HEALTHY MICHIGAN FORMULARY
Transcription
HEALTHY MICHIGAN FORMULARY
HEALTHY MICHIGAN FORMULARY Effective December 2014 Provided by EnvisionRxOptions Introduction The Total Health Care (THC) Healthy Michigan Formulary was developed to serve as a guide for physicians, pharmacists, health care professionals and members in the selection of cost-effective drug therapy. Total Health Care recognizes that drug therapy is an integral part of effective health management. Total Health Care continually reviews new and existing medications to ensure the Formulary remains responsive to the needs of our members and health professionals. Criteria used to evaluate drug selection for the formulary includes, but is not limited to: safety, efficacy and cost-effectiveness data, as well as comparison of relevant benefits of similar prescription or over-the counter (OTC) agents while minimizing potential duplications. Notice The information contained in this formulary is provided by THC, solely for the convenience of medical providers and members. THC does not warrant or assure accuracy of this information, nor is it intended to be comprehensive in nature. This formulary is not intended to be a substitute for the knowledge, expertise, skill or judgment of the medical provider in their choice of prescription drugs. Total Health Care assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer’s product literature or standard references for more detailed information. How to Read the Formulary Drug Name All formulary drugs are listed either by their generic names (in lowercase) or by their brand names (in uppercase). Drugs are grouped together by their therapeutic drug category. Specific drug listings may be accessed by using the index, using the covered generic name or the covered brand name of the drug. The brand names listed are for reference use only, and do not denote coverage, unless specifically noted. Any drug not found in this Formulary listing shall be considered a non-formulary drug. i Requirements/Limits This field includes potential limitations to the formulary drug. It also may contain additional information about the coverage of the drug such as applicable quantity limits (QL). For certain agents within the Healthy Michigan Formulary, a recommended prescribing guideline may apply. Prescribing Guidelines Prescribing guidelines may apply to select drugs on the THC formulary. Prescribing guidelines may vary by benefit design but may include: Prior Authorization Required (PA) Drug requires prior authorization through a specific physician request process. Over the Counter Drugs (OTC) Drug coverage is available for drugs that are available OTC with an authorized prescription from your provider. Specialty Drugs (SP) Drug requires processing through THC’s contracted specialty pharmacy, Diplomat Specialty Pharmacy. Quantity Limit (QL) Drug coverage may be limited to specific quantities per prescription and/or time period. Age Limit (AL) Drug coverage may depend on patient age. Gender Restriction (GR) Drug coverage may depend on patient gender. Step Therapy Required (ST) Drug coverage requires that an alternative or trial of another drug be used before the medication is covered. Benefit Coverage and Limitations This formulary does not define benefit coverage and limitations. Members should contact Total Health Care at 1800-826-2862 if they have questions regarding their coverage. Please note that the formulary process is evolutionary and changes can occur throughout the year. Prior Authorization (PA) Drugs indicated with a “PA” require Prior Authorization for coverage. A prescriber may complete a Prior Authorization form that can be found on the Total Health Care website at www.THCmi.com. You may also request a form by calling Total Health Care at 1-844-222-5584. Completed prior authorization forms should be faxed to 1-877503-7231. Prior Authorization review of prescribing guidelines will be evaluated utilizing the established drug review criteria approved by Total Health Care. If the request does not meet the approved criteria, the request will not be approved and alternative therapy may be recommended along with the proper course of alternative action. The requesting provider will be provided written notification of Total Health Care review decisions. THC’s website has a contact link where members can contact THC’s Pharmacy Department to ask for an exception request. Non-Formulary Agents Drugs not found on the Total Health Care Healthy Michigan Formulary, or any updates published by Total Health Care, shall be considered a non-formulary drug. Requests for coverage of non-formulary agents may be requested by ii the health professional depending on specific coverage parameters. Review for non-formulary drug requests will require a Prior Authorization request with documentation of medical necessity. Generally, the following basic medical necessity guidelines are used in conducting a review: The patient has failed an appropriate trial of formulary or preferred agents. The use of preferred or formulary agent is contraindicated in the patient. The formulary drug or preferred agents are not suited for the present patient care need, and the drug selected is required for patient safety. If the request does not meet the established guidelines request, it will not be approved and alternative therapy may be recommended along with the proper course of alternative action. Common Drug Exclusions The member’s plan design may exclude certain drug classes. Prior authorization is generally not available for drugs that are specifically excluded by benefit design. Common excluded coverage may include, but are not limited to: Drug products used for cosmetic purposes Drug products for erectile dysfunction Drug products for infertility treatment Experimental drug products, or any drug product used in an experimental manner Foreign drugs or drugs not approved by the United States Food & Drug Administration (FDA) Healthy Michigan Carve Out List The State of Michigan has a carve-out list for the Healthy Michigan formulary. The carve-out drugs include mental health, HIV/AIDS, Oncology, Hemophilia and other miscellaneous drugs that have been added to the State's 100% carve-out list. These drugs must be billed directly by the pharmacies at point-of-sale to the Michigan Department of Community Health's contracted Pharmacy Benefits Manager (PBM). A list of the carve-out drugs can be found at https://michigan.fhsc.com/Providers/DrugInfo.asp. Mandated Generic Substitution Total Health Care advocates the use of cost-effective generic drugs where FDA- approved generic equivalent drugs are available. Generic products are listed in the Formulary and noted as “generic” wherever an FDA-approved generic drug product is available. The brand names listed in the formulary are for reference only. Total Health Care Pharmacy and Therapeutics (P&T) Committee Total Health Care’s Pharmacy &Therapeutic Committee meets quarterly to review and recommend medications for formulary consideration. The Committee considers clinical information on drugs that are new to the market and drugs that are typically included in an outpatient pharmacy benefit. This assures that the formulary remains responsive to patient and physician needs. The Committee is composed of physicians, pharmacists, and health care professionals. The Committee also uses reference materials from our Pharmacy Benefits Manager's Pharmacy and Therapeutics Advisory Panel. Product Selection Criteria The primary goal of the THC Pharmacy & Therapeutic Committee is to maintain and update the formulary based upon an objective analysis of the safety, efficacy, approved indications, adverse effects, contraindications, patient administration/compliance considerations and cost effectiveness of available drugs. When a drug is considered for iii formulary inclusion, it will be reviewed relative to similar drugs including those currently in the THC Formulary. Physicians may request a copy of THC’s drug criteria by calling the Pharmacy Department at 1-800-826-2862. Diabetic Testing Supplies Total Health Care works with J&B Medical Supply to provide diabetic testing supplies to our members. Covered diabetic testing supplies include Glucocard Vital glucometer, Glucocard Expression glucometer, and SD Biosensor GlucoNavii glucometer, Glucocard Vital test strips, Glucocard Expression test strips, SD Biosensor GlucoNavii test strips, lancets, insulin syringes, alcohol swabs and ketone strips. These supplies are to be filled through J&B Medical Supply. If you have any questions about our diabetic supply program, please contact J&B Medical Supply at 1-844236-7933. Specialty Bio-Pharmaceutical Pharmacy Program Total Health Care works with Diplomat Specialty Pharmacy to provide Specialty Bio-Pharmaceutical Pharmacy products to our members. These medications are to be filled exclusively through Diplomat Specialty Pharmacy. A Specialty Drug Prior Authorization Request form must be completed and faxed to EnvisionRxOptions at 1-877-5037231 with supporting documentation and the prescription. A prescriber may obtain a Specialty Drug Prior Authorization Request form found on the Total Health Care website at www.THCmi.com. Once the order is received, EnvisionRxOptions obtains authorization from Total Health Care. If the specialty prior authorization is approved, Total Health Care notifies Diplomat Specialty Pharmacy. Then the Diplomat Specialty Pharmacy staff ships the medication directly to the physician's office or the patient’s home. All packages are individually marked for each patient and refrigerated items are shipped in insulated containers. Where appropriate, each shipment includes needles, syringes and alcohol swabs. If you have any questions about our Specialty BioPharmaceutical Pharmacy program, please contact EnvisionRxOptions at 1-844-222-5584 or Diplomat Specialty Pharmacy at 1-877-977-9118. Contact Information The Total Health Care Healthy Michigan formulary is designed to assist physicians, members and other health care professionals in the selection of cost-effective agents. Total Health Care encourages your input and feedback on how we can assist in improving this document and the formulary management process. You may contact THC at 1-800-826-2862. Medication Limitations Quantity Limitations Quantity Limitations are on medications throughout the formulary and are indicated with a "QL" notation. These are medications that have a daily dose restriction, quantity/days’ supply limitation, and/or a limitation on the duration of therapy. Age Limitations Age Limitations are on medications throughout the formulary and are indicated with an "AL" notation. Coverage for a medication is indicated by the age limitation. This could be a minimum age, maximum age, and/or the combination of a minimum and maximum age edit. Gender Restrictions Gender restrictions are indicated with a “GR” on the formulary and require the member to be a specific gender for coverage. iv Step Therapy Criteria Step Therapy medications are indicated with a “ST” on the formulary and require that an alternative, first line medication be tried and failed before the requested medication can be covered. The online claims adjudication system will automatically allow for the requested medication to be filled based on electronic claims history indicating that the first line medication was filled. Step-Therapy Criteria Therapy Class First Line Second Line Step Therapy Criteria Acetylcholinesterase Inhibitors Aricept ImmediateRelease Galantamine Immediate-Release Prior use of Aricept ImmediateRelease in the last 60 days Antibiotics Cefadroxil, Cefaclor, Cefprozil Prior use of Amoxicillin, Ampicillin, Amoxicillin & Clavulanate, Cefpodoxime, Cefdinir, Cefuroxime, Cephalexin, Ciprofloxacin, Clindamycin, Dicloxacillin, Doxycycline, Erythromycin, Penicillin, SulfamethoxazoleTrimethoprim or Tetracycline in the last 30 days Antidiabetic Agents Amoxicillin, Ampicillin, Amoxicillin & Clavulanate, Cefpodoxime, Cefdinir, Cefuroxime, Cephalexin, Ciprofloxacin, Clindamycin, Dicloxacillin, Doxycycline, Erythromycin, Penicillin, SulfamethoxazoleTrimethoprim, Tetracycline Metformin Januvia, Janumet, PioglitazoneGlimepiride Prior use of Metformin in the last 90 days Glucocorticoid Inhaler Qvar Prior use of Qvar within the last 90 days. Pediculicides Lice-B-Gone Kit, Lice-B-Gone Shampoo, Pyrethrins-Piperonyl Butoxide Liquid, Permethrin Spray & Pyrethins-Piperonyl Butoxide Shampoo Kit Dulera, Symbicort, Advair Diskus 100/50 Malathion Lotion, v Prior use of Lice-B-Gone Kit, Lice-B-Gone Shampoo, Pyrethrins-Piperonyl Butoxide Liquid, Permethrin Spray & Pyrethins-Piperonyl Butoxide Shampoo Kit in the last 30 days Urinary Antispasmodics Oxybutynin, Oxybutynin Syrup, Oxytrol OTC Oxybutynin Extended-Release, Tolterodine, Tolterodine Extended-Release Prior use of Oxytrol OTC or Oxybutynin/Oxybutynin Syrup in the last 90 days. *Formulary Disclaimer: Coverage for some drugs may be limited to specific dosage forms and/or strengths. The benefit design determines what is covered. The medications listed on this formulary are subject to change pursuant to the formulary management activities of EnvisionRxOptions. The presence of a medication on this formulary list does not guarantee coverage. vi Drug Name Requirements/ Limits ANALGESICS Analgesics acetamin sup 650mg acetaminophen cap 500 mg acetaminophen chew tab 80 mg acetaminophen elixir 160 mg/5 acetaminophen liquid 160 mg/5 acetaminophen soln 100 mg/ml acetaminophen suppos 120 mg acetaminophen suppos 325 mg acetaminophen susp 80 mg/0.8m acetaminophen tab 325 mg acetaminophen tab 500 mg acetaminophen tab cr 650 mg acetaminophen-caffeine-py aspirin-acetaminophen-caffein butalbital-acetaminophen tab butalbital-acetaminophen-caff butalbital-acetaminophen-caff butalbital-acetaminophen-caff butalbital-aspirin-caff w/ co butalbital-aspirin-caffeine c BUTALBITAL-ASPIRIN-CAFFEINE T eql acetamin tab 160mg eql acetamin tab 80mg non-aspirin chw 160mg jr pain & fever sol 160/5ml Opioid Analgesics, Long-acting fentanyl td patch 72hr 100 mc PA fentanyl td patch 72hr 12 mcg PA fentanyl td patch 72hr 25 mcg PA fentanyl td patch 72hr 50 mcg PA fentanyl td patch 72hr 75 mcg PA hydromorphone hcl tab 2 mg hydromorphone hcl tab 4 mg hydromorphone hcl tab 8 mg meperidine hcl tab 100 mg meperidine hcl tab 50 mg methadone hcl conc 10 mg/ml methadone hcl soln 10 mg/5ml methadone hcl soln 5 mg/5ml methadone hcl tab 10 mg methadone hcl tab 5 mg methadone hcl tab for oral su morphine sulfate (concentrate morphine sulfate oral soln 10 morphine sulfate oral soln 20 AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 1 Formulary last updated date (11/01/2014) Drug Name morphine sulfate tab 15 mg morphine sulfate tab 30 mg morphine sulfate tab cr 100 m morphine sulfate tab cr 15 mg morphine sulfate tab cr 30 mg morphine sulfate tab cr 60 mg oxycodone hcl cap 5 mg oxycodone hcl conc 100 mg/5ml oxycodone hcl soln 5 mg/5ml oxycodone hcl tab 15 mg oxycodone hcl tab 30 mg oxycodone hcl tab 5 mg Opioid Analgesics, Short-acting acetaminophen w/ codeine soln acetaminophen w/ codeine tab acetaminophen w/ codeine tab acetaminophen w/ codeine tab codeine sulf tab 15mg codeine sulf tab 60mg codeine sulfate tab 30 mg hydrocodone-acetaminophen sol hydrocodone-acetaminophen sol hydrocodone-acetaminophen sol hydrocodone-acetaminophen tab hydrocodone-acetaminophen tab hydrocodone-acetaminophen tab hydrocodone-acetaminophen tab hydrocodone-acetaminophen tab hydrocodone-acetaminophen tab hydrocodone-acetaminophen tab hydrocodone-acetaminophen tab hydrocodone-acetaminophen tab hydrocodone-acetaminophen tab hydrocodone-acetaminophen tab oxycodone w/ acetaminophen ca oxycodone w/ acetaminophen ta oxycodone w/ acetaminophen ta oxycodone w/ acetaminophen ta oxycodone w/ acetaminophen ta oxycodone w/ acetaminophen ta oxycodone w/ acetaminophen ta oxycodone-aspirin tab 4.8355tramadol hcl tab 50 mg Requirements/ Limits QL 900/90 QL 900/90 QL 900/90 QL 240/30 ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS Smoking Cessation Agents bupropion hcl (smoking deterr QL 180/365 CHANTIX PAK 0.5& 1MG QL 60/30 AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 2 Formulary last updated date (11/01/2014) Drug Name CHANTIX PAK 1MG CHANTIX TAB 0.5MG nicotine inhaler system 1 nicotine polacrilex gum 2 mg nicotine polacrilex gum 4 mg nicotine polacrilex lozenge 2 nicotine polacrilex lozenge 4 NICOTINE SYS KIT TRANSDER nicotine td patch 24hr 14 mg/ nicotine td patch 24hr 21 mg/ nicotine td patch 24hr 7 mg/2 NICOTROL NS SPR 10MG/ML Requirements/ Limits QL 60/30 QL 60/30 QL 360/30 QL 270/30 QL 270/30 QL 270/30 QL 270/30 QL QL QL QL ANTI-INFLAMMATORY AGENTS Nonsteroidal Anti-inflammatory Drugs ascriptin tab aspirin buffered (ca carb-mg QL 30/30 AL aspirin buffered tab 325 mg QL 30/30 AL aspirin chew tab 81 mg AL aspirin suppos 300 mg aspirin suppos 600 mg aspirin tab 325 mg AL aspirin tab 500 mg aspirin tab 650mg ec aspirin tab 81 mg AL aspirin tab delayed release 3 AL aspirin tab delayed release 5 aspirin tab delayed release 8 AL choline & magnesium salicylat choline & magnesium salicylat choline & magnesium salicylat choline & magnesium salicylat diclofenac potassium tab 50 m diclofenac sodium tab delayed diclofenac sodium tab delayed diclofenac sodium tab delayed diclofenac sodium tab sr 24hr diflunisal tab 500 mg etodolac cap 200 mg etodolac cap 300 mg etodolac tab 400 mg etodolac tab 500 mg etodolac tab sr 24hr 400 mg etodolac tab sr 24hr 500 mg etodolac tab sr 24hr 600 mg fenoprofen calcium tab 600 mg flurbiprofen tab 100 mg flurbiprofen tab 50 mg AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 3 Formulary last updated date (11/01/2014) Drug Name goodys tab ex st halfprin tab 162mg ec ibuprofen jr chw 100mg ibuprofen susp 100 mg/5ml ibuprofen susp 40 mg/ml ibuprofen tab 200 mg ibuprofen tab 400 mg ibuprofen tab 600 mg ibuprofen tab 800 mg indocin sus 25mg/5ml indomethacin cap 25 mg indomethacin cap 50 mg ketoprofen cap 50 mg ketoprofen cap 75 mg ketorolac tromethamine tab 10 meclofenamate sodium cap 50 m meloxicam tab 15 mg meloxicam tab 7.5 mg nabumetone tab 500 mg nabumetone tab 750 mg NAPRELAN TAB 375MG CR NAPRELAN TAB 500MG CR NAPRELAN TAB 750MG CR naproxen kit comfort naproxen pow NAPROXEN POW SODIUM naproxen sodium cap 220 mg naproxen sodium tab 220 mg naproxen sodium tab 275 mg naproxen sodium tab 550 mg naproxen susp 125 mg/5ml naproxen tab 250 mg naproxen tab 375 mg naproxen tab 500 mg naproxen tab ec 375 mg oxaprozin tab 600 mg piroxicam cap 10 mg piroxicam cap 20 mg salsalate tab 500 mg salsalate tab 750 mg sm ibuprofen tab 100mg jr sulindac tab 150 mg sulindac tab 200 mg Requirements/ Limits QL 360/30 QL 120/30 QL 20/5 QL 120/30 QL 60/30 ANTIBACTERIALS Aminoglycosides neomycin sulfate tab 500 mg Antibacterials, Other AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 4 Formulary last updated date (11/01/2014) Drug Name clindamycin hcl cap 150 mg clindamycin hcl cap 300 mg clindamycin hcl cap 75 mg clindamycin sol 75mg/5ml dapsone tab 100 mg dapsone tab 25 mg DORIBAX INJ 250MG DORIBAX INJ 500MG erythromycin-sulfisoxazole fo MACRODANTIN CAP 25MG METHENAM MAN TAB 500MG methenamine hippurate tab 1 g methenamine mandelate tab 1 g metronidazole tab 250 mg metronidazole tab 500 mg nitrofurantoin macrocrystalli nitrofurantoin macrocrystalli nitrofurantoin monohydrate ma PRIMSOL SOL 50MG/5ML sulfamethoxazole-trimethoprim sulfamethoxazole-trimethoprim sulfamethoxazole-trimethoprim trimethoprim tab 100 mg vancomycin hcl for inj 10 gm vancomycin hcl for inj 1000 m vancomycin hcl for inj 500 mg vancomycin hcl for inj 5000 m VANCOMYCIN INJ 750MG VANCOMYCN 25 SOL 25MG/ML VANCOMYCN 50 SOL 50MG/ML Beta-lactam, Cephalosporins cefaclor cap 250 mg cefaclor cap 500 mg CEFACLOR SUS 125/5ML CEFACLOR SUS 250/5ML CEFACLOR SUS 375/5ML cefadroxil cap 500 mg cefadroxil for susp 250 mg/5m cefadroxil for susp 500 mg/5m cefadroxil tab 1 gm cefdinir cap 300 mg cefdinir for susp 125 mg/5ml cefdinir for susp 250 mg/5ml cefpodoxime proxetil for susp cefpodoxime proxetil for susp cefpodoxime proxetil tab 100 cefpodoxime proxetil tab 200 Requirements/ Limits QL 60/30 QL 60/30 QL 60/30 QL 600/30 QL 60/30 PA PA PA PA PA QL 20/14 QL 10/14 ST ST ST ST ST QL 40/10 ST ST ST QL 20/10 ST AL AL QL 60/30 QL 60/30 AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 5 Formulary last updated date (11/01/2014) Drug Name cefprozil for susp 125 mg/5ml cefprozil for susp 250 mg/5ml cefprozil tab 250 mg cefprozil tab 500 mg CEFTIN SUS 250/5ML ceftriaxone sodium for inj 1 ceftriaxone sodium for inj 25 ceftriaxone sodium for inj 50 cefuroxime axetil for susp 12 cefuroxime axetil tab 250 mg cefuroxime axetil tab 500 mg cephalexin cap 250 mg cephalexin cap 500 mg cephalexin for susp 125 mg/5m cephalexin for susp 250 mg/5m Beta-lactam, Penicillins amoxicillin & k clavulanate c amoxicillin & k clavulanate c amoxicillin & k clavulanate f amoxicillin & k clavulanate f amoxicillin & k clavulanate f amoxicillin & k clavulanate t amoxicillin & k clavulanate t amoxicillin & k clavulanate t amoxicillin (trihydrate) cap amoxicillin (trihydrate) cap amoxicillin (trihydrate) chew amoxicillin (trihydrate) chew amoxicillin (trihydrate) for amoxicillin (trihydrate) for amoxicillin (trihydrate) for amoxicillin (trihydrate) for amoxicillin (trihydrate) tab amoxicillin (trihydrate) tab ampicillin cap 250 mg ampicillin cap 500 mg ampicillin for susp 125 mg/5m ampicillin for susp 250 mg/5m BICILLIN C-R INJ 1200000 BICILLIN C-R INJ 900/300 dicloxacillin sodium cap 250 dicloxacillin sodium cap 500 penicillin v potassium for so penicillin v potassium for so penicillin v potassium tab 25 penicillin v potassium tab 50 Macrolides Requirements/ Limits ST ST QL 60/30 ST QL 60/30 ST AL QL 10/30 QL 10/30 QL 10/30 AL QL 28/14 QL 28/14 QL 4/28 QL 4/28 AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 6 Formulary last updated date (11/01/2014) Drug Name azithromycin for susp 100 mg/ azithromycin for susp 200 mg/ azithromycin tab 250 mg azithromycin tab 500 mg azithromycin tab 600 mg clarithromycin for susp 125 m clarithromycin for susp 250 m clarithromycin tab 250 mg clarithromycin tab 500 mg clarithromycin tab sr 24hr 50 ERY-TAB TAB 250MG EC ERY-TAB TAB 333MG EC ERYPED SUS 200/5ML ERYPED SUS 400/5ML erythromycin ethylsuccinate t erythromycin stearate tab 250 erythromycin tab 250 mg erythromycin tab 500 mg erythromycin tab delayed rele erythromycin w/ delayed relea PCE TAB 333MG EC PCE TAB 500MG EC Quinolones ciprofloxacin hcl tab 100 mg ciprofloxacin hcl tab 250 mg ciprofloxacin hcl tab 500 mg ciprofloxacin hcl tab 750 mg levofloxacin tab 250 mg levofloxacin tab 500 mg levofloxacin tab 750 mg ofloxacin tab 200 mg ofloxacin tab 300 mg ofloxacin tab 400 mg Sulfonamides sulfadiazine tab 500 mg Tetracyclines doxycycline hyclate cap 100 m doxycycline hyclate cap 50 mg doxycycline hyclate tab 100 m doxycycline monohydrate for s minocycline hcl cap 100 mg minocycline hcl cap 50 mg minocycline hcl cap 75 mg TETRACYCLINE CAP 500MG tetracycline hcl cap 250 mg VIBRAMYCIN SYP 50MG/5ML Requirements/ Limits QL 12/30 QL 12/30 QL 60/30 QL 14/14 QL 14/14 QL 14/14 QL 60/30 QL 60/30 QL 60/30 ANTIDEMENTIA AGENTS AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 7 Formulary last updated date (11/01/2014) Drug Name Cholinesterase Inhibitors donepezil hydrochloride tab 1 donepezil hydrochloride tab 5 galantamine hydrobromide tab galantamine hydrobromide tab galantamine hydrobromide tab Requirements/ Limits ST ST ST ANTIEMETICS Emetogenic Therapy Adjuncts DIMENHYDRIN INJ 50MG/ML dimenhydrinate tab 50 mg DRAMAMINE CHW 50MG dronabinol cap 10 mg dronabinol cap 2.5 mg dronabinol cap 5 mg meclizine hcl chew tab 25 mg meclizine hcl tab 12.5 mg meclizine hcl tab 25 mg meclizine hcl tab 32 mg MECLIZINE POW HCL ondansetron hcl oral soln 4 m ondansetron hcl tab 4 mg ondansetron hcl tab 8 mg ondansetron orally disintegra ondansetron orally disintegra trimethobenzamide hcl cap 300 PA PA PA QL 50/30 ANTIFUNGALS Antifungals fluconazole for susp 10 mg/ml fluconazole for susp 40 mg/ml fluconazole tab 100 mg fluconazole tab 150 mg fluconazole tab 200 mg fluconazole tab 50 mg griseofulvin microsize susp 1 griseofulvin microsize tab 50 griseofulvin ultramicrosize t griseofulvin ultramicrosize t ketoconazole tab 200 mg nystatin tab 500000 unit terbinafine hcl tab 250 mg QL 30/30 QL 4/30 QL 30/30 QL 30/30 ANTIGOUT AGENTS Antigout Agents allopurinol tab 100 mg allopurinol tab 300 mg colchicine w/ probenecid tab COLCRYS TAB 0.6MG QL 20/30 probenecid tab 500 mg AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 8 Formulary last updated date (11/01/2014) Drug Name Requirements/ Limits ANTIMIGRAINE AGENTS Serotonin (5-HT) 1b/1d Receptor Agonists sumatriptan succinate tab 100 sumatriptan succinate tab 25 sumatriptan succinate tab 50 QL 9/30 QL 9/30 QL 9/30 ANTIMYASTHENIC AGENTS Parasympathomimetics pyridostigmine bromide sy pyridostigmine bromide ta pyridostigmine bromide ta ANTIMYCOBACTERIALS Antituberculars cycloserine cap 250 mg ethambutol hcl tab 100 mg ethambutol hcl tab 400 mg isoniazid syrup 50 mg/5ml isoniazid tab 100 mg isoniazid tab 300 mg pyrazinamide tab 500 mg rifabutin cap 150 mg rifampin cap 150 mg rifampin cap 300 mg RIFATER TAB TRECATOR TAB 250MG ANTINEOPLASTICS Antineoplastics anastrozole tab 1 mg GR bicalutamide tab 50 mg capecitabine tab 150 mg PA capecitabine tab 500 mg PA cyclophosphamide tab 25 mg cyclophosphamide tab 50 mg ELIGARD INJ 22.5MG PA ELIGARD INJ 30MG PA ELIGARD INJ 45MG PA ELIGARD INJ 7.5MG PA flutamide cap 125 mg PA HEXALEN CAP 50MG PA hydroxyurea cap 500 mg INTRON-A INJ 10MU PA INTRON-A INJ 18MU PA INTRON-A INJ 18MU PA INTRON-A INJ 25MU PA INTRON-A INJ 50MU PA letrozole tab 2.5 mg QL 30/30 AL leucovorin calcium tab 15 mg leucovorin calcium tab 25 mg AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 9 Formulary last updated date (11/01/2014) Drug Name leucovorin calcium tab 5 mg LEUKERAN TAB 2MG lomustine cap 10 mg lomustine cap 100 mg lomustine cap 40 mg LUPRON DEPOT INJ 11.25MG LUPRON DEPOT INJ 22.5MG LUPRON DEPOT INJ 3.75MG LUPRON DEPOT INJ 30MG LUPRON DEPOT INJ 7.5MG MATULANE CAP 50MG megestrol acetate susp 40 mg/ megestrol acetate tab 20 mg megestrol acetate tab 40 mg mercaptopurine tab 50 mg methotrexate sodium tab 2.5 m MYLERAN TAB 2MG TABLOID TAB 40MG tamoxifen citrate tab 10 mg ( tamoxifen citrate tab 20 mg ( tretinoin cap 10 mg Requirements/ Limits PA PA PA PA PA PA PA PA PA PA PA PA PA ANTIPARASITICS Anthelmintics STROMECTOL TAB 3MG Antibacterials, Other atovaquone susp 750 mg/5ml Antiprotozoals chloroquine phosphate tab 250 DARAPRIM TAB 25MG hydroxychloroquine sulfate ta mefloquine hcl tab 250 mg PRIMAQUINE TAB 26.3MG quinine sulfate cap 324 mg QL 20/90 QL 210/18 PA QL 6/30 QL 5/30 QL 14/30 ANTIPARKINSON AGENTS Antiparkinson Agents, Other amantadine hcl cap 100 mg amantadine hcl syrup 50 mg/5m bromocriptine mesylate cap 5 bromocriptine mesylate tab 2. carbidopa tab 25 mg selegiline hcl cap 5 mg Dopamine Agonists carbidopa & levodopa tab 10-1 carbidopa & levodopa tab 25-1 carbidopa & levodopa tab 25-2 carbidopa & levodopa tab cr 2 carbidopa & levodopa tab cr 5 AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 10 Formulary last updated date (11/01/2014) Drug Name pramipexole dihydrochloride t pramipexole dihydrochloride t pramipexole dihydrochloride t pramipexole dihydrochloride t pramipexole dihydrochloride t ropinirole hydrochloride tab ropinirole hydrochloride tab ropinirole hydrochloride tab ropinirole hydrochloride tab ropinirole hydrochloride tab ropinirole hydrochloride tab ropinirole hydrochloride tab Requirements/ Limits ANTIPSYCHOTICS 1st Generation/Typical prochlorperazine maleate tab prochlorperazine maleate tab prochlorperazine suppos 25 mg QL 60/30 ANTIVIRALS Anti-HIV Agents, Other EPIVIR HBV SOL 5MG/ML lamivudine tab 100 mg Anti-influenza Agents RELENZA MIS DISKHALE rimantadine hydrochloride tab TAMIFLU CAP 30MG TAMIFLU CAP 45MG TAMIFLU CAP 75MG TAMIFLU SUS 6MG/ML Antihepatitis Agents INFERGEN INJ 15MCG INFERGEN INJ 9MCG PEG-INTRON KIT 120 RP PEG-INTRON KIT 150MCG PEG-INTRON KIT 50MCG RP PEG-INTRON KIT 80MCG ribavirin cap 200 mg Antiherpetic Agents acyclovir cap 200 mg acyclovir susp 200 mg/5ml acyclovir tab 400 mg acyclovir tab 800 mg QL 1800/30 QL 90/30 QL 20/5 QL 10/5 QL 10/5 QL 10/5 QL 120/10 AL PA PA PA PA PA PA PA AL ANXIOLYTICS Anxiolytics, Other hydroxyzine hcl syrup 10 mg/5 hydroxyzine hcl tab 10 mg hydroxyzine hcl tab 25 mg hydroxyzine hcl tab 50 mg AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 11 Formulary last updated date (11/01/2014) Drug Name hydroxyzine pamoate cap 100 m hydroxyzine pamoate cap 25 mg hydroxyzine pamoate cap 50 mg Requirements/ Limits BLOOD GLUCOSE REGULATORS Antidiabetic Agents acarbose tab 100 mg acarbose tab 25 mg acarbose tab 50 mg BYDUREON INJ chlorpropamide tab 100 mg chlorpropamide tab 250 mg glimepiride tab 1 mg glimepiride tab 2 mg glimepiride tab 4 mg glipizide tab 10 mg glipizide tab 5 mg glipizide tab sr 24hr 10 mg QL 60/30 glipizide tab sr 24hr 2.5 mg QL 60/30 glipizide tab sr 24hr 5 mg QL 60/30 glyburide micronized tab 1.5 glyburide micronized tab 3 mg glyburide micronized tab 6 mg glyburide tab 1.25 mg glyburide tab 2.5 mg glyburide tab 5 mg glyburide-metformin tab 1.25glyburide-metformin tab 2.5-5 glyburide-metformin tab 5-500 INVOKANA TAB 100MG PA INVOKANA TAB 300MG PA JANUMET TAB 50-1000 QL 60/30 ST JANUMET TAB 50-500MG QL 60/30 ST JANUVIA TAB 100MG QL 30/30 ST JANUVIA TAB 25MG QL 30/30 ST JANUVIA TAB 50MG QL 30/30 ST metformin hcl tab 1000 mg metformin hcl tab 500 mg metformin hcl tab 850 mg metformin hcl tab sr 24hr 500 metformin hcl tab sr 24hr 750 nateglinide tab 120 mg QL 90/30 nateglinide tab 60 mg QL 90/30 pioglitazone hcl tab 15 mg (b QL 30/30 pioglitazone hcl tab 30 mg (b QL 30/30 pioglitazone hcl tab 45 mg (b QL 30/30 pioglitazone hcl-metformin hc QL 60/30 pioglitazone hcl-metformin hc QL 60/30 AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 12 Formulary last updated date (11/01/2014) Drug Name Glycemic Agents GLUCAGON KIT 1MG glucose gel 40% Insulins APIDRA INJ U-100 HUMULIN N PN INJ U-100 HUMULIN PEN INJ 70/30 LANTUS INJ 100/ML LEVEMIR INJ NOVOLIN INJ 70/30 NOVOLIN N INJ U-100 NOVOLIN R INJ U-100 NOVOLOG MIX INJ 70/30 Requirements/ Limits QL 2/365 BLOOD PRODUCTS/MODIFIERS/ VOLUME EXPANDERS Anticoagulants enoxaparin sodium inj 100 mg/ PA QL AL GR enoxaparin sodium inj 120 mg/ PA QL AL GR enoxaparin sodium inj 150 mg/ PA QL AL GR enoxaparin sodium inj 30 mg/0 PA QL AL GR enoxaparin sodium inj 300 mg/ PA QL AL GR enoxaparin sodium inj 40 mg/0 PA QL AL GR enoxaparin sodium inj 60 mg/0 PA QL AL GR enoxaparin sodium inj 80 mg/0 PA QL AL GR heparin sodium (porcine) inj heparin sodium (porcine) inj heparin sodium (porcine) inj heparin sodium (porcine) inj heparin sodium (porcine) inj heparin sodium (porcine) pf i warfarin sodium tab 1 mg warfarin sodium tab 10 mg warfarin sodium tab 2 mg warfarin sodium tab 2.5 mg warfarin sodium tab 3 mg warfarin sodium tab 4 mg warfarin sodium tab 5 mg warfarin sodium tab 6 mg warfarin sodium tab 7.5 mg xarelto tab 10mg PA QL 35/35 Blood Formation Modifiers EPOGEN INJ 10000/ML PA EPOGEN INJ 2000/ML PA EPOGEN INJ 20000/ML PA EPOGEN INJ 3000/ML PA EPOGEN INJ 4000/ML PA NEUPOGEN INJ 300/0.5 PA NEUPOGEN INJ 300MCG PA AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 13 Formulary last updated date (11/01/2014) Drug Name NEUPOGEN INJ 480/0.8 NEUPOGEN INJ 480MCG PROCRIT INJ 40000/ML Platelet Modifying Agents anagrelide hcl cap 0.5 mg anagrelide hcl cap 1 mg cilostazol tab 100 mg cilostazol tab 50 mg clopidogrel bisulfate tab 300 clopidogrel bisulfate tab 75 dipyridamole tab 25 mg dipyridamole tab 50 mg dipyridamole tab 75 mg EFFIENT TAB 10MG EFFIENT TAB 5MG ticlopidine hcl tab 250 mg Requirements/ Limits PA PA PA QL 5/90 QL 30/30 PA PA CARDIOVASCULAR AGENTS Alpha-adrenergic Agonists midodrine hcl tab 10 mg midodrine hcl tab 2.5 mg midodrine hcl tab 5 mg Angiotensin II Receptor Antagonists losartan potassium tab 100 mg QL 30/30 losartan potassium tab 25 mg QL 30/30 losartan potassium tab 50 mg QL 30/30 Angiotensin-converting Enzyme (ACE) Inhibitors benazepril hcl tab 10 mg QL 30/30 benazepril hcl tab 20 mg QL 30/30 benazepril hcl tab 40 mg benazepril hcl tab 5 mg QL 30/30 captopril tab 100 mg captopril tab 12.5 mg QL 30/30 captopril tab 25 mg QL 30/30 captopril tab 50 mg QL 30/30 enalapril maleate tab 10 mg QL 30/30 enalapril maleate tab 2.5 mg QL 30/30 enalapril maleate tab 20 mg enalapril maleate tab 5 mg QL 30/30 fosinopril sodium tab 10 mg QL 30/30 fosinopril sodium tab 20 mg QL 30/30 fosinopril sodium tab 40 mg lisinopril tab 10 mg QL 30/30 lisinopril tab 2.5 mg QL 30/30 lisinopril tab 20 mg QL 30/30 lisinopril tab 30 mg QL 30/30 lisinopril tab 40 mg lisinopril tab 5 mg QL 30/30 AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 14 Formulary last updated date (11/01/2014) Drug Name moexipril hcl tab 15 mg moexipril hcl tab 7.5 mg quinapril hcl tab 10 mg quinapril hcl tab 20 mg quinapril hcl tab 40 mg quinapril hcl tab 5 mg ramipril cap 1.25 mg ramipril cap 10 mg ramipril cap 2.5 mg ramipril cap 5 mg trandolapril tab 1 mg trandolapril tab 2 mg trandolapril tab 4 mg Antiarrhythmics amiodarone hcl tab 200 mg disopyramide phosphate cap 10 disopyramide phosphate cap 15 flecainide acetate tab 100 mg flecainide acetate tab 150 mg flecainide acetate tab 50 mg NORPACE CAP 100MG CR NORPACE CAP 150MG CR propafenone hcl tab 150 mg propafenone hcl tab 225 mg propafenone hcl tab 300 mg quinidine gluconate tab cr 32 quinidine sulfate tab 200 mg quinidine sulfate tab 300 mg Antihypertensive Combinations amlodipine besylate-benazepri amlodipine besylate-benazepri amlodipine besylate-benazepri amlodipine besylate-benazepri amlodipine besylate-benazepri amlodipine besylate-benazepri atenolol & chlorthalidone tab atenolol & chlorthalidone tab AZOR TAB 10-20MG AZOR TAB 10-40MG AZOR TAB 5-20MG AZOR TAB 5-40MG benazepril & hydrochlorothiaz benazepril & hydrochlorothiaz benazepril & hydrochlorothiaz benazepril & hydrochlorothiaz bisoprolol & hydrochlorothiaz bisoprolol & hydrochlorothiaz Requirements/ Limits QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 60/30 QL 120/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 PA QL 30/30 PA QL 30/30 PA QL 30/30 PA QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 15 Formulary last updated date (11/01/2014) Drug Name bisoprolol & hydrochlorothiaz captopril & hydrochlorothiazi captopril & hydrochlorothiazi captopril & hydrochlorothiazi captopril & hydrochlorothiazi enalapril maleate & hydrochlo enalapril maleate & hydrochlo lisinopril & hydrochlorothiaz lisinopril & hydrochlorothiaz lisinopril & hydrochlorothiaz losartan potassium & hydrochl losartan potassium & hydrochl losartan potassium & hydrochl metoprolol & hydrochlorothiaz metoprolol & hydrochlorothiaz metoprolol & hydrochlorothiaz propranolol & hydrochlorothia propranolol & hydrochlorothia quinapril-hydrochlorothiazide quinapril-hydrochlorothiazide quinapril-hydrochlorothiazide Beta-adrenergic Blocking Agents acebutolol hcl cap 200 mg acebutolol hcl cap 400 mg atenolol tab 100 mg atenolol tab 25 mg atenolol tab 50 mg bisoprolol fumarate tab 10 mg bisoprolol fumarate tab 5 mg BYSTOLIC TAB 10MG BYSTOLIC TAB 2.5MG BYSTOLIC TAB 20MG BYSTOLIC TAB 5MG carvedilol tab 12.5 mg carvedilol tab 25 mg carvedilol tab 3.125 mg carvedilol tab 6.25 mg diltiazem hcl cap sr 24hr 120 labetalol hcl tab 100 mg labetalol hcl tab 200 mg labetalol hcl tab 300 mg metoprolol succinate tab sr 2 metoprolol succinate tab sr 2 metoprolol succinate tab sr 2 metoprolol succinate tab sr 2 metoprolol tartrate tab 100 m metoprolol tartrate tab 25 mg Requirements/ Limits QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 PA PA PA PA QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 16 Formulary last updated date (11/01/2014) Drug Name metoprolol tartrate tab 50 mg nadolol tab 20 mg nadolol tab 40 mg nadolol tab 80 mg pindolol tab 10 mg pindolol tab 5 mg propranolol hcl cap sr 24hr 1 propranolol hcl cap sr 24hr 1 propranolol hcl cap sr 24hr 6 propranolol hcl cap sr 24hr 8 propranolol hcl oral soln 20 propranolol hcl oral soln 40 propranolol hcl tab 10 mg propranolol hcl tab 20 mg propranolol hcl tab 40 mg propranolol hcl tab 60 mg propranolol hcl tab 80 mg sotalol hcl (afib/afl) tab 12 sotalol hcl (afib/afl) tab 16 sotalol hcl (afib/afl) tab 80 sotalol hcl tab 120 mg sotalol hcl tab 160 mg sotalol hcl tab 240 mg sotalol hcl tab 80 mg timolol maleate tab 10 mg timolol maleate tab 20 mg timolol maleate tab 5 mg Calcium Channel Blocking Agents amlodipine besylate tab 10 mg amlodipine besylate tab 2.5 m amlodipine besylate tab 5 mg diltiazem hcl cap sr 12hr 120 diltiazem hcl cap sr 12hr 60 diltiazem hcl cap sr 12hr 90 diltiazem hcl cap sr 24hr 180 diltiazem hcl cap sr 24hr 240 diltiazem hcl coated beads ca diltiazem hcl coated beads ca diltiazem hcl coated beads ca diltiazem hcl coated beads ca diltiazem hcl coated beads ca diltiazem hcl coated beads ta diltiazem hcl coated beads ta diltiazem hcl coated beads ta diltiazem hcl coated beads ta diltiazem hcl coated beads ta diltiazem hcl extended releas Requirements/ Limits QL 30/30 QL 30/30 QL 30/30 QL 60/30 QL 60/30 QL 60/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 17 Formulary last updated date (11/01/2014) Drug Name diltiazem hcl tab 120 mg diltiazem hcl tab 30 mg diltiazem hcl tab 60 mg diltiazem hcl tab 90 mg felodipine tab sr 24hr 10 mg felodipine tab sr 24hr 2.5 mg felodipine tab sr 24hr 5 mg nicardipine hcl cap 20 mg nicardipine hcl cap 30 mg nifedipine cap 10 mg nifedipine cap 20 mg nifedipine tab sr 24hr 30 mg nifedipine tab sr 24hr 60 mg nifedipine tab sr 24hr 90 mg nifedipine tab sr 24hr osmoti nifedipine tab sr 24hr osmoti nifedipine tab sr 24hr osmoti verapamil hcl cap sr 24hr 100 verapamil hcl cap sr 24hr 120 verapamil hcl cap sr 24hr 180 verapamil hcl cap sr 24hr 200 verapamil hcl cap sr 24hr 240 verapamil hcl cap sr 24hr 300 verapamil hcl cap sr 24hr 360 verapamil hcl tab 120 mg verapamil hcl tab 40 mg verapamil hcl tab 80 mg verapamil hcl tab cr 120 mg verapamil hcl tab cr 180 mg verapamil hcl tab cr 240 mg Cardiovascular Agents, Other clonidine hcl tab 0.1 mg clonidine hcl tab 0.2 mg clonidine hcl tab 0.3 mg digoxin tab 125 mcg (0.125 mg digoxin tab 250 mcg (0.25 mg) doxazosin mesylate tab 1 mg doxazosin mesylate tab 2 mg doxazosin mesylate tab 4 mg doxazosin mesylate tab 8 mg guanfacine hcl tab 1 mg guanfacine hcl tab 2 mg hydralazine hcl tab 10 mg hydralazine hcl tab 100 mg hydralazine hcl tab 25 mg hydralazine hcl tab 50 mg isosorbide dinitrate sl tab 2 Requirements/ Limits QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 18 Formulary last updated date (11/01/2014) Drug Name isosorbide dinitrate tab 10 m isosorbide dinitrate tab 20 m isosorbide dinitrate tab 30 m isosorbide dinitrate tab 5 mg isosorbide dinitrate tab cr 4 isosorbide mononitrate tab 20 isosorbide mononitrate tab sr isosorbide mononitrate tab sr isosorbide mononitrate tab sr methyldopa tab 250 mg methyldopa tab 500 mg minoxidil tab 10 mg minoxidil tab 2.5 mg NITRO-BID OIN 2% nitroglycerin cap cr 2.5 mg nitroglycerin cap cr 6.5 mg nitroglycerin cap cr 9 mg nitroglycerin td patch 24hr 0 nitroglycerin td patch 24hr 0 nitroglycerin td patch 24hr 0 nitroglycerin td patch 24hr 0 NITROSTAT SUB 0.3MG NITROSTAT SUB 0.4MG NITROSTAT SUB 0.6MG pentoxifylline tab cr 400 mg prazosin hcl cap 1 mg prazosin hcl cap 2 mg prazosin hcl cap 5 mg terazosin hcl cap 1 mg terazosin hcl cap 10 mg terazosin hcl cap 2 mg terazosin hcl cap 5 mg Diuretics, Carbonic Anhydrase Inhibitors acetazolamide cap sr 12hr 500 acetazolamide tab 125 mg acetazolamide tab 250 mg methazolamide tab 25 mg methazolamide tab 50 mg Diuretics, Loop bumetanide tab 0.5 mg bumetanide tab 1 mg bumetanide tab 2 mg furosemide oral soln 10 mg/ml furosemide tab 20 mg furosemide tab 40 mg furosemide tab 80 mg torsemide tab 10 mg Requirements/ Limits QL 90/30 AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 19 Formulary last updated date (11/01/2014) Drug Name torsemide tab 100 mg torsemide tab 20 mg torsemide tab 5 mg Diuretics, Potassium-sparing amiloride hcl tab 5 mg spironolactone tab 100 mg spironolactone tab 25 mg spironolactone tab 50 mg Diuretics, Thiazide amiloride & hydrochlorothiazi chlorothiazide tab 250 mg chlorothiazide tab 500 mg chlorthalidone tab 100 mg chlorthalidone tab 25 mg chlorthalidone tab 50 mg DIURIL SUS 250/5ML hydrochlorothiazide cap 12.5 hydrochlorothiazide tab 25 mg hydrochlorothiazide tab 50 mg indapamide tab 1.25 mg indapamide tab 2.5 mg methyclothiazide tab 5 mg metolazone tab 10 mg metolazone tab 2.5 mg metolazone tab 5 mg spironolactone & hydrochlorot triamterene & hydrochlorothia triamterene & hydrochlorothia triamterene & hydrochlorothia triamterene & hydrochlorothia Dyslipidemics, Fibric Acid Derivatives fenofibrate micronized cap 13 fenofibrate micronized cap 20 fenofibrate micronized cap 67 gemfibrozil tab 600 mg Dyslipidemics, HMG CoA Reductase Inhibitors atorvastatin calcium tab 10 m atorvastatin calcium tab 20 m atorvastatin calcium tab 40 m atorvastatin calcium tab 80 m lovastatin tab 10 mg lovastatin tab 20 mg lovastatin tab 40 mg pravastatin sodium tab 10 mg pravastatin sodium tab 20 mg pravastatin sodium tab 40 mg pravastatin sodium tab 80 mg Requirements/ Limits QL 600/30 AL QL 30/30 QL 30/30 QL 30/30 QL 30/30 AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 20 Formulary last updated date (11/01/2014) Drug Name simvastatin tab 10 mg simvastatin tab 20 mg simvastatin tab 40 mg simvastatin tab 5 mg Dyslipidemics, Other cholestyramine powder 4 gm/do cholestyramine powder packets colestipol hcl granule packet colestipol hcl granules 5 gm colestipol hcl tab 1 gm fenofibrate tab 160mg fenofibrate tab 54mg NIACOR TAB 500MG Requirements/ Limits QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 QL 30/30 CENTRAL NERVOUS SYSTEM AGENTS Multiple Sclerosis Agents AVONEX KIT 30MCG avonex prefl kit 30mcg COPAXONE KIT 20MG/ML EXTAVIA INJ 0.3MG PA PA PA PA DENTAL AND ORAL AGENTS Dental and Oral Agents anbesol liq 10% BABY ORAJEL LIQ 7.5% benzocaine dental cream 20% benzocaine dental gel 10% benzocaine dental gel 20% benzocaine dental gel 7.5% benzocaine dental liquid 20% benzocaine dental paste 20% benzocaine dental soln 20% benzocaine dental swab 20% benzodent oin 20% chlorhexidine gluconate soln clotrimazole troche 10 mg lidocaine hcl laryngotracheal lidocaine hcl viscous soln 2% little teeth mis pain rel nystatin susp 100000 unit/ml ORA-FILM MIS 6% oramagic pls sus 10% pilocarpine hcl tab 5 mg sodium fluoride cream 1.1% stannous fluoride conc 0.63% stannous fluoride gel 0.4% toothache gum triamcinolone acetonide denta DERMATOLOGICAL AGENTS AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 21 Formulary last updated date (11/01/2014) Drug Name Dermatological Agents ALneomycin-bacitracin-polymyxi ALneomycin-bacitracin-polymyxi ALnit remover - gelALALAL ALnystatin topical powderALAL A-200 GEL 0.33-4% abreva cre 10% ACETONE SOL ACNE MEDICAT LOT 10% acne medicat lot 5% ACNOTEX LOT ACTIPHYTE OF LIQ LEMONGRA alclometasone dipropionate cr alclometasone dipropionate oi ALCOHOL ISOP SOL 50% WINT alevazol oin 1% AMMONIUM LAC SOL 70% ANISE OIL bacitracin oint 500 unit/gm bacitracin zinc oint 500 unit BARC LIQ BENSULFOID CRE BENZOYL PER GEL 2.5% benzoyl peroxide cleanser 3.5 benzoyl peroxide cream 10% benzoyl peroxide cream 2.5% benzoyl peroxide creamy wash benzoyl peroxide creamy wash benzoyl peroxide gel 10% benzoyl peroxide gel 4% benzoyl peroxide gel 5% benzoyl peroxide liq 10% benzoyl peroxide liq 2.5% benzoyl peroxide liq 5% benzoyl peroxide lotion 6% BENZOYL PEROXIDE LOTION 8% BENZYL BENZO LIQ betamethasone dipropionate au betamethasone dipropionate cr betamethasone dipropionate lo betamethasone dipropionate oi betamethasone valerate cream betamethasone valerate lotion betamethasone valerate oint 0 BP CLEANSING LOT 4% BRASIVOL PST CAMPHOR SOL SPIRITS Requirements/ Limits QL 100/30 QL 90/30 QL 120/30 QL 90/30 QL 90/30 QL 120/30 QL 90/30 AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 22 Formulary last updated date (11/01/2014) Drug Name CAPSAGEL GEL 0.025% CAPSAGEL MS GEL 0.075% CAPSAGEL XS GEL 0.05% capsaicin cream 0.025% capsaicin cream 0.075% capsaicin cream 0.1% CAPZASIN LIQ 0.15% castiva lot CASTOR OIL CEDAR LEAF OIL CELERY SEED OIL CHLORHEXIDIN SOL GLUCONAT CHLOROFORM SOL ciclopirox solution 8% CINNAMON OIL ARTIFIC CITRONELLA OIL clean&clear kit acne clindamycin phosphate lotion clindamycin phosphate soln 1% clindamycin phosphate swab 1% clobetasol propionate cream 0 clobetasol propionate oint 0. clobetasol propionate soln 0. clotrimazole cream 1% clotrimazole soln 1% clotrimazole w/ betamethasone clotrimazole w/ betamethasone CLOVE OIL cortisporin oin 1% cortizone-10 liq /aloe 1% COTTONSEED OIL DENATURED SOL ALCOHOL denorex dual sha 1%-3% DERMA-SMOOTH OIL /FS BODY DERMA-SMOOTH OIL /FS SCLP desonide oint 0.05% DIFLORASONE DIACETATE OINT 0. DIMETHYL SOL SULFOXID econazole nitrate cream 1% EFFACLAR DUO SOL 5.5% erythromycin gel 2% erythromycin soln 2% ETHER SOL ETHYL ALCOHO SOL 70% ETHYL ALCOHO SOL 95% ethyl chlor aer mist EUCALYPTUS OIL Requirements/ Limits QL 6.6/30 QL 120/30 QL 120/30 QL 100/30 QL 90/24 QL 60/24 QL 36/30 QL 120/30 QL 120/30 QL 120/30 QL 120/30 AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 23 Formulary last updated date (11/01/2014) Drug Name EUGENOL SOL EURAX CRE 10% EURAX LOT 10% exoderm bar fleet naturl ene cleansng fluocinolone acetonide cream fluocinolone acetonide cream fluocinolone acetonide oint 0 fluocinonide cream 0.05% fluocinonide emulsified base fluocinonide gel 0.05% fluocinonide oint 0.05% fluocinonide soln 0.05% fluorouracil cream 5% fluorouracil soln 2% fluorouracil soln 5% fluticasone propionate cream fluticasone propionate oint 0 gentamicin sulfate cream 0.1% gentamicin sulfate oint 0.1% GLYCERIN LIQ GLYCERIN SOL SYNTHETC GLYCINE SOYA SOL EXTRACT GLYCINE SOYA SOL PROTEIN GNP ALCOHOL SOL DENATURE grandpas bar thylox GUAIACOL SOL halobetasol propionate cream halobetasol propionate oint 0 HC DERMAPAX SPR 0.5-0.5% hc-1% hemorr oin 1% hydrocort ac cre 0.5% hydrocortisone acetate cream hydrocortisone acetate suppos hydrocortisone acetate suppos hydrocortisone cream 0.5% hydrocortisone cream 1% hydrocortisone cream 2.5% hydrocortisone enema 100 mg/6 hydrocortisone gel 1% hydrocortisone lotion 1% hydrocortisone lotion 2.5% hydrocortisone oint 0.5% hydrocortisone oint 1% hydrocortisone oint 2.5% hydrocortisone rectal cream 1 hydrocortisone rectal cream 2 Requirements/ Limits QL 120/365 QL 120/365 QL 120/30 QL 120/30 QL 120/30 QL 120/30 QL 120/30 QL 120/30 QL 120/30 QL 120/30 QL 120/30 QL 120/30 QL 100/30 QL 100/30 QL 60/30 QL 120/30 QL 60/30 QL 28/14 QL 28/14 QL 60/30 QL 120/30 QL 90/30 QL 60/30 QL 240/30 QL 120/30 QL 60/30 QL 60/30 QL 90/30 AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 24 Formulary last updated date (11/01/2014) Drug Name hydrocortisone soln 1% hydrocortisone valerate cream hydrocortisone valerate oint hydrocortisone-aloe vera crea hydrocortisone-aloe vera crea IONIL SHA IPECAC SYP ISOP ALCOHOL SOL 50% ISOP ALCOHOL SOL 70% WG ISOP ALCOHOL SOL 91% isop alcohol sol 99% ISOPROPYL ALCOHOL, RUBBING 70 ISOPROPYL LIQ PALMITAT JUNIPER TAR OIL ketoconazole cream 2% ketoconazole shampoo 2% lactic acid (ammonium lactate lactic acid (ammonium lactate lactic acid (ammonium lactate lactic acid (ammonium lactate lactic acid w/ vitamin e crea LAVENDER OIL LEMON OIL LICE B GONE KIT LICE B GONE SHA lidocaine hcl gel 2% lidocaine hcl soln 4% lidocaine oint 5% lidocaine-prilocaine cream 2. LIME OIL lindane lotion 1% lindane shampoo 1% LINSEED OIL RAW LIQUIMAT LOT 5% MACADAMIA OIL NUT OIL malathion lotion 0.5% METHANOL SOL 99% metronidazole cream 0.75% metronidazole gel 0.75% metronidazole lotion 0.75% miconazole nitrate aerosol 2% miconazole nitrate aerosol po miconazole nitrate cream 2% miconazole nitrate ointment 2 miconazole nitrate powder 2% MIRANEL AF SOL 2% mometasone furoate cream 0.1% Requirements/ Limits QL 90/30 QL 120/30 QL 120/30 QL 90/30 QL 90/30 QL 107/30 QL 30/30 ST QL 60/30 AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 25 Formulary last updated date (11/01/2014) Drug Name mometasone furoate oint 0.1% mometasone furoate solution 0 mupirocin calcium cream 2% mupirocin oint 2% NEOSPORIN KIT TRIAL NIAOULI OIL noble mystiq cre emu-lac nuox gel 6-3% nystatin cream 100000 unit/gm nystatin oint 100000 unit/gm nystatin-triamcinolone cream nystatin-triamcinolone oint 1 OC8 GEL 7% OIL-ALMOND OIL SWEET OIL-COCONUT OIL OLIVE OIL ORANGE OIL panoxyl-4 liq crem wsh panoxyl-8 liq crem wsh PEANUT OIL PEPPERMINT OIL PEPPERMINT SOL SPIRIT permethrin aerosol 0.5% permethrin cream 5% permethrin creme rinse 1% permethrin lotion 1% permethrin spray & pyrethinsphisohex liq 3% pin-x sus 50 PINE OIL PINE TAR LIQ plexion liq 9.8-4.8% podofilox soln 0.5% POLYSORBATE LIQ 60 POLYSORBATE LIQ 80 POLYSORBATE SOL 20 POLYSORBATE SOL 40 povidone-iodine soln 10% pramosone cre 1% prednicarbate oint 0.1% PRETZ SOL pro:12 aer mousse pronto aer 0.4% pyre/piperon liq pyreth-piperonyl butox sham-p pyrethrins-piperonyl butoxide pyrethrins-piperonyl butoxide Requirements/ Limits QL 60/30 QL 60/30 ST QL 30/30 QL 60/30 AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 26 Formulary last updated date (11/01/2014) Drug Name pyrethrins-piperonyl butoxide pyrethrins-piperonyl butoxide RA ACNE MAX PAD 2% RA LOT REZAMID LOT ROSE OIL ROSEMARY OIL RUB ALCOHOL SOL 70% ETHY SAFFLOWER OIL salicylic acid & sulfur shamp SANTYL OIN 250U/GM SASSAFRAS OIL SASTID BAR 3-5% SCHOOLTIME SHA SEBASORB LOT selenium sulfide lotion 2.5% SESAME OIL silver sulfadiazine cream 1% SOD SILICATE SOL SOD SILICATE SOL 40% SOYBEAN OIL SPEARMINT OIL starch suppositories 51% STEP 2 SOL 8% sulf lime sol sulfacetamide sodium lotion 1 sulfacetamide sodium w/ sulfu sulfacetamide sodium w/ sulfu sulfacetamide sodium w/ sulfu sulfacetamide sodium w/ sulfu sulfacetamide sodium w/ sulfu sulfacetamide sodium-sulfur i SULFOAM SHA 2% SULFUR BAR 10% sulfur bar 5% TANGERINE OIL TEGRIN-LT KIT terbinafine hcl cream 1% tretinoin cream 0.025% tretinoin cream 0.05% tretinoin cream 0.1% tretinoin gel 0.01% tretinoin gel 0.025% triamcinolone acetonide cream triamcinolone acetonide cream triamcinolone acetonide cream triamcinolone acetonide lotio Requirements/ Limits QL 45/30 AL QL 45/30 AL QL 45/30 AL QL 45/30 AL QL 45/30 AL QL 160/30 QL 160/30 QL 60/30 QL 120/30 AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 27 Formulary last updated date (11/01/2014) Drug Name triamcinolone acetonide lotio triamcinolone acetonide oint triamcinolone acetonide oint triamcinolone acetonide oint trypsin w/ castor oil & peruv trypsin w/ castor oil & peruv TURPENTINE LIQ SPIRITS TURPENTINE OIL UNDECYLENIC LIQ ACID urea cream 40% zeasorb-af lot 2% ZOSTRIX-HP MIS 0.075% Requirements/ Limits QL 120/30 QL 160/30 QL 160/30 QL 60/30 QL 60/30 QL 60/30 GASTROINTESTINAL AGENTS Antispasmodics, Gastrointestinal belladonna alkaloids-phenobar clidinium & chlordiazepoxide dicyclomine hcl cap 10 mg dicyclomine hcl tab 20 mg glycopyrrolate tab 1 mg glycopyrrolate tab 2 mg hyoscyamine sulfate elixir 0. hyoscyamine sulfate soln 0.12 hyoscyamine sulfate tab 0.125 hyoscyamine sulfate tab disp hyoscyamine sulfate tab sl 0. hyoscyamine sulfate tab sr 12 propantheline bromide tab 15 Digestive Enzymes CREON CAP 12000UNT CREON CAP 24000UNT CREON CAP 3000UNIT CREON CAP 36000UNT CREON CAP 6000UNIT PANCREAZE CAP 10500UNT PANCREAZE CAP 16800UNT PANCREAZE CAP 21000UNT PANCREAZE CAP 4200UNIT PANCRELIPASE CAP 5000UNIT PERTZYE CAP PERTZYE CAP ULTRESA CAP 13800UNT ULTRESA CAP 20700UNT ULTRESA CAP 23000UNT VIOKACE TAB VIOKACE TAB ZENPEP CAP 10000UNT ZENPEP CAP 15000UNT AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 28 Formulary last updated date (11/01/2014) Drug Name ZENPEP CAP 20000UNT ZENPEP CAP 25000UNT ZENPEP CAP 3000UNIT Gastrointestinal Agents, Other ALlactobacillus acidophilus-pe ACIDOPHILUS/ TAB CIT PECT AGORAL LIQ MAX ST ALAMAG CHW 300-150 ALKA SELTZER TAB HEARTBRN alum & mag hydroxide-simethic alum & mag hydroxide-simethic alum & mag hydroxide-simethic aluminum hydroxide-magnesium aluminum hydroxide-magnesium aluminum hydroxide-magnesium ANTACID CHW benzocaine-docusate sodium re BICARSIM TAB 125MG BICARSIM TAB 80MG bisacodyl suppos 10 mg bisacodyl tab delayed release bismuth subsalicylate chew ta bismuth subsalicylate susp 26 bismuth subsalicylate susp 52 bismuth subsalicylate tab 262 cal carb & mag hydrox-simethi CALCIUM CARB TAB 648MG calcium carbonate (antacid) c calcium carbonate (antacid) c calcium carbonate (antacid) c calcium carbonate (antacid) c calcium carbonate (antacid) c calcium carbonate (antacid) c calcium carbonate-mag hydroxi calcium carbonate-mag hydroxi calcium carbonate-mag hydroxi calcium carbonate-mag hydroxi calcium carbonate-simethicone calcium polycarbophil tab 625 CITROCARBONA GRA clearlax pow clearlax pow clearlax pow CLEARLAX POW CORRECTOL MIS HERBAL CULTURELLE CAP CULTURELLE CHW DI Requirements/ Limits AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 29 Formulary last updated date (11/01/2014) Drug Name cvs purelax pow cvs purelax pow DEWEES CARMI LIQ DI-GEL CHW DI-GEL SUS diphenoxylate w/ atropine liq diphenoxylate w/ atropine tab docusate calcium cap 240 mg docusate sodium cap 100 mg docusate sodium cap 250 mg docusate sodium cap 50 mg docusate sodium enema 283 mg docusate sodium liquid 150 mg docusate sodium syrup 60 mg/1 docusate sodium tab 100 mg DOCUSOL KIDS ENE 100MG/5M DULCOLAX KIT BOWEL dulcolax pow balance E-Z-GAS II GRA eq clearlax pow eql clearlax pow EQL NATURAL POW FIBER EQUALACTIN CHW 625MG EVAC-U-GEN CHW 10MG FLEET BISACO ENE 10/30ML GAS-X CHILD MIS 40MG GAS-X EX-STR MIS 62.5MG GAS-X/MAALOX CHW EXTRA ST gavilax pow gentlelax pow glycerin suppos 1 gm glycerin suppos 1.2 gm glycerin suppos 1.5 gm glycerin suppos 2 gm glycerin suppos 2.1 gm glycerin suppos 80.7% glycolax pow 3350 nf gnp clearlax pow hm clearlax pow HYDROCIL INS POW 95% IMODIUM A-D CHW 2MG KONSYL POW 100% KONSYL POW 28.3% KONSYL POW 60.3% KONSYL POW 60.3% KONSYL POW 71.67% KONSYL-D POW 52.3% Requirements/ Limits AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 30 Formulary last updated date (11/01/2014) Drug Name lactulose solution 10 gm/15ml laxaclear pow LITTLE TUMMY DRO LAXATIVE loperamide hcl cap 2 mg loperamide hcl liq 1 mg/5ml ( loperamide hcl liq 1 mg/7.5ml loperamide hcl tab 2 mg MAALOX JR CHW /ANTIGAS MAALOX TC SUS MAG OXIDE CAP 400MG MAG-AL LIQ MAGN OXIDE POW HEAVY magnesium citrate soln magnesium oxide tab 250 mg magnesium oxide tab 400 mg magnesium oxide tab 420 mg METAMUCIL POW 28% METAMUCIL POW 63% METAMUCIL WAF methylcellulose powder laxati metoclopramide hcl soln 5 mg/ metoclopramide hcl tab 10 mg metoclopramide hcl tab 5 mg MYLANTA SUS ULTIMATE MYLANTA TAB NAT FIBER POW 58.6% NAT SENNA TAB LAXATIVE natura-lax pow 3350 nf OPIUM TINCT TIN 2MG/5ML PEDIA-LAX LIQ 50MG PEDIA-LAX SUP 2.8GM peg 3350 pow peg 3350-kcl-na bicarb-nacl-n peg 3350-kcl-na bicarb-nacl-n polyeth glyc pow 3350 nf polyeth glyc pow 3350 nf polyeth glyc pow 3350 nf polyeth glyc pow 3350 nf polyeth glyc pow 3350 nf polyeth glyc pow 3350 nf POLYETH GLYC POW 3350 NF polyeth glyc pow 3350-grx powderlax pow PROBIOTIC W/ CAP PREBIOTI psyllium cap 0.52 gm psyllium powder 100% psyllium powder 28.3% Requirements/ Limits AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 31 Formulary last updated date (11/01/2014) Drug Name psyllium powder 30% psyllium powder 30.9% psyllium powder 33% psyllium powder 48.57% psyllium powder 55.46% psyllium powder 58.6% psyllium powder 68% psyllium powder 95% ra laxative pow RA LAXATIVE POW RI-MAG PLUS SUS ROLAIDS CHW EX ST SB NAT FIBER POW 49% SENNA LEAVES MIS SENNA SYP SENNA TAB 187MG sennosides cap 8.6 mg sennosides chew tab 15 mg sennosides syrup 8.8 mg/5ml sennosides tab 15 mg sennosides tab 17.2 mg sennosides tab 25 mg sennosides tab 8.6 mg sennosides-docusate sodium ta simethicone cap 125 mg simethicone cap 180 mg simethicone chew tab 125 mg simethicone chew tab 80 mg simethicone liquid 40 mg/0.6m simethicone susp 40 mg/0.6ml sm clearlax pow smooth lax pow sodium bicarbonate tab 325 mg sodium bicarbonate tab 650 mg SODIUM POW BICARBON sucralfate tab 1 gm sw clearlax pow TITRALAC CHW PLUS URO-MAG CAP 140MG ursodiol cap 300 mg Histamine2 (H2) Receptor Antagonists cimetidine hcl soln 300 mg/5m cimetidine tab 200 mg cimetidine tab 300 mg cimetidine tab 400 mg cimetidine tab 800 mg famotidine inj 20 mg/2ml Requirements/ Limits AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 32 Formulary last updated date (11/01/2014) Drug Name famotidine inj 200 mg/20ml FAMOTIDINE INJ 20MG/50M famotidine inj 40 mg/4ml famotidine inj 500 mg/50ml famotidine tab 10 mg famotidine tab 20 mg famotidine tab 40 mg misoprostol tab 100 mcg misoprostol tab 200 mcg PEPCID AC CHW 10MG PEPCID AC CHW MAX ST ranitidine hcl syrup 15 mg/ml ranitidine tab 150mg ranitidine tab 300mg Proton Pump Inhibitors heartburn tr cap 15mg hrtbrn rel cap 15mg dr lansoprazole cap 15mg dr lansoprazole cap 15mg dr lansoprazole cap 15mg dr lansoprazole cap 15mg dr lansoprazole cap 15mg dr lansoprazole cap 15mg dr lansoprazole cap 15mg dr lansoprazole cap 15mg dr lansoprazole cap 15mg dr lansoprazole cap 15mg dr lansoprazole cap 15mg dr lansoprazole cap 15mg dr lansoprazole cap 15mg dr lansoprazole cap 15mg dr LANSOPRAZOLE SUS 3MG/ML NEXIUM 24HR CAP 20MG omepra/bicar cap 20-1100 omepra/bicar cap 20-1100 omepra/bicar cap 20-1100 omepra/bicar cap 20-1100 omepra/bicar cap 20-1100 omepra/bicar cap 20-1100 omepra/bicar cap 20-1100 omepra/bicar cap 20-1100 omeprazole cap delayed releas omeprazole cap delayed releas pantoprazole sodium ec tab 20 pantoprazole sodium ec tab 40 PRILOSEC OTC TAB 20MG Requirements/ Limits QL 60/30 QL 60/30 QL 60/30 QL 60/30 QL 60/30 QL 60/30 QL 60/30 QL 60/30 QL 60/30 QL 60/30 QL 60/30 QL 60/30 QL 60/30 QL 60/30 QL 60/30 QL 60/30 QL 150/30 QL 60/30 QL 60/30 QL 60/30 QL 60/30 QL 60/30 QL 60/30 QL 60/30 QL 60/30 QL 60/30 QL 60/30 QL 30/30 QL 30/30 QL 60/30 QL 60/30 GENITOURINARY AGENTS AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 33 Formulary last updated date (11/01/2014) Drug Name Antispasmodics, Urinary bethanechol chloride tab 10 m bethanechol chloride tab 25 m bethanechol chloride tab 5 mg bethanechol chloride tab 50 m ENABLEX TAB 15MG ENABLEX TAB 7.5MG oxybutynin chloride syrup 5 m oxybutynin chloride tab 5 mg oxybutynin chloride tab sr 24 oxybutynin chloride tab sr 24 oxybutynin chloride tab sr 24 OXYTROL/WOMN DIS 3.9MG/24 tolterodine tartrate cap sr 2 tolterodine tartrate cap sr 2 tolterodine tartrate tab 1 mg tolterodine tartrate tab 2 mg trospium chloride tab 20 mg VESICARE TAB 10MG VESICARE TAB 5MG Benign Prostatic Hypertrophy Agents finasteride tab 5 mg tamsulosin hcl cap 0.4 mg Genitourinary Agents, Other methylergonovine maleate tab Phosphate Binders calcium acetate (phosphate bi calcium acetate (phosphate bi RENAGEL TAB 400MG RENAGEL TAB 800MG sevelamer carbonate tab 800 m Vaginal Products CLEOCIN SUP 100MG clindamycin phosphate vaginal clotrimazole vaginal cream 1% clotrimazole vaginal cream 2% ESTRACE VAG CRE 0.1MG/GM GYNAZOLE-1 CRE 2% metronidazole vaginal gel 0.7 miconazole nitrate vaginal cr miconazole nitrate vaginal su miconazole nitrate vaginal su miconazole nitrate vaginal su NONOXYNOL-9 GEL 2% NONOXYNOL-9 GEL 3% nystatin vaginal tab 100000 u PROGESTERONE SUP VGS 100 Requirements/ Limits ST ST ST ST ST QL 8/30 ST ST ST ST ST ST ST QL 60/30 QL 28/365 PA PA PA AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 34 Formulary last updated date (11/01/2014) Drug Name PROGESTERONE SUP VGS 200 PROGESTERONE SUP VGS 25 PROGESTERONE SUP VGS 400 PROGESTERONE SUP VGS 50 terconazole vaginal cream 0.4 terconazole vaginal cream 0.8 terconazole vaginal suppos 80 Requirements/ Limits HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL) Glucocorticoids/Mineralocorticoids cortisone acetate tab 25 mg dexamethasone conc 1 mg/ml dexamethasone elixir 0.5 mg/5 dexamethasone soln 0.5 mg/5ml dexamethasone tab 0.5 mg dexamethasone tab 0.75 mg dexamethasone tab 1.5 mg dexamethasone tab 2 mg dexamethasone tab 4 mg dexamethasone tab 6 mg DEXPAK PAK 10 DAY fludrocortisone acetate tab 0 hydrocortisone tab 10 mg hydrocortisone tab 20 mg hydrocortisone tab 5 mg methylprednisolone tab 4 mg methylprednisolone tab 4 mg d methylprednisolone tab 8 mg prednisolone sod phosphate or prednisolone syrup 15 mg/5ml prednisone oral soln 5 mg/5ml prednisone tab 1 mg prednisone tab 10 mg prednisone tab 10 mg dose pac prednisone tab 2.5 mg prednisone tab 20 mg prednisone tab 5 mg prednisone tab 5 mg dose pack prednisone tab 50 mg HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/ MODIFIERS) Androgens PA GR testosterone cypionate im in testosterone cypionate im in PA GR Contraceptives ALORA DIS 0.025MG QL 8/28 GR ALORA DIS 0.05MG QL 8/28 GR ALORA DIS 0.075MG QL 8/28 GR AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 35 Formulary last updated date (11/01/2014) Drug Name ALORA DIS 0.1MG altavera altavera altavera alyacen 1/35 apri aubra aubra aviane camila caziant cesia chateal chateal chateal CYCLAFEM 1/35 CYCLAFEM 1/35 cyclafem 7/7/7 cyclafem 7/7/7 dasetta 1/35 dasetta 1/35 dasetta 7/7/7 delyla desogestrel/ethinyl estradiol emoquette emoquette enpresse-28 enpresse-28 enpresse-28 enskyce enskyce errin estradiol & norethindrone ace estradiol & norethindrone ace falmina falmina falmina gildess 1.5/30 gildess 1.5/30 gildess 1.5/30 gildess 1/20 gildess 1/20 gildess 1/20 gildess fe 1.5/30 gildess fe 1/20 heather introvale Requirements/ Limits QL 8/28 GR QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 28/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 28/23 GR QL 28/23 GR QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 21/28 QL 21/28 QL 21/28 QL 21/28 QL 21/28 QL 21/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 91/91 AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 36 Formulary last updated date (11/01/2014) Drug Name introvale jencycla jencycla jolessa jolivette junel 1.5/30 junel 1/20 junel fe 1.5/30 junel fe 1/20 kurvelo kurvelo larin 1.5/30 larin 1.5/30 larin 1/20 larin 1/20 larin fe 1.5/30 larin fe 1.5/30 larin fe 1/20 larin fe 1/20 lessina levonest levonest levonorgestrel tab 0.75 mg levonorgestrel tab 1.5 mg levonorgestrel/ethinyl estrad levonorgestrel/ethinyl estrad levonorgestrel/ethinyl estrad levonorgestrel/ethinyl estrad levonorgestrel/ethinyl estrad levonorgestrel/ethinyl estrad levora 0.15/30-28 lutera lyza marlissa marlissa medroxyprogesterone acetate i microgestin tab 1/20 microgestin tab fe 1/20 microgestin 1.5/30 microgestin 1.5/30 microgestin 1/20 microgestin fe microgestin fe 1.5/30 myzilra myzilra necon 0.5/35-28 necon 1/35 Requirements/ Limits QL 91/91 QL 37.5/28 QL 37.5/28 QL 91/91 QL 37.5/28 QL 21/28 QL 21/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 21/28 QL 21/28 QL 21/28 QL 21/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 2/30 GR QL 2/30 GR QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 91/91 QL 91/91 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 1/90 GR QL 37.5/28 QL 21/28 QL 21/28 QL 21/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 37 Formulary last updated date (11/01/2014) Drug Name necon 1/50-28 necon 10/11-28 nora-be norethindrone norethindrone norethindrone norethindrone norethindrone norethindrone norethindrone norethindrone norethindrone norethindrone acetate/ethinyl norethindrone acetate/ethinyl nortrel 0.5/35 nortrel 0.5/35 (28) nortrel 1/35 nortrel 1/35 nortrel 1/35 nortrel 7/7/7 orsythia orsythia pirmella 1/35 pirmella 1/35 portia-28 quasense solia sronyx trivora-28 velivet velivet wera wera ZOVIA 1/50E Estrogens esterified estrogens & methyl esterified estrogens & methyl estradiol tab 0.5 mg estradiol tab 1 mg estradiol tab 2 mg estradiol td patch weekly 0.0 estradiol td patch weekly 0.0 estradiol td patch weekly 0.0 estradiol td patch weekly 0.0 estradiol td patch weekly 0.0 estradiol td patch weekly 0.1 estropipate tab 0.75 mg Requirements/ Limits QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 21/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 21/28 QL 21/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 91/91 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 37.5/28 QL 21/28 GR QL 21/28 GR GR GR GR QL 4/21 GR QL 4/21 GR QL 4/21 GR QL 4/21 GR QL 4/21 GR QL 4/21 GR QL 21/28 GR AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 38 Formulary last updated date (11/01/2014) Drug Name estropipate tab 1.5 mg estropipate tab 3 mg FEMHRT TAB 0.5-2.5 MENEST TAB 0.3MG MENEST TAB 0.625MG MENEST TAB 1.25MG MENEST TAB 2.5MG norethindrone acetate-ethinyl PREMARIN TAB 0.3MG PREMARIN TAB 0.45MG PREMARIN TAB 0.625MG PREMARIN TAB 0.9MG PREMARIN TAB 1.25MG PREMPHASE TAB PREMPRO TAB .625-2.5 PREMPRO TAB 0.3-1.5 PREMPRO TAB 0.45-1.5 PREMPRO TAB 0.625-5 Progestins medroxyprogesterone acetate t medroxyprogesterone acetate t medroxyprogesterone acetate t norethindrone acetate tab 5 m Requirements/ Limits QL 21/28 GR QL 21/28 GR QL 28/28 GR GR GR GR GR QL 21/28 GR QL 30/30 GR QL 30/30 GR QL 30/30 GR QL 30/30 GR QL 30/30 GR QL 30/30 GR QL 30/30 GR QL 30/30 GR QL 30/30 GR QL 30/30 GR QL 28/28 GR QL 120/30 GR QL 30/30 GR QL 60/30 GR HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (PITUITARY) Hormonal Agents, Stimulant/Replacement/ Modifying (Pituitary) desmopressin acetate nasal sp desmopressin acetate nasal sp desmopressin acetate tab 0.1 desmopressin acetate tab 0.2 HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (THYROID) Hormonal Agents, Stimulant/Replacement/ Modifying (Thyroid) ARMOUR THYRO TAB 120MG ARMOUR THYRO TAB 15MG ARMOUR THYRO TAB 180MG ARMOUR THYRO TAB 240MG ARMOUR THYRO TAB 300MG levothyroxin tab 100mcg levothyroxin tab 100mcg levothyroxin tab 100mcg levothyroxin tab 100mcg levothyroxin tab 112mcg levothyroxin tab 112mcg levothyroxin tab 112mcg levothyroxin tab 112mcg levothyroxin tab 125mcg levothyroxin tab 125mcg levothyroxin tab 125mcg AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 39 Formulary last updated date (11/01/2014) Drug Name levothyroxin tab 125mcg levothyroxin tab 137mcg levothyroxin tab 137mcg levothyroxin tab 137mcg levothyroxin tab 150mcg levothyroxin tab 150mcg levothyroxin tab 150mcg levothyroxin tab 150mcg levothyroxin tab 175mcg levothyroxin tab 175mcg levothyroxin tab 175mcg levothyroxin tab 200mcg levothyroxin tab 200mcg levothyroxin tab 200mcg levothyroxin tab 25mcg levothyroxin tab 25mcg levothyroxin tab 25mcg levothyroxin tab 25mcg levothyroxin tab 300mcg levothyroxin tab 300mcg levothyroxin tab 300mcg levothyroxin tab 50mcg levothyroxin tab 50mcg levothyroxin tab 50mcg levothyroxin tab 50mcg levothyroxin tab 75mcg levothyroxin tab 75mcg levothyroxin tab 75mcg levothyroxin tab 75mcg levothyroxin tab 88mcg levothyroxin tab 88mcg levothyroxin tab 88mcg levoxyl tab 100mcg levoxyl tab 112mcg levoxyl tab 125mcg levoxyl tab 137mcg levoxyl tab 150mcg levoxyl tab 175mcg levoxyl tab 200mcg levoxyl tab 25mcg levoxyl tab 50mcg levoxyl tab 75mcg levoxyl tab 88mcg NATURE-THROI TAB 130MG NATURE-THROI TAB 195MG NATURE-THROI TAB 260MG NATURE-THROI TAB 32.5MG Requirements/ Limits AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 40 Formulary last updated date (11/01/2014) Drug Name NATURE-THROI TAB 325MG NATURE-THROI TAB 48.75MG NATURE-THROI TAB 65MG NATURE-THROI TAB 97.5MG thyroid tab 16.25 mg thyroid tab 30 mg (1/2 grain) thyroid tab 60 mg (1 grain) thyroid tab 90 mg (1 1/2 grai unithroid tab 100mcg unithroid tab 100mcg unithroid tab 112mcg unithroid tab 112mcg unithroid tab 125mcg unithroid tab 125mcg unithroid tab 137mcg unithroid tab 150mcg unithroid tab 150mcg unithroid tab 175mcg unithroid tab 175mcg unithroid tab 200mcg unithroid tab 200mcg unithroid tab 25mcg unithroid tab 25mcg unithroid tab 300mcg unithroid tab 300mcg unithroid tab 50mcg unithroid tab 50mcg unithroid tab 75mcg unithroid tab 75mcg unithroid tab 88mcg unithroid tab 88mcg Requirements/ Limits HORMONAL AGENTS, SUPPRESSANT (PITUITARY) Hormonal Agents, Suppressant (Pituitary) LUPR DEP-PED INJ 11.25MG LUPR DEP-PED INJ 15MG LUPR DEP-PED INJ 7.5MG PA PA PA HORMONAL AGENTS, SUPPRESSANT (THYROID) Antithyroid Agents methimazole tab 10 mg methimazole tab 5 mg propylthiouracil tab 50 mg IMMUNOLOGICAL AGENTS Immune Suppressants azathioprine tab 50 mg cellcept sus 200mg/ml PA cyclosporine cap 100 mg cyclosporine cap 25 mg AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 41 Formulary last updated date (11/01/2014) Drug Name cyclosporine modified cap 100 cyclosporine modified cap 25 cyclosporine modified cap 50 cyclosporine modified oral so leflunomide tab 10 mg leflunomide tab 20 mg mycophenolate mofetil cap 250 mycophenolate mofetil tab 500 tacrolimus cap 0.5 mg tacrolimus cap 1 mg tacrolimus cap 5 mg Immunizing Agents, Passive RHOGAM PLUS INJ 300MCG SYNAGIS INJ 100MG/ML SYNAGIS INJ 50MG Vaccines ZOSTAVAX INJ Requirements/ Limits PA PA AL INFLAMMATORY BOWEL DISEASE AGENTS Aminosalicylates APRISO CAP 0.375GM balsalazide disodium cap 750 DELZICOL CAP 400MG mesalamine enema 4 gm SFROWASA ENE 4GM Sulfonamides sulfasalazine tab 500 mg sulfasalazine tab delayed rel QL 120/30 QL 180/30 QL 180/30 QL 180/30 METABOLIC BONE DISEASE AGENTS Metabolic Bone Disease Agents alendronate sodium tab 10 mg alendronate sodium tab 35 mg alendronate sodium tab 40 mg alendronate sodium tab 5 mg alendronate sodium tab 70 mg calcitonin (salmon) nasal sol QL 4/28 MISCELLANEOUS Miscellaneous QL 12/30 ALCONDOMS - MALEALALAL ALoral vehiclesALALAL ALsodium polystyrene sulfonate 1 ML SYRIMGE MIS 18GX1" QL 100/30 1 ML SYRINGE MIS 22X1-1/2 QL 100/30 1ML SYR/NEED MIS 26GX5/8" QL 100/30 1ML SYRINGE MIS 23GX1" QL 100/30 1ML SYRINGE MIS 25GX1" QL 100/30 1ML SYRINGE MIS 25GX5/8" QL 100/30 1ML SYRINGE MIS 26GX3/8" QL 100/30 AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 42 Formulary last updated date (11/01/2014) Drug Name ADRENACLICK INJ 0.3MG AKRAY EXPRESSION TEST STRIPS ARKRAY GLUCOCARD VITAL TEST S AUTOSHIELD MIS 29X3/16" AUTOSHIELD MIS 29X5/16" AUTOSHIELD MIS 30GX3/16 GR SAF-T-INT KIT 24GX0.75 chemet cap 100mg cherry syp CONDOMS LATEX LUBRICATED CONDOMS LATEX NON-LUBRICA CONDOMS NON-LATEX NON-LUB CONTOUR NEXT TEST STRIPS, BOX CONTROL SOLUTION, ARKRAY EXPR CONTROL SOLUTION, ARKRAY GLUC CONTROL SOLUTION, FREESTYLE CONTROL SOLUTION, ONE TOUCH U CONTROL SOLUTION, SD GLUCONAV CONTROL SOLUTION, SD GLUCONAV CURITY PREP PAD ALCOHOL epinephrine inj 0.3mg EPINEPHRINE INJ 0.3MG EPIPEN 2-PAK INJ 0.3MG EPIPEN-JR INJ 0.15MG HUMAPEN MIS MEMOIR HUMATROPEN MIS FOR 6MG INSUFLON MIS 25GX0.71 INSULIN SYRG MIS 0.3/28G INSULIN SYRG MIS 0.3/29G INSULIN SYRG MIS 0.3/29G INSULIN SYRG MIS 0.3/29G INSULIN SYRG MIS 0.3/29G INSULIN SYRG MIS 0.3/30G INSULIN SYRG MIS 0.3/30G INSULIN SYRG MIS 0.3/30G insulin syrg mis 0.3/30g INSULIN SYRG MIS 0.3/30G INSULIN SYRG MIS 0.3/31G INSULIN SYRG MIS 0.3/31G INSULIN SYRG MIS 0.5/27G insulin syrg mis 0.5/28g INSULIN SYRG MIS 0.5/29G INSULIN SYRG MIS 0.5/29G INSULIN SYRG MIS 0.5/29G INSULIN SYRG MIS 0.5/29G INSULIN SYRG MIS 0.5/29G INSULIN SYRG MIS 0.5/30G Requirements/ Limits QL 2/90 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 12/30 QL 12/30 QL 12/30 QL 2/90 QL 2/90 QL 2/90 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 43 Formulary last updated date (11/01/2014) Drug Name INSULIN SYRG MIS 0.5/30G insulin syrg mis 0.5/30g INSULIN SYRG MIS 0.5/30G INSULIN SYRG MIS 0.5/30G INSULIN SYRG MIS 0.5/31G INSULIN SYRG MIS 0.5/31G INSULIN SYRG MIS 1ML INSULIN SYRG MIS 1ML/25G INSULIN SYRG MIS 1ML/25G INSULIN SYRG MIS 1ML/25G INSULIN SYRG MIS 1ML/26G INSULIN SYRG MIS 1ML/27G INSULIN SYRG MIS 1ML/27G INSULIN SYRG MIS 1ML/28G INSULIN SYRG MIS 1ML/28G INSULIN SYRG MIS 1ML/29G insulin syrg mis 1ml/29g INSULIN SYRG MIS 1ML/29G insulin syrg mis 1ml/30g INSULIN SYRG MIS 1ML/30G insulin syrg mis 1ml/30g INSULIN SYRG MIS 1ML/30G INSULIN SYRG MIS 1ML/31G INSULIN SYRG MIS 1ML/31G INSULIN SYRG MIS 2/27.5G INSULIN SYRG MIS 2ML/29G INSULIN SYRINGE MIS 0.3/30G INSULIN SYRINGE MIS 0.3/31G INSULIN SYRINGE MIS 0.5/29G INSULIN SYRINGE MIS 0.5/30G INSULIN SYRINGE MIS 0.5/31 G INSULIN SYRINGE MIS 1ML/29G INSULIN SYRINGE MIS 1ML/30G INSULIN SYRINGE MIS 1ML/31G insulin syringe/needle u-100 INSULIN SYRINGE/NEEDLE U-100 INSULIN SYRINGE/NEEDLE U-100 INSULIN SYRINGE/NEEDLE U-100 INSULIN SYRINGE/NEEDLE U-100 INSULIN SYRINGE/NEEDLE U-100 INSULIN SYRINGE/NEEDLE U-100 INSUPEN SENS MIS 32GX8MM INSYTE AUTOG MIS 24GX3/4" J-TIP KIT KIT ADAPTERS KETOSTIX TEST STRIPS LITE TOUCH INSULIN PEN NEEDLE LITE TOUCH INSULIN PEN NEEDLE Requirements/ Limits QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 44 Formulary last updated date (11/01/2014) Drug Name LTXF PRIM IV MIS SET/MICR LUER-LOK SYR MIS 1ML/20G MEDI-JECTOR MIS VISION NEEDLE-FREE KIT A NEEDLE-FREE MIS SYRG A NOVOFINE MIS 30GX8MM NOVOFINE MIS 32GX6MM NOVOTWIST MIS 32GX5MM OMNIFLEX DPR ORTHO COIL DPR KIT 100 ORTHO COIL DPR KIT 105 ORTHO COIL DPR KIT 50 ORTHO FLAT DPR KIT 55 ORTHO FLAT DPR KIT 60 ORTHO FLAT DPR KIT 65 ORTHO FLAT DPR KIT 70 ORTHO FLAT DPR KIT 75 ORTHO FLAT DPR KIT 80 ORTHO FLAT DPR KIT 85 ORTHO FLAT DPR KIT 90 ORTHO FLAT DPR KIT 95 ORTHO FLEX DPR 65MM ORTHO FLEX DPR 70MM ORTHO FLEX DPR 75MM ORTHO FLEX DPR 80MM PEN NEEDLES MIS 29GX12.7 PLAS ADAPT MIS 1ML PRECISN XTRA TES KETONE PRODIGY MIS 29GX1/2" ROCHE - FASTCLIIX LANCETS, BO SD GLUCONAVII TEST STRIPS SURE-LANCE MIS LANCETS SURE-T INFUS MIS SET 23" TENDER 1 KIT 31" UNIFINE PNTP MIS 29GX12MM UNIFINE PNTP MIS 31GX5MM UNIFINE PNTP MIS 31GX6MM UNIFINE PNTP MIS 31GX8MM UNIFINE PNTP MIS 32GX4MM water for irrigation, sterile WIDE-SEAL DPR KIT 60 WIDE-SEAL DPR KIT 65 WIDE-SEAL DPR KIT 70 WIDE-SEAL DPR KIT 75 WIDE-SEAL DPR KIT 80 WIDE-SEAL DPR KIT 85 WIDE-SEAL DPR KIT 90 Requirements/ Limits QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 1/365 QL 1/365 QL 1/365 QL 1/365 QL 1/365 QL 1/365 QL 1/365 QL 1/365 QL 1/365 QL 1/365 QL 1/365 QL 1/365 QL 1/365 QL 1/365 QL 1/365 QL 1/365 QL 1/365 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 100/30 QL 1/365 QL 1/365 QL 1/365 QL 1/365 QL 1/365 QL 1/365 QL 1/365 AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 45 Formulary last updated date (11/01/2014) Drug Name wide-seal dpr kit 95 Requirements/ Limits QL 1/365 OPHTHALMIC AGENTS Ophthalmic Agents, Other ALartificial tear ophth ointme ALartificial tear ophth soluti ALwhite petrolatum-mineral oil BLINK TEARS DRO 0.25% OP BLINK TEARS DRO 0.25% OP brimonidine tartrate ophth so carboxymethylcellulose sodium carboxymethylcellulose sodium carboxymethylcellulose-glycer CLEAR EYES DRO DRY EYES COMPUTER EYE SOL DROPS GENTEAL GEL genteal mild dro 0.2% glycerin-hypromellose-peg 400 GONIOVISC SOL 2% hypotears sol 1-1% hypromellose gonioscopic soln hypromellose ophth soln 0.3% hypromellose ophth soln 0.4% iso carbacho sol 3% op ISOPTO TEARS SOL 0.5% OP moisture eye sol p/f muro 128 sol 2% op naphazoline hcl ophth soln 0. naphazoline w/ pheniramine op naphazoline w/ pheniramine op naphazoline-glycerin ophth so naphazoline-glycerin ophth so naphazoline-glycerin ophth so naphazoline-hypromellose opht naphazoline-polyethylene glyc nutratear sol 0.6% phospholine sol 0.125%op polyethylene glycol-propylene POLYVINYL ALCOHOL OPHTH SOLN polyvinyl alcohol-povidone op polyvinyl alcohol-povidone op proparacaine hcl ophth soln 0 propylene glycol-glycerin oph refresh cell dro 1% op REFRESH DRO RELIEF refresh sol optive RETAINE MGD EMU 0.5-0.5% sodium chloride hypertonic op AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 46 Formulary last updated date (11/01/2014) Drug Name sodium chloride hypertonic op soothe dro 0.6-0.6% STERILE LUBR DRO 0.7% SYSTANE BAL SOL RESTOR SYSTANE GEL 0.3% systane liq dro 0.4-0.3% TEARS AGAIN GEL NGHT/DAY tetrahydrozoline hcl ophth so tetrahydrozoline w/ polyethyl tetrahydrozoline w/ zinc sulf theratears sol op vasoclear a sol op visine tears dro VIVA DROPS DRO 1% Ophthalmic Anti Infectives bacitracin ophth oint 500 uni bacitracin-polymyxin b ophth ciloxan oin 0.3% op CIPROFLOXACIN 0.2% SOL ciprofloxacin hcl ophth soln erythromycin ophth oint 5 mg/ gentamicin sulfate ophth oint gentamicin sulfate ophth soln neomycin-bacitrac zn-polymyx NEOMYCIN-POLYMY-GRAMICID OP S ofloxacin ophth soln 0.3% polymyxin b-trimethoprim opht sulfacet sod oin 10% op SULFACETAMIDE SODIUM OPHTH SO tobramycin ophth soln 0.3% tobrex oin 0.3% op trifluridine ophth soln 1% Ophthalmic Anti-allergy Agents azelastine hcl ophth soln 0.0 cromolyn sodium ophth soln 4% dorzolamide hcl ophth soln 2% ketotifen fumarate ophth soln Ophthalmic Anti-inflammatories atropine sulfate ophth oint 1 atropine sulfate ophth soln 1 bacitracin-polymyxin-neomycin BLEPHAMIDE OIN S.O.P. BLEPHAMIDE SUS OP BLEPHAMIDE SUS OP BLEPHAMIDE SUS OP blephamide sus op cyclomydril sol op Requirements/ Limits QL 5/30 QL 5/30 QL 5/30 AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 47 Formulary last updated date (11/01/2014) Drug Name cyclopentolate hcl ophth soln dexamethasone sodium phosphat diclofenac sodium ophth soln FLAREX SUS 0.1% OP FLUOROMETHOLONE OPHTH SUSP 0. flurbiprofen sodium ophth sol FML FORTE SUS 0.25% OP FML OIN 0.1% OP homatropine hbr ophth soln 5% iso homatrop sol 2% op ketorolac tromethamine ophth ketorolac tromethamine ophth latanoprost ophth soln 0.005% neomycin-polymyxin-dexamethas neomycin-polymyxin-dexamethas neomycin-polymyxin-hc ophth s pred mild sus 0.12% op prednisolone acetate ophth su PREDNISOLONE SODIUM PHOSPHATE sulfacetamide sodium-predniso tobradex oin 0.3-0.1% tobramycin-dexamethasone opht tropicamide ophth soln 0.5% tropicamide ophth soln 1% Ophthalmic Antiglaucoma Agents betaxolol hcl ophth soln 0.5% carteolol hcl ophth soln 1% COSOPT SOL 2-0.5%OP DORZOLAMIDE HCL-TIMOLOL MALEA dorzolamide hcl-timolol malea levobunolol hcl ophth soln 0. levobunolol sol 0.25% op metipranolol ophth soln 0.3% timolol maleate ophth soln 0. timolol maleate ophth soln 0. timoptic ocu sol 0.25% op timoptic ocu sol 0.5% op Requirements/ Limits QL 5/30 QL 5/10 OTIC AGENTS Otic Agents acetic acid 2% in aluminum ac acetic acid otic soln 2% antipyrine-benzocaine otic so carbamide peroxide 6.5% otic CLEARCANAL KIT EAR WAX hydrocortisone w/ acetic acid neomycin-polymyxin-hc otic so neomycin-polymyxin-hc otic su AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 48 Formulary last updated date (11/01/2014) Drug Name ofloxacin otic soln 0.3% pinnacaine dro 20% otic Requirements/ Limits RESPIRATORY TRACT AGENTS Anti-inflammatories, Inhaled Corticosteroids AL budesonide inhalation susp 0. budesonide inhalation susp 0. AL FLOVENT DISK AER 100MCG QL 60/30 AL FLOVENT DISK AER 50MCG QL 60/30 AL FLOVENT HFA AER 44MCG QL 10.6/30 AL QVAR AER 40MCG QL 8.7/30 QVAR AER 80MCG QL 8.7/30 Antihistamines ALER-DRYL TAB 50MG AL cetirizine hcl oral soln 1 mg cetirizine hcl tab 10 mg cetirizine hcl tab 5 mg CHLORPHENIR POW MALEATE chlorpheniramine maleate syru chlorpheniramine maleate tab chlorpheniramine maleate tab CLARITIN RDT TAB 5MG clemastine fumarate syrup 0.6 clemastine fumarate tab 1.34 clemastine fumarate tab 2.68 cyproheptadine hcl syrup 2 mg cyproheptadine hcl tab 4 mg dexchlorpheniramine maleate s diphenhydramine hcl cap 25 mg AL diphenhydramine hcl chew tab AL diphenhydramine hcl elixir 12 AL diphenhydramine hcl liquid 12 AL diphenhydramine hcl syrup 12. AL diphenhydramine hcl tab disp AL ED CHLORPED LIQ 2MG/ML ED-CHLOR-TAN TAB 8MG fexofenadine hcl susp 30 mg/5 loratadine rapidly-disintegra loratadine syrup 5 mg/5ml loratadine tab 10 mg promethazine hcl suppos 12.5 QL 28/14 promethazine hcl suppos 25 mg QL 28/14 promethazine hcl suppos 50 mg QL 28/14 promethazine hcl syrup 6.25 m promethazine hcl tab 12.5 mg promethazine hcl tab 25 mg promethazine hcl tab 50 mg Antileukotrienes AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 49 Formulary last updated date (11/01/2014) Drug Name montelukast sodium chew tab 4 montelukast sodium chew tab 5 montelukast sodium tab 10 mg Bronchodilators, Anticholinergic ATROVENT HFA AER 17MCG cromolyn sodium soln nebu 20 ipratropium bromide inhal sol TUDORZA PRES AER 400/ACT Bronchodilators, Sympathomimetic ADVAIR DISKU AER 100/50 albuterol sulfate soln nebu 0 albuterol sulfate soln nebu 0 albuterol sulfate syrup 2 mg/ albuterol sulfate tab 2 mg albuterol sulfate tab 4 mg ANORO ELLIPT AER 62.5-25 BREO ELLIPTA INH 100-25 DULERA AER 100-5MCG DULERA AER 200-5MCG FORADIL CAP AEROLIZE metaproterenol sulfate syrup metaproterenol sulfate tab 10 metaproterenol sulfate tab 20 SEREVENT DIS AER 50MCG SYMBICORT AER 160-4.5 SYMBICORT AER 80-4.5 terbutaline sulfate tab 2.5 m terbutaline sulfate tab 5 mg VENTOLIN HFA AER Nasal Agents cromolyn sodium nasal aerosol flunisolide nasal soln 25 mcg flunisolide nasal soln 29 mcg fluticasone propionate nasal ipratropium bromide nasal sol ipratropium bromide nasal sol NASACORT ALR SPR 55MCG/AC oxymetazoline hcl nasal soln saline nasal spray 0.65% Respiratory Tract Agents, Other ALpe-apap cap & doxylamine-peA-S PL SINUS TAB 7.8-325 A-S PLS SINU CAP ALLR/CGH acetaminophen w/ dm liq 1000acetaminophen w/ dm liq 160-5 acetaminophen-guaifenesin tab acetaminophen-guaifenesin tab Requirements/ Limits QL 12.9/30 QL 1/30 QL 60/30 ST PA QL 14/30 QL 60/30 QL 13/30 ST QL 13/30 ST QL 60/30 QL 120/30 QL 10.2/30 ST QL 10.2/30 ST QL 18/25 QL 50/30 QL 50/30 QL 16/30 QL 30/30 QL 15/30 QL 90/30 AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 50 Formulary last updated date (11/01/2014) Drug Name acetylcysteine inhal soln 10% acetylcysteine inhal soln 20% ADVIL ALLERG TAB CONGEST ADVIL ALLERG TAB SINUS ADVIL COLD/ CAP SINUS ADVIL CONGST TAB RELIEF ALA-HIST PE TAB 2-10MG ALBATUSSIN LIQ NN ALKA-SELT PL CAP COLD/CGH ALKA-SELT PL MIS DAY/NGHT ALKA-SELT PL TAB CLD/FLU ALKA-SELT PL TAB COLD/CGH ALKA-SELT PL TAB NGHT CLD benzonatate cap 100 mg benzonatate cap 200 mg BICLORA LIQ BICLORA TAB 25-25MG BICLORA-D LIQ BICLORA-D TAB BIOBRON SF SYP BIONEL LIQ PEDIATRC BIOSPEC DMX LIQ BPM-PSE-DM LIQ 4-20-20 BROHIST D TAB 4-10MG brompheniramine & phenylephri brompheniramine & phenylephri brompheniramine & phenylephri brompheniramine & pseudoephed BRONCOTRON DRO PED BRONCOTRON-S LIQ 20-400/5 BRONKAID TAB 25-400MG BRONKIDS DRO BRONKIDS LIQ 10-4-10 BRONTUSS DX LIQ CAPCOF SYP CAPMIST DM TAB CAPRON DM LIQ CARBAPHEN 12 LIQ CARBAPHEN CH SUS CARBAPHEN SUS PED CH CCP CAFFEINE TAB FREE CERTUSS-D TAB cetirizine-pseudoephedrine ta CHEST CONGES GRA CHILDREN CHEST CONGST GRA CHILDRNS CHEST CONGST GRA COUGH CHLO TUSS EX LIQ 12.5-100 Requirements/ Limits AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 51 Formulary last updated date (11/01/2014) Drug Name CHLO TUSS LIQ CHLO TUSS LIQ CHLOPHED LIQ chlorphen-pe-apap tab & diphe chlorphen-pe-apap tab 2-5-325 chlorphen-phenylephrine w/ ap chlorphen-phenylephrine w/ ap chlorphen-phenylephrine w/ ap chlorphen-phenylephrine w/ ap chlorphen-pseudoephedrine w/ chlorphen-pseudoephedrine w/ chlorpheniramine & phenylephr chlorpheniramine & phenylephr chlorpheniramine & phenylephr chlorpheniramine & phenylephr chlorpheniramine & pseudoephe chlorpheniramine & pseudoephe chlorpheniramine & pseudoephe chlorpheniramine w/ codeine l chlorpheniramine-acetaminophe chlorpheniramine-dm liquid 1chlorpheniramine-dm liquid 2chlorpheniramine-dm tab 4-30 chlorpheniramine-phenylephrin CLOFERA LIQ CNTC CLD/FLU PAK DAY/NGHT CNTC CLD/FLU TAB MAX ST CODAR AR LIQ CODAR D LIQ CODAR GF LIQ CODITUSS DM SYP COMPLETE SIN TAB RELIEF CONEX SOL CLD/ALRG CONEX TAB 2-60MG CORICIDIN NT LIQ COLD/CGH CORICIDN HBP MIS MULTI SY COUGH D SYP CPB WC LIQ DALLERGY DRO 1-2.5MG DALLERGY SYP DALLERGY TAB 1-5MG DALLERGY TAB 25-10MG day/nyquil liq severe DAYTIME LIQ COLD MED DECON-A ELX 2-5MG/5M DECON-A LIQ DROPS DECON-G DRO 2-1-40MG Requirements/ Limits AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 52 Formulary last updated date (11/01/2014) Drug Name DELTUSS DP LIQ 1-30/5ML DESPEC DM SYP DESPEC-DM TAB DEX-TUSS LIQ 300-10/5 DEXATREX D ELX CF-NASAL dexbrompheniramine & pseudoep dextromethorphan hbr syrup 15 dextromethorphan-apap-chlorph dextromethorphan-apap-chlorph dextromethorphan-doxylamine-a dextromethorphan-doxylamine-a dextromethorphan-doxylamine-a dextromethorphan-guaifenesin dextromethorphan-guaifenesin dextromethorphan-guaifenesin dextromethorphan-guaifenesin dextromethorphan-guaifenesin dextromethorphan-guaifenesin dextromethorphan-guaifenesin dextromethorphan-guaifenesin dextromethorphan-guaifenesin dextromethorphan-guaifenesin dextromethorphan-guaifenesin dextromethorphan-guaifenesin dextromethorphan-phenylephrin dextromethorphan-phenylephrin dextromethorphan-phenylephrin dextromethorphan-phenylephrin DIABETIC CAP COLD/FLU DIABETIC TUS LIQ COLD/FLU DICEL CD LIQ DIMETAPP CLD CHW /ALLERGY DIMETAPP SYP CGH/COLD diphenhydramine-acetaminophen diphenhydramine-acetaminophen diphenhydramine-acetaminophen diphenhydramine-phenylephrine diphenhydramine-phenylephrine diphenhydramine-phenylephrine diphenhydramine-phenylephrine diphenhydramine-phenylephrine diphenhydramine-phenylephrine diphenhydramine-phenylephrine diphenhydramine-phenylephrine diphenhydramine-phenylephrine diphenhydramine-phenylephrine diphenhydramine-pse w/ apap t Requirements/ Limits AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 53 Formulary last updated date (11/01/2014) Drug Name dm-gg-pot cit-citric acid liq DOLOGEN TAB DOMETUSS-DA LIQ 1-2.5MG DONATUSSIN SYP doxylamine-dm 6.25-15 mg/15ml doxylamine-dm liquid 6.25-15 doxylamine-phenylephrine-apap DRIXORAL CAP CGH & ST DRIXORAL TAB COLD/FLU DURAVENT PE TAB 10-395MG dyphylline-guaifenesin liqd 1 dyphylline-guaifenesin tab 20 ED CHLORPED DRO D ELIXOPHYLLIN ELX 80/15ML ELIXSURE GEL CONGEST ENDACON SYP ENTEX LQ LIQ ENTEX T TAB 60-375MG ENTRE-COUGH SUS TANNATE ephedrine-guaifenesin tab 12. EQL INFANT DRO DCON/CGH FATHER JOHNS SOL PLUS FENESIN DM TAB 15-400MG GILTUSS LIQ PED-C GILTUSS TR CAP 7-14-288 guaifenesin liquid 100 mg/5ml guaifenesin liquid 200 mg/5ml GUAIFENESIN POW guaifenesin syrup 100 mg/5ml guaifenesin tab 200 mg guaifenesin tab 400 mg guaifenesin tab sr 12hr 600 m guaifenesin-codeine liquid 22 guaifenesin-codeine soln 100guaifenesin-codeine soln 100HERBAL EXPEC LIQ 150/15ML HISTEX-DM SYP HISTEX-PE SYP 2.5-10/5 hydrocod polst-chlorphen pols hydrocodone w/ homatropine sy hydrocodone w/ homatropine ta LITTLE REMED LIQ COLDS LODRANE D CAP 4-60MG LOHIST-PSB LIQ 4-20/5ML loratadine & pseudoephedrine loratadine & pseudoephedrine LORTUSS DM LIQ Requirements/ Limits AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 54 Formulary last updated date (11/01/2014) Drug Name LORTUSS EX LIQ LORTUSS LQ LIQ LUFYLLIN TAB 200MG LUFYLLIN TAB 400MG LUSAIR LIQ M-END DMX LIQ M-END MAX D LIQ M-END PE LIQ MAR-COF BP LIQ MAXIFED DMX TAB MEDI-GRAINE TAB MUCINEX FAST MIS DAY/NGHT MUCINEX FAST TAB 5-10-200 MUCINEX TAB 1200MG NASAL DECON SYP 30MG/5ML NASOPEN LIQ NASOPEN PE LIQ NEO DM SYP NEOTUSS PLUS LIQ NEOTUSS-D LIQ NEOTUSS-D LIQ NITE-TIME LIQ COLD/FLU NOREL AD TAB 4-10-325 NOREL CS LIQ NOTUSS-NX LIQ NOTUSS-NXD LIQ ONSET FORTE TAB PAIN RELIEF TAB COLD PE PANATUSS DXP LIQ PANATUSS DXP LIQ PEDIATRI PANATUSS PED DRO PANATUSS PED LIQ 60-2-25 pe-dm-apap & pe-cpm-dm-apap t pe-dm-apap cap & doxylamine-d pe-dm-apap liq & doxylamine-d pe-dm-gg-apap tab & pe-diphen PE-HIST DM SYP 5-2-15MG PECGEN DMX LIQ 15-125MG phenyleph-chlorphen-dm w/apap phenyleph-chlorphen-dm w/apap phenyleph-chlorphen-dm w/apap phenylephrine w/ acetaminophe phenylephrine w/ acetaminophe phenylephrine w/ acetaminophe phenylephrine w/ acetaminophe phenylephrine w/ dm-gg liqd 1 phenylephrine w/ dm-gg liqd 1 Requirements/ Limits AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 55 Formulary last updated date (11/01/2014) Drug Name phenylephrine w/ dm-gg liqd 1 phenylephrine w/ dm-gg liqd 2 phenylephrine w/ dm-gg liqd 2 phenylephrine w/ dm-gg liqd 2 phenylephrine w/ dm-gg liqd 2 phenylephrine w/ dm-gg liqd 5 phenylephrine w/ dm-gg liqd 5 phenylephrine w/ dm-gg liquid phenylephrine w/ dm-gg syrup phenylephrine w/ dm-gg tab 10 phenylephrine w/ dm-gg tab 10 phenylephrine-apap-gg liqd 10 phenylephrine-apap-gg tab 10phenylephrine-apap-gg tab 5-3 phenylephrine-brompheniramine phenylephrine-brompheniramine phenylephrine-brompheniramine phenylephrine-brompheniramine phenylephrine-brompheniramine phenylephrine-chlorphen-dm li phenylephrine-chlorphen-dm li phenylephrine-chlorphen-dm li phenylephrine-chlorphen-dm li phenylephrine-chlorphen-dm li phenylephrine-dm soln 2.5-5 m phenylephrine-dm-gg w/ apap l phenylephrine-dm-gg w/ apap l phenylephrine-dm-gg w/ apap t phenylephrine-dm-gg w/ apap t phenylephrine-dm-gg w/ apap t phenylephrine-doxylamine-dm-a phenylephrine-guaifenesin liq phenylephrine-guaifenesin liq phenylephrine-guaifenesin syr phenylephrine-guaifenesin tab phenylephrine-guaifenesin tab phenylephrine-guaifenesin tab phenylephrine-promethazine w/ PHENYLHIST LIQ DH POLY HIST TAB 7.5-10MG POLY-HIST DM LIQ 5-25-10 POLY-HIST PD LIQ POLY-TUSSIN LIQ AC POLY-VENT DM TAB POLY-VENT DM TAB POLY-VENT IR TAB 60-380MG PRO-CHLO LIQ Requirements/ Limits AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 56 Formulary last updated date (11/01/2014) Drug Name PRO-RED AC SYP 5-1-9/5 promethazine & phenylephrine promethazine w/ codeine syrup promethazine-dm syrup 6.25-15 pseudoeph-chlorphen-dm w/ apa pseudoeph-chlorphen-dm w/ apa pseudoeph-chlorphen-dm w/ apa pseudoeph-chlorphen-dm w/ apa pseudoeph-chlorphen-dm w/ apa pseudoeph-doxylamine-dm w/ ap pseudoeph-doxylamine-dm w/apa pseudoephed-bromphen-dm elixi pseudoephed-bromphen-dm syrup pseudoephed-bromphen-dm syrup pseudoephed-chlorphen-dm liq pseudoephed-chlorphen-dm liq pseudoephed-chlorphen-dm liq pseudoephed-dexchlorphen-chlo pseudoephedrine hcl liq 15 mg pseudoephedrine hcl tab 30 mg pseudoephedrine hcl tab 60 mg pseudoephedrine hcl tab abuse pseudoephedrine hcl tab sr 12 pseudoephedrine w/ acetaminop pseudoephedrine w/ apap-dm ca pseudoephedrine w/ apap-dm li pseudoephedrine w/ apap-dm ta pseudoephedrine w/ cod-gg sol pseudoephedrine w/ cod-gg syr pseudoephedrine w/ dm-gg cap pseudoephedrine w/ dm-gg liqu pseudoephedrine w/ dm-gg liqu pseudoephedrine w/ dm-gg syru pseudoephedrine-bromphen-code pseudoephedrine-chlophedianol pseudoephedrine-dexchlorpheni pseudoephedrine-dm liqd 15-7. pseudoephedrine-dm syrup 30-1 pseudoephedrine-dm-gg w/ apap pseudoephedrine-guaifenesin c pseudoephedrine-guaifenesin s pseudoephedrine-guaifenesin t pseudoephedrine-guaifenesin t pseudoephedrine-guaifenesin t pseudoephedrine-guaifenesin t pseudoephedrine-ibuprofen sus pseudoephedrine-ibuprofen tab Requirements/ Limits AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 57 Formulary last updated date (11/01/2014) Drug Name pseudoephedrine-naproxen sodi PULMOZYME SOL 1MG/ML PYRIL DM SUS pyrilamine mal-phenylephrine pyrilamine-phenylephrine tab RESCON-DM SYP RESPAIRE-30 CAP ROBITUS NGHT LIQ 12.5-30 ROBITUSSIN D LIQ CGH/COLD ROBITUSSIN LIQ CF ROBITUSSIN LIQ NIGHT TM ROBITUSSIN MIS DAY/NGHT ROBITUSSIN MIS DAY/NITE ROBITUSSIN MIS DAY/NITE RU-HIST-D LIQ 30-10/5 RU-HIST-D TAB 30-10MG RYCONTUSS LIQ 5-2-10/5 RYDEX G TAB 38.5-398 RYMED TAB 2-10MG SAFE TUSSIN LIQ PM SCOT-TUSSIN LIQ ORIGINAL SCOT-TUSSIN LIQ SENIOR SEV SIN CONG TAB DAYTIME SINADRIN PE TAB 2-10-650 SINUS-MAX MIS DAY/NGHT sodium chloride aero soln 0.9 sodium chloride soln nebu 0.9 STAHIST AD LIQ STAHIST AD TAB 25-60MG STATUSS LIQ GREEN SUDAFED 24HR TAB 240MG SUDAFED PE PAK DAY&NGHT SUPPRESS A DRO 5-1-10 SUPRESS DM DRO 5-50/ML SUPRESS-PE DRO PEDIATRI TERPIN HYDR POW MONOHYDR THEO-24 CAP 100MG CR THEO-24 CAP 200MG CR THEO-24 CAP 300MG CR theophylline tab sr 12hr 100 theophylline tab sr 12hr 200 theophylline tab sr 12hr 300 theophylline tab sr 12hr 450 THERACOF PLS LIQ CGH/COLD THERAFLU CLD MIS CGH DAY THERAFLU FLU PAK SORE THR THERAFLU FLU POW CHST CON Requirements/ Limits PA AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 58 Formulary last updated date (11/01/2014) Drug Name THERAFLU LIQ WARM RLF THERAFLU PAK COLD/CGH THERAFLU POW THERAFLU POW MAX-D THERAFLU SEV PAK COLD/CGH TREXBROM LIQ 10-4-25 TRIACTIN SOL CHST CON TRIACTING LIQ CGH/RUN TRIAMIN FLU/ SYP CGH/FVR TRIAMINIC CHW TRIAMINIC CHW TRIAMINIC LIQ TRIAMINIC LIQ CHST/NAS TRIAMINIC MIS CGH/COLD TRIAMINIC MIS COLD/CGH TRIAMINIC MIS GRAPE TRIAMINIC NT MIS COLD/CGH TRIAMINIC SOL COLD/CGH TRIAMINIC SYP CGH/SORE triaminic syp child TRIAMINIC SYP CHST/NSL TRIAMINIC SYP COLD/ALL TRIAMINIC SYP COLD/CGH TRIAMINIC-D SYP TRICODE AR LIQ TRICODE GF LIQ triprolidine & pseudoephedrin triprolidine & pseudoephedrin triprolidine & pseudoephedrin TRISPEC DMX LIQ 10-187/5 TRISPEC PSE LIQ TRISPEC PSE LIQ TUSICOF LIQ TUSNEL CAP TUSSAFEX-A LIQ 6-2-15/5 TYLENOL CGH PAK SORE THR TYLENOL CHES LIQ CONGEST TYLENOL CHLD SUS CLD/CGH TYLENOL CHLD SUS STUFFY TYLENOL COLD LIQ RELIEF TYLENOL SINU MIS DAY/NITE UNIFED LIQ 30MG/5ML VANACOF APE LIQ VANACOF CD LIQ VANACOF DM LIQ VANACOF G LIQ VANACOF GPE LIQ Requirements/ Limits AL AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 59 Formulary last updated date (11/01/2014) Drug Name VANACOF-8 LIQ 25-50/15 VANATAB DX TAB VICKS NATURE LIQ COLD/FLU VICKS NATURE LIQ CONGEST VICKS NYQUIL LIQ CHILDREN VICKS NYQUIL LIQ COLD/FLU WAL-DRYL-D TAB 25-60MG Z-TUSS AC LIQ 2-9/5ML Z-TUSS E LIQ ZODRYL AC 25 SUS ZODRYL AC 30 SUS ZODRYL AC 35 SUS ZODRYL AC 40 SUS ZODRYL DAC SUS 25 ZODRYL DAC SUS 30 ZODRYL DAC SUS 35 ZODRYL DAC SUS 40 ZODRYL DEC25 SUS ZODRYL DEC30 SUS ZODRYL DEC35 SUS ZODRYL DEC40 SUS ZYNCOF SYP 20-400/5 Requirements/ Limits SKELETAL MUSCLE RELAXANTS Skeletal Muscle Relaxants baclofen tab 10 mg baclofen tab 20 mg chlorzoxazone tab 500 mg cyclobenzaprine hcl tab 10 mg cyclobenzaprine hcl tab 5 mg methocarbamol tab 500 mg methocarbamol tab 750 mg tizanidine hcl tab 2 mg tizanidine hcl tab 4 mg QL 90/30 QL 90/30 THERAPEUTIC NUTRIENTS/ MINERALS/ ELECTROLYTES Electrolyte/Mineral Modifiers calcitriol cap 0.25 mcg calcitriol cap 0.5 mcg SENSIPAR TAB 30MG PA SENSIPAR TAB 60MG PA Electrolyte/Mineral Replacement CYTRA-K SOL K-PHOS TAB NO 2 ORACIT SOL phenazopyridine hcl tab 100 m phenazopyridine hcl tab 200 m pot & sod citrates w/ cit ac potassium citrate & citric ac AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 60 Formulary last updated date (11/01/2014) Drug Name sodium chloride irrigation so sodium citrate & citric acid Nutrients ATABEX CHW PRENATAL ATABEX EC TAB ATABEX TAB PRENATAL BRAINSTRONG MIS PRENATAL CENTRUM SPEC PAK PRENATAL CO-NATAL FA TAB 29-1MG COMP PRNATAL MIS DHA COMPLETE NAT PAK DHA COMPLETENATE CHW CVS PRENATAL CHW GUMMY ENFAMIL MIS EXPECTA EZFE FORTE CAP LACTOCAL-F TAB MISSION PREN TAB MISSION PREN TAB /FA MYNATAL CAP NATALVIT TAB 75-1MG NUTRIENTS TAB PRENATAL O-CAL FA TAB O-CAL TAB PRENATAL OBSTETRIX EC TAB OBSTETRIX PAK DHA ONE A DAY MIS PRENATAL PRENAT MULTI CAP +DHA PRENATA CHW 29-1MG PRENATAL CAP FORMULA PRENATAL CAP OMEGA-3 PRENATAL FRM TAB A-FREE PRENATAL MUL CAP +DHA PRENATAL TAB FORMULA PRENATAL TAB PLUS DHA PRENATAL TAB PLUS FE PRENATAL+DHA MIS SE-NATAL 19 TAB SE-NATAL 90 TAB SETONET PAK SM ONE DAILY MIS PRENATAL STUART ONE CAP TARON-BC MIS THERANATAL MIS COMPLETE TRINATAL RX TAB 1 TRIVEEN-DUO PAK DHA TRIVEEN-U CAP ULTRA TABS TAB Requirements/ Limits AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 61 Formulary last updated date (11/01/2014) Drug Name VINATE CAL TAB VINATE IC CAP VINATE II TAB VINATE M TAB VITA-PREN TAB Vitamins ALb-complex w/ c & folic acid ALb-complex w/ c & folic acid ALiron combination capALALAL ALmultiple vitamin tabALAL ALmultiple vitamins w/ iro ALmultiple vitamins w/ mineral ALmultiple vitamins w/ mineral ALmultiple vitamins w/ mineral ALmultiple vitamins w/ mineral ALMULTIPLE VITAMINS W/ MINERAL ALMULTIPLE VITAMINS W/ MINERAL ALMULTIPLE VITAMINS W/ MINERAL ALORAL ELECTROLYTE SOLUTIONALALAL ALoral electrolyte tabALALAL ALpediatric multiple vitamin l ALpediatric multiple vitamin w ALpediatric multiple vitamin w ALpediatric multiple vitamin w ALpediatric multiple vitamin w ALpediatric multiple vitamin w ALpediatric multiple vitamin w ALpediatric multiple vitamin w ALpediatric multiple vitamins ALpediatric multiple vitamins ALpediatric vitamins acd w/ fl ALpediatric vitamins acd w/ fl ALpediatric vitamins adc d ACEROLA C WAF 500MG antioxidant cap ascocid-iso- pow ph ascorbic acid cap cr 500 mg ascorbic acid chew tab 100 mg ascorbic acid chew tab 250 mg ascorbic acid chew tab 500 mg ascorbic acid inj 500 mg/ml ascorbic acid liquid 500 mg/5 ascorbic acid lozenge 60 mg ascorbic acid syrup 500 mg/5m ascorbic acid tab 100 mg ascorbic acid tab 1000 mg ascorbic acid tab 250 mg Requirements/ Limits AL AL AL AL AL AL AL AL AL AL AL AL AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 62 Formulary last updated date (11/01/2014) Drug Name ascorbic acid tab 500 mg ascorbic acid tab cr 1000 mg ascorbic acid tab cr 1500 mg ascorbic acid tab cr 500 mg b-1 tab 500mg b-2-400 cap B-NATAL LOZ 25MG B-NATAL LOZ 25MG B1 NATURAL TAB 250MG BE WELL PAK ROUNDED BENFOTIAMINE CAP 150MG biotin cap 1mg biotin cap 2.5 mg biotin cap 5 mg biotin forte tab 3mg biotin tab 1000 mcg BIOTIN TAB 10MG biotin tab 2.5 mg biotin tab 300 mcg biotin tab 5 mg BIOTIN TAB 7500MCG biotin tab 800 mcg BONE MEAL TAB BUFFERED VIT CAP C 1000MG ca citrate tab 250mg CA HI-CAL/D TAB 250MG CA HI-CAL/D TAB 500MG ca hi-cal/d tab 500mg CA PANTOTHEN TAB 100MG ca pantothen tab 200mg CAL CIT MAL/ TAB VITAMIND CAL-CITRATE CAP 150MG cal-citrate tab plus d CAL-CYUM WAF 500MG CAL-MAG CHEL CAP 70-83MG CAL-QUICK LIQ 500-400 CAL/MAG TAB CHEW CALC CITRATE LIQ VIT D3 CALC/VIT D3 CHW 200-200 CALCET BITES CHW 500-400 CALCIUM &MAG TAB calcium 1000 tab + d CALCIUM ASCORBATE TAB 500 MG calcium carbonate tab 1250 mg CALCIUM CARBONATE-CHOLECALCIF CALCIUM CARBONATE-CHOLECALCIF calcium carbonate-cholecalcif Requirements/ Limits AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 63 Formulary last updated date (11/01/2014) Drug Name calcium carbonate-cholecalcif calcium carbonate-cholecalcif calcium carbonate-cholecalcif calcium carbonate-cholecalcif CALCIUM CARBONATE-CHOLECALCIF CALCIUM CARBONATE-CHOLECALCIF calcium carbonate-ergocalcife CALCIUM CARBONATE-VITAMIN D C calcium carbonate-vitamin d c calcium carbonate-vitamin d t calcium carbonate-vitamin d t calcium carbonate-vitamin d t calcium carbonate-vitamin d t calcium carbonate-vitamin d t calcium carbonate-vitamin d t calcium carbonate-vitamin d t CALCIUM CHW 600-400 CALCIUM CIT TAB 1040MG CALCIUM CIT TAB W/VIT D calcium citrate tab 950 mg (2 calcium citrate-vitamin d tab calcium citrate-vitamin d tab CALCIUM CITRATE-VITAMIN D TAB CALCIUM CITRATE-VITAMIN D TAB calcium glubionate syrup calcium gluconate tab 500 CALCIUM GRA CITRATE CALCIUM PANTOTHENATE TAB 500 CALCIUM PLUS CAP VIT D calcium plus cap vit d calcium tab magnesiu calcium w/ magnesium tab 250CALCIUM W/ MAGNESIUM TAB 333CALCIUM W/ MAGNESIUM TAB 500CALCIUM W/ VITAMIN D TAB 600 calcium/vitd cap 600-400 calmag thins tab 200-50mg CALNA TAB carbonyl iron chew tab 15 mg CARBONYL IRON SUSP 15 MG/1.25 child-multi chw vitamins cholecalciferol cap 400 unit cholecalciferol tab 400 u CLUSIMAR SYP COMPLETE DRO PE cyanocobalamin inj 1000 mcg/m cyto b2 pow Requirements/ Limits AL QL 60/30 QL 60/30 AL AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 64 Formulary last updated date (11/01/2014) Drug Name DIALYVITE TAB SUPREM D DOLOMITE TAB 10GR ELDERTONIC ELX elite ca/mg tab 100-50mg ELITE IRON TAB 15MG EQL CALCIUM CAP VIT D EQL VIT D-3 TAB ergocalciferol cap 50000 unit ergocalciferol soln 8000 fe aspartate tab fe fumarate w/ b12-vit c-fa-i fe fumarate-vit c-vit b12-fa femiron tab feosol tab 45mg ferate tab 28mg ferretts fe chw 18mg FERRETTS IPS SOL FERRIMIN 150 TAB FERROUS FUM TAB 29MG FERROUS FUMA TAB ferrous fumarate tab 325 mg ( FERROUS GLUC TAB 225MG ferrous gluc tab 324mg ferrous gluconate tab 240 mg ferrous gluconate tab 324 mg ferrous gluconate tab 325 mg FERROUS SULF GRA ferrous sulf syp 300/5ml ferrous sulf tab 140mg ferrous sulf tab 324mg ec ferrous sulfate dried tab 200 ferrous sulfate dried tab cr ferrous sulfate dried tab cr ferrous sulfate elixir 220 mg ferrous sulfate soln 75 mg/ml ferrous sulfate tab 134 mg (2 ferrous sulfate tab 27 mg (el ferrous sulfate tab 325 mg (6 ferrous sulfate tab cr 142 mg ferrous sulfate tab cr 47.5 m FERROUS SULFATE TAB CR 50 MG ferrous sulfate tab ec 325 mg ferrous sulfate-vit c-folic a flintstones chw toddler folic acid tab 1 mg folic acid tab 200mcg folic acid tab 400 mcg Requirements/ Limits QL 4/28 AL AL QL 30/30 AL GR AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 65 Formulary last updated date (11/01/2014) Drug Name folic acid tab 800 mcg GUMMY BITES CHW HONEY BEARS CHW IRON-ZIN IRON HIGH CAP POTENCY iron polysacch complex-vit b1 iron tab 18mg iron tab 18mg cr IRON UP LIQ K-PHOS TAB KP PRENATAL TAB MULTIVIT KPN PRENATAL TAB liquid c 500 liq 500/15ml liquid calci cap with d3 LOZI-FLUR LOZ 1MG F M2K CAP 60MG mag carbonat pow 250mg/gm MAG CARBONAT POW HEAVY MAG CITRATE TAB 100MG mag-200 tab MAG-TAB SR TAB 84MG MAGIMIN TAB 80MG MAGINEX DS GRA 1230MG MAGINEX TAB 615 MG MAGN CHLORID CRY HEXAHYDR MAGN CHLORID POW magn sulfate cap 70mg MAGNEBIND TAB 200 MAGNESIUM CAP 100 MG MAGNESIUM CAP 300MG magnesium cap 400mg MAGNESIUM CHLORIDE INJ 200 MG magnesium chloride tab cr 535 magnesium gl tab 550mg MAGNESIUM GLUCONATE TAB 27.5 MAGNESIUM GLUCONATE TAB 500 M MAGNESIUM GLUCONATE TAB 500 M magnesium gluconate tab 500 m MAGNESIUM OXIDE CAP 500 MG (E magnesium oxide tab 250 mg (m magnesium oxide tab 400 mg (2 magnesium oxide tab 400 mg (2 MAGNESIUM OXIDE TAB 500 MG (M magnesium pow oxide MAGNESIUM SULFATE 1% IN D5W magnesium sulfate inj 4% magnesium sulfate inj 50% magnesium sulfate inj 8% Requirements/ Limits QL 30/30 AL GR AL AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 66 Formulary last updated date (11/01/2014) Drug Name magnesium tab 100 mg magnesium tab 200 mg magnesium tab 250 mg MAGNESIUM TAB 30MG MAGNESIUM TAB 30MG MAGNESIUM TAB 500MG MAGONATE LIQ 1000/5ML magtrate tab 500mg mega biotin cap 10mg mephyton tab 5mg mg aspartate tab 65mg MG GLUCONATE TAB 250MG MG SO4/D5W INJ 20MG/ML multi-delyn liq /iron mykidz iron sus 10mg/2ml MYKIDZ IRON SUS 15/1.5ML nanovm pow 1-3 yrs NANOVM T/F LIQ neuro-k-250 cap t.d. niacin cap cr 250 mg niacin cap cr 500 mg niacin tab 100 mg niacin tab 250 mg niacin tab 50 mg niacin tab 500 mg niacin tab cr 250 mg niacin tab cr 500 mg niacin tab cr 750 mg NIACIN TR TAB 1000MG niacinamide tab 100 mg niacinamide tab 500 mg NIACINAMIDE TAB 500MG PR novaferrum cap 50mg NOVAFERRUM DRO 15MG/ML NUTRICION TAB PORVIDA ORAZINC TAB 110MG OS-CAL CHW OSTEO-PORETI TAB ostigen mis 350mg OYST SHELL/D TAB 250MG oyster shell calcium tab oyster shell tab plus d PABA TAB 100MG panto-250 cap PANTOTHENIC ACID TAB 500 MG PARVA-CAL TAB 250-100 PARVA-CAL TAB 500MG Requirements/ Limits AL AL AL AL AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 67 Formulary last updated date (11/01/2014) Drug Name PERFECT IRON TAB 25MG PERRY PRENAT CAP PHLEXY-VITS POW phos-nak pow concentr phytonadione tab 100 mcg POLYSACCHARIDE IRON COMPLEX C POLYSACCHARIDE IRON COMPLEX C POSTURE TAB pot bicarbonate & chloride ef pot phos monobasic w/sod phos POTABA CAP 500MG POTABA TAB 500MG potassium bicarbonate effer t potassium chloride cap cr 10 potassium chloride cap cr 8 m potassium chloride microencap potassium chloride microencap potassium chloride microencap potassium chloride oral liq 1 potassium chloride powder pac potassium chloride tab cr 10 potassium chloride tab cr 8 m PRENATAL TAB PRENATAL TAB 27-0.8MG PRENATAL TAB COMPLETE PRENATAL TAB VITAMINS profe cap 180mg PROFERRIN ES TAB 12 MG protexin syp pur-absorb liq 5mg/20ml pyridoxine hcl tab 100 mg pyridoxine hcl tab 200 mg pyridoxine hcl tab 25 mg pyridoxine hcl tab 250 mg pyridoxine hcl tab 50 mg pyridoxine hcl tab 500 mg pyridoxine hcl tab cr 200 mg RA CA/BORON TAB RA ESSENCE-C POW LMN-LIME ra oys shl/d tab 250mg ra vitamin c chw 300mg RIBOFLAVIN CAP 100MG RIBOFLAVIN CAP 50MG RIBOFLAVIN TAB 100 MG riboflavin tab 25 mg RIBOFLAVIN TAB 400MG riboflavin tab 50 mg Requirements/ Limits AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 68 Formulary last updated date (11/01/2014) Drug Name scooby-doo chw slow rel fe tab 143mg cr slow release tab 143mg sodium chloride tab 1 gm sodium fluoride chew tab 0.5 sodium fluoride chew tab 1 mg SODIUM FLUORIDE SOLN 0.5 MG/M STROVITE FOR SYP SUPERVITE EC TAB SYNATEK CAP thiamine cap 50mg thiamine hcl tab 100 mg THIAMINE HCL TAB 250 MG thiamine hcl tab 50 mg THIAMINE MONONITRATE TAB 100 tl g-fol os tab udamin sp tab UPCAL D POW UPCAL D POW vita-c cry VITA-CALCIUM WAF vitamin b-12 tab 1000mcg vitamin c cap 500mg VITAMIN C CHW 1000MG vitamin c chw gummie VITAMIN C SOL ZINC 15 TAB 66MG zinc loz ZINC SULFATE CAP 220 MG (50 M ZINC SULFATE GRA HEPTAHYR ZINC SULFATE INJ 1MG/ML ZINC SULFATE INJ 5MG/ML zinc sulfate pow zinc sulfate tab ZINC SULFATE TAB 220 MG (50 M ZINC TAB 220MG Requirements/ Limits AL AL-Age Limit GR- Gender Restriction PA-Prior Authorization Required ST-Step Therapy Required QL-Quantity Limit per 30 days For additional information call Member Services at 844-222-5584 69 Formulary last updated date (11/01/2014) * *artificial tear ophth ointme 46 *artificial tear ophth soluti 46 *b-complex w/ c & folic acid 62 *condoms - male*** 42 *iron combination cap*** 62 *lactobacillus acidophilus-pe 29 *multiple vitamin tab** 62 *multiple vitamins w/ iro 62 *multiple vitamins w/ mineral 62 *neomycin-bacitracin-polymyxi 22 *nit remover - gel*** 22 *nystatin topical powder** 22 *oral electrolyte solution*** 62 *oral electrolyte tab*** 62 *oral vehicles*** 42 *pe-apap cap & doxylamine-pe50 *pediatric multiple vitamin l 62 *pediatric multiple vitamin w 62 *pediatric multiple vitamins 62 *pediatric vitamins acd w/ fl 62 *pediatric vitamins adc d 62 *sodium polystyrene sulfonate 42 *white petrolatum-mineral oil46 1 1 ml syrimge mis 18gx1" 42 1 ml syringe mis 22x1-1/2 42 1ml syr/need mis 26gx5/8" 42 1ml syringe mis 23gx1" 42 1ml syringe mis 25gx1" 42 1ml syringe mis 25gx5/8" 42 1ml syringe mis 26gx3/8" 42 A a-200 gel 0.33-4% 22 abreva cre 10% 22 acarbose tab 100 mg 12 acarbose tab 25 mg 12 acarbose tab 50 mg 12 acebutolol hcl cap 200 mg 16 acebutolol hcl cap 400 mg 16 acerola c waf 500mg 62 acetamin sup 650mg 1 acetaminophen cap 500 mg 1 acetaminophen chew tab 80 mg 1 70 acetaminophen elixir 160 mg/51 acetaminophen liquid 160 mg/5 1 acetaminophen soln 100 mg/ml 1 acetaminophen suppos 120 mg 1 acetaminophen suppos 325 mg 1 acetaminophen susp 80 mg/0.8m 1 acetaminophen tab 325 mg 1 acetaminophen tab 500 mg 1 acetaminophen tab cr 650 mg 1 acetaminophen w/ codeine soln 2 acetaminophen w/ codeine tab 2 acetaminophen w/ dm liq 100050 acetaminophen w/ dm liq 160-5 50 acetaminophen-caffeine-py 1 acetaminophen-guaifenesin tab 50 acetazolamide cap sr 12hr 500 19 acetazolamide tab 125 mg 19 acetazolamide tab 250 mg 19 acetic acid 2% in aluminum ac 48 acetic acid otic soln 2% 48 acetone sol 22 acetylcysteine inhal soln 10% 51 acetylcysteine inhal soln 20% 51 acidophilus/ tab cit pect 29 acne medicat lot 10% 22 acne medicat lot 5% 22 acnotex lot 22 actiphyte of liq lemongra 22 acyclovir cap 200 mg 11 acyclovir susp 200 mg/5ml 11 acyclovir tab 400 mg 11 acyclovir tab 800 mg 11 adrenaclick inj 0.3mg 43 advair disku aer 100/50 50 advil allerg tab congest 51 advil allerg tab sinus 51 advil cold/ cap sinus 51 advil congst tab relief 51 agoral liq max st 29 akray expression test strips 43 ala-hist pe tab 2-10mg 51 alamag chw 300-150 29 albatussin liq nn 51 albuterol sulfate soln nebu 0 50 albuterol sulfate syrup 2 mg/ 50 albuterol sulfate tab 2 mg 50 albuterol sulfate tab 4 mg 50 alclometasone dipropionate cr 22 alclometasone dipropionate oi 22 alcohol isop sol 50% wint 22 alendronate sodium tab 10 mg 42 alendronate sodium tab 35 mg 42 alendronate sodium tab 40 mg 42 alendronate sodium tab 5 mg 42 alendronate sodium tab 70 mg 42 aler-dryl tab 50mg 49 alevazol oin 1% 22 alka seltzer tab heartbrn 29 alka-selt pl cap cold/cgh 51 alka-selt pl mis day/nght 51 alka-selt pl tab cld/flu 51 alka-selt pl tab cold/cgh 51 alka-selt pl tab nght cld 51 allopurinol tab 100 mg 8 allopurinol tab 300 mg 8 alora dis 0.025mg 35 alora dis 0.05mg 35 alora dis 0.075mg 35 alora dis 0.1mg 36 altavera 36 alum & mag hydroxidesimethic 29 aluminum hydroxidemagnesium 29 alyacen 1/35 36 amantadine hcl cap 100 mg 10 amantadine hcl syrup 50 mg/5m 10 amiloride & hydrochlorothiazi 20 amiloride hcl tab 5 mg 20 amiodarone hcl tab 200 mg 15 amlodipine besylate tab 10 mg 17 amlodipine besylate tab 2.5 m 17 amlodipine besylate tab 5 mg 17 amlodipine besylate-benazepri 15 ammonium lac sol 70% 22 amoxicillin & k clavulanate c 6 amoxicillin & k clavulanate f 6 amoxicillin & k clavulanate t 6 amoxicillin (trihydrate) cap 6 amoxicillin (trihydrate) chew 6 amoxicillin (trihydrate) for 6 amoxicillin (trihydrate) tab 6 ampicillin cap 250 mg 6 ampicillin cap 500 mg 6 ampicillin for susp 125 mg/5m 6 ampicillin for susp 250 mg/5m 6 anagrelide hcl cap 0.5 mg 14 anagrelide hcl cap 1 mg 14 anastrozole tab 1 mg 9 anbesol liq 10% 21 anise oil 22 anoro ellipt aer 62.5-25 50 antacid chw 29 antioxidant cap 62 antipyrine-benzocaine otic so 48 apidra inj u-100 13 apri 36 apriso cap 0.375gm 42 arkray glucocard vital test s 43 armour thyro tab 120mg 39 armour thyro tab 15mg 39 armour thyro tab 180mg 39 armour thyro tab 240mg 39 armour thyro tab 300mg 39 a-s pl sinus tab 7.8-325 50 a-s pls sinu cap allr/cgh 50 ascocid-iso- pow ph 62 ascorbic acid cap cr 500 mg 62 ascorbic acid chew tab 100 mg 62 ascorbic acid chew tab 250 mg 62 ascorbic acid chew tab 500 mg 62 ascorbic acid inj 500 mg/ml 62 ascorbic acid liquid 500 mg/5 62 ascorbic acid lozenge 60 mg 62 71 ascorbic acid syrup 500 mg/5m 62 ascorbic acid tab 100 mg 62 ascorbic acid tab 1000 mg 62 ascorbic acid tab 250 mg 62 ascorbic acid tab 500 mg 63 ascorbic acid tab cr 1000 mg 63 ascorbic acid tab cr 1500 mg 63 ascorbic acid tab cr 500 mg 63 ascriptin tab 3 aspirin buffered (ca carb-mg 3 aspirin buffered tab 325 mg 3 aspirin chew tab 81 mg 3 aspirin suppos 300 mg 3 aspirin suppos 600 mg 3 aspirin tab 325 mg 3 aspirin tab 500 mg 3 aspirin tab 650mg ec 3 aspirin tab 81 mg 3 aspirin tab delayed release 3 3 aspirin tab delayed release 5 3 aspirin tab delayed release 8 3 aspirin-acetaminophen-caffein 1 atabex chw prenatal 61 atabex ec tab 61 atabex tab prenatal 61 atenolol & chlorthalidone tab 15 atenolol tab 100 mg 16 atenolol tab 25 mg 16 atenolol tab 50 mg 16 atorvastatin calcium tab 10 m 20 atorvastatin calcium tab 20 m 20 atorvastatin calcium tab 40 m 20 atorvastatin calcium tab 80 m 20 atovaquone susp 750 mg/5ml 10 atropine sulfate ophth oint 1 47 atropine sulfate ophth soln 1 47 atrovent hfa aer 17mcg 50 aubra 36 autoshield mis 29x3/16" 43 autoshield mis 29x5/16" 43 autoshield mis 30gx3/16 43 aviane 36 avonex kit 30mcg 21 avonex prefl kit 30mcg 21 azathioprine tab 50 mg 41 azelastine hcl ophth soln 0.0 47 azithromycin for susp 100 mg/ 7 azithromycin for susp 200 mg/ 7 azithromycin tab 250 mg 7 azithromycin tab 500 mg 7 azithromycin tab 600 mg 7 azor tab 10-20mg 15 azor tab 10-40mg 15 azor tab 5-20mg 15 azor tab 5-40mg 15 B b1 natural tab 250mg 63 b-1 tab 500mg 63 b-2-400 cap 63 baby orajel liq 7.5% 21 bacitracin oint 500 unit/gm 22 bacitracin ophth oint 500 uni 47 bacitracin zinc oint 500 unit 22 bacitracin-polymyxin b ophth 47 bacitracin-polymyxin-neomycin 47 baclofen tab 10 mg 60 baclofen tab 20 mg 60 balsalazide disodium cap 750 42 barc liq 22 bd saf-t-int kit 24gx0.75 43 be well pak rounded 63 belladonna alkaloids-phenobar 28 benazepril & hydrochlorothiaz 15 benazepril hcl tab 10 mg 14 benazepril hcl tab 20 mg 14 benazepril hcl tab 40 mg 14 benazepril hcl tab 5 mg 14 benfotiamine cap 150mg 63 bensulfoid cre 22 benzocaine dental cream 20%21 benzocaine dental gel 10% 21 benzocaine dental gel 20% 21 benzocaine dental gel 7.5% 21 benzocaine dental liquid 20% 21 benzocaine dental paste 20% 21 benzocaine dental soln 20% 21 benzocaine dental swab 20% 21 benzocaine-docusate sodium re 29 benzodent oin 20% 21 benzonatate cap 100 mg 51 benzonatate cap 200 mg 51 benzoyl per gel 2.5% 22 benzoyl peroxide cleanser 3.522 benzoyl peroxide cream 10% 22 benzoyl peroxide cream 2.5%22 benzoyl peroxide creamy wash 22 benzoyl peroxide gel 10% 22 benzoyl peroxide gel 4% 22 benzoyl peroxide gel 5% 22 benzoyl peroxide liq 10% 22 benzoyl peroxide liq 2.5% 22 benzoyl peroxide liq 5% 22 benzoyl peroxide lotion 6% 22 benzoyl peroxide lotion 8% 22 benzyl benzo liq 22 betamethasone dipropionate au 22 betamethasone dipropionate cr 22 betamethasone dipropionate lo 22 betamethasone dipropionate oi 22 betamethasone valerate cream 22 betamethasone valerate lotion22 betamethasone valerate oint 0 22 betaxolol hcl ophth soln 0.5%48 bethanechol chloride tab 10 m 34 bethanechol chloride tab 25 m 34 bethanechol chloride tab 5 mg 34 bethanechol chloride tab 50 m 34 bicalutamide tab 50 mg 9 bicarsim tab 125mg 29 bicarsim tab 80mg 29 bicillin c-r inj 1200000 6 bicillin c-r inj 900/300 6 biclora liq 51 biclora tab 25-25mg 51 biclora-d liq 51 biclora-d tab 51 biobron sf syp 51 bionel liq pediatrc 51 biospec dmx liq 51 biotin cap 1mg 63 biotin cap 2.5 mg 63 biotin cap 5 mg 63 biotin forte tab 3mg 63 biotin tab 1000 mcg 63 biotin tab 10mg 63 72 biotin tab 2.5 mg 63 biotin tab 300 mcg 63 biotin tab 5 mg 63 biotin tab 7500mcg 63 biotin tab 800 mcg 63 bisacodyl suppos 10 mg 29 bisacodyl tab delayed release 29 bismuth subsalicylate chew ta29 bismuth subsalicylate susp 26 29 bismuth subsalicylate susp 52 29 bismuth subsalicylate tab 262 29 bisoprolol & hydrochlorothiaz 15, 16 bisoprolol fumarate tab 10 mg 16 bisoprolol fumarate tab 5 mg 16 blephamide oin s.o.p. 47 blephamide sus op 47 blink tears dro 0.25% op 46 b-natal loz 25mg 63 bone meal tab 63 bp cleansing lot 4% 22 bpm-pse-dm liq 4-20-20 51 brainstrong mis prenatal 61 brasivol pst 22 breo ellipta inh 100-25 50 brimonidine tartrate ophth so 46 brohist d tab 4-10mg 51 bromocriptine mesylate cap 5 10 bromocriptine mesylate tab 2.10 brompheniramine & phenylephri 51 brompheniramine & pseudoephed 51 broncotron dro ped 51 broncotron-s liq 20-400/5 51 bronkaid tab 25-400mg 51 bronkids dro 51 bronkids liq 10-4-10 51 brontuss dx liq 51 budesonide inhalation susp 0. 49 buffered vit cap c 1000mg 63 bumetanide tab 0.5 mg 19 bumetanide tab 1 mg 19 bumetanide tab 2 mg 19 bupropion hcl (smoking deterr 2 butalbital-acetaminophen tab 1 butalbital-acetaminophen-caff 1 butalbital-aspirin-caff w/ co 1 butalbital-aspirin-caffeine c 1 butalbital-aspirin-caffeine t 1 bydureon inj 12 bystolic tab 10mg 16 bystolic tab 2.5mg 16 bystolic tab 20mg 16 bystolic tab 5mg 16 C ca citrate tab 250mg 63 ca hi-cal/d tab 250mg 63 ca hi-cal/d tab 500mg 63 ca pantothen tab 100mg 63 ca pantothen tab 200mg 63 cal carb & mag hydrox-simethi 29 cal cit mal/ tab vitamind 63 cal/mag tab chew 63 calc citrate liq vit d3 63 calc/vit d3 chw 200-200 63 calcet bites chw 500-400 63 calcitonin (salmon) nasal sol 42 cal-citrate cap 150mg 63 cal-citrate tab plus d 63 calcitriol cap 0.25 mcg 60 calcitriol cap 0.5 mcg 60 calcium &mag tab 63 calcium 1000 tab + d 63 calcium acetate (phosphate bi 34 calcium ascorbate tab 500 mg63 calcium carb tab 648mg 29 calcium carbonate (antacid) c 29 calcium carbonate tab 1250 mg 63 calcium carbonate-cholecalcif 63, 64 calcium carbonate-ergocalcife 64 calcium carbonate-mag hydroxi 29 calcium carbonate-simethicone 29 calcium carbonate-vitamin d c 64 calcium carbonate-vitamin d t64 calcium chw 600-400 64 calcium cit tab 1040mg 64 calcium cit tab w/vit d 64 calcium citrate tab 950 mg (2 64 calcium citrate-vitamin d tab 64 calcium glubionate syrup 64 calcium gluconate tab 500 64 calcium gra citrate 64 calcium pantothenate tab 500 64 calcium plus cap vit d 64 calcium polycarbophil tab 625 29 calcium tab magnesiu 64 calcium w/ magnesium tab 25064 calcium w/ magnesium tab 33364 calcium w/ magnesium tab 50064 calcium w/ vitamin d tab 600 64 calcium/vitd cap 600-400 64 cal-cyum waf 500mg 63 cal-mag chel cap 70-83mg 63 calmag thins tab 200-50mg 64 calna tab 64 cal-quick liq 500-400 63 camila 36 camphor sol spirits 22 capcof syp 51 capecitabine tab 150 mg 9 capecitabine tab 500 mg 9 capmist dm tab 51 capron dm liq 51 capsagel gel 0.025% 23 capsagel ms gel 0.075% 23 capsagel xs gel 0.05% 23 capsaicin cream 0.025% 23 capsaicin cream 0.075% 23 capsaicin cream 0.1% 23 captopril & hydrochlorothiazi16 captopril tab 100 mg 14 captopril tab 12.5 mg 14 captopril tab 25 mg 14 captopril tab 50 mg 14 capzasin liq 0.15% 23 carbamide peroxide 6.5% otic48 carbaphen 12 liq 51 carbaphen ch sus 51 carbaphen sus ped ch 51 carbidopa & levodopa tab 10-1 10 carbidopa & levodopa tab 25-1 10 carbidopa & levodopa tab 25-2 10 carbidopa & levodopa tab cr 2 10 73 carbidopa & levodopa tab cr 5 10 carbidopa tab 25 mg 10 carbonyl iron chew tab 15 mg64 carbonyl iron susp 15 mg/1.25 64 carboxymethylcellulose sodium 46 carboxymethylcellulose-glycer 46 carteolol hcl ophth soln 1% 48 carvedilol tab 12.5 mg 16 carvedilol tab 25 mg 16 carvedilol tab 3.125 mg 16 carvedilol tab 6.25 mg 16 castiva lot 23 castor oil 23 caziant 36 ccp caffeine tab free 51 cedar leaf oil 23 cefaclor cap 250 mg 5 cefaclor cap 500 mg 5 cefaclor sus 125/5ml 5 cefaclor sus 250/5ml 5 cefaclor sus 375/5ml 5 cefadroxil cap 500 mg 5 cefadroxil for susp 250 mg/5m 5 cefadroxil for susp 500 mg/5m 5 cefadroxil tab 1 gm 5 cefdinir cap 300 mg 5 cefdinir for susp 125 mg/5ml 5 cefdinir for susp 250 mg/5ml 5 cefpodoxime proxetil for susp 5 cefpodoxime proxetil tab 100 5 cefpodoxime proxetil tab 200 5 cefprozil for susp 125 mg/5ml 6 cefprozil for susp 250 mg/5ml 6 cefprozil tab 250 mg 6 cefprozil tab 500 mg 6 ceftin sus 250/5ml 6 ceftriaxone sodium for inj 1 6 ceftriaxone sodium for inj 25 6 ceftriaxone sodium for inj 50 6 cefuroxime axetil for susp 12 6 cefuroxime axetil tab 250 mg 6 cefuroxime axetil tab 500 mg 6 celery seed oil 23 cellcept sus 200mg/ml 41 centrum spec pak prenatal 61 cephalexin cap 250 mg 6 cephalexin cap 500 mg 6 cephalexin for susp 125 mg/5m 6 cephalexin for susp 250 mg/5m 6 certuss-d tab 51 cesia 36 cetirizine hcl oral soln 1 mg 49 cetirizine hcl tab 10 mg 49 cetirizine hcl tab 5 mg 49 cetirizine-pseudoephedrine ta 51 chantix pak 0.5& 1mg 2 chantix pak 1mg 3 chantix tab 0.5mg 3 chateal 36 chemet cap 100mg 43 cherry syp 43 chest conges gra children 51 chest congst gra childrns 51 chest congst gra cough 51 child-multi chw vitamins 64 chlo tuss ex liq 12.5-100 51 chlo tuss liq 52 chlophed liq 52 chlorhexidin sol gluconat 23 chlorhexidine gluconate soln 21 chloroform sol 23 chloroquine phosphate tab 250 10 chlorothiazide tab 250 mg 20 chlorothiazide tab 500 mg 20 chlorphenir pow maleate 49 chlorpheniramine & phenylephr 52 chlorpheniramine & pseudoephe 52 chlorpheniramine maleate syru 49 chlorpheniramine maleate tab 49 chlorpheniramine w/ codeine l 52 chlorpheniramine-acetaminophe 52 chlorpheniramine-dm liquid 152 chlorpheniramine-dm liquid 252 chlorpheniramine-dm tab 4-30 52 chlorpheniramine-phenylephrin 52 chlorphen-pe-apap tab & diphe 52 chlorphen-pe-apap tab 2-5-325 52 chlorphen-phenylephrine w/ ap 52 chlorphen-pseudoephedrine w/ 52 chlorpropamide tab 100 mg 12 chlorpropamide tab 250 mg 12 chlorthalidone tab 100 mg 20 chlorthalidone tab 25 mg 20 chlorthalidone tab 50 mg 20 chlorzoxazone tab 500 mg 60 cholecalciferol cap 400 unit 64 cholecalciferol tab 400 u 64 cholestyramine powder 4 gm/do 21 cholestyramine powder packets 21 choline & magnesium salicylat 3 ciclopirox solution 8% 23 cilostazol tab 100 mg 14 cilostazol tab 50 mg 14 ciloxan oin 0.3% op 47 cimetidine hcl soln 300 mg/5m 32 cimetidine tab 200 mg 32 cimetidine tab 300 mg 32 cimetidine tab 400 mg 32 cimetidine tab 800 mg 32 cinnamon oil artific 23 ciprofloxacin 0.2% sol 47 ciprofloxacin hcl ophth soln 47 ciprofloxacin hcl tab 100 mg 7 ciprofloxacin hcl tab 250 mg 7 ciprofloxacin hcl tab 500 mg 7 ciprofloxacin hcl tab 750 mg 7 citrocarbona gra 29 citronella oil 23 clarithromycin for susp 125 m 7 clarithromycin for susp 250 m 7 clarithromycin tab 250 mg 7 clarithromycin tab 500 mg 7 clarithromycin tab sr 24hr 50 7 claritin rdt tab 5mg 49 clean&clear kit acne 23 clear eyes dro dry eyes 46 74 clearcanal kit ear wax 48 clearlax pow 29 clemastine fumarate syrup 0.6 49 clemastine fumarate tab 1.34 49 clemastine fumarate tab 2.68 49 cleocin sup 100mg 34 clidinium & chlordiazepoxide28 clindamycin hcl cap 150 mg 5 clindamycin hcl cap 300 mg 5 clindamycin hcl cap 75 mg 5 clindamycin phosphate lotion 23 clindamycin phosphate soln 1% 23 clindamycin phosphate swab 1% 23 clindamycin phosphate vaginal 34 clindamycin sol 75mg/5ml 5 clobetasol propionate cream 0 23 clobetasol propionate oint 0. 23 clobetasol propionate soln 0. 23 clofera liq 52 clonidine hcl tab 0.1 mg 18 clonidine hcl tab 0.2 mg 18 clonidine hcl tab 0.3 mg 18 clopidogrel bisulfate tab 300 14 clopidogrel bisulfate tab 75 14 clotrimazole cream 1% 23 clotrimazole soln 1% 23 clotrimazole troche 10 mg 21 clotrimazole vaginal cream 1% 34 clotrimazole vaginal cream 2% 34 clotrimazole w/ betamethasone 23 clove oil 23 clusimar syp 64 cntc cld/flu pak day/nght 52 cntc cld/flu tab max st 52 codar ar liq 52 codar d liq 52 codar gf liq 52 codeine sulf tab 15mg 2 codeine sulf tab 60mg 2 codeine sulfate tab 30 mg 2 codituss dm syp 52 colchicine w/ probenecid tab 8 colcrys tab 0.6mg 8 colestipol hcl granule packet 21 colestipol hcl granules 5 gm 21 colestipol hcl tab 1 gm 21 comp prnatal mis dha 61 complete dro pe 64 complete nat pak dha 61 complete sin tab relief 52 completenate chw 61 computer eye sol drops 46 co-natal fa tab 29-1mg 61 condoms latex lubricated 43 condoms latex non-lubrica 43 condoms non-latex non-lub 43 conex sol cld/alrg 52 conex tab 2-60mg 52 contour next test strips, box 43 control solution, arkray expr 43 control solution, arkray gluc 43 control solution, freestyle 43 control solution, one touch u 43 control solution, sd gluconav 43 copaxone kit 20mg/ml 21 coricidin nt liq cold/cgh 52 coricidn hbp mis multi sy 52 correctol mis herbal 29 cortisone acetate tab 25 mg 35 cortisporin oin 1% 23 cortizone-10 liq /aloe 1% 23 cosopt sol 2-0.5%op 48 cottonseed oil 23 cough d syp 52 cpb wc liq 52 creon cap 12000unt 28 creon cap 24000unt 28 creon cap 3000unit 28 creon cap 36000unt 28 creon cap 6000unit 28 cromolyn sodium nasal aerosol 50 cromolyn sodium ophth soln 4% 47 cromolyn sodium soln nebu 20 50 culturelle cap 29 culturelle chw di 29 curity prep pad alcohol 43 cvs prenatal chw gummy 61 cvs purelax pow 30 cyanocobalamin inj 1000 mcg/m 64 cyclafem 1/35 36 cyclafem 7/7/7 36 cyclobenzaprine hcl tab 10 mg 60 cyclobenzaprine hcl tab 5 mg 60 cyclomydril sol op 47 cyclopentolate hcl ophth soln 48 cyclophosphamide tab 25 mg 9 cyclophosphamide tab 50 mg 9 cycloserine cap 250 mg 9 cyclosporine cap 100 mg 41 cyclosporine cap 25 mg 41 cyclosporine modified cap 100 42 cyclosporine modified cap 25 42 cyclosporine modified cap 50 42 cyclosporine modified oral so 42 cyproheptadine hcl syrup 2 mg 49 cyproheptadine hcl tab 4 mg 49 cyto b2 pow 64 cytra-k sol 60 D dallergy dro 1-2.5mg 52 dallergy syp 52 dallergy tab 1-5mg 52 dallergy tab 25-10mg 52 dapsone tab 100 mg 5 dapsone tab 25 mg 5 daraprim tab 25mg 10 dasetta 1/35 36 dasetta 7/7/7 36 day/nyquil liq severe 52 daytime liq cold med 52 decon-a elx 2-5mg/5m 52 decon-a liq drops 52 decon-g dro 2-1-40mg 52 deltuss dp liq 1-30/5ml 53 delyla 36 delzicol cap 400mg 42 denatured sol alcohol 23 denorex dual sha 1%-3% 23 derma-smooth oil /fs body 23 derma-smooth oil /fs sclp 23 desmopressin acetate nasal sp 39 desmopressin acetate tab 0.1 39 desmopressin acetate tab 0.2 39 desogestrel/ethinyl estradiol 36 75 desonide oint 0.05% 23 despec dm syp 53 despec-dm tab 53 dewees carmi liq 30 dexamethasone conc 1 mg/ml 35 dexamethasone elixir 0.5 mg/5 35 dexamethasone sodium phosphat 48 dexamethasone soln 0.5 mg/5ml 35 dexamethasone tab 0.5 mg 35 dexamethasone tab 0.75 mg 35 dexamethasone tab 1.5 mg 35 dexamethasone tab 2 mg 35 dexamethasone tab 4 mg 35 dexamethasone tab 6 mg 35 dexatrex d elx cf-nasal 53 dexbrompheniramine & pseudoep 53 dexchlorpheniramine maleate s 49 dexpak pak 10 day 35 dextromethorphan hbr syrup 15 53 dextromethorphan-apap-chlorph 53 dextromethorphan-doxylaminea 53 dextromethorphan-guaifenesin 53 dextromethorphan-phenylephrin 53 dex-tuss liq 300-10/5 53 diabetic cap cold/flu 53 diabetic tus liq cold/flu 53 dialyvite tab suprem d 65 dicel cd liq 53 diclofenac potassium tab 50 m 3 diclofenac sodium ophth soln 48 diclofenac sodium tab delayed 3 diclofenac sodium tab sr 24hr 3 dicloxacillin sodium cap 250 6 dicloxacillin sodium cap 500 6 dicyclomine hcl cap 10 mg 28 dicyclomine hcl tab 20 mg 28 diflorasone diacetate oint 0. 23 diflunisal tab 500 mg 3 di-gel chw 30 di-gel sus 30 digoxin tab 125 mcg (0.125 mg 18 digoxin tab 250 mcg (0.25 mg) 18 diltiazem hcl cap sr 12hr 120 17 diltiazem hcl cap sr 12hr 60 17 diltiazem hcl cap sr 12hr 90 17 diltiazem hcl cap sr 24hr 120 16 diltiazem hcl cap sr 24hr 180 17 diltiazem hcl cap sr 24hr 240 17 diltiazem hcl coated beads ca 17 diltiazem hcl coated beads ta 17 diltiazem hcl extended releas 17 diltiazem hcl tab 120 mg 18 diltiazem hcl tab 30 mg 18 diltiazem hcl tab 60 mg 18 diltiazem hcl tab 90 mg 18 dimenhydrin inj 50mg/ml 8 dimenhydrinate tab 50 mg 8 dimetapp cld chw /allergy 53 dimetapp syp cgh/cold 53 dimethyl sol sulfoxid 23 diphenhydramine hcl cap 25 mg 49 diphenhydramine hcl chew tab 49 diphenhydramine hcl elixir 12 49 diphenhydramine hcl liquid 12 49 diphenhydramine hcl syrup 12. 49 diphenhydramine hcl tab disp 49 diphenhydramineacetaminophen 53 diphenhydraminephenylephrine 53 diphenhydramine-pse w/ apap t 53 diphenoxylate w/ atropine liq 30 diphenoxylate w/ atropine tab 30 dipyridamole tab 25 mg 14 dipyridamole tab 50 mg 14 dipyridamole tab 75 mg 14 disopyramide phosphate cap 10 15 disopyramide phosphate cap 15 15 diuril sus 250/5ml 20 dm-gg-pot cit-citric acid liq 54 docusate calcium cap 240 mg 30 docusate sodium cap 100 mg 30 docusate sodium cap 250 mg 30 docusate sodium cap 50 mg 30 docusate sodium enema 283 mg 30 docusate sodium liquid 150 mg 30 docusate sodium syrup 60 mg/1 30 docusate sodium tab 100 mg 30 docusol kids ene 100mg/5m 30 dologen tab 54 dolomite tab 10gr 65 dometuss-da liq 1-2.5mg 54 donatussin syp 54 donepezil hydrochloride tab 1 8 donepezil hydrochloride tab 5 8 doribax inj 250mg 5 doribax inj 500mg 5 dorzolamide hcl ophth soln 2% 47 dorzolamide hcl-timolol malea 48 doxazosin mesylate tab 1 mg 18 doxazosin mesylate tab 2 mg 18 doxazosin mesylate tab 4 mg 18 doxazosin mesylate tab 8 mg 18 doxycycline hyclate cap 100 m7 doxycycline hyclate cap 50 mg7 doxycycline hyclate tab 100 m 7 doxycycline monohydrate for s7 doxylamine-dm 6.25-15 mg/15ml 54 doxylamine-dm liquid 6.25-15 54 doxylamine-phenylephrine-apap 54 dramamine chw 50mg 8 drixoral cap cgh & st 54 drixoral tab cold/flu 54 dronabinol cap 10 mg 8 dronabinol cap 2.5 mg 8 dronabinol cap 5 mg 8 dulcolax kit bowel 30 dulcolax pow balance 30 dulera aer 100-5mcg 50 dulera aer 200-5mcg 50 duravent pe tab 10-395mg 54 dyphylline-guaifenesin liqd 1 54 76 dyphylline-guaifenesin tab 2054 E econazole nitrate cream 1% 23 ed chlorped dro d 54 ed chlorped liq 2mg/ml 49 ed-chlor-tan tab 8mg 49 effaclar duo sol 5.5% 23 effient tab 10mg 14 effient tab 5mg 14 eldertonic elx 65 eligard inj 22.5mg 9 eligard inj 30mg 9 eligard inj 45mg 9 eligard inj 7.5mg 9 elite ca/mg tab 100-50mg 65 elite iron tab 15mg 65 elixophyllin elx 80/15ml 54 elixsure gel congest 54 emoquette 36 enablex tab 15mg 34 enablex tab 7.5mg 34 enalapril maleate & hydrochlo 16 enalapril maleate tab 10 mg 14 enalapril maleate tab 2.5 mg 14 enalapril maleate tab 20 mg 14 enalapril maleate tab 5 mg 14 endacon syp 54 enfamil mis expecta 61 enoxaparin sodium inj 100 mg/ 13 enoxaparin sodium inj 120 mg/ 13 enoxaparin sodium inj 150 mg/ 13 enoxaparin sodium inj 30 mg/0 13 enoxaparin sodium inj 300 mg/ 13 enoxaparin sodium inj 40 mg/0 13 enoxaparin sodium inj 60 mg/0 13 enoxaparin sodium inj 80 mg/0 13 enpresse-28 36 enskyce 36 entex lq liq 54 entex t tab 60-375mg 54 entre-cough sus tannate 54 ephedrine-guaifenesin tab 12. 54 epinephrine inj 0.3mg 43 epipen 2-pak inj 0.3mg 43 epipen-jr inj 0.15mg 43 epivir hbv sol 5mg/ml 11 epogen inj 10000/ml 13 epogen inj 2000/ml 13 epogen inj 20000/ml 13 epogen inj 3000/ml 13 epogen inj 4000/ml 13 eq clearlax pow 30 eql acetamin tab 160mg 1 eql acetamin tab 80mg 1 eql calcium cap vit d 65 eql clearlax pow 30 eql infant dro dcon/cgh 54 eql natural pow fiber 30 eql vit d-3 tab 65 equalactin chw 625mg 30 ergocalciferol cap 50000 unit 65 ergocalciferol soln 8000 65 errin 36 eryped sus 200/5ml 7 eryped sus 400/5ml 7 ery-tab tab 250mg ec 7 ery-tab tab 333mg ec 7 erythromycin ethylsuccinate t 7 erythromycin gel 2% 23 erythromycin ophth oint 5 mg/ 47 erythromycin soln 2% 23 erythromycin stearate tab 250 7 erythromycin tab 250 mg 7 erythromycin tab 500 mg 7 erythromycin tab delayed rele 7 erythromycin w/ delayed relea 7 erythromycin-sulfisoxazole fo 5 esterified estrogens & methyl 38 estrace vag cre 0.1mg/gm 34 estradiol & norethindrone ace 36 estradiol tab 0.5 mg 38 estradiol tab 1 mg 38 estradiol tab 2 mg 38 estradiol td patch weekly 0.0 38 estradiol td patch weekly 0.1 38 estropipate tab 0.75 mg 38 estropipate tab 1.5 mg 39 estropipate tab 3 mg 39 ethambutol hcl tab 100 mg 9 ethambutol hcl tab 400 mg 9 ether sol 23 ethyl alcoho sol 70% 23 ethyl alcoho sol 95% 23 ethyl chlor aer mist 23 etodolac cap 200 mg 3 etodolac cap 300 mg 3 etodolac tab 400 mg 3 etodolac tab 500 mg 3 etodolac tab sr 24hr 400 mg 3 etodolac tab sr 24hr 500 mg 3 etodolac tab sr 24hr 600 mg 3 eucalyptus oil 23 eugenol sol 24 eurax cre 10% 24 eurax lot 10% 24 evac-u-gen chw 10mg 30 exoderm bar 24 extavia inj 0.3mg 21 ezfe forte cap 61 e-z-gas ii gra 30 F falmina 36 famotidine inj 20 mg/2ml 32 famotidine inj 200 mg/20ml 33 famotidine inj 20mg/50m 33 famotidine inj 40 mg/4ml 33 famotidine inj 500 mg/50ml 33 famotidine tab 10 mg 33 famotidine tab 20 mg 33 famotidine tab 40 mg 33 father johns sol plus 54 fe aspartate tab 65 fe fumarate w/ b12-vit c-fa-i 65 fe fumarate-vit c-vit b12-fa 65 felodipine tab sr 24hr 10 mg 18 felodipine tab sr 24hr 2.5 mg 18 felodipine tab sr 24hr 5 mg 18 femhrt tab 0.5-2.5 39 femiron tab 65 fenesin dm tab 15-400mg 54 fenofibrate tab 160mg 21 fenofibrate tab 54mg 21 fenofibrate micronized cap 13 20 fenofibrate micronized cap 20 20 fenofibrate micronized cap 67 20 fenoprofen calcium tab 600 mg 3 77 fentanyl td patch 72hr 100 mc 1 fentanyl td patch 72hr 12 mcg 1 fentanyl td patch 72hr 25 mcg 1 fentanyl td patch 72hr 50 mcg 1 fentanyl td patch 72hr 75 mcg 1 feosol tab 45mg 65 ferate tab 28mg 65 ferretts fe chw 18mg 65 ferretts ips sol 65 ferrimin 150 tab 65 ferrous fum tab 29mg 65 ferrous fuma tab 65 ferrous fumarate tab 325 mg (65 ferrous gluc tab 225mg 65 ferrous gluc tab 324mg 65 ferrous gluconate tab 240 mg 65 ferrous gluconate tab 324 mg 65 ferrous gluconate tab 325 mg 65 ferrous sulf gra 65 ferrous sulf syp 300/5ml 65 ferrous sulf tab 140mg 65 ferrous sulf tab 324mg ec 65 ferrous sulfate dried tab 200 65 ferrous sulfate dried tab cr 65 ferrous sulfate elixir 220 mg 65 ferrous sulfate soln 75 mg/ml 65 ferrous sulfate tab 134 mg (2 65 ferrous sulfate tab 27 mg (el 65 ferrous sulfate tab 325 mg (6 65 ferrous sulfate tab cr 142 mg 65 ferrous sulfate tab cr 47.5 m 65 ferrous sulfate tab cr 50 mg 65 ferrous sulfate tab ec 325 mg 65 ferrous sulfate-vit c-folic a 65 fexofenadine hcl susp 30 mg/5 49 finasteride tab 5 mg 34 flarex sus 0.1% op 48 flecainide acetate tab 100 mg 15 flecainide acetate tab 150 mg 15 flecainide acetate tab 50 mg 15 fleet bisaco ene 10/30ml 30 fleet naturl ene cleansng 24 flintstones chw toddler 65 flovent disk aer 100mcg 49 flovent disk aer 50mcg 49 flovent hfa aer 44mcg 49 fluconazole for susp 10 mg/ml 8 fluconazole for susp 40 mg/ml 8 fluconazole tab 100 mg 8 fluconazole tab 150 mg 8 fluconazole tab 200 mg 8 fluconazole tab 50 mg 8 fludrocortisone acetate tab 0 35 flunisolide nasal soln 25 mcg 50 flunisolide nasal soln 29 mcg 50 fluocinolone acetonide cream 24 fluocinolone acetonide oint 0 24 fluocinonide cream 0.05% 24 fluocinonide emulsified base 24 fluocinonide gel 0.05% 24 fluocinonide oint 0.05% 24 fluocinonide soln 0.05% 24 fluorometholone ophth susp 0. 48 fluorouracil cream 5% 24 fluorouracil soln 2% 24 fluorouracil soln 5% 24 flurbiprofen sodium ophth sol48 flurbiprofen tab 100 mg 3 flurbiprofen tab 50 mg 3 flutamide cap 125 mg 9 fluticasone propionate cream 24 fluticasone propionate nasal 50 fluticasone propionate oint 0 24 fml forte sus 0.25% op 48 fml oin 0.1% op 48 folic acid tab 1 mg 65 folic acid tab 200mcg 65 folic acid tab 400 mcg 65 folic acid tab 800 mcg 66 foradil cap aerolize 50 fosinopril sodium tab 10 mg 14 fosinopril sodium tab 20 mg 14 fosinopril sodium tab 40 mg 14 furosemide oral soln 10 mg/ml 19 furosemide tab 20 mg 19 furosemide tab 40 mg 19 furosemide tab 80 mg 19 G galantamine hydrobromide tab 8 gas-x child mis 40mg 30 gas-x ex-str mis 62.5mg 30 gas-x/maalox chw extra st 30 gavilax pow 30 gemfibrozil tab 600 mg 20 gentamicin sulfate cream 0.1% 24 gentamicin sulfate oint 0.1% 24 gentamicin sulfate ophth oint 47 gentamicin sulfate ophth soln 47 genteal gel 46 genteal mild dro 0.2% 46 gentlelax pow 30 gildess 1.5/30 36 gildess 1/20 36 gildess fe 1.5/30 36 gildess fe 1/20 36 giltuss liq ped-c 54 giltuss tr cap 7-14-288 54 glimepiride tab 1 mg 12 glimepiride tab 2 mg 12 glimepiride tab 4 mg 12 glipizide tab 10 mg 12 glipizide tab 5 mg 12 glipizide tab sr 24hr 10 mg 12 glipizide tab sr 24hr 2.5 mg 12 glipizide tab sr 24hr 5 mg 12 glucagon kit 1mg 13 glucose gel 40% 13 glyburide micronized tab 1.5 12 glyburide micronized tab 3 mg 12 glyburide micronized tab 6 mg 12 glyburide tab 1.25 mg 12 glyburide tab 2.5 mg 12 glyburide tab 5 mg 12 glyburide-metformin tab 1.2512 glyburide-metformin tab 2.5-5 12 glyburide-metformin tab 5-500 12 glycerin liq 24 glycerin sol synthetc 24 glycerin suppos 1 gm 30 glycerin suppos 1.2 gm 30 glycerin suppos 1.5 gm 30 glycerin suppos 2 gm 30 glycerin suppos 2.1 gm 30 glycerin suppos 80.7% 30 glycerin-hypromellose-peg 400 46 glycine soya sol extract 24 glycine soya sol protein 24 glycolax pow 3350 nf 30 glycopyrrolate tab 1 mg 28 glycopyrrolate tab 2 mg 28 78 gnp alcohol sol denature 24 gnp clearlax pow 30 goniovisc sol 2% 46 goodys tab ex st 4 grandpas bar thylox 24 griseofulvin microsize susp 1 8 griseofulvin microsize tab 50 8 griseofulvin ultramicrosize t 8 guaiacol sol 24 guaifenesin liquid 100 mg/5ml 54 guaifenesin liquid 200 mg/5ml 54 guaifenesin pow 54 guaifenesin syrup 100 mg/5ml 54 guaifenesin tab 200 mg 54 guaifenesin tab 400 mg 54 guaifenesin tab sr 12hr 600 m 54 guaifenesin-codeine liquid 22 54 guaifenesin-codeine soln 10054 guanfacine hcl tab 1 mg 18 guanfacine hcl tab 2 mg 18 gummy bites chw 66 gynazole-1 cre 2% 34 H halfprin tab 162mg ec 4 halobetasol propionate cream 24 halobetasol propionate oint 0 24 hc dermapax spr 0.5-0.5% 24 hc-1% hemorr oin 1% 24 heartburn tr cap 15mg 33 heather 36 heparin sodium (porcine) inj 13 heparin sodium (porcine) pf i 13 herbal expec liq 150/15ml 54 hexalen cap 50mg 9 histex-dm syp 54 histex-pe syp 2.5-10/5 54 hm clearlax pow 30 homatropine hbr ophth soln 5% 48 honey bears chw iron-zin 66 hrtbrn rel cap 15mg dr 33 humapen mis memoir 43 humatropen mis for 6mg 43 humulin n pn inj u-100 13 humulin pen inj 70/30 13 hydralazine hcl tab 10 mg 18 hydralazine hcl tab 100 mg 18 hydralazine hcl tab 25 mg 18 hydralazine hcl tab 50 mg 18 hydrochlorothiazide cap 12.5 20 hydrochlorothiazide tab 25 mg 20 hydrochlorothiazide tab 50 mg 20 hydrocil ins pow 95% 30 hydrocod polst-chlorphen pols 54 hydrocodone w/ homatropine sy 54 hydrocodone w/ homatropine ta 54 hydrocodone-acetaminophen sol 2 hydrocodone-acetaminophen tab 2 hydrocort ac cre 0.5% 24 hydrocortisone acetate cream 24 hydrocortisone acetate suppos 24 hydrocortisone cream 0.5% 24 hydrocortisone cream 1% 24 hydrocortisone cream 2.5% 24 hydrocortisone enema 100 mg/6 24 hydrocortisone gel 1% 24 hydrocortisone lotion 1% 24 hydrocortisone lotion 2.5% 24 hydrocortisone oint 0.5% 24 hydrocortisone oint 1% 24 hydrocortisone oint 2.5% 24 hydrocortisone rectal cream 1 24 hydrocortisone rectal cream 2 24 hydrocortisone soln 1% 25 hydrocortisone tab 10 mg 35 hydrocortisone tab 20 mg 35 hydrocortisone tab 5 mg 35 hydrocortisone valerate cream 25 hydrocortisone valerate oint 25 hydrocortisone w/ acetic acid 48 hydrocortisone-aloe vera crea 25 hydromorphone hcl tab 2 mg 1 hydromorphone hcl tab 4 mg 1 hydromorphone hcl tab 8 mg 1 hydroxychloroquine sulfate ta10 hydroxyurea cap 500 mg 9 hydroxyzine hcl syrup 10 mg/5 11 hydroxyzine hcl tab 10 mg 11 hydroxyzine hcl tab 25 mg 11 hydroxyzine hcl tab 50 mg 11 hydroxyzine pamoate cap 100 m 12 hydroxyzine pamoate cap 25 mg 12 hydroxyzine pamoate cap 50 mg 12 hyoscyamine sulfate elixir 0. 28 hyoscyamine sulfate soln 0.12 28 hyoscyamine sulfate tab 0.125 28 hyoscyamine sulfate tab disp 28 hyoscyamine sulfate tab sl 0. 28 hyoscyamine sulfate tab sr 12 28 hypotears sol 1-1% 46 hypromellose gonioscopic soln 46 hypromellose ophth soln 0.3% 46 hypromellose ophth soln 0.4% 46 I ibuprofen jr chw 100mg 4 ibuprofen susp 100 mg/5ml 4 ibuprofen susp 40 mg/ml 4 ibuprofen tab 200 mg 4 ibuprofen tab 400 mg 4 ibuprofen tab 600 mg 4 ibuprofen tab 800 mg 4 imodium a-d chw 2mg 30 indapamide tab 1.25 mg 20 indapamide tab 2.5 mg 20 indocin sus 25mg/5ml 4 indomethacin cap 25 mg 4 indomethacin cap 50 mg 4 infergen inj 15mcg 11 infergen inj 9mcg 11 insuflon mis 25gx0.71 43 insulin syrg mis 0.3/28g 43 insulin syrg mis 0.3/29g 43 insulin syrg mis 0.3/30g 43 insulin syrg mis 0.3/31g 43 insulin syrg mis 0.5/27g 43 insulin syrg mis 0.5/28g 43 insulin syrg mis 0.5/29g 43 79 insulin syrg mis 0.5/30g 43, 44 insulin syrg mis 0.5/31g 44 insulin syrg mis 1ml 44 insulin syrg mis 1ml/25g 44 insulin syrg mis 1ml/26g 44 insulin syrg mis 1ml/27g 44 insulin syrg mis 1ml/28g 44 insulin syrg mis 1ml/29g 44 insulin syrg mis 1ml/30g 44 insulin syrg mis 1ml/31g 44 insulin syrg mis 2/27.5g 44 insulin syrg mis 2ml/29g 44 insulin syringe mis 0.3/30g 44 insulin syringe mis 0.3/31g 44 insulin syringe mis 0.5/29g 44 insulin syringe mis 0.5/30g 44 insulin syringe mis 0.5/31 g 44 insulin syringe mis 1ml/29g 44 insulin syringe mis 1ml/30g 44 insulin syringe mis 1ml/31g 44 insulin syringe/needle u-100 44 insupen sens mis 32gx8mm 44 insyte autog mis 24gx3/4" 44 intron-a inj 10mu 9 intron-a inj 18mu 9 intron-a inj 25mu 9 intron-a inj 50mu 9 introvale 36, 37 invokana tab 100mg 12 invokana tab 300mg 12 ionil sha 25 ipecac syp 25 ipratropium bromide inhal sol50 ipratropium bromide nasal sol 50 iron high cap potency 66 iron polysacch complex-vit b1 66 iron tab 18mg 66 iron tab 18mg cr 66 iron up liq 66 iso carbacho sol 3% op 46 iso homatrop sol 2% op 48 isoniazid syrup 50 mg/5ml 9 isoniazid tab 100 mg 9 isoniazid tab 300 mg 9 isop alcohol sol 50% 25 isop alcohol sol 70% wg 25 isop alcohol sol 91% 25 isop alcohol sol 99% 25 isopropyl alcohol, rubbing 70 25 isopropyl liq palmitat 25 isopto tears sol 0.5% op 46 isosorbide dinitrate sl tab 2 18 isosorbide dinitrate tab 10 m 19 isosorbide dinitrate tab 20 m 19 isosorbide dinitrate tab 30 m 19 isosorbide dinitrate tab 5 mg 19 isosorbide dinitrate tab cr 4 19 isosorbide mononitrate tab 20 19 isosorbide mononitrate tab sr 19 J janumet tab 50-1000 12 janumet tab 50-500mg 12 januvia tab 100mg 12 januvia tab 25mg 12 januvia tab 50mg 12 jencycla 37 jolessa 37 jolivette 37 j-tip kit kit adapters 44 junel 1.5/30 37 junel 1/20 37 junel fe 1.5/30 37 junel fe 1/20 37 juniper tar oil 25 K ketoconazole cream 2% 25 ketoconazole shampoo 2% 25 ketoconazole tab 200 mg 8 ketoprofen cap 50 mg 4 ketoprofen cap 75 mg 4 ketorolac tromethamine ophth 48 ketorolac tromethamine tab 10 4 ketostix test strips 44 ketotifen fumarate ophth soln 47 konsyl pow 100% 30 konsyl pow 28.3% 30 konsyl pow 60.3% 30 konsyl pow 71.67% 30 konsyl-d pow 52.3% 30 kp prenatal tab multivit 66 k-phos tab 66 k-phos tab no 2 60 kpn prenatal tab 66 kurvelo 37 L labetalol hcl tab 100 mg 16 labetalol hcl tab 200 mg 16 labetalol hcl tab 300 mg 16 lactic acid (ammonium lactate 25 lactic acid w/ vitamin e crea 25 lactocal-f tab 61 lactulose solution 10 gm/15ml 31 lamivudine tab 100 mg 11 lansoprazole cap 15mg dr 33 lansoprazole sus 3mg/ml 33 lantus inj 100/ml 13 larin 1.5/30 37 larin 1/20 37 larin fe 1.5/30 37 larin fe 1/20 37 latanoprost ophth soln 0.005% 48 lavender oil 25 laxaclear pow 31 leflunomide tab 10 mg 42 leflunomide tab 20 mg 42 lemon oil 25 lessina 37 letrozole tab 2.5 mg 9 leucovorin calcium tab 15 mg 9 leucovorin calcium tab 25 mg 9 leucovorin calcium tab 5 mg 10 leukeran tab 2mg 10 levemir inj 13 levobunolol hcl ophth soln 0. 48 levobunolol sol 0.25% op 48 levofloxacin tab 250 mg 7 levofloxacin tab 500 mg 7 levofloxacin tab 750 mg 7 levonest 37 levonorgestrel tab 0.75 mg 37 levonorgestrel tab 1.5 mg 37 levonorgestrel/ethinyl estrad 37 levora 0.15/30-28 37 levothyroxin tab 100mcg 39 levothyroxin tab 112mcg 39 levothyroxin tab 125mcg 39, 40 levothyroxin tab 137mcg 40 levothyroxin tab 150mcg 40 levothyroxin tab 175mcg 40 levothyroxin tab 200mcg 40 levothyroxin tab 25mcg 40 levothyroxin tab 300mcg 40 levothyroxin tab 50mcg 40 levothyroxin tab 75mcg 40 80 levothyroxin tab 88mcg 40 levoxyl tab 100mcg 40 levoxyl tab 112mcg 40 levoxyl tab 125mcg 40 levoxyl tab 137mcg 40 levoxyl tab 150mcg 40 levoxyl tab 175mcg 40 levoxyl tab 200mcg 40 levoxyl tab 25mcg 40 levoxyl tab 50mcg 40 levoxyl tab 75mcg 40 levoxyl tab 88mcg 40 lice b gone kit 25 lice b gone sha 25 lidocaine hcl gel 2% 25 lidocaine hcl laryngotracheal 21 lidocaine hcl soln 4% 25 lidocaine hcl viscous soln 2% 21 lidocaine oint 5% 25 lidocaine-prilocaine cream 2. 25 lime oil 25 lindane lotion 1% 25 lindane shampoo 1% 25 linseed oil raw 25 liquid c 500 liq 500/15ml 66 liquid calci cap with d3 66 liquimat lot 5% 25 lisinopril & hydrochlorothiaz 16 lisinopril tab 10 mg 14 lisinopril tab 2.5 mg 14 lisinopril tab 20 mg 14 lisinopril tab 30 mg 14 lisinopril tab 40 mg 14 lisinopril tab 5 mg 14 lite touch insulin pen needle 44 little remed liq colds 54 little teeth mis pain rel 21 little tummy dro laxative 31 lodrane d cap 4-60mg 54 lohist-psb liq 4-20/5ml 54 lomustine cap 10 mg 10 lomustine cap 100 mg 10 lomustine cap 40 mg 10 loperamide hcl cap 2 mg 31 loperamide hcl liq 1 mg/5ml (31 loperamide hcl liq 1 mg/7.5ml 31 loperamide hcl tab 2 mg 31 loratadine & pseudoephedrine 54 loratadine rapidly-disintegra 49 loratadine syrup 5 mg/5ml 49 loratadine tab 10 mg 49 lortuss dm liq 54 lortuss ex liq 55 lortuss lq liq 55 losartan potassium & hydrochl 16 losartan potassium tab 100 mg 14 losartan potassium tab 25 mg 14 losartan potassium tab 50 mg 14 lovastatin tab 10 mg 20 lovastatin tab 20 mg 20 lovastatin tab 40 mg 20 lozi-flur loz 1mg f 66 ltxf prim iv mis set/micr 45 luer-lok syr mis 1ml/20g 45 lufyllin tab 200mg 55 lufyllin tab 400mg 55 lupr dep-ped inj 11.25mg 41 lupr dep-ped inj 15mg 41 lupr dep-ped inj 7.5mg 41 lupron depot inj 11.25mg 10 lupron depot inj 22.5mg 10 lupron depot inj 3.75mg 10 lupron depot inj 30mg 10 lupron depot inj 7.5mg 10 lusair liq 55 lutera 37 lyza 37 M m2k cap 60mg 66 maalox jr chw /antigas 31 maalox tc sus 31 macadamia oil nut oil 25 macrodantin cap 25mg 5 mag carbonat pow 250mg/gm66 mag carbonat pow heavy 66 mag citrate tab 100mg 66 mag oxide cap 400mg 31 mag-200 tab 66 mag-al liq 31 magimin tab 80mg 66 maginex ds gra 1230mg 66 maginex tab 615 mg 66 magn chlorid cry hexahydr 66 magn chlorid pow 66 magn oxide pow heavy 31 magn sulfate cap 70mg 66 magnebind tab 200 66 magnesium cap 100 mg 66 magnesium cap 300mg 66 magnesium cap 400mg 66 magnesium chloride inj 200 mg 66 magnesium chloride tab cr 535 66 magnesium citrate soln 31 magnesium gl tab 550mg 66 magnesium gluconate tab 27.5 66 magnesium gluconate tab 500 m 66 magnesium oxide cap 500 mg (e 66 magnesium oxide tab 250 mg 31 magnesium oxide tab 250 mg (m 66 magnesium oxide tab 400 mg 31 magnesium oxide tab 400 mg (2 66 magnesium oxide tab 420 mg 31 magnesium oxide tab 500 mg (m 66 magnesium pow oxide 66 magnesium sulfate 1% in d5w 66 magnesium sulfate inj 4% 66 magnesium sulfate inj 50% 66 magnesium sulfate inj 8% 66 magnesium tab 100 mg 67 magnesium tab 200 mg 67 magnesium tab 250 mg 67 magnesium tab 30mg 67 magnesium tab 500mg 67 magonate liq 1000/5ml 67 mag-tab sr tab 84mg 66 magtrate tab 500mg 67 malathion lotion 0.5% 25 mar-cof bp liq 55 marlissa 37 matulane cap 50mg 10 maxifed dmx tab 55 meclizine hcl chew tab 25 mg 8 meclizine hcl tab 12.5 mg 8 meclizine hcl tab 25 mg 8 meclizine hcl tab 32 mg 8 meclizine pow hcl 8 81 meclofenamate sodium cap 50 m 4 medi-graine tab 55 medi-jector mis vision 45 medroxyprogesterone acetate i 37 medroxyprogesterone acetate t 39 mefloquine hcl tab 250 mg 10 mega biotin cap 10mg 67 megestrol acetate susp 40 mg/ 10 megestrol acetate tab 20 mg 10 megestrol acetate tab 40 mg 10 meloxicam tab 15 mg 4 meloxicam tab 7.5 mg 4 m-end dmx liq 55 m-end max d liq 55 m-end pe liq 55 menest tab 0.3mg 39 menest tab 0.625mg 39 menest tab 1.25mg 39 menest tab 2.5mg 39 meperidine hcl tab 100 mg 1 meperidine hcl tab 50 mg 1 mephyton tab 5mg 67 mercaptopurine tab 50 mg 10 mesalamine enema 4 gm 42 metamucil pow 28% 31 metamucil pow 63% 31 metamucil waf 31 metaproterenol sulfate syrup 50 metaproterenol sulfate tab 10 50 metaproterenol sulfate tab 20 50 metformin hcl tab 1000 mg 12 metformin hcl tab 500 mg 12 metformin hcl tab 850 mg 12 metformin hcl tab sr 24hr 50012 metformin hcl tab sr 24hr 75012 methadone hcl conc 10 mg/ml 1 methadone hcl soln 10 mg/5ml 1 methadone hcl soln 5 mg/5ml 1 methadone hcl tab 10 mg 1 methadone hcl tab 5 mg 1 methadone hcl tab for oral su 1 methanol sol 99% 25 methazolamide tab 25 mg 19 methazolamide tab 50 mg 19 methenam man tab 500mg 5 methenamine hippurate tab 1 g 5 methenamine mandelate tab 1 g 5 methimazole tab 10 mg 41 methimazole tab 5 mg 41 methocarbamol tab 500 mg 60 methocarbamol tab 750 mg 60 methotrexate sodium tab 2.5 m 10 methyclothiazide tab 5 mg 20 methylcellulose powder laxati 31 methyldopa tab 250 mg 19 methyldopa tab 500 mg 19 methylergonovine maleate tab 34 methylprednisolone tab 4 mg 35 methylprednisolone tab 4 mg d 35 methylprednisolone tab 8 mg 35 metipranolol ophth soln 0.3% 48 metoclopramide hcl soln 5 mg/ 31 metoclopramide hcl tab 10 mg 31 metoclopramide hcl tab 5 mg 31 metolazone tab 10 mg 20 metolazone tab 2.5 mg 20 metolazone tab 5 mg 20 metoprolol & hydrochlorothiaz 16 metoprolol succinate tab sr 2 16 metoprolol tartrate tab 100 m 16 metoprolol tartrate tab 25 mg 16 metoprolol tartrate tab 50 mg 17 metronidazole cream 0.75% 25 metronidazole gel 0.75% 25 metronidazole lotion 0.75% 25 metronidazole tab 250 mg 5 metronidazole tab 500 mg 5 metronidazole vaginal gel 0.7 34 mg aspartate tab 65mg 67 mg gluconate tab 250mg 67 mg so4/d5w inj 20mg/ml 67 miconazole nitrate aerosol 2% 25 miconazole nitrate aerosol po 25 miconazole nitrate cream 2% 25 miconazole nitrate ointment 225 miconazole nitrate powder 2% 25 miconazole nitrate vaginal cr 34 miconazole nitrate vaginal su 34 microgestin tab 1/20 37 microgestin tab fe 1/20 37 microgestin 1.5/30 37 microgestin 1/20 37 microgestin fe 37 microgestin fe 1.5/30 37 midodrine hcl tab 10 mg 14 midodrine hcl tab 2.5 mg 14 midodrine hcl tab 5 mg 14 minocycline hcl cap 100 mg 7 minocycline hcl cap 50 mg 7 minocycline hcl cap 75 mg 7 minoxidil tab 10 mg 19 minoxidil tab 2.5 mg 19 miranel af sol 2% 25 misoprostol tab 100 mcg 33 misoprostol tab 200 mcg 33 mission pren tab 61 mission pren tab /fa 61 moexipril hcl tab 15 mg 15 moexipril hcl tab 7.5 mg 15 moisture eye sol p/f 46 mometasone furoate cream 0.1% 25 mometasone furoate oint 0.1% 26 mometasone furoate solution 0 26 montelukast sodium chew tab 4 50 montelukast sodium chew tab 5 50 montelukast sodium tab 10 mg 50 morphine sulfate (concentrate 1 morphine sulfate oral soln 10 1 morphine sulfate oral soln 20 1 morphine sulfate tab 15 mg 2 morphine sulfate tab 30 mg 2 morphine sulfate tab cr 100 m 2 morphine sulfate tab cr 15 mg 2 morphine sulfate tab cr 30 mg 2 morphine sulfate tab cr 60 mg 2 mucinex fast mis day/nght 55 mucinex fast tab 5-10-200 55 mucinex tab 1200mg 55 multi-delyn liq /iron 67 mupirocin calcium cream 2% 26 82 mupirocin oint 2% 26 muro 128 sol 2% op 46 mycophenolate mofetil cap 250 42 mycophenolate mofetil tab 500 42 mykidz iron sus 10mg/2ml 67 mykidz iron sus 15/1.5ml 67 mylanta sus ultimate 31 mylanta tab 31 myleran tab 2mg 10 mynatal cap 61 myzilra 37 N nabumetone tab 500 mg 4 nabumetone tab 750 mg 4 nadolol tab 20 mg 17 nadolol tab 40 mg 17 nadolol tab 80 mg 17 nanovm pow 1-3 yrs 67 nanovm t/f liq 67 naphazoline hcl ophth soln 0. 46 naphazoline w/ pheniramine op 46 naphazoline-glycerin ophth so 46 naphazoline-hypromellose opht 46 naphazoline-polyethylene glyc 46 naprelan tab 375mg cr 4 naprelan tab 500mg cr 4 naprelan tab 750mg cr 4 naproxen kit comfort 4 naproxen pow 4 naproxen pow sodium 4 naproxen sodium cap 220 mg 4 naproxen sodium tab 220 mg 4 naproxen sodium tab 275 mg 4 naproxen sodium tab 550 mg 4 naproxen susp 125 mg/5ml 4 naproxen tab 250 mg 4 naproxen tab 375 mg 4 naproxen tab 500 mg 4 naproxen tab ec 375 mg 4 nasacort alr spr 55mcg/ac 50 nasal decon syp 30mg/5ml 55 nasopen liq 55 nasopen pe liq 55 nat fiber pow 58.6% 31 nat senna tab laxative 31 natalvit tab 75-1mg 61 nateglinide tab 120 mg 12 nateglinide tab 60 mg 12 natura-lax pow 3350 nf 31 nature-throi tab 130mg 40 nature-throi tab 195mg 40 nature-throi tab 260mg 40 nature-throi tab 32.5mg 40 nature-throi tab 325mg 41 nature-throi tab 48.75mg 41 nature-throi tab 65mg 41 nature-throi tab 97.5mg 41 necon 0.5/35-28 37 necon 1/35 37 necon 1/50-28 38 necon 10/11-28 38 needle-free kit a 45 needle-free mis syrg a 45 neo dm syp 55 neomycin sulfate tab 500 mg 4 neomycin-bacitrac zn-polymyx 47 neomycin-polymy-gramicid op s 47 neomycin-polymyxindexamethas 48 neomycin-polymyxin-hc ophth s 48 neomycin-polymyxin-hc otic so 48 neomycin-polymyxin-hc otic su 48 neosporin kit trial 26 neotuss plus liq 55 neotuss-d liq 55 neupogen inj 300/0.5 13 neupogen inj 300mcg 13 neupogen inj 480/0.8 14 neupogen inj 480mcg 14 neuro-k-250 cap t.d. 67 nexium 24hr cap 20mg 33 niacin cap cr 250 mg 67 niacin cap cr 500 mg 67 niacin tab 100 mg 67 niacin tab 250 mg 67 niacin tab 50 mg 67 niacin tab 500 mg 67 niacin tab cr 250 mg 67 niacin tab cr 500 mg 67 niacin tab cr 750 mg 67 niacin tr tab 1000mg 67 niacinamide tab 100 mg 67 niacinamide tab 500 mg 67 niacinamide tab 500mg pr 67 niacor tab 500mg 21 niaouli oil 26 nicardipine hcl cap 20 mg 18 nicardipine hcl cap 30 mg 18 nicotine inhaler system 1 3 nicotine polacrilex gum 2 mg 3 nicotine polacrilex gum 4 mg 3 nicotine polacrilex lozenge 2 3 nicotine polacrilex lozenge 4 3 nicotine sys kit transder 3 nicotine td patch 24hr 14 mg/ 3 nicotine td patch 24hr 21 mg/ 3 nicotine td patch 24hr 7 mg/2 3 nicotrol ns spr 10mg/ml 3 nifedipine cap 10 mg 18 nifedipine cap 20 mg 18 nifedipine tab sr 24hr 30 mg 18 nifedipine tab sr 24hr 60 mg 18 nifedipine tab sr 24hr 90 mg 18 nifedipine tab sr 24hr osmoti 18 nite-time liq cold/flu 55 nitro-bid oin 2% 19 nitrofurantoin macrocrystalli 5 nitrofurantoin monohydrate ma 5 nitroglycerin cap cr 2.5 mg 19 nitroglycerin cap cr 6.5 mg 19 nitroglycerin cap cr 9 mg 19 nitroglycerin td patch 24hr 0 19 nitrostat sub 0.3mg 19 nitrostat sub 0.4mg 19 nitrostat sub 0.6mg 19 noble mystiq cre emu-lac 26 non-aspirin chw 160mg jr 1 nonoxynol-9 gel 2% 34 nonoxynol-9 gel 3% 34 nora-be 38 norel ad tab 4-10-325 55 norel cs liq 55 norethindrone 38 norethindrone acetate tab 5 m 39 norethindrone acetate/ethinyl 38 norethindrone acetate-ethinyl 39 norpace cap 100mg cr 15 norpace cap 150mg cr 15 83 nortrel 0.5/35 38 nortrel 0.5/35 (28) 38 nortrel 1/35 38 nortrel 7/7/7 38 notuss-nx liq 55 notuss-nxd liq 55 novaferrum cap 50mg 67 novaferrum dro 15mg/ml 67 novofine mis 30gx8mm 45 novofine mis 32gx6mm 45 novolin inj 70/30 13 novolin n inj u-100 13 novolin r inj u-100 13 novolog mix inj 70/30 13 novotwist mis 32gx5mm 45 nuox gel 6-3% 26 nutratear sol 0.6% 46 nutricion tab porvida 67 nutrients tab prenatal 61 nystatin cream 100000 unit/gm 26 nystatin oint 100000 unit/gm 26 nystatin susp 100000 unit/ml 21 nystatin tab 500000 unit 8 nystatin vaginal tab 100000 u 34 nystatin-triamcinolone cream 26 nystatin-triamcinolone oint 1 26 O obstetrix ec tab 61 obstetrix pak dha 61 oc8 gel 7% 26 o-cal fa tab 61 o-cal tab prenatal 61 ofloxacin ophth soln 0.3% 47 ofloxacin otic soln 0.3% 49 ofloxacin tab 200 mg 7 ofloxacin tab 300 mg 7 ofloxacin tab 400 mg 7 oil-almond oil sweet 26 oil-coconut oil 26 olive oil 26 omepra/bicar cap 20-1100 33 omeprazole cap delayed releas 33 omniflex dpr 45 ondansetron hcl oral soln 4 m 8 ondansetron hcl tab 4 mg 8 ondansetron hcl tab 8 mg 8 ondansetron orally disintegra 8 one a day mis prenatal 61 onset forte tab 55 opium tinct tin 2mg/5ml 31 oracit sol 60 ora-film mis 6% 21 oramagic pls sus 10% 21 orange oil 26 orazinc tab 110mg 67 orsythia 38 ortho coil dpr kit 100 45 ortho coil dpr kit 105 45 ortho coil dpr kit 50 45 ortho flat dpr kit 55 45 ortho flat dpr kit 60 45 ortho flat dpr kit 65 45 ortho flat dpr kit 70 45 ortho flat dpr kit 75 45 ortho flat dpr kit 80 45 ortho flat dpr kit 85 45 ortho flat dpr kit 90 45 ortho flat dpr kit 95 45 ortho flex dpr 65mm 45 ortho flex dpr 70mm 45 ortho flex dpr 75mm 45 ortho flex dpr 80mm 45 os-cal chw 67 osteo-poreti tab 67 ostigen mis 350mg 67 oxaprozin tab 600 mg 4 oxybutynin chloride syrup 5 m 34 oxybutynin chloride tab 5 mg 34 oxybutynin chloride tab sr 24 34 oxycodone hcl cap 5 mg 2 oxycodone hcl conc 100 mg/5ml 2 oxycodone hcl soln 5 mg/5ml 2 oxycodone hcl tab 15 mg 2 oxycodone hcl tab 30 mg 2 oxycodone hcl tab 5 mg 2 oxycodone w/ acetaminophen ca 2 oxycodone w/ acetaminophen ta 2 oxycodone-aspirin tab 4.8355- 2 oxymetazoline hcl nasal soln 50 oxytrol/womn dis 3.9mg/24 34 oyst shell/d tab 250mg 67 oyster shell calcium tab 67 oyster shell tab plus d 67 P paba tab 100mg 67 pain & fever sol 160/5ml 1 pain relief tab cold pe 55 panatuss dxp liq 55 panatuss dxp liq pediatri 55 panatuss ped dro 55 panatuss ped liq 60-2-25 55 pancreaze cap 10500unt 28 pancreaze cap 16800unt 28 pancreaze cap 21000unt 28 pancreaze cap 4200unit 28 pancrelipase cap 5000unit 28 panoxyl-4 liq crem wsh 26 panoxyl-8 liq crem wsh 26 panto-250 cap 67 pantoprazole sodium ec tab 20 33 pantoprazole sodium ec tab 40 33 pantothenic acid tab 500 mg 67 parva-cal tab 250-100 67 parva-cal tab 500mg 67 pce tab 333mg ec 7 pce tab 500mg ec 7 peanut oil 26 pecgen dmx liq 15-125mg 55 pedia-lax liq 50mg 31 pedia-lax sup 2.8gm 31 pe-dm-apap & pe-cpm-dm-apap t 55 pe-dm-apap cap & doxylamined 55 pe-dm-apap liq & doxylamine-d 55 pe-dm-gg-apap tab & pe-diphen 55 peg 3350 pow 31 peg 3350-kcl-na bicarb-nacl-n 31 peg-intron kit 120 rp 11 peg-intron kit 150mcg 11 peg-intron kit 50mcg rp 11 peg-intron kit 80mcg 11 pe-hist dm syp 5-2-15mg 55 pen needles mis 29gx12.7 45 penicillin v potassium for so 6 penicillin v potassium tab 25 6 penicillin v potassium tab 50 6 pentoxifylline tab cr 400 mg 19 84 pepcid ac chw 10mg 33 pepcid ac chw max st 33 peppermint oil 26 peppermint sol spirit 26 perfect iron tab 25mg 68 permethrin aerosol 0.5% 26 permethrin cream 5% 26 permethrin creme rinse 1% 26 permethrin lotion 1% 26 permethrin spray & pyrethins26 perry prenat cap 68 pertzye cap 28 phenazopyridine hcl tab 100 m 60 phenazopyridine hcl tab 200 m 60 phenyleph-chlorphen-dm w/apap 55 phenylephrine w/ acetaminophe 55 phenylephrine w/ dm-gg liqd 1 55, 56 phenylephrine w/ dm-gg liqd 2 56 phenylephrine w/ dm-gg liqd 5 56 phenylephrine w/ dm-gg liquid 56 phenylephrine w/ dm-gg syrup 56 phenylephrine w/ dm-gg tab 10 56 phenylephrine-apap-gg liqd 10 56 phenylephrine-apap-gg tab 1056 phenylephrine-apap-gg tab 5-3 56 phenylephrinebrompheniramine 56 phenylephrine-chlorphen-dm li 56 phenylephrine-dm soln 2.5-5 m 56 phenylephrine-dm-gg w/ apap l 56 phenylephrine-dm-gg w/ apap t 56 phenylephrine-doxylamine-dma 56 phenylephrine-guaifenesin liq56 phenylephrine-guaifenesin syr 56 phenylephrine-guaifenesin tab 56 phenylephrine-promethazine w/ 56 phenylhist liq dh 56 phisohex liq 3% 26 phlexy-vits pow 68 phos-nak pow concentr 68 phospholine sol 0.125%op 46 phytonadione tab 100 mcg 68 pilocarpine hcl tab 5 mg 21 pindolol tab 10 mg 17 pindolol tab 5 mg 17 pine oil 26 pine tar liq 26 pinnacaine dro 20% otic 49 pin-x sus 50 26 pioglitazone hcl tab 15 mg (b 12 pioglitazone hcl tab 30 mg (b 12 pioglitazone hcl tab 45 mg (b 12 pioglitazone hcl-metformin hc 12 pirmella 1/35 38 piroxicam cap 10 mg 4 piroxicam cap 20 mg 4 plas adapt mis 1ml 45 plexion liq 9.8-4.8% 26 podofilox soln 0.5% 26 poly hist tab 7.5-10mg 56 polyeth glyc pow 3350 nf 31 polyeth glyc pow 3350-grx 31 polyethylene glycol-propylene 46 poly-hist dm liq 5-25-10 56 poly-hist pd liq 56 polymyxin b-trimethoprim opht 47 polysaccharide iron complex c 68 polysorbate liq 60 26 polysorbate liq 80 26 polysorbate sol 20 26 polysorbate sol 40 26 poly-tussin liq ac 56 poly-vent dm tab 56 poly-vent ir tab 60-380mg 56 polyvinyl alcohol ophth soln 46 polyvinyl alcohol-povidone op 46 portia-28 38 posture tab 68 pot & sod citrates w/ cit ac 60 pot bicarbonate & chloride ef 68 pot phos monobasic w/sod phos 68 potaba cap 500mg 68 potaba tab 500mg 68 potassium bicarbonate effer t 68 potassium chloride cap cr 10 68 potassium chloride cap cr 8 m 68 potassium chloride microencap 68 potassium chloride oral liq 1 68 potassium chloride powder pac 68 potassium chloride tab cr 10 68 potassium chloride tab cr 8 m 68 potassium citrate & citric ac 60 povidone-iodine soln 10% 26 powderlax pow 31 pramipexole dihydrochloride t 11 pramosone cre 1% 26 pravastatin sodium tab 10 mg 20 pravastatin sodium tab 20 mg 20 pravastatin sodium tab 40 mg 20 pravastatin sodium tab 80 mg 20 prazosin hcl cap 1 mg 19 prazosin hcl cap 2 mg 19 prazosin hcl cap 5 mg 19 precisn xtra tes ketone 45 pred mild sus 0.12% op 48 prednicarbate oint 0.1% 26 prednisolone acetate ophth su 48 prednisolone sod phosphate or 35 prednisolone sodium phosphate 48 prednisolone syrup 15 mg/5ml 35 prednisone oral soln 5 mg/5ml 35 prednisone tab 1 mg 35 prednisone tab 10 mg 35 85 prednisone tab 10 mg dose pac 35 prednisone tab 2.5 mg 35 prednisone tab 20 mg 35 prednisone tab 5 mg 35 prednisone tab 5 mg dose pack 35 prednisone tab 50 mg 35 premarin tab 0.3mg 39 premarin tab 0.45mg 39 premarin tab 0.625mg 39 premarin tab 0.9mg 39 premarin tab 1.25mg 39 premphase tab 39 prempro tab .625-2.5 39 prempro tab 0.3-1.5 39 prempro tab 0.45-1.5 39 prempro tab 0.625-5 39 prenat multi cap +dha 61 prenata chw 29-1mg 61 prenatal cap formula 61 prenatal cap omega-3 61 prenatal frm tab a-free 61 prenatal mul cap +dha 61 prenatal tab 68 prenatal tab 27-0.8mg 68 prenatal tab complete 68 prenatal tab formula 61 prenatal tab plus dha 61 prenatal tab plus fe 61 prenatal tab vitamins 68 prenatal+dha mis 61 pretz sol 26 prilosec otc tab 20mg 33 primaquine tab 26.3mg 10 primsol sol 50mg/5ml 5 pro 12 aer mousse 26 probenecid tab 500 mg 8 probiotic w/ cap prebioti 31 pro-chlo liq 56 prochlorperazine maleate tab 11 prochlorperazine suppos 25 mg 11 procrit inj 40000/ml 14 prodigy mis 29gx1/2" 45 profe cap 180mg 68 proferrin es tab 12 mg 68 progesterone sup vgs 100 34 progesterone sup vgs 200 35 progesterone sup vgs 25 35 progesterone sup vgs 400 35 progesterone sup vgs 50 35 promethazine & phenylephrine 57 promethazine hcl suppos 12.549 promethazine hcl suppos 25 mg 49 promethazine hcl suppos 50 mg 49 promethazine hcl syrup 6.25 m 49 promethazine hcl tab 12.5 mg 49 promethazine hcl tab 25 mg 49 promethazine hcl tab 50 mg 49 promethazine w/ codeine syrup 57 promethazine-dm syrup 6.25-15 57 pronto aer 0.4% 26 propafenone hcl tab 150 mg 15 propafenone hcl tab 225 mg 15 propafenone hcl tab 300 mg 15 propantheline bromide tab 15 28 proparacaine hcl ophth soln 0 46 propranolol & hydrochlorothia 16 propranolol hcl cap sr 24hr 1 17 propranolol hcl cap sr 24hr 6 17 propranolol hcl cap sr 24hr 8 17 propranolol hcl oral soln 20 17 propranolol hcl oral soln 40 17 propranolol hcl tab 10 mg 17 propranolol hcl tab 20 mg 17 propranolol hcl tab 40 mg 17 propranolol hcl tab 60 mg 17 propranolol hcl tab 80 mg 17 propylene glycol-glycerin oph 46 propylthiouracil tab 50 mg 41 pro-red ac syp 5-1-9/5 57 protexin syp 68 pseudoeph-chlorphen-dm w/ apa 57 pseudoeph-doxylamine-dm w/ ap 57 pseudoeph-doxylamine-dm w/apa 57 pseudoephed-bromphen-dm elixi 57 pseudoephed-bromphen-dm syrup 57 pseudoephed-chlorphen-dm liq 57 pseudoephed-dexchlorphenchlo 57 pseudoephedrine hcl liq 15 mg 57 pseudoephedrine hcl tab 30 mg 57 pseudoephedrine hcl tab 60 mg 57 pseudoephedrine hcl tab abuse 57 pseudoephedrine hcl tab sr 1257 pseudoephedrine w/ acetaminop 57 pseudoephedrine w/ apap-dm ca 57 pseudoephedrine w/ apap-dm li 57 pseudoephedrine w/ apap-dm ta 57 pseudoephedrine w/ cod-gg sol 57 pseudoephedrine w/ cod-gg syr 57 pseudoephedrine w/ dm-gg cap 57 pseudoephedrine w/ dm-gg liqu 57 pseudoephedrine w/ dm-gg syru 57 pseudoephedrine-bromphencode 57 pseudoephedrine-chlophedianol 57 pseudoephedrine-dexchlorpheni 57 pseudoephedrine-dm liqd 15-7. 57 pseudoephedrine-dm syrup 30-1 57 pseudoephedrine-dm-gg w/ apap 57 pseudoephedrine-guaifenesin c 57 pseudoephedrine-guaifenesin s 57 86 pseudoephedrine-guaifenesin t 57 pseudoephedrine-ibuprofen sus 57 pseudoephedrine-ibuprofen tab 57 pseudoephedrine-naproxen sodi 58 psyllium cap 0.52 gm 31 psyllium powder 100% 31 psyllium powder 28.3% 31 psyllium powder 30% 32 psyllium powder 30.9% 32 psyllium powder 33% 32 psyllium powder 48.57% 32 psyllium powder 55.46% 32 psyllium powder 58.6% 32 psyllium powder 68% 32 psyllium powder 95% 32 pulmozyme sol 1mg/ml 58 pur-absorb liq 5mg/20ml 68 pyrazinamide tab 500 mg 9 pyre/piperon liq 26 pyreth-piperonyl butox sham-p 26 pyrethrins-piperonyl butoxide 26, 27 pyridostigmine bromide sy 9 pyridostigmine bromide ta 9 pyridoxine hcl tab 100 mg 68 pyridoxine hcl tab 200 mg 68 pyridoxine hcl tab 25 mg 68 pyridoxine hcl tab 250 mg 68 pyridoxine hcl tab 50 mg 68 pyridoxine hcl tab 500 mg 68 pyridoxine hcl tab cr 200 mg 68 pyril dm sus 58 pyrilamine mal-phenylephrine 58 pyrilamine-phenylephrine tab 58 Q quasense 38 quinapril hcl tab 10 mg 15 quinapril hcl tab 20 mg 15 quinapril hcl tab 40 mg 15 quinapril hcl tab 5 mg 15 quinapril-hydrochlorothiazide16 quinidine gluconate tab cr 32 15 quinidine sulfate tab 200 mg 15 quinidine sulfate tab 300 mg 15 quinine sulfate cap 324 mg 10 qvar aer 40mcg 49 qvar aer 80mcg 49 R ra acne max pad 2% 27 ra ca/boron tab 68 ra essence-c pow lmn-lime 68 ra laxative pow 32 ra lot 27 ra oys shl/d tab 250mg 68 ra vitamin c chw 300mg 68 ramipril cap 1.25 mg 15 ramipril cap 10 mg 15 ramipril cap 2.5 mg 15 ramipril cap 5 mg 15 ranitidine hcl syrup 15 mg/ml 33 ranitidine tab 150mg 33 ranitidine tab 300mg 33 refresh cell dro 1% op 46 refresh dro relief 46 refresh sol optive 46 relenza mis diskhale 11 renagel tab 400mg 34 renagel tab 800mg 34 rescon-dm syp 58 respaire-30 cap 58 retaine mgd emu 0.5-0.5% 46 rezamid lot 27 rhogam plus inj 300mcg 42 ribavirin cap 200 mg 11 riboflavin cap 100mg 68 riboflavin cap 50mg 68 riboflavin tab 100 mg 68 riboflavin tab 25 mg 68 riboflavin tab 400mg 68 riboflavin tab 50 mg 68 rifabutin cap 150 mg 9 rifampin cap 150 mg 9 rifampin cap 300 mg 9 rifater tab 9 ri-mag plus sus 32 rimantadine hydrochloride tab 11 robitus nght liq 12.5-30 58 robitussin d liq cgh/cold 58 robitussin liq cf 58 robitussin liq night tm 58 robitussin mis day/nght 58 robitussin mis day/nite 58 roche - fastcliix lancets, bo 45 rolaids chw ex st 32 ropinirole hydrochloride tab 11 rose oil 27 rosemary oil 27 rub alcohol sol 70% ethy 27 ru-hist-d liq 30-10/5 58 ru-hist-d tab 30-10mg 58 rycontuss liq 5-2-10/5 58 rydex g tab 38.5-398 58 rymed tab 2-10mg 58 S safe tussin liq pm 58 safflower oil 27 salicylic acid & sulfur shamp 27 saline nasal spray 0.65% 50 salsalate tab 500 mg 4 salsalate tab 750 mg 4 santyl oin 250u/gm 27 sassafras oil 27 sastid bar 3-5% 27 sb nat fiber pow 49% 32 schooltime sha 27 scooby-doo chw 69 scot-tussin liq original 58 scot-tussin liq senior 58 sd gluconavii test strips 45 sebasorb lot 27 selegiline hcl cap 5 mg 10 selenium sulfide lotion 2.5% 27 se-natal 19 tab 61 se-natal 90 tab 61 senna leaves mis 32 senna syp 32 senna tab 187mg 32 sennosides cap 8.6 mg 32 sennosides chew tab 15 mg 32 sennosides syrup 8.8 mg/5ml 32 sennosides tab 15 mg 32 sennosides tab 17.2 mg 32 sennosides tab 25 mg 32 sennosides tab 8.6 mg 32 sennosides-docusate sodium ta 32 sensipar tab 30mg 60 sensipar tab 60mg 60 serevent dis aer 50mcg 50 sesame oil 27 setonet pak 61 sev sin cong tab daytime 58 87 sevelamer carbonate tab 800 m 34 sfrowasa ene 4gm 42 silver sulfadiazine cream 1% 27 simethicone cap 125 mg 32 simethicone cap 180 mg 32 simethicone chew tab 125 mg32 simethicone chew tab 80 mg 32 simethicone liquid 40 mg/0.6m 32 simethicone susp 40 mg/0.6ml 32 simvastatin tab 10 mg 21 simvastatin tab 20 mg 21 simvastatin tab 40 mg 21 simvastatin tab 5 mg 21 sinadrin pe tab 2-10-650 58 sinus-max mis day/nght 58 slow rel fe tab 143mg cr 69 slow release tab 143mg 69 sm clearlax pow 32 sm ibuprofen tab 100mg jr 4 sm one daily mis prenatal 61 smooth lax pow 32 sod silicate sol 27 sod silicate sol 40% 27 sodium bicarbonate tab 325 mg 32 sodium bicarbonate tab 650 mg 32 sodium chloride aero soln 0.9 58 sodium chloride hypertonic op 46, 47 sodium chloride irrigation so 61 sodium chloride soln nebu 0.9 58 sodium chloride tab 1 gm 69 sodium citrate & citric acid 61 sodium fluoride chew tab 0.5 69 sodium fluoride chew tab 1 mg 69 sodium fluoride cream 1.1% 21 sodium fluoride soln 0.5 mg/m 69 sodium pow bicarbon 32 solia 38 soothe dro 0.6-0.6% 47 sotalol hcl (afib/afl) tab 12 17 sotalol hcl (afib/afl) tab 16 17 sotalol hcl (afib/afl) tab 80 17 sotalol hcl tab 120 mg 17 sotalol hcl tab 160 mg 17 sotalol hcl tab 240 mg 17 sotalol hcl tab 80 mg 17 soybean oil 27 spearmint oil 27 spironolactone & hydrochlorot 20 spironolactone tab 100 mg 20 spironolactone tab 25 mg 20 spironolactone tab 50 mg 20 sronyx 38 stahist ad liq 58 stahist ad tab 25-60mg 58 stannous fluoride conc 0.63% 21 stannous fluoride gel 0.4% 21 starch suppositories 51% 27 statuss liq green 58 step 2 sol 8% 27 sterile lubr dro 0.7% 47 stromectol tab 3mg 10 strovite for syp 69 stuart one cap 61 sucralfate tab 1 gm 32 sudafed 24hr tab 240mg 58 sudafed pe pak day&nght 58 sulf lime sol 27 sulfacet sod oin 10% op 47 sulfacetamide sodium lotion 1 27 sulfacetamide sodium ophth so 47 sulfacetamide sodium w/ sulfu 27 sulfacetamide sodium-predniso 48 sulfacetamide sodium-sulfur i27 sulfadiazine tab 500 mg 7 sulfamethoxazole-trimethoprim 5 sulfasalazine tab 500 mg 42 sulfasalazine tab delayed rel 42 sulfoam sha 2% 27 sulfur bar 10% 27 sulfur bar 5% 27 sulindac tab 150 mg 4 sulindac tab 200 mg 4 sumatriptan succinate tab 100 9 sumatriptan succinate tab 25 9 sumatriptan succinate tab 50 9 supervite ec tab 69 suppress a dro 5-1-10 58 supress dm dro 5-50/ml 58 supress-pe dro pediatri 58 sure-lance mis lancets 45 sure-t infus mis set 23" 45 sw clearlax pow 32 symbicort aer 160-4.5 50 symbicort aer 80-4.5 50 synagis inj 100mg/ml 42 synagis inj 50mg 42 synatek cap 69 systane bal sol restor 47 systane gel 0.3% 47 systane liq dro 0.4-0.3% 47 T tabloid tab 40mg 10 tacrolimus cap 0.5 mg 42 tacrolimus cap 1 mg 42 tacrolimus cap 5 mg 42 tamiflu cap 30mg 11 tamiflu cap 45mg 11 tamiflu cap 75mg 11 tamiflu sus 6mg/ml 11 tamoxifen citrate tab 10 mg ( 10 tamoxifen citrate tab 20 mg ( 10 tamsulosin hcl cap 0.4 mg 34 tangerine oil 27 taron-bc mis 61 tears again gel nght/day 47 tegrin-lt kit 27 tender 1 kit 31" 45 terazosin hcl cap 1 mg 19 terazosin hcl cap 10 mg 19 terazosin hcl cap 2 mg 19 terazosin hcl cap 5 mg 19 terbinafine hcl cream 1% 27 terbinafine hcl tab 250 mg 8 terbutaline sulfate tab 2.5 m 50 terbutaline sulfate tab 5 mg 50 terconazole vaginal cream 0.435 terconazole vaginal cream 0.835 terconazole vaginal suppos 80 35 terpin hydr pow monohydr 58 testosterone cypionate im in 35 tetracycline cap 500mg 7 tetracycline hcl cap 250 mg 7 tetrahydrozoline hcl ophth so 47 tetrahydrozoline w/ polyethyl 47 88 tetrahydrozoline w/ zinc sulf 47 theo-24 cap 100mg cr 58 theo-24 cap 200mg cr 58 theo-24 cap 300mg cr 58 theophylline tab sr 12hr 100 58 theophylline tab sr 12hr 200 58 theophylline tab sr 12hr 300 58 theophylline tab sr 12hr 450 58 theracof pls liq cgh/cold 58 theraflu cld mis cgh day 58 theraflu flu pak sore thr 58 theraflu flu pow chst con 58 theraflu liq warm rlf 59 theraflu pak cold/cgh 59 theraflu pow 59 theraflu pow max-d 59 theraflu sev pak cold/cgh 59 theranatal mis complete 61 theratears sol op 47 thiamine cap 50mg 69 thiamine hcl tab 100 mg 69 thiamine hcl tab 250 mg 69 thiamine hcl tab 50 mg 69 thiamine mononitrate tab 100 69 thyroid tab 16.25 mg 41 thyroid tab 30 mg (1/2 grain) 41 thyroid tab 60 mg (1 grain) 41 thyroid tab 90 mg (1 1/2 grai 41 ticlopidine hcl tab 250 mg 14 timolol maleate ophth soln 0. 48 timolol maleate tab 10 mg 17 timolol maleate tab 20 mg 17 timolol maleate tab 5 mg 17 timoptic ocu sol 0.25% op 48 timoptic ocu sol 0.5% op 48 titralac chw plus 32 tizanidine hcl tab 2 mg 60 tizanidine hcl tab 4 mg 60 tl g-fol os tab 69 tobradex oin 0.3-0.1% 48 tobramycin ophth soln 0.3% 47 tobramycin-dexamethasone opht 48 tobrex oin 0.3% op 47 tolterodine tartrate cap sr 2 34 tolterodine tartrate tab 1 mg 34 tolterodine tartrate tab 2 mg 34 toothache gum 21 torsemide tab 10 mg 19 torsemide tab 100 mg 20 torsemide tab 20 mg 20 torsemide tab 5 mg 20 tramadol hcl tab 50 mg 2 trandolapril tab 1 mg 15 trandolapril tab 2 mg 15 trandolapril tab 4 mg 15 trecator tab 250mg 9 tretinoin cap 10 mg 10 tretinoin cream 0.025% 27 tretinoin cream 0.05% 27 tretinoin cream 0.1% 27 tretinoin gel 0.01% 27 tretinoin gel 0.025% 27 trexbrom liq 10-4-25 59 triactin sol chst con 59 triacting liq cgh/run 59 triamcinolone acetonide cream 27 triamcinolone acetonide denta 21 triamcinolone acetonide lotio27, 28 triamcinolone acetonide oint 28 triamin flu/ syp cgh/fvr 59 triaminic chw 59 triaminic liq 59 triaminic liq chst/nas 59 triaminic mis cgh/cold 59 triaminic mis cold/cgh 59 triaminic mis grape 59 triaminic nt mis cold/cgh 59 triaminic sol cold/cgh 59 triaminic syp cgh/sore 59 triaminic syp child 59 triaminic syp chst/nsl 59 triaminic syp cold/all 59 triaminic syp cold/cgh 59 triaminic-d syp 59 triamterene & hydrochlorothia 20 tricode ar liq 59 tricode gf liq 59 trifluridine ophth soln 1% 47 trimethobenzamide hcl cap 300 8 trimethoprim tab 100 mg 5 trinatal rx tab 1 61 triprolidine & pseudoephedrin 59 trispec dmx liq 10-187/5 59 trispec pse liq triveen-duo pak dha triveen-u cap trivora-28 tropicamide ophth soln 0.5% tropicamide ophth soln 1% trospium chloride tab 20 mg trypsin w/ castor oil & peruv tudorza pres aer 400/act turpentine liq spirits turpentine oil tusicof liq tusnel cap tussafex-a liq 6-2-15/5 tylenol cgh pak sore thr tylenol ches liq congest tylenol chld sus cld/cgh tylenol chld sus stuffy tylenol cold liq relief tylenol sinu mis day/nite U udamin sp tab ultra tabs tab ultresa cap 13800unt ultresa cap 20700unt ultresa cap 23000unt undecylenic liq acid unifed liq 30mg/5ml unifine pntp mis 29gx12mm unifine pntp mis 31gx5mm unifine pntp mis 31gx6mm unifine pntp mis 31gx8mm unifine pntp mis 32gx4mm unithroid tab 100mcg unithroid tab 112mcg unithroid tab 125mcg unithroid tab 137mcg unithroid tab 150mcg unithroid tab 175mcg unithroid tab 200mcg unithroid tab 25mcg unithroid tab 300mcg unithroid tab 50mcg unithroid tab 75mcg unithroid tab 88mcg upcal d pow urea cream 40% uro-mag cap 140mg ursodiol cap 300 mg 89 59 61 61 38 48 48 34 28 50 28 28 59 59 59 59 59 59 59 59 59 69 61 28 28 28 28 59 45 45 45 45 45 41 41 41 41 41 41 41 41 41 41 41 41 69 28 32 32 V vanacof ape liq 59 vanacof cd liq 59 vanacof dm liq 59 vanacof g liq 59 vanacof gpe liq 59 vanacof-8 liq 25-50/15 60 vanatab dx tab 60 vancomycin hcl for inj 10 gm 5 vancomycin hcl for inj 1000 m 5 vancomycin hcl for inj 500 mg 5 vancomycin hcl for inj 5000 m 5 vancomycin inj 750mg 5 vancomycn 25 sol 25mg/ml 5 vancomycn 50 sol 50mg/ml 5 vasoclear a sol op 47 velivet 38 ventolin hfa aer 50 verapamil hcl cap sr 24hr 100 18 verapamil hcl cap sr 24hr 120 18 verapamil hcl cap sr 24hr 180 18 verapamil hcl cap sr 24hr 200 18 verapamil hcl cap sr 24hr 240 18 verapamil hcl cap sr 24hr 300 18 verapamil hcl cap sr 24hr 360 18 verapamil hcl tab 120 mg 18 verapamil hcl tab 40 mg 18 verapamil hcl tab 80 mg 18 verapamil hcl tab cr 120 mg 18 verapamil hcl tab cr 180 mg 18 verapamil hcl tab cr 240 mg 18 vesicare tab 10mg 34 vesicare tab 5mg 34 vibramycin syp 50mg/5ml 7 vicks nature liq cold/flu 60 vicks nature liq congest 60 vicks nyquil liq children 60 vicks nyquil liq cold/flu 60 vinate cal tab 62 vinate ic cap 62 vinate ii tab 62 vinate m tab 62 viokace tab 28 visine tears dro 47 vita-c cry 69 vita-calcium waf 69 vitamin b-12 tab 1000mcg 69 vitamin c cap 500mg 69 vitamin c chw 1000mg 69 vitamin c chw gummie 69 vitamin c sol 69 vita-pren tab 62 viva drops dro 1% 47 W wal-dryl-d tab 25-60mg 60 warfarin sodium tab 1 mg 13 warfarin sodium tab 10 mg 13 warfarin sodium tab 2 mg 13 warfarin sodium tab 2.5 mg 13 warfarin sodium tab 3 mg 13 warfarin sodium tab 4 mg 13 warfarin sodium tab 5 mg 13 warfarin sodium tab 6 mg 13 warfarin sodium tab 7.5 mg 13 water for irrigation, sterile 45 wera 38 wide-seal dpr kit 60 45 wide-seal dpr kit 65 45 wide-seal dpr kit 70 45 wide-seal dpr kit 75 45 wide-seal dpr kit 80 45 wide-seal dpr kit 85 45 wide-seal dpr kit 90 45 wide-seal dpr kit 95 46 X xarelto tab 10mg 13 Z zeasorb-af lot 2% 28 zenpep cap 10000unt 28 zenpep cap 15000unt 28 zenpep cap 20000unt 29 zenpep cap 25000unt 29 zenpep cap 3000unit 29 zinc 15 tab 66mg 69 zinc loz 69 zinc sulfate cap 220 mg (50 m 69 zinc sulfate gra heptahyr 69 zinc sulfate inj 1mg/ml 69 zinc sulfate inj 5mg/ml 69 zinc sulfate pow 69 zinc sulfate tab 69 zinc sulfate tab 220 mg (50 m69 zinc tab 220mg 69 zodryl ac 25 sus 60 zodryl ac 30 sus 60 zodryl ac 35 sus 60 zodryl ac 40 sus 60 zodryl dac sus 25 60 zodryl dac sus 30 60 zodryl dac sus 35 zodryl dac sus 40 zodryl dec25 sus zodryl dec30 sus 90 60 60 60 60 zodryl dec35 sus zodryl dec40 sus zostavax inj zostrix-hp mis 0.075% 60 60 42 28 zovia 1/50e z-tuss ac liq 2-9/5ml z-tuss e liq zyncof syp 20-400/5 38 60 60 60