
40 / 30 days
HUMULIN 70/30 KWIKPEN SUSP PEN (70-30) 100
UNIT/ML
BRAND
QL
30 / 30 days
HUMULIN 70/30 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
HUMULIN R SOLUTION 100 UNIT/ML
BRAND
QL
40 / 30 days
LANTUS SOLOSTAR SOLN PEN 100 UNIT/ML
BRAND
QL
30 / 30 days
LANTUS SOLUTION 100 UNIT/ML
BRAND
QL
30 / 30 days
INSULINS
PAGE 45
PRODUCT DESCRIPTION
BRAND/GEN
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
QL
30 / 30 days
NOVOLOG 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)
QL
enoxaparin sodium (inj 100 mg/ml, inj 150 mg/ml)
generic
MFL
C
QL
enoxaparin sodium (inj 80 mg/0.8ml, inj 120 mg/0.8ml)
generic
MFL
C
QL
enoxaparin sodium inj 30 mg/0.3ml
generic
MFL
C
QL
enoxaparin sodium inj 300 mg/3ml
generic
MFL
C
PAGE 46
4 per day
14 / 7 days
3 / 180 days
PA required if > 7 days
of therapy
12 / 7 days
3 / 180 days
of therapy
5 / 7 days
3 / 180 days
of therapy
42 / 7 days
3 / 180 days
of therapy
PRODUCT DESCRIPTION
BRAND/GEN
QL
generic
MFL
C
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
QL
6 / 7 days
3 / 180 days
of therapy
9 / 7 days
3 / 180 days
of therapy
35 / 180 days
MDD
1 per day
XARELTO TAB 15 MG
BRAND
MDD
2 per day
XARELTO TAB 20 MG
BRAND
MDD
1 per day
aminocaproic acid syrup 25%
generic
QL
60 / claim
aminocaproic acid tab 500 mg
generic
QL
24 / claim
QL
30 / 5 days
GL
Female
AL
12 to 49 yrs old
COAGULANTS
tranexamic acid tab 650 mg
generic
MFL
1 / month
PLATELET MODIFYING AGENTS
BRILINTA (TAB 60 MG, TAB 90 MG)
BRAND
MDD
2 per day
cilostazol (tab 50 mg, tab 100 mg)
generic
MDD
2 per day
clopidogrel bisulfate tab 75 mg (base equiv)
generic
MDD
1 per day
dipyridamole (tab 25 mg, tab 50 mg, tab 75 mg)
generic
EFFIENT (TAB 5 MG, TAB 10 MG)
BRAND
MDD
1 per day
PAGE 47
PRODUCT DESCRIPTION
BRAND/GEN
CARDIOVASCULAR AGENTS
ALPHA-ADRENERGIC AGONISTS
clonidine hcl (tab 0.1 mg, tab 0.2 mg, tab 0.3 mg)
generic
guanfacine hcl (tab 1 mg, tab 2 mg)
generic
methyldopa (tab 250 mg, tab 500 mg)
generic
midodrine hcl (tab 2.5 mg, tab 5 mg, tab 10 mg)
generic
ALPHA-ADRENERGIC BLOCKING AGENTS
doxazosin mesylate (tab 1 mg, tab 2 mg, tab 4 mg, tab 8
mg)
generic
prazosin hcl (cap 1 mg, cap 2 mg, cap 5 mg)
generic
ANGIOTENSIN II RECEPTOR ANTAGONISTS
irbesartan (tab 75 mg, tab 150 mg, tab 300 mg)
generic
MDD
1 per day
losartan potassium (tab 25 mg, tab 50 mg, tab 100 mg)
generic
MDD
1 per day
valsartan (tab 40 mg, tab 80 mg, tab 160 mg, tab 320 mg)
generic
MDD
1 per day
benazepril hcl (tab 5 mg, tab 10 mg, tab 20 mg)
generic
MDD
1 per day
benazepril hcl tab 40 mg
generic
MDD
2 per day
captopril (tab 12.5 mg, tab 25 mg, tab 50 mg, tab 100 mg)
generic
MDD
3 per day
enalapril maleate (tab 2.5 mg, tab 5 mg, tab 10 mg, tab 20
mg)
generic
MDD
2 per day
EPANED RECON SOLN 1 MG/ML
BRAND
AL
fosinopril sodium (tab 10 mg, tab 20 mg, tab 40 mg)
generic
MDD
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
quinapril hcl (tab 5 mg, tab 10 mg, tab 20 mg, tab 40 mg)
generic
MDD
1 per day
ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS
PAGE 48
Up to 8 yrs old
PRODUCT DESCRIPTION
BRAND/GEN
ramipril (cap 1.25 mg, cap 2.5 mg, cap 5 mg, cap 10 mg)
generic
MDD
2 per day
trandolapril (tab 1 mg, tab 2 mg, tab 4 mg)
generic
MDD
4 per day
ANTIARRHYTHMICS
amiodarone hcl tab 200 mg
generic
disopyramide phosphate (cap 100 mg, cap 150 mg)
generic
flecainide acetate (tab 50 mg, tab 100 mg, tab 150 mg)
generic
mexiletine hcl (cap 150 mg, cap 200 mg, cap 250 mg)
generic
NORPACE CR 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
RYTHMOL SR (CAP ER 12H 225 MG, CAP ER 12H 325
MG, CAP ER 12H 425 MG)
BRAND
sotalol hcl (afib/afl) ((afib/afl) tab 80 mg, (afib/afl) tab 120
mg, (afib/afl) tab 160 mg)
generic
MDD
2 per day
sotalol hcl (tab 80 mg, tab 120 mg, tab 160 mg)
generic
MDD
2 per day
sotalol hcl tab 240 mg
generic
TIKOSYN (CAP 125 MCG, CAP 250 MCG, CAP 500 MCG)
BRAND
BETA-ADRENERGIC BLOCKING AGENTS
acebutolol hcl (cap 200 mg, cap 400 mg)
generic
atenolol (tab 25 mg, tab 50 mg, tab 100 mg)
generic
MDD
2 per day
bisoprolol fumarate (tab 5 mg, tab 10 mg)
generic
MDD
1 per day
carvedilol (tab 3.125 mg, tab 6.25 mg, tab 12.5 mg)
generic
MDD
3 per day
carvedilol tab 25 mg
generic
MDD
4 per day
COREG CR (CAP ER 24H 20 MG, CAP ER 24H 40 MG,
CAP ER 24H 10 MG, CAP ER 24H 80 MG)
BRAND
MDD
1 per day
labetalol hcl tab 100 mg
generic
MDD
3 per day
generic
MDD
6 per day
PAGE 49
PRODUCT DESCRIPTION
BRAND/GEN
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
CALCIUM CHANNEL BLOCKING AGENTS
amlodipine besylate (tab 2.5 mg, tab 5 mg, tab 10 mg)
generic
MDD
1 per day
diltiazem hcl (cap 12hr 90 mg, cap 12hr 120 mg, cap 12hr
60 mg, cap 24hr 240 mg)
generic
MDD
2 per day
diltiazem hcl (cap 24hr 120 mg, cap 24hr 180 mg)
generic
MDD
1 per day
diltiazem hcl (tab 30 mg, tab 60 mg, tab 90 mg, tab 120
mg)
generic
MDD
3 per day
diltiazem hcl coated beads (beads cap 24hr 300 mg, beads
cap 24hr 180 mg, beads cap 24hr 120 mg)
generic
MDD
1 per day
diltiazem hcl coated beads cap sr 24hr 240 mg
generic
MDD
2 per day
diltiazem hcl extended release beads (beads cap 24hr 360
mg, beads cap 24hr 180 mg, beads cap 24hr 300 mg,
beads cap 24hr 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
nifedipine (cap 10 mg, cap 20 mg)
generic
MDD
4 per day
PAGE 50
PRODUCT DESCRIPTION
BRAND/GEN
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 sr 24hr 120 mg, cap sr 24hr 180 mg,
cap sr 24hr 240 mg, tab cr 120 mg, tab cr 180 mg, tab cr
240 mg)
generic
MDD
2 per day
verapamil hcl (tab 40 mg, tab 80 mg, tab 120 mg)
generic
MDD
3 per day
verapamil hcl cap sr 24hr 360 mg
generic
MDD
1 per day
amiloride & hydrochlorothiazide tab 5-50 mg
generic
MDD
1 per day
amlodipine besylate-benazepril hcl (cap 2.5-10 mg, cap 510 mg, cap 5-20 mg, cap 10-20 mg)
generic
MDD
1 per day
atenolol & chlorthalidone (tab 50-25 mg, tab 100-25 mg)
generic
MDD
1 per day
benazepril & hydrochlorothiazide (tab 5-6.25 mg, tab 1012.5 mg, tab 20-12.5 mg, tab 20-25 mg)
generic
MDD
1 per day
bisoprolol & hydrochlorothiazide (tab 5-6.25 mg, tab 106.25 mg)
generic
MDD
1 per day
captopril & hydrochlorothiazide (tab 25-25 mg, tab 25-15
mg, tab 50-25 mg, tab 50-15 mg)
generic
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
CARDIOVASCULAR AGENTS, OTHER
PAGE 51
PRODUCT DESCRIPTION
BRAND/GEN
losartan potassium & hydrochlorothiazide (tab 50-12.5 mg,
tab 100-25 mg, tab 100-12.5 mg)
generic
MDD
1 per day
metoprolol & hydrochlorothiazide (tab 50-25 mg, tab 10025 mg, tab 100-50 mg)
generic
MDD
2 per day
pentoxifylline tab cr 400 mg
generic
propranolol & hydrochlorothiazide (tab 40-25 mg, tab 80-25
mg)
generic
reserpine (tab 0.1 mg, tab 0.25 mg)
generic
spironolactone & hydrochlorothiazide tab 25-25 mg
generic
triamterene & hydrochlorothiazide (cap 37.5-25 mg, tab
37.5-25 mg, tab 75-50 mg)
generic
MDD
1 per day
triamterene & hydrochlorothiazide cap 50-25 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
1 per day
DIURETICS, CARBONIC ANHYDRASE INHIBITORS
acetazolamide (cap sr 12hr 500 mg, tab 125 mg, tab 250
mg)
generic
DIURETICS, LOOP
bumetanide (tab 0.5 mg, tab 1 mg, tab 2 mg)
generic
furosemide (oral soln 8 mg/ml, oral soln 10 mg/ml, tab 20
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
spironolactone (tab 25 mg, tab 50 mg, tab 100 mg)
generic
DIURETICS, POTASSIUM-SPARING
DIURETICS, THIAZIDE
chlorothiazide tab 250 mg
generic
MDD
2 per day
chlorothiazide tab 500 mg
generic
MDD
4 per day
chlorthalidone (tab 25 mg, tab 50 mg)
generic
PAGE 52
PRODUCT DESCRIPTION
BRAND/GEN
hydrochlorothiazide (cap 12.5 mg, tab 25 mg, tab 50 mg)
generic
indapamide (tab 1.25 mg, tab 2.5 mg)
generic
metolazone (tab 2.5 mg, tab 5 mg, tab 10 mg)
generic
DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES
fenofibrate micronized (cap 134 mg, cap 200 mg)
generic
MDD
1 per day
fenofibrate micronized cap 67 mg
generic
MDD
2 per day
fenofibrate tab 160 mg
generic
MDD
1 per day
fenofibrate tab 54 mg
generic
MDD
3 per day
gemfibrozil tab 600 mg
generic
MDD
2 per day
atorvastatin calcium (tab 10 mg, tab 20 mg, tab 40 mg, tab
80 mg)
generic
MDD
1 per day
lovastatin (tab 10 mg, tab 20 mg)
generic
MDD
1 per day
lovastatin tab 40 mg
generic
MDD
2 per day
pravastatin sodium (tab 10 mg, tab 20 mg, tab 40 mg, tab
80 mg)
generic
MDD
1 per day
simvastatin (tab 5 mg, tab 10 mg, tab 20 mg, tab 40 mg)
generic
MDD
1 per day
MDD
2 per day
DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS
DYSLIPIDEMICS, OTHER
cholestyramine (powder 4 gm/dose, powder packets 4 gm)
generic
cholestyramine light (powder 4 gm/dose, powder packets 4
gm)
generic
colestipol hcl granules 5 gm
generic
colestipol hcl tab 1 gm
generic
niacin tab cr 750 mg (antihyperlipidemic)
generic
NIACOR TAB 500 MG
BRAND
VASODILATORS, DIRECT-ACTING ARTERIAL
hydralazine hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab 100
mg)
PAGE 53
generic
PRODUCT DESCRIPTION
BRAND/GEN
minoxidil (tab 2.5 mg, tab 10 mg)
generic
VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS
isosorbide dinitrate (sl tab 2.5 mg, sl tab 5 mg, tab 5 mg,
tab 10 mg, tab 20 mg, tab 30 mg, tab cr 40 mg)
generic
isosorbide mononitrate (tab 10 mg, tab 20 mg)
generic
MDD
2 per day
isosorbide mononitrate (tab 24hr 120 mg, tab 24hr 60 mg,
tab 24hr 30 mg)
generic
MDD
1 per day
NITRO-BID OINTMENT 2 %
BRAND
nitroglycerin (cap cr 2.5 mg, cap cr 6.5 mg, cap cr 9 mg, td
patch 24hr 0.4 mg/hr, td patch 24hr 0.2 mg/hr, td patch
24hr 0.1 mg/hr, td patch 24hr 0.6 mg/hr)
generic
NITROSTAT (SL TAB 0.3 MG, SL TAB 0.4 MG, SL TAB
0.6 MG)
BRAND
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)
PAGE 54
6 to 18 yrs old
1 per day
3 to 18 yrs old
2 per day
6 to 18 yrs old
2 per day
3 to 18 yrs old
3 per day
6 to 18 yrs old
1 per day
PA
BRAND
MDD
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES
dexmethylphenidate hcl (tab 2.5 mg, tab 5 mg, tab 10 mg)
AL
generic
MDD
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 cr 20
mg, tab sa osm 18 mg, tab sa osm 27 mg, tab sa osm 54
mg)
generic
methylphenidate hcl (tab 5 mg, tab 10 mg, tab 20 mg)
generic
AL
MDD
AL
MDD
methylphenidate hcl (tab cr 10 mg, tab sa osm 36 mg)
AL
generic
MDD
AL
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
6 to 18 yrs old
2 per day
6 to 18 yrs old
1 per day
3 to 18 yrs old
3 per day
6 to 18 yrs old
2 per day
6 to 18 yrs old
1 per day
6 to 18 yrs old
MDD
2 per day
CENTRAL NERVOUS SYSTEM, OTHER
BUPAP TAB 50-650 MG
BRAND
butalbital-acetaminophen tab 50-325 mg
generic
butalbital-acetaminophen-caffeine (cap 50-325-40 mg, tab
50-500-40 mg, tab 50-325-40 mg)
generic
MDD
4 per day
butalbital-aspirin-caffeine cap 50-325-40 mg
generic
MDD
4 per day
PHRENILIN FORTE CAP 50-650 MG
BRAND
FIBROMYALGIA AGENTS
duloxetine hcl (cap 20 mg, cap 30 mg, cap 60 mg)
AL
generic
MDD
SAVELLA (TAB 12.5 MG, TAB 25 MG, TAB 50 MG, TAB
100 MG)
PAGE 55
At least 18 yrs old
1 per day
PA
BRAND
MDD
2 per day
PRODUCT DESCRIPTION
BRAND/GEN
SAVELLA TITRATION PACK MISC 12.5 & 25 & 50 MG
BRAND
QL
55 / 365 days
PA
MULTIPLE SCLEROSIS AGENTS
AVONEX KIT 30 MCG
BRAND
PA
AVONEX PEN AUT-IJ KIT 30 MCG/0.5ML
BRAND
PA
AVONEX PREFILLED PREF SY KT 30 MCG/0.5ML
BRAND
PA
COPAXONE SOLN PRSYR 40 MG/ML
BRAND
PA
GILENYA CAP 0.5 MG
BRAND
PA
glatiramer acetate soln prefilled syringe 20 mg/ml
generic
PA
PLEGRIDY (SOLN PEN 125 MCG/0.5ML, SOLN PRSYR
125 MCG/0.5ML)
BRAND
PA
PLEGRIDY STARTER PACK (PACK SOLN PEN 63 94
MCG/0.5ML, PACK SOLN PRSYR 63 94 MCG/0.5ML)
BRAND
PA
TECFIDERA (CAP DR 120 MG, CAP DR 240 MG, MISC
120 & 240 MG)
BRAND
PA
DENTAL AND ORAL AGENTS
chlorhexidine gluconate soln 0.12%
generic
pilocarpine hcl tab 5 mg
generic
MDD
6 per day
sodium fluoride (dental) (cream, gel (0.5% f))
generic
MPL
1 / claim
sodium fluoride rinse 0.2%
generic
stannous fluoride conc 0.63%
generic
1 / claim
DERMATOLOGICAL AGENTS
aluminum chloride soln 20%
generic
MPL
ANALPRAM-HC LOTION 2.5-1 %
BRAND
QL
60 / claim
calcipotriene (cream, soln (50 mcg/ml))
generic
QL
60 / claim
clindamycin phosphate-benzoyl peroxide gel 1-5%
generic
MPL
PAGE 56
1 / 30 days
PRODUCT DESCRIPTION
BRAND/GEN
clotrimazole w/ betamethasone cream 1-0.05%
generic
MPL
clotrimazole w/ betamethasone lotion 1-0.05%
generic
QL
30 / claim
QL
30 / 30 days
ELIDEL CREAM 1 %
BRAND
PA
AL
At least 2 yrs old
QL
10 / claim
40 / claim
EPIFOAM FOAM 1-1 %
BRAND
fluorouracil (topical) (soln 2%, soln 5%)
generic
fluorouracil cream 0.5%
generic
fluorouracil cream 5%
generic
QL
hydrocortisone (topical) (cream 1%, lotion 2.5%, oint 2.5%)
generic
MPL
hydrocortisone cream 2.5%
generic
hydrocortisone oint 1%
generic
QL
MPL
imiquimod cream 5%
generic
1 / claim
QL
1 / claim
60 / 30 days
1 / 30 days
48 / 180 days
PA
isotretinoin (cap 10 mg, cap 20 mg, cap 40 mg)
generic
AL
12 to 22 yrs old
MDD
2 per day
lactic acid (ammonium lactate) cream 12%
generic
MPL
1 / claim
lactic acid (ammonium lactate) lotion 12%
generic
MPL
1 / 31 days
lidocaine hcl cream 3%
generic
MPL
1 / claim
lidocaine oint 5%
generic
MPL
1 / claim
podofilox soln 0.5%
generic
QL
4 / claim
selenium sulfide lotion 2.5%
generic
QL
120 / claim
sulfacetamide sodium liquid 10%
generic
MPL
sulfacetamide sodium lotion 10% (acne)
generic
QL
120 / claim
QL
30 / 30 days
tacrolimus oint 0.03%
generic
PA
AL
PAGE 57
1 / claim
At least 2 yrs old
PRODUCT DESCRIPTION
BRAND/GEN
QL
tacrolimus oint 0.1%
generic
PA
AL
TAZORAC (CREAM 0.05 %, CREAM 0.1 %, GEL 0.05 %,
GEL 0.1 %)
BRAND
tretinoin (cream 0.05%, cream 0.1%)
generic
tretinoin cream 0.025%
tretinoin gel 0.01%
tretinoin gel 0.025%
urea (cream, lotion)
MPL
At least 16 yrs old
1 / claim
QL
20 / 30 days
AL
Up to 21 yrs old
QL
20 / claim
AL
Up to 21 yrs old
QL
15 / 30 days
AL
Up to 21 yrs old
AL
Up to 21 yrs old
generic
generic
generic
generic
30 / 30 days
MPL
1 / 30 days
MPL
1 / claim
MDD
40 per day
ENZYME REPLACEMENT/MODIFIERS
CREON (CP DR PART 3000-9500, CP DR PART 6000,
CP DR PART 12000, CP DR PART 24000, CP DR PART
36000)
BRAND
PANCREAZE (CP DR PART 4200, CP DR PART 10500,
CP DR PART 16800, CP DR PART 21000)
BRAND
pancrelipase (lip-prot-amyl) dr cap 5000-17000-27000 unit
generic
ZENPEP (CP DR PART 3000-10000, CP DR PART 10000,
CP DR PART 15000, CP DR PART 20000, CP DR PART
25000)
BRAND
GASTROINTESTINAL AGENTS
ANTISPASMODICS, GASTROINTESTINAL
dicyclomine hcl (cap 10 mg, tab 20 mg)
generic
dicyclomine hcl oral soln 10 mg/5ml
generic
DONNATAL ELIXIR 16.2 MG/5ML
BRAND
PAGE 58
PRODUCT DESCRIPTION
BRAND/GEN
glycopyrrolate (tab 1 mg, tab 2 mg)
generic
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
MDD
4 per day
GASTROINTESTINAL AGENTS, OTHER
PA
CHOLBAM (CAP 50 MG, CAP 250 MG)
BRAND
MDD
5 per day
diphenoxylate w/ atropine (w/ liq mg/5ml, w/ tab mg)
generic
loperamide hcl cap 2 mg
generic
paregoric 2 mg/5ml
generic
ursodiol cap 300 mg
generic
MDD
3 per day
ursodiol tab 250 mg
generic
MDD
7 per day
MDD
27 per day
HISTAMINE2 (H2) RECEPTOR ANTAGONISTS
cimetidine (tab 200 mg, tab 300 mg, tab 400 mg, tab 800
mg)
generic
cimetidine hcl soln 300 mg/5ml
generic
famotidine (tab 20 mg, tab 40 mg)
generic
ranitidine hcl (cap 150 mg, tab 150 mg, tab 300 mg)
generic
MDD
2 per day
ranitidine hcl cap 300 mg
generic
MDD
1 per day
ranitidine hcl syrup 15 mg/ml (75 mg/5ml)
generic
AL
Up to 6 yrs old
MDD
20 per day
LAXATIVES
lactulose (encephalopathy) solution 10 gm/15ml
generic
lactulose solution 10 gm/15ml
generic
peg 3350-kcl-sod bicarb-nacl for soln 420 gm
generic
MPL
1 / claim
peg 3350-kcl-sod bicarb-sod chloride-sod sulfate (soln 236
gm, soln 236 gm, soln 240 gm)
generic
MPL
1 / claim
PAGE 59
PRODUCT DESCRIPTION
BRAND/GEN
polyethylene glycol 3350 oral packet
generic
polyethylene glycol 3350 oral powder
generic
MDD
34 per day
PROTECTANTS
misoprostol (tab 100 mcg, tab 200 mcg)
generic
sucralfate tab 1 gm
generic
MDD
4 per day
omeprazole (cap 20 mg, cap 40 mg)
generic
MDD
1 per day
pantoprazole sodium ec tab 20 mg (base equiv)
generic
MDD
1 per day
pantoprazole sodium ec tab 40 mg (base equiv)
generic
MDD
2 per day
2 per day
PROTON PUMP INHIBITORS
GENITOURINARY AGENTS
ANTISPASMODICS, URINARY
flavoxate hcl tab 100 mg
generic
oxybutynin chloride (tab 24hr 15 mg, tab 24hr 10 mg, tab
24hr 5 mg)
generic
MDD
oxybutynin chloride syrup 5 mg/5ml
generic
QL
oxybutynin chloride tab 5 mg
generic
MDD
3 per day
tolterodine tartrate (cap 24hr 4 mg, cap 24hr 2 mg)
generic
MDD
1 per day
tolterodine tartrate (tab 1 mg, tab 2 mg)
generic
MDD
2 per day
trospium chloride tab 20 mg
generic
MDD
2 per day
finasteride tab 5 mg
generic
MDD
1 per day
tamsulosin hcl cap 0.4 mg
generic
MDD
2 per day
terazosin hcl (cap 1 mg, cap 2 mg, cap 5 mg, cap 10 mg)
generic
480 / 30 days
BENIGN PROSTATIC HYPERTROPHY AGENTS
GENITOURINARY AGENTS, OTHER
bethanechol chloride (tab 5 mg, tab 10 mg, tab 25 mg, tab
50 mg)
PAGE 60
generic
PRODUCT DESCRIPTION
BRAND/GEN
CUPRIMINE CAP 250 MG
BRAND
ELMIRON CAP 100 MG
BRAND
phenazopyridine hcl (tab 100 mg, tab 200 mg)
generic
pot phos monobasic w/sod phos di & monobas tab 155852-130mg
generic
potassium citrate & citric acid powder pack 3300-1002 mg
generic
potassium citrate (alkalinizer) (tab 5 (540, tab 10 (1080)
generic
sodium chloride irrigation soln 0.9%
generic
sodium citrate & citric acid soln 500-334 mg/5ml
generic
MDD
3 per day
MDD
8 per day
PHOSPHATE BINDERS
calcium acetate (phosphate binder) cap 667 mg (169 mg
ca)
generic
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)
APEXICON E CREAM 0.05 %
BRAND
MPL
1 / claim
betamethasone dipropionate augmented cream 0.05%
generic
MPL
1 / claim
betamethasone valerate (cream, oint)
generic
MPL
1 / claim
betamethasone valerate lotion 0.1%
generic
QL
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
DESOXIMETASONE CREAM 0.05 %
BRAND
MPL
1 / claim(s)
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
PAGE 61
60 / claim
150 / 30 days
1 / claim
PRODUCT DESCRIPTION
BRAND/GEN
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 soln 0.1%
generic
MPL
1 / claim
methylprednisolone (tab 4 mg, tab 8 mg, tab therapy pack
4 mg (21))
generic
MILLIPRED TAB 5 MG
BRAND
mometasone furoate (cream, oint, solution (lotion))
generic
MPL
1 / claim
prednicarbate (cream, oint)
generic
MPL
1 / claim
prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml
base)
generic
prednisolone sod phosphate oral soln 15 mg/5ml (base
equiv)
generic
prednisolone syrup 15 mg/5ml (usp solution equivalent)
generic
prednisone (oral soln 5 mg/5ml, tab 1 mg, tab 2.5 mg, tab 5
mg, tab 10 mg, tab 20 mg, tab 50 mg, tab therapy pack 5
mg (21), tab therapy pack 5 mg (48), tab therapy pack 10
mg (21), tab therapy pack 10 mg (48))
generic
PREDNISONE INTENSOL CONC 5 MG/ML
BRAND
TOPICORT CREAM 0.05 %
QL
240 / claim
BRAND
MPL
1 / claim(s)
triamcinolone acetonide (topical) (cream 0.1%, oint
0.025%, oint 0.1%)
generic
MPL
1 / claim
triamcinolone acetonide (topical) (lotion 0.025%, lotion
0.1%)
generic
triamcinolone acetonide cream 0.025%
PAGE 62
QL
MPL
generic
C
60 / claim
1 / claim
454: Package
15: Package
Limit=2/claim
PRODUCT DESCRIPTION
BRAND/GEN
triamcinolone acetonide cream 0.5%
generic
QL
15 / claim
MPL
1 / claim
triamcinolone acetonide dental paste 0.1%
generic
QL
5 / claim
triamcinolone acetonide oint 0.5%
generic
QL
15 / claim(s)
VERIPRED 20 SOLUTION 20 MG/5ML
BRAND
QL
150 / claim
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)
desmopressin acetate (tab 0.1 mg, tab 0.2 mg)
generic
MDD
3 per day
desmopressin acetate nasal soln 0.01% (refrigerated)
generic
QL
5 / claim
desmopressin acetate nasal spray soln 0.01%
generic
QL
5 / claim
desmopressin acetate nasal spray soln 0.01%
(refrigerated)
generic
QL
5 / claim
NORDITROPIN FLEXPRO (SOLUTION 5 MG/1.5ML,
SOLUTION 10 MG/1.5ML, SOLUTION 15 MG/1.5ML,
SOLUTION 30 MG/3ML)
BRAND
PA
NORDITROPIN NORDIFLEX PEN SOLUTION 30 MG/3ML
BRAND
PA
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)
ANDROGENS
ANDRODERM (PATCH 24HR 4 MG/24HR, PATCH 24HR
2 MG/24HR)
BRAND
ANDROXY TAB 10 MG
BRAND
METHITEST TAB 10 MG
BRAND
testosterone cypionate im inj in oil 200 mg/ml
generic
MDD
1 per day
QL
4 / 30 days
QL
8 / 28 days
GL
Female
GL
Female
ESTROGENS
COMBIPATCH (PATCH TW 0.05-0.14 MG/DAY, PATCH
TW 0.05-0.25 MG/DAY)
BRAND
desogest-eth estrad & eth estrad tab 0.15-0.02/0.01
mg(21/5)
generic
PAGE 63
MDD
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
desogest-ethin est tab 0.1-0.025/0.125-0.025/0.150.025mg-mg
generic
desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg
generic
GL
MDD
GL
MDD
DESOGESTREL-ETHINYL ESTRADIOL TAB 0.150.02/0.01 MG (AZURETTE, KARIVA, PIMTREA,
VIORELE, CAZIANT, CESIA, VELIVET)
BRAND
DESOGESTREL-ETHINYL ESTRADIOL TAB 0.15-30 MGMCG (APRI, EMOQUETTE, ENSKYCE, RECLIPSEN,
SOLIA)
BRAND
drospirenone-ethinyl estradiol tab 3-0.03 mg
generic
GL
MDD
GL
MDD
GL
MDD
Female
1 per day
Female
1 per day
Female
1 per day
Female
1 per day
Female
1 per day
DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG
(GIANVI, LORYNA, NIKKI, VESTURA, OCELLA, SYEDA,
ZARAH)
BRAND
GL
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, tab 10.5 mg)
generic
MDD
estradiol (patch 0.025 mg/24hr, patch 0.0375 mg/24hr
(37.5 mcg/24hr), patch 0.05 mg/24hr, patch 0.06 mg/24hr,
patch 0.075 mg/24hr, patch 0.1 mg/24hr)
generic
estradiol (patch 0.025 mg/24hr, patch 0.0375 mg/24hr,
patch 0.05 mg/24hr, patch 0.075 mg/24hr, patch 0.1
mg/24hr)
generic
MDD
estradiol (tab 0.5 mg, tab 1 mg, tab 2 mg)
generic
GL
Female
estropipate (tab 0.75 mg, tab 1.5 mg)
GL
generic
Female
PAGE 64
43 / claim(s)
1 per day
4 / 28 days
GL
Female
GL
generic
MDD
ETHYNODIOL DIACETATE & ETHINYL ESTRADIOL TAB
1 MG-35 MCG (KELNOR, ZOVIA)
1 per day
QL
MDD
estropipate tab 3 mg
Female
GL
BRAND
MDD
0.29 per day
1 per day
Female
2 per day
Female
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
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)
BRAND
LEVONORGESTREL-ETHINYL ESTRAD TAB 0.15-30 MG
(ALTAVERA, CHATEAL, KURVELO, LEVORA,
MARLISSA, PORTIA)
BRAND
NECON 1/50 (28) TAB 1-50 MG-MCG
BRAND
GL
MDD
1 per day
QL
91 / claim
GL
Female
GL
Female
MDD
GL
MDD
GL
MDD
GL
MDD
GL
NECON 10/11 (28) TAB 35 MCG
BRAND
MDD
NORELGESTROMIN-ETHINYL ESTRADIOL TD PTWK
150-35 MCG/24HR (XULANE)
BRAND
NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.4
MG-35 MCG (BALZIVA, BRIELLYN, GILDAGIA, PHILITH,
VYFEMLA, ZENCHENT)
BRAND
NORETHINDRONE & ETHINYL ESTRADIOL TAB 0.5
MG-35 MCG (NECON, NORTREL, WERA)
BRAND
NORETHINDRONE & ETHINYL ESTRADIOL TAB 1 MG35 MCG (ALYACEN, CYCLAFEM, DASETTA, NECON,
NORTREL, PIRMELLA)
BRAND
NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB 1
MG-20 MCG (GILDESS, JUNEL, LARIN, MICROGESTIN)
BRAND
NORETHINDRONE ACE & ETHINYL ESTRADIOL TAB
1.5 MG-30 MCG (GILDESS, JUNEL, LARIN,
MICROGESTIN)
BRAND
NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE
TAB 1 MG-20 MCG (GILDESS, JUNEL, LARIN,
MICROGESTIN)
BRAND
PAGE 65
Female
1 per day
Female
1 per day
Female
1 per day
Female
1 per day
Female
1 per day
QL
1 / 28 days
GL
Female
GL
Female
MDD
GL
MDD
GL
MDD
GL
MDD
GL
MDD
GL
MDD
1 per day
Female
1 per day
Female
2 per day
Female
1 per day
Female
1 per day
Female
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE
TAB 1.5 MG-30 MCG (GILDESS, JUNEL, LARIN,
MICROGESTIN)
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
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)
BRAND
NORINYL 1+50 (28) TAB 1-50 MG-MCG
BRAND
GL
MDD
GL
MDD
GL
MDD
GL
MDD
GL
MDD
GL
MDD
GL
NUVARING RING 0.12-0.015 MG/24HR
OGESTREL TAB 0.5-50 MG-MCG
PREMPHASE TAB 0.625-5 MG
BRAND
BRAND
ZOVIA 1/50E (28) TAB 1-50 MG-MCG
BRAND
Female
1 per day
Female
1 per day
Female
2 per day
Female
Female
GL
Female
1 per day
Female
1 per day
GL
Female
QL
28 / 28 days
GL
Female
GL
Female
MDD
GL
MDD
PAGE 66
1 per day
GL
MDD
PREMPRO (TAB 0.3-1.5 MG, TAB 0.45-1.5 MG, TAB
0.625-5 MG, TAB 0.625-2.5 MG)
Female
1 / claim
GL
BRAND
1 per day
QL
MDD
PREMARIN CREAM 0.625 MG/GM
Female
1 per day
BRAND
BRAND
1 per day
MDD
BRAND
PREMARIN (TAB 0.3 MG, TAB 0.45 MG, TAB 0.625 MG,
TAB 0.9 MG, TAB 1.25 MG)
Female
1 per day
Female
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
PROGESTERONE AGONISTS/ANTAGONISTS
ELLA TAB 30 MG
BRAND
QL
4 / 365 days
QL
1 / claim
GL
Female
GL
Female
PROGESTINS
DEPO-SUBQ PROVERA 104 SUSPENSION 104
MG/0.65ML
BRAND
generic
generic
MFL
4 / 365 days
QL
1 / 21 Days
GL
Female
MFL
MAKENA OIL 250 MG/ML
BRAND
medroxyprogesterone acetate (tab 2.5 mg, tab 5 mg, tab
10 mg)
generic
medroxyprogesterone acetate im susp 150 mg/ml
generic
4 / 365 days
PA
QL
1 / claim
GL
Female
GL
Female
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
generic
QL
30 / 30 days
progesterone micronized cap 200 mg
generic
QL
20 / 30 days
generic
MDD
MDD
1 per day
SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS
raloxifene hcl tab 60 mg
1 per day
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)
ARMOUR THYROID (TAB 15 MG, TAB 30 MG, TAB 60
MG, TAB 90 MG, TAB 120 MG, TAB 180 MG, TAB 240
MG, TAB 300 MG)
PAGE 67
BRAND
PRODUCT DESCRIPTION
BRAND/GEN
levothyroxine sodium (tab 25 mcg, tab 50 mcg, tab 75 mcg,
tab 88 mcg, tab 100 mcg, tab 112 mcg, tab 125 mcg, tab
137 mcg, tab 150 mcg, tab 175 mcg, tab 200 mcg, tab 300
mcg)
generic
liothyronine sodium (tab 5 mcg, tab 25 mcg, tab 50 mcg)
generic
THYROLAR-1 TAB 60 (12.5-50) MG (MCG)
BRAND
THYROLAR-1/2 TAB 30 (6.25-25) MG (MCG)
BRAND
THYROLAR-1/4 TAB 15 (3.1-12.5) MG (MCG)
BRAND
THYROLAR-2 TAB 120 (25-100) MG (MCG)
BRAND
THYROLAR-3 TAB 180 (37.5-150) MG (MCG)
BRAND
HORMONAL AGENTS, SUPPRESSANT (THYROID)
ANTITHYROID AGENTS
methimazole (tab 5 mg, tab 10 mg)
generic
propylthiouracil tab 50 mg
generic
SSKI SOLUTION 1 GM/ML
BRAND
IMMUNOLOGICAL AGENTS
IMMUNE SUPPRESSANTS
AZASAN (TAB 75 MG, TAB 100 MG)
BRAND
MDD
3 per day
azathioprine tab 50 mg
generic
cyclosporine (cap 25 mg, cap 100 mg)
generic
MDD
4 per day
cyclosporine modified (for microemulsion) (cap 25 mg, cap
50 mg, cap 100 mg)
generic
MDD
4 per day
cyclosporine modified oral soln 100 mg/ml
generic
MDD
8 per day
ENBREL (RECON SOLN 25 MG, SOLN PRSYR 25
MG/0.5ML, SOLN PRSYR 50 MG/ML)
BRAND
PA
ENBREL SURECLICK SOLN A-INJ 50 MG/ML
BRAND
PA
HUMIRA (PREF SY KT 20 MG/0.4ML, PREF SY KT 40
MG/0.8ML)
BRAND
PA
HUMIRA PEDIATRIC CROHNS START PREF SY KT 40
MG/0.8ML
BRAND
PA
PAGE 68
PRODUCT DESCRIPTION
BRAND/GEN
HUMIRA PEN PEN KIT 40 MG/0.8ML
BRAND
PA
HUMIRA PEN-CROHNS STARTER PEN KIT 40
MG/0.8ML
BRAND
PA
HUMIRA PEN-PSORIASIS STARTER PEN KIT 40
MG/0.8ML
BRAND
PA
methotrexate sodium (inj 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
generic
MDD
2 per day
mycophenolate mofetil for oral susp 200 mg/ml
generic
MDD
15 per day
mycophenolate mofetil tab 500 mg
generic
MDD
4 per day
mycophenolate sodium tab dr 180 mg (mycophenolic acid
equiv)
generic
MDD
2 per day
mycophenolate sodium tab dr 360 mg (mycophenolic acid
equiv)
generic
MDD
4 per day
RAPAMUNE SOLUTION 1 MG/ML
BRAND
MDD
4 per day
RHEUMATREX TAB 2.5 MG
BRAND
SANDIMMUNE SOLUTION 100 MG/ML
BRAND
PA
MDD
8 per day
sirolimus tab 0.5 mg
generic
sirolimus tab 1 mg
generic
MDD
6 per day
sirolimus tab 2 mg
generic
MDD
2 per day
tacrolimus (cap 0.5 mg, cap 1 mg, cap 5 mg)
generic
MDD
3 per day
TREXALL (TAB 5 MG, TAB 7.5 MG, TAB 10 MG, TAB 15
MG)
BRAND
IMMUNIZING AGENTS, PASSIVE
HYPERRHO S/D SOLN PRSYR 1500 UNIT
BRAND
RHOGAM ULTRA-FILTERED PLUS SOLN PRSYR 1500
UNIT
BRAND
PAGE 69
PRODUCT DESCRIPTION
BRAND/GEN
IMMUNOMODULATORS
leflunomide (tab 10 mg, tab 20 mg)
generic
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
SFROWASA ENEMA 4 GM/60ML
BRAND
GLUCOCORTICOIDS
hydrocortisone enema 100 mg/60ml
generic
QL
hydrocortisone rectal cream 2.5%
generic
MPL
1 / claim
420 / claim
SULFONAMIDES
sulfasalazine (tab 500 mg, tab delayed release 500 mg)
generic
METABOLIC BONE DISEASE AGENTS
alendronate sodium (tab 35 mg, tab 70 mg)
generic
MDD
0.15 per day
alendronate sodium (tab 5 mg, tab 10 mg, tab 40 mg)
generic
MDD
1 per day
alendronate sodium oral soln 70 mg/75ml
generic
MDD
10.8 per day
calcitonin (salmon) nasal soln 200 unit/act
generic
QL
4 / 30 days
calcitriol (cap 0.25 mcg, cap 0.5 mcg)
generic
MIACALCIN SOLUTION 200 UNIT/ML
BRAND
QL
2 / 30 days
risedronate sodium (tab 5 mg, tab 30 mg)
generic
PA
MDD
PAGE 70
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
risedronate sodium tab 35 mg
generic
QL
4 / 28 days
PA
MISCELLANEOUS THERAPEUTIC AGENTS
*lancet devices***
generic
QL
1 / 180 days
*respiratory therapy supplies - misc**
generic
QL
1 / 360 Days
ACURA CONTROL (SOLUTION HIGH, SOLUTION LOW)
BRAND
QL
1 / 90 days
ADVOCATE CONTROL SOLUTION (SOLUTION LIQUID
HIGH, SOLUTION LIQUID LOW)
BRAND
QL
1 / 90 days
ADVOCATE REDI-CODE+ CONTROL (SOLUTION HIGH,
SOLUTION LOW)
BRAND
QL
1 / 90 days
AEROCHAMBER MINI CHAMBER DEVICE
BRAND
QL
2 / 360 days
AEROCHAMBER MV MISC
BRAND
QL
2 / 360 days
AEROCHAMBER PLUS FLO-VU LARGE MISC
BRAND
QL
2 / 360 days
AEROCHAMBER PLUS FLO-VU MEDIUM MISC
BRAND
QL
2 / 360 days
AEROCHAMBER PLUS FLO-VU MISC
BRAND
QL
2 / 360 days
AEROCHAMBER PLUS FLO-VU SMALL MISC
BRAND
QL
2 / 360 days
AEROCHAMBER PLUS FLO-VU W/MASK MISC
BRAND
QL
2 / 360 days
AEROCHAMBER PLUS FLOW VU MISC
BRAND
QL
2 / 360 days
AEROCHAMBER W/FLOWSIGNAL MISC
BRAND
QL
2 / 360 days
AEROCHAMBER Z-STAT PLUS CHAMBR MISC
BRAND
QL
2 / 360 days
AEROCHAMBER Z-STAT PLUS MISC
BRAND
QL
2 / 360 days
AEROCHAMBER Z-STAT PLUS/LARGE MISC
BRAND
QL
2 / 360 days
AEROCHAMBER Z-STAT PLUS/MEDIUM MISC
BRAND
QL
2 / 360 days
AEROCHAMBER Z-STAT PLUS/SMALL MISC
BRAND
QL
2 / 360 days
AEROVENT PLUS DEVICE
BRAND
QL
2 / 360 days
AGAMATRIX CONTROL SOLUTION HIGH
BRAND
QL
1 / 90 days
PAGE 71
PRODUCT DESCRIPTION
BRAND/GEN
BAYER BREEZE 2 CONTROL (2 LIQUID LOW, 2 LIQUID
HIGH)
BRAND
QL
1 / 90 days
BAYER CONTOUR (LIQUID HIGH, LIQUID LOW)
BRAND
QL
1 / 90 days
BAYER CONTOUR NEXT CONTROL SOLUTION LOW
BRAND
QL
1 / 90 days
BD AUTOSHIELD MISC 29G X 8MM
BRAND
MDD
5 per day
BD INSULIN SYRINGE MICROFINE (MISC 27G 5/8" 1
ML, MISC 28G 1/2" 0.3 ML)
BRAND
MDD
5 per day
BD INSULIN SYRINGE MISC 26G X 1/2" 1 ML
BRAND
MDD
5 per day
BD INSULIN SYRINGE ULTRAFINE MISC 31G X 15/64" 1
ML
BRAND
MDD
5 per day
BD LANCET ULTRAFINE 30G MISC
BRAND
QL
200 / 30 days
BD LANCET ULTRAFINE 33G MISC
BRAND
QL
200 / 30 days
blood glucose calibration (liquid normal***, liquid***)
generic
QL
1 / 90 days
BREATHERITE COLL SPACER ADULT MISC
BRAND
QL
2 / 360 days
BREATHERITE COLL SPACER CHILD MISC
BRAND
QL
2 / 360 days
BREATHERITE COLL SPACER INFANT MISC
BRAND
QL
2 / 360 days
BREATHERITE MISC
BRAND
QL
2 / 360 days
BREATHERITE RIGID SPACER/MASK MISC
BRAND
QL
2 / 360 days
BREATHERITE SPACER NEONATE MISC
BRAND
QL
2 / 360 days
BREATHERITE SPACER SMALL CHILD MISC
BRAND
QL
2 / 360 days
BREATHERITE/LARGE MASK MISC
BRAND
QL
2 / 360 days
BREATHERITE/MEDIUM MASK MISC
BRAND
QL
2 / 360 days
BREATHERITE/SMALL MASK MISC
BRAND
QL
2 / 360 days
CHEK-STIX CONTROL STRIP
BRAND
QL
1 / 30 days
CHEMSTRIP K STRIP
BRAND
QL
1 / 30 days
CLEVER CHOICE GLUCOSE CONTROL (LIQUID HIGH,
LIQUID LOW)
BRAND
QL
1 / 90 days
PAGE 72
PRODUCT DESCRIPTION
BRAND/GEN
COMFORT ASSURED LANCETS 28G MISC
BRAND
QL
200 / 30 days
COMFORT ASSURED LANCETS 33G MISC
BRAND
QL
200 / 30 days
COMPACT SPACE CHAMBER DEVICE
BRAND
QL
2 / 360 days
COMPACT SPACE CHAMBER/LG MASK DEVICE
BRAND
QL
2 / 360 days
COMPACT SPACE CHAMBER/MED MASK DEVICE
BRAND
QL
2 / 360 days
COMPACT SPACE CHAMBER/SM MASK DEVICE
BRAND
QL
2 / 360 days
CVS LANCETS 21G MISC
BRAND
QL
200 / 30 days
CVS LANCETS MICRO THIN 33G MISC
BRAND
QL
200 / 30 days
CVS LANCETS THIN 26G MISC
BRAND
QL
200 / 30 days
CVS LANCETS ULTRA THIN 30G MISC
BRAND
QL
200 / 30 days
CVS ULTRA THIN LANCETS MISC
BRAND
QL
200 / 30 days
DIASTAR EASY TEST II LANCETS MISC
BRAND
QL
200 / 30 days
DIASTAR EASY TEST LANCETS MISC
BRAND
QL
200 / 30 days
DIATRUE CONTROL LEVEL 1 SOLUTION LOW
BRAND
QL
1 / 90 days
DIATRUE CONTROL LEVEL 3 SOLUTION HIGH
BRAND
QL
1 / 90 days
DRUG MART LANCETS THIN 26G MISC
BRAND
QL
200 / 30 days
DRUG MART LANCETS ULTRA THIN MISC
BRAND
QL
200 / 30 days
E-Z JECT LANCET MICRO-THIN 33G MISC
BRAND
QL
200 / 30 days
E-Z JECT LANCET SUPER THIN 30G MISC
BRAND
QL
200 / 30 days
E-Z JECT LANCETS 21G MISC
BRAND
QL
200 / 30 days
E-Z JECT LANCETS MISC
BRAND
QL
200 / 30 days
E-Z JECT LANCETS THIN 26G MISC
BRAND
QL
200 / 30 days
E-Z SPACER DEVICE
BRAND
QL
2 / 360 days
E-Z SPACER THE BODY GUARDS PK DEVICE
BRAND
QL
2 / 360 days
PAGE 73
PRODUCT DESCRIPTION
BRAND/GEN
EASIVENT MASK LARGE MISC
BRAND
QL
2 / 360 days
EASIVENT MASK MEDIUM MISC
BRAND
QL
2 / 360 days
EASIVENT MASK SMALL MISC
BRAND
QL
2 / 360 days
EASIVENT MISC
BRAND
QL
2 / 360 days
EASY PLUS CONTROL (SOLUTION HIGH, SOLUTION
LOW)
BRAND
QL
1 / 90 days
EASY PLUS II CONTROL (SOLUTION HIGH, SOLUTION
LOW)
BRAND
QL
1 / 90 days
EASY STEP CONTROL (SOLUTION HIGH, SOLUTION
LOW)
BRAND
QL
1 / 90 days
EASY TALK CONTROL (SOLUTION HIGH, SOLUTION
LOW)
BRAND
QL
1 / 90 days
EASY TOUCH LANCETS 28G/TWIST MISC
BRAND
QL
200 / 30 days
BRAND
QL
200 / 30 days
BRAND
QL
200 / 30 days
BRAND
QL
200 / 30 days
EASY TRAK CONTROL (SOLUTION HIGH, SOLUTION
LOW)
BRAND
QL
1 / 90 days
EASYGLUCO CONTROL (SOLUTION HIGH, SOLUTION
LOW)
BRAND
QL
1 / 90 days
EASYMAX CONTROL (SOLUTION HIGH, SOLUTION
LOW)
BRAND
QL
1 / 90 days
ECLIPSE CONTROL (LIQUID HIGH, LIQUID LOW)
BRAND
QL
1 / 90 days
ELEMENT CONTROL (LIQUID HIGH, LIQUID LOW)
BRAND
QL
1 / 90 days
ELEMENT PLUS CONTROL (SOLUTION HIGH,
SOLUTION LOW)
BRAND
QL
1 / 90 days
EMBRACE CONTROL SOLUTION LOW
BRAND
QL
1 / 90 days
EMBRACE EVO CONTROL LEVEL 1 LIQUID LOW
BRAND
QL
1 / 90 days
EMBRACE GLUCOSE CONTROL LIQUID HIGH
BRAND
QL
1 / 90 days
PAGE 74
PRODUCT DESCRIPTION
BRAND/GEN
ENVISION CONTROL (SOLUTION HIGH, SOLUTION
LOW)
BRAND
QL
1 / 90 days
EQL COLOR LANCETS 21G MISC
BRAND
QL
200 / 30 days
EQL COLOR LANCETS MICRO 33G MISC
BRAND
QL
200 / 30 days
EQL SUPER THIN LANCETS 30G MISC
BRAND
QL
200 / 30 days
EQL THIN LANCETS 26G MISC
BRAND
QL
200 / 30 days
FINE 30 MISC
BRAND
QL
200 / 30 days
FLEXICHAMBER DEVICE
BRAND
QL
2 / 360 days
FORA CONTROL (SOLUTION HIGH, SOLUTION LOW)
BRAND
QL
1 / 90 days
FORACARE GDH CONTROL (SOLUTION HIGH,
SOLUTION LOW)
BRAND
QL
1 / 90 days
formaldehyde solution 10%
generic
QL
90 / claim
FORTISCARE CONTROL (SOLUTION HIGH, SOLUTION
LOW)
BRAND
QL
1 / 90 days
GLUCOCOM CONTROL LIQUID HIGH
BRAND
QL
1 / 90 days
GLUCOLAB CONTROL (LIQUID HIGH, LIQUID LOW)
BRAND
QL
1 / 90 days
GNP LANCETS 21G MISC
BRAND
QL
200 / 30 days
GNP LANCETS MICRO THIN 33G MISC
BRAND
QL
200 / 30 days
GNP LANCETS MISC
BRAND
QL
200 / 30 days
GNP LANCETS SUPER THIN 30G MISC
BRAND
QL
200 / 30 days
GNP LANCETS THIN 26G MISC
BRAND
QL
200 / 30 days
GNP LANCETS THIN MISC
BRAND
QL
200 / 30 days
GNP MICRO THIN LANCETS 33G MISC
BRAND
QL
200 / 30 days
GNP SUPER THIN LANCETS 30G MISC
BRAND
QL
200 / 30 days
HEALTHWISE LANCETS 30G MISC
BRAND
QL
200 / 30 days
INFINITY CONTROL (SOLUTION HIGH, SOLUTION
LOW)
BRAND
QL
1 / 90 days
PAGE 75
PRODUCT DESCRIPTION
BRAND/GEN
INSPIRACHAMBER/LARGE DEVICE
BRAND
QL
2 / 360 days
INSPIRACHAMBER/MEDIUM DEVICE
BRAND
QL
2 / 360 days
INSPIRACHAMBER/MOUTHPIECE DEVICE
BRAND
QL
2 / 360 days
INSPIRACHAMBER/SMALL DEVICE
BRAND
QL
2 / 360 days
INSPIREASE BAGS MISC
BRAND
QL
3 / 180 days
INSPIREASE MISC
BRAND
QL
2 / 360 days
INSPIREASE MOUTHPIECE MISC
BRAND
QL
1 / 180 Days
INSPIREASE RESERVOIR BAGS MISC
BRAND
QL
3 / 180 days
insulin pen needle 29 g x 12 mm (1/2")
generic
MDD
5 per day
insulin pen needle 29 g x 12.7 mm
generic
MDD
5 per day
insulin pen needle 30 g x 8 mm (1/3" or 5/16")
generic
MDD
5 per day
generic
MDD
5 per day
generic
MDD
5 per day
generic
MDD
5 per day
generic
MDD
5 per day
generic
MDD
5 per day
generic
MDD
5 per day
insulin syringe (disp) u-100 1 ml
generic
MDD
5 per day
INSULIN SYRINGE MISC 29G X 1" 0.3 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 76
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
KETOCARE (, STRIP)
BRAND
QL
1 / 30 days
KETOSTIX STRIP
BRAND
QL
1 / 30 days
KROGER LANCETS 21G MISC
BRAND
QL
200 / 30 days
KROGER LANCETS MICRO THIN 33G MISC
BRAND
QL
200 / 30 days
KROGER LANCETS SUPER THIN MISC
BRAND
QL
200 / 30 days
KROGER LANCETS THIN 26G MISC
BRAND
QL
200 / 30 days
KROGER LANCETS ULTRATHIN 30G MISC
BRAND
QL
200 / 30 days
LANCETS 28G MISC
BRAND
QL
200 / 30 days
LANCETS 30G MISC
BRAND
QL
200 / 30 days
LANCETS MICRO THIN 33G MISC
BRAND
QL
200 / 30 days
LANCETS SUPER THIN 28G MISC
BRAND
QL
200 / 30 days
LANCETS THIN MISC
BRAND
QL
200 / 30 days
LANCETS ULTRA FINE MISC
BRAND
QL
200 / 30 days
LANCETS ULTRA THIN 30G MISC
BRAND
QL
200 / 30 days
PAGE 77
PRODUCT DESCRIPTION
BRAND/GEN
LANCETS ULTRA THIN MISC
BRAND
QL
200 / 30 days
LIBERTY GLUCOSE CONTROL SOLUTION HIGH
BRAND
QL
1 / 90 days
LITEAIRE DEVICE
BRAND
QL
2 / 360 days
MEDICINE SHOPPE LANCETS MISC
BRAND
QL
200 / 30 days
MEDICINE SHOPPE LANCETS THIN MISC
BRAND
QL
200 / 30 days
MEIJER LANCETS MISC
BRAND
QL
200 / 30 days
MEIJER LANCETS THIN MISC
BRAND
QL
200 / 30 days
MEIJER LANCETS UNIVERSAL 30G MISC
BRAND
QL
200 / 30 days
MEIJER LANCETS UNIVERSAL 33G MISC
BRAND
QL
200 / 30 days
MEIJER SUPER THIN LANCETS MISC
BRAND
QL
200 / 30 days
methylergonovine maleate tab 0.2 mg
generic
MICROCHAMBER MISC
BRAND
QL
2 / 360 days
MICROLET LANCETS MISC
BRAND
QL
200 / 30 days
MICROSPACER MISC
BRAND
QL
2 / 360 days
MICROTAINER SAFETY FLOW LANCET MISC
BRAND
QL
200 / 30 days
MONOLET LANCETS MISC
BRAND
QL
200 / 30 days
MONOLET OPD LANCETS MISC
BRAND
QL
200 / 30 days
ONETOUCH VERIO SOLUTION HIGH
BRAND
QL
1 / 90 days
OPTICHAMBER ADVANTAGE MISC
BRAND
QL
2 / 360 days
OPTICHAMBER ADVANTAGE-LG MASK MISC
BRAND
QL
2 / 360 days
OPTICHAMBER ADVANTAGE-MED MASK MISC
BRAND
QL
2 / 360 days
OPTICHAMBER ADVANTAGE-SM MASK MISC
BRAND
QL
2 / 360 days
OPTICHAMBER DIAMOND (DEVICE, MISC)
BRAND
QL
2 / 360 days
OPTICHAMBER DIAMOND-LG MASK DEVICE
BRAND
QL
2 / 360 days
PAGE 78
PRODUCT DESCRIPTION
BRAND/GEN
OPTICHAMBER DIAMOND-MD MASK MISC
BRAND
QL
2 / 360 days
OPTICHAMBER DIAMOND-SM MASK MISC
BRAND
QL
2 / 360 days
OPTIHALER MISC
BRAND
QL
2 / 360 days
ORTHO DIAPHRAGM ALL-FLEX (DIAPHRAGM
DIAPHRAGM 65, DIAPHRAGM DIAPHRAGM 70,
DIAPHRAGM DIAPHRAGM 75, DIAPHRAGM
DIAPHRAGM 80)
BRAND
ORTHO DIAPHRAGM COIL (DIAPHRAGM KIT 100,
DIAPHRAGM KIT 105)
BRAND
QL
1 / 180 Days
ORTHO DIAPHRAGM COIL KIT 50 MM
BRAND
QL
1 / 365 Days
ORTHO DIAPHRAGM FLAT (DIAPHRAGM KIT 55,
DIAPHRAGM KIT 60, DIAPHRAGM KIT 65, DIAPHRAGM
KIT 70, DIAPHRAGM KIT 75, DIAPHRAGM KIT 80,
DIAPHRAGM KIT 85, DIAPHRAGM KIT 90, DIAPHRAGM
KIT 95)
BRAND
QL
1 / 180 Days
POCKET CHAMBER DEVICE
BRAND
QL
2 / 360 days
PREFERRED PLUS LANCETS COLORED MISC
BRAND
QL
200 / 30 days
PREFERRED PLUS LANCETS THIN MISC
BRAND
QL
200 / 30 days
PRESTIGE GLUCOSE CONTROL (LIQUID HIGH, LIQUID
LOW)
BRAND
QL
1 / 90 days
PRODIGY CONTROL SOLUTION (SOLUTION SOLUTION
HIGH, SOLUTION SOLUTION LOW)
BRAND
QL
1 / 90 days
RA E-ZJECT COLOR LANCETS 33G MISC
BRAND
QL
200 / 30 days
RA E-ZJECT LANCETS 28G MISC
BRAND
QL
200 / 30 days
RA E-ZJECT LANCETS THIN 26G MISC
BRAND
QL
200 / 30 days
RA E-ZJECT LANCETS THIN 28G MISC
BRAND
QL
200 / 30 days
RA E-ZJECT LANCETS ULTRA THIN MISC
BRAND
QL
200 / 30 days
RELION LANCETS MICRO-THIN 33G MISC
BRAND
QL
200 / 30 days
RELION LANCETS THIN 26G MISC
BRAND
QL
200 / 30 days
RELION LANCETS ULTRA-THIN 30G MISC
BRAND
QL
200 / 30 days
PAGE 79
PRODUCT DESCRIPTION
BRAND/GEN
RELION ULTRA THIN LANCETS 30G MISC
BRAND
QL
200 / 30 days
RELION ULTRA THIN PLUS LANCETS MISC
BRAND
QL
200 / 30 days
REXALL LANCETS ULTRA THIN 30G MISC
BRAND
QL
200 / 30 days
RIGHTEST GC300 CONTROL LIQUID HIGH
BRAND
QL
1 / 90 days
RITEFLO DEVICE
BRAND
QL
2 / 360 days
SM LANCETS 21G MISC
BRAND
QL
200 / 30 days
SM LANCETS 33G MISC
BRAND
QL
200 / 30 days
SM SUPER THIN LANCETS 30G MISC
BRAND
QL
200 / 30 days
SM THIN LANCETS 26G MISC
BRAND
QL
200 / 30 days
SMART SENSE COLOR LANCETS 33G MISC
BRAND
QL
200 / 30 days
SMART SENSE STANDARD LANCETS MISC
BRAND
QL
200 / 30 days
SMART SENSE SUPER THIN LANCETS MISC
BRAND
QL
200 / 30 days
SMART SENSE THIN LANCETS 26G MISC
BRAND
QL
200 / 30 days
SOLUS V2 CONTROL (SOLUTION HIGH, SOLUTION
LOW)
BRAND
QL
1 / 90 days
SURE COMFORT LANCETS 28G MISC
BRAND
QL
200 / 30 days
SURE COMFORT LANCETS 30G MISC
BRAND
QL
200 / 30 days
SURE EDGE GLUCOSE CONTROL (SOLUTION HIGH,
SOLUTION LOW)
BRAND
QL
1 / 90 days
SURECHEK CONTROL SOLUTION (SOLUTION LIQUID
HIGH, SOLUTION LIQUID LOW)
BRAND
QL
1 / 90 days
SURESTEP PRO HIGH GLUCOSE LIQUID
BRAND
QL
1 / 90 days
SURESTEP PRO LOW GLUCOSE LIQUID
BRAND
QL
1 / 90 days
TECHLITE LANCETS 30G MISC
BRAND
QL
200 / 30 days
TECHLITE LANCETS MISC
BRAND
QL
200 / 30 days
TGT LANCET ALTERNATE SITE MISC
BRAND
QL
200 / 30 days
PAGE 80
PRODUCT DESCRIPTION
BRAND/GEN
TGT LANCET MICRO THIN 33G MISC
BRAND
QL
200 / 30 days
TGT LANCET SUPER THIN 30G MISC
BRAND
QL
200 / 30 days
TGT LANCET THIN 23G MISC
BRAND
QL
200 / 30 days
TGT LANCET THIN 26G MISC
BRAND
QL
200 / 30 days
TGT LANCET ULTRA THIN 28G MISC
BRAND
QL
200 / 30 days
TGT LANCET ULTRA THIN 30G MISC
BRAND
QL
200 / 30 days
QL
TRUE METRIX AIR KIT W/DEVICE
BRAND
1 / 365 Days
MDD
5 per day
5 per day
TRUE METRIX BLOOD GLUCOSE TEST STRIP
BRAND
MDD
TRUE METRIX LEVEL 1 SOLUTION LOW
BRAND
QL
1 / 90 days
TRUE METRIX LEVEL 3 SOLUTION HIGH
BRAND
QL
1 / 90 days
QL
TRUE METRIX METER KIT W/DEVICE
BRAND
1 / 365 Days
MDD
5 per day
TRUEPLUS LANCETS 26G MISC
BRAND
QL
200 / 30 days
BRAND
QL
200 / 30 days
BRAND
QL
200 / 30 days
BRAND
QL
200 / 30 days
TRUEPLUS SAFETY LANCETS 28G MISC
BRAND
QL
200 / 30 days
QL
TRUERESULT BLOOD GLUCOSE KIT W/DEVICE
BRAND
1 / 365 Days
MDD
5 per day
5 per day
TRUETEST TEST STRIP
BRAND
MDD
TRUETRACK GLUCOSE CONTROL LIQUID LOW
BRAND
QL
TRUETRACK TEST STRIP
BRAND
MDD
5 per day
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
UNILET COMFORTOUCH LANCET MISC
BRAND
QL
PAGE 81
1 / 90 days
200 / 30 days
PRODUCT DESCRIPTION
BRAND/GEN
UNILET EXCELITE II MISC
BRAND
QL
200 / 30 days
UNILET EXCELITE MISC
BRAND
QL
200 / 30 days
UNILET G.P. SUPERLITE LANCET MISC
BRAND
QL
200 / 30 days
UNILET GP 28 ULTRA THIN MISC
BRAND
QL
200 / 30 days
UNISTRIP CONTROL (SOLUTION HIGH, SOLUTION
LOW)
BRAND
QL
1 / 90 days
UNIVERSAL 1 LANCETS THIN 26G MISC
BRAND
QL
200 / 30 days
UNIVERSAL 1 LANCETS ULTRA THIN MISC
BRAND
QL
200 / 30 days
VALUE PLUS LANCET STANDARD 21G MISC
BRAND
QL
200 / 30 days
VALVED HOLDING CHAMBER DEVICE
BRAND
QL
2 / 360 days
VISTOGARD PACKET 10 GM
BRAND
VOCAL POINT CONTROL (SOLUTION HIGH, SOLUTION
LOW)
BRAND
QL
1 / 90 days
VORTEX VALVED HOLDING CHAMBER DEVICE
BRAND
QL
2 / 360 days
WALGREENS LANCETS MICRO THIN MISC
BRAND
QL
200 / 30 days
WALGREENS LANCETS MISC
BRAND
QL
200 / 30 days
WALGREENS LANCETS SUPER THIN MISC
BRAND
QL
200 / 30 days
WALGREENS THIN LANCETS MISC
BRAND
QL
200 / 30 days
WALGREENS ULTRA THIN LANCETS MISC
BRAND
QL
200 / 30 days
WATCHHALER DEVICE
BRAND
QL
2 / 360 days
atropine sulfate ophth oint 1%
generic
QL
4 / claim
atropine sulfate ophth soln 1%
generic
MPL
1 / claim
bacitracin-polymyxin b ophth oint
generic
QL
4 / claim
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS, OTHER
PAGE 82
PRODUCT DESCRIPTION
BRAND/GEN
BLEPHAMIDE S.O.P. OINTMENT 10-0.2 %
BRAND
QL
4 / claim
BLEPHAMIDE SUSPENSION 10-0.2 %
BRAND
MPL
1 / claim
cyclopentolate hcl (soln 1%, soln 2%)
generic
MPL
1 / claim
naphazoline hcl ophth soln 0.1%
generic
QL
15 / claim(s)
neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt
op oin
generic
QL
4 / claim
neomycin-polymy-gramicid op sol 1.75-10000-0.025mgunt-mg/ml
generic
QL
10 / claim
neomycin-polymyxin-dexamethasone ophth oint 0.1%
generic
QL
4 / claim
neomycin-polymyxin-dexamethasone ophth susp 0.1%
generic
QL
5 / claim
neomycin-polymyxin-hc ophth susp
generic
QL
8 / claim
phenylephrine hcl ophth soln 2.5%
generic
MPL
1 / claim
polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%
generic
QL
PRED-G SUSPENSION 0.3-1 %
BRAND
MPL
1 / claim
sulfacetamide sodium-prednisolone ophth soln 100.23(0.25)%
generic
MPL
1 / claim
tobramycin-dexamethasone ophth susp 0.3-0.1%
generic
MPL
1 / claim
tropicamide ophth soln 0.5%
generic
QL
tropicamide ophth soln 1%
generic
MPL
1 / claim
QL
5 / claim
10 / claim
15 / claim
OPHTHALMIC ANTI-ALLERGY AGENTS
ALOCRIL SOLUTION 2 %
BRAND
ST
QL
ALOMIDE SOLUTION 0.1 %
BRAND
10 / claim
ST
azelastine hcl ophth soln 0.05%
QL
generic
MPL
cromolyn sodium ophth soln 4%
PAGE 83
generic
QL
6 / claim
1 / 30 days
10 / claim
PRODUCT DESCRIPTION
BRAND/GEN
OPHTHALMIC ANTI-INFLAMMATORIES
dexamethasone sodium phosphate ophth soln 0.1%
generic
QL
5 / claim
diclofenac sodium ophth soln 0.1%
generic
MPL
1 / claim
fluorometholone ophth susp 0.1%
generic
MPL
1 / claim
flurbiprofen sodium ophth soln 0.03%
generic
QL
3 / claim
FML OINTMENT 0.1 %
BRAND
QL
4 / claim
ketorolac tromethamine ophth soln 0.4%
generic
MFL
1 / 30 days
ketorolac tromethamine ophth soln 0.5%
generic
MPL
1 / claim
QL
NEVANAC SUSPENSION 0.1 %
BRAND
3 / claim
PA
PRED MILD SUSPENSION 0.12 %
BRAND
QL
10 / claim
prednisolone acetate ophth susp 1%
generic
MPL
1 / 30 days
PREDNISOLONE SODIUM PHOSPHATE SOLUTION 1 %
BRAND
MPL
1 / 30 days
VEXOL SUSPENSION 1 %
BRAND
MPL
1 / claim
OPHTHALMIC ANTIGLAUCOMA AGENTS
apraclonidine hcl ophth soln 0.5% (base equivalent)
generic
AZOPT SUSPENSION 1 %
BRAND
MPL
1 / claim
betaxolol hcl ophth soln 0.5%
generic
MPL
1 / claim
BETOPTIC-S SUSPENSION 0.25 %
BRAND
MPL
1 / claim
brimonidine tartrate ophth soln 0.2%
generic
MPL
1 / claim
carteolol hcl ophth soln 1%
generic
MFL
1 / 30 days
dorzolamide hcl ophth soln 2%
generic
QL
10 / claim
dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml
generic
QL
10 / claim
IOPIDINE SOLUTION 1 %
BRAND
PAGE 84
PRODUCT DESCRIPTION
BRAND/GEN
levobunolol hcl ophth soln 0.25%
generic
levobunolol hcl ophth soln 0.5%
generic
methazolamide (tab 25 mg, tab 50 mg)
generic
metipranolol ophth soln 0.3%
generic
pilocarpine hcl (soln 1%, soln 2%, soln 4%)
generic
timolol maleate (ophth) (gel forming soln 0.5%, soln 0.25%,
soln 0.5%)
TIMOPTIC OCUDOSE (SOLUTION 0.25 %, SOLUTION
0.5 %)
MPL
1 / claim
generic
MPL
1 / claim
BRAND
MPL
1 / claim
generic
QL
3 / claim
acetic acid otic soln 2%
generic
QL
15 / claim
antipyrine-benzocaine otic soln 54-14 mg/ml (5.4-1.4%)
generic
MPL
1 / claim
CIPRODEX SUSPENSION 0.3-0.1 %
BRAND
QL
8 / claim
fluocinolone acetonide (otic) oil 0.01%
generic
MPL
hydrocortisone w/ acetic acid otic soln 1-2%
generic
QL
10 / claim
neomycin-polymyxin-hc otic soln 1%
generic
QL
10 / claim
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml1%
generic
MPL
1 / claim
pramoxine-hc-chloroxylenol otic soln 10-10-1 mg/ml
generic
MPL
1 / 30 days
AEROSPAN AERO SOLN 80 MCG/ACT
BRAND
QL
8.9 / 30 days
budesonide (inhalation) (susp 0.25 mg/2ml, susp 0.5
mg/2ml)
QL
generic
120 / 30 days
AL
Up to 6 yrs old
budesonide inhalation susp 1 mg/2ml
QL
generic
60 / 30 days
AL
Up to 6 yrs old
OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS
latanoprost ophth soln 0.005%
OTIC AGENTS
1 / 30 days
RESPIRATORY TRACT/PULMONARY AGENTS
ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS
PAGE 85
PRODUCT DESCRIPTION
BRAND/GEN
FLOVENT DISKUS (AER POW BA 100 MCG/BLIST, AER
POW BA 250 MCG/BLIST)
BRAND
MDD
FLOVENT DISKUS AER POW BA 50 MCG/BLIST
BRAND
QL
60 / 25 days
FLOVENT HFA (AEROSOL 110 MCG/ACT, AEROSOL
220 MCG/ACT)
BRAND
QL
12 / 25 days
FLOVENT HFA AEROSOL 44 MCG/ACT
BRAND
QL
11 / 25 Days
flunisolide nasal soln 25 mcg/act (0.025%)
generic
QL
25 / claim
flunisolide nasal soln 29 mcg/act (0.025%)
generic
fluticasone propionate nasal susp 50 mcg/act
generic
QL
16 / claim
PULMICORT FLEXHALER (AER POW BA 90 MCG/ACT,
AER POW BA 180 MCG/ACT)
BRAND
QL
1 / 25 Days
azelastine hcl (0.1% (137 mcg/), 0.15% (205.5 mcg/), 137
mcg/(1 mg/ml))
generic
MPL
1 / 30 days
QL
generic
240 / claim
AL
Up to 12 yrs old
QL
240 / 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
QL
2 / claim
AL
At least 2 yrs old
QL
240 / claim
AL
At least 2 yrs old
2 per day
ANTIHISTAMINES
cyproheptadine hcl (syrup 2 mg/5ml, tab 4 mg)
generic
diphenhydramine hcl elixir 12.5 mg/5ml
generic
hydroxyzine hcl (syrup 10 mg/5ml, tab 10 mg, tab 25 mg,
tab 50 mg)
generic
hydroxyzine pamoate (cap 25 mg, cap 50 mg, cap 100 mg)
generic
promethazine hcl (tab 12.5 mg, tab 25 mg, tab 50 mg)
generic
promethazine hcl suppos 12.5 mg
generic
promethazine hcl suppos 25 mg
promethazine hcl syrup 6.25 mg/5ml
PAGE 86
generic
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
QL
INCRUSE ELLIPTA AER POW BA 62.5 MCG/INH
BRAND
MPL
ipratropium bromide inhal soln 0.02%
generic
QL
375 / 25 days
ipratropium bromide nasal soln 0.03% (21 mcg/spray)
generic
QL
30 / 25 days
ipratropium bromide nasal soln 0.06% (42 mcg/spray)
generic
QL
15 / 30 days
TUDORZA PRESSAIR AER POW BA 400 MCG/ACT
BRAND
MPL
ADRENACLICK (SOLN A-INJ 0.15 MG/0.15ML, SOLN AINJ 0.3 MG/0.3ML)
BRAND
QL
2 / 30 days
albuterol sulfate (soln nebu 0.63 mg/3ml, soln nebu 1.25
mg/3ml)
generic
QL
375 / 30 days
albuterol sulfate (syrup 2 mg/5ml, tab 2 mg, tab 4 mg, tab
sr 12hr 4 mg, tab sr 12hr 8 mg)
generic
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)
generic
QL
375 / 25 days
albuterol sulfate soln nebu 0.5% (5 mg/ml)
generic
MDD
EPINEPHRINE (SOLN A-INJ 0.15 MG/0.15ML, SOLN AINJ 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
FORADIL AEROLIZER CAP 12 MCG
BRAND
MDD
2 per day
metaproterenol sulfate (tab 10 mg, tab 20 mg)
generic
metaproterenol sulfate syrup 10 mg/5ml
generic
MDD
30 per day
SEREVENT DISKUS AER POW BA 50 MCG/DOSE
BRAND
MDD
2 per day
BRONCHODILATORS, ANTICHOLINERGIC
26 / 30 days
1 / 30 days
1 / month
BRONCHODILATORS, SYMPATHOMIMETIC
PAGE 87
2 per day
PRODUCT DESCRIPTION
BRAND/GEN
terbutaline sulfate (tab 2.5 mg, tab 5 mg)
generic
VENTOLIN HFA AERO SOLN 108 (90 BASE) MCG/ACT
BRAND
MPL
KALYDECO (PACKET 50 MG, PACKET 75 MG, TAB 150
MG)
BRAND
PA
ORKAMBI TAB 200-125 MG
BRAND
PA
tobramycin nebu soln 300 mg/5ml
generic
PA
2 / 30 days
CYSTIC FIBROSIS AGENTS
PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE
aminophylline (tab 100 mg, tab 200 mg)
generic
caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv)
generic
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
MFL
2 / lifetime
QL
475 / claim
AL
At least 10 yrs old
QL
30 / 30 days
AL
At least 10 yrs old
RESPIRATORY TRACT AGENTS, OTHER
acetylcysteine (soln 10%, soln 20%)
generic
benzonatate cap 100 mg
generic
benzonatate cap 200 mg
generic
MFL
AL
BREO ELLIPTA AER POW BA 200-25 MCG/INH
BRAND
1 / 30 days
At least 18 yrs old
MPL
1 / claim(s)
COMBIVENT RESPIMAT AERO SOLN 20-100 MCG/ACT
BRAND
QL
4 / 30 days
cromolyn sodium soln nebu 20 mg/2ml
generic
QL
240 / 30 days
DULERA (AEROSOL 100-5 MCG/ACT, AEROSOL 200-5
MCG/ACT)
BRAND
QL
13 / claim
PAGE 88
PRODUCT DESCRIPTION
BRAND/GEN
hydrocodone w/ homatropine syrup 5-1.5 mg/5ml
generic
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml
generic
phenylephrine-promethazine w/ codeine syrup 5-6.25-10
mg/5ml
generic
promethazine & phenylephrine syrup 6.25-5 mg/5ml
generic
promethazine w/ codeine syrup 6.25-10 mg/5ml
promethazine-dm syrup 6.25-15 mg/5ml
MDD
12 per day
QL
240 / claim
AL
At least 2 yrs old
QL
240 / claim
AL
At least 2 yrs old
QL
240 / claim
AL
At least 2 yrs old
QL
240 / claim
AL
At least 2 yrs old
QL
240 / claim
QL
11 / claim
MDD
3 per day
generic
generic
pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml
generic
sodium chloride soln nebu 0.9%
generic
SYMBICORT (AEROSOL 80-4.5 MCG/ACT, AEROSOL
160-4.5 MCG/ACT)
BRAND
SKELETAL MUSCLE RELAXANTS
chlorzoxazone tab 500 mg
generic
cyclobenzaprine hcl (tab 5 mg, tab 10 mg)
generic
methocarbamol (tab 500 mg, tab 750 mg)
generic
SLEEP DISORDER AGENTS
GABA RECEPTOR MODULATORS
temazepam (cap 15 mg, cap 30 mg)
generic
MDD
1 per day
triazolam (tab 0.125 mg, tab 0.25 mg)
generic
MDD
1 per day
zaleplon (cap 5 mg, cap 10 mg)
generic
zolpidem tartrate (tab 5 mg, tab 10 mg)
PAGE 89
AL
generic
At least 18 yrs old
MDD
1 per day
MDD
1 per day
PRODUCT DESCRIPTION
BRAND/GEN
SLEEP DISORDERS, OTHER
flurazepam hcl (cap 15 mg, cap 30 mg)
generic
MDD
*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
1 per day
THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES
ELECTROLYTE/MINERAL MODIFIERS
454 / claim
PA
ELECTROLYTE/MINERAL REPLACEMENT
KLOR-CON M15 TAB ER 15 MEQ
BRAND
KLOR-CON PACKET 25 MEQ
BRAND
potassium bicarbonate effer tab 25 meq
generic
potassium chloride (cap cr 10 meq, oral soln 10% (20
meq/15ml), oral soln 20% (40 meq/15ml), powder packet
20 meq, tab cr 8 meq (600 mg), tab cr 10 meq)
generic
potassium chloride cap cr 8 meq
generic
potassium chloride microencapsulated crystals cr
(mioencapsulated ys tab 10, mioencapsulated ys tab 20)
generic
sodium fluoride (chew tab 0.25 mg f (from 0.55 mg, chew
tab 0.5 mg f (from 1.1 mg, chew tab 1 mg f (from 2.2 mg,
soln 0.125 mg/drop f (0.275 mg/drop, soln 0.5 mg/ml f
(from 1.1 mg/ml)
generic
*multiple vitamins w/ minerals tab**
generic
*pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/ml**
generic
*pediatric multiple vitamins w/ fluoride chew tab 1 mg***
b-complex w/ c & folic acid (w/ ap 1, w/ tab 1)
PAGE 90
MDD
1 per day
MDD
1 per day
QL
50 / claim
AL
Up to 13 yrs old
QL
30 / 30 days
AL
Up to 13 yrs old
generic
generic
MDD
1 per day
PRODUCT DESCRIPTION
CAVAN PRENATAL/EC CALCIUM TAB DR 28-1 MG
BRAND/GEN
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
CO-NATAL FA TAB
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
COMPLETE-RF PRENATAL TAB 90-1 MG
BRAND
BRAND
Female
AL
Up to 45 yrs old
generic
ergocalciferol cap 50000 unit
generic
folic acid tab 1 mg
generic
GESTICARE TAB DR 28-1 MG
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
BRAND
1 per day
GL
Female
AL
Up to 45 yrs old
MDD
INATAL ULTRA TAB
1 per day
GL
MDD
INATAL ADVANCE TAB
1 per day
GL
MDD
cyanocobalamin inj 1000 mcg/ml
1 per day
GL
MDD
COMPLETENATE CHEW TAB 29-1 MG
1 per day
1 per day
GL
Female
AL
Up to 45 yrs old
MDD
1 per day
levocarnitine oral soln 1 gm/10ml (10%)
generic
MDD
30 per day
levocarnitine tab 330 mg
generic
MDD
3 per day
MEPHYTON TAB 5 MG
BRAND
MYNATAL CAP
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
PAGE 91
1 per day
PRODUCT DESCRIPTION
MYNATE 90 PLUS TAB ER
BRAND/GEN
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
NATALVIT TAB
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
NIVA-PLUS TAB 27-1 MG
BRAND
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
Female
AL
Up to 45 yrs old
AL
generic
pediatric multivitamins w/fl (w/ soln 0.25 mg/ml***, w/ soln
0.5 mg/ml***)
generic
pediatric vitamins acd w/ fluoride (w/ soln 0.25 mg/ml***, w/
soln 0.5 mg/ml***)
generic
PNV FE FUM/DOCUSATE/FOLIC ACID TAB 29-1 MG
BRAND
BRAND
BRAND
QL
50 / claim
AL
Up to 13 yrs old
QL
50 / claim
AL
Up to 13 yrs old
GL
Female
AL
Up to 45 yrs old
1 per day
GL
Female
AL
Up to 45 yrs old
1 per day
GL
Female
AL
Up to 45 yrs old
MDD
PAGE 92
Up to 13 yrs old
1 per day
MDD
PNV PRENATAL PLUS MULTIVITAMIN TAB 27-1 MG
1 per day
MDD
MDD
PNV FOLIC ACID + IRON TAB 27-1 MG
1 per day
GL
MDD
pediatric multivitamins w/fl (w/ chew tab 0.25, w/ chew tab
0.5)
1 per day
GL
MDD
O-CAL PRENATAL TAB
1 per day
GL
MDD
O-CAL FA TAB 27-1 MG
1 per day
1 per day
PRODUCT DESCRIPTION
PNV TABS 29-1 TAB 29-1 MG
BRAND/GEN
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
POLY-VITAMIN/FLUORIDE/IRON SOLUTION 0.5-10
MG/ML
PRENAFIRST TAB 17-1 MG
QL
50 / claim(s)
AL
Up to 13 yrs old
GL
Female
AL
Up to 45 yrs old
BRAND
BRAND
MDD
PRENATABS FA TAB
BRAND
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
1 per day
GL
Female
AL
Up to 45 yrs old
MDD
PAGE 93
1 per day
GL
MDD
SE-NATAL 19 (19 TAB MG, 19 CHEW TAB MG)
1 per day
GL
MDD
PRETAB TAB 29-1 MG
1 per day
GL
MDD
PREPLUS TAB 27-1 MG
1 per day
GL
MDD
PRENATAL VITAMINS PLUS TAB 27-1 MG
1 per day
GL
MDD
PRENATAL PLUS TAB 27-1 MG
1 per day
GL
MDD
PRENATAL PLUS IRON TAB 29-1 MG
1 per day
1 per day
PRODUCT DESCRIPTION
SE-NATAL 90 TAB ER 90-1 MG
BRAND/GEN
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
TRI-VIT/FLUORIDE/IRON SOLUTION 0.25-10 MG/ML
TRIADVANCE TAB 90-1 MG
QL
50 / claim(s)
AL
Up to 13 yrs old
GL
Female
AL
Up to 45 yrs old
BRAND
BRAND
MDD
TRICARE TAB
BRAND
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
BRAND
Female
AL
Up to 45 yrs old
1 per day
GL
Female
AL
Up to 45 yrs old
MDD
PAGE 94
1 per day
GL
MDD
VIRT-ADVANCE TAB 90-1 MG
1 per day
GL
MDD
VINATE M TAB 27-1 MG
1 per day
GL
MDD
VINATE CALCIUM TAB 27-1 MG
1 per day
GL
MDD
VENATAL-FA TAB 29-1 MG
1 per day
GL
MDD
TRINATAL RX 1 TAB 60-1 MG
1 per day
GL
MDD
TRINATAL GT TAB 90-1 MG
1 per day
1 per day
PRODUCT DESCRIPTION
VITAFOL-OB TAB
BRAND/GEN
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
VITASPIRE TAB 29-1 MG
BRAND
GL
Female
AL
Up to 45 yrs old
MDD
VOL-PLUS TAB 27-1 MG
BRAND
BRAND
1 per day
GL
Female
AL
Up to 45 yrs old
MDD
VOL-TAB RX TAB 29-1 MG
1 per day
1 per day
GL
Female
AL
Up to 45 yrs old
MDD
1 per day
ANTISPASTICITY AGENTS
baclofen (tab 10 mg, tab 20 mg)
generic
tizanidine hcl (tab 2 mg, tab 4 mg (base equivalent), tab 4
mg)
generic
PAGE 95
Index of covered drugs
A
ALKERAN
33
allopurinol
31
abacavir sulfate
39
ALOCRIL
83
abacavir sulfate-lamivudine-zidovudine
39
ALOMIDE
83
acamprosate calcium
19
alprazolam
42
acebutolol hcl
49
alum & mag hydrox-simethicone
acetaminophen
4,8
aluminum chloride
acetaminophen w/ codeine
17
aluminum hydroxide gel
acetazolamide
52
amantadine hcl
35
acetic acid (otic)
85
amiloride & hydrochlorothiazide
51
acetylcysteine
88
amiloride hcl
52
6
56
6
ACNE MEDICATION
5
aminocaproic acid
47
ACNE MEDICATION 10
4
aminophylline
88
ACNE MEDICATION 5
5
amiodarone hcl
49
ACURA CONTROL
71
amitriptyline hcl
29
acyclovir
42
amlodipine besylate
50
acyclovir topical
42
amlodipine besylate-benazepril hcl
51
ADRENACLICK
87
amoxapine
30
ADVOCATE CONTROL SOLUTION
71
amoxicillin
23
ADVOCATE REDI-CODE+ CONTROL
71
amoxicillin & pot clavulanate
23
AEROCHAMBER MINI CHAMBER
71
amphetamine-dextroamphetamine
54
AEROCHAMBER MV
71
ampicillin
23
AEROCHAMBER PLUS FLO-VU
71
AMPICILLIN
23
AEROCHAMBER PLUS FLO-VU LARGE
71
ANALPRAM-HC
56
AEROCHAMBER PLUS FLO-VU MEDIUM
71
anastrozole
34
AEROCHAMBER PLUS FLO-VU SMALL
71
ANDRODERM
63
AEROCHAMBER PLUS FLO-VU W/MASK
71
ANDROXY
63
AEROCHAMBER PLUS FLOW VU
71
antipyrine-benzocaine
85
AEROCHAMBER W/FLOWSIGNAL
71
APEXICON E
61
AEROCHAMBER Z-STAT PLUS
71
APIDRA
45
AEROCHAMBER Z-STAT PLUS CHAMBR
71
APIDRA SOLOSTAR
45
AEROCHAMBER Z-STAT PLUS/LARGE
71
apraclonidine hcl
84
AEROCHAMBER Z-STAT PLUS/MEDIUM
71
APTIVUS
40
AEROCHAMBER Z-STAT PLUS/SMALL
71
ARIAL CHAMBER
AEROSPAN
85
aripiprazole
37
AEROVENT PLUS
71
ARMOUR THYROID
67
AGAMATRIX CONTROL
71
artificial tear ointment
11
AIMSCO LUBRICATED
8
ASACOL
70
albuterol sulfate
alcohol swabs
alendronate sodium
PAGE 96
87
8
70
8
aspirin
3
aspirin buffered (cal carb-mag carb-mag oxide)
3
aspirin tab chew 81 mg
3
atenolol
49
benzoyl peroxide
atenolol & chlorthalidone
51
benztropine mesylate
35
atorvastatin calcium
53
betamethasone dipropionate augmented
61
ATRIPLA
39
betamethasone valerate
61
atropine sulfate (ophthalmic)
82
betaxolol hcl (ophth)
84
ATROVENT HFA
87
bethanechol chloride
60
AVANDAMET
43
BETOPTIC-S
84
AVANDARYL
43
bicalutamide
33
AVANDIA
43
bisacodyl ec tab dr 5 mg
7
AVONEX
56
bisacodyl laxative suppos 10 mg
7
AVONEX PEN
56
bismuth subsalicylate
6
AVONEX PREFILLED
56
bisoprolol & hydrochlorothiazide
51
AZASAN
68
bisoprolol fumarate
49
azathioprine
68
BLEPHAMIDE
83
azelastine hcl
86
BLEPHAMIDE S.O.P.
83
azelastine hcl (ophth)
83
blood glucose calibration
72
BREATHERITE
72
BREATHERITE COLL SPACER ADULT
72
BREATHERITE COLL SPACER CHILD
72
BREATHERITE COLL SPACER INFANT
72
azithromycin
AZOPT
23,24
84
B
5
b-complex w/ c & folic acid
90
BREATHERITE RIGID SPACER/MASK
72
bacitracin (ophthalmic)
21
BREATHERITE SPACER NEONATE
72
bacitracin (topical)
5
BREATHERITE SPACER SMALL CHILD
72
bacitracin zinc
5
BREATHERITE/LARGE MASK
72
bacitracin-polymyxin b (ophth)
82
BREATHERITE/MEDIUM MASK
72
baclofen
95
BREATHERITE/SMALL MASK
72
BACTROBAN NASAL
21
BREO ELLIPTA
88
balsalazide disodium
70
BRILINTA
47
BAYER BREEZE 2 CONTROL
72
brimonidine tartrate
84
BAYER CONTOUR
72
BRINTELLIX
28
BAYER CONTOUR NEXT CONTROL
72
bromocriptine mesylate
35
BD AUTOSHIELD
72
brompheniramine & phenyleph
12
4
brompheniramine & pseudoeph
12
BD GLUCOSE
BD INSULIN SYRINGE
72
budesonide (inhalation)
85
BD INSULIN SYRINGE MICROFINE
72
bumetanide
52
BD INSULIN SYRINGE ULTRAFINE
72
BUNAVAIL
19
BD LANCET ULTRAFINE 30G
72
BUPAP
55
BD LANCET ULTRAFINE 33G
72
buprenorphine hcl
19
benazepril & hydrochlorothiazide
51
buprenorphine hcl-naloxone hcl dihydrate
19
benazepril hcl
48
bupropion hcl
benzonatate
88
bupropion hcl (smoking deterrent)
PAGE 97
27,28
20
28
celecoxib
16
28
cephalexin
22
buspirone hcl
42
CEREBYX
26
butalbital-acetaminophen
55
cetirizine hcl
11
butalbital-acetaminophen-caffeine
55
butalbital-acetaminophen-caffeine w/ codeine
17
11
11
butalbital-aspirin-caffeine
16,55
11,86
butalbital-aspirin-caffeine w/cod
17
cetirizine hcl tab 10 mg
11
BYDUREON
43
cetirizine-pseudoephedrine
12
BYETTA 10 MCG PEN
43
CHANTIX
20
BYETTA 5 MCG PEN
43
CHANTIX CONTINUING MONTH PAK
20
CHANTIX STARTING MONTH PAK
20
CHEK-STIX CONTROL
72
C
CAFERGOT
32
CHEMET
90
caffeine citrate
88
CHEMSTRIP K
72
calcipotriene
56
childrens loratadine syrup 5 mg/5ml
11
calcitonin (salmon)
70
chlordiazepoxide hcl
42
calcitriol
70
chlorhexidine gluconate
calcium acetate (phosphate binder)
61
chlorhexidine gluconate (mouth-throat)
56
calcium carbonate
13
chloroquine phosphate
34
8
calcium carbonate (antacid)
6
chlorothiazide
52
calcium polycarbophil
7
chlorpheniramine & phenylephrine
12
camphor & menthol
5
chlorpheniramine maleate
11
capsaicin
5
chlorpheniramine maleate tab 4 mg
11
captopril
48
chlorpromazine hcl
36
captopril & hydrochlorothiazide
51
chlorthalidone
52
carbamazepine
26
chlorzoxazone
89
carbamide peroxide (otic)
11
CHOLBAM
59
CARBATROL
26
cholestyramine
53
carbidopa
35
cholestyramine light
53
carbidopa-levodopa
36
choline & mag salicylate
16
carteolol hcl (ophth)
84
cilostazol
47
carvedilol
49
CILOXAN
24
CAVAN PRENATAL/EC CALCIUM
91
cimetidine
6,59
cefaclor
22
cimetidine hcl
59
cefadroxil
22
CIPRODEX
85
cefdinir
22
ciprofloxacin hcl
24
cefprozil
22
ciprofloxacin hcl (ophth)
24
CEFTIN
22
citalopram hydrobromide
28
ceftriaxone sodium
22
clarithromycin
24
cefuroxime axetil
22
clemastine fumarate tab 1.34 mg
11
PAGE 98
CLEVER CHOICE GLUCOSE CONTROL
72
CREON
58
clindamycin hcl
21
CRIXIVAN
40
clindamycin palmitate hydrochloride
21
cromolyn sodium
88
clindamycin phosphate (topical)
21
cromolyn sodium (nasal)
8
clindamycin phosphate vaginal
21
cromolyn sodium (ophth)
83
clindamycin phosphate-benzoyl peroxide
56
CUPRIMINE
61
clobetasol propionate
61
CVS LANCETS 21G
73
clobetasol propionate emollient base
61
CVS LANCETS MICRO THIN 33G
73
clomipramine hcl
30
CVS LANCETS THIN 26G
73
clonazepam
42
CVS LANCETS ULTRA THIN 30G
73
clonidine hcl
48
CVS ULTRA THIN LANCETS
73
clopidogrel bisulfate
47
cyanocobalamin
91
clorazepate dipotassium
42
cyclobenzaprine hcl
89
cyclopentolate hcl
83
cyclophosphamide
33
clotrimazole (topical)
clotrimazole vaginal
4,30
4
clotrimazole w/ betamethasone
57
cyclosporine
68
clozapine
38
cyclosporine modified (for microemulsion)
68
CO-NATAL FA
91
cyproheptadine hcl
86
coal tar extract
5
COARTEM
34
D
codeine sulfate
17
dapsone
33
COLCHICINE
31
DELZICOL
70
colchicine w/ probenecid
32
DEPACON
25
COLCRYS
32
DEPO-SUBQ PROVERA 104
67
colestipol hcl
53
DESCOVY
39
COMBIPATCH
63
desipramine hcl
30
COMBIVENT RESPIMAT
88
desmopressin acetate
63
COMFORT ASSURED LANCETS 28G
73
desmopressin acetate refrigerated
63
COMFORT ASSURED LANCETS 33G
73
desmopressin acetate spray
63
COMPACT SPACE CHAMBER
73
desmopressin acetate spray refrigerated
63
COMPACT SPACE CHAMBER/LG MASK
73
desogestrel & ethinyl estradiol
64
COMPACT SPACE CHAMBER/MED MASK
73
desogestrel-ethinyl estradiol (biphasic)
63
COMPACT SPACE CHAMBER/SM MASK
73
desogestrel-ethinyl estradiol (triphasic)
64
COMPLERA
39
Desogestrel-Ethinyl Estradiol TAB 0.15-0.02/0.01 MG
complete ready-to-use enema enema 7-19 gm/118ml 7
(Azurette, Kariva, Pimtrea, Viorele, Caziant, Cesia,
COMPLETE-RF PRENATAL
91
Velivet)
COMPLETENATE
91
Desogestrel-Ethinyl Estradiol TAB 0.15-30 MG-MCG
COPAXONE
56
(Apri, Emoquette, Enskyce, Reclipsen, Solia)
64
COREG CR
49
DESOXIMETASONE
61
cortisone acetate
61
dexamethasone
61
COTELLIC
34
DEXAMETHASONE INTENSOL
61
PAGE 99
64
dexamethasone sodium phosphate
61
disopyramide phosphate
49
dexamethasone sodium phosphate (ophth)
84
disulfiram
19
dexmethylphenidate hcl
55
divalproex sodium
26
dextroamphetamine sulfate
54
docusate sodium
7
dextromethorphan polistirex
12
docusate sodium cap 100 mg
7
dextromethorphan polistirex er liquid er 30 mg/5ml
12
donepezil hydrochloride
27
dextromethorphan-doxylamine-acetaminophen
12
DONNATAL
58
dextromethorphan-guaifenesin
12
dorzolamide hcl
84
dextromethorphan-phenylephrine-acetaminophen
12
dorzolamide hcl-timolol maleate
84
doxazosin mesylate
48
dextrose (diabetic use)
4
DIASTAR EASY TEST II LANCETS
73
doxepin hcl
30
DIASTAR EASY TEST LANCETS
73
doxycycline hyclate
25
DIATRUE CONTROL LEVEL 1
73
doxylamine succinate (sleep)
13
DIATRUE CONTROL LEVEL 3
73
drospirenone-ethinyl estradiol
64
diazepam
42
Drospirenone-Ethinyl Estradiol TAB 3-0.03 MG (Gianvi,
diazepam (anticonvulsant)
26
Loryna, Nikki, Vestura, Ocella, Syeda, Zarah)
64
DROXIA
34
dibucaine
5
diclofenac potassium
16
DRUG MART LANCETS THIN 26G
73
diclofenac sodium
16
DRUG MART LANCETS ULTRA THIN
73
diclofenac sodium (ophth)
84
DULERA
88
dicloxacillin sodium
23
duloxetine hcl
55
dicyclomine hcl
58
DUREX EXTRA SENSITIVE
didanosine
39
DUTOPROL
diflorasone diacetate
61
diflunisal
16
E
digoxin
51
E-Z JECT LANCET MICRO-THIN 33G
73
dihydroergotamine mesylate
32
E-Z JECT LANCET SUPER THIN 30G
73
DILANTIN
27
E-Z JECT LANCETS
73
diltiazem hcl
50
E-Z JECT LANCETS 21G
73
diltiazem hcl coated beads
50
E-Z JECT LANCETS THIN 26G
73
diltiazem hcl extended release beads
50
E-Z SPACER
73
E-Z SPACER THE BODY GUARDS PK
73
dimenhydrinate
4
8
51
DIMETAPP LONG ACT COUGH/COLD
12
E.E.S. 400
24
diphenhydramine hcl
12
E.E.S. GRANULES
24
diphenhydramine hcl (sleep)
13
EASIVENT
74
11
EASIVENT MASK LARGE
74
12
EASIVENT MASK MEDIUM
74
diphenhydramine hcl elixir 12.5 mg/5ml
86
EASIVENT MASK SMALL
74
diphenhydramine hcl liquid 12.5 mg/5ml
12
EASY PLUS CONTROL
74
diphenoxylate w/ atropine
59
EASY PLUS II CONTROL
74
dipyridamole
47
EASY STEP CONTROL
74
PAGE 100
EASY TALK CONTROL
74
EQL THIN LANCETS 26G
75
EASY TOUCH LANCETS 28G/TWIST
74
ergocalciferol
91
74
ergoloid mesylates
27
74
ERY-TAB
24
74
ERYPED 200
24
EASY TRAK CONTROL
74
ERYPED 400
24
EASYGLUCO CONTROL
74
ERYTHROCIN STEARATE
24
EASYMAX CONTROL
74
erythromycin (acne aid)
24
ECLIPSE CONTROL
74
erythromycin (ophth)
24
econazole nitrate
31
ERYTHROMYCIN BASE
24
ED BRON GP
12
erythromycin base
24
EDURANT
39
ERYTHROMYCIN ETHYLSUCCINATE
24
EFFIENT
47
erythromycin-sulfisoxazole
24
ELEMENT CONTROL
74
escitalopram oxalate
28
ELEMENT PLUS CONTROL
74
esterified estrogens & methyltestosterone
64
ELEXA NATURAL FEEL
8
ESTRACE
64
ELEXA STIMULATING
8
estradiol
64
ELEXA ULTRA SENSITIVE
8
estradiol & norethindrone acetate
64
ELIDEL
57
estropipate
64
ELIQUIS
46
ethambutol hcl
33
ELLA
67
ethosuximide
25
ELMIRON
61
Ethynodiol Diacetate & Ethinyl Estradiol Tab 1 MG-35
EMBRACE CONTROL
74
MCG (Kelnor, Zovia)
64
EMBRACE EVO CONTROL LEVEL 1
74
etodolac
16
EMBRACE GLUCOSE CONTROL
74
EURAX
35
EMTRIVA
39
EVOTAZ
40
enalapril maleate
48
EVZIO
19
enalapril maleate & hydrochlorothiazide
51
exemestane
34
ENBREL
68
ENBREL SURECLICK
68
enoxaparin sodium
46,47
F
famotidine
6,59
ENVISION CONTROL
75
FANTASY LUBRICATED
8
EPANED
48
FANTASY LUBRICATED/SPERMICIDE
8
EPIFOAM
57
FARESTON
33
EPINEPHRINE
87
felbamate
26
EPIPEN 2-PAK
87
felodipine
50
EPIPEN JR 2-PAK
87
fenofibrate
53
EPZICOM
39
fenofibrate micronized
53
EQL COLOR LANCETS 21G
75
fentanyl
17
EQL COLOR LANCETS MICRO 33G
75
FERRETTS
14
EQL SUPER THIN LANCETS 30G
75
ferrous fumarate
14
PAGE 101
ferrous sulfate
14
12
G
12
gabapentin
26
7
GABITRIL
26
27
fiber cap 0.52 gm
finasteride
60
galantamine hydrobromide
FINE 30
75
gauze pads & dressings
FIRST-VANCOMYCIN 25
21
gemfibrozil
53
FIRST-VANCOMYCIN 50
21
gentamicin sulfate (ophth)
20
flavoxate hcl
60
gentamicin sulfate (topical)
20
flecainide acetate
49
GENVOYA
38
FLEXICHAMBER
75
GESTICARE
91
FLOVENT DISKUS
86
GILENYA
56
FLOVENT HFA
86
glatiramer acetate
56
fluconazole
31
glimepiride
43
fludrocortisone acetate
62
glipizide
43
flunisolide (nasal)
86
glipizide-metformin hcl
43
fluocinolone acetonide (otic)
85
GLUCAGEN HYPOKIT
45
fluocinonide
62
GLUCAGON EMERGENCY
45
fluocinonide emulsified base
62
GLUCOCOM CONTROL
75
fluorometholone (ophth)
84
GLUCOLAB CONTROL
75
fluorouracil (topical)
57
glyburide
43
fluoxetine hcl
28
glyburide micronized
44
fluphenazine decanoate
36
glyburide-metformin
44
fluphenazine hcl
36
glycerin (laxative)
flurazepam hcl
90
glycopyrrolate
59
flurbiprofen
16
GNP LANCETS
75
flurbiprofen sodium
84
GNP LANCETS 21G
75
flutamide
33
GNP LANCETS MICRO THIN 33G
75
fluticasone propionate
62
GNP LANCETS SUPER THIN 30G
75
fluticasone propionate (nasal)
86
GNP LANCETS THIN
75
fluvoxamine maleate
29
GNP LANCETS THIN 26G
75
FML
84
GNP MICRO THIN LANCETS 33G
75
14,91
GNP SUPER THIN LANCETS 30G
75
folic acid
8
7
FORA CONTROL
75
griseofulvin microsize
31
FORACARE GDH CONTROL
75
griseofulvin ultramicrosize
31
FORADIL AEROLIZER
87
guaifenesin
13
formaldehyde
75
guaifenesin-codeine
13
FORTISCARE CONTROL
75
guanfacine hcl
48
fosinopril sodium
48
GYNAZOLE-1
31
fosinopril sodium & hydrochlorothiazide
51
furosemide
52
PAGE 102
H
hydroxyzine hcl
86
hydroxyzine pamoate
86
haloperidol
36
hyoscyamine sulfate
59
haloperidol decanoate
36
HYPERRHO S/D
69
haloperidol lactate
36
HYPOTEARS
11
HARVONI
38
hypromellose (ophth)
11
HEALTHWISE LANCETS 30G
75
HEMANGEOL
34
I
heparin sodium (porcine)
47
ibuprofen
HUMALOG
45
ibuprofen tab 200 mg
HUMALOG KWIKPEN
45
imipramine hcl
30
HUMALOG MIX 50/50
45
imiquimod
57
HUMALOG MIX 50/50 KWIKPEN
45
INATAL ADVANCE
91
HUMALOG MIX 75/25
45
INATAL ULTRA
91
HUMALOG MIX 75/25 KWIKPEN
45
INCRUSE ELLIPTA
87
HUMIRA
68
indapamide
53
HUMIRA PEDIATRIC CROHNS START
68
indomethacin
16
HUMIRA PEN
69
INFINITY CONTROL
75
HUMIRA PEN-CROHNS STARTER
69
INSPIRACHAMBER/LARGE
76
HUMIRA PEN-PSORIASIS STARTER
69
INSPIRACHAMBER/MEDIUM
76
HUMULIN 70/30
45
INSPIRACHAMBER/MOUTHPIECE
76
HUMULIN 70/30 KWIKPEN
45
INSPIRACHAMBER/SMALL
76
HUMULIN 70/30 PEN
45
INSPIREASE
76
HUMULIN N
45
INSPIREASE BAGS
76
HUMULIN N KWIKPEN
45
INSPIREASE MOUTHPIECE
76
HUMULIN N PEN
45
INSPIREASE RESERVOIR BAGS
76
HUMULIN R
45
76
hydralazine hcl
53
insulin pen needle 29 g x 12.7 mm
76
hydrochlorothiazide
53
76
hydrocodone w/ homatropine
89
76
hydrocodone-acetaminophen
17,18
76
3,16
3
hydrocortisone
62
76
hydrocortisone (intrarectal)
70
76
hydrocortisone (rectal)
70
76
76
hydrocortisone (topical)
5,57
hydrocortisone butyrate
62
INSULIN SYRINGE
76
hydrocortisone w/acetic acid
85
insulin syringe (disp) u-100 1 ml
76
insulin syringe/needle u-100
76
hydrocortisone-aloe vera
5
hydromorphone hcl
18
76
hydroxychloroquine sulfate
34
76
hydroxyurea
34
77
PAGE 103
insulin syringe/needle u-100 1 ml 25 x 1"
77
KIMONO MICRO THIN
8
77
KIMONO MICRO THIN PLUS
9
77
KIMONO PLUS
9
77
KIMONO PS
9
77
KIMONO PS PLUS
9
77
KIMONO SENSATION
9
77
KIMONO SENSATION PLUS
9
77
KLOR-CON
90
77
KLOR-CON M15
90
INTELENCE
39
KOMBIGLYZE XR
44
INVIRASE
41
KPN PRENATAL
14
IOPIDINE
84
KROGER LANCETS 21G
77
ipratropium bromide
87
KROGER LANCETS MICRO THIN 33G
77
ipratropium bromide (nasal)
87
KROGER LANCETS SUPER THIN
77
ipratropium-albuterol
89
KROGER LANCETS THIN 26G
77
irbesartan
48
KROGER LANCETS ULTRATHIN 30G
77
irbesartan-hydrochlorothiazide
51
ISENTRESS
38
L
isoniazid
33
labetalol hcl
ISONIAZID
33
lactic acid (ammonium lactate)
isosorbide dinitrate
54
lactulose
59
isosorbide mononitrate
54
lactulose (encephalopathy)
59
isotretinoin
57
lamivudine
40
itraconazole
31
lamivudine-zidovudine
40
lamotrigine
26
lancet devices
71
J
49,50
5,57
JADENU
90
LANCETS 28G
77
JENTADUETO
44
LANCETS 30G
77
LANCETS MICRO THIN 33G
77
LANCETS SUPER THIN 28G
77
K
KALETRA
41
LANCETS THIN
77
KALYDECO
88
LANCETS ULTRA FINE
77
8
LANCETS ULTRA THIN
78
77
KAMELEON LUBRICATED
KETOCARE
77
LANCETS ULTRA THIN 30G
ketoconazole (topical)
31
lansoprazole
ketoprofen
16
LANTUS
45
ketorolac tromethamine
16
LANTUS SOLOSTAR
45
ketorolac tromethamine (ophth)
84
latanoprost
85
KETOSTIX
77
leflunomide
70
ketotifen fumarate (ophth)
11
letrozole
34
leucovorin calcium
34
KIMONO
PAGE 104
9
7
LEUKERAN
33
loxapine succinate
36
levetiracetam
25
LUFYLLIN
88
levobunolol hcl
85
levocarnitine (metabolic modifiers)
91
M
levofloxacin
25
magnesium citrate solution 1.745 gm/30ml
7
Levonorg-Eth Est Tab 0.15-0.03MG(84) & Eth Est Tab
magnesium oxide
6
0.01MG(7) (Amethia, Camrese, Daysee)
magnesium oxide (mg supplement)
14
MAKENA
67
malathion
35
maprotiline hcl
29
65
Levonorgest-Eth Estrad 91-Day TAB 0.15-0.03 MG
(Introvale, Jolessa, Quasense)
65
levonorgestrel (emergency oc)
8,67
Levonorgestrel-Eth Estra Tab 0.05-30/0.075-40/0.125-
MAXX
9
30MG (Enpresse, Levonest, Myzilra, Trivora)
MAXX PLUS
9
Levonorgestrel-Ethinyl Estrad TAB 0.1-20 MG (Aubra,
meclizine hcl
4,30
Aviane, Delyla, Falmina, Lessina, Lutera, Orsythia,
MEDICINE SHOPPE LANCETS
78
MEDICINE SHOPPE LANCETS THIN
78
Levonorgestrel-Ethinyl Estrad TAB 0.15-30 MG
medroxyprogesterone acetate
67
(Altavera, Chateal, Kurvelo, Levora, Marlissa, Portia)65
medroxyprogesterone acetate (contraceptive)
67
levothyroxine sodium
68
mefloquine hcl
34
LEXIVA
41
megestrol acetate
67
LIBERTY GLUCOSE CONTROL
78
MEIJER LANCETS
78
lidocaine
57
MEIJER LANCETS THIN
78
19,57
MEIJER LANCETS UNIVERSAL 30G
78
lidocaine hcl (mouth-throat)
19
MEIJER LANCETS UNIVERSAL 33G
78
lidocaine-prilocaine
19
MEIJER SUPER THIN LANCETS
78
liothyronine sodium
68
meloxicam
16
lisinopril
48
memantine hcl
27
lisinopril & hydrochlorothiazide
51
meperidine hcl
18
LITEAIRE
78
MEPHYTON
91
lithium
43
meprobamate
42
lithium carbonate
43
mercaptopurine
34
LOHIST-D
13
mesalamine
70
metaproterenol sulfate
87
6
metformin hcl
44
loratadine
12
methadone hcl
17
loratadine & pseudoephedrine
13
methazolamide
85
loratadine allergy relief tab disp 10 mg
12
methenamine mandelate
21
12
methenamine-hyosc-methylene blue-sod phos-phenyl
lorazepam
42
sal
21
losartan potassium
48
methimazole
68
losartan potassium & hydrochlorothiazide
52
METHITEST
63
lovastatin
53
methocarbamol
89
Sronyx)
lidocaine hcl
loperamide hcl
loperamide hcl tab 2 mg
PAGE 105
65
65
6,59
methotrexate sodium
69
montelukast sodium
87
methyldopa
48
morphine sulfate
methylergonovine maleate
78
multiple vitamins w/ minerals
90
methylphenidate hcl
55
mupirocin
21
METHYLPHENIDATE HCL ER
55
mupirocin calcium (topical)
21
methylprednisolone
62
mycophenolate mofetil
69
metipranolol
85
mycophenolate sodium
69
metoclopramide hcl
30
MYLERAN
33
metolazone
53
MYNATAL
91
metoprolol & hydrochlorothiazide
52
MYNATE 90 PLUS
92
metoprolol succinate
50
metoprolol tartrate
50
N
metronidazole
21
nabumetone
16
metronidazole (topical)
21
nadolol
50
metronidazole cream 0.75 %
21
naloxone hcl
19
metronidazole gel 0.75 %
21
naltrexone hcl
19
metronidazole vaginal
21
naphazoline hcl
83
mexiletine hcl
49
naproxen
16
MIACALCIN
70
naproxen sodium
MICONAZOLE 3
31
17,18
3,17
3
miconazole nitrate (topical)
4
naratriptan hcl
32
miconazole nitrate vaginal
4
NARCAN
19
MICROCHAMBER
78
NASAL DECONGESTANT
9
MICROLET LANCETS
78
nasal moisturizing spray solution 0.65 %
9
MICROSPACER
78
NATALVIT
92
MICROTAINER SAFETY FLOW LANCET
78
nateglinide
44
midazolam hcl
42
NATROBA
35
midodrine hcl
48
NECON 1/50 (28)
65
7
NECON 10/11 (28)
65
milk of magnesia suspension 400 mg/5ml
MILLIPRED
62
nefazodone hcl
29
minocycline hcl
25
neomycin sulfate
20
minoxidil
54
neomycin-bacitracin zn-polymyxin
83
mirtazapine
28
neomycin-bacitracin-polymyxin
misoprostol
60
neomycin-polymy-dexameth
MISSION PRENATAL
14
neomycin-polymyxin w/ pramoxine
MISSION PRENATAL FA
14
neomycin-polymyxin-gramicidin
83
MISSION PRENATAL HP
14
neomycin-polymyxin-hc (ophth)
83
MOLINDONE HCL
36
neomycin-polymyxin-hc (otic)
85
mometasone furoate
62
NESSI SPACER WITH MASK LARGE
9
MONOLET LANCETS
78
NESSI SPACER WITH MASK SM/MED
9
MONOLET OPD LANCETS
78
NESSI SPACER WITH MOUTHPIECE
9
PAGE 106
4
83
5
NEVANAC
84
norethindrone acetate
nevirapine
39
Norethindrone Tab 0.35 MG (Camila, Deblitane, Errin,
7
Heather, Jencycla, Jolivette, Lyza, Nora-BE, Norlyroc,
NEXIUM 24HR
67
niacin
14
Sharobel)
67
niacin (antihyperlipidemic)
53
Norethindrone-Eth Estradiol Tab 0.5-35/0.75-35/1-35
NIACOR
53
MG (Alyacen, Cyclafem, Dasetta, Necon, Nortrel,
nicardipine hcl
50
Pirmella)
66
nicotine
3
Norethindrone-Eth Estradiol Tab 0.5-35/1-35/0.5-35
NICOTINE
3
MG (Aranelle, Leena)
nicotine polacrilex
3
Norgestimate & Ethinyl Estradiol Tab 0.25 MG-35 MCG
66
NICOTROL
20
(Estarylla, Mono-Linyah, MonoNessa, Previfem,
NICOTROL NS
20
Sprintec)
66
nifedipine
50,51
NINLARO
34
MG (Tri-Estarylla, Tri-Linyah, Tri-Previfem, Tri-
NITRO-BID
54
Sprintec, Trinessa)
nitrofurantoin
21
Norgestrel & Ethinyl Estradiol Tab 0.3 MG-30 MCG
nitrofurantoin macrocrystal
21
(Cryselle, Elinest, Low-Ogestrel)
66
nitrofurantoin monohyd macro
21
NORINYL 1+50 (28)
66
nitroglycerin
54
NORPACE CR
49
NITROSTAT
54
nortriptyline hcl
30
NIVA-PLUS
92
NORVIR
41
NORDITROPIN FLEXPRO
63
NOVA MAX PLUS KETONE TEST
NORDITROPIN NORDIFLEX PEN
63
NOVOLIN 70/30
46
NOVOLIN 70/30 RELION
46
NOVOLIN N
46
Norethindrone & Ethinyl Estradiol Tab 0.4 MG-35 MCG
NOVOLIN N RELION
46
(Balziva, Briellyn, Gildagia, Philith, Vyfemla,
NOVOLIN R
46
NOVOLIN R RELION
46
Norethindrone & Ethinyl Estradiol Tab 0.5 MG-35 MCG
NOVOLOG
46
(Necon, Nortrel, Wera)
NOVOLOG FLEXPEN
46
Norethindrone & Ethinyl Estradiol Tab 1 MG-35 MCG
NOVOLOG MIX 70/30
46
(Alyacen, Cyclafem, Dasetta, Necon, Nortrel,
NOVOLOG MIX 70/30 FLEXPEN
46
NOVOLOG PENFILL
46
NUTRICION PORVIDA
14
NUVARING
66
Norethindrone Ace & Ethinyl Estradiol Tab 1.5 MG-30
nystatin
31
MCG (Gildess, Junel, Larin, Microgestin)
nystatin (mouth-throat)
31
Norethindrone Ace & Ethinyl Estradiol-FE Tab 1 MG-20
nystatin (topical)
31
nystatin-triamcinolone
31
Norelgestromin-Ethinyl Estradiol TD PTWK 150-35
MCG/24HR (Xulane)
Zenchent)
Pirmella)
65
65
65
65
Norethindrone Ace & Ethinyl Estradiol Tab 1 MG-20
65
65
65
Norgestimate-Eth Estrad Tab 0.18-35/0.215-35/0.25-35
66
9
Norethindrone Ace & Ethinyl Estradiol-FE Tab 1.5 MG30 MCG (Gildess, Junel, Larin, Microgestin)
PAGE 107
66
OXYCONTIN
O
17
O-CAL FA
92
P
O-CAL PRENATAL
92
PANCREAZE
58
ODEFSEY
39
pancrelipase (lipase-protease-amylase)
58
ofloxacin
25
pantoprazole sodium
60
ofloxacin (ophth)
25
paregoric
59
ofloxacin (otic)
25
paroxetine hcl
29
OGESTREL
66
PCE
24
olanzapine
37
ped multivitamins w/fl & iron
90
omeprazole
60
pediatric multiple vitamin w/ c
14
7
pediatric multiple vitamin w/ c & fa
14
ondansetron hcl
30
pediatric multiple vitamins w/ iron
14
30
pediatric multivitamins w/fl
30
pediatric vitamins acd w/ fluoride
92
ONETOUCH VERIO
78
pediatric vitamins adc
14
ONGLYZA
44
peg 3350-kcl-sod bicarb-sod chloride-sod sulfate
59
OPTICHAMBER ADVANTAGE
78
peg 3350-potassium chloride-sod bicarbonate-sod
OPTICHAMBER ADVANTAGE-LG MASK
78
chloride
59
OPTICHAMBER ADVANTAGE-MED MASK
78
penicillin v potassium
23
OPTICHAMBER ADVANTAGE-SM MASK
78
PENTASA
70
OPTICHAMBER DIAMOND
78
pentoxifylline
52
OPTICHAMBER DIAMOND-LG MASK
78
permethrin
OPTICHAMBER DIAMOND-MD MASK
79
perphenazine
30
OPTICHAMBER DIAMOND-SM MASK
79
perphenazine-amitriptyline
28
OPTICHAMBER FACE MASK-LARGE
9
PERRY PRENATAL
15
OPTICHAMBER FACE MASK-MEDIUM
9
phenazopyridine hcl
61
OPTICHAMBER FACE MASK-SMALL
9
phenelzine sulfate
28
omeprazole delayed release tab 20 mg
90,92
5,9,35
OPTIHALER
79
phenobarbital
26
oral electrolytes
13
phenyleph-promethazine w/ cod
89
ORKAMBI
88
phenylephrine hcl (ophth)
83
ORTHO DIAPHRAGM ALL-FLEX
79
phenylephrine hcl tab 10 mg
9
ORTHO DIAPHRAGM COIL
79
phenylephrine-cocoa butter
5
ORTHO DIAPHRAGM FLAT
79
phenylephrine-dm
oxaprozin
17
phenylephrine-shark liver oil-cocoa butter
5
oxazepam
43
phenylephrine-shark liver oil-mineral oil-petrolatum
6
oxcarbazepine
27
PHENYTEK
27
oxybutynin chloride
60
phenytoin
27
phenytoin sodium extended
27
oxycodone hcl
17,18
13
oxycodone w/ acetaminophen
18
PHRENILIN FORTE
55
oxycodone-aspirin
18
pilocarpine hcl
85
PAGE 108
pilocarpine hcl (oral)
56
PREFERRED PLUS LANCETS COLORED
79
pindolol
50
PREFERRED PLUS LANCETS THIN
79
pioglitazone hcl
44
PREMARIN
66
pioglitazone hcl-metformin hcl
44
PREMIUM CONDOMS LUBRICATED
piroxicam
17
PREMPHASE
66
PLEGRIDY
56
PREMPRO
66
PLEGRIDY STARTER PACK
56
PRENAFIRST
93
PNV FE FUM/DOCUSATE/FOLIC ACID
92
PRENATABS FA
93
PNV FOLIC ACID + IRON
92
prenatal multivit-min w/fe-fa
14
PNV PRENATAL PLUS MULTIVITAMIN
92
PRENATAL PLUS
93
PNV TABS 29-1
93
PRENATAL PLUS IRON
93
POCKET CHAMBER
79
prenatal vit w/ ferrous fumarate-folic acid
15
podofilox
57
PRENATAL VITAMINS PLUS
93
POLY-VITAMIN/FLUORIDE/IRON
93
PREPLUS
93
POLYCOSE
15
PRESTIGE GLUCOSE CONTROL
79
PRETAB
93
41
9
polyethylene glycol 3350
7,60
polymyxin b-trimethoprim
83
PREZISTA
polysaccharide iron complex
15
PRILOSEC OTC
polyvinyl alcohol
11
primaquine phosphate
34
pot phosphate monobasic w/ sod phosphate dibasic &
primidone
26
monobasic
61
probenecid
32
potassium bicarbonate
90
prochlorperazine
30
potassium chloride
90
prochlorperazine maleate
30
potassium chloride microencapsulated crystals cr
90
PRODIGY CONTROL SOLUTION
79
potassium citrate (alkalinizer)
61
progesterone micronized
67
potassium citrate-citric acid
61
promethazine & phenylephrine
89
pramipexole dihydrochloride
35
promethazine hcl
86
6
86
pramoxine-hc-chloroxylenol
85
86
pravastatin sodium
53
promethazine w/codeine
89
prazosin hcl
48
promethazine-dm
89
propafenone hcl
49
pramoxine hcl (rectal)
PRECISION XTRA KETONE
9
7
PRED MILD
84
propranolol & hydrochlorothiazide
52
PRED-G
83
propranolol hcl
50
prednicarbate
62
propylthiouracil
68
prednisolone
62
pseudoephed-bromphen-dm
prednisolone acetate (ophth)
84
pseudoephedrine hcl
prednisolone sodium phosphate
62
pseudoephedrine hcl er tab er 12h 120 mg
10
PREDNISOLONE SODIUM PHOSPHATE
84
pseudoephedrine hcl tab 30 mg
10
prednisone
62
pseudoephedrine w/ codeine-gg
13
PREDNISONE INTENSOL
62
pseudoephedrine-chlorphen-dm
13
PAGE 109
13,89
9
pseudoephedrine-ibuprofen
psyllium
13
7
RHOGAM ULTRA-FILTERED PLUS
69
rifampin
33
80
PTS PANELS KETONE TEST
10
RIGHTEST GC300 CONTROL
PULMICORT FLEXHALER
86
risedronate sodium
70,71
PURIXAN
34
risperidone
37,38
pyrazinamide
33
risperidone odt (tab 3 mg, tab 4 mg)
37
37
pyrethrins-piperonyl butoxide-permethrin-nit remover 6
37
pyridostigmine bromide
37
38
RITEFLO
80
pyrethrins-piperonyl butoxide
6
33
Q
quetiapine fumarate
37
rivastigmine
27
quinapril hcl
48
rivastigmine tartrate
27
quinidine gluconate
49
rizatriptan benzoate
32
quinidine sulfate
49
ropinirole hydrochloride
35
ROXICET
18
RYTHMOL SR
49
R
RA E-ZJECT COLOR LANCETS 33G
79
RA E-ZJECT LANCETS 28G
79
S
RA E-ZJECT LANCETS THIN 26G
79
saline
10
RA E-ZJECT LANCETS THIN 28G
79
salsalate
17
RA E-ZJECT LANCETS ULTRA THIN
79
SANDIMMUNE
69
raloxifene hcl
67
SAVELLA
55
ramipril
49
SAVELLA TITRATION PACK
56
ranitidine hcl
6,59
SE-NATAL 19
93
RAPAMUNE
69
SE-NATAL 90
94
REALITY LATEX/ULTRA TEXTURED
10
selegiline hcl
36
REALITY LATEX/ULTRA THIN
10
selenium sulfide
RELENZA DISKHALER
41
SELZENTRY
RELION LANCETS MICRO-THIN 33G
79
senna tab 8.6 mg
7
RELION LANCETS THIN 26G
79
senna-docusate sodium tab 8.6-50 mg
7
RELION LANCETS ULTRA-THIN 30G
79
sennosides
7
RELION ULTRA THIN LANCETS 30G
80
SEREVENT DISKUS
87
RELION ULTRA THIN PLUS LANCETS
80
sertraline hcl
29
RELPAX
32
SFROWASA
70
RESCRIPTOR
39
silver sulfadiazine
25
reserpine
52
simethicone
respiratory therapy supplies
8,71
6,57
40
6,10
simvastatin
53
REXALL LANCETS ULTRA THIN 30G
80
sirolimus
69
REYATAZ
41
SIVEXTRO
21
RHEUMATREX
69
SM LANCETS 21G
80
PAGE 110
SM LANCETS 33G
80
SURECHEK CONTROL SOLUTION
80
SM SUPER THIN LANCETS 30G
80
SURESTEP PRO HIGH GLUCOSE
80
SM THIN LANCETS 26G
80
SURESTEP PRO LOW GLUCOSE
80
SMART SENSE COLOR LANCETS 33G
80
SUSTIVA
39
SMART SENSE STANDARD LANCETS
80
SYMBICORT
89
SMART SENSE SUPER THIN LANCETS
80
SYMLINPEN 120
44
SMART SENSE THIN LANCETS 26G
80
SYMLINPEN 60
44
sodium bicarbonate (antacid)
6
sodium chloride (gu irrigant)
61
T
sodium chloride (inhalant)
89
tacrolimus
sodium citrate & citric acid
61
tacrolimus (topical)
sodium fluoride
90
TAMIFLU
41
sodium fluoride (dental)
56
tamoxifen citrate
34
tamsulosin hcl
60
sodium phosphates
7
69
57,58
sodium polystyrene sulfonate
90
TAZORAC
58
SOLUS V2 CONTROL
80
TECFIDERA
56
sotalol hcl
49
TECHLITE LANCETS
80
sotalol hcl (afib/afl)
49
TECHLITE LANCETS 30G
80
SOVALDI
38
TEGRETOL-XR
27
SPINOSAD
35
temazepam
89
spironolactone
52
temozolomide
33
spironolactone & hydrochlorothiazide
52
terazosin hcl
60
SSKI
68
terbinafine hcl
31
stannous fluoride
56
terbinafine hcl (topical)
stavudine
40
terbutaline sulfate
88
STRIBILD
38
terconazole vaginal
31
SUBOXONE
19
testosterone cypionate
63
sucralfate
60
tetrahydrozoline hcl (ophth)
11
sulfacetamide sod-prednisolone
83
TGT LANCET ALTERNATE SITE
80
sulfacetamide sodium
57
TGT LANCET MICRO THIN 33G
81
sulfacetamide sodium (acne)
57
TGT LANCET SUPER THIN 30G
81
sulfacetamide sodium (ophth)
25
TGT LANCET THIN 23G
81
sulfamethoxazole-trimethoprim
25
TGT LANCET THIN 26G
81
sulfasalazine
70
TGT LANCET ULTRA THIN 28G
81
sulindac
17
TGT LANCET ULTRA THIN 30G
81
sumatriptan nasal spray (5 mg/act, 20 mg/act)
32
THEO-24
88
sumatriptan succinate
32
theophylline
88
SUMATRIPTAN SUCCINATE
32
thioridazine hcl
36
SURE COMFORT LANCETS 28G
80
thiothixene
36
SURE COMFORT LANCETS 30G
80
THYROLAR-1
68
SURE EDGE GLUCOSE CONTROL
80
THYROLAR-1/2
68
PAGE 111
6
THYROLAR-1/4
68
TRICARE
94
THYROLAR-2
68
trifluoperazine hcl
36
THYROLAR-3
68
trifluridine
42
tiagabine hcl
26
trihexyphenidyl hcl
35
TIKOSYN
49
trimethoprim
21
timolol maleate
50
TRINATAL GT
94
timolol maleate (ophth)
85
TRINATAL RX 1
94
TIMOPTIC OCUDOSE
85
TROJAN MAGNUM WARM SENSATIONS
10
TROJAN SUPRAS SPERMICIDAL
10
tioconazole vaginal
4
TIVICAY
39
TROJAN TWISTED PLEASURE
10
tizanidine hcl
95
tropicamide
83
TOBRADEX
20
trospium chloride
60
tobramycin
88
TRUE METRIX AIR
81
tobramycin (ophth)
20
TRUE METRIX BLOOD GLUCOSE TEST
81
tobramycin sulfate
20
TRUE METRIX LEVEL 1
81
tobramycin-dexamethasone
83
TRUE METRIX LEVEL 3
81
TOBREX
20
TRUE METRIX METER
81
tolmetin sodium
17
TRUEPLUS LANCETS 26G
81
6
81
tolterodine tartrate
60
81
TOPICORT
62
81
topiramate
26
TRUEPLUS SAFETY LANCETS 28G
81
torsemide
52
TRUERESULT BLOOD GLUCOSE
81
TRADJENTA
44
TRUETEST TEST
81
tramadol hcl
18
TRUETRACK GLUCOSE CONTROL
81
tramadol-acetaminophen
18
TRUETRACK TEST
81
trandolapril
49
TRUSTEX COLOR CONDOMS + LUBE
10
tranexamic acid
47
TRUSTEX LUB/RIBBED/STUDDED
10
tranylcypromine sulfate
28
TRUSTEX LUB/SPERMICIDE EX ST
10
trazodone hcl
29
TRUSTEX LUB/SPERMICIDE XL
10
TRECATOR
33
TRUSTEX LUBRICATED
10
tretinoin
58
TRUSTEX LUBRICATED EX LARGE
10
TREXALL
69
TRUSTEX LUBRICATED EXTRA ST
10
TRI-VI-SOL/IRON
15
TRUSTEX LUBRICATED/SPERMICIDE
10
TRI-VIT/FLUORIDE/IRON
94
TRUSTEX NATURAL CONDOMS + LUBE
10
TRIADVANCE
94
TRUSTEX NON-LUBRICATED
10
triamcinolone acetonide (mouth)
63
TRUSTEX RIA LUB/SPERMICIDE
10
triamcinolone acetonide (topical)
62,63
TRUSTEX RIA LUBRICATED
10
tolnaftate
TRIAMINIC COLD/COUGH DAY TIME
13
TRUSTEX RIA NON-LUBRICATED
10
triamterene & hydrochlorothiazide
52
TRUSTEX-NONOXYNOL-9/RIB/STUD
10
triazolam
89
TRUVADA
40
PAGE 112
TUDORZA PRESSAIR
87
VISTOGARD
82
TYBOST
40
VITAFOL-OB
95
VITASPIRE
95
VIVITROL
19
U
ULTILET INSULIN SYRINGE
81
VOCAL POINT CONTROL
82
UNILET COMFORTOUCH LANCET
81
VOL-PLUS
95
UNILET EXCELITE
82
VOL-TAB RX
95
UNILET EXCELITE II
82
VORTEX VALVED HOLDING CHAMBER
82
UNILET G.P. SUPERLITE LANCET
82
VYVANSE
54
UNILET GP 28 ULTRA THIN
82
UNISTRIP CONTROL
82
W
UNIVERSAL 1 LANCETS THIN 26G
82
WALGREENS LANCETS
82
UNIVERSAL 1 LANCETS ULTRA THIN
82
WALGREENS LANCETS MICRO THIN
82
urea
58
WALGREENS LANCETS SUPER THIN
82
ursodiol
59
WALGREENS THIN LANCETS
82
WALGREENS ULTRA THIN LANCETS
82
warfarin sodium
47
V
valacyclovir hcl
42
WATCHHALER
82
valganciclovir hcl
38
white petrolatum-mineral oil
11
valproate sodium
26
valproic acid
26
X
valsartan
48
XARELTO
valsartan-hydrochlorothiazide
52
VALUE PLUS LANCET STANDARD 21G
82
Z
VALVED HOLDING CHAMBER
82
zaleplon
89
vancomycin hcl
22
ZENPEP
58
VENATAL-FA
94
ZEPATIER
38
venlafaxine hcl
29
ZIAGEN
40
VENLAFAXINE HCL ER
29
zidovudine
40
VENTOLIN HFA
88
zinc oxide (topical)
verapamil hcl
51
ziprasidone hcl
38
VERIPRED 20
63
zolmitriptan
32
VEXOL
84
zolpidem tartrate
89
VIDEX
40
ZOMIG
32
VIGAMOX
25
zonisamide
25
VIIBRYD
29
ZOVIA 1/50E (28)
66
VINATE CALCIUM
94
ZOVIRAX
42
VINATE M
94
ZUBSOLV
19
VIRACEPT
41
VIREAD
40
VIRT-ADVANCE
94
PAGE 113
47
6

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